Every finding on record at Ahva Care of Stickney

Based on interviews and record review, the facility failed to ensure physician and/or nurse practitioner orders were accurately transcribed and timely implemented for a resident experiencing altered mental status. Specifically, the facility failed to hold prescribed pain medications as ordered and failed to initiate increased monitoring for a resident exhibiting signs and symptoms of central nervous system (CNS) depression. This affected one of three residents (R44) reviewed for change in condition. This failure resulted in (R44) being found lethargic and slow to respond to verbal stimuli which progressed to (R44) was unresponsive to verbal/tactile stimuli, (R44) was transferred to the local hospital and presented to the emergency room with oxygen saturation levels in the 80s on room air and worsening neurological status. (R44) was diagnosed with gabapentin-induced toxicity, baclofen overdose, and toxic metabolic encephalopathy. (R44) was admitted to the intensive care unit and required intubation.Findings include:On 3/19/26 at 9:50 AM, V3 NP (nurse practitioner) stated that she does not recall if staff alerted her to R44 being slow to respond on 1/28/26. V3 stated that when V3 saw R44 on 1/29, R44's mental status was altered so she sent R44 to the hospital via EMS (emergency medical services) 911. V3 stated that V3 expects the nurse to enter V3's telephone/verbal orders into the resident's electronic medical record. V3 stated that V3 does not remember the pain medications R44 was receiving at the facility. V3 stated that V3 expects the nurse to not administer medications when a resident has altered mental status and is slow to respond.R44's outside private ambulance service report, dated 1/29/26, notes dispatch was notified at 8:58 AM for a resident with altered mental status. The crew were at R44's bedside at 9:39 AM. The report narrative notes R44 was found unresponsive to verbal stimuli. Per nurse, R44 is normally alert and oriented x 2; R44 has been declining since yesterday. The outside ambulance service transported R44 emergently to the closest hospital.On 3/19/26 at 4:00 PM, V4 ADON (assistant director of nursing) stated that R44 was sleeping and lethargic since she received her wound care treatment on 1/28 at 8:20 AM. V4 stated that she notified V3 NP and was instructed to monitor R44. V4 stated that she held the afternoon doses of scheduled medications due to increased lethargy. V4 stated that when she notified V3 prior to end of shift at 7:30 PM, V3 instructed staff to continue to monitor. V4 stated that she was not aware that V21 (nurse) administered suboxone and baclofen to R44 on 1/28 night shift. V4 stated that R44 was not responsive to verbal stimuli on 1/29.R44's hospital record, dated 1/29/26, notes R44 presented to the emergency room for altered mental status x 2 days. R44 presents lethargic and nonverbal. R44 grossly diaphoretic upon arrival. Physical exam noted mucous membranes were dry. Neurological exam noted R44 withdraws from pain. R44 able to protect her own airway. Noted to be hypoxic (oxygen saturation level 88% on room air) but saturating well with supplemental oxygen. R44 on numerous medications that may be causing encephalopathy, baclofen, pregabalin, gabapentin, suboxone, tramadol, and tizanidine. At 1:40 PM, R44 with worsening hypoxia, low blood pressure (95/47), and pupils pinpoint. R44 placed on venturi mask 15 liters of oxygen. R44 was noted to be aggressively somnolent with concern for inability to protect airway due to home polypharmacy. R44 was intubated and transferred to the intensive care unit. R44's diagnoses included, but not limited to, gabapentin-induced toxicity, baclofen overdose, and toxic metabolic encephalopathy.R44's POS (physician order sheet), dated 1/10/26, notes the following orders:Pregabalin 300 mg (milligrams), give one capsule by mouth every 12 hours for pain.Tizanidine 4 mg tablets give 4 mg by mouth one time a day for muscle spasms. It increased to 4mg twice daily on 1/18/26. Baclofen 20mg, give 20 mg by mouth every 8 hours for moderate pain.Suboxone sublingual film, give 1 film sublingually three times a day for pain.Tramadol 50 mg tablets, give 1 tablet by mouth every 8 hours for pain.Gabapentin 600 mg, give 600 mg by mouth every 8 hours as needed for pain.Naproxen 500 mg tablets, give 500 mg by mouth every 12 hours as needed for moderate pain. R44's MAR (medication administration record), dated January 2026, notes R44 was receiving these medications as prescribed. R44's medical record, dated 1/28 - 1/29, notes the following:At 4:26 PM, V4 RN notified V3 NP that R44 was lethargic and slow to respond. V3 gave order to hold baclofen.At 5:21 PM, V4 RN notified V3 NP that R44 continues to sleep, lethargic when attempting to wake R44. V3 gave order to hold tizanidine.At 7:06 PM, V4 RN notified V3 NP that R44 is sleeping but very lethargic and slow to respond. R44 moans when she is moved, didn't yell like she usually does. R44 has been asleep since wound care treatment this morning. V3 NP gave order to hold suboxone and tramadol until R44 is more responsive. On 1/29 at 7:40 AM, V4 RN noted R44 lethargic and slow to respond to sternal rub. V4 confirmed with the night shift (7:00 PM - 7:00 AM) nurse, V21, that R44 has not received any medications by mouth since 1/28 at 8:20 AM. V3 NP gave order to send R44 to the hospital for higher level of care. R44's MAR notes on 1/28/26 V21 (nurse) administered suboxone at 9:00 PM and baclofen at midnight to R44. R44's POS does not note any orders given by V3 NP to hold medications until R44 was more responsive were transcribed and initiated. The outside ambulance service was not notified until 8:58 AM transport needed for R44. Per drugs.com, using suboxone together with other medications that cause central nervous system (CNS) depression can lead to serious side effects such as respiratory distress, coma, and even death. Baclofen, gabapentin, pregabalin, tizanidine, and tramadol can cause CNS depression. Patients need increased monitoring when receiving suboxone and any of these medications. Per Medscape drug interaction notes serious interactions between tizanidine and suboxone, and gabapentin and suboxone. These drugs increase sedation; avoid or use alternative drug; limit use to patients for whom alternative treatment options are inadequate. Significant interactions - monitor closely: Gabapentin interactions with suboxone and/or tramadol can result in serious, life-threatening, and fatal respiratory depression. Monitor for respiratory depression and sedation. Pregabalin interactions with suboxone and/or tramadol can result in serious, life-threatening, and fatal respiratory depression. Monitor for respiratory depression and sedation.Tizanidine, gabapentin, baclofen, tramadol, pregabalin interact and increase sedation. Use caution/monitor.

