La Bella Of Morrison

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify the ombudsman of a discharged resident for 1 of 3 residents (R1) reviewed for discharge in the sample of 3.The findings include:R1s admission record shows she was admitted to the facility on [DATE], and she discharged on 3/11/2026 to home.R1s resident assessment and care screening of 3/3/26 documents her as cognitively intact. She was independent with supervision for her self-care needs, and independent with mobility.On 3/19/26 at 9:40 AM, V4 (Ombudsman) said R1 was issued an involuntary discharge due to non-payment. She was working with R1 on the case, including filing an appeal and setting up a hearing for April. V4 said she obtained representation for R1 regarding the hearing and notified the facility. She said a message had been left for her by V3 (Adult Protective Services-APS) care worker R1 had discharged from the facility. She said R1 had been discharged on 3/11/26, and to this day the facility still had not sent any notification of discharge. V4 said the judge has to be notified and the involuntary discharge has to be withdrawn.On 3/19/26 at 11:45 AM, V1 (Administrator) said on 2/13/26 she issued R1 an involuntary discharge due to non-payment. Her date of discharge was set for 3/16/26, but after the appeal R1 would have been able to stay longer. V1 said R1 chose to discharge on her own 3/11/26. V1 said it should have been herself or social services to notify the Ombudsman office of R1 discharging. V1 reviewed her email communications with V4 and said there had been no notifications. V1 said she should have notified the Ombudsman office. The facility's 10/13/25 policy for transfer and discharge documents 4. Generally, the notice must be provided at least 30 days prior to a transfer or discharge of the resident. Exceptions to the 30-day requirement apply when the transfer or discharge is affected because: e. In these exceptional cases, the notice must be proved to the resident, resident's representative if appropriate, and ombudsman as soon as practicable before the transfer or discharge. 5. The facility will maintain evidence that the notice was sent to the ombudsman. 6. If the information in the notice changes prior to affecting the transfer or discharge, the social services director or designee must update the recipients of the notice as soon as practicable once the updated information becomes available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to administer resident medications at the correct time and as per physician order. The facility failed to monitor a resident's blood glucose (sugar) level at the correct time and as per physician order. These failures apply to 1 of 3 residents (R5) reviewed for medication administration in the sample of 7.The findings include:R5's admission record showed R5 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus.On 2/24/26 at 10:23 AM, V15 (R5's Power of Attorney/POA) stated the facility had not been checking R5's blood glucose levels like they were supposed to. V15 also stated the facility had been giving R5 his medications late. R5's February 2026 Medication Administration Record showed the following orders for R5;Accu-checks (blood glucose monitoring) to be done before meals and at bedtime. R5's accu-checks to be done daily at 6:30 AM, 11:30 AM, 4:30 AM, 9:00 PM.Humulin R (regular insulin); inject 3 units subcutaneously (SQ) with meals at 7:30 AM, 12:00 PM, 5:30 PM.Reglan (medication for gastric reflux) 10 milligrams, give one tablet before meals at 6:30 AM, 11:30 AM, 4:30 PM.On 2/24/26 at 8:32 AM, R5 was seated in the dining room with his breakfast tray in front of him. R5 had consumed approximately 25% of his breakfast. R5 told nearby facility staff that he was done eating his meal. At 8:33 AM, V13 Licensed Practical Nurse (LPN) checked R5's blood glucose (after he had eaten). V13's blood glucose was 256. At 8:39 AM, V13 administered 3 units of Humulin R to R5 (over 2 hours late). At 8:56 AM, V13 administered 10 milligrams of Reglan to R5 (over 2 hours late and after R5 had eaten).On 2/24/26 at 10:53 AM, V2 (Director of Nursing) stated medications are to be administered at the scheduled time and as per physician order. V2 stated medication administration is considered late if the medication is given later than one hour past it's scheduled time. V2 stated, Residents blood sugars are to be checked prior to them eating so we have an accurate result. If a blood sugar is checked after a resident eats, the sugar will be high and not accurate. The facility's Blood Glucose Monitoring policy dated 10/13/25 showed, The facility will perform blood glucose monitoring as per physician's orders.The facility's Timely Administration of Insulin policy dated 10/13/25 showed, It is the policy of this facility to provide timely administration of insulin in order to meet the needs of each resident and to prevent adverse effects on a resident's condition. All insulin will be administered in accordance with physician's orders.The facility's Medication Administration policy dated 10/13/25 showed, Ensure that the six rights of medication administration are followed: a. Right resident b. Right drug c. Right dosage d. Right route e. Right time d. Right documentation. Administer medications as ordered in accordance with manufacturer specifications.

Based on interview and record review the facility failed to honor and implement a resident's DNR (do not resuscitate) status as indicated per the resident's POLST form (Physician Orders for Life-Sustaining Treatment form) for 1 of 3 residents (R5) reviewed for advance directives in the sample of 7.The findings include:R5's admission record showed R5 was admitted to the facility, from a local hospital, on 2/10/26. R5's hospital discharge orders dated 2/10/26 showed R5 was a DNR. R5's admission care plan dated 2/10/26 showed R5 was cognitively impaired. R5's care plan showed no documentation related to R5's advanced directives. R5's healthcare Power of Attorney (POA) form dated 12/8/25 showed V15 was R5's POA. A POLST form dated 2/20/26 showed R5 was a DNR.On 2/24/26 at 10:23 AM, V15 (R5's POA) stated, (R5) is supposed to be a DNR. They (facility) have a signed POLST form showing this, but they said they couldn't honor the form until their (the facility's) medical director signs off on the DNR. That doesn't make sense.A physician order dated 2/12/26 showed R5 was a Full Code. On 2/24/26 at 10:53 AM, V2 Director of Nursing (DON) stated if a resident's POLST form shows a resident is a DNR, the facility is to honor the resident's request. V2 stated if the resident already has a POLST form signed by a physician, the facility's medical director does not also need to sign off on the form for the form to be valid. V2 reviewed R5's POLST form, hospital discharge orders, and current admission orders. V2 stated, I don't know why he (R5) is a Full Code. He should be a DNR. The facility's Residents' Rights Regarding Treatment and Advance Directives policy dated 10/13/25 showed, It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate advance directives. Upon admission, should the resident have an advance directive, copies will be made and placed in the chart as well as communicated to the staff. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide incontinence care to residents dependent on staff for cares for 2 of 4 residents (R1, R2) reviewed for activities of daily living (ADLs) in the sample of 7. The findings include:1.R1's resident assessment dated [DATE] showed R1 was cognitively impaired and was dependent on staff for toileting and incontinence care. On 2/23/26 at 10:24 AM, V6 (R1's private caregiver) stated she visits R1 daily in the facility. V6 stated, They don't toilet (R1) or change her brief unless I ask them too. She will sit in the same brief for hours.On 2/23/26 at 8:28 AM, R1 was dressed and seated in the dining room eating breakfast. V4 Certified Nursing Assistant (CNA) stated she had last changed R1's incontinence brief around 7:00 AM that morning, prior to getting her dressed for the day.On 2/23/26 at 9:13 AM, R1 was moved from the dining room to the activity room by facility staff. On 2/23/26 at 9:45 AM, R1 remained seated in her wheelchair in the activity room.On 2/23/26 at 10:00 AM, R1 remained seated in the activity room. V6 (R1's private caregiver) was seated next to R1.On 2/23/26 at 11:10 AM, R1 remained seated in the activity room with V6 seated next to R1. On 2/23/26 at 12:07 PM, R1 was in her room with V6. V6 stated, I have been here since 10:00 AM. No one has offered to toilet or change her since I have been here. On 2/23/26 at 12:37 PM, R1 was transferred into bed by V4 and V11 CNAs. V11 removed R1's incontinence brief. V4 stated R1's brief has not been changed since 7:00 AM (over 5 hours). R1 was incontinent of urine. R1's buttocks were red. 2.R2's resident assessment dated [DATE] showed R2 was severely cognitively impaired and dependent on staff for toileting and incontinence care. The assessment showed R2 was incontinent of stool and urine.R2's current care plan showed, Check resident every two hours and assist with toileting as needed due to R2's incontinence. On 2/23/26 at 8:32 AM, R2 was seated in a wheelchair in her room. An odor of stool was noted in the room. V8 CNA stated R2's incontinence brief was last changed by facility night staff; sometime before 5:00 AM (at least 3.5 hours prior). V8 stated, When I got here at 5:00 AM, (R2) was already up and dressed for the day. V8 and V11 CNAs transferred R2 into bed and removed R2's incontinence brief. R2 was incontinent of a large amount of liquid stool. R2's buttocks appeared bright pink. On 2/24/26 at 10:53 AM, V2 Director of Nursing stated residents that require staff assistance with toileting and/or incontinence care are to be toileted and/or provided with incontinence care every 2 hours and as needed. The facility's Incontinence policy dated 10/13/25 showed, Based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services.

Based on observation, interview and record review the facility failed to provide daily wound treatments to a resident's leg laceration for 1 of 3 residents (R1) reviewed for wounds in the sample of 7.The findings include:R1's progress notes and hospital records dated 1/23/26 showed R1 sustained a laceration to her left lower leg while being transferred into bed by facility staff. R1 was emergently transported via ambulance to a local hospital for an evaluation of her laceration. R1's leg laceration was repaired with nine (9) sutures. R1 was discharged back to the facility with orders for facility staff to provide daily wound treatments and dressing changes to R1's laceration.On 2/23/26 at 10:24 AM, R1 was seated next to V6 (R1's private caregiver) in the activity room. A gauze dressing was noted around R1's left lower leg. No date was noted on the dressing. V6 stated, Every day, I have to ask them (facility staff) to change her leg dressing. There were two days, on February 11 and 12th, they didn't change her dressing at all.On 2/23/26 at 2:00 PM, this surveyor reviewed R1's February 2026 Treatment Administration Record (TAR). A physician order dated 2/7/26 showed, Cleanse wound to LLE (left lower extremity) with wound cleanser. Cover with xeroform (bandage), maxorb (bandage), abdominal pad, and wrap with kerlix dressing, every day shift. The TAR showed no documentation that wound treatments and dressing changes were provided to R1's wound on 2/11/26 or 2/12/26. On 2/24/26 at 8:51 AM, R1 was seated in her wheelchair next to V6 (R1's private caregiver). The gauze dressing around R1's left lower leg appeared dirty with a moderate amount of yellow drainage noted on the undated dressing. V6 stated, I was here until 7:00 PM last night. No one changed her dressing yesterday. On 2/24/26 at 10:00 AM, this surveyor again reviewed R1's February 2026 TAR. The TAR showed no wound treatment or dressing change was provided to R1's left leg wound on 2/23/26. The TAR showed new documentation, from V2 Director of Nursing (DON), that V2 had provided wound care and a dressing change to R1's leg wound on 2/11/26 and 2/12/26. On 2/24/26 at 10:53 AM, V2 DON stated resident wound care treatments and dressing changes are to be completed, as ordered, by facility nursing staff. V2 stated only the nurse completing the wound care can document that the care had been provided in a resident's electronic medical record. When V2 was asked if she provided wound care to R1's leg laceration on 2/11/26 and 2/12/26, as per the new documentation noted on R1's February 2026 TAR, V2 stated, No, I didn't do her wound care on those days. I was always told by corporate to never leave that charting blank so when I saw (R1's) TAR was blank on those dates, I put my initials on those dates in her chart last night.The facility's Wound Treatment Management policy dated 10/13/25 showed, Wound Treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change.

