**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to properly clean an indwelling urinary catheter, failed to complete and document indwelling catheter care as ordered, failed to verify an indwelling urinary catheter flush order, failed to monitor intake and output as ordered, and failed to ensure a resident's indwelling was properly positioned and covered for 3 of 3 residents (R1, R2, R5) reviewed for indwelling urinary catheters in the sample of 11. These failures caused R2 to experience increased pain and sepsis secondary to developing a catheter associated urinary tract infection. Findings Include:1. R2's admission Record document, print date of 8/18/25, documented R2 was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses including Wernicke's encephalopathy, type 2 diabetes mellitus, chronic gout, insomnia, alcohol abuse, major depressive disorder, polyneuropathy, hypertension, and obstructive and reflux uropathy.R2's MDS, dated [DATE], documented R2 was severely cognitively impaired, dependent on staff for toileting and hygiene needs, and had an indwelling urinary catheter.R2's care plan, initiation date of 6/30/25, documented R2 required use of an indwelling catheter related to obstructive uropathy and was at risk of infection. Care plan interventions include monitor for s/s (signs/symptoms) of UTI (urinary tract infection), notify MD (Medical Doctor) of abnormal findings, staff to monitor patency of catheter, and record output as directed. R2's care plan did not address indwelling catheter care although R2's admission orders, dated 6/30/25, documented indwelling catheter care every shift as needed.R2's TAR (Treatment Administration Record), dated 7/2025, documented an order for indwelling catheter care every shift as needed. This TAR did not document R2's catheter care was completed at all on 7/2/25 nor was it completed on every shift as ordered on 7/11/25, 7/21/25, nor 7/23/25. This TAR documented monitor urine for infection q (every) shift. This TAR did not document this was completed on 7/2/25. This TAR also documented monitor (indwelling urinary catheter) placement q shift. This TAR does not document it was completed every shift on 7/2/25, 7/6/25, 7/10/25, 7/12/25, 7/21/25, nor on 7/23/25.R2's TAR, dated 8/2025, does not document R2's catheter care was completed every shift as ordered on 8/8/25.R2's progress note authored by V12 Nurse Practitioner, dated 7/1/25, documented obstructive and reflux uropathy, unspecified, continue (indwelling catheter) care and management. Monitor I&O (intake and output).R2's catheter output record, dated 7/1/25, did not document any output on 7/1/25, nor did it document R2's urinary output was completed every shift on 7/6/25, 7/8/25, 7/10/25, 7/12/25, 7/13/25, 7/14/25, nor on 7/15/25.R2's output record, print date of 8/20/25, does not document R2's urine output was monitored every shift as ordered on 7/22/25, 7/30/25, 7/31/25, 8/1/25, 8/3/25, 8/5/25, 8/6/25, 8/7/25, nor 8/10/25.R2's fluid intake records for July and August of 2025 are not documented every shift as ordered on 7/1/25, 7/2/25, 7/6/25, 7/8/25, 7/10/25, 7/12/25, 7/13/25, 7/14/25, 7/15/25, 7/18/25, 7/21/25, 7/30/25, 7/31/25, 8/1/25, 8/4/25, 8/5/25, 8/6/25, 8/8/25, and 8/10/25.R2's progress notes, dated 7/3/25, documented at 4 PM while assisting CNA (Certified Nurse Assistant) noted urine in drainage bag to have the appearance of thin beige liquid. (R2's Facily) states she would like this to be expedited. Call placed to NP (Nurse Practitioner) at 4:40 PM, received order to send out to ER (Emergency Room) if family desired. At 4:50 PM, family stated they would like him sent to ER.R2's hospital Discharge summary, dated [DATE], documented R2 was hospitalized with severe sepsis secondary to CAUTI (catheter associated urinary tract infection). Suspect (indwelling urinary catheter) was dislodged or clogged as patient had immediate large volume output with new (indwelling urinary catheter) placement.R2's hospital discharge orders, dated 7/5/25, documented an order to flush R2's indwelling urinary catheter with 30 ML NS (normal saline) BID (two times per day).R2's facility progress note, dated 7/5/25 at 5:55 PM, documented resident returned to the facility by way of (local) EMS (emergency medical service) in company of (R2's Family). Resident is alert and oriented x 1-2, (indwelling urinary) catheter in place draining yellow urine with small amount of sediment noted in the tubing. New orders for amoxicillin 500 mg PO (by mouth) every 12 hours for 7 days and Keflex 500 mg PO 3 times daily for 10 days. Instructions to flush (indwelling urinary) catheter with 30 ml of saline every 12 hours.R2's MAR (Medication Administration Record), dated 7/2025, documented an order, dated 7/5/25, to flush R2's indwelling urinary catheter with 30 CC H20 (water) Q 12 hours. This MAR documented R2's indwelling urinary catheter was flushed with 30 CC H20 Q 12 hours twice a day from 7/7/25 through 7/31/25.On 8/18/25 at 1:55 PM V3 LPN/CPC (Licensed Practical Nurse/Care Plan Coordinator) stated she completed the admission for R2 on 7/5/25, the indwelling catheter flush order didn't specify what it should be flush with. V4 stated she put the order in as water. Surveyor asked V4 what kind of water was used for the flushes and V4 replied tap water. Surveyor requested that order.On 8/18/25 at 2:04 PM V3 came to surveyor and stated I know where that water order came from, it was from the R2's urologist on 8/4/25. V4 presented the order, the order documents catheter flushing every 8 hours. The order does not specify what to flush with.R2's progress note, dated 8/4/25 at 9:27 AM, documented left facility for appointment with urologist. Accompanied by (R2's Family) and CNA (Certified Nurse Assistant).R2's after visit summary from R2's urologist, dated 8/4/25 at 10 AM, documented orders for topical antibiotics around the tip of R2's penis and indwelling urinary catheter flushing every 8 hours.R2's progress note, dated 8/4/25 at 1:18 PM, documented returned to facility at this time. No changes in orders. R2's progress notes do not document the orders to increase R2's indwelling urinary catheter flush to every 8 hours, no documentation of any facility nursing staff calling R2's physicians for clarification of what to flush R2's catheter with, nor does it document a topical antibiotic was ordered for R2's penis pain and infection.On 8/18/25 at 8:06 AM V11, (R2's Family), stated she did inform R2's nurse of R2's new orders from his urologist for topical antibiotics and to increase R2's indwelling urinary catheter to every 8 hours from every 12 hours. V11 stated she provided the facility nurse with a copy of the orders. V11 stated she had a care plan meeting with the facility staff on 8/5/25 to discuss a very long list of issues and she brought up the catheter flush upgrade to every 8 hours as well as the topical antibiotic and R2's reporting of pain at his penis. V11 stated when she visited R2 on 8/8/25 and R2 once again told her the tip of his penis hurt. V11 stated she approached the nurse's station to check on R2's topical antibiotic order and found the facility had never implemented R2's topical antibiotic order.R2's August 2025 MAR documented R2's topical antibiotic bacitracin was not implemented until 8/9/25. This MAR documented flush (indwelling urinary) catheter with 30 cc H20 Q 8 hours for UTI. This was ordered on 8/4/25 by R2's urologist although it was not implemented until 8/5/25 at 4 PM. R2's progress notes do not document any physician notification to clarify what R2's indwelling urinary catheter should be flushed with.R2's Medication Review Report documented R2 had a physician order, dated 7/16/25, for (indwelling urinary catheter) and bag, change monthly and as needed 16 FR (French) with 10 cc balloon.R2's progress note, dated 8/5/25 at 2:22 PM, documented (indwelling urinary) catheter leaking, scant amount of cloudy amber urine in tubing. Bulb deflated, and (indwelling urinary catheter) removed. New #16 FR indwelling catheter inserted with 30 ml normal saline. R2's medical record did not document any orders for a size 16 FR with 30 ml bulb.R2's progress note, dated 8/6/25 at 8:35 AM, documented care plan meeting, met with the whole family and most of the department heads. It continues, we went over his urology appt (appointment) wants his (indwelling catheter) flushed every 8 hours instead of 12.R2's progress note, dated 8/12/25 at 7:15 AM, documented nursing notified provider that resident had a fall early this am where he slid from his bed to the floor. Post fall BP (blood pressure) was 70s/60s. Additionally, labs that resulted overnight revealed WBC (white blood cell) was critical high at 38k (38,000), with elevated procalcitonin level as well. Gave order to send resident to ED (emergency department) d/t suspected septic shock.R2's critical care medicine history and physical note, dated 8/12/25, documented septic shock, etiology likely secondary to PNA (pneumonia) vs CAUTI. (Indwelling catheter) replaced in ED due to leaking around cuff on 8/12. 2L urine output returned.2. R1's admission Record, print date of 8/18/25, documented R1 has diagnoses including rheumatoid arthritis, malnutrition, chronic fatigue, heart failure, altered mental status, neuromuscular dysfunction of bladder, cognitive communication deficit, hypertension, and acquired absence of right shoulder. R1's MDS (Minimum Data Set), dated 7/11/25, documented R1 is moderately cognitively impaired.R1's care plan, undated, documented R1 has an (indwelling urinary catheter) related to neurogenic bladder and is at risk of infection. Interventions include keep drain bag covered to promote privacy. R1's care plan does not address catheter care.R1's physician orders, dated 7/24/25, documented monitor for foley catheter position and placement every shift, intake and output every shift, and catheter care every shift. R1's August 2025 TAR (Treatment Administration Record) did not document R1's indwelling urinary catheter care was completed on the day shift on 8/15/25, evening shift on 8/7/25, 8/8/25, nor 8/15/25, nor on the night shift on 8/8/25.R1's August 2025 TAR documented monitor for (indwelling urinary catheter) position and placement q (every) shift. This TAR does not document this as completed on the day shift of 8/15/25, evening shift on 8/7/25, 8/8/25, nor on 8/15/25, nor on the night shift of 8/8/25. R1's urinary output record, print date of 8/20/25, does not document R1's urine output was documented every shift on 8/7/25, 8/8/25, 8/10/25, 8/12/25, 8/13/25, 8/15/25, nor on 8/17/25. On 8/20/25 at 12:27 PM V1 Administrator provided intake stated she could not find any intake records for R1 for July nor August 2025.On 8/18/25 at 8:38 AM R1 was observed in bed with her breakfast in front of her. R1's indwelling urinary