Every finding on record at Accolade Healthcare of Waterloo

Based on observation, interview and record review, the facility failed to follow physician's orders for STAT labs and x rays for 2 (R4, R103) of 4 residents reviewed for following physician's orders in a sample of 49. This failure resulted in delayed treatment for symptomatic pneumonia. Findings include: 1. R4's Undated Face Sheet, documents initially admitted on [DATE] with diagnoses including acute respiratory disease and chronic cough.R4's Quarterly Minimum Data Set (MDS), dated [DATE], documents she was alert.R4's Progress Note, dated 1/9/2025 at 1:15 PM New orders: STAT (immediately/without delay) STAT CXR (chest x ray) and STAT KUB (abdominal x ray) orders placed. R4's POS (Physician's Order Sheet), dated 1/9/2025 documents STAT chest x ray and STAT KUB. R4's Medical Record, including progress notes no documentation STAT chest x ray or KUB was done on 1/9/2025 or 1/10/2025. R4's Progress Note, dated 1/11/2025 5:11 PM documents, Spoke with radiology company regarding STAT x ray for her KUB and cxr that was ordered on 1/9/2025. Per radiology they will be out today for the x ray. R4's Radiology Report, dated 1/11/2025 chest x ray documents, worsening bilateral lobe opacities are concerning for pneumonia. No documentation this chest x ray was ordered STAT. R4's Progress Note, dated 1/11/2025 at 10:40 AM documents, Resident started Vancomycin today for infection. R4's POS, dated 1/11/2025 documents a new physician's order for Vancomycin 125 milligrams (mg) every 6 hours x 10 days. R4's Progress Note, dated 3/20/2025 at 2:54 PM documents, It was brought to this nurse's attention by POA (power of attorney) that resident is experiencing weakness, tachypnea, and excessive shakiness this afternoon, upon assessment vital signs taken T (temperature)100.7 BP (blood pressure) 153/78 P (pulse) 91 O2 (Oxygen saturation) unable to obtain d/t (due to) resident having cold fingers. Warm towel given to warm up hands, pulse ox reading 76% on 4L (liters) O2 (oxygen). NP (nurse practitioner) made aware of resident's condition, POA present and does not want resident sent out. New orders received STAT CBC, CMP, 2 view CXR, O2 PRN to keep sats > 92%. PRN (as needed) Tylenol administered as ordered, cool rag placed on forehead, will re-check temp in 30 minutes. Pulse ox obtained via ear lobe, reading 97% @ 2L. Resident resting in bed quietly, respirations even and unlabored, call light within reach and POA present at bedside. R4's Medical Record, including progress notes, dated 3/20/2025 no documentation of resident getting chest x ray. R4's Progress Note, dated 3/21/2025 at 6:26 AM documents, Resident congested, respiration are even and unlabored. Labs and chest x-ray pending to be done. Vitals TP (temperature tympanic) 97.3, HR (heart rate) 18, BP (blood pressure) 98/62., 02 sats 95%. R4's Progress Note, dated 3/21/2025 at 2:46 PM documents, Lab was here today to draw for CMP and CBC. R4's Radiology Report, dated 3/21/2025 documents, Pneumonia should be considered. No documentation this chest x ray was ordered STAT. R4's Laboratory Results, dated 3/21/2025, CBC with differential documents R4's had elevated white blood count. No documentation these labs were completed STAT as ordered. R4's POS dated, 3/22/2025 documents a new physician's order for Levofloxacin 500 mg x 7 days. R4's Progress Note, dated 3/22/2025 at 8:27 AM, documents Res started Levaquin 500mg q day x7 days this AM r/t (related to) PNA (pneumonia.) 2. R103's Undated Face Sheet, documents initially admitted to the facility on [DATE] diagnosis including acute respiratory disease and bacterial pneumonia. R103's Significant Change MDS, dated [DATE] documents cognitively impaired. R103's POS (physician order sheet) dated, 3/1/2025 new physician's order: STAT chest x ray. R103's Medical Record, including progress notes no documentation R103's STAT chest x ray was done on 3/1/2025. R103's Progress Note, dated 3/2/2025 at 12:15 PM documents called radiology company as STAT CXR was still not completed that was due yesterday. Received fax from radiology company stating they will be here today between 4pm-6pm to obtain CXR. POA (power of attorney) here and aware. Res continues with NP (nonproductive) cough and congestion. Per POA res was able to spit it up. PRN Robitussin given and effective. VSS. VS: 97.4-69-16- 138/70- 92%RA. No s/s pain or discomfort at this time. R103's Progress Note, dated 3/2/2025 at 4:45 PM, documents radiology company here for STAT CXR. R103's Progress Notes, dated 3/2/2025 at 5:18 PM, documents physician in facility and labs from 02/28/25 reviewed and NNO (no new orders). Physician aware of cough and congestion and awaiting CXR results. R103's Progress Note, dated 3/2/2025 8:57 PM documents, CXR results right lower lobe airspace disease can be related to pneumonia or atelectasis. Call placed to exchange, awaiting call back. POA here and aware of results, will await orders from MD (physician.) R103's Progress Note, dated 3/2/2025 at 9:16 PM documents received call back from NP (nurse practitioner) and new orders received r/t (related to) CXR results. N.O. (new order) to start Levaquin 500mg QD (every day) x 5 days. POA aware. Orders entered. R103's POS, dated 3/2/2025 documents a physician's order Levaquin 500 mg every day for 5 days. R103's Progress Note, dated 3/3/2025 at 10:14 AM documents resident started Levaquin 500 mg x 5 days for pneumonia. On 7/22/2025 at 11:15 AM R103 was sitting up in his Broda chair, he was not interviewable. No breathing abnormalities assessed. On 7/24/2025 at 9:40 AM, V17, RN (Registered Nurse) stated the facility had an issue getting all regularly ordered and STAT labs and x rays being done in a timely manner. V17 stated both lab and x ray companies told her they were short staffed so they couldn't get to the facility within a timely manner. V17 reported the issues to V2, Director of Nurses (DON) and V3, Assistant Director of Nurses (ADON) and the facility recently switched companies and they no longer have an issue getting the labs and x rays done in a timely manner.On 7/24/2025 at 9:50 AM, V20, LPN (Licensed Practical Nurse) stated early in the year of 2025 regular ordered and STAT labs and x rays were not being done in a timely manner at the facility both previous lab and x ray companies stated they were short staff or had to travel from Missouri to come to get the test done. V20 reported the issue to V2 and V3 and they recently changed companies for both lab and x ray and now it's no longer an issue. On 7/24/2025 at 10:00 AM, V18, LPN stated there were issues with getting labs and x rays done in a timely manner but the facility recently got new companies for both lab and x ray and they now have a lab technician at the facility 5 days a week for 5 hours a day and if they have a STAT lab ordered they call the lab and they send a technician out and it's drawn within the hour or so and reported in a timely manner. On 7/24/2025 at 10:10 AM, V16, LPN stated the previous lab and x ray companies were not coming to the facility in a timely manner and the STAT labs and x rays are supposed to be done immediately and they were not being done for at least a day and she reported the issues to V2 and V3 and they have switched companies and no longer have issues getting the labs and x rays done in a timely manner.On 7/24/2025 at 10:18 AM V3, Assistant Director of Nurses (ADON) stated staff reported to her that the facility had significant issues with the lab and x ray company getting regular and STAT labs and x rays being done in a timely manner, but they recently changed companies for both labs and x rays and now they are being done in a timely manner.On 7/24/2025 at 10:30 AM V2, Director of Nurses (DON) stated earlier this year they had a lot of issues with getting regular and STAT labs and x rays being done and reported in a timely manner were affected by this. The facility has switched companies in April 2025 and there is no longer an issue with getting these tests done in a timely manner. V2 stated the previous lab and x ray companies told them they didn't have enough staff and that was why the labs and x rays were not being done in a timely manner. On 7/24/2025 at 2:32 PM V2, DON stated due to the STAT labs and x rays not being done in a timely manner did delay the treatment of pneumonia for R4 and R103.The Facility's Radiology & Diagnostic Services Policy, revised on 4/1/2014, documents x rays and diagnostic services are preformed when ordered, no documentation of a STAT diagnostic order should be done by.The Facility's Laboratory Services & Testing Policy, revised 4/1/2014, documents STAT lab orders take a minimum of a 4-hour turnaround.

Based on interview, observation and record review the facility failed to document the date a multi dose vial of Tuberculin Purified Protein Derivative (Mantoux) Tubersol was opened for 4 of 4 residents (R45,R80,R118,R130) reviewed for medication storage and labeling in the sample of 49. Findings include:R45's, R80's, R118's and R130's face sheets document they were admitted within the last 30 days.On 07/23/2025 at 2:05 PM during review of memory care medication storage room, V10, Registered Nurse (RN) showed Tuberculin Purified Protein Derivative (Mantoux) Tubersol box had been opened, and the vial was not dated. V10 stated she was not sure when the vial was opened and would discard it immediately since it is not dated. V10 states the vial is used for residents on memory care unit for TB tests that are given upon admission and annually. On 7/23/2025 at 2:21 PM during review of long-term care unit medication storage room V4, RN showed Tuberculin Purified Protein Derivative (Mantoux) Tubersol box had been opened, and vial was not dated. V4 stated she was not sure when the vial was opened and will discard it immediately. V4 states the vial is used for the residents on the long-term care unit. V4 states TB tests are given upon admission and annually.On 7/25/2025 at 9:23 AM V2, Director of Nursing, (DON) states she expects staff to date and time Tuberculin Purified Protein Derivative (Mantoux) Tubersol vial when opened. V2 states Tuberculin tests are given upon admission and yearly. V2 states she would expect staff to discard vial immediately if not dated. The instructions on the Mantoux box documents Discard opened product after 30 days.The facility's policy Labeling of Medications and Biologicals dated 9/15/22 documents All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. Policy Explanation and Compliance Guidelines: 8. Labels for multi-use vials must include: a. the date the vial was initially opened or accessed (needle-punctured); b. all opened or accessed vials should be discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.

Based on interview and record review the Facility failed to ensure progressive interventions were being implemented for 1 of 14 residents (R8) reviewed for falls in the sample of 49.Findings include: R8's POS dated July 2025 documents a diagnosis of cellulitis of right lower limb, major depression disorder, acute respiratory disease, cystostomy infection, depression. neuromuscular dysfunction of bladder, stress fracture, unspecified tibia and fibula; methicillin resistant staphylococcus aureus infection, urethral discharge, colostomy status; paraplegia, pressure ulcer of left heel, stage 4. RR MDS dated [DATE] documents BIMS 15/15: Uses a wheelchair. Impairment on both sides for lower extremities. Needs substantial/ maximal assistance for most ADL's (Activities of daily living).R8's Progress Notes dated 5/18/2025 at 1:15 PM, Called to front lobby per receptionist. Maple and cottonwood nurse responded to emergency. Pt (patient) said he was coming inside as a guest opened the door for him his w/c (wheelchair) flipped backwards and pt hit back of head. Noted small hematoma to back of head. Ice applied. Pt denies headache or dizziness. Pt able to move arms without difficulty. No cuts scrapes or bruises noted. Pts back appears free of injury. Dressing in place to back. No s/sx (signs or symptoms) of acute distress noted. Ortho/Neuros started.R8's Incident Report dated 5/18/2025 at 1:15 PM, Patient coming in from outside. Guest holding 2nd door into building as patient flipped wheelchair backwards. Hit back of head. Intervention: Continue current POC (Plan of Care); Isolated Incident. (No other interventions were documented).R8's Progress Notes dated 5/29/2025 at 9:44 AM, IDT (Intradisciplinary Team) met to discuss fall on 5/18/25 at 1:15 pm in front lobby doorway, hematoma to back of head. IDT: Cont. POC (Plan of Care).R8's Care Plan: Resident has a fall risk score 10 placing them at high risk for falls. Care Plan does not document any intervention for fall on 5/18/2025.On 7/23/2025 at 9:28 AM, V2, Director of Nursing stated the Intervention for R8's Fall was continued current POC (Plan of Care); isolated incident. The corrective actions were those two because it was an isolated incident. There were no other interventions.The Fall Prevention Policy with a revision date of 5/14/2024 documents, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Provide interventions that address unique risk factors measured by the risk assessment tool; medications, psychological, cognitive status, or recent changes in functional status.