Based on interview and record review the facility failed to safely transfer residents and in a manner to prevent resident falls and injuries for 2 of 5 residents (R1, R3) reviewed for resident safety and supervision in the sample of 7. This failure resulted in R1 sustaining a large leg skin laceration, during a transfer, that required emergent transport to a local hospital for suture repair. The findings include:1.R1's progress notes and hospital records dated 1/23/26 showed R1 sustained a laceration to her left lower leg while being transferred into bed by facility staff. R1 was emergently transported via ambulance to a local hospital for an evaluation of her laceration. R1's leg laceration was repaired with nine (9) sutures. R1 was discharged back to the facility on antibiotics for the laceration and with orders to follow up with the hospital's wound care team.R1's admission physical therapy evaluation dated 1/8/26 showed, Per consultation, patient demonstrated fear of falling as evidenced from patient getting anxious and unable to stand with 1 person assist despite max assistance given. Patient demonstrated severe posterior lean when attempted to stand. Patient was able to stand with CGA (contact guard assistance) of 2 people. The evaluation showed R1 required the assistance of 2 staff for transfers and standing. On 2/23/26 at 11:16 AM, V7 Certified Nursing Assistant (CNA) stated she was transferring R1, from her wheelchair to the bed, on 1/23/26 when R1's leg laceration occurred. V7 stated, It was my first time taking care of her, so I didn't know how she transferred. I went to stand her up and she started freaking out. She became frantic and panicked which made me anxious, so I just hurried up and got her on the bed. She immediately said her leg was hurting. I pulled up her pant leg and saw a big skin tear. My guess is that her leg got caught on the leg of the wheelchair when I was transferring her. I should have stopped and gotten someone else to help me move her. I should have given her time to calm down. On 2/23/26 at 2:19 PM, V12 Restorative Nurse stated to ensure R1's safety, R1 should be transferred by two staff due to her extreme anxiety and fear of falling. On 2/23/26 at 12:11 PM, V10 Medical Director stated staff are to transfer residents in accordance with the recommendations made by skilled therapy or restorative services. V10 stated his expectation is that residents are not injured while being cared for by staff. 2.R3's care plan dated 11/5/25 showed R3 had history of falls in the facility. R3 was at risk for falls due to her impaired cognition and the paralysis of her right arm and right leg due to a previous stroke. R3 was nonverbal. The plan showed R3 required the use of a gait belt and the assistance of one staff for transfers, standing, and ambulation. R3's fall incident report dated 1/27/26 showed R3 sustained a fall in her bathroom while being cared for by V4 CNA. R3 struck her head on the sink as she fell. R3 complained of right leg pain post-fall. R3 was emergently transported by ambulance to a local hospital for an evaluation. R3's hospital radiology studies were negative for any fractures or injuries. R3 was discharged back to the facility on 1/27/26. On 2/23/26 at 2:04 PM, V4 CNA stated on 1/27/26, she assisted R3 to a standing position, off the toilet, without using a gait belt. V4 stated, When I turned away from (R3) to take off my gloves and wash my hands, she fell to the ground. I wasn't holding onto her at all when she fell.On 2/23/26 at 2:19 PM, V12 Restorative Nurse stated staff are to use a gait belt when transferring R3. The facility's Use of Gait Belt policy dated 10/13/25 showed, It is the policy of this facility to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident was free of significant medication errors for 1 of 3 residents (R1) reviewed for medication administration in the sample of 7. This failure resulted in R1 requiring 1:1 supervision related to increased restlessness and agitation and resulted in R1 not receiving prescribed antibiotics and being readmitted to the hospital with pneumonia. The findings include: R1's face sheet showed he was admitted to the facility 10/16/25 with diagnoses to include pneumonia due to other gram-negative bacteria, generalized anxiety disorder, malignant neoplasm of prostate, Alzheimer's Disease, and heart failure. R1's facility assessment dated [DATE] showed he had severe cognitive impairment and was dependent upon staff for all cares. R1's October 2025 Physician Order Sheet showed he was admitted with orders for buspirone, alprazolam, Cefdinir, Doxycycline, and furosemide. R1's Care Plan initiated 10/17/25 showed, [R1] has an eye infection, Neomycin-Polymyxin-Dexamethasone Ophthalmic Ointment. Instill 1 application in both eyes three times a day for reduce redness, swelling, or itching. Infection will be resolved without complications. Give therapeutic ointments, drops as ordered by physician.R1's October 2025 eMAR (electronic Medication Administration Record) showed R1 missed doses of his antibiotic ointment for his eye infection, Neomycin-Polymyxin-Dexamethasone Ophthalmic Ointment on 10/16/25, 10/17/25, 10/18/25, 10/19/25, and 10/20/25. R1's Care Plan initiated 10/17/25 showed, [R1] has bacterial pneumonia he takes doxycycline and Cefdinir for 4 days. [R1] pneumonia will be resolved without complications. Give medications as ordered.R1's October 2025 eMAR showed R1 missed doses of his antibiotic, Cefdinir on 10/16/25, 10/17/25, 10/18/25 and 10/19/25 (7 doses). R1's Care Plan initiated 10/17/25 showed, [R1] is on diuretic therapy Lasix (furosemide) and Spironolactone related to edema and hypertension. Administer diuretic medications as ordered by physician. R1's October 2025 eMAR showed R1 missed doses of his diuretic furosemide and spironolactone on 10/16/25 and 10/17/25.R1's Care Plan initiated 10/17/25 showed, [R1] uses anti-anxiety medications Xanax (Alprazolam) and Buspirone. the resident will be free from discomfort or adverse reactions related to antianxiety therapy through the review date. Administer antianxiety medications as ordered by physician.R1's October 2025 eMAR showed R1 missed doses of his antianxiety medication, buspirone on 10/16/25, 10/17/25, and 10/18/25 (5 missed doses). The same eMAR showed R1 missed doses of his antianxiety medication, alprazolam on 10/16/25, 10/17/25, 10/18/25, and 10/19/25 (7 missed doses). On 11/25/25 at 10:01 AM, V11 (Facility's Pharmacist) said the first delivery of R1's medications to the facility occurred on 10/19/25 at 3:45 AM. The pharmacy's Packing Slip Proof of Delivery showed the 10/19/25 delivery included R1's following medications: buspirone, doxycycline, and furosemide. V11 said R1's Cefdinir (antibiotic) and Alprazolam (antianxiety medication) was delivered to the facility 10/20/25 at 2:43 AM and R1's antibiotic eye drops were delivered to the facility 10/21/25 at 3:21 AM. On 11/22/25 at 11:15 AM, V4 LPN (Licensed Practical Nurse) said, [R1] was in a really bad state of being. [R1] was mostly nonverbal. He was 1:1 at times due to being very combative. I was told in report that he was in a bed that was low to the floor, he was constantly hitting and kicking, and trying to get ahold of staff but because of his condition he was not very successful with that.On 11/25/25 at 9:21 AM, V7 RN (Registered Nurse) said, [R1] was very anxious, he was combative, and it was very hard to communicate with him and calm him down. They had him on 1:1 due to his agitation, anxiety, and combativeness. He would kick and hit if you got too close. Once the alprazolam and buspirone were onboard, it helped. That is why he was a 1:1, we were contacting the pharmacy constantly telling them we needed these. On 11/25/25 at 12:05 PM, V10 (Previous CNA Supervisor) said, [R1] was 1:1 due to increased behaviors. He was a very high fall risk. He became agitated from time to time. He would yell out and become combative at times. On 11/25/25 at 1:18 PM, V1 (Administrator) said, I started [R1] on the one-on-one supervision because when he first arrived, he was trying to climb out of the chair and out of the bed, I didn't want him to fall and get hurt. He had trouble communicating. I started it for safety. It started the day he came because of him climbing out of everything. R1's Nursing Progress Note dated 10/26/25 at 6:13 PM showed, Resident was sitting up in broda chair next to nurse's station, napping off and on comfortably. No issues. CNA (Certified Nursing Assistant) came to this Nurse stating resident's wife came and took him in his broda chair into his room and was giving him drinks of water while he was lying back in the broda. Upon entering the room this Nurse saw the wife sitting beside resident with a cup of water on the bed stand next to them. The wife/POA began saying how the resident has been coughing all day and that she only gave him water because he was thirsty. This Nurse observed no coughing issues during the 2 hours I was around the resident. POA/wife wanted to call 911 because she knows he has Pneumonia I told her that was her choice if she wanted him to be evaluated. VS taken (blood pressure) 90/60 (Pulse) 64 (Respirations)18 Temperature 97.8 SPO2 88% on room air. Call to 911 was placed. R1's Nurse Progress Note dated 10/27/25 at 1:00 AM showed, Writer called [local acute care hospital] and spoke to ER (Emergency Room) nurse. the resident is admitted for pneumonia.The facility's policy and procedure revised 10/1/25 showed, Medication Errors. Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safety in an environment free of significant medication errors. Medication Error means the observed or identified preparation or administration of mediations of biologicals which is not in accordance with the prescriber's order. Significant medication error means one which causes the resident discomfort or jeopardizes his/her health and safety. 1. The facility shall ensure medications will be administered as follows: a. According to physician's orders. c. In accordance with accepted standards and principles which apply to professionals providing services. 4. The facility will consider factor indicating error in medication administration, including, but not limited to, the following: a. Medication administered not in accordance with the prescriber's order. Examples include, but not limited to: . Medication omission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a physician was overseeing the facility. This applies to all residents residing in the facility.The findings include:The facility provided a resident roster dated 11/22/25 which showed 36 residents residing at the facility.On 11/22/25 at 11:15 AM, this surveyor observed a note posted at the nursing station that showed, [The Medical Director] is on vacation 11/20 - 12/1 . DO NOT CALL OR TEXT - IF YOU NEED ASSISTANCE CALL THE OFFICE at [PHONE NUMBER]. A note was handwritten under the posting that showed, no one answers at this number, on any of the extensions and there is no option to leave a message with anyone but billing. [Administrator] and DON (Director of Nursing) are aware - unsure of the situation at this time. If any issues just send to ED (Emergency Department). Also, won't have any scripts (prescriptions) available. This posting showed it was faxed to the facility by the Medical Director's office. On 11/22/25 at 11:15 AM, V4 LPN (Licensed Practical Nurse) said, It has been an impossibility for a very long time to contact the physician. [The Medical Director] since the [new company] took over, has been very hard to communicate with. I have not had access to a physician since I don't know how long. I was told that we supposedly have to go through the DON and that only the DON can call the doctor. No effective communication for some time. I should be able to get ahold of someone if I need to talk to the physician. Now [the Medical Director] is on vacation and we can't call or text him. There is no one covering that I know of. If I needed to get ahold of a physician, I don't know what I could do. The note says to send out to the Emergency Department. If I need a prescription? (shrugged shoulders).On 11/22/25 at 1:07 PM, V1 (Administrator) said she does not know if the Medical Director is the physician for all residents in the facility. V1 said she did not know if anyone was covering for him while he was on vacation. V1 said she knows the medical director has a receptionist (V13) and she is working on figuring it out. V1 said she spoke with their company's Clinical [NAME] President, and she confirmed that the Medical Director does not have a Nurse Practitioner covering. On 11/22/25 at 1:45 PM, V1 said she spoke with the Medical Director's secretary (V13) and was told that even though he is on vacation, he has not provided coverage because he is still available to the nursing homes. V1 provided a copy of what was being posted at the nursing station after the previous posting was removed. The phone numbers provided on the new posting were different than the previous office number provided on the original posting. On 11/22/25 at 1:59 PM, V13 (Medical Director's Nursing Home Coordinator) said, He is still taking call. I have just told [V1] if for some reason, you cannot get ahold of him she could get ahold of me, and I could get ahold of him. I don't know why that note was faxed. They were supposed to let everyone know that he was going to be on vacation, I don't know why it said that it was supposed to say that he was on vacation and that it might take them longer to respond. There would have no way for them to get into contact with anyone at that phone number. I have no idea why they sent that. I think the girls were notifying that he was on vacation and out of the office, but they should have put on there that we have Nurse Practitioner to cover for him, if need be, during the day and after hours would still be the physician. I'm assuming the notice came from one of the two front office girls and it is completely incorrect.On 11/25/25 at 9:21 AM, V7 RN (Registered Nurse) said, . Notify physician of changes in condition or if I need prescriptions written. I didn't have to send anyone out 911 during that time frame. I was already prepared though when I realized that [V14] was on vacation, and no one was there to contact. I would have contacted the Administrator and the Director of Nursing and told them I was using my nursing judgement and sending the resident out.On 11/25/25 at 9:49 AM, V5 LPN (Licensed Practical Nurse) said, . I tried to get ahold of [V14] the first day of his vacation because someone was wanting to discharge. I couldn't get ahold of anyone and couldn't leave any messages with any of the options except billing. I never got ahold of anyone. Generally, we contact them for abnormal vitals, falls, new admissions, and any concerns with medications. I tried every number I could find with no luck. The facility's policy and procedure revised 10/13/25 showed, Medical Director Responsibilities. Policy: the facility retains a physician designated as Medical Director, to coordinate the medical care provided by attending physicians, and to assist with the development and implementation of resident care policies. 2. The Medical Director will have his own caseload of residents as well as being available to oversee the medical care of all residents within the facility when other Attending Physicians are not available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure nurses had access to the convenience medications and failed to ensure medications were available from the pharmacy for 2 of 3 residents (R1 and R3) reviewed for pharmacy services in the sample of 7.The findings include:1. R1's face sheet showed he was admitted to the facility 10/16/25 with diagnoses to include pneumonia due to other gram-negative bacteria, generalized anxiety disorder, malignant neoplasm of prostate, Alzheimer's Disease, and heart failure. R1's facility assessment dated [DATE] showed he had severe cognitive impairment and was dependent upon staff for all cares. R1's October 2025 Physician Order Sheet showed he was admitted with orders for buspirone, alprazolam, Cefdinir, Donepezil HCL, Doxycycline, furosemide, memantine, spironolactone, and tamsulosin. R1's October 2025 eMAR (electronic Medication Administration Record) showed the only medication he was administered for the first 48 hours after his admission was his melatonin. On 11/25/25 at 9:49 AM, V5 LPN (Licensed Practical Nurse) said, Switching over the pharmacy, it was taking several days to get medications, we were calling them and resending the orders. We did everything we could, I worked Saturday after his admission [DATE]) and none of [R1's] medications were here. I asked his wife if she had any of his medications she could just bring, but she was in such bad shape herself, I think she forgot before she even left here. The [electronic convenience medication cart] has Wi-Fi problems and disconnects all the time. We all know how to get in it but it hasn't been functioning at all. It hasn't been accessible. It's constantly having to be reset.On 11/22/25 at 11:15 AM, V4 LPN (Licensed Practical Nurse) said R1 was not at the facility very long. V4 said R1 was in a bad state of being during his stay. V4 said R1 was mostly nonverbal. He was 1:1 at times due to being very combative. V4 said medications are usually here the following day after admission but with the constant changing of ownership and pharmacy it has been terrible. V4 said, As of October 1, the facility ownership and pharmacy changed. V4 said R1's medications took quite a while to come in. V4 said she remember it taking a long time for R1's medications to arrive. V4 said the new pharmacy did bring an [electronic convenience medication cart] but the nursing staff cannot access it. V4 said she hasn't had time to even try and figure out the [electronic convenience medication cart] because she thinks it needs to be reset. V4 said she has only been able to access the [electronic convenience medication cart] one time since October 1. V4 said we really should have access to those medications for the residents. V4 said she didn't understand why, but there was a lot of confusion with the change-over. V4 said they used to have just boxes with convenience medications but now with the new company we have the electronic cart for those medications, and it doesn't seem to work. On 11/25/25 at 12:10 PM, V12 RN (Agency Registered Nurse) said, I would say there would at least one patient each time that I have worked that a resident didn't have medications. I questioned if I was able to access [electronic convenience medication cart] the for medications and I was told because I'm agency I didn't have access to it. as a seasoned agency nurse, that was one of my first questions when I started. I was informed then, by the nurse I received report from that I didn't have access to it. I had a conversation with the DON (Director of Nursing) and she confirmed that as well. I expressed concerns a few times. It is concerning to me because. because I would need it if a patient was prescribed a new medication or is out of medication. It would be standard of care. Standard rule of thumb, when a medication is missing, we would try and locate it, obviously we could possibly pull it from convenience medications.On 11/25/25 at 9:21 AM, V7 RN (Registered Nurse) said, . We always run out of prescriptions, with the new changes and the new company it has gotten worse. The new company took over October 1st and since then everything has been haywire. All the medications are late, and all the nurses would try to fill the medications, but the pharmacy isn't filling them. It isn't just the new prescriptions that are taking a long time, it's all the medications. When [R1] came in, the pharmacy was delayed for a few days. He was not getting his medications because the pharmacy wasn't delivering his medications. All his medications took a while to come in. It wasn't because of the practitioner, and it was because of the nurses, it was because of the new pharmacy. With the previous pharmacy we were able to get medications from a convenience box. Now they got a [electronic convenience medication cart] that needs Wi-Fi__33. In [R1's] case we would have had to get the medications out of the [electronic convenience medication cart] and agency nurses don't have access to it. I heard it also wasn't up and running and wasn't working, then they had issues with logging in and Wi-Fi. I don't think that problem has been corrected. we were contacting the pharmacy constantly telling them we needed [R1's] medications. [R3] takes scheduled doses of Lactulose and that has been taking a long time to come in as well. She has been out of that frequently. On 11/25/25 at 10:01 AM, V11 (Facility's Pharmacist) said the first delivery of R1's medications to the facility occurred on 10/19/25 at 3:45 AM. The pharmacy's Packing Slip Proof of Delivery showed the 10/19/25 delivery included R1's following medications: buspirone, donepezil, doxycycline, furosemide, hydrocortisone cream, ibuprofen, ketoconazole cream, and memantine. V11 said R1's Cefdinir (antibiotic) and Alprazolam (antianxiety medication) was delivered to the facility 10/20/25 at 2:43 AM and R1's antibiotic eye drops were delivered to the facility 10/21/25 at 3:21 AM. On 11/25/25 at 1:18 PM, V1 (Administrator) said, We have had some delay when we first got the new pharmacy. It is not typical. We had the convenience box from previous pharmacy and then the new pharmacy took over and brought [an electronic convenience medication cart]. Many medications are available in the [an electronic convenience medication cart]. If a medication is not in the cart, I would expect the nurses to call the pharmacy and get the medication out. V1 said she was not aware there were issues getting the [electronic convenience medication cart] to work or that the agency nurses were unable to access the convenience cart. V1 said the facility's agency nurses should have access to the convenience medications for the residents. 2. R3's face sheet showed she was admitted to the facility 12/2/2014 with diagnoses to include dementia without behavioral disturbance, schizophrenia, anxiety disorder, major depressive disorder, hypothyroidism, slow transit constipation, insomnia, and chronic kidney disease. R3's facility assessment dated [DATE] showed she has no cognitive impairment. On 11/22/25 at 9:22 AM, R3 said, . Sometimes they are out of my medications. The most recent one I have trouble with is my laxative that I need to take. Some of the nurses will replace it with a different laxative. It does affect me if I don't take it, I get constipated.R3's November 2025 eMAR (electronic Medication Administration Record) showed on 11/9/25, R3's Lactulose was not available at this time and on 11/13/25, R3's Potassium Chloride and Nortriptyline was unavailable. The facility's policy and procedure with review date of 10/13/25 showed, Medication Administration. Policy: Medications are administered by licensed nurses. as ordered by the physician and in accordance with professional standards or practice. 1. Keep medication cart clean, organized, and stocked with adequate supplies.The facility's policy and procedure reviewed 10/13/25 showed, Unavailable Medications. This facility shall use uniform guidelines for unavailable medications. 1. This facility maintains a contract with a pharmacy provider to supply the facility with routine, prn (as needed), and emergency medications. 2. A STAT (as soon as possible) supply of commonly used medications is maintained in-house for timely initiation of medications. 3. The facility shall follow established procedures for ensuring residents have a sufficient supply of medications. 4. Medications may be unavailable for a number of reasons. Staff shall take immediate action when it is known that the medication is unavailable: a. Determine reason for unavailability, length of time medication is unavailable, and what efforts have been attempted by the facility or pharmacy provider to obtain the medication. B. Notify physician of inability to obtain medication upon notification or awareness that medication is not available. Obtain alternative treatment orders and/or specific orders for monitoring resident while medication is on hold.The facility's policy and procedure reviewed 7/18/18 showed, . Emergency Pharmacy Service and Emergency Kits, Policy: Emergency pharmacy service is available on a 24-hour basis. Emergency needs for medication are met by using the facility's approved Emergency Medication Kit/Box or by special order from [the pharmacy]. [The pharmacy] supplies emergency medications including emergency drugs, antibiotics, controlled substances. to serve the immediate clinical needs of the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a discharge planning process and include this process in the resident's electronic medical record including the comprehensive plan of care for 2 of 3 residents (R2, R3) reviewed for discharge planning in the sample of 5.The findings include:1. On 9/16/25 R2 stated he was ready to go home and has been for a while. R2 stated he was supposed to be discharged on Monday, that did not happen. R2 stated now someone stated it would probably be on Thursday. R2 stated he was told that they were waiting for the doctor's signature before he can leave. R2 stated he did not know anything about his discharge plans other than he is going to be discharged . On 9/16/25 at 12:11 PM, V9 Social Services stated R2 was finished with therapy and waiting for the doctor's order for discharge. V9 stated the facility just had a new medical director start and they are waiting on the order from him. V9 stated the current plan is for R2 to discharge home on Thursday (9/18/25) with his wife. On 9/16/25 at 1:30 PM, V3 Licensed Practical Nurse (LPN) stated in the Minimum Data Set (MDS) for a resident it will show if the resident plans to discharge from the facility. V3 reviewed R2's current care plan and stated she did not see a plan for R2's discharge. V3 stated the way the nurse will know about a resident's discharge is through communication on the electronic medical records home page. V3 stated she does not become involved in the resident's discharge until the day of discharge. V3 stated she doesn't see a lot of discharge information for residents. V3 stated it is important to know what the resident will need and that safety measures are in place.On 9/16/25 at 1:40 PM, V4 LPN stated discharges are communicated by dashboard alerts in the electronic medical record. V4 stated a resident should have a care plan in place regarding discharge; it is a regulatory requirement. V4 reviewed R2's medical record and stated she did not see any discharge plans in place and R2 is being discharged . V4 stated social services should initiate the process and the MDS/Care Plan Coordinator should do the care plan.On 9/16/25 at 1:51 PM V5 MDS/Care Plan Coordinator stated they start talking about a resident's discharge when they first come into the building. V5 stated it is discussed at the first care plan meeting. V5 stated if the resident is a rehab to home resident, then she has a form that she fills out. The information from the form is used to fill out an assessment in the electronic medical record. V5 stated she writes it on paper and then fills it in later. V5 stated R2 did not have an assessment or discharge plan in the electronic medical record. The Interim Care Plan assessment dated [DATE] for R2 showed a discharge plan was initiated and R2 would need assistance with some activities of daily living. The Minimum Data Set, dated [DATE] for R2 showed under section Q the resident's overall goal was to return to the community. Under the section for discharge plan it was marked that an active discharge plan was occurring for the resident to return to the community. R2's Comprehensive Care Plan dated 8/4/25 showed under the Social Service section the name that he prefers to be called and his code status; there was no discharge plan in place. The rest of R2's care plan did not show any current and/or future plan for discharge.On 9/16/25 at 2:35 PM, V1 Administrator and V2 Director of Nursing stated residents should have a discharge plan in place. They stated the facility did not have a medical record for three weeks. R2 is waiting for an order so he can go home. The Physician Orders for September 2025 for R2 did not show any orders for discharge.The Face Sheet dated 9/16/25 for R2 showed diagnoses including chronic obstructive pulmonary disease, heart failure, type 2 diabetes mellitus, hypothyroidism, hypertension, hyperlipidemia, aortic stenosis, benign prostatic hypertrophy, and atherosclerotic heart disease. The facility's Transfer and Discharge policy (11/2024) showed the comprehensive, person-centered care plan shall contain the resident's goals for admission and desired outcomes shall be in alignment with discharge. Supporting documentation shall include evidence of the residents or residents representative's verbal or written notice of intent to leave the facility, a discharge plan, and documented discussions with the resident and/or resident representative. 2. On 9/16/25 R3 stated she did not know how long she would be at the facility. R3 stated she has an injured right shoulder and has cancer that she is going to be receiving treatments. R3 stated she didn't know what her plan was; just that she was going to be treated for cancer.The MDS dated [DATE] for R3 showed under section Q that her overall goal was to be discharged to the community.The Care Plan dated 8/29/25 for R3 did not show any information and or plan related to discharge.The Face Sheet dated 9/16/25 for R3 showed diagnoses including emphysema, tobacco use, lung cancer, chronic gastric cancer, personal history of pulmonary embolism, anxiety disorder, ocular myiasis, and aural myiasis.On 9/16/25 at 2:35 PM, V1 Administrator and V2 Director of Nursing stated residents should have a discharge plan in place.The facility's Transfer and Discharge policy (11/2024) showed the comprehensive, person-centered care plan shall contain the resident's goals for admission and desired outcomes shall be in alignment with discharge. Supporting documentation shall include evidence of the residents or residents representative's verbal or written notice of intent to leave the facility, a discharge plan, and documented discussions with the resident and/or resident representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident's comprehensive careplan included interventions for a chest harness which applies to 1 of 12 residents (R20) reviewed for careplans in a sample of 12.
The findings include:
During the survey, R20 was observed wearing a restraint harness while in her wheelchair. R20 was utilizing the harness on 3/3/25 at 8:45 AM, 3/4/25 at 1:40 PM and 2:55 PM.
R20's Medical record showed no assessment was completed since R20's admission on [DATE].
On 3/4/25 at 10:35 AM, V2 Director of Nursing stated a restraint should be in a resident's care plan.
R20's current care plan showed no focus area or interventions in place for a restraint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident's nails were trimmed for a resident with a hand contracture which applies to 1 of 12 residents (R15) reviewed for activities of daily living in a sample of 12.
The findings include:
R15's admission Record printed on 3/5/25 showed R15 to be a [AGE] year old male resident, originally admitted to the facility on [DATE] with diagnoses which include a contracture to the left hand and muscle weakness.
On 3/3/25 at 10:10 AM, R15 was in his room watching television. R15's nails were noted to be approximately 1/4 inch long. R15 opened his hand with other hand. R15's left palm had indentations from his fingernails pressing into his palm.
On 3/4/25 at 9:20 AM, R15 still had long nails with left hand closed.
On 3/4/25 at 1:30 PM, V11 Certified Nursing Assistant assisted R15 with opening his hand. R15 had indentation marks from his fingernails in his palm. V11 stated R15's nails were too long (approximately 1/4 inch) and needed to be trimmed. V11 stated when they have taken care of R15 they have not had R15 refuse hygiene assistance.
On 3/4/25 at 1:45 PM, V8 Certified Nursing Supervisor stated nails are usually trimmed during a resident's shower. R15's nails were too long.
R15's undated (current) Care Plan showed R15 needing activities of daily living (ADL) assistance due to R15 having a stroke which caused R15's left side to be affected.
The facility's Activities of Daily Living Policy, dated 5/2024, showed resident care needs will be provided by staff which includes bathing, dressing, grooming and oral care.