catheter bag was uncovered and lying directly on the floor under the bed. V3 Care Plan Coordinator/LPN (Licensed Practical Nurse) walked in and stated to R1 where is your catheter bag? V3 then picked the catheter bag up off the floor, placed the bag in the bag cover, and attached it to R1's bed. 3. R5's admission Record document, print date of 8/18/25, documented R5 has diagnoses including multiple myeloma, ataxia following nontraumatic intracranial hemorrhage, polyneuropathy, glaucoma, hypertension, benign prostatic hyperplasia, and obstructive and reflux uropathy. R5's MDS, dated [DATE], documented R5 is moderately cognitively impaired although at time of interviews R5 was alert and oriented. R5's care plan, undated, documented R5 is at risk for complications related to receiving chemotherapy, R5 requires use of an indwelling catheter related to obstructive uropathy and is at risk of infection, and R5 requires enhanced barrier precautions (EBP) related to indwelling medical device. R5's care plan interventions include staff to wear gown and gloves when performing ADL's (activities of daily living) including when providing hygiene care. R5's physician orders, print date of 8/18/25, documented orders for enhanced barrier precautions for indwelling medical device urinary catheter, indwelling catheter care every shift as needed, and I & O (intake and output) q shift. On 8/18/25 at 8:40 AM surveyor asked R5 how often the nurses and CNAs clean around his catheter. R5 replied not very often, I can't remember the last time they cleaned it.On 8/18/25 at 11:02 AM V6 CNA and V9 CNA were observed as they provided indwelling urinary catheter care for R5. V6 and V9 had the clean supplies set up on a bedside table covered with a clean towel although the clean gloves were off to the side of the towel and directly on the bedside table. R5's door to his room is clearly marked with enhanced precautions signs and PPE (personal protective equipment) including gowns was readily available on the isolation door supply caddy. Neither V6 nor V9 donned gowns at any time during this observation. V9 cleansed R5's penis, scrotum, and inner thighs but did not cleanse R5's indwelling catheter tubing. V6 and V9 rolled R5 onto his right side without repositioning the catheter bag or tubing causing the urine to back flow in the tubing. R5's 8/25 TAR documented (indwelling urinary) catheter care every shift as need although it was not documented as completed every shift on 8/7/25, 8/8/25, nor 8/15/25. R5's catheter output record, print date of 8/20/25, did not document R5's urine output was monitored every shift on 7/22/25, 7/23/25, 7/27/25, 7/28/25, 7/29/25, 8/2/25, 8/3/25, 8/4/25, 8/5/25, 8/7/25, 8/8/25, 8/10/25, 8/12/25, 8/13/25, 8/15/25, 8/16/25, nor 8/17/25. R5's fluid intake records for July and August of 2025 do not document R5's intake was recorded every shift as ordered on 7/17/25, 7/19/25, 7/23/25, 7/26/25, 7/27/25, 7/31/25, 8/1/25, 8/2/25, 8/3/25, 8/6/25, 8/7/25, 8/10/25, 8/12/25, nor 8/15/25.On 8/20/25 at 11:07 AM V2, DON, and V15, ADON were interviewed. V2 stated she would expect the CNAs to don (put on) gowns and cleanse the indwelling catheter tubing while providing catheter care. V15 stated she expects the CNAs to reposition the urinary catheter tubing and bag during turning and repositioning to prevent the urine from back flowing. V2 stated she and the other nurses did not view R2's urologist's instructions on 8/4/25 as physician orders therefore they were not clarified nor implemented. V15 stated she did not view them as orders either. V15 stated she would expect the CNAs and nurses to complete and document catheter care and I&Os as ordered.The facility's (Indwelling) Catheter Care policy, dated 4/2019, documented Policy: Daily and PRN catheter care will be done to promote comfort and cleanliness. Equipment: The following equipment and supplies will be necessary when giving catheter care: 1. Basin with warm water and soap/or pre-moistened disposable cloths. 2. Personal protective equipment (i.e. gowns, gloves, etc.) as necessary. 3. Towel and washcloth. 4. Protective bed pad. Procedure: 1. Wash your hands before beginning the procedure. 2. Assemble all equipment and supplies that will be necessary to perform the procedure. 3. Knock before entering the room. 4. Arrange the supplies so they can be easily reached. 5. Identify yourself. Explain procedure to resident. It continues, 11. Cleanse area of catheter insertion site, using soap and water or pre-moistened wipes. 12. Wash catheter itself by holding on to catheter at insertion site, wash with one stroke downward, using same procedure for rinsing. The facility's Intake and Output policy, dated 6/2015, documented General: Intake and/or output are monitored accurately to ensure adequate fluid balance for residents. Responsible Party: all nursing staff. Guideline: 1. All staff can record the intake or output in the resident record. 2. Intake is recorded for residents with the following: a. Fluid restriction, b. IV therapy, c. Tube feedings, d. Order. 3. Output is recorded for residents with the following: a. (indwelling) catheter, b. Suprapubic catheters c. Order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide resident care in a timely manner to promote resident's dignity for 3 of 5 residents (R1, R2, and R5) reviewed for dignity in a sample of 5. This failure resulted in R2 having feelings of frustration due to soiling herself and being left on a bedpan for 29 minutes and reporting pain related to this. Findings include: 1. R2's Face sheet documented she was admitted to the facility on [DATE] with diagnoses of, in part, congenital subaortic stenosis, type two diabetes mellitus, and acquired absence of bilateral legs below the knee. R2's Minimum Data Set (MDS) dated [DATE], documented she was cognitively intact and dependent on staff for toileting hygiene assistance. R2's Care Plan dated 6/27/25 documented she was at risk for skin complications related to immobility. R2's Care Plan dated 6/20/25 documented she has an alteration in comfort advanced disease process, chronic physical or psychological disability circulatory, musculoskeletal, neurological, skin/tissue impairment trauma. R2's Care Plan dated 6/20/25 also documented she required assist with daily care needs related to morbid obesity, bilateral lower extremity amputee. On 7/7/25 at 9:00 AM, R2 stated she has to wait anywhere from 30 minutes to an hour and 20 minutes for her call light to be answered at times. R2 stated it makes her feel frustrated because she ends up sometimes soiling herself instead of using the bed pan because it took the staff too long to respond. R2 stated she should be treated with respect and care. R2 stated she should feel safe and trust that the staff will take care of her appropriately. On 7/7/25 at 11:05 AM, R2 put her call light on to use the bed pan and at 11:06 AM V6, Certified Nurse's Aide, (CNA) responded and placed R2 on a bed pan. At 11:10 AM, R2 pressed her call light and notified V6 she was done using the bed pan. V6 stated she would be back after helping assist with a mechanical lift. On 7/7/25 at 11:25 AM, R2 stated, How long has it been? I thought she would be right back. R2 stated the bed pan was causing her a lot of discomfort and pain. R2 stated she wants to make sure none of the other residents who can't speak up for themselves have to go through this. R2 stated her pain level was a 9 out of 10 on a pain scale being a sharp/shooting pain caused from the bed pan that was not there prior to being placed on it. On 7/7/25 at 11:35 AM, V6 came back to R2's room with incontinence supplies. V6 had V5 (CNA's) assisted with incontinence care. When R2's bed pan was removed, a noticeable reddened outline on R2's skin from where the bed pan sat was observed. On 7/7/25 at 1:11 PM, V6, stated she had to help assist another CNA with a resident needing a mechanical lift because two people are required for that and couldn't get back to R2 until after that was done. V6 stated she tries to get residents off bed pans as soon as possible because she's sure it can cause discomfort and pain. 2. R1's Face sheet documented she was admitted to the facility on [DATE] with diagnoses of, in part, type two diabetes mellitus, chronic bronchitis, and type two diabetes mellitus with diabetic neuropathy. R1's MDS dated [DATE] documented she was cognitively intact and dependent on staff for toileting hygiene assistance. On 7/7/25 at 9:10 AM, R1 stated sometimes it takes staff 30 minutes to respond and that makes her feel like they don't care about her and that she is just an option. 3. R5's Face sheet documented she was admitted to the facility on [DATE] with diagnoses of, in part, chronic obstructive pulmonary disease, hypotension, and acute respiratory failure. R5's MDS dated [DATE] documented she is moderately cognitively impaired and dependent on staff for toileting hygiene assistance. 7/7/25 at 10:50 AM, R5 stated call lights can take a long time to get answered typically 15-20 minutes. R5 stated she wouldn't put her dog or cat in this place. On 7/7/25 at 1:10 PM, V5, CNA, stated she would expect a resident to be removed from a bed pan within 5-10 minutes after being done with it. V5 stated a bed pan can cause pain and discomfort if left in place for too long. On 7/7/25 at 11:12 PM, V4, CNA, stated she tries to get residents off bed pans as soon as possible and they can be uncomfortable to be on. V4 stated she thinks there is enough staff employed to respond to residents timely except for when there are call offs, today we have a lot. On 7/7/25 at 3:40 PM, V1, Administrator, stated she would expect residents to be removed from a bed pan in the least amount of time possible, and she is sure being left on one for an extended amount of time would cause pain or discomfort. V1 stated she expects staff to respond to residents within 5 minutes if possible. Resident Council Meeting Minutes dated 4/3/25, 5/1/25, and 6/5/25 all documented nursing concerns of call lights not being answered in a timely manner. The facility's Pain Management policy revised on 1/2025, documented it is to facilitate and provide guidance on pain observations and management. To facilitate resident independence, promote resident comfort and preserve resident dignity. This will be accomplished through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. The facility's Resident Rights policy revised on 10/2024 documented, It is the facility's policy to identify and provide reasonable accommodation for resident needs and preferences except when it would endanger the health or safety of the resident or other residents. Residents have the right to retain and use personal possessions to promote a homelike environment and to support each resident in maintaining their