Every finding on record at Accolade HC of Paxton on Pells

Based on observation, interview, and record review the facility failed to implement fall interventions and thoroughly investigate falls for two of three residents (R1, R2) reviewed for falls in the sample list of three. Findings include:The facility's Accidents and Incidents policy dated as revised January 2026 documents all accidents/incidents involving residents will be investigated and the charge nurse conducts an immediate investigation and implements immediate appropriate interventions. This policy documents the Risk Management and accompanying documentation will be reviewed by the Director of Nursing (DON)/designee, the DON will conduct an investigation of the accident/incident, and the interdisciplinary team will be notified of findings so that the care plan can be updated as needed. The facility's Transfers policy dated as revised June 2026 documents to follow the resident's care plan to ensure the use of proper transfer technique. 1.) R1's census documents R1 admitted to the facility on [DATE] and discharged [DATE]. R1's admission Minimum Data Set (MDS) dated [DATE] documents R1 was cognitively intact, R1 was frequently incontinent of urine, and required partial/moderate staff assistance with transfers, dressing, and toileting. This MDS documents R1 had a history of falls prior to admission. R1's Fall Risk assessment dated [DATE] documents R1 as a high fall risk, including risk factors of weakness and overestimates/forgets limits of R1's abilities. R1's Care Plan revised 7/1/26 documents R1 required one assist for transfers, R1 was at risk for falls with interventions including non-skid socks (4/4/26 and 4/27/26) and keeping items within reach (4/4/26). R1's care plan does not document R1 refuses to wear or removes the non-skid socks. R1's Fall Report dated 4/26/26 at 6:45 PM, completed by V12 Licensed Practical Nurse (LPN), documents R1 was found on the floor next to R1's bed and recliner, R1 had a skin tear to the back of right hand, and R1 was not wearing shoes. This report documents R1 reported R1 was laying down and slid out of bed onto the floor. The root cause of the fall is documented as resident (R1) slid out of bed and non-skid socks as the post fall intervention. V16's (Certified Nursing Assistant (CNA)) Employee Statement dated 4/26/26 documents V16 was coming back from the dining room and found R1 sitting on the floor near R1's bed and V16 had last seen R1 before dinner walking with family back to R1's room. This statement documents after the fall V16 cleaned up the urinal spill on R1's floor and applied R1's non-skid socks. R1's fall investigation does not include when R1 was last toileted or urinal emptied and does not include any documentation that R1 refused to wear non-skid socks or removed them. R1's Fall Report dated 5/13/26 at 8:20 AM documents CNA (V10) reported R1 was in the shower room turning to sit down to prepare for shower, lost balance and had a witnessed fall with skin tear to right elbow. R1 reported R1 thought his hand slipped off the railing while attempting to turn and sit down. V10's Employee Statement dated 5/13/26 documents R1 walked to the toilet and was in the process of sitting down as V10 grabbed a shower chair, V10 turned to see R1 lying on his side and R1's walker on the floor. R1's Fall Report dated 6/12/26 at 6:30 AM, completed by V18 LPN, documents R1 reported R1 had fallen 30-45 minutes prior, had gotten himself up, and R1 had a 1.5 centimeter (cm) by 0.5 cm hematoma (bruising/swelling) to his left outer hand. R1 was unable to provide details about the fall. This report documents the root cause of the fall as R1 slipped while walking, R1 was encouraged to ask for assistance and signs were posted to ask for help and use the walker. There are no staff interviews regarding this fall besides V18's statement. The investigation of this fall does not identify who last saw R1 prior to the fall and R1's activity at that time, when R1 was last toileted, or R1's footwear when R1 fell. On 7/27/26 at 9:12 AM V4 LPN stated R1 was one assist for transfers and walking with use of gait belt and wheeled walker. V4 stated R1 was alert and oriented to person, place, and time but had intermittent confusion especially at night. V4 stated R1's fall interventions included non-skid socks, which R1 was compliant in wearing. On 7/27/26 at 9:28 AM V18 LPN stated on 6/12/26 around 6:00 AM R1 reported R1 had lost his balance, fell, and gotten himself back up, initially reported to V19 CNA. V18 stated R1 had a hematoma to the outer palm. V18 stated V18 had not seen R1 prior to the fall that morning since it was at the beginning of the shift. On 7/27/26 at 2:01 PM in regard to R1's fall on 5/13/26, V10 CNA stated R1 was in the shower room, as R1 went to sit down on the toilet V10 turned to grab the shower chair and R1 fell. V10 stated V10 had her back to R1 and was approximately a foot away. V10 stated V10 should have waited until R1 was fully seated on the toilet before getting the shower chair as R1 needed supervision for transfers. V10 stated V10 used a gait belt when R1 was walking in the hallway but did not use a gait belt or provide hands on assist during R1's toilet transfer/fall. On 7/27/26 at 4:04 PM V16 CNA confirmed V16 was R1's assigned CNA on 4/26/26. V16 stated prior to R1's fall that night, V16 last saw R1 walking with his family back to his room around 4:00 PM and V16 had emptied R1's urinal prior to that. V16 stated R1 used a urinal at the bedside, R1 would often spill the urinal or dribble urine on the floor, and V16 would frequently have to clean up R1's floor. V16 stated R1 was found on the floor near R1's bed, R1 had on regular socks that were wet from urine on the floor. V16 stated R1 did not have on non-skid socks due to refusing to wear them and removing them, and if R1 had on non-skid socks that would have prevented this fall. On 7/27/26 at 5:45 PM V12 LPN stated on 4/26/26 R1 was found on the floor between the bed and recliner, and it appeared as if R1 had slid out of bed. V12 stated R1 had a skin tear to the back of his hand and R1 had on regular socks without non-skid tread. V12 stated R1 was cooperative in wearing non-skid socks and didn't refuse them, and R1 was provided non-skid socks after the fall. V12 stated V12 believes non-skid socks would have prevented the fall. V12 stated V12 had not seen R1 prior to the fall that day as it was near the start of V18's shift. On 7/28/26 at 9:52 AM V2 DON reviewed R1's 6/12/26 fall investigation and confirmed there were no staff interviews/statements for the prior shift to identify when R1 was last seen or toileted prior to this fall. V2 stated R1 was getting out of bed and thought to have slid due to wearing regular socks for the 4/26/26 fall, and R1 would sometimes refuse to wear the non-skid socks or remove them, but there is no documentation of this. V2 confirmed R1's non-skid socks were care planned as a fall intervention when R1 admitted to the facility on [DATE], prior to the 4/26/26 fall. 2.) R2's MDS dated [DATE] documents R2 has severe cognitive impairment and is dependent on staff assistance for transfers and toileting. This MDS documents R2 has impaired range of motion to both legs and is always incontinent of bowel and bladder. R2's Fall Risk assessment dated [DATE] documents R2 is at high risk for falls. R2's Care Plan dated as revised 6/29/26 documents R2 has a diagnosis of Huntington's Disease and fall interventions include the use of a non-skid mat in the seat of R2's geriatric reclining back wheelchair (9/29/25), offer toileting before supper (6/21/25), and new style call light will be provided when it arrives (11/10/2025). This Care Plan also includes an intervention to keep call light within easy reach and encourage R2 to use it. R2's Fall Report dated 6/28/26 at 6:40 PM, completed by V12 LPN, documents R2 was found sitting on the floor on top of the leg rest of R1's wheelchair, the chair was tipped forward and R2's back was against the seat of the chair. R2 was incontinent of bladder and R2 had a small scratch to the top of R2's forehead. The fall investigation included three staff statements/interviews with V12, V24 CNA and V5 CNA, and did not identify when R2 was last toileted prior to the fall or if R2's chair had a non-skid mat. On 7/27/26 at 10:16 AM and 12:14 PM R2 was in bed. R2's touch sensor call light was on the fall mat on the floor beside R2's bed, and not within easy reach for R2. R2 did not respond to questions regarding R2's fall. At 12:14 PM V25 CNA stated V25 placed R2's call light on the fall mat due to R2 moving about in bed which would frequently trigger the call light. V25 confirmed the call light was not within R2's reach.On 7/28/26 at 8:25 AM R2 was asleep and sitting in a reclined geriatric wheelchair in the television room on the [NAME] wing. On 7/27/26 at 3:30 PM V24 CNA stated V24 found R2 sitting on the footrest of R2's geriatric reclining back wheelchair and the chair was tilted/upright in the air. V24 did not recall if there was a non-skid mat in R2's chair at that time. On 7/27/26 at 5:45 PM V12 LPN stated V12 had not seen R2 that night prior to his fall as it was the beginning of the shift. V12 stated R2 was found in the television lounge sitting on the footrest of his wheelchair which caused the chair to tip forward. V12 stated R2 was incontinent at the time of the fall and was assisted to bed. At 6:17 PM V12 did not recall if there was a non-skid mat in R2's chair during this fall. On 7/28/26 at 9:23 AM V23 Care Plan Coordinator stated R2 has a touch pad call light which should be kept near R2 within reach. V23 confirmed the care plan is where staff would look for documented fall interventions. On 7/28/26 at 9:52 AM V2 DON stated R2 fidgets and moves around a lot due to Huntington's Disease which causes R2 to slide down in R2's wheelchair. V2 stated V2 believes R2 slid to the foot of R2's wheelchair causing it to tip forward. V2 stated there should have been a non-skid mat in R2's wheelchair as that was a fall intervention prior to this fall. V2 confirmed R2's fall investigation did not include if a non-skid mat was in place or when R2 was last toileted or provided incontinence cares. V2 confirmed R2's call light should be within R2's reach and not on the fall mat. V2 stated V2 will need to do educate the CNAs regarding this.

Based on interview and record review the facility failed to maintain documentation of neurological assessments for one of three residents reviewed (R1) for falls in the sample list of three. Findings include:The facility's undated Neurological Screenings Guidelines documents to use the guide for unwitnessed falls or when a resident has hit his/her head during a fall. This guide documents to complete and document neurological assessments on the Neurological Flow Sheet including monitoring for changes from baseline such as confusion, drowsiness, or deterioration and obtain vital signs every 15 minutes times four, then every four hours times four, then every eight hours times nine, equaling a minimum of 72 hours. The facility's Content of the Medical Record policy dated August 2017 documents the Medical Records Clerk is responsible for ensuring all required information is in the resident's medical record, and the Administrator should ensure all medical records are maintained according to regulations and guidelines. R1's Fall Report dated 6/12/26 at 6:30 AM, completed by V18 Licensed Practical Nurse (LPN), documents R1 reported R1 had fallen 30-45 minutes prior and had gotten himself up, and R1 had a 1.5 centimeter (cm) by 0.5 cm hematoma (bruising/swelling) to his left outer hand. R1 was unable to provide details about the fall and neurological assessments were initiated. R1's 72-Hour Fall Monitoring Assessments dated 6/12/26 at 4:07 PM and 6/13/26 at 2:54 PM document neurological assessments were completed, R1's neurological status was intact but does not include R1's level of consciousness, hand grasps, pupil response or vital signs as outlined on the corresponding 72-Hour Neurological Flow Sheet for this fall. R1's 72-Hour Neurological Flow Sheet initiated on 6/12/26 is incomplete and does not document assessment findings for level of consciousness/orientation, pupil response, hand grasps or vital signs for 15 minute and hourly checks on 6/12/26 or on the 6:00 AM-2:00 PM shift on 6/13/26. R1's Nursing Note dated 6/29/2026 at 10:40 PM documents R1 sustained a fall with noted head injury bleeding from laceration to right forehead. R1 was transferred to the local emergency room for evaluation. R1's Nursing Note dated 6/30/26 at 1:29 AM documents R1 returned to the facility with five sutures for right forehead laceration and neurological assessments continued per facility protocol with no noted changes. R1's Nursing Note dated 6/30/2026 at 9:45 PM documents R1's dressing was changed; sutures were intact and there was extensive bruising across R1's forehead and right eye appeared swollen consistent with recent trauma. Neurological status was assessed and remained in normal limits. There is no documentation in R1's medical record that a 72-Hour Neurological Flow Sheet was completed for R1's fall on 6/29/26.On 7/27/26 between 11:38 AM and 1:11 PM the following interviews were conducted: V6 Registered Nurse (RN) stated V6 completed neurological assessments for R1 on the evening shift on 6/30/26 and R1 had no noted changes. V21 RN stated R1 returned to the facility on V21's shift and neurological assessments continued, which were documented on a paper form for 72 hours post fall. V14 LPN confirmed V14 was R1's assigned nurse on dayshift on 6/30/26. V14 stated R1 was on 72 hour fall monitoring including neurological assessments, and R1 did not have any changes in his neurological status. On 7/28/26 at 8:53 AM V18 LPN confirmed V18 was R1's assigned nurse on dayshift on 6/12/26. V18 reviewed R1's post fall assessments and neurological assessments dated 6/12/26. V18 stated V18 completed neurological assessments that day and doesn't know why this information wasn't documented. V18 also verified R1's vital signs were not documented for the 15 minute and hourly checks as indicated on the Neurological Flow Sheet. On 7/27/26 at 11:28 AM V2 Director of Nursing (DON) confirmed R1's Neurological Flow Sheet dated 6/12/26 was incomplete. On 7/27/26 at 12:20 PM V3 Assistant DON stated when R1 returned from the hospital R1 would have been due for neurological assessments every shift. V3 confirmed R1's post fall assessments document neurological status as intact but does not document findings of the assessment, and confirmed R1 did not have a 72-Hour Neurological Flow Sheet for the 6/29/26 fall. On 7/28/26 at 10:25 AM V1 Administrator stated V1 believes a 72-Hour Neurological Flow Sheet was completed for R1's 6/29/26 fall, the form was misplaced and was not uploaded into R1's electronic medical record.

Based on observation, interview and record review the facility failed to maintain the kitchen equipment in clean, sanitary, operable condition to prevent cross contamination, maintain freezer temperatures and ensure pureed food is a safe consistency. These failures have the potential to affect all 93 residents that reside in the facility.Findings include:1.On 4/12/26 at 8:30 am during the initial kitchen tour, V6, Dietary Manager (DM) confirmed that the walk-in -freezer temperature log dated 4/01/26 through 4/12/26 documented temperatures measured between four and ten degrees Fahrenheit. The bottom of the same walk-in freezer temperature log documents the freezer temperature should be measured at minus two or below, Fahrenheit. The dial on the freezer thermometer gauge displayed the current freezer temperature measured as 15 degrees Fahrenheit. The walk-in freezer was filled with frozen food. V6, DM stated We did know the freezer temperatures were not right. It is supposed to be below zero. V6, DM also stated the facility had the maintenance department look at the freezer temperature several times over the past couple weeks and has ordered new parts and tried several other things to fix the thermostat.2.On 4/13/26 at 9:50 am - 10:45 am on follow- up tour of the kitchen, V23, [NAME] was observed pureeing the meal for the day. V23, [NAME] pureed cooked chicken breast in a food processor. Due an abundance of [NAME]-like granules in chicken texture, (when sampled by this surveyor, V6 DM and V23 Cook), The chicken breast required extended periods of time (approximately 5 minutes, x 3 attempts) to process to a safe smooth texture to prevent the potential of resident aspiration.During the same observation V6, DM confirmed the foods required longer processing in order to become smooth. V6 stated We only have two blades for the food processor, one (blade) is at the hardware store being sharpened. This one (blade being used) will be sent to the hardware store next. It needs sharpened too.During the same observation V6, DM removed cooked pureed vegetables from the stove. V6, DM confirmed the vegetables were already pureed, and ready to serve. The pureed vegetables were then sampled by this surveyor, and V6, DM and V23, Cook. V6, DM confirmed the pureed vegetable had small chucks of vegetables and an overall sand-like textures present. V6 DM confirmed the vegetables were not pureed long enough, and posed a potential risk of aspiration to residents on the pureed diet. V6 DM directed V23, [NAME] to repeat processing the vegetables to smooth texture.During the same observation V23, [NAME] removed a tray from the refrigerator. The tray contained 15 bowls. The 15 bowls contained individual portions of presumed pureed servings. V23 confirmed that the pureed processing was complete, and the pears were ready to serve. V23 said these were pureed yesterday on evening shift. V23 Cook, and this surveyor sampled the pears to assess the consistency. V23 confirmed there were chunks of pears in resident's pureed pears. V23 confirmed the texture was not smooth enough to be served to the residents that require pureed food. V6, DM was present and directed V23 to repeat the puree processing to a smooth and safe consistency. During the same observation V6 DM stated the pasta on the menu for today, won't be smooth enough to serve the residents due to the dull blade in the food processor. V6, DM stated they will have to substitute mash potatoes.3. During the same 4/13/26 at 9:50 am - 10:45 am follow- up tour of the kitchen V6, DM continued the tour of the kitchen and confirmed the tabletop can opener was rusty and had a grease buildup with food particle present in the gears, and the veneer of the blade was worn down to bare metal. V6, DM stated The facility needs a new table-top can opener because the current one is very old and no longer cleans up well.The CMS Long Term Care Application for Medicare and Medicaid documents 93 residents reside in the facility.The facility undated policy Equipment documents the following: Policy Statement: All food service equipment will be clean, sanitary, and in proper working order.

Based on observation, interview and record review the facility failed to maintain residents right to dignified care, for two of two residents (R10 and R13) reviewed for activity of daily living assistance/dignity, on the sample list of 36.Findings include:1.R10's current Diagnoses List documents the following: Unspecified Dementia, Mild, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety, Type II Diabetes Mellitus Without Complications, and Other, Lack of Coordination.R10's Minimum Data Set (MDS) dated [DATE] documents R10's Brief interview of Mental Status (BIMs) score as seven out of a possible 15, indicating severe cognitive impairment. The same MDS documents, R10, requires staff assistance with all activities of daily living.On 04/12/2026 12:10 pm R10 was seated in a low wheelchair, in the resident assistance dining room. R10's dining table was level with R10's neck. R10 had a dinner sized plate with mechanical soft turkey and gravy, rice with gravy, and cooked carrots. R10 also had a brownie on a separate plate. R10 raised her elbow out to her side at shoulder height, and stretch her arms forward to reach up to the dinner plate on the dining room table. R10 pulled the dinner plate off the table, part of the way and leaned forward to scoop turkey with a spoon and leaned back in her wheelchair to eat the scooped portion of food. R10 dropped small amounts of food in her lap several times. R10 then pushed the entree plate away and lifted the brownie plate off the table, holding the small plate with one hand while she ate the brownie with the fork in her other hand. R10 stated It would be very nice if I had a lower table. I am short and it is hard for me to eat. I can't reach it and I get messy. I don't like that. Maybe you could use your pull and get me a table that is a little lower. On 4/12/26 at 12:15 pm V10, Dietary Assistant confirmed R10's table height puts R10's food out of her reach, making it difficult for R10 to reach her food and dine with dignity. V10, Dietary Assistant bent down, looked under the table and said, this one (dining table) does not adjust. It is broken. R10 stated to V10, Dietary Assistant, Can you hand me my plate then, so I can eat.On 4/12/26 at 3:08 pm V2, Director of Nursing confirmed R10 dining at a low table was a dignity issue. V1 Administrator was present and stated R10 is petite and requires a shorter table to dine comfortably.2. R13's current diagnoses list documents the following: Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side.R13's Minimum Data Set, dated [DATE] documents R13's Brief Interview of Mental Status score as 15 out of a possible 15 which indicates R13 has no cognitive impairment. R13's same MDS documents, R13, is totally dependent of staff assistance for toileting.On 4/13/26 at 12:25 pm R13 was propelling herself out of the dining room, in a wheelchair and down the hallway. R13 had a flaccid left side. R13 had one footrest that held her left foot. R13 was propelling her wheelchair with her right foot and using the handrail with her right hand to pull the wheelchair forward. R13 was hurried and stated to this surveyor, I am having a bad time. R13 stated I asked (V19, Certified Nursing Assistant) to help me to the bathroom. (V19, CNA) said she did not have time. She needed to take other people to the dining room and start feeding them. I (R13) can't sit in the dining room to eat, knowing I am going to go (evacuate bladder) in my (incontinence brief). I need to (urinate) on the toilet. I need to go bad. I can't unfasten my (incontinence brief). I just want to get out of here. I have to take myself now, I am afraid I won't make it. On 4/13/26 at 12:30 pm V19, Certified Nursing Assistant (CNA) stated Yes, I told (R13) I couldn't take her to the bathroom. I was in her room, changing her roommate (R53) and had to take her (R53) to the dining room. All of us CNA's were getting people out to the dining room. We had to feed people. I did not have time, and I did not ask anyone else to take her (R13). I told her she would have to wait. That was a while ago. I figured she took herself.On 4/13/26 at 2:05 pm V2, Director of Nursing (DON) stated she is aware that V19 told R13 that she could not take her to the bathroom. V2, DON confirmed Yes, this is a dignity issue.The facility Policy Resident Privacy and Dignity dated as revised January 2026 documents the following: PURPOSE: To provide all residents with a home like environment that promotes dignity and respect to the residents of the facility.POLICY: To ensure that all residents are provided with dignity and privacy.RESPONSIBILITY: It is the responsibility of all staff to ensure that all residents have privacy and dignity.

Based on interview and record review the facility failed to protect the residents' right to be free from verbal abuse by another resident for two of four residents (R75 and R84) reviewed for abuse on the sample list of 36. Findings include:R75's Minimum Data Set (MDS) dated [DATE] documents R75's Brief Interview of Mental Status (BIMS) score of 14 out of a possible 15 indicating no cognitive impairment. This same MDS documents R75 has no delusions or hallucinations, and no behaviors directed towards self or others.On 4/12/26 at 2:50 pm R75 and V26, R75's Family Member were seated in R75's room. R75 stated that R84 came past her room in the hallway one day and scream into R75's room. (R84) called me an (F expletive B expletive). I kept it to myself. I did not say anything to any staff. We (R84 and R75) were friends. This had come out of nowhere. I was really just worried about my roommate (R9). She (R9) doesn't get out of bed very often. She likes to sleep. I worried about her and figured he (R84) could come into our room, though, he (R84) hadn't. The next day, it happened again. This time he exploded with very bad nasty, curse words. Some I did not even know. His (R84) tone was so angry, I knew they (the words she didn't know) were bad words also. I was crying. He just kept it up for what seemed like several minutes. I (got up my courage) then and told him to go away. I told him to leave the building. He stayed outside in the hall looking through the window of the assisted dining room. He was watching me, and I was really uncomfortable and still crying. V26, R75's Family Member stated My Mom (R75) was really upset. She was tearful, each time I talked to her for the next couple days. R75 stated You can talk to (V29 Certified Nursing Assistant) CNA she can tell you all about it. I am not afraid of anyone else, staff or residents. I have no fear here, since he (R84) was ejected (discharged )from the facility.On 4/13/26 at 7:15 am V1, Administrator/Abuse Prevention Coordinator stated the facility did not conclude in their verbal abuse investigation between R84 and R75 that abuse occurred. V1 stated the conclusion she arrived at was because she thought it had to be a willful intent to harm. She reviewed the facility abuse prevention policy to clarify her understanding. V1stated she can see now that it only had to be an intentional act. V1 confirmed R84 intentionally cursed at R75.On 4/14/26 at 10:00am V28, Registered Nurse (RN) stated I reported the resident to resident incident between (R75) and (R84) to the (V1, Abuse Prevention Coordinator) Administrator. That is our protocol after we make sure the residents are separated. (V29, Certified Nursing Assistant/CNA) was pushing (R75's) wheelchair down the hall. (R29, CNA) asked me if I heard what (R75) had just said. I said no and (R75) was tearful and told me that (R84) had just screamed profanities at her (R75) in the dining room. V28, RN also stated V28, RN stated (R75) became more upset when she started telling me what he said. (R75) said he called her an (F expletive B expletive), and was saying all kinds of other harsh, foul words. My heart broke for (R75). I took her to the nurses station and asked (V29, CNA) to stay with her. I went to find (R84) because I did not want him around other residents. (R84) was in his room. Of course, I asked him what he (R84) said to (R75). He denied anything inappropriate was said between him and (R75). He looked angry when I talked to him, but he did not say anything in his agitated state. I went immediately and reported it to (V1, Administrator/Abuse Prevention Coordinator). All staff on the unit knew to watch his room, to make sure he stayed there until the ambulance came to transport to the hospital for evaluation.R84's current diagnoses list documents: Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety, and Depression.R84's MDS dated [DATE] documents the following: R84's BIMS score of ten out of a possible 15, indicating moderate cognitive impairment. R84's Physician Order Sheet dated March 2026 documents the following Psychotropic Medications: Sertraline HCl Oral Tablet 50 MG (milligrams), Give 50 mg by mouth in the morning, Divalproex Sodium Oral Capsule, Delayed Release Sprinkle 125 MG, (Divalproex Sodium), Give 250 mg by mouth two times a day and Trazodone HCl Oral Tablet 50 MG, Give 0.5 tablet by mouth at bedtime.R84's corresponding Medication Administration Sheet dated March 2026, documents R84 refused to take R84's above psychotropic medications for 16 days out of 24 days, (prior to verbally abusing R75 on 3/25/26).R84's current Care Plan documents: (R84) receives antidepressant medication related to Depression and behaviors of wearing non-appropriate clothing in hallways, anger. The same care plan documents: (R84) refuses taking his medications.R84's Behavior Note Narrative dated 3/24/2026 at 7:40 pm documents the following: Note Text: Resident was having pleasant conversation with another resident, when he suddenly became angry and started cussing at her. Staff immediately separated residents, (R84 and R75) and (R84) went to his room. Other resident (R75) remained with staff, and was calm, just confused as to why he (R84) suddenly became angry with her. Resident has not been taking medications per his refusals; EMS (Emergency Medical Service) was called resident sent to local ER (Emergency Room).The facility Illinois Department of Public Health Final Report dated 3/2726, documents: Resident (R84) to (R75) Resident Verbal Abuse on 3/25/26. Conclusion: Abuse FINAL Investigation (R75) is no longer scared and has maintained distance. (R84) is now able to get to the level of psychiatric care that he needs and should not be returning to the facility. The facility policy Abuse and Retaliation Prevention Program dated January 2026 documents the following: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, retaliation, misappropriation of property, deprivation of goods and services by staff mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. ln order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to ensure 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.The same policy documents: Abuse: Abuse means any physical or mental injury; retaliation; or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain and/or maintain physical, mental, and psychosocial well-being. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish. The term willful in the definition of abuse means; the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on observation, interview and record review the facility failed to protect a resident's right to be free from sexual abuse by another resident. This failure affects two of four residents (R5 R4) reviewed for abuse on the sample list of five. This past non-compliance occurred from 10/17/25 to 10/17/25. Findings Include: The Minimum Data Set, dated [DATE] documents R4 is cognitively intact.The Minimum Data Set, dated [DATE] documents R5 is cognitively impaired.Nursing Progress Notes dated 10/17/2025, document R4 was seen with his hand underneath R5's shirt. The Notes document the Abuse Coordinator, Power of Attorney and the Medical Director were notified. On 11/25/25 at 8:25AM, V5 (Licensed Practical Nurse) stated he was the nurse that day on 10/17/25 when R4 touched R5. V5 stated he was going down the hall by the dining room and saw R4's hand underneath R5's shirt. V5 stated V5 saw R4 moving his right hand up and around R5's breast. V5 stated he immediately separated the two residents and reported to the Administrator. V5 stated that R4 had done this to R5 in December 2024, which V5 stated he reported to the Administrator (previous). On 11/25/25 at 8:35am, V6 (Licensed Practical Nurse) stated that R4 has touched R5 recently and that the residents were immediately separated and the abuse coordinator was contacted. V6 stated, R4 is to be watched at all times while R4 is out of R4's room and is assisted to and from the dining room. On 11/24/25 at 11:35AM, R4 was observed being supervised by the certified nursing staff at the table for lunch, eating with another male resident. At that time R4 stated he put his hand up R5's shirt because R4 missed his wife that only visits occasionally.On 11/25/25 at 10:05AM, V1 (Administrator) stated she started working at the facility on 10/17/25 when this incident happened. V1 stated she immediately started an investigation and sent an initial and final report to Illinois Department of Public Health. V1 stated that when completing a sweep of R4's chart, R4 had an incident documented with R5 on 12-15-24 of R4 putting his hands up R5's blouse. V1 stated V1 completed a facility wide sweep and immediately started education with all staff. Prior to the survey date of 11/25/25, the facility took the following actions to correct the noncompliance:1. On 10/17/25 the facility Quality Assurance Committee developed a plan of correction for the 10/17/2025 abuse allegation incident.2. On 10/17/25 the Quality Assurance Committee and also the facility management completed a whole facility audit of all residents to address high risk and low risk residents who may be prone to sexual abuse. Care plans were put in place for all high-risk residents by V1. 3. On 10/17/25 all management staff received formal training on sexual abuse identification / reporting / suspensions by corporate quality nursing and operations staff. On 11/25/25 at 9:58AM, V2 Director of Nursing confirmed V2 received the training.4. On 10/17/25 all facility staff were Inservice on sexual abuse through one to one trainings with Quality Assurance Compliance staff and through computer based trainings. On 11/25/25 at 8:25AM,V5 confirmed that on 10/17/25 V5 received education on who to report sexual abuse to and when to report it. V5 stated he also completed computer based training. On 11/25/25 at 8:35am,V6 also stated that in-services were completed on 10/17/25 with the administration and corporate staff on abuse and when and what to report. 5. Sexual abuse allegations on October 17, 2025 were determined by the Quality Assurance Tool to have been timely and directly reported to V1 (Administrator / Abuse Coordinator) and the accused resident was put on continuous supervision when out of the room and from continued access to residents6. On 11/25/25 at 9:58AM, V2, (Director of Nursing) stated R4 has been care planned to be supervised when R4 is out of R4's room. V2 stated care plans/interventions were put in place on 10/17/25. On 11/24/25 at 11:35AM, R4 was observed being supervised by the certified nursing staff at the table for lunch, eating with another male resident.

