Every finding on record at Wabasso Restorative Care Center

Based on observation, interview, and record review the facility failed to implement appropriate interventions and supervision, monitor and assess changes in mood and mental status, coordinate care with psychiatric providers, and notify the providers of changes in mood/behavior for 1 of 3 residents (R1) who had a significant history of suicidal ideation and suicide attempts. These failures resulted in Immediate Jeopardy (IJ) when R1 attempted suicide after a progressive decline in mood and behavior following the discontinuation of two psychotropic medications without increased monitoring, provider notification, or revision of interventions. Additionally, following R1's return from the hospital, the facility failed to ensure objects that could be used for self-harm were removed or secured despite ordered suicide precautions.The Immediate Jeopardy (IJ) began on 6/23/26, when it was identified R1 had a change in mood and behaviors, interventions and monitoring were not reviewed, and psychiatry was not notified of changes; then on 6/27/26 R1 attempted suicide by stabbing himself in the neck with a shard of mirror glass and required hospitalization. On 7/6/26 at 1:30 p.m., the Administrator and director of nursing (DON) were notified of the IJ. The IJ was removed on 7/8/26, after it was verified the facility implemented an acceptable removal plan. However, non-compliance remained at a lower scope and severity of D, no actual harm, with potential for more than minimal harm.Findings include:R1's face sheet identified diagnoses of suicidal ideations, generalized anxiety disorder, insomnia due to other mental disorders, and major depressive disorder, recurrent, severe without psychotic features.R1's after visit summary of hospitalization dated 3/7/26-3/19/26, identified R1 had been admitted to the hospital for suicidal ideation. Behavioral health consult requested to be done within two weeks of discharge. R1's physician orders directed to start taking Duloxetine (antidepressant medication) on 3/20/26 (did not include dose).R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had no cognitive impairment and did not have inattention, disorganized thinking, or altered level of consciousness. R1 had no hallucinations, delusions, or behaviors with staff or other residents. R1's PHQ-9 (assessment used to identify depression symptoms) was zero, which indicated R1 did not have any symptoms of depression and was administered an antidepressant. R1 had no impairments on upper body, but impairments on both sides of lower extremities. However, was dependent on staff for activities of daily living that involved mobility. R1 was continent of bowel and bladder and used a wheelchair.R1's physician order dated 3/19/26, included the order for Duloxetine 30 milligrams (mg) by mouth daily as per the hospital discharge summary. On 3/20/26 the dose was changed to 60 mg.R1's Social Service Trauma Informed Care History dated 3/24/26, indicated the most difficult time in his life was when his older brother committed suicide and he had a traumatic marriage. R1 got through those difficult times by learning about it. R1 relied on my own strategies to go through hard times. I work on a positive attitude. R1's triggers were if I become moody and get down, it's a trigger to more depressed feelings.R1's social service progress note dated 3/25/26 at 9:52 a.m., indicated a [NAME] assessment was completed which identified R1 was at low risk for suicide (the Columbia Suicide Severity Rating Scale supports suicide risk assessment through a series of simple, plain-language questions and identifies whether someone is at-risk for suicide, severity and immediacy of that risk, and gauges the level of support the person needs). R1 signed psychiatric consents and will see psychiatry today. R1 was on 15-minute checks for safety. R1 stated if he were to end his life, he would stop eating, drinking, and taking medications. The progress note did not identify R1's responses, the scoring, or the clinical rationale supporting the low-risk determination. The completed assessment was requested but not received.R1's nursing order dated 3/25/26, identified in the Medication Administration Record (MAR) to ensure R1 takes all medications, check mouth to confirm all medications are swallowed, and report any refusals.R1's psychiatric visit note dated 3/25/26, identified after meeting with R1 it was HIGHLY recommended HOSPITALIZATION at a geripsych unit if possible or specialist psych unit as R1 CANNOT BE ADEQUATELY CARED FOR IN A SAFE AND SOUND FASHION at current facility due to inability to complete 1:1 observation due to staff limitations. If R1 returned from ED, must be placed on 1:1 observation or at minimum 10-minute checks with room clearing. R1's progress note dated 3/25/26 at 2:01 p.m., identified R1 was evaluated by the rural psychiatric physician and was ordered to be sent to the emergency department (ED) for further evaluation. If R1 returned he would be placed on 1:1 observation and would be seen by rural psychiatrist 3/26/26.R1's Emergency Department After Visit Summary (AVS) dated 3/25/26, identified R1 was seen at the Emergency Department (ED) for suicidal ideation and depression. R1's NP Psychiatric-Mental Health ED consult evaluation dated 3/26/26, included R1 came from facility due to suicidal ideation in which he was going to stop eating and drinking to commit suicide. R1 continued to endorse suicidal ideation. R1 stated he had been having suicidal thoughts and failed to kill himself in January when he attempted to slit wrists with a butter knife as well as a sharp plate edge. The facility should include a part to the care plan on how to appropriately respond to R1's report of suicidal thoughts and when they require additional assessment at the ED. R1 may benefit from a 1:1 assist in reassuring safety at the facility and certain sharp objects should be monitored while medication adjustments and therapy take place. The therapist can develop a plan with R1 moving forward and work with facility. The AVS summary included discharge instructions to follow-up with outpatient recommendations from psychiatric consultant, and return for worsening depression, increased thoughts of self-harm, isolation, or new concern. Patient education included: a suicidal crisis can move quickly. A person may feel ok in one moment, be affected by something that happens that is upsetting to them and jump to making decisions without thinking. Plan for safety by limiting access to things that can harm you including medications, poisons, sharps, items to strangle or suffocate, alcohol and firearms. Increase communication. Additional patient education had a section that listed The Danger Signs of Suicide which included (but not limited to): Suddenly become happier or calmer and making funeral plans/setting affairs in order/or giving away belongings. Education also included Symptoms of Depression which included (but not limited to) Irritability, increased crying, anxiety, and panic attacks.R1's progress note dated 3/26/26, identified R1 returned from hospital with no new orders.R1's care plan dated 3/26/26, identified ineffective coping related to history of traumatic events, suicidal thoughts, mental health, brother's death, and triggers moody when depressed. Interventions included: allow to express feelings, assist to acknowledge the traumatic event and begin to work through the event by talking about the experience and expressing feelings in a calm, safe environment. Encourage resident to resume normal activities and begin new ones. The focus interventions dated 3/28/26 informed staff of R1's past traumas and he got through difficult times by finding coping strategies and working on positive attitude however the care plan did not identify if R1's coping strategies were different than 3/26/26 interventions, and no strategies or interventions to maintain or develop a positive attitude were defined or individualized.R1's care plan dated 3/26/26, identified R1 used psychotropic medications related to depression, anxiety, and insomnia. Target behaviors dated 3/26/26 included: negative thought process, self-isolation, low self-worth, teariness (sic). Behavioral interventions dated 3/26/26 included grounding techniques (techniques were not specified), show empathy, encourage to join activities, and mealtime outside of room. Behavior Triggers dated 3/28/26: 1-being away from daughters/grandchildren; 2-remembering difficult times. Additional interventions included referral to psych services and administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness every shift. Care plan directed staff to monitor/document/report as needed (PRN) adverse reactions to antidepressant therapy which included (not limited to): change in mood/behavior/cognition, hallucinations/delusions, social isolation, suicidal thoughts, fatigue, insomnia, appetite loss, and weight loss. Further directed to monitor/document/report as needed (PRN) any adverse reactions to anti-anxiety therapy which included (not limited to): drowsiness, lack of energy, depression, dizziness, and impaired thinking/judgement. Target behaviors included Additional intervention directed referral to psych services. Review of R1's record between 3/25/26 through 3/26/26 indicated, following R1's psychiatric evaluation and emergency department assessment for suicidal ideation on 3/25/26 and 3/26/26 it was not evident the facility revised R1's care plan to address the psychiatric providers' resident-specific recommendations. Specifically, the care plan did not address staff response when R1 verbalized suicidal thoughts, circumstances requiring additional emergency psychiatric evaluation, the recommended level of observation of 1:1 or 10-minute checks to maintain R1's safety, or environmental safety interventions, including room clearing and monitoring access to sharp objects while medication adjustments and therapy were taking place. Additionally, the care plan did not identify therapeutic interventions or therapist involvement to develop an ongoing plan addressing R1's suicidal ideation and behavioral health needs.R1's progress note dated 3/27/26 at 5:49 a.m., identified R1 remained on 15-minute safety checks due to suicidal ideation. R1 observed to be pleasant with no signs/symptoms of distress. R1 denied plans for self-harm. R1 stayed in bed throughout entire shift. At 8:25 a.m., R1 had suicidal ideation but no plan at the time. R1 stated he felt like not eating or drinking anything in order to die. R1 ate fairly for all meals offered. R1 complained of extreme pain on his legs and lack of sleep. R1 was on medication for sleep and pain control but felt they were not effective. Provider notified.R1's psychiatric visit note dated 3/27/26, identified R1 began Risperidone (antipsychotic) 1-2 mg at bedtime to address severe depression and perseveration. Recommendation also included being referred for psychotherapy and pain management. Agreed with maintaining R1 on 15-minute checks with ongoing close monitoring along with daily telehealth visits for seven days.R1's progress note dated 3/27/26 at 1:48 p.m., identified R1 was seen by psych provider via telehealth. R1 expressed numerous times he no longer wanted to live and prayed every day that he would. R1 stated he had no quality of life, was a bad person, and just wanted a needle that will end his life just like a sick dog. R1 told his daughters not to visit him. R1 felt if he had better sleep, he may not feel like this. Psych provider prescribed Trazadone 50 mg at bedtime. Staff are to complete [NAME] scores daily, 15-minute checks, and observe that R1 was taking medications. R1 would also have televisits daily with psych provider over the weekend and into the next week. Psych provider also ordered Risperidone 1 mg at bedtime starting 3/28/26. Record review identified the directives were transcribed into the electronic health record as nursing orders.R1's progress note dated 3/29/26 at 5:36 p.m., identified R1 wished to die but denied an intent or plan. Risperidone had not arrived to facility but will start as soon as available. R1 was cheerful but complained of feeling sad still regarding stroke and recovery. Continue suicide precautions with 15-minute checks and daily psych visits.R1's Columbia Suicide Severity Rating Scale dated 3/31/26, identified in the past month R1 did not wish he was dead or wished he could go to sleep and not wake up, did not have a response marked for if he had any thoughts of killing himself, and answered 'NO' to thinking about how he might do it, having these thoughts and some intention of acting on them. Another unanswered question was if he had started to work out or worked out the details of how to kill himself and if he intended to carry out the plan. The final question involved asking if he had ever done anything, started to do anything, or prepared to do anything to end his life which was answered 'NO'. Based on the results R1 was a low risk for suicide however, the record did not indicate how the low-risk categorization was determined despite the incomplete assessment.R1's care plan dated 3/31/26, identified R1 had a mood problem related to depression and was at risk for decreased socialization, worsening depression, and anxiety. Interventions included: administer medications as ordered. Monitor/document for side effects and effectiveness; behavioral health consults as needed (psycho-geriatric team, psychiatrist etc); monitor/document/report PRN any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing medications or therapy, sense of hopelessness or helplessness, impaired judgement or safety awareness; monitor/record mood to determine if problems seem to be related to external causes: medications, treatments, concern over diagnosis.R1's Medication Administration Record (MAR) for 3/1/26-3/31/26, identified R1 took his Risperidone on 3/29/26, 3/30/26, and 3/31/26.R1's progress note dated 4/1/26, at 10:36 a.m., identified R1 had a telehealth psych appointment. R1 was in a good mood and stated he no longer had thoughts of dying.R1's progress note dated 4/3/26, but recorded as a late entry, identified R1 graduated from daily telehealth psych visits and would be seen for a regular follow-up appointment 4/9/26. R1 was discontinued from 15-minute checks and Columbia Suicide assessments.R1's telehealth psych visit note dated 4/9/26, identified R1 stated he was returning to his old self and no longer wearing a mask. Attributed dramatic improvement to initiation of Risperidone. Endorsed good appetite and good sleep. Denied hopelessness or low self-worth. Significant improvement in anxiety. Described suicidal ideation as a temporary blimp and uncharacteristic. Expressed strong motivation for self-advocacy and helping others. R1 expressed multiple future-orientated goals including moving closer to family.R1's telehealth psych visit note dated 4/16/26, identified past suicide attempts included refusal of medications, food, and fluids, cutting of wrists and throat with serrated butter knife and broken plate, and purchasing of a tarp and knife to cut wrists and throat in freezing weather. Staff report R1 continued to have a good mood and was pleasant. Sleeping and eating well. Does not appear overly anxious, had been getting up in wheelchair and wheeling around facility. No significant behaviors and no recent suicidal or homicidal statements. R1 stated his mood was fine with no current feelings of depression beyond frustration with residing at facility. Continue current scheduled medication regimen without changes given significant improvement and follow-up in one month. R1 and facility staff aware of reaching out sooner should concerns, questions, or side effects arise. Safety plan included to utilize holistic approach of healthy eating, journaling, and general self-care. Proactively ensure medications/sharps/weapons/firearms/etc. are always secured. R1 was in a monitored environment without access to firearms and medications administered by nursing. In the event of a crisis, R1 would reduce time alone, inform staff, contact professional supports, or return to clinic. In the event of an emergency, call 911 and present to the ED.R1's MAR dated 4/1/26-4/30/26, documented R1 took Duloxetine 60 mg daily, and Risperidone 1 mg daily without refusals of either medication documented.R1's nursing order dated 4/24/26, identified to monitor R1 for suicidal ideation with regular mood and safety checks. Track all food and fluid intake each meal, encourage eating, offer alternatives if meals are refused. Notify provider of poor intake or worsening condition.R1's telehealth psych visit note dated 4/30/26, identified R1 should continue Duloxetine 60 mg and Risperidone 1 mg for treatment-resistant major depressive disorder daily. R1 reported stable mood without significant depression but would experience occasional lows due to current living environment. No acute safety concerns expressed and denied self-injurious thoughts and behaviors, suicidal ideation, homicidal ideation, and psychosis.R1's progress notes on 5/9/26, 5/10/26, 5/13/26, identified R1 was monitored for suicidal ideation with no suicidal ideation noted.R1's progress note dated 5/14/26, identified R1 had a telehealth psych visit. R1 stated everything was going well. No medication changes and follow-up in one month.R1's progress note dated 5/15/26, identified R1 had no suicidal ideation or comments.R1's progress notes dated 5/20/26, identified R1 requested to have multiple medications discontinued as he does not want them.R1's progress note dated 5/21/26, identified per pharmacy reviews, R1's Risperidone had been discontinued. R1 was ok with this. R1's handwritten patient orders dated 5/21/26, identified to discontinue Risperidone 1 mg. This order was signed by APRN-A and acknowledged by LPN-A.Although the facility identified Risperidone was discontinued based on a pharmacy recommendation; however, despite request, no pharmacy recommendation supporting the discontinuation was providedDuring a telephone interview on 7/6/26 at 9:12 a.m., pharmacist (PH)-B reviewed R1's record from pharmacy. PH-B could not locate a gradual dose reduction recommendation for Risperidone or a pharmacy recommendation to discontinue. PH-B stated her record showed on 5/21/26, APRN-A had signed a handwritten order to discontinue Risperidone. PH-B stated the order to discontinue Risperidone raised a red flag for her and she did not think Risperidone should have stopped abruptly.During a return call telephone interview on 7/8/26 at 9:05 a.m., pharmacist (PH)-A reviewed her pharmacy recommendations for R1 from April and May 2026. PH-A stated in April, she gave a recommendation for clarification on the diagnosis used for Risperidone. PH-A stated she did not make any recommendations in May to discontinue or change the Risperidone.R1's progress note dated 5/23/26, identified R1 was monitored for suicidal ideation, none noted. R1 was happy and described the day started good.R1's progress note dated 5/25/26, identified R1 was monitored for suicidal ideation and none noted.R1's progress note dated 5/28/26, at 7:44 a.m., indicated R1 did not want to take Duloxetine. Progress note at 10:45 a.m., R1 had spoken to LPN-A, who also identified as nurse manager, that he would like his Duloxetine discontinued as he doesn't need it anymore. Note further indicated a physician order was obtained to taper off Duloxetine every other day for two weeks then discontinue.R1's physician order dated 5/29/26, identified Duloxetine 60 mg give one day off and one day on until 6/12/26.R1's MAR dated 5/1/26-5/31/26, documented R1 was administered Risperidone daily without refusal until the last dose was given on 5/20/26. The MAR also documented Duloxetine was administered daily when scheduled without refusal.R1's progress note dated 6/1/26, identified R1 had no suicidal ideation during the shift.R1's social service progress note dated 6/2/26, identified R1 came to the office about a past complaint. Social service offered a grievance form but R1 declined and stated he would let it go. R1 requested to return to Assisted Living he had previously resided at or another facility.R1's progress note dated 6/10/26 at 1:26 p.m., identified R1 had been seen for wound rounds. Provider and LPN-A noted R1 to be sarcastic and short-tempered during visit. R1 was tapered off his Duloxetine, last dose 5/28/26.R1's telehealth psych visit note dated 6/11/26, identified nursing staff reported R1 requested to discontinue Duloxetine, and was currently being tapered off with plan to be discontinued on 6/12/26. Risperidone was discontinued 5/21/26 (sic), following pharmacy recommendation. Since these adjustments were made, R1 had seemed more negative and gruff, made comments that come across as more critical and harsh. Had not made suicidal or homicidal statements. Does not appear overly anxious, no concerns with eating or sleeping habits. Requested to discharge from facility to live closer to family. R1 stated he couldn't be better. Denied depression, irritability, hopelessness, or low self-worth, excessive risk-taking activities. R1 stated he could think clearly since Risperidone discontinued and Duloxetine changed. Medications discontinued and tapered by primary care physician. No acute safety concerns as R1 denied suicidal ideation, homicidal ideation, and hallucinations. No medication adjustments recommended due to the significant medication changes completed one week apart. Recommend ongoing close monitoring by facility staff for any return of suicidal ideation which occurred upon admission to facility which required initiation of Risperidone approximately three months ago to address. Safety plan remained unchanged. Will plan for a 1-month follow-up meeting sooner should concerns or questions arise.Review of R1's record from 5/20/26 through 6/27/26 indicated the facility did not increase the frequency of mood monitoring or suicide risk assessments following the discontinuation of Risperidone and Duloxetine despite psychiatry's recommendation for ongoing close monitoring.R1's progress note dated 6/11/26, identified R1 had a telehealth psych visit. Provider made no medication changes. Staff to monitor for mood changes due to decrease in antidepressants. Follow-up in one month.R1's progress note dated 6/12/26, identified R1 was monitored for suicidal ideation with no suicidal ideation noted.R1's progress note dated 6/16/26 at 10:52 p.m., identified R1 had used profanity and disrespected staff. R1 was lying in bed, awake, staring at the ceiling, perturbed, irritated, and ruminating. R1 was not getting the answers he wanted to hear and did not want to have a positive/problem solving conversation. Interventions attempted included reapproach and firm boundaries which were not effective.Although R1 was showing signs of mood changes, the facility did not report concerns to psychiatry or primary care provider, and the care plan was not revised with new interventions to address the decline.R1's progress note dated 6/23/26 at 11:58 a.m., identified R1 was seen due to concerns of self-isolation, depressive symptoms, and negative interactions with staff. R1 recently discontinued Duloxetine and Risperidone and stated he was doing well without them. Discussed psychiatric follow-up for medication management or talk therapy. R1 declined and stated he did not need psychiatric services. Education provided regarding the benefits of ongoing psychiatric support. R1 verbalized understanding and declined services.Although R1's 6/23/26 progress note identified concerns with self-isolation, depressive symptoms, and negative interactions with staff, the medical record did not reflect documentation supporting the frequency or progression of these behaviors beyond the progress notes dated 6/10/26, 6/11/26, and 6/16/26. There was no evidence the facility increased mood monitoring or completed additional assessments in response to R1's decline. Further, the record did not indicate the physician or psychiatry were notified of the change in R1's mood despite the subsequent offer of psychiatric services. Additionally, there was no evidence the care plan was evaluated for effectiveness or revised to include resident-specific interventions addressing the documented decline.R1's social service note on 6/23/26 at 1:24 p.m., identified R1 requested assistance for a ride to his bank. R1 stated his account was hacked and he needed to go in-person to fix it. Social service and health unit coordinator (HUC)-A attempted to help R1 with ride costs. R1 was unkind with words toward HUC-A, and used the F word. HUC-A redirected R1 and he responded calmer.R1's Columbia Suicide Severity Rating Scale dated 6/23/26, identified R1 answered 'NO' to all questions and was a low risk for suicide.R1's progress note dated 6/25/26, identified R1 stated he did not like anything about the facility. Inquired of discharge plan and R1 stated that is none of anyone's business. No one needs to know. R1 did not follow all of therapist's instructions during therapy session. Refused to do therapy band exercises and stated the band did not do him any good. When reflected back to R1 that he used to have a pleasant relationship with therapist, R1 replied I know. Now everything has changed. R1 would not elaborate or respond to telling therapist what could be done to improve situation.During an interview on 7/1/26 at 12:02 p.m., DON stated she thought R1's primary care provider was notified of R1's change of mood and behaviors, could not recall if psychiatry had been notified of the changes but was unable to locate notification of changes to either provider for 6/16/26, 6/23/26, or 6/25/26. R1 declined taking medications and that is why facility started monitoring him. DON had reviewed the progress note from 6/16/26, and that is why she went to talk with him on 6/23/26 (seven days later). R1 did not respond very nice to the conversation. R1 had behavior of isolating; he would come out for some activities sometimes and would watch games and movies. DON stated of R1's behaviors leading up to the incident not something you could see that was bad, but you can notice somebody, when you know them, when something is wrong. DON stated it was not a lot of behaviors but seeing something going on, isolated, being quiet, not saying hi, just general mood going down but had not increased the mood and behavior monitoring.R1's progress note dated 6/26/26 at 12:55 p.m., identified R1 was monitored for suicidal ideation and signs/symptoms of depression. R1 appeared depressed. No suicidal ideation noted. R1's Columbia Suicide Severity Rating Scale dated 6/26/26, identified R1 answered 'NO' to all questions and was a low risk for suicide.During an interview on 7/6/26 at 1:32 p.m., LPN-E stated he worked 6/26/26, that was the first time he noticed R1 was not talking as much as usual. The facility had an order to monitor for moods, so LPN-E documented that R1 was not having usual moods. LPN-E completed the Columbia Suicide assessment because of R1's mood and felt R1 was honest during the assessment. LPN-E had not been informed by NA's or other nurses that R1 had been acting differently in May or June. LPN-E did not notify physician or psychiatry of R1's mood change.During an interview on 7/6/26 at 8:02 a.m., NA-C stated she started working at the facility mid-May. When NA-C first came R1 was happy to see us, was in a good mood, wanted to go to lunch, therapy, and outside during the shift. NA-C thought a couple of weeks ago R1 started to refuse medications, getting depressed, not talking as much. NA-C gave examples that R1 used to talk about his family a lot and then suddenly would only say thank you and not engage in conversation. NA-C recalled one day R1 was really sad and depressed because his granddaughter was home and he could not see her. Sometimes when he would have therapy he would get in a bad mood. R1 socially isolated a lot more but some days were better than others.During an interview on 7/6/26 at 10:18 a.m., licensed practical nurse (LPN)-C stated he had noticed R1 had shown more signs of withdrawing since medication discontinuation but not much of a noticeable difference. LPN-C could not recall when R1's mood started to decline.During an interview on 7/6/26 at 6:46 a.m., NA-A stated prior to 6/27/26, beginning the end of May or beginning of June, R1 was more depressed, socially isolated, had some moments when he was talking like he was sad and hopeless and other days he would act and talk normal. NA-A stated at first she had noticed R1 had a lot of anger, then would be quiet. NA-A recalled on 6/27/26, R1 got up around 9:45 a.m. instead of 11:00 a.m. R1 was thanking everyone at lunch which now that I think about it, might have been something. He had been more social than normal but not too social.During an interview on 7/1/26 at 10:10 a.m., maintenance (MN)-A stated R1 had been a very open spirit to me but had appeared a bit more down lately.During an interview on 7/1/26 at 10:15 a.m., housekeeper (HK)-A stated on 6/27/26, she went to his room to clean. R1 was lying in bed. HK-A stated they said good morning to each other and that was it. R1 was being really quiet that morning and that was kind of off for him.R1's progress note dated 6/27/26 at 1:54 p.m., identified LPN-B was notified of an urgent need to respond immediately to the yard. R1 was observed with fresh blood on his shirt but not actively bleeding at the time. LPN-B instructed staff to call 9-11 while he remained with R1. R1 initially refused attempt by staff to apply pressure to neck area, where a puncture wound was suspected. R1 stated I am in prison. I just want to go meet my mother and friends who recently died. LPN-B was able to persuade R1 to surrender a piece of glass, which may have been used to puncture his neck. R1 continued to be closely monitored under supervision until he was taken to the ED. Earlier in the day, R1 had been observed in a good mood, taken medications, ate lunch in the dining room, and had a conversation with LPN-B.R1's ED notes dated 6/27/26-6/30/36, identified R1 had been in the ED since 6/27/26, due to a suicide attempt. R1 took a piece of broken glass, cut small puncture wounds to neck, chest and right upper thigh. R1 required six total stitches. R1 was medically cleared for inpatient psychiatric care but was declined due to needing assistance and medical floor declined due to not having acute medical need. R1 stated he decided to face reality and reset priorities and goals. R1 reported stabbing himself with the mirror was him acting out so he could leave the facility. R1 did not want to try another antidepressant and stated he did not like how they made him feel. R1 did not want to go to a therapist I am smarter than the therapist. R1 planned to cope at discharge with journaling and reading. R1 had staff he trusted at the facility he would reach out to if suicidal thoughts returned. R1 completed a [NAME]-Brown Safety Plan on 6/30/26, prior to return to facility. Step 1: warning signs: silent/being quiet, shut down/stop interacting. Step 2: internal coping strategies included: writing/journaling, humor, watch news, read, draw, praying/religion. Step 3: list of family/friends to contact, go outside/sit in sun. Step 4: list of people to ask for help. Step 5: list of professionals to contact including suicide prevention number. Step 6: R1 did not identify environmentally lethal methods at facility. R1 stated treating people with respect, not being alone, and life were important and worth living for to him.Review of R1's post-hospital care plan did/did not identify incorporation of the [NAME]-Brown Safety Plan, warning signs, coping strategies, or resident-specific interventions recommended by the emergency department.During a telephone interview on 7/1/26 at 10:48 a.m., nursing assistant (NA)-A stated that a couple of weeks before 6/27/26, R1 complained about his roommate and reported he could not sleep but did not explain why. NA-A had never heard R1 make comments of self-harm, and the suicide attempt shocked her. On 6/27/26, R1 got out of bed around 9:45 a.m. and nothing about his behavior caused concern. Around 1:30 p.m., after a resident reported glass and blood on the floor, NA-A

