Every finding on record at Accolade Healthcare of Peoria

Based on Observation, Interview and Record review, the facility failed to ensure a resident who is dependent for all turning and positioning, was safely positioned in bed during cares to avoid falling, conduct vital signs and a body assessment, initiate neurological checks, notify all appropriate parties, complete a fall assessment and update a residents care plan to adequately reflect their fall risk for three of three residents (R1, R2, R3) reviewed for falls in the sample of three. Findings include:1. R1's Care Plan, dated 4/10/26, documents R1 was admitted to the facility on [DATE] and has diagnoses of Heart Failure, Dementia, and Parkinson's Disease, this care plan also documents (R1) is at high risk for falls related to readmission, diagnoses of Parkinson's, and Dementia.R1's Nursing Progress notes, dated 4/10/26 and completed on 4/12/26 at 9:34 PM by V4 (Licensed Practical Nurse, LPN), documents Late Entry: CNA (Certified Nursing Assistant) reported to me that resident was on the dining room floor. This note continues on to document the resident was assessed and assisted back to a chair.R1's electronic medical record does not document any nursing notes for the 4/10 fall, a post fall assessment, neurological checks or notifications of the fall to the physician, family or director of nursing prior to 4/12/26.R1's Nursing Progress notes, dated 4/11/26 at 8:30 PM, documents R1 was transferred to the local emergency room for pain and swelling to R1's left leg.R1's Nursing Progress notes, dated 4/12/26 at 1:24 AM, documents R1 was admitted to the hospital with a diagnosis of left hip fracture.On 5/4/26 at 2:30 PM, V1 (Administrator) confirmed that R1 had a fall on 4/10/26 and there is not a fall assessment, nursing progress notes or documentation of the facility's post fall requirements until 4/12/26. V1 stated (V4, LPN) did not document a fall assessment, initiate neuro checks, 72-hour vital signs and post fall assessments, document that the fall occurred or notify nursing management until two days after the incident when the resident was in the hospital and found to have a fractured hip. V1 also stated The DON (Director of Nursing, V2) or a nurse manager was not made aware when the fall occurred (4/10/26) so upon learning of the fracture on 4/12/26, we talked with staff and found about (R1's) fall.2. R3's Care Plan, dated 3/23/26, documents R3 was admitted to the facility on [DATE] with diagnoses of Muscle Wasting, Neuromuscular Dysfunction, Paraplegia, Multiple Sclerosis, and Stage III Pressure Ulcer. This same care plan also documents (R3) is cognitively intact and has limited physical mobility related to decreased stamina and physical deconditioning, and multiple sclerosis. (R3) has a pressure ulcer to Left Ischium, sacrum related to disease process, Immobility, resident preference of bed position is back/head of bed elevated, air mattress. (R3) is at risk for falls related to impaired mobility.R3's Nursing Progress notes, dated 3/23/26, documents Resident experienced a witnessed fall during routine wound care this shift. Staff was assisting resident in bed when she slid from the surface. Resident stated she's not sure how she lost her grip. On 5/5/26 at 11:55 AM, R3 was sitting in her room in bed. R3 confirmed that her bed has an air mattress and that she recently had a fall from bed during wound care. R3 stated I can't control my lower legs so when the nurse (V11, Licensed Practical Nurse/ Wound Nurse) rolled me to my side during care, my momentum sent me over the other side. My leg was positioned over the leg underneath for my treatment and then I fell. That happened on 3/23/26. I feel scared when I am getting my treatment now unless someone stands in front of me. I don't want to fall out of bed again.3. R2's Care Plan, dated 12/16/25, documents R2 was admitted to the facility on [DATE] with diagnoses of Muscle Wasting and Atrophy, Unsteadiness on Feet, and Lack of Coordination. This same care plan documents (R2) is at Moderate risk for falls related to fall history.R2's Nursing Progress notes dated 12/16/26, document R2 suffered an unwitnessed fall in her room.R2's Fall Assessment, dated 12/16/25, documents R2 was identified at a High Risk for falls.On 5/5/26 at 2:00 PM, V1 (Administrator) confirmed R3 and R2 suffered falls while in the facility. V1 confirmed that R3 is paraplegic and unable to control her lower body and was placed on her side before falling from the bed. V1 confirmed R2's fall was unwitnessed in her room. V1 stated Staff are supposed to make sure that there are two in the room during (R3's) wound care now and (R2) was assessed to be at a high risk for falling. V1 confirmed that R2's care plan was not updated from moderate risk to high risk after falling in December 2025 and stated that it should have been updated to reflect her heightened risk of falling.The facility's Accidents and Incidents policy, dated 8/2/17, documents To provide staff with guidelines for investigating, reporting, and recording accidents and incidents. All accidents/ incidents involving a resident, visitor or volunteer will be investigated and then recorded in risk management of (electronic record). Incident reports will be retained in accordance with state statute of limitations and record-retention laws. It is the responsibility of the nurse to complete the accident and incident risk management report and notify physicians and responsible parties and document information accordingly. Accidents and incidents, including injuries of an unknown origin and accident/ incident report form must be completed on the shift that the accident or incident occurred. An employee witnessing an accident or incident involving a resident, employee, or visitor, must report such occurrence to his or her immediate supervisor as soon as practical. Do not leave an accident victim unattended unless it is necessary to summon assistance. The nurse must be informed of all accidents or incidents so that medical attention can be provided. This policy also documents The nurse shall examine all accidents/ incident victims. The medical director or the resident's personal physician shall be notified of the accident/ incident. The nurse must conduct an immediate investigation or the accident/ incident and implement appropriate interventions to affected parties. The risk management must be filled out completely. The nurse must also document the accident/ incident in the progress notes using the fall incident progress note if a resident is involved. SBAR (Situation, Background, Assessment, Recommendation), Fall Risk, and Pain assessments will be filled out following each fall. Neurological assessments will be initiated if fall is unwitnessed and there is suspected head injury or known head injury is identified. Physicians, resident representatives, and director of nursing will be notified of each fall.The facility's Care Planning policy, dated 8/2/17, documents Purpose: To utilize the results of the comprehensive assessment to develop resident's care plan. To provide a method for all staff to have needed information in caring for the residents. Policy: Each resident will have a plan of care to identify problems, needs and strengths that will identify how the interdisciplinary team will provide care. The resident care plan is the tool used to coordinate all care provided to the resident to be sure care is necessary, appropriate, and planned to meet the individual needs of the resident consistent with the physicians plan of care. Procedure: Each resident upon admission or a significant change of conditions will be assessed by all necessary disciplines. The Interdisciplinary Team along with the resident and/or family members will identify resident problems, needs and strengths. Sources are, but not limited to: Problems related to provision of safety. All problems identified on all assessments. All problems that require care. Problems related to physical deficits. All care plans must be updated at least quarterly and as needed.

Based on Interview and Record Review, the facility failed to ensure a resident and resident's family was provided a notification of a room move, with rational for the move, prior to transferring the resident to a different room in the facility for one of three residents (R2) reviewed for resident rights in the sample of three.Findings include:On 5/4/26 at 1:30 PM, V9 (R2's Family) stated (R2) was in the facility for a few months for rehabilitation. On 2/24/26, she was out at lunch, when she came back to her room there had been a room change. There was a note and all of her things had already been moved. Later I found out that there was work that needed to be completed in her room. I was not notified of her room change. (R2) just found out when she came back to her room that was already moved. She had several room moves while in the facility and I wasn't aware of them beforehand. (R2) had confusion and was having some Dementia at times, I am her first contact and Power of Attorney. I could not be there all the time. I didn't feel like I was getting informed of everything I needed to be.R2's electronic Census Report, documents R2 was admitted to the facility on [DATE], moved rooms on 1/1/26, 2/27/26 and 3/11/26.R2's electronic medical record does not contain documentation that R2 or V9 were notified of the room move on or before 1/1/26. R2's Room Transfer/New Roommate form, dated 2/27/26, documents R2 was moved from room [ROOM NUMBER] to 402 due to new admission. This form documents date of notice 2/27/26 and is left blank without a date for date of room change.On 5/5/26 at 12:16 PM, V12 (Licensed Practical Nurse) stated When a resident is being transferred rooms, we tell the residents and phone call families with the reason and document that in nursing notes. There isn't any written form that we (nursing) give to the family or the resident.On 5/5/26 at 12:25 PM, V13 (Social Service Director) confirmed that when a resident is transferred rooms, they should receive the notice in writing, and the notice should be scanned into the computer. On 5/5/26 at 2:00 PM, V1 (Administrator) confirmed that residents should be notified of a room move prior to the transfer and if they are not alert and orientated, then the notification should be provided to family with the reason for the room move.The Ombudsman Program Resident Rights handbook, dated 11/2018, and provided to residents on admission to the facility, documents As an individual living in a long-term care facility, you retain the same rights as every citizen of the (state) and of the United States. The following regulations provide clarity on specific rights granted to residents living in long-term care facilities. You have the right to be told in advance and in writing if your room is being changed. You have the right to receive notice, including the reason for the change before you room or roommate in the facility is changed.

Based on observation, interview, and record review, the facility failed to provide a safe and comfortable environment. This has the potential to affect all 132 residents living in the facility.Findings include:R36's MDS/Minimum Data Set, dated [DATE], documents R36's diagnoses include Alzheimer's Dementia, is severely impaired for cognition, uses a manual wheelchair, and dependent for cares. R36's current care plan documents R36 is a high risk for falls. R50's MDS, dated [DATE], documents R50's diagnoses include Non-Alzheimer's Dementia, is severely impaired for cognition, uses a wheelchair, and is dependent for care. R50's current care plan documents R50 is a high risk for falls. On 2/17/26 at 9:45am, R12's bathroom had two ceiling tiles with a brown substance on two of the corners that spread out towards the center on approximately 1/4 of each tile, and one tile was sagging down from the ceiling. The wall across from R12's bed has blue construction tape on the wallpaper where the wallpaper has been ripped down the center of the wall from the floor to approximately four foot up the wall. The floor trim is loose and pulled out from the wall where the drywall is crushed/missing in a three-foot length by six-inch-tall section of the wall where it is exposing the insulation and wood studs in the wall. Rooms 2XX-2XX hallway has one tile in the hallway where over one half of it is covered in a brown substance and cracked down the center. 300 hallway has two tiles where over one half of them are covered in a brown substance down the center. R36 and R50's room has one wall where the whole baseboard trim on the wall was pulled away from the wall. Approximately two foot of the trim was pulled away from the wall (the rest was attached to the wall) and was laying on the floor in the center aisle between the foot of R36 and R50's beds and the wall where the staff and residents have to walk by to get into their beds and get resident supplies. On 2/17/26 at 10:20am, V4 Project Manager stated There was a leak in the roof where one residents room (room [ROOM NUMBER]XX- empty) had to have the drywall removed, replaced, and repainted along with the baseboard flooring in the bathroom because of mold. There is another resident's room (R12) that needs redone for the same reason. On 2/18/26 at 8:50am, R12 was alert and oriented, in bed, and stated The wall has been like that, they fixed the other side of the wall but not mine, and I would like the wall to be fixed so I don't get sick. On 2/18/26 at 9:50am, a tour of the facility was conducted with V12 Maintenance Assistant due to the Maintenance Director off of work. At that same time, V12 stated the following: We have an app called 'Tels' that the whole facility staff has access to where they send us work requests from their computers. There was a line leak on the roof from the air/heat unit above room [ROOM NUMBER]XX and R12's room. It leaked into the rooms (at that time V12 verified R12's room needed the wall/trim/ceiling tiles fixed). I was unaware of the trim coming off the wall in R36 and R50's room, I do not have a maintenance request for that, and that is a tripping hazard. I was unaware of the ceiling tiles needing replaced on 200 and 300 halls. Facility Maintenance Director Job Description, undated, documents The Maintenance Director includes the overall maintenance/upkeep of the facility and grounds including preventative maintenance, repairs, and inspections. Primary Responsibilities: Ensure all aspects of the facility are in a good state of repair. Facility room roster, dated 2/17/26, documents 132 residents reside in the facility.

Based on record review and interview the facility failed to follow enhanced barrier precautions during wound care for one of eight residents reviewed for wound care (R3) in the sample of eight. Findings include: R3's medical record documents R3 is receiving daily wound care for an unstageable pressure ulcer of the left buttock. R3's physicians Order Sheet includes the following wound care order: WOUND: left buttock- Apply (medicated solution)-soaked gauze and pat dry, apply (medicated ointment) and pack with (medicated gauze) and island border dressing daily. On 1/15/24 at 7:30am sign on R3's door stated Enhanced Barrier Precautions were in place for R3, including donning a gown and gloves when providing close contact cares. On 1/15/25 at 7:30am V3 Wound Nurse entered R3's room to perform wound care for R3's left buttock pressure ulcer. V3 did not don a gown while performing R3's wound care. V3 completed R3's wound care without wearing a protective gown. On 1/15/25 at 1:50pm, V2 DON/Director of Nursing stated Nurses should wear gowns when providing wound care. V2 stated V3 had informed her she had not followed EBP protocol for R3's wound care. The facility's Enhanced Barrier Precautions policy, dated 10/21/22, documents: EBP (Enhanced Barrier Precautions) requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (Multi-Drug Resistant Organisms) to staff hands and clothing. High-contact resident care activities requiring gown and glove use among residents that trigger EBP use include Wound care: any skin opening requiring a dressing.

Based on observation, record review, and interview, the facility failed to follow its policy to use facial hair beard restraints while in the kitchen, and failed to ensure food items were labeled with identification and dates. This failure has the potential to affect 121 residents who reside at the facility. Findings include: Facility's Hair Restraints Policy, Undated, documents: Guideline: Hair restraints shall be worn by all dining services staff when in food production area, dishwashing areas, or when serving food. 2. Hair restraints, hats, and/or beard guards shall be used to prevent hair from contacting exposed food. Facility's Food Storage (Dry, Refrigerated, and Frozen) Policy, dated 2020, documents: Procedure: 1.a. All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. On 9/3/24 at 9:10am, V8 Dietary Aide washed dishes in the facility's kitchen; V8 did not have his facial hair beard covered. V8 Dietary Aide stated, I just know about the hairnet for head; I do not know if my beard is supposed to be covered. At this same time, V7 Dietary Manager stated that she was not sure what the facility policy was for staff covering their beards while in the kitchen. On 9/3/24 at 9:05am in the facility's Walk-In Freezer, one bag of frozen mixed vegetables was not labeled or dated; 11 medium sized plastic bags filled with hot dog buns and one plastic bag filled with sliced loaf bread were not labeled or dated. On 9/3/24 at 9:05am, V7 Dietary Manager stated, Anyone who opens the boxes or containers are responsible for labeling and dating the food. These items should have labels and dates. The facility's Long-Term Care Facility Application for Medicare and Medicaid (Centers for Medicare and Medicaid Services/CMS 671) form, dated 9/3/24, documents 122 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to revise care plans for six (R9, R22, R94, R110, R265, and R415) of 24 residents reviewed for care plan revision in a sample of 59. Findings include: Facility Care Planning, revised 6/24, documents Utilize the results of the comprehensive assessment to develop, revise and review resident's care plan. To provide a method for all staff to have needed information in caring for the residents. Each resident will have a plan of care to identify problems, needs and strengths that will identify how the team will provide care. Facility Dialysis Protocol, revised 9/23, documents The residents care plan will reflect their dialysis needs. 1. R9's medical record documents R9 has the following diagnoses: Depression and Paranoid Schizophrenia. R9's Physician Orders for September 2024 documents the following: Fluoxetine HCl/Hydrochloride Oral Capsule 20 MG/Milligram (Fluoxetine HCl) Give 2 capsule by mouth in the morning for depression related to Depression Unspecified; Quetiapine Fumarate Oral Tablet 300 MG (Quetiapine Fumarate) Give 350 mg by mouth at bedtime for Schizophrenia related to Paranoid Schizophrenia; and Olanzapine Oral Tablet 10 MG (Olanzapine) Give 1 tablet by mouth at bedtime related to Paranoid Schizophrenia. R9's current care plan has no documentation of nonpharmacological interventions for the above medications. On 9/6/24 at 12:02 PM, V9 Care Plan Coordinator verified there were no nonpharmacological interventions on R9's Care Plan and there should be. 2. R110's medical record documents R110 has the following diagnoses: Anxiety and Depression. R110's Physician Orders for September 2024 documents the following: Escitalopram Oxalate Oral Tablet 5 MG (Escitalopram Oxalate) Give 1 tablet by mouth in the morning for depression; Trazodone HCl Oral Tablet 100 MG (Trazodone HCl) Give 1 tablet by mouth at bedtime for depression; and Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth three times a day related to Anxiety Disorder. R110's current care plan has no documentation of nonpharmacological interventions for the above medications. On 9/6/24 at 12:02 PM, V9 Care Plan Coordinator verified there were no nonpharmacological interventions on R110's Care Plan and there should be. 3. R265's medical record documents R265 has the following diagnoses: End Stage Renal Disease; and acquired absence of kidney. R265's current care plan has no documentation of who to contact for emergencies/complications; a target weight; an assessment and care of the right chest dialysis port; and resident specific dialysis orders on the care plan. On 9/3/24 at 10:05 AM, R265 had a right chest dialysis catheter port. At that same time, R265 stated I am on dialysis. On 9/6/24 at 12:02 PM, V9 Care plan Coordinator stated R265's Care Plan did not address complications, emergencies, target weight, nephrologist, or an assessment of the right chest catheter site. V9 also verified the care plan did not include resident specific dialysis orders. V9 stated R265's Care Plan, needs updated. 4. R94's medical record documents R94 has the following diagnoses: Ileostomy status. R94's Physician Orders for September 2024 documents the following: Ostomy: Monitor Colostomy, empty pouch when 1/3 full, change appliance every three to five days. On 9/04/24 at 2:55 PM, R94 stated I hope to get the colostomy reversed, and all stool comes out of the colostomy because I had to have my colon removed. R94's current care plan documents (R94) has constipation and ileostomy, with the interventions of Encourage resident to sit on toilet to evacuate bowels if possible. On 9/6/24 at 12:02 PM, V9 Care Plan Coordinator verified R94's care plan needed updated. 33970 5. R415's Physician Order Sheet dated September 2024 documents that she takes Buspirone 5 mg (milligram) three times a day for anxiety, Duloxetine 60 mg every morning for panic disorder, anxiety disorder, and Quetiapine Fumarate 25 mg twice daily for depression. R415's current care plan documents (R415) has a behavior problem of yelling out when no assistance is needed. The Interventions/Tasks for this focus area documents administer medications as ordered, allow choices within individuals decision making abilities and anticipate and meet the resident's needs. The care plan does not document what R415's decision making abilities are. The care plan does not have any other nonpharmacological interventions in place. R415's current care plan documents (R415) receives an antidepressant medication. The interventions/tasks for this focus area documents Administer antidepressant medications as ordered by physician. There were no nonpharmacological interventions listed. R415's current care plan documents (R415) takes anti-anxiety medications. The interventions/tasks for this focus area documents Administer anti-anxiety medications as ordered by the physician. There were no nonpharmacological interventions listed. On 09/06/24 at 12:02 PM, V9/Care Plan Coordinator confirmed there aren't nonpharmacological interventions in place for R415. 30722 6. R22's Order Summary Report dated 09/04/24 documents R22 has diagnoses which include Unspecified Dementia, Unspecified Severity with other behavioral disturbance, Bipolar Disorder, Major Depressive Disorder and Delusional Disorders. R22's Order Summary Report documents an order for Quetiapine Fumarate 25 milligrams by mouth two times daily. R22's Care Plan last revised on 06/14/24 documents R22 receives antipsychotic medications Quetiapine related to Bipolar Disorder. Listed interventions include: 1) Administer Antipsychotic medications as ordered by physician. Observe for side effects and effectiveness every shift. 2) Discuss with physician, family regarding ongoing need for use of medication. Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy. 3) Observe/document/report as needed any adverse reactions of psychotropic medications. R22's Care Plan did not have any nonpharmacological interventions in place. On 09/06/24 at 12:02 PM V9/Care Plan Coordinator verified there are no nonpharmacological interventions in place for R22's behaviors.

