Every finding on record at Accolade Healthcare of Pontiac

Based on observation, interview and record review the facility failed to use foot pedals when transporting a resident in a wheelchair and failed to follow a care plan intervention to utilize a mechanical lift to transfer a resident for two (R2 and R7) of three residents reviewed for accidents in the sample of eight residents. These failures resulted in R2 falling from the wheelchair and suffering a head laceration requiring sutures and R7 suffering a fractured rib when staff transferred R7 without using the mechanical lift. Findings Include:1. According to the current Electronic Health Record (EHR), R2 has diagnoses including unspecified hydronephrosis, weakness, repeated falls, muscle wasting and atrophy of the bilateral thighs, lack of coordination, abnormal posture, cognitive communication deficit, chronic fatigue, osteoarthritis, obesity, anemia, lymphedema, and hypertension.The Care Plan Dated Revised on 5/14/2026 documents R2 as requiring assistance during transfers and being at high risk for falls related to weakness and non-compliance with transfer recommendations on the Minimum Data Set. Interventions include one-person assistance with transfers utilizing a gait belt and front-wheeled walker/grab bar.Emergency Department documentation dated 5/14/2026 documents R2 was evaluated after falling from her wheelchair and striking the left side of her head. The documentation states, Patient was in wheelchair and fell out of the wheelchair striking the left side of her head. The resident complained of head pain and required diagnostic evaluation including a CT (Computed Tomography) scan of the head, CT scan of the cervical spine, and right hip x-ray. The After Visit Summary dated 5/14/2026 documents R2 received sutures to the left side of her head.On 5/18/2026 at 10:58 a.m., the Interdisciplinary Team (IDT) Note documents R2 had requested to be wheeled to a prom event and did not have foot pedals attached to the wheelchair. The note states the resident normally self-propels using her feet and documents plans to obtain wheelchair bags to store foot pedals and educate staff to apply foot pedals before pushing residents in wheelchairs.5/18/2026 at 12:13 p.m., the IDT Note documents, IDT met to review fall. Root cause- resident fell out of wheelchair d/t (due to) foot pedals not being in place. Intervention- ensure foot pedals on wheelchair when staff is pushing resident.On 6/15/2026 at 10:05 a.m., V6 (Receptionist), stated V6 was wheeling R2 back to her room because the resident wanted to change clothes. V6 stated while transporting the resident, R2 stated her legs were dangling and getting tired. V6 stated she stopped and R2 fell forward, striking the left side of her head on a door frame in the hallway. V6 further stated she had not signed any education regarding wheelchair foot pedal requirements following the incident or before the incident.On 6/15/2026 at 11:30 a.m., V5 (Assistant Director of Nursing) confirmed R2 should have had foot pedals on the wheelchair due to R2's weakness. V5 stated not all staff have been in-serviced on foot pedals following the incident due to V5 believing only nursing staff should be pushing residents in wheelchairs. V5 confirmed auxiliary staff transported residents in wheelchairs and stated the facility had recently implemented a process to store wheelchair foot pedals in bags attached to the backs of wheelchairs.On 6/15/2026 at 11:45 a.m., approximately ten wheelchairs in the dining room did not have foot pedals in bags on the backs of the wheelchairs as intended by the facility's corrective action.On 6/15/2026 at 11:57 a.m., V1, (Administrator), stated foot pedals were required whenever staff push residents in wheelchairs and stated she could not guarantee all wheelchairs had foot pedals available in the designated storage bags. V1 also confirmed that R2's foot pedals should have been provided and the fall could have been prevented.2. According to the current EHR, R7 has diagnoses including Type II Diabetes Mellitus with skin ulcer, abnormal posture, dysphagia, abnormalities of gait and mobility, cognitive communication deficit, bilateral muscle wasting and atrophy, lack of coordination, repeated falls, chronic kidney disease stage IV, atrial fibrillation, hyperlipidemia, hypertension, unilateral osteoarthritis of the hip, unilateral osteoarthritis of the left knee, and presence of a right artificial knee joint.The Care Plan dated 4/7/26 documents R7 requires transfer assistance and documents, transfer with mechanical (full) lift x 2 (times two) staff. Resident uses (geriatric) chair and is dependent on staff for propel.On 6/9/2026 at 2:38 p.m., Nursing Documentation on the electronic medical record documents R7 was noted to have bruising and swelling to the left arm and shoulder. V8 (Licensed Practical Nurse) documents R7 reported the injury occurred during a transfer. V8 notified Hospice and R7's Power of attorney (POA) was informed of the change in condition. The resident reported pain, and new orders were obtained for morphine sulfate concentrate 0.5 mL (milliliters) every 6 hours for 7 days, with 0.25 mL every 2 hours as needed for pain management.On 6/9/2026 at 7:08 p.m., Nursing Documentation from the EMR documents a physician order was received for a portable two-view x-ray of the left rib area due to bruising and pain, and the POA was notified. The POA requested additional imaging of the shoulder. Hospice was re-contacted regarding coverage for imaging, and response was pending.On 6/9/2026 at 7:18 p.m., Nursing Documentation from the EMR documents the Radiology Department was notified and a technician was scheduled to complete the ordered imaging.The X-ray Report dated 6/10/26 documents R7 has a left lateral seventh rib fracture.On 6/16/2026 at 5:05PM, V15 (Certified Nursing Assistant) confirmed while assisting R7 to bed, R7 was in her geriatric chair and V15 provided a pivot transfer by bear hugging the resident and turning to position R7 on the bed. V15 stated R7 requires a full mechanical lift and V15 should have received help. V15 stated, V15 was suspended regarding the incident and was told by V1 Administrator that V15 was getting a break from R7's hall.On 6/16/2026 at 2:38 p.m., V30 (Certified Nursing Assistant), stated she worked with V15, Certified Nursing Assistant, on 6/8/2026. V30 stated R7 required transfer assistance and reported V15 completed the transfer without the required assistance. V30 further stated that following the incident, V15 was no longer assigned to the hall where R7 resided.On 6/16/2026 at 1:56 p.m., V2, (Interim Director of Nursing), stated R7 requires a mechanical lift for transfers and staff were expected to use two staff members when transferring the resident. V2 stated she would not expect staff to improvise transfer methods or equipment. V2 stated radiological testing had been ordered following concerns regarding injury to R7.On 6/16/2026 at 11:30 p.m., V20, (Physician), stated he reviewed radiographs for R7 at the request of facility administration and referred back to the radiologist that R7 had a rib fracture.On 6/16/2026 at 3:03 p.m., V1, (Administrator), stated she requested physician review of the radiographs following concerns regarding injury to R7.

Based on observation, interview and record review the facility failed to ensure residents' rights to dignity, respect, and timely assistance were maintained by failing to respond to call lights in a timely manner for three (R3, R4 and R8) of four residents reviewed for call light response time in the sample list of eight. Findings Include: The facility's grievance logs for April, May, and June 2026 document concerns related to delayed call light response times, including complaints that call lights were not monitored, and response times exceeded acceptable limits.The facility Resident Privacy and Dignity Policy revised 1/26, documents the facility is responsible for ensuring all residents are provided dignity and respect at all times. The policy further requires staff to respond appropriately to resident needs as part of maintaining a home-like environment that promotes dignity and respect.On 6/15/2026 at 10:45 a.m., R3 reported waiting over 45 minutes for R3's call light to be answered.On 6/15/2026 at 10:59 a.m., a call light was flashing at the nursing station with no Certified Nursing Assistants visible in the immediate area, while two additional call lights were observed activated.On 6/15/2026 at 11:07 a.m., R8's call light was actively sounding at the nurses station with a timer displaying approximately 29 minutes in duration.On 6/15/2026 at 11:10 a.m., V8 (Licensed Practical Nurse) confirmed that call lights should be answered within 5-10 minutes and acknowledged that the call light for R8's room had been active for approximately 29 minutes, which V8 stated should not have happened.On 6/15/2026 at 11:04 a.m., V10 (R4's Power of Attorney) stated that although R4's call light functions, staff response is frequently delayed beyond 30 minutes when assistance is needed for care.

Based on record review and interview the facility failed to ensure resident records were accurate for one of two residents (R7) reviewed for documentation accuracy on a sample list of eight.Findings Include:1. R7's Nursing Note dated 6/11/26 at 2:31 PM documents, (V21 Medical Director) also assessed resident, resident had no pain or discomfort in the rib area. No signs of fracture of the area. (V21) stated it looked like a noddle (sic) or legion. (Xray Company) called to re-review Xray and call back with findings.On 6/16/26 at 11:30AM, V5 (Assistant Director of Nursing) stated V21 (Medical Director) physically assessed R7 for a fracture.On 6/16/2026 at 11:16AM, V21, (Medical Director), stated he reviewed radiographs for R7 at the request of facility administration and referred to the radiologist. V21 stated he did not physically assess or see R7. V21 was stopped by V1 (Administrator) on his way out the door to have him review the radiographs.R7's Nurse's Note dated 6/12/26 at 9:56 AM authored by V1 (Administrator) documents, (V20 Physician) also assessed imaging and also did not see a fracture but a legion or nodes. He reviewed the other images that showed no findings from the same area the next day that had a misc. (miscellaneous) find of calcified LT hilar Lymph Nodes. He also assessed resident and she was at baseline for PROM (Passive Range of Motion) no pain at the time of assessment. The 2 sets of images were reviewed by 2 different techs with different findings. X-ray tech was called from the first imaging to re-review image and call administrator back with findings.On 6/16/26 at 3:03PM, V1 (Administrator) stated that she saw V20 (Physician) on Central Hall in the facility and V1 stopped him and asked him to look at R7's radiographs. V20 reported to V1 that he did not feel like R7 had a fracture rib. V20 told V1 that R7 was not his patient. V20 looked at R7's arm and pushed on it. V1 reviewed R7's Nurses Note, dated 6/12/26 at 9:56AM, authored by V1. V1 stated she just documented what she saw. V1 reports she told V20 that R7's passive range of motion was at her baseline. She did not have V20 enter his assessment himself on R7's chart because R7 was not his patient and he was just looking over the fractures for V1.On 6/16/26 at 2:53PM, V20 (Physician) stated that R7 is being followed by V21 (Medical Director). V1 (Administrator) did have V20 review radiographs for R7 on 6/12/26. V20 did not see a fracture. V20 stated he would refer to V21, as R7 is not V20's patient, so he is not familiar with R7. V20 stated he did not see and never physically assessed R7.

Based on interview and record review, the facility repeatedly failed to follow physician's orders to utilize a Bilevel Positive Airway Pressure (BiPAP) machine and failed to notify the physician when the BiPAP was not administered for one (R1) out of three residents reviewed for quality of care on a sample list of eight. R1's Administration Record dated April of 2026 documents an order, with a start date of 4/4/26, for R1 to wear a BIPAP every night.A Resident/Family Concern Grievance Form dated 4/6/26 at 9:00AM, documents R1 was concerned that his BiPAP was not at the facility when he admitted to the facility.An email exchange from V13 (Admissions/Marketing Coordinator) with the equipment company, dated 4/10/26, documents V13 notified the equipment company of an issue with R1's BiPAP tubing. The equipment company responded with information and V13 confirmed she would follow-up if the staff could not figure it out.R1's Orders-Administration Note, dated 4/10/26 at 7:07PM, documents that R1's BiPAP was not applied because it needs different equipment to function correctly.R1's Orders-Administration Note, dated 4/12/26 at 7:54PM, documents R1's BiPAP was not applied because it needs separate equipment to function properly.R1's Orders-Administration Note, dated 4/16/26 at 9:34PM, documents R1's BiPAP was not applied due to the BiPAP machine not having all of the correct parts to function correctly.R1's Orders-Administration Note, dated 4/23/26 at 8:15PM, documents the BiPAP is not working and a new one is being delivered.R1's Progress Notes do not contain documentation of physician notification that R1's BiPAP was not functioning.R1's Bed Hold Policy note, dated 4/27/26 at 8:15AM documents R1 was transferred to a local hospital for respiratory distress.R1's Nursing Note, dated 4/27/26 at 1:07PM, documents R1 was admitted to the hospital with a diagnosis of respiratory failure.On 6/15/26 at 10:24AM, V14 (R1's Power of Attorney) stated R1 was discharged from the hospital to the facility in early April of 2026. V14 stated the first week facility staff did not put R1's Bilevel Positive Airway Pressure (BiPAP) machine on him. V14 stated the facility kept telling V14 that they did not have the machine or couldn't find the machine. Once the facility did find the machine, then the staff did not know how to use the machine. V14 stated R1 only wore the BiPAP machine one or two nights during his stay at the facility. V14 stated the doctor ordered that R1 should wear it every night. V14 stated then R1 had to go to the local hospital because he was having breathing issues again. V14 stated R1 was very worried and scared about having to go back to the hospital. On 6/15/26 at 11:33AM, V11 (Registered Nurse) stated R1's BiPAP machine was having issues because the supply company did not send all the correct parts for it. V11 stated the machine tubing the supply company sent was for a Continuous Positive Airway Pressure (CPAP) machine, not a BiPAP. V11 stated V11 does not know when or if the part came in. V11 stated V11 called V5 (Assistant Director of Nursing) and V5 said she was calling the supply company to have them deliver the correct tubing.On 6/15/26 at 1:35PM, V13 (Admissions/ Marketing Coordinator) stated she ordered R1's BiPAP machine equipment and did not have to re-order any parts for it. V13 stated V5 (Assistant Director of Nursing) fixed the BiPAP machine and there were not any other issues with it.On 6/15/26 at 1:53PM, V5 (Assistant Director of Nursing) stated the box with the BiPAP for R1 was delivered on the day of admission, but staff did not know where it was delivered to in the facility. V5 stated the following morning, staff saw R1's BiPAP machine on North East hall and took it to R1. The machine was not working correctly, so V5 adapted the tubing. V5 stated other nurses may not be comfortable with the way V5 adapted the machine.On 6/15/26 at 3:23PM, V31 (Registered Nurse) stated R1's BiPAP has never worked. V31 stated there was a missing piece that R4's family was supposed to bring to the facility at some point. On 6/16/26 at 1:54PM, V5 (Assistant Director of Nursing) stated she is unsure if the physician was ever notified that R1's BiPAP was not functioning correctly. If the physician was notified then it would be documented in the Progress Notes. On 6/16/26 at 11:43AM, V2 (Interim Director of Nursing) stated R1's BiPAP could not be located upon admission. It was found a day or two later. V2 stated V2 is unaware of any further issues with R1's BiPAP. V2 stated If R1's BiPAP was not functioning, the nurses should document it and notify the physician, Power of Attorney, and management.On 6/16/26 at 1:56PM V2 (Interim Director of Nursing) stated the staff should not adapt any equipment or machines.On 6/15/26 at 1:46PM, V12 (Nurse Practitioner) stated R1's inconsistent use of BiPAP potentially lead to his hospitalization on 4/27/26.The facility's Physician Orders Policy, revised in September of 2023, documents any questions in regard to physician orders should be directed to the Director of Nursing.

Based on observation, interview, and record review, the facility failed to protect a resident from physical abuse by another resident. This failure affects two residents (R1 and R2) out of twelve residents reviewed for abuse on the sample list of 26.Findings include:R1's Medical Diagnoses List dated 5/1/26 documents R1 experiences Delusional Disorder and Major Depression.R2's Medical Diagnoses List dated 5/1/26 documents R2 experiences Delusional Disorder, Dementia, and Paranoid Schizophrenia.The facility's Initial Report to Illinois Department of Public Health dated 3/28/26 documents an occurrence between R1 and R2 with R1 scratching R2 on the arm.R1's Nursing Progress Notes dated 3/19/26, 3/20/26, 3/21/26, 3/23/26, and 3/24/26 documented R1 exhibiting behaviors, albeit these behaviors are not specified. On 3/25/26 R1's Nursing Progress Note documents R1 being upset and yelling at staff.On 3/24/26 R1's Nursing Progress note documents: Note Text: Was a behavior observed? YES. Res upset this morning due to (R1) does not like the Certified Nursing Assistant on (R1's) hallway. One on one completed with brief positive results. Res began wheeling (R1's self) down the hallway and cursing and screaming due to (R1's) clothing. Laundry brought (R1) all (R1's) clothes and completed one on one with good results.R1's Nursing Progress Note dated 3/28/2026 documents: Incident Note, Note Text: (R1) got upset at another resident (R2) in the hallway, (R1) started yelling and lunged at (R2), scratching (R2) on the left forearm. They were separated by staff members, abuse coordinator called immediately. Immediate intervention is to escort residents to and from the dining room, so they have no further interactions. Power of Attorney called and completely understandable about the situation, stated (R1) always has been like this even before the stroke.R1's current Care Plan dated 5/1/26 documents R1 exhibits behavioral issues such as: (R1) has a behavior problem related to (R1) will transfer (R1's self) to other resident's wheelchairs when they are not in use and then refuse to get out of the chair when staff attempts to assist (R1) back into (R1's) wheelchair. Date Initiated: 11/17/2022; and at times, does not prefer for others to sit with (R1) at (R1's) table, (R1) can become agitated at certain times with certain residents, Monitor for signs of agitation and provide one to one. Date Initiated: 02/13/2020.On 4/29/26 at 11:42 am, V12, Licensed Practical Nurse, stated V12 didn't physically see the incident between R2 and R1. V12 stated R2 had come up to V12 in the hallway and asked for a (adhesive bandage). V12 stated V12 asked R2 what R2 needed a bandage for and R2 showed V12 R2's arm. V12 further stated there were visible scratches that were bleeding. V12 clarified that the blood was not gushing out but it was the surface blood that shows up from missing skin and it was enough blood that it smeared around on R2's arm when V12 cleaned R2 up because the blood was running out of the scratches.On 4/29/26 at 12:02 PM, R2 displayed R2's left forearm which had four healed scars. Three of the scars were dull red in appearance and indented below the surface of the surrounding skin, and one scar was dull red and superficial. R2 stated R2 had been grabbed by R1 and R1 really f***ed me up.On 5/1/26 at 2:45 PM, V26, Certified Nursing Assistant, stated V26 was there the day of the incident between R1 and R2. V26 stated V26 was propelling another resident in the hallway and saw R1 and R2 having a face-off because R1 was in R2's way, I (V26) moved R1 to let R2 go past and when R2 went past, R1 lunged at R2. V26 continued to state V26 didn't initially see R1 grab or scratch R2, but after V26 took the other resident to the dining room V26 was on V26's way back and saw R2 with the nurse putting a bandage on R2's arm. V26 concluded by stating when R1 lunged at R2 it wasn't an accident like R1 was falling and reaching out to steady R1's self, R1 was going for R2.