Based on observation, interview, and record review the facility failed to notify the physician for 1 of 3 residents (R1) reviewed for change of condition.Findings include:R1's face sheet dated 7/1/26, identified diagnoses of suicidal ideations, generalized anxiety disorder, major depressive disorder, insomnia due to other mental disorders, and major depressive disorder recurrent severe without psychotic features.R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had no cognitive impairment. R1 had no hearing impairment and wore glasses. R1 did not have inattention, disorganized thinking, or altered level of consciousness. R1 had no hallucinations, delusions, or behaviors with staff or other residents. R1's PHQ-9 (assessment used to identify depression symptoms) was zero, which indicated R1 did not have any symptoms of depression. R1 was on an antidepressant. R1 had no impairments on upper body but impairments on both sides of lower extremities, was dependent on staff for toileting, bathing, dressing, rolling, sitting, and transfers. R1 was continent of bowel and bladder. R1 used a wheelchair for mobility.R1's care plan dated 3/26/26, identified R1 used psychotropic medications related to depression, anxiety, and insomnia. Interventions included: administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness every shift. monitor/document/report as needed (PRN) adverse reactions to antidepressant therapy: change in mood/behavior/cognition, hallucinations/delusions, social isolation, suicidal thoughts, withdrawal, decline in activities of daily living ability, continence, no voiding, constipation, fecal impaction, diarrhea, gait (walking) changes, rigid muscles, balance problems, movement problems, tremors, muscle cramps, falls, dizziness/vertigo, fatigue, insomnia, appetite loss, weight loss, nausea/vomiting, dry mouth, and dry eyes; monitor/document/report PRN any adverse reactions to anti-anxiety therapy: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion/disorientation, depression, dizziness, lightheadedness, impaired thinking/judgement, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects: mania, hostility, rage, aggressive or impulsive behavior, hallucination; referral to psych services; target behaviors: negative thought process, self-isolation, low self-worth, teariness.R1's order dated 5/21/26, identified to discontinue Risperidone (antipsychotic) 1 milligram (mg). R1 had been on this medication for off-labeled use of major depressive disorder.R1's progress note dated 5/28/26, at 7:44 a.m., identified R1 did not want to take Duloxetine (antidepressant) 60 mg anymore, nurse notified. At 10:45 a.m., R1 had spoken to licensed practical nurse (LPN)-A, who also identified as nurse manager, that he would like his Duloxetine discontinued as he doesn't need it anymore. Order from physician to taper off Duloxetine every other day for two weeks then discontinue.R1's progress note dated 6/16/26 at 10:52 p.m., identified R1 had used profanity and disrespected staff. R1 was laying in bed, awake, staring at the ceiling, perturbed, irritated, and ruminating. R1 was not getting the answers he wanted to hear and did not want to have a positive/problem solving conversation. Interventions attempted included reapproach and firm boundaries which were not effective. R1's record did not identify notification to physician or psychiatry regarding this incident.R1's progress note dated 6/23/26 at 11:58 a.m., identified R1 was seen due to concerns of self-isolation, depressive symptoms, and negative interactions with staff. R1 recently discontinued Duloxetine and Risperidone and stated he was doing well without them. Discussed psychiatric follow-up for medication management or talk therapy. R1 declined and stated he did not need psychiatric services. Education provided regarding the benefits of ongoing psychiatric support. R1 verbalized understanding and declined services. R1's record did not identify notification to physician or psychiatry regarding this incident.R1's progress note dated 6/25/26, identified R1 stated he did not like anything about the facility. Inquired of discharge plan and R1 stated that is none of anyone's business. No one needs to know. R1 did not follow all of therapists instructions during therapy session. Refused to do therapy band exercises and stated the band did not do him any good. When reflected back to R1 that he used to have a pleasant relationship with therapist, R1 replied I know. Now everything has changed. R1 would not elaborate or respond to telling therapist what could be done to improve situation. R1's record did not identify notification to physician or psychiatry regarding this incident.R1's progress note dated 6/26/26 at 12:55 p.m., identified R1 was monitored for suicidal ideation and signs/symptoms of depression. R1 appeared depressed. No suicidal ideation noted. R1's record did not identify notification to physician or psychiatry regarding this incident.During an interview on 7/6/26 at 6:46 a.m., nursing assistant (NA)-A stated beginning the end of May or beginning of June, R1 was more depressed, socially isolated, had some moments when he was talking like he was sad and hopeless and other days he would act and talk normal. NA-A stated at first she had noticed R1 had a lot of anger, then would be quiet. Now, he is just doing a little bit of speaking.During an interview on 7/6/26 at 8:02 a.m., NA-C stated she started working at the facility mid-May. When NA-C first came R1 was happy to see us, was in a good mood, wanted to go to lunch, therapy, and outside during the shift. NA-C thought a couple of weeks ago R1 started to refuse medications, getting depressed, not talking as much. NA-C gave examples that R1 used to talk about his family a lot and then suddenly would only say thank you and not engage in conversation. NA-C recalled one day R1 was really sad and depressed because his granddaughter was home and he could not see her. Sometimes when he would have therapy he would get in a bad mood. R1 socially isolated a lot more but some days were better than others.R1's record did not identify these mood changes noted by NA's were reported to nurses, physician, or psychiatrist.During an interview on 7/6/26 at 1:32 p.m., licensed practical nurse (LPN)-E stated he worked 6/26/26, that was the first time he noticed R1 was not talking as much as usual. The facility had an order to monitor for moods so LPN-E documented that R1 was not having usual moods. LPN-E stated he did not notify physician or psychiatry of R1's mood change.During an interview on 7/1/26 at 12:02 p.m., DON stated she thought R1's primary care provider was notified of R1's change of mood and behaviors, could not recall if psychiatry had been notified of the changes but was unable to locate notification of changes to either provider for 6/16/26, 6/23/26, or 6/25/26. R1 had behavior of isolating. He would come out for some activities sometimes and would watch games and movies. DON stated of R1's behaviors leading up to the incident not something you could see that was bad, but you can notice somebody, when you know them, when something is wrong. DON stated it was not a lot of behaviors but seeing something going on, isolated, being quiet, not saying hi, just general mood going down.During a telephone interview on 7/6/26 at 9:52 a.m., medical director (MD)-A stated the facility should absolutely notify the providers of changes in mood and behaviors after every occurrence.The Notification of Changes policy reviewed 7/7/26, identified the facility must inform the resident, consult with residents physician, family or legal representative when there is a change requiring such notification such as significant change in residents mental or psychosocial condition.

Based on observation, interview, and record review the facility failed to assess continued need of as needed (prn) psychotropic medications for 1 of 3 residents (R2) with provider every 14 days.Findings include:R2's face sheet dated 7/7/26, identified diagnoses of suicidal ideations, generalized anxiety disorder, and major depressive disorder.R2's admission Minimum Data Set (MDS) dated [DATE], identified R2 had no memory issues, no issues with hearing or speech. R2 did not have behaviors towards staff or other residents. R2 was independent with activities of daily living. R2 was on an antipsychotic and received on a routine basis.R2's care plan dated 4/15/26, identified R2 used psychotropic medications due to depression, anxiety, insomnia, post-traumatic stress disorder, and history of suicidal ideations. Interventions included: administer psychotropic medications as ordered. Monitor for side effects and effectiveness every shift. Behavioral interventions: redirection, offer walk outside, distraction. Monitor/document/report as needed adverse reactions of psychotropic medications: unsteady gait, tardive dyskinesia, shuffling gait, rigid muscles, shaking, frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person. Referral to psych services, target behaviors of social isolation, pacing.R2's physician orders dated 4/14/26, identified Hydroxyzine Pamoate 50 milligrams (mg) capsule by mouth every 12 hours as needed for anxiety.R2's medication administration record (MAR) dated 4/1/26-4/30/26, identified R2 received Hydroxyzine 50 mg on 4/16/26, 4/18/26, 4/20/26, 4/21/26, 4/26/26, and 4/27/26.R2's physician encounter note dated 4/28/26, identified R2 was seen at facility on day 14 but did not address Hydroxyzine PRN usage for renewal or discontinuation.R2's physician encounter note dated 4/29/26, identified R2 was seen at facility on day 15 but did not address Hydroxyzine PRN usage for renewal or discontinuation.R2's Pharmacist's Recommendation to Prescriber dated 5/14/26, identified Hydroxyzine 50 milligrams (mg) was ordered on 4/14/26, and is overdue for 14-day review. It had not been used at all in May. Please consider discontinuation of PRN Hydroxyzine. Rationale included if PRN is to exceed 14 days, prescriber must document rationale in the medical record-AND-indicate the duration for the PRN order.R2's MAR dated 5/1/26-5/31/26, identified R2 received Hydroxyzine 50 mg on 5/16/26, 5/18/26, and 5/20/26.R2's handwritten physician order dated 5/21/26, identified discontinue Hydroxyzine 50 mg signed but not dated by physician.During an interview on 7/7/26 at 12:55 p.m., licensed practical nurse (LPN)-C and LPN-E were seated at the nurse's station. LPN-E stated for PRN psychotropic medications the floor nurse would monitor them. The medication should have a stop date on it so it would not just be continuous. LPN-C wondered if maybe that was why there were orders to monitor those medications in the MAR. When the floor nurse would notice the medication was at the 14-day mark, the provider should be emailed to renew the medication. LPN-C stated the medication should not be given after the 14-day mark unless the provider was aware. LPN-C and LPN-E verified R2 had not had a stop date on Hydroxyzine and it had been given to R2 after 14 days.During an interview on 7/2/26 at 12:42 p.m., director of nursing (DON) stated the doctor had to assess prn psychotropic medications every 14 days. Nurses and management review psychotropic PRN medications and sometimes would miss them. That is why the facility had the pharmacy recommendations monthly, they are there to help the facility when they miss it. DON could not articulate why R2 did not have the Hydroxyzine addressed by a physician during rounds.During a telephone interview on 7/6/26 at 9:52 a.m., medical director (MD)-A stated PRN psychotropics should be reviewed every 14 days for necessity. When reviewed they should determine if the medication could be discontinued, kept PRN, or prescribed.The facility Use of Psychotropic Medications policy reviewed 7/7/26, identified residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the residents medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. Psychotropic medication used on a PRN basis must have a diagnosed specific condition and indication for the PRN use documented in the residents medical record and is subject to limitations. PRN orders for antipsychotic medications only shall be limited to 14 days with no exceptions. If the attending physician or prescribing practitioner believes it is appropriate to write a new order for the PRN antipsychotic they must first evaluate the resident to determine if the new order for the PRN antipsychotic is appropriate. The policy did not address PRN psychotropic medication orders.

Based on observation, interview, and record review the facility failed to follow physician orders for 1 of 3 residents (R1) reviewed for weight gain.Findings include:R2's face sheet identified diagnoses of heart failure, rheumatoid arthritis, and localized edema.R2's admission Minimum Data Set (MDS) dated [DATE], identified R2 had no memory issues, no issues with hearing or speech. R2 was independent with activities of daily living.R2's care plan dated 4/15/26, identified R1 received diuretic for congestive heart failure. Interventions included: administer diuretic medication as ordered by physician. Monitor for side effects and effectiveness every shift. Monitor dose. May require modification in order to achieve desired effects while minimizing adverse consequences, especially when multiple antihypertensives are prescribed simultaneously. When discontinuing, gradual tapering may be required to avoid adverse consequences caused by abrupt cessation. Monitor/document/report PRN adverse reactions to diuretic therapy: dizziness, postural hypotension, fatigue, and in increased risk of falls.R2's physician order dated 4/14/26, identified Furosemide (diuretic) 20 mg for edema PRN daily for 1.5 pounds above baseline.R2's weights with corresponding medication administration record (MAR) for Furosemide administration from 4/15/26-5/12/26, identified:4/15/26-baseline weight was 168.0 pounds.4/16/26-no weight was obtained.4/17/26-weight was 169.8 pounds. This was 1.8 pounds above the baseline weight of 168.0 pounds. No PRN Furosemide given.4/18/26- weight was 169.7 pounds. This was 1.7 pounds above the baseline weight of 168.0 pounds. No PRN Furosemide given.4/19/26-weight was 169.6 pounds. This was 1.6 pounds above the baseline weight of 168.0 pounds. No PRN Furosemide given.4/20/26- weight was 171.6 pounds. This was 3.6 pounds above the baseline weight of 168.0 pounds. No PRN Furosemide given.4/21/26- weight was 172.1 pounds. This was 4.1 pounds above the baseline weight of 168.0 pounds. No PRN Furosemide given.4/22/26- weight was 173.2 pounds. This was 5.2 pounds above the baseline weight of 168.0 pounds. No PRN Furosemide given.4/23/26- no weight was obtained.4/24/26- weight was 173.9 pounds. This was 5.9 pounds above the baseline weight of 168.0 pounds. No PRN Furosemide given.4/25/26- weight was 176.0 pounds. This was 8.0 pounds above the baseline weight of 168.0 pounds. No PRN Furosemide given.4/26/26-weight was 178.0 pounds. This was 10 pounds above the baseline weight of 168.0 pounds. No PRN Furosemide given.4/27/26- weight was 177.0 pounds. This was 9.0 pounds above the baseline weight of 168.0 pounds. No PRN Furosemide given.4/28/26- weight was 182.0 pounds. This was 14 pounds above the baseline weight of 168.0 pounds. No PRN Furosemide given.4/29/26- weight was 182.0 pounds. This was 14 pounds above the baseline weight of 168.0 pounds. No PRN Furosemide given.4/30/36- weight was 183.2 pounds. This was 15.2 pounds above the baseline weight of 168.0 pounds. No PRN Furosemide given.5/1/26- weight was 185.2 pounds. This was 17.2 pounds above the baseline weight of 168.0 pounds. No PRN Furosemide given.5/2/26- weight was 184.2 pounds. This was 16.2 pounds above the baseline weight of 168.0 pounds. No PRN Furosemide given.5/3/26- weight was 183.1 pounds. This was 15.1 pounds above the baseline weight of 168.0 pounds. No PRN Furosemide given.5/4/26- weight was 186.8 pounds. This was 18.8 pounds above the baseline weight of 168.0 pounds. No PRN Furosemide given.5/5/26- weight was 186.6 pounds. This was 18.6 pounds above the baseline weight of 168.0 pounds. No PRN Furosemide given.5/6/26- weight was 181.0 pounds. This was 13.0 pounds above the baseline weight of 168.0 pounds. No PRN Furosemide given.5/7/26- weight was 182.4 pounds. This was 14.4 pounds above the baseline weight of 168.0 pounds. No PRN Furosemide given.5/8/26- weight was 187.2 pounds. This was 19.2 pounds above the baseline weight of 168.0 pounds. No PRN Furosemide given.5/9/26- weight was 188.4 pounds. This was 20.4 pounds above the baseline weight of 168.0 pounds. No PRN Furosemide given.5/10/26- weight was 188.6 pounds. This was 20.6 pounds above the baseline weight of 168.0 pounds. No PRN Furosemide given.5/11/26- weight was 190.4 pounds. This was 22.4 pounds above the baseline weight of 168.0 pounds. No PRN Furosemide given.5/12/26- weight was 190.6 pounds. This was 22.6 pounds above the baseline weight of 168.0 pounds. No PRN Furosemide given.Although R2 had a continuous weight gain greater than 1.5 pounds per day, PRN Furosemide was not administered from 4/14/26-5/12/26.During an observation and interview on 7/6/26 at 10:10 a.m., R2 was in his room, sitting in a wheelchair. R2 stated the hospital had changed his Furosemide from daily to PRN why take Furosemide off when I had congestive heart failure. Unacceptable. Could have built fluid around my heart. R2 stated he did not feel fluid buildup on himself. During an interview on 7/6/26 at 6/46 a.m., registered nurse (RN)-A stated R2 had diagnoses of localized edema and heart failure. RN-A stated R2 was ordered to get daily weights but could not articulate why the facility did not capture the weight gain. Furosemide should have been given in April and May each time the weight was above baseline as the order said.During an interview on 7/2/26 at 12:42 p.m., DON stated she would have expected nursing staff to give Furosemide every time R2's weight had increased 1.5 pounds as the order directed. The point of daily weights was for the facility to track if they are gaining weight. At the beginning of R2's stay the facility was not monitoring properly but when it was discovered, the facility did what it could to rectify the situation.