Based on observation, interview, and record review the facility failed to provide an appropriate indication for use of antipsychotic medications in seven residents (R22, R39, R70, R81, R102, R214, R415) with diagnosis of Dementia and failed to identify non-pharmacological interventions for two residents (R9, R110) receiving antidepressant medications of nine residents reviewed for unnecessary psychotropic medications in the sample of 59. Findings include: Facility Policy/Psychotropic Medications dated/revised 1/2024 documents: Residents will only be given antipsychotic drugs when clinically indicated according to appropriate diagnosis and physician's order. Duplicate Drug Therapy: Any drug therapy that duplicates a particular drug effect on the resident without any demonstrative therapeutic benefit. Any two or more drugs, whether from the same category or not, that have a sedative effect. Antipsychotic Drug: A neuroleptic drug that is helpful in the treatment of psychosis and has a capacity to ameliorate thought disorders. Psychotropic medications shall be used only after alternative methods have been tried unsuccessfully and only upon the written order of a physician and after informed consent has been received from the resident/representative. The resident's care plan will include objectives for gradual dose reduction as well as alternative interventions to assist in gradual dose reduction. 1) Current Physician Order Summary Report indicates R39 has orders for Risperdal (antipsychotic) 0.25mg (milligrams) at bedtime related to Unspecified Dementia with Anxiety (order date 7/18/24). R39's medical record indicates R39 has diagnoses of Dementia with Other Behavioral Disturbance and Anxiety with start date of 1/11/24. Consent for Psychotropic Medications indicates consent was given on 7/18/24 to receive Risperdal for Dementia with behaviors. Psychiatry Note dated 1/25/24 indicates Start Risperdal 0.5mg twice daily due to exhibits Dementia behaviors including physical and verbal aggression, refusal of care including refusal to get out of bed. Note indicates no audio/visual hallucinations, no symptoms of psychosis. R39's Care Plan indicates (R39) receives an antipsychotic medication related to Dementia without behavioral disturbance. R39's Care Plan also indicates R39's behaviors related to Dementia are yelling out and arguing with staff, looking for her grandson; has potential to be physically aggressive with staff related to Dementia. On 9/3/24, 9/4/24 and 9/6/24 R39 was seen in the memory care unit participating in activities during lunch meals. On 9/6/24 at 11:35am V12, Memory Care Unit Director stated R39's only behaviors are being resistive to care at times and putting herself on the floor. 2) R70's medical record indicates R70 has diagnoses of Dementia, Moderate with Mood Disturbance dated 10/1/23 and Alzheimer's Disease dated 8/1/23. R70's Current Physician Order Summary Report indicates R70 has orders for Olanzapine (antipsychotic)2.5mg twice daily for Dementia with Mood Disorder (date ordered 5/22/24). Consent for Psychotropic Medications indicates consent was given on 5/20/24 via telephone for R70 to receive Olanzapine. Consent does not include indication for use, diagnosis, or target behaviors. Psychiatry Note dated 8/8/24 indicates R70 continues to have sundowning behaviors almost daily, with behaviors starting around 4pm and sometimes continuing until 10pm. Note indicates no audio/visual hallucinations, no symptoms of psychosis or mania. Note indicates We will shift her Olanzapine today in hopes to better target her Dementia related behaviors and agitation. Note also indicates R70 receives the following psychotropic medications: Escitalopram and Mirtazapine (antidepressants) for Depression Melatonin for Insomnia, Depakote (Mood Stabilizer) for Mood. Current Care Plan indicates R70 receives antipsychotic medications related to Bipolar Disorder dated/revised 8/31/22. Care Plan indicates R70's behaviors are related to Dementia - packing belongings and going home, looking for a baby, interferes with other resident's care, looking for her sister and Physically aggressive to staff related to Dementia. On 9/3/24, 9/4/24 and 9/6/24 R70 was seen in the memory care unit participating in activities during lunch meals. On 9/3/24 and 9/6/24 V13, R70's Spouse stated he visits R70 every day and most of R70's behaviors are after he leaves for the day and R70 wants to go home. Behavior tracking 8/6/24 to 9/4/24 indicate R70's behaviors do not occur every day and are episodic. 3) Current Physician Order Summary Report indicates R81 has orders for Olanzapine (antipsychotic) 10mg in the evening and 5mg daily related to Bipolar Disorder (date ordered 5/10/24). Report also indicates R81 receives Haldol (antipsychotic) Decanoate injection 25mg weekly for Bipolar (order date 5/10/24). R81's medical record indicates R81 has the following diagnoses: Dementia with other Behavioral Disturbance 12/9/22 (admit), Unspecified Psychosis 12/9/22. Bipolar 12/12/22 and Bipolar Hypomanic 5/12/23 Consent for Psychotropic Medication(s) dated 5/10/24 indicates consent was received for R81 to receive Haldol 25mg weekly and on 5/2/24 for R81 to receive Olanzapine 10mg at bedtime and 5mg daily for Bipolar Disorder. Psychiatry Note dated 8/13/24 indicates R81 is now receiving Hospice Care, does continue to wander the halls, but has not been overly intrusive. Note indicates no symptoms of psychosis or mania. R81's Care Plan indicates R81 receives antipsychotic medication related to Bipolar. Care Plan indicates R81's behaviors are related to Dementia - refuses labs, wanders, resisting care and aggressive with staff; hovers over residents while they eat, removes utensils from their hands; refuses medications, refuses to eat. and is verbally aggressive with staff related to Dementia. Care Plan does not identify behaviors related to Bipolar Disorder. On 9/3/24, 9/4/24 and 9/6/24 R81 was seen in the memory care unit either sleeping in her bed or wandering the halls. On 9/6/24 at 11:40am V12, Memory Care Director stated that R81's behaviors are mainly pacing (R81) is unable to actively participate in activities. 4) R102's Medical Record indicates R102 has the following diagnoses: Dementia without Behavioral Disturbance, Mood or Anxiety dated 4/23/24 (admit) and Disorganized Schizophrenia 4/23/24. Current Physicians Order Summary Report indicates R102 receives Seroquel (antipsychotic) 50mg at bedtime for Disorganized Schizophrenia (date ordered 7/4/24). Psychiatry Note dated 7/25/24 indicates on that date R102 was pleasant and in good spirits. Note indicates R102 continues to respond to internal stimuli but does so quietly and pleasantly. Note indicates there is no evidence of auditory nor visual hallucinations and no symptoms of psychosis or mania. No substance cravings for nicotine dependence. R102's Care Plan indicates R102 receives antipsychotic medication related to Disorganized Schizophrenia (revised 5/23/24) and that R102 has a behavior problem related to Disorganized Schizophrenia - has a habit of refusing showers when out of cigarettes. No other behaviors of Dementia or Schizophrenia were identified in R102's care plan. Consent for Psychotropic Medication(s) dated 7/4/24 indicates consent was given on that date to increase R102's Seroquel from 25mg to 50mg at bedtime. Consent does not indicate reason for increase, diagnoses, or target behaviors. No progress notes were found or presented documenting the reason or justification for Seroquel ordered/increased on 7/4/24. On 9/3/24, 9/4/24 and 9/6/24 R81 was seen in the memory care unit in activities and during meals. On 9/6/24 at 11:40am V12, Memory Care Director stated that R102's behaviors are refusing showers when can't have a cigarette. I don't know of any other behaviors that (R102) has. 5) R214's Medical Record indicates R214 has the following diagnoses: Admitting Diagnosis: Dementia with Agitation/Psychotic Disturbance 8/20/24 Secondary Diagnosis: Bipolar Disorder 8/20/24 Current Physician Order Summary Report indicates R214 receives Haldol (antipsychotic) Injection 5mg every 8 hours as needed for agitation X 14 days (date ordered 8/29/24); Olanzapine (antipsychotic) 5mg daily for Bipolar Disorder date ordered 8/29/24; Quetiapine (antipsychotic) 50mg twice daily related to Bipolar Disorder date ordered 8/28/24 Psychiatry Note dated 8/22/24 indicates R214 is a new admit, combative, resisting care, hits, kicks, and fights. Note indicates R214 does not experience any psychotic symptoms, including auditory or visual hallucinations, no mania. Note indicates R214 has an underlying neurocognitive disorder that could be exacerbated by current medication regimen. Note indicates author of note recommends to add Olanzapine (as needed). Current Care Plan indicates R214 has Behavior of Resisting Cares and verbally and physically aggressive with staff related to Dementia, stands up from wheelchair without assist, makes inappropriate comments to staff - dated initiated 8/21/24/revised 8/28/24. No progress notes indicating circumstances/necessity of ordering multiple psychotropic medications for R214 including duplicate antipsychotic therapy were found or presented. No care plan was found or presented for any of R214's psychotropic/antipsychotic medications. On 9/3/24, 9/4/24 and 9/6/24 R214 was seen in the memory care unit in during meals and in her room with her spouse. On 9/4/24 at 10:30am V14, Spouse stated that R214 is confused and is resistive to care. V14 stated he was informed of the need for the (psychotropic) medications due to R214's behaviors. V14 stated he stays with R214 every day until about 630pm. On 9/6/24 at 11:50am V1, Administrator stated I agree there seems to be a lack of justification for these medications. We need to do better with this. 34131 6. R9's medical record documents R9 has the following diagnoses: Depression and Paranoid Schizophrenia. R9's Physician Orders for September 2024 documents the following: Fluoxetine HCl/Hydrochloride Oral Capsule 20 MG (Fluoxetine HCl) Give 2 capsule by mouth in the morning for depression related to Depression Unspecified; Quetiapine Fumarate Oral Tablet 300 MG (Quetiapine Fumarate) Give 350 mg by mouth at bedtime for schizophrenia related to Paranoid Schizophrenia; and Olanzapine Oral Tablet 10 MG (Olanzapine) Give 1 tablet by mouth at bedtime related to Paranoid Schizophrenia. R9's medical record has no documentation of nonpharmacological interventions and no identified indicators/behaviors for use for the above medications. On 9/6/24 at 12:02PM, V2 DON/Director of Nursing verified there were no nonpharmacological interventions and no identified indicators/behaviors for use for R9 and there should be. 7. R110's medical record documents R110 has the following diagnoses: Anxiety and Depression. R110's Physician Orders for September 2024 documents the following: Escitalopram Oxalate Oral Tablet 5 MG (Escitalopram Oxalate) Give 1 tablet by mouth in the morning for depression; Trazodone HCl Oral Tablet 100 MG (Trazodone HCl) Give 1 tablet by mouth at bedtime for depression; and Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth three times a day related to Anxiety Disorder. R110's medical record has no documentation of nonpharmacological interventions and no identified indicators/behaviors for use for the above medications. On 9/6/24 at 12:02PM, V2 DON verified there were no nonpharmacological interventions and no identified indicators/behaviors for use for R110 and there should be. 33970 8. R415's Physician Order Sheet dated September 2024 list diagnoses of disorientation, claustrophobia, unspecified dementia without behavioral disturbance, psychotic disturbance, anxiety disorder and panic disorder. R415's Physician Order Sheet dated September 2024 documents that R415 was started on Quetiapine Fumarate, an antipsychotic medication, for depression on 9/3/24. On 9/6/24 at 11:30AM V2 (Director of Nursing) stated An antipsychotic shouldn't have been ordered for depression. I need to educate our providers. (R145's) behaviors all seem to stem from her dementia and her anxiety. 30722 9. R22's Order Summary Report dated 09/04/24 documents R22 has diagnoses which include Unspecified Dementia, Unspecified Severity with other behavioral disturbance, Bipolar Disorder, Major Depressive Disorder and Delusional Disorders. R22's Order Summary Report documents an order for Quetiapine Fumarate 25 milligrams by mouth two times daily. R22's Care plan last reviewed 08/12/24 documents R22 has been verbally aggressive towards staff related to dementia. R2 is/has potential to be physically aggressive towards staff related to dementia, R22 is resistive to care, refuses medications related to dementia. R22 has impaired cognitive function/dementia or impaired thought processes related to dementia, cerebrovascular accident. R22's Behavior Tracking Report documents R22 had four behaviors between 03/01/24 and 06/30/24 which include: 03/23/24 Mood Changes, 03/24/24 Compulsive, 04/26/24 Uncooperative, and 06/07/24 Uncooperative. On 09/03/24 at 10:53 AM, R22 was in her wheelchair near the dining room. R22 appeared calm while sitting and watching other people. On 09/03/24 at 1:10 PM, R22 was sitting in her wheelchair in her room. R22 was alert, confused and appeared calm. On 09/04/22 at 11:10 AM, R22 was in the hallway speaking with staff. R22 appeared calm and was asking about lunch time. On 09/06/22 at 11:32 AM, R22 was receiving cares. R22 was alert, confused and appeared to be in a pleasant mood while interacting with staff. On 09/06/22 at 11:32 AM, V5/CNA and V6/CNA stated they were not aware of R22 having behaviors. V5 stated R22 was a real nice lady. On 09/06/24 at 10:33 AM, V1 verified the facility Behavior Tracking Tool (undated) did not list R22 as having any behaviors between 07/03/24 and 09/03/24.

Based on interview and record review the facility failed to notify the appropriate State Agency of a new diagnosis of bipolar disorder for one resident (R81) of four residents reviewed for Preadmission Screening in the sample of 59. Findings include: Current Physician's Order Summary Report indicates R81 was admitted to the facility on [DATE] with Primary Admission Diagnosis of Dementia with Other Behavioral Disturbance. R81's PASRR (Pre-Admission Screening and Resident Review) dated 11/14/22 indicates PASRR Level I Determination: No Level II required. There is no evidence of a PASRR condition of an intellectual/developmental disability or a serious behavioral health condition. If changes occurs or new information refutes these findings, a new screen must be submitted. R81's medical record diagnosis list indicates a diagnosis of Bipolar was added on 12/12/22 and Bipolar/Hypomanic added on 5/12/23. No documentation was found or presented to indicate another Pre-admission screen was completed after addition of Bipolar diagnosis on 12/12/22 and 5/12/23. On 9/6/24 at 1:45pm V1, Administrator confirmed the State Agency should have been notified to complete a new screening based on R81's new Bipolar diagnosis.

