Every finding on record at Alden North Shore Rehab & HCC

Based on observation, interview, and record review, the facility failed to follow infection control practices affecting 1 of 5 (R60) residents reviewed for infection control in a total sample of 16. Findings Include:On 7/21/2026 at 11:30 AM during point of care blood glucose (BG)monitoring, V7 (Registered Nurse) did not perform hand hygiene before, during, or after completing task. V7 put on gloves and prepared BG monitoring equipment on the medication cart positioned at the nurse station without performing hand hygiene. V7 proceeded to R60's room and performed BG monitoring wearing the same pair of gloves worn during preparation. After performing BG monitoring, V7 walked out of R60's room with one of the gloved hands (lowered but not removed) containing the BG machine, used lancet and used BG strip with visible blood of R60. V7 returned to her medication cart positioned at nurse station, removed her gloves, and donned a new pair of gloves without performing hand hygiene to clean and disinfect BG machine. V7 states she did not have time to do hand hygiene.On 7/22/2026 at 11:05 AM, V2 (Director of Nursing) said hand hygiene should be performed when point of care blood glucose monitoring is to be done, after removing gloves, and before donning a new pair of gloves. This is important because of infection control.Policy and ProcedureTitle: Hand Hygiene, 10/2024Guidelines:There are 2 methods for hand hygiene:1. Alcohol-based hand sanitizer (ABHS) a. Immediately prior to touching a resident. d. After touching a resident or the resident's immediate environment. e. Immediately upon removal of gloves and PPE2. Hand hygiene with soap and water b. After any contact with blood, body fluids or contaminated surfaces

Based on observation, interview, and record review, the facility failed to ensure expired medication was discarded affecting 1 of 1 (R60) resident reviewed for medication storage in a total sample of 16. Findings Include:On 7/21/2026 at 10:03 AM, in the second-floor medication room fridge, observed an outdated/expired Omeprazole liquid for R60 and with a label of do not use after 7/16/2026. V7 (Registered Nurse) said medication should have been removed and discarded.On 7/22/2026 at 11:05 AM, V2 (Director of Nursing) said expired medications should be removed from the fridge, discarded, and not administered after the used by date. EMAR (Electronic Medication Administration Record), order date of 5/15/2026, reads Omeprazole+Syrspend SF AlkaOral Suspension 2 MG/ML(Omeprazole) Give 5 ml via PEG-Tube one time a day.R60's Electronic Medication Administration (EMAR), 7/1/2026 - 7/31/2026, indicates the expired medication was administered on 7/17, 7/18, 7/19, 7/20, and 7/21/2026 at 6:00 AM.Policy and Procedure:Title: Storage/Labeling/Packaging of MedicationsB. Policy10. Medication containers that are damaged, soiled, contaminated, or outdated are immediately removed and either returned or disposed of according to procedure. Reorder from the pharmacy as applicable.

Based on interview and record review, the facility failed to follow its abuse policy related to training, prevention, reporting and investigating for one (R1) of three residents reviewed for abuse. As a result of this failure, R1 felt hurt, scared, and afraid. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 3/11/2025 when the facility failed to implement their abuse policy after an alleged abuse was reported by R1 to V2 (Director of Nursing). V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 3/24/2025 at 1:00 PM. The survey team confirmed by observation, interview, and record review, the Immediate Jeopardy was removed on 3/26/2025, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R1's face sheet, dated 3/18/2025, documents R1 is a [AGE] year-old resident admitted to facility on 2/13/2025. R1 has diagnoses including, but not limited to: dislocation of internal left hip prosthesis, infection following procedure and chronic obstructive pulmonary disease. R1's Minimum Data Set (MDS) section C0500, dated 2/17/2025, documents Brief Interview for Mental Status (BIMS) score of 14, indicating cognition is intact. MDS section GG0130, dated 2/17/2025, documents resident needs supervision or touching assistance with the following: eating and personal hygiene. Resident needs partial/moderate assistance with the following: oral hygiene and shower/bathe self. Resident needs substantial/maximal assistance for the following: toileting hygiene, upper body dressing, lower body dressing, and putting on/taking off footwear. Concern form, dated 3/11/2025, documents resident expressed issue with previous V5 (previous evening CNA). Per resident would prefer female CNA, with the exception of one AM CNA she gets along with also expressed not wanting her brief checked. Follow up action taken: Will assign female CNAs only with the exception of the specified CNA. Discussed importance of having brief checked by staff to ensure that resident is clean/skin checks. Time sheet for V5 documents V5 clocked in on 3/10/2025 at 9:59 PM. Time sheet documents V5 clocked out at 6:30 AM 3/11/2025. V5 timecard punches show V5 worked 3/11/2025, 3/13,2025, 3/14/2025, 3/15/2025, 3/16/2025 and 3/17/2025. V5 continued to work until 3/18/2025, facility informed of alleged abuse. On 3/18/2025 at 11:08 AM, V6 (Family Member) stated, On 3/12/2025 after I spoke to the front desk, I came to talk to (R1). (V1, Administrator) came to talk to me and (R1) in (R1's) room, and with me separately. (R1) told me that (V5, Certified Nursing Assistant/CNA) was rough with (R1) checking the diaper, and putting a finger into (R1's) vagina. I told (V1) that. (V2, Director of Nursing) talked to me the day before that (3/11/2025). (V2) told me about (V5) being aggressive/rough with diaper change before I found out the whole story. On 3/18/2025 at 11:42 AM, V2 stated, I am not aware of any sexual abuse allegation for (R1). I did speak to (V6), but did not speak to her regarding any sexual abuse allegation. I am not aware of any sexual abuse. The only thing I spoke with (V6) about regarding a male CNA was (R1's) preference was not to have a male CNA. On 3/18/2025 at 11:55 AM, V1 stated, I am not aware of any sexual abuse allegation for (R1). I did not speak to (V6) or (R1) regarding any sexual abuse allegation. I did speak with (V6) in person on Wednesday morning (3/12/2025) in private, away from (R1) regarding discharge information. I did speak with (R1) Tuesday morning (3/11/2025) regarding her preference for no male CNA caregivers due to preference, except for the morning CNA (V4) that she likes. I did confirm to (V6) and (R1) that (V5, CNA) or any other male would not care for (R1) except (V4). (V5) is still working here. (V5) works nights. On 3/18/2025 at 12:41 PM, V6 (family member of R1) stated, I said to (V1, Administrator) that (V5, CNA) was rough changing (R1's) diaper, and he put his finger in (R1's) vagina, which is what (R1) said to me. I did not tell that to (V2) because I was not aware of that yet. I am sure I told (V1) about the situation. (V1) stated to me that (R1) did not tell me the detail of (V5) putting his finger in (R1's) vagina, just that (V5) was rough with (R1). (R1) said to me that she did not want any males to work with her after that experience with (V5). (R1) said that to (V2, DON) and also to (V1, Administrator), but that was after this incident. On 3/18/2025 at 1:14 PM, V1 provided initial report of abuse. V1 stated, (V5) is suspended pending investigation. On 3/18/2025 at 1:18 PM, V5, CNA, stated, I worked last Monday night (3/10/2025). I do not feel like I was rough with (R1) at any time. I did not stick my fingers in (R1's) vagina. I just did my normal routine by wiping once on the left side and the right and then the back. I do not remember (R1) telling me that (R1) felt I was rough with her. On 3/18/2025 at 1:58 PM, R1 stated, I told what happened to (V22, CNA), (V21, Resident Care Coordinator) and (V2, DON). I told them the details that he was rough with me and put his finger in my vagina. On 3/19/2025 at 11:26 AM, V1 stated, I am unsure if the doctor was notified of sexual allegation. I will find out if the doctor has been notified of the sexual abuse allegation and let you know. On 3/19/2025 at 12:31 PM, V17, Certified Nursing Assistant (CNA), stated, I am an agency CNA. I did report to (V19, Registered Nurse/RN) the nurse. (V19) is not here today. The situation was there was another CNA (V18) working, and she was talking to (R1), and (V18) came and got me for the conversation. (V18) is not here today. (V18) works pm or overnight shift. I do not know when it took place or anything. (R1) would just say 'I don't want to be changed' and 'I don't want to get anyone in trouble'. On 3/19/2025 at 1:10 PM, V20 (Physical Therapist) stated, I did look at (R1's) chart and see she had a fall, and then no male CNA is to care for her. I feel like (R1) was trying to tell me something without telling me something that I suspected as abuse, but it was already being handled. I guess yes, I should have reported, but I thought it was already reported. On 3/19/2025 at 2:00 PM, V19, RN stated, Nobody reported any type of abuse allegation to me. On 3/20/2025 at 11:05 AM, V18, CNA, stated, I heard about (R1) Thursday night (3/13/2025) and Saturday (3/15/2025) night, but (R1) did not say anything to me. Someone said there was abuse and they said it was (R1). (V17) was the one who told me. (V17) told me Thursday or Saturday. When (V17) told me this, I did not report it because she was not sure. I never reported it to anyone. I told (V17) to tell the nurse or DON. (V17) never told me if she told the nurse or not. (R1) never said nothing to me about being abused or nothing like that (sic). On 3/24/2025 at 11:13 AM, V2 stated, If the administrator is not here, I would step up in the place of the Abuse Coordinator. Staff would report abuse to me immediately, we would remove alleged perpetrator, we would start investigations immediately, interviews immediately, send reportable within a few hours. These would be my responsibilities if Administrator is not here. Abuse Policy, dated 09/20, documents: POLICY: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility will report reasonable suspicion of a crime. This facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. This will be done by: 6. Implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively, and making the necessary changes to prevent future occurrences; 7. Filing accurate and timely investigative reports; 4. Identification Employees are required to immediately report any occurrences of potential mistreatment they observe, hear about, or suspect to a supervisor or the administrator. Supervisors shall immediately inform the administrator or designee of all reports of potential mistreatment. Upon learning of the report, the administrator or designee shall initiate an incident investigation. The nursing staff is additionally responsible for reporting on a facility incident report the appearance of bruising of unknown origin, lacerations or other abnormalities as they occur. Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing the documentation and reporting to the administrator or designee. If the resident complains of physical injuries or if resident harm is suspected, the resident physician will be contacted for further instructions. c. Employees of the facility who have been accused of mistreatment will be removed from resident contact immediately until the results of the investigation has been reviewed by the administrator or designee. e. Employees accused of possible abuse shall not complete the shift as a direct care provider to residents. 7. Reporting Initial Reporting of Allegations shall be completed immediately upon notification of the allegation. The written report shall be sent to the Department of Public Health. The Immediate Jeopardy began on 03/11/2025 and was removed on 03/26/24, when the facility took the following actions to remove the immediacy: On 3/26/2025 at 10:53 AM, V1 stated, I was retrained on abuse on 3/24/2025. Basically it covered the abuse policy, abuse prevention, investigation, the immediacy, and the thoroughness of it. It also covered identified vulnerable residents and providing emotional support after the fact. I am the Abuse Coordinator. The DON steps in as Abuse Coordinator if I was not here. If rough handling is alleged, it is considered abuse. Investigation starts immediately. If there is an alleged staff member, they would be placed on suspension immediately. Body check would be completed. MD (Medical Doctor) would be notified. Family would be notified. Interviews would be started. A reportable would be filed within 2 hours. If I come across a resident that is afraid and states they do not want to get anyone in trouble, I would speak with the resident in a private area, and encourage them to let us know what happened. I would let the doctor and responsible party know and see if they would open up to either one of them. I would interview staff. If they have a good repore with a specific staff member, I would try to have them talk to the resident. If they continue to refuse to share, I would try to provide support as best as we can. Ask them if we could make changes to care that would make them more comfortable. (V5) is still on suspension pending police investigation. As of yesterday afternoon, police still had not contacted (V5). The next step is to go to his house. Police said it is still at officer level and will next go to a detective. On 3/26/2025 at 11:09 AM, V16 (Registered Nurse/RN) stated, I was re-trained on abuse recently it was in the last couple days. It covered types of abuse, when to report abuse and a quiz. Abuse Coordinator is (V1), the Administrator. Rough handling is considered abuse. If someone reported rough handling to me, I would report to my supervisor, and the Administrator, and the DON reports to the Administrator. I would remove the resident from harms way. The alleged perpetrator would be removed. If I had a resident that seemed scared and stated they did not want to get anyone in trouble, I would still report. They may just be afraid of retaliation. I would do the same steps in that instance. On 3/26/2025 at 11:14 AM, V29 (Housekeeping) stated, I was recently trained on abuse yesterday. They covered types of abuse, reporting abuse to Abuse Coordinator, (V1). Being handled roughly is abuse. If someone told me they were handled roughly, I would report to the nurse and the Abuse Coordinator. If I came across a resident that seemed afraid and said that they don't want to get anyone in trouble, I would try to be supportive but report to the nurse and Abuse Coordinator. On 3/26/2025 at 11:22 AM, V30 (2nd floor Unit Manager) stated, I was recently trained on abuse this past week. We talked about reporting to Administrator any suspected abuse or witnessed abuse. We also covered types of abuse which include verbal, mental, sexual, physical, misappropriation of property and exploitation, mistreatment, serious body injury, and neglect. Rough handling is considered abuse. If a resident told me they were handled roughly, I would offer to listen to patient and get a nurse and report to administrator immediately. Administrator, (V1) is our Abuse Coordinator. If (V1) is not here, the DON is our Abuse Coordinator. If I came across a resident that stated they were afraid and did not want to get anyone in trouble, I would listen to the resident and communicate it right away to the Administrator. On 3/26/2025 at 11:31 AM, V23 (Physical Therapist) stated, I was just retrained on abuse yesterday. It covered reporting structure, who, when, etc. Types of abuse was covered. The three R's which are remove, remove, report. Abuse Coordinator is (V1). Rough handling is considered abuse. If a resident reported rough handling to me, I would ask the resident if they wanted to talk to someone, report to my supervisor and to the Abuse Coordinator. If a resident reported they are scared and do not want to get anyone in trouble, I would do the same thing. I would ask them if they want to speak to someone about that, report to my supervisor and to the Abuse Coordinator. On 3/26/2025 at 11:37 AM, V31 (Housekeeping) stated, I was retrained on abuse yesterday. They talked about the 10 different kinds of abuse. They talked about reporting any problems to (V1) Abuse Coordinator immediately. Rough handling is abuse. If a resident told me someone was rough with me, I would report it immediately to Administrator. If a resident told me they were scared and don't want to get anyone in trouble, I would report that to the administrator as soon as possible and try to calm the resident. On 3/26/2025 at 11:42 AM, V32 (Building Manager) stated, I did recently get retrained on abuse yesterday. They covered the 10 different types of abuse, reporting immediately, remove, and report. (V1) is the Abuse Coordinator. Rough handling is considered abuse. If a resident reported rough handling to me, I would report immediately to (V1), and try to remove the resident and alleged perpetrator. If a resident reported they were afraid but did not want to get anyone in trouble, I would remember what room it was and go report it to (V1) immediately. On 3/26/2025 at 11:48 AM, V33 (Resident Care Coordinator) stated, I did recently get trained on abuse yesterday. They covered the 10 types of abuse, who to report to (Administrator), timeliness of reporting, and what to do if you see abuse occur. Abuse Coordinator is (V1), the Administrator. Rough handling is considered abuse. If a resident reported rough handling to me, I would tell the Administrator immediately. If a resident reported to me that they were afraid and did not want to get anyone in trouble, I would still report immediately to the Administrator. On 3/26/2025, V34 (CNA) stated, I was recently trained on abuse yesterday or the day before. They covered the different types of abuse, who to report to (Administrator), what to do if you witness or experience any type of abuse. Rough handling is considered abuse. If a resident reported rough handling to me, I would remove the patient from the situation, and report to the Administrator. If a resident told me they were afraid and did not want to get anyone in trouble, I would still report to the Administrator. On 3/26/2025 at 11:59 AM, V2 stated, I was retrained on abuse on 3/24/2025. We were re-trained on how to investigate abuse, how to respond to any allegation of abuse, how to interview the resident, informing family and doctors, and how to find who the resident is comfortable with to talk to the resident. Types of abuse were covered (10 types); we did quizzes. We educated the staff as well. Abuse Coordinator is the Administrator, and if she is absent, it is me. Rough handling is considered abuse. If a resident reported rough handling to me, I would try to get details from resident, remove abuser, and report to (V1). If I had a resident report to me that they were afraid, and did not want to get anyone in trouble, I would try to get details from resident, report to V1, inform family and doctor, and try get someone to talk to resident that they are comfortable with. On 3/26/2025 at 12:59 PM, Updated Abuse Policy reviewed. No concerns noted. On 3/26/2025 at 1:02 PM, QAPI (Quality Assurance Performance Improvment) meeting minutes for QAPI meeting held on 3/24/2025 reviewed. No concerns noted. On 3/26/2025 at 1:05 PM, Abuse, Abuse Prevention Policy and reporting and investigating,and Abuse Prevention policy and putting interventions in place to protect resident and provide support Inservice/Meeting Attendance Records reviewed for 3/24/2025. No concerns noted. On 3/26/2025 at 1:10 PM, Initial Incident Report and Final Incident Report reviewed for R1. No concerns noted. On 3/26/2025 at 1:11 PM, Incident Referral Card, dated 3/24/2025 reviewed. No concerns noted. On 3/26/2025 at 1:13 PM, Abuse Prevention Quizzes 2025 and Abuse Quizzes reviewed. No concerns noted. On 3/26/2025 at 1:15 PM, QAPI Assessment Tool Investigate/Prevent/Correct Alleged Violation, dated 3/20/2025, 3/21/2025, 3/22/2025, 3/23/2025, and 3/24/2025 reviewed. No concerns noted. On 3/26/2025 at 1:18 PM, QA/QI (Quality Assurance/Quality Improvement) Monitoring sheet labeled F607 and F600 Free from Abuse and Neglect dated 3/24/2025, 3/25/2025, and 3/26/2025 reviewed. No concerns noted.