Based on interview and record review the facility failed to establish clear communication regarding notification to a funeral home to remove a resident R1 remains for 1 of 3 residents reviewed for death.This past non-compliance occurred from [DATE] to [DATE].Findings include: R1's Facility Census documents show that R1 was admitted to the facility on [DATE] and was discharged on [DATE]. R1 had the following medical diagnoses: Traumatic Subdural Hemorrhage with Loss of Consciousness, Dementia, COPD, Heart Disease, Chronic Kidney Disease Stage 4, Anxiety Disorder, Scoliosis, GERD, and Repeated Falls.R1's Nursing Note dated [DATE] at 11:58 AM documented that R1 expired at 11:52 AM. A hospice nurse and family were at the bedside, and V2, Director of Nursing, was notified.R1's Nursing Note dated [DATE] at 10:33 AM documented that the funeral home arrived and removed R1's body from the facility.On [DATE] at 10:00 AM, V6, Licensed Practical Nurse (LPN), stated that on [DATE] V6 was working the 6:00 AM to 2:00 PM shift and that R1 was in V6's group. V6 stated that R1 passed away at 11:52 AM, which was confirmed by V12, Hospice Registered Nurse. V6 stated that at shift change, V6 informed V7, Licensed Practical Nurse, that R1 had expired and that the funeral home had not picked up R1's remains. V6 stated that V6 did not call the funeral home to inform them that R1 had expired, assuming that V12 had made the call. V6 stated that V6 should have confirmed with V12 that the funeral home had been notified.On [DATE] at 10:15 AM, V7, Licensed Practical Nurse (LPN), stated that on [DATE] V7 worked from 2:00 PM to 6:00 PM and, upon receiving report, was notified by V6 that R1 had expired and was still in R1's room. V7 stated that at the end of V7's shift, R1 had still not been picked up by the funeral home, and V7 informed V8, Licensed Practical Nurse (LPN), that R1 remained in the room. V7 stated that V7 did not call the funeral home.On [DATE] at 10:30 AM, V10, Licensed Practical Nurse (LPN), stated that on [DATE] V10 worked the 6:00 AM to 6:00 PM shift and was informed during report that R1 had expired on [DATE] at 11:52 AM, but was not informed that R1 was still present in the facility. V10 stated that at 10:00 AM, V11, Housekeeper, informed V10 that upon entering R1's room to clean it, V11 observed R1 in bed. V10 stated that notifications were made to V13, the duty manager, and that the funeral home was called and picked up R1's remains at 10:33 AM.On [DATE] at 10:48 AM, V9, [NAME] President of Hospice Operations, stated that on [DATE] V12's hospice nursing notes documented that R1 was pronounced expired at 11:52 AM. V9 stated that V12 notified the Ford County Coroner, and the coroner released R1's body to the funeral home in [NAME] City at 12:21 PM. V12 stated that V12 informed V6 that the family wanted some time with R1, and that after the family left, the facility would provide postmortem care and that the facility was responsible for calling the funeral home.On [DATE] at 10:58 AM, V11, Housekeeping, stated that on [DATE] V11 worked the 6:30 AM to 3:00 PM shift. V11 stated that V11 was informed that R1 had passed away and that V11 would need to clean R1's room. V11 stated that at 10:00 AM V11 went to clean R1's room and, upon opening the door, observed R1's body still in bed. V11 stated that V11 informed V6, Licensed Practical Nurse, that R1's body was still in the room.On [DATE] at 11:10 AM, V2, Director of Nursing, confirmed that R1 had expired on [DATE] at 11:52 AM and that the funeral home was not notified until [DATE] at 10:05 AM to remove R1's remains. V2 stated that the facility should have communicated with V12, Hospice Registered Nurse, to ensure that hospice had notified the funeral home. V2 stated that there was no documentation in R1's chart indicating that R1's remains were removed from the facility until [DATE].Prior to the survey date of [DATE], the facility took the following actions to correct the non-compliance:On [DATE], R1 expired at the facility under hospice care at 11:52 AM.On [DATE], the Quality Assurance Committee developed a Plan of Correction for the [DATE] incident and a Performance Improvement Plan.On [DATE], the Director of Nursing and Administrator provided in-service education to nursing staff on documentation and communication requirements for end-of-life care, after-death care, the death checklist, midnight census procedures, and shift-to-shift reporting following a death.On [DATE], the facility standardized communication pathways with hospice, the funeral home, and the coroner.Starting on [DATE], the Director of Nursing and/or designee began auditing resident end-of-life documentation, the funeral home/coroner notification log, shift-to-shift handoff reports, and after-death care after every resident death for one month.The facility QAPI Committee will continue to monitor performance to ensure corrective actions related to the [DATE] incident are effective.Completion date of substantial compliance: [DATE].

Based on interview and record review the facility failed to prevent elopement of a resident when staff did not verify that the exit door was properly secured after use. This failure effected one (R1) of three residents reviewed for elopement. Findings include:R1's Facility Census documents R1 was admitted to the facility on [DATE] and has the following medical diagnoses; Dementia, Metabolic Encephalopathy, Type 2 Diabetes, Muscle Wasting and Atrophy, Lack of Coordination, Abnormal Posture, Abnormalities of Gait and Mobility, Difficulty in Walking, Intervertebral Disc Degeneration, Alzheimer's Disease, Heart Failure, Anxiety Disorder, Colostomy, Fall on Same Level, Depression, Cognitive Communication Deficit, Repeated Falls, Weakness and Age-related Cognitive Decline.On 9/12/25 at 10:10 AM, V3 Licensed Practical Nurse stated on 8/27/25 at 6:15 PM V3 and V4 Certified Nursing Assistant went outside to smoke, exiting the employee service door which has a key code lock. V3 stated that sometimes the door does not lock if it doesn't close all the way, and V3 is unsure if it locked that day. V3 stated that shortly after returning into the facility V4 informed V3 that R1 was outside of R1's room tapping on the window. V3 stated V4 went and pushed R1 in R1's wheelchair back into the facility and to R1's room. On 9/12/25 at 10:56 AM, V4 Certified Nursing Assistant stated that on 8/27/25 at 6:15pm V4 and V3 Licensed Practical Nurse went outside to smoke. V4 stated that while walking to the employee service door V4 observed R1 in the hallway. V4 stated that V4 and V3 used the employee service door to go outside, and this door does have a keypad lock. V4 stated that sometimes the door doesn't latch, and you have to pull it closed to lock. V4 stated V4 does not recall if V4 or V3 pulled the door closed to make sure was locked. V4 stated that at 6:20 PM V4 and V3 returned back into the facility. V4 was gathering supplies to change a resident, and upon walking past R1's room, V4 heard a knocking noise. V4 stated V4 went into the room and observed R1 knocking on the window from outside. V4 stated V4 and another CNA went outside and got R1 and brought R1 to R1's room. On 9/12/25 at 1:01 PM, R1 stated that a couple of weeks ago R1 followed the girls out the door, and when R1 got out the door it locked and R1 could not get back in. R1 stated that R1 went over to a room window and knocked on the window until staff seen R1 and came and got R1 back inside the facility.On 9/12/25 V1 Administrator stated that on 8/27/25 at 6:25 PM V8 Certified Nursing Assistant called V1 and informed V1 that R1 was outside of R1's window knocking on R1's window from outside. V1 stated V4 further stated to V1 that this was around 6:15 PM and V4 and V3 Licensed Practical Nurse were going outside for a smoke, and R1 appeared to be propelling back towards the dining room. V1 stated that V4 informed V1 that V4 retuned back into the facility about 5 minutes later, and while passing R1's room heard knocking on the window, and upon going into R1's room, observed R1 outside R1's window. V1 stated that V1 interviewed V3 Licensed Practical Nurse who stated to V1 that V3 and V4 went outside to smoke, exiting the employes service door. V1 stated V3 returned back into the facility at 6:20pm and V4 informed V3 that R1 was outside knocking on R1's window. V1 stated V3 brought R1 back into the facility. V1 stated that neither V3 nor V4 were able to confirm if the door locked when they exited the facility. The Facilities Missing Person's Policy revised 1/23 documents: Purpose: to provide facility staff with the guidance for ensuring the health, safety and welfare of all the residents, and protocol to be followed when a resident is noted to be missing. Policy: Each unit charge nurse, during their respective tour of duty will be aware and responsible for knowing the location of their residents at all times. When residents are participating in various programs such as physical therapy, recreational activities, dining, etc., the staff at these program areas will exercise sound judgement and be aware and responsible for the health, safety and welfare of their participants. Nursing personnel must report and investigate all reports of missing residents.

Based on observation, interview, and record review the facility failed to thoroughly and accurately assess and measure pressure wounds at least weekly for two residents (R2, R3) of three residents in a sample list of nine residents. This failure caused (R2, R3) to experience worsening of facility acquired pressure ulcers.Findings Include:1. R3's Current diagnoses list includes the following diagnoses: Hearing Loss, Anxiety, Muscle Wasting and Atrophy, Difficulty Walking, Depression, Pressure Ulcer Left Buttock, and History of Lumbar Spinal Fusion.R3's wound assessment dated [DATE] by V7, Licensed Practical Nurse (LPN) Wound nurse documents R3 has a Stage 3 Facility Acquired Pressure Ulcer first identified on 7/2/25. There are no wound assessments or measurements observed documented prior to 7/8/25. The 7/8/25 assessment documents the wound as measuring 5 CM (Centimeters) in length by 4 CM in width by 0.2 CM in depth. A photograph included in the wound assessment supports this assessment.On 8/25/25 at 11:00AM, V7 verified there was no wound assessment or measurements on this wound between 7/2/25 and 7/8/25. V7 stated I was on vacation, and I became aware of (R3's) wound during my vacation, but I didn't get back to measure it until 7/8/25.R3's Care Plan problem list was updated by V2, Director of Nursing on 7/31/25 to include (R1) has an unstageable pressure ulcer of the sacrum related to Immobility and incontinence of bowels. This differs from the 7/8/25 Wound assessment and no wound related interventions are documented to have been added to R3's Care Plan since 4/30/25. R3's wound assessment dated [DATE] by V7, Licensed Practical Nurse (LPN) Wound nurse documents R3 has an unstageable Facility Acquired Pressure Ulcer first identified on 7/2/25. The 8/12/25 assessment documents the wound as measuring 9 CM in length by 10 CM in width by 2CM in depth. V7 documented the presence of undermining at 7 O'clock to 9 O'clock measuring 2.0 CM and at 3 O'clock to 4 O'clock measuring 2.0 CM. A photograph included in the wound assessment documents an oval shaped wound over half covered by black leathery tissue with rolled edges and a narrow deep tract surrounding half the wound. On 8/25/25 at 7:40AM, V21 (R3's family member) stated I was told by the facility (R3) had a Stage 3 pressure ulcer, but when I went to the hospital when (R3) was supposed to be having a suprapubic catheter put in I was shocked by what I saw. The odor was so bad it made me nauseated. The wound was deep and partly covered with black rotting flesh. The hospital couldn't do the catheter because of this horrible wound.2. R2's current diagnoses list includes the following diagnoses: Macular Degeneration, Gout, Anxiety, Peripheral Vascular Disease, and History of Vertebral and Hip fractures.R1 was R2's roommate on 8/10/25. R1's progress note dated 8/10/25 at 9:55PM documents Was told per CNA (Certified Nursing Assistant) that (R2) was doing care on her roommate. Went to (R1and R2's) room and (R1) was standing by (R2's) bed side rubbing (R2's) feet and telling nurse that there might be something wrong with (R2's) feet. Explained to (R1) that it is our job to take care of her roommate. (R1) acknowledged this and stated she would not do it again. Explained to (R1) about state laws and that this is not allowed. R2's progress note dated 8/13/25 at 2:13PM documents Called to the shower room by CNA. Noted discolored areas to bilateral heels. Areas assessed. R2 denied pain. Wound nurse, (physician) and Power of Attorney notified. Foam dressings applied and heels floated. R2's Physician's orders document a treatment to cleanse wound, apply skin prep and a bordered foam dressing was initiated at that time.R2's Multi Wound Chart Details by V9, Wound Care Physician's Assistant dated 8/19/25 documents Initial Exam Stage 2 Pressure Ulcer Right, Distal, Plantar, Posterior, Inferior, heel measuring 1.0CM in length 0.5 CM in width 0.1 CM in depth and Left Distal, Plantar, Posterior, Inferior, heel measuring 3.0CM in length 1.5 CM in width 0.1 CM in depth. R2's Wound assessment dated [DATE] by V7 wound nurse documents the wounds are Deep Tissue Injuries as opposed to Stage 2 Pressure Ulcers. V9's documentation states the wounds were acquired 8/10/25 as opposed to 8/13/25. V9's wound care orders included in the 8/19/25 document state Cleanse wound with 0.125% Dakin's solution while the actual order being administered states to cleanse with wound cleanser. On 8/26/25 at 10:00AM, V7 stated (R2's) heel wounds are closed unstageable pressure ulcers. You would not want to clean intact skin with Dakin's solution. The order in place is to clean with wound cleanser apply skin prep and cover with foam border dressing. V7 removed in place foam border dressings from R2's heel wounds. R2's left heel observed to have a half dollar sized purple intact Deep Tissue Injury. R2's right heel observed to have a dime sized purple Deep Tissue Injury.On 8/26/25 at 1:35PM V9 stated (R2's) heel wounds are Deep Tissue Injuries. V9 verified Dakin's Solution would not be used for intact skin. When asked why his wound assessment indicated both wounds are Stage 2 Pressure injuries V9 stated I believe I documented that by mistake. When asked what type of experience or certification V9 maintains in Wound Care V9 stated I've been a Physician's Assistant for a long time. V9 did not indicate any specialized wound care experience or certification.

Based on interview and record review the facility failed to identify potential triggers for Post Traumatic Stress Disorder (PTSD) and failed to initiate resident centered interventions to address PTSD for one resident (R1) admitted to the facility with a diagnosis of PTSD of three residents reviewed for admission transfer discharge rights in a sample list of nine residents. Consequently, R1 experienced an exacerbation of behavioral symptoms leading to emergent hospitalization.Findings include:R1's progress note documents R1 was admitted to the facility from home on 7/17/25 at 3:09PM. R1's physician's note dated 7/1/25 documents R1 is a candidate for assisted living. R1's most recent diagnoses list includes the following diagnoses: Parkinson's Disease, Chronic Obstructive Pulmonary Disease, Lupus Erythematosus, Generalized Anxiety Disorder, Post-Traumatic Stress Disorder, Major Depression, Osteoarthritis, and Sedative/Hypnotic/Anxiolytic Dependence.R1's Brief Trauma Questionnaire dated 7/28/25 fails to address R1's Diagnosis of PTSD and fails to identify possible triggers for behavior. R1's Care Plan updated 8/19/25 does not include interventions or possible triggers in relation to R1's PTSD.Surveyor attempted to reach R1 by phone on 8/25/25 at 8:13AM, 8/26/25 at 1:52PM and 8/27/25 at 10:00AM. The message mailbox was full. Unable to leave message.On 8/25/25 at 12:00PM V5, Social Service Director stated R1 was high functioning. V5 stated he had spoken with R1 in regard to whether or not R1 might be interested in assistance to find a less restrictive placement option. V1, Administrator and V5 both stated R1 was never going to be involuntarily discharged it was just an offer of assistance should that be R1's wishes. V5 stated after that conversation R1 became very suspicious of staff and seemed to believe she was being discharged which was not the case.On 8/11/25 at 11:49AM, V16 Licensed Clinical Social Worker (LCSW) contracted by the facility documented in R1's progress notes Client presents in severe emotional distress on this date. Client appears to be in a manic episode and experiencing symptoms of posttraumatic stress disorder. Client is verbally stating she is getting kicked out of the nursing home and put on the streets to be homeless, which is not true confirmed by multiple administrators and staff at this facility. Client is seen packing her bags and using her roommate's phone to make phone calls to leave. Client does not have anywhere to go. Client is making multiple accusations towards staff that they are kicking her out based on her age, race, and disabilities although staff is not making client leave. Through assessment, clinician identifies client is experiencing a manic, post-traumatic stress disorder trigger due to her challenges in interpersonal relationships and childhood/family trauma. Client does not feel welcome here and due to this personal belief, she is unable to be redirected or regulated emotionally at this time. Clinician utilized multiple interventions, including mindfulness of deep breathing, sorting through thoughts, and emotions, identifying emotions, encouragement of active listening, and removing client from the stressful environment without any success. Social services director and administration are involved in client's care. Client will be sent out for a psychiatric evaluation if she is agreeable or leaving AMA (Against Medical Advice).V1 Administrator's Social Service Note dated 8/11/25 at 5:21PM stated At approximately 5:00pm, (R1) was at front door demanding to be let out as she wanted to leave the facility. She had her belongings packed. When asked to sign AMA paperwork, (R1) stated she would not sign the papers as she did not see a doctor. (R1) was informed that if she left the facility the police would be called as the facility was looking out for her safety. (R1) stated to call the police as she was leaving. (R1) exited front door. The police were notified. V17, LPN, (Licensed Practical Nurse) stayed with (R1), until police arrived. (V19 local police officer) was informed of the incidents that occurred throughout the day, that lead resident to this point. (V19) stated that the conversation that was had with the resident in the parking lot, and writer was recorded on camera. (V19) stated even though she did not sign AMA paperwork, (R1) was alert and oriented and willing to make the decision to leave AMA without signing papers. (V19) stated (R1) would become the concern of the Police Department at this time. Staff continued to monitor (R1) and (V19). At 5:42pm, (V19) continued to remain with (R1) in the parking lot and an ambulance arrived on scene. EMT entered facility and received paperwork for transport to (hospital). (family member) was updated on the situation and was appreciative of the update. On 8/27/25 at 10:45AM V17, verified that V17 was observing R1 at all times from the time R1 went into the parking lot until R1 consensually left in the ambulance to be transferred to the hospital for evaluation and treatment. V5 stated R1 then opted to be discharged from the hospital in the care of a family member.

Based on observation, interview, and record review the facility failed to develop and implement pressure relieving interventions, complete pressure ulcer and skin assessments, and notify the physician of new pressure ulcers to obtain treatment orders for one of four residents (R70) reviewed for pressure ulcers in the sample list of 38. These failures resulted in R70 developing two stage two and one stage three pressure ulcers. Findings include: On 1/13/25 at 9:15AM, 12:38 PM, 1:46 PM and 2:05 PM R70 was sitting in a wheelchair in R70's room. R70 was in her wheelchair in the assisted dining room from 11:50 AM until 12:23PM. At 2:08 PM V12 and V13 Certified Nursing Assistants (CNA) entered R70's room with a full mechanical lift and transferred R70 into bed. R70 was wearing pressure relieving boots. V12 and V13 stated R70 was not laid down after breakfast today due to having a shower and being in activities, but R70 is supposed to lay down between meals. V13 stated we try to offload pressure when R70 is in the wheelchair by shifting her weight with a rolled bath blanket that was used today. V12 and V13 stated R70 did not start using pressure relieving boots until after R70's heel wound developed. On 1/14/25 between 12:10 PM and 12:52 PM V9 Wound Nurse, V18 Wound Nurse Practitioner, and V40 CNA entered R70's room to assess R70's wounds and administer wound treatments. V18 removed an undated dressing from R70's right heel which contained a moderate amount of tan colored drainage. There was a circular open wound to R70's right heel. V18 stated the wound was a stage three pressure ulcer. As V18 cleansed the wound, R70 said oh and tried to pull her foot away. This wound measured 1.76 centimeters (cm) long by 2.31 cm wide by 0.2 cm deep. There was a superficial open area to R70's left buttock, which V18 stated was a stage two pressure ulcer. This wound measured 1.66 cm by 2.83 cm by 0.1 cm. V40 and V9 turned R70 in bed and there was an undated dressing that was partially dislodged on R70's right ischium. V40 stated V40 was unsure how long the wound had been there and V9 stated V9 was not aware of the wound. V18 stated the wound was a stage two pressure ulcer and to apply calcium alginate with a bordered dressing. This wound measured 1.66 cm by 2.83 cm by 0.1 cm. V9 cleansed each wound and administered the wound treatments as ordered but did not date any of the wound dressings. R70 yelled out oh, oh, ow and had facial grimacing as V9 cleansed and dressed R70's right heel wound. V9 and V40 told R70 I'm sorry when R70 cried out in pain. V9 stated the nurses are supposed to document weekly skin assessments under the assessments section of the resident's electronic medical record (EMR). V9 confirmed R70's dressings were not labeled with a date. V9 stated staff have been using a pillow to shift R70's weight in the wheelchair, but R70 should be laid down between meals to offload pressure and repositioned from side to side in bed, and R70 can't tolerate being up as much as R70 used to. V9 stated R70 has scheduled Tylenol but was unsure when the last dose was given. V9 confirmed V9 did not coordinate pain medication administration prior to R70's treatments. On 1/15/25 at 10:30 AM V2 Director of Nursing (DON) entered R70's room to observe R70's buttock wounds. V2 confirmed the left buttock wound observed on 1/14/25 was the left buttock wound that was previously healed as of 1/7/25, and not the gluteal cleft wound. The facility's Wound Report dated 7/13/24-1/13/25 documents R70 had a stage two pressure ulcer of right buttock on 10/27/24 that healed on 11/12/24, a stage two pressure ulcer of the coccyx on 11/12/24 that healed on 11/22/24, a stage two pressure ulcer to the left buttock on 12/21/24 that healed on 1/7/25 and a stage three pressure ulcer to the right heel as of 1/7/25. R70's Wound Report dated 11/1/24-1/14/25 documents an abrasion/trauma wound of the gluteal cleft as of 1/7/25. R70's Minimum Data Set (MDS) dated [DATE] documents R70 has severe cognitive impairment, is dependent on staff assistance for toileting, hygiene, transfers, and bed mobility, and has no pressure ulcers. R70's Braden Assessments dated 10/28/24 and 12/22/24 document R70 is at moderate risk for developing pressure ulcers. R70's current Care Plan documents R70 is at risk for skin impairment and has not been updated to include R70's pressure ulcers or any new pressure relieving interventions since 2022. There are no pressure relieving interventions documented on R70's EMR profile or in the section for CNA charting. R70's ongoing weight log documents R70's weight (pounds) as follows: 120 on 4/4/24, 107.5 on 8/6/24, 102.5 on 9/4/24, 103 on 10/6/24 (14.17% loss in six months), 97.5 on 11/12/24 (5.34% in one month), 98 on 12/1/24, and 95 on 1/5/25 (15.93% loss in six months). R70's Skin Assessments dated 12/6/24 and 1/10/25 document no new wounds but does not identify if there were any existing wounds found on the head-to-toe assessment as instructed. R70's Skin assessment dated [DATE] documents R70's stage two pressure ulcer to the left buttock measured 1.0 centimeter (cm) x 0.5 cm x less than 0.1 cm deep. These skin assessments document a turn schedule as the only pressure relieving interventions, the sections for specialized mattress, heels floated, and heel protectors are not marked. There are no other documented skin assessments in R70's EMR between 12/1/24 and 1/14/25. R70's Nursing Note dated 1/6/2025 at 12:51 PM documents V9 Wound Nurse was notified that R70 had an open area to the right heel that was previously scabbed over, and a treatment order was implemented. R70's Nursing Note dated 1/10/2025 at 12:52 PM documents an air mattress was applied to R70's bed and R70's wheelchair cushion was changed. There is no documentation that R70's right ischium wound was reported to a physician and treatment orders were implemented prior to 1/14/25. R70's December 2024 Treatment Administration Record (TAR) documents a treatment order to cleanse left buttock wound, apply skin protectant to the periwound, apply calcium alginate, and cover with a hydrocolloid dressing three times per week initiated on 12/21/24. R70's January 2025 TAR documents R70's left buttock wound treatment was discontinued on 1/7/25 when this wound resolved and there are no treatments for this wound after. There are no documented treatments for R70's right heel wound prior to 1/7/25. These TARs document R70's skin assessments were completed on 12/13/24, 12/20/24, 12/27/24 and 1/3/25, but there are no corresponding skin assessments documented to indicate if R70's skin was intact or impaired. There are no documented assessments in R70's EMR of R70's left buttock wound until 12/22/24, R70's right heel wound prior to 1/7/25, R70's left buttock wound between 1/8/25 and 1/13/25, or R70's right ischium wound prior to 1/14/25. R70's Multi Wound Chart Details documents on 1/7/25 R70's right heel stage three pressure ulcer measured 1.8 cm by 1.8 cm by 0.3 cm and this wound was debrided (removal of dead tissue), and R70's gluteal cleft wound measured 1.9 cm by 0.2 cm by no measurable depth. This report documents to elevate R70's heels off bed at all times, turn/reposition frequently per facility protocol and avoid direct pressure to wound site. R70's January 2025 Medication Administration Record documents Tylenol Extra Strength Tablet 500 milligrams three times daily as of 8/28/23 and the noon dose was not administered as of 12:46 PM on 1/14/25. There are no other pain medication orders. On 1/14/25 at 12:53 PM V18 Wound Nurse Practitioner stated R70 should be repositioned side to side in bed every two hours using cushions to relieve pressure and R70 should not be up in the wheelchair for more than two hours. V18 stated V18's office was not aware of R70's right ischium wound prior to today. On 1/14/25 at 1:37 PM V18 stated R70 should have pressure relieving boots or heels floated with a pillow when in bed. V18 confirmed weight loss is a risk factor that can contribute to the development of pressure ulcers and pressure relieving interventions should be implemented to prevent skin breakdown. V18 stated R70's skin is thin and wounds can develop overnight. On 1/14/25 at 12:57 PM V12 CNA stated R70 has had a dressing to the right buttock for at least three or four days. On 1/14/25 at 1:00 PM V10 Licensed Practical Nurse stated V10 had not yet given R70's scheduled noon dose of Tylenol today. V10 stated V10 reported R70's right ischium wound to V9 yesterday, but V9 thought V10 was referring to R70's left buttock wound. V10 stated yesterday V10 covered the wound with a dressing but did not do anything else besides notify V9. V10 stated the wound was not there on Friday (1/10/25) when V10 last cared for R70. On 1/14/25 at 1:28 PM V40 CNA stated pressure relieving interventions are listed as part of the CNA charting or on the resident's dashboard profile in the EMR. On 1/14/25 at 1:30 PM V12 CNA stated prior to the pressure relieving boots, V12 used pillows to float R70's heels in bed. V12 stated depending on who works night shift depends on if R70's pressure relieving interventions are implemented as V12 has come on duty and found that R70's heels weren't floated or boots weren't in place. On 1/14/25 at 1:35 PM V9 stated R70's pressure relieving boots weren't implemented until last week. V9 stated pressure relieving interventions should be listed on the bottom of the skin assessments and was unsure where this information is documented for the CNAs to see. On 1/14/25 between 4:15PM and 4:28PM V2 DON stated skin assessments should be done weekly and documented in the assessment section of the resident's EMR and confirmed R70's missing skin assessments in December 2024 and January 2025. V2 stated that is something V2 was going to work on, V9 was recently hired within the last two weeks and V2 planned to have V9 follow up on skin assessments to ensure they were being completed and follow up to ensure pressure relieving interventions are implemented. V2 stated pressure relieving boots and an air mattress were initiated last week for R70. V2 stated V2 is working on having the pressure relieving interventions on the resident's profile and on the kardex, which is pulled from the resident's care plan. V2 confirmed R70's profile does not document pressure relieving interventions. V2 stated V2 has been having a hard time keeping up with wounds and updating the care plans. V2 stated V2 was not aware that R70's left buttock wound had reopened and that it had healed on 1/7/25. V2 stated V20 was not aware of R70's right ischium wound, and the nurse should have notified V9. V2 confirmed there were no documented assessments for this wound prior to today. V2 confirmed staff should coordinate pain medication prior to wound treatments and stated it is hard since the facility doesn't always know what time V18 will be rounding. On 1/15/25 at 8:50 AM V2 stated wound dressings are not dated, per facility policy, and the TAR is used as the documentation for when dressings are changed. At 12:35 PM V2 confirmed all of R70's December 2024 and January 2025 wound assessments were provided. On 1/15/25 at 10:50 AM V28 Nurse Practitioner stated V28 was not consulted regarding R70's pain during wound treatments and the nurses should be coordinating pain medication to be given prior to wound treatments. On 1/15/25 at 11:30 AM V15 MDS Coordinator confirmed R70's care plan had not been updated with R70's pressure ulcers and pressure relieving interventions. The facility's Wound Treatments policy dated April 2023 documents to implement prevention protocol according to resident needs, turn at least every two hours, reposition in chair, and provide appropriate redistribution and pressure reducing devices. The facility's Treatment Administration policy dated April 2023 documents treatment orders are documented on the Treatment Administration Record, ensure pain medication is offered and given as needed prior to treatments, and document all significant observations in the resident's electronic medical record. The facility's Skin and Wound Management Guidelines dated April 2023 documents to notify the wound care nurse of new alterations in skin, if the wound nurse is not in the facility, then the staff nurse must notify the physician and obtain a treatment order. This guide documents to ensure immediate pressure relieving interventions are implemented. This guide documents the wound care nurse will assess, measure, photograph, and document; and update the resident's plan of care with identified site and new interventions. This guide documents the nurse management or wound care nurse will review shower documentation and weekly skin checks to ensure compliance and identify new wounds at an early stage and will round to ensure residents are positioned correctly and heels are off loaded.

Based on interview and record review the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services. This failure has the potential to affect all 92 residents within the facility. Findings include: The Long-Term Care Facility Application for Medicare and Medicaid Services dated 1/13/25 documents 92 residents reside in the facility. On 1/13/25 at 9:00 AM V3, dietary manager, stated V3 is not a certified dietary manager and has no certifications. On 1/14/25 at 11:00 AM V2, Director of Nursing (DON), stated that V7, Registered Dietician (RD), visits once a week on Tuesdays and is not in the facility full time. On 1/14/25 at 2:13 PM, V7 stated while she does consult at facility for weight loss and dietary recommendation for residents, she does not write the menus and has been told by facility administration that they have an outside company that deals with menus, food ordering, education, and kitchen. V7 stated she has offered educational services as well as menu writing. V7 stated she had concerns with nutritional values of the menus. V7 stated she has attempted to get in touch with this company and filed a formal complaint on 12/11/24 with V1 administrator and contracted dietary company. V7 stated she has had no response from company but has informed both that she will not approve the next menu cycle. On 1/14/25 at 2:23 PM, V24 Registered Dietician (RD) from consulting dietary services company stated the registered dietician, who wrote the menus for facility is no longer employed with the company. V24 stated she believes the local RD inspects the kitchen at the facility and ensures menus are followed, but she does not have accurate name or contact information for the local RD and no collaboration has been attempted. V24 stated they are a software company and have not been onsite recently at this facility. V24 stated the facility is responsible for alternative menus and ensuring compliance. On 1/14/25 at 3:50 PM, V3 provided a binder containing dietary staff certifications. This binder contained food handling certifications for 11 dietary staff, including aides and cooks. V3's food safety certification was not included. V3 stated she is having trouble printing her certification off of the computer but is working on it. On 1/15/24 V3 was not in the facility. V1 stated at 10:05 AM on 1/16/25 that V3 does not have any certifications for dietary at this time. The Facility policy titled Director of Food and Nutrition Services, undated, documents the director of food and nutrition services will be responsible for all aspects of the food and nutrition services department including but not limited to food safety, staff safety, cost management, and meeting nutritional needs of patients/residents served. The policy also documents that the requirements for dietary manager include holding an active certified dietary manager or food service manager certification.

