Every finding on record at Washington Senior Living

Based on interview and record review the facility failed to remove a staff member from resident care after an allegation of abuse. This failure has the potential to affect all 84 residents who currently reside in the facility. The Facility's Abuse Prevention Program dated 10/2022 documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of good and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents.The Facility's Abuse Prevention Program dated 10/2022 documents The nursing staff is responsible for reporting the appearance of suspicious bruises, lacerations, or other abnormalities of an unknown origin as soon as it is discovered. The report is to be documented on a facility incident report and provided to the nursing supervisor, administrator or designated individual. Following the discovery of any suspicious bruises, lacerations or other abnormalities of an unknown origin, the nurse shall complete a full assessment of the resident for other bruises, laceration, or pain.The Facility's Abuse Prevention Program dated 10/2022 documents For resident injuries not involving an allegation of abuse or neglect, the administrator will appoint a person to gather further facts to make a determination as to whether the injury should be classified as an injury of unknown source. An injury should be classified as an injury of unknown source when both of the following conditions are met: the source of the injury was not observed y any person or the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location (e.g. the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. The Facility's Abuse Prevention Program dated 10/2022 documents If classified as an injury of unknown source the person gathering facts will document the injury, the locations and time it was observed, any treatment given and notifications of the resident's physician, responsible party. The (State Agency) will be notified . Time frames for reporting and investigating abuse will be followed. The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable.The Facility's Abuse Prevention Program dated 10/2022 documents Employees of this facility who have been accused of abuse. Neglect, exploitation, mistreatment or misappropriation of resident property will be removed from resident contact immediately. The employee shall not be permitted to return to work until the results of the investigation have been reviewed by the administrator and it is determined that any allegation of abuse, neglect, exploitation, mistreatment or misappropriation of resident property is unsubstantiated.On 5/8/2026 V4 (Activity Aide) stated that on 4/27/2026 she saw R1 sitting in the hallway after receiving a shower from V5 (Certified Nurse Aide) and R1 said she was scared and she thought someone was trying to kill her. V4 stated R1 had bruising noted to her wrist so V4 was concerned and went to V3 (Activity Director). On 5/8/2026 V3 (Activity Director) confirmed that V4 (Activity Aide) came to her with concerns regarding R1's wrist and that R1 seemed so afraid of V5 (CNA). V3 (Activity Director) stated she immediately notified (V1/Administrator) because she felt that V4 (CNA) was voicing a suspicion of abuse. On 5/8/2026 V1 (Administrator) provided undated/untimed/unsigned handwritten notes regarding R1's bruise. V1 was not able to provide any documentation of interviews with residents whom V5 (CNA) had cared for. On 5/13/2026 V1 (Administrator) confirmed that he responded to V3 (Activity Director)'s report of concerns regarding a bruise on (R1). V1 confirmed he was aware that V4 (Activity Aide) was alleging that R1 was overly scared of V5 (Certified Nurse Aide) and that V4 voiced concerns about a bruise to R1's hand. V1 (Administrator) confirmed that V5 (CNA) continued to work that afternoon/evening that he was here investigating and that he never suspended or sent V5 away from all the residents.

Based on interview and record review the facility failed to recognize an incident as an allegation of abuse and failed to thoroughly investigate a bruise of unknown origin for one resident (R1) of three residents reviewed for abuse. The Facility's Abuse Prevention Program dated 10/2022 documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of good and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents.The Facility's Abuse Prevention Program dated 10/2022 documents The nursing staff is responsible for reporting the appearance of suspicious bruises, lacerations, or other abnormalities of an unknown origin as soon as it is discovered. The report is to be documented on a facility incident report and provided to the nursing supervisor, administrator or designated individual. Following the discovery of any suspicious bruises, lacerations or other abnormalities of an unknown origin, the nurse shall complete a full assessment of the resident for other bruises, laceration, or pain.The Facility's Abuse Prevention Program dated 10/2022 documents For resident injuries not involving an allegation of abuse or neglect, the administrator will appoint a person to gather further facts to make a determination as to whether the injury should be classified as an injury of unknown source. An injury should be classified as an injury of unknown source when both of the following conditions are met: the source of the injury was not observed y any person or the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location (e.g. the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. The Facility's Abuse Prevention Program dated 10/2022 documents If classified as an injury of unknown source the person gathering facts will document the injury, the locations and time it was observed, any treatment given and notifications of the resident's physician, responsible party. The (State Agency) will be notified . Time frames for reporting and investigating abuse will be followed. The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable.The Facility's Abuse Prevention Program dated 10/2022 documents The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked will be interviewed. On 5/8/2026 V4 (Activity Aide) stated that on 4/26/2026 she saw R1 sitting in the hallway after receiving a shower from V5 (Certified Nurse Aide) and R1 said she was scared and she thought someone was trying to kill her. V4 stated R1 had bruising noted to her wrist so V4 was concerned and went to V3 (Activity Director). On 5/8/2026 V3 (Activity Director) confirmed that V4 (Activity Aide) came to her with concerns regarding R1's wrist and that R1 seemed so afraid of V5 (CNA). V3 (Activity Director) stated she immediately notified (V1/Administrator) because she felt that V4 (CNA) was voicing a suspicion of abuse. On 5/13/2026 V1 (Administrator) confirmed he was notified by V3 (Activity Director) of concerns with a bruise on (R1). V1 stated he did not treat the incident as an abuse investigation because R1 is always fearful and upset after a shower due to her cognition and she propels her own wheelchair, she probably hit it when she was doing that. On 5/13/2026 V1 (Administrator) confirmed that R1's current care plan does not include any information regarding R1 always being fearful with showers. V1 confirmed R1's care plan does not address any risk for bruising to hands. V1 also confirmed that there was no documentation of R1's wrist bruise prior to V2 (Director of Nursing) made a note of the bruise on 4/27/2026. R1's Nurse's Notes dated 4/27/2026 at 6:15 PM documents that floor nurse reported to Director of Nurse that bruise was found. Moderate sized bruise dark purple with yellowish tints, no open areas. Resident unable to verbalize what happened. On 5/13/2026 V2 (Director of Nursing) confirmed she found out about R1's bruise on 4/27/2026 and assessed the bruising. V2 confirmed she had never assessed bruising on R1 prior to that and there was no previous documentation of R1's bruising prior to her own on 4/27/2026 at 6:15 PM.

Based on interview and record review the facility failed to report an allegation of abuse to the State Reporting Agency and the family for one resident (R1) of three residents reviewed. The Facility's Abuse Prevention Program dated 10/2022 documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of good and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents.The Facility's Abuse Prevention Program dated 10/2022 documents The nursing staff is responsible for reporting the appearance of suspicious bruises, lacerations, or other abnormalities of an unknown origin as soon as it is discovered. The report is to be documented on a facility incident report and provided to the nursing supervisor, administrator or designated individual. Following the discovery of any suspicious bruises, lacerations or other abnormalities of an unknown origin, the nurse shall complete a full assessment of the resident for other bruises, laceration, or pain.The Facility's Abuse Prevention Program dated 10/2022 documents For resident injuries not involving an allegation of abuse or neglect, the administrator will appoint a person to gather further facts to make a determination as to whether the injury should be classified as an injury of unknown source. An injury should be classified as an injury of unknown source when both of the following conditions are met: the source of the injury was not observed y any person or the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location (e.g. the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time.The Facility's Abuse Prevention Program dated 10/2022 documents When an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of resident property has been made, the administrator, or designee, shall notify (State Survey Agency) regional immediately by telephone or fax. The report shall include the following information, if known at the time of the report: name, age, diagnosis, and mental status of the resident allegedly abuse, neglected, exploited, mistreated, or from whom property was misappropriated; type of abuse reported, date, time, location and circumstances of the alleged incident, any obvious injuries or complaints of injury and steps the facility has take to protect the resident,The Facility's Abuse Prevention Program dated 10/2022 documents The investigator will report the conclusions of the investigation in writing to the administrator or the designee within five working days of the reported incident. The final investigation report shall contain the following: name, age ,diagnosis, and mental status of the resident allegedly abused, neglected, exploited, mistreated, or from whom property was misappropriated, the original allegation, facts determined during the process of the investigation, review of medical record and interview of witnesses; conclusion of the investigation based on known facts, the police report, if applicable. On 5/8/2026 V4 (Activity Aide) stated that on 4/27/2026 she saw R1 sitting in the hallway after receiving a shower from V5 (Certified Nurse Aide) and R1 said she was scared and she thought someone was trying to kill her. V4 stated R1 had bruising noted to her wrist so V4 was concerned and went to V3 (Activity Director). On 5/8/2026 V3 (Activity Director) confirmed that V4 (Activity Aide) came to her with concerns regarding R1's wrist and that R1 seemed so afraid of V5 (CNA). V3 (Activity Director) stated she immediately notified (V1/Administrator) because she felt that V4 (CNA) was voicing a suspicion of abuse. On 5/13/2026 V1 (Administrator) confirmed that he had not notified (State Agency) when the bruise was discovered or 5 days later.

Based on observation, record review and interview the facility failed to post grievances/complaints procedures in a prominent location throughout the facility. This failure has the potential to affect all 67 residents residing in the facility. Findings include: The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 3/9/26 and signed by V1/Administrator documents 67 residents reside within the facility.The facility's Filing Grievances/Complaints Policy, dated December 2004, documents, Our facility will assist residents, their representatives (sponsors), other interested family members, or resident advocates in filing grievances or complaints when such requests are made. The Policy's Interpretation and Implementation documents, 2. Upon admission, residents are provided with written information on how to file a grievance or complaint. A copy of our grievance/complaint procedures is posted on the resident bulletin board.On 3/10/26 at 1:15 PM, during Resident Council meeting, R3, R13, R22, R46, R58, R59, R60, and R84 all stated they do not know how or where to file a grievance at the facility.On 3/11/26 at 12:45 PM, a tour was conducted with V1/Administrator asking V1 to demonstrate where the grievance procedure was located in the building. V1 verified there was not a posted grievance procedure in any prominent locations around the building, including next to the grievance forms and the resident bulletin board.

Based on Interview and Record Review, the facility failed to ensure that direct resident care staffing was adequate to meet the needs of residents in the facility. This failure has the potential to affect all 67 residents residing in the facility.Findings include: The facility's Facility Assessment, dated 8/1/25, documents the facility has an average daily census of 70. This same assessment documents Evaluation of overall number of facility staff needed to ensure a sufficient number of qualified staff are available to meet each resident's needs.The facility's Call Light System Policy and Procedure, undated, documents Policy: it is the policy of this facility to provide a means of communication to meet the needs of each resident. Staff will follow established procedures to respond to the residents' requests and needs. Procedure: Respond promptly when the call light is activated.On 3/09/26 at 3:20pm R81 was sitting on the toilet in her room with the bathroom door open and her wheelchair outside the door. R81 stated she no longer uses her call light when she needs to get out of bed or use the bathroom because they (staff) don't come, it takes a long time for them to answer it, and she cannot wait that long to use the bathroom. R81 stated she always transfers herself in and out of bed to and from her wheelchair and from her wheelchair to and from the toilet. On 03/10/2026 at 1:46 PM, during resident council, R3, R13, R22, R46, R58, R59, R60, and R84 all stated they had concerns with long wait times on call lights and concerns with weekend/night shift staff. They all stated they notice that there are not as many staff and must wait longer for call lights/medications. 03/11/2026 12:06 PM R80 reported staff take a long time to answer his call light on night shift when he turns it on and needs assistance. R80 stated sometimes it can take longer than 30 minutes for staff to respond to his call light. The Resident Council Meeting, dated 3/18/25, documents concern with Nursing CNAs seemed rushed to finish task and not spending enough time with residents.The Resident Council Meeting, dated 7/22/25, documents Nursing: third shift rounds feel like more than two hours.The Resident Council Meeting, dated 9/23/25, documents concern with Nursing CNAs not focusing and completing task at hand and will state they will be right back and come back to the task an hour later.The Resident Council Meeting, dated 12/16/25, documents Nursing: CNAs to cover to many residents. Extra help needed. Concern on night shift.The State Agency's Notice of Staffing Violations, dated 8/15/25, documents the facility received notice of staffing violations and documents the facility was not in compliance with the minimum staffing ratios for the quarter period January 1st through March 31st, 2025. This same staffing violation documents Total number of days of shortfall: 25. Number of days Registered Nurse short fall: 20. Number of days Licensed Nurse shortfall: 1. Number of days miscellaneous shortfall: 8.The [NAME] PBJ (Payroll Based Journal) report for this survey identifies excessively low weekend staffing and a 1-star staff rating for the facility's fourth quarter of 2025.The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 3/9/26 and signed by V1/Administrator documents 67 residents reside within the facility.

Based on interview, observation and record review the facility failed to provide and offer snacks throughout the day and evening for all residents in the facility. This failure has the potential to affect all 67 residents residing in the facility.Findings include:The facility's Fortified Foods, Supplements, and Snacks policy dated 2020 documents Snacks: regular food items that are available on the units or can be specified to be served at designated times (such as for a diabetic) and generally not required to be ordered by the physician.On 3/10/26 during the surveyor-led Resident Council Meeting at 1:00pm, the consensus of the 8 residents present, (R3, R13, #22, R46, R58, R59, R60 and R84) was snacks are not offered throughout the day, and bedtime snacks are not passed out, and only available sometimes.On 3/10/26 at 10:03am R65 stated snacks are not offered to the residents at any time, and residents have to ask for a snack. R65 stated she was diabetic. R65's medical record includes a diagnosis of diabetes.On 3/10/26 at 10:35am R81 sated the staff do not offer snacks to the residents and she was unsure if residents could have snacks.On 3/10/26 at 2:45pm R19 stated she was unaware of snacks being offered or available to residents.On 310/26 R54 stated snacks are not offered at any time throughout the day. On 3/11/26 at 12:45pm V5 Dietary Manager stated the facility does not have designated snack times throughout the day and snacks are not available on the units or Nurses Stations during the day until 7:00pm when a cart of snack items is wheeled to the unit and into the ice room, where they stay. V5 stated there were no physician-ordered snacks for residents, including diabetics, and snacks are not offered, residents have to request a snack. V5 stated the nurses can request something for diabetics in the event a resident has low blood sugar during the day, and There is a bin of peanut butter sandwiches in the kitchen if needed.On 3/11/26 at approximately 12:50pm V1 administrator stated a snack cart is wheeled to the units at 7:00pm every evening and, if a resident requests a snack, they are given one.

Based on Observation, Interview and Record Review, the facility failed to ensure the main kitchen and serving kitchen's refrigerated food items and dry food items were labeled, dated and free from expiration, the facility's dish machine chemicals were tested daily to ensure effective sanitation levels, cool down temperatures were taken for food items cooked ahead and then stored in the refrigerator, and that a fan utilized at meal times and blown towards prepared food was kept clean and without dust and debris. This failure has the potential to affect all 67 residents residing in the facility. Findings include:The facility's Labeling and Dating Foods policy, dated 2020, documents All foods stored will be properly labeled according to the following guidelines. Once opened the individual food items from the case are dated with the date the item was received into the facility and will be using first-in- first out method of rotation. Once a package is opened, it will be re-dated with the date the item was opened and shall be used by the safe food storage guidelines or by the manufacture's expiration date.The facility's Dishwashing: Machine Operation guideline policy, dated 2020m documents Check the dishwashing machine before first use. If the dishwashing machine has not been used for several hours, it is generally recommended to allow the dishwashing machine to cycle for one or two cycles to allow dishwashing machine to come up to proper function. Record log documents twice daily for either final rinse temperature (high temperature machine) or sanitizer concentration (low temperature machine with chemical sanitizer).The facility's Cooking and Cooling policy, dated 2020, documents Foods will be cooked thoroughly, reaching the appropriate internal temperature specific to each item. Cooked foods will be cooled properly to ensure food safety. Cool foods using a two-step process; 135 degrees Fahrenheit (F) to 70 degrees F in the first two hours, and then 70 degrees F to 41 degrees F in the next four hours. Foods must be cooled quickly to keep bacteria from growing and spreading. The denser the food and the greater amount of food, the longer it will take to cool. If food has not reached 70 degrees F within two hours, it must be reheated to 165 degrees F within the first two hours or thrown out.On 3/9/26 at 9:50 AM a tour of the facility's kitchen was conducted. At this time the facility's walk-in refrigerator contained two pitchers of tea, three pitchers of water and one pitcher of cranberry juice all without a label or date. V5 (Dietary Manager) verified the contents of each pitcher and confirmed they should have labels with dates on them for discard.On 3/9/26 at 10:05 AM the facility's dining room kitchen nook refrigerator contained a gallon jug of 2% milk with an expiration date of 2/2/26. This same fridge contained two squeeze condiment bottles without a label or date. V5 stated That's ranch dressing and it should have been dated when poured into the squeeze bottle. In this same dining room nook, a metal rack contained four plastic containers of poured in dry cereal. These containers did document a recent label and two contained a label that documented use by 12/2/25. V5 stated that labels are not accurate and the cereal should have received updated labels when poured into the containers.On 3/9/26 at 10:20 AM V5 stated the facility uses a low temperature dish machine. V5 stated the machine should reach between 150 to 200 parts per million (PPM) quaternary level of sanitation with each cycle. V5 stated I do not have any documentation to show that the sanitation levels are monitored. The dish machine's chemical level is not tested and documented daily. (Kitchen staff) have only ever been told to check the water temperatures with each mealtime, which reach about 100 degrees. The method to sanitize is chemical, so checking that makes more sense.On 3/9/26 at 11:45 AM, the noon meal steam table food temperatures were checked by V6 (Dietary Aide). During this check a large round industrial fan was sitting on a chair in the kitchen nook and blowing forced air directly towards V6 and steam table with prepared food. This fan was coated with thick accumulation of fuzzy gray dust, grime and debris substances. At this time V6 stated (Kitchen staff) always have that fan on because it gets so hot when serving food. On 3/10/26 at 9:30 AM, the kitchen's walk-in refrigerator contained a pitcher of lemonade without a label or date. In this same fridge was a metal container with foil on the top labeled breakfast sausage 3/8/26. V5 confirmed the sausage was from Sunday's breakfast and then stated they (kitchen staff) do not have a cool down log for the sausage. On 3/11/26 at 9:27 AM V17 (Maintenance Director) verified that the fan in the facility's dining area blows forced air directly on the serving steam table and is coated with dust a grime. V17 stated the kitchen staff should be cleaning that fan and it needs cleaned.The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 3/9/26 and signed by V1(Administrator) documents 67 residents reside within the facility.

Based on observation, interview, and record review, the facility failed to ensure resident room floors were clean and free of debris for four of four residents (R8, R10, R16, R36) reviewed for clean and homelike environment in the sample of 48. Findings include: The Housekeeping Supervisor Job Description, dated 10/2020, documents Primary Purpose of this Position: The primary purpose of this position is to assist in supervising the day-to-day activities of the housekeeping department as directed by the Director of Environmental Services to assure that facility is maintained is a clean, safe and comfortable manner. Duties and Responsibilities: Ensure that the resident environment is safe, clean, comfortable and home-like. Oversee the housekeeping services necessary to maintain a sanitary, orderly and comfortable interior. Conduct routine housekeeping rounds. The Housekeeping Job Description, dated 10/2020, documents The primary purpose of this position is to perform the day-to-day activities of housekeeping as directed by the Housekeeping Supervisor to assure that the facility is maintained in a clean, safe, and comfortable manner. Perform specified tasks in accordance with daily work assignments, coordinate daily housekeeping services with nursing services when performing routine assignments in resident living and/or recreation areas, clean floors by sweeping, dusting, damp/wet mopping, stripping, waxing, buffing, and disinfecting, perform day-to-day housekeeping functions as assigned, perform specific tasks in accordance with daily work assignments. The Houskeeper's Daily Schedule dated 3/8/26 to 3/21/26 documents two housekeepers worked 3/8/26, two and a half housekeepers worked 3/9/26, one and a half housekeepers worked 3/10/26, and two housekeepers worked on 3/11/26. The facility's Resident Council Meeting, dated 1/20/26, documents Housekeeping: Concerns with short staffing.The facility's Resident Council Meeting, dated 6/24/25, documents Housekeeping: Complained of room not being cleaned in a timely fashion. The facility's Resident Council Meeting, dated 9/23/25, documents Housekeeping: Sticky floors in Assisted dinging room at the time of this meeting. 1. On 3/10/26 at 9:57AM R8's room was covered in dried debris, red colored liquid stains, and was sticky. On 3/11/26 at 9:21 AM R8's room floor remined the same with the same red colored liquid stain by R8's bed. 2. On 3/10/26 at 9:54 AM R10's room floor had dried stains throughout the floor, was sticky, and covered in debris. Around the wall base of R10's room, thick debris was observed. On 3/11/26 9:19 AM R10's floor remained the same as the day before. R10's room floor remained sticky with stains and debris along with thick debris around the wall base. 3. On 3/10/26 at 9:52 AM R16's was dirty, sticky, and covered in debris. Thick black debris was observed in the corners of R16's room. On 3/11/26 at 9:18 AM R16's floor remained the same as the day before, sticky, dirty with dried debris all over. The corners of R16's room remained with thick black debris. 4. On 03/10/26 at 9:55 AM R36's room floor was covered in stains, was sticky, and was covered in pieces of food and dried debris. On 3/11/26 at 9:20 AM R36's room floor remained the same as day before. R36's floor was covered in stains, was sticky, and was covered in pieces of food and dried debris. On 3/11/26 at 9:27 AM V17/Maintenance Director stated he was given the task to oversee housekeeping services on 3/9/26. A tour was conducted of R8, R10, R16, and R36's room at this time. V17 verified R8, R10, R16, and R36's room floors were dirty and stated, A housekeeper called in this week so that may be why the rooms are not getting cleaned like they should. The rooms should be swept and mopped at least daily, and these rooms have not been. On 3/11/26 at 9:35 AM V1/Administrator stated V17/Maintenance Director has been assigned Housekeeping Supervisor as of Monday 3/9/26. V1 stated, We have not had a Housekeeping Supervisor for the past 6 months. I have been overseeing it when I can. We have had a housekeeper call off this week and a housekeeper that has switched to dietary aide, so that may be why some of the rooms have not been getting cleaned daily. We should have at least three housekeepers per day and have only had one to two this week. V17 stated all rooms should be at least swept and mopped daily and verified at this time the housekeeping schedule provided is accurate.

Based on observation, interview, and record review the facility failed to ensure a call light was in reach for three of 18 residents (R14, R36, and R54) reviewed for call lights in the sample of 48.Findings include: The facility's Call Light Policy and Procedure, undated, documents Policy: It is the policy of this facility to provide a means of communication to meet the needs of each resident. Staff will follow established procedures to respond to the residents' requests and needs. Procedure: Assure the call light is within easy reach of the resident. 1.R36's MDS (Minimum Data Set) assessment dated [DATE] documents R36 is moderately cognitively intact. R36's current Care Plan documents R36 is risk for falls and requires assistance of staff for bed mobility, transfers, toilet use, dressing, and bathing. This same Care Plan documents interventions to prevent falls include keeping R36's call light within reach. On 3/9/26 at 9:39 AM R36 was lying in her bed and was slid down halfway in the bed on her back. R36 was requesting to be pulled up in the bed, but her call light was not within reach. R36's call light was lying on the right side of R36's bed, on the floor next to R36's nightstand, and out of R36's reach. R36 stated she is unable to get up on her own to get her call light or pull herself back up in bed. On 3/9/26 at 10:09 AM V8/Certified Nursing Assistance verified R36's call light was on the floor out of R36's reach. V8 picked up R36's call light off the floor and attached it to R36s bed sheet by R36's right hand. V8 stated, Resident call lights should always be within reach. 2. R14 is a [AGE] year-old resident with diagnoses including Active Primary Progressive Multiple Sclerosis and left-sided Hemiplegia and Hemiparesis. R14's current Care Plan includes the following focus and intervention: Focus: (R14) is at risk for falls related to: MS (Multiple Sclerosis); Musculoskeletal Impairment and Limited ROM Interventions/Tasks: Be sure call light is within reach and encourage to use it for assistance as needed. On 3/11/26 at 9:30am R14 was sitting in a slouched down in a high-back wheelchair next to the bed and an odor of urine was noticeable in the room. R14's pants were visibly soaked, and a puddle of fluid had collected under his wheelchair. R14's call light was fastened at the head of bed, approximately 4 feet from where R14's wheelchair, and out of R14's reach. R14 verified he was unable to reach his call light to call for help. 3. R54 is a [AGE] year-old resident with diagnoses including: Active Primary Multiple Sclerosis; Muscle Wasting and Atrophy of multiple sites. R54's current Care Plan includes the following Focus and intervention: the following focus and intervention: Focus: (R54) is at risk for alteration in musculoskeletal status related to: MS (Multiple Sclerosis); Interventions/Tasks: . Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. On 3/11/26 at 9:30am R54 was laying in bed. R54's call light was sitting on his bedside cabinet, clearly out of his reach. R54 verified he was unable to reach his call light. On 3/11/26 at 9:52am V16 CNA/Certified Nursing Assistant verified both R54 and R14's call lights were out of their reach.

Based on Interview and Record Review, the facility failed to ensure residents were provided information on Advance Directives and ensure that a POLST (Physician's Order for Life Sustaining Treatment) and emergency code status were documented in the resident's medical record for three of four residents (R46, R77, R78) reviewed for Advanced Directives in the sample of 48.Findings include:The facility's Advance Directives policy (undated), documents It is the policy of this facility to allow the resident, authorized legal representative or next of kin to make decisions regarding health care, per Illinois law. Advanced Directives shall not be required as a provision of services or admission. At the time of admission, the social service director shall provide each resident or their legal representative, educational information regarding state and federal laws. Advance Directives shall be reviewed by the interdisciplinary team when completing the comprehensive assessment and addressed on the resident's plan of care, physician progress notes, physician's orders and in the social service progress notes. A written physician's order is required in response to the resident's advanced directive regarding CPR (Cardio-Pulmonary Resuscitation). Written physician's orders shall be specific and addressed as appropriate. A copy of the original order and related physician progress notes regarding advance directives shall be maintained in the medical record with advance directive documents. 1. R46's Physician Order Sheet (POS), dated [DATE], documents R46 was admitted to the facility on [DATE] and does not document a physician's order for code status. R46's electronic medical record does not document an emergency code status or any advanced directives for R46. On [DATE] at 1:00 PM, V2 (Director of Nursing) verified that R46's medical record does not document advanced directives or a code status. V2 stated (R46'S) code status is not in his record. I am not sure why, but there is nothing in his medical record at the facility to show any advanced directives or code status. Social Services (V18) does go over advance directives paperwork on admission and then when I get a POLST, I can input it into the computer under physician's orders. On [DATE] at 1:18 PM, V18 (Social Services Director) verified she is the person who meets with new admission residents and discusses advanced directives and code status in the event of an emergency. V18 stated (R46) does not have advanced directives in his record. I think when he came in (admission, [DATE]), (R46) was more confused and he has since gotten better. I don't believe we've had a care conference since then. 2. R77's Physician Order Sheet (POS), dated [DATE], documents R77 was admitted to the facility on [DATE] and does not document a physician's order for code status. R77's electronic medical record does not document an emergency code status or any advanced directives for R77. 3. R78's Physicans Order Sheet (POS), dated [DATE], documents R78 was admitted to the facility on [DATE] and does not document a physician's order for code status. R78's electronic medical record does not document an emergency code status or any advanced directives for R78. On [DATE] at 3:15 PM, V1 (Administrator) stated both R77 and R78 did not come to the facility with any advanced directives and assumed since they had none, that they were assumed to be full code. V1 confirmed the facility did not initiate an advance directive for either R77 or R78.

Based on Observation, Interview and Record Review, the facility failed to document an appropriate diagnosis, provide justification for a failed gradual dose reduction (GDR), and identify and monitor targeted behaviors to warrant the use of Seroquel (antipsychotic medication) and for one of one resident (R39) reviewed for antipsychotic medications in the sample of 48.Findings include:The facility's Psychopharmacologic Drug Use Procedure policy (undated) documents To assure that appropriate monitoring is provided to residents receiving psychopharmacologic drugs, that the lowest possible dose necessary for the benefit of the resident to improve or control mood, mental status and/or behavior is utilized, and to reduce or eliminate the usage of these medications. Residents shall not be given antipsychotic drugs unless antipsychotic drug therapy is necessary to treat a specific or suspected condition as diagnosed and documented in the clinical record or to rule out the possibility of one of the conditions listed in guidelines of recognized external review agencies. Documentation of behaviors and conditions requiring the use of these medications must be done on a routine basis including resident response to the medication. Dose reductions must be attempted, unless medically or psychiatrically contraindicated as documented by the interdisciplinary team and/or the physician.R39's Physician Order Sheet (POS), dated 3/10/26, documents R39 has cognitive and mood diagnoses including Dementia without behavioral disturbance, Alzheimer's disease, Depression, Depressive Mood and Anxiety. This order sheet documents R39 has an order for Quetiapine 25 milligrams (mg) (Seroquel, antipsychotic medication) by mouth two times a day for Dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety.R39's Care Plan, dated 11/18/25, documents (R39) is at risk for psychosocial issues related to impaired vision, Cognitive Communication Deficit, Dementia, Alzheimer's Disease, Depression, Anxiety Disorder. Moderate risk for abuse related to dependance on others, psychiatric history, complaints or chronic pain/illness, anxiety/fear/anger, depression, displays behaviors including delusions, wandering, yelling/screaming, crying, resistive to care, kicking/hitting, exit seeking.R39's behavior monitoring flow sheet, dated 2/9/26-3/9/26, documents R39 exhibited a behavior of wandering 13 times in 30 days. This sheet does not document any other behaviors for R39.R39's Progress note, dated 2/2/26 at 11:43 AM, documents Behavior Note. Describe behavior: Resident hit restorative aid when encouraged verbally to stay and eat her lunch. Environmental, Physiological, Psychosocial factors/triggers: Noise in crowded dining room. Intervention: Redirected to eating her food, asked what is wrong giving her time to vent feelings, offered a drink of water, allowed to change locations to more quiet space in hopes to direct her after change in mood back to her lunch to finish her meal. Resident response: Resident went to a more quiet space in hallway and spoke to other staff not recalling her earlier behavior, when asked if she was hungry, she said yes and made her way back to the dining room at restorative table.R39's Progress notes, dated 2/2/26 at 5:37 PM documents Social Service Note. Note Text: After lunch today, resident was observed telling another resident repeatedly to get out of her way. Shortly after that (R39) was seen pushing another resident's wheelchair stating to keep moving. Another employee came to SSD (V18, Social Service Director) informing that during Bingo (R39) was seen using her middle finger. (R39) was easily redirected after each incident. No other resident felt threated or scared by (R39). (V19, R39's family) was called to see if he was able to come and spend some time with her due to the increased agitation. (V19) was sick. (R39) was placed on one on one (staff) with activities. Shortly after she requested to go to sleep. No other unwanted behaviors observed for the rest of the day.R39's Progress note dated, 2/8/2026 at 12:26 PM documents (R39) seen by (psychiatric services), new order received for Seroquel 25 MG two times a day related to failed GDR (gradual dose reduction). Consent received from (V19).On 3/10/26 at 9:14 AM, R39 was lying in bed with her eyes closed and a wheelchair at her bedside. On 3/11/26 at 9:35 AM, V19 (R39's family) stated he placed R39 in the facility after she became more confused and her Dementia progressed. V19 confirmed R39 has some behaviors that require more attention and stated They did start a new medication for (R39's) behaviors. Those behaviors lately have been like stealing food from other people's plates and wandering. She used to talk about getting out and about her husband coming to get her and he's been deceased for a while. (R39) just had wacky behaviors. She would expect her husband to arrive and pick her up or talk about going back to her apartment. She also would roam around and steal food. (R39) has been less verbal and sleepier over about the past six months.On 3/11/26 at 11:46 AM, V10 (Registered Nurse) stated I don't typically care for R39, so her behaviors aren't the most prominent in my head. I do remember (R39) used to come out of her room and scoot around and now she doesn't do that as much.On 3/11/26 at 11:50 AM, R39 was sitting in the facility's dining room eating lunch. R39 moved her wheelchair on her own and was easily redirected back to the table by dining room staff. At this time V15 (Licensed Practical Nurse) stated (R39) has behaviors of wandering and exit seeking. Sometimes if staff are trying to re-direct her, she will yell and can get angry towards the staff. I have never seen (R39) strike or be aggressive towards other residents.On 3/11/26 at 1:00 PM, V2 (Director of Nursing) stated July 7th, 2025, is the date that (R39) was referred to (psychiatric services) and she was already taking Seroquel. (R39's) behaviors involve constantly exit seeking, pulling the fire alarm, getting in and out of bed, and asking about her husband. Her recent Seroquel GDR failed and that was due to her trying to transfer herself and falling in February, rolling herself into a nursing area and getting hand-sanitizer then trying to drink it and striking a restorative aide. So, they increased her Seroquel back to two times daily instead of once a day. V2 confirmed R39's behaviors align with Dementia and aren't psychotic in nature. V2 verified R39 does not have a diagnosis that warrants the use of an antipsychotic and stated R39 has never struck or been aggressive to another resident.