Based on interview and record review, the facility failed to prevent and protect a resident (R1) from staff-to-resident sexual abuse. This failure affected one (R1) resident out of three residents reviewed for abuse. As a result of this failure, R1 felt hurt, scared, and afraid. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 3/11/2025 when R1 was sexually abused by V5 (Certified Nursing Aide). V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 3/24/2025 at 1:00 PM. The survey team confirmed by observation, interview, and record review, the Immediate Jeopardy was removed on 3/26/2025, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R1's face sheet, dated 3/18/2025, documents R1 is a [AGE] year-old resident admitted to facility on 2/13/2025. R1 has diagnoses including, but not limited to: dislocation of internal left hip prosthesis, infection following procedure, and chronic obstructive pulmonary disease. R1's Minimum Data Set (MDS) section C0500, dated 2/17/2025, documents a Brief Interview for Mental Status (BIMS) score of 14, which indicates cognition is intact. MDS section GG0130, dated 2/17/202,5 documents resident needs supervision or touching assistance with the following: eating and personal hygiene. Resident needs partial/moderate assistance with the following: oral hygiene and shower/bathe self. Resident needs substantial/maximal assistance for the following: toileting hygiene, upper body dressing, lower body dressing, and putting on/taking off footwear. Progress note, dated 3/11/2025 at 2:14 PM, documents in part: V6 also made aware that R1 is requesting that no male CNAs provide her care. Facility agrees to only assign female CNA per resident's request. Concern form, dated 3/11/2025, written by V1 documents nature of concern, resident expressed issue with previous evening CNA. Per resident would prefer female CNA, with the exception of one AM CNA she gets along with. Also expressed not wanting her brief checked. Follow up action taken: Will assign female CNA's only with the exception of the specified CNA. Discussed importance of having brief checked by staff to ensure that resident is clean/skin checked. Initial report of allegation, dated 3/18/2025, documents: R1 is a [AGE] year-old female, admitted to facility on 2/13/2025, with diagnoses stated above for skilled Physical Therapy/Occupational Therapy. On 3/18/25, Illinois Department of Public Health (IDPH) Surveyor came to facility for a complaint investigation. Made Administrator aware of a resident who was alleging that she was inappropriately touched by a male CNA. Alleged CNA suspended pending investigation. Investigation initiated. Final report to follow. Progress note, dated 3/19/2025, documents: Note Text: Writer spoke with V26 (Physician Assistant) for V27 (Doctor) and notified of resident's allegation with no new orders given at this time. Per documented facility schedule, V5 continued to work until 3/18/2025, when surveyor informed facility of alleged abuse. V5 timecard punches show V5 worked 3/11/2025, 3/13,2025, 3/14/2025, 3/15/2025, 3/16/2025 and 3/17/2025. Time sheet for V5 documents V5 clocked in on 3/10/2025 at 9:59 PM. Time sheet documents V5 clocked out at 6:30 AM 3/11/2025. Bladder incontinence task sheet documents R1 was continent at 5:16 AM on 3/11/2025. This was the only entry for overnight shift starting 3/10/2025 at 9:59 PM to 6:30 AM on 3/11/2025. On 3/18/2025 at 11:05 AM, R1 and V6 (Family Member) were present in room. R1 was asked if R1 had been inappropriately touched. R1 stated, I was inappropriately touched. I was touched, but I was assured that the person who did it was censured. R1 was asked what does censured mean. R1 stated, It means that this would not happen to me or anyone else. V6 stated, We were assured by (V2) that a male staff (V5, Certified Nursing Assistant/CNA) was rough in checking (R1's) diaper, and he would not be working with (R1) anymore. I do not know his name. (R1) told me this happened Monday night last week. R1 stated, The only reason I feel safe in this environment is that the people came and responded so quickly. V6 stated, (V2) knows, (V1, Administrator) knows. I don't know who told (V1). I came here after that happened on Wednesday, because (R1) was upset. (R1) thought she had a broken hip because she fell out of bed Monday night last week (March 10, 2025). (R1) is here after hip replacement surgery, so we were concerned of the hip. Hip is ok. (R1) did not break anything. After I spoke to front desk, I came to talk to (R1). (V1) came to talk to me, with (R1) in the room, and also with me separately. (R1) told me that (V5) was rough with her when checking the diaper, and also put a finger into her vagina. I told (V1) that. (V2) talked to me the day before that. (V2) told me about him (V5) being aggressive before I found out the whole story. Police was not called regarding (V5) as far as we know. R1 stated, I wanted to call the state to report the issue after I left this place, but you are here now. V6 stated, (V1) asked me to walk out of the room to talk to privately about the situation, and also to talk about plans after (R1's) stay here. R1 stated, This happened after I fell out of bed. It was the next morning, and (V5) looked at me and said 'you couldn't still be dry' (speaking about my diaper). (V5) went in there and he was hurting me. I felt like he was moving things rough and put his finger in my vagina. This happened Tuesday morning, 3/11/2025, after the fall. It was just (V5) and me. I do not know (V5's) name. I had only seen (V5) a few times. (V5) was a big guy. (V5) was average height. (V5) had dark brown or black hair. I am unsure of markings or tattoos. I do remember that when (V5) got where he wanted to get to, (V5) said, 'yeah you are right you are dry'. I have not seen (V5) since that time. V6 stated, (V2) is the head nurse that works days. (R1) has some confusion, but I do think it happened. On 3/18/2025 at 11:42 AM, V2 stated, I am not aware of any sexual abuse allegation for (R1). I did speak to (V6), but did not speak to her regarding any sexual abuse allegation. I spoke to (V6) regarding (R1) having a fall the night before. Tuesday morning when I went to speak with (R1), she did not want me to call (V6) regarding the fall. (R1) told me she did not want a male CNA that night, and she did not want a male CNA per her preference. I verified (V6) was Power of Attorney (POA) and verified BIMS, and had to notify (V6). The only thing I spoke with (V6) about regarding a male CNA, was that (R1) preference was not to have a male CNA. There was no allegation of sexual abuse. The male CNAs name is (V5), and that was the only time she had a male CNA. (V5) is a night CNA, and he was assigned to (R1) Monday night when (R1) had the fall. On 3/18/2025 at 11:55 AM, V1 stated, I am not aware of any sexual abuse allegation for (R1). I did not speak to (V6) or (R1) regarding any sexual abuse allegation. I did speak with (V6) in person on Wednesday morning in private away from (R1), regarding discharge information. (V6) is very overwhelmed with (R1) going home, and (R1's) confusion. I was not made aware of any male CNA being rough with (R1), or any sexual abuse allegation. I did speak with (R1) Tuesday morning regarding her preference for no male CNA caregivers due to preference, except for the morning male CNA that she likes. I did ask (R1) why she did not want any male CNA caregivers and she stated she is uncomfortable with any male CNA's caring for her private areas except for (V4). (V4) is a female who appears as a male. (R1) stated '(V4) is like a son to me he is the only male I want caring for me'. Monday night there was a male CNA, (V5), caring for (R1). I did confirm to (V6) and (R1) that (V5) or any other male would not care for (R1), except (V4). (R1) or (V6) did not identify or specify something with (V5), they just said any male in general, except (V4). (V5) is still working here. (V5) works nights. My conversation with (R1) was to follow up with her fall from Monday night. We talked about that for the majority of the time. R1 stated, 'you know I had a man taking care of me during the night. I am uncomfortable with men taking care of me like that except for (V4)'. That was not a huge point of the conversation. (R1) then was telling me about (V6) and her life story and all of that. That conversation took place Tuesday morning (3/11/2025). Then Wednesday morning (3/12/2025), staff informed me (V6) was in the building. We quickly touched on (R1) preferring female staff only, we talked about her confusion getting worse since December and our plan for that, and she was very appreciative of everything. For the rest of the conversation, we were talking about (R1's) discharge planning and (V6) being overwhelmed and things like that. On 3/18/2025 at 12:41 PM, V6, Family Member, stated, I said to (V1) that (V5) was rough changing (R1's) diaper and he put his finger in her vagina, which is what (R1) said to me. I did not tell that to (V2) because I was not aware of that yet. I am sure I told (V1) about the situation. (V1) stated to me, '(R1) did not tell me the detail of (V5) putting his finger in her vagina, just that (V5) was rough with her'. (R1) said to me that she did not want any males to work with her after that experience with (V5). (R1) said that to (V2) and also to (V1), but that was after this incident. On 3/18/2025 at 1:14 PM, V1 provided surveyor with initial report of abuse, dated 3/18/2025. V1 stated, CNA (V5) is suspended pending investigation. On 3/18/2025 at 1:18 PM, V5 stated, I worked last Monday night (3/10/2025). I do recall (R1) having a fall. (R1) was not complaining of pain when we put her back in bed, but she was weak. (R1) said she was trying to get to the chair from the bed. Later that night, (R1) used the call light because she was wet, and I went to change (R1) by myself, because I was assigned to her. I did not have any problems changing (R1), and I directed her what to do, she obeyed, and (R1) had no complaints. I can remember only changing (R1) once after the fall, and in the morning she was dry. That was about 4:30 AM. I did not open (R1's) brief when she stated she was dry. I do not feel like I was rough with (R1) at any time. I did not stick my fingers in (R1's) vagina. I just did my normal routine by wiping once on the left side and the right and then the back. I do not remember (R1) telling me that she felt I was rough with her. I have never touched any other residents inappropriately or been rough with them. V5 was asked if he was accused of inappropriate touching of resident in the past. V5 stated, I remember one lady in (room #) stated that I was inappropriate with her. I do not remember her name. I think there was another lady in (room #) bed one that stated I was inappropriate with her. On both occasions the facility was on my side. I did not touch them inappropriately; I am just doing my job. On 3/18/2025 at 1:56 PM, R1 stated, A week ago Monday night I had a fall. When I woke up this guy (V5) grabbed me and put his hands in me; he was doing all this stuff with his hands back and forth, and I was scared. I am very clear about what was going on inside of me. This happened after the fall; it happened the next day. It was morning time then. It was before lunch, but I am not sure what time. The only thing he said was 'oh you were right' (about being dry). I was saying 'don't do that, oh my god stop it.' He (V5) was hurting me, and it scared me. I don't remember falling asleep, but I remember waking up in my bed after that happened. Someone told me that I need to report this, but I don't want to tell you who that is, because I don't want her to lose her job. I am looking out for (V6) and me right now, and I can't talk about it. I told what happened to (V22, CNA), (V21, Resident Care Coordinator), and (V2, DON). I told them the details that (V5) was rough with me and put his finger in my vagina. They are all upper management. I am feeling really bad telling you this much. They might uh, I don't know. I am in such a strange situation right now. I am afraid I may never get out of here. I don't know what is going to happen. I understand your situation. I really do. I just told you more than I wanted to. This place has a very good reputation, and I don't want to have to leave here except to go home. I have been here almost a month. For the most part it has been ok, except for this situation. The reason I do not want any other male staff working with me except (V4) is because of this incident. I cannot and will not tell you who that is. Right now, I am so afraid because of things that have happened in the last hour. I cannot tell you what. You have a really hard job, and I am sorry, but I did not mean to get involved in all this. There is a lot of stuff going on right now for me and I do not want to rock the boat. I do not want to talk about this anymore. On 3/18/2025 at 3:15 PM, V1 was aksed if V5 had any other previous allegations of abuse. V1 stated, (V5) has had a previous allegation of abuse. (V5) just had one that I am aware of. (V5) is my only male CNA in the whole entire building. On 3/19/2025 at 10:12 AM, V6 stated, I am POA for healthcare for (R1). When I came in upset at the front desk (on 3/12/2025), I spoke with (V24) front desk. I told (V24) I am here because (R1) wants me to call the police. (R1) thinks her leg is broken. I asked who is in charge. I told (V24) I am going to (R1's) room to see what's going on. I did not tell (V24) about the allegation, because (R1) was more focused on her leg being hurt. (V1) ended up coming into the room and talking to me and (R1), and then with me alone in the hallway. (V1) did speak about the allegation with (R1) and me in the room, and asked (R1) to describe what happened, and (R1) did. Then (V1) asked if she could talk to me outside. This all happened on Wednesday 3/12/2025. When we talked in the hall, (V1) asked me what I knew. I told her what (R1) told me. (V1) stated she was surprised because the detail of (V5) inserting his finger in R1's vagina was not a detail that (R1) had told (V1) previously. I think if you go speak to (R1), she is going to clam up. Let me speak to (R1) and see if I can get her to tell me who told her to report this. On 3/19/2025 at 10:30 AM, V1 stated, (V5) has not had any discipline at all. (V5) started with us last July. I am getting my interviews in order. (V5) has been suspended as of yesterday (3/18/2025), and in-services on abuse have been started today. Last abuse training was in February this year at skills fair. Police have not been called. I can reach out to (V6) to see if she wants us to file a police report. On 3/19/2025 at 11:24 AM, V1 was asked why a concern form was filled out. V1 stated, Regarding the concern form, the issue was not wanting a male CNA. (V5) came at 10pm Monday night and worked overnights not evenings. The concern form was written the following morning by me, and was meaning there was an issue with (V5), who worked overnights the previous night. The issue was that (R1) was uncomfortable with a male taking care of her down there. The issue with (R1) not wanting to have her brief checked, was that she did not want her brief checked in the morning. I explained the need for it, and (R1) was fine. We get requests all the time that residents do not want a male, so I did not think anything of it. (V6) was here because she thought (R1) thought she broke her leg. I went to speak with (V6) regarding this, and other things were brought up, but the male CNA was just a blip in our conversation. On 3/19/2025 at 11:56 AM, V25 (CNA) stated, I have worked here only one day through an agency. I have not witnessed any abuse here. I was trained for abuse at my old job in January 2024. The agency I work for does not train us for abuse that I know of. I have not had abuse training this year. This facility has not trained me on abuse. On 3/19/2025 at 12:29 PM, V17 (CNA) stated, (R1) did disclose to me that she did not want to be changed due to something happening, but did not want to get anyone in trouble. (R1) did not mention whether it was female or male. I told (R1) if something happened to (R1), she needed to tell me so I could report it. (R1) does get confused more at night, but in the daytime (R1) knows what's going on. I do believe something happened to (R1). On 3/19/2025 at 12:39 PM, V6 stated, My thoughts on the situation is that I am angry on her behalf. (R1) thinks I want revenge, I disagree. I think there are rules and protocols that are supposed to be in place and this guy (V5) did not follow them. I am trying to keep (R1) safe. For the most part (R1) is pretty clear, there are times (R1) is a little confused. (R1) is really clear right now that I am the enemy. (R1) said to me 'I have enough problems to deal with, I don't want to deal with this anymore I just want to go home'. I am so frustrated. I do know something happened. I am just so frustrated. I never expected to have to deal with this. I feel like I am drowning. On 3/20/2025 at 11:01 AM, surveyor asked V18 how was R1. V18 (CNA) stated R1 was just a little bit nervous and shaky. On 3/24/2025 at 10:52 AM, V1 was asked what is supposed to happen when an allegation of abuse is reported. V1 stated, The alleged perpetrator is to be put on suspension immediately pending investigation in an allegation of abuse. If it is unfounded, they can come back to work. If it is founded, probable termination, depending on severity. I am the Abuse Coordinator. My process involves investigating, suspending individual involved, reporting, and possibly calling the police. Each department has their part to do. Nursing may have to do head to toe body assessment, notify doctor, carry out orders, etcetera. My DON (V2) steps in as Abuse Coordinator for me if I was not here. On 3/24/2025 at 11:10 AM, V2 stated, If someone reports abuse, the Administrator is to be notified immediately. The alleged perpetrator is removed from the situation. The Administrator would be in charge of suspending alleged perpetrator. For nursing, we would notify family, doctor, and any required parties. We would need to do a body assessment. On 3/24/2024 at 6:58 PM, V1 stated, According to agency, abuse training is required prior to employees starting with the agency. V1 was asked if facility provides abuse training to agency staff prior to start date. V1 replied, No, this is something we have recognized and have put in place. On 3/25/2025 at 10:37 AM, V1 was asked if the document, dated 2/5/2025, was facility's annual abuse training. V1 stated, Yes, it was a skills fair that included abuse. V1 was asked if document submitted included abuse training for all staff. V1 stated, Yes. All employees were not listed. V1 stated, Some employees may have been called on the phone. I will look to see if I have any further documentation. V5 was not listed on the attendance document to have received abuse training on 2/5/2025. V1 provided Abuse Policy Acknowledgement Form signed by V5 on 7/26/24, when asked to provide documentation of previous abuse training. Abuse Policy, dated 09/20, documents in part: POLICY: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility will report reasonable suspicion of a crime. This facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. This will be done by: 2. Orientating and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of mistreatment, neglect and abuse; 3. Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment; 4. Identifying occurrences and patterns of potential mistreatment; 5. Immediately protecting residents involved in identifying reports of possible abuse; 6. Implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively, and making the necessary changes to prevent future occurrences; 7. Filing accurate and timely investigative reports; This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. This facility will not knowingly employ individuals who have been convicted of abusing, neglecting or mistreating individuals. DEFINITIONS: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in a facility. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful means the individual acted deliberately, not that the individual must have intended the injury or harm. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain and/or maintain physical, mental and psychosocial well-being. This includes suspicion of a crime. Assuring that physical restraints are used sparingly and properly, and that chemical restraints are not used. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish. Sexual Abuse is non-consensual sexual contact of any type with a resident. This includes, but is not limited to, sexual harassment, sexual coercion or sexual assault. b. Staff obligations to prevent and report abuse, neglect, theft and how to distinguish theft from lost items and willful abuse from insensitive staff actions that should be corrected through counseling and additional training. Staff should report their knowledge of allegations without fear of reprisal. e. What constitutes abuse (physical, mental, sexual, verbal), involuntary seclusion, neglect, and misappropriation of resident property. g. Reporting reasonable suspicion of a crime. Annually staff will receive a review of the above topics. Supervisory personnel will receive training on their obligations under law when receiving an allegation of abuse, neglect, theft and suspicion of crime how to monitor and correct Inappropriate or insensitive staff actions, words or body language. 3. Prevention The facility desires to prevent abuse, neglect and theft by establishing a resident sensitive and resident secure environment. 4. Identification Employees are required to immediately report any occurrences of potential mistreatment they observe, hear about, or suspect to a supervisor or the administrator. An employee who actually witnesses an act of abuse should immediately try to stop the act. All residents, visitors, volunteers, family members or others are encouraged to immediately report their concerns or suspected incidents of potential mistreatment to a supervisor or the administrator. Such reports may be made without fear of retaliation against any employee who makes a report, causes a lawful report to be made. Anonymous reports will also be thoroughly investigated. Supervisors shall immediately inform the administrator or designee of all reports of potential mistreatment. Upon learning of the report, the administrator or designee shall initiate an incident investigation. If the resident complains of physical injuries or if resident harm is suspected, the resident physician will be contacted for further instructions. 5. Protection of Residents The facility will take steps to prevent mistreatment while the investigation is underway. b. Accused individuals not employed by the facility will be denied unsupervised access to the resident during the course of the investigation. c. Employees of the facility who have been accused of mistreatment will be removed from resident contact immediately until the results of the investigation has been reviewed by the administrator or designee. e. Employees accused of possible abuse shall not complete the shift as a direct care provider to residents. The Immediate Jeopardy began on 03/11/2025 and was removed on 03/26/24, when the facility took the following actions to remove the immediacy: On 3/26/2025 at 10:53 AM, V1 stated, I was retrained on abuse on 3/24/2025. Basically it covered the abuse policy, abuse prevention, investigation, the immediacy and the thoroughness of it. It also covered identified vulnerable residents and providing emotional support after the fact. I am the Abuse Coordinator. The DON steps in as Abuse Coordinator if I was not here. If rough handling is alleged, it is considered abuse. Investigation starts immediately. If there is an alleged staff member, they would be placed on suspension immediately. Body check would be completed. MD would be notified. Family would be notified. Interviews would be started. A reportable would be filed within 2 hours. If I come across a resident that is afraid and states they do not want to get anyone in trouble, I would speak with the resident in a private area and encourage them to let us know what happened. I would let the doctor and responsible party know and see if they would open up to either one of them. I would interview staff. If they have a good repore with a specific staff member, I would try to have them talk to the resident. If they continue to refuse to share, I would try to provide support as best as we can. Ask them if we could make changes to care that would make them more comfortable. (V5) is still on suspension pending police investigation. As of yesterday afternoon, police still had not contacted (V5). The next step is to go to his house. Police said it is still at officer level and will next go to a detective. On 3/26/2025 at 11:09 AM, V16 (Registered Nurse/RN) stated, I was re-trained on abuse recently it was in the last couple days. It covered types of abuse, when to report abuse, and a quiz. Abuse Coordinator is the Administrator. Rough handling is considered abuse. If someone reported rough handling to me, I would report to my supervisor, and the Administrator, and the DON reports to the Administrator. I would remove the resident from harms way. The alleged perpetrator would be removed. If I had a resident that seemed scared and stated they did not want to get anyone in trouble, I would still report. They may just be afraid of retaliation. I would do the same steps in that instance. On 3/26/2025 at 11:14 AM, V29 (Housekeeping) stated, I was recently trained on abuse yesterday. They covered types of abuse, reporting abuse to Abuse Coordinator, (V1). Being handled roughly is abuse. If someone told me they were handled roughly, I would report to the nurse and the Abuse Coordinator. If I came across a resident that seemed afraid and said that they don't want to get anyone in trouble, I would try to be supportive but report to the nurse and Abuse Coordinator. On 3/26/2025 at 11:22 AM, V30 (2nd floor Unit Manager) stated, I was recently trained on abuse this past week. We talked about reporting to Administrator any suspected abuse or witnessed abuse. We also covered types of abuse which include verbal, mental, sexual, physical, misappropriation of property and exploitation, mistreatment, serious body injury, and neglect. Rough handling is considered abuse. If a resident told me they were handled roughly, I would offer to listen to patient, and get a nurse and report to Administrator immediately. Administrator, (V1), is our Abuse Coordinator. If (V1) is not here, the DON is our abuse coordinator. If I came across a resident that stated they were afraid and did not want to get anyone in trouble, I would listen to the resident and communicate it right away to the Administrator. On 3/26/2025 at 11:31 AM, V23 (Physical Therapist) stated, I was just retrained on abuse yesterday. It covered reporting structure, who, when, etc. Types of abuse was covered. The three R's which are remove, remove, report. Abuse coordinator is (V1). Rough handling is considered abuse. If a resident reported rough handling to me, I would ask the resident if they wanted to talk to someone, report to my supervisor, and to the Abuse Coordinator. If a resident reported they are scared and do not want to get anyone in trouble, I would do the same thing. I would ask them if they want to speak to someone about that, report to my supervisor and to the Abuse Coordinator. On 3/26/2025 at 11:37 AM, V31 (Housekeeping) stated, I was retrained on abuse yesterday. They talked about the 10 different kinds of abuse. They talked about reporting any problems to (V1), Abuse Coordinator, immediately. Rough handling is abuse. If a resident told me someone was rough with them, I would report it immediately to Administrator. If a resident told me they were scared and don't want to get anyone in trouble, I would report that to the Administrator as soon as possible and try to calm the resident. On 3/26/2025 at 11:42 AM, V32 (Building Manager) stated, I did recently get retrained on abuse yesterday. They covered the 10 different types of abuse, reporting immediately, remove, and report. (V1) is the Abuse Coordinator. Rough handling is considered abuse. If a resident reported rough handling to me, I would report immediately to (V1) and try to remove the resident and alleged perpetrator. If a resident reported they were afraid but did not want to get anyone in trouble, I would remember what room it was and go report it to (V1) immediately. On 3/26/2025 at 11:48 AM, V33 (Resident Care Coordinator) stated, I did recently get trained on abuse yesterday. They covered the 10 types of abuse, who to report to (Administrator), timeliness of reporting, and what to do if you see abuse occur. Abuse coordinator is (V1), the Administrator. Rough handling is considered abuse. If a resident reported rough handling to me, I would tell the Administrator immediately. If a resident reported to me that they were afraid and did not want to get anyone in trouble, I would still report immediately to the Administrator. On 3/26/2025, V34 (CNA) stated, I was recently trained on abuse yesterday or the day before. They covered the different types of abuse, who to report to (Administrator), what to do if you witness or experience any type of abuse. Rough handling is considered abuse. If a resident reported rough handling to me, I would remove the patient from the situation and report to the Administrator. If a resident told me they were afraid and did not want to get anyone in trouble, I would still report to the Administrator. On 3/26/2025 at 11:59 AM, V2 stated, I was retrained on abuse on 3/24/2025. We were re-trained on how to investigate abuse, how to respond to any allegation of abuse, how to interview the resident, informing family and doctors, and how to find who the resident is comfortable with to talk to the resident. Types of abuse were covered (10 types); we did quizzes. We educated the staff as well. Abuse Coordinator is the Administrator, and if she is absent, it is me. Rough handling is considered abuse. If a resident reported rough handling to me, I would try to get details from resident, remove abuser, and report to (V1). If I had a resident report to me that they were afraid and did not want to get anyone in trouble, I would try to get details from resident, report to (V1), inform family and doctor, and try get someone to talk to resident that they are comfortable with. On 3/26/2025 at 12:52 PM - Abuse assessments, dated 3/24/2025-3/25/2025, reviewed for the following residents: R4, R5, R6, R7, and R8. No concerns noted. <br [TRUNCATED]

