Every finding on record at Aliya of Crestwood

Based on interview and record review, the facility failed to follow the resident's plan of care and accepted standards of practice for ostomy care by failing to monitor, measure, and document ileostomy output, resulting in lack of adequate nurse-to-provider communication, for one of one resident (R1) reviewed for ostomy care and services. This failure resulted in R1 having significant abdominal pain, being transported to the hospital, and diagnosed with a bowel obstruction.Findings include: R1's facility sheet shows diagnoses of colostomy status. R1's MDS dated [DATE] section H for bowel and bladder shows appliances- ostomy, bowel incontinence shows nine (9) Not rated, resident had an ostomy or did not have a bowel movement for the entire 7 days.R1's care plan for R1 has potential risk for complications r/t (related to) altered elimination device for (bowel/bladder) elimination, as evidence by having colostomy, date initiated 5/1/2026. R1 will remain free from complication r/t device for altered elimination through next review. Interventions- check elimination device during routine care for appropriate fit leakage need for emptying. Irrigate ostomy as ordered. Monitor for signs and symptoms of complications and report to nurse abdomen for signs and symptoms distention results complaints of pain. Monitor ostomy site for swelling pain or redness around stoma site. Notify MD of any abnormal findings. Provide ostomy care per standards, assessing skin around stoma site for signs of irritation, breakdown, notify MD (medical doctor) of abnormal findings. Provide privacy during ostomy care, promoting resident dignity and reducing adverse feelings related to elimination devices.On 6/28/26 at 11:00am V4 (Certified Nursing Assistant/CNA) said she did not empty R1's ileostomy bag when she worked with R1 on 5/10/26 during the overnight shift. V4 said R1 emptied her own bag.On 6/28/26 at 11:17am V6 (Nurse Manager/LPN) said she received a call because she is one of the managers on the unit where R1 resided. V6 said she was made aware that R1 complained of abdominal pain, and refused testing. V6 said maybe the provider ordered an X-ray. V6 followed up with clarification and said R1 refused a KUB (kidney, ureter, and bladder diagnostic procedure). V6 said the provider did not give her an order for a KUB. V6 confirmed that R1 orders shows that the facility staff was managing and caring for R1's ostomy, not R1.On 6/27/26 at 12:31pm V1 (R1's Family Member) said on 5/11/26 he visited R1. Around 3:00pm to 4:00pm, R1 informed him that she had abdominal pain. He escorted R1 to the nurse station informed the nurse who stated they would call the physician. V1 said the nurse had not followed up with R1 prior to him leaving. V1 said later R1 called him crying and stated she wanted to go to the hospital. V1 returned to the facility and took R1 to the hospital. V1 said R1 was diagnosed with a bowel obstruction. V1 said he remembers the nurse stating that they could run test at the facility, and he stated why they didn't do that already, he told them that he was taking R1 to the hospital.On 6/28/26 at 2:08pm V8 (Licensed Practical Nurse/LPN) said she was R1's nurse on 5/11/26. V8 said she does recall that R1 was complaining of abdominal pain after dinner. V8 said she assessed R1's abdomen and R1 did not have any fluids in her ostomy bag. V8 said R1 told her that she had not had a bowel movement in 2-3 days. V8 said R1 rated her pain as 20 out of 20. V8 said she paged the provider, with no response. V8 said the manager on duty said the facility could do a KUB. V8 said the provider did not call her back and give her any orders for a KUB, that information was coming from the manager on duty. V8 said R1 was yelling out, asking when are they going to get her. V8 said R1 was asking about her son, because her son was returning to take R1 to the hospital. V8 said R1 decline pain medication. V8 said the Director of Nursing/DON was made aware and was returning to the facility to assist, but she doesn't recall seeing the DON. V8 said R1's son took R1 to the hospital, she escorted R1 to the car in a wheelchair. V8 said she documented that R1 refused testing at the facility, but the doctor/provider never gave orders for testing. V8 said that is not considered a refusal of testing. V8 said R1 left the facility around 7:00pm. V8 said she did not document that R1 ileostomy bag did not have any fluids in it and she did not document the assessment of R1's abdomen. V8 said she should have documented the assessment and the findings. V8 said she did not empty R1's ostomy pouch during her shift. V8 said when she texted the provider, she mentioned that R1 was complaining of abdominal pain, she did not mention her findings in the text.On 6/28/26 at 3:18pm V10 (LPN) said she did not empty R1's ileostomy bag during her shift on 5/11/2026. V10 worked with R1 during the morning shift.On 6/30/26 at 10:06am V16 (Nurse Practitioner) said he received a message from the nurse that R1 complained of abdominal pain and was sent to the hospital. V16 said the nurse did not give details of R1's pain rated 20-20 and the assessment of no fluids in the ileostomy pouch. V16 said he should have been notified right away. V16 said she should be made aware of all details so that he can make a competent decision on the care. V16 said the output of the ileostomy should be monitored and documented. V16 said he saw R1 that morning, she had no complaints at that time. V16 said he documented it at 3:31pm, but that is not the time he saw R1. V16 said R1's ostomy was chronic, and it is not uncommon that R1 cared for her ostomy, but the staff should have asked R1 about what was emptied from her ileostomy pouch and documented what she said also.On 6/28/26 at 12:10pm V5 (Physician) said the facility should be monitoring and documenting the output for an ileotomy. V5 said the providers review and use that information to identify concerns. R1's physician order sheet did not contain an for a KUB.R1's progress notes dated 5/11/26 completed by V8 (LPN) denotes resident complained of abdominal pain, 10 out of 10. Resident stated that she has not produced a bowel movement in 2-3 days. Provider was contacted. Resident refused treatment, including pain interventions and diagnostic testing. Resident opted to be transferred to the emergency room by her son in private vehicle. R1's care plan does not reflect that R1 will care for her ileostomy. R1's care plan does not reflect that R1 was educated on risk and benefits independently caring for her ileostomy site. R1's care plan does not reflect that R1 was educated on informing the facility of the output of her ileostomy site/pouch. The facility did not present any documentation that R1 refused to allow the staff to care for her ileostomy site.R1's progress notes dated 5/12/26 denotes in-part writer called (hospital name) to get follow up on resident; admitted to hospital; dx ( diagnosis): small bowel obstruction.Facility ostomy care policy dated 1/2026 does not mention documentation monitoring the output.Facility policy dated 1/2026 titled comprehensive care plan denotes in part the facility must develop a comprehensive person-centered care plan for each resident. The care will include focused, measurable goals, and interventions specific to the residents medical, nursing, mental and psychosocial needs. The comprehensive care plan should drive the care and services provided for the residents and allow for the highest level of physical, mental and psychological function based on comprehensive MDS assessment.

Based on observation, interview and record review, the facility failed to follow their facility policies and protocols, failed to implement fall care plan interventions failed to follow basic life support/CPR protocol, failed to provide sufficient rounding/supervision to ensure resident's needs were met, and failed to provide care and services in accordance with professional standards of practice needed for one resident that required life sustaining services after experiencing a fall. The facility also failed to provide a working call light for one (R25) resident. These failures affected two (R4 and R25) of six residents reviewed for quality of care. These failures resulted in R4 experiencing an unwitnessed fall and sustaining life-threatening injuries and subsequence death due to left frontal scalp/periorbital hematoma, acute L1 anterior vertebral body fracture with mild retropulsion, acute fracture along anterior/superior end plate at C7 with widening of the anterior C7-T1 disk space and widening of C7-T1 facet joints. R4 remained unattended on the floor for a prolonged period following traumatic injuries. R4 expired on [DATE] as a result of these injuries. Findings include: R4's death certificate documents cause of death as fall and complications of spinal injuries. R4's face sheet documents R4 was admitted to the facility on [DATE] and documents the following diagnoses: encephalopathy, generalized muscle weakness, muscle wasting/atrophy, cognitive communication deficit, chronic kidney disease, seizures, and repeated falls. R4's minimum data set ([DATE]) documents a brief interview of mental status summary score of 10, indicating R4 was cognitively impaired and required partial to moderate assistance with activities of daily living. R4's minimum data set ([DATE]) indicates R4 died within the facility. R4's hospital records, dated [DATE], (prior to admission to the facility), documents, in part, (R4) brought to the ED (emergency department) by the EMS (emergency medical services) with complaint of fall and altered mental status concerning for new onset seizure with postictal encephalopathy. CT head on admission with no evidence of acute abnormalities. Chest x-ray with no evidence of focal infiltrates, consolidation or pleural effusion. R4's FRI (facility reported incident), dated [DATE], documents, in part, (R4) is incontinent of bowel and bladder; he (R4) has impaired mobility and requires assistance with ADL (activities of daily) care and transfers as W/C (wheelchair) is the primary source of transportation. (R4) was observed laying on the floor on his left side in front of the dresser, head towards the window, feet pointed towards the door, brief soiled with urine. He (R4) had non-skid footwear. After interviewing staff and meeting with IDT, it was determined that the cause of the fall was secondary to cardiac arrest. (R4) was last seen by the nurse at approximately 5:20am at which time he (R4) was lying asleep in bed. Sent to ER (emergency room). (R4) later expired at (hospital). R4's FRI (facility reported incident), date reported [DATE], documents, in part, (R4) is incontinent of bowel and bladder; he (R4) has impaired mobility and requires assistance with ADL (activities of daily) care and transfers as W/C (wheelchair) is the primary source of transportation. (R4) was observed laying on the floor on his left side in front of the dresser, head towards the window, feet pointed towards the door, He (R4) had non-skid footwear. R4 was taken to (Hospital) admitted to ICU with Cardiac Arrest, Laceration to Right side of forehead (eyebrow) with 3 staples and 3 sutures, there was no intracranial/subdural hemorrhages and Hypoxic Ischemic Encephalopathy. X0ray report revealed 1. Acute bilateral pulmonary emboli within the right hear strain. 2. Acute L1 anterior vertebral body fracture. 3. Acute non-displaced right anterior 3-6 rib fracture. 4 Acute fracture C7-T1. (R4) expired on [DATE] 3:17pm. It was determined that the cause of the fall was secondary to Acute Bilateral Pulmonary Embolisms, and Cardiogenic Shock, STEMI. R4 has a history of CVA and Bilateral PE's caused him to collapse; he (R4) became unresponsive and ultimately arrested; and hit his head on the dresser when he fell causing left side eyebrow laceration causing 3 staples and 3 sutures, rib fractures 3-6, and C7-T1 fractures are consistent with the initiation of chest compressions and use of the [NAME] Chest Compression device as well as multiple rounds of CPR performed in ED. R4's admission Evaluation ([DATE]) documents R4 was at high risk for falls due to impaired memory/judgement, history of falls, predisposing conditions such as HTN, CVA, Parkinson, Hypotension, Seizure, Osteoporosis, Unsteady gait and/or use of ambulatory device (cane, walker, wheelchair), age greater than 75, and incontinence. R4's advanced directives in the assessment indicate R4 is a full code. R4's progress note dated, [DATE], documents, in part, Patient (R4) was observed to have altered mental status, alert and oriented to self only, with limited response to questions. He (R4) is a Full code. The hospital conveyed that he has an unsteady gait. He (R4) has enough strength to stand and pivot but requires supervision for any transfer. He (R4) is known to be incontinent of urine and continent of bowel. R4's Functional Abilities and Goals, dated [DATE], documents in part, that R4 is dependent for toileting hygiene; requires substantial/maximal assistance for shower/bathe, lower body dressing; and sit to stand position; and requires partial/moderate assistance for personal hygiene, sit to lying position, lying to siting on side of bed. R4's progress note dated, [DATE], per V29 (Licensed Practical Nurse/LPN), documents, in part, CNA asked to get resident (R4) up and placed in day room due to confusion; major fall risk. R4's progress note dated, [DATE], per V38 (Nurse Practitioner), documents, in part, Full Code. Repeated falls. Staff to assist with activities of daily living (AD Ls) and mobility. Resident has increased risk for falls. Restorative rehabilitation should be provided as tolerated. Falls plan of care documented that includes balance, strength, and gait training OR referral to an exercise program. Patient HAS a history of falls. R4's Physical Rehabilitation Initial Evaluation, dated [DATE], documents, in, part, Impaired ADL and mobility dysfunction due to generalized weakness. (R4) is an [AGE] year-old with a past medical history of Repeated Falls. Patient was admitted to this facility on [DATE] from hospital with acute encephalopathy and new-onset seizure activity following a fall at home with witnessed seizure-like episodes. Post-admission, he (R4) remains lethargic, confused, and functionally impaired, requiring skilled nursing care for neurological monitoring and medication management. Once patient stabilized, was discharged to this NH (nursing home) for continuation of care/rehab. The patient (R4) was referred for skilled therapy related to a noted functional decline. Patient (R4) is demonstrating new onset decrease in strength, balance, transfers, ambulation, and ability to perform self-care ADLs. Current Level Of Function (CLOF): Bed Mobility Roll left and right= Partial/moderate assistance; Sit to lying = Partial/moderate assistance; Lying to silting on side of bed = Partial/moderate assistance; Transfers Sit to stand= Substantial/maximal assistance; Chair/bed-to-chair transfer = Not attempted due to medical conditions or safety concerns; Toilet transfer= Not attempted due to medical conditions or safety concerns; Car transfer = Not attempted due to environmental limitations; Ambulation Walk 10 feet = Patient refused. Patient is now on therapy services for decline in ADLs, function, mobility and sip hospitalization. Consultation was requested for management of decline in function with impaired mobility and self-care. RLE (right lower extremity) Strength = Impaired; LLE (left lower extremity) Strength = Impaired; RLE Strength Hip = Impaired; Knee = Impaired; Ankle = Impaired. Patient noted to have the following diagnoses and/or comorbidities which are impacting functional status. 1. Muscle Weakness resulting in impaired strength, endurance, balance, and transfer ability. Risk: High; Continue AROM exercises independently; Patient (R$) will continue to work on transfers, mobility, and strengthening to improve safety and independence to the maximal level. Staff to encourage participation in ADLs. 2. Impaired Mobility and ADLs Following Hospitalization. Risk: Moderate; Continue skilled PT/OT for transfers, gait mechanics, balance, and ADL participation Emphasis on safety awareness and fall prevention; 3. Repeated falls-Risk: MODERATE; Risk for fall, fall precautions in place, will continue working with therapy; Monitor closely for any signs of unsteadiness or difficulty during therapy sessions. Adjust the environment to minimize fall hazards. R4's care plan ([DATE]) identifies R4 is at high risk for falls r/t repeated falls at home due to seizures, recent hospitalization. R4's goal for R4's high fall risk was to remain free of falls causing hospitalizations. Interventions to address the high fall risk include, Educate resident on the importance of complying with safety measures. Document residents understanding of education and instances of noncompliance ([DATE]), Provide proper, well-maintained footwear ([DATE]), Encourage appropriate use of wheelchair ([DATE]), Keep bed in lowest position ([DATE]), Move resident to room with optimal visual access from the nurses station ([DATE]), Promote placement of call light within reach and assess residents ability to use. ([DATE]), Rounding at a minimum of q2 hours and prompt or assist for change in position, toileting, offer fluids, and ensure resident is warm and dry ([DATE]), and Staff to assist as needed. R4's Change in Condition Evaluation ([DATE]) documents on [DATE] at 5:50 AM, R4 had a functional status change including a fall with suspected serious injury, was unresponsive, had a laceration to the left side of the forehead. R4's blood pressure and pulse were zero. EMS was initiated and R4 was sent to the emergency department for evaluation. R4's progress notes document on [DATE], R4 was having a change in condition including Bleeding (other than GI), Falls Unresponsiveness. Recommendations and interventions include activating EMS for transport to the hospital. There is no narrative description of the incident/fall within the progress or nurse's notes. There is no indication that CPR was initiated. On [DATE] at 8:30 AM, V2 (Director of Nursing) documented, Writer called (Hospital) for update on resident's status and spoke with nurse and resident admitted to Hospital with Cardiac Arrest. There is no documentation that R4 expired in the hospital within the progress notes. There is no documentation that R4 expired in the hospital within the progress notes. Record review of R4's Ambulance Run Sheet, dated [DATE], documents, in part, Unit Notified: [DATE] 6:06am; At the scene [DATE] 6:14am. In summary crew was dispatched to the above location for a fall. Crew noted a 2-inch laceration to the left side of pts (R4) forehead that was no longer actively bleeding. Crew noted the blood in pts (R4) hair had already coagulated. Staff sated they began CPR between 5-10 minutes ago. Staff said the event was unwitnessed and they had walked into pt (R4) room and found him (R4) on the floor pulseless. Staff stated pt (R4) was last seen in bed between 4:00am to 5:00am. Staff was unable to provide exact time pt (R4) was last seen alive. Crew was informed by pts (R4) roommate (R6) that he (R6) heard pt fall between 4:00am to 4:30am. Crew placed pt (R4) on cardiac monitor and crew interpreted rhythm as asystole. Crew had placed pt (R4) in cervical c-collar due to possible spinal injury. Crew noted pupils were non-reactive and blown. R4's hospital records, dated [DATE], documents, in part, Pt. (patient/R4) found down and pulseless after unwitnessed fall at his (R4) nursing home. Last known well was several hours before. Per EMS (emergency medical services) patient (R4) LKN (last known normal) was 4:00am to 5:00am. (R4), with a history of dementia, was admitted following an unwitnessed fall at his (R4) nursing home and subsequent pulseless electrical activity cardiac arrest requiring prolonged CPR (cardiopulmonary resuscitation) and multiple rounds of epinephrine before return of spontaneous circulation was achieved. The principal problem was cardiac arrest, but subsequent evaluation including emergent transesophageal echocardiogram demonstrated no was motion abnormalities or overt cardiomyopathy. STEMI (ST-elevation myocardial infarction) alert was cancelled as ST changes were attributed to severe metabolic acidosis rather than acute myocardial infarction. Troponin and BNP (B-type natriuretic peptide) negative. Family ultimately decided to go comfort focused care and the patient ultimately passed at 3:17 PM on [DATE]. DNR status confirmed. Time of Death: 3:17pm Date: [DATE]. R4's CT (Computed Tomography) of the head, dated [DATE], documents, in part, Early changes of global hypoxic ischemic encephalopathy; Left frontal scalp/periorbital hematoma. R4's CTA (Computed Tomography Angiography) of the chest, abdomen, and pelvis, dated [DATE], documents, in part, Acute L1 (lumbar) anterior vertebral body fracture with mild retropulsion; Acute nondisplaced right anterior 3 through 6 rib fractures. R4's CT (Computed Tomography) of the cervical spine, dated [DATE], documents, in part, Acute fracture along the anterior/superior endplate at C7 (cervical) with widening of the anterior C7 through T1 (thoracic) disc space, highly concerning for associated ligamentous injury secondary to hyperextension fracture; Slight widening of the C7 trough T1 facet joints which may represent associated capsular injury. R6's face sheet documents diagnose that include but are not limited to pain in right leg, fusion of spine, muscle wasting and atrophy, and radiculopathy of lumbar region. R6's BIMS (brief interview for mental status) score, dated [DATE], is 13 which indicates R6 is cognitively intact. On [DATE] at 10:14am, R6 (R4's roommate), BIMS of 13, said, Oh yeah, my roommate (R4) was an older man. He (R4) fell the first day I was here (facility). I heard a boom and seen R4 on the floor. I pushed the call light button and looked at the clock and it about 4ish. Yeah. 4 in the morning. Surveyor observed a clock hanging on the wall, across from R6's bed. Surveyor noted that the clock currently had the correct time. R6 stated, My roommate's (R4) head was near my bed, and blood was coming from his (R4) head. No one (staff) was coming. I did try to yell for help, but I was in a lot of pain. They (staff) didn't come for like 2 hours. I looked at the clock, and it was almost 6:00am. Tear eyed, R6 said, I wish I could have helped him (R4). I was just in so much in pain. If it happened today, I could have helped him (R4). I know CPR. I can get up now. I just couldn't get up that day ([DATE]). It was my first day here (facility). The nurse (V9/RN) finally came in and screamed, What happened?! I don't know her (V9/RN) name. She (V9/RN) was in and out of the room. Finally, staff came and were trying to save him (R4). Then the paramedics showed up and took over. I hear there's not enough staff. I hear the staff complaining and I haven't even been here long. How can you let a man just lie there and die. I'm thankful I'm going home Saturday ([DATE]), because I don't want to be the next one dead. On [DATE] at 1:41pm, V9 (Registered Nurse/RN) said, Yes, I'm familiar with R4. Yes, I was working when he (R4) fell and went to the hospital. I had been doing rounds. The last time I physically saw him (R4) was around 5:20am ([DATE]). I just peaked my head in the room and saw him (R4) sleeping. At that time, I went to another room to complete medication pass and a dressing change. Later, I noticed his (R4) call light was on and observed him (R4) on the floor. I assessed him (R4) and found him (R4) unresponsive. I initiated CPR, and 911 arrived shortly afterward and took over care. He (R4) was lying on his (R4) left side with blood underneath his (R4) head. It appeared he had sustained a head injury. He (R4) had a lot of hair, so I could not clearly see the injury. He (R4) was considered a very high fall risk. Interventions in place included the bed in the low position and frequent rounds. The last time I saw him (R4), he (R4) was asleep in bed. His (R4) room cannot usually be seen directly from the nurse's station. I almost want to say he (R4) was barefoot when found. In my opinion, he (R4) required increased supervision beyond what we were providing. He (R4) was fairly new to us (facility), but he (R4) was confused, and usually oriented only to person and sometimes place. He (R4) was very impulsive and frequently attempted to get up without asking for assistance, both while in the wheelchair and in bed. He (R4) was found near the dresser, lying on his left side. Looked like maybe he (R4) was on his (R4) to the bathroom. Yes, he (R4) was near his (R4) roommates' bed, kinda between both beds, like at the end of the beds. There were no other changes in his (R4) condition prior to the fall. He (R4) up in his (R4) wheelchair before going to bed. I know the CNA that also had R4 was V10 (Certified Nursing Assistant/CNA). It was myself, the supervisor (V13/LPN/Licensed Practical Nurse/Nursing Supervisor), and another nurse working on the unit, but the other nurse had different hallways, that were taken part in the code for R4. V10 (Certified Nursing Assistant/CNA) was monitoring fall risk residents at the nurse's station. No, I can't remember the name of the residents that V10 was monitoring. We performed 30 chest compressions to 2 breaths. At that time, I did not observe the chest rise and fall. I am CPR certified through the American Heart Association as of [DATE]. When I saw R4 and began CPR, I yelled for someone to call 911 and initiate the emergency response/cold call procedure. The supervisor (V13) called 911. We (facility) do have an AED at the facility. I applied the AED, and it advised hands off, indicating a shock recommendation. I do not recall whether it delivered a shock, but I believe it may have. When paramedics arrived, I believe they continued CPR, including additional shocks, although I cannot say that with certainty. I documented the incident in Risk Management. Typically, we (facility staff) document these situations in Risk Management rather than in the resident's medical record. No, I wasn't aware that The Risk Management form is not part of the resident's record. I documented the previous day vital signs when I transferred him (R4) out because when we (staff) found him on the floor, we (staff) were unable to obtain current vital signs because we (staff) immediately initiated CPR and emergency interventions. I mean, yeah, they (R4's vital signs charted on [DATE] at 5:50am) were not his (R4) vital signs when we (staff) coded him (R4) because he (R4) didn't have any vitals. I notified the resident's brother and informed him that there had been an incident and that the resident was transported to the hospital. When I assessed R4's body, he (R4) was still warm. I did not observe rigor mortis. I did not see any other obvious trauma, such as dislocated hips, scrapes, or additional injuries. I do not recall seeing urine or feces underneath him on the floor. He (R4) was wearing a brief/diaper at the time. His (R4) diaper was incontinent of urine, but I can't remember if the diaper was incontinent of stool. I later learned of his (R4) passing when the supervisor contacted me the following day to check on me and informed me that R4 had passed away. Record of R4's progress notes do not indicate V9 (Registered Nurse/RN) seen R4 at 5:20am. R4's eINTERACT SBAR Summary for Providers, dated [DATE] at 5:50am, documents, in part, At the time of evaluation resident/patient vital signs were Blood Pressure:113/60 - [DATE] 10:04pm, Pulse: 70 - [DATE] 10:04pm, RR (respiratory rate):17.0 - [DATE] 10:04pm; and Temp: 97.8 - [DATE] 10:04pm. There is no documentation that R4 was last seen at 5:20am. On [DATE] at 2:02pm, V2 (Director of Nursing/DON) said, After R4 fell, R4 was found unresponsive with no vital signs. I didn't think I had to call you (IDPH-State Survey Agency) to report R4's death because he (R4) died in the hospital and was admitted with cardiac arrest. The day of fall, R4 was admitted with cardiac arrest. Yes, we (facility) knew R4 died that day. I did send in a reportable of the incident to you guys (IDPH-State Survey Agency). On [DATE] at 3:40pm, V10 (Certified Nursing Assistant/CNA) said, Yes, I was working when R4 fell on [DATE]. I was not present during the actual fall, so I cannot say exactly how it happened. V9 (Registered Nurse/RN) hollered for me to yell for V13 (Nursing Supervisor/LPN/Licensed Practical Nurse) because V13 had just left our area. Yeah, V13 was visible down the hall, and I yelled for him (V13). I was monitoring high fall risk residents at the nurse's station. V13 started coming and then V9 was running my way to get the crash cart. Yeah, V12 (Registered Nurse/RN) came later. I'm not sure how much later. I was told to call the code over the intercom, and I did (this contradicts a later statement that V34/LPN called the code over the intercom). No, I wasn't present when they (staff) were doing CPR on R4. I did see the resident (R4) afterward, when the paramedics were taken to the hospital. I noticed that he (R4) had some bleeding, and it appeared to be a laceration. I'm not sure if he (R4) was barefoot. As far as R4 himself, that was only about my second time working with him (R4). I last seen him (R4) at 4:30am when I changed (R4). Yes, he (R4) was incontinent. However, I do know R4 was considered a fall risk, and staff were rounding on him every two hours. R4 uses the wheelchair, and I was told R4 needs to be watched closely because R4 is a high fall risk. I'm not sure if he (R4) was really impulsive. The incident really affected me emotionally because my son previously suffered a traumatic brain injury, so seeing R4 in that condition caused me a lot of anxiety and concern. Record of R4's progress notes do not indicate V10 (Certified Nursing Assistant/CNA) saw R4 at 4:30am. Record review of R4's POC Response History for Incontinence Care documents the last time staff provided incontinent care for R4 was [DATE] at 5:25pm. On [DATE] at 11:01am, V9 (Registered Nurse/RN) said, The last time I seen him (R4) was 5:20am, in bed asleep, when I peeked my head in the room and seen him (R4) sleeping. I can't hear the call light, but I can see it (call light). I just came out of room and seen it (R4's room call light) was on. I'm a say not even a good 10 minutes I was in another resident's room. I gave a med and changed a dressing. About 5 to 7 minutes, it took me in the other room. On [DATE] at 11:06am, V12 (Registered Nurse/RN) said, I was working that day (R4's fall on [DATE]). When the code was called, I was giving treatment to one of my patients. I heard code called. Immediately ran down to assist with code. I got to the room, and they (V9 and V13) were performing CPR with Ambu bag, chest compressions. They is V9 and V13. Yes, the AED was on. I seen blood, I didn't see a laceration, but I wasn't paying attention or looking for a laceration. Occasionally I will work A and B, but I was working C and D. Yes, D is the locked with dementia residents. I wouldn't say the halls are close to each other. If I'm on A, I cannot see B side or hear the call light. Call lights sound like an AI (artificial intelligence) voice but disconnects cause of internet or something and most of the time there is no sound for the call lights. If that's (sound when the call light is activated) not working, you just gotta keep monitoring your lights. Honestly, the sound for the call lights doesn't work often. Honestly, I don't remember about protective measures for his (R4) feet. No, not enough staff. We (facility) need another nurse and another CNA for the second floor for night shift. Some residents need extra attention. Some are confused and fall risks. On [DATE] at 12:03pm, V19 (CNA/Certified Nursing Assistant) said, Yes, I was working (R4's fall on [DATE]). I did not have R4 assigned to me that night ([DATE]). Around 6:00am, I heard a code being called while I was assisting another patient and helping get her into the dining room. By the time I came out, the ambulance was already there, so I did not personally witness what happened or see the resident on the floor. I think V10 (Certified Nursing Assistant/CNA) was at the nurse's monitoring the resident. We (V19 and V10) took turns monitoring the residents at the nurse's station. I did not see R4 at all the night of the incident (R4's fall [DATE]) because he (R4) was not my assigned patient. I had cared for him (R4) before, though. He (R4) was often confused. When placed in his wheelchair, he would lean or sit forward a lot, so he (R4) required close monitoring. When he (R4) was in bed, he (R4) usually did fine. He (R4) had attempted in the past to get up from both the wheelchair and the bed without assistance, so at times he (R4) did require increased supervision. I do remember seeing the call light (R4's room) on earlier that night because his (R6) roommate frequently used it. I believe I noticed it (R4's room call light) around midnight, but I cannot say for certain exactly when it (R4's room call light) was turned on. No, I didn't answer it (R4's room call light). Later, around approximately 12:45 am, I remember looking back toward the room (R4) and noticing that the call light was off. I do not recall seeing the call light on after midnight after that point. I only spoke with the roommate (R6) briefly after the incident. It was R6's first night here (facility), and the roommate (R6) did not say anything to me about the incident. I do not recall there being any specific call light system or monitor in the back nurses' station that clearly indicated which call lights were on now or before. I do not recall any changes in R4's condition that night or anyone mentioning that he (R4) was acting differently. Earlier in the shift, when I walked past the room on my way to the soiled utility area to get something from the cart, he (R4) was in bed sleeping. Around 12:00 a.m. or shortly after, the call light was on, but other than that I did not notice anything unusual. Again, I wasn't assigned to R4's area so I didn't see much. On [DATE] at 2:27 PM, V25 (Restorative Nurse, Licensed Practical Nurse) affirmed V25 oversees the fall program in the facility, however, the entire interdisciplinary team (IDT) is involved in fall prevention efforts. V25 recalled R4's care needs; R4 had poor cognition/memory, required one staff assistance for activities of daily living (ADLs) and used a wheelchair for mobility. R4 had dementia, was able to speak but not always communicate needs clearly. V25 denied recalling any behaviors or impulsivity but did recall staff would often keep R4 at the nurse's station for increased supervision. Staff try their best to keep high fall risk residents in high visibility common areas. R4 was a high fall risk. V25 believed R4 was admitted to the facility from a hospitalization following a fall that was related to seizure activity. V25 affirmed V25 was involved with the fall investigation, but V1 (Administrator) and V2 (Director of Nursing) were primarily involved in completing the investigation. From what V25 could recall from the investigation, R4 got up from bed, ambulated and then fell because R4 went into cardiac arrest. Cardiac arrest was the root cause of the fall. V25 was not aware R4 sustained any fractures as a result of the fall. V25 believed R4 did sustain a head injury. V25 explained from the unit R4 was assigned to, you cannot see into any resident room from the nurse's station and R4's room was over halfway down the hall, not in optimal visual location from the nurse's station. V25 stated staff try to place the residents at risk as close as they can to the nurse's station as practicable given the facility's physical layout/construction. Surveyor inquired as to why R4's room was halfway and not closer as other rooms were closer to the nurse's station. V25 replied that it depends on what is available, there may be a priority for other residents with obvious fall risk behaviors. Surveyor inquired the rationale as R4 had impulsivity, poor cognition, significant history of falls, is a very high fall risk, why R4 was not a priority to have a closer room. V25 replied staff cannot say one resident's needs are more important than the other. (This statement directly contradicts V25's statement that some residents are a priority for high fall risk behaviors). V25 explained since V25 started at the facility over a month ago, V25 has educated staff repeatedly on getting residents up from their rooms and out in high visibility areas to for increased supervision as well as rounding frequently, alternating nurses and CNAs. Even if the care plan doesn't state it, round often. V25 denied the facility had a system in place to ensure rounding was completed or completed timely. V25 explained in an ideal world, nursing assistants would document each time they provided care to a resident, but the facility expectation is once per shift. If the charting was not completed, it means it wasn't done. R4's ADL charting was reviewed with V25 and V25 confirmed there was no documentation R4 received ADL assistance or toileting assistance/incontinence care during the shift of the incident ([DATE]). The last documented shift that CNAs provided care was evening shift the day prior ([DATE]). Surveyor inquired if V25 felt the staffing levels were adequate or safe in the facility, and V25 replied, we staff according to CMS guidelines. I mean, if it were up to me, CNAs would only care for 2-3 residents. On [DATE] at 3:11 PM, V2 (Director of Nursing) affirmed V2 oversees the nursing services provided in the facility. V2 affirmed V2 was familiar with R4. V2 recalled seeing R4 one or two times as R4 had only been admitted to the facility for about a week before the incident occurred. When V2 saw R4, R4 was in the dining room in a wheelchair. V2 affirmed R4 had impaired cognition and was alert/oriented times 1-2 (oriented to person and sometimes place, not oriented to time or situation). V2 confirmed R4's room was not near the nurse's station and was over halfway down the hall. V2 affirmed staff would be able to see a call light illuminated from the nurse's station but would be unable to see into the room or hear noises from the room. V2 explained there is other areas on the hallway including sitting areas and a vending machine area that is before resident rooms between the hall and the nurse's station (which increases the distance further from the nurse's station). V2 affirmed there are no rooms that you can see into or that are fairly close to the nurse's station on that unit. V2 denied the intervention of moving the resident into a room for optimal visual supervision to the nurses' station was an appropriate intervention for R4 or any resident on those units. V2 confirmed V2 was the staff member that c