Based on record review and interview the facility failed to ensure safe transfer techniques were implemented for one (R1) of three residents reviewed for accidents. The resident sustained a fracture of the left knee when a mechanical lift transfer requiring two staff members was performed by only one staff member.Findings Include The Facilities Hydraulic Lift (Hoyer) Policy revised on 1/26 documents all nursing staff will be trained on the proper use of the hydraulic (hoyer) lifts that are used within the facility, to ensure safe transfer for residents. This Policy also documents that the staff is to obtain assistance from a second staff member.On 11/29/26 at 3:04AM, the Nursing Progress notes documents: R1was sent to the hospital after complaining of pain in the area above her left knee. R1 received Norco (pain medication) just before leaving for the hospital. The hospital gave R1 Tylenol, Fentanyl and Ketorolac for pain management. R1 returned from hospital at 6:00AM. The Hospital diagnosis after the left knee Xray showed a Sprain of Medial Collateral Ligament of Left Knee.On 11/29/26 at 5:28AM, R1's Nursing Progress note documents: call received from the Emergency Department (ED) nurse. R1 was being discharged . Left knee x-ray was negative. R1 said R1 heard a pop when being transferred with a total body mechanical lift. R1 was given fentanyl 50mcg (microgram) given IM (Intramuscular) for pain management. No other concerns currently.On 11/29/25 through 12/3/25, R1 complained of pain in R1's left knee. R1 was given HYDROcodone-Acetaminophen Oral Tablet 7.5/325mg (Milligrams) for pain management.On 12/3/2025 the Nurse Practitioner's (NP) note documents R1 was assessed in R1's room lying in bed. NP reviewed R1's urine culture which showed mixed growth with possible contamination. R1 stated R1 still doesn't feel well. R1 was sent to the ED in the past week and stated that the Certified Nursing Assistant (CNA) hurt R1. The x-ray was performed of R1's left knee which was negative for a fracture. R1 stated R1 knows something is wrong and wants an MRI (Magnetic Resonance Imaging). The NP explained that R1 can be referred to ortho for further diagnostic testing and patient began yelling that she wants something done now and that she's tired of this place. The NP will refer R1 to ortho and instructed the nursing staff to get another UA (urinalysis).On 12/11/25 at 1:30PM, R1 had an appointment with the orthopedic doctor and completed a CT (computed tomography) scan of the left knee. The CT scan showed a Left Knee Fracture.R1's Minimum Data Set (MDS) dated [DATE] documents R1 is Dependent with all transfers and is cognitively intact.On 2/9/26 at 10:40AM, R1 was lying in bed and stated that V9 CNA (Certified Nursing Assistant) was transferring R1 via a total body mechanical lift without the assistance of a second CNA. V9 was pushing on me, then suddenly R1 heard a pop and a crack. R1 stated that V9 told R1 look your standing up. R1 stated I haven't stood up in years. R1 stated that R1's feet were touching the floor and R1's left knee hit the side of the bed. On 2/9/26 at 11:05AM, V9 CNA confirmed that V9 did complete a total body mechanical lift transfer for R1 without the assistance of a second staff member.On 2/9/26 at 11:05AM, V2 DON (Director of Nursing) stated that R1 was sent to the hospital, and the x-ray from the Emergency Department stated it was only a sprain. V2 confirmed two nursing staff should have been performing the transfer and not just one. V2 stated V9 CNA had disciplinary action taken against him as a result of this incident.On 2/9/26 at 11:15AM, V3 ADON (Assist Director of Nursing) stated a two-person transfer is required for all staff when using a total body mechanical lift.

Based on observation, interview and record review the facility failed to ensure an incident resulting in a fracture was reported to the State Agency within the required timeframe for one (R1) of three residents reviewed for Accidents. Findings IncludeThe Facilities Accidents and Incidents policy revised on 1/26 documents that reporting accidents and incidents, including injuries of an unknown origin, must be reported to the department supervisor and an Accident/Incident Report form must be completed on the shift that the accident or incident occurred. This document also states that the Director of Nursing (DON)/Designee will report any accident/incident of major injury to the State Agency within 24 hours.On 11/29/26 at 3:04AM, R1's Nursing Progress note documents R1 was sent to the hospital after complaining of pain in the area above R1's left knee. R1 received Norco for pain management just before leaving for the hospital. The Hospital gave R1 Tylenol, Fentanyl and Ketorolac for pain management. R1 returned from the hospital at 6:00AM. The hospital diagnosis after review of the left knee Xray shows Sprain of medial collateral ligament of left knee.On 12/11/26 at 1:30PM, R1 went and saw the orthopedic doctor and completed a computed tomography scan (CT scan) of the left knee. The CT scan showed a Left Knee Fracture.R1's Minimum Data Set, dated [DATE] documents that R1 is Dependent with all transfers and is cognitively intact.On 2/9/26 at 11:05AM, V2 Director of Nursing confirmed that a reportable incident was not sent to the State Agency.On 2/9/26 at 1:15PM, V1 Administrator confirmed that R3's fracture that was received on 12/11/25 was not reported to the State Agency.

Based on interview and record review, the facility failed to ensure documentation of the required transfer/discharge process for one (R3) of three residents reviewed for transfer/discharge. The facility discharged R3 without documentation of the required discharge notice and required elements in the medical record.The Facility Discharge/Transfer Policy revised 1/25 documents the facility is to provide guidelines for appropriate discharge and transfer procedures. The facility also documents that the facility will have a written or telephone order from the attending physician for the transfer or discharge of a resident. R3 was admitted to the facility on [DATE] per R3's nursing progress notes.Per R3's Hospital notes dated 2/23/26, R3 was dropped off at the Emergency Department (ED) from the facility with complaints of social concern. Per the facility, it was discovered during R3's background check that R3 had a sexual offense and could not be admitted to the facility. The Facility attempted to find different placement but could not. The Facility brought R3 back to the Emergency Department for nursing home placement. On 3/10/26 at 10:36AM, V7 (R3's) Power of Attorney stated the facility told V7 that R3 was being sent back to the hospital due to R3's background check results. On 3/10/26 at 11:00AM, V8 Social Service Director (SSD) stated R3's CHIRP (Criminal History Information Response Process) dated 2/23/26 was received and V8 SSD tried to find placement for R3. R3 was sent back to the hospital due to the CHIRP results showing R3 is listed as a Sexual Offender. On 3/10/26 at 9:35AM, V1 Administrator confirmed no discharge documentation or discharge orders were found in the chart for R3.

Based on Interview, Observation and Record Review the facility failed to follow admission orders for c-collar care for one (R1) out three residents reviewed on a sample list of three. Findings Include:On 7/18/2025, R1 had a fall that resulted in a C2 fracture of the neck. R1 was sent to the emergency room for evaluation due to pain in the left shoulder and returned on 7/19/25 with an Aspen C-Collar (Cervical Collar) and orders for care of the C-Collar. On 8/2/25 at 8:05AM, V8 (Certified Nursing Assistant) stated V8 put resident (R1) to bed on 7/18/25, there was no recliner in the room, which V8 stated that R1 usually sleeps in recliner. On 7/18/25, V8 found resident (R1) had rolled out of bed and was complaining of shoulder pain and with the assistance of V9 (Certified Nursing Aide) and V10 (Registered Nurse) resident (R1) was put back to bed via Hoyer lift.On 8/2/25 at 1:18 PM, V10 stated that after resident (R1) returned, the facility received orders to complete skin checks weekly. V10 stated since the bed had been taken out, there was only a recliner in the room and R1's c collar wasn't fitting right. The staff tried to adjust the C-Collar in the recliner, but the recliner wouldn't lay flat and R1 was in pain and yelling it hurts and is burning. V10 called the Medical Director and R1 was sent to the ER. V10 stated no daily skin checks were completed on R1 and 7/24/25 was the first time the C-Collar had been adjusted.On 8/5/25 at 8:30AM, V11 (Medical Director) stated that R1 needed to be lying flat when C-Collar was adjusted and not in a recliner and skin checks needed to be completed every day.On 8/5/2024 at 11:10AM, V1(Administrator) and V2(DON) agreed that admission orders were not followed when R1 returned to the facility on 7/19/25 that R1 readmission orders confirmed skin checks daily and R1 needed to be laid flat in a bed instead of a recliner that doesn't lay flat. Policy: admission Orders and Process dated 7/25 documents that upon admission/readmission, orders for care of the resident are received from attending physician, placed on physician's order sheet. This policy also documents that the facility will review all available transfer information.

Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) for two (R1, R2) of three residents reviewed for infection control in the sample list of three. Findings include: The facility's Enhanced Barrier Precautions policy dated 1/20/24 documents EBP is an intervention designed to reduce the transmission of multidrug-resistant organisms by using gowns and gloves during high contact resident care activities for residents with indwelling medical devices or chronic wounds. The Centers for Disease Control and Prevention Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities dated June 2021 documents Facilities should develop a method to identify residents with wounds or indwelling medical devices, and post clear signage outside of resident rooms indicating the type of PPE (Personal Protective Equipment) required and defining high risk resident care activities. Gowns and gloves should be available outside of each resident room, and alcohol-based hand rub should be available for every resident room (ideally both inside and outside of the room). On 6/23/25 at 8:15AM there was an EBP sign posted on R1's room door that indicated to wear gown and gloves for high contact resident care activities that included toileting, dressing, and transfers. On 6/23/25 at 8:30AM there was no EBP sign posted on R2's room door that indicated the facility is to wear gown and gloves for high contact resident care activities that included toileting, dressing and transfers due to R2's indwelling catheter. On 6/23/25 at 10:00AM V5 Certified Nursing Assistant (CNA) entered 's room and emptied R1's catheter. R1 was on Contact Isolation for E-Coli Infection and V5 drained the urine out of the catheter bag and emptied the urine into the shared toilet with R1's roommate. On 6/23/25 at 10:30AM, V5 was asked about EBP and V5 stated nobody ever wears them and when asked if V5 cleaned the toilet after pouring the urine into the toilet, V5 stated no, but I should have. On 6/23/25 at 12:30PM, V7 Registered Nurse and V6 CNA provided R2's urinary catheter cleaning/care. R1 and R2's Physician Orders documents EBP due to urinary catheter, UTI and R2's wounds. R1's Electronic Medical Record (EMR) section titled Diagnosis documents R1 on 6/18/25 has the diagnosis of Urinary Tract Infection (UTI) with E-Coli and has a catheter which is why she is on EBP precautions. R2's EMR documents R2 receives hospice services and was readmitted on [DATE] from the hospital and has an indwelling catheter with also skin breakdown, reason for his EBP status. On 6/23/25 at 11:13 AM, V7 stated The reason we did not have the equipment carts outside the rooms is because she was admitted over the weekend and no EBP was put out. On 6/23/25 at 2:30PM, V1 stated the admitting nurse should have known the resident needed to be on EBP when admitted due to her chronic wounds and catheter.

Based on interview and record review, the facility failed to provide numerous showers as scheduled for dependent residents. These failures affect two residents (R34 and R63) of six reviewed for activities of daily living in the sample list of 35. Findings include: The facility's Bath/Shower Policy dated 8/2023 documents: Purpose: To provide a procedure for bathing/showering the resident. Policy: A bath/shower for cleanliness and comfort will be scheduled at least weekly for all residents. Responsibility: It's the responsibility of the nursing assistants to provide the bath/shower to each resident per schedule. It is the responsibility of the Charge Nurse to ensure that bath/shower schedule is followed, and residents receive bath/shower per facility schedule. 1. R34's Facility Census documents R34 was admitted to the facility on [DATE] and has the following medical diagnosis; Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Aphasia, Lack of Coordination, Convulsions, Major Depressive Disorder, Delusional Disorders, Need for Assistance with Personal Care, Unsteadiness on Feet and Abnormalities of Gait and Mobility. R34's Minimum Data Set (MDS) dated [DATE] documents R34's Brief Interview for mental Status (BIMS) score 0, severe cognitive impairment and needs substantial/maximum assistance from staff with Activities of Daily Living (ADLs). R34's Shower Schedule dated April 3, 2025 - June 6, 2025, documents R34 is scheduled for showers on Tuesday, Thursday and Saturdays. R34 did not receive showers on 4/29, 5/1, 5/6, 5/13, 5/17, 5/20, 5/27, 5/29 and 6/3/25. 2. R63's Facility Census documents R63 was admitted to the facility on [DATE] and has the following medical diagnosis; Muscle Wasting and Atrophy, Cognitive Communication Deficit, Lack of Coordination, Multiple Fractures, Acute and Chronic Respiratory Failure and Unsteadiness on Feet. R63's Minimum Data Set (MDS) dated [DATE] documents R63's Brief Interview for mental Status (BIMS) score 15, cognitively intact and is dependent on staff with Activities of Daily Living (ADLs). R63's Shower Schedule dated April 3, 2025 - June 6, 2025, documents R63 is scheduled for showers on Thursday and Sundays. R34 did not receive showers on 4/17, 4/20, 4/24, 4/27, 5/1, 5/4, 5/8, 5/11, 5/15, 5/18 and 5/25/25. On 6/3/25 at 11:30am R63 stated that R63 does not get two showers a week. R63 stated R63 is lucky to get any. R63 stated that staff always have an excuse to why they can't give R63 a shower. R63 stated R63 needs assistance from staff to get a shower. On 6/3/25 at 11:08am V13 Licensed Practical Nurse stated Certified Nursing Assistant's should be providing the residents their showers per the residents scheduled shower, which are two showers a week. V13 stated after giving the resident a shower, the CNA should be documenting it in the resident's chart. V13 stated that if a resident refuses a shower, the CNA should be notifying the nurse so they can speak with the resident in an attempt to provide the scheduled shower. V13 stated that if the resident still refuses, the refusal should be documented by the CNA in the resident's chart. On 6/3/25 at 1:20pm V17 Certified Nursing Supervisor stated that all residents are scheduled to receive two showers a week. V17 stated that all showers are documented under the tasks in the resident's chart. V17 stated that if it's not documented in the resident's chart, then the resident did not receive a shower. V17 stated staff can also document if the resident received a bed bath or refused the shower. V17 confirmed that R34 and R63 did not receive all scheduled showers and did not have any documented refused showers or bed baths.