Based on observation, interview, and document review the facility failed to ensure alcohol sanitizing clothes were stored safely out of reach for 1 of 1 resident (R1). The facility's failures resulted in harm for R1 after she obtained alcohol sanitizing/germicidal wipes, placed them in a glass with water, ingested the solution, and required hospitalization with a resulting diagnosis that included acute kidney injury. Findings include: R1's face sheet dated 5/20/26, identified diagnoses of alcohol abuse, attention deficit hyperactivity disorder, major depressive disorder, and seizures. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition, had no behaviors or rejection of care, was independent with transfers and mobility with the use of a walker. R1's care plan dated 6/9/25, identified R1 had a substance abuse/dependence of alcohol abuse as evidenced by current triggers, isolation, and emotions. Interventions as follows: -Assure resident does not have access to alcohol-based products. Dated 11/6/25. -If resident goes out and brings bags, ask resident to look to assure no alcohol-based products in bags. Notify director of nursing if found. Dated 1/19/26. R1's hospital emergency department (ED) notes dated 1/14/26, identified R1 was seen in the emergency department (ED) after drinking a half a bottle of hand sanitizer attempting to get drunk. During an interview on 5/20/26 at 12:40 p.m., licensed practical nurse (LPN)-A stated she was working on 5/17/26 at around 3:00 p.m., R1 was observed running into things as she was walking, staff had entered R1's room to search for alcohol and found a drinking mug full of sanitizing wipes called Super Sani-Cloth Germicidal Wipes. R1 had admitted placing the wipes in a cup and adding some water and drinking the liquid. LPN-A stated staff found an almost empty container of the wipes in a drawer and removed them and made sure all of the wipes were all locked up in the facility. During an interview on 5/20/26 at 1:14 p.m., nursing assistant (NA)-A stated she worked the day shift on 5/17/26 and found a cup on R1's nightstand full of sanitizing wipes with some water in the bottom. NA-A informed the nurse right away and then performed an inspection of R1's room and found an almost empty container or sanitizing wipes in the drawer in her nightstand. R1 wound not tell her where she had obtained the wipes. NA-A stated R1 had a history of drinking hand sanitizer and staff were supposed to make sure R1 did not have any access to any alcohol containing products. When NA-A did a quick visual check of R1's room, she did not see any alcohol containing products in her room. NA-A stated R1 was independent with her walker and ambulate in the facility and was unsure how she would have obtained them, because all of the alcohol-based sanitizing wipes were all kept under lock and key in the nursing department. According to the manufacture label on the container of Super Sani-Cloth Germicidal Disposable Wipe (trademark name), it contained 55 percent of Isopropyl alcohol. According to the Safety Data Sheet for Super Sani-Cloth Disposable Wipes dated 3/16/26, toxicology information for ingestion as ingestion unlikely due to product form. No adverse effects. According to the National Institutes of Health (NIH) indicated isopropanol ingestion is characterized by ketosis without significant metabolic acidosis and is generally managed with supportive therapy. Approximately 80% of ingested isopropanol is absorbed within 30 minutes, with peak blood concentrations occurring between 30 minutes and 3 hours after ingestion. About 80% of absorbed isopropanol is metabolized by hepatic alcohol dehydrogenase to acetone. Isopropanol has an elimination half-life of approximately 3-7 hours, whereas acetone has a longer half-life of approximately 22 hours and is primarily excreted by the kidneys. Although most patients recover with supportive care, large-volume ingestions may result in significant central nervous system depression, hypotension, respiratory compromise, coma, and death. Toxicology references commonly cite a potentially lethal dose of approximately 2-4 mL/kg, although survival has been reported following larger ingestions. During an interview on 5/20/26 at 2:03 p.m., NA-B stated R1 had a history of drinking hand sanitizer so staff need to make sure all the supplies are not left out so she could get a hold of something she was not supposed to having. NA-B explained R1 had a history of going to outside appointment and stealing the hand sanitizer from the clinic. R1 used her walker independently in the facility and had a pouch on the front of her walker and could have found the wipes somewhere and hid them in there and then proceeded to try and drink them. During an interview on 5/20/26 at 2:22 P.M., trained medication aide (TMA)-A stated R1 had a history of drinking hand sanitizer so staff would check her room each shift according to the directive on the Kardex (abbreviated care plan) to see if R1 had any items that contain alcohol in her possession. However, staff did not document the checks were documented. R1's progress note dated 5/17/26 at 9:40 p.m., identified R1 was in bed and began to have a grand mal seizure (a sudden loss of consciousness and violent, involuntary muscle contractions). R1 seized for three minutes for the first seizure and for 65 seconds for the second seizure. R1 was then sent to the emergency department for evaluation. R1's hospital history and physical dated 5/18/26, identified R1 was seen for altered mental status following ingestion of alcohol wipes on 5/17/26 mixed with water. Poison control was called and recommended testing Tylenol, salicylate and alcohol levels which were normal. Altered mental status was noted upon transfer from another hospital. On arrival, drowsiness and disorientation to time and place. Acute kidney injury was noted with creatinine (a test to determine how well the kidneys are working) was elevated to 2.32 from a baseline of 1.07 (according to Mayo Clinic a normal creatinine for an adult woman is 0.59 to 1.04 mg/dl (milligrams/deciliter). R1 reported that she attempted suicide by consuming the liquid from sanitizing wipes. Creatinine noted to be back at baseline after intravenous fluids. Assessment and plan was altered mental status, agitation in the setting of suspected ingestion of alcohol wipes/water with osmolar gap(the difference between the measured osmolarity of blood-it screens for toxic alcohols like methanol (wood alcohol)) thought to be from the isopropyl alcohol per poison control. Osmolar gap is present but felt to be from possible isopropyl alcohol ingestion and no fomepizole (antidote for suspected methanol poisoning) needed per poison control as the renal function is improving and anion gap (a blood test to identify if your body is too acidic or too alkaline) was normal. R1's hospital behavior health note dated 5/19/26, identified R1 was seen for an altered mental status following drinking water that had alcohol wipes steeped in it. R1 had relevant history of alcohol use disorder and possible epilepsy. During an interview R1 was profoundly labile (rapid, intense, and often uncontrollable shifts in emotional state) and dysregulated (a state where your body or mind loses the ability to properly control it normal process) and reported ingesting the solution as an effect to feel differently and distract her mind from ruination on suicidal attempts. Assessment of presenting event that it was not a suicide attempt. Is at high risk for suicide and currently too dysregulated to engage in treatment planning. During an observation on 5/20/26 at 12:53 p.m., surveyor entered the therapy room through an unsecured door that was left open with no staff present and/or in the vicinity. At the back of therapy room there was a container of sanitizing germicidal wipes on a shelf about 5 feet above the ground and not locked in a cabinet. During an interview on 5/20/26 at 1:15 p.m., occupational therapist (OT) stated the therapy department does use sanitizing wipes. OT walked to the where the wipes were stored then confirmed that the wipes were not locked up. OT stated, the residents do not know they are here. OT explained she locked the door to the therapy room when she was not in the room, but at times she did leave the door open when she went to get a resident for therapy which would leave the room unsupervised and allow a resident to enter the room and grab the container. OT further explained she had not had any formal education on the process for keeping chemicals locked up at all times when not in use. During an interview on 5/20/26 at 2:44 p.m., director of nursing (DON) stated she had been contacted on 5/17/26 that R1 had placed a bunch of sanitizing wipes in a cup and added water to it and had been drinking the liquid. DON stated she was unsure how R1 had obtained the sanitizing clothes since nursing keeps all the sanitizing clothes under lock and key but was unaware that the therapy department had a bottle in their room that was not currently locked up. DON explained she had not checked in that department and assumed each department was responsible for ensuring the chemicals were locked up. During an interview on 5/20/26 at 2:57 p.m., social services director (SSD) stated she had provided education on 5/20/26 to the occupational therapist that all of the sanitizing clothes need to be locked up and out of resident reach at all times when staff are not using them. These types of clothes should have not been left out so a resident could easily get a hold of them and possibly ingest them. The facility would be placing them in a cabinet when not in use now and should have not been left out so a resident could easily get a hold of them and possibly ingest them. Review of an email dated 5/18/26 at 12:24 p.m., identified a performance improvement project was discussed to develop a solid plan to ensure the corrective process is implemented successfully: -Each department will have a designated locked storage area for supplies; Maintenance (boiler room); Laundry (laundry room); Nursing (white closet near therapy); Therapy (therapy room). During an interview on 5/20/26 at 4:25 p.m., administrator stated the therapy director had been included in a meeting to discuss how the facility was going make sure toxic chemicals were kept in a locked area to prevent the possibility of resident(s) ingestion. The staff member who did not follow the facility protocol for securing chemicals was given corrective action. During an interview on 5/20/26 at 3:42 p.m., medical director (MD) stated by R1 getting access to the Super Sani-Cloths that contained isopropyl alcohol then proceeding to create a kind of tea to drink, this caused her to have the acute kidney injury, however, it quickly resolved with fluids while in the hospital. MD stated the wipes should have been all kept in a locked cabinet to prevent any residents obtaining them. The facility's education with staff began on 5/19/26 included any product with high alcohol content should always be locked in a locked location. This included but is not limited to Sani-Cloths, hand sanitizers, and alcohol prep pads. Residents were not allowed to keep or have access to any products with high alcohol content. The facility also created a supply inventory checklist for each item, and a supply sign out sheet to document if and when an employee removed the product from the locked unit to ensure it would be returned. Review of the facility's Alcohol Based Hand Rub Policy dated 3/31/25, identified a new chemical management and accountability process (that was undated when added) for staff use within the building: -Each department will have a designated locked storage area containing the chemical and supplies required for that department's daily operations. Specific amounts will be maintained for each item to help ensure supplies do not run out during shifts. -Effective immediately, all staff members who remove chemicals from storage for use must sign out before use and sign them back in immediately upon return. Staff are responsible for maintaining direct supervision of any chemical brought onto the floor at all times. Chemicals must remain in the possession of the staff members using them and may not be left unattended under any circumstances. -In accordance with facility policy, no chemicals are permitted to be left in resident rooms. This includes, but is not limited to, alcohol wipes, bleach spray, urine remover, or any other cleaning or disinfecting products. Residents are not permitted access to these chemicals. -Access to the garage storage area will be limited to managers, nursing assistants, and designated staff members responsible for restocking supplies. -At the end of each shift, the staff member assigned to chemical accountability will review the sign-out sheets to verify all items have been returned and properly accounted for. Any low stock items will be restocked before the end of the shift. -If, during the review process, an item is found to be missing without proper documentation, the staff member responsible for oversight must immediately follow up with all staff members who had access to determine the item's whereabouts. If the item cannot be accounted for the group of staff will search all areas of the building to find it. If after all staff members working in that department during the shift will receive re-education on the chemical management policy, and a retraining sign-off sheet will be completed to document the education provided.

Based on interview and record review the facility failed to report an injury of unknown origin within the two-hour time period for reporting for 1 of 2 residents (R2) who had an injury of unknown origin of the right tibia (shin bone) and fibula (calf bone).Findings include:Findings include:R2's face sheet dated 4/28/26, identified diagnoses of paraplegia (paralysis to lower half of body), unspecified fracture of shaft of right tibia subsequent encounter for closed fracture with routine healing, unspecified fracture of shaft of right fibula subsequent encounter for closed fracture with routine healing, reduced mobility, weakness, adult failure to thrive neuralgia (severe nerve pain) and neuritis (inflammation of nerve).R2's comprehensive Minimum Data Set (MDS) dated [DATE], identified R2 had no cognitive impairment. R2 had impairment to both sides of lower extremities, required staff assistance with dressing, turning, and transferring surfaces. R2 used a wheelchair for mobility.R2's activities of daily living (ADL) care plan dated 5/5/25, identified R2 was able to use a wheelchair independently in the facility, and transferred with total dependence of two with a mechanical lift. Bedrest with air mattress, up to chair for one hour per shift.R2's progress note dated 4/14/26 at 8:05 a.m., identified the night nurse reported that R2 had developed edema (swelling) on the right lower leg. R2 was assessed and denied hitting his leg on anything. Physician was informed of the situation and ordered ACE wraps to begin with. R2 should be observed and if the foot does not get better, get an x-ray. R2's legs were wrapped and are being observed.R2's progress note dated 4/14/26 at 10:34 p.m., identified the on-call physician was notified due to increased swelling of R2's right lower extremity. Assessment completed with +3 pitting edema, poor capillary refill noted. R2 was sent to the emergency department for further evaluation of suspected fracture.R2's Emergency Department care summary dated 4/15/26, identified R2 presented to emergency department with complaints of right lower extremity swelling and crepitus (crackling, popping or grinding sensation or sound that occurs in joints, bones, or soft tissue). Facility reported swelling started one to two days ago. No recent falls or notable injury to cause this. X-rays identified R2 had an acute oblique longitudinal fracture of the distal tibial shaft with a lateral cortical step-off measuring up to 6 millimeters (mm) (indicating a higher energy injury), he also had a mildly displaced distal fibular shaft fracture all about 10 centimeters (cm) from the ankle. It was reported that R2 accidentally hit his right lower leg in a wheelchair. R2 was splinted and discharged back to facility.R2's progress notes dated 4/15/26 at 2:17 a.m., identified R2 returned from the emergency department with a diagnosis of closed fracture of right tibia and fibula initial encounter. Physician and director of nursing (DON) notified. Will notify power of attorney (POA) in the morning.The State Agency had no incident report submitted pertaining to R2's fractures. During an interview on 4/29/26 at 12:32 p.m., director of nursing (DON) and admissions director (AD)-A present. DON stated the incident was not reported to the State Agency and that she found out that he had fractures around 8:00 a.m., on 4/15/26. AD-A stated the origin of the injury came from the wheelchair when R2 came back to the facility he told us and it was in the notes from the hospital so it didn't meet criteria to report. If the source of injury was unknown, facility would report two hours from the time it happened. DON stated before R2 went to the hospital he did not know how the injury occurred. When R2 returned from the hospital the paperwork stated that it was from the wheelchair. R2 had a new power wheelchair and had assessments done and passed them so he was able to use the power chair. AD-A stated R2 changed to a different story a couple days after he returned from the hospital, reporting the fracture was caused from a transfer. DON stated as soon as R2's story changed she began education with nursing staff. DON had begun watching staff complete mechanical and sit-to-stand lift transfers, it is a work in progress. DON stated she watched R2 go in and out of the smoking area door as she thought maybe the door shut to hard and got his foot but R2 went in and out without difficulty. R2 was also reassessed by therapy for the power wheelchair. AD-A stated the facility was unable to determine a root cause for the fracture because all the staff that transferred R2 on the days leading up to the incident could not recall R2 bumping his leg, the names of staff he gave worked on 4/11/26 together, only NA-D worked 4/13/26, and they could not nail down a time so it was inconclusive.

Based on observation, interview, and document review the facility failed to ensure accurate comprehensive assessments for full body mechanical lift slings according to manufacturer's guidelines to ensure safe transfers for 2 of 2 residents (R2, R4) reviewed for accidents. The manufacturer instructions for Sling Selection Guide dated 5/1/26, indicated sling selection to use with the full body lift was determined by both the resident's height and weight. The guide identified it was very important to use the correct sized sling and make sure it was fitted properly prior to lifting. Size small ranged from 75 pounds (lb.) to 150 lbs. with height from 4 feet (ft) 11 inches (in) to 5 ft 4 in, medium sized ranged from 125 lbs. to 200 lbs. with height range of 5 ft 3 in to 5 ft 8 in, large slings from 175 lbs. to 300 lbs. with height of 5 ft 7 in to 6 ft, extra-large slings were from 275 lbs. to 500 lbs. with height from 5 ft 11 in to 6 ft 4in, extra extra large slings from 350 lbs. to 600 lbs. with height determined as needed.R2's face sheet dated 4/28/26, identified diagnoses of paraplegia (paralysis to lower half of body), unspecified fracture of shaft of right tibia subsequent encounter for closed fracture with routine healing, unspecified fracture of shaft of right fibula subsequent encounter for closed fracture with routine healing, reduced mobility, weakness, and adult failure to thrive.R2's comprehensive Minimum Data Set (MDS) dated [DATE], identified R2 had no cognition issues. R2 had impairment to both sides of lower extremities, required staff assistance with dressing, turning, and transferring surfaces. R2 used a wheelchair for mobility. R2 weighed 235 pounds and was 69 inches (5 feet 7.5 inches).R2's activities of daily living (ADL) care plan dated 5/5/25, identified R2 was able to use a wheelchair independently in the facility, and transferred with total dependence of two with a Hoyer (brand of full body mechanical lift). R2's care plan did not identify what size mechanical lift sling to use during transfers.R2's care plan did not identify what size mechanical lift sling to use for transfers.R2's Lift Mobility Status-V1 dated 1/8/26, completed by a registered nurse (RN), identified R2 was not bedfast, could not stand, pivot, or walk. R2 could tolerate a semi-reclined position and R2 will continue to use full lift with two staff assist for transfers. The assessment did not identify [NAME], weight, nor the sling size R2 required for transfers. R4R4's face sheet dated 4/29/26, identified diagnoses of spondylosis (degenerative changes to spine) without myelopathy (spinal cord compression) or radiculopathy (compression of spinal nerve root) lumbar (lower spine) region, muscle weakness, unsteadiness on feet, and spinal stenosis (narrowing of spinal canal).R4's admission MDS dated [DATE], identified R4 had no cognition issues. R4 required substantial assistance to roll, sit to lying, lying to sitting, sitting to standing and was dependent on staff to transfer from surfaces. R4 weighed 220 pounds and was 71 inches (5 feet 9 inches). R4's Lift Mobility Status-V1 dated 4/12/26, completed by an RN identified R4 was not bedfast, could not stand, pivot, or walk. R4 could tolerate a semi-reclined position, weight was between 376-420 pounds (which was inconsistent with the MDS dated [DATE].) and required Hoyer (brand of mechanical lift). Further, the assessment did not identify which size sling R4 required. R4's ADL care plan dated 4/11/26, identified R4 was dependent for transfers. R4's care plan did not identify what size mechanical lift sling R4 required or what device to use for transfers.During an interview on 4/29/26 at 9:34 a.m., nursing assistant (NA)-B stated there were three different sizes for mechanical lift slings depending on how large the person was. On each lift sheet there is a label that says sizes and which one to use is based on weight. NAs choose the size based off that information; NA-B did not articulate height was also required to determine appropriate size.During an interview on 4/29/26 at 10:32 a.m., NA-C stated the nurse would determine sling size. On the sling it would say small, medium, large, or extra-large. NA's could find the information in the care plan.During an interview on 4/29/26 at 9:43 a.m., licensed practical nurse (LPN)-A stated at admission the nurse completed an assessment on resident transfers. Sling sizing goes by resident weight and therapy determines sling size. LPN-A reviewed R4's care plan and verified the care plan did not identify mechanical lift sling size or what type of machine R4 needed to transfer. LPN-A reviewed R2's care plan and verified the care plan did not identify mechanical lift sling size. LPN-A stated the director of nursing (DON) or medical records complete the care plan, not the floor nurses. LPN-A would expect the sling sizes and what lift to use for residents would be in the care plan.During an interview on 4/29/26 at 10:03 a.m., certified occupational therapy assistant (COTA)-A stated nursing was in charge of sizing slings for residents that use mechanical lifts. Therapy did not make that determination.During an interview on 4/29/26 at 12:32 p.m., DON stated nursing assesses sling sizes for residents. The weight of the resident determines what sling size to use; DON did not articulate height was also required to determine appropriate sling size. The MDS or floor nurses would put the information in the resident care plan. DON stated it was not her expectation that mechanical lift sling sizes would be included in the care plans but that the information would be in a binder at the nurse's station. DON went to the nurses' station and took the NA binder and looked through it, there was no information about sling sizes in the NA binder. DON stated she would find an NA and ask how they know the sling sizes. DON went to NA-B who stated NA's decided sling size by looking in the storage closet by the office at the sling size guide and resident's weight.

Based on observation, interview, and document review the facility failed to develop an individualized pain management plan for wound treatments and failed to provide pain management during wound treatment for 1 of 2 residents (R1) reviewed for pain management.Findings include:R1's face sheet dated 4/28/26, identified diagnoses of polyneuropathy (breakdown of nerves), fracture of unspecified part of neck of left femur (thigh bone), and polyosteoarthritis (degeneration of joints leading to pain and stiffness).R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had mild cognitive impairment. R1 had verbal behaviors directed towards others one to three days and would reject cares one to three days. R1 required supervision/touch assistance with dressing, and was independent with transferring, bed mobility, and moving surfaces. R1 was occasionally incontinent of urine and frequently incontinent of bowels. R1 was not at risk for developing pressure injuries and did not have pressure injuries.R1's care plan dated 4/22/26, identified R1 was on aspirin therapy. Interventions included to administer anticoagulation medication as ordered by physician.R1's care plan dated 4/22/26, identified R1 was on opioid pain medication related to fracture. The goal was for R1 to be free of any discomfort or adverse side effects from pain medication. Interventions included to administer analgesic medications as ordered by physician, monitor/document side effects and effectiveness every shift, for respiratory depression: monitor respiratory rate, depth, and effort after administration of pain medications, monitor for increased risk of falls, monitor/document/report as needed adverse reactions to analgesic therapy: altered mental status, anxiety, constipation, depression, dizziness, lack of appetite, nausea, vomiting, pruritis (itchy skin), respiratory distress/decreased respirations, sedation, and urinary retention. Monitor/document pain on a scale of 0 to 10 before and after implementing measures to reduce pain. R1's care plan did not address R1's acceptable level of pain. R1's care plan dated 2/12/26, identified R1 had chronic pain related to absence of toes on both feet, polyneuropathy, and gastroesophageal reflux disease. Interventions included R1's pain was aggravated by neuropathy, pain was alleviated by Tylenol, Gabapentin, and rest. Monitor/record/report to nurse R1's complaints of pain or requests for pain treatment. Notify physician if interventions are unsuccessful or if current complaint is a significant change from R1's past experience of pain.R1's care plan dated 4/7/26, identified R1 had pressure wounds. Although the care plan included the intervention to treat pain as per orders prior to treatment/turning etc to ensure comfort- there was no associated physician order that directed which analgesic should be administered or when prior to the wound treatment. R1's physician orders dated 4/29/26, included Aspirin 81 milligrams (mg) daily, Tylenol 1,000 mg every 6 hours as needed for moderate pain, Gabapentin 600 mg every 8 hours as needed for pain, Oxycodone 5 mg every 4 hours as needed for severe pain with a maximum daily does of 30 mg.R1's medication administration record (MAR) dated April 2026, identified non-pharmacological pain interventions: 1. Ice 2. Distraction 3. Rest. Effectiveness-Effective or Not Effective every day and night shift document non-pharmacological interventions tried alongside of medication for pain. Offer resident pain medications frequently. Every day and night shift.In review of R1's records there was no indication of a comprehensive assessment or treatment orders or care plan interventions that addressed R1's pain prevention during wound treatments. R1's MAR dated 4/30/26, identified Aspirin was given at 8:00 a.m. with a pain level identified at 6. The record revealed no indication non-pharmacological interventions were offered or attempted and no indication R1 was offered or administered Tylenol, Gabapentin, or Oxycodone.During an observation and interview on 4/30/26 at 11:49 a.m., licensed practical nurse (LPN)-A entered R1's room to complete a dressing change to R1's buttocks. R1 was lying on his back on the bed on top of an overlay air mattress. LPN-A opened R1's brief and noticed R1 had enlarged testicles, which LPN-A stated had not been enlarged the day before. LPN-A examined R1's testicles and asked R1 if it caused him pain. Registered nurse (RN)-A entered room and examined testicles. R1 stated it did not hurt when RN-A touched abdomen and testicles. R1 began to get upset and yell at LPN-A for taking so long to do the dressing change. R1 stated he was cold and hurts. LPN-A and RN-A began to roll R1 to his right side and R1 yelled that they needed to lift his leg when they rolled him. LPN-A removed the dressing on R1's bottom and began cleaning the wound. R1 continued to yell that he was in pain and made noises oooooohhhhhhhm ahhhhhhhhh, mmmmmmmm and f*ck. R1 then screamed that it stung and that LPN-A needed to hurry up. LPN-A stated he would get R1 pain medication and R1 stated oh, I'm gonna need it.During an interview on 4/30/26 at 3:26 p.m., nursing assistant (NA)-C stated R1 screamed in pain every time he was turned or repositioned. R1 had a lot of pain and NA-C would attempt to soothe him and explain what was going to calm him. NA-C stated she would report that R1 was in pain to the nurses and trained medication aides (TMA) every time she worked with R1.During an interview on 4/30/26 at 3:31 p.m., trained medication assistant (TMA)-C stated R1 was quite stiff and would yell every time he moved positions.During an interview on 4/30/26 at 2:38 p.m., TMA-B stated she only gave as needed pain medication if a resident asked for it or the nurse told her to give it. The nurse did not have to assess the resident prior to TMA-B administering the medication but the nurse would assess for effectiveness. TMA-B was assigned to pass medications to R1 on 4/30/26. During the morning medication pass TMA-B gave R1 aspirin and rated his pain at 6. TMA-B did not notify LPN-A what R1's pain level was. R1 did not ask for pain medication and he usually would. This afternoon, R1's pain was at a 7 and LPN-A told TMA-B to give R1 Tylenol for pain. R1 asked for Gabapentin at that time also.During an interview on 4/30/26 at 2:35 p.m., LPN-A stated with a pain level of 6 you can start with the lowest Aspirin or Tylenol if R1 could have it. LPN-A stated if those interventions did not work then R1 could try Oxycodone. LPN-A stated 8 would be considered severe pain. LPN-A did not offer R1 pain medication prior to the dressing change we had started already and I should have maybe given before because R1 was in pain every time he was turned he had aspirin this morning. LPN-A stated R1 had rated his pain at 8. After the dressing change was completed LPN-A asked TMA-B to give R1 pain medication and she gave Tylenol. After reviewing R1's medication orders and the FACES pain scale, LPN-A stated R1 should have received Oxycodone for severe pain. LPN-A stated most of the time when he asked R1 about his pain he would be laying down and not in pain but when R1 moved that was when he was in pain.During an interview on 4/30/26 at 3:35 p.m., director of nursing (DON) stated R1 should have been offered pain medication when his pain was identified at 6. DON would have expected LPN-A and RN-A to stop the dressing change when R1 voiced pain. DON stated staff are to utilize non-pharmacological interventions such as putting pillows under R1's legs, calling R1's daughter, and putting Western shows on the television prior to pain medication administration. R1 had returned from the hospital on 4/29/26, and prior to the hospitalization the facility had worked with the physician on R1's pain and he had Oxycodone scheduled not just as needed. Staff should use pain scale or the FACES scale to determine level of pain. DON stated Tylenol would be an appropriate choice for pain level of 8, start with the lowest medication first and move up. DON stated R1's pain needed to be assessed and documented for the physician to review and determine if the medication should be scheduled or remain as needed. DON stated that a nurse must assess the resident prior to a TMA giving as needed medications.The facility FACES Pain Assessment Tood undated, identified the facility utilizes a numeric/faces pain assessment tool which combines a 0-10 numeric scale with corresponding facial expressions and severity categories. The scale defines 0 as no pain, 1-3 as mild, 4-6 as moderate, 7-9 as severe to very severe, and 10 as worst pain possible, and is intended to promote consistent identification and communication of pain levels.The facility 0-10 Scale of Pain Severity undated, identified severity and description of experience:0-no pain I have no pain.1-minimal my pain is hardly noticeable.2-mild I have a low level of pain. I am aware of my pain only when I pay attention to it.3-uncomfortable My pain bothers me but I can ignore it most of the time.4-moderate I am constantly aware of my pain but I can continue most activities.5-distracting I think about my pain most of the time. I cannot do some of the activities I need to do each day because of the pain.6-distressing I think about my pain all of the time. I give up many activities because of my pain.7-unmanageable I am in pain all the time. It keeps me from doing most activities.8-intense my pain is so severe that it is hard to think of anything else. Talking and listening are difficult.9-severe my pain is all that I can think about. I can barely talk or move because of the pain.10-unable to move I am in bed and cant move due to my pain. I need someone to take me to the emergency room to get help for my pain.