Based on observation, interview and record review, the facility failed to staff the facility with a sufficient number of licensed nurses and nursing assistants to meet residents' needs, failed to staff the facility in accordance with the staffing needs/plan identified within the facility assessment, and failed to ensure sufficient staff were available to answer call light when one resident (R6) used the call light device to obtain help for his roommate (R4). The lack of sufficient staffing resulted in R4 self-ambulating, falling and experiencing a delay in care resulting in R4 sustaining major injuries. These failures affected one (R4) of seven residents reviewed for staffing and have the potential to affect all 145 residents residing in the facility. Findings include: Facility census ([DATE]) document 145 residents reside in the facility. Record review for facility's Daily Assignment Sheet, date [DATE] night shift (R4's fall), documents that V9 (Registered Nurse/RN), V12 (Registered Nurse/RN), V10 (Certified Nursing Assistant/CNA) and V19 (Certified Nursing Assistant/CNA) worked floor 2; and V42 (Certified Nursing Assistant/CNA) worked the locked unit on floor2. V13 (Registered Nurse/RN), V34 (Registered Nurse/RN), V37 (Registered Nurse/RN), V43 (Certified Nursing Assistant/CNA), V44 (Certified Nursing Assistant/CNA), V45 (Certified Nursing Assistant/CNA), V46 (Certified Nursing Assistant/CNA), and V47 (Certified Nursing Assistant/CNA) worked floor 1. R4's face sheet documents R4 was admitted to the facility on [DATE] and documents the following diagnoses: encephalopathy, generalized muscle weakness, muscle wasting/atrophy, cognitive communication deficit, chronic kidney disease, seizures, and repeated falls. R4's minimum data set ([DATE]) documents a brief interview of mental status summary score of 10, indicating R14 was cognitively impaired and required partial to moderate assistance with activities of daily living. R4's minimum data set ([DATE]) indicates R4 died within the facility. R4's admission Evaluation ([DATE]) documents R4 was at high risk for falls due to impaired memory/judgement, history of falls, predisposing conditions such as HTN, CVA, Parkinson, Hypotension, Seizure, Osteoporosis, Unsteady gait and/or use of ambulatory device (cane, walker, wheelchair), age greater than 75, and incontinence. R4's advanced directives in the assessment indicate R4 is a full code. R4's Change in Condition Evaluation ([DATE]) documents on [DATE] at 5:50 AM, R4 had a functional status change including a fall with suspected serious injury, was unresponsive, had a laceration to the left side of the forehead. R4's blood pressure and pulse were zero. EMS was initiated and R4 was sent to the emergency department for evaluation. Record review of R4's Ambulance Run Sheet, dated [DATE], documents, in part, Unit Notified: [DATE] 6:06am; At the scene [DATE] 6:14am. In summary crew of 2302 was dispatched to the above location for a fall. Crew noted a 2-inch laceration to the left side of pts (R4) forehead that was no longer actively bleeding. Crew noted the blood in pts (R4) hair had already coagulated. Staff stated they began CPR between 5-10 minutes ago. Staff said the event was unwitnessed and they had walked into pt (R4) room and found him (R4) on the floor pulseless. Staff stated pt (R4) was last seen in bed between 4:00am to 5:00am. Staff was unable to provide exact time pt (R4) was last seen alive. Crew was informed by pts (R4) roommate (R6) that he (R6) heard pt fall between 4:00am to 4:30am. Crew placed pt (R4) on cardiac monitor and crew interpreted rhythm as asystole. R4's hospital records, dated [DATE], documents, in part, Pt. (patient/R4) found down and pulseless after unwitnessed fall at his (R4) nursing home. Last known well was several hours before. Per EMS (emergency medical services) patient (R4) LKN (last known normal) was 4:00am to 5:00am. (R4), with a history of dementia, was admitted following an unwitnessed fall at his (R4) nursing home and subsequent pulseless electrical activity cardiac arrest requiring prolonged CPR (cardiopulmonary resuscitation) and multiple rounds of epinephrine before return of spontaneous circulation was achieved. Family ultimately decided to go comfort focused care and the patient ultimately passed at 3:17 PM on [DATE]. DNR status confirmed. Time of Death: 3:17pm Date: [DATE]. On [DATE] at 10:14am, R6 (R4's roommate), BIMS of 13, said, Oh yeah, my roommate (R4) was an older man. He (R4) fell the first day I was here (facility). I heard a boom and seen R4 on the floor. I pushed the call light button and looked at the clock and it about 4ish. Yeah. 4 in the morning. Surveyor observed a clock hanging on the wall, across from R6's bed. Surveyor noted that the clock currently had the correct time. R6 stated, My roommate's (R4) head was near my bed and blood was coming from his (R4) head. No one (staff) was coming. I did try to yell for help, but I was in a lot of pain. They (staff) didn't come for like 2 hours. I looked at the clock and it was almost 6:00am. Tear eyed, R6 said, I wish I could have helped him (R4). I know CPR. R6 further stated, The nurse (V9/RN) finally came in and screamed, What happened?! Finally, staff came and were trying to save him (R4). Then the paramedics showed up and took over. On [DATE] at 1:41pm, V9 (Registered Nurse/RN) said, The last time I physically saw him (R4) was around 5:20am. I just peaked my head in the room and saw him (R4) sleeping. At that time, I went to another room to complete medication pass and a dressing change. Later, I noticed his (R4) call light was on and observed him (R4) on the floor. I assessed him (R4) and found him (R4) unresponsive. I initiated CPR, and 911 arrived shortly afterward and took over care On [DATE] at 3:40pm, V10 (Certified Nursing Assistant/CNA) said, I was monitoring high fall risk residents at the nurse's station. V13 started coming and then V9 was running my way to get the crash cart. Yeah, V12 (Registered Nurse/RN) came later. I'm not sure how much later. I was told to call the code over the intercom. No, I wasn't present when they (staff) were doing CPR on R4. I noticed that he (R4) had some bleeding, and it appeared to be a laceration. I'm not sure if he (R4) was barefoot. As far as R4 himself, that was only about my second time working with him (R4). However, I do know R4 was considered a fall risk, and staff were rounding on him every two hours. R4 uses the wheelchair, and I was told R4 needs to be watched closely because R4 is a high fall risk. I'm not sure if he (R4) was really impulsive. On [DATE] at 11:06am, V12 (Registered Nurse/RN) said, I was working that day (R4's fall on [DATE]). When the code was called, I was giving treatment to one of my patients. I heard code called. Immediately ran down to assist with code. I got to the room, and they (V9 and V13) were performing CPR with Ambu bag, chest compressions. They is V9 and V13. Yes, the AED was on. No, not enough staff. We (facility) need another nurse and another CNA for the second floor for night shift. Some residents need extra attention. Some are confused and fall risks. Review of the facility assessment (4/2026) identifies the licensed nurse staffing ratio in post-acute units as 1:20 (staff to resident). In long term care units, the staffing ratio is for licensed nursing is 1:25. For direct care staff, the staffing ratio is 1:12 (1:13 in long term care units) for day/evening shifts, and 1:9 on all units for night shift. On [DATE] at 10:45 AM, V35 affirmed V35 had not completed the morning medication pass and still had to pass medications to residents that were due at 8-9 AM. V35 stated medications are to be administered an hour before and an hour after the administration time. V35 explained V35's is assigned to care for at least 27 residents on V35's current assignment. V35 recalled beginning the medication pass promptly after receiving report after V35 arrived to V35's shift at 7:00 AM. V35 explained the staffing assignment V35 is assigned to has a lot of care needs, such as most residents require blood pressure to be taken before medication is administered, multiple diabetic residents that require blood sugar monitoring, residents that require supervision due to high fall risks, multiple residents that need breathing treatments, and most residents with overall more care needs than a typical nursing home unit. V35 expressed V35 tries V35's best to ensure medications are delivered timely, but with all the extra work and resident/family needs, it is not feasible or safe. Record review of V35's assignment provided by V2 (Director of Nursing) documents V35 was responsible for 34 resident's care (9 residents more than the staffing ratio indicated within the facility assessment to meet the resident's needs). Record review of R1's Medication Administration Record (MAR), dated [DATE], documents that V31 (Licensed Practical Nurse/LPN) administered R1's am medications scheduled for 7:30am, 8:00am, and 9:00am late. Record review of R1's Medication Administration Record (MAR), dated [DATE], documents that V31 (Licensed Practical Nurse/LPN) administered R1's am medications scheduled for 7:30am and 8:00am late. On [DATE] at 12:24pm, V31 (Licensed Practical Nurse/LPN) said, Ummm. I mean honestly I cannot recall those exact days ([DATE] and [DATE] R1's AM medications given late), but I do my best to administer all medications in a timely manner. Often times there are situations when residents have to get sent out, call lights have to be answered, and the Wi-Fi isn't the best, but I try to administer in a timely fashion. I cannot remember what happened those days ([DATE] and [DATE] R1's AM medications given late). It's all about prioritizing. I try to do the best I can. I have approximately around 23 other residents. It would be great, and ideal to have another nurse. Usually, I'm able to manage, but things always happen and get hectic, and medications may be a little late. The workload is doable and I'm usually able to pass in a timely fashion, but the call lights and help residents might need might come first. I have to prioritize. Medications that are time sensitive and prioritize the needs of the residents. Usually able to manage good but have to prioritize sometimes. On [DATE] at 1:23 PM, V2 (Director of Nursing) affirmed V2 is involved with the staffing levels in the facility. V2 recalled residents had complained about getting medications administered late. V2 in-serviced the staff when the residents complained about late medication administration. V2 affirmed medications should can be given an hour before or an hour after the medication is due. V2 affirmed since being the director of nursing, V2 has only completed medication pass on the dementia unit and had not attempted to complete medication pass for V35's unit (unit 2). V2 affirmed the facility is staffed according to census and acuity. V2 believed the staffing in the facility was sufficient to meet the resident's needs. Record review of R1's Medication Administration Record (MAR), dated [DATE], documents that V32 (Licensed Practical Nurse/LPN) administered R1's am medications due for 7:30am, 8:00am, and 9:00am late. On [DATE] at 3:32pm, V32 (Licensed Practical Nurse/LPN) said, Previously, we (facility) had three nurses on the unit, but after the new company took over, staffing was reduced to two nurses. Because the unit is very busy and understaffed, medications are sometimes administered late. In my opinion, we (facility) need another nurse to safely manage the workload. I do not believe the level of supervision is adequate for residents who are considered high fall risks. Staffing assignments are split differently on day shift, but night shift coverage is not safe in my opinion. On [DATE] at 3:41 PM, V32 (Licensed Practical Nurse) affirmed V32 was familiar with V35 and stated V35 was a good nurse. V32 recalled being assigned to the assignment V35 was assigned to. V32 explained, The assignment requires the most care no matter what changes they make to the resident population or who comes and goes. At one point, there was 14 residents on that assignment that needed blood sugar monitoring, which is pretty much impossible when you have to get 14 blood sugars before someone eats lunch. I (V32) think we could at least use another nursing assistant, if not another nurse. So many things can happen. If there is ever a change in condition, you'd never be able to complete anything you need to, especially in the morning. I've been late passing meds or doing other tasks because I'll have to call 911 and send a resident out and there's so many residents to care for. I don't think there is enough time in the nursing assignments to accurately chart. Residents do complain to me that we don't have enough staff. I have heard them complain about waiting over an hour for call light to be answered, they complain the most about the night shift staffing. V32 further stated, Yes, I do recall times when coming in on my shift (days) residents have been excessively soiled and didn't get timely incontinence care. I have worked overnights, and I can't speak for a lot of the other units, but there's like 3 nurses and 3 aides. The unit 2 has like 50 residents assigned to one nurse on the night shift. We used to have 2 nurses for V35's assignment, but when the new company bought the building, they cut the nurse. I don't know why they cut the nurse, we need it. On [DATE] at 1:19pm, V10 (Certified Nursing Assistant/CNA) said, On [DATE] at 1:19pm, V10 (Certified Nursing Assistant/CNA) said, The 2 high risk fall residents were being monitored at the nurse's station the whole night. I was told one of them (residents) had Xanax or something discontinued which was why she was up all night. Yes, the residents were being monitored at the nurse's station from 11:00pm to 7:00am, the whole shift. No, I can't answer call lights if I'm monitoring residents at the nurse's station. Someone (staff) else would have to get the light. Can't remember the names (resident being monitored at the nurse's station). We could use another CNA at night, because some of these residents should be 1:1, but they (facility management) are not allowing them to be 1:1. R16's face sheet documents R16 is a [AGE] year-old resident with prior diagnoses, including but not limited to: systemic lupus erythematosus, osteomyelitis, type 2 diabetes mellitus, anemia in chronic kidney disease, obesity, sickle cell disease, chronic kidney disease, acquired absence of left and right legs, and osteoarthritis. R16's minimum data set ([DATE]) documents a brief interview of mental status summary score of 13, indicating R16 is cognitively intact. On [DATE] at 10:30 AM, R16 expressed that it takes a long time for call lights to be answered upwards of 20 minutes at a time on days an evening shifts. R16 explained night shift is the worst and takes a long time for them to address call lights. R16 explained the facility needs more CNAs on all shifts, as there is no way a day shift CNA can be assigned 15-17 residents and be able to complete good quality care. R16 affirmed R16's medications are usually administered late. R16's medication administration audit (5/2025) documents multiple days and shifts that R14 received medications over an hour late. On [DATE], R16's 8:00 AM scheduled medications were administered after 10:20 AM. R14's face sheet documents R14 is a [AGE] year-old resident with diagnoses including: type 2 diabetes mellitus, morbid obesity, cardiomegaly, chronic obstructive pulmonary disease, atopic dermatitis, spinal stenosis, chronic diastolic heart failure, atrial fibrillation, hypothyroidism, fibromyalgia, major depressive disorder, and anxiety disorder. R14's minimum data set ([DATE]) documents a brief interview of mental status summary score of 14, indicating R14 is cognitively intact. R14's medication administration audit (5/2025) documents multiple days and shifts that R14 received medications over an hour late. On [DATE], R14's 8:00 AM scheduled medications were administered around or after 9:30 AM. On [DATE] at 1:00 PM, R14 stated the staff are not good about tending to R14's needs. R14 explained it can take a long time to get needs met, especially on third shift (overnight), It depends on who is working and with call offs. R14 recalled on [DATE] (the holiday) 3 certified nursing assistants called off, so it took a lot longer to get care. R14 affirmed R14 had received medications late in the past, 8 o'clock meds being administered at noon. R14 recalled the resident council bringing up the facility needing more staff to the administration many times, and nothing gets done. R14 affirmed the facility needs more staff to meet the resident's needs. R1's face sheet documents an admission date of [DATE] and diagnoses that include but are not limited to abnormalities of gait, unsteadiness on feet, muscle wasting and atrophy, lack of coordination, cognitive communication deficit, and low back pain. R1's minimum data (dated [DATE]) documents a brief interview of mental status summary score of 15 indicating R1 is cognitively intact. On [DATE] at 2:45 PM, R1 explained R1 does not use the call light because it is no use. R1 recalled usually waiting over an hour for R1's call light to be answered or the call light wouldn't be answered by the staff at all. R1 stated, I could be dead by the time the staff respond (to the call light). R1 explained the facility is very understaffed and sometimes gets medications administered late. R1 felt bad for the nurses from the staffing levels. R1 explained that night shift is the worst to get needs responded to. Staff cannot hear the call light and you'll wait over 45 minutes for them to come especially if they are working down another hall. Staff cannot see the call lights when we (residents) put them on. R1 believes the turnover rate is over 50% for staff because the work conditions of the staff. They get tired and overworked. All shift staffing is bad. Record review of R1's Medication Administration Record (MAR), dated [DATE], documents that V29 (Licensed Practical Nurse/LPN) administered R1's AM medications that are due for 8:00am and 9:00am late. Record review of R1's Medication Administration Record (MAR), dated [DATE], documents that V29 (Licensed Practical Nurse/LPN) administered R1's am medication for 8:00am late. On [DATE] at 3:30pm, V29 (Licensed Practical Nurse/LPN) said, I sometimes pass the medications late cause it gets busy, and we (facility) can use more help. Yeah, on 5/4 and 5/12 ([DATE]; [DATE]) I was late passing medications. There's a lot of residents and a lot to do. I try my best. I do feel like we (facility) could use more staff, especially to watch the residents that are confused and risk for falls. I sometimes pass the medications late cause it gets busy, and we (facility) can use more help. On [DATE] at 9:25am, V34 (Licensed Practical Nurse/LPN) said, Yeah, we (facility) can use more CNAs with the type of patients we are getting in. A lot of high fall risk residents. They (facility) don't give us (facility) extra staff to supervise the residents. We (facility) need more CNAs just for high-fall-risk residents because some of them (residents) need 1:1. On [DATE] at 11:56am, V24 (Medical Director) said, I think a delay in assessing the resident (R4) is the problem and is a big issue. If it took that long, that's on the facility. That's bad. Delay in care can be a serious problem. Staffing with all honesty is a concern. The staff is good. I think the amount of residents they have is a concern. I know the staff are having difficulties with the amount of residents assigned. R24's face sheet documents R24 is a [AGE] year-old resident and has active diagnoses (including but not limited to): chronic obstructive pulmonary disease, asthma, anxiety disorder, osteoarthritis, rheumatoid arthritis, bursitis of left elbow. R24's minimum data set ([DATE]) documents a brief interview of mental status summary score of 15, indicating R24 is cognitively intact. On [DATE] at 3:15 PM, R24 affirmed R4 has been a resident of the facility for 5 years. R24 believed the facility was better under the previous ownership. R24 explained staffing on all shifts are bad. R24 has had to put on the call lights on numerous times. The CNAs are lazy. R24 recalled activating the call light so her roommate can get incontinence care and recalled CNAs coming into the room, shutting off the light and coming back for over an hour. R24 explained that the resident council has brought up concerns about the call lights, nursing assistants not checking/supervising the residents as they should for over a year now and nothing changes. R24 affirmed R24's medications are usually administered late. R24 expressed staffing is terrible across all shifts, but the worst on third shift (night shift). R24 believed the facility needs more staff on all shifts across the facility. On [DATE] at 2:19 AM, V1 (Administrator) explained the purpose of the facility assessment is to identify what resources are needed to effectively care for the facility's residents. V1 reviewed the facility assessment and affirmed the staffing ratios in the facility assessment were correct and were the required staffing ratios to meet the resident's needs. V1 affirmed the facility assessment was last reviewed on 4/2026. V1 stated the facility used to run 9 total certified nursing assistants on night shift but recently added a 10th certified nursing assistant about a week ago to night shift. V1 affirmed the staffing ratio for night shift nursing assistants was correct and should be 1 certified nursing assistant to 9 residents, which would have the most staffing for certified nursing assistants. V1 affirmed the current facility census for [DATE] was 144 and 10 CNAs were scheduled to work that night. (A staffing ratio of 1 CNA to 9 residents would require 16 CNAs to be staffed at night to meet this ratio). The staffing ratio was discussed and compared to the census and V1 agreed the facility would need to be staffing 16 CNAs on the night shift to meet the staffing ratios outlined in the facility assessment. V1 was unsure why the facility was not staffing an additional 6 certified nursing assistants on the night shift. V1 stated, I'll have to look into that. V1 was unaware V35 was scheduled to care for 34 residents ([DATE]) and affirmed the staffing ratio is 1:25 for that assignment. V1 believed the staffing levels were adequate in the facility to meet the resident's needs. V1 affirmed the staffing ratio in the facility assessment was accurate, and that the facility should have been staffed according to the facility assessment on [DATE]. The facility job description for the job title, Administrator (undated) documents the Administrator position directs the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities, to assure that the highest degree of quality care is maintained at all times. On [DATE] at 3:10 PM, staffing ratio in the facility assessment was reviewed with V2 and V2 indicated the staffing ratio sounded right. V2 (Director of Nursing) affirmed the facility is generally staffing between 9-10 certified nursing assistants at night. V2 affirmed that 9-10 CNAs does not meet the staffing ratio listed in the facility assessment. V2 denied being involved in the development or updating of the facility assessment. V2 believed the staffing within the facility was sufficient to meet the resident's needs. The facility job description for the job title, Director of Nursing (undated) documents the director of nursing is responsible for determining and maintaining staffing needs in the nursing department, concerning the operation of the nursing department ensuring that a sufficient number of nurses and CNAs are available for each shift and overseeing work assignments/scheduling and duty hours with the Staffing coordinator. Record review of facility policy titled, Staffing, dated 5/2025, documents, in part, To have appropriate numbers of staff available to meet the needs of the residents. Staffing is based on the IDPH formula for determining numbers and levels of staff. Staffing is then increased based on the needs of the resident population. A schedule is made on a monthly basis and reviewed on an ongoing basis. Staffing is supplemented as needed by outside agencies. Record review of pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, in part, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis. You must not be abused, neglected, or exploited by anyone - financially, physically, verbally, mentally, or sexually. Your facility must be safe, clean, comfortable, and homelike. You may participate in developing a person-centered care plan which states all the services your facility will provide to you and everything you are expected to do. This plan must include your personal and cultural choices. Your facility must make reasonable arrangements to meet your needs and choices. You should receive the services and/or items included in the plan of care. Review of Medicare's care compare system indicates the facility has a 1-star staffing rating indicating the facility's staffing levels are much below average. The facility is below both the Illinois and National Average for registered nurses hours per resident/day, nursing aide hours per resident/day, and total number of nurse staff hours per resident per day on the weekends. Total number of nurse staff hours per resident per day for the facility is 3 hours and 3 minutes (National average: 3 hours and 52 minutes, Illinois average: 3 hours and 29 minutes). Registered Nurse hours per resident per day for the facility is 37 minutes (National average: 41 minutes, Illinois average: 43 minutes). LPN (Licensed Practical Nurse) hours per resident per day is 46 minutes (National average: 52 minutes). Nurse aide hours per resident per day is 1 hour and 40 minutes (National average: 2 hours and 20 minutes, Illinois average: 2 hours and 7 minutes). Total number of nurse staff hours per resident per day on the weekend is 2 hours and 55 minutes (National average: 3 hours and 26 minutes, Illinois average: 3 hours and 6 minutes).