Based on observation, interview, and record review, the facility failed to assess pain and administer pain medications as ordered for one (R43) of one resident reviewed for pain in the sample of 34. This failure resulted in R43 experiencing severe pain to both shoulders and knees, becoming so anxious R43 was unable to perform daily activities. Findings include: R43 is an [AGE] year old, female, admitted in the facility on 03/10/23, with diagnoses of Bilateral Primary Osteoarthritis of Knee and Restless Legs Syndrome. R43's MDS (Minimum Data Set), dated 04/18/24, documented R43 has BIMS (Brief Interview for Mental Status) score of 10 which means moderate impairment in cognition. Her MDS also recorded: Section J - Pain Management: receives scheduled pain medication regimen. R43's POS (Physician Order Sheet) documented the following: 03/14/23 - Acetaminophen tablet 500 mg (milligrams) give two tablets by mouth every 6 hours as needed for pain management 03/14/23 - Acetaminophen tablet 500 mg give two tablets by mouth two times a day for pain management 03/10/23 - Comfort-Focused Treatment: Maximizing comfort: Relieve pain and suffering through the use of medication, oxygen, suctioning and manual treatment of airway obstruction. 04/05/24 - Tramadol HCl (Hydrochloride) oral tablet 25 mg give one tablet by mouth in the morning for pain management R43's care plan documented in part but not limited to the following: Alteration in comfort due to arthritis, bilateral knees and shoulders (date initiated 03/10/23) Intervention: Administer pain strategies according to MAR (medication administration record)/TAR (treatment administration record); Assess pain every shift; Complete pain assessment; Monitor for non-verbal indicators of pain daily with tasks and activities; Observe resident for effectiveness of pain relief. MAR (Medication Administration Record) dated 05/18/24 recorded: Pain evaluation every shift - Days: pain level was charted as 0. On 05/20/24 11:20 AM, R43 was observed in her room. She was sitting in the wheelchair by the foot of the bed. She was observed listening to music. Her bedside table was placed in front of her. There were reading materials and spiritual books on top of the bedside table. R43 was alert, oriented, able to verbalize needs and concerns. R43 stated she loves listening to music and reading prayer books. She was asked if she has concerns related to care in the facility. R43 stated, I have a concern regarding my medications last Saturday (05/18/24). I did not receive my medications in the morning on time. I had this severe pain, like 10 as the worst pain, in my shoulders and knees. The nurse who was on duty gave my medications including pain pills late in the morning. I always take it early in the morning. I have arthritis, and that time, my shoulders hurt like I cannot breathe anymore. I felt suffocated, and my knees were in so much in pain that my legs were so restless. I told (V5, Certified Nurse Aide, CNA) about the pain. She told me that she will tell the nurse. The nurse was not my regular nurse, that was the first time I saw her. She gave all my medications at 11:00 AM. I was so sick with pain, they should have never assigned somebody here who does not know the residents. On 05/21/24 at 10:29 AM, V5 was asked regarding R43 and incident last 05/18/24. V5 replied, I am the regular CNA of (R43). That incident was last Saturday, 05/18/24. She usually gets her medications around breakfast between 7:30 AM to 8AM, including pain medications. Around 10:00 AM she pressed her call light. I went to her room, she said she had not received all her medications. She was in a lot of pain, complaining of pain on her shoulder and knees. I told the nurse, she was an agency nurse, don't remember her name, about (R43's) medications and pain. The nurse said she (R43) got all her medications and those are all the medications she saw in the system. (R43) kept on saying she was in pain. She usually goes to the dining room every day, but that Saturday, she did not because of pain. She said she did not receive all her medications. The agency nurse went to her room and saw her but she did not call the physician. She was in severe pain, so I gave her a hot pack; she said it helped. On 05/21/24 at 10:45 AM, V6 (Registered Nurse, RN) was interviewed regarding R43. V6 stated, She has Tramadol, scheduled in the morning between 8 AM and 9 AM. She knows her medications, she will verbalize if she is in pain. Observation made on 05/20/24 and 05/21/24 at 11:45 AM showed R43 eats lunch in the main dining room. On 05/21/24 at 1:43 AM, V7 was asked regarding incident on 05/18/24 with R43. V7 verbalized, I worked in the facility last 05/18/24, 7 AM to 3 PM shift. That was my first time working on the second floor. For (R43), I remember her, she got all her 9 AM medications. She did not complain to me but to CNA (V5) that she needs pain medicine. I don't remember her pain medications. I went to see her and asked if she has pain and that she has pain medications which are due for me to give that time. She said she was not in pain. I passed a few medications, and I was in the hallway when I got busy with a family member, the new resident and the roommate who was screaming at the time. I got off track, and I also called therapy. I went back to (R43) and asked if she has any pain, she said her shoulders hurt and it was 3. I gave her medications. She said the medications were late. But it was only 45 minutes late; the medications should be given at 9 AM and I gave all her medications around 9:45 AM. She said her pain level was 3. I did assess her after I gave the medications, she said she was not in pain anymore. On 05/22/24 at 11:05 AM, V9 (Staffing Coordinator) was asked on who was the nurse assigned to care for R43. V9 stated it was V7 (Agency Licensed Practical Nurse, LPN) and worked from 7:00 AM to 3:00 PM shift. On 05/23/24 at 10:40 AM, R43 was observed in her room, sitting in her wheelchair. She was observed listening to music. Her bedside table was placed in front of her. There were reading materials and spiritual books, religious items and television remote controls on top of the bedside table. R43 was pleasant, not in any form of distress. R43 was asked regarding typical day activities. R43 verbalized, I get up around 6:30 AM to 7:30 AM for the morning care like change my clothes and change my brief. I go to the bathroom, wash face, hands, and brush teeth. At 7:30 AM, I go to the dining room for breakfast. I eat in the dining room. During breakfast, the medications are prepared, and I will take them, including pain pills right after breakfast. After breakfast, I will go back to my room and will listen to music, read prayer books, pray, watch TV, and water my plants every other day. I go back to bed by 7-8 PM. But that Saturday (05/18/24), when I went to the dining room to eat breakfast, my medications were not there. I finished breakfast and still no medications. It was 9 AM and my shoulders are painful. My legs were so restless, I was very anxious because of the pain. I felt like I am so suffocated and strangled in the neck. My medications were given at 11 AM. That day, I ate lunch inside my room because I was still in pain. On 05/22/24 at 10:42 AM, V8 (Physician Assistant) was asked regarding R43 and pain management. V8 stated, Been taking care of her (R43) since her admission to facility. She is a very nice resident, friendly. She is here for assistance, ADLs (activities of daily living) due to arthritis in shoulders and knees that is managed. She is alert, oriented to time, place and person, able to verbalize needs and concerns. She is on pain medications; she has a scheduled Tramadol and Acetaminophen in the morning. If she has pain, she will vocalize it to the nurse. If its scheduled pain medication, it should be given at the time it is scheduled. If a resident complained of pain, nurse should be informed, nurse will assess the resident and will give medications as ordered and if there is still pain - they have to notify physician or nurse practitioner. On 05/22/24 at 11:33 AM, V2 (Director of Nursing) stated, Each medication is specific, we have 9 AM, 1 PM for day shift. Each medication is according to the doctor's order. If a resident has a medication, including pain pill for 9 AM, the medication can be given as early as 8 AM until 10 AM. (R4 is a longterm care patient here. She requires assistance with ADLS, alert, oriented. She has scheduled pain medications. If a resident is in pain, the nurse needs to assess for location, a numeric pain scale associated with, any relieving factors, administer pain medications as ordered. Reassess after giving pain medication, and if not relieved, we would need to contact the physician. If she (R43) was given medications at 11 AM, that is not acceptable. Medications should be given on time, within specified time frame, as ordered. Facility's policy titled Medication Administration: General Guidelines, dated 03/2021, stated the following: A. Policy: To ensure that medications are administered safely as prescribed. D. Procedure: 6. If the physician's medication order cannot be followed, the physician should be notified, depending upon the situation. 8. Medications are administered within one (1) hour of prescribed time. Unless otherwise specified by the physician, routine medications are administered according to established medication administration schedule. Facility's policy titled Pain Management Evaluation, dated 09/2020, documented the following: Purpose: Our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. Procedure: 4. During the pain evaluation, determine the most workable pain rating for the resident. The following scales are available: a. The numeric rating scale (NRS): 1-3 (mild), 4-6 (mod), 7-10 (severe) b. PAINAD scale 1-3 (mild), 4-6 (mod), 7-10 (severe) 5. Pain will be evaluated each shift.