independence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to ensure an environment free from abuse for 2 of 4 residents (R1, R2) reviewed for abuse in the sample of 4. This Failure caused R1 to be fearful of R2 and causes her to have trouble sleeping. Findings include: R1's Face Sheet documents, R1 was admitted to the facility on [DATE] with diagnoses, including type 2 diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, anxiety, depression, osteoarthritis, and muscle weakness and atrophy. R1's Minimum Data Set, (MDS), dated [DATE] documented, R1 was independent with cognitive skills for daily decision making with short term memory intact. The MDS documented R1 required substantial/maximal assistance with bed mobility and transfer and ambulated with manual wheelchair. R1's Undated Care Plan, documents, R1 is at risk for abuse and neglect. R2's Face Sheet, documents, R2 was admitted to the facility on [DATE] with diagnoses, including encephalopathy, multiple sclerosis, difficulty walking, lack of coordination, weakness, insomnia, bipolar disorder, schizoaffective disorder, and major depressive disorder. R2's MDS dated , 04/17/24, documented, R2 was moderately cognitively impaired with inattention and disorganized thinking, used wheelchair, and required partial/moderate assistance with bed mobility and transfer. R2's Undated, Care Plan, does not address risk for abuse or identified sexual behaviors. The Facility's 04/18/24, Room Roster, documents, R1 and R2 resided in room [ROOM NUMBER]. R2's Progress Note, by V9, Licensed Practical Nurse, (LPN), on 04/18/24, at 11:54PM, documents, R2 crawled into roommate's bed. R2's Progress Note, by V9, LPN, on 04/19/24 at 4:28AM, documents, Resident noted to be talking sexually to roommate making sexual comments stating that her roommate is her lover, yelling for staff, roommate, people to have sex with her, asked her roommate for help with masturbation, and making sexual comments and personal questions when roommate was receiving care. Resident was able to be redirected and asked to lower her voice, r/t, (related to), others sleeping, will continue to monitor. (V2) and (V1) notified of behavior. On 04/24/24, at 3:53PM, V9, LPN, stated, early in the morning of 04/19/24, the (unknown) CNA, (Certified Nursing Assistant), reported to her, that R2 tried to crawl in bed with R1. She stated, R1 pushed her call light and told the CNA. When V9 entered the room, R2 was saying inappropriate things, and she told R2 that was inappropriate, and she should try to get some sleep. On 04/25/24, at 8:35AM, V14, CNA stated, On the night of 04/18/24, I responded to (R1)'s call light and found (R2) sitting in (R1)'s bed rubbing her leg and asking her to help her masturbate. I separated them and put (R2) back in (her) bed and notified the nurse. When I (first) walked in the room (R1) mouthed, Help me, and said she felt extremely uncomfortable. Prior to that, (R2) kept interrupting (R1)'s care, making sexual comments when we were trying to care for (R1) and asking us to touch her. On 04/20/2024, at 4:20PM, R1 stated, One day (R2) came to my bed and was rubbing my legs, and telling me she could masturbate with me, and I could watch if I wanted or she could touch me if I wanted her to and I said, No. On 04/24/24, at 1:00PM, R1 stated, I was scared .afraid (R2) was going to do something to me. She came over to me and said, I masturbate a lot. Would you like to come over and watch? I told her, I don't think so. My eyes aren't so good, and I probably couldn't see anyway. She yelled, a lot and talked constantly in a very loud voice, so I had trouble sleeping, but I was also afraid to go to sleep, after that day she sat on my bed and was rubbing my leg. I asked her to get up and she wouldn't, so I told her I was going to call the nurse. Then she got up. I told staff about it the next day. I know (R2) was disturbed, but she made me very nervous. Honestly, she scared the hell out of me. On 04/25/24, at 11:50AM, V16, Nurse Practitioner, (NP), stated, she visited R2 for her initial evaluation in the Facility on 04/18/24. She stated, R2 had word garbage, was not able to have coherent conversation, had sporadic words, most of them vulgar, vulgar gestures, and was impulsive. V16 stated, at that point there was nothing that led her to believe, R2 was at risk for touching others and did not think there was anything the Facility could have done to prevent it. On 04/25/24, at 9:56AM, V1, Administrator, stated, she expects the Facility to follow its abuse policy. The Facility's Abuse Policy and Prevention Program 2022 revised 10/2022 documents, This facility affirms the right of our resident to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The Facility failed to ensure a bruise of unknown origin was investigated and the appropriate corrective actions were initiated for 1 of 3 residents (R2) reviewed for injuries in the sample of 9. Findings include: R2's Physician Order Sheet for January 2024 documents a diagnosis of: Abnormalities of gait and mobility, lack of coordination, displaced supracondylar fracture without intercondylar extension of lower end of left femur, subsequent encounter for closed fracture with routine healing, abnormal weight gain, cognitive communication deficit, major depression, paraplegia, idiopathic peripheral autonomic neuropathy, anemia, acute infraction of spinal cord, pressure ulcer of sacral region, and altered mental status. R2's Minimum Data Set (MDS) documents she is moderately impaired for cognition. Bed mobility R2 was scored as 3/3 (extensive assist of two plus staff). Transfer 4/3, (total dependence on staff of two plus staff members). R2 does not walk, for toilet use she was scored a 4/3, and for personal hygiene 4/3. For Moving from seated to standing position, walking, turning around, and moving on and off the toilet she was documented as this activity did not occur. R2 was scored from surface-to-surface transfer (between bed and chair) as not steady and only able to stabilize with staff assistance). R2 is in a wheelchair. For Roll left to right, she requires Substantial/maximal assistance and for sit to lying, and lying to sitting she Dependent- staff does all the effort. R2's Care Plan documents, R2 has Alteration in musculoskeletal status related paraplegia. Intervention: Monitor. Document for risk of falls, educate residents, family/caregivers on safety measures that need to be taken in order to reduce risks for falls. Alteration in musculoskeletal status related paraplegia. Fall (Focus Area) Resident is at risk for falls. R2's Shower Sheet dated 12/19/2023 documents red area with an arrow pointing towards the high thigh area on the left side. R2's Shower Sheet dated 12/24/2023 documents a bruise on the right knee area. All abuse investigations were requested on for the past three months and there were no abuse investigations including injury of unknown origin for R2. On 1/2/2024 at 3:04 PM, V12, Registered Nurse (RN) Hospital Nurse stated, I was working in the ER (emergency room) when (R2) was brought in from the facility. The color of the bruising was almost dark red, you could tell by just looking at the leg because of the rotation of the foot and the degree in which the knee rotated out and that the leg was broken. I cannot say how long it had been like this. We took x-rays and she had a tibia spiral fracture. (R2) could not move or use her legs. I put my hand on her leg and she said she could feel the warmth of my hand but that was all. (R2) could not move her legs, she could only feel the temperature difference. (R2) was not in any pain. The x-rays showed she had a history of previous injuries, but this injury was new. (R2) has a lot of complications because of her spinal cord injuries and she also has issues with her hips and spine. I am not sure how she got the injury, but it was a new injury when she arrived at the hospital, and she could not move her legs. On 1/11/2024 at 4:11 PM, V18, Certified Nursing Assistant (CNA) stated, I gave (R2) a bed bath, and I noticed bruising on her knee and marked it on the shower sheet, but I did not report it to the nurse. I did not report it to the nurse because it was an old bruise and had yellow coloring to it, so I thought it had already been reported. I did not report it to the nurse. On 1/11/2024 at 4:35 PM, V2, Director of Nursing stated, I would expect any staff if they saw a bruise new or old to inform a nurse so we can make sure we investigate. I am not sure why (V18) did not report it but she should have reported it. On 1/2/2024 at 12:10 PM, V4, Licensed Practical Nurse (LPN) stated, I usually do not work that hall. I was working that night as a CNA and the nurse got sent home because she tested positive for COVID. (V10) the CNA working that hall came and got me because she said she was doing rounds and (R2's) leg looked really weird to her and did not look right and she asked if I would come and take a look at it. When I saw it, I was not even sure what was going on and she had bruising on her leg, but it looked old to me because it was greenish purple in color. I immediately took a photo of it and sent it to the NP, and she had me send her out. What I remember the most is that her foot was turned in to a 90-degree ankle and that is not normal. Her leg looked bad to me, and I sent her out. I found out later that she had a fracture, but it did not surprise I could tell something was off. On 1/11/2023 at 11:24 AM, V10, CNA stated, I am an agency CNA. I was doing my round and when I first went into R2's room she was covered up. A little later the call light went on and (R2) is confused and does not use the call light but her roommate (R6) does use the call light. I entered the room thinking (R6) needed something and I asked her what she needed but (R6) said no, I need you to check on (R2) because she has been moaning and I think she is in pain. Can you look at (R2). (R2) can't move her legs because she is a paraplegic. But I pulled back the covers to make sure everything was okay, and you do not have to be a rocket scientist to know that your foot does not rotate 360 degrees. (R2) had what appeared to be old bruising with green coloring and I immediately went and got the nurse because I could tell (R2) was injured. The nurse called the Nurse Practitioner and (R2) was sent out to the hospital where we learned later, (R2) had a spinal fracture. On 1/11/2023 at 11:44 AM, R6 stated she was roommates with (R2) and she really missed her. She stated she remembers that night (R2) left because she had not been (R2) acting herself the past few days. She was more confused and a little off. She also said she was moaning in her sleep and thought she might be in pain, so she put on the call light to have the CNA come and make sure everything was okay with (R2). The CNA ran and got the nurse to come and look