Based on observation, interview and record review, the facility's administration and quality assurance and performance improvement (QAPI) committee failed to make good faith attempts to correct known quality issues after a QAPI meeting was held in response to one resident's (R4) death, failed to disclose/provide QAPI committee records to the state survey agency to evaluate compliance with related QAPI regulations, failed to follow the facility's QAPI plan. These failures have the potential to affect all 145 residents that reside in the facility. Findings include: Facility census ([DATE]) documents 145 residents reside in the facility. R4's FRI (facility reported incident), dated [DATE], documents, in part, (R4) is incontinent of bowel and bladder; he (R4) has impaired mobility and requires assistance with ADL (activities of daily) care and transfers as W/C (wheelchair) is the primary source of transportation. (R4) was observed laying on the floor on his left side in front of the dresser, head towards the window, feet pointed towards the door, brief soiled with urine. He (R4) had non-skid footwear. After interviewing staff and meeting with IDT, it was determined that the cause of the fall was secondary to cardiac arrest. (R4) was last seen by the nurse at approximately 5:20am at which time he (R4) was lying asleep in bed. Sent to ER (emergency room). (R4) later expired at (hospital). R4's FRI (facility reported incident), date reported [DATE], documents, in part, (R4) is incontinent of bowel and bladder; he (R4) has impaired mobility and requires assistance with ADL (activities of daily) care and transfers as W/C (wheelchair) is the primary source of transportation. (R4) was observed laying on the floor on his left side in front of the dresser, head towards the window, feet pointed towards the door, He (R4) had non-skid footwear. R4 was taken to (Hospital) admitted to ICU with Cardiac Arrest, Laceration to Right side of forehead (eyebrow) with 3 staples and 3 sutures, there was no intracranial/subdural hemorrhages and Hypoxic Ischemic Encephalopathy. Xray report revealed 1. Acute bilateral pulmonary emboli within the right hear strain. 2. Acute L1 anterior vertebral body fracture. 3. Acute non-displaced right anterior 3-6 rib fracture. 4 Acute fracture C7-T1. (R4) expired on [DATE] 3:17pm. It was determined that the cause of the fall was secondary to Acute Bilateral Pulmonary Embolisms, and Cardiogenic Shock, STEMI. R4 has a history of CVA and Bilateral PE's caused him to collapse; he (R4) became unresponsive and ultimately arrested; and hit his head on the dresser when he fell causing left side eyebrow laceration causing 3 staples and 3 sutures, rib fractures 3-6, and C7-T1 fractures are consistent with the initiation of chest compressions and use of the [NAME] Chest Compression device as well as multiple rounds of CPR performed in ED. On [DATE] at 10:51 AM, V40 (Regional Director of Operations) affirmed V40 is a member of the governing body. V40 was aware of the incident and R4's death on [DATE]. V40 affirmed V40 was involved in the investigation process of the incident and was present in the facility the morning of [DATE] after the incident. V40 denied V40 was involved in a QAPI meeting that day. V40 recalled V40 did hear there was a possibility the root cause of R4's fall was trying to go to the bathroom. On [DATE] at 11:56am, V24 (Medical Director) said, He (V1/Administrator) just called me and told me about it (R4's fall on [DATE]). I don't know nothing about much going on. He (V1/Administrator) said that we (IDPH-State Survey Agency) might call him. I didn't know what happened until now. Can you explain it to me? I did not know nothing about it. I'm probably not going to be Medical Director much longer. I'm leaving end of month . Staffing with all honesty, is a concern. The staff is good. I think the amount of residents they have is a concern, but that's more of an Administrator question. They (staff) need to take care of the residents. I know the staff are having difficulties with the amount of residents assigned. This is the first time I'm hearing about staff supervising residents at the nurse's station. They (facility) don't tell me things like that. No, we haven't done a QAPI meeting for this incident (R4's fall on [DATE]). This one (R4's fall on [DATE]) they (facility staff) called me about 2 days ago. I did not know management and corporate came out the day of incident. They (facility management) try to do the bare minimum with me. I was never notified that there were issues with call lights. First time hearing about this. I think they (staff) should be able to hear the call light if a resident needs them. Of course I expect them (staff) to follow the care plan. Or if there is an order for it. I didn't help with the root cause analysis of this incident (R4's fall on [DATE]) . They (facility staff) called me about this incident (R4's fall [DATE]) after you (IDPH) got there (facility). On [DATE] at 2:19 AM, V1 (Administrator) affirmed V1 is a member of the facility's QAPI committee. V1 explained after the incident, a QAPI meeting was held the same day to review the incident. V1 denied the medical director or any other physician attended the QAPI meeting. V1 recalled V2 (Director of Nursing), V40, and other members of the interdisciplinary team attended the meeting (this statement directly contradicts V40's statement indicating V40 was not present at the time of the meeting). V1 did not identify specifically the other IDT members that were in attendance. V1 explained the QAPI committee discussed the interviews obtained by the staff members, reviewed the chart and risk factors and identified areas of improvement with a plan to move forward. During the meeting, the committee identified quality issues including R4's room not being close enough to the nurse's station per the care plan, and the need for the staff to complete return demonstrations of code status to see how staff react to similar situations. V1 recalled completing the return demonstrations with the night shift staff that were working that night. V1 denied any staff completed return demonstrations with other nursing shifts. Surveyor inquired if an action plan/corrective action was completed to address the known quality deficiencies. V1 replied, No, we never did any action plan or any formal action. V1 denied that any audits were developed or identification of other residents at risk from not having a room close enough to the nurse's station when they required a room closer to the nurse's station. V1 denied any other QAPI meetings took place until the QAPI meeting was conducted with the abatement plan. V1 affirmed V1 believed the QAPI committee completed a good faith attempt to fix the identified quality issues. Surveyor requested clarification if V1 believed a good faith attempt occurred when the committee failed to identify other residents that are at risk from the deficient quality practices, no return demonstration audits were completed on all shifts, no action plan was developed, no audits or quality assurance processes were developed to monitor/ensure compliance with the deficient quality practices, V1 replied, yeah, I think we did a good faith attempt. V1 stated the purpose of QAPI is to identify data and trends and come up with ways to fix issues as well as track improvements. V1 affirmed the QAPI has a responsibility to correct and fix issues of known quality. On [DATE] at 3:10 PM, V2 (Director of Nursing) affirmed V2 is a member of the QAPI committee. V2 recalled being in attendance for the QAPI meeting that occurred after the incident on [DATE]. V2 affirmed V1 and V40 were the only members of the QAPI committee that attended the meeting. V2 denied any other members of the IDT attended, including the medical director or other physicians, the infection preventionist, or other members of staff (all of which are required to attend QAPI meetings). (this statement directly contradicts V40's statement indicating V40 was not present at the time of the meeting and directly contradicts V1's statement that members of the interdisciplinary team were present for the QAPI meeting). V2 explained that we (V1, V40) talked about things we could have done better, like having the resident moved closer to the nurse's station, answering call lights in a timely manner, and talking about who to notify when events like that happen. We talked about completing simulations for events like this, staff needed to show us what happened. We had V9 (Registered Nurse) and V13 (Licensed Practical Nurse, Nurse Supervisor) show us what happened and we didn't have concerns. We looked with restorative if they had that (room close to nurse's station) within the care plan. I don't really remember all of it, I know an audit was made. (This statement directly contradicts V1's interview that audits were not created). I don't recall if I ever saw the audit being completed, I would have to check. V2 explained the notification issues, there wasn't anything wrong it was more to remind them to call everyone. When surveyor asked about the quality issues related to the call light not being answered timely, V2 stated V10 (Certified Nursing Assistant) saw the call light on and didn't answer the call light because V9 (Registered Nurse) went to another room and it just went on right before V9 walked into a nearby room. V2 affirmed all staff were in-serviced on answering call lights timely after this meeting. V2 recalled the QAPI meeting multiple times to review data after the meeting related to the incident and V40 was not present for those meetings. (This statement directly contradicts V1's statement that no further QAPI meetings were held or any further data/audits were collected). Surveyor requested documentation of the audits completed and documentation of the QAPI committee's actions on [DATE]. V1 (Administrator) provided the QAPI plan on [DATE], that indicates V1 signed it on [DATE]. No other meeting sheet was provided to indicate which QAPI members attended the meeting on [DATE]. No other meeting minutes were provided to the surveyor or other related documentation that was discussed during the QAPI meeting on [DATE]. The QAPI plan provided documents V25 (Medical Director) was notified [DATE] at 3 PM. No further related documentation was provided to the survey team prior to the exit of the survey regarding further QAA meetings, audit tools, or other data collected as indicated by V2. Facility QAPI plan ([DATE]) documents VISION At [NAME] OF CRESTWOOD, we're bringing healthcare back to basics. Back to a place where people take care of people. That starts with our approach, our staff, and our residents. MISSION [NAME] OF CRESTWOOD puts people first. We spotlight each individual's needs and build custom care plans that help our residents rise up and get back on their feet. PURPOSE The purpose of QAPI in [NAME] of CRESTWOOD Facilities is to take a proactive approach to continually improve individualized patient care so that we may realize our vision to lead healthcare back to the basics where people take care of people. To do this, [NAME] of CRESTWOOD of shall promote individualized care plans helping our residents rise up and get back on their feet as part of the ongoing QAPI efforts. QAPI is an integral part of [NAME] of CRESTWOOD. It is a continuous process that aims to provide quality of care for our patients . 4. The focus of QAPI program is to improve processes instead of individual behaviors. Thus, the interdisciplinary team shall be encouraged to communicate any system gaps/breakdowns or opportunities without fear of punishment. 5. [NAME] of CRESTWOOD shall utilize multiple data sources to monitor performance, adverse events, feedback from patients/families/partner vendors and the like to ensure quality care and services are provided. 6. A systematic analysis of data shall serve as a guide in performing root cause analysis in order to identify and prioritize performance improvement projects. 7. Appropriate interventions to address issues/adverse events/negative outcomes shall be implemented. Failure Mode and Effects Analysis shall be done to ensure effectiveness and sustainability of any change . The QAPI program of [NAME] of CRESTWOOD shall have a GOVERNING BODY/EXECUTIVE LEADERSHIP that shall be composed of the following members: - Administrator - Administration - Director of Nursing - Assistant Director of Nursing -Medical Director The Executive Leadership team shall be tasked with ensuring execution of all components of the QAPI plan. B. QAPI top-level management leaders make up the QAPI Committee and shall be responsible and accountable in monitoring their respective department for opportunities for improvement, data gathering, interpretation, and presentation, as well as PIP development, implementation, and evaluation . Minutes of the meeting shall be documented by the QAPI Champion and filed in a binder or electronic record. Minutes and reports shall be kept by Administration.Agenda shall be composed of: Date of Meeting Names of Participants MinutesMinutes shall comprise of: Recap from previous meeting Current issues (include presentation of data, analysis, andcorrective actions) Decision (quorum must be met) Implementation of change discussion; delegation of task;follow-upESSENTIAL FUNCTIONS OF THE QAPI COMMITTEEa. The QAPI Committee shall be responsible for ensuring that high quality care isconsistently and effectively delivered to patients in accordance with best clinicalpractices, state and federal regulations.b. The QAPI Committee shall provide support to the employees by providing the necessaryresources to enable them to fulfill their roles.c. The QAPI Committee shall provide strategic guidance and hold employees accountablefor day-to-day activities.d. The QAPI Committee shall be responsible for data gathering and analysis as well asdevelopment of appropriate PIP that would encompass the goals and interventions.e. The QAPI Committee shall evaluate QAPI initiatives to ensure effectiveness andsustainability.f. The QAPI committee shall meet on a monthly basis and as neededIV. FEEDBACK, DATA SYSTEMS, AND MONITORINGA. [NAME] of CRESTWOOD will be drawing data from multiple sources to monitor care andservices, as listed below:Nursing Home CompareCASPER Report- CarewatchPoint Click Care Data AnalyticsClinical Score CardsInternal MetricsB. Listed (but not limited to) are sources of data that shall be monitored through QAPI- Customer satisfaction ratings (survey report from residents, family, others)- Resident Council minutes/feedbackAdverse Events (falls, injuries, infection, etc.)/ Reportable cases- Department Health Surveys/ Accreditation SurveysComplaints/Grievance- Star ratings- Employee retentionPerformance Indicators . VI. SYSTEMATIC ANALYSIS AND SYSTEMIC ACTION . B. Root Cause Analysis Tools shall be utilized to evaluate the source of the problem/issues to ensure appropriate interventions are put in place .

