Every finding on record at Wabash Senior Living & Rehab

Based on observation, interview, and record review the facility failed to notify the physician when a pressure ulcer deteriorated for 1 (R6) of 4 residents reviewed for physician notification in the sample of 40. This failure resulted in an abrasion to the right gluteus progressing to a Stage 4 pressure ulcer that became infected, requiring R6 to be hospitalized with sepsis on two occasions and requiring surgical wound debridement. The Immediate Jeopardy began on 03/23/2026 when R6's wound was identified as deteriorating and the physician was not notified to obtain new treatments or implement new interventions. The Administrator (V1) and the [NAME] President of Clinical Services (V21) were notified of the Immediate Jeopardy on 5/27/26 at 2:36 PM. The Immediacy was removed on 5/27/26, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.1. R6's admission Record with a print date of 5/26/26 documents R6 was admitted to the facility on [DATE] and included diagnoses of major depressive disorder, atrial fibrillation, obesity, osteoarthritis, and pressure ulcer of left heel. R6's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15, indicating R6 is cognitively intact. This same MDS documents R6 requires substantial/maximal assistance to roll left and right in bed and is dependent on staff for transfer. Under Section M, Skin Conditions this MDS documents R6 is at risk of developing pressure ulcers with one Stage 4 pressure ulcer documented. Under Skin and Ulcer/Injury Treatments the following interventions are documented that should be implemented, pressure reducing device for chair and bed, pressure ulcer/injury care, application of nonsurgical dressings (with or without topical medications) other than to feet and applications of ointments/medications other than to feet. R6's current Care Plan documents a Focus area of I have alterations in my skin integument. See skin and wound module for sites and updates. Date Initiated: 05/19/2026. This Focus area includes the following interventions with a date initiated of 5/19/26, Float heels while in bed.Monitor for pain and offer analgesics per order.Monitor for worsening or infection and report to PCP (primary care physician) prn (as needed).Nutritional support per order.Pressure relief device to bed/chair.RD (Registered Dietitian) consult per regulatory guidelines and prn upon request.Treatment per order.Turn/repo (reposition) q (every) 2 hours as tolerated.Weekly skin assessments. Report abnorms (abnormal) to PCP prn .Wound specialist per order. This same Care Plan documents a Focus area of (R6) has actual impairment to skin integrity r/t (related to) incontinence and limited mobility and DM2 (diabetes mellitus 2) Dx (diagnosis) Date Initiated: 06/25/2024. This Focus area includes the following interventions, 12/22/25, utilize pillows to offload pressure, 1/8/26, remind/assist resident to turn/reposition at least every two hours and as needed, 7/1/24, ensure folds are clean and dry, 5/7/26, see treatment administration records for treatment orders, 1/8/26 pressure redistributing mattress on bed and position resident off affected area. R6's Braden Scale for Predicting Pressure Ulcer Risk dated 4/11/26 documents a score of 16, indicating R6 is at low risk for skin breakdown. R6's Braden Scale for Predicting Pressure Ulcer Risk dated 4/17/26 documents a score of 13, indicating R6 is at moderate risk of developing skin breakdown. R6's Skin Issues report dated 2/16/26 documents a new skin issue identified as an abrasion to R6's right gluteus that measures 2.62 x (by) 2.97 centimeters (cm's). R6's Progress Note dated 2/17/26 at 12:43 AM documents, Resident is back from (name of local hospital) via ambulance transport. She was admitted to the hospital due to UTI (urinary tract infection) . Skin assessment showed new abrasion to right hip, new abrasion to right gluteus, and new open lesion to coccyx. R6's Order Summary Report dated 6/1/26 includes the following order with a start date of 2/16/26. Cleanse abrasion to right gluteus with normal saline, pat dry, apply xeroform, and cover with foam dressing. Report to MD (physician) for complications. Every night shift for altered skin integrity. R6's Treatment Administration Record (TAR) dated 2/1/26 to 2/28/26 documents a physician order with a start date of 2/17/26 of, Cleanse abrasion to right gluteus with normal saline, pat dry, apply xeroform, and cover with foam dressing. Report to MD (physician) for complications. This TAR documents initials indicating the treatment was administered as ordered. R6's Skin Issues report dated 2/24/26 documents the abrasion to her right gluteus is deteriorating and measures 2.84 x 2.5 cm's. R6's Order Summary Report dated 6/1/26 includes the following order with a start date of 2/24/26, Cleanse abrasion to right gluteus with normal saline, pat dry, manukaHD, and cover with silicone super absorbent dressing. Report to MD for complications. Every night shift for altered skin integrity. R6's TAR dated 2/1/26 to 2/28/26 documents a physician order with a start date of 2/24/26 and discontinue date of 3/11/26 of, Cleanse abrasion to right gluteus with normal saline, pat dry, manukaHD, and cover with silicone super absorbent dressing. Report to MD for complications. Every night shift for altered skin integrity. This TAR documents initials indicating the treatments were administered as ordered. R6's Skin Issues report dated 3/2/26 documents the abrasion to her right gluteus as deteriorating and measures 2.94 x 2.91 cm's. R6's Skin Issues report dated 3/9/26 documents the abrasion to her right gluteus as deteriorating, non-healing, stabbing pain, with moderate purulent drainage and a faint odor. R6's Progress Notes document the following: 3/11/26, Reviewed wound review with recommendations to add 2x (times) protein at breakfast and supper. Care plan and meal tickets updated.3/11/26, Seen (V16/Wound Nurse Practitioner) NP (Nurse Practitioner) related to wound. New order to apply triad over wound bed and leave open to air every other day and PRN (as needed), POA (Power of Attorney) called. V16's (Wound Nurse Practitioner) Nursing Home Visit Progress Note for R6 dated 3/11/26 documents this is the first time R6 is being seen by V16. This Progress Note documents the area to R6's right gluteus as an unstageable pressure ulcer that measures 3.8 x 3.5 cm's (centimeters). The Progress Note documents under, Plan: Discussed with RN (Registered Nurse). Likely needs debridement but will trial on triad for 1 week. Apply a generous amount of triad over the sacrum and buttocks. Pressure relieving measures every 2 hours while in bed and every hour while in chair. We will follow up with her in 1 week. R6's Order Summary Report dated 6/1/26 includes a physician order with a start date of 3/11/26 of, Cleanse abrasion to right gluteus with normal saline, pat dry, apply triad over wound bed, and leave open to air, every other day and PRN (as needed). Report to MD for complications. Every night shift on even days for altered skin integrity. R6's TAR dated 3/1/26 to 3/31/26 documents a physician order with a start date of 3/12/26 and discontinue date of 3/31/26 of, Cleanse abrasion to right gluteus with normal saline, pat dry, apply triad over wound bed, and leave open to air, every other day and PRN (as needed). Report to MD for complications. Every night shift on even days for altered skin integrity. This TAR documents initials indicating the treatments were administered as ordered. R6's Skin Issues report dated 3/17/26 documents the area to R6's right gluteus as an abrasion that is deteriorating, non-healing, with aching pain that measures 3.88 x 3.59 cm's. R6's Progress Notes dated 3/17/26 documents, RD (Registered Dietitian) recommends adding 2x protein at breakfast and supper d/t (due to) deteriorating wounds. POA (Power of Attorney) (POA name) aware. V16's (Wound Nurse Practitioner) Nursing Home Visit Progress Note for R6 dated 3/18/26 documents the same information verbatim as V16's progress note dated 3/11/26. On 6/1/26 at 10:10 AM, V16 (Wound Nurse Practitioner) stated she signed her note from 3/11/26 on 3/18/26 and assumes that is the 3/18/26 Progress Note referenced above. V16 stated she did not see R6 on 3/18/26 but did a record review including the wound modules which documented assessments including pictures of the area. R6's Dietary Note dated 3/18/26 documents, 3/11/26 RD (Registered Dietitian) reviewed wound review with recommendations to add 2 x (times) protein at breakfast and supper. Care plan and meal tickets updated. R6's Nurses Note dated 3/23/26 documents, Resident has wound to right buttock. Increased drainage, slough, and foul odor noted. Area has adipose tissue exposed. Resident needs to see doctor. May need antibiotic. Under this note there are check marks next to, Show on Shift Report, Show on 24 hour report, Show on MD/Nursing Communications Report. This Nurses Note was signed by V26 (Licensed Practical Nurse/LPN). On 5/26/26 at 2:23 PM, V26 (LPN) stated she wrote the progress note dated 3/23/26. V26 stated she printed off the progress note and left it for V17 (Physician). V26 stated she also notified V4 (DON) of the deterioration of the pressure ulcer. V26 stated she was told R6 had recently been seen, and a new treatment had been put in place. V26 stated she assumed it had been taken care of because the physician had already been notified. V26 stated she didn't know at the time R6 was being followed by V16 (Wound Nurse Practitioner). When asked if she documented the notification to V17 (Physician), V26 stated if it wasn't documented in the progress note it wouldn't be documented. V26 stated she also discussed the deterioration of the pressure ulcer with V2 (Infection Preventionist/Wound Nurse). On 5/26/26 at 3:23 PM, V21 (Vice President of Clinical Services) showed this surveyor a line on the bottom of R6's 3/23/26 progress note that says MD/Nursing Communication. The box is checked next to it. When asked where it is documented and what V17 ordered when he was notified, V21 stated he wanted V16 (Wound Nurse Practitioner) to see and treat the pressure ulcer. The facility was unable to provide reproducible evidence V17 was notified and what V17's response was. R6's Skin Issue report dated 3/24/26 documents the pressure ulcer to R6's right gluteus as an abrasion that is deteriorating, non-healing, increased smell, intermittent pain, and moderate purulent drainage. This report documents the pressure ulcer measures at 3.88 x 4.21 cm's.R6's Skin Issue report dated 3/31/26 documents the pressure ulcer to R6's right gluteus as an abrasion that is deteriorating, red and bleeding, increased smell, heavy purulent drainage, and a strong odor after cleaning that measures 6.85 x 4.61 cm's. A telephone communication from V16 (Wound NP) provided to this surveyor by the facility dated 3/31/26 documents, Received notification from ADON (Assistant Director of Nursing who is now V4/DON) at (name of facility) insuring I was coming to the NH (nursing home) on 04/01/2026 due to deteriorating wound. Plans to round at (name of facility) tomorrow 04/01/2026. R6's Progress Notes dated 4/1/2026 documents, Wound Nurse here to see. Received order to start Doxycycline 100 mg (milligrams) BID (twice daily) x (times) 7 days. Multi Vitamin with minerals, Prostat 30 ml (milliliters) BID, obtain u/a (urinalysis) with c&s (culture and sensitivity). Res (resident) aware. V16's (Wound Nurse Practitioner) Nursing Home Visit Progress Note for R6 dated 4/1/2026 documents, . I did see the patient about 3 weeks ago and it was noted to have some necrotic tissue. RN (Registered Nurse) reports that it has significantly declined since previous visit. Assessment: 1. Pressure injury of right buttocks, unstageable.Plan: Discussed with RN. Will have her set up an appointment tomorrow for up (sic) in office debridement. Wound cultures taken. Patient to have a debridement for (sic) at 3:00 p.m. V16's (Wound Nurse Practitioner) Nursing Home Visit Progress Note for R6 dated 4/2/26 documents, History: the patient is a 60 y.o. (year old) female with a past medical history notable for type 2 diabetes, obesity, AFib (atrial fibrillation), GERD (gastroesophageal reflux disease), hypertension, SVT (supraventricular tachycardia), recurrent UTI's (urinary tract infections) who initially presented to the wound clinic for debridement of right buttocks wound. The patient resides at (name of nursing home) where I have been following her just recently for right buttocks wound. I initially saw her on 03/11 for unstageable wound. She was using triad to try chemical debridement. I followed up with her on 04/01 and the wound had significantly deteriorated. Discussed with patient and plan was made for debridement in office. Wound cultures were obtained. She presented today for debridement. Debridement was started in the office and quickly realized that it was significantly deeper than expected. I did discuss with (name of doctor) who did a debridement. It extended deep into subcutaneous fat. Decision was made to admit patient and plan for for (sic) their debridement in the operating room. Recommend: Will plan for further debridement in OR (operating room) tomorrow. Okay for diabetic diet tonight. NPO (nothing by mouth) at midnight. Consent for debridement. IV (intravenous) antibiotics with Zosyn based on prelim cultures growing gram neg (negative) rods. Hospitalists consult for medical management. Will restart home medications. Continue with foley catheter. R6's local hospital record dated 4/3/2026 documents surgical debridement of the Stage 4 pressure ulcer to right buttocks (gluteus). This local hospital record documents under the physician Progress Note dated 4/4/26, Was called in early this morning for persistent bleeding. She had gone in and out of an SVT (supraventricular tachycardia) (she has history of and possible AFib) even in the operating room but when she did it last night, she was started on Lovenox. And then started to bleed through her dressing. Due to her persistent problems with hypotension and dysrhythmia, eventually required pressors she was transferred to (name of regional hospital) . R6's Wound Culture results dated 4/4/26 documents many (4 plus) proteus mirabilis, moderate (3 plus) gram negative rods, and moderate (3 plus) enterococcus faecalis. R6's regional hospital record admission date 4/4/26 documents, .The patient presents to (initials of regional hospital) a transfer from (name of local hospital) for evaluation of shock.Shock, hemorrhagic versus septic.Large stage IV (4) buttock pressure wound s/p (status post) debridement at (name of local hospital), wounds polymicrobial, on empiric antibiotics.On arrival to our hospital patient was in shock with low blood pressures, tachycardia. [NAME] count was elevated.Urine cultures showed Proteus mirabilis and Enterococcus aerogenes. Wound culture was growing Proteus mirabilis, Enterococcus faecalis and Serratia fonticuli. Patient was started on broad-spectrum IV antibiotics.Sepsis is present and due to pressure ulcer.Admitting Diagnosis 1. Septic versus hemorrhagic shock: Patient did receive 3 units of PRBC (packed red blood cells) transfusion.Stage IV decubitus ulcer in right buttock with superimposed infection.Hospital Course: 60 y.o. (year old) female with a past history significant for AFib, on Eliquis and metoprolol, type 2 DM (diabetes mellitus), HTN (hypertension), obesity, SVT, anxiety, neuropathy, stage IV chronic decutibitus ulcer with recent debridement admitted on [DATE] with complaints of bleeding from her surgical site. She began to decline hemodynamically requiring pressors at the outside hospital. She received 3 units of PRBC and then was requested for transfer to (name of regional hospital) for further management.On arrival to our hospital patient was in shock with low blood pressure, tachycardia. [NAME] count was elevated . On 5/26/26 at 10:49 PM, V28 (Registered Nurse) stated she was the nurse who did the first assessment on the pressure ulcer on R6's right gluteus. V28 stated the area was deteriorating and when she came back to work on 2/24/26 there was a new treatment order in place. This surveyor reviewed the Skin Issue reports from 3/9, 3/17, 3/24, and 3/31 with V28. V28 stated she would take pictures when she did the treatments so if the wound nurse came in, she would have updated pictures to review. When asked if she notified any physician of the deterioration to that pressure ulcer during the time frame of 3/9-3/31, V28 stated she assessed the area, took picture, and placed in on her report for day shift to see. V28 stated she didn't remember if there were any changes or any communication back to her related to the deterioration. On 5/26/26 at 10:44 AM, when asked if he was notified between 3/17 and 3/31/26 of any changes/deterioration to the pressure ulcer located on R6's right gluteus, V17 (Physician) stated he had reviewed R6's medical record and he didn't find any notifications from the facility. V17 stated someone may have said something to him in passing. V17 stated he couldn't say if he was notified of the deterioration but there was no documentation of notification. V17 stated V16 (Wound Nurse Practitioner) should have been notified and he knew she had said she would follow up in a week and then didn't. V17 stated if she had been notified, they could have been more aggressive with the treatment. When asked if the outcome would have been different if the area had been treated sooner V17 stated, I can't say. When asked for any documentation to show the facility had reported the deterioration in R6's wound to V16 and/or V17 between 3/11/26 and 3/31/26, an email was provided to this surveyor dated 3/18/26 documenting a message from V16 (Wound Nurse Practitioner) of, Late follow up entry-Discussed treatment options with (V4 - Director of Nurses/DON) at (name of facility). Insurance does not pay for santyl, will apply Triad daily. There is no evidence in this email documenting V16 had been notified of R6's wound deteriorating. On 5/26/26 at 12:15 PM, V16 (Wound Nurse Practitioner) stated she was notified on 3/9/26 R6 had a wound that had deteriorated. V16 stated the treatment R6 received from 2/7/26 until she saw her on 3/11/26 would have been a discharge order from the hospital and/or from her primary care physician (V17). V16 stated if she had been notified prior to 3/09/26 she could have placed orders and prevented it from getting as bad as it did. V16 stated on 3/18/26 she reviewed R6's chart including the wound module which documents assessments including pictures of the area and spoke with V4 (DON) about changing the treatment. V16 stated the insurance wouldn't cover the preferred treatment of santyl so they continued the original treatment order of Triad. V16 stated the next notification she received from the facility was on 3/31/26 that showed signs of infection and deteriorating. V16 stated she was going to the facility on 4/1/26 to do rounds and planned to see her then. When asked why she was talking about changing the treatment on 3/18/26, V16 stated she reached out to V4 after she (V16) did a chart review. V16 stated she was not notified of any change in R6's condition from 03/18/26 until 3/31/26. V16 stated if she had been notified, she would have made changes. V16 reviewed R6's record and stated she was looking at the assessment picture on 3/24/26. V16 stated she could see the drainage in the picture. V16 stated if she had been notified, she would have debrided the area and gotten a wound culture. When asked if she had debrided the area sooner if it could have been done at the office without a hospital stay, V16 stated, Probably, but it is hard to tell at times. V16 stated she saw R6 on 4/1/26 and scheduled an office visit for debridement on 4/2/26. V16 stated R6 was sent from her office to the hospital. V16 stated R6 had symptoms of sepsis and was hypotensive. V16 stated R6's hospital records document sepsis versus hemorrhagic shock. V16 stated they determined it was sepsis from the wound. On 05/25/26 at 10:56 PM, V23 (Licensed Practical Nurse/LPN) stated right after R6 returned from the hospital on 4/11/26 she took a picture of the pressure ulcer located on her right gluteus. V23 stated she only took the picture because the nurse working didn't have access to the application they use. When asked what she does if there is a change or concern with a pressure ulcer, V23 stated she would leave a note for V4 (DON) and write a note to the physician. V23 stated if it was urgent she would text the on-call service and they would get in touch with a physician. V23 stated they can also check notify MD (physician) on the progress note. V23 stated no one ever told her but she assumed the physician could see those notes. V23 stated she also prints all of the pertinent information and leaves it on the desk V17 (Physician) uses at the facility. When asked how she notifies V16 (Wound Nurse Practitioner), V23 stated she normally just messages V4 (DON) and sends all skin issues to V17 (Physician) also. R6's Skin Issue report dated 4/11/26 documents the pressure ulcer to right gluteus measures 9.18 x 8.67 x 0 cm's. R6's Order Summary Report dated 6/1/26 includes the following physician orders with a start date of 4/10/26 of, Wound Vac: Apply to right gluteus every day shift every Mon, Wed, Fri. Wound Vac: Check and change Wound Vac cannister when full every shift.Wound Vac: Check function every shift.Piperacillin Sod-Tazaobactam So Solution Reconstituted 4-0.5 GM (gram) Use 4.5 gram intravenously every 8 hours for infection for 22 days.Vancomycin HCI Oral Capsule 125 MG (milligrams).Give 1 capsule by mouth one time a day for infection for 20 days. V16's Progress Note dated 4/13/26 documents the same assessment of 4/1/26. R6's Wound Culture dated 4/13/26 documents a culture of the right buttock was taken on 4/1/26 due to a foul odor. The results document the following organisms grew in the culture, many (4 plus) proteus mirabilis, moderate enterococcus faecalis, and moderate serratia fonticola. The culture report documents Patient on appropriate antibiotics. R6's Skin Issues report dated 4/17/26 documents the Stage IV pressure ulcer measures 11.55 x 12.34 x 6 cm's. This report doesn't document an assessment of the area. R6's Skin Issues report dated 4/24/26 documents the Stage 4 pressure ulcer as improving and measures 7.07 x 5.38 x 4.5 cm's. R6's Skin Issues report dated 4/29/26 documents the Stage 4 pressure with no measurements or assessments. R6's Skin Issues report dated 5/1/26 documents the Stage 4 pressure ulcer as improving with measurements of 8.43 x 6.19 x 2 cm's. R6's Skin Issues report dated 5/5/26 documents the Stage 4 pressure with no measurements or assessments. V16's (Wound Nurse Practitioner) Nursing Home Visit Progress Note for R6 dated 5/6/26 documents, . Patient did undergo a debridement (name of local hospital) hospital. She subsequently develop (sic) some postoperative bleeding and hypotension therefore she was transferred to (name of regional hospital). She was seen by infectious disease which started her on some IV antibiotics. She completed Zosyn on 5/1. Wound Vac is in place. The nursing staff is changing it Monday Wednesday and Friday. Patient was seen sitting in the chair. She reports that she feels sick to her stomach. Denies any fever. She was getting ready to take a shower. Stage 4 pressure ulcer with slough present at bottom of the wound. She does have some maceration and opening surrounding the wound. This is likely from drainage in poor securement. R6's Order Summary Report dated 6/1/26 includes a physician order with a start date of 5/6/26 to, Cleanse wound with normal saline apply santyl into wound bed, cover with wound vac one time a day every Mon (Monday), Wed (Wednesday), Fri (Friday) for wound. R6's Skin Issues report dated 5/8/26 documents the Stage 4 pressure ulcer as stable and measures 7.18 x 5.65 x 3 cm's. R6's Skin Issues report dated 5/13/26 documents the Stage 4 pressure ulcer with no measurements or assessment. R6's Skin Issues report dated 5/15/26 documents the Stage 4 pressure ulcer as deteriorating with measurements of 6.69 x 8.28 x 5 cm's. On 05/18/2026 at 10:21 AM, R6 was laying in bed, covered with a blanket and denied concerns with care. There was a foul odor noted in R6's room. On 5/19/26 at 8:12 AM, this surveyor began observation of wound care with V4 (DON) present and V18 (LPN) administering care. V18 administered a treatment to R6's abdominal fold. When this surveyor inquired about the drain tubes noted on R6's back, V18 stated that was her wound vac. V18 stated that treatment was not scheduled for this date and observation would need to be done on the next day. The foul odor in the room seemed to dissipate after the abdominal fold was cleaned. On 5/20/26 at approximately 1:00pm this surveyor was told by V4 (DON) and V21 (Vice President of Clinical Services) the Nurse Practitioner (V16) had assessed R6 this morning and changed the dressing to the pressure ulcer on R6's right gluteus. V4 stated R6 was being sent to the hospital for admission for surgical debridement. This surveyor was unable to observe the wound prior to R6 leaving the facility. R6's Progress Notes dated 05/20/2026 documents the following: Seen by NP (V16) related to wound. Order given for resident to be a direct admit for surgical debridement and IV antibiotics. Wet to dry dressing completed at bedside by NP, POA (Power of Attorney) and resident aware. Res (resident) left via facility to (name of local hospital) direct admit, Report called to floor nurse. V16's history and physical note for R6 dated 5/21/26 documents, The patient is a 60 y.o. (year old) female with a past medical history.stage IV pressure ulcer who has been followed at (name of facility). Upon rounds yesterday, it was noted that the wound had significantly deteriorated, foul odor, Bedside debridement was done. Decision was made to admit the patient for possible surgical debridement and IV antibiotics. The patient was admitted .She was started on IVF (intravenous fluids) and IV (intravenous) antibiotics with Zosyn and vancomycin. Overnight, she went into SVT with HR (heart rates) sustained in the 150's. IV labetolol was attempted without success. Impression: 1. Sepsis- likely secondary to infected Stage IV pressure ulcer vs (versus) UTI (urinary tract infection). 2. Necrotic Stage IV pressure ulcer. 3. SVT - likely reactive secondary to sepsis. 4. Hypokalemia 5. Uncontrolled DM (diabetes mellitus) II (2) 6. Chronic indwelling catheter. On 5/25/26 at 11:04 PM, V24 (LPN) stated she remembered the pressure ulcer on R6's right gluteus deteriorated very fast. V24 stated it went from bad to horrible. V24 stated R6 didn't like to turn and reposition but she would encourage her to do so. When asked if she ever notified the physician of the pressure ulcer deteriorating, V24 stated the way they do it at the facility is different. V24 stated, When we submit something to the physician it feels like it hangs in the balance. When asked what that meant, V24 stated they put the information on V17's desk at the facility. When asked how she would notify the physician of a wound deteriorating, V24 stated, We would put it on his desk. V24 stated she thought V17, or his nurse practitioner came in every weekday. When asked if there was any documentation when the physician was notified, V24 stated if it isn't charted on the progress notes, the medication administration record, or treatment administration record then essentially it wasn't done. V24 stated, Do I think there wasn't anything done, I think there was but not fast enough obviously. On 5/26/26 at 3:00 PM, V4 (DON) stated R6 returned to the facility from a hospital stay on 2/16/26 with an abrasion to the right gluteus. V4 stated the area was treated with xeroform until V17 (Physician) changed the order on 2/24/26 and referred R6 to the wound specialist. V4 stated V16 (Wound Nurse Practitioner) was notified the pressure ulcer was deteriorating on 3/9/26, V16 assessed R6 on 3/11/26 and gave an order for triad. This surveyor reviewed R6's Skin Issue reports with V4 and asked if there was any physician notification when the pressure ulcer is documented as deteriorating from 3/17/26 to 3/31/26. V4 stated on 3/18/26, V16 (Wound NP) asked me if insurance covered a new treatment she wanted to order. V4 stated the insurance did not cover it so they continued the same treatment. V4 stated V16 was supposed to assess R6 on 3/25/26 but couldn't because her children were sick. When asked if any physician was notified of the deterioration of the pressure ulcer, V4 stated, I would not say so. V4 stated the physician should have been notified. When asked if any physician was notified of the deterioration of the pressure ulcer from 5/15/26 to 5/20/26, V4 stated, Not that I see. When asked if she would expect a physician to be notified, V4 stated, Oh yeah, definitely. When asked if she had any concerns with wound care at the facility, V4 stated she didn't. V4 stated they are normally good about notifying the physician if a wound/pressure deteriorates. On 5/26/26 at 12:15 PM, when asked if she was notified of a deterioration in the pressure ulcer from 5/15/26 to 5/20/26, V16 (Wound Nurse Practitioner) stated she completed a chart review on 5/14/26 but wasn't notified of any deterioration from 5/15 to 5/20/26. V16 stated when she assessed R6 on 5/20/26, she noted a foul odor in the wound, R6 appeared sick, and was tachycardic. V16 stated the pressure ulcer needed debrided and with R6's history she had her admitted to the local hospital for surgical debridement in the operating room. V16 stated when they did the debridement the bone was exposed. This surveyor asked if R6 had osteomyelitis and V16 stated she was surprised that she didn't, but all the tests were negative. When asked if she had any concerns with wound care at the facility, V16 stated she thought they did a great job with wound care, but they needed protocols in place on when to get the wound specialist involved. On 5/26/26 at 10:44 AM, V17 (Physician) stated he thought wound care specialists were seeing R6 from 5/15/26 to 5/20/26. V17 stated he remembered talking with the facility earlier in May and they were worried about the area but V16 (Wound Nurse Practitioner) was following the pressure ulcer and had made treatment order changes. V17 stated he didn't have any documentation or remember being notified of a deterioration from 5/15 to 5/20/26. The undated facility Guidelines for Notifying Physicians of Change of Condition documents, These guidelines are intended to help ensure that 1) medical care problems are communicated to the medical staff in a timely, efficient and effective manner and that 2) all significant changes in the resident's status are assessed, documented in the medical record and communicated with the primary care physician.The charge nurse or supervisor should contact the attending physician if a clinical situation appears to require immediate discussion and management. The undated facility Assessment and documentation of wounds policy documents, The purpose of this procedure is to provide information to the primary care provider and the resident representative regarding identification of wounds/wound characteristic changes and interventions for specific risk factors.1. Report changes in wound characteristics to the PCP (primary care physician) and the resident representative.3. Document the interaction in the progress notes including the PCP whom was contacted and the resident representative. The Immediate Jeopardy that began on 3/23/26 was removed on 5/27/26 when the facility took the following actions to remove the immediacy: The facility has implemented and educated staff on notifications of the PCP (primary care physician) of changes in wound condition: Licensed Facility personnel will be or have been educated by the Administrator, (V1), DON (V4), and Regional Nurse (V21) to ensure that they are aware of policy rela