Based on interview and record review, the facility failed to notify a resident and their representative in writing about a hospital transfer and failed to provide a bed hold notice for five of five residents (R9, R26, R50, R63 and R74) reviewed for hospitalizations on the sample list of 35. The facility's Bed Reserve Policy Notification no date, documents this bed reserve policy will be given to you at the time of admission and a copy will be given to you each time you are transferred from the facility. 1. R9's Nursing Notes document R9 was transferred to the emergency room on 3/29 and 5/25/25. R9's medical record does not contain documentation that a bed hold notice, or a written notice of transfer was provided to R9's representative for R9's hospitalizations on 3/29 and 5/25/25. The facility could not provide documentation that R9's representative was provided a written copy of the Bed Hold Policy when R9 was transferred to the emergency room on 3/29 and 5/25/25. 2. R26's Nursing Notes document R26 was transferred to the emergency room on 5/14 and 5/25/25. R26's medical record does not contain documentation that a bed hold notice, or a written notice of transfer was provided to R26's representative for R26's hospitalizations on 5/14 and 5/25/25. The facility could not provide documentation that R26's representative was provided a written copy of the Bed Hold Policy when R26 was transferred to the emergency room on 5/14 and 5/25/25. 3. R50's Nursing Notes document R50 was transferred to the emergency room on 4/25/25. R50's medical record does not contain documentation that a bed hold notice, or a written notice of transfer was provided to R50's representative for R50's hospitalizations on 4/25/25. The facility could not provide documentation that R50's representative was provided a written copy of the Bed Hold Policy when R50 was transferred to the emergency room on 4/25/25. 4. R63's Nursing Notes document R63 was transferred to the emergency room on 3/29/25, 4/11/25, 4/16/25 and 5/26/25. R63's medical record does not contain documentation that a bed hold notice, or a written notice of transfer was provided to R63's representative for R63's hospitalizations on 3/29, 4/11, 4/16 and 5/26/25. The facility could not provide documentation that R63's representative was provided a written copy of the Bed Hold Policy when R63 was transferred to the emergency room on 3/29, 4/11, 4/16 and 5/26/25. On 6/3/25 at 10:58am V4 Social Service director stated that the resident or resident representative signs the bed reserve-policy notification form upon admission. V4 stated that nursing staff do not provide a bed hold policy form when residents are transferred out of the facility. V4 stated that V7 Admissions will follow up with the resident in the hospital. On 6/3/24 at 11:08am V13 Licensed Practical Nurse stated that when V13 transfers a resident out of the facility to the emergency room, V13 does not provide the resident with a bed hold policy. V13 stated V7 admission or V4 Social Service follows up with that paperwork. On 6/3/25 at 11:30am R63 stated that the nurse did not give R63 any bed hold policy or paperwork when R63 was transferred to the hospital. R63 stated that R63 has been to the hospital several times in the last couple months and was never given a bed hold notice. 5. R74's Nursing Notes document R74 left the facility for a procedure on 4/21/25. Progress Notes dated 4/21/25 - 4/25/25 document R74 was hospitalized . R74's medical record does not contain documentation that a bed hold notice, or a written notice of transfer was provided to R74's representative for R74's leave. The facility could not provide documentation that R74's representative was provided a written copy of the Bed Hold Policy when R74 left the faciity on 4/21/25.

Based on observation, interview, and record review, the facility failed to develop and implement a person-centered comprehensive care plan. This failure affects one (R50) of 19 residents reviewed for care plans in the sample list of 35. Findings include: The facility's Care Planning Policy (revised June 2024) documents the following: To 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 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 consonant with the physician's plan of care. The resident care plan must be kept current at all times. On 6/1/25, 6/2/25, 6/3/25, and 6/4/25 during intermittent observations throughout the survey period, R50 was observed with a nasal cannula in place in R50's nares. R50's Face Sheet dated 6/4/25 documents R50 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease and Atrial Fibrillation. R50's Physician Order Sheet (current) documents the following orders: O2 (Oxygen) 2 liters via nasal cannula as needed to keep O2 saturation above 90% and Apixaban (Anticoagulant) oral tablet 2.5 milligrams, give 1 tablet by mouth two times a day for blood thinner. R50's Minimum Data Set, dated [DATE] documents R50 is receiving oxygen therapy and taking an anticoagulant. R50's Care Plan (current) does not include R50's oxygen use and/or monitoring. This same record does not include anticoagulant medication use and/or monitoring. On 6/4/24 at 11:10am, V1 Administrator stated care plans are to be updated with any change in condition and should include R50's anticoagulant and oxygen use. V1 confirmed R50's care plan does not include oxygen therapy and anticoagulant use and interventions for monitoring.

Based on observation, interview and record review the facility staff failed to provide complete incontinence care for R18. R18 is one of one resident sampled for incontinence care in a total sample of 35. Findings include: The Electronic Medical Record under the section Medical Diagnoses dated 6/3/25 documents the primary diagnosis for R18 is Unspecified Cord Compression. Progress Notes dated 5/13/25 and 6/3/25 document R18 received antibiotics for urinary tract infections. V18, CNA (Certified Nurse Assistant) performed incontinence care for R18 on 6/3/25 at 2:40 PM. V18, used wash clothes to cleanse, rinse and dry R18's inner and outer labia. V18 then stated she was completed with perineal care for R18. V18 was asked about cleaning the groin area and the buttocks. V18 said Yes I should of cleaned R18's buttock's area. R18 stated on 6/3/25 at 2:35 PM she was feeling strange and she had started a new antibiotic today (6/3/25) for another urinary tract infection. V1, Administrator stated on 6/3/25 at 3:15 PM Yes, they are supposed to clean the entire area front and back when staff complete peri (perineal) care. The Facility policy dated Toileting and Incontinent Care revision date 8/2023 documents #8 Wash all soiled skin areas and dry very well, especially between skin folds.

2. R13's Medical Diagnosis sheet which is current has the following two diagnoses for R13, Dependence on Renal Dialysis and End stage Renal Disease. R13's Physician's Order Sheet (POS) dated June 2026 does not document dialysis treatment orders for R13. V24, LPN (Licensed Practical Nurse) stated on 6/1/25 at 10:30 AM R13 has dialysis five times a week and R13 goes to Dialysis every morning Monday thru Friday. V16, Regional QA (Quality Assurance) stated on 6/4/25 at 10:30 AM that R13's dialysis order must of fallen off the physician's orders sheet. V16 stated (R13) goes to dialysis every morning Monday thru Friday. Based on interview and record review, the facility failed to have an order for the provision of dialysis treatments for two (R13 and R46) of two residents reviewed for dialysis in the sample list of 35. Findings include: The facility's Long-Term Care Facility Renal Dialysis Affiliation Agreement dated 11/8/2019 documents the Dialysis Facility shall accept medically stable residents into its home Renal Dialysis program, within the limits of its programs and facilities, Each such resident accepted into the Dialysis Facility's home hemodialysis program is referred to herein as a Dialysis Resident. The medical management of the Dialysis Residents will be under the direction of each Dialysis Resident's attending physician. The LTC Facility retains primary responsibility for the development and implementation of each Dialysis Resident's overall plan of care. Coordination of care may include coordination of the following: Day(s), date(s), and time(s) of appointments with the Dialysis Facility and dialysis access orders. The facility's Dialysis Residents list documents R13 and R46 as Dialysis Residents. 1. R46's Face Sheet (current) documents R46 was readmitted to the facility on [DATE] with diagnoses: End Stage Renal Disease, Stage 4 Chronic Kidney Disease, and Dependence on Renal Dialysis. R46's Physician Orders (current) do not document any dialysis treatment orders for R46. R46 did not have dialysis treatment orders from 3/22/25 until 6/3/25. On 6/3/25 at 1:37pm, R46 stated R46 receives dialysis treatments in the facility Monday through Friday. On 6/3/25 at 2:21pm, V15 Licensed Practical Nurse confirmed R46 does not have any dialysis treatment orders.

Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) for two (R2 and R275) of seven residents reviewed for EBP on the sample list of 35. Findings include: The facility's Enhanced Barrier Precautions policy dated 10/21/22 documents EBP expands the use of gloves and gowns to be worn during high-contact care activities that provides opportunities for Multidrug Resistant Organisms (MDROs) to be transferred between staff hands or clothing and between residents during these high-contact cares. This policy documents residents with wounds and indwelling medical devices are at high risk of acquisition and colonization of MDROs. This policy documents to wear gown and gloves when assisting residents on EBP with high-contact care activities, including dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, providing device care or wound care. R2's care plan dated 4/8/24 documents that staff will always maintain EBP during high-contact resident care areas. R2's physician's orders dated 9/17/2024 documents an order for EBP when providing cares involving R2's indwelling medical device. On 6/2/25 at 12:08 PM, there was a sign posted on R2's room door that documented EBP and to wear a gown and gloves for the high-contact care activities listed. On 6/2/25 at 12:10 PM, V10 Certified Nurse Assistant (CNA) emptied R2's urine collection bag but did not put on a gown. On 6/2/25 at 12:25 PM, V10 stated that staff are supposed to wear gowns when emptying R2's urine collection bag. V10 stated that she should have put on a gown. R275's care plan dated 6/2/25 documents that staff will always maintain EBP during high-contact resident care activities. R275's physician's orders dated 6/2/25 documents an order for EBP when providing cares involving R275's indwelling medical device. On 6/1/25 at 12:08 PM, V11 Registered Nurse emptied R275's urine collection bag. V11 was not wearing a gown. On 6/3/25 at 10:00 AM, V2 Director of Nursing stated that all staff should wear a gown and gloves during high-contact resident care activities.

Based on observation, interview, and record review the facility failed to implement an ordered nutritional supplement and failed to notify a resident representative of the significant weight loss for one of two residents (R379) reviewed for nutrition in the sample list of 26. These failures resulted in R1's severe weight loss of 10.8% in 12 days. Finding include: On 8/20/2024 at 11:55 AM, R379 was sitting in a wheelchair in the dining room eating lunch with V17 (family) present. No nutritional supplements were present on the tray. At this time, V17 states R379 has lost a lot of weight since his surgery, which was prior to being admitted to the facility. V17 is not aware of any ordered nutritional supplements and has not been notified by the facility of any weight loss since R379 being admitted . V17 stated V17 is at the facility for most of R379's meals and acknowledges that R379 has a decreased appetite and intake. R379's ongoing Census documents R379 was admitted to the facility of 8/07/2024. R379's ongoing Weight Log documents a weight of 149.8 pounds on 8/07/2024 and 133.6 pounds on 8/19/2024. This weight loss calculates as a 10.8% weight loss in 12 days. R379's Dining RD Request for Diet Change report dated 8/08/2024 documents (R379) is at risk for altered nutrition status r/t (related to) reduced meal intake, recent surgery, and dx (diagnosis) of Dementia. Recommend {to} add house supplement 1 dly (daily) and liq (liquid) pro (protein) 30ml (milliliters) dly (daily). Monitor wt (weight). This report recommendation was signed and accepted by V11 (Nurse Practitioner) on 8/09/2024. R379's ongoing August 2024 Physician Order Sheet does not contain the accepted dietary recommendations for nutritional supplements. On 8/21/2024 at 8:35 AM, R379 was sitting at the dining room table eating breakfast which consisted of: scrambled eggs with cheese, cornflakes, toast, milk, and coffee. R379 consumed: 100% of coffee, 10% of eggs, 0% toast, 0% cornflakes, 0% milk. No nutritional supplement was present at breakfast. On 8/21/2024 at 8:40 AM, V6 CNA (Certified Nursing Assistant) states I am not aware of any nutritional supplement (R379) is supposed to get but I (V6) usually work in the evenings. V6 acknowledged that if R379 was getting a supplement it would be on the tray. On 8/21/2024 at 08:45 AM, V4 RN (Registered Nurse) confirms that R379 has not received any nutritional supplements. V4 looked in the EMR (Electronic Medical Record) and confirmed there was no order transcribed for a nutritional supplement. On 8/21/24 at 10:55 AM, V8 RD (Registered Dietitian) confirmed that V8 recommended the above nutritional supplements on 8/09/2024 for R379, and states V8 would have expected the supplement to be given by now. V8 also stated if R379 was receiving the nutritional supplements as recommended and ordered, it could have possibly prevented R379's additional weight loss. On 8/21/24 at 12:38 PM, R379 was in the dining room with V17 eating lunch with no nutritional supplement present. On 8/21/24 at 12:52 PM, V1 (Administrator) with V2 (Director of Nursing) present stated that V8 had notified V1 that the ordered supplement was not implemented because V8 sent the signed recommendations to an invalid email address. R379's computerized Medical Record does document a history of CHF (Congestive Heart Failure), however R379's Progress Notes do not document any signs and symptoms of CHF. V10's (Nurse Practitioner) Progress Notes on 8/12/2024 and 8/19/2024 do not document any CHF signs or symptoms, nor does V11's (Nurse Practitioner) Progress Note on 8/08/2024, 8/12/2024, and 8/16/2024. On 8/22/24 at 8:10 AM, V8 confirmed that the order for the nutritional supplement was not implemented and that it was an error on V8's part due to sending the signed recommendation to an invalid email address. The facilities policy Fortified Foods, Supplements, and Snacks dated 2020 documents residents who cannot consume adequate amounts of regular foods at meals to meet their nutritional needs may be considered for Fortified Foods, snacks, or supplements in order to increase nutritional intake. Residents will be evaluated by the Registered Dietitian when additional nutritional intervention is warranted. Commercially prepared supplements, including liquid high calorie and high protein supplements, will be ordered by the physician. Fortified foods, house supplements, or snacks will be provided within the specifications of the diet order.

Based on interview and record review the facility failed to trend (show increase or decrease) the facility's monthly resident infections. This failure has the potential to affect all 76 residents residing in the facility. Findings include: The facility did not provide an Infection Control Surveillance and Monitoring Policy and no documents were provided for how the facility trends monthly infections to prevent further infection throughout the facility. The facility has no documentation for the identified infections pattern/trend and interventions. On 8/21/24 at 2:30 PM, V2 Infection Preventionist, stated V2 has not completed the trending for the facility's infections. The facility's The Long Term Care Facility Application for Medicare and Medicaid dated 8/20/24, documents there are 76 residents residing in the facility.

Based on observation, interview and record review the facility failed to maintain the facility kitchen food service areas, and equipment in a clean, sanitary condition to prevent potential cross-contamination and food-borne illness to residents. This failure has the potential to affect all 76 residents residing in the facility. Findings include: On 08/20/24 at 9:50 am, during the initial tour of the facility kitchen, accompanied by V7, Dietary Manager (DM), the commercial table mounted can opener had a build-up of a grease-like substance in the gears. Adhering to the grease-like substance were metal fragments, and rust. The commercial can opener also had the silver laminate missing from the bottom inch of the blade. The commercial can opener blade had exposed bare metal and rust at the tip of the blade. V7, DM confirmed the observation and stated he would have to get the build-up debris and blade tip cleaned properly before using the can opener. During the same initial tour, the facility flat-top grill and stove burners had a range hood that spanned over all cook surfaces. The range hood had six separated metal framed filters. Each of the six metal enclosed filters had a build-up of dark and light brown, grease-like substance adhering to the surface. The grease-like substance had scattered strands of a dust-like substance, that dangled down one to two inches, and directly over the cooking areas. V7, DM stated the facility has a cleaning service that cleans the range hood filters every three months. V7 confirmed the soiled condition of the range hood screen like filters. V7 said he will have to clean the filter, and the contracted cleaning service will need to clean the filter more often. On 8/22/24 at 10:45 am during subsequent tour of the kitchen, V7, Dietary Manager confirmed the following: The 15 foot long, metal food preparation table had caulking at the wall junction. The caulking had embedded brown and black sticky, food-like substance that adhered to the top and bottom of the caulking. The caulking had food-like particles that were crusted in patches. V7, DM confirmed the caulking debris build-up was a potential contaminate to the food preparation areas as V7 easily scraped off the crusted food debris with V7's finger. The facility three well, wash, rinse and sanitizer water had a windowsill that set directly above it. V7 confirmed that above the three well sink window had screens on the lower half of the window. The screens had copious amount of dust-like buildup and a build- up of grease and dust across the windowsill. Above the window there was a three-inch deep window frame, that junctions with the ceiling. The ceiling and wall junction of the window frame had rust and chipped paint across the full six foot width of the frame. The frame hung over the three well sink. The clean area of the dishwasher station, next to the three well sink was also exposed to chipped paint and thick clusters of dust-like strands and cobwebs on the ceiling above the clean racks of dishes. V7 confirmed these areas were heavily soiled and need to be cleaned to prevent cross contamination. The facility policy Cleaning Instructions: Hoods and Filters dated 5/2021 documents the following: Policy: Stove hoods and filters will be cleaned according to a cleaning schedule, or at least monthly. Procedure: 1. Remove the screens from the hoods. 2. Place the screens in soapy water in the sink. Scrub thoroughly. Rinse. (Or run through the dish machine if appropriate.) 3. Air dry screens after cleaning. 4. Replace the screens into the hoods. 5. To clean the interior and exterior of the hood, use a clean cloth soaked in soapy detergent water. Rinse thoroughly and air dry. A more abrasive cleaning agent may be needed in some cases. A cleaning agent that can handle grease may be needed. 6. Hoods and filters should be cleaned professionally at least yearly The facility Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 08/20/24 documents 76 residents reside in the facility.