Based on observation, interview and record review, the facility failed to ensure the quality assurance and performance improvement (QAPI) committee's monitoring of systemic compliance identified deficient practices with quality of care, failed to identify systemic deficient practices with the facility's malfunctioning call light system, failed to identify systemic deficient practices with insufficient staffing, failed to identify systemically deficient practices regarding root cause analysis of incident investigation/reporting. Additionally, the facility's quality assurance processes failed to correct repeated history of non-compliance regarding professional standards of care, quality of care, functioning call lights, and infection control. These failures affect all 145 residents that reside in the facility. Findings include: Facility census (5/18/2026) documents 145 residents reside in the facility. 1) Record review of CMS-2567 (survey exit date 4/23/2026) documents the facility was cited at F0919 for having a malfunctioning call light system. During this survey, concerns were identified with F0919 for the call light system in disrepair. This repeat deficiency demonstrates an overall failure of the facility's QAPI committee/program's responsibility of systemic monitoring and correcting deficient practices to ensure compliance with federal regulations. On 5/19/26 at 11:06am, V12 (Registered Nurse/RN) said, Call lights sound like an AI voice but disconnects cause of internet or something and most of the time there is no sound for the call lights. If that's not working you just gotta keep monitoring your lights. Honestly, the sound for the call lights doesn't work often. On 5/19/26 at 12:03pm, V19 (CNA) said, I do not recall there being any specific call light system or monitor in the back nurses' station that clearly indicated which call lights were on now or before. On 5/20/2026 11:05 AM, V20 (Unit Manager, Licensed Practical Nurse) affirmed V20 is the unit supervisor for unit two. V20 affirmed there is no panel or other system that notifies staff of a call light being activated other than a light outside the resident's door. V20 denied knowledge of any system the facility uses to track call light response times or rounding. On 5/20/2026 at 11:16 observed V14 (Staffing Director) sitting at the unit 2 nurse's station. V14 observed the nurse's station and affirmed there was no panel or other way staff know what call light is activated. Beeping was heard in the background of the nurse's station, but V14 was unsure what the beeping was from or if it was a call light. V20 gestured to powered off television (TV) and explained the call lights used to show on the television, indicating which resident's light had been activated. V14 recalled the TV last operating to show call lights over 2 months ago. V14 recalled issues with the call light system in the past, such as the alarms going off whenever any resident would activate the alarm at both nurse's stations. V14 explained staff would have to go to all the units throughout the facility to figure out which call light was on. V14 observed R4's old room from the nurse's station and affirmed R4's room was not near the nurse's station.On 5/26/26 at 2:02pm, V3 (Maintenance Director) said, I wasn't aware that R17's call light doesn't work. I'll check it (R17's call light) out now. On 5/26/26 at 3:06pm, V3 (Maintenance Director) said, There was a bad relay in main control box and wouldn't send a signal for light to turn on. I switched out the wire and traced from room to main box. It's (R17's call light) working now.R1's face sheet documents an admission date of 11/24/25 and diagnoses that include but are not limited to abnormalities of gait, unsteadiness on feet, muscle wasting and atrophy, lack of coordination, cognitive communication deficit, and low back pain.R1's BIMS (brief interview for mental status) score, dated 3/2/26, is 15 which indicates R1 is cognitively intact.On 5/26/2026 at 2:45 PM, R1 explained R1 does not use the call light because it is no use. R1 recalled usually waiting over an hour for R1's call light to be answered or the call light wouldn't be answered by the staff at all. R1 stated, I could be dead by the time the staff respond (to the call light). Staff cannot hear the call light and you'll wait over 45 minutes for them to come especially if they are working down another hall. Staff cannot see the call lights when we (residents) put them on. On 5/28/2026 at 2:19 AM, V1 (Administrator) denied knowledge on how long the call light system was in disrepair. V1 explained the system's wiring was in disrepair and had to be repaired so the call light would illuminate near the nurse's station and so the audible sound could be heard when the call lights are activated. On 5/28/2026 at 3:10 PM, V2 (Director of Nursing) confirmed V2 was aware of the call light system in disrepair and not having an audible alarm to notify staff. V2 denied telling administration or other responsible parties that the call light system was not working properly. V2 stated V2 didn't report anything wrong at the time because the call light system had not been functioning and having an audible alarm since V2 was a floor nurse working night shift. V2 stated that the call light not having an audible alarm was just the way things were, the staff knew it was just the way it was. Record review of facility's call light logs (quality assurance) for (12/2025-present) do not document any identification that the overall call light system was in disrepair. Isolated repairs for resident rooms were noted. There was no documentation of assessment of the overall system that was not directly related to the call light in the resident's room (such as audible alarming at the nurse's station). Record review of QAPI committee meeting minutes (1/2026-Present) do not document any identification that the overall call light system was in disrepair. On 5/27/26 at 11:56am, V24 (Medical Director) affirmed V24 is a member of the facility's QAPI committee. V24 denied knowledge of any issues with the call light system. On 5/28/2026 at 2:19 AM, V1 (Administrator) affirmed V1 is a member of the facility's QAPI committee. V1 denied knowledge on how long the call light system was in disrepair. V1 explained the system's wiring was in disrepair and had to be repaired so the call light would illuminate near the nurse's station and so the audible sound could be heard when the call lights are activated. V1 denied the call light malfunction was ever reviewed, discussed or identified by the QAPI committee prior to the survey. V1 stated the purpose of QAPI is to identify data and trends and come up with ways to fix issues as well as track improvements. On 5/28/2026 at 3:10 PM, V2 (Director of Nursing) affirmed V2 is a member of the facility's QAPI committee. V2 confirmed V2 was aware of the call light system in disrepair and not having an audible alarm to notify staff. V2 denied telling administration or other responsible parties that the call light system was not working properly. V2 stated V2 didn't report anything wrong at the time because the call light system had not been functioning and having an audible alarm since V2 was a floor nurse working night shift. V2 stated that the call light not having an audible alarm was just the way things were, the staff knew it was just the way it was. V2 denied the call light malfunction was ever reviewed, discussed or identified by the QAPI committee prior to the survey. No further documentation was provided that indicates the QAPI committee was aware of the systemic failure of the facility's call light system prior to the exit of the survey. 2) Review of Medicare's Nursing Home Care Compare system indicates the facility has a 1-star staffing rating indicating the facility's staffing levels are much below average. The facility is below both the Illinois and National Average for registered nurses hours per resident/day, nursing aide hours per resident/day, and total number of nurse staff hours per resident per day on the weekends. Total number of nurse staff hours per resident per day for the facility is 3 hours and 3 minutes (National average: 3 hours and 52 minutes, Illinois average: 3 hours and 29 minutes). Registered Nurse hours per resident per day for the facility is 37 minutes (National average: 41 minutes, Illinois average: 43 minutes). LPN (Licensed Practical Nurse) hours per resident per day is 46 minutes (National average: 52 minutes). Nurse aide hours per resident per day is 1 hour and 40 minutes (National average: 2 hours and 20 minutes, Illinois average: 2 hours and 7 minutes). Total number of nurse staff hours per resident per day on the weekend is 2 hours and 55 minutes (National average: 3 hours and 26 minutes, Illinois average: 3 hours and 6 minutes). Record review for facility's Daily Assignment Sheet, date 5/8/26 night shift (R4's fall), documents that V9 (Registered Nurse/RN), V12 (Registered Nurse/RN), V10 (Certified Nursing Assistant/CNA) and V19 (Certified Nursing Assistant/CNA) worked floor 2; and V42 (Certified Nursing Assistant/CNA) worked the locked unit on floor2. V13 (Registered Nurse/RN), V34 (Registered Nurse/RN), V37 (Registered Nurse/RN), V43 (Certified Nursing Assistant/CNA), V44 (Certified Nursing Assistant/CNA), V45 (Certified Nursing Assistant/CNA), V46 (Certified Nursing Assistant/CNA), and V47 (Certified Nursing Assistant/CNA) worked floor 1.Record review of V35's assignment provided by V2 (Director of Nursing) documents V35 was responsible for 34 resident's care (9 residents more than the staffing ratio indicated within the facility assessment to meet the resident's needs). Record review of the facility assessment (4/2026) identifies the licensed nurse staffing ratio in post-acute units as 1:20 (staff to resident). In long term care units, the staffing ratio is for licensed nursing is 1:25. For direct care staff, the staffing ratio is 1:12 (1:13 in long term care units) for day/evening shifts, and 1:9 on all units for night shift. Record review of QAPI committee meeting minutes (1/2026-Present) do not document any identification insufficient staffing was identified by the QAPI committee. On 5/20/2026 at 10:45 AM, V35 affirmed V35 had not completed the morning medication pass and still had to pass medications to residents that were due at 8-9 AM. V35 stated medications are to be administered an hour before and an hour after the administration time. V35 explained V35's is assigned to care for at least 27 residents on V35's current assignment. V35 recalled beginning the medication pass promptly after receiving report after V35 arrived to V35's shift at 7:00 AM. V35 explained the staffing assignment V35 is assigned to has a lot of care needs, such as most residents require blood pressure to be taken before medication is administered, multiple diabetic residents that require blood sugar monitoring, residents that require supervision due to high fall risks, multiple residents that need breathing treatments, and most residents with overall more care needs than a typical nursing home unit. V35 expressed V35 tries V35's best to ensure medications are delivered timely, but with all the extra work and resident/family needs, it is not feasible or safe. On 5/21/2026 at 3:40 PM, V32 (Licensed Practical Nurse) affirmed V32 was familiar with V35 and stated V35 was a good nurse. V32 recalled being assigned to the assignment V35 was assigned to. V32 explained that assignment requires the most care no matter what changes they make to the resident population or who comes and goes. At one point, there was 14 residents on that assignment that needed blood sugar monitoring, which is pretty much impossible when you have to get 14 blood sugars before someone eats lunch. I (V32) think we could at least use another nursing assistant, if not another nurse. So many things can happen. If there is ever a change in condition, you'd never be able to complete anything you need to, especially in the morning. I've been late passing meds or doing other tasks because I'll have to call 911 and send a resident out and there's so many residents to care for. I don't think there is enough time in the nursing assignments to accurately chart. Residents do complain to me that we don't have enough staff. I have heard them complain about waiting over an hour for call light to be answered, they complain the most about the night shift staffing. Yes, I do recall times when coming in on my shift (days) residents have been excessively soiled and didn't get timely incontinence care. I have worked overnights, and I can't speak for a lot of the other units, but there's like 3 nurses and 3 aides. The unit 2 has like 50 residents assigned to one nurse on the night shift. We used to have 2 nurses for V35's assignment, but when the new company bought the building, they cut the nurse. I don't know why they cut the nurse, we need it. R16's face sheet documents R16 is a [AGE] year-old resident with prior diagnoses, including but not limited to: systemic lupus erythematosus, osteomyelitis, type 2 diabetes mellitus, anemia in chronic kidney disease, obesity, sickle cell disease, chronic kidney disease, acquired absence of left and right legs, and osteoarthritis. R16's minimum data set (4/13/2026) documents a brief interview of mental status summary score of 13, indicating R16 is cognitively intact. On 5/26/2026 at 10:30 AM, R16 expressed that it takes a long time for call lights to be answered upwards of 20 minutes at a time on days an evening shifts. R16 explained night shift is the worst and takes a long time for them to address call lights. R16 explained the facility needs more CNAs on all shifts, as there is no way a day shift CNA can be assigned 15-17 residents and be able to complete good quality care. R16 affirmed R16's medications are usually administered late. R14's face sheet documents R14 is a [AGE] year-old resident with diagnoses including: type 2 diabetes mellitus, morbid obesity, cardiomegaly, chronic obstructive pulmonary disease, atopic dermatitis, spinal stenosis, chronic diastolic heart failure, atrial fibrillation, hypothyroidism, fibromyalgia, major depressive disorder, and anxiety disorder. R14's minimum data set (4/14/2026) documents a brief interview of mental status summary score of 14, indicating R14 is cognitively intact. On 5/26/2026 at 1:00 PM, R14 stated the staff are not good about tending to R14's needs. R14 explained it can take a long time to get needs met, especially on third shift (overnight), It depends on who is working and with call offs. R14 recalled on 5/25/2026 (the holiday) 3 certified nursing assistants called off, so it took a lot longer to get care. R14 affirmed R14 had received medications late in the past, 8 o'clock meds being administered at noon. R14 recalled the resident council bringing up the facility needing more staff to the administration many times, and nothing gets done. R14 affirmed the facility needs more staff to meet the resident's needs. R1's face sheet documents an admission date of 11/24/25 and diagnoses that include but are not limited to abnormalities of gait, unsteadiness on feet, muscle wasting and atrophy, lack of coordination, cognitive communication deficit, and low back pain.R1's minimum data (dated 3/2/26) documents a brief interview of mental status summary score of 15 indicating R1 is cognitively intact.On 5/26/2026 at 2:45 PM, R1 explained R1 does not use the call light because it is no use. R1 recalled usually waiting over an hour for R1's call light to be answered or the call light wouldn't be answered by the staff at all. R1 stated, I could be dead by the time the staff respond (to the call light). R1 explained the facility is very understaffed and sometimes gets medications administered late. R1 felt bad for the nurses from the staffing levels. R1 explained that night shift is the worst to get needs responded to. Staff cannot hear the call light and you'll wait over 45 minutes for them to come especially if they are working down another hall. Staff cannot see the call lights when we (residents) put them on. R1 believes the turnover rate is over 50% for staff because the work conditions of the staff. They get tired and overworked. All shift staffing is bad. R24's face sheet documents R24 is a [AGE] year-old resident and has active diagnoses (including but not limited to): chronic obstructive pulmonary disease, asthma, anxiety disorder, osteoarthritis, rheumatoid arthritis, bursitis of left elbow. R24's minimum data set (5/13/2026) documents a brief interview of mental status summary score of 15, indicating R24 is cognitively intact. On 5/27/2026 at 3:15 PM, R24 affirmed R4 has been a resident of the facility for 5 years. R24 believed the facility was better under the previous ownership. R24 explained staffing on all shifts are bad. R24 has had to put on the call lights on numerous times. The CNAs are lazy. R24 recalled activating the call light so her roommate can get incontinence care and recalled CNAs coming into the room, shutting off the light and coming back for over an hour. R24 explained that the resident council has brought up concerns about the call lights, nursing assistants not checking/supervising the residents as they should for over a year now and nothing changes. R24 affirmed R24's medications are usually administered late. R24 expressed staffing is terrible across all shifts, but the worst on third shift (night shift). R24 believed the facility needs more staff on all shifts across the facility. On 5/26/2026 at 3:30pm, V29 (Licensed Practical Nurse/LPN) said, I do feel like we (facility) could use more staff, especially to watch the residents that are confused and risk for falls. I sometimes pass the medications late cause it gets busy, and we (facility) can use more help. On 5/27/26 at 9:25am, V34 (Licensed Practical Nurse/LPN) said, Yeah, we (facility) can use more CNAs with the type of patients we are getting in. A lot of high fall risk residents. They (facility) don't give us (facility) extra staff to supervise the residents. We (facility) need more CNAs just for high-fall-risk residents because some of them (residents) need 1:1. On 5/27/26 at 11:56am, V24 (Medical Director) affirmed V24 is a member of the facility's QAPI committee. V24 affirmed staffing is a known concern within the facility. V24 stated, Staffing with all honesty is a concern. The staff is good. I think the amount of residents they have is a concern, but that's more of an Administrator question. They (staff) need to take care of the residents. I know the staff are having difficulties with the amount of residents assigned. On 5/28/2026 at 2:19 AM, V1 (Administrator) explained the purpose of the facility assessment is to identify what resources are needed to effectively care for the facility's residents. V1 reviewed the facility assessment and affirmed the staffing ratios in the facility assessment were correct and were the required staffing ratios to meet the resident's needs. V1 affirmed the facility assessment was last reviewed on 4/2026. V1 stated the facility used to run 9 total certified nursing assistants on night shift but recently added a 10th certified nursing assistant about a week ago to night shift. V1 affirmed the staffing ratio for night shift nursing assistants was correct and should be 1 certified nursing assistant to 9 residents, which would have the most staffing for certified nursing assistants. V1 affirmed the current facility census for 5/28/2026 was 144 and 10 CNAs were scheduled to work that night. (A staffing ratio of 1 CNA to 9 residents would require 16 CNAs to be staffed at night to meet this ratio). The staffing ratio was discussed and compared to the census and V1 agreed the facility would need to be staffing 16 CNAs on the night shift to meet the staffing ratios outlined in the facility assessment. V1 was unsure why the facility was not staffing an additional 6 certified nursing assistants on the night shift. V1 stated, I'll have to look into that. V1 was unaware V35 was scheduled to care for 34 residents (5/20/2026) and affirmed the staffing ratio is 1:25 for that assignment. V1 believed the staffing levels were adequate in the facility to meet the resident's needs. V1 affirmed the staffing ratio in the facility assessment was accurate, and that the facility should have been staffed according to the facility assessment on 5/9/2026. V1 (Administrator) affirmed V1 is a member of the facility's QAPI committee. V1 denied insufficient staffing was ever reviewed, discussed or identified by the QAPI committee prior to the survey. V1 stated the purpose of QAPI is to identify data and trends and come up with ways to fix issues as well as track improvements. On 5/28/2026 at 3:10 PM, staffing ratio in the facility assessment was reviewed with V2 and V2 indicated the staffing ratio sounded right. V2 (Director of Nursing) affirmed the facility is generally staffing between 9-10 certified nursing assistants at night. V2 affirmed that 9-10 CNAs does not meet the staffing ratio listed in the facility assessment. V2 denied being involved in the development or updating of the facility assessment. V2 believed the staffing within the facility was sufficient to meet the resident's needs. V2 (Director of Nursing) affirmed V2 is a member of the facility's QAPI committee. V2 denied insufficient staffing was ever reviewed, discussed or identified by the QAPI committee prior to the survey. No further documentation was provided that indicates the QAPI committee was aware of the systemic failure of the facility's insufficient staffing prior to the exit of the survey. The facility job description for the job title, Administrator (undated) documents the Administrator position directs the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities, to assure that the highest degree of quality care is maintained at all times. The facility job description for the job title, Director of Nursing (undated) documents the director of nursing is responsible for determining and maintaining staffing needs in the nursing department, concerning the operation of the nursing department ensuring that a sufficient number of nurses and CNAs are available for each shift and overseeing work assignments/scheduling and duty hours with the Staffing coordinator. Facility QAPI plan (5/9/2026) documents VISION At [NAME] OF CRESTWOOD, we're bringing healthcare back to basics. Back to a place where people take care of people. That starts with our approach, our staff, and our residents. MISSION [NAME] OF CRESTWOOD puts people first. We spotlight each individual's needs and build custom care plans that help our residents rise up and get back on their feet. PURPOSE The purpose of QAPI in [NAME] of CRESTWOOD Facilities is to take a proactive approach to continually improve individualized patient care so that we may realize our vision to lead healthcare back to the basics where people take care of people. To do this, [NAME] of CRESTWOOD of shall promote individualized care plans helping our residents rise up and get back on their feet as part of the ongoing QAPI efforts. QAPI is an integral part of [NAME] of CRESTWOOD. It is a continuous process that aims to provide quality of care for our patients . 4. The focus of QAPI program is to improve processes instead of individual behaviors. Thus, the interdisciplinary team shall be encouraged to communicate any system gaps/breakdowns or opportunities without fear of punishment. 5. [NAME] of CRESTWOOD shall utilize multiple data sources to monitor performance, adverse events, feedback from patients/families/partner vendors and the like to ensure quality care and services are provided. 6. A systematic analysis of data shall serve as a guide in performing root cause analysis in order to identify and prioritize performance improvement projects. 7. Appropriate interventions to address issues/adverse events/negative outcomes shall be implemented. Failure Mode and Effects Analysis shall be done to ensure effectiveness and sustainability of any change . The QAPI program of [NAME] of CRESTWOOD shall have a GOVERNING BODY/EXECUTIVE LEADERSHIP that shall be composed of the following members: - Administrator - Administration - Director of Nursing - Assistant Director of Nursing -Medical Director The Executive Leadership team shall be tasked with ensuring execution of all components of the QAPI plan. B. QAPI top-level management leaders make up the QAPI Committee and shall be responsible and accountable in monitoring their respective department for opportunities for improvement, data gathering, interpretation, and presentation, as well as PIP development, implementation, and evaluation . Minutes of the meeting shall be documented by the QAPI Champion and filed in a binder or electronic record. Minutes and reports shall be kept by Administration.Agenda shall be composed of: Date of Meeting Names of Participants MinutesMinutes shall comprise of: Recap from previous meeting Current issues (include presentation of data, analysis, andcorrective actions) Decision (quorum must be met) Implementation of change discussion; delegation of task;follow-upESSENTIAL FUNCTIONS OF THE QAPI COMMITTEEa. The QAPI Committee shall be responsible for ensuring that high quality care isconsistently and effectively delivered to patients in accordance with best clinicalpractices, state and federal regulations.b. The QAPI Committee shall provide support to the employees by providing the necessaryresources to enable them to fulfill their roles.c. The QAPI Committee shall provide strategic guidance and hold employees accountablefor day-to-day activities.d. The QAPI Committee shall be responsible for data gathering and analysis as well asdevelopment of appropriate PIP that would encompass the goals and interventions.e. The QAPI Committee shall evaluate QAPI initiatives to ensure effectiveness andsustainability.f. The QAPI committee shall meet on a monthly basis and as neededIV. FEEDBACK, DATA SYSTEMS, AND MONITORINGA. [NAME] of CRESTWOOD will be drawing data from multiple sources to monitor care andservices, as listed below:Nursing Home CompareCASPER Report- CarewatchPoint Click Care Data AnalyticsClinical Score CardsInternal MetricsB. Listed (but not limited to) are sources of data that shall be monitored through QAPI- Customer satisfaction ratings (survey report from residents, family, others)- Resident Council minutes/feedbackAdverse Events (falls, injuries, infection, etc.)/ Reportable cases- Department Health Surveys/ Accreditation SurveysComplaints/Grievance- Star ratings- Employee retentionPerformance Indicators . VI. SYSTEMATIC ANALYSIS AND SYSTEMIC ACTION . B. Root Cause Analysis Tools shall be utilized to evaluate the source of the problem/issues to ensure appropriate interventions are put in place .

Based on observation, interview and record review, the facility failed to respect the resident's right of confidentiality of their personal health information, failed to dispose of personal health information in a manner that renders the information unreadable, indecipherable and otherwise unreconstructable. This failure affected five (R14, R16, R17, R18, and R19) residents in a sample of five reviewed during medication administration and has the potential to affect all 34 residents that reside in the unit 2 assignment. Findings include: R14's face sheet documents R14 is a [AGE] year-old resident with diagnoses including: type 2 diabetes mellitus, morbid obesity, cardiomegaly, chronic obstructive pulmonary disease, atopic dermatitis, spinal stenosis, chronic diastolic heart failure, atrial fibrillation, hypothyroidism, fibromyalgia, major depressive disorder, and anxiety disorder. On 5/20/2026 at 9:30 AM, observed medication pass with V35 (Licensed Practical Nurse). V35 withdrew R14's medications from the cart. The medications were packed into individual plastic sleeves that contained R14's name, medication, and dosing. V35 opened the top of each sleeve and placed the medications into a plastic medication cup. V35 disposed of R14's into the garbage receptacle on the cart. Observed R14's name, medication and dosing information while in the trash can. The garbage receptacle was approximately 60% full of other discarded resident's plastic sleeves that contained personal health information. R18's face sheet documents R18 is a [AGE] year-old resident with diagnoses including: non-traumatic intracerebral hemorrhage, type 2 diabetes mellitus, morbid obesity, hemiplegia of unaffected side, basal cell carcinoma, atopic dermatitis, chronic pain syndrome, atrial fibrillation, and hypertension. On 5/20/2026 at 9:54 AM, V35 withdrew R18's medications from the cart. The medications were packed into individual plastic sleeves that contained R18's name, medication, and dosing. V35 opened the top of each sleeve and placed the medications into a plastic medication cup. V35 disposed of R18's into the garbage receptacle on the cart. Observed R18's name, medication and dosing information while in the trash can. R17's face sheet documents R17 is a [AGE] year-old resident with diagnoses including: Ogilvie syndrome, moderate protein calorie malnutrition, anemia, enterocolitis due to clostridium difficile, acute kidney failure, cachexia, hypoxemia, major depressive disorder, anxiety disorder, and unspecified psychosis. On 5/20/2026 at 9:58 AM, V35 withdrew R17's medications from the cart. The medications were packed into individual plastic sleeves that contained R17's name, medication, and dosing. V35 opened the top of each sleeve and placed the medications into a plastic medication cup. V35 disposed of R17's into the garbage receptacle on the cart. Observed R17's name, medication and dosing information while in the trash can. R19's face sheet documents R19 is a [AGE] year-old resident with diagnoses including: chronic obstructive pulmonary disease, muscle wasting and atrophy, multiple sclerosis, type 2 diabetes mellitus, quadriplegia, osteoarthritis, and metabolic encephalopathy. On 5/20/2026 at 10:07 AM, V35 withdrew R19's medications from the cart. The medications were packed into individual plastic sleeves that contained R19's name, medication, and dosing. V35 opened the top of each sleeve and placed the medications into a plastic medication cup. V35 disposed of R19's into the garbage receptacle on the cart. Observed R19's name, medication and dosing information while in the trash can. R16's face sheet documents R16 is a [AGE] year-old resident with prior diagnoses, including but not limited to: systemic lupus erythematosus, osteomyelitis, type 2 diabetes mellitus, anemia in chronic kidney disease, obesity, sickle cell disease, chronic kidney disease, acquired absence of left and right legs, and osteoarthritis. On 5/20/2026 at 10:25 AM, V35 withdrew R16's medications from the cart. The medications were packed into individual plastic sleeves that contained R16's name, medication, and dosing. V35 opened the top of each sleeve and placed the medications into a plastic medication cup. V35 disposed of R16's into the garbage receptacle on the cart. Observed R16's name, medication and dosing information while in the trash can. On 5/20/2026 at 10:30 AM, V35 accessed R16's electronic health record. V35 affirmed V35 needed to obtain another medication from the refrigerator to administer to R16. V35 left the medication cart and left the electronic health record open and unlocked on the medication administration record, which would allow any passerby access to any resident's personal health information. Observation was confirmed with V35. V35 affirmed the record should be closed when not in use. On 5/20/2026 at 10:45 AM, observed the discarded medication sleeves that contained residents' name, medication and dosing with V35. Observation confirmed with V35. V35 affirmed the information on the sleeves contained protected health information. V35 explained the procedure for the disposal of the sleeves is to tie the sleeves and place them in the garbage can. V35 stated, That's what we (nurses) all do. Is there something different we are supposed to be doing?. V35 denied staff ever ensure the personal health information is unreadable, indecipherable or otherwise unreconstructable when disposing of the used medication sleeves. On 5/21/2026 at 1:23 PM, V2 (Director of Nursing) affirmed the sleeves of the medication have personal health information. V2 explained after a nurse dispenses medication from the sleeve, the expectation is the sleeve is disposed of in a shredder or other manner that would ensure the resident's health information could not be read or reproduced. V2 affirmed nurses should not be disposing the discarded sleeves in the trash can. Facility policy titled, HIPAA Privacy and Security Policy (1/1/2025) documents the purpose of the policy is to ensure compliance with the Health Insurance Portability and Accountability Act of 1996 as well as applicable federal and state privacy/security regulations. Definitions follow 45 C.F.R. S 160.103 and subsequent applicable federal rules,including: PHI includes all individually identifiable health information, whether oral, written, orelectronic . 5. SAFEGUARDS FOR PHI & EPHI Facility will implement administrative, physical, and technical safeguards, including Encrypted storage and transmission of PHI, Multi-factor authentication (MF A) for system access, Endpoint detection and response (EDR) solutions, Secure disposal of PHI per current [NAME] guidelines. There is no safeguards listed for safeguards of written PHI. 9. INDIVIDUAL RIGHTS Facility recognizes and supports patient rights to: Access their PHI in the format requested (electronic or hard copy), Request amendments, Request restrictions on disclosures, Obtain accounting of disclosures, Receive electronic PHI via email upon request. This policy does not identify the resident's rights to the resident's right to privacy and confidentiality of their personal medical records. Review of Illinois Long-Term Care Ombudsman Program's Residents' Rights for People in Long-Term Care Facilities (revised 11/2018) documents residents have the right to privacy and confidentiality of their personal and medical records.

Based on interview and record review, the facility failed to ensure facility staff were trained properly on CPR; failed to ensure staff initiated appropriate emergency response for a resident; failed to promptly activate Emergency Medical Services (EMS)/911 upon discovering an unresponsive resident; failed to accurately assess for the presence or absence of a pulse; and failed to perform uninterrupted cardiopulmonary resuscitation (CPR) for one (R4) of seven residents reviewed for cardiopulmonary resuscitation. These facility failures resulted in R4 not receiving uninterrupted CPR and emergency care prior to EMS arrival and has the potential to affect all 91 full code residents residing in the facility.Findings include: Record review of facility document untitled, dated [DATE], documents 91 full code residents residing at the facility. R4's face sheet documents R4 was admitted to the facility on [DATE] and documents the following diagnoses: encephalopathy, generalized muscle weakness, muscle wasting/atrophy, cognitive communication deficit, chronic kidney disease, seizures, and repeated falls. R4's minimum data set ([DATE]) documents a brief interview of mental status summary score of 10, indicating R14 was cognitively impaired and required partial to moderate assistance with activities of daily living. R4's minimum data set ([DATE]) indicates R4 died within the facility. R4's admission Evaluation ([DATE]) documents R4 was at high risk for falls due to impaired memory/judgement, history of falls, predisposing conditions such as HTN, CVA, Parkinson, Hypotension, Seizure, Osteoporosis, Unsteady gait and/or use of ambulatory device (cane, walker, wheelchair), age greater than 75, and incontinence. R4's advanced directives in the assessment indicate R4 is a full code. R4's Change in Condition Evaluation ([DATE]) documents on [DATE] at 5:50 AM, R4 had a functional status change including a fall with suspected serious injury, was unresponsive, had a laceration to the left side of the forehead. R4's blood pressure and pulse were zero. EMS was initiated and R4 was sent to the emergency department for evaluation. R4's progress notes document on [DATE], R4 was having a change in condition including Bleeding (other than GI), Falls Unresponsiveness. Recommendations and interventions include activating EMS for transport to the hospital. There was no narrative description of the incident/fall within the progress or nurse's notes nor was there indication that CPR was initiated. Record review of R4's Ambulance Run Sheet, dated [DATE], documents, in part, Unit Notified: [DATE] 6:06am; At the scene [DATE] 6:14am. In summary crew of 2302 was dispatched to the above location for a fall. Crew noted a 2-inch laceration to the left side of pts (R4) forehead that was no longer actively bleeding. Crew noted the blood in pts (R4) hair had already coagulated. Staff stated they began CPR between 5-10 minutes ago. Staff said the event was unwitnessed and they had walked into pt (R4) room and found him (R4) on the floor pulseless. Staff stated pt (R4) was last seen in bed between 4:00am to 5:00am. Staff was unable to provide exact time pt (R4) was last seen alive. Crew was informed by pts (R4) roommate (R6) that he (R6) heard pt fall between 4:00am to 4:30am. Crew placed pt (R4) on cardiac monitor and crew interpreted rhythm as asystole. R4's hospital records, dated [DATE], documents, in part, Pt. (patient/R4) found down and pulseless after unwitnessed fall at his (R4) nursing home. Last known well was several hours before. Per EMS (emergency medical services) patient (R4) LKN (last known normal) was 4:00am to 5:00am. (R4), with a history of dementia, was admitted following an unwitnessed fall at his (R4) nursing home and subsequent pulseless electrical activity cardiac arrest requiring prolonged CPR (cardiopulmonary resuscitation) and multiple rounds of epinephrine before return of spontaneous circulation was achieved. Family ultimately decided to go comfort focused care and the patient ultimately passed at 3:17 PM on [DATE]. DNR status confirmed. Time of Death: 3:17pm Date: [DATE]. R4's FRI (facility reported incident), dated [DATE], documents, in part, (R4) is incontinent of bowel and bladder; he (R4) has impaired mobility and requires assistance with ADL (activities of daily) care and transfers as W/C (wheelchair) is the primary source of transportation. (R4) was observed laying on the floor on his left side in front of the dresser, head towards the window, feet pointed towards the door, brief soiled with urine. He (R4) had non-skid footwear. After interviewing staff and meeting with IDT, it was determined that the cause of the fall was secondary to cardiac arrest. (R4) was last seen by the nurse at approximately 5:20am at which time he (R4) was lying asleep in bed. Sent to ER (emergency room). (R4) later expired at (hospital). On [DATE] at 10:14am, R6 (R4's roommate), BIMS of 13, said, Oh yeah, my roommate (R4) was an older man. He (R4) fell the first day I was here (facility). I heard a boom and seen R4 on the floor. I pushed the call light button and looked at the clock and it about 4ish. Yeah. 4 in the morning. Surveyor observed a clock hanging on the wall, across from R6's bed. Surveyor noted that the clock currently had the correct time. R6 stated, My roommate's (R4) head was near my bed and blood was coming from his (R4) head. No one (staff) was coming. I did try to yell for help, but I was in a lot of pain. They (staff) didn't come for like 2 hours. I looked at the clock, and it was almost 6:00am. R6 had tears in his eyes and said, I wish I could have helped him (R4). I know CPR. R6 further stated, The nurse (V9/RN) finally came in and screamed, What happened?! Finally, staff came and were trying to save him (R4). Then the paramedics showed up and took over. On [DATE] at 1:41pm, V9 (Registered Nurse/RN) said, The last time I physically saw him (R4) was around 5:20am. I just peaked my head in the room and saw him (R4) sleeping. At that time, I went to another room to complete medication pass and a dressing change. Later, I noticed his (R4) call light was on and observed him (R4) on the floor. I assessed him (R4) and found him (R4) unresponsive. I initiated CPR, and 911 arrived shortly afterward and took over care. When I saw R4 and began CPR, I yelled for someone to call 911 and initiate the emergency response/code call procedure. The supervisor (V13) called 911. I documented the previous day vital signs when I transferred him (R4) out because when we (staff) found him on the floor, we (staff) were unable to obtain current vital signs because we (staff) immediately initiated CPR and emergency interventions. I mean, yeah they (R4's vital signs charted on [DATE] at 5:50am) were not his (R4) vital signs when we (staff) coded him (R4) because he (R4) didn't have any vitals. R4's eINTERACT SBAR Summary for Providers, dated [DATE] at 5:50am, documents, in part, At the time of evaluation resident/patient vital signs were Blood Pressure:113/60 - [DATE] 10:04pm, Pulse: 70 - [DATE] 10:04pm, RR (respiratory rate):17.0 - [DATE] 10:04pm; and Temp: 97.8 - [DATE] 10:04pm. On [DATE] at 12:11pm, V9 (Registered Nurse/RN) said, When I left the room, I went to answer R4's call light because I noticed it was on. I stepped inside the room and seen R4 on the floor bleeding. I assessed R4, couldn't find a pulse, and screamed out the door for help. I called V34 (Licensed Practical Nurse/LPN) via my cellphone and asked her (V34) to call a code. The code was called overhead. No, I didn't stop CPR to use my phone to call her (V34). I was calling and doing CPR, it was just easier. V13 came running and I went to get the crash cart. I guess I did stop CPR to get the crash cart, but V13 came right after I left the room. On [DATE] at 1:35 PM, V13 (Nurse Supervisor, Licensed Practical Nurse) affirmed V13 is the supervisor for the facility on night shift. V13 affirmed V13 was familiar with R4. V13 recalled R4 was confused, impulsive and frequently tried to get up from the wheelchair on his own. V13 frequently saw R4 at the nurse's station because of the impulsive behaviors. R4 was incontinent of bowel and bladder. V13 recalled the incident on [DATE]. V13 recalled completing a dressing change with a nearby resident at around 5:30 or 5:40 with V9 (Registered Nurse). V10 (Certified Nursing Assistant) was at the nurse's station monitoring 2 high fall risk residents. V13 said he didn't notice if his call light was on before the incident. V13 was making rounds after the dressing change and around 5:50 AM, V9 (Registered Nurse) called me saying R4 was on the floor. I called the code and CPR was initiated right away. When V13 entered the room, only R6 was in the room with R4. (This statement contradicts that CPR was initiated right away by V9 or V13). V13 placed a pulse oximeter on R4's finger to assess for vital signs. V13 denied checking V13's vital signs. V13 recalled CPR was initiated by V9, and V9 went to get the crash cart while V13 called 911 (indicating V9 stopped CPR to obtain a crash cart). V13 explained R4 was close to the bathroom so V13 suspected R4 could have been trying to go to the bathroom at the time of the fall. V13 recalled R4 had a head injury and there was blood on R4. V13 used the automated external defibulator (AED) during the code process. Eventually paramedics arrived to the scene and took over CPR. R4 was transported to the hospital by the paramedics and expired in the hospital. V13 recalled the paramedics used an automatic CPR machine to administer chest compressions. V13 notified R4's representative to notify them of R4's expiration and to obtain R4's belongings. V13 recalled interviewing R6 after the incident occurred on [DATE], and R6 told V13 R4 tried to get up and fell. R6 could not remember when the fall happened during V13's interview. V13 affirmed the last time V13 saw R4 was around 1:30 AM during rounds. V13 confirmed the last time a staff member saw R4 was at 3:40 AM, when V9 (Registered Nurse) administered medication. V13 recalled V9 stating the last time V9 was in the room was 3:40 when V9 administered medication. V13 was not sure when V10 (Certified Nursing Assistant) provided care to R4 as V10 had to supervise high fall risk residents at the nurse's station. V13 affirmed the facility expectation is that CNAs document the care provided at least once during their shift. Surveyor asked V13 to explain the American Heart Association's chain of survival in the basic life support protocol. V13 replied, it is ABC, airway, breathing, circulation. V13 explained CPR should begin before someone calls for help. Surveyor inquired how someone is supposed to assess a non-responsive resident's pulse according to BLS protocol. V13 paused and did not reply. Surveyor repeated the question, and V13 replied, uhh . check the carotid pulse. V13 denied V13 checked R4's carotid artery while assessing for a pulse and affirmed V13 used a pulse oximeter. V13 affirmed V13 should have palpated R4's carotid artery instead of a pulse oximeter. V13 affirmed the purpose of the pulse oximeter is to measure oxygen saturation and stated, I guess that's not so important in that situation. V13 denied V13 assessed R4's respirations. Surveyor asked how someone assesses respirations. V13 responded, umm . uhh . V13 did not respond. Surveyor repeated the question. V13 stated, I don't know how to assess respirations. V13 affirmed the last time V13 received training on CPR was about a year ago. On [DATE] at 4:13 PM, V2 (Director of Nursing) affirmed staff should be following basic life support protocols. V2 affirmed staff should be alerting another staff member to call 911 and grab the AED while chest compressions are given. V2 explained staff should be assessing for consciousness then checking the pulse by palpating the carotid artery. If no pulse is felt, staff should begin chest compressions. Chest compressions are given at a ratio of 30 compressions to two breaths. V2 affirmed respirations are assessed by counting the rise and fall of the chest. On [DATE] at 3:32pm, V32 (Licensed Practical Nurse/LPN) said, The last time I was trained on CPR was today ([DATE]). When asked the ratio of chest compressions to breathes for AHA BLS CPR, V32 replied 20:2 (30:2 is the correct ratio). On [DATE] at 1:19pm, V10 (Certified Nursing Assistant/CNA) said, The 2 high risk fall residents were being monitored at the nurse's station the whole night. I was told one of them (residents) had Xanax or something discontinued which was why she was up all night. Yes, the residents were being monitored at the nurse's station from 11:00pm to 7:00am, the whole shift. No, I can't answer call lights if I'm monitoring residents at the nurse's station. Someone (staff) else would have to get the light. Can't remember the names (resident being monitored at the nurse's station). We could use another CNA at night, because some of these residents should be 1:1, but they (facility management) are not allowing them to be 1:1. On [DATE] at 9:25am, V34 (Licensed Practical Nurse/LPN) said, Yes, she (V9/RN) called me on cellphone, and I answered right away and asked to call a code blue for R4, so I overhead paged code blue for R4. I did it (overhead page) twice. She (V9/RN) could have called her (V9) unit floor. We're not required to have a phone on us. She (V9) would have to come out of room and go to nurse's station to make a call. If she (V9) has to go out the room that would delay CPR. On [DATE] at 11:56am, V24 (Medical Director) said, I think a delay in assessing the resident (R4) is the problem and is a big issue. If it took that long, that's on the facility. That's bad. Code Blue status, I do the carotid pulse and jump on CPR on spot. A lot of benefits, mortality benefit, to start CPR immediately and not interrupted. Check blood sugar. The minute I get the pulse back; I take the blood pressure. If no pulse, don't stop CPR whatsoever. Delay in care can be a serious problem. Record review of American Heart Association BLS CPR Guidelines, dated 2025, documents in part, 1. Verify unresponsiveness: Check for responsiveness, Assess breathing and pulse simultaneously for no more than 10 seconds; 2. Activate emergency response: Call 911 or activate the emergency response system and obtain an AED immediately. Begin high-quality CPR : Compression rate: 100–120 compressions per minute, Compression depth: at least 2 inches (5 cm) in adults, Allow complete chest recoil, Minimize interruptions., Compression fraction should be greater than 80%; 3. Compression-to-ventilation ratio: Adults without an advanced airway, 30 compressions : 2 breaths (single or multiple rescuers)., Deliver enough air to produce visible chest rise and avoid excessive ventilation. 4; Use an AED as soon as available. AHA continues to stress that CPR should begin immediately and interruptions should be minimized. Healthcare providers are encouraged to perform both compressions and ventilations for adult cardiac arrest. Record review of facility policy titled, Call Light Response, dated 2/2026, documents, in part, Code Blue, dated 5/2025, documents, in part, A code is initiated for all residents requiring emergency medical attention. If a resident requires emergency medical attention then a Code Blue should be announced. Upon finding a person without respirations and/or a pulse, call for help and confirm presence/absence of ADVANCE DIRECTIVES/CODE STATUS. If the resident is not a DNR, then a CODE BLUE should be announced and start CPR. When announcing a code blue, state the unit, room number or place. The bring the closest crash cart to the area of the code. As staff arrive the DON or designee should assign staff to the following items: a. Someone to call 911 b. Someone to assist with CPR c. Someone to notify the physician and family d. Someone to start the transfer form, get the paperwork together and notify the hospital. e. Someone to hold the elevator on the first floor, if applicable. f. Someone to remove other residents from the area and ensure there is a clear path for the paramedics. Record review of pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, in part, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis. You must not be abused, neglected, or exploited by anyone - financially, physically, verbally, mentally, or sexually. Your facility must be safe, clean, comfortable, and homelike. You may participate in developing a person-centered care plan which states all the services your facility will provide to you and everything you are expected to do. This plan must include your personal and cultural choices. Your facility must make reasonable arrangements to meet your needs and choices. You should receive the services and/or items included in the plan of care.