Based on record review and interview, the facility failed to obtain a level II PASRR (Pre-admission Screening and Resident Review) for three of five residents (R3, R55, and R69) reviewed for pre-admission screenings in the sample of 48.Findings include:1. R3's admission Record, dated 3/10/26, documents R3 admitted to the facility on [DATE]. This same admission Record documents a medical diagnosis of Bipolar Disorder with an onset date of 4/21/2022.R3's Minimum Data Set (MDS), dated [DATE], documents R3's BIMS (Brief Interview for Mental Status) of 14, indicating R3 is cognitively intact.R3's OBRA-I (Omnibus Budget Reconciliation Act-I) Initial Screen, dated 9/4/20, documents, in Part III: Reasonable Suspicion to Suspect a Mental Illness, under 4. There are other indicators of mental illness in Part III: Reasonable Basis to Suspect a Mental Illiness: 'Yes. This same document later lists a medical diagnosis of Depression.R3's Medical Record was reviewed and there was no evidence of a PASRR (Pre-admission Screening and Resident Review) Level II Screen.On 3/10/26 at 10:00 AM, V1/Administrator confirmed the facility did not have documentation of a PASRR Level II Screen.2. R55's admission Record, dated 3/10/26, documents R55 admitted to the facility on [DATE]. This same admission Record documents a medical diagnosis of Bipolar Disorder with an onset date of 6/12/2018.R55's Minimum Data Set (MDS), dated [DATE], documents a BIMS (Brief Interview for Mental Status) score of 9, indicating moderate cognitive impairment.R55's OBRA-I (Omnibus Budget Reconciliation Act-I) Initial Screen, dated 6/16/18, documents, in Part III. Reasonable Suspicion to Suspect a Mental Illness, 'Yes' to 1)The individual has been formally diagnosed with a mental illness verified by a DSMIV classification which substantially impairs the person's cognitive, emotional, and/or behavioral functioning, excluding organic disorders/dementia, developmental disabilities, and alcohol/substance use. And, 'Yes' to, 4)There are other indicators of mental illness. Reasonable Suspicion to Suspect a Mental Illness, under 4. There are other indicators of mental illness in Part III: Reasonable Basis to Suspect a Mental Illiness: 'Yes. This same document later lists a medical diagnosis of Depression.R55's Medical Record was reviewed and there was no evidence of completion of a PASRR Level I or PASRR Level II Screening after to include the diagnosis of Bipolar Disorder.On 3/10/26 at 10:00 AM, V1/Administrator confirmed the facility did not have documentation of a Level II PASRR Screen.3. R69's admission Record, dated 3/10/26, documents R69 admitted to the facility on [DATE]. This same admission Record documents a medical diagnosis of Delusional Disorders with an onset date of 11/20/24.R69's Minimum Data Set (MDS), dated [DATE], documents a BIMS (Brief Interview for Mental Status) of 15, indicating R69 is cognitively intact.R69's PASRR (Pre-admission Screening and Resident Review) Level I Screen, dated 6/19/24, documents, No Level II Required-No SMI/ID/RC.R69's Medical Record was reviewed and there is no evidence of completion of a PASRR Level I or PASRR Level II after the addition of the medical diagnosis of Delusional Disorders on 11/20/24.On 3/10/26 at 10:00 AM, V1/Administrator confirmed the facility did not have documentation of a Level II PASRR Screen.

Based on Observation, Interview and Record Review, the facility failed to ensure a resident's independent smoking assessment was accurate and smoking materials were not kept in the resident's possession when not in use, and ensure a dependent resident was provided assistance of two staff members during a mechanical lift transfer, for two of four residents (R46, R55) reviewed for accidents in the sample of 48.Findings include: The facility's Resident Smoking policy, dated 12/202, documents All residents who will be assessed by the interdisciplinary team to determine if the individual is appropriate for independent smoking. It is recommended that independent smokers store their smoking materials at the nursing station for the safety of others. If they choose not to then they should keep them secure at all times. The facility's Safe Lifting and Movement of Residents Policy, dated September 2008, documents in part, Policy Statement: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses mechanical lifting devices for the lifting and movement of residents. Policy Interpretation and Implementation: 1. Mechanical lifting devices shall be used for any resident needing a two person assist. Except during emergency situations or unavoidable circumstances, manual lifting is not permitted. 2. Staff responsible for direct resident care will be trained in the use of mechanical lifting devices. The manufacturer of purchased equipment shall provide initial staff training on the use of mechanical lifts, as well as on the routine checks and long-term maintenance of equipment. Subsequent training and retraining of staff on the use of mechanical lifting devices shall be conducted by designated team leaders. 6. The transferring needs of residents shall be assessed on an ongoing basis. Resident transferring and lifting needs shall be documented in the care plan. Assessment of the resident's transferring needs shall include a. Mobility of the resident (degree of dependency), b. Size of the resident, c. Weight-bearing ability, and d. Cognitive status. 1. R46's Current Care plan, dated 2/5/26, documents R46 was admitted to the facility on [DATE] and has diagnoses including Major Depressive Disorder, Wernicke's Encephalopathy, Lack of Mobility, Abnormalities of Gait and Mobility and Generalized Anxiety. This plan of care documents (R46) is a smoker. (R46) has a history of substance abuse related to alcohol abuse. (R46) is an Identified Offender: violate order of protection 4/2024; theft 12/2023; domestic battery 9/2017; aggravated assault 8/2019; aggravated battery 8/2006. Risk level determined by ISP (Illinois State Police), moderate risk. Interventions: Continue to offer (R46) counseling services; Frequent one on one care to observe for behavior changes; Monitor/document/report as needed any risk for harm to self. R46's Smoking Contract, dated 11/12/25 and signed by R46 and V18 (Social Service Director), documents I will not smoke anywhere else in the building, including my room or bathroom, the dining room, the lobby. I understand it is recommended that I will surrender all smoking materials to the facility, including cigarettes, cigars, pipes, matches, and lighters, I will not carry on my person or possess in my room or clothes any smoking materials. R46's Criminal History Analysis Report for Identified Offender's Program, dated 2/5/26, documents R46 has a history of mental and substance abuse and was identified at a moderate risk level. This report documents Moderate Risk: The resident requires closer supervision and more frequent observation than standard or routine for most residents in an open facility. Regular monitoring should be attentive to behavioral changes that may signal a need for closer observation or sustained visual monitoring on a time-limited basis. Periodic assessments should ascertain whether the level of supervision is sufficient. This report also documents The following specific considerations were important in arriving at the above recommendations: (R46) is a [AGE] year old male who has a lengthy criminal history from 2004 to 2025 with convictions for criminal trespass to land twice, violate IOP (Individual Order of Protection) four times, criminal trespass to building, assault, domestic battery twice, criminal damage to property, criminal trespass to residence twice, aggravated battery to go official, harassment by telephone, DUI (Driving Under Influence), resist peace officer. (R46) has a mental illness and a lengthy history of alcohol. He has had no incidents of physical or verbal aggression since his admission on [DATE]. I would deem (R46) a moderate risk based upon his mental illness and substance abuse and his very lengthy criminal history. His compliance with treatment and abstinence from drugs and alcohol should be closely monitored. R46's Smoking Assessment, dated 2/9/26, documents ten yes or no assessment questions and documents Smoking Assessment: Any yes answers deems supervision is needed. This assessment documents no to all ten questions including Does resident have impaired short-term memory? and Does the resident have a past history of poor judgement related to: safety of self or others? On 3/9/26 at 1:25 PM, R46 was observed on the smoking patio. R46 stated he keeps his smoking materials, lighter and cigarettes on him and in his room. On 3/10/26 at 9:30 AM, R46 was in his room lying in bed. R46 awoke with an initial greeting and then closed his eyes and went back to resting in bed with his eyes closed. At this time, R46's table at the bedside contained a blue lighter that was not secured. On 3/11/26 at 1:18 PM V18 (Social Services Director) confirmed that R46 was assessed to be an independent smoker and can smoke without supervision. V18 stated I did (R46's) smoking assessment and contract. (R46) is not supposed to keep cigarettes and his lighter on himself or at his bedside. He should be giving it to the reception desk. V18 verified that R46 is a moderate risk identified offender and stated I was surprised when I saw him placed at a moderate risk. I guess he does have a history of making unsafe decisions. So, the question about unsafe decisions on his smoking assessment probably should have been marked yes. 2. R55's admission Record, dated 3/10/26, documents R55 was admitted to the facility on [DATE], with medical diagnoses including but not limited to: Unspecified Lack of Coordination, Cognitive Communication Deficit, Altered Mental Status, Other Symptoms and Signs Involving the Musculoskeletal System, Other Abnormalities of Gait and Mobility, Difficulty in Walking, Not Elsewhere Classified, Muscle Weakness (Generalized), Unsteadiness on Feet, Repeated Falls, Age-Related Physical Debility, and Other Chronic Pain. R55's MDS (Minimum Data Set) assessment, dated 12/28/25, documents a BIMS (Brief Interview for Mental Status) score of nine, indicating R55 has moderate cognitive impairment. This same MDS assessment documents R55 is Dependent (Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for chair/bed-to-chair transfers. R55's Order Summary Report, dated 3/10/26, documents a Prescriber Written order with an order date of 11/11/25, (Mechanical lift) x two (assist) for all transfers per (local hospice company). R55's Care Plan, dated 3/10/26, documents R55 is at high risk for falls with an intervention, dated 11/11/25, (Mechanical lift) x two (assist) for all transfers per (local hospice company). On 3/9/26 at 10:52 AM, V11/Certified Nursing Assistant was observed transferring R55 from R55's wheelchair to R55's bed with a mechanical lift without the assistance of another staff member. On 3/9/26 at 10:55 AM, V11//Certified Nursing Assistant confirmed she transferred R55 with a mechanical lift alone from R55's wheelchair to R55's bed, without the assistance of another staff member, and should have had another staff member to assist with the transfer using a mechanical lift. V11 stated two people are required for all mechanical lift transfers and R55 requires a two-person transfer from her wheelchair to her bed.

Based on observation, interview, and record review, the facility failed to ensure indwelling urinary catheter tubing and the collection bag were positioned below the level of the bladder and remained off the floor for one of two residents (R49) reviewed for indwelling urinary catheters in the sample of 48.Findings include:The facility's Catheter Care, Urinary Policy, dated September 2005, documents in part, The purpose of this procedure is to prevent infection of the resident's urinary tract. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Be sure the catheter tubing and drainage bag are kept off the floor.R49's admission Record, dated 3/10/26, documents R49 was admitted to the facility on [DATE] with medical diagnoses to include but not limited to: Unspecified Severe Protein-Calorie Malnutrition, Active Primary Progressive Multiple Sclerosis, Neuromuscular Dysfunction of Bladder, Cerebral Cryptococcosis, Paraplegia, Unspecified Escherichia Coli (E. Coli), and Urinary Tract Infection.R49's Care Plan, dated 1/30/26, documents a focus area with a date of 8/18/25 in part, (R49) has (an) indwelling urinary catheter due to neuromuscular dysfunction with a goal documented in part as, (R49) will show no signs or symptoms of urinary infection through review date. This same Care Plan documents another focus area with a date of 3/9/26, (R49) is in Contact Isolation d/t (due to) a Urinary Tract Infection r/t (related to) ESBL (Extended-Spectrum Beta Lactamase) of the urine.R49's Urine Culture Lab Results Report, with a reported date of 3/7/26, documents Escherichia coli ESBL 50-100,000 colonies/mL (milliliters).R49's Order Summary Report, dated 3/10/26, documents Prescriber Written orders: Change suprapubic catheter every 3 weeks and PRN (as needed), Contact Isolation Precautions for ESBL of the urine, and Nitrofurantoin Macrocrystal Capsule 100 mg (antibiotic) for UTI (Urinary Tract Infection).On 3/10/26 at 8:17 AM, R49 was observed sitting in his wheelchair at the table in the main dining room eating his breakfast with R49's indwelling catheter collection bag lying on R49's abdomen.On 3/10/26 at 8:20 AM, V10/Registered Nurse confirmed R49's indwelling urinary catheter collection bag was lying on R49's abdomen. V10 stated R49's indwelling urinary catheter collection bag should not be lying on R49's abdomen and should always be below the level of R49's bladder to prevent backflow of urine from the indwelling urinary catheter collection bag and tubing into R49's bladder.On 3/10/26 at 11:15 AM, R49 was observed in bed with R49's indwelling urinary catheter collection bag on the floor next to R49's bed.On 3/10/2026 at 11:20 AM, V16/Certified Nursing Assistant confirmed R49's indwelling urinary catheter collection bag was on the floor next to R49's bed. V16 stated R49's urinary catheter bag should not be laying on the floor.

Based on observation, interview, and record review the facility failed to ensure oxygen tubing/humidification and a nebulizer mask, canister, and tubing was dated, changed every seven days, and placed in a bag when not in use and ensure an order was in place for oxygen for three of three residents (R27, R50, and R78) reviewed for respiratory care in a sample of 48.Findings include: The facilities Oral Inhalation Administration, dated 11/4/14, documents, Nebulizer- When equipment is completely dry, store it in a plastic bag with the resident's name and the date on it. Change equipment and tubing every seven days. The facilities Oxygen Administration Policy, dated 3/2004, documents Prepare: The purpose of this procedure is to provide guidelines for safe oxygen administration. Steps in the procedure: 18. Make sure the oxygen humidifier jar is labeled properly. 1.R27's Order Summary Report documents a Physician order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3)MG (milligram)/3ML (milliliter) one vial inhalation every six hours as needed. On 3/9/26 at 9:42 AM R27's nebulizer mask and nebulizer tubing were lying on R27's dresser, unbagged and undated. On 3/9/26 at 2:31 PM V3/Infection Preventionist verified at this time that R27's nebulizer mask and nebulizer tubing were undated and unbagged. V4 stated, Third shift is supposed to change all nebulizer mask, canister, and tubing every Sunday evening. Third shift should be labeling the nebulizer supplies with a date and it should be stored in a bag when not in use. 2. On 03/9/2026 at 10:45 AM, R50 was in her room, in her wheelchair, dressed. R50 had oxygen flowing at 2L (liters) per nasal cannula. Oxygen tubing was not labeled, and humidification bottle was not labeled. R50's Facesheet dated 3/11/2026 documents the following medical conditions, congestive heart failure, and chronic obstructive pulmonary disease. R50's Physician's Order Sheet dated 3/11/2026 documents, Administer 02 (oxygen) at 2L (liters) via nasal cannula as needed for difficulty breathing or SOB (shortness of breath) related to chronic obstructive pulmonary disease. R50's Physician's Order Sheet dated 3/11/2026 documents, Oxygen tubing and humidifier bottle to be changed every seven days while on oxygen. On 3/10/2026 at 2:32 PM, V9 (Registered Nurse) confirmed R50's oxygen tubing was not labeled or dated. V9 also confirmed that R50's humidification bottle was not labeled. V9 stated both oxygen tubing and humidification bottle should be labeled with a date. On 3/11/2026 at 3:10 PM, V2 (Director of Nursing) confirmed all oxygen tubing, and humidification bottles should always have a label and a date. 3. On 03/9/2026 at 10:27 AM, R78 was in her room, in her bed. Oxygen flowing at 3L (liters) per nasal cannula. Humidification bottle was not labeled. R78's Facesheet dated 3/11/2026 documents the following medical conditions, chronic obstructive pulmonary disease, obstructive sleep apnea, and shortness of breath. R78's Physician's Order Sheet dated 3/11/2026 does not document an order for oxygen use. R78's Physician's Order Sheet dated 3/11/2026 documents, Oxygen tubing and humidifier bottle to be changed every seven days while on oxygen. On 3/10/2026 at 2:30 PM, V9 (Registered Nurse) confirmed R78's humidification bottle was not labeled. V9 confirmed the humidification bottle should have a label and date. On 3/11/2026 at 3:10 PM, V2 (Director of Nursing) confirmed all oxygen humidification bottles should always have a label and a date. V2 also confirmed an order should always be in place for oxygen use.

Based on observation, interview and record review the facility failed to properly store urine-soiled resident clothing in a bag during incontinence care for one resident (R14) and failed to follow Contact Isolation Precautions and don appropriate PPE/Personal Protective Equipment before manipulating an indwelling urinary catheter collection bag for one resident (R49) of 18 residents reviewed for infection control procedures in the sample of 48 residents.Findings include:1. After several attempts, the facility was unable to provide an Incontinence Care policy. The facility's Infection Prevention and Control Manual Transmission-Based Precautions Policy, dated 2020, documents in part, The purpose of contact precautions is to prevent transmission of infections that are spread by direct (e.g., person-to-person) or indirect contact with the resident or environment. Contact precautions require the use of Personal Protective Equipment (PPE), including a gown and gloves upon entering the room or making contact with the resident or resident environment. CDC/Center for Disease Control documents the following: Key CDC Guidelines for Incontinence Care: Disposal: Properly seal soiled linen and incontinence pads in appropriate bags to prevent contamination of the environment. R14's medical record documents R14 is a [AGE] year-old resident with diagnoses including: Active Primary Progressive Multiple Sclerosis; Hemiplegia and Hemiparesis. On 3/11/25 at 9:40am R14 was sitting in a wheelchair in his room. R14's pants were visibly wet with urine, a puddle of liquid was noted beneath his wheelchair, and an odor of urine permeated R14's room. On 3/11/26 at 9:52 V16 CNA/Certified Nursing Assistant was R14's room, changing his clothes and performing incontinence care for R14. R14's soiled, wet clothing was noted sitting in a pile on the surface of a dresser in R14's room. The soiled clothing was not enclosed in a plastic bag. After transferring R14 into his wheelchair, V16 picked up the soiled and wet clothing from the top of the dresser, left the room and placed them in a laundry bin for soiled laundry sitting in the hallway. On 3/11/26 at approximately 1:18pm, V2 DON/Director of Nursing stated soiled residents' clothing should be contained in a sealed bag and never placed on the surface of any furniture in the resident's room. 2. R49's admission Record, dated 3/10/26, documents R49 was admitted to the facility on [DATE] with medical diagnoses to include but not limited to: Unspecified Severe Protein-Calorie Malnutrition, Active Primary Progressive Multiple Sclerosis, Neuromuscular Dysfunction of Bladder, Cerebral Cryptococcosis, Paraplegia, Unspecified Escherichia Coli (E. Coli), and Urinary Tract Infection. R49's Urine Culture Lab Results Report, with a reported date of 3/7/26, documents Escherichia coli ESBL (Extended-Spectrum Beta Lactamase) 50-100,000 colonies/mL (milliliters). R49's Order Summary Report, dated 3/10/26, documents a Prescriber Written Order with an order date of 3/9/26, Strict Contact Isolation for ESBL of the urine. R49's Care Plan, dated 1/30/26, documents a focus area with a date of 3/9/26, (R49) is in Contact Isolation d/t (due to) a Urinary Tract Infection r/t (related to) ESBL of the urine. On 3/10/26 at 11:19 AM, R49's room door was observed with a contact isolation precautions sign in place and PPE available in a caddy on the door as V16/Certified Nursing Assistant entered R49's room without any PPE on. V16 then picked up R49's indwelling urinary catheter collection bag off the floor with her bare hands, and hooked the indwelling urinary collection bag to R49's bed frame. On 3/10/26 at 11:20 AM, V16/Certified Nursing Assistant confirmed R49's door had a contact isolation precautions sign and PPE present and she did not follow contact isolation precautions by putting on a gown and gloves before entering R49's room and handling R49's indwelling urinary catheter collection bag. V16 stated she should have put on a gown and gloves before entering R49's room to pick R49's indwelling urinary catheter bag up off the floor. On 3/10/26 at 1:30 PM, V1/Administrator confirmed the facility's policy documents that PPE, including a gown and gloves, should be donned upon entering a room or before making contact with the resident or their environment for a resident requiring contact isolation precautions.

Based on observation, interview, and record review the facility failed to educate residents on what a grievance is, provide grievance forms, and provide a clear and noticeable destination for grievances to be submitted. This failure has the potential to affect all 63 residents who reside in the facility. Findings Include:The Filing Grievances/Complaints policy dated 12/2004 documents Our facility will assist residents, their representatives (sponsors), other interested family members, or resident advocates in filing grievances or complaints when such requests are made. The Ombudsman Program Residents' Rights Booklet (undated) documents Your personal property rights. You have the right to keep and wear your own clothing. Your facility must try to keep your property from being lost or stolen. If your property is missing, the facility must try to find it.The Resident Council meeting minutes dated 7/8/2025 documents, R11, R28, R38, R48, and R64 all confirmed they did not know what a grievance was or how to file a grievance.The facility census sheet dated 8/18/2025 documents 63 residents reside in the facility.On 8/18/2025 at 1:13PM, R8 voiced she has had a brown jacket missing since Christmas and has never gotten it back. R8 voiced she did not know what a grievance was or how to file one.On 8/18/2025 at 1:20PM, R3 stated she has a turquoise dress missing for months and that laundry keeps saying they are looking for it. R3 voiced she did not know what a grievance was.On 8/18/2025 at 1:30 PM, R4 voiced she had pink pants missing and she does not know what a grievance is. R4 stated she has had a lot of clothing items come up missing and that this happens all the time.On 8/18/2025 at 3:05PM, V4 (Laundry Aide) stated residents tell me things are missing all the time V4 stated she will try and go to the laundry room and look for the article of clothing that is missing and if she cannot find it, she will tell V5 (Housekeeping/Laundry Supervisor). V4 does not know about grievances or how to tell residents to file one.On 8/19/2025 at 8:30AM, V5 (Housekeeping/Laundry Supervisor) stated when a resident does voice that they cannot find an article of clothing she will checks the lost and found, check resident closets, and throw the word out there and keep looking V5 stated there is a list in the laundry office of resident missing clothing items for other laundry staff to keep an eye out for but does not advice residents to file a grievance.On 8/19/2025 at 12:05PM, The laundry room had four carts for each hall, room numbers in sections of what rooms each cart had, and clothes had labels of each resident's piece of clothing. The bulletin board hung that above the folding table by the dryer on the wall had no list of missing clothing items. On 8/19/2025 at 12:05 PM, V11 (Laundry Aide) stated when residents complain of missing clothing items, she will search the lost and found cart. If she cannot locate it on the lost and found cart, V11 stated she will then search in the residents closet and if the item is not found V11 will put a note on the bulletin board. V11 stated there is no list of residents with missing items. V11 confirmed R4's pink pants, R8's brown jacket, and R3's dress has been missing.On 8/19/2025 at 12:40PM, V12 (Social Services Director/SSD) stated she was supposed to oversee grievances when she was hired in November 2024. V1 (Administrator) did not train V12, and she was directed to send all grievances to V1. V12 stated she still does not know the process of a grievance and does not have the forms and does not know the process. V12 stated she does know R6 had family bring in four new pairs of black pants and the pants were never found. V12 stated R6 did not know how to file a grievance and R6's pants were never found. V12 stated V1 replaced two pairs of R6's pants but not all four. V12 stated R7 is still missing her sweatshirt that has kittens on it and R7 has voiced for months how she still has not received the sweatshirt. V12 stated R7 voiced this to V1, and nothing has been resolved.On 8/19/2025 at 1PM, V13 (Activities Director) stated residents do occasionally complain that they have missing clothing. V13 stated she will then look in laundry for the missing clothing item if she cannot find it, V13 will report it to V11, and V11 tells V13 to look for the item. V13 stated she did not know about grievances and has never helped a resident fill out a grievance. V13 stated there is no place to place a grievance and there is no process in place.On 8/19/2025 at 3PM, V1 (Administrator) confirmed he has never shown V12 (SSD), or V13 (Activities Director) how to address grievances and V1 directed V12 to send all residents with concerns to him. V1 also confirmed there is not a publicly visible place for residents to get a grievance form or a box grievance form.

Based on interview and record review the facility failed to notify the Residents Family/Representative promptly of a change of condition for one of three residents (R1) reviewed for injury of unknown origin in the sample of three. Findings include: The Notification of Resident Change in Condition Policy (undated) documents Policy: It is the policy of this facility to promptly notify the resident, their legal representative(s) and attending physician of changes in the resident's health condition. Policy Specifications: To establish guidelines for assuring residents, their legal representatives and attending physicians are informed of changes in the resident's condition. Responsibility: Director of Nursing and Licensed Nurses. Standards: 1. A licensed nurse shall promptly inform the resident, consults with the resident's physician and if known, notify the residents legal representative or an interested family member of: a. An accident involving the resident in which there is a potential for an actual injury which could require nursing or medical intervention. b. A significant change in the resident's physical, mental or psychosocial status, i.e. (example) deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complication. c. A need to alter treatment significantly i.e. need to discontinue an existing form of treatment. d. A decision to transfer or discharge the resident from the facility. 2. The licensed nurse is to use professional judgment in determining changes in condition based on assessment and findings or signs and symptoms of change which could lead to deterioration if not treated. 3. Clinical change in condition is determined by resident visualization, medical record review, clinical assessment findings and care plan review. Review of high-risk clinical issues such as skin breakdown, falls, weight loss, dehydration and others are conducted on a daily basis. 4. Following the assessment, observing signs and symptoms, and obtaining vital signs, the attending physician, family/guardian will be promptly notified of significant findings. 12. Resident representative(s) notifications and attempts will be made promptly and documented in the nurse's notes. In the event the licensed nurse is unable to contact the resident's representative, after a reasonable time period, the Director of Nursing will be notified. R1's Nursing Note written by V11/Licensed Practical Nurse dated 7/23/25 at 5:29 AM, documents that staff reported discoloration to R1's Left Lower Extremity from the knee down. R1 was guarding and facial grimacing when the leg was touched or moved. The knee was swollen and warm to the touch. No record of a fall. A message was left with Hospice. The Initial Facility Incident Report sent to the (State agency) dated 7/23/25 at 7:00 AM, documents that R1 has diagnoses which include Alzheimer's Disease with Late Onset, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Generalized Anxiety Disorder, Hyperlipidemia, and Delusional Disorder. R1 has confusion regarding time/place/person. Brief Interview of Mental Status 2/15 (severer cognitive impairment). R1 was noted with discoloration and swelling to the Left Lower Extremity. R1 noted guarded and unwilling or unable to extend her leg fully. R1's Family/Resident Representative was notified on 7/23/25 at 11:00 AM. On 8/4/25 at 5:50 PM, V17/R1's Power of Attorney/POA stated that she was upset that she was not notified immediately that R1 had bruising and swelling to R1's leg. I did not here from the facility about (R1's) injury. The first I knew of it was when I was told by hospice. I let (V2/Previous Director of Nursing) know that I was not happy about the lack of communication. On 8/5/25 at 1:55 PM, V15/Hospice Registered Nurse stated that on 7/23/25 at 10:59 AM V15 talked to V2/Previous Director of Nursing about R1's injury and what should be done. V13/Nurse Practitioner had come in to examine R1 and had decided that an x-ray of R1's leg needed done. V13 had said that R1 could be sent to the emergency room for the x-ray, or it could be ordered to be done in house. V13 said that V17/R1's Power of Attorney should make the final decision. That is when V15 found out that V17 was not notified of R1's injury by the facility. V15 called V17 to discuss R1's injury and V17 was upset that she had not been called earlier by the facility. V15 also stated Although (R1) is receiving hospice care (V17) should have been notified by the facility of (R1's) injury. I was told the injury was found around 5:45 AM on 7/23/25. I did not talk to (V17) until around 11:00 AM on 7/23/25. On 8/6/25 at 12:47 PM, V2/Previous Director of Nursing stated (V11/Licensed Practical Nurse/LPN) was the nurse that was working when (R1's) injury was noted on (R1's) leg. (V11) reported the injury to hospice, and (V18/Assistant Director of Nursing) but did not report the injury to (V17/R1's POA). When I ask (V11) why she did not call (V17), (V11) said that she was used to working in another state where hospice would contact the POA. I told (V11) that was not the protocol here. I told her that she should have notified the POA immediately.