Based on observation, interview, and record review, the facility failed to accurately identify a change in condition and immediately notify the physician regarding a resident (R29) who demonstrated signs of respiratory distress from [DATE] until [DATE]. This failure affected one (R29) of one resident who was emergently transferred to a local hospital due to a change of condition on [DATE] at 12:36PM, and resulted in R29 expiring at the hospital at 3:50PM. Findings include: R29 is [AGE] years old and admitted to the facility on [DATE]. R29 had diagnoses that included lateral sclerosis, intracranial injury with loss of consciousness, anarthria (loss of speech), and pressure ulcers. On [DATE] at 11:21AM, R29 was observed in bed, with continuous gastric tube running, unresponsive to verbal stimuli, and noted with shallow audible respirations. R29 was breathing with mouth open and had a nasal cannula applied with humidity at 2L (liters). An indwelling catheter was observed thick cloudy bloody tinged sediment. At 12:28PM, a CNA (Certified Nursing Assistant) was observed going into R29's room, to call the roommate of R29 to lunch, and did not check on R29. At 12:37PM, CNA was noted to come back to the room to serve lunch to the roommate and did not check on R29, who was in the same position. At 12:52, another CNA went into the room and did not render care for or check R29. At 1:24PM, V11, RN (Registered Nurse), came into the room and removed the completed gastric feeding. V11 came into the hallway to ask the unit manager for assistance to change position of R29. At 2:47PM, Surveyor asked V11 about R29's breathing. V11 said, The CNA's are responsible for taking vitals which are usually daily or per shift. V11 stated V11 had not personally taken vitals for R29 during the shift and was unsure of when they were last taken. V11 also said R29 is a mouth breather, and the current state was baseline. V11 went on to say, when they first cared for R29 closer to admission, V11 sent R29 out to the hospital for the same concern, but R29 was sent back the same day. V11 took the oxygen saturation and pulse upon request, with results of 99% oxygen and pulse 94 bpm (beats per minute). On [DATE] at 9:22AM, R29 presented in bed, unresponsive to verbal stimuli and on 2L continuous nasal cannula. R29 was turned on the left side had a visual bounding pulse to the right neck. Respirations were shallow, audible, and visibly distinguished counted at 42 breaths per minute using a stopwatch. The indwelling catheter was clean. V11 was the nurse on duty, and said R29's condition had been unchanged since the previous day. On [DATE] at 12:18PM, V11 was observed on the unit and said the previous night shift nurse endorsed this morning that R29 had a fever overnight, which was treated with acetaminophen. V2 said they took the temperature of R29 with no additional vital signs, documented as 97.8F, and called V8 PA (Physician's Assistant) to receive orders. V11 was asked by the Surveyor to obtain a manual set of vitals for R29. R29 presented in bed, with shallow, audible respirations and forced work of chest and abdominal breathing. Vital signs obtained were as follows: Oxygen: 92% on 2L of oxygen via nasal cannula, Temperature: 103.3F Pulse: 156bpm Respirations: 40 and Blood Pressure ,d+[DATE]. V11 said R29 did not demonstrate this state of breathing when assessed earlier this morning, but pointed to a simple oxygen face mask that they brought into the room just in case. V11 applied the oxygen mask from the bedside and said it would be better for R29 to receive oxygen through the mouth due to the way she was breathing. V11 then said they would call the doctor for further orders. Fire Department report, dated [DATE]: paramedics were dispatched to the facility at 12:35PM and arrived at the bedside of R29 at 12:38PM. R29 was assessed to be unconscious, non-verbal, and without any eye movement. Vital signs taken: Blood Pressure: ,d+[DATE]; Pulse 162 beats per minute; Respirations (shallow) 40 breaths per minute; SpO2 (oxygen): 93% on a non-rebreather mask. R29 was transported to the hospital at 1:05PM. Hospital emergency room report, dated [DATE], stated when R26 arrived to the hospital, emergency room diagnoses included: Sepsis, Hypernatremia, Dehydration and Pneumonia of right lower lobe due to infectious organism. There were no nursing notes documented for R29 from [DATE] until [DATE]. Progress Note written for [DATE] 12:25PM: Public Health Surveyor came up to the floor and asked this writer about resident's condition. This writer notified surveyor that new orders were received from (V8, Physician Assistant/PA) to do stat cbc/cmp/chest x-ray and ua/cs. The surveyor wants to see the resident and wants this writer to check resident's current vitals. Resident was seen in bed breathing heavily and warm to touch at this time. T-103.3 P-150 R-40 BP-,d+[DATE] SAT-92% with 02 at 2liters/nc. Resident was switch to medium concentration 02 (oxygen) mask at this time due to (shortness of breath). This writer notified the surveyor that MD will be called to get order to send out resident to the hospital for evaluation. PA was notified of resident's condition and agreed to send resident to the hospital via 911 for evaluation. 911 was called and took over care. Resident son was called and notified of residents' condition and agreed with the transfer. Resident was switch to non-rebreather oxygen mask before (leaving the facility) and 02 was increased to 5 liters. Progress note written at 6:36PM noted: Received a call from Hospital informing this (nurse on duty) that patient expired at 15:50. DON made aware. MD notified. Endorsed. On [DATE] at 12:54PM, V11 said, prior to the observation at the bedside with the surveyor, V11 didn't recognize R29 was in any distress and that the breathing prior to the observation was normal. V11 applied the simple oxygen mask in that moment due to R29 being a mouth breather, and the mask will provide higher amount of oxygen delivered than a nasal cannula. V11 said just before the paramedics arrived, R29 was placed on a non-rebreather mask that provides even more oxygen support than the simple face mask and nasal cannula. V11 did not think it was needed prior to that time. V11 said they did not take vitals because there were no orders to take vital signs during their shift. On [DATE], at 10:50AM, V8, PA (Physician's Assistant), said nursing staff this morning informed V8 about an increased temperature that was taken during the night shift. V8 gave orders to the nurse to complete a STAT (rapid) chest-Xray, urinalysis with culture and blood lab values. Based on previous assessments, V8 would expect for R29's respirations to be between ,d+[DATE] breaths per minute as normal, and they rely on the nurses to accurately assess all vital signs as they should be reported when abnormal and they are reviewed during rounds. V8 said they, or the attending physician, is usually available during the day and some weekends on-call, and when they are not available, the facility uses a telehealth service for immediate resident needs or concerns. V8 said if the respiratory rate was outside of the baseline parameters, they would want to know the oxygenation level which would lead a path to determine if R29 was stable, and they would expect the nursing staff to notify them right away because R29 is high risk of urinary tract infections and aspiration pneumonia. On [DATE] at 11:12AM, V2, DON (Director of Nursing), said normal respirations are between 12 to 20 breaths per minute, however normal is determined by the resident's baseline. V2 said vital signs are normally taken with a machine, which is operated by nursing staff, and is automatically uploaded into the chart. The [electronic health record] determines the baseline considering previous results and alerts the nurse of abnormalities as noted by change of color. V2 said vital signs are expected at least once daily (once every 24 hours), or more frequently as ordered by the physician. The nurses, however, do not need a physician's order to obtain vital signs outside of those parameters if the resident is presenting with any change of condition. On [DATE] at 1:23PM, V10, Medical Director, said they were not alerted by staff that R29 was having a physical decline, and the staff will predominately contact V8, PA, for relaying labs or change of condition. V10 said, If it was noted (R29) was exhibiting increased respirations, the assessment should be relayed to the doctor or the PA that something was abnormal. This would prompt the provider to ask more questions to determine a big picture and proceed with monitoring or treatment. V10 said if they were notified the respirations were elevated on [DATE], they would have likely done something about it, such as give orders, but could not say exactly without knowing the immediate circumstance. V10 said they were not notified by staff of R29's transfer to the hospital or that R29 expired. V10 said they were notified the morning of [DATE], after logging into the hospital electronic health record. Facility Policy Vital Signs- Temperature, Pulse and Respirations, revised ,d+[DATE], states: If temperature is unusually high or low, check with another thermometer. If results are consistent, notify nurse and physician as appropriate. Change of Condition policy- revised ,d+[DATE] states; Purpose: to ensure that the resident's physician/physician on call/NP (nurse practitioner) and responsible party is kept informed regarding the resident's change in condition. Policy: The attending physician or physician on call/NP and responsible party will be notified with changes in a resident's condition. Procedure: 1. Attending physician or physician on call/NP and responsible party will be notified of all changes I condition. 2. Follow framework for reporting changes in vital signs or laboratory values based on AMDA Guidelines.3. Follow suggested guidelines for reporting clinical problems based on AMDA Guidelines. 4. Document time of call, physician or nurse practitioner or other person spoken to; reason for call and result or orders received. 5. Place call to responsible party to notify them of the resident's change in condition. Facility presented printed training module, dated 2011 for vital signs; Vital Signs (report why vial signs were taken). This document indicated respirations greater than 28 and a temperature of over 100.5F should be reported immediately. Oxygen Therapy Devices- revised ,d+[DATE] states; Policy: Oxygen delivered by simple mask, will be used to prevent or reverse hypoxia and improve tissue oxygenation. Procedure: 6. Set the flow rate, as ordered. Liter flows should be adjusted between 5 to 8 liters per minute.