Based on observation, interview and record review, the facility failed to adequately sanitize reusable durable medical equipment between patient use, failed to perform hand hygiene before preparing medications for administration and failed to have accurate signage posted for isolation precautions (R17), These failures affected four residents (R14, R17. R18 and R19) and has the potential to affect all 34 residents who receive medications from unit one medication cart. Findings include: Facility census report (5/21/2026) documents 19 residents receive routine blood pressure monitoring. R14's face sheet documents R14 is a [AGE] year-old resident with diagnoses including: type 2 diabetes mellitus, morbid obesity, cardiomegaly, chronic obstructive pulmonary disease, atopic dermatitis, spinal stenosis, chronic diastolic heart failure, atrial fibrillation, hypothyroidism, fibromyalgia, major depressive disorder, and anxiety disorder. On 5/20/2026 at 9:30 AM, began observing V35 complete medication pass. Observed V35 (Licensed Practical Nurse) withdraw an automatic wrist blood pressure machine from the medication cart to obtain R14's blood pressure. The blood pressure cuff/machine was not sanitized prior to V35 entering R14's room. V35 affirmed the blood pressure machine was V35's personal machine and not owned by the facility. V35 obtained R18's blood pressure and returned to the medication cart. The blood pressure cuff/machine was not sanitized after use. V35 placed the unsanitized cuff directly on the medication cart without a barrier, which caused the top of the medication cart (preparation area) to become contaminated. The medication cart was not sanitized after the cuff was placed on the top of the medication cart. R18's face sheet documents R18 is a [AGE] year-old resident with diagnoses including: non-traumatic intracerebral hemorrhage, type 2 diabetes mellitus, morbid obesity, hemiplegia of unaffected side, basal cell carcinoma, atopic dermatitis, chronic pain syndrome, atrial fibrillation, and hypertension. On 5/20/2026 at 9:55 AM, observed V35 (Licensed Practical Nurse) grab the unsanitized blood pressure machine from the medication cart to obtain R18's blood pressure. V35 obtained R18's blood pressure and returned to the medication cart. The blood pressure cuff/machine was not sanitized after use. V35 did not complete hand hygiene after obtaining the blood pressure reading. V35 withdrew R18's medications from the medication cart and placed the medications in a medication cup. V35 did not complete hand hygiene after medications were placed in a cup. V35 entered R18's room and administered medications. No hand hygiene was completed prior to administering the medications. R17's face sheet documents R17 is a [AGE] year-old resident with diagnoses including: Ogilvie syndrome, moderate protein calorie malnutrition, anemia, enterocolitis due to clostridium difficile, acute kidney failure, cachexia, hypoxemia, major depressive disorder, anxiety disorder, and unspecified psychosis. On 5/20/2026 at 9:58 AM, observed V35 grab the unsanitized blood pressure machine, and enter R17's room. A contact isolation sign with personal protective equipment was on R17's door. R17 did not wear any personal protective equipment prior to entering the room. V35 obtained R17's blood pressure and placed the unsanitized machine on the medication cart. The blood pressure cuff/machine was not sanitized after use. V35 did not complete hand hygiene after obtaining the blood pressure reading. V35 placed the unsanitized cuff directly on the medication cart without a barrier, which caused the top of the medication cart (preparation area) to become contaminated. The medication cart was not sanitized after the cuff was placed on the top of the medication cart. V35 withdrew R17's medications from the medication cart and placed the medications in a medication cup. V35 did not complete hand hygiene after medications were placed in a cup. V35 entered R17's room and administered medications. No hand hygiene was completed prior to administering the medications. V35 observed the contact isolation sign and confirmed the contact isolation sign was on the door. V35 stated the sign was old and R17 hadn't been on isolation in months. V35 stated the sign should have been taken down. R17's physician orders do not document an active order for contact isolation. R19's face sheet documents R19 is a [AGE] year-old resident with diagnoses including: chronic obstructive pulmonary disease, muscle wasting and atrophy, multiple sclerosis, type 2 diabetes mellitus, quadriplegia, osteoarthritis, and metabolic encephalopathy. On 5/20/2026 at 10:05 AM, observed V35 grab the unsanitized blood pressure machine from the medication cart to obtain R19's blood pressure. V35 obtained R19's blood pressure and returned to the medication cart. The blood pressure cuff/machine was not sanitized after use. V35 did not complete hand hygiene after obtaining the blood pressure reading. V35 placed the unsanitized cuff directly on the medication cart without a barrier, which caused the top of the medication cart (preparation area) to become contaminated. The medication cart was not sanitized after the cuff was placed on the top of the medication cart. V35 withdrew R19's medications from the medication cart and placed the medications in a medication cup. V35 entered R19's room and administered medications. R16's face sheet documents R16 is a [AGE] year-old resident with prior diagnoses, including but not limited to: systemic lupus erythematosus, osteomyelitis, type 2 diabetes mellitus, anemia in chronic kidney disease, obesity, sickle cell disease, chronic kidney disease, acquired absence of left and right legs, and osteoarthritis. On 5/20/2026 at 10:23 AM, observed V35 grab the unsanitized blood pressure machine from the medication cart to obtain R16's blood pressure. V35 obtained R16's blood pressure and returned to the medication cart. The blood pressure cuff/machine was not sanitized after use. V35 did not complete hand hygiene after obtaining the blood pressure reading. V35 placed the unsanitized cuff directly on the medication cart without a barrier, which caused the top of the medication cart (preparation area) to become contaminated. The medication cart was not sanitized after the cuff was placed on the top of the medication cart. V35 withdrew R16's medications from the medication cart and placed the medications in a medication cup. V35 entered R16's room and administered medications. On 5/20/2026 at 10:45 AM, V35 confirmed V35 did not sanitize the blood pressure cuff/machine between obtaining the blood pressures for each resident. V35 explained V35 typically sanitizes the blood pressure cuff after 3-4 residents get their blood pressure taken. When V35 has sanitized the cuff in-between each resident in the past, the residents complain that the cuff causes their skin to itch or they will break out. V35 affirmed hand hygiene should be performed before/after taking a blood pressure, and before/after medication administration. On 5/21/2026 at 1:23 PM, V2 (Director of Nursing) explained the nursing staff should be sanitizing durable, multi-use medical equipment, including blood pressure cuffs between each resident. Staff should be using things like bleach wipes to sanitize the equipment and allowing sufficient time for the chemicals to dry. V2 explained the purpose of sanitizing equipment between resident use is to prevent the spread of infections. V2 affirmed hand hygiene should be performed after medication administration and completing care. V2 confirmed R17 did not have active orders for isolation, and the sign should be enhanced barrier precautions. Facility policy titled, DISINFECTING REUSABLE EQUIPMENT (Reviewed 2/2025) documents the purpose of the policy is to provide guidance on how to clean reusable equipment between residents. The policy instructs staff to obtain bleach or disinfectant wipes and apply gloves. Take a pre-moistened disinfectant wipe and clean the entire surface of the equipment.Inspect to ensure all areas are clean. Allow product to remain on equipment according to manufacturer's recommendations. Remove and discard gloves. Sanitize hands. Repeat process between resident use. Facility policy titled, 5.2 Medication Administration (7/2024) documents staff should be washing hands before beginning medication administration, whenever the staff's hands are contaminated and if contact is made with the medication. Facility policy titled, Infection Control Program- General (revised 7/2025) documents the facility is committed to ensuring that all appropriate infection and control measures are in place as determined by State and Federal Regulations as well as CDC recommendations and guidance. The facility has established a policy to Identify, Record, Investigate, Control, Test, and Prevent infections in the facility. A sign will be provided outside the room for residents on transmission-based precautions indicating the type of precaution (Contact, Droplet, or EBP). As long as the type of infection is not included in the signage, the isolation sign is compliant with F583 in the SOM.Hand hygiene will be performed by staff and contracted workers before and after direct patient contact and after each situation that necessitates hand hygiene.

Based on observation, interview and record review, the facility staff failed to administer subcutaneous injections in accordance with the facility's procedure for subcutaneous injections and in accordance with professional standards for subcutaneous injections. This failure affected one (R16) in a sample of five residents reviewed for medication administration. Findings include: R16's face sheet documents R16 is a [AGE] year-old resident with prior diagnoses, including but not limited to: systemic lupus erythematosus, osteomyelitis, type 2 diabetes mellitus, anemia in chronic kidney disease, obesity, sickle cell disease, chronic kidney disease, acquired absence of left and right legs, and osteoarthritis. R16's minimum data set (4/13/2026) documents in part a brief interview of mental status summary score of 13, indicating R16 is cognitively intact. R16's care plan (4/23/2025) identifies R16 has renal failure due to chronic kidney disease, has alterations in hematological status related to anemia and is at risk for complications. Both identified care needs have interventions including giving medications as ordered by R16's physician. R16's physician orders (3/13/2026) document an active order for Epoetin Alfa Injection Solution (Epoetin Alfa) Inject 3000 unit subcutaneously one time a day every Monday, Wednesday and Friday for anemia. On 5/20/2026 at 10:39 AM, observed V35 (Licensed Practical Nurse) draw up 3000 units of Epoetin into a syringe with a subcutaneous needle. V35 entered R16's room and cleansed the lower right quadrant of R16's abdomen with an alcohol pad. V35 grabbed R16's skin and held the syringe at an approximately 15-degree angle, flush to R16's skin. V35 injected the medication at the 15-degree angle into R16's skin. R16 stated, I didn't even feel anything. I like when (V35) does (injects) it because I never feel anything. On 5/20/2026 at 10:45 AM, V35 recalled administering R16's Epoetin at a 15-30-degree angle. V35 was not sure what angle subcutaneous injections are performed. V35 stated, I can't remember maybe 5-10 degrees?. On 5/21/2026 at 1:23 PM, V2 (Director of Nursing) explained subcutaneous injections need to be administered at a 90-degree angle as the nurse pinches the resident's skin. V2 explained the purpose of the injection being at a 90-degree angle is to ensure the medication is delivered to the right area of the skin (subcutaneous tissue) so it is properly absorbed. If the medication is not delivered to the right area, it may not be as effective.On 5/27/2026 at 12:53 PM, V24 (Medical Director) affirmed V24 is the medical director for the facility. V24 affirmed the purpose of Epoetin Alfa is to increase red blood cell production to treat patients that have anemia, or chronic kidney disease. V24 confirmed Epoetin Alfa is administered as a subcutaneous injection. V24 was unsure what would happen if the medication was not administered correctly into the subcutaneous tissue or wrongly injected into another area of the skin like the dermis. V24 assumed the medication would not be as effective. V24 was informed V35 injected the Epoetin Alfa at the 15-degree angle into R16's skin. V24 affirmed staff should be injecting medication in accordance with professional standards and stated, that (injecting at the wrong angle) scares me a little. Review of FDA label prescribing information for Epogen (epoetin alfa) (9/2017) documents Epogen is indicated for the treatment of anemia due to chronic kidney disease (CKD), including patients on dialysis and not on dialysis to decrease the need for red blood cell (RBC) transfusion and is an injection for subcutaneous or intravenous use. Record review of the National Library of Medicine's Medline Plus Medical Encyclopedia's (An official website of the United States Government) page titled Subcutaneous (SQ) injections documents, Subcutaneous (SQ or Sub-Q) injection means the injection is given in the fatty tissue, just under the skin . The following steps should be followed when injecting the medicine (subcutaneously): -With the hand that is not holding the syringe, pinch an inch (2.5 cm) of skin and fatty tissue (not the muscle) between your fingers. - Quickly insert the needle all the way into the pinched skin at a 90-degree angle (45-degree angle if there is not much fatty tissue). -Once the needle is all the way in, release the skin. -Inject all the medicine by pushing in the plunger. -Once the medicine is all in, pull out the needle quickly . Some soreness is expected at the injection site. This article was peer reviewed by multiple board-certified physicians on 10/19/2025 and developed in accordance with several references to evidence-based standards of practice. (retrieved at https://medlineplus.gov/ency/patientinstructions/000430.htm)Facility procedure for subcutaneous medication administration (7/2024) documents the purpose of medications administered via subcutaneous injection is when a rapid, systemic effect is desired and to administer medications that cannot be given orally. The procedure indicates the staff member should complete hand hygiene, apply gloves, draw up the medication into a syringe using a 23-gauge needle (or smaller), cleanse the site with alcohol prep, grasp/pinch a cushion of flesh while inserting the needle quickly at a 45-degree angle, bevel side up. After, medication should be injected slowly, and the needle removed from the skin. This policy does not meet standards of practice as evidenced by current standards being injected at a 90-degree angle, unless the resident does not have sufficient fatty tissue.

Based on interview and record review, facility failed to follow their medication administration policy and failed to ensure residents were free from significant medication errors. These failures affected one (R1) in a sample of six residents reviewed for medication administration. Findings include:R1's face sheet documents an admission date of 11/24/25 and diagnoses that include but are not limited to abnormalities of gait, unsteadiness on feet, muscle wasting and atrophy, lack of coordination, cognitive communication deficit, and low back pain.R1's BIMS (brief interview for mental status) score, dated 3/2/26, is 15 which indicates R1 is cognitively intact.R1 is a closed record. R1 is currently admitted to the hospital with a diagnosis of chest pain.R1's progress note, dated 5/16/ 26, documents, in part, Called (Hospital) ER (emergency room) for update on resident (R1), he (R1) was admitted with dx (diagnosis) of chest pain.Record review of R1's Medication Administration Record (MAR), dated May 4, 2026, documents that V29 (Licensed Practical Nurse/LPN) administered R1's following medications late: Metoprolol Succinate ER that was due for 8:00am was administered at 11:15am (2 hours and 15 minutes late); and Gabapentin and Apixaban that were due for 9:00am were administered at 11:16am (one hour and 16 minutes late). Record review of R1's Medication Administration Record (MAR), dated May 12, 2026, documents that V29 (Licensed Practical Nurse/LPN) administered R1's Metoprolol Succinate ER that was due for 8:00am was administered at 10:05am (1 hours and 5 minutes late).On 5/26/25 at 3:30pm, V29 (Licensed Practical Nurse/LPN) said, I sometimes pass the medications late cause it gets busy, and we (facility) can use more help. Yeah, on 5/4 and 5/12 (5/4/26; 5/12/26) I was late passing medications. There's a lot of residents and a lot to do. I try my best.Record review of R1's Medication Administration Record (MAR), dated May 8, 2026, documents that V32 (Licensed Practical Nurse/LPN) administered R1's following medications late: Insulin Aspart Injection due for 7:30am was administered at 10:47am (2 hours 17 minutes late); Metoprolol Succinate ER due for 8:00am was administered at 10:56am (1 hour and 56 minutes late); Gabapentin due for 9:00am was administered at 10:56am (56 minutes late); Apixaban due for 9:00am was administered at 10:49am (49 minutes late); and Lantus due for 9:00am was administered at 10:56am (56 minutes late).On 5/21/26 at 3:32pm, V32 (Licensed Practical Nurse/LPN) said, I have been here 6 years. Previously, we (facility) had three nurses on the unit, but after the new company took over, staffing was reduced to two nurses. Because the unit is very busy and understaffed, medications are sometimes administered late. In my opinion, we (facility) need another nurse to safely manage the workload.Record review of R1's Medication Administration Record (MAR), dated May 11, 2026, documents that V30 (Licensed Practical Nurse/LPN) administered R1's following medications late: Insulin Aspart Injection due for 7:30am was administered at 11:05am (2 hours 35 minutes late); Metoprolol Succinate ER due for 8:00am was administered at 11:06am (2 hour and 6 minutes late); Gabapentin and Apixaban due for 9:00am was administered at 11:07am (1 hour and 7 minutes late); and Lantus due for 9:00am was administered at 11:10am (1 hour and 10 minutes late).On 5/20/26 at 12:01pm, V30 (Licensed Practical Nurse/LPN), said, Ummm. that day (5/11/26 R1's AM meds documented late) the Wi-Fi was probably down. Wi-Fi comes in and out all the time here. Yeah, I gave them (R1's medications) on time. The Wi-Fi goes out a lot on both sides all the time. Unit 1 and 2 loses Wi-Fi. When the Wi-Fi is out, I can't computer chart and have to wait for the Wi-Fi to go back up. I'm not sure what I'm supposed to do when the Wi-Fi is out, and I cannot computer chart. I'm learning as I go. I am a new nurse.Record review of R1's Medication Administration Record (MAR), dated May 13, 2026, documents that V31 (Licensed Practical Nurse/LPN) administered R1's following medications late: Insulin Aspart Injection due for 7:30am was administered at 10:10am (1 hours 40 minutes late); Metoprolol Succinate ER due for 8:00am was administered at 10:54am (1 hour and 54 minutes late); Gabapentin and Apixaban due for 9:00am was administered at 10:56am (56 minutes late); and Lantus due for 9:00am was administered at 10:55am (55 minutes late).Record review of R1's Medication Administration Record (MAR), dated May 16, 2026, documents that V31 (Licensed Practical Nurse/LPN) administered R1's following medications late: Insulin Aspart Injection due for 7:30am was administered at 10:04am (1 hours 34 minutes late); and Metoprolol Succinate ER due for 8:00am was administered at 10:04am (1 hour and 4 minutes late).On 5/20/26 at 12:24pm, V31 (Licensed Practical Nurse/LPN) said, Ummm. I mean honestly I cannot recall those exact days (5/13/26 and 5/16/26 R1's AM medications given late), but I do my best to administer all medications in a timely manner. Often times there are situations when residents have to get sent out, call lights have to be answered, and the Wi-Fi isn't the best, but I try to administer in a timely fashion. I cannot remember what happened those days (5/13/26 and 5/16/26 R1's AM medications given late). It's all about prioritizing. I try to do the best I can. I have approximately around 23 other residents. It would be great, and ideal to have another nurse. Usually, I'm able to manage, but things always happen and get hectic, and medications may be a little late. The workload is doable and I'm usually able to pass in a timely fashion, but the call lights and help residents might need might come first. I have to prioritize. Medications that are time sensitive and prioritize the needs of the residents. Usually able to manage good but have to prioritize sometimes.On 6/1/26 at 2:50pm, V2 Director of Nursing/DON) said, Facility's protocol if staff can't chart in the computer, then they (staff) go back to paper charting until system comes back up. There's also a back backup system in the back room to computer chart if there are issues with other computers. The medication is signed off immediately, once they (resident) swallow the medication. I expect staff to give medications on time. One hour before or one hour after the actual time the medication is due. They (staff) should let other nurses or management know if they (nurses) are busy and need some help. Giving heart medications late may have a bad affect on someone's blood pressure or heart rate. It depends on how late the med was given. Yes, blood thinning medications given late can have a bad outcome like blood clots or PEs. Late insulin can cause hypo or hyperglycemia. Depends on the resident and how late.Record review of facility policy titled, Medication of Administration, dated 2/2026, documents, in part, General: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Verify that the medication is being administered at the proper time, in the prescribed dose, and by the correct route. Document as each medication is prepared on the MAR.Record review of CMS's RAI (Resident Assessment Instrument) 3.0 Manual Chapter 3 MDS Items [N) (dated October 2025) documents in part the following: N0415: High-Risk Drug Classes: Use and Indication: Anticoagulant; Antiplatelet; Hypoglycemic including insulin; and anticonvulsant.Record review of facility policy titled, Physician Orders, dated 5/1/25, documents, in part, I. Medication orders specify the following: Time or frequency of administration. Documentation of the Medication Order: Each medication order is documented in the resident's medical record with the date and signature of the person receiving the order. The order is recorded on the physician order sheet in PCC and the Medication Administration Record (MAR) or Treatment Administrative Record (TAR).