Based on observation, interview and record review the facility failed to ensure residents medications, including Schedule II controlled substances, were stored appropriately within visual control of the nurse. This failure affects four of 22 residents (R2, R31, R35, R25) reviewed for medication storage for the sample list of 26. Findings include: On 8/21/2024 at 4:09 PM, the [NAME] Wing Medication Cart was unlocked and not secured to the wall. There were no staff present. There was an opened stock bottle of Melatonin 5 mg (milligrams) sitting on top of medication cart. On 8/21/2024 at 4:10 pm, V16 LPN (Licensed Practical Nurse) exited the [NAME] Wing Medication Room and walked down the hall and into a resident room, leaving the unsecured medication cart in the hallway, unlocked and out of V16's sight. V16 returned to the medication cart at 4:12 PM, gathered supplies and walked away from the cart again at 4:17 PM and entered another resident room, leaving the cart unlocked, unattended and out of V16's sight until 4:20 PM. V16 returned to the cart at 4:21 PM to gather supplies, then left the cart again, leaving it unlocked, unsecured and out of V16's sight while in a resident room. At 4:22 PM, V2 (Director of Nursing) approached the medication cart and confirmed the Melatonin should not be on top of the medication cart and states the medication cart should be locked when staff are not within sight. At 4:25 PM, upon V16's return to the medication cart, V2 stated, do you see we are in your cart; it should have been locked. Included in the unlocked medication cart were the following controlled substances: Norco (Narcotic) 10/325 mg for R31, Norco (Narcotic) 7.5/325 mg for R2, Methylphenid (Central Nervous System Stimulant) 20 mg for R35, Reprexain (Narcotic) 10mg/200mg for R25; all which are classified as Schedule II narcotics. The facilities Storage of Medications policy dated 10/2023 documents all medications will be safe and properly stored at all times. All medications for all residents shall be stored in or near the nurse's station, in a locked cabinet, a locked medication room, or in locked, secured medication cart. Mobile medication carts, when not in the visual control of the nurse, shall be stored in a locked room affixed in such a way to render them immobile. All scheduled II controlled substances shall be stored in the drawer of the medication cart which is separately keyed and locked.

Based on observation, interview and record review, the facility failed to ensure R1, at risk for elopement (leaving the facility unnoticed), received supervision to prevent R1 from leaving the facility alone and unnoticed. This failure resulted in R1 exiting the facility alone and undetected by staff during the pre-dawn hours on 7/5/21. R1 was found by the local police department a half a mile away from the facility on the ground in a residential neighborhood with bruising and swelling above R1's right eye. R1's injuries included an Acute Subarachnoid Hemorrhage, an Acute Right-sided Orbital Floor Blowout Fracture with Inferior Displacement and Prolapse of Orbital Fat, Right Maxillary [MEDICATION(S)] and Nasomaxillary Fractures, Large Right Pre-septal and Periorbital Soft Tissue Hematoma. This failure had the potential to affect seven of seven residents (R1-R7) reviewed for being at risk for elopement in the sample of seven. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 7/20/21, the facility remains out of compliance at severity level two. The facility is in the process of training and educating staff on the facility's missing resident policy and procedures as well as conducting drills to ensure the policy and procedures are being followed. Findings include: R1's Minimum Data Set (MDS) dated [DATE] documents R1's diagnoses including [CONDITION(S)], Diabetes Mellitus, Alzheimer's Disease, Non-Alzheimer's Dementia, Lack of Coordination, Falls and Automatic Implantable Cardiac Defibrillator. This MDS documents R1 has severe cognitive impairment and wanders daily. R1's Care Plans dated 7/6/21 documents R1 had a fall with injury related to leaving the facility unsupervised and impaired cognitive status/Alzheimer's Disease. These Care Plans document R1 exhibits wandering behavior with goals including R1 will remain safe and undesirable behaviors will be monitored and managed. These Care plans document R1 has an activities of daily living (ADL) deficit related to Dementia and R1 may be up ad lib (in accordance with R1's wishes) for ambulation but requires supervision due to wandering. R1's Care Plans also document R1 is an elopement risk/wanderer related to impaired cognitive function related to Alzheimer's. R1 states R1 is going home and wanders throughout the facility. These Care Plans also document R1 has poor safety awareness. The facility is located near the Local County Jail, Local State Prison, a river, and is surrounded by well traveled two lane city streets. R1's Elopement report dated 7/5/21 at 5:39am documents the following: V21, Certified Nursing Assistant (CNA) reported to V20, Licensed Practical Nurse (LPN) R1 had been wandering around the hall and had last been seen on 7/5/21 at 3:30am. V21 had went to provide cares for R1 and it was noted R1 wasn't on unit. Immediate Action Taken: Code Yellow (Missing Resident) was called and all staff searched facility and the outside on premises and the nearby park. This report documents 911 was notified to assist with searching for the resident but does not document time of emergency personnel notification. Mental Status: R1 has a history of wandering about facility and interventions were attempted and unsuccessful. V21, CNA statement documents on 7/5/21 V21 attempted to take R1 to the bathroom at 3:30am. R1 did not want to go (to the bathroom) and wanted to wander about unit. 1:1 was ineffective. V21 attempted to provide R1 with snacks, but R1 refused and was walking about R1's unit. V21 went to finish (V21's) rounds on other residents. At 3:50am, V21 noticed R1 was not on the unit and V20, LPN called a Code Yellow. V20, LPN statement documents V21, CNA reported to V20 on 7/5/21 at 3:50am, that V21 was unable to find R1. This statement documents V20 had last seen R1 at 2:30am when R1 was laying in bed awake. V22, Registered Nurse (RN) and V24, CNA were working a different unit and had not seen R1 wandering the facility on 7/5/21. The facility's work in progress Summary of Event dated 7/5/21 documents R1 used to work at the facility up until three years prior to being admitted to the facility. R1 has a history of wandering and is assessed as at risk for elopement. R1's investigation report documents the facility camera's were reviewed and R1 was seen on camera leaving the employee entrance door in the back of the facility on 7/5/21 at 3:37am. The local police department Incident Report dated 7/5/21 at 5:09am documents emergency personnel were alerted to a report of a missing resident (R1) from the facility. This report documents upon the report of R1 missing, the local police department found R1 on the ground located in a residential neighborhood a half a mile away from the facility after R1 had fallen to the ground and had bruising and swelling above R1's right eye. R1 was transferred to the local hospital emergency room for evaluation. A web based local weather application dated 7/5/21 documents the local weather around the time R1 eloped and was missing from the facility including a temperature between 70 and 71 degrees Fahrenheit with humidity ranging from 84-90%. While at the local hospital emergency room post elopement with fall, R1's CT (Computed Tomography) of Head or Brain without Contrast radiology report dated 7/5/21 documents, IMPRESSION: 1. Minimal foci of acute subarachnoid hemorrhage within right temporal lobe sulci. There is also a hyperdense vessel within the adjacent right sylvian fissure, suspicious for acute thrombus. Further clinical correlation is needed as discussed above . 3. Acute right-sided orbital floor blowout fracture, with inferior displacement and prolapse of orbital fat. Additional right maxillary [MEDICATION(S)] and nasomaxillary fractures. 4. Large right preseptal and periorbital soft tissue hematoma . CRITICAL RESULT OF NEW INTRACRANIAL HEMORRHAGE IDENTIFIED . On 7/5/21 at 10:24am, R1's Hospital Notes document R1's CT was re-read and showed a subarachnoid bleed and new lesion from head CT completed this morning. Patient was seen and initially discharged from the local hospital emergency roiagnom on [DATE] after R1 had an unwitnessed fall outside after escaping from the facility. R1's hospital records dated 7/5/21 document R1 was called back to the hospital due to the re-read of R1's head CT. R1's local hospital emergency room record physician certification statement dated 7/5/21 documents R1's Medical Reasoning for Transport: Subarachnoid bleed, closed orbital fracture. If an interhospital transfer, is it for: Higher level of care; Services not available at the originating hospital. This statement also documents Services needed but not available are: Trauma. R1's Neurology Teaching Service Consult H&P (History and Physical) dated 7/5/21 documents, CT head, there is no hyperdense vessel sign, findings likely due to dehydration. Low concerns for seizures at this point. Given possible epileptogenic focus of the subarachnoid hemorrhage in the right temporal lobe sulci, would like to evaluate with EEG (Electroencephalogram) but the patient will be non cooperative, hence will defer now. Impression: Acute Subarachnoid hemorrhage likely due to trauma. This note documents R1 resides in nursing home, around 4 or 5:00 a.m. this morning (R1) went missing from the nursing home, (R1) was found 2 blocks from the nursing home where (R1) resides. (R1) has severe cognitive impairment at baseline due to Alzheimer's Dementia, at baseline occasionally sees her name . might remember her birthday but otherwise cannot take care of herself or perform activities of daily living . (R1) was initially taken to the local emergency room for evaluation and was found to have right orbital fracture and was discharged to nursing home but the CT head read came back positive for subarachnoid hemorrhage and possible right MCA (middle cerebral artery) dense vessel sign hence was transferred (to the Level 2 Trauma Center) for further management. R1's General Surgery Trauma Progress Note dated 7/7/21 documents, (R1) with past medical history of Alzheimer's who was involved in a GLF (ground level fall) resulting in the following injuries: List of Acute Injuries/Acute Problems . Right orbital fracture . Fall from ground level, SAH (subarachnoid hemorrhage), Closed fracture of right side of maxilla. R1's note of care plan held with family dated 7/6/21 by V1, Administrator documents V21, CNA attempted to provide care and R1 was left in a safe place to calm although R1's elopement report documents R1 was up wandering about the facility. On 7/8/21 at 2:20pm, V17, CNA stated R1 has a history of wandering throughout the facility throughout the day which usually occurs after family leaves. On 7/8/21 at 2:24pm, V16, CNA stated R1 has a history of wandering at times. R1's wandering is worse after family visits. V16 stated R1 wanders through out the building and R1 used to work here at the facility, and looks for things to do. R1 has set off the west door by the nurse's station a few times in the past, but had never gotten outside of the doors until 7/5/21. R1 would talk about leaving with/needing to go find family. On 7/8/21 at 3:17pm, V15, CNA stated R1 wanders all day long, and would wander other units and other hallways throughout the facility. V15 stated R1 has sounded door alarms before and made attempts to leave the facility in the past. On 7/12/21 at 3:15pm, V1, Administrator stated V1 was unaware of what outside parameters were searched when R1 was missing. V1 indicated that the facility relies on an electronic audible exterior door alarm sysem to alert staff if an exterior door is opened. V1 stated the facility had determined the door alarm had sounded at door of R1's exit however the sound was not loud enough to alert staff that would be out on the halls where the residents reside, further away from the back. There was an alarm sounding at the back employee entrance door which was heard when the search was in progress. V1 stated the code yellow for a missing resident had already been called because the facility knew R1 was missing. V1 stated V21, CNA had found that alarm was going off. V1 stated I (V1) want to say the door alarm was shut off for the funeral home to come obtain an unidentified resident's body. I don't know if it was that night without checking. Staff would typically shut the alarm off, not funeral home staff. I don't think we documented the review of the hallway cameras for (R1) or if (R1) was seen wandering the halls on the cameras. V1 stated R1 ambulates independently inside the facility without assistive devices and is fast. There was no follow up or documentation regarding facility staff shutting the door alarm off. On 7/13/21 at 4:55am, V22, Registered Nurse (RN) stated V22 had not seen R1 on the date of the incident. V22 stated V22 went to the unit to assist in finding R1 after the code yellow was announced on the overhead paging system. V22 stated the employee entrance door alarm where R1 had exited the facility was not functioning properly and had not been functioning properly for some time. V22 stated staff would just enter the code on the door alarm keypad to silence the alarm because it would just go off for no reason. V22 stated the staff were unable to hear the alarm when R1 eloped from the facility because the alarm was very low in sound and there are no central locations to where staff would have been close enough to hear the alarm. V22 stated after the code yellow was announced on the overhead paging system, V22 stated V22 then thought about the door not functioning properly and stated V22 knew (R1) had gotten out that door. V22 stated R1 is not safe to navigate outside/leave the facility unattended due to R1's Dementia in addition to R1 having an unsteady gait. V22 stated, we were short staffed on overnight shift on 7/4/21 to 7/5/21 due to a call off by V23, CNA. V22 stated the staff were busy due to only having four staff members (V20, LPN, V22, RN, and V21 and V24, CNA's) to care for the entire facility at the time R1 eloped from the facility on 7/5/21 which had between 70 and 80 residents. On 7/13/21 at 5:36am, the Employee Break Room exit door alarm which is located down a service hall near the back employee entrance was activated and sounding loudly. Five minutes later at 5:41am, V19, Human Resources responded to the alarm. At 5:45am, nine minutes after the alarm began sounding, V19 announced on the overhead speaker system code yellow. On 7/14/21 at 2:08pm, 2:20pm, and on 7/15/21 at 10:40am, 1:47pm, 2:06pm, 2:16pm, 2:17pm, and 2:29pm the alarm control tower located centrally in the hall was audibly sounding, warning, some of your devices (door alarm sensors) are not responding. On 7/15/21 at 2:20pm, V6, Maintenance stated V6 had heard the alarm sound but, we don't know why it (alarm tower) is saying that and that the facility was not sure which of the two alarm sensors it was referring to as the alarm did not identify/differentiate the sensors. V6 stated the facility had not reached out to the alarm company to find out troubleshooting steps as to what was wrong. V6 stated V6 would call the company and get it fixed. On 7/15/21 at 2:54pm, V6 stated V6 spoke with the alarm company and the facility has one additional alarm sensor for that alarm system that was causing the warning. V6 stated the additional sensor was not in use and deactivated, but had to be taken out of the system per the alarm company. V6 stated the centrally located alarm tower no longer sounded with the warning. The centrally located door alarm was observed to be properly functioning with no alarms heard on 7/15/21 at 2:54pm. V6 was unable to distinguish which alarm sensor (the one installed on the employee/service entrance or the additional alarm sensor not in use) was not responding/communicating with the alarm tower until V6 removed the extra sensor from the alarm system and the alarm tower no longer sounded the warning. The facility's undated Door Alarms policy documents the doors are alarmed to alert employees when someone has gone out the door. There is a central panel behind the nurses station that has indicators lights to indicate the alarm is activated. Red lights mean alarms are engaged and on, if light is green, someone has gone out the door, opened the door, or alarm is not activated. Green should be investigated. Not all door alarms are indicated on the panel. Responding to the door alarms: If the alarm is activated, go to the alarming door immediately. Do not reset the keypad alarm. First the alarm sounding must be investigated. The outdoor parameter must be checked to fully investigate the situation. If unable to determine the reason for the door alarm sounding, the Charge Nurse is to be notified and a Code Yellow (Missing Resident) must be paged in order to do a complete head count to ensure there are no missing residents. Once completed, the keypad can be reset at the door and at the nurses station. This policy documents, If you experience any problems with any of the alarms, notify the Administrator and/or Maintenance Supervisor immediately. The facility's At Risk to Wander list with names and photographs dated 7/6/21 documents R1-R7 are at risk for wandering/elopement. An Immediate Jeopardy situation was identified on July 12, 2021. The Immediate Jeopardy was identified to have begun on 7/5/21 when R1 left the facility unnoticed and sustained potential life threatening injuries. Staff were unaware of R1's location for over ninety minutes until notified by local law enforcement. On 7/12/21 at 4:38pm, V1, Interim Administrator was notified of the Immediate Jeopardy situation. The surveyor confirmed through observation, interview and record review that the facility took the following actions to remove the immediate jeopardy: 1.) On 7/7/21 at 12:40pm, V1, Interim Administrator stated R1 was to return to the facility on [DATE] from the Level 2 Trauma Center following evaluation and treatment for injuries. 2.) On 7/5/21 V6, Maintenance Supervisor checked all door alarms to ensure they were functioning properly. 3.) On 7/5/21, V6, Maintenance Supervisor began checking door alarms which is to be done 5 days a week by opening door and waiting for alarm to sound. This check will monitor for immediate physical response of staff to sounding door alarm. On 7/20/21, it was confirmed with V34, Executive Director that the facility updated/implemented the audit tools the facility is using to conduct elopement/door alarm drills to include documentation of staff immediate response. 4.) On 7/5/21, an elopement drill was completed by V31, Assistant Director of Nursing (ADON). 5.) On 7/6/21, V1, Interim Administrator ensured R1-R7, identified residents at risk for elopement were reassessed using the elopement evaluation to ensure assessments were current and accurate. 6.) On 7/6/21, V35, Care Plan Coordinator updated care plans related to risk for elopement for R1-R7. 7.) On 7/6/21, V1, Interim Administrator completed a full facility audit of all residents to determine those at risk using the electronic elopement risk evaluation. 8.) On 7/6/21, V31, Activity Director updated R1-R7's pictures and posted the updated pictures at nurses stations, the front desk, by the time clock and distributed to the managers. 9.) The employee/service entrance was monitored by facility staff from 7/5/21 at 7:00am-7/9/21 at 6:00pm until an additional alarm that would sound locally was installed. 10.) On 7/6/21, Maintenance, Housekeeping, Activities and Dietary staff are to be stationed at any door if an alarm fails to function until a new alarm can be installed. 11.) On 7/6/21, elopement drill and door alarm response information was added to new hire orientation check off sheet by V19, Human Resources. 12.) On 7/6/21, facility door alarm panels were labeled to instruct staff all lights on the panel should be red indicating the alarms are engaged at all times by V6, Maintenance Director. 13.) On 7/6/21, a back up alarm was available to install at a door should an alarm malfunction per V6, Maintenance Director. 14.) On 7/6/21, V6, Maintenance Director called the alarm company to the facility and parts were ordered for an additional alarm to be placed on the back door to sound audibly to a tower at a central location. 15.) On 7/6/21 and ongoing, Interdisciplinary Team members met as a subcommittee of the Quality Assurance and Performance Improvement committee to review the action plan. 16.) On 7/7/21, V5, Certified Nursing Assistant (CNA) Supervisor and V31, ADON began to re-educate staff and continue to re-educate staff on door alarm response and elopement drill for all staff. Staff must respond physically to sounding door alarm immediately to determine who/what set the alarm off. 17.) On 7/9/21, the alarm company installed the additional alarm on the rear service entrance exterior door which audibly sounds at a central location in the facility. Completed by Maintenance Director.

