Every finding on record at Alden Estates of Orland Park

Based on interview and record review, the facility failed to prevent fall incidents and failed to provide safe transfer using a mechanical lift equipment. This deficient practice affects R2 of three residents reviewed for fall incidents.Findings Include:R2 is a [AGE] year-old female resident with diagnoses but not limited to: Morbid Severe Obesity, Vascular Dementia, Depression, Anxiety and Hypertension. BIMS (Bried Interview for Mental Status) of 9/15 (Moderate Cognitive Impairment). R2's fall incident on 4/23/26 at 2015PM, reads in part: Nurse walked into the room and saw R2 laying on the floor on her left side with a pillow under her head sling pads underneath R2. extremities were laid on her left side. Did not notice any injuries but R2 complaining of her back and head hurting. Nurse contacted doctor and left a voicemail. Nurse also tried to perform range of motion but R2 was laid on her left side. Nurse called Director of Nursing right away and was told to send the R2 to hospital.On 5/20/26 at 12:10PM, V7 (Assigned Nurse to R2 on 4/23/26) stated that V7 heard noise coming from R2's room, when V7 entered in R2's room, R2 had already fallen and was on the floor. 2 CNAs was with R2. V7 stated she called 911 and stayed with R2 until paramedics arrived in the facility.On 5/21/26 at 10:35AM, V17 (CNA) stated we tried to calm down R2, R2 would calm down for a little bit and start screaming and moving again. We put the sling on the mechanical lift, V14 stood on one side of the bed. V17 operated the mechanical lift. Stated that R2 is a heavy resident and hard to position, so the other CNA (V14) was guiding R2 during the transfer. R2 was calm for a little bit, for about a minute and when we lifted off from chair and onto trying to position R2 in the middle of the bed, R2 started trying to reach for the top of the mechanical lift (the area where the sling connects). When placing and moving towards the middle of the bed, R2 was already holding on the top part of the mechanical lift (where the sling connects). R2 was still hanging as we tried placing the sling and R2 in the middle of the bed, so when we lower the mechanical lift down, R2 could be in the middle. We tried to calm R2 down, R2 continued to scream for help. We reminded R2 we are almost done and that we just need to lower R2. R2 continued with the behavior, sling was swinging in mid-air. R2 was moving a lot and the whole body was swinging in mid-air.The mechanical lift moved and started tilting and V17 tried to hold the mechanical lift, but the lift continued to tilt on the side. R2 fell on the bed and mechanical lift fell in the corner of the bed. Mechanical lift started sliding down and it pulled R2 along with mattress. Mechanical lift was tilted but stayed on the bed frame. V14 and V17 were able to hold the bed, and we were about to call the nurse, and the nurse already heard the incident and came to the room.R2 and mechanical lift sling were still connected to the machine when it fell. On 5/21/26 at 1:00PM, V2 (DON) stated V1 (Administrator) did thorough investigation of the incident, and what V2 knows is that the staff were transferring R2 and the lift appropriately positioned under the bed and R2 was at the time above the bed and became agitated and started moving around. R2 is heavy set, the weight of her movement started the mechanical lift from tipping. Machine's legs were under the bed frame and as R2 moved around, the mechanical lift started tilting and lifting the bed frame off the floor and R2 landed on the mattress then slid to the floor with the mattress. For what I know she was not agitated enough for the transfer not to happen. If we waited for her, she would not have been transferred because she screamed a lot.On 5/21/26 at 1:30PM, V1 (Administrator) stated R2 was in her chair and got attached to the lift. They lifted out of the chair and R2 was position over the bed. Mechanical legs were positioned under the bed, and the R2 was directly on top of the bed. V17 (CNA) was in control of the mechanical lift and V14 (CNA) had walked around on the other side of the bed to spot R2. Just as V14 started walking to go on the other side. R2 started thrusting around and throwing her arms and legs, flailing her arms and legs, yelling I want water. V17 stated the mechanical lift begin to tip and V17 tried to grab the mechanical lift to keep it upright but R2's weight carried R2 towards the foot of the bed. Back leg of the mechanical lift machine lifted the head of the bed. R2 landed on the foot of the bed, landed on the bed mattress first. The mattress broke R2's fall. The pressure of R2's falling on the bed and the mechanical lift leg lifting the head of the bed, R2 seesawed the bed upright and R2 rolled over from the foot of the bed to the floor.R2's has a care plan for At Risk for Falls due to cognitive deficits and functional deficits (date Initiated 10/25/22) with interventions of Assess resident for anxiety and agitation prior to transfer (Date Initiated: 4/24/26).Hospital record dated 4/23/26, reads in part: R2 to Emergency Department from facility after falling out of mechanical lift. R2 states fell on the right side and hit her head. Complaint of right sided head and back pain. Denied loss of consciousness. Per EMS, R2 received Ativan prior to being put in to Mechanical Lift.Management of Falls policy dated 8/2020 reads in part: 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 in order to minimize the risk for fall incidents and/or injuries to resident.Develop plan of care to include goals and interventions which address resident risk factors. Risk factors may include but are not limited to the following: Contributing diagnoses/disorders/disease processes/active infections/other comorbidities, history of fall incidents, Incontinence, Medications (Narcotics, Antihypertensive, etc.) assistance required with ADL's gait/transfer/balance issues, behaviors and/or cognitive status.Provide assistive devices for mobility, hearing and vision as appropriate for the residents.Fall Management Program dated 8/2020 reads in part: The facility is committed to minimizing resident falls and/or injury so as to maximize each resident's physical, mental and psychosocial well-being. While preventing all residents fall is not possible, it is the facilities policy to act in a proactive manner to identify and assess those residents at risk for fall, plan for preventive strategies and facilitate a safe environment.

Based on interviews and record reviews, the facility failed to provide adequate supervision and fall prevention measures for one resident (R11) with advanced dementia, resulting in a preventable accident. This affected one of three residents (R11) reviewed for supervision, monitoring and avoidable accidents. This failure resulted in R11 propelling to an emergency door exit door opening the door and falling down a flight of stairs sustaining a right femur fracture and left humerus fracture.Findings include: On 4/3/26 at 10:48 AM, V11 (nurse) stated that V12 CNA (certified nurse aide) got R11 up at 5:00 AM on 3/23/26. V11 stated that V12 brought R11 to the nurses' station. V11 stated that he was rounding on residents at that time. V11 stated that R11 self-propelled wheelchair down the middle hallway and exited the unit by the emergency exit. V11 stated that he heard the door alarm sound, and he went searching for where alarm coming from. V11 stated that R11 was found at the bottom of stairs with wheelchair. V11 stated that R11 needs constant re-direction when in wheelchair. V11 stated that there weren't any fall precautions in place for R11. V11 stated that the residents of this nursing unit have dementia and Alzheimer's disease.On 4/3/26 at 11:43 AM, V12 CNA stated that R11 was trying to get out of bed without assistance on 3/23. V12 stated that R11 is a fall risk so she got R11 dressed, transferred to wheelchair, and brought R11 to the nurses' station. V12 stated that everybody was rounding so no one was at nurses' station monitoring residents. V12 stated that when she heard the alarm, she checked the stairwell and found R11 at bottom of stairs with wheelchair.R11's hospital record, dated 3/23/26, notes R11 presented to the emergency room after unwitnessed fall down flight of stairs. R11 unable to tolerate left arm being moved. R11 with diffuse bruising. X-ray of right femur shows comminuted fracture of the distal femur extending to the joint space. X-ray of left humerus shows comminuted humeral head and neck fracture with mild displacement of the distal fragment anteriorly. R11 underwent surgical repair of right femur fracture.R11's falls report, dated 3/23/26, notes R11 was observed in supine position with wheelchair over lower extremities in the emergency stairwell. Upon assessment, R11 noted to be grimacing and guarding extremities. R11's orientation is x 1 with memory impairment, consistent with baseline cognition. R11 has predisposing factors including but not limited to impaired memory, poor safety awareness, and weakness.R11's falls care plan, dated 3/10/26, notes R11 is at risk for falls, history of fall, weakness, impaired cognition, use of assistive device, use of narcotic medication, and use of psychotropic medication.R11's cognitive care plans note R11 with impaired cognitive functioning related to advanced vascular dementia and history of stroke resulting in significant cognitive decline. R11 exhibits unpredictable behaviors and actions. R11 has deficits in short term/long term memory and ability to make decisions. R11 has difficulties in effectively communicating her needs and at times does not reflect signs of comprehension or understanding during simple communications.

Based on interview and record review, the facility failed to provide a cognitively impaired resident with known exit seeking behaviors, adequate supervision to prevent resident from eloping. This failure affected one (R75) of 14 residents wearing an electronic alert band in the total sample of 71 residents. This failure resulted in R75 walking out the front door of the facility unsupervised and the facility unaware R75 was missing until R75 was returned to the facility by local police who saw R75 walking alone on the street. The facility also failed to follow policy procedures and failed to implement fall prevention interventions for three (R27, R61, R132) of 71 residents in the sample reviewed for falls. This past noncompliance occurred from 09/08/2025 to 09/12/2025 This was identified as an immediate jeopardy which began on 09/08/2025 at 2:30am when R75 was last seen by staff. V1 (Administrator) was informed of the immediate jeopardy, and a template was presented on 03/16/2026 at 2:26pm. The survey team confirmed by observation, interviews, and record reviews that the Immediate jeopardy was removed on 09/12/2025 when the facility initiated corrective actions to remove the immediacy. This is being cited as past non-compliance. Findings include: #1 The (09/08/2025) List of residents on electronic alert band documented there were 14 residents on electronic alert band which include R75. R75's (08/01/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 6. Indicating R75's mental status as severely impaired. Section I - Active Diagnoses. Neurological. Other. I8000. A Dementia. C. Arthritis. D. Long Term use of Aspirin. R75's (05/11/2025) Nurses Note documented, in part electronic alert band applied to rt (right) ankle per MD orders d/t (due to) exit seeking behavior. Resident w/ (with) increased confusion. Verbal consent obtained via telephone for electronic alert band placement. Authored by: V52 (Former Registered Nurse) R75's (Date Initiated: 05/11/2025) care plan documented, in part Focus: is at-risk for elopement related to cognitive impairment, exit-seeking behavior, making comments regarding leaving the facility, physical ability to leave unit/facility, wandering behavior. Goal: Wil safely remain on unit or off under supervision. Intervention: Utilize electronic alert band as appropriate. R75's (07/08/2025) Exit Seeking/Wandering/Elopement Risk Assessment documented that R75 is at risk for elopement. R75's (09/08/2025 at 5:01am) progress note documented, in part The police brought resident to the facility at 3:36 am. Writer was told by the police that resident was located outside the facility at 3:00(am) at 97th avenue. Writer notified (V51 -Primary Care Physician/Medical Director) on-call service and (V58 – R75's family member) of the incident. The facility was unaware that the resident left the building. On 03/12/2026 at 9:30am, on 97th Avenue, facing the facility, there were 2 monument signs standing one on each side of the driveway that leads to the front of the facility. Behind the right monument sign was an ungated pond with sidewalk; the pond was adjacent to a residential building. Across the street was a movie theatre. On 03/12/2026 at 11:50am, V44 (Social Services Director) stated her elopement risk care plan was initiated on 5/11/2025. She was making comments about wanting to leave the facility. She (R75) was kind of wandering at the facility. On 03/12/2026 at 12:13pm, V44 handed R75's 5/11/2025 progress noted to this surveyor and stated it was a nurse who observed her (R75)'s exit seeking behavior. On 03/12/2026 at 5:10pm, V52 (Former Registered Nurse) stated she could not remember the incident. This surveyor read the progress note written by V52 on 05/11/2025. V52 stated she could not remember the exit seeking behavior, but she wrote the progress note because she (V52) observed the exit seeking behavior. On 03/09/2026 at 11:57am, R75 stated she did not know how to get to the parking lot, she has no reason to go there. R75 stated her family take turns visiting her and they usually sit in the dining room. R75 stated she never walked out of the facility alone. On 03/14/2026 at 9:07am, V45 (Certified Nursing Assistant) stated she just finished doing patient care with another resident and she was walking toward the soiled linen room when the nurse told her (R75) got out. Inquiring while she was walking towards the soiled linen room if she heard the alarm went off. V45 stated she did not hear the alarm went off because the double doors were closed. V45 stated the sound of the alarm was between the double doors. V45 stated, she did not hear it. V45 stated when the nurse told her (R75) got out., she (R75) was already back in her room. V45 stated the last time she saw her (R75) was between 2:15am and 2:30am on 09/08/2025; she was lying down on her bed, and her eyes were closed. V45 stated she (R75) was sleeping. V45 reiterated she did not hear the alarm went off because the double doors were closed. On 03/12/2026 at 10:11am, V42 (Former Licensed Practice Nurse) stated all she could remember was she was attending to another resident, and the police came to the front desk. V42 stated the police asked if she knew the resident (R75). She stated, Yes and the police told her she was found outside of the facility. V42 stated she was not aware the resident left the facility. On 3/11/2026 at 1:15pm, V1 (Administrator) confirmed that R75 left the facility without the facility's knowledge. V1 affirmed that the root cause of the incident was that the electronic alert alarms could not be heard at the nurse's station. On 03/16/2026 at 1:45pm, V1 stated when they installed the electronic alert system and checked for the sound of the alarm, she was standing between the double doors, and she could hear the alarm. Inquiring if anyone thought of checking for the sound of the alarm outside of the double doors. V1 stated no one had thought about it. On 03/12/2026 at 11:50am, V44 (Social Services Director) stated her elopement risk care plan was initiated on 5/11/25. She (R75) was making comments about wanting to leave the facility, she was kind of wandering at the facility. Surveyor inquired if resident was able to elope, were the interventions in place effective. V42 stated it was not effective. Inquiring about the risk and danger posed to R75 who was cognitively impaired and who was able to elope from the facility. V44 stated she (R75) could be hit by a car because the facility is in the middle of residential areas and she could have drowned in the pond; there is an ungated pond close to the facility. On 03/12/2026 at 1:13pm, V51 (R75's Primary Care Physician/Medical Director) stated he was familiar with the resident. V51 stated he was made aware by the facility that she (R75) eloped. V51 stated she has cognitive issues, and the facility has a system in place for residents with elopement risk. This surveyor inquired if a resident was able to elope, was the system in place effective? V51 stated it was discussed during the meeting and there have been changes the facility made. V51 stated the changes the facility made are effective. Inquiring about a resident who was cognitively impaired and was able to elope, what are the risks or dangers to this resident when she was outside of the facility without supervision. V51 stated there are a lot of danger out there. V51 stated she (R75) could be hit by a car, she could get stuck outside, she could freeze. V51 stated there's a lot of risk factors. On 03/17/2026 at 3:29pm, V1 (Administrator) stated she cannot speculate as to what could have happened to her (R75). The (11.2023) electronic alert system documented, in part POLICY: Electronic alert system may be utilized and maintained to mitigate elopement risk. PROCEDURE: 11) Testing protected doors/elevators will be conducted weekly and after power outages. The (09.2020) Incident/accident Reports documented, in part POLICY: The Incident/Accident Report is completed for all unexplained bruises or abrasions, all accidents or incidents where there is injury or the potential to result in injury, allegations of theft and abuse registered by residents, visitors or other, and resident-to-resident altercations. 15. Facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The Immediate Jeopardy that began on 09/08/2025 at 2:30am was removed on 09/12/2025, when the facility took actions to remove the immediacy prior to the survey date of 03/09/2026 On 03/16/2025, the survey team verified by observations, interviews, and record review, that the facility implemented the following to remove the immediacy. Corrective Action Taken: R75 was reassessed for elopement risk beginning on 9/8/25 and ending on 9/8/25 after the elopement occurred and deemed an elopement risk. R75 was located and returned to the facility on 9/8/25. A head-to-toe assessment was completed by the assigned nurse with no signs of injury. R75's care plan was updated on 9/8/25 pertaining to the elopement that occurred on 9/8/2025 by the Resident Care Coordinator. V58 (R75's family member and V51 (Primary Care Physician/Medical Director) were notified of the elopement on 9/8/25. On 9/8/2025 the DON, Administrator, ADON, and Medical Director reviewed the facility policies related to the occurrence: Elopement, Routine Resident Checks, Incidents/Accidents, Alarms, electronic alert band , Wanderers and Changes in Condition. The Wanderguard Policy was updated on 9/8/25 to include that in the event of equipment failure, facility may consider implementing alternative interventions including but not limited to room change to a more secure floor. Starting on 9/8/2025, the Memory Care Director, Resident Care Coordinator and Social Service Director updated the assessments and care plans for elopement risk residents. The assessments were completed on 9/10/2025. The immediacy was removed on 9/9/2025 as (R75) was placed on one to one supervision pending move to a more secured unit. Also, the only other resident requiring electronic monitoring was moved to a higher more secured unit on 9/9/2025. All residents were reassessed for elopement risk on 9/8/2025 and completed on 9/10/2025. All new admissions will have an elopement risk assessment that will be completed according to the MDS schedule; Within 7 days of admission, annually and as needed (by SSD/MCD). All residents that are identified as-risk for elopement during admission had a review of their care plan and updates were made where applicable, this audit began on 9/8/2025 and was completed on 9/10/2025. Pictures of at-risk residents were placed in a binder on all nursing stations (1st,2nd,3rd floors) and the receptionist desk which was completed on 9/10/2025 (by MCD). All residents determined to be at-risk for elopement and with active exit-seeing behaviors will be evaluated for a possible room change to a more secured unit to limit access to the front entrance door on the first floor. Additionally, residents will be evaluated to determine if an electronic monitoring bracelet is appropriate. Beginning on 9/8/2025, interviews were conducted (by the Administrator) with staff to determine further potential risk and completed on 9/10/2025. Code [NAME] Drills were conducted on all shifts to check staff knowledge and preparedness beginning on 9/8/2025 and ending on 9/12/2025 All staff and managers are being reeducated on routine resident checks, exit seeking, incidents/accidents, elopement policy and procedure and where to locate the at risk of elopement binders. The reeducation was provided on 9/8/2025 and was completed on 9/12/2025 All staff completed competency quizzes on elopement beginning on 9/8/2025 and ending on 9/12/2025 All staff and managers are being reeducated on elopement risk and reporting behaviors or changes in factors related to elopement risk to appropriate discipline. This was started on 9/8/2025 and completed by 9/12/2025. All reception staff were reeducated on monitoring the front doors and resident safety and proper procedure for code green started on 9/8/25 completed on 9/12/2025 All staff were educated on the electronic monitoring system starting on 9/8/2025 and completed on 9/12/2025. Exit doors will be monitored by staff when unalarmed. The receptionist will monitor the front entrance door 8am-8pm. From 8pm-8am door will be armed by receptionist and monitored by 1st floor nurses through the duration of that time. First floor staff will check and sign monitoring sheet for the alarm panel every 1/2 hour between the hours of 8pm to 8am to ensure that door alarms are activated while doors are not monitored by staff. Exterior door alarms will be checked weekly by the maintenance director and EVS Supervisor to ensure they are in working order and secured starting on 9/8/2025 and ongoing. After initial elopement on 9/8/2025 R75 was placed on one to one supervision. During that time the facility met with daughter and discussed new interventions. A plan was established and implemented. A work order was initiated to add an annunciator panel to the first floor nurses station to amplify the sounding alarm. Administrator initiated training on elopement as part of the annual abuse training to ensure staff knowledge of elopement plans. A review of compliance using Quality Assurance Audit tool for elopement and door checks was started (by the Administrator) on 9/8/2025. The Audits will be done daily for two weeks then twice weekly for four weeks, then monthly x 3 months, and evaluated at the monthly QAPI meeting to determine compliance. Audits to be completed by members of the IDT team and turned into Administrator who will ensure audits are being completed. A review of results of audit regarding elopement and door alarm working condition with the facility's interdisciplinary team started on 9/8/2025. Audits will be done weekly for four weeks, then monthly x 3 months, and then randomly by Administrator/designee until goal is attained. Results of these audits will be reviewed at the monthly QAPI to determine compliance Administrator to Audit daily that exterior front door alarm is being activated each day by receptionist at 8pm prior to leaving. During orientation of new hires, the facility (Business Office Manager) will educate newly hired staff on elopement and conduct competency quizzes. The facility Quality Assurance Team/ IDT (including Medical Director, Administrator, Social Services, DON, ADON and facility consultant) shall meet at least monthly to review elopement risk residents, trends, patterns and develop and implement action steps as necessary. The QA meeting is held monthly for three months, then quarterly and as needed. An emergency QA meeting was held on 9/10/2025 by the Administrator with the Interdisciplinary Care Team and Medical Director. The Elopement from the facility on 9/8/2025 was discussed along with the Removal Plan. The Medical Director and Interdisciplinary Care Team approved this Removal Plan. This will be monitored by the Administrator, DON, ADON, and Social Services. #2. R132's (Active Order as Of: 03/09/2026) documented, in part Diagnoses: (include but are not limited to) congestive heart failure, Type 2 Diabetes Mellitus, dependence on enabling machines and devices. Order Summary: OT (occupational therapy) Frequency 3-6/week x 8 weeks. Active: 02/18/2026. PT (physical therapy) Frequency 3-6/week x 8 weeks. Active: 02/17/2026. R132's (02/20/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R15's mental status as cognitively intact. Section GG. Functional Abilities. GG0170. D. Sit to Stand and F. Toilet transfer: 01 – Dependent - Helper does ALL of the effort. 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 activity. E. Chair/bed – to chair transfer: 88 – Not attempted due to medical condition or safety concerns. R132's (02/16/2026) care plan documented, in part Focus: requires the use of mechanical lift for transfer. Goal: will tolerate total body lift transfer from surface to surface with staff assistance. Intervention: Provide 2 staff assistance for transferring. Use total body (Hoyer lift) when transferring resident. On 03/09/2026 11:42 AM, V19 (Certified Nursing Assistant) transferred R132 from the wheelchair to the toilet seat using the stand lift by herself. V19 stated when transferring her (R132) from the wheelchair to the toilet seat using the stand lift, there should be 2 persons doing the transfer; unfortunately, the facility is short staff, and she (V19) could not get any one to assist her with transfer. V19 stated there should be two persons assisting her with transfer to ensure no falls happened. On 03/10/2026 at 2:16pm, V25 (Restorative Nurse) stated restorative is in charge of care planning resident with transfer and use of mechanical lift. If a resident is careplanned for 2 staff assist with mechanical lift, it should be followed. V25 stated if the resident is coded 'dependent' with transfer, there should be 2 staff assisting her with transfer. The importance of following the careplan is for safety to prevent injuries and falls; to prevent staff and resident from getting hurt or injured. On 03/10/2026 AT 2:46PM, V61 (Physical Therapy Assistant) stated she (R132) is on ongoing treatment for therapeutic transfer. Once she (R132) is done with therapy, the Therapy Department will give recommendations for transfer. V61 stated there was no recommendation for transfer yet because she is still on therapy. On 03/19/2026 at 9:36am, V25 (Restorative Nurse) stated if she was careplanned to use a total body lift for transfer, the CNA is expected to follow the care plan and use total body lift to transfer the resident for safety. The (11/2017) Comprehensive Care Plans documented, in part POLICY STATEMENTAn individualized, person centered comprehensive care plan, including measurable objectives with timetables to meet Resident's physical, psychosocial and functional needs, is developed and implemented for each Resident. PROCEDURE: 1.) In coordination with the Resident and Resident representative, as applicable, the interdisciplinary team will develop and implement a person centered, comprehensive plan of care. Care plans are comprised of Focus statements, Goals and Interventions. 6.) The comprehensive person centered care plan will: a. Reflect treatment goals, timetables and objectives in measurable outcomes; b. Describe the services that are to be provided to attain or maintain the highest practical physical, mental and psychosocial well-being. R61's diagnoses include hemiplegia and hemiparesis affecting right dominant side. R61's (2/11/26) functional assessment affirms the resident is dependent on staff for chair/bed to chair transfer, walking was not attempted due to medical condition or safety concerns. R61's (2/6/26) fall risk assessment affirms that resident is at risk. R61's (3/17/23) care plan states resident is at risk for falls related to weakness, impaired mobility, use of assistive device and use of psychotropic medication, interventions: ensure that the bed is in the appropriate lowest position for the patient. Mechanical lift for transfers. R61's (2/11/26) BIMS (Brief Interview Mental Status) determined a score of 15 (cognition intact). On 3/9/26 at 11:14am, R61 was lying in bed which was noted to be waist high. Surveyor inquired if R61 requires assistance with transfers. R61 stated, Yes and affirmed that a wheelchair is used for locomotion. On 3/9/26 at 11:16am, surveyor inquired if R61 can transfer herself. V5 (LPN/Licensed Practical Nurse) stated, No, she's (R61) a (mechanical lift) transfer. Surveyor inquired about R61's fall prevention interventions. V5 responded, Making sure we (staff) keep her safe in bed and 2-hour checks. If need be, we pull her (R61) up in the bed and bed in the lowest position. Surveyor inquired about the current height of R61's bed. V5 subsequently entered the room and replied, Her (R61) bed is up high, elevated I (V5) would say to the waist. We (staff) have to put your (R61) bed at the lowest position for safety. R27's diagnoses include paraplegia. R27's (12/8/25) functional assessment affirms the resident is dependent on staff for chair/bed to chair transfer. R27's (3/4/26) fall risk assessment affirms that resident is at risk for falls. R27's (6/21/23) care plan states the resident is at risk for falls related to weakness, impaired mobility, and use of assistive device, intervention: ensure that the bed is in the appropriate lowest position for the patient. R27's (12/8/25) BIMS determined a score of 15. On 3/9/26 at 11:25am, R27 was lying in bed which was noted to be waist high. Surveyor inquired if R27 can transfer himself and/or stand without assistance. R27 stated, No. On 3/9/26 at 11:28am, surveyor inquired if R27 can transfer himself. V5 (LPN) stated, No. Surveyor inquired about the height of R27's bed. V5 subsequently entered the room and responded, I'd (V5) say waist high. On 3/11/26 at 2:47pm, surveyor inquired about facility prevention interventions for residents at risk for falling. V2 (Director of Nursing) stated, We (facility) have a list of them, they would be in the care plans. Surveyor inquired about the required height of resident beds. V2 responded, In low position however we (facility) have a couple of residents that like it higher and won't let us (staff) lower it down. The (08/2020) fall management program states 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 residents at risk for falls, plan for preventive strategies and facilitate a safe environment. Use standard fall/safety precautions for all residents. The bed will be maintained in a position appropriate for resident transfers.