Based on observation, interview, and document review the facility failed to ensure proper hand hygiene and failed to ensure clean surface are for wound supplies for 2 of 2 residents (R2, R1) reviewed for pressure ulcers.Findings include:R2's face sheet dated 4/28/26, identified diagnoses of paraplegia (paralysis to lower half of body), pressure ulcer stage 4 right buttock, pressure ulcer stage 4 left buttock, and pressure ulcer stage 4 of the sacral region.R2's comprehensive Minimum Data Set (MDS) dated [DATE], identified R2 had no cognition impairment. R2 had impairment to both sides of lower extremities, required staff assistance with dressing, turning, and transferring surfaces. R2 used a wheelchair for mobility.R2's care plan dated 11/1/25, identified R2 required enhanced barrier precautions (EBP) (use of gown and gloves during high contact interactions) related to open wounds, colostomy, and urinary catheter. Interventions included direct care staff to utilize gown and gloves for all personal care, monitor for signs/symptoms of infection. Document and properly report signs/symptoms of potential infections. Monitor psychosocial and mental well-being related to EBP. Document any changes and report any symptoms promptly.During an observation on 4/30/26 at 10:19 a.m., licensed practical nurse (LPN)-A entered R2's room wearing EBP. R2 was lying on an overlay mattress on his back in bed. LPN-A did not sanitize the work space prior to beginning wound care. LPN-A lowered R2's brief and began examining R2's penis with his gloved hands. LPN-A continued to wear the same gloves and turned around and grabbed 4 inch (in) by 4 in gauze from the gauze container. Using the same gloves, LPN-A wiped around the head of R2's penis. LPN-A removed gloves and applied a new pair without sanitizing hands. LPN-A applied barrier cream to his gloved finger and wiped it around R2's penis. LPN-A removed gloves and put on a new pair without sanitizing hands. R2 rolled to his left side. LPN-A removed all three of R2's dressings. LPN-A removed gloves and applied a new pair without sanitizing his hands. LPN-A took gauze from the container, soaked it with a wound cleanser and placed the gauze inside the right pressure ulcer. LPN-A removed gloves and applied a new pair without sanitizing hands. LPN-A took gauze from the container, soaked it with a wound cleanser and placed the gauze inside the left pressure ulcer. LPN-A removed more gauze from the container, soaked it, removed a glove and put a new one on without sanitizing his hands and put the gauze in the sacral ulcer. LPN-A removed gloves and applied a new pair without sanitizing hands. LPN-A removed the gauze from all three wounds. LPN-A removed gloves and applied a new pair without sanitizing hands. LPN-A applied wound cleanser to gauze and began wiping around right ulcer. LPN-A threw away the gauze and reached his hand into the gauze container and got more gauze. Applied wound cleanser to gauze and began wiping around left ulcer. LPN-A removed a glove, did not sanitize his hands, and applied a new glove. LPN-A grabbed more gauze from the container, soaked it in wound cleanser and wiped around the sacral and perineal region. LPN-A removed gloves and applied a new pair without sanitizing hands. LPN-A opened a package of Calcium Alginate (highly absorbent material used to manage drainage and promote healing in wound care) and took a bandage scissors and cut the Calcium Alginate into three strips. LPN-A took a strip and placed it in the left ulcer. LPN-A removed gloves and applied a new pair without sanitizing hands. Took another strip and placed in the right wound. LPN-A removed gloves and applied a new pair without sanitizing hands. LPN-A then took the final strip and placed it in the sacral wound. LPN-A began touching the Calcium Alginate that was in the left ulcer. LPN-A picked up a Mepilex (bordered foam dressing) and removed the sticky back piece. LPN-A then reached into the gauze container and grabbed some gauze. LPN-A wiped the gauze around the sacral and left ulcers. LPN-A applied Mepilex dressings to the ulcers. LPN-A removed gloves and adjusted R2 in bed. LPN-A took the full garbage and left room. LPN-A walked down the hallway and entered the utility room, threw garbage away and washed hands.R1R1's significant change MDS dated [DATE], identified R1 had no cognitive impairment. R1 had a stage 3 pressure ulcer.R1's care plan dated 4/7/26, identified R1 had pressure wounds. Interventions included treat pain as per orders prior to treatment/turning etc. to ensure the residents comfort. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue, and exudate.During an observation on 4/30/26 at 11:49 a.m., LPN-A entered R1's room wearing EBP and brought wound supplies into room to perform a dressing change to R1's ulcer. LPN-A set the supplies on the overbed table. LPN-A removed the tabs from R1's brief and pulled the brief down. R1's testicles were enlarged and LPN-A began examining them with his gloved hands. LPN-A took some gauze from the container and wiped around R1's penis and testicles. LPN-A removed gloves and applied a new pair without sanitizing hands. LPN-A lifted the wound supplies into his hand and arm, took a sanitizing wipe, wiped down the overbed table, and placed the supplies back on the table. LPN-A opened Calcium Alginate. LPN-A removed gloves and applied a new pair without sanitizing hands. Registered nurse (RN)-A entered room wearing EBP to assist with dressing change. RN-A examined R1's penis and testicles, removed gloves and applied a new pair without sanitizing hands. LPN-A and RN-A rolled R1 to his right side. R1 was incontinent of bowels. LPN-A cleaned bowels. LPN-A removed gloves and applied a new pair without sanitizing hands. LPN-A removed dressing from R1's sacral ulcer. LPN-A removed gloves and applied a new pair without sanitizing hands. LPN-A sprayed wound cleanser onto gauze and cleaned ulcer. LPN-A removed gloves and applied a new pair without sanitizing hands. LPN-A placed Calcium Alginate on wound bed, opened and placed Mepilex over ulcer. LPN-A removed gloves and applied a new pair without sanitizing hands. RN-A removed gloves and applied a new pair without sanitizing hands. RN-A applied cream to penis and removed gloves. LPN-A and RN-A boosted R1 in bed. LPN-A picked up wound supplies, washed overbed table, and left room.During an interview on 4/30/26 at 12:28 p.m., LPN-A stated when doing dressing changes he would sanitize his hands prior to the first glove application and when the dressing was completed. LPN-A stated he should have cleaned the work surface prior to setting wound supplies on it for R2.During an interview on 4/30/26 at 3:35 p.m., director of nursing (DON) stated hands should be sanited before and after wound care is completed. DON expected the surface that the wound supplies would be placed on should be cleaned prior to putting wound supplies on it.The facility Hand Hygiene policy undated, identified the use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to putting on gloves, and immediately after removing gloves. Hand hygiene should be completed when, during resident care, moving from a contaminated body site to a clean body sit

Based on observation, interview and document review the facility failed to ensure 1 of 3 residents were free from avoidable accidents from hot liquids. This resulted in actual harm to R1 who spilled hot coffee on her lap and sustained a third-degree burn. In addition, the facility failed to implement a system to assess residents for safety with hot liquids. The facility implemented appropriate corrective action prior to the onsite investigation; therefore, the deficiency is being cited at past non-compliance.Findings include:A Vulnerable Adult Maltreatment Report submitted to the State Agency on 2/19/26, identified R1 was transferred to the emergency room (ER) related to fever and lethargy. R1 was noted to have a severe burn that was covering a large portion of the thigh with peeling skin. The burn was reported by R1 to be caused by spilling hot water on her thigh on 2/9/26. R1's admission Minimum Data Set, dated [DATE], identified R1 had intact cognition, walked independently with use of a walker and was independent with eating. Diagnoses included diabetes, peripheral neuropathy (damage to peripheral nerves that result in numbness, pain, and weakened in the hands and feet), malnutrition, and anxiety. R1's care plan dated 1/7/26, identified R1 was able to eat independently, a care plan revision was made on 2/12/26 to add staff were to ensure lid was on and secure for resident with hot liquids. R1's Risk Management Report dated 2/9/26, indicated R1 was having lunch and spilled hot water on her upper right thigh. The report did not include a description or measurements of the burn wound. R1's Progress Notes indicated the following:2/9/26 at 3:03 p.m., R1 spilled hot water on her right upper thigh. R1's upper thigh was visibly red. R1 was educated to be careful with hot liquids and ask for help when she needs it. The physician ordered application of Vaseline to the affected area and pain medication was administered.2/10/26 at 11:38 a.m., R1 has reddened area to her right thigh with blister approximately five inches by three inches. Provider gave orders for Xeroform, cover area with ABD (dressing) and secure with kerlix (gauze wrap), to be changed daily and as needed. R1 was also added to wound rounds on 2/12/26.2/12/26 at 11:38 a.m., partial thickness burn acquired in house, length 0.35 cm; 0.6 cm depth; 0.17 cm area; moderate dressing saturation (verified by later interviews that measurements were incorrect). 2/13/26 at 12:59 p.m., notified R1's primary care provider (PCP) that wound is not healing and asked for Silvadene (cream used for burns).2/14/26 at 10:44 a.m., R1 complaining of not feeling well and transferred to ER for further evaluation.2/16/26 at 15:28 a.m. update from ER; R1 was in surgery having fractured left ankle repaired, R1 had recurrent urinary tract infection (UTI), R1 would be seeing wound care to address burn to upper right thigh region once out of surgery. R1's PCP Nursing Home Visit note dated 2/10/26, identified PCP saw R1 in facility and was evaluated for Vitamin D deficiency; no other issues or concerns voiced from nursing staff at this time. Physical examination of skin: warm and dry. No rashes or lesions on exposed skin. The note did not include any documentation regarding R1's thigh burn. R1's telephone order on 2/10/26 at 11:45 a.m. indicates dressing to right thigh; xeroform to area, cover with ABD (dressing) and secure with kerlix, change daily and as needed. R1's Nursing Home Visit note dated 2/12/26, indicated R1 was seen by PCP for routine wound evaluation of her right thigh stage 2 (two) burn site. Photo taken of wound and debridement of wound completed. Multiple comorbidities affecting would healing and wound progression, as well as risk for wound including reduced mobility, muscle weakness, DMII (Type two diabetes), risk of malnutrition. Orders for daily wound care provided. R1's hospital Wound Care Initial Consult dated 2/17/26, identified R1's right thigh burn wound was chemically and mechanically debrided (a procedure that thoroughly cleans the wound and removes all dead tissue, foreign debris, and residual material from dressings). Wound measurements were 15 x 26 x 0.1 centimeters (cm). The burn wound was described as a partial thickness burn (involving the epidermis and part of the dermis layer of the skin) that was blistered, fragile, bleeding, and erythematous (abnormal redness of the skin).During observation and interview on 2/23/26 at 3:05 p.m., R1 was sitting on her bed fully clothed and stated she had fractured her ankle and had surgery recently and then a few days later (could not remember the exact date) the cover was not sitting correctly on top of her plastic thermal mug and it popped off causing the hot water to splash out onto her hand; it startled her and she instinctively jerked and the remainder of the hot water spilled on her right thigh. R1 further indicated that she had horrible pain, and it continued to burn through her sweatpants while the nursing assistant brought her back to her room and found the nurse. R1 indicated she had burnt most of the top of her right thigh and the hot water continued to soak into the incontinent brief which caused a burn on the right groin fold. R1 stated it took 20-30 minutes for a nurse to come, and she had attempted to independently remove the clothing but struggled. R1 stated the nurses put Vaseline on it. R1 further identified she had neuropathy in her fingers, feet, and legs so she doesn't feel pain like other people do. R1 indicated nurses change the dressing on her right thigh every day and it still caused her some pain but not as bad as it was. R1 said she was now receiving wound care from outside the facility. During a follow up observation and interview on 2/25/26 at 2:15 p.m., licensed practical nurse (LPN)-A performed right thigh wound care and dressing change. Observation of the wound extends throughout a majority of her upper thigh and into the right groin folds (panty line) and displayed a red, bubbly appearance with eschar (layer of dead skin tissue). R1 stated it still hurts a little. During observation and interview on 2/25/26 at 8:55 a.m., the dining specialist (DS) said all hot water and coffee were served out of the kitchen and the water was too hot, so it was being turned down today 2/25). DS further identified she was working at the time R1 was burnt by the hot water but did not give her the hot water and was not sure who did. DS stated, I am assuming as bad as her [R1] burn was, it [the water] was way too hot. DS indicated after R1's burn, the dietary department has a new policy now that says all hot water and coffee should have the temperature taken before it leaves the kitchen and if the temperature is greater than 140 degrees Fahrenheit (f), they would add a couple ice cubes to it. DS clarified they did not have a policy on hot water prior to the incident. During interview on 2/25/26 at 11:24 a.m., nursing assistant (NA)-A identified she was notified by dietary staff that R1 had spilled hot water on herself and took R1 back to her room immediately and left to find the charge nurse. NA-A said R1 had attempted to remove her pants by the time the nurse responded and described R1's leg as a large really red area on her right thigh with a blister forming. NA-A stated, I could tell it was significant and reported R1 expressed a lot of pain and frustration with the situation.During an interview on 2/25/26 at 11:41 a.m., RN-B indicated she was working the day of R1's incident, had not seen the wound but by the documentation considered the burn to be significant. RN-B stated the facility had not previously done hot water assessments on residents but after the incident, on 2/10/26, hot water assessments were done on all residents, and care plans were updated. During an interview on 2/25/26 at 1:43 p.m., registered nurse (RN)-A stated she was called to R1's room for a burn and found R1's right thigh with angry red skin, she called the PCP and received an order to put Vaseline on the burn and was told by the night nurse the following day that a blister had formed. RN-A stated she did not feel the burn wound was significant right away but did consider it a significant burn the next day because of the blister. RN-A identified that she assessed the wound but did not measure the burn wounds as part of that assessment. During an interview on 2/25/26 at 1:25 p.m., the director of nursing (DON) indicated she was notified of R1's burn on 2/9/26 and was in the facility. The DON identified she did not consider the burn significant until 2/12/26. The DON stated immediately upon notification of the incident, she called an emergency response meeting, and a hot water assessment was completed for all residents, care plans were updated, auditing of food and water temperatures before it is served to the residents, and a policy and education was given to all staff related to hot water temperatures. During an interview on 2/25/26 at 1:40 p.m., the certified dietary manager (CDM) indicated she was aware of R1's burn by hot water. The CDM further explained DS-B reheated the water in the microwave and was told during the investigation that the water was temped, and it was 138 degrees F. The dietary staff are supposed to log the temperatures on a temperature log and that the hot water policy was not new. The facility's Hot Liquid Safety policy implemented 11/25, identified all residents are assessed for their ability to handle containers and consume hot liquids. Residents with difficulties will receive appropriate supervision and use of assistive devices in order to consume hot liquids. Interventions will be individualized and noted on the resident's plan of care. The policy also identified time and temperature relationship to serious burns and at 133 degrees F it would the time required for a 3rd degree burn to occur would be 15 seconds and at 140 degrees F, the time would be 5 seconds (The reported water temperature of the hot water given to R1 was 138 degrees F). Burns can occur even at water temperature below those identified in the table, depending on an individual's condition and length of exposure. The facility's undated policy titled, Accidents and Supervision identified the resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: identifying hazards and risks; evaluating and analyzing hazards and risks; implementing interventions to reduce hazards and risks; and monitoring for effectiveness and modifying interventions when necessary. Supervision is an intervention and a means of mitigating risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision is defined by type and frequency and based on the individual resident's assessed needs and identified hazards in the resident environment. The following facility's corrective actions dated 2/10/26 were verified as implemented prior to the survey: -All residents were assessed for hot liquid safety-All resident care plans were updated to include risk assessment.-Education on temperature logs in the kitchen and in the breakroom-Education on hot water policy, all food/liquids need to be temped and logged before giving to the resident, and what to do in case of a hot liquid burn.

Based on interview and document review the facility failed to report an allegation of neglect to the State Agency immediately (2 hours) for 1 of 1 resident (R1) who spilled hot liquid on her upper thigh which result in a significant injury.Findings include: A Vulnerable Adult Maltreatment Report submitted to the State Agency on 2/19/26, identified R1 was transferred to the emergency room (ER) related to fever and lethargy. R1 was noted to have a severe burn that was covering a large portion of the thigh with peeling skin. The burn was reported by R1 to be caused by spilling hot water on her thigh on 2/9/26. R1's admission Minimum Data Set, dated [DATE], identified R1 had intact cognition, walked independently with use of a walker and was independent with eating. Diagnoses included diabetes, peripheral neuropathy (damage to peripheral nerves that result in numbness, pain, and weakened in the hands and feet), malnutrition, and anxiety. R1's Progress Notes indicated the following:2/9/26 at 3:03 p.m., R1 spilled hot water on her right upper thigh. R1 had a visible red upper right thigh. R1 was educated to be careful with hot liquids and ask for help when she needs it. The physician [unknown] ordered to apply Vaseline to the affected area and pain medication was administered [to R1].2/10/26 at 11:38 a.m., R1 has reddened area to her right thigh with blister approximately five (5) inches by three (3) inches. Provider at the facility and gave orders for Xeroform to cover area with abd (pad) and secure with kerlix and to changed daily and as needed. Provider added her to wound rounds. R1's progress notes lacked evidence the facility reported R1's burn to the state agency on 2/10/26 when it resulted in a serious injury. R1's hospital Wound Care Initial Consult dated 2/17/26, identified R1's right thigh burn wound was chemically and mechanically debrided (a procedure that thoroughly cleans the wound and removes all dead tissue, foreign debris, and residual material from dressings). Wound measurements were 15 x 26 x 0.1 centimeters (cm). The burn wound was described as a partial thickness burn (involving the epidermis and part of the dermis layer of the skin) that was blistered, fragile, bleeding, and erythematous (abnormal redness of the skin). During an interview on 2/25/26 at 1:25 p.m., the director of nursing (DON) indicated she was notified of R1's burn on 2/9/26 and was in the facility. The DON identified she did not consider the burn significant until 2/12/26. The DON verified the facility did not assess the residents for mitigation of hazards related to hot liquids prior to R1's burn and did not report R1's burn to thigh to the State Agency. During an interview on 2/25/26 at 2:55 p.m., the administrator indicated staff texted or called him immediately after R1's burn incident but verified the incident had not been reported to the State Agency. Review of facility policy titled The Abuse, Neglect, and Exploitation Policy last reviewed 6/16/25, identified neglect as failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy further defined serious bodily injury as an injury involving extreme physical pain, involving substantial risk of death, involving protracted loss or impairment of the bodily member, organ, or mental faculty, requiring medical interventions such as surgery, hospitalization, or physical rehabilitation, or an injury resulting from criminal sexual abuse. The policy further indicated the facility was to report all alleged violations to the administrator, state agency, adult protective services, and all other required agencies (law enforcement when applicable) within specified timeframes: Immediately, but not later than 2 hours after the allegation was made for events that caused the allegation to involve abuse or result in serious bodily injury.