Based on interview and record review the facility failed to promote an environment free of inappropriate staff behavior and failed to provide respect and dignity for residents. This failure has the potential to affect all 79 residents residing in the Facility. Findings include: The Facility Resident Census Roster, dated 6/19/25, documents 79 Residents residing in the Facility. The Facility Statement of Resident Rights, undated, documents: the Resident has a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the Facility; must treat each Resident with respect and dignity and care for each Resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each Resident's individuality; protect and promote the rights of the Resident; and has the right to be treated with respect and dignity; have a right to a safe and homelike environment including but not limited to treatment and supports for daily living safely; and a safe comfortable and homelike environment; ensuring the Resident receive care and services safely and that the physical layout of the Facility maximizes Resident independence and does not pose a safety risk. The Facility Administrator Job Description, revised 10/2020, documents: primary purpose of this position is to direct day-to-day functions of the Facility in accordance with current federal, state and local standards, guidelines and regulations; assume responsibility and accountability for all programs in the Facility; ensure each Resident receives care and services to attain/maintain the highest practical physical, mental and psychosocial well-being; ensure human resource management policies and programs are planned, implemented and evaluated in compliance with government laws and regulations; counsel/discipline personnel as requested or necessary in accordance with local, state and federal labor laws and implement facility policies; and terminate employment of personnel when necessary. The Facility Resident Council Meeting Minutes, dated 3/18/25, document issues that Residents hear CNAs (Certified Nursing Assistants) arguing. The Facility Resident Concern Form dated 3/18/25 and 6/10/25, documents concerns with staff approach. The Facility Certified Nursing Assistant Job Description, revised 10/2020, documents: must attend and participate in Facility in-service training programs including Resident Rights, Abuse, Behavioral Management; must be a supportive team member, contribute to and be an example of team work and team concept; possess ability to deal tactfully with personnel, Residents, family members, visitors, government agencies/personnel and the general public; possess ability and willingness to work harmoniously with other personnel; have patience, tact and cheerful disposition and enthusiasm; and must be able to cope with the mental and emotional stress of the position. A typewritten investigation statement, unsigned and undated, documents that on (6/13/25) at 8:12 am, (V5/CNA) walks onto Southwest hallway and approaches (V6/CNA). They start to argue, V6 starts to walk away and points for V5 to return to (V5's) hallway. At this point V5 moves closer to V6 and is in her (V6) face at which point (V6) pushes (V5). The nurse breaks them up and at 8:13 am, (V11/Human Resource Director) and (V1/Administrator) walk down the hall to diffuse the situation and remove the parties from the floor. V5's (Certified Nursing Assistant/CNA) Employee Record, documents a Resignation/Discharge Form, dated 6/17/25, that V5 was hired on 2/25/25 and discharged on 6/13/25. V5's Disciplinary Report, dated 6/16/25, documents V5 had an incident on 6/13/25 of threatening or engaging in violence and was terminated. V5's Employee Record also documents an electronically signed Employee Handbook/Workplace Violence, dated 3/6/25 at 11:39 am, to commit to creating and maintaining a safe workplace and prohibits any physical, verbal or mental abuse or intimidation of co-workers and fighting threats violence or disorderly conduct on the job (including verbal or physical harassment); and behaviors not acceptable are physical, verbal or mental abuse of co-workers. V5's Employee Record also documents Disciplinary Reports, dated 4/17/25 and 5/16/25 for tardiness/attendance (3/10/25, 3/15/25, 3/16/25, 3/20/25, 3/21/25, 3/24/25, 3/30/25, 4/3/25, 4/7/25, 4/8/25, 4/12/25, 4/13/25, 4/20/25, 4/21/25, 4/22/25, 4/26/25, 4/27/25, 5/1/25, 5/2/25, 5/5/25, 5/6/25, 5/7/25, 5/10/25, 5/11/25, 5/15/25 and 5/16/25). V6's (Certified Nursing Assistant/CNA) Employee Record, documents a Resignation/Discharge Form, dated 6/17/25, that V6 was hired on 1/23/25 and discharged on 6/13/25. V6's Disciplinary Report, dated 6/17/25, documents V5 had an incident on 6/13/25 of threatening or engaging in violence and was terminated. The Employee Record also documents an electronically signed Employee Handbook/Workplace Violence, dated 1/22/25 at 7:02 pm, to commit to creating and maintaining a safe workplace and prohibits any physical, verbal or mental abuse or intimidation of co-workers and fighting threats violence or disorderly conduct on the job (including verbal or physical harassment); and behaviors not acceptable are physical, verbal or mental abuse of co-workers. V6's Employee Record also documents Disciplinary Reports, dated 3/21/25 and 3/24/25 for tardiness/attendance (1/27/25, 1/28/25, 1/29/25, 2/1/25, 2/8/25, 2/19/25, 2/22/25, 2/23/25, 2/26/25, 2/27/25, 3/1/25, 3/2/25, 3/3/25, 3/8/25 3/9/25, 3/10/25, 3/16/25, 3/17/25 and 3/21/25), 4/9/25 (out of uniform) and 4/18/25 (for improper Resident Transfer with a mechanical lift). On 6/19/25 at 11:38 am, R1 (Resident Council President/alert and oriented) stated, I hear the residents and other staff complain about the staff fighting with each other. On 6/19/25 at 12:50 pm, R2 (alert and oriented) stated, Some of the staff can be snotty with each other and unprofessional, it is uncomfortable sometimes. On 6/20/25 at 11:20 am, V2 (Director of Nursing/DON) stated, I was not there (on 6/13/25) but I did watch it on the camera. (V5/CNA) and (V6/CNA) got into an argument. (V5) was assigned to the North Hall and (V6) was assigned to the South Hall. I ended up having to keep them on opposite sides of the building because their personalities just clashed. What happened was, (V5) came over from the North Hall to the South Hall, where (V6) was assigned to and (V5) had no reason to be over there. I could see them arguing in the middle of the hallway. I think (V6) just got frustrated because (V5) kept interrogating (V6), and it appeared that (V6) finally pushed (V5) back to get out of her personal space. They had a personality conflict and there had been tension between them, so I ended up scheduling them on opposite sides of the building to keep them away from each other. (V1/Administrator) went and intervened. (V5) and (V6) both ended up getting terminated over it. On 6/19/25 at 8:03 am, V1 (Administrator) stated, I watched back the video tape of the fight that (V5 and V6) got into in the front South Hallway, (V5 and V6) were verbally arguing, then (V6) pushed (V5). I separated both of them and I had to terminate both (V5/CNA) and (V6/CNA) because we do not tolerate that behavior. V1 verified that (V5 and V6) were in the front lobby hallway (South Hallway) where residents reside when the incident occurred.

Based on interview and record review the facility failed to conduct a thorough abuse investigation for two of four residents (R1 and R2) reviewed for abuse and failed to protect residents from further potential abuse. This failure has the potential to affect all 79 Residents residing in the Facility. Findings include: The Facility Abuse Prevention Program Policy, dated 10/2022, documents: the Facility must affirm the right of our residents to be free from abuse; prohibits abuse; facility has established a resident sensitive and resident secure environment; assures that the Facility is doing all that is within its control to prevent occurrences of abuse; the Facility will establish an environment that promotes resident sensitivity and resident security; identify occurrences and patterns of potential mistreatment; immediately protect residents involved in identified reports of possible abuse; implement systems to promptly and aggressively investigate all reports and allegations of abuse and make necessary changes to prevent future occurrences; filing accurate and timely investigation reports; abuse is defined as physical or mental injury inflicted upon a resident other than by accidental means and is the willful infliction of injury resulting in physical harm, pain or mental anguish, physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment; verbal abuse is a gestured language that willfully includes disparaging and derogatory terms to residents, within their hearing distance regardless of age, ability to comprehend or disability; resident concerns will be documented, reviewed, addressed and responded to using the Facility's concern identification and grievance procedures; staff will identify residents with increased vulnerability for abuse; through the care planning process, staff will identify any problems, goals or approaches which would reduce the chances of abuse; staff will continue to monitor the goals and approaches on a regular basis and update as necessary; all investigations will be reviewed and assessed for any corrective action while conducting investigations and assessments for patterns, like cases and changes in protocol will be done immediately and reviewed; reports will be documented and a record kept of the documentation; upon learning of the abuse report, the administrator or designee shall initiate an incident investigation; the resident's physician and representative shall be notified of any incident or allegation of abuse; residents who allegedly abuse another resident shall be immediately evaluated to determine the most suitable therapy, care approaches and placement, considering his/her safety or safety of other residents; ensure the safety of residents including, but not limited to, the separation of residents; all incidents will be documented, whether or not abuse; any incident or allegation involving abuse will result in an investigation; the appointed investigator will, at a minimum attempt to interview the person who reported the incident, anyone likely to have direct knowledge and the Resident and any written statements that have been submitted will be reviewed, along with any pertinent medical records and Residents whom the accused has regularly provided care and employees, will be interviewed; the investigator will report the conclusions of the investigation in writing to the administrator or designee within five working days and the final investigation report shall include (name, age, diagnoses, mental status, original allegation day, time, specific allegation, perpetrator, witnesses and circumstances surround the occurrence, facts determined, police report if applicable, conclusion of investigation and the final written report will be sent to the Department of Public Health within five working days of the reported incident; initial reporting of allegations shall be sent immediately by fax/phone to the Department of Public Health. The Facility Administrator Job Description, revised 10/2020, documents: primary purpose of this position is to direct day-to-day functions of the Facility in accordance with current federal, state and local standards, guidelines and regulations; assume responsibility and accountability for all programs in the Facility; ensure the planning, development, implementation and monitoring of Facility policies and procedures; ensure all employees and Residents follow the Facility's policies and procedures; and consult with department directors concerning the operation of their departments to assist in eliminating/correcting problem areas and/or improving services; develop and implement Facility compliance program that meets state and federal requirements. The Facility Resident Census Roster, dated 6/19/25, documents 79 Residents residing in the Facility. The Facility local State Agency Initial Report, dated 6/20/25, documents an altercation that occurred on 6/13/25 between R1 and R2. R2 hit R1 in the knees multiple times. On 6/19/25 at 8:29 am, R1 (alert and oriented/Resident Council President) stated, About a week ago, I was in the dining room and (R2) was trying to get through the tables and chairs and the area was not big enough and there was not enough room for his wheelchair, so I told him it would be easier for him to just go around. Then (R2) started yelling at me and kicked me a several times on my knees. It hurt because I have bad knees. (V1) talked to me and told me that (R2's) medication was going to get changed, but I never heard anything else. (R2) never hit me before, but (R2) always acts out and is loud and gets frustrated with everyone. It is just frustrating listening to him yell at people all the time. No one ever followed up with me or looked at me or my knees. On 6/19/25 at 12:50 pm, R2 (alert) stated, I do not like when people get in my way, I have to defend myself. On 6/25/25 at 8:30 am, V12 (CNA) stated, (On/13/25) I was in the Assistive Dining Room and heading over to the Main Dining Room and I heard some commotion. I came in and saw (R1) and (R2) arguing. (R1) said that (R2) kicked her and tried hitting her. I guess (R2) was trying to come through the tables by (R1) and there was not enough room for his wheelchair and (R2) gets aggravated easily and was yelling. They were both upset so I separated them. At this time, V12 verified V12 reported R1 and R2's altercation to V1. On 6/20/25 at 10:14 am, R5 (alert and oriented) stated, My room is real close to (R2's) and (R2) yells all the time, it gets scary and gets loud, I always wonder what could possibly happen one day down the road. On 6/19/25 at 1:20 pm, V4 (Activity Director) stated, (R2) has a lot of behaviors and can be verbally aggressive. Just today he tried to run my foot over. I did not know anything about (R2) kicking (R1) until today. It was never discussed in any of our meetings. On 6/20/25 at 9:59 am, V9 (Licensed Practical Nurse/LPN) stated (R2) does yell a lot and can be a little aggressive at times. On 6/20/25 at 11:20 am, V2 (Director of Nursing/DON) stated, I did not hear a lot about the incident on 6/13/25 between (R1) and (R2). (V1/Administrator) handles everything and nothing was communicated with me and we did not discuss this incident in morning meeting either. On 6/20/25 at 11:38 am, an interview was conducted with V1 (ADM) and R1 in the Facility Conference Room. R1 stated that on 6/13/25, R1 and R2 were in the Main Dining Room and R2 was trying to get through the tables. There was not enough room between the table and chairs for R2 to get to R2's table. R2 then kicked R1 in the knees multiple times and gave me the finger. All (R2) does is yell and scream. My knees did hurt me for a couple days after that and no one from nursing checked on me or looked me over. My knees hurt and I did not get offered any pain medication. On 6/19/25 at 8:03 am, V1 (Administrator/ADM) stated, I have not done an investigation on the 6/13/25 incident between (R1) and (R2), so I cannot provide an investigation report. I only interviewed (R1). I did not investigate this.

Based on Observation, Interview and Record Review the facility failed to prevent neglect of a cognitively impaired, high fall risk resident for one of three residents (R1) reviewed for neglect in the sample of five. This failure resulted in R1 lying on a cold, hard floor for an undetermined amount of time and was found to be cold with a shivering body appearance and chattering teeth in the early hours of the morning. Findings include: R1's current Care Plan, dated 1/21/25, documents R1 was admitted to the facility on [DATE] with diagnoses of Dementia, Agitation, Orthostatic Hypotension, Delirium, Chronic Obstructive Pulmonary Disorder, Heart Failure, Obstructive Sleep Apnea, Muscle Wasting and Atrophy, Difficulty in Walking, Abnormalities of Gait and Mobility and Lack of Coordination. This same care plan documents R1 is at risk for falls and injuries with an intervention, dated 1/15/25, to Keep bed in low position when resting in bed with mattress on right side of bed when resting in bed. R1's Fall Risk Assessment, dated 1/15/25, documents R1 is at a high risk of falling due to history of falling, diagnoses, chair bound incontinent status, disorientation at all times and recent changes in medications. On 1/22/25 at 1:00 PM, R1 was observed sleeping in his bed with blankets covering him. R1's bed was against the wall and in a low position and a mattress was on the floor to the side of R1's bed. R1's Nursing Progress Notes, dated 1/19/25 at 6:52 PM and completed by V5 (Licensed Practical Nurse, LPN), documents Patient fell on to floor no injury, denies hitting head, combative, assisted back to bed. Did not send out due to being care planned to floor. R1's Nursing Progress Notes, dated 1/20/25 at 2:29 AM and completed by V5, documents Patient on floor, will not stay in bed. Moving all around room and broke roommate's nightstand tabletop drawer. Pulling on room curtain divider, pushing staff hands away, will not stay in bed or on floor mat. R1's Facility Incident Report, dated 1/20/25, documents, Staff member (V4 Restorative Certified Nursing Assistant, CNA), reported to (V1) Administrator that she felt the nurse (V5) on duty neglected R1 during third shift. On 1/22/25 at 1:24 PM, V4 (Restorative CNA) stated, Monday (1/20/25) morning about 4:15 AM, my restorative aide (V10, Restorative CNA) and I were going down the hallway. (V10) said (R1) was on the floor. The nurse (V5, LPN) said he'd been there and that he was care planned to be on the floor. There was no mattress, he was lying on the hard floor. (R1) wasn't sleeping when I entered the room. (R1) was really cold, he was shivering, and his teeth were chattering. It was so sad. He had clothes on but no blankets and the floor was cold. Once (V10 and I) got him in the bed, he thanked us. We got him changed and got blankets on him. The area in his hall has been super cold since Saturday (1/18/25). Not dangerously cold, but below 70 degrees and lying on the floor with no blankets would be very cold. I went to the computer to see if he was care planned for being on the floor and he was not. I felt this was neglectful. This wasn't a case of (V5) not knowing he was on the floor, she knew, and she said he'd been there all night. V5's written statement, dated 1/21/25 and provided by V1 (Administrator), documents upon being interviewed V5 stated, I was made aware by a CNA (unknown) that (R1) had a fall at 6:52 PM. I notified the on-call nurse (unknown) and documented the incident. (R1) was combative but was able to be assisted back to bed. At 8:00 PM, 10:00 PM, between 1:00-2:00 AM and 4:00 AM, I noticed (R1) was on the floor and made sure he was placed back into bed. For the incidents at 8, 10, and between 1-2, I witnessed (R1) having a blanket around him. At some point I noticed that (R1) had rummaged with the roommate's nightstand and there were items on the floor. (R1) was off his mat and towards the other side of the room at this point. I believed that what was demonstrated throughout the night was behaviors but were redirectable. I did not notify the DON (V2, Director of Nursing) or Administrator regarding his behavior. I did not document the actions throughout the night, there was a lot going on that night. When (V4) came around 4:00 AM, she stated (R1) was on the floor. I stated he was care planned to be, that is what I was told. On 1/22/25 at 1:22 PM, V1 confirmed the facility has been working on getting a new part for the furnace/boiler system and it is affecting the heat output in some areas of the building. V1 stated while not in a dangerous temperature below 55 degrees Fahrenheit, the hall in which R1 resides has been cooler around 66 to 68 degrees Fahrenheit since the heat issues began on 1/18/24. On 1/22/25 at 2:58 PM, V2 (Director of Nursing) confirmed that R1 is very new to the facility with an admitted [DATE] and has had a couple falls prior to the night of 1/19/25. V2 confirmed R1's care plan does not include instructions or interventions to allow R1 to lay on the floor after a fall or anytime. V2 stated, (V5) quit employment via text message today. When I spoke with (V5) regarding the incident she did say that (R1) had fallen multiple times that night and I confirmed with her that none of it was charted. She didn't notify the doctor, family or anyone. (V5) didn't chart assessments of the resident, fall details or fill out risk management fall investigations. (R1) was supposed to have a mattress beside his bed and I don't know where it was. V5 told me There was no mattress that night. When someone has a fall the nurse conducts an immediate assessment, assists the resident back to a safe bed or chair and starts neurological checks, if it was unwitnessed. The nurse will complete risk management fall assessments and should notify the doctor and the family. Nothing was done to ensure (R1) was medically ok that night. After experiencing multiple falls that evening, (V5) let (R1) lay on the cold ground and she confirmed all of it. The facility's Abuse Prevention policy, dated 10/2022, documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This policy also documents Neglect means the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain or mental anguish. Neglect means a facility's failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness of a resident including deprivation of goods and services by staff. The facility's Fall Clinical Protocol policy, dated 5/2024, documents Fall Risk Assessment shall be completed on admission, quarterly, after a fall, and as clinically indicated. In addition, the nurse shall assess and document/report the following: Vital signs, Recent injury, especially fracture or head injury, Musculoskeletal function (observing for change in normal range of motion, weight bearing), Change in cognition or level of consciousness, Neurological status, Pain, Frequency and number of falls since last physician visit, Precipitating factors (details on how fall occurred), All current medications (especially those associated with dizziness or lethargy), All active diagnose. The staff will evaluate, and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etcetera. The staff, with the physician ' s guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. If a resident has an unwitnessed fall or hits their head initiate neurological checks. If a resident has an unwitnessed fall or hits their head and is on anticoagulation medication, then send resident to the ER (emergency room ) for an evaluation.

Based on observation, interview, and record review, the facility failed to protect a resident (R2) from sexual abuse by another resident (R1) and failed to ensure a resident (R4) was free from physical abuse by another resident (R3) with a known history of verbal and physical aggression for two of four residents reviewed for abuse in a sample of six. This failure resulted in R3 verbally yelling and physically slamming his door on R4's hand. R4 sustained bleeding lacerations and fractures to three fingers on R4's right hand which required hospitalization evaluation where 12 sutures were placed to R4's fingers; further surgical intervention is pending. These failures have the potential to affect R4 and other dementia residents residing in the facility. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 9/24/24, the facility remains out of compliance at Severity Level 2 as additional time is needed to evaluate the implementation and effectiveness of the facility's removal plan and quality assurance monitoring. Findings include: 1. The facility's Abuse Prevention Program policy, dated 10/2022, documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This policy continues with This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. This policy also states Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical hare, pain, or mental anguish to a resident .The term 'willful' in the definition of 'abuse' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The facility's undated Residents Rights Statement documents, All residents have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. This facility will protect and promote the rights of each resident, including each of the following rights: 38. The resident has the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and involuntary seclusion .47. The facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. R3's current Face sheet documents diagnoses including but not limited to Restlessness and Agitation, Acute Kidney Failure, and Cognitive Communication Deficit R3's Minimum Data Set/MDS assessment, dated 7/15/24, documents R3 as cognitively intact with behaviors including physical symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), verbal symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others), rejection of cares, and wandering. R3's Documentation Survey Reports for behavior tracking, dated August 2024 and September 2024, document R3 displayed behaviors including yelling/screaming, kicking/hitting, grabbing, pinching/scratching/spitting, wandering, abusive language, threatening behavior, sexually inappropriate and rejection of cares. R3 had one or more of these type of behaviors on one or more shifts on the following dates: 8/4, 8/9, 8/10 - 8/12, 8/14 - 8/16, 8/19 - 8/22, 8/24, 8/25, 8/28 - 8/30, 9/1, 9/3, and 9/8/24. Also documented is (R3's) response to staff interventions including any one or more of these responses: Increased activity/mobility/agitation, Combative (physically and/or verbally), and Unable to redirect/engage. R3's Progress Note, dated 8/1/24 by V11 Licensed Practical Nurse/LPN, documents, Resident became combative upon room entry. R3's Progress Note, dated 8/11/24 by V12 Registered Nurse/RN, documents, Describe behavior: Patient (R3) slammed peer's (R4's) hands into his (R3's) door when she (R4) was standing in his doorway. Patient (R3) was cursing at peer (R4) stating 'get out of my f***ing room or I will hurt you.' Before staff could diffuse situation patient (R3) did slam both (R4's) hands into his door. Environmental, Physiological, Psychosocial factors/triggers: Patient (R3) is easily agitated with aggressive tendencies and stated after slamming peer's (R3's) hands into the door, 'I don't f***ing care if I hurt her (R4) or not, damn b**ch does not need to be in here.' While assessing peer (R4) out in the hall patient (R3) came out of room shouting that he did not cause this harm but rather staff. Patient (R3) was making false accusations against staff stating that they slammed her (R4's) hands into the door. Intervention: Reviewed with patient (R3) that we needed to take care of peer (R4) involved and that they needed to go back into their room which he (R3) slammed the door and told all staff 'We can go f*** ourselves.' Resident response: did not come out of room. Notifications made: Director of Nursing notified. R3's Progress Note, dated 8/22/24 by V3 Director of Nursing/DON, documents, Staff approached this nurse stating resident (R3) punched CNA (Certified Nursing Assistant/V11) in the stomach and the face. (V11) states when (V11) went into resident room to deliver room tray to resident (R3) when he (R3) punched her (V11) in the stomach and then the face. (V11) has notable red mark to her stomach where resident (R3) punched her. Police called and resident (R3) stated to police, 'I have told them I don't want their food.' Police took report. Report number 26-01054. Resident sent to (named hospital) for psych (psychiatric) eval (evaluation). R3's Nurse Practitioner Progress Note, dated 8/23/24, includes but is not limited to: Restlessness and agitation. Patient (R3) frequently having behaviors and agitation. He has made multiple attempts to harm staff and other residents. Staff injury reported today. Patient (R3) to be sent to the hospital for a psych evaluation. Patient (R3) is considered a threat to the safety of others and is not appropriate to reside in this long-term care setting. Patient refuses to see rounding mental health provider. HPI (History of Present Illness) Interval History: Staff report patient (R3) continues to have aggressive and harmful behaviors towards staff and other residents. Today, a staff member was providing patient with a meal tray and patient punched the staff member. He (R3) has had episodes of yelling while using profanity and hitting in the past. He often throws dishes in his room with the attempt to break them and subsequently poses risk to himself and staff members. Patient has previously slammed his door on another resident's fingers while yelling profanity at that resident. He has put other residents' safety at risk and vocalizes no remorse for injuring others. Patient is noncompliant with cares and medication orders despite frequent attempts to educate on the importance of bathing, eating, and taking medications as ordered. R4's current Face sheet documents diagnoses including but not limited to Unspecified Dementia, Unspecified severity, without Behavioral disturbance, Psychotic disturbance, Mood disturbance, and Anxiety; Chronic Kidney disease, stage 3; Displaced Fracture of middle phalanx of right middle, right ring, and right little finger; Presence of Cardiac Pacemaker; Syncope and collapse, and Weakness. R4's MDS assessment, dated 6/27/24, documents R4 is severely cognitively impaired and wanders. R4's current Care plan includes a focus of: (R4) has impaired cognitive function/dementia or impaired thought processes r/t (related to) Dementia with interventions including but not limited to (R4) requires approaches that maximize involvement in daily decision making and activity limit choices, use cueing, task segmentation, written lists, instructions. R4's Progress Note, dated 8/11/24 by V12 Registered Nurse/RN, documents Resident (R4) noted by staff walking into peers (R3's) room. Peer (R3) became immediately agitated and yelled 'get out of my f***ing room.' While staff was attempting to redirect resident (R4) out of peer's (R3's) room, Peer (R3) slammed the door and caught resident's (R4's) hands in the door. Immediate blood noted to right hand. Staff helped patient (R4) into chair and vitals started. Patient (R4) was found to be diaphoretic and very pale. Patient's (R4's) pulse ox (oximetry) was 76% upon assessment and patient (R4) was holding chest. Blood pressure was not palpable. Patient (R4) had head back in wheelchair .911 call placed for emergent transport to (named hospital). R4's Hospital After Visit Summary, dated 8/11/24, documents Reason for Visit: Loss of Consciousness; Diagnoses: Loss of consciousness, Crushing injury of right hand, initial encounter. R4's Progress Note, dated 8/11/24, documents, Resident brought back to facility by daughter (POA/Power of Attorney) around (3:00pm), resident assessed and vitals WNL (within normal limits), x-ray done to right hand done by (named hospital) with no break/fractures, resident has no c/o (complaints of) pain, resident in wheelchair at nurses' station, no concerns at this time. R4's Progress note, dated 8/12/24 by V17 Facility Nurse Practitioner, documents: HPI (History of Present Illness) Interval History: Resident returns to the facility after being assessed by the ER (emergency room ) after a hand injury. Patient had her hand shut in a door of another resident's room. The ER ruled out any fracture. Patient denies pain at this time but due to dementia is not an accurate historian. Bruising and scabbing noted on her right hand. She is able to move all finger and wrist joints without difficulty. Patient has PRN (as needed) Tylenol available for pain relief. R3 and R4's Progress Notes, dated 9/8/24 and 9/9/24 respectively, by V11 LPN, document, (V11) was at the north nurse's station and had just hung up the phone with doctor about another resident and had started making notes. (V11) heard resident yelling 'get the f*** away from here, get the f*** out now.' (V11) slid (V11's) chair back away from the computer so that she could see where the commotion was taking place, (R4) was standing up in front of (R4's) wheelchair at (R3's) door with her (R4's) hand on the doorframe. (V11) jumped up from (V11's) chair at the north nurse's station and ran towards (R4) while trying to yell to (R3) that (V11) would get (R3), but before (V11) could finish the sentence and intervene, (R3) slammed the door shut while still yelling at (R4) saying 'stupid bitch, get the f*** away from here.' (R4's) hand was caught in the door and a loud crunching sound was heard. (R4) sat back in wheelchair and looked down at her hand which was bleeding and stated, 'that really hurts.' (V11) moved (R4) away from (R3's) room door to the north nurse's station and inspected (R4's) hand. (V11) could see visible open bleeding wounds to (R4's) right hand digits 3, 4 and 5. (V11) wrapped (R4's) hand with a towel to try and stop the bleeding. (V11) went to take a look into (R3's) room and (R3) started yelling for (V11) to 'get the f*** away from here nigger.' (R3) also stated 'I didn't do anything to (R4), she shouldn't have brung (sic) her ass into my room.' (V11) called out for help and started giving orders for an aide to stay with (R3) and for an aide to stay with (R4) while (V11) made necessary phone calls to the proper authorities, management, Dr. (doctor), and POA (Power of Attorney), resident was transported to (named) ED (Emergency Department), (V16 Medical Director), (V3) DON (Director of Nursing) and POA notified of incident. R3's Progress note, dated 9/8/24 by V17 Facility Nurse Practitioner, includes but is not limited to: HPI (History of Present Illness) Interval History: Provider notified of a repeated incidence of patient significantly harming another resident while slamming his room door on another resident's hand and using profanity to call that resident names and for them to get away from the door. This is not the first time he has injured another resident at the facility. He continues to have aggressive and harmful behaviors towards staff and other residents, with noted episodes of striking staff members. He still has episodes of yelling while using profanity and striking out at staff and other residents. He will throw dishes in his room with the attempt to break them and subsequently poses risk to himself and staff members. He once again puts other residents' safety at risk and vocalizes no remorse for the significant hand injury that occurred. Patient is noncompliant with cares and medication orders despite frequent attempts to educate on the importance of bathing, eating, and taking medications as ordered. He is to be sent to the hospital for a psychiatric evaluation due to continued outbursts of anger and physical aggression towards staff and other residents. R4's X-ray report of right hand, dated 9/8/24, documents Impression: 1. Acute posttraumatic fractures of the third-fifth digit middle phalanges. R4's Progress Note, dated 9/9/24 by V17 Facility Nurse Practitioner documents: HPI (History of Present Illness) Interval History: Patient returns to the facility after being evaluated at (named) ER (emergency room ). Patient (R4) had her right hand slammed shut in the door of another resident's room. Per daughter, patient does have a fracture and is to follow up with ortho (orthopedics) tomorrow to discuss possible surgery. Patient denies any pain at this time but due to dementia, is not reliable with her ROS (Review of Systems). She does have noted stitches on the inside of her fingers. Multiple areas of dark bruising. Patient was started on a prophylactic antibiotic while at the ER to prevent infection. Patient also recently tested positive for COVID-19. She continues to have a clear runny nose, per baseline. No cough noted. On 9/18/24, at 12:04pm, R4 sat in her room then got up and walked over to the door entrance of her room. R4 showed this writer R4's right hand. R4's middle, index and pinky fingers are inflamed and purplish red in color with sutures noted across the first knuckle of all three fingers. R4 denies pain except when closes fist, R4 stated it doesn't feel too good. R4 is unable to recall how it happened and stated, did my family put me here? R4 then ambulated out of her room and wandered down the hall. On 9/19/24, at 9:28am, R4 sat in a wheelchair and self-propelled in the hallway. On 9/19/24, at 12:14pm, R4 stood in the hallway near the door of another resident's room. R4 ambulated a little further to the next resident's room and entered. On 9/20/24, at 9:59am, R4 self-propelled in her wheelchair up and down the hallway. R4 followed then caught up to this writer and stated, Did I go too fast? What's going on out there? while looking towards an exit door. On 9/19/24, at 9:31am, V13 Certified Nursing Assistant/CNA stated the following, (R4) is supposed to be in a wheelchair unless a CNA ambulates with her. She is a wanderer and has dementia. She wanders by self-propelling in her wheelchair. She goes in/out of resident rooms .She holds onto door frames as she peers into resident rooms looking, not always going in .She does it often and goes into a lot of rooms. After those two incidents we re-direct and try to keep her out of the center hallway especially if going towards his room in the center hallway. He usually left his door closed if he was in his room and leave it open when not in it. He was not a nice person .He was his own person, did not have dementia, refused cares and if we brought him water, he would bring it back out, slam it down and say I didn't want that. (R4) stops in doorways frequently every day. On 9/19/24, at 9:41am, V14 CNA stated the following, (R4) is a wanderer and has dementia. I was not working those days she got her hand caught in the door. She wanders in her wheelchair and sometimes leaves it and gets up to walk. I typically only work weekends so last weekend when I was working, I saw her hand with sore fingers. The nurse told me she got it slammed in the door and we were to keep her out of other peoples' rooms. I have seen (R4) go into resident rooms all the time. I kind of keep my eye on her and if she is going into another's room, I take her back to her room. She's got dementia so bad five minutes later she asks, 'where's my room.' When she walked, she braced herself by holding onto the doorframes. She does not get one on one supervision, but that would be a good idea. Can't have her in eyesight all the time. Keeping an eye on where she is all the time is impossible. She is here one minute and next minute she is down the hall. She's fast whether walking or in her wheelchair. On 9/19/24, at 10:29am, V11 LPN stated the following: I remember (R3 and R4's 9/8 incident). I was at nursing station on phone about another resident and hung up to write notes on the computer. I heard yelling so I swung my chair around and saw (R4) standing at (R3's) door but (R4) didn't go in. I could see (R4) peering into (R3's) room from the doorway standing up with (R4's) wheelchair behind (R4). I yelled out 'hey (R3)' but before I could finish the door went boom and I could hear (R4's) fingers crushing. Oh my god. (R4) sat down in her wheelchair and looked at her hand and said, 'wow that really hurts'. I don't think (R4) really understood. As I was going towards (R4) I could see the blood. I wheeled (R4) back towards the nurse's station while trying to call (V3 Director of Nursing/DON). The other nurse didn't know what to do. (R3) was still in his room yelling. He said, 'get away from here you nigger.' I said, 'you just smashed her fingers.' (R3) didn't care. (R3) said '(R4) shouldn't have brought her ass into my room.' (R4) is a wanderer and has dementia. She wanders in her wheelchair. (R4) likes to look around everywhere. We usually let her go about her business if she is in the wheelchair. She'll glide it around and look at things. (R4) just doesn't know what's going on. I thought (R4) would pass out or cry. (R3's) door is usually cracked open. I think (R4) may have gone into (R3's) room. (R4) was holding onto the doorframe when peering into (R3's) room. That is what (R4) would usually do and (R4) would do this when peering into other's rooms. I knew of their previous incident. I was on shift 8/11/24 and worked 2pm - 6:30am. That incident I did not see. I did see her fingers - her index finger and even more sore her thumb had skin torn off. We spoke with (R3) and explained (R4) doesn't know and is harmless so if (R4) comes to (R3's) door let us know and we will get (R4). (R3) is stuck in his ways. (R3) is aggressive and throws things and cusses. (R3) can be sweet when wants something. (R3) said, 'you keep (R4) out of here;' there is no reasoning with (R3). We try to keep an eye on (R4) as much as we can. There is only so much we can do while doing our job. It wasn't even five minutes that she had got away. (R4's) room is northeast and she was down the hallway and if there I know (R4) is okay down there and I show (R4) her room. (R4) had stopped at the nurses' station before I made the call then (R4) was gone .(R4) wanders into rooms often - she is looking for her room .(R3) punched a staff person in the stomach and (R3) has thrown things at staff. On 9/19/24, at 11:36am, V12 Registered Nurse/RN stated the following regarding R3 and R4's incident on 8/11/24: (R4) tends to wander and was in the doorway of (R3) and we heard yelling. Before we got there (R3) went to slam the door and (R4) had her hand in the door .Her hand was bleeding. We sent her out for chest pain, and we wanted her hand checked too. (R4) was on her feet from the minute she woke up and wandered a lot. There was constant redirection back to her hall. She had dementia .We were trying to redirect (R4) but it was difficult as she was going all over the place. I am not aware of anything (increased supervision/monitoring) in place. No increased supervision - I don't know how we would do that. We were already constantly going to get her .(R4) was not in eyesight 100% of the time but (R4) was never in her room. She was always staff asking, 'what do I do now.' It was so odd the way it happened because I was three doors down. (R3) is very vocal and (R4) was at (R3's) doorway. It happened so fast. (R3) is very private. (R3) is a strange character and knows more to what he plays on. (R3) is not nice. He may have arguments at times with residents but no other aggressive incidents that I know of. I stopped working about [DATE]th or so. I did not know it happened again. We didn't do anything different for (R4) or (R3). We asked (V18 Previous Administrator) about it and (V18) said 'this did not result in an injury and (V18) will handle it.' We felt (R3) needed a psychiatric evaluation to see if something was going on. I believe this was (R3's) first time it was an actual behavior harming someone. It is kind of hard to keep someone like (R4) safe. Breaks my heart that it happened again. On 9/19/24, at 12:54pm, V7 Social Service Director/SSD stated there was no increased supervision for (R4) or any care plan updates after the 8/11/24 for (R4's) wandering. V7 said, I wasn't in any discussion about it. I was in on discussion after the 9/9/24 incident and it happened so fast; the police were called. Everything was in place to get her out of that situation by redirecting. We don't usually have people in here that do things like slamming doors on others. V7 denies that any increased supervision or monitoring of (R4) was put into place. Confirmed that since a second similar incident occurred redirecting didn't really work. On 9/19/24, at 1:30pm, V3 Director of Nursing/DON stated the following: On the 8/11 incident I was not there. I received a call from (V12 RN) when it happened. (V12) said (R4) was by (R3's) room in the hallway. (R3) became angry and slammed (R4's) hand in the door. (R4) became diaphoretic and was pale so we sent (R4) out to see if any injury to her hand and there was not. As for (R4), we try to redirect her away and do our best and watching (R3) and staff approaching when (R3) is getting worked up. (R4) is a known wanderer and has dementia. (R4) hovers in a doorway, looks in, then keeps going. V3 confirmed redirecting was already in place for R4 prior to this incident. V3 stated, The 9/8 incident happened at night on 2nd shift. I got called by (V11 LPN). (V11) said (V11) was at the nurse's desk and could see (R3's) room. (V11) heard (R3) screaming and cussing at (R4). (V11) tried to get there but (R3) had slammed (R4's) hands on the door again. When (V11) got there (R4's) hand was visibly injured, cut open and bleeding. It appeared that (R4) had just used (R3s) doorframe to stand. (R4) sat right back down afterwards. We called the cops on (R3). (R4) was sent to a separate hospital for evaluation. (R4) had three fractured fingers and 12 sutures total to all three fingers, ring middle and pinky. (R4) has an ortho (orthopedic) referral for surgery. (R4) had COVID so will need to be rescheduled till clear of COVID. We sent (R3) for a psych (psychiatric) eval (evaluation). (R3) was deemed decisional. We called the hospital about (R3) being aggressive and noncompliant. (R3) has been sent out several times for psych evals and they send him back. I sent (R3) in once. (R3) became aggressive on staff when they went to change him. Cops were called and (R3) hit the cop . (R3) hit (V15 CNA) in the face and stomach when (V15) was taking his room tray in. We called the cops. All three incidents occurred within 30 days. We tried to reason with (R3). (R3) was mean on purpose. We don't have the staff to do one on one supervision. We are not a locked unit; no way to watch her every second. We do our best to keep our eye on her. It was a busy night, and everyone was busy right after dinner hour laying people down and the nurse was on the phone. There was a lot going on. Obviously, I want to protect (R4), but it could have been anybody. He was mean and impulsive all the time. I think (R3) was dangerous in general; not an (R4) thing. (R3) refused psych evals with our psych (psychiatric doctor) and refused meds (medications). On 9/20/24, at 1:36pm, V3 DON stated, (R3) was aggressive any chance he got. (R3) would break dishes, cuss us out or become aggressive. (R3) did this almost on a daily basis. It got to this point where (R3) started calling the cops. (R3) was decisional and knew what he was doing. (R3) was choosing these behaviors like threatening staff and residents so we started calling cops on him .(R3) refused a psychiatric evaluation and refused his medications frequently. The Facility Incident Report Form, regarding a Reportable Event, documents an abuse allegation occurred on 9/8/24 at 7:30pm involving R3 and R4. --- 32061 2. The facility policy, Abuse Prevention Program, dated 10/2022 directs staff, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish. Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion or sexual assault. The facility Incident Report Form, Date of Occurrence 8/19/24 at 7:30 P.M. Initial: Staff member (V6/Laundry Aide) reported to the Abuse Prevention Coordinator (V3/Director of Nurses) designee that R1 was allegedly touching R2 inappropriately in the dining room. R1 and R2 immediately separated. R2 assessed, no injuries noted. R1 being seen by psych (psychiatric services) and NP (Nurse Practitioner). Investigation initiated, final to follow. POA (Power of Attorney) of R2 notified. R1 is his own representative. MD (Medical Doctor) notified. Local Authorities notified. R1's facility Admission Record documents that R1 was admitted to the facility on [DATE] with the following diagnoses: Senile Degeneration of Brain, Chronic Kidney Disease and Adjustment Disorder. R1's Minimum Data Set Assessment, dated 6/12/2024 documents R1's cognitive status as 12 out of 15 (moderate cognitive impairment). R1's Nursing Progress Note, dated 8/20/2024 documents, Incident was reported to the writer by a staff member. Staff member reports seeing the resident in close proximity to a female resident in the dining room. Staff member saw resident's hand on the thigh of the female resident. R2's facility Admission Record documents that R2 was admitted to the facility on [DATE] with the following diagnosis: Alzheimer's Disease. R2's Minimum Data Set Assessment, dated 7/4/20204 documents R2's cognitive status as 3 out of 15 (cognitively impaired). R2's current Care Plan includes the following Focus Area: (R2) has impaired cognitive function/dementia or impaired thought processes related to Alzheimer's, Dementia, Delusional Disorders, Mood Disorder. Also included are the following Interventions: (R2) needs supervision and assistance with all decision making. The facility Incident Report Form dated August 26, 2024, documents, Final: Investigation completed. Interviews with staff and resident completed. Per interview with R1, resident adamantly denies allegations stating he is [AGE] years old and has no sexual desires and would not touch anyone in an inappropriate manner. R1 has resided at the facility for a long time and has not had any behaviors or inappropriate interactions. This would be completely out of character for him. R1 states he might touch a resident on the hand to offer comfort or greeting but would never do anything inappropriate. It must be noted that R1 has impaired vision and is almost blind. It is highly likely that he could have made contact accidentally. R1 is alert and oriented X 2 with a BIMS (Brief Interview for Mental Status) of 12 and a hospice patient. R2 is not interviewable due to advanced dementia. (R2) is alert and oriented X 1 with a BIMS of 3. V1 the staff member who reported this incident states she was cleaning the dining room. R2 was sitting with her back to V1 as she walked further into the dining room, she observed R1 and R2 sitting across from each other knee to knee. V1 reports she observed R1's hand on R2's thigh. It appeared to be near the groin area of R2. R2's hands were positioned beside her in her wheelchair. V1 then told R1 to remove his hands and went and got the nurse who separated R1 and R2. V1 stated R2 was wearing long pants which were fully intact. V1 reports that no other staff or residents observed the incident. Peer reviews done with other women on the unit, none of which mentioned any sexual misconduct during their stays. R2 was assessed and no injury or evidence of sexual interaction was found. IDT (Interdisciplinary Team) met and reviewed plan of care for both R1 and R2 and updated accordingly. R1 UA (urinalysis) is negative, was seen by NP (Nurse Practitioner) who did med (medication) review. R1 refused to have psych (Psychiatric) eval (evaluation). R1 will continue to be monitored for any inappropriate conduct. The investigation determined insufficient evidence to substantiate abuse due to lack of intent, physical or mental distress. On 9/18/2024 at 1:24 P.M., V6/Laundry Aide stated, On (8/19/24) around 7:15 in the evening, I saw (R1) touching (R2) in her crotch. They were sitting side by side in the ADR (Activity Dining Room). They were the only two in the room. I happened to be walking through. Their wheelchairs were side by side. (R1's) left hand was on (R2's) inner right thigh and (R1's) right hand was in (R2's) crouch. It was on the outside of (R2's) gray sweatpants. I was able to see the position of his hands clearly. Her hands were down by her side. (R2) wasn't saying anything. (R1) was talking really low to (R2). I could not make out what (R1) was saying to (R2). (R1) was very angry when he saw me. He yelled at me and said, 'I am very offended of your presence.' (R1) immediately withdrew his hand. I went to the nurse; I don't know what her name is. She is an Agency nurse. She still works here. The nurse came into the ADR and separated them and told (R1) to keep his hands to himself. (R1) was still very angry with me, telling me that I was a dirty person and had a dirty mind. The nurse had me come to the nurse's station and write a statement. V8/CNA (Certified Nursing Assistant) was standing at the nurse's station talking to V3/DON (Director of Nurses) on the phone. He took a picture of my statement with his phone and sent it to (V3). (R1) likes to flirt with all the ladies. (R1) says he is looking for a lover. On 9/19/24 at 9:20 A.M., R1 stated, I have lived here for a few years. (R2) is my friend. I love her. I have touched (R2) many times, on the hand and face. I don't see (R2) much anymore. I miss (R2). On 9/19/24 at 10:00 A.M., V11/Agency Nurse stated, I recall the incident that happened (between R1 and R2 on 8/19/24). (R1) likes to think he's a ladies' man. (R1)'s always talking to the ladies and calling them his girlfriends. (R1) likes to say, 'I have everything I need, except a lover.' The Immediate Jeopardy was identified to have begun on 8/11/24 wh[TRUNCATED]