Based on observation, interview, and record review, the facility failed to ensure kitchen staff did not store personal food items inside the facility's kitchen and failed to ensure kitchen staff with facial hair were wearing beard guards in an effort to prevent contamination of residents' food. These failures have the potential to affect all 154 residents taking oral nourishment at the facility. Findings include:The (03/09/2026) facility census was 175. The list of residents on NPO (nothing per Orem (Mouth) provided on 03/09/2026 documented there were 21 residents on NPO.On 03/09/2026 at 9:59am with V15 (Dietary Supervisor) inside the Kitchen's Dry Storage room, there were 2 General merchandising retail store plastic bags, one black plastic bag, and a tumbler inside the storage room. V15 (Dietary Supervisor stated there should be no personal belongings or personal food items inside the dry storage room because she would not know how the food items were prepared and would not know the sanitation of the staff's kitchen. V15 stated she did not want to contaminate the residents food with the staff food items. This surveyor pointed out to V15 the 2 General merchandising retail store plastic bags, the black plastic bag, and a tumbler on the food cart inside the Dry storage room. V15 checked the tumbler and stated there's coffee inside the tumbler. V18 (Chef) went inside the Dry Storage room and stated the plastic bags and the tumbler were hers. V18 showed this surveyor and V15 the food items in one of the plastic bags. Inside the plastic bag were soft tortillas and jalapeno; the black bag contained 3 pieces of bread. V18 stated, she brought the food items to share with the ladies.On 03/09/2026 at 9:47am inside the facility kitchen, V8 (Executive Chef/Dietary Supervisor) had facial hair. V8 was not wearing beard guard. On 03/10/2026 at 9:45am inside the kitchen, V8 was not wearing a beard guard. This was pointed out to V8. V8 stated he should be wearing beard guard upon entrance to the kitchen. V8 stated he works with food and he does not want hair to get into the food; he does not want to contaminate the residents' food. On 03/10/2026 at 9:49am inside the kitchen, V29 (Chef) had facial hair; he was not wearing a beard guard. V29 stated he should have worn beard guard all the time while in the kitchen to prevent hair from getting into the residents' food. The (08/18) HAIR COVERING documented, in part POLICY: Hair will be covered when in the kitchen operations areas. PURPOSE: To prevent physical contamination of food. PROCEDURE: 1. While in the kitchen operations area staff will cover hair to prevent physical contamination of food. 3.Staff with facial hair, with the exception of eyebrows and eyelashes, will wear a beard cover. The (8/18) EMPLOYEE FOOD documented, in part POLICY: The Food & Nutrition Services employees will not store their food in dietary refrigerators. PURPOSE: To reduce the risk of food borne illness. PROCEDURE: 2. There will be a refrigerator designated for employee food.

Based on observation, interview, and record review, the facility failed to ensure the dumpster's lids were closed and failed to ensure the dumpster's surrounding area was clean in an effort to prevent pest or rodent migration. These failures have the potential to affect all the 175 residents at the facility. Findings include:The (03/09/2026) facility census was 175.On 03/09/2026 at 10:09am with V15 (Dietary Supervisor), the facility's 2 dumpsters were enclosed. Two lids of one of the dumpsters were open. There were bags of trash and loose trash within the enclosure. V15 stated the dumpster lids should be closed at all times because pests and rodents are attracted to the food, and the facility does not want the pest and rodents to get inside the facility. These may infiltrate the building. V15 stated the surrounding area of the dumpster should also be clean, free of trash for the same reason. On 03/09/2026 at 10:30am, the exit/entrance door behind the building was close. There was a gap between the floor and the door. V15 stated the flush door was not properly sealed to prevent small critters from migrating to the facility. The (11/25) GARBAGE DISPOSAL documented, in part POLICY: Maintain and dispose of garbage in a clean, safe manner. PURPOSE: To reduce the risk of odors, breeding places for pests, and to keep the FNS (Food and Nutrition Services) Department clean. PROCEDURE: 5. Outside dumpsters shall be kept closed at all times.

Based on observation, interview, and record review, the facility failed to ensure that staff don required PPE (Personal Protective Equipment) prior to repositioning (R15) and failed to ensure that soiled linen was bagged prior to placing it in the laundry chute to prevent contamination. These failures have the potential to affect all 175 residents residing at the facility. Findings include: Facility census dated 3/09/26, documents 175 residents residing in the facility.R15's face sheet documents diagnoses that include but are not limited to aphasia, psychosis, dementia, and gastrostomy. R15's MDS (Minimum Data Set), Section C: Cognitive Patterns, dated 2/19/2026, documents that R15's cognitive skills for daily decision making is severely impaired.R15 is unable to be interviewed due to altered mental status.On 3/09/26 at 10:07am, an Enhanced Barrier Precautions (EBP) sign was observed posted on R15's bedroom door. R15 was observed lying sideways in bed with both legs hanging out of the bed. V12 (Vent Certified Nursing Assistant/CNA) and V13 (Certified Nursing Assistant/CNA) entered the room without donning required personal protective equipment (PPE). V12 and V13 were observed wearing gloves; however, the required gowns for personal protective equipment (PPE) were not worn. V12 and V13 then made direct physical contact with R15 while assisting R15 by lifting and placing R15's legs back into the bed and repositioning the resident in bed.R15's physician order, dated 2/17/26, documents, in part, EBP (enhanced barrier precaution) for device care or use of feeding tube.R15's physician order, dated 8/06/25, documents, in part, every night shift every Wed observe & document g-tube site weekly. On 3/09/26 at 10:21am, V12 (Vent Certified Nursing Assistant/CNA) said that gowns and gloves are worn for residents that are on enhanced barrier precautions for prolonged contact and when changing the residents.On 3/09/26 at 11:58am, accompanied by V7 (Housekeeping Supervisor), a tour of the facility's laundry room was conducted. An open cart located directly below the laundry chute was observed containing soiled linen. The linen bag in the cart was not secured and remained open, with soiled linen exposed and hanging out of the bag. The laundry chute door above the cart was closed; however, a white cloth was observed protruding through the crack of the closed chute door. Upon opening the laundry chute door, the surveyor observed a bag of soiled linen that was not securely closed. The bag contained visibly soiled linens, including a white sheet that was partially hanging out of the bag with two quarter-sized brownish stains present. V7 said, Everything is supposed to be bagged. All dirty laundry is supposed to be bagged for infection control.On 3/11/26 at 10:00am, V30 (Infection Preventionist/Registered Nurse/RN) said that Enhanced Barrier Precautions are used for protective infection control measures, almost similar to neutropenic infections. The purpose is to prevent residents from developing nosocomial (healthcare-associated) infections. Residents who have chronic wounds, or medical devices that enter the body are often placed on Enhanced Barrier Precautions. This includes residents with ostomies or hardware exiting the body, as well as those with devices such as Foley catheters or gastrostomy tubes. Enhanced Barrier Precautions require the use of personal protective equipment during high-contact resident care activities. High-contact care includes activities such as changing the resident, providing peri-care, bathing, or any task that requires direct contact with the resident's body. Activities such as feeding the resident or simply answering the call light are not considered high-contact care. However, repositioning a resident in bed is considered a high-contact activity. Regarding soiled linen disposal, isolation linens are placed in black bags with red liners and tied securely before being placed in the laundry chute. Non-isolation linens are placed in clear bags. Each resident's linen is bagged separately. One bag of linen for one resident and then empty it before proceeding to the next resident. Hand hygiene is performed between residents. It is the facility's expectation that bags are closed before being placed into the chute. This applies to both linen and garbage. The purpose of closing the bags is to prevent microorganisms or infectious materials from entering the chute and potentially spreading illness to staff or others. This practice helps protect everyone's safety, including both residents and staff. Record review of facility policy titled, Soiled Linen Processing, dated 6/18, documents, in part, Soiled linen will be handled safely and processed in a manner to provide clean linen in adequate numbers to meet the needs of the facility. All soiled linen will be transported either by hand, cart, or chute in closed impermeable bags to the soiled linen room located in the laundry. All soiled linen is regarded as potentially contaminated. Laundry personnel will use Personal Protective Equipment (PPE - gown, gloves, mask) when sorting soiled linen and filling the washing machines. Record review of facility policy titled, Enhanced Barrier Precautions, dated 12/2024, documents, in part, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) in nursing homes. As well as to prevent multi-drug resistant organism acquisition of those with an increased risk of acquiring MDROs including residents with a chronic wound or an indwelling medical device. EBP involves gown and gloves use during high-contact resident care activities for residents known to be infected or colonized with MDROs when contact precautions do not otherwise apply. As well as residents with a chronic wound and/or indwelling medical device. Residents that have indwelling medical devices, regardless of MDRO status, will be on EBP. a. Some examples may include central vascular line (including hemodialysis catheter), urinary catheter, feeding tube, tracheostomy, and ventilator (excludes peripheral IVs). Record review of pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, in part, . Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis. Your facility must be safe, clean, comfortable, and homelike. You may participate in developing a person-centered care plan which states all the services your facility will provide to you and everything you are expected to do. This plan must include your personal and cultural choices. Your facility must make reasonable arrangements to meet your needs and choices. You should receive the services and/or items included in the plan of care.

Based on observation, interview and record review, the facility failed to follow policy and procedure and failed to clean the lint screen thoroughly to provide a safe environment for the residents. This failure has the potential to affect all 175 residents residing at the facility.Findings include:Facility census dated 3/09/26, documents 175 residents residing in the facility.On 3/09/26 at 11:58am, accompanied by V7 (Housekeeping Supervisor), a tour of the facility's laundry room was conducted. V7 opened the lint compartment for dryer #1 (dryer farthest from the washing machines) and the lint compartment floor had loose lint on the floor, and the lint screen was fully covered with lint. V7 said, Yeah. This (dryer #1's lint compartment) definitely needs a little bit of attention. We (staff) clean the dryers out daily and after each dry. Lint compartments are cleaned out to prevent a fire and so the laundry dries.Record review of facility policy titled, Equipment Maintenance, dated 06/18, documents, in part, Laundry staff will clean all dryer lint screens and any accumulation of lint below the screens at the end of each shift and more often if needed. Laundry Supervisor will monitor to assure screens are cleaned. Lint accumulation may cause inefficient drying and dryer malfunction. Building Manager will vacuum the dryer(s) fire box, lint compartment, blower motors and any lint accumulation behind the dryers weekly. Record review of pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, in part, . Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis. Your facility must be safe, clean, comfortable, and homelike. You may participate in developing a person-centered care plan which states all the services your facility will provide to you and everything you are expected to do. This plan must include your personal and cultural choices. Your facility must make reasonable arrangements to meet your needs and choices. You should receive the services and/or items included in the plan of care.

Based on observation, interview, and record review, the facility failed to ensure that five residents (R30, R80, R107, R117, and R145) of 71 residents reviewed for resident rights, were treated with dignity and respect.Findings include: R80's face sheet documents diagnoses that include but are not limited to dementia with psychotic disturbance and frontotemporal neurocognitive disorder. R80's BIMS (brief interview for mental status) score, dated 12/30/25, is 1 which indicates R80's cognition is severely impaired. R80 is unable to be interviewed due to altered mental status. R80's care plan, dated 2/26/24, documents, in part, (R80) demonstrates socially inappropriate behaviors as evidenced by: Spitting on her roommate's bed, with interventions that document, in part, Support appropriate moods and behaviors. R80's care plan, dated 12/02/24, documents, in part, (R80) has dementia. Due to the disease prognosis, (R80) may not be able to make preferences known. On 3/09/26 at 12:06pm, R80 was observed, in the dining room, seated at a table with 3 other residents (R30, R117, and R145) during lunch. R80 was observed expectorating into a clear cup, and two spots of thick mucus-like secretions, each approximately the size of a quarter, were observed on the table surface. R30 said, There she (R80) go again. She (R80) gonna make me puke. R80's clear cup was observed to be approximately an inch high filled with R80's sputum. On 3/09/26 at 12:09pm, R80 expectorated again and missed the cup, resulting in sputum landing on the table. R80 then used R80's fingers in an attempt to pick up the thick sputum from the table and place it into the cup. On 3/09/26 at 12:13pm, R30 said, She (R80) spitting in that cup, keeps spitting in that cup. On 3/09/26 at 12:15pm, R80 was again observed expectorating into a clear cup at the table seated with 3 other residents (R30, R117, and R145) during lunch. On 3/09/26 at 12:18pm, R80 was again observed expectorating into a clear cup at the table seated with 3 other residents (R30, R117, and R145) during lunch. R30 pointed at R80 and said, Look at what she (R80) doing. V14 (Aide) said, I know (talking to R30). She (R80) can't help it. On 3/09/26 at 12:19pm, R80 was again observed expectorating into a clear cup at the table seated with 3 other residents (R30, R117, and R145) during lunch. R145 said, Here we go again. She (R80) makes herself spit. She (R80) usually spits on the floor, but they (staff) gave her a cup a today. Well, I don't like it, but I don't think she (R80) can help herself (R80). On 3/09/26 at 12:20pm, R80 stood up and walked out of the dining room. On 3/09/26 at 12:23pm, R107 entered the dining room and sat in the chair previously occupied by R80. R107 then placed R107's arm on the table, coming into contact with R80's respiratory secretions that were present on the table surface. On 3/11/26 at 12:14pm, V2 (Director of Nursing/DON) said, I can't imagine residents would appreciate that (R80 expectorating into a cup at the table). V2 affirmed that many of the residents residing on the floor with R80 are cognitively impaired and based on the reasonable person concept the residents would not appreciate that (R80 expectorating into a cup at the table). R30's face sheet documents diagnoses that include but are not limited to chronic obstructive pulmonary disease and dementia. R30's BIMS (brief interview for mental status) score, dated 1/20/26, is 4 which indicates R30's cognition is severely impaired. R107's face sheet documents diagnoses that include but are not limited to chronic obstructive pulmonary disease and dementia. R107's BIMS (brief interview for mental status) score, dated 2/03/26, is 9 which indicates R107's cognition is moderately impaired. R117's face sheet documents diagnoses that include but are not limited to vascular dementia and chronic kidney disease stage 4. R117's BIMS (brief interview for mental status) score, dated 2/03/26, is 10 which indicates R117's cognition is moderately impaired. R145's face sheet documents diagnoses that include but are not limited to hypertensive heart disease with heart failure and dementia. R145's BIMS (brief interview for mental status) score, dated 2/12/26, is 15 which indicates R145 is cognitively intact. Record review of facility policy titled, Residents' Rights, dated 11/17, documents, in part, The facility will respect and uphold residents' rights. Record review of pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, in part, . Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis. Your facility must be safe, clean, comfortable, and homelike. You may participate in developing a person-centered care plan which states all the services your facility will provide to you and everything you are expected to do. This plan must include your personal and cultural choices. Your facility must make reasonable arrangements to meet your needs and choices. You should receive the services and/or items included in the plan of care.

Based upon observation, interview and record review the facility failed to follow policy procedures, failed to ensure that (R79's) nebulizer tubing/mouthpiece were dated, and failed to ensure that respiratory equipment was properly contained when not in use - to prevent contamination for four of 71 residents (R38, R71, R79, R112) in the sample reviewed for respiratory care. Findings include: R38 is [AGE] years old and has resided at the facility since 2021, face sheet listed the following past medical history: Bilateral osteoarthritis of knee, type 2 diabetes, chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypercapnia, chronic diastolic (congestive) heart failure, hyperlipidemia, hyperlipidemia, generalized anxiety disorder, etc. 03/09/2026 11:20AM, R38 in room sitting up in wheelchair, alert and oriented stated that she has been at the facility for 5 years, originally came for therapy and ended up long term. Respiratory equipment mask noted on top of resident's bedside table open to air and not contained. R38 have the following active order DuoNeb Solution 0.5-2.5 (3) MG/3ML (Ipratropium- DuoNeb Soiution 0.5-2.5 (3) MG/3ML (Ipratroplum-Albuterol) 1 vial inhale orally via nebulizer every 6 hours as needed for Respiratory Symptoms related to hypertensive heart disease without heart failure. R112's (Active Order as Of: 03/09/2026) Order Summary Report documented, in part Diagnoses: (include but are not limited to) chronic cough, hypertension, and COPD (Chronic Obstructive Pulmonary Disease). Order Summary. Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 3 ml inhale orally via nebulizer every 4 hours for Respiratory Symptoms: Shortness of Breath and/or Wheezing. Active: 03/06/2026. On 03/09/2026 at 11:06am inside R112's room, R112's nebulizer mouth piece was not in used and was not contained. This surveyor requested V21 (Registered Nurse) to check R112's nebulizer mouth piece. V21 stated her mouth piece had to be in a plastic bag, contained for infection control. V21 stated she did not see a plastic bag in the room. On 03/11/2026 at 9:50am, V2 (Director of Nursing) stated it is expected when the nebulizer mouthpiece is not in used, this should be bagged for infection control and to maintain the cleanliness of the mouthpiece. R112'S (03/06/2026) care plan documented, in part noted with potential for respiratory difficulty secondary to active diagnosis of COPD. Will tolerate oxygen therapy. On 3/09/26 at 10:15am, R71's oxygen tubing and oxygen mask, which were not currently in use, were observed in R71's room across from the bed under a hanging wall shelf. R71's oxygen tubing and oxygen mask were observed on top of R71's oxygen concentrator, removed from a clear plastic bag, laying on top of the bag, leaving the equipment exposed and not contained. R71's face sheet documents diagnoses that include but are not limited to Alzheimer's disease, dementia, delusional disorders, and dysphagia following nontraumatic intracerebral hemorrhage. R71's BIMS (brief interview for mental status) score, dated 2/10/26, is 1 which indicates R71's cognition is severely impaired. R71's physician order, order date: 9/18/25; end date: indefinite, documents, in part, respiratory: oxygen per nasal cannula @ 2 liters per minute prn as needed for respiratory symptoms: shortness of breath. R71 is unable to be interviewed due to altered mental status. On 3/09/26 at 10:22am, V12 (Vent Certified Nursing Assistant/CNA) confirmed R71's oxygen tubing and oxygen mask were not contained laying on top of R71's oxygen concentrator and removed from a clear plastic bag, laying on top of the bag. V12 stated that the nurse's take care of the oxygen stuff. R79's diagnoses include chronic obstructive pulmonary disease. R79's (11/27/25) physician orders state change nebulizer tubing/mask/mouthpiece weekly. On 3/9/26 at 1:20pm, R79's (undated) nebulizer mouthpiece was observed in the dresser (uncontained). Surveyor inquired if R79's nebulizer tubing and/or mouthpiece were dated. V5 (Licensed Practical Nurse) inspected R79's nebulizer tubing/mouthpiece and stated, It's not labeled. Surveyor inquired about concerns with R79's nebulizer tubing/mouthpiece storage. V5 responded, It's not in a bag. Surveyor inquired if nebulizer tubing and mouthpiece are supposed to be labeled and bagged when not in use. V5 replied, It should be. The (10/2025) Equipment Change Schedule documented, in part POLICY: Equipment will be changed following established schedules to prevent cross contamination. 6. NEBULIZERS: Nebulizer tubing shall be stored appropriately in a bag when not in use. Record review of pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, in part, . Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis. Your facility must be safe, clean, comfortable, and homelike. You may participate in developing a person-centered care plan which states all the services your facility will provide to you and everything you are expected to do. This plan must include your personal and cultural choices. Your facility must make reasonable arrangements to meet your needs and choices. You should receive the services and/or items included in the plan of care.