Based on observation, interview, and record review, the facility failed to: ensure food items were labeled and dated per facility policy, failed to ensure plastic bins are clean, failed to ensure foods are not expired, failed to ensure items are air dried before stacking the dishes, and failed to ensure no dented cans were in the dry storage area. This applies to 65 residents that receive oral nutrition and food prepared in the facility kitchen. Findings include: On [DATE] at 9:54 AM, tour was done with V3 (Executive chef), and the following observations were observed: Walk in refrigerator: *Mozzarella cheese that was opened and did not have an open date labeled on the package. V3 stated, It was opened today, but they must have forgot to label it. He stated he did not open the package and it should have been labeled. *Package of parmesan cheese that was opened and did not have an open date labeled on package. V3 did not know when that was opened, and it should have been dated. V3 stated the use by date is 7 days after package is opened or the food is prepared. *A tray of individual cups of something was in the refrigerator with caps, but none were dated or labeled. V3 stated they were syrups and sauces from a previous event, and should have been labeled and dated. *Tray of uncooked substance was not labeled what it was, but did have date of ,d+[DATE]. V3 stated those were meatballs and should have been labeled. When asked if the year should be on the package date, V3 stated it should. *Opened block of unknown substance, dated [DATE], was not labeled and was stored above cheeses. V3 stated it was deli ham and should have been labeled. *Open bread potato rolls were not dated. V3 stated they should have been dated. Freezer; *A frozen substance was not labeled. V3 stated it was canoli cream. *Tray of unknown substance was not labeled. V3 stated they are Matzo balls for soup. *Tray of unknown substance stated by V3 to be Breadsticks, dated ,d+[DATE] were not labeled. *Tray of unknown substance stated by V3 as Salmon, dated [DATE] was not labeled. Dry storage room: *Light corn syrup received [DATE] with use by [DATE] was still on shelf in dry storage area. *Honey opened ,d+[DATE] did not have use by date. *Oats with a best before date of [DATE] still on shelf. *White wheat flour with a best if used by [DATE] still on shelf. *Dented can of cherry pie filling - 7 lb can, and dented can of refried beans - 7 lb can, comingled with other cans on shelf. *Pasta opened with no date on bag. *Orzo pasta opened with no date on container. *Bin of navy beans dated [DATE] with a use by date sticker of [DATE]. *Green peas dated [DATE] with a use by sticker [DATE]. *Barley dated [DATE] with no use by date. *Container of Almonds with a date of [DATE] no use by date. V3 stated V3 will get with his manager and give surveyor a paper showing recommended use by dates for Almonds. *A tin container wrapped with saran wrap was not labeled or dated. V3 stated it has powder sugar in it, but could not provide dates or when it was prepared. Kitchen area in front of manager office: *5 bins labelled flour, sugar, panko bread crumbs, oatmeal and cake flour all had the tops of the bins dirty and had debris and dust on top of them. Season cart: *Open bottle of vanilla extract was not dated when it was opened. Upon touring the dish drying area, there were three large pans stacked on top of each other on drying table. Upon surveyor asking V3 to unstack pans to see the inside, water ran out of each pan that was stacked on top of the other and pans insides were visibly wet. On left side of wash, rinse, sanitize sinks there was a red bucket with liquid in it. Surveyor asked V3 to test liquid. Liquid tested at 0ppm. V3 stated bucket is used for sanitizer, but we just dumped it out a little while ago and put soap and water in it. V3 was asked what the red buckets are supposed to have in them. V3 stated it should always have sanitizer in it. When asked what the green buckets were for, V3 stated they are for soap and water. Freezer and Refrigerator logs were checked, and discrepancy noted on [DATE] PM shift; no recording of temperature on log. On [DATE] at 9:55 AM, V4 (Kitchen manager) stated all days on temperature logs should be filled in for every shift. If missed, she in-services her staff. Regarding food labeling and dating, V4 stated all items should have a received dated and a used by date, as well as a label of what food the item is. V4 also stated when items are opened, the open date should be on the item, and the open date +7 days should be the discard date. Open date is day 1. V4 stated trays of food should be labeled with date and food type when put in refrigerator or freezer. V4 also stated there should not be any expired foods in the refrigerator, freezer, or dry storage. Regarding the large bins for flour, etc. V4 stated they should be clean inside and outside. They are cleaned weekly when they are refilled with shipments, but the tops should be cleaned if they are dirty. On [DATE], documentation provided by V4 from USDA (United States Department of Agriculture) with recommended consumption times for almonds. V4 states 4 months is the date they would go by, as it was in the dry storage room. Dented Can Policy, dated ,d+[DATE], states: Procedure: 1. Canned foods with swelled top or bottom, leakage, flawed seals, rust or dents will be rejected. 2. Compromised cans will be stored on a shelf marked -do not use. Cleaning and Storing of Dishware's Policy, dated ,d+[DATE], states: Procedure: 1. Dishware's will be properly washed, rinsed, sanitized, and air-dried. Labeling & Dating Policy, dated ,d+[DATE], states: Procedure 1. Ready-to-eat time/temperature for safety (TCS) food that is held for less than 24 hours may be labeled with the common name, date and time it is placed in the refrigerator. 2. On premise preparation of ready-to-eat TCS item that is to be held for longer than 24 hours in the refrigerator will be marked to indicate which date or day the food must be consumed or discarded. 3. Commercially processed TCS that is to be held for longer than 24 hours in the refrigerator will be marked to indicate which date or day the food must be consumed or discarded. The day or date marked by the food service establishment may not exceed the manufacturer's use by date. 7. All food products that have Pre-printed by manufacturer date labels on on them will be discarded by that noted date printed on the product. 9. Spices containers will be dated when opened.

Based on interview and record review, the facility failed to provide bed hold notification when transferring residents to a local hospital. This failure affected 5 residents (R1, R21, R29, R52, R64) reviewed for bed hold notification in a sample of 34. Findings include: R1 initially admitted on : 4-12-2024 with most recent readmission on 4-27-2024, with diagnoses that include but not limited to: pleural effusion, acute pulmonary edema, diabetes, and kidney transplant. R1 was transferred to a local hospital on 5-16-2024 per progress notes. Per record review no bed hold notification on record. R21 initially admitted on [DATE] with most recent readmission 5-6-24, with diagnoses that include but not limited to: Infection and inflammatory reaction due to internal right knee prosthesis, acute embolism and thrombosis of right calf muscular vein, and major depressive disorder. R21 was transferred to a local hospital on 5-3-24 per progress notes. Per record review, no bed hold notification on record. R52 initially admitted on [DATE] with most recent admission of 04/29/2024, with diagnoses that include but not limited to: wedge compression fracture of fourth thoracic vertebra, heart disease, parkinsonism, and depression. R52 was transferred to a local hospital on 4/26/2024 per progress notes. Per record review, no bed hold notification on record. R64 initially admitted on [DATE], with diagnoses that include but are not limited to: metabolic encephalopathy, sepsis, and non-traumatic chronic subdural hemorrhage. R64 was transferred to a local hospital on 4/26/2024 per progress notes. Per record review no bed hold notification on record. R29 initially admitted on [DATE], with diagnoses that include but are not limited to: primary lateral sclerosis, intracranial injury, monoplegia of upper limb, and severe protein calorie malnutrition. R29 was transferred to a local hospital on 4/7/24 and 05/22/24 per progress notes. Per record review no bed hold notifications on record. On 5-22-2024 at 1:45 PM, V2 (Director of Nursing/DON) stated, We did not give a bed hold policy to (R21). Surveyor asked V2 to provide bed hold policy given to R1. During course of the survey, V2 unable to provide proof of bed hold policy given to R1. On 05/23/2024 at 2:00 PM, V2 (DON) stated, I cannot provide bed hold notifications for (R1), (R21), (R29), (R52), and (R64). I do not have them. Bed Hold/Ombudsman Notification Documentation Policy, dated 12/2018, states: Policy: The facility will be responsible for documenting that the bed hold policy was given to the Resident at the time of transfer, and to the Resident Representative within 24 hours. The facility will also be responsible for documenting that the Ombudsman will be notified via the monthly transfer log for all hospital transfers and therapeutic leaves. Procedure: 1. The Nurse will be responsible for opening the Bed Hold and Ombudsman Notifications Assessment for any resident being transferred to the hospital or going out on therapeutic leave. 2. The nurse will document that the bed hold notification was provided to the resident, and to the Resident Representative if present. 3. The Facility Designee will provide the Resident Representative the bed hold notification within 24 hours, if not previously given, and document completion in the Bed Hold and Ombudsman Notification Assessment. 4. The facility Designee will also document that the Ombudsman will be notified via the monthly transfer log in the Bed Hold and Ombudsman Notifications Assessment.

Based on observation, interview, and record review, the facility failed to have resident-specific and effective interventions in place for a resident with multiple falls while in the facility; failed to ensure care plan interventions are being carried out per the resident's plan of care; and failed to have a fall care plan in place for a resident who was assessed to be at risk of falls. These failures applied to two (R2 and R3) of three residents reviewed for falls, and resulted in R2 sustaining multiple rib fractures after a fall, and R3 sustaining a pelvic fracture as a result of a fall. Findings include: 1. R2 is a [AGE] year-old resident, originally admitted to the facility on [DATE]. R2 has medical diagnoses that include but are not limited to: Parkinson's Disease without dyskinesia, dementia, history of falling, mild cognitive impairment, and longtime use of Aspirin. R2's MDS (Minimum Data Set) assessment, dated 6/21/23, documents R2 requires limited assistance of one person for toilet use and is occasionally incontinent of urine. Review of R2's fall risk assessments from 08/12/23 to current, all document R2 is at risk for falls. Nursing Progress Note, dated 8/27/23, documents R2 is one person assist with ADL's (activities of daily living). Nursing Progress Note, dated 9/13/23, documents R2 is incontinent of bowel & bladder and requires one person assist with ADL's. There are several nursing progress notes that document ,R2 does not use a bed/chair alarm, and R2 forgets to use the call light (these are dated throughout October 2023) Review of R2's medical record shows R2 had the following falls while at the facility: 8/12/23 - fell out of wheelchair in room (no injury) 9/13/23 - fell from bed (no injury) 10/25/23 - fell in room near bedside table (no injury) 11/13/23 - fall on bed, resulting in rib fracture 1/5/24 - fell in room (no injury) R2 had a significant change MDS, completed on 10/17/23, which documents R2 had a BIMS (Brief Interview for Mental Status) score of 5, which indicates severe cognitive impairment and that R2 is frequently incontinent of bowel and bladder. Facility submitted incident report, documenting on 11/13/23, R2 was transferred to local hospital at approximately 12am due to chest pain and per report from, he had fallen onto his bed. Hospital record from 11/13/23 admission, documents R2 sustained displaced fractures of left 7-11 ribs due to a fall. Review of R2's care plan for falls includes interventions for falls, however, R2 was still having falls in the facility. On 01/19/2024 at 2:35pm, V11 (Licensed Practical Nurse/LPN) stated, I sent (R2) to the hospital after a fall back in November because he had rib pain, increased respirations, blood pressure, and chest pain. 911 was called and then the hospital confirmed he had multiple rib fractures. The fall was unwitnessed, and he was in his room. (R2's) normal baseline is alert and oriented x 1. Before the fall, he ambulated better. but now he uses the wheelchair. We watch him all the time. He is always one person assist. On 1/19/24 at 2:12pm, V25 (Certified Nursing Assistant/CNA) stated, (R2) is confused, and he needs help. V25 continued to state that she was not on duty when R2 fell back in November, but she heard he fell a couple weeks ago. V25 stated, I always watch (R2) because I know that he is confused, and he doesn't use the call light. At this time, R2 was found to be lying in bed, and it was noted R2's wheelchair was pulled up next to R2's bed (in between the bed and the wall), and there was no bed alarm in place for R2; bed alarm was on the wheelchair. V25 said, The alarm is not supposed to be here, and the wheelchair is not locked. I'm sorry, I don't know who put him in bed; I just got in and haven't gotten a chance to do my rounds. On 1/21/24 at 3:59pm, V2 (Director of Nursing) stated, We are constantly assisting (R2) and taking him into consideration. He's in the room close to the nurses' station and we encourage him to stay in areas where he can be seen. We weren't sure how to label it (11/13/23 fall), because he didn't have a change of plane. He wouldn't have been able to get himself off the floor. We think that he attempted to self-transfer from the bed and maybe he hit himself with the side rail of the bed. It may have had to do with his ability to self-transfer. V2 stated she was not sure why that intervention (bed alarms) was not added sooner. It is noted bed and chair alarm interventions were added to the care plan after the fall on 01/05/24. 2. R3 is a [AGE] year-old resident, admitted to the facility on [DATE]. R3 has medical diagnoses that include but are not limited to: history of falling, dementia, fracture of right pubis, fracture of right ischium, and unsteadiness on feet. Facility submitted incident report, documenting R3 had an unwitnessed fall on 12/3/23 at approximately 4:20pm on the bathroom floor. R3 was subsequently transferred to the local hospital and per hospital records, was found to have an acute fracture of the right inferior pubic ramus and a mildly comminuted, acute fracture of the right ischial tuberosity. Hospital record also documents R3's son was contacted and stated R3 has frequent falls and worsening weakness recently, has baseline dementia, walks with assistance, but doesn't regularly use walker. Based on facility documentation of investigation, multiple staff reported resident ambulates on his own to the bathroom, without assistance. R3's most recent fall risk assessment prior to falling on 12/3/23 was completed on 9/25/23, and was scored at a 3 - At Risk. The fall risk assessment completed on 9/25/23 documents R3 is alert & oriented x 3 (mentation) and R3 is regularly continent (no assist to get to the toilet); both of these categories are conflicting with the information documented on the resident's MDS (Minimum Data Set) assessment of approximately the same timeframe. R3's most recent MDS assessment prior to falling on 12/3/23 was completed on 9/28/23, and documents the following: (BIMS) Brief Interview for Mental Status score is 7, which indicates severe cognitive impairment; ADL (Activities of Daily Living) needs include limited assistance, one person assist with bed mobility, transfers, walking in room, and toilet use; R3 is occasionally incontinent of bowel. Review of R3's medical record includes psychiatry note dated 9/26/23, which documents: Chief Complaint/Nature of Presenting Problem: dementia History of Present Illness: F/U with [AGE] year-old patient who has a history of dementia. Patient found in his room, with baseline level of confusion . Facility was asked to provided fall risk care plans for R3, and it is noted the fall care plan provided was not initiated until 12/6/23. Although the care plan has interventions initiated in 2019, there were no recent care plan interventions for all of 2023, prior to R3's fall on 12/3/23. On 01/19/24 at 2:24PM, V10 (Registered Nurse) stated, (R3) used to be independent, but now he needs help of one person assistance. (R3) had another fall on 01/04/24 while I was on duty; he went into the bathroom in the hall. When I heard a loud sound coming from the bathroom, I went to check and found (R3) on the floor. He did not have any injuries with this fall. On 1/21/24 at 3:59pm, V2 (Director of Nursing) stated, (R3) had a hospital stay and then came right back and the care plan was initiated when he came back. Surveyor asked why the fall care plan was not updated all of the prior year, and V2 stated t if he hadn't had a fall prior to that, then his care plan wouldn't have been updated. We don't change the dates of the interventions if they are still applicable. Surveyor asked if the care plan should be updated since the resident has declined or had a change in condition since he first arrived in the facility several years ago, and V2 stated that she does not know, because she was not working here then. The MDS (Minimum Data Set) coordinators update the care plans quarterly. It (fall on 12/3/23) was an unwitnessed fall. He was attending activities in the lower level and then went to the bathroom; he went to the bathroom without asking for assistance. Sometimes he's not compliant with asking for help; he thinks that he is more independent than he is. The discrepancy in the MDS and assessment could be two different people are completing them. Assuming that they are looking at the same information, I would expect them to be the same. We do have trainings and in-services to ensure that staff are on the same page to confirm what they are describing and seeing accurately. Assessments need to be completed correctly so that everyone can be aware of the residents current functioning and need level. Facility provided policy titled, COMPREHENSIVE CARE PLANS, dated 11.2017, reads: Policy Statement An 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. 2.) The Interdisciplinary team includes, but is not limited to: a. The Attending Physician b. A nurse and nurse's aide that have responsibility for the Resident; c. A member of the food and nutrition services staff d. The Resident and Resident representative, if applicable; e. Other appropriate staff or professionals determined by the Resident's needs, preferences, or requests. 3.) The Resident's comprehensive, person-centered care plan will be kept consistent with the Resident's rights to participate in the development and implementation of his or her plan of care, including the right to: a. Participate in the care planning process; b. Identify individuals or departments to be included; c. Request meetings; d. Request revisions to the plan of care; e. Provide input into the expected goals and desired outcomes of care; f. Receive the care and services as outlined in the plan of care; g. View the care plan after significant changes are made. 4) Care plan interventions are initiated based on an analysis of information collected throughout the comprehensive assessment process. 5.) The medical record will show evidence of an explanation if the Resident or Resident representative's participation in the development of the plan of care is determined to not be practicable. 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; c. Describe services that would be provided to attain the above, but the Resident refuses; d. Describe specialized services to be provided based on PASARR recommendations; e. Include the Resident's goals for progress, reflect the Resident's expressed wishes regarding care and treatment goals, including discharge planning; f. Identify the professional services that are responsible for interventions; 7.) The comprehensive, person-centered plan of care is developed within 7 days of the completion of the required comprehensive MDS. 8.) Assessment of the Resident is ongoing and care plans are revised based on the Resident condition, preferences, treatments and goals change. 9.) After the initial comprehensive, person-centered plan of care is developed, formal care plan reviews will be held in conjunction with the MDS schedule and shall be no longer than 92 days apart.