Based on interviews and record reviews, the facility failed to follow the plan of care intervention to ensure that the resident's environment was free of clutter, which is necessary to promote a safe environment. This deficiency affected one of three residents (R4). As a result, R4 rolled from the bed and struck her head on the garbage can, causing facial lacerations that required 8 sutures. Findings include: R4 face sheet shows R4 has diagnoses of unspecified dementia, muscle wasting and atrophy, other abnormalities of gait and mobility, lack of coordination, insomnia. Facility final investigation to the department dated 1/9/25 denotes in-part, fall, R4, alert x/times one. [AGE] year-old, BIMS/Brief Interview for Mental Status) of zero. On 1/5/25 the doctor gave orders to send R4 to the hospital to be examined for a fall. The physician and family were informed. During the final investigation process and medical records review the following facts were determined: On 1/5/25 R4 returned from the hospital with eight stiches to her left eyebrow. During the investigation process R4 roommate informed staff that R4 rolled out of bed onto the floor mat by her bed and somehow hit her head on the trash can by her bed. Facility incident report dated 1/5/25 denotes in-part V2 (Registered Nurse) stated nurse responded to a noise of what sound like a garbage can and upon entry into resident's room the resident was noted lying on the floor mattress with head closest to the head of bed. On 1/15/25 at 1:58pm V3 (CNA- certified Nursing aide) stated R4 was observed on the floor mattress (floor mat) at around 11:00pm or so. V3 stated V3 and V2 (RN) put R4 back in bed. V3 stated R4 brief was dry. V3 stated around 12:30am, R4 was observed on the floor mattress again. V3 stated R4 body was on the floor mattress and R4 head was off the floor mattress on the floor. V3 stated R4 was bleeding from the head/face. V3 stated the garbage can was flipped over by R4's head. V3 stated R4 could have hit her face on the wall socket also. V3 stated the Nurse did not give her any new directives after they picked R4 up from the floor the first time that night. V3 expressed that R4 was not a good fit for that room. V3 stated R4 roommate liked the television loud and the room cold. V3 stated R4 didn't sleep well at night in that room. V3 stated she has mentioned this to the Nurse. V3 stated she (V3) has mentioned that R4 was not a good fit several times. V3 stated she does rounds every two hours maybe every hour usually. V3 stated she has observed R4 on the floor mattress prior to that night. V3 stated R4 is at risk for falls. On 1/15/25 at 4:01pm V2 (RN) stated R4 was removed from the floor mattress prior to being observed on the floor mattress bleeding from the head. V2 stated the first time they (V2 and V3) put R4 back in the bed, the interventions were to check to see if R4 was wet and R4 was dry. V2 stated then put R4 back in bed. V2 stated R4 is rounded on every 1 to 2 hours. V2 stated she did not give V3 any further directives for R4 at that time of the first fall. V2 stated she did not recognize R4 first incident as a fall as R4 was having behaviors. V2 stated she did not contact anyone for directives when R4 was having behaviors. V2 stated the second incident is when she heard noise of a garbage can, as she went to investigate, R4 roommate put the call light on and stated R4 was doing something with the garbage can. V2 stated R4 was observed on the floor mattress bleeding from the head/face. V2 stated she rendered first aid; she V2 observed a laceration above R4 left eyebrow and a laceration under the left eye. V2 stated the garbage can was by R4s head. V2 stated she was not in the room so she can't say what happened. V2 denied knowing about R4 roommate keeping the room too cold and the television too loud for R4 to sleep. V2 stated R4 roommate does like to keep her fan on in the room. V2 stated she can't discern what is considered a loud TV. V2 stated R4 didn't sleep well at night but she administered melatonin to R4. V2 stated the melatonin only worked a few hours for R4. V2 stated she endorsed in the past for the nurse to inform the provider that the melatonin only worked for a few hours for R4. V2 stated she doesn't know if the Nurse reported to the Physician/Nurse practitioner. R4 progress notes dated 1/5/25 denotes in-part unwitnessed fall event. Writer observed resident lying on her left side on floor mattress at bedside. Left side of face bleeding with open areas x2. Resident noted awake and alert, at baseline. Pressure applied, sites cleaned, and dry dressings applied. Resident was assisted back into bed with staff assist x2. Head to toe assessment performed. No other visual injuries noted. Neuro (neurological) check performed. ROM (range of motion) to all extremities at baseline. Resident has Dx (diagnosis): Dementia, unable to state how fall occurred. Vitals: T(temperature) 97.6, R (respirations) 20. Unable to obtain B/P (blood pressure, pulse, and SPO2 because resident did not remain still long enough for an accurate reading. On call DON (Director of Nursing) made aware. V4 (Physician) made aware, awaiting MD (medical doctor) response. Attempt to make son aware, no answer. Left message to contact facility. Call to 911 to send resident to (hospital name) Hospital per facility protocol. On 1/15/24 at 3:00pm V5 (Director of Nursing) stated the first incident of R4 observed on the floor mat (full size mattress) was a fall. V5 stated the nurse failed to recognize that R4 had a fall. V5 stated V2 did not inform her that R4 had a fall or that R4 was experiencing behaviors prior to being observed bleeding from head. V5 stated V2 informed her that the garbage can was by R4 head, and that's why she implemented to remove the garbage can from R4's room. V5 stated V2 should have implemented a new intervention for R4 after the first fall that night. V5 stated the nurse should have used nursing judgement to determine an intervention based on what was observed at the time of the fall. V5 stated the Nurse does not have to wait for her directives to implement an intervention, she educated her staff on that. V5 stated she was aware that R4 didn't sleep well at night that's why she got the order for the melatonin. V5 stated she was not aware that the melatonin was only effective for a few hours and that R4 continued to be awake at night. V5 stated she was not aware that R4 roommate was not a good fit for R4 because the room was cold, and the television is loud at night. V5 stated the aide did not make her aware of this allegation/observation. V5 stated R4 floor mat was not the same height as the bed as mentioned by V2. V5 stated R4 did have a fall, it was a change in plane for both incidents. V5 stated she has to educate V2 and V3. V5 stated the nurse informed her that the garbage can was near R4 head and that's she implemented the intervention of removing the garbage can from R4 room. V5 stated she concluded that R4 hit her face/head on the garbage can. R4 plan of care with initiated date of 7/19/2024 denotes in-part the resident has a potential for falls due to current medical condition and confusion, deconditioning, gait/balance problems, poor communication/comprehensive, unaware of safety needs. Actual fall (12/12/24 and 1/5/25). The resident will not sustain serious injury through next review date, target date 1/15/25. Reduce the risk of injury by next review. The resident falls will be minimized. Interventions: anticipate the resident needs, encourage the resident to wait for the staff for assistance before performing any activities of daily living such as transfer, toileting etc. Ensure the resident is wearing appropriate footwear and floor mattress next to the resident bed. Keep bed at the lowest position and keep the floor dry to prevent the resident from slipping. Keep the pathway and resident's environment free from clutter. Keep the resident call light within reach and encourage the resident to use it for assistance as needed. May wear helmet to head PRN (as needed) when restless or agitated, to protect against head injuries as tolerated. Move resident room closer to nurse station. Orient the resident to the environment. Therapy to evaluate and treat as ordered by the physician and no garbage can at the bed side. 1/16/25 at 2:49pm V6 (Administrator) stated R4 fall with injury was an accident. V6 stated he (V6) does not understand how R4 hit her face/head on the garbage can. V6 state he only interviewed the resident during this investigation and that the Director of Nursing interviewed the nurse (V2) and CNA (V3). Upon exit of this survey V6 failed to present further information of how R4 suffered the two lacerations to her face after the fall/accident. Facility falls- (clinical protocol) policy with revised date of March 2020 denotes in-part the staff will evaluate, and document falls that occur while the individual is in the facility, the staff and physician will monitor the resident's response to interventions intended to reduce falling or consequences of falling. If the individual continues to fall, the staff and physician/NP will reevaluate the situation and consider other possible reasons for the residents falling and will reevaluate the continued relevance of current interventions.

Based on observation, interview, and record review, the facility failed to provide a clean environment in good repair for two of three units in the facility. This failure has the potential to affect all 16 residents residing on the first floor and all 43 residents residing in the facility. Findings include: 9/18/2024 at 9:30AM upon entering the facility for an onsite complaint investigation and walking to the basement with V1 (Administrator), surveyor observed lots of peeling paint on the walls leading to the therapy room and towards the bathroom in the basement. There are also two rusted pipes on the wall with peeling paint and a big hole on the wall leading to the ceiling inside the therapy room. 9/18/2024 at 11:18AM, surveyor conducted observation of the shower room on the first floor with V3 (CNA) and noted a large area with dark materials on the ceiling, the wall was noted to be peeling with holes, and there were patches of peeling paint all over the bathroom wall. V3 stated there is leakage from the second-floor bathroom when they are giving showers, she thinks that is where the dark deposits on the bathroom ceiling is coming from, V3 added that she has not really paid close attention to it, but it does not look good. 9/18/2024 at 12:03PM, V1 (Administrator) stated that the dark area in the ceiling of the first-floor bathroom is not mold, it is caused by leakage from the second-floor bathroom. V1 stated they usually have it (ceiling) painted but have not done so lately. V1 stated the last time fire safety came to the facility, they saw it and gave them verbal instruction to fix it. V1 stated that they are aware of the repairs and paint needed in the facility. V1 stated the owners repaired the roof to prevent leakage all over the facility. V1 stated they are currently dealing with a plumbing problem and the plan is to start with the inside repairs in November. 9/18/2024 at 12:05PM, V6 (Maintenance Director) was showing surveyor the dark deposit area in the first-floor bathroom ceiling, stating that he just scraped it, and it is not mold. V6 stated it is because of leakage from the second-floor bathroom. V6 added that fire safety told him to fix it when they were in the facility in March. V6 stated he has not had a chance to do it. Surveyor asked V6 if they ever tested the deposits for mold, and he (V6) stated no. A document presented by V1 (Administrator), (undated), titled general maintenance policy states as follows: the facility shall maintain the building in good repair, safe and free of hazards. The same document stated in part, 1. The maintenance director shall make physical plant repair as needed. 4. Maintain the interior and exterior finishes of the building as needed to keep it attractive and clean and safe (painting, washing and other types of maintenance). 9. Maintain plumbing fixtures and piping in good repair and properly functioning.

Based on interview and record review, the facility failed to honor resident's advance directives for DNR (Do Not Resuscitate) for 1 resident (R1) of 3 residents reviewed for CPR (cardiopulmonary resuscitation)/Advanced Directives in the sample. Findings include: R1 is a [AGE] year-old with diagnoses including metabolic encephalopathy, left heel pressure ulcer, Dementia with psychotic disturbance, heart failure, and Alzheimer's Disease. R1 was shown to have a DNR (Do Not Resuscitate) order that was signed by his guardian on [DATE]. On [DATE] at 12:20 PM, V2 director of nursing (DON) stated, R1 was in his 80's or 90's, alert times one and up and about with 2-staff assist using mechanical lift. He (R1) hangs out in the dining room, is verbal but confused and needs assist with feeding. V2 stated I (V2) was in the building in the morning and when I left, I was called by (V4) about R1's change of condition when I (V2) came in the building around 4:00 PM, V4 licensed practical nurse (LPN) stated she called V3 assistant director of nursing (ADON) and gave a report and we had called a code blue and R1 went to the hospital. Paramedics came and continued CPR after staff-initiated CPR. Surveyor asked which staff performed CPR, V2 indicated that there were two people, one of which was V4 but did not know the other staff person but was possibly a CNA. On [DATE] at 12:25 PM V3 (ADON) stated, The staff will know the advanced directive of DNR or Full Code and it is shown in the electronic medical record. She (V4) told me she found (R1) unresponsive and she had already initiated CPR and she called 911 and had the paperwork and that paramedics were enroute. It's in PCC (electronic medical record system) if they are DNR or full code. If the resident was full code that would mean to initiate CPR and if DNR they know not to provide resuscitation and otherwise they would call a code. On [DATE], efforts to reach V4 could not be obtained for interview. However, on [DATE] at 4:58 PM, V4 wrote in part, Nurses Notes Note Text: resident sitting at dining room table, head facing table, no response noted when name called. Resident color appears dusk, no blood pressure, no carotid or brachial pulse noted. No vital signs noted. No spo2 noted. CPR started, Oxygen applied via nasal cannula 911 called, left voicemail with state guardian and family member, DON and ADON aware. 3 paramedics arrived, continued CPR and oxygen. Resident placed on stretcher, Paramedics transporting to nearest hospital. Records showed a DNR order dated ,d+[DATE] 24 signed by R1's State Guardian which reads in part: Do Not Attempt Cardiopulmonary Resuscitation (CPR); Do Not Attempt Respiratory Resuscitation. Facility policy titled Advanced Directive Code Policy dated [DATE] reads in part, It is the policy of this facility to adhere to the residents' rights to formulate advanced directives. in accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information.

