Every finding on record at Alden Estates of Barrington

Based on interview and record review, the facility failed to keep a resident (R1) free from being sexually assaulted by a nurse (V1) as the nurse's DNA from saliva was found on R1's breasts for one out of three residents reviewed for abuse in a total sample of five. This failure resulted in severe psychosocial harm including fear, embarrassment, and/or dehumanization using the reasonable person concept. The past noncompliance occurred from 2/22/26-2/23/26. Findings Include: R1 is the subject of the complaint. R1 is a [AGE] year old with the following diagnosis: epilepsy, major depressive disorder, cocaine abuse, psychosis, generalized anxiety disorder, and history of sudden cardiac arrest, and psychoactive substance abuse. R1 no longer resides in the facility. The surveyor called V1 (Former Nurse) on 7/7/26 at 12:40PM at the number listed on V1's employment forms. The number listed is currently not accepting calls.The surveyor called the number listed on the face sheet for R1 and V3 (R1's Family Member) on 7/8/26 at 11:10AM. V3 answered and refused to let R1 speak to the surveyor due to feeling uncomfortable letting her talk to anyone. On 7/7/26 at 3:17PM, V6 (Detective) stated someone in R1's family called to report a sexual assault by one of the nurses (V1) at the facility. V6 reported the patrol officers picked up R1 and brought R1 to the hospital. V6 stated at the hospital a rape kit was performed where DNA samples were collected from R1's vagina as well as the chest area. V6 reported that R1 told police that V1 came into R1's room on two separate occasions. V6 stated during the first encounter, V1 sucked on R1's breasts and the second time V1 penetrated R1's vagina with V1's penis. V6 stated that per R1, V1 ejaculated not on the inside of R1, but pulled out and finished on R1's stomach area then cleaned off the semen with some type of towel. V6 reported they got a search warrant to collect DNA samples from V1 and found that the DNA sample collected from R1's chest matched V1's DNA. V6 reported male DNA was found in R1's vagina, but it was not enough to match it to V1. V6 stated once the DNA matches, the detectives proceeded with filing charges, and V1 was arrested and charged with criminal sexual assault on 6/16/26. V6 reported that V1 continues to adamantly deny any of this story but stated V1's DNA from saliva was found on R1. V6 stated R1 denied having sex with anyone else for months and R1's story remained consistent throughout the investigation. V6 reported V1 is currently still being held in jail until V1's case is heard by a judge On 7/8/26 at 11:10AM, V3 (R1's Family Member) stated per what R1 told V3, V1 first time came in and tried to have R1 give V1 oral sex. V3 reported R1 told V1 no so then V1 pulled down R1's shirt and began sucking on R1's breasts. V3 stated R1 then said V1 inserted V1's fingers into R1's vagina and after V1 was finished V1 left the room. V3 reported R1 said V1 came back a second time and that is when V1 put V1's penis in R1's vagina but ejaculated on R1's stomach area. V3 was unaware how much time passed in between the first time V1 came into the room and the second. V3 stated R1 called her boyfriend and he called the police. V3 reported know the detective said they found V1's DNA from saliva on R1's breast. On 7/9/26 at 9:36AM, V7 (Administrator) stated V7 was notified in the morning of 2/22/26 that R1 voiced allegations of abuse. V7 reported that the police did not notify any staff members of the reasoning R1 was removed from the facility and V7 was not informed that a rape kit was performed on R1 until about 11 AM. V7 stated a full abuse investigation was initiated. V7 reported V1 denied any inappropriate interactions with R1. V7 reported by the time they were made aware of the allegations V1 had gone home and was then called and told V1 would be suspended pending the investigation. V7 stated R1 was background checked upon higher, and V1 had no hits. V7 denied V1 having any previous behaviors or other concerns from residents or staff. V7 reported R1 did have some cognitive impairment after suffering from a cardiac arrest before being admitted to the facility. V7 stated the facility had rehabilitated R1 to the point that it was no longer appropriate for R1 to reside in the facility. V7 reported R1 had a behavior of voicing false allegations in the past as R1 was telling staff that R1 was having sexual relations with a boyfriend and wanted a baby. V7 stated the boyfriend denied having any relations with R1 so the facility deemed it as R1 was attempting to appear older than what R1 acted mentally. V7 reported the detective called V8 (Regional Operations Director/Former Administrator) about three weeks ago and informed the facility they had enough evidence to make an arrest on V1. V7 denied any reports of R1 claiming to be abused before R1 left the facility. On 7/9/26 at 10:00AM, V8 stated V7 called V8 immediately after speaking with the hospital and reported the allegations to V8. V8 reported that V7 and V8 began immediately working on the investigation together. V8 stated when the facility first talked to V1, V1 was very confused by the allegation and denied ever touching R1 inappropriately. V8 reported R1 had a lot of gaps in mental clarity. V8 stated towards the end of R1's stay at the facility, R1 had a boyfriend coming to visit, and R1 began telling staff that the boyfriend and R1 were having sex trying to have a baby. V8 reported speaking with the boyfriend and the boyfriend denied having sex with R1. V8 stated the facility had R1 psych tested to see if R1 could consent to sexual activity and during the testing, it was concluded that R1 may have been trying to make up stories such as having sex with a boyfriend to appear more age-appropriate, but is mentally like an early teenager. V8 stated V8 only spoke with V3 on the day of the incident and R1 or V3 have not returned any of V8 calls. V8 reported R1 had a background check before hire and the police also did a background check on V1 to which V1 had no prior record. V8 stated the detective called V8 and said that the DNA came back matching V1 but did not tell V8 where the DNA was found or what kind of DNA it was. V8 reported the detective only told V8 that the DNA found was not semen. V8 stated V1 reported spilling water on R1 while assisting with oral care, and V1 wiped the water up with a towel near R1's chest area, but V1 continue to deny anything inappropriate happening. A Nursing note dated 2/22/26 at 8:14AM documents at around 3:40AM the police arrived to the facility and requested to be brought to R1's room. The police asked for the nurse's identification and the paramedics took R1 to the hospital. The police denied stating why R1 was being taken. The physician and family were notified.A Nursing note dated 2/22/26 at 2:32PM documents the nurse called the hospital for an update. The nurse was notified R1 was discharged home with family. The family then came to the facility around 9:30AM and requested R1's medication which was given per physician's orders.A Nursing note dated 2/22/26 at 4:41PM documents the hospital case worker called the administrator to notify them of the reported allegation. An internal investigation was initiated with the help of other staff. The administrator then called the family and confirmed R1 was discharged with family.The Police Record dated 2/22/26 documents R1's boyfriend called the police to report R1 called the boyfriend around 12:30AM and stated a male nurse was asking R1 for sexual favors (oral sex) as well as inserting his fingers into R1's vagina. The boyfriend stated R1 asked not to call the police, but the boyfriend thought it was the right thing to do. The boyfriend stated R1 is still able to communicate after R1's accident but does talk differently. The boyfriend reported this is the first time R1 reported any sexual misconduct. The officer arrived and spoke with R1. The police officer asked what was going on and R1 stated he touched me. R1 was lying in bed with a pink blanket covering R1. R1 was wearing a tank top with only underwear on. A man walked towards R1's room and was identified as V1. R1 identified V1 as the nurse that touched R1. The police asked R1 where V1 touched R1 and R1 said, private parts. The police instructed R1 to pointed to the area V1 touched and R1 pointed to the vaginal region. R1 reported the incident happened hours ago and confirmed this was the first time V1 had done anything like this. R1 stated V1 had put two fingers into R1's vagina and also kissed R1's breasts. R1 reported R1 was awake during the incident and told V1 to stop when V1 inserted his fingers into R1's vagina. R1 stated V1 still continued to touch R1's vagina with V1's fingers. R1 said that V1 told R1 that he was horny. R1 reported around 12:50AM about 20 minutes after the first incident, V1 came back into R1's room to have sex with R1. R1 stated V1 was not using a condom and ejaculated on the outside of R1's private parts. R1 said V1 cleaned off the semen with some napkins and he took the napkins he used to clean. R1 stated the sexual penetration did not last too long. R1 reported R1 did not say anything to V2 during the sexual penetration and just laid there. The police documented R1 as lucid and able to answer questions without any assistance. The fire department was dispatched to transport R1 to the hospital. V1 never questioned why there was police presence at the facility nor why the police were transporting R1 to the hospital. Once the police arrived, V1 never entered R1's room again. At 8:07AM, the nurse confirmed the rape kit was completed and ready to be picked up. The nurse reported there was redness and swelling around R1's vagina along with a significant amount of vaginal discharge although it could not be determined if it was discharged from R1 or V1's semen. The nurse stated R1's panties were damp which is consistent with R1's claim that V1 ejaculated on R1's stomach and around the vagina area where the underwear were still present before it was cleaned by V1. The arrest information documents V1 was arrested on 6/16/26 and charged with criminal sexual assault.The Hospital Records dated 2/22/26 document a forensic exam was performed on R1. R1 was discharged home with parents. The discharge diagnosis was sexual assault of an adult. R1 reported being sexually assaulted by a nurse about three hours before arrival. R1 stated the nurse (V1) penetrated R1 with the nurse's penis and ejaculated on R1 but not inside. R1 denied having any injuries and denied taking R1's clothes off/showering since the sexual assault. A SANE nurse came to perform the examination on R1.The Final Investigation Report dated 2/27/26 documents at 4AM on 2/22/26, R1 was transferred to the hospital with police presence. The hospital later notified the facility R1 alleged sexual abuse against a specific male nurse. The nurse was placed on administrative leave and denied all allegations. R1 called R1's boyfriend and said the assault happened around 12:30-12:50AM while R1 was in the room. The police reported the boyfriend called 911 at 2:43AM. Police interviewed R1 upon arrival to the facility and did not notify the facility about the allegation. A forensic exam was performed at the hospital and R1 denied any injuries from the alleged abuse. The police notified the administrator around 11AM of the allegation. Interviews with staff and other residents resulted in concern against the nurse that was accused. Camera footage does not place the nurse in R1's room during the timeframe of the alleged incident. On 2/25/26, the nurse provided a DNA sample without hesitation. Police denied any concerns at this time due to the nurse's level of cooperation. Police reported DNA results should be available within 1-2 weeks. The nurse is still on administrative leave. Administration has been in contact with R1's family who stated R1 is doing well and has no mentioned the abuse since discharging.The Timecard documents V1 clocked in on 2/21/26 at 10:53PM and clocked out on 2/22/26 at 8:27AM.The Abuse Risk assessment dated [DATE] documents R1 is not at risk for abuse. There are no other more recent abuse risk assessments.The Cognitive assessment dated [DATE] documents R1 reportedly has a romantic partner visiting and concerns have been reported regarding R1 telling staff that R1 wants to have a baby and is having physical relations with a boyfriend. Concern was expressed regarding R1's ability to consent to sexual contact and insight regarding the potential consequences of intercourse, including pregnancy. R1 denies however, facility staff reports that R1 has been telling people that R1 is having a sexual relationship and wants to have a baby. The boyfriend reportedly denies a physical relationship with R1. R1 reported that they use condoms and R1 does not want another child. R1's thought process is impaired reality. R1 is delusional and telling staff that R1 is having a sexual relationship, although the boyfriend denies this. It is unclear if R1 is attention seeking or trying to be more typical for R1's age. R1 also reportedly told the gynecological doctor that R1 wants to have another baby. R1 exhibits issues with reality testing, and delusions about what R1 is able to do alone. R1 is emotionally immature and vulnerable in combination with magical thinking and delusional patterns. R1's judgment is fair to poor. R1 is attention seeking and will share information with others that may or may not be true and is somewhat indiscriminate with whom R1 speaks. R1 reports wanting to have a baby but does not have insight into the challenges R1 would experience. R1 has a history of smiling and nodding at questions, but it is often unclear whether R1 actually understands more complex discussions. R1 is also noted to fake good during interviews, telling medical personnel what R1 thought the right answer was or to show R1 in the best light. R1 becomes quieter and more reserved when challenged or faced with a difficult task that R1 cannot do well. R1 does exhibit impulsivity, and as an emotionally vulnerable adult, R1 may be taken advantage or encouraged to engage in activities appropriate for R1's chronological age, but not for the cognitive limitations and emotional age. R1 suffered a brain injury in 2023, following an overdose on narcotics that resulted in cardiac arrest and hypoxic respiratory failure. R1 exhibits marked impairment and mental tasks of executive functioning, insight, judgment, and safety awareness. More mild impairment present are in short-term memory, long-term memory, social communication, and attention/concentration. R1 exhibits impulsive decision-making, attention seeking behaviors at times, and emotional maturity significantly younger than chronological age.The care plan was reviewed and there is no documentation of any care plans regarding abuse or risk for abuse. The Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score as 15 (no cognitive impairment). R1 has no disorganized thinking, inattention, or altered level of consciousness. Section GG of the MDS documents R1 needs supervision/touching assistance with ADL care, bed mobility, transfers, and walking.The policy titled, Abuse Policy, dated 03/2025 documents, Policy: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. The facility will report reasonable suspicion of a crime. This facility, therefore, prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all within its control to prevent occurrences of mistreatment, neglect, or abuse of our residents. This facility is committed to protecting our residents from abuse by anyone, including, but not limited to, facility staff, or residents, consultants, volunteers, and staff from other agencies, providing services to the individual, family members or legal guardians, friends, or any other individuals. Definitions: The following definitions are based on federal and state laws, regulations, and interpretive guidelines. Abuse means any physical or mental injury, or sexual assault inflicted upon a resident other than by accidental means in the facility. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful means the individual acted deliberately, not that the individual must have intended the injury or harm. Sexual abuse is non-consensual sexual contact of any type with a resident. This includes, but is not limited to, sexual harassment, sexual corrosion, or sexual assault.Prior to the survey dated of 7/7/26, the facility had taken the following action to correct the noncompliance: V1 was suspended pending investigation, staff was educated by the Administrator, Regional Director, DON, and other IDT on facility abuse/sexual abuse policies, abuse prevention, incidents and accidents, appropriate notification reporting, and investigation process. Education focused on staff with the potential to be impacted by the noncompliance and not limited to staff involved in the actual incident. Staff pop quizzes in interviews were initiated by the management team. Resident interviews were also conducted by management. All residents were reassessed for risk of abuse with care. Plan updated as needed. Residents identified at risk for abuse had a review of the care plan with updates made as needed. This was completed 2/23/26. Skin checks were performed on all residents that were completed on 2/23/26. A review of all male HR files who work on the B wing were conducted and completed on 2/23/26. The management team conducted a review of compliance, using quality assurance, audit tools for monitoring, abuse allegations, reporting, and investigation processes. Audit started on 2/22/26 and will be conducted two times a week for four weeks, then weekly for four weeks, then monthly for three months. The result of the QA audit shall be reviewed by the facility team to determine any necessary changes. A copy of the meeting was held on 2/22/26 by the administrator with the interdisciplinary team and Medical Director. The meeting included discussion on abuse, allegations, investigation processes, and removal plan. The Medical Director and management team approved this removal plan. Ongoing compliance will be monitored by facility management. All in services with a topic of abuse with a focus of sexual abuse were conducted on 2/2226 and 2/23/26 with all staff in the building. All abuse prevention quizzes were reviewed by the staff. All quizzes were completed by 2/23/26.Staff were interviewed and asked if they have ever observed a resident being abused, ever observed Staff, abusing our one, if residents have expressed concern regarding abuse from Staff, and if they felt safe working in the facility. No concerns were noted with the staff interviews. Staff interviews were completed on 2/23/26.Resident interviews were conducted, and they were asked if they feel safe in the facility, if they have ever had any concerns with the one, if they ever had any concerns with other staff related to abuse, if they had heard of any other residents expressing concerns about V1, and if they have ever been abuse in the facility. No concerns were noted with resident interviews. Resident interviews were completed on 2/23/26.All abuse risk assessment were updated on every resident in the facility as of 2/23/26. R2, R3, R4, and R5 were documented as not being at risk for abuse. Their care plans were not updated based on this assessment showing them not being at risk review.Skin check audits were completed on all residents by 2/23/26. R1, R2, R3, R4, and R5 were documented as having no skin impairment, marks, or bruises.A review of all male staff employee files who work off shift on the B wing were audited on 2/23/26. No corrective action was needed in any of the employee files. All background checks were completed and up-to-date with no disqualifying actions.QA Audit Monitoring Tool for resident abuse was reviewed from 02/2026 through 07/2026. The facility is completing these audit tools on a weekly basis. Per the audits, there are no residents that have voiced feeling unsafe in the facility, had any concerns with a staff member, or needed to report any kind of abuse. The second QAPI Audit Monitoring Tool were reviewed from 02/2026 through 07/2026. It is documented that no residents that were audited have reported any allegations of abuse.The copy of the team meeting attendance sheet was reviewed and documents all members of the IDT were present as well as the Medical Director.Interviews with staff started at 10:45AM and ended at 11:49AM on 7/9/26. Interviews were conducted with V2 (Business Office Manager/Human Resources), V7 (Administrator), V8 (Regional Director of Operations/Former Administrator), V9 (CNA), V10 (CNA/Unit Manager), V11 (LPN), V12 (LPN), V13 (Housekeeping Supervisor), V14 (Housekeeper), V15 (Activity Aide), V16 (Social Service Director), and V17 (DON). All staff interviewed were able to report the abuse coordinator is the administrator and that all allegations of abuse must be reported to V7. All staff denied any residents reporting any allegations of abuse or feelings of being unsafe in the facility since 02/22/26. All staff were able to name the types of abuse and that residents must be separated immediately All staff reported being given quizzes after the in-services to determine their level of understanding. V2 stated all off shift (11PM-7AM) male staff members that work on the B wing had their employee files reviewed and background checks reviewed with no issues. V16 stated all resident had updated abuse risk assessment completed on 2/23/26 and any residents that were at risk for abuse had their care plans updated. V17 reported along side the wound care nurse skin checks were preformed on all residents and no strange marks/bruising were noted on residents. V7, V8, and V17 stated a QAPI meeting was held immediately after the allegation was reported so the team could come up with a plan of correction. V7, V8, and V17 stated two different QA Audit tools were used to assess residents randomly to make sure their were not being abused and felt safe in the facility and the other was to make sure staff was naming the correct procedure to use if abuse was reported. R2, R3, R4, andR5 were interviewed on 7/9/26 starting at 12:13PM and ended at 12:41PM. R2, R3, R4, and R5 stated they felt safe in the facility and reported no staff have abused or harmed them.