Based on interview and record review the Facility failed to ensure resident was being properly supervised and in a clutter-free environment that was free of hazards for 1 of 5 residents (R80) reviewed for falls in the sample of 56. This failure resulted in R80 who had a history of falls tripping over a chair or bedside table in the sunroom, requiring seven stitches. Findings include: R80's Physician Order Sheet for August 2024 documents a diagnosis of Alzheimer disease, atrial fibrillation, overweight retention of urine, generalized anxiety disorder, myocardial infarction, major depressional disorder, type 2 diabetes mellitus without complications. R80's Minimum Data Set, dated dated dated [DATE] documents R80 was severely impaired for cognition for activities of daily living. R80's Care Plan documents he has a history of falls and had fallen on 12/14/2023, 1/28/2024, 2/16/2024 and 3/3/2024. R80's Care Plan with start date of 8/23/2023 documents, Problem: Increased susceptibility to falling that may cause physical harm r/t (related to) history of falls, age, use of assistive devices, visual or hearing difficulties, incontinence, impaired physical mobility, cognitive impairment, w/c (wheelchair) use, weakness, poor safety awareness, poor standing balance, poor insight into deficits, impulsiveness. 3/26/24 fall in Sunroom minor injury, RCA (root cause analysis) tripped on chair IDT (interdisciplinary team) sunroom rearranged non- essential furniture removed. R80's Progress Notes dated 3/26/2024 at 6:55 PM, At approximately 6:00 PM resident was walking in sunroom, tripped on chair and fell on to R (right) side. Deep laceration noted to R eyebrow - unable to measure d/t (related to) amount of sanguineous drainage (bloody discharge). 1.5cm x 0.5cm skin tear noted to Right elbow - wound cleansed and dressing applied. Staff assisted resident to couch and applied pressure to Right eyebrow wound. Resident able to move all extremities WNL (within normal limits) but unable to voice pain at this time. Verbal responses at baseline. Physician notified and assessed resident. N.O. (new order) send resident to ER (emergency room ). Unable to reach POA (power of attorney), left message and then contacted daughter, who spoke with V26, Family R80 and agreed to send res to (Hospital) EMS (emergency medical services) contacted. R80's Incident Report dated 3/26/2024 at 6:00 PM, Resident was walking in sunroom, tripped on chair and fell on to right side. Resulting in right eyebrow laceration and skin tear to right elbow. R80's Post Management Post Fall Assessment Tool dated 3/26/2024 documents, Laying on right side on floor of sunroom. Staff to assist resident when ambulating. Sunroom assessed, rearranged, and all nonessential furniture removed. R80's Progress Notes dated 3/26.2924 at 11:26 AM, Resident returned at approximately 11:30 PM, via ambulance. Bruising noted to right eye lid, 7 stitches intact. Resident appears to leaving the area alone. R80's Progress Notes dated 3/29/2024 at 9:54 AM, Patient continues to be on observation related to follow up fall day #3 and orders related to Zoo {sic}. Bruising continues to right eyebrow, stitches intact. R80's Progress Notes dated 8/23/2024 at 11:59 AM, V22, Registered Nurse (RN) Nurse stated, (R80) was out in the sunroom the day he fell . He used to be ambulatory and had a decline and he was in a wheelchair. We are thinking one of his feet got hooked on the chair or side table and got a gauge on eyebrow and fell out of the wheelchair. He was sent out to the hospital where he got stitches. R80's Hospital discharge Records dated 3/26/2024 documents, You have 7 stitches that will need to be removed in 7-10 days. On 8/23/2024 at 12:30 PM, V27, Nurse Practitioner stated, (R80) had a heart attack before thanksgiving and did have a decline in health. I would expect areas like the sunroom to be clutter free and free of hazards. It was unfortunate that he fell . The Fall Policy dated 10/27/2023 documents, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level or risk to minimize level of risk to minimize the likelihood of falls. A 'fall' is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force (e.g. resident pushes another resident). The even may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere.

Based on interview and record review the facility failed to identify and immediately report allegations of physical and sexual abuse for 4 (R5, R124, R430, R103) residents reviewed for abuse. This failure has the potential to affect all residents in the facility. Findings include: 1. R5's face sheet, dated 8/14/24, documented R5 has diagnoses of dementia, depression, generalized anxiety disorder, and hypertension. R5's MDS (Minimum Data Set), dated 5/22/24, documented R5 is severely cognitively impaired. R5's incident report, dated 8/9/24 at 5:30 pm, documented R5 has a 2 cm by 2 cm raised dark purple bruise noted to the left side of forehead. On 8/13/24 at 9:05 am R5 was observed with an approximately 2 cm by 2 cm yellow and purple bruise to the left side of her forehead. R5 was unable to recall how she obtained the bruise. V12 CNA (Certified Nurse Assistant) documented in a written statement dated 8/9/24 I was in the resident (R5) room this morning with employee V13 CNA. We were getting the resident up and the resident was acting a little combative, upon putting the resident in the chair with the lift R5 started swinging and V13 grabbed the resident's hand and was really like tussling with the resident and was pretty rough. I was in awe. I had never witnessed anything like that before. In the midst of the tussling the resident was still hooked up to the machine and the iron from the lift hit her forehead. Upon leaving the room I had told my hall partner V14 about it and another CNA and they said that V13 had been reported before about abuse on several occasions and nothing had been done so I was hesitant about saying anything because if V13 has been reported before and nothing been done. I'm thinking what would make anyone think I'm telling the truth. But as I was going to the dining room, I seen R5 in the hallway, she had a green bruise on her forehead, so I knew I had to put my trust in God and report it. These residents are vulnerable, and they don't deserve to be abused. On 8/13/24 at 12:51 pm V12 stated that on 8/9/24 around 8:30 am she and V13 CNA went to get R5 out of bed. V12 stated that V13 was already frustrated because she said she didn't want to work that hall. V12 stated R5 was a little combative when she was in the lift, R5 was transferred into her chair, the lift was still connected to R5, and that V13 aggressively grabbed R5's arm, and then started to tussle with R5. V12 stated that V13 was swinging her arms and her hand hit R5's arm and that V13 continued to tussle with R5. V12 stated the iron bar hit R5's forehead during the tussle. V12 stated that she went and told the other CNAS and that they stated nothing will be done as V13 has been reported before. V12 stated that she did not report the incident until that evening when she saw the bruise on R5's head. On 8/13/24 at 8:50 am V1 Administrator stated that V12 did not report the allegation against V13 until 5:30 pm on 8/9/24. V1 stated that she suspended V12 for not immediately reporting the incident and she suspended V13 pending investigation. 2. R124's face sheet, dated 8/14/24, documented R124 has diagnoses of dementia, generalized anxiety disorder, hypertension, pulmonary fibrosis, chronic kidney disease, and depression. R124's MDS, dated [DATE], documented R124 is severely cognitively impaired. Statement dated 7/22/24 by V11 RN, ADON (Registered Nurse, Assistant Director of Nursing) documented On Monday, July 22, 2024, I asked V15 RN how R124 was doing. I had heard over the weekend she was having some behavior issues such as hitting, kicking, and refusing medications. V15 stated that this past weekend was terrible, and that R124 would not take medications, was yelling at staff, and then she called her granddaughter on Saturday and told her that the male staff members here rape the residents. I asked V15 who overheard R12 call her granddaughter and V15 stated that she is the one who overheard this conversation. V15 then proceeded to tell me that V16 CNA was taking care of R124 this weekend and she yelled RAPE! very loudly, multiple times while V16 was in the room with her. V15 stated that V16 was scared by this and yelled for a nurse's help. I immediately reported this information to V2 DON. I then called V16 and asked for his side of the story, and his story coincided with V15's story. I explained to him that if anything like this were to happen that he needs to report it to V1 or V2 immediately. I then told him to no longer go in R124's room alone when providing care. V15 was educated on needing to report these kinds of situations. On 8/14/24 at 9:00 am V1 stated that the allegation by R124 against V16 happened over a weekend and was not reported to management until the following Monday, July 22, 2024. On 8/14/24 at 9:00 am V2 stated that they did not report this allegation to the state because R124 is severely confused and because the resident immediately yelled rape as soon as the staff member walked in. Statement dated 7/24/24 by V7 CNA documented this evening around 3:30-4 pm I went into R124's room to get her evening vitals. I said hello and explained what I was there to do. I picked up her left arm and was able to put the cuff up to her elbow and she started to get frustrated and started yanking her arm back. I was finally able to get the cuff off and she swatted at me and started screaming I hit her. I immediately stopped everything and got V17 Social Worker. She came in and talked to her and I went on taking evening vitals. Statement by V17 Social Worker, undated, documented on 7/24/24 at 4pm. V7 CNA came and stated that R12 said someone hit her. I went to talk to R124, and she said some crazy lady hit her on her right lower arm. She pointed to her wrist area. I asked for her to describe the lady and just said that she was crazy. I asked what happened before that and just said that she wanted to go home. R124 continued to state that we are all liars and that she just wanted to go home. Statement, dated 7/24/24, by V2 DON documented I visited with R124 in her room. I asked R124 how everything was going here. She stated her kids put her here and she doesn't want to be here or understand why. She was asked if anyone had been mean to her, raising their voice to her or touching her. She stated no, she didn't have any problems like that, but everyone likes to lie about her, and she does or says and there is just a bunch of liars here. I talked with R124 and informed her no one was saying anything about her, and no one was lying about her. She smiled and said thank you and laid down. On 8/14/24 at 9:05 am V2 DON stated that the facility did not report the allegation with R124 and V7 to the State and did not suspend V7 pending investigation because R124 is severely confused. 3. R430's face sheet, print date 8/14/24, documented that R430 had diagnoses of hemiplegia, frontotemporal neurocognitive disorder, front-temporal dementia, neuromuscular dysfunction of bladder, and depression. R430's MDS, dated [DATE], documented R430 was completely cognitively intact. V18's statement, dated 1/23/24, documented POA (Power of Attorney) called me stating that a CNA named V14 was touching R430 ways she did not want to be touched. POA stated she did not think anything happened but wanted to let me know. On 8/14/24 at 9:08 am V1 Administrator stated that the facility did not report the allegation to IDPH (Illinois Department of Public Health) nor did they notify the police. 4. R103's face sheet, dated 8/14/24, documented R103 has diagnoses of chronic kidney disease, dementia, depression, hallucinations, glaucoma, osteoarthritis, and macular degeneration. R103's MDS, dated [DATE], documented R103 is severely cognitively impaired. On 8/13/24 at 1:20 pm V2 DON presented a stack of abuse allegations and stated that they were not reported to IDPH (Illinois Department of Public Health) because they determined within 2 hours of the allegations that they were not abuse. During review of these documents, it was noted that R13's allegation documents contained a statement by R103, dated 1/23/24, that was obtained by V17 Social Service. R14's statement documented R103 said when he first took care of him that he fondled his genitals but has never done it again. I reminded him to report anything that makes him feel uncomfortable. He voiced understanding. On 8/13/24 at 3:00 PM V1 stated if we believe it is truly an allegation of abuse then we report it. On 8/14/24 at 8:10 am V1 again stated that they did not report the allegation made by R103 on 1/23/24. On 8/14/24 at 12:50 PM V1 stated we do not have a designated Abuse Coordinator. V1 stated that she, V2, and V17 look at each allegation and decide from there if it should be reported or not. V1 stated that she does not know why R124's, R430's, and R103's allegations were not reported to the State. The Long-Term Care Facility Application for Medicare and Medicaid dated 8/20/24 documented 133 residents reside in the facility. The facility Freedom from Abuse, Neglect, Misappropriation and Exploitation Policy, undated, documented it is the policy of Oak Hill to maintain an environment where residents are free from abuse, neglect, exploitation and misappropriation of resident property and all residents, staff, families, visitors, volunteers, and resident representatives are encouraged and supported in reporting any suspected acts of abuse, neglect, misappropriation of resident property, or exploitation. It continues, the Nursing Home Administrator or designees will report abuse to the state agency per Illinois and Federal requirements. It continues, all reports of suspected crime and/or alleged sexual abuse must be immediately reported to local law enforcement to be investigated.

Based on interview and record review the facility failed to thoroughly investigate allegations of physical and sexual abuse for 3 (R124, R430, R103) residents reviewed for abuse. This failure has the potential to affect all residents in the facility. Findings include: 1.R124's face sheet, dated 8/14/24, documented R124 has diagnoses of dementia, generalized anxiety disorder, hypertension, pulmonary fibrosis, chronic kidney disease, and depression. R124's MDS, dated [DATE], documented R124 is severely cognitively impaired. Statement dated 7/22/24 by V11 RN, ADON (Registered Nurse, Assistant Director of Nursing) documented On Monday, July 22, 2024, I asked V15 RN how R124 was doing. I had heard over the weekend she was having some behavior issues such as hitting, kicking, and refusing medications. V15 stated that this past weekend was terrible, and that R124 would not take medications, was yelling at staff, and then she called her granddaughter on Saturday and told her that the male staff members here rape the residents. I asked V15 who overheard R124 call her granddaughter and V15 stated that she is the one who overheard this conversation. V15 then proceeded to tell me that V16 CNA was taking care of R124 this weekend and she yelled RAPE! very loudly, multiple times while V16 was in the room with her. V15 stated that V16 was scared by this and yelled for a nurse's help. I immediately reported this information to V2 DON. I then called V16 and asked for his side of the story, and his story coincided with V15's story. I explained to him that if anything like this were to happen that he needs to report it to V1 or V2 immediately. I then told him to no longer go in R124's room alone when providing care. V15 was educated on needing to report these kinds of situations. On 8/14/24 at 9:00 am V1 stated that the allegation by R124 against V16 happened over a weekend and was not reported to management until the following Monday, July 22, 2024. On 8/14/24 at 9:00 am V2 stated that they did not report this allegation to the state because R124 is severely confused and because the resident immediately yelled rape as soon as the staff member walked in. V2 stated that the facility did not notify the police, did not question other employees, and they did not examine R124's genitalia. Statement dated 7/24/24 by V7 CNA documented this evening around 3:30-4 pm I went into R124's room to get her evening vitals. I said hello and explained what I was there to do. I picked up her left arm and was able to put the cuff up to her elbow and she started to get frustrated and started yanking her arm back. I was finally able to get the cuff off and she swatted at me and started screaming I hit her. I immediately stopped everything and got V17 Social Worker. She came in and talked to her and I went on taking evening vitals. Statement by V17 Social Worker, undated, documented on 7/24 at 4 pm. V7 CNA came and stated that R124 said someone hit her. I went to talk to R124, and she said some crazy lady hit her on her right lower arm. She pointed to her wrist area. I asked for her to describe the lady and she just said that she was crazy. I asked what happened before that and just said that she wanted to go home. R124 continued to state that we are all liars and that she just wanted to go home. Written statement, dated 7/24/24, by V2 DON documented I visited with R12 in her room. I asked R124 how everything was going here. She stated her kids put her here and she doesn't want to be here or understand why. She was asked if anyone had been mean to her, raising their voice to her or touching her. She stated no, she didn't have any problems like that, but everyone likes to lie about her, and she does or says and there is just a bunch of liars here. I talked with R124 and informed her no one was saying anything about her, and no one was lying about her. She smiled and said thank you and laid down. On 8/14/24 at 9:05 am V2 DON stated that the facility did not investigate the allegation with R124 and V7, did not suspend V7 pending investigation, did not question other residents and employees, and did not conduct nor document a physical assessment of R124 because R124 is severely confused. 2. R430's face sheet, print date 8/14/24, documented that R430 had diagnoses of hemiplegia, frontotemporal neurocognitive disorder, front-temporal dementia, neuromuscular dysfunction of bladder, and depression. R430's MDS, dated [DATE], documented R430 was completely cognitively intact. V18's written statement, dated 1/23/24, documented POA (Power of Attorney) called me stating that a CNA named V14 was touching R430 ways she did not want to be touched. POA stated she did not think anything happened but wanted to let me know. R430's progress note, dated 1/23/24 at 10:56 am, documented POA [NAME] called and stated that resident reported that CNA V14 was touching resident where she did not want to be touched. This nurse reported to ADON V11 about situation. On 8/14/24 at 9:08 am V1 Administrator stated that the facility did not question R430 regarding the allegation, the facility did not report the allegation to the State, the facility did not suspend nor remove V14 CNA from the schedule because he is agency, they did not question other staff regarding the allegation, nor did they notify any authorities regarding the allegation. 3. R103's face sheet, dated 8/14/24, documented R103 has diagnoses of chronic kidney disease, dementia, depression, hallucinations, glaucoma, osteoarthritis, and macular degeneration. R103's MDS, dated [DATE], documented R103 is severely cognitively impaired. On 8/13/24 at 1:20 pm V2 DON presented a stack of abuse allegations and stated that they were not reported to IDPH (Illinois Department of Public Health) because they determined within 2 hours of the allegations that they were not abuse. During review of these documents, it was noted that R430's allegation documents contained a statement by R103, dated 1/23/24, that was obtained by V17 Social Service. R103's statement documented R103 said when he first took care of him that he fondled his genitals but has never done it again. I reminded him to report anything that makes him feel uncomfortable. He voiced understanding. On 8/13/24 at 3:00 PM V1 stated that they did not complete an investigation into the allegation made by R103 on 1/23/24. On 8/14/24 at 8:10 am V1 again stated that they did not conduct an investigation, nor did they report the allegation made by R103 on 1/23/24. V1 then stated that she asked R103 this morning if he has ever been touched inappropriately and he stated no. On 8/14/24 at 12:50 PM V1 stated that the facility does not have a designated Abuse Coordinator. V1 stated that she, V2, and V17 look at each allegation and decide from there if it should be investigated or not. V1 stated she does not know why R124's, R430's, and R103's allegations were not investigated. The Long-Term Care Facility Application for Medicare and Medicaid dated 8/20/24 documented 133 residents reside in the facility. The facility Freedom from Abuse, Neglect, Misappropriation and Exploitation Policy, undated, documented it is the policy of Oak Hill to maintain an environment where residents are free from abuse, neglect, exploitation and misappropriation of resident property and all residents, staff, families, visitors, volunteers, and resident representatives are encouraged and supported in reporting any suspected acts of abuse, neglect, misappropriation of resident property, or exploitation. It continues, the Nursing Home Administrator or designees will report abuse to the state agency per Illinois and Federal requirements. It continues, it is the policy of Oak Hill that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation, and misappropriation of property) are promptly and thoroughly investigated. The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately upon identification of alleged abuse. A root cause investigation and analysis will be completed. The information gathered is given to administration. a. Investigation of abuse: When an incident or suspected incident of abuse is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include: 1. Who was involved 2. Residents' statements a. For non-verbal residents, cognitively impaired residents or residents who refuse to be interviewed, attempt to interview resident first. If unable, observe resident, complete an evaluation of resident behavior, affect and response to interaction, and document findings. 3. Resident's roommate statements 4. Involved staff and witness statements of events 5. A description of the resident's behavior and environment at the time of the incident 6. Injuries present including a resident assessment 7. Observation of resident and staff behaviors during the investigation. It continues, all reports of suspected crime and/or alleged sexual abuse must be immediately reported to local law enforcement to be investigated.