Based on observation, interview and record review the facility failed to safely transfer, pursuant to the Plan of Care, one resident (R1) of three residents reviewed for falls in a sample list of five residents. This failure resulted in R1 sustaining a Displaced [MEDICAL CONDITION] Femur which required surgical intervention. Findings include: R1's Minimum Data Set ((MDS) dated [DATE] documents R1 requires extensive assistance of two or more staff members to transfer. R1's Brief Interview of Mental Status (BIMs) score dated 1/1/2020 documents R1 scored a 15 of a possible 15 indicating R1 is completely cognitively intact. R1's Care Plan last revised 7/9/19 documents (R1) requires extensive assist with transfers. Staff uses the sit to stand (mechanical lift) getting (R1) in/out of bed. While in the bathroom, (R1) can use the grab bars to stand up and maintain balance. Goal: (R1) will maintain current ability to stand in the bathroom during each toileting safely with the assist of 1 staff. Interventions: Explain task to be done. Place walker in front of (R1) and cue to push up. Cue to grab the bars. Assure proper footwear and apply gait belt. Encourage (R1) to sit/stand 3 times at each toileting. Practice and praise. Self-propels w/c (wheelchair) Toilet use: (R1) requires extensive assist of 1 staff for toileting. Transfer: (R1) requires sit to stand lift with transfers. V14, (R1's primary care physician) signed an order dated 10/8/19 for R1 to have physical therapy documenting Treatment Diagnosis: [REDACTED]. R1's progress note by V6 Licensed Practical Nurse (LPN) dated 1/26/2020 at 7:05PM documents At approximately 2:00 pm (R1) was observed laying in bathroom on Left side. This nurse (V6) had been called to room by (V9) CNA. (V9) stated resident initially on knees but laid on side for comfort. Physical assessment: Range of Motion to All Extremities Within Normal Limits with complaint of pain to Right knee at a 4 (on 0-10 scale). No redness or deformities noted. Cause: Resident was transferring to wheelchair with 1 assist from toilet, (R1) sat to quickly, not sitting far enough back and slid off front of chair. Immediate Intervention: Resident was positioned for comfort, taking pressure off knee. Assisted up to wheelchair with two assists. Able to bear weight without difficulty Notification: MD (physician) notified of initial fall. Orders received to get Stat (Now) X-ray for Right Lower Extremity. Power of Attorney notified. R1's progress note by V15, Licensed Practical Nurse (LPN) dated 1/26/2020 at 9:59PM documents Critical x-ray results called in from (X-Ray provider) re: (regarding) Right knee. Acute displaced fracture of distal lateral femoral condyle/shaft. Not knee replacement, this is a new fracture. No fracture seen with hip. results faxed to facility. Copy placed in DON's (Director of Nursing) box. (computer based medical service) notified of results via text and sent image. Per (medical service) On call, (V16), Medical Doctor, send (R1) to emergency room due to displaced fracture. (V16) does not want any further possible shifting to take place. R1's hospital record printed 2/18/2020 documents R1's right femoral fracture was surgically repaired on 1/26/2020 by V17, Orthopedic Surgeon. On 2/18/2020 at 10:52AM R1 was seated in a wheelchair in room. R1 was wearing a splint from left thigh to left ankle. R1 stated I fell in the bathroom of the room I was in before I was in the hospital. (V9) CNA got me off the toilet and did not use a gait belt or the sit to stand lift. I went to turn using my wheelchair to lean on. I couldn't get back far enough to sit in the wheelchair and I fell on my knees. I was in a lot of pain. (V9) called (V12), certified Nurse's Aide (CNA) and (V6), Licensed Practical Nurse (LPN). They stood me up. It really hurt, but once I sat down it was a little better. Then at dinner I could hardly stand it and (V6) called and got an X-ray. I went to the hospital and (V17) did surgery to fix the fracture. Now I can't stand up at all and it still hurts some. I told (V9) I needed the lift that day, but (V9) didn't listen (V9) told me that I could stand up. R1's MDS dated [DATE] documents R1 as completely cognitively intact. On 2/18/2020 V12, Certified Nurse's Aide (CNA) stated The night (R1) fell (V9) called me to (R1's) room to help. (R1) was laying on the floor in the bathroom. (V6), Licensed Practical Nurse (LPN) came in and we got (R1) to stand and sit in the wheelchair. (V9) told me (V9) was transferring (R1) to the wheelchair and dropped (R1). (R1) was having pain. I think then we were always using the sit to stand (lift) for (R1). On 2/18/2020 at 12:30PM V10, Certified Nurse's Aide stated I have worked here about a year. Before (R1) broke (R1's) leg we always used a sit to stand for (R1) On 2/18/2020 at 12:30PM V11 Certified Nurse's Aide stated If (R1) says (R1) needed at sit to stand (Prior to fracture) we used it. (R1) has always been able to tell us what (R1) needs. On [DATE]20 at 8:51AM V9 stated on the evening (R1) fell (R1) rang for help. I went in and (R1) needed to use the bathroom. (R1) could stand and pivot using the grab bar. (R1) was able to get on the toilet, but when I went to help (R1) go from the toilet to the wheelchair (R1) missed the wheelchair and went down to the floor on (R1's) knees. If (R1) is weak we would use the sit to stand lift. When asked if R1 needed a walker V9 stated No we never have used a walker for (R1) that I know of. On [DATE]20 at 2:30PM V4, RN (Registered Nurse) Care Plan Coordinator stated If I had read the care plan before (R1) fell I'd have thought we needed to use a walker if (R1) was being transferred from the toilet. The thing is the bathroom for the room (R1) was in before the fall is so small that you couldn't get a walker in there let alone a sit to stand. When asked how that kind of information gets on the care plan V4 stated The CNAs would tell a nurse, then me or another nurse would assess (R1) and we would update the care plan. When asked if an assessment was done for the space issue in R1's bathroom V4 stated not that I'm aware of. On 2/20/2020 at 7:30AM V17, Orthopedic Surgeon stated I can certainly say that this fracture of (R1's) femur was caused by the fall. This type of fracture is generally caused by trauma. The fact that (R1) has an old knee replacement has nothing to do with this new fracture. V17 verified that a plate and screws were implanted to stabilize R1's right femur. The facility's policy Transfers issued 8/2017 revised 8/2018, 7/2019,1/2020 states Policy: To promote safe transfer for the residents, as well as the staff, gait belts, (Sling type mechanical lifts) and/or sit to stand (lifts) 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. It is the responsibility of the Director of Nursing/Designee to ensure that adequate training is provided to all nursing staff on the proper use of gait belts, (Sling type mechanical lifts) and/or sit to stand (lifts).

Based on record review, interview and observation, the facility failed to develop/implement fall prevention interventions and supervise a resident (R1) that was known to have a history of falls and at risk for additional falls. This failure resulted in R1 falling and sustaining multiple fractures and lacerations with hospitalization . R1 is one of three residents reviewed for supervision and falls in the sample of seven. Findings include: R1's cumulative [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documents R1 with an admitted [DATE], This same MDS documents R1 being severely cognitively impaired, needing extensive assist of two or more staff in transferring. R1 is not able to stabilize self, needing staff assistance when moving from surface to surface or from a sitting position to standing. R1's Fall Risk Evaluation dated 11/25/19 documents R1 having one to two falls within the past three months, chair bound, requiring restraints and assist with elimination, balance problems while standing or walking. The assessment documents R1 at risk for falls. Physical Therapy Notes dated 12/20/19 document that R1 was less than 25 percent of the time able to transfer safely per self. R1's Nursing Notes dated 1/8/2020 document that R1 was observed on the floor lying on R1's right side of a stationary chair. Certified Nursing Assistant (V13) reported that V13 was walking down hall and saw resident get up from R1's chair to self transfer to wheelchair, took one step and fell . Bleeding was noted to right forehead and right ear. R1 complained of pain to bilateral lower extremities and hips. The physician was notified and an order to send R1 to the emergency room was received. R1's emergency room Reports dated 1/8/2020 document the following: Chief Complaint: dated 1/8/2020 (R1) is a [AGE] year old who presented to the ED (Emergency Department) after a ground level fall at (facility). (R1) is a poor historian and all information was obtained from previous charting and (facility) staff. Per the (facility staff) (R1) was reported to have an unwitnessed fall. (R1) did have a ground level fall. This presumably happened when (R1) tried to transfer herself from (R1's) chair independently. (R1) came to ED and complained about bilateral hip pain and with increase pain when attempting to move her legs. This was not a witnessed fall and therefore it is unclear if (R1) lost consciousness. (R1) was found to have a small laceration on the right forehead and skin tear on the right shoulder and laceration of the right ear. Repairs to lacerations were made in the ED. (R1) admitted to the Medical Floor. Hospital Radiographs dated 1/8/2020 and reviewed by V14, Radiologist document the following: Exam: X-ray elbow minimum 3 Views right Indications: Unwitnessed fall with right shoulder, elbow and leg pain. History of [MEDICAL CONDITION]. Impression: 1. Acute Supracondylar Simple Fracture of Right Distal Humerus. Exam: X-ray Hip 2 views Bilateral with AP (anterior/posterior) Pelvis Indications: Unwitnessed fall with right shoulder, elbow, and leg pain. History of [MEDICAL CONDITION]. Impression: 1. Fractures of the right pubic bone extending into the superior pubic ramus as well as likely the inferior pubic ramus., both of which appear acute. Associated sacral fractures cannot be excluded. Consider pelvic CT (Computerized Topography). 2. [MEDICAL CONDITION] changes of the lower lumbar spine, bilateral hips, and symphysis pubis. R1's Computerized Topography (CT) Reports dated 1/8/2020 and reviewed by V14, Radiologist document the following: Exam: CT Abdomen Pelvis with out contrast: Indications: Unwitnessed fall today with pain in right shoulder, elbow, and right leg. Unable to raise right arm. Assess for abdominal/pelvic trauma. Findings: There is a minimally displaced [MEDICAL CONDITION] posteriolateral rib #10. Additional minimally displaced fractures of the left posterior rib #11 in two sites, one more laterally and one at the costovertebral junction. Additional minimal displaced fracture of T12 (12th [MEDICATION NAME] vertebrae of spine) on the left at the costovertebral junction. These fractures all appear acute. Interdevelopment of an acute anterior compression fracture of L1 (1st Lumbar vertebrae of spine) with approximately 40 percent loss of vertebral body height, with mild retropulsion of fracture fragments at this level and resultant mild spinal canal stenosis. As seen on comparison pelvic radiographs of the same date (1/8/2020), there is a mildly displaced [MEDICAL CONDITION] pubic bone extending into the superior pubic ramus. Additional nondisplaced [MEDICAL CONDITION] pubic ramus. A vertically oriented insufficiency [MEDICAL CONDITION] hemisacrum is apparent, with mild comminution of fracture fragments anteriorly adjacent to the SI (Sacroiliac) joint. Multilevel [MEDICAL CONDITION] changes of the thoracolumbar spine, particularly affecting the lower lumbar facet joints. Mild [MEDICAL CONDITION] changes of the bilateral hips, slightly greater on the left. Mild osteitis pubis. Mild [MEDICAL CONDITION] changes of the bilateral SI joints. Impression: 1. Right hemipelvic and hemisacum fractures. 2. Acute fractures of the left posterior ribs #10 through 12 with compound fracture of left posterior rib #11. 3. Acute compression [MEDICAL CONDITION] vertebral body with mild retropulsion of fracture fragments and spinal canal stenosis. Hospital Discharge Orders dated 1/13/2020 document R1 with a right arm cast, sutures to lacerations and weightbearing as tolerated. Nursing Notes dated 1/13/2020 document R1 returning from the hospital via facility transport and was assisted by two staff into the building. On 1/16/2020 at 12:30 pm, V9 Registered Nurse/Care Plan Coordinator and Minimum Data Set Coordinator confirmed the facility was aware that R1 had been self-transferring multiple times in the facility and R1 was at risk for falls. V9 confirmed there were no fall preventions in place on R1's Care Plan on 1/8/2020. V9 stated R1 was documented as a two person assist on assessment for transfers. V9 also confirmed that R1 was left unsupervised on 1/8/2020 in the facility solarium on the west side of the building. On 1/16/2020 at 12:45 pm, V10 Therapy Director stated V10 had been the primary therapist working with R1 and stated (R1) was not consistently safe to transfer independently. On 1/16/2020 at 1:00 pm, R1 was sitting up in bed. R1's head was lowered and appeared to be sleeping. R1's right arm was in a sling with a cast applied. R1's right side of forehead, orbital region, extending to the nose, cheek and right ear had purple bruising. R1 was not able to be interviewed. On 1/16/2020 at 1:08 pm V11, Licensed Practical Nurse/Primary Care for R1 stated R1 has never been safe to transfer herself. On 1/16/2020 at 1:15 pm V2 Director of Nursing confirmed that R1 had been left unsupervised in the solarium. V2 stated probably after attending an activity. V2 confirmed that R1 had been seen previous to the fall self-transferring several times. V2 also confirmed that R1 should not have been left unsupervised knowing her fall history, fall risk and staff observations of self-transfer. The facility policy titled Fall Prevention dated 8/2019 documents the following: To provide guidelines on preventing resident falls or injury. Review hospital records for fall related information. Interview family or resident for history of prior falls, frequency of falls. Common cause of falls. Complete the fall assessment initially on admission, then quarterly. A score of 14 or above indicates resident at risk for falls. Initiate risk reducing interventions. Verify and obtain orders as needed. Develop admission care plan. Complete Minimum Data Set. Complete Resident Assessment Protocol. Identify problem or need. State measurable goal. Specify target date. List interventions. Provide resident, family education as appropriate. Provide ongoing risk reducing interventions. Initiate physician orders [REDACTED]. Provide ongoing evaluation of resident response to interventions. Shift to shift report. 24 hour report. Interdisciplinary Meeting. Quality Improvement Process. Review and discuss potential root cause of fall. Complete follow-up event documentation as clinically indicated. New or changes in current interventions will be discussed by the interdisciplinary team and the care plan will be updated accordingly.