Based on interview and record review, the facility failed to follow their policy Management of resident with confirmed or suspected Covid-19 infection or identified as a close contact by not testing one resident after 24 hours (R8) after the roommate tested positive for Covid-19, and by allowing a staff member to come to work with sore throat, who tested positive for Covid-19 after working with direct patient contact. These failures have the potential to affect all residents living in the facility. Findings include: R7 is an [AGE] year-old female admitted on [DATE], with medical diagnosis that include and are not limited to: hemiplegia and hemiparesis, hypertension, and dementia. On 1-17-2024 at 9:13pm, R7 tested positive for Covid-19 at a local emergency room ; V1 (Administrator) and V2 (Director of Nursing) informed. On 1-19-2024 at 9:20am, V1 (Administrator) said, Our census is 65 patients with one positive Covid-19 patient (acquired in the facility); currently (R7) is in a private room on isolation. (R7) tested positive on 1-17-2024. We are monitoring the other residents for any signs and symptoms; we are not doing any broad approach testing. We did not test the roommate because (R8) does not have any symptoms. On 1-19-24 at 9:30am, V2 (Director of Nursing) said, We are not to do any tests on any resident unless the patient presents with any Covid-19 respiratory sign and symptoms. The nurse consultant is the Infection Preventionist. On 1-19-2024 at 1:50pm, V9 (Dietary/ Dining Room Aide) said, I am responsible to do the distribution of the trays in the dining room, another person plates the food and I take the tray and set it up for the patient in the dinner table. I work the first shift; I passed the breakfast and lunch trays on the second floor. On 12-31-2023, I came to work with a sore throat, I was not able to sleep the night prior. I make sure to serve the breakfast and the discomfort was getting worse and worse; at about 10:00am, I asked the nurse to please give me the rapid Covid-19 test, and the results were positive. On 1-19-24 at 3:40pm, V2 (Director of Nursing) said, We have not done any Covid-19 tracking and tracing, we are only monitoring for signs and symptoms. We do not take any broad approach of testing any other residents. The staff members know that if they are sick they need to call the facility report to the supervisor; if they have Covid-19 signs and symptoms they need to make sure to test themselves. If they need to be tested , they can come and we can do the test at the facility if they are negative and they are well enough to work, they can work, if they are positive, they need to make sure to go home and quarantine for 10 days before they are able to return to work. My expectation is that no one that is sick or have a sore throat comes to work, if they have any signs and symptoms, they need to be off work. On 1-20-2024 at 12:10pm, VI6 (Medical Doctor) said, No staff member should report to work if they are sick with any signs and symptoms of Covid-19. Residents that are positive for Covid-19 need to be closely monitor and the facility needs to follow the CDC recommendations. On 1-20-2024 at 1:00pm, V23 (Infection Preventionist/ Corporate Consultant) said, The Director of Nursing (V2) and me are responsible for the tracking and monitoring of the infections. I need to make sure that Infection control policy is followed, if a patient is positive for Covid-19 we isolate for 10 days and monitor the other for signs and symptoms, take vitals; High exposure- Roommate- will be tested within 24, 48 hours and the fifth day. We did not do any tracing for (R7) since the patient is a long-term care and does not go out of the facility. I do not know why (R8) was not tested yesterday after she was directly exposed by (R7) (roommate). On 1-20-2024 at 1:00pm, V23 (Infection Preventionist/ Corporate Consultant) said, My expectation is that anyone with symptoms do not allow to work, the employee is to test at home if they are having any signs and symptoms of Covid-19 and they should not be in direct contact with the residents in the facility. Policy titled: Management of resident with confirmed or suspected Covid-19 infection or identified as a close contact, dated: 1-5-2024, reads: the facility will manage residents with confirmed or suspected Covid-19 infection in accordance with recommendations from CDC. Resident identified as close contact: testing is recommended immediately and if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative.

Based on interview and record review, the facility failed to implement their Clothing List policy for one resident (R4) of three residents reviewed for clothing list. Findings include: R4 is an [AGE] year-old female, originally admitted on [DATE], with diagnosis includiung dementia, surgery on the digestive system, muscle weakness, and lack of coordination. On 1-19-2024 at 12:20pm, V24 (R4's family member) said, The facility was not responsible to do (R4's) laundry because she was a short-term care resident, and the family is responsible to do the laundry. When (R4) was admitted on [DATE], she came in with several outfits and she did not have them when she was discharged ; no inventory was done. The facility did not do an inventory list when she was admitted to account for her belongings. I reported to the facility staff, and I did not get any solution. On 1-20-2024 at 10:15am, V21 (Certified Nurse Assistant) said, The nursing staff is responsible to complete the inventory form and document what the patient is coming with and report to the nurse if they have any valuables like wallet, jewelry for them to follow up with the patient and the family. On 1-20-2024 at 2:04am, V1 (Administrator) said, We do not have (R4's) inventory form, it was not done. On 1-20-2024 at 2:30pm, V2 (Director of Nursing) said, We do not do any inventory list because we are not responsible to manage the personal clothes of any of our short-term care residents. I was not aware that (R4) was missing any clothing pieces. We are not responsible to do the laundry for any short-term care resident. Policy titled: Clothing list, dated: 09-20, reads: resident belongings will be recorded upon admission and whenever brought in. Belongings will be verified upon discharge or transfer.

Based on interview and record review, the facility failed to follow their protocols and have interventions in place to prevent a resident admitted with intact skin from developing a pressure ulcer. This failure applied to one (R2) of one resident reviewed for pressure ulcers, and resulted in R2 developing an unstageable pressure ulcer to the sacrum that required surgical debridement. Findings include: R2 is an [AGE] year-old female, originally admitted on [DATE], and has diagnoses including but not limited to: metabolic encephalopathy, hypertensive chronic kidney disease, and dementia. Minimum Data Set (MDS) dated [DATE], documents R2 needs extensive assistance of two staff members for bed mobility and transfer, R2 needs extensive assistance of one person for locomotion in wheelchair, dressing, toileting, and personal hygiene. Section M indicates R2 is at risk for pressure ulcers. Record Review from a local emergency room reads in part: on 12-19-2023, R2 was identified with a pressure injury mid sacrum. (R2) presents with unstageable pressure injury to sacrum and area of increased dusky tissue on right lateral lower buttock which, upon testing, is partially blanching. On 12-21-2022, Initial Nutrition Assessment reads: skin integrity: stage 3 left sacrum pressure injury, unstageable mid sacrum pressure injury. Increased nutrient needs (protein) related to increased demand for nutrient secondary to loss of skin integrity, delayed wound healing or pressure injury. On 12-23-2022, R2 had a sharp debridement to the sacrum area. On 6-30-2023 at 2:55pm, V5 (R2's family member) said, I told V4 (Registered Nurse) a week after (R2) was admitted that I noticed a small wound to (R2's) buttocks. I asked for the doctor to be contacted and requested a treatment to avoid it getting worse. The following day I checked with V4 again, and the nurse told me no treatment was obtained. On 12-19-2022, (R2) went to the hospital; the nurse told me (R2) had a bedsore in the coccyx area when she arrived at the emergency room . On 6-30-2023 at 11:00am, V4 (Registered Nurse) said, I am the regular nurse for the morning shift. (R2) was in my set. (R2) was alert and oriented but confused. (R2) was dependent on all ADL's, assistance with turning, incontinence care, feeding. I can see in the electronic medical record that (R2) was admitted to the facility on [DATE]. According to the assessment, (R2) did not have any open skin; it was documented old scarring from history of pressure ulcer to the left buttocks. On 12-19-2022, (R2) was sent out to the hospital because we received some abnormal laboratory results. BUN (Blood Urea Nitrogen) was 79, normal level is 7-23 mg/dL and Sodium (Na) 150 normal level is 133 - 148 mmol/L. On 6-30-2023 at 2:20pm, V12 (Certified Nurse Assistant) said, (R2) was my patient in the morning. I provided care, changed her, washed her and dressed her. The family member was with me when I was cleaning (R2) in the room most of the time. I do not remember if (R2) had any wounds. On 7-1-2023 at 10:40am, V10 (Licensed Practical Nurse) said, If a patient develops any skin issue, we need to make sure the doctor and the family are contacted. We need to obtain treatment orders, update the care plan, and put the new interventions in place. We do not do any shower sheets. On 7-1-2023 at 1:20pm, V2 (Director of Nursing) said, (R2) was admitted on [DATE]. According to her initial assessment, she had an old scarring area to the left buttocks; the care plan does not have any interventions, No interventions were implemented at the time of the admission. (R2) did not have any open skin. (R2) had a Braden assessment (skin assessment) on 12-9-2022, with results of score of 12. (R2) was determined to be at high risk for developing a wound. (R2) was supposed to have an skin assessment done every day when we are doing rounds on the patients. Part of the skin assessment is done when we provide care to the patient. Daily skin assessments are part of the Medicare charting as well. The last skin documentation before (R2) went to the hospital was done on 12-16-2022; we did not do a skin assessment on 12-17, 12-18, and (R2) was sent to the hospital on 12-19-2022. On 12-19-2022, (R2) was sent out to the hospital for evaluation. We do not have any documentation that (R2) had any impaired skin. On 7-1-2023 at 2:30pm, V11 (Wound Care Physician) said, When a patient has a healed wound, the area where the wound was is prone to develop a new wound, because the skin is more sensitive and the skin is not as strong. The facility needs to put interventions in place to prevent any re-opening. The wound would be classified as the prior stage since we do not back stage. The facility should do a body assessment before the patient goes out to the hospital to avoid the hospital blaming the nursing home, and the nursing home blaming the hospital for the development of the wound. (R2) had multiple co-morbidities including diabetes, rheumatoid arthritis, and low hemoglobin levels, that will affect the skin integrity and increase the risk for breakdown. On 7-1-2023, V1 presented policy titled: Prevention and Treatment of pressure injury and other skin alterations, dated: 3-2-2021, documenting: identify residents at risk for developing pressure injuries, implement preventive measures and appropriate treatment modalities for pressure injuries and/or other skin altercations through individualized resident care plan.

Based on observation, interview, and record review, the facility failed to provide adequate assistance to R1 during a transfer from the wheelchair to the bed, and failed to document and report the incident during the transfer in a timely manner. These failures caused R1 to sustain a fracture of the right hip requiring hospitalization and surgery. This deficiency affects one (R1) of three residents reviewed for Resident safety/Accident prevention in a total sample of 4. Findings include: R1 iwas admitted on [DATE], with diagnosis listed in part, but not limited to: Displaced intertrochanteric fracture of right femur subsequent encounter for closed fracture with routine healing, Orthopedic aftercare following surgical amputation, Acute osteomyelitis right ankle and foot, Surgical aftercare following surgery on the circulatory system, Peripheral Vascular Disease, Generalized muscle weakness, Gait and mobility abnormality, history of falling, Metabolic encephalopathy. R1's Care plan indicated: R1 has limited transfer skills due to toe amputation. R1 has impaired ADLs in the following areas: hygiene and grooming, dressing, and sitting balance. R1 has limited trunk strength and mobility affecting posture/postural control and function, especially regarding sitting balance, repositioning in wheelchair and bed. She has ADL self-care performance deficit due to recent hospitalization , weakness, post amputation of right 2nd toe. She is at risk for falls due to unsteady gait, weakness, use of psychotropic, recently hip fracture and hospitalization due to altered mental status. R1's MDS (Minimum Date set) admission assessment, dated 12/6/22, Section G, Functional Status, indicated: ADL ( Activity of Daily Living) assistance: A. Bed mobility- how the resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture. Self-performance: Extensive assistance (resident involved in activity, staff provide weight bearing support). Support: 2 + person physical assist. B. Transfer- how resident moves between surfaces including to or from bed chair, wheelchair, standing position. Self- performance: Extensive assistance. Support: 2+ person physical assist. Incident report of bruise and right hip pain, dated 12/20/22 at 6:00am, completed by V15, LPN (Licensed Practical Nurse), indicated: R1 complained of right hip pain with pain scale of 5, PRN ( as needed) Tylenol given with relief, noted with bruise, when asked what happened, R1 verbalized I bumped my hip somewhere while transferring from wheelchair to bed last night. I feel pain when I'm moving it but if I don't move it, I'm okay. Staff provided an ice pack and it helped. Nurse Practioner and family notified. Radiology report, dated 12/20/22 8:38pm, impression: impacted basicervical fracture with varus deformity. Incident/accident notification Final report 12/23/22 (initial report sent on 12/21/22) submitted to IDPH documented R1 is [AGE] years old and admitted to facility on 11/30/22, with diagnosis above for PT/OT. R1 is alert and oriented x 2-3. R1 had as incident while transferring from wheelchair to her bed, and right hip pain noted immediately after. X-ray ordered at facility. Results showed what appears to be an impacted basicervical fracture of right femoral neck with some varus deformity. Attending physician ordered for resident to be sent out to hospital for further evaluation. Investigation initiated. Facility Response/Follow up: Per interview with R1, she was transferring with V14, CNA, from wheelchair to bed, when she lost her balance, and believes she hit something, but unable to identify. R1's room was inspected, and situation was re-enacted. It is possible R1 could have come in contact with half side rails as R1 uses them to adjust self in bed. Per interview with staff, therapy and therapy recommendation, R1 is able to pivot transfer with 1 person assist. Per interview with V14, CNA, stated she assisted R1 from wheelchair to bed when she suddenly lost her balance. Attending physician ordered for resident to be sent out for further evaluation at that time, however, R1 and family requested that she transfer the following morning. Pain medication provided and per staff and R1, she slept comfortable through the night. R1 admitted to hospital for hip fracture and surgical intervention. Facility has been in contact with R1's family and R1 will return to facility to continue short term rehabilitation. Review R1's therapy records with V13, Therapy Director, indicates: Physical Therapy Evaluation and plan of treatment, certification period :12/1/22 to 1/29/23 indicated: Referred to PT due to new onset of decrease strength, decrease in functional mobility, decrease in transfers, reduced balance, reduces ability to safely ambulate, reduced functional activity tolerance and increased need for assistance from others. Medical precautions: Right toe amputation WBAT RLE in forefoot offloading post op shoe. Behaviors: Attentive, oriented, cooperative, and able to make needs known. Underlying impairments: Standing balance: static balance- poor maximum assist and upper extremity support to maintain standing balance and reach ipsilaterally, unable to weight shift. Dynamic standing- unable (total dependence) Functional assessment: Bed mobility- Maximum Assistance Transfer- Maximum Assistance Gait- level surfaces- Total dependence without attempt to initiate Wheelchair mobility- Total dependence without attempt to initiate Objectives: R1 will safely perform functional transfer with maximum assist and 75% verbal cues and 75% tactile cues for weight shift over center of gravity, for push up from arms of chair and for safety while turning in order to decrease level of assistance from caregivers, safely return to house hold activity and return to prior level of functional abilities. R1's Therapy treatment encounter notes, dated 12/19/22, indicated: Therapeutic activities: Sliding board transfer training to increase functional task performance, training in weight shifting for SB position under patient buttock with minimal assist. Verbal instructions and tactile cues for hands/feet position moderate assist and extra time scooting along the board: to initiate sliding board transfer, sequencing and hands position on the board. Physical Medicine Rehabilitation notes follow up, dated 12/19/22, indicated: Chief complaint: mobility and ADL dysfunction secondary to other acute osteomyelitis, right ankle and foot, encounter for orthopedic aftercare following surgical amputation now with left thumb, index and middle finger numbness and electrical pain. Assessment: Transfers- Maximum assist with sliding board. Hospital record ,dated 12/21/22, indicated: Chief complaint- Fracture due to fall and underlying osteoporosis. [AGE] year-old female presented to emergency department status post fall. She fell 2 days ago when trying to transfer back to bed from chair. Hospital discharged summary, dated 12/26/22, indicated: status post right hip fracture. On 12/22/22, she underwent right hip ORIF (Open Reduction Internal Fixation). On 1/24/23 at 10:35am, R1 was observed for contact isolation due to shingles. R1 was lying in bed with O2 (oxygen) via NC (nasal cannula) at 0.5 LPM (liters per minute). R1 is alert and oriented, but forgetful. R1 is not a good historian. R1 remembers of banging her hip during transfer causing her pain and hospitalization due to fracture, but cannot give details of the incident. On 1/24/22 at 2:38pm, V13, Therapy Director, said R1 is evaluated and has certification for therapy from 12/1/22 to 1/29/23. V13 said R1 needs 2 persons assist for transfer. V13 said they communicated to nursing staff regarding assistance needed for transfers. V13 said they recommended sliding board for transfers due to her unsteady when standing due to rheumatoid changes to the joints. V13 said for safety transfer, they recommended sling board with 2 persons assist. V13 they informed the nursing staff regarding R1's safety transfers. On 1/24/23 at 3:30pm, reviewed R1's medical record regarding FRI (Facility reported incident) dated 12/21/22 with V1, Administrator and V3, ADON (Assistant Director of Nursing). Informed V1 that FRI reported did not indicate the date the incident occurred. It was identified at first, right hip pain and bruise of unknown origin on 12/20/22, then during investigation, it was found out R1 had an incident of hitting her right hip on side rails when V14, CNA (Certified Nursing Assistant), transferred her from wheelchair to bed on 12/19/22. No incident report or documentation in R1's progress notes was done. On 1/14/23 at 3:40pm, V3, ADON, said any incident report will be discussed by IDT (interdisciplinary team) for root cause analysis, and care plan will be updated based on root cause analysis to prevent future re-occurrence of the incident. V3 said V2, DON (Director of Nursing), updates the care plan and risk management. Informed V3 and V6, Nurse Consultant, R1's care plan was not updated in relation to the incident. No new intervention was formulated to prevent re-occurrence of the incident. V3 and V6 reviewed R1's care plan, and said there are no updates in the care plan pertaining to the facility reported incident. On 1/24/23 at 3:48pm, V14, CNA, said that V14 transferred R1 by herself on 12/19/22 around 7pm, from wheelchair to bed, and R1 lost her balance. V14 said R1 probably hit her hip to the side rail and landed on the bed. R1's both legs were hanging off the bed. She asked V16, LPN, for assistance to put her on bed. R1 complained of pain on her right leg. She said the nurse is aware of the incident. R1 complained of pain, and V16 gave her pain medication. V14 said she applied ice pack to R1's leg. V14 said she did not use gait belt when transferring R1 to bed. She is not aware R1 needs 2 person assistance, and she is not aware R1 needs sliding board for transfer. On 1/25/23 at 11:24am, V2 said V1, Administrator, did the investigation of the incident. V2 said V16, LPN, should have documented and reported the incident that happened on 12/19/22 when R1 lost her balance and hit the side rail during transfer with V14, CNA, especially since R1 complained of pain. Incident report was made on 12/20/22, when R1 complained of pain, and a bruise was noted on the right hip at 6am to V15, LPN. V2 said R1's X-ray of the right hip was ordered at 10am, but there is no documentation what time it was taken. The Xray result with fracture hip was received at 8:30pm. V2 said the Xray tech should come within 4 hours from the time it was ordered. R1 was sent out to the hospital on 12/21/22 per family request, because it was already late, and family would like to be with R1 when she goes to the hospital On 1/25/23 at 12:54pm, V16, LPN, said on 12/19/22, V14, CNA, called him for assistance in R1's room. He found R1 lying in bed with legs off the bed. He helped V14 straighten R1 in bed, and boosted her up. R1 complained of right hip pain. R1 said she hit her right hip to the wheelchair during transfer. He did not see any redness or bruising at that time. He gave her PRN pain medication, and V14 applied ice pack to her hip. He said he did not document or make an incident report, because he was busy with another resident. He forgot to endorse it to the next shift because he got busy. He said he should have documented in the progress notes the incident tha happened during transfer and should have made an incident report. R1's admission MDS assessment, dated 12/6/22, indicated R1 needs extensive assistance with 2 + person assist for transfer. R1's therapy notes indicated R1 needs sliding transfer board for safety. At the time of incident report, R1 was transferred by V14, CNA, by herself, with gait belt, and not using transfer board. R1's care plan was not updated when she returned from the hospital after surgery due to fracture, to prevent re-occurrence of the incident. V14 was not aware R1 needs 2 persons assist and need sling board for transfer. V2 said the therapist should communicate with nursing staff regarding R1's safety transfer. V2 said a gait belt should be used during transfer. Facility's policy on Incident/accident reports indicates: 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. Procedure: An accident refers to any unexpected or unintentional incident, which may result in injury or illness to a resident. This does not include adverse outcomes that are a direct consequence or treatment or care that is provided in accordance with current standards of practice. 4. All unusual occurrences. 9. An incident/ accident report is to be completed and shall include A. Date and time of incident/accident B. Description and possible cause of incident, physical assessment, injuries noted, vital signs, treatment rendered and notification of appropriate parties. 10. The facilities shall maintain a file of each incident and accident affecting a resident that is not the expected outcome of the resident's condition or disease process. A descriptive summary of each incident or accident affecting a resident shall also be recorded in the process notes or nurse's notes of that resident. 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 accident. Facility's policy on transfer techniques indicates: Purpose: To safely transfer the resident from bed to chair to from one location to another. 7. Place gait belt around the resident's waist unless contraindicated. Facility's policy on Gait belt/transfer belt indicates: Policy: To assist with a transfer or ambulation. A gait belt will be used with weight-bearing residents who require hands on assistance. Facility's policy on Management of falls indicates: Policy: The facility will assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate resident interventions and revise the resident plans of care in order to minimize the risks for fall incidents and or injuries to the resident.