Based on observation, interview and record review the facility failed to ensure infection control procedures were in accordance with current standards of practice for Covid-19. This failure has the potential to affect all 133 residents residing in the facility. Findings Include: On 8/20/24 the facility provided a document titled, Covid Positive which noted R113 and R51 are the resident's currently residing in the facility who are positive for Covid-19 at this time. 1. On 8/20/2024 at 12:00 PM R51 was observed lying in bed, as well as R12 sitting up in a chair within the same room. No masks being worn by either resident and the privacy curtain was not observed as being pulled to separate the residents. R12 stated My roommate has COVID. She really is not feeling well. I had COVID in 2021 and was very sick. I was not offered a mask or to move rooms. I know how to take the necessary precautions. Despite R12's statement of knowing how to take necessary precautions, no precautions that were being taken were expressed. R51's Face Sheet documents an admitted [DATE]. Diagnosis include Sepsis due to Enterococcus, Acute hypoxia due to respiratory failure, Acute kidney failure, Hypo-osmolality, hyponatremia, Chronic lymphocytic leukemia of B-cell type not having achieved remission, etc . R51's Minimum Data Set, MDS, dated [DATE] documents R51 is moderately cognitively impaired and requires partial/moderate assist with mobility. R51's Care Plan updated 8/19/2024 Problem: At risk for invading viral organisms related to COVID pandemic as evidenced by advanced age, community living setting, comorbidities. 6 feet apart if in outbreak status. Will test per Illinois Department of Public Health, IDPH/ facility policy if in outbreak. 8/19/24 Positive for Covid. R51'a progress notes dated 8/20/2024 at 6:30AM documents This nurse changed R51's dressing due to leaking. R51 continues isolation related to positive COVID results. Vital signs stable. No signs or symptoms noted. R51 turned every 2 hours. No complaints of pain or discomfort currently, call light within reach. R51's Covid Rapid Test documented on 8/19/24 at 5:30 AM, a positive test for Covid-19 with symptoms present being listed as a cough. R12's Face Sheet documents an admitted [DATE]. Diagnosis include Gastrointestinal Hemorrhage, Type 2 Diabetes, Chronic Kidney Disease, Hypertensive heart, and Chronic Kidney Disease without heart failure. R12's MDS updated 7/8/2024 documents R12 has no cognitive impairments and requires supervision/touching assist with mobility. R12's COVID rapid test results dated 8/19/2024 documents negative result. 2. On 8/20/24 at 9:30 AM R113 has a sign on his door stated Contact and Droplet Isolation. Personal Protective Equipment (PPE) is outside of his door. R113 and R110 were observed as being roommates during this survey. Throughout this survey, the door to their room was never observed being closed. R113 COVID (Coronavirus) Rapid Test dated 8/19/24 documents R113 is positive for COVID. R113's Nurses Note dated 8/19/24 documents resident tested for COVID with positive results. Resident is aware and agreeable to stay in room. Denies feeling bad. Resident continues on enhanced barrier precautions. R113's Minimum Data Set (MDS) dated [DATE] documents R113 is cognitively intact. R113's Dietary Note dated 8/19/24 documents resident recently tested positive for COVID on 8/19/24 will remain in isolation period through 8/29/24 off of isolation on 8/30/24. R110's COVID Rapid Test dated 8/19/24 documents R110 is negative for COVID. R110's Social Service Note dated 8/21/24 documents attempted to call POA (Power of Attorney) to offer a room move D/T (due to) roommate is on isolation precautions. She did not answer, so I left a message. R110's Social Service Note dated 8/22/24 documents received message from POA (Power of Attorney) that she does not want dad moved D/T being exposed to COVID. R110's Minimum Data Set, dated dated dated [DATE] documents R110 is cognitively intact. On 8/23/2024 at 8:45 AM V20, Infection Control Preventionist, stated When a resident is positive for COVID and they have a roommate that is negative, we try to find a different room for the roommate if a room is available. If another room is unavailable, we keep the curtain closed and provide care to the non-COVID resident first. On 8/20/24 at 9:55 AM, V19 Certified Nurse Assistant (CNA) stated that she had concerns regarding Covid-19 practices at the facility. V19 stated that Covid-19 positive residents are being allowed to leave their rooms and enter into common areas, such as the dining room and have direct contact and interaction with other residents who are not positive for Covid. V19 stated that staff have presented their concerns to facility administration and were told that residents who are Covid positive have the right to leave their room. V19 stated that it was expressed to administration that it was not understood why staff had to wear full Personal Protective Equipment (PPE) entering into a Covid positive room, but then positive residents are allowed to come out of their rooms with no PPE on. V19 stated staff were instructed if they made further complaints regarding Covid concerns, they would be disciplined. On 8/21/24 at 10:25 AM, V1 (Administrator) stated that resident's who have tested positive for Covid-19 are encouraged to utilize a mask and/or quarantine in their room, but are not required to. V1 stated Covid-19 positive residents are allowed to exit their room and choose not to wear personal protective equipment as it is part of their resident rights. V1 confirms Covid positive residents may interact with non Covid-19 positive residents. V1 stated social distancing is encouraged in common areas as the facility's effort to help protect resident's who have not tested positive for Covid-19. V1 also stated that if space allows, if one resident has tested positive for Covid-19 in a room and the room mate is negative, the resident's would be moved to separate rooms. V1 confirms that the facility is not at full capacity at this time. On 8/21/24 at 11:15 AM, V20 (Infection Preventionist) stated it is the facility's expectation to follow the Center for Disease Control (CDC) guidelines regarding Covid-19. V20 stated she has received complaints from staff regarding resident's who are positive for Covid-19 being allowed to leave their room without personal protective equipment. V20 stated that staff were notified that it was the resident's right to leave their room and education should be provided to the resident, encouraging them to quarantine and/or utilize source control. V20 confirmed resident's who are positive for Covid-19 are placed on contact and droplet isolation. Facility policy updated 2024 states Residents with suspected or confirmed SARS-CoV-2 infection should be placed in a single person room with door kept closed, if safe to do so, and a dedicated bathroom if possible. If cohorting, only residents with the same respiratory pathogen should be housed in the same room. Review of the not dated policy provided by the facility titled, COVID-19 Prevention, Response and Reporting documents, It is the policy of this facility to ensure that appropriate interventions are implemented to prevent the spread of COVID-19 and promptly respond to any suspected or confirmed COVID-19 infections. The Centers for Disease Control titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (Covid-19) Pandemic, dated March 18, 2024 documents the following: Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing .Source control is recommended for individuals in healthcare settings who: Have suspected or confirmed SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) infection or other respiratory infection .or had close contact (patients and visitors) or a highter-risk exposure (HCP) with someone with SARS-CoV-2 infection, for 10 days after their exposure. Place a patient with suspected or confirmed SARS-CoV-2 in a single-person room. The door should be kept closed (if safe to do so) .Limit transport and movement of the patient outside of the room to medically essential purposes. The Long-Term Care Facility Application for Medicare and Medicaid dated 8/20/24 documented 133 residents reside in the facility. 36969 42834

Based on interview, record review, and observation the facility failed to provide supervision to prevent falls for 1 of 14 resident (R5) reviewed for falls in the sample of 33. Findings Include: On 10/26/23 at 11:48 AM V17, Certified Nurse's Aide, CNA assisted R5 with transferring R5 from the bed to the wheelchair and then from the chair back to bed with gait belt. R5's Face Sheet, undated, documents R5's has diagnoses of unspecified dementia, repeated falls, and fracture of unspecified part of neck of left femur, R5's Minimum Data Set (MDS) dated [DATE] documents R5 is a limited assistance of one staff for transfers. R5's MDS documented that R5's balance was not steady only able to stabilize with staff assistance for going from seated to standing and moving on and off the toilet. The MDS documented R5 required one-person physical assistance with transfers and toileting. The MDS also documents R5 is severely cognitively impaired. R5's Fall Risk Acuity form dated 6/8/23 documents that R5 is not high risk for falls. R5's Incident/Accident report, dated 7/16/23, at 4:45 PM, documented resident found on floor @ (at) foot of bed, legs extended towards doorway on her back. The Report documented cont. (continue) visual check. Resident not left unattended in restroom. R5's Nurse's Noted dated 7/16/23 documents at approximately 4:45 PM. This nurse was in hallway providing care for other residents during a code yellow alert, resident roommate noted to be shouting for help. this writer and 2 Certified Nursing Assistants (CNA) went to room immediately. Resident (R5) was found lying on her back with (BLE) bilateral lower extremities extended outward towards the door and head near her footboard. Resident (R5) reported she had gotten herself out of the bathroom since she knew everyone was busy. Resident assessed for injury. ROM WNL (Range of Motion Within Normal Limits). able to bend at bilateral knee and ankles, reports pain to left knee. neuro assessment WNL. denies hitting head on floor, reports she went down sideways onto her knee and side. neurological assessment continues. grips equal, pupils equal and light reactive. VSS (Vital Signs) 98.7 (temperature)-98 (pulse)-22 (respiration)-145/89 (blood pressure)-98% (oxygen saturation level) RA (room air). Resident presents very restless pertaining to fall. Assisted back upright to wheelchair with 2 staff assist. tolerated OK, able to bear weight with complaints of pain. later transfers to toilets with one assist via pivot transfer with complaints. The Note documented that R5's medical doctor (MD) was notified and ordered a Xray of left knee. R5's Nurse's Note dated 7/16/23 at 8:15 PM documented staff & (and) resident education provided, resident not to be left unattended in restroom. resident education provided on call light use, safety precautions, proper body mechanics to prevent injuries. increased visual checks and monitoring to continue. R5's Radiology Report dated 7/16/23 documents an Acute Distal Diametaphyseal Fracture. R5's Nurse's Note dated 7/17/23 documents R5 had an acute distal diametaphyseal fracture of left femur. R5's Nurse's Note, dated 7/17/23 at 11:10 AM, documented that MD wanted R5 sent to emergency room to treat fracture. Care Plan dated 10/24/23 documents Problem: Increased susceptibility to falling that may cause physical harm R/T (related to) H/O (history of) frequent falls, age related debility, uses of assistive device (walker, cane), visual/hearing difficulties, incontinence, impaired physical mobility, poor safety awareness, poor insight into deficits. 5/3/20 fall in bedroom, no injury. 5/28/20 fall in room, no injury. 7/16/23 fall in bedroom, fractured L femur. Fall Interventions are toileting every 2 hours, staff to make frequent checks while she is in her room, shoes or nonskid socks, review medication regimen. On 10/27/23 at 11:00 AM V2 Director of Nursing (DON) stated We placed her on the toilet, and then we had a code yellow. She (R5) thought we were busy and tried to put herself to bed. On 10/27/23 at 11:30 AM V30, Certified Nurse's Aide, CNA stated, I remember someone yelling for help. A group of us ran to the room. She (R5) was on the floor in front of the wheelchair. She was either coming out or going into the bathroom. We work together on that hall. I didn't place her on the toilet. On 10/27/23 at 11:48 AM V29, Nurse Practitioner, so the hard part of this I didn't assume care until after this fall. In general, it would depend on if the patient could put on the call light when they are done. You would expect them to pull the light. The facility policy Fall Prevention Program, dated 9/16/22, documents each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.