Based on observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that (R27, R47, R52, R53, R60, R159, R184) multidose medications were dated when opened, failed to ensure that (R42) treatment was labeled/contained, failed to discard (R100) expired medication, failed to ensure that TB (Tuberculin) solution was stored within the required temperature range, failed to ensure that (R1, R53, R54, R122, R127) refrigerated medications were stored within the required range, and failed to maintain the (2nd floor) medication refrigerator temperature within the required range. This failure has the potential to affect 60 (2nd floor) residents.Findings include:The [DATE] facility census includes 60 (2nd floor) residents.On [DATE] at 2:08pm, the (1st floor - back hall) medication cart was inspected with V5 (LPN/Licensed Practical Nurse). R60's Systane solution was opened and undated. Surveyor inquired if there was an opened date on R60's Systane. V5 stated, It's open but there's no date on it. R52's Latanoprost solution was opened and undated. Surveyor inquired if R52's Latanoprost was dated when opened. V5 responded, No. R27's Brinzolamide ophthalmic suspension was also opened and undated. Surveyor inquired if V5 knows when R27's Brinzolamide was opened. V5 replied, I don't. On [DATE] at 2:12pm, the (2nd floor - front hall) medication cart was inspected with V21 (RN/Registered Nurse). Hydrocortizone cream was noted to be opened, unlabeled, and uncontained in the drawer. Surveyor inquired about the Hydrocortizone cream. V21 stated, That's for (R42's name) because I (V21) know it's for his arm. Surveyor inquired if the Hydrocortizone cream was labeled with R42's name. V21 responded, No. Surveyor inquired if R42's Hydrocortizone cream was bagged. V21 replied, No and proceeded to place it in a bag. R100's Systane Ultra solution was opened and dated 1/14 (almost 2 months ago). Surveyor inquired when eye drops expire (after opened). V21 stated, If it's opened, its 28 days. On [DATE] at 2:28pm, the (2nd floor) medication refrigerator was inspected with V21 (RN) the temperature (per thermometer) was noted to be 50F (Fahrenheit). V21 inspected the thermometer and stated, This is 50, the target is 41 but it can go all the way to 46.On [DATE] at 2:31pm, surveyor inquired about the temperature of the (2nd floor) medication refrigerator V31 (ADON/Assistant Director of Nursing) inspected the thermometer - dangling from the door and stated, It's 62, I (V31) don't think this is accurate cause now it's going to 63. Surveyor inquired what the medication refrigerator temperature should be. V31 responded, The target is between 46 and 36. V31 subsequently inspected the medication refrigerator thermometer - on the 2nd shelf and stated, This one in here says 52. Surveyor inquired if there was ice buildup on the freezer (inside the medication refrigerator). V31 responded, Yeah. The following contents were inside the refrigerator: TB solution. R1's Zerbaxa IVPB (Intravenous Piggyback). R53's Procrit. R54's B12 solution. R122's Vancomycin suspension. R127's Vancomycin suspension. On [DATE] at 2:35pm, the (2nd floor - split) medication cart was inspected with V31 (ADON). R53's Bromonidine opthalmic solution was opened and undated. Surveyor inquired if R53's Brimonidine was dated when opened. V31 stated, There's no date on it. V31 subsequently affirmed that R159's Dorzolamide/Timolol ophthalmic solution was also opened and undated. Surveyor inquired about the requirement for opened multidose vials. V31 responded, It has to be labeled.On [DATE] at 2:40pm, the (2nd floor - vent) medication cart was inspected with V32 (LPN). R47's Albuterol inhaler was opened/unboxed and undated. Surveyor inquired when R47's Albuterol was opened. V32 stated, I'm not sure, they (staff) didn't put a date on here (referring to the plastic bag that it was contained in). R184's Albuterol inhaler was also opened/unboxed and undated. Surveyor inquired if R184's Albuterol was dated V32 responded, No. Surveyor inquired about the requirement for opened multidose medications. V32 replied, We (staff) put a label on it and mark it with a date when it was opened.The (12/2023) storage/labeling/packaging of medications policy states medications requiring refrigeration should be stored at temperatures between 36F to 46F. The (03/2021) multi-dose vials, use of policy states 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 sharps container, and a new vial of medication should be obtained. If this is a new vial, remove the cap from the vial. Using an ink pen, write the opened and expiration date as well as the staff initials, on the vials label or pharmacy provided sticker.

Based on interview and record review, the facility failed to follow their psychotropic medication policy by failing to ensure that residents on psychotropic medications have a valid consent before receiving the ordered medications. This failure affected two (R163 and R184) of five residents reviewed for psychotropic medication. Findings include:R163 is [AGE] years old and has resided at the facility since 2022, face sheet listed the following medical history: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia following cerebral infarction, dysphagia following cerebral infarction, trigeminal neuralgia, other muscle spasm, essential primary hypertension, chronic pain syndrome, etc. Minimum Data Set (MDS) assessment dated 12 /26/2025 section C (cognitive) scored resident with a brief interview for mental status (BIMS) score of 00 out of 15, indicating that resident is not cognitively intact.Physician order listed the following medication, Mirtazapine 15mg, give 1 tablet by mouth at bedtime for depression.R184 is [AGE] years old and has resided at the facility since 2025. Past medical history includes, but not limited to amyotrophic lateral sclerosis primary, acute respiratory failure with hypoxia, depression, insomnia, dysphagia unspecified, generalized anxiety disorder, etc. MDS assessment dated [DATE] is not completed and did not indicate any BIMs score for R184.R184 have the following orders: Lorazepam 1mg, 1 tablet via G-tube every 4 hours and as needed for anxiety. Sertraline 25mg once a day via G-tub for depression. R184 has been on these medications since 2025.On 3/11/2026 at 12:09PM, V32 (LPN) said that she got the consent for the psychotropic medication for R163 and R184, the protocol is to have resident sign the consent upon admission, if the resident cannot sign, the family member/POA will be contacted, V32 is not sure if there is a policy for the staff to write a progress note when the family is contacted, but the name of the person contacted will be documented with the date and time. V32 added that verbal consent can be obtained by one nurse, the copy of the verbal consent is kept and the family/POA will be asked to sign when they come in.Review of psychotropic medication consents provided by the facility for both R163 and R184 showed R163 has a verbal consent dated 1/26/2026, resident has been onMirtazapine Oral Tablet 15 MG (Mirtazapine) since 8/12/2025, surveyor requested for any other informed consent for R163, but facility did not provide any. R184's consent stated that resident cannot sign, then there is a signature beside the writing, V32 (LPN) was documented as the nurse obtaining consent. A question on the consent form that asked for the classification and side effect medication was marked no to all categories of medication. Surveyor presented this observation to V32, and she said, Oh I am sorry, I must have done that in a hurry. For the signature on R184's consent, V32 said, this is not my signature, I don't know who signed this. On 3/11/2026 at 4:21PM, V2 (DON) said that the facility does not have any other consent for R163's psychotropic medication, the nurse is in the process of getting one now, she is calling the family, but they are not picking up the phone.Psychotropic medication use policy dated 09/2022 stated in part: Purpose: To establish a standardized system to inform residents and/or their responsible parties about psychotropic medications and their side effects.Policy: A resident will not receive psychotropic medications unless behavioral programming and/or environmental changes have failed to sufficiently modify a resident's target behavioral disturbance. A resident will not receive psychotropic medications unless such medication is ------------------------------------------------------------ to treat clearly defined target behaviors.Consent:1. For each psychotropic medication ordered either verbal or written consent from the resident or the resident's responsible party will be obtained prior to initiation of the medication. Consent will not be obtained for a dosage decrease.2. Information regarding possible side effects will be discussed with the residents or the resident's responsible party.3. If the consent is verbal, a copy of the form will be placed in the chart, and the original will be sent to the party responsible for a signature. A copy will remain in the chart until replaced by the returned original.4. The resident and/or resident party responsible will be notified regarding any changes in medication dosage, this information will be documented in the resident's medical record.

Based on observation, interview, and record review the facility failed to ensure that linen (layers) were not beneath a resident while lying on a LALM (Low Air Loss Mattress), failed to replace a malfunctioning LALM, failed to ensure that a LALM was on the correct setting (while in use), and/or failed to ensure that nursing staff were aware of required LALM settings, for three of 71 residents (R5, R13, R27) in the sample reviewed for pressure ulcers. Findings include:R5's (2/2/26) initial physician wound assessment includes the following pressure wounds (stage 4) sacral extending to both hips, (stage 3) right buttock, left heel, and (unstageable) right heel. R5's (2/19/26) POS (Physician Order Sheets) include low air loss mattress.On 3/9/26 at 10:24am, R5 was observed lying atop of a LALM however multiple layers (incontinence brief, flat sheet, and additional folded sheet) were noted beneath the resident - which impedes mattress air flow. Surveyor inquired about the layers beneath R5 V4 (Registered Nurse) stated We (staff) have a sheet, diaper, and draw sheet. Surveyor inquired how many draw sheet layers were beneath R5 V4 responded, 2 parts therefore 3 linen layers and a brief were between the mattress and resident.The (3/2/21) prevention and treatment of pressure injury and other skin alterations policy states implement preventative measures and appropriate treatment modalities for pressure injuries and/or other skin alterations.The (undated) low air loss mattress operation manual states you may place a thin cotton sheet over the quilted mattress top cover. R13's diagnoses include paraplegia.R13's (5/16/25) POS includes low air loss mattress.R13's (12/12/25) BIMS (Brief Interview Mental Status) determined a score of 15 (cognition intact).On 3/9/26 at 10:15am, R13 was observed lying atop of a LALM and the alarm was sounding. The Low Pressure setting on the LALM was noted to be flashing (orange) at this time. Surveyor inquired about concerns with the LALM. R13 responded, The mattress is missing a bubble, it's so uncomfortable. It's like a void in the mattress. Eight (8) months ago I (R13) asked for a new mattress, and they (staff) never followed up. On 3/9/26 at 10:17am, surveyor inquired why R13's LALM was alarming. V3 (Certified Nursing Assistant) stated, He (R13) probably just moved from side to side. V3 subsequently inspected R13's LALM settings and stated, It says low pressure, it only does it when he moves however the mattress should not alarm when resident moves.The (undated) low air loss mattress operation manual states a visible indicator (orange) warns the pressure is below a preset or user-defined level.R27's diagnoses include paraplegia.R27's (11/7/23) POS includes low air loss mattress.R27's (12/8/25) BIMS determined a score of 15 (cognition intact).On 3/9/26 at 11:25am, R27 was lying atop of a LALM while in static mode. Surveyor inquired about concerns with the LALM. R27 responded, It's supposed to let down and rose up, it haven't done nothing lately and affirmed the mattress is firm. On 3/9/26 at 11:28am, surveyor inquired about R27's LALM settings. V5 (Licensed Practical Nurse) stated, I (V5) would have to look at the exact order. V5 subsequently inspected R27's LALM settings and stated, It should be stagnant. Surveyor inquired if R27's LALM should be in static mode while lying in bed. V5 responded, I'm not 100% sure. On 3/11/26 at 1:46pm, V2 (DON/Director of Nursing) stated We (facility) don't have a policy for the use of our low air loss mattresses and affirmed that staff follow the manufacturer guidelines.On 3/11/26 at 2:43pm, surveyor inquired about requirements for use of LALM V2 (Director of Nursing) stated Anyone with multiple stage 2, or stage 3, stage 4 or if they (residents) are requesting it for comfort. Surveyor inquired how many layers are allowed between the resident and LALM. V2 responded, I'm (V2) not gonna guess, I (V2) will let you know and affirmed that she (V2) was unsure. Surveyor inquired when static mode is required for LALM use. V2 replied, This is outside of my (V2) lane; this is wound care and affirmed that she didn't know. Surveyor inquired about staff requirements for malfunctioning LALM - in use. V2 stated, To notify somebody.On 3/11/26 at 4:01pm, surveyor inquired about requirements for use of LALM. V31 (Assistant Director of Nursing) stated, I (V31) know it's a weight-based requirement; we (facility) use them for people with pressure wounds and things like that. Surveyor inquired what's allowed on the LALM while in use. V31 responded, Just a flat sheet. Surveyor inquired what static mode indicates on the LALM. V31 replied, The static mode is to firm the mattress, but the resident is not on it continuously. The (undated) low air loss mattress operation manual states in static mode, the mattress provides a firm surface.

Based on observation, interview, and record review, the facility failed to follow policy procedures, failed to follow physician orders, failed to implement care plan interventions, and failed to ensure that an IV dressing was changed (weekly) to prevent infection, for one (R5) of 71 residents in the sample reviewed for quality of care.Findings include:R5's (2/18/26) Physician Orders include IV midline: Transparent sterile dressing change weekly and prn (as needed).R5's (2/19/26) care plan states resident requires IV medication, intervention: change midline/PICC (Peripherally Inserted Central Catheter) dressing weekly and prn (as needed).On 3/9/26 at 10:24am, R5's right upper extremity IV dressing was dated 2/22/26 (15 days ago). Surveyor inquired about R5's IV access. V4 (Registered Nurse) stated, This is um midline, a PICC line. Surveyor inquired how frequent IV dressings are changed at the facility. V4 responded, We (staff) change every weekly. Surveyor inquired about the date on R5's IV dressing V4 replied 2/22/26. On 3/9/26 at 10:36am, surveyor inquired when IV dressings should be changed at the facility V6 (Assistant Director of Nursing) stated Usually we (staff) change it when they (residents) first come in from the hospital then PRN (as needed) and also I think after a month. On 3/11/26 at 2:45pm, surveyor inquired when IV dressing changes are required, V2 (Director of Nursing) stated At least weekly and if noted to be soiled. R5's (March 2026) Medication Administration Record includes IV midline: transparent sterile dressing change weekly (every Sunday), which was documented on 3/8 (the day prior) as administered.The (04/2025) central venous access catheter devices: dressing change policy states dressings are changed one (1) time per week and PRN.