Based on observation, interview, and document review, the facility failed to appropriately identify, assess, and intervene for 1 of 3 residents (R2) with a change in condition. This caused actual harm when R2 experienced a delay in treatment after developing signs and symptoms of a worsening infection with the potential for sepsis (life-threatening infection) with a known history of infection, who was subsequently transferred to a higher level of care and was hospitalized . The non-compliance that began on 5/4/25 was corrected prior to the survey when the facility implemented corrective action on 8/5/25, to prevent recurrence; therefore, the tag was issued at PAST NON-COMPLIANCE. Findings include: Review of the National Library of Medicine article, SIS, qSOFA and New Sepsis Definition, located at https://pmc.ncbi.nlm.nih.gov/articles/PMC5418298/, identified a patient had to meet 2 SIRS (Systemic Inflammatory Response Syndrome) criteria, and have a confirmed or suspected infection. The additional criteria listed was a heart rate greater than (>) 90 beats/minute, a respiratory rate >20 breaths/min, a temperature of (>) 100.4 F or less than (<) 96.8 F, a high white blood cell (cells that fight infection) count, or low white blood cell count and were used as early screening tools for potential sepsis. R2's 12/16/25, quarterly Minimum Data Set (MDS) assessment identified his cognition was intact and had a diagnosis of paraplegia (paralysis) and infection of a wound. R2 had a Stage 3 and a Stage 4 unhealed pressure ulcer that was present on admission. R2's 3/7/25, Nurse Admission-readmission assessment identified R2's primary reason for admission was wound care, history of sepsis, and the need for antibiotic therapy. R2's 5/12/25, hospital discharge summary identified R2 was admitted to the regional hospital intensive care unit (ICU) on 5/8/25 for evaluation of fever and feeling unwell, with purulent exudate (thick drainage indicating an infection) from their buttock wound. He was started on empiric (precautionary) antibiotic therapy and admitted to the ICU. He briefly required vasopressors (a medication often used in shock, heat failure, or sepsis, typically to critically ill patients to raise blood pressure) but was rapidly weaned off. Infectious disease (ID) was consulted, due to chronic osteomyelitis (bone infection) and chronic decubitus ulcer (bedsores caused by sustained pressure). The ID physicians recommended continuing 48 hours of empiric antibiotic therapy and subsequently discontinue them, if blood culture remained negative. R2 remained stable and his blood cultures remained negative for more than 48 hours. He was without fever but was at risk for having recurrent infection related to his infected decubitus ulcer. The physician recommended for R7 to follow-up with physicians in the outside setting, for definitive source (of infection) control if he was able to be clean (drug or alcohol free) from multiple substance abuse. Review of R2's progress notes identified the following: 4/30/25 at 11:01 p.m., R2 had been up in his chair and out to smoke. He was pleasant and cooperative. He was without fever and had no side effects noted from the antibiotic. R2's blood pressure (BP) was 111/59 millimeters of mercury (mm/hg) (normal is 120's/80) taken at 10:25 a.m. 5/3/25 at 10:28 p.m., R2 had a temperature of 102 degrees Fahrenheit (F) at the beginning of the shift. He was offered Tylenol and his fever dropped to within normal limits to 98.5 F and his blood pressure was 113/74 mm/hg. (There was no documentation to support R2's nurse practitioner had been contacted about increased signs and symptoms of potential worsening infection or that staff took a full set of vitals, to identify if R2 met SIRS criteria necessitating he be sent to the local ER for laboratory workup, and further medical examination and/or specialist consultation.) 5/4/25 at 9:12 a.m., staff noted R2 had bloody drainage noted on the wound on his left buttock and had minimal discharge noted on the navel area. (There was no documentation to support R2's nurse practitioner had been contacted about increased signs and symptoms of potential further infection.) 5/4/25 at 5:35 p.m., R2 had a fever of 102.3 F and was given 650 milligrams (mg) of Tylenol. His BP was assessed at 10:35 p.m. and was 91/59 mm/hg. (There was no documentation to support R2's nurse practitioner had been contacted about increased signs and symptoms of potential further infection.) 5/5/25 at 11:35 p.m., R2 had a low-grade fever of 99. R2 had Tylenol for fever from the p.m. shift. R2 denied any pain or shortness of breath (SOB). His BP was assessed at 10:34 p.m. and was 93/48 mm/hg. (There was no documentation to support R2's nurse practitioner had been contacted about increased signs and symptoms of potential further infection.) 5/6/25 at 1:50 p.m., staff noted R2 was seen by the nurse practitioner this morning regarding continued elevated temperatures. His nurse practitioner ordered labs to be collected in 3 days on 5/9/25 and to ensure he received 20 grams of protein three times a day. (There was no indication staff had questioned R2's nurse practitioner of their decision for delayed diagnosis and treatment or consulted the medical director for assistance when R2 was showing signs and symptoms of worsening infection which may lead to potential sepsis). 5/7/25 at 5:50 a.m., R2 had a fever of 102.2 at the beginning of the shift, Tylenol was administered. His temperature came down to 98.7 F. (Staff noted no other signs or symptoms were noted, however, there was no documentation to support a full nursing assessment occurred.) 5/7/25 at 4:23 p.m., R2 has a temperature of 100.2. He complained of chills. Tylenol was administered for his elevated temperature. Resident was scheduled to be seen by the in-house nurse practitioner on 5/8/25. His BP was noted to be 91/59 mm/hg. 5/7/25 at 11:31 p.m., R2 was then sent to the local hospital emergency room (ER) for a fever of 104.0. Staff noted his fever started on the p.m. shift and they administered Tylenol. He was transported by ambulance at 8:20 p.m. 5/8/25 at 5:54 a.m., the ER updated the facility that R7 was transferred to the regional hospital Intensive Care Unit (ICU) for suspicion of sepsis. Interview on 1/14/26 at 1:00 p.m., with the registered nurse consultant (RN-E) identified she acknowledged R2's progress notes (identified above) and her expectation would have been that staff would notify the physician at the first change in his condition. After the nurse practitioner saw him on rounds and his symptoms continued into the next day, she would have expected the interdisciplinary team to identify the concerns through review of the nursing progress notes the following morning. In her opinion, R2 should have been sent to the hospital for evaluation sooner to prevent worsening of his infection and earlier medical treatment. Interview on 1/14/25 at 1:14 p.m., with licensed practical nurse (LPN)-A identified he was working during the time of R2's increasing symptoms on infection. He thought R2's fever could be caused by the existing infection and antibiotic medication he was being administered. LPN-A was unaware of SIRS criteria that is used by nurses and physicians to determine the need for further medical evaluation, or the need for full set of vitals (BP, heart rate, respiratory rate, oxygen saturation etc.) to assess the resident comprehensively. Attempts were made to contact 2 other staff who were working during the above dates with no success. An attempt was made to call the nurse practitioner on 1/14/25 during survey with no success. Interview on 1/14/25 at 6:00 p.m., with the medical director (MD) identified he would have expected when R2 started having elevated temperatures, nursing should have completed a full assessment of R2's wounds and vitals. When the nurse practitioner saw R2 for the continued elevated temperature and ordered labs, he would have expected those labs to be drawn that day rather than waiting 3 days. He identified, in his opinion, it can be hard to determine when R2 should have been sent to the ER. It would depend on if he was experiencing cardiovascular instability. The medical director did not elaborate on how cardiovascular instability would be identified. The current, undated facility provided Notification of Changes policy identified the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include a significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status, life threatening conditions or clinical complications. and circumstances that require a need to alter treatment. This may include new treatment, discontinuation of treatment, acute conditions or exacerbation of chronic conditions. The deficient practice was corrected on 8/5/25, when it could be verified through observation, staff interviews, and document review, the facility had re-educated staff to identify a change of condition, identified steps to take when those changes occur, including appropriate notification, and performed competencies of staff on a change of condition.

Based on observation, interview, and document review, the facility failed to ensure the kitchen and dining area was clean and sanitary to prevent cross contamination when preparing and serving food. In addition, the facility failed to ensure the garbage dumpster was securely closed to prevent attracting pests and rodents. This had the potential to affect all 41 residents residing in the facility. Findings include: Observation on 1/11/26 at 11:00 a.m., during the initial tour of the kitchen with the dietary manager (DM) present identified the following:The reach-in refrigerator the facility called the Milk Refrigerator, had an unknown substance that appeared wet and felt sticky. In addition, debris that appeared to be food crumb-like and was white and yellow in color, was scattered throughout the bottom shelf.The Veggie freezer had a sticky substance and residue smeared over the freezer doors and handles with visible fingerprints on and around the door handles. The bottom half of the freezer doors were covered in drip marks from spillage that started about half-way down the door and extended to the bottom edge of the door. Inside the freezer on the bottom shelf were white and orange food-like particles. A cardboard box was stuck to the bottom of the freezer, and a screw was observed laying on the bottom shelf.The cooking range had food crumbs and a grease-like residue on the burners and on the flat surface between the burners. The dials used to control the temperatures were covered in dirt and grease-like debris and the numbers on the dials were no longer readable because of it. The oven doors had a residue dripping down the front of the doors from the handles to the bottom edge, extending across the entire surface.A stainless-steel countertop with a can opener mounted on the edge had recently been used as evidenced by wet food on the can opener. There was also 3 large personal drink tumblers with straws belonging to staff.The steam table had a yellowish thick substance smeared across the lid of one of the wells, and on the flat surface between the wells. In addition, there were other unknown substances and food-like crumbs on the steam table between the wells. Cook-A was observed placing gravy into the dirty steam table for lunch service. Interview on 1/11/26 11:21 a.m., with cook-A identified she was preparing the steam table for lunch service. She identified the yellow smeared substance on the steam table was from eggs served earlier that morning for breakfast. She was not certain what the other debris on the steam table was from. Staff cleaned the steam table only once per week and not after each meal service. Observation on 1/11/26 at 11:21 a.m., identified the facilities dumpster located outside the building were overflowing, inhibiting the covers to be closed securely. The garbage was visible from the road. Observation on 1/11/26 at 2:24 p.m., the outside dumpster lids remained open, however, the dumpster had been emptied but since the covers were not ensured to be closed after staff put refuse in them, 3 bags of garbage were visible inside, open to pest and rodent contamination. Observation and interview on 1/12/26 at 11:57 p.m., with the dietary manager (DM) identified the outside dumpster lids were completely open, and the dumpster contained 3 large bags of garbage. The DM agreed with the above findings and identified it was her expectation that staff would ensure the dumpster lids would be securely closed at all times. In addition, she identified she had concerns with the cleanliness of the kitchen and it was her expectation that all surfaces would be wiped down as needed and the steam table would be cleaned after each meal. She had completed training and provided sign-off sheets that staff were to initial after completing tasks but noted she had not completed any documented audits to ensure staff were completing the tasks correctly. The facilities Food Safety Requirement policy identified staff would ensure all equipment used in the handling of food shall be cleaned and sanitized and handled in a manner to prevent contamination. Staff shall follow facility procedures for dishwashing and cleaning fixed cooking equipment.

Based on observation and interview the facility failed to maintain floor covering in 2 of 2 resident-shared rooms (one room inhabited by R45 and R27 and the other room inhabited by R37 and R51). In addition, the facility failed to ensure the exterior wall in 1 of 1 dining room was maintained in good condition. This had the potential to affect all 41 residents. Findings include: RESIDENT ROOMS Observation on 1/11/26 at 2:55 p.m., of R45 and R27's room identified there were 10 broken tiles. Some had large missing pieces and others had smaller missing pieces. Neither resident residing in the room were aware of any facility plans to repair the tile and they had been that way a long time. Observation on 1/11/26 at 3:04 p.m., of R37 and R51's room identified there was a hole in the carpet in the doorway with some fraying strings observed. The area was at the seam of the hall carpet and the room carpet in the doorway that was approximately 3 inches wide by 12 inches long. One resident residing in the room used a walker and the other resident walked independently. Neither resident was aware of any plans to repair the carpet. Interview on 1/12/26 at 2:25 p.m., with maintenance director identified that he was aware of the broken tiles in room [ROOM NUMBER]. He reported that the tiles were 9 x 9 and he was unable to get replacements, so he needed to replace all the tiles in the entire room with a new style. He was unable to do this until a room opened so that room [ROOM NUMBER] could be empty while he repaired it. He was also aware of room [ROOM NUMBER] with the hole in the carpet as he had trimmed up the loose frayed strings from the carpet once already. He had been busy working on the new shower in the facility and had not had time to repair it yet. He stated he would get a piece of trim ordered to cover the hole in carpet in the doorway for room [ROOM NUMBER] today. Interview on 1/13/26 at 2:26 p.m., with administrator identified the tiles in R45 and R27's room had been broken since he started 3 months ago. The issue was that the room needed to be empty so that the facility could replace the entire floor in that room as they could not get tiles the same size. He had been made aware of the hole in the carpet in the doorway of R37 and R51's room by maintenance yesterday and reported the maintenance director did get a trim piece ordered to install in the doorway to cover the hole in the carpet. His expectation was that items would be repaired as issues were identified to maintain the facility in good repair. DINING AND REFUSE Observation on 1/11/26 at 12:07 p.m. in the dining room identified just above floor level on the west wall (per the facility map) in the dining room, was a quarter-sized hole leading to the exterior of the building and open to the outside. Below the hole was a square piece of unfinished wood nailed to the wall panel that covered another hole. Above that piece of wood and to the right was another hole approximately silver dollar-sized in diameter, with what appeared to be a washcloth stuffed into it. Interview on 1/12/26 at 11:39 a.m., with the dietary manager identified the facility used to have an air conditioning unit mounted through there. They put it in the dining room in the summertime. I know it's been in here the last couple of summers. I guess the washcloth is a temporary fix. Interview and observation on 1/12/26 at 2:17 p.m., with the maintenance director regarding the dining room walls identified agreed there were 3 holes in the exterior wall that were used for an air conditioning unit in the summertime. He covered the largest hole with a board, the 2nd hole is for the air conditioners drainpipe, and the 3rd hole is just a hole. He stated, I didn't know it was a problem. He agreed this could cause a problem with pest control and identified they have a pest control company that visits the facility monthly. There was no policy related to the maintenance and upkeep/repair of the facility provided.

Based on observation and interview the facility failed to monitor for expired items and appropriately store items in a sanitary manor for 1 of 1 medication room.Findings include: Observation and interview on [DATE] at 9:57 a.m., of the medication room with registered nurse (RN)-D and RN-E identified RN-D opened the refrigerator located inside the medication room. Inside, there were 3 pre-filled elastomeric pumps (also known as balloon pumps for controlled delivery of medication over a specified period) of Vancomycin (antibiotic to treat serious bacterial infections) for R50 who RN-D reported had discharged back in [DATE]. There were 9 boxes of barrier wipes that all had expired [DATE] boxes of a 4 pack of COVID tests that had expired [DATE], and 6 boxes of bacitracin (antibacterial ointment) packets that expired [DATE]. RN-E confirmed the expiration of items and reported they should have been removed once expired. There were also 4 boxes of Ensure (nutritional supplement) sitting on the floor next to the refrigerator and 3 boxes of Ensure sitting inside a plastic box on the floor next to the refrigerator. RN-E stated no items should be stored on the floor. RN-E was the consulting nurse for the facility and was unaware of what the protocol was for monitoring for expired items and storage in the medication room. Review of the February 2023, Medication Storage policy identified that the consultant pharmacist routinely inspected the medication room for outdated, discontinued, defective, or deteriorated medications with missing labels, or illegible labels. There was no mention of monitoring for storing items in a sanitary manner.

Based on observation and interview the facility failed to follow appropriate infection control practices when obtaining a blood sugar (BS) level for 1 of 1 resident (R19) while in the dining room. The facility also failed to disinfect 1 of 1 sampled multiple-resident use glucometer. This had the potential to affect all 3 residents seated at the dining table with R19 and 2 other residents who used the multi-resident use glucometer. Findings include: R19's 11/27/25, accepted comprehensive Minimum Data Set (MDS) assessment identified R19's cognition was moderately impaired. R19 required substantial assistance from staff for cares. He had diagnoses of hypertension, GERD, diabetes and depression. R19's Order Summary Report identified an order for blood glucose monitoring before meals and at bedtime related to diabetes management. R19's 12/10/25, care plan identified R19 had diabetes. Staff were to administer medication as ordered. Observation and interview on 1/11/26 at 12:31 p.m., of registered nurse (RN)-D identified she entered the dining room with several residents already seated at tables. RN-D walked over to a table of 3 residents and proceeded to put on gloves, set up the glucometer and used a lancet to prick R19's finger and obtain a blood sample while R19 was seated at the table in front of other residents. Once RN-D finished, R19 was observed to have a small amount of blood on tip of his finger. R19 placed his hand on the table and touched his bloody finger on the top of the table. RN-D reported that she normally did not check residents' BS in the dining room; however, R19's BS needed to be done prior to eating and he was already in the dining room. Observation on 1/11/26 at 12:36 p.m. of RN-D identified she returned to the medication cart located by the nurse's station. RN-D placed the contaminated glucometer back into the medication cart drawer without disinfecting it. Continuous observation and interview on 1/11/26 from 12:26 p.m. until 1:06 p.m. of RN-D identified RN-D removed the contaminated glucometer she had placed in the drawer. RN-D removed the glucometer and took a Sani-Cloth wipe and wiped the glucometer off without ensuring surface remained wet for the correct amount of time per the manufacturer to ensure disinfection had occurred. RN-D then gathered the rest of her supplies and proceeded to enter R3's room. RN-D checked R3's BS and returned to the medication cart. When asked, RN-D reported she felt she had appropriately disinfected the glucometer by using the Sani-Cloth wipe per facility protocol but was unaware Sani-Wipes required a 2-minute wet-contact time to ensure disinfection occurred. Interview on 1/11/26 at 3:51 p.m., with the infection preventionist (IP) identified the Assure glucometer should be wiped off first to clean it and then disinfected with the wet time of 2 minutes and air-dry per the instructions on the Sani-Cloth disinfectant wipe manufacturer. That machine was used by 3 residents. Interview on 1/14/26 at 11:19 with RN-C identified BS should be done prior to meals, and no BS should be done in common areas including the dining room. Review of the 2023, Blood Glucose Monitoring policy identified that the nurse would perform BS testing per the glucometer manufacture's instruction. The nurse would abide by the facility infection control protocols for cleaning and disinfecting the glucometers. The nurse would gather supplies, provide privacy, and perform the BS testing. Review of the 2024, Glucometer Disinfection policy identified glucometers would be cleaned and disinfected after each use and according to manufacturer's instructions. Glucometer would be disinfected with a wipe pre-saturated with an EPA registered health care disinfectant that was effective against HIV, Hepatitis C and Hepatitis B virus. Following use of the glucometer, staff would retrieve 2 disinfectant wipes from the container. The first wipe was to remove heavy soil, blood or other contaminants from the surface of the glucometer. The second wipe was to disinfect the glucometer thoroughly following the manufacture's instruction and allow the glucometer to air-dry. Sani-Cloth direction to disinfect, use wipe to remove visible soil prior to disinfecting. Use the wipe to thoroughly wet surface and allow the surface to remain wet for 2 minutes and let air-dry.

Based on interview and document review, the facility failed to ensure 2 of 5 (R16 and R21) sampled residents were offered and/or provided updated vaccinations for pneumococcal disease, in accordance with Centers for Disease Control (CDC). Findings include: Review of the current, 10/26/24, Centers for Disease Control (CDC) Pneumococcal Vaccine Recommendations, located at https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/index.html, identified based on shared clinical decision-making, adults 65 years or older have the option to get PCV20 or PCV21, or to not get additional pneumococcal vaccines. They can get PCV20 or PCV21 if they have received both the PCV13 (but not PCV15, PCV20, or PCV21) at any age and a PPSV23 at or after the age of [AGE] years old. R16 R16's face sheet identified they were admitted to the facility in October 2025. R16's accepted 10/29/25 at 4:02 a.m., comprehensive Minimum Data Set (MDS) identified R16 was [AGE] years old and had a diagnoses spinal fusion, multidrug resistance organism (MDRO) (bacteria or fungi developed resistance to multiple antibiotics), substance abuse and pressure ulcer of the sacral (lower back) region. Section O, of the MDS Identified R16's PCV vaccine status was not up to date. R16 received the PPSV-23 on 12/19/11. There was no indication that R16 was offered or decline the vaccine. R21R21's face sheet identified they were admitted to the facility in October 2025. R21's accepted 10/21/25 at 7:37 p.m., comprehensive MDS identified R21 was [AGE] years old and had diagnoses of depression, alcohol dependence, post-traumatic stress disorder (PTSD) and clostridium difficile (C-diff) (causes severe diarrhea of the colon). Section O, of the MDS identified R21 PCV vaccine status was not up to date. There was no indication that R21 was offered or declined the vaccine. Callback interview on 1/14/2026 at 11:13 a.m., with the infection preventionist (IP) identified she voiced agreement residents were to be assessed of their vaccine status upon admit to the facility and/or provided risk to benefits and a declination form for PCV vaccines according to Centers of Disease Control (CDC) guidelines. Review of October 2024, Pneumococcal Vaccine policy identified the facility was to follow State or local guidance for PCV vaccines and to assess resident status upon admission. The PCV vaccine was to be offered, and a consent was to be signed, unless it was medically contraindicated. Resident or resident representative had the right to refuse the vaccine and was to be recorded in the resident's medical record. Overall, the PCV vaccine offered was to depend on the recipients age, risk factors, and previous vaccine history, in accordance with Centers of Disease Control (CDC) recommendations.