Based on observation, interview, and record review, the facility failed to provide a scheduled shower/bath to a resident for 3 weeks. This deficiency affects one (R2) of three residents reviewed for ADL care personal hygiene in a total sample of 4. Findings include: On 1/24/23 at 10:58am, R2 was lying in bed. She was alert and responsive coherently, able to verbalize needs. She said she was not given a shower for almost a month, but when she complained about it, she was given a shower. On 1/24/23 at 11:28am, reviewed R2's e-medical record for bathing, with V4, CNA (Certified Nursing Assistant), and V9, LPN (Licensed Practical Nurse). Both said R2's shower/bathing schedule is every Tuesday evening (PM) and Saturday morning (AM). R2's bathing documentation for [DATE] indicated she did not receive a bath/shower from [DATE] to [DATE]. The shower record was marked 88 (activity did not occur) on the following dates: 1/3, 1/10, 1/13, 1/10, 1/13, 1/17 and 1/20/23. V4 said usually they mark 88 if the resident refused, and will inform the nurse to document it. There was no documentation of her refusal. R2's care plan did not indicate she refused showers. R2 was given a shower on 1/22/23. On 1/24/23 at 1:30pm, informed V1, Administrator, and V6, Nurse Consultant, of R2's [DATE] bathing /shower documentation, which indicated she did not receive a bath/shower from [DATE] to [DATE]. On 1/24/23 at 3:30pm, V3, ADON (Assistant Director of Nursing), said CNAs should report to the nurse if the resident refused a shower/bath, then the nurse will document encouragement done, and reason for the shower/bath refusal in resident's progress notes. Resident care plan will be updated for shower refusal. On 1/25/23 at 11:24am, informed V2, DON (Director of Nursing), of concern identified with R2's complaint of not given a shower for almost a month, and her shower/bathing documentation. R2's bathing documentation for [DATE] indicated she did not receive bath/shower from [DATE] to [DATE]. V2 said CNAs should report to the nurse residents who refused shower/bathing; the nurse will document encouragement done, and reason of shower/bathing refusal in resident's progress notes, and update the care plan. Facility unable to provide policy on ADL (Activity of Daily living) for personal hygiene- bathing /shower.

Based on observation, interview, and record review, the facility failed to treat a resident with respect and dignity when providing care and service to the resident. This failure relates to one resident (R186) who reported staff would not take him to the bathroom. As a result, R186 expressed he felt belittled when he was forced to urinate in a container (urinal). Findings include: According to the face sheet, R186 is [AGE] years old. Current diagnoses include but are not limited to: Anxiety Disorder, Benign Prostatic Hyperplasia without Lower Urinary Tract Infection, Need for Personal Assistance, Neuromuscular Dysfunction of Bladder, Other Specified Depressive Episodes, Epilepsy, and Parkinson's Disease. R186's current diagnoses indicate: Anxiety Disorder, Benign Prostatic Hyperplasia without Lower Urinary Tract Infection, Need for Personal Assistance, Neuromuscular Dysfunction of Bladder, Other Specified Depressive Episodes, Epilepsy, and Parkinson's Disease. R186's MDS Minimum Data Set (Comprehensive Assessment). dated 9/19/22. documents a BIMS (Brief Interview for Mental Status) score of 13 out of 15, which indicates he is cognitively intact. The same assessment shows R186 is extensive assist with a minimum of 1 person assistance to go to the toilet. R186's functional status indicates he requires extensive assist with his ADL's (Activities of Daily Living) including bed mobility, transfers, moving in and about the unit, personal hygiene, and using the toliet. R186's care plan indicates socially inappropriate behaviors as evidenced by cursing at staff members. Date initiated: 09/27/2022. The care planned concern is not documented in R186's electronic medical documentation. R186 is at risk for falls- Hx: fall with SDH (subdural hematoma), SAH (subacute hemorrhage) 9/14/2022. Interventions state: Encourage resident to Call, don't fall. 9/14/2022 R186 is receiving (Lexapro, Ritalin, and Melatonin) psychotropic medication. Noted to have diagnosis of: Depression and Anxiety Noted with behavior or mood issues of: feeling down, sadness, loss of interest, anxiousness. 9/15/2022 R186 has potential for injury related to seizure disorder. 9/13/2022 R186 Is a risk for bladder distention, incomplete emptying of the bladder and/or UTI secondary to benign prostatic hypertrophy. 9/26/2022 Interventions state: Encourage prompt, complete bladder emptying. 9/14/2022 R186 has the Potential for extreme fatigue and weakness related to dx of anemia. 9/26/2022 R186 is at risk for impaired mobility with Diagnosis of Parkinson's disease disorder. 9/14/2022 Interventions state: Assist with mobility as needed and Assist with transfer as needed. 9/14/2022 R186 experiences bladder incontinence. 9/2/2022 Interventions state: Provide assistance for toileting. 9/26/22 R186 is at risk for abuse related to diagnosis of Other Specified Depressive Episodes and alleged disagreement about toileting needs. 9/15/22 Interventions state: Consider possible antecedents: fear, fatigue, loss of control over a situation 9/15/2022. Respond with re-assurance. Do not argue. 9/15/2022 Investigate accusation. 9/27/2022 The 9/27/2022 Resident Safety/Abuse Screening Assessment completed by V10, Social Services Director, indicates: 10. Is there a history of /current socially inappropriate behavior (see comprehensive assessment, if applicable)? No. On 09/26/22 at 11:31 AM, R186 stated, Night staff are bossy and insensitive. I'm not crazy about the staff here. I have no idea who the staff was, I thought I heard someone say (V11). They want to move at their own pace, but I know they're busy. I didn't talk to anyone; I think they protect each other. I asked to go to the bathroom at night and I wanted to get up and walk. This was a few nights ago. She (the staff) told me to use the bottle. At 3:26 PM, R186 stated to surveyors, I am forced to go to the bathroom using this 'bottle' (pointing to a plastic urinal). Several nights ago, I asked this one nurse that I needed to be taken to the bathroom and she just shouted at me while she was at my doorway. 'Go use the plastic thing I gave you!' I didn't like her bossy tone and it annoyed me that she'd force me to go to the bathroom in a bottle. Surveyors asked how it made him feel. R186 stated, Well, it made me feel real small. I am a tough guy, and no one can intimidate me, but I should not be taking that kind of mistreatment here. I'm here to get well and no one can talk to me that way! Surveyors asked if staff did not assist him to the bathroom how he could relieve himself? R186 stated, Well other than going in this bed, I'm forced to use this bottle to pee in and I'm not about to do that! Surveyors asked if this was an on-going problem. R186 stated, I've been here only a couple of weeks and I'd say that during the day it's much better, but at night it's an entirely different problem. I have asked to go to the bathroom and all I get from everyone is to go in a bottle. I've told some nurses or aides, but I can't tell who they are because they never introduce themselves and they boss you around to do something like go to bed. They just want to shut you up and not be bothered by you. So yes, this isn't the first time this has happened, and no one does anything about it. If you look around, you'll see all the bottles laying around because, they don't want to be bothered to take me to the bathroom. Surveyors looked and observed 3 used urinals; one hanging on the bedrail, one in the bathroom, and another on the night stand next to the bed. Surveyors asked if he could walk to the bathroom himself. R186 stated, I could, but I need someone to help me otherwise I'm afraid I'd fall. Surveyors asked R186 to describe the staff person and to describe the interaction again he had with the staff person. R186 stated, She had [NAME] hair and I heard her speaking in Spanish to another person who I thought was the nurse's aide. She was right at the door, didn't come in to talk to me, but just shouted at me and said, 'Go in the bottle!' and then walked away like she was too busy to help me. I should not be treated that way and again it made me feel very small. Surveyors asked what he meant by feeling very small. R186 stated, It is humiliating to have to go in a bottle to pee when I can go in the toilet. At 3:20 PM, V1, Administrator, with V2, DON/Director of Nursing, V3, Consultant, and V4, ADON/Assistant Director of Nursing present in the room were questioned about R186 concerns. V3 stated, The nurse (V5) said she spoke with the resident from the doorway of the room and asked if he had to go number 1 or number 2 (referring to either going to urinate or defecate) because he uses his urinal and it didn't make sense if he had to go number 2. Surveyor asked whether R186 was on isolation precautions and if that was the reason V5 was speaking with R186 from the doorway, and did not approach the resident to inquire about his needs. V3 stated, No, he was not on any isolation. Survey team asked whether R186 should be assisted to the bathroom regardless of whether he had to urinate or defecate. V3 stated, Well it's a collaboration of care. It's ok to ask if the resident needs to go number 1 or number 2. (R186) is only a minimal assist; he can go to the bathroom on his own. On 9/27/22 at 1:40 PM, V7, CNA/Certified Nursing Assistant was asked: Does R196 require assistance with going to the restroom? What type of assistance is needed? V7 stated, (R186) he is limited assistance to get him up out of the bed and he uses the walker to the bathroom. I answer his call light and he tells me he wants to go to the bathroom, and I help him to the bathroom and help him change his (incontinence brief). At 3:17 PM, V5 LPN (Licensed Practical Nurse) stated, I'm a nurse, LPN. I am familiar with this resident. 9 out of 10 times he's my patient. I give him medications in the morning and also if he uses the call light for repositioning or emptying his urinal. The surveyor asked whether R186 ever voiced any concerns about not being assisted to the bathroom or any improper care. V5 stated, Never while under my care because I make rounds repeated in English and in Spanish for his needs. V5 was asked if V5 asked R186 while standing in the doorway if he had to go number 1 or number 2. V5 stated, I never asked him if he had to go number 1 or number 2. He never requested to go to the bathroom. He uses a urinal to go to the bathroom. I personally have never had him request to use the restroom. It's either I hand him his urinal, empty it, reposition him in bed, or give him medications. Surveyors asked whether she ever assisted R186 to the bathroom during the 9 or 10 times she took care of R186. V5 stated, I never had to. The aides have never asked my assistance for that. Surveyors asked how she communicates with the resident. V5 stated, (R186) is Spanish speaking. He asked me in Spanish about some care things, but with this resident our conversations are extremely limited. Surveyors asked again whether anything was communicated to her about any care concerns or mistreatment. V5 stated, No, there were no conversations about care. V5 raised her voice and tells the survey team, You are splitting hairs about how I speak to him directly. I mean I have to go in so as not to startle him, but again I have not noticed any behavior change or any complaints from this resident. Surveyors asked again whether at any point during the 9 or 10 times she cared for R186, whether there was incident or anything out of the ordinary that would warrant further investigation. V5 stated, Well there was one night that the resident verbally cursed at me, and there was some verbal exchange between (V8, CNA) and (R186). She (V8) told me the patient became verbally aggressive. Surveyors asked whether she investigated further the cause of the verbal exchange between V8 and R186. V5 stated, No, I did not report this behavior to anybody because it never happened again. Surveyors asked whether an incident of this nature should have been reported to anyone. V5 stated, Like I said, it only happened once so I didn't feel the need to tell anyone. On 09/28/22 at 9:11 AM, V6, RN/Registered Nurse, was asked: Does R186 require assistance with going to the restroom? What type of assistance is needed? V6 stated, He pulls the call light and asks if he wants to go to the bathroom, wants to eat, or wants a pain pill. I took him to the bathroom one time. I got him out of bed and set him in the wheelchair. I took him to the bathroom, stood him up and helped him to the toilet. I waited for him. Sometimes he just wants to use the urinal. He is limited assistance. He can use a walker; he's unsteady. He's a one person assist because he has Parkinson's. Therapy told us to assist him. On my shift he never gets up or goes to the bathroom by himself. He always pulls the light. He knows to pull the light. Surveyor asked, has R186 said anything about staff being rude, insensitive and rushing his care? V6, RN, stated, Haven't heard about staff not helping him. On 9/28/22 at 11:22 AM, V8, CNA/Certified Nursing Assistant, stated, I'm familiar with (R186). I work with (V9 LPN), but (V5, LPN) is the nurse who mostly works as night. I'm a CNA. I have had contact with (R186); most of the time he is my patient. I worked here for one year and two months. Surveyors asked how R186 goes to the bathroom. V8 stated, The first time, maybe the first day he asked to go to the bathroom because when he stands up he gets dizzy and he uses the bottle (referring to the urinal). Most of the time he does it on the bed and uses the urinal. He calls me to empty it. Surveyors asked how V8, CNA communicates with R186. V8 stated, He (R186) speaks English. I had him most of the time; we never talk though. I never take him to the bathroom because he uses the bottle. Surveyors asked whether R186 requests to be assisted to the bathroom. V8 stated, He never does, he just calls to empty his bottle. Surveyors asked about R186's demeanor. V8 stated, He's covering his face with a blanket most of the time. He wasn't comfortable when he first came in and he mostly calls for us to empty his bottle. The past two days though he's been requesting to go to the bathroom, so I told him do you have to have a bowel movement or just pee? I thought his request was unusual because he does it only in his bottle (referring to urinating). Surveyors asked why the question of whether a resident has to go number 1 or number 2 has to be clarified if the resident is already requesting to be assisted to the bathroom.V8 stated, If I know they have a bottle already, then it's automatically they go in the bottle. All my residents know, they just don't want to get up. All the time, (R186) uses his bottle. Surveyors asked if she noticed any change in R186's behavior since taking care of him. V8 stated, Most of the time he's quiet, but maybe he got more quiet, I don't know. Surveyors asked if there was any incident she reported to the nurse pertaining to R186. V8 stated, Well, he asked one time to reposition him on his left side and I told him where else do you want to go? He said the F word to me. I think he wasn't comfortable. He just kept calling me and kept calling me in even though his bottle was not even full (of urine). So he kept calling for the same reason over and over, so I told one of the nurses at the time.? Surveyors asked whether she got frustrated over R186's continued requests for care. V8 stated, I didn't understand what he wanted, so I told the nurse he cursed at me because he wanted me to put him on the toilet. I told him that he gets dizzy and because we don't want him to fall so I showed him the bottle. Some nights all he does he points to the bottle. Surveyor asked V10, Social Services Director, if she was familiar with R186 and if she was aware of the abuse allegation.V10 stated, Yes, I'm familiar with (R186). I did go and interview the resident on Monday. I asked him what happened, and he told me the situation; that he got into an argument with one night staff members. He wanted to use the bathroom to urinate, but the staff told him to use the urinal. I asked (R186) if he could identify the staff member. (R186) said he couldn't because it was the middle of the night, and he couldn't really see them that well. I asked if he could tell me anything about the staff member and he said that staff member spoke Spanish and that's all he could remember. I asked if he could identify the staff members color of the uniform and he couldn't. I asked after the incident if he felt safe and he said he didn't have any other concerns.