Based on interview and record review, the facility failed to ensure physician's orders were implemented for one of four residents (R67) reviewed for hospitalization s in the sample of 19. R67 returned to the facility from being hospitalized for [REDACTED].This failure resulted in R67 receiving 45 doses of [MEDICATION NAME] in error and R67 to develop an ongoing, worsening Acute Kidney Injury (AKI) due to Dehydration from continued [MEDICATION NAME] use and a Urinary Tract Infection. Findings include: R67's Medication Review Report dated (MONTH) (YEAR) documents R67's [DIAGNOSES REDACTED]. This report also documents an order for [REDACTED]. There is no documentation in R67's medical record of history of [MEDICAL CONDITION] or [MEDICAL CONDITION]. R67's Basic Metabolic Panel (BMP) laboratory results (labs) sheet dated 3/14/17 documents R67's labs that are within reference range as follows: Blood Urea Nitrogen (BUN) 21 mg (milligrams)/dL (deciliter) Creatinine (Cr) 0.93 mg/dL Glomerular Filtration Rate > = (greater than or equal to) 60 mL (milliliters)/min (minute)/1.73 sq (square) m (meters). This laboratory sheet also documents the reference ranges for the labs as follows: BUN 8 - 26 mg/dL Cr 0.70 - 1.30 mg/dL GFR > = 60 mL/min/1.73 sq m. R67's Hospital Discharge Summaries dated 3/27/18 document R67 was sent to the emergency roiagnom on [DATE] and was found to be clinically dehydrated. The summary also documents, Following overnight hydration, patient (R67) is more awake and oriented this morning. This summary also documents R67 had an acute kidney injury, [MEDICATION NAME] and [MEDICATION NAME] (HCTZ), (Diuretic) were held and intravenous fluids were administered to R67. This summary documents R67's creatinine level had improved. This Summary documents medications at discharge including Stopped [MEDICATION NAME] 40mg tabs. R67's BMP laboratory sheet documents lab results as follows: 3/26/18 (upon arrival to the emergency room ) BUN 34 mg/dl Cr 1.42mg/dl GFR 49 3/27/18 (morning of R67's discharge back to the facility after stopping [MEDICATION NAME] and administering intravenous fluids for hydration) BUN 23 mg/dL Cr 1.08 GFR > (greater than) 60 R67's Progress Notes dated 3/27/18 at 8:36pm document R67 returned from the hospital at 7:00pm. Medication list updated. R67's After Visit Summary dated 3/27/18 document orders including, Your medications have changed, STOP taking: [MEDICATION NAME] 40mg tabs (tablets). The orders to discontinue the [MEDICATION NAME] medications were not transcribed or carried out by the facility. On 4/19/18 at 12:30pm, V2, Director of Nursing stated he spoke to V17, Licensed Practical Nurse (LPN) who stated V17 overlooked the order to stop the [MEDICATION NAME]. V2 stated that the orders to discontinue the [MEDICATION NAME] were overlooked and not transcribed or carried out by the facility and that they should have been. On 4/24/18 2:30pm V17, LPN, stated a nurse puts the orders in from the hospital and a second nurse from another shift double checks the orders. V17 stated when a resident comes back from the hospital, the nurses are to compare the orders from the hospital with what the resident was on at the facility prior to the hospital and update the orders at the facility with any new orders. V17 stated she would call the physician for clarification of an order if she saw a red flag or needed clarification, but this was just human error and she overlooked the order to discontinue the [MEDICATION NAME] that was on the hospital discharge paperwork. V17 stated she didn't know if there is documentation of the double check of orders anywhere. V17 stated R67's orders from previous stay prior to hospitalization were still active, since R67 was not totally discharged from the electronic medical record system, so R67's medications from prior to hospitalization were still active. V17 stated she was unaware of the order to discontinue the [MEDICATION NAME] upon readmission for R67 until V2, Director of Nursing called her in to the office and showed her the order and told her of the error. R67's Progress Notes dated 3/28/18 at 1:29pm by V5, Nurse Practitioner (NP) document [MEDICATION NAME] therapy was discontinued at discharge (3-27-18). R67's (MONTH) (YEAR) Medication Administration Record [REDACTED]. R67's (MONTH) (YEAR) MAR indicated [REDACTED]. R67 continued to receive the [MEDICATION NAME] 40mg BID in error for a total of 45 doses. R67's Progress Notes dated 4/2/18 by V5, Nurse Practitioner (NP) document staff reported concerns of lethargy and R67 had been compliant with cares which is atypical for R67. This note documents V5 would order laboratory blood tests, including BMP. R67's BMP laboratory result sheet dated 4/4/18 documents decline in kidney function with laboratory results as follows: BUN 28 Cr 1.45 GFR 47 R67's Medication Review Report dated (MONTH) (YEAR) document orders dated 4/10/18 for a BMP to be drawn on 4/11/18. Laboratory BMP blood draw tests V5, NP had requested on 4/10/18 to be completed on 4/11/18 were not completed until 4/16/18 with results documenting ongoing decline in kidney function as follows: BUN 27 Cr 1.70 GFR 39 R67's Urinalysis with Urine Culture laboratory sheets dated 4/17/18 documents results with reference ranges in parentheses as follows: White Blood Cell (WBC) Esterase- 3+ (Negative) Urine Blood- 2+ (more than) (Negative) Urinalysis Clarity- Cloudy WBC- Packed (Negative, 0-5/hpf (high power field)) Urine Red Blood Cells (RBC)- 6-10 (Negative, 0-5/hpf) Bacteria- Moderate (Negative/hpf) On 4/19/18 at 2:20pm, V21, R67's hospital physician who provided care of R67 during the hospitalized from [DATE]-3/27/18 for Acute Kidney Injury and Dehydration stated the orders upon discharge were for the facility to discontinue [MEDICATION NAME] because of the AKI due to R67's Dehydration. V21 stated the facility should have followed the orders to discontinue the [MEDICATION NAME] upon R67's return to the facility on [DATE]. V21 stated continuing the [MEDICATION NAME] after discharge could jeopardize R67's renal function of which was back to baseline upon discharge from the hospital on [DATE]. On 4/19/18 at 11:10am, V5, Nurse Practitioner (NP) stated R67 has been declining since the last admission on 3/27/18. V5 stated R67 does not have a history of [MEDICAL CONDITION] or [MEDICAL CONDITION]/Impairment. V5 stated she told R67 she had concerns R67's kidneys were shutting down and that staff had stated R67's urine was pretty strong smelling. V5 stated she did not restart R67's [MEDICATION NAME] and it should not have been restarted. V5 stated she was unaware R67 was receiving the [MEDICATION NAME] medication as the facility was to be following the orders from the hospital to discontinue the [MEDICATION NAME]. V5 stated the [MEDICATION NAME] was never discontinued as ordered and that it should have been. V5 stated I just went in and discontinued the [MEDICATION NAME] order for (R67). V5 stated she thought R67's kidney function was declining for other reasons until she was asked by the state surveyor about R67's current orders and documentation of administration of [MEDICATION NAME] 40mg by mouth twice daily since readmission to the facility for a total of 45 doses. V5 stated [MEDICATION NAME] can cause an increase in Creatinine levels and impaired renal function. On 4/23/18 at 11:35am, V22, R67's Primary Care Physician (PCP) stated R67 does not have a history of [MEDICAL CONDITION] or [MEDICAL CONDITION]/Impairment. V22 stated he was not notified of the incidents of R67's declining kidney function or that there were 45 doses of [MEDICATION NAME] given in error. V22 stated the facility continuing to administer the [MEDICATION NAME] to R67 would definitely cause the acute kidney injury for R67, especially at such a high dose ([MEDICATION NAME] 40mg by mouth twice daily). V22 stated R67 receiving 45 doses of [MEDICATION NAME] 40mg after it was discontinued for Acute Kidney Injury (AKI) is definitely a problem and that the orders upon readmission to the facility on [DATE] clearly document to hold the [MEDICATION NAME]. V22 said the facility continuing to administer the [MEDICATION NAME] to R67 caused R67's ongoing decline in renal function and put R67 at a high risk for permanent kidney damage. He said R67's kidney function would absolutely decline if the facility continued to administer the [MEDICATION NAME] and that the continued administration of the [MEDICATION NAME] is the probable cause of R67's AKI. He also stated the resident now has a Urinary Tract Infection which is also a problem from the dehydration from the continued administration of [MEDICATION NAME]. V22 stated R67's ongoing decline in renal function was avoidable if the [MEDICATION NAME] would have been stopped as ordered.

Based on observation, interview and record review, the facility failed to ensure physician's orders related to diuretic use were implemented for one of four residents (R67) reviewed for hospitalization s in the sample of 19. R67 returned to the facility from being hospitalized for [REDACTED]. The facility also failed to ensure fluids were within reach and encouraged for hydration of the resident. This failure resulted in R67 receiving 45 doses of [MEDICATION NAME] in error and R67 to develop an ongoing, worsening Acute Kidney Injury (AKI) due to Dehydration from continued [MEDICATION NAME] use and a Urinary Tract Infection. Findings include: R67's Medication Review Report dated (MONTH) (YEAR) documents R67's [DIAGNOSES REDACTED]. This report also documents an order for [REDACTED]. There is no documentation in R67's medical record of history of [MEDICAL CONDITION] or [MEDICAL CONDITION]. R67's Basic Metabolic Panel (BMP) laboratory results (labs) sheet dated 3/14/18 documents R67's labs that are within reference range as follows: Blood Urea Nitrogen (BUN) 21 mg (milligrams)/dL (deciliter); Creatinine (Cr) 0.93 mg/dL; and Glomerular Filtration Rate (GFR) > =(greater than or equal to) 60 mL (milliliters)/min (minute)/1.73 sq (square) m (meters). This laboratory sheet also documents the reference ranges for the labs as follows: BUN 8 - 26 mg/dL; Cr 0.70 - 1.30 mg/dL; and GFR > = 60 mL/min/1.73 sq m. R67's Hospital Discharge Summaries dated 3/27/18 document R67 was sent to the emergency roiagnom on [DATE] and was found to be clinically dehydrated. This summary documents R67's Computed Tomography (CT) of the head showed questionable subacute ischemic changes in the right caudate and internal capsule besides multiple old infarcts but no bleed. The summary also documents, Following overnight hydration, patient (R67) is more awake and oriented this morning. This summary also documents R67 had an acute kidney injury, [MEDICATION NAME] and [MEDICATION NAME] (HCTZ), (Diuretic) were held and intravenous fluids were administered to R67. This summary documents R67's creatinine level had improved. This Summary also documents medications at discharge including Stopped [MEDICATION NAME] 40mg tabs (tablets). R67's BMP laboratory sheet documents lab results as follows: 3/26/18 (upon arrival to the emergency room ) BUN 34 mg/dl; Cr 1.42mg/dl; and GFR 49 3/27/18 (morning of R67's discharge back to the facility after stopping [MEDICATION NAME] and administering intravenous fluids for hydration) BUN 23 mg/dL; Cr 1.08; and GFR > (greater than) 60 R67's Progress Notes dated 3/27/18 at 8:36pm document R67 returned from the hospital at 7:00pm. Medication list updated. R67's After Visit Summary dated 3/27/18 document orders including, Your medications have changed, STOP taking: [MEDICATION NAME] 40mg tabs. The orders to discontinue the [MEDICATION NAME] medications were not transcribed or carried out by the facility. On 4/19/18 at 12:30pm, V2, Director of Nursing stated he spoke to V17, Licensed Practical Nurse (LPN) who stated V17 overlooked the order to stop the [MEDICATION NAME]. V2 stated that the orders to discontinue the [MEDICATION NAME] were overlooked and not transcribed or carried out by the facility and that they should have been. On 4/24/18 2:30pm V17, LPN, stated a nurse puts the orders in from the hospital and a second nurse from another shift double checks the orders. V17 stated when a resident comes back from the hospital, the nurses are to compare the orders from the hospital with what the resident was on at the facility prior to the hospital and update the orders at the facility with any new orders. V17 stated she would call the physician for clarification of an order if she saw a red flag or needed clarification, but this was just human error and she overlooked the order to discontinue the [MEDICATION NAME] that was on the hospital discharge paperwork. V17 stated she didn't know if there is documentation of the double check of orders anywhere. V17 stated R67's orders from previous stay prior to hospitalization were still active, since R67 was not totally discharged from the electronic medical record system, so R67's medications from prior to hospitalization were still active. V17 stated she was unaware of the order to discontinue the [MEDICATION NAME] upon readmission for R67 until V2, Director of Nursing called her in to the office and showed her the order and told her of the error. R67's Progress Notes dated 3/28/18 at 1:29pm by V5, Nurse Practitioner (NP) document [MEDICATION NAME] therapy was discontinued at discharge (3-27-18). R67's (MONTH) (YEAR) Medication Administration Record [REDACTED]. R67's (MONTH) (YEAR) MAR indicated [REDACTED]. R67 continued to receive the [MEDICATION NAME] 40mg BID in error for a total of 45 doses. R67's Progress Notes dated 3/28/18 at 1:50pm document V20, Registered Dietician (RD) nutritional evaluation for readmission. This note does not document R67's hydration needs due to the use of diuretics and R67's hospitalization for Acute Kidney Injury with Dehydration on 3/26/18. R67's Progress Notes dated 4/2/18 by V5, Nurse Practitioner (NP) document staff reported concerns of lethargy and R67 had been compliant with cares which is atypical for R67. This note documents V5 would order laboratory blood tests, including BMP and staff are to ensure R67 is drinking fluids. R67's BMP laboratory result sheet dated 4/4/18 documents decline in kidney function with laboratory results as follows: BUN 28; Cr 1.45; and GFR 47 R67's Medication Review Report dated (MONTH) (YEAR) document orders dated 4/10/18 for a BMP to be drawn on 4/11/18. Laboratory BMP blood draw tests V5, NP had requested on 4/10/18 to be completed on 4/11/18 were not completed until 4/16/18 with results documenting ongoing decline in kidney function as follows: BUN 27; Cr 1.70; and GFR 39 R67's Urinalysis with Urine Culture laboratory sheets dated 4/17/18 documents results with reference ranges in parentheses as follows: White Blood Cell - WBC Esterase: 3+ (Negative) Urine Blood: 2+ (Negative) Urinalysis Clarity: Cloudy (Clear) WBC: Packed (Negative, 0-5/hpf (high power field)) Urine Red Blood Cells - RBC: 6-10 (Negative, 0-5/hpf) Bacteria: Moderate (Negative/hpf) R67's Care Plans dated 2/5/18 documents R67 receives a diuretic medication daily, but does not document potential dehydration focus or goals and/or interventions related to R67's hydration needs. The following observations were made throughout the survey: 4/16/18 11:35 AM R67 was in R67's room. R67's lips and skin were very dry and flaky. There were no fluids within reach of R67. 4/16/18 12:48 PM R67 was in the dining room. R67's clear cup for water was upside down on the table. R67's clear cup remained upside down, unused at this meal. R67 received one cup of hot cocoa of which R67 drank 100% with no additional fluids being offered. 4/16/18 01:30 PM R67 was sitting up in wheelchair in room. R67 did not have fluids within reach. There were three bottles of water located on the bedside table which was positioned two feet behind the R67. 04/18/18 11:38 AM R67 was in bed. R67's bedside table with three unopened and one 2/3 full water bottles were on the bedside table. V16, Registered Nurse (RN) was in R67's room and left room without ensuring R67's fluids were within reach. 4/19/18 4:18 PM R67 was up in the wheelchair in R67's room. R67 stated R67 was not feeling well. R67's lips and skin were dry and flaky. There were three full unopened water bottles and one water bottle 1/3 full on R67's bedside table in addition to a cup with lid that was positioned three feet away from R67. Res with left foot rest on and right leg dependent to floor with foot on floor. 4/24/18 8:40 AM R67 was in bed. R67's head of bed was elevated. There were two full bottles of water on the bedside table located at the end of R67's bed and not in reach for R67. R67's Care Plans dated 4/3/18 do not document/address R67's at risk for dehydration. R67's AKI, dehydration were not identified on R67's Minimum Data Set ((MDS) dated [DATE]. On 4/19/18 at 2:20pm, V21, R67's hospital physician who provided care of R67 during the hospitalized from [DATE]-3/27/18 for Acute Kidney Injury and Dehydration stated the orders upon discharge were for the facility to discontinue [MEDICATION NAME] because of the AKI due to R67's Dehydration. V21 stated the facility should have followed the orders to discontinue the [MEDICATION NAME] upon R67's return to the facility on [DATE]. V21 stated continuing the [MEDICATION NAME] after discharge could jeopardize R67's renal function of which was back to baseline upon discharge from the hospital on [DATE]. On 4/19/18 at 11:10am, V5, Nurse Practitioner (NP) stated R67 has been declining since the last admission on 3/27/18. V5 stated R67 does not have a history of [MEDICAL CONDITION] or [MEDICAL CONDITION]/Impairment. V5 stated she has been telling staff to make sure R67 has water within reach due to risk for dehydration and to help R67 with hydration by encouraging and assisting as needed to drink fluids. V5 stated she told R67 she had concerns R67's kidneys were shutting down and that staff had stated R67's urine was pretty strong smelling. V5 stated she did not restart R67's [MEDICATION NAME] and it should not have been restarted. V5 stated she was unaware R67 was receiving the [MEDICATION NAME] medication as the facility was to be following the orders from the hospital to discontinue the [MEDICATION NAME]. V5 stated the [MEDICATION NAME] was never discontinued as ordered and that it should have been. V5 stated I just went in and discontinued the [MEDICATION NAME] order for R67. V5 stated [MEDICATION NAME] can cause an increase in Creatinine levels and impaired renal function. V5 stated R67 had been resistive to hospice but after V5's discussion related to R67's declining kidney function agreed to a hospice consult. V5 stated she placed a hospice consult due to R67's decline and kidney function concerns. On 4/23/18 at 11:35am, V22, R67's Primary Care Physician (PCP) stated R67 does not have a history of [MEDICAL CONDITION] or [MEDICAL CONDITION]/Impairment. V22 stated he was not notified of the incidents of R67's declining kidney function or that there were 45 doses of [MEDICATION NAME] given in error. V22 stated the facility continuing to administer the [MEDICATION NAME] to R67 would definitely cause the acute kidney injury for R67, especially at such a high dose ([MEDICATION NAME] 40mg by mouth twice daily). V22 stated R67 receiving 45 doses of [MEDICATION NAME] 40mg after it was discontinued for Acute Kidney Injury (AKI) is definitely a problem and that the orders upon readmission to the facility on [DATE] clearly document to hold the [MEDICATION NAME]. V22 stated the facility continuing to administer the [MEDICATION NAME] to R67 caused R67's ongoing decline in renal function and put R67 at a high risk for permanent kidney damage. V22 stated R67's kidney function would absolutely decline if the facility continued to administer the [MEDICATION NAME] and that the continued administration of the [MEDICATION NAME] is the probable cause of R67's AKI. V22 also stated the resident now has a Urinary Tract Infection which is also a problem from the dehydration from the continued administration of [MEDICATION NAME]. V22 stated R67's ongoing decline in renal function was avoidable if the [MEDICATION NAME] would have been stopped/discontinued as ordered.