Based on interview, record review, and observation the facility failed to provide safe transfers to prevent falls for 1 of 17 residents (R117) reviewed for falls in the sample of 49. This failure resulted in R117's falling and sustaining a right elbow fracture. Findings Include: R117's Minimum Data Set (MDS) dated [DATE] documents R117 is cognitively intact and requires Extensive Assistance with 2 person physical assist in transfer; moving from seated to standing position-not steady, only able to stabilize with staff assistance; surface-to-surface transfer-not steady, only able to stabilize with staff assistance. R117's Face Sheet undated documents R117 diagnoses as [CONDITION(S)], unspecified affecting right dominant side, Muscle weakness, [CONDITION(S)] following cerebral infarction. On 09/13/22 at 3:46 PM, R117 stated An agency Certified Nursing Assistant (CNA) (V28), got her (R117) right arm in the bed side rail when the CNA tried to help (R117) out of bed. R117 stated, The CNA did not know what she was doing. After I slid to the floor with my arm caught in the side rail, the CNA left me. I started yelling for help. It happened around 8:45 AM. I was taken to a local hospital. The staff are getting me up tomorrow using the mechanical body lift. The Fall Investigation dated 9/12/22 documents R117 was lowered to the floor from bed. Complaining of right side of temple pain and right elbow pain. R117 was sent to local emergency room (ER). V28, agency CNA, interviewed stating she left R117 on the side of bed with her legs dangling off bed and upper body lying back on bed to get someone to help her with the transfer of R117. The staffing agency was contacted, and V28, CNA, was placed on the Do Not Return (DNR) list. R117 returned to the facility with right elbow fracture. Corrective Action: Interdisciplinary Team (IDT) recommendation dated 9/12/22 Make sure 2 staff members, lift, bed to floor. A undated note attached to the 9/12/22 Fall Investigation from V28, CNA, documents, I came in (R117's) room to get her ready for breakfast I started to sit her up but I needed assistance I left her (R117). She (R117) had her legs on the side of the bed partially laying back and when I made it back to her room nurses where in her room and she said she fell on the floor. On 9/15/22 at 2:40 PM, V24, CNA, states, Yes, I was here that day that the fall happened. Everyone knows (R117) is a 2 person assist. It was an agency CNA and did not take her time. She wanted to rush and get things done but you can't rush through everything. We all convened to (R117's) room when (R117) called out for help. On 9/16/22 at 11:30 AM, V2, Director of Nursing (DON) states, To avoid things like this we have care cards in each residents room because we want staff to know to care for our residents. It was also there because we do hire agency staff and it was there to help them. My expectations are that they would follow the care cards to avoid problems like this. My expectations are that all staff follow the care cards. R117's Hospital records dated 9/12/22 documents diagnosis: closed non displaced fracture of the right radius.

Based on observation, record review and interview the facility failed to timely identify, assess, and monitor the formation of a pressure ulcer for 1 of 4 residents (R114) reviewed for pressure ulcers in the sample of 65. This failure resulted in R114 developing an unstageable pressure ulcer on her elbow. Findings Include: R114's Minimum Data Set (MDS) dated [DATE] documents R114 has moderate cognitive impairment. R114's Electronic Health Record (EHR) Progress Note dated 6/24/21 documents, report was received from a regional hospital. We were informed that a [AGE] year old Caucasian female who fell on [DATE], and was admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R114's Baseline Care Plan Observation/Admission Note dated 6/24/21 documents R114 has bruises to her arms, hands, and right hip. She has a surgical incision to her right hip and leg. R114 has a bruise to her left and was an intravenous site. R114's buttocks and coccyx were red. R114's Baseline Care Plan Observation/Admission Note dated 6/24/21 does not document a pressure ulcer to R114's right elbow. R114's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R114's EHR Progress Note dated 6/25/21 documents R114 has a sling to her right arm. R114's EHR Progress Note dated 6/27/21 documents R114's skin color is pink right arm sling in place. Heel protectors are in place. R114's Skin Monitoring: Comprehensive CNA (Certified Nursing Assistant) Shower review form dated 6/27/21 documents R114 skin is clear and nothing is new. R114's EHR Progress Note dated 7/7/21 documents, guest c/o (complained of) right elbow pain. Sling removed and noted a pressure ulcer 1.5 cm (centimeters) x 2.0 cm. Area around open area red. (V12's, Medical Doctor {MD}) office notified for TX (treatment) orders. Was notified by PT (Physical Therapy) and they stated 'she is keeping her elbow drawn back on to bed.' Need to make sure sling is tighter and arm across abdomen. It also documents that R114 is friendly and cooperative. R114's Wound and Skin Care Management Documentation Form dated 7/7/21 documents the right elbow wound was not present upon admission. The right elbow wound measures 1.5 cm x 2.0 cm is an unstageable pressure injury: obscured full-thickness skin and tissue loss with slough R114's dressing is [MEDICATION(S)]. R114's Wound and Skin Care management Documentation Form dated 7/14/21 documents R114's right elbow wound measures 2.0 cm x 2.0 cm is an unstageable pressure injury: obscured full-thickness skin and tissue loss with slough. Her dressing is [MEDICATION(S)]. R114's Weekly Pressure Injury Log dated 7/18/21 through 7/24/21 documents her right elbow pressure ulcer is unstageable, and it measures 2.0 cm x 2.0 cm, and has a scant serous drainage. R114's treatment Is [MEDICATION(S)] twice daily. R114's Wound and Skin Care Management Documentation Form dated 7/28/21 documents R114's right elbow wound measures 2.0 cm x 2.0 cm is an unstageable pressure injury: obscured full-thickness skin and tissue loss with slough. On 7/29/21 at 10:30 AM, V4, Licensed Practical Nurse (LPN), entered R114's room and informed R114 that she was going to change her dressing. V4 removed the old dressing dated 7/28/21. V4 placed [MEDICATION(S)] and a new dressing on R114's elbow. V4 stated, She complained of elbow pain and we removed the Sling, and found the pressure ulcer. R114's elbow pressure ulcer was red around the perimeter measuring about 1.5 inches by 1.5 inches. On 07/29/21 at 12:25 PM, V5, Care Plan Nurse, stated, She (R114) had a sling on her arm from the hospital. When it was taken off, it (the right elbow pressure ulcer) was there. It was found on 7/7/21, and she was admitted on [DATE]. We looked at her arm on admission and she didn't have a pressure ulcer. She (R114) was supposed to wear the sling for 4 weeks, and then it can come off. That's why the sling is not on this week. On 7/29/21 at 3:56 PM, V12, Medical Doctor, stated, She (R114) was refusing to move; she is refusing therapy. She was resistant to care, it was challenging. She was refusing to get out of bed. It doesn't surprise me she got a pressure area. If she was allowing care, we may have seen the redness before the pressure area. The facility's Wound Care and Management policy and procedure, dated 7/16/18, documents, Policy Statement Residents who enter the facility without pressure ulcers do not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable. The NPUAP (National Pressure Ulcer Advisory Panel) at https://cdn.ymaws.com/npuap.site-ym.com/resource/resmgr/npuap_pressure_injury_stages.pdf documents the definition, Unstageable Pressure Injury: Obscured full- thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed.

Based on observation, interview and record review the Facility failed to ensure all staff were following Center for Disease Control and Prevention (CDC) guidelines for wearing the proper Personal protective Equipment (PPE) in a nursing home setting. This has the potential to affect all 128 residents living in the Facility. Findings include: On 7/27/2021 at 11:35 PM to 11:55 PM, V9, Cook, was assisting in the kitchen and preparing food. V9 was not wearing any mask to cover her mouth and/or nose. V9 continued to grind pork for sausage without her nose being covered while preparing residents' food. On 7/27/2021 at 12:05 PM, V10, Dietary Manger, stated, (V9) should be wearing a mask that covers her mouth and nose. With COVID and everything, I expect all staff to be wearing a mask with their mouth and nose covered when preparing residents' food. On 7/27/2021 at 2:44 PM, V1, Administrator, stated I expect all staff when working the floor to wear a mask. I would expect kitchen staff to wear mask covering their mouth and nose when serving food. The Facility's COVID Policy Changes: Vitals Monitoring and Mask Use dated 3/18/2021 document, The mask is to cover your mouth and nose at all times. If your mask becomes loose and does not provide a tight seal of protections, it must be replaced with a new mask. The Facility's Resident Census and Conditions of Residents form, CMS 672, dated 7/27/2021 documented there were 128 residents residents living in the facility.

Based on observation, interview and record review the facility failed to dispose of expired medications and ensure in use insulin was dated and labeled for 9 of 9 residents (R7, R25, R26, R32, R44, R76, R77, R117, R124) reviewed for medications in the sample of 65. Findings include: On 7/29/21 at 10:35 AM, upon investigation on Maple (600) hall medication cart with V4, Licensed Practical Nurse (LPN), 1. R7's [MEDICATION(S)] insulin pen was not dated, and both the [MEDICATION(S)] insulin pen and [MEDICATION(S)] insulin pen were not labeled. 2. R44's [MEDICATION(S)] insulin pen was not dated, and both the [MEDICATION(S)] insulin pen and the [MEDICATION(S)] insulin pen were not labeled. 3. R124's Novolog insulin pen and [MEDICATION(S)] insulin pen were not labeled. 4. R26's [MEDICATION(S)] insulin pen and Humolog insulin pen were not labeled. 5. R32's [MEDICATION(S)] insulin pen was not labeled. On 7/29/21 at 10:15 AM, upon investigation on Hickory (700) hall medication cart with V8, Registered Nurse (RN), 6. R117's Novolog insulin bottle was not dated, and her [MEDICATION(S)] insulin pen was not labeled. 7. R76's [MEDICATION(S)] flex insulin pen was not labeled. 8. R25's [MEDICATION(S)] insulin pen was not dated. On 7/29/21 at 10:25 AM, upon investigation on [MEDICATION(S)] (800) hall medication cart with V6, LPN, 9. R77's [MEDICATION(S)] insulin pen had no label. R72's [MEDICATION(S)] pen did not have a label. On 7/29/21 at 10:45 AM, upon investigation on Evergreen (900) hall medication cart #1 with V7, LPN, showed a facility stock medication fiber powder was opened in the cart that expired 3/2021. V7 said expired medications should be discarded and should not be on the medication cart. During an interview on 7/29/21 at 12:30 PM, V2, Director of Nursing (DON), said expired medications should not be on the medication carts. The nurses are responsible for removing expired medications from the carts and pharmacy staff check the carts monthly as well. V2 also said all insulin should be dated when opened because they expired 28 days after opening. V2 did not know if insulin should be labeled or not. The facility's insulin storage policy, revised 4/1/2014, documents in part Policy statement: to ensure insulin is stored safely and at its optimal quality. Procedure: must date vial when opened and discard after 28 days. The facility's storage and expiration dating of medications policy, revised 10/28/19, documents in part procedure: once any medication package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dated for opened medications.

Based on observation, interview and record review the facility failed to supervise 1 of 3 residents (R2) reviewed for wandering unsupervised in the facility in the sample of 6. Findings include: R2's Physician order [REDACTED]. On 01/16/20 at 9:01 AM, V1, Administrator stated, (R2) has dementia and he is on locked down Dementia Unit in the facility, he really does not know what he is doing and is cognitively impaired. R2's Minimum Data Set, (MDS), dated [DATE] document R2's cognition is severely impaired. On 01/24/20 from 9:50 AM - 10:45 AM, R2 was in his wheelchair in the locked down Dementia Unit. R2 was sitting at the dining room table alone. No staff were observed nearby or in the dining room. R2 was not receiving any one on one care from staff. No staff member was observed to be in close proximity to R2 or sitting next to R2. On 01/24/20 at 9:50 AM, When V15, LPN was questioned she stated she was unaware if, R2 was still receiving 1:1 care and requiring close supervision. On 01/24/20 at 10:01 AM, V14, Certified Nursing Assistant, CNA, was questioned and V14 stated, she was unaware if R2 was still receiving 1:1 care and requiring close supervision. On 01/16/20 at 12:17 PM, V2, Director of Nursing stated, (R2) is private pay and we asked the family to do one on ones with him after he was found in a female resident's room touching her inappropriately. However, currently the facility is providing the 1:1 and Yes, we are doing the 1:1. I am not sure we have our students watch him. I am not sure why no one was watching (R2). R2's Care Plan does not document previous behaviors of being sexually, inappropriate prior to 01/09/20. R2's Care Plan does not document any behavior of wandering in and out of other residents' rooms. R2's Care Plan documents, R2 had 3 altercations with resident to resident abuse on 03/04/19, 03/26/19 and 10/03/19. R2's Care Plan failed to develop person-centered interventions to prevent, R2 from wandering. R2's Care Plan does not identify or address any type of abuse. R2's Behavioral Tracking, does not document R2 wandering into other residents' rooms, resident to resident abuse or verbal sexual comments made by R2 to residents and staff. On 01/24/20 at 10:01 AM, V14, CNA, We try our best to keep an eye on (R2), but sometimes he gets loud and, in your face, and he will hit staff. Yes, (R2) likes to wander in out of resident's rooms. On 01/24/20 at 9:50 AM, V15, Licensed Practical Nurse, LPN, stated, R2 can be pleasant but, he has his moments when he becomes agitated and aggressive. He makes sexual comments to staff, he will say things like, If I had a lady like you, I could keep you satisfied or if you ever needed a man. He makes innuendos and is flirty. He will try and grab your arm during care, yell out and swear. We try and keep him busy; he likes to wander into other rooms. He needed to be on 1:1 but, it is just not possible all the time. I am not sure if he is currently on 1:1. On 01/16/20 at 9:22 AM, V11, Family of R2 stated, On 12/31/19 at 3:00 PM, I received a call from the facility telling me my father was found in another resident's room the evening before touching a female resident inappropriately and the Facility demanded a family member come in and sit with (R2), 24 hours/7 seven days a week. R2's Nurses Notes dated 12/31/19 at 5:41 PM, Late entry: Certified Nursing Assistant, (CNA), reported last night this resident (R2), was found in female peer's room. Resident was removed and taken to his room and no further incident reported. R2'S Care Plan, Problem date of 12/05/18 documents, Gated Community/Discharge Plan, no plans for discharge related to need for 24-hour care and supervision. Assess frequency of disorientation and wandering. R2's Care Plan does not document any previous behaviors of being sexually inappropriate prior to 01/09/20. R2's Care Plan does not document any behavior of wandering in and out of other residents' rooms. R2's Care Plan documents R2 had 3 altercations with resident to resident abuse on 03/04/19, 03/26/19 and 10/03/19. R2's Care Plan failed to develop person-centered interventions to prevent R2 from wandering. R2's Care Plan does not identify or address any type of abuse. On 01/16/20 at 3:13 PM, V10, CNA stated, (R2) is a people person. Yes, he sometimes wanders but, we try and stay on top of things. (R2) likes to crack jokes. Yes, I have caught him trying to go into other's rooms. Yes, (R2) has made inappropriate comments about my breast, sexual things to me. V8's statement dated 12/30/19 documents I noticed the door to the female resident's room (R4) was closed. I walked in and male resident (R2), had wheeled up to her bed. Pulled back covers, lifted up gown and was feeling around her chest and brief. I removed male resident from the room immediately and made sure female resident was okay. The resident was reported to the nurse. On 01/16/20 at 11:10 AM V6, Dementia Director, stated, I was informed that (R2) went into a female peer's room (R4), on 12/30/19 at 6:30 PM, and (V8) the female CNA who was putting residents to bed noticed the door was shut to the ladies' room. (V8) was curious because neither of the residents walk, so she opened the door and found (R2) was next to (R4's) bed touching her breast area, and over her brief while she was asleep. Currently he is on a secure unit. Yes, (R2) wanders. The Facility Behavioral Health Services Policy with a revision dated of 07/16/16 documents, The (Facility) will provide sufficient staff to provide direct services to residents with the appropriate skills sets to provide nursing and related services. The staff of (dementia unit) shall provide visual supervision of the residents while the residents are in the indoor or outdoor activity areas.