Based on interview and record review, the facility failed to ensure a safe environment and provide adequate supervision and assistance to prevent falls for two residents (R1 and R2) by failing to implement appropriate fall prevention interventions and ensure adequate assistance during high-risk care. This failure affects one ventilator-dependent, quadriplegic resident (R1), and one cognitively impaired resident (R2). These failures resulted in R1 falling during incontinence care by staff iand R1 sustaining fractures to the left tibia and fibula, requiring surgical intervention and R2 falling immediately following an activity, while not being supervised by staff resulting in three sutures to the left eyebrow. Findings include:1. R1 is admitted to the facility on [DATE] 2025 on ventilator support with the diagnoses including morbid obesity, subarachnoid hemorrhage due to cerebral aneurysm, hydrocephalus, epilepsy, quadriplegia, chronic kidney disease, pulmonary embolus, and left lower extremity Deep vein thrombosis, diastolic heart failure, atrial fibrillation. R1 is incontinent of bowel and bladder and has a urinary catheter and receives enteral nutrition.Facility reported incident documents that on [DATE], the nurse on duty was called to R1's room and R1 was found on the floor in a supine position. R1 remained on the floor with staff present while 911 was called and was then transferred to local hospital for emergency services. Minimum Data Set (MDS) assessment of [DATE] documents the following:Section C 1000(Cognitive skills for daily decision making) score is 3 (indicating severe impaired decision making)Section GG: R1 is dependent for toileting hygiene, roll left and right, shower, oral care, dressing, and lying to sitting. The helper does all the effort. The resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activityXXX[DATE] at 12:17 PM V3 RN said, R1 is a total care resident on a ventilator under hospice care. I was the nurse caring for him when he fell. I was passing medications when I heard someone calling for help. When I went to the R1's room, R1 was on the floor and I called 911. The emergency team came fast and picked him and sent him to the hospital. I assessed R1, checked vital signs, oxygen saturation, and started an intravenous line, and 911 came and took over. I saw blood on the left leg below the knee and I did not clean or do anything because 911 was already there and took over. R1 was cared for by one person instead of two during his care. When asked, V3 said, I think he was one assist with his care. V4 (Certified Nursing Assistant) was caring for R1 the day of the fall and V4 did not ask for my assistanceXXX[DATE] at 12:50 PM, V4 (Certified Nursing Assistant) said, I was doing my last rounds around 5:00 AM when I pulled R1's covers. I noticed that R1 had a bowel movement and I started to change him. First, I cleaned his front and I turned him on his side. I pulled the sheets towards me and started to clean his back. R1 was still having a bowel movement. I reached out to grab more wipes to clean R1 when he kicked out with his left leg and started to fall. I held him and called for help. But when the nurse came into the room, R1 was already on the floor. Initially, I did not see any blood on his left leg because he had foam boots on. Then, after we removed the boots, I saw blood just before 911 came in. The nurses and everyone came to help but I could not stop the fall. The resident is a total assist and technically I was supposed to use two (person) assist but I was caring for him by myself. R1 had a low air loss mattressXXX[DATE] at 2:37 PM, V7 (Restorative Nurse/Fall coordinator) said, R1 had a fall from the bed and was sent out to the hospital. R1 was a total assist and required one assist. V7 did not provide any additional details regarding the fall. On review of the hospital record, R1 had a comminuted fracture of the left distal tibia. Dorsal displacement and angulation of distal fracture fragments. Fracture distal fibula with dorsal displacement major fracture fragment. V8 (Orthopedic Surgeon) notes indicated that operative versus nonoperative management was discussed with R1's brother and POA (power of attorney) wanted to proceed with surgery after risks and benefits were discussed, which included death, stroke, and myocardial infarction, to name a few risks mentioned by the surgeon. V9 (Critical Care Physician) notes indicated that R1 was taken to surgery and suffered a cardiac arrest upon induction. R1's code status was DNR (Do not Resuscitate) and in accordance with R1's wishes, no ACLS (Advanced Cardiovascular Life Support) was initiated and R1 expired at [DATE] 11:45 AM in a local hospitalXXX[DATE] at 2:49 PM, V2 (Director of Nursing) said, R1 had a bariatric air loss mattress and weighed 269 pounds, under hospice care, and was in and out of the facility, going back and forth to the hospital for being hypodermic or hypotensive. The interdisciplinary team met with the family and decided to go with hospice. During the fall, R1 was being cared for by one nurse assistant. R1 was having a bowel movement. R1 was not able to help or provide directions. R1 was not able to follow commands. The nursing assistant would call for help if they need assistance. V2 continued to say that a total/dependent resident with a ventilator, air loss mattress, who is incontinent only requires one person assist for care and that is what they always used for R1.Despite surveyor asking during interviews and review of documentation, there is no documentation supporting one-person assist during turning/incontinence care for R1.2. R2 admitted to the facility on [DATE] with the diagnoses including, Anxiety, heart failure, anemia, depression, hypertension, and dementia.Facility reportable documents that R2 was found lying on the floor on her back in the activity room on [DATE].Minimum Data Set (MDS) assessment of [DATE], Section C documents R2's BIMS (Brief Interview for Mental Status) score as 6/15, indicating severe cognitive impairment. MDS of [DATE], Section GG documents that R2 requires supervision or touching assistance. Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as the resident completes the activity. Assistance may be provided throughout the activity or intermittentlyXXX[DATE] at 11:20 AM, R2 said, I fell in the past but the last fall was bad. I was in the activity room and we had just finished making decorations for Christmas. I had my walker near me and just got up and started to walk when I saw a small box on the floor and I thought I could walk and tripped over it. The small box was on the floor because we were wrapping up and putting it away. I was by the Christmas tree. When I fell, I stayed there until 911 came to pick me up. I was taken to the hospital because I hurt my left eyebrow. I can walk around the facility and the staff will help me. R2 said that she did not call for assistance or wait to get assistance after the activitiesXXX[DATE] at 1:42 PM, V6 (Activities Aide) said, I was not present when R2 fell. I was bringing the other residents to their rooms after the end of the activities. The activity that the residents were doing that day was a craft and we were making a Christmas tree with felt. The Christmas bins with supplies were behind us and we were seated by the window; R2 was sitting next to me. R2 was with us for about 1-4 hours and there was no box on the floor near R2. On the other side, there was a Christmas tree with a small nativity under the tree and I did not see any box on the floor. The activity ended around 4:00 PMXXX[DATE] at 2:15 PM, V11 (Certified Nursing Assistant) said, I was not there when R2 fell. I was passing by and I heard R2 had fallen and was already on the floor. Someone was already there with a paper over her forehead. I think the person was a visitor or a family member. I asked R2 how she was and R2 said she was okay. R2 was in the middle near the Christmas tree and there were little boxes of gifts as decorations under the tree. R2 walks around the facility with supervisionXXX[DATE] 2:49 PM, V2 (Director of Nursing) said, there should always be someone supervising residents during activities and when residents are going back to their rooms. I don't think we have an activity room policy/monitoring during and after activitiesXXX[DATE] 2:57 PM, V10 (Assistant Director of Nursing) said, R2 stood up without her walker and R2 said she kicked a small ornament, a square box, and lost her balance and fell. R2 had an unwitnessed fall just after finishing the activity. We had an activity aide in the kitchen and another was bringing residents to their rooms. When questioned about any activity room policy and monitoring during and after activities, V10 said that she didn't think there was any facility policy regarding activity room observation and monitoringXXX[DATE] at 12:24 PM V5 (Activity Aide) said, I was washing dishes in the activity kitchen next to the activity room after the activities and getting ready for dinner and my co-worker V6 (Activity Aide) stepped away from the activity when I heard a commotion and R2 was on the floor. R2 was sitting on her bottom near the Christmas tree and I did not see any box next to the tree and R2's walker was next to her. R2 can ambulate around the facility.Review of R2's hospital emergency room records and discharge notes document that R2 required three sutures to the forehead.Throughout the course of this survey, the facility was unable to provide a policy, procedure, or staff guidance regarding the supervision of residents in the activity room during or after activities for residents who are at high risk of falls.Facility Policy titled, Fall Management Program (revised on 08/2020), which reads: The facility is committed to minimizing residents' falls and or injury so as to maximize each resident's physical a psychosocial wellbeing. While preventing all residents' falls is not possible, it's the facility's policy to act in a proactive manner to identify and assess those residents at risk for falls and plan for preventive strategies and facility a safe environment .4. Plan care reviewed and updated at the time of occurrence, quarterly, and as needed in order to minimize risks for fall incidents.Facility Policy titled Activity Calendar (revised on 11/16) reads: .4. The Activity Director or Designee will determine level of functioning through the assessment process and care plan this level per resident. The following information will be utilized to determine level of functioning: information from assessments, clinical observations, and the BIMS score from the MDS 3.0: 13-15: Cognitively intact, High Functioning, 8-12: Moderately impaired, Moderate Functioning, 0-7: Severely impaired, Low Functioning .10. Adaptations for residents will be determined based off the Comprehensive Activity/Memory Care Assessments and will be made on-going based off of the residents' needs.

Based on interview and record review, the facility failed to implement effective interventions to monitor a resident at high risk for falls. This failure affected one (R1) of three residents reviewed for falls and resulted in R1 sustaining a fall while in front of the nursing station for supervision, that resulted in emergent hospital transfer for treatment of a closed nondisplaced fracture of the acromial end of the left clavicle. Findings include: R1 is an [AGE] year-old female admitted to the facility on [DATE] with the diagnosis history of Congestive heart failure, hypoxemia, chronic obstructive pulmonary disease, dementia, cataract, gastric esophageal reflex disease, hyperlipidemia, and aphasia after cerebral infarct. On 10/15/2024 record review documents that R1 fell in front of the nursing station requiring R1 to go to the emergency room for further evaluation. Hospital records reviewed document that R1 had a closed nondisplaced fracture of the acromial end of the left clavicle and R1 was admitted to the hospital. On the (MDS) Minimal data Set assessment of 09/03/2024 section C the BIMS (Brief Interviewed Mental Status) score was 01/15 (severe cognitive impairment). On MDS of 09/03/2024 GG section R1 requires supervision/touching assistance with manual wheelchair mobility on 50 feet distance. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. On 12/02/2024 at 11:02AM interviewed R1 who was not able to answer questions, but only repeat the last words of each question such as pain for the question; Do you have pain? Did you have a fall? R1 answered fall. On 12/02/2024 at 11:25 AM V6 (Certified Nursing Assistant) said, R1 was assisted with her toileting needs after breakfast and brought to the nursing station for V5 (Registered Nurse) to monitor because R1 is a high fall risk. During the fall, V6 stated that she was in a room providing care to another resident. R1 can get anxious and not able to follow cues and redirections depending how R1's day is going. On 12/02/2024 at 12:44 AM V5 (Registered Nurse) said that she was standing at least 100 feet away from R1 by her medication cart when R1 started to self-propel on her wheelchair and started to lean to the right side and slid out of the wheelchair. V5 said, R1 was too far and fell before she got to R1. R1 is alert to person has dementia and requires maximum assistance with her activities of daily living. R1 may follow direction or cues depending how her day is going and if R1 slept at night. Usually there are 3-4 residents in front of the nursing station for nursing to monitor closely to prevent falls and the day of R1's fall, V5 was the only person close to nursing station by the rooms in the 100's wing. V5 said that it is hard and almost impossible to monitor 3-4 residents at the nursing station and provide care to other residents. On 12/02/2024 at 1:35PM V4 (Restorative Aide) said that R1 is under restorative program and needs to be provided cues and to hear let's walk a couple of times before R1 can follow commands. R1 sometimes will not follow cues. R1 uses wheelchair under supervision/touching assistance in the unit. On 12/02/2024 at 1:30PM V3 (Restorative Nurse) said that R1 uses a wheelchair and requires supervision/touching assistance and nurses and nursing assistance will communicate on report on how much assistance each resident requires. R1 has dementia and will not follow cues at times. V3 was unable to say how much close supervision and touching assistance R1 requires. On 12/02/2024 at 3:03PM V2 (Director of Nursing) said, R1 has dementia and usually is responsive to name only but can follow cues at times and self-propel on her wheelchair under supervision/touching assistance. V2 was asked if a distance of 100 feet is acceptable for supervision of R1 while at the nursing station and V2 did not answer. V2 said, I do not expect nurses to provide one to one supervision. V5 (Registered Nurse) was close to the nursing station on her medication cart and unable stop the fall. Upon review of R1's medical record, it was noted that there is no wheelchair mobility and/or locomotion care plan to communicate to the interdisciplinary team how to safely provide care to R1 while using wheelchair, taking into account R1's cognitive impairment. On 12/02/2024 at 1:00PM V1 (Administrator) presented facility Policy Titled, Management of Falls (dated 08/2020), which reads: Policy: The facility will assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate resident interventions, and revise the resident's plan of care to minimize the risks for fall incidents.

Based on interview and record review, the facility failed to prevent a resident from sustaining an injury during care for one (R272) of three residents reviewed for injury in a sample of 25. The deficient practice resulted in R272 sustaining a linear incomplete oblique fracture of the mid and proximal shaft of the right humerus. Findings Include: Initial State Reportable dated 7/12/23 documents: R272 is a long-term resident at facility. R272 has the following diagnosis anxiety, BPH, protein calorie malnutrition, epilepsy, type 2diabetes and muscle spasms. On 7/11/23 an x-ray was performed on R272's right arm due to swelling and resulted in an incomplete right humerus fracture. Investigation started immediately. Final report to follow. Final State Reported dated 7/17/23 documents: Investigation completed, it was noted through staff and resident interview that no trauma or fall occurred. Resident is severely contracted which most likely contributed to the facture. Resident has returned to the facility. Pain management in place, care plan has been updated. NP Progress note dated 7/12/23 documents that R272 was seen for follow-up and increased right arm swelling noted. On 7/11/23 an x-ray was done and it was reported that it showed a linear incomplete oblique fracture of the mid and proximal shaft of the right humerus. R272 with no reported fall or trauma. R272 sent to ER for further evaluation. R272 underwent an x-ray which showed a right humerus minimally displaced spiral fracture of the right proximal and mid right humoral shaft. NP Progress note dated 7/17/23. R272 was seen by orthopedic in ER and it was recommended that R272 is non-weightbearing to right upper extremity. The Incident Report dated 7/11/23 an x-ray was performed on R272's right arm due to swelling reported by the CNA and resulted in an incomplete right humerus fracture. R272 was sent out for further evaluation and returned to the facility the next day but is no longer in the facility (sic). On 8/16/23 at 2:12pm V20 (Primary Physician) stated that, due to R272 being contracted, he was always in a contracted position to his right side and difficult to move from that position. V20 stated that R272 was at high risk for fracture because of his comorbidity, low calorie intake, low muscle mass, and non-weight bearing and thinner bone. V20 stated that, she believes the facture was accidental and can happen from twisting the arm. V20 stated I don't think this was avoidable even with all precaution taken. On 8/16/23 at 2:37 pm, V19 (Nurse Practitioner) stated that she last saw the resident on 7/3/23 and did not see any swelling on the resident's arm. V19 stated that R272 was seen and sent out on 7/12/23 for further evaluation. V19 stated that residents are seen once a month, but R272 was seen more often or as needed due to his high comorbidity. V19 stated that she is not aware how the swelling happened. On 8/17/23 at 10:00am, V18 (RN) stated that she took care of R272 on 7/10/23 and did not notice any swelling. V18 stated that she was informed by V17 on 7/11/23 that R272's arm was swollen. V18 stated that she notified V19 (NP) who ordered an x-ray. V18 stated that the night nurse got the results, and the resident was sent out to the emergency room (ER) for further evaluation. V18 stated I know he is contracted; spiral fractures happen from sudden movement. V18 stated that R272 returned to the facility the same day with a splint. On 8/17/23 at 10:15 am, V17 (CNA) stated that she reported the swelling to the nurse after returning from a day off (7/10). V17 stated I saw the arm was different and asked the mom who was at the bedside if she noticed any difference with the arm. I reported it to the nurse. On 8/17/23 at 10:45am, V15 (Restorative Nurse) stated that R272 was in a restorative, splint and PRM program 5-6 times provide by restorative aid. V15 stated she did not receive any information about R272 having a swollen arm. We found out when the nursing assistant reported it to the nurse. V15 stated that Therapy orders the brace and restorative follow their recommendations. On 8/17/23 at 11:am, V1(Administrator) stated that R272 was in a vegetative state, V1 stated the fracture could have happened when he was being turned or when they were trying to put a gown on him. I do not think it was intentional and the staff that cares for the resident on a regular basis was not able to tell me what happened and how it happened. On 7/17/23 at 11:40am V22 (RN) stated that she worked the night shift on 7/12/23 and did not notice any swelling to R272's arms. V22 stated that R272 was normal with no pain and the arm did not look swollen. V22 stated that she got the results that morning and notified the NP. On 7/17/23 at 1:50 V28(Director of Nursing) stated that he saw R272 daily and did not notice any swelling to his arms as he always had his gown on. Care plan reads; assist and instruct family and staff in proper splinting and positioning to manage existing/improved/prevent contractures of the bilateral upper extremities while in bed. Bed Mobility . Be sure your physical contact is gentle do not grab right upper extremity, monitor for presence of pain/intolerance, total assist with bed mobility. Radiology report dated 7/11/23 reads; Procedure: X-ray exam of humerus. Reason, Pain and swelling. Impression: Linear incomplete oblique fracture of the mid and proximal shaft of the right humerus. R272's Hospital discharge record dated 7/12/23 document: what causes a humerus Fracture? A humerus facture is most often the result of trauma. This may be from fall, blow, accident or sport injury. Facility unable to provide ADLs (Activity of Daily Care) policy.

Based on interview and record review the facility failed to supervise a resident that was a high fall risk and presented with impulsive behaviors for 1 of 3 residents (R176) in a total sample of 25. This failure resulted in R176 having an unwitnessed fall sustaining a laceration to her head and requiring 14 staples. Findings include: On 8-16-23 at 12:13 PM, V1 (Administrator) said R176 is alert and oriented to self and able to make simple needs known. R176 does not use the call light. R176 has impulsive behaviors and will get up by herself without asking for help. R176 requires 1 person assist with transfers. V1 thinks R176 would be high risk for falls. R176 has history of falls prior to facility. V1 said R176 was last seen in the dining room and must have left the dining room on her own and was later found by CNA in her room. R176 was noted with active bleeding from the head and was on anticoagulants. R176 was sent out 911, treated, received 14 sutures to her head and returned the same day. On 8-17-223 at 11:15 AM, V2 (DON) said R176 is alert, oriented x1, unable to carry meaningful conversation. R176 is confused and forgetful and has Alzheimer's. R176 has poor safety awareness due to forgetfulness and impulsivity. R176 will get up from bed and chair without asking for helping. requires 1 person assistance for transfers. R176 has history of fall at facility and high risk for falls. On 8-17-23 at 9:36 AM, V15 (Restorative Nurse) said is alert to self, confused and forgetful. R176 is able to make simple needs known. R176 is forgetful and forgets to use the call light. R176 has poor safety awareness due to impulsivity and forgetting to ask for assistance. R176 requires 1 person physical assistance for transfer and ambulation. R176 is a high fall risk. R176 has a history of falls at facility and at home. This was unwitnessed fall. Staff was aware of fall risk, frequent rounding, keep items in reach, low bed, call light in reach, encourage activity, by nursing station for supervision. Around 7:30 AM, R176 had unwitnessed fall in room, nurse saw R176 in wheelchair, nurse saw blood and R176 said she lost balance when walking in the room and did not ask for help. This was unwitnessed fall. On 8-16-23 at 12:04 PM, V10 (RN) said R176 is alert to self and confused at night. R176 is able to make her needs known. R176 does use the call light and will get up by herself. R176 is a fall risk due to impulsivity and needs assistance with transferring. R176 thinks she can do more than she can and has impaired safety awareness. R176 requires supervision every 15 minutes in her room or kept in common area with staff supervision. On 8-16-23 at 12;29 PM V11 (CNA) said R176 is alert and sometimes able to make her needs known. R176 seldom uses the call light. R176 is impulsive, gets up by herself, R176 requires 1 person assistance with transfers and getting up. R176 is high fall risk because she is impulsive. R176 has dementia and thinks she is more independent than she actually is and therefore has poor safety awareness. V11 said R176 was kept at the nurse station under staff supervision. R176 prefers to be in the room however it not safe to let R176 stay in the room because she will get up by herself. R176 needs frequent checks when she is in her room for safety. On 8-16-23 at 12:44 PM, V12 (LPN) said is alert and oriented x1. R176 is confused forgetful and impulsive. R176 would get up by herself without calling for help. R176 require 1 person assistance with transfers. R176 is a fall risk due impulsiveness, confusion, unsteady gate, and poor safety awareness. LPN is aware of R176 having history of falls and has seen R176 attempt to get up without using her call light. Staff was doing frequent checks, kept in the common area (by nursing station or activities) for supervision. LPN said she noted R176 in her wheelchair with bleeding to her head. Progress not said R176 told LPN she must have fallen. R176 was sent out via 911. R176's Fall Risk Assessments (dated 1-23-23, 3-5-23, and 4-17-23) document R176 as a High Fall Risk. MDS (ARD 6-6-23) documents: 1 Person Physical Assistance for Support Transfers, Moving from seated to standing position: not steady, Walking: not steady. Final State Reportable (dated 4-18-23) documents: R176 is [AGE] year old female resident at facility. She admitted to facility after CVA with left side hemiparesis and fall with scalp hematoma. R176 developed hydrocephalus during her hospitalization requiring a shunt. She has diagnosis Cerebral Edema, muscle weakness, unsteadiness on feet, abnormalities of gait/mobility. Pulmonary fibrosis, left hemiplegia, unspecified urinary incontinence, dementia, overactive bladder and Alzheimer's disease and osteoporosis. On 4-17-23, R176 was observed in her wheelchair with small amount of blood on her left arm and posterior left occipital area. Resident reports having an unwitnessed fall and did not alert staff at the time of the incident. Initial assessment by the nurse revealed small laceration to head, therefore she was sent to the ER for evaluation per MD order. Resident required 14 staples to laceration site. The facility conducted an investigation it was note through interviews that the resident was assisted by assigned CNA with morning care and dressing and then assisted to the dining room for breakfast. Resident wheeled herself back to the room, got out of wheelchair to ambulate around her room. She lost her balance resulting in a fall. R176's Hospital Record (dated 4-17-23) documents: HPI: Patient is a [AGE] year old female with extensive past medical history presents to the emergency department via EMS from facility after unwitnessed fall. Patient has history of dementia and is an unreliable historian. Patient had a fall hit the back of her head sustaining a minor laceration. Patient states she falls a lot. Comments: 2 inch laceration left side posterior occipital scalp. Procedure Note: Laceration repair: the 2 inch laceration was irrigated with normal saline under normal pressure and anesthetized locally with 1% lidocaine. 14 staples were placed in simple interrupted fashion. Hemorrhage controlled. Fall Policy (dated 8-20) documents: The facility is committed to minimizing resident falls and/or injury so as to maximize each resident's physical, mental, and psychosocial wellbeing. While preventing all resident falls is not possible, it is the facility policy to act in a proactive manner to identify and assess those residents at risk for falls, plan for preventive strategies and facilitate a safe environment.