Based on observations, interviews, and record review the facility failed to maintain current Food Protection Manager Certification for Director of Food and Nutrition Services and provide services of a person-in-charge (PIC) with the required Food Protection Manager Certification. These failures have the potential to affect all 44 residents residing in the facility. Findings include: On [DATE] at 11:10 AM V1 (Administrator) provided facility census listing 44 residents residing in the facility during course of the survey. On [DATE] at 11:00 AM during initial kitchen tour, surveyor observed V9 (Dietary Aid) cooking lunch. Surveyor asked V9 what she is making today, V9 responded, I'm making pulled pork and bean burrito, Mexican rice, and zucchini. Normally, it's me, another dietary aid, and our cook who's also a dietary manager in the kitchen, but she is not here today. On [DATE] at 2:12 PM surveyor interviewed V1 (Administrator) who stated in summary: V14 (Dietary Manager/Cook) is not here today, she had loss in the family, is on bereavement leave, and we don't know when she'll be coming back. V9 (Dietary Aid) is covering for V14. V14 arranged for V13 (Former Cook) to cover for her during her absence, but I don't know why he's not here today, he was supposed to be here at 7:00 AM this morning. On [DATE] at 3:36 PM surveyor interviewed V13 (Former Cook) who stated in summary: I work in another facility, I'm a cook there. V14 (Dietary Manager/Cook) notified me this morning ([DATE]), that she might need me to cover for her, but I didn't hear anything else from her, so I didn't come this morning. V1 (Administrator) called me later today and asked what time I was coming over; I didn't know they still needed me, but I confirmed that I'll be coming shortly. I'll stay to cover for V14 until she's back. On [DATE] at 11:08 AM surveyor observed V13 (Former Cook) sitting in the nook outside of the kitchen. On [DATE] at 11:27 AM during kitchen tour surveyor observed V9 (Dietary Aid) cooking lunch. Surveyor clarified with V9 what she cooked since yesterday during abscess of person-in-charge (PIC) with the required Food Protection Manager Certification, V9 stated I'm cooking chicken teriyaki, rice, and cabbage today. I cooked all three meals yesterday, breakfast, lunch, and dinner, and breakfast today. I started cooking lunch today as well, and that's when V13 took over. On [DATE] at 1:13 PM surveyor interviewed V15 (Dietician) who stated in summary: The cook's (V14) license (Food Protection Manager Certification) has been expired for about two months now. V9 (Dietary Aid) would have to have the Food Protection Manager Certification in order to cook the food; otherwise, she is not qualified to cook the food. On [DATE] at 11:02 AM V1 (Administrator) provided, after multiple requests, V14's (Dietary Manager/Cook) Food Protection Manager Certification search result which showed V14's certification has expired on [DATE] and is invalid. V9's (Dietary Aid) Food Handler Certification issued on [DATE], valid through 3 years from issue date reviewed. No additional certificates available for V9. The facility Person-in-charge (PIC) with the required Food Protection Manager Certification policy unavailable upon multiple requests.

Based on interview and record review, the facility failed to ensure two residents (R1 and R2) were free from theft from their personal trust fund accounts by staff. This failure applied to two of two (R1, R2) residents reviewed for abuse. Findings include: R1 is an [AGE] year-old male who originally admitted to the facility on [DATE] and currently resides in the facility. R2 was an [AGE] year-old male who originally admitted to the facility on [DATE], was sent to the hospital on [DATE] and later expired. Per facility reported incident dated [DATE] states in part but not limited to the following: On [DATE] a monthly routine trust fund audit was completed and there were discrepancies and concerns found regarding trust activity in R1 and R2's account. The facility determined that there were fraudulent checks written from R1 and R2's trust account. Police Incident Report dated [DATE] shows that police were called to facility for a report due to deceptive practice and fraudulent checks. Upon arrival, we were met by V1 (Administrator) who had advised us that two unauthorized checks for large sums were written and cashed from the trust fund accounts of R1 and R2. V1 had reported that only two staff members have access and were authorized to write checks from these accounts, V1 and V3 (Previous Business Office Manager Consultant). V1 advised me that someone had to [NAME] his signature on the checks to get these checks to be authorized. Copies of checks and Police Incident Report shows that a check for $3,600 from R1's account was written and cashed to an unknown name through a mobile deposit. It also shows that a check for $2,770.90 was written on [DATE] from R2's account and cashed to an unknown name on [DATE] through a currency exchange. On [DATE] at 11:32, V1 was interviewed regarding incident on [DATE]. V1 said on [DATE], I was auditing the resident trust fund sheet and I noticed a discrepancy. There were two withdrawals from R1 and R2's account and they are unable to make these withdrawals themselves. R2 expired in January of 2023 and R1 has a guardian/POA that did not make this request. The person that was handling the trust funds was V3 who was a consultant at the time. I attempted to call V3 however she refused to speak with me, ended up resigning, and not working with the facility anymore. I have never been able to speak with her about this incident. I did call the police the day of the incident which have an active investigation at this time. V1 said we are responsible for the resident's trust funds. V3 was responsible for making out checks for the residents when requested in the past. I do an audit on the trust funds every month, but we do not have a system in place that requires documentation. This is just something that I do. V1 said when a consultant is hired or starts working within our facility, they are trained on our policies and procedures regarding abuse. However, there is no documentation where they sign off on this like our staff do. It is to be noted that V1 was asked for any documentation that V3 was trained on their abuse policy and procedures. However, during the course of the survey, no such documentation was received. At 12:04PM, V5 (Lead Detective) was interviewed regarding investigation of incident on [DATE]. V5 said we were called to the facility due to two fraudulent checks that were written from the facility. V1 had told me that only V1 and V3 were authorized to write checks out of the resident's trust fund accounts, and he had not written these checks. My investigation showed that one of these checks was deposited via a mobile deposit and one was cashed at a currency exchange. They were both written to unknown names and cashed under unknown names. Unfortunately, I cannot say much more as this is still an ongoing investigation. Facility Policy titled Resident Trust Fund Policy Notification and Authorization states in part but not limited to the following: Residents have the right to have the facility keep their money in a trust account to safeguard and manage personal spending money. Facility Policy titled Policy and Guidelines on the Prevention of Abuse and Neglect dated [DATE] states in part but not limited to the following: The facility must provide a safe resident environment and protect residents from abuse. The residents of the facility have the right to be free from abuse, neglect, misappropriation of resident's property and exploitation as defined in this policy. Examples of misappropriation of resident property include but are not limited to theft of money from bank accounts. Staff must not accept or ask a resident to borrow personal items or money, nor should they attempt to gain access to resident's holdings, money, or personal possessions.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, and comfortable environment. The facility failed to repair broken wall-mounted toilet tissue holders with shared bathroom, missing baseboard exposing bathroom hot water heating system. The facility also failed to repair missing floor and wall tiles in the bathroom resulting in uneven concrete floor for a shared bathroom. This applies to all 40 residents residing in the facility. The findings include: On 8/26/23 at 10:10 PM, observed room AA's bathroom wall tile with two broken and missing ceramic tile pieces behind the toilet. On 8/26/23 at 10:15 AM, the shared bathroom across from room AA was observed with missing floor tiles (6 inches x 12 inches), leaving an uneven, loose, and inch-deep concrete floor close to the bathroom entrance door resulting in potential tripping hazard. Both shared bathrooms on the first floor close to room AA were observed with a broken wall-mounted toilet tissue holder, exposing sharp edges to residents. On 8/26/23 at 11:00 AM, observed the second-floor shared bathroom on the southwest side with a broken wall-mounted toilet tissue holder exposing sharp edges to residents. On 8/26/23 at 11:05 AM, observed the second-floor shared bathroom on the northwest side with a broken wall-mounted toilet tissue holder exposing sharp edges to residents. On 8/26/23 at 11:10 AM, observed two north unit shared bathrooms (close to room B) with a missing baseboard to the hot water heating system, exposing the inside heating element. On 8/26/23 at 12:45 PM, V6 (Maintenance Director) stated, I started three months ago, and we didn't have a maintenance director when I started. I am working on catching up on the maintenance work. The resident should have a clean and hazard-free environment. I ordered tissue holders and will take care of them on Monday. I will replace the missing tiles in the bathrooms. The facility presented a Homelike Environment (revised in August 2011) policy statement states that the residents are provided with a safe, clean, comfortable, and homelike environment . 5. Notify the interdisciplinary team and or anyone in the maintenance department for any concerns related to the resident's environment, such as broken equipment or changes in the room temperature of the resident room. On 8/26/23 at 9:45 AM, V2 stated that there are 40 residents with their facility as of today's census.