Based on obervation, interview and record review the facility failed to address safety of wandering, sexual behavior, and resident to resident abuse in residents with Dementia, for 1 of 6 residents, (R2) reviewed for Dementia care in the sample of 6. Findings include: R2's Physician order [REDACTED]. R2's POS also documents [REDACTED]. R2's current POS, does not document R2 as having any behaviors. On 01/16/20 at 9:01 AM, V1, Administrator stated, R2 has Dementia and he is on locked down Dementia Unit in the facility, he really does not know what he is doing and is cognitively impaired. R2's Minimum Data Set, MDS, dated [DATE] document R2's cognition is severely impaired. On 01/24/20 from 9:50 AM - 10:45 AM, R2 was in his wheelchair in the locked down Dementia Unit. R2 was sitting at the dining room table alone. No staff were observed nearby or in the dining room. R2 was not receiving any one on one care from staff. No staff member was observed to be in close proximity to R2 or sitting next to R2. On 01/24/20 at 9:50 AM, When V15, LPN was questioned she stated she was unaware if R2, was still receiving 1:1 care and requiring close supervision. On 01/24/20 at 10:01 AM, V14, Certified Nursing Assistant, CNA, was questioned and V14 stated she was unaware if R2 was still receiving 1:1 care and requiring close supervision. On 01/16/20 at 12:17 PM, V2, Director of Nursing stated, R2 is private pay and we asked the family to do one on ones with him, after he was found in a female resident's room touching her inappropriately. The family was fine with it until, they got the bill. We put R2 on the medication [MEDICATION NAME]. We changed him to a different Hall, but he is still on a locked Dementia Unit. We will wean R2, off the [MEDICATION NAME] medication if he does not have any more episodes. We haven't talked about how long he will be on the medication, as it has not even been 14 days yet. R2's Care Plan Behavioral Symptoms dated 01/23/19, documents, Attention seeking behavior, will deliberately put self on the floor. Likes the attention that he gets from staff. Laughs and boasts about it after the fact. 01/09/20 [MEDICATION NAME] daily to suppress sexual inappropriateness. Approaches document, 01/10/20 Hormone therapy, ([MEDICATION NAME]), initiated, 01/02/20, 1 on 1 sitter, 01/02/20 moved room. R2's Care Plan Problem date of 12/05/2018 documents, Cognitive Loss /Dementia. Alteration in cognitive status, (cognitive loss), related to dementia. Potential for changes in level of consciousness, behaviors, cognition, [MEDICAL CONDITION], related progression of dementia. R2's Care Plan, Behavioral Symptoms dated 12/05/2018. R2 has alteration in behavioral/mood related to Dementia, receives Memantine. Displays agitation with staff when performing care, and agitates peers at meals. 03/04/19 had altercation with a female peer which resulted in a skin tear on her hand. They were separated, no further issues. On 03/26/19 Attempting to take a female peer's glasses from her, then squeezed her left hand, separated, no further issue. On 10/03/19, R2 slapped a female peer in the face more than once. He was admitted to (Psychiatric Hospital) for evaluation. R2's Medical Records document upon R2's return from the Psychiatric hospital on [DATE], there were no interventions put into place to address R2's behaviors or Physical Altercation. R2'S Care Plan Problem date of 12/05/18 documents, Gated Community/Discharge Plan, no plans for discharge related to need for 24-hour care and supervision. Family does not want to be asked about discharge with all assessments. Do Not Resuscitate. Approach start date: 12/05/2018, Assess frequency of disorientation and wandering. R2's Care Plan does not document previous behaviors of being sexually inappropriate prior to 01/09/20. R2's Care Plan does not document any behavior of wandering in and out of other residents' rooms. R2's Care Plan documents R2 had 3 altercations with resident to resident abuse on 03/04/19, 03/26/19 and 10/03/19. R2's Care Plan failed to develop person-centered interventions to prevent R2 from wandering. R2's Care Plan does not identify or address any type of abuse. R2's Behavioral Tracking does not document R2 wandering into other residents' rooms, resident to resident abuse or verbal sexual comments made by R2 to residents and staff. On 01/24/20 at 1:50 PM, V6, Dementia Director, stated (R2) when he went out to the Psychiatric Hospital, in (MONTH) 2019, he came back with a [DIAGNOSES REDACTED]. I think they just forgot to update his chart with the new diagnosis. On 01/24/20 at 10:01 AM, V14, CNA stated, If (R2) sees a new girl he will make his move and say something sexually inappropriate to them. He will for example ask the staff with large breasts if they have any milk for him to drink or suck on things like that, he wanders in and out of rooms. We try our best to keep an eye on him, but sometimes he gets loud and, in your face, and he will hit staff. Sometimes he is pleasant. He can go from zero to sixty in seconds. I am not sure if he is on 1:1 currently. On 01/24/20 at 9:50 AM, V15, LPN, stated, R2 can be pleasant but, he has his moments when he becomes agitated and aggressive. He makes sexual comments to staff he will say things like, If I had a lady like you, I could keep you satisfied or if you ever needed a man, he makes innuendos and is flirty. He will try and grab your arm during care, yell out and swear. We try and keep him busy, he likes to wander into other rooms. He needed to be on 1:1 but, it is just not possible all of the time. On 01/16/20 at 9:22 AM, V11, family of R2 stated, On 12/31/19 at 3:00 PM, I received a call from the facility telling me my father was found in another resident's room the evening before touching a female resident inappropriately and the facility demanded a family member come in and sit with (R2), 24 hours/7 seven days a week. R2's Nurses Notes dated 12/31/19 at 5:41 PM, Late entry: CNA, reported last night this resident was found in female peer's room. Resident was removed and taken to his room and no further incident reported. On 01/16/2020 PM, at 2:19 PM, V3, Assistant Director of Nursing, ADON, stated, Yes, (R2) wanders in and out of room. I know some of the staff stated he liked to put himself on the floor to look at female breasts when they bend down. No, I am not aware of him ever touching anyone or saying inappropriate things. (R2) has Dementia and is on a locked unit. On 01/16/20 at 3:13 PM, V10, CNA stated, (R2) is a people person, yes, he sometimes wanders but, we try and stay on top of things. (R2) likes to crack jokes. Yes, I have caught him trying to go into other's rooms. Yes, (R2) has made inappropriate comments about my breasts, sexual things to me. On 01/16/20 at V12, Physician of R2 stated, this was not R2's first episode, he has a history being verbally sexually with staff and physical with other residents. R2 has made sexual comments and innuendo to staff. There has been a lot of discussion with the team on what to do with R2. I have been following R2 now for several years as he was in an assisted living before coming to the facility. Antidepressants can kill libidos and R2 has been on antidepressants and because, of his behaviors of getting in your face, hollering and now the sexual abuse I ordered the [MEDICATION NAME]. V8's statement dated 12/30/19 documents I noticed the door to the female resident's room R4's door was closed. I walked in and R2 had wheeled up to R4's bed. Pulled back covers, lifted up R4's gown and was feeling around her chest and brief. I removed R2 from the room immediately and made sure R4 was okay. This was reported to the nurse. On 01/16/20 at 11:10 AM V6, Dementia Director, stated, I was informed that R2 went into a female peer's room, R4's on 12/30/19 at 6:30 PM, and CNA, V8 was putting other residents to bed noticed the door was shut to R4's room. V8 was curious because, neither of the residents walk, so she opened the door and found R2 was next to R4's bed touching her breast area, and over her brief while she was asleep. R2 does make sexual comments to staff and he likes to put himself on the floor and look down staff's shirt, R2 had never touched anyone before. We met with the family and his daughter expressed her father was a Casanova. We immediately called the victims daughter, Power of Attorney, notified the Sheriff's Department, notified R2's family, and contacted Illinois Department of Public Health, (IDPH). I immediately moved R2 to a different hall the next day. I told the family to provide 1 to 1 and the family agreed. We thought it was the family's responsibility to pay for the care. The family agreed but, were upset about the cost. We gave them contacts for the agency for staffing 1 on 1's. Also, the daughter was going to call other facilities to see about transferring her father. I was trying to assist her in finding another facility with Dementia Unit, and because, of his sexual behaviors the outside facility, said they could not meet his needs. I did call a second outside facility and they couldn't accept him either. I also called a third and fourth outside facility, but no-one would take him. Currently he is on a secure unit. I called the Ombudsman on 01/02/20 and didn't hear back and called her again, because of the holiday. I requested advice and she told me she didn't have an idea; this was tough for everybody. We did a Care Plan meeting on 01/09/20. The family likes this facility and referenced not to move but, the sitter cost was too expensive, R2 is private pay. The son suggested since he is in bed at night to have sitter during waking hours and move his wheelchair to the bathroom, so he can't see it and won't transfer himself. The Ombudsman said it was the facility's responsibility for the 1 to 1, so our attorney is looking into it. We also added a vinyl door covering to deter others who walk from entering, R2's room at night. The family agreed to trying a female hormone. The family told us they were open to medication changes, and the Director of Nursing suggested a female hormone to the family, and they were agreeable. The victim's family was concerned and asked for the police report and I gave her the number. She came in and we met face to face, explained that the male peer, R2 had been moved and would not have contact with her mother, R4. She was satisfied and said she felt safe now. Our goal is to keep everyone safe. Yes, R2 wanders. The Facility's Behavioral Health Services Policy with a revision date of 12/01/2011 documents, It is the policy of (Facility) that each resident must receive and (Facility) must provide the necessary behavioral health care and services and medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well- being, in accordance with the appropriate skills sets to provide nursing and related services. The Interdisciplinary Team, (IDT), will utilize information from the Preadmission Screening and Resident Review, (PASARR), process as well as to complete a comprehensive assessment of resident needs, strengths, goals, life history and preference using the Resident Assessment Instrument, (RAI), specified by Center for Medicare and Medicaid Services. The undated Criteria for Admission Special Care Unit Designation Policy documents, Admission Criteria, are not danger to themselves or others, do not negatively affect the wellbeing of other residents on the unit, and meet the admission criteria of (Facility). The staff shall provide visual supervision of the residents while the residents are in the indoor or outdoor activity areas. The central location of the nurse's station allows the charge nurse to observe both dining rooms and courtyards.

Based on interview and record review the facility failed to adequately develop an ongoing infection control program that; adequately collects data to calculate and analyze infection rates, and failed to operationalize infection control policies to adequately define infection control practice in the facility. This has the potential to affect all 136 residents living in the facility. Findings Include: The facility's Line Listing of Resident Infections(Infection Control Log), dated 05/17/19, documents R227 had a [DIAGNOSES REDACTED]. R227 was admitted from a local hospital with a UTI. R227 was placed on [MEDICATION NAME] 875 milligrams (mg) by mouth (po) every 8 hours for 7 days. The Line Listing of Resident Infections for R227 did not document the organism causing the UTI. The facility's Line Listing of Resident Infections, dated 05/30/19, documents R226 had a [DIAGNOSES REDACTED]. R226 was treated [MEDICATION NAME] mg po twice daily for 7 days. The Line Listing of Resident Infections for R226 did not document the organism causing the UTI. The facility's Line Listing of Resident Infections, dated 06/17/19, documents R224 had a [DIAGNOSES REDACTED]. R224 was treated with [MEDICATION NAME] 300 mg po twice daily until 6/20/19. The Line Listing of Resident Infections for R224 does not document the organism causing the UTI. The facility's Line Listing of Resident Infections, dated 06/27/19, documents R225 had a [DIAGNOSES REDACTED]. R225 was treated with Keflex 500 mg po four times daily for 14 days. The Line Listing of Resident Infections for R225 does not document the organism causing the infection. On 07/25/19 at 2:00 PM, V5, Infection Control Nurse, stated she had never received the hospital lab results for the residents from the rehab unit before, but she would start getting their information from the hospital. The facility's Infection Prevention and Control Program Policy and Procedure, dated 07/2019, documents the facility will designate one or more individuals as the Infection Preventionist who is responsible for the facility's infection prevention and control program. Surveillance, including process and outcome surveillance will include monitoring, data analysis, documentation and communicable diseases reporting. The facility's Resident Census and Conditions of Residents form, dated 07/25/19, documented the facility had 136 residents living in the facility.