at (R2's) legs. I cannot get out of bed so I cannot tell you what (R2's) legs look like but I heard that she had bruising on both of her legs and was sent out to the hospital and had broken some bones. (R2) is so fragile, poor thing. R2's Hospital Records dated 1/1/2024 document, (R2) a [AGE] year-old female with history of neurogenic bladder paraplegic, neuropathy, constipation, COPD, marginal zone lymphoma presents from (nursing home facility), due to staff noticing bruising over right and left knees. Patient is paraplegic and reports not falling. She is not pleased with her care at the facility and describes the staff being rough with moving her from the bed to the wheelchair. She notes lying in the bed for multiple hours prior to receiving care when she is asking for help. She states feeling mistreated at the facility was placed approximately one year ago. Denies any pain or significant ROS. Unaware of when bruising occurred or reported any incident where patient fell or was dropped. R2's Hospital Records also document a complete foot drop, Capillary Refill: Capillary Refill takes less than two seconds. Findings: Bruising present. There were bruises noted on both knees. X-rays were taken and documents, Indication: Leg bruising under right knee without documentation of recent fall. Patient is paralyzed from waist down. X-rays show an acute proximal tibial fracture and a bilateral chronic displace femoral fractures. On 1/2/2024 at 3:04 PM, V12, Registered Nurse (RN) Hospital Nurse stated, I was working in the ER (emergency room) when (R2) was brought in from the facility. The color of the bruising was almost dark red, you could tell by just looking at the leg because of the rotation of the foot and the degree in which the knee rotated out and that the leg was broken. I cannot say how long it had been like this. We took x-rays and she had a TibFib, (Tibia, Fibula) fracture. (R2) could not move or use her legs. I put my hand on her leg and she said she could feel the warmth of my hand but that was it. (R2) could not move her legs, she could only feel the temperature difference. (R2) was not in any pain. The x-rays showed she had a history of previous injuries, but this injury was new. (R2) has a lot of complications because of her spinal cord injuries and she also has issues with her hips and spine. I am not sure how she got the injury, but it was a new injury when she arrived at the hospital, and she could not move her legs. The Facility Abuse Policy and Prevention Program dated 2022 documents, The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivations of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. The nursing staff is responsible for reporting the appearance of suspicious bruises, lacerations, or other abnormalities of an unknown origin as soon as it is discovered. The report is to be documented on a facility incident report and provided to the nursing supervisor, administrator, or designated individual. Following the discovery of any suspicious bruises, lacerations or other abnormalities of an unknown origin, the nurse shall complete a full assessment of the resident for other bruises, laceration or pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the Facility failed to ensure a safe transfer for 1 of 3 residents (R2) reviewed for transfers in the sample of 9. This failure resulted in R2 being picked up by staff after a fall and transferred to a chair and sent out to the hospital later where she sustained a tibia spiral fracture. Findings include: R2's Physician Order Sheet for January 2024 documents a diagnosis of : Chronic obstructive pulmonary disease, abnormalities of gait and mobility, lack of coordination, displaced supracondylar fracture without intercondylar extension of lower end of left femur, subsequent encounter for closed fracture with routine healing, abnormal weight gain, cognitive communication deficit, major depression, reflex neuropathic bladder, paraplegia, idiopathic peripheral autonomic neuropathy, anemia, acute infraction of spinal cord, pressure ulcer of sacral region, and altered mental status. R2's Minimum Data Set (MDS) documents she is moderately impaired for cognition. Bed mobility R2 was scored as 3/3 (extensive assist of two plus staff). Transfer 4/3, (total dependence on staff of two plus staff members). R2 does not walk, for toilet use she was scored a 4/3, and for personal hygiene 4/3. For Moving from seated to standing position, walking, turning around, and moving on and off the toilet she was documented as this activity did not occur. R2 was scored from surface to surface transfer (between bed and chair) as not steady and only able to stabilize with staff assistance). R2 is in a wheelchair. For Roll left to right, she requires Substantial/maximal assistance and for sit to lying, and lying to sitting she Dependent- staff does all of the effort. R2's Care Plan documents, R2 has Alteration in musculoskeletal status related paraplegia. Intervention: Monitor. Document for risk of falls, educate residents, family/caregivers on safety measures that need to be taken in order to reduce risks for falls. Alteration in musculoskeletal status related paraplegia. Fall (Focus Area) Resident is at risk for falls. Functional Deficits. 8/28/2023 Resident slid out of bed onto floor. Intervention, Bed changed to low position. 9/10/2022 Resident slid out of bed onto floor. Intervention: (Not documented). 12/21/2023 Fall in room, no noted injuries. Intervention: Canoe mattress. Rounding at a minimum of every 2 hours and prompt or assist for change in position, toileting, offer fluids. And ensure resident is warm and dry. ADL: Resident requires assist with daily care needs related paraplegia. Two person assist for transfers, assist resident with ADL's, Encourage/assist with turning and repositioning every two hours and as needed. On 1/2/2024 at 9:03 AM, V2, Director of Nursing stated, (R2) fell on December 21, 2023. She is a paraplegic, and when we asked her how she fell out of the bed she told us she had been up walking in her room, which is not possible. (R2) was confused. She has a history of falls as well. When the nurse was in her room, she saw she had a bruise on her leg and we then sent her out to the hospital where we later found out she had a fracture. (R2) is still in the hospital. On 1/2/2024 at 9:11 AM, V1, Administrator stated, I believe you are here because of (R2) having a fall. (R2) fell in her room, a few days later the nurse discovered a bruise. (R2) was sent to the hospital where we learned later that she had a fracture. (R2's) foot was turned out but that was nothing new, her foot always turned out. R2's Nurse's Notes dated 12/21/2023 at 4:20 PM, Heard resident state, 'girl'. As this nurse looked down hallway, observed resident on floor with head peeking out of the room. When asked what happened stated, I have been walking. Resident is a paraplegic and has been for years. ROM (Range of Motion) noted to be at baseline all extremities. Denies any pain at this time. Assisted with 3 with gait belt into wheelchair, then transported to the dining room to work on puzzles. R2's Initial Fall dated 12/21/2023 at 4:20 PM, documents, Resident was observed with her head out of her doorway lying on the floor. Resident description, I was walking, and my feet slipped. Resident is paraplegic for many years. Mental status confused/forgetful, orientated to situation. IDT (interdisciplinary team) meeting to discuss fall from 12/21/2023. Resident fell in room from bed. States she was walking. Resident is paraplegic. Resident is alert with confusion. BIMS 10 (moderately impaired). Resident requires dependence with ADL's and (mechanical lift) for transfers. Indwelling catheter. Incontinent of bowels. RCA: Attempting to walk: paraplegic. Poor safety awareness. All previously care planned interventions in place, adding canoe mattress. Continue to encourage use of wheelchair and call light. All parties agree with plan of care. Care plan reviewed and updated. R2's Final Investigation from 12/21/2023 documents, (R2) was evaluated at the ER and found to have acute appearing minimally displaced spiral-like fracture of the proximal tibia metadiadiaphysis. (R2) had an immobilizer placed at the hospital. (R2) did not return from the hospital so an interview was not able to be completed with her. Despite messages left for POA (Power of Attorney) she did not return Administrators call. On 1/2/2024 at 12:10 PM, V4, Licensed Practical Nurse (LPN) stated, I usually do not work (R2's) hall. I was working that night as a CNA and the nurse got sent home because they tested positive for COVID. (V10) the CNA working that hall came and got me because she said she was doing rounds and (R2's) leg looked weird to her and did not look right and she asked if I would come and look at it. When I saw (R2's) legs I was not even sure what was going on. (R2) had bruising on her leg but the bruising looked old to me because it was greenish purple in color. I immediately took a photo of it and sent it to the Nurse Practitioner and she had me send her out. What I remember the most is that (R2's) foot was turned in to a 90-degree ankle and that is not normal. Her leg looked bad to me and I sent her out. I found out later that she had a fracture but I knew something was not right with it. You could tell it was broken because it was twisted. On 1/2/2024 at 12:24 PM, V6, CNA, Activities stated, (R2) cannot walk and is unable to move any of her legs. She is able to move her upper body/arms. She is very confused and has gotten worse over the years. I think she came here a few years ago with a broken back. (R2) has been here for several years. (R2) is convinced that (V7) kidnapped her and brought her here to the facility. I know a few years back she was supposed to wear a brace on her leg, and she refused, and we stopped doing that. Her foot turned out a little but nothing major, not 90 degrees. She was not complaining of pain, and we were able to get her out of bed. (R2) could not move her legs but ways always saying she walked here, or she walked there. We have been getting her in and out of bed without any issues. On 1/2/2024 at 12:32 PM, V7, CNA stated, (R2) is very confused and gets things mixed up. For whatever reason she is convinced I kidnapped her after she walked here for hours to come and work, and now I will not let her leave. (R2) thinks she can walk but she cannot walk. (R2) is not even able to move her legs. (R2) can push herself up. I am not aware of her foot turning out. We have been transferring her from the bed to her wheelchair without any issues. On 1/2/2024 at 12:49 PM, V8, CNA stated I use to work here and then I left but I am back now. I remember (R2). From what I remember she is paralyzed and cannot move her legs, but she is able to move her arms. (R2) is