Based on interviews, record review, and observation the facility failed to prevent resident to resident physical abuse for 1 of 1 (R42) residents reviewed for abuse in a sample of 52. This failure resulted in R42 being attacked on 5/19/2026 by R38, causing a skin tear to her left wrist, bruise to her left thumb, and becoming fearful for her safety.Findings Include:R42's admission Record documents an admission date of 12/18/2025 with diagnoses of type 2 diabetes mellitus without complications, unsteadiness on feet, need for assistance with personal care and muscle weakness among others. R42's MDS (Minimum Data Set) dated 3/24/2026 documents R42 with a BIMS (Brief Interview for Mental Status) score of 15 out of 15 which indicates R42 is cognitively intact. This same MDS documents R42 uses a walker for ambulation and is independent with most activities of daily living.R38's admission Record documents an admission date of 11/19/2025 and diagnoses of type 2 diabetes mellitus without complications, dementia with other behavioral disturbance and essential hypertension. R38's MDS dated [DATE] documents R38 with a BIMS score of 13 out of 15 total with indicates R38 is cognitively intact. This same MDS document R38 has no impairment to her extremities, uses a walker and a wheelchair for locomotion and is independent with most activities of daily living.On 5/20/2026 at 11:30am, R42 said two nights ago (5/19/26), R38 attacked her around 2:30am in the morning. R42 said she got up from her bedside recliner and walked to the bathroom. R42 said when she came back into the bedroom from the bathroom, R38 was on her side of the room getting into her refrigerator. R42 said when she told R38 to get out of her things, R38 became angry and violently grabbed her left wrist, hit her on the left hand and scratched R42 causing a skin tear and bruising to R42's left hand and thumb area. R42 said she was afraid of R38, and she was glad R38 was moved to another unit and won't be able to hurt her again. R42 said R38 has a mental problem and doesn't know what she is doing and has not been right since R38 recovered from a Covid-19 infection. R42 said her left hand was swollen and sore and she feared she may need an Xray.On 5/20/2026 at 11:30pm, R42's left wrist/hand was bandaged to cover a wound to her left wrist, and an observable bruise was noted to the outer base of R42's left thumb. R42's left hand/wrist was slightly swollen and R42 complained of pain to the injuries when she touched them.The facility document titled Illinois Department of Public Health Initial report documents on 5/19/2026 at 3:05am, R38 made unwanted contact with R42. Both residents were separated, and nursing assessments were completed on both residents. R42's Progress Note entry dated 5/19/2026 at 3:56am documented R42 received a new wound with partial skin flap loss. Wound acquired in house. Wound length 1.84 cm (centimeters) with width of 1.59cm, no depth was recorded.The facility investigation of this incident included written statements from V10 (Registered Nurse) and V11 (Certified Nursing Assistant).V10's written statement documented the following occurred on the night of 5/19/2026: I was at lunch, was notified of resident-to-resident altercation. I came back in and took statements from both residents. (R38) made unwanted contact to R42's left forearm and wrist. R38 was in fridge by R42's chair and R38 came at R42 and caused skin tears and a bruise to her left forearm/hand. Administrator, Power of Attorney, medical doctor and Assistant Director of Nursing aware, see nurse's notes for more information. R42's Progress Note dated 5/19/26 at 3:10am documents CNA staff heard yelling coming from (R42's) room. Staff went to check on residents. (R42) was standing in front of her recliner chair and roommate was standing next to her bed when staff walked in the room. (R42) stated that she had been in her bathroom and she came out and (R38) was standing next to (R42's) chair (and was in R42's) fridge. (R42) stated that (R38) called her by her sister's name and then made unwanted contact with her left arm/wrist. Residents immediately separated. Skin assessment completed and skin tear noted to left outer wrist and bruising noted to left thumb. Skin tear cleansed with normal saline, patted dry and steri-strips applied. Administrator notified. Medical doctor (was) notified via fax. (R42) is own responsible party and aware.On 5/21/2026 at 12:10pm, V10 said she was R38 and R42's nurse on the night of 5/19/2026 and V11 was the CNA assigned to their hall. V10 said she was at lunch when staff alerted her to a resident-to-resident altercation. V10 said she went to assess the residents and to investigate what happened. V10 said R42's said R38 attacked her and hurt her left hand/wrist by grabbing it and caused cuts on it. V20 said she had the residents separated for the night to prevent any further abuse from happening and dressed R42's injuries.V11's written statement documented the following occurred on 5/19/2026: At approximately 3:00am, I overheard residents (on assigned hall) yelling. (R42) yelled get your hands off my shit shortly after, the call light came on, as I was walking down to investigate. Upon entering the room, I observed both residents on their own respective sides of the room. (R42) stated that (R38) was getting into her things so she said to get her hands off her shit and (R42) said that (R38) attacked her. (R42) stated that she was grabbed violently, shoved and scratched. I observed a cut on the (left) forearm of (R42). I immediately notified the nursing and followed her instructions.On 5/21/2026 at 11:45am, V11 said he was at the nurse's station when he heard yelling from R42. V11 said when he entered R42's room, R38 and R42 had been arguing and R42 said R38 attacked her by violently grabbing her left wrist, hit, scratched and shoved her. V11 said R42 was scared of R38, and he escorted R38 to another room for the night. V11 said R42 had cuts on her left wrist and was bleeding, but the nurse cleaned and dressed her wounds.On 5/21/2026 at approximately 11:00am, V1 (Administrator) said he was still investigating the incident of 5/19/2026 between R38 and R42 and could not say at this point in the investigation if resident to resident abuse had occurred. V1 also said he could not say whether he would or would not substantiate if abuse had occurred for this investigation.The facility policy titled Abuse Prevention dated 8/16/2025 documents the following in part: this facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends and any other individuals. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Physical abuse includes but is not limited to, hitting, slapping, punching, biting and kicking.

Based on interview, observation, and record review the facility failed to ensure an effective treatment was implemented for a newly identified wound and report worsening of the wound for 1 of 4 (R9) residents reviewed for quality of care in the sample of 40. This failure resulted in deterioration of R9's arterial wound to the right leg.Findings Include:R9's admission Record with a print date of 5/26/26 documents R9 was admitted to the facility on [DATE] with diagnoses that include iron deficiency anemia, depression, cognitive communication deficit, muscle weakness, hypertension, diabetes, and chronic obstructive pulmonary disease.R9's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score of 03, indicating a severe cognitive deficit.R9's current Care Plan documents a Focus area of, I have the potential/actual risk for pressure ulcer development or altered skin integrity r/t (related to) impaired mobility. 05/12/2026 Unstageable pressure ulcer Right lateral calf with an initiation date of 09/15/2025. This Focus area includes the following interventions dated 9/15/25: educate family/caregivers as to causes of skin breakdown, follow facility policies/protocols for the prevention/treatment of skin breakdown, obtain and evaluate lab/diagnostic work as ordered, pressure reduction mattress, evaluate skin changes, and evaluate nutritional status. This Focus area includes the following interventions dated 5/14/26: cleanse skin tear to right calf with normal saline, pat dry, apply medihoney and collagen to wound and cover with bordered gauze daily.On 05/18/2026 at 10:25 AM, R9 was lying in bed with heel protectors in place and partially covered. R9 denied all concerns with care.R9's Skin Issue report dated 4/10/26 documents a new unstageable pressure ulcer/injury, acquired in house, to the right lateral calf that measures 4.65 x 2.3 cm (centimeters) with onset unknown.R9's Order Details document on 4/11/26 V30 created the order to change dressing to inner right lower leg every other day and V17 (Physician) didn't sign the order until 5/6/26. This order was discontinued on 5/7/26.R9's Order Summary Report dated 4/1/26 to 5/21/26 documents the following physician orders: Change drsg (dressing) to inner RLL (right lower leg) QOD (every other day) every 48 hours for altered skin integrity with a start date of 4/11/26 and an order status of discontinued and no documented end date. Change drsg to inner RLL QOD every day shift, every other day for altered skin integrity with a start date of 4/13/26 and an order status of discontinued and no documented end date.On 5/27/26 at 12:07 PM, V30 (LPN) stated she worked on 4/9 and 4/11 and was off work on 4/10/26. This surveyor reviewed the physician order dated 4/11/26 with V30 and she stated that order wasn't for the right lateral calf. Then V30 stated she wasn't sure what area that order was for. V30 stated the way the order was written would mean she called V17's (Physician) office and got the order. V30 stated she didn't work on 4/10/26 and reviewed her notes and stated she didn't have anything documented on 4/11/26, and she would have documented it. V30 stated, maybe V4 (Director of Nurses) told her to put the orders in. V30 was unable to recall what wound was treated, how the orders were obtained, or who she spoke with for the orders.On 5/27/26 at 10:44 AM, V17 (Physician) stated his notes document he was notified of the area to R9's right lateral calf on 4/7/26 and he implemented pressure-reducing interventions at that time. V17 stated the facility staff were to elevate R9's lower extremities and reduce pressure.On 5/26/26 at 3:00 PM, V4 (Director of Nurses) stated the wound on R9's right lateral calf was identified on 4/10/26. This surveyor reviewed R9's Treatment Administration Record (TAR) and physician orders with V4 and asked where the treatment for the area was. V4 stated the treatment to the right lower inner leg was the treatment that was ordered for the wound located on R9's right lateral calf. This surveyor asked what kind of dressing should have been used since the order documents change dressing with no specific dressing documented. V4 stated it was probably a dry dressing. When asked how the nurses would know that, V4 stated, they wouldn't. When asked how the nurses would know the wound they were treating was on the right lateral calf when the order documents the right lower inner leg, V4 stated, they wouldn't.R9's Progress Notes document the following:4/17/26: unstageable pressure ulcer to right lateral calf, deteriorating, 5.02 cm x 2.44 cm x 0 cm, no tunneling or undermining.4/22/26: Seen (V16- Wound Nurse Practitioner) related to wound on right calf. Ordered triad to wound bed and cover with dry dressing. POA (Power of Attorney) called. Unable to reach.V16's (Wound Nurse Practitioner) Progress Note for R9 dated 4/22/26 documents, She was seen today at (name of facility).I have seen patient for various pressure sores during her NH (nursing home) stay. I was asked to evaluate the patient for right calf wound. RN (Registered Nurse) reports worsening of right calf wound. Unsure what caused the wound, but it is getting worse. There are no wound orders in. Under Assessment documents Non-pressure chronic ulcer of right calf, unspecified ulcer stage. Under Plan documents Some sloughing on the wound bed. Will do triad every other day and cover with dry dressing. May switch to collagen next week. Obtain arterial and venous dopplers.R9's Order Summary Report dated 4/1/26 to 5/21/26 includes the following physician orders: Cleanse right calf with normal saline, pat dry, apply triad and cover with dry dressing. In the morning every other day for Wound care with a start date of 4/22/26 and no discontinue date documented but discontinued documented under order status.On 5/26/26 at 3:00 PM, V4 (Director of Nurses) stated she assumed V17 (Physician) was notified when the area was first identified and V16 (Wound Nurse Practitioner) was notified after that. V4 stated V16 was coming every two weeks but comes weekly now. This surveyor reviewed R9's Skin Issue report dated 4/17/26 when it documents the wound deteriorated and asked V4 if any physician was notified of the deterioration. V4 stated, No, just 4/21/26. When asked why a physician was not notified of the deterioration V4 stated, lack of communication. When asked who the lack of communication was between, V4 stated the floor nurses know to let the nurse manager, power of attorney, and physician know if an area deteriorates. V4 stated they (administration) should have caught it when they came to work on 4/18/26. V4 stated she would expect the nursing staff to make all necessary notifications when a wound is deteriorating. V4 stated there was no communication documented with V17 (Physician). V4 stated the facility staff should have called V17.On 5/27/26 at 10:44 AM, V17 (Physician) stated he didn't have any documentation from 4/7/26 to 4/17/26 and didn't have documentation that he had ordered a treatment for the wound. V17 stated he typically goes along with whatever the facility recommends for treatments.V16's (Wound Nurse Practitioner) Progress Note for R6 dated 5/6/26 documents, She did have arterial Dopplers that showed severe arterial stenosis of the bilateral lower legs. She is allergic to contrast dye but does have a referral placed for vascular surgery.Assessment: 1. Peripheral artery disease. 2. Arterial leg ulcer. 3. Skin tear of left lower leg without complication, subsequent encounter.Plan: Switch dressings to right lower leg to Medihoney and collagen. Cover with dry dressing. Change every other day.On 5/21/26 at 9:56 AM, V30 (Licensed Practical Nurse/LPN) administered treatments with V2 (Infection Preventionist) present. V30 cleaned the wound on the back of R9's right calf with normal saline, patted it dry, covered with medihoney, collagen powder, and covered with a border foam dressing using current standards of practice. The area was open with slough present. V30 and V2 stated it started as a skin tear, and they didn't know how it deteriorated.On 5/26/26 at 12:05 PM, V16 (Wound Nurse Practitioner) stated she was notified of the wound to R9's right lateral calf on 4/21/26 and saw her on 4/22/26. V16 stated there were no orders for treatment prior to that. When asked when she would expect to be notified of a new area. V16 stated ideally, I would have liked to have seen her on 4/10/26 but for sure on 4/17/26 when it looked a lot worse. When asked how they knew what treatment to administer if she hadn't seen her, V16 stated, I don't know if they have protocols in place. When asked if she had seen her sooner and treatments had been implemented if the outcome would be different, V16 stated if she had been notified, she would have ordered something and hopefully prevented it from getting to the sloughy way it looked on 4/17/26. V16 stated after it was treated with triad it looked better and smaller.The facility undated Treatments/Wound Care policy documents, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation: 1. Verify that there is a physician's order for this procedure.Reporting: 1. Notify the supervisor if the resident refuses the wound care. 2. Report other information in accordance with facility policy and professional standards of practice.