Based on interviews and record reviews, the facility failed to ensure that two of their dietary employees who handle and prepare food, were current with the food handlers training certificate program and failed to follow their facility policy on food handling. This failure has the potential to affect all 42 residents who reside at the facility, whose meals are prepared by dietary staff. Findings include: Reviewed facility staff roster provided by V1 (Administrator) which listed V10 as a dietary aide and V11 as a housekeeper/cook. Reviewed the dietary department staff schedules provided by V5 (Human Resources/Scheduler) from [DATE] to current which listed both V10 and V11 as current dietary staff. On [DATE], requested food handlers' certificates for all dietary staff from V1 (Administrator). Certificates not provided for V10 (Dietary Aide) and V11 (Housekeeper/Cook). At 2:30 PM, V1 said that he was waiting for V10 and V11 to provide him with a copy. On [DATE] at 11:10 AM, V1 (Administrator) provided food handler certificates for V10 (Dietary Aide) and V11 (Housekeeper/Cook) that both showed issued/completion date of [DATE]. On [DATE] at 12:33 PM, V3 (Dietary Manager) verified who all the current employed dietary staff were which included V10 (Dietary Aide) and V11 (Housekeeper/Cook). V3 then said V10 and V11's food handler certificates both expired last week and were both told to retake the course as soon as possible. Requested the expired certificates for V10 and V11 from V3 who said, they threw them away. On [DATE] at 12:38 PM, V5 (Human Resources/Scheduler) said she asked V10 (Dietary Aide) for her food handler certificate on ,d+[DATE] but V10 said she couldn't find it. V5 then said that V11 (Housekeeper/Cook) went from housekeeping to the cook position on [DATE] and that V5 had requested V11's food handler certificate multiple times since this date but it was never provided to her. V5 (Human Resources/Scheduler) said she asked V11 for her certificate again on [DATE] and was then told by V11 that her license expired in 2021. At 1:08 PM, V5 said V10 (Dietary Aide) was rehired to the facility on [DATE], then provided a copy of V10's previous food handler certificate with expiration date listed as [DATE]. On [DATE] at 1:16 PM, V11 (Housekeeper/Cook) said her previous certificate expired between 2021 and 2022 so she threw it away. She then said she started working in kitchen on [DATE] and both V3 (Dietary Manager) and V5 (Human Resources/Scheduler) asked her multiple times for her certificate but she kept forgetting it. V11 then said the last time V5 asked for her certificate was two to three weeks ago and V11 told her that she had to renew it and was told to complete as soon as possible. On [DATE], V11 said she was asked by V3 and V5 if she had her certificate and again said she didn't have it done. V11 was told by V3 and V5 to get it done today. V11 (Housekeeper/Cook) then said it's important to have a current food handler certificate due to safety and sanitary issues. V5 added that she has had multiple food handler/infection control in-services this year. On [DATE] at 1:47 PM, V5 (Human Resources/Scheduler) said V11 works in housekeeping, laundry and dietary and when pulled into dietary, V11 works as either a dietary aide or cook, wherever she is needed. On [DATE] at 1:51 PM, V2 (Director of Nursing/Infection Preventionist) said all food handlers should be certified so they know the process of properly handling food, food temps and the dangers of improperly prepared food to avoid foodborne illness. Reviewed facility's Preventing Foodborne Illness-Food Handling policy last revised [DATE] that reads in part: Policy Interpretation and Implementation: All employees who handle, prepare, or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents.

Based on interview and record review, the facility failed to initiate a water treatment plan to prevent the growth of Legionnaire's and other opportunistic waterborne pathogens; failed to provide evidence to ensure the water treatment plan was consistently being implemented to minimize the risk of Legionella and other opportunistic pathogens in building water systems; failed to follow their water management program policy and procedures that demonstrate its documented program measures. This failure has the potential to affect all 41 residents who currently reside in the facility. Findings include: On 03/15/2023 at 11: 50 AM, surveyor requested water management plan from V1 (Administrator) who stated the maintenance director had been working from home the last several weeks/months and had the facility's water management plan in his home along with all the documents needed to show what measures were in place to prevent the growth of waterborne pathogens within the building water systems. V1 added that this maintenance director passed away two weeks ago, and facility staff have been unable to retrieve these documents from within his home. At 2:34 PM, V1 (Administrator) stated the facility did not use an outside source for anything because the maintenance director did all the required testing. V1 then stated he would attempt to find an outside source to initiate and/or complete their water management plan requirements. On 03/16/2023 at 10:44 AM, V1 (Administrator) provided a proposed agreement from an outside source to perform Legionella water testing at the facility. Review of facility's undated water management program policy showed, the facility will implement the water management program to reduce the risk for Legionnaire's disease associated with the building water system and devices, reduce the growth and spread of Legionella bacteria in the facility and to identify areas or devices in the facility where Legionella might grow or spread to people so that the facility can reduce the risk. Under procedure, the policy showed the water management team will be an interdisciplinary team of facility department representatives who will oversee the program, identify control locations and limits, communicate regularly about the program, monitor and document the performance of the program and identify and take corrective actions as needed. Policy continued with the maintenance director completing a building assessment using a form to identify buildings at increased risk and implement the water management program if needed. Under facility water systems, any identified areas of concern would have control measures applied and monitored. Under quality of water, the quality of water will be measured on a weekly and as needed basis to ensure that changes that may lead to Legionella growth (such as drop in chlorine levels) are not occurring.

Based on observations, interviews, and records reviewed, the facility failed to notify physician of an acute change in condition of noted swelling, redness, and discharge of bilateral lower extremities. This failure resulted in delayed treatment orders for one of three residents (R2) reviewed for assessment, notification and treatment. Findings include: On 5/24/22 at 10:52 AM, R2 observed sitting in wheelchair with sheet across her head. R2 was wearing long, stained, yellow socks. Swelling and redness in legs could be seen above the sock. R2 stated, My legs are bad, and they don't do anything for them. They don't wrap them. They just put [MEDICATION(S)] on them. On 5/24/2022 at 10:54 AM V5 (LPN) removed R2's socks. Both of R2's legs were swollen and red with yellowish/brownish large, layered patches of scaly flaking skin. Some areas were weeping with small amount of reddish/brownish exudate. Right leg noted to be more swollen than left leg. R2 stated, I've been telling them I don't feel good. I need to go to the hospital. R2 stated, I f I complain they say they will send me to Psych. On 5/24/2022 at 1:00 PM Resident still has on the yellow socks and no ace wrap. On 5/24/22 at 1:13 PM V10 (CNA) stated, When showers are given, we document on the shower sheet any issues. Then we give it to the nurse. V10 stated, R2's legs look bad. V10 stated when she saw R2 over a week ago her legs were wrapped. V10 stated, I didn't know it looked that. V10 stated, I saw her skin like that about a week ago. I don't know why her legs are not wrapped anymore. Her legs have not been wrapped for about a week. Surveyor asked V10 to describe what R2's legs look like. V10 stated, R2's legs are scaly, reddish, and yellowish. On 5/24/22. 1:40 PM V5 (LPN) stated ADON told her treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . V5 stated she does not know if there is another treatment. V5 stated, nothing pops up on my screen to do. I'm only aware of [MEDICATION(S)]. At 1:45 PM surveyor showed V5 the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . V5, then stated I'll go wrap it now. On 5/24/2022 1:54 PM V6 (PCP) stated, R2 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . V6 stated she saw R2 a couple weeks ago. V6 stated R2's legs were a little edematous, clean dry and not weeping. V6 stated R2's legs were not red when she saw R2 a couple weeks ago. V6 stated R2 can get cellulites very quickly. V6 stated, no one from the facility has called her today regarding R2. V6 stated if R2's legs are swollen and red she expects the facility to call her. V6 stated she expects staff to follow her orders. V6 stated, the standard treatment are for R2's legs to be wrapped with ace bandages. On 5/24/2022 2:16 PM surveyor asked V5 to describe R2 legs looked like to her today when she took R2's socks off this morning. V5 stated, they looked like she has [CONDITION(S)]. V5 stated R2 legs are swollen, red, and have scaly patches. V5 stated she [R2] is not diagnosed with [CONDITION(S)] but that is what it looks like. V5 stated she took care of R2 on Tuesday or Thursday of last week also. V5 stated, Her (R2's) legs looked the same as they do now. V5 stated she is not sure if anyone has called the doctor about R2 legs. V5 stated, Don't remember getting report about her legs. Last week she had socks on. I don't recall her having them wrapped with ace. V6 stated, R2 refused ace wrap just now and she will chart it. V6 stated, I'm going to call doctor because I actually looked at her legs and I'll look to see if anyone had called the doctor. Otherwise, I will call and give the doctor an update and see if they want to change anything. V5 stated from what I saw it looked like [CONDITION(S)]. On 5/24/2022 at 2:54pm. V5 entered therapy room while surveyor was interviewing V7 and stated she just talked to V6 and an antibiotic was ordered with ace wrap and [MEDICATION(S)]. V5 stated I'm about to put the orders in the computer now. On 5/24/2022 3:26 PM V2 (Assistant DON) stated, if a resident has a change in condition the nurse should do a full assessment and notify the doctor and family. V2 (DON) stated she saw R2's legs yesterday and there was swelling, brownish like with [MEDICATION(S)], scaling from weeping. V6 stated R2's legs were red when she saw them yesterday. V2 stated R2's doctor is aware of the condition of her legs. Surveyor asked how V2 knows that the doctor is aware of the condition of R2's legs? V2 replied, Well, I'm not sure if the doctor is aware. V2 stated when she sees redness, swelling, and [CONDITION(S)] she thinks that the doctor should be made aware of it. V2 stated, she did not notify doctor yesterday when she saw R2's leg because she believed the doctor was already aware of it. On 5/25/2021 at 1:19 PM V6 (PCP) stated that she ordered an antibiotic in case R2 is developing a skin infection. V6 stated she saw a picture of R2's legs, but you can't always tell in a picture. V6 stated, I ordered antibiotic to cover it until I can see the patient tomorrow. On 5/24/2022 12:31 V3 (LPN) stated if a resident has a change in condition we should assess resident, and let doctor and family know. On 5/24/2022 3:02 PM V8 (CNA/shower aid) A week ago I helped her. V8 stated, R2 legs were swollen, reddish and they have been like that for a month or so. R2's Care plan reviewed on 5/24/2022 is absent of any care plan or update for her current skin condition. The last update for skin was 6/22/2021. On 5/25/2021 at 1:19 PM V6 (PCP) stated she ordered an antibiotic in case resident is developing a skin infection. I saw a picture of it, but you can't always tell in a picture. So, I ordered antibiotic to cover it until I can see the patient tomorrow. Review of R2's orders document an order by V6 (PCP) dated 5/24/22 at 3:19 PM as follows: [MEDICATION(S)] Tablet 875-125 MG ([MEDICATION(S)]-Pot Clavulanate) Give 1 tablet orally two times a day for prophylaxis until 6/3/2022. V8's signed Shower sheets for R2 from 4/2/22 to 5/16/22 documents swollen legs 8 times. R2's weekly Treatment Administration record documents R2 should have a weekly head-to-toe skin assessment. Last assessment was on 5/13/2022 and 5/20/2022 is blank. They only skin note found for R2 was from 7/24/2021. The facility's Wound Prevention Program, Page 4 documents the following: 8. Wound Treatment: Notify the physician for any changes in the skin condition and obtain wound care treatment orders. Apply wound treatment as ordered by the physician.