Based on observation, interview, and record review the facility failed to ensure elastic bandages (tubi grips) were applied for a resident with a history of lower extremity edema for 1 of 12 residents (R5) reviewed for quality of care in the sample of 12.
The findings include:
On 3/3/25 at 10:35 AM, R5 was up in her wheelchair propelling herself in the activity room. R5 had socks on to her ankles and her skin was visible above the sock (no elastic wraps were in place).
On 3/3/25 at 1:49 PM, R5 was up in her wheelchair in the activity room with no visible elastic wraps on her legs.
On 3/4/25 at 1:22 PM, R5 was sitting up in her wheelchair in the activity room with her feet on the floor. V3 Certified Nursing Assistant (CNA) lifted R5's pant leg and R5 only had on socks that came up to her ankles. There were no elastic bandages observed. V3 said she is supposed to have wraps on her legs.
On 3/4/25 at 1:24 PM, V4 Licensed Practical Nurse said R5 is supposed to wear elastic bandages during the day for circulation and to prevent edema. V4 said R5 has had the order for some time and R5 doesn't refuse for the staff to put them on. V4 said the elastic bandages are supposed to be on from her toes to her knees.
On 3/4/25 at 1:26 PM, V5 CNA said she was assigned R5 today and she didn't put R5's elastic bandages on. V5 said she didn't know R5 was supposed to have them on.
On 3/4/25 at 2:01 PM, V2 Director of Nursing (DON) said R5 has had a lot of edema in the past and a history of cellulitis. V2 said R5 sometimes refuses to lay down or elevate her legs in the recliner, she likes to be up and doing things, so the elastic bandages help keep the swelling in her legs down.
R5's Physician Orders dated 11/18/24 shows Apply Tubi Grips to BLE [bilateral lower extremities]. Start at toes and go up to knees. Every day and night shift for lower leg swelling on in the AM and off at Bedtime.
R5's Care Plan dated 4/9/24 shows, The resident has Congestive Heart Failure:
-The resident will be free of peripheral edema through the review date.
-Apply Tubi Grips to BLE. Start at toes and go up to knees. Every day and night shift for lower leg swelling ON in the AM and off at Bedtime.
-Monitor/document/report PRN [as needed] any s/sx [signs/symptoms] of Congestive Heart Failure: dependent edema of legs and feet, periorbital edema, SOB [shortness of breath] upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of the lungs, Orthopnea, weakness and/or fatigue, increased heart rate (Tachycardia) lethargy and disorientation.