Based on observation, interview, and record review the facility failed to obtain orders and implement interventions for 1 (R6) of 4 residents reviewed for pressure ulcers in the sample of 40. This failure resulted in an abrasion to the right gluteus deteriorating and becoming infected, requiring R6 to be hospitalized with sepsis on two occasions and requiring surgical wound debridement and the development of a Stage 2 pressure ulcer on R6's left heel. Findings Include:1. R6's admission Record with a print date of 5/26/26 documents R6 was admitted to the facility on [DATE] and included diagnoses of major depressive disorder, atrial fibrillation, obesity, osteoarthritis, and pressure ulcer of left heel. R6's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15, indicating R6 is cognitively intact. This same MDS documents R6 requires substantial/maximal assistance to roll left and right in bed and is dependent on staff for transfer. Under Section M, Skin Conditions this MDS documents R6 is at risk of developing pressure ulcers with one Stage 4 pressure ulcer documented. Under Skin and Ulcer/Injury Treatments the following interventions are documented that should be implemented, pressure reducing device for chair and bed, pressure ulcer/injury care, application of nonsurgical dressings (with or without topical medications) other than to feet and applications of ointments/medications other than to feet. R6's current Care Plan documents a Focus area of I have alterations in my skin integument. See skin and wound module for sites and updates. Date Initiated: 05/19/2026. This Focus area includes the following interventions with a date initiated of 5/19/26, Float heels while in bed.Monitor for pain and offer analgesics per order.Monitor for worsening or infection and report to PCP (primary care physician) prn (as needed).Nutritional support per order.Pressure relief device to bed/chair.RD (Registered Dietitian) consult per regulatory guidelines and prn upon request.Treatment per order.Turn/repo (reposition) q (every) 2 hours as tolerated.Weekly skin assessments. Report abnorms (abnormal) to PCP prn .Wound specialist per order. This same Care Plan documents a Focus area of (R6) has actual impairment to skin integrity r/t (related to) incontinence and limited mobility and DM2 (diabetes mellitus 2) Dx (diagnosis) Date Initiated: 06/25/2024. This Focus area includes the following interventions, 12/22/25, utilize pillows to offload pressure, 1/8/26, remind/assist resident to turn/reposition at least every two hours and as needed, 7/1/24, ensure folds are clean and dry, 5/7/26, see treatment administration records for treatment orders, 1/8/26 pressure redistributing mattress on bed and position resident off affected area. R6's Braden Scale for Predicting Pressure Ulcer Risk dated 4/11/26 documents a score of 16, indicating R6 is at low risk for skin breakdown. R6's Braden Scale for Predicting Pressure Ulcer Risk dated 4/17/26 documents a score of 13, indicating R6 is at moderate risk of developing skin breakdown. R6's Skin Issues report dated 2/16/26 documents a new skin issue identified as an abrasion to R6's right gluteus that measures 2.62 x (by) 2.97 centimeters (cm's). R6's Progress Note dated 2/17/26 at 12:43 AM documents, Resident is back from (name of local hospital) via ambulance transport. She was admitted to the hospital due to UTI (urinary tract infection) . Skin assessment showed new abrasion to right hip, new abrasion to right gluteus, and new open lesion to coccyx. R6's Order Summary Report dated 6/1/26 includes the following order with a start date of 2/16/26. Cleanse abrasion to right gluteus with normal saline, pat dry, apply xeroform, and cover with foam dressing. Report to MD (physician) for complications. Every night shift for altered skin integrity. R6's Treatment Administration Record (TAR) dated 2/1/26 to 2/28/26 documents a physician order with a start date of 2/17/26 of, Cleanse abrasion to right gluteus with normal saline, pat dry, apply xeroform, and cover with foam dressing. Report to MD (physician) for complications. This TAR documents initials indicating the treatment was administered as ordered. R6's Skin Issues report dated 2/24/26 documents the abrasion to her right gluteus is deteriorating and measures 2.84 x 2.5 cm's. R6's Order Summary Report dated 6/1/26 includes the following order with a start date of 2/24/26, Cleanse abrasion to right gluteus with normal saline, pat dry, manukaHD, and cover with silicone super absorbent dressing. Report to MD for complications. Every night shift for altered skin integrity. R6's TAR dated 2/1/26 to 2/28/26 documents a physician order with a start date of 2/24/26 and discontinue date of 3/11/26 of, Cleanse abrasion to right gluteus with normal saline, pat dry, manukaHD, and cover with silicone super absorbent dressing. Report to MD for complications. Every night shift for altered skin integrity. This TAR documents initials indicating the treatments were administered as ordered. R6's Skin Issues report dated 3/2/26 documents the abrasion to her right gluteus as deteriorating and measures 2.94 x 2.91 cm's. R6's Skin Issues report dated 3/9/26 documents the abrasion to her right gluteus as deteriorating, non-healing, stabbing pain, with moderate purulent drainage and a faint odor. R6's Progress Notes document the following: 3/11/26, Reviewed wound review with recommendations to add 2x (times) protein at breakfast and supper. Care plan and meal tickets updated.3/11/26, Seen (V16/Wound Nurse Practitioner) NP (Nurse Practitioner) related to wound. New order to apply triad over wound bed and leave open to air every other day and PRN (as needed), POA (Power of Attorney) called. V16's (Wound Nurse Practitioner) Nursing Home Visit Progress Note for R6 dated 3/11/26 documents this is the first time R6 is being seen by V16. This Progress Note documents the area to R6's right gluteus as an unstageable pressure ulcer that measures 3.8 x 3.5 cm's (centimeters). The Progress Note documents under, Plan: Discussed with RN (Registered Nurse). Likely needs debridement but will trial on triad for 1 week. Apply a generous amount of triad over the sacrum and buttocks. Pressure relieving measures every 2 hours while in bed and every hour while in chair. We will follow up with her in 1 week. R6's Order Summary Report dated 6/1/26 includes a physician order with a start date of 3/11/26 of, Cleanse abrasion to right gluteus with normal saline, pat dry, apply triad over wound bed, and leave open to air, every other day and PRN (as needed). Report to MD for complications. Every night shift on even days for altered skin integrity. R6's TAR dated 3/1/26 to 3/31/26 documents a physician order with a start date of 3/12/26 and discontinue date of 3/31/26 of, Cleanse abrasion to right gluteus with normal saline, pat dry, apply triad over wound bed, and leave open to air, every other day and PRN (as needed). Report to MD for complications. Every night shift on even days for altered skin integrity. This TAR documents initials indicating the treatments were administered as ordered. R6's Skin Issues report dated 3/17/26 documents the area to R6's right gluteus as an abrasion that is deteriorating, non-healing, with aching pain that measures 3.88 x 3.59 cm's. R6's Progress Notes dated 3/17/26 documents, RD (Registered Dietitian) recommends adding 2x protein at breakfast and supper d/t (due to) deteriorating wounds. POA (Power of Attorney) (POA name) aware. V16's (Wound Nurse Practitioner) Nursing Home Visit Progress Note for R6 dated 3/18/26 documents the same information verbatim as V16's progress note dated 3/11/26. On 6/1/26 at 10:10 AM, V16 (Wound Nurse Practitioner) stated she signed her note from 3/11/26 on 3/18/26 and assumes that is the 3/18/26 Progress Note referenced above. V16 stated she did not see R6 on 3/18/26 but did a record review including the wound modules which documented assessments including pictures of the area. R6's Dietary Note dated 3/18/26 documents, 3/11/26 RD (Registered Dietitian) reviewed wound review with recommendations to add 2 x (times) protein at breakfast and supper. Care plan and meal tickets updated. R6's Nurses Note dated 3/23/26 documents, Resident has wound to right buttock. Increased drainage, slough, and foul odor noted. Area has adipose tissue exposed. Resident needs to see doctor. May need antibiotic. Under this note there are check marks next to, Show on Shift Report, Show on 24 hour report, Show on MD/Nursing Communications Report. This Nurses Note was signed by V26 (Licensed Practical Nurse/LPN). On 5/26/26 at 2:23 PM, V26 (Licensed Practical Nurse/LPN) stated she wrote the progress note dated 3/23/26. V26 stated she printed off the progress note and left it for V17 (Physician). V26 stated she also notified V4 (DON) of the deterioration of the pressure ulcer. V26 stated she was told R6 had recently been seen, and a new treatment had been put in place. V26 stated she assumed it had been taken care of because the physician had already been notified. V26 stated she didn't know at the time R6 was being followed by V16 (Wound Nurse Practitioner). When asked if she documented the notification to V17 (Physician), V26 stated if it wasn't documented in the progress note it wouldn't be documented. V26 stated she also discussed the deterioration of the pressure ulcer with V2 (Infection Preventionist/Wound Nurse). On 5/26/26 at 3:23 PM, V21 (Vice President of Clinical Services) showed this surveyor a line on the bottom of R6's 3/23/26 progress note that says MD/Nursing Communication. The box is checked next to it. When asked where it is documented and what V17 ordered when he was notified, V21 stated he wanted V16 (Wound Nurse Practitioner) to see and treat the pressure ulcer. The facility was unable to provide reproducible evidence V17 was notified and what V17's response was. R6's Skin Issue report dated 3/24/26 documents the pressure ulcer to R6's right gluteus as an abrasion that is deteriorating, non-healing, increased smell, intermittent pain, and moderate purulent drainage. This report documents the pressure ulcer measures at 3.88 x 4.21 cm's.R6's Skin Issue report dated 3/31/26 documents the pressure ulcer to R6's right gluteus as an abrasion that is deteriorating, red and bleeding, increased smell, heavy purulent drainage, and a strong odor after cleaning that measures 6.85 x 4.61 cm's. A telephone communication from V16 (Wound NP) provided to this surveyor by the facility dated 3/31/26 documents, Received notification from ADON (Assistant Director of Nursing who is now V4/DON) at (name of facility) insuring I was coming to the NH (nursing home) on 04/01/2026 due to deteriorating wound. Plans to round at (name of facility) tomorrow 04/01/2026. R6's Progress Notes dated 4/1/2026 documents, Wound Nurse here to see. Received order to start Doxycycline 100 mg (milligrams) BID (twice daily) x (times) 7 days. Multi Vitamin with minerals, Prostat 30 ml (milliliters) BID, obtain u/a (urinalysis) with c&s (culture and sensitivity). Res (resident) aware. V16's (Wound NP) Nursing Home Visit Progress Note for R6 dated 4/1/2026 documents, . I did see the patient about 3 weeks ago and it was noted to have some necrotic tissue. RN (Registered Nurse) reports that it has significantly declined since previous visit. Assessment: 1. Pressure injury of right buttocks, unstageable.Plan: Discussed with RN. Will have her set up an appointment tomorrow for up (sic) in office debridement. Wound cultures taken. Patient to have a debridement for (sic) at 3:00 p.m. V16's (Wound NP) Nursing Home Visit Progress Note for R6 dated 4/2/26 documents, History: the patient is a 60 y.o. (year old) female with a past medical history notable for type 2 diabetes, obesity, AFib (atrial fibrillation), GERD (gastroesophageal reflux disease), hypertension, SVT (supraventricular tachycardia), recurrent UTI's (urinary tract infections) who initially presented to the wound clinic for debridement of right buttocks wound. The patient resides at (name of nursing home) where I have been following her just recently for right buttocks wound. I initially saw her on 03/11 for unstageable wound. She was using triad to try chemical debridement. I followed up with her on 04/01 and the wound had significantly deteriorated. Discussed with patient and plan was made for debridement in office. Wound cultures were obtained. She presented today for debridement. Debridement was started in the office and quickly realized that it was significantly deeper than expected. I did discuss with (name of doctor) who did a debridement. It extended deep into subcutaneous fat. Decision was made to admit patient and plan for for (sic) their debridement in the operating room. Recommend: Will plan for further debridement in OR (operating room) tomorrow. Okay for diabetic diet tonight. NPO (nothing by mouth) at midnight. Consent for debridement. IV (intravenous) antibiotics with Zosyn based on prelim cultures growing gram neg (negative) rods. Hospitalists consult for medical management. Will restart home medications. Continue with foley catheter. R6's local hospital record dated 4/3/2026 documents surgical debridement of the Stage 4 pressure ulcer to right buttocks (gluteus). This local hospital record documents under the physician Progress Note dated 4/4/26, Was called in early this morning for persistent bleeding. She had gone in and out of an SVT (supraventricular tachycardia) (she has history of and possible AFib) even in the operating room but when she did it last night, she was started on Lovenox. And then started to bleed through her dressing. Due to her persistent problems with hypotension and dysrhythmia, eventually required pressors she was transferred to (name of regional hospital) . R6's Wound Culture results dated 4/4/26 documents many (4 plus) proteus mirabilis, moderate (3 plus) gram negative rods, and moderate (3 plus) enterococcus faecalis. R6's regional hospital record admission date 4/4/26 documents, .The patient presents to (initials of regional hospital) a transfer from (name of local hospital) for evaluation of shock.Shock, hemorrhagic versus septic.Large stage IV (4) buttock pressure wound s/p (status post) debridement at (name of local hospital), wounds polymicrobial, on empiric antibiotics.On arrival to our hospital patient was in shock with low blood pressures, tachycardia. [NAME] count was elevated.Urine cultures showed Proteus mirabilis and Enterococcus aerogenes. Wound culture was growing Proteus mirabilis, Enterococcus faecalis and Serratia fonticuli. Patient was started on broad-spectrum IV antibiotics.Sepsis is present and due to pressure ulcer.Admitting Diagnosis 1. Septic versus hemorrhagic shock: Patient did receive 3 units of PRBC (packed red blood cells) transfusion.Stage IV decubitus ulcer in right buttock with superimposed infection.Hospital Course: 60 y.o. (year old) female with a past history significant for AFib, on Eliquis and metoprolol, type 2 DM (diabetes mellitus), HTN (hypertension), obesity, SVT, anxiety, neuropathy, stage IV chronic decutibitus ulcer with recent debridement admitted on [DATE] with complaints of bleeding from her surgical site. She began to decline hemodynamically requiring pressors at the outside hospital. She received 3 units of PRBC and then was requested for transfer to (name of regional hospital) for further management.On arrival to our hospital patient was in shock with low blood pressure, tachycardia. [NAME] count was elevated . On 5/26/26 at 10:49 PM, V28 (Registered Nurse/RN) stated she was the nurse who did the first assessment on the pressure ulcer on R6's right gluteus. V28 stated the area was deteriorating and when she came back to work on 2/24/26 there was a new treatment order in place. This surveyor reviewed the Skin Issue reports from 3/9, 3/17, 3/24, and 3/31 with V28. V28 stated she would take pictures when she did the treatments so if the wound nurse came in, she would have updated pictures to review. When asked if she notified any physician of the deterioration to that pressure ulcer during the time frame of 3/9-3/31, V28 stated she assessed the area, took picture, and placed in on her report for day shift to see. V28 stated she didn't remember if there were any changes or any communication back to her related to the deterioration. On 5/26/26 at 10:44 AM, when asked if he was notified between 3/17 and 3/31/26 of any changes/deterioration to the pressure ulcer located on R6's right gluteus, V17 (Physician) stated he had reviewed R6's medical record and he didn't find any notifications from the facility. V17 stated someone may have said something to him in passing. V17 stated he couldn't say if he was notified of the deterioration but there was no documentation of notification. V17 stated V16 (Wound NP) should have been notified and he knew she had said she would follow up in a week and then didn't. V17 stated if she had been notified, they could have been more aggressive with the treatment. When asked if the outcome would have been different if the area had been treated sooner V17 stated, I can't say. When asked for any documentation to show the facility had reported the deterioration in R6's wound to V16 and/or V17 between 3/11/26 and 3/31/26, an email was provided to this surveyor dated 3/18/26 documenting a message from V16 (Wound Nurse Practitioner) of, Late follow up entry-Discussed treatment options with (V4 - Director of Nurses/DON) at (name of facility). Insurance does not pay for santyl, will apply Triad daily. There is no evidence in this email documenting V16 had been notified of R6's wound deteriorating. On 5/26/26 at 12:15 PM, V16 (Wound NP) stated she was notified on 3/9/26 R6 had a wound that had deteriorated. V16 stated the treatment R6 received from 2/7/26 until she saw her on 3/11/26 would have been a discharge order from the hospital and/or from her primary care physician (V17). V16 stated if she had been notified prior to 3/09/26 she could have placed orders and prevented it from getting as bad as it did. V16 stated on 3/18/26 she reviewed R6's chart including the wound module which documents assessments including pictures of the area and spoke with V4 (DON) about changing the treatment. V16 stated the insurance wouldn't cover the preferred treatment of santyl so they continued the original treatment order of Triad. V16 stated the next notification she received from the facility was on 3/31/26 that showed signs of infection and deteriorating. V16 stated she was going to the facility on 4/1/26 to do rounds and planned to see her then. When asked why she was talking about changing the treatment on 3/18/26, V16 stated she reached out to V4 after she (V16) did a chart review. V16 stated she was not notified of any change in R6's condition from 03/18/26 until 3/31/26. V16 stated if she had been notified, she would have made changes. V16 reviewed R6's record and stated she was looking at the assessment picture on 3/24/26. V16 stated she could see the drainage in the picture. V16 stated if she had been notified, she would have debrided the area and gotten a wound culture. When asked if she had debrided the area sooner if it could have been done at the office without a hospital stay, V16 stated, Probably, but it is hard to tell at times. V16 stated she saw R6 on 4/1/26 and scheduled an office visit for debridement on 4/2/26. V16 stated R6 was sent from her office to the hospital. V16 stated R6 had symptoms of sepsis and was hypotensive. V16 stated R6's hospital records document sepsis versus hemorrhagic shock. V16 stated they determined it was sepsis from the wound. On 05/25/26 at 10:56 PM, V23 (Licensed Practical Nurse/LPN) stated right after R6 returned from the hospital on 4/11/26 she took a picture of the pressure ulcer located on her right gluteus. V23 stated she only took the picture because the nurse working didn't have access to the application they use. When asked what she does if there is a change or concern with a pressure ulcer, V23 stated she would leave a note for V4 (DON) and write a note to the physician. V23 stated if it was urgent she would text the on-call service and they would get in touch with a physician. V23 stated they can also check notify MD (physician) on the progress note. V23 stated no one ever told her but she assumed the physician could see those notes. V23 stated she also prints all of the pertinent information and leaves it on the desk V17 (Physician) uses at the facility. When asked how she notifies V16 (Wound Nurse Practitioner), V23 stated she normally just messages V4 (DON) and sends all skin issues to V17 (Physician) also. R6's Skin Issue report dated 4/11/26 documents the pressure ulcer to right gluteus measures 9.18 x 8.67 x 0 cm's. R6's Order Summary Report dated 6/1/26 includes the following physician orders with a start date of 4/10/26 of, Wound Vac: Apply to right gluteus every day shift every Mon, Wed, Fri. Wound Vac: Check and change Wound Vac cannister when full every shift.Wound Vac: Check function every shift.Piperacillin Sod-Tazaobactam So Solution Reconstituted 4-0.5 GM (gram) Use 4.5 gram intravenously every 8 hours for infection for 22 days.Vancomycin HCI Oral Capsule 125 MG (milligrams).Give 1 capsule by mouth one time a day for infection for 20 days. V16's Progress Note dated 4/13/26 documents the same assessment of 4/1/26. R6's Wound Culture dated 4/13/26 documents a culture of the right buttock was taken on 4/1/26 due to a foul odor. The results document the following organisms grew in the culture, many (4 plus) proteus mirabilis, moderate enterococcus faecalis, and moderate serratia fonticola. The culture report documents Patient on appropriate antibiotics. R6's Skin Issues report dated 4/17/26 documents the Stage IV pressure ulcer measures 11.55 x 12.34 x 6 cm's. This report doesn't document an assessment of the area. R6's Skin Issues report dated 4/24/26 documents the Stage 4 pressure ulcer as improving and measures 7.07 x 5.38 x 4.5 cm's. R6's Skin Issues report dated 4/29/26 documents the Stage 4 pressure with no measurements or assessments. R6's Skin Issues report dated 5/1/26 documents the Stage 4 pressure ulcer as improving with measurements of 8.43 x 6.19 x 2 cm's. R6's Skin Issues report dated 5/5/26 documents the Stage 4 pressure with no measurements or assessments. V16's (Wound Nurse Practitioner) Nursing Home Visit Progress Note for R6 dated 5/6/26 documents, . Patient did undergo a debridement (name of local hospital) hospital. She subsequently develop (sic) some postoperative bleeding and hypotension therefore she was transferred to (name of regional hospital). She was seen by infectious disease which started her on some IV antibiotics. She completed Zosyn on 5/1. Wound Vac is in place. The nursing staff is changing it Monday Wednesday and Friday. Patient was seen sitting in the chair. She reports that she feels sick to her stomach. Denies any fever. She was getting ready to take a shower. Stage 4 pressure ulcer with slough present at bottom of the wound. She does have some maceration and opening surrounding the wound. This is likely from drainage in poor securement. R6's Order Summary Report dated 6/1/26 includes a physician order with a start date of 5/6/26 to, Cleanse wound with normal saline apply santyl into wound bed, cover with wound vac one time a day every Mon (Monday), Wed (Wednesday), Fri (Friday) for wound. R6's Skin Issues report dated 5/8/26 documents the Stage 4 pressure ulcer as stable and measures 7.18 x 5.65 x 3 cm's. R6's Skin Issues report dated 5/13/26 documents the Stage 4 pressure ulcer with no measurements or assessment. R6's Skin Issues report dated 5/15/26 documents the Stage 4 pressure ulcer as deteriorating with measurements of 6.69 x 8.28 x 5 cm's. On 05/18/2026 at 10:21 AM, R6 was laying in bed, covered with a blanket and denied concerns with care. There was a foul odor noted in R6's room. On 5/19/26 at 8:12 AM, this surveyor began observation of wound care with V4 (DON) present and V18 (LPN) administering care. V18 administered a treatment to R6's abdominal fold. When this surveyor inquired about the drain tubes noted on R6's back, V18 stated that was her wound vac. V18 stated that treatment was not scheduled for this date and observation would need to be done on the next day. The foul odor in the room seemed to dissipate after the abdominal fold was cleaned. On 5/20/26 at approximately 1:00pm this surveyor was told by V4 (DON) and V21 (Vice President of Clinical Services) the Nurse Practitioner (V16) had assessed R6 this morning and changed the dressing to the pressure ulcer on R6's right gluteus. V4 stated R6 was being sent to the hospital for admission for surgical debridement. This surveyor was unable to observe the wound prior to R6 leaving the facility. R6's Progress Notes dated 05/20/2026 documents the following: Seen by NP (V16) related to wound. Order given for resident to be a direct admit for surgical debridement and IV antibiotics. Wet to dry dressing completed at bedside by NP, POA (Power of Attorney) and resident aware. Res (resident) left via facility to (name of local hospital) direct admit, Report called to floor nurse. V16's history and physical note for R6 dated 5/21/26 documents, The patient is a 60 y.o. (year old) female with a past medical history.stage IV pressure ulcer who has been followed at (name of facility). Upon rounds yesterday, it was noted that the wound had significantly deteriorated, foul odor, Bedside debridement was done. Decision was made to admit the patient for possible surgical debridement and IV antibiotics. The patient was admitted .She was started on IVF (intravenous fluids) and IV (intravenous) antibiotics with Zosyn and vancomycin. Overnight, she went into SVT with HR (heart rates) sustained in the 150's. IV labetolol was attempted without success. Impression: 1. Sepsis- likely secondary to infected Stage IV pressure ulcer vs (versus) UTI (urinary tract infection). 2. Necrotic Stage IV pressure ulcer. 3. SVT - likely reactive secondary to sepsis. 4. Hypokalemia 5. Uncontrolled DM (diabetes mellitus) II (2) 6. Chronic indwelling catheter. On 5/25/26 at 11:04 PM, V24 (LPN) stated she remembered the pressure ulcer on R6's right gluteus deteriorated very fast. V24 stated it went from bad to horrible. V24 stated R6 didn't like to turn and reposition but she would encourage her to do so. When asked if she ever notified the physician of the pressure ulcer deteriorating, V24 stated the way they do it at the facility is different. V24 stated, When we submit something to the physician it feels like it hangs in the balance. When asked what that meant, V24 stated they put the information on V17's desk at the facility. When asked how she would notify the physician of a wound deteriorating, V24 stated, We would put it on his desk. V24 stated she thought V17, or his nurse practitioner came in every weekday. When asked if there was any documentation when the physician was notified, V24 stated if it isn't charted on the progress notes, the medication administration record, or treatment administration record then essentially it wasn't done. V24 stated, Do I think there wasn't anything done, I think there was but not fast enough obviously. On 5/26/26 at 3:00 PM, V4 (DON) stated R6 returned to the facility from a hospital stay on 2/16/26 with an abrasion to the right gluteus. V4 stated the area was treated with xeroform until V17 (Physician) changed the order on 2/24/26 and referred R6 to the wound specialist. V4 stated V16 (Wound Nurse Practitioner) was notified the pressure ulcer was deteriorating on 3/9/26, V16 assessed R6 on 3/11/26 and gave an order for triad. This surveyor reviewed R6's Skin Issue reports with V4 and asked if there was any physician notification when the pressure ulcer is documented as deteriorating from 3/17/26 to 3/31/26. V4 stated on 3/18/26, V16 (Wound NP) asked me if insurance covered a new treatment she wanted to order. V4 stated the insurance did not cover it so they continued the same treatment. V4 stated V16 was supposed to assess R6 on 3/25/26 but couldn't because her children were sick. When asked if any physician was notified of the deterioration of the pressure ulcer, V4 stated, I would not say so. V4 stated the physician should have been notified. When asked if any physician was notified of the deterioration of the pressure ulcer from 5/15/26 to 5/20/26, V4 stated, Not that I see. When asked if she would expect a physician to be notified, V4 stated, Oh yeah, definitely. When asked if she had any concerns with wound care at the facility, V4 stated she didn't. V4 stated they are normally good about notifying the physician if a wound/pressure deteriorates. On 5/26/26 at 12:15 PM, when asked if she was notified of a deterioration in the pressure ulcer from 5/15/26 to 5/20/26, V16 (Wound Nurse Practitioner) stated she completed a chart review on 5/14/26 but wasn't notified of any deterioration from 5/15 to 5/20/26. V16 stated when she assessed R6 on 5/20/26, she noted a foul odor in the wound, R6 appeared sick, and was tachycardic. V16 stated the pressure ulcer needed debrided and with R6's history she had her admitted to the local hospital for surgical debridement in the operating room. V16 stated when they did the debridement the bone was exposed. This surveyor asked if R6 had osteomyelitis and V16 stated she was surprised that she didn't, but all the tests were negative. When asked if she had any concerns with wound care at the facility, V16 stated she thought they did a great job with wound care, but they needed protocols in place on when to get the wound specialist involved. On 5/26/26 at 10:44 AM, V17 (Physician) stated he thought wound care specialists were seeing R6 from 5/15/26 to 5/20/26. V17 stated he remembered talking with the facility earlier in May and they were worried about the area but V16 (Wound Nurse Practitioner) was following the pressure ulcer and had made treatment order changes. V17 stated he didn't have any documentation or remember being notified of a deterioration from 5/15 to 5/20/26. 2. R6's Wound Ostomy Eval and Treat note with a service date of 4/5/26 documents, Left posterior heel: area of callous-like skin with circumferential blanchable erythema. Unknown etiology but cannot r/o (rule out) pressure component. Recommendations: Left heel- 1. Cleanse wound with soap and water daily. Use remedy cleanser in green and white bottle. No Hibiclens. 2. Cover with a 4x4 foam bordered (mepilex) dressing. Date and time dressing. 3. Remove dressing daily to cleanse and assess wound then reapply. 4. Dressing should be changed when drainage is visible to the edges of the foam pad. It may be used for up to 7 days. 5. Notify physician. for no improvements or concerns. R6's Skin Issues report dated 4/11/26 does not document an area to R6's left heel. R6's Order Summary Report dated 6/1/26 does not document treatment orders or preventative measures for the area to R6's left heel. R6's Skin Monitoring: CNA (Certified Nurse Assistants) Shower Review sheets dated 5/1, 5/4, 5/6, 5/8, and 5/15/26 do not document an area on R6's left heel. On 5/19/26 at 8:12 AM, V18 (LPN) administered treatment to R6's abdominal fold with V4 (DON) present. After the treatment was completed per current standards of practice, this surveyor asked R6 if she had any other pressure ulcers/sores. R6 stated she did on her heels. This surveyor observed both feet lying flat on the bed. When asked if they did treatments on her heels, R6 stated they were usually propped up on pillows. When asked why they weren't propped up now R6 responded that she wasn't sure. When asked how long they had been flat on the bed, R6 stated, since last night. This surveyor, with the assistance of V18, observed both of R6's heels. The right heel was pink/red with no open areas or sores. The left heel had a dark red/black area that was closed and soft to touch (per V18/LPN). When asked if they were aware of the area prior to this observation, V18 and V4 both stated they were not. R6's Progress Notes document the following:5/19/26 at 2:00 PM, Resident stated t