Based on observation, interview and record review, the facility failed to discard expired house stock medications and label multi-dose medications with open date for three of four medication carts and one of one medication room observed for medication storage and labeling. This deficiency can affect all 126 residents residing in the facility. Findings include: On [DATE] at 1:20PM during observation with V33 (Registered Nurse/RN), Cart 4 in C-wing was observed with the following: 1. Opened house stock Lactobacillus acidophilus bottle with expiration date ,d+[DATE] 2. R67's budesonide 0.5 milligrams (mg)/2 milliliters (ml) nebules in an open foil pouch with no open date 3. R9's budesonide 0.5 milligrams (mg)/2 milliliters (ml) nebules in an open foil pouch with no open date At 2:05PM during observation with V14 (Licensed Practical Nurse/LPN), Cart 2 in B-wing was observed with the following: 1. R22's opened 10ml vial of Heparin sodium 5000 units/ml with no open date 2. R12's opened 10ml vial of Heparin sodium 5000 units/ml with no open date At 2:40PM during observation with V31 (LPN), B-wing medication room was observed with opened multidose vial of tuberculin purified protein derivative (PPD) with no open date. At 2:51PM during observation with V7 (LPN), Cart 1 of C-wing was observed with the following: 1. R110's opened 10ml vial of Heparin sodium 5000 units/ml with no open date 2. R110's opened latanoprost solution 0.05% eye drops with no open date with label that reads Discard 42 days after opening 3. Two opened 10 ml vials of R95's Heparin sodium 5000 units/ml with no open date On [DATE] at 1:30PM, V33 said that the house stock lactobacillus bottles should have been discarded and the budesonide foil pouch should indicate an open date once opened. On [DATE] at 2:15PM, V14 said that she does not know why the vials did not have open dates. She added that they should have an open date, so they know when to stop using it. On [DATE] at 2:45 PM, V31 said that the PPD vial should have an open date so other nurses would know when to discard it and not use it. On [DATE] at 3:10PM, V7 said all multidose vials should have an open date and the eye drops that has a specific instruction of when to discard should be labeled with open date as well. Facility Documents: Title: Medicine Information Leaflet (Budesonide) Patient Information and Instruction for Use: How should I store budesonide inhalation suspension? Budesonide inhalation suspension vials can be stored for 2 weeks after opening the protective aluminum foil envelope. Patient Instructions for Use: 1. Budesonide inhalation suspension vials come in a sealed protective aluminum foil envelope. Do not open the sealed pouch until you are ready to use a dose of budesonide inhalation suspension. Record the date that you opened the foil in the space provided on the envelope. Policy Title: Medication Pass Guidelines Date: ,d+[DATE] 16. House stock medications Check expiration dates of all medications before administration. 19. Eye medications Eye drops/ointments/gels are considered safe and effective for use until the manufacturer ' s expiration date when stored according to manufacturer guidelines, unless otherwise specified by the manufacturer or pharmacy. Policy Title: Multi-Dose Vials, Use of Date: ,d+[DATE] C. Policy: Multi-dose vials (MDVs) contain preservative, so they may be used multiple times. The opened and beyond-use (expiration) dates will be noted and initialed at the time the vial cap is removed. D. Procedure: 4. If this is a previously opened vial, check that the opened and expiration dates are noted and initialed and that the vial has not expired. a. If the vial has been opened longer than 28 days, or has expired per the manufacturer ' s guidance, it should no longer be used and should be discarded in a sharp container and a new vial of medication should be obtained. 5. If this is a new vial, remove the cap from the vial. Using an ink pen, write the opened and expiration dates, as well as the nurse ' s initials, on the vial ' s label or pharmacy-provided sticker.

Based on observation, interview and record review the facility failed to label the enteral tube feeding bags with the date and time it was initiated for four of thirteen residents (R24, R32, R52, R323) reviewed for tube feeding in a sample of 25. Findings include: On 08/15/2023 at 10:32AM during observation, R52 was observed with enteral tube feeding attached to her gastrostomy tube labeled with initiation date of 8/14/2023 with no time indicated. At 11:06 AM during observation, R32 was observed with enteral tube feeding attached to her gastrostomy tube labeled with initiation date of 8/14/2023 with no time indicated. At 11:10 AM during observation, R323 was observed with enteral tube feeding attached to her gastrostomy tube without label indicating the resident's name, and date and time it was initiated. At 12:13 PM during observation, R24 was observed with enteral tube feeding attached to her gastrostomy tube labeled with initiation date of 8/14/2023 with no time indicated. On 08/15/2023 at 12:02PM, V33 (Registered Nurse/RN) stated that they only write the date the feeding was initiated on the enteral feeding not the time because they go by the electronic medication administration record (eMAR). On 08/15/2023 at 12:19PM, V34 (RN) said that she is not sure if the time has to be written down on the enteral feeding. R52's admission record indicated admitted [DATE] and diagnoses including dysphagia oropharyngeal phase. R52's order listing report dated 08/17/2023 indicated active order of enteral feeding with order date of 08/04/2023. R32's admission record indicated admitted [DATE] and diagnoses including dysphagia and encounter for attention to gastrostomy. R32's order listing report dated 08/17/2023 indicated active order of enteral feeding with order date of 06/05/2023. R323's admission record indicated admitted [DATE] and diagnoses including dysphagia and encounter for attention to gastrostomy. R323's order listing report dated 08/17/2023 indicated active order of enteral feeding with order date of 08/11/2023. R24's admission record indicated admitted [DATE] and diagnoses including encounter for attention to gastrostomy. R24's order listing report dated 08/17/2023 indicated active order of enteral feeding with order date of 06/14/2023. Facility Policy: Title: Enteral Nutrition Feeding Date: 09/2020 Procedure: 13. Change enteral feeding solution and bag/bottle per manufacturer guidelines. Nestle: Enteral feeding closed system can hang up for up to 48 hours. Enteral feeding in an open system bag should be changed every 24 hours (bag itself). A carton/can (250 milliliters/ml) should be used/infused within an 8 hour hang time. Label bag/container with name, date, time. Change spike set with each new ready to hang bottle. Change irrigation set and/or piston syringe weekly and prn (as needed). Label with name, use and date. Shake formula well and check for expiration date prior to administration.

Based on observation, interview and record review the facility failed to provide an extra tracheostomy (trach) cannula at the bed side and failed to have enough water in the aerosol bottle at the bed for two residents (R58 and R322) of nine residents reviewed for Trach care in a total sample of 25 residents. Findings Include: 1. On 8/15/23 at 11:30 am during screening R58's humidifier was observed with approximately 2 milliliters of water in the bottle, no bubbles were seen in the aerosol bottle or in the large bore corrugated tubing while still connected to R58's tracheostomy (trach) collar. There was no extra emergency tracheostomy cannula at the bedside. V23 (LPN) was observed going out to request an extra cannula from the respiratory therapist, V23 was informed by V24 (Respiratory Therapist) that there was an extra piece of cannula in R58's cupboard. V23 did not know where to find the extra emergency tracheostomy cannula. On 8/15/23 at 11:35 am, V23 and V24 both stated that there should be an extra tracheostomy cannula at the bedside in case of an emergency. Both stated that, the humidifier bottle should have enough water to keep the tracheostomy moist. V24 stated that the humidifier is used to prevent plug formation. R58 was admitted on [DATE] with multiple sclerosis, functional quadriplegia, and dependence on supplemental oxygen. Care plan dated 7/28/23 reads, adjust oxygen to maintain saturation with adequate parameters, R58 has alteration due to Trach and has potential for complications secondary to tracheostomy . Facility policy dated 09/2020 titled, Oxygen Therapy Devices High Humidity. Policy: Oxygen delivered with high humidity or high humidity without O2 will be set up to enhance humidification of mucous membrane . Procedure: 3. High humidity -with oxygen, can be provided using an aerosol bottle, large bore corrugated tubing, 02 device and 100% source . 46560 2. On 08/15/2023 at 11:33AM during observation with V36 (Registered Nurse), R322 was observed with tracheostomy attached to wall oxygen with no extra emergency tracheostomy kit and artificial manual breathing unit (AMBU) at bedside. On 08/15/2023 at 11:33AM, V36 said that residents on tracheostomy tubes usually have a spare tracheostomy kit and AMBU at bedside but she does not know why R322 did not have one. R322's face sheet indicated admitted [DATE], and diagnoses including paralysis of vocal cords and larynx, bilateral, encounter for attention to tracheostomy and dependence on supplemental oxygen. R322's order listing report dated 8/17/2023 indicated and active order for in case of emergency, trained nurse may reinsert outer cannula of tracheostomy as needed with order date of 7/10/2023. Facility unable to provide policy.

Based on observation, interviews and record review, the facility failed to follow their call light policy. The facility failed to place call light within reach. This deficient practice affects three residents (R15, R41 and R71) of three residents reviewed for call light placement in a total sample of 25 residents. Findings Include: On 8/15/23 at 10:30AM, Observed R71 in bed, observed call light placement not within reach. Call light was on the floor on the right side of R71's bed. R71 stated that she does not know where her call light is. Also stated that when her call light is not within reach, R71 will yell or call for help. On 8/15/23 at 10:35AM, V13 (RN) confirmed that the call light of R71 is on the floor and not within R71's reach. V13 also stated that she will inform the maintenance that the call light needs a clip. On 8/15/23 at 10:45AM, R15 in bed, observed call light wrapped in left upper side rail, No clip. R15 said she don't know where her call light is at that moment. Pointed at the left side rail, and R15 said I cannot see or reach it. On 8/15/23 at 10:50AM, V13 also confirmed that the fall light placement is not within reach of R15. State surveyor asked R15 if she is able to reach the call light, R15 said No. V13 again said she will let the maintenance know that the clip is not available. On 08/15/23 11:27AM, surveyor asked R41 to activate her call light. R41 said she cannot activate her call light because she cannot reach the call light. On 08/15/23 11:27AM, R41's call light was not accessible and was on the floor in back of R41's wheelchair. R41's left arm is in a splint and was not able to reach the call light on the floor. V30 (CNA) noted R41's call light on the floor and in back of R41's wheelchair. V30 was able to reach behind and attach the call light to the side rail and ensure call light is R41's in reach. On 8/17/23 at 1:45PM, V28 (DON) stated that call light should be within residents' reach. Use of Call Light Policy reads in part: To respond promptly to resident's call for assistance. When providing care to residents, position the call light continently for the resident's use. Tell the residents where the call light is and show him/her how to use the call light and provide reminders to use the call light as needed. Be sure call lights are placed within resident reach at all times.

Based on interview and record review, the facility failed to ensure a resident's call light was in working condition. This failure affected 1 resident (R80) of 4 reviewed for call lights in a total sample of 25. Findings include: On 08-15-23 at 11:26 AM, asked R80 to push the call light and the resident was unable to activate the call light. The call light button and was unable to activate the call light. V30(CNA) asked to verify that the call light was working. V30 was observed pushing the the call light button several times and noted the light outside the room was not activated. V30 pulled the call light cord from the wall and replaced the cord. V30 pushed the call light button and the call light worked. On 08-15-23 at 11:26 AM, R80 said she is pushing the call light however the hallway light is not activated and there was no sound noted. On 8-18-23 at 12:55 PM, V1 (Administrator) said all staff are responsible for ensuring call lights are working. On 08-15-23 at 11:26 AM, V30 (CNA) said it is staff responsibility to ensure the call lights are working and in reach of the residents.

Based on observation and interview, the facility failed to properly store Bi-pap masks and Nebulizer mask and left masks open to air on bedside table. This failure affected 2 residents (R8 and R88) of 3 reviewed for oxygen equipment in a total sample of 25. Findings include: On 08/15/23 at 10:30 AM, observed R88's Bi-pap mask on the bedside table exposed to the air (not stored in plastic bag) as observed by V14 (LPN). On 08/15/23 at 10:49 AM, observed R8's nebulizer mask on the bedside table open to air (not stored in a plastic bag) as verified by V29 (CNA) and V29 immediately placed nebulizer mask in plastic bag in front of surveyor. On 8/17/23 at 11:48 AM, V2 (DON) said Bi-pap masks and nebulizer masks are stored in plastic bags. The masks are kept in a bag to keep masks clean after being cleaned per policy. On 08/15/23 at 10:30 AM, V14 (LPN) said the CNA is to inform the nurse and the nurse will place the Bi-pap mask in the bag. V14 said she will place the Bi-pap mask in a bag to keep it clean. On 08/15/23 at 10:49 AM, V29 (CNA) said it is the nurse's job to store nebulizer masks in a bag to keep it clean. On 08/15/23 at 11:01 AM, V31 (LPN) said the face mask is stored in a plastic bag for infection control. Bi-Pap Policy (dated 9-20), Nebulizer Policy (dated 9-20), and Infection Control Policy were reviewed but there was no guidance provided on mask storage.

Based on observation, interview and record review the facility failed to follow their prevention and treatment of pressure injury policy and failed to implement preventative measure appropriately by not following the operation manual for a pressure injury preventative mattress. This deficient practice affected one resident (R38) of three residents reviewed for skin alterations in a total sample of 25 residents. Findings Include: On 8/15/23 at 11:00AM, observed R38 in bed, using a low air loss mattress (pressure injury preventative mattress). Machine checked and it is set on 230lbs (pound in weight). On 8/15/23 at 11:10AM, V14 (LPN) confirmed that the machine is set for 230 lbs. Stated that the low air loss mattress is supposed to be set to the weight of R38 and that she will check the weight of the resident and change the setting as necessary. On 8/16/23 at 10:00AM, observed R38 in bed, using a low air loss mattress (pressure injury preventative mattress). Machine checked and it is set on 280lbs (pound in weight). Machine for the low air loss mattress had six lights for weight by lbs. The light goes in 80lbs, 130lbs, 180lbs, 230lbs, 280lbs, and 340lbs. On 8/16/23 at 10:35AM, V5 (Wound Care Coordinator) stated that the mattress machine setting check is done randomly by her wound care team and they make adjustments when needed. The light should be close to the weight of the resident. The weight light lit in the machine should show closer to the weight of R38. R38 had a history of pressure injuries but they are already healed and we are using the special mattress as preventative measure for R38. R38 is assessed as moderate risk for skin alteration. We follow the recommendation setting of the manufacturer of the mattress, which to set it for the weight of the resident using the machine. It defeats the purpose of the machine if the recommendation is not followed. I will in-service the staff and educate them about the importance of the low air loss mattress in the right setting. R38's weight in July 2023 was 144.6lbs and in August of 2023 was 146.6lbs. Braden Scale Assessment (predicting pressure injury risk) dated 6/3/23 shows R38 scored 14 (Moderate Risk). R38 has a care plan for alteration of skin integrity related to moisture to under breast and a history of pressure wounds to bilateral buttocks. R38 requires extensive assist in ADL care, bed mobility, and transfers. R38 has occasional incontinece of bowel and bladder and intentional friction of buttocks against bed. Intervention initiated: pressure redistribution support-low air loss mattress in bed. Operation Manual for low air loss mattress provided by the facility, reads in part: Pressure set up: users can adjust the pressure level of the air mattress to the desired firmness by themselves or according to the suggestions from a health care professional. Note: It is recommended to press auto firm on the panel when the mattress is first inflated. Users can easily adjust the air mattress to a desired firmness according to the patient's weight and comfort. Braden Scale for Predicting Pressure Injury Risk policy, reads in part: To be completed for all residents to assess level of risk for developing pressure injury. Regardless of the resident's total risk score, eacj risk factor and potential cause(s) should be reviewed individually. Implement intervention according to the resident's Braden Score and/or individual risk factors identified. Prevention and Treatment of Pressure injury and Other Skin Alterations policy, reads in part: identify residents at risk for developing pressure injuries. Implement preventative measures and appropriate treatment modalities for pressure injuries and/or other skin alterations through individualized resident care plan. Identify residents at risk for developing pressure injuries utilizing the Braden scale.