Based on observation, interview, and record review, the facility failed to observe, assess, and document on a colostomy for one (R94) of one resident reviewed for colostomies in a sample of 59. Findings include: R94's medical record documents R94 has the following diagnoses: Ileostomy status. R94's Physician Orders for September 2024 documents the following: Ostomy: Monitor Colostomy, empty pouch when 1/3 full, change appliance every three to five days. On 9/04/24 at 2:55 PM, R94 stated I hope to get the colostomy reversed. At that same time R94 pulled down her covers and showed surveyor colostomy. R94's medical record including the TAR/treatment administration record, MAR/Medication administration record, and nurses' notes have no documentation of monitoring, assessing, or changing R94's colostomy. On 9/06/24 at 11:11AM, V1 Administrator stated, I have no documentation to give you for (R94's) outputs from her colostomy. On 9/6/24 at 12:02PM, V9 Care Plan Coordinator verified R94's medical record had no routine documentation on R94's monitoring, assessing, or changing of her colostomy.

Based on observation, interview, and record review, the facility failed to have specific dialysis orders related to the type of dialyzer, flow rate, and length of time; nephrologist; target weights; and care of the dialysis port for one (R265) of two residents reviewed for dialysis in a sample of 59. Findings include: Facility Dialysis Protocol, revised 9/23, documents To provide guidance to the facility on how to care for the dialysis resident within the facility. All residents who need dialysis will be properly cares for within the facility. It is the responsibility of nursing to provide care for the dialysis resident. Nursing will monitor the access site for signs and symptoms of infection or bleeding at the site. The residents care plan will reflect their dialysis needs. R265's medical record documents R265 has the following diagnoses: End Stage Renal Disease; and acquired absence of kidney. R265's medical record has no dialysis orders, no nephrologist listed, no post dialysis target weight, or orders to cares for R265's dialysis port. On 9/3/24 at 10:05 AM, R265 had a right chest dialysis catheter port. At that same time, R265 stated I am on dialysis. On 9/4/24 at 11:15 AM, V10 LPN/Licensed Practical Nurse stated she was unsure who (R265's) nephrologist was, all nurses need to monitor the dialysis site and document, all residents on dialysis should have orders for dialysis in their chart and should have a target weight in the chart for residents on dialysis. On 9/4/24 at 2:10 PM, V11 RN/Registered Nurse in Dialysis stated they are contracted by the facility, facility does not have access to their records for specific resident orders for dialysis, expect the staff to observe and be aware of any concerns with residents dialysis access sites and call if any concerns, should know the nephrologist to contact in case of an emergency, and have their target weight for post dialysis.

Based on observation, interview, and record review, the facility failed to ensure medications were not left at a resident's bedside for one of 24 residents (R40) reviewed for medication storage in the sample of 59. Findings Include: The Facility's Administration of Medications policy dated 8/2023 documents Residents shall receive their medications on a timely basis in accordance with state and federal guidelines and within established facility policies. Self-administration of medications is permitted when approved by the interdisciplinary team, with a written order from the primary attending physician. On 9/6/24 at 9:30 AM, R40 was lying in bed with R40's bedside table over his bed. A clear medicine cup containing 11 pills was noted on R40's bedside table. The medication cup had been tipped over with approximately half of the pills spilled out onto the table. R40 stated, This is what some of the nurses do. R40 was not able to name his medicine or state which pill was what. R40's Medical Record did not contain any assessments or physician orders for self-administration of medications. On 9/6/24 at 10:00 AM, V3 (License Practical Nurse) verified V3 gave R40 his morning medications on 9/6/24. V3 verified V3 did not stay with R40 until all R40's medications were consumed but should have. On 9/6/24 at 10:05 AM, V2 (Director of Nursing) stated that the medicine in front of R40 would have been his morning medicine. R40's Medication Administration Record for September documents that R40's morning medicines on 9/6/24 would include: Escitalopram 20 mg (milligrams), Multivitamin 1 tablet, Omeprazole 40 mg, Vitamin B6 100 mg, Vitamin C 500 mg, Vitamin D 1 tablet, Zinc 1 tablet, Zyrtec 10 mg, Tylenol 650 mg, Bupropion ER (Extended Release) 100 mg, Buspar 5 mg, and Carbidopa-Levodopa 25-100 mg.

Based on observation, record review and interview, it was determined the facility failed to ensure call lights were answered in a timely manner and responded to accommodate the residents needs for 2 of 2 residents (R3, R4) with mobility restrictions observed for call light accessibility. Findings include: On 4/24/24, R3 was admitted to the facility for rehabilitation services status post lumbar fusion surgery. On 4/24/24, R3's Care plan indicates limited physical mobility related to surgical aftercare and spinal stenosis. On 5/6/24 at 12:10 PM, R3 was observed sitting in a wheelchair with Spine brace on; R3 had a hand over forehead, head down and grimacing; pulling and moving brace around and complained of pain. R3 stated We (R3 and R5 (R3's roommate) put the call light on twice. They (Certified Nurse Aides/CNA) said they would be back. At 1:04 PM, R3 was sitting in wheelchair with a back brace on R5 stated I put on the call light. They had to go find a mechanical lift. At 3:08 PM, R3 stated I'm still waiting for the gals to come put me on my side. I've been on my back since I got back in bed. R5 put the light on once but I still haven't had anyone come back. I called V10 (Healthcare Power of Attorney) earlier when they left me up in the chair and told V10. V10 called the front desk and told them to put me back in bed. That's why they came in. On 5/7/24 at 8:48 AM, V10 stated Yesterday around 11:00 AM or so, R3 called me crying saying R3 was left in the wheelchair with the back brace on for a half hour. They (staff) said they would be right back, but they hadn't been back. R3 has called me about 3 or 4 other times and says R3 pushes the call button but no one comes, I have pushed the call light a couple of times, and no one has answered but I'll go out there and complain. On 8/1/23, R4 was admitted rehabilitation services related to weakness, muscle atrophy, abnormality of gait and mobility. R4's care plan dated 8/2/23 documented R4 was at risk for acute/chronic pain related to medical postoperative right lower leg fracture discomfort and an Activities of Daily Living self-care performance deficit related to displaced bi-malleolar fracture of right lower leg. The 4/25/24 through 5/7/24 Plan of Care Response History titled Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment documented R4 requires partial/moderate, substantial/maximal assistance or dependent on helper assistance. On 5/6/24 at 12:20 PM, R4 stated I got up to the commode with help from the Certified Nurse Aide/CNA and I didn't see the CNA again. I can't wipe my butt. The CNA told me she didn't see my light on, but it was on for 2 hours. I have trouble breathing and I need assistance. I need help with getting up and I have trouble holding my bowels and bladder. I can't walk because I broke my ankle and tail bone. I am so upset (about being left on the commode). I'm not getting out of bed for the rest of the day.

Based on observation, record review and interview, the facility failed to ensure call lights were available for resident use for 1 of 2 residents (R3) reviewed with mobility restrictions observed for call lights. Findings include: The Daily Care policy, dated 8/2/17, documented the guidelines and procedures for daily cares to all residents. The policy documented to Place call light within reach. On 4/24/24, R3 was admitted to the facility for rehabilitation services status post lumbar fusion surgery. On 4/24/24, R3's Care plan indicated limited physical mobility related to surgical aftercare and spinal stenosis. On 4/24/24, The Physical Therapy and Occupational Therapy Evaluation and Plan of Treatment documented Precaution Details: ** Spine Brace to be worn while patient is up doing transfers and/or ambulating. Does not need to be worn while in bed or chair. SPINAL PRECAUTIONS- NO BLT (NO BENDING, LIFTING more than 7 pounds), OR TWISTING. FALL RISK, 8/10 pain in right hip and bilateral knees. The evaluation documented R3 required substantial/maximal assistance with bed mobility, partial/moderate assistance with transfers and was dependent on staff with ambulation. On 5/6/24 at 12:10 PM, R3 was sitting in a wheelchair with back brace on. R3's call light was draped over the bed and unreachable. At 1:04 PM, R3 was sitting in wheelchair with brace on. R3's roommate (R5) stated I put on the call light because R3 wanted to go back to bed, and she can't reach it (call light). At 1:06 PM, V13 (Certified Nurse Aide) was observed to enter R3's room, providing cares and exited to go get another staff member for assistance. The call light was draped over the bed and unreachable. At 1:20 PM, R3 was lying in bed with call light on nightstand and unreachable. At 3:08 PM, R3 stated I'm still waiting for the gals to come put me on my side. I've been on my back since I got back in bed. R5 put the light on once but I still haven't had anyone come back. I called V10 (Healthcare Power of Attorney) earlier when they left me up in the chair and told V10. V10 called the front desk and told them to put me back in bed. That's why they came in. On 5/7/24 at 8:48 AM, V10 stated Yesterday around 11:00 AM or so, R3 called me crying saying R3 was left in the wheelchair with the brace on for a half hour. They (staff) said they would be right back, but they hadn't been back. Sometimes when I get there, we can't find the call light. One time it was wrapped up and hung up on the wall. On 5/7/24 at 3:00 PM, V1 (Administrator) stated staff should ensure call lights are within reach of the residents prior to exiting the room.

Based on observation, record review and interview, the facility failed to provide resident-centered care for one resident (R3) who required rehabilitation services status post-surgical fusion of the lumbar spine, as evidenced by lack of physician orders for spinal precautions; no care plan intervention related to spinal precautions or back brace use; improper use of mobility devices and inadequate assessment of medication management. Findings include: R3 was admitted on [DATE] post a lumber fusion surgery and a history of Gastro Esophageal Reflux Disease (Heartburn/Indigestion/GERD). On 4/23/24, the facility received R3's Hospital Transfer Papers which documented Up to chair 3 (three) times per day. Spine brace (back brace designed to give support to thoracic and lumbar spine by preventing twisting and flexion (bending forward) to be worn while up ambulating. Does not need to be worn while up in chair or bed. On 4/24/24, The Physical Therapy and Occupational Therapy Evaluation and Plan of Treatment documented Precaution Details: ** Spine Brace to be worn while patient is up doing transfers and/or ambulating. Does not need to be worn while in bed or chair. SPINAL PRECAUTIONS- NO BLT (NO BENDING, LIFTING more than 7 pounds), OR TWISTING. FALL RISK, 8/10 pain in right hip and bilateral knees. The evaluation documented R3 required substantial/maximal assistance with bed mobility, partial/moderate assistance with transfers and was dependent on staff with ambulation. On 4/24/24, R3's Care plan documented R3 has limited physical mobility related to surgical aftercare, spinal stenosis and lacked interventions related to the Spinal Precautions and use of Spine brace. On 4/25/24, a Physician's Order for Spine Brace on when resident up every shift was implemented although lacked a physician's order for Spinal Precautions and to elevate the head of the bed to facilitate breathing. As of 5/6/24, the Order Summary lacked documentation of Spinal Precautions. On 4/25/24, a Physician's Order for WOUND: Back- Keep incision clean, dry and intact until follow up appointment, monitor for signs and symptoms of infection.' On 5/6/24 at 12:10 PM, R3 was sitting in a wheelchair with Spine brace on; R3 had a hand over forehead, head down and grimacing; pulling and moving brace around. R3 stated It (Spine brace) hurts. It's pushing on my belly, and I feel sick to my stomach. I'm not supposed to have this thing (brace) on when I'm in the wheelchair. It's just digging into me and hurting my back. At 12:38 PM, R3 was observed sitting in a wheelchair with brace on. At 1:04 PM, R3 was sitting in a wheelchair with brace on. At 1:10 PM, V13 (Certified Nurse Aide) was observed to enter R3's room. Upon entrance V13 had hooked R3's sling up to the mechanical lift. V13 stated I need to go get a spotter. R3 and R5 (R3's roommate) both stated V13 got R3 and R5 both up by V13 only this morning. At 1:20 PM, R3 was lifted into bed by V13 and V14 (Certified Nurse Aide) via mechanical lift with the Spine brace on. V13 stated to V14 V15 (Physical Therapy) took R3's brace off this morning and I put the brace (R3's Spine brace) back on wrong. R3 was positioned in bed in supine position without the head of the bed elevated. At 3:08 PM, R3 stated R3's pain level was at an eight (0- no pain and 10- worst pain). R3 stated The brace rubbed on my back incision. I'm still waiting for the gals to come put me on my side. I've been on my back since I got back in bed. I have indigestion so bad; I feel like there's a big heavy lump here (pointed to upper sternum). At home I drink milk and take Pepcid, but I've asked for some milk and haven't gotten anything yet. I called V10 (Healthcare Power of Attorney) earlier when they left me up in the chair and told V10. V10 called the front desk and told them to put me back in bed. That's why they (staff) came in (at 1:20 PM to put R3 back in bed). At 3:25 PM, V16 (Licensed Practical Nurse) was at the nurse's station and was informed that R3 was requesting to be turned and to conduct a dressing check/skin assessment. At 3:28 PM, V11 (Certified Nurse Aide Supervisor) told V16 that R3 requested something for R3's upset belly. At 3:35 PM, V16 walked into R3's room and proceeded to administer medication without identifying R3, asking about R3's symptoms, level of discomfort or explaining what the medication was for. At 3:40 PM, V16 proceeded to have R3 put R3's bent left leg over the top of the of the right leg and pushed R3 to R3's right side (twisting motion) and R3 cried out. The dressing covering the back incision was balled up at the top of R3's back and was not covering the incision. V16 peeled off plastic tape which was stuck to R3's skin and rolled up. V16 then left the room to go get supplies for the dressing change and left R3 rolled over on right side with the bed in a high position and with the incision not covered. During this time R3 stated that earlier in the day, R3 had been constipated and R3's belly was bloated. R3 stated I begged them (staff) to get me up to the toilet instead of going in my bed. R3 stated They just tell me to go in my briefs. Approximately 10 minutes later (3:50 PM) V16 enters R3's room and performed the dressing change. On 5/7/24 at 8:48 AM, V10 stated Some girls came in about the 4th day (after admission) and yanked on R3's leg. It really hurt R3. They are doing stuff they aren't supposed to do. This was a different surgery and it's way more painful. R3 should wear the brace when up and when R3 does therapy. They use that hoist (mechanical lift), and I don't think they are supposed to do that. They aren't walking R3 very much. Yesterday around 11:00 AM or so, R3 called me crying saying R3 was left in the wheelchair with the brace on for a half hour. They (staff) said they would be right back, but they hadn't been back. I wasn't very happy about that. R3 doesn't tolerate pain well. I called (the facility) and complained and apparently, they put her back in bed. On 5/6/24 at 3:33 PM, the Medication Administration Record/MAR documented V16 administered hydrocodone (opioid narcotic) for a pain level of 6 (0-no pain 10-worst pain). The record lacked an assessment of R3's complaints of indigestion or upset belly. The MAR lacked documentation medication for indigestion was administered on an as needed bases as ordered. On 5/7/24 at 12:30 PM, V15 (Physical Therapist) stated Orders come from the Admission Orders and put into (medical record) by V12 (Assisting Director of Nursing.). We (Therapy) communicate with staff regarding weight bearing status and such. Today we changed R3's wheelchair to a high-backed reclining wheelchair so that R3 doesn't have the brace pushing into R3's groin/stomach and chest. V15 stated Therapist do not attend care plan meetings; R3's record lacked a Physician Order for Spinal Precautions; and the staff were not educated on Spinal Precautions and the use of the Spine brace. V15 stated staff should be utilizing the log roll technique (no twisting). V15 stated the Spine brace should have been removed while R3 was in the wheelchair and prior to mechanical lift. On 5/7/24 at 3:00 PM, V1 (Administrator) stated V15 has already been out to educate staff about the Spine brace and Spinal Precautions. V1 stated V15 was concerned about the lack of staff education. The Transfers policy, dated 8/2017, documented it was the duty of the Director of Nursing or Designee to ensure that adequate training is provided to all nursing staff on the proper use of (mechanical lifts). The policy stated a minimum of two staff members is recommended when transferring with a (mechanical lift) and to follow the Plan of Care to ensure the use of proper transfer technique. The Management of Pain policy, dated 8/2/17, documented to encourage residents to self-report pain; assess pain in non-verbal and cognitively impaired residents; and prevent and minimize anticipated pain when possible. The policy documents the licensed nurse will assess pain under any of the following circumstances: Resident is on routine pain medication and pain is not controlled, persistent, or worsening. A change in pain related behaviors, cognition, or mood occurs. Nursing Observation Pain may be indicated when there are changes in the following: Facial expressions. Body movements.