Based on observations, interviews and record review the facility failed to follow their change in condition policy and failed to notify physician of an acute change in condition of noted swelling, redness and discharge to bilateral extremities for 1 of 3 residents (R2) reviewed for notification of change. Findings include: On 5/24/22 at 10:52 AM, R2 observed sitting in wheelchair with sheet across her head. R2 was wearing long, stained, yellow socks. Swelling and redness in legs could be seen above the sock. R2 stated, My legs are bad, and they don't do anything for them. They don't wrap them. They just put [MEDICATION(S)] on them. On 5/24/2022 at 10:54 AM V5 (LPN) removed R2's socks. Both of R2's legs were swollen and red with yellowish/brownish large, layered patches of scaly flaking skin. Some areas were weeping with small amount of reddish/brownish exudate. Right leg noted to be more swollen than left leg. R2 stated, I've been telling them I don't feel good. I need to go to the hospital. R2 stated, I f I complain they say they will send me to Psych. On 5/24/22 at 1:13 PM V10 (CNA) stated, When showers are given, we document on the shower sheet any issues. Then we give it to the nurse. V10 stated, R2's legs look bad. V10 stated when she saw R2 over a week ago her legs were wrapped. V10 stated, I didn't know it looked that. V10 stated, I saw her skin like that about a week ago. I don't know why her legs are not wrapped anymore. Her legs have not been wrapped for about a week. Surveyor asked V10 to describe what R2's legs look like. V10 stated, R2's legs are scaly, reddish, and yellowish. On 5/24/2022 1:54 PM V6 (PCP) stated, R2 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . V6 stated she saw R2 a couple weeks ago. V6 stated R2's legs were a little edematous, clean dry and not weeping. V6 stated R2's legs were not red when she saw R2 a couple weeks ago. V6 stated R2 can get cellulites very quickly. V6 stated, no one from the facility has called her today regarding R2. V6 stated if R2's legs are swollen and red she expects the facility to call her. V6 stated she expects staff to follow her orders. V6 stated, the standard treatment are for R2's legs to be wrapped with ace bandages. On 5/24/2022 2:16 PM surveyor asked V5 to describe R2 legs looked like to her today when she took R2's socks off this morning. V5 stated, they looked like she has [CONDITION(S)]. V5 stated R2 legs are swollen, red, and have scaly patches. V5 stated she [R2] is not diagnosed with [CONDITION(S)] but that is what it looks like. V5 stated she took care of R2 on Tuesday or Thursday of last week also. V5 stated, Her (R2's) legs looked the same as they do now. V5 stated she is not sure if anyone has called the doctor about R2 legs. V5 stated, Don't remember getting report about her legs. Last week she had socks on. I don't recall her having them wrapped with ace. V6 stated, R2 refused ace wrap just now and she will chart it. V6 stated, I'm going to call doctor because I actually looked at her legs and I'll look to see if anyone had called the doctor. Otherwise, I will call and give the doctor an update and see if they want to change anything. V5 stated from what I saw it looked like [CONDITION(S)]. On 5/24/2022 3:02 PM V8 (CNA/shower aid) stated, A week ago I helped her. Her legs were swollen, reddish and they have been like that for a month or so. R2's Care plan reviewed on 5/24/2022 is absent of any care plan or update to her current skin condition. Last update for skin was 6/22/2021 and there is no mention of swelling, redness, or scaly flaking skin to bilateral lower extremities. On 5/24/2022 3:26 PM V2 (Assistant DON) stated, if a resident has a change in condition the nurse should do a full assessment and notify the doctor and family. V2 (DON) stated she saw R2's legs yesterday and there was swelling, brownish like with [MEDICATION(S)], scaling from weeping. V6 stated R2's legs were red when she saw them yesterday. V2 stated R2's doctor is aware of the condition of her legs. Surveyor asked how V2 knows that the doctor is aware of the condition of R2's legs? V2 replied, Well, I'm not sure if the doctor is aware. V2 stated when she sees redness, swelling, and [CONDITION(S)] she thinks that the doctor should be made aware of it. V2 stated, she did not notify doctor yesterday when she saw R2's leg because she believed the doctor was already aware of it. On 5/25/2021 at 1:19 PM V6 (PCP) stated that she ordered an antibiotic in case R2 is developing a skin infection. V6 stated she saw a picture of R2's legs, but you can't always tell in a picture. V6 stated, I ordered antibiotic to cover it until I can see the patient tomorrow. On 5/24/2022 12:31 V3 (LPN) stated if a resident has a change in condition we should assess resident, and let doctor and family know. Review of R2 orders documents an order by V6 (PCP) dated 5/24/22 at 3:19 PM as follows: [MEDICATION(S)] Tablet 875-125 MG ([MEDICATION(S)]-Pot Clavulanate) Give 1 tablet orally two times a day for prophylaxis until 6/3/2022. The facility's Change in Condition Policy dated 1/28/22, documents the following: The nurse on duty or designee will promptly notify the resident, the attending physician, or the physician representative (On call physician, Nurse Practitioner (NP), Physician Assistant (PA)) and Resident responsible party upon assessment of changes in the resident's medical/mental condition.