confused and always telling everyone she was kidnapped, and she wants to leave here. On 1/11/2024 at 9:57 AM, V11, Registered Nurse (RN) stated, I remember (R2) was poking her head out of the room and I saw her on the floor. Her foley catheter was wrapped around her like a purse. She was laying on the ground and we attempted to attach her to the (mechanical lift) but the machine would not go down far enough. I do not usually work with the mechanical lifts the certified nursing assistants use them more than me. We had a pad underneath (R2) but I do not know if it was us not doing something right or if it was the machine now working properly because we could not get (R2) attached to the mechanical lift. I then grabbed (R2's) legs and (V6, CNA) and the agency CNA used a gait belt and put it around her shoulders, and we lifted (R2) back to her wheelchair. I did not use a blanket, we just grabbed her and put her back in her wheelchair. R2's Investigation from 12/21/2023 included statements from questions the facility had asked. The Facility asked V11 some questions regarding R2 and V11. It was documented that V11 told the facility We attempted (mechanical lift) but couldn't get it low enough. Two aids got around her top with gait belt and I grabbed her legs. We lifted her up into her wheelchair. On 1/11/2024 at 10:11 AM, V6, Certified Nursing Assistant (CNA) stated, I had seen (R2) earlier and she wanted to get up. I was in the middle of doing rounds and I told her after I was doing rounds I would come back and I would help get her up. It was not even five minutes and the nurse came and got me (V11) because she found (R2) on the floor sitting up on a pillow. We tried to transfer (R2) with the mechanical lift and she had a pad underneath here but it was not working so I put a gait belt around her waist and the other CNA and I pulled her up as (V11) grabbed her legs and we lifted her up into the chair. R2's Investigation from 12/21/2023 with a statement from V6 documents, (Mechanical Lift) wouldn't reach the floor so the agency nurse, (V11) and I got her up by picking her up. 2 CNAs were at shoulders, nurse (V11) got her legs with gait belt we lifted her up into chair. Despite her yelling at us to stand her up. R2's Hospital Records document, (R2) a [AGE] year-old female with history of neurogenic bladder paraplegic, neuropathy, constipation, COPD, marginal zone lymphoma presents from (nursing home facility), due to staff noticing bruising over right and left knees. Patient is paraplegic and reports not falling. She is not pleased with her care at the facility and describes the staff being rough with moving her from the bed to the wheelchair. She notes lying in the bed for multiple hours prior to receiving care when she is asking for help. She states feeling mistreated at the facility was placed approximately one year ago. Denies any pain or significant ROS. Unaware of when bruising occurred or reported any incident where patient fell or was dropped. R2's Hospital Records also document a complete foot drop, bruising present. There were bruises documented on both of R2's knees. On 1/11/2023 at 11:24 AM, V10, CNA stated, I am an agency CNA. I was doing my round and when I first went into R2's room she was covered up. A little later the call light went on and (R2) is confused and does not use the call light but her roommate (R6) does use the call light. I entered the room thinking (R6) needed something and I asked her what she needed but (R6) said no, I need you to check on (R2) because she has been moaning and I think she is in pain. Can you look at (R2)? (R2) can't move her legs. But I pulled back the covers to make sure everything was okay, and you do not have to be a rocket scientist to know that your foot does not rotate 360 degrees. (R2) had what appeared to be old bruising with green coloring and I immediately went and got the nurse because I could tell (R2) was injured. The nurse called the Nurse Practitioner and (R2) was sent out to the hospital where we learned later, (R2) had a spinal fracture. On 1/11/2024 at 9:11 AM, Mechanical lift was lowered to the lowest position and a pad was on the ground and it was attached to the lift by V7, CNA (Certified Nursing Assistant) with no issues. With the pad flat on the ground it was still able to be attached to the mechanical lift. There were two brands of mechanical lifts in the building and a total of two mechanical lifts observed total on the 100 hall without any issues. On 1/11/2023 at 9:22 AM, the other mechanical lifts on the 100 hall. machine was tested with V7, CNA on the 100 hall. The mechanical lift was in working condition and was able to be lowered and the mechanical pad was able to be attached from the floor with the strap, with the pads flat on the ground, they were still able to be attached to the lifts without any complications. R2's Hospital Records dated 1/1/2024 document, (R2) a [AGE] year-old female with history of neurogenic bladder paraplegic, neuropathy, constipation, COPD, marginal zone lymphoma presents from (nursing home facility), due to staff noticing bruising over right and left knees. Patient is paraplegic and reports not falling. She is not pleased with her care at the facility and describes the staff being rough with moving her from the bed to the wheelchair. She notes lying in the bed for multiple hours prior to receiving care when she is asking for help. She states feeling mistreated at the facility was placed approximately one year ago. Denies any pain or significant ROS. Unaware of when bruising occurred or reported any incident where patient fell or was dropped. R2's Hospital Records also document a complete foot drop, Capillary Refill: Capillary Refill takes less than two seconds. Findings: Bruising present. There were bruises noted on both knees. X-rays were taken and documents, Indication: Leg bruising under right knee without documentation of recent fall. Patient is paralyzed from waist down. X-rays show an acute proximal tibial fracture and a bilateral chronic displace femoral fractures. On 1/2/2024 at 3:04 PM, V12, Registered Nurse (RN) Hospital Nurse stated, I was working in the ER (emergency room) when (R2) was brought in from the facility. The color of the bruising was almost dark red, you could tell by just looking at the leg because of the rotation of the foot and the degree in which the knee rotated out and that the leg was broken. I cannot say how long it had been like this. We took x-rays and she had a tibia sprial fracture. (R2) could not move or use her legs. I put my hand on her leg and she said she could feel the warmth of my hand but that was at. (R2) could not move her legs, she could only feel the temperature difference. (R2) was not in any pain. The x-rays showed she had a history of previous injuries, but this injury was new. (R2) has a lot of complications because of her spinal cord injuries and she also has issues with her hips and spine. I am not sure how she got the injury, but it was a new injury when she arrived at the hospital and she could not move her legs. On 1/5/2024 at 4:11 PM V14, Nurse Practitioner stated if a resident was a paraplegic and they had a fall she would expect the resident to respond differently than someone who had feeling it their legs. A lot depends on if their spinal cord is damaged the resident may not felt any injuries, and it could affect how the body would heal from that injury as well. For a paraplegic they may respond differently. I would expect the staff to monitor a paraplegic after a fall every 2 hours for 48 hours to ensure there were no injuries. I would expect staff to look for bruising, discoloration, swelling, disfigurement, things of that nature. I would expect them to be looking at the skin. I would expect a resident who is a paraplegic to always be transferred with a mechanical lift if they are not weight bearing. I would expect the staff to monitor as this is the crucial time frame if there was an injury. If a resident was transferred without a mechanical lift there is always the possibility if injuring the patient during the transfer. I did see (R2's) photo and the bruising appeared both new and old. It is possible her injury was sustained from the transfer and or the fall. I would expect all transfers to be with a mechanical lift and not a gait belt for (R2). The Facility Fall Policy with a review date of 9/2023 documents, This facility is committed to maximizing each resident's physical, mental and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 1/18/2023 at 10:11 AM, R13 stated he had $300.00 dollars that someone took back in January and the facility never replaced it and he did not think it was right. R13's MDS dated [DATE] documents R13 was cognitively alert and orientated for activities of daily living. Investigation Report undated documents, Social Service Director (SSD) spoke with (R13). (R13) stated that the last time he saw his $300.00 was about nine days ago. He had three one-hundred-dollar bills in his wallet which he kept under the seat of his rollator walker. He did not see anyone else in the room besides the aids and nurses. He denies giving anyone any money. Statement V15, Housekeeping Supervisor dated 1/12/2023 documents, To whom it may concern: I (V15) is [sic] aware that resident (R13) kept three $100.00 dollar bills in his blue walker, zip up pocket. (R13) has had this amount of money for quite sometimes as he showed me back in April of 2021. Facility Incident Report event occurred 1/5/2023 at 11:30 AM, Resident reported to staff alleged misappropriation of resident funds. Statement from V16, Physical Therapist, dated 1/11/2023 documents, I (V16), was asked by (R13) on an unknown date in December to get $1.00 out of patient's wallet to give resident to buy a soda. When retrieving the dollars in his wallet. I asked if he was aware of the money and he said, 'yes.' I also educated resident that he can give the money to facility staff to keep in safe, but he declines. Last week, (R13) asked me to get him another $1.00 for a soda. He said he had $18.00 and the three $100.00 dollars, but there was no money in his wallet. Facility staff notified immediately. On 10/24/2023 at 10:05 AM, V16 stated, (R13) always had money in his wallet and he had a hard time opening his wallet and needed assistance to get in and out of his wallet and take the money in and out. After therapy he was always asking staff to assist him, and I know he always had three large one hundred dollar bills in his wallet along with a few dollars here and there for his sodas. He always likes to get sodas. When (R13) told me his money was missing I looked for it and we could not find his money. It makes me sad that anyone would steal from him. On 10/18/2023 at 3:32 PM, V1, Administrator stated, We were able to determine that (R13) had