Based on observation, interview, and record review the facility failed to promote dignity for 4 of 7 (R9, R29, R50, and R54) residents reviewed for resident rights in the sample of 40. Findings Include: 1. R9's admission Record with a print date of 5/21/26 documents R9 was admitted to the facility on [DATE] with diagnoses that include dysphagia, depression, cognitive communication deficit, and diabetes. R9's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 03, indicating a severe cognitive deficit. R9's current Care Plan documents a Focus area of, Nutritional Risk r/t (related to) dx (diagnosis) DM (diabetes mellitus) type 2, depression. Below IBWR (ideal body weight range) with recent wt (weight) gain. Varied intake leaves 25% or more uneaten. 4/10/26 change from reg (regular) cons (consistency) to mech (mechanical) soft. Date Initiated: 09/16/2025. This Focus area includes the interventions of: serve diet as ordered and encourage oral intake. 2. R29's admission Record with a print date of 5/22/26 documents R29 was admitted to the facility on [DATE] with diagnoses that include dementia, anxiety, and need for assistance with personal care. R29's MDS dated [DATE] documents a severe cognitive impairment. R29's current Care Plan documents a Focus area of, I am demonstrating poor appetite and fluid intake Date Initiated 07/03/2025. This Focus area includes interventions of administer supplements as ordered, and assist with intake as needed. 3. R50's admission Record with a print date of 5/22/26 documents R50 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease, dysphagia, and adult failure to thrive. R50's MDS dated [DATE] documents a BIMS score of 00, indicating a severe cognitive deficit. R50's current Care Plan documents a Focus area of Nutritional Risk- Alzheimer's, severe dementia with agitation, anxiety, failure to thrive .Date Initiated: 04/15/2025. This Focus area includes intervention of review and monitor weights as ordered. 4. R54's admission Record with a print date of 5/22/26 documents R54 was admitted to the facility on [DATE] with diagnoses that include dysphagia, diabetes, and heart disease. R54's MDS dated [DATE] documents a severe cognitive deficit. R54's current Care Plan documents a Focus area of, I have dementia and require assistance with various aspects of my life with ADLs (Activities of Daily Living), medical needs, personal preferences, mobility, and some communication challenges .Date Initiated: 07/15/2025. This Focus area includes interventions of assess with daily activities and respect individual dignity and autonomy. On 5/18/26 at 12:09 PM, the noon meal of country fried steak, corn, noodles, mashed potatoes, gravy, and mandarin oranges was served to the residents in the dining room. R9, R29, R39, R54, and R90 were sitting at one table. R90 was served her meal at 12:09 PM. R9 was served her meal at 12:14 PM, R39 was served their meal at 12:16 PM, R54 was served their meal at 12:17 PM. At 12:29 PM, an unknown staff member asked where R29's meal was at. R29's meal was served at 12:31 PM. On 5/19/26 the noon meal of ravioli, breadstick, carrots, salad, and cake was served. R9, R28, R50, and R54 were sitting at the same table. R28 was served his meal at 12:06 PM. At 12:15 PM R9 asked, Am I gonna get my food. At 12:21 PM, R9 asked, Where's my food. At 12:33 PM, R50 was served his meal, and at 12:40 PM R54 was served his meal. R9's meal was not served until 12:43 PM. On 5/20/26 at 10:44 AM, V29 (Activities Director) stated the tables observed on 5/18 and 5/19/26 are where the residents who require assistance with eating sit. V29 stated the Certified Nursing Assistants pass the hall trays and then go to the dining room to assist the residents. V29 stated they try to put the meal tickets in order so all of the residents at a table get served at the same time. V29 stated they try to serve everyone at the same time and it usually works that way. V29 stated she wasn't sure what happened on 5/18 and 5/19/26. V29 stated everyone sitting at a table should get their meal close to the same time. V29 stated they don't want a resident sitting and watching another resident eat. The facility policy titled The Dining Experience: Staff Roles dated 2016 documents, Staff will strive to enhance the resident's quality of life while serving meals that meet nutritional needs, offers choice, is served with dignity and considers the person-centered care plan. Staff will offer personal attention to each resident and monitor the resident and monitor the resident's satisfaction and food intake .The staff will promote resident independence and dignity in the dining room.

Based on interview, observation, and record review the facility failed to follow the menu and serve the complete serving size of altered diet textures for 5 (R9, R18, R34, R64, R87) of 5 residents reviewed serving sizes in a sample size of 40. Findings include: The diet spreadsheet dated day 9 lunch documents: pureed country fried steak # 6 scoop (5.33 ounces), thick cream gravy 2 ounces, mashed potatoes with thick gravy #8 scoop, pureed seasoned pasta #8, pureed buttered soft bread #16, and pureed mandarin oranges #10. The diet spreadsheet dated day 9 lunch dental soft (mechanical soft) documents: ground country fried steak with cream gravy #8 scoop (4 ounces), mashed potatoes with gravy #8 scoop, seasoned pasta #8 scoop, buttered soft bread 1 slice, and Mandarin oranges #8 scoop. The diet spreadsheet dated day 12 lunch documents: pureed panko mustard chicken #6 scoop, pureed scalloped potatoes #8 scoop, pureed pickled beets #12 scoop, pureed buttered bread #16 scoop and pureed peach parfait #8 scoop. The diet spreadsheet dated day 12 lunch dental soft (mechanical soft) documents: ground panko mustard chicken with gravy #8 scoop, scalloped potatoes #8 scoop, chopped pickled beets 4 ounces, soft buttered bread 1 slice, and chopped peach parfait 1 each. 1.R34's admission Record documents an admission date of 03/09/26 with diagnoses including: bronchopneumonia, Alzheimer's disease, peripheral vascular disease, and severe protein calorie malnutrition. R34's Order Summary Report documents a dietary order for regular diet, pureed texture, regular liquid consistency, fortified pudding at lunch/supper, whole milk with meals, ice cream at lunch and supper with a start date of 03/10/26 and an order status of active. On 05/18/26 at approximately 12:20 PM, R34 received approximately 0.5 of a #8 (4 ounces) scoop of the pureed country fried steak. On 05/21/26 at approximately 12:22 PM, R34 received approximately 0.66 of a #6 (5.33 ounce) scoop of pureed panko mustard chicken. 2.R64's admission Record documents an admission date of 03/14/24 with diagnoses including: gastro-esophageal reflux disease, history of transient ischemic attack and cerebral infarction. R64's Order Summary Report documents a dietary order for regular diet with pureed texture with regular liquid consistency with a start date of 08/20/25 with an order status of active. On 05/18/26 at approximately 12:17 PM, R64 received approximately 0.5 of a #8 (4 ounces) scoop of the pureed country fried steak and approximately 0.5 of a #8 scoop of mashed potatoes. On 05/21/26 at approximately 12:11 PM, R64 received approximately 0.66 of a #6 (5.33 ounce) scoop of pureed panko mustard chicken and approximately 0.66 of a #8 scoop of pureed scalloped potatoes. 3.R87's admission Record documents an admission date of 07/16/24 with diagnoses including: hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side, aphasia, dementia, abnormal weight loss, and dysphagia. R87's Order Summary Report documents a dietary order for regular diet with pureed texture with regular liquid consistency, 2x protein at breakfast, and whole milk in place of menu milk with a start date of 03/12/26 with an order status of active. On 05/18/26 at approximately 12:15 PM, R87 received approximately 0.5 of a #8 (4 ounces) scoop of the pureed country fried steak and approximately 0.5 of a #8 scoop of mashed potatoes. On 05/21/26 at approximately 12:08 PM, R87 received approximately 0.66 of a #6 (5.33 ounce) scoop of pureed panko mustard chicken and approximately 0.66 of a #8 scoop of pureed scalloped potatoes. 4.R9's admission Record documents an admission date of 09/11/25 with diagnoses including: dysphagia, iron deficiency, gastro-esophageal reflux disease, type 2 diabetes mellitus, and chronic obstructive pulmonary disease. R9's Order Summary Report documents a regular diet with mechanical soft texture, regular liquid consistency, 2x protein at breakfast/lunch, whole milk with meals, super cereal with breakfast, fortified pudding with lunch/dinner, ice cream with lunch/dinner and extra butter to hot vegetables and extra gravy/sauces with a start date of 04/29/26 and an order status of active. On 05/18/26 at approximately 12:15 PM, R9 received approximately 0.5 of a #8 (4 ounces) scoop of the ground country fried steak and approximately 0.5 of a #8 scoop of mashed potatoes. On 05/21/26 at approximately 12:08 PM, R9 received approximately 0.66 of a #8 scoop of ground panko mustard chicken and approximately 0.66 of a #8 scoop of scalloped potatoes. 5.R18's admission Record documents an admission date of 12/01/23 with diagnoses including: Alzheimer's disease, dysphagia, dementia, iron deficiency, and edema. R18's Order Summary Report documents a dietary order of regular diet with mechanical soft texture with regular liquid consistency with an order date of 11/26/25 and an order status of active. On 05/18/26 at approximately 12:17 PM, R18 received approximately 0.5 of a #8 scoop of the ground country fried steak and approximately 0.5 of a #8 scoop of mashed potatoes. On 05/21/26 at approximately 12:10 PM, R18 received approximately 0.66 of a #8 scoop of ground panko mustard chicken and approximately 0.66 of a #8 scoop of scalloped potatoes. On 05/21/26 at 3:10 PM, V1 (Administrator) stated the menu should be followed, therefore, full scoops of the mechanically altered diets should be served. The facility policy titled, Menu Planning and Requirements documents: Menus are planned to provide nourishing, palatable, attractive meals that meet the nutritional needs of residents served, (based on age, size, gender, physical activity and state of health), in accordance with the Dietary Reference intakes/Recommended Dietary Allowances as issued by the Food and Nutrition Board of the National Research Council, of the national Academy of Sciences, unless otherwise contraindicated by medical conditions and needs. 1. The use of standard, acceptable menu planning tools are employed to create menus. Such tools include the 2010 Dietary Guidelines for Americans publication/recommendations and the USDA's choose my plate tool.

Based on interview, observation, and record review the facility failed to provide a resident access to personal property for 1 of 1 resident (R80) reviewed for resident rights in a sample of 40.Findings Include:R80's admission Record documents an admission date of 6/27/2025 with diagnoses of type 2 diabetes mellitus, muscle weakness, dysphagia and venous insufficiency among other. R80's MDS (Minimum Data Set) dated 3/13/26, documents a BIMS (Brief Interview for Mental Status) score of 15 out of 15 total which indicates R80 is cognitively intact. This same MDS documents R80 has impairment to bilateral legs, uses a wheelchair for locomotion, is dependent on staff for toileting and needs substantial/maximum assistance with showers and dressing.On 5/18/2026 at approximately 9:15am, R80 said about a week ago, he was moved to this new room on a different hall because he and his roommate got into a fight. R80 said the facility did not move his belongings when they moved him and it has been over a week since he had access to his belongings. R80 said he was very mad at the facility for not moving his belongings yet. R80 said he's been asking for the staff to bring his belongings to his new room every day since moving, but they had not done it yet. R80's Progress Note in the medical record dated 5/11/2026 at 15:28 (3:28pm), documented R80 and his roommate had an altercation and R80 was temporarily moved to a new room.On 5/19/2026 at 10:30am, V5 (Housekeeper) was cleaning rooms on the hall where R80 previously resided. V5 said R80 moved to a different hall about a week ago. V5 entered R80's old room on the previous hall and verified R80 did not have his personal belongings yet as the belongings were still in the old room. V5 said she would move the belongings after while when she could get to it.On 5/19/2026 at 11:30am, V6 (Housekeeper) said on 5/11/26, R80 was moved to a different hall. V6 said the housekeeping staff are responsible for moving resident belongings when they move rooms and should have moved R80's belongings the same day he was moved. V6 said that is how things are usually done.On 5/19/2026 at 11:30am, R80's personal belongings were observed to still be in R80's old room and had not been moved to R80's new room on a different hall.On 5/19/2026 at 11:46am, V3 (Corporate Administrator) was asked what he felt was a reasonable time for a resident to wait before their personal belongings were moved due to a room change and V3 answered, 8 days.On 5/19/2026 at 12:24pm, V7 (Housekeeper) said when a resident moves from one room to another room, their belongings are moved immediately to the new room by housekeeping staff. On 5/20/2026 at 3:00pm, R80 was observed with his personal belongings in his new room. The facility's admission contract under the section titled Residents' Rights documents the following in part: As a long-term care resident in Illinois, you are guaranteed certain rights, protections and privileges according to state and federal laws. Your personal property rights, you have the right to keep and wear your own clothing, you may keep and use your own property, you have the right to expect your facility to have a safe place where you can keep small valuables which you can get too daily.

Based on interview, observation, and record review, the facility failed to implement care plan fall interventions for 1 of 6 residents (R81) reviewed for accidents in the sample of 40. Findings Include: R81's admission Record documents an admission date of 12/1/23 with diagnoses including dementia, Alzheimer's disease, repeated falls, insomnia, and polyneuropathy. R81's Minimum Data Set (MDS) dated [DATE] documents R81 has a Brief Interview for Mental Status (BIMS) score of 99 indicating resident was unable to answer questions due to her poor cognition which puts her at risk for poor self-safety awareness. The same MDS documents R81 requires assistance of a walker for ambulation, requires supervision and/or touch assist for transfers from bed to chair, sitting to standing and transition from lying to sitting on side of bed, and R81 has a history of falls. R81's Fall Risk assessment dated [DATE] documents a fall risk score of 14 indicating R81 continues to be at risk for falls. R81's Care Plan documents a focus area for increased risk of falls. Interventions for this focus area includes an assist bar added to left side of bed to assist with balance before standing dated 11/14/25. On 5/20/26 at 9:41 AM, R81's bed was observed, with V9 (Memory Care Director) present, to have no assist bar on either side of R81's bed. V9 (Memory Care Director) verified there was no assist bar on either side of R81's bed. This surveyor and V9 verified R81's most recent care plan in her electronic health record an assist bar to the left side of R81's bed is listed as a fall intervention. V9 agreed R81 should have the assist bar on her bed if it is a fall intervention. V9 denied the lack of an assist bar increased R81's risk of falls because she is strong and has good mobility. However, V9 did agree if the assist bar is ordered as a fall intervention, then it should be in place on R81's bed. On 05/21/2026 at 8:20 AM, an assist bar was observed attached to R81's bed frame. On 5/21/26 at 8:23 AM, V14 (Registered Nurse) stated she does remember seeing R81's assist bar on side of her bed in the past but can't remember the last time she saw it. V14 stated she would expect the assist bar to be on the bed if ordered or implemented as a fall precaution. V14 stated one of the possible risks if an assist bar isn't on the bed frame would be an increased risk of falls/injuries. On 5/21/26 at 12:54 PM, V1 (Administrator) stated he is familiar with R81, but he is not familiar with her fall precautions without looking them up. V1 stated he would expect the fall precaution of an assist bar to be implemented if recommended by the interdisciplinary team or ordered by the physician. V1 stated if it is not implemented or removed it could increase R81's risk for falls or injuries from falls. The facility's fall policy with a revision date of March 2018 documents, Staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The same document includes staff will identify and implement relevant interventions to try to minimize serious consequences of falling.