Based on interview and record review, the facility failed to monitor and supervise a high fall risk resident with myoclonic movements and failed to implement appropriate interventions for these myoclonic movements for one resident (R1) out of three residents reviewed for falls in a total sample of five. This failure resulted in R1 falling over the side of the medically reclining chair and sustaining five facial fractures to the right side of the face. Findings Include: R1 is an [AGE] year-old with the following diagnosis: gastrostomy status, repeated falls, fracture of nasal bones, fracture of [NAME] of skull, right sided malar fracture, and right sided medial and lateral fracture of the orbital wall. R1 admitted to the facility on [DATE]. A Post Fall Evaluation note dated 3/4/22 documents R1 fell around 3:55PM in the dining room and a laceration to the right eyebrow was noted. The Fall Event dated 3/4/22 documents the nurse was alerted by staff that R1 had fallen over onto the floor on R1's right side and was bleeding from the right eyebrow. R1 was unable to explain what caused the fall. Prior to the incident, R1 was sitting quietly in the dining room. R1 is one oriented times one. A Nursing note dated 3/4/22 documents prior to the incident R1 was sitting quietly in the dining room. R1 was sitting in a Geri chair (reclining medical chair on wheels). R1 was unable to explain the cause of the fall. Some bleeding was noted from the right eyebrow. 911 was called. The Hospital Records dated 3/4/22 document R1 presented to the emergency room post falls with multiple facial fractures. It was reported the fall was unwitnessed at the nursing home. R1 is alert and oriented times 1 at baseline. R1 is moving all extremities and making incomprehensible sounds. There is bleeding and bruising noted to the right periorbital region that is controlled. Swelling is also noted. The CT scan of the head documents there is a complex and mildly displaced acute right zygomaticomaxillary complex fracture. And acute mildly depressed inferior right orbital wall fracture which travels to the right infraorbital foremen is also noted. An acute mildly depressed fracture of the right temporal calvaria bone and an acute nondisplaced fracture of the right superior lateral or oral wall are present. The CT scan of the face show the same fractures listed as above along with fractions to the right nasal bone. R1 was admitted to the intensive care unit for close monitoring and to monitor for bleeding. A Nursing note dated 3/5/22 documents R1 was readmitted to the facility. R1 has multiple facial fractures in stitches on the right eyebrow. The Final Investigation Report dated 3/5/22 documents R1 was sent to the hospital on 3/4/22 to be evaluated for a fall. On 3/5/22, the hospital called to inform the facility that R1 was diagnosed with facial fractures. R1 stood up in the dining room and fell before the CNA could intervene. R1 returned from the hospital with facial fractures and three stitches to the right eyebrow. On 04/15/22 at 11:40AM, V2 (DON) stated, R1 was in the dining room in a Geri chair. There was another CNA in the room watching them. R1 stood up and fell over. R1 sustained multiple fractures to the face. R1 was a high fall risk. R1 was a resident we wanted to keep in line of sight during wake hours. R1 also has very poor safety awareness. The weakness in his legs caused the fall but it was because of the confusion and poor judgment that made R1 stand up. There was no reason why R1 got up that day. We make sure we monitor him in the dining room with staff present or sit R1 in front of the nurse's station. On 04/15/22 at 12:07PM, V3 (Nurse) stated, That day I was doing an admission in another room and a CNA came to get me to tell me R1 fell . R1 doesn't try to get up constantly but R1 would try sometimes. R1 would forget what he can't do. R1 has dementia and R1's speech was not clear and R1 was only alert and oriented to his name. R1 could hear it but R1 would just not follow or understand the directions you were telling R1. I don't think anyone was sitting next to R1 when he fell . I don't know exactly what happened, but I was told the CNA who was sitting in the room was trying to reposition another resident that was trying to get up and that's when R1 fell . It takes a second like that for something to happen. I assessed R1 and saw he was bleeding on the right side of his head near his eye. R1 was a high fall risk. The hospital called us later to tell us that R1 had fractures in R1's face. R1 moved around a lot so we were always having to check on R1 and make sure he was in a good position in the bed. I don't know why R1 moved around so much. I think that was just what R1's body was comfortable with. We just tried to reposition R1 when we were in R1's room. That's really the only thing you could do for that. On 04/15/22 at 12:28PM, V4 (CNA) stated, That day I was walking through the dining room to start my shift as a CNA, and I saw V10 (CNA) was in the dining room helping another resident sit down in their chair. R1 moves and rocks his body a lot and uses a Geri chair. R1 slides in the chair and his legs will go through the side of the chair. R1 was rocking his body and moving around and as I was walking up; I could see he was going to fall but I couldn't catch R1 in time. R1 flipped over the side of the Geri chair. I think the movements are involuntary. We always have someone to sit with if R1 is sitting up. R1 constantly needs to be repositioned. R1 doesn't follow directions. R1 could only understand when you called his name. We always have someone next to him because of this. R1 would need to be repositioned every 15 or 20 minutes. This time I think V10 just took her eyes off R1 to help the other resident for a second and this happened. Yes, R1 a high fall risk. R1 is weak and confused and R1 can't walk. On 04/15/22 at 2:41PM, V10 stated, I was sitting in the dining room by R1. There was 7 people I was watching. Another resident went to stand up and I walked over to them to have them sit back down because they weren't listening to what I was saying. I was on the other side of the table from R1, and my back was facing R1. R1 was moving a lot so this is why I was sitting by him. I don't know if R1 was getting up or what R1 was trying to do but I know V4 was coming in and V4 couldn't grab him. R1 was a high fall risk. I felt like I could manage the dining room, but it was just that one time when the other residents stood up is when I couldn't watch R1 while I was doing that. On 04/19/22 at 11:28AM, V12 (Primary Physician) stated, I know he fell on e day, and he had multiple fractures to his face. This can happen easier in older residents because the bones are more fragile and easier to fracture. I don't know how the fall happened. I know he does have myoclonic (sudden involuntary muscle jerk/shake/spasm) jerking movements or tremors. There are a lot of reasons these could be happening. For him it is an unknown cause. I would just say monitor him especially if he is a high fall risk with these types of movements. On 04/19/22 at 2:34PM, V2 stated, R1 doesn't have a diagnosis for those movements, but I would guess it is from the medications he takes for [CONDITION(S)]. Sometimes those medications can cause those movements. R1 was repositioned as needed and we used a towel to cover the G tube on days he was pulling at it. No, we didn't do anything else with the movements. We also would round on R1 every hour between the nurses and the CNAs. The Fall Risk Evaluation dated 12/1/21 documents R1 is at risk for falls. R1 is disoriented times 3 at all times, has a history of falls in the past three months, and requires the use of assistive devices. The Minimum Data Set (MDS) dated [DATE] documents the Brief Interview for Mental Status score as a 99 indicating R1 was unable to complete the interview. R1 is documented to have memory problems both short term and long term. R1 has moderately impaired cognitive skills for daily decision-making. R1 makes poor decisions and cues/supervision are required. R1 has behaviors of being in attentive, disorganized thinking, and an altered level of consciousness. These behaviors are continuously present and do not fluctuate. The Care Plan dated 12/8/21 documents R1 is high risk for falls related to confusion and unaware of safety needs. The Care Plan dated 12/9/21 documents R1 is at risk for falls. An intervention of consider a helmet and encourage R1 to call for assistance with all transfers are documented on 3/5/21. There is no care plan or interventions related to R1's jerking motions or R1's movements. The Fall Occurrence Investigation report dated 3/4/22 documents R1 tries to stand/transfer/walk unassisted and tries to get out of bed unassisted. R1's judgment at the time of the fall is documented as poor judgment and not aware of safety. R1's gait at the time of fall is unsteady. The investigation findings document R1 is alert and oriented times one with periods of confusion and forgetfulness. R1 sustained a fall in the dining room before staff could intervene periods of confusion and impaired judgment; and gait/mobility abnormality were noted. R1 was admitted to the hospital with multiple facial fractures. Root cause of the fall is documented as loss of balance due to gait/mobility abnormalities. The policy titled, Falls Prevention Program, dated 10/2016 documents, Policy Statement: Fall prevention program will be implemented to assure that safety of all residence in the facility whenever possible this program should include a measure which determines the individual needs of each resident by assessing the risks for falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Monitoring and Follow-Up: .5. As needed, document the presence of uncorrectable risk factors, including reasons why any additional search for causes is likely to be helpful. The policy titled, Fall Prevention Program, dated 2/28/14 documents, Policy: it is the policy of the facility to have a fall prevention program to ensure the safety of all residents in the facility, when possible. Program will include measures which determine the individual needs or each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality assurance programs will monitor the program to assure ongoing effectiveness. The fall prevention program includes the following: 1. Message to identify risk factors two. Methods to identified residence at risk three. Assessment time frames four. Use an implementation of professional standards of practice five. Changes in interventions that were unsuccessful six. Notification of physician, family/legal representative seven. Communication with direct care staff members eight. Documentation requirements nine. Adherence to manufacturers recommendations and use of alarm and medical devices in special care equipment 10. Care plan incorporates: a. identification of all risk/issue b. Interventions are changed with each fall, as appropriate C. Preventative measures . safety precautions for residence at risk: 1. The resident will be checked approximately every two hours, or as according to the care plan, to ensure they are in a safe position. The frequency of safety monitoring will be determined by the residence rest factors and the plan of care.