Based on observation, interview, and record review the facility failed to ensure interventions were placed when a pressure injury was identified and failed to ensure treatments and pressure reducing interventions were in place for 2 of 3 residents (R33, R21) reviewed for pressure in the sample of 12. This failure resulted in R33 sustaining a stage 3 pressure injury to her coccyx.
The findings include:
1. On 3/3/25 at 10:15 AM, R33 was in bed sleeping. R33's air mattress was deflated, and R33 was laying on the bed frame. The air mattress controller said standby. Heel protection boots were observed in R33's wheelchair in the room. At 10:19 AM, V3 Certified Nursing Assistant came into the room and said the air mattress controller was not supposed to say standby. V3 tried to un-plug and re-plug the unit and the mattress did not inflate. V3 looked at the control unit again and discovered the unit was turned off. V3 turned on the unit, and the mattress inflated. V3 said the mattress needs to be turned on in order to relieve pressure and R33 is supposed to have the heel protection boots on when in bed.
On 3/4/25 at 9:46 AM, V2 Director of Nursing said the floor nurses do weekly skin assessments and complete a progress note if there is a skin issue. V2 said the nurses are supposed to do an assessment with measurements, get treatment orders, and alert her if there is a wound. V2 said she checks the documented measurements and makes sure the doctor is contacted for treatment orders. V2 said, if necessary, the wound doctor can see them.
R33's Skin/Wound Note dated 2/17/25 at 10:45 PM shows, Resident had shower this evening. Bilateral lower and upper (BL/UL) discolorations. Open sore on coccyx.
R33's Skin/Wound Note dated 2/27/25 at 1:49 PM shows Pressure wound to sacrum measuring 2.1 x 1.5 x 0.3 cm [centimeters] found during cares. [V6 Wound Physician] in building and saw resident today. Will admit to wound care services. Area cleaned with wound cleanser. New treatment order from [V6] to cleanse wound with wound cleanser. Apply hydrocolloid sheet BID [twice per day] and PRN [as needed] for 30 days.
On 3/4/25 at 1:52 PM, V2 said R33 has a facility acquired pressure injury. V2 said last Thursday (2/27/25) the Certified Nursing Assistants reported it to her after the wound was found while R33 was being changed. V2 said she looked at the wound and V6 was in the building, so she had him see R33. V2 said she was not aware that it was found on 2/17/25 according to the nurse progress note. V2 said the nurses should have notified her and got treatment orders. V2 said R33 has pressure reducing interventions including an air mattress and cushioned heel boots. V2 said the air mattress should be plugged in and the resident should not be laying on a deflated mattress. V2 said R33 should have her heel boots on when in bed.
On 3/5/25 at 10:44 AM, V7 Licensed Practical Nurse said she was in training on 2/17/25 and recalled R33's open area but could not recall details of the wound. V7 said she did not take measurements, get treatment orders, or notify V2.
On 3/5/25 at 2:25 PM, V6 Wound Physician said he saw R33 for the first time on 2/27/25 and was told they had found the wound that day. V6 said he classified the wound as a stage 3 pressure injury. V6 said his report shows duration of > (greater than) 3 days, which was based on his clinical judgement of how the wound looked to him. V6 said he saw granulation tissue in the wound and it takes more than 48 hours for granulation tissue to evolve, it doesn't show up right away. V6 said he would expect without treatment, a wound would decline further. V6 said a wound would not improve on its own. V6 said lack of treatment and pressure reducing interventions would contribute to the wound worsening.
R33's Most recent Braden Scale for Predicting Pressure Ulcer Risk (provided by the facility) dated 7/27/24 shows R33 is at high risk for pressure injury.
R33's Initial Wound Evaluation and Management Summary by V6 is dated 2/27/25 and shows, Stage 3 Pressure Wound Sacrum Full Thickness, duration: >3 days, measuring 2.1 x 1.5 x 0.3 cm. Recommendations off-load wound, reposition per facility protocol, group 2 mattress.
R33's Physician Orders for February 2025 do not contain wound treatment orders or pressure relieving interventions for R33's coccyx wound until 2/27/25. R33's treatment order were started on 2/27/25 and show, air mattress to bed for proper weight distribution, check every shift and PRN for proper inflation.
2. R21's Wound Evaluation & Management Summary dated 1/23/25 shows R21 has a stage 2 pressure wound of her left, medial buttock (Site 10) with a duration greater than three days measuring 3.6 centimeters (cm) by 1.9 cm by 0.1 cm and is to receive wound treatment three times a week for 30 days.
R21's Wound Evaluation & Management Summary dated 1/30/25 shows R21's Stage 2 pressure wound (Site 10) had increased in severity to a stage 3 pressure wound measuring 11.2 cm by 6.7 cm by 0.2 cm. R21's Treatment Administration Record (TAR) for 1/1/25 through 1/31/25 does not show any treatment scheduled for R21's pressure ulcer of her left, medial buttock.
R21's current Order Summary Report for 1/20/25 through 3/31/25 and Order Summary Report for 1/20/25 through 3/31/25 for discontinued orders both show there are no orders for wound treatment of R21's pressure ulcer of her left, medial buttock from 1/23/25 through 2/5/25.
On 3/4/25 at 1:52 PM, V2, Director of Nursing and Wound Care Nurse, said R21's pressure ulcer of her left medial buttock was identified when she was doing wound rounds with the Wound Care Physician, V6. On 3/5/25 at 10:19 AM, V2 said V6 does his progress notes of each resident wound right away after his wound rounds on Thursdays. V2 said she accesses V6's progress notes (Wound Evaluation & Manage Summary) and enters his treatment orders into their computer system and treatment orders are started the next day.
On 3/5/25 at 2:22 PM, V6 said he would expect a wound to worsen/decline if wound treatment is not being provided.
The facility's Assessment of Skin Alteration Policy dated 11/2017 shows residents with skin alteration will be assessed and treatment will be provided as ordered by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed ensure water temperatures were monitored and maintained in resident care areas, and failed to ensure a resident's call light was within reach which applies to all 35 residents in the facility.
The findings include:
1. The CMS-671 document dated 3/3/25 showed the facility census was 35 residents.
On 3/3/25 at 1:55 PM, the resident bathroom for rooms [ROOM NUMBERS] (shared bathroom) hot water temperature was 121.5 degrees Fahrenheit (F). An electronic calibrated thermometer was used for this reading.
On 3/3/25 at 2:05 PM, the facility's hot water heater thermometer read 125 degrees Fahrenheit. The mixing valve thermometer read 120 degrees Fahrenheit.
On 3/3/25 at 2:15 PM, V9 took rooms [ROOM NUMBERS]'s hot water temperature. The reading was 119.4 degrees (F). V9 stated the water temperature is high. V9 stated he was getting higher temperatures than that and turned down the hot water heater to 125 degrees about a week ago. V9 stated he called a local plumber to come out and look at the system. V9 stated they would get back to him after they returned from vacation. V9 stated he did not call any other plumbers after that. V9 stated the temperature for hot water should be around 110 degrees Fahrenheit. V9 Maintenance Director stated he believed the mixing valve was the problem. The mixing valve should be adding cold water to the hot water to bring it down to around 110 degrees to the resident rooms and facility.
On 3/4/25 between 9:25 AM and 9:35 AM hot water temperatures were taken of the central hallway resident bathrooms. room [ROOM NUMBER]/103 was 117.9 (F), 102/104 116.7 (F), 105/107 115.4 (F), and 106/108 118.1 (F). The facilities working shower room shower hot water temperature was 115 degrees (F) by the shower head temperature gauge, and 115.8 degrees (F) by laconic handheld thermometer. This shower is the only shower room used by residents in the facility.
The facility water temperature logs for January 2025 and February 2025 showed no water temperature over 111 degrees (F).
On 3/4/25 at 10:00 AM, V9 stated he did not do other water temperature checks in resident rooms other than on Fridays for regular rounds. V9 stated they did not do any more frequent checks after they had found the temperatures out of normal ranges. V9 stated the temperatures were hotter prior to turning down the hot water heater but did not give a specific temperature.
The facility's Safe Water Temperatures Policy dated 12/1/24 (per V1 Administrator) showed the facility should maintain appropriate water temperatures in resident rooms. The water temperature should not exceed 110 degrees Fahrenheit.
2. R4's admission Record printed on 3/5/25 showed R4 to be a [AGE] year old female admitted to the facility on [DATE] with diagnoses which include dementia and the need for assistance with personal care.
On 3/3/25 at 10:55 AM, R4 was lying in bed with R4's head to the left end of the bed. R4's call light was coiled, out of reach, on the floor under the foot board which was the right end of the bed.
R4's Fall assessment dated [DATE] showed R4 to be at high risk for falls.
On 3/4/25 at 10:30 AM V2 Director of Nursing stated a residents call light should be placed within reach.
On 3/5/25 at 11:00 AM, V10 Certified Nursing Assistant stated a residents call light needs to be within reach and/or secured so they can reach it.
The facility's Call Light Policy dated 6/2024 showed staff will ensure call lights will be within reach of resident and secured as needed.

Based on observation and interview, the facility failed to post the daily staffing for all 35 residents reviewed for staffing.
The findings include:
The facility's Long Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 3/3/25 shows there is a resident census of 35.
On 3/3/25-3/5/25 upon entering the facility, there were no staffing postings observed near the front door on the entry table or the bulletin boards.
On 3/5/25 at 1:25 PM, V8 Certified Nursing (CNA) Supervisor stated staffing is posted in the staffing binder at the nurse's station. V8 said the binder has the monthly and daily schedules for nursing and CNA. V8 said staffing is not posted near the front door for visitors to see. V8 said she was not aware staffing needed to be visibly posted.

Based on observation, interview, and record review the facility failed to ensure psychotropic medication orders contained a duration for 1 of 6 residents (R33) reviewed for psychotropic medications in the sample of 12.
The findings include:
On 3/5/25 at 10:30 AM, V1 Administrator said all psychotropic as needed medications need to have a stop date.
R33's Physician Orders contained an order dated 1/13/25 for Lorazepam Oral Concentrate 2 MG (milligrams)/ML (milliliter) Give 0.25 ml by mouth every 2 hours as needed for anxiety related to generalized anxiety disorder. The order did not contain a stop date (duration).
The facility's Use of Psychotropic Medications Policy dated 3/2025 shows PRN [as needed] orders for psychotropic medication, excluding antipsychotics, shall be limited to no more than 14 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were assessed and offered pneumococcal immunizations upon admission for 2 of 5 residents reviewed for vaccinations in the sample of 12.
The findings include:
R15's admission Record dated 3/5/25 shows he was admitted to the facility on [DATE]. R15's Immunizations list provided on 3/5/25 shows no historical or current record of R15 having had or being offered a pneumococcal immunization.
R21's admission Record dated 3/5/25 shows she was admitted to the facility on [DATE]. R21's Immunizations list provided on 3/5/25 shows no historical or current record of R21 having had or being offered a pneumococcal immunization.
On 3/5/25 at 10:26 AM, V2, Director of Nursing/Infection Prevention Nurse, said when a resident is admitted , the admitting nurse is supposed to screen the residents for their vaccination status and administer them. V2 said the previous DON, dropped the ball on vaccines.
The facility's Pneumococcal Vaccine Policy (reviewed 1/2025) shows, .each resident will be assessed for pneumococcal immunization upon admission . and each resident will be offered a pneumococcal immunization .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident was assessed for the use of a restraint which applies to 1 of 1 resident (R20) reviewed for restraints in a sample of 12.
The findings include:
R20's admission Record printed on 3/5/25 showed R20 as a [AGE] year old cognitively impaired female resident with diagnoses which includes autistic disorder and Downs syndrome.
On 3/3/25 at 8:45 AM, R20 was sitting in a wheelchair with a restraint vest on near the nurse's station. The vest had a strap with a clip on each corner of the vest. One strap went on either side of R20's head and the other 2 straps went under R20's armpits to fasten to the back of the chair.
On 3/4/25 at 12:35 PM, R20 was sitting in a recliner in a common area near the nurse's station. R20 started having behaviors, which included pushing over a bedside table, and lashing out towards staff. Staff escorted R20 to her room. At 1:40 PM, V3 Certified Nursing Assistant (CNA) brought R20 out of her room in her wheelchair with the harness in place.
R20's physician orders showed no order for a wheelchair harness.
R20's medical record showed no restraint assessment completed since admission on [DATE].
On 3/4/25 at 1:55 PM, V3 stated R20 can move the top 2 straps over their head so the harness is only around her waist. V3 stated they thought R20 was able to unbuckle the clips at her sides. V3 stated when R20 is having behaviors she is an increased fall risk.
On 3/5/25 at 10:35 AM, V2 Director of Nursing stated V3 had not had a restraint assessment since her admission.
On 3/5/25 at 10:55 AM, V10 CNA stated they had not seen R20 ever undo the harness herself. V10 stated we (care staff) are the ones who undo the harness when R20 needs to get in and out of the chair.
The facility did not provide a restraint policy prior to exiting the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess, care plan and obtain physician orders for 2 of 12 residents (R27 and R22) to self-administer medications in the sample of 12 residents reviewed for medication safety.
The findings include:
1. On 3/3/25 at 10:22 AM, R27 showed surveyor a box of lidocaine patches (medicated pain patches) in her bedside stand. R27 said she uses them on her right hip for pain. R27 also showed surveyor her inhaler and said the facility gave her both medications to use.
R27's admission Record dated 3/5/25 shows she is a [AGE] year old resident admitted to the facility on [DATE]. R27's Order Summary Report dated 3/3/25 shows an order for Aspercreme Lidocaine External Patch 4% (Lidocaine) apply to lower back topically one time a day for pain, on in AM and off at bedtime. May keep in room and remove per schedule, but it does not show an order for R27 to self-administer any of her medications.
On 3/3/25 at 10:19 AM, V2, Director of Nursing (DON), said there are no residents in the facility with orders or an assessment to self-administer their medications. V2 said if a resident wants to self-administer medications, the facility needs to complete an assessment to make sure they can safely perform self-administering of medications, they need an order from the resident's physician, and the care plan needs to reflect the medication self-administration plan.
The facility was unable to provide a medication self-administration assessment for R27.
2. R22's admission Record showed R22 is a [AGE] year old, cognitively intact resident admitted to the facility on [DATE] with diagnoses which include: chronic obstructive pulmonary disease and congestive heart failure.
On 3/3/25 at 10:40 AM, R22 was sitting up in bed with the bedside table across R22 and the bed. R22 had an inhaler sitting on the bedside table. R22 stated she needed the inhaler to take a couple of puffs when she gets short of breath and would not have to wait for the nurse to bring it.
On 3/4/25 at 10:35 AM, V2 Director of Nursing stated there were no residents at the facility who self-administer any medications. A resident needs an assessment and a physician's orders to be able to self-administer medications.
R22's Physician Order Sheet printed on 3/3/25 showed R22 having an order for an Albuterol Sulfate inhaler every 6 hours as needed for shortness of breath. This order sheet showed no orders for R22 to be able to self-administer any medications.
R22's electronic medical record showed no assessments being completed for R22 to be able to self-administer medications.
R22's current Care Plan showed no focus areas pertaining to R22 being able to self-administer medications.
The facility's Resident Self-Administration of Medication Policy dated 11/2024 showed a residents interdisciplinary team needs to be assessed, educated, and care planned when a resident is deemed safe to self-administer mediations.