Based on interview and document review, the facility failed to investigate a potential crime involving illegal drugs involving 1 of 1 resident (R41). Findings include: Interview on 1/11/26 at 1:00 p.m. with the administrator identified on 1/4/26, there was a concern with alcohol and illegal drugs brought into the facility by R41. Law enforcement were involved. Police were referring the case to the county attorney for review of charges. R41 was not arrested at the time of the incident. R41 has since been discharged and would not be returning to the facility. Review of the 1/4/26 at 1:06 p.m., Redwood County Sheriff's Office Incident Report identified officers arrived at the facility at 1:19 p.m., to investigate the report of a resident possibly under the influence. During interview, R41 admitted to having possession of the crystal-like substance, which was field tested and tested presumptive positive by the sheriff's office as methamphetamine. R41 reported the substance had been given to him by another resident, [R17]. During interview with the officer, R41 displayed quick, fidgety movements with his hand and had dilated pupils. A second bag that was confiscated by police, contained a blue, glass pipe and two lighters, which staff identified had been thrown over the fence surrounding the outdoor smoking area. Charges for drug possession were to be sent to the District Attorney's (DA) office for review. The resident council meeting on 1/13/26 at 10:30 a.m., held with surveyors identified it was reported by members the social worker had been made aware of their concerns of drugs and alcohol being brought into the facility, but there had been no action or investigation into their concerns. Residents stated the facility had found alcohol bottles and contraband. The police had been at the facility about 5 times in the last month. There are residents who are visibly intoxicated. Review of the January 2026 resident council meeting minutes identified there was no recorded mention of resident council members' concerns for drug and alcohol use in the facility. Interview on 1/13/26 at 12:05 p.m., with the ombudsman (O) identified she attends resident council meetings at the facility. Residents did discuss concerns at the 1/8/26 meeting about drug and alcohol use in the facility at that meeting. R41's 1/8/26 submitted, admission Minimum Data Set (MDS) assessment identified he was admitted in December of 2025, following hospitalization. His cognition was intact, he was independent with activities of daily living, (ADLS), and had diagnosis including alcohol-induced chronic pancreatitis (inflammation of the pancreas, causing severe upper abdominal pain, nausea, and vomiting, often triggered by gallstones or alcohol), anxiety disorder, alcohol use, and alcoholic hepatitis, (liver inflammation from heavy alcohol use). Review of the 1/4/26 at 12:15 p.m. fall incident report listed R41 was heard calling for help, registered nurse (RN)-B responded and discovered R41 had fallen and gotten himself up and denied any injuries. There was no mention of the suspicion R41 was possibly under the influence of drugs or alcohol, but it was documented he was very unsteady. Staff had reported he seemed off. No additional information was documented in the report. R41's undated, current care plan listed a problem of substance abuse/dependence with a goal to refrain from use while in the facility, identify triggers through the review date, meet with LADC (licensed alcohol and drug counselor), for assessment within 30 days of admission, (identified as overdue). Interview on 1/13/26 at 11:13 a.m. with nursing assistant (NA)-A confirmed she had been working on 1/4/26 and had initially observed R41 in his room at 12:45 p.m., and then at 1:00 p.m. she was informed R41 had fallen and was very unsteady. NA-A assisted by NA-B went to clean up the spilled items from the floor and noted R41 was focused on a Walmart bag on his bed. Both NAs reported R41, seemed off, but were not aware of what the problem was. R41 was taken from the room to have his weight and vital signs checked, but prior to leaving, quickly shoved the Walmart bag into the drawer on his nightstand. When he was out of the room, NA-B reported she felt there was something going on and they needed to check what R41 had put in the drawer. Upon opening the drawer, the bag was open and a small zip-lock bag was visible which contained a crystal-like substance. NA-A took the bag to registered nurse (RN)-B, who secured it in the medication room and contacted the non-emergent 911 sheriff's office, the administrator, interim director of nursing (IDON), and social service designee (SSD). No facility management came to the facility following the report. Emergency medical services (EMS) responded and assessed R41 who refused to be transferred to the emergency department (ER) for further evaluation. When law enforcement ([NAME]) arrived, they tested the crystalline substance and confirmed it was methamphetamine. [NAME] then confiscated the illegal drugs. Interviews were obtained by [NAME] personnel of NA-A & B, in addition to R41 and R17. An addition officer (accompanied by a K-9 drug dog) searched both R41's and R17's rooms, and the outdoor smoking area. Additional drugs and/or paraphernalia were discovered on the outside of the fence surrounding the smoking area. [NAME] reported R41 was being charged but not arrested, and the information was being referred to the DA for determination. R41 discharged on 1/6/26 with his family member to return to his home setting. Interview on 1/13/26 at 2:25 p.m. with RN-C identified when a resident was admitted , a log was made of any personal items brought with them. The signed admission agreement listed drugs and alcohol were not permitted, unless prescribed by their physician (MD). There had been incidents within the past month when residents were thought to be under the influence of drugs or alcohol, and the procedure was to contact the physician for further directions, to monitor vital signs, and send to the ER for further evaluation if indicated. Interview on 1/13/26 at 3:01 p.m. with RN-B reported on 1/4/26, R41 had fallen and gotten himself back up without injury. She telephoned the non-emergency sheriff's office line, the administrator, the IDON, and the SSD but neither came to the facility after being notified. RN-B completed an incident report for R41's fall but had not completed an incident report for the illegal drug incident. Interview on 1/13/26 at 3:11 p.m. with the administrator reported he had been telephoned by the sheriff with an update on what had occurred but noted he did not come to the facility. He voiced agreement that an incident report should have been completed. No further investigation into the incident was completed by the facility. Iif a resident consumed alcohol or a prohibited substance, the facility was to contact the physician for their recommendation, and if indicated, would do 1:1 monitoring but facility response was made on the individual case situation. Interview on 1/14/26 at 4:25 p.m. with the RN-E, who was the facility nursing consultant, identified if a resident was discovered to have illegal substances, the facility was to contact law enforcement to search for and seize any illegal substance. She confirmed an incident report should have been completed with investigation and documentation completed. Her expectation for staff was to be aware of the procedure to be followed and complete appropriate documentation of an investigation. Interview on 1/14/26 at 5:51 p.m. with the medical director (MD)- A identified his expectation for the facility to have a protocol for monitoring residents for signs and symptoms od substance use, and facility management or designee to assess the situation and/or resident and take charge of the situation. He would expect an investigation be completed. Review of the October 2025 Resident Possession and Use of Illegal Substances policy identified the residents' right to have and use personal possessions unless it interfered or affected health or safety for other residents. Illegal substance use was not allowed in the facility. Staff were to be knowledgeable of signs or symptoms for residents using illegal substances such as changes in behavior, increased, unexplained drowsiness, lack of coordination, slurred speech, mood changes, and loss of consciousness. If the facility determined a resident may have access to illegal substances, the facility was to notify [NAME]. The facility was to provide additional monitoring and supervision. There was no mention of conducting an investigation to determine if other residents were at risk or how the substances were brought into the facility to potentially prevent further incidents.

Based on interview and document review the facility failed to notify the responsible party of a hospital transfer for 1 of 4 sampled residents (R7) reviewed for hospitalizations. Findings include: R7's 12/19/25, quarterly accepted Minimum Data Set (MDS) assessment identified she had moderate cognitive impairment. She required moderate staff assistance with activities of daily living (ADLS), impairment on one side upper extremity, uses a wheelchair for mobility, and required extensive staff assistance for toileting, dressing and grooming. R7 received both scheduled and as needed (PRN) pain medication for frequent pain which interfered with her day-to-day activities and was described as severe. She had diagnoses of generalized weakness, psychoactive substance abuse, acute respiratory failure with hypoxia, adult failure to thrive, bipolar and anxiety disorder, and Buerger's disease (inflammatory condition that affects circulation and clotting in small to medium blood vessels of the extremities). R7's 10/31/25, accepted end of stay with return anticipated MDS assessment identified R7 had been discharged to the hospital. The 11/3/25, accepted readmission to facility MDS identified R7 returned on 10/31/25. Review of R7's progress notes on 10/26/25 identified she was transferred to the hospital. The progress note lacked identification that the family member had been notified of the transfer to the hospital. R7's hospital notes identified dates of stay as 10/26/25 through 10/31/25. R7 was hospitalized with shortness of breath, cough, and hypoxia, with a diagnosis of pneumonia and kidney injury. There was no documentation that notification had been made to the resident's representative of R7's transfer to the hospital with an admission. Interview and document review on 1/12/26 at 2:11 p.m., with registered nurse (RN)- C of R7's medical record confirmed there was no documentation of notification to R7's family/emergency representative of her transfer and subsequent admission to the hospital. The facility policy was to notify the provider, ombudsman, and family/emergency representative when a resident was transferred from the facility. Interview on 1/14/26 at 3:30 p.m. with the interim director of nursing (IDON) identified her expectation was for the policy to be followed for appropriate notifications with documentation when a resident was transferred from the facility. A policy was requested but not provided by time of survey exit.

Based on observation, interview, and document review, the facility failed to revise 1 of 12 sampled resident's (R4) care plan for behaviors.Findings include: R4's 10/31/25, accepted comprehensive Minimum Data Set (MDS) assessment identified R4's cognition was intact but had verbal behavioral symptoms directed towards others 1 to 3 days during the assessment period. R4 required substantial assistance from staff for cares and transfers. He took pain medication as needed and reported he had occasional moderate pain. R4 was noted to have had 2 or more falls with minor injury. He took an antipsychotic, antidepressant, antibiotic, and anticonvulsant during the assessment period. R4 had been seen by speech therapy and occupational therapy. R4's goal was to return to the community. R4's 1/14/26, Diagnosis Report identified diagnoses of paranoid schizophrenia, spinal stenosis (narrowing of the spine), cognitive communication deficit, dysphagia (difficulty swallowing), abnormal posture, borderline personality disorder, cannabis dependence, difficulty walking, high blood pressure, and generalized anxiety disorder. He also had a history of falling, insomnia, major depressive disorder that was severe with psychotic symptoms, stimulant dependence, muscle spasms, muscle weakness, Post-Traumatic Stress Disorder (PTSD), and schizoaffective disorder. Observation and interview on 1/11/26 at 4:31 p.m., with R4 identified was seated in his wheelchair. He was hunched over reportedly due to neck pain and his hair was disheveled from rubbing his hands through his hair. R4 reported he would fall out of his wheelchair and bed and did it on purpose because he did not like his wheelchair and would also do it when he wanted to get out of bed. He stated it did not hurt as he does it right. R4 also noted he did not like where he was seated in the dining room, but was told he needed to sit at a certain spot for staff to be able to assist him. R4 stated staff were dirty, rotten scoundrels.they should be aides here and [nurse] is their crew leader. R4 identified he felt staff had not liked to help him, and felt they avoided his room, even when he would put the call light on. Observation on 1/12/26 at 9:50 a.m., of R2 identified staff were wheeling him in his wheelchair to the day room. R4 was swearing stating he did not give a [expletive] about this place.this place is a [expletive]. Further observation at 2:02 p.m., identified R4 was wheeling himself down the hall towards the smoking area. R4 was exhibiting behaviors by swearing at staff other residents as he saw them when he proceeded down the hall. There were no observations obtained during the survey of R4 placing himself onto the floor. R4's progress notes identified on:12/3/25, R4 moved around in his wheelchair. He had a habit of lowering himself to the floor from his wheelchair. His mood during the shift was aggressive and abusive when he didn't get his will.12/5/25, R4 reported he placed himself onto the floor. When R4 was asked why he placed himself onto the floor, he replied to get staff attention. When asked what attention he needed from staff, and he replied nothing.and noted he just wanted their attention. Staff discussed safety and other [more productive] ways to get staff attention.12/7/25, R4 was yelling and swearing throughout the shift at staff members. He was agitated that he could not be taken out to smoke. R4 continuously laid himself on the floor from his wheelchair. Multiple attempts were made by staff to redirect R4.12/8/25, R4 was yelling and swearing throughout the shift at staff members. R4 attempted a self-transfer from his wheelchair in order to walk outside and had fallen.12/20/25, R4 was yelling, cursing, screaming, and putting himself on the floor.12/23/25, R4 voluntarily got out of his wheelchair and laid himself on the floor.12/24/25, R4 had behaviors and threw himself on the floor.12/24/25, R4 voluntarily slipped onto the floor from his wheelchair.12/25/25, R4 stated to staff he will put himself on the floor.12/28/25, R4 put himself onto the floor as a behavior.12/28/25, R4 was on behavior monitoring as he voluntarily slipped twice from his wheelchair to the floor by the nurse's station.12/29/25, R4 was noted to be having behaviors during the shift. R4 would lower himself to the floor as a bid to get attention. Staff noted he did this three times during the shift.12/29/25, R4 was using inappropriate words, had lowered himself to the ground on several occasions in order to get attention from staff, with the goal of getting help to go outside to the smoking area.12/30/25, R4 laid himself on the floor multiple times throughout the shift.12/31/25, R4 was yelling, using inappropriate words and lowered himself to ground on several occasion, to get staff attention with goal of getting help to the smoking area.1/8/26, R4 lowered himself to floor from wheelchair stating he needed help getting into bed. R4's 10/17/25, care plan identified a potential for ineffective coping skills related to his PTSD. Staff were to allow him to express his feelings, communicate that he was safe and situations were not his fault, and they were sorry that had happened to him. Staff were to remain with R4 and offer support at times of high anxiety and offer music. R4 had the potential to be verbally aggressive, use profanity related to ineffective coping skills, and mental and emotional illness. Staff were to administer medication and monitor for side effects as ordered and were to assess and anticipate R4's needs, such as food, thirst, toileting, comfort, body positioning and pain. Staff were to intervene before agitation escalated. If R4's response was aggressive, staff were to walk calmly away and approach later. Staff were to also give many choices and offer snacks or small pieces of candy when he becomes upset. R4's target behaviors were poor self-esteem, potential to be withdrawn, lack of social skills, and irrational thought process. R4 was high risk for falls related to impaired cognition and mobility. R4 had been moved closer to the nurse's station and in a high traffic area. Staff were to assist him when he went out to smoke. R4 had anti-roll back breaks on his wheelchair. Staff assisted R4 with toileting, and offer him his urinal at 2 a.m R4 had a sign placed to call don't fall in his room, and staff were to ensure his bed was at appropriate height when sitting bedside and encourage R4 to ask for assistance. There was no mention that R4 would intentionally place himself on the floor from his wheelchair or his bed. Interview and care plan review on 1/14/26 at 11:19 a.m., with registered nurse (RN)-C identified R4's target behaviors would be hollering out, threatening to put himself on the floor, swearing, being withdrawn, lack of social skills, and having irrational thoughts. RN-C reviewed the care plan listed target behaviors as noted above and agreed, there was no mention of R4 placing himself on the floor as a behavior. Interview on 1/13/26 at 2:45 p.m., with NA-B identified R4's target behaviors as yelling out, swearing, and he will put himself on the floor. NA-B reported R4's behaviors had improved since he had some medications adjusted and he started a pain patch. R4 would put himself on the floor when staff did not get to him immediately when he wanted something. For instance, R4 will ask to lay down in his bed and then want to get back up in 10 minutes and if staff did not get there right away, he would put himself on the floor. NA-B reported staff have to run to his light when it goes on, or he will put himself on the floor. Review of 2023, Comprehensive Care Plans policy identified that the care plan would be developed using the MDS assessment and other factors identified by the interdisciplinary team, and with the resident's preferences. The care plan would include individualized interventions and be developed by the interdisciplinary team. The care plan will be reviewed and revised after each MDS assessment. The care plan will include measurable goals and time frames and be monitored for progress. The care plan was to be revised after each comprehensive and quarterly MDS assessment. There was no mention of ensuring the care plans were updated more often if necessary for behaviors identified.