Based on interview and record review, the facility failed to develop and implement interventions for a resident's behaviors of fidgeting with equipment, myoclonic jerking movements, and high movement level while in bed for one resident (R1) out of three reviewed for gastrostomy tubes (G tube) in a total sample of five. This failure resulted in R1 removing R1's G tube and the site scabbed closed requiring R1 to have surgical replacement. Findings Include: R1 is an [AGE] year-old with the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 admitted to the facility on [DATE]. A Nursing note dated 3/22/22 at 8:49 AM documents R1 was noted with the G-tube completely out. The nurse is unable to administer bolus feeding at this time and the doctor was notified. A Nursing note dated 3/22/22 at 9:02 AM documents R1 was transferred to the hospital at this time. The Hospital Records dated 3/22/22 document R1 was sent to the nursing home due to misplacement of G-tube. The nurse noticed the G-tube was out and couldn't give any medication through it in the morning. No specific time is documented. The G-tube site was found to be scabbed over and the ER physician was unable to replace it. Gastroenterology was consulted and plan to place a new G-tube. The G-tube was successfully replaced by the Gastroenterology team 48 hours after being seen in the emergency room . A Nursing note dated 3/28/22 documents R1 receives bolus feedings every four hours. R1 pulls at equipment. On 04/15/22 at 11:40AM, V2 (DON) stated, R1 has been known to pull at the tube. R1 fidgets and messes with things all the time. We will try to hide the tube from R1 by putting a towel over it to distract him for a little bit. I think of it as an out of sight out of mind. We also tried switching to bolus feeds instead of continuous, so R1 wasn't plugged up all the time. I know that time R1 pulled the G-tube out and the hospital had to put in another one. G-tube medications are usually at 6 AM and 6 PM. The last time someone saw R1's tube and was probably around 6 AM that morning when giving medications. I don't remember seeing a scab that day but as soon as we noticed it, he was sent out. There was no waiting. I don't know how many hours it was out for. I know they couldn't get it in while he was in the ER so he had to get it put in again surgically. That's what they told us. On 04/15/22 at 12:28PM, V4 (CNA) stated, R1 moves and rocks R1's body a lot and uses a Geri chair. I think R1's movements are involuntary. R1 constantly needs to be repositioned. R1 would do the same moving and rocking in the bed. R1 doesn't follow directions. R1 could only understand when you called R1's name. R1 would need to be repositioned every 15 or 20 minutes. On 04/15/22 at 12:59PM, V5 (Nurse) stated, I went to do morning care on R1 and give R1 medication around 9 o'clock and I noticed R1's G-tube was dislodged. When I first assessed it around 7 in the morning when I came on I didn't see any issues. I called the doctor and he told me to send them out to the hospital. R1 was sent out within an hour or even sooner. When I checked on it at seven I just saw that the port where the medications go was where it was supposed to be, tucked under his brief, but I didn't see the stoma part. R1 moves around a lot in the bed. I didn't see him pulling on it that day. There are times when I've seen R1 with R1's head at the foot of the bed and R1's feet where his head should be. R1 will roll back-and-forth from side to side. We don't really do anything we just let R1 move how R1 wants. When I got report, the night nurse didn't tell me she had any issues with the G-tube. I never saw any scabs on the site. On 04/15/22 at 1:06PM, V6 (Nurse) stated, I had to give R1 medications around 5 in the morning when I was doing my last round. I didn't have any issues with his G tube. I would have noticed it completely out then if it was. R1 had a behavior of pulling the tube. We would redirect R1 if we saw R1 doing that or put something else in R1's hands. R1 didn't sleep much at night so I was in there often telling R1 to stop pulling the tube or reposition R1. No, I normally never put anything over the G-tube. On 04/15/22 at 1:44PM, V7 (CNA) stated, I do rounds every hour. If it was out that last time, I checked on R1 around 6 in the morning I would've told the nurse. The way I do my rounds I would've seen him between 5:30AM and 6AM. I remember I cleaned R1 up and R1 still had it inserted. I don't remember seeing him pulling up at night, but I did see R1 move around a lot. R1 just has a habit of moving R1's body all around the bed. No, I never saw the G-tube covered with anything. On 04/19/22 at 11:28AM, V12 (Primary Physician) stated, I know there was a situation where R1's G-tube had come out and R1 needed to go to the hospital to get it back in. I actually spoke with the gastroenterologist on this, and he said those sites normally take up to three hours to close. They come out fairly easily and not too much force is needed. I don't know what they did to protect it, but I've seen facilities put a dressing over it or a binder to keep it secure. I don't think a towel could protect it if the person was able to move it away. R1 needed to have the surgery to have it put in again because R1 had no other options. R1 wasn't able to eat by mouth. For someone R1's age, surgery is harder to recover but R1 had no other choice. On 04/19/22 at 2:34PM, V2 stated, R1 doesn't have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Sometimes those medications can cause those movements. R1 was repositioned as needed and we used a towel to cover the G tube on days R1 was pulling at it. No, we didn't do anything else with the movements. We also would round on him every hour between the nurses and the CNAs. The Minimum Data Set (MDS) dated [DATE] documents the Brief Interview for Mental Status score as a 99 indicating R1 was unable to complete the interview. R1 is documented to have memory problems both short term and long term. R1 has moderately impaired cognitive skills for daily decision-making. R1 makes poor decisions and cues/supervision are required. R1 has behaviors of being in attentive, disorganized thinking, and an altered level of consciousness. These behaviors are continuously present and do not fluctuate. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A new order is placed on 3/28/22 for feedings to occur every four hours. There is no care plan or interventions related to R1's jerking motions or R1's movements.

Based on observation, interview and record review, the facility failed to discard stock medication, used for all residents, and failed to discard expired medication for 1 of 1 resident (R32). This failure has the potential to affect 22 of 39 residents. Findings include: On 2/1/2022 at 1:15 PM surveyor reviewed medication cart on the 2nd floor with V3 (Licensed Practical Nurse - (LPN)). Findings: 1. An unopened pack of 30 tablets of [MEDICATION(S)] 25 mg for R32 which expired on 11/2021 was found in the medication cart with unexpired medications. 2. 12 tablets of [MEDICATION(S)] chewable tablets expired on 1/2022 found in the medication cart. On 2/1/2022 at 1:30 PM V3 said that the expired medications should have been taken out and put in a bin designated for expired medication, and the stocked medication discarded. On 2/4/2022 at 11:10 am, V2 (Director of Nursing) said, if the expired medication is a stocked medication, she expects her staff to discard them, otherwise all expired medication should be sent back to the pharmacy. Facility Policy: All medications are checked for expiration dates by respective department. Procedure: #4. Expired items are disposed of or returned to sender.

Based on interview and record review, the facility failed to follow Policy Falls Prevention Program by not promptly notifying MD/NP of inconclusive radiology report of left [CONDITION(S)] which resulted in resident being transferred to hospital 3 days later for CT which then diagnosed fracture. This failure affected 1 of 3 residents reviewed for falls. Findings include: On 9-21-21 at 11:46 AM, V2 (DON) said 2nd shift nurse (who received R1's radiology report) attempted to notify MD/NP of R1's Radiology report but was unsuccessful in reaching either on 9-9-21. V2 was able to update MD/NP 3 days later and received orders to send to hospital for further evaluation on 9-12-21. R1 was admitted to hospital and initial hospital x-ray was inconclusive. Hospital then did a CT (9-13-21) which documented comminuted fracture of left greater trochanter extending to base of lateral neck. On 9-21-21 at 1:13 PM, V6 (MD) said he is not sure he received R1's inconclusive radiology results on 9-9-21. V6 said NP informed him of results when R1 was sent to hospital. The Facilities Falls Prevention Program (revised 10-16) documents, the staff, with physician guidance, will follow up on any fall with an associated injury until the resident is stable and any complications such as fracture or subdural hematoma have been ruled out or resolved. Radiology Report (dated 9-9-21), documents Pelvis X-ray 1 view, Impression: mild suspicion of impacted fracture of the lateral aspect of the left femoral neck, versus positional artifact. Clinical correlation recommended. I recommend dedicated AP (anterior posterior) and frog leg oblique views of left hip for further assessment. Hospital x-ray Report (dated 9-13-21), documents x-ray hip left 2 or 3 views, Findings: slight cortical irregularity involving the greater trochanter may be normal for this patient or could be due to old trauma, but a subtle nondisplaced fracture cannot be excluded. CT left hip, Findings: The bones are demineralized. There is a comminuted fracture of the left greater trochanter extending to its base of the lateral neck. HPI: Patient lives at a nursing home and had an unwitnessed fall 4 days ago. X-rays were initially obtained but were not followed up on, they were found to have possible greater trochanter fracture. Nurses Note (dated 9-12-21) documents Resident alert and oriented x 2-3. Pelvis x-ray findings relay to NP. New orders receive to send resident out for possible impacted left femoral neck fracture. Resident sent to local hospital for further evaluation. Management made aware. Emergency contact (daughter) notified. Resident denies any pain or discomfort at this time. All due medication received. Will continue to monitor closely. Fall precautions maintained. Surveyor and V2 reviewed progress notes together and could not find any nursing note documenting MD/NP follow up until 9-12-21.