Based on observation, interview, and record review the facility failed to provide adequate supervision, failed to ensure exit door alarms were answered immediately by staff, failed to develop and implement a monitoring schedule as directed by the facility's policy for a known wandering resident, failed to ensure staff were aware of residents they were responsible for monitoring and providing care for one of three residents (R1) reviewed for elopement risk in the sample of three. These failures resulted in cognitively impaired resident (R1) with a known history of wandering, who required assistance of staff for locomotion and walking, exiting the facility without staff knowledge and for an undetermined amount of time, being found wandering aimlessly and confused, across the street from the facility approximately 400 feet from the facility. The street R1 had crossed was a street with a high activity of traffic. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 6-1-23, the facility remains out of compliance at a severity Level II as the facility continues to audit all exit doors daily, audit all residents at risk for wandering weekly and update elopement assessments and care plans. The facility continues to audit staffing daily for sufficient staffing for monitoring residents, and the quality assurance committee continues to monitor the facility's performance and compliance to ensure that corrections are achieved. Findings include: The facility's Door Alarm Policy (undated) documents, When a door alarm sounds, staff shall: 1. Check the alarm panel to determine which door has been opened. Do not assume someone else has already done this. 2. Check the exit door for any exiting resident by means of a visual check. Also perform search of the building parameter for exited resident. The facility Wandering Residents policy dated 08/2006 documents, Every effort will be made to prevent wandering episodes while maintaining the least restrictive environment for residents who are at risk for elopement. All residents who are at risk for harm because of wandering will be assessed. If a resident repeatedly wanders off the unit, a monitoring schedule will be implemented to ensure resident safety. The resident's care plan will be documented as to the implementation of the monitoring schedule. The facility's Elopement and Search (Code Pink) policy dated 02/2014 documents, Policy: To establish methods for protecting residents who are at risk for elopement and for conducting an organized search for a resident who cannot be located. Policy Specifications: 1. All nursing personnel are responsible for: a. Knowing the whereabouts of residents for which they are assigned. c. Staff are responsible for keeping the nurse informed of a resident's whereabouts. 3. Residents are not allowed to leave the building unless a physician order is present. 7. All personnel are responsible for promptly going to the location and determining the cause of the activated audible door alarm. 8. When a resident makes repeated/continuous attempts to leave the building, the resident will be visibly observed every fifteen (minutes) until the behavior has resolved. R1's Admission Note dated 6-1-23 and signed by V12 (R1's Physician) documents, (R1) admitted to (facility) from (assisted living facility) on 2-21-23 with Alzheimer's Disease due to the inability to provide self-cares and wandering. (R1) is conversational but confused making history unreliable or unknown. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is a [AGE] year-old that was admitted to the facility on [DATE]. This same MDS Assessment documents R1 is moderately cognitively impaired, requires one assist of physical assistance of staff for locomotion on and off of the unit and for walking in R1's room and in the corridor, and has a behavior of wandering. R1's current Elopement Risk/Wanderer Care Plan last updated 5-30-23 does not include a monitoring schedule. R1's Elopement Evaluation dated 2-21-23 documents R1 is at risk for elopement and has a history of elopement or an attempted elopement while at home, a history of elopement or attempted leaving the facility without informing staff, has verbally expressed the desire to go home or stayed near an exit door, wanders, and wanders aimlessly or non-goal directed (confused, moved without purpose, may enter others' rooms, or explore others' belongings). R1's Fall Risk Evaluation dated 5-22-23 documents R1 has intermittent confusion, had balance problems while walking, and is at risk for falling. R1's Nursing Admission Note dated 2/21/2023 at 7:16 PM documents, (R1) admitted to facility from home. Residents' family at facility upon residents' arrival. Resident was a resident at (Assisted Living Facility) prior to going home. Resident has Alzheimer's diagnosis. (R1) known to wander at last facility. (R1) alert with confusion. R1's Social Service Note dated 2/24/2023 at 4:49 PM documents R1 does wander the facility and expressed wishes to leave and has a Wander guard on to help keep him safe. R1's Nursing Note dated 5/26/2023 at 4:30 PM and signed by V5 (Agency RN/Registered Nurse) documents, Writer received a call at the southwest nurses station regarding (R1). The young woman stated, 'I'm walking with (R1). I used to work at a facility he was at, so that is how I recognized (R1).' Writer alerted (R1's) nurse that patient was outside. Writer went to assist (R1) back into building. (R1) was talkative, no physical or verbal aggression noted. (R1) refused to state how he was let out of the building. (R1) denied pain or discomfort. Nurse notified that (R1) was back in facility. The facility's Daily Assignment Sheet dated 5-26-23 documents V8 (Agency CNA) was directly responsible for R1's care and monitoring on 5/26/23 between 2:30 PM and 10:30 PM. This same Daily Assignment Sheet documents V9 (Agency CNA) was working a different section on the hallway R1 resided on and V11 (RN) was the nurse responsible for R1's care and monitoring on 5-26-23 from 1:45 PM through 10:30 PM. R1's Facility Incident Report Form dated 5-26-23 and signed by V3 (Assistant Director of Nursing) documents, Diagnosis and Mental Status: Alzheimer's Disease, Asthma, Epilepsy, Hypothyroidism, Dementia, History of Falling, Unsteadiness on Feet, Muscle Weakness, Unspecified Lack of Coordination, and Non-Compliance with other medical treatment and regimen due to unspecified reason. (R1) was observed outside by the assisted living facility across the street. They (assisted living) called this campus to inform us. (R1) was brought back inside and assessed by the nurse. No unusual findings. POA (Power of Attorney), MD (Medical Doctor), DON (Director of Nursing), and Administrator made aware. (R1) is being observed for any change in mood, status, or behavior. Wander guard (electronic monitoring device) in place and alarm sounded. (R1) stated (he) followed someone outside and was just looking around. Investigation initiated. On 6-1-23 at 8:50 AM V4 (CNA/Certified Nursing Assistant) stated, I heard (R1) left the building unattended by staff the other day. (R1) is always wandering throughout all halls of the facility. (R1) gets confused and is not always aware of his surroundings. I am not sure if (R1) would know where he was going if he went outside without staff. (R1) is not on a monitoring schedule that I am aware of. I just try to watch (R1) more if I can. On 6-1-23 at 9:15 AM V5 (Agency RN/Registered Nurse) stated, I was doing a medication pass around 4:30 PM and got a call from a staff member at the assisted living facility across the street from the facility that (R1) was walking on the sidewalk of the east side of the assisted living in front of a church and ballfield. I am not sure the name of the assisted living staff. The assisted living staff member recognized (R1) from taking care of him in the past and called the facility to report he was outside. I left and went across the street to bring (R1) back into the facility. (R1) stated he was just taking a walk and would not tell me how he got out of the facility. I did not know the front door alarms were sounding until the assisted living staff member called to report (R1) was at their facility. Both the Wander guard (electronic monitoring device) door alarm and the regular door alarm were sounding when I had left the building to go get (R1). If residents with Wander guard are sitting in the room next to the alarm, the Wander guard door alarm is always sounding so sometimes we are not even sure if a resident has left the facility. We get used to hearing the alarm. We (facility staff) did not know that (R1) left the facility. When I returned him to the building, he was fine and had no injuries. The weather was nice and was not raining. On 6-1-23 at 9:25 AM V6 (Agency CNA/Certified Nursing Assistant) stated, I was working the front south hallway and was told (R1) had gotten out of the building unattended on (5-26-23). I did not hear any of the front alarms working when (R1) had gotten out the front door. I was not the staff member responsible for (R1) that night. (R1) is frequently trying to get out the front door and is sneaky. I have heard (R1) tries to leave behind visitors when the visitors leave the facility. An employee of the assisted living building had found (R1) walking on the sidewalk across the street from this facility. I let the nurse (V5) and (R1) back in the front door when (V5) had gone to get (R1). (R1) was not in any distress. (R1) is always trying to get out of the facility. (R1) gets confused. If we had enough staff (R1) should have a one-on-one staff member to watch him more closely. On 6-1-23 at 10:30 AM V3 (Assistant Director of Nursing) stated, (R1) always wanders on all hallways. I am not aware of a specific monitoring schedule to increase (R1's) supervision. (R1's) care plan does not have a monitoring schedule. (R1) was not put on 15-minute visual checks until after he left the facility unattended (5-26-23). (V8/CNA), V9 (CNA), and V11 (RN) were the staff responsible for (R1) on 5-26-23 when (R1) left the building without staff. (V8) would have been his direct staff that was responsible for (R1) as (V8) was assigned to the Northwest hallway for the half of the residents that included (R1). I do not know how long (R1) was outside unattended by staff. I was told (R1) was found by the church across the street. On 6-1-23 at 10:45 AM V8 (Agency CNA) stated, I do not know who (R1) is or what (R1) looks like. I worked the Northwest hallway on (5-26-23) from 2:30 PM through 10:45 PM. I was never told on (5-26-23) that (R1) got out of the building unattended. I was not (R1's) responsible staff member on (5-26-23). On 6-1-23 at 10:50 AM V10 (RN) stated, I know (R1) lived up on the front hallways before and was always trying to leave out the front doors. (R1) has wandered since admission and always tries to leave. (R1) is hard to re-direct. (R1) was not on any type of frequent checks before. I am not aware of (R1) ever actually getting out of the facility without staff or being found at the assisted living facility. I know within the last few days (R1) has been on 15-minute visual checks. I do not know why (R1) has been put on 15-minute checks. (R1) is definitely not safe outside by himself. (R1) would not know where he was. On 6-1-23 at 11:30 AM V6 (RN Shift Supervisor) stated, I was working the evening that (R1) eloped (5-26-23). (R1) had a history of attempting to leave the building at the facility he lived at prior to admission to this facility. (R1) is always wandering all hallways and attempts to leave the building frequently, especially out of the front doors. I cannot remember who told me that (R1) had gotten out of the facility without staff. I went up to the front hallway as soon as I was told (R1) was found and both the Wander guard alarm and door alarm was sounding. I cannot answer why staff had not responded to the alarms. I did not ask the staff when they had last saw (R1) that night before he had left the facility unattended. (R1) did not have a monitoring schedule prior to 5-26-23. I started 15-minute checks the night of 5-26-23. (R1) is unsafe to leave the building unattended. (R1) had poor safety awareness and has Dementia. On 6-1-23 at 8:45 AM R1 was walking the North-West hallway independently. R1 was confused to time and place when asked and stated, I did not do it when asked if he had gone outside without staff. On 6-1-23 at 12:00 PM this surveyor viewed the streets and church where R1 was found on 5-26-23. The facility's front parking lot exits onto a high traffic road. The sidewalk across from the facility is located parallel to the high traffic road and wraps around to the east to an additional high traffic road. The church (R1) was found in front of is located approximately 400 feet from the facility. These two roads have a high level of traffic due to having a central school located on these roads and multiple businesses. The Immediate Jeopardy started on May 26, 2023, when the facility failed to provide R1 with adequate supervision, failed to answer door alarms timely, and failed to develop and implement elopement interventions which resulted in R1 being found outside of the facility, unattended by staff, wandering aimlessly and confused, across a street with a high activity of traffic. V1 (Administrator) and V3 (Assistant Director of Nursing) were notified of the Immediate Jeopardy on 6-1-23 at 1:10 PM. On 6-5-23 the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. R1 and all other residents at risk for elopement were assessed for elopement risks and care plans were updated on 6-1-23 by V12 (Social Service Director) to include R1's monitoring schedule of 15-minute visual checks. 2. A report and investigation of R1's elopement has been sent to IDPH (Illinois Department of Public Health). 3. All door alarms were tested by V14 (Maintenance Director) on 6-1-23 and daily. 4. All staff were re-educated on the door alarm policy, elopement policy, and the resident's elopement binder locations by V3 (ADON) on 6-1-23 and electronically via the company's website.

Based on record review and interview the facility failed to properly prepare and administer medications to prevent a significant medication error for one resident (R3) and failed to prepare medications properly for three residents (R5, R6, and R8) of four residents reviewed for medication administration in a total sample of four. These failures resulted in R3 receiving the wrong medication and being hospitalized for low blood pressure and cardiac monitoring. These failures resulted in an immediate Jeopardy. While the immediacy was removed on 4/26/23. The facility remains out of compliance at severity level 2 while the Facility continues to educate the nursing staff on proper medication preparation and administration and conduct audits to ensure continued compliance. Findings Include: The Facility's Medication Administration Policy dated February 2014 documents Setting up of doses for more than one (1) scheduled administration is not permitted. The policy documents Residents will be positively identified prior to medication administration and shall not be left alone until the medication is consumed or refused. Policy also documents Medications errors, drug side effects and adverse drug reactions, including overdoses or poisoning, will be immediately reported to the attending physician, Director of Nursing, and pharmacist. The error or clinical symptoms will be documented in the clinical record and on the facility designated form. The Facility's Medication Error Investigation Summary dated 4/20/2023 documents Nurse reported to nurse supervisor of administering wrong medication to (R3). V9 (LPN) statement on 4/19/23: I grabbed the wrong cup of medications and administered the Seroquel and Trazodone to (R3). On 4/25/23 at 12:30 PM V3 (LPN/Acting Director of Nursing) stated that on 4/19/23 around 6:30 PM R3 received all of R4's 4PM and 8PM scheduled medications to include: Atorvastatin Calcium 80 mg (milligrams), Docusate Sodium 200 mg, Quetiapine 625 mg, Trazadone 150 mg, Eliquis 5 mg, Lactobacillus 1 capsule, Sennosides Tablet 8.6 mg, Topamax 100 mg and Gabapentin 300 mg. V3 stated, (V9) had pulled (R4)'s medication up and labeled the cup and gave them to (R3) by mistake. V3 stated, Medications should not be prepared and left in the top of the cart for administration later. R3's Progress Notes dated 4/19/23 at 6:55 PM documents, gave wrong medication, very tired, low bp (blood pressure) 72/44, did vitals called 911 notified md (Medical doctor) and called son but there was no answer sent to (emergency room ) for evaluation. Resident was responsive and answering questions. R3's emergency room Record dated 4/19/23 at 8:00 PM, Poison Control initial note: Case # 5175395. Goals for labs: Mag 2, Potassium 4, Calcium 9. Combination of meds will cause hypotension (low blood pressure), drowsiness and lethargy. Titrate (Norepinephrine/blood pressure maintenance support) as needed. Repeat EKG (electrocardiogram/cardiac monitoring) in 6 hours. R3's emergency room Record documents admit to hospital due to hypotension due to drugs, accidental medication error. On 4/25/23 at 11:00 AM V14 (Nurse Practitioner) stated, That (medication error on 4/19/23) was definitely a significant medication error, R3 is in the hospital receiving treatment for low blood pressure directly related to the error. R3's Medical Record documented she was hospitalized from 4/19/23 until 4/26/23 for treatment of low blood pressure. On 4/26/23 at 10:45 AM V15 (Pharmacist) stated that R3 receiving R4's 4:00 PM and 8:00 PM medications on 4/19/23, certainly qualifies as significant. On 4/25/23 at 12:50 V10 (RN) had a medication cup with R5's name on it and a pill inside of it in the top drawer of her medication cart. V10 stated, That is (R5)'s Buspar. There was another empty cup with R7's name on it with Zoloft written on it. V10 stated that was to remind her to administer R7's medications. There was a medication cup with a small amount of crushed up pill noted in it with R6's name on it. V10 stated the crushed-up medication was R6's Eliquis. On 4/25/23 at 1:00 PM V11 (LPN) had a medication cup with R8's name on it and a pill inside of it in the top drawer of her medication cart. V11 stated, That is (R8)'s Gabapentin. The immediate Jeopardy began on 4/9/23 at 5:45 PM when V9 administered the wrong pre-prepared medications to R3. V1 (Administrator) was notified of the Immediate Jeopardy on 4/27/23 at 12:48 PM. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. R3's medical record confirms R3 was sent immediately to the emergency room for treatment of low blood pressure and remained in the hospital until 4/26/23. 2. On 4/19/23 the V2 (DON/Director of Nursing) immediately in-serviced the nurse involved in the medication error on proper medication pass procedures. 3. On 4/20/23 V3 (LPN/Acting Director of Nursing) completed all nursing staff training on proper med pass procedures and to never open medications prior to administering to residents. A whole house nursing staff training was repeated on 4/25/23 and 4/26/23 and all nursing staff reviewed proper procedure instructions and signed off. Anyone not signed off will review and signoff on training prior to their next scheduled shift. 4. On 4/25/23 an audit of all med carts to ensure no other medications were opened in advance of administering to residents was completed by V3 and continued 4/26/23. 5. DON or Designee will audit all med carts, 5 days a week, for 4 weeks to make sure no pills are opened in advance of administering to residents. 6. The facility will audit medication carts at least quarterly X 1 year to ensure that corrections are achieved. 7. On 4/25/23 V9 (LPN) confirmed that she had gotten immediate education on how to properly dispense medications. 8. On 4/27/23 V4 (LPN) V9 (LPN), V10 (RN), V11 (LPN), V12 (RN) and V13 (RN) confirmed they had received education and multiple trainings on proper medication preparation and administration procedures since 4/20/23. 9. On 4/27/23 V3 stated that she will be auditing all medication carts daily five times a week for 4 weeks to check for pre-prepared medications. Then the audits will be done at least quarterly for a year. 10. On 4/27/23 Medication Cart Audit completed by V3 (LPN) was reviewed with no concerns. 11. On 4/27/23 Education on Proper Medication Administration dated 4/25/23 and 4/26/23 sign in sheets and course material reviewed with no concerns.