Based on observation, interview and record review, the facility failed to assure that menus and menu substitutions are developed, prepared, and followed to meet residents' therapeutic diets and nutritional needs while using established national guidelines. This failure affects one of four residents (R70) reviewed for nutrition and has the potential to affect all 92 residents residing in the facility. Findings include: 1.) The Long-Term Care Facility Application for Medicare and Medicaid Services dated 1/13/25 documents 92 residents reside in the facility. Continuous observations of the lunch meal service were conducted on 1/14/25 from 11:28AM-12:35PM as follows: The steam table set up at the kitchen service window included a large pan of barbecue pork (regular texture), small pan of mechanical soft pork, and small pan of puree pork. The mid-steam table contained two containers of hot vegetables one for mechanical soft texture and one for puree. Directly to the left of the hot vegetables was a large pan of regular cold coleslaw. Individual scoops for each item were placed in the food. All scoops were the same size a half cup scoop. There were no other items on the steam table. The rolling cart contained trays of dessert bars that were all one portion size. Individual dining tickets were handed to V20, cook, for plate service. Tickets indicated resident name and diet including allergies and preferences. V20 proceeded to plate food for each ticket based upon mechanical texture of diet. Mechanical soft diet received ground meat and hot vegetable, piece of cornbread and dessert bar. Puree received puree meat, pureed hot vegetable, and cup of pureed dessert bar. Regular texture received whole pieces of meat, scoop of coleslaw, cornbread, and dessert bar. There were no variations of items served based upon therapeutic diets and no smaller or larger portions were served. There were no fruit items served during this meal. During this lunch service on 1/14/25 individual tickets were observed as follows: At 12:00 PM, R44's meal ticket dated 1/14/25 titled Week 2 Tuesday Lunch documents for Low Concentrated Sweets (LCS)/ No Added Salt (NAS) diet: BBQ Pork Shoulder (#12 scoop = 2oz pro); Coleslaw (diet) (#8 scoop = 1/2 cup); spiced pear bar (1/2 piece); cornbread (1 Piece); margarine (1tsp); coffee/tea (6 oz); sugar substitute, pepper (1 ea.). R44's plate served contained 1 scoop (1/2 cup) barbecue pork, 1/2 cup regular coleslaw, and 2 slices of white bread. At 12:05 PM, R42's meal ticket dated 1/14/25 titled Week 2 Tuesday Lunch documents for Low Concentrated Sweets (LCS)/ No Added Salt (NAS) diet: BBQ Pork Shoulder (#12 scoop = 2oz pro); Coleslaw (diet) (#8 scoop = 1/2 cup); spiced pear bar (1/2 piece); cornbread (1 Piece); margarine (1tsp); coffee/tea (6 oz); sugar substitute, pepper (1 ea.). R42's plate served contained 1 scoop (1/2cup) barbecue pork, 1/2 cup regular coleslaw, 1 piece of cornbread, 1 full dessert bar, and a chocolate shake (8 ounces). The document titled (Facility) Menu F/W 24/25 Week at a Glance for Regular/Regular week 2, documents Tuesday Lunch meal as BBQ Pork shoulder (PP, double protein), coleslaw (V, vegetable), spiced pear bar (G, grain), cornbread (G) with option of salad in small bowl. There was no fruit or salad observed or offered at this meal. Document titled Daily Spreadsheet Week 2 Tuesday documents variations of daily menu based upon therapeutic diet ordered. The Spreadsheet documents Low concentrated sweets (LCS) diet is to receive diet coleslaw instead of regular and one half of dessert bar instead of whole. On 1/14/25 at 1:30 PM, V2 Director of Nursing (DON), provided the recipe book that dietary staff use when preparing the menu. The recipe book contains recipes for regular diet and additives for making puree. There are no recipes for low salt or low concentrated sugars. On 1/14/25 at 1:40 PM, V20 confirmed the book that V2 provided is the book used to prepare food on the menu. V20 denied knowledge of any variations and showed the binders utilized in the kitchen. Two binders were labeled Menu Handbook were noted and V20 stated V20 has no idea what those are for and stated they never use them. The Menu Handbook dated last revision of September 2021, contains information from the contracted dietary service company which includes current the menu and menu spreadsheets. The Handbook contains policy and procedures for therapeutic diet guidelines and appropriate nutritional substitutions, calorie count breakdown of each item, and how each item is counted towards national nutritional guidelines. Page 3 of the menu handbook documents the general diet is planned following guidance from the Dietary Guidelines for Americans 2020-2025 and the Food exchange list provided by the Academy of Nutrition and Dietetics. Documents general diet follows guidelines for 2000 calorie level which includes 6 ounces of protein, 5 fruit and vegetable servings including one source of vitamin C with breakfast daily and 3 sources of Vitamin A per week, 6 servings of grains and 2 servings of dairy. Documents general diet is then altered for resident needs. At 2:13 PM on 1/14/25, V19, facility Registered Dietician, stated she has serious concerns with the facility's current menu not meeting state requirements of five plus servings of fruits and vegetables with Vitamin A and Vitamin C. V19 stated the menu does not meet the required minimum national dietary standards. V19 stated she has attempted to explain to V1, administrator, but is told an outside company makes menu choices. V19 stated she has reached out to the consulting dietary company to discuss her concerns several times with no response and on 12/11/24 she filed a formal complaint and informed the facility she will not be approving the next quarter menus. At 2:23 PM on 1/14/25, V24, contracted Registered Dietician Supervisor, stated the dietician assigned to the facility no longer works for the company. V24 stated facility menus are written based upon the facilities needs and the dietary manager can make changes through the software. V24 stated they use a combination method when counting fruits and vegetable daily servings. V24 stated there is a sample list of appropriate menu substitutions provided but ultimately the facility makes that list according to their budget. V24 stated that she is unclear why the facility would not be following dietary changes for low concentrated sweets or no added salt diet. At 2:00 PM on 1/15/25 V28, facility Nurse Practitioner, stated she was unaware that residents were not receiving appropriate diets. V28 stated this could negatively affect resident health and treatment especially if they aren't receiving minimum nutritional needs. The document titled Menu Nutritional Analysis documents breakdown of all the foods on the menu for week. The Analysis documents that by receiving a regular diet, residents that require a no added salt diet are receiving an extra 871 mg of sodium in four weeks, and residents that require a LCS diet are receiving an extra 25 grams of carbohydrates. The facility order listing report dated 1/15/25 documents 49 of the current 92 residents' dietary orders are for low concentrated sweets (LCS), no added salt (NAS) or both LCS and NAS. On 1/16/25 at 9:37AM, V19, Registered Dietician, stated she has reviewed the upcoming quarter menus, and while these do have more fruit and vegetables than the last menu, these still don't meet dietary needs in V19's opinion. V24 stated that garnishes are being counted such as taco toppings, fruit gelatin, etcetera as servings. V19 stated she is hesitant to count some of the casseroles in the vegetable servings as it is unlikely you are truly getting a serving in each slice of casserole and the same with the tomato salad which is a tomato slice on top of some lettuce. V19 stated many residents don't receive the garnishes or are offered fruit due to allergies and no substitutions with equal nutritive value are being offered. The Facility assessment dated [DATE] documents in Part 2: Services and Care offered based upon resident needs documents that individual dietary requirements, therapeutic diets, nutrition, hydration, cultural or ethical dietary needs including any fluid and dietary restrictions are provided. 40385 2.) The facility's Daily Spread Sheet Week 2 Monday documents puree chicken, puree penne pasta, puree Italian vegetables, and puree pears for the puree noon meal. The noon meal in the assisted dining room of the 100 and 200 halls was observed on 1/13/25 from 11:50 AM until 12:25 PM. Small dishes of pears or applesauce were distributed to the residents. R70's meal was served in a three-compartment plate and R70 was not served or offered fruit. V13 CNAs fed R70's lunch, V13 stated R70's lunch was pureed vegetables, pureed chicken and pasta, and pureed mashed potatoes. Dishes of ice cream were brought around and offered to all residents in this dining room and was served to R70. R70's meal ticket documented pureed pears as part of the noon meal. V13 confirmed R70 was not served fruit for lunch as her meal ticket indicates. V13 stated R70 was given ice cream instead since R70 wanted the ice cream. R70 ate a few bites of R70's meal, was finished eating at 12:23 PM and transported out of the dining room. R7's Minimum Data Set, dated dated dated [DATE] documents R70 has severe cognitive impairment and has had a significant weight loss in one or six months. On 01/14/25 at 3:24 PM V19 Registered Dietitian stated the staff should serve R70 the food that is listed on R70's meal ticket and ice cream would not be considered an appropriate substitute for pears. V19 stated V19 had asked the dietary staff today if they have had any substitutes because they haven't been logging that information, and V19 was told there hasn't been any substitutes. V19 stated applesauce would be a substitute for pears and should be logged, and has told dietary staff this previously. The facility's (contracted dietary based company) Menu Substitutions policy dated 2014 documents substitutes should be available, planned with the dietitian, and of similar nutritive value from the same food group as the menu item.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This failure has the potential to affect all 92 residents in facility. Findings include: The Long-Term Care Facility Application for Medicare and Medicaid Services dated 1/13/25 documents 92 residents reside in the facility. On 01/13/25 at 8:30 AM V3 Dietary Manager gave a tour of the kitchen and storage area. There was food debris noted inside the toaster, on the countertop in front of the toaster and on the floor directly inside the kitchen door. There were boxes of food from a delivery that were stacked in the food prep area in front of both coolers and the dry storage. There were clear bulk bin containers on a rolling cart behind the kitchen door next to the sink and cooler in a heavy traffic area. The label on the bin documents dry cereal. Inside the walk-in freezer, the top right shelf contained clear bins dated 3/13/24 labeled Meatballs. The substance inside was unidentifiable and contained a block of solid substance with freezer burn crystals noted throughout. The standing cooler next to the stove contained sliced ham in a clear bag that was not labeled with a date. Directly under the sliced ham, the shelf contained sliced cheese wrapped in clear plastic and a bag of shredded cheese. In the dietary aide cooler, there were four trays containing clear small serving bowls with a white gelatin substance, all uncovered, and none were dated. V3, dietary manager, stated the bowls contained pudding. In the dry storage, there were four large bins sitting on the floor against the wall in the back. The bins were labeled as follows: Oatmeal with date of 7/15/24, no expiration date noted; brown sugar dated 9/9/24 no expiration date, one uncovered scoop noted on top of the brown sugar bin with one half of a scoop covered in the dry oatmeal. The flour bins were dated 9/9/24 and sugar bin dated 10/29/24 and had no expiration or discard dates. At 11:25 AM on 1/14/25, the clear, bulk bins containing the dry cereal remained as noted above. On 1/14/25 between 11:28AM-12:35PM continuous observation of lunch meal service were completed and included: The steam table set up at the kitchen service window included large pan of barbecue pork (regular texture), a small pan of mechanical soft pork, and puree pork. The mid-steam table contained two containers of hot vegetable one for mechanical soft texture and one puree. Directly to left of hot vegetables was large pan of cold coleslaw. The rolling cart with trays of dessert bars was next to the steam table. Individual dining tickets were handed to V20, cook, for plate service. The tickets indicated resident name and diet including allergies and preferences. V20 did not temp the food prior to serving. At 11:45 PM on 1/14/25 V21 Dietary Aide was requested to obtain the temperature of all food on the steam table with temperatures as follows regular meat 156 degrees Fahrenheit (F), mechanical meat 173 degrees F, puree meat 171 degrees F, mechanical hot vegetable 173 degrees F. pureed hot vegetable 172 degrees F, and cold coleslaw 54 degrees F. Food service continued at current temperatures. There were no other temperature checks observed. V21 stated there are no issues with temperatures of food currently. There was no hand hygiene performed during the meal service and no glove changes made after touching surfaces. V20 used gloved hand to place cornbread on each individual plate served to resident. At 12:10 PM, V3 Dietary Manager, stated they usually don't check the temperature food during service. V20, cook, provided a binder where temperatures and menus are kept at 1:15 PM on 1/14/25. V20 demonstrated binders are used for temperature logs and current weeks recipe for menu. The Document titled Production Sheet - 1/14/2025 - Facility Menu F/W 24/25 Week 2 Tuesday documents food serving temperatures at service time start. Ground BBQ Pork Shoulder 130. Coleslaw 36. On 1/14/25 at 2:13 PM V19, Registered Dietician, stated she has serious concerns with the dietary services. V19 stated that while she is the in-house dietician, the facility uses an outside consulting group for menus, food ordering, and kitchen services. V19 stated that V1, administrator, has told her that this consulting company manages food services and inspection. V19 stated that a start food temperature of 130 degrees F is below the 140 benchmark for hot foods and that especially with pork, her concern is that the meat was not cooked to temperature and therefore could cause residents to become very ill. V19 also stated that coleslaw at a temperature of 54 degrees F should have been immediately pulled off service. At 2:34 PM on 1/14/25, V24, contracted Registered Dietician Supervisor, stated the person assigned to the facility no longer works for the company. V24 stated she is not aware of the last time that someone from their company had been into the facility but stated she will contact the administrator. On 1/14/25 at 3:45 PM V3, Dietary Manager prepared the dinner meal. On 1/15/25 at 10:00 AM, the food service temperature log does not document the temperature of the food served prior, during or after meal service. On 1/15/25 at 11:50 AM, the walk-in freezer still contained the clear bin on the top shelf of the cooler dated 3/13/24 Meatballs. The substance inside was unidentifiable and contained a block of solid substance with freezer burn crystals throughout. The cooler labeled dietary aides, contained two trays of a yogurt like substance. The tray on the top shelf has pink colored yogurt dished into individual souffle cups with another serving tray placed upside down on top of cups. There was no covering on each individual cup, no identifying label, and no dates. The next tray contained an opened yogurt container with no date. The second shelf directly under contained a white yogurt substance dished into individual portion cups that were uncovered and undated with a serving tray placed upside down on top of the cups. The yogurt container next to this tray was also opened and undated. The left side of dietary aides cooler contained a shelf with a tray containing employee drinks, some unopened, and others with lids with straws. There were two containers of thickened lemon water that were not labeled with dates. In the cold storage next to the stove, there were two large slabs of red meat on trays, uncovered, both had dark red substance pooling on the tray underneath around the raw meat. At 2:00 PM on 1/15/25 V28, facility Nurse Practitioner, stated that any food not handled, stored, or cooked appropriately could cause residents to have adverse effects such as gastrointestinal upset, nausea, vomiting, diarrhea, and dehydration. The Undated facility policy, titled Chapter 3: Food production and food safety 3-22;3-23 Food Storage, documents scoops must be provided for bulk foods, the scoops are not to be stored in food and must be kept covered in protected area near the containers. Scoops are to be washed and sanitized on a regular basis. The same policy documents all foods must be covered, labeled, and dated with use by date. All leftover food must be used within 7 days or discarded per 2017 Federal Food Code. All meats, fish and poultry are to be stored below fruits, vegetables, and dairy products in coolers. The Undated facility policy, titled Chapter 3: Food production and food safety 3-26; General food preparation and handling documents, all thawing meat must be kept in a drip pan in a manner to avoid cross contamination, all meat must be cooked to temperature and internal temperature must be checked at interval times. The Dietary document titled (Name) food safety and sanitation dated 2014 documents food should not be kept in the danger zone of 41 degrees F to 135 degrees F; hot foods should be served at 135 degrees F and above and all cold foods should be served at 41 degrees F and below.

Based on interview and record review the facility failed to have a qualified Infection Preventionist with the required training in infection prevention and control. This failure has the potential to affect all 92 residents in the facility. Findings include: The facility's Facility assessment dated [DATE] documents the facility will have an Infection Control Preventionist as part of its staffing plan. On 1/14/25 at 10:48 AM V1 Administrator stated V9 Wound Nurse/Infection Preventionist was recently hired as the Infection Preventionist for the facility with the intention of V9 completing the Infection Prevention training course. V1 stated nurse managers and V1 have collectively been overseeing the Infection Preventionist role prior to V9 being hired. On 1/15/25 at 1:33 PM V1 confirmed V1 does not have completed infection prevention training to provide for any of the nurse managers who are involved in the infection control program. On 1/15/25 at 9:05 AM V9 stated V9 has not officially taken over as the facility's Infection Preventionist and V1 has been handling the infection prevention and control. V9 stated V9 has not completed the infection prevention and control training course. The facility's Long Term Care Facility Application for Medicare and Medicaid Services dated 1/13/25 documents a census of 92 residents.

Based on observation, interview, and record review the facility failed to track culture results and organisms as part of the resident infection control logs. This failure has the potential to affect all 92 residents in the facility. The facility also failed to implement enhanced barrier precautions (EBP), provide hygienic wound care, and identify and report changes in urine for four of 24 residents (R24, R70, R45, R39) reviewed for infection control in the sample list of 38. Findings include: 1.) The facility's August 2024 - January 2025 resident infection control logs do not document culture results for wound or urinary tract infections or tracking of bacterial organisms as part of the surveillance monitoring used to identify any trends. On 1/16/25 at 9:24 AM V1 Administrator confirmed the facility's infection control logs do not document if cultures were completed or tracking of organisms. V1 stated that is something we are doing, but it just isn't logged. The facility's Long Term Care Facility Application for Medicare and Medicaid Services dated 1/13/25 documents a census of 92 residents. The facility's Surveillance and Baseline Calculations for Nosocomial Infections policy dated April 2024 documents the Infection Control Nurse or Designee is responsible for monitoring infections to determine incidences of infections, outbreaks, probably cause, and prevention. This policy documents an infection incidence report will be completed monthly, quarterly, and annually and information will be obtained including laboratory records and infection control rounds. 2.) On 1/13/25 at 2:08 PM V12 and V13 CNAs entered R70's room with a full mechanical lift and transferred R70 into bed. V12 and V13 did not apply a gown prior to entering R70's room. There was a sign on R70's door indicating EBP and to wear a gown and gloves during high contact care including transfers. V13 stated the EBP sign on R70's door was for R70's roommate. V12 and V13 stated EBP is followed only for when they are providing urinary catheter or wound care. On 1/14/25 between 12:10 PM and 12:52 PM V9 Wound Nurse, V18 Wound Nurse Practitioner, and V40 CNA entered R70's room to assess R70's wounds and administer wound treatments. These staff were not wearing gowns during R70's wound care. V9 brought the treatment cart into R70's room and placed supplies on top of the cart including R70's wound supplies and the cellular phone used to photograph wounds. V9 cleansed and applied R70's wound treatments to the left buttock wound, right ischium wound, and right heel wound. During R70's wound treatments V9 did not consistently perform hand hygiene and glove changes prior to and during each wound treatment, after handling the cellular phone, after removal of soiled dressings, after cleansing wounds, and after applying the treatment. V9 tore a piece of calcium alginate that was applied to R70's right heel and right ischium wounds while wearing the same gloves used when handling the cellular phone. V9 did not disinfect the cellular phone or treatment cart prior to or after R70's wound care. V9 left R70's room and continued rounding with V18 down the hallway with the treatment cart and cellular phone. The EBP sign remained posted on R70's door. On 1/14/25 between 4:15 PM and 4:28 PM V2 Director of Nursing stated V9 should not have taken the treatment cart into R70's room since R70 is on EBP. V2 confirmed EBP is implemented for residents with pressure ulcers and urinary catheters and gowns/gloves should be worn for all high contact cares. V2 stated V2 will need to do more education with staff on EBP. On 1/15/25 at 9:05 AM V9 stated V9 was not aware that a treatment cart should not be brought into a resident's room during wound treatments. V9 stated V9 uses a bleach wipe to disinfect scissors after use and the cellular phone used to photograph wounds. V9 confirmed V9 did not disinfect the cellular phone and treatment cart after R70's wound treatments on 1/14/25. V9 stated hand hygiene should be performed during wound care when moving from soiled to clean and when changing gloves. V9 stated V9 changes gloves and performs hand hygiene after removing soiled dressings and then V9 cleans the wound and applies the clean dressing. V9 confirmed V9 was inconsistent with glove changes and hand hygiene during R70's wound care. V9 stated V9 was not aware of EBP until after V2 spoke with V9 yesterday. V9 confirmed gowns were not worn during R70's wound care. The facility's Infection Control Enhanced Barrier Precautions policy dated 10/21/22 documents EBP expands the use of gown and gloves to be worn during high contact resident care activities that provide opportunities to transfer multidrug resistant organisms (MDROs) to staff hands and clothing that may be indirectly transferred to other residents. This policy documents that residents with indwelling medical devices and wounds are at high risk of acquiring MDROs. The facility's Hand Washing policy dated March 2024 documents hand hygiene is used to prevent the spread of infections and staff should wash their hands before/after direct contact with residents; after contact with blood, body fluids, secretions, mucous membranes, or non-intact skin; after removing gloves; and after handling items potentially contaminated with blood, body fluids or intact skin. This policy documents to use hand sanitizer if hands are not visibly soiled before/after direct resident contact; before performing non-surgical invasive procedures; before handling clean or soiled dressings; before moving from contaminated body site to a clean site during cares; after contact with a resident's skin; after handling soiled dressings and contaminated equipment; and after removing gloves. The facility's Treatment Administration policy dated April 2023 documents to place all necessary supplies in the treatment cart, complete the treatment as ordered using stringent infection prevention and control measures and discard disposable dressings and return reusable items to the proper location. 3.) On 1/14/25 at 1:35 PM V12 Certified Nursing Assistant (CNA) was in R24's room using a sit to stand mechanical lift to transfer R24. R24 was not wearing a gown or gloves during R24's transfer. There was a sign on R24's door indicating EBP and to wear gown and gloves for high contact care including transfers. There was no personal protective equipment cart in or near R24's room. R24's Physician Order dated 2/21/24 documents R24 uses a urinary catheter. R24's Physician Order dated 3/12/24 documents R24 is on EBP. 50322 4.) R45's current care plan documents R45 has an ostomy and buttock wound. On 01/14/25 at 3:15 PM Wound care observed for R45 with wound nurse practitioner V18 and wound nurse V9. There was an EBP sign on the door and there was no personal protective equipment available outside R45's room or visualized in R45's room. No gowns or masks were worn by either V18 or V9 while assessing R45's wounds and hand hygiene was not performed before or after R45's treatment. V18 donned one glove only while touching R45 and assessing the wound. V9 brought in the treatment cart with wound care into R45's room and placed next to R45's bed. V9 did not change gloves or perform disinfection at any time prior, during, and after R45's treatment. V9 placed used instruments on top of the treatment cart, then opened drawers and grabbed items with the same dirty gloves on. On 1/14/25 between 4:15 PM and 4:28 PM V2 Director of Nursing confirmed EBP is implemented for residents with pressure ulcers and urinary catheters and gowns/gloves should be worn for all high contact cares. V2 stated V2 will need to do more education with staff on EBP. 51951 5. On 01/13/25 at 09:20 AM, R39 had an EBP (Enhanced Barrier Precautions) sign posted outside of R39's room but there was no PPE (Personal Protective Equipment) cart at R39's door. At this time, R39 stated staff wear gloves but not gowns when providing cares to R39. On 1/14/25 at 08:40 AM, R39 was lying in bed with a urinary catheter in place. The EBP sign remained posted outside of R39's room. At this time, R39 stated R39 had been told by V30 LPN (Licensed Practical Nurse) that his urine was cloudy but then a couple weeks later, R39 ended up being hospitalized with a UTI (Urinary Tract Infection). On 1/15/25 at 9:08 AM, V30 LPN stated R39 has a history of UTI's and confirmed that V30 had noticed R39's urine was cloudy, prior to R39 being hospitalized with a UTI. V30 stated V30 had written that update on a communication sheet for V28 NP (Nurse Practitioner) but that V28 never responded or replied to the update. V30 stated V28 is in the facility two days one week and three days the next. V30 provided a copy of the undated/untitled communication form that documents on 12/15/24, R39's urine is starting to get cloudy-do you want a UA (Urinalysis)? This communication form did not have a response from V28. R39's Hospital Discharge Note dated 1/2/25 documents R39 was hospitalized from 12/30/24 - 1/2/25 for a UTI. On 1/15/25 at 9:30 AM, V2 DON (Director of Nursing) stated that nursing staff are to notify the provider on call when a change of condition is observed. On 01/15/25 at 11:25 AM, an EBP sign remained posted at R39's door but there was no PPE cart in sight. V33 and V34 CNAs entered R39's room to provide catheter care and donned gloves but did not don a gown. V33 and V34 completed catheter care and exited R39's room. At this time, both V33 and V34 stated they have received EBP training but normally do not wear gowns when performing catheter cares for R39. The facility's Catheter Care and Maintenance Policy dated March 2024 documents, residents with indwelling catheters will receive the appropriate care and monitoring as indicated in the procedures. The facility will monitor the resident's urine for unusual appearance (i.e., blood, color, consistency, odor, etc.) and will report any changes in condition such as pain or the resident experiencing fullness in the bladder, to the health care provider. The facility will monitor the resident for signs and symptoms of urinary tract infection and urinary retention which can include abdominal distention and pain, changes in volume and appearance of urinary output, fever, altered mental status or increased confusion, nausea, or vomiting, etc. Negative findings will be reported to the health care provider. The facilities Physician Notification of Resident Change of Condition Policy dated August 2023 documents, the resident's attending physician will be notified of changes that occur in the resident's condition by Licensed Personnel as warranted.

Based on interview and record review, the facility failed to notify a resident and their representative in writing about a hospital transfer and failed to provide a bed hold notice for four of four residents (R39, R17, R25 and R52) reviewed for hospitalization s on the sample list of 38. Findings Include: 1. R39's ongoing Census documents R39 was hospitalized from 7/6/24 - 7/24/24 and 12/30/24 - 1/2/25. R39's medical record does not contain a copy of the facility Bed Hold Policy. On 01/14/25 at 8:40 AM, R39 stated R39 went to the hospital recently but unsure of the exact date. R39 stated the facility did not talk with him about a Bed Hold Policy. On 1/14/25 at 12:21 pm, V2 DON (Director of Nursing) stated Bed Holds are to be filled out by the nurses when a resident is sent to the hospital; a copy is sent with the resident, and we keep a copy. On 1/14/25 at 12:55 pm, V2 DON stated after talking with the nurses, they are no longer doing the Bed Holds at the time of hospitalization and also stated nothing is being sent to families. 2. R17's ongoing census documents R17 was hospitalized from 4/5/24-4/8/24 and 2/6-2/9/24. R17's medical record does not contain a copy of the facility Bed Hold Policy. On 1/14/25 at 12:21 pm, V2 DON (Director of Nursing) stated Bed Holds are to be filled out by the nurses when a resident is sent to the hospital; a copy is sent with the resident, and we keep a copy. On 1/14/25 at 12:55 pm, V2 DON stated after talking with the nurses, they are no longer doing the Bed Holds at the time of hospitalization and also stated nothing is being sent to families. The facility Discharge/Transfer Policy dated August 2023 documents before a facility transfers a resident to a hospital or allows a resident to go on therapeutic leave, the nursing facility must provide written information to the resident and a family member or legal representative that specifies the duration of the facilities bed to hold policy and the facilities policies regarding bed hold periods. The resident/resident responsible party will be given the Resident Rights Regarding Bed Holds. Give a copy of the jointly signed and dated Bed Hold form to the resident (or representative) and place a copy of it in the residents' medical record until the resident is readmitted . 41002 3. On 1/14/24 at 3:12pm V1 Administrator confirmed the facility does attach the Bed Hold Policy to the Resident's Transfer paperwork when the resident is sent to the emergency room however, they do not provide a written copy upon transfer to the resident's representative. On 1/14/24 at 12:15am V7 Licensed Practical Nurse stated that on 11/4/24 V7 sent R25 to the hospital due to shortness of breath. V7 stated that V7 did not provide R25's representative with a copy of the bed hold policy. On 1/14/25 at 12:55 pm V2 Director of Nursing (DON) stated after talking with the nurses, they are no longer doing the bed holds at the time of hospitalization . V2 also stated nothing is being send to families. R25's Orders-General Note dated 11/4/24 at 7:16am documents R25 leaving with Ambulance bed hold sent with R25, cell phone and charger. The facility could not provide documentation that R25's representative was provided a written copy of the Bed Hold Policy when R25 was transferred to the emergency roiagnom on [DATE]. 4. On 1/14/24 at 3:12pm V1 Administrator confirmed the facility does attach the Bed Hold Policy to the Resident's Transfer paperwork when the resident is sent to the emergency room however, they do not provide a written copy upon transfer to the resident's representative. On 1/14/25 at 12:55 pm V2 Director of Nursing (DON) stated after talking with the nurses, they are no longer doing the bed holds at the time of hospitalization . V2 also stated nothing is being send to families. R52's Communication with Family Note dated 11/20/24 at 8:53am documents spoke with R52's Power of Attorney concerning R52's change in condition and Nurse Practitioner order to send for further evaluation. R52's Power of Attorney agrees with plan of care and requests that R52 be sent to the hospital. R52's Nursing Note dated 9/19/24 at 1:45pm documents staff spoke to R52's Power of Attorney regarding change in condition and new order. R52's Power of Attorney agrees with plan of care to send to hospital. Ambulance here to transport R52 to hospital. R52 was transferred to stretcher with 3 assists. Left the facility at this time. R52's medical record does not contain documentation that a bed hold notice or a written notice of transfer was provided to R52's representative for R52's hospitalization s on 11/20/24 and 9/19/24. The facility could not provide documentation that R52's representative was provided a written copy of the Bed Hold Policy when R52 was transferred to the emergency roiagnom on [DATE] and 11/20/24.

Based on observation, interview, and record review the facility failed to maintain privacy during wound care for one (R70) of 24 residents reviewed for privacy in the sample of 38. Findings include: R70's Minimum Data Set, dated dated dated [DATE] documents R70 has severe cognitive impairment. On 1/14/25 between 12:10 PM and 12:52 PM V9 Wound Nurse, V18 Wound Nurse Practitioner, and V40 Certified Nursing Assistant (CNA) performed R70's wound assessments and treatments. V9 and V40 entered and exited R70's room during R70's wound care. The privacy curtain wasn't pulled to block the view from R70's doorway and hallway while R70's buttocks/perineal area was exposed. On 1/15/25 at 9:05 AM V9 confirmed R70's privacy curtain should have been pulled during R70's wound care to block the view from the doorway and hallway. On 1/15/25 at 10:30 AM V2 Director of Nursing entered R70's room to observe R70's wounds. V2 did not pull the privacy curtain to block the view from the hallway and R70's doorway. V31 CNA entered and exited R70's room while R70's buttocks/perineal area was exposed. V2 stated the privacy curtain should be pulled during wound care. The facility's policy titled Resident Privacy and Dignity dated 8/2/24 documents Privacy will be maintained for all the residents receiving ADLS (Activities of Daily Living) such as bathing, dressing and pericare with the resident room/shower room door closed and curtain drawn.

Based on observation, interview, and record review the facility failed to offer services to maintain or increase range of motion for one of three residents (R34) reviewed for range of motion in the sample list of 38. Findings include: On 1/13/25 at 9:04 AM R34 was sitting in a wheelchair in R34's room and there was a brace on R34's right leg. R34 stated R34 is unable to walk and unable to move R34's right arm and leg, and R34 has not received any therapy services or exercise programs since R34 admitted to the facility. On 1/13/25 at 3:41 PM V15 MDS (Minimum Data Set) Coordinator stated the facility doesn't have restorative nursing services where participation is recorded, but they have walk to dine programs. At 3:48 PM V15 stated R34 has not yet been evaluated by therapy since R34 transferred from another facility where therapy had just been completed. On 1/14/25 at 3:47 PM V2 Director of Nursing stated V2 just became aware yesterday that skilled nursing facilities (SNF) are supposed to offer restorative nursing services and confirmed this had not been implemented for R34. On 1/14/25 at 3:53 PM V2 stated we don't really have restorative services, but we have therapy evaluate and treat periodically. V1 Administrator stated R34 had transferred from another SNF where R34 received therapy, R34 was on the list to be screened by therapy but then R34 got pneumonia. V1 stated therapy is supposed to screen R34 tomorrow. R34's Admission Minimum Data Set (MDS) dated [DATE] documents R34 has moderate cognitive impairment and has impaired range of motion to one upper and one lower extremity. This MDS documents R34 did not receive therapy or restorative nursing services. R34's current care plan documents R34 admitted on [DATE] and has diagnoses of hemiplegia of the right dominant side and Cerebral Infarction. This care plan does not document a problem, goals, and interventions to address R34's impaired range of motion. There is no documentation in R34's medical record that therapy or restorative nursing services were provided for R34's impaired range of motion. R34's January 2025 Medication Administration Record documents R34 received antibiotics for respiratory infection/pneumonia from 1/3/25-1/14/25. The facility's Functional Maintenance Program dated September 2022 documents: A resident may be started on a functional maintenance program when he or she is admitted to the facility with functional needs, but is not a candidate for formalized rehabilitation therapy, or when functional needs arise during a long-term stay, or in conjunction with formalized rehabilitation therapy. Generally, functional maintenance programs are initiated when a resident is discharged from formalized physical, occupational, or speech rehabilitation therapy. The facility will complete a Contracture Risk Evaluation upon admission, with a significant change in condition, and quarterly to assess risks. Residents at risk will have custom interventions added to their plan of care to prevent decline or to maintain current functional status. Therapy will provide recommendations for maintenance programming based on therapy outcomes or screenings. Individual custom tasks will be documented in (electronic charting system) of the EHR (electronic health record). Measurable objectives, goals and interventions will be documented in the care plan.