Based on observation, interview, and record review, the facility failed to have sufficient operating call light system; and failed to ensure two resident's (R17 and R25) call lights were working properly. These failures affected two (R17 and R25) of 7 residents reviewed for call lights but have the potential to affect 145 residents residing in the facility. Findings include: On 5/19/26 at 11:06am, V12 (Registered Nurse/RN) said in part, Call lights sound like an AI voice but disconnects cause of internet or something and most of the time there is no sound for the call lights. If that's not working, you just gotta keep monitoring your lights. Honestly, the sound for the call lights doesn't work often. On 5/20/2026 11:05 AM, V20 (Unit Manager, Licensed Practical Nurse) affirmed in part V20 is the unit supervisor for unit two. V20 affirmed there is no panel or other system that notifies staff of a call light being activated other than a light outside the resident's door. V20 denied knowledge of any system the facility uses to track call light response times or rounding. On 5/20/2026 at 11:16 observed V14 (Staffing Director) sitting at the unit 2 nurse's station. V14 observed the nurse's station and affirmed there is no panel or other way staff know what call light is activated. Beeping was heard in the background of the nurse's station, but V14 was unsure what the beeping was from or if it was a call light. V20 gestured to powered off television (TV) and explained the call lights used to show on the television, indicating which resident's light had been activated. V14 recalled the TV last operating to show call lights over 2 months ago. V14 recalled issues with the call light system in the past, such as the alarms going off whenever any resident would activate the alarm at both nurse's stations. V14 explained staff would have to go to all the units throughout the facility to figure out which call light was on. On 5/21/26 at 2:14pm, R6 said, When you press the call button, you expect staff to come. That's what it (call light) is for. On 5/21/26 at 3:32pm, V32 (Licensed Practical Nurse/LPN) said, Regarding the call light system, there is no audible sound at the nurses' station, so staff must physically look to see whether a call light is on. State surveyors previously came in and the system worked properly for a few weeks afterward and stopped working. The call light system hasn't been working properly for years. If a staff member is supervising residents at the nurses' station, they absolutely cannot leave the residents to answer call lights. On 5/26/26 at 1 PM, R17 indicated my call light has not been working for 2 weeks. They gave me the front desk telephone number so I can call from my cell phone, and they can page the CNA that is taking care of me. The maintenance guy told me they are working on fixing it because it's a system issue and no one has given me an update on when it will be fixed. Surveyor pushed R17's call light and the call light for the empty bed in R17's room and verified neither were operational. On May 26, 2026 at 12:30 AM the CNA came in to change my disposable brief and I never saw the CNA again the whole shift. I called the front numerous times about every 2-3 hours starting at 1 AM because I had bad diarrhea and needed my disposable brief changed. Every time I call, they pick up the phone and hang up. I called again at 5 a.m. and staff hung up again. I have been laying in diarrhea since 1 AM and it leaked onto the bed. Since no one answered my call, I dialed 911 (the fire department after they hung up on me at 5 a.m. The fire department called facility called facility to tell them a resident needs help. I could not stand laying in the diarrhea any longer, so I crawled out of bed and yelled for help. V35(Licensed Practical Nurse) came to help. She is very nice. My skin is sore and feels raw and painful because I was laying in diarrhea from 1 AM to 5 AM. On May 26, 2026 at 1:30 PM, R17 showed surveyor his personal cell phone dated May 26 and it captured R17 made 45 calls to the facility front by 7:01 AM. Surveyor called 911 dispatch center that provides response coverage for the facility's call(s) to verify 911 call from R17's cell phone number. Dispatch supervisor indicated they cannot share that information over the phone. On 5/26/26 at 2:02pm, V3 (Maintenance Director) said, I wasn't aware that R17's call light doesn't work. I'll check it (R17's call light) out now. On 5/26/26 at 3:06pm, V3 (Maintenance Director) said, There was a bad relay in main control box and wouldn't send a signal for light to turn on. I switched out the wire and traced from room to main box. It's (R17's call light) working now. In an email dated May 28, 2026, at 10:28 AM to the surveyor, documents in part: V1 indicated if there is any type of issue with call lights or any other equipment issues, staff are expected to notify management immediately. Management staff may either verbally notify the Maintenance Department or submit a work order through the facility's maintenance tracking system, TELS. Once the work order is entered into TELS, the system notifies Maintenance of the issue requiring repair or follow-up. Maintenance is then responsible for addressing the issue and closing out the work order in the system upon completion of the repair or corrective action. V1 indicated the call light was tested following the repair and confirmed to be functioning appropriately. Call light logs for the past 6 months (December 2025 to current) and no issues were noted from December 2025 through April 2026. Replacement and repairs were noted, On 5/28/2026 at 2:19 AM, V1 (Administrator) denied knowledge on how long the call light system was in disrepair. V1 explained the system's wiring was in disrepair and had to be repaired so the call light would illuminate near the nurse's station and so the audible sound could be heard when the call lights are activated. On 5/28/2026 at 3:10 PM, V2 (Director of Nursing) confirmed V2 was aware of the call light system in disrepair and not having an audible alarm to notify staff. V2 denied telling administration or other responsible parties that the call light system was not working properly. V2 stated V2 didn't report anything wrong at the time because the call light system had not been functioning and having an audible alarm since V2 was a floor nurse working night shift. V2 stated that the call light not having an audible alarm was just the way things were, the staff knew it was just the way it was. On 6/01/26 at 10:46am, with V3 (Maintenance Director), R25's call light and electrical box was observed not working, not attached to the wall, and without a required battery needed to function. V1 (Administrator) affirmed that R25's call light and electrical box was observed not working, not attached to the wall, and without a required battery needed to function. V3 said, I can't find the battery (battery to R25's call light). Maybe housekeeping swept it up. R25's face sheet documents diagnoses that include but are not limited to blindness right eye, paralytic syndrome, neuromuscular dysfunction, and epilepsy. R25's BIMS score, dated 4/9/26, is 13 which indicates R25 is cognitively intact. R25's care plan documents, in part, Motorized Wheelchair: (R25) has impaired functional mobility related to old gunshot wounds. He requires a motorized wheelchair to move around. FALL: (R25) is at high risk for falls r/t (related to) recenthospitalization. On 6/1/26 at 10:47am, observed R25 sitting in a wheelchair, and R25 said, I'm not sure how long my call light has been broke. Sometimes it (call light) works, sometimes it (call light) doesn't. On and off. Oh yeah, I definitely use the call light. On 6/1/26 at 2:21pm, V50 (Licensed Practical Nurse/LPN) said, The call lights have improved. Faster response. Employees are answering it no matter who it is. Like housekeeper or even kitchen. The sounding is way more helpful. When I would be charting, I'd have to look up every so often to and see if the lights are on. On 6/1/26 at 2:31pm, V51 (Restorative Nurse) said, The call lights have a sound now which makes it much easier now to know when the residents need help. When you'd look down the hall and see a call light, you can only guess how long it's been on. Base it on the last time you checked. On 6/1/26 at 2:40pm, V52 (Certified Nursing Assistant/CNA) said, It's (answering call lights) easier now that we (staff) can hear the call lights. We (staff) didn't know when someone's light was on unless we (staff) went down the halls and looked at each light. On 6/1/26 at 2:58pm, V54 (Registered Nurse/RN) said, The sound now when a call light is on, is easier cause you can hear the light in the room and its loud so you know. You had to go searching and looking to see if call lights were on. Record review of facility policy titled, Call Light Response, dated 2/2026, documents, in part, To provide the staff with guidance on responding to residents' requests and needs. Report all defective call lights to the nurse supervisor or maintenance director promptly. Answer the patient or resident's call as soon as possible. If assistance is needed when you enter the room, summon help to the room.

Based on observation, interview and record review, the facility failed to ensure one (R10) resident was free from unnecessary antipsychotic medication use, failed to ensure antipsychotic medication was not prescribed without adequate indication, and failed to document/identify targeted symptoms for antipsychotic use. These failures affected one resident (R10) in a sample of 72 residents reviewed for unnecessary psychotropic medication use. These failures resulted in R10 having been administered an unnecessary antipsychotic medication, resulting in the development of extrapyramidal symptoms/tardive dyskinesia side effects and increased risk of death. Findings include: R10's face sheet documents in part the following diagnoses: spinal stenosis, unspecified dementia with psychotic disturbance, protein calorie malnutrition, epilepsy, anxiety disorder, severe intellectual disabilities, major depressive disorder, contractures of right upper arm, dysphasia, tremors, dysphagia, and muscle weakness. There is no diagnosis of any schizophrenia, schizoaffective disorder, schizophreniform disorder. R10's face sheet lists that R10's legal guardian is a state guardian (V46). R10 was never married. R10's minimum data set (1/20/2026) documents in part that R10 is rarely/never understood and has severe cognitive impairment for daily decision making. Additionally, the MDS indicates there were no behaviors in the lookback period and does not have serious mental illness, schizophrenia, schizoaffective disorder. The MDS does not identify that R10 utilizes antipsychotic medication. R10's minimum data set (12/17/2025) does not document any behaviors, hallucinations/delusions. R10's minimum data set (12/2/2025) does not document any behaviors, hallucinations/delusions. R10's minimum data set (10/20/2025) does not document any behaviors, hallucinations/delusions. R10's minimum data set (10/13/2025) does not document any behaviors, hallucinations/delusions. R10's minimum data set (8/9/2025) does not document any behaviors, hallucinations/delusions. R10's minimum data set (7/13/2025) does not document any behaviors, hallucinations/delusions. R10's admission minimum data set (2/16/2024) does not document any behaviors, hallucinations/delusions. On 4/20/2026 at 9:44 AM, an entrance conference was held with V1 (Administrator) and V2 (Director of Nursing). V2 affirmed during the entrance conference V2 is responsible for managing the psychotropic medication program. On 4/20/2026 at 11:00 AM, R10 was observed sitting in a central positioning wheelchair (high back wheelchair) in R10's room, calm and resting. R10 was unable to answer any questions or follow commands. R10's lips were observed smacking involuntarily about one movement per second. Small jerking motions were observed to R10's jaw as R10's lips smacked. R10 did not appear to notice the lip smacking. These observations were confirmed with V2 (Director of Nursing). V2 stated Yes, it looks like his lips are smacking. I haven't seen this before with (R10). That is a sign of tardive dyskinesia, which is a side-effect of long-term antipsychotic use. V2 affirmed that R10 receives anti-psychotic medication. On 4/20/2026 at 12:15 PM, V2 (Director of Nursing) confirmed that R10 was receiving Olanzapine for dementia-related psychosis. V2 read the black box warning attached to the Olanzapine order and affirmed that the black box warning indicates Olanzapine is not approved to treat dementia related psychosis. R10's census documents in part R10 was discharged from the facility to the hospital on 8/9/2025. R10 returned to the facility on 8/17/2026. R10's hospital progress notes (8/17/2025) document R10 was admitted to the hospital related to feeding tube dysfunction. Other active problems treated during the hospital stay include displaced g-tube, coronary artery disease, hypertension, seizure disorder, depression, recent scabies infection, cervical mylopathy, and intellectual disability. R10 was discharged on Olanzapine 20 mg nightly from this hospitalization. There is no indication in the hospital records why R10 was ordered olanzapine. R10's Psychotropic Medication Assessment form (10/8/2025) document that R10 is receiving Olanzapine 20 mg for a diagnosis/indication of schizophrenia and it is unknown how long the resident has been on the medication. There is no targeted symptoms identified, no non-pharmacological interventions attempted to manage symptoms, and is not documented if warranted or unwarranted. The assessment is otherwise blank. The Psychotropic Medication Assessment form (2/5/2026) documents that R10 is receiving Olanzapine 20 mg for a diagnosis/indication of schizophrenia and it is unknown how long the resident has been on the medication. The targeted symptoms are agitation and there was no reduction attempt. Redirection was attempted as a non-pharmacological alternative. The medication reduction is not warranted due to clinical condition would deteriorate, non-pharmacological interventions not fully effective without medication management, regularly assessed by physician/psychiatrist, and is medically appropriate for the target symptom. The Psychotropic Medication Assessment form (4/20/2026) documents R10 is receiving Zyprexa 10 mg for dementia/psychosis was started over a year ago. There is no target symptoms or non-pharmacological interventions listed. R10's care plan (1/28/2026) documents in part, PSYCHOTROPIC MEDS: (R10) Requires the use of psychotropic medication (Olanzapine) to assist with managing mood and behavior related to DX of schizophrenia with targeted symptoms/ behaviors of agitation or aggression. The goal of the identified issue states, (R10) Will remain free of complications and reviewed for possible decrease throughout next review. Interventions to meet this goal include, Antipsychotic side effects: constipation, dry mouth, difficult urination, blurred vision, sedation, excitation, confusion, tremors, rigidity, restlessness, muscle spasms, involuntary facial movements, shuffling gait, drooling, hypotension, tachycardia. Notify MD of abnormal findings. Antipsychotic side effects: constipation, dry mouth, difficult urination, blurred vision, sedation, excitation, confusion, tremors, rigidity, restlessness, muscle spasms, involuntary facial movements, shuffling gait, drooling, hypotension, tachycardia. Notify MD of abnormal findings. (10/8/2025). The care plan does not indicate any non-pharmacological interventions attempted prior to the initiation of the anti-psychotic medication or any risk vs. benefit rationale of why the resident is receiving the medication. R10's psychotropic consent form (10/08/2025) for Olanzapine 20mg does not document the indication or diagnosis related to the use of Olanzapine. R10's physician orders document (8/17/2025) Olanzapine 20mg Give 20 mg via G-Tube in the evening for treat schizophrenia. This order was discontinued on 1/31/2026. On 2/1/2026, Zyprexa Oral Tablet 15 MG (Olanzapine) Give 1 tablet via G-Tube in the evening for for dementia with psychosis was ordered and discontinued on 4/18/2026. On 4/18/2026, Zyprexa Oral Tablet 10 MG (Olanzapine) Give 1 tablet via G-Tube at bedtime for Dementia with Psychosis Give 10mg qHS (every evening) was ordered and discontinued on 4/22/2026. The black box warning for Olanzapine within the electronic health record documents, Warning: Increased mortality in elderly patients with dementia-related psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Analyses of 17 placebo-controlled trials (modal duration, 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients between 1.6 and 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was approximately 4.5%, compared with a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (eg, heart failure, sudden death) or infectious (eg, pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patient is not clear. Olanzapine is not approved for treatment of patients with dementia-related psychosis. R10's Abnormal Involuntary Movement Scale (AIMS) assessment (1/16/2025) documents R10 did not have any history of any involuntary movements. On 8/17/2025, the AIMS scale indicates MILD eg movements of forehead, eyebrows, periorbital area, cheeks; include frowning, blinking, smiling, grimacing and Minimal/None puckering, pouting, smacking of the lips. AIMS assessment (4/10/2026) documents MILD eg puckering, pouting, smacking of the lips and MILD eg biting, clenching, chewing, mouth opening, lateral movement of the jaw. Both assessments indicate that R10 does not have any problems with dentition and that R10 does not utilize dentures. R10's progress notes (4/23/2025-4/23/2026) does not document any agitation or other behaviors and repeatedly note R10 is calm and cooperative. There is no indications of any psychotic symptoms. On 8/9/2025, R10's progress notes indicate, Called (hospital) to check on status of resident, he has been admitted for 23 hour observation for g tube feeding dysfunction, per ER nurse, should return to facility tomorrow. On 8/10/2025, Called (Hospital) to check on status of resident, IR is not open on the weekends to resident has been admitted till tomorrow when g tube will be replaced, and (R10) should return Monday sometime, per (RN) the floor nurse. On 8/17/2026, Resident returned from (Hospital) via stretcher with 2 attendees. Alert and oriented to self. NKA (no known allergies). Full code. Returned with new feeding tube and binder. G-tube flushed well. NPO. Jevity 1.2 @20ml/hr (millileteres per hours).Flush 100mls q4. MD (physician) made aware of return and reviewed medication list. Augmentin BID (twice a day) for 2 more days r/t (related to) UTI (urinary tract infection). Open area to left ankle. Dryness and scabs throughout body. Incontinent of bowel and bladder. Kept clean throughout shift. TB tested administered to right forearm. There is no documentation in the progress notes that indicate a new schizophrenia diagnosis or why the olanzapine was continued after the hospital stay. On 4/20/2026 at 11:33 AM, V2 documented, Zyprexa decreased per GDR from 15mg to 10mg. Lip smacking was observed. (V49, Psychiatric Nurse Practitioner) notified new order given for Cogentin 0.5mg daily. State guardian notified. On 4/23/2026 at 3:49 PM, V2 documented, After speaking with (V49), it was determined that medication Zyprexa should be dc (discontinued) at this time d/t (due to) possible adverse reactions. Behavior monitoring in place and continue Cogentin. Emergency contact made aware.Record review of R10's medication administration records (MAR) (8/2025-present) indicate that R10 regularly received Olanzapine daily for Schizophrenia or Dementia Related Psychosis. Olanzapine was not administered in the MAR before 8/17/2025. On 4/22/2026 at 12:39 PM, V5 (Social Services Director) affirmed V5 had worked at the facility for over 20 years and monitors the behaviors of the residents. V5 denied any recollection that R10 was ever aggressive, agitated, had any hallucinations/delusions or any other psychosis symptoms. V5 stated that R10's baseline mental status is cognitively impaired and limited to answering yes/no questions. On 4/22/2026 at 1:49 PM, V48 (MDS Nurse, Registered Nurse) affirmed V48 was familiar with R10 and affirmed R10 was receiving antipsychotic medication for dementia related psychosis. V48 stated that according to the resident assessment instrument (RAI), antipsychotic use is only appropriate for residents that have schizophrenia/schizoaffective disorder, Huntington's or Tourette's, otherwise it can affect quality measures. V48 recalled the interdisciplinary team had discussed R10's antipsychotic use during a case mis index (CMI) meeting but was unsure why it was not discontinued. Record review of CMS Resident Assessment Instrument (RAI) dated October 2025, documents in part, Health-related Quality of Life The use of unnecessary medications in long term care settings can have a profound effect on the resident's quality of life. Antipsychotic medications are associated with increased risks for adverse outcomes that can affect health, safety, and quality of life. In addition to assuring that antipsychotic medications are being utilized to treat the resident's condition, it is also important to assess the need to reduce these medications whenever possible. Planning for Care Identify residents receiving antipsychotic medications to ensure that each resident is receiving the lowest possible dose to achieve the desired therapeutic effects. Monitor for appropriate clinical indications for continued use. Implement a system to ensure gradual dose reductions (GDR) are attempted at recommended intervals unless clinically contraindicated . 17. Psychotropic Medication Use Any medication, prescription or non-prescription, can have benefits and risks, depending on various factors (e.g., active medical conditions, coexisting medication regimen). However, psychotropic medications, prescribed primarily to affect cognition, mood, or behavior, are among the most frequently prescribed agents for elderly nursing home residents. While these medications can often be beneficial, they can also cause significant complications such as postural hypotension, extrapyramidal symptoms (e.g., akathisia, dystonia, tardive dyskinesia), and acute confusion (delirium) . On 4/22/2026 at 2:12 PM, V45 (Pharmacist) affirmed V45 supervises the consulting pharmacy services for the facility. V45 explained, Olanzapine is an atypical anti-psychotic medication used for schizophrenia, bipolar disorder, and dementia with behavioral disturbances. V45 reviewed the manufacturer's instructions for Olanzapine and affirmed that dementia related psychosis was not indicated. V45 explained, Atpyical antipsychotics can cause drowsiness, increased appetite, and dry mouth-- those are the main ones. There's also serious side effects that don't occur often, such as tardive dyskinesia. Tardive dyskinesia is involuntary movements usually of the face, lips and tongue. Can be jerking movements too. Sometimes tardive dyskinesia is mistaken for dental issues like ill-fitting dentures. Back in the day, we used to prescribe Cogentin (benztropine) for the extrapyramidal symptoms and tardive dyskinesia, but now we have medications like Ausetdo and Ingrezza when the AIMS score is over 5. Yes, there is a black box warning for atpical antipsychotic use for dementia related psychosis for increased risk of mortality and death. V45 reviewed the black box warning for Olanzapine in R10's electronic health record, and affirmed that Olanzapine was not approved for dementia related psychosis. V45 stated, Olazapine is an off-label use for dementia psychosis. It's not approved, but it's used all the time. There is one medication used for dementia related psychosis, it is Rexulti. But it is a new drug, some psychiatrists use it, some don't. V45 reviewed R10's electronic health record and confirmed R10 was receiving Olanzepine 10 mg nightly for dementia related psychosis. We don't document why the medication was first ordered, but it was first ordered and initiated on 8/17/2025. That was the first time (R10) was prescribed that medication in our records, the first time we filled it. I am reviewing his diagnosis list, I don't see any diagnosis for Schizophrenia. Oh wait, on 12/18/2025, (V49 Psychiatric Nurse Practitioner), has a diagnosis of schizophrenia in the note. I don't see any indication of schizophrenia from before that, but the original order (8/17/2025) said for schizophrenia. The pharmacist wouldn't have questioned that because the original order had an appropriate diagnosis. CMS' regulations for GDRs are vague, it says the facility must do GDRs in modest increments, there is no requirement anymore for like twice in one year. The GDR wasn't initiated until 1/16/2026 by the consultant pharmacist's recommendation. I do not have documentation that indicates the pharmacist had any recommendations related to the appropriateness of the antipsychotic use prior to the GDR. Yes, there should be target behaviors and other interventions tried prior to initiating an antipsychotic medication. They (staff) should be documenting that. There should also be justification for the use and why the medication could not be discontinued. I would expect the psych provider to be documenting that. Yes, psychotropic medications need informed consent and consideration of risks vs. benefits. Usually, providers will taper the medication if the resident has been on it a long time to avoid any reoccurrence of symptoms. I'd say a long time is like over a year. The prescribing information for Zyprexa (Olanzapine) received from V45 documents in part multiple black box warnings, including WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSISElderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Analyses of seventeen placebo-controlled trials (modal duration of 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of between 1.6 to 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was about 4.5%, compared to a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear. ZYPREXA (olanzapine) is not approved for the treatment of patients with dementia-related psychosis [see Warnings and Precautions (5.1, 5.12) and Patient Counseling Information (17.2)] . WARNINGS AND PRECAUTIONSWhen using ZYPREXA and fluoxetine in combination, also refer to the Warnings and Precautions section of the package insert for Symbyax.5.1 Elderly Patients with Dementia-Related PsychosisIncreased Mortality - Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. ZYPREXA is not approved for the treatment of patients with dementia-related psychosis [see Boxed Warning, Warnings and Precautions (5.12), and Patient Counseling Information (17.2)].In placebo-controlled clinical trials of elderly patients with dementia-related psychosis, the incidence of death in olanzapine-treated patients was significantly greater than placebo-treated patients (3.5% vs 1.5%, respectively).Cerebrovascular Adverse Events (CVAE), Including Stroke - Cerebrovascular adverse events (e.g., stroke, transient ischemic attack), including fatalities, were reported in patients in trials of olanzapine in elderly patients with dementia-related psychosis. In placebo-controlled trials, there was a significantly higher incidence of cerebrovascular adverse events in patients treated with olanzapine compared to patients treated with placebo. Olanzapine is not approved for the treatment of patients with dementia-related psychosis [see Boxed Warning and Patient Counseling Information (17.2)] .What is the most important information I should know about ZYPREXA?ZYPREXA may cause serious side effects, including:1.Increased risk of death in elderly people who are confused, have memory loss and have lost touch with reality (dementia-related psychosis).2.High blood sugar (hyperglycemia).3.High fat levels in your blood (increased cholesterol and triglycerides), especially in teenagers age [AGE] to 17 or when used in combination with fluoxetine in children age [AGE] to 17.4.Weight gain, especially in teenagers age [AGE] to 17 or when used in combination with fluoxetine in children age [AGE] to 17.These serious side effects are described below.1. Increased risk of death in elderly people who are confused, have memory loss and have lost touch with reality (dementia-related psychosis). ZYPREXA is not approved for treatingpsychosis in elderly people with dementia .What should I avoid while taking ZYPREXA? ZYPREXA can cause sleepiness and may affect your ability to make decisions, think clearly, or react quickly. You should not drive, operate heavy machinery, or do other dangerous activities until you know how ZYPREXA affects you. Avoid drinking alcohol while taking ZYPREXA. Drinking alcohol while you take ZYPREXA may make you sleepier than if you take ZYPREXA alone.What are the possible side effects of ZYPREXA? Serious side effects may happen when you take ZYPREXA, including: See What is the most important information I should know about ZYPREXA?, which describes the increased risk of death in elderly people with dementia-related psychosis and the risks of high blood sugar, high cholesterol and triglyceride levels, and weight gain. Increased incidence of stroke or mini-strokes called transient ischemic attacks (TIAs) in elderly people with dementia-related psychosis (elderly people who have lost touch with reality due to confusion and memory loss). ZYPREXA is not approved for these patients . Tardive Dyskinesia: This condition causes body movements that keep happening and that you can not control. These movements usually affect the face and tongue. Tardive dyskinesia may not go away, even if you stop taking ZYPREXA. It may also start after you stop taking ZYPREXA. Tell your doctor if you get any body movements that you can not control .R10's psychiatric care progress notes completed by V49 (Psychiatric Nurse Practitioner) document that V49 began overseeing R10's psychiatric care on 3/8/2025. No progress notes indicate any history of psychosis, hallucinations, delusions, aggression, agitation. There are no behaviors identified in the progress notes. There are no medications listed in the progress notes or rationales for why V49 is taking psychotropic medicines. On 12/20/2025, V49, stating Pt. Has previous hx (history) of diagnosed schizophrenia and diagnosed R10 with Schizoaffective disorder, unspecified. There are no DSM-V indications for the schizophrenia or schizoaffective disorder diagnosis in V49's notes or identification of how V49 identified the previously diagnosed schizophrenia. There is no identification or justification of the antipsychotic medication use in progress notes authored by V49 that meet professional or regulatory standards. The notes appear grossly the same from month-to-month with the same narrative of Patient's mood appears to be better, mildly anxious, feels less depressed, no SI, improved by nursing and care. This has been going on for multiple days. Appetite is okay, sleep is generally fair. Patient and staff deny significant SE (side effects) from medications . V49s repeatedly identifies R10 as Alert and Oriented x3 (person, place, time, which requires a patient to able to speak) yet also indicates V49 is non-verbal with short and long term memory within normal limits. Additionally, V49 repeatedly documents that R10's speech, rate, rhythm, and volume are generally within normal limits, which is incongruent with R10 being non-verbal. V49 documents during each progress note risk, benefits and alternative therapies were reviewed but does not identify why the risks of the medications outweigh the benefits, including the antipsychotic medication use.On 4/22/2026 at 2:46 PM, V49 (Psychiatric Nurse Practitioner) affirmed V49 is the psychiatric provider for the facility and manages R10's psychiatric care. V49 affirmed that V49 is a nurse practitioner and has full practice authority. When asked if V49 has a collaborating physician, V49 stated, no, we just have a contracted one. I am the provider that sees (R10). V10 affirmed that the Olanzapine was started in the hospital, and explained, I was not the provider that started the Olanzapine. It was just continued. I didn't order it. The Olanzapine is for dementia with psychosis. Again, it was started in the hospital, I don't know why I didn't order it. I don't know the provider that ordered it. (R10) was given it originally upon admission because of agitation. Olanzapine can be used to control behavioral issues like that. I haven't seen (R10) be aggressive towards staff or residents, I think that was more when (R10) was admitted . I have started GDRs for (R10) but I didn't discontinue the medication because I didn't want to cause a relapse in symptoms. V49 could not identify the targeted symptoms. V49 stated, I GDR'ed it though in January. I am doing what I should be doing. He was on it for years and was on it when he first came in. V49 denied V49 spoke with any other provider, including the original ordering provider, about the olanzapine use despite continuing the order for months without indication. V49 denied any communication with the pharmacist about the olanzapine use. When asked about why V49 diagnosed R10 with schizophrenia in December of 2025, V49 replied, I saw it in the chart so I added it. I don't know where I saw it so I included it as a history. When asked if adding a diagnosis because a provider saw it in the chart was standard of care, V49 stated, Well no, it was a history of schizophrenia. I was told that by R10's wife. (R10's face sheet and MDS indicate R1 was never married). V49 explained schizophrenia is diagnosed using the DSM-V, but that V49 could not diagnose R10 with schizophrenia because R10 is non-verbal and couldn't report the needed symptoms to diagnose schizophrenia. V49 affirmed that V49 was aware of the black box warning of dementia with psychosis and olanzapine and stated, yes, that's why I am doing a GDR. Surveyor inquired why the medication couldn't be discontinued, and V49 repeated, because he will have a worsening of symptoms. Surveyor inquired if the resident did not have schizophrenia, has never had any documented agitation/aggression/behaviors, hallucinations/delusions, etc. what symptoms or behaviors would worsen? V49 stated, I don't have the chart in front of me. I am driving. V49 agreed to call the surveyor at a later time after V49 could more thoroughly review the chart. On 4/22/2026 at 4:38 PM, V2 affirmed V2 expects the facility staff to follow the facility's policies and procedures. V2 stated, I want to present to you what we found, (R10) was on the medication when (R10) admitted from the group home back before the facility was bought. V2 produced records from an old health care system dated 11/2024. V2 accessed R10's electronic health records. V2 reviewed the records and confirmed the following observations in the record: 1) Olanzapine was not administered in the medication administration record by the facility prior to the initiation on 8/17/2025. [DATE]/2025 documents that R10 did not receive the medication until R10 readmitted on [DATE]. 8/1/2025-/8/9/2025 R10 did not receive the medication. 2) There was no medication orders in the system prior to the hospitalization stay 3) There was no behaviors exhibited in R10's progress notes within the last year that warranted antipsychotic medication use. 4) The last 30 days of behavior charting did not document any behaviors that warranted antipsychotic medication use 5) The original order for the olanzapine on 8/17/2026 was for schizophrenia. There was no diagnosis of schizophrenia in R10's chart. V2 stated R10 was getting the olanzapine for the diagnosis of dementia with behavioral disturbance and did not have a diagnosis of schizophrenia. 6) R10's care plan indicated R10 was receiving antipsychotic medication for schizophrenia, the care plan did not address any targeted behaviors, and there were no non-pharmacological interventions attempted prior to the initiation of the antipsychotic medication use. 7) V49 was the provider managing R10's psychiatric care since 3/2025 and diagnosed R10 was schizophrenia on 12/20/2025. 8) The hospital records (8/17/2026) did not indicate the use for olanzapine. 9) The psychotropic medication assessments were inaccurate and identified R10 had agitation/aggression that was not documented, and did not have adequate interventions prior to initiating the antipsychotic. 10) R10 had routinely received the olanzapine since 8/17/2025 and was not GDR'ed or addressed until 1/2026. 11) There is no indication in the progress notes why the medication was continued. 12) There is no notification to the physician that the olanzapine was ordered without an appropriate diagnosis and the rationale from the physician on why the medication was to be continued. V2 explained that V2 is covering the psychotropic medication program because the facility did not have an assistant director of nursing now, as the prior assistant director left. V2 affirmed the pharmacist discusses antipsychotic medication use in QAPI and it is reviewed in the case mix index meetings. V2 was unsure if R10's olanzapine use and diagnosis was addressed in the case mix index meetings. V2 explained that V2 had not seen the tardive dyskinesia symptoms prior to 4/20/2026 so V2 reached out to V49 as V49 is the provider than manages R10's psychiatric medications. V49 did not want to stop the medication because V49 thought R10 would get worse and stated, (V39) just discontinued it just a little bit ago. I just talked to him. V2 affirmed that there were no target behaviors and the dementia with behavioral disturbance was an not an appropriate diagnosis. V2 affirmed that R10's diagnosis is dementia with behavioral disturbance, not schizophrenia. V2 affirmed that providers should be using the DSM-V to diagnose mental health conditions. On 4/23/2026 at 10:07 AM, V49 affirmed V49 reviewed R10's chart and was adequately prepared to be interviewed. V49 stated that it was 49's fault that the conversation with R10's family should have been documented in the progress notes and targeted symptoms/behaviors. V49 stated R10 received the antipsychotic medication when R10 came from the group home (this statement is inaccurate as evidenced by the facility's electronic health records, pharmacy dispensing records, hospital records all indicating R10 did not get this medication prior to the hospitalization on 8/9/2026-8/17/2026). So V49 did a GDR two times and has since discontinued other psychotropic medications. The first order (8/17/2025) was started by another prescriber and V49 was not responsible for their actions. V49 stated the appropriate starting dose of olanzapine was 2.5 mg. Surveyor inquired as R10's psychiatric provider, why V49 would have not questioned the dose that was administered when R10 returned to the hospital (as the dose V49 continued was 800% larger (excessive) than the appropriate starting dose) until January. V49 replied, I GDRed it and that's my goal to get him off. If you look at my prescribing in the facility, I don't really prescribe antipsychotics. The electronic health record was reviewed with V49 and R10's health record indicated R10's olanzapine was discontinued on 4/22/2026 after interview with the surveyor. V49 affirmed the olanzapine was discontinued because R10 was experiencing symptoms of tardive dyskinesia, reported by staff (V2 -Director of Nursing). Surveyor asked why V2 reported it on (4/21/2026) to V49, V49 didn't discontinue the medication then? Why was cogentin prescribed instead of discontinuing the medication? V49 repeated that V49 discontinued the medication because it wasn't working. V49 denied ever witnessing R10 have tardive dyskinesia or extrapyramidal symptoms. V49 stated the facility usually completed the AIMS assessment, but that V49 would go to the facility and assess the resident tonight. When asked about tardive dyskinesia, V49 stated tardive dyskinesia is reversable. Surveyor clarified is tardive dyskinesia is always reversable, or is it potentially irreversible, and V49 [