Based on interview and record review, the facility failed to follow their Management of falls policy and modify the plan of care with interventions to prevent future fall for 1 of 3 (R1) residents reviewed for care plan revisions. Findings include: R1's Fall Care Plan does not document any actual fall, or any new interventions to prevent further falls. On 11-17-21 at 9:27 AM, V2 (DON) said V2 does not see any update to actual fall (7-9-21) or new interventions in place post fall. New interventions are implemented to prevent future falls. On 11-17-21 at 10:37 AM, V1 (Administrator) said facility did not update R1's fall care plan with new fall interventions to prevent future falls. Review of Care Plan Policy, dated 11-2017, documents the interdisciplinary team is responsible for periodic review and adjustments to the plan of care: when there has been a significant change in the Resident's condition. Management of Falls Policy, dated 8-2020, documents 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. Review and/or modify the resident's plan of care at least quarterly and as needed in order to minimize risk for fall incident sand/or injury.

Based on observation, interview, and record review, the facility failed to follow their infection control policy by having the doors open for patients with contact and droplet precautions and failing to conduct surveillance and tracking of COVID-19 infections in the facility. This deficient practice affected fourteen residents; (R1 thru R14) and has the potential to affect all 32 residents currently in the facility. Findings Include: On 11-27-2020 at 11:00am, noted on first floor, R3, R5, R6, R7, R8, R9, R10, R11, R13, and R14, the bedroom doors were observed to be open even though all ten residents have posted signs indicating the need for contact and droplet isolation, available Personal Protective Equipment (PPE) by entry door, and orders for quarantine. On 11-27-2020 at 11:10 am, V4 (Registered Nurse) said on the first floor, I have 10 patients on contact and droplet isolation, all of them are on quarantine for potential COVID exposure. We have the bedroom doors open because some of the patients are confused, and some are high risk for fall, and we need to make sure we have easy access to the bedroom. We never close the door to the quarantine rooms for R3, R5, R6, R7, R8, R9, R10, R11, R13, and R14. I know the door should be close for infection control. On 11-27-2020 at 11:35am, on the second floor, noted R1, R2, and R4's bedroom doors were open, even though all three residents have posted signs indicating the need for contact and droplet isolation, available Personal Protective Equipment (PPE) by entry door, and orders for isolation. On 11-27-2020 at 11:50am, V5 (Registered Nurse) said R1 and R2 are positive COVID, and R4 is on quarantine as re-admission from the hospital; all three patients are on contact/droplet isolation. We never close the bedroom door, the door is always kept open at all times because we need to make sure to see the patient from the hallway. I have 5 other patients in the same hallway that are not on any isolation. On 11-27-2020 at 2:50pm, V2 (Director of Nursing) said my expectation is that the bedroom doors are closed for all patients with positive COVID-19, under investigation, or in quarantine; the doors need to be closed by the staff at all times for infection control purposes. On 11-28-2020 at 8:50am, V3 (Assistant Administrator) said R12 was the first COVID positive case on 10-30-2020, after multiple months without any positive cases. To be honest with you we did not do any root cause analysis to find out who was the carrier that infected the patient. We did not do any tracking and tracing. Facility policy titled, COVID-19 Control Measures (dated: 5-7-2020), reads: the facility is committed to reducing the spread and transmission of COVID-19 and will continue to follow all guidance and recommendations from the Center for Disease Control (CDC), state and local health departments. If patients have been screened and their testing is positive for COVID-19 door remain closed at all times.

Based on observation, interview and record review, the facility failed to assist residents identified as needing assistance for grooming and personal hygiene. This applies to 2 of 4 residents (R4 and R44) reviewed for ADLs (activities of daily living) in the sample 15. The findings include: 1. Face sheet, dated 6/20/18, showed R4 had multiple [DIAGNOSES REDACTED]. R4's MDS (minimum data set) BIMS (Brief Interview for Mental Status), dated 6/12/18, showed R4's cognition was severely impaired. The same MDS also showed that R4 requires extensive assistance with regards to personal hygiene. On 6/18/18 at 10:36 AM, R4 was in bed unshaven and with fresh and dried drool extending from his lips to his chin. V7 (Certified Nursing Assistant - CNA) was present during the observation and stated he is very contracted and cannot extend or use his arms. R4 was noted lying on a sheet that was saturated with urine in the presence of V7 and V8 (Nurse Clinical Coordinator). In addition R4's nails were long and uneven on 6/18/18 and the same on 6/19/18 at 9:02 AM. R4's ADL care plan showed that the resident has an ADL Self Care Deficit and needs assistance with most ADLs, is vision impaired and has contractures to extremities with limited range of motion and requires assistance with regards to personal hygiene. The care plan shows, Assist with ADL tasks as needed Assist with personal hygiene as needed 2. R44 has multiple [DIAGNOSES REDACTED]. R44's MDS dated [DATE] showed BIMS (Brief Interview for Mental Status) showed R44 with a score of 07 which meant that the resident is severely impaired with cognition. The same MDS also showed that R44 requires extensive assistance with personal hygiene and bathing. On 06/18/18 at 11:55 AM, R44 was in bed and noted with long facial and chin hairs. R44 stated once a month they put him in a chair, take him for a shower and stated he would like to have more frequent showers. R44 stated that he is right handed and has to use his left hand for everything. He sated he can not do things well with his right hand because the stroke affected his right side. R44 added he has tried to shave himself with his electric razor, but the shaver was no working so well and he was challenged to do it well using his left hand. 06/20/18 at 10:31 AM in the presence of V4 (nurse), R44 stated he would like more showers instead of once a month. At 10:33 AM, V5 (CNA) stated its difficult on the evening shift because it takes two people and everyone is so busy helping residents. On 6/20/18 at 12:55 PM, V9 (Resident Care Coordinator) stated her assessment showed R44 is weak on the right side, R44's hand was shaking when he attempted to use it to feed himself and is in need of restorative therapy. R44's ADL care plan, target date (MONTH) 2, (YEAR), showed that the resident has an ADL Self Care Deficit related to diagnoses, has limitations with range of motion, and requires assistance with regards to ADL self care. The care plan shows, Assist with ADL tasks as needed Assist with personal hygiene as needed The undated 2nd Floor Shower Schedule showed R44 is scheduled a shower on the day shift on Tuesdays and the evening shift on Saturday.

Based on observation, interview and record review, the facility failed to ensure proper positioning of indwelling urinary catheters to facilitate the flow of urine for two residents (R3, R10) of three residents reviewed for indwelling urinary catheters in a sample of 16. Findings include: R10's Physician order [REDACTED]. On 5/1/17 at 9:37am, R10 was laying flat in bed with her legs propped on two pillows. R10's indwelling urinary catheter was positioned under R10's left knee which was up on the pillows. The catheter tubing was elevated above R10's bladder. The urine was stagnant in the portion of the tubing that was under R10's left knee. On 5/1/17 at 2:07pm, R10 was prepared for an x-ray of her abdomen. E10 (CNA-Certified Nurse Assistant) placed R10's indwelling urinary catheter under the left leg which was still up on two pillows. R10's bed was in a jack knife position which caused the tubing of the catheter to be above the bladder. The urine was stagnant in the portion of the tubing that was under R10's left knee. At 2:20pm, R10 was in the same position with the indwelling catheter tubing positioned under the left leg. At 2:40pm, R10 was in the same position. On 5/2/17 at 10:05am, R10's indwelling urinary catheter was looped under the left knee. Dark yellow urine with whitish sediment was noted in the urine that was in the tubing. R10's Care Plan reads: Focus: (R10) requires the use of an Indwelling Catheter, [MEDICAL CONDITION] Bladder, [MEDICAL CONDITION]. Interventions: Keep tubing free from kinks. R3's Admission Record documents, in part, the following medical Diagnosis: [REDACTED]. R3's POS documents an order dated 4/9/17 that reads: CATHETER: MAY USE INDWELLING URINARY CATHETER DUE TO STAGE 4 SACRAL SORE. On 5/1/17 at 2:45pm, it was noted that urine was collecting in the most proximal portion of the clear tubing of the indwelling urinary catheter. E7 (CNA) pulled back R3 ' s bed sheets and found that the rubber portion of the indwelling urinary catheter was pinched in R3's groin and the incontinence brief was fastened tightly. E7 stated, The diaper may be a little too tight. E7 repositioned the rubber portion of the tubing so that it was free from R3's groin and loosened R3's incontinence brief. It was noted that the urine that began to flow was blood tinged. E7 indicated that she would let the nurse know. On 5/3/17 at 9:38am, E8 (CNA) confirmed that R3 ' s indwelling catheter was looped under R3's left leg and hanging on the right side of the bed. E8 repositioned the indwelling urinary catheter and indicated that the tubing should be above the leg. At 9:46am, after providing incontinence care, E8 turned R3 onto his back. In doing this, R3's indwelling urinary catheter was looped under his left leg and was hanging on the right side of the bed. R3's urinary catheter remained in this position until 10:25am at which time R3 was turned for a wound care treatment. According to the facility's Infection Control Log, R3 has a history of a urinary tract infection [MEDICAL CONDITION] on 4/22/17. R3's Order Listing Report documents and order dated 4/22/17 that reads: [MEDICATION NAME] 500 mg (milligrams) by mouth three times a day related to Urinary Tract Infection. A urine analysis and a urine culture was performed on 5/1/17. Results indicate a UTI. R3's Care Plan documents: Focus: (R3) requires the use of an Indwelling Catheter related to stage 4 sacral ulcer. Interventions: Keep tubing free from kinks. On 5/3/17 at 1:00pm, E3 (ADON-Assistant Director of Nursing) indicated that he was the infection control nurse. E3 stated, The positioning of the (indwelling urinary) tubing should be over the leg. If it's under the leg, could cause pressure and could cause skin breakdown. It could also lead to urine retention and a UTI. A facility policy dated 11/16 and titled, Indwelling Catheter documents, in part: POLICY: Indwelling Catheters will be utilized to facilitate urinary drainage when medically necessary. PROCEDURE: Place urinary drainage bag below the level of the resident's bladder to facilitate drainage and minimize stasis of urine.

Based on interview and record review, the facility failed to follow their policy for pacemaker care. This applies to 4 of 4 residents (R3, R6, R7, R11) reviewed for pacemakers in the sample of 15 and 3 residents (R17, R21, R22) in the supplemental sample. The findings include: 1). On April 25, 2016 at 10:15 AM during initial tour with E5 (Admissions Director), R3 was laying in bed. R3 was unresponsive to verbal stimuli. E5 said R3 recently suffered from aspiration pneumonia at home requiring hospitalization in January 2016, at which time a [DEVICE] (gastrostomy) was placed for feedings. E5 said R3 is a full code. The facility's face sheet dated April 28, 2016 shows R3's original admitted as January 28, 2016. R3's [DIAGNOSES REDACTED]. The facility lacked documentation to identify R3's pacemaker rate, date of insertion, location of insertion, type of pacemaker, battery life, or the date of the last pacemaker check. 2). On April 26, 2016 at 9:15 AM, R7 was sitting in her room. R7 was able to converse and tell about her 14 children and coming to America from another country many years ago. R7 said, I have a pacemaker, but I don't remember getting it checked lately. The facility's face sheet dated April 28, 2016 shows R7 was initially admitted to the facility on [DATE] and R7's [DIAGNOSES REDACTED]. The facility lacked documentation to identify R7's defibrillator date of insertion, location of insertion, type of defibrillator, battery life, or the date of the last defibrillator check. The facility provided a list of residents in the facility with pacemakers. This list included R3, R6, R7, R11, R17, R21, and R22. On April 28, 2016 at 9:59 AM, E3 (Nurse Consultant) said prior to April 26, 2016, the facility lacked the documentation required in the facility's policy for pacemakers for R3, R6, R7, R11, R17, R21 and R22. The facility's Pacemaker Care policy dated April 2014 shows: Procedure: 1. In the medical record, identify the pacemaker rate, date of insertion, location of insertion and type of pacemaker, if known. 2. The normal life of a pacemaker battery may very. Check with the physician if you have any questions regarding this.5. Pacemaker checks will be done as ordered by physicians.