Based on interview and record review the facility failed to investigate and record a fall incident and failed to complete fall risk assessments for one of one resident (R39) reviewed for falls on the sample list of 38. Findings include: On 01/14/25 at 08:40 AM R39 reported slipping out of his wheelchair when R39 was in transport van because the full mechanical lift sling was under R39 and caused R39 to slip down in R39's wheelchair. R39 explained that R39 did not completely hit the van floor but rather slipped to the edge of the chair and R39's legs were holding R39 up because R39's legs were pinned against the seat in front of R39. R39 stated R39 did not hit the floor. On 01/16/25 at 09:09 AM V2 (DON) provided an electronic mail from V29, transporter, dated Tuesday, December 31, 2024, at 6:42 AM. V29's email to V2 explained that on December 30th, 2024, V29 was transporting R39. V29 stated that within blocks of the destination, R39 stated that he was sliding out of R39's chair a bit. V29 explained that on arrival at the location, R39 was now midway between R39's wheelchair and the floor, with R39's jacket hooked on the handle, helping R39 stay upright. V29 called 911 for fire department with help getting R39 into R39's wheelchair. V29 reported that R39 was a bit slower than usual to answer V29's questions, stated R39 did not have the same energy that R39 displayed prior to leaving the facility. V29 stated that was cause for concern so V29 asked for a nurse to come for a quick evaluation of R39. V29 stated the unidentified nurse decided to call an ambulance and the ambulance transported R39 to the hospital. On 1/14/25 at 12:55 PM, V2, DON, stated R39 did not have a fall on 1/3/25, instead that is when V2 put in the documentation and explained R39 slid down in R39's chair while on the van on 12/30/24. V2 stated V2 didn't consider it a fall and did not do an investigation or even talk to R39 about it yet and confirmed no new interventions were put into place at that time. V2 stated the fall on 1/9/25 was due to poor positioning and R39 had to be lowered to the ground. R39's Falls Progress Notes document a fall on 1/3/25 and 1/9/25. There are no fall risk assessments in R39's medical record since 2023 until 1/2/25 = low risk, and 1/9/25 = low risk (not accurate as it doesn't score previous fall). R39's Care Plan dated 12/20/24 was not updated after the fall on 1/3 with a new intervention. This care plan was updated after the fall on 1/9/25 with new intervention of staff education on appropriate positioning when transferring. On 1/14/25 at 1:04 PM, V2 (DON) confirmed no fall risk assessments were completed in 2024 and stated they should be done quarterly and as needed with a fall or change in condition. The facilities Accidents & Incidents Policy dated November 2023 states all accidents/incidents involving a resident will be investigated, and then recorded in Risk Management of the electronic medical record software. It is the responsibility of the Charge Nurse to complete the Accident and Incident Risk Management report and notify attending physician and responsible parties and document information accordingly. It is the responsibility of the DON (Director of Nursing)/Designee to investigate and ensure appropriate completion, notification, and follow-up on all Accidents and Incidents. The Charge Nurse must conduct an immediate investigation of the accident/incident and implement immediate appropriate interventions to affected parties. The Interdisciplinary Team will be notified of the accident/incident so that appropriate changes may be made to the care plan as needed.

Based on observation, interview, and record review the facility failed to develop and implement fall interventions and safety measures, provide effective supervision to prevent a fall, and thoroughly investigate falls for two (R2, R3) of three residents reviewed for falls in the sample list of four. These failures resulted in R2 sustaining two falls with head lacerations that required suture and staple closure. Findings include: 1.) R2's Admission Minimum Data Set (MDS) dated [DATE] documents R2 admitted to the facility on [DATE]. R2 had moderate cognitive impairment, was always incontinent of bowel and bladder, and required dependence on staff for toileting, moving from sitting to standing, and with chair/bed transfers. R2's Nursing Notes document R2 expired on [DATE]. R2's Fall Risk assessment dated [DATE] documents R2 as a high fall risk, R2 would overestimate or forget limits, R2 was bedbound and did not walk. R2's Hospice Comprehensive Assessment and Plan of Care Update Report dated [DATE] documents R2 admitted to hospice on [DATE] with a history of multiple falls. This care plan documents R2 as weak and drowsy, and a fall risk. This care plan documents R2 had increased anxiety about getting up from bed but was too lethargic to be up safely. R2's Care Plan dated [DATE] documents R2 had impaired self-performance of Activities of Daily Living and requires two staff for transfers. This care plan documents R2 as a high fall risk and includes interventions dated [DATE] for appropriate footwear, keeping items and call light within reach, orientation to room, anticipate and meet resident's needs, follow facility's fall protocol, review past falls to determine root cause, remove potential causes, and educate family and caregivers of potential causes. R2's Care Plan dated [DATE] documents R2 had a fall and includes an intervention dated [DATE] to bring R2 to the common area when awake and anxious. and interventions dated [DATE] to encourage R2 to ask for assistance, fall prevention program, hospice to provide bolsters (padded raised edge) to bed and high rise fall mats, and place frequently used items in reach. R2's Nursing Note dated [DATE] at 5:42 AM documents R2 was restless throughout the night, often found sideways in bed, R2 tried to get up by himself, denied pain/discomfort, was easily directed back to bed, and the call light was within reach. There is no documentation that any new fall or safety interventions were implemented at this time. R2's Nursing Note dated [DATE] at 11:28 AM documents R2 was found lying on the right side of the floor, beside R2's bed, and the overbed table was away from the bed. R2's incontinence brief was wet, R2 was barefoot, and R2 had a skin tear to the left hand. R2 reported that he was reaching for his phone and fell out of bed. The post fall intervention is to bring R2 to the common area when anxious. There are no other documented new safety interventions that were developed and implemented to keep R2 safe if R2 fell out of bed. R2's Nursing Note dated [DATE] at 12:07 AM documents R2 was found on the floor face down, between the wall and the bed. R2 had multiple skin tears to right forearm, left elbow, and left hand, a large laceration/hematoma (bruising/swelling) to his right forehead, and a large hematoma to his left knee. This note documents the cause of the fall as R2 was very restless and fell out of bed causing R2 to hit his head on the wall and baseboard, and the post fall intervention was to put the bed in lowest position. R2's emergency room Notes dated [DATE] document R2 presented to the emergency room after a reported fall. R2 reported that he has occasional leg pain and weakness, and that R2's legs gave out as he was trying to get to the bathroom. This note documents R2 appears to have struck his head and R2 had a 2-centimeter laceration with 3-millimeter depth to the right forehead that required four sutures to close. R2's Fall Investigation, provided by V2 Director of Nursing (DON), documents R2 had an unwitnessed fall from bed on [DATE] at 11:00 PM and sustained a head laceration. This investigation documents V3 Licensed Practical Nurse (LPN) reported R2 had been restless the entire shift, PRN (as needed) medications were administered, R2 was last observed in bed sleeping approximately 15 minutes prior to the fall and the bed was at knee level. This investigation documents V8 LPN administered Ativan at 8:15 PM for anxiety/restlessness. This investigation documents staff will bring R2 to the common area when he is anxious/restless as the new post fall intervention. R2's Nursing Note dated [DATE] at 11:41 PM documents R2 was found lying on the floor on his right side with his right arm underneath of him. R2 had a large laceration to the top of his head, a large hematoma to the right forehead, and a large skin to tear to his right elbow. R2's emergency room Notes dated [DATE] documents R2 presented to the emergency room with dementia, R2 had fallen out of his wheelchair and hit his head. R2 had a 6-centimeter curved laceration to the top of his head that required 13 staples to close. R2's [DATE] Fall Investigation, provided by V2, documents on [DATE] around 6:10 PM R2 had an unwitnessed fall from his reclining geriatric chair and sustained a head laceration. This investigation documents V3 LPN saw R2 in the geriatric chair in the television room with some restlessness approximately five minutes prior to the fall. R2 was given scheduled anxiety medication at 4:41 PM. This investigation documents R2 attempted to get out of his chair without assistance causing R2 to fall and hit his head on another resident's (R4) chair. This investigation documents R2's anxiety and cognition have declined since his admission, and he continues to have poor safety awareness. Hospice consultation and evaluation of medications was the post fall intervention. There is no documentation that R2 was offered/given pain medication prior to the fall. R2's fall investigations were not thoroughly completed to include the last time R2 was toileted or provided incontinence cares prior to R2's falls to determine if this was a contributing factor. On [DATE] at 9:46 AM there was a thick fall mat folded up in the hallway outside of R2's room, and V8 LPN confirmed this was R2's fall mat. V8 recalled R2 and described R2 as very restless, stripping off his clothing and trying to get out of his chair. V8 stated staff would get R2 up in the morning and he would be trying to crawl out of bed at that time. V8 stated on [DATE] R2 was up in his chair until 7:,d+[DATE]:00 PM, R2's bed was in the lowest position, but R2 did not use fall mats on the floor at that time. V8 stated the fall mats and bolsters were implemented after the falls on [DATE]. On [DATE] between 11:29 AM and 11:47 AM V3 LPN stated the first week R2 admitted he would try to get out of bed on his own and take himself to the bathroom. V3 confirmed R2 was a high fall risk. V2 stated usually if R2 was fidgety it was a sign that he needed to be toileted and that helped calm him. V3 stated R2 had an unwitnessed fall on the evening of [DATE] during shift change; R2 had been very fidgety that day, up and down from chair/bed, and R2 was given Ativan. V3 stated V3 saw R2 in bed asleep approximately 15 minutes prior to the fall, R2's bed was approximately knee height in the lowest position, but it was a hospice bed, so it did not go as low as the facility's beds. V3 confirmed R2 was found between the bed and the wall and sustained a head laceration. V3 stated a fall mat probably would have helped prevent R2's injury, but hospice didn't bring in the thick fall mat until after R2's fall. V3 stated on [DATE] R2 had an unwitnessed fall from his reclining geriatric chair while sitting in the television area, and R4 reported that R2 struck R2's head on R4's wheelchair during the fall. V3 stated R2's chair was reclined back because R2 would try and touch R2's feet. V3 described R2 as being a little fidgety leaning forward in his chair that night, and staff told him to sit back and relax. V3 stated R2 almost needed constant supervision, which is why we frequently had R2 sit at the nurses' station where staff frequently passed by. V3 confirmed there was no staff directly supervising R2 when R2 fell . V3 stated other than someone sitting there watching R2 and providing one to one supervision, I don't know what else could have been done to prevent his fall. V3 was asked if V3 administered any medications to address R2's restlessness, and V3 stated R2's scheduled Ativan was given at 4:30 PM. On [DATE] at 12:19 PM V9 Certified Nursing Assistant (CNA) stated on [DATE] V9 witnessed R2 leaning forward in his chair a few times prior to R2's fall and V9, as well as other staff, told R2 to sit back. V9 stated V9 did not witness R2's fall. On [DATE] at 2:59 PM V2 DON stated when R2 admitted R2 walked with assistance of two staff and then had a decline within a few days and began using the geriatric chair. V2 stated R2 had a decline between [DATE] and [DATE]. V2 stated V2 was not aware that R2 was restless and swinging his legs over the side of the bed on the night prior to R2's [DATE] falls. V2 stated if the night nurse would have reported that to V2, V2 probably would have implemented the floor fall mats at that time. V2 stated the fall mats and bolsters were implemented on [DATE] as a post fall intervention. V2 confirmed there were no new safety interventions implemented prior to R2's fall on [DATE]. V2 confirmed R2's fall investigations do not identify when R2 was last toileted or provided incontinence cares prior to each fall and confirmed R2's falls were unwitnessed. V2 stated staff should have given pain medication if R2 was restless. V2 confirmed there is no documentation that R2 was administered pain medication prior to the [DATE] fall and confirmed restlessness can be a sign of pain. V2 confirmed staff should have supervised R2 or laid R2 down to address R2's restlessness. V2 stated hospice evaluated R2's medications after the [DATE] fall and Dilaudid (pain medication) was scheduled routinely. On [DATE] at 4:20 PM V2 stated R2 fell on the morning of [DATE] and the post fall intervention was to bring R2 to the common area when restless and bolsters to his bed. V2 stated R2's bolsters were not applied until the next day when provided by hospice. On [DATE] at 3:49 PM V13 Nurse Practitioner confirmed the facility should develop and implement new safety interventions when there are changes in a resident's condition that increase the risk of falling and injury. V13 stated a floor mat possibly could have prevented R2's injury when he fell from bed. V13 stated if Ativan is given and is ineffective, then pain should be considered as a possible contributing factor of restlessness. V13 confirmed R2's head lacerations would be consistent with an injury sustained from a fall. 2.) R3's MDS (minimum data set) dated [DATE] documents R3 has severe cognitive impairment, R3 requires substantial/maximal staff assistance for sitting to standing and bed/chair transfers. R3's Fall Risk assessment dated [DATE] documents R3 as high risk for falls. R3's Care Plan dated [DATE] documents R3 has a history of falls and includes an intervention dated [DATE] to offer to lay R3 down after lunch and an intervention dated [DATE] for staff re-education on fall interventions. R3's Fall Investigation dated [DATE] documents the following: R3 had an unwitnessed fall at approximately 2:30 PM when R3 was found sitting on her knees on the floor against her bed without injury. R3 reported R3 was attempting to get into bed. R3 self-propels her wheelchair throughout the facility and into her room and does not ask for assistance with transferring to bed or the toilet. Staff have been educated to offer to lay R3 down after lunch to prevent R3 from attempting to self-transfer into bed. The root cause of the fall was R3 attempted to self-transfer and staff were re-educated on R3's care plan and the need to lay R3 down to help minimize falls. On [DATE] at 9:53 AM R3 was sitting in a wheelchair on the 100 hallway, which is on the opposite end of the facility of where R3 resides. On [DATE] at 1:11 PM V7 CNA applied a gait belt and transferred R3 from the wheelchair onto the toilet. R3 attempted to self-transfer from the toilet and V7 stated that is why we have to stay with her. On [DATE] at 1:56 PM V14 CNA stated V14 found R3 on the floor of her room the day she fell , and V14 was R3's assigned CNA that day. V14 stated it looked like R3 had tried to self-transfer. V14 stated R3 was toileted after lunch that day, but V14 did not offer to lay R3 down. V14 stated that is not something that R3 likes to do, so it is not offered. V14 stated no education was provided to V14 regarding R3's fall, but the facility may have conducted an in-service on R3's fall interventions. On [DATE] at 2:59 PM V2 DON stated R3's fall was unwitnessed in R3's room when R3 attempted to self-transfer into bed. V2 confirmed V14 did not offer to lay R3 down after lunch, which was a post fall intervention per R3's care plan. V2 stated R3's [DATE] post fall intervention was staff re-education on R3's fall interventions and to offer to lay R3 down after meals. The facility's Fall Risk assessment dated [DATE] documents 1. Assess resident for potential of being a high-risk faller. 2. Care Plan accordingly. The facility's Accidents & Incidents policy dated [DATE] documents The Charge Nurse must conduct an immediate investigation of the accident/incident and implement immediate appropriate interventions to affected parties. The DON/Designee will conduct an investigation of the accident/incident. Findings will be indicated on the Accident/Incident Report Form in appropriate area. The IDT (Interdisciplinary Team) will be notified of the accident/incident to stay appropriate changes may be made to the care plan as needed.

Based on observation, interview, and record review the facility failed to prevent a fall by failing to explain cares and ensure safety while elevating a bed for one (R1) of three residents reviewed for falls on the sample list of three. This failure resulted in R1 falling from the bed to the floor and sustaining a skull fracture with a brain bleed. Finding include: R1's hospital records dated 6/15/24 document R1 was sent to the emergency room due to a fall. This record documents, (R1) was being repositioned and rolled out of bed at nursing home. (R1) has obvious signs of head trauma. R1's CT (computerized tomography) scan showed intracranial hemorrhage (brain bleed), acute C1 and C2 fractures (spinal fractures), and left frontal calvarium fracture (skull fracture). R1's Incident Note dated 6/15/2024 at 12:45 AM documents, (R1) was being bed checked by CNAs (V3 and V4 Certified Nurse's Assistants). While rolling (R1) to change (R1) rolled out of bed and fell to floor. CNA attempted to catch (R1) but was unable to. (R1) has laceration on (left) upper forehead. Also noted raised area on (left) top of head. This note also documents that R1 was sent to the emergency room . R1's undated Fall with Injury report documents an interview with V4 that states, We (V3, V4) were about to pass (R1's) room when we noticed she was laying fairly close to the edge of her bed. As we approached the room, (V3) was entering the room and I was still in the doorway. (R1) pulled the blanket off and immediately tumbled to the floor. It happened so fast; we were unable to catch her. This report also documents an interview with V3 that states, I asked (V4) to help me with my residents and we went in to reposition (R1). When I first saw her, she was laying in the edge of the bed, wrapped up in her cover, with it over her face. I think that's the only thing that kept her from falling from the bed before we got to her. As I was walking around the bed and raising it, (R1) started to move and pulled her blanket back, at that point she tumbled from the bed. It happened so quick that I couldn't get to her to catch her. On 7/1/24 at 9:51 AM, V3 stated in regard to R1's fall on 6/15/24 when V3 and V4 walked past R1's room she was lying to close to the side of the bed. V3 stated they entered the room and V3 was starting to raise the bed up when R1 pulled the cover back. V3 stated she attempted to run around to catch her, but she fell to the floor. On 7/1/24 at 12:42 PM, V4 stated in regard to R1's fall on 6/15/24 that V3 asked her to help her pull up her residents. V4 stated R1's bed was in a lower position, and she was at the edge of the bed. V4 stated, we stopped at her room and V3 went in and started to elevate the bed. V4 stated as she started to raise the bed, R1 noticed we were about to do care and this startled her and before we could do anything she flung her blanket back and rolled over her right arm, face first onto the floor. V4 stated R1 can be combative with cares. V4 stated when V3 hit the button it startled R1. V4 stated R1 was asleep and that they had not woke R1 up to explain cares. On 7/1/24 at 12:28 PM, V5 Licensed Practical Nurse stated when he started his shift on 6/15/24 he made rounds and noted that all the beds were in the low position. V5 stated that later in the shift V4 notified him that R1 had rolled out of the bed. V5 stated the bed in the room was then elevated. V5 stated R1 was lying on the floor, and he called emergency services due to R1 having a head injury. V5 stated there was blood coming from R1's forehead. V5 stated V3 and V4 told me they were rolling her, and she rolled too far, and they were unable to catch her. On 7/1/24 at 10:30 AM, V2 Director of Nursing walked into the room in which R1 resided. V2 stated the bed was in the same location as the day that R1 fell . V2 demonstrated where V3 was standing when R1 fell out of the bed. V2 was standing at the foot of the bed and stated V3 was standing here at the foot of the bed. V2 stated V4 was standing in the doorway which was nearest to the foot of the bed. V2 stated that V3 used the controls located on the outside of the footboard when she started to raise R1 in bed. V2 then lowered the bed to the floor using these controls. V2 then began to raise the bed and the bed shook and made a loud noise when it was starting to raise up. V2 stated that this sound could have startled R1. V2 stated that prior to raising the bed either V3 or V4 should have been standing on the side of the bed to prevent R1 from falling out of the bed. On 7/1/24 at 2:42 PM, V12 Nurse Practitioner stated R1 had graduated from hospice and then was put back on it after her 6/15/24 fall. V12 stated R1 had a fall with a fracture and a bleed. V12 stated R1 could be combative with cares. V12 stated the staff should attempt to explain cares to R1 prior to providing cares and if the bed is being raised then they should be on the side in case R1 were to roll out. R1's care plan dated with a reviewed dated of 5/20/24 documents R1 requires assistance with bed mobility and can be uncooperative with cares, have hallucinations and delusions related to a diagnosis of Dementia and Alzheimer's disease. This care plan documents and an intervention to give clear explanation of all care activities prior to and as they occur during each contact with R1. The facility's Resident Handling Policy Bed Positioning policy with a revision date of 9/18 documents the purpose of the policy is to ensure a safe working environment for resident's handlers. This policy documents to, 4. Explain the procedure to the resident prior to completing the procedure.

Based on observation, interview, and record review the facility failed to notify the resident representative and physician of significant weight loss, update a care plan with interventions to address/prevent weight loss for (R11) and implement nutritional recommendations for three (R11, R40, R4) of four residents reviewed for nutrition in the sample list of 50. This failure resulted in R11 experiencing a severe weight loss of 12.01 % in six months. Findings include: 1.) R11's Minimum Data Set (MDS) dated [DATE] documents R11 has severe cognitive impairment and a significant one-month weight loss that was not physician prescribed. R11's Care Plan dated 11/10/23 documents R11 has unplanned and unexpected weight loss and includes interventions to notify the physician and dietitian immediately when weight loss persists, evaluate weight loss, and follow facility protocol for weight loss. This care plan does not document that R11 receives any nutritional supplements or any new interventions after 11/10/23. R11's Diet order dated as revised 4/9/21 documents regular diet, pureed texture, honey consistency, and to offer a frozen nutritional supplement twice daily. There are no other supplement orders documented. R11's weight log with date range 10/24/18-3/12/24 includes the following weights: 150 pounds (lbs) on 7/3/23. 145 lbs on 8/1/23. 143.2 lbs on 9/3/23. 135 lbs on 10/6/23 (10% loss in three months/5.73% loss in one month). 134 lbs on 11/6/23 and 12/4/23. 130.5 lbs on 1/2/24. 126 lbs on 2/8/24 (12.01% loss in six months). 123 lbs on 3/12/24 (8.21% loss in three months). There is no documentation in R11's medical record that R11's physician and representative were notified of R11's weight loss between 10/6/23 and 3/19/24. R11's Nutrition/Dietary Note dated 10/11/23 at 4:12 PM documents R11's Body Mass Index (BMI) is 18.9 (low) and R11 had a significant weight loss of 5.7% in one month, 10% in three months, and 11.2 % in six months. This note documents that a frozen nutritional supplement is offered to R11 twice daily. R11's Nutrition/Dietary Notes dated 12/5/23 at 12:05 PM and 12/12/23 at 12:20 PM document a recommendation to add a nutritional shake three times daily. R11's Nutrition/Dietary Note dated 1/9/24 at 11:34 AM documents R11 had a significant weight loss of 13% in six months and includes a recommendation to add nutritional shakes three times daily. This note documents R11's BMI was 18.3. R11's Nutrition/Dietary Note dated 2/13/2024 at 11:49 AM documents R11 triggered for a 13.1 % loss in six months and R11's BMI is 17.7. This note documents R11's diet is pureed with honey thickened liquids and staff report that R11 enjoys coffee and would be more accepting of coffee with the supplement rather than a supplement alone. This note documents a recommendation to give (nutritional supplement) 60 cc (cubic centimeters) three times daily in R11's honey thickened coffee. There is no documentation that this recommendation was reported to R11's physician or implemented. R11's Nutritional Supplement Intake Log with date range 2/19/24-3/18/24 does not identify what supplement is given and there are 33 of 58 entries that are missing/not recorded. This log documents Not Applicable for the noon meal on 3/6-3/8/24 and for the evening meal on 2/19/24 and 2/26/24. On 3/19/24 at 11:30 AM, R11 was sitting at the dining room table eating lunch which consisted of coffee, creamed corn, mashed potatoes, and pureed meat. On 3/19/24 at 11:39 AM R11 ate all of R11's meal and R11 was not served any nutritional supplements. On 3/19/24 at 12:49 PM V3 Dietary Manager viewed R11's meal ticket and stated R11's meal ticket documents to give a nutritional shake for the noon meal and a frozen nutritional supplement at the noon and supper meals. R11's meal ticket documents the nutritional shake, and the frozen nutritional supplement are each 118 milliliters. V3 stated R11 sometimes refuses the supplements, and the staff may not have given R11's supplements since R11 refuses them at times. V3 stated the staff should still offer R11 the supplements and dietary staff know what supplements to serve by looking at the dietary tickets. V3 stated the Certified Nursing Assistants are responsible for documenting supplement intakes. V3 confirmed R11's supplement intake documentation does not consistently document the supplements are given twice daily or differentiate between the nutritional shakes and frozen nutritional supplement. On 3/19/24 at 1:51 PM V2 Director of Nursing (DON) stated the facility has weekly weight meetings with V13 Registered Dietitian (RD) and weights are reviewed during the meetings. V2 stated V13 runs the weight report and the residents with weight changes are reviewed. V2 stated the nurses are the first to review the weights and they should notify the resident's family and physician, and document this in the nursing notes. V2 stated the nutritional shakes and frozen nutritional supplements are served by dietary staff and the nutritional supplement comes from the nurses, and these supplements should be documented as part of the resident's diet order and documented on the Medication Administration Record. V2 reviewed R11's diet order and confirmed the frozen nutritional supplement is the only documented supplement. V2 stated V13 sends V13's recommendations via electronic mail to V2 and the recommendations are then given to V29 Nurse Practitioner for review during V29's weekly rounds. V7 Assistant DON stated R11 wouldn't accept the nutritional supplement and R11 only likes coffee. V7 stated there was talk of putting the nutritional supplement in R11's coffee like a creamer, but V7 didn't think that was implemented since staff was unsure if it would curdle. On 3/19/24 between 2:54 PM and 3:24 PM V2 confirmed the 60-cc nutritional supplement recommended on 2/21/24 was not implemented. V2 stated it was not followed up with the physician or Nurse Practitioner. V2 confirmed there was no documentation that R11's family and physician were notified of R11's weight loss. V2 stated V2 could not locate documentation of when the nutritional shake was implemented. V2 stated weight loss should be updated with new interventions on the care plan. On 3/19/24 at 2:12 PM V13 RD stated V13 attends the facility's weekly weight meetings and generates a report for one, three, and six months. V13 stated it depends on when the staff have all of the resident weights in on when V13 runs this weight report. V13 stated V13's typed recommendations are given to the facility during the weight meetings and V13 prepares a generated report for the staff to notify the physician of V13's recommendations. V13 stated R11 was not accepting the nutritional shakes three times daily that was recommended in January, so that was why V13 changed to the (nutritional supplement) in February to be given in R11's coffee. V13 stated staff should document in the progress notes if the resident is refusing supplements, and if there isn't a note then V13 assumes the resident is taking the supplement. V13 stated V13 had asked for staff to put the supplements such as the frozen nutritional supplement in a separate order so it is easier to identify. V13 confirmed R11 should still be getting the frozen nutritional supplement if it is listed on R11's diet order. V13 stated if the resident isn't getting the supplements, this can contribute to further weight loss. The facility's Weight Management policy dated March 2023 documents a resident's unexplained significant weight loss will be reviewed with the physician to obtain orders for a nutritional supplement, this will be discussed during the weekly risk meeting to determine appropriate interventions and the resident's care plan will be updated to include weight interventions. This policy documents to notify the resident's family/representative of significant weight changes and the care plan, and document this in the resident's medical record. This policy documents the Director of Nursing is responsible for reporting the dietary recommendations to the Physician and Nurse Practitioner to obtain approval. 35046 2.) R4's electronic weight log documents R4 weighed 157 pounds on 9/1/23 and weighed 123.5 pounds on 3/4/24 (21.66 percent weight loss). R4's Nutrition/Dietary Note dated 3/9/23 at 10:11 PM documents R4's current weight as 123.5 pounds. This note documents R4 has a weight loss of 8.33 percent at one month, and 25.86 weight loss in six months. This note documents R4 had a recent diet change to pleasure feedings, allowing him to have regular texture and is now eating more as he can have foods, he likes due to texture change. This note documents R4 receives a health shake twice a day and high protein ice cream with meals. On 3/20/24 at 11:48 AM, R4 was sitting at a table eating lunch. R4 was eating a hotdog and a bowl of soup was on R4's table. There was a container of yogurt and pudding sitting in front of R4. A health shake and ice cream were not on R4's table. On 3/20/24 at 11:50 AM, V4 Cook/Dietary Aide provided R4's dietary slip. This slip dated 3/20/24 documents R4 should receive a health shake, high protein ice cream, two hotdogs, soup, and whole milk for the lunch meal. At that time, V4 confirmed that R4 is supposed to receive a health shake and high protein ice cream with his lunch meal. V4 stated R4 did not receive a health shake or the high protein ice cream with his lunch and stated they are supposed to offer it but didn't. 3.) R40's electronic health record weight log documents R40 weighed 272.5 on 9/5/23 and weighed 220.6 on 3/12/24 (19.05 percent weight loss) R40's Nutrition/Dietary Note dated 2/23/2024 at 10:25 AM documents R40's pressure and diabetic ulcers. This note documents R40 has a significant weight loss of 16.47 percent in six months and documents to offer a health shake twice a day. On 3/20/24 at 11:55 AM, R40 was lying in bed eating lunch. R40's lunch was sitting on the bedside table. A health shake was not present on R40's bedside table. R40 stated he did not get a health shake and that he had a little piece of cake, chicken, and a salad. On 3/20/24 at 12:00 PM, V4 Cook/Dietary Aide provided R40's dietary slip. This slip dated 3/20/24 documents R40 should receive health shake, chicken ala king, chocolate cake, and a side salad. At that time, V4 confirmed that R40 is supposed to receive a health shake with his lunch meal. V4 stated R40 did not receive a health shake and they are supposed to offer it but didn't.