Based on observation, record review and interview, the facility failed to ensure interventions were implemented to prevent the development of pressure ulcers or worsening of wounds for 1 of 1 resident (R3) reviewed for wound and at high risk for a pressure ulcers. Findings include: On 4/18/24. R3 had a lumber fusion surgery and required Precaution Details:** Spine Brace (back brace designed to give support to thoracic and lumbar spine by preventing twisting and flexion (bending forward) to be worn while patient is up doing transfers and/or ambulating. Does not need to be worn while in bed or chair. SPINAL PRECAUTIONS- NO BLT (NO BENDING, LIFTING more than 7 pounds), OR TWISTING. FALL RISK, 8/10 pain in right hip and bilateral knees. On 4/24/24 R3's Braden Scale for Predicting Pressure Sore Risk Assessment was documented as a 12 (twelve), high risk. On 4/24/24, R3's Minimum Data Set (MDS) section M documented R3 had a stage 2 pressure ulcer (resolved as of 5/6/24), a surgical wound and was at risk for a pressure ulcer. On 4/24/24, R3's Careplan documented R3 has limited physical mobility related to surgical aftercare, spinal stenosis; has potential/actual impairment to skin integrity of the back and right buttock related to fragile skin and to encourage frequent repositioning. On 5/1/24, R3's Physician's order for Heel Protectors to bilateral heels every shift while in bed was obtained. On 5/6/24 at 12:10 PM, heel protectors were not observed in R3's room and the wheel chair lacked a pressure relieving pad. On 5/6/24 at 12:10 PM, R3 was observed sitting in a wheelchair without a pressure relieving pad On 5/6/24 at 1:10 PM, R3 was transferred from the wheelchair to the bed and was positioned in a supine position without heel protectors placed. On 5/6/24 at 3:08 PM, R3 rated R3's pain level at an eight (0- no pain and 10- worst pain). R3 stated I 'm still waiting for the gals to come put me on my side. I've been on my back since I got back in bed. and was observed to not have on heel protectors. On 5/6/24 at 3:25 PM, V16 (Licensed Practical Nurse) was asked to turn R3 and conduct a dressing check/skin assessment. On 5/6/24 at 3:40 PM, R3 was rolled to R3's right side and the dressing covering the back incision was balled up at the top of R3's back and was not covering the incision. V16 peeled off plastic tape which was stuck to R3's skin and rolled up. On 5/7/24 at 8:48 AM, V10 (R3's Healthcare Power of Attorney) Yesterday around 11:00 AM or so, R3 called me crying saying R3 was left in the wheelchair with the brace on for a half hour. They said they would be right back but they hadn't been back. I wasn't very happy about that. R3 doesn't tolerate pain well. I called (the facility) and complained. On 5/7/24 at 9:30 AM, heel protectors were observed in R3's bed. R3 stated they were new and had not seen them before. On 5/8/24 at 3:00 PM, V1 (Administrator) stated R3 did have heel protectors, although they were in the closet because R3 didn't like to wear them. The Formulized Turning and Positioning Program, dated 8/2017, documented residents at moderate to high risk on the Pressure Ulcer Risk Assessment and who are immobile are turned, toileted and repositioned in a formulized manner per the plan of care. The policy documented the turning schedule will occur every 2 (two) hours or when a resident asks. The Preventative Skin Care policy, dated 8/2017, documented that residents identified as being at increased risk for potential skin breakdown shall be repositioned as needed based on assessment and Pressure Redistribution Mattresses may be used in chairs.

Based on observation, record review and interview, the facility failed to ensure staff were competent to perform cares for a 1 of 1 resident (R3) reviewed for specialized equipment and spinal precautions. Findings include: R3 was admitted to the facility on [DATE] post a lumber fusion surgery and spinal stenosis. On 4/23/24, the facility received R3's Hospital Transfer Papers which documented Up to chair 3 (three) times per day. Spine brace (back brace designed to give support to thoracic and lumbar spine by preventing twisting and flexion (bending forward) to be worn while up ambulating. Does not need to be worn while up in chair or bed. On 4/24/24, The Physical Therapy and Occupational Therapy Evaluation and Plan of Treatment documented Precaution Details: ** Spine Brace to be worn while patient is up doing transfers and/or ambulating. Does not need to be worn while in bed or chair. SPINAL PRECAUTIONS- NO BLT (NO BENDING, LIFTING more than 7 pounds), OR TWISTING. FALL RISK, 8/10 pain in right hip and bilateral knees. The evaluation documented R3 required substantial/maximal assistance with bed mobility, partial/moderate assistance with transfers and was dependent on staff with ambulation. On 4/24/24, R3's Care plan documented has limited physical mobility related to surgical aftercare, spinal stenosis and lacked interventions related to the Spinal Precautions and the Spine brace. On 4/25/24 R3's Order Summary documented a Physician's Order for Spine Brace on when resident up every shift and lacked documentation of Spinal Precautions or the application of the Spine brace. On 5/6/24 at 12:10 PM, R3 was sitting in a wheelchair with the Spine brace on; R3's hand was over forehead, head down and grimacing; pulling and moving brace around. R3 stated We (R3 and R5) put the call light on twice. It hurts. It's pushing on my belly, and I feel sick to my stomach. I'm not supposed to have this thing (brace) on when I'm in the wheelchair. It's just digging into me and hurting my back. R3's call light was draped over bed and unreachable. At 12:38 PM, R3 was observed sitting in a wheelchair with brace on. On 5/6/24 at 1:04 PM, R3 was sitting in a wheelchair with brace on. R3's roommate R5 stated I put on the call light. They had to go find a mechanical lift. On 5/6/24 at 1:10 PM, V13 (Certified Nurse Aide) was observed to enter R3's room. Upon entrance V13 had hooked R3's sling up to the mechanical lift. V13 stated I need to go get a spotter. R3 and R5 both stated V13 got R3 and R5 both up by V13 only this morning. On 5/6/24 at 1:20 PM, R3 was lifted into bed by V13 and V14 (Certified Nurse Aide) via mechanical lift with back brace on. V13 stated V15 took R3's brace off this morning and I put the brace (R3's Spine brace) back on wrong. R3 was left laying supine, flat on the bed with call light on nightstand. On 5/6/24 at 3:08 PM, R3 stated R3's pain level was at an eight (0- no pain and 10- worst pain). R3 stated The brace rubbed on my back incision. I'm still waiting for the gals to come put me on my side. I've been on my back since I got back in bed. R5 put the light on once but I still haven't had anyone come back. I have indigestion so bad; I feel like there's a big heavy lump here (pointed to upper sternum). I called V10 (Healthcare Power of Attorney) earlier when they left me up in the chair and told V10 how much pain I was in. V10 called the front desk and told them to put me back in bed. That's why they came in (at 1:10 PM to put R3 back into bed). On 3/6/24 at 3:25 PM, V16 (Licensed Practical Nurse) was asked to turn R3 and conduct a dressing check/skin assessment. On 5/6/24 at 3:40 PM, V16 proceeded to have R3 put a bent left leg on top of the right leg and pushed R3 to R3's right side (twisting motion). The dressing covering the back incision was balled up at the top of R3's back and was not covering the incision. V16 peeled off plastic tape which was stuck to R3's skin and rolled up. V16 then left the room to go get supplies for the dressing change and left R3 rolled over on right side with the bed in a high position and with the incision open to air. During this time R3 stated that earlier in the day, R3 had been constipated and R3's belly was bloated. R3 stated I begged them (staff) to get me up to the toilet instead of going in my bed. R3 stated They just tell me to go in my briefs. Approximately 10 minutes later (3:50 PM) V16 enters R3's room and performed the dressing change. On 5/7/24 at 8:48 AM, V10 stated Some girls came in about the 4th day and yanked on R3's leg. It really hurt R3. They are doing stuff they aren't supposed to do. This was a different surgery and it's way more painful. R3 should wear the brace when up and when R3 does therapy. They use that hoist (mechanical lift), and I don't think they are supposed to do that. R3 called me one day and told me R3 was in the hoist for a half hour. They aren't walking R3 very much. Yesterday around 11:00 AM or so, R3 called me crying saying R3 was left in the wheelchair with the brace on for a half hour. They (staff) said they would be right back, but they hadn't been back. I wasn't very happy about that. R3 doesn't tolerate pain well. I called (the facility) and complained and apparently, they put her back in bed. R3 has called me about 3 or 4 other times and says R3 pushes the call button but no one comes. Sometimes when I get there, we can't find the call light. One time it was wrapped up and hung up on the wall. I have pushed the call light a couple of times, and no one has answered but I'll go out there and complain. It gets done then. On 5/7/24 at 12:30 PM, V15 (Physical Therapist) stated Orders come from the Admission Orders and put into (medical record) by V12 (Assisting Director of Nursing.). We (Therapy) communicate with staff regarding weight bearing status and such. Today we changed R3's wheelchair to a high-backed reclining wheelchair so that R3 doesn't have the brace pushing into R3's groin/stomach and chest. V15 stated Therapist do not attend care plan meetings, R3's record lacked Physician Orders for Spinal Precautions and the staff were not educated on Spinal Precautions and the use of the Spine brace and they should have had. V15 stated staff should be utilizing the log roll technique (no twisting). V15 stated the Spine brace should have been removed while in the wheelchair and prior to using the mechanical lift for transfer. On 5/7/24 at 3:00 PM, V1 (Administrator) stated V15 has already been out to educate staff about the Spine brace and Spinal Precautions. V1 stated V15 was concerned about the lack of staff education. The Transfers policy, dated 8/2017, documented it was the duty of the Director of Nursing or Designee to ensure that adequate training is provided to all nursing staff on the proper use of (mechanical lifts) lifts. The policy stated a minimum of two staff members is recommended when transferring with a mechanical lift and to follow the Plan of Care to ensure the use of proper transfer technique.

Based on record review and interview the facility failed to ensure the right resident received IV (intravenous) access hydration, micronutrient therapy and failed to obtain a physician's order to administer IV hydration and micronutrient (vitamin and mineral therapy) for one of three residents (R1) reviewed for IV therapy in the sample of three. Findings include: R1's Incident Report dated 1-17-24 at 1:23 PM and signed by V2 (Director of Nursing) documents, Incident Description: (IV therapy company) inserted an IV on (R1's) right wrist. (R1) did not receive much, maybe 100 ml (milliliter). (R1) pulled IV out and was waving it around. No injuries noted. Witnesses: V9 (IV Hydration RN/Registered Nurse) statement: I (V9) got the A and B (resident) bed mixed up and when I asked (R1) her name, she said yes. V8 (IV Hydration RN) statement: I had a trainee (V9) and (V9) mixed up the A and B bed. R1's Order Summary Report and Physician's Orders dated 1-1-24 through 1-31-24 do not include an order for R1 to receive IV hydration or micronutrient therapy, or for staff to obtain IV access. R1's Progress Notes dated 1-17-24 at 8:35 PM document R1 received a bruise to the right wrist due to an IV stick. On 4-12-24 at 10:10 AM V3 (R1's Power of Attorney) stated, I went to visit (R1) on 1-17-24 and I noticed (R1's) right arm had a bruise to the right wrist. I called the facility the next day and spoke to (V2/Director of Nursing) and she told me an outside group does vitamin infusions and a trainee for the vitamin infusion group gave (R1) an intravenous stick and infused some of a vitamin infusion in her right arm. On 4-12-24 at 10:30 V8 (Intravenous Hydration Registered Nurse) stated I was (V9's/Intravenous Hydration RN) preceptor and (V9) got the resident beds mixed up. I was down the hallway with another resident and (V9) asked (R1) her name and (V9) gave (R1) the infusion thinking (R1) was the right resident. (V9) came down to the room with me and (V2) came down and told me (R1) removed the IV. (V2) dressed the site so it was not bleeding anymore. I looked at our list and noticed (R1) was not supposed to get the IV and went and notified (V2). (R1) had gotten approximately 300 ml of our nutrition solution (vitamin C, b-complex, zinc, magnesium, calcium, amino acids). (V9) should have asked (R1) her first and last name, birthdate, and verified (R1's) picture in the medication administration record before administering the IV. The facility's IV Hydration and Micronutrient Therapy Guideline Contract dated 10/2023 documents, Nutrition Infusion: The nutrition infusion is an intervention for patients who are experiencing nutritional deficiencies, weight loss, decrease appetite, refusal to eat, or on weight management protocols. Ingredients: Vitamin C, B-Complex Vitamin, B-5 Vitamin, B-12 Vitamin, Calcium Gluconate, [NAME], Amino Acid Blends, and Branched-Chain Amino Acids (protein-based amino acids). V2 (Director of Nursing, V (Assistant Director of Nursing) or designee will contact the physician or nurse practitioner for review of the evaluation and recommendations and will secure specific orders for the specific type of IV infusion, fluid option, infusion rate, and administration route.

Based on interview and record review, the facility failed to consistently offer/provide bedtime snacks to six residents (R8, R14, R27, R43, R63, R93) which include the Resident Council President (R8) of 16 residents reviewed for bedtime snacks in the sample of 45. Findings include: Facility policy/Bedtime Snacks dated 8/2017 documents: To ensure that residents are offered bedtime snacks daily. All residents within the facility shall be offered a snack at bedtime. Charge Nurse and Nursing Assistants will offer snacks to all residents every evening prior to bedtime. On 10/11/23 at 10am, Resident group meeting was held with 16 residents. Six residents (R8, R14, R27, R43, R63, R93) including the Resident Council President (R8) stated they were not consistently offered or provided with bedtime snacks. R8, R63 and R93 stated the kitchen puts out snacks at the nurse's station but the CNA's don't consistently offer or pass out. R63 stated there have been two residents who will take all of the snacks back to their room and the staff don't replace them. On 10/12/23 at 2:40pm, V19 CNA (Certified Nurse Assistant) identified herself as a 2nd shift CNA. At that time V19 stated she's usually on break when the snacks need to be passed I'm not usually around to do that. The snacks are set out at the nurse's station. If they ask, I'll bring it to them. On 10/12/23 at 2:45pm, V20 CNA stated certain residents automatically get snacks and the other snacks are saved for residents who might have blood sugar problems. On 10/12/23 at 2:50pm, V18 LPN (Licensed Practical Nurse) stated sometimes residents come from other units to get snacks before bed because there are a couple residents who will take all the snacks for themselves.

Based on observation, interview, and record review, the facility failed to develop a baseline care plan for a resident's anticoagulant and insulin medications (R359) and a resident's CPAP/continuous positive airway pressure machine (R309) for two of 25 residents (R309 and R359) reviewed for care plans in the sample of 45. Findings include: The facility's 24 Hour (Interim) Care Plan Policy revised 02/21 states, Purpose: To provide guidelines for completion of a 24-Hour (Interim) Plan of Care for newly admitted residents. A 24-Hour Care Plan guides provision of care from the time of the resident transfer/admission until the Interdisciplinary Care Plan is completed. Policy: Based on information obtained during the admission process an Interim care plan will be developed as soon as possible after admission. Responsibility: It is the responsibility of the Interdisciplinary Team (IDT) to develop the Interim Care Plan. It is the responsibility of the Charge Nurse/Care Plan Coordinator to complete an Interim Care Plan on all newly admitted residents. Procedure: 1. An Interim Care Plan will be developed as soon as possible after initial admission. 2. The Interim Care Plan will be based on Physicians Orders and Nursing Admission Assessment. 3. The Interim Care Plan will guide all resident care until the Interdisciplinary Care Plan is developed. This same policy documents the Interim Care Plan should include resident medications. 1. R359's current Admission Record documents R359 admitted to the facility on [DATE]. R359's current Medication Review Report documents an order for Insulin Aspart Subcutaneous Solution Pen-Injector 100 units/ml (per milliliter) per sliding scale with an order start date of 10/3/2023, and an order for the anticoagulant medication Warfarin Sodium 6 milligram tablet via Gastrostomy Tube with an order start date of 10/3/2023. R359's Baseline Care Plan, dated 10/3/2023, Section D documents Medications Resident is Taking. The boxes Insulin and Anticoagulants are not marked. On 10/11/23 at 9:00 AM, V14 (Licensed Practical Nurse) entered R359's bedroom and administered three units of insulin subcutaneously to R359's right lower quadrant. As of 10/11/23, R359's Interim Care Plan did not document R359's insulin, or anticoagulant medications. On 10/12/2023 at 11:29 AM, V2 (Director of Nursing) stated insulin and anticoagulant medications should be documented on the resident's baseline care plan by the admitting nurse. At this time, V2 verified R359's base line care plan did not document R359's insulin, or anticoagulant medications. 34131 2. On 10/10/23 at 11:10am and 10/12/23 at 9:19am, R309's CPAP was on the right side of her bed. On 10/10/23 at 11:10am, R309 stated I take care of my own CPAP and wear it at night, I have had it since I got here. R309's current care plan does not have R309's CPAP documented. On 10/13/23 at 1:02 PM, V2 RN/Registered Nurse DON/Director of Nursing verified R309's care plan did not include her CPAP use.