Based on observation, interview, and record review the facility failed to ensure the resident shower room was clean, comfortable, and homelike and failed to ensure hot water was available in resident bathrooms. This applies to all 35 residents residing at the facility.
The findings include:
The facility's Long Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 3/3/25 shows there is a resident census of 35.
1. On 3/4/25 at 9:31 AM, in the resident shower room V3 Certified Nursing Assistant pointed out the drain in the floor. The drain was uncovered with a hole exposed (the size of a softball) in the center of the shower room floor, under the shower head. V3 stated this morning I gave a shower and the wheel of the wheelchair got stuck in the drain. Look at this room! The tiles are missing and some tiles tape to hold them up.
On 3/4/25 at 1:19 PM, R8 stated I've been here for 9 years and every year I complain about shower room. It was really pretty bad. This is a little better than before. It is still bad though, the walls have holes, tiles are missing, but it is the only place for showers, so I have had to live with it.
On 3/5/25 at 9:00 AM, V4 Licensed Practical Nurse said there is only one shower room for all the residents.
On 3/5/25 at 9:02 AM, the resident shower room had tiles missing along 3 walls by the floor. One wall on the left side of the room (when standing in the doorway), had exposed wood framing in several areas. One exposed was half covered with a plastic piece of material. Multiple areas on all walls had tiles pushed in. A large area of tiles around the faucet were pushed in and heavily caulked. There were rolled towels on floor to keep water from going out the door and along the left wall. The wall the door was on had tiles held in place with black duct tape.
On 3/5/25 at 3:00 PM, V1 Administrator said they are aware of the shower room.
The facility's Resident Council Minutes dated 6/18/2024 shows showers need updated.
The Facility's Resident Rights for People in Long-Term Care Facilities Policy (from the Illinois Long-Term Care Ombudsman Program shows Your facility must be safe, clean, comfortable and homelike.
2. On 3/3/25 at 10:08 AM, R29 said there is no hot water in his bathroom. R29 said it freezes in the winter even if they let the water run all night, it never gets warm. After running the hot water continually for two minutes in R29's bathroom sink, the water never got any warmer and still felt cold to the touch.
On 3/3/25 at 1:55 PM, R29 and R10's bathroom sink water ran for two minutes. All temperatures taken during this investigation were obtained using a calibrated, digital thermometer. The cold tap water was 65 degrees Fahrenheit (F), and the hot tap water was 55 degrees F.
On 3/3/25 at 2:15 PM, V9 said the north wing has issues with the hot water; he does not believe there is a return circuit for the hot water.
On 3/4/25 between 9:35 AM to 9:40 AM the hot water temperature in R10 and R29's bathroom sink was 58.9 degrees F. On 3/4/25 between 9:42 AM and 9:46 AM the hot water temperature in R11, R13, and R18's bathroom was 59.2 degrees F. On 3/4/25 between 9:47 AM and 9:52 AM the hot water temperature in R21, R23, and R28's bathroom sink was 60.7 degrees F.
The Residents' Rights for People in Long-Term Care Facilities handbook (revised 11/2018) shows, Your facility must be safe, clean, comfortable, and homelike.

Based on observation, interview, and record review the facility failed to ensure a catheter had a secure device in place, the drainage bag was kept off the bed, and the catheter tubing was cleaned in a manner to prevent contamination for 1 of 1 resident (R17) reviewed for catheters in the sample of 13.
The findings include:
On 4/10/24 at 2:23 PM, R17 was laying on her back in bed with her catheter drainage bag attached to the lower bed frame of her bed. R17 did not have a device in place to secure the catheter tubing. V9 CNA (Certified Nursing Assistant) and V10 CNA put on gowns and gloves and went into R17's room to provide catheter care. V9 took a wet washcloth, cleaned R17's groin, and discarded the washcloth. V9 took another wet washcloth, wiped R17's vaginal area and then wiped straight down the catheter tubing. V9 placed the drainage bag on R17's bed when V9 and V10 were repositioning R17 in bed. V9 and V10 stated they were not aware that the catheter drainage bag could not lay on the resident's bed. V9 stated she should have gotten a clean washcloth to wipe down R17's catheter tubing. V9 stated she washed R17's vaginal area and then went straight down the catheter tubing.
On 4/11/24 at 10:23 AM, V2 DON (Director of Nursing) stated, the catheter drainage bag should never be on the bed for infection control. Staff are supposed to fold the washcloth a different direction before moving to a new area or cleaning the catheter tubing to avoid contamination. I put one (catheter tubing secure device) on R17 not to long ago because I noticed her tubing was pulling. I put it on to prevent the catheter from coming out. A day or two later I noticed the secure device was not on and I asked who took it off, but no one could tell me who did it. I noticed her tubing tugs so R17 should have one on.
The Physician Orders dated 4/1/24 for R17 showed medical diagnoses including neurogenic bladder, mass of adrenal gland, expressive aphasia, history of cerebral vascular accident with right sided weakness, sleep apnea, pulmonary hypertension, peripheral neuropathy, hypertension, deep venous thrombosis, diabetes mellitus, diverticulosis, coronary artery disease, atrial fibrillation, and arthritis.
The Care Plan dated 4/3/24 for R17 showed she is on an antibiotic related to a wound infection to her coccyx (pressure ulcer). She has a catheter. Catheter care every shift and change every week; 18 French 30 ml (catheter/balloon size) were the only catheter interventions listed.
The facility's Catheter Care policy (12/8/10) showed, 7. Wash the catheter tubing from the opening of the urethra outward 4 inches or farther if needed. Do not pull on catheter. The policy did not state to use a clean washcloth or to turn an existing washcloth prior to cleaning the tubing.
The facility's Catheterizations, Catheter Insertion policy (2/2018) showed, 7. Secure the catheter to the thigh and attach drainage collection unit.

Based on observation, interview, and record review, the facility failed to ensure the facility water system was tested for Legionella and failed to ensure water was not sedentary in an unoccupied area of the facility.
This failure had the potential to affect all 28 facility residents.
The findings include:
The facility's 4/9/24 application for Medicare and Medicaid form showed there were 28 residents in the facility.
On 04/10/24 at 11:02 AM, V4 Maintenance said weekly he flushes toilets and runs water for 2-3 minutes on anything that has a faucet on the south hall. V4 said he was unsure if a water system assessment had been done to identify potential problem areas that may be conducive to water borne pathogen growth. V4 said he did not know the last time water testing for Legionella was done if ever. Testing results and a policy were requested. V4 said V5 Business Office Manager (BOM) was his supervisor.
At 11:21 AM, V5 said she thought the facility was last tested for Legionella in 2019. V5 said she would check with the city since they do some testing. This surveyor requested a copy of the facility's Legionella test results.
At 11:37 AM, V5 said she was told by the city that they only test for chlorine and fluoride. They do not do Legionella testing. V5 said she had no evidence Legionella testing was ever done at the facility. V5 said there's only one shower room being used. The whirlpool down the north hall was not used because it needs repairs. It hasn't been used in the six years she had been there. V5 said they use the room to toilet residents but don't use the tub.
At 11:57 AM, V5 said there were no logs to show any flushing or water temperature checks were done on the south hall. V5 said V4 wrote in a notebook that he ran water in all sinks and toilets on 3/22/24 and 3/28/24.
On 04/10/24 at 12:34 PM, there was a large therapeutic bathtub with a lift system in a common bathroom near the north nurse's station. There was a continual slow dripping of water from an opening on the right side (facing the faucet) of the tub. There was a long brown stained area which followed the dripping water down the side of the tub. Staff were observed toileting residents in the room. The room door was wide open when not in use. The entire south end of the facility was unoccupied, and a second large therapeutic soaking tub was located near the south nurse's station.
On 04/11/24 at 08:34 AM, V1 Administrator said ASHRAE (the American Society of Heating, Refrigerating and Air Conditioning Engineers) has the standard to ensure the water systems are clear and safe. I know that Legionella testing must be done from ASHRAE. I am unsure what the facility policy is regarding Legionella testing or the industry standard.
On 04/11/24 at 11:06 AM, V4 said he was aware the north tub had a stained area due to consistent dripping of water from the faucet of the unused whirlpool tub. V4 said the south hall had been unoccupied since 2018-2019. V4 said the whirlpool soaker tub on the south hall was inoperable so he doesn't run the water in it when he comes to flush toilets down there. This surveyor accompanied V4 to the south hall tub room. V4 turned on the faucet in the tub and water did come from it.
The facility's 5/24/23 Legionella Environmental Assessment Form completed by a Corporate Administrator showed there were no hot tubs, whirlpool or hydrotherapy spas on the premises. This assessment showed it was very important to measure and document the current physical and chemical characteristics of the potable water, as this can help determine whether conditions are likely to support Legionella growth. A sampling strategy and procedure are suggested along with a flow sheet to record results to track the results. The flowsheet was marked N/A (not applicable). (There was no evidence the facility utilized this sampling procedure). This assessment, Appendix C applied to hot tubs, whirlpool and hydrotherapy spas and was marked N/A although there were two such tubs in the facility. No maintenance disinfecting or monitoring of the tubs was evident. There was no evidence the facility followed the recommendations to prevent Legionella in the tubs as evidenced by the lack of monitoring. This assessment showed it should be performed by an epidemiologist or environmental health specialist.
The facility's 8/10/18 Legionella Management Procedure showed the Corporate Maintenance Director will ensure all staff are kept fully informed of developments in Legislation and good practices relating to the management of Legionella, ensure approved contractors are available to undertake surveys/risk assessments upon (?), to ensure surveys are undertaken as and when this procedure dictates (?). Total Viable Cell Counts (Dip Slides) shall be taken during each risk assessment. If and when Legionella water samples are required, the samples should be sent away to an independent accredited laboratory for analysis within 48 hours.
The facility's undated Legionella Policy and Procedure showed to ensure water cannot stagnate anywhere in the system.
The facility's water temperature logs did not include any rooms on the unoccupied south hall or either facility tub directly.
The Illinois Compiled Statutes (210 ILCS 45/3-206.06) Sec. 3-206.06 showed Testing for Legionella bacteria. A facility shall develop a policy for testing its water supply for Legionella bacteria. The policy shall include the frequency with which testing is conducted. The policy and the results of any tests shall be made available to the Department upon request. a) A facility shall develop a policy for testing its water supply for Legionella bacteria. The policy shall include the frequency with which testing is conducted. The policy and the results of any tests and corrective actions taken shall be made available to the Department upon request. (Section 3-206.06 of the Act) b) The policy shall be based on the ASHRAE Guideline Managing the Risk of Legionellosis Associated with Building Water Systems and the Centers for Disease Control and Prevention's Toolkit for Controlling Legionella in Common Sources of Exposure. The policy shall include, at a minimum:1) A procedure to conduct a facility risk assessment to identify potential Legionella and other waterborne pathogens in the facility water system; 2) A water management program that identifies specific testing protocols and acceptable ranges for control measures; and 3) A system to document the results of testing and corrective actions taken.
Any and all facility testing results for Legionella was requested numerous times and none was received.

Based on interview and record review, the facility failed to have a certified Infection Preventionist.
This failure could affect all 28 facility residents.
The findings include:
The facility's 4/9/24 application for Medicare and Medicaid form showed there were 28 residents in the facility.
On 04/10/24 at 10:05 AM, V2 Director of Nursing (DON) said she has been at the facility since January 29, 2024. V2 said she is the facility's Infection Preventionist (IP). V2 said she did not have IP certification.
On 04/11/24 at 08:34 AM, V1 Administrator said I am aware it is required to have a certified infection preventionist in the facility. V1 said V2 is trying to get through the course but is not currently certified. It's important to have a certified IP. We need to make sure the residents are safe and protected from infection.
The facility's 3/3/23 Infection Preventionist Job Description showed qualifications: must have completed specialty training in infection prevention and control through accredited continuing education such as Centers for Disease Control and Prevention (CDC) or APIC (consulting firm) Infection Preventionist.
The facility's QAPI (quality assurance performance improvement) team roster identified V2 as the facility Infection Preventionist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident's advanced directives were updated as requested for 1 of 1 resident (R18) reviewed for advanced directives in the sample of 13.
The findings include:
R18's profile face sheet documents he was admitted to the facility on [DATE]. The Practitioner Order for Life-Sustaining Treatment (POLST) form dated 12/16/21 shows R18 opted to be a full code. The April 2024 POS (Physician order sheet) notes R18 to be a full code. A new POLST form, undated, on the front of R18's chart shows he opted to become a DNAR (Do not attempt resuscitation). The form is signed by R18 and has no witness signature and no signature by the health care practitioner.
The facility's 3/21/24 assessment for a significant change documents R18 to be cognitively intact.
On 4/11/24 at 9:39 AM, R18 said they did go over all of the options with me, and I signed the paper to not do anything for me.
On 4/11/24 at 8:15 AM, V3 RN (Registered Nurse) said R18 was placed on hospice, and it appears he has a DNR signed, but it is not dated and not signed by the physician so he would still be considered a full code. The form needs to be sent to the physician to be signed.
On 4/11/24 at 11:31 AM, V2 DON (Director of Nursing) said on admission the nurse will have the residents fill out and sign the POLST form and will send it out for the physician to sign. The form should be signed and dated on the chart.
The facility's 9/27/17 policy for advance directives documents the patient self determination act states that individuals have the right to make their own decisions and to formulate advance directives to serve as decisions when the individual is incapacitated. 3. After confirming the accuracy of provided documents with the resident/responsible party, document will be sent for appropriate signatures. No order for No Code or DNR shall be effective until the POLST form is signed by resident/responsible party and physician order is received and documented.