the money and we are going to be replacing the money now. 3. R4's Physician Order Sheet for April 2023 document diagnoses of chronic obstructive pulmonary disease, multiple sclerosis, abnormal posture, schizoaffective disorder, seizures, and anxiety disorder. R4's MDS dated [DATE] document R4 was cognitively alert for decision making. R4's MDS documents R4 requires extensive assistance of two staff for med mobility and transfers. On 10/24/2023 at 9:40 AM R4 stated that when staff were putting her to bed, they hit her head and, on the headboard, and it surprised her and hurt her head. R4 stated I was upset, and I told (V13 Certified Nursing Assistant) and she got mad at me and yelled at me and told me not to point my finger at her and if I did just wait and see what happens. I do not think staff should threaten me and it really did scare me. There was another CNA in the room (V12). She did not do anything. The Facility Incident Report date of Incident 4/5/2023 documents, (V12, Certified Nursing Assistant) reported to (V1, Administrator) that while putting (R4) up in bed on Wednesday, they pulled her up too far and her head hit the headboard. (R4) pointed her finger at (V13, Certified Nursing Assistant (CNA) and told her that she did it on purpose. (V13) responded by telling her to see what happens if she points that finger at her again. R4's Final Report, undated documents Conclusion unsubstantiated. At the conclusion of the investigation, it appears no abuse occurred. Based on witness statements, (R4's) head getting hit was not intentional. There was poor customer service in the way (V13) responded to the resident. V13's Personal File documents she was terminated from the facility on 5/8/2023 for customer service. R4's Care Plan documents does not document she is at risk for abuse. R4's Investigation documenting Date/Time Administrator was reported 4/7/2023 at 10:45 AM. Immediate Assessment: No physical injuries noted, stated she did have a headache that day but no longer does. Resident states she feels safe when (V13) is not here. The Facility Investigation report for R4 dated 4/7/2023 document, The administrator attempted to reach (V13) but was only able to leave a voice message asking her to call the facility and speak with the Administrator. 4/11/2023 The administrator interviewed (V13) regarding the concerns reported by (R4). (V13) stated that last Wednesday while in (R4's) room, (V13) almost poked her in the eye three times. Each time (V13) did it, (R4) said that she told (V13) not to poke her or put her finger in her face. When asked if she made the statement 'see what happens if you point that finger at me again,' (V13) stated that was a lie. A statement from V12 dated 4/7/2023 documents, On 4/5/2023 CNA (V13) and I went to pull (R4) up in bed, and she hit her head on the headboard; we both apologized to the resident, which then started yelling out (V13) stating very upset pointing in (V13's) face yelling. (V13) became upset with resident yelling back at resident. A statement from V14,CNA, dated 4/7/2023 documents, I have been told by several residents that (V13) has been verbally abusive and when they ask for something she does not get it. She takes forever to answer call lights, A lot of residents have said they wait too long before their lights get answered. The Abuse Policy and Prevention Program 2022 documents, The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivations of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Sexual Abuse includes, but is not limited to sexual harassment, sexual coercion, or sexual assault (42 CFR.483.12 interpretive Guidelines) including nonconsensual or noncompetent to consent sexual activity. Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individual's age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never to be able to see his/her family again (42 CFR 483.12 Interpretive Guidelines). Based on interview and record review, the facility failed to prevent abuse for 4 of 5 residents (R4, R13, R38, R102) reviewed for abuse in the sample of 43. This failure resulted R102 who is demented being fondled by R38 in the dining room and a reasonable person would not want to be sexually fondled/abused. Findings include: 1.R38's Face Sheet, with print date of 10/192/3, documents R38 has diagnoses of personal history of traumatic brain injury, major depressive disorder, schizoaffective disorder, bipolar type, and altered mental status. R38's Care Plan, dated 9/11/23, documents Resident's memory is impaired, and resident has difficulty with decision-making, insight, logic, planning, and organization of the thoughts. The Care Plan Interventions documented Provide clear explanations regarding expectations and procedures prior to providing care. R38's Care Plan documents Resident has a history of aggressive, inappropriate, attention-seeking and/or maladaptive behavior, but has demonstrated stability during the admission screening process and is therefore considered appropriate for admission. The history includes: kicking at other residents and their wheelchairs, and aggressively grabbing at staff. The Interventions documents Intervene when any inappropriate behavior is observed. Communicate assertively that the resident must exercise control over impulses and behaviors (Social skills training). R38's Minimum Data Set, MDS, dated [DATE] documents R38 is moderately cognitively impaired. R102's Face Sheet, undated, documents R102 has diagnosis of Unspecified Dementia without behavioral disturbance. R102's MDS dated [DATE] documents R102 is severely cognitively impaired. R38's Nurse's Note dated 10/17/23 at 6:15 PM documented CNA (Certified Nursing Assistant) came to this nurse with report that this resident (R38) had potentially abused another resident (R102). Administrator notified at 6:16 PM. Resident is being monitored on one on one per staff. R102's Nurse's Note dated 10/17/23 documents CNA brought resident to this nurse with report of potential abuse from another resident @ 615pm. Resident questioned and denied pain. Resident stated when asked what happened that's about how it goes. Administrator notified at 6:16pm. Skin assessment completed with no new skin issues found. Son notified and MD notified. Facility Reported Incident, dated 10/17/23, documents This resident was found with alleged perpetrator standing over her with his hands on her brief. The Report documented the Police, Medical Director and Power of Attorney were contacted and notified. V24, Certified Nurse's Assistant, CNA, statement, dated 10/17/23 at 6:28 PM documents At approx. (approximately) 6:15 PM I walked in the dining room and witness (R38) standing over (R102). When I walked up closer, I witnessed one of (R38's) hands two knuckles down in (R102's) (incontinent brief), and the other hand on her (R102) strap of her (incontinence brief). I immediately remove his (R38's) hands and remove (R102) from the dining room and took her with me for safety. I reported what I saw to the nurse. On 10/19/23 At 12:44 PM V24 stated, I was walking a couple of residents to go smoke I saw (R38) standing over (R102). I saw his hands down her pants I took her to the nurse and reported what I seen. V27's, Dietary Aide, statement dated 10/17/23 documents I (V27) had just told (R38) that he cannot help (R102) with incontinence brief and that a nurse or a CNA will have to help (R102) with her incontinence brief, and that was around 5:45 PM 6:00PM last night. On 10/19/23 at 12:48 PM V27 stated, I prepared the residents dialysis breakfast and took it to the nurses the station. When I returned, I saw (R38) standing close to her (R102), and her incontinent brief was unfastened. I told him to go sit down. V23's, Licensed Practical Nurse (LPN) Witness Statement dated 8/17/23 documents I asked (R38) why he was touching (R102's) (incontinence brief) and he smiled at me and stated you have no proof. On 10/19/23 at 1:5 PM, V23 stated At 6:15 PM a CNA brought (R102) to me and said that (R38) had his hand down inside of her incontinence brief and looked like her vaginal area. When she brought (R102) to me the right side of her (incontinent brief) was unfastened and the front of her pants were pulled down. I did skin assessment, and no skin issues were found. She denied pain. I asked (R38) if he had touched (R102), and he stated, 'you have no proof.' I made him a one to one. V25's Witness Statement, dated 10/17/23 documents At about 6:15 PM me and (V24) was walking through the dining area to take the residents out for a smoke break. Upon entering the dining area, I saw (R38) standing over (R102) holding her underwear. Her shirt was midway up her stomach. (V24) immediately removed (R102) and took her (R102) to the nurse to report. I asked (R38) what was he doing with her (R102), and he (R38) stated nothing. I asked him (R38) what was nothing, and why was he tugging on her (R102) underwear and he didn't respond. On 10/19/23 at 1:22 PM V19 LPN stated, He (R38) has grabbed my butt He (R38) tries to flip other residents out of the wheelchair. On 10/19/22 23 at 1:24 PM V30, CNA stated, He (R38) says weird stuff he (R38) tries to push people wheelchair. He is very aggressive. He (R38) tries to elope. On 10/19/23 at 1:32 PM V32, CNA stated, He (R38) has inappropriate behaviors all the time. He (R38) pulls his penis out of his pants and pees on the floor. He grabbed butts and he took (R21's) drink and tried to give it to her. On 10/19/23 at 1:40 PM V1 Administrator stated, We are trying to get him to a more appropriate facility. We have referrals sent out. 10/20/23 at 3:21 PM V29, Nurse Practitioner stated, I think he is appropriate for the facility. They are both confused. It's the staff's job to watch, and they got to him quickly and removed his hand. Care Plan Meeting note dated 7/5/23 Attendance: Administrator, Social Services, Wound Nurse, MDS/Care Plan Coordinator, Activities Invitation to Resident and Care Plan Representative: Daughter and Son-in-law Meeting Note: Family state that they are aware resident needs a more structured facility more structured for Traumatic Brain Injury (TBI) patients. Family state that they cannot care for him at home. Social services stated that they are inquiring to other facilities to meet resident's needs. It was discussed with resident's daughter some of his recent behaviors i.e.: Trying to elope, trying to take other residents out, getting more aggressive with staff. Family stated they are glad resident has come to (facility) as resident (R38) is well enough to leave facility for a facility to assist with his TBI needs. Resident states he is just waiting to see what facility is found for him. Daughter was assured that staff will touch base with them and keep them in the loop as to what facilities referrals are sent to.