Based on observation, interview and record review the facility failed to provide appropriate and sufficient supervision to prevent falls to residents who are at high risk. This deficiency resulted in R1 (who recently had a left hip surgery for a fracture) sustaining a dislocated prosthetic left hip and R3 sustaining a fractured hip requiring surgery and hospitalization . The facility also failed to implement fall prevention care plan interventions, failed to accurately complete the fall assessment and failed to use a gait belt when transferring a resident. This deficiency affects all four (R1, R3, R5 and R6) residents reviewed for fall prevention management. Findings include: 1. R1 is admitted on [DATE] with diagnosis listed in part but not limited to Intracapsular fracture of left femur, left artificial hip joint, Type 2 Diabetes Mellitus with mild non proliferative diabetic retinopathy, Dementia, Hypertension, Generalized muscle weakness, Cognitive communication deficit, Difficulty in walking, Visual loss both eyes, Legal blindness, Long term use of anti-coagulant, History of falling, History of neoplasm of large intestine. Admission fall assessment dated [DATE] indicated score of 10, at risk for fall. Physician Order sheet indicated: Hip precaution and WBAT (weight bearing as tolerated to left extremity) .Physical, Occupational and Speech therapy evaluation and treatment. Surgical site: Left hip monitor daily for sign and symptoms of infection. Use Aquacel dressing to left hip and do not remove until 5-7 days. R1's unwitnessed fall incident report dated 10/20/22 indicated: CNA's rounding noted R1 on the floor in her room next to her bed at 11:20pm. R1 confused, cannot explain what happened. R1 was sent out to the hospital for evaluation due to being prescribed blood thinners. R1's family notified at 12:30am. 10/21/22 - Root cause analysis- IDT (Interdisciplinary Team) met after fall. R1 was noted with fall at bedside, unable to verbalize what happened, R1 was sent out to the hospital for further evaluation. R1's fall assessment after fall 10/20/22 indicated score of 6, at risk for fall. R1's progress notes dated 10/21/22, R1 was admitted with diagnosis of displaced hip and stroke. R1's fall care plan indicated: at risk for fall and at high risk for fall was initiated on 10/21/22 after R1 was admitted to the hospital. Surveyor unable to interview with Nurse and CNA who worked with R1 on the shift that she fell . V1 Administrator, V2 Assistant administrator and V3 DON are aware. V2 said that V15 LPN who worked with R1 on the night that she fell is no longer working in the facility. R1's hospital emergency room record dated 10/21/22 indicated: R1 is an 85year old female presenting with complaints of a fall. R1 recently has a left hip surgery for fracture about 8 days ago. R1 has history of dementia. R1 apparently got out of bed and fell . R1 was found by staff on her knees. R1 complained of bilateral knee pain worsen on right than on left. R1 denies nay headache or neck pain. Physical Exam: Extremities: rotated internally and shortened. Left hip and pelvis x-ray showed a dislocated prosthetic left hip. Conscious sedation and reduction of the left hip done. On 1/10/23 at 2:28pm V11 Restorative/Fall Coordinator said that they have 48 hours to do base line plan of care of the resident. V11 said that she has spoken to V13 Family member prior to fall occurrence regarding fall interventions of R1 since she is at high risk of fall such as low bed, floor mat, frequent rounding, call light within reach, etc. but she did not write in R1's care plan. Informed V11 of inconsistency in R1's fall assessment. V11 said that she will do in-services with the nurses regarding properly completing of fall assessment. The score should go up not goes down after fall. R1 is at high risk for fall. On 1/11/23 at 11:27am, V12 CNA said that she took care of R1 on morning shift of 10/20/22 prior to fall. R1 is confused and restless and moving in bed. She placed wedges on both side of the bed and bilateral floor mat. R1 was complaining of pain and not comfortable in bed. V12 reported to the nurse and endorsed to next shift. R1 needs total care with ADLs due to her confusion and restlessness. R1 needed 2 persons to boost her up to bed because she is restless and keeps on moving. R1 stayed in bed during her shift. On 1/11/23 at 11:45am V14 Therapy Director said that he evaluated R1 on 10/19/22. V14 said that R1 was referred to Physical therapy (PT)due to exacerbation of decrease in strength, decrease in functional mobility, decrease in transfers, reduced balance and reduced ability to safely ambulate indicating the need for PT to increase LE (lower extremity) ROM ( range of motion) and strength, increase functional activity tolerance, improve dynamic balance, facilitate with all functional mobility and increase independence with gait. R1 is on fall risk precautions, posterior hip precautions, WBAT, legally blind. After evaluation V14 discussed precautions to the floor Nurse and CNA for safety. R1 is total dependence with ADLs and transfers. On 1/11/23 at 2:28pm V11 Restorative/Fall Coordinator said that if resident is confused and restless, they should provide close supervision/monitoring for safety. 2. R3 is admitted on [DATE] with diagnosis listed in part but not limited to Myocardial infarction, Enterocolitis due to Clostridium Difficile, Infection and inflammation due to indwelling catheter, Urinary tract infection, Hypotension, Difficulty walking, Hypertension, Coronary artery disease, Inguinal hernia, Benign prostate hypertrophy, long term use of aspirin. Care plan indicated: Impaired ambulatory skills. ADLs self-care performance deficit. At risk for falls r/t weakness and UTI, generalized weakness secondary to ST elevation, hypotension, polyosteoarthritis and hernia. Incontinent of bowel. Admission fall assessment dated [DATE] indicated score of 9, at risk for fall. Fall assessment after fall dated 12/30/22 indicated score of 6, at risk for fall. R3's witnessed fall incident reported to IDPH dated 12/30/22 indicated at 5:10pm, R3 was walking to the bathroom without staff assistance. R3 was witnessed coming back from bathroom and lost hi balance and fell . V16 RN assessed R3 and notified Nurse practitioner to send R3 to hospital for evaluation. R3 was admitted with closed fracture of right femur investigation completed and it was revealed through staff and resident interviews that R3 was attempting to go to the bathroom without assistance. Staff witnessed R3 walking and very unsteady, staff immediately went to R3 to attempt to assist however R3 lost his balance and fell . Safety interventions will be implemented upon return from hospital. This is the final report dated 1/4/22. R3's hospital record dated 12/30/22 indicated: an [AGE] year-old male presents with chief complaint of mechanical fall today. R3 was at the rehab facility after being discharged from the hospital . R3 was allowed to walk to the bathroom himself when he tripped and fell o his right side. No head injury or LOC (Loss of consciousness). R3 is complaining of pain on the right hip worse with movement, no alleviating factors with no associated symptoms. R3 had history of left hip replacement. Physical exam: Significant tenderness on the right hip, limited ROM. CT of the right lower extremity indicated: Acute intracervical fracture of right femoral neck. Hospital admission diagnosis: Closed fracture of neck of right femur. On 1/10/23 at 2:28pm, Informed V11 of inconsistency in R3's fall assessment. V11 said that she will do in-services with the nurses regarding properly completing of fall assessment. The score should go up not goes down after fall. On 1/11/23 at 10:44am, V17 CNA said that she took care of R3 in the morning shift of 12/30/22 prior to his fall. V17 said that R3 is confused and restless. R3 needs total assist due to his confusion. R3 needs 2 persons assist for transfers from bed to wheelchair. V17 does not know if R3 can walk because he was just admitted a day before she took care of him. The therapist has not informed them regarding his mobility. R3 uses wheelchair for mobility. V17 said that R3 eats independently but needs supervision. V17 said that during her shift R3 attempted to get out from bed. He is restless in bed, so V18 RN and her transfer him to wheelchair and endorsed it to the next shift. On 1/11/23 at 11:05am, V18 RN said that she took care of R3 on 12/30/22 in the morning shift prior to fall. V18 said that R3 is confused and restless. She and V17 CNA transferred him to wheelchair because he is restless and keeps moving in bed. They endorsed R3 to the next shift for monitoring/supervision due to his confusion and restlessness. On 1/11/23 at 12:30pm V16 RN said that she worked with R3 on 12/30/22 on 3-11 shift. V16 said that she saw R3 walking from his bathroom going back to his bed without walker. V16 said she run to assist him walking. She did not hold to guide him, she just stands behind him when he was walking toward his bed. When he was close to his bed, he lost his balance and fell on the floor. V16 said that she could not prevent the fall. V16 said that R3 is confused. She is not aware that R3 is at risk for fall. She was not aware that R3 was restless and attempted to get out from bed in the morning shift. She is not aware that she R3 needs supervision and monitoring. V16 said that there is gait in the room that is accessible, but she did not use with R3 because he is already walking when she saw him. V16 said that she should use the gait belt to assist him in ambulation back to his bed. Surveyor unable to interview CNA who worked with R3 on 12/30/22 on 3-11 shift. V1 Administrator, V2 Assistant administrator and V3 DON are aware. On 1/11/23 at 11:45am, V19 Physical Therapist (PT) said that she evaluated R3 on 12/30/22. V19 said that he was referred for PT services to evaluate need for assistive device, promote safety awareness, enhance rehab potential, increase awareness of environmental hazards, minimize falls, increase LE ROM and strength and increase functional activity tolerance in order to enhance patient quality of life by improving ability to safely return to ALF ( assisted living facility), decrease level of care required from caregivers, perform steady gait and facilitate increased independent with functional mobility throughout facility. R3 needs moderate assistance with ADLs and transfers. R3's precautions: Fall risk, isolation, contact and droplet precaution due to possible COVID 19 exposures, catheter. V19 said that after her evaluation with R3 she discussed precautions to the floor nurse and CNA for safety. V19 said that she left walker at bedside for R3 to use when ambulating with staff supervision. On 1/11/23 at 2:28pm V11 Restorative/Fall Coordinator said that if resident is confused and restless, they should provide close supervision/monitoring for safety. 3. R5 is admitted on [DATE] with diagnosis listed in part but not limited to Type 2 Diabetes Mellitus with diabetic polyneuropathy, Vascular dementia, Kidney transplant, Epilepsy, Hypertension, Anxiety disorder, End stage renal failure, Gastroesophageal reflux disease, Long term use of insulin, history of traumatic brain injury. Care plan indicated: ADLs self-care performance deficit. AT risk for fall r/t generalized weakness and decreased safety awareness secondary to history of left femur fracture after fall, epilepsy, dementia, history of traumatic brain injury, left hip ORIF (Open reduction internal fixation). Currently receiving psychotropic medications due to anxiety and depression. Noted with behavior or mood issues of restlessness, anxiousness and feeling disconnected to everything. Admission fall assessment done on 5/14/21 indicated score of 9, at risk for fall. Fall assessment after fall dated 1/21/22 indicated score of 5, at risk for fall. Fall assessment after fall dated 2/15/22 indicated score of 10, at risk for fall. Fall assessment after fall dated 4/18/22 score of 3, at risk for fall. Fall assessment after fall dated 1/1/23 score of 6, at risk for fall. R5's fall incident dated 1/1/23 reported to IDPH indicated: R5 was sitting in the TV room when staff witnessed her fall forward. The nurse assessed and notified the doctor. She was sent tot hospital for evaluation. Hospital notified staff that she was diagnosed with nasal fracture. Investigation completed and revealed that R5 was in the TV room watching TV when she fell asleep and fell forward. She returned to facility, pain management and safety intervention implemented. This is the final report dated 1/6/23. Pain management intervention was not implemented. R5's fall incident dated 4/18/22 indicated: R5 found on the floor on her left side in her bedroom. R5 said that she was attempting to walk to the bathroom, tripped and fell on the floor. R5 denied hitting her head. R5 was sent out to the hospital for Right hip, sacral, thoracic and spinal x-ray. 4/18/22 Root cause analysis- IDT met after fall R5 alert and oriented x 2. R5 noted with fall in bedroom, per R5 she attempted to transfer unassisted. R5 will be encouraged to participate in activities that promote maintenance of gross motor skills. X-ray to sacral and right hip, will continue to monitor. Fall care plan interventions was not updated based on IDT recommendation. R5's fall incident dated 2/15/22 indicated: Heard R5 yelling for help at 3am. Found R5 sitting on the floor in her room. R5 said that she was trying to get out of bed and slid off of bed. R5 complained of lower back pain. R5 was sent out to the hospital for lumbar and sacral x-ray. 2/16/22-Root cause analysis- IDT met after the fall. R5 was noted with fall in her room. R5 stated that she slid from bed, intervention increase rounding at a minimum of every 2hrs and prompt or assist for change in position, toileting, offer fluids and ensure resident is warm and dry and keep in lowest position. No documentation of increased rounding/monitoring that was done. R5's fall incident dated 1/21/22 indicated: Heard R5 screaming for help. Found R5 on the floor. R5 said that she fell asleep in the wheelchair and fell on the floor and hit her head. R5 complained of left hip pain. R5 was sent out to the hospital for evaluation. 1/22/22- Root cause analysis. IDT met after fall. R5 fell due to falling asleep in her room. Intervention: Encourage participation in activities to keep resident's focus on task, maintain resident in well supervised areas when up in wheelchair. On 1/11/23 at 10:10 am Observed R5 lying in bed, restless and moaning. R5 said that she is in pain and has been waiting for the nurse for pain medication. R5 has facial bruising on her check bilateral cheek bone. Her bed is in high position. She has bilateral floor mat on side of the bed. Called V20 RN and showed observation made. V20 said that the CNA probably left the bed in a high position when providing the breakfast tray to R5. V20 said that R5's bed should be in the lowest position when she is in bed for safety. R5 is at a high risk for falls. V20 put the bed in the lowest position. V20 said that she has not given R5 her pain medication. V20 said that R5 is confused and always complains of pain. V20 checked R5's e-MAR. She said that the last time R5 had her pain medication was yesterday at 4:45pm. On 1/11/23 at 12:15pm, Informed V11 Restorative/Fall Coordinator of inconsistency in R5's fall assessment. V11 said that she will do in-services with the nurses regarding properly completing fall assessments. The score should go up not go down after falls. Informed V11 of observation made with R5's bed in high position with V20 RN. V11 said that R5's bed should be in lowest position when she is in bed. Informed V11 that pain management for R5 as plan of care after the recent fall is not implemented. 4. R6 is admitted on [DATE] with diagnosis list ed in part but not limited to Cerebral edema, History of falling, Hemiplegia and hemiparesis following intracerebral hemorrhage affecting left non dominant side, Facial weakness following cerebral infarction, Laceration with foreign body of part of head, Unsteadiness on feet, generalized muscle weakness, Dementia, age related cataract, hearing loss, chronic kidney disease, age related osteoporosis, Alzheimer's disease. Care plan indicated: ADLs self-care performance deficit. At risk for fall secondary to recent hospitalization with dx of cerebral edema is noted with increased weakness. Unsteadiness on feet. Gait/mobility abnormality. Has other co-morbidities, pulmonary fibrosis, left hemiplegia, urinary incontinence, dementia, overactive bladder and Alzheimer's disease. She has impaired cognitive function. Admission fall assessment done but not signed on 12/5/22 indicated score of 8, at risk for fall. Fall assessment after fall incident on 12/22/22 was not done. Fall assessment after fall incident on 1/5/23 indicated score of 12, at high risk for falls. Fall assessment after fall incident on 1/9/23 indicated score of 13, at high risk for falls. R6's fall incident dated 1/9/23 reported to IDPH on 1/10/23 indicated: At approximately 9:45pm, R6 was observed sitting in her wheelchair next to her bed with laceration to the back of her head. R6 said that she attempted to self-transfer and fell , hitting her head. R6 then got herself back into her wheelchair. R6 is alert and oriented to self but pleasantly confused. Nurse assessed laceration, applied pressure, cleansed, and covered with dry gauze. R6 was sent out to the hospital for evaluation. R6 returned to the facility with 3 staples to the back of the head. Pain management in place. Investigation started. Final report to follow. 1/10/23- Root cause analysis- IDT met after fall. R6 was noted with fall at bedside sent out for further evaluation, came back with laceration to left side of head. Intervention: initiate 3-day elimination record and increase rounding at a minimum of every 2 hours and prompt or assist for change in position, toileting, offer fluids and ensure R6 is warm and dry. Facility unable to provide documentation of increased rounding/monitoring of R6. R6's fall incident dated 1/5/23 indicated: At approximately 4am, noted sitting in her chair at bedside. R6 is conscious, alert, and oriented to self but pleasantly confused and forgetful. R6's roommate uses her call light to call for help and verbalized that she saw R6 on the floor but did not see how she fell . R6 unable to give description on what happened due to confusion. R6 has an old healing laceration to the left side of head with dry scab but after she fell noted the dry scab re-opened measuring 1.5cm x 1cm with scant blood. Site cleansed with NS and kept clean and dry. R6 assisted back to bed with 2 persons assist. R6 was sent out to the hospital for CT of the head. 1/7/23-Root cause analysis- IDT met after fall. R6 was noted with fall and sent out to hospital for eval. Came back with negative findings. Intervention: dx UTI. Currently on anti-biotics, staff will increase frequent monitor. Facility unable to provide documentation of increased monitoring. V3 DON said that they did not submit report to IDPH because the scab re-opened causing open wound and not new injury related to fall. R6's fall incident dated 12/24/22 indicated: R6 found in other resident room. R6 said that when she realized that it was not her room, she turned too fast and lost her balance and fell on the resident's bed. No injury noted 12/24/22-Root cause analysis - IDT met after fall. R6 was noted with fall due to impaired balance and was not wearing proper shoes, intervention: R6 was provided with proper footwear/nonskid socks. No fall assessment done after fall incident. On 1/11/22 at 10:18am, Observed R6 lying in bed. She is alert and responsive, able to verbalize needs. She is hard of hearing. Her bed is in a high position. Her call light is on the floor on right side of the bed. She does not have floor mat. Called V21 CNA and showed observation. V21 said that R6's bed should be in the lowest position. V21 said that she raised her bed when she provided her breakfast meal and forgot to put it down. V21 picked up the call light on the floor placed it within reach. Informed V11 Restorative/Fall coordinator of observation made. On 1/11/23 at 10:51am, Observed V21 CNA transferred R6 from toilet to wheelchair without using a gait belt. V21 said that she forgot to use a gait belt. V21 said that she should use a gait belt when transfering R6. R6 is high risk for falls. On 1/11/23 at 12:15pm, Informed V11 Restorative/Fall Coordinator of R6's fall assessment after fall incident on 12/24/22 was not done. V11 said that floor nurse should complete fall assessments after each fall occurrence. Informed V11 of observation made V21 CNA transferring R6 from toilet to wheelchair without gait belt. V11 said that CNA should use a gait belt when transferring resident or ambulating for safety. On 1/11/23 at 12:31pm, V10 CNA Supervisor said that CNA should use a gait belt when transferring resident for safety. On 1/11/23 at 2:04pm V3 DON and V11 Restorative /Fall Coordinator said that they don't document their monitoring for residents' who are high risk for falls as indicated in care plan. Informed both the fall care plan interventions for R5 and R6 who has recently fallen and sustained injuries- R5 sustained basal fracture and R6 sustained laceration at the back of the head both requires visit to the hospital for treatment. Both residents fall care plan intervention indicted increased rounding /monitoring. V3 and V11 said that they just informed the CNAs to do frequent or increased rounding/monitoring, but they don't have documentation of date and frequency of time residents' are being monitored. Facility's policy on Fall risk assessment indicates: Policy: Residents will be assessed for risk factors that increase their potential falls in order to identify the need to initiate additional safety measures. Procedures: 1. Residents shall be assessed upon admission, re-admission, with significant change , post fall , quarterly and annual . 2.The resident who scores 0-1 shall be considered at risk for fall 3.The resident who scores 12 or greater will have considered at high risk 4.All resident will have universal fall intervention applied 6. With each fall, the care plan interventions will be reviewed for their effectiveness and modified as appropriate to reduce hazards and risk to the residents. Facility's policy on Management of falls indicates: Policy: The facility will assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate resident interventions and revised the resident 's plan of care in order to minimize the risk for fall incidents and or injuries to the resident. Facility's policy on Fall management program indicates: Policy: The facility is committed to minimizing resident falls and or injury so as to maximize each resident's physical, mental and psychosocial wellbeing. While preventing all resident falls is not possible, it is the facility's policy to act in a proactive manner to identify and assess those resident at risk for falls, plan for preventive strategies and facilitates a safe environment. Facility's policy on Gait belt/Transfer belt indicates: Policy: To assist with a transfer or ambulation. A gait belt will b eused with weight bearing residents who requires hands on assistance.