Based on interview, observation, and record review, the facility failed to maintain equipment that was present on the crash cart and available for use for 1 of 3 residents (R1) reviewed for emergency events in a sample of 36. This failure has the potential to effect 32 residents (R4-R36) residing in the facility with active orders to attempt resuscitation/CPR (Cardiopulmonary Resuscitation). The findings include:R1's admission Record documents an admission date of [DATE] and includes diagnoses of Acute and Chronic Respiratory Failure with Hypercapnia and Hypoxia, Nonrheumatic Tricuspid Insufficiency, Obstructive Sleep Apnea, Atelectasis, Oxygen Dependent, Pulmonary Hypertension, Peripheral Vascular Disease, and Chronic Kidney Disease. R1'S MDS Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 is cognitively intact. Section GG documents R1 is dependent on staff for hygiene, bathing, and dressing. Transfers were not attempted due to medical condition. R1's Practitioner Order Form Life-Sustaining Treatment (POLST) form documents R1's signature dated [DATE] and documents V14's (Physician) signature on [DATE]. In Section A, a checkmark is documented for Yes CPR (Cardiopulmonary Resuscitation): attempt CPR, utilize all indicated modalities per standard medical protocol. In Section B, a check mark is documented for Full Treatment: goal is to attempt to prevent cardiac arrest by using all indicated treatments. Utilize intubation, mechanical ventilation, cardioversion, and all other treatments as indicated.R1's Progress Notes authored by V9 (Licensed Practical Nurse) dated [DATE] at 5:05PM documents (name) PT (Physical Therapist) came to get this nurse at 4:30pm r/t (related to) res (resident) being unresponsive, upon entering room this nurse observed resident not breathing, no pulse found. CPR initiated at 4:34pm, 911 called at that time. Paramedic came at 4:40PM, he called ER (Emergency Room) Medical Director, given at 4:47 to stop CPR, resident pronounced dead at 4:47pm. This nurse called responsible party, notified of death. Coroner notified of death, arriving at 5:00 and will discuss arrangements with family.On [DATE] at 1:30PM, V9 (Licensed Practical Nurse/LPN) stated that on [DATE] she was notified by a physical therapist that R1 was nonresponsive. V9 stated she went directly to R1's room and started CPR. V9 stated she was assisted by V11 (LPN) and V11 went and retrieved the crash cart. V9 stated when V11 was preparing to hookup the AED (Automated External Defibrillator) there were no pads in the crash cart and the battery was showing low battery. V9 stated they continued chest compressions until EMS (Emergency Medical Services) arrived. V9 stated she has worked at this facility for the last 6 years. V9 stated she was not sure who checked the crash cart, but she had never checked it. V9 stated she was aware that there was an AED machine on the cart, and she has had training to use the AED machine. On [DATE] at 6:52PM, V11 stated she has worked at the facility for 2 years. V11 stated there has always been an AED machine on the crash cart but she has never had to attempt to use it before [DATE] when R1 was found unresponsive. V11 stated she was summoned to the room immediately when R1 was found unresponsive. V11 stated she ran and got the crash cart while V9 was starting compressions. V11 stated when she returned to the room with the crash cart, she unlocked it and grabbed the Ambu bag (bag valve mask) and gave it to one of the other staff members in the room and she grabbed the AED machine. V11 stated she started searching for pads and could not find any pads anywhere on the cart, V11 stated she opened the AED machine, and it automatically turns on, the AED started saying low battery, low battery. V11 stated she finally closed the door on the AED because she could not do anything without the pads and the machine was still saying low battery. V11 stated EMS arrived and time of death was called at 4:47PM. V11 stated she has had training on AED's through her CPR class. V11 stated she was taught in CPR training that if you have an AED available to use it and that is what she tried to do. V11 stated she notified V2 (Director of Nursing/DON) immediately and told her there were no pads and it was saying low battery. V11 stated another nurse, V12 (Registered Nurse/RN), told her she had used the last set of pads on a code on [DATE] and had reported it to V6 (Assistant Director of Nursing/ADON) that there were no more pads. V11 stated she felt like she wasted time looking for pads and trying to get R1 hooked to the AED.On [DATE] at 10:04AM, V6 stated there is only one crash cart for the whole facility. V6 stated she is in charge of checking the crash cart monthly. V6 stated they did have an AED (Automated External Defibrillator) on the crash cart, but it has been removed recently as of Monday [DATE]. V6 stated the last time the AED was used, it did work she thinks but the battery was low. V6 stated V1 (Administrator) is in charge of ordering new pads for the AED. V6 stated the AED is in the administrator's office at this time until they get a new battery. V6 was asked if there is a check list of the items checked on the crash cart and V6 provided a document titled Crash Cart Checklist. The list did not include a check for an AED machine. The last documented check was on [DATE]. V3 stated the cart must be checked monthly. V6 stated she was not aware of the AED not being used while the AED was present on the cart. V6 stated all the staff get training about every 6 months on CPR and includes the use of an AED. On [DATE] at 1:07PM, V6 stated when she checked the crash cart monthly, she stated she would turn on the AED machine every time. V6 stated battery low would display every time for the last 4 months (since [DATE]). V6 stated we talked to (V13 Facility Owner) and he stated we didn't need one (battery) but he did just finally approve the purchase of a battery I believe. V6 said the pads to the AED were used on the last code on [DATE] and she believes pads have been ordered. V6 stated she also would check for pads when she checked the AED, and she said there were always 2 sets of pads on the cart. V6 stated the pads were used when they had codes in between the monthly checks evidently so there were no pads when the last resident coded on [DATE]. V6 stated the nursing staff have all been CPR trained and this includes the use of an AED.On [DATE] at 11:24AM, V1 (Administrator) was asked if he receives work orders from maintenance or whoever orders supplies for equipment. V1 stated he does receive request for supplies that need to be ordered. V1 was asked if he was notified that the battery was low on the AED machine, V1 stated yes, he has known for a while and has sent up request and it is a process we have to go through to get approvals for items that need to be ordered. V1 stated I believe we have permission now. V1 was asked if the battery and the pads have been ordered yet and he stated no, not yet. V1 stated the AED machine has been pulled from the crash cart and is in his office until the battery and pads have been ordered and received and at that time the AED machine will be returned to the crash cart.On [DATE] at 12:08PM, V8 (Regional Director of Operations) stated he was unaware that there was an AED in the facility, and it must have been in the facility when the company bought the facility. V8 stated it is not a regulation to have an AED until 2030 and he doesn't see the problem. V8 was informed that the AED had been present on the crash cart but not checked or maintained.On [DATE] at 12:34PM, V2 (Director of Nursing) stated she was aware that there was an AED on the crash cart. V2 stated V6 checks the crash cart monthly and includes AED checks. V2 stated they had known the battery was low for a while but thought that it still functioned even though it said low battery. V2 stated the AED was used on another resident in December but showed a non-shockable rhythm. V2 stated I guess that is when the last set of pads were used because when they had another resident to code on [DATE], there were no adult pads available, and the battery was low. V2 stated the nurses are expected to use the AED machine when it is available. V2 stated the battery has been low for a couple of months and that is as far back as she knows because she has only worked here a couple of months. V2 stated she does not have documentation to prove the AED was checked monthly as it is not on the crash cart checklist. V2 stated the supplies are ordered by Medical Records/supplies personnel.On [DATE] at 9:12AM spoke with V6 in regard to checking of the AED. V6 stated she checked it monthly, and she would open it up and make sure it came on and then closed it. V6 stated she does not remember any lights on the machine she just remembers that it would voice prompt low battery. V6 stated she would then close it back down. On [DATE] at 10:15AM, V13 (Facility Owner) stated he was aware that the battery was low on the AED machine. V13 stated the AED was still functioning even with a low battery. V13 stated they (nurses) didn't need to use the AED on R1 the last code. When V13 was asked to clarify, V13 replied she was dead and they started CPR, they continued CPR until the EMS arrived and they then called the code. V13 stated you know when someone is really dead, and you still have to do CPR. V13 stated as soon as the facility was made aware that they were out of pads, the pads were ordered for the AED machine. V13 was asked if he expected the staff to keep documentation of the checks on the AED machine and V13 stated I refuse to answer that question. On [DATE] at 12:25PM, the AED machine was observed with V1 present. The AED Machine was opened up and automatically was flashing red lights and had an activated voice prompt of Low Battery, Low Battery repeatedly for 35 seconds. On [DATE] at 3:00PM, V15 (Regional Community Liaison) provided the invoices for the AED battery and pads. The invoice documents that Adult Pads were ordered on [DATE], with order confirmation date of [DATE]. The invoice for the AED battery documents the order was placed on [DATE].On [DATE] at 2:14PM, V17 (Sales Representative) with the medical supply company that the order for the AED pads were placed, confirmed the order number documented on the invoice provided by V15 and stated that the order date was [DATE] and not [DATE] as documented on the invoice provided by V15. V17 provided the invoice with the documented order date of [DATE].On [DATE] at 1:50PM, V16 (Sales Representative) with the medical supply company that the AED battery was placed, confirmed the order number of the invoice provided by V15 and stated that the order was placed late on [DATE] and that there were no other orders placed by this the facility for an AED battery before [DATE]. V16 stated their invoice documents and order date of [DATE] because order was placed late in the evening, so date fell to the next business day. V16 provided this invoice with the order date of [DATE].The Owners Manual for the AED documents under the section titles Schedule Maintenance documents daily maintenance: Check the Status Indicator to ensure that it is green. When the light is Green, the AED is ready for rescue. If the indicator is RED, refer to troubleshooting table on page 5-3. Indicator troubleshooting table documents for battery: the last battery indicator (LED) is red and flashing. Solution: The battery is low. Replace with a new battery. Monthly maintenance: Open the AED lid, wait for the AED to indicate status. Observe the change of the status indicator or RED. After 5 seconds, verify that the Status Indicator returns to GREEN. Check that the battery has adequate charge. If the battery indicator is red, replace the battery.The facility policy titled Policy for Emergency Cart (E-Cart) with a revision date of [DATE] documents Purpose: To organize and maintain the emergency cart (E-Cart) to ensure adequate needed equipment for CPR procedures. Under the section titled Policy documents The E-Cart will be inventoried and restocked after each use and checked at least monthly and documented.The facility policy titled Emergency Procedure-Cardiopulmonary Resuscitation with a revision date of February 2018 documents under Preparation for Cardiopulmonary Resuscitation 2. Maintain equipment and supplies necessary for CPR/BLS (Basic Life Support) in the facility at all times.An Order Listing Report dated [DATE] documents active orders for life sustaining treatment or all residents residing in the facility. There are 32 residents (R4-R36) on this report with active orders to attempt resuscitation/CPR.

Based on interview and record review, the facility failed to timely transmit Minimum Data Set (MDS) Assessments for 2 (R20 & R25) of 2 residents reviewed for timely MDS submission in the sample of 45. The findings include: 1. R20's Face Sheet documented an admitted [DATE] and included diagnoses of Chronic Obstructive Pulmonary Disease, Anxiety, and Depression. This same document listed a discharge date of [DATE]. R20's last transmitted MDS was an admission assessment and was completed on 11/27/24. 2. R25's Face Sheet documented an admitted [DATE] and included diagnoses of repeated falls, anemia, type 2 diabetes, and muscle weakness. This same document listed a discharge date of [DATE]. R20's last transmitted MDS was an admission assessment and was completed on 11/5/24. On 4/23/25 at 11:00 AM, V4 (MDS Coordinator) stated that she just took over this job in March of 2025 and recognizes that R20 and R25's assessments are showing up as overdue quarterly assessments, however a discharge assessment should have been completed and transmitted with a due date of 12/5/24 for R20, and a discharge assessment should have been completed and transmitted with a due date of 11/26/25 for R25. On 4/24/25 at 11:30 AM, V4 stated that she had completed and transmitted the discharge MDS's for R20 and R25. Review of the final validation report documents that R20's discharge assessment target date was 12/05/2024, but was not transmitted as complete until 4/24/25 and documents a message that the completion date is more than 14 days after the assessment reference target date. This same report documents that R25's discharge assessment target date was 11/26/24, but was not transmitted as complete until 4/24/25 and documents the same message that the completion date is more than 14 days after the assessment reference target date.

Based on interview and record review, the facility failed to ensure residents received the correct medications in accordance with their physician's orders for 2 (R83, R92) of 7 residents reviewed for significant medication errors in the sample of 45. This past noncompliance occurred between 3/17/2024 and 4/1/2025. Findings include: 1. R83's Admission Record documented an admitted [DATE] and included diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance mood, anxiety disorder, unspecified, and unspecified atrial fibrillation. R83's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 5, which indicates severe cognitive impairment. R83's Physician Order Summary documented divalproex (seizure and/or mood stabilization treatment) oral tablet delayed release 500mg (milligrams) -1 tablet by mouth twice a day, acetaminophen (pain reliever) oral tablet 500mg-give 2 tablets by mouth two times a day and apixaban (blood thinner) 5mg tablet-take 1 tablet by mouth twice a day. R83's Progress Note dated 3/17/2025 by V3 (Registered Nurse/RN) documented that she was passing medications and took R83 and R92 back to their shared room. V3 documented that she heard a conflict up the hall that made her accidentally mix up the unlabeled medication cups. V3 documented R83 was given R92's medications including donepezil (dementia treatment) 5mg. 2. R92's Admission Record documented an admitted [DATE] and included diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance mood, altered mental status and muscle weakness. R92's MDS dated [DATE] documented a BIMS score of 3, which indicates severe cognitive impairment. R92's Physician Order Summary documented donepezil hydrochloride (dementia treatment) 5mg-1 tablet by mouth at bedtime and memantine (dementia treatment) 10mg tablet, take 1 tablet by mouth twice a day. R92's Progress Note dated 3/17/2025 by V3 (RN) documented that she was passing medications and took R92 and R83 back to their shared room. V3 documented that she heard a conflict up the hall and accidentally swapped the medication cups. V3 documented R92 was given R83's medications including acetaminophen 1000mg, valproate 500mg and apixaban 5mg. On 04/24/25 at 10:00 AM, V1 (Administrator) stated, he had been notified by V3 (RN) that she administered the wrong medications to R83 and R92. V1 stated, he advised V3 to contact V2 (Director of Nursing/DON) and then he immediately started working on the plan of correction that included education and observation of medication administration by nursing staff. On 04/24/25 at 10:36 AM, V2 (DON) stated, she was notified via phone by V3 (RN) that she had given R83 and R92 the wrong medications. V2 stated V5 (Physician) was contacted, vitals were obtained on R83 and R92 with monitoring scheduled for every 2 hours for the next 24 hours. V2 stated V1 immediately started a plan of correction that included education and auditing of the nursing staff being observed during medication administration on 10 residents. The facility policy Adverse Consequences and Medications Error (revised April 2014) documented under Policy The interdisciplinary team evaluates medication usage in order to prevent and detect adverse consequences and mediation-related problems such as adverse drug reactions (ADRs) and side effects. Adverse consequences shall be reported to the Attending Physician and Pharmacist, and to federal agencies as appropriate. Under Policy, 5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professionals' standards and principles of the professional(s) providing services. Prior to the survey date, the facility took the following actions to correct the non-compliance: 1. Incident Investigation of 2 residents on one wing had received the wrong medication during the bedtime medication pass. 2. Per review of the Interdisciplinary team, it is felt that there is potential for other residents. 3. Staff member had been offered education regarding 5 rights of medication administration. Completed by 4/1/2025. Mediation Administration rate at 0% during survey. 4. All nursing staff to be educated regarding 5 rights of medication administration. Completed by 4/1/2025, Medication Administration rate at 0% during survey. 5. The Administrator/Director of Nursing and/or designee will observe return demonstration of medication on each nurse with 10 residents med passes being observed. V2 completed audits by 4/1/2025 with V1 and V2 in attendance. 6. QAPI (Quality Assurance Performance Improvement) meeting held - any issue identified will be immediately corrected and re-education will be offered and reviewed during QAPI meeting. This was also completed by 4/1/25.

Based on interview and record review, the facility failed to transfer a resident safely for 1 (R1) of 3 residents reviewed for accidents in the sample of 6. This past non-compliance occurred between 12/01/2024 to 12/13/2024. The findings include: R1's Admission Record documents R1 was admitted to the facility on [DATE] and includes diagnoses of cerebral aneurysm, non-ruptured, contracture of muscle, multiple sites, adult failure to thrive, altered mental status, delusional disorder, generalized anxiety disorder, and Paroxysmal Atrial Fibrillation. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 01, indicating R1 has severe cognitive impairment. The same MDS documents that R1 has impairment on both upper and lower extremities, is dependent for showers, bed to chair transfers, and getting in and out of shower. R1's Care Plan documents that R1 has an ADL (Activities of Daily Living) self-care performance deficit. Documented interventions include that R1 requires extensive assist with bathing/dressing/hygiene and R1 requires two assist with full body mechanical lift for all transfers. R1's Kardex documents for Toilet Use: R1 requires two assist with full body mechanical lift for all transfers and R1 requires two assist with full body lift for all transfers or two assists with transfers. R1's Physician's Orders dated as of 11/1/2024 document an order for Eliquis tablet 2.5mg (milligrams) two times a day for AFib (Atrial Fibrillation). R1's Progress Note dated 12/2/24 at 12:51 PM by V12 (Licensed Practical Nurse) documents (R1) noted to have a large bruise to right forearm. (R1) reported that staff transferred her to shower without using hoyer (mechanical) lift yesterday afternoon. MD (physician) and POA (Power of Attorney) notified. R1's Nurse's Progress Note dated 12/2/24 at 3:21pm by V1 documents I spoke with (R1) today regarding a bruise that occurred the night before during a transfer prior to her shower. (R1) stated that the aides in no way intentionally set out to harm her in any way. She thanked me for talking with her and had no other concerns at this time. On 12/10/24 at 2:00pm, V2 (Assistant Administrator) said there was an incident on 12/1/24 involving R1 that occurred on 12/1/24. V2 said that there were 2 Certified Nurse's Aides (CNA), that do not usually work that hall, that gave R1 a shower. V2 said that instead of using the mechanical lift, they lifted R1 under her arms. V2 said that both staff told her that R1 never screamed or yelled or even told them they needed to use the lift. V2 said that the incident was brought to her attention on 12/2/24 (Monday) that R1 had a large bruise on her right forearm from not being transferred with the mechanical lift. V2 said that V15 (Certified Nurse's Aide/CNA) said that there were no issues with the mechanical lifts, they just didn't use it and lifted her without it. V2 said that they should have used the mechanical lift, but didn't. V2 also said that R1 is on Eliquis which is a blood thinner and does bruise easily. On 12/10/24 at 11:30am, R1 was sitting in her recliner in her room. R1 said she did not want to talk about it and she had told the story a million times and was not going to say it again. R1 would not let this surveyor look at her arm. R1 was alert and answered questions appropriately at this time. On 12/12/24 at 11:25 AM, R1 was asked about the incident on 12/1/24 and R1 said they didn't use the lift and those girls were never going to shower her again. R1 said they are not allowed in her room again. R1 said she did not tell them to stop or to use the lift when they transferred her. R1 said that she is ok and that that will not happen again. R1 said they made this big bruise on her arm. R1 was asked to see the bruise and R1 would not let this surveyor look at the bruise. R1 was observed to have contractures in both hands and unable to use them. The lower part of the bruising towards her wrist was visible and it was reddish pink in color. R1 was alert and answered questions appropriately at this time. On 12/12/24 at 3:15 PM, V15 (CNA) said she worked on 12/1/24 and said she was told that R1 needed a shower and no one told her that she needed a mechanical lift. V15 said she was not aware of looking at the kardex and has been employed at the facility for maybe 9-10 weeks. V15 said that they transferred R1 under her arms and held the seat of her pants. V15 said that facing R1 she put her arm under R1's arms in the arm pit area and R1's arm pit area was in the bend of her arm. V15 said she also had ahold of the seat of R1's pants. V15 said that R1 did not scream or yell and all that R1 said they were never giving her a shower again. V15 said they used the shower in the 800 hall that was closed since the showers on the 500 hall were being used. V15 said that R1 never told them to stop and they should use the lift or they would have used it. V15 said to her knowledge, the lifts were not broken. V15 said there was bruising on R1's right arm before they showered her. V15 said after R1's shower, they lifted her back in bed. V15 said they did not use the lift putting her in bed. V15 also said she did not use a gait belt. On 12/10/24 at 3:24pm, V16 (CNA) said she was not aware that R1 required a mechanical lift for transfers. V16 said she was being trained and had only worked a couple of days. V16 said that on 12/1/24 she transferred R1 with V15. V16 said she was on the opposite side of V15 and placed her arm under R1's arm with R1's weight resting in the bend of her arm and used her other hand to hold the seat of R1's pants. V16 also said she did not use a gait belt. V16 said R1 never told them they needed to use the lift. V16 said they took R1 to the 800 hall to shower since the shower on the 500 hall was being used. V1 6 said that no one could have heard R1 screaming and yelling since she did not yell or scream at all. V16 said that R1 kept saying you will never give me a shower again and that was it. V16 said they showered her without any issues and then put her back in bed again not using the lift. On 12/11/24 at 10:00am, V12 (Licensed Practical Nurse/LPN) said she came in on Monday (12/2/24) and saw bruising on R1's right arm. V12 said that R1 told her that the CNA's couldn't get the lift to work and lifted her under her arms and that is where the bruise came from yesterday (12/1/24) V12 said R1 also told her that they were transferring her to a chair. V12 said she took a picture of the bruise and reported it to administration on 12/2/24 and also called the physician and R1's POA (Power of Attorney). On 12/11/24 at 10:50am, V14 (Registered Nurse/RN/Infection Preventionist/wound nurse) said that she is aware of the incident. V14 said she was not aware of any bruising present on R1's right arm prior to the incident on 12/1/24. The facility policy titles Safe Lifting and Movement of Residents (revised July 2021) documents Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. A resident that requires a mechanical lift may also be a two person assist with the use of proper equipment i.e (in example) gait/transfer belts.