Based on interview and record review the facility staff failed to provide safe transfer for one resident (R1) when using the mechanical lift for transfer. This failure resulted in R1 sustaining a non-displaced fracture to the Right Humerus. (R1) is one of four residents reviewed for accidents in a sample of four. Findings include: R1's Facility Census dated 3/9/24 documents R1 was admitted to the facility on [DATE] and has the following medical diagnoses; Hemiplegia and Hemiparesis Following Cerebrovascular Disease Affecting Right Dominant, Dysphagia, Aphasia, Dysarthria. Type 2 Diabetes Mellitus, Cerebral Infarction, Contracture Right Shoulder, Contracture Right Elbow, Combined Rheumatic Disorders of Mitral Aortic and Tricuspid Valves, Deficiency of Vitamins, Apraxia, Hyperlipidemia, Anemia, Adjustment Disorder with Mixed Anxiety and Depressed Mood, Muscle Weakness, Abnormal Posture, Personal History of COVID-19, Atelectasis, Presence of Urogenital Implants, Lack of Coordination, Gastrostomy Status, HTN/Hypertension and Osteoarthritis. R1's Facility weights dated 3/6/24 documents R1 weight 188.0 pounds. R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview for Mental Status (BIMS) score 3, severe cognitive impairment, and Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair) is dependent on staff. R1's Care Plan documents R1 has an Activities of Daily Living self-care deficit related to disease process Cerebral Vascular Accident (CVA): right sided weakness. Intervention mechanical lift for transfers with 2 staff assist. R1's Incident Note dated 2/24/24 at 12:49pm documents V3 Licensed Practical Nurse (LPN) was called at 1135 to R1's room by V4 Certified Nursing Assistant (CNA). R1 was observed on the right side (shoulder, hip, feet, and head) touching floor, facing east door between mechanical legs. Mechanical lift strap frayed in half. Checked Range of Motion (ROM), pain, vitals, 129/78,59,98.2,94,20. 1140 called management,1143 called V5 Physician, and V6 R1's Power of Attorney (POA) (left message no answer on either contact). 1147 called 9-1-1. 1153 ambulance arrived. EMT placed resident on back board then to stretcher after assessment. 1215 called emergency department when ambulance left. R1's Hospital X-Rays dated 2/24/24 documents X-Ray right shoulder 3 views. Impression: Probable nondisplaced fracture of the proximal Right Humerus. R1's Hospital Vascular and Interventional Radiology Procedure Note dated 2/24/24 documents: Impression: Soft tissue swelling with questionable radial head fracture. Facilities Fall Investigation dated 2/24/24 documents R1 had a fall in R1's room at approximately 11:35am on 2/24/24. During transfer from bed to wheelchair the strap on the sling for the mechanical lift broke and the resident fell to the floor. V3 Registered Nurse (RN) was called to R1's room by V4 Certified Nursing Assistant. Upon entering the room V3 observed R1 on the right side with shoulder, hip, foot, and head touching the floor, hanging from the mechanical lift, sling between the mechanical lift legs. During Assessment of range of motion pain was noted to head, right shoulder, and right hip. Contusion to right arm, right knee, and right pinky toe also noted. V5 Physician notified and V6 R1's Power of Attorney (POA) notified of fall. EMS/Emergency Medical Service transferred R1 onto the stretcher from the floor and took to hospital. Conclusion and action Taken: Upon reviewed of the evidence and the statements obtained during investigation, the non-displaced fracture to Right Humerus and Hematoma to right buttocks were sustained at time of fall. The root cause of the fall was the mechanical lift sling broke, and R1 fell to the floor. Mechanical Lift User Instruction Manual documents; Safety Instructions: Always check the sling is suitable for the particular patient and is the correct size and capacity. Never Use a sling, which is frayed or damaged. Facilities Hydraulic Lift Policy dated 9/2018 documents: Purpose: to provide staff with proper guidelines for the use of a hydraulic lift. Policy: All nursing staff will be trained on the proper use of the hydraulic lifts that are used within the facility, to ensure safe transfer for residents. Mechanical lifts will be used as ordered and per nursing judgement. Procedure: 1. Assemble Equipment. Obtain assistance from second staff member. On 3/9/24 at V4 Certified Nursing Assistant (CNA) stated, on 2/24/24 at 11:35am V4 was transferring R1 using a mechanical lift from R1's bed to a shower chair located next to R1's bed. V4 stated, V4 was conducting the transfer by V4's self, and there should have been another staff member assisting with the transfer. V4 stated, V4 believes that V4 was using the proper size sling for R1. V4 stated, as R1 was being transferred towards the shower chair, the upper right sling strap snapped and R1 fell to the floor onto R1's right side. On 3/9/24 at 11:24am V3 Licensed Practical Nurse (LPN) stated, on 2/24/24 at 11:35am V4 Certified Nursing Assistant (CNA) called for V3 to come to R1's room. V3 stated, upon entering R1's room, V3 observed R1 lying on the floor on R1's right side between the legs of the mechanical lift. V3 stated, V4 told V3 that the sling strap broke and R1 fell out of the sling onto the floor. V3 stated, V3 observed the strap where it broke, and it was frayed and torn in half. V3 stated, V4 was the only staff conducting the transfer and there should have been another staff assisting with the transfer. On 2/9/24 at 2:00pm V1 Administrator stated, on 2/24/24 V1 was notified of R1's fall from the mechanical lift with injuries. V1 stated, V1 interviewed V3 Licensed Practical Nurse (LPN) and V4 Certified Nursing Assistant (CNA). V1 stated, V1 learned that V4 was transferring R1 from R1's bed to a shower chair next to R1's by V4's self. V1 said, V4 should have had another staff member assisting V4 as with all mechanical lift transfers. V1 stated, as V4 was transferring R1 towards the shower chair, the right upper sling strap snapped and R1 fell to the ground onto R1's right side. V1 stated, the hospital later called and informed the facility that R1 sustained a non-displaced fracture to the Right Humerus and Hematoma to the right buttocks. V1 stated, the root cause of the fall was that the sling strap broke, and that V4 should always have another staff member present when transferring with a mechanical lift.

Based on observation, interview, and record review the facility failed to document a fall in the resident medical record and failed to prevent resident falls by failing to thoroughly investigate falls and implement fall interventions. These failures affect three (R2, R3, R4) of four residents reviewed for falls in the sample list of four. These failures resulted in R2 falling and sustaining a dislocated right ring finger. Findings include: 1.) R2's Admission Minimum Data Set (MDS) dated [DATE] documents R2 has severe cognitive impairment, R2 requires supervision assistance of one staff person for transfers and locomotion on/off the unit, and R2 requires limited assistance of one staff for toileting. This MDS documents R2 is occasionally incontinent of bladder and frequently incontinent of bowel. R2's Fall Risk assessment dated [DATE] documents R2 is at high risk for falls. R2's Care Plan revised 9/18/23 documents R2 has hypotension, poor balance, poor communication/comprehension and R2 has had falls. This Care Plan includes interventions for R2's family to provide new slippers (dated 10/19/23) and nonskid socks and better fitting slippers (dated 9/21/23). R2's Fall Investigation dated 9/5/23 at 12:06 PM documents R2 was found lying on the floor of R2's room with one shoe on and one shoe off. R2 had a skin tear to the left elbow. The root cause is documented as resident (R2) self-ambulating and the intervention is call don't fall sign. R2's Fall Investigation dated 9/5/23 at 4:32 PM documents R2 was found lying on the floor in R2's doorway of the bathroom with skin tears to the right and left arms that were bleeding. The root cause of this fall is documented as orthostatic hypotension and the intervention was to send to the emergency room for evaluation. R2's Fall Investigation dated 9/16/23 at 9:50 AM documents R2 was standing at the nurse's station and fell . R2 had an injury to the right rear iliac crest (buttock). The documented root cause of the fall was that R2's legs became weak causing R2 to fall, and R2's blood pressure was low for R2. R2 was recently diagnosed with orthostatic hypotension (low blood pressure with position changes) and the intervention was to monitor orthostatic blood pressures for three days. R2's Fall Investigation dated 9/20/23 at 6:51 PM documents R2 was walking with R2's wheeled walker in the hallway, tripped over a wet floor sign causing R2 to lose balance and fall. This note documents under the cause that R2's slippers were not fitting well, and nonskid socks were applied as the immediate intervention. This note documents that R2's poor fitting slippers contributed to R2's fall and better fitting slippers will be purchased. R2's Fall Investigation dated 10/6/23 at 10:00 AM documents there was a loud crash heard from R2's room and R2 was found lying on the floor with R2's head near R2's dresser. R2 reported that R2 was attempting to sit on the edge of the bed and missed the bed. This investigation documents R2 as a one-person physical assist and the intervention was to offer R2 to lay down after meals. There is no documentation that interviews were conducted as part of R2's fall investigations to determine when R2 was last checked on or toileted prior to each fall, or what R2 was last observed doing prior to each fall. R2's September 2023 Medication Administration Record (MAR) and Vitals Log do not document R2's orthostatic blood pressure readings on 9/22/23 and 9/23/23 as scheduled/ordered and as part of R2's post fall intervention for R2's 9/20/23 fall. R2's Nursing Note dated 10/18/2023 at 2:42 PM documents R2 was found on the floor of R2's room facing roommate's (R4) bed. R2 had on slip on slippers. R2 stated R2 hit R2's head. This note documents R2's family was contacted to bring in nonskid slippers with a back/heel coverage. R2 kept pointing to the gauze on the back of R2's hand from a blood draw, and R2 was anxious because of the blood draw. This note documents R2's left hand grasp was greater than R2's right hand, which is baseline for R2. R2's Nursing Note dated 10/18/2023 at 8:10 PM documents x-ray was ordered for right ring finger swelling. R2's Nursing Note dated 10/19/2023 at 10:11 AM documents R2 had right hand swelling with bruising to the right ringer finger, and R2 was unable to perform range of motion which was a change compared to the previous day. R2's Right Hand X-ray dated 10/19/23 at 3:16 PM documents Impression: Subluxation (partial dislocation) seen at the proximal interphalangeal joint (middle joint) of the fourth finger posteromedially. R2's emergency room Note dated 10/19/23 at 5:19 PM documents R2 presented with finger injury after fall yesterday, per facility RN (Registered Nurse) R2 fell yesterday and tried to reach out to catch R2's self. Staff noted tenderness, swelling, and deformity of right ring finger this morning. This note documents R2's right ring finger interphalangeal dislocation required gentle traction to correct the dislocation and R2's finger was placed in a splint. On 10/23/23 at 9:14 AM R2's right hand was observed wrapped in an elastic bandage. R2 was walking in R2's room per self with no staff present in R2's room and R2 was wearing slippers with an open back. R2 was asked about R2's right hand, and R2 replied that R2 had a recent fall. R2 was unable to provide any additional details regarding any of R2's falls. On 10/23/23 at 9:14 AM R4 stated R4 witnessed R2's recent fall. R4 stated when R2 fell , R2's finger got hung up on the wheelchair. R4's MDS dated [DATE] documents R4 is cognitively intact. At 10:25 AM R2 was lying in a bed positioned low to the floor and R2 was wearing open back slip-on slippers. On 10/23/23 at 10:33 AM V5 Licensed Practical Nurse (LPN) was working when R2 fell about a month ago, R2 was walking in R2's room, lost balance, and fell near R2's dresser causing a skin tear to the elbow. V5 described R2 as very confused, has poor safety awareness, and requires a lot of reorientations. V5 stated R2 requires standby assistance of staff for transfers and walking, and standby means walking side by side with R2. V5 stated R2 walks with a wheeled walker and frequently forgets to use R2's walker. On 10/23/23 at 10:36 AM V3 LPN stated R2 had a prior fall when R2 was standing at the nurse's station, got weak, and fell . R2 had R2's walker with R2, and there was no staff walking with R2 at the time. V3 stated R2 had a bruise to R2's back following R2's fall. On 10/23/23 at 1:28 PM V8 LPN stated (in regard to R2's fall on 10/18/23) R2 was found lying on the floor with R2's bed in low position. V8 stated R2's roommate (R4) witnessed R2's fall and R4 said that R2 attempted to stand from R2's bed and fell . V8 stated R2 was wearing open back slippers and following R2's fall V8 requested R2's family provide different slippers. R2 had blood drawn just prior to R2's fall and was anxious regarding the blood draw. V8 stated R2 assessed R2's hand grasps which the right was weaker than the left, per R2's baseline, and R2's hand grasps remained the same for R2's shift. V8 stated the next morning R2's finger was completely different; it was swollen and very bruised and at that time V8 changed R2's x-ray order to STAT (emergency). On 10/23/23 at 3:35 PM V2 Director of Nursing (DON) reviewed R2's fall investigations. V2 stated R2's falls on 9/5/23 were unwitnessed and R2 was self-ambulating in R2's room. V2 stated the root cause of R2's fall on 9/5/23 at 4:32 PM was R2's orthostatic hypotension and R2 was transferred to the emergency room as the post fall intervention. V2 stated R2's fall on 9/16/23 was witnessed, R2's legs became weak and R2 fell . V2 stated the post fall intervention was to monitor orthostatic blood pressures for three days, and this should be documented on R2's MAR or vitals log. V2 confirmed R2's MAR and vitals log do not document blood pressure readings on 9/22/23 and 9/23/23. V2 stated R2's fall on 9/20/23 was witnessed, the root cause was R2 lost balance and R2's slippers were a contributing factor. V2 stated the facility provided R2 with new slippers with a back, heel coverage. V2 stated R2's fall on 10/6/23 was unwitnessed, the root cause was R2 attempted to sit on the edge of the bed, and the post fall intervention was staff to offer to lay R2 down after meals. V2 stated R2 was found on the floor on 10/18/23, the root cause was R2 was self-ambulating in poor fitting slippers, and the post fall intervention was the facility contacted R2's family to provide new slippers. V2 stated R2's slippers should have been removed from R2's room after R2's fall on 9/20/23. V2 confirmed R2's slippers worn on 10/23/23 and during the 10/18/23 fall were the same slippers that R2 was wearing during R2's fall on 9/20/23. V2 stated R2's dislocated finger was identified on 10/19/23 and was a result of R2's fall on 10/18/23. V2 confirmed R2's fall investigations are not thorough and do not include when R2 was last checked on or toileted prior to each fall or what R2 was doing when last observed by staff. On 10/24/23 at 9:43 AM V11 Nurse Practitioner was asked the cause of R2's dislocated finger. V11 stated R2 had a fall on 10/18/23, the day prior, and V11 could speculate that the injury was a result of R2's fall. V11 confirmed this type of injury would be consistent with a fall with and the resident's hand positioned in the wheelchair spokes/wheel. V11 stated slippers with a back would have provided better support. 49492 2.) R3's Fall Incident Report dated 9/30/23 at 4:45 PM documents resident had a fall, R3 was laying on the floor near his wheelchair on his left side. R3's Medical Record does not include nursing notes referencing the fall dated 9/30/23 at 4:45 PM. R3's Incident Report dated 10/12/23 at 7:10 PM documents resident was observed sitting on the floor in front of his wheelchair. R3 stated he forgot to lock the brakes on his wheelchair and slid from his wheelchair while reaching for an object on the floor. R3's incident report dated 10/12/23 at 7:10 PM does not include staff interviews or the last time resident was seen or checked for safety. On 10/23/23 at 9:48 AM R3 stated he slid from his wheelchair to the floor at his bedside while reaching for an object he dropped on the floor. On 10/23/23 at 11:06 AM V2 Director of Nursing stated the nurses could be better about documenting falls. On 10/24/23 at 8:37 AM V2 reviewed R3's nursing notes and confirmed there is no documentation that R3 fell on [DATE]. On 10/24/23 at 11:00 AM V2 Director of Nursing reviewed R3's nursing notes/incident report and confirmed R3's fall investigation dated 10/12/23 is not thorough and does not contain staff interviews. The facility's Accidents & Incidents policy revised March 2021 documents resident incidents/accidents will be investigated and documented on an incident report, the charge nurse is responsible for conducting an immediate investigation of the incident/accident, and appropriate interventions will be implemented. This policy documents the Director of Nursing or designee will investigate incidents/accidents and the interdisciplinary team will be notified of incidents/accidents to make changes on the resident's care plan as needed. This policy documents incidents/accidents will be documented in a nursing note.

Based on observation, interview, and record review the facility failed to complete post fall neurological assessments, complete post fall assessments/monitoring, identify a change in condition, and properly transfer a resident (R1) following a fall. These failures affect three (R1, R2, R3) of four residents reviewed for falls in the sample list of four. These failures resulted in R1 experiencing uncontrolled pain and a delay in treatment of R1's left hip fracture following a fall. Findings include: The facility's Accidents & Incidents policy with revised date of March 2021 documents falls will be reported to the resident's physician and if necessary, transfer the injured resident to the hospital. This policy documents the resident will be placed on the 24-hour report and follow up charting for 72 hours. Fall risk, neurological assessments, and pain assessments will be completed after each fall. This policy documents not to move the resident after a fall until the resident has been assessed for possible injuries, and each morning the Director of Nursing or designee will review the 24-hour report documentation. The facility's Management of Pain policy revised August 2019 documents: Pain will be assessed and managed in a timely fashion, especially if it is of recent onset. The physician will be notified of resident's complaint of pain when not relieved by medication as ordered by the physician. The facility's undated Neurological Screenings Guidelines documents neurological assessments should be completed for unwitnessed falls or witnessed falls where the resident hit his/her head and documented on the Neurological Flow Sheet. This guide documents neurological assessments should be completed every 15 minutes four ties, then every hour four times, then every eight hours nine times, for a minimum of 72 hours. 1.) R1's Minimum Data Set (MDS) dated [DATE] documents R1 has moderate cognitive impairment, requires extensive assistance of one staff person for transfers, did not receive scheduled pain medication or was offered PRN (as needed) pain medication. This MDS documents R1 did not have any pain during the 5-day lookback period. R1's Care Plan with revised date 10/23/23 documents R1 had a fall with injury, R1 is a new admission, has poor balance, poor communication/comprehension, and unsteady gait. This care plan includes an intervention dated 8/9/23 to Observe/document /report PRN x 72h (for 27 hours) to MD (Medical Doctor) for s/sx (signs/symptoms): Pain, bruises, change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. R1's September 2023 Medication Administration Record (MAR) documents R1 received Apixaban (anticoagulant) 5 mg (milligrams) one tablet twice daily from 9/20/23-9/30/23. This MAR documents R1's pain was assessed every shift 9/20/23-9/30/23 with 0 indicating no pain. R1's October 2023 documents R1 does not have routine scheduled or PRN pain medication ordered. This MAR documents R1's pain was assessed each shift on 10/2/23 but does not document a pain score. R1's Nursing Note dated 9/29/2023 at 2:00 PM documents R1 was found at 7:00 AM kneeling on the floor next to R1's bed. R1 was standing on R1's right leg and kneeling on R1's left leg, and partially resting on R1's bed. R1 was assessed and had no apparent injuries and R1 denied hitting R1's head. This note documents an initial neurological assessment was completed and within normal limits. There is no documented post fall neurological assessments in R1's medical record after the initial assessment. R1's Nursing Note dated 9/30/2023 at 1:56 AM documents R1 denied pain. There are no documented post fall assessments/monitoring in R1's medical record after the initial assessment. R1's Nursing Note dated 10/2/23 at 11:42 AM, recorded by V19 Physician's Assistant, documents R1 had no pain or impaired range of motion to R1's legs. R1's Nursing Note dated 10/2/2023 at 4:15 PM documents the following: R1 was heard calling for help from R1's room. V12 Registered Nurse (RN) found R1 sitting in the wheelchair without oxygen and without socks/shoes on. R1's buttocks were near the edge of the wheelchair and R1 was unable to scoot back. R1 complained of left leg pain when V12 attempted to assist R1 in scooting back in the wheelchair which was unsuccessful and R1 was lowered to the floor onto R1's buttocks. R1 had good range of motion to all extremities and complained of left leg pain rated a 3 on a 10 scale. V12 and CNA (V13 Certified Nursing Assistant) transferred R1 back into the wheelchair. This note does not document how R1 was transferred. R1's Fall Incident Report/Investigation dated 10/2/23 documents R1 fall occurred at 3:15 PM. The section of this report titled Agencies/People Notified is left blank and does not document R1's physician was notified of R1's fall. There are no documented post fall assessments after the initial assessment following R1's 10/2/23 fall until 10/3/23 at 10:03 AM (almost 19 hours after R1's fall). R1's Nursing Note dated 10/3/23 at 10:03 AM documents R1 complained of left hip pain rated a 10 on a 0-10 scale, and R1 was unable to bear weight related to R1's fall on 10/2/23. This note documents V11 Nurse Practitioner was notified and gave orders to send R1 to the emergency room . There is no documentation that V11 or V4 Physician were notified of R1's fall or left hip pain prior to 10/3/23 at 10:03 AM. R1's Fall Investigation dated 10/3/23 documents on 10/2/23 V12 RN lowered R1 to the ground from the wheelchair and R1 initially complained of left hip pain rated 3 out of 10. The following morning R1 was transferred to the emergency department where x-ray showed left intertrochanteric hip fracture. This investigation documents per V12's interview, V12 and two Certified Nursing Assistants (CNAs) assisted R1 from the floor to standing position and R1 complained of left leg pain. R1 had range of motion as within normal limits. V12 finished the remainder of V12's shift and R1 did not have any further complaints of left leg pain. This investigation documents per V3 Licensed Practical Nurse (LPN) interview, V3 cared for R1 on the morning of 10/3/23. R1 was in bed when V3 arrived at 6:00 AM and a CNA reported that R1 was working with therapy and yelling out in pain. This interview documents V3 attempted to perform range of motion to R1's left leg, R1 yelled out in pain, and rated the pain as a 10 on a 0-10 scale. V3 asked R1 what happened, and R1 stated R1 fell last night. This investigation documents per V5's (LPN) interview, on 10/3/23 V5 was asked to come to R1's room due to R1 complaining of severe pain and R1 was unable to get out of bed. R1 was sitting on the side of the bed and R1's left upper thigh looked swollen. R1 complained of pain when V3 touched R1's thigh. R1 was laid down and V3 noted distinct difference in length between R1's right and left leg, with the left leg appearing shorter. The investigation concludes that after review of evidence and statements, R1 sustained a fall at the facility with injury identified on 10/3/23. R1's Emergency Department Note dated 10/3/23 documents R1 complained of left upper leg pain following a fall last night. This note documents R1 reported falling out of R1's wheelchair landing on R1's left side and left hip. R1 complained of left hip pain, has not received any pain medication, and was transferred to the hospital. This note describes R1's left hip pain as maximal. R1's Hospital Admission History & Physical dated 10/3/23 at 12:25 PM documents R1 presented to the emergency room after a fall with left hip pain and Left Intertrochanteric hip fracture after fall. This physical also notes R1 has a diagnosis of Osteopenia (a disease that weakens bones). R1's Left Femur x-ray dated 10/3/23 at 10:12 AM documents: History: Pain after fall and Findings: Left intertrochanteric hip fracture with moderate comminution and significant angulation. R1's Orthopedic Surgery Operative Note dated 10/6/23 documents R1 required surgical nailing to repair R1's left hip fracture. On 10/23/23 at 9:40 AM R1 stated R1 had a recent fall while reaching for the remote, R1 slid from R1's wheelchair, and fell to the floor. R1 stated R1 told the staff that R1 had left hip pain and R1 had left hip surgery while at the hospital following R1's fall. R1 was unable to give additional details of the fall on 10/2/23 and did not recall falling on 9/29/23. On 10/23/23 at 1:39 PM R1 was lying in bed and had visible scarring to the left outer thigh, where staples had been removed. R1 had an incision with intact staples to the left hip. On 10/23/23 at 8:40 AM V3 LPN stated V3 was the nurse who sent R1 to the hospital on the morning of 10/3/23. V3 stated R1 was complaining of left leg pain and R1 reported that R1 had fallen the night before. V3 stated nothing was passed on in shift report regarding R1's fall/pain. V3 stated R1 had generalized leg swelling and R1 would not allow V3 to assess range of motion because R1 was in so much pain. On 10/23/23 at 8:47 AM V6 Physical Therapy Assistant stated around 8:00 AM on 10/3/23 R1 was lying in bed and V7 Certified Occupational Therapy Assistant sent a message to V6 saying R1 was screaming every time R1 moved R1's leg. V6 stated R1 told V6 that R1 fell out of R1's wheelchair the night before while trying to reach the remote. At 1:00 PM V6 stated V6 provided R1's therapy session prior to R1's fall on 10/2/23 and R1 had no complaints of pain to the left hip or signs of injury prior to 10/3/23. On 10/23/23 at 10:05 AM V12 RN stated on 10/2/23 between 3:00 PM and 4:00 PM V12 found R1 sitting on the edge of R1's wheelchair in R1's room, attempting to reach for a remote control. V12 stated V12 tried to scoot R1 back in the wheelchair and was unable, so V12 lowered R1 to the floor onto R1's buttocks with R1's legs extended. V12 stated R1 complained of minor pain to the left leg prior to and after the fall. V12 stated V12 reported R1's fall to V2 Director of Nursing (DON) and V1 Administrator. V12 was unable to recall if V12 reported R1's fall to anyone else. On 10/23/23 at 10:26 AM V5 LPN stated V5 was called to R1's room that morning (10/3/23) due to R1 having trouble sitting up. V5 stated R1 complained of pain to the upper thigh, R1 was laid back down, and had swelling to R1's thigh. V5 stated when R1 laid down there was a difference in length between the right leg and left leg, and R1 told V5 that R1 had fallen the night before. On 10/23/23 at 12:04 PM V17 CNA stated V17 provided incontinence cares for R1 in bed during night shift on 10/2/23 and R1 complained of pain when R1 was rolled onto R1's side. V17 described R1 as yelping. V17 stated V17 reported R1's pain to the nurse and that R1 was asking for pain medication. V17 stated it was passed on from the prior shift that R1 had been complaining of pain in R1's hips earlier that night. On 10/23/23 at 2:15 PM V16 CNA stated V16 was R1's assigned CNA for 2nd shift on 10/2/23. V16 stated R1 was yelling out in pain that night around 6:00 PM or 7:00 PM and R1 complained of left hip pain. V16 stated V16 required V12's assistance to transfer R1 to bed, and R1 stood on both legs during the transfer. On 10/23/23 at 2:53 PM V13 CNA stated at the beginning of second shift on 10/2/23 V12 told V13 that R1 had fallen. V13 stated V13 and V12 assisted R1 to a standing position from the floor following R1's fall. V13 confirmed a mechanical lift or gait belt was not used during this transfer. V13 stated R1 did not take any steps and complained of left leg pain and R1 continued to complain of R1's leg hurting the rest of the night. On 10/23/23 at 1:05 PM V6 Physical Therapy Assistant stated V6 provided R1's therapy session on 10/2/23 and R1 performed exercises and transfers without any complaints or problems that day. On 10/23/23 at 11:06 AM V2 DON stated when a fall occurs the nurses should complete an initial assessment of pain and injury and notify the Physician/Nurse Practitioner. V2 stated post fall assessments/monitoring for pain/injury should be conducted every shift for 72 hours following the fall and documented in a nursing note. V2 stated the nurses could be better at documenting falls and post fall assessments. At 11:25 AM V2 stated unwitnessed falls should have a neurological assessment form uploaded under the miscellaneous tab in the resident's chart. V2 confirmed there were no post fall neurological assessments completed after R1's fall on 9/29/23. At 3:35 PM V2 stated if a resident falls, they are to be transferred off of the floor with a full mechanical lift. V2 confirmed staff should have used a full mechanical lift to transfer R1 off of the floor on 10/2/23. V2 confirmed the nurses are expected to report resident falls and pain to the physician, R1's post fall assessments were not consistently documented following R1's fall on the 9/29/23, there are no documented post fall assessments after R1's initial assessment on 10/2/23, and there is no documentation that R1's physician was notified of R1's fall and complaints of left leg pain until 10/3/23. On 10/24/23 at 9:43 AM V11 Nurse Practitioner stated the nurses notify V11 during the day between 7:00 AM and 7:00 PM and V11 did not see where V11 was notified of R1's fall or pain on 10/2/23. V11 stated V11 was notified the following morning and gave orders to send R1 to the hospital. V11 stated V11 would have sent R1 to the emergency room right away if V11 was notified of R1's fall and hip pain. V11 stated the nurses should monitor range of motion and pain as part of post fall assessments for 72 hours after a fall. V11 stated R1 has diagnoses of Vitamin D deficiency and Bone Density Disorder that increase R1's risk for fractures. V11 stated V11 assumes R1's hip fracture is the result of R1's fall, since the fall occurred the day prior. V11 was asked what effects would a delay in treating R1's left hip fracture have. V11 stated it would cause R1 pain. 2.) R2's Admission MDS dated [DATE] documents R2 has severe cognitive impairment. R2's Nursing Note dated 9/16/2023 at 9:43 AM documents R2 was standing at the nurses' station and fell . R2's Fall Incident Report dated 9/16/23 at 9:50 AM documents R2's fall was witnessed, R2 did not hit R2's head, and a head-to-toe assessment was conducted. This report documents R2 had an injury to the right rear iliac crest. The only documented post fall assessment in R2's medical record is a nursing note dated 9/17/2023 at 12:57 AM. R2's Nursing Note dated 9/20/23 at 6:51 PM documents R2 was ambulating in the hall with R2's wheeled walker, tripped over a wet floor sign, lost balance, and sat on R2's bottom. This note documents range of motion was within normal limit and R2 had no injury or complaints of pain. The only documented post fall assessment is noted in V11 Nurse Practitioner Progress Note dated 9/21/2023 at 3:26 PM. R2's Nursing Note dated 10/06/2023 at 10:00 AM documents a loud crash was heard from R2's room and R2 was found lying on the floor with R2's head near R2's dresser. Neurological assessments were initiated, and range of motion was assessed. R2's skin was assessed with no new findings. R2's Nursing Notes document the only post fall assessments were completed on 10/07/2023 at 1:17 PM, 10/07/2023 at 4:52 PM, and 10/8/23 at 1:52 PM. On 10/23/23 at 11:06 AM V2 DON stated post fall assessments/monitoring for pain/injury should be conducted every shift for 72 hours following the fall and documented in a nursing note. V2 stated the nurses could be better at documenting falls and post fall assessments. 49492 3.) R3's Incident Report dated 10/12/23 7:10 PM documents R3 fell with no injury noted. R3 was found sitting on R3's bottom in front of R3's wheelchair. After the initial assessment there are no documented post fall assessments in R3's record following this fall until 10/16/2023 at 5:57 AM. R3's Incident Report dated 09/30/23 4:45 PM documents R3 was found lying on the floor of R3's room on R3's left side. R3 had a skin tear to the right hand. After the initial assessment there are no documented post fall assessments in R3's record following this fall. On 10/24/23 8:37 AM V2 Director of Nursing reviewed R3's nursing notes and confirmed R3 did not have documented post fall assessments every shift following R3's falls.

Based on observation, interview and record review the facility failed to timely report a resident fall to the resident's representative and physician for one (R1) of four residents reviewed for falls in the sample list of four. This failure resulted in R1 experiencing uncontrolled pain and a delay in treatment for R1's left hip fracture following a fall. Findings include: On 10/23/23 at 9:40 AM R1 stated R1 had a recent fall while reaching for the remote, R1 slid from R1's wheelchair, and fell to the floor. R1 stated R1 told the staff that R1 had left hip pain and R1 had left hip surgery while at the hospital following R1's fall. On 10/23/23 at 1:39 PM R1 was lying in bed and had visible scarring to the left outer thigh, where staples had been removed. R1 had an incision with intact staples to the left hip. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has moderate cognitive impairment. R1's Care Plan with revised date 10/23/23 documents R1 had a fall with injury, R1 is a new admission, has poor balance, poor communication/comprehension, and unsteady gait. This care plan includes an intervention dated 8/9/23 to Observe/document /report PRN (as needed) x 72h (for 27 hours) to MD (Medical Doctor) for s/sx (signs/symptoms): Pain, bruises, change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. R1's Nursing Note dated 10/2/23 at 11:42 AM, recorded by V19 Physician's Assistant, documents R1 had no pain or impaired range of motion to R1's legs. R1's Nursing Note dated 10/2/2023 at 4:15 PM documents R1 was heard calling for help from R1's room and V12 Registered Nurse (RN) found R1 sitting in the wheelchair without oxygen and without socks/shoes on. This note documents R1's buttocks was near the edge of the wheelchair and R1 was unable to scoot back. R1 complained of left leg pain while V12 attempted to assist R1 in scooting back in the wheelchair which was unsuccessful and V12 lowered R1 to the floor onto R1's buttocks. This note documents R1 had good range of motion to all extremities and complained of left leg pain rated a 3 on a 10 scale. R1's Nursing Note dated 10/3/23 at 10:03 AM documents R1 complained of left hip pain rated a 10 on a 0-10 scale, and R1 was unable to bear weight related to R1's fall on 10/2/23. This note documents V11 Nurse Practitioner was notified, V11 gave orders to send R1 to the emergency room , and V20 (R1's Power of Attorney) was notified. There is no documentation that V11 Nurse Practitioner, V4 (R1's Physician), or V20 were notified of R1's fall or complaints of left leg pain prior to 10/3/23. R1's Fall Incident Report/Investigation dated 10/2/23 documents R1's fall occurred at 3:15 PM. The section of this report titled Agencies/People Notified is left blank and does not document V4, V11, or V20 were notified of R1's fall. R1's Left Femur x-ray dated 10/3/23 at 10:12 AM documents: History: Pain after fall and Findings: Left intertrochanteric hip fracture with moderate comminution and significant angulation. On 10/23/23 at 10:05 AM V12 RN stated on 10/2/23 between 3:00 PM and 4:00 PM V12 found R1 sitting on the edge of R1's wheelchair in R1's room, attempting to reach for a remote control. V12 stated V12 tried to scoot R1 back in the wheelchair and was unable, so V12 lowered R1 to the floor onto R1's buttocks with R1's legs extended outward. V12 stated R1 complained of minor pain to the left leg prior to and after the fall. V12 stated V12 reported R1's fall to V2 Director of Nursing (DON) and V1 Administrator. V12 was unable to recall if V12 reported R1's fall to anyone else. On 10/23/23 at 10:26 AM V5 Licensed Practical Nurse stated after a fall, the nurses notify the resident's family and physician, and this is documented in a risk management report that carries over into a nursing note in the resident's medical record. On 10/23/23 at 12:04 PM V17 Certified Nursing Assistant stated V17 provided incontinence cares for R1 in bed during night shift on 10/2/23, and R1 complained of pain when R1 was rolled onto R1's side. V17 described R1 as yelping. V17 stated V17 reported R1's pain to the nurse and that R1 was asking for pain medication. V17 stated it was passed on from the prior shift that R1 had been complaining of pain in R1's hips earlier that night. On 10/23/23 at 3:35 PM V2 Director of Nursing confirmed there is no documentation that R1's physician or representative were notified of R1's fall and left leg pain prior to 10/3/23 when R1 was transferred to the hospital. On 10/24/23 at 9:43 AM V11 Nurse Practitioner stated the nurses notify V11 during the day between 7:00 AM and 7:00 PM, and V11 did not see where V11 was notified of R1's fall or pain on 10/2/23. V11 stated V11 was notified the following morning and gave orders to send R1 to the hospital. V11 stated V11 would have sent R1 to the emergency room right away if V11 was notified of R1's fall and hip pain. V11 was asked what effects would a delay in treating R1's left hip fracture have. V11 stated it would cause R1 pain. The facility's Accidents & Incidents policy with revised date of March 2021 documents falls will be reported to the resident's physician and the resident's responsible party. The facility's Management of Pain policy revised August 2019 documents: Pain will be assessed and managed in a timely fashion, especially if it is of recent onset. The physician will be notified of resident's complaint of pain when not relieved by medication as ordered by the physician.