Based on observation, interview and record review the facility failed to implement its written policy to prevent abuse of residents by failure to suspend an accused employee of possible abuse pending investigation. Facility also failed to complete the resident safety abuse assessment upon admission and update the assessment, and complete the assessment accurately. Facility failed to formulate an abuse prevention care plan as triggered in the assessment and update the care plan after the abuse investigation was conducted. This deficiency affects all three (R2, R4 and R7) residents reviewed for Abuse prevention program. Findings include: 1. R2 is admitted on [DATE] with diagnosis listed in part but not limited to Surgical aftercare following surgery on the digestive system, Diverticulitis of the intestine, Disruption of external operation wound, Chronic respiratory failure, Cognitive impairment, Aphonia, Generalized weakness, Difficulty walking, Hypertension, abnormal posture, Anxiety, Gartroesophageal Reflux disease, Gastrostomy, Colostomy, Ventilator, Supplemental oxygen. No abuse /neglect screening assessment done upon admission. No abuse/neglect prevention care plan formulated. R2's alleged abuse incident report dated 12/14/22 indicated: On 12/15/22, R2's family called V1 Administrator and alleged that V22 LPN hit R2 in the head the evening prior. Skin check was completed with no abnormalities found consistent with allegations voiced. Family identified the alleged V22 LPN but R2 unable to provide additional information. Investigation was immediately conducted through interviews with resident, staff and other residents. As a result of these interviews, it was determined that no abuse nor trauma occurred. Despite facility's investigation, R2's family decided to notify the police of their allegations as well. Police officer conducted interviews with R2 and her family at the facility and could not substantiate abuse either. During officer's interview with R2 and family, family became verbally aggressive towards officer, expressing that they felt he did not know how to do his job. As facility 's investigation was being conducted. R2 transferred out to the facility and is not in an Long Term Acute Care Hospital (LTACH) as part of her plan of care/ Care plan has been updated. This is the final report. On 1/10/23 at 11:12am, V22 LPN said that R2 accused her of physical abuse. R2 alleged her of physical abuse by hitting her in head/face. V22 denied abuse allegation. V22 said that she admitted R2 with family at bedside on 12/13/22. R2 has tracheostomy tube connected to vent, colostomy. She is depressed, alert able to verbalize needs but limited in expression because of trach. She has a good rapport with R2 and Family. V22 said on 12/15/22 at 3pm, she was called to the nursing office before reporting to the unit and informed her about the allegation of abuse of R2 against her. She denied allegation made. The police also talked to her, and they did not find any bruise/injury on R2 's face/head. She was not suspended. V1 told her not to take care of R2 but she still worked on the same unit with other residents. On 1/10/23 at 1:07pm, V9 Human Resource said that she did not hear that V22 LPN was accused of alleged abuse by R2. V22 was not suspended. V9 said that usually, V1 will coordinate with her if there are any employee's that will be suspended pending investigation of abuse allegation. V9 presented V22's work schedule time in and out record from 12/13 to 12/22/22. V22 was not suspended. On 1/11/23 at 11:03am, Informed V2 Assistant Administrator that R2's safety abuse assessment was not done, and abuse prevention care plan was not formulated and updated when R2 and her family complained of alleged physical abuse by V22 LPN. V2 said that she was covering for the Social Service Director who was on maternity leave. V2 said that she did not complete R2's admission safety abuse assessment and develop abuse prevention care plan. She is aware that R2 and her family has a complaint of alleged physical abuse by V22 LPN. She said that she should've completed the abuse assessment, developed and updated an abuse prevention care plan. V2 said that during an abuse investigation, an employee who is accused of alleged abuse should be suspended pending investigation. On 1/1/23 at 3:15pm, V1 Administrator said that he did not suspend V22 LPN pending investigation because they will be short of nurses on the unit. 2. R4 is admitted on [DATE] with diagnosis listed in part but not limited to Metabolic encephalopathy, Transient cerebral ischemic attack, Hypertension, Weakness, Unsteadiness on feet, Generalized muscle weakness, dysphagia, aphasia, cognitive communication deficit, Depression, Anxiety, History of neoplasm. Care plan indicated: Impaired ADLs. She presents with severe cognitive/communication deficit impacting memory, attention, reasoning and problem solving. She has ADLs self-care performance deficit. She is at risk for fall related to generalized weakness and impaired balance secondary to encephalopathy, history of TIA, dementia, polyneuropathy. She is currently receiving psychotropic medications to manage behaviors or mood issues of agitation, becoming withdrawn, refusing care related to (r/t) anxiety disorder and depression. She is incontinent of bowel and bladder. She has severely impaired cognitive function r/t dementia with agitation. She has an alteration in visual function r/t glaucoma. She is noted to resist care as evidenced by refusing to take medication and participate in therapy due to anxiety, cognitive impairment, dementia. R4 has several fall incidents without injury. Admission abuse/neglect assessment done on 12/22/22 indicated marked No to all factors triggered. On 1/11/23 at 9:56am, Observed R4 lying in bed. She is alert and responsive, able to verbalize needs to staff. She ambulates with rolling walker. On 1/12/23 at 10:34am, V2 Assistant Administrator said that she did the safety abuse assessment for R4 on 12/22/22 because she is covering for the Social Service Director who was on medical leave. Review R4's medical record with V2. Informed that R4's abuse screening is inaccurately completed. V2 said that she should've marked #14 yes instead of No. Abuse prevention care plan should've been formulated because it triggered in the assessment. Resident safety abuse screening assessment form indicated: #14 Is there a current diagnosis of severe mental illness ( e.g, schizophrenia, schizoaffective, major depression, etc) Intellectual/developmental deficit, Dementia ( e,g Alzheimer's Vascular, etc). 3. R7 is admitted on [DATE] with diagnosis listed in part not limited to Spinal stenosis, lumbar region, Type 2 Diabetes Mellitus, Radiculopathy, Depression, Benign Prostate Hypertrophy, Adjustment disorder with depressed mood, chronic kidney disease. Care plan indicates ADLs self-care performance deficit. Receiving psychotropic medications due to depression. Noted with mood behavior or mood issues of sadness due to needing an increasing amount of assistance with ADLs and is not able to return home alone. Impaired cognitive functioning due to current medical dx of cognitive communication deficit. No resident safety abuse assessment done upon admission. No abuse prevention care plan formulated. R7's abuse resident to resident altercation incident reported to IDPH dated 11/17/22 indicated: On 11/18/22 R7 reported to staff that a resident-to-resident altercation has occurred between him and his roommate (who no longer resides in the facility). R7 alleged that in the middle of the night, he was woken up by his former roommate who he claimed approached and slapped him in the head. Residents' were immediately separated. Head to toe assessment completed on R7 with no injuries nor abnormalities noted. X-rays ordered with results all returning negative. Investigation initiated and allegations were fully investigated through interviews with staff and residents. Through this interview process, R7's allegation could not be substantiated, and it was determined that no harm occurred to R7. In further discussing the investigation with R7, just a few days after initial allegations were made. R7 cannot recall the details of his claims and stated that he no longer believes that his former roommate slapped him. R7 further expressed that he got along well with his former roommate during their time as roommate and does not feel he would intentionally try to harm him. Nonetheless, resident remains separated. Care plan updated. Final report dated 11/23/22. On 1/12/23 at 11:45am, Observed R7 up in high back wheelchair. He is alert and oriented and responsive. He can verbalize needs to staff. He is total care with ADLs and transfers. He uses mechanical lift for transfers with 2 persons assist. On 1/12/23 at 12:10pm, Reviewed R7's Abuse incident report and his medical record with V2 Assistant Administrator. Informed V2 that resident safety abuse assessment was not done upon admission and was not updated during the abuse investigation. R7 does not have abuse prevention care plan and care plan was not updated as indicated in the Abuse report plan of action submitted to IDPH. V2 said that Resident abuse safety assessments should be done upon admission, quarterly and as needed. Abuse care plans should be formulated and updated during an abuse investigation. V2 said that V8 Social Service Designee is responsible for completing R7's abuse assessment and developing abuse prevention care plans. On 1/12/23 at 12:12pm, V8 Social Service Designee (SSD) said that she completes the resident abuse safety assessment 72 hours upon admission and initiating abuse prevention care plan as indicted. She receives report when there is abuse allegations presented by residents. She is aware that R7 had an abuse resident to resident altercation with his former roommate. She said that she just missed completing R7's resident abuse safety assessment upon admission, quarterly and during the abuse investigation. She also said that she did not develop and update the abuse prevention care plan after the abuse investigation. Facility's policy on Abuse prevention program indicates: Policy: The facility affirms the right of our residents to be fee from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. The facility will report reasonable suspicion of a crime. This facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. 3. Prevention: The facility desires to prevent abuse, neglect and theft by establishing a resident sensitive and resident secure environment. d. As part of the social service assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals and approaches which would reduce the chances of mistreatment for these residents. Staff will continue to monitor the goals and approaches on a regular basis. 5 Protection of Residents: The facility will take steps to prevent mistreatment while investigation is underway. c. Employees of the facility who have been accused of mistreatment will be removed from the resident contact immediately until the results of the investigation has been reviewed by the administrator or designee. e. Employees accused of possible abuse shall not complete the shift as a direct care provider to residents. Facility's policy on Resident safety/abuse assessment indicates: Policy: It is the policy to protect the health, safety and welfare of all individuals that reside in this facility. One of the steps the facility utilizes in protecting its residents is the Resident safety/abuse assessment. Procedure: 1. Upon admission to the facility, the Social service designee (SSD) will complete a resident safety/abuse assessment on each individual. This assessment will determine if the resident at risk as a vulnerable adult. A resident is at risk if any of the questions result in a yes response. 2. If the individual meets the criterion, the SSD will generate a care plan with appropriate interventions in relation to the assessed criteria. This will be reviewed with the IDT. 3. The resident safety/abuse assessment will be completed upon initial admission, quarterly, annually, with any significant change, and or as indicated by IDT.

Based on interview and record review, the facility failed to provide and distribute nourishing snacks at bedtime to all residents in the facility. This failure affects all 89 residents receiving food from the facility. Findings include: On 9/12/22 V1 (administrator) presented the survey team with the number of residents currently in the facility. Facility census provided showed 121 total residents. Of these residents V7 (dietary manager) indicated there were 89 residents receiving food from the kitchen. On 9/12/22 at 11:45 am during the initial tour of the facility, R13 was observed in bed and spoke with the surveyor about her some concerns. R13 stated, I am concerned about the food as sometimes I get cold food given to me. I cannot walk or put myself on the wheelchair because I need a lot of help to do that so I rely on staff to do this for me. I sometimes go to bed hungry and I can't get a snack at night or anything. I have to wait until the next morning for breakfast before I eat and I am so hungry. Surveyor asked if she is ever offered any snacks during bed time or whether anyone comes around to offer snacks in the evening, R13 stated, Never. I'm told they are delivered at the nursing station but when I request for something, I never receive any or I'm told that they are out of snacks. All I want is a cookie or something, anything. Surveyor asked what time she usually has dinner, R13 stated, Dinner here is served really early so I get to eat dinner around 5:00 PM or 5:30 PM and then like I said I have to wait until the next morning around 8:30 AM to eat breakfast. That's just way to long to lay here and starve. On 9/14/22 at 10:10 AM, 10 residents present in the resident council meeting were interviewed on the concerns and complements they had with the facility. During this meeting with the surveyor, R42 (resident council president) stated to surveyor that obtaining evening snacks was an issue. Surveyor asked for specifics, R42 stated, I've had residents complain to me and to management that bedtime snacks aren't being passed around. I have no issue getting any but I am able to get around but some residents who are bed-ridden can't get any snacks and sometimes I've experienced that when I go to the nursing station that they even run out of snacks or the snacks never came out from the kitchen. Surveyor asked the rest of the resident council participants if this was their experience, all 9 residents in attendance concurred and wanted assistance from the surveyor to correct the issue. On 9/14/22 at 11:30 AM, V7 was asked about the bedtime snacks, V7 stated, We usually bring out a tray of snacks and they are placed at the nursing station. Surveyor asked who's responsibility it was for these snacks to be distributed to residents, V7 stated, Not my staff, it's the nurses that should do this if the residents ask for it. Surveyor asked whether any staff offer residents snacks, V7 stated, No that's the nurses job. Surveyor team asked V7 for any policies and procedures for the distribution of evening snacks but was not provided any after several requests to do so.

Based on observation, interview, and record review the facility failed to properly cover and label food items stored in the refrigerator and failed to follow their food storage policy and food storage guideline policy for the use of and discarding of foods. This failure has affected all 89 residents that receives meals from the kitchen. Findings include: On 09/12/2022 V1 (administrator) presented the survey team with the number of residents currently in the facility. Facility census provided showed 121 residents. Of these residents V7 (dietary Manger) indicated there were 89 residents receiving food from the kitchen. 09/12/22 at 9:59am During the observation of the refrigerator the surveyor noted two pans of Jell-O in the refrigerator not covered or dated, In the freezer there 4 packs of hot dog buns one noted with an expiration date of 09/06/2022 the other three packs of buns did not have dates . The buns have freezer burn on all 4 packs of bread. Observation of the dry storage room surveyor noted one can of dented sliced apples on the shelf mixed in with the non-dented cans, two packs of flour tortillas with the expiration date of 07/21/2022. On 09/12/2022 at 11:10am interview with V7 (Dietary manger) said We had extra bread the use by date is September 6th it can be frozen we kept it for emergency purpose we get bread delivered every Tuesday. If the bread gets freezer burn we have to throw it away. The flour tortillas are staff food no they are not allowed to have their food in the resident food storage. When we get dented cans we store them here but the staff know not to use them. Yes they know not to use them then we give them back. Because they automatically know not to touch it we store them with the regular cans and then give them back. Jell-O should be stored in the refrigerator covered with the date on it but we was letting it cool and then we will cover it and put the date on it. On 09/13/2022 at 11:10am Interview with V8 (Dietary consultant) said Bread is good as long as it doesn't have any sign of mold or spoilage. Yes we use the first in, first out (FIFO) the staff should be checking to make sure the bread is good before serving it. The staff should be checking to see if the Hot dogs buns have freezer burn and if it does they should throw them away. Dented cans should be put aside they should not be stored with regular cans. Food items of staff should not be stored with the resident's food items. Record review of a document titled Food storage guidelines with the dates of 7/17 and 8/18. Under policy states: Food will be stored and used in an acceptable amount of time. Under procedure number 5. Common terms letter C states Expiration date is the last day the product must be used or eaten. The food is no longer safe to eat after the expiration date and will be discarded. Record review of a document titled Food storage with the dates of 6/97, 2/12 and 7/17 under policy states Food storage areas will be maintained in a clean, safe and sanitary manner. Under procedure number 3 states: Food inventory will be maintained using the first in, first out (FIFO). Food stock will be rotated by placing new stock behind old. Items will be marked with date prior to storage. Number 6 states: Food taken from their original container will be label by common name.

Based on observation, interview, and record review, the facility failed to follow federal regulations and their infection prevention and control program regarding donning personal protective equipment (PPE) prior to entry into a resident's room who is under contact isolation precautions, failed to practice proper PPE use and/or perform hand hygiene during food preparation to minimize the spread of infection. This failure has the potential to affect all 121 residents that reside in the facility. Findings include: On 09/12/2022 at 11:50 AM, observed standard precaution and contact isolation signs both posted on the outside of R73's room door which both indicated to don gloves and gown prior to entering. Also observed a three-drawer bin next to the doorway of R73's room that contained personal protective equipment and supplies. Reviewed resident isolation list provided by the facility for September 2022 that showed R73 is under contact isolation precautions for CRAB/ESBL in sputum/urine. Reviewed R73's active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Reviewed R73's immunization records that showed consent denied for all Covid-19 vaccinations. On 09/13/2022 at 11:41 AM, surveyor observed V11 (Nurse Practitioner) enter R73's room without donning gloves or an isolation gown. V11 then removed a stethoscope from around her neck and shoulders and proceeded to auscultate R73's heart and lungs with this stethoscope. V11 (Nurse Practitioner) placed the stethoscope back onto her shoulders then exited R73's room. Surveyor did not observe V11 sanitize the stethoscope upon leaving R73's room. At 11:44 AM, V11 (Nurse Practitioner) said she is new to the facility and did not notice the isolation signs on the door. Surveyor then observed a second nurse practitioner rounding on hall 3 of C wing with her face mask flipped up, nose and mouth both were exposed. On 09/14/2022 at 2:10 PM, V4 (Infection Preventionist) said R73 is under contact and droplet isolation precautions for ESBL in the urine and CRAB in the sputum. At 2:16 PM, V4 (Infection Preventionist) said her expectation is for the nurse who received lab results and new orders, to initiate antibiotic and must inform floor staff of the type of isolation and PPE required. V4 then said all staff must wear an N95 mask and face shield and apply proper PPE such as gown and gloves for example, if a resident has [CONDITION(S)] (c-diff) to avoid cross contamination. V4 (Infection Preventionist) added that the nurse practitioners are contracted through the facility's medical providers and her expectations for contract staff are the same as facility staff and are to follow guidelines for infection control purposes to avoid the spread. Reviewed community level of Covid-19 transmission provided by facility for 09/06/22-09/13/22 that showed high for facility's county. Reviewed list of fully vaccinated practitioners provided by facility that showed 17 in total. Facility did not indicate V11's (Nurse Practitioner) vaccination status. Reviewed facility's infection prevention and control program policy and procedures that showed the following: The primary mission is to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The policy for infection prevention and control is based upon information from facility assessment and follows national standards and guidelines to prevent, recognize and control the onset and spread of infection and shall include standard and transmission-based precautions to be followed to prevent the spread of infections through selection, use of PPE, and hand hygiene procedures to be followed by staff involved in direct resident contact. The policy indicates that standard precautions include but are not limited to hand hygiene; use of gloves, gown, mask, eye protection or face shield. Also, equipment or items handled in a manner to prevent transmission of infectious agents (e.g., wear gloves for direct contact, properly clean and disinfect or sterilize reusable equipment). The intent is to implement standard precautions and when transmission-based precautions should be utilized, including type of precautions for particular infections and organisms and require staff follow hand hygiene practices consistent with accepted standards of practice. The elements of the program include policies, procedures, and practices which promote consistent adherence to evidence-based infection control practices such as managing food safety, including employee health and hygiene. Observations and interview by a fell ow surveyor noted during this survey include: On 09/12/22 at 9:59am, entrance into the kitchen area surveyor noted two employees doing food preparation without mask on. V12 Dietary Aide grab a mask off the counter and put the mask on but did not perform hand hygiene before handling the food she was wrapping (salads and cut vegetables). On 09/13/2022 at 11:32am, observation of lunch being served on B-wing V14 Dietary aid noted with her N95 mask not completely on with one strap over her head and the other strap hanging from her chin. V10 Dining room hostess noted to readjust her mask with her gloves on and did not perform hand hygiene or change her gloves before doing temperature of food. On 09/13/2022 at 11:50am, V13 Dietary Aide picked a bowel off the floor and did not perform hand hygiene or change her gloves before continuing her task of plating resident food. On 09/14/2022 at 10:57am, interview with V7 dietary manger said If the staff have to readjust their mask my expectation is that the staff have to wash their hands or use alcohol gel before doing the task. They need to take the gloves of wash their hands and then put the gloves back on. They should pick up the dish put it on the bottom of the cart then take their gloves off, wash their hands and put gloves back on to complete whatever they was doing.

Based on observation, interviews, and record reviews, the facility failed to follow the plan of care for a resident with a pressure ulcer by not turning and repositioning the resident every two hours to aid in the prevention and healing of a sacral pressure ulcer. This failure applied to one (R70) of four residents reviewed for pressure ulcers in the sample of 53. Findings include: R70 is a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to MDS (Minimum Data Set) dated 08/04/2022 under Section C, R70 has a BIMS (Brief Interview of Mental Status) score of 15 indicating a high level of cognitive functioning; under section G, R70 requires extensive assistance in bed mobility with two+ person physical assist; under section M, R70 has one stage IV pressure ulcer that was not present upon admission. On 09/12/22 02:30 PM V15 (family member) expressed concerns regarding lack of repositioning, V15 stated, I'm here on Wednesday and when I'm in the room staff doesn't come to reposition R70, he remains in the same position for hours. On 09/12/22 02:35 PM Surveyor observed R70's wound care. V4 (Licensed Practical Nurse) and V3 (Licensed Practical Nurse) both indicated that they are substituting for a regular wound care nurse who is absent at this time. Surveyor observed no dressing covering R70's sacral wound upon initial observation. V3 (LPN) indicated that it must have fallen off during R70's transport to and from the doctor's visit earlier that today. V3 proceeded to clean the site with normal saline and applied [MEDICATION(S)] calcium alginate and dry dressing as per order. Current wound size is 3cmx4.5cmx1.5cm at this time. Wound care progress note dated 09/07/2022 reads in part, Sacral pressure ulcer, size 2cmx4.2cmx1cm, indicating that wound has increased in size. On 09/12/2022 at 3:07 PM V3 stated, R70 has had this wound for a very long time. I believe he acquired it here (at the facility). R70 is prone to developing wounds due to several factors, such as comorbidities, nutrient intake and others. Surveyor asked if repositioning would have an impact in acquiring sacral wound, V3 indicated that lack of repositioning would have a negative impact on the wound not only in acquiring but also healing. On 09/13/2022 at 09:42 AM Surveyor observed R70 lying in bed positioned onto his right side. On 09/13/2022 at 10:00 AM Surveyor observed two Certified Nursing Assistants reposition R70 onto supine position. During continuous observations, surveyor noted that at 12:07 PM, R70 remained in supine position after two-hour period. Care plan for R70 focus area Alteration in skin integrity, dated 11/19/2019, reads in part, Avoid turning body to sacral area with pressure ulcer as much as possible. Turn and reposition every two hours and as need/tolerated.