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and observation the facility failed to implement fall safety measures for one of three residents, (R3) reviewed for falls in the sample of 8. This failure resulted in R3 falling and fracturing the distal end of her clavicle. Findings Include: R3's Minimum Data Set, (MDS), dated [DATE] documents R3 is an extensive assist of two staff members for transfers and bed mobility. R3's MDS also documents, for balance moving on and off the toilet and moving from seated to standing is not steady only able to stabilize with staff assistance. R3 is moderately cognitively impaired. R3's Transferring Care Plan dated 3/10/23 documents (R3) has a self-care deficit in transferring r/t, (related to), hemiplegia secondary to past CVA, (Cerebrovascular Accident). She requires extensive assist to complete tasks currently. 1. Explain procedure. 2. Lock wheelchair brakes. 3. Apply gait belt. 4. Instruct and assist to standing position using extensive assist and gait belt. 5. Instruct and assist to pivot and sidestep towards the front of the chair. 6. Instruct and assist to slowly sit down in w/c, (wheelchair). 8. Praise all efforts. 9. Provide encouragement during transfer if becomes fearful. 10. Attempt transferring using limited assist x, (times), 1, three times per week, provide more assist if unable. Fall Care plan dated 3/10/23 documents (R3) slid out of her wheelchair on 3/9/23 and a note was added to her wheelchair as well as educate the resident to call for help. The fall care plan dated 3/10/23. The fall of 4/11/23 documents the intervention: is staff educated to not leave (R3) unattended in the bathroom. R3's Fall Risk Evaluation dated 4/12/23 documents R3 is a high risk for falls. R3's Nurses Note dated 4/11/23 documents, resident fell in her bathroom and hit her head. (R3) was lying on her left side. No c/o, (complaint of), pain or discomfort. Resident refused to go to the hospital. POA, (power of attorney), made aware and said, if vitals are stable, it was okay for the resident to stay in the facility and not go to the hospital as the doctor requested. R3's Nurses Note dated 4/12/23 documents, (R3) is complaining of pain to her left shoulder, (R3) fell yesterday in her bathroom and has refused to go to the hospital to get checked out. Request was made to (V17), Nurse Practitioner, (NP), for X-ray, (V17) ordered resident be sent to ER, (emergency room), resident continues to refuse to go to ER. Educated (R3) on importance of getting checked out, prn, (whenever necessary), pain medication given. R3's Nurses Note dated 4/12/23 at 6:32PM documents, order received for X-ray of left shoulder faxed. R3's Nurses Note dated 4/12/23 at 9:32PM documents, technician completed X-ray of residents left shoulder and clavicle. R3's Nurses Note dated 4/12/23 at 10:30PM documents, comminuted FX, (fracture), of distal end of clavicle. Nurse contacted (V6), Primary Care Physician, new order for referral to ortho, (orthopedics). R3's Nurses Note dated 4/14/23 documents, (V18), daughter, of R3 spoke with this writer and she has arranged an ortho appointment for (R3) at (local) Orthopedics and Sports medicine for Friday, April 21st at 9am. Transportation is arranged through residents' insurance. Resident made aware of upcoming appointment. Plan of care continues. R3's Nurses Note dated 4/21/23 documents, Ortho appointment for resident has been rescheduled for Tuesday May 2nd at 1:30PM. Arrangements for transportation will be made. (V18), daughter/POA, made aware. On 4/25/23 at 2:40PM V7, Social Service Assistant/Transportation, stated, they went to the wrong address to pick her up for her appointment. They had the wrong address on file. Even though I gave them the correct address. On 4/26/23 at 10:40AM V13 and V14, (CNAs), Certified Nursing Assistants, entered the room and asked R3, if they could toilet her. V14 placed a gait belt around R3's waist and rolled her into the bathroom. V13 and V14 locked her chair. R3 stated, I'm scared I don't want to fall again, they let me fall. V13 and V14 lifted her up out of her chair with the gait belt and asked her to pivot to the toilet. Once lined up with the toilet they removed her BM, (bowel Movement), soiled incontinence brief and sat R3 on the toilet, where she urinated. Incontinence care was provided with no issues, and R3 was transferred back to her wheelchair. R3's Initial/Final Report dated 4/11/23 documents reported by nurse on duty, (R3), was being toileted and attempted to reposition self on toilet and fell. Final Report documents, slightly comminuted fracture of Distal end of the Left Clavicle. The Final Report also documents, (V10), stated, she was in the room outside of the bathroom completing a task for the resident's roommate. V12 stated, that she placed the resident, (R3), in the bathroom and began to complete another task in bedroom right outside the bathroom. They both stated, they heard a noise and noted the resident, (R3), laying on her left side near the toilet. Intervention of educating staff to not leave resident unattended in bathroom. On 4/26/23 at 9:39AM, V10, CNA, stated, I went in there with the other CNA, (V12), sat her on the toilet. The bathroom in her bedroom, the door to the bathroom was open. I was making her bed, and (V12), was making the other resident's bed and (R3) fell off the toilet. (V12) ran to get the nurse, and I stayed with (R3). (R3) was yelling I'm not going to the hospital. On 4/26/23 at 9:43AM, V11, Licensed Practical Nurse, (LPN), stated, They call me down there, because she, (R3), was on the floor, on her left side. We started Neuro checks, and V6, Primary Care Physician, wanted her, (R3), to go out to the hospital, but she refused. She wanted to go smoke. They will not let her smoke in the hospital. There was no complaint of pain all night and the next day. She complained after I went home. On 4/26/23 at 1:35PM V12 stated, I was the one who actually put her on the toilet. I take her to the bathroom in her room. (V10) came with me, we sat her on the toilet. Her wheelchair was right there in the doorway I was going to make her bed. I turned to see her leaning, but she had already hit the ground. On 4/27/23 at 10:55AM, V17 stated, No she should not have been left in the bathroom alone. The facility policy Fall Prevention and Management dated 7/2022 documents this facility is committed to maximizing each resident's physical, mental, and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed. All incidents and accidents with serious physical injury will be reported to IDPH, (Illinois Department of Public Health), within 24 hours. A full written investigate report is required by IDPH within 5 days of the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the Facility failed to provide timely care and treatment to address a change in condition for 1 of 5 residents (R2) reviewed for quality of care in the sample of 13. This resulted R2 having 16-hour delay in treating his pneumonia. Findings include: R2's admission Record, print date of 12/8/22, documents R2 was admitted to this facility on 4/18/22. R2's Minimum Data Set (MDS), dated [DATE], documents that R2 is cognitively intact (BIMS of 13) and requires extensive assistance from two staff members for all Activities of Daily Living. R2's Nurse's Note, dated 12/4/22 at 6:45 AM, documents At approximately 4:00 AM, resident asked CNA (Certified Nursing Assistant) to get him up and take him to the dining room to watch tv (television). When he was up, he told CNA to go and tell the nurse to call an ambulance because he wanted to go to the ER. This nurse asked resident what was wrong, and he said that when (V7, Registered Nurse) and (V6, Physician) had seen him yesterday that (V6) had touched him and put an evil spell on him and (V7) had given him a shot of something on her way out the door. Resident said that those things had caused him to lose his ability to move. This nurse took his vital signs and assessed him physically. temperature = 99.1 166/100 (blood pressure), 76 (pulse), 96% on room air, Respirations = 18, neuro checks at baseline, bowel sounds four quadrants, lung sounds severely diminished. Temperature and blood pressure were high, but at the time they were taken, resident was yelling at nurse and calling her a f****** b****. This nurse attempted to convince resident that it would be best to run some tests at facility instead of going to the emergency room, because the ER is meant for emergency situations. R2's Nurse's Note, dated 12/4/22 at 10:12 AM, documents Resident has been agitated this morning. He stated that (V6) came to visit him last night and put an evil spell on me. Resident stated he cannot walk, but he is not ambulatory. Resident did take morning medication. He also stated, I know someone put something in my food, VS (Vital Signs) 100.5 (temperature)-68 (pulse)-18 (respirations)-128/78 (blood pressure). O2 sat, 94% on room air. Lung sounds are diminished with scattered rales. Occasional non-productive cough. I called (V6) and informed him about resident's condition. New orders were received for chest x-ray and laboratory tests. I will continue to monitor resident. R2's Chest Xray Results, with reported date as 12/4/22 and time 6:10 PM, documents Findings: There appear to be patchy interstitial infiltrates in the right lower lung field extending from the right infrahilar region. The lung fields are otherwise essentially clear. Impression: Chest: Heart is within normal limits with patchy interstitial infiltrates in the right lower lung field extending from the right infrahilar region. R2's Nurse's Note, dated 12/4/22 at 7:29 PM, documents Received STAT (Emergent) CXR (Chest X-Ray) results and reported to (V6) with new orders received for Ceftin BID (twice a day) for 7 days related to PNA (Pneumonia) and Probiotic BID (twice daily) for 10 days. Resident made aware and agrees with plan of care. R2's Physician Order, dated 12/4/22, documents Cefuroxime Axetil (antibiotic) Tablet 500 MG. Give one tablet by mouth two times a day for pneumonia for 7 Days. R2's December 2022 Medication Administration Record, documents R2 received his first dose of Cefuroxime Axetil at 10:00 PM. This was 16 hours after R2 had requested to be sent to emergency room and nurse had assessed him with lung sounds severely diminished. R2's Social Service Note, dated 12/6/22 a 11:55 AM, documents 11:48 AM, Spoke with nurse (V2, Director of Nursing/DON) who informed this writer that (R2) is running a fever. She gave Tylenol approximately 60 minutes ago. 11:50 AM, SSD (Social Service Director) spoke with resident to see how he was feeling and ask if he wanted to go to the hospital. He stated he does want to go. 11:56 AM, Face sheet, med list and POLST (Physicians Order for Life Sustaining Treatment) forms printed for ER and EMS. 12:00 PM, (Local) EMS called for