Based on interview and record review, the facility failed to provide adequate supervision and monitoring, including maintaining visual oversight, for residents assessed to be at risk for falls in accordance with their care plans and assessed needs. This affected two of four residents (R#3 and R4) reviewed for accidents and fall prevention in a sample of 44 residents. This failure resulted in R3 accessing the staff nurses' closet without supervision and sustained a fall resulting in a head laceration requiring two staples. R3 also sustained a subsequent fall in the dining room while in the presence of staff, resulting in a femur fracture. R4, who had a history of forgetfulness and dementia, sustained an unwitnessed fall after being left unsupervised in her room, resulting in a left hip laceration, scalp contusion, and arm fracture.Findings Include: R3 R3 was admitted to the facility on [DATE] with a diagnosis of dementia with psychotic disturbances, history of falling, orthostatic hypotension, syncope and collapse. R3 memory care initial assessments dated 10/22/25 documents fast scale of stage 5 moderate dementia. In this stage of dementia, the person needs more help to survive, she does not assistance with toileting or eating but does need help choosing proper clothing to wear fo the day. The person displays increased difficulty with serial subtraction. The person may not know the date and year or where she lives. However, she does know who she is and names of family. R3 Minimum Data Set, dated [DATE] document under cognitive patterns R3 has memory problems under short term memory; under cognitive skills for daily decision-making documents a 3 which indicates severely impaired never /rarely makes decisions. R3 toilet transfer documents a score of three which indicate partial /moderate assistance. R3's fall risk assessment dated [DATE] documents at risk for falls. R3 was located on a locked dementia unit. The area where R3's fall took place on 10/25/25 was in a room labeled nurse's closet. The door to the nurses closet has a pad lock on the door and you need a code to enter the room. Upon entering the room there is a small space for staff personal items and a small chair. There is a second door leading to a staff bathroom. R3's incident report dated 10/25/25 documents: The resident was found on the floor in the common bathroom, where she had apparently attempted to use the bathroom. No staff witnessed the fall. The resident was lying on her left side with bleeding noted to the back of the head toward the left side. Under notes dated 10/30/25; Facility has investigated the occurrence, and the details as followed. R3 sent to local hospital for an opening to left occipital area due to fall. two staples were placed and to be removed within 7- 10 days. Based on interviews with staff, resident had been in her wheelchair at the nurse's station prior to the fall. A staff member observed resident in staff bathroom on the floor with wheelchair next to her. Resident fully clothes with pants on and nonskid socks. It is probable the resident wheeled herself to the bathroom and when she arose lost her balance and fell. Root cause analysis is resident lost her balance when she stood up from the wheelchair to use the commode and fell. R3's progress note dated 10/25/25 documents: The resident was found on the floor in the common bathroom, where she had apparently attempted to use the bathroom. No staff witnessed the fall. The resident was lying on her left side with bleeding noted to the back of the head toward the left side.Bleeding area cleansed and controlled. Full body assessment completed. No swelling, deformity, or pain noted in upper or lower extremities during assessment. VS obtained and WNL. 911 called; resident transported to Hospital for further evaluation. R3's ambulance run report dated 10/25/25 documents: R3 found sitting on bathroom floor and leaning against the wall in nursing home. Staff on scene holding towel on the back of the head. Staff state they heard R3 fall and found in current position. R3 presents with an approximate one-inch laceration on the back of her head. R3 said she slipped in the bathroom and hit her head on the door. R3's hospital records dated 10/25/25 documents: discharge diagnosis laceration of the scalp: unwitnessed fall. orientation assessment: not oriented to place or time, identifies self and situation. Under complaint: R3 in ER for unwitnessed fall. Per Emergency medical staff (EMS) R3 found in the bathroom after staff heard fall. laceration to back of the head. Laceration repair length 0.5 centimeters. Skin closure two staples. R3's progress note dated 10/26/25 documents: Received the resident back from hospital. Full body assessment completed. Two staples noted on the back of the head, covered with clean dry gauze. On 2/11/26 at 5:01PM, V8(Certified nursing aide, CNA) said the nursing closet door is usually closed for security, so residents do not go in there. On 2/13/26 at 11:44AM, V17(nurse) said the nursing closet is usually closed unless staff is in the room On 2/11/26 at 3:47pm, V7(Nurse) said she was working with R3 on day of incident on October 25. R3's floor is a locked dementia unit, residents wander, and some rooms have codes to enter. V7 said R3 gait was unsteady and had behavior of trying to get up and walk. V7 said last saw R3 at the nursing station during change of shift around 7:45PM with no concerns. V7 said staff informed her of fall while she was passing medications on the hallway. V7 said she observed R3 on the floor in the staff bathroom, wheelchair at the door on her back. Blood on the back of her head and V7 called 911 to assist R3. V7 said someone must have left the door open. V7 said the door to the room R3 was found is usually closed and requires a code to enter. R3's progress note dated 11/6/25 at 11:00AM created date of 11/7/25 documents: Resident restless yelling at staff to leave her alone and screaming get away from me while redirecting her to have a sit. Resident standing and trying to walk unassisted. Resident covering her mouth refusing oral medication from nurse and screaming at nurse. Interventions Implemented: Resident was ambulated with device and staff assistance around the unit 3x's. Did Intervention(s) work? no. R3's progress note dated 11/6/25 at 12:25PM documents: Resident seen standing attempting to ambulate near nurses station. Writer attempted to redirect resident to sit safely. Resident stated she didn't want to sit writer educated resident on safety of asking for assistance with standing resident said ok and sat down resident redirected to activities. R3's progress note dated 11/6/25 at 3:34pm with a created date of 11/7/25 documents: Describe Behavior: Crying, yelling, screaming at staff, attempting to ambulate unsafely (without staff assistance- staff assisted with walking x2 prior in the day). Stating so leave her alone, get away from her. Interventions Implemented: offered word searches, coloring books, assisted therapy with walking [NAME] around the unit, playing calming music, moving to a quiet area, offering to use the phone to call her family (refused-stating she didn't want to talk to them) Did Intervention(s) work? No R3's point of care behaviors charting for November 2025 documents under interventions: Symptoms if R3 is crying interventions: 1. offer to play music, 2. Offer coloring books, 3. Offer word search, 4. Assist with calling her family, 5. All interventions utilized. On 11/6/25 documents at 1:07 no behaviors; at 1:59 behaviors yes, interventions 4 and 5 utilized with behavior decreased. At 9:59PM, yes behaviors intervention 5 with behaviors continuing. Under interventions if R3 is anxious and restless 1. Offer coloring book, 2 sit with R3 and talk about family, 3. Ofer to take R3 on walk around unit. 4. Play calming music, 5. All interventions utilized. On 11/6/25 documents at 1:07 no behaviors; at 1:59 behaviors yes, intervention 3 with behavior decreased. At 9:59PM, yes behaviors intervention 5 with behaviors continuing. R3's incident report dated 11/6/25 documents: Resident brought to the dining area for dinner. Shortly after another resident reported that R3 stood up from her wheelchair. CNA observed the R3 walk around the table before she fell. CNA was assisting another resident and unable to reach the resident in time to prevent the fall. was this incident witnessed documents no. Under notes documents, R3 requires moderate to maximal assist with activities of daily living. Staff observed R3 ambulating without staff assistance around the table she was seated at. Root cause analysis: R3's fall attributed to gait imbalance, not utilizing staff assistance with ambulation and impaired safety awareness R3's progress note dated 11/6/25 at 6:15pm documents: Writer notified of assistance needed in dining room. writer observed resident in dining room Near table lying on back pillow applied under head while being assessed. Writer and 1 staff assessed R3 visible swelling to left leg. Nonverbal pain scale resident pain at 8/10. 911 called for transport related to pain and swelling to left leg for further evaluation. R3's post fall occurrence note dated 11/6/25 at 6:15pm documents Description of occurrence : (If initial) Resident was brought to the dining area for dinner. Shortly after, another resident reported that the resident stood up from her wheelchair. CNA observed the resident walked around her table before she fell. CNA was assisting another resident and unable to assist at the moment of the fall. R3's facility final report dated 11/12/25 documents: staff observed R3 ambulating without staff assistance around the table she had been seated at. Staff attempted to assist R3 but were unable to get the resident before falling, staff report R3 seemed more confused and restless earlier in the day. New order for urinalysis and culture. Staff report spending a lot of time redirecting R3 and state R3 is spontaneous. R3's fall attributed to gait imbalance, not utilizing staff assistance with ambulation and impaired safety awareness. Investigation statements document: V10(nurse) statement said she did not see the fall. V10 statement documents staff were in the dining room attending to other residents the time of fall. no one actually saw R3 fall. V17(nurse) statement documents: Several staff were in the dining room but nobody saw R3 actual fall. R3 is impulsive and restless. V17 notified by staff that R3 fell. R3 was on the floor two spots over from where she was seated. V15 (CNA) statement documents she did not see the fall and her back was to R3. V32(CNA) said she was in the dining room but could not see R3 table from where she was seated. V11 statement documents: V11 said she just picked up a tray from the service counter and turned to walk towards a resident. V11 said she heard another resident say hey sit down and looked in that direction and saw R3 attempting to ambulate. V11 said she immediately turned her back to place the tray back at the service encounter to assist R3 and by the time V11 turned back around, R3 had already fallen. V11 said she was a few seats away from where she was originally seated and it looked as though she was attempting to walk around the table. On 2/13/26 at 2:21Pm, V11(Certified nursing aide, CNA) said she was in the dining room at time of R2 fall on 11/6/25. V11 said she recalls seeing R3 standing up by her table and V11 said she turned around to put a tray down at a table and R3 fell. Unable to recall any other details related to fall. V11 was showed typed statement and confirmed that was what she saw a time of incident On 2/20/26 at 3:19Pm V31 (Certified nursing aide, CNA) said she does not recall seeing R3 fall in the dining room on 11/6/25. V31 thinks she was feeding another resident at the time of the fall. On 2/11/26 at 5:01PM, V8(Certified nursing aide, CNA) who was assigned to R3 the evening of 11/6/25, said he does not recall R3 having any behaviors that day. V8 said he brought R3 in the dining room in her wheelchair to the table and locked the wheelchair. V8 said he did not see R3 fall because he was assisting other residents into the dining room. V8 said R3 has behaviors of trying to get up unassisted and we redirect her to sit down. On 2/13/26 at 11:44AM, V17(nurse) said R3 would need one to one monitoring if she was trying to get up and ambulate. On day of the incident, R3 was at the nursing station prior to dinner and V17 said she assisted bringing R3 into the dining room and locked her wheelchair at the table. V17 said she did not see R3 fall. V17 said a resident called out that R3 fell. V17 said she was near the dining room exit door when she heard the resident. V17 was found on the floor a few feet from her wheelchair. Wheelchair was still locked. V17 said R3 went around the wheelchair to stand up and was holding onto the table as she walked around before falling per staff interview. Ambulance run report dated 11/6/25 documents: timeline: 11/6/25 5:38PM- symptom onset; 5:46PM, unit notified by dispatched. Upon arrival R3 was located in her room with staff. Staff stated R3 began to walk where she fell injuring her left leg. R3 hospital records dated 11/6/25 documents witnessed fall at nursing home with left leg deformity. R3 presents to emergency room for witnessed fall that occurred at nursing home. R3 had gone from seated to standing position in dining room and fell. Xray of left femur documents midshaft left femur fraction with anterior angulation. On 2/19/26 at 3:21PM, V29 (NP) said she was familiar with R3. R3 has behaviors of being agitated, crying, and trying to stand up. V29 said she not familiar with the falls but would expect staff to be monitoring R3. V29 said If R3 was exhibiting behaviors she would expect staff to intervene and provide supervision. V29 said supervision and monitoring would include being within close distance to the resident and with staff visual fields. On 2/17/26 at 3:41PM, V28 (memory care coordinator) said in the dining room, staff are monitoring residents needs and having there eyes on the residents. Staff are spot checking residents and passing out trays during mealtimes. V28 said there is not a designated staff monitoring the room when staff are passing out meal trays. R3's care plan dated 10/16/25 documents R3 is at risk for falls related to history of falls, weakness, impaired balance and mobility, use of assistive device, impaired cognition, wanders on the unit, hypotension. Interventions: encourage appropriate use of wheelchair dated 10/16/25; ensure bed is in the appropriate lowest position for the patient and ensure bed is locked. Initiated 10/27/25; fall risk assessment quarterly and as needed 10/27/25; monitor resident for attempting to get out of chair or not using assistive device to ambulate. Cue resident to accordingly if this is noted dated 10/25/25; offer resident assistance with toileting dated 10/27/25; promote placement of call light within reach dated 10/27/25; provide environment free of clutter dated 10/27/25; provide proper well-maintained footwear dated 10/27/25; Redirect Resident and offer toileting opportunities when resident appears to be wandering dated 10/31/25. Facility Fall Management Program policy dated 8/2020 documents: The facility is committing to minimizing resident falls and/or injury so as to maximize each resident's physical, mental, psychosocial wellbeing. While preventing all resident's falls is not possible, it is the facility's policy to act in a proactive manner to identity and assess those residents at risk for falls, plan for preventative strategies and facilitate a safe environment. Facility Management of Falls policy dated 8/2020 documents: The facility will assess hazards and risks, develop a plan pf care to address hazards and risks, implement appropriate resident interventions and revise the residents plan of care in order to minimize the risks for the fall incidents and/or injuries to the resident. Assess and monitor resident's immediate environment to ensure appropriate management of potential hazards. (R4) R4 care plan dated 5/18/2018 documents: R4 is at risk for fall secondary to unsteady gait, use of A.D (walker, rollator), hypertension medication, anti-depressant medication use, history of seizures, occasional incontinence, COPD/SOB with exertion and pain, history of fall. (10/31/24) R4 has Dementia. R4 has difficulties with short- and long-term memory acquisition and confusion. Section GG (functional abilities) dated 7/25/25 documents: R4 needs supervision or touching assistance (helper provides verbal cures and/or touching/steading and /or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently with sit to stand: the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. Fall Risk assessment dated [DATE] document a score of seven which indicates at risk. Mobility: Unsteady gait and/or use of ambulatory device. Mentation: Impaired memory. Drugs that have a diuretic effect or increase GI motility. Drugs that affect the though process (i.e., sedative, hypnotics, narcotic, analgesics). Dugs that create a hypotensive effect (new ordered or dosage adjustment.) Elimination status Regularly continent, needs assist to get to the toilet. On 2/17/26 at 2:47pm, V6 (nurse), said, R4 has a history of Dementia. R4 is alert but forgetful. V6 said, R4 required monitoring every fifteen minutes. V6 said, R4 should never be left in her room unless she is sleep. V6 said, R4 must be encouraged to use her rollator because she is forgetful. V6 said, R4 can ambulate by herself when she is in her room but need staff assistance when ambulation in the hallway/from the nursing station back to her room to use the bathroom due to an unsteady gait. V6 said, when she works, she keeps R4 at the nursing station for monitoring. V6 said, she walked past R4's room and saw R4 sitting on her bed or the rollator seat. V6 said, upon returning back up the hallway, she heard R4 yelling. V6 said, R4 was observed by the window on the floor. V6 said, R4 had a hematoma on the top of her head and was complaining of pain to her left arm. V6 said, she does not know what R4 hit or how she fell. V6 said, she asked R4 what she was doing, R4 replied she was answering the phone. V6 said, there wasn't a phone in R4's room. V6 said, she told R4 she had a fall. R4 replied by screaming, she did not fall. Nursing note dated 10/6/2025 documents: Are there any injuries: yes, bruising/hematomas. Detail of any findings: Red raised are to the top of head. Fall incident dated 10/6/2025 documents: Resident (R4) noted on floor by window in bedroom. Resident noted lying on right side. Rollator positioned against the window closet to her upper body. Resident Description: R4 states, I was going to answer the telephone. Immediate Action Take: Full body assessment done with bleeding noted to right side of her lip. Complained of pain to right arm. Hematoma to top of head/scalp. Level of consciousness Alert. Mental status: Oriented to person. Mobility: ambulatory without assistance. Predisposing physiological factors: Impaired memory. Other Info: R4 was last seen around 3:30pm by V6. Notes dated 10/9/25 documents: R4 has a history of Dementia. R4 is alert and oriented times one-two and noted with some confusion. Facility Reportable 10/7/26 documents: Asked R4 how she fell, and she stated, I was going to answer the phone and I don't know what happened. V6 witness statement documents: She did not witness R4 fall. V6 states, R4 will randomly get up and walk around her room. V6 stated, R4 had walked to the opposite side of the room by her roommate's bed which is not unusual for her. That's where she was observed on the floor. V9 witness statement documents: R4 walker was not near her when she fell. R4 was bleeding from her lip and holding her right arm. Hospital paperwork dated 10/6/25 documents: chief complaint-unwitnessed fall at nursing home resulting in head injury. Noted to have a laceration to left lip and abrasion to left scalp. Noted to have a right supracondylar fracture and intraparenchymal contusion. Mental Status alert and orient time one. Care plan dated 10/10/25 documents: re-admitted status post fall diagnosis of close displaced simple supracondylar fracture of Right humerus and intracerebral hemorrhage. Facility Fall Management Program policy dated 8/2020 documents: The facility is committing to minimizing resident falls and/or injury so as to maximize each resident's physical, mental, psychosocial wellbeing. While preventing all resident's falls is not possible, it is the facility's policy to act in a proactive manner to identity and assess those residents at risk for falls, plan for preventative strategies and facilitate a safe environment. Facility Management of Falls policy dated 8/2020 documents: The facility will assess hazards and risks, develop a plan pf care to address hazards and risks, implement appropriate resident interventions and revise the residents plan of care in order to minimize the risks for the fall incidents and/or injuries to the resident. Assess and monitor resident's immediate environment to ensure appropriate management of potential hazards.

Based on interview and record review the facility failed to administer medications as ordered by the physician for one resident (R1) in a sample of 8 residents reviewed for quality of care. Findings include: R1 is [AGE] years old with diagnosis including but not limited to: Chronic Kidney Disease, Stage 4, Hypertensive Heart And Chronic Kidney Disease With Heart Failure And Stage 1 Through Stage 4 Chronic Kidney Disease, Functional Quadriplegia, Dementia, Heart Failure , Chronic Obstructive Pulmonary Disease, Hyperkalemia, Acute Kidney Failure, Disorder Of Mineral Metabolism, Pleural Effusion, Pneumonia, Diabetes Mellitus , Cognitive Communication Deficit, Sedative, Hypnotic Or Anxiolytic Dependence, Severe Protein-Calorie Malnutrition, Polyosteoarthritis, Pressure Ulcer Of Sacral Region, Stage 4, Diaper Dermatitis, Erythema Intertrigo, Hypertension, Gout, Obesity, Neuromuscular Dysfunction Of Bladder. R1's BIMS (Brief Interview for Mental Status) score is 6 meaning R1 is not cognitively intact. R1's medication administration record for October 2025 documents the following scheduled medications as not given or the record has a blank box (not documented as given or not given with the reason to why not): Carvedilol (cardiac medication) Oral Tablet 12.5 MG (milligrams) on 10/10/25 and 10/24/25 at 6 pm (order date 10/7/25 at 4:15 pm and discontinued on 11/4/25 at 6:57 pm) Sodium Zirconium Cyclosilicate Oral Packet (Lokelma) (Potassium Lowering medication) 10 GM (grams) on 10/24/25 at 5 pm (Order Date 09/30/2025 6:15 pm and discontinued on 11/04/2025 at 6:57 pm). On 12/13/25 at 9:16 am V11 Registered Nurse (RN) said after she gives a resident medication, she will document in the electronic health record, and she clicks in the MAR (medication administration record) on the medication that was given. V11 said, the MAR will show if the medication was given, if there is a check mark that means given for the scheduled medications, and if the box is blank that means it's not given. On 12/13/25 at 9:28 am V12 (RN) was observed administering medications. V12 said, he is staff here and he has given R1 her scheduled morning medications. V12 said, on the MAR, if there is a blank space that means it was not given, if a medication was held for some reason, there should be a reason documented. On 12/13/25 at 9:46 am V14 (RN) said related to administering medications, if the medication is not checked off or signed out on the medication administration record, that means it was not given. On 12/13/25 at 12:02 pm V2 Director of Nursing (DON) said V15 Licensed Practical Nurse (LPN) was assigned nurse to R1 on 10/10/25. V2 said, in nursing what is not documented is not done, however that is not always the fact. V2 said, staff were holding R1's medications, due to R1 having an upset stomach, and it should have been documented if the medication was not given with the reason. V2 said, she has spoken to R1's family and made them aware R1 is receiving her medications that are ordered. V2 said, R1's family did ask her about the medication Lokelma and it was few months ago, they asked if she was getting it and V2 informed them R1 was receiving the medication. V2 said, out of the entire month there were 2 days not documented on the mar that medications were given or not given, but V2 believes it was held for emesis. Surveyor asked V2 if R1 was having upset stomach and emesis why other medications were given to her that day, V2 said that even if the medication was held, there is a place on the mar to document as held. Review of R1's progress notes for 10/10/25 and 10/24/25, affirm no progress note was written to any medications being withheld. Facility's staffing sheets document: 10/10/25 V15 (LPN) was working (V2 confirmed she was the assigned nurse to R1) and on 10/24/25 V4 (RN) was assigned to R1. On 12/12/2025 at 2:41pm V2, Director of Nursing (DON) stated, R1 was in the hospital from [DATE] to 9/30/2025. Resident returned to facility with discharge orders from hospital on 9/30/2025. When the resident returns from hospital, the nurse verifies the medication with the physician at the facility. R1 had new medications one topical medication and one Lokelma (Sodium Zirconium) Cyclosilicate. She did not go to the hospital in October. R1 did not get Carvedilol on 10/10/25 or 10/24/25 PM shift (6:00pm dose). I need to see why. If a medication is not given, the nurse will document the reason on the Medication Administration Record. On 10/22/25 Carvedilol was held due to blood pressure. On 10/24/25 I cannot tell why Carvedilol medication was not given. V4, Registered Nurse was the nurse, and no note was written as to why medication was not given. On 10/10/25 V15, Licensed Practical Nurse was the nurse, but she does not work here anymore. She was terminated and there is no note as to why medication was not given. On 12/12/2025 at approximately 3:30pm V4 (RN) stated, I took care of R1 on 10/24/2025 7am-7pm. I give medication according to the order. I sign out medication on the MAR. If not signed, means you either gave and forgot to sign or did not give the medication depending on what happened. You must document why the box is blank or did not give the medication. I am not sure why I did not document. Maybe because R1 was throwing up and it was held. I was supposed to have documented a note, I forgot. She does have emesis, but I would let NP know. I cannot hold medicine for no reason, I think just forgot to document it. Either I forgot to sign out or forgot to document. I cannot really remember what happened. I must have forgotten to sign out when I gave her the medicine or maybe she was having emesis, and the medicine was held but I am not for sure. I am supposed to sign out medicine right away. If I cannot give medicine, I have to document why I cannot give medicine and notify the doctor why I did not give medicine. I should have documented something in the box as to why not given or held and used code. On 12/12/2025 at 3:52pm V2 stated, box for 10/10/2025 is blank, it could mean missed documentation although medication still given, or I guess that would be the only thing. There should be documentation. After the medication is given, the nurse should document when the medication is given, the nurse should document administration. If not documented not done and there should be a note. R1's Family did speak to me about R1's medication not being given. They asked if she was getting the Lokelma (Sodium Zirconium) Cyclosilicate. The medication was under a different name, and I showed it to her (R1's daughter) that she was getting it. I am not aware of any other medications. On 12/13/2025 at 11:33am V16, RN stated, when medication is given, I document administration immediately after I give the medicine in the box on the MAR. If the resident does not take their medicine, we document using one of the codes in the box and write a note. If the administration box is left blank, it means you did not give the medicine. The box should not be left blank. Facility's JOB DESCRIPTION Staff Nurse (Registered Nurse/License Practical Nurse) documents in part: P. Prepare and administer medications and treatments if appropriate as ordered by the physician. Q. Review medication record for completeness of information, accuracy in the transcription of the physician's order, and adherence to stop order policies. Facility's (3/2021) Medication Administration: General Guidelines documents in part: 5. Each dose administered shall be properly recorded on the resident's MAR, TAR, or eMAR, immediately following administration. On paper records, initials are verified by signature each month in the section provided on the back of the MAR/TAR. 6. If the physician's medication order cannot be followed, the physician should be notified, depending upon the situation. On paper records, the authorized staff initials are circled on the front of the MAR indicating the dose was not given; reason is recorded on the back. If an eMAR is being utilized, document in the record the reason the medication was not given.

Based on interview and record review, the facility failed to ensure effective supervision and monitoring of residents in the dining room to prevent accidents. Specifically, staff failed to maintain visual supervision of a resident assessed to be at risk for falls. This affected one of three residents (R1) reviewed for falls. This failure resulted in R1 sustaining an unwitnessed fall in the dining room and being sent to the local hospital where R1 was treated for a hip fracture. This past non-compliance occurred from 8-15-2025 to 8-29-2025. Findings include:R1's face sheet shows diagnoses including chronic hepatic failure hepatic encephalopathy anemia Alzheimer's type 2 diabetes COPD depression anxiety hypertension and dementia. MDS dated [DATE] section C shows Brief Interview for Mental Status (BIMS) score of 4 (cognitive impairment).The facility final report to the State department dated 8/22/25 denotes in-part R1 is a [AGE] year-old female resident who was admitted to the facility to 2/19/25 with diagnosis that include but not limited to chronic hepatic failure hepatic encephalopathy anemia Alzheimer's type 2 diabetes COPD depression anxiety hypertension and dementia. Resident is alert and oriented times one to two spheres and requires partial to moderate assist with ADL's (activities of daily living). BIMS 4/15. Resident was observed lying on the floor in the dining room with reports of pain resident alert and oriented times one to two per baseline. Hospice notified with orders to send to ER (emergency room) for further evaluation. POA (Power of Attorney) also notify of occurrence. Resident was transported to (hospital name) then subsequently transferred to (hospital name) where she was admitted with a right femoral neck fracture. It is probable residence led to floor based on proximity of wheelchair to table. Table mates were unable to provide detail regarding incident the nurse interview reveal the resident was seated at the table properly positioned with proper footwear a few minutes prior to the incident. During this investigation abuse was not found to be a factor based on staff/ resident interviews.On 9/3/25 at 2:05pm V5, Licensed Practical Nurse (LPN) said she was covering for R1's nurse because she was on break. V5 said she walked pass the dining room where she observed R1 sitting in her wheelchair at the second table to the left (front facing when walking through the doors of the dining room) R1's back was to the door. V5 said she did not see any food trays in the dining room, lunch was over. V5 said she went and sat down at the nurse station, across from the dining room. V5 said she could not see R1 from her position. V5 said she was monitoring the dining room from the Nurse station. V5 said a couple minutes later two staff members approached her an informed her that R1 was on the floor in the dining room, V5 said this was around 1:20pm, she looked at the clock. V5 said she did not see R1 fall. She did not see what R1 was doing just before she fell. V5 said she was not aware that R1 was at risk for falls, V5 said the Nurse did not give her a report before she took her break. V5 said she assessed R1, she observed R1 laying on the floor on her right side, she was laying in between two tables, her head was toward the wall and her feet was out. V5 said she palpated R1's body and when she touched R1 back, R1 winced and complained of pain. V5 said R1 did not have pain when she palpated R1's hip. V5 said R1 was not moved from the floor, and 911 was summoned, physician notified, and R1 daughter was notified. V5 said 911 took R1 to the hospital for further evaluation. V5 said there's no solid rule that someone must be in the dining room to monitor the residents, they can be monitored from the Nurse station. V5 said she did not see R1 fall, while she was monitoring the dining room.On 9/3/25 at 2:25pm V6 (Director of Nursing) said R1 had an unwitnessed fall. V6 said the root cause of R1 fall was maybe R1 was trying to take herself back to her room after lunch as she often did. V6 said V5 was monitoring the dining room when R1 fell. V6 said if the residents are in dining room staff should be there to monitor the residents. V6 said the staff should be able to see all the residents when monitoring the dining room. V6 said if she had to do things different, she would have the staff bring the residents out of the dining room after lunch. V6 said the residents can sit near the Nurse station for observation by staff.On 9/3/25 V2 (LPN) said R1 had to often be redirected and asked to sit down in her wheelchair because she could fall.9/3/25,12:46pm V4, Certified Nursing Assistant (CNA) said R1 had to often be redirected and asked to sit down in her wheelchair because she could fall.9/4/25 at 1:32pm V7 (CNA) said he was picking up lunch trays from the resident's rooms, as he headed to the dining room R1 was observed on the floor on her back. V7 said there were no other residents in there with R1. There were no staff in there with R1. V7 said he summoned the Assistant Director of Nursing and V5 (LPN). V7 said R1 was trying to get up a few times but she couldn't, V7 said he even went downstairs to get a lift pad just incase they was going to get R1 up. V7 said R1 often stood up from her chair and sat back down, and if the wheels were not locked the chair would roll backwards. V7 said he believes that what happened. V7 said V5 did assess R1, 911 was called and R1 was sent to the hospital for further evaluation.R1's care plan with initiated date of 2/19/25 denotes in-part R1 is at risk for falls related to weakness impaired mobility use of narcotic cognitive impairment diagnosis hepatic encephalopathy and Alzheimer's disease use of assistive device, use of medications that affects GI (gastrointestinal) motility, use of psychotropics overactive bladder continent of bowel and bladder. Goal: will remain free of falls through next review. Interventions: assure resident is wearing eyeglasses. Encourage appropriate use of Walker. Encourage appropriate use of wheelchair. Ensure that the bed is inappropriate lowest position for the patient and the bed is locked as appropriate. Fall risk assessment quarterly and as needed. Monitor for changes in ability to navigate the environment. Offer resident assistance to bathroom as needed throughout the night early morning when making rounds. Orientate resident to surroundings frequently including location of bathroom dining room bedroom and activity locations. Place resident in bed if returning her to her room period do not leave in room in wheelchair without supervision/monitoring. Promote placement of call light within reach. Provide an environment clear of clutter. Provide proper well-maintained footwear. Remove resident from common areas after completion of her meal.R1 fall risk assessment dated [DATE] denotes in-part post fall assessment, unsteady gait and or use of ambulatory device, confused, 1-2 falls in the last 3 months, taking medications that have a diuretic effect, drugs that affects thought process, and drugs that effect hypotensive effect, regularly incontinent: needs assist to et to the toilet. Score is 8, at risk for falls.R1 hospital record dated 8/15/25 denotes in-part Xray, hip, there is sclerosis the femoral neck, there is suspicious for an impacted nondisplaced right femoral neck fracture. Impression, probable nondisplaced femoral neck fracture.Facility policy titled Fall management program dated 8/2020 denotes in-part the facility is committed to minimizing resident falls and or injury so as to maximize each resident physical mental cycle social well-being. 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 residents at risk for falls plan for preventive strategies and facilitate a safe environment.Prior to the survey date of 9/11/2025, the facility had taken the following action to correct the noncompliance:1. On 8/18/2025 the facility reviewed all residents that were a fall risk in the past 3 months and care plans were reviewed and interventions put in place.2. On 8/22/2025 thru 8/29/2025 the facility in-serviced all nursing staff on fall management program, fall prevention, and management of falls. Staff in-service on resident supervision while dining and after dining.3. On 8/18/2025 QA audit tool for dining room supervision developed and monitoring of resident started and continues to be done (8/18/2025 to 9/4/2025) audits reviewed.4. 8/29/2025 and emergency QA meeting was held by the Administrator with the interdisciplinary team and Medical Director and the team approved the past noncompliance plan.