Based on observation, interview, and record review, the facility failed to serve food in a manner that maintained proper holding temperatures. This failure affected all 89 residents that receive meals from the kitchen. Findings include: On 09/12/2022 V1 (administrator) presented the survey team with the number of residents currently in the facility. Facility census provided showed 121 residents. Of these residents V7 (dietary Manger) indicated there were 89 residents receiving food from the kitchen. On 09/12/2022 at 11:54am during an interview with Resident # 25 said when they bring my food in its cold and dried out so I don't eat it I send it back. Sometimes I do ask for something else and sometimes I don't be as hungry. On 09/12/2022 at 12:32pm during an interview with Resident # 75 said The food here is sometimes a hit or miss. It does be cool sometimes depending on what it is. Yes i have mention this to the dietary they supposed to be working on it. Hall trays are place on a hot heated food cart. On 09/13/2022 at 12:18pm Test tray temperatures was completed with (V10 Dietary hostess). The temperatures read: Mash potatoes and gravy at 134 degrees Fahrenheit Egg Noodles 118 degrees Fahrenheit Puree beef Stroganoff is at 115 degrees Fahrenheit Soup is at 140 degrees Fahrenheit. On 09/14/2022 at 10:57am interview with V7 (dietary manger) said Some of our residents like their food to be cold well not cold cold but not warm. We don't have a standard temperature we use. Food that come off the steam table we have up to four hours to serve the food before bacteria start to grow. Our facility say we have to serve it with in 30 minutes. The hot holding is 135 degrees Fahrenheit. During a resident council meeting held at 10:07am on 09/14/2022 with fell ow surveyor there was 10 residents that attended this meeting and all 10 residents was in agreement that the facility serves cold meals and they prefer meal be a little warmer. Record review of a document submitted by the facility titled Food Temperatures with no date noted under policy states: Food will be served to the resident at a temperature that is palatable. Under procedure number 4 states: Food will be transported via methods that maintain the proper temperature of the foods being served. Number 5 states hot foods will be presented to the resident within 30 minutes of leaving the steam table. Record review of a document titled At risk hot food and Beverage Temperature service with a date of 5/19 under Procedure number 2 states: Food will be held at 135 degrees Fahrenheit or higher, minimizing excessively high temperatures.

Based on observation, interview, and record review, the facility failed to administer medications as ordered (at ordered times). There were 30 opportunities with 2 errors resulting in a 6.67% error rate. This applies to one (R53) of five residents reviewed during the medication pass task. Findings include: On 09/13/2022 at 11:40 AM Surveyor observed V5 (Licensed Practical Nurse) administer the following medications to R53: 1. [MEDICATION(S)] Capsule 300 MG 1 capsule by mouth with apple sauce 2. [MEDICATION(S)] Tablet 5 MG 1 tablet by mouth with apple sauce On 09/13/2022 R53's Order Summary Report state in part; 1. [MEDICATION(S)] Capsule 300 MG 1cap by mouth three times a day 2. [MEDICATION(S)] 5 mg 1 tablet by mouth every 12 hours On 09/13/2022 at 11:50 am, review of R53's Medication Administration Audit for 09/13/2022. [MEDICATION(S)] Capsule 300 MG has a Schedule Date of 09/13/2022, with scheduled administration times of 0800, 1400, and 2000. [MEDICATION(S)] 5 mg 1 tablet has a Schedule Date of 09/13/2022, with scheduled administration times of 0900 and 2100. On 09/13/2022 at 11:57 AM V5 stated, I administered R53's medications late because I had a busy morning. It's important to give medications on time to prevent anything abnormal from happening and follow doctor's orders. We do have a one-hour window before and after medication administration time. If morning medications are administered late the expectation is to follow up with the doctor to see what needs to be done with later doses. On 09/14/2022 at 02:04 PM V1 (Administrator) stated, My expectation regarding medication administration is to give out medication on time. Medication administration window is one hour before and one hour after medication administration time, but there are circumstances when medications get administrated outside of the time frame. In such case, nurses should call the physician to notify of the change. There are certain medications that have parameters and are time sensitive; therefore, it is even more important to notify physician if these medications are given outside of the time frame. V1 further indicated that if medication is scheduled multiple times a day, following doses get affected and physician's expertise is needed to be able to proceed with further medication administration. 09/14/2022 at 02:37 PM Per record review, no indication of late medication administration physician notification noted. Medication Administration policy dated 09/2020 reads in part, Drugs must be administered in accordance with the written orders of the attending physician.

Based on interview and record review, the facility failed to have sufficient staff as per comprehensive assessment to provide safe bed mobility and transfer for R1. The facility also failed to set the low air loss mattress to the static mode to provide a firm surface that makes it easier for residents to transfer or reposition. This failure caused R1 to fall from the bed when left unassisted and sustain bilateral femur fractures. This applied to 1 of 3 residents (R1) reviewed for resident fall and injury in a sample of 3. Findings include: R1 is an [AGE] year-old female, alert-oriented, having a BIMS (Brief Interview for Mental Status) score of 12. R1 was admitted with an admitting diagnosis including muscle weakness, gout, abnormalities of gait and mobility, [CONDITION(S)], and polyneuropathy. On [DATE] at 11:20 AM, R1 stated, I had fallen on [DATE] and fractured both legs (femurs). On [DATE], CNA (V4) dressed me up and let me sit at the bedside. I think V4 went to grab the wheelchair, and I slipped off to the floor, causing fractures on both my legs. Record review on fall risk assessment dated [DATE] document that R1 was at risk for fall. Record review on fall care plan document to ensure resident properly transferred and assisted with ADL (activities of daily living) care. Record review Minimum Data Set (MDS) dated [DATE] document that R1 was a two-person extensive assist with transfer and bed mobility. On [DATE] at 11:35 AM, V4 (Certified Nursing Assistant - CNA) stated, On [DATE], I told my coworker (V5) to stop by R1's room for assistance to get R1 up using a sit-to-stand lift. Then I went to R1's room, changed R1 brief, and sat R1 at the bedside. I stick out my head at the door, looking for V5 to get help. Meantime, R1 slipped to the floor, and I couldn't stop when R1 slipped down. Two people are required for her bed mobility and transfer. The other CNA was busy, and she didn't show up. A second staff with me could have avoided that potential fall. On [DATE] at 2:10 PM, V4 added, R1 was on low air loss mattress. I didn't make any changes to the bed settings before I made R1 sit at the bedside to get R1 up using a sit-to-stand lift. It's possible that air inflation can slip R1 down to the floor. I didn't know how to put the low air loss mattress to a static mode/CPR (Cardiopulmonary resuscitation) position to avoid slipping. On [DATE] at 11:42 AM, V5 (CNA) stated, V4 called me for help before V4 went to R1's room. I was helping other residents. When I got there, R1 was already on the floor. The paramedics were already there, and her CNA (V4) was there. We use a sit-to-stand lift to get R1 up, requiring two people's help. On [DATE] at 11:25 AM, V2 (Director of Nursing) stated, If R1 is assessed for two people's extensive assistance for bed mobility and transfer, two staff should be present to provide that care. I don't think it was safe to leave the resident at the bedside, and V4 walked to the door to look for a second CNA for help. V4 should have stayed close by R1 to prevent slipping off her to the floor. The facility presented Fall Management Program dated ,d+[DATE] policy statement document: It's the facility's policy to act in a proactive manner to identify and assess those residents at risk for falls, plan for preventative strategies and facilitate a safe environment.

Based on observation, interview and record review, the facility failed to follow their policy on prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in R1 developing a deep tissue injury and being sent to the local hospital where R1 was assessed and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. On 10/5/21 at 9:41am, V3, Wound Care Nurse ( WCN) said that R1 was admitted on [DATE] with skin intact. R1 had Braden scale score of 10 which indicated high risk for pressure ulcer. R1 developed DTI ( Deep tissue injury) on 9/14/21. Braden scale was done with score of 10 ( high) and care plan was updated. V3 spoke with V4, R1's Family member and referred R1 to V15, Wound Care Physician (WCP). R1 was placed on special low air loss (LAL) mattress. V3 completed the consent form for wound care and unavoidable pressure ulcer injury condition on 9/14/21 and signed by V15 Wound care Physician (WCP) on 9/15/21. V15 did not talk to V4 (Family member) regarding R1's wound condition. V3, WCN said that R1 was seen by V15, WCP on 9/16/21. V3 and V15 did not call V4 to update regarding R1's wound condition (100% maroon colored) and plan of care and new treatment order( [MEDICATION(S)] dressing and foam dressing). V3 stated that R1 was seen again by V15 and V3 on 9/22/21 regarding R1's wound condition ( 50% maroon and 50% necrotic /black) and plan of care and new treatment order (Santyl [[MEDICATION(S)] ointment], [MEDICATION(S)] dressing and foam dressing). V3 also said that the family was not updated with the changes of treatment and wound condition either 9/16/21 or 9/22/21. V3 said that the floor nurses did the wound dressing on 9/23 to 9/26/21 until R1 was sent out to the hospital. No nurses or Certified Nursing Assistants (CNAs) told V3 that R1's wound got worse not until R1 was being sent out to the hospital for wound evaluation on 9/26/21 by V14, Registered Nurse (RN). Surveyor asked how these 3 different nurses would be able to determine any changes in the wound condition of the R1. V3 said that the floor nurses can see or access R1's wound assessment in the chart and compare if there are any changes. On 10/6/21 at 12:46pm, V17, RN and V11, RN, who took care of R1 on 9/23/21 and 9/24/21, both said that they took care of wound dressing on R1 for the first time. Both said that they don't know if there was any difference in wound condition. Both said that it is not part of their daily work routine to read the wound assessments done by V3 and notify him if there is any changes from his notes. They said that if there is an identified and established wound, the wound care nurse will notify V15 and resident's family member. They notify V3 if there is a new development of skin alteration. On 10/6/21 at 2:09pm, V14, RN said that she took care of R1 on 9/25/21 and 9/26/21 and did R1's wound treatment. V14 said she did not know any difference in R1's wound condition because she took care of R1 for the first time. V14 does not read the V3's notes. It is not routine for her to read the wound assessments completed by V3. V14 said that she just followed the wound treatment as written in TAR (Treatment administration record). V14 will notify V3 if there is any new wound/skin alteration developed. V14 RN said that she did R1's sacral wound dressing after breakfast on 9/26/21. R1 did not have wound dressing when she did the wound care. V14 said that V13 CNA did not report to her that R1 had episodes of diarrhea. She said that V4 (R1's Family member) came to visit on 9/26/21, V14 observed V4 taking pictures of R1's sacral area and said that V4 wanted R1 to be sent out to the hospital immediately due to worsening of R1's wound and verbalized concern regarding care. V4 called 911. On 10/6/21 at 10:19am, V15 Wound Care Physician (WCP) stated that he usually does not talk to the Residents's family member. V15 expected V3 (Wound Care Nurse) to call and update the Resident's family member of wound progress plan. V15 stated that he was informed by V3 that R1 was sent out to the hospital for wound evaluation on 9/26/21. V15 was not notified that R1's wound had worsened. V15 expected the nurses on the floor who do the daily dressing to notify V3 or him (V15) or the infectious physician for any changes in wound condition or any sign and symptoms of infection. V15 said that DTI (Deep Tissue Injury) is caused by continuous pressure on sacral area and a co-morbidity will increase chances of development. DTI could be prevented by turning and repositioning every 2 hours, incontinence care after each episode, keeping it dry and use of LAL (Low Air Loss) mattress. A review of R1's hospital record dated 9/26/21 noted that R1 had a CT scan which revealed CT of abdomen and pelvis shows heterogenous air collection measuring 10x4x 6cm within the subcutaneous tissues of gluteal crease. Findings compatible with necrotizing soft tissue infection and or emphysematous [CONDITION(S)] of the coccyx. R1 was treated and admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. R2's medical record denotes R2 dignosis include Critical illness [CONDITION(S)], Chronic Respiratory failure, [CONDITION(S)], [CONDITION(S)], Dependent on respiratory ventilator, Pressure ulcer left hip stage 4, Pressure ulcer of left buttocks stage 3. On 10/6/21 at 11:04am, R2 was lying in bed with [CONDITION(S)] connected to oxygen. R2 has special LAL mattress. R2 is alert and responds with gestures. Observed V3, WCN and V8, CNA prepare R2 for wound care. A fitted sheet (thick linen similar to bath blanket), cloth pad and pillowcase were noted underneath R2. V3 said that he already in-serviced the CNAs regarding only 2 layers of sheets underneath residents on LAL mattress 3. R3's medical record indicated R3 was admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Wound care assessment identifies R3 with Stage 3 pressure ulcer on 9/16/21. On 10/5/21 at 11:18am, R3 was lying in bed. R3 opens eyes when called but has no verbal response. R3 has [CONDITION(S)] connected to oxygen. R3 is on special LAL mattress. Observed flat sheet, cloth pad and disposable adult brief underneath R3. V3 removed sacral wound dressing (foam dressing) soaked with reddish greenish brown drainage, moderate in amount. V3 stated that R3 has unstageable pressure ulcer, with greenish slough formation attached to wound base. 4. R4's medical record denoted R4 was admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/6/21 at 11:33am, R4 was lying in bed. R4 had [CONDITION(S)] connected to ventilator. R4 was on special LAL mattress. Observed flat sheet, cloth pad and folded towel in between R4's upper thigh and groin up to the suprapubic area. V3 removed the sacral dressing which had a small amount of serosanguinous drainage. V3 said that R4 has stage 3 pressure ulcer on left buttocks. On 10/6/21 at 12:06pm, V9, Unit Manager/CNA stated that residents on special LAL should have only 2 layers over the mattress. Flat sheet and disposable adult brief or cloth pad only. Residents with pressure ulcers are being repositioned and checked for incontinence every 2 hours. Residents should be kept dry and clean. On 10/6/21 at 12:31pm, V10, CNA stated that she is the CNA for R3 and she (V10) applied flat sheet, cloth pad and disposable adult brief after she cleaned R3 this morning. On 10/6/21 at 12:30pm, V18, Nurse Consultant stated that the nurse should notify the physician and responsible party of any changes in medical condition such as worsening of wound. On 10/8/21 at 12:04pm, V1, Administrator stated that wound care/treatment is done between V3 and floor nurses. The Wound care Coordinator, V3 does assessments and evaluations of new admission, wound vac care and priority wound treatment. The floor nurses are dictated to do the wound care/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurses are trained to know if there are sign and symptoms of changes of wound worsening or wound infection and to notify V3 or physician. Guideline for linen usage for specialty support surfaces, ( Low air loss, overlay, gel, water): May use: 1 sheet and 1 pad or incontinence brief between the skin and support surface. Facility's policy on Alternating Pressure Air Mattress indicated: Purpose: 1. To maintain and promote adequate circulation. 2. To relieve pressure and aid in the healing and prevention of pressure ulcers. 3. To reduce pain due to pressure. NOTE: AVOID USING ADDITIONAL LINEN THAT WILL NEGATE ACTION OF THE ALTERNATING PRESSURE MATTRESS. Facility's policy on Change of Resident Condition indicated: to ensure that the resident's physician /physician on call/Nurse Practitioner and Responsible party is kept informed regarding the resident's change in condition. Procedure: 1. Attending physician or physician on call/Nurse Practitioner and responsible party will be notified of all changes in condition. 5. Place call to responsible party to notify them of the resident's change in condition. Facility's policy on Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Policy: 1. To identify resident at risk for developing pressure injuries. 2. To identify the presence of pressure injuries and or other skin alterations. 3. Implement preventive measures and appropriate treatment modalities for pressure injuries and or other skin alterations through individualized resident care plan. Procedure: 8. At least daily, staff should remain alert for potential changes in the skin during resident care.

Based on interview and record review, the facility failed to provide safe bed mobility for 1 of 3 residents (R6) and failed to provide a safe transfer for 1 of 3 residents (R4) reviewed for falls in the sample of 6. This failure resulted in a resident (R6) sustaining a fractured nose and subdural cranial bleed and resident (R4) sustaining a right femoral condyle fracture (bone near the knee). The findings include: 1) R4's electronic face sheet printed on 11/16/20 showed R4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R4's facility assessment dated [DATE] showed R4 is cognitively intact and requires 2+ staff assistance for transfers. R4's fall risk assessment dated [DATE] showed R4 is at risk for falls. R4's care plan dated 6/23/20 showed, (R4) requires the use of a mechanical lift for transfers related to [MEDICAL CONDITION]. Provide 2 staff assistance for transferring. R4's care plan dated 6/24/20 showed, (R4) will tolerate total body mechanical lift transfers from surface to surface. R4's nursing progress notes dated 7/9/20 showed, Post-occurrence documentation: Resident fell on buttocks with right leg under buttocks. Assisting certified nursing assistant (CNA) attempted to use (full mechanical lift) to get resident out of bed. Resident refused to use (full mechanical lift) and to transfer to wheelchair with assistance. When resident stood up, resident immediately fell to the ground. The facility's incident report dated 7/9/20 showed R4 had no shoes on, gait imbalance, weakness and was alert and oriented to person, place, time and situation and had improper footwear on during the transfer. The facility's interview with V5 (Nursing Assistant in Training-NAT) on 7/9/20 showed, I was trying to transfer resident to wheelchair with (full mechanical lift) but resident refused to use the lift. The resident stood up and fell during the transfer landing on her buttocks. V6's (Licensed Practical Nurse-LPN) incident report showed, On 7/9/20 at about 3pm (V5) reported to the nurse that (R4) had a fall during transfer from her bed to her wheelchair. She is alert and oriented x 3 and cognitively intact and requires extensive assistance with activities of daily living. When asked what occurred she stated, CNA was helping me transfer from bed to wheelchair so she can get my weight and I felt weak and started to fall down. (R4) complained of pain to her right knee. She was assessed and x-rays were ordered and showed a distal femoral fracture. (R4) was sent to the hospital and returned with a stabilizer to her right knee to be worn at all times. V6's hospital emergency room records showed, This is an [AGE] year old woman who presents to the emergency department from (facility) for evaluation of injuries to the right knee .Reportedly patient fell earlier in the afternoon today during a transfer .computed tomography (CT) shows: Minimally displaced [MEDICAL CONDITION] femoral condyle. On 11/15/20 at 9:45AM, R4 stated, The CNA was trying to help me and I told her she can't do it by herself but she did it anyway. She didn't have a belt around me or anything. They have to move me with a (full mechanical lift) now. They were supposed to be moving me with a lift that starts in the sitting position and then raises me up with 2 people. On 11/15/20 at 12:27PM, V5 (Nursing Assistant in Training) stated, (R4) refused the (full mechanical lift) so I told the nurse and came back in her room and transferred her by myself. If a resident is not transferred as ordered, they could fall and get hurt possibly. If a resident refuses to be transferred as ordered, the nurse should be notified. You should not transfer the resident on your own if they need 2 people, you should wait for help. On 11/15/20 at 12:10PM, V6 (LPN) stated, I was the nurse working the day (R4) fell . V5 (CNA) reported to me that she had refused the (full mechanical lift) and had a fall. V5 transferred her by herself and did not notify me that (R4) had refused the (full mechanical lift). If a resident refuses to be transferred as ordered, the nurse should be notified immediately, the staff should not just transfer them however they want. On 11/15/20 at 3:30PM, V1 (Administrator) and V2 (Director of Nursing) stated, (R4) was not a full mechanical lift at the time of her fall. She was ordered to have a standing lift with 2 staff members assisting for all transfers. She should not have been transferred with just 1 staff member. On 11/16/20 at 1:13PM, V16 (facility medical director) stated, Yes, I remember talking to the facility about (R4)'s fall. I know there was a mishap during a transfer and she fell and experienced right hip and shoulder pain. Her injuries were definitely a result of her fall, there's no question about that. The facility's policy titled Transfer Techniques dated 09/2020 showed, Purpose: To safely transfer the resident from bed to chair or from one location to another .4. Obtain help when necessary, or as identified on the care plan, care card .1. Obtain equipment from designated area and bring to bedside. 2. Obtain assistance of another person, if necessary, for safe transfer. 2) R6's electronic face sheet printed on 11/16/20 showed R6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R6's facility assessment dated [DATE] showed R6 is not cognitively intact and requires 2+ staff assistance for bed mobility and bathing. R6's fall risk assessment dated [DATE] showed R6 is a fall risk. As of 11/15/20, R6's care plan did not show that R6 was a fall risk or any interventions to prevent falls for R6. R6's nursing progress notes dated 9/3/20 showed, Per CNA, she was giving (R6) a bed bath, she rolled her on her side to do perineal care and noted the patient sliding off the bed. CNA was unable to prevent the patient from sliding off the bed. (R6) was assessed and 911 was called and patient was taken to the local hospital. The facility's incident investigation for R6 dated 9/3/20 showed, No predisposing factors to fall, impaired memory and patient is nonverbal and total care/dependent. Laceration to patient's nose, hematoma and bump on left side of forehead. R6's hospital records from the local emergency room dated 9/3/20 showed, Subdural hematoma, anterior nasal bone fracture, left anterior scalp laceration and hematoma. On 11/15/20 at 2:22PM, V13 (Registered Nurse-RN) stated, (R6)'s fall happened at the beginning of my shift. V (Certified Nursing Assistant-CNA) was washing (R6)'s face and I told her to call me for help if she needed it. (R6) is a 2 assist for all cares, especially bed mobility and transfers. There was just 1 aide in the room with her. Had I known she was going to do heavier cares with (R6) I would have stayed in the room and helped her. On 11/15/20 at 3:30PM, V1 (Administrator) and V2 (Director of Nursing) stated, (R6) requires 2 staff assist for all of her activities of daily living. 2 staff members should have been assisting with her bath on 9/3/20 to prevent an accident like this happening. On 11/16/20 at 10:17AM, V14 (CNA) stated, If I am unsure of how a resident transfers or how many staff needed to care for a resident I go to the plan of care charting or ask the nurse. With (R6) she needs 2 staff members for all cares because she is completely dependent. On 9/3/20, not all of the staff had arrived for our shift yet and I knew (R6) needed a bed bath so I decided to do it on my own. When I turned her she seemed okay for a few minutes but when I let go of her and started changing the sheets, her legs began to fall off the bed. I couldn't catch her. Normally we use 2 staff members to turn her and bathe her but I didn't wait for help and I should have. On 11/16/20 at 10:35AM, V15 (Nurse Practitioner) stated, (R6)'s injuries were absolutely a result of her fall. It was an unfortunate accident and she needed an emergency room visit. She sustained a fractured nose and a brain bleed as a result of her fall on 9/3/20. On 11/16/20 at 1:13PM, V16 (facility medical director) stated, I briefly recall hearing about her falling out of the bed. Yes, her injuries were a result of her falling out of her bed. As of 11/16/20, the facility was unable to provide a policy regarding safe bed mobility or safe patient handling for bedbound residents.