Based on interview and record review the facility failed to provide behavioral health services as indicated in the Facility Assessment as a service offered to meet the needs of residents with mental health concerns for one of three residents (R1) reviewed for Behavioral Health Services in a sample of six. This failure resulted in R1 requiring hospitalization for behaviors and being issued an involuntary discharge order by the facility. Findings include: A Facility assessment dated [DATE] documents the facility can provide care for residents with psychiatric/ mood disorders including residents with impaired cognition, mental disorders, Depression, Anxiety disorders, behavior that needs attention, Alzheimer's disease, and non-Alzheimer's Dementia. This Facility Assessment states it can, Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, and can identify and implement interventions to help support individuals with issues such as dealing with Anxiety, care of someone with cognitive impairment, Depression or other psychiatric diagnoses. In addition, the Facility Assessment documents the facility will provide needed support staff to manage these patient types including Behavioral and Mental Health providers and Psychiatric Services. R1's electronic medical record documents R1 has current diagnoses which includes Dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, Schizophrenia, Cognitive Communication Deficit, Encephalopathy. R1's progress notes document R1 had progressively worsening behaviors from the time of R1's admission on 11/29/22 until R1's involuntary emergency discharge to the hospital for behavioral issues on 2/26/23. R1's progress notes document that R1's behaviors indicated R1 was actively exit seeking, physically and verbally aggressive with other residents and staff, refused cares and medications. R1's progress notes dated 2/23/23 and signed by V3 (Assistant Director of Nurses/ADON) document that R1, is a safety risk to her peers AEB (As evidenced by) multiple attempts of physical aggression towards peers, wandering aimlessly into peers' rooms becoming agitated with peers when asked to exit and becoming physically aggressive with peers. (R1) is an active elopement risk putting self at potential risk of harm to self when exiting out exit doors. Action: Involuntary Discharge issued to (R1) due to facility is not the proper placement and R1 needs a more suitable psychiatric facility. Response: MD (physician) in agreeance for safety of peers and resident, IVD (Involuntary Discharge) orders processed at this time for alternative placement of (R1). R1's progress notes do not indicate R1 was emergently discharged to the hospital on that date (2/23/23) nor do these progress notes document the specific needs R1 has that can be met at another facility that cannot be met at this facility. R1's progress notes dated 2/26/23 at 1:11a.m. document R1 was alert and oriented and do not include documentation that R1 had any untoward behaviors or posed a danger to herself or others on that date (2/26/23). R1's nursing documentation does not show any other nursing or physician's progress notes entered for 2/26/23. R1's progress notes dated 2/27/23 document R1 was in the hospital. None of R1's progress notes document R1 was offered the services of behavioral health providers or Psychiatric Services as stated in the Facility Assessment. R1's emergency room physician's progress note dated 2/26/23 documents R1 was admitted to the hospital because of acute exacerbation of chronic Schizophrenia. R1's hospital case management records document the facility has refused to take R1 back once R1 is ready for discharge. The hospital records document as of 3/8/23, R1 was still in the hospital with no long term care placement available at that time. R1's behavior tracking dated 12/22, 1/23, and 2/23 documents R1 was being monitored for behaviors including refusal of medications, refusal of treatments, restlessness, and agitation. On 3/7/23 at 10:26 a.m., V5 (Social Services Director) stated she manages residents' behaviors in the facility. V5 stated R1 had the behaviors of exit seeking, physical and verbal aggression toward staff and other residents, refusal of cares and treatments. V5 stated she had developed and asked staff to implement many interventions to prevent or reduce R1's behavior problems. V5 stated she had several meetings with V9 (R1's Power of Attorney/POA) to try to figure out how the facility could help curb R1's behaviors. V5 stated the facility has a behavioral health nurse practitioner who was supposed to evaluate R1 for the first time on 2/2/23 and provide recommendations and treatments for R1's behaviors related to R1's dementia and Schizophrenia. V5 stated she does not know what recommendations the specialist made because she cannot find any progress notes from that evaluation. V5 stated if the behavioral health practitioner had written orders or recommendations, they would have been listed in their progress note from the visit with R1. V5 proceeded to review R1's physician's orders and a file where all the behavioral health specialist keeps their progress notes for residents they have evaluated but could not locate any such notes documenting that R1 had been seen. V5 stated she thought another long-term care facility that offers mental health services would be more appropriate for R1's mental health and behavioral needs. On 3/8/23 at 9:28 a.m. V8 (R1's physician) stated R1 had behavioral problems related to dementia and Schizophrenia. V8 stated the facility sought out behavioral health services by sending R1 to the emergency room to calm R1 down for one to two days. V8 stated he did not personally evaluate R1 or document any progress notes pertaining to the need for R1's involuntary discharge or the facility's inability to meet R1's behavioral needs but, instead, I rely on what the nurses tell me, and I go off what the nurses tell me. On 2/7/23 at 9:50 a.m., 2:50 p.m.; and on 3/8/23 at 10:00 a.m., 1:20 p.m., and 2:15 p.m., V3 stated V3 evaluated R1 prior to admission to ensure the facility could meet R1's needs as a resident in the facility. V3 stated V3 determined R1 was appropriate for admission. V3 stated R1 did have the diagnoses of Dementia with behaviors and Schizophrenia at the time and V3 determined the facility could meet R1's needs. V3 stated that while R1 was a resident, R1 had multiple instances of aggressive behaviors, wandering, attempts to elope, and refusing care. V3 stated R1 was sent to the hospital several times for behavioral issues. V3 stated the facility decided it could not meet R1's needs and decided for the safety of other residents, R1 needed an involuntary discharge. V3 stated the facility tried to refer R1 for admission to other long term care facilities, including ones that specialize in caring for residents with behaviors, but R1 was not accepted. V3 stated the facility decided to issue R1 an involuntary discharge order as of 2/24/23. V3 stated R1 ended up being emergently transferred to the hospital for more behaviors on 2/26/23 before the 30-day involuntary discharge could take place. V3 stated the facility is not going to allow R1 to readmit once her treatment is complete at the hospital. V3 stated the facility does not offer the mental health services that R1 needs. V3 stated R1 needs to be transferred to a facility that can offer enough staff to monitor R1 more frequently and offer more specialized mental health care. V3 verified the facility does offer a Behavioral Health practitioner who comes to the facility on ce per month. However, R1 was never provided services from that behavioral health specialist. V3 stated V9 (R1's Power of Attorney) had not yet signed a consent form for R1's referral to the behavioral health specialist. V3 stated it may not have mattered that R1 was not evaluated because the behavioral health practitioner won't write phone orders or make recommendations unless she is already in the facility evaluating a resident.

Based on observation, interview and record review, the facility failed to ensure a resident with a known diagnosis of Dementia with Behavioral disturbances and Schizophrenia was adequately supervised by staff to prevent multiple resident to resident physical and mental abuse occurrences, for three of three residents (R1, R4, R5) reviewed for abuse in a sample of six. This failure resulted in R4 experiencing pain and fear related to the abuse and R5 receiving a laceration and bruise to the forearm. Findings include: The facility's Abuse Prevention Program policy, dated 11/22/17, documents, Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This same policy also documents, Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment. Mental Abuse is also the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. 1. R1's current care plan, dated 2/7/23, documents, (R1) has a diagnosis of schizophrenia and dementia with behaviors. She is alert with much confusion, poor safety awareness, and poor reasoning skills. (R1) can be paranoid and delusional at times. She is able to verbally express needs and wants. She can often become very agitated and resistive to cares and medications. She will sometimes curse at residents and others around her. She will sometimes wander toward exit doors and will sometimes attempt to leave facility through exit doors unsupervised. She is not always easily redirected. The facility's Incident Report Form, dated 2/10/23, documents that on 2/10/23, (R1) came into the dining room for lunch She went to one of the tables that she normally would not sit at. (R4) confronted (R1) verbally about being at the wrong table and that upset (R1) whom then stuck (R4) in the chest. This same report documents on 2/10/23, V11 (Certified Nursing Assistant, CNA) stated, I saw (R1) roll up to the table in the dining room where (R4) was sitting. (R1) tried to sit at the table with (R4) and (R4) told her it was not her table. (R1) usually sits at another table in the dining room. (R1) got mad and hit (R4) on the right breast. (After being separated) (R1) continued to try to claw and scream at (R4). The facility's Incident Report Form, dated 2/19/23, documents that on 2/19/23 at 10:00 AM, (R1) went into (R4's) room grabbing items that were not hers. When (R4) asked (R1) not to touch the items (R1) got agitated and was cursing at (R4) and struck (R4) on the left shoulder. On 2/28/23 at 11:15 AM, V9 (Certified Nursing Assistant) confirmed witnessing R1 and R4's incident on 2/19/23. V9 stated, I heard someone yell 'get out of here.' I went in the room and (R1) was holding pajamas and she gave them to me. (R1) was already yelling at (R4) saying nonsense and cuss words. I had (R4) step outside the door with her cane and as I was taking (R1) out, she (R1) hit (R4). If another resident tries to correct (R1) or tell her she's in the wrong, she wants to get aggressive with them. (R1) will hit or get them closer. When an incident happens like that it just makes (R1) very angry and she hits them and starts yelling. On 2/28/23 at 12:50 PM, R4 was lying in her bed in her room. R4 confirmed she has had incidents where she's been struck by R1. R4 stated, (R1) used to come into my room all the time. She'd take things out of here. (R1) has hit me on my right breast where I have had cancer. She also hit me on my shoulder on a different day. I was getting very leery of (R1). She made me feel afraid because she was getting scary. It hurt when she hit me. She is a strong woman. It sure did hurt. I am not sad that (R1) is gone (discharged ). 2. R1's Nursing Progress notes, dated 2/17/23 at 6:49 PM, documents, (R1) was in the dining room in her wheelchair and another resident (R5) with a walker, walked by and was grabbed by the right arm. (R1) began arguing and fighting with (R5). (R1) continued to yell and try to get at the other residents. The facility's Incident Report Form, dated 2/17/23, documents, (R1) went to one of the tables that she would normally not sit at. (R5) confronted (R1) verbally about being at the wrong table and upset (R1) who then grabbed (R5's) arm. R5's Nursing Progress notes, dated 2/17/23 at 7:22 PM, documents, This nurse (V8, Registered Nurse) was made aware that there was an incident with (R5) another resident (R1) in the dining room. Went to assess (R5) and saw a discoloration/bruise to the right forearm. R5's Nursing Progress notes, dated 2/20/2023 at 12:55 PM, documents, Bruising noted to right forearm measuring 7.5 x 7.0 (centimeters), light red in color with two pin sized dark purple bruises in the center. This appears to be from an altercation that occurred on 2/17/23, monitoring orders processed. On 2/28/23 at 1:15 PM, V10 (Registered Nurse) stated, I was doing charting in the dining room to oversee things in there. I looked up and there was a confrontation. I didn't see it because I was charting but I heard aides and a resident yell. (R1) was in (R5's) spot and (R5) told her 'this is not your spot'. (R1) grabbed (R5's) arm. You couldn't understand (R1). She is very aggressive. (R1) is able to move about freely and be out fast. We try to keep track of her, but it is hard. On 2/28/23 at 1:30 PM, V8 (Registered Nurse) stated, I didn't see what happened in the dining room. The CNA's came and got me. (R1) had grabbed (R5's) arm and scratched it. (R5) had thin scratches on her arm which became larger and bruised after a day or two. On 2/28/23 at 1:50 PM, V3 (Assistant Director of Nursing) stated, (R1) has always had aggression, but it's escalated lately. We tried to keep her in closer proximity to staff. V3 confirmed there is not any documentation to show where R1 was being monitored or supervised by staff more frequently to prevent other residents from being abused.

Based on observation, interview and record review the facility failed to ensure exit doors were secure and the door alarm system was in working order, failed to properly assess residents at risk for elopement, failed to develop a care plan and implement interventions for residents at risk for wandering/elopement, failed to follow facility elopement policies, and failed to provide adequate supervision for three of three residents (R4, R8, R9) reviewed for elopement risk in the sample of nine. These failures resulted in cognitively impaired residents (R4, R8, and R9) who require extensive assistance with ADL's (Activities of Daily Living) exiting the facility without staff knowledge and being found on separate dates, wandering aimlessly, and confused, out in the west side of the building's parking lot approximately 50 feet from the exit doors. This parking lot is located next to a road that has high activity of traffic. R4 and R8 were found before dawn, in the dark, and the weather was chilly. R9 was found sitting on the end of a car bumper. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 1-25-23, the facility remains out of compliance at a severity Level II as the facility continues to audit all exit doors on a daily basis for six weeks and then weekly thereafter to make sure they are secure and that the alarms are present and in working order, audit all residents at risk for wandering on a weekly basis for six weeks and then quarterly thereafter, installs a new door alarm system, provides training to new staff on the elopement policy, and the quality assurance committee monitors the facility's performance to ensure that corrections are achieved. Findings include: The facility's Door Alarm Drill Policy dated 1-1-15 documents, It is the policy of this facility that the door alarm drill will function to assure exit doors are functioning properly and alert staff that a resident has left the building. It will also assure staff respond to door alarms immediately and follow the door alarm and elopement policy. The facility's Wandering Residents policy dated 08/2006 documents, Every effort will be made to prevent wandering episodes while maintaining the least restrictive environment for residents who are at risk for elopement. 1. All residents who are at risk for harm because of wandering (elopement) will be assessed. 2. The resident's care plan will be modified to indicate whether the resident is at risk for elopement episodes. Staff will be informed at shift change of the modification to the resident's care plan. 3. Interventions for elopement episodes will be entered onto the resident's care plan and medical record. 4. Should an elopement episode occur, the contributing factors, as well as the interventions tried, will be documented on the nurses' notes. 5. If a resident repeatedly wanders off the unit, a monitoring schedule will be implemented to ensure resident safety. The resident's care plan will be documented as to the implementation of the monitoring schedule. The facility's Elopement and Search Policy dated 02/2014 documents, Policy: To establish methods for protecting residents who are at risk for elopement and for conducting an organized search for a resident who cannot be located. 1. All nursing personnel are responsible for: a. Knowing the whereabouts of residents for which they are assigned. b. Department supervisors are responsible for conducting resident rounds. c. Staff are responsible for keeping the nurse informed of a resident's whereabouts. 3. Residents are not permitted to leave the building alone unless a physician order is present. 5. Residents who have been identified as cognitively impaired and who have been assessed as an elopement risk will be provided with an elopement prevention device or be placed in an area of the facility that has a door alarm device with audible sound, or on a secured/locked unit. 6. Facility exit door alarms are checked daily for function. All personnel are responsible for promptly reporting/replacing malfunctioning elopement prevention devices. Maintenance is responsible for fixing/replacing any exit doors that do not alarm. 8. When a resident makes repeated/continuous attempted to leave the building, the resident will be visibly observed every fifteen (minutes) until the behavior is resolved. 10. When the resident is found (after elopement) a licensed nurse will: a. Announce Code Pink All Clear over the paging system. b. Perform a clinical assessment of the resident's skin and functional status and determine if the resident requires medical interventions. g. Complete the appropriate observations/forms. h. Initiate/update the care plan to include interventions to prevent reoccurrence. 11. The Administrator/designee is responsible for notifying the State Department of Public Health and any other appropriate local authorities (Adult Protective Services, Ombudsman) of the occurrence when applicable according to state and federal requirements. 13. Appropriate security measures will be implemented to assure the resident is monitored to prevent reoccurrence. 14. All facility staff will be informed of residents at elopement risk. The facility's Doors, Locks, and Alarms Test Operation of Doors Logbook dated 11-1-22 through 1-24-23 documents the doors and alarms are only being checked once weekly instead of daily as required by the facility's Elopement and Search policy. On 1-24-23 from 8:40 AM through 9:15 AM tour was done at the facility. The North-West hallway activity exit door had a Velcro stop sign attached across and had a sign posted on the door stating, If you are caught turning off door alarms without (V1's/Administrator's) approval you will be subject to termination. Residents have been getting out of the facility because alarms have been shut off. The North Nurse's Station had a binder labeled Elopement Book. This Elopement Book contained pictures and identifying information for all residents at risk for elopement within the facility. This book did not contain pictures or identifying information of R4, R8, and R9. 1. On 1-24-23 at 10:15 AM R4 was standing up and walking around his room without assistance of staff. R4's wheelchair was located next to R4's bed. R4 was confused to person, place, and time. On 1-24-23 at 10:05 AM V17 (RN/Registered Nurse) stated, (R4) has always been disorientated and tries to open doors and leave. (R4) needs re-direction. On 11-26-22 sometime before 5:00 AM I had left the facility to go to the gas station. When I came back, I found (R4) walking out in the North-West employee parking lot. (R4) was confused. (R4) was walking without his wheelchair and had gone out of the end North-West activity door. It was chilly out and (R4) did not have a coat or shoes on. (R4) had on a t-shirt, sweatpants, and socks. (R4) was cold. I have no idea how long (R4) was in the parking lot. I brought (R4) back into the facility and notified the on-call supervisor (V19/LPN/Licensed Practical Nurse). I asked (V19) what I should do. (V19) said she would talk to (V3/Assistant Director of Nursing) and let me know. I never heard anything back from (V19) or (V3). I did not document the incident. I am not sure if any interventions were implemented to increase (R4's) supervision. I know (R4) was supervised every 15 minutes for around 24 hours, but no other interventions were implemented after that. No door alarms were alarming at the panel at the nurses' desk. The alarms did not work when (R4) went outside. I do not know how long (R4) was outside. (R4) needs staff assistance when walking. I am not aware of the facility having an elopement book with residents at risk of elopement. R4's current Electronic Diagnoses Listing documents R4 has diagnoses of Non-Traumatic Intracerebral Hemorrhage, Alcohol Abuse with Intoxication, Alcohol Dependence, Cognitive Communication Deficit, and Unsteadiness on Feet. R4's MDS (Minimum Data Set) assessment dated [DATE] and Care Plan dated 10-17-22 documents R4 is severely cognitively intact, has inattention and disorganized thinking, is totally dependent on staff for transfers, and requires extensive assistance of staff for locomotion on and off the unit. This same MDS documents R4 uses a wheelchair for locomotion. R4's Elopement Evaluation dated 1-2-23 documents, Does the resident have a history of elopement or attempted leaving the facility without informing staff? No. Does the resident wander? Yes. Is the wandering behavior a pattern, or goal-directed? No. Does the resident wander aimlessly or non-goal directed? Yes. R4's current Care Plan does not include a plan of care with interventions to address R4's wandering and elopement. R4's Electronic Medical Record dated 11-1-22 through 1-24-23 does not include any documentation, nurse assessment, or investigation regarding R4's elopement on 11-26-22. On 1-24-23 at 10:00 AM V10 (Registered Nurse/RN) stated, (R4) tries to open exit doors frequently. We (facility staff) cannot always hear the alarm going off at the nurses' station when we are at the end of the hallways. The alarms do not alarm at the doors, only at the nurses' station. On 1-24-23 at 12:35 PM V3 (Assistant Director of Nursing) stated, (R4's) record has no documentation about (R4) being found out in the parking lot unattended on (11-26-22) and (R4) has not had care plan developed or implemented regarding (R4's) elopement/wandering. There is no documentation of (R4's) family being notified of the incident. (R4's) incident has not been investigated. On 1-24-23 at 12:40 PM V22 (CNA/Certified Nursing Assistant) stated, (R4) wanders constantly and tries to get to the doors and leave. We try to re-direct him. 2. On 1-23-23 at 4:35 PM V15 (RN/Registered Nurse) stated, I was working on 1-7-23 the Northeast hallway. (R8) was found outside unattended in the employee parking lot by the garbage cans (approximately 50 feet from the exit door) around 5:00 in the morning. (R8) had gone out of the activity room door to the outside. I do not know how long (R8) was outside. The door alarm did not work at the door or at the panel by the nurses' station. (R8) tries to leave the facility all of the time. (R8) goes up to the exit doors and tries to push them open. I called the on-call supervisor (V19/LPN/Licensed Practical Nurse) and informed her that (R8) was found outside, and the door alarm did not work. I was not (R8's) nurse that day. I am not sure who was the nurse. (V14/Activity Assistant) was called in to check the doors. (V14) told me that the door alarm was working. (V18/Maintenance Director) has been told numerous times that the door alarms do not work correctly and do not alarm at the panel like they should. Nothing is ever done about it. I know (R4) has gotten out of that same door unattended before and was found in the parking lot. I do not know if the facility has an elopement book. R8's current Electronic Diagnoses Listing documents R8 has diagnoses of Drug Induced Subacute Dyskinesia, Schizophrenia, Mental Disorder, Difficulty in Walking, Muscle Weakness, Cognitive Communication Deficit, Dementia, Unspecified Severity, with other behavioral disturbance, Restlessness, and Agitation. R8's MDS assessment dated [DATE] and current Care Plan documents R8 is severely cognitively impaired, has disorganized thinking, and requires extensive assistance of staff for transfers and walking, and limited assistance of staff for locomotion. R8's current Care Plan does not include a plan of care with interventions to address R8's wandering and elopement. R8's Electronic Medical Record dated 1-1-23 through 1-24-23 does not include any documentation, nurse assessment, or investigation regarding R8's elopement on 1-7-23. On 1-23-23 at 4:10 PM V13 (Activity Director) stated, (R8) comes to the activity exit door and tries to push it open. I was told that (R8) got out into the parking lot without staff knowing. I am not sure what date that was. On 1-24-23 at 9:00 AM V20 (R8's Family Member) stated, I came in the facility on 1-8-23 and was told by the staff that (R8) had gotten out of the building unattended on Saturday (1-7-23). I am concerned that they facility is not watching (R8) close enough and (R8) will get lost. (R8) is very confused and cannot be outside. I called the Administrator (V1) on Monday (1-9-23) and told him about my concerns with (R8) getting out of the building and not being watched closely. On 1-24-23 at 10:32 AM V1 (Administrator) stated, (V20/R8's Family Member) called me on Monday (1-9-23) and reported that she was upset because (R8) had been found outside unattended and nobody had notified her. I brought (R8's) incident to morning meeting the next day to be investigated by the nurse managers. I am not sure if anyone investigated the incident (R8's elopement). I know the investigation was never reported to IDPH (Illinois Department of Public Health). On 1-24-23 at 11:25 AM V3 (Assistant Director of Nursing) stated, I was not aware that (R8) had gotten out of the facility unattended (1-7-23). No one had reported that to me. (R8's) record has no documentation about the incident and (R8) has not had an elopement risk assessment done or a care plan developed or implemented regarding (R8's) high risk of elopement/wandering. There has been no investigation completed. (R8's) family was not notified of the incident according to (R8's) medical record. The elopement book should contain all residents at risk for elopement and is located at the nurses' stations, and social service office. The elopement book has not been updated for a long time. (R4, R8, R9) information and pictures are not in the elopement book and should be. The Social Service Director (V21) is responsible to keep the elopement book updated. On 1-24-23 at 12:12 PM V19 (LPN) stated, (V15/RN) called me around 4:56 AM on 1-7-23 and reported that the staff had found (R8) outside in the employee parking lot, unattended by staff. (V15) reported to me that the door alarm did not alarm at the panel, so the staff did not know (R8) had sent outside. I told (V15) to notify (R8's) family, the physician, and (V2/Director of Nursing), and to perform an assessment of (R8). I also reported the incident in the morning meeting on Monday (1-9-23). I contacted (V18/Maintenance Director) and let him know the door alarms were not working and needed looked at. On 1-24-23 at 11:05 AM V14 (Activity Director) stated, I was called on 1-7-23 to go in and check the Northwest Activity Exit door alarm to make sure it was working because (R8) had gotten out of that door and staff found her in the parking lot. When I went in the door alarm was working. The day before I was working in activities and took Christmas supplies out to the shed. I turned the toggle on the door off so the alarm would not sound when I opened that door. I guess I am not supposed to use that door. I believe on Monday (1-9-23) V18 (Maintenance Director) zip tied the box so that the toggle switch could no longer be turned off. 3. On 1-24-23 between 9:45 AM and 10:30 AM R9 was wandering aimlessly in her wheelchair up and down the north hallways. On 1-24-23 at 1:10 PM V7 (Wound Nurse) stated, On 1-10-23 around 7:00 AM I was arriving to work and saw dietary staff talking about an old lady sitting on the end of a bumper of a blue car and was not sure who it was. I went to talk to the lady and noticed it was one of our residents (R9) sitting on a bumper of a car. (R9) stated, I am not going back. I want to go home. (R9) did not have her wheelchair with her and was cold. I then went and got a wheelchair and had the CNA's take her back to the floor. On 1-24-23 at 1:20 PM this surveyor and V7 viewed the west side parking lot that (R9) was found in on 1-10-23, (R4) was found in on 11-22-22, and (R8) was found in on 1-7-23. The parking lot exits onto Newcastle Road, Washington Illinois. This road has a high level of traffic with a central school and multiple businesses located on this road. V7 confirmed that R9 was found sitting on a bumper of a car approximately 50 feet from the exit doors in this parking lot. R9's Investigation Report dated 1-10-23 and unsigned documents, (R9) states that she was leaving and going home. (V17/RN) states that she took (R9) back to the Northwest desk (earlier that morning) and informed (V23/RN) that (R9) was attempting to go out the door on maintenance hall. (V23) was unaware of situation when questioned but is increasing monitoring at this time. Summary: (R9) was observed sitting on a bumper outside in the parking lot. (R9's) wheelchair was observed sitting in maintenance hallway. Maintenance cage door was unlocked which goes out into back parking lot. R9's current Electronic Diagnoses Listing documents R9 has diagnoses of Altered Mental Status, Chronic Respiratory Failure with Hypoxia, Cognitive Communication Deficit, and Unsteadiness on Feet. R9's MDS assessment dated [DATE] documents R9 requires extensive assistance of staff for transfers, walking, and locomotion off the unit. R9's Care Plan dated 1-20-23 documents R9 is at risk for falls due to confusion, deconditioning, gait/balance problems, incontinence, impaired mobility, and being unaware of safety needs. R9's Care Plan dated 4-14-22 through 1-9-23 did not include a plan of care to address R9's wandering behavior. R9's Elopement Evaluation dated 1-10-23 documents, Does the resident have a history of elopement or attempted leaving the facility without informing staff? No. Is the resident's wandering behavior likely to affect the safety or well-being of self/others? Yes. On 1-23-23 at 4:35 PM V15 (RN/Registered Nurse) stated, (R9) wanders in her wheelchair around all hallways. On 1-24-23 at 10:05 AM V17 (RN) stated, I know a few weeks ago (R9) was found outside in the parking lot. (R9) had went out of the door of the service hallway which is in the middle of the building between the North and South hallways. (R9) has always wandered and states she wants to go home. (R9) gets confused and would not be safe outside unattended by staff. On 1-24-23 at 1:30 PM V3 (Assistant Director of Nursing) stated, (R9) was found in the parking lot on 1-10-23. It was determined that (R9) had exited out of the middle service hallway, out of the maintenance cage (maintenance supply room) exterior door. Someone had left the cage door unlocked and (R9) was able to leave out of the exterior door. That door has no alarm on it, so staff were unaware of (R9) getting out of the facility. (R9) did not have a care plan developed for wandering or elopement risk prior to her exiting the building on 1-10-23. (R9's) Elopement Evaluation dated 1-10-23 is inaccurate and should have been coded as Yes to the question asking if (R9) has a history of elopement or attempted leaving the facility without informing staff. On 1-24-23 at 11:15 AM V18 (Maintenance Director) stated, I got a call from (V15/RN) on 1-7-23 early in the morning that (R8) was outside, and the door alarm did not work. I went in to check the alarm and (V14) said the alarm was working. The North hallway exit doors do not have alarms on the doors. When these doors are opened, they alarm at the nurses' station alarm panel (located in the center of the Northwest and Northeast hallways). There is a toggle switch on the doors that employees can use to turn off the alarms at the nurses' panel. Staff should never turn that toggle switch off. After the incident with (R8) I zip tied the toggle switch compartment shut so employees could no longer turn the alarm off. Employees are not supposed to use the end of the hallway exit doors. There are times the panel alarms for no reason. If it is really cold outside the door alarms malfunction at the panel. I have not called any alarm company in to check these door alarms for malfunctioning. I check the door alarms weekly. When (R9) got outside (1-10-23) and was found in the parking lot my cage (maintenance supply door) was unlocked. Dietary staff were trying to open the hallway door for a delivery and could not get in the hallway door, so they used a key and unlocked the maintenance room door. The dietary staff did not make sure the door was locked after they used it. When that door is left unlocked the residents can get out of the facility through the cage and out of the exterior door. The exterior door off of the maintenance room is not alarmed. On 1-24-23 at 1:38 PM V21 (Social Service Director/SSD) stated, I did not know I was in charge of updating the elopement book with information and pictures of residents at risk for elopement. I have not been updating the book. The Immediate Jeopardy started on November 26, 2022, when the facility failed to provide R4 with adequate supervision and implement elopement interventions which resulted in R4 being found outside of the facility, unattended by staff, and R4 was cold and did not have a coat or shoes on. V1 (Administrator), V3 (Assistant Director of Nursing), and V25 (Director of Operations) were notified of the Immediate Jeopardy on 1-25-23 at 12:05 PM. On 1-26-23 the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 1-24-23 V21 (SSD) completed an updated Elopement Risk Assessment for R4, R8, and R9. 2. On 1-24-23 V28 (MDS Coordinator) developed an elopement care plan with interventions for R4, R8, and R9's. 3. On 1-24-23 (V1/Administrator) sent an initial report to IDPH (Illinois Department of Public Health) to investigate R4, R8, and R9's elopement and an investigation of these elopement was started. 4. On 1-25-23 a whole house review of elopement assessments was done and updated by V28 and V7 (Wound Nurse). 5. On 1-24-23 V18 (Maintenance Director) installed new battery-operated door alarms on the Northwest door, Northeast door, and Maintenance door to ensure staff could hear the door alarming at the location of the doors as well as at the nurses' station. 6. On 1-24-23 V1 ordered a new alarm system to put at the doors with a keypad to silence the alarms was ordered on 1.24.23 and should reach the facility by next week. 7. On 1-24-23 and 1-25-23 V18 in-serviced all staff on the proper function of door alarms. 8. On 1-24-23 on first shift, and 1-25-23 on second and third shift V18 held elopement drills with all staff. 9. On 1-24-23 and 1-25-23 V3 (ADON) re-educated all staff on the facility's alarm policy and the elopement Policy. This education included information that residents do not have to leave the property to be considered an elopement. A second education was provided electronically on 1-24-23 and 1-25-23 via the company website for all staff to log in and complete training. 10. On 1-25-23 V2 re-educated all nurses on proper documentation when a resident gets outside the building and notifying the power of attorney, doctor, and administration when a resident gets outside of the building. 11. V18 Maintenance Director/Designee will audit all exit doors on a daily basis for 6 weeks to make sure they are secure and that the alarms are present and in working order. After 6 weeks, he will do this on a weekly basis. An audit will be turned in to Administrator at the end of each week. 12. V3 ADON/Designee will audit all residents at risk for wandering on a weekly basis for 6 weeks to be sure that their Elopement Assessment and Care Plan are up-to-date with accurate information and interventions in place. After 6 weeks, they will be audited on a quarterly basis. The Quality Assurance Committee will monitor the facility's performance to ensure that corrections are achieved. Completion Date: 1-25-23.