Failures at this level required more than one deficient practice statement. A.) Based on interview and record review, the facility failed to ensure physician's orders were implemented for one of four residents (R67) reviewed for hospitalization s in the sample of 19. R67 returned to the facility from being hospitalized for [REDACTED]. This failure resulted in R67 receiving 45 doses of [MEDICATION NAME] in error and R67 to develop an ongoing, worsening Acute Kidney Injury due to Dehydration from continued [MEDICATION NAME] use and a Urinary Tract Infection. B.) Based on observation, interview and record review, the facility failed to ensure the appropriate preventative dry skin treatment was in place per physician's orders for one of three residents (R67) reviewed for skin care needs in the sample of 19. Findings include: a.) R67's Medication Review Report dated (MONTH) (YEAR) documents R67's [DIAGNOSES REDACTED]. This report also documents an order for [REDACTED]. R67's Basic Metabolic Panel (BMP) laboratory results sheet dated 3/14/18 documents R67's labs that are within reference range as follows: Blood Urea Nitrogen (BUN) 21 mg (milligrams)/dL (deciliter); Creatinine (Cr) 0.93 mg/dL; Glomerular Filtration Rate (GFR) > = 60 mL (milliliters)/min (minute)/1.73 sq (square) m (meters). This laboratory sheet also documents the reference ranges (normal) for the labs as follows: BUN 8 - 26 mg/dL; Cr 0.70 - 1.30 mg/dL; and GFR > = 60 mL/min/1.73 sq m. R67's Hospital Discharge Summaries dated 3/27/18 document R67 was sent to the emergency roiagnom on [DATE] and was found to be clinically dehydrated. This summary documents R67's Computed Tomography (CT) of the head showed questionable subacute ischemic changes in the right caudate and internal capsule besides multiple old infarcts but no bleed. The summary also documents, Following overnight hydration, patient (R67) is more awake and oriented this morning. This summary also documents R67 had an acute kidney injury, [MEDICATION NAME] and [MEDICATION NAME] (HCTZ), (Diuretic) were held and intravenous fluids were administered to R67. This summary documents R67's creatinine level had improved. This Summary also documents medications at discharge including Stopped [MEDICATION NAME] 40mg tabs. R67's BMP laboratory sheet documents lab results as follows: 3/26/18 (upon arrival to the emergency room ) BUN 34 mg/dl; Cr 1.42mg/dl; and GFR 49 3/27/18 (morning of R67's discharge back to the facility after stopping [MEDICATION NAME] and administering intravenous fluids for hydration) BUN 23 mg/dL; Cr 1.08; and GFR >60 R67's Progress Notes dated 3/27/18 at 8:36pm document R67 returned from the hospital at 7:00pm. Medication list updated. R67's After Visit Summary dated 3/27/18 document orders including, Your medications have changed, STOP taking: [MEDICATION NAME] 40mg tabs. The orders to discontinue the [MEDICATION NAME] medications were not transcribed or carried out by the facility. On 4/19/18 at 12:30pm, V2, Director of Nursing stated he spoke to V17, Licensed Practical Nurse (LPN) who stated V17 overlooked the order to stop the [MEDICATION NAME]. V2 stated that the orders to discontinue the [MEDICATION NAME] were overlooked and not transcribed or carried out by the facility and that they should have been. On 4/24/18 2:30pm V17, LPN, stated a nurse puts the orders in from the hospital and a second nurse from another shift double checks the orders. V17 stated when a resident comes back from the hospital, the nurses are to compare the orders from the hospital with what the resident was on at the facility prior to the hospital and update the orders at the facility with any new orders. V17 stated she would call the physician for clarification of an order if she saw a red flag or needed clarification, but this was just human error and she overlooked the order to discontinue the [MEDICATION NAME] that was on the hospital discharge paperwork. V17 stated she didn't know if there is documentation of the double check of orders anywhere. V17 stated R67's orders from previous stay prior to hospitalization were still active, since R67 was not totally discharged from the electronic medical record system, so R67's medications from prior to hospitalization were still active. V17 stated she was unaware of the order to discontinue the [MEDICATION NAME] upon readmission for R67 until V2, Director of Nursing called her in to the office and showed her the order and told her of the error. R67's Progress Notes dated 3/28/18 at 1:29pm by V5, Nurse Practitioner (NP) document [MEDICATION NAME] therapy was discontinued at discharge. R67's (MONTH) (YEAR) Medication Administration Record [REDACTED]. R67's (MONTH) (YEAR) MAR indicated [REDACTED]. R67 continued to receive the [MEDICATION NAME] 40mg two times a day in error for a total of 45 doses. R67's Progress Notes dated 4/2/18 by V5, Nurse Practitioner (NP) document staff reported concerns of lethargy and R67 had been compliant with cares which is atypical for R67. This note documents V5 would order laboratory blood tests, including BMP and staff are to ensure R67 is drinking fluids. R67's BMP laboratory result sheet dated 4/4/18 documents decline in kidney function with laboratory results as follows: BUN 28; Cr 1.45; and GFR 47 R67's Medication Review Report dated (MONTH) (YEAR) document orders dated 4/10/18 for a BMP to be drawn on 4/11/18. Laboratory BMP blood draw tests V5, NP had requested on 4/10/18 to be completed on 4/11/18 were not completed until 4/16/18 with results documenting ongoing decline in kidney function as follows: BUN 27; Cr 1.70; and GFR 39 R67's Urinalysis with Urine Culture laboratory sheets dated 4/17/18 documents results with reference ranges in parentheses as follows: White Blood Cell - WBC Esterase: 3+ (Negative) Urine Blood: 2+ (Negative) Urinalysis Clarity: Cloudy (Clear) WBC: Packed (Negative, 0-5/hpf (high power field)) Urine Red Blood Cells - RBC: 6-10 (Negative, 0-5/hpf) Bacteria: Moderate (Negative/hpf) On 4/19/18 at 2:20pm, V21, R67's hospital physician who provided care of R67 during the hospitalized from [DATE]-3/27/18 for Acute Kidney Injury and Dehydration, stated the orders upon discharge were for the facility to discontinue [MEDICATION NAME] because of the AKI due to R67's Dehydration. V21 stated the facility should have followed the orders to discontinue the [MEDICATION NAME] upon R67's return to the facility on [DATE]. V21 stated continuing the [MEDICATION NAME] after discharge could jeopardize R67's renal function of which was back to baseline upon discharge from the hospital on [DATE]. On 4/19/18 at 11:10am, V5, Nurse Practitioner (NP) stated she told R67 she had concerns R67's kidneys were shutting down and that staff had stated R67's urine was pretty strong smelling. V5 stated she did not restart R67's [MEDICATION NAME] and it should not have been restarted. V5 stated she was unaware R67 was receiving the [MEDICATION NAME] medication as the facility was to be following the orders from the hospital to discontinue the [MEDICATION NAME]. V5 stated the [MEDICATION NAME] was never discontinued as ordered and that it should have been. V5 stated I just went in and discontinued the [MEDICATION NAME] order for R67. V5 stated [MEDICATION NAME] can cause an increase in Creatinine levels and impaired renal function. On 4/23/18 at 11:35am, V22, R67's Primary Care Physician (PCP) stated he was not notified of the incidents of R67's declining kidney function or that there were 45 doses of [MEDICATION NAME] given in error. V22 stated the facility continuing to administer the [MEDICATION NAME] to R67 would definitely cause the acute kidney injury for R67, especially at such a high dose ([MEDICATION NAME] 40mg by mouth twice daily). V22 stated R67 receiving 45 doses of [MEDICATION NAME] 40mg after it was discontinued for Acute Kidney Injury (AKI) is definitely a problem and that the orders upon readmission to the facility on [DATE] clearly document to hold the [MEDICATION NAME]. V22 said the facility continuing to administer the [MEDICATION NAME] to R67 caused R67's ongoing decline in renal function and put R67 at a high risk for permanent kidney damage. He said R67's kidney function would absolutely decline if the facility continued to administer the [MEDICATION NAME] and that the continued administration of the [MEDICATION NAME] is the probable cause of R67's AKI. He also stated the resident now has a Urinary Tract Infection which is also a problem from the dehydration from the continued administration of [MEDICATION NAME]. V22 stated R67's ongoing decline in renal function was avoidable if the [MEDICATION NAME] would have been stopped as ordered. b.) On 04/18/18 11:12 AM V16, (Wound Nurse) stated to R67, you (R67) need lotion to your legs and bilateral lower legs were noted to have dry thick scaly skin. V16 stated she could not remember if the facility was using Dermacept or another lotion for R67's bilateral lower legs. V16 stated she would have to look it up. V16 then stated she thought the facility was using R67's personal lotion that was brought in for R67. V16 then searched through R67's drawers and pulled a bottle of Diabetics dry relief lotion from under other personal care items in R67's bottom drawer in R67's room and stated, this is what is being used now. had to look for it, in bottom dresser drawer under other personal care items. On 4/18/18 at 11:12am V31 , R67's Wound Physician stated the current orders dated 4/4/18 were to apply [MEDICATION NAME] cream to R67's bilateral lower extremities daily. R67's Wound Assessment and Plan sheets dated 4/4/18 document additional orders to apply [MEDICATION NAME] cream to the skin of the bilateral lower legs daily. R67's electronic Medication Review Report documents an order dated (MONTH) (YEAR) do not document the order for the [MEDICATION NAME] cream to the bilateral lower extremities. The facility's Preventative Skin Care policy dated (MONTH) (YEAR) documents preventative skin care will be provided to all residents. This policy documents it is the responsibility of the charge nurse and the nursing assistant to ensure preventative skin care is completed. This policy also documents after thorough cleaning of the area, lotion should be applied.

Based on observation, interview and record review the facility failed to monitor indwelling catheter output, anchor the indwelling catheter to prevent dislodgment or self removal, and failed to notify the physician of hematuria and abdominal distention for two of three residents (R2 and R3) reviewed for catheter care in a sample of fourteen. This failure resulted in R2 being hospitalized with Acute [MEDICAL CONDITION] Secondary to [MEDICAL CONDITION] and Hematuria (Traumatic) with Acute Kidney Injury. Findings include: 1. R2's face sheet documents admission to the facility on [DATE]. R2 has a [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] document R2's cognition is moderately impaired and requires extensive assistance for toilet use. R2's Intake (fluid) and Output (urinary) record for September 2016 documents no intake on the night shift from 9/1/2016 through 9/10/2016, the only intake documented on the morning shift was 240 cubic centimeters (cc) on 9/7/2016, and evening shift documented 250 cc of fluid intake on 9/1 and 9/4 and 300 cc intake on 9/2 and 9/5. R2's output sheet documents an output of 1000 plus cc on 9/1 through 9/4/2016 and 9/6/2016, 75 cc out on 9/7/2016, 925 cc out on 9/7, 500 cc out on 9/8 with nothing documented for the night shift, 850 cc on 9/9/2016, 100 cc out on the PM (afternoon/evening) shift for 9/10 with crossed out areas for AM (morning) and NI (night) shifts and 250 cc out on the NI and AM shifts for 9/11/2026. On 9/16/2016 at 9:30AM, E12 Certified Nurses Aide (CNA) stated the CNA's empty the indwelling catheter bags and document the output on the output sheet. The nurses review the outputs at the end of the shift. On 9/14/2016 at 10:00AM, E2 (Director of Nursing) stated The nurses are to monitor the output and notify the physician if the output is low. The out put sheet for (R2) should have been questioned by the nurses since it was blank. There is no way to know if (R2) had an adequate output on those days the sheet is blank. No, the nurses did not accurately monitor (R2's) output. They should have also assessed the abdomen for distention and the indwelling catheter for proper placement, asking the physician for irrigation orders if needed. They should always notify a physician if a resident has hematuria. There is no facility protocol or policy for intake and output. R2's Progress Note dated 9/3/2016 at 11:32AM, documents (R2) got up to go to the bathroom and pulled out (R2's) indwelling catheter. Re-inserted without any issues. Urine is blood tinged with a few clots noted. The next documented Progress note was 9/4/2016 at 3:23PM documenting (R2) is alert and oriented. (R2) requires assistance with transfers. Urine has a large amount of blood in it. Catheter pulled out by accident by (R2) at the end of the shift. Second shift nurse re-inserted the new one. (R2's) progress notes document hematuria again on 9/7/2016 at 4:43PM and 9/8/2016 at 9:21PM. R2's medical record has no documentation that the physician was notified of the catheter being pulled out by the resident on 9/3/2016 or 9/4/2016 or the hematuria on 9/7 or 9/8. On 9/14/2016 at 2:45PM, E6 (Nurse) stated I inserted a 16 french indwelling catheter with a 10cc balloon on 9/3/2016. (R2) got up to go to the bathroom and forgot the indwelling catheter bag was attached to the bed, self removing the catheter with the balloon intact. I did not document the size of indwelling catheter I inserted in the progress notes, just that I reinserted the indwelling catheter. The facility does not have any indwelling catheter anchors so none was utilized on (R2). On 9/4/2016 (R2) again self removed the indwelling catheter with the balloon intact. The evening shift nurse (E8) reinserted the indwelling catheter at that time. The indwelling catheter change is to be documented on the Treatment Sheet, I did not document the reinsertion there either. I replaced the catheter with the size that (R2) had before removal. There are no indwelling catheter orders on the Physicians Order Sheet for size or daily catheter care. I should have called the physician for orders as well as notified the physician of the catheter self removal and hematuria. On 9/14/2016 at 3:15PM, E2 (Director of Nursing) stated The physician is to give the orders for the size catheter and daily catheter care. E2 verified no orders were available in R2's medical record for catheter care or re-insertion size. E2 also stated the facility does not anchor indwelling catheter to the residents leg to prevent accidental removal of the indwelling catheters. We do not have catheter anchors in the facility to utilize. On 9/16/2016 at 9:15AM, E11,Certified Nurses Aide (CNA) stated I was (R2's) CNA on 9/7, 9/8 and 9/9/2016. I did indwelling catheter care for (R2) all three days. (R2) would say my bladder hurts. (R2) would tell that to anyone who would listen, my bladder hurts. I told the nurse each day,but I don't remember who the nurses were. On 9/13/2016 at 11:15AM, E13 (Nurse) stated (R2) complained of abdominal pain for a couple of days before (R2) was transferred to the hospital. (R2) said my bowels need to move. I was told by (E12) CNA that (R2) had a bowel movement on 9/10/2016. I did not do an abdominal assessment (check bowel sound or abdominal distention) or notify the physician of the complaint of abdominal pain until 9/11/2016, the day (R2) was transferred to the hospital. I did not check to ensure the indwelling catheter was in the proper placement or attempt to irrigate the catheter. R2's Progress Notes dated 9/9/2016 document (R2) complained to family about not having a bowel movement, will assess after lunch. There was no documented bowel assessment or description of the abdomen or physician notification in (R2's) medical record for 9/9/2016. On 9/10/2016 the Dietary Manager (E15) documents (R2) states went yesterday and had no discomfort at the time. Visited again in the afternoon and (R2) stated went today. There is no nursing documentation in R2's medical record for 9/10/2016. The next Progress Note for (R2) is on 9/11/2016 at 5:55PM documenting increased confusion, blood in urine, and abdominal distention. The Progress Note dated 9/11/16 at 8:05pm documents that Z4, R2's Physician came to see R2. On 9/15/2016 at 1:00PM, Z4 (R2's Physician) stated I was not notified that (R2) self removed the indwelling catheter twice, was having hematuria or that (R2) complained of any abdominal pain prior to 9/11/2016. On 9/11/2016 when I arrived at the facility (R2) was in acute respiratory distress, gasping, [MEDICAL CONDITION] and had acute lower abdominal pain and distention with tenderness to touch. (R2's) respirations were 40. I immediately sent (R2) to the hospital. I should have been notified of these issues as they occurred. I would have sent (R2) out to the hospital for evaluation for the hematuria [MEDICATION NAME] more than 24 hours after catheter self removal. R2's emergency room (ER) Report dated 9/11/2016 at 8:50PM, documents (R2) is noted to have severe lower abdominal pain. Abdomen is distended, firm and painful to touch. Nurses note urine from the indwelling catheter is mostly blood. ER Physical exam documents distended firm abdomen. Pain in the left lower quadrant. Firm mass in lower abdomen. The ER note at 11:02 PM documents urinary catheter appears to be in prostate and not in bladder. (R2) has [MEDICAL CONDITION] on Computerized Tomography Scan (CT) with stranding of bilateral kidneys. Indwelling catheter exchanged and (R2) has had over 2000 milliliters of urine output. Urine is dark in color. Per family, patient (R2) pulled catheter out on (R2's) first day at the nursing home on 9/1/2016. Indwelling catheter was replaced. It is not clear how long the indwelling catheter has been in the prostate or had poor output. The (CT) dated 9/11/2016 at 10:18PM documents the impression-Indwelling catheter balloon inflated in the prostatic urethra. Repositioning into the urinary bladder recommended. Enlarged prostrate gland measuring 6.3 centimeters (cm) by 6.9 cm. Marked distention of the urinary bladder, presumably on the basis of indwelling catheter malposition. Bilateral ureterectasis and hydro[DIAGNOSES REDACTED] due to bladder distention. Layering intermediate density material in the urinary bladder. Hemorrhage, debris, or cellular [MEDICAL CONDITION] material could have this appearance. R2's Hospitalist Admission History and Physical dated 9/12/2016 at 9:45AM, documents chief complaint is abdominal pain and Acute [MEDICAL CONDITION] secondary to improper placement of the indwelling catheter. When catheter was removed approximately three liters of urine (2300 cc of bloody urine) was removed and (R2) had an elevated [MEDICATION NAME] level of 8.10 (normal 0.70-1.30). (R2) was also hyperkalemic and kayexylate was given. R2's hospital Discharge Summary dated 9/14/2016 documents (R2) presented with acute [MEDICAL CONDITION] secondary to [MEDICAL CONDITION]. Urology was consulted for further management for (R2's) urinary obstruction and indwelling catheter was placed in the operating room with subsequent improvement in (R2's) renal function and urinary drainage. 2. On 9/14/16 at 2:05pm R3's indwelling urinary catheter was not anchored/secured to R3's leg. On 9/14/2016 at 2:05PM, R3 stated They do not use indwelling catheter anchors here. I have had my indwelling catheter tubing tugged on multiple occasions, but it has never been removed by being pulled out. It hurts when the tubing is pulled. On a pain scale of one to ten about an eight or nine when the tubing is pulled.