This deficiency has two deficient practice statements: 1. Based on observation, interview and record review the facility failed to properly prevent the spread of infections such as COVID-19 and failed to implement infection control practices according to the Centers for Disease Control and Prevention (CDC) guidelines and facility policy on newly admitted or returning residents whose COVID-19 status was unknown, as evidenced by failures to: (A) prevent cohorting (imposed grouping of people, such as patients, potentially exposed to designated diseases) for four (R1, R2, R3 and R4) residents under monitoring due to possible exposure to COVID-19 during hospitalization with residents who were asymptomatic and confirmed negative from COVID-19; (B) ensure a nursing staff and a nurse practitioner donned appropriate personal protective equipment (PPE) per CDC's recommendation when entering the room of two (R1 and R2) residents which the facility determined should be under monitoring due to possible exposure to COVID-19 during hospitalization ; and, (C) prevent cohorting two (R1 and R2) residents with one of the residents being positive for [DIAGNOSES REDACTED] Pneumoniae (bacteria that normally live in the intestines and feces. These bacteria are harmless when they're in the intestines. But if they spread to another part of your body, they can cause severe infections). These practices resulted in an Immediate Jeopardy (IJ) to the health and safety of these residents who were at high risk of contracting the highly contagious COVID-19 and [DIAGNOSES REDACTED] Pneumoniae which may result in [MEDICAL CONDITION], serious adverse outcome and/or death. The IJ began on 5/8/20 when the facility cohorted R3 and R4 in one room after R3 was readmitted from the hospital with possible exposure to COVID-19 during hospitalization . The IJ was identified on 5/22/20. The Administrator and the Director of Nursing (DON) was notified of the IJ via telephone on 5/22/20 at 1:15pm. The IJ was removed on 5/25/20, based on the facility's implementation of an acceptable removal plan as verified on-site by the surveyor. Although the immediacy was removed, the facility remained out of compliance at the scope of pattern and a severity of potential for more than minimal harm that was not immediate jeopardy due to sustained compliance that has not been verified by the survey team and other noncompliance with infection control practices identified during the survey. Findings include: According to the Centers for Disease Control and Prevention, Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19. o All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. o Testing residents upon admission could identify those who are infected but otherwise without symptoms and might help direct placement of asymptomatic [DIAGNOSES REDACTED]-CoV-2-infected residents into the COVID-19 care unit. However, a single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. Testing should not be required prior to transfer of a resident from an acute-care facility to a nursing home. o New residents could be transferred out of the observation area or from a single to a multi-resident room if they remain afebrile and without symptoms for 14 days after their last exposure (e.g., date of admission). Testing at the end of this period could be considered to increase certainty. A. Review of R1's, R2's, R3's and R4's current [DIAGNOSES REDACTED]. Sometimes the person can have both problems. The usual exchange between oxygen and carbon [MEDICATION NAME] in the lungs does not occur. As a result, enough oxygen cannot reach the heart, brain, or the rest of the body. This can cause symptoms such as shortness of breath, a bluish tint in the face and lips, and confusion. The most concerning complication of COVID-19 is acute hypoxaemic (with abnormally low amount of oxygen in the blood, especially arterial blood) [MEDICAL CONDITION] requiring ventilation). R1, R2, R3 and R4 were all dependent on mechanical ventilator (a machine that helps a patient breathe (ventilate) when they cannot breathe on their own). Further review of the current [DIAGNOSES REDACTED]. R1, R3 and R4 also had diabetes mellitus (A disease that makes the person more susceptible to developing infections, as high blood sugar levels can weaken the person's immune system defenses. In addition, some diabetes-related health issues, such as nerve damage and reduced blood flow to the extremities, increase the body's vulnerability to infection.). 1) Review of R4's Census Record revealed that R4 had a room change on 3/20/20. R3 and R4 became roommates on 3/20/20 and continued as such until 5/5/20 when R3 was transferred to the hospital. Review of R3's Census Record revealed that R3 was readmitted to the facility on [DATE] and returned to his previous room which he shared with R4. Review of R3's current, completed and discontinued physician orders [REDACTED]. Review of R3's current care plans, including resolved and cancelled items on the care plan, revealed that there was no indication that R3 was put on contact and droplet isolation precautions when he was readmitted to the facility on [DATE]. Per CDC guidelines, R3 should have been on contact and droplet precautions from 5/9/20 until 5/22/20. Observation on 5/21/20 at 4:56pm revealed that R3 was not on any isolation precautions. Review of the Isolation Tracking Form dated 5/22/20 revealed that R3 was not on the list of residents that were on transmission based precautions. In an interview with the DON on 5/27/20 at 4:30pm, when asked about cohorting R3 and R4 on 5/8/20 when R3 returned from the hospital, the DON did not make any comment. 2) Observation on 5/21/20 at 3:28pm, revealed that R1 and R2 shared the same room. Review of R1's current, completed and discontinued physician orders [REDACTED]. Review of R1's physician order [REDACTED]. Per CDC guidelines, R1 should be on contact and droplet precautions from 5/14/20 until 5/27/20. Review of R2's Census Record revealed that R2 was admitted to the facility on [DATE] and would have been off quarantine (a period or place of isolation in which people that have arrived from elsewhere or been exposed to infectious or contagious disease are placed) and off contact and droplet precautions on 5/14/20 (the day when R1 was put on contact and droplet precautions). Review of R2's Progress Notes from 4/29/20 until 5/13/20 revealed no indication that R2's contact and droplet precautions should have been extended after 5/13/20 until R1 was cohorted with R2 in one room and caused unnecessary possible re-exposure of R2 to COVID-19. In an interview with the Administrator and the DON on 5/22/20 at 1:15pm, when asked why R1 and R2 were cohorted in one room when R2 would have been off contact and droplet precautions, the DON stated, (There was) no room available for a female ventilator. Review of R1's Progress Notes also revealed that R1 was sent to the emergency roiagnom on [DATE] for a CT (computerized tomography) scan (combines a series of X-ray images taken from different angles around your body and uses computer processing to create cross-sectional images of the bones, blood vessels and soft tissues inside your body) after a fall incident. In an interview with the DON on 5/27/20 at 4:30pm, when asked if there was a need to reset the number of days for R1 to be on contact and droplet precautions, the DON agreed and stated, It doesn't take 24 hours to get [MEDICAL CONDITION] so anyone that goes out and comes back would have to be put on contact and droplet precautions. 3) Observation on 5/21/20 at 4:56pm, revealed that R3 and R4 shared the same room. Further observation revealed that there was no isolation set-up outside of R3's and R4's room and there was no sign indicating that these residents were on contact and droplet isolation precautions. Review of R4's Census Record revealed that R4 was transferred to the hospital on [DATE], readmitted to the facility on [DATE] and returned to his previous room which he shared with R3. Review of R3's Census Record revealed that R3 was readmitted from the hospital on [DATE] and the facility failed to put R3 on contact and droplet precautions from 5/9/20 until 5/22/20. Review of R3's Progress Notes from 5/8/20 until 5/21/20 revealed no indication that R3's contact and droplet precautions (if was appropriately put in place by the facility) should have been continued after the 14-day quarantine period until R3 was cohorted with R4 in one room and caused unnecessary possible re-exposure of R3 to COVID-19. Review of R4's current care plans revealed under Focus, (R4) is with isolation precautions COVID 19 Exposure, COVID 19 [MEDICATION NAME] until 6/3/20, initiated on 5/23/20. The type of isolation precautions was not specified. Review of R4's current physician orders [REDACTED]. Review of R4's physician order [REDACTED]. Per CDC guidelines, R4 should be on contact and droplet precautions from 5/22/20 until 6/4/20. In an interview with the Administrator and the DON on 5/22/20 at 1:15pm, when asked why R3 and R4 were cohorted in one room, the DON stated, (There were) no other rooms available. Review of the facility's Interim Guidance on Admission/Readmission to Long Term Care Facilities last updated on 5/8/20 revealed under Policy, The facility is committed to reducing the spread and transmission of COVID-19 and will continue to follow all guidance and recommendations from CDC, state and local health departments. This guidance will be followed when admitting/readmitting patients from the hospital or other referral source, unless otherwise directed by their local health department. Further review of the same policy and procedure revealed under Admission Guidance - New Admissions or Returning Residents Where the COVID-19 Status is Unknown, .At time of admission, the resident will be admitted to a single room within the designated facility transition area and will remain a contact/droplet precautions for 14 days from the date of admission. Contact/droplet precautions can be discontinued, and the resident can be moved to a regular unit after 14 days providing the resident has been afebrile for 72 hours and has improvement in respiratory symptoms, if applicable . B. Review of R1's and R2's current care plans revealed that both residents were on contact and droplet isolation precautions related to possible exposure to COVID-19 during hospitalization . 1) Observation on 5/21/20 at 3:28pm, revealed that Registered Nurse (RN)1 went inside R1's and R2's (roommates) room to do his initial shift rounds. RN1 was only wearing an N95 mask. RN1 was not wearing any eye protection nor was RN1 wearing gown. In an interview with the Administrator, Assistant Administrator, DON and Nurse Consultant on 5/21/20 at 5:43pm, when told about the observation of RN1 going inside R1's and R2's room only wearing an N95 mask, the Administrator stated, (Wearing) a Mask is acceptable (if he was just doing rounds). The DON added, There's a certain amount of feet, about three feet (staff members were allowed to just wear mask). Review of the facility's Infection Prevention and Control Manual - Transmission-Based Precautions dated 2019, revealed under Droplet Precautions, .in contrast to contact transmission, respiratory droplets carrying infectious pathogens transmit infection when they travel directly from the respiratory tract of the infectious individual to susceptible mucosal surfaces of the recipient .which would require facial protection . Further review of the same policy and procedure revealed, Infectious agents for which Droplet Precautions are indicated .include .[DIAGNOSES REDACTED] (severe acute respiratory syndrome)-Associated coronavirus . The same policy and procedure indicated, .A single resident room is preferred for residents who require Droplet Precautions .The maximum distance for droplet transmission is currently unresolved, but the area of defined risk based on epidemiological findings is approximately 3-10 feet . 2) Observation on 5/21/20 at 4:59pm, revealed that the Nurse Practitioner (NP) was talking to R1 and was on a squatting position right next to R1's bed. The NP was wearing gloves, mask, goggles and hair cap but was not wearing gown. In an interview with the Administrator, Assistant Administrator, DON and Nurse Consultant on 5/21/20 at 5:55pm, when told about the observation of the NP not wearing gown while talking to R1, the Administrator stated, She should have worn a gown. Review of the facility's Infection Prevention and Control Manual - Transmission-Based Precautions dated 2019, revealed under Contact Precautions, .Healthcare personnel caring for residents on Contact Precautions should wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment . Further review of the same policy revealed under Procedure for Contact Precautions: .Gowns, 1. Don gown upon entry into the room .5. Gowns should also be worn when body contact with environmental surfaces and items in the room that may be contaminated is anticipated . C. Observation on 5/21/20 at 3:28pm, revealed that R1 and R2 shared the same room. Review of R1's current care plans initiated on 5/14/20 revealed, (R1) is receiving oral antibiotic therapy for DX (diagnosis) of Klesibella (sic) PNA (pneumonia) ([DIAGNOSES REDACTED] pneumonia is a prominent nosocomial pathogen that accounts for up to 10% of all hospital-acquired infections. It is a frequent cause of ventilator-associated pneumonia) . Review of R2's current care plans revealed that R2 did not have the same kind of infection. Review of R2's current [DIAGNOSES REDACTED]. In an interview with the Administrator and the DON on 5/22/20 at 1pm, when asked why R1 and R2 were sharing the same room when R1 was positive for [DIAGNOSES REDACTED] Pneumoniae while R2 was not, the DON stated, We don't put residents positive for [DIAGNOSES REDACTED] (Pneumoniae) on isolation precautions. According to CDC's article titled, Healthcare Facilities: Information about CRE (Carbapenem-resistant [MEDICATION NAME] - one example is [DIAGNOSES REDACTED] Pneumoniae), Carbapenem-resistant [MEDICATION NAME] (CRE) are a serious threat to public health. Infections with CRE are difficult to treat and have been associated with mortality rates of up to 50% for hospitalized patients. Healthcare facilities should: .Ensure precautions are implemented for CRE colonized or infected patients. These include: Whenever possible, place patients currently or previously colonized or infected with CRE in a private room with a bathroom and dedicate noncritical equipment (e.g., stethoscope, blood pressure cuff) to CRE patient. Have and enforce a policy for using gown and gloves when caring for patients with CRE . According to the scientific article, [MEDICAL CONDITION] Infection published in 2017 in the journal Understanding [MEDICAL CONDITION] Pathology by Richard Kradin et al, noted that [DIAGNOSES REDACTED] pneumonia generally occurs in patients who are immunocompromised due to age, [MEDICATION NAME] abuse, or diabetes mellitus. It is a common ventilator-associated pneumonia. Like the pneumococcus, [DIAGNOSES REDACTED] classically produce a lobar pneumonia, with an unexplained predilection for the upper lobes. Infection produced hemorrhagic necrosis, micro-abscesses, and cavity formation. IMMEDIACY REMOVAL: Based on observation, interview and record review, it was determined the IJ that began on 5/8/20 was removed on 5/25/20. The facility completed all items submitted on the approved IJ removal plan. The following information provided by the facility was used to determine that the Immediate Jeopardy had been removed: Interview with the DON/Infection Preventionist revealed that room changes were made to provide a single room for each of the newly admitted or readmitted residents which included R1, R2, R3 and R4. Other previous admissions were reviewed and room changes and/or transfer to other facilities and/or discharge to home were conducted to ensure that newly admitted or readmitted residents whose COVID-19 status was unknown were not cohorted with other residents. The Administrator, Medical Director, DON and the Interdisciplinary Team (IDT) conducted a review of the Admission/Readmission to Long Term Facilities; COVID-19 IDPH Interim Guidance; Transmission Based Precautions; and, Infection Control Standards according to CDC guidelines. No revisions to any existing policy and procedure were made according to the DON/Infection Preventionist. Interviews were conducted with nursing, respiratory, therapy, housekeeping and administrative staff. Each employee was asked regarding his/her understanding of the current policy and procedure to assure staff fully understood his/her responsibilities regarding infection prevention. In addition to the review of the facility's current policies and procedures, the facility's recent employee in-service provided was reviewed. Based on the review, all staff completed the mandatory training on Appropriate PPE for Contact and Droplet Precautions, Infection Control Practices, CDC's Guidelines and Facility's Infection Control Policy and Procedure with special attention to prevention of COVID-19 and other types of infection transmission. Staff Competency on Donning and Doffing PPE was also assessed. The nurse practitioner and nursing staff who were involved in the noncompliance related to PPE were provided individual education and competency assessed individually. The in-service training and staff competency assessment were started on 5/22/20 and completed for all staff by 5/25/20. The Nurse Consultant provided the in-service training and re-education of all the management employees regarding the Admission/Readmission Criteria for Long Term Care on 5/22/20. On 5/22/20, Quality Assurance Tools were developed for Admission/Readmission including Room Changes and Appropriate PPE when Entering Transmission Based Precautions Room. These QA Tools were being utilized by the Administrator and IDT on a daily basis starting on 5/22/20 and will be used daily for 60 days which will be reduced to three times per week for 30 days, then weekly for 30 days and monthly, thereafter. Random spot-checks of newly admitted or readmitted residents were being conducted to ensure compliance with the Admission/Readmission Guidelines on not cohorting residents with unknown COVID-19 status. Between 10:30am and 4:30pm, random observations of staff were conducted which revealed that all staff members were donning appropriate PPE per CDC's recommendation when they were entering residents' rooms on transmission based precautions. Random interviews of staff were also conducted which revealed that all staff members were knowledgeable of the facility's policies and procedures related to Admission/Readmission Criteria and Appropriate PPE to be Used When Entering Transmission Based Precautions Room. Random observations of residents on droplet and contact precautions revealed that the residents were not cohorted with another resident except when both residents had the same infection. 2. Based on observation, interview and record review the facility failed to properly prevent the spread of infections such as COVID-19 as evidenced by failures to: (A) follow infection control practices related to the use of glucometer (medical device used to measure sugar levels in the blood) for six (R5, R6, R7, R8, R9 and R10) residents; (B) perform hand hygiene when delivering meal tray for 17 (R9, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25 and R26) residents; (C) properly clean and disinfect a mechanical lift after resident use for three (R27, R28 and R29) residents; and, (D) ensure that pulse oximeter (medical device used to measure pulse rate and oxygen saturation level) and blood pressure (BP) cuff shared among residents were properly cleaned and disinfected after resident use for four (R30, R31, R32 and R33) residents. Findings include: A. Review of R5's, R6's, R7's, R8's, R9's and R10's current [DIAGNOSES REDACTED]. In addition, some diabetes-related health issues, such as nerve damage and reduced blood flow to the extremities, increase the body's vulnerability to infection.). 1) Observation of RN2 on 5/21/20 at 11:02am, revealed RN2 used the Assure Platinum glucometer to check R5's blood sugar in R5's room. Without using any barrier to protect the blood glucose test strip case and glucometer from contamination by the surface of R5's over-bed table, RN2 sat the glucometer and blood glucose test strip case on R5's over-bed table. After checking R5's blood sugar, RN2 went back to the medication cart and sat the glucometer and blood glucose test strip case on top of the medication cart without using a barrier. RN2 wiped the glucometer with a Clorox Healthcare Hydrogen Peroxide wipe for eight seconds. Using the same wipe, RN2 wiped the blood glucose test strip case for three seconds and sat both the glucometer and the blood glucose test strip case on top of the medication cart without using any barrier. The blood glucose test strip case and the glucometer were visibly wet for approximately 10 seconds after RN2 wiped them with the disinfecting wipe. 2) Observation of RN2, on 5/21/20 at 11:10am, revealed RN2 used the unsanitized Assure Platinum glucometer to check R6's blood sugar in R6's room. Without using any barrier to protect the glucometer and blood glucose test strip case from contamination by the surface of R6's over-bed table, RN2 sat the glucometer and blood glucose test strip case on top of the over-bed table. After checking R6's blood sugar, RN1 went back to the medication cart and sat the glucometer and blood glucose test strip case on top of the medication cart without using a barrier. RN2 wiped the glucometer with a Clorox Healthcare Hydrogen Peroxide wipe for 10 seconds. Using the same wipe, RN2 wiped the blood glucose test strip case for three seconds and sat both the glucometer and blood glucose test strip case on top of the medication cart without using any barrier. The blood glucose test strip case and the glucometer were visibly wet for approximately 10 seconds after RN2 wiped them with the disinfecting wipe. 3) Observation of RN3, on 5/21/20 at 11:15am, revealed RN3 used the Assure Platinum glucometer to check R7's blood sugar in R7's room. After checking R7's blood sugar, RN3 went back to the medication cart and RN3 wiped the glucometer with the Clorox Healthcare Hydrogen Peroxide wipe for 10 seconds. The glucometer was visibly wet for approximately 15 seconds after RN3 wiped it with the disinfecting wipe. 4) Observation of RN3 on 5/21/20 at 11:23am, revealed RN3 used the Assure Platinum glucometer to check R8's blood sugar in R8's room. Without using any barrier to protect the glucometer from contamination by the surface of R8's over-bed table, RN3 sat the glucometer case on top of the over-bed table. After checking R8's blood sugar, RN3 went back to the medication cart and wiped the glucometer with the Clorox Healthcare Hydrogen Peroxide wipe for five seconds. The glucometer was visibly wet for approximately 15 seconds after RN3 wiped it with the disinfecting wipe. 5) Observation of Licensed Practical Nurse (LPN)1, on 5/21/20 at 11:34am, revealed LPN1 used the Assure Platinum glucometer to check R9's blood sugar in R9's room. After checking R9's blood sugar, LPN1 went back to the medication cart and wiped the glucometer with the Clorox Healthcare Hydrogen Peroxide wipe for 10 seconds. The glucometer was visibly wet for approximately 10 seconds after LPN1 wiped it with the disinfecting wipe. LPN1 sat the glucometer on top of the medication cart without using any barrier. 6) Observation of LPN2, on 5/21/20 at 11:39am, revealed LPN2 used the Assure Platinum glucometer to check R10's blood sugar in R10's room. After checking R10's blood sugar, LPN2 went back to the medication cart and wiped the glucometer with the Clorox Healthcare Hydrogen Peroxide wipe for 10 seconds. The glucometer was visibly wet for approximately 10 seconds after RN3 wiped it with the disinfecting wipe. In an interview with the Administrator, Assistant Administrator, DON and Nursing Consultant on 5/21/20 at 5:11pm, when told about the observation of nursing staff sitting the glucometer and blood glucose test strip case on residents' over-bed tables and medication cart without using any barrier, the Nursing Consultant stated, There should be a barrier (between surfaces and the glucometer and blood glucose test strip case). When asked about the contact time (also known as the wet time and the time that the disinfectant needs to stay wet on a surface in order to ensure efficacy) of the Clorox Healthcare Hydrogen Peroxide wipe, the Nurse Consultant stated, Our policy says one minute. Review of the facility's Assure Platinum Blood Glucose Monitoring policy and procedure dated 3/20 revealed under Procedure: .12. After each use clean/disinfect outside of the meter with disinfectant wipes: a. All surfaces of Blood Glucose Monitoring Machine if visibly soiled need to be physically cleaned to remove gross soil with one wipe and then a second wipe to disinfect the surface; b. If using Clorox Hydrogen Peroxide Cleaner Disinfectant wipes or Oxivir 1, treated surface of the Blood Glucose Monitoring Machine (must) remain visibly wet for a full 1 minute. Use additional wipes if needed to assure continuous 1 minute wet contact time. Allow to air dry . Further review of the same policy and procedure revealed that the policy did not address the use of a barrier or liner for the glucometer to protect it from contamination from environmental surfaces. According to a Centers for Disease Control and Prevention (CDC) article titled, Guidelines for Environmental Infection Control in Health-Care Facilities published on 6/6/03 under Recommendations - Environmental Services on subsection Cleaning and Disinfecting Strategies for Environmental Surfaces in Patient Care Areas, .3. Use barrier protective coverings as appropriate for noncritical surfaces that are 1) touched frequently with gloved hands during the delivery of patient care; 2) likely to become contaminated with blood or body substances . B. Review of the current [DIAGNOSES REDACTED]. Review of R16's and R26's current [DIAGNOSES REDACTED]. 1) Observation of nursing assistant (NA)1 on 5/21/20 at 11:50am revealed that NA1 was delivering a meal tray to R11's, R12's, R13's, R14's, R15's, R16's, R17's and R18's rooms. Further observation revealed that NA1 entered these residents' rooms and assisted in setting up the lunch trays on residents' over-bed tables. NA1 went in and out of the residents' rooms without performing hand hygiene. 2) Observation of the Unit Manager on 5/21/20 at 11:50am revealed that the Unit Manager was delivering a meal tray to R9's, R19's and R20's rooms. Further observation revealed that the Unit Manager entered these residents' rooms and assisted in setting up the lunch trays on residents' over-bed tables. The Unit Manager went in and out of the residents' rooms without performing hand hygiene. In an interview with the Unit Manager on 5/21/20 at 2:31pm, when asked about the need to perform hand hygiene in between rooms when delivering meal tray to residents' rooms, the Unit Manager stated, I forgot to do it. 3) Observation of NA2 on 5/21/20 at 11:50am revealed that NA2 was delivering a meal tray to R21's, R22's, R23's and R24's rooms. Further observation revealed that NA2 entered these residents' rooms and assisted in setting up the lunch trays on residents' over-bed tables. NA2 went in and out of the residents' rooms without performing hand hygiene. 4) Observation of NA3 on 5/21/20 at 11:50am revealed that NA3 was delivering a meal tray to R25's and R26's rooms. Further observation revealed that NA3 entered these residents' rooms and assisted in setting up the lunch trays on residents' over-bed tables. NA3 went in and out of the residents' rooms without performing hand hygiene. In an interview with the DON, Nurse Consultant, Administrator and Assistant Administrator on 5/21/20 at 5:21pm, when asked of their expectations of nursing staff when delivering meal tray to residents' rooms, the DON stated, (Nursing staff should perform) hand hygiene in between rooms. Review of the facility's Hand Washing and Hand Hygiene policy and procedure dated 3/19 revealed under Purpose: Appropriate hand hygiene is essential in preventing the spread of infectious organisms in healthcare settings. Further review of the same policy and procedure revealed, 1. Hand hygiene must be performed after touching .contaminated items. Specific examples include but are not limited to: .c) Before touching medication or food to be given to a resident .g) After touching any item or surface that may have been contaminated with blood or body fluids, excretions or secretions . C. Review of the current [DIAGNOSES REDACTED]. Further review of the current [DIAGNOSES REDACTED]. Sometimes the person can have both problems. The usual exchange between oxygen and carbon [MEDICATION NAME] in the lungs does not occur. As a result, enough oxygen cannot reach the heart, brain, or the rest of the body. This can cause symptoms such as shortness of breath, a bluish tint in the face and lips, and confusion. The most concerning complication of COVID-19 is acute hypoxaemic [MEDICAL CONDITION] requiring ventilation). R27 and R28 were both dependent on respirator (ventilator - a machine that takes over the body's breathing process when disease has caused the lungs to fail and provides mechanical ventilation by moving b (TRUNCATED)