Based on interview and record review the facility failed to monitor the use of antibiotics and failed to provide antibiotic stewardship for 5 of 5 residents (R224, R225, R226, R227, R31) reviewed for antibiotic stewardship in the sample of 52. Findings Include: 1. R224's Physician order [REDACTED]. The facility's Line Listing of Resident Infections (Infection Control Log), dated 06/17/19, documents R224 was admitted to the facility from a local hospital on [MEDICATION NAME] 300 mg by mouth (po). The Urine Culture and Sensitivity was not obtained from the local hospital, and the organism causing the UTI was not known. The organism's susceptibility to [MEDICATION NAME] was not known. 2. R225's POS, dated 06/27/19, documents R225 was on [MEDICATION NAME] (an antibiotic) 500 mg four times daily. The facility's Line Listing of Resident Infections, dated 06/27/19, documents R225 was admitted to the facility from a local hospital with a UTI, and he was treated with [MEDICATION NAME] 500 mg four times daily. R225's Urine Culture and Sensitivity was not obtained from the local hospital, and the organism causing the UTI was not known. The Organism susceptibility to [MEDICATION NAME] was not known. 3. R226's POS, dated 05/30/19, documents R226 was [MEDICATION NAME](an antibiotic) 250 mg twice daily for 7 days. The facility's Line Listing of Resident Infections, dated 05/30/19, documents R226 was admitted to the facility from a local hospital [MEDICATION NAME] mg twice daily for a UTI. R226's Urine Culture and Sensitivity was not obtained from the local hospital, and thus the organism was not known. The organisms susceptibility [MEDICATION NAME] not known. 4. R227's POS, dated 05/17/19, documents R227's was on [MEDICATION NAME] (an antibiotic) 500 mg every eight hours from 5/17/19 through 6/4/19. The facility's Line Listing of Resident Infections, dated 05/17/19, documents R227 was admitted to the facility from the local hospital on [MEDICATION NAME] 500 mg every eight hours for a UTI. R227's Urine Culture and Sensitivity was not obtained from the local hospital, and thus the organism was not known. The organism susceptibility to [MEDICATION NAME] was not known. On 07/25/19 at 2:00 PM, V5, Infection Control Nurse, stated, Those residents are from evergreen, and I will start getting their information from the hospital. 5. R31's Physician order [REDACTED]. On 07/23/2019 at 8:59 AM, R31 stated, I am constantly having UTI. I get them so easily. I just had a UTI and had to go out to the hospital back in June. It feels like I am always on some sort of antibiotic. R31's Nurses Notes, dated 06/26/2019 at 3:12 PM, document, Per overnight CNA (Certified Nursing Assistant). (R13) was disoriented to place and confused during care. She continues to complain about dysuria (discomfort with urinating). Encouraged to drink more water/fluids but is not compliant. Last UA (Urinalysis ) done was negative for Urinary Tract Infection on 06/20/2019. Temperature 96.4 degrees Fahrenheit, Heart Rate 66, Respiratory rate 16, Blood Pressure 162/78 and oxygen saturation 100% on room air. Message left for (V4), Physician's office. R31's Nurses Notes, dated 06/27/2019 at 4:58 PM, Received New Order per (V4, Physician), to start Bactrim Double Strength (DS) (an antibiotic) two times a day for 7 days related to Nursing UA results. R31's Nurses Notes, dated 06/27/2019 at 11:59 PM, documents, (R31) refused Bactrim DS to treat bladder infection. Stated that it doesn't work for her. Requested Keflex (an antibiotic) instead. (V4) notified and ordered Keflex 500 mg four times daily for seven days. R31's Nurses Notes, dated 06/29/2019 at 2:10 PM, documents, Sensitivity report came in and reported to Medical Doctor (MD)(V4). (V4) wanted resident to go to hospital and receive Intramuscular antibiotic. Resident is now receiving Keflex 500 mg four times a day for 7 days. Reported to POA (Power of Attorney) what the MD wanted to do and he stated, 'Let me think about it for a couple of hours to see if I want her sent to (local hospital). MD notified of POA does not want resident sent to hospital. R31's Nurses Notes, dated 06/29/2019 at 2:55 PM, Husband here and agreed to have resident transferred to (Local Hospital) for intramuscular antibiotic report given husband is taking her by private car. R31's Urinary Analysis Lab Report collected on 06/27/2019 at 2:30 PM, documents organisms are resistant to Bactrim and Keflex was not documented on the Urinary Analysis Report. R31's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. On 07/25/2019 at 3:33 PM, V2, Director of Nursing (DON), stated, I am not sure why (R31) received the antibiotics or why they were given when they are on the list as being resistant, noneffective towards the organism. The Facility's Antibiotic Stewardship Program, dated 11/01/2017, documents, The Facility's antibiotic stewardship program promotes the appropriate use of antibiotics and a system of monitoring to improve resident outcome and reduce antibiotic residence. Antibiotics will be prescribed for the correct indication, dose and duration to appropriately treat the resident while attempting to reduce the development of antibiotic resistant organisms or other adverse consequences or outcomes. The Antibiotic Stewardship Program will be incorporated in the overall infection prevention and control program and reviewed on an annual basis and as needed. It continues, 4. When diagnostics are ordered by the practitioner, the nurse will contact the lab/radiology to notify of physician order. It further documents, 6. If the resident admitted to (Facility) with an antibiotic offered, the nurse is to identify: a. Indication for use (diagnosis, lab/radiology results, symptoms, etc.). Documentation for dose, route and duration (ensuring stop date). 7. The nurse will observe and document effectiveness of antibiotic, side effects and potential adverse consequences. 1. Resident evaluation, vital signs and observation for symptoms will be identified and documented. B. Resident will be evaluated for signs/symptoms of [MEDICAL CONDITION] infection. C. Resident will be observed for potential side effects of the antibiotic. 8. The antibiotic will be discontinued when no longer necessary.

Based on observation, record review and interview, the facility failed to provide supervision and effective and progressive interventions to prevent falls for 2 of 12 residents (R36, R110) reviewed for falls in the sample of 52. Findings include: 1. The Fall Risk Assessment, dated 5/14/2019, documents R36 has intermittent confusion, poor recall, judgement and safety awareness and has balance problems while standing and walking. R36's Fall Risk score is 6 (score of 10 or higher represents a high risk for falls). R36's Minimum Data Set (MDS), dated [DATE], documents a BIMS (Brief Interview for Mental Status) score of 10, which is moderate impairment with cognition. The MDS documents R36 does not ambulate, requires assistance for transfer and toileting,and has unsteady balance, with no limitation with range of motion. R36's MDS, dated [DATE], documents she continues to have problems with balance and requires assistance with transfers with limited range of motion to the lower extremities. R36's Elopement Risk Observation, dated 5/13/2019, documents a history of wandering, is disorganized to place and has impaired decision making. On 7/23/2019 at 11:30 AM, R36 was observed in another resident's empty room going through the drawers. R36 was in a wheelchair. There was no staff around R36 and assistance had to be obtained to redirect her. R36 was alert, but confused. The Incident/Accident Logs for R36 documents falls on 3/31, 4/2, 4/31, 6/17, 6/23, 7/2 and 7/17/2019. The Incident/Accident Report, dated 3/31/2019 at 4:30 PM, documents, in part, R36 Missed the chair when transferring self from the toilet to the wheelchair. R36 had no injury. The intervention to prevent a repeat occurrence after the IDT (interdisciplinary team) met is documented Educated to try and wait for assistance before transferring self. The Incident/Accident Report, dated 4/2/2019 at 4:10 PM, documents R36 was found in a peer's room sitting on the floor by the bed and wheelchair, with no injury. The Report documents R36 stated, I was playing hide and seek, and no safety or assistive devices were in place. The Report documents, poor safety awareness, spontaneous, cognitive impairment. Corrective action taken/change to prevent a repeat occurrence-IDT-encourage to stay in common area. The Incident/Accident Report, dated 4/31/2019 at 4:15 PM, documents R36 was seated in the wheelchair, attempted to stand and slipped out of the wheelchair onto the floor. The Report has no documentation any safety or assistive devices were in place at that time. The IDT corrective action taken was non skid pad initiated. The Incident/Accident Report, dated 6/17/2019 at 1:50 AM, documents R36 was found on the floor in another resident's room. R36 had no injury. The Report documents R36 slid off the wheelchair. There is no documentation the nonskid pad was in place or any other safety device was in place at the time of the fall. The IDT corrective action documented is Continue same intervention, isolated, misjudged. The Incident/Accident Report, dated 6/23/2019 at 6:50 PM, documents R36 was found on the floor near the bed with the wheelchair behind her. R36 had no injury but was trying to get in the wrong bed. The IDT corrective action recommended is Staff to ask resident right after supper if she wants to lay down. Continue same interventions. There is no documentation in the Report that safety or assistive devices were in place for R36 at the time of the fall. The Incident/Accident Report, dated 7/17/2019 at 9:50 PM, documents R36 was again found on the floor with no injury. The IDT corrective action documented is Do not lay resident down too early in the evening, Resident enjoys a bed time snack most days. There is no documentation in the Report safety or assistive devices were in place. R36's Care Plan, dated as edited 7/19/2019, documents R36 is at risk for falls, has poor standing balance, poor safety awareness, and impulsiveness. 2. R110's Fall Assessment, dated 5/08/2019, documents he requires the use of a wheelchair, has confusion, poor recall, judgement and safety awareness, with a risk score of 17 (10 or higher is high risk). R110's MDS, dated [DATE], documents a BIMS score of 8, which is moderately impaired with cognition and requires assistance with transfers, ambulation and toilet use. The MDS documents R110 has no impairment with range of motion to the extremities and requires assistance with balance. R110's MDS, dated [DATE], documents he is unable to complete the BIMS and is now severely impaired with cognition and decision making. The MDS documents R110 has unsteady balance without staff assistance and has no limitation with range of motion. The Accident/Incident Logs documents R110 has had falls on 2/03, twice on 2/04, 2/17, 6/09 and 7/13/2019. The incident/Accident Report, dated 2/03/2019 at 12:00 PM, documents R110 was found on the floor of his room with a skin tear to the left inner arm. The IDT corrective action to prevent repeat occurrence is documented as Resident to ambulate with staff. There is no documentation any safety devices were in place. The incident/Accident Report for R110, dated 2/04/2019 at 7:15 AM, documents, in part, Resident hollered out help. Found sitting on the floor in room between TV (television) and wardrobe. R110 sustained a bruise to the lower left back area. R110 stated, I was going to the bathroom. There is no documentation any safety or assistive devices were used prior to the fall. The IDT corrective action is documented as Resident to ambulate with staff. The incident/Accident Report, dated 2/04/19 at 3:00 PM, documents R110 wheeled himself to a peer's room across the hall and slipped out of the wheelchair onto his buttocks. R110 had no injury. There is no documentation any safety or assistive devices were used prior to the fall. The IDT corrective action is documented as (non skid pad) to wheelchair seat. R110's Care Plan dated 7/10/2019 documents a chair alarm in recliner and wheelchair was added on 2/05/2019 for 30 days. The incident/Accident Report, dated 2/17/2019 at 4:40 AM, documents R110 fell in his room and hit his head. R110 suffered a hematoma to the back of his head. The Report documents a chair alarm was working. The IDT corrective action is documented as Staff to sit outside of resident's room when not completing rounds. Continue chair alarm and increased monitoring. The incident/Accident Report, dated 6/09/2019 at 1:45 PM, documents R110 had taken himself to the bathroom via the wheelchair. R110 attempted to sit down and missed the wheelchair. No injury occurred. The Report has no documentation any safety devices were in place at the time of the fall. The Report documents the floor was wet from being mopped. The IDT corrective action is documented as Wet floor signs should be put up before resident goes back to room. Also when resident says 'No' he doesn't want room cleaned. This should be respected. The incident/Accident Report, dated 7/08/2019 at 5:35 PM, documents R110 was attempting to ambulate pushing the wheelchair when he fell in the hall, landing on his back. No injury occurred. There was no documentation any safety or assistive devices were in place at the time of the fall. The IDT corrective action recommended to prevent further falls is documented as restorative evaluation. The incident/Accident Report, dated 7/17/2019 at 8:20 PM, documents R110 attempted to ambulate from the wheelchair to the bedroom with an unsteady gait and fell forward hitting his forehead, sustaining a hematoma. The Report has no documentation any safety mechanical/assistive devices were in place at the time of the fall. The IDT corrective action taken was documented as Assist resident to recliner when showing signs and symptoms of anxiousness, On 7/25/2019 at 10:30 AM, V6, Care plan/Restorative Nurse, reported there was no restorative evaluation completed for R110, nor was one located in the EHR (electronic health record). R110's Care Plan, dated as edited 7/23/2019, documents a chair alarm was restarted after the fall of 7/17/2019. On 7/25/2019 at 2:30 PM, R110 was seen asleep alone in his room with the lights off. R110 was seated in his recliner with a chair alarm attached and on. On 7/26/2019 at 9:30 AM, V2, Director of Nursing (DON), reported that use of sounding alarms to prevent falls agitates the residents on the Memory Unit. V2 stated, We try to put a stop and start date on the alarms. V2 reported when they place a resident on a close observation status to watch them to prevent falls, they do not document this information anywhere. The facility's policy and procedure, reviewed 4/16/2019 and entitled, Incident and Accident Response, Investigation and Reporting Policy, documents, (the facility) makes every effort to prevent accidents by providing a safe environment and free from any known hazards. The (facility) identifies residents at risk for falls and care plans address their risk assessment. The (facility) implements procedures in an attempt to prevent an accident/incident.

Based on record review and interview, the facility failed to notify power of attorney/emergency contact for 1 of 4 residents (R2) reviewed for notify of change in the sample of 8. Findings include: R2's Minimum Data Set (MDS), dated [DATE], documents severe cognitive impairment, and is an extensive assist from staff with bed mobility, toileting and personal hygiene. R2's Nurses Notes dated 3/2919 at 5:46 AM documents that R2 had a fall. And in that documentation or any other nurse's notes to follow, does it document R2's fall being report to her POA. On 4/11/19 at 10:45 AM, V7 Registered Nurse (RN) stated that she did not notify at that time, she waited until the POA came in that morning because she normally comes in on Fridays. I should have called after it happened. But I didn't. On 4/11/19 at 1:10 PM V2, Director of Nurses (DON), stated, She did notify the POA. It wasn't immediately. But I understand. I think she was going by the old policy. The facility policy on Condition Change dated 01/2019 documents under Procedure: #1 After all falls, injuries or condition changes, in part. # 3 Notify resident's responsible party. #4 Notification of the physician and family should be done as soon as possible after the incident. In that same documentation under: Documentation: #4 Notification of a physician and family.