Based on interview and record review, the facility failed to ensure that the Infection Preventionist participated in the facility's QAA/QAPI programming. This failure has the potential to affect all 174 residents that reside within the facility. Findings include:On 9/09/25 at 1:49pm, V16 (Assistant Administrator) affirmed that V15 (Assistant Director of Nursing/ADON & Infection Preventionist) Became IP (Infection Preventionist) in February 2025.On 9/09/25 at 12:06pm, upon review of the Facility's Quality Assurance and Assessment (QAA) Committee meeting sign-in sheets dated 3/11/25, 4/08/25, 7/08/25, and 8/12/25 with V16 (Assistant Administrator), there was no documented signature from V15 (Assistant Director of Nursing and designated Infection Preventionist) to confirm her attendance. V16 (Assistant Administrator) confirmed that the facility's designated Infection Preventionist did not attend the Quality Assurance and Assessment (QAA) Committee meetings. V16 further acknowledged that, the Infection Preventionist is required to participate in QAA Committee meetings as a standing member. V16 confirmed that the intent of QAPI is to ensure that residents consistently receive safe, effective, and high-quality care that is subject to ongoing evaluation and continuous quality improvement.Facilities policy titled, QAPI Plan, revised date October 2019, documents, in part, . Leadership of our facility shall be ultimately responsible for the QAPI Program. The Administrator is responsible for assuring that this facility's QAPI Program complies with federal, state, and local regulatory agency requirements.Facility job description titled, Infection Preventionist Nurse, dated 7/2024, documents, in part, . Participate in staff meetings, QA meetings.Pamphlet titled, Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities, revised date 11/18, documents, in part, Your facility must provide services to keep your physical and mental health, at their highest practical levels. Your facility must be safe, clean, comfortable, and homelike.Facility census, dated 9/08/2025, documents 174 residents residing at the facility.

Based on observation, interview and record review, the facility failed to protect a resident's rights to be free from abuse. This applies to 1 of 1 resident (R1) reviewed for abuse. Findings include: R1 was admitted to the facility on [DATE] with multiple diagnoses which included encephalopathy, end stage renal disease, acquired absence of kidney, chronic obstructive pulmonary disease, hypertensive heart and chronic kidney disease. R1's MDS (Minimum Data Set) dated 05/21/25 showed R1 was cognitively intact. The facility's 06/11/25 Initial Report to the State Survey Agency showed R1 reported to V1 (Administrator) that V7 (CNA/Certified Nursing Assistant) kicked his bed while providing care to his roommate. The report stated R1 was able to identify the staff member involved. A police report was filed with the local police (report number 2025-00102089). The facility's Final Report dated 06/17/25 to IDPH showed the facility was not able to substantiate the allegation. V7 was allowed to return to work on a different unit. On 07/01/25 at 9:43 AM, R1 was in bed watching TV (Television). R1 had a camera in his room. R1 stated on 06/10/25 at 9:27 PM, V7 (CNA/Certified Nursing Assistant) was taking care of his roommate. The privacy curtain was closed. R1 stated V7 came in between the beds to turn off the call light. R1 stated he asked V7 where was the other CNA, you shouldn't be in my room. He got pissed and shook the side of my bed. R1 stated he informed V7 that he was recoding him. R1 stated he reported the situation to the Assistant Administrator and the ADON (Assistant Director of Nursing). R1 stated no other staff was present in the room when the incident occurred. On 07/01/25 at 2:00 PM, R1 showed a video that was on his laptop to the surveyor. The video had a date and time stamp of 06/10/2025 at 9:28 PM. The video showed R1 sitting upright in his bed with the privacy curtain drawn. The video began and at the 1:21 time mark, an unseen person standing on the other side of the privacy curtain, grabbed the top left side rail, and began to shake the bed continuously for three seconds. R1 pulled the privacy curtain open. The person's face was never visible in the video. The remainder of the video showed R1 arguing with the person. R1 was heard saying You had no business touching my bed like that, like an idiot because you're mad. On 07/01/25 at 2:25 PM, R2 stated he was in the room with R1 when the incident happened. R2 stated he did not see anything happen, but he heard R1 yelling. R2 stated it was only him, R1 and V7 in the room when the incident occurred. On 07/01/25 at 4:00 PM, V1 stated R1 notified her on 06/11/25, that V7 donkey kicked his bed. V1 stated R1 told her he felt the person kick his bed, he swung the curtain open and pointed the camera in V7's face. We are supposed to make sure all residents in the facility are free from abuse. If a resident is abused there could be some mental anguish or emotional feelings. The facility's Abuse Policy dated 03/25 showed, 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's Abuse Prevention Program dated 03/25 showed, Orientation and training of Employees, d. How to recognize and deal with burnout, frustration and stress that may lead to inappropriate responses or abusive reactions to residents.

Based on interview and record review the facility failed to timely notify a resident's family after a fall that required transportation to a local hospital for evaluation for 1 of 3 residents (R2) review for notification of change in the sample of 6. This past non-compliance occurred from 1/9/25 to 1/14/25. The findings include: R2's Fall Investigation Report shows that on 1/9/25 at 9:30 PM, R2 had a fall from his wheelchair resulting in a bruise to the right side of his head, an abrasion to his face and blood on his lips/mouth area due to biting his lip when he fell . R2 was transported to the hospital for evaluation. The report shows that V14 (R2's Mother) was notified on 1/10/25 at 4:40 AM. R2's Nursing Notes from 1/10/25 at 3:59 AM shows, The resident was returned to the facility from [Local Hospital] at 3:30 AM .The resident had been sent out as a result of a fall at 9:30 PM on 1/9 . On 1/17/25 at 12:25 PM, V14 said that she was notified at 6:56 AM on 1/10/25 that R2 had fallen, was sent to the emergency room and had returned to the facility and was fine. V14 said that the facility never called her when he fell or notified her that he was being sent out to the hospital. On 1/17/25 at 2:49 PM, V2 (Director of Nursing) said that family should be notified immediately after a resident falls. V2 said that family should be notified if a resident is being sent out to the hospital for a change in condition. V2 said that V14 approached her on 1/10/25 and said that she was not notified that R2 had a fall and was sent to the hospital. V2 said that she spoke with V17 (Licensed Practical Nurse) and he said that he notified V14 when R2 returned from the hospital but did not notify her when he fell and was sent out to the hospital. The facility's Change of Condition (Resident) policy dated 9/20 shows, The .responsible party will be notified with changes in a resident's condition. Prior to the survey date of 1/17/25, the facility had taken the following action to correct the noncompliance: 1. On January 10, 2025- January 13, 2025 all facility nurses were educated on notification of family after a change in condition. 2. On January 14, 2025 the facility Compliance Assurance Committee developed a plan of correction regarding notification of family after a change in condition. 3. Subsequent changes in condition from 1/10/25 to 1/17/25 were determined by the Quality Assurance Tool to have been completed timely.

Based on observation, interview, and record review the facility failed to ensure a resident was assessed and monitored after a fall and failed to document that the fall occurred for 1 of 3 residents (R2) reviewed for quality of care in the sample of 6. The findings include: On 1/17/25 at 12:25 PM, V14 (R2's Mother) showed a video of R2 falling out of bed on 12/18/24. The video showed that on 12/18/24 at 10:20 AM, R2 was sitting on the floor in his room with his back up against the right side of his bed. Two staff members entered the room (identified by V14 as V15 (Wound Certified Nursing Assistant-CNA) and an unknown CNA) and picked R2 up from the floor and placed him in bed. On 1/17/25 at 4:11 PM, V15 said that on an unknown date, she was walking past R2's room and saw him on the floor. V15 said that she called for someone to help her get him back to bed. V15 said that she does not recall who helped her get him back to bed or how they got him back to bed but it was probably another aide. V15 said that she did notify the nurse but she does not recall what nurse. On 1/17/25 at 10:40 AM, V6 (Registered Nurse) said that after a resident falls, the staff should immediately notify the nurse before moving the resident so the nurse can do an assessment. V6 said that the assessment should include doing vital signs, checking for bruising, bleeding or injuries and checking the resident's range of motion and pain. V6 said that if everything appears ok, the resident is moved back into bed. V6 said that the physician should be notified along with the family and any new orders carried out. V6 said that the assessment should be documented in the resident's clinical records. On 1/17/25 at 2:49 PM, V2 (Director of Nursing) said that all falls should be documented in the medical record. V2 said that if a resident falls, the staff should not touch the resident until after the nurse does a full body assessment. V2 said that the physician, family, and herself should be notified of the fall. V2 said that new fall interventions should be immediately implemented and their care plan updated to try and prevent future falls. R2's clinical records from 12/18/24 does not document any falls or assessments from the fall that happened at 10:20 AM. On 1/17/25 at 4:30 PM, V1 (Administrator) said that the facility does not have a policy or procedure for the staff to follow after a resident falls. The facility's Fall Risk Assessment Policy dated 8/2020 shows, If a resident fall, the nurse will complete an Occurrence Report and Initiated Post-Occurrence documentation.

Based on observation, interview, and record review, the facility failed to implement safety measures for residents at risk for wandering, to prevent a cognitively impaired resident from eloping from a locked unit and exiting the facility without supervision on two separate occasions. This failure resulted in R1 eloping from the facility without staff knowledge or supervision, walking past a pond and across a thoroughfare to a movie theater parking lot where R1 remained for an hour. R1 eloped from the facility a second time in the afternoon six days later when she walked past the receptionist and into the parking lot. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on 09/04/2024 at 8:03 PM when R1 eloped from the facility unwitnessed by staff. This failure effects 1 of 5 residents (R1) reviewed for elopement risk in the sample of 8. V1 (Administrator) and V18 (Nursing Consultant) were notified of the Immediate Jeopardy on 09/18/24 at 9:29 AM and the IJ template was provided. V1 provided an Immediacy Removal Plan at 10:45 AM on 9/18/2024, which was rejected and returned to V1 at 11:55 AM. The facility's second Immediacy Removal Plan was provided by V1 at 1:30 PM and it was accepted at 1:55 PM. The Surveyor confirmed the immediacy was removed on 09/19/2024 at 2:38 PM, however the facility remains out of compliance at a Severity Level II due to the need to evaluate the implementation of new procedures and Quality Assurance monitoring. Findings include: 1. On 9/13/2024 at 10:45 AM, R1 was in her bed on the locked dementia unit with the head of her bed elevated. R1 was asked a few questions to which she provided short answers or shook her head yes or no. R1 was asked if she remembered leaving the facility and being at the movie theater parking lot and she shook her head no; R1 shook her head no when asked if she knew the name of the facility; and R1 answered she had been at the facility for 15 days (R1's Face Sheet showed she was admitted [DATE], five months earlier) when she was asked. R1 answered no when asked if she knew where she lived before, and stated she was not sure what town her daughter lived in. R1 answered she doesn't know if she had ever left the facility unsupervised before. R1 answered yes to using the elevator before, but wasn't sure of how she got there, or where she was going. R1 responded slowly to questions and her voice was very quiet. R1's Face Sheet showed her diagnoses include moderate vascular dementia, unspecified psychosis, and major depressive disorder, single episode, severe with psychotic features. On 9/13/2024 at 12:15 PM, V1 (Administrator) showed and explained facility video covering R1 leaving the facility unattended on 9/4/2024. V1 stated video was timestamped as 8:03 PM when R1 was noted descending the concrete stairs in front of the building and then walking off to the right, out of the frame. V1 stated the facility received a call from the movie theater at 9:11 PM (over an hour later) that R1 was in their parking lot. V1 stated R1 was gone from the facility for over an hour and she did not know how R1 was able to get off the locked unit. On 9/13/2024 at 2:00 PM, V7 (Operations Manager at local movie theater) showed the theater's security video from the evening of 9/4/2024, explaining it as it was viewed. V7 stated R1 is first seen on camera at 8:17 PM (14 minutes after leaving the facility). V7 stated there was one car parked behind a tree in the north parking lot and R1 walked up to it and waited. At 9:03 PM (45 minutes after R1 coming into view), two movie patrons exited the theater and went to their car and found R1 waiting there. V7 explained that one [NAME] stayed near the car and the other went back into the theater to get the manager and security. V7 stated that at 9:06 PM, security and the manager came out to talk to R1, and R1 was only able to tell them her name and that she was thirsty. V7 explained that a Police car drove by and theater staff flagged him down. V7 stated that an item R1 was carrying had the facility name on it. V7 stated a call was placed to the facility at 9:11 PM, notifying them that R1 was at the theater. V7 stated at 9:17 PM, facility staff members arrived at the theater parking lot to escort R1 back to the facility. On 09/13/24 at 1:50 PM, Surveyor drove in a car from the facility to the movie theater. The GPS (GPS/Global Positioning System) showed if walking along the roads to the theater, the distance from the facility to the movie theater was 900 feet. There was a thoroughfare between the facility and the movie theater and a retention pond between the facility and the movie theater. On 9/13/2024 at 12:35 PM, V13 (Therapy Director) stated she had worked directly with R1 and R1 had confusion and diminished safety awareness. V13 stated R1 had problems with task segmentation and higher-level tasks where there is more complexity and difficulty. R1's 7/22/2024 Minimum Data Set showed R1 was moderately cognitively impaired. R1's 4/16/2024 Exit Seeking/Wandering/Elopement Risk Assessment showed R1 had the physical ability to leave unit/facility, cognitive impairment with a diagnosis of dementia, and history/current behavior of elopement attempts and exit-seeking. The Assessment category showed R1 was At Risk for elopement. R1's 4/22/2024 Behavior/Interventions progress note showed she was attempting to exit the stairwell doors. R1's 8/9/2024 Social Services progress note showed Noted to be standing by elevator frequently, attempting to board elevator . R1's 8/15/2024 Behavior progress note showed Noted to be standing by elevator she was attempting to board elevator and becoming aggressive with staff . R1's 8/20/2024 Behavior note showed R1 was standing by the elevator, attempting to push button to open the door . R1's 9/5/2024 Exit Seeking/Wandering/Elopement Risk Assessment (the day after R1's 9/4/2024 elopement) continued to show R1 was At Risk for elopement. On 09/13/2024 at 9:34 AM, V15 (Memory Care Director) stated we are not sure how R1 was able to get out of the building. V15 stated R1 was scored as high risk for elopement when she was admitted on [DATE]. On 9/13/2024 at 1:15 PM, V10 (RN-Registered Nurse) stated If people mistakenly push 3rd floor on the elevator, the elevator goes up to 3rd floor. On 9/18/2024 at 12:05 PM, V1 stated at 8:00 PM, the Receptionist is to deactivate the front door to be opened if someone tries to enter from outside, and it then alarms any time it opens at all. V1 stated the Receptionist punched out at 8:11 PM the night of 9/04/2024 and did not set the door alarm before leaving work. On 09/19/24 at 12:34 PM, V22 (Medical Doctor) stated he is the primary Physician for R1 while she resides in the facility. V22 stated he was aware of R1 eloping from the facility two times. V22 stated R1 has diagnoses of dementia and psychosis and R1 is not decisional due to her diagnoses. R1's 9/8/2024 Nursing progress note showed Resident was standing by elevator. [Certified Nursing Assistant-CNA] tried redirecting resident to room. Resident became aggressive and tried to punch CNA. R1's 9/9/2024 Social Service note showed Per [night shift] staff, [R1] was agitated, attempting to get onto elevator all shift, attempting .to enter the elevator by using force to move staff out of the way . On 9/13/2024 at 9:34 PM, V15 (Memory Care Director) stated that on 09/10/2024, R1 was found in the parking lot and was brought back to the unit by a staff member around 3:30 PM. V15 stated we do not know how R1 was able to get on the elevator a second time. V15 stated R1 walked past the receptionist and went outside on 9/10/2024. V15 stated our receptionist sits at the desk from 8:00 AM to 8 PM. V15 stated a resident with dementia that leaves a locked unit unsupervised could have a fall, leave the grounds where they can't be located, and put themselves in dangerous situations. V15 stated it is all staff members responsibility to make sure the residents are safe and in the building. On 9/13/2024 at 12:30 PM, V1 (Administrator) showed and explained facility video surveillance for R1's second elopement on 09/10/24. V1 stated R1 walked out of the main entrance of the facility at 2:53 PM, and then leaves the video frame. V3 (Receptionist) is then seen outside the front door at 3:17 PM (24 minutes later), looking toward the parking lot. V1 explained V3 got V4 (Human Resources/Business Office Manager-HR/BOM) and V5 (Activity Aide) for help and at 3:33 PM, R1 was brought back in the facility in a wheelchair. On 09/13/2024 at 3:50 PM, V3 (Receptionist) verified she was the receptionist on duty on 09/10/24 when R1 eloped from the facility the second time. V3 stated she was sitting at the reception desk and she did not see R1 go past her and leave. V3 stated a family member called the facility and said, a lady was trying to get into her car and I think she's one of your residents. V3 stated she went outside and saw R1 in the parking lot. V3 stated she informed V4 (HR/BOM) that R1 was outside in the parking lot. V3 stated she did not call a code green for resident elopement. On 09/13/24 at 12:55 PM, V14 (Speech Language Pathologist) stated R1 was not oriented to time and place and had moderate to severe dementia. V14 stated while R1 was receiving therapy, the sessions were cut short due to R1 always having somewhere to go. R1's Elopement care plan (initiated 4/16/2024) showed a focus of .at-risk for elopement related to cognitive impairment, physical ability to leave unit/facility. She will also stand in front of the elevator, attempt to push the button. An intervention from 4/16/2024 showed Monitor behaviors. The facility's 3/28/2023 Elopement and Management of Missing Resident Policy defined elopement as .a dependent (cognitively impaired, non-decisional) resident leaving a facility without staff awareness and under circumstances that place the resident's health, safety, or welfare at risk. The policy further showed 2. i. The Administrator and Director of Nursing will evaluate the situation and develop a plan of action based on the individual resident . The Immediate Jeopardy that began on 9/4/2024 was removed on 9/19/2024 when the facility took the following actions: Allegations of non-compliance #1 * Lack of supervision of a cognitively impaired resident who wanders. Corrective Action Taken: * Resident was reassessed for elopement risk on 9/5/2024 after the elopement occurred and deemed an elopement risk. The resident elopement risk assessment was reviewed on 9/11/2024 by Memory Care Director with no changes warranted. * Resident was located and returned to the facility on [DATE] and on 9/10/2024. A head-to-toe assessment was completed (by the assigned nurses), with no signs of injury on either occurrence. * The Resident care plan was updated pertaining to the elopement that occurred on 9/4/2024, (by the Memory Care Director - MCD) and further reviewed and updated on 9/10/2024 (by the MCD). * On 9/10/2024 the DON, Administrator, ADON, and Medical Director reviewed the facility policies related to the occurrence: Elopement, Routine Resident Checks, Exit Seeking, and Incidents/Accidents. No changes were made. * Starting on 9/5/2024, the Memory Care Director and Social Service Director updated the assessments and care plans for elopement risk residents. The assessments were completed on 9/11/2024. On 9/10/2024 the Administrator initiated further education that a resident exhibiting exit seeking behaviors should be placed on enhanced monitoring including 15 minute checks and 1:1 supervision until the behavior subsides or alternate measures are put into place. Staff were educated to alert the nurse of exit seeking behaviors who would then implement increased intervention. This was completed on 9/11/2024. Identifying other residents having the potential to be affected by the same deficient practice: * All residents were reassessed for elopement risk on 9/5/2024 and completed on 9/11/2024. A further review was conducted by Social Services Director and Memory Care Director on 9/11/2024 to determine if there were any changes and there were none. * All new admissions will have an elopement risk assessment that will be completed within 24 hours upon admission and interim care plan will be initiated based off the assessment, and will be reassessed every three months, and as needed (by MCD). * All residents that are identified as-risk for elopement during admission had a review of their care plan and updates were made where applicable, completed on 9/10/2024 and further reviewed on 9/11/2024. Pictures of at-risk residents were placed in a binder on all nursing stations (1st,2nd,3rd floors) and the receptionist desk which was completed on 9/10/2024 and reviewed on 9/11/2024 (by MCD). * All residents determined to be at-risk for elopement and with active exit-seeing behaviors will be evaluated for a possible room change to the secured unit on the third floor to limit access to the front entrance door on the first floor. * Beginning on 9/4/2024, interviews were conducted (by the Administrator) with staff to determine further potential risk and completed on 9/5/2024. Additional interviews were initiated on 9/10/2024 and completed on 9/11/2024 to further identify any potential risk factors. Measures taken to ensure that the problem is corrected and will not recur: * All staff and managers are being reeducated on routine resident checks, exit seeking, incidents/accidents, elopement policy and procedure and where to locate the at risk of elopement binders. The reeducation was provided on 9/5/2024 and was completed on 9/10/2024. * All staff and managers are being reeducated on elopement risk and reporting behaviors or changes in factors related to elopement risk to appropriate discipline. This was started on 9/5/2024 and completed by 9/10/2024. * All reception staff were reeducated on monitoring the front doors and resident safety and proper procedure for code green completed on 9/11/2024 * Exit doors will be monitored by staff when unalarmed. The receptionist will monitor the front entrance door 8am-8pm. From 8pm-8am door will be armed by receptionist and monitored by 1st floor nurses through the duration of that time. * Exterior door alarms will be checked daily by the maintenance director and EVS Supervisor to ensure they are in working order and secured. Completed 9/5/2024 and checked again on 9/11/2024. * After initial elopement on 9/4/2024 resident was placed on 15 minute checks for 24 hours. During that time the facility met with daughter and discussed new interventions. A plan was established and implemented. * 1:1 Visual monitoring was initiated (by staff) for the resident (9/11/2024). Intervention will remain in place until the facility's wandering management system is installed and determined to be effective to prevent further incident. * Elevator monitor was initiated for 3rd floor (9/11/2024). Elevator will remain monitored 24 hours a day until wandering management system is installed and determined to be effective to prevent further incident. Measures or systems the facility will alter to ensure that the problem will be corrected and will not recur. * A review of compliance using Quality Assurance Audit tool for elopement started (by the Administrator) on 9/5/2024. The Audits will be done daily for two weeks then twice weekly for four weeks, then monthly x 3 months, and evaluated at the monthly QAPI meeting to determine compliance. Audits to be completed by members of the IDT team and turned into Administrator who will ensure audits are being completed. * A review of results of audit regarding elopement and door alarm working condition with the facility's interdisciplinary team started on 9/5/2024. Audits will be done weekly for four weeks, then monthly x 3 months, and then randomly by Administrator/designee until goal is attained. Results of these audits will be reviewed at the monthly QAPI to determine compliance. * Administrator to Audit daily that exterior front door alarm is being activated each day by receptionist at 8pm prior to leaving. * A facility wandering management system install was initiated 9/10/2024. * During orientation of new hires, the facility (Business Office Manager) will educate newly hired staff on elopement and conduct competency quizzes. Quality Assurance Plans to monitor facility performance: * The facility Quality Assurance Team/ IDT (including Medical Director, Administrator, Social Services, DON, ADON and facility consultant) shall meet at least monthly to review elopement risk residents, trends, patterns and develop and implement action steps as necessary. * The QA meeting is held monthly for three months, then quarterly and as needed. An emergency QA meeting was held on 9/5/2024 and 9/10/2024 by the Administrator with the Interdisciplinary Care Team and Medical Director. The Elopement from the facility on 9/4/2024 and 9/10/24 were discussed along with the Removal Plan. The Medical Director and Interdisciplinary Care Team approved this Removal Plan. This will be monitored by the Administrator, DON, ADON, and Social Services.