Based on observation, interview, and record review, the facility failed to assess a resident's ability to safely self-administer medication, failed to obtain a doctor's order to self-administer medication, and failed to care plan self-administration of medication prior to initiating self-administration of medication. These failures affected one (R59) resident reviewed for self-administration of medication and has the potential to affect all 147 residents at the facility.Findings include: R59's admission Record documented that R59's diagnoses include but are not limited to hypertension, adult failure to thrive, and cognitive communication deficit. R59's (03/09/2026) Minimum Data Set documented, in part Section C. - Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 06. Indicating the resident's mental status as severely impaired.R59's (Active Order As Of: 04/20/2026) Order Summary Report was reviewed with no order noted to may self-administer his medications.R59's (Target Date: 06/10/2026) whole care plan was reviewed. R59 was not care planned to may self-administer his medications. R59's (04/20/2026) Self-Administration of Medication documented, in part Self-Determination. 1. Does the resident want to self-administer medications? C. No. B. Cognitive Status. 1. What is the resident's decision-making ability. d. Severely impaired. 3. Can resident name dosage, frequency, and reason for use of each medication? b. No. 4. Can resident tell time and state the time that each medication is due? b. No. Of note, assessment was completed on the day a med cup with 6 medications was observed at R59's bedside table.On 04/20/2026 at 11:03am, there was a med cup on R59's bedside table. This was pointed out to V12 (Social Services Coordinator) and stated she was going to take the medications because it should not be at his bedside. R59 stated he did not know who put the med cup on his bedside table. V12 counted the medications in the med cup per this surveyor's request and stated there were 6 pills in the med cup. On 04/20/2026 at 11:08am, V11 (Registered Nurse) was in the hallway facing the med cart. V11 stated she left the medications at (R59) bedside table. V11 stated she was not supposed to leave the medications at bedside and to make sure he took the medications before she left his room. On 04/22/2026 at 12:02pm, V2 (Director of Nursing) stated he is not on self-administration of medication. V2 stated his BIMS (Brief Interview of mental status) is low. V2 stated residents on self-administration of medication should be able to do a return demonstration of taking the medication, able to state the indication of each medication, and able to state when and how often to take each medication. V2 stated self-administration of medication needs order from the physician and it has to be care planned. V2 stated he is not able to self-administer medications, and his medications should absolutely not be left attended on his bedside table because residents could walk in his room and take his medications and the facility does not know if these other residents are allergic to the ingredients of his medications. V2 stated leaving medications at resident's bedside could potentially affect all residents at the facility; the facility only has one resident floor. The (2/2026) Self Administration of Medications and Treatments documented, in part Self-administration of medications and treatments is done to maintain their independence. The decision for self-administration is made by the interdisciplinary team. Guideline: 1. Self-administration of medications and treatments is determined by an order after determining that the resident can self-administer. Procedure: 2. Determination of the ability to self-administer medication will be done by the nursing using the form in PPC titled Medication Self-Evaluation Administration. 7. A care plan is for resident who self-administer, and documentation should be present in the nursing notes of teaching related to self-administration of the medications or treatments.

Based on observation, interview, and record review, the facility failed to follow their policy by 1. Failed to ensure male staff properly wear beard nets while in the kitchen. 2. Failed to ensure gloves were removed during food preparation after touching multiple nonfood surfaces and items in the kitchen, and 3. Failed to ensure food in the freezer was properly labeled and dated with a use by date. These failures have the potential to affect all 139 residents receiving food from the facility kitchen.Findings include,On 04/20/2026 at 10:48 AM, upon entrance to the kitchen, V7 Dietary Director is noted to have a beard. The beard guard he is wearing is under his chin. V7 was observed to pull the beard guard on when this surveyor entered the kitchen.On 04/20/2026 at 10:51 AM, upon entrance to the walk-in freezer there are two packages of frozen peppers and onions with no label/open date on the packages. V7 was inquired of them. V7 said, They should've been labeled and dated separately.On 04/21/2026 at 9:51 AM, upon entrance to the kitchen, V7 Dietary Director and V38 Dietary Aide are observed wearing a beard guard that is under their chins. V7 and V38 were observed pulling the beard guard up onto their face when this surveyor entered the kitchen. On 04/21/2026 at 11:00 AM, V36 [NAME] is preparing grilled cheese sandwiches and burgers for lunch substitutions. V36 donned gloves and is handling the bread and cheese with her hands, placing them into a pan on the stove and turning the sandwiches with her hands. V36 continued using the same gloved hands to handle frozen beef patties and put them on a sheet pan in the oven. V36 continued using the same gloved hands to touch multiple surfaces and objects in the kitchen. On 04/22/2026 at 10:38 AM, V7 Dietary Manager was inquired of staff wearing beard guards and glove use. V7 said, [NAME] guards should be put on when you come into the kitchen to prevent hair from falling into food. Gloves should be removed and changed with hand washing between each task to prevent cross contamination.PoliciesThe undated OnTray Dietary Policies and Procedures states in part:Dress CodePolicy: Dietary employees should wear a uniform that meets the established guidelines of the facility.Purpose: To present safe, sanitary, and professional appearanceProcedure: 7. [NAME] nets should be used for employees with facial hair.The undated OnTray Dietary Policies and Procedures states in part:Storage Labeling & DatingPolicy: Product inventory must be stored, labeled, dated, rotated, and discarded properly according to federal and state guidelines. Purpose: To ensure inventory is stored in a safe, sanitary manner to provide the best food quality and safety.Procedure: All stored products will be labeled with the name, appropriate dates and rotated following the First-In, First-Out method. (FIFO).FreezerOpened products stored in the freezer must be labeled with their received date, open date, and UB (use by) date. Opened bulk food must have a UB date. The undated OnTray Dietary Policies and Procedures states in part:Gloves for Food HandlingPolicy: Disposable gloves should be used appropriately by all employees.Purpose: To promote food safety and prevent the contamination of food.Procedure: 3. The gloves should be discarded when damaged, torn, soiled, or when interruptions occur or when handling something beyond the scope of food prep.

Based on observation, interview, and record review, the facility failed to ensure staff don appropriate personal protective equipment (PPE) when providing high contact care to a resident, failed to utilize personal protective equipment per facility policy when coming in contact with soiled linen, and failed to ensure soiled linen was bagged tightly before sending it to the laundry to be cleaned. These failures affected one (R154) resident reviewed for infection control and had the potential to affect all 147 residents at the facility. Findings include: On 04/20/2026 at 11:25am, there was an EBP sign posted close to R154's door frame. V22 (Physical Therapy Assistant) donned gloves, entered R154's room, assisted R154 in putting R154's knee brace. V22 placed a walker closer to her and R154 and hung R154's indwelling catheter bag on one of the supports of the walker, touched R154's hand and asked R154 if he was dizzy. R154 stated he was not dizzy. V22 then placed a gait belt around R154's waist, placed the walker in front of R154 and assisted R154 to stand and let R154 use the walker and instructed R154 to make sure he was holding the wheelchair before sitting on the wheelchair. V22 assisted R154 to transfer from the bed to the wheelchair without donning a gown. V23 (Director of Rehab) entered R154's room donning gloves only. On 04/20/2026 at 11:31am, this observation was pointed out to V10 (Unit 2 Supervisor) and stated she (V22) should be wearing gown and gloves when transferring a resident to protect the resident so she would not transfer any infectious organism to the resident. V22 stated she was supposed to wear gown and gloves if a resident is on EBP. V22 pointed at R154's door and stated but there was no sign posted on the door. Of note, the EBP sign was posted close to R154's door frame. On 04/22/2026 at 12:23pm, V2 (Director of Nursing) checked (R154) electronic health record and stated he is on EBP (Enhanced Barrier Precautions) because he has an indwelling urinary catheter. The expectation is for staff, including rehab staff, to don gown and gloves if they are going to transfer a resident; to follow the EBP signage, to protect the resident during transfer. V2 stated it has the potential to affect other residents they are doing rehab; not knowingly, they may have organism on their uniform and transfer it to the residents. R154's admission Record documented that R154's diagnoses include but are not limited to Type 2 Diabetes Mellitus, hypertension, and acute respiratory failure. R154's (Active Order As Of: 04/20/2026) Order Summary Report documented, in part Change urinary catheter as needed, if displaced, clogged or no urine output to ensure catheter patency; as needed for catheter patency. Active. 04/16/2026. PT clarification and order to eval(uate) and treat for 4-6weeks x 30 days. Active. 04/17/2026. R154's (04/22/2026) Minimum Data Set documented, in part Section C. – Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating the resident's mental status as cognitively intact. R154's (04/16/2026) careplan documented, in part requires use of an indwelling catheter r/t (related to) Dx (diagnosis) Neurogenic Bladder. The (undated) EBP (Enhanced Barrier Precautions) Residents list includes R154. The (1/2026) Enhanced Barrier Precautions (EBP) documented, in part EBP extends the use of PPE (personal protective equipment) and refers to the use of gowns and gloves during high contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. MDRO and XDRO indirectly transferred from residents to residents during this high contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs and XDRO's. The use of gown and gloves for high contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/ or indwelling medical devices regardless of MDROs & XDROs colonization as well as for residents with MDRO and XDRO infection or colonization. Policy: EBP requires the use of gowns and gloves during high contact resident care activities that provide opportunities for transfer of MDROs and XDRO's to staff hands and clothing. High contact resident care activities requiring gown and gloves use among residents that trigger EBP use include: transferring. Note: EBP should be followed during transfers or assisting and when working with the resident in the therapy gym. Specifically, when anticipating close physical contact with transfers and mobility. On 4/21/2026 at 11:08 AM V33 (Housekeeping & Laundry Director) and surveyor observed soiled linen in the laundry chute not in a plastic bag, and laundry in the dirty laundry receiving bin not in a plastic bag. V33 stated the facility policy is soiled linen should be sent to the laundry room in a plastic bag so it is protected, does not touch laundry staff, and does not cause cross contamination which could affect laundry staff or residents. On 4/21/2026 at 11:12 AM surveyor observed an isolation gown hung on a hook behind the door in the dirty utility room. V33 (Housekeeping & Laundry Director) stated isolation gowns are not to be reused. Staff wear isolation gowns in the dirty utility room because they are in contact with dirty linens that sometimes carry infectious diseases. Isolation gown are single use and reuse can cause spread of infection to the staff that then can be passed on to residents. On 4/21/2026 at 11:25 V34 (Laundry Aide) was observed putting on the isolation gown that was hanging on the hook behind the door to the dirty utility room. V34 stated it was the second time today V34 used that isolation gown. V34 stated I use the gowns usually once or twice before I change them. I know I should use a new one each time to prevent contamination. V33 (Housekeeping/Laundry Director) was present and stated the expectation is staff should use a new gown is each time they put on an isolation gown and a gown and gloves should be worn when working with dirty linen. Policy titled Linen Handling revised 1/2026 stated double bagging linen is recommended only if the outside of the bag is visibly contaminated. Employees will wear appropriate personal protective equipment (PPE) when handling contaminated linen (gloves and gowns in the laundry area).

Based on observation, interview, and record review the facility failed to maintain a safe, functional, and sanitary environment by failing to ensure dryer lint traps were clean and without damage. This failure has the potential to cause a fire and has the potential to affect all 147 residents at the facility. Findings include: On 4/21/2026 at 11:20 AM V35 (Housekeeping/Laundry Aide) stated dryer lint traps were cleaned every two hours. V33 (Housekeeping/Laundry Director), V35 and surveyor observed dryer number two which had a damaged lint screen and large amount of lint. V35 stated V34 (Laundry Aide) told V8 (Maintenance Director) about the damaged lint trap at least a week ago.On 4/21/2026 at 11:25 AM V34 (Laundry Aide) stated the damaged lint trap was reported yesterday or the day beforeOn 4/21/2026 at 11:28 AM V8 (Maintenance Director) was asked about the damaged lint trap. V8 stated, V8 was just informed today. V33 (Housekeeping/Laundry Director) just told V8. No one reported it before today.On 4/22/2026 at 2:50 PM V8 (Maintenance Director) stated dryer number two was taken out of service on 4/21/2026 after surveyor identified the damaged lint trap. V8 stated the lint trap prevents lint from going into the exhaust and outside into the environment. A damaged lint trap can cause a fire.Facility Policy titled Lint Cleaning dated January 2026 stated all dryers and lint traps must be kept clean to prevent fire hazards and maintain a safe, sanitary environment. After each load, remove lint from the lint screen.Illinois Long Term Care Ombudsman Program Residents' Rights for People in Long Term Care Facilities stated your rights to safety include facility must be safe, clean, comfortable

Based on observation, interview and record review, the facility failed to prepare food that was palatable, attractive and prepared in a manner that conserved nutritive value, flavor and appearance. This failure affected 139 residents that consume food from the kitchen. Findings include: Facility census (4/20/2026) documents that 147 residents reside in the facility. Document titled, NPO (Nothing By Mouth) Residents documents in part 8 residents do not consume oral intake, indicating that 139 residents consume food from the kitchen. R17's face sheet documents diagnoses that include but are not limited to type 2 diabetes, multiple sclerosis, depression, suicidal ideations, and spastic hemiplegia. R17's BIMS (brief interview for mental status) score, dated 2/24/26, is 14 which indicates R17 is cognitively intact. On 4/20/26 at 10:01am, R17 said, The nurses are really good here. My main concern here (facility) is the food. They (kitchen staff) can't even cook vegetables. They (kitchen staff) overcook vegetables. There's no taste and sometimes I can't even tell what is on my plate. R104's face sheet documents diagnoses that include but are not limited to chest pain, aortocoronary bypass, and hernia. R104's BIMS (brief interview for mental status) score, dated 2/24/26, is 15 which indicates R104 is cognitively intact. On 4/20/26 at 10:06am, R104 said, I don't know if you were planning on talking to me, but can you please do something about the food here. Most of us (residents) are eating out because the food is not edible. Some food is unrecognizable. Some of us (residents) don't have the money to be eating out, but whatcha gonna do. I ate better living on the streets. The food is cold, and the meat is like carboard. R132's face sheet documents diagnoses that include but are not limited to type 2 diabetes, COPD (chronic obstructive pulmonary disease), and myocardial infarction. R132's BIMS (brief interview for mental status) score, dated 3/11/26, is 13 which indicates R132 is cognitively intact. On 4/20/26 at 10:46am, R132 said, Baby! Baby! Please come here. I need your help. The food is awful here. I'm not talking like the food is bland, the food is gross. It has taste, but not a good taste. The food is always cold and tough. They (facility) barely give you any food on your plate, which I would be complaining about, but it tastes so awful I don't want it. Thank you baby! R5's face sheet documents in part the following diagnoses: other pulmonary embolism, type 2 diabetes mellitus with foot ulcer, chronic obstructive pulmonary disease, chronic diastolic heart failure, fibromyalgia, gastro-esophageal reflux disease, hypertension, spinal stenosis, hypothyroidism, major depressive disorder, and anxiety disorder. R5's minimum data set (1/14/2026) documents in part a brief interview of mental status summary score of 15, indicating R5 is cognitively intact. On 4/20/2026 at 11:15 AM, R5 stated, The food here is terrible! Horrible! The other day we had a French toast casserole and it tasted horrible. I don't understand why they couldn't just serve it all separate. Separate eggs, sausage and French toast. But no, I had to put syrup on my eggs. It's not just breakfast it's all the foods. The food is overcooked all the time and under seasoned. We complain over and over but the facility doesn't do anything about it. On 04/21/2026 11:03 AM, a resident council meeting was held. 14 residents were in attendance. The resident council unanimously agreed that the council had concerns with the food. Things like the food being cold, unseasoned. The resident council agreed that these concerns were addressed to the facility, but nothing has been done. Food is still an issue. Facility dietary spreadsheet for 4/21/2026 documents in part the lunch meal served is Baked Fish 3 oz, Cheesy [NAME] #8 scoop, Buttered Peas 4 oz spdl, Bread/Margarine 1 slice /1 tsp, Pudding #8 scoop, Beverage 8 oz. The facility recipe for the baked fish instructs to cook the [NAME] by completing the following steps: The portion size for the cod is indicated to be 3 ounces. A QR code on the recipe shows a picture of the presentation of the meal: The plate has a piece of off-white tan fish that occupies approximately 1/3 of the plate, full, vibrant green peas approximately 1/3 of the plate and a portion of golden yellow rice within a sauce mixture (appears to be a cheese sauce). The fillet looks well-seasoned with herbs, appears moist, and appetizing. R27's face sheet documents the following diagnoses: degenerative disk disease, hyperlipidemia, hypertension, bradycardia, and vitamin B12 deficiency anemia. R27's minimum data set (3/05/2026) documents in part a brief interview of mental status (BIMS) summary score of 8, indicating R27 is cognitively impaired. On 4/21/2026 at 12:15 PM, observed dining in dining room (behind Rooms 51-59). The lunch served was [NAME], rice with cheese, and green peas. Observed R27's meal and R27 had pieces of [NAME] that appeared dry, whitish color. The piece of [NAME] was about ¾ of an inch thick. R27 affirmed that the food is warm, but that the fish tasted dry and the food was bland. Observed R27 ask R155 for R155's barbeque sauce to add moisture to the fish. R155's face sheet documents in part the following diagnoses: chronic obstructive pulmonary disease, emphysema, hyperlipidemia, anxiety, heart failure, and shortness of breath. R155 was admitted on [DATE]. On 4/21/2026 at 12:16 PM, observed R155 in the dining room eating lunch. R155's [NAME] on the plate appeared dry and hard. The piece of [NAME] was about ¾ of an inch thick. The peas appeared a dull green color. R155 was interviewed and appeared cognitively intact. R155 stated The food is terrible. The fish is dry and there is no taste. The peas look stale. I asked for a hamburger instead. Observed a partially wrapped hamburger on R155's tray with a bite out of it. R155 added, We have brought these (food issues) up at the resident council and nothing is done. On 4/21/2026 at 12:47 PM, a test tray was provided by V7 (Dietary Manager). The test tray consisted of 1 piece of baked [NAME] fillet, peas, white rice with clumps of orange cheese throughout, a plastic cup with vanilla pudding, and fruit juice beverage. The [NAME] appeared desiccated and approximately three quarters of an inch thick. The [NAME] was golden brown and tough in texture. The peas appeared dry. V7 affirmed that the [NAME] appeared overbaked. V7 denied wanting to taste the food on the test tray. On 4/21/2026 at 12:51 PM, the test tray was observed by V1 (Administrator). V1 denied the test tray appeared palatable, and stated, yeah the fish looks dry, the peas look very dry too. V1 denied the tray appeared appetizing. V1 denied wanting to taste the food that was served on the test tray. V1 stated, I will address this with the dietary staff. On 4/21/2026 at 12:58 PM, V9 (Registered Dietician) affirmed V9 is the dietician for the facility. V9 observed the test tray and confirmed the fish appeared a little dried out. V9 explained that the fish was delivered in 3 ounce pre-cut fillets and baked. V9 denied wanting to consume the fish or peas on the test tray. V9 consumed the cheesy rice and affirmed that the rice tasted like rice and cheese, and did not want to consume the fish or peas. V9 stated, the peas look like peas to me. V7 (Dietary Manager) stated the [NAME] were new on the menu, and they had cooked down from the 3 oz portion that was delivered. Surveyor requested that the facility weigh the [NAME] portion served on the test tray. Observed the food scale and V9 affirmed the scale was zeroed and in working condition. V9 placed the [NAME] fillet from the test tray on the scale and the scale registered 1.5 oz. This finding was confirmed with V7 and V9. V7 stated, that yeah, they cooked down in the pan from when they were delivered. All the residents we served 1 fillet. V9 confirmed that the fish was the protein served for lunch and was unsure the total amount of protein being served. V7 denied that the dietary staff weighed the [NAME] fillets prior to serving them to the residents. V9 affirmed that best practice is to be weighing protein items prior to being served to ensure the right number of ounces are being served. V9 affirmed the facility should be following the recipes and that food should be palatable when served. On 4/21/2026 at 4:03 PM, R5 stated, No, I didn't get the fish served at lunch today. I heard it was dry from other residents. I got a chicken, it was so dry, so rough. It had no seasoning. I would have ate the [NAME], I don't know why they switched me. The chicken didn't taste or look good. Like I told you, everything here is either cooked to oblivion or not cooked enough. R90's face sheet documents in part the following diagnoses: Chronic obstructive pulmonary disease, type 2 diabetes mellitus, unspecified dementia, unspecified psychosis, muscle wasting, atrophy, hypertensive heart disease, generalized osteoarthritis, hypothyroidism, bipolar disorder, and chronic pain syndrome. R90's minimum data set (4/8/2026) documents in part, a brief interview of mental status (BIMS) summary score of 13, indicating R90 is cognitively intact. On 4/22/2026 at 10:52 AM, R90 stated, The food here is not good, not good at all. Yes, they (the staff) know, we complain a lot about it. I have served on the resident council for years in this facility, I am very active with the council. Yesterday I had the fish, I couldn't even cut it. It was too hard. They cook chicken too long too everything is too crispy. Too overcooked. On 4/22/2026 at 12:39 PM, V5 (Social Services Director) affirmed that V5 assists with the grievance process within the facility. V5 stated, Yes, I have heard residents complain about the food. They will say like the chicken is dry. When a resident complains about the food, I tell V7 (Dietary Manager) so that the dietary department can follow up. On 4/22/2026 at 4:38 PM, V2 (Director of Nursing) recalled that residents have voiced concerns to V2 about the food but could not recall which residents. V2 stated, I remember them saying things like the food is bland or not well seasoned. V2 explained that protein is important for overall health and the healing process, including wound healing. Undated email provided by the facility authored by V47 (Director of Nutrition Services, Registered Dietician) indicates the baked fish served for lunch was supposed to be a 3-ounce portion for a total serving of protein of 7.66 ounces of protein a day. Facility policy titled, GUIDELINES IN MENU PLANNING documents in part, All menus meet the Centers of Medicare and Medicaid Services health requirements. Serving size equivalents are typically 1/2 cup (4 ounce) portion sizes . Facility policy titled Presentation of the Meal (2025) documents Policy: Meals are served attractively, accurately, efficiently and at the appropriate temperature. Purpose: Food is presented attractively to encourage optimum consumption .