Based on interview, observation and document review, the facility failed to ensure adequate supervision and a comprehensive assessment was completed to help prevent resident to resident sexual abuse. As a result of the facilities failures an immediate jeopardy (IJ) situation was identified when resident (R2) wrote unwanted paper notes that were sexual in nature and hand delivered them to R1, resulting in psychosocial harm related to triggering symptoms of PTSD (Post-Traumatic stress disorder) derived from childhood sexual abuse and feelings of insecurity for 1 of 2 residents (R1) reviewed for abuse. The IJ began on 3/27/25 when three residents reported inappropriate behavior by R2, including writing notes that were sexual in natural and touching residents. The facility administrator and director of nursing (DON) were notified of the IJ on 5/22/25 at 4:10 p.m. The IJ was removed on 5/28/25 at 11:09 a.m., but non-compliance remained at the lower scope and severity of D. Findings include: A Vulnerable Adult Maltreatment Report submitted to the State Agency (SA) on 5/16/25 at 12:00 p.m., alleged abuse and neglect to R1 when R1 reported feeling unsafe at the facility due to R2 being sexually inappropriate, sexually harassing, and making unwanted sexual advances by writing letters and talking about sexual desires R2 had with R1. Several of the female residents stated they did not feel safe in the facility because of R2's behaviors. A Nursing Home Incident Report (NHIR) submitted to the SA on 5/16/25 at 1:57 p.m., alleged abuse when a resident (R1) reported during resident council on 5/15/25 that they did not feel safe because a resident (R2) stares at them. R1 R1's New admission Information dated 10/15/24, indicated R1 had diagnoses of Alcoholic encephalopathy, Post Traumatic Stress Disorder (PTSD), anxiety, and depression. R1's cognition was confused, and behaviors were confused but pleasant. The form also identified R1 was independent with activities of daily living (ADLs). The facility was to provide occupational therapy (OT), speech therapy (ST), and substance abuse treatment. R1 was admitted with a commitment order (court ordered mandate to be involuntarily place in an institution for treatment or care). Additional information included R1 had poor cognition, very forgetful, needs reminders that R1 had completed tasks. R1's admission Trauma Informed Care History dated 10/16/24 identified R1 was molested as a child. Triggers that make it worse were indicated as use to have a lot of them but overcame them with counseling. R1's care plan initiated on 10/16/24, identify a potential for ineffective coping related to PTSD and reported history of traumatic event(s) from her childhood attention seeking behavior of sexual comments towards men. Goal was to feel safe and enjoy daily activities of her choice for the next 90 days. Interventions included allow to express feeling, communicate with them that they are safe, it's not their fault, you are sorry this happened and you are glad they are alive; identify support system and us them as appropriate; and provide a safe therapeutic environment where they can regain control as needed. R1 is a smoker and can smoke unsupervised. R1 has impaired cognitive function/dementia or impaired thought processes related to Wernicke's encephalopathy (brain and memory disorder), diagnoses and BIMS (brief interview of mental status) score. Interventions included administer medications, cue, reorient, and supervise as needed; has a pad of paper in her room to put information on for her to remember; and has a sign on the wall to remind her that her wallet is with her husband and nursing has her cigarettes. R1's safety is at risk and there is a potential for abuse due to anxiety, chemical dependency, current medical condition, use of medications and need for assistance with cares and mobility. Interventions were to remove R1 from potentially dangerous situations. R1's Preadmission Screening and Resident Review (PASARR) screening dated 11/11/24, identified serious mental disorder, intellectual disability or related disorder existed. R1's Vulnerability and Susceptibility to Abuse assessment dated [DATE], indicated R1 was at risk for abuse related to cognitive impairment, alcohol/substance abuse, physical impairment. R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment, minimal depression, no behaviors, and no hallucinations or delusions. Diagnoses included Wernicke's encephalopathy insomnia, history of suicidal behavior, anxiety, depression, post-traumatic stress disorder (PTSD), and alcoholic hepatitis (inflammation of the liver). R1's Montreal Cognitive Assessment (MoCA) dated 3/4/25, indicated R1 had higher mild cognitive impairment. R1's Cognitive care area assessment (CAA) dated 3/10/25, identified risk for psychosocial well-being changes d/t recent hospitalization and factors of cognitive loss and ETOH (alcohol) abuse. At risk for further clinical declines, re-hospitalization if psychosocial well-being is not addressed. R1's Nursing Note dated 5/4/25 at 2:24 a.m., identified R1 and another resident approached writer at 7:40 p.m., and stated that they did not feel safe as R2 was harassing them by calling them offensive names when they were out in the smoking area. R1 further stated that the harassing resident [R1] stays at his door and when they go out to smoke, he follows them. Writer request R1 to stay away from the other resident as much as they could. Writer offered an alternative smoking area for the meantime and in the event [R1] wanted to go to the regular smoking area to inform staff so they could be with staff all the time. Law enforcement involved. Director of nursing DON was notified and social worker to be informed. (no other mention of feeling unsafe in the notes) R1's Resident Location charting dated 4/27/25, 4/28/25, and 4/29/25 indicate 15-minute checks for protection. (no other information given) R1's psychiatry Therapy note dated 5/23/25, identified R1 reported getting letters from a male resident a couple of months ago and have become inappropriate over time and R1 notified staff of this. R1 now feels uneasy around the person. R1 further reports feelings of unease like tension in her chest when wondering if she will see that person and brings up feelings like when she was sexually abused as a child. R1 feels she needs to watch her back and protect herself since reporting her concerns about the peer. R1 reports it is taking a long time to get to sleep and waking up 2-3 times a night. R1 requested to increase her session frequency to two times a week for additional support at this time. R1's record lacked indication a comprehensive assessment was completed to determine psychosocial harm, interventions put in place to ensure safety, supportive services provided, or monitoring systems for supervision and mood/behavior changes were implemented to keep R1 safe from ongoing abuse. R2 R2's quarterly MDS dated [DATE], identified R2 had moderately impaired cognition, with no hallucinations or delusions, no wandering or rejection of cares. R2 had verbal behaviors directed towards others 1 to 3 days weekly and behavioral symptoms not directed at others 1 to 3 days weekly. R2's diagnosis list includes emotional lability, alcohol use, depression, anxiety disorder, osteonecrosis (death of the bone due to lack of blood supply). R2's care plan initiated 1/25/25 indicates potential for ineffective coping related to reported history of traumatic event no triggers noted. Interventions included allow to express feelings, provide a safe therapeutic environment where they can regain control as needed; prefers female caregivers; does not want male caregivers for intimate cares. R2 requires assist of staff with bed mobility, toileting, transferring, and dressing lower body. R2 does not ambulate. R2 is a smoker and can smoke unsupervised. R2 used psychotropic medications related to depression and anxiety. Interventions included monitor/record occurrence of target behavior symptoms of rapidly shifts between different emotions, self-isolation, sense of impending doom, and hyper-fixation. Target behavioral interventions is journalling, talk therapy, distractions/redirections, remind to focus on what is controllable, and drawing. R2 is at risk and there is a potential for abuse due to anxiety, and chemical dependency. Interventions include: ensure I am safe around others that might take advantage of my confusion, encourage participation in separate meaningful activity, provide positive reinforcement when resident handle conflicts appropriately. R2's care plan lacked updates or potential sexual behaviors toward others. R2's progress notes dated 3/27/25 at 4:28 p.m., three female residents approached writer and another nurse manager to report that a male resident has been acting inappropriately toward them. They shared that the resident writes notes to them and follows them to the smoking area. The residents expressed feeling uncomfortable with his behavior. The writer and other nurse spoke with R2 about the concerns and R2 explained he only wrote letters to one of them [R1], who had shown interest in him. Education given to the resident, verbalize understanding. R2's Nursing Note dated 4/27/25 at 4:51 p.m., R2 was reported being sexual [sexually] inappropriate to R1. Per R1 she has been sexually abused by this resident and does not feel comfortable. R1 safety is being ensured by checking on R1 when she goes out to smoke. R2 was educated on sexual abuse and verbalized understanding. R2's 15-30-60 Minute Monitoring Flowsheet dated 5/3/25 and 5/4/25, identified R2 was on 15-minute checks for safety reasons, started 5/3/25 at 2:45 p.m. to 5/4/25 at 11:30 a.m. R2 flowsheet lacked monitoring on 5/4/25 between 11:45 a.m. to 6:00 p.m. then resumed on 5/4/25 at 6:00 p.m., with last entry at 5/5/25 at 5:45 a.m. R2's record lacked additional behavior management, assessments or monitoring to mitigate risk of R2's alleged sexual behaviors towards R1. During an interview on 5/19/25 at 1:42 p.m., the business office manager (BOM) indicated she attended the resident council meeting on 5/15/25 and concerns were expressed about feeling unsafe at the facility related to R2 writing some notes to R1 and R2 watching and waiting for R1 to go out to the smoking area and R1 did not want to be by R2. The BOM reported the ombudsman was in the meeting and was going to follow up on the concern and did report their concerns to the DON and administrator. The BOM denied having prior knowledge of the letters. During an observation and interview on 5/19/25 at 2:15 p.m., R2 identified he was in trouble at the facility because he had a relationship with R1 and wrote her some love notes. R1 decided she did not want them anymore; they called the cops and we were supposed to stay away from each other. Law enforcement returned on Friday 5/16/25 and talked to me again. R2 stated, all the staff knew about it and the social worker told R2 that he was stalking R1 but could not remember when that conversation occurred. R2 reported writing love notes to R1 for approximately two months. During observation and interview on 5/20/25 at 8:55 a.m., R1 stated she had concerns about her safety because of R2 saying stuff to me like he likes me and started passing me some sexual notes. R1 indicated being married and would not consent to a relationship with R2. R1 further identified the notes started to get disturbing and showed staff the notes a week or so ago, can't remember. R1 indicated R2 would usually approach her in the smoking area, which was unsupervised by staff. During an interview on 5/20/25 at 9:05 a.m., R4 indicated R2 was obsessed with R1 and would sit in the doorway and stare at her, write letters to R1, and play love songs for R1 to hear. R4 further indicated about a month ago, R1 and R3 told the DON about the letters and the DON made copies of the letters and they moved R2 to a room even closer to R1. R4 indicated the DON told them they were all adults and needed to work it out. During an interview on 5/20/25 at 9:20 a.m., R3 indicated R2 sexually harasses R1 and has read the letters that R2 had written to R1, and they were sexual and graphic. R3 stated, R2 is scaring the [expletive] out of her. R3 indicated the allegation was reported to the social worker and nursing staff about six weeks to two months ago but moved R2's room even closer to R1. R3 said after the resident council meeting on 5/15/25, R1 and R2 were to go to two different smoking areas. During an interview on 5/20/25 at 9:50 a.m., NA-B indicated the conflict between R1, R2, and R3 is an everyday thing. NA-B indicated night shift had reported seeing R2 in R1's room and reported it to the charge nurse. NA-B identified R1 expressed concerns with the letters from R2 a couple of weeks ago that R1 continued to receive letters from R2 and that R1 wanted them stopped, stating R1 felt stalked. NA-B reported to the charge nurse. NA-B identified they were told to supervise the hallways as much as we can but there are no restrictions on what R1 and R2 can do but, R1 is good about not being in the same area as R2. During an interview on 5/20/25 at 10:15 a.m., R5 indicated being upset because of the sexual harassment to R1 by R2 and stated, it has to stop. R5 reported she had read the letters and found them to be sexual harassment but not threatening. R5 further indicated R1 had expressed her concerns with the letters and given them to registered nurse (RN)-A and the DON about six weeks ago and the facility made copies of the letters but did nothing to help R1. During an interview at 5/20/25 at 10:30 a.m., RN-A indicated she was made aware of the letters to R1 written by R2 sometime in April. RN-A described the letters she read to be kind letters, like you are beautiful, and want you to be my friend. RN-A identified she talked to R2, and he did not feel the letters were inappropriate for their relationship. RN-A stated R1 was concerned enough about the letters that she brought them to us and law enforcement was called a couple of times. RN-A identified she did not feel R1 had the capacity to consent and needed to figure something out [related to the relationship between R1 and R2]. During an interview on 5/20/25 at 11:08 a.m., the director of nursing (DON) indicated she was aware that R1 and R2 had an off and on relationship that had been ongoing for a while. Indicated R1 has memory issues but R2 does not. The DON indicated R1 brought the letters to her back in April sometime, did an investigation, interviewed both R1 and R2, and determined R1 knows what she is doing so did not report the concern to the State Agency. The DON was not sure how they determined R1's capacity to consent. The DON indicated she was not made aware of any further concerns about the letters until resident council meeting on 5/15/25. After the resident council meeting, implemented 15-minute checks on R1 and told staff to make sure R1 and R2 are not seen together. During an interview on 5/20/25 at 11:32 a.m., family member (FM-A) identified R1 calls her about eight times a day and had concerns about R1's safety and security related to the unwanted letters, treats, snacks, and gifts from R2. FM-A further indicated R1 had called her crying because the abusive situation is triggering R1's PTSD symptoms from earlier childhood trauma. FM-A indicated the facility has talked to R2 and told him to stop but, it was just ramping it up. FM-A shared concerns that the facility was not following through with their safety plan because he was still writing R1 letters and handing them to her. During an interview on 5/20/25 at 1:04 p.m., the activity director (AD) reported R1 felt unsafe around R2 and received letters from in the past. The AD indicated the letters were given to management and grievances were written. The AD indicated the letters were given to the social worker and R2 did stop writing letters for a while. During an interview on 5/20/25 at 2:36 p.m., social service designee (SSD) with administrator present during interview. The SW identified she was aware of a mutual relationship between R1 and R2 and described the relationship as R2 is infatuated and R1 enjoys the attention. The SW further indicated R1 and R2 are close friends and two adults but their relationship depends on the day. The SW did not know when the letters first started but did not think they had all the letters because she felt the letters that were copied were friendly in nature with some drawings. The SW identified the letters were in a soft file. The SW based R1's capacity to consent off the brief interview for mental status (BIMS) which indicated a score of seven which equated to severe cognitive impairment and the totality of knowing [R1]. The SW indicated she felt R1 could make decisions in the moment but 5-6 hours later would not be confident in her choices. During a follow up interview on 5/22/25 at 11:05 a.m., R1 reported receiving letters from R2 for at least a few months and brought her concerns and the notes to staff at least twice before bringing her concerns to the resident council meeting with the ombudsman in attendance. R1 identified the first time she reported her concerns about the notes written by R2, she was told (by facility staff) they would talk to him; the second time she approached staff about the notes, she did not receive any follow up on what had happened. R2 continued to write, and hand deliver the notes to R1 in the designated smoking area or in the hallway. R1 stated, I would hold my breath going down the hallway, hoping he didn't see me. R1 stated, the sexual abuse PTSD really amped up and brought it back. R1 reported informing her counselor of the PTSD and the unwanted attention and the doctor was going to look at adjusting one of my medications but don't know if that happened. R1 was tearful and continued to report trouble sleeping since the notes started as R1 worried about R2 coming into her room at night when the staff was not looking. R1 stated R2's notes made her feel disgusting, unsettled, and disturbed. R1 indicated the letters from R2 stopped after the resident council meeting on 5/15/25. The letters provided by the facility are as follows: 3/27/25: My Luv Bug, you are my favorite addiction Miss Lovely in every xxxxxx way. BTW: I love your tight [NAME]. Yummy to my tummy. Any ways I'm leaving here when you leave becuz [unreadable] I need, want, and love will be gone when you depart my lady. I love you [R1] Undated letter: I just hope you know I am taking an onslaught of haters by expressing my affection for you Lovely. I am about ready to tap out. It doesn't mean I don't love you, but I am gonna let off the gas pedal soon. I can only hope you still wanna lay in my arms someday. All night, All night. 4/2/25: Baby I still love you [R1] always will. [phone number written] Last letter circled. Letters provided by R1: 4/10/25 at 9:26 p.m.: [R1] I love you always [R2]. I will give U [NAME] love 4 a lifetime if I can trade u my heart for your beautiful body baby bunz. 4/21/25 at 7:57 p.m.: Love [R2] I want 2 kiss you forever and a day [R1]! I will always love you. U lifted up baby 4/23/25 at 9:56 p.m.: I want to kiss your smile smile. I'm falling 4 you [R1] badly. I love you so much I feel you in my bones baby. I want to kiss you forever. 4/26/25 at 7:35 p.m.: 4 ever love [R2] I will never stop adoring you everything you do drives me crazy 4 you [R1] and I love you 4 it more. Undated: Happy May Day my lady. Good morning my lover and best friend you were so amazingly perfect to my eyes. I just longed to touch you everywhere on your baby silk smooth flawless skin. You allowing me to touch you and massage your back and legs gave me a soothing peace I need every day. You are my darling and will and always enjoy pleasuring you anywhere any day {R1]. [heart sign] R2 Undated: Happy may day baby - to [R1] we need a night 2getherness. Good morning [R1] I love you more today than before. Thank you for letting me touch you and caress your [unreadable] last night. I need to touch you more. Your body is so silky smooth is soothing you know for me more than it probably is too you. Love [R2] Undated: Baby Bunz, you look so absolutely stunning today. I want to kiss you until me and you both feel loved. [R1] you look more beautiful than ever before. U make me wanna .69 long .until .cream. Undated: [R1} I love u and I know it! I have fallen 4 you [R1] 2 me through my eyes u are the most beautiful women I have ever had a soul connection with by far. No matter what happens you will never be forgotten and will always have a special piece of my [arrow drawn]. There is just something about you baby. Undated: Zangi.com(a private messaging app) [R2's number is listed] Undated: I feel better just being in love with you Undated: P.S .I [heart drawn]U [R1]! I hope someday we can be alone so I can kiss and hold you until you feel my love. Undated: To my lady [R1] my lover, my lady, my friend, my woman, my wife, my life, my love, yours always [R2] Undated: I need you to know how I feel about you. Its not even funny you're the first and the last thought in my head every day even when we [unreadable] together, just cant get enough of you. The look on your face when you are telling me how you feel about me makes me about melt or when your pushing my buttons trying to be cute makes my head swim even though its frustrating as xxxx it doesn't bother me. The hardest part is trying to not let how I feel show on my face all day long. I selfish and want you all to myself for the remainder of the time we have together. I guess what Im really saying is that I love you and everything about you. Facility documents R1's Grievance Form dated 4/2/25, indicated R1 did not want letters from R2 anymore. The investigation summary identified the DON spoke with R2 about letter writing and R2 wrote his last letter. Attached to the grievance form was a letter written by R1dated 4/2/25, indicated last letter with baby, I still love you, always will with phone numbers written on the note. A county sheriff's office Incident Report dated 5/3/25 at 8:15 p.m., indicated the sheriff's office received a 911 call indicated residents harassing each other and one feels unsafe. Residents were separated and advised to leave each other alone. The residents involved were R1, R2, and R3. The facilities Resident Council Minutes dated 5/15/25, identified social services concerns were resident feelings of being stalked and harassed by other residents and social worker stretched thin (over worked). The facility's undated policy titled, Abuse, Neglect and Exploitation identified it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implanting written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Sexual abuse is defined as non-consensual sexual contact of any type with a resident. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility will make efforts to ensure all resident are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. The facility's undated policy titled, Resident Right, identifies the resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The resident has the right to voice grievances to the facility or other agency without discrimination or reprisal. Such grievance includes those with respect to care and treatment which has been furnished as well as that which has not been furnished; the behavior of staff and of other residents; and other concerns regarding their LTC facility stay. The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have. The immediacy of the IJ was removed on 5/28/25 at 11:09 a.m., when it was verified, the facility had implemented the following: 1) R1 immediately assessed by nursing and social service staff for psychological impact related to PTSD, behavioral changes, mood, and cognitive status. 2) R1 had an appointment over the phone with rural psychiatry services on 5/23/25 at 11:00 a.m. 3) R1 and R2 were placed on 15-minute checks by facility staff. R1's 15-minute checks were to monitor for signs of distress, anxiety, or change in behavior. R2's 15-minute checks were for behavior monitoring. 4) R1 reassured of right to safety and privacy. 5) R1 was offered emotional support services and a counseling session was scheduled for 5/23/25 at 11:00 a.m. 6) Mental health provider will be completing a capacity to consent. The facility is in the process of finding a provider that is able to complete this. 7) Primary care provider and rural psychiatry services were updated of the sexual abuse of R1 by R2 on 5/22/25. 8) Social service designee had routine check-in's with R1 on 5/22/25 and 5/23/25. Check-in's will continue on Tuesday, Thursday, and Saturday evenings. 9) IDT meeting held on 5/22/25 which included increased supervision for R1 and R2, ensure supervising staff are briefed on relevant background and IJ findings, review of current living/social environment for safety and appropriateness, offer relocation to a different facility if resident wishes, remove or limit access to triggering individuals or settings where possible, remove or limit access to triggering individuals or settings where possible, counseling arranged to occur as needed, engage family or guardians where/when appropriate, engage commitment manager/relocation, worker/therapist/clergy when/where appropriate. 10) R2's care plan and behavioral intervention plans updated to include all written and verbal communications with R1 would be monitored by staff to ensure appropriateness and maintain a respectful, safe environment. 11) All residents were assessed to ensure no others were impacted by similar behavior from R2. 12) Abuse policy was revised to include written/verbal communications and resident to resident sexual harassment procedures. 13) Mandatory in-service training on 5/22/25, including definitions and examples of sexual abuse including written communications and mandated reporting. 14) System in place to determine capacity to consent on admission for all residents. 15) Weekly audits of resident interactions both written and verbal for 4 weeks, monthly for 3 months, and reviewed at quality assurance and performance improvement (QAPI) meetings. 16) All allegations of abuse will be reviewed immediately by IDT and brought to QAPI.

Based on observation, interview and document review the facility failed to identify a significant change in condition and provide timely medical intervention for 1 of 1 resident (R33) who had increasing, significant weight gain and other symptoms consistent with congestive heart failure (CHF) exacerbation. This resulted in actual harm for R33 when physician orders were not followed and appropriate, timely interventions for significant weight gain were not implemented. R33 was eventually admitted to the local hospital for IV diuretics (medication to remove fluid from the body) caused by CHF exacerbation. Findings include: R33's 10/25/24 quarterly Minimum Data Set (MDS) assessment identified her cognition was severely impaired, she required extensive assist with dressing, toileting, and transfers, and had diagnosis of congestive heart failure, hypertension, diabetes myelitis, and coronary artery disease. R33's current, undated care plan identified she had congestive heart failure. Staff were to administer cardiac medications and monitor for signs and symptoms of congestive heart failure. They were to report changes in lower extremity edema, periorbital edema, shortness of breath (SOB) upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of the lungs, orthopnea, weakness and/or fatigue, increased heart rate, lethargy and disorientation. R33 was a Full Code. R33's 6/5/24 discharge orders to the facility following hospital admission identified a diagnosis of congestive heart failure with orders to weigh R33 the morning after discharge and consider this weight as a goal weight. Staff were to report any change in shortness of breath/edema in legs or abdomen as well as weight changes 2-3 pounds (lbs)overnight, gain of 5 lbs in a week, or loss of 5 lbs from goal weight and to call 911 if R33 was having a medical emergency. R33's 6/6/24, order summary report identified the facility Medical Director wrote new orders to change the hospital discharge order to daily weights for only one week. R33's weight sR33's weights record reflected the following: 1) 6/5/24 at 1:36 p.m., (day of discharge from the hospital) 161.4 lbs. 2) 6/9/24 at 4:06 p.m., 163.4 lbs. 3) 6/12/24 at 1:13 p.m., 170 lbs. 4) 6/13/24 8:39 a.m., 171.2 lbs. 5) 6/18/24 at 7:59 p.m., 183 lbs. 6) 6/19/24 at 7:58 p.m., 185.8 (a gain of 24.4 lbs in 14 days) 7) 6/22/24 at 3:50 p.m., 186.8 lbs 8) 6/23/24 at 10:45 p.m., 188.4 lbs. 9) 6/24/24 at 12:22 p.m., 188.2 lbs. 10) 6/26/24 at 12:41 p.m., 192.4 lbs. 11) 6/26/24 at 10:10 p.m., 196.5 lbs. 12) 6/30/24 at 7:32 a.m., 200.8 lbs Further review of R33's weights identified R33 weights were as follows on: 1) 7/1/24 at 7:25 a.m., 205.2 lbs. 2) 7/2/24 at 7:07 a.m., 207.8 lbs. 3) 7/3/24 at 7:12 a.m., 210.8 lbs. 4) 7/4/24 at 7:11 a.m., 212.6 lbs. 5) 7/5/24 at 7:15 a.m., 213.8 lbs. 6) 7/6/24 at 12:56 p.m., 215.8 lbs. 7) 7/7/24 at 10:22 a.m., 216.4 lbs. 8) 7/8/24 at 9:13 a.m., 217 lbs. 9) 7/9/24 at 8:34 a.m., 218.2 lbs. 10) 7/10/24 at 7:02 a.m., 217.8 lbs. 11) 7/11/24 at 10:32 a.m., 221 lbs. 12) 7/12/24 at 10:37 a.m., 220.1 lbs. 13) 7/13/24 at 10:10 a.m., 223.2 By 7/13/24, R33 had a total weight gain of 61.8 lbs since re-admission on 6/5/24. Review of R33's nursing and physician progress notes lacked indication of provider notification or medical intervention related to weight gain from 6/5/24 (return from hospitalization ) until 6/29/24. 6/20/24, nursing progress note at 3:19 a.m., identified at 2:58 a.m., R33 had complained of shortness of breath. oxygen saturations were 84%, she described feeling like an elephant sitting on her chest. Oxygen supplementation was started at 2 liters (L per nasal cannula and a nitroglycerin (a medication used for treatment of chest pain (nitro)) 0.4 mg tab was given. R33 stated at 3:01 a.m., she was feeling better. Oxygen saturations came up to 95%. Staff documented no concerns at this moment. The medical record lacked indication that staff informed the physician of R33's weight gain at this time. 6/23/24, nursing progress note at 9:06 p.m., identified R33 had been on famotidine at hour of sleep (HS) for heartburn, GI distress. Famotidine (used to treat heart burn) was discontinued. She has been having chest pain, upper GI distress during the night and wants medication restarted. Will email physician these concerns. The medical record lacked evidence the physician had been notified of significant weight gain. 6/25/24, nursing progress note at 2:13 p.m., identified they received new order to restart famotidine and increase insulin. The record lacked indication of provider notification of weight gain. 6/29/24, nursing progress note at 9:00 p.m., identified R33 had been complaining of pain and has some edema in lower extremities. oxygen sats 99%, T 98.7, Blood pressure (BP) 112/76, pulse 89, weight 215.4. Physician called. Verbal order was given for a one-time dose of Lasix 40 mg and tramadol for pain. The MD ordered staff to start daily weights. 7/1/24, physician progress note at 10:28 a.m., identified R33 was seen during routine doctor rounds at the facility. Physician identified R33 had concerns of congestive heart failure and some lethargy over the weekend. The note identified she had been admitted to the nursing home for congestive heart failure and atrial fibrillation (A-fib) after a recent hospitalization . She had episode of lethargy with increased edema and shortness of breath. Some tightening in the chest. The MD ordered an increase in trazodone for sleep and increase Lasix to 40 mg daily and for staff to make cardiology appointment and labs. Although R1 was on 40mg of daily Lasix, she continued to gain weight between 1 to 7 pound each day which is a possible sign of excessive fluid in the body. 7/7/24, nursing progress note at 11:01 p.m., identified R33 had been complaining of shortness of breath and retaining fluid. Oxygen saturation is 97% on room air. She has had weight increase and requests oxygen supplementation. Oxygen started at 2 liters; resident reports much improved. There remained no indication staff identified the need for further evaluation. R33 had gained 11.2 lbs since last seen by the physician on 7/1/24. R1 continued to gain weight between 1 to 7 pound each day which is a possible sign of excessive fluid in the body. 7/9/24, nursing progress note at 1:33 p.m., identified the Minimum Data Set (MDS) registered nurse initiated a Significant Change assessment due to decline in activities of daily living, increase in incontinence, increased complaints of shortness of breath and increased weight gain. 7/9/24 dietary progress note at 2:56 p.m., identified diet was updated to a low sodium diet per dietitian recommendations. 7/11/24, nursing progress note at 3:11 a.m., R33 short of breath, coughing up frothy sputum, states it hurts to breath, I'm scared! Crackles heard in bases, BP 143/88 pulse 90, respirations 22, oxygen 97%. R33 requests to sit in recliner. There was no indication staff identified R33's concerns for the need for immediate medical evaluation and treatment by a higher level of care hospital. 7/11/24, nursing progress note at 4:04 a.m., R33 has been resting in recliner now with less shortness of breath, will continue to monitor. Audible wheezing is heard with respirations at times. 7/11/24, nursing progress note at 3:56 p.m., identified the registered nurse (RN) completed a respiratory assessment, the note identified R33 reports shortness of breath at rest, with activity, and with head of bed flat. She has spent a few nights sleeping in recliner in the day room to help with her breathing. R33 is utilizing her scheduled and prn inhalers and nebulizer treatments with some relief. She has had to use supplemental oxygen via nasal cannula at night for increased shortness of breath. discussed using an incentive spirometer and the benefits of using this device. R33 agreed to try it. R3's 7/13/24 July 24 (registered dietician) RD Review resident list noted R33 was identified for an assessment to be performed by the RD for a weight gain of +50 lbs. in 30 days. 7/14/24 nursing progress note at 1:16 a.m., identified R33 had complained of shortness of breath and generalized body aches rated 9/10, she requested to be sent to the emergency room for care. Nursing called the facility medical director and was given an order to administer Lasix 40 mg and increase her current Lasix order from 40 mg daily to 60 mg daily. R33 was informed of the physicians' orders and agreed to try the medication change. 7/14/24 nursing progress note at 2:36 a.m., identified R33 again requested to be seen at the emergency room , physician was contacted and gave an okay to send resident via ambulance to ER. R33 was admitted to the hospital after evaluation with congestive heart failure. Review of the 7/18/24, hospital discharge summary report identified R33 presented in the ER with COPD, congestive heart failure, preserved ejection fraction, coronary artery disease, and atrial flutter with a 60-pound weight gain over the past month after being discharged to the nursing home from the hospital. Patient was noted to have had a NSTEMI (heart attack that happens when the heart does not get enough oxygen) thought to be secondary to CHF exacerbation. R33 was diuressed (given IV diuretic medication to remove fluid) with IV Lasix and then switched to oral torsemide with good improvement in her breathing. R33's weight decresed 20 lbs and she was discharged back to the facility on [DATE]. Hospital discharge summary indicated R33's baseline weight is between 160 and 170 pounds. Interview on 11/18/24, at 10:18 a.m., with RN-A agreed the facility did not follow the hospital discharge orders to get a baseline weight the morning after R33 discharged back to the facility, complete daily weights, and report weight gain of more than 2.5 pounds overnight or 5 pounds weight gain in a week to the physician. She identified the facility medical director had changed the order to complete daily weights for only one week and identified she had entered that order into administration record, but agreed staff did not follow that order either. Interview on 11/14/24 at 10:24 a.m., with R33's physician (MD)-A, identified the facility should have been updating him with any weight gain of 3 pounds in 24 hours or more then 5 pounds in a week. He agreed the facility should have been updating him of R33's weight changes more frequently. Interview on 11/14/24 at 11:51 a.m., with attending physician from the local ED identified she believed in her professional opinion that had the facility sent R33 over to the clinic earlier on when she started experiencing weight gain and complaining of shortness of breath and chest pain, they likely could have treated her and avoided harm. The attending ER physician also identified that the clinic's heart nurse reached out to the facility in June to follow up with R33, she asked for an update on her over-all health status but never received a call back. Interview on 11/13/24 at 3:29 p.m., with the director of nursing (DON) identified she would have expected staff to update the physician with any weight gain of more than 3 pounds overnight or 5 pounds in a week. Staff should have called 911 for an emergency transport to the ER for evaluation when R33 had serious complaints of shortness of breath, chest pain, and found to have had a significant weight gain rather than calling or emailing the medical director. She identified that in most cases they advise nursing to call the medical director for guidance as they attempt to keep residents in house and use their own facilities own resources. She agreed MD-A was not updated regarding R33's weight changes timely. The DON identified they had no professional standards reference for nursing to utilize other than medication reference guides. A request was made to the facility to provide any training, or competencies completed related to recognizing a change of condition with the nursing staff that had entered progress notes identifying R33's symptoms of chest pain, shortness of breath, weight gain, and left arm pain. The facility provided training on identifying a change in condition for only 1 of the 5 licensed nurses on staff. Nothing more was provided by the end of the survey. The facility utilized no nursing standards of practice references for nursing staff to follow to assist in identifying medical emergencies or changes in condition. A policy on identifying and acting on a change in condition was requested but was later identified to not have any policy/procedure per management.