Based on observation, interview and record review, the facility failed to ensure medications were administered as ordered for 1 (R77) of 10 residents reviewed for medication administration in the sample of 38. This failure resulted in R77 experiencing a significant medication error in which 5 additional doses of diuretic medication were administered resulting in dizziness, abnormal lab values, Intravenous Fluid administration, supplemental Potassium medication, and a hospital admission for an Acute Kidney Injury. This past non-compliance occurred between 3/14/24 and 3/19/24. Findings Include: R77's Admission Record documented R77 was [AGE] years old with an admitted to the facility of 03/08/2023. Diagnoses listed in their entirety on this document are: Alzheimer's Disease with late onset; Essential Hypertension; Dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R77's Progress Note dated 3/8/2024 with a time of 1:48 P.M. documented V12 (Physician) was here for rounds in which he reviewed medications, labs, vitals and weights. Received new order to start Duo nebs BID (twice daily) x 7 days and Zaroxolyn 5mg (milligrams) daily for 5 days. R77's Progress Note dated 03/18/2024 with a time of 2:23 P.M. documented R77 was complaining of dizziness, reported to V12. New orders were received for a CBC (Complete Blood Count), CMP (Complete Metabolic Panel), UA (Urinalysis Analysis) and orthostatic B/P (blood pressure). R77's Progress Note dated 03/19/2024 with a time of 12:44 A.M. documented R77 is currently receiving 2 diuretics, Furosemide 40 mg two times a day and Zaroxolyn 5 mg in the morning. R77 was noted to be experiencing dizziness, dry mouth, and urinating less this shift. Had to ambulate to the bathroom with one assist. A Progress Note dated 03/19/2024 with a time of 1:31 P.M. documented R77 was prescribed Zaroxolyn on 03/08/2024 intended for 5 days. Medication was ordered in the system for an indefinite end date therefore R77 has been receiving Zaroxolyn since 03/09/2024. Held this AM (03/19/2024) due to symptoms. V12 notified to discontinue medication and V13 (Nurse Practitioner/NP) will see R77 today. R77's Medication Administration Record documented Zaroxolyn was administered daily from 03/09/2024 - 03/18/2024 and held on 03/19/2024. R77's Progress Note dated 03/19/2024 with a time of 1:31 P.M. documented new orders for Potassium 40 meq (milliequivalent) by mouth three times a day and a 500 milliliters intravenous (IV) bolus. R77 was then to have an additional 100 milliliters per hour times two hours, along with a BMP daily for 3 days, and close monitoring for fluid overload. Additionally, R77's Furosemide was to be decreased to 20mg BID for 3 days. A document labeled CBC/CMP dated 03/19/2024 documents the following: BUN (blood urea nitrogen) 96 (high) normal value 7-25, Creatinine 2.8 (high) normal value 0.6-1.3, Sodium 134 (low) normal 136-145, Potassium 2.3 (Low) normal 3.5-5.1, and GFR 14 (low) normal >90. R77's Medication Administration Record dated March 2024 documented the bolus and intravenous fluids ordered to be given were Normal Saline Solution 0.9% with administration completed as ordered. R77's Progress Note dated 03/19/2024 with a time of 6:20 P.M. documented that the certified nurse assistant reported R77 pulled IV out. R77's Progress Note dated 03/19/2024 with a time of 7:15 P.M. documents that IV attempts were made with no success. R77 was refusing additional attempts. R77's Progress Notes further document that on 03/20/2024 at 3:27 A.M., R77 was reapproached and explained the need to restart the IV. R77 tolerated the restart well, and voiced no concerns. IV of Normal Saline was hung at 100 ml / hr (hour). On 03/20/2024 at 05:15 A.M., a note documented that lab was here to draw the BMP at this time. A nurses note dated 03/20/2024 with a time of 10:13 A.M. documented V13 was notified of a BUN critical at 100--new order received to give bolus of 500mL NS (Normal then back to 100mL per hour at previous dosage). A nurses note dated 3/20/2024 with a time of 10:40 A.M. documented an IV of 500mL bolus NS infused and hung new bag, set rate at 100mL per hour. IV site patent at this time and no redness, no edema noted. A nurse note dated 03/20/2024 with a time of 12:06 P.M. documents R77 pulled out IV line. R77 does not comprehend what IV is or what it is for. A nurse note dated 3/20/2024 with a time of 2:40 P.M, documented received order from V13 to send to (name of local hospital) for direct admit. The local hospital discharge summary dated 3/22/24 documented R77 had an admitted to the hospital of 03/20/2024 with a diagnosis of Acute Kidney Injury. This same document noted R77 was having worsening edema in the long term care facility and more aggressive diuretics were ordered however, the length of treatment was extended beyond what was initially ordered. R77 experienced a decline in renal function. R77 had received IV fluids at the facility however, R77 continued to remove the IV. During R77's hospitalization R77 was treated with IV fluids for the Acute Kidney Injury, and diuretics were held. R77 initially had a creatine of 2.9 (No reference range given although lab results indicated high), creatine down to 1.7 (no reference [NAME], although a high but improving level is noted). A Progress Note dated 03/20/2024 with a time of 2:20 P.M. documented R77 admitted back to facility around 12:30 PM. On 04/19/2024 at 8:53 A.M., V3 (Director of Nursing/DON) stated she was made aware of the medication error by V14 (Licensed Practical Nurse). After reviewing the incident, it was discovered that when V10 (LPN) placed the order in the Electronic Medical Record (EMR) system with no end date. The EMR system places an end date of indefinite on each order unless a different date is selected. R77 was assessed by medical staff at the time of the medication error discovery and new orders were received for treatment that same day. R77 was treated in the facility until she wouldn't keep her IV in. V3 started a QAPI (Quality Assurance Performance Improvement) plan on the medication error. V3 checks the physician orders daily to ensure that the orders were written correctly. V3 stated that moving forward, all new orders will be matched against the nurses note. V3 educated all nursing staff on properly placing an order with an end date. On 04/19/2024 at 9:18 A.M. V10 (LPN) stated that she received the order for Zaroxolyn and that she was the nurse who placed the order for R77 Zaroxolyn in the computer. V10 stated that she did not place an end date on the order. V10 stated that she had been educated since the incident to ensure if the order contains an end date to make sure it is on the order in the EMR. On 04/18/2024 at 12:35 P.M., V12 stated that the expectation is that the facility follow physician orders. V12 stated that the extra doses of Zaroxolyn was a medication error. The extra doses of the medication lead to admission to a local hospital with diagnosis of Acute Kidney Injury. V12 stated that there was timely notification of the medication error and the hospitalization was a direct result of the medication error. A document titled Med Error, dated 3/19/24 documented R77 was prescribed Zaroxolyn 5mg daily times 5 days starting on 03/09/2024. When the order was placed there was no end date, so the order was indefinite. R77 has been receiving metolazone (Zaroxolyn) from 03/09/2024 - 03/18/2024 due to medication being held 03/19/2024 due to R77 having symptoms of dizziness. R77 was unable to give description. Action taken documents V13 saw R77 on rounds. Labs were ordered and done on R77. New order for IV fluids for 2 days, Oral Potassium 40 meq three times a day, decrease Furosemide to 20 mg for 3 days then return to 40 mg dose. Monitor for fluid overload. Do BMP daily times three days. A note dated focus area in R77's Plan of Care documented R77 receives diuretic therapy related to edema of bilateral lower legs and feet. The goal listed for this focus area is that R77 will be free of any discomfort or adverse side effects of diuretic therapy through the review date. The policy titled Administering Medications with a revised date of April 2019 documented, Medications are administered in a safe and timely manner. The same policy goes on to state .4. Medications are administered in accordance with prescriber orders, including any required time frame. Prior to the survey date, the facility took the following actions to correct the deficient practice: 1. A Quality Assurance and Performance Improvement (QAPI) meeting was held on 3/20/24. The incident was reviewed and identification of others at risk was discussed. In attendance - V1 (Administrator), V3 (DON) and V12 (Medical Director). 2. Interventions put into place to reduce risk of recurrence: Nursing staff educated regarding double checking orders for end dates upon entry. All nursing staff education was completed by 3/20/24. 3. Monitoring/Effectiveness: Administrator (V1), DON (V3) or designee will monitor order entries for end dates, 2 new orders will be monitored 5 days per week for 4 weeks. Any issue identified will be immediately corrected and re-education will be offerred and reviewed during QAPI Meetings.

Based on interview and record review, the facility failed to ensure a window alarm was in working order for a resident at a high risk for elopement for 1of 3 residents (R1) reviewed for elopement in the sample of three. This past non-compliance occurred between 11/9/23 and 11/16/23. Findings include: R1's Face Sheet documented an admitted [DATE] and listed diagnoses including Unspecified Dementia, Severe, with Anxiety, Chronic Obstructive Pulmonary Disease, Depression, and Hypertension. Elopement Risk Assessments for R1 were completed on 10/5/23 and 11/10/23. The Elopement Risk Assessments document the following: Residents are at a high risk for elopement when yes is answered to both questions in section A or a score of 5 or greater. R1's Elopement Risk assessment dated [DATE] documents a score of 19.5 and R1's Elopement Risk assessment dated [DATE] documents a score of 18.5, indicating R1 is a high risk for elopement. Both questions in section A of the Elopement Risk Assessments completed on 10/5/23 and 11/10/23 have a documented answer of yes. R1's Care Plan dated 11/10/23 documented a problem area, (R1) is an elopement risk/wanderer related to a Dementia diagnosis. A Nursing Progress Note dated 11/9/23 at 5:40pm , authored by V1, Administrator, documented, I spoke to (V3, Certified Nursing Assistant) who was working on Wing 7 and she saw someone at the Wing 7 door, and went to assist them in. As she got closer to the door she realized it was (R1) so she approached her calmly and slowly and assisted her back to her room on Wing 6. Investigation revealed her window was closed, but the screen was up and clothing (was) outside her window. A string of personal items were along the sidewalk to the Wing 7 entrance. A Summary of Incident dated 11/9/23 documented,Summary of investigation: (R1) is a [AGE] year old female admitted [DATE] and resides on our lockdown Memory Care Unit. (R1) is independent with transfers/ambulation throughout (the unit). It appears (R1) exited her room through her window and walked to the next wing and entered the building through those doors. (R1) was last seen in the dining room at 4:45pm by staff and went toward her room. At 5:15pm, (V3) assisted (R1) as she was trying to enter the building through the Wing 7 entrance. The screen to (R1's) window in room was open and clothes were scattered outside on the ground leading to the path she took. Prior to 11/9/23, (R1) wasn't observed exit seeking out a window. An Elopement Details Report dated 11/9/23 documented, Time resident went missing: 11/9/23 at 5:15pm. Time resident found: 11/9/23 at 5:15pm, at Wing 7 entrance, found by (V3, Certified Nurses Assistant). Conclusion: Root Cause: Resident had an appointment outside the facility earlier in the day. Resident stated (to V3) that she 'needed a break from everything.' Resident also thought she saw her husband outside. Head to toe assessment: No injuries noted. (Personal perimeter alarm) in place and functioning. Window alarms assessed for function and batteries were checked. (Initiated) Frequent checks for 72 hours. A Smart Action Plan documented a problem,Resident eloped through a window on the Memory Care Unit, with a corresponding goal, No resident will leave the premises or a safe area without authorization or necessary supervision, and corresponding action items, Head to toe body assessment, frequent checks for 72 hours, replace batteries in window alarm, assess (personal perimeter bracelet alarm), husband to decrease frequency of visits as visits increase behaviors. Target completion date 11/10/23. Audit all Elopement Assessments to ensure any resident at risk is identified. Target completion date 11/10/23. Audit care plans of residents who are at risk of elopement. Target completion date 11/10/23. Test window alarms weekly. Target date 11/10/23 and ongoing. Re-inservice staff on Elopement Policy. Target date 11/13/23. On 11/28/23 at 11:10am, V5, Memory Care Unit Coordinator, stated R1's cognition varies widely according to the day, and her exit seeking behavior seems to be exacerbated by her husband visiting. V5 stated on 11/9/23 at about 5:15pm, after V5 had left for the day, R1 was observed by staff to be standing outside the Wing 7 entrance doors. V5 stated it was determined by investigation that R1 had exited the building via the window of her room. V5 stated the investigation determined the battery in the window alarm was dead, resulting in the alarm not sounding when the window was raised. V5 stated there was a trail of clothing and personal care items outside the building leading from underneath the window to the Wing 7 entrance door. V5 stated R1's personal perimeter alarm was in place and was working, but is only triggered if one of the doors to the outside is breached, therefore it did not sound when R1 crawled out the window. V5 stated V4, Maintenance Director, was supposed to be checking the window alarm batteries. V5 stated she is now responsible for checking them weekly. On 11/28/23 at 11:30am, R1 was alert and oriented to herself only. R1 stated she did not remember anything about having crawled out her window to exit the building. R1 stated her memory is bad and she often forgets things. On 11/28/23 at 11:40am, V4 stated after the elopement he checked all the window alarms in the building, all of which are located on the Memory Care Unit (Wing 6) which were all working with the exception of R1's room, due to the battery being dead. V4 stated he immediately replaced the battery, which he estimates, Should last about a year. V4 stated he checked the batteries in all the window alarms approximately 2 months prior to the incident, and stated this is not documented. V4 stated he doesn't think there is any policy about when to check the batteries. On 11/28/23 at 11:50am, V2, Assistant Administrator, stated there is no policy as to when the batteries in the window alarms should be checked, but the action plan that was developed after the elopement specifies that V5 will now be checking the batteries weekly and documenting. On 11/28/23 at 12:20pm, V3 stated she works the 2pm to 10pm shift, and on 11/9/23 she was working on Wing 7. At about 5:15pm, she saw somebody standing outside in front of the Wing 7 entrance door. V3 stated it was R1, wearing a T-shirt, jacket, sweatpants and shoes. V3 stated R1 seemed confused and anxious, which she usually does. V 3 stated when she opened the door for R1, her personal perimeter bracelet alarm set off the door alarm so it was obviously working. V3 stated she asked R1 what she was doing and how she got outside and R1 said 'she was taking a break from everything'. V3 stated there were no signs of injuries. V3 stated the temperature outside was in the 50s, it had been sunny that day, there was no rain, and it was around sunset but it wasn't completely dark out yet. V3 stated she took R1 back to Wing 6, where staff were not aware she had gotten out. On 11/28/23 at 2:05pm, V2 stated on 11/9/23, R1 was last seen in the Wing 6 Dining Room at 4:45pm headed back to her room after eating supper. V2 stated R1 would have been outside for a maximum period of 15 to 30 minutes. V2 stated a full body assessment was immediately performed and R1 had no injuries. V2 stated frequent checks for a 72 hour period were immediately implemented. V2 stated R1's window alarm battery was found to be dead and was replaced. V2 stated all other window alarms were checked and found to be operational. V2 stated V5 is now doing weekly window alarm battery checks for all Wing 6 windows. V2 stated R1's husband has agreed to do fewer visits, and to not knock on windows or doors when he is leaving, as he sometimes does. V2 stated all Elopement Risk Assessments in the facility, including R1's, were updated to make sure any at risk residents had been identified. V2 stated all staff were re educated on the Elopement Policy, and R1's Care Plan was also updated. V2 stated all members of the Quality Assurance Committee, including the Medical Director, have discussed the incident and approved the resulting action plan. V2 stated R1 had an doctors appointment and a visit from her husband the day before the incident, and staff feel this led to an increase in exit seeking behavior. An Elopement Prevention and Response Policy dated 2/19/21 documented,The community provides a safe environment for all residents. Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. Prior to the survey date, the facility took the following actions to correct the non-compliance: 1. On 11/10/23, members of the Quality Assurance Committee met to discuss the elopement and team members reviewed the Smart Action Plan and the Elopement Policy. 2. On 11/10/23, all staff members were re-inserviced on the facility's Elopement Policy. 3. On 11/9/23, the batteries in R1's window alarm were replaced, and the batteries in all the window alarms on the Memory Care Unit were tested and found to be working. 4. On 11/16/23, V5 initiated weekly testing of all the window alarms on the Memory Care Unit, with documentation on the 'Wing 6 Window Alarms flow sheet. 5. On 11/10/23, R1's husband agreed to reduce the frequency of his visits in order to minimize R1's exit seeking behavior following his visits. 6. On 11/10/23, R1's Elopement Risk Assessment and Care Plan were updated, and all Elopement Risk Assessments in the facility were audited.

Based on interview and record review the facility failed to provide written documentation which stated the reason the facility could not meet the resident's needs for 1 (R1) of 3 residents reviewed for discharge procedure in the sample of 3. Findings include: 1. R1's face sheet documented R1 was admitted to the facility on [DATE] with diagnoses including: pneumonitis due to inhalation of food and vomit, dysphagia, unspecified intellectual disorders, autistic disorder, insomnia. R1's care plan documented R1 had several physical behaviors such as hitting, pinching, and biting staff. R1's 6/22/23 Minimum Data Set (MDS) documented R1 was severely cognitively impaired. On 8/24/23 at 10:11 AM, V1 (Administrator) said R1 was admitted after a hospital stay due to aspiration pneumonia. V1 said R1 was going to work with speech therapy and be discharged back to the group home R1 was residing prior to hospital stay. On 8/24/23 at 12:29 PM, V2 (R1's Legal Guardian) said R1 was living in a group home and was transferred to the hospital due to aspiration problems. V2 said the hospital had recommended placing a feeding tube in R1 but V2 felt that was unnecessary and wanted a second opinion. V2 said R1 was transferred to another hospital for a second opinion and declined a feeding tube be placed again. V2 said R1 is not verbal and would not have been able to maintain a feeding tube. V2 said he chose R1 to be placed on palliative care if R1's only other option was having a feeding tube placed. V2 said R1 was transferred to the facility with the intention of end of life care. On 8/24/23 at 2:37 PM, V3 (Social Services Assistant) said R1 was admitted to the facility with the expectation R1 would be receiving services of hospice. V3 said when R1 arrived to the facility it was clear R1 was not going to be a candidate for hospice services. V3 said when R1 arrived to the facility he was very mobile and did have some aggressive behaviors with staff such as bending staff's finger back, twisting staff's wrists, attempting to bite staff, and pounding on doors trying to get out of the building. V3 said he did not recall R1 having any aggressive behaviors towards other residents. V3 said R1 was transferred to an acute psychiatric facility for evaluation of his behaviors. V3 was asked why the facility could not meet R1's needs V3 said it was mainly nursing not being able to be one on one with R1. V3 said R1 required constant supervision due to exit seeking and wandering. V3 stated we (the facility) can't have a single staff follow a resident around the building all day. On 8/24/23 at 10:11 AM, V1 (Administrator) said R1 had been transferred to an acute psychiatric hospital for behaviors. V1 said the hospital had notified the facility they were R1's base line behaviors and R1 would be discharged back to the facility. V1 said the facility had completed an emergency involuntary discharge after being notified there was no improvement to R1's behaviors. R1's Electronic Medical Record (EMR) documented several progress notes documenting the facility's attempts to find placement in group homes like the group home R1 had previously resided in. R1's EMR documented a 6/26/23 at 3:00 PM progress note .(Acute psychiatric hospital) called. They can accept (R1). They would like for him to be sent with 3 outfits and night clothes if he wears them . sent current medications . Transportation notified that (R1) has been accepted . R1's EMR documented a 7/3/23 at 12:17 PM progress note .(Acute psychiatric hospital) called and requested (R1) to be picked up from their facility this Friday at 1100. Transportation Supervisor is aware and will make arrangements for transportation. (Acute psychiatric hospital) reported that (R1) is still pinching and exit seeking but can be easily redirected . R1's EMR documented a 7/6/23 at 11:13 AM progress note .called with an update on (R1) today from (Acute psychiatric hospital). (R1) is eating and sleeping well, he is exit seeking, pinching, getting physical today when being redirected. Doctor has said this is his baseline behavior and they don't feel they can do anymore with him. They do feel like he has more behaviors with male staff and advise if we can avoid this it may be helpful, he prefers female staff. I did ask if they can keep him a bit longer to try and help with the behaviors as we feel it will put our other guests at risk. She said she understands and does feel like he would be in a better setting like his previous home but they're unable to do anything further as doctor said it's his baseline behavior . R1's EMR documented a 7/6/23 at 4:59 PM progress note . Phone call made this afternoon to (R1's) guardian, (V2), letting him know that the facility would be doing an involuntary/ emergency discharge at this time . R1's 7/6/23 Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents documented an emergency transfer or discharge from the facility citing . your welfare and needs cannot be met in the facility, as documented in your clinical records by your physician . and .the safety of individuals in this facility is endangered The facility was not able to produce any documentation R1 was a danger to other residents or documentation from R1's physician why R1's needs could not be met in the facility. R1's 7/6/23 Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents also documented . on the date of transfer or discharge, you will be relocated to: Facility/ Person: (V3/ R1's Legal Guardian) . R1 was discharged to an acute psychiatric hospital. On 8/24/23 at 12:29 PM, V2 (R1's Legal Guardian) said the facility had called him to inform him R1 would not be allowed to be readmitted to the facility after his stay in the acute psychiatric hospital because the facility could not handle R1's behaviors. V2 stated he was unsure why they were unable to find R1 placement in a group home after his return from the hospital. V3 said R1 was still at the acute psychiatric hospital at the time of this investigation. V3 said he was told there was an appeal process but V3 did not know what he was supposed to do or who to talk to about that. On 8/24/23 at 1:44 PM, V5 (Chief Nursing Officer at the Acute Psychiatric Hospital) said R1 had been in the Acute Psychiatric Hospital for almost 2 months and had only had approximately 5 days with aggressive behaviors and was doing well. On 8/29/23 at 9:45 AM, V1 (Administrator) was asked why an emergency involuntary discharge was performed when R1 had been at the acute psychiatric hospital for 10 days and responded R1 was initially sent to the acute psychiatric hospital for behaviors and when they called back and told us his behaviors were his base line that is when we initiated the emergency involuntary discharge. V1 said she felt like the acute psychiatric hospital was better equipped to care for R1's behavioral needs. V1 verified there was no documentation from R1's physician documenting why the facility could not meet R1's needs, what interventions had been put in place, and why the receiving facility was better equipped to care for R1. The facility's 9/1/09 Transfer/ Discharge policy documented .1. When a resident is transferred or discharged , the resident's chart will be documented by a physician. 2. Each resident is allowed to request or agree to relocate within the community or transfer to another facility, and to participate in the transfer or discharge . 4. Notification of transfer or discharge will follow the regulations of the State in which (the facility) is licensed and will be made at least 30 days in advance unless the individual qualifies for a State- defined emergency relocation .