Based on observation, interview, and record review, the facility failed to ensure safe resident transfers for three residents (R1, R4, and R5) of six residents reviewed for falls and transfers in a sample of six. These failures caused R1 to sustain a left [CONDITION(S)] and pain, and R4 and R5 to sustain lacerations requiring sutures. Findings include: The facility's policy Falls and Fall Risk, Managing, revised August 2008, documents Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. 1. On 6-3-22, at 9:24am, R1 was in bed. R1 stated the following: The girl (V6 Certified Nursing Assistant/CNA) was trying to fix my chair. I was trying to put my other hand on the walker and lost my balance. (V6) was adjusting the foot rest so it would stay up. I was getting out of the chair so they could work on it. (V6) couldn't catch me because (V6) had her back to me. R1's Progress Note, dated 5-22-22, at 7:23pm, V3 Registered Nurse/RN writes: Staff (V6 CNA) reported observing resident during a fall in room. R1's Minimum Data Set/MDS assessment, dated 5-9-22, documents R1 as cognitively intact and requires one person physical assist for transfers and walking in the room. R1's MDS assessment also documents R1's balance during transitions and walking as not steady, only able to stabilize with staff assistance for moving from seated to standing position, for walking (with assistive device if used), for turning around and facing the opposite direction while walking, and for surface-to-surface transfers (transfer between bed and chair or wheelchair). On 6-3-22, at 11:40am, V6 CNA stated what occurred on 5-22-22: (R1) pressed the call light. I went in and (R1) was already standing up. (R1) was all upset because her recliner wasn't swiveling. (R1) was standing up at her walker. I was talking to (R1) and said let's sit down. I'll try to fix it .(R1) started back pedaling and shuffling backwards and started to lose (R1's) balance. I tried to catch (R1), but it happened too fast .Supervision with limited assist is what (R1) is supposed to be, but sometimes (R1) does it by herself. Supervision means to be with (R1) and help her. (R1) can do a lot by herself .My intention was to sit her on the bed and then fix the chair. On 6-3-22, at 1:30pm, V9 Certified Occupational Therapy Assistant/COTA assisted R1 to stand at the bedside three times with rest periods in between. R1 rubbed R1's left hip surgical area and stated, it hurts. At this time, conversation between R1 and V9 included R1 stating They thought that since I walk with a walker that I don't need help. But I did need help. V9 replied Yes, you need them to help you. R1's left hip X-ray report, dated 5-23-22, documents Left hip slightly impacted subcapital fracture of left femoral neck with no significant displacement. 2. The facility's Safe Lifting and Movement of Residents policy, revised August 2008, documents Policy Statement: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses mechanical lifting devices for the lifting and movement of residents. The facility's policy Lifting Machine, Using a Portable, revised August 2008, documents Purpose: The purpose of this procedure is to help lift residents using a manual lifting device. 1. Review the resident's care plan to assess for any special needs of the resident .3. To transfer a resident from a bed to a chair, you should .(m.) To position the resident comfortably in the chair, grasp the top of the sling with one hand and pull back on the sling while lowering the resident into the chair. (Note: You can also push gently on the resident's knees while lowering the resident into the chair). On 6-8-22, at 10:24am, R4 was in bed with dressings noted to bilateral forearms and left lower leg. At this time V20 and V21 Certified Nursing Assistants/CNAs transferred R4 from his bed to a wheelchair using a mechanical lift device. On 6-8-22, at 10:30am, R4 stated the following occurred on 5-27-22: Two girls were getting me up (with the mechanical lift). When letting me down into the wheelchair they had not unhooked the hooks yet. One CNA (V18) was operating the lift and the other CNA (V17) was behind me tried to straighten me up and the (mechanical lift) fell and tipped over the top of me. It hit my arms and caused my left leg to hit against the wheel chair. Both arms got skin tears and my leg injury required sutures at the hospital. A CNA said it was a malfunction of the (mechanical lift). R4's current care plan includes (R4) has impaired skin integrity to BLE (bilateral lower extremities) r/t (related to) multiple ruptured hematomas, date initiated 5-16-22. This focus has interventions/tasks including Ensure resident's legs are supported during transfers, date initiated 5-11-22. This same care plan also documents (R4) has a Transfer ADL (Activities of Daily Living) Self Care Performance Deficit r/t (related to) Limited ROM (Range of Motion). Goal: (R4) will transfer using safe technique to/from bed, wheelchair, with total x two assist with (mechanical lift) for safety by review date. Transfer: (R4) requires (mechanical lift) x two staff for transfers. R4's Progress Note, dated 5-27-22 at 11:45am by V25 Licensed Practical Nurse/LPN, documents: While transferring from bed to wheelchair with (mechanical lift), (R4) obtained skin tears on both forearms and on left leg. Left leg wound was bleeding profusely, and it was this nurse's opinion that resident be sent to ED (Emergency Department) for evaluation .Resident transferred to (hospital) via AMT (ambulance medical transportation). The facility's final report to State Agency for R4 documents On 5-27-22 at 11:45am (R4)sustained a laceration to left lower leg .Staff interviews noted that there were two CNAs and a (mechanical lift) was used to transfer (R4) to wheelchair .As (R4) was being lowered down into wheelchair, staff grabbed positioning straps on the (mechanical lift) to position (R4) in the wheelchair as that occurred the (mechanical lift) tipped towards (R4) when (R4) was right above the wheelchair, causing skin tears to right and left upper extremity and laceration to left posterior leg. R4's Minimum Data Set/MDS assessment, dated 5-11-22, documents R4 is cognitively intact, requires total dependence and two person physical assist, weighs 332 pounds and is six foot three inches in height. On 6-7-22, at 11:56am, V17 CNA stated the following occurred on 5-27-22: Therapy (V9 COTA/Certified Occupational Therapy Assistant) came in while we were getting (R4) up. Another agency CNA (V18) was there to help me. (V9) was just outside the room during the (mechanical lift) transfer. I said (R4) might need a bigger sling and (V9) said there were none. (V9) was standing behind me, (V18) maneuvered the (mechanical lift), and I was holding onto the sling by the handles so (R4) didn't twist or turn in the air. While up in the air you have to pull on the sling to position (R4) into the chair. While we did that the (mechanical lift) tipped over while (V18) was trying to lower and I'm trying to align (R4). It fell over (R4's) head and was on its front wheels only, the other two were off the floor. It gashed (R4's) leg, a big gash. They had to call 911. It was bad. And both (R4's) arms had skin tears too .Not sure why it tipped. It wasn't (R4's) weight, it was the old (mechanical lift). And (R4) needed a bigger sling. On 6-8-22, at 10:44am, V18 CNA stated the following: (On 5-27-22) I was in the process of transferring (R4) with another girl (V17 CNA) .We attached the (mechanical lift) and it made a funny noise but it seemed to be okay. It was making a clicking noise as we were lifting him off the bed as though it would break, but all was still okay. I was controlling the (mechanical lift) and (V17) had (R4) and was holding the sling. I extended the legs to the fullest and put it at the side of the wheelchair - one leg in front of the wheelchair and one through the middle. After making sure it was extended, we lowered (R4) into the wheelchair .The problem was with (R4's) weight. Once V17 CNA grabbed (R4's) weight by the sling, (R4) went properly into the wheelchair, but the mechanical lift fell on top of (R4) - tilted towards (R4) .It didn't make sense. The (mechanical lift) was extremely old .If not mistaken I don't think the legs were locked. I don't think it had locks and don't recall locking it or seeing a lock for it. The shifter handle didn't lock. The legs never moved and were fully extended .The sling provided in (R4's) chair is too skinny for (R4). (R4) needed a wider sling. Whatever snagged (R4's) leg gashed it really bad. On 6-7-22, at 1:53pm, V9 COTA (Certified Occupational Therapy Assistant) stated the following: (On 5-27-22) The CNAs were ready to get (R4) up and his chair was in the hallway so I put it in the doorway for them. I stepped out in the hallway and was observing. The back of the wheel chair was facing the doorway. They lifted (R4) up with the (mechanical lift) coming in on the side of (R4's) chair with one leg (of the lift) in between the front and back wheels and second leg (of the lift) out in front of the chair. (R4) was positioned over a reclining type of. One CNA (V17) was at the back of (R4's) chair and one (V18 CNA) was operating the (mechanical lift). Once (R4) was elevated and positioned over the chair the other CNA (V17) reclined the chair. (V17) took the handles at the sides of the sling and pulled him back to position (R4) to go down and that's when the (mechanical lift) tilted towards (R4) on its side and took (R4) into the chair - (R4) rapidly descended into the chair, cockeyed a little, and (R4's) legs were off center. On 6-9-22, at 10:33am V9 COTA confirmed that during (R4's) transfer on 5-27-22, V9 didn't see any CNA supporting (R4's) legs. V9 stated that V9 did not see (V18's) hands on (R4) during the lowering, only the (V17 CNA) who had her hands on the back of (R4's) sling to position (R4). On 6-7-22 at 1:36pm, V10 Scheduler produced the educational material (located at each Nurse's station) and stated it is regarding (mechanical lift) transfers and was used for the in-service held after (R4's) incident. These education material handouts titled How to Use a (Mechanical) Lift were located at each nursing station. Number 9 on page 4 documents Practice good lifting technique. The (mechanical) lift does most of the work for you, but you will still need to move the user in and out of the sling. You should follow safe lifting practices to minimize risk of injury. On 6-9-22 at 1:56pm, V13 Resident Care Coordinator stated that the following occurred on 5-27-22: At the end (of R4's transfer) when pulling the sling back, the bars of the mechanical lift bumped (R4's) wheelchair which caused (R4's) weight shifting back and caused the (mechanical lift) to tip. Our intervention was education on proper positioning, how to utilize it, and locking the brakes on the lift. They did not lock the (mechanical lift) with the locks it has at the bottom manually. They should have locked it once in position and centered over the top of the wheelchair to go down into it correctly. On 6-9-22, at 2:10pm, V1 Administrator stated the following: The mechanical lift with the scale #8 was used on (R4 on 5-27-22) and it is one of our own (mechanical lifts). No one told me it made a clicking noise. It shouldn't click but it may squeak since it's hydraulic .No one said the sling used was too small. (R4's) sling was at the back of (R4's) knees and top of (R4's) shoulders which was proper placement - I saw it. V1 confirmed (R4) received skin tears to each arm and left leg; left leg laceration required sutures. V1's email stated The (mechanical lift) did not malfunction and nothing was broken. It was due to the shifting of the weight of the resident. On 6-7-22, at 10:30am, R4 sat in a wheelchair in his room. R4 stated the following: On May 11 or 12th, I was sitting in a wheelchair. A CNA (V24) was putting my feet up on the leg rests. (V24) had my left one up, grabbed my right one by my calf and caused a skin tear that needed stitches at the hospital. (V24's) hand pulled the skin right off as (V24) raised it. My skin is very fragile. The actual report said it was the wheelchair, but I sent a correction that it was (V24's) hand that pulled off my skin. The facility's final report to State Agency for R4 documents: On 5-11-22 at 5:30pm, (R4) sustained a skin tear to right posterior leg .(R4) sent to emergency room .(R4) returned to facility with a noted 10 centimeter skin tear to right posterior leg. 10 sutures and 4 steri-strips were used to repair skin tear .Two CNAs and a (mechanical lift) was used to transfer (R4) to chair. Staff interviews also note that they did not hit (R4's) leg on any object. Upon completion of the transfer CNA noted blood on (R4's) right leg. The facility's statement from V24 CNA on 5-12-22 includes that after another CNA and (V24) did a mechanical lift transfer from bed to wheelchair, (V24) placed the foot pedals on (R4's) wheelchair, (R4's) left foot went up perfectly, the right foot didn't, as I held on with both hands to (R4's) leg, (R4's) leg was about to bend and be placed correctly on the wheelchair but it didn't and (R4's) leg slipped from the foot pedal and I lost grip and (R4's) skin tore. On 6-9-22, at 2:22pm, V13 Resident Care Coordinator stated that (V24 CNA) had said that (R4's) leg was big and swollen with [CONDITION(S)]. V24 said V24 lost her grip, (R4's leg) didn't hit anything, but (V24) looked down and (R4's) leg was bleeding. (R4's) skin is very fragile so even the lightest touch could do that to (R4's) legs. Could have been her hands. 3. On 6-7-22, at 9:56am, R5 sat in a wheelchair in her room. V14 and V15 CNAs transferred R5 from the wheelchair to (R5's) bed using a mechanical lift. R5's Minimum Data Set/MDS assessment, dated 2-4-22, documents R5 is cognitively impaired and requires total dependence and two person physical assist for transfers. R5's Progress Note, dated 3-20-22 at 7:20pm, documents Nurse called into resident room due to skin tear located to resident RLE (right lower extremity). (Mechanical lift) used as transfer, still in resident room. R5's Progress Note, dated 3-20-22 at 11:40pm, documents Resident returned to facility .Resident received 5 sutures to laceration of right lower leg. The facility's statement from V26 CNA on 3-20-22 includes During transfer of (R5), (R5's) leg brushed up against the (mechanical lift) causing a skin tear.

Based on observation, interview, and record review the facility failed to perform therapy recommended range of motion exercises and failed to place therapy recommended hand device for one (R1) of three residents reviewed for contractures in the sample of three. These failures resulted in R1 developing severe contractures of bilateral wrists and fingers causing R1's left thumb bone to protrude through the skin and R1 being scheduled for amputation of left thumb. Findings include: The facility's Rehabilitative Nursing Care policy and procedure, revised April 2007, documents Policy Interpretation and Implementation: 1. General rehabilitative nursing care is that which does not require the use of a Qualified Professional Therapist to render such care. 2. Nursing personnel are trained in rehabilitative nursing care. Our facility has an active program of rehabilitative nursing which is developed and coordinated through the resident's care plan. 3. The facility's rehabilitative nursing care program is designed to assist each resident to achieve and maintain an optimal level of self-care and independence. 4. Rehabilitative nursing care is performed for those residents who require such service. Such program includes but is not limited to: . b. Encouraging and assisting bedfast residents to change positions at least every two (2) hours (day and night) to stimulate circulation and to prevent decubitus ulcers, contractures, and deformities; . f. Assisting residents with their routine range of motion exercises . 5. Through the resident care plan, the goals of rehabilitative nursing care are reinforced in the Activities Program, Therapy Services, etc. The facility's Range of Motion Exercises policy and procedure, revised August 2008, documents The purpose of this procedure is to exercise the resident's joints and muscles .The following information should be recorded in the resident's medical record: 1. The date and time that the exercises were performed. 2. The name and title of the individual(s) who performed the procedure. 3. The type of ROM (range of motion) exercise given. 4. Whether the exercise was active or passive. 5. How long the exercise was conducted. 6. If and how the resident participated in the procedure or any changes in the resident's ability to participate in the procedure. 7. Any problems or complaints made by the resident related to the procedure. 8. If the resident refused the treatment, the reasons(s) why and the intervention taken. 9. The signature and title of the person recording the data. The Clinical Admission Evaluation for R1, dated 5/19/20, documents R1's initial admission assessment to the facility as R1's functional status being able to move all extremities with impairment to bilateral lower extremities. There is no documentation regarding upper extremities functional deficits or wounds to R1's hands. The Occupational Therapy Plan of Care for R1, dated 5/20/21, documents R1's initial therapy assessment Current Left UE (upper extremity) Completes up to 50% of normal range. Range of Motion Right UE completes up to 50% of normal range. Strength, Left UE 3-/5 (The muscle is able to contract and provide resistance, but when maximum resistance is exerted, the muscle is unable to maintain the contraction) and Strength, Right UE 3-/5. Tone, Left UE normal. Tone, Right UE normal. Gross Motor Control of LUE and RUE moderately impaired. Fine Motor Control LUE and RUE moderately impaired. Rehab potential Fair due to: Demonstrated higher functional level compared to current condition. The therapist Progress & Discharge Summary for R1, dated 5/29/20, documents Discharge: Goals not met - Program Complete. This Discharge Summary documents Completed caregiver training on ROM and positioning needs. The Occupational Therapy Plan of Care for R1, dated 10/29/20, documents a therapy screen was completed for R1 with the Treatment Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . due to worsening contracture of right hand - OT (Occupational therapy) to evaluate for use of splint to address development of contracture . Therapy Necessity: Skilled OT is necessary to develop a restorative/positioning program in order to maximize ROM/prevent worsening contracture. The Occupational Therapy Referral for Functional Maintenance Program for R1, dated 11/7/20, documents Range of Motion (Passive) as tolerated - Slow/rhythmic motor and Splint or Brace Assistance. Right hand palm protector - off for hygiene (wash/dry hand). Restorative Program to start on 11/7/20, to be done 6 to 7 times a week, one time daily, and ongoing. The Occupational Therapy Plan of Care (Evaluation Only) for R1, dated 8/26/21, documents Treatment Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . LTC (long term care) resident at (facility) referred to skilled OT for bilateral hand contractures resulting in significant pain, positioning deficits, and decreased functional use of hands. Pt's (patient's) L (left) hand contracture resulted in a significant L thumb wound warranting medical attention from orthopedic MD (medical doctor). Pt will be re-screened in order to develop a restorative nursing program for contracture management once wound has healed. This referral also documents Unable to assess due to pt refusing due to pain. On 11/5/21 at 11:25 am, V7 COTA/Therapy Program Manager stated R1 was initially screened for OT (Occupational Therapy) on 5/20/20 when she first came to the facility and V7 does not recall R1 having severe contractures at that time. V7 stated R1 and was picked up on therapy and discharged from OT on 5/29/20 due to inability to follow commands and resistive with treatment. V7 stated the Restorative Staff was educated on R1's positioning needs. V7 stated on 10/29/20 R1 was referred to OT because of worsening contracture of R1's right hand and we screened her and referred her to Restorative for Passive ROM (range of motion) for maintenance programing and for a palm protector for her right hand that should have started on 11/7/20. V7 stated (V7) received another referral for R1 on 8/26/21 for evaluation of R1's bilateral hand contractures, which caused a wound to R1's left hand and PT (Physical Therapy) also received a referral for R1 regarding contractures to R1's lower extremities. V7 stated at initial assessment in May of 2020 was completed for R1 and at that time R1 had 50% of movement in upper extremities and had normal tone and now does not and has significant contractures of her upper extremities, both arms, hands, and fingers. V7 stated the palm protector would have helped to keep R1's hand clean and fingernails from digging into her skin if it had been used or used correctly. V7 stated when a resident comes off of therapy, they will start a restorative program, the restorative nurse is educated on the program needed and the CNA's (Certified Nursing Assistants) are to do the programs. On 11/5/21 at 2:30 pm, V8 Restorative CNA stated she has been the restorative CNA for 2 years and does not recall any restorative programs coming through for R1. V8 stated no one is currently working with R1 and no one has in the past that she is aware of. On 11/5/21 at 2:40 pm, V9 LPN Restorative Nurse, stated she does not recall any restorative programs being done for R1 since she has worked at the facility and is unaware of R1 using a palm protector or any other type of device for contracture prevention. V9 stated when a resident is admitted the skilled therapy staff pick them up and when therapy discharges them I re-screen the resident for restorative programing and the Restorative CNA does the programs. The Care Plan for R1, created on 4/26/21, documents Alteration in musculoskeletal status r/t (related to) contractures of bilateral hands. The interventions include to Assist with use of applying rolled wash clothes to bilateral hands daily. Monitor and inspect daily for signs and symptoms of skin impairment daily. Report changes to nurse. The Care Plan for R1, created on 1/19/21, documents R1 has a ROM ADL (Activities of Daily Living) self-care performance deficit related to limited ROM and musculoskeletal impairment. The interventions include Explain all procedures/tasks before starting. Palm Protector to right hand daily. Right hand Palm protector - May remove for bathing and hygiene. The Care Plan for R1, created on 8/3/21, documents (R1) has actual skin impairment to left hand r/t contractures. The interventions include Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . to MD. The POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Cleanse with wound cleanser. Apply calcium alginate. Ensure palm protector is in place every day and evening shift for wound. Discontinued on 8/30/21. The POS, dated 8/19/21 documents Send to Methodist ER for evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The POS, dated 8/30/21, document Open area to palm L hand, thumb area. Cleanse with wound cleanser. Apply calcium alginate. Ensure palm protector is in place every day shift for wound. The POS, dated 10/12/21 documents CBC (Complete Blood Count) with diff (differential), RCMP (Comprehensive Metabolic Profile), CRC (Chest X-ray), EKG (Electrocardiogram), clearance from PCP (Primary Care Physician) for amputation of L (left) thumb. On 11/4/21 at 9:30 am, R1 was lying in bed with her arms bent at the elbows with severe wrist and finger deformities. There are no washcloths or palm protectors visible in R1's hands. V3 LPN (Licensed Practical Nurse)/Wound Nurse was at R1's bedside performing wound care to R1's left thumb. R1 was screaming out loudly as V3 LPN/Wound Nurse was trying to clean and apply dressing to R1's left thumb wound. On 11/4/21 at 4:20 pm, R1 did not have a palm protector or washcloth in her hands. On 11/4/21 at 9:45 am, V3 LPN/Wound Nurse stated R1 has severe contractures to her hands and her thumb treatment is very difficult to do. On 11/4/21 at 2:40 pm, V2 DON stated R1 has severe contractures to both of her upper extremities and has a bone protruding through the skin of her left thumb. V2 stated a referral was made to an orthopedic surgeon who recommended amputation of her left thumb and the facility is trying to get Cardiac clearance so that R1 can have the surgery. On 11/5/21 at 9:30 am, V5 and V6 CNA's provided cares to R1 and transferred R1 into a reclining wheelchair. V5 and V6 did not place a palm protector or washcloth into R1 hands. On 11/5/21 at 9:32 am and 9:38 am, V5 and V6 CNA's respectively stated R1 is not able to move around, is unable to move her arms or open her hands, does not use a palm protector or washcloths because of her contractures and is total assist for all cares. On 11/5/21 at 9:20 am and 11/8/21 at 8:18 am, R1 did not have a palm protector or washcloth in her hands. The Nursing Note for R1, dated 8/2/21, documents Resident noted with dried blood and bleeding to inner left hand, cleansed hand with water softly. Open sore to inner left thumb. Area bleeding placed 4 x 4 gauze over the open sore. Wash cloth in place. Left hand is contracted. Notified wound nurse. Left hand noted with fungal odor, [MEDICATION(S)]. The Skin/Wound Note for R1, dated 8/2/21, documents Blood observed on towel in left hand. Upon assessment open area noted, however unable to examine full area d/t (due to) contractures. Area cleansed with wound cleanser and calcium alginate with silver applied. MD (Medical Doctor) made aware. The Transfer and Transfer to Hospital Summary Notes for R1, dated 8/19/21, document R1 was sent to the local hospital per Nurse Practitioner for an evaluation of left-hand wound. The Nursing Note for R1, dated 8/20/21, documents Resident returned to facility from (local hospital) via (transport company) stretcher. N.E. (new order) follow up with facility physician. The Nursing Note for R1, dated 8/23/21, documents Left hand x-ray back and shows mild soft tissue swelling with some flexion deformity of the fingers and wrist with no evidence of recent fracture or dislocation. Clinical correlation is requested. BAR (situation, background, assessment, and recommendation form) filled out and papers in doctor box. The Heath Status Note for R1, dated 8/25/21, documents Res (resident) continues on Reflex for infection in L (left) hand. Wound MD to follow . The Skin/Wound Note for R1, dated 8/25/21, documents Wound MD at facility for rounds. Resident is being seen for full thickness wound to L 4th finger. Orders received to continue calcium alginate as previously ordered. The Nursing Note for R1, dated 8/25/21, documents This writer spoke with PO (power of attorney) and informed PO that resident has a referral to see an Ortho (orthopedic) surgeon for her left thumb .on 9/3/21 at 8 am. The GNP (Nurse Practitioner) Progress Note for R1, dated 8/19/21 documents .She (R1) has severe contractures of hands, fingers, wrist. Her left thumb IP (intercalate - finger) joint is extending out abnormally to the point her anterior thumb surface has gotten an open area. It is covered with calcium alginate at present. (R1) per her baseline gets very anxious and yells out when trying to examine this. Intervention is needed. She will need sedation for examination. Wound nurse says it is worse today than it was just a couple days ago. The PCP (Primary Care Physician) Progress Note for R1, dated 8/23/21, documents I was asked to see the patient for a pressure wound on the left-hand thumb. My nurse practitioner sent patient to the hospital for treatment, but patent returned without any orders. Patient does not want me to look at her left thumb as patient starts hollering . Left first digit 2 cm x 2.5 cm wound present with protruding mass. Unable to tell if bone or tendon. Left thumb is contracted .: Ordered wound consult with Dr. [NAME]. Ordered left hand x-ray two-view, ESR, CRP, CMP and CBC. Start [MEDICATION(S)] 100 mg p.o. twice daily for 7 days and [MEDICATION(S)] 250 mg twice daily for 14 days. The PCP Progress Note for R1, dated 9/15/21, documents . I was asked to see the patient for H&P clearance for left thumb amputation. Patient had an open wound and was evaluated by hand surgeon who recommended amputation. Labs and testing and antibiotic therapy completed. Patient was seen by hand surgeon who recommended amputation. On 9/9/21 patient was seen by cardiology who performed an echocardiogram with EF (ejection fraction) . After reviewing cardiology note I do not see any clearance for surgery. Instructed nursing to call cardiology for cardiac clearance. The NP Progress Note, dated 10/14/21, documents She (R1) is scheduled for surgical intervention for her left thumb. She has a contracture that opened and her distal phalanx (finger bone) is sticking out of her skin. (Orthopedic surgeon) is going to take care of it. She is cleared for surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] The NP Progress Note, dated 11/4/21, documents . Been trying to get her thumb fixed/amputated so she won't get [CONDITION(S)] but can't get her cardiac clearance for surgery. She seems miserable but cannot get family to agree to comfort measures. She has no quality of life. Mainly lives with anxiety and cannot express self, dependent on all cares . All joints some degree contractures. Thumb open wound with bone exposed from contracture . The facility Wound Doctor Evaluation and Management Summary, dated 8/25/21, documents Patient presents with a wound on her left, fourth finger . At the request of the referring provider (R1's PCP), a thorough wound care assessment and evaluation was performed today. She has a wound of the left, fourth finger for a least 1 days duration. There is moderate serous exudate. The patient appears to have associated pain evidenced by agitation . full thickness . Duration > 1 day . manage exudate, manage pain, palliation. Wound Size (L x W x D): 1 x 0.8 x 0.1 cm. Surface area: 0.80 cm. Exudate: Moderate Serous. Granulation tissue: 65%. Other visible tissues: 35% (Bone) . She (R1) has severe hand contractures, and the wound is on the palmar side of the proximal phalanx of thumb. Bone is visible in center of hypergranulated wound bed. She had been sent to ED (emergency department) last week, but no workup done to evaluate for [CONDITION(S)] there. Xray was done a few days ago in (facility) and was negative. Clinically this is [CONDITION(S)]. Medical management with at least 6 weeks of IV strength of abx (antibiotic) to try to cure. Surgical management is resection of involved bone or amputation of digit. Could refer to hand surgeon for assistance if patient is not palliative goals. Discussed with primary care NP in facility and they will arrange for referral to see hand surgeon if family agrees with that plan . Primary Dressing(s): Alginate calcium w/silver apply once daily for 30 days: tuck between thumb and first finger. The facility Wound Doctor Evaluation and Management Summary, dated 9/1/21, documents . she (R1) has a wound of the left, first finger for at least 7 days duration. There is moderate serosanguinous exudate . Wound Size (L x W x D): 1 x 1 x 0.1 cm. Surface Area: 1.00 cm. Exudate: Moderate Serosanguinous. Granulation tissue: 100%. Wound progress: No change. Additional Wound Detail: left thumb not 4th finger. EMR (electronic medical record) data entry error last visit. Very difficult to see due to contracture and she screams out when try to relax her fingers apart. Less bone visible with friable, hypergranulation over now. Has ortho consult pending . Primary Dressing(s): Alginate calcium w/silver apply once daily for 23 day: tuck between thumb and first finger. The facility Wound Doctor Progress Note, dated 9/8/21, documents Signing off on patient who remains in the facility. She has seen ortho and plans for amputation. Awaiting cardiac clearance. On 11/5/21 at 3:00 pm, V3 LPN/Wound Nurse stated the CNA's (Certified Nursing Assistants) alerted her of R1's left hand bleeding after (R1's) shower one day in August and when first assessed (V3) thought it was an abrasion but due to R1's severe contractures it is difficult to see in R1's hands. V3 stated R1's hands are completely contracted, almost in opposite direction which has caused R1's thumb bone to protrude through her skin. V3 stated when she noticed the bone, she sent R1 to the hospital for an evaluation and the hospital sent (R1) back with an Ortho (Orthopedic) consult. The Ortho doctor recommended an amputation of R1's left thumb and ordered some testing to be done. V3 stated all the labs and testing have been completed and (V3) has been going back and forth with R1's cardiologist and the Ortho to communicate. V3 stated the Cardiologist gave the ok but had questions about the anesthesia that would be used and some other questions that (V3) had the Cardiologist contact the Ortho because she didn't know the answers. V3 stated she has been going back and forth between the Ortho and Cardiologist and can't seem to get them on the same page. V3 stated R1's contractures are getting worse and it's getting more difficult to assess and treat R1's wound. V3 stated the wound clinic saw R1 a couple of times but is no longer following her because we are in process of getting R1's thumb amputated. V3 stated, I didn't think we would still be dealing with this at this point. On 11/8/21 at 9:25 am, V2 DON confirmed R1's therapy referrals and documentation of R1's Restorative Referral, R1's need for range of motion exercises, and was unaware that restorative was not being done for R1 or that devices were not being used for R1 to prevent contractures. V2 stated the facility has been working on getting R1's Cardiologist clearance for the amputation of her left thumb since August 2021.

Based on observation, interview, and record review the facility failed to follow a plan of care for one (R1) of three residents reviewed for falls in the sample of three. This failure resulted in R1 falling out of bed and receiving a cervical neck fracture, facial and leg bruising and experiencing increased pain. Findings include: The electronic medical record for R1 includes the following diagnoses: Cerebral Infarction, Alzheimer's disease, General Anxiety Disorder, Contractures of bilateral knee, feet, and right hand, [CONDITION(S)] of hip, muscle weakness, Gastrostomy feeding tube, Cardiac Pacemaker, Dementia, Weakness, Chronic Kidney Disease, and Congestive Heart Failure. The Quarterly MDS (Minimum Data Set) Assessment for R1, dated 8/9/21, documents R1 with moderately impaired cognition, requires extensive assist of two staff for bed mobility, total assist of two for transfers, does not ambulation, requires total assist of one for wheelchair locomotion, extensive assist of one for dressing and personal hygiene, and total assist of one for bathing, eating, and toileting and is always incontinent of bowel and bladder. The hospital After Visit Summary for R1, dated 10/30/21, documents Fall as the reason for visit. The Diagnoses documents, Fall from bed, initial encounter; Contusion of forehead, initial encounter; Closed nondisplaced fracture of second cervical vertebra, unspecified fracture morphology, initial encounter; Urinary tract infection without hematuria, site unspecified and Cervical collar was placed. The facility's Falls and Fall Risk, Managing policy and procedure, revised August 2008, documents Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Prioritizing Approaches to Managing Falls and Fall Risk . 6. Staff will identify and implement relevant interventions (e.g., hip padding or treatment of [CONDITION(S)], as applicable) to try to minimize serious consequences of falling. Monitoring Subsequent Falls and Falls Risk: . 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. The current Fall Care Plan for R1, created on 7/2/20 and revised on 8/10/21, documents R1 is At high risk for falls. This Care Plan lists the following interventions: Low bed at all times. Call light in reach. Follow fall protocol. Furniture in locked position, Keep needed items in reach. Maintain clear pathway in room, free of obstacles. Fall Mat to floor, rolled edged mattress to bed and cervical neck collar as ordered. The Post Fall Evaluation dated 10/30/21 at 6:00 am, documents Fall Details: R1 with unwitnessed fall in resident room at 6:00 am. R1 with bump to left side of forehead and sent to emergency room . Resident fell out of bed. Bump to left side of forehead noted. Floor mat on floor and improper bed height. Resident with socks on at time of fall. The Charge Nurse Fall Investigation: Bed boundaries is documented as the cause of the fall. Rolled out of bed. On 11/4/21 at 9:00 am, R1 was lying in a low bed with blue, black, and purple bruising to the entire left side of R1's face with a cervical collar in place around (R1's) neck and discolored bruising to R1's left lower leg and ankle. V3 LPN (Licensed Practical Nurse)/Wound Nurse was providing care to R1 with R1's bed elevated to the height of V3's waist level. R1's call light was hanging over R1's headboard. V3 exited R1's room without lowering R1's low bed to the floor position or placing R1's call light within R1's reach. On 11/5/21 at 9:20 am, V4 LPN was at R1's bedside providing care with R1's low bed positioned at the height of V4's waist. V4 exited R1's room without lower R1's low bed to floor level. On 11/8/21 at 8:18 am, R1 was lying in bed and R1's call light was hanging on the drawer handle of R1's night stand out of R1's reach. On 11/5/21 at 2:46 pm, V10 LPN stated she was working at the time R1 fell out of bed on 10/30/21 around 5:55 am and heard R1 yelling. V10 stated she entered R1's room and saw R1 laying on the floor mat face down. V10 stated she (R1) does not have a history of falls and won't try to get up from bed by herself. V10 stated R1 does have tremors in her hands and arms but can't move them around. V10 stated V11 CNA (Certified Nursing Assistant) and V12 LPN from first shift and V13 Agency CNA were present with her in R1's room. V10 stated V13 Agency CNA was scheduled to work R1's hall on third shift and had already been in R1's room to turn and reposition R1 and R1's bed should have been lower than it was. V10 stated she is unsure if V13 Agency CNA lowered R1's bed as it was positioned just above V10's knees which was about two to three feet from the floor. On 11/7/21 at 3:35 pm, V11 CNA stated she was at the desk the morning of 10/30/21 when she heard a loud noise and then heard R1 yelling out. V11 stated (V11), V12 LPN, and V13 Agency CNA ran down to R1's room, where V10 LPN was. R1 was laying on the floor, face down on the floor mat. V11 stated We didn't know what happened except that maybe she was lying too close to the edge of her air mattress. V11 stated V13 Agency CNA said she had just been in the room and had turned R1. V11 stated she noticed R1's bed was not lowered all the way down, it was up about knee height, a couple of feet or so from the floor. The Nurse assessed her, we got (R1) back into bed and sent (R1) to the hospital. V11 confirmed that R1's bed should have been lowered to the floor. On 11/7/21 at 7:46 pm, V12 LPN stated she was working first shift the morning of 10/30/21 and heard V10 LPN yelling for (V12) from R1's room. V12 stated when she got to R1's room, R1 was lying face down on the floor mat next to (R1's) bed. V12 stated V10 LPN assessed R1 while (V12) went to get papers ready to send R1 out to the hospital. V12 stated R1 did have an air mattress on her low bed at the time of the fall but didn't notice the height of R1's bed but it should have been only about ankle high from the floor. V12 also stated R1 does have slight tremors in her hands and if anxious or upset she will have increased tremors. V12 stated R1 will not try to get up by herself and is a total assist for bed mobility and transfers. On 11/5/21 at 9:25 am, 9:32 am, and 9:38 am, V4 LPN, V5 CNA, and V6 CNA respectively stated R1 is a total assist for all cares, is unable to move her arms or hands, has hand tremors but does not move around in the bed. On 11/4/21 at 2:40 pm V2 DON (Director of Nursing) stated she completes all the facility fall investigations and then (V2) or the Care Plan Coordinator puts the new interventions on the care plan. V2 stated R1 rolled out of her bed on 10/30/21 landing face down on the fall mat. V2 stated she believes during last rounds, third shift staff turned and repositioned R1 onto R1's left side, R1 was having tremors and jerky movements of her hands which may have offset R1's air mattress causing R1 to roll out of her bed onto the floor mat. V2 DON stated R1 was sent to the local hospital and returned with a cervical fracture of her neck and bruising to her face. V2 stated R1 is unable to move on her own and won't try to get up by herself. V2 stated low beds are to be lowered as far to the floor as possible, but not to disengage the bed brake. V2 confirmed waist high was too high and that call lights should be within resident reach.