Based on interview and record review, the facility failed to provide stand-by assistance to a resident who required assistance to ambulate. This failure led to R1 falling and fracturing her nasal bone. This applies to 1 of 3 residents (R1) reviewed for accidents and supervision in a sample of 7. Findings include: R1's Hospital Records showed Clinical Summary: [AGE] year-old female had a fall easily agitated and restless developed sundowning [she] had epistaxis from her right nare that was repaired. Patient had cauterization as well as a rhino rocket since patient is on Eliquis and thus contributed to her bleeding. The Record also showed on May 13, 2024 at 07:04 PM, a CT (Computed Tomography) of the maxillofacial bones, orbits, and paranasal sinuses without contrast was taken with results showing Bilateral comminuted nasal bone fractures are visualized. R1's Incident Report dated May 13, 2024 at 12:42 PM showed a statement written by V3, which showed the following: Writer heard a loud noise went into the dining area, noted resident on the floor lying on her left side of the face. Resident was trying to get up. Writer noticed blood on the floor. Resident was bleeding from her nose. [Abdominal] pads applied to stop bleeding. Vital signs taken and 911 called. Family informed as well as NP (Nurse Practitioner) [Name] informed as well. Paramedic came and transfer resident to [Hospital]. The Incident Report also showed a statement by V2, which showed the following: On 5/13/24 at approximately 12 noon resident was ambulating in dining room with her rolling walker and was witnessed to have tripped either on her foot or the wheel of the walker and fell on her left side striking her nose on the floor per witness statements. Discoloration noted to bridge of nose with swelling along with copious amount of bleeding from nares. First aid rendered with ice packs to nose. Complete body check done no other injuries observed, 911 called. MD (Medical Doctor) and family aware of occurrence. Resident taken to [Hospital] for further evaluation. Resident stated that she fell . Resident stated that no one caused her to fall when asked. Based on staff statements any occurrence of abuse was ruled out due to residents seating prior to fall and the fact that no other residents were around or nearby [R1] at time of fall. Report called to ER (emergency room ). The EMR (Electronic Medical Record) shows diagnoses including hypertension, Alzheimer's disease, atrial fibrillation, type 1 diabetes mellitus, chronic obstructive pulmonary disease, and fall from chair. R1's discharge MDS (Minimum Data Set) dated May 13, 2024 showed R1 had modified independence with daily decision making. R1 required set up assistance for eating, oral hygiene, toileting hygiene, shower/bathing, upper body dressing, putting on/taking off footwear, and personal hygiene. R1 required supervision for lower body dressing. R1 required supervision or touching assistance to ambulate 10 feet, 50 feet, and 150 feet. R1's care plan initiated on May 9, 2024 had a focus which showed R1 was at risk for falls. R1's admitting interventions included Monitor for changes in ability to navigate the environment. Promote placement of call light within reach. Provide an environment clear of clutter. Provide proper, well-maintained footwear. On May 11, 2024, the following interventions were included after R1 fell : Encourage appropriate use of wheelchair . Walk along side of resident when walking. On May 21, 2024 at 8 AM, V13 (Family Member) said R1 had fallen but she had heard multiple stories about what happened. V13 said she was told her mother had been walking and fell ; another story was she had fallen and hit her head on the table; and lastly R1 told her she had been pushed. V13 said she was trying to figure out what had happened, and the facility did not have cameras to confirm. V13 said R1 broke her nose, had two black eyes, and at first could not even open her eyes. V13 said R1 used a rollator to walk. V13 said R1 had fallen first on May 11, 2024. V13 said she was told R1 tripped and fell to her knees. V13 said the second fall was on May 13, 2024 and she had received a call about it from V3 (LPN) at 11:54 AM. On May 21, 2024 at 1:20 PM, V4 (CNA/Certified Nurse Assistant) said he had seen R1 ambulating around the unit using a walker by herself. On May 22, 2024 at 2:20 PM, V4 said V6 had said someone needed to walk behind R1 but R1 usually walked by herself from her room to the dining room and back. V4 said R1 was independent with walking. On May 21, 2024 at 1:25 PM, V17 (Memory Care Aide) said the residents were in the dining room because they had finished the morning group activities. V17 said she told the residents who could ambulate by themselves to find their seats for lunch, which included R1. V17 said she saw R1 stumble and fall forward to the ground. V17 said she was not sure if R1 tripped on her shoes or the walker. V17 said V16 (Memory Care Aide) was the first person to get to her. V17 said there were no residents behind her and the closest resident to her was farther up in front of her. V17 said R1 had a bloody nose and a bump on her forward in between her eyebrows and was sent out to the hospital. On May 22, 2024 at 02:05 PM, V17 said she was not notified R1 needed assistance to walk and had asked V18 (Memory Care Aide) if R1 had any changes, and V18 said R1 was able to ambulate on her own. On May 21, 2024 at 1:43 PM, V3 (LPN) said according to the activity aides, they had told R1 to sit somewhere else. V3 said he did not see R1 fall but heard her fall and went to assess her. V3 said R1 fell on to her face and was bleeding uncontrollably. V3 said he brought the treatment cart as well as the crash carts, put abdominal pads on R1's face and applied pressure to get the bleeding to stop. On May 23, 2024 at 9:43 AM, V3 said he was aware R1 had fallen in the facility prior to her fall on May 13, 2024, but he was not clear on what had happened. V3 said he thought it had something to do with the walker, but he was aware R1 was a fall risk. V3 said during the stand up meeting held every morning, he was told to closely monitor R1, keep her bed low, make sure she was using her walker correctly, and fall mats when she was in bed. V3 said no one had notified him that R1 required stand by assistance to ambulate. V3 said he had not notified the staff about it either but said everyone knew she was a fall risk. On May 22, 2024 at 3:10 PM, V20 (Medical Doctor) said R1 had a history of falls. V20 said he was notified R1 had fallen on May 11, 2024 and he said he would expect the staff to follow their interventions. V20 said if R1 required assistance for transporting, the staff should be walking with her because she would be at a higher risk of falling. V20 said R1 did fall, which caused her to fall on her face, requiring her to go to the hospital. On May 22, 2024 at 9:22 AM, V16 (Memory Care Aide) said she was working on May 13, 2024 when R1 fell . V16 said they had just finished their regular morning group and needed to rearrange the residents back into their regular seats for lunchtime. V16 said the residents were sitting in a circle with the tables behind them. V16 said there were some residents that were able to ambulate by themselves, and R1 was someone who walked by herself. V16 said V17 asked R1 to go back to her table for lunch. V16 said she and V17 were moving the residents who needed assistance to their tables when they heard another resident yell and saw that R1 had fallen. V16 said she did not see R1 fall but she was the first person to get to her when she fell . V16 said R1 was face down on the side and when she got to her, and R1 was freaking out. V16 said there were no other residents near her close enough to touch her or push her. V16 said R1 was known to stumble a bit. V16 said prior to her fall on May 13, 2024, she had notified V5 (LPN) how R1 stumbled when she walked and had told R1's daughter her shoes seemed too heavy for her to walk with. V16 said the staff often had to tell R1 to slow down because she walked fast. On May 23, 2024 at 09:06 AM, V16 said she was walking alongside R1 on May 11, 2024 when she stumbled. V16 said she tried to grab R1 from falling and they both fell down, with R1 falling onto her knees. V16 said she had another CNA (Certified Nurse Assistant) help get R1 back up and she notified the nurse. V16 said none of the staff notified her after her fall on May 11, 2024 that R1 needed to be in a wheelchair or needing stand-by assistance to ambulate. V16 said R1 had also walked to the dining hall by herself on May 13, 2024. On May 22, 2024 at 2:15 PM, V18 said she was working on May 13, 2024, but did not witness R1 falling as she was in the TV room. V18 said she was never given any instructions about R1 needing someone to walk with her. V18 said she went to the stand-up meeting that morning, and she did not remember hearing them instruct on that. On May 22, 2024 at 1:24 PM, V5 (LPN) said she did not witness R1's fall on May 11, 2024, but an activity aide had. V5 said it sounded like R1 had tripped on her shoes and went down on her knees but did not get hurt. V5 said R1 used the walker pretty well. V5 said there were no changes to R1's care after her fall because she was fine, so no changes were made. At 1:40 PM, V5 came to the Surveyor to clarify R1's care had changed, and she needed someone to walk with her to assist her. V5 said she had just asked V6 (Restorative Nurse) and V6 told her the intervention was to standby assist R1 during ambulation. On May 22, 2024 at 1:52 PM, V6 (Restorative Nurse) said she assessed R1 when R1 was admitted , and again when she tripped on May 11, 2024. V6 said she had told the staff they needed to walk by her side at all times but was still safe to walk using the rollator. V6 said she mentioned it to the nurse taking care of R1, as well as during the stand-up meeting, so the staff were made aware of the changes. V6 said the staff should be assisting her from one seat to another seat. On May 22, 2024 at 3:52 PM, V21 (Physical Therapy Aide) said when a resident requires stand-by assistance, it means whoever is assisting the resident did not need to touch the resident but had to walk with the resident. V21 said if a resident needed stand-by assist, it meant there was a risk the resident could fall. On May 23, 2024 at 9:25 AM, V22 (CNA) said R1 was independent, and she was not notified R1 needed stand by assistance to walk. On May 23, 2024 at 12:03 PM, V7 (Patient Care Coordinator) said if a resident needed stand by assistance, any time they were up, the staff needed to stand by them to ambulate with them just in case they lost their balance. V7 said if the resident needing stand by assistance was not given assistance, they could possibly fall. The facility's Management of Falls policy dated August 2020 showed 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 in order to minimize the risks for fall incidents and/or injuries to the resident. Develop a plan of care to include goals and interventions which address resident's risk factors. Risk factors may include but are not limited to the following .history of fall incidents .assistance required with ADL's (Activities of Daily Living), gait/transfer/balance issues, behaviors, and/or cognitive status. Review and/or modify the resident's plan of care at least quarterly and as needed in order to minimize risk for fall incidents and/or injury.

Based on interview and record review, the facility failed to remove a transdermal narcotic pain medication patch before applying a new transdermal narcotic pain medication patch. This failure resulted in R1 being transferred to the emergency room with shortness of breath and altered mental status. This applies to 1 of 2 residents (R1) reviewed for fentanyl patch use. The findings include: On 10/24/23 at 10:41 AM, V28 (Family Member) said R1 was admitted to the hospital and was intubated and on a ventilator. V28 said the hospital found two fentanyl patches on her, one dated 10/15/23 and the second dated 10/18/23. V28 said R1 was overdosed. V28 said R1 was also given sleeping pills. V28 said they should have pulled off the old fentanyl patch before applying a new one. R1's History and Physical Reports from [hospital] dated 10/21/23 showed pt [patient] arrives with EMS (Emergency Medical Services) for SOB (Shortness of Breath) and AMS (Altered Mental Status) from [facility]. 2 fentanyl patches found on pt back, Narcan administered per EMS with increased response from pt. R1's ED (Emergency Department) Nurse Record dated 10/21/23 at 07:52 AM documented the following: pt arrived from [facility], upon arrival with EMS, pt was having SOB and confusion. EMS found 2 fentanyl patches on pt back, dated 10/15 and 10/18. EMS administered Narcan and report that pt became more alert afterward. RN (Registered Nurse) called [facility] to ask about pt baseline. [Facility] staff states pt is normally alert and oriented times 4 and wheelchair bound with assistance. RN asked when pt last known norm was and they did not know. [Facility] RN stated that pt expressed SOB and difficulty talking earlier in the night. This RN asked [Facility] RN what she meant by difficulty talking whether pt was having difficulty talking due to SOB vs difficulty forming words. [Facility] RN did not answer question. This RN, again, asked when pt LKN [Last Known Normal] was and [Facility] RN stated around 8 PM when she spoke to family on the phone. This RN asked about pt fentanyl patches that were found on her back, and [Facility] RN reported that they are to be removed every 72 hours. This RN informed them about the 2 that were found on pt. R1's EMR (Electronic medical Record) showed R1 had diagnoses including chronic obstructive pulmonary disease, heart failure, type 2 diabetes mellitus, dependence on supplemental oxygen, and insomnia. R1's MDS (Minimum Data Set) dated 10/13/23 showed R1 was cognitively intact, but the rest of the MDS was in progress. R1's POS (Physician Order Sheet) showed an order for fentanyl patch 72 hours 50 mcg (Micrograms) with instructions to apply transdermally at bedtime every three days for pain and remove per schedule. The POS also shows an order for melatonin 1 mg (Milligram) every 24 hours as needed at bedtime for insomnia, and zolpidem 5 mg every 24 hours as needed at bedtime for insomnia. R1's October MAR (Medication Administration Record) showed R1 received a fentanyl patch on 10/15/23 and 10/18/23. The MAR showed melatonin was not administered on 10/20/23 and zolpidem was discontinued on 10/17/23. On 10/26/23 at 03:25 PM, V20 (NP/Nurse Practitioner) said the residents should only have one fentanyl patch on at a time because it can potentially cause respiratory suppression. On 10/24/23 at 03:57 PM, V12 (LPN/Licensed Practical Nurse) said she applied a new fentanyl patch on R1, and when applying the fentanyl patch, the nurses have to rotate the sites. On 10/25/23, during separate interviews, V15 (RN), V16 (LPN), and V19 (LPN) said they would remove the old fentanyl patch before applying the new fentanyl patch. On 10/26/23 at 03:12 PM, V2 (DON/Director of Nursing) said the nurses should look for the old fentanyl patch and remove it before applying a new patch. V2 said the effect of having two fentanyl patches could cause slowed breathing, unresponsiveness, or even death. The facility's Medication Administration Policy dated 09/20 showed Medications will be administered in accordance with the established policies and procedures. Drugs must be administered in accordance with the written orders of the attending physician.

Based on observation, interview and record review the facility failed to keep a resident free from neglect when they failed to provide routine provider visits, make timely identification, and notification to the physician of a change in status, provide initial and ongoing nursing assessments, and provide care meeting profession standards leading to a cumulative effect and resident decline. This applies to 1 of 6 residents (R1) reviewed for change in condition. This failure resulted in R1 receiving delayed care and hospitalization which lead to R1 declining sooner than anticipated and being placed on hospice care. Findings include: R1's Admission Record dated 4/7/2023 documents R1 as an [AGE] year old resident with diagnoses to include Myelodysplastic Syndrome, Pancytopenia, Dementia, Multiple Myeloma in Remission, Anemia, and Waldenstrom Macroglobulinemia. R1's Admission Record 4/7/2023 documents R1 with an initial admitted [DATE] and V16 (Medical Director), V17 and V28 (Nurse Practitioner) as R1's Providers. R1's Progress and Provider Notes October 2022-March 31, 2023 document one provider visit by V17 on 10/11/2022, one by V28 on 11/22/2022, and no visits by V16. R1's Provider Note dated 11/22/2022 documents to monitor R1's lab. There are no provider visits after 11/22/2022. R1's Laboratory Report completed and reviewed by V17 on 10/13/2022 shows abnormalities, including an elevated blood urea nitrogen, and low hemoglobin, hematocrit and platelet counts. There are no further laboratory reports in R1's Electronic Medical Record. R1's Physician Order Report October 2022-March 2023 document no lab orders to monitor R1's abnormal lab or overall status of his medical comorbidities. On 4/4/2023 at 11:34 AM V8 (Director of Rehabilitation) stated an unknown staff member noted a decline earlier the week of 3/27/2023 and asked for therapy to complete an evaluation. V8 stated she also noticed the decline stating he did not present as himself, his demeanor had changed and he was not initiating conversation as usual. On 4/5/2023 at 2:40 PM V22 (Nurse) stated stated he worked 3/28/2023 from 7 PM-7 AM. V22 reported that evening he noticed R1 may have been a little lethargic which he explained as R1 did not refuse his medications as usual and he was not talking as he normally did. On 4/4/2023 at 1:15 PM V11 (Nursing Assistant) stated R1 was not in his assigned group, but 2-3 days before he was sent to the hospital (3/30/2023) V11 noticed R1 was declining and not interacting as he usual did. V11 stated R1 was not eating well and he required staff to assist him to eat his lunch when he usually fed himself. On 4/5/2023 9:45 AM V13 (Nursing Assistant) stated he was R1's normal assigned Nursing Assistant on the day shift and he worked 3/29 and 3/30/2023. V13 stated R1 was normally active and talks a lot, but those 2 days before he went to the hospital he appeared tired, wasn't eating well and appeared weak. V13 stated nursing was aware. On 4/7/2023 at 9:38 AM V20 (Nursing Assistant) stated, R1 was in her assigned group on 3/29/2023. V20 stated R1 usually talks a lot and was quieter that day, didn't eat and was out of it. V20 clarified this by saying it was like someone had given him something to calm down and he was not acting like himself. R1's Progress Notes 3/27-3/31/2023 do not document any resident assessments or physician notification of changes. R1's Weight and Vital Summary Report document only one set of vitals between 3/28-29/2023 on 3/28/2023 at 5:33 AM. On 4/4/2023 at 12:35 PM, V7 (Nurse) stated on 3/30/2023 R1 was not his usual self when she first saw him around 8 AM, describing him as quieter. V7 stated R1 was assisted up to his wheelchair before lunch and she noticed he wasn't eating lunch, only taking sips of chocolate milk, and his left hand was tinged blue. V7 checked his oxygen saturation level which registered at 70% and she started oxygen; R1 was not short of breath. V7 sent a message to V17 (Nurse Practitioner) at 12:39 PM and was instructed to monitor R1. V7 stated she was concerned with that direction so she sent a copy of the text conversation with V17 to V16 (R1's Primary Care Physician/Medical Director) hoping V16 would instruct her to send R1 to the hospital-R1's oxygen saturation level was at 74% at that time. V16 instructed V7 to continue to monitor which she did. V7 shared the texts and pictures with the surveyor and both of R1's hands appear blue but the left was significantly worse. V7 stated she continued to be concerned and she called V15 (Transitional Care Nurse) who was unable to come at that time so V7 continued to monitor R1. Then at around 3:45 PM V4 (Assistant Director of Nursing) was contacted because V7 was unable to get a pulse oxygen saturation reading and R1 had become lethargic and was sweating. V7 stated both V4 and V15 arrived around the same time, 911 was called and R1 was sent to the hospital. On 4/5/2023 at 10:29 AM V15 stated V7 called and she was unable to assist at that time, but arrived to the unit about 45 minutes later. V15 stated she was aware V17 had already been contacted and instructed V7 to monitor R1 and did not realize the urgency. V15 stated she immediately called 911 because of the way R1 looked- his skin color was blue, mainly his hands stating it was obvious he was not perfusing. On 4/5/2023 at 11:45 AM V4 stated V7 contacted her to assess R1 and when she arrived R1 was sitting with his head down, alert to his name, but his fingers were blue and they couldn't get a good temperature on him. V4 stated 911 was called because his appearance, especially the coloring of his fingers, indicated he need to go out right away. On 4/5/2023 11:25 AM V3 (Director of Nursing) stated, when a status change is identified the physician should be notified and the resident monitored, including a thorough assessment and vitals signs to be documented in progress notes minimally every shift. V3 also stated, if a practitioner does not give orders appropriate to their clinical presentation, the primary care physician should be contacted, if that is not effective, call the Medical Director. V3 further stated the nurses should notify her or one of the nurse managers if they are not comfortable with the orders provided, time is of the essence. 4/5/2023 3:57 PM V16 stated he should have been notified of R1's changes timely and then basic labs could have been drawn to see what was going on and the issue may have been identified earlier. V16 stated the outcome was likely the same due to R1's age and multiple comorbidities, but if they had notified him timely the decline may not have been as drastic. V16 confirmed the facility should have quickly identified R1's change in status and notified him of the changes. On 4/6/2023 at 9:30 AM V16 stated, I do understand the value of routinely seeing them (residents) and I agree that seeing them regularly I can monitor and identify issues that may not get picked up by staff. R1's Hospital emergency room Physician Notes document R1 arriving at the hospital via ambulance on 3/30/2023 at 4:59 PM with a chief complaint of altered mental status. The Hospital Discharge Summary dated 3/31/2023 documents R1 with diagnoses to include acute kidney failure with severe metabolic acidosis (too much acid in the blood) requiring an emergent hemodialysis catheter placement, limb ishemia (no blood flow) with arterial occlusions to the left lower extremity, and severe hypernatriema (high sodium blood level) and hyperkalemia (high potassium blood level). A Consultation Report, completed by V27 (Vascular Surgeon), dated 3/30/2023 at 7:46 PM, documents R1 with a clear altered mental status and multiple significant and life-threatening metabolic derangements, including a potassium of 7.9 (Normal 3.5-5.1) and creatinine of 17 (Normal 0.7-1.3). V27's report documents V18 noted threat R1's left leg was cold and pulseless and testing found no meaningful blood flow at the level below the knee. V27's Physical exam documents R1 laying in mild distress with the left lower extremity mottled from the foot to the ankle and ice cold to touch up to the knee with no palpable pedal pulses. V27's Assessment/Plan documents R1 with severe acute renal failure, life-threatening hyperkalemia and severe lactic acidosis and acidemia. V27 documents R1 as critically ill and not a surgical candidate for open revascularization for R1's limb ishemia which would be best resolved with an emergency left knee amputation to remove the source of ishemia and acidosis. All of these notes document R1's prognosis as poor and the family opting to not initiate emergent dialysis or perform the amputation and hospice was consulted. On 4/6/2023 at 5:45 PM V18 (emergency room Physician) stated, Our concern was there was extensive neglect. He came to us with limited history, altered mental status and they could not tell us how long this had been going on. I haven't seen lab values like that in a very long time, definitely not at that level with those specific abnormalities. He was very hypernatrimic with a sodium level of 165 and had a pulseless leg, needing immediate dialysis. V18 further stated, he probably didn't need to get to that point if he received good care where he came from. V18 stated R1's condition definitely did not develop in just a few hours and his renal failure did not occur quickly, likely occurring over several days. V18 stated his pulseless leg can occur quickly over a few hours, but he definitely had concerning skin changes which were caught immediately in the emergency room . V18 also stated, if R1 was being monitored and receiving good care the changes should have been noted and identified. R1's Minimum Data Set, dated dated dated [DATE] documents R1 as moderately cognitively impaired and requiring only set up assistance and supervision for eating. R1's Occupational Evaluation and Plan of Treatment dated 3/30/2023 documents R1 evaluated due to a significant decline with activities of daily living (ADL), transfers and cognition. The clinical impression includes R1 as exhibiting decreased ADL, decreased balance, and decreased cognition. The policy Physician Visits dated 9/2020 documents physician visits are required upon admission, every 30 days for the first 90 days after admission, and then every 60 days. The Physician, Nurse Practitioner or Physician's Assistant shall review each residents total plan of care including medications and treatments and monitor for changes in the resident medical status every 30 days. The Abuse Policy dated 09/2020 documents Neglect as the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish or emotional distress.