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice that includes post fall assessment, monitoring, and implementation of fall interventions for 4 of 4 residents (R1, R2, R3, and R4) reviewed for accidents in a sample of 4. Findings include: 1. R1's face sheet documented an admitted [DATE] and diagnoses including: cerebral infarction, atrial fibrillation, hypertension, obstructive sleep apnea, insomnia, hyperlipidemia. R1's 1/19/23 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating R1 was cognitively intact. The facility's Occurrence Type Falls printed 3/22/23 documented R1 had 15 falls in the facility since R1's admission. R1's care plan with a revision date of 1/19/23 documented R1 was at risk for falls with a 2/4/23 intervention documenting in part .Resident to not be left unattended in wheelchair in room . and a 1/31/23 intervention documenting .urinal to remain in reach . On 3/23/23 at 2:03 PM and 3:04 PM, R1 was sitting in his wheelchair in his room unattended with his urinal hanging in his bathroom on the handrail. On 3/24/23 at 1:09 PM, R1 was sitting in his room in his wheelchair unattended. On 3/23/23 at 2:03 PM, R1 said he has fallen several times in the facility. R1 said he thought his last fall was a couple weeks ago. R1 said he was trying to get his urinal. R1 said he did not want to bother staff and tried to use his urinal without help when he could. R1 said he was unsure how he had fallen any other times. On 3/23/23 at 1:37 PM, V9 (Certified Nurse's Assistant/CNA) said fall interventions for R1 could be found in R1's care plan in R1's Electronic Medical Record (EMR). V9 said R1 had an intervention for his urinal to be in reach, but V9 was unsure why that was in R1's care plan because R1 was not physically able to use a urinal by himself. V9 said R1 had an intervention to not be left in his wheelchair unattended. V9 said R1 was in his room in his wheelchair unattended at the time of this interview but R1 had gotten better about not falling out of his wheelchair and was safe to be in his room in his wheelchair unattended because his room was close to the nurses station. R1's 1/17/23 facility fall investigation documented R1 had an unwitnessed fall, and the facility was unable to produce any documentation of serial neurological checks being performed. R1's 1/22/23 facility fall investigation documented R1 had an unwitnessed fall, and the facility was unable to produce any documentation of serial neurological checks being performed. R1's 1/27/23 facility fall investigation documented R1 had an unwitnessed fall, and the facility was unable to produce any documentation of serial neurological checks being performed. R1's 3/5/23 facility fall investigation documented R1 had an unwitnessed fall, and the facility was unable to produce any documentation of serial neurological checks being performed. On 3/23/23 at 1:51 PM, V2 (Director of Nursing/DON) said R1 had several falls in the facility. V2 said on the interventions put in place for R1 was R1 was not to be left in his wheelchair in his room unattended. V2 said when R1 was up in his wheelchair he should be in common areas where he can be supervised by staff. V2 said when R1 is in his room he should be assisted to his recliner or to his bed. V2 said she was not sure why R1 did not have serial neurological checks completed after every unwitnessed fall. V2 said the facility did not have a designated person to review resident's EMRs for completeness and timeliness of assessments after a resident fall. V2 said after an unwitnessed fall the neurological assessment form was sent to medical records to be scanned into the resident's EMR but no auditing was being done. 2. R2's face sheet documented an admitted ,d+[DATE]//23 and diagnoses including: dementia, hypertension, hyperlipidemia, macular degeneration, depression. R2's 3/4/23 MDS documented a BIMS score of 5, indicating severe cognitive impairment. The facility's Occurrence Type Falls printed 3/22/23 documented R2 had falls in the facility on 3/5/23, 3/13/23, and 3/14/23. R2's 3/14/23 facility fall investigation documented R2 had an unwitnessed fall and no documentation of neurological checks being completed could be produced. R2's 3/14/23 facility fall investigation documented in part . Root Cause: Attempting to toilet, incontinent of loose stools. Interventions: Nursing to have MD/ NP (Medical Doctor/ Nurse Practitioner) review lactulose dosage related to loose stools and ammonia levels decreasing . R2's 3/1/23 through 3/31/23 Medication Administration Record (MAR) documented a 3/13/23 order for Lactulose 20 grams per 30 milliliters (ml) give 30 ml by mouth four times a day for elevated ammonia levels and bowel movement regimen do not hold due to loose stools. No changes to this order were made after R2's 3/14/23 fall. R2's care plan with a revision date of 3/14/23 documented R2 was at risk for falls and a 3/15/23 intervention of .nursing to have MD (Medical Doctor) review lactulose dosage r/t (related to) loose stools and ammonia levels decreasing . no other interventions were documented after 3/15/23. On 3/23/23 at 1:51 PM, V2 (DON) said she was not sure why R2 did not have neurological checks completed after R2's 3/14/23 unwitnessed fall. V2 said R2's 3/14/23 fall was due to R2 trying to ambulate to the bathroom without calling for assistance and R2 taking lactulose and causing loose stools. V2 said the interdisciplinary team had met and put an intervention in place for R2's medical provider to assess R2's lactulose dosage and possible decrease it so R2 would have less loose stools. V2 said R2's lactulose dosage was not changed after R2's 3/14/23 fall and the facility had not put any other fall interventions in place. 3. R3's face sheet documented an admitted [DATE] and diagnoses including: hypertensive heart disease with heart failure, dementia, hyperlipidemia, anxiety disorder, major depressive disorder, muscle weakness, history of falling. R3's 2/21/23 MDS documented a BIMS score of 13, indicating R3 was cognitively intact. The facility's Occurrence Type Falls printed 3/22/23 documented R3 had falls in the facility on 1/23/23, 2/3/23, 3/1/23, and 3/15/23. R3's 3/15/23 facility fall investigation documented R3 had an unwitnessed fall on 3/15/23 at 12:00 AM. R3's 3/15/23 Neurological Assessment Flow Sheet documented vital signs were recorded every fifteen minutes from 12:00 AM until 12:45 AM but no neurological checks were documented as being completed, for 1:00 AM through 4:00 AM no vital signs or neurological checks were completed and sleeping was documented at 1:00 AM, and 8:00 PM. For 3/16/23 at 12:00 AM no vital signs or neurological checks were documented as being completed but sleeping was documented, for 4:17 AM vital signs were documented but no neurological check were documented as being completed, no further vital signs or neurological checks were documented. On 3/23/23 at 11:43 AM, V4 Licensed Practical Nurse (LPN) said she was the nurse caring for R3 on the night of 3/14/23 to the morning or 3/15/23 when R3 had an unwitnessed fall. V4 said after a resident has an unwitnessed fall neurological checks should be started immediately. V4 said neurological checks included vital signs, pupillary response, assessing for any change in orientation, and assessing for any changes in bilateral body movement. V4 said she was unsure why R3's neurological checks were not completed on 3/15/23. V4 said a resident can refuse to have a neurological check completed and refused should be documented on the Neurological Assessment Flow Sheet. On 3/23/23 at 10:12 AM, V2 (DON) said she was unsure why R3's neurological checks were not completed and the resident being asleep should not be the reason a nurse does not complete a neurological check after an unwitnessed fall. 4. R4's face sheet documented an admitted [DATE] and diagnoses including: cirrhosis of the liver, dementia, dysphasia, iron deficiency anemia, hepatic encephalopathy, depression. R4's 1/27/23 MDS documented a BIMS score of 8, indicating mild cognitive impairment. The facility's Occurrence Type Falls printed 3/22/23 documented R4 had falls on 1/31/23, 2/17/23, 3/4/23, 3/16/23, and 3/19/23. On 3/23/23 at 3:06 PM and on 3/24/23 at 11:00 AM and 1:09 PM, R4 was sitting in a recliner in her room watching television with a bedside commode at the foot of her bed. On 3/24/23 at 1:09 PM, R4 said she was able to get up and walk to her bedside commode without staff's assistance. On 3/24/23 at 1:37 PM, V9 (CNA) said fall interventions for residents could be found on the residents Kardex (summary of care areas for the resident) in the residents EMR. V9 said R4 did not have a fall intervention to remove the bedside commode from R4's room on the Kardex. V9 said fall interventions could also be found in the resident's care plan in the residents EMR. V9 said she was not aware R4 was supposed to have the bedside commode removed from her room. V9 said she did not think R4 was strong enough to walk to the bathroom and it would be unsafe for R4 not to have a bedside commode. V9 said she did not know how staff would be alerted to changes in a resident's care plan. R4's 1/31/23 facility fall investigation documented R4 had an unwitnessed fall, and the facility was unable to produce any documentation of serial neurological checks being performed. R4's 3/16/23 facility fall investigation documented R4 had an unwitnessed fall, and the facility was unable to produce any documentation of serial neurological checks being performed. R4's 3/19/23 facility fall investigation documented R4 had an unwitnessed fall, and the facility was unable to produce any documentation of serial neurological checks being performed. R4's revised 2/1/23 care plan documented R4 is at risk for falls with a 3/20/23 intervention of staff to remove bedside commode. R4's Kardex printed 3/24/23 did not show staff were to remove bedside commode from R4's room. On 3/24/23 at 1:51 PM, V2 (DON) said she expected staff to complete serial neurological checks per the facility's protocol after all unwitnessed falls and was unsure why R4 did not have serial neurological checks after R4's 1/31/23, 3/16/23, 3/17/23, and 3/19/23 unwitnessed falls. V2 said one of the interventions put in place after R4's 3/19/23 fall was to remove the bedside commode from R4's room. V2 said R4 was getting up without calling for help and the interdisciplinary team thought if R4 did not have a bedside commode in her room she would be less likely to get up without calling for help. V2 said staff should be aware of all fall interventions put in place for residents and use guidance from the resident's care plan. The facility's 2/17/20 Fall Prevention - Steady Steps Policy documented in part .Post Fall Intervention . Assess Resident for changes in condition post fall (immediately after the fall and for 72-hours post fall) . Complete Neuro checks per protocol on any resident who has an unwitnessed fall or has hit his/ her head and document in the clinical record . attempt to determine appropriate fall intervention (s) and implement as soon as possible after the fall . Care plan will be reviewed and revised with additional/ modified fall interventions as indicated . The facility's 12/7/11 Neurological Assessment policy documented in part . a neurological assessment will be performed by a licensed nurse when the resident status warrants, such as head injury, possible PVA (stroke), and/ or unwitnessed fall . 3. Neurological assessment should be performed as follows for a 72 hour., unless otherwise ordered by the attending physician. Every 15 minutes x4, Every 1 hour x4, Every 2 hours x4, Every 4 hours until 72 hour period complete 5. Documentation should be made in the nurses notes or on a flow sheet, describing the required aspects. Neurological checks should be complete, specific, and compare the right side of the body with the left .

Based on observation, interview, and record review, the facility failed to provide two staff members to carry out a mechanical lift transfer for one of one resident (R13) reviewed for mechanical lift transfers in the sample of forty two. Findings include: On 01/17/23 at 10:55am, the surveyor entered the room of R13 . V2, Certified Nursing Assistant (CNA), was observed performing a mechanical lift transfer of R13 from the bed into the wheelchair. V2 was unassisted by other staff. V5, R13's family member, was also present during this transfer. V2 completed the procedure and left the room. V5, and R13, who was alert and oriented to person, place, and time, both stated this was not the first time only one staff member had performed a mechanical lift transfer for R13 . R13's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status Score of 12, indicating R13 has minimal deficits in cognitive function. The same MDS documented that R13 requires extensive assistance from at least two staff members for transfers. On 1/18/23 at 9:52am, V1, Administrator, stated V2 had approached V1 and V2 reported to V1 that V2 had done R13's transfer by herself. V1 confirmed there should always be at least two staff members present when performing mechanical lift transfers. V1 stated she told V2 that V2 would be disciplined when V2 came back from lunch. V1 stated V2 did not return after lunch, thereby terminating V2's employment. V1 stated staff were immediately re-educated about safe mechanical lift transfers. On 1/19/23 at 9:45am, V3 CNA, confirmed there should always be at least two staff present during mechanical lift transfers. V3 stated in the past few days, staff were re-educated about safe transfers. A Mechanical Lift Transfers Policy dated 01/30/20 documented, Guidelines: #5: Two nursing or therapy associates are required when using a mechanical lift.

Based on interview and record review, the facility failed to provide documentation to support treatments were administered for one of six residents (R48) reviewed for pressure ulcer/injury in a sample of 47. Findings include: R48 Resident Profile Sheet documents R48 was admitted to this facility on 01/05/21 with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R48's care plan dated 07/27/21, updated 10/19/21 documents the following - (Resident) has the potential for pressure injury development and altered skin integrity r/t (related to) incontinence and decreased mobility- Stage 3 pressure injury to right heel. R48's most recent quarterly MDS (Minimum Data Set) dated 8/9/21 documents not assessed under section C for BIMS (Brief Interview for Mental Status) score. This same assessment documents R48 requires extensive 2+ person assist for bed mobility and transfers. R48's Admission Braden assessment dated [DATE] documents a score of 14, indicating R48 is at moderate risk for skin breakdown. R48's October 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Monitor for complications. On 10/21/21 at 10:57 AM, R48's wound treatment to the right heel was observed with V9 (Registered Nurse/Wound Nurse - RN) and V14 (Licensed Practical Nurse - LPN). V9 stated treatments are documented in the resident record on the Treatment Administration Record (TAR). V9 stated she measures resident wounds weekly and documents the measurements on the facility Skin and Wound Evaluation form. R48's Skin and Wound Evaluation documents right heel wound measurements in part: 10/08/21 - 0.9 cm (centimeters) area x 0.7 cm length x 1.5 cm width; 10/12/21 - 5.1 cm x 4.5 cm x 1.5 cm; and 10/19/21 - 2.1 cm x 1.3 cm x 2.1 cm. R48's August, September, and October 2021 Treatment Administration Record (TAR) was reviewed. The following dates were blank with no corresponding progress note - August: 08/03; 08/08; 08/17; 08/30. September: 09/01; 09/09; 09/15; 09/18; 09/19; 09/27; 09/29. October: 10/07; 10/12; 10/17. On 10/21/21 at 11:37 AM, when asked what the blank spot on R48's TAR for the right heel treatment meant, V14 (LPN) stated if the TAR is blank for a certain date that means the treatment was not done. There should be a progress note to document why. On 10/21/21 at 1:30 PM, V3 (Acting Director of Nursing - DON) stated each hall has a nursing unit manager and one of their duties is to review the TAR and make sure everything is completed and signed off. There should not be blanks left on treatments. V3 continued to state R48 has behaviors and will refuse treatments, but staff should have followed up and completed the TAR and written a progress note if R48 continued to refuse treatment. The facility policy titled, Skin/Pressure Ulcer Risk Evaluation with a revision date of 01/16/14 documents the following in part - Purpose: 1. To establish a consistent and objective method of evaluating the resident's risk for pressure ulcer development .Procedure: .6 .The findings of the skin inspection will be documented on the Treatment Administration Record (TAR).

Based on observation, interview, and record review, the facility failed to provide Range of Motion (ROM) services for two of six residents (R1, R55) reviewed for limited Range of Motion in the sample of 47. Findings Include: 1. On 10/19/21 at 10:42 AM, R1 who was alert and oriented to person, place, and time stated R1 has limited movement to left arm as R1 previously had a stroke. Resident demonstrated little movement to left leg, left arm and left hand was observed as being contracted. R1 stated the stroke was in 1999. R1 stated there used to be a girl at the facility who would come in and move R1's left fingers around for R1, but stated the girl no longer works here and would guess she (the employee) left about 6 months ago. R1 stated R1 also used to wear a brace to help keep R1's fingers from digging into R1's hand but doesn't know where it went. R1 stated left hand ROM has declined since being at the facility. R1 stated the hand is tighter now. R1 stated R1 has been at the facility approximately a year. On 10/21/21 at 09:00 AM, ROM services were observed being provided by V8 (Certified Nurse Assistant / Restorative Aide) for R1. V8 stated R1 is compliant and participates in restorative programming daily. V8 stated R1 does not utilize a brace to the left hand. During ROM observation, R1 was observed as having very limited range to left arm/shoulder/hand/leg with R1 attempting to follow ROM directions given by V8. R1 was observed as being unable to complete the motions, with V8 not assisting. V8 stated R1 was admitted to the facility with limited ROM to both left upper and lower extremities following a previous stroke. Review of R1's Plan of Care with an initiation date of 4/14/21 documented a focus area of Activities of Daily Living self-care performance deficit related to history of [CONDITION(S)] with left side [CONDITION(S)], sciatica, spinal compression fractures, and impaired balance. Interventions included an Active Range of Motion (AROM) Program that states, Restorative Nurse Assistant to give R1 verbal cues and gestures for her to complete AROM exercises to both arms and legs --10 reps per joint, 2 times per day. Review of R1's Minimum Data Set (MDS) dated [DATE], Section G0400 Limited ROM to one side upper and lower extremities. On 10/21/21 at 11:35 AM, V3 (Director of Nursing) stated with V2 (Assistant Administrator) present, that after looking into R1's record, it was acknowledged R1 was only receiving an active range of motion program, with no passive range of motion program in place despite not being able to fully move R1's left upper and lower extremities due to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . V3 stated that R1 is being referred to Occupational Therapy today for evaluation but acknowledged with R1's inability to fully move left upper and lower extremity, a passive program would be indicated. V3 stated that she believes R1's programming was not correct, due to the previous restorative nurse at the facility who V3 reports, was not doing her job and has since been fired. Review of R1's Admission Record documents an admitted to the facility as 11/24/20. 2. On 10/19/21 at 9:52 AM, R55 who was alert and oriented to person, place, and time stated R55 used to receive therapy services, but no longer does as R55 was told she has used up therapy days. R55 stated R55 can't say the date, but ROM services used to be completed in therapy and R55 has been out of therapy for quite some time. R55 stated R55 does have limited ROM to bilateral legs as R55 has had both knees replaced. R55 stated R55 no longer receives any therapy services, and no ROM/stretching services with facility or therapy staff. Review of R55's MDS dated [DATE] documents in section G0400 that R55 has limited range of motion to one side of her lower extremities. Review of R55's Plan of Care documents an initiation date of 7/16/21 which states R55 has an ADL self-care performance deficit ADL r/t (related to) Activity Intolerance, Fatigue. Interventions include, AROM program: Staff to give R55 verbal cues and gestures for R55 to complete AROM exercises to left hips, bilateral knees and ankle .per joint sitting daily. Review of R55's Clinical Record contains no documentation of an AROM program or otherwise being completed. On 10/21/21 at 01:37 PM, V1 (Administrator) verified that there is no task in place for staff to be performing any range of motion programming with R55. V1 stated that the facility has recently fired their restorative nurse, and identifies there was an error. V1 stated with R55 being identified as having limited range of motion, a program would be indicated to be in place. Review of R55's Admission Record documents an admitted to the facility as 7/9/21. Review of the facility policy titled, Range of Motion Exercises with a revision date of 12/7/11 states, Staff will provide exercise to the resident's joints and muscles, as required.

Based on observation, interview, and record review, the facility failed to follow accepted standards of practice in maintaining infection control while providing incontinence/catheter care for one of ten residents (R25) reviewed for urinary catheter/urinary tract infection in the sample of 47. Findings Include: R25's admission record dated 10/26/2021 documents R25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R25 has a history of urinary tract infections with the most recent local hospital urinalysis lab report dated 10/08/21 documenting the following abnormal results; positive for nitrites, three plus leukocytes, two plus blood, cloudy in appearance, and brown in color. R25's order recap report dated 10/01/21 to 10/31/2021 documents an order with a start date of 10/11/21 for [MEDICATION(S)] 100 milligrams twice daily for seven days for an abnormal urine. This indicates R25 was positive for a urinary tract infection on 10/08/21. On 10/21/21 at 10:42 AM, V15 (Certified Nursing Assistant/CNA) provided catheter care/incontinence care to R25 with V16 (CNA) assisting. R25 was incontinent of bowel and V15 used personal hygiene wipes to clean the feces off R25's buttocks. Without changing her gloves or performing hand hygiene, V15 then provided pericare/catheter care to R25. When asked if that was how she typically provided incontinence/catheter care V15 stated it was. When asked why she didn't change her gloves or perform hand hygiene after wiping feces and before providing catheter care, V15 stated she should have. On 1/21/21 at 1:37 PM, V3 (Director of Nurses) stated she would expect the CNA's to perform hand hygiene and change their gloves after cleaning feces and before providing pericare. The facility Prevention of Catheter Associated Urinary Tract Infections policy dated 2020 documents under perineal care, The peri-urethra is cleaned regularly with mild soap and water and then rinsed. Always wash from area of least contamination to area of greatest contamination . The facility Procedures for Contact Precautions dated 2020 documents under gloves, 1. In addition to wearing gloves as outline under Standard Precautions, clean, non-sterile gloves are worn when providing direct care to residents 4. During providing care for residents, gloves will be changed after having contact with infective material that may contain high concentrations of microorganisms (fecal material or wound drainage).

Based on interview, observation, and record review, the facility failed to maintain a side rail by not replacing a missing end safety cap, which left a sharp metal surface exposed, causing an eleven centimeter laceration requiring sutures, and blood transfusions for one of three residents (R2) reviewed for injuries in the sample of three. Findings include: 1. R2 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. R2's March, 2015 Medication Administration Record indicates she was receiving 5 milligrams of Apixaban twice a day, and 81 milligrams of Aspirin daily by mouth prior to the incident of 03-05-15. R2's Investigation of Skin Tear, Bruises & Abrasions report documented by E4 (Licensed Practical Nurse) on 03-05-15 at 8:10 PM indicates the following: Location of Injury-Left lower leg; Description of area: Laceration to left lower leg; Equipment check: Bed frame or side rail (side rail circled) Jagged edge--end of side rail cap missing. On 04-06-15 at 11:17 AM, E4 indicated the bottom cap was missing from R2's side rail. E4's Nurses Progress Note dated 03-05-15 at 21:17 indicates: "res' left lower leg was hit on bed rail causing a 11 by 1 centimeter laceration to left lower leg, area was cleaned and wrapped. MD and family notified. res sent to ER for treatment". On 04-06-15 at 11:45 AM, E5 (Certified Nurse Aide) indicated she and E3 (Certified Nurse Aide) were transferring R2 to bed on 03-05-15. Her leg caught on a piece of the side rail. One cap was missing. We saw her leg was bleeding after we got her in bed. On 04-06-15 at 9:50 AM, E3 indicated on 03-05-15, they stood R2 up and pivoted her. She got scared and dropped her legs, and her leg hit the side rail. On 04-06-15 at 2:00 PM, E6 (Certified Nurse Aide) indicated he was in R2's room on 03-05-15 during the transfer. R2 hollered as she started to go down, and after they got her into bed, he noticed her left leg was bleeding. E6 indicated she had blood running down her leg. It wasn't deep, it was a long cut. R2's Clinical Report-Physician/Mid Levels sheet dated 03-05-15 at 21:04 indicates: Extremities: Left leg: moderate tenderness and swelling, deep laceration greater than 5.0 cm (centimeters) and large ecchymosis located in the lateral aspect of mid leg. Progress and Procedures: Laceration Repair: Location: left leg. Length: 12 cm. Wound depth/shape-curved and subcutaneous. Wound is clean. Contused tissue present. Distal neuro/vascular/tendon status normal. Local anesthesia using 1% lidocaine. Prepped with Shur-Clens. Wound Cleansed. Closure of superficial layer interrupted 4-0 nylon (15 sutures). R2's Nurses Progress Note dated 03-06-15 at 03:58 indicates: "Res. returned back via ambulance from HMH, has a laceration to LLE (left lower leg) with 15 stitches". On 03-06-15 at 23:14, E10 (Registered Nurse) documented in nurse progress notes, "Problem/Symptom is lethargic, pallor. Other things that have occurred with this problem/symptom are Obtained leg wound 03-05-15. Continues to have copious amount of bleeding from wound. Send to ER for eval and tx". R2's laboratory report dated 03-07-15 indicated her hemoglobin was 8.0 (Low), and hematocrit was 25.50 (low). R2 was admitted to the hospital on 03-07-15 with blood loss anemia, secondary to Chronic anticoagulation from a laceration on her left leg, Atrial Fibrillation, and UTI per review of the Discharge Summary sheet dated March 8, 2015. On 04-06-15 at 9:20 AM, R2's outer aspect of her left lower leg was observed with multiple steri strips with dry old blood, and a large hematoma near the top of the laceration. On 04-06-15 at 2:25 PM, Z1 indicated he did not know the cause of the injury to R2's left lower leg. He looked at her leg, and the concern was if it would become infected. The aspirin and Apixaban were put on hold. She was anemic to start with. Her hemaglobin and hematocrit went down. The facility notified me in a timely manner of R2's changes.