Based on observation, interview, and record review, the facility failed to ensure resident preferred television programs were displayed on the unit television viewing area for one (R84) of 45 residents reviewed for dignity in the sample of 45. Findings include: Facility Policy/Resident Privacy and Dignity dated 8/2/17 documents: Provide all residents with a home-like environment that promotes dignity and respect to the residents of the facility. On 10/10/23 at 10:44am, R84 was sitting in the memory care television viewing area watching the television. The program on the television was a cartoon with violent and graphic content. At that time, R84 stated she did not like watching cartoons, and acknowledged the content was offensive. R84 also stated she would prefer to watch a program that didn't make her feel like a 4th grader. On 10/10/25 at 10:50am, V22 and V23 (R92's family members) entered the television viewing room with R92. At that time, V22 noted the cartoons on the television, looked over at R84, and asked her if she would rather watch a different program. R84 stated she would rather watch something else. V22 changed the television program to a black and white classic movie with dancing and singing. R84 stated Oh, I like that with a smile on her face. At 11:00am V22 and V23 stated that they visit every day and have often found inappropriate programs on the television and (with the residents permission) change the channel to a program the residents prefer. V22 and V23 stated they believe staff are changing the channels to programs the staff prefer, and not to the resident preference. R84's current Care Plan indicates she likes movies, watching golf/basketball/baseball, music, and singing.

Based on observation, interview, and record review the facility failed to implement appropriate fall interventions for one of three residents (R1) reviewed for falls in a sample of three. This failure resulted in R1 obtaining bilateral black eyes, fracturing her right nasal bone, and knocking out two natural teeth. Findings include: The facility's Fall Prevention Program, revised 1/21, documents to provide ongoing risk reducing interventions. This form also documents to provide ongoing evaluation of resident response to intervention. On 6/14/23 at 10:30am, R1 was in her wheelchair in activities. R1 had black yellowish bruising on her bilateral cheek bones. R1 also had a healing laceration under her [NAME]. At 1:40pm, R1 stated that she does not remember what happened the night of the fall but knew that it hurt. R1's Fall Risk Assessment, dated 6/10/23, documents a score of 12, indicating R1 is at risk for falls. R1's current care plan documents that R1 requires the assist of one for toileting needs and transfers or ambulating. R1's Progress Notes, dated 6/10/23 at 8:15pm, R1 was observed laying on the floor in the prone position. R1's hands were curled to her side, legs together with her pants around her ankles, there was a small amount of blood on the floor at R1's head. V3, Registered Nurse, called out R1's name, with no response. V3 cradled R1's head and rolled her onto her right side. R1 had a facial injury with R1's lower mouth actively bleeding. R1's partial denture found on floor. Resident's eyes were open, pupils equal in size. R1 then responded when her name was called out. With concern for her safety, R1 was not moved again. R1 stated she thought her right hip was broken. Upon ambulance arrival, R1 stated she had pain in her back, neck, hip, and face. R1 was placed on a sheet and slid on the floor to make room for gurney. R1 was lifted off the floor and placed on the gurney. R1's emergency room notes, dated 6/10/23, documents that R1 presented with pain, laceration to face and puncture through her [NAME]. R1 broke her dentures and possibly other teeth. R1's assessment documents that R1's upper dentures were broken and removed in three pieces. R1's upper lip has a skin abrasion, and her lower lip is diffusely swollen. R1 has a 1.5cm (Centimeter) laceration on the lower aspect of the external lower lip, near her [NAME]. R1's Computed Tomography scan showed a chronic right nasal bone fracture. On 6/14/23 at 3:10pm, V6 CNA, (Certified Nursing Assistant), stated that R1 was standing in the bathroom holding on to the grab bar. V6 stated that she removed R1's brief, when R1 grabbed the brief away from V6. V6 stated that R1 threw the soiled brief at V6. V6 stated that R1 was agitated, started to yell, and curse at V6. V6 stated that she left R1 standing at the grab bar, with her pants down to her feet, to get help. V6 stated that R1 turned and attempted to walk to her bed and fell . V6 stated that R1's face smacked the floor. V6 stated that she then went to get V3. V6 stated that she should have yelled for assistance, instead of leaving R1 standing alone. On 6/14/23 at 1:40pm, V5, (R1's Family) stated that R1's upper dentures are shattered, and she also lost two of her own bottom teeth, during the fall. V5 stated that R1 should not have been unattended in the bathroom, due to R1's continued falls.

Based on observation, record review and interview, the facility failed to utilize a mechanical lift to transfer a resident (R2) and failed to utilize a gait belt and ensure surfaces were dry when transferring a resident in the shower room (R1), for two of three residents (R1, R2) reviewed for falls in a sample of three. This failure resulted in R2 falling on 2/09/23 and sustaining a fracture of the right tibia and fibula, when V3 (Certified Nursing Assistant) attempted to pivot transfer R1 from the bed to the wheelchair. This past non-compliance, which involved R2, occurred from 2/09/23 to 3/16/23. Findings include: The facility policy, titled Transfers (revised 1/2020), documents Purpose: To provide guidelines to nursing assistant/nurse for proper technique for transferring residents. Policy: To promote safe transfer for the residents, as well as the staff, gait belts, (mechanical) lifts, and/or sit to stand will be used, unless otherwise specified. Responsibility: It is the responsibility of all nursing staff to ensure the use of safe transfer techniques when transferring a resident. Procedure: 1. Explain to resident what task you are going to be performing. Enlist their assistance with the task if they are able to provide it. 2. The transfer technique used for the resident will be evaluated and determined by therapy or nursing as appropriate. 3. A minimum of two staff members is recommended when transferring with a (mechanical) lift. 4. When using a (mechanical) lift, pay close attention to be sure that the (mechanical lift) sling is properly positioned. 5. When using a gait belt, apply the belt around the resident's waist over clothing. Never apply gait belt over bare skin. 6. If sit to stand is being used, ensure resident is able to stand. 7. Follow Plan of Care to ensure the use of proper transfer technique. The Electronic Medical Record documents R2 was admitted to the facility on [DATE] with the diagnoses of Lack of Coordination, Difficulty Walking, Unsteadiness on Feet, and Reduced Mobility. A Fall Risk Assessment, dated 2/02/23, documents R2 as high risk for falls. R2's Plan of Care, dated 12/19/22, documents (R2) has (Activities of Daily Living) self-care performance deficit (related to) Activity Intolerance, Confusion, Fatigue, Impaired Balance, Limited Mobility, Stroke and advises direct care staff that (R1) can transfer with extensive assist of two staff and at times requires mechanical lift by two staff to move between surfaces. A Minimum Data Set assessment, dated 2/03/23, documents R2 as having minimal cognitive impairment and requiring the extensive physical assistance of 2+ staff members for transfers. A Fall Report, dated 2/09/23, documents Incident Description - Nursing Description: Assisted fall to the floor by (V3/Certified Nursing Assistant) in resident room during bed to chair transfer. Resident Description: 'My legs buckled, and I couldn't stand so she lowered me to the floor.' The Fall Report further documents, under Notes, At approximately (7:00 am), (R2's) legs gave out during a transfer from her bed to her wheelchair. (R2) had no complaint of pain, and no physical abnormalities were noted. (R2) was assisted into her wheelchair and taken to therapy. (R2) was noted to have a bruise and (right lower extremity) was tender to touch. Physician and family representative were notified. Received a physician's order for x-ray of the right leg. X-ray results indicate acute to subacute fracture of the proximal tibia and fibula. Physician was notified of diagnostic results and gave new order to send the resident to the (emergency department) for evaluation and treatment. (R2) returned the same day with an immobilizer on and instructions to follow up with orthopedics. A Progressive Disciplinary Form, dated 2/10/23, documents V3 received a written discipline for pivot transferring R2 independently, when R2 was to be transferred with two staff and a mechanical lift. emergency room Records, dated 2/09/23, document R2 presented after sustaining a ground level fall and developing tenderness and swelling to the proximal right lower leg. Hospital x-ray results document R2 as having mildly displaced, comminuted and impacted proximal right tibial metaphysis fracture and probable mildly displaced fracture of the fibular head. On 4/17/23 at 12:14 pm, R2 was observed lying in bed with an immobilizer brace on her right leg. At that time, R2 explained on 2/09/23, V3 entered her room and had her sit on the side of the bed. V3 told R2 that they were going to stand and transfer to the wheelchair. R2 stated, I told (V3) I wasn't ready to transfer like that. Therapy hadn't cleared me to transfer that way, but (V3) insisted. I tried again to tell her 'No' and they use a lift, but everything went so fast. (V3) told me to put my hand on the arm of the wheelchair and (V3) pulled me up and I fell forward to my knees. R2 stated V3 was not using a gait belt. R2 indicated the nurse on duty assessed her leg. R2 stated she had some discomfort in the right lower leg, but it wasn't horrible, so she went on to her scheduled therapy session. R2 stated the Physical Therapist noticed bruising on her lower right leg and an x-ray was ordered that day, which found a fracture. On 4/18/23 at 10:55 am, V5 (Physical Therapist) confirmed on 2/09/23, when R2 presented to Therapy after her fall, R2 was complaining of pain in the right leg and there was bruising and swelling to the area below the right knee. V5 only worked R2's left leg that day and R2 was seen by the facility's Nurse Practitioner right after her Therapy Session. On 4/17/23 at 12:28 pm, V2 (Director of Nursing) stated they did determine that V3 had improperly transferred R2 on 2/09/23 and she should have been transferred from the bed to the wheelchair using a mechanical lift. V2 indicated V3 was disciplined for performing an improper transfer and received education. Prior to the survey date of 4/18/23, the facility had taken the following actions to correct the non-compliance: A. On 2/13/23, a facility wide audit was completed to ensure all resident's Kardex reflected their correct current transfer status. B. On 2/10/23, all direct care staff received education regarding safety during transfers and the need to utilize the Kardex to identify each resident's transfer status. C. On 2/16/23 and ongoing, Management has conducted random observations of direct care staff performing transfers to ensure proper technique and transfer status was followed. D. Beginning 2/16/23, Management will audit four residents weekly for four weeks to ensure all transfers are being performed as identified in the resident's Kardex. This will be verified by interviews with staff and the residents on how the residents are being transferred in comparison to their transfer status in the Plan of Care and Kardex. E. On 2/16/23, a monitoring system was implemented to ensure all new residents have a Clinical Mobility Assessment completed and their transfer status added to the Kardex for staff to reference. The Electronic Medical Record documents R1 was admitted to the facility on [DATE] with the diagnoses of Cerebral Infarct, Lack of Coordination, Abnormal Gait and Mobility, Seizure Disorder and Abnormal Posture. A Minimum Data Set assessment dated [DATE], documents R1 is cognitively intact, requires the extensive assistance of one staff for transfers, is not steady and can only stabilize with staff assistance when moving from surface to surface/seated to standing. A Fall Risk Assessment, completed on 2/18/23, failed to identify R1 as a potential fall risk, despite R1's history of Seizure Disorder and Abnormal Gait/Mobility. Progress Notes, dated 3/9/2023, document R1 had a witnessed fall in the shower room after resident was reaching for item(s) at time of the fall. Progress Notes document R1 sustained a hematoma on her head as a result of the fall and was sent to the emergency room , with all testing results returning negative. A Fall Report, dated 3/09/23, documents (R1) was observed on floor in front of (wheelchair) in center of shower stall leaning on her left side/arm. (R1) was naked due to having just finished a shower. (R1) was wet and slid out of (wheelchair) onto the floor. (R1) was assessed and had hematoma to back of her head and abrasion to her left scapula. (R1) assisted back to (wheelchair) by two staff members and then into bed. (R1) was sent to the (emergency department) to (evaluate) and treat due to being on blood thinners. (R1) came back from the (emergency department) with (no new orders). Neuros (Neurological checks) and fall vitals started. Care Plan updated to shower with two assist. On 4/17/23 at 2:02 pm, R1 was sitting up in her wheelchair in her room. R1 had obvious impairment to the function of her left side as a result of a recent stroke. At that time, R1 explained what happened when she fell on [DATE] in the shower room. R1 stated V4 (Certified Nursing Assistant) helped shower her and when it was over, V4 was helping transfer her to her wheelchair from the shower chair. R1 indicated V4 did not use a gait belt at any point while transferring her in the shower room. R1 stated, I was still wet, and the floor was wet, and I slid right out of my wheelchair. R1 stated she hit the back of her head on the tile and her left arm was hurting afterwards. R1 stated the nurse working came into the shower room to help V4 get her up off the floor, which is when they pulled her up by her arms. R1 stated the staff did not use a gait belt when getting her up off the floor and she was naked at the time. R1 stated staff usually put towels on the ground if it is wet and dry her off better before transferring her to the wheelchair after a shower. On 4/17/23 at 1:52 pm, V6 (Registered Nurse) stated V4 had summoned her to the shower room on 3/09/23, as R1 had fallen. V6 stated, when she entered the shower room, R1 was on the floor, naked and still wet, in front of her wheelchair. V6 stated she could feel a bump on the back of R1's head immediately after the fall. On 4/17/23 at 2:57 pm, V7 (Care Plan Coordinator) stated she interviewed R1 after she fell on [DATE], to determine the circumstances behind the fall. V7 stated R1 told her that her bottom was still wet and she slid out of the wheelchair, hitting her head. V7 stated R1 was very concerned about hitting her head and indicated she had not been dried off before being transferred. V7 stated she interviewed V4 after the fall, as well. V7 indicated V4 told her R1 was leaning forward in her wheelchair, trying to grab a towel and fell . V7 stated she did not believe R1's hematoma to the back of the head was consistent with that scenario, but nothing more was questioned for the investigation of the fall. On 4/17/23 at 1:53 pm, V4 (Certified Nursing Assistant) stated R1 fell from her wheelchair in the shower on 3/09/23 when she was leaning forward to grab a towel that was on the shower bar. V4 described R1 sliding out of the wheelchair onto the floor as she leaned forward, and her wheelchair cushion sliding out with her. On 4/18/23 at 10:25 am, V4 was interviewed again for more details regarding R1's fall. V4 stated she was in the last shower stall of the shower room and had transferred R1 from her wheelchair to the shower chair for her shower. V4 indicated she did not use a gait belt to transfer R1 from one chair to the other, because R1 was naked. After showering R1, V4 stated she dried off R1, but indicated R1 was still a little wet. V4 then transferred R1, naked and without a gait belt, back to her wheelchair from the shower chair. V4 stated, as she was backing R1 out of the shower stall, R1 leaned forward and slid out of the wheelchair. V4 stated she was unsure how R1 hit the back of her head during the fall. V4 asked for help from V6 to get R1 up off the floor. V4 stated they did not use a gait belt to get R1 up, because she was naked and R1 has a stoma that was exposed on her abdomen. V4 was questioned as to what she could have done to possibly prevent R1's fall and make her environment safer. V4 concluded that she could have made sure R1 was totally dry and could have put a hospital gown on R1 to utilize a gait belt when transferring her and getting her up off the floor.

Based on interview and record review, the facility failed to have fall mat interventions in place from a prior fall for one (R1) of three residents reviewed for falls in a sample of three. This failure resulted in R1 obtaining a subdural hematoma, and a forehead laceration with three sutures. Findings include: Facility Policy: Falls, dated July 2021, documents Falls are a major cause of injury. Older adults are at risk for falls. The purpose of this guideline is to describe strategies that can identify individuals at risk for falls and develop interventions that are individualized to each resident. Reassessing fall risk and fall prevention programs will ensure a proactive approach to reducing falls. Fall prevention program includes residents identified as at risk for falls have interventions added to the plan of care. R1's medical record, dated 1/21/22, documents R1 needs extensive assistance of two persons for activities of daily living. Facility Daily Hall Assignments, dated 1/25/22, documents V4 and V6 both Certified Nurse Aides/CNAs were working second shift on R1's hall. R1's medical record documents R1 was admitted to the facility on [DATE] and had falls on 1/25/2022, 1/16/2022, 7/13/2021, and 7/2/2021. R1's current care plan documents (R1) is at risk for falling related to a history of falls secondary to deconditioning and weakness with a history of [CONDITION(S)]/[CONDITION(S)]. R1's medical record documents a fall on 1/15/22 with an intervention for floor mats. R1's medical record, dated 1/25/2022 at 11:11pm by V5 Registered Nurse/RN, documents Writer called to resident's room by Certified Nurse Aid/CNA because Resident is on the floor and bleeding. Resident was found lying on his left side and bleeding profusely from an open wound on the left side of his forehead. A neurological evaluation was performed, and resident seemed confused because he could not tell what happened. He was cleaned up and assisted to bed. Advanced Medical Transport/AMT was called, and resident was sent out for further evaluation because despite attempts to stop the bleeding, it won't stop. R1's medical record documents R1 was discharged from the facility on 1/25/22 and readmitted on [DATE]. R1's local hospital emergency room /ER notes, dated 1/25/22 at 10:21pm by V13 Medical Doctor/MD, documents (R1) had a ground level fall with a head laceration while on [MEDICATION(S)]. The primary encounter diagnosis was Traumatic [CONDITION(S)] (HCC). A diagnosis of Forehead laceration was also pertinent to this visit. admitted to the Neuro ICU. R1's Advanced Medical Transport/AMT notes, dated 1/25/22 at 10:22pm, documents (R1) remembered falling from the bed and fell on to the floor. R1's local hospital emergency room /ER notes, dated 1/25/22 at 11:26pm by V14 MD, documents (R1) has a primary medical history of [CONDITION(S)] taking [MEDICATION(S)] and [MEDICATION(S)], and a history of [CONDITION(S)] ([CONDITION(S)] Accident) and Dementia who presents to the Emergency Department/ED via Emergency Medical Service/EMS for concerns of fall, and head laceration (left forehead). According to EMS, they were called from nursing home staff that the patient had an unwitnessed fall and was found lying on the ground in a pool of blood with a laceration over his forehead. Patient will not elaborate on details of the fall. R1's local hospital laceration repair notes, dated 1/25/22 at 11:33pm by V15 MD, documents (R1's) forehead Laceration length: 5 centimeters/cm; and Number of sutures: 3. R1's local hospital notes, dated 1/26/22 at 1:49am by V15 neurosurgeon MD, documents I have personally reviewed (R1's) imaging which shows a tentorial SDH (Subdural Hematoma) without brain compression. (R1's) Left forehead laceration- Approximately 5 cm laceration over left forehead with small Hematoma underneath. On 2/8/22 at 11:02am and 2/9/22 at 11:19am, V6 Certified Nurse Aid/CNA stated I was working when (R1) fell on [DATE]. When we went to do rounds, he was on the floor, (V4 CNA) and I found him, his bed was in the middle of the room, he was transferred from the 400 unit onto the dementia unit that day, he did not have his fall mats, he fell on the floor, and he could not tell us what happened. On 2/8/22 at 11:40am, V12 R1's family stated (R1) was trying to get up out of bed and fell , he told me he was getting out of bed, and he knows he can't do it. He has had a couple of falls before doing stuff he knows he can't do, and I have been wondering if he is being looked after enough. I just don't understand why he keeps falling. On 2/8/22 at 1:40pm, V4 CNA stated I was working when (R1) fell on [DATE]. When we came to do rounds, he was on the floor, no floor mats, he said he fell , he was bleeding from his head, and he was sent to the hospital.