Based on observation, record review and interview, the facility failed to provide good hand washing techniques to prevent the spread of infection for 3 of 11 residents, (R87, R117, R54) reviewed for toileting, incontinent and catheter care in the sample of 45. Findings include: 1. On 9/27/2018 at 9:51 AM, V11, Certified Nurses Aide (CNA) took R54 to the bathroom. V11 put on gloves and applied a gait belt to transfer R54 to the toilet. R54 had a small bowel movement while on the toilet. V11 assisted R54 to stand and instructed her to hold onto the side rail. While holding onto the gait belt with her gloved left hand, V11 used her gloved right hand to wipe R54's rectal area using toilet paper to remove the feces twice. Without removing her soiled gloves, V11 used her right hand to pull up the incontinent brief, pants and arrange R54's jacket and blouse. V11 then removed her gloves and transferred R54 back into the wheelchair. V11 then washed her hands. R54's Minimum Data Set ((MDS) dated [DATE], documents R54 requires assistance with of one staff for transfers, toileting and personal hygiene. The facility's policy and procedure, dated (YEAR) and entitled, PURPOSE: To cleanse hands to prevent the spread of potentially deadly infections, to provide a clean and healthy environment for residents, staff and visitors. To reduce the risk to the healthcare provider of colonization of infections acquired from a resident. 2. R87's MDS dated [DATE] documents R87 is totally dependent on staff for transfers and toileting, requires extensive assist for dressing, occasionally incontinent of bowel and has an indwelling urinary catheter. On 9/26/18 at 9:52 AM, V8 and V9, both Certified Nursing Aides (CNAs), provided catheter care to R87 in bed. R87 was uncircumcised, and his adult brief had moderate amount of stool on it. V8 retracted the foreskin and cleansed the head of the penis, cleansed the catheter from the meatal opening downwards, washed the groin area, dried the areas. V8 changed gloves. V8 and V9 turned R87 to his right, some dried feces on the upper inner buttocks and left ischial area. V8 cleansed the rectal area, changed gloves, applied clean briefs under R87 and missed cleaning the dried feces from the left ischial area. V8 and V9 put on clean briefs, and it was noted R87 had some dried feces and cleansed the missed spots. V8 and V9 washed hands after taking off their gloves at the end of the procedure.V8 and V9 changed gloves when moving from soiled to clean area during care but failed to perform any form of hand hygiene between glove changing. 3. On 9/26/18 at 11:12 AM, V9 and V10, both Certified Nursing Aides (CNAs), provided incontinent care to R117. V9 and V10 washed hands and gloved. V9 cleansed the vagina from front to back using the same washcloth with the same surface of the washcloth three times while V10 spread the labia. V9 cleansed the groin area. V9 and V10 turned R117 to her right side. V10 held R117 on her bare hip and upper thigh using the same gloves she wore while spreading the vaginal folds. R117 had a large, formed stool that just came out. V9 washed the rectal area, then rinsed the rectal area 3 times using the same surface of the rinsing washcloth. At this time, R117 voided and wet her inner thighs and the incontinent pad. V9 washed the rectal area again and V9 and V10 turned R117 to her back. Wearing the same pair of gloves, V9 cleansed the vagina from back to front. V9 rinsed the groin area 3 times with the same surface area of the washcloth. V9 dried the groin, across the vagina from back to front. V9 and V10 replaced their gloves without prior hand hygiene. V9 and V10 put a clean incontinent brief on R117 and straightened her covers. V9 and V10 took off their gloves and washed their hands and stated they were done with care. V9 and V10 failed to perform hand hygiene consistently between glove changing, failed to change gloves when moving from dirty to clean area during care and failed to use a clean surface of the of the same washcloth when washing the resident. On 9/27/18 at 3:01 PM, V2, Director of Nursing (DON) stated she expects staff to perform hand hygiene between glove changing, to change gloves from dirty to clean and discard the washcloth after one wipe to avoid any repeated contact of any area of the used washcloth.

A. Based on observation, record review and interview, the facility failed to provide supervision and progressive interventions to prevent multiple falls for 2 of 7 residents (R7, R54) reviewed for falls in the sample fo 45. Findings include: 1. R7's EHR (electronic health record) documents diagnoses, in part, as Dementia with Behavioral Disturbance, Displaced [MEDICAL CONDITION] radial styloid process and Anxiety. The Minimum Data Set, ((MDS) dated [DATE] documents R7 has a BIMS (brief interview of mental status) of 3 which is severely impaired with cognition and ambulates and transfers independently. The incident/Accident Report, dated 4/19/2018 at 10:30 AM, documents R7's Left arm is reddened, warm to touch and slightly [MEDICAL CONDITION]. Said did not fall. Not that I remember 10 cm (centimeter) X 4 cm bruise on left arm and bruise to right hip. An X-ray Report, dated 4/19/2018 documents R7 has a acute distal left forearm fracture. The injury of unknown origin was investigated for abuse and unsubstantiated. There is no intervention documented on the Report. The Incident/Accident Report, dated 5/04/18 at 12:44 AM, documents R7 was ambulating independently wearing slippery socks, fell in her room and sustained a displaced [MEDICAL CONDITION] trochanter. R7 was wearing a cast to her left wrist at the time of the fall. The intervention on the Report documents, Second serious fall in last month resulting in 2 fractures of bones, left distal radius; displaced fracture and now right hip. Encourage resident to wear anti-slip socks. R7 was taken to the hospital for surgical intervention. The Incident/Accident Report, dated 5/9/2018 at 10:10 PM, documents R7 was found on the floor mat next to her bed. The Report documents R7 was very anxious, but not injured. The intervention documented on the Report, Continue education on the call light-sporadically compliant, frequent room checks. The Incident/Accident Report dated 5/11/2018 at 1:00 PM, documents R7 fell to the floor while trying to go to the bathroom. No injury occurred. The intervention after this fall is documented on the Report as Med (medication) review-on ABT (antibiotic) for UTI (urinary tract infection). The Incident/Accident Report, dated 5/13/2018 at 9:00 PM, documents R7 attempted to transfer herself from the wheelchair, then slid to the floor landing on her buttocks. The report documents R7 was alert with confusion. The report documents interventions of Resident (R7) sat with nurse except at meal times. Transfer from wheelchair to dining room chair, anti-roll backs on wheelchair. The Incident/Accident Report, dated 5/26/2018 at 6:00 AM, documents R7 was found in her room on the floor next to her low bed with no injury. The intervention to prevent reoccurrence is Get out of bed as soon as possible in AM. The Incident/Accident Report, dated 6/03/2018 at 12:00 PM, documents R7 was again found on the floor, lying on her right side with no injury. The intervention documented will attempt to keep resident in more populated area while awake. The Incident/Accident Report, dated 6/07/2018 documents R7 was again found on the floor of her room near the bathroom and reported she fell against the wall, sustaining a 1 cm (centimeter) raised area on her scalp and an abrasion to the right elbow. The interventions documented are Continue to get out of bed as soon as awake and Room monitor initiated. The MDS, dated [DATE], documents R7 now requires the limited assistance of one staff for transfers, and no longer ambulates independently. The Incident/Accident Report, dated 7/24/2018 at 5:30 AM, documents, in part, Resident (R7) stood up from wheelchair alarm sounding, the fell forward left, landing on floor and left temporal region. Alert and confused. The interventions again recommend Staff to keep up in common area, monitor for dehydration/possible UTI, encourage to stay awake during the day, one to one attention, have resident stay busy by folding clothes. R7's Care Plan, dated as edited 9/25/2018, documents, in part, Increased susceptibility to falling that may cause physical harm related to history of falls ( 1 to 2 in last 3 months). The Care Plan documents on 6/14/18, a chair and bed alarm were added, but were discontinued on 7/16/18 due to R7 manipulating the tabs monitor/bed alarm). The Care plan documents a monitor remains in R7's room and at the nurses station. On 9/25/18 at 10:11 AM, R7's bed was low to the floor. R7 was in her wheelchair and moved about using her feet. On 9/27/18 at 12:45 PM. R7 was in bed awake while lying on her back. The bed was on the floor. 0 9/27/18 at 11:02 AM, R7 was still in bed, awake with the door closed. At that time, V34, Licensed Practical Nurse (LPN) stated, She (R7) had a bed and chair alarm but she broke them. Took them apart. The tab alarm she would unpin or hide. She's had a monitor since (MONTH) (YEAR). Alarms do not work for her. A monitor was sitting in the nurses station on the desk. On 9/27/2018 at 12:45 PM, R7 was back in bed with the door closed and the light out. R7 was awake and talking to herself. A few minutes later, on the sound monitor at the nurses station R7 could be heard talking with other muffled sounds in the room. On 9/27/18 at 1:30 PM, V22, Certified Nurses Aide, (CNA) stated, I went in to check on her and she was already out of bed, so I put her in the wheelchair. She tries to get up by herself. She's so fast. We check on her often, every 1 or 1 1/2 hour. The PT (Physical Therapy) assessment dated [DATE] documents, in part, for displaced fracture of right femur due to fall on 5/04/18. Pt (patient)ambulated independently without an AD (assistive device) through out memory unit with no limitations Required supervision for toileting and ADL's (activities of daily living) at time due to cognitive deficits and poor safety insight, Left arm cast for wrist fracture of 4/2018. Current level Supervision or touching assistance. 2. The EHR for R54 documents diagnoses, in part, as Dementia and Age Related Physical Debility. The MDS, dated [DATE], documents R54 is non-ambulatory, requires assistance of one for transfers, with poor balance for seated to standing and surface to surface transfers. The MDS documents R54 has a BIMS score of 5, which is severely impaired with cognition and has limited range of motion to her lower extremities. The Incident/Accident Report, dated 4/18/2018 at 7:00 PM, documents R54 fell in her room and was found on the floor. R54 sustained 2 skin tears to the right lower extremity. The Report documents R54's chair alarm was not working. The Report documents, Resident had a towel in chair making sensory not go off. The intervention documents, Up with assist-lacks safety awareness. Had towel in chair to prevent chair alarm from sounding. Towel removed. The Incident/Accident Report, dated 4/19/2018 at 12:30 PM< R54 slid out of the wheelchair and landed on her buttocks on the floor. R54 sustained a scratch to the right leg. The chair alarm was not sounding. The intervention documents, in part, No longer will be allowed to be in her room alone. Will check with family about last eye exam and possible checkup. The Report has no documentation a chair alarm was in place or working. The Incident/Accident Report, dated 5/20/2018 at 1:50 PM, documents R54 slid off the toilet while trying to clean herself after having a bowel movement. The intervention is to place a tabs alarm on the bathroom door to alert staff she is going to the bathroom. The Incident/Accident Report, dated 5/27/2018 at 6:15 AM, documents R54 was found in the dining room bathroom lying on her back. R54 sustained a skin tear to the left wrist. The intervention documented in the Report is, Reteach how to ask for help before trying to do it herself. Toilet prior to taking to dining room as needed and to encourage her to ask for assistance from staff. The Incident/Accident Report, dated 6/13/2018 at 1:45 PM documents R54 was found on the floor in front of the wheelchair with no injury. The interventions documented are, Educate resident about staff assistance. Bed ad chair alarms initiated. On 9/27/2018 at 4:00 PM, V2, Director of Nursing (DON) reported that telling a severely confused woman to remember to ask for help is not an effective intervention and alarms should be in working order. R54's Care Plan, dated 7/25/2018 documents she is at risk for falls related to history of falls prior to admit. The facility's policy and procedure, dated as revised 12/2014 and entitled, Fall Risk Observation Form, documents, in part, The facility uses the Fall Risk Observation form to assist in evaluating residents and identifying those residents who are at risk for falling. Incident/Accident reports are used to try and determine possible causes of incident/accident/falls by doing an investigation at the time of the incident. The investigation may assist in preventing further incidents/accidents by determining the possible causes/trends/patterns. B. Based on observation, interview and record review, the facility failed to appropriately secure wheelchair during vehicle transport for one of one residents (R284) reviewed for safe transport in the sample of 45. Findings include: 1. R284's Minimum Data Set (MDS), dated [DATE], documents, R284 was admitted to the facility on [DATE] from an out of state hospital. R284's MDS also identifies R284 having a Brief Interview of Mental Status (BIMS) score of 5 indicating that R284 has severe impaired cognition. R284's Encounter Information form from an out of state hospital documents, R284 was admitted to the out of state hospital from 8/30/18-9/5/18 after a fall from standing receiving bilateral pathologic femur fractures and having surgical repairs completed. A Computed Tomography (CT scan) dated 9/4/18 on R284 documents in part: 83 y/o woman with a history [MEDICAL CONDITION](Stroke), [MEDICAL CONDITION] in remission, who was admitted on [DATE] with fall from standing and bilateral pathologic femur fractures. Noted to have extensive lytic [MEDICAL CONDITION] on x rays. High suspicion for neoplastic process, [MEDICAL CONDITION] vs. myeloma. R284's Hospital course note dated 9/5/18 Identified bilateral pathologic mid femoral fractures resulting from a fall at home on 8/30/2018. On 09/26/18 at 09:55AM. R284 stated that she had been in an accident in the facility van because the driver was driving too fast and had to slam on his brakes. R284 further stated that she fell to the bottom of the floor of the van and had to be cut out of the seat belt by the ambulance staff. R284 also stated that she broke her right arm and two ribs from the accident. 9/14/18 5:30 PM Nurses Notes: Readmit from out of state hospital after car accident resulting in fracture right humerus, fx. (Fracture). r (right) 6th Rib, and left 10th rib. The Facility's incident investigation dated 9/18/18 documents: On 9/13/18 at approximately 7 AM resident was being transported to medical appointment in facility van, the employee driving the van reported he had to abruptly apply the brakes to avoid colliding with another vehicle. Resident fell forward in the van. EMS was called to transport resident to the hospital for evaluation. The investigation continues to document: On 9/14/18 R284 returned to facility with arm brace to right arm. Right humerus x-ray impression revealed diffuse appendicular lytic [MEDICAL CONDITION] can be seen in setting of metastatic disease or [DIAGNOSES REDACTED] with displaced pathologic [MEDICAL CONDITION] humerus. CT of lumbar spine with contrast impression revealed there are lytic [MEDICAL CONDITION] in the bilateral iliac bones and what appears to be a pathological [MEDICAL CONDITION] posterior 6th rib which may be secondary to metastatic disease of [DIAGNOSES REDACTED]. There is an acute [MEDICAL CONDITION] posterior 10th rib. During interview with employee, he was not sure if he applied the safety belt properly. The safety belt was still on her when she fell forward and was cut off by Emergency Medical Service (EMS) when they assisted her out the van. During an interview with V15 (Restorative Aid/Driver) at 11:00 AM on 9/27/18, V15 stated We were in a hurry rushing that morning for an early Doctor's appointment. There was a lot of traffic, the person in front of me suddenly hit his brakes and I hit my breaks, R284 went forward and fell out of the wheel chair. The chair did not move it was locked and stayed in place. The seat belt was around her waist and shoulders. I'm not sure if I attached the seat belt correctly because there were a whole lot of pieces lying about the van. I am not the regular driver; I might drive once a month. During an interview with V17, (R284's Power of Attorney/Daughter) on 9/27/18 at 11:24 AM, V17 stated I was present for the transfer for the appointment that morning and rode in the van with my mother. The usual van driver was not present that day. V15 had difficulty opening the gait on the van; it took him a very long time trying to figure out the seat belts, and how to lock them in place and how to apply the seat belts to the chair. The seatbelt was locked across the top/waist of my mother but it was not locked into the bottom of the van. I was seated up front in the passenger seat. I saw the red light at the intersection and saw people breaking but V15 did not even begin to break until I said something to him and he then slammed on the breaks. My mother fell to the floor onto her right side. When the local Emergency Medical Service (EMS) arrived they had to but the seat belt to get my mom out. EMS said that the seat belt had not been placed on correctly. My mother sustained three new fractures from the accident, fracture right humerus, fracture right 6th rib and fracture left 10th rib. The Local Emergency Medical Service (EMS) report dated 9/13/18 at 7:28 AM Narrative documents in part: Dispatched for an elderly female with a possible broken arm. Arrived on the scene to find the patient (R284) tangled up in a seatbelt in the backseat of a van. Patient (R284) is in severe pain, in her right arm and legs. Patient (R284) was in a van sitting in a wheel chair when the driver slammed on the brakes. The patient (R284) launched out of the wheelchair and was wrapped in the seatbelt and wedged between two seats in front of her. Seat belt had to be cut off the patient (R284). Cervical spine was cleared. Binder lift was placed around the patient for moving purposes. Patient (R284) was then lifted and laid backwards on a backboard for moving purposes, Patient (R284) is not ambulatory so patient (R284) was lifted with the back board and placed on the stretcher. EMS had an extensive on scene time due to patient extrication from the vehicle. Patient (R284) was secured with all straps and rails. Patient (R284) was loaded in the ambulance without incident. Full trauma assessment was done noting crepitus in upper right arm area and pain upon palpation in the thighs on both sides. Patient (R284) was given 4 mg of [MEDICATION NAME] and pain is now a 2. Patient's (R284) right arm was splinted. Pulse Motor Sensation was checked before and after splinting. On 9/27/18 at 10:40AM the van was observed in the facility's parking lot. There were numerous metal brackets and attachments noted throughout the van. There was one seat belt with a cut through it. The Facility's Transportation (Basic) Policy dated 3/2015 does not include directions on how to properly secure residents for transport. An in service Attendance Form dated 7/19/2018, completed on Securing wheelchair/passenger into grand [MEDICATION NAME]/ ramp safety and use of van for patient transport was presented by V27, (Auto Representative) documents that V28, (LPN- primary driver), V29, (Maintenance) and V30, (Activity Department) were the only staff directly in serviced on 7/19/18 from V27 the auto representative. During interview with V2 at 1:15 PM. V2 stated that V28 (LPN-Primary driver) in serviced V15 on securing wheelchair/passenger to [MEDICATION NAME]. The note documents I (V28) showed (V15) with return demonstration how to secure patient in wheel chair into van. I showed him how to function van as we were shown by the representative. The note is dated 7/19/18. The Wheel chair passenger Safety solutions user instructions document in part: Secure passenger 1. Attach Lap Belts- use integrated stiffeners to feed belts through openings between seat backs and bottoms, and /or armrests to ensure proper belt fit around occupant.