Based on observation, interview, and record review the facility failed to identify a self closing door as an accident hazard and failed to transfer a resident per the plan of care and assessment for one (R1) of four residents reviewed for accidents in the sample list of 16. These failures resulted in R1 sustaining a posttraumatic amputation of the right third finger distal phalanx (fingertip). Findings include: R1's Minimum Data Set, dated dated dated [DATE] documents R1 is cognitively intact and requires assistance of two staff for transfers. R1's Care Plan revised on 11/15/22 documents R1 has an Activity of Daily Living self care performance deficit and includes an intervention dated 10/15/2020 to transfer R1 with assistance of two staff and the use of a mechanical sit to stand lift. R1's laceration report dated 11/15/22 at 5:50 AM documents: V26 Certified Nursing Assistant (CNA) told V24 Registered Nurse (RN) that R1 put R1's finger in the bathroom door and the fingernail was cut off. V24 assessed R1's hand, and R1's fingertip had cut off. The root cause of R1's injury was Resident (R1) got finger smashed in door of bathroom due to door closing automatically. Intervention: all staff in-serviced, door hinge changed to not close automatically. V26's witness statement dated 11/15/22 documents at approximately 4:43 AM V26 transferred R1 with a mechanical sit to stand lift from the bed to the bathroom. As V26 positioned R1 over the toilet and R1's bathroom door began to close at the same time that R1 reached out and placed R1's hand on the door jam near the door hinge. The door then closed on R1's right middle fingertip, and R1 jerked R1's hand back. There was blood dripping onto the floor. R1's Hospital Summary dated 11/15/22 documents: R1 presented to the emergency room with right middle finger injury. R1 was using the bathroom with a sit to stand mechanical lift, when the door closed on R1's right middle finger. R1 had right middle fingertip tenderness with an open wound. R1's encounter diagnoses are listed as Closed nondisplaced fracture of distal phalanx of right middle finger and open fracture of tuft of distal phalanx of finger. R1's Right Hand X-Ray dated 11/15/22 at 7:44 AM documents: Diagnosis/Reason for Exam: blunt trauma, distal 3rd digit wound/injury, also pain to digits 4-5 without wound. Findings/Impression: Loss of the soft tissue and distal bony cortex at the third finger distal phalanx, consistent with posttraumatic distal digit amputation site. The facility's undated investigation report of R1's right middle finger injury documents: R1's bathroom door hinge was changed from a hinge that was designed to close automatically to a door requiring manual closure. The facility is providing education to staff on transfers. On 11/28/22 at 10:56 AM R1 had a bandage covering R1's right middle finger. R1 stated: R1's bathroom door would not stay open, and would automatically close. Around June/July 2022 R1 requested a doorstop for R1's bathroom door, and was told that the facility was looking into implementing a magnetic strip. A few weeks ago V26 transferred R1 to the bathroom with the sit to stand lift. R1's hand was on the door frame and the door closed on R1's finger cutting off the tip of R1's finger. It happened so fast. The door had been closing slowly, and staff would have to use their foot to hold the door open. Now staff use two people when transferring R1. They took the pins out of the hinge after the incident, so that the doors won't close automatically. On 11/30/22 at 1:54 PM V25 Wound Nurse administered R1's right middle fingertip wound treatment. R1's fingertip was amputated and R1's finger had approximately half the length of a fingernail. R1's wound was open, red, and surrounded by white tissue. On 11/28/22 at 10:51 AM V27 CNA stated about 3-4 weeks ago R1's bathroom door would not stay open. We had to use (R1's) room door to hold it open. These doors are heavy. They hurt when they close and hit you. V27 reported the door issue to an unidentified staff person, but did not fill out a work order for maintenance staff. On 11/28/22 at 11:12 AM V7 Maintenance Director stated V7 was notified there was a problem with R1's bathroom door when R1 got R1's finger cut. After the incident we removed pins and springs from the hinges of R1's bathroom door, and 9 other resident bathroom doors. No one had reported any problems with the doors prior to R1's incident. On 11/30/22 at 2:12 PM V24 RN stated: On the day of R1's injury, V26 told V24 that R1's finger was bleeding. V26 had transferred R1 to the toilet with the mechanical lift, R1 put R1's hand on the doorframe, and the door closed on R1's hand. Initially V26 said the fingernail was cut off, but the tip of R1's finger was cut off. V24 placed the fingertip on ice and notified the physician and ambulance. On 11/30/22 at 2:25 PM V26 CNA stated: V26 transferred R1 with a sit to stand mechanical lift by V26's self into the bathroom. Before R1 was positioned over the toilet, R1 raised R1's hand. I think (R1) was trying to stop the door from closing on me (V26). R1's hand was in the gap between the door and the doorframe, near the hinge. It closed on R1's finger, and R1 started hollering. R1's bathroom door was different than all of the other doors. It closed super fast and would slam shut on you. R1's door had always been like that, and other staff mentioned that they had similar problems with the door. V26 did not report R1's door issues to anyone. Having a second staff person for R1's transfer may have helped prevent R1's injury. On 11/30/22 at 2:55 PM V1 Administrator stated: Staff have the ability to fill out work order requests for maintenance. V1 was not aware of any issues with the self closing bathroom doors prior to R1's injury. On 11/30/22 at 3:30 PM V2 Director of Nursing confirmed R1's Care Plan and MDS document R1 requires assistance of two staff and mechanical sit to stand lift. On 12/1/22 at 9:05 AM V3 CNA stated the 100 halls were where the self closing bathroom doors were at and they've all been replaced. We had asked if we could get something to slow (R1's) door down and it just didn't happen. We had been asking for 6 months to a year. On 12/1/22 at 9:27 AM V5 CNA stated we used to prop (R1's) bathroom door with the outside door to keep it open. A trash can wouldn't even keep it open because it was too heavy. We tell the nurse if something is broken. We don't usually do the computer thing for work orders. They knew about (R1's) door. We had told them it was a problem and what happened to her was traumatic for all of us. On 12/1/22 at 9:20 AM V4 Maintenance Technician stated: V4 changed the bathroom door hinges, including R1's. R1's door would shut fast. The hinges were changed from spring loaded to regular hinges. We did it to keep anyone else from getting hurt. I didn't know that (R1) was having trouble with (R1's) door.

Based on interview and record review the facility failed to ensure R2 was not subject to sexual abuse by R1. This failure resulted in R2 having increased anxiety and feelings of shame. R1 and R2 are two of three residents reviewed for abuse in the sample of four. Findings include: R2's Face Sheet dated 2/1/22 documents R2 is diagnosed with [CONDITION(S)], Obesity, [CONDITION(S)], Depression, and Anxiety. R2's Minimum Data Set, dated dated dated [DATE] documents R2 is cognitively intact and requires extensive assist for bed mobility and locomotion and is totally dependent upon staff for transfers. R2 uses a wheelchair for mobility assistance. R2's Care Plan dated 1/30/22 documents R2 is at risk for changes in psychosocial well-being related to recent episodes with another resident (R1). R1's Face Sheet dated 2/1/22 documents R1 is diagnosed with Cerebral Infarction, Left side [CONDITION(S)] and [CONDITION(S)], Alcohol Abuse, and Dementia with Behaviors. R1's Minimum Data Set, dated dated dated [DATE] documents R1 requires supervision while using his wheelchair for mobility/locomotion. R1's Care Plan dated 1/26/22 documents R1 has exhibited the behavior of displaying inappropriate sexual behavior towards others. The Final Incident Report documents on 1/25/22 R2 stated R1 was in the doorway of R2's room masturbating. The incident report documents both R1 and R2 are Alert and Orientated residents. On 2/1/22 at 1:55 PM R2 stated R1 lived across the hall from her and would frequently be at her doorway multiple times per day. R2 stated R1 would often look at her (R2) while fondling himself (R1) with his hand inside his (R1) pants and on two specific occasions R1 began masturbating with his hand inside his pants. R2 stated R1 frequently opened her (R2) door when it was closed without permission and would sometimes make his (R1) way into her (R2)room uninvited to give her (R2) things (about 10 times). R2 stated staff were aware because R2 often had to call for them to remove R1 from her doorway or they would hear R2 yelling at R1 and come to help. R2 stated she would tell him (R1) to get the f*** (expletive) out of here. R2 stated, when (R1) was masturbating while looking at me it made me feel ashamed and dirty, even though I know I didn't do anything wrong. R2 stated R1 invaded her privacy and made her feel very uncomfortable. R2 stated R1's sexual behavior towards her increased her anxiety significantly and it bothered her that R1 seemingly could come into her room uninvited anytime he(R1) wanted to. (R2 then began to cry) R2 stated on 1/26/22 R1 came to sit at her table in the dining room and his presence made her so uncomfortable that she couldn't take it anymore and she had to ask to leave the dining room in order to finish her meal. R2 stated she went back to her room after lunch and cried. Later that day (1/26/22) R2 found out R1 was leaving the facility and she hasn't seen him since. R2 stated she feels relieved now that R1 is gone. On 2/1/22 at 12:00 PM V10 Licensed Practical Nurse stated over the last month she has observed R1 a few times, pleasuring himself in public areas in the facility (dining room, nurses station, hallway), make sexual comments to staff, and sitting at R2's door with his hands down inside his pants, pleasuring himself. R2 would put her call light on and ask us to move R1 from her doorway. V10 LPN confirmed she does consider R1's sexual behavior abuse when it comes to R2 because R2 cannot get up and leave, shut her door, or remove herself from the situation without staff assistance. On 2/1/22 at 12:16 PM V7 Licensed Practical Nurse stated R1 would often sit at R2's doorway and would open R2's door if it was closed. V7 stated she was providing care for R2 once and R1 opened the door. Luckily they had R2 covered up and so she was not exposed. V7 stated R1 kept doing it though no matter how many times the staff would tell him to stop. On 2/1/22 at 12:30 PM V4 Certified Nurses Assistant stated both R1 and R2 are alert and orientated residents. V4 stated within the last month or so R1 has been sitting in front of R2's door and opening her door and other resident's doors when they are closed. V4 stated R1 does sit in front of R2's door with his hands down his pants and would masturbate. V4 stated at first R1 was easily redirected but after R2 reported an incident on 1/25/22 and after the staff began keeping a close eye on R1, he became much more aggressive with his response to redirection. R1 would move around the halls and then stop and put his hand down his pants. R1 would masturbate in front of R2's doorway. On 1/26/22 R1 did this five or six times. When redirected he would cuss and spit at staff and then 20-30 minutes he would be doing it again. V4 stated she never recognized R1's actions as abusive before now. On 2/1/22 at 1:03 PM V11 Certified Nurses Assistant stated she has observed R1 sitting in front of resident's doors and opening doors to resident's rooms including R2. V11 stated she has observed R1 with his hands down his pants touching himself while sitting at the nurses' station in the view of staff and other residents. V11 stated she has observed R1 open R2's door when the staff were providing care for R2. R1 had to be redirected. On 2/1/22 at 1:05 PM V5 Licensed Practical Nurse stated when he came on shift on 1/26/22 he was told in report that R1 was to be watched closely and redirected away from other resident's rooms and doorways. We were supposed to watch R1 closely because the day before he had been masturbating in front of R2's doorway. During my shift on 1/26/22 R1 was repetitively going to R2's door and was being very combative when staff were attempting to redirect him. R1 began spitting, cursing, and yelling at staff whenever redirected. I was informed by V4 Certified Nursing Assistant that R1 was observed in front of R2's door with his hands down his pants in a sexually obscene manner. I informed V1 Administrator about this and about the increase in R1's sexual behavior and angry outbursts. On 2/1/22 at 2:06 PM V13 Certified Nurses Assistant stated she observed R1 in the hallway with his hands in his pants, pleasuring himself on multiple occasions. V13 stated R1 would do it at least twice every time she worked which was on average five days per week. R1 also opened the door to enter into R2's room when the door was closed for privacy and care. R2 mentioned at that time that R1 would often come into her room uninvited. On 2/1/22 at 2:45 PM V3 Social Service Director confirmed R2 is a vulnerable resident who cannot move on her own and who requires staff assistance for transfers and mobility. V3 confirmed if staff were aware of R1 masturbating or feeling himself sexually outside of R2's door they should have reported it to V1 Administrator so he could investigate it. V3 confirmed that prior to R2's allegation on 1/25/22, staff had never reported R1 masturbating in front of R2. V3 confirmed R2 was upset about the situation and was relieved that R1 was no longer in the facility. V3 stated R2 seemed to be doing better than she was a few days prior. The facility's Abuse and Prevention Program dated February 2021 documents the facility affirms the rights of residents to be free from abuse, neglect, or misappropriation. The same document defines abuse as any physical or mental injury or sexual assault inflicted upon a resident other than accidental means. Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.

Based on observation, interview and record review the facility failed to safely transfer two of three residents (R1 and R3) using a partial weight bearing mechanical device. This failure resulted in R1 being manually lowered to the floor and sustaining a shoulder and humerus fracture. Findings Include: 1.)The undated manufacturer's safety instructions document on page nine Lower leg straps: Accessory used to ensure that the lower parts of the resident's legs stay close to the knee support. They pass around the knee supports, then around the resident's lower calves. To fasten, click the strap into it's socket as with a seatbelt. Ensure that the straps are firm but comfortable for the resident. R1's Progress Notes document the following: 9/17/20 - R1 was seen via telemedicine by V14 Physician. The patient {R1} states that she {R1} does not feel well. (R1) has a history of (urinary tract infection and [MEDICAL CONDITION]). Appears more weak and lethargic than normal. Medications reviewed. [MEDICATION NAME] and [MEDICATION NAME] ordered with chest xray. [MEDICAL CONDITION] suspected. 9/19/20 - R1 observed sitting on the bathroom floor with Certified Nursing Assistant assisting R1 to maintain a seated position, legs out in front of R1. R1's left arm flaccid per baseline and complaining of left arm pain. R1's right leg gave out while on the (partial weight bearing mechanical lift) and the Certified Nursing Assistants lowered the resident to the ground. 9/21/20 - R1 has been in bed all shift, still complaining of left shoulder discomfort. Bruising noted to both axilla areas. Orders received to obtain left shoulder xrays. 9/21/20 - xray completed of the left shoulder R1's Patient Report dated 9/21/20 by V21 Physician/Radiologist documents, Interval appearance of an acute or subacute horizontal fracture through the proximal metaphysis/diaphysis of the humerus, with up to 1.2 cm (centimeter) medial displacement of the distal fracture molety. Interval appearance of an acute or subacute [MEDICAL CONDITION] to distal diaphysis of the left clavicle, with up to 2.8 mm (millimeters) cortical displacement at the fracture margins. R1's Progress Notes dated 9/21/20 documents R1 was sent to hospital for shoulder and humerus fractures. On 10/28/20 at 10:55 AM, R1 stated that R1 slipped and fell off of the sit to stand, resulting in a broken shoulder in two places. I {R1} told them {unidentified Certified Nursing Assistants} that my {R1's} leg wouldn't hold that day, but they {unidentified Certified Nursing Assistants} said we {unidentified Certified Nursing Assistants} won't let you {R1} fall. R1 stated there were two staff present during the transfer. R1's undated incident report documents V7 Certified Nursing Assistant and V17 Certified Nursing Assistant were present for R1's transfer and witnessed foot slip and leg give out. R1's Minimum (MDS) data set [DATE] documents R1's cognitively intact. On 10/28/20 at 10:53 AM V7, Certified Nursing Assistant stated that V7 could not remember if V7 used a leg strap with R1 during the transfer on 9/19/20, when R1's leg gave away during the transfer. On 10/28/20 at 11:11 AM R1 stated that the unidentified Certified Nursing Assistants did not use a leg strap when they transferred R1 on the day that R1's leg gave away during the transfer. On 10/28/20 at 11:14 AM V7 Certified Nursing Assistant stated that V7 usually uses the straps on R1 because R1 has a history of legs buckling. On 10/28/20 at 11:25 AM V12 Occupational Therapy Assistant stated that a partial weight bearing mechanical lift could be used for a person with some leg weakness as long as they had some upper arm strength which R1 did have; however a leg strap should always be used. On 10/28/20 at 1:05 PM V10 Physical Therapy Assistant (PTA) stated that V10 was aware of at least one partial weight bearing mechanical lift in the building with a leg strap. V10 PTA stated that if a resident is weak and a partial weight bearing mechanical lift is used, without a leg strap, it can lead to injury. On 10/28/20 at 1:06 PM V11 Certified Nursing Assistant stated that (V11) does not use a leg strap unless instructed to do so. 2.) R3's undated Face Sheet documents a [DIAGNOSES REDACTED]. R3's Care Plan dated 8/6/20 documents R3 requires a partial weight bearing mechanical lift with maximum assistance of two staff for transfers. On 10/28/20 at 11:10 am, V7 CNA (Certified Nursing Assistant) and V8 CNA entered R3's room with the partial weight bearing mechanical lift, to transfer R3 from the bed to R3's wheelchair. V7 assisted R3 to a sitting position on the side of the bed and placed a standing sling around R3's back and hooked the sling onto the lift. V7 assisted R3 in placing R3's feet on lift's foot platform. V7 raised R3 up to standing position, using the partial weight bearing mechanical lift while V8 moved R3's wheelchair closer to R3. R3 was then lowered into the wheelchair. The partial weight bearing mechanical lift had a safety leg strap that was tied up to the machine and not used during R3's transfer. At 11:14 am, V7 stated V7 uses the leg straps sometimes on residents whose legs buckle. At 11:15 am, V8 stated, we {facility} use the leg straps on resident with weak legs. The undated Safety Instructions for the Partial Weight Bearing Mechanical Lift documents, Lower Leg Straps: Accessory used to ensure that the lower parts of the resident's legs stay close to the knee support. They pass around the knee supports, then around the resident's lower calves. To fasten, click the strap into it's socket as with a seatbelt. Ensure that the straps are firm but comfortable for the resident.

Based on observation, record review and interview, the facility failed to assess a new pressure ulcer, implement pressure relieving interventions, prevent cross contamination of the pressure ulcer, and failed to perform hand hygiene for three of three residents (R1, R2, and R3) reviewed for pressure ulcers on the sample list of six. This failure resulted in R2 developing three unstageable pressure ulcers. Findings Include: The facility Pressure Ulcer Prevention, Identification and Treatment Policy dated February 20 documents a Prevention program will be utilized for all residents who have been identified of being at risk for developing pressure ulcers. The facility will initiate an aggressive treatment program for those residents who have pressure ulcers. A pressure ulcer is defined as any lesion caused by unrelieved pressure that results in damage to underlying tissue. Pressure ulcers usually occur over bony prominence's and are graded or staged to classify the degree of tissue damage observed. Suspected Deep Tissue Injury is a purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Stage II pressure ulcer is a partial thickness of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister. Unstageable ulcers are full thickness tissue loss in which the base of ulcer is covered by slough (yellow, tan, gray or brown) and/or eschar (tan, brown, or black) in the wound bed. When a pressure ulcer is identified, whether in-house, or upon a resident's admission, the area will be assessed and an initial treatment started per physician's orders [REDACTED]. Assessment is to include: characteristics: (size, depth, color, drainage), presence of granulation tissue/necrotic tissue, treatment and response to treatment, and prevention technique (turning and repositioning, skin care, protective devices). 1. R2's undated face sheet documents R2 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. R2's MDS (Minimum Data Set) documents R2 is alert and oriented, independent with decision making, and requires limited assist of one for bed mobility and transfers. R2's Skin Risk assessment dated [DATE] documents R2 is at risk for skin breakdown. R2's Weekly Skin assessment dated [DATE] documents R2 has a surgical incision as toes have been amputated. R2's Weekly Skin assessment dated [DATE] documents R2 has an unstageable pressure ulcer to the left heel measuring 2.6 cm (centimeters) by 2.1 cm by UTD (unable to determine), that was found on 6/18/20. R2's Progress Notes dated 6/18/20 by V15 IP/WN (Infection Preventionist/Wound Nurse) documents, complained of pressure to the left heel. V15 noted a hard metal splint in place to the back of R2's leg. Foam placed to help relieve pressure. Discolored area is dark purple and measures 2.6 cm by 2.1 cm. R2 states the foam dressing has helped. R2's Wound Notes by V28 APRN (Advanced Practice Registered Nurse) dated 6/22/20 documents R2 has a deep tissue pressure injury to the heel. This note documents new orders: add extra padding to the heel, ensure heel is floated and offloaded at all times, boot on when using wheelchair or traveling for protection, and strict non-weight bearing to the left lower extremity. R2's August 2020 Physician order [REDACTED]. R2's Weekly Skin assessment dated [DATE], documents R2's left heel pressure ulcer measures 3.0 cm by 2.9 cm by 0.2 cm {an increase in size}, and remains unstageable as 90% of the wound bed is covered in eschar with 10% slough. This Weekly Skin Assessment also documents R2 has a new unstageable pressure ulcer found on 7/24/20 to the right heel measuring 1.0 cm by 0.8 cm by UTD. On 8/20/20 at 9:39 am, R2 was sitting up in a wheelchair in R2's room, with both feet/heels resting on the metal base of the overbed table. R2 did not have a boot on the left foot or offloaded {as ordered}. On 8/20/20 at 10:00 am, V29 LPN (Licensed Practical Nurse) entered R2's room to complete the ordered pressure ulcer treatments. R2 was lying in bed, on a regular mattress, with R2's left foot resting on a pillow and R2's right foot/heel resting on the mattress. V29 donned gloves after washing hands and removed the dressing to R2's left foot. V29 changed gloves but did not wash V29's hands or use ABHR (Alcohol Based Hand Rub). V29 then cleansed R2's left heel ulcer with soap and water, rubbing back and forth over R2's ulcer, then applied R2's new dressing without changing gloves or performing hand hygiene. V29 then removed gloves, and washed hands prior to donning gloves and removing R2's right foot dressing. R2 stated, this is what hurts, while pointing to an area on the posterior heel, that appeared to be a resolving blister that had two black, eschar areas within it. V29 measured the blistered area as 2 cm by 0.5 cm. V29 stated, it was a lot squishier, it's getting better. V29 then measured an eschar area on the bottom of R2's right heel as 1 cm by 0.8 cm. V29 washed the entire heel with NS, wiping back and forth over the blistered area and eschared wounds several times, then completed the wound treatment without changing gloves or performing hand hygiene. At this time, R2 stated R2 has always been on a regular mattress and hasn't used any heel protectors. R2 stated, I try and keep my left foot up on a pillow but sometimes I wake up in the middle of the night and the pillows are on the floor, and R2's heels are on the bed. On 8/20/20 at 10:16 am, V29 confirmed that V29 wiped back and forth across R2's wounds several times when cleaning them, potentially contaminating the wounds. V29 also confirmed V29 did not perform hand hygiene after removing the dressing, cleaning the wounds, or applying the new dressings. On 8/20/20 at 10:45 am, V2 DON (Director of Nursing) stated wound prevention interventions like a low air loss mattress or heel booties are individualized based off of the residents Skin Risk Assessment, nutritional status, history of wounds, and presence of wounds, but they would do R2 good. V2 stated V2 expects V15 IP/WN to get into contact with V30 Wound Physician to address the fact that a current intervention isn't working and to implement further interventions. V2 also stated, staff should be cleansing wounds from the inside out, not rubbing back and forth across the wound. On 8/25/20 at 10:07 am, V25 NP (Nurse Practitioner) stated staff need to re-evaluate pressure relieving interventions if the current intervention isn't working, and try something else, to prevent further pressure ulcers from developing. V25 also stated with R2's sensory impairment due to the [MEDICAL CONDITION], and possibly not being able to feel the discomfort from pressure, interventions such as a low air loss mattress could help with R2. The facility Hand Washing Policy dated July 2019 documents, this facility considers hand hygiene the primary means to prevent the spread of infections. All staff will properly wash hands after direct contact with any contaminated substances, after direct resident care, and as instructed. Employees must wash their hands for fifteen to twenty seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: before and after direct contact with residents, after contact with blood, body fluids, secretions, mucous membranes, or non intact skin, after removing gloves, and after handling items potentially contaminated with blood, body fluids or secretions. 2. R3's Ulcer/Wound Documentation dated 6/15/20 documents on 6/15/20, R3 was found to have a stage II blister to the left heel measuring 2.0 cm by 1.0 cm by UTD (unable to determine). R3's August 2020 Physician order [REDACTED]. On 8/20/20 at 9:19 am, V27 LPN (Licensed Practical Nurse) and V26 CNA (Certified Nursing Assistant) entered R3's room to complete R3's ordered treatment. V27 removed R3's dressing to reveal a 0.1 cm (centimeter) by 0.1 cm open wound to R3's left heel. V27 cleansed the wound with wound cleanser and a gauze pad by rubbing back and forth over R3's wound, potentially contaminating the wound. V27 then completed the treatment as ordered. On 8/20/20 at 10:45 am, V2 DON (Director of Nursing) stated, staff should be cleansing wounds from the inside out, not rubbing back and forth across the wound. 3. R1's Progress Notes document R1 was seen on 8/6/20, 8/10/20 and 8/13/20 by V5 NP (Nurse Practitioner) for blisters to the right foot that R1 states appears intermittently and limits R1's ability for transfers and mobility. V5's notes do not document the size, number or exact location of the blisters. R1's August 2020 Physician order [REDACTED]. R1 has no initial or weekly Skin/Wound Assessments that documents the characteristics of the blisters, presence of granulation or necrotic tissue, a treatment or prevention techniques used. On 8/19/20 at 2:44 pm, V5 NP stated V5 was suppose to see R1 again on 8/19/20 to monitor R1's foot blisters however R1 ended up in the hospital due to a wound developing on the left foot. V5 stated R1 had two blisters, side by side, on the outer distal plantar portion of R1's foot. It looked like a friction issue, from the area rubbing against (R1's) shoe. On 8/20/20 at 10:45 am, V2 DON (Director of Nursing) stated, when a new pressure area develops, the staff should assess and measure the wound and document the size. They also need to call the physician and obtain a treatment for [REDACTED].