Based on observation, interview, and record review the facility failed to ensure a resident received necessary treatment and services for her amputated leg including following up with her surgeon, obtaining a sleeve for her stump and assisting in the process to prepare and obtain a prosthetic leg for 1 of 1 resident (R26) reviewed for quality of care in the sample of 13.
The findings include:
On 4/9/24 at 10:45 AM, R26 was sitting in her wheelchair in her room and had a left above the knee leg amputation. R26 stated she has been at the facility for 9 months. R26 stated she came to the facility after a house fire in which she jumped out of a second story window and sustained numerous injuries' including the amputation of her leg. R26 stated she was supposed to have a sleeve for her left leg stump after surgery. R26 stated the facility said they would get her one. It took 4.5 months to get a shrinker and no one measured her for it. R26 stated she has swelling to her left leg/stump. R26 pulled her leggings down to show an elastic type covering to her leg stump that had a lot of extra material and appeared too large for her. R26 stated the shrinker was too big. R26 stated she was never measured for the shrinker and thinks the facility ordered it online. R26 stated she had numerous doctors in the hospital after the incident and doesn't know who did the amputation of her leg. R26 stated she never followed up with the surgeon after being transferred to the facility. R26 stated the staples to her stump were removed at the facility. R26 stated R26 has not been fitted for a shrinker or leg prosthesis.
The hospital After Visit Summary dated 8/8/23 for R26 showed, follow up with outpatient burn & trauma clinic in 2 weeks; follow up trauma/burn for wound evaluation and staples removal.
The hospital Post Acute Care Transition Document dated 8/8/23 for R26 showed her level of functioning, case management assessment, burns, wounds, external fixator, medications, all physicians to follow up with including their names and contact numbers. The document showed R26 was to follow up with the surgeon at the burn & trauma clinic in 2 weeks.
The Nurses Notes for R26 showed the following: 8/8/23 - R26 was admitted to the facility with burn sites, left above the knee amputation with closure measures in place, and external fixator to bilateral hips. R26's Nurse's Notes from 8/8/23 through 4/11/24 did not show any follow up appointments with the surgeon or any fitting of a sleeve for R26's left above knee amputation.
The Physician Order Sheet dated 1/1/24 for R26 showed an order on 1/24/24 for a referral to the orthopedic doctor for re-evaluation, shrinker for left residual limb and include measurements. An order dated 1/29/24 for R16 showed, referral back to surgeon for stump shrinker/prosthesis ordering and follow up post surgery.
The Face Sheet dated (no date) for R26 showed medical diagnoses including stable burst fracture of T11-T12 (back) vertebra, ileus, minimally displaced fracture of the sacrum, muscle weakness, unspecified fracture of T9-T10 (back), burns of 10-19% of body surface, and acquired absence of left leg above the knee.
On 4/10/24 at 11:55 PM, V2 DON (Director of Nursing) stated follow up appointments for residents are made by her or social services. V2 looked at the desk calendar at the nurse's desk, flipped through several months and stated she did not see any appointments related to R26's left leg stump. V2 was shown the order in R26's chart dated 1/29/24 and she stated she was not aware of the order. V2 stated she did not know anything about the sleeve/shrinker for R16's stump. V2 stated it would be important to have measurements for the shrinker and have the rights size so R26 can get a prosthesis. V2 stated R26 is waiting for a leg prosthesis and wants one.
On 4/10/24 at 3:05 PM, V6 (Social Services) stated she was not aware of the order on 1/24/24 for R24. V6 stated V2 should be going through the orders to make sure they are done. V6 stated she wasn't here at the facility when this order was received and did not start until 2/5/24. V6 stated she doesn't know anything about the shrinker or where it came from. V6 stated she talked to R26 who said she thought someone ordered it off the internet and no one measured her for it. V6 stated she was by an outside clinic that R26 needs to be measured for a sock to shrink the stump and it is important so she can get a prosthesis.
On 4/11/24 at 8:35 AM, V3 RN (Registered Nurse) stated, the end goal is to shrink that (stump) and reduce the swelling so R26 can have a prosthetic. I don't know about any follow ups for R26's stump. I don't know what doctor was managing the stump. The NP (Nurse Practitioner) wrote an order and wanted her to go somewhere. The previous process (for appointments) was if we get an order for a referral, we give it to soc services, and they make the appointment. If the doctor writes an order it is supposed to be followed. The standard of care would be to follow up with the surgeon after a leg amputation.
On 4/11/23 at 2:00 PM, V1 (Administrator) stated the facility did not have a policy for quality of care, post surgical care, or current standards of practice related to the care of a resident after an amputation. The only policy the facility had for following physician orders was a policy of Conformance with Physician Medication Orders (9/27/17).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
2. On 4/9/24 at 10:06 AM, R4 was in his room in a wheelchair that did not have any pressure relieving device in the chair.
On 4/9/24 at 2:13 PM, R4 was up in his wheelchair propelling himself down the hall. R4 went to the nurse's station to tell V3 RN (Registered Nurse) that he needed medicine for his cold. R4 did not have any pressure relieving device in his chair.
On 4/9/24 at 2:18 PM, V3 RN stated, R4 is supposed to have a pressure relief cushion in his chair and confirmed there wasn't one in his chair. V3 stated that V3 asked hospice for a cushion and thought they brought one. R4 stated he did not have a cushion for his wheelchair. There wasn't a cushion for R4's chair in his room.
On 4/11/24 at 10:23 AM, V2 DON (Director of Nursing) stated for a resident with pressure ulcer(s) they should have offloading of the wound, treatment orders, wound treatments done, and the wound doctor following the resident. V2 stated having a pressure relief cushion to the chair is important to relieve pressure so the wound doesn't get any worse.
The Wound Care Provider's Note dated 4/8/24 for R4 showed, stage 2 pressure wound to the left medial buttock partial thickness - hydrocolloid sheet (thin) apply three times per week for 23 days; skin prep apply three times per week for 23 days; limit sitting to 60 minutes, off load wound, turn side to side in bed every 1-2 hours if able, reposition per facility protocol.
The Physician Order Sheet dated 4/1/24 for R4 showed medical diagnoses including falls, hypertension, chronic obstructive pulmonary disease, restless leg syndrome, dementia, coronary artery disease with coronary artery bypass graft, chronic kidney disease, atrial fibrillation, iron deficiency, celiac disease, chronic back pain, and compression fracture.
The Care Plan Dated 2/19/24 for R4 showed, Risk for impaired skin integrity. Educate resident/representative about proper skin care to prevent skin breakdown. The care plan did not show R4 has a stage 2 pressure ulcer or interventions in place for offloading and repositioning every 1-2 hours if able.
The facility's Decubitus Care/Pressure Areas policy (1/2018) showed, when a pressure ulcer is identified additional interventions must be established and noted on the care plan in an effort to prevent worsening or re-occurring pressure ulcers.
Based on observation, interview, and record review the facility failed to ensure pressure injury interventions were in place as ordered and failed to identify a pressure injury prior to the injury becoming a stage 2 pressure injury for 2 of 5 residents (R5, R4) reviewed for pressure injuries in the sample of 13.
The findings include:
1. R5's profile face sheet documents she was admitted to the facility on [DATE]. The facility's annual assessment of 1/10/24 documents R5 to be cognitively intact. The same document shows she is at risk for pressure injuries and had one or more unhealed pressure injuries. The 12/14/23 wound evaluation and management summary report shows an initial evaluation of a stage 2 pressure wound to the sacrum of greater than 4 days in duration. The wound measured 2.9 cm (centimeters) in length, 0.3 cm (width) and 0.2 cm (depth). The nursing progress notes were reviewed and no not show a report or initial identification of any open pressure areas.
R5's December 2023 treatment record does not show any skin checks ordered or completed. She had a new order for ointment to the sacrum dated 12/14/23, the same day she was seen by the wound physician.
R5's care plan of 8/15/2019 documents she was a moderate risk for skin breakdown and needs a weekly skin check with documentation.
On 4/11/24 at 10:32 AM, V3 RN (Registered Nurse) said skin checks depend on the resident, (R5) should have a skin check weekly. V3 said R5 is incontinent so her skin would be checked when performing incontinence care, and her pressure injury should have been identified earlier. Wounds should not be found at a stage two, ideally, they are found at a stage one and get a treatment in place to prevent it from progressing. All of the wound details should be in the nursing progress notes when the injury is found, and the assessment.
On 4/11/24 at 11:25 AM, V2 DON (Director of Nursing) said pressure injuries should be found prior to becoming a stage 2. Some residents have skin checks daily and some are scheduled weekly. R5's bottom would have been looked at during care and should have been identified sooner. Nurses should fill out the skin assessment and notify the physician to get treatment orders. All of that information would be in the nursing progress notes. A copy of the assessment and wound treatment is then forwarded to me for evaluation.