Based on observation, interview and record review the facility failed to follow physician order, therapy recommendation for use of splints/braces and follow its restorative program policy to prevent further decrease of range of motion for residents who have limited mobility and contractures. This deficiency affects four residents (R3, R6, R24 and R10) in the sample of 16 residents reviewed for limited range of motion. Findings include: 1/7/2020 at 11:20am, R6 is up in wheelchair with left hand contracture noted. No splint is noted to be applied to the left hand contracture. 1/7/2020 at 2:21pm, R6 in bed, no left-hand splint applied to the left hand. 1/8/2020 at 8:58am, R6 up in wheelchair no splint applied on left hand. 1/8/19 at 12:37pm, V2 (DON/Restorative Nurse) stated that R6 has left hand splint but he refused to use it. Review R6's medical record with V2 that he has [DIAGNOSES REDACTED]. He does not have an order for [REDACTED]. Review of Facility's list of residents on restorative program given by V2 (DON/Restorative Nurse). No residents on splint /brace application program. 1/9/2020 at 10:30am, the following was observed: R24 is up in wheelchair with a right leg brace, R10 on motorized chair with bilateral ankle foot orthosis (AFO) and left hand splint and R6 noted with a left hand splint. Review of R10 and R24's medical records indicted both residents are not in restorative program for splint/brace application. R24's Care plan did not reflect use of splint/brace. R10 care plan indicated application of bilateral leg brace and left-hand splint at night 9pm. MDS was not coded for use of splint/brace. All splint and braces are applied by V17 (Restorative Aide). 1/9/2020 at 10:59am, V20 (Occupational therapist) stated that they assess residents who have limited movement and decline in ADLs. They recommends splints and braces to resident who have contractures and limited ranges of motion. R6 was admitted in (YEAR). R6's left hand splint was given on (YEAR). R6 is compliant in using R6's splint and did not refuse the splint. R6 is currently in therapy to increase R6's tolerance from 2 hours to 4 hours of splint usage. R10 was admitted with left hand splint and bilateral AFO braces due to her [MEDICAL CONDITION]. R24 has a right knee brace due to her knee contracture. 1/10/2020 at 9:15am, V2 (DON/Restorative/MDS Coordinator) stated that she just continued the existing restorative program in the facility. R6, R10 and R24 are using splint/braces but are not care planned or coded for MDS for application. R10 bilateral leg braces and splint should be applied in the morning and removed at bedtime. On 1/9/2020 at 9:30am R3 observed in dining area with right hand contracture and no splint. On 1/9/2020 at 9:45am V20 (occupational therapist) said I was not aware that R3 had a splint. R3 is under restorative care, if there are changes then we will pick up the resident again. R3 was discharged off occupational therapy on 4/14/2017 and started with the restorative aide for the splint to be applied daily. On 1/9/2020 at 10:20am V17 (restorative aide) I do what is on my restorative list and applying a splint is not on that list. On 1/9/2020 at 11:50am V22 (therapy manager) said I was not aware that R3 had a splint and we cannot find it, so I will order another splint once they are discharged from the therapy we send them to restorative care. On 1/9/2020 at 12:00pm V2 (restorative care nurse, and director of nursing) stated: I do restorative and keep up with the restorative aide , I was not aware that R3 had a splint , it is not included in the care plan for a splint. On 1/9/2020 at 10:00am, Physician order [REDACTED]. Occupational therapy plan of care dated from 2/28/2017 discharged on [DATE] for restorative aide to apply splint daily. A restorative program list with R3 listed for AROM, eat and swallow, dressing and grooming no application of splint. A care plan review dated 12/20/2017 does not have a hand splint application goal. Facility policy: Rehabilitative/Restorative Nursing care number 3. The facility's rehabilitative/restorative nursing care program is designed to assist each resident to achieve and maintain an optimal level of self-care and independence. Letter D. assisting residents to adjust to their disabilities, to use their prosthetic devices, and to redirect their interests, if necessary.

Based on observation, interview, and record review, the facility failed to follow their policies on medication administration/Storage and Expiration for labeling and dating opened medications. For five residents, R6, R11, R12, R15, and R25 reviewed for labeling and storage of medications. Findings Include: On [DATE] at 10:35 AM, the following were found: R6 Humalog insulin expired date ,[DATE] with no year on medicine. [MEDICATION NAME] 100 units/ml opened no opened date noted on medicine. R11 Latanoprost sol opened, no opened date noted on medicine. R12 [MEDICATION NAME] ,[DATE].5mg opened, no opened date noted on medicine. R15 Brimondine sol-02% to left eye opened [DATE] and [MEDICATION NAME] ophthalmic gel forming solution 0.5% opened [DATE]. R25 [MEDICATION NAME] injection 1ml monthly opened no opened date noted. At 10:37 AM V13 LPN (Licensed Practical Nurse) stated We date the day we open medications and place the expired date 28 days. Some eye drops can last for 60 days depends on the manufacturer. Policy Titled Administering Medications 8. When opening a multi-dose container, the date opened shall be recorded on the container. Policy Titled Expired Products or items dated ,[DATE] 3. Each respective department should physically check all products with expired dates routinely.

Based on observation, interview and record review the facility failed to follow their policies on self-administration of medication and administering medication for one (R36) of one resident reviewed for self-medication administration in a sample of 16. Finding Include: On 01/08/20 at 8:47 AM, during medication pass R36 was found with an [MEDICATION NAME] inhaler at R36's bedside table. The inhaler had no opened date on the inhaler. R36 stated around 2 months ago I was told I can keep the red inhaler because I get short of breath at night. V23 LPN (Licensed Practical Nurse) stated I did not know (R36) had it, (R36) has an order for [REDACTED].>On 01/09/20 01:41 PM V3 (Assistant Director of Nurses) stated According to the BIMS (Brief interview for mental status) score, the resident can self-medicate, then we notify the Doctor and he gives an order. At 01:50 PM V1 (Administrator) stated BIMS score for self-administration of medication is 13 or 15. On 01/08/19 09:00 [NAME]M. Record review R36 has no assessment or order for self-administration of medications. Policy Titled Self Administration of Medication dated Revised (MONTH) (YEAR): 1. As part of their overall evaluation, the staff and practitioner shall review resident's mental and physical abilities to determine whether a resident is capable of self-administering medications. 6. Self-administered medications must be stored in a safe and secure place. Policy Titled Administering Medications dated Revised (MONTH) (YEAR): 22. Residents may self-administer their own medications only if the Attending Physician in conjunction with the interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely.

Based on observation, interview and record review, the facility failed to ensure physician ordered lower extremity compression wraps were applied for 1 of 1 resident (R19) reviewed for compression wraps in a sample of 16. Findings include: On (MONTH) 09, 2020 at 9:00am R19 was observed up in wheelchair with compression stockings on bilateral lower extremities with [MEDICAL CONDITION] observed to left upper calf. On (MONTH) 09, 2020 at 11:42am V3 (assistant director of nursing) was asked who applied compression stockings on R19. V3 said the nurse applies all compression stockings, I'll have her come down. On (MONTH) 09, 2020 at 12:30pm V9 (licensed practical nursing) was asked: did you apply compression stockings to R19's lower extremities? V9 answered no and added: the nurse on 11-7 shift does that . V9 was asked if V9 knew what type of compression R19 should have applied to R19's lower extremities. V9 answered V9 thought it was compression stockings. V9 was asked if V9 knew R19 has an order for [REDACTED]. On (MONTH) 09, 2020 at 1:00pm V10 (certified nursing assistant) was asked if R19 had on compression stockings this morning. V10 said yes, R19 did have on compression stockings. V10 was asked if R19 usually has on compression stockings or compression wraps? V10 said some days wraps and some days stockings, but night shift applies those, we don't. On (MONTH) 09, 2020 at 2:00pm V11 (licensed practical nurse) was asked if V11 applied the compression stockings to R19's lower extremities. V11 said no, the CNA put those stockings on R19, and I told the CNA that R19 should have on compression wraps. The CNA said this is what the night nurse puts on R19 all the time. V11 was asked if V11 asked the CNA to remove them? V11 said no, I did not because the CNA works with that group all the time. On (MONTH) 09, 2020 at 2:08 pm V12 (certified nursing assistant) was asked if V12 applied the compression stockings to R19's lower extremities? V12 said yes, I did, I have R19 every day and that's what is in R19's room all the time. V12 was asked if V12 ever sees R19 with compression wraps on bilat extremeties. V12 answered that sometimes V12 does see the compression wraps, when the stockings are not there, but I don't put those on the nurse does. On (MONTH) 09, 2020 at 9:30am a record review of R19's Physician orders dated on 11/16/2019 open ended, for: ace wraps daily to bilateral legs for [MEDICAL CONDITION]. Facility's Policy : Applying ace wraps bandage, the purpose of this procedure is to improve or minimize [MEDICAL CONDITION] to upper or lower extremities. Preparation: 1. Verify that there is a physician's order for the use of [REDACTED]

Based on observation interview and Record review the facility failed to follow their policy on oxygen administration for three residents R9, R22 and R30 out of four residents reviewed for oxygen Therapy in a sample of 16. Findings Include: 1. On 1/9/19 at 11:15 AM V16 (CNA - Certified Nurse Aide) was turning R9 and placed the pillow under R9's head next to the Oxygen tubing and R9 winced. V16 moved oxygen tubing from R9's right ear and found an open red wound. 2. On 1/9/19 at 11:26 AM, R22 had a small red sore in the crease of R22's left ear. On 1/9/19 at 11:26 AM R22 stated I have a little soreness and pain here on my ear, they put pads on the tubes but it comes off. 3. At 11:29 AM upon removal of oxygen tubing from R30. R30 let out a scream and an open sore in the crease of R30's right ear was found. On 1/9/19 V3 at 11:37 AM V3 (Assistant Director of Nurses) stated The nurses are to do a skin assessment weekly. Policy Titled Oxygen Administration dated revised (MONTH) (YEAR) 8. Securely anchor the tubing so that it does not rub or irritate the resident's nose, pad behind the resident's ears to decrease pressure and monitor for skin break down.