Based on record review and interview the facility failed to safely transfer and supervise one of three residents (R1) reviewed for falls in the sample of three residents. This failure resulted in R1 sustaining a fall with a left hip fracture. Findings include: 1. R1's Physician order [REDACTED]. R1's Care Plan dated 3/1/17 documents R1 is at risk for falls due to potential medication side effects, unsteady gait, and history of falls. The care plan documents Reinforce w/c (wheelchair) safety as needed with (R1) such as locking brakes. R1's Progress Notes dated 7/21/17 document R1 stood up on own and fell at 11:30 am and complained of left hip pain. The notes document L (left) leg appears shortened. 911 called, daughter (Z1, R1's daughter) notified and is here now with res (resident, R1). R1's Minimum Data Set ((MDS) dated [DATE] documents R1 is severely, cognitively impaired and requires the assistance of one person for walking, ambulation and transfers. The MDS documents R1's assistive devices include walker and wheelchair. R1's Incident Report Dated 7/21/17 documents R1 fell on [DATE] at 11:30 am. The report documents E3, Assistant Director of Nursing, transferred R1 to a wheeled office type chair in a room behind the nurses station and turned to grab supplies then heard a noise and found R1 laying on floor on left side complaining of left hip pain. The report documents left hip with rotation noted. On 8/9/17 at 1:50 pm E3, Assistant Director of Nursing, stated that on 7/21/17 E3 transferred R1 from the walker to a rolling, desk chair in a private room behind the nurses station. E3 stated E3 was planning to apply leg wraps to R1's lower extremities for leg swelling. E3 stated E3 left R1 in the room behind the nurse's station and went to the nurses cart to get R1's bandages. E3 stated E3 walked away from R1 and that R1 was out of (E3's) view. E3 stated E3 then heard a thud noise as E3 was gathering the supplies for the leg wraps. E3 stated E3 ran back into the room and R1 was on the floor and calling out. E3 stated R1's left leg was rotated and we immediately called the ambulance and sent (R1) out (to the emergency room ). E3 stated R1 is severely cognitively impaired and should not have been left alone. E3 stated R1's fall was not witnessed. E3 stated I should not have placed (R1) in a rolling, desk chair. E3 stated the rolling, desk chair did not have brakes. R1's Pain/Pain Assessment in Advanced Dementia (PAINAD) Evaluation dated 7/21/17 at 11:37 am documents R1's pain level was rated as six (6/10)on a scale of ten. R1's Hospital Report dated 7/21/17 documents R1 presented to the emergency department after suffering a fall at the nursing home where R1 resides. R1's Imaging X-Ray of the Left Hip dated 7/21/17 with a comparison X-ray of 6/7/16 documents Findings: There is a new acute, comminuted, intertrochanteric left hip fracture with varus angulation and proximal migration of the femoral shaft. No evidence for left hip dislocation, however the left hip joint is poorly visualized on the crosstable lateral view due to overlapping soft tissues. Partially visualized hardware in the proximal right femur. Surgical clips in the lower abdomen. Degenerative changes in the lower lumbar spine and hips. Possibly worsening compression deformity of the L4 vertebral body. Impression: 1. Acute intertrochanteric left hip fracture. 2. Possibly worsening compression deformity of the L4 vertebral body. Consider dedicated lumbar spine radiographs. On 8/10/17 at 11:30 am Z2, R1's Primary Care Physician, states R1's fall on 7/21/17 contributed to R1's left hip fracture. Z2 stated R1 should not have been transferred to a wheeled office chair and left unattended in the first place. The Falls Practice Guide dated December 2011 documents that fall reduction and injury prevention strategies that can be implemented upon admission may include, but not limited to the provision of assistive devices, as clinically indicated such as wheelchair, cane, walker, crutches. The Gait Belt policy dated December 2009 documents when transferring to a wheelchair, prepare chair by locking both wheel brakes. 2. R1's Progress Notes dated 8/1/17 documents that R1 was evaluated by therapy to be a full mechanical lift for transfers. R1's Care Plan History/Task History documents on 8/2/17 R1 was a full mechanical lift for transfers then changed to a slide board transfer then changed back to a full mechanical lift. The Task History documents the following revisions in order of occurrence: -On 7/27/17 at an undocumented time R1 was a full mechanical lift transfer. -On 8/2/17 at an undocumented time R1's transfer was changed to slide board to R (right) side. -On 8/2/17 at an undocumented time R1's transfer was the slide board to right side and may use a full lift if needed. -On 8/2/17 at an undocumented time R1 transfer was full mechanical lift. On 8/9/17 at 12:30 pm E5, Certified Nursing Assistant (CNA) stated R1 is total care and is transferred with a mechanical lift and two persons. E5 stated I think therapy transferred (R1) with a board (slide board). I've always used a full lift. On 8/9/17 at 3:40 pm E8, CNA, stated Z1 (R1's daughter) wanted R1 to be transferred to bed and there was a slide board already in the room. E8 stated We had seen therapy use it. E8 stated E8 was shown how to transfer R1 with slide board on 8/1/17. E8 stated E8 and E9, CNA's, placed the slide board under R1 while R1 was seated in the wheelchair then pivoted the slide board to the bed then transferred R1 to the bed. E8 stated R1's cardex (Care Plan History/Task History) is on the computer and documents how R1 is to be transferred. E8 stated R1's cardex documents (R1) was a full mechanical lift. Just remember seeing the slide board in (R1's) room and therapy showing CNA how to transfer (R1) with slide board the day before. On 8/9/17 at 4:00 pm E9 stated E9 assisted E8 to transfer R1 from the wheelchair to bed using a slide board that was in R1's room. E9 stated the transfer occurred sometime after supper (evening meal). E9 stated R1's cardex indicated R1 was a full mechanical lift with two people. E9 stated therapy was demonstrating the slide board transfer the day (8/1/17) before and thought that's how R1 was to be transferred. On 8/9/17 at 3:51 E3, Assistant Director of Nursing stated that R1 was determined to be a slide board transfer by staff for a short time but could not recall the date. On 8/10/17 at 2:00 pm E10, Physical Therapist (PT), stated R1 was being transferred in therapy with slide board from 7/28/17 to 8/2/17. E10 stated on 7/28/17 at 9:45 am E10 and E21, Occupational Therapist, were transferring R1 with slide board in R1's room and there were some CNAs that stopped in to watch while we were transferring R1 from the wheelchair to the bed. E10 stated This was not a training. We told CNAs we were working on slide board transfers in therapy. They (CNAs) just watched us transfer (R1). There was no instruction to the CNAs on the transfer. Only instruction to the resident as we did the transfer. E6, Therapy Director, stated R1 was in therapy following hip fracture surgery and was being transferred in therapy with a slide board. E7, LPN (Licensed Practical Nurse), stated that on 8/2/17 at the morning department meeting E7 requested that R1 was to be transferred with a slide board and two assistants. E7 stated then later that same day R1 was changed back to a full mechanical lift transfer. On 8/10/17 at 2:30 pm E2, Director of Nursing, stated E6, PT, requested R1's transfer status from full mechanical lift to slide board on 8/2/17 in the morning. E2 stated then sometime in the afternoon around 3:00 pm R1's transfer status was changed back to full mechanical lift. E2 stated CNAs are supposed to look at the cardex task for a resident's transfer status. E2 stated R1's slide board transfer by E8 and E9 occurred after supper on 8/2/17 and R1's transfer status at that time was a full mechanical lift. E2 stated E8 and E9 should have transferred R1 with a full mechanical lift. The Injury Prevention Lifts and Injury-Reducing Devices Manual dated July 2015 documents to use the appropriated lift and friction-reducing devices for each patient assessed. The manual also documents Determining the method for transferring a patient is a serious matter and cannot be taken lightly; the risk of injury to the patient or the employee is to great. Understanding key characteristics of a patient's condition will assist the employee in completing safe transfers.

Based on record review and interview the facility failed to operationalize its abuse prohibition procedures by failing to form a reasonable suspicion that a crime may have been committed against (R40) and failed to report to local police authorities that (R40's) valuable watch was missing. R40 is one of three residents reviewed for abuse in a sample of eight. Finding include: R40's Progress Notes dated 7/30/2013 at 1:07 PM state the following: Note Text: late entry: spoke to son (Z2) about missing Rolex watch. Explained would look at documentation and get back to him 7/19/2013. Today spoke to (Z2)- Rolex watch valued at 1,000 dollars per inventory sheet could not be located. Watch not able to be located still today." This progress note was written by E1 (Administrator). The Resident Concern Form dated 7/30/2013 states :Z2 (R40's son) reports upon discharge his father is missing his Rolex watch. (Z2) stated it was here and now gone. Listed on inventory sheet in chart." On 2/18/2014 E1 (Administrator) stated " I started a concern form on 7/30/2013 when (Z2) told me his Rolex watch was missing. I interviewed all the staff who worked with the resident (R40). They could not remember him wearing a watch. I also conducted a search of the facility and the watch was not found. The son never said the watch was stolen. I was not suspicious that a crime had occurred so I did not call the police or report to the Department of Public Health. " On 2/19/2014 at 8:55 AM, Z1 (Paxton Police Sergeant) stated the family made a report of a missing watch on 2/14/2014. Z1 also stated the facility had not filed a report at this time regarding a missing watch. The facility policy and procedure for "Abuse, Neglect and Misappropriation of Patient Property Prevention Policy" states on page 12 "Staff members who suspect that a crime has occurred against a patient , must file a report with local law enforcement and the state agency ."

Based on observation, interview, and record review, the facility failed to operationalize its Policy and Procedures to protect male residents from an alleged perpetrator (R18) of inappropriate sexual touching, and failed to identify, investigate, and report allegations of inappropriate sexual touching. These failures resulted in a second incident of inappropriate sexual touching of another male resident (R19) by R18, and a third incident of inappropriate sexual touching of a male resident (R26) by R18. R18, R19, R23, and R26 are four of four residents reviewed for abuse in the sample of 19. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 12/04/13, the facility remains out of compliance at a severity level two in that the facility is in the process of monitoring the effectiveness of staff retraining directed at identification, reporting, investigation, and resident protection related to abuse. Findings include: 1. R23's Physician order [REDACTED]. R23's Minimum Data Sets ((MDS) dated [DATE], 6/06/13, and 9/05/13 document that R23 is severely cognitively impaired, requires extensive assistance with bed mobility and total assistance with transferring and locomotion on the unit, and has highly impaired vision. R19's POS dated 12/2013 documents the following Diagnoses: [REDACTED]. R19's MDS dated [DATE] documents that R19 is moderately cognitively impaired and requires supervision with ambulation and transferring, and extensive assistance with dressing and bathing. R26's MDS dated [DATE] documents that R26 is severely cognitively impaired, and requires extensive assistance with bed mobility, transferring, and Activities of Daily Living (ADL). R18's MDS dated [DATE] and 09/12/13 documents that R18 is cognitively intact, has no range of motion limitations of his upper and lower extremities, and moves about the facility independently without supervision. R18's Care Plan initiated on 10/12/12 and revised on 9/25/13, documents that R18 has a history of inappropriate sexual touching of male residents and that staff is to provide supervision in social gatherings/recreation programs. On 12/04/13 at 1:00pm, R18 propelled himself independently in his wheelchair in the halls of the facility. R18's Progress Notes dated 04/24/13 at 3:42pm document that "(R18) had his hand down the front of (R23's) pants" in the public observation area across from the nurse's station. On 12/04/13 at 2:20pm, E11, Certified Nursing Assistant (CNA), stated that on 04/24/13 she witnessed R18 sitting with his wheelchair very close to R23's reclining geriatric chair. E11 stated that R18 had his left hand down inside the front of R23's pants and his (R18's) right hand on his own lap. E11 stated that she told R18 to "Stop," and immediately took R23 to the nurse on duty to report R18's inappropriate touching of R23 (E11 stated she does not remember the nurse's name). On 12/5/13 at 10:00am, E1, Administrator, stated that R18's inappropriate touching of R23 was reported to her on 04/24/13, that no investigation was conducted, and that no protection from R18 was provided for male residents. E1 stated that she did not report the allegation of inappropriate touching to the State Licensing and Certification Agency or to local law enforcement. 2. R18's Progress Notes dated 08/10/13 at 12:30pm document that R18 was in the dining room sitting at the dining table with R19. The Progress Notes document that R18 asked R19 if he could see his penis, and that he (R18) touched R19's penis. On 12/04/13 at 11:25am, E12, Housekeeping/Laundry Aide, stated that on 08/10/13 she witnessed R18 ask R19 if he could see his penis because he had not "seen a black one." E12 stated that R19 stood up from the dining room table, dropped his pants, and showed R18 his penis. E12 stated that R18 touched R19's penis. E11 stated that there were "a few other residents" also present in the dining room at that time. E12 stated that she immediately removed R19 from the dining room and took him to the nurse on duty. E12 stated that she immediately reported the inappropriate touching to the nurse on duty and E2, Director of Nursing (DON). E12 stated that she does not remember the nurse's name to whom she reported the incident. On 12/05/13 at 11:15am, R19 stated that R18 repeatedly asked to see his penis, so R19 stated he finally showed it to R18. On 12/5/13 at 10:00am, E1, Administrator, stated that R18's inappropriate touching of R19 was reported to her on 08/12/13, two days after the incident occurred, and that no investigation was conducted, and that no protection from R18 was provided for male residents. E1 stated that she did not report the allegation of inappropriate touching to the State Licensing and Certification Agency or to local law enforcement. 3. R18's Progress Notes dated 12/01/13 at 3:55pm documents that R18 was found in R26's room touching R26's genitals. E16, CNA, wrote in her statement dated 12/01/13 "(R18) was holding (R26's) brief down with his right hand and with his left hand fondling (R26's) penis. R26 was swinging his right hand." On 12/03/13 at 11:10am, E1, Administrator, stated that on 12/01/13 R18 was found in R26's room standing next to R26's bed, holding R26's pants open with one hand and touching R26's genitals with his other hand. On 12/06/13 at 11:52am, E15, Registered Nurse (RN), stated that on 12/01/13, R18 was found holding open R26's pants and touching R26's genitals. On 12/04/13 at 10:25am, Z2, Primary Care Physician (PCP), stated "(R18) knows what he is doing--what (R18) is doing is criminal... We need to address this (R18's behavior) more aggressively." R18's Progress Notes document the following incidents: 8/15/13 3:30pm- R18 pushed a male resident (R28) into a dark Hospice room. E14, Licensed Practical Nurse (LPN) documented that R28 told staff "Oh no, get me out of here." On 12/04/13 at 3:37pm, R28 stated "(R18) pushed me in my wheelchair into a dark room. (R18) is up to no good. (R18) keeps trying to drag me into his room... something about his penis. I just stay away from him." R28's MDS dated [DATE] documents that R28 is moderately cognitively impaired. 8/24/13 3:13pm-R18 "caught trying to get another resident (R29) into his bathroom." On 12/06/13 at 10:15am, R29 stated that R18 entered his (R29's) bathroom and watched R29 urinate. R29 stated that he yelled at R18 to get out. R29 stated that he reported the incident to E13, Activity Director. R29's MDS dated [DATE] and 11/14/13 document that R29 is cognitively intact. 8/24/13 3:38pm-"(R18) came out of (R7's) room...(R7) stated that (R18) had entered his room wanting to give him a massage." On 12/04/13 at 11:55am, R7 stated that R18 had entered his (R7's) room while R7 was asleep in bed. R7 stated that he awoke when R18 placed his hand on R7's stomach. R7's MDS dated [DATE] documents that R7 is cognitively intact. 09/04/13 4:14pm-"(R18)...invited the other patient (R27) to his room to watch football and that (R18) was just patting him on the leg saying look at that on the TV." R27's MDS dated [DATE] documents that R27 is severely cognitively impaired. 09/14/13 3:48pm-R18 found in another male resident's (R23) room, sitting close to (R23's) bed. "(R23) was lying in bed and his brief was undone with genitals exposed." R23's Progress notes dated 04/03/13 through 12/04/13 document no behaviors in which R23 removes his own brief, exposing himself. R23's POS dated 12/2013 documents that R23 has left sided paresis, dementia, and is totally dependent functionally. On 12/04/13 at 9:45pm, E1 stated that the above incidents had been reported to her as follows: the incident of 04/23/13 reported on 04/23/13; incident 08/10/13 reported on 08/12/13; incident 08/15/13 reported on 08/15/13; incidents 08/24/13 at 3:13pm and 3:38pm reported on 08/24/13; incident on 09/04/13 reported on 09/04/13; incident 09/14/13 reported on 09/16/13. E1 stated that the incidents were not investigated or reported to the State Licensing and Certification Agency, and that no protection from R18 was provided to male residents. R18's Progress Notes dated 04/24/13 and 09/14/13 document that E13, Activity Director, spoke with R18 (following the incidents of the same dates) regarding his inappropriate behavior. R18's Progress Notes dated 08/15/13, 09/13/13, and 09/16/13 written by E3, Social Service Director (SSD), document that E3 spoke with R18 regarding R18's inappropriate behavior that had a "sexual tone." On 12/04/13 at 11:55am, E3 stated "Those (behaviors) are sexual abuse. We missed something here." The Facility's Abuse, Neglect and Misappropriation of Patient Property Prevention Policy (2012) identifies sexual abuse as sexual harassment, sexual coercion, or sexual assault, and directs that all allegations of abuse are to be immediately reported to the administrator of the facility. The Policy further directs that the alleged abuser will immediately be removed from contact with residents, that a thorough investigation will be conducted on "any allegations of abuse," and that allegations of abuse will be immediately reported to the State Licensing and Certification Agency. The Policy directs staff to file a report with local law enforcement if a crime has occurred against a resident. On 12/04/13 at 5:30pm, E18, Corporate Consultant, stated that she felt the facility staff did not follow the facility's Abuse Policy because they did not recognize R18's inappropriate sexual touching as abuse due to their "normalizing" of R18's behavior. The facility's undated Mood and Behavior Practice Guide describes normalization as "When we do not intervene with a behavioral symptom ...because 'The patient always does that,' or 'It's just Joe being Joe,' or 'That's normal for them.'" On 12/04/13 at 1:00pm, E1, Administrator, stated that until she began the investigation of the inappropriate touching of R26 by R18 which occurred on 12/01/13, she was unaware of the pattern of R18's behavior. E1 stated that she was unaware that R18 had touched any other residents (R23, R19) in a sexually inappropriate manner. On 12/04/13 an Immediate Jeopardy was identified to have begun on 04/24/13 when staff failed to investigate allegations of the sexual abuse (of R23) by R18 and failed to protect male residents from subsequent incidents of inappropriate touching by R18. The facility also failed to report to the State Licensing and Certification Agency and to local law enforcement allegations of the sexual abuse (of R23) by R18. On 12/04/13 at 5:00pm, E1, Administrator, was notified of the Immediate Jeopardy. The Immediate Jeopardy was removed on 12/04/13. The surveyor confirmed through observation, interview, and record review on 12/04/13 that the facility took the following actions to remove the Immediate Jeopardy: 1. On 12/04/13 at 5:30pm, E1, Administrator, moved R18 to a private room across from the Nurse's Station. 2. R18 placed on 1:1 constant supervision on 12/02/13 at 3:30pm by E1. 3. Administrator and Core Managers inserviced (re-educated) by Corporate Consultant on Abuse Guidelines, Behavior Guidelines, Normalizing Behaviors, and PREVENT Guidelines on 12/02/13. 4. Corporate Consultant completed 100% Staff Education related to Abuse Guidelines, Behavior Guidelines, Normalizing Behaviors, and PREVENT Guidelines on 12/02/13.

Based on interview and record review the facility failed to thoroughly investigate and report to the Illinois Department Of Public Health an allegation of possible misappropriation of resident property for 1 of 3 (R40) residents reviewed for abuse in a sample of 8. Findings include: The facility face sheet states R40 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R40's "Inventory of Personal Effects" dated 12/2/2009 in the 'items of specific value' column states 'Rolex watch value 1,000 dollars.' The facility initiated a "Concern Form" dated 7/30/2013. The documented concern states "(R40's) son reports upon discharge (R40's) Rolex watch is missing. The son stated the watch was here and now its gone. The watch is listed on the inventory sheet for dads (R40's) record. " According to E1, Administrator on 2-18-14 at 1:15 p.m. the investigation did not include notifing the police of a misssing item or notifing the Illinois Department of Public Health (IDPH). The facility was aware that the watch was missing on 7/19/2013 and did not interview staff or search the facility for the watch until 7/30/2013 when the concern form was intiated. The Social Worker E3 was never interviewed by the facility. E3 signed the inventory sheet on 7/31/2013 at time of discharge as well as remembered the watch (Rolex) on R40's wrist. On 2/18/2014 at 1:15 PM, E1 (Administrator) stated " The son of ( R40), (Z2) called me on 7/19/2013 and said some of his fathers (R40's) items were missing. (Z2) said he would call back with specific items that were missing after talking with his brother. (Z2) did not call me back until 7/30/2013.( Z2 )said his fathers Rolex watch was missing. I started the concern process on 7/30/2013. I interviewed the staff that worked regularly with him (R40) none of them could remember the watch. I also had the facility searched for the watch and it was not found. No I did not call the police to report the watch missing because the son (Z2) never said the watch was stolen. I was not suspicious that the missing watch was a crime. " On 2/18/2014 at 1:30PM, E2 stated "If a crime was commited I would call IDPH and the local police within two hours per policy." R40's nursing progress note, completed by E1, dated 7/30/2013 note text states late entry: "spoke to (Z2) about missing Rolex watch. Explained would look at documentation and get back to him 7/19/2013. Today spoke to son- Rolex watch valued at 1,000 dollars per inventory sheet could not be located. Notified Regional Operations Director of lost item with explanation of unsure why it was not discussed with patient of family upon admission. The son relays today that was only nominal and not a good value. Watch not able to be located still today. last seen several months ago on patient (R40) per sons conversation. Son will refer to brother for value that is expected to be reimbursed by center for lost /stolen item." The note was written by E1. On 2/19/2014 at 9:05 AM, E3 (Social Services Director) stated "I remember him (R40) having a watch on his wrist that was silver with a white face and said Rolex on it. I think I talked to the family about him having this expensive watch because I was alarmed he (R40 ) had this watch due to his poor cognition ([MEDICAL CONDITION]) and confusion. I looked back through all my progress notes since he was admitted and could not find this documented." On 2/19/2014 at 8:55AM, Z1 (Paxton Police Sargent) stated " The department was notified that a Rolex watch was missing by a family member of a resident who had lived at the nursing home on 2/14/2014. The facility did not file a police report at this time. The family member said the watch was missing since 7/16/2013." On 2/19/2014 at 10:00AM, The facility safe contents were checked with E10 (Business Office Manager) with no watch being found. E10 stated occasionally a residents personal item will be locked in the safe, but facility policy is that the family must retrieve the item within 24 hours. On 2/19/2014 at 10:15 AM the five secure medication carts in the building were also checked for the watch. No watch was found.

Based on observation, interview, and record review, the facility failed to respond to a reported allegation of the inappropriate sexual touching of R23 by R18. The facility failed to protect male residents from alleged perpetrator R18, failed to investigate the allegation of inappropriate sexual touching, and failed to report the allegations of inappropriate sexual touching to the State Licensing and Certification Agency and the local law enforcement agency. This failure resulted in a second incident of inappropriate touching of another male resident (R19) by R18, and a third incident of inappropriate touching of a male resident (R26) by R18. R18, R19, R23, and R26 are four of four residents reviewed for abuse in the sample of 19. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 12/04/13, the facility remains out of compliance at a severity level two in that the facility is in the process of monitoring the effectiveness of staff retraining directed at identification, reporting, investigation, and resident protection related to abuse. Findings include: 1. R23's Physician order [REDACTED]. R23's Minimum Data Sets ((MDS) dated [DATE], 6/06/13, and 9/05/13 document that R23 is severely cognitively impaired, requires extensive assistance with bed mobility and total assistance with transferring and locomotion on the unit, and has highly impaired vision. R19's POS dated 12/2013 documents the following Diagnoses: [REDACTED]. R19's MDS dated [DATE] documents that R19 is moderately cognitively impaired and requires supervision with ambulation and transferring, and extensive assistance with dressing and bathing. R26's MDS dated [DATE] documents that R26 is severely cognitively impaired, and requires extensive assistance with bed mobility, transferring, and Activities of Daily Living (ADL). R18's MDS dated [DATE] and 09/12/13 documents that R18 is cognitively intact, has no range of motion limitations of his upper and lower extremities, and moves about the facility independently without supervision. R18's Care Plan initiated on 10/12/12 and revised on 9/25/13, documents that R18 has a history of inappropriate sexual touching of male residents and that staff is to provide supervision in social gatherings/recreation programs. On 12/04/13 at 1:00pm, R18 propelled himself independently in his wheelchair in the halls of the facility. R18's Progress Notes dated 04/24/13 at 3:42pm document that "(R18) had his hand down the front of (R23's) pants" in the public observation area across from the nurse's station. On 12/04/13 at 2:20pm, E11, Certified Nursing Assistant (CNA), stated that on 04/24/13 she witnessed R18 sitting with his wheelchair very close to R23's reclining geriatric chair. E11 stated that R18 had his left hand down inside the front of R23's pants and his (R18's) right hand on his own lap. E11 stated that she told R18 to "Stop," and immediately took R23 to the nurse on duty to report R18's inappropriate touching of R23 (E11 stated she does not remember the nurse's name). On 12/5/13 at 10:00am, E1, Administrator, stated that R18's inappropriate touching of R23 was reported to her on 04/24/13, that no investigation was conducted, and that no protection from R18 was provided for male residents. E1 stated that she did not report the allegation of inappropriate touching to the State Licensing and Certification Agency or to local law enforcement. 2. R18's Progress Notes dated 08/10/13 at 12:30pm document that R18 was in the dining room sitting at the dining table with R19. The Progress Notes document that R18 asked R19 if he could see his penis, and that he (R18) touched R19's penis. On 12/04/13 at 11:25am, E12, Housekeeping/Laundry Aide, stated that on 08/10/13 she witnessed R18 ask R19 if he could see his penis because he had not "seen a black one." E12 stated that R19 stood up from the dining room table, dropped his pants, and showed R18 his penis. E12 stated that R18 touched R19's penis. E11 stated that there were "a few other residents" also present in the dining room at that time. E12 stated that she immediately removed R19 from the dining room and took him to the nurse on duty. E12 stated that she immediately reported the inappropriate touching to the nurse on duty and E2, Director of Nursing (DON). E12 stated that she does not remember the nurse's name to whom she reported the incident. On 12/05/13 at 11:15am, R19 stated that R18 repeatedly asked to see his penis, so R19 stated he finally showed it to R18. On 12/5/13 at 10:00am, E1, Administrator, stated that R18's inappropriate touching of R19 was reported to her on 08/12/13, two days after the incident occurred, and that no investigation was conducted, and that no protection from R18 was provided for male residents. E1 stated that she did not report the allegation of inappropriate touching to the State Licensing and Certification Agency or to local law enforcement. 3. R18's Progress Notes dated 12/01/13 at 3:55pm documents that R18 was found in R26's room touching R26's genitals. E16, CNA, wrote in her statement dated 12/01/13 "(R18) was holding (R26's) brief down with his right hand and with his left hand fondling (R26's) penis. R26 was swinging his right hand." On 12/03/13 at 11:10am, E1, Administrator, stated that on 12/01/13 R18 was found in R26's room standing next to R26's bed, holding R26's pants open with one hand and touching R26's genitals with his other hand. On 12/06/13 at 11:52am, E15, Registered Nurse (RN), stated that on 12/01/13, R18 was found holding open R26's pants and touching R26's genitals. On 12/04/13 at 10:25am, Z2, Primary Care Physician (PCP), stated "(R18) knows what he is doing--what (R18) is doing is criminal... We need to address this (R18's behavior) more aggressively." R18's Progress Notes document the following incidents: 8/15/13 3:30pm- R18 pushed a male resident (R28) into a dark Hospice room. E14, Licensed Practical Nurse (LPN) documented that R28 told staff "Oh no, get me out of here." On 12/04/13 at 3:37pm, R28 stated "(R18) pushed me in my wheelchair into a dark room. (R18) is up to no good. (R18) keeps trying to drag me into his room... something about his penis. I just stay away from him." R28's MDS dated [DATE] documents that R28 is moderately cognitively impaired. 8/24/13 3:13pm-R18 "caught trying to get another resident (R29) into his bathroom." On 12/06/13 at 10:15am, R29 stated that R18 entered his (R29's) bathroom and watched R29 urinate. R29 stated that he yelled at R18 to get out. R29 stated that he reported the incident to E13, Activity Director. R29's MDS dated [DATE] and 11/14/13 document that R29 is cognitively intact. 8/24/13 3:38pm-"(R18) came out of (R7's) room...(R7) stated that (R18) had entered his room wanting to give him a massage." On 12/04/13 at 11:55am, R7 stated that R18 had entered his (R7's) room while R7 was asleep in bed. R7 stated that he awoke when R18 placed his hand on R7's stomach. R7's MDS dated [DATE] documents that R7 is cognitively intact. 09/04/13 4:14pm-"(R18)...invited the other patient (R27) to his room to watch football and that (R18) was just patting him on the leg saying look at that on the TV." R27's MDS dated [DATE] documents that R27 is severely cognitively impaired. 09/14/13 3:48pm-R18 found in another male resident's (R23) room, sitting close to (R23's) bed. "(R23) was lying in bed and his brief was undone with genitals exposed." R23's Progress notes dated 04/03/13 through 12/04/13 document no behaviors in which R23 removes his own brief, exposing himself. R23's POS dated 12/2013 documents that R23 has left sided paresis, dementia, and is totally dependent functionally. On 12/04/13 at 9:45pm, E1 stated that the above incidents had been reported to her as follows: the incident of 04/23/13 reported on 04/23/13; incident 08/10/13 reported on 08/12/13; incident 08/15/13 reported on 08/15/13; incidents 08/24/13 at 3:13pm and 3:38pm reported on 08/24/13; incident on 09/04/13 reported on 09/04/13; incident 09/14/13 reported on 09/16/13. E1 stated that the incidents were not investigated or reported to the State Licensing and Certification Agency, and that no protection from R18 was provided to male residents. R18's Progress Notes dated 04/24/13 and 09/14/13 document that E13, Activity Director, spoke with R18 (following the incidents of the same dates) regarding his inappropriate behavior. R18's Progress Notes dated 08/15/13, 09/13/13, and 09/16/13 written by E3, Social Service Director (SSD), document that E3 spoke with R18 regarding R18's inappropriate behavior that had a "sexual tone." On 12/04/13 at 11:55am, E3 stated "Those (behaviors) are sexual abuse. We missed something here." The Facility's Abuse, Neglect and Misappropriation of Patient Property Prevention Policy (2012) identifies sexual abuse as sexual harassment, sexual coercion, or sexual assault, and directs that all allegations of abuse are to be immediately reported to the administrator of the facility. The Policy further directs that the alleged abuser will immediately be removed from contact with residents, that a thorough investigation will be conducted on "any allegations of abuse," and that allegations of abuse will be immediately reported to the State Licensing and Certification Agency. The Policy directs staff to file a report with local law enforcement if a crime has occurred against a resident. On 12/04/13 at 5:30pm, E18, Corporate Consultant, stated that she felt the facility staff did not follow the facility's Abuse Policy because they did not recognize R18's inappropriate sexual touching as abuse due to their "normalizing" of R18's behavior. The facility's undated Mood and Behavior Practice Guide describes normalization as "When we do not intervene with a behavioral symptom ...because 'The patient always does that,' or 'It's just Joe being Joe,' or 'That's normal for them.'" On 12/04/13 at 1:00pm, E1, Administrator, stated that until she began the investigation of the inappropriate touching of R26 by R18 which occurred on 12/01/13, she was unaware of the pattern of R18's behavior. E1 stated that she was unaware that R18 had touched any other residents (R23, R19) in a sexually inappropriate manner. On 12/04/13 an Immediate Jeopardy was identified to have begun on 04/24/13 when staff failed to investigate allegations of the sexual abuse (of R23) by R18 and failed to protect male residents from subsequent incidents of inappropriate touching by R18. The facility also failed to report to the State Licensing and Certification Agency and to local law enforcement allegations of the sexual abuse (of R23) by R18. On 12/04/13 at 5:00pm, E1, Administrator, was notified of the Immediate Jeopardy. The Immediate Jeopardy was removed on 12/04/13. The surveyor confirmed through observation, interview, and record review on 12/04/13 that the facility took the following actions to remove the Immediate Jeopardy: 1. On 12/04/13 at 5:30pm, E1, Administrator, moved R18 to a private room across from the Nurse's Station. 2. R18 placed on 1:1 constant supervision on 12/02/13 at 3:30pm by E1. 3. Administrator and Core Managers inserviced (re-educated) by Corporate Consultant on Abuse Guidelines, Behavior Guidelines, Normalizing Behaviors, and PREVENT Guidelines on 12/02/13. 4. Corporate Consultant completed 100% Staff Education related to Abuse Guidelines, Behavior Guidelines, Normalizing Behaviors, and PREVENT Guidelines on 12/02/13.