Based on interview and record review the facility staff failed to recognize and take immediate action for a critical change in a resident's condition by failing to act promptly upon a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in a delay of treatment, resulting in R3 being hospitalized in critical condition. FINDINGS INCLUDE: The facility Assessment Tool completed 07/13/21 documents, The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs as well as your capabilities to provide services to the residents of your facility. Part 2. Services and Care We Offer Based on Our Resident's Needs: Management of medical conditions-Assessment, early identification of problems/deterioration, management of medical and psychiatric symptoms and conditions such as heart failure, diabetes, [CONDITION(S)], gastroenteritis, infections such as [CONDITION(S)] (urinary tract infection) and gastroenteritis, pneumonia, [CONDITION(S)]. Part 3. Facility Resources Needed to Provide Competent Support and Care for Our Resident Population Every Day and During Emergencies: Staff training/education and competencies- Identification of resident changes in condition, including how to identify medical issues appropriately, how to determine if symptoms represent problems in need of intervention, how to identify when medical interventions are causing rather than helping relieve suffering and improve quality of life. R3's current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's SNF (Skilled Nursing Facility) History and Physical, performed on 11/05/21 by V6 Physician documents, (R3) with a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's current vital signs are: Blood Pressure 142/84, Pulse 84/regular, Temperature 98.2, Respiratory Rate 20 and SpO2 (Oxygen Saturation) 97%. Cardiovascular: Normal rate and rhythm. Pulmonary: Normal breath sounds. Order to monitor blood pressures every shift and have physician assistant (V7) see (R3) on Monday (11/08/21). Order CMP (Complete Metabolic Panel), CBC (Complete Blood Count) and TSH ([CONDITION(S)] Stimulating Hormone). R3's Laboratory Report, dated 11/08/21 documents, Specimen received 11/08/21 at 12:29 PM, Results: elevate White Blood Count of 23.0 (Normal range 4.8-10.8), decreased Hemoglobin of 8.2 (Normal range 12.0-16.0) and decreased Hematocrit 26.4 (Normal range 37.0-47.0). R3's electronic Progress Notes, date 11/08/21 at 5:57 PM document, Faxed lab (laboratory) results to first call (physician on call), (New order) from NP (Nurse Practitioner V7) as follows: UA (Urinalysis), Chest X-Ray, Repeat CBC (Complete Blood Count) tomorrow. R3's Radiology Results Report, dated 11/09/21 at 5:00 PM documents, Near complete Opacification of the Right Lung may be related to Lobar collapse/Atelectasis, consolidation or Pleural Effusion. This obscures evaluation for a small Pneumothorax. There is rightward mediastinal shift. R3's electronic Progress Notes, dated 11/09/21 at 8:51 PM document, X-ray results called to on call agency. New order to do vitals every 4 hours and have (R3) see (V7) in AM (morning) if pulse ox drops or resident becomes anxious, send to E.D. (Emergency Department). R3's electronic Progress Notes, dated 11/10/21 at 12:27 AM document R3's vital signs, Temperature 97.7, Blood Pressure 119/71, Pulse 77/regular, Respirations 18 and SpO2 97%. R3's electronic Progress Notes, dated 11/10/21 at 11:10 AM, by V3 Registered Nurse document, (R3) give [MEDICATION(S)] (pain medication) for c/o (complaints of) pain to left hip and leg. Noted that (R3) felt diaphoretic. BP (Blood Pressure) 84/50, Pulse 180/regular, Pulse Ox 90% on 2 liters oxygen. Denies SOB (short of breath). Will monitor and recheck after her pain med (medication) begins to work. R3's electronic Progress Notes, dated 11/10/21 at 11:50 AM, by V3 Registered Nurse document, Reassessed resident (R3). State's pain is better 4/10. BP remains low-77/50, Pulse 160. Respirations 32 on 2 liters oxygen. Increased oxygen to 3 liters. Pulse ox 88%. Remains diaphoretic. Lungs (sounds) diminished posteriorly with some rales anteriorly. Will notify doctor (V6). On 11/10/21 at 11:55 AM R3's electronic Progress Notes, document, Notified (V6 Physician) of (R3's) condition. Orders received to send to hospital for evaluation related to current condition and altered labs and CXR (chest X-ray) on Monday (11/08/21). R3's electronic Progress Notes, dated 11/10/21 at 12:05 PM document, Called AMT (Advanced Medical Transport) to transport (R3) to (local hospital). 12:23 PM, AMT left with (R3) for hospital. R3's Hospital History and Physical, dated 11/10/21 at 12:43 PM documents, (R3's Assessment and Plan) Septic Shock: SIRS (Systemic [CONDITION(S)] Response Syndrome) criteria met by WBC (White Blood Count) 19.74, [CONDITION(S)] and Tachypnea. Initially Hypotensive but Blood Pressure improved with fluids. Blood and urine culture sent. (R3) received 2-liter bolus in ER (emergency room ) and 2 PRBC (Packed Red Blood Cells) for [CONDITION(S)]. [MEDICATION(S)] (antibacterial) and [MEDICATION(S)] (antibacterial) given in ER. Pneumonia: Right lower lobe densities. Antibiotics as above. RLL (Right Lower Lobe) Atelectasis: Suspect mucous plugging. Chest CPD (Chest Physiotherapy). Lactic Acidosis: Secondary to [CONDITION(S)] and Hypotensive as above. IV (Intravenous) fluid and blood ordered. SVT ([CONDITION(S)] [CONDITION(S)]): Resolved after fluids and [MEDICATION(S)] (antiarrhythmic). Likely secondary to Septic Shock as above. Acute [CONDITION(S)]: Likely secondary to acute blood loss due to recent hip surgery. 2 PRBC. Thrombocytosis: Likely secondary to acute blood loss. Acute on Chronic Hypoxemia: Related to RLL (Right Lower Lobe) Pneumonia and Atelectasis. Elevated Liver Enzymes: May be secondary to Septic Shock as above. On 11/29/21 at 2:53 PM, V3 Registered Nurse stated, I was aware on the morning of 11/10/21 that R3 had an elevated white count and (R3's) chest x-ray, 'didn't look good'. I assessed (R3) at 11:10 AM and noticed (R3) was diaphoretic, [CONDITION(S)] and had a low BP (Blood Pressure) and Oxygen Saturation. I did not call the doctor at that time but administered a pain pill to (R3) and thought I would reassess (R3) later. I didn't think of it as [CONDITION(S)], I thought (R3) was just having pain. V3 verified R3 is usually Hypertensive and has never had a pulse rate of 180. V3 stated, I reassessed (R3) about forty minutes later and noted (R3's) BP and oxygen level had decreased further and notified (V6 Physician) of the findings. (V6) requested (R3) be sent to the ER for evaluation. V3 RN verified she did not assess R3's lungs on the initial exam but did assess the lungs on the later exam. On the second exam V3 noted R3 to have rales/crackles in bilateral lungs. V3 stated that R3's lungs were usually clear. The (undated) facility policy, Significant Change of Condition, directs staff, The facility shell promptly notify the resident, his or her attending physician and representative of changes in the resident's condition and/or status. The nurse will notify the resident's attending physician or physician extender when there is a significant change in the resident's physical, mental or psychosocial status. On 11/30/21 at 11:52 AM, V6 Physician stated, (R3) was critically ill when (R3) went to the hospital. (R3) was Septic from Pneumonia. I should have been notified when V3 Registered Nurse assessed (R3) and found (R3) diaphoretic, [CONDITION(S)] and tachypneic, all three signs of Septic Shock. On 11/30/21 at 12:45 PM, V2 Director of Nurses who stated, (V3) should have called (V6) immediately after she assessed (R3) and found (R3) to be diaphoretic, with an elevated heart rate and respiratory rate. (R3) needed to go the ER right away.

Based on interview and record review, the facility failed to notify the Physician in a timely manner when they were unable to initiate intravenous (IV) fluids for one of three residents (R2) reviewed for dehydration in the sample of 10. This failure resulted in a delay of treatment, and R2 was admitted to the hospital intensive care unit with [DIAGNOSES REDACTED]. Findings include: The facility's Change in a Resident's Condition or Status (revised 5/17) documents, The nurse will notify the resident's attending physician when: c. There is a need to alter the resident's treatment significantly, and f. Deems necessary or appropriate in the best interest of the resident. V3's (PA/Physician Assistant) Skilled Progress Note regarding R2, dated 9/28/20, documents, Due to patient's lethargy, poor appetite and chronic medical conditions with recent acute illness, order for stat labs, 1 (one) L (liter) IV fluid, 150ml per hour, CXR (chest x-ray) and UA. Recommend close monitoring by nursing staff. R2's Physician Orders, dated 9/28/20 at 2:45 PM, documents the following order: Normal Saline 0.9% (percent), 1 (one) liter to run at 100ml per hour for a total of one liter, signed by V3. R2's Medication Administration Record [REDACTED]. R2's Progress Notes, Medicare Charting Notes, and MAR, dated 9/27/20 and 9/28/20, do not document any other attempts to initiate the IV fluids, or that R2's physician was notified. On 10/7/20 at 12:51 PM and 1:50 PM respectively, V6, Registered Nurse (RN) /second shift nurse working 9/28/20, and V7, Licensed Practical Nurse (LPN) /third shift nurse working 9/28/20-9/29/20, stated they were unable to initiate R2's IV fluids, and they did not notify R2's physician. On 10/7/20 at 9:10 AM, V4, RN, and first shift nurse coming on duty 9/29/20, stated she immediately notified the on-call physician of R2's condition and that the IV fluids had not been initiated, and the on-call physician ordered R2 transported to the ER immediately. On 10/7/20 at 9:50 AM, V3, PA, stated she examined R2 on 9/28/20, and R2 was very dehydrated. V3 stated due to R2's condition, she expected staff to notify the physician right away if they could not get the IV fluids initiated. R2's ER Provider Notes, dated 9/29/20 at 8:40 AM, document [DIAGNOSES REDACTED]. R1's comprehensive metabolic panel dated 9/29/20 and obtained in the ER, document the following lab values: Sodium 149 millimoles/liter (mmol/L), BUN 32 milligrams/deciliter (mg/dL), creatinine 1.60 mg/dL. On 10/7/20 at 3:00 PM, V2, Director of Nursing, could provide no other information or documentation regarding notification of the physician regarding the inability to administer the IV fluids for R2.

Based on interview and record review, the facility failed to ensure one of three residents (R2) reviewed for dehydration received intravenous fluids as ordered in the sample of 10. This failure resulted in R2 a delay of treatment and R2 being admitted to the hospital intensive care unit with [DIAGNOSES REDACTED]. Findings include: R2's Progress Notes, dated 9/28/20 at 3:06 PM, document R2 was seen by ((V3, Physician's Assistant (PA)), during rounds new orders received for 1 (one) liter IVF (intravenous fluids) at 100 ml (milliliters) per hour due to dehydration, UA/C&S (urinalysis/ culture and sensitivity) and chest x-ray. V3's Skilled Progress Note regarding R2, dated 9/28/20, documents R2's oral mucosa is dry, and Opens her eyes to verbal and physical stimuli. Does not answer questions. Appears restless and drowsy. V3's Plan documents, Due to patient's lethargy, poor appetite and chronic medical conditions with recent acute illness, order for stat labs, 1 (one) L (liter) IV fluid, 150ml per hour, CXR (chest x-ray) and UA. Recommend close monitoring by nursing staff. R2's Physician Orders, dated 9/28/20 at 2:45 PM, documents the following order: Normal Saline 0.9% (percent), 1 (one) liter to run at 100ml per hour for a total of one liter, signed by V3. R2's Medication Administration Record [REDACTED]. R2's Progress Notes, Medicare Charting Notes, and MAR, dated 9/27/20 and 9/28/20, do not document any other attempts to initiate the IV fluids. R2's Progress Notes, dated 9/29/20 at 7:53 AM document R1 was sent to ER (emergency room ) for evaluation r/t (related to) change in LOC (loss of consciousness)/ mentation. R2's ER Provider Notes, dated 9/29/20 at 8:40 AM, document [DIAGNOSES REDACTED]. R1's Comprehensive metabolic panel, dated 9/29/20 and obtained in the ER, document the following lab values: Sodium 149 millimoles/liter (mmol/L), BUN 32 milligrams/deciliter (mg/dL), creatinine 1.60 mg/dL R2's Hospitalist History and Physical, dated 9/29/20, documents, The nursing home attempted to get IV access but was unable to, and the following active hospital problems: Pneumonia due to COVID-19 virus, Altered Mental Status,[MEDICAL CONDITION], Acute Kidney Injury, [MEDICAL CONDITION]ly due to hypovolemia, given IVF. On 10/7/20 at 11:41 AM, V5, LPN (Licensed Practical Nurse) and Ward Clerk, stated she received the order from V3 to administer the IV fluids for R2 on 9/28/20 and entered the order into the computer about 2:45 PM. V5 stated she then interrupted report between V4, RN (Registered Nurse) (the nurse going off duty), and V6, RN (the nurse coming on duty), and told them R2 was to have IV fluids initiated. V5 stated the order for the IV fluids was not stat, but it was meant to be initiated as soon as possible. V5 stated she thought the nurses would implement the order, and she could not start the IV because she was an LPN. On 10/7/20 at 12:51 PM, V6, RN (second shift nurse), stated he does not remember being told about R2's order for the IV fluids during report. V6 stated he was very busy during his shift with several new admissions, and he didn't have time to try to start the IV for R2. V6 stated he stayed after his shift and tried twice to start R2's IV after 2:00 AM. On 10/7/20 at 1:50 PM, V7, LPN (third shift nurse), stated when V6 reported off to her, he told her she needed to start an IV on R2. V7 stated she told him she was an LPN and could not start an IV. V7 stated V6 stayed late and tried twice unsuccessfully to start R2's IV, and then went home. On 10/7/20 at 9:10 AM, V4, RN, stated when she came on duty 9/29/20, she called the on-call physician and received orders to immediately transfer R2 to the ER. V4 stated R2's mouth and lips were very dry. On 10/7/20 at 9:50 AM, V3, PA, stated she examined R2 on 9/28/20, and R2 was very dehydrated. V3 stated she expected the IV order to be acted on right away. V3 stated she was not surprised that it was difficult to start R2's IV because she (R2) was very dry (dehydrated). On 10/7/20 at 3:00 PM, V2, Director of Nursing, could provide no other information or documentation regarding the administration of the IV fluids for R2.