Based on interviews and record reviews, the facility failed to notify the doctor of a resident's chest x-ray results, which read [MEDICAL CONDITION] venous congestion. This affected 1 out of 5 residents (R2) reviewed for improper nursing care. This failure resulted in delayed care of R2 who died , with one of the causes of death, being acute [MEDICAL CONDITION]. Findings include: Record review of R2's face sheet reads medical [DIAGNOSES REDACTED]. R2's care plan reads a potential to develop [MEDICAL CONDITION] (swelling) and weight gain related to R2's [DIAGNOSES REDACTED]. Progress note effective [DATE] 9:20 PM written by V20 (Nurse Practitioner) reads R2's renal function was worsening and there were concerns for weight gain and fluid retention. V20 informed R2 the need for daily weights due to these concerns. Review of R2's weights read the most recent weight was 242.8 pounds taken on [DATE]. The previous weight recorded was 200.2 pounds which was taken on [DATE]. Warning notation reads greater than 10% weight change. On [DATE] at 10:00 AM, V20 stated a 42.6 pound weight gain in 10 days is concerning. V20 stated she would be worried about R2 having shortness of breath or having respiratory distress. Progress note dated [DATE] 10:00 AM ,written by V5 reads; R2's oxygen saturation was at 77% (normal reference range of ,[DATE]%). V5 received orders to place R2 on oxygen and to obtain a chest x-ray. Chest x-ray done on [DATE] reads an impression of cardiomegaly and changes consistent with [MEDICAL CONDITION] venous congestion. On [DATE] at 10:00 AM, V20 stated [MEDICAL CONDITION] venous congestion means fluid overload impending [MEDICAL CONDITION] due to fluids in the lungs. V20 stated R2 needed diuretics to remove the extra fluid. Progress note dated [DATE] 11:08 PM written by V19 (Nurse) reads V25 (R2's Attending Physician) was paged to relay the chest x-ray results; however, V25 did not return the page. V19 wrote she was going to endorse the results to the oncoming nurse. On [DATE] at 3:00 PM, V27 (Nurse) stated he did not receive report about relaying chest x-ray results to V25. V27 stated he did not call V25 on [DATE] about any results. On [DATE] at 11:23 AM, V25 stated he does not remember the facility notifying him of the chest x-ray results. V25 stated based on findings, he would have prescribed diuretics or sent R2 to the hospital. V25 stated water in the lungs is consistent with water gain and retention which can contribute to respiratory distress. V25 stated respiratory distress may not happen within minutes but can take a couple or few days to occur. V25 stated if left untreated a patient will develop respiratory distress. On [DATE] at 3:46 PM, V17 (Nurse) stated she heard R2 calling for help the morning of [DATE]. V17 stated R2 was asking to be sat up in bed because R2 felt short of breath. Per V17's progress note of the incident, R2 was agitated and requested to be repositioned promptly. V17 stated R2 was anxious and screaming to be repositioned faster. After being repositioned, V17 stated R2 suddenly dozed off and was unresponsive. V17 stated a code blue was called and emergency services arrived at the facility but, unfortunately, R2 expired. Record review of R2's Certificate of Death Worksheet reads one of the causes of death being acute [MEDICAL CONDITION].

Based on observations, interviews and record reviews, the facility failed to follow physician's orders to weigh a resident, failed to notify the physician that weights were not done, and failed to notify the physician of the resident's significant weight gain. This affected 1 out of 5 residents (R2) reviewed for improper nursing care. This failure resulted in delayed care of R2 who gained 42.6 pounds in 10 days and died with one of the causes of death being acute [MEDICAL CONDITION]. Findings include: Record review of R2's face sheet reads medical [DIAGNOSES REDACTED]. R2's care plan reads a potential to develop [MEDICAL CONDITION] (swelling) and weight gain related to R2's [DIAGNOSES REDACTED]. Progress note effective [DATE] 9:20 PM, written by V20 (Nurse Practitioner) reads R2's renal function was worsening and there were concerns for weight gain and fluid retention. V20 informed R2 the need for daily weights due to these concerns. Record review of R2's physician orders read the following orders: - One (time) weight, call MD with results in the morning for 1 Day swollen extremities which was ordered on [DATE] to start [DATE] - Check weight and relay to MD every day shift for 1 Day which was ordered on [DATE] to start [DATE] - (Weight) for 2 days every day shift for 2 Days which was ordered on [DATE] to start [DATE] Review of R2's weights read the most recent weight was 242.8 pounds taken on [DATE]. No weights were taken on [DATE], [DATE] and [DATE]. The previous weight recorded was 200.2 pounds which was taken on [DATE]. Warning notation reads greater than 10% weight change. Progress note effective [DATE] 4:35 PM, written by V5 (Nurse) reads weight for [DATE] was not done because the scale did not work. On [DATE] at 2:30 PM, V5 stated R2 needed to be weighed because R2 was noticeably puffy around the eyes and face. V5 stated R2 wasn't weighed because scale was broken. V5 stated she does not remember notifying the doctor that the weights were not done. V5 also stated she does not remember notifying the doctor of R2's weight on [DATE]. V5 stated if actions were not charted, then it was not done. On [DATE] at 11:48 AM, V3 (Director of Nursing) and V4 (Assistant Director of Nursing) showed surveyor facility's two wheelchair scales. Both stated no instance where both scales were broken. V3 stated if one scale was broken, resident can be weighed using the other scale. On [DATE] at 12:16 PM, V3 stated facility also has a mechanical lift with a scale that can be used if needed. On [DATE] at 11:23 AM, V25 (R2's Attending Physician) stated he does not recall the facility notifying him of R2's weight gain. V25 stated he would have sent R2 to the hospital to get R2 [MEDICATION NAME] and evaluated by the kidney doctor. V25 stated with that amount of weight gain it is concerning and the patient needs to go to the hospital. On [DATE] at 10:00 AM, V20 stated R2 had abdominal distention and appeared to be gaining weight. V20 stated she was not notified that R2's weights were not done. V20 also stated that she was not notified of R2's documented weight gain. V20 stated a 42.6 pound weight gain in 10 days is concerning. V20 stated if she was notified of the weight gain, she would have ordered for R2 to go to the hospital. V20 stated she would be worried about R2 having shortness of breath or having respiratory distress. Progress note dated [DATE] 10:00 AM written by V5 reads R2's oxygen saturation was at 77% (normal reference range of ,[DATE]%). V5 received orders to place R2 on oxygen and to obtain a chest x-ray. Chest x-ray done on [DATE] reads an impression of cardiomegaly and changes consistent with [MEDICAL CONDITION] venous congestion. On [DATE] at 10:00 AM, V20 stated [MEDICAL CONDITION] venous congestion means fluid overload impending [MEDICAL CONDITION] due to fluids in the lungs. V20 stated R2 needed diuretics to remove the extra fluid. On [DATE] at 11:23 AM, V25 stated water in the lungs is consistent with water gain and retention which can contribute to respiratory distress. V25 stated respiratory distress may not happen within minutes but can take a couple or few days to occur. V25 stated if left untreated a patient will develop respiratory distress. On [DATE] at 3:46 PM, V17 (Nurse) stated she heard R2 calling for help the morning of [DATE]. V17 stated R2 was asking to be sat up in bed because R2 felt short of breath. Per V17's progress note of the incident, R2 was agitated and requested to be repositioned promptly. V17 stated R2 was anxious and screaming to be repositioned faster. After being repositioned, V17 stated R2 suddenly dozed off and was unresponsive. V17 stated a code blue was called and emergency services arrived at the facility but unfortunately R2 expired. Record review of R2's Certificate of Death Worksheet reads one of the causes of death being acute [MEDICAL CONDITION]. Facility policy titled 'Weights' reads: Residents will be weighed to establish baseline weights and identify trends of weight loss or weight gain. It continues to read: 3. Report to nursing supervisor, physician/NP, dietary supervisor, RD consultant and family/responsible party of any weight loss or gain greater than 5% within one (1) month, 7.5% within three (3) months or 10% within six (6) months. 4. Notification to the attending physician/NP and family/responsible party in regard to the above will be documented in the medical record.

Based on interviews and record reviews, the facility failed to notify the doctor or nurse practitioner that a resident (R2) with a high potassium level refused SPS (Sodium [MEDICATION NAME]) Suspension, a medication used to lower potassium levels. This affected 1 out of 7 residents (R2) reviewed for medications. This failure resulted in delayed care of R2 who died with one of the causes of death being severe [MEDICAL CONDITION] (elevated potassium levels.) Findings include: Record review of R2's face sheet reads medical [DIAGNOSES REDACTED]. R2's care plan reads a potential to develop electrolyte imbalance related to R2's [DIAGNOSES REDACTED]. On [DATE] at 10:00 AM, V20 (Nurse Practitioner) stated due to R2's kidney function, R2's potassium levels were elevated. V20 stated she was ordering [MEDICATION NAME] to treat R2's high potassium levels. Review of R2's physician order [REDACTED]. According to R2's lab reports, R2 had a high potassium level of 5.8 MEQ/L (normal reference range of 3XXX,[DATE].1 MEQ/L) on [DATE]. Review of R2's physician order [REDACTED]. Progress note effective [DATE] 11:15 PM written by V19 (Nurse) reads R2 refused the medication. On [DATE] at 4:03 PM, V19 stated she did not remember calling V25 (R2's Attending Physician) or V20 to inform them that R2 had refused the ordered medication. V19 stated she would have charted it if she notified V25 or V20. Progress notes do not read V19 informed V25 or V20. Interviewed V5 (Nurse) on [DATE] at 2:30 PM with V3 (Director of Nursing) as witness. V5 stated if a patient refuses a medication, the nurse is to mark it as refused in the Medication Administration Record [REDACTED] On [DATE] at 10:00 AM, V20 stated she would have charted in her progress notes if she was notified that R2 refused the medication on [DATE]. V20 stated she evaluated R2 the following day and did not write it in her progress note. V20 stated she would have ordered another dose of [MEDICATION NAME] or diuretic. V20 stated she would have advised the facility to send R2 to the emergency room if R2 refused. V20 stated R2 would have to go to the hospital for cardiac monitoring because high potassium levels can cause irregular heart rhythms and death. On [DATE] at 11:23 AM, V25 stated he was aware R2 was refusing doses of [MEDICATION NAME] but could not remember if the facility informed him of R2's refusal of the medication on [DATE]. V25 stated the care team has to try medications in the facility. If that doesn't work, then R2 has to go to the hospital because with a high potassium level of 5.8, R2 cannot be cared for at the nursing home level. On [DATE] at 3:46 PM, V17 (Nurse) stated she heard R2 calling for help the morning of [DATE]. V17 stated R2 was asking to be sat up in bed because R2 felt short of breath. Per V17's progress note of the incident, R2 was agitated and requested to be repositioned promptly. After being repositioned, V17 stated R2 suddenly dozed off and was unresponsive. V17 stated a code blue was called and emergency services arrived at the facility but unfortunately R2 expired. Record review of R2's Certificate of Death Worksheet reads one of the causes of death being severe [MEDICAL CONDITION] (high potassium levels).

Based on observation, record review and interviews the facility failed to promote wound healing and prevent further skin breakdown for (R22) one of three residents reviewed for pressure sores/ulcers in a sample of 23 residents. As a result of this failure R22 was hospitalized with soiled, red, painful, excoriated skin and soiled dressings. Findings Include: R22 is a [AGE] year old female had a [DIAGNOSES REDACTED]. R22 had multiple stage 2 and Stage 3 pressure ulcers on the sacrum, left and right thighs. R22 was able to make her needs known and was very pleasant according to facility staff. On August 17, 2012 at 9:00 am during an interview with E5 (staff nurse); "on June 22, 2012 at 8:30 a.m. (R22) appeared to be very tired". E5 stated that (R22) " always seems to have pain on her left side, intense phantom pain from her amputation". E5 stated she went to take R22's blood pressure at about 11:00 a.m. and noticed that (R22) kept calling her nurse instead of her name. E5 stated this was very unusual because (R22) knew her by name. R22's blood pressure was 80/50 and had a low grade fever of 99.6. E5 stated she went to call Z3 (Physician Assistant -PA) to report the change in condition of (R22). On June 22, 2012 at 2:00 p.m. R22 arrived by ambulance to the local hospital emergency room (ER). (R22) was admitted to the hospital with [REDACTED]. On July 26, 2012 at 10:00 a.m. during a telephone interview, Z2 (ER nurse) stated she observed and completed the head to toe assessment for R22 on June 22, 2012 at 3:33 p.m. Z2 stated that R22 was confused, had excoriated skin to bilateral buttocks, hip right side, and right leg. there were layers of barrier cream with pustulant drainage noted of a yellowish, green color. The skin did not appear to have been cleaned between applications of barrier cream. R22's skin was excoriated, red and painful; there was bleeding from the cracked skin with multiple layers of barrier cream surrounding it. R22 had additional small areas of excoriation to the left anterior hip. R22 had a left upper anterior leg dressing that was soiled with a moderate amount of drainage and a foul odor and the resident complained of pain to the left leg where the dressing was. R22 has a stage 3 pressure ulcer to the right lower lateral leg. The wound was covered with a non adhesive dressing and abdominal pad with small amounts of reddish and yellowish drainage was noted. R22 had a Stage 3 and a stage 2 sacral pressure wound also. Review of facility's TAR (Treatment Administration Record) for (R22) stated to change dressings to wounds daily and as needed. Facility's TAR for May, June and July showed that the treatments for R22 was signed off as done.