Based on interview, observation and record review, the facility failed to provide dedicated staff to care for COVID positive residents, ensure COVID positive residents were not cohorted with Non-COVID (negative) residents, ensure proper room placement to prevent non-COVID (negative) residents from being housed between residents currently in quarantine precautions and residents currently COVID positive, perform hand hygiene throughout cares, and sanitize a blood glucose monitor after use. These failures have the potential to affect all 34 residents (R1 - R34) residing in the facility's southeast and southwest hallways. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 9/30/2021, the facility remains out of compliance at a Severity Level II as the facility administers staff education on infection control practices and current COVID procedure and protocol, conducts ongoing resident monitoring, and performs frequent auditing to ensure that corrections are achieved. Findings include: The facility's COVID-19 Cohorting Policy & Procedure policy (effective 02/03/21) documents the following: Purpose: To prevent and reduce the risk of transmission of the Coronavirus Disease (COVID-19) in this facility. Policy: This facility will designate a location to care for residents with positive suspected or confirmed COVID-19, separate from other residents. If possible, this location should have designated staff. This same policy also documents the following: Red Zone: COVID positive residents. Place in Contact & Droplet precautions for 10 days. Blue Zone: Quarantined residents who transferred to the facility. New Admissions or readmissions are quarantined for 14 days from date of arrival. If no symptoms develop, residents can move to the green zone. Green Zone: Asymptomatic unexposed residents (includes all COVID negative residents). The facility's Cleaning and Disinfecting Blood Glucose Meters policy (undated) documents the following: If a glucometer that has been used for one resident must be reused for another resident, the device must be cleaned and disinfected before it can be used for another resident. Procedure: Apply gloves; Thoroughly clean all visible soil or organic material from glucometer prior to disinfection; Using gloves as indicated, disinfect the glucometer with a wipe and make sure the surface is thoroughly wet and allow for drying time as indicated per manufacturer. Use EPA list N disinfectant (to kill COVID-19); To allow the meter to remain wet for the contact time- you can wrap the meter in the wipe. After contact time has passed, throw away the wipe; Perform hand hygiene immediately after removal of gloves and before touching other medical supplies intended for use on other residents. The facility's Obtaining a Fingerstick Glucose Level policy (revised 08/2008) documents the following procedure after obtaining a blood glucose reading: Clean reusable equipment according to the manufacturer's instructions; Remove gloves and discard into designated container; Wash hands. The facility's Cleaning and Disinfection Policy (Revised 04/08/21) documents the following: Equipment can be taken in and out of a room with transmission-based precautions if it is cleaned and disinfected between uses and before leaving the room. The facility's Handwashing/Hand Hygiene policy (Revised August 2008) documents the following: Appropriate ten to fifteen second handwashing with antimicrobial or nonantimicrobial soap and water must be performed under the following conditions: After contact with blood, body fluids, secretions, mucous membranes, or nonintact skin; after handling items potentially contaminated with blood, body fluids, or secretions. This policy also documents, If hands are not visibly soiled, use an alcohol-based hand rub for the following situations: Before direct contact with residents, before performing any non-surgical invasive procedures; Before preparing or handling medications; After contact with the resident's skin; After contact with inanimate objects (e.g., medical equipment) in the immediate vicinity of the resident; After removing gloves. The facility's Oral Medication Administration policy (effective 11/04/14) documents the following: Wash hands before beginning a med pass, or when contact with resident is expected or has occurred. This policy also documents, When finished with each resident, wash hands with antimicrobial soap and water or use facility-approved hand sanitizer. On 09/27/21 at 09:30 AM, V3 (Assistant Director of Nursing) stated the facility is currently utilizing three zones for resident room placement, the red zone, blue zone and green zone. V3 stated, The southwest hall contains all three zones, and all other halls in the building are designated as the green zone at this time. COVID positive residents are housed in the red zone on contact and droplet isolation precautions and segregated behind a barrier wall from all other residents. The blue zone houses new admissions and residents who have been out of the building for appointments, and the green zone houses the asymptomatic residents that have tested negative for COVID. V3 explained that in the facility's southwest hall, the red zone is located at the far end of the hall behind a barrier wall, some green zone residents are currently housed in rooms in the middle of the wing and the blue zone is located at the entrance to the wing. V3 then stated that a nurse is assigned to care for all of the residents housed in the facility's southeast and southwest halls. V3 stated, We also assign one CNA (Certified Nursing Assistant) to the southwest hall (red, blue and green zones), and two CNAs to the southeast hall (green zone). If the southwest hall CNA needs assistance, one of the two CNAs from the southeast hall go over and help. V3 stated the facility currently has five residents positive for COVID, We actually have six residents in the COVID unit, five are currently positive and one is not. (R1) and (R2) are cousins and have always been roommates. Both (R1) and (R2) have the same POA (Power of Attorney). When (R1) tested positive, the POA insisted (R1 and R2) remain roommates, even though (R2) has no symptoms and has been negative for COVID each time she's been tested . On 09/27/21 at 01:20 PM, V2 (Director of Nursing) stated, For this current outbreak, 09/14/21 was the date of the first three residents testing positive for COVID, and two of them are still at the facility in the COVID unit. We have since has had two additional cases test positive on 09/24/21. V2 stated one facility staff member is currently at home isolating due to a positive COVID test. V2 stated the facility is not at a critical staffing level and is able fill all open shifts/holes in their staffing schedule, Some of the staff will work overtime or the department heads will fill in when needed. On 09/27/21 at 10:00 AM, V5 (Registered Nurse) was standing at the medication cart near the nurse's station of the facility's southwest hall. V5 proceeded to exit the southwest hall, enter the southeast hall and approach the medication cart. V5 stated she is currently assigned to care for all of the residents residing in the facility's southeast and southwest halls, including the residents residing in the red zone and blue zone, as well as the remaining residents in the green zone, I go back and forth between southeast and southwest. Today I'm taking care of all of the residents in southeast and southwest, which is basically all of the residents in the front two halls of the building. On 09/27/21 at 11:00 AM, V4 (CNA/Certified Nursing Assistant) was standing near the nurse's station in the facility's southwest hall. V4 stated she is currently the CNA assigned to work the southwest hall. V4 stated, There are a couple of residents who require a (mechanical lift), which requires two staff members to be present, so when I need a second person, I go over and get one of the CNAs from the southeast hall to help me. On 09/27/21 at 11:15 AM, the door to R1 and R2's room was open with the call light indicator above the door lit, and both R1 and R2 were sitting in wheelchairs in close proximity of each other with the television on. Neither R1 nor R2 was wearing any type of facial covering or mask. R1 was nonverbal and wrapped in a blanket. R2 stated, I need to use the bathroom. The facility's COVID Testing Results Log documents the following: On 09/07/21, 09/14/21, 09/17/21, and 09/21/21, R1 had a negative result when tested for COVID. This same testing log documents on 09/24/21, R1 was positive for COVID when a test was conducted. This log also documents on 09/07/21, 09/14/21, 09/17/21, 09/21/21, 09/24/21 and 09/28/21, R2 had a negative result when a test for COVID was conducted. On 09/28/21 at 12:24 PM, V6 (Registered Nurse) was standing at the medication cart near the nurse's station in the facility's southwest hall. V6 prepared R4's scheduled medications in a medication cup, obtained a zipped case containing a blood glucose meter from a drawer in the medication cart, approached a PPE (personal protective equipment) supply storage area near a barrier wall entrance into the red zone, and applied PPE. V6 then proceeded to unzip the barrier wall entrance site and enter the red zone/COVID Unit. V6 approached and entered R4's room, where R4 was sitting in a wheelchair with a bedside table positioned in front of her. V6 handed R4 the medication cup containing her medications, which R4 ingested at that time. V6 then set the blood glucose monitor case on R4's bedside table, unzipped the case, removed the blood glucose monitor and set it in front of R4 on her bedside table. V6 performed a finger stick to R4's right index finger and obtained a blood glucose reading. Once R4's blood glucose was completed, V6 placed the blood glucose monitor back into its case, exited R4's room, discarded the PPE she was wearing, exited the red zone and approached the southwest hall's medication cart. V6 set the blood glucose monitor case on top of the medication cart for a few moments while she accessed the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . V6 did not clean or sanitize the blood glucose monitor or its case before placing it back into the medication cart. V6 then proceeded to exit the southwest hall, enter the southeast hall, approach and unlock the medication cart, and prepare medications for R5. V6 then walked down the southeast hallway to R5's room carrying a cup of medications intended for R5, entered R5's room and administered his medications. V6 did not perform hand hygiene throughout this time. On 09/28/21 at 12:42 PM, V6 confirmed that she placed the case containing a blood glucose monitor back into the medication cart without sanitizing it after use. V6 stated that she needed a sanitizing wipe. V6 also confirmed she did not perform hand hygiene before, during or after administering medications or performing a blood glucose check on R4. On 09/28/21 at 01:15 PM, V2 (Director of Nursing) stated staff is required to sanitize a blood glucose monitor after each use. V2 stated V6 (Registered Nurse) should have performed hand hygiene after administering medications and completing a blood glucose check on R4. (V6) shouldn't have taken the case into (R4's) room, with (R4) currently being positive for COVID. She should have just taken the monitor in to do the blood glucose check. The case and the blood glucose monitor should have been sanitized. On 09/28/21 at 01:30 PM, V2 (Director of Nursing) confirmed that although R2 is not positive for COVID, R2 is currently residing in the facility's designated COVID unit. V2 stated that R1 and R2 are cousins and have the same POA/Power of Attorney. Their POA would not allow me to split them up because they would not do well being separated. V2 stated currently three residents are residing in the facility's blue zone at the entrance of the southwest hall. V2 stated, Although the guidelines have changed, our doctor still requires new admits to quarantine for 14 days regardless of their vaccination status. If we didn't do this, we'd have it (COVID) everywhere in the building. V2 stated that R6, R7 and R8 are currently the residents residing in blue zone, and a gown, gloves, face shield/goggles, and an N95 mask are required to be worn prior to entering their rooms. V2 then confirmed that there are currently four residents, R9, R10, R11 and R12, residing in the southwest hall's green zone, whose rooms are located directly in between the red zone and blue zone. V2 stated the following: Ideally, we don't like having any green zone residents near the red or blue zones. We do have a few green zone rooms available in the three other halls. (R9) was in the blue zone and could move on 09/25/21, but we don't move people over the weekend. She can be moved now. (R12) was in contact isolation precautions for ESBL (extended spectrum beta-lactamase) of her urine. She was able to move once she finished her antibiotic, and she finished taking her antibiotic on 09/24/21, so she can also be moved. I had her in the southwest hall because I like to keep all of the isolation people together. (R10 and R11) are both significantly confused and are wanderers. It would be detrimental to move them. They'd never be able to find their new room if we move them. The Facility's Census sheet (dated 09/27/21) documents the following residents currently reside in the facility's southeast and southwest halls: R1 - R34. The immediate jeopardy was identified on 09/30/21 at 12:15 PM to have begun on 09/14/21 when R2 was initially cohorted with COVID positive residents in the facility's red zone, as well as placement of the southwest hall's green zone in close proximity directly between the red zone and blue zone. V1 (Administrator) and V2 (Director of Nursing) were notified of the immediate jeopardy on 09/30/2021 at 12:25 PM. The surveyor confirmed through interview, observation and record review that the facility took the following actions to remove the Immediate Jeopardy: On 09/30/21, the facility implemented a yellow zone, which is an area in the southwest hall to house asymptomatic residents with known exposure to COVID positive roommates. R2 was moved out of the facility's red zone on 09/30/21 and placed in the yellow zone for 14 days per facility protocol. R2, along with all other facility residents not currently positive or recently positive for COVID will continue to be monitored daily and tested for COVID per facility policy and local guidelines. On 09/30/21, R9, R10, R11 and R12 were moved from the southwest hall to one of the green zone beds available in the facility's southeast, northwest and northeast halls. Green zone residents are no longer residing in the facility's southwest hall. The southwest hall now houses residents in the blue zone, yellow zone and red zone, which require staff to apply a gown, gloves, eye protection and an N95 mask prior to entering a room in each of those zones. R7 and R8 were relocated from the facility's southwest hall blue zone to a green zone bed available in one of the facility's other green zone hallways upon completion of their 14-day quarantine precautions. R7 was moved on 09/28/21, and R8 was moved on 09/30/21. R6 is currently not residing at the facility due to being sent to a local hospital and admitted on [DATE]. On 10/04/21, V2 (Director of Nursing) stated residents who leave the facility for appointments, new admissions, and readmissions will continue to be placed in the blue zone on quarantine precautions for 14 days, and then will be placed in a green zone bed if they do not display any symptoms of COVID or test positive for COVID. Documentation provided indicates that on 9/30/21, V2, (Director of Nursing/DON) was in-serviced to provide dedicated staff to care for COVID-19 positive residents when possible (when staffing allows), and re-educated on COVID-19 Cohorting Policy and Procedure. Documentation provided indicates that on 9/30/21 management staff were re-educated to ensure proper room placement per the COVID-19 Cohorting Policy and Procedure. Documentation provided indicates that on 9/29/21 all nurses were re-educated on infection control procedures related to cleaning and disinfection of equipment and glucose meter cleaning. On 10/04/21, Multiple facility staff members were interviewed (V1, Administrator; V2, Director of Nursing; V7, Certified Nursing Assistant; V8, Activity Director; V9, Licensed Practical Nurse; V10, Housekeeping/Laundry; V11, Licensed Practical Nurse; V12, Certified Nursing Assistant; and V13, Dietary Manager), and were knowledgeable of the recent education in servicing that has been administered, including infection control practices, and the facility's COVID policy and procedure. All staff interviewed verbalized CNAs are no longer floating between the facility's southwest and southeast halls and remain designated to their assigned hall. All residents will continue to be monitored by the DON daily for symptoms and tested every 3-7 days during an outbreak.

Based on observation, interview, and record review the facility failed to prevent the development of an unstageable pressure ulcer for one of three residents (R1) reviewed for pressure ulcers in a sample of 14. R1's pressure ulcer was identified as a stage 2 pressure ulcer on 6/20/20 but treatment orders were not obtained until 6/26/20 resulting in R1's pressure ulcer deteriorating into an unstageable pressure ulcer. Findings include: A Prevention of Pressure Wounds policy dated 1/2017 documents that, Pressure injuries are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue. The policy further states that, Pressure injuries are a serious skin condition for the resident. In addition, this policy also states, The facility should always have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed. R1's Minimum Data Set (MDS) assessment dated [DATE] documents R1 is severely cognitively impaired and requires extensive assistance of two people for bed mobility, transfers, toilet use and hygiene. R1's MDS also documents that R1 uses a wheelchair for mobility. R1's Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] documents that R1 scored a 19 which is a low or no risk for developing pressure ulcers despite being chairfast with limited mobility. R1's admission nurse's note dated 6/19/20 does not document that a skin assessment was performed on R1 at that time. R1's nurse's note dated 6/20/20 documents a head-to-toe assessment was completed for R1 in which the assessment noted that R1's skin was within normal limits meaning no abnormalities and intact. R1's nurses' notes dated 6/21/20 document that R1 had developed a stage 2 pressure ulcer to the left buttock but no documentation that R1's physician was notified for treatment orders. There are no nurses' notes to address R1's stage 2 pressure ulcer from 6/22/20 to 6/25/20. On 6/26/20 R1's nurses' notes, entered by V27 (Wound Nurse), document that R1 had developed an open area to her left gluteal fold (buttock) and V27 had obtained a new physician's orders [REDACTED]. R1's physician's orders [REDACTED]. R1's current comprehensive care plan does not include interventions to prevent or treat actual or potential impairments to R1's skin integrity until 8/3/20. R1's wound physician's initial progress note dated 7/8/20 documents that R1 had an unstageable pressure ulcer to the left buttock, due to necrosis (dead tissue), which measured 2.7cm (centimeters) long x 2.2cm wide x 0.2cm deep. This progress note also indicated that there was scarring around R1's wound indicating she had history of a previous wound in that same area. On 8/6/20 at 8:51a.m. V27 (Wound Nurse) stated that she assessed R1's skin and noted R1's pressure ulcer on 6/26/20. V27 stated that she read through R1's transfer records from R1's previous residence and did not see any documentation that R1 had an existing wound at the time of transfer. V27 stated she also reviewed R1's physician's orders [REDACTED]. V27 verified orders to treat R1's wound were not obtained until 6/26/20. On 8/3/20 at 12:09p.m. V2 (Director of Nurses) verified that R1's transfer documentation from her previous facility does not show that R1 had a pressure ulcer at the time of discharge and prior to the transfer to this facility. V2 verified R1's pressure ulcer was not documented as discovered by the facility until 6/21/20. On 8/4/20 at 9:40a.m. V10 (R1's Nurse Practitioner) stated that V10 was R1's health care provider at R1's previous facility before she transferred to this currently facility. V10 stated that R1 did not have a pressure ulcer at the time of transfer. V10 stated that R1's stage 2 pressure ulcer which deteriorated into an unstageable pressure was an avoidable wound. V10 stated that she would have expected the facility's nursing staff to obtain a physician's treatment order as soon as R1's wound was identified.

Based on observation, interview and record review, the facility failed to recognize, treat and perform ongoing monitoring and assessment of a pressure ulcer and failed to change gloves and perform hand hygiene during pressure ulcer care for two of four residents (R53 and R330) reviewed for pressure ulcers in the sample of 35. These failures resulted in the development of R53's pressure ulcer on 9/4/19 which did not have immediate interventions and treatments implemented resulting in the deterioration of R53's pressure ulcer to an unstageable pressure ulcer on 10/30/19. Findings include: 1. R53's Skin and wound evaluation dated 9/4/19 documents the following: Type: pressure, Stage: Stage 2: Partial-thickness skin loss with exposed dermis, Location Sacrum, In-House Acquired, Exact date: 9/5/19, Wound Measurements, Area 0.4cm (centimeters), Length 0.9 cm, Width 0.5 cm, Not Applicable for Depth, undermining and tunneling. No evidence of infection. Other, pink or red. No exudate drainage or odor. Surrounding Tissue: [DIAGNOSES REDACTED], Treatment: none. The facility's Wound Care Guidelines document the following: Supportive Interventions: To utilize the supportive interventions, determine the etiology of the wound on the left and consider the supportive interventions listed. Evaluate need for Turning and Repositioning devices, nutritional supplement. On 11/7/19 at 2:20 p.m. V2 (Director of Nursing) stated when this wound was documented on 9/4/19 the Wound Care Guidelines should have been followed. V2 stated the Wound Care Guidelines are standing orders that the nurses can use to treat wounds. V2 was unable to find documentation that the facility's wound care guidelines were implemented on 9/4/19. V2 verified there was not a treatment implemented on 9/4/19 until 9/23/19 when preventative cream was ordered. V2 stated the preventative cream order was ordered as needed and did not document it was to treat R53's buttock wound. R53's progress notes dated 9/4/2019 at 9:32 p.m. documents the following: CNA (Certified Nursing Assistant, unidentified) reports pressure sore on resident's sacrum. R53's medical record did not contain documentation addressing R53's Sacral/Coccyx wound between 9/5/19 and 9/20/19. On 9/21/2019 at 12:44 p.m. R53's Progress Nursing Note documents the following: (R53) He is complaining of back, buttocks and foot pain. R53's progress nursing note dated 9/23/2019 at 9:06 p.m. documents the following: Resident (R53) is starting to develop redness on his bottom. R53's medical record does not contain a progress nursing note describing R53's sacrum/coccyx or buttocks wound. R53's progress nursing note dated 10/24/2019 at 8:46 p.m. documents the following: On pain management. Dressing changed to Pressure wound at his coccyx area, Prescribed cream applied. R53's progress nursing note dated 10/25/2019 at 9:05 p.m. documented the following: (R53) He had loose stool this morning. Placed him on bed and he had 1 episode of watery diarrhea foul smell. Ordered to place on Contact Isolation Precaution as ordered. Wound cleansed and covered with skin prep, and kept open. Resident is complaining of pain while cleaning his wound. On 10/26/2019 at 12:08 p.m. R53's progress Nursing Note documents the following: (R53) Resident laid down in bed after meals d/t (due to) wound on coccyx area. Area open et scant amount of blood coming from wound. R53's Skin and Wound evaluation dated 10/28/19 documents the following: Type: Moisture Associated Skin Damage (MASD), In-House acquired. The section of this form titled How long has the wound been present, exact date is blank. This same form documents the following: wound measurements, area-3.5 cm (centimeters), length-3.9 cm, width 1.2cm. (depth, undermining and tunneling documents not applicable). Wound bed [MEDICATION NAME], 10% of wound covered, Granulation 70% of wound filled, Slough 20% of wound filled. Exudate Light, Serosanguinous and no odor. Surrounding tissue: [DIAGNOSES REDACTED] and Fragile. The sections titled wound pain and goal of care are blank. This same form documents the progress of this wound is deteriorating. R53's Skin/Wound Note dated 10/29/2019 at 9:51 p.m. documents the following: Stage 2 pressure sore to coccyx, skin remained open, redness noted around the wound. R53's Specialty Physician Wound Evaluation and Management Summary dated 10/30/19 documents the following: Patient (R53) presents with a wound on his sacrum. He has an unstageable (due to necrosis) sacrum. There is moderate serous exudate. Wound size (L x W x D): 5.2 x 1.8 x not measurable, moderate serous exudate, 100% thick adherent devitalized necrotic tissue. R53's progress Infection Note dated 10/31/2019 at 10:15 p.m. documents the following: Started on Doxy ([MEDICATION NAME], Antibiotic) 100 mg (milligrams) BID (twice daily) for 7 days for his wound to coccyx area. R53's progress Infection Note dated 11/2/2019 at 8:55 p.m. documents the following: On oral antibiotic for pressure sore stage 2 with pain 5/10 and manage with [MEDICATION NAME]. R53's progress Nursing Note dated 11/6/2019 at 2:32 p.m. documents the following: Wound rounds done with wound doctor on unstageable sacrum wound. The wound bed is 100% slough filled. Measuring 5.2 x 1.8. Mechanical wound debridement done to remove necrotic tissue and and establish new viable tissue. R53's Specialty Physician Wound Evaluation and Management Summary dated 11/6/19 documents the following: Dressing was absent this afternoon. R53's current care plan did not document R53 was at risk for a pressure ulcer nor that R53 currently had sacrum/coccyx skin alterations. On 11/6/19 at 1:36 p.m. V14 and V15 (Certified Nursing Assistants/CNAs) used a mechanical lift to transfer R53 from the chair to the bed. V14 and V15 then removed R53's adult brief and cleaned stool wiping from the front towards the pressure ulcer. When V14 and V15 removed R53's adult brief, R53's pressure ulcer did not have a dressing. On 11/07/19 at 08:06 AM V5 (LPN/Nurse Manager) stated the following: I follow pressure, venous and arterial wounds. From 9/4 to 10/1 I would not have rounded on R53 unless he had a pressure ulcer. V5 stated she was unable to find a wound/tracking log for R53. V5 stated I am not sure what other interventions are in place for (R53)'s pressure ulcer other than a pad is in (R53)'s wheelchair. V5 was unable to clarify when or how R53's coccyx/sacral wound started or how it progressed. V5 was unable to identify a staff member that could speak to the development and progression of R53's sacrum/coccyx wound. 2. The facility's Standard Precautions policy (12/2006) documents the following: Standard Precautions will be used in the care of all residents regardless of their [DIAGNOSES REDACTED]. Wear gloves (clean, non-sterile) when touching blood, body fluids, secretions, excretions and contaminated items. Change gloves between tasks and procedures on the same resident after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments. R330's current electronic physician's orders [REDACTED]. R330's Nursing Progress Note (11/3/19) documents the following: (Bilateral) buttocks with pressure sore approximately 1-2 centimeter (cm) diameter, started red to purplish color on admission, currently progressed to Stage II as resident recently sits and sleeps in the recliner, did not want to lay down to bed. On 11/6/19 at 1:45 PM, V13 (Registered Nurse) performed R330's pressure ulcer care. V13 pulled down R330's adult brief exposing R330's buttocks. R330's bilateral buttocks contained purplish scattered discoloration. R330's right buttock contained a small pinpoint, non-blanchable area that contained a red center and scant amount of serosanguinous drainage. V13 cleansed R330's bilateral buttocks and pressure ulcer with a cleansing wipe. V13 then used the same gloves to apply R330's Z-guard paste to R330's bilateral buttocks and pressure ulcer with V13's gloved hand. V13 did not remove V13's contaminated gloves, perform hand hygiene and put on clean gloves after cleansing R330's buttocks and pressure ulcer and prior to applying R330's z-guard paste. On 11/6/19 at 1:50 PM, V13 verified that V13 cleansed R330's buttocks and pressure ulcer and then used the same gloves to apply R330's Z-guard paste to R330's buttocks and pressure ulcer. V13 verified that V13's gloves would be considered contaminated after cleansing R330's buttocks and pressure ulcer and stated that V13 should have removed V13's contaminated gloves, performed hand hygiene and put on clean gloves after cleansing the pressure ulcer and prior to applying the Z-guard paste.

Based on interview and record review the facility failed to ensure a physician was notified when staff were unable to insert an intravenous catheter (IV) into a hypotensive resident requiring intravenous fluids, and failed to notify the physician when antihypertensive medications were administered to a hypotensive resident against physician orders [REDACTED]. These failures resulted in R2 developing severe [MEDICAL CONDITION], requiring emergent hospitalization , and which also resulted in R2 sustaining Cardiac Demand Ischemia following the antihypertensive medication administration. Findings include: A Change in Condition policy dated 5/12/08 states, It is the policy of (the facility) that a licensed staff member will notify the attending physician and responsible party of change in condition. R2's Change in Condition Evaluation dated 12/18/16 at 3:45p.m. documents R2 had a change in condition related to abnormal vital signs, food and/or fluid intake was decreased, nausea and vomiting. The Change in Condition Evaluation documents R2's blood pressure (BP) was 93 systolic blood pressure (SBP) and 48 diastolic blood pressure (DBP) or 93/48mmhg (millimeters of mercury), heart rate 117 bpm (beats per minute), and respirations were 50 breaths per minute all of which was reported to Z1 (R2's physician). A nurse's note dated 12/18/16 at 4:49p.m., states, New orders .hold B/P med (medication) if SBP is less than 120 and DBP is less than 60. R2's physician's orders [REDACTED]. R2's nurse's note dated 12/18/16 at 11:27p.m., documents that an IV catheter inserted into R2's left arm which was infusing IV fluids at a rate of 75cc per hour. R2's nurse's note dated 12/19/16 at 3:31a.m., documents that R2's IV catheter infiltrated (stopped functioning) and, RNs (Registered Nurses) tried six times to start another. Sent fax to Z1 (R2's physician) to state RN cannot get another IV started .awaiting reply. The nurse's notes do not indicate that staff tried to reach Z1 by telephone in addition to staff sending a fax to Z1's office. R2's nurse's note at 7:00a.m. documents R2's IV and IV fluids were not restarted until that time, three and one half hours later. R2's Blood Pressure log dated 12/19/16 at 7:52a.m., documents R2's blood pressure at that time was 108/56mmhg. R2's Medication Administration Record [REDACTED] R2's Blood Pressure log dated 12/19/16 at 9:46a.m. documents R2's blood pressure at that time was 114/78mmhg. R2's MAR indicated [REDACTED]. R2's Blood Pressure log dated 12/19/16 documents R2's next blood pressure was not taken again for five hours at 2:56p.m., at which time it was 68/40mmhg. R2's nurse's note dated 12/19/16 at 3:38p.m. and 4:15p.m., document that Z1 was then notified of R2's condition and orders were given for R2 to be transferred to the emergency room . On 2/2/17 at 3:06p.m., E7 (Registered Nurse) verified that E7 administered R2's blood pressure medication Moexipril [MEDICATION NAME] 15mg and [MEDICATION NAME] 0.1mg at 8:00a.m. on 12/19/16 despite R2's blood pressure of 108/56mmhg and also administered [MEDICATION NAME] 0.1mg at 12:00p.m. despite R2's blood pressure at 9:46a.m., of 114/78. E7 stated that before administering the antihypertensive medications she was sure she had taken R2's B/P stating, It was OK, but I don't remember what it was. E7 stated that there were no physician notifications made because R2 was, doing well, up in the chair, and eating and drinking. R2's hospital Critical Care physician's History and Physical progress note dated 12/19/16 documents when R2 was admitted to the emergency room , laboratory (lab) tests were performed. The progress note documents R2's lab results for a Troponin level (a protein released when heart muscle is damaged) was elevated which was, Likely caused by demand ischemia. Plan: Will hold antihypertensive medications. On 2/6/17 at 2:25p.m., E2 (Director of Nurses) stated that Z1 (R2's physician) should have been notified by the nursing staff that R2 had received antihypertension medications when R2's blood pressure was already low. On 2/2/17 at 11:35a.m., Z1 stated, I would have expected facility staff to monitor R2's B/P more closely since it had been low and R2 was getting IV fluids. I would have expected to be notified by phone when facility staff were unable to restart R2's IV catheter since I am not in my office in the middle of the night. I would have expected the nurse would call me when R2 received her antihypertensive medications when R2's blood pressure was less than 120SBP and less than 60DPB. If staff had notified me by phone that an IV could not be started for R2, I would have had R2 sent to the hospital for evaluation and treatment. If staff had notified me that R2 received her blood pressure medications when her B/P was already low I would have sent her to the hospital for evaluation and treatment. R2's B/P could have been severely low during that five hour period when no blood pressures were taken. But since Z2 (Nurse Practitioner) and I were not notified until R2's B/P was 68/40, R2 had to be sent to the hospital emergently. R2's [DIAGNOSES REDACTED].