Based on observation, interview and record review the facility failed to identify, monitor, and report a resident change in condition timely. This applies to 1 of 3 residents (R1) reviewed for condition changes in a sample of 6. This failure resulted in R1 receiving delayed care and hospitalization which lead to R1 declining sooner than anticipated and being placed on hospice care. Findings include: R1's Admission Record dated 4/7/2023 documents R1 as an [AGE] year old resident with diagnoses to include Myelodysplastic Syndrome, Pancytopenia, Dementia, Multiple Myeloma in Remission, Anemia, and Waldenstrom Macroglobulinemia. On 4/4/2023 9:47 AM V6 (emergency room Nurse) stated on 3/30/2023 R1 was received in the emergency room (ER) due to reported shortness of breath for an hour. V6 stated R1 arrived lethargic with a rectal temp of 92.5, and no pulse below his knee on the left leg. V6 stated her concern was R1's changes should have been identified sooner. On 4/4/2023 at 11:34 AM V8 (Director of Rehabilitation) stated an unknown staff member noted a decline earlier the week of 3/27/2023 and asked for therapy to complete an evaluation. V8 stated she also noticed the decline stating he did not present as himself, his demeanor had changed and he was not initiating conversation as usual. V8 could not indicate who requested the consultation nor the date of this request. On 4/5/2023 at 2:40 PM V22 (Nurse) stated stated he worked 3/28/2023 from 7 PM-7 AM. V22 reported that evening he noticed R1 may have been a little lethargic which he explained as he did not refused his medications as usual and he was not talking as he normally did. On 4/4/2023 at 1:15 PM V11 (Nursing Assistant) stated R1 was not in his assigned group but 2-3 days before he was sent to the hospital (3/30/2023) V11 noticed R1 was declining. V11 stated R1 was not eating well and V11 had to assist him with to eat when he usually fed himself. V11 additionally stated R1 was not interacting and acting like himself. On 4/5/2023 9:45 AM V13 (Nursing Assistant) stated he was R1's normal assigned Nursing Assistant on the day shift and he worked 3/29 and 3/30/2023. V13 stated R1 was normally active and talks a lot but those 2 days before he went to the hospital he appeared tired, wasn't eating well and appeared weak. V13 stated nursing was aware. On 4/7/2023 at 9:38 AM V20 (Nursing Assistant) stated, R1 was in her assigned group on 3/29/2023. V20 stated R1 usually talks a lot and was quieter that day, didn't eat and was out of it. V20 clarified this by saying it was like someone had given him something to calm down and he was not acting like himself. R1's Progress Notes 3/15-3/31/2023 do not document any resident assessments or physician notification of changes. R1's Weight and Vital Summary Report document only one set of vitals between 3/28-29/20203 at 5:33 AM on 3/28/2023. On 4/4/2023 at 12:35 PM V7 (Nurse) stated on 3/30/2023 R1 was not his usual self in the morning when she first saw him around 8 AM, describing him as quieter. V7 stated R1 was assisted up to his wheelchair before lunch and she noticed he wasn't eating lunch, only taking sips of chocolate milk, and his left hand was tinged blue. V7 checked his oxygen saturation level which as 70% and and started oxygen; R1 was not short of breath. V7 sent a message to V17 (Nurse Practitioner) at 12:39 PM and was instructed to monitor R1. V7 stated she was concerned with that direction so she then sent a copy of the conversation with V17 to V16 (R1's Primary Care Physician/Medical Director) hoping V16 would instruct her to send R1 out, stating R1's oxygen saturation level was at 74% at that time. V16 instructed V7 to continue to monitor which she did. V7 shared the texts and pictures with the surveyor and both of R1's hands appear blue but the left was significantly worse. V7 stated she continued to be concerned so she at some point called V15 (Transitional Care Nurse) who was unable to come at that time and V7 continued to monitor R1. Then at around 3:45 PM V4 (Assistant Director of Nursing) was contacted because V7 was unable to get a pulse oxygen saturation reading and R1 had become lethargic and was sweating. V7 stated both V4 and V15 arrived around the same time, 911 was called and R1 was sent to the hospital. On 4/5/2023 at 10:29 AM V15 stated V7 called and she was unable to assist her at that time but arrived to the unit about 45 minutes later. V15 stated she did not realize it was urgent, V17 had already been contacted and instructed V7 to monitor R1. V15 stated she immediately called 911 because R1's skin color was blue, mainly his hands and it was obvious he was not perfusing. On 4/5/2023 at 11:45 AM V4 stated V7 asked her to come and assess R1 indicating she had been monitoring R1 per V17's instructions. V4 stated R1 was sitting with his head down, alert to his name, but his fingers were blue and they couldn't get a good temperature on him. V4 stated 911 was called, further stating his appearance, especially his fingers, indicated he need to go out right away. On 4/5/2023 11:25 AM V3 (Director of Nursing) stated, when a status change is identified the physician should be notified and the resident monitored, including a thorough assessment and vitals signs and documented in progress notes minimally every shift. V3 also stated, if a practitioner does not give orders appropriate to their clinical presentation, the primary care physician should be contacted and if that is not effective, then call the Medical Director. V3 further stated the nurses should notify her or one of the nurse managers if they are not comfortable with the orders provided, time is of the essence. 4/5/2023 3:57 PM V16 stated he should have been notified of R1's changes timely and then basic labs could have been drawn to see what was going on and the issue may have been identified earlier. V16 stated the outcome was likely the same due to his age and multiple comorbidities, but if they had notified him the decline may not have been as drastic. V16 confirmed the facility should have quickly identified R1's change in status and notified him of the changes. R1's 3/30/2023 Hospital emergency room Physician Notes document R1 arriving at the hospital via ambulance on 3/30/2023 at 4:59 PM with a chief complaint of altered mental status. The Hospital Discharge Summary dated 3/31/2023 documents R1 with diagnoses to include acute kidney failure with severe metabolic acidosis (too much acid in the blood) requiring an emergent hemodialysis catheter placement, limb ishemia (no blood flow) with arterial occlusions to the left lower extremity, and severe hypernatriema (high sodium blood level) and hyperkalemia (high potassium blood level). A Consultation Report, completed by V27 (Vascular Surgeon), dated 3/30/2023 at 7:46 PM, documents R1 with a clear altered mental status and multiple significant and life-threatening metabolic derangements, including a potassium of 7.9 (Normal 3.5-5.1) and creatinine of 17 (Normal 0.7-1.3). V27's report documents V18 noted threat R1's left leg was cold and pulseless and testing found no meaningful blood flow at the level below the knee. V27's Physical exam documents R1 laying in mild distress with the left lower extremity mottled from the foot to the ankle and ice cold to touch up to the knee with no palpable pedal pulses. V27's Assessment/Plan documents R1 with severe acute renal failure, life-threatening hyperkalemia and severe lactic acidosis and acidemia. V27 documents R1 as critically ill and not a surgical candidate for open revascularization. V27 documents R1's limb ishemia would be best resolved with an emergency left knee amputation to remove the source of ishemia and acidosis. All of these notes document R1's prognosis as poor and the family opting to not initiate emergent dialysis or perform the amputation and hospice was consulted. On 4/6/2023 at 5:45 PM V18 (emergency room Physician) stated, Our concern was there was extensive neglect. He came to us with limited history, altered mental status and they could not tell us how long this had been going on. I haven't seen lab values like that in a very long time, definitely not at that level with those specific abnormalities. He was very hypernatrimic with a sodium level of 165 and had a pulseless leg, needing immediate dialysis. V18 further stated, he probably didn't need to get to that point if he received good care where he came from. V18 stated R1's condition definitely did not develop in just a few hours and his renal failure did not occur quickly, likely occurring over several days. V18 stated his pulseless leg can occur quickly over a few hours, but he definitely had concerning skin changes which were caught immediately in the emergency room . V18 also stated, if R1 was being monitored and receiving good care the changes should have been noted and identified. R1's Minimum Data Set, dated dated dated [DATE] documents R1 as moderately cognitively impaired and requiring only set up assistance and supervision for eating. R8's Occupational Evaluation and Plan of Treatment dated 3/30/2023 documents R1 evaluated due to a significant decline with activities of daily living (ADL), transfers and cognition. The clinical impression includes R1 as exhibiting decreased ADL, decreased balance, and decreased cognition. The Change in Condition policy dated 09/2020 documents to notify the practitioner of any resident changes in condition.

Based on observation, interview, and record review, the facility failed to implement preventative measures to promote the healing of pressure injuries. This applies to 1 of 3 residents (R13) reviewed for pressure injuries in a sample of 15. This failure resulted in R13 receiving untimely care causing a delay in healing, exposing wounds to infectious organisms and potentially delaying the resolution of the current wound infection. Findings include: On 1/14/2023, during continuous observations between 10:35 AM-12:10 PM, R13 laid in bed with a pillow under her left shoulder on an air mattress. V20 and V21, were the only assigned Nursing Assistants present until 12 PM and no care was provided to R13, including incontinence care or positioning. V26 (Nursing Assistant) arrived to this unit at 12:00 PM. On 1/14/2023 at 11:30 AM V20 stated he began working at 6 AM and has not changed or provided any care to R13 since he arrived. On 1/14/2023 at 12:05 PM V21 stated R13 was last provided care, including positioning and incontinence care, at approximately 7 AM. V21 confirmed care is to be provided approximately every 2 hours and confirmed she has not changed or turned R13 since 7 AM. At this time V20 checked R13's incontinence brief and confirmed she needed changed. At 12:10 PM V26 and V20 provided incontinence care to R13 who had liquid stool in her brief that had soaked into her left buttock and sacral wound dressings. V26 removed these dressings and stool was seen under the dressings and around and in the open pressure injuries. R13's Care Plan dated 1/11/2023 documents R13 with existing pressure injuries with interventions to include completion of incontinence care after an incontinent episode and turn and reposition every 2 hours. On 1/14/2023 at 12:40 PM V26, V12 (Wound Care Nurse) and V28 (Nurse) changed R13's dressings. R13 was noted with wounds to her sacrum, right knee, upper thigh, foot and shin; left buttock, knee, medial leg and hip. V12 stated R13 had wounds previous to her 11/29/2022 hospital admission but returned from the hospital on 12/9/2022 with more new wounds. R13's sacral and left hip wounds were large and open. R13's 12/15/2022 Wound Care Report, completed by V31 (Wound Care Physician), documented the initial evaluation of R13's new pressure injuries on 12/15/2023 to include: unstageable pressure injuries to her right medial shin/ankle, right upper thigh, left knee, and left hip; and a Stage 3 to the left buttock (2 areas), and right knee. This report also documents R13 with existing wounds to include a Stage 4 to her sacrum date of 6/30/2022 and the presence of several arterial wounds. R13's 12/29/2022 Wound Care Report documents V31 ordering R13 sent to the hospital for debridement of the left hip pressure injury. R13's hospital Discharge Summary dated 1/9/2023 documents R13 returning and as being treated for osteomyelitis of the coccyx and with infected stage 4 pressure injuries to her buttock (left hip) and coccyx area and undergoing debridement of those wounds on 12/29/2023. R13's Wound Progress Note dated 1/9/2023 documents R13's wound assessment to include a sacral pressure injury measuring 6.5 x 5 x 2.4 cm and the left hip pressure injury measuring 18 x 8 x 3.8 cm upon readmission. This note also documents a wound vacuum being used and applied to the left hip pressure injury. R13's Infectious Disease initial evaluation on 1/10/2023 documents R13 returning to the facility on [DATE] with orders for 6 weeks of intravenous antibiotics to treat osteomyelitis of the coccyx. On 1/17/2023 at 2:59 PM V31 stated, R13's wounds are not preventable due to multiple comorbidities including, Diabetes, End Stage Renal Failure receiving dialysis, significant contractures, and Peripheral Artery Disease. V31 stated most of R13's pressure injuries occurred during hospitalization and were noted after her return on 12/9/2022. V31 stated R13 is declining and the wounds are difficult to heal for multiple reasons, including sitting in a dialysis chair for hours. V31 stated she has recommended hospice, but the family has not consented. V31 stated R13 did not have gangrene while hospitalized , but was diagnosed with and is being treated for osteomyelitis. V31 stated the facility should turn and reposition her regularly and provide timely incontinence care. V31 stated further, I agree, healing will be delayed if she is not repositioned timely and sitting in a wet or soiled brief. In addition, it is not good if she is not receiving timely care and her dressings were soiled with stool. She has open wounds which are already infected and it puts her at risk for further infection and possible delay in resolving the current infection . R13's Admission Record dated 1/18/2023 documents R13 hospitalized ,d+[DATE]-[DATE], 12/29/2022-1/9/2023, and 1/16/2023-present. This document also shows R13 with Malnutrition, Diabetes, and Peripheral Vascular Disease. The facility policy Prevention and Treatment of Pressure Injuries and other Skin Alterations dated 3/2/2021 documents implement preventative measures and other treatment modalities through individualized care plans.

Based on observation, interview and record review the facility failed to provide post operative eye drops. This applies to 1 of 3 residents (R3) reviewed for post operative care in a sample of 11. This failure resulted in R3 developing iritis (inflammation of the iris) of the right eye. Findings include: On 1/9/20 at 1:10 PM, V18 (R3's Power of Attorney/Daughter) stated R3's eye became red and irritated because the facility failed to provide R3 all of her post surgical eye drops. On 1/14/20 at 12:50 PM, R3's right eye sclera was clear and without redness. R3 stated she had right eye surgery recently. R3 stated after surgery her drops were not applied correctly and her eye became uncomfortable. R3's Operative Report dated 12/12/19 documents R3 had a right cataract extraction with lens implant completed. R3's Eye Exam Report dated 12/13/19 documents R3 doing well post surgery. R3's Medication Instructions included [MEDICATION NAME] 0.4% to right eye 4 times a day for 7 days then decrease to 2 times a day for days 8-28 and [MEDICATION NAME] 1% to right eye 4 times a day for 7 days then decrease to 2 times a day for days 8-28. R3's Eye Exam Report dated 12/19/19 documents R3 doing well post surgery and to continue eye drops as ordered. R3's Eye Exam report dated 12/30/19 documents R3 being seen urgently due to pain and redness to the right eye. This report documents R3's eye drops have not been given correctly. R3 was diagnosed with [REDACTED]. This report documents R3 received a sub-conjunctival kenelog injection after weighing the risk and benefits due to poor compliance with drops at facility. R3's new orders included to continue [MEDICATION NAME] drops and to increase the frequency of [MEDICATION NAME] to 4-6 times a day. R3's (MONTH) 2019 Medication Administration Record [REDACTED]. R3's [MEDICATION NAME] was re-initiated twice per day on 12/26/19. There is no documentation of R3 being given [MEDICATION NAME] drops 12/20/19 through 12/25/19 nor [MEDICATION NAME] drops between 12/20/19 through 12/31/19. On 1/14/20 at 4:00 PM, V2 (Director of Nursing) confirmed the facility is supposed to follow post surgical orders. On 1/15/20 at 1:10 PM, V19 (R3's Primary Physician) stated she expects the facility to implement the ophthalmologists recommended post procedure orders to avoid complications. V19 confirmed R3 should have received the eye drops as recommended. R3's Minimum (MDS) data set [DATE] documents R3 with moderate cognitive impairments. The Physician order [REDACTED].

Based on interviews and record reviews, this facility failed to monitor and assure medications were administered according to physician orders [REDACTED]. This failure resulted in R9 being admitted to the hospital on [DATE] with a critically high blood glucose level. Findings include: Review of the medical record notes R9 was admitted to this facility on 1/8/19 with [DIAGNOSES REDACTED]. On 1/18/19 at 4:15pm, V20 RN (registered nurse/clinical support specialist) acknowledged that the nurses are expected to document in the resident's MAR (medication administration record) immediately after any medication is administered, held, or refused. R9's medical record was reviewed with V20. V20 was unable to find any documentation noting R9's blood glucose was checked 1/9/19 at 8:00pm or that R9 received any insulin at that time. On 1/22/19 at 1:00pm, V24 RN stated that V24 worked on the first floor nursing unit on the evening of 1/9/19. V24 stated that R9 was transferred from the second floor to the first floor nursing unit. V24 stated that about 4:00pm, a CNA (certified nurse aide) informed V24 that R9 would be coming some time during V24's shift. V24 stated that at 9:30pm, during end of shift rounds, V24 saw an extra resident in one of the rooms. V24 did not speak with R9 because R9's eyes were closed. V24 stated that V24 was not given report by the nurse transferring R9 or informed when R9 arrived onto the unit. V24 stated that V24 passed to the oncoming nurse to follow up with R9's medications and report from the other nursing unit. Review of R9's hospital medical record, dated 1/10/19, notes R9 presented to the emergency department at 7:28am. At 7:39am, R9's blood glucose level was 525, critically high (normal value is 70-99). R9's admitting [DIAGNOSES REDACTED]. Review of R9's POS (physician order [REDACTED]. units and notify physician); and fast acting insulin 15 units subcutaneously three times daily before meals. Review of R9's MAR (medication administration record), (MONTH) 2019, notes R9 received one dose of long acting insulin on 1/8/19. There is no documentation noting R9 received a dose of this insulin on 1/9. There is also no documentation noting R9's blood glucose was checked or received any fast acting insulin at bedtime on 1/9. Review of R9's care plan, dated 1/9/19, notes R9 has the potential low/high blood glucose reactions secondary to [DIAGNOSES REDACTED]. Review of R9's blood glucose monitoring results documentation notes on 1/9 at 6:00am R9's blood glucose was documented on the MAR for scheduled fast acting insulin -- 380 and for sliding scale insulin; R9 did not receive the additional 8 units of fast acting insulin per physician order. There is no documentation on 1/9 at 8:00pm noting R9's blood glucose was checked or any fast or long acting insulin was administered. Review of this facility's medication pass guidelines, dated 06/2014, notes document administration of medication on the resident's MAR immediately after administration. If a medication is refused or held/delayed, document it in an objective manner on the MAR, including the reason for delay or refusal.

Based on interview and record review the facility failed to obtain treatment orders for a new alteration in skin condition for 4 days for 1 of 3 residents (R5) reviewed for pressure ulcer prevention. This failure resulted in R5 being identified with a unstageable pressure measuring 8cm (Centimeters) in width by 8 cm in length with 100% slough and eschar tissue. Findings Include: R5 was re-admitted to the facility on [DATE] with one stage 4 pressure ulcer located on the Sacrum, MASD-moisture associated skin damage to perianal area, and a non-pressure related ulcer on the right foot. V3 documented on 9/6/17 that R5 acquired a new unstageable pressure ulcer on 9/5/17 to the right ischium. On 4/4/18 at 10:40AM V3 was asked to describe the skin alteration that was observed on 9/5/17 and V3 described seeing slough on the base of the wound and eschar tissue. R5's Wound Care Evaluation completed by V16 (Wound Care Physician), dated 9/6/17 shows Ulcer; right ischium, type; pressure, color/type; yellow black, Eschar; 100, exudate; moderate. (According to the National Pressure Ulcer Panel: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed) On 3/15/18 at 12:00pm writer asked V3 how did R5, acquire a pressure ulcer measuring 8cm (centimeters) in width by 8 cm length in 6 days; since your last assessment date of 8/30/17. V3 stated R5 was at high risk for developing pressure ulcer due to R5s history and co morbidities. V3 stated because of R5's skin and the location the ulcer may not have been noticeable. V3 was asked how often are skin assessments completed for residents? V3 stated the CNA's-(Certified Nursing Assistant) do the skin checks daily and during showers. V3 stated if the CNA find any red/ raw/open areas, bruises, rashes any breaks in the skin that the CNA should notify the nurse and the nurse would make an assessment and then notify the wound nurse. On 4/4/18 at 10:40 A.M, V3 was asked are there any extra interventions put into place when the residents are of high risk for developing pressure ulcers versus a resident that is not, V3 stated there are no extra interventions put in place for residents that are of high risk for developing pressure ulcers. On 3/5/18 at 12:00PM Writer requested all skin assessment sheets and was told by V1 (DON- Director of Nursing) that the facility can only provide 30 days of skin assessments. V1 stated any other dates would need to be approved by the cooperate office. On 3/15/18 at 2:08pm V1 presented shower legend report that show dates from 8/19/17- 9/3/17. The grid labeled bathing shows on 9/1/2017 at 13:59 there's an 8, 8, 1. The number legend report shows that 8 indicates activity itself did not occur or family and/or non-facility staff provided care 100% of the time for that activity, and the number 1 shows New Skin Abnormality. Review of the facility's assignment sheet dated 9/1/17 shows V20 (CNA) was assigned to R5. V20 was not available for interview during this investigation. On 4/5/18 at 12:34 P.M V17 CNA (Certified Nursing Assistant) was presented with the Legend Report for R5 showers, V17 stated that the information on the report shows the dates of showers and stated that the number 8 means the CNA provided total care for the resident and the number 1 means that the CNA found a new skin condition and the nurse was notified. On 4/6/18 at 2:20pm V1 verified that V20 documented the information on 9/1/17 for R5. Review of R5's progress notes is without any documentation showing the nurse was not notified of any new skin abnormality on 9/1/17. It was not until 4 days later on 9/5/17 that documentation was written regarding any new skin condition for R5. On 4/4/18 at 10:40AM, V3 stated that the Nurse and CNA's individually does skin checks daily, however when this pressure ulcer was not identified, it measured at 8cm by 8cm and was unstageable with 100% necrotic tissue. The Facility's policy dated 12/2017 titled Prevention and treatment of [REDACTED].