Based on observation, interview, and record review, the facility failed to operationalize its Abuse and Neglect Policy for R18, R19, R23, and R26. The facility failed to follow their policy which requires them to protect male residents from an alleged perpetrator (R18) of inappropriate sexual touching. The facility failed to follow their policy which requires them to identify, investigate, and report allegations of inappropriate sexual touching. These policy implementation failures resulted in a second incident of inappropriate sexual touching of another male resident (R19) by R18, and a third incident of inappropriate sexual touching of a male resident (R26) by R18. Repetitious policy failures resulted in neglect of R18, R19, R23, and R26. R18, R19, R23, and R26 are four of four residents reviewed for abuse in the sample of 19. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 12/04/13, the facility remains out of compliance at a severity level two in that the facility is in the process of monitoring the effectiveness of staff retraining directed at identification, reporting, investigation, and resident protection related to abuse. Findings include: 1. R23's Physician order [REDACTED]. R23's Minimum Data Sets ((MDS) dated [DATE], 6/06/13, and 9/05/13 document that R23 is severely cognitively impaired, requires extensive assistance with bed mobility and total assistance with transferring and locomotion on the unit, and has highly impaired vision. R19's POS dated 12/2013 documents the following Diagnoses: [REDACTED]. R19's MDS dated [DATE] documents that R19 is moderately cognitively impaired and requires supervision with ambulation and transferring, and extensive assistance with dressing and bathing. R26's MDS dated [DATE] documents that R26 is severely cognitively impaired, and requires extensive assistance with bed mobility, transferring, and Activities of Daily Living (ADL). R18's MDS dated [DATE] and 09/12/13 documents that R18 is cognitively intact, has no range of motion limitations of his upper and lower extremities, and moves about the facility independently without supervision. R18's Care Plan initiated on 10/12/12 and revised on 9/25/13, documents that R18 has a history of inappropriate sexual touching of male residents and that staff is to provide supervision in social gatherings/recreation programs. On 12/04/13 at 1:00pm, R18 propelled himself independently in his wheelchair in the halls of the facility. R18's Progress Notes dated 04/24/13 at 3:42pm document that "(R18) had his hand down the front of (R23's) pants" in the public observation area across from the nurse's station. On 12/04/13 at 2:20pm, E11, Certified Nursing Assistant (CNA), stated that on 04/24/13 she witnessed R18 sitting with his wheelchair very close to R23's reclining geriatric chair. E11 stated that R18 had his left hand down inside the front of R23's pants and his (R18's) right hand on his own lap. E11 stated that she told R18 to "Stop," and immediately took R23 to the nurse on duty to report R18's inappropriate touching of R23 (E11 stated she does not remember the nurse's name). On 12/5/13 at 10:00am, E1, Administrator, stated that R18's inappropriate touching of R23 was reported to her on 04/24/13, that no investigation was conducted, and that no protection from R18 was provided for male residents. E1 stated that she did not report the allegation of inappropriate touching to the State Licensing and Certification Agency or to local law enforcement. 2. R18's Progress Notes dated 08/10/13 at 12:30pm document that R18 was in the dining room sitting at the dining table with R19. The Progress Notes document that R18 asked R19 if he could see his penis, and that he (R18) touched R19's penis. On 12/04/13 at 11:25am, E12, Housekeeping/Laundry Aide, stated that on 08/10/13 she witnessed R18 ask R19 if he could see his penis because he had not "seen a black one." E12 stated that R19 stood up from the dining room table, dropped his pants, and showed R18 his penis. E12 stated that R18 touched R19's penis. E11 stated that there were "a few other residents" also present in the dining room at that time. E12 stated that she immediately removed R19 from the dining room and took him to the nurse on duty. E12 stated that she immediately reported the inappropriate touching to the nurse on duty and E2, Director of Nursing (DON). E12 stated that she does not remember the nurse's name to whom she reported the incident. On 12/05/13 at 11:15am, R19 stated that R18 repeatedly asked to see his penis, so R19 stated he finally showed it to R18. On 12/5/13 at 10:00am, E1, Administrator, stated that R18's inappropriate touching of R19 was reported to her on 08/12/13, two days after the incident occurred, and that no investigation was conducted, and that no protection from R18 was provided for male residents. E1 stated that she did not report the allegation of inappropriate touching to the State Licensing and Certification Agency or to local law enforcement. 3. R18's Progress Notes dated 12/01/13 at 3:55pm documents that R18 was found in R26's room touching R26's genitals. E16, CNA, wrote in her statement dated 12/01/13 "(R18) was holding (R26's) brief down with his right hand and with his left hand fondling (R26's) penis. R26 was swinging his right hand." On 12/03/13 at 11:10am, E1, Administrator, stated that on 12/01/13 R18 was found in R26's room standing next to R26's bed, holding R26's pants open with one hand and touching R26's genitals with his other hand. On 12/06/13 at 11:52am, E15, Registered Nurse (RN), stated that on 12/01/13, R18 was found holding open R26's pants and touching R26's genitals. On 12/04/13 at 10:25am, Z2, Primary Care Physician (PCP), stated "(R18) knows what he is doing--what (R18) is doing is criminal... We need to address this (R18's behavior) more aggressively." R18's Progress Notes document the following incidents: 8/15/13 3:30pm- R18 pushed a male resident (R28) into a dark Hospice room. E14, Licensed Practical Nurse (LPN) documented that R28 told staff "Oh no, get me out of here." On 12/04/13 at 3:37pm, R28 stated "(R18) pushed me in my wheelchair into a dark room. (R18) is up to no good. (R18) keeps trying to drag me into his room... something about his penis. I just stay away from him." R28's MDS dated [DATE] documents that R28 is moderately cognitively impaired. 8/24/13 3:13pm-R18 "caught trying to get another resident (R29) into his bathroom." On 12/06/13 at 10:15am, R29 stated that R18 entered his (R29's) bathroom and watched R29 urinate. R29 stated that he yelled at R18 to get out. R29 stated that he reported the incident to E13, Activity Director. R29's MDS dated [DATE] and 11/14/13 document that R29 is cognitively intact. 8/24/13 3:38pm-"(R18) came out of (R7's) room...(R7) stated that (R18) had entered his room wanting to give him a massage." On 12/04/13 at 11:55am, R7 stated that R18 had entered his (R7's) room while R7 was asleep in bed. R7 stated that he awoke when R18 placed his hand on R7's stomach. R7's MDS dated [DATE] documents that R7 is cognitively intact. 09/04/13 4:14pm-"(R18)...invited the other patient (R27) to his room to watch football and that (R18) was just patting him on the leg saying look at that on the TV." R27's MDS dated [DATE] documents that R27 is severely cognitively impaired. 09/14/13 3:48pm-R18 found in another male resident's (R23) room, sitting close to (R23's) bed. "(R23) was lying in bed and his brief was undone with genitals exposed." R23's Progress notes dated 04/03/13 through 12/04/13 document no behaviors in which R23 removes his own brief, exposing himself. R23's POS dated 12/2013 documents that R23 has left sided paresis, dementia, and is totally dependent functionally. On 12/04/13 at 9:45pm, E1 stated that the above incidents had been reported to her as follows: the incident of 04/23/13 reported on 04/23/13; incident 08/10/13 reported on 08/12/13; incident 08/15/13 reported on 08/15/13; incidents 08/24/13 at 3:13pm and 3:38pm reported on 08/24/13; incident on 09/04/13 reported on 09/04/13; incident 09/14/13 reported on 09/16/13. E1 stated that the incidents were not investigated or reported to the State Licensing and Certification Agency, and that no protection from R18 was provided to male residents. R18's Progress Notes dated 04/24/13 and 09/14/13 document that E13, Activity Director, spoke with R18 (following the incidents of the same dates) regarding his inappropriate behavior. R18's Progress Notes dated 08/15/13, 09/13/13, and 09/16/13 written by E3, Social Service Director (SSD), document that E3 spoke with R18 regarding R18's inappropriate behavior that had a "sexual tone." On 12/04/13 at 11:55am, E3 stated "Those (behaviors) are sexual abuse. We missed something here." The Facility's Abuse, Neglect and Misappropriation of Patient Property Prevention Policy (2012) identifies sexual abuse as sexual harassment, sexual coercion, or sexual assault, and directs that all allegations of abuse are to be immediately reported to the administrator of the facility. The Policy further directs that the alleged abuser will immediately be removed from contact with residents, that a thorough investigation will be conducted on "any allegations of abuse," and that allegations of abuse will be immediately reported to the State Licensing and Certification Agency. The Policy directs staff to file a report with local law enforcement if a crime has occurred against a resident. On 12/04/13 at 5:30pm, E18, Corporate Consultant, stated that she felt the facility staff did not follow the facility's Abuse Policy because they did not recognize R18's inappropriate sexual touching as abuse due to their "normalizing" of R18's behavior. The facility's undated Mood and Behavior Practice Guide describes normalization as "When we do not intervene with a behavioral symptom ...because 'The patient always does that,' or 'It's just Joe being Joe,' or 'That's normal for them.'" On 12/04/13 at 1:00pm, E1, Administrator, stated that until she began the investigation of the inappropriate touching of R26 by R18 which occurred on 12/01/13, she was unaware of the pattern of R18's behavior. E1 stated that she was unaware that R18 had touched any other residents (R23, R19) in a sexually inappropriate manner. On 12/04/13 an Immediate Jeopardy was identified to have begun on 04/24/13 when staff failed to investigate allegations of the sexual abuse (of R23) by R18 and failed to protect male residents from subsequent incidents of inappropriate touching by R18. The facility also failed to report to the State Licensing and Certification Agency and to local law enforcement allegations of the sexual abuse (of R23) by R18. On 12/04/13 at 5:00pm, E1, Administrator, was notified of the Immediate Jeopardy. The Immediate Jeopardy was removed on 12/04/13. The surveyor confirmed through observation, interview, and record review on 12/04/13 that the facility took the following actions to remove the Immediate Jeopardy: 1. On 12/04/13 at 5:30pm, E1, Administrator, moved R18 to a private room across from the Nurse's Station. 2. R18 placed on 1:1 constant supervision on 12/02/13 at 3:30pm by E1. 3. Administrator and Core Managers inserviced (re-educated) by Corporate Consultant on Abuse Guidelines, Behavior Guidelines, Normalizing Behaviors, and PREVENT Guidelines on 12/02/13. 4. Corporate Consultant completed 100% Staff Education related to Abuse Guidelines, Behavior Guidelines, Normalizing Behaviors, and PREVENT Guidelines on 12/02/13.

Based on interview and record review, facility Administration failed to ensure that incidents of sexual abuse involving R18, R19, and R23 were identified, failed to ensure that allegations of sexual abuse involving R18, R19, and R23 were thoroughly investigated, and failed to ensure that allegations of sexual abuse involving R18, R19, and R23 were reported to the State Licensing and Certification Agency and to the local law enforcement agency. The facility Administration failed to ensure that male residents at risk for sexual abuse were protected (R19, R26). R18, R19, R23, and R26 are four of four residents reviewed for abuse in the sample of 19. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 12/04/13, the facility remains out of compliance at a severity level two in that the facility is in the process of monitoring the effectiveness of staff retraining directed at identification, reporting, investigation, and resident protection related to abuse. Findings include: 1. F223- Based on observation, interview, and record review, the facility failed to identify an allegation of inappropriate touching of a male resident (R23) by R18 as sexual abuse. This failure resulted in a second incident of inappropriate touching of another male resident (R19) by R18, and a third incident of inappropriate touching of a male resident(R26) by R18. This failure to identify the inappropriate touching as sexual abuse resulted in the alleged perpetrator of the abuse, R18, having continued access to other male residents in the facility. These failures resulted in an Immediate Jeopardy. 2. F224- Based on observation, interview, and record review, the facility failed to operationalize its Abuse and Neglect Policy for R18, R19, R23, and R26. The facility failed to follow their policy which requires them to protect male residents from an alleged perpetrator (R18) of inappropriate sexual touching. The facility failed to follow their policy which requires them to identify, investigate, and report allegations of inappropriate sexual touching. These policy implementation failures resulted in a second incident of inappropriate sexual touching of another male resident (R19) by R18, and a third incident of inappropriate sexual touching of a male resident (R26) by R18. Repetitious policy failures resulted in neglect of R18, R19, R23, and R26. R18, R19, R23, and R26 are four of four residents reviewed for abuse in the sample of 19. These failures resulted in an Immediate Jeopardy. 3. F225- Based on observation, interview, and record review, the facility failed to respond to a reported allegation of the inappropriate sexual touching of R23 by R18. The facility failed to protect male residents from alleged perpetrator R18, failed to investigate the allegation of inappropriate sexual touching, and failed to report the allegations of inappropriate sexual touching to the State Licensing and Certification Agency and the local law enforcement agency. This failure resulted in a second incident of inappropriate touching of another male resident (R19) by R18, and a third incident of inappropriate touching of a male resident (R26) by R18. These failures resulted in an Immediate Jeopardy. 4. F226- Based on observation, interview, and record review, the facility failed to operationalize its Policy and Procedures to protect male residents from an alleged perpetrator (R18) of inappropriate sexual touching, and failed to identify, investigate, and report allegations of inappropriate sexual touching. These failures resulted in a second incident of inappropriate sexual touching of another male resident (R19) by R18, and a third incident of inappropriate sexual touching of a male resident (R26) by R18. These failures resulted in an Immediate Jeopardy. On 12/04/13 an Immediate Jeopardy was identified to have begun on 04/24/13 when staff failed to investigate allegations of the sexual abuse (of R23) by R18 and failed to protect male residents from subsequent incidents of inappropriate touching by R18. The facility also failed to report to the State Licensing and Certification Agency and to local law enforcement allegations of the sexual abuse (of R23) by R18. On 12/04/13 at 5:00pm, E1, Administrator, was notified of the Immediate Jeopardy. The Immediate Jeopardy was removed on 12/04/13. The surveyor confirmed through observation, interview, and record review on 12/04/13 that the facility took the following actions to remove the Immediate Jeopardy: 1. On 12/04/13 at 5:30pm, E1, Administrator, moved R18 to a private room across from the Nurse's Station. 2. R18 placed on 1:1 constant supervision on 12/02/13 at 3:30pm by E1. 3. Administrator and Core Managers inserviced (re-educated) by Corporate Consultant on Abuse Guidelines, Behavior Guidelines, Normalizing Behaviors, and PREVENT Guidelines on 12/02/13. 4. Corporate Consultant completed 100% Staff Education related to Abuse Guidelines, Behavior Guidelines, Normalizing Behaviors, and PREVENT Guidelines on 12/02/13.

Based on observation, interview, and record review, the facility failed to identify an allegation of inappropriate touching of a male resident (R23) by R18 as sexual abuse. This failure resulted in a second incident of inappropriate touching of another male resident (R19) by R18, and a third incident of inappropriate touching of a male resident(R26) by R18. This failure to identify the inappropriate touching as sexual abuse resulted in the alleged perpetrator of the abuse, R18, having continued access to other male residents in the facility. R19, R23, and R26 are three of four residents reviewed for abuse in the sample of 19. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 12/04/13, the facility remains out of compliance at a severity level two in that the facility is in the process of monitoring the effectiveness of staff retraining directed at identification, reporting, investigation, and resident protection related to abuse. Findings include: 1. R23's Physician order [REDACTED]. R23's Minimum Data Sets ((MDS) dated [DATE], 6/06/13, and 9/05/13 document that R23 is severely cognitively impaired, requires extensive assistance with bed mobility and total assistance with transferring and locomotion on the unit, and has highly impaired vision. R19's POS dated 12/2013 documents the following Diagnoses: [REDACTED]. R19's MDS dated [DATE] documents that R19 is moderately cognitively impaired and requires supervision with ambulation and transferring, and extensive assistance with dressing and bathing. R26's MDS dated [DATE] documents that R26 is severely cognitively impaired, and requires extensive assistance with bed mobility, transferring, and Activities of Daily Living (ADL). R18's MDS dated [DATE] and 09/12/13 documents that R18 is cognitively intact, has no range of motion limitations of his upper and lower extremities, and moves about the facility independently without supervision. R18's Care Plan initiated on 10/12/12 and revised on 9/25/13, documents that R18 has a history of inappropriate sexual touching of male residents and that staff is to provide supervision in social gatherings/recreation programs. On 12/04/13 at 1:00pm, R18 propelled himself independently in his wheelchair in the halls of the facility. R18's Progress Notes dated 04/24/13 at 3:42pm document that "(R18) had his hand down the front of (R23's) pants" in the public observation area across from the nurse's station. On 12/04/13 at 2:20pm, E11, Certified Nursing Assistant (CNA), stated that on 04/24/13 she witnessed R18 sitting with his wheelchair very close to R23's reclining geriatric chair. E11 stated that R18 had his left hand down inside the front of R23's pants and his (R18's) right hand on his own lap. E11 stated that she told R18 to "Stop," and immediately took R23 to the nurse on duty to report R18's inappropriate touching of R23 (E11 stated she does not remember the nurse's name). On 12/5/13 at 10:00am, E1, Administrator, stated that R18's inappropriate touching of R23 was reported to her on 04/24/13,that no investigation was conducted, and that no protection from R18 was provided for male residents. 2. R18's Progress Notes dated 08/10/13 at 12:30pm document that R18 was in the dining room sitting at the dining table with R19. The Progress Notes document that R18 asked R19 if he could see his penis, and that he (R18) touched R19's penis. On 12/04/13 at 11:25am, E12, Housekeeping/Laundry Aide, stated that on 08/10/13 she witnessed R18 ask R19 if he could see his penis because he had not "seen a black one." E12 stated that R19 stood up from the dining room table, dropped his pants, and showed R18 his penis. E12 stated that R18 touched R19's penis. E11 stated that there were "a few other residents" also present in the dining room at that time. E12 stated that she immediately removed R19 from the dining room and took him to the nurse on duty. E12 stated that she immediately reported the inappropriate touching to the nurse on duty and E2, Director of Nursing (DON). E12 stated that she does not remember the nurse's name to whom she reported the incident. On 12/05/13 at 11:15am, R19 stated that R18 repeatedly asked to see his penis, so R19 stated he finally showed it to R18. On 12/5/13 at 10:00am, E1, Administrator, stated that R18's inappropriate touching of R19 was reported to her on 08/12/13, two days after the incident occurred, and that no investigation was conducted, and that no protection from R18 was provided for male residents. 3. R18's Progress Notes dated 12/01/13 at 3:55pm documents that R18 was found in R26's room touching R26's genitals. E16, CNA, wrote in her statement dated 12/01/13 "(R18) was holding (R26's) brief down with his right hand and with his left hand fondling (R26's) penis. R26 was swinging his right hand." On 12/03/13 at 11:10am, E1, Administrator, stated that on 12/01/13 R18 was found in R26's room standing next to R26's bed, holding R26's pants open with one hand and touching R26's genitals with his other hand. On 12/06/13 at 11:52am, E15, Registered Nurse (RN), stated that on 12/01/13, R18 was found holding open R26's pants and touching R26's genitals. On 12/04/13 at 10:25am, Z2, Primary Care Physician (PCP), stated "(R18) knows what he is doing--what (R18) is doing is criminal... We need to address this (R18's behavior) more aggressively." R18's Progress Notes document the following incidents: 08/15/13 3:30pm- R18 pushed a male resident (R28) into a dark Hospice room. E14, Licensed Practical Nurse (LPN) documented that R28 told staff "Oh no, get me out of here." On 12/04/13 at 3:37pm, R28 stated "(R18) pushed me in my wheelchair into a dark room. (R18) is up to no good. (R18) keeps trying to drag me into his room... something about his penis. I just stay away from him." R28's MDS dated [DATE] documents that R28 is moderately cognitively impaired. 08/24/13 3:13pm-R18 "caught trying to get another resident (R29) into his bathroom." On 12/06/13 at 10:15am, R29 stated that R18 entered his (R29's) bathroom and watched R29 urinate. R29 stated that he yelled at R18 to get out. R29 stated that he reported the incident to E13, Activity Director. R29's MDS dated [DATE] and 11/14/13 document that R29 is cognitively intact. 08/24/13 3:38pm-"(R18) came out of (R7's) room...(R7) stated that (R18) had entered his room wanting to give him a massage." On 12/04/13 at 11:55am, R7 stated that R18 had entered his (R7's) room while R7 was asleep in bed. R7 stated that he awoke when R18 placed his hand on R7's stomach. R7's MDS dated [DATE] documents that R7 is cognitively intact. 09/04/13 4:14pm-"(R18)...invited the other patient (R27) to his room to watch football and that (R18) was just patting him on the leg saying look at that on the TV." R27's MDS dated [DATE] documents that R27 is severely cognitively impaired. 09/14/13 3:48pm-R18 found in another male resident's (R23) room, sitting close to (R23's) bed. "(R23) was lying in bed and his brief was undone with genitals exposed." R23's Progress notes dated 04/03/13 through 12/04/13 document no behaviors in which R23 removes his own brief, exposing himself. R23's POS dated 12/2013 documents that R23 has left sided paresis, dementia, and is totally dependent functionally. On 12/04/13 at 9:45pm, E1 stated that the above incidents had been reported to her as follows: the incident of 04/23/13 reported on 04/23/13; incident 08/10/13 reported on 08/12/13; incident 08/15/13 reported on 08/15/13; incidents 08/24/13 at 3:13pm and 3:38pm reported on 08/24/13; incident on 09/04/13 reported on 09/04/13; incident 09/14/13 reported on 09/16/13. E1 stated that the incidents were not investigated or reported to the State Licensing and Certification Agency, and that no protection from R18 was provided to male residents. R18's Progress Notes dated 04/24/13 and 09/14/13 document that E13, Activity Director, spoke with R18 (following the incidents of the same dates) regarding his inappropriate behavior. R18's Progress Notes dated 08/15/13, 09/13/13, and 09/16/13 written by E3, Social Service Director (SSD), document that E3 spoke with R18 regarding R18's inappropriate behavior that had a "sexual tone." On 12/04/13 at 11:55am, E3 stated "Those (behaviors) are sexual abuse. We missed something here." The Facility's Abuse, Neglect and Misappropriation of Patient Property Prevention Policy (2012) identifies sexual abuse as sexual harassment, sexual coercion, or sexual assault, and directs that all allegations of abuse are to be immediately reported to the administrator of the facility. The Policy further directs that the alleged abuser will immediately be removed from contact with residents and that a thorough investigation will be conducted on "any allegations of abuse." On 12/04/13 an Immediate Jeopardy was identified to have begun on 04/24/13 when staff failed to identify, and investigate allegations of the sexual abuse (of R23) by R18. Facility staff also failed to protect male residents from subsequent incidents of inappropriate touching by R18. On 12/04/13 at 5:00pm, E1, Administrator, was notified of the Immediate Jeopardy. The Immediate Jeopardy was removed on 12/04/13. The surveyor confirmed through observation, interview, and record review on 12/04/13 that the facility took the following actions to remove the Immediate Jeopardy: 1. On 12/04/13 at 5:30pm, E1, Administrator, moved R18 to a private room across from the Nurse's Station. 2. R18 placed on 1:1 constant supervision on 12/02/13 at 3:30pm by E1. 3. Administrator and Core Managers inserviced (re-educated) by Corporate Consultant on Abuse Guidelines, Behavior Guidelines, Normalizing Behaviors, and PREVENT Guidelines on 12/02/13. 4. Corporate Consultant completed 100% Staff Education related to Abuse Guidelines, Behavior Guidelines, Normalizing Behaviors, and PREVENT Guidelines on 12/02/13.

A.) Based on record review and interview, the facility failed to have interventions in place to help prevent falls for one of seven residents (R1) reviewed for falls out of a sample of 19. This failure contributed to a fall with fractures of the pubis and humerus, which required surgical repair. Findings include: According to the current [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] and 10/24/13 respectively assesses R1 with severe cognitive impairment, weights of 100 pounds, and requiring limited to extensive assistance for transfers, locomotion, and activities of daily living (ADLs.)These MDSs show R1 requires extensive assistance of two staff for toileting. Original admission records and initial nurses notes dated 12/25/12 state R1 was admitted to the facility on that date following a fall at home resulting in a fractured hip. The Incident Report dated 3/24/13 at 11:30pm stated that R1 was heard yelling for help, and R1 was found on the floor in the bathroom. R1 sustained a skin tear with this fall. The Conclusion section in the Investigation Report states the following: ". . .nonskid socks replaced with slippers. {R1} doesn't want to be assisted to bathroom, will not use call light even after instructions, this is not uncommon for this resident. Will continue to monitor. . . .Pt (patient) educated regarding proper footwear and use of call light." . . .Will continue with plan of care until time of surgery." No fall risk recommendations or interventions were identified in this report related to refusing care or impaired cognition. Nurses notes state that R1 was discharged home with family on 4/5/2013, but then was readmitted on [DATE] when the family was unable to care for R1 at home. The Careplan last reviewed on 11/7/13 states R1 is at risk for falls due to "history of falls, potential medication side effects, impaired mobility, difficulty walking, weakness, arthralgia, osteoporosis." The stated goal is "minimize risk for falls." Both focus and goal was initiated on 4/11/13. Interventions include administration of medications, "encourage to transfer and change positions slowly," "provide assist to transfer and ambulate as needed," reinforce need to call for assistance," "reinforce {wheelchair} safety as needed such as locking brakes," and other basic interventions. All these interventions are dated as initiated on 4/11/13. None of these interventions address R1's severe cognitive impairment or attempts to get up or transfer herself. The Incident Report dated 7/6/13 at 3:00pm states that R1 was "observed sitting on floor in her room near closet with wheelchair nearby." The Statement by E17 (Certified Nurse Aide) states that E17 heard R1 "yelling for help. . . .found {R1} on her L' (left) side on the floor near her closet. . . .her hand slipped trying to get into her closet and she fell . . . .{R1} was in a lot of pain and crying." This investigation does not include a Conclusion or recommendations for interventions. The undated Summary of the Investigation for this incident states that R1 "has confusion related to her Alzheimer's disease and dementia. She is oriented only to person. She needs assistance and encouragement/cueing with all of her ADLs. She needs reminders to use her call light and to ask for help from the staff. She is known for attempting to transfer herself and refusing to ask for assistance from staff. . .Will continue with plan of care until time of surgery." No fall risk recommendations or interventions were identified in this report related to impaired cognition. Nurses Notes dated 7/6/13 state that Z3 (Nurse Practitioner) was notified of the fall and the swelling and pain in the left elbow and coccyx area. According to the Nurse's Notes Z3 at first did not order R1 to go out to the hospital but to just apply ice. Upon further assessment and request of the family, R1 was sent to the hospital. X-rays done on 7/6/13 showed a "mildly displaced fracture of . . . .distal humeral metaphysis. . . ," and "mildly displaced fracture of the right os pubis." X-rays also show old fractures of the pubic rami, old T11 compression fracture, status [REDACTED]. According to the Nurse's Notes R1 returned to the facility the evening of 7/6/13, with a long-arm splint and orders to see Z1 (Orthopedist) Nurses notes state R1 was medicated for pain four times on 7/7/13, three times on 7/8/13, and twice on 7/9/13, prior to going out to see Z1. R1 returned from Z1 with a plan for surgical repair on 7/16/13. According to Nurse's Notes, R1 continued to be medicated for pain on 7/10, 7/11, 7/12, and 7/13/13. According to Nurse's Notes, R1 went to the hospital and had ORIF (open reduction internal fixation) of the left elbow on 7/16/13. R1 returned to the facility on [DATE]. No new or additional interventions were added to the careplan. The Incident Report dated 7/22/13 at 1:30pm, states that R1 was "discovered on her bathroom floor was incontinent of stool attempting to transfer self." R1 stated that she "didn't know what happened." Nurses notes for 7/22/13 state that when R1 was discovered "in the bathroom attempting to transfer self she still had ahold of bathroom bar. . . ." The Conclusion of the Investigation Report dated 7/22/13 stated that "will attempt to keep in area where she is supervised closely." Also added to this conclusion on 7/23/13 is "Sensor alarm applied to wheelchair. Res (resident) education performed. Staff education performed." The sensor alarm and checking the alarm were added to the careplan on 7/23/13. On 12/4/13 at 11:30am, these incidents and the careplan were reviewed with E2 (Director of Nursing.) E2 stated she thought that at some point they placed anti-roll bars on R1's wheelchair. E2 stated that R1 has had "many near misses," but that they (facility) does "not automatically put sensors on everyone." E2 agreed that education and reminders may not be as effective for a resident with cognitive impairment, but education is always done after an incident. On 12/5/13 at 9:30am, E7 (Registered Nurse) stated that after returning from surgery on 7/18/13, they thought R1 was in so much pain and didn't move, and would not be as much as a fall risk. According to Nurse's Notes, R1 then fell again on 7/22/13. E7 stated on 12/05/13 at 9:30am that she agreed that the careplan prior to 7/23/13 did not include specific interventions to prevent falls for R1, and that reminders/ encouragement may not be effective with this cognitively impaired resident. The facility Fall Practice Guide dated 12/2011, recommends multiple fall reduction and injury prevention strategies, including low beds, floor mats, hip protectors, and assistive devices. B.) Based on observation, record review and interview the facility failed to ensure that hot water available at resident handwashing sinks was at a safe temperature to prevent burn hazards to residents. The facility also failed to store potentially hazardous disinfecting wipes in a secure area to prevent resident access. These failures affected six of 16 residents (R1, R11, R12, R17,R19, R20) reviewed for safety in the sample of 19 and three residents (R31, R30, R29) in the supplemental sample. The findings include: 1. On 12/04/13 at 3:30 pm the 100 and 200 resident Wings were toured with Housekeeping Supervisor, E4. The hot water temperatures at random resident handwashing sinks, showers and bathtubs on the unit were checked. The hot water was measured to be from 116-119 degrees Fahrenheit (F.) and felt extremely hot to the touch. Housekeeping Supervisor E4 was present during the observations. The examples included: On 12/04/13 at 3:30 pm the hot water at the sink in the Central Bathing Room of the 100 wing registered 119 degrees Fahrenheit (F.). On 12/04/13 at 4:10 pm the hot water at the handwashing sink in R19's room measured 116 degrees F. at 4:10 pm. On 12/04/13 at 4:15 pm the hot water measured 117 degrees F. at R11's handwashing sink. R11 was seated in her wheelchair and was able to move her wheelchair independently. R11 is assessed as being severely cognitively impaired per the 11/14/13 quarterly Minimum Data Set (MDS). On 12/04/13 at 4:15 pm the hot water at the handwashing sink measured 119 degrees F. in R29's bedroom. On 12/04/13 at 4:30 pm the hot water measured 117 degrees F. at R30's sink. R30 was present and stated that the water was hotter than usual. On 12/04/13 at 4:25 pm the hot water at R12's room measured 119 degrees F. E4 was present at the time and stated she could see steam coming off the water. The water was very hot to touch. R12 is assessed as severely cognitively impaired per the 11/01/13 quarterly assessment. R12 was able to propel her wheelchair independently in the room and hallway on 12/03/13 at 10:00 am. R29 was present in the room and also propelling self in the wheelchair in the corridor at 4:25 pm. R29 could not answer any questions about the hot water due to her cognitive impairment. On 12/04/13 at 4:35 pm the hot water was measured to be 118 degrees F. at the handwashing sink in R20's room. On 12/04/13 at 4:40 pm the hot water at the handwashing sink shared by R1 and R17 measured 118 degrees F. The water was very hot to the touch. R1 was mobile in the wheelchair in the room and was very confused. R1 is assessed with [REDACTED]. R17's MDS dated [DATE] documents that R17 is severely cognitively impaired. Maintenance Director E5 stated on 12/04/13 at 5:45 pm that he had made an adjustment to the hot water setting on 12/04/13 around 7:00 am and stated he had turned off the recirculating pump at that time. E5 had forgotten to turn the recirculating pump back on which allowed the hot water temperature to get too high. E5 stated that he normally checks hot water temperatures in the morning when he gets to work, and stated he hasn't been checking temperatures in the evening. 2. On 12/04/13 at 9:20 am the three drawer isolation cart was in the hallway outside of R21's room. There was a box of 20 individually packaged bleach wipes and four loose packets in the drawer. Housekeeper E6 stated at the time, that staff wipe all surfaces in the isolation room with the bleach wipes. E6 stated that R21 was in Contact Isolation for a [DIAGNOSES REDACTED] (Clostridium difficile) infection. On 12/04/13 at 11:30 am the cart still contained the wipes and there were no staff in the vicinity. The label on the disinfectant wipes stated that the wipes contained 6500 parts per million (ppm) Sodium Hypochlorite. On 12/04/13 at 4:25 pm R31 was going through the top drawer of the isolation cart that was outside the door of R32's room. R31 had a roll of plastic bags in her hands. There was also a box of hospital cleaner disinfectant towels with bleach in individual packages in the drawer. The precautionary statement on the wipes said "Keep out of reach of children, Caution not to be used as a baby wipe. Contains 6500 ppm Sodium Hypochlorite Premoistened towels with 1:10 dilution of bleach 6% and detergent....Causes moderate eye irritation, Avoid contact with eyes or clothing." Housekeeping Supervisor E4 was present during the observation and assisted the resident away from the cart. E4 was not aware that the wipes should not be stored in the isolation cart.