Based on record review and interview, the facility failed to thoroughly investigate the circumstances surrounding falls, develop effective interventions to prevent falls, monitor to ensure that the interventions on the care plan are implemented to prevent falls, provide adequate supervision during periods of unsafe ambulation/change in condition, and evaluate the environment for accident hazards for 3 of 11 residents (R3, R5, R8) reviewed for falls in the sample of 11. R3, who was assessed as high risk for falls (Fall Risk Evaluation dated [DATE]), sustained 6 falls from the time period of [DATE] through [DATE] (Incident/Accident Log). According to R3's Death Certificate dated [DATE], the immediate cause of death was Bilateral Subdural Hematomas due to or as a consequence of Head to Face Trauma due to or as a consequence of two Falls. R5, who was assessed as high risk for falls (Fall Risk Evaluation, most recently dated [DATE]), sustained 6 falls from the time period of [DATE] through [DATE] (Incident/Accident Log). According to R5's Death Certificate of [DATE] R5's death was a result of a fracture of the Femoral Neck and as a consequence caused a Pulmonary Fat Embolism that resulted in Respiratory Arrest and death on [DATE]. These failures concerning R3 and R5 resulted in an Immediate Jeopardy. The facility identified on [DATE] that 91 of the 137 residents in the facility are assessed as high fall risk. While the Immediacy was removed on [DATE], the facility remains out of compliance at Severity Level 2 as the facility continues to educate staff and evaluate the effectiveness of new fall assessments and interventions. The findings include: 1. According to the April, 2012 physician's orders [REDACTED]. R3's Minimum Data Sets dated [DATE] and [DATE] document that R3 had long and short term memory problems. The facility Fall Risk Evaluation for R3 dated [DATE] documents that R3 was high risk for falls at time of admit to the facility. The facility incident/accident reports were reviewed for R3 and it was found that she had 6 falls from [DATE] to [DATE]. A. The Incident/Accident Report for a fall on [DATE] at 6:45 pm (first fall) documents that R3 was not acting herself and was confused. This report also indicates that R3 was ambulating down the hallway briskly with her walker and fell to the floor, hitting head on the carpeted floor. This report lists the cause as R3's walking too fast with her walker. R3's Care Plan with start date of [DATE] lists a new intervention to be implemented of encourage R3 to slow down with wheeled walker. The facility Investigation Conclusion documents that R3 will at times forget to use the walker and is to be checked on frequently to ensure safety and comfort. There is no plan on R3's care plan that addresses how frequent visual checks are to be done nor a plan to address R3's non-use of the walker at times or walking too quickly. B. The Incident/Accident Report for a fall on [DATE] at 7:25 pm (second fall) documents that R3 refused to use a wheel chair to go back to R3's room and took off ambulating without walker and fell face forward to the floor with staff trying to stop the fall. R3 did not sustain an injury according to this report. The Post Fall Investigation for this incident verifies that R3 fell to the floor. R3's Care Plan with start date of [DATE] lists a new intervention to request from the physician an order for [REDACTED]. There was no plan initiated that addresses how frequently visual checks are to be done nor a plan to address R3's non-use of the walker at times. Also, there in no plan with interventions on the Care Plan to address using the wheeled walker appropriately. C. The Incident/Accident Report for a fall on [DATE] at 10:30 am (third fall) could not be found according to E2, Director of Nurses, on [DATE] at 10 am. R3's Nurse's Notes dated [DATE] at 10:30 am document that R3 was ambulating down the hallway without her walker and fell face forward scraping the bridge of her nose on the carpet. R3's Care Plan with start date of [DATE] lists a new intervention to notify family for different slippers. The facility Investigation Conclusion for this incident documents that R3 was ambulating down the hallway without her walker, lost her balance, was assessed and found to have a scrape on R3's nose. This form also states R3 forgets walker at times, has been more confused lately, slippers were loose and did not fit well which could be hazardous (replace slippers), and is checked on frequently to ensure safety and comfort. R3's care plan dated [DATE] has an original approach for a problem of potential for falls that states to "Make sure resident has proper fitting shoes with laces tied or skid free slippers on before all transfers or ambulation." There was no plan initiated that addresses how frequently visual checks are to be done nor a plan to ensure that R3 used her walker at all times. D. The Incident/Accident Report for a fall on [DATE] at 9:10 am (fourth fall) documents that R3 was ambulating with her walker between an electric lift recliner and the wall, tripped on the power cord, falling face first to the floor. According to the nurse's notes dated [DATE] at 9:10 am, R3 did not respond when name was said and was having a seizure which lasted 5 minutes. The nursing notes state R3 sustained an abrasion to the right eyebrow with bruising and swelling already present to the right side of her face. R3's Nursing Notes dated [DATE] at 9:10 am document that R3 tripped over a power cord for a lift chair in the back lobby. The facility Investigation Conclusion documents that pressure was applied to the abrasion of the left eye until bleeding stopped, R3 alert within 5 minutes after seizure but feeling tired. This Investigation Conclusion also states R3 and Z4, R3's Power of Attorney, refused to go to the emergency room and Z1, physician, ordered an x-ray of the right cheek bone/face. R3's Care Plan dated [DATE] has an original approach for falls to "Keep pathway clutter free. Monitor environment for wet spots or items placed below field of vision on the floor." This approach was not followed due to the power cord of a lift chair being stretched across the open space between the chair and the wall. No plan with interventions to increase supervision was implemented to prevent further falls. E. The Incident/Accident Report for a fall on [DATE] at 6:20 pm (fifth fall) documents that R3 was confused when R3 was found in the bathroom floor on her right side with a skin tear to the left forearm and right elbow and that R3 was taken to the hospital. R3's Nurse's Notes of [DATE] at 6:20 pm document R3 was found on the bathroom floor incontinent of bowel, had emesis on her clothing, and had increased confusion. This notes state R3 was transported to the hospital. A Nurse's Note for R3 dated [DATE] at 2:15 am documents R3 was admitted with Bilateral Subdural Hematomas. The facility Investigation Conclusion form documents that family did not want the neurosurgeon to attempt a craniotomy and R3 was sent back to the nursing home for comfort care. The plan of action to prevent reoccurrence on the Investigation Conclusion states, "Continue risk vs benefits analysis, resident's independence in ambulation and her overall independence were of high importance to her. Attempting to have her SBA (stand by assist) or assist of 1 caused her increased anxiety, stress and increased behaviors. Res. (resident) and fmly (family) were aware of likelihood of continued falls with injuries but resident dignity and independence were higher on her list than the risk of fall. There was no plan with interventions initiated that analyzes the falls and addresses increasing supervision to prevent further falls. There was no consideration given to interventions such as need to assist with toileting and increase activities in a setting that is supervised. F. The Incident/Accident Report for a fall on [DATE] at 5:15 am (sixth fall) documents R3 fell out of bed and was found curled up in a ball on the floor with a pillow under R3's head. R3 was confused according to this report. The Investigation Conclusion Form for this incident documents R3 had altered safety awareness and declining condition due to Subdural Hematomas. The Investigation Conclusion Form for this incident also stated "Staff did not consider the monitor prior to because it would have been a dignity issue and would have upset her." The Care Plan dated [DATE] stated a new approach was started on [DATE] of Pressure monitor at all times. Review of R3's Care Plan dated [DATE] documents R3 had a problem of potential for falls and/or injury related to history of falls. The approaches listed do not include a plan to increase supervision of R3. E5, Registered Nurse - Care Plan Coordinator, stated during an interview on [DATE] at 10:40 am that the undated approaches are the original approaches at the time of the original Care Plan and after each fall the fall date is then added to the Care Plan with an approach also added. The first 7 approaches on R3's Care Plan are not individualized and are the same approaches found on the care plans of R5, and R8. Review of the Incident/Accident Reports and the Post Fall Investigations of R3's falls document that areas were not completed on the forms. On R3's [DATE] Post Fall Investigation form the transfer assistance was not completed On the [DATE] at 6:20 pm Incident/Accident Report does not list the immediate intervention implemented to prevent re-occurrence and the Post Fall investigation of this incident does not indicate transfer assistance and ambulation assistance required. On the [DATE] at 5:15 am Post Fall Investigation form, the transfer assistance and the ambulation assistance required was not completed. Z1, Physician, was interviewed on [DATE] at 11:25 am. Z1 stated that he was notified of R3's falls on [DATE] and said that R3's level of cognitive ability was not regained after the falls on [DATE]. He also verified that R3 had Alzheimer's Disease. Z1 also stated that he agreed with the cause of death on the Death Certificate. The Certification of Death Record for R3 documents date of death as [DATE] and the cause of death "Bilateral Subdural Hematoma", "Head and Facial Trauma", and Falls times Two". The Description of how the injury occurred is given as "1. Tripped over power cord from lift chair. 2. Found on bathroom floor, reason unknown." 2. The Cover Sheet for R5's Care Plan dated [DATE] (completed at the time of the Annual Minimum Data Set and reviewed quarterly) documents that R5 had [DIAGNOSES REDACTED]. R5's Care Plan documents a problem of at risk for falls with injury related to his [DIAGNOSES REDACTED]. E5, Registered Nurse - Care Plan Coordinator, stated during an interview on [DATE] at 10:40 am that the undated approaches are the original approaches at the time of the original Care Plan and after each fall the fall date is then added to the Care Plan with an approach also added. The first 7 approaches on R3's Care Plan are not individualized and are the same approaches found on the care plans of R5, and R8. Review of R5's Nurse's Notes document increased confusion on [DATE] at 11 am and [DATE] at 6 pm. Also, the Nurse's Notes dated [DATE] at 10 am stated R5 is "feeling better but cont (continues) to be weak. will monitor." According to the facility Fall Risk Assessment, R5 was assessed as high risk for falls on [DATE], [DATE], [DATE], and [DATE]. The facility incident/accident reports were reviewed for R5 and it was found that he had 6 falls from [DATE] to [DATE]. Review of the Incident/Accident Reports and the Post Fall Investigations of R5's falls document that areas were not completed on the forms. On R5's [DATE] Post Fall Investigation form the area addressing transfer assistance and ambulation assistance were not completed. A. The Incident/Accident Report for a fall on [DATE] at 4:45 pm (first fall) documents that R5 was ambulating with a walker in his room to the bathroom to change clothes and fell on his buttocks near the end of his bed at which time he sustained a hematoma to the back of the head. R5 stated after the incident that he felt weak recently. The cause of the incident was listed on this report as slipped walking in sock feet. R5's Nurses's Notes dated [DATE] at 4:45 pm state that therapy is to screen R5 due to increased weakness and gait is unsteady. A new intervention was added to Care Plan dated [DATE] to refer to skilled therapy. The facility Investigation Conclusion Form documents that R5 has a slow gait and is unsteady at times. Also this form states R5 is checked on frequently to ensure safety and comfort. Review of R5's Care Plan of [DATE] does not include a plan with interventions to provide frequent checks for R5 and supervision when unsteady. Also, the facility did not follow R5's Care Plan approaches by allowing R5 to wear regular socks instead of wearing shoes or nonskid socks to prevent slipping while walking. B. The Incident/Accident Report for a fall on [DATE] at 5:30 am (second fall) documents that R5 was found by staff sitting in the floor on his bottom next to his bed. R5 stated he was trying to put his clothes on. The immediate intervention implemented according to this report was to place appliques beside R5's bed and educate R5 to wear shoes, use call light and ask for help. Review of R5's Care Plan of [DATE] does not include a plan with interventions to provide frequent checks for R5. There is no mention in the incident information that the [DATE] fall information was taken into consideration and used in the analysis of the falls and used to develop a plan for increased supervision during times when R5 would be changing clothes. The facility did not follow R5's Care Plan of [DATE]. R5's Care Plan does include an intervention to "Make sure resident has proper fitting shoes with laces tied or skid free slippers on before all transfers or ambulation." C. The Incident/Accident Report for a fall on [DATE] at 11:15 am (third fall) documents that R5 was attempting to get up off the edge of the bed and his foot slid causing him to fall face forward resulting in a knot on R5's forehead and a skin tear to the right ear. R5's Care Plan dated [DATE] had a new intervention added on [DATE] to encourage R5 to keep door open. Review of R5's Care Plan of [DATE] does not include a plan with interventions to provide frequent checks for R5. There is no mention in the incident information that the facility looked at the previous falls and used the information to develop a plan with interventions for increased supervision and R5's increasing weakness. D. The Incident/Accident Report for a fall on [DATE] at 12:30 am (fourth fall) documents that R5 was observed laying on the edge of the bed and was observed to roll out of bed onto the floor on his right side. The immediate intervention listed on this report was to replace the old nonskid socks with new ones and educate R5 to use his call light if he needs assistance. The Post Fall Investigation documents that R5 is a one person transfer and needs assistance with ambulation. R5's Nurse's Notes of [DATE] documents after this fall R5 had "gait slow - unsteady - shuffles - slumps - speech slow - slurred". Review of R5's Care Plan of [DATE] does not include a plan with interventions to provide frequent checks for R5. There is no mention in the incident information that the facility looked at the previous falls and used the information to develop a plan with interventions for increase supervision and R5's increasing weakness with declining condition. E. The Incident/Accident Report for a fall on [DATE] at 8:20 pm (fifth fall) documents that R5 fell out of bed onto right hip with no injury. The facility Post fall investigation of that date documents that R5 was again sleeping on the edge of the bed and is a one person assist for transfer and ambulation. The new intervention to be implemented on R5's Care Plan of [DATE] was a concave mattress. Review of R5's Care Plan of [DATE] does not include a plan with interventions to provide frequent checks for R5. There is no mention in the incident information that the facility looked at the previous falls and increasing confusion .to develop a plan with interventions for increased supervision nor did they consider looking at toileting schedules, sleep schedules, and need for increased activities for R5. F. The Incident/Accident Report for a fall on [DATE] at 2 pm (sixth fall) documents R5 was heard yelling and was found in his bathroom on floor in front of the toilet. R5 was assessed and found to have external rotation of the left leg and R5 complained of extreme pain and was placed on a back board with left leg and hip stabilized with pillows. R5's Nurses Notes dated [DATE] at 2 pm document R5 was found on the bathroom floor complaining of severe left hip pain and was transported to the emergency room . Review of R5's Nurse's Notes for [DATE] at 4 am documents that the hospital called to inform the facility that R5 had expired. The Certificate of Death record for R5 documents date of death as [DATE] and the cause of death "Respiratory Arrest", with sequential conditions leading to the cause as "Fall, Femoral Neck Fracture, and Pulmonary Fat Embolism". The Certificate of Death lists the date of the injury as [DATE] at 2:30 pm. The description of how the injury occurred is given as "Fall". Z2, R5's Physician, was interviewed on [DATE] at 4:35pm and stated that he was informed of R5's falls and his decline in physical condition. Z2 stated that R5 had gradual weakness and failure to thrive. Also, Z2 said it was possible for the Femoral Neck Fracture to have caused the Pulmonary Fat Embolism and R5's death. 3. R8 is a [AGE] year old resident with a [DIAGNOSES REDACTED]. This information was obtained from review of the Hospital Discharge Summary dated [DATE]. On admit, the facility assessed R8 as high risk for falls as noted on the Fall Risk Evaluation dated [DATE]. R8's initial Minimum (MDS) data set [DATE] assessed R8 as needing extensive assist with bed and transfer mobility as well as toileting. Balance was assessed as being not steady and only able to stabilize with staff assist. A. Review of the nurses notes and the Facility Incident/Accident Report both dated [DATE] noted that R8 had a fall with no injury on [DATE] at 4:45 am in her room. This fall was witnessed by a Certified Nurse Aide who was entering the room at the time. R8 had been seen 15 minutes before the fall transferring herself to the bed side commode. The report indicates that R8 was reminded that she was to call for assistance because she had a fractured hip, with R8 replying to staff that she was not "here" for them to take care of her and that she could do what she wanted. R8, according to the report, did not recall that she had recently fractured her right hip and a mobility monitor was put in place at that time. R8 was diagnosed with [REDACTED]. The current care plan (with a run date of [DATE]) does not include an individualized plan with interventions to provide supervision to prevent R8 from attempting self transferring. B. A second fall occurred on [DATE] at 1:15 am in her room as noted by review of the Facility Incident/Accident report dated [DATE]. The Incident Report indicates that R8 had been agitated all night and had increased confusion. The report also notes that R8 had been sitting at the nurses station in a wheel chair 10 minutes prior to the fall but had wheeled herself down to her room. It indicates that R8's mobility alarm was sounding at the time she was found. R8 sustained a skin tear to the right arm. The same care plan dated above had an approach added on [DATE] to contact the physician for a follow up urinalysis because of signs and symptoms (of continuing urinary tract infection). No other approaches are noted after this second fall such as increased monitoring schedule, increased toileting or increasing fluid intake to assist in treatment of [REDACTED]. E1, Administrator, stated per interview on [DATE] at 4:30 pm that any approaches added after the second fall are noted on the care plan (as noted above). Review of R8's Care Plan document that no other approaches were attempted. C. R8's third fall occurred on [DATE] at 5:45 pm in R8's room as noted by review of the Facility Incident/Accident report dated [DATE]. It indicates that R8 had disconnected her mobility alarm and stated that she just wanted to get up and walk around her room. According to the report, R8 had last been observed eating supper 5 minutes earlier. R8's Nursing Notes for [DATE] at 5:45 pm document that R8 complained of pain to her left hip and a skin tear of her left arm was noted. R8's x-ray report dated [DATE] indicated that the x-ray was normal. The mobility alarm was discontinued and a pressure alarm was implemented at all times on [DATE] according to R8's Care Plan. On [DATE] the nurses notes indicate that R8 was continuing to complain of left hip pain and soreness and a pelvic x-ray was ordered and indicated a possible left hip fracture. Ultimately, a Computerized Topography (CT) scan was performed on [DATE] and an acute fracture of the left femoral neck was noted according to R8's CT report. There is no indication that the facility took into account R8's first two falls occurred in her room and used the information to implement additional approaches on the Care Plan to address the issue, resulting in R8's third fall and another fractured hip. 4. E1, Administrator, and E2, Director of Nurses, E3, Assistant Director of Nurses, were notified of the Immediate Jeopardy on [DATE] at 9:35 am. The Immediate Jeopardy was determined to have begun on [DATE] when R3 sustained Bilateral Subdural Hematomas due to head and face trauma from falling twice on that date. The facility failed to thoroughly investigate falls, develop interventions to prevent falls, monitor to ensure that care plan interventions are implemented to prevent falls, provide adequate supervision during periods of unsafe ambulation/change in condition, and evaluate the environment for accident hazards. The surveyor confirmed through interview, observation, and record review that the facility took the following actions to remove the Immediate Jeopardy. A. The staff completed an environmental assessment of lobby and lift chair and moved the lift chair . Completion date [DATE]. B. The facility identified current and new residents at high risk as defined by a Fall Risk Evaluation score of 10 or above. Completion date [DATE] and ongoing. C. Current and new residents identified at high risk will be evaluated utilizing the Fall-Accident Prevention Auditing Tool to guide the development, review, and revision of Care Plans. Completion date of [DATE] and ongoing. D. Review of Certified Nurse Aide care records for inclusion of fall prevention interventions. Completion date of [DATE] and ongoing. E. The facility Safety Committee will evaluate the physical environment to identify and correct potential hazards . Completion date of [DATE] and ongoing on a monthly basis. F. Staff will be educated on the Fall Prevention Policy and Fall management Process. Any staff who has not received this inservice training will be pulled from the schedule and not return to work until they receive the training. Completion date of [DATE]. G. New employee orientation content will be modified to include Fall Prevention Policy and Fall Prevention Process. Completion date of [DATE] and ongoing. H. Residents who have experienced a fall will be evaluated utilizing the Fall-Accident Prevention Auditing Tool weekly for four weeks, then monthly for three months then quarterly. Completion date of [DATE]. I. The Quality Assurance Committee which includes the Medical Director will review the audits of fall for continued compliance with staff knowledge and competency of protocol until the compliance is maintained as determined by the Quarterly Assurance Committee review. Completion date of [DATE]

I. Based on observation, interview, and record review the facility failed to provide appropriate assessment and services for pain relief for one of three residents observed during wound treatment (R1) from sample of twenty-four. This failure resulted in severe pain, as evidenced by the resident crying out in pain during treatment. Finding include: 1. Minimum Data Set of 03/03/11 indicated R1's cognition is severely impaired. Comprehensive Pain Assessment of 04/26/11 indicated R1 has severe pain during treatment of [REDACTED]. On 04/26/11 at 10:00 AM observed E5 (Registered Nurse) doing wound care on the Stage IV decubitus. R1 was observed yelling out " You're hurting me" several times and asking "Are you about done?" Prior to the treatment E5 stated that she was concerned with the pain R1 experiences with the wound care. Review of physician's orders [REDACTED]. In an interview on 04/27/11 at 9:15AM, with E2, Director of Nurses, stated that prior to R1's hospitalization of 04/14/11 to 04/16/11, R1's medication regimen included [MEDICATION NAME] 50 mcg. Interview with E5 on 04/27/11 at 12:40PM indicated R1 has pain with each wound treatment and this is recorded on the 04/18/11 and 04/26/11 Weekly Wound Documentation sheet. Interview with E1 (Administrator) and E2 on 4/27/11 at 9:15 AM indicated the facility had not contacted the physician or family for added pain medication to be given prior to treatment. II. Based on interview and review of records, the facility failed to provide appropriate treatment for [REDACTED]. Findings include: According to the current physician's order [REDACTED]. During a resident interview on 4/26/11 at 11:00 a.m., R10 stated that she was angry with her nurse, E7, for not assisting her with her pain. R10 did not recall the exact date, but stated that E7 brought her 2 tablets of [MEDICATION NAME] at breakfast time, due to complaints of headache. R20 stated that she only wanted to take one of the pills, and that E7 threw the other pill away. R20 stated that she asked for additional pain relief later, and that E7 stated that she could not have anything else until 3:30 p.m. R20 stated that she was crying in pain and asking for relief, and that E7 stated that she would have to wait. R20 stated that she reported the problem, but did not know what was done. In an interview with E1, Administrator, at 1:00 p.m. on 4/26/11, E1 stated that she had spoken with E7, and that E7 did not realize that R10 could alternate her [MEDICATION NAME] and her [MEDICATION NAME]. When asked if R10 had received any non-pharmaceutical interventions to assist her with her pain or if R10 ' s physician had been consulted regarding her failure to achieve pain relief, E1 acknowledged that neither had occurred.