Based on interview and record review the facility failed to ensure a resident was free from abuse for one (R1) of three residents reviewed for abuse in a sample of eight. This failure resulted in R1 being sexually assaulted and receiving professional emotional counseling. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 8/25/19., the facility remains out of compliance at Severity Level 2, as additional time is needed to monitor the effectiveness of the re-education of staff Findings include: The facility's Abuse Prevention Program dated 11/28/16 documents, Purpose: This facility prohibits mistreatment, neglect, exploitation, misappropriation resident property,or abuse of its residents by: Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment. The facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends or any other individual. On 8/17/19 at 2:00 PM R1 stated, I was asleep and woke up to a man on top of me having sex with me. I sort of pushed the man but he continued to have sex with me in my private parts. I have seen this man before but can't remember who he is. He is African American. I have not seen him since. R1 denied anyone ever touching her or doing anything that made her upset or uncomfortable before. On 8/28/19 at 9:05 AM, V3/Certified Nurses Assistant/CNA stated, I was working on (R1's) hall 8/24/19. I put (R1) to bed about 630-645 PM. I cleaned her up and brushed her hair like always and put her in bed. (R1) sleeps like a princess. She lays in bed like you put her. She doesn't move. I went to lunch about 7:00 PM and came back at 730 PM. Me and V4 (Certified Nurses Assistant/CNA) started our rounds about 9:00 PM. I was on my end of the hall and she was on hers. She got done first and came and asked me if I was done I said no I was headed in (R1's) room. When we got to (R1's) room I knew something wasn't right. When I turned on the light I noticed (R1's) bed was moved over sideways sort of and her blankets were messy like someone balled them up and dropped them on her. Her hair was wet and matted across her face. It wasn't like that when I put her to bed. I lifted the corner of the cover and her adult brief was pulled down around her ankles and one side was undone. The look on her face was like she was terrified. Her gown was pulled all the way up over her breast. I noticed red blotches on her right side of her face and forehead. I stayed with (R1) and V4/CNA went to get the nurse. When the nurse examined (R1) she had red markings in both groin areas, and they weren't there when I put her to bed. I also seen black hairs on her too that aren't (R1's). She was wet in between her legs. All the other residents were in bed during rounds. (R1's) roommate was sleeping when we entered the room and slept through it all. She is hard of hearing, you have to talk very loud when you talk to her. I've never witnessed any inappropriate behaviors from any of the residents on that hall. To my knowledge (R1) did not have any relationship with any of the other residents. On 8/27/19 at 8:30 AM, V1/Administrator stated, So I was called Saturday night by V2/Licensed Practical Nurse/LPN and notified that (R1) was found in bed with her blankets messy, her hair wet and matted and her adult brief pulled down to her ankles, her gown pulled up with redness to her groin. I told V2/LPN to notify the (R1's) guardian, physician and police. I immediately came in and saw (R1). (R1) was sent to the local emergency room and they obtained a rape kit. We sent all (R1's) blankets and clothing, we did not touch anything. There were black hairs on her that weren't hers. Her groin area was red. I immediately started my investigation. V2/LPN stated she was in (R1's) room at 8:00 PM to give (R1's) roommate medications and said (R1) was resting comfortably, fully covered and saw nothing unusual. I asked (R1) when she returned from the hospital if she knew why she went to the hospital. (R1) told me because a man she had seen before was on top of her. She described him as a big African American man. She didn't know how he entered her room because she woke up to him on top of her. (R1) said she told him to stop but that he didn't say anything to her. (R1) said that he touched her , putting his private parts inside her private parts. There are only two ambulatory male residents on that hall, one is African American and the other Caucasian. I placed the African American male that resided on her hall on 1:1 with staff as I continued my investigation. The local police came and filed a report. They came on 8/26/19 and took a DNA sample from the two male staff members and the male resident on (R1's) hall. I removed (R1) off the locked unit when she returned from the hospital. On 8/28/19 at 1:45 PM V4/Certified Nurses Assistant/CNA stated, I was helping V3/CNA on Saturday night while doing rounds. When we opened (R1's) door we noticed (R1's) bed was pushed kind of sideways. We knew something wasn't right. Her blankets looked like they were thrown on top of her and her hair was matted to her face and that's not how we put her to bed. (R1's) adult brief was undone on the right side and pulled down to her ankles. V3/CNA stayed with (R1) while I went to get V2/LPN. There were red blotches on (R1's) face and red marks and a cut on (R1's) groin area. On 8/28/19 at 2:10 PM V2/Licensed Practical Nurse/LPN stated, Saturday night about 9:30 PM or so V4/Certified Nurses Assistant came and got me and said something was not right with (R1). When I went in (R1's) room it was not like it was when I was in there at about 8:00 PM to give her roommate medications. Her blankets were all messed up and her hair was wet and matted to her face. She had petechiae to the left side of her face. She had an abrasion to her right groin approximate 3 inches long. There were red marks on her left thighs. We didn't want to touch anything. I immediately called V1/Administrator and notified her of our findings. I then called (R1's) state guardian, physician and local police and ambulance. (R1's) roommate was sleeping when I came in the room. She is hard of hearing and only has one eye can can barely see. I didn't see any male staff on the unit until after we found (R1) like this, and it was the housekeeper , he was getting equipment for the floors. I have never seen or heard of any of the residents on (R1's) unit display any sexual inappropriate behaviors. R1's Nursing Noted dated 8/25/19 at 5:11 AM from a local hospital documents, Patient (R1) presents to the emergency department for sexual assault. Patient has centimeter by 2.5 centimeter rectangular patch of reddened skin noted to left posterior neck/shoulder and 2 centimeter by 2.25 centimeter rectangular patch of light brown skin noted to right posterior neck/shoulder. R1's Medical Foresinic Documentation Form dated 8/25/19 from the local hospital documents, Erthema noted to bilateral labia and transparent white secretions noted in vagina. Methods used by assailant include grabbed/held down. Patient(R1) stated when I tried to get up he would push me back down. R1's Physician order [REDACTED]. R1's Progress Note dated 8/26/2019 at 11:41 AM documents, Social Services Note Text: Referral made to local Psychology specialist for consulting. R1's Progress Note dated 8/26/2019 at 12:43 PM documents, Social Services Note Text: appointment made for 8/27/19 at 3pm with local Psychologist. The facility's Final Report to state agency dated 8/28/19 documents, Conclusion: Information gathered during the course of the investigation, reveals evidence consistent with the conclusion that sexual activity occurred. Hospital records are consistent with this conclusion, describing bruising and other signs of contact. The investigation narrowed down the possible males involved and believed that another resident was involved. Other resident was immediately placed on 1:1 monitoring. (R1) has been moved to a new hallway and is being provided additional support. (R1) has only been assigned female staff for her comfort. The Immediate Jeopardy was identified to have begun on (MONTH) 24th 2019 at 9:45 PM when R1 was found to have been sexually assualted in the facility. V7/Assistant Administrator was notified of the Immediate Jeopardy on 9/12/19 at 9:13 AM. The surveyor confirmed through observation, interview and record review that the facility took the following Immediate Corrective Action: Actions completed by V1/Administrator, V5/Social Service Director and V7/Assistant Administrator: On 8/24/19 at approximately 10:20pm, facility placed suspected peer (R4) on 1:1. It was at this time that the facility investigation revealed this peer (R4) may have been involved. Facility maintained 1:1 with R4 until his discharge on 8/27/19 at 11:40am. On 8/25/19 at 10am, Facility Social Service Director and Administrator, both of which are licensed nurses, reviewed all medical records of patients on the secured unit and assessed for at risk behaviors. Facility will continue to assess all new admissions upon admission for at risk behaviors and initiate appropriate interventions. On 8/25/19 at 10:30am, Facility Administrator reviewed staffing levels to ensure adequate staffing for supervision of patients with at risk behaviors. On 8/25/19 at 11:20am, Facility Administrator and Assistant Administrator completed staff re-education on Abuse Prevention Program/Policies. Any staff that were not in serviced on that date, will be in serviced before they are allowed to work any future shifts. Abuse training will continue to occur during new employee orientation, on an as needed basis, during annual compliance training and as scheduled on the facility's education calendar.

Based on record review, interview and observation, the facility failed to provide and document sufficient preparation and resident orientation in order to ensure safe and orderly discharge from facility and failed to return personal belongings, cell phone and home keys upon discharge, for one of three residents (R1) reviewed for discharge planning in the sample of three. This failure resulted in R1 spending the night on his porch during 90 degree Fahrenheit temperatures. Subsequently R1was hospitalized for [REDACTED]. Findings include: The facility's Discharge: Home or Non- Institutional Setting policy, dated December 2009, states that the purpose of this policy is: To provide safe departure from center to home or non-institutional setting. This policy includes, under Procedure: Day of Discharge to Home or Non-Institutional Setting to Complete discharge summary paperwork and place into medical record. R1's clinical record includes [DIAGNOSES REDACTED]. R1's BIMS (Brief Interview for Mental Status) score, dated 6/6/17, indicating R1 has minimal cognitive impairment. R1's electronic clinical record includes an interdisciplinary, discharge instruction document, titled My Transition Home 1, dated 6/12/17. This document includes numerous blank sections, including: Discharge Information, Patient/Resident Representative Education and Discharge Instructions from Nursing, Therapy and Social Services. The Medication section is also blank, including the sub-sections titled, Medication I Will Be Taking When I Go Home, Instructions, and Discharge Medication Education. On 6/21/17 at 2:00p.m., E8, RN stated that she was R1's nurse on 6/14/17 and received report that R1 was discharging, via facility van, to home around 3:00p.m. that day. The transport guy said he was leaving in a few minutes around change of shift. When asked about the discharge instructions for R1, E8 stated, We do some of those, but the ward clerk usually does them. On 6/22/17 at 9:00a.m., E3, ADON (Assistant Director of Nursing) stated, My Transition Home is the discharge instruction packet for residents, with instructions regarding equipment needed, medications, appointments. E3 stated that R1's discharge instruction packet was not completed prior to discharging R1 home on 6/14/17. E3 verified that R1's discharge instructions and education by Nursing, Social Services and Therapy were blank and should have been completed for R1 prior to R1's discharge home. R1's electronic clinical record includes a Progress Note by E8, RN (Registered Nurse), dated 6/14/17 at 3:15p.m. stating, Patient discharged to home with belongings. Transported per facility van. On 6/20/17 at 11:00a.m., E6, facility Chauffeur, stated that on 6/14/17, at approximately 3:15p.m., R1 was discharged from the facility to his home and transported, via the facility van, by E6, Chauffeur and E7, Chauffeur trainee. E6 stated that R1 had discharge papers from the facility in his possession upon discharge from the facility. Upon arrival at R1's house, E6 stated he and R1 checked the front and back doors and discovered both doors were locked. E6 verified that R1 told E6 and E7 that R1 did not have his house keys. E6 stated that he and E7 left R1's house to return to the facility and last saw R1 sitting in his back yard at approximately 3:45p.m. on 6/14/17. On 6/21/17 at 10:35 a.m., E7, Chauffeur trainee, verified that on 6/14/17, E6 and E7 transported R1 to R1's house around 3 or 4 o'clock. E7 stated that when they arrived at R1's house, the doors were locked and there was no response to knocking. E7 added that R1 told the Chauffeurs that R1 had lost his keys. On 6/21/17 at 8:45a.m., E6, Chauffeur, stated that Z1 (Caregiver), called the facility on 6/15/17 and asked E6 if R1's keys and cell phone were at the facility. E6 stated, I took a note and wrote it down and called the Nurses Station. I don't think they ever got found. Nothing ever came of it. On 6/20/17 at 1:10p.m., E9, LPN (Licensed Practical Nurse), stated that R1's cell phone and personal keys were present in the medication cart's locked narcotic box for a number of days prior to R1's discharge from the facility. E9 stated these items were accounted for upon narcotic reconciliation at each change of shift. Z1's local hospital ER (emergency room ) record, dated 6/16/17 at 1:22p.m., by Z6, RN, documents that R1 was transported to the hospital via ambulance on 6/16/17 and arrived at 1:22p.m. on 6/16/17 for lower extremity swelling. An ER nursing note by Z8, RN states: Patient was discharged from (facility) on 6/14 and spent the night on his porch because he lost his keys and phone there. Caregiver came 6/15 and called a locksmith and he was able to get into his house. Today when caregiver went back, he had a lot of swelling in his feet. He has a sunburn on his legs arms and hands from spending all that time on his porch. Patient states he has no family. Patient's jeans covered in feces. Patient hasn't eaten today because I forgot. The National Weather Service, on 6/15/17, had a high temperature of 90 degrees Fahrenheit on 6/14/17 in the town in which R1's house is located. R1's ER Chief Complaint note, dated 6/16/17 at 3:52p.m., by Z7, R1's ER doctor, documents the following: Patient presents with Foot Swelling. The history is provided by the patient. (R1), with history [MEDICAL CONDITION](hypertension), who presents to the ED (Emergency Department) via (local ambulance)for the evaluation of bilateral, lower extremity swelling that began two weeks ago. The leg swelling is unchanged today. R1's local hospital inpatient record documents that R1 was admitted to the hospital on [DATE] after a 23-hour in-house observation period in the ER. On 6/21/17 at 11:00a.m., R1 was sitting up in bed in his room at a local hospital. R1 was alert and appropriate, with lightly tanned skin on face and extremities. R1 stated that he was discharged from (facility) on June 14, 2017, Two men took me home in the (facility) van. R1 stated that the van drivers walked him to the front and back doors and both doors were locked. I had no keys. I just sat down on the cement in the back of my house and they left. When asked how and when he gained access to his home, R1 said he waited for (his caregiver, Z1) to arrive and slept on his porch overnight, I got a little sunburned on my arms and legs. R1 stated his caregiver arrived the next morning, 6/15/17 and called a locksmith to open the door to his home. R1 stated that he had his cell phone and house keys with him when he was admitted to the facility and, I didn't have my cell phone or house keys when they took me home. When asked how long he was locked outside of his house, R1 replied, 24 hours. R1 recalled that his house keys and cell phone had been brought in to him earlier that morning, stating A man from (facility) brought them to me this morning. I think they were in the nurses station. On 6/21/17 1:30pm, E1, Administrator, stated that R1's cell phone and house keys were located in the narcotic box in the facility's medication cart and he delivered them to R1 at the hospital earlier that morning. On 6/23/17 at 11:40a.m., E1, Administrator, stated that residents usually go home with belongings and a discharge booklet. E1 verified that R1's discharge instructions were incomplete.

Based on record review and interview the facility failed to follow established policy and proceedure in order to adequately monitor and intervene to prevent a reoccurence of a life threatening situation. This neglect resulted in R4 being found lifeless at the facility after experiencing a second [MEDICAL CONDITION] decannulation two days after an initial decannulation. R4 is one of four residents reviewed for [MEDICAL CONDITION] care in a sample of sixteen. These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of protocols and oversight visits. Findings include: R4's [DATE] physician's orders [REDACTED]. R4's [DATE] POS include the following physician's orders [REDACTED]. Duo nebs every four hours per nebulizer. [MEDICAL CONDITION] care every shift. [MEDICAL CONDITION]: [MEDICATION NAME] 8 mm/ cuff. Change trachea inner cannula daily. Suction as needed for excessive secretions. Change trachea ties weekly. Pulse Oximetry every shift. Right side hand mitt, remove every two hours and clean hand. Change oxygen tubing and mask weekly. And oxygen at ten liters with 28% humidity. R4's Care Plan, dated [DATE], instructs staff to..." evaluate lung sounds and vital signs as needed, obtain pulse Oximetry and report abnormal findings, administer oxygen as per physician order, trachea care per protocol, wear right arm mitten to prevent pulling trachea out and report abnormalities to physician...". R4's Nurses notes from [DATE] at 00:03 A.M. state "... patient ( R4 ) is restless and feet are off bed. When nurse entered the room it was noted ( R4 ) had pulled trache out. ( R4 ) was looking around with very wide eyes. Trachea Kit removed from bedside drawer and reinserted into [MEDICAL CONDITION] hole in neck... (R4 ) had removed mitt and had took apart the O2 tubings and pulled out trach..". On [DATE] at 08:30 A.M. E8 ( Licensed Practical Nurse ) stated " ...On the night of september seventeenth I was making my rounds at midnight and noticed ( R4 )'s feet were off of the bed. I could hear ( R4 ) thrashing around in bed. When I went into the room ( R4 )'s eye was wide open. ( R4 ) looked frantic. I noticed ( R4 ) '[MEDICAL CONDITION] was laying on ( R4 )'s shoulder and ( R4 )'[MEDICAL CONDITION] come all the way out. It was lying on ( R4 )'s neck next to the opening. I reached into ( R4 )'s drawer right next to the the bed and got the new one and immediately put it into the hole. I put [MEDICAL CONDITION] on and then reapplied [MEDICAL CONDITION]. I did not check ( R4 )'s oxygen level. After awhile, I guess three to four minutes, ( R4 ) calmed down was breathing normal. I did not notify the Physician or the Respiratory Therapist when ( R4 ) pulled ( R4 )'s trachea out on september seventeenth. I didn't know I was supposed to.. R4's Nurses notes from [DATE] at 03:05 A.M. state..." was call (ed) to ( R4 ) room stat. ( R4 ) was laying with ( R4 )'s trache pulled out, it was laying on ( R4 )'s chest. ( R4 ) had no respirations...Staff continued CPR ( Cardiopulmonary Resuscitation ) and 911 was called. On [DATE] at 2:35 P.M. via telephone, Z1 ( Respiratory Therapist ) stated"...I had worked with ( R4 ) since ( R4 ) was admitted to the facility. ( R4 ) was able to maintain his oxygen levels without oxygen for fifteen, maybe twenty minutes...( R4 ) could not tolerate being without ( R4 )'[MEDICAL CONDITION] all. I would have never attempted to try ( R4 ) without ( R4 )'[MEDICAL CONDITION] this time. ( R4 ) could not tolerate being without it...No staff ever told me that ( R4 ) had pulled ( R4 )'[MEDICAL CONDITION]. If I had know that I would have immediately spoken with the staff to help them understand the importance of preventing that from happening. I would have instructed the staff to make sure ( R4 )'[MEDICAL CONDITION] were tight. And I would have told them the importance of putting mitts on both hands. Most our facilities do that anyway as standard precautions". On [DATE] at 02:30 P.M. Z2 ( Physician ) stated " the facility did not notify me that ( R4 ) had pulled his trachea out on [DATE]... If I had known this information, I would have recommended that the facility watch ( R4 ) more closely, immediately replace ( R4 )'s trachea if it came out, monitor ( R4 )'s oxygen levels and notify me". Facility policy titled " Respiratory: [MEDICAL CONDITION] Insertion/ Reinsertion" dated ,[DATE] instructs staff ... a licensed nurse may reinsert the tube to restore the airway. If this occurs,... the tube is reinserted using the quickest means possible. Physician is then notified...". On [DATE] at 9:50 AM an Immediate Jeopardy was identified to have begun on [DATE] when staff failed to notify R4's physician of a [MEDICAL CONDITION] decannulation. On [DATE] at 10:00 AM E1 ( Administrator ) was notified of the Immediate Jeopardy. The surveyor confirmed through interview and record review the facility took the following actions to remove the Immediate Jeopardy: 1. Initiated [DATE], licensed staff have received education regarding the ( Corporate ) policy on [MEDICAL CONDITION]. This education was conducted by the Administrative Director of Nursing and Assistant Director of Nursing. Information covered include: *[MEDICAL CONDITION] insertion/reinsertion *[MEDICAL CONDITION] maintenance *[MEDICAL CONDITION] emergencies *[MEDICAL CONDITION] management Those employees not able to attend the education will be educated before their next scheduled shift. If not scheduled to work, education will be completed by [DATE]. 2. Initiated [DATE], Completed [DATE] like residents were identified as those with tracheotomies have been assessed by a Registered Nurse. Documentation of assessment was completed on [DATE]. 3. The Administrative Director of Nursing or designee will audit new nurse hires to ensure completion of [MEDICAL CONDITION] insertion/reinsertion, and maintenance and [MEDICAL CONDITION] emergencies and management for 3 months. Report of findings will be given to Administrator weekly and reviewed by the QAA committee monthly for further recommendations as needed. The Administrator will be responsible for assuring that compliance is attained and maintained. 4. An ad-hoc QAA meeting was conducted on [DATE] including the facility Medical Director. The facility QAA committee through Ad Hoc or full QAA shall monitor weekly for 4 weeks to review any trends or findings, issues or concerns and develop plan of action for follow up and resolution. Findings will be submitted to QAA weekly and reviewed to ensure system is sustained. QAA meetings will be conducted weekly for 4 wweks.