Based on observation, interview, and record review the facility failed to safely transfer a resident for 1 of 3 residents (R1) reviewed for safety in the sample of 3. This failure resulted in R1 sustaining a left leg laceration requiring 29 sutures.
The findings include:
The facility's Reported Incident Final dated 12/29/23 shows on 12/27/23, R1 sustained a skin tear to left lower extremity. Per staff interviews on file, it was noted resident was being assisted by 2 Certified Nursing Assistants (CNA) from wheelchair to bed using a mechanical lift. During the transfer resident was noted to bump leg on wheelchair.
On 1/3/24 at 9:15 AM, R1 was sitting up in a reclining wheelchair in her room. R1 had padded protection sleeves on both arms and lower legs. V4 CNA rolled the padded sleeve down on R1's left lower leg. R1 had a gauze bandage covering her left lower leg. R1 stated I had 29 stitches. It hurts still. I can tell there is something there. V4 said she and V5 CNA were transferring R1 from her bed to the wheelchair and they bumped R1's leg on the wheelchair. V4 said R1 had the sleeves on her legs at the time. V4 said they were in the process of lowering R1 into the wheelchair when R1 said ouch! V5 entered the room, joined the conversation, and said when R1 said ouch, they finished lowering her to the wheelchair and then rolled down the protective sleeve. V5 said there was a large piece of skin hanging with fresh bright red blood dripping. V5 said the skin tear was very large and was more long than wide. V4 and V5 said they got the nurse right away. R1 said she remember saying ouch when being transferred but didn't remember what her leg bumped.
On 1/3/24 at 9:34 AM, V3 Registered Nurse lowered R1's protective sleeve on her left leg. V3 removed the gauze dressing. R1's left lower shin contained a large uneven laceration with visible sutures. R1's wound had sutures visible along the edges where R1's skin flap was secured back in place. R1's wound was red with some open areas that appeared moist. R1 complained of soreness during the dressing removal and change. V3 said R1 had picked out some of the sutures herself and was scheduled to have the sutures removed after 10 days. V3 said R1's laceration happened during a transfer with the mechanical lift.
R1's Hospital Emergency Department Physician Note dated 12/27/23 shows Patient has a laceration to her left distal shin. Patient is bed bound, injured while on mechanical lift at facility. Laceration is 6 centimeters in length. Shape: irregular, flap. Skin closure: 29 sutures, simple technique, interrupted technique. The same paperwork shows R1 was prescribed tramadol 50 mg twice daily for pain.
The facility's witness statement from V4 dated 12/27/23 shows shortly after 3 PM, this CNA and another CNA (V5) used the mechanical lift to transfer R1 into her reclining wheelchair. During the transfer residents left leg hit side of chair. R1 said ouch my leg. After we lowered her into chair, V5 pulled down leg sleeve then noticed skin. Nurse was then notified.
The facility's witness statement from V5 dated 12/27/23 shows shortly after 3 PM went to check and change resident, when done transferred her into the reclining wheelchair and her leg hit the side of the wheelchair. The resident said ouch. We proceeded to lower her into the chair. When resident was safely in her chair, I pulled down the leg sleeve and noticed a skin tear and notified the nurse.
On 1/3/24 at 10:24 AM, V1 Administrator said the investigation revealed that R1's injury happened during the transfer when her leg hit the side of the wheelchair.
The facility's Limited Lift Resident Handling Policy and Procedures shows purpose: to ensure that employees use safe resident handling and movement techniques for tasks that are designated as high-risk for safe resident handling and movement injuries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure residents were free from abuse for 3 of 5 residents (R2, R3 and R4) reviewed for abuse on the sample list of 5.
The findings include:
1. R1's Minimum Data Set assessment dated [DATE] documents R1 admitted to the facility on [DATE], has severely impaired cognition, requires supervision with walking in her room and corridors and has had physical and verbal behaviors directed towards other.
R2's Minimum Data Set Assessment (MDS) dated [DATE] documents R1's cognition is intact.
On 7/19/23 at 12:00 PM, R2 said that R2 was just sitting in the dining room and out of the blue, [R1] came up to R2 and punched her in the left eye and started shaking her walker. R2 stated, It hurt really bad. She makes me nervous when she is around me because I don't know what she is going to do.
On 7/19/23 at 11:03 AM, V5 (Certified Nursing Assistant) said that V5 witnessed the altercation between R1 and R2. V5 stated, I was in the dining room getting everyone ready for lunch. I had the music on and was singing and dancing with [R2]. [R1] came in like I was playing [Heavy Metal Rock Band], all mosh pit style and smacked her on the cheek and then started shaking her walker. V5 said that R1 was not provoked by anything, and that R1 just walked into the dining room. V5 said that R1 does have behaviors so she just lets her do her own thing. V5 said that R1 can be aggressive and mean at times. V5 said that recently R1 has been wandering into other resident rooms and stealing their belongings.
R2's Final Abuse Allegation Investigation Report dated 6/26/23 shows, Investigation showed that [R2] was noted to be sitting in the dining area in her wheelchair. [R1] was ambulating around the dining area, and stopped at [R2's] table, moved a few items on the table around, and [R2] requested her to stop. [R1] then made contact to [R2's] arm using her open hand .
On 7/19/23 at 1:00 PM, V1 (Administrator) said that it was substantiated that the situation between R1 and R2 happened. V1 said that in the final report, he mistyped, and it should have said cheek and not arm.
R2's Nursing Notes dated 6/21/23 at 12:45 PM shows, It was reported to this nurse that a different resident came up and struck her in the face
2. R3's Final Abuse Allegation Investigation Report dated 6/13/23 shows, It was found that [R1] tried to take away [R3's] silverware while he was sitting at a table in the dining hall at dinner [R3] yelled 'get away from me'. This created a resident-to-resident altercation, with [R1] hitting [R3] in the back.
On 7/19/23 12:41 PM, V6 (Dietary Aide) said that he witnessed R1 hit R3. V6 said R3 was sitting in the dining room and R1 came up to R3 and hit him. V6 said that V6 was in the kitchen window area looking into the dining room when it happened.
3. R4's MDS dated [DATE] shows that R4's cognition is impaired.
R4's Final Abuse Investigation Report dated 3/10/23 shows, Investigation showed that [R4] was noted to be sitting outside the dining room area in his wheelchair. [R1] was ambulating out of the dining area, and stopped at [R4], bent down and made contact to his face using her lips [R4] denies making any comments to attract her attention. [R1] does not have any recollection to kissing [R4] or can state why. [R1] just says, he must have needed a kiss.
On 7/19/23 at 11:20 AM, V7 (Licensed Practical Nurse) said that she witnessed R1 kiss R4. V7 said that R1 can be aggressive at times to other residents. V7 said that R1 wanders around the facility often and is watched by all the staff members.
On 7/19/23 at 1:36 PM, V3 (MDS Coordinator) said that R1 is monitored by all the staff frequently. V3 said that R1 wanders and has dementia and can be aggressive but she does not intend to harm anyone. V3 said that she does not think it is ideal for R1 to be in the activity room without staff present. V3 said that she does not know if the incidents involving R1 are abuse but she does not want the residents to feel unsafe. V3 said that if a resident hits another resident, it is considered physical abuse. V3 stated, If it wasn't, we wouldn't have reported it. V3 said that if a resident kissed another resident and it was not wanted, it could be considered abuse but depends on the residents [cognition] and the investigation.
R1's Nursing Notes show:
3/18/23-Combative during cares .Goes into other residents' rooms Not easy to redirect.
6/9/23-Hitting CNA, agitated, combative .
6/9/23-Combative and striking nurse .
6/11/23-Resident is having increased agitation, physical and verbal behaviors noted
6/12/23-Aggressive towards other
7/6/23-Resident remains on risperidone. Some behaviors noted
7/14/23-Continues risperidone with little effect on behaviors. Resident is lashing out at staff and other residents
R2's Psychosocial Care Plan started on 3/16/23 shows, Inappropriate observance of personal/social boundaries (personal business and/or space) as evidenced by approaching residents in their personal space. [R1] has demonstrated behaviors since admission [R1] has impaired cognition and does not always understand boundaries Interject and gently guide resident to appropriate distance from others . R2's Care Plan has not been updated and no new interventions were added since 3/16/23.
The facility's Abuse Prevention Program revised on 11/28/16 shows, The facility affirms the right of our residents to be free from abuse .Abuse is the willful injection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm Physical Abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Sexual Abuse is non-consensual sexual contact of any type with a resident Resident Assessment staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of mistreatment, neglect, and abuse of these residents .