Based on interview and record review the facility failed to follow a physician's orders to hold antihypertensive medications for specified blood pressure parameters, and failed to give intravenous fluids at the ordered rate for one of five residents (R2) reviewed for physician's orders in a sample of 13. These failures resulted in R2 developing severe [MEDICAL CONDITION], requiring emergent hospitalization , sustaining Cardiac Demand Ischemia following the antihypertensive medication administration. Findings include: A Medication Orders - Not Controlled Substances policy dated 12/21/09 states, Standard Protocols written by the physician will name the condition and prescribe the action to be taken in caring for the patient, including the dosage and route of administration for a drug .Record the order on the physician order sheet. A Following Physician Orders policy (undated) states that staff, Cannot change a physician order without another order from the physician .Orders to be carried out as written .Notify the physician when you are unable to carry out the orders as written. R2's Change in Condition Evaluation dated 12/18/16 at 3:45p.m., documents R2 had a change in condition related to abnormal vital signs, food and/or fluid intake was decreased, nausea and vomiting. The Change in Condition Evaluation documents R2's blood pressure (BP) was 93 systolic blood pressure (SBP) and 48 diastolic blood pressure (DBP) or 93/48mmhg (millimeters of mercury), heart rate 117 bpm (beats per minute), and respirations were 50 breaths per minute all of which was reported to Z1 (R2's physician). A nurse's note dated 12/18/16 at 4:49p.m., states, New orders .hold B/P med (medication) if SBP is less than 120 and DBP is less than 60. A nurse's note dated 12/18/16 at 9:30p.m. documents R2's physician was notified that R2's family was requesting intravenous (IV) fluids for R2. R2's Blood Pressure log dated 12/18/16 documents that R2's blood pressure was still 93/48mmhg at 10:27p.m. R2's physician's order (POS) dated 12/18/16 following R2's low B/P documents R2 was prescribed two liters of Normal Saline IV fluids to infuse at a rate of 75cc (cubic centimeters) per hour. R2's nurse's note dated 12/18/16 at 11:27p.m., documents that an IV catheter was inserted into R2's left arm which was infusing IV fluids at a rate of 75cc per hour. R2's Blood Pressure log dated 12/19/16 at 7:52a.m.,documents R2's blood pressure at that time was 108/56mmhg. R2's Medication Administration Record [REDACTED]. R2's Blood Pressure log dated 12/19/16 at 9:46a.m. documents R2's blood pressure at that time was 114/78mmhg. R2's MAR indicated [REDACTED]. R2's Blood Pressure log dated 12/19/16 documents R2's next blood pressure was not taken again for five hours at 2:56p.m., at which time it was 68/40mmhg. R2's nurse's note dated 12/19/16 at 3:38p.m. and 4:15p.m., document that Z1 was then notified of R2's condition and orders were given for R2 to be transferred to the emergency room . A Disciplinary Report dated 12/28/16 documents that E2 (Registered Nurse) increased R2's IV fluids infusion rate from the ordered 75cc/ hour to 150cc/ hour for approximately 45 minutes prior to R2's transfer to the hospital on [DATE]. On 2/2/17 at 3:06p.m., E7 (Registered Nurse) verified that E7 administered R2's blood pressure medication Moexipril [MEDICATION NAME] 15mg and [MEDICATION NAME] 0.1mg at 8:00a.m. on 12/19/16 despite R2's blood pressure of 108/56mmhg and also administered [MEDICATION NAME] 0.1mg at 12:00p.m. despite R2's blood pressure at 9:46a.m., of 114/78mmhg. E7 stated that before administering the antihypertensive medications she was sure she had taken R2's B/P stating, It was OK, but I don't remember what it was. E7 stated that there were no physician notifications made because R2 was, doing well, up in the chair, and eating and drinking. R2's hospital Critical Care physician's History and Physical progress note dated 12/19/16 documents when R2 was admitted to the emergency room at which time laboratory (lab) tests were performed. The progress note documents R2's lab results for a Troponin level (a protein released when heart muscle is damaged) was elevated which was, Likely caused by demand ischemia. Plan: Will hold antihypertensive medications. On 2/2/17 at 11:35a.m., Z1 (R2's physician) stated, When Z2 (Nurse Practitioner) was called on the afternoon of 12/19/16, when R2's B/P was 68/40, that nurse told Z2 that she had increased the rate of the IV fluids to 150cc/hour. I would have expected the nurse to infuse R2's IV fluids at the ordered rate and not change the rate without calling me first. Also I would have expected the nurse would call me when R2 received her antihypertensive medications when R2's blood pressure was less than 120SBP and less than 60DPB. If staff had notified me that R2 received her blood pressure medications against my orders to hold for SBP less than 120 and DBP less that 60, when her B/P was already low, I would have sent her to the hospital for evaluation and treatment sooner. R2's B/P may have already been severely low during that five hour period when no blood pressures were taken. But since Z2 and I were not notified until R2's B/P was 68/40 on 12/19/16 at approximately 3:00p.m., R2 had to be sent to the hospital emergently. R2's elevated troponin level with [DIAGNOSES REDACTED].

Noncompliance resulted in multiple deficient practices. Based on interview and record review the facility failed to ensure a hyopotensive resident was not administered antihypertensive medications, and blood pressures were monitored for that hypotensive resident which affected one of nine residents (R2) reviewed for medication administration parameters in a sample of thirteen. These failures resulted in R2 developing severe [MEDICAL CONDITION], requiring emergent hospitalization , sustaining Cardiac Demand Ischemia following the antihypertensive medication administration. Findings include: A Medication Orders - Not Controlled Substances policy dated 12/21/09 states, Standard Protocols written by the physician will name the condition and prescribe the action to be taken in caring for the patient, including the dosage and route of administration for a drug . A Following Physician order [REDACTED].Orders to be carried out as written .Notify the physician when you are unable to carry out the orders as written. A Lippencott,(NAME)and(NAME)Nursing Drug Handbook dated 2011 instructs to monitor blood pressure frequently while taking [MEDICATION NAME]. A(NAME)Nursing Guide (undated) documents that an adverse effect of administering Moexipril is [MEDICAL CONDITION]. R2's Change in Condition Evaluation dated 12/18/16 at 3:45p.m. documents R2 had a change in condition related to abnormal vital signs, food and/or fluid intake was decreased, nausea and vomiting. The Change in Condition Evaluation documents R2's blood pressure (BP) was 93 systolic blood pressure (SBP) and 48 diastolic blood pressure (DBP) or 93/48mmhg (miilimeters of mercury), heart rate 117 bpm (beats per minute), and respirations were 50 breaths per minute all of which was reported to Z1 (R2's physician). A nurse's note dated 12/18/16 at 4:49p.m., states, New orders .hold B/P med (medication) if SBP is less than 120 and DBP is less than 60. A nurse's note dated 12/18/16 at 9:30p.m. document R2's physician was notified that R2's family was requesting intravenous (IV) fluids for R2. R2's Blood Pressure log dated 12/18/16 documents that R2's blood pressure was still 93/48mmhg at 10:27p.m. R2's physician's orders [REDACTED]. R2's nurse's note dated 12/18/16 at 11:27p.m., documents that R2 had an IV catheter inserted into R2's left arm which was infusing IV fluids at a rate of 75ml (milliliters) per hour. R2's nurse's note dated 12/19/16 at 3:31a.m., document that R2's IV catheter infiltrated (stopped functioning) and, RNs (Registered Nurses) tried six times to start another. Sent fax to Z1 (R2's physician) to state RN cannot get anoather IV started .awaiting reply. The nurse's notes do not document that Z1 was called in addition to sending a fax to Z1's office. R2's nurse's note dated 12/19/16 at 7:00a.m. documents R2's IV and IV fluids were restarted at that time. R2's Blood Pressure log dated 12/18/16 and 12/19/16 does not document R2 had blood pressure monitoring from 10:27p.m. on 12/18/16 to 7:52a.m. 12/19/16 at which time R2's blood pressure was 108/56mmhg. R2's MAR indicated [REDACTED] R2's Blood Pressure log dated 12/19/16 at 9:46a.m. documents R2's blood pressure at that time was 114/78mmhg. R2's MAR indicated [REDACTED]. R2's Blood Pressure log dated 12/19/16 documents R2 did not have another blood pressure taken until 2:56p.m., five hours later, which was 68/40mmhg. R2's nurse's note dated 12/19/16 at 3:38p.m. and 4:15p.m., documents that Z1 was notified of R2's condition and ordered for R2 to be transferred to the emergency room for evaluation and treatment. On 2/2/17 at 3:06p.m., E7 (Registered Nurse) verified that E7 administered R2's blood pressure medication Moexipril [MEDICATION NAME] 15mg and [MEDICATION NAME] 0.1mg at 8:00a.m. on 12/19/16 despite R2's blood pressure of 108/56mmhg and also administered [MEDICATION NAME] 0.1mg at 12:00p.m. despite R2's blood pressure at 9:46a.m., of 114/78. E7 stated that, before administering the antihypertensive medications she was sure she had taken R2's B/P stating, It was OK, but I don't remember what it was. E7 stated that there were no physician notifications made because R2 was, doing well, up in the chair, and eating and drinking. R2's hospital Critical Care physician's History and Physical progress note dated 12/19/16 documents R2 was admitted to the emergency room where laboratory (lab) tests were performed. The progress note documents R2's lab results for a Troponin level (a protein released when heart muscle is damaged) was elevated which was, Likely caused by demand ischemia. Plan: Will hold antihypertensive medications. A Disciplinary Report dated 12/28/16 documents that E2 (Registered Nurse) increased R2's IV fluids infusion rate from the ordered 75cc/ hour to 150cc/ hour for approximately 45 minutes prior to R2's transfer to the hospital on [DATE]. On 2/6/17 at 2:25p.m. E2 (Director of Nurses) verified that on 12/19/16 at approximately 3:00p.m. E2 increased R2's IV fluid rate to 150cc/hr for about 45 minutes. E2 also stated that Z1 (R2's physician) should have been notified by the nursing staff that R2 had received antihypertension medications when R2's blood pressure was already low and stated, If a resident has a low BP, I would think you would monitor it more frequently. But, I wasn't there that day. On 2/2/17 at 11:35a.m., Z1 (R2's physician) stated, When Z2 (Nurse Practitioner) was called on the afternoon of 12/19/16, when R2's B/P was 68/40, that nurse told Z2 that she had increased the rate of the IV fluids to 150cc/hour. I would have expected the nurse to infuse R2's IV fluids at the ordered rate and not change the rate without calling me first. Also I would have expected the nurse would call me when R2 received her antihypertensive medications when R2's blood pressure was less than 120SBP and less than 60DPB. If staff had notified me that R2 received her blood pressure medications against my orders to hold for SBP less than 120 and DBP less that 60, when her B/P was already low, I would have sent her to the hospital for evaluation and treatment sooner. R2's B/P may have already been severely low during that five hour period when no blood pressures were taken. But since Z2 and I were not notified until R2's B/P was 68/40 on 12/19/16 at approximately 3:00p.m., R2 had to be sent to the hospital emergently. R2's elevated troponin level with [DIAGNOSES REDACTED].

Based on observation, interview, and record review the facility failed to ensure a resident at high risk for developing pressure ulcers was positioned to prevent unrelieved pressure, and that incontinence care was performed to maintain clean, dry skin for one of three residents (R1) reviewed for pressure ulcers in a sample of thirteen. These failures resulted in R1 developing a stage 4 pressure ulcer with Osteomylitis to the coccyx. Findings include: A National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury Staging Guide (undated) documents the definition of a stage 4 pressure ulcer as, Full thickness tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. A Wound Management policy dated 1/14/14 states, A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s) .Any condition that may contribute to the resident's risk of developing an ulcer and that may affect functional independence or alter the healing process will also be treated. R1's pressure ulcer risk assessment dated [DATE] documents R1's ability to respond meaningfully to pressure-related discomfort was very limited. R1's ability to walk is severely limited or non-existent. R1 can make occasional slight changes in body or extremity position, but is unable to make frequent or significant changes independently. R1 has probable inadequate nutritional intake, requires moderate to maximum assistance in moving, and has a potential problem with friction and shear damage to the skin. R1's pressure ulcer risk assessment also documents that R1's skin is not constantly moist, but is often moist requiring linens to be changed at least once per shift. R1's Minimum Data Set (MDS) assessment dated [DATE] documents R1 requires the extensive assistance of two people for toileting and bed mobility, and is always incontinent of bowel and bladder. R1's MDS dated [DATE] documents R1 totally dependent on staff for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, personal hygiene, and is always incontinent of bowel and bladder. R1's MDS also documents R1 has a functional limitation in range of motion to both lower extremities. R1's care plan dated 10/5/15 documents, R1 has potential impairment to skin integrity . instructing staff to, identity/document potential causative factors and eliminate where possible. Keep skin clean and dry. R1's care plan intervention dated 10/12/15 documents to, Check R1 at least every two hours and as required for incontinence. R1's CNA (Certified Nurse Aide) Skin Attention Forms dated 11/15/16 to 11/22/16 document R1's coccyx (At the top and center of the buttocks) had an area that the CNA, noticed an abnormality or change in color, moisture, temperature, integrity or turger. That area was marked as an X on the Skin Attention Form. Each of these forms was signed by R1's nurses indicating the nurses completed a follow up to the Skin Attention Forms. R1's CNA Skin Attention Form dated 11/29/16 was not initialed by R1's CNA indicating there were, No skin problems noted. R1's nurses' notes dated 10/30/16 to 1/31/7 show that there were no nurses' notes from 10/30/16 until 11/15/16. The 11/15/16 note states, no new issues at this time. R1's nurses' note dated 11/18/16 documents that no skin issues were reported. R1's nurses' notes dated 11/27/16 states, No recommendations, as the only entry. R1's next nurses' note was not until 12/8/16 which documents R1 has a wound to the sacrum. R1's nurses' notes date 1/17/16 states, IDT (interdisciplinary team) met for quarterly review .Weight has been stable over the last quarter (10/11/16 to 1/11/17). A Weekly Pressure Ulcer Surveillance Report dated 1/25/17 documents R1 developed a facility acquired stage 4 pressure ulcer to the coccyx on 11/30/16. R1's Wound Care Specialist Evaluation dated 11/30/16 documents R1's coccyx wound was the result of shear and measured 4.0 cm (centimeters) long X 2.0cm wide X Not measurable depth on that date. R1's Wound Care Specialist Evaluation dated 12/7/16 documents R1's wound had deteriorated as a result of ineffective pressure relief to R1's coccyx while in the chair. R1's Wound Care Specialist Evaluation dated 12/14/16 states, Necrosis much deeper now, consistent with pressure injury not shearing. The evaluation also documented R1's wound was considered unstageable on that date. R1's Wound Care Specialist Evaluation Dated 1/4/17 documents R1's Coccyx wound had deteriorated into a stage 4 pressure ulcer measuring 4.5cm long X 4.5cm wide X non-measurable depth. A Hospice Nurse's note dated 1/12/17 states, to assess coccyx wound. R1 has a stage 4 pressure injury located on the coccyx. The wound measures is full thickness tissue loss with small area of bone exposed .measures 6.8cm X 4.4cm X 1.9cm .Majority of wound bed is covered in slough and eschar. A Hospice Nurse's note dated 1/23/17 at 3:31p.m., states, Upon arrival .R1's (incontinence brief), draw sheet and bed sheets soaked with urine. R1's top and pants also wet with urine. R1 was also incontinent of small amount of stool .Requested that R1's (incontinence briefs) be checked every two hours and that R1 be turned and repositioned in bed at that time .R1 is dependent on facility staff for all ADL's (activities of daily living) . At 3:55p.m., attended care plan meeting at facility today .Voiced concern that R1's (incontinence brief), clothing, and bed linens were soaked with urine this morning upon arrival. Was informed that these matters would be addressed. A Hospice Nurse's note dated 1/26/17 at 10:00a.m. states, Upon arrival .Wound draining a moderate amount of serosanguinous exudate that is foul smelling . Z1 (R1's physician) stated that when Z1 saw R1 earlier this morning for assessment Z1 found R1 lying in bed with linens, clothes, and (incontinence brief) soaked with urine. R1 was also incontinent of stool. On 2/1/7 at 10:20a.m. E5 (Registered Nurse/RN) was preparing to change R1's pressure ulcer dressing. E5 and E6 (CNA) removed R1's pants and incontinence brief. R1's incontinence brief as well as R1's stage 4 coccyx pressure ulcer dressing were saturated with urine. R1's wound was a large deep wound approximately 6cm long X 4.5cm wide X 4cm deep with undermining deep enough that bone was visible within the wound. On 2/1/17 at 3:15p.m. E5 (RN) stated, I've come in to work in the morning before and hospice has come to me stating R1 was soaked, the whole bed and clothing soaked. One time the hospice nurse asked me to help turn R1. We pulled back the covers and R1 was soaked. R1's (incontinence brief) and bottom covers too. Z1, on Wednesday last week, found R1 wet also. Z1 said to make sure R1 was dry, turned, and repositioned. On 1/31/17 at 10:00a.m., Z1 stated that the facility was not providing R1 with appropriate incontinence care. Z1 stated that (Z1) and R1's hospice nurses have found R1 soaked with urine on multiple occasions. Z1 stated that on 1/26/17, Z1 entered R1's room to do an examination. Z1 stated, I touched R1's covers and they were saturated from the fitted sheet through to the comforter. R1 also had feces around her mouth and under her fingernails. I told a CNA and she said R1 really wasn't on her hallway but that she could clean R1 up after she finished with her patient. Z1 stated that as a result of R1's poor incontinence care, R1's coccyx pressure ulcer became infected and the bone was infected with Osteomylitis. Z1 stated that R1's wound had a foul smelling purulent discharge draining from it. Z1 stated that R1's stage 4 pressure ulcer was caused from unrelieved pressure and from R1 laying in her own waste. Z1 stated that as a result of the severity of R1's pressure ulcer and because the exposed bone within R1's wound has developed Osteomylitis, R1's death is imminent. On 2/2/17 at 10:30a.m. E1 (Administrator) stated that R1 had passed away during the previous night.

Based on observation, interview, and record review the facility failed to ensure a resident with bowel and bladder incontinence was provided with incontinence care for one of three residents (R1) reviewed for incontinence in a sample of thirteen. This failure resulted in R1 laying in R1's own waste causing the development of a stage 4 pressure ulcer with Osteomylitis to the coccyx. Findings include: R1's pressure ulcer risk assessment dated [DATE] documents R1 was at high risk for developing a pressure ulcer. R1's pressure ulcer risk assessment also documents that R1's skin is not constantly moist, but is often moist requiring linens to be changed at least once per shift. R1's Minimum Data Set (MDS) assessment dated [DATE], documents that R1 requires the extensive assistance of two people for toileting and bed mobility, and is always incontinent of bowel and bladder. R1's MDS dated [DATE] documents that R1 is totally dependent on staff for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, personal hygiene, and is always incontinent of bowel and bladder. R1's MDS also documents that R1 has a functional limitation in range of motion to both lower extremities. R1's care plan dated 10/5/15 documents, R1 has potential impairment to skin integrity . instructing staff to, identity/document potential causative factors and eliminate where possible. Keep skin clean and dry. R1's care plan intervention dated 10/12/15 documents to, Check R1 at least every two hours and as required for incontinence. A Weekly Pressure Ulcer Surveillance Report dated 1/25/17 documents R1 developed a facility acquired stage 4 pressure ulcer to the coccyx on 11/30/16. A Hospice Nurse's note dated 1/23/17 at 3:31p.m., states, Upon arrival .R1's (incontinence brief), draw sheet and bed sheets soaked with urine. R1's top and pants also wet with urine. R1 was also incontinent of small amount of stool .Requested that R1's (incontinence briefs) be checked every two hours and that R1 be turned and repositioned in bed at that time .R1 is dependent on facility staff for all ADL's (activities of daily living). At 3:55p.m., Attended care plan meeting at facility today .Voiced concern that R1's (incontinence brief), clothing, and bed linens were soaked with urine this morning upon arrival. Was informed that these matters would be addressed. A Hospice Nurse's note dated 1/26/17 at 10:00a.m. states, Upon arrival .Wound draining a moderate amount of serosanguinous exudate that is foul smelling . Z1 (R1's physician) stated that when Z1 saw R1 earlier this morning for assessment Z1 found R1 lying in bed with linens, clothes, and (incontinence brief) soaked with urine. R1 was also incontinent of stool. On 2/1/7 at 10:20a.m., E5 (Registered Nurse/RN) was preparing to change R1's pressure ulcer dressing. E5 and E6 (CNA) removed R1's pants and incontinence brief. R1's incontinence brief as well as R1's stage 4 coccyx pressure ulcer dressing were saturated with urine. R1's wound was a large deep wound approximately 6cm long X 4.5cm wide X 4cm deep with undermining deep enough that bone was visible within the wound. On 2/1/17 at 3:15p.m. E5 (RN) stated, I've come in to work in the morning and hospice has come to me stating R1 was soaked, the whole bed and clothing soaked. One time the hospice nurse asked me to help turn R1. We pulled back the covers and R1 was soaked. R1's (incontinence brief) and bottom covers too. Z1 (R1's physician) last week found R1 wet also. Z1 said to make sure R1 was dry, turned, and repositioned. On 1/31/17 at 10:00a.m., Z1 stated that the facility was not providing R1 with appropriate incontinence care. Z1 stated that Z1 and R1's hospice nurses have found R1 soaked with urine on multiple occasions. Z1 stated that on 1/26/17, Z1 entered R1's room to do an examination. Z1 stated, I touched R1's covers and they were saturated from the fitted sheet through to the comforter. R1 also had feces around her mouth and under her fingernails. I told a CNA and she said that R1 really wasn't on her hallway but that she could clean R1 up after she finished with her patient. Z1 stated that R1's wound has a foul smelling purulent discharge draining from it. Z1 stated that R1's stage 4 pressure ulcer was caused from unrelieved pressure and from R1 laying in her own waste. Z1 stated that as a result of the severity of R1's pressure ulcer and because the exposed bone within R1's wound has developed Osteomylitis, R1's death is imminent. On 2/2/17 at 10:30a.m. E1 (Administrator) stated R1 had passed away during the previous night.

Based on interview and record review the facility failed to identify and investigate a significant medication error for one of five residents (R2) reviewed for medication errors in a sample of 13. This failure resulted in R2 developing severe [MEDICAL CONDITION], requiring emergent hospitalization , sustaining Cardiac Demand Ischemia following the antihypertensive medication administration. Findings include: A Medication Monitoring Identifying and Managing Medication Errors and Adverse Consequences policy, dated 5/1/14 states, The staff and practitioner shall try to prevent medication errors and adverse medication consequences, and shall strive to identify and manage them appropriately when they occur .The staff shall report clinically significant adverse medication consequences and medication errors with adverse clinical consequences to the resident's Attending Physician immediately. Any and all facility protocols related to the investigation and monitoring of medication errors should be initiated and followed immediately following the discovery of a medication error. Nursing staff will document appropriately detailed accounts of any incidents on an appropriate report form. R2's Change in Condition Evaluation dated 12/18/16 at 3:45p.m. documents R2 had a change in condition related to abnormal vital signs, food and/or fluid intake was decreased, nausea and vomiting. The Change in Condition Evaluation documents R2's blood pressure (BP) was 93 systolic blood pressure (SBP) and 48 diastolic blood pressure (DBP) or 93/48mmhg (millimeters of mercury), heart rate 117 bpm (beats per minute), and respirations were 50 breaths per minute all of which was reported to Z1 (R2's physician). A nurse's note dated 12/18/16 at 4:49p.m., states, New orders .hold B/P med (medication) if SBP is less than 120 and DBP is less than 60. R2's physician's orders [REDACTED]. R2's nurse's note dated 12/19/16 at 3:31a.m., documents that R2's IV catheter infiltrated (stopped functioning) and, RNs (Registered Nurses) tried six times to start another. Sent fax to Z1 (R2's physician) to state RN cannot get another IV started .awaiting reply. The nurse's notes do not indicate that staff tried to reach Z1 by telephone in addition to staff sending a fax to Z1's office. R2's nurse's note at 7:00a.m. documents that R2's IV and IV fluids were not restarted until that time, three and one half hours later. R2's Blood Pressure log dated 12/19/16 at 7:52a.m., documents that R2's blood pressure was 108/56mmhg. R2's Medication Administration Record [REDACTED] R2's Blood Pressure log dated 12/19/16 at 9:46a.m., documents that R2's blood pressure at that time was 114/78mmhg. R2's MAR indicated [REDACTED]. R2's Blood Pressure log dated 12/19/16 documents R2's next blood pressure was not taken again for five hours at 2:56p.m., and was 68/40mmhg. R2's nurse's note dated 12/19/16 at 3:38p.m. and 4:15p.m., document that Z1 was then notified of R2's condition and orders were given for R2 to be transferred to the emergency room . On 2/2/17 at 3:06p.m. E7 (Registered Nurse) verified that E7 administered R2's blood pressure medication Moexipril [MEDICATION NAME] 15mg and [MEDICATION NAME] 0.1mg at 8:00a.m. on 12/19/16 despite R2's blood pressure of 108/56mmhg and also administered [MEDICATION NAME] 0.1mg at 12:00p.m. despite R2's blood pressure at 9:46a.m., of 114/78. E7 stated that before administering the antihypertensive medications, she was sure she had taken R2's B/P stating, It was OK, but I don't remember what it was. E7 stated that there were no physician notifications made because R2 was, doing well, up in the chair, and eating and drinking. R2's hospital Critical Care physician's History and Physical progress note dated 12/19/16 documents when R2 was admitted to the emergency room , laboratory (lab) tests were performed. The progress note documents R2's lab results for a Troponin level (a protein released when heart muscle is damaged) was elevated which was, Likely caused by demand ischemia. Plan: Will hold antihyupertensive medications. On 2/6/17 at 2:25p.m. E2 (Director of Nurses) stated that Z1 (R2's physician) should have been notified by the nursing staff that R2 had received antihypertension medications when R2's blood pressure was already low. E2 also stated no medication error investigation had been initiated to determine why E7 administered R2's antihypertension medications when R2's blood pressure was below the parameters ordered by Z1 (R2's physician). On 2/2/17 at 11:35a.m. Z1 stated, I would have expected facility staff to monitor R2's B/P more closely since it had been low and R2 was getting IV fluids. I would have expected to be notified by phone when facility staff were unable to restart R2's IV catheter and administer IV fluids since I am not in my office in the middle of the night. I would have expected the nurse would call me when R2 received her antihypertensive medications when R2's blood pressure was less than 120SBP and less than 60DPB. If staff had notified me by phone that an IV could not be started for R2, I would have had R2 sent to the hospital for evaluation and treatment. If staff had notified me that R2 received her blood pressure medications when her B/P was already low I would have sent her to the hospital for evaluation and treatment. R2's B/P may have been severely low during that five hour period when no blood pressures were taken. But since Z2 (Nurse Practitioner) and I were not notified until R2's B/P was 68/40, R2 had to be sent to the hospital emergently. R2's [DIAGNOSES REDACTED].

Based on record review and interview, the facility failed to assess and treat pain for one of three residents (R1) reviewed for pain in the sample of three. This failure resulted in R1 experiencing severe pain for several days. Findings include: Pain Management policy dated 6/20/13, states, "Pain will be assessed and managed in a timely manner. The physician will be notified of resident's complaint of pain when not relieved by medication as ordered by the physician. Thorough communication with the physician will ensure an appropriate pain management plan." In addition, the policy states, "Residents receiving scheduled pain medication will have the effectiveness documented each shift on the MAR (Medication Administration Record)." Report titled, "IHS Physician Transfer Report," dated 10/16/14, documents [MEDICATION NAME] 50 mcg (microgram)/hour, commonly known as [MEDICATION NAME]. Place one patch onto the skin every third day, [MEDICATION NAME] 7.5 MG (milligrams)-Take one tablet by mouth daily." October 2014 MAR (Medication Administration Record) for R1 documents, "[MEDICATION NAME]-50 patch-Apply one patch every 72 hours for pain," ordered on [DATE] and discontinued on 10/23/14. On 10/17/14, the medication is documented as not given with reason noted as, "awaiting delivery." On 10/20/14, the medication is documented as not given with reason noted as, "Duplicate." October 2014 MAR for R1 documents [MEDICATION NAME] Tablet 7.5 mg (milligram) given daily beginning 10/16/14. There is no documentation of the effectiveness. On 11/12/14 at 2:10 p.m., E2 (Director of Nursing) stated resident pain should be assessed every shift and documented on the MAR (Medication Administration Record). On 11/13/14 at 10:40 a.m., E2 (Director of Nursing) stated after investigation E2 found that R1's [MEDICATION NAME] Patch 50 mcg was never received from the pharmacy and R1 did not have it administered per physician order. E2 stated "there is no evidence that (R1's) physician was notified that the [MEDICATION NAME] (50 mcg) was not given from 10/16/14 through 10/23/14." E2 denied knowledge of why the [MEDICATION NAME] was not administered. On 11/13/14 at 11:09 a.m., E3 (Physical Therapy Assistant) stated, "I was (R1's) main therapist." E3 stated R1 experienced severe pain in R1's lower back and hips. E3 stated, "A lot of times (R1) was writhing and rocking back and forth in pain." E3 stated R1's first week at the facility, R1 was uncomfortable and weak but able to function. E3 stated R1's second week at the facility, R1's pain increased and affected R1's ability to function. E3 stated "I did report (R1's pain) to the nurse and I know there was a pain patch in question." Interview with Z3 (Pharmacy Director) on 11/13/14 at 11:37 AM, Z3 stated the pharmacy did not dispense [MEDICATION NAME] 50 micrograms for R1 from 10/16/14 to 10/23/14. Z3 also stated, "There is no record of any follow up from the nurses at (the facility) asking where (R1's) [MEDICATION NAME] was. This would have triggered (the pharmacy) to look into it." Nurses Notes dated 10/16/14 through 11/7/14, document R1's pain levels as follows: 10/16/14: 4 out of 10; 10/17/14: 4 out of 10; 10/18/14: 4 out of 10; 10/19/14: 6 out of 10; 10/22/14: 4 out of 10; 10/23/14: 6 out of 10; 10/24/14: 4 out of 10; 10/27/14: 2 out of 10; 10/29/14: 4 out of 10; 10/30/14: 5 out of 10; 10/31/14 5 out of 10; 11/1/14: 9 out of 10; 11/2/14 "severe pain in lower back...crying, moaning and gowning"; 11/3/14: "10++"; 11/3/14: 10 out of 10; 11/3/14: 5 out of 10; 11/4/14: 5 out of 10; 11/6/14: 7 out of 10; 11/7/14: 5 out of 10.