Based on interview and record review the facility failed to put interventions in place to prevent potentially fatal air hunger for one of four residents reviewed for [MEDICAL CONDITION] care in the sample of sixteen. R4 self decannulated [MEDICAL CONDITION] twice while at the facility. The second time R4 was found lifeless in the facility. These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of protocols and oversight visits. Findings include: R4's admission physician's orders [REDACTED]. R4's [DATE] POS include the following physician's orders [REDACTED]. Duo nebs every four hours per nebulizer. [MEDICATION NAME] 3 milliliter unit dose per nebulizer every [MEDICAL CONDITION] care every shift. [MEDICAL CONDITION]: [MEDICATION NAME] 8 mm/ cuff. Change trachea inner cannula daily. Suction as needed for excessive secretions. Change trachea ties weekly. Pulse Oximetry every shift. Right side hand mitt, remove every two hours and clean hand. Change oxygen tubing and mask weekly. Oxygen at ten liters with 28% humidity. R4's Care Plan dated [DATE] instructs staff to..." evaluate lung sounds and vital signs as needed, obtain pulse oximetry and report abnormal findings, administer oxygen as per physician order,administer medications/ treatments per physician order,elevate the head of the bed, maintain [MEDICAL CONDITION] and ambu bag at bedside, trachea care per protocol, wear right arm mitten to prevent pulling trachea out and report abnormalities to physician...". R4's admission Nurses Notes dated [DATE] document that R4 "...has a [MEDICATION NAME] trach...( R4 ) is on continuous oxygen...(R4 ) is resting in bed". R4's Nurses Notes datetd [DATE] at 06:10 A.M. state"... restlessness noted thru the night, noted resident pulling [MEDICAL CONDITION] several times thru the night..." R4's Nurses Notes dated [DATE] at 06:53 A.M. state"...moving arms trying to pull at pillow and tubes...needs repositioned several times has been scooting down in bed with feet hanging off of bed..." R4's Nurses Notes dated [DATE] at 00:03 A.M. state "... patient ( R4 ) is restless and feet are off bed. When nurse entered the room it was noted ( R4 ) had pulled trache out. ( R4 ) was looking around with very wide eyes. Trachea Kit removed from bedside drawer and reinserted into [MEDICAL CONDITION] hole in neck... ( R4 ) had removed mitt and had took apart the O2 tubings and pulled out trach.." R4's Nurses Notes dated [DATE] at 02:07 A.M. state"...( R4 ) continues to be restless, squirming about the bed..." R4's Nurses Notes dated [DATE] at 10:42 A.M. state"...resident frequently pulling [MEDICAL CONDITION] and pulling off. ( R4 ) also moving around in bed, kicking feet off side of bed..." On [DATE] at 08:30 A.M. E8 ( Licensed Practical Nurse ) stated " ...On the night of September seventeenth I was making my rounds at midnight and noticed ( R4 )'s feet were off of the bed. I could hear ( R4 ) thrashing around in bed. When I went into the room ( R4 )'s eye was wide open. ( R4 ) looked frantic. I noticed ( R4 ) '[MEDICAL CONDITION] was laying on ( R4 )'s shoulder and ( R4 )'[MEDICAL CONDITION] come all the way out. It was lying on ( R4 )'s neck next to the opening. I reached into ( R4 )'s drawer right next to the the bed and got the new one and immediately put it into the hole. I put [MEDICAL CONDITION] on and then reapplied [MEDICAL CONDITION]. I did not check ( R4 )'s oxygen level. After awhile, I guess three to four minutes ( R4 ) calmed down was breathing normal. I did not notify the Physician or the Respiratory Therapist when ( R4 ) pulled ( R4 )'s trachea out on September seventeenth. I didn't know I was supposed to..." R4's Nurses Notes dated [DATE] at 03:15 A.M. state"...had been moving arms and pulling on tubes...repositioned several times d/t ( due to ) ( R4 ) moving about in bed and scooting down in bed..." R4's Nurses Notes dated [DATE] at 02:10 A.M. state"( R4 ) restless at this time, ( R4 ) has removed his mit...( R4 ) is moving left arm and hand more tonoc..during trache care ( R4 ) put arms above head..." R4's Nurses Notes dated [DATE] at 02:45 A.M. state"( R4 ) had removed the trache mask with ( R4)'s left hand and had mit almost off right hand..." R4's Nurses Notes dated [DATE] at 03:05 A.M. state " was call to ( R4 ) room stat. ( R4 ) was laying with ( R4 )'[MEDICAL CONDITION] out, it was laying on ( R4 )'s chest. ( R4 ) had no respirations.[MEDICAL CONDITION] reinserted and ambu bag started over trach, and code was called. Staff continued CPR ( Cardiopulmonary Resuscitation ) and 911 was call." Facility policy titled " Respiratory: [MEDICAL CONDITION] Insertion/ Reinsertion" dated ,[DATE] instructs staff ... a licensed nurse may reinsert the tube to restore the airway. If this occurs,... the tube is reinserted using the quickest means possible. Physician is then notified...". On [DATE] at 2:35 P.M. via telephone, Z1 ( Respiratory Therapist ) stated"...I had worked with ( R4 ) since ( R4 ) was admitted to the facility. ( R4 ) was able to maintain his oxygen levels without oxygen for fifteen, maybe twenty minutes...( R4 ) could not tolerate being without ( R4 )'[MEDICAL CONDITION] all. I would have never attempted to try ( R4 ) without ( R4 )'[MEDICAL CONDITION] this time. ( R4 ) could not tolerate being without it...No staff ever told me that ( R4 ) had pulled ( R4 )'[MEDICAL CONDITION]. If I had know that I would have immediately spoken with the staff to help them understand the importance of preventing that from happening. I would have instructed the staff to make sure ( R4 )'[MEDICAL CONDITION] were tight. And I would have told them the importance of putting mitts on both hands. Most our facilities do that anyway as standard precautions." On [DATE] at 02:30 P.M. Z2 ( Physician ) stated " the facility did not notify me that ( R4 ) had pulled [MEDICAL CONDITION] on [DATE]... If I had known this information, I would have recommended that the facility watch ( R4 ) more closely, immediately replace ( R4 )'[MEDICAL CONDITION] it came out, monitor ( R4 )'s oxygen levels and notify me." On [DATE] at 9:50 AM an Immediate Jeopardy was identified to have begun on [DATE] when staff failed to notify R4's Physician of a [MEDICAL CONDITION] decannulation. On [DATE] at 10:00 AM E1 ( Administrator ) was notified of the Immediate Jeopardy. The surveyor confirmed through interview and record review the facility took the following actions to remove the Immediate Jeopardy: 1. [DATE] licensed staff have received education regarding the ( Corporate ) policy on [MEDICAL CONDITION]. This education was conducted by the Administrative Director of Nursing and Assistant Director of Nursing. Information covered include: *[MEDICAL CONDITION] insertion/reinsertion *[MEDICAL CONDITION] maintenance *[MEDICAL CONDITION] emergencies *[MEDICAL CONDITION] management Those employees not able to attend the education will be educated before their next scheduled shift. If not scheduled to work, education will be completed by [DATE]. 2. [DATE] all residents with tracheotomies have been assessed by a Registered Nurse. Documentation of assessment was completed on [DATE]. 3. Initiated [DATE] the Administrative Director of Nursing or designee will review nursing Progress Notes five times per week for 4 weeks, to ensure facility protocols are followed for patients with tracheotomies following a change in condition. Report of findings will be given to Administrator weekly and reviewed by the QAA committee monthly for further recommendations as needed. The Administrator will be responsible for assuring that compliance is attained and maintained.

Based on record review and interview the facility failed to immediately consult with R4's Physician regarding an incident involving [MEDICAL CONDITION] decannulation. This failure resulted in a second incident of [MEDICAL CONDITION] decannulation resulting with R4 being found without respirations. R4 is one of four residents reviewed for [MEDICAL CONDITION] care in a sample of sixteen. Findings include: R4's [DATE] physician's orders [REDACTED]. R4's [DATE] POS includes the following physician's orders [REDACTED]. Duo nebs every four hours per nebulizer. [MEDICAL CONDITION] care every shift. [MEDICAL CONDITION]: [MEDICATION NAME] 8 millimeter cuff. Change trachea inner cannula daily. Suction as needed for excessive secretions. Change trachea ties weekly. Pulse Oximetry every shift. Right side hand mitt, remove every two hours and clean hand. Change oxygen tubing and mask weekly. And oxygen at ten liters with 28% humidity. R4's Care Plan, dated [DATE], instructs staff to..." evaluate lung sounds and vital signs as needed, obtain pulse oximetry and report abnormal findings, administer oxygen as per physician order, trachea care per protocol, wear right arm mitten to prevent pulling trachea out and report abnormalities to physician..." R4's Nurses Notes dated [DATE] at 00:03 A.M. state "... patient ( R4 ) is restless and feet are off bed. When nurse entered the room it was noted ( R4 ) had [MEDICAL CONDITION]. ( R4 ) was looking around with very wide eyes. Trachea Kit removed from bedside drawer and reinserted into [MEDICAL CONDITION] hole in neck... ( R4 ) had removed mitt and had took apart the O2 tubings and pulled out trach..". R4's Nurses Notes dated [DATE] at 03:05 A.M. state..." was call (ed) to ( R4 ) room stat. ( R4 ) was laying with ( R4 )'s trache pulled out, it was laying on ( R4 )'s chest. ( R4 ) had no respirations...Staff continued CPR ( Cardiopulmonary Resuscitation ) and 911 was called..." On [DATE] at 08:30 A.M. E8 ( Licensed Practical Nurse ) stated " ... I did not notify the Physician or the Respiratory Therapist when ( R4 ) pulled ( R4 )'[MEDICAL CONDITION] on September seventeenth. I didn't know I was supposed to..." On [DATE] at 02:30 P.M. Z2 ( Physician ) stated " the facility did not notify me that ( R4 ) had pulled his trachea out on [DATE]... If I had known this information, I would have recommended that the facility watch ( R4 ) more closely, immediately replace ( R4 )'s trachea if it came out, monitor ( R4 )'s oxygen levels and notify me." Facility policy titled " Respiratory: [MEDICAL CONDITION] Insertion/ Reinsertion," dated ,[DATE], states" ... a licensed nurse may reinsert the tube to restore the airway. If this occurs,... the tube is reinserted using the quickest means possible. Physician is then notified..."

Based on interview and record review, the facility failed to provide supervision to prevent a fall for one of three residents (R6) reviewed for falls in the sample of sixteen. An x-ray report dated 9/19/13, documents R6 sustained a right femur fracture. Findings include: Current Physician Orders, documents R6 is an [AGE] year old female with [DIAGNOSES REDACTED]. A Minimum (MDS) data set [DATE], documents R6 is independent with decision making skills with no short or long term memory problems, and requires extensive assistance with transfers and toileting needs. An Activities of Daily Living (ADL) Task List dated 9/18/13, documents R6 requires extensive assist of two and is a fall risk. Nurses Notes, dated 9/8/13 at 1:45 p.m. and 9/14/13 at 1:06 p.m., document R6 requires extensive assistance of one for most ADL's. A Plan of Care dated 8/1/13, documents R6 is at risk for falls due to unsteady gait and history of falls. A Therapy progress note dated 9/19/13, documents R6 requires moderate assistance with transfers and maximum assistance with toileting. An Incident Report dated 9/18/13 at 7:30 p.m., states (R6) transferred self from commode to bed and fell ; (R6) complained of right leg pain; Investigation started and continues." An x-ray report dated 9/19/13 at 12:18 a.m., documents R6 had a fractured right femur. An Investigation Summary titled "(E7)" (date unknown), documents E7 (Certified Nurse Aide) was suspended "due to the fact that (E7) was not with (R6) that needed assist while (R6) was on the commode." On 9/24/13 at 12:45 p.m., R6 stated R6 was in bed and turned on the call light for assistance with toileting. R6 stated E7 (Certified Nurse Aide) came in and told R6 to be more independent since R6 was going home in a few days. R6 stated E7 stood by her while R6 transferred to a commode directly next to R6's bed. R6 stated E7 was standing at the foot of R6's bed looking at the television. R6 stated R6 attempted to "clean myself" and started to stand up when R6's right knee gave out and R6 fell down on right knee. R6 stated "the pain was terrible and E7 had a hard time getting R6 off the floor and into the bed. E7 stated R6 did not use a gaitbelt at any time. R6 stated "I hate to say anything to get (E7) in trouble. I was hesitant to tell on (E7) that night for the same reason." On 9/24/13 at 11:10 a.m., E7 stated on 9/18/13 at approximately 7:30 p.m., R6 was on the commode and E7 had turned away from R6. E7 stated when E7 turned around R6 was down on R6's right knee on the floor. E7 stated R6 complained of right knee pain. E7 stated R6 was transferred to bed per R6's request. E7 stated there were no other witnesses to R6's fall. E7 stated R6 had attempted to transfer independently in the past. E7 stated a few weeks prior to R6's fall on 9/18/13, R6 had transferred to bed independently. E7 stated "I told (R6) it wasn't safe and to ask for assistance." E7 stated E7 was suspended on 9/19/13 for R6 falling and an investigation was being conducted. E7 stated E7 reviewed R6's most recent "kardex" after R6 had fallen and the kardex documented R6 required two assist with transfers. On 9/24/13 at 10:40 a.m., E3 (Assistant Director of Nursing) stated any time a resident requires assistance with transfers a gait belt should be used. On 9/24/13 at 2:15 p.m., E8 (Physical Therapist) stated R6 required extensive assistance with transfers. E8 stated not only did R6 have a right knee deformity due to previous surgeries but R6 had poor upper body strength and struggled to push up to stand. E8 stated no recommendations had been made to the Nursing Department for R6 to be more independent with transfers. E8 stated R6 was at risk for falls and not safe to transfer independently. On 9/24/13 at 11:45 a.m., E1 (Administrator) stated E7 (Certified Nurse Aide) was suspended for discrepancies in the story of R6's fall on 9/18/13. E1 stated an investigation was conducted and E7 is being terminated for not providing assistance for R6 that resulted in a fall with injury.