Based on interview and record review, the facility failed to protect 4 residents (R1,R2,R3,R4) from misappropriation of narcotic medications. This applies to 4 of 10 residents reviewed for misappropriation in the sample of 13.
The findings include:
1) R1's physician's orders dated 5/15/23 showed, Hydrocodone-Acetaminophen 7.5-325mg take 1 tablet by mouth 4 times per day.
The facility's pharmacy delivery record dated 5/15/23 showed 120 tabs of Hydrocodone-Acetaminophen 7.5-325mg tabs were delivered for R1.
The facility was unable to account for 60 of R1's Hydrocodone tabs.
2) R2's physician's orders dated 4/26/23 showed, Hydrocodone-Acetaminophen 10-325mg take 1 tablet by mouth 3 times per day.
The facility's pharmacy delivery record dated 5/11/23 showed 90 tabs of Hydrocodone-Acetaminophen 10-325mg tabs were delivered for R2.
The facility was unable to account for 60 of R2's Hydrocodone tabs.
3) R3's physician's orders dated 4/12/23 showed, Hydrocodone-Acetaminophen 5-325mg take 1 tablet by mouth every 6 hours as needed for pain.
The facility's pharmacy delivery record dated 5/11/23 showed 30 tabs of Hydrocodone-Acetaminophen 5-325mg tabs were delivered for R3.
The facility was unable to account for 60 of R3's Hydrocodone tabs.
4) R4's physician's orders dated 1/4/23 showed, Hydrocodone-Acetaminophen 7.5-325mg take 1 tab by mouth every 6 hours as needed for pain.
The facility's pharmacy delivery record dated 5/1/23 showed 30 tabs of Hydrocodone-Acetaminophen 5-325mg tabs were delivered for R4.
The facility was unable to account for 15 of R4's Hydrocodone tabs.
On 6/14/23 at 9:59AM, V5 (Registered Nurse) stated she faxed V7 (Nurse Practitioner) for the above residents regarding their Hydrocodone and requested refills for all of them. V5 stated this was on a Friday and when she came back the following Monday, the medications still were not at the facility. V5 then contacted the pharmacy and was informed that the medications were being refilled too soon. V5 stated she then alerted V3 (Interim Director of Nursing (DON)/Minimum Data Set (MDS) coordinator) of the medications being out for the above residents and it was handled by V3 from that point forward.
On 6/14/23 at 10:06AM, V3 stated it was reported to her that Hydrocodone had not arrived to the facility for a few residents so she called the pharmacy and received notice that the medications were all being refilled too soon. V3 then initiated an investigation and audited all other residents' narcotics and records and found multiple discrepancies with the recorded amount of narcotics and the actual amount present in the medication cart. V3 then stated she notified V7 (Nurse Practitioner) informing her of the initial missing medications. V3 stated she was informed by the nurse that no residents had went without their pain medications. (It was later found that R1 had missed 17 doses of his pain medication). V3 stated she is aware that this is misappropriation of resident property and the facility is unable to locate any of the missing Hydrocodone.
On 6/15/23 at 8:51AM, V7 (Nurse Practitioner) stated she received the refill requests for R1-R4 and thought she had recently filled them but stated she trusts the nurse's at the facility so she sent in the prescription request for them. V7 stated she was alerted by V5 (Registered Nurse) a few days later that the medications were not delivered because they were being refilled too soon. V7 stated V5 alerted V3 of the discrepancies and then V3 initiated an investigation. V7 was then informed of the initial amount of Hydrocodone missing (30-60 tabs) but had not been informed of the final amount missing (195 tabs).
The facility's policy titled, Missing Controlled Substance reviewed on 3/16/23 showed, It is the policy of this facility to prevent the loss of controlled substances and vigorously investigate incorrect inventory of controlled drugs, medications or pharmaceuticals reported by pharmacists, physician's or licensed nurses .1. All controlled drugs will be counted by the oncoming and outgoing nurse at the change of each shift .4. Should the count prove to be incorrect compared to actual inventory at any time, a report will be made to the Director of Nursing immediately.
The facility's policy titled, Abuse Prevention Program revised on 11/28/2016 showed, The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below .This facility therefore prohibits mistreatment, exploitation, neglect of abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to reconcile narcotic medications for 4 of 10 residents, and failed to ensure medications were available as ordered (R1,R2,R3,R4) reviewed for medications in the sample of 10.
The findings include:
1) R1's electronic face sheet printed on 6/15/23 showed R1 has diagnoses including but not limited to Parkinson's disease, depression, anxiety, hip pain, chronic obstructive pulmonary disease, and neuropathy.
R1's facility assessment dated [DATE] showed R1 has mild cognitive impairment.
R1's physician's orders dated 5/15/23 showed, Hydrocodone-Acetaminophen 7.5-325mg take 1 tablet by mouth 4 times per day.
R1's medication administration record (MAR) for May 2023 showed R1 missed 13 doses of his Hydrocodone from 5/11/23-5/15/23.
R1's MAR for June 2023 showed R1 missed 18 doses of his Hydrocodone from 6/1/23-6/5/23.
The facility was unable to locate a Controlled Substance Proof of Use form for R1 from 4/29/23-5/4/23 and 5/12/23-6/5/23.
R1's MAR for June 2023 showed R1 received 4 doses of his Hydrocodone from 6/6/23-6/8/23; however, R1's Controlled Substance Proof of Use form showed R1 only received 3 doses of his Hydrocodone on these dates with no fourth dose signed out for R1.
The facility's pharmacy delivery records dated 5/15/23 showed the pharmacy delivered 120 tabs of Hydrocodone-Acetaminophen 7.5-325mg for R1. (With R1's current orders this medication should not have needed to be refilled until 6/15/23).
On 6/14/23 at 12:32PM, R1 stated the facility has run out his medications before but not very often that he is aware of. R1 stated his whole right side is painful for him and he needs pain medicine to be able to go out to activities every day.
2) R2's electronic face sheet printed on 6/15/23 showed R2 has diagnoses including but not limited to neuropathy, congestive heart failure, chronic obstructive pulmonary disease, anxiety, and peripheral vascular disease.
R2's facility assessment dated [DATE] showed R2 has no cognitive impairment and has occasional pain.
R2's physician's orders dated 4/26/23 showed, Hydrocodone-Acetaminophen 10-325mg take 1 tablet by mouth 3 times per day.
R2's MAR for June 2023 showed R2 missed 4 doses of his Hydrocodone between 6/5/23-6/7/23.
The facility's pharmacy delivery records dated 5/11/23 showed the pharmacy delivered 90 tabs of Hydrocone-Acetaminophen 10-325mg for R2. (With R2's current orders this medication should not have needed to be refilled until 6/11/23).
The facility was unable to locate a Controlled Substance Proof of Use form for R2 from 5/17/23-5/25/23.
On 6/14/23 at 8:43am, R2 stated the facility has run out of his pain medications before for a few days and he just has to wait until pharmacy brings the medication. R2 stated he has a lot of pain in his legs and just sits in pain when the facility runs out his medications.
3) R3's electronic face sheet printed on 6/15/23 showed R3 has diagnoses including but not limited to osteoarthritis, Alzheimer's disease, and fracture of left femur.
R3's facility assessment dated [DATE] showed R2 has moderate cognitive impairment.
R3's physician's orders dated 4/12/23 showed, Hydrocodone-Acetaminophen 5-325mg take 1 tablet by mouth every 6 hours as needed for pain.
The facility's pharmacy delivery records dated 5/11/23 showed the pharmacy delivered 30 tabs of Hydrocodone-Acetaminophen 5-325mg for R3. (With R3's current orders she should have had 30 tabs of Hydrocodone left).
The facility was unable to locate a Controlled Substance Proof of Use form for any of R3's Hydrocodone.
4) R4's electronic face sheet printed on 6/15/23 showed R4 has diagnoses including but not limited to sepsis, chronic obstructive pulmonary disease, lymphedema, chronic pain, and depression.
R4's facility assessment dated [DATE] showed R4 has no cognitive impairment and has frequent pain.
R4's physician's orders dated 1/4/23 showed, Hydrocodone-Acetaminophen 7.5-325mg take 1 tab by mouth every 6 hours as needed for pain.
R4's MAR for May 2023 showed R4 had not used any doses of her Hydrodocone; however, R4's Controlled Substance Proof of Use form showed R4 had used 5 doses of her Hydrocodone.
The facility's pharmacy delivery records dated 5/1/23 showed the pharmacy delivered 30 tabs of Hydrocodone-Acetaminophen 7.5-325mg for R4 and was signed for with an illegible signature. (With R4's current orders and proof of use form, R4 should have had 25 remaining doses of her Hydrocodone).
On 6/14/23 at 8:54AM, V4 (Registered Nurse) stated that medications are usually delivered on the night shift and the nurse working has to check all medications with the pharmacy delivery driver and sign for the medications. The nurse is then supposed to fill out the Controlled Substance Proof of Use form and put it in the narcotic book and then lock the narcotic medications in the narcotic drawer in the medication cart. V4 stated the facility used to use multiple proof of use sheets for larger narcotic orders (ex: 120 tabs would get 4 proof of use forms for 30 tabs each) but now the facility is going to use 1 proof of use sheet for all narcotic deliveries. V4 stated at the beginning and end of every shift, 2 nurses count the number of narcotic cards, number of controlled count sheets, the number of bottles/vials/boxes/syringes, and how many cards/vials/boxes/syringes were emptied and received on their respective shift. V4 stated this form is then signed off on by both nurse's verifying the accuracy. At 9:47AM, V4 stated when narcotic cards are completed and empty, the nurse is to put the empty card and narcotic sheet into the mailbox of the Director of Nursing (DON). (At this time, V4 stated the facility has been without a DON for 1 month and V3 (Minimum Data Set (MDS) Coordinator) has been the interim DON. V4 was separating a large stack of empty narcotic cards and proof of use sheets from 5/29/23-present that had been sitting in the DON mailbox).
On 6/14/23 at 10:06AM, V3 (Interim DON/MDS coordinator) stated, When narcotics are delivered, the nurses are to put the count sheet in the book and then put the narcotics in the locked drawer in the medication cart. At the beginning and end of every shift, the outgoing and incoming nurse's count the amount of narcotics they have, how many vials/boxes/syringes, how many count sheets, and how many medications were emptied and received on their shift. The 2 nurse's then sign off the sheet for accuracy. If there is a discrepancy, then I am to be notified immediately and no staff are to leave until I get here and speak with them. To be honest, the sheet that is filled out at the beginning of every shift is very confusing and when I work the floor I always get it wrong. I don't know how the nurse's would even keep it straight. I should have been paying more attention to this and doing random audits. I can't provide some of the Controlled Substance Proof of Use forms for a few residents because I don't know where they are.
The facility's document titled, Cards/Vials/Bottles Count from 5/1/23-6/14/23 showed out of the 45 days, there were 37 errors in the count sheet with inaccurate numbers and no nurse signatures.
The facility's policy titled, Controlled Substances reviewed on 3/16/23 showed, It is the policy of the facility that all drugs listed as schedule II drugs are subject to specified handling, storage, disposal and record keeping .4. All schedule II drugs must be administered and recorded on a disposition sheet as follows: date and time of administration, signature of nurse administering drug, and quantity on hand/balance left .7. The drugs in schedule II will be counted and reconciled by the nurse coming on duty with the nurse that is going off duty. These records will be retained for at least 1 year.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident tube feeding bag was changed for one of one resident (R5) reviewed for tube feeding in the sample of 12.
The findings include:
R5's face sheet printed on 5/25/23 showed diagnoses including but not limited to dementia, cognitive communication deficit, and dysphagia (difficulty swallowing). R5's facility assessment dated [DATE] showed moderate cognitive impairment and requires staff assistance with bed mobility, transfers, dressing, toilet use, and hygiene.
R5's May physician orders showed an order start dated 5/12/23 for Jevity 1.5 (liquid nutritional formula) 30 milliliters per hour continuous feeding. May hold 3 to 6 hours for discomfort.
On 5/23/23 at 10:47 AM, R5 was lying in bed and her feeding tube was running at 30 milliliters per hour. The liquid nutrition was in a bag dated 5/20/23 and the tubing had a tag on it. The tag did not have any documentation on it. At 1:42 PM, R5 was not in her room and the feeding tube pump was not running. The same bag dated three days ago was still hanging from the pole. At 1:48 PM, V3(Licensed Practical Nurse) observed the feeding tube bag and said this bag is no good. They should only be used for 24 hours. The night nurses must be pouring the nutritional formula into the bag without changing it. This bag is three days old and needs to be changed now. V3 said the tag on the tubing should also be labeled and is only good for 24 hours. V3 said it is important the bags and tubing get changed daily. They can clog or cause a stomach infection if they are not changed. V3 said this should have been changed days ago. I should have noticed it this morning too and I missed it.
On 5/25/23 at 9:58 AM, V4 (Licensed Practical Nurse) said feeding tube formula is only good for 24 hours once it is opened. The bag and tubing should be changed then too. Bacteria can build up and cause resident illness, GI issues, or stomach upset.
The facility Enteral Feeding Drip Infusion policy date 4/07 states: 23. Unused product may be stored covered in a refrigerator. Opened, unused product must be used or disposed of within 24 hours of opening unless otherwise noted by the manufacturer. The policy did not address when feeding tube bags and tubing should be changed for continuous use feedings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide dignity for 1 of 1 resident (R34) reviewed for dignity in the sample of 12.
The findings include:
R34's face sheet documents she was admitted to the facility on [DATE]. The May 2023 POS (Physician Order Sheet) documents multiple diagnoses including dementia. The treatment orders include catheter care twice daily.
The quarterly resident assessment of 4/14/23, shows R34 to have moderate cognitive impairment. The same assessment shows R34 requires limited assist of one person for ADL's (Activities of Daily Living).
On 5/23/23 at 9:12 AM, R34 was observed sitting in a high back wheelchair at the nurses station. She had a urinary drainage bag hanging on the side of her wheelchair. The bag was not placed in a dignity bag and had yellow urine visible in the bag.
On 5/24/23 at 12:00 PM, V7 and V8 CNAs (Certified Nursing Assistants) said the facility does have dignity bags for the urinary drainage bags, but they tear easily. Each said the urinary drainage bags should not be on the floor and should be in a dignity bag under their chair.
On 5/25/23 at 10:49 AM, V4 RN (Registered Nurse) said all urine bags should be in a dignity bag under their wheelchair, and not on the floor. That could cause contamination and infection. She said it can also be embarrassing for a resident to have a bag of urine showing.
The State of Illinois Department on Aging Residents Rights for People in Long-Term Care facilities list privacy as a resident right. Medical and personal care are private.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to assess and monitor a resident (R7) with a history of pneumonia showing a change in condition. This failure resulted in R7 being admitted to the hospital in poor condition. The facility also failed to correctly apply elastic bandages to a resident (R29) with lower extremity edema. This applies to two of two residents (R7 and R29) in the sample of 12 reviewed for quality of care.
The findings include:
1. The Physician Order Sheet (POS) for R7 shows diagnosis to include anemia, coronary artery disease and chronic obstructive pulmonary disease. The POS shows orders for oxygen at 2-4 liters via a nasal cannula as needed to keep the oxygen saturations above 90%. The facility assessment dated [DATE] shows R7 to be cognitively intact.
On 5/23/23 at 9:21 AM, R7 was observed being taken from the bathroom by staff and placed in her wheelchair. R7 immediately fell asleep, and her breathing sounded congested. R7 would wake up when her name was said but would immediately fall back to sleep. R7 had an oxygen concentrator in her room but it was not being used. At 9:30AM, V3 Licensed Practical Nurse (LPN) was asked about R7's current condition and V3 said R7 has been like this lately due to her medications being changed.
On 5/23/23 at 10:16 AM, R7 continued to sit in her wheelchair in her room asleep, leaning over to the right, with her right hand hanging down. R7's breathing sounds congested, and she was coughing.
On 5/23/23 at 10:44 AM, R7 was still in her room asleep in her wheelchair, both hands are hanging down by her side.
On 5/23/23 at 11:48 AM, R7 was moved to the dining room leaning over to the right, still sleeping, hands hanging down. The staff and other residents were saying her name and she would wake up for a very short period and immediately fall back to sleep. R7 was spilling her lunch on the floor. R7 could be heard coughing at times. At 12:48PM, R7 had been pushed into the activity room and was still asleep in her wheelchair with her hands hanging down by her side and leaning to the right side. At 1:16 PM, R7 was still in the activity room, asleep in her wheelchair.
On 5/23/23 at 1:20PM, R7 was pushed down the hall by 2 Certified Nursing Assistants (CNA). One CNA was pushing the wheelchair and the other was holding her legs up. V3 came into R7's room and checked her blood pressure and oxygen saturations. V3 applied the oxygen nasal cannula to R7 and was observed adjusting the oxygen and rechecking her oxygen saturations. V3 left the room and returned with a oxygen mask which she then applied to R7 and continued to check R7's oxygen saturation. V3 left the room again and returned with a nebulizer treatment for R7. V3 said she had notified the Nurse Practitioner for a chest x-ray order. R7 continued to have a difficult time staying awake and following commands.
On 5/23/23 at 1:55 PM, R7 was in bed asleep, and her oxygen is set at 8 liters using the mask. R7 was observed using her abdominal muscles to breath.
On 5/23/23at 2:59 PM, R7 was asleep in bed with her oxygen at 8 liters per mask, using accessory muscles to breath.
On 5/24/23 at 8:00AM, R7 was not in her room. R7's medical record shows a note dated 5/23/23 at 3PM by V3 that R7 was having a hard time staying awake, was lethargic and slept through lunch. V3 documented that R7's oxygen saturation was 81% and she had started oxygen at 6 liters via a mask. V3 wrote she had contacted the NP and an order was received for a chest Xray and cough syrup. The note also shows a nebulizer treatment was completed and R7's saturations went up to 91% on 6 liters of oxygen. No further nursing notes were made by V3 that day for R7 regarding her change in condition.
On 5/24/23 at 9:15 AM, V5 NP said she would have expected the nurse on duty to intervene and assess her earlier in the day since you informed her of the lethargy, cough and congestion. V5 said earlier intervention does have better outcomes.
On 5/24/23 at 1:53 PM, V7 CNA said R7 does act more tired in the morning and will fall asleep quickly but yesterday was different, she spilled food on her for breakfast and for lunch. She usually [NAME] up after breakfast but yesterday she did not. That was different I told the nurse she was acting differently that day.
On 5/25/23 at 8:17 AM, V6 LPN said she was the nurse who sent R7 out to the hospital. V6 said she was told in report at 6 PM that R7 was very sleepy, her oxygen saturations were in the 70's and was having a hard time breathing, hard to arouse. When I went in around 8PM to give meds, her skin was gray, she was having a hard time breathing and was hard to arouse, she would not take her meds, she was short of breath and had crackles in her lungs and was spitting up green sputum. V6 said she called the NP and was told to send her to the emergency room. V6 said she later called the hospital to check on R7 and was told she had to be transferred to another hospital for high flow oxygen.
On 5/25/23 at 9:54 AM, V3 said when this surveyor approached her about R7, she felt it was just the usual behavior for R7. She did not feel the need to go check her. V3 said when she saw the CNA's bring her down the hall holding up her feet, she decided to go check her. Her oxygen saturations were 71 % at that time. V3 said she started the oxygen and gave R7 a breathing treatment and notified the NP that R7 was unresponsive, had low oxygen saturations and was coughing. I received an order for a chest x-ray and cough syrup. V3 said R7 had just had pneumonia last month and getting a chest X-ray was standard protocol for shortness of breath.
The nursing progress notes for R7 shows V6 documented at 8PM that R7's color was gray, she was very lethargic, short of breath and R7 could not tell V6 where she was. R7 was coughing up green phlegm. The chest X-ray report came back showing R7 had pneumonia. The NP was notified and R7 was to be sent to the emergency room.
There were no nursing notes showing R7 was monitored or assessed between 3 PM and 8PM on 5/23/23.
The emergency room note from the local hospital R7 was first sent to shows R7 was brought to the hospital by ambulance for shortness of breath and pneumonia. The note shows the report they received from the nursing home was R7 had been short of breath that day and her oxygen saturations were in the 70's and that no call had been made earlier for a patient evaluation. R7's temperature was recorded as 100.7 and oxygen saturations were 86%. The note also shows R7 was transferred to another hospital in poor condition. The records for R7 shows a COBRA transfer record to send R7 to another hospital for a higher level of care due to her unstable condition.
The hospital notes from the second hospital R7 was sent to shows a plan to treat her bilateral pneumonia, respiratory failure and sepsis.
The X-ray obtained at the facility dated 5/23/23 showed a right basilar pneumonia.
R7's facility care plan shows for chronic obstructive pulmonary disease (COPD) with interventions to include: instruct and monitor for early signs of COPD exacerbation such as confusion or excessive sleepiness, shortness of breath and coughing.
The facility policy with a revision date of 12/7/17 for notification for change in resident condition or status shows the facility shall promptly notify appropriate individuals such as NP or the residents attending physician when there has been a marked change in relation to usual signs or symptoms.
2. On 5/23/23 at 9:35 AM, V3 was observed doing wound care on R29. R29's both lower leg were edematous and discolored. V3 wrapped R29's legs with ace wrap for his edema. V3 started at the knee and wrapped the ace wrap down to the toes.
On 5/25/23 9:00AM, V2 LPN said when wrapping a residents lower legs, always start at the bottom and work your way up.
On 5/25/23 at 9:11 AM, V4 Registered Nurse (RN) said when wrapping ace wraps to a residents legs for edema, always start at the bottom and work your way to the top to promote venous return.
On 5/25/23 at 2:00PM, V11 Wound Physician said to promote venous return to lower legs for edema, always wrap from the toes to about 2 inches below the knees.
The Physician Order Sheet (POS) for R29 shows diagnosis to include hypertension and type 2 diabetes. The POS shows an order for ace elastic bandages to affected areas daily.
The care plan for R29 shows alteration in circulation to both lower legs and causing stasis ulcer/wounds.
The facility stated they had no policy for application of elastic bandages.

Based on interview and record review the facility failed to provide 8 hours of Registered Nurse (RN) coverage daily. This applies to all 35 residents residing in the facility.
The findings include:
The facility Resident Census and Conditions report dated 5/23/23, shows the facility census to be 35 residents.
On 5/23/23, V3 LPN (Licensed Practical Nurse) said the nurses work 12 hour shifts, and she is the only nurse on duty for the facility, the DON (Director of Nursing) was on vacation. She said there was no RN in the facility at this time.
A review of the nursing schedule for May 16- May 31,2023 shows on May 18th, 19th, 22nd, and 23rd, no RN coverage was scheduled.
On 5/25/23 at 09:20 AM, V2 LPN/MDS coordinator (Licensed Practical Nurse/Minimum Data Set) said the DON had been on vacation since 5/18/23. V2 said the DON worked the night shift on 5/17/23. V2 said she was aware of the required 8 hours of RN coverage and said the facility does not meet the requirement.
On 5/25/23 at 9:30 AM, V1 (Administrator) said the facility had no written policy for staffing, they follow the state requirements in the regulations.