Based on observation, interview and record review the Facility failed to perform safe transfer techniques to prevent accidents and injuries for 2 of 12 residents (R1 and R2) reviewed for transfers in the sample of 12. This failure resulted in R2 falling from a sit to stand mechanical lift and sustaining a head injury requiring 5 staples. Findings include: 1. R2's Physical Therapy Plan of Care Notes with a start date of 10/26/2016 document in part, The patient has shown a decline in safe transfer status recently due to medically complex conditions resulting from dementia and weakness. Therapy Necessity: Therapy necessary for transfer training to improve safety with transfer for patient and staff. Without therapy patient at risk for greater dependence of care and loss of toileting on commode. Functional Deficit Other: Patient requires constant verbal cues during use of stand lift transfers to stand up and keep hands safely in lift. Current Level of Function: This patient is able to safely complete transfers requiring stand lift with maximum verbal and tactile cues to stand upright and maintain proper hand placement. This document was signed by Z1, R2's Physician, on 11/8/2016. R2's Minimum Data Set ((MDS) dated [DATE] document R2's Brief Interview for Mental Status (BIMS) score was a 5 out of 15 (severely impaired). R2's MDS documents she requires extensive assistance of one staff person (3/2) for transfers. Occupational Therapy (OT) Note signed by E14, Certified Occupational Therapy Assistant (COTA) on 12/14/2016 document in part, Guided patient to transfer to bed with use of sit to stand lift with staff present. R2's OT Note signed by E15, COTA on 12/15/2016 document in part, Instructed patient in functional transfer training from bed to wheelchair with the use of sit to stand lift. Educated patient to pull up more with handles to relieve pressure under arms. Patient took hand off lift when initially starting to stand, verbal cue and assist provided for replacement of right hand on grab bar. Patient did not attempt to remove hand again. R2's Progress Note, dated 12/19/2016, document at 6:21 PM Resident is not doing well with the sit to stand. She refuses to keep arms and hands on the lift. She is screaming a lot during attempts at transferring with sit to stand. The CNA (Certified Nurse's Aide) has to manually lift her because she refuses to use the sit to stand. R2's OT Note signed by E15 on 12/19/ document in part, Staff educated that patient is to resume sit to stand lift and to call if experiencing any difficulty. R2's OT Note dated 12/23/2016 document R2 was discontinued with OT using stand lift and positioning. R2's Progress Note, dated 12/25/2016, document at 4:52 PM, Resident is continuing to put arms inside of sit to stand and slides right out of sling; it takes 2 people to get her up so she doesn't fall out of sling. There is documentation in the Progress Notes on 12/25/2016, that R2 was having difficulty using the sit to stand but there is no documentation in the OT notes of staff notifying them of any difficulty. R2's Progress Note, dated 02/14/2017, documents at 10:01 PM, CNA reported to this nurse that resident had slid out of the sit/stand lift sling by tucking her arms inside the sling; resident had hit her head and bleeding couldn't be controlled; MD (Medical Doctor) was notified and resident was sent to the ER (emergency room ). Emergency Hospital Records with the Arrival date of 02/14/2017 document R2 had a head injury with a head laceration measurements at least 4.9 centimeters (cm) by (x) 2.6 cm x 2.0 cm. Staples were not documented. R2's Progress Note, dated 02/14/2017, documents at 11:04 PM, Resident arrived back to facility at 10:35 PM. In bed resting at this time. Checks every 4 hours to staples initiated. Denies pain at this time. R2's Progress Note, dated 02/22/2017, at 6:13 PM documents 5 intact staples removed with assistance from CNA. The Facility's Incident Report, dated 02/14/2017, at 6:45 PM documents CNA reported resident slid her arms inside sit to stand sling and slid out of sling; hit head, sent to emergency room . The Report documents Corrective Action Taken as Need mechanical lift. Will now be mechanical lift for safety. On 03/01/2017 at 2:43 PM, E4, CNA stated I strapped her (R2) stand up lift and as I was pushing (R2). She let go of the handles and slid through the straps and fell backwards. I don't usually take care of her. I usually work the Alzheimer Unit and that night I was filling in for another CNA as she had a death. No one informed me that sometimes she (R2) lets go of the handles. On 03/01/2017 at 1:20 PM, E5, Program Manager for Occupational Therapy (OT) stated We started trials on (R2) because she had been ill and we working her back to a stand lift and doing transfer trainings. We were still actively seeing her until 12/25/2016. I know we had a lot of discussions during her treatments. (R2) was discharged on [DATE] with a sit to stand. I do not see any documentation after 12/25/2016 of any communication (R2) having difficulty with stand lift transfers. On 03/01/2017 at 3:10 PM, E2 stated when a resident has changes such as their sit to stand ability and is declining most of the time it is the Restorative Nurse who makes the changes and would perhaps change to a mechanical lift. When asked if she was aware of R2 having any difficulties with transfer she stated I knew she was in therapy but she was released. She was approved for a sit to stand. I am not sure why she was not changed to a mechanical lift before the fall. I will have to look. I thought she was being seen in therapy. I expect staff to tell us if residents are having changes. On 03/02/2017 at 8:59 AM, E2, Director of Nursing (DON) stated if residents were having issues with the sit to stand E5, Program Manager, OT, would be the person who be notified. On 03/03/2017 at 9:09 AM, E2 stated she did not personally tell Z1, R2's Physician, of R2 having issues with not holding on to the handles with the sit to stand. E2 stated I could not tell you if anyone told (Z1) she (R2) was having problems. On 03/02/2017 at 12:03 PM, Z1, Physician of R2 stated If a resident was no longer able to hold on to the handles for a sit to stand I would expect the staff to notify me of the changes of the resident and have the resident changed to a mechanical lift. I was not aware (R2) was having issues with the inability to hold on the handles and the staff/aids had not shared with me any inconsistencies or the inability for (R2) to hold on to handles. On 03/03/2017 at 9:44 AM, Z2, Manufacturer Safety Director of mechanical Lift stated If the patient cannot support their own weight they should be put on a sit to stand body mechanical lift. The Safe Lift Policy dated 7/2006 document Purpose: This policy is intended to maximize the safety of residents and staff during the lifting and transferring procedure. The policy documents 4. Changes in the resident's condition must be reported to the charge nurse. The therapy department, Care Plan Nurse and Charge Nurse will re-evaluate the method of transfer. If changes are indicated the above procedures will be completed. The Policy documents Class 3 - Extensive Assistance- Mechanical Stand Up Lift 3. Residents in most cases should be able to grasp handles of the lifting device. 4. Resident must be cognitively able to follow directions in order to cooperate with the use of the equipment. R2's Care Plan with a Start Date of 02/23/2017 document in part, Increased susceptibility to falling that may cause physical harm. Related to history of falls (1-2 in past 3 months), age, use of assistive device (walker), visual or hearing difficulties, incontinence, impaired physical mobility, cognitive impairment, wheelchair use, poor safety awareness, poor standing balance, poor insight into deficits. Approach documents Date 12/01/2016 Transfer assist with 1 and stand up lift. Sit to stand lift for transfers. On 03/01/2017 at 9:31 AM, E6 and E7 transferred R2 using a large mechanical lift sling and full body mechanical lift. Staff did not check the sizing of the sling, pause or pull on sling for safety. R2 was moaning out and yelling stating Oh, please don't drop me. Promise me you will not drop me. On 03/01/2017 at 9:38 AM, E6 was asked what size sling was being used on R2 and he stated The large sling. The Manufacture Guidelines of the mechanical lift used to transfer R2 documented staff should utilize a medium sized sling to transfer a person weighing 100-210 pounds. The Guidelines document a large sling should be used for persons weighing 210-310 pound person. R2's Vitals Report document R2 was last weighed on 02/27/2017 and document R2 at 187.6 pounds. 2. R1's [DIAGNOSES REDACTED]. R1's MDS dated [DATE] documents BIMS score of 15 out of 15 cognitively intact. The MDS also documents that R1 is a one person physical assist and has impairment on one side of upper and lower extremities. On 3/2/2017, at 9:21 AM, R1 was sitting in her wheelchair. E9 and E10, CNAs approached R1 to transfer R1 from the wheel chair to the bed with a mechanical sit to stand lift. After placing the sling to R1 and fastening it around her abdomen, and placing the strap around R1's legs, E9 instructed R1 to take hold of the handles of the mechanical lift. R1 held onto the lift with her right hand and her left arm dangled flaccid as E10 raised the lift to a standing position and transported R1 to the bed. On 3/2/2017 at 9:25 AM, E9 and E10 placed the sling around R1's abdomen and placed the strap around R1's legs, R1 was instructed to hold onto the handles of the lift. R1 held onto the lift with her right hand and her left arm dangled flaccid as E10 raised the lift to a standing position and transported R1 from her bed to the wheelchair. On 3/2/2017 at 10:30 AM, E8, Restorative Registered Nurse (RN) was asked if someone cannot hold onto a sit to stand mechanical lift during transfer if she would expect staff to continue with the sit to stand transfer. E8 replied, No. E8 was asked if she expected staff to stop and check the belt for correct position after it was applied, E8 stated, Yes I expect them to stop and check the belt for correct positioning. The Safe Lift Policy dated 7/2006 document Purpose: This policy is intended to maximize the safety of residents and staff during the lifting and transferring procedure. The policy documents 4. Changes in the resident's condition must be reported to the charge nurse. The therapy department, Care Plan Nurse and Charge Nurse will re-evaluate the method of transfer. If changes are indicated the above procedures will be completed. The Policy documents Class 3 - Extensive Assistance- Mechanical Stand Up Lift 3. Residents in most cases should be able to grasp handles of the lifting device. 4. Resident must be cognitively able to follow directions in order to cooperate with the use of the equipment.