Based on interview and record review the facility failed to assess, identify and treat for abdominal distention and pain for one of three residents (R2) reviewed for medical follow up in a sample of fourteen. This delay in treatment resulted in Acute [MEDICAL CONDITION] Secondary to [MEDICAL CONDITION] with Severe Abdominal Pain for R2. Findings include: R2's face sheet documents admission to the facility on [DATE]. R2 has a [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] document R2's cognition is moderately impaired and requires extensive assistance for toilet use. On 9/16/2016 at 9:15AM, E11,Certified Nurses Aide (CNA) stated I was (R2's) CNA on 9/7, 9/8 and 9/9/2016. (R2) complained of abdominal pain all three days. I told the nurse each day. I don't remember who it was I told. R2's progress notes dated 9/9/2016 document (R2) complained to family about not having a bowel movement, will assess after lunch. There was no documented bowel assessment or description of the abdomen or physician notification in (R2's) medical record for 9/9/2016. On 9/10/2016 the dietary manager (E15) documents (R2) states went yesterday and had no discomfort at the time. Visited again in the afternoon and (R2) stated went today. There was no nursing documentation in R2's medical record for 9/10/2016. The next documented progress note for (R2) is on 9/11/2016 at 5:55PM documenting increased confusion, blood in urine, and abdominal distention. On 9/15/2016 at 1:00PM, Z4 (R2's Physician) stated I was not notified that (R2) complained of any abdominal pain prior to 9/11/2016. On 9/11/2016 when I arrived at the facility (R2) was in acute respiratory distress, gasping, [MEDICAL CONDITION] and had acute lower abdominal pain and distention with tenderness to touch. (R2's) respirations were 40. I immediately sent (R2) to the hospital. I would have sent (R2) out to the hospital for evaluation with complaint of abdominal pain with distention. I would have also expected the nurses to do a complete abdominal assessment (check for abdominal distension, bowel sounds and tenderness to touch) if a resident complains of pain. On 9/14/2016 at 1:00PM, Z6 (Family of R2) stated (R2) started complaining about abdominal pain and discomfort at least three days before (R2) was hospitalized . I insisted the doctor be notified and see (R2) on 9/11/2016. When the doctor saw (R2) the doctor immediately sent (R2) to the hospital. The nurses at the facility did not call the doctor or do anything until I insisted. R2's emergency room (ER) Report dated 9/11/2016 at 8:50PM, documents (R2) is noted to have severe lower abdominal pain. Abdomen is distended, firm and painful to touch. Nurses note urine from the indwelling catheter is mostly blood. ER Physical exam documents distended firm abdomen. Pain in the left lower quadrant. Firm mass in lower abdomen. The ER note at 11:02 PM documents urinary catheter appears to be in prostate and not in bladder. (R2) has [MEDICAL CONDITION] on Computerized Tomography Scan (CT) Indwelling catheter exchanged and (R2) has had over 2000 milliliters of urine output . The (CT) dated 9/11/2016 at 10:18PM documents the impression-Indwelling catheter balloon inflated in the prostatic urethra. Repositioning into the urinary bladder recommended. Enlarged prostrate gland measuring 6.3 centimeters (cm) by 6.9 cm. Marked distention of the urinary bladder, presumably on the basis of indwelling catheter malposition. Bilateral ureterectasis and hydro[DIAGNOSES REDACTED] due to bladder distention. Layering intermediate density material in the urinary bladder. Hemorrhage, debris, or cellular [MEDICAL CONDITION] material could have this appearance. R2's Hospitalist Admission History and Physical dated 9/12/2016 at 9:45AM, documents chief complaint is abdominal pain and Acute [MEDICAL CONDITION] secondary to improper placement of the indwelling catheter. When catheter was removed approximately three liters of urine (2300 cc of bloody urine) was removed

Based on record review, observation and interview, the facility failed to ensure safety/supervision during toileting and correct positioning to prevent falls for two residents (R1, R3) reviewed for falls from a sample of three. These failures resulted in R1 sustaining facial fractures and cerebral hemorrhage, and R3 sustaining a laceration and dislocated toe. Findings include: 1. R1's Physician order [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documents R1 as severely cognitively impaired and having disorganized thinking and inattention. R1 is not stable and is only able to stabilize herself with staff assistance during sitting. R1 is non-ambulatory. The Fall Risk assessments dated 12/23/13, 3/17/14 and 9/1/14, document R1 as a high risk for falls. R1's Plan of Care updated 9/9/14, directs staff to recline R1's geriatric chair since "(R1) tends to lean forward." The careplan also states that R1 is to have a tab alarm on at all times. A facility report titled "Resident Incident Report" and dated 9/9/14 documents R1 with an unwitnessed fall from her geriatric chair in the hallway and found on the floor. R1 had bleeding from the forehead and was sent out to the emergency room (ER) for evaluation. R1 returned to the facility with sutures to her forehead. Intervention for this fall is documented as "reiterate to staff to recline (R1) slightly if left in (geriatric) chair." The Resident Incident Report dated 10/15/14 documents E7, Activity Aid wheeled R1 to the dayroom in the geriatric chair, then went to get some paperwork from a cabinet. E7 turned around from the cabinet and saw R1 suddenly falling straight forward onto her head. The report states the root cause as the geriatric chair not being reclined. The Resident Incident Report dated 10/24/14 states that R1 was toileted on a bedside commode by E8, Certified Nursing Assistant. After sitting R1 on the bedside commode, E8 turned and walked across the room to get a piece of clothing for R1 from the closet. The report documents "(R1) suddenly leaned forward and fell on to the floor, bleeding was noted from a laceration on left side of face...." This report goes on to document that R1 was sent out to the local ER and was subsequently sent to a trauma hospital for further follow up due to facial fractures and a cerebral bleed. An ER report dated 10/24/14 documents that R1 was treated for [REDACTED]. A head Computed Tomography (CT) report dated 10/24/14 documents, ". . . Traumatic subarachnoid hemorrhage. . . . Foci of intraparenchymal hemorrhage . . . . . Multiple facial bone fractures including left zygomaticomaxillary complex fracture and left orbital fractures . . . Discussed with neurosurgeon, who accepted (R1) for transfer to (Trauma Hospital) for further evaluation and treatment." On 11/13/14 at 10:05 am R1 had faded bruising was noted on her entire face, with a small crusted laceration to the left orbital area. On 11/13/14 at 11:05 am E1, Administrator acknowledged that E8 should not have walked away from R1, leaving R1 alone on the commode. On 11/13/14 at 3:50 pm E4, MDS and Care Plan Coordinator stated "we do in-services all the time with our staff instructing them not to leave residents alone on the toilet if they have tab alarms or have been assessed at high risk for falls. (E8) should not have left (R1's) side since R3 is a high risk for falls." 2. R3's POS dated November 2014 documents [DIAGNOSES REDACTED]. The MDS dated [DATE] documents that R3 is cognitively impaired, is not stable and is only able to stabilize with staff assistance. R3 requires one assist with walker for walking and transferring. R3 also uses a wheelchair for mobility. The Resident Incident Report dated 9/19/14 documents R3 being toileted by E6, CNA. The report states that once R3 was finished with toileting, R3 could not lift her left hand to the walker. E6 took R3's closed hand and placed it on the walker. R3 could not open her hand to grasp the walker. The report documents that E6 held R3's closed hand on the walker and proceeded to walk her. When R3's hand slipped off the walker, R3 lost her balance and E6 lowered R3 to the floor. The report documents that R3 later complained of pain to her left foot. Upon assessment, "R3's second toe was bleeding with what appeared to be bone exposed. The second toe was at a 90 degree angle to the other toes." R3 was sent to the ER for evaluation and treatment. The ER notes dated 9/19/14 document R3 with an apparent open fracture from a fall. The x-ray dated 9/19/14 documents, "There is dorsal dislocation of the middle and distal phalanges of the second toe without definite fracture . . . ." The ER notes document that R3's toe was reduced and sutured with a dressing applied. R3 returned to the facility at 9:45 pm on 9/19/14 per Nursing Notes. R3 had new orders for antibiotics and daily dressing changes. On 11/13/14 at 3:00 pm E4 acknowledged that E6 should not have transferred R3 when R3 could not lift or open her left hand. E4 stated "(E6) should have immediately got the nurse to come and do an assessment. (R3) obviously was not in any shape to use a walker safely." On 11/1314 at 3:05pm, E2, Director of Nursing acknowledged that E6 should not have walked R3 without both hands having proper grasps on the walker. E2 stated "Of course if you don't have control of the walker you're going to lose your balance." E2 agreed that E6 should have gotten a nurse before any attempts to walk R3.

A. Based on record review and interview, the facility failed to utilize a gait belt while transferring R6, resulting in a fall. R6 received a Left Hip Fracture from the fall. The facility also failed to use a functional personal alarm and supervise R7 while on the toilet resulting in two falls. R6 and R7 are two of nine residents reviewed for falls, in the sample of 16. The findings include: 1. R6's July 2013 Physician order [REDACTED]. R6's quarterly Minimum Data Set ((MDS) dated [DATE] documents R6 as cognitively intact, requiring limited assistance of one staff for bed mobility, transfers, and ambulation. R6 was assessed as having two previous falls without injury. The January 2013 Monthly Summary for mobility documents "Pt (Patient) ambulatory with walker. Maximum One Assist. Gait Belt, RW (Rolling Walker)." The section titled Restorative Nursing states, "ambulation with two, gait belt and walker and w/c(wheelchair) behind." The Incident Report dated 2/7/13 documents on 2/07/13 at 6:45 pm R6 was walking with E4, Certified Nurse Assistant (CNA) when R6 stumbled, lost balance and fell . Staff unable to hold resident upright. R6 complained of left hip pain and was sent to the emergency room for evaluation. The undated Investigative Report for falls documents the fall occurred while attended by staff. E4's written statement dated 2/07/13 documented "Had (R6) on the toilet walking her back from toilet with walker when she stumbled going from the walker to w/c (wheelchair)..tried to catch her but was unable to do so. She fell down and she hit the floor, was hurting.." On 7/17/13 at 9:15 am R6 stated, "I was going to the bathroom with (CNA E4) with no gait belt on me. As we were coming out of the bathroom I stumbled and since there was no gait belt she had no way to hold me and I fractured my hip." R6 stated she was in the hospital for 6 days, then for 2 months she was non weight bearing, had to use a mechanical lift and could not go to therapy. R6 stated before the fall she could walk with a gait belt and walker with assist one staff about 200 feet. R6 stated now she is working with therapy but can only go about 30-40 feet with two staff helping. R6 stated "If the fracture hadn't happened I probably would be walking on my own by now." On 7/17/13 at 2:15 pm E4 stated that on 2/05/13 she walked R6 into the bathroom with a walker to the toilet. E4 stated R6 told her that she didn't think she could walk out with the walker because she felt weak and had balance problems. E4 stated she got the resident's wheelchair and was assisting R6 to turn around and transfer into the wheelchair when R6 caught her foot on the wheelchair and lost her balance. E4 stated she tried to catch her and hold her but couldn't. E4 stated she had not used a gait belt for the transfer. E4 stated "I know I was supposed to use a gait belt." The facility policy entitled " Gait Belts For Transfer" states Gait belts are provided to assist staff to safely transfer or ambulate residents." Director of Nursing (DON) E2 stated on 7/18/13 at 10:55 am that staff are to use gait belts with any resident that needs assistance to transfer." 2. R7's physician's orders [REDACTED]. The Minimum (MDS) data set [DATE] documents R7 is cognitively impaired and requires extensive assistance with transfers and toilet use. The Fall Risk Assessments dated 2/25/13 and 5/20/13 show that R7 is at high risk for falls. The Care Area assessment dated [DATE] documents "(R7)...... Unsteady balance." R7's Care Plan dated 5/30/13 documents R7 utilizes alarms when in the recliner chair and wheelchair. On 7/16/13 at 9:30 am E7 (Licensed Practical Nurse) stated that R7 has a seat cushion alarm and wheelchair alarm as R7 tends to lean over and try to pick something up. On 7/16/13 at 11:10 am E6 (Certified Nurse Assistant) stated that R7 is unsteady on her feet and needs reminded not to get up and that's why R7 has the motion alarms. The Resident Incident Report dated 4/28/13 documents that R7 attempted to get up out of her chair, lost her balance and fell to the floor. The seat alarm in the chair did not sound due to a dead battery. On 7/17/13 at 2:28 pm E2 (DON) referenced R7's fall on 4/28/13 stating that the seat alarm didn't sound and the battery indicator light showed "low battery." E2 stated that all motion alarms are checked every Monday and/or Tuesday, however, E2 did not have documentation available to confirm when R7's alarms were checked. The Resident Incident Report dated 6/21/13 documents that R7 fell when she attempted to self transfer off the toilet to the wheelchair and was "yelling help me...." On 7/17/13 at 1:00 pm E2 stated that R7 is impulsive and attempts to get up and has impaired cognition. E2 DON referenced R7's fall on 6/21/13 and stated that a new Certified Nurse Assistant had placed R7 on the toilet and left R7 unattended. R7's Care Plan dated 5/15/13 stated "Do not leave unattended in room when staff is not around." B. Based on observation, record review and interview, the facility failed to ensure that hot water available at resident handwashing sinks and shower locations was at a safe temperature to prevent burn hazards. This had the potential to affect six of 16 residents in the sample (R6, R12, R14, R15, R16, R18) and 20 residents (R23-R 42) on the supplemental sample. The findings include: 1. On 7/17/13 at 11:20 am hot water temperatures in resident accessible handwashing sinks and bathing locations were checked. The hot water at the handwashing sinks in the unlocked Northeast Wing visitor and staff restrooms measured 120 degrees Fahrenheit (F.). The water was very hot to the touch. Maintenance Director E9 who was present during the observation(7/17/13 at 11:20 am) stated that this was too hot and needed to be turned down. E9 stated that the hot water heater for the unit was in the adjacent mechanical room. This water heater serves the entire wing. The hot water travels down the left side of the wing and loops back up the right side of the wing ending in the Spa Tub Room. The hot water at the handwashing sink in the next adjacent resident room from the visitor restrooms measured 117 degrees F. at 11:25 am on 7/17/13. This room was unoccupied. Additional occupied resident room handwashing sinks and showers were tested on the Northeast Wing. The following resident locations had hot water that exceeded 115 degrees F. on 7/17/13: R23's handwashing sink measured 118 degrees and R23's shower measured 0115 degrees F. at 11:30 am. R24's handwashing sink measured 117 degrees F. at 11:35 am. R25's handwashing sink measured 117 degrees F. at 11: 40 am. R6's handwashing sink measured 120 degrees F. at 11:45 am. On 7/17/13 at 11:45 am the temperature gauge after the mixing valve on the hot water heater was registering 120 degrees F. On 7/17/13 at 11:45 am E9 stated the hot water at resident rooms and baths are checked on a daily basis early in the morning approximately 7:00-7:30 am. E9 did not know why the hot water had gotten so high. On 7/17/13 at 12 Noon the hot water at the Central Shower Room (#140) was tested . The hot water at the handwashing sink was registering 120 degrees F. and the hot water at the shower was measuring 124 degrees F. On 7/17/13 at 12:00pm E9 stated at 8:00am that morning the hot water was measuring 109 degrees F. E9 stated that someone must have adjusted the mixing valve. Administrator E1 stated on 7/17/12 at 4:30 pm that E9 reported that there was a problem with the antisocial valve on the Central Wing water heater. Certified Nurse Aides E10 and E11 stated on 7/17/13 at 2:00 pm that they bath all but one resident on the Central Wing in the Central Shower Room. This would include R6, R12, R14, R15, R16, R18, and R24-R42. The hot water temperature logs were reviewed for July 2013. The last entry was dated 7/2/13 for Bathing Area C (Central) and recorded 109 degrees F. Maintenance Assistant E12 stated on 7/17/13 at 12:50 pm that he only checks the hot water at the sink when he does water temperatures in the shower room for Central Wing.