Based on observation, interview, and document review the facility failed to complete comprehensive pressure ulcer assessments and ensure physician ordered wound vac therapy was adequately managed for 2 of 3 residents (R1, R3) who required wound vac therapy. The facility's failures resulted in an immediate jeopardy (IJ) for R1's when their pressure ulcer deteriorated resulting in necrosis, bone exposure and hospitalization . The immediate jeopardy began on 6/26/23, when wound clinic identified R1's wound had deteriorated to the bone from improper dressing placement and mismanagement of the wound vac. The IJ was identified on 7/10/23 and the administrator, assistant administrator, and director of nursing (DON) were notified of the IJ on 7/10/23 at 5:45 p.m. The immediate jeopardy was removed on 7/12/23, but noncompliance remained at the lower scope and severity level of D- isolated with no more than minimal harm that is not immediate jeopardy. Findings include: Stage 4 pressure ulcer as defined by the State Operation Manual, last updated 11/22, is full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Negative Pressure Wound Therapy (NWPT) also known as a wound vac helps to heal wounds by providing a moist environment, promote new tissue formation, and removing excess fluid and infection. Negative pressure wound therapy uses suction, tubing, and wound dressing to remove excess exudate and any infectious material that may be present in the wound. Negative pressure wound therapy, also called wound vac or NPWT, provides an ideal and clean environment to promote wound healing in acute or chronic wounds. Offering significant clinical benefits for large, chronic wounds and acute, complicated wounds, negative pressure wound therapy is used by healthcare teams and wound care specialists to support faster wound healing. The negative pressure or vacuum suction is provided by a pump that is connected to a wound. A foam dressing is placed in the wound and covered with an occlusive dressing. The fluid that is removed is collected in a canister on the pump. A Vulnerable Adult Maltreatment report submitted to the state agency (SA) on 6/27/23 at 9:10 a.m., indicated the facility incorrectly followed wound care orders which caused worsening of R1's stage 4 sacral (a bone located at the base of your spine) ulcer and additional skin breakdown of 25.0 centimeters (cm) x 8.0 cm of previously good skin. The mismanagement of the wound vac and ulcer resulted in further necrosis (death of living tissue), infection, and hospitalization . A second Vulnerable Adult Maltreatment report submitted to the SA on 6/28/23 at 2:45 p.m., noted concerns regarding the facilities' ability to manage R1's stage 4 sacral ulcer and wound vac due to the deterioration of the ulcer while under their care resulting in R1's excess pain and long hospitalization stay. R1's Medical Diagnosis List last updated on 6/12/23, identified diagnoses of stage 4 pressure ulcer of sacrum, diabetes with polyneuropathy, severe chronic kidney disease, and heart failure. R1's hospital document titled, Discharge to Skilled Nursing Facility dated 6/12/23, identified an order for NWPT (wound vac) to sacral ulcer with further direction to use one large, black granufoam dressing, pack wound to skin level (including undermining). Recommended skin prep and 2-inch barrier ring to periwound skin and bridge wound up to hip, do not place [NAME] pad over the wound or over any bony prominence. Change Monday, Wednesday, and Friday. Cleanse wound with saline or wound cleanser when dressing changed. Suction set at 125 mmHg continuous. The patient's NPWT device should be on at least 22 hours of every day. If there is a malfunction of the pump, trouble shooting failed, and suction is off for 2 hours, you should remove the foam packing from the wound and pack gauze moistened with saline or sterile water. Change this dressing twice daily until the dressing can be replaced. The patient education section included: *The canister is changed once/week or when it is full. R1's Hospital discharge orders dated 6/12/23, included the aforementioned treatment orders for the wound vac dressing change to the sacral ulcer. R1's Skin Wound Evaluation dated 6/12/23, included stage 4 pressure ulcer in the middle of the sacrum present on re-admission to the facility. The wound measured 7.2 cm in length, 6.2 cm wide, 6.5 cm deep, with 6.5 cm of undermining (wider area of breakdown under the wound opening) and no tunneling (forms passageways underneath the surface of the skin). The pressure ulcer showed no signs of infection. Surrounding tissue is fragile skin and risk for breakdown. Primary dressing was wound vac. No further assessment of the sacral wound was identified. R1's Braden assessment dated [DATE], indicated R1 was at mild risk for pressure ulcers. R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment. Required extensive assist of staff for bed mobility, dressing, toileting, repositioning, transferring, and mobility. R1 was occasionally incontinent of bowel and had a urinary catheter. R1 was identified to be at risk for pressure ulcers. R1 had one stage four pressure ulcer, one venous ulcer, and one surgical wound. The MDS identified the following interventions were in place: pressure reducing device for chair and bed, turning and repositioning program, nutrition/hydration intervention to manage skin problems, pressure ulcer/injury care, application of non-surgical dressings, applications of ointments/medications to feet and areas other than to the feet. R1's Care Plan initiated on 6/14/23, indicated R1 had a stage 4 pressure ulcer to sacrum related to immobility, left hemiplegia, polyneuropathy. Interventions included administer treatments as ordered and monitor for effectiveness; avoid positioning the resident on back; monitor nutritional status; serve diet as ordered; monitor and record intake; the resident needs assistance to turn/reposition every two hours or more often as needed or requested; up in chair for no more than 1 1/2 to 2 hours; air mattress to bed and cushion in chair, and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. R1's care plan did not address interventions or direction for the wound vac. R1's Nurse-Readmission assessment dated [DATE], indicated R1 was readmitted from the hospital on 6/12/23. The assessment identified R1 had a pressure ulcer on the sacrum that required a wound vac. The assessment did not include wound measurements, drainage, pain presence, periwound skin integrity, or wound vac function. The assessment further indicated R1 had an alternating air mattress. Facility Negative Pressure Wound Therapy policy dated 2014, directed the following: NPWT is contraindicated in residents who have wounds with necrotic tissue with eschar, untreated osteomyelitis, non-enteric fistula or a malignancy. Documentation: 1. The wound status at time of application of negative pressure. 4. The resident's tolerance of the procedure. 6. The date and time negative pressure therapy was started and stopped. Reporting: 1. any problems with procedure. 2. Marked changes in the wound from baseline or previous dressing change. Physician order dated 6/14/23 included a wound clinic referral. R1's Treatment Administration Record (TAR) identified the wound vac dressing change order that directed to change R1's wound vac three times a week on Monday, Wednesday, and Friday. R1's dressing changes were completed on 6/14/23 by registered nurse (RN)-A. On 6/16/23, the dressing change was marked completed by the director of nursing (DON). On 6/19/23 and on 6/21/23, the TAR identified R1's dressing had not been changed and was marked with a chart code of 9 which indicated the treatement was not completed and directed to see progress notes. Progress notes dated 6/19/23 and 6/21/23 did not identify why the wound vac treatment was not completed. Review of R1's medical record from 6/12/23 to 6/16/23, did not include any routine monitoring for signs/symptoms of infection, amount of drainage including color, wound bed characteristics, and skin surrounding the pressure ulcer. There was no indication if R1 had any pain that was associated with wound vac placement or if the wound vac suction was set at 125 mmHg continuous at 22 hours every day as ordered by the physician. R1's progress note dated 6/16/23, at 2:30 p.m. indicated R1 voiced coccyx area discomfort when sitting in her chair; the tubing and [NAME] were directly over the wound was causing discomfort, she was assisted to bed which was helpful. R1 also has phantom limb pain and polyneuropathy pain. She had been administered as needed hydromorphone (narcotic pain medication) in the morning and scheduled Tylenol which were effective. R1 declined stronger pain medication at that time. In a subsequent note at 2:35 p.m. the physician was notified who then ordered Oxycodone (narcotic pain medication) 10 milligrams (mg) every 12 hours. R1's progress note dated 6/16/23, at 9:55 p.m. indicated R1 complained of almost constant pain from her sugical site on right stump and coccyx/sacrum area. R1 rated her pain 10 out of 10; she had non-verbal signs of pain facial expressions and protective body movements that indicate pain as well. She recieved scheduled and as needed medications of hydromorphone, Tylenol, and Oxycodone. Repositioning and rest help to alleviate some of her pain as well. Although the TAR dated 6/16/23, identified R1's wound vac treatment was changed, it was not evident the pain evaluation included checking the placement and/or integrity of the wound dressing as a causal factor of R1's pain. After 6/16/23, R1's record identified the next progress note was a physican visit dated 6/21/23. R1's wound clinic After Visit Summary dated 6/21/23, indicated it was R1's initial visit. R1 received wound care services for ongoing management of ulcerations that included sacral stage 4 pressure ulcer. The note included Wound VAC dressings were removed from the sacrum. This was not applied properly. The dressing was to be bridged to one of R1's hips however, they (facility staff) had the plastic flange directly over R1's sacrum; there was not enough black foam exposed for the plastic flange to adhere. 200 milliliters (ml) of drainage in the canister. Measurements of the wound showed the ulcer measured 5.8 cm x 6.0 cm x 4.0 cm. Undermining noted throughout the wound; at the 12 o'clock position 3.5 cm, 1 o'clock 4.5 cm, 3 o'clock 3.0 cm, 6 o'clock 1.0 cm, and 9 o'clock 3.0 cm. Wound bed is roughly 2% necrotic tissue and 50% granular. No periwound erythema, induration, stricture, or fluctuance. The wound was debrided to the level of the muscle. The following detailed instructions were given for the NWPT dressing changes to the sacrum: Clean wound bed with gauze and wound cleanser Treat periwound with skin barrier prep Place transparent dressing in the periwound skin for protection, this should be draped up to her hip for bridging. Pack the wound with the black granufoam (be sure to pack all undermined areas) and bridge this up to the hip over the transparent dressing. Be sure that all of the black foam is touching and not in contact with R1's skin. Secure all down with another transparent drape Cut out a 1.0 cm hole over the bridged portion to expose the black foam Place the plastic flange over the exposed black foam Secure the plastic flange down with transparent strips Turn the wound vac on at -125 mmHg continuous pressure. Be sure there are no leaks. Change Monday, Wednesday, and Friday. The visit note further included: It is very important that the wound vac is applied correctly and that it is bridged to the hip. Continue to check the wound vac through the day at least every shift or more often to be sure that there is a good seal and not malfunctioning. R1 should be on a pressure relieving mattress, change position ever 1-2 hours to reduce pressure to the sacrum. Plan is to see R1 at the facility next visit (6/26/23) as it would be beneficial to show the facility nursing staff how to place the wound vac appropriately for R1's safety. R1's care plan revised on 6/21/23, added the intervention of wound vac to sacral wound per orders. R1's TAR indicated registered nurse (RN)-A completed the wound vac dressing change to the sacral wound on 6/23/23. In review of R1's medical record between 6/17/23 to 6/26/23, the record did not include evidence of routine monitoring for signs/symptoms of infection, comprehensive wound assessments, evaluations for wound improvement or deterioration with dressing changes, and comprehensive pain assessment associated with wound vac placement. Additionally, not evident the wound vac was monitored for drainage amounts and continuous function. R1's Wound Care Follow Up Progress Notes written by nurse practitioner (NP)-A dated 6/26/23, indicated the wound team completed R1's visit at the facility with RN-A present. The note indicated R1 continued to have pain in the coccyx region. R1's dressing was removed from the coccyx but unfortunately, when the foam was bridged to the hip, there was not transparency drape placed under the foam [as ordered] so it did cause skin damage and is quite irritated. No drainage in the wound vac canister and a moderate odor was noted to the wound. Wound bed is full thickness, 75% eschar/slough, 25% granular. The wound bed measures 6.5 cm x 5.5 cm x 4.0 cm with undermining noted of the entirety and exposed bone that is easily felt. With appearance of wound on buttocks, vitals were obtained by nursing facility nurse, temp 100, blood pressure was not hypotensive, heart rate 86, respiratory rate 20. Mild temp, bone exposed, worsening wound erythema, advised that she should be seen in the emergency department. Likely will need imaging and lab work to rule out osteomyelitis and may need to see surgeon for bone debridement and wound debridement. R1 was sent to the emergency room for further evaluation. R1's facility progress note dated 6/27/23, indicated R1 had been transferred from the emergency room to a higher-level hospital and was receiving antibiotics. A follow up progress noted on 6/28/23, indicated R1 would not tolerate a surgery at that time and is getting debridement (a procedure to remove debris or infected/dead tissue from a wound) on the sacral wound. R1's social service note dated 7/11/23, indicated R1 would be discharged from the hospital on 7/12/23 after spending 16 days in the hospital for wound management. During an interview on 7/6/23 at 4:23 p.m., RN-A stated awareness of R1's wound vac dressing's being applied incorrectly. Further stated the facility had not provided any formal training but had worked with wound vacs at prior facilities. Normal process is to check for drainage when you walk by, RN-A had not recorded the checks, but stated it was something staff should be doing. During an interview on 7/10/23 at 11:30 a.m., contracted wound care certified medical assistant (MA)-A stated they first saw R1's wound on 6/21/23, at the wound care clinic. MA-A explained the wound vac dressing was done incorrectly; the tubing was placed directly over the sacral ulcer, the dressing was loose and not sealed adequately to allow for proper suction. MA-A indicated R1 was having a lot of pain at the time. R1's sacral dressing was replaced in the clinic and detailed instructions were provided to the facility on how to correctly change and bridge the dressing. MA-A stressed the black foam could not be on good skin because it would cause breakdown; the healthy skin needed to be protected by a transparent film. MA-A stated R1's next visit on 6/26/23, was at the facility. When taking off R1's dressing the black foam had been placed on healthy skin and caused skin irritation of about 25 centimeters(cm) x 8.0 cm and the bone was exposed so the nurse practitioner(NP)-A advised sending R1 to the emergency department (ED) as a result of the facility not provding adequate care and oversight of the wound vac. During an interview on 7/10/23 at 11:40 a.m., NP-A stated on R1's wound clinic visit on 6/21/23, the wound vac dressing was not applied the way the provider ordered it. The 6/26/23 visit was conducted at the facility so the facility staff could be educated on how to perform the dressing change according to the physician orders. NP-A explained the facility staff would have put the dressing on R1's wound on 6/23/23. When that dressing was removed on 6/26/23, the dressing had been bridged but transparency film was not put down first to protect the health skin which caused R1 pain when removing the black foam. The area of R1's skin that was denuded (loss of skin caused by moisture and friction) measured 25.0 cm x 8.0 cm. Also noted exposed bone in the wound bed, necrotic (death of living tissue) skin, and elevated temperature which resulted in an order to transfer to the ED. During an interview on 6/26/23 at 5:16 p.m., RN-B indicated she and the DON had completed R1's wound vac sacral dressing changes twice but did not bridge it as ordered because there was no explanation why the bridging needed to be done. RN-B verified she did not contact the wound care clinic or surgeon to clarify the order. During an interview on 7/6/23 at 11:20 a.m., DON stated normally she completed wound rounds once a week which included documenting and taking a picture. The DON verified the facility nurses did not have any documented wound vac training in their personnel files. The DON stated she was made aware by the wound clinic team of missing the step of putting the barrier down and then not bridging correctly for R1's dressing change. The DON then identified the need for wound vac training so scheduled the wound vac supplier to train nurses on 7/17/23. R3's hospital After Visit Summary dated 7/1/23, indicated R3 was discharged to the facility following hospitalization for an abscess spinal epidural (infection in the spine) and laminectomy. This document included an order to leave wound vac on for 5 days and to change dressing pads as needed. R3's admission MDS dated [DATE], indicated R3 did not have cognitive impairment. R3 required assist of two staff with bed mobility, transferring, dressing, toileting. R3 did not walk or get up in a wheelchair. R3 had one surgical wound. R3's Braden Scale for Predicting Pressure Sore Risk dated 7/1/23, indicated R3 was moderate risk for pressure sores. R3's wound vac physician order dated 7/5/23, directed to place incisional wound vac change every third day, take picture of incision with every change, set wound vac at 75 mmHg of continuous suction. R3's Care plan last updated 7/5/2, indicated R3 had a potential/actual impairment to skin integrity and identified interventions of barrier cream. The care plan lacks any documentation of R3's wound vac, management, and monitoring. R3's Skin and Wound Evaluation initially done on 7/10/23 at 10:39 a.m. (10 days after admission) identified R3 had a surgical wound closed with 15 sutures present upon admission to the facility. The surgical wound measured 7.3 cm long and 0.9 cm wide. The evaluation did not include any other wound characteristics such as drainage, presence/absence of signs/symptoms of infection, dressing type, or wound vac therapy. R3's July 2023 treatment administration record (TAR) did not identify the physician orders for wound vac dressing changes nor indicate the dressings had been completed per the physician order. Further in review of R3's medical record it was not evident of ongoing monitoring for signs/symptoms of wound infection and not evident of ongoing monitoring of wound vac function and efficacy. During observation and interview on 7/6/23 at 2:30 p.m., R3 stated the wound vac had been unplugged and not working for an undetermined amount of time and had not heard the wound vac making suction noises since the previous day (7/5/23). No wound drainage observed in the wound vac drainage chamber. Family member (FM)-A stated the wall plug-ins were loose and it must have fallen out again. R3 stated no one checked her wound vac unless she asked them to and was still waiting for the new wound vac and dressing change. During an interview on 7/6/23 at 4:23 p.m., the DON was informed of R3's report and evaluator's observation of R3's wound vac being unplugged for an undetermined amount of time. The DON verified that staff did not routinely check the wound vac for proper functioning. DON had not been aware of R3's wound vac not working and would add a check for wound vac function to R3's treatment administration record. During observation on 7/6/23 at 5:32 p.m., RN-B and the DON changed R3's wound vac and dressing. DON was unable to get the camera to take a picture of the wound. No wound assessment was completed or documented by RN-B or the DON. The wound vac was observed to be functioning. During observation and interview on 7/10/23 at 10:14 a.m., FM-A stated R3's machine was noted to be unplugged the previous morning (7/9/23) at 8:00 a.m. and immediately plugged it in and it started to suction. FM-A did not know how long the wound vac had been unplugged and R3 stated she was not aware the wound vac was unplugged until FM-A told her. A small amount of drainage was observed in the wound vac tubing. During an observation on 7/10/23 at 10:30 a.m., RN-A and licensed practical nurse (LPN)-A changed R3's wound dressing. R3 told RN-A that a picture was supposed to be taken of the wound with the dressing change. RN-A left the room to get the tablet computer. RN-A stated the camera on the tablet automatically measured the wound but if the camera was not functioning, they were to manually measure the wound, and document in the medical record. RN-A verified the wound vac was not functioning properly at 140 mmHg (which was not consistent with the physician order that directed 75 mmHg) RN-A then left R3's room. RN-A stated she was unsure of the battery life of the wound vac, there was an instruction book on the wound vacs but was not sure where it was located and would have to check with the DON. During a follow up interview on 7/10/23 at 11:31 a.m., RN-A verified R3's wound vac was set at 140 mmHg of pressure but thought it was supposed to be set at 125 mmHg. After checking with the DON, RN-A stated the physician order was for 75 mmHg and would change the settings immediately. During an interview on 7/10/23 at 11:40 a.m., NP-A indicated a wound vac setting of 140 mmHg causes more suction and could cause increased pain. Recommendation was to start with a lower pressure setting as most people can't tolerate a setting of 140 mmHg. During an interview on 7/10/23 at 12:09 p.m., DON verified wound measurements and assessment were not done on R3 during the 7/6/23, dressing change. DON stated she was unsure of how the suction setting would have been changed on R3's wound vac and unaware that it had been unplugged. Interview on 7/11/23 at 2:12 p.m., the Administrator stated wound vacs were new to the facility within the past month and anytime there is something new like that (wound vacs) there needs to be education. The facility policy titled, Negative Pressure Wound Therapy, last revised 2/2014 directs to assess the wound prior to selecting the type, size, and thickness of dressing material. Create a barrier dressing to protect healthy skin; there should be at least a 1-inch barrier around the margins of the wound. Initiate negative pressure settings on the pump as ordered. Document in the resident's medical record the wound status at the time of application of negative pressure, the number of sponge pieces used in the wound dressing, the negative pressure and time settings on the pump, and the resident's tolerance of the procedure, the date and time of the dressing application/change, the date and time negative pressure therapy was started and stopped, the names and initials of the person performing the dressing change. The immediate jeopardy that began on 6/12/23, was removed on 7/12/23, when it could be verified the facility implemented the following; -Reviewed facility policy/procedures for wound vac and wound care -Identified residents who were at risk, completed comprehensive wound assessments, reviewed/revised care plans and physician orders according to assessments. -Nursing staff were provided with Wound Vac training and demonstrated competency.