Based on observation, interview and record review, the facility failed to monitor and prevent an avoidable fall incident for 1 of 3 residents R1 all reviewed for falls and failed to follow their fall prevention policy and develop effective fall prevention interventions for 3 residents (R1, R2, R3) out of 3 residents reviewed for falls. This failure resulted in R1 falling in the bathroom on 6/30/15 and hospitalization on [DATE] for a subdural hemorrhage and pelvic fracture as a result of the fall. Findings include: R1 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. R1's admission fall risk assessment score on 6/25/15 was 18 (High Risk). The range for the fall risk assessment scores is 12 or above means the resident is high risk for falling. On 7/29/15 at 10:30am E2 (Director of Nursing) stated that residents who are assessed as high risk for falling are in the falling star program as a prevention measure for falls. R1 was in the falling star program since R1 was high risk for falling. E2 stated that R1 had a star on her door and on her wheelchair so that facility staff would know that R1 was high risk for falling. R1's incident report dated 6/30/15 at 22:27 reads Witness statement of what happened written by E4 (Certified Nursing Assistant) entered by E3 (Registered Nurse) - Stated I was at the door post waiting for R1 to finish having bowel movement when suddenly alarm sound and I rush inside and found R1 on the floor, then I immediately call the nurse. On 7/29/15 at 10am, E4 stated that she helped R1 get on the toilet on 6/30/15 at approximately 7pm. E4 stated that after she helped R1 get on the the toilet, she went into R1's bedroom by the TV because R1 wanted privacy. E4 stated that she checked on R1in the bathroom because she was quiet and observed R1 standing. E4 stated that R1 then fell on her left side and hit her head on the floor. E4 stated that she immediately called the nurse. On 8/4/15 at 2:55pm, E4 stated that she did not know that R1 was high risk for falling. E4 stated that she did not know that R1 was on the falling star program. E4 stated that most residents on the dementia floor are high risk for falling. On 8/4/15 at 3:15pm, E2 (Director of Nursing) stated that E4 did know that R1 was high risk for falling because the high risk status is displayed on the electronic charting system. On 7/30/15 at 10:15am, E3 (Registered Nurse) stated that he was not sure if E4 was present when R1 fell on [DATE]. E3 stated that he would have to refer to his paperwork. E3 stated that he observed R1 on the bathroom floor with bleeding noted to the left side of her head. E3 stated that he applied an ice pack to her head and sent R1 to the hospital emergency room . E3's paperwork dated 6/30/15 at 22:18 reads E4 stood by door post for privacy. Suddenly R1 stood up alarm sounding and E4 went in and saw R1 on the left side of the floor with laceration/hematoma on the left side of R1's head. R1 went to the hospital emergency room . R1's emergency room notes dated 6/30/15 at 22:20 reads R1 is an [AGE] year old female with dementia who presents to the emergency room after experiencing a fall off the toilet tonight. R1 appears to have had an unwitnessed fall while she was in the bathroom, suffering an injury to the back of her head. R1 was also complaining of left hip pain. CT scan dated 6/30/15 reads CT scan did reveal a 3.2 cm by 8 mm in depth subdural hematoma in the occipital left aspect of the brain. R1's posterior scalp had a 2 and half centimeter lacerations of the left occipital aspect of the scalp. 7 staples were placed. X-ray of the left hip did reveal a superior rami fracture of the pelvis nondisplaced. On 7/30/15 at 2:30pm, E6 (Physical Therapist) stated that R1 was moderate assistance to rise from sit to stand. E6 stated that R1 needed physical assistance to lift from sitting to standing position. On 7/30/15 at 3:05pm, Z1 (Attending Physician) stated that the report he received regarding R1's fall on 6/30/15 was that E4 was standing outside the door when R1 fell . On 7/31/15 at 1:45pm, E5 (Restorative Nurse) stated I wouldn't think we would leave a resident in the bathroom by themselves if they have dementia and is high risk for falling. R1's face sheet lists dementia as one of her admitting [DIAGNOSES REDACTED]. On 8/4/15 at 2:45pm, E3 stated that residents who are high risk for falling should not be left unattended. E3 stated We cannot leave them alone in the bathroom if they are confused. R1's admission fall risk assessment was 18 (High Risk) for falling. On 8/5/15 at 10:10am, E10 (Certified Nursing Assistant) stated that she cared for R1. E10 stated that one time when she toileted R1, R1 asked her to leave. E10 stated that she stood by the door but could see R1 at all times. E10 stated R1 attempted to stand up but E10 explained to R1 that she has to stay on the toilet and wait for E10. E10 stated that she never left R1 alone in the bathroom. E10 stated that R1 was confused and even though R1 wanted privacy, it was impossible to give her privacy because she was at risk for falling. E10 stated In situations like this, you have to be there because R1 was high risk for falling. R1's physical therapy evaluation dated 6/25/15 reads R1 referred to physical therapy due to exacerbation of pain, decrease in strength, decrease in functional mobility, reduced ability to safely ambulate, decreased neuromotor control, reduced balance, reduced functional activity tolerance, cognitive deficits and increased need for assistance from others. R1's MDS (Minimum Data Set) dated 6/30/15 reads under Functional Status Moving on and off toilet & moving from seated to standing position - not steady, only able to stabilize with staff assistance. R1's brief interview for mental status score dated 6/30/15 was 7 out of 15. R1's care plan dated 6/25/15 reads R1 has an ADL (activity of daily living) self care performance deficit related to activity intolerance, limited mobility, fatigue, impaired balance, recent hospitalization , weakness. R1's intervention includes Assist with toileting needs as necessary. R2 is an [AGE] year old female with dementia. R2 has had 8 unwitnessed falls since 10/1/14. R2 fell on [DATE], 10/7/14, 11/10/14, 12/30/14, 1/4/15, 1/30/15, 7/1/15 and 7/10/15. R2's fall risk assessment score on 7/10/15 was 17 (high risk) for falling.R2's clinical notes on 7/1/15 read Continue to monitor R2 at all times. On 7/29/15 at 11am, R2 was observed being transferred to the bathroom via mechanical lift by E8 (Certified Nursing Assistant). R2's clinical notes dated 7/27/15 read Needs 2 person assist with adls of transfer and hygiene. E8 left R2 in the bathroom unattended and went into R2's bedroom to get a pad from R2's cabinet. E8 then returned to the bathroom where R2 was on the toilet. R2's MDS dated [DATE] under functional status reads Toilet use - 2 person assist. R2's care plan dated 1/19/12 reads R2 is at high risk for falls related to: history of falls, use of assistive devices, poor safety awareness related to Diagnosis: [REDACTED]. R3 is an [AGE] year resident with dementia. R3 was admitted to the facility of 3/18/15 with [DIAGNOSES REDACTED]. R3 has had 3 unwitnessed falls on 5/10/15, 5/21/15 and 7/15/15. R3's fall risk assessment score on 5/22/15 was 22 (high risk) for falling. R3's occurrence report dated 5/21/15 reads Certified Nursing Assistant heard R3 yelling for help from R3's bathroom floor and summoned help to the scene. The conclusion of the incident reads R3 requires assistance from staff with her ADLs (activities of daily living), toileting and transfer needs. It was found that R3 was placed on the toilet by E12 (Certified Nursing Assistant), E12 provided privacy and within a few minutes while E12 quickly attempted to provide care to another resident in the hallway, E12 responded to R3 calling out for help. R3's brief interview for mental status score was 2 out of 15 on 5/25/15. R3's care plan reads at High Risk for falls secondary to history of falls, unsteady gait and cognitive deficits. Interventions include Accompany and stay with R3 during toileting for frequent monitoring and encourage R2 is placed in a high visible area while she is waiting for assistance. R2's clinical notes dated 7/15/15 read Continue to monitor R3 at all times. On 7/29/15 at 11:10am, R2 was observed propelling herself in the hallway without any staff supervision. On 8/5/15 at 1:50pm, E9 (Registered Nurse) stated that on 5/21/15 at 9:30am, R3 wheeled herself into the bathroom and had an unwitnessed fall on the bathroom floor. E9 stated that there were no injuries. E9 stated that R3 was yelling for help from the bathroom floor. E9 stated that R3 likes to wheel herself into the bathroom and staff need to keep an eye on R3. On 8/5/15 at 2:05pm, E10 (Certified Nursing Assistant) stated that another nursing assistant (E12) put R3 on the toilet on 5/21/15 and then left R3 alone in the bathroom. E10 stated the next thing she knew, R3 was on the bathroom floor yelling for help. On 8/5/15 at 2:30pm, E12 (Certified Nursing Assistant) stated that she does not remember putting R3 on the toilet on 5/21/15 and does not remember R3 on the bathroom floor yelling for help. E12 stated at she does not remember the incident on 5/21/15 regarding R3. The facility's fall risk assessment policy dated 3/12 reads Residents will be assessed for risk factors that increase their potential for falls in order to identify the need to initiate additional safety measures. The resident who scores 12 or greater will have individual High Risk interventions implemented, including Falling Star Program. The facility's prevention of falls policy dated 6/13 reads 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 in order to minimize the risks for fall incidents and/or injuries to the resident. The policy reads Initiate falling star program for residents who are at high risk for falls (refer to falling star program policy). The facility's falling star program policy dated 11/10 reads To minimize the chance that a fall will occur, residents who are assessed at high risk for falls, or who have a history of falls within the last 180 days, will be included in the falling star program. The falling star program procedure reads 1)Place a falling star icon outside the resident's room next to the resident's name. 2) Attach a falling star icon to the resident's mode of transportation, (i.e. wheelchair, walker, cane) if applicable. 3) Initiate/update fall risk care plan and 4) Educate the resident and/or family on the falling star program and the resident's individualized high risk interventions.

Based on observation, interview, and record review, the facility failed to follow their fall prevention policy and implement fall prevention interventions for 4 of 6 residents (R1,R3,R11,R12) reviewed for falls. This failure resulted in R1 falling, sustaining a fractured left hip, and requiring surgery to fix the fracture. Findings include: Closed record documents R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Fall Risk Assessment 5/30/14 and 5/31/14 score R1 as a high risk for falls. Fall Care Plan initiated on 5/30/14 has the intervention of personal or pressure sensitive alarms when resident is in chair or bed, ensure no-slip socks are used, and provide proper, well maintained footwear. Occurrence Report 5/31/14 12:50am, R1 was visually observed sitting on the floor by the bedside. R1 stated he was trying to get back in bed after going to the bathroom when he slid to the floor. Preventive Measures at the Time of Fall document "alarm - none". Follow Up documents R1 had 3 falls in the 3 days prior to admission to the facility on [DATE]. Recommendations added after the fall are re-orient resident to surroundings "frequently" and perform "frequent" rounding on resident while in the room. Occurrence Report 6/1/14 12:00am documents a bed alarm was sounding. Z6(Nurse) ran down the hallway and saw R1 standing by the doorway, then turned. When Z6 arrived at the room, R1 was sitting on the floor with his back to the door and legs extended. R1 stated to Z6 that he got up to use the bathroom. General Follow Up documents upon investigation, R1 stated he wanted to use the bathroom; R1 has a history of being impulsive and "requires constant redirection" due to poor safety awareness; R1's left leg is noted to be laterally rotated and painful. Hospital records document R1 has [DIAGNOSES REDACTED]. Consent to Operation 6/2/14 documents "pinning of left hip femoral neck fracture". emergency room Note 6/1/14 document R1 fell at the facility while walking to the bathroom, family is at the bedside. Physician History and Physical 6/1/14 R1 stated R1 got up from bed and while walking, made a sudden turn, slipped, and fell down. X-ray is positive for a femur neck fracture. On 11/25/14 at 6pm, by phone, Z12(Family) stated R1 wore his own white athletic socks at the facility, they did not give him the socks with anti-skid strips on the bottom. On 12/4/14 at 2:30pm, by phone, Z7(Family) stated R1 had an alarm clipped to him after the fall on 5/31/14, not before. R1 wore his own white athletic socks the entire time he was at the facility. R1 was not provided with anti-slip socks. R1 had his own socks on at 9pm 5/31/14, and still had them on in the emergency roiagnom on [DATE] after the second fall. R1 told Z7 that he slipped and fell because he was wearing regular white socks and the floor was slippery. On 12/4/14 at 2:40pm, by phone, R1 stated during the night of both falls (5/31/14 and 6/1/14) he turned on the call light because he had to go to the bathroom but no one came. The second night when no one answered the call light, R1 got up by himself, walked to the door, looked down the hallway, and called to the nurse. "It was kind of a slippery floor and I didn't have those silicone socks on. I turned and fell on my hip." R1 clarified that "silicone socks" were the colored socks with sticky strips on the bottom that prevent slipping, and that he wore his own white socks the entire time at the facility. On 12/15/14 at 9:20am, by phone, E4(Nurse Aide) stated she was assigned to R1 but was late for the night shift on 6/1/14 and was not there when R1 fell . On 12/15/14 at 10:05am, by phone, Z3(Nurse) stated she does not remember R1 or the falls on 5/31/14 and 6/1/14. On 12/15/14 at 11:15am, by phone, Z5(Physician) stated R1 had multiple falls at home before admission to the facility. Z5 stated that when R1's alarm is activated, they need to get to him fast. Additional interventions for R1 would be to keep him at the nurse's station, move to a room closer to the station, anti-skid socks, personal alarms, reminders not to get out of bed, and check on him more frequently. Z5 does not remember if R1 wore socks. On 12/15/14 at 12:10pm, E2(Director of Nursing) stated fall care plans are specific to the resident's needs. A resident assessed as high risk for falls will have interventions such as falling star program to alert staff that the resident is a risk for falls, low bed, call light, floor matts, therapy evaluation, alarms, proper footwear, and "frequent monitoring" more than the standard every 2 hours. All interventions should be in place to attempt to prevent falls. E2 could not specify or clarify how "frequent" R1 needed to be monitored. E2 could not provide any documentation on how frequently R1 was being monitored. E2 stated fall interventions for residents are to be put into place as documented on the care plans. Eight attempts (12/15/14-10am, 11:30am, 4:15pm, 6:50pm; 12/16/14 - 8am, 1:20pm; 12/17/14 - 9:14am, 12pm) were made to reach Z6(Nurse) by phone regarding R1's fall on 6/1/14 which resulted in a fractured femur. The number provided for Z6 would not accept any messages. Unable to reach Z6 for an interview. On 11/28/14 at 2:20pm, R3 sat in a recliner. A chair alarm was on the chair, but was turned off and was not attached to R3. R3 was moving around and leaning forward in the chair. Each time R3 leaned forward, his momentum would move the chair forward. At 2:35pm, R3 leaned forward to reach for the counter at the nurse's station, attempting to stand up. E15(Nurse) asked E16(Nurse Aide) to move R3 closer to where staff was sitting. Both E15 and E16 did not notice that the chair alarm was not on or attached to R3. At 2:40pm, E2(Director of Nursing) approached E15 and discovered that the alarm was not on or attached to R3. Occurrence Reports 11/9/14 and 11/21/14 document R3 had falls. Fall Care Plan 11/21/14 documents the use of alarms when R3 is in the chair or bed and 11/8/14 use proper maintained footwear. Occurrence Report 11/21/14 R2 was found on the floor by the bed, footwear is documented as socks only, slipper socks or shoes were not in use. Fall Risk Assessment 11/9/14 and 11/21/14 document R3 as a high risk for falls. On 11/28/14 at 11:45pm, R12 was sitting in a reclining chair at the nurse's station. R12 did not have any socks or shoes on his feet. Occurrence Reports 10/25/14 and 11/6/14 document R12 got out of bed and fell . Footwear is documented as socks only, not slipper socks. Fall Care Plan 8/1/14 documents the use of proper footwear as a fall prevention intervention for R12. Fall Risk Assessments 10/25/14 and 11/6/14 document R12 is a high risk for falls. On 11/30/14 at 12:10am, R11 was in bed, restless and moving around. R11 had white athletic socks on, without anti-skid bottoms. Occurrence Report 10/27/14 documents R11 had a fall. Fall Care Plan 7/22/14 documents the use of non-skid footwear as a fall prevention intervention. Fall risk assessment 10/27/14 scores R11 a high risk for falls. Prevention of Falls 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 in order to minimize the risks for fall incidents and/or injuries to the resident. Develop a plan of care to include goals and interventions which address resident's risk factors. Assess and monitor resident's immediate environment to ensure appropriate management of potential hazards. Fall Risk Assessment policy - The resident who scores 12 or greater will have individualized High Risk interventions implemented. Falling Star Program - Educate the resident and/or family on the Falling Star Program and the resident's individualized high risk interventions.

Based on interview and record review the facility failed to monitor and ensure adequate hydration was given to 1 of 3 residents (R7), who was identified to be at risk for dehydration. This failure resulted in R7 being admitted to the hospital and was diagnosed with [REDACTED]. Findings include: According to the clinical record R7 was admitted to the facility on [DATE] status [REDACTED]. According to R7's interim plan of care R7 is identified with dehydration risk related to dry skin, unable to reach fluids independently and difficulties with chewing and swallowing. The interim plan of care also indicates that the facility will take the following approaches to monitor R7 for signs and symptoms of dehydration: monitor labs as ordered, offer fluids with every activity, and monitor skin turgor. According to the nursing notes dated 11/6/2011 (all shifts included) through 11/13/2011 (2pm through 10pm), there were no entries noting R7's fluid intake. The same dates as noted above under the gastrointestinal area of the notes indicating if fluids were encouraged and documentation of appetite were found to be blank. In reviewing the notes there were also no entries indicating an assessment of R7's skin turgor. According to the physician order [REDACTED]. The order was written by Z3 (Nurse ractitioner). On 2/9/12 at 11:30am via telephone Z3 (Nurse Practitioner) said that it is her routine to have labs collected at the beginning of the week and within the first week of a new residents admission. Z3 said that she was aware that R7 was admitted on [DATE] and that on 11/9/11 she gave orders for labs to be collected on 11/14/11, nine days later. Z3 said that she sees a lot of residents and that it's easier for her review lab work if it's drawn at the beginning of the week. Z3 said that she ordered labs so she can get a baseline on R7's status based off of the results. Z3 was asked if it was usual to wait 9 days before drawing baseline labs on a new resident and Z3 said for her it is because she likes labs collected at the beginning of the week. Z3 denied that the facility staff alerted her that R7 was identified as being at risk for dehydration. Z3 said that the facility nursing staff should have documented R7's intake of food and fluids in the nursing notes and notified R7's attending physician of any abnormal or low intake of food/fluids. Z3 also indicated that free water deficit may be indicative to poor intake by mouth. On 2/8/11 at 10:30am E19 (Assistant Director of Nursing), said that residents identified to be at risk for dehydration, nursing staff monitors the residents intake by mouth and encourages fluids, however, E19 was unable to verbalize how the facility actually measured and ensured fluid intake is measured for residents at risk for dehydration. E19 said that if the physician does not write an order for [REDACTED]. On 2/9/2012 via telephone at 1:00pm Z1(physician) said that he only saw R7 once. Z1 said that he was not made aware of R7 being identified as being at risk for dehydration. Z1 also said that intake of fluids and food should be documented in the nursing notes. Z1 said if the facility nursing staff would have notified him that R7's oral intake was poor, Z1 said he could have ordered strict monitoring of intake/output. Z1 said it's routine to collect labs within the first week of admission, not necessarily at the beginning of the week. Z1 said that he wasn't notified of R7's status until 11/13/11 when he wrote orders for stool softener and enema. Z1 also said that he reviewed R7's labs dated 11/14/11 yesterday (2/9/2012). According to the clinical record chemistry results dated 11/14/11 R7's blood urea nitrogen level 91mg/dl (normal range - 6 -24 mg/dl), creatinine level 2.59 mg/dl (normal range - 0.6 - 1.4 mg/dl), sodium level 153 meq/L (normal range 135 - 148 meq/L). According to R7's nursing notes there is no documentation or entries indicating that R7's physician was notified of the abnormal lab results. According to Z1 he reviewed the lab results for the first time yesterday (2/9/2012). According to the facility's hydration policy a plan of care will be developed utilizing identified risk factors based on resident's individualized needs. The policy also indicates that the effectiveness of the hydration plan of care will be monitored through clinical observations, and lab monitoring. According to the hospital records dated 11/15/11 at 2:52pm R7's chemistries were noted creatinine level 5.1 mg/dl (normal range 0.6 - 1.0 mg/dl), blood urea nitrogen 143 mg /dl (normal range 7 - 18 mg/dl), and sodium level 156 meq/L (normal range - 136 -145 meq/L). According to the hospital record assessment and plan R7 presented to the hospital with multiple medical problems/issues to include: acute [MEDICAL CONDITION] secondary to dehydration and severe free water deficit. According to the hospital record x-ray of the abdomen dated 11/15/11 impression indicates fecal retention and colonic ileus (disruption of normal propulsive ability).