transport. R2's Physician Order, dated 12/6/22, documents Send to ER for evaluation. R2's Nurse's Note, dated 12/6/22 at 6:32 PM, documents Resident returned to facility via ambulance with two EMT'S (Emergency Medical Technicians) present. Resident assisted to bed per EMT'S and staff no c/o (complaint of) pain, voiced no s/s (signs/symptoms) of distress, noted N.O. (New Order) received Azithromycin 250 MG tablet one tablet PO (oral) daily. Take first two tablets together, then one tablet every day until finished. Order faxed to pharmacy. R2's Physician Order, dated 12/6/22, documents Azithromycin Tablet 250 MG. Give 500 MG by mouth one time a day for infection for one day, then give 250 MG by mouth one time a day for infection for four Days. R2's Hospital Visit Summary, dated 12/6/22, documents Diagnosis: Pneumonia due to infectious organism, unspecified laterality, unspecified part of lung. On 12/7/22 at 12:50 PM, R2 stated I told the nurse (V3, Registered Nurse/RN) that I wanted to go to the hospital because I didn't feel good and she said no because I didn't have enough symptoms to go to the ER, and that the ambulance was going to cost me money. She took my temperature and blood pressure and still did not send me. My temperature went up to 101. A couple days later, I told another nurse that my whole body was hurting and that I asked (V3) to send me to the hospital but she didn't, and that nurse told me that I had a right to go to the hospital whenever I wanted. When I finally went to the hospital, the doctor said I had Pneumonia. I am on antibiotics now and feel a whole lot better. R2 appeared very upset over this incident of not getting sent to the ER. R2 stated multiple times that he has a right to go to the hospital when he wants. On 12/8/22 at 9:40 AM, R2 stated I did see (V6, Medical Doctor) on Saturday (12/3/22). I told him that my muscle spasms were getting worse, and I was having some arms and shoulder pain and was achy all over. He told me I probably needed some therapy. As soon as the doctor left, I started feeling bad. Then that night or early the next morning (12/4/22) is when I wanted to go to the ER and was told that I couldn't go. Then later that morning, another nurse came in and I told her I wasn't feeling good, so she called the doctor, and I had an x-ray done that day. They then started me on antibiotics that evening. Then on Tuesday (12/6/22), I was feeling really bad and had a high fever, that's when (V2, DON/Director of Nurses) came in and said that I was hot and burning up and she sent me to the ER. On 12/7/22 at 2:35 PM, V4, Licensed Practical Nurse (LPN), stated If a resident wants to go to the ER and is totally alert, I will send them. They have a right to go. I would assess them first and maybe let them know what my findings are, but if they still want to go, I will call for them to go. I would then call their physician and let them know. On 12/7/22 at 3:35 PM, V5, LPN, stated If a resident request to go to the hospital, I would call the physician, the Administrator and the POA (Power of Attorney) to make them aware. I would do a complete assessment on that resident and if they are in their right mind, will send them to the ER. They have that right to go when they want to. On 12/7/22 at 3:40 PM, V2 stated If a resident wanted to go to the ER, I would do a thorough assessment, obtain their vital signs, maybe read some past notes in their medical record and talk to some of the staff about it. I will always do what's best for the resident. If they're insistent on going, I will send them, they know their body if it's hurting or not, more than I do. Based off my nursing judgement, I would have sent (R2) to the ER. He had a change of condition and appeared worse to me the morning I saw him. He was normally alert as he was the morning, I cared for him. On Tuesday (12/6/22) at around 10:00 AM, (R2) appeared worse to me and he asked to go to the hospital and since he was alert and oriented, I went ahead and sent him out. He's normally not like that so he probably should have been sent when he was saying crazy things. On 12/7/22 at 3:50 PM, V1, Administrator, stated We try to not send our residents to the hospital. We are a twenty-four-hour medical service here and can do a lot for our residents to avoid going to the hospital. Our standard procedure is to assess the resident, call the physician to get orders if needed, and can treat that resident here at the facility without sending them to the hospital. I believe that is what our nurse was doing that morning. On 12/8/22 at 10:45 AM, V6, Physician, stated I was at the facility on Saturday evening (12/3/22) to see some other residents, but I have been taking care of (R2) for a long time now, so I stopped in to see him. (R2) was full of complaints about his contractions hurting his arms and shoulders. I assessed him and did not see anything. He was not tachycardic, and I did not see him coughing at that time. I did not see anything at that time that would have met the criteria for a hospital admission, or I would have sent him then. I got a call the next day about his complaints, and I ordered an x-ray. When I got the results indicating an infiltrate, I ordered an antibiotic. (R2) does have a right to go to the ER when he wants to. I didn't even know he went to the hospital on Tuesday (12/6/22). I do think that sixteen hours to get an antibiotic started is too long for someone with Pneumonia. The Facility's Change in Condition Policy, dated 9/2022, documents It is the policy of the facility, except in a medical emergency, to alert the resident, resident's physician and resident's responsible party of a change in condition. 1. Nursing will notify the resident's physician or nurse practitioner when: a. The resident is involved in an accident or incident. b. There is a significant change in the resident's physical, mental, or emotional status. c. There is a pattern of refusing treatment or medication. d. The resident wants to be discharged or leaves AMA. e. It is deemed necessary or appropriate in the best interest of the resident. 2. Once the physician has been notified and a plan developed, the nursing or social service staff will alert the resident and family of the issue and any physician orders. 3. The communication with the resident and their responsible party as well as the physician will be documented in the resident's medical record or other appropriate documents. 4. The resident's care plan will be updated as appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the Facility failed to conduct ongoing assessment and monitoring of a resident with significant weight loss for 1 of 5 residents (R12)reviewed for nutrition in the sample of 26. This failure resulted in continued weight loss for the resident. Findings include: On 8/31/22 at 1:14 PM, R12 was sitting in a geriatric chair at a table in the dining room and stated, I've been here before. R12 was feeding herself pureed spaghetti, mixed vegetables, ice cream, and cake fortified with powdered milk. R12's Face Sheet documents R12 was admitted to the facility on [DATE] and has diagnoses including unspecified severe protein calorie malnutrition, dysphagia (difficulty swallowing), abnormal weight loss, unspecified dementia without behavioral disturbance, major depressive disorder, and gastroesophageal reflux disease without esophagitis. R12's Minimum Data Sheet (MDS) dated [DATE] documents R12 has significant cognitive impairment and requires extensive 2+ person assistance with eating. R12's Physician Order Sheet (POS) documents, Regular diet, pureed texture, thin liquids consistency for diet until July 13, 2024. Health Shakes two times a day for weight loss, 120cc. The Facility's Monthly Weight Report documents R12 weighed 132.8 pounds in November 2021 and 119.4 pounds in May 2022. This reflects a 13.4 pound or 10% weight loss over 6 months which is significant. R12's Care Plan dated 6/20/2022 documents, I have a nutritional/potential nutritional problem r/t (related to) not wanting to eat my meals. Monitor/record/report to MD (medical doctor) PRN (as needed) s/sx (signs/symptoms) of malnutrition: Emaciation (cachexia), muscle wasting, significant weight loss: 3 lbs (pounds) in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. RD (Registered Dietitian) to evaluate and make diet change recommendations PRN. Resident had experience unplanned weight loss related to decreased appetite, post hospitalization, acute illness. R12's Progress Note from Registered Dietitian (RD) dated 5/13/2022 at 9:48 AM documents, RD annual assessment. 91 y/o (year old) female with dx (diagnoses) including dementia, MDD (major depressive disorder), GERD (gastroesophageal reflux disease), HLD (hyperlipidemia), osteoporosis, hypothyroid, L (left) femur fx (fracture), h/o (history of) falling, cerebral infarction, HTN (hypertension), malnutrition. Current medications include raloxifene, escitalopram, DSS (docusate sodium), omeprazole, donepezil, mirtazapine. Current diet ordered is regular with mech (mechanical) soft texture, fortified foods with all meals; ice cream (with) lunch and supper, 90 mL (milliliters) house supplement TID (three times daily). PO (oral) intake ranges 0-100%. Current ht (height) 64, wt (weight) 119.4# (pounds), BMI (body mass index) 20.4. Noted wt (weight) fluctuation since admission. No skin concerns noted. No new labs available for review. Estimated nutrition needs: 1626 kcal (kilocalories) (30 kcal/kg (kilogram)), 65 g (grams) protein (1.2 g/kg), and 1626 mL fluid (30 mL/kg). Continue with prescribed diet and supplementation as tolerated. Noted recent addition of mirtazapine, which will likely have positive effect on appetite. Continue to monitor intake and wt. Refer to RD as needed. R12's Monthly Weight Report documents R12 weighed 119.4 pounds in May 2022 and 112.0 pounds in August 2022. This reflects an additional 6.2% weight loss over the time R12 was not being monitored by a RD. On 8/31/22 at 9:03 AM, requested that V1, Administrator, provide RD phone number and/or additional documentation from RD. On 9/1/22 at 8:34 AM, requested that V1 provide RD phone number and/or additional documentation from RD. On 9/1/22 at 9:42 AM, V11, Nurse Practitioner, stated, The team meets weekly and reviews weight losses. Then I am notified of any weight loss and recommendations by the dietitian. I would have expected to be notified by the team of (R12's) weight loss. On 9/1/22 at 10:12 AM, requested that V7, Dietary Manager, provide RD phone number. He stated he would have to check with V1, Administrator. On 9/1/22 at 12:12 PM, V1 stated, I have no additional RD documentation since May. She wasn't seen. On 9/2/22 at 10:40 AM, no contact information for RD was received from the Facility. V1, Administrator, stated, We do not have a policy on Nutrition Assessment.