Based on observation, interview, and record review, the facility failed to ensure that staff ordered and administered medications to a newly admitted resident (R156); failed to document the administration of medications immediately following administration for 12 (R6, R25, R52, R61, R87, R106, R115, R120, R126, R131, R139, and R142) residents. These failures affected 13 residents reviewed in a sample of 76 residents. Findings include: 1) R6's Medication Admin Audit Report, dated 4/22/26, documents that on 4/08/26, R6's medications that were due for 9:00am: Docusate Sodium, Hydroxyzine HCl, Levetiracetam, Furosemide, Loratadine, Gabapentin, Aspirin, Calcium, Nabumetone, Polyethylene Glycol, Magnesium Oxide, and Vitamin C were administered at 11:33am (one hour and 33 minutes late). R25's Medication Admin Audit Report, dated 4/22/26, documents that on 4/08/26, R25's medication, Cetirizine, that was due for 8:00am was given at 2:15pm (5 hours and 15 minutes late) and R25's medication, Lexapro, that was due for 9:00am was given at 2:15pm (4 hours and 15 minutes late). R52's Medication Admin Audit Report, dated 4/22/26, documents that on 4/08/26, R52's medications that were due for 9:00am: Eliquis and Memantine HCl were given at 3:45pm (5 hours and 45 minutes). R61's Medication Admin Audit Report, dated 4/22/26, documents that on 4/08/26, R61's medication, Sucralfate, that was due for 7:00am was given at 2:01pm (6 hours and one minute late); R61's medications that were due for 9:00am: Aspirin, Amlodipine, Losartan were given at 3:51pm (5 hours and 51 minutes late); and R61's medications that were due for 9:00am: Carvedilol, Plavix, Docusate Sodium, Ferosul, Tizanidine, Polyethylene Glycol were given at 5:05pm (7 hours and 5 minutes late). R87's Medication Admin Audit Report, dated 4/22/26, documents that on 4/08/26, R87's medications that were due for 9:00am: Famotidine, Pyridoxine HCl, Thiamine HCl, Carvedilol, Losartan Potassium, Dapagliflozin Propanediol, and Folic Acid were given at 1:43pm (3 hours and 43 minutes late). R106's Medication Admin Audit Report, dated 4/22/26, documents that on 4/08/26, R106's medications that were due for 9:00am: Protonix, Lexapro, Hydralazine, Ferrous Sulfate, Folic Acid, Aspirin, Amlodipine Besylate, Potassium Chloride, And Metoprolol Tartrate were given at 2:54pm (4 hours and 54 minutes late). R115's Medication Admin Audit Report, dated 4/22/26, documents that on 4/08/26, R115's medications that were due for 9:00am: Metformin, Amlodipine Besylate, Metoprolol Tartrate, Baclofen, Vitamin C, and Gabapentin were given at 2:30pm (4 hours and 30 minutes late). R120's Medication Admin Audit Report, dated 4/22/26, documents that on 4/08/26, R120's medication, Aspirin, that were due for 8:00am was given at 1:29pm (4 hours and 29 minutes late) and R120's medications that were due for 9:00am: Multivitamin, Cholecalciferol, Amlodipine Besylate, and Enalapril Maleate were given at 1:29pm (3 hours and 29 minutes late). R126's Medication Admin Audit Report, dated 4/22/26, documents that on 4/08/26, R126's medications that were due for 8:00am: Cholecalciferol and Coreg were given at 11:57am (2 hours and 57 minutes late); R126's medication, Metformin and Lasix, that was due for 8:00am was given at 5:11pm (8 hours and 11 minutes late); and R126's medications that were due for 9:00am: Gabapentin, Eliquis, and Farxiga were given at 5:12pm (7 hours and 12 minutes late). R131's Medication Admin Audit Report, dated 4/22/26, documents that on 4/08/26, R131's medications that were due for 9:00am: Aspirin, Calcium, Docusate Sodium, Ferrous Sulfate, Lasix, Cephalexin, and Acetaminophen were given at 12:00pm (2 hours late). R139's Medication Admin Audit Report, dated 4/22/26, documents that on 4/08/26, R139's medication, Depakote, that was due for 8:00am was given at 3:53pm (6 hours and 53 minutes late) and R139's medications: Polyethylene Glycol, Levetiracetam, and Loratadine, that were due for 9:00am were given at 3:53pm (5 hours and 53 minutes late). R142's Medication Admin Audit Report, dated 4/22/26, documents that on 4/08/26, R142's medications that were due for 9:00am: Gabapentin, Duloxetine HCl, and Centrum were given at 5:00pm (7 hours late). On 4/22/26 at 2:58pm, V28 (Registered Nurse/RN) affirmed that V28 was responsible for administering medication to R6, R25, R52, R61, R87, R106, R115, R120, R126, R131, R139, and R142 on 4/08/26 am shift (7:00am to 3:00pm). V28 said, I believe I gave the medications on time, and I just signed them out at a later time than when they (medications) were actually given. I gave them (medications) on time and signed them out later. It being my first day off orientation, I just wanted to make sure I got all the medications passed out on time. When I give the medication I am supposed to sign it off. Right away. Record review of facility document titled, Daily Assignment Sheet, dated 4/08/26, documenting that V28 (Registered Nurse/RN) was the nurse assigned to R6, R25, R52, R61, R87, R106, R115, R120, R126, R131, R139, and R142 on 4/08/26 am shift (7:00am to 3:00pm). On 4/22/26 at 4:08pm, V2 (Director of Nursing/DON) said, Sign off that the medication was given immediately, once they swallow the medication. I did speak with all the nurse's about that. Record review of facility policy titled, Medication Administration, dated 2/2026, documents, in part, General: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Check medication administration record prior to administering medication for the right medication, dose, route, patient/resident and time. Verify that the medication is being administered at the proper time, in the prescribed dose, and by the correct route. Document as each medication is prepared on the MAR (medication administration record). Explain procedure to resident and give the medication. Remain with the resident to ensure that the resident swallows the medication. If medication is not given as ordered, document the reason on the MAR and notify the Health Care Provider if required. If the physician's order cannot be followed for any reason, the physician should be notified in a timely manner (depending on the situation), and a note should reflect the situation in the resident's medical record. Record review of pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, in part, Your facility must be safe, clean, comfortable, and homelike. 2) R156 is [AGE] years old admitted to the facility on [DATE], face sheet listed the following past medical history, chronic obstructive pulmonary disease, hypokalemia, alcohol abuse with withdrawal, rheumatoid arthritis, tobacco abuse counseling, hypothyroidism, noninfective gastroenteritis, chest pain, etc. admission evaluation dated 4/20/2026 documented that R156 is alert and oriented x3, can make needs known and communicate with a clear speech. Review of medical record showed after visit summary from the hospital, medication list and 5 medication scripts scanned on 4/20/2026 at 1600. On 04/21/2026 1:30 PM, R156 was observed in her room, awake and alert with the daughter and both were visibly upset. R156 said that she was admitted to the facility yesterday (4/20/2026) at 1:30PM, she did not receive any medication the whole day until this morning. R156 stated that she was upset and up all night, she did not get her anxiety medication or breathing treatments, she ended up calling her daughter in the middle of the night. The nurse on duty kept on telling her that she is working on her medications. Resident's daughter stated that she handed her medication list from the hospital to the social worker when they arrived, and she does not understand why facility could not get her medication on time. On 04/21/2026 12:00PM, V25 (LPN) said that R156 is very upset about not getting her medication yesterday, she came around 2:00PM, V25 said that she took the initial vitals and handed it over to the afternoon shift nurse. Resident's daughter brought her, and she did not come with any packet, her medication list was not available. On 4/21/2026 at 1:45PM V44 (Admissions Director) said that R156 arrived at the facility around 2PM with paperwork that included medication list and about 5 scripts, the documents were scanned into the system but the person at the front desk forgot to give it back to the person transporting the resident to the unit. V44 said that the documents were scanned two hours later, and it was given to the nursing staff when they asked for it. V44 is not sure how long it takes the nurses to get medications from pharmacy. Medication administration record (MAR) for R156 showed that the following medications were not signed out as given on 4/20/2026: Mirtazapine 15mg tablet scheduled at 2100, Ativan 1mg tablet every 8 hours for anxiety, Ipratropium-albuterol 0.5mg-3mg (25mg base) for wheezing, Lomotil oral tablet 2.5-0.25mg. 1 tablet by mouth every 6 hours for diarrhea, and Albuterol 90mcg/actuation inhaler, inhale 1 puff into lungs every 4 hours as needed for wheezing. On 4/22/2026 at 2:07PM, V2 (DON) said that when a new resident is admitted , the nurse is supposed to send the medication list to pharmacy after verifying the medication with the physician and clarify the expected time of arrival (ETA). If the medication does not arrive on time, the nurse is supposed to pull the medication from the emergency box if it takes time for the medication to arrive. All nurses have been in-serviced, and they all have access to the emergency box. Emergency medication list provided by V2 showed that, Ativan 1mg tablet every 8 hours for anxiety, Ipratropium-albuterol 0.5mg-3mg (25mg base and Albuterol 90mcg/actuation inhaler were among the listed medications. Surveyor attempted several times to speak to the afternoon shift and night shift nurses assigned to R156 on 4/20/2026 but none of them answered their phone. Surveyor informed V2 (DON) of not being able to contact the 2 nurses and she said, I have tried to call them, and they did not answer, I cannot force them to answer their phone. Surveyor requested a facility policy on ordering medications for new admissions, but none was provided. Job description for registered nurses (RN) and practical licensed nurses (LPN) (undated) documents in part: Basic Function: Under the direction of the physician, is responsible for total nursing care to all residents on assigned unit during the assigned shift including responsibility for delegation of duties, resident nursing care, staff performance and adherence by staff members to facility policies and procedures. Essential Duties 1. Participate in the development and implementation of individualized patient care plan for the residents with allied health team members. 9. Recognize significant changes in the condition of residents and take necessary action. 10. Document nursing care rendered, resident response, and all other pertinent and necessary data as outlined in facility's policies and procedures. United RX STAT orders policy dated July 2024 stated in part: Emergency pharmaceutical services will be available at all times. An emergency need for medication will be met by using facility's approved contingency supply or by sending an emergency order to unitedRX pharmacy. Procedure: 1. When an emergency or STAT order is received, the nurse will determine if the medication is in the emergency dispensing kit by referring to the list of contents posted on it. 2. If the medication is not available, an emergency delivery can be requested by faxing a stat order to the pharmacy. 3. The pharmacy will deliver the emergency or stat medications as soon as possible, usually within 2 to 4 hours.

Based on observation, interview, and record review, the facility failed to implement individualized fall prevention intervention for a resident identified at risk for falls, failed to prevent falls during provision of ADL (activities of daily living) care, and failed to ensure oxygen tanks were secured in the storage room. These failures affected two (R4 and R8) residents and have the potential to affect all 17 residents in Unit C Wing. Findings include: 1) On 04/20/2026 at 1:33pm, R8 stated the CNA (who was later identified as V40 – CNA) was changing him and she put him on his side facing the window and she was pushing something on his side and the next thing he knew he was on the floor, naked. R8 stated (V40) left him for about 35minutes. She came back with other staff (who was later identified as V17 – CNA, V25 (Licensed Practical Nurse), and V41 CNA) and they picked him up on the floor. R8 stated he informed (V16 – Licensed Practical Nurse) the next day that he fell; and she told him he needed to go the hospital. On 04/22/2026 at 9:46am, V40 (Certified Nursing Assistant) stated she was working the 7a-3pm shift. She got the towels and linens to give him a bed bath and to change the linens on his bed. V40 stated she noticed his bed sheet was wet because his indwelling urinary catheter was leaking. V40 stated it was not the urinary bag because she checked inside the bag, and it was not wet, so she knew the leak was coming from the indwelling urinary catheter. V40 stated she put the head of bed up at about 75 degrees, made sure he had his gown on; she left the room and let (V25- Licensed Practical Nurse) know his indwelling urinary catheter was leaking; she (V25) said she'd be in the room to change the indwelling urinary catheter. V40 stated she went back to the room and gave him a bed bath. She stripped the bed sheet, turned him (R8) to the left side towards the window and tucked in the clean linen under, and all of the sudden he fell over the side of the bed. He was between the bed and the window. V40 stated she went to the other side of the bed and helped him down to the floor. V40 stated she made sure he did not hit anything, and he (R8) said he was fine and did not hit anything. This surveyor inquired what contributed to the fall. V40 stated his mattress was wet because his indwelling urinary catheter was leaking and she was tucking fresh linen underneath him while he was on his side, the mattress was wet because of the urine and he slipped. V40 stated she should not have tucked the linen underneath him while he was on his side with a wet mattress. She should have dried the mattress first so he would not slipped and rolled over. V40 stated it is not expected of a resident to fall during ADL (Activities of Daily Living) care. On 04/22/2026 at 10:54am, V41 (Certified Nursing Assistant) stated he was doing his rounds on the hall and she (V40) was waiting for his (R8) nurse. He (V41) asked her what was going on and she (V40) informed him (V41) that (R8) fell off the bed. V41 stated he (V41) went to (R8) room and assessed the situation. V41 stated he saw (R8) was on the floor, on the left side of the bed by the window facing the ground kind of on the side. V41 stated he asked (V40) what happened and she stated she was doing a bed bath and he rolled out of the bed. V41 stated it was not expected of a resident to fall while performing adl care. V41 stated what contributed to the fall was, he (R8) was using a low air loss mattress, the mattress was wet and she rolled him on his side; there is a high tendency for a resident to fall and injure self because the mattress is slippery when wet. V41 stated best practice is to keep the mattress dry before turning the resident on their side to prevent them from slipping and rolling out of bed. On 04/22/2026 at 12:20pm, V2 (Director of Nursing) stated it is not expected of a resident to fall during ADL (Activities of Daily Living) care. The expectation is not to roll a resident on a wet mattress, especially a low air loss mattress, to prevent falls because if the mattress is wet, it becomes slippery, and the resident will slip. V2 stated the CNAs are not expected to put fresh linen if the mattress is wet with urine; the expectation is to make sure the mattress is clean and dry before putting fresh linen in. R8's admission Record documented that R8 diagnoses include but are not limited to Type 2 Diabetes Mellitus, hypertension, and spastic quadriplegia. R8's (Active Order As Of: 04/20/2026) Order Summary Report documented, in part Change urinary catheter as needed, if displaced, clogged or no urine output to ensure catheter patency as needed for catheter patency. Active R8's (02/20/2026) Minimum Data Set documented, in part Section C. – Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 14. Indicating the resident's mental status as cognitively intact. Section G. Functional Abilities. GG 0170. Mobility. A. rolling left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed. 01 - Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. Section H – Bladder and Bowel. H0100. Appliances. A. Indwelling catheter. R8's (11/17/2025) care plan documented, in part is at risk for falls decline in mobility and recent hospitalization. will remain free from falls through. Intervention: Notify MD and family of any new fall. R8's (11/17/2025) careplan documented, in part requires use of an indwelling catheter r/t (related to) Dx (diagnosis) Neurogenic Bladder. R8's (11/17/2026) careplan documented, in part At risk for skin complications r/t comorbidities including but not limited to impaired mobility, incontinence of bowel, cerebral palsy, contractures. Intervention: Use pressure redistribution surface if bed-or chair-bound. R8's (11/18/2025) care plan documented, in part has Alteration in musculoskeletal status r/t DX GOUT , dx Scoliosis. Intervention: Monitor for risk of falls. Educate resident, family /caregivers on safety measures that need to be taken in order to reduce risk of falls. R8's (12/03/2025) careplan documented, in part Wound healing /may be delayed related to Diabetes Mellitus, Immobility, Incontinence. Intervention: Pressure redistribution mattress. Keep linen clean, dry and wrinkle free. 2) R4's face sheet documents in part the following diagnoses: cerebral infarction, hemiplegia, pneumonia, dependence on supplemental oxygen, disorder of kidney and ureter, type 2 diabetes mellitus, hyperlipidemia, and morbid (severe) obesity. R4 is a DNR and on hospice service since 2/10/26. On 04/20/2026 11:20AM, R4 is alert and oriented to person with a BIM's score of 4. Observed R4 laying in bed in high position. R4 stated he cannot lower or raise the bed. Observed there was no thick floor mat to the right side of R4's bed. On 04/20/2026 2:50 PM, observed R4 in bed with mid-level height and no thick floor mat next to resident's bed. Observed 2 thick mattresses folded and upright by the resident's door. On 4/21/26 10:46 AM, no thick floor mattress to right side of R4's bed. The care plan dated 12/12/25 indicates resident has mattress in room. On 4/21/26 3:04 PM, observed V10 (Unit 2 Supervisor) placing thin floor mat in R4's room. Noted the 2 thick mattresses were missing. V10 (Unit 2 Supervisor) stated 2 mattresses were delivered on 4/20/26 and one was for R4 but both were taken back by accident. On 04/20/2026 11:20AM, R4's face sheet documents in part the following diagnoses: cerebral infarction, hemiplegia, pneumonia, dependence on supplemental oxygen, disorder of kidney and ureter, type 2 diabetes mellitus, hyperlipidemia, and morbid (severe) obesity. R4 is a DNR and on hospice service since 2/10/26. R4 is on Enhanced Barrier Precautions (EBP). R4 is alert and oriented to person with a BIM's score of 4. R4 laying in bed in high position. R4 states he cannot lower or raise the bed. R4 is a hoyer lift with 2 person assistance. Surveyors observed there was no thick floor mat to the right side of R4's bed. On 04/20/2026 2:50 PM, R4 is in bed with mid-level height and no thick floor mat next to resident's bed. Observed 2 thick mattresses folded and upright by the resident's door. On 4/21/2026 10:46 AM, no thick floor mattress to right side of R4's bed. The care plan dated 12/12/25 indicates resident has mattress in room. On 4/21/2026 3:04 PM, observed V10 (Unit 2 Supervisor) placing thin floor mat in R4's room. Noted the 2 thick mattresses were missing. V10 (Unit 2 Supervisor) stated 2 mattresses were delivered on 4/20/26 and one was for R4 but both were taken back by accident. On 4/22/2026 10:50 AM, R4 had thin floor mat to the right side of R4's bed. On 4/22/2026 5:00 PM, reviewed facility's falls' logs from January 2026 to current. R4 had two falls. Fall occurred on 2/6/2026 22:30 (10:30 PM) and on 4/20/2026 04:45 (4:45 a.m.). R4's falls incident report dated 2/6/2026 22:30 (10:30 PM) noted R4 observed on the side of the bed on the floor. R4 stated he was trying to reach for the bed remote. R4 verbalized hitting his head and had pain to bilateral lower extremities (BLE). Physician notified and staff received order to send R4 to the hospital for further evaluation. R4's incident report dated 4/20/2026 04:45 (4:45 AM) noted nursing observed R4 sitting on the floor on the side of the bed on the right side. R4 denied hitting his head. Note indicates R4 is confused and unable to give description of events. 3) Facility census, dated 4/20/26, documents 17 residents residing on the C Wing Unit 2 hall. On 4/20/26 at 10:14am, upon observation of the C Wing Unit 2 storage room with V18 (Housekeeping Aide), 2 unsecured oxygen tanks (1-approximately 1/4 full; 1-approximately half full) were observed on the floor. Also observed were 7 other secured oxygen tanks. V18 said that V18 would notify the nurse about the 2 unsecured oxygen tanks because we (facility) don't need things exploding. On 4/20/26 at 10:54am, upon observation of the C Wing Unit 2 storage room with V19 (Licensed Practical Nurse/LPN), the same 2 unsecured oxygen tanks (1-approximately 1/4 full; 1-approximately half full) were observed on the floor. V19 said, These oxygen tanks need to be in rack with others (oxygen tanks). V19 preceded to pick up and place the 2 unsecured oxygen tanks in the oxygen racks and replied, They (oxygen tanks) should be in the racks, so they (oxygen tanks) don't tip over and explode. On 4/22/26 at 4:08pm, V2 (Director of Nursing/DON) said, The tanks (oxygen tanks) should be on a rack, so they (oxygen tanks) are secured. Oxygen tanks are combustible, so the rack secures the tank (oxygen) and prevents that (combustion). Record review of facility policy titled, Oxygen Cylinder, dated 1/2026, documents, in part, Standards for the safe handling of cylinder gases are set by the national fire protection association (NFPA) and regulated by the Compressed Gas Association (CGA). AdministrativeAuthorities shall ensure that these standards and any others that apply are met. Storage of Oxygen Cylinders: Store in designated oxygen storage area, Oxygen cylinders must be protected from mechanical shock, falling objects, etc. Record review of facility policy titled, Oxygen Therapy, dated 2/2026, documents, in part, Oxygen therapy may be provided through various types of supply and delivery systems. Equipment may include the provision of oxygen through nasal cannulas, trans-tracheal oxygen catheters, oxygen canisters, cylinders or concentrators. Record review of pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, in part, Your facility must be safe, clean, comfortable, and homelike. The (undated) Residents' Right For People in Long Term Care Facilities documented, in part As a long-term care resident in the State, you are guaranteed certain rights, protection, and privileges according to state and federal laws. Your rights to dignity and respect. Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide services to keep your physical and mental health, at their highest practical levels. The (2/2026) Fall Prevention and Management documented, in part This facility is committed to maximizing each resident's physical, mental, and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe and environment as possible.

Based on observation, interview and record review, the facility failed to remove expired medication from three of four carts reviewed for medication storage. This failure has the potential to affect 53 residents that receive medications from these carts.Findings include: On 04/20/2026 1:17 PM, checked the Hall A-1 cart with V25 (LPN) and observed the following: 1 bottle of Zinc Oxide 50 mg with an expiration date of 11/2025.1 bottle of Vitamin B tablets with an expiration date of 12 /12/20251 bottle of Famotidine 20 mg with expiration date of 2/20261 bottle of Loratadine 10 mg, expiration date 02/20251 bottle of Vitamin A 2400 mcg, expiration date 9/2025.V25 was presented with this observation, and she acknowledged that the medications are expired, V25 added that someone from pharmacy usually comes to check the carts, not sure how those medications are still in the cart04/20/2026 2:05 PM, checked the Hall D/B Cart with V26 (LPN) and noted the following: Locked Controlled Substances - No issues or concerns.1 bottle of Aspirin 81 mg, expiration date 3/20261 bottle of liquid Pink-Bismuth, expiration date 3/2026, opened 4/8/26.V26 was presented with this observation, she confirmed that the medications are expired and stated that she does not even know how the liquid pink Bismuth has an open date of 4/8/2026 when it is expired.On 04/20/2026 2:30 PM, reviewed the medication cart in the locked unit with V27 (LPN) and noted the following:On bottle of liquid Pink-Bismuth (unopened) with expiration date of 2/2026.V27 confirmed that the medication had expired and said that she does not know why it was still in the cart, she will just get rid of it.On 4/22/2026 at 2:07PM, V2 (DON) said that expired medications are not supposed to be in the medication cart.Medication storage policy revised 2/2026 stated in part:General: Medications and biologicals are stored safely, securely, and properly following the manufacturer or supplier's recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.14. Outdated, contaminated, or deteriorated drugs and those in containers which are cracked, soiled, or without secure closures will be immediately withdrawn from stock by the facility. They will be disposed of according to drug disposal procedures and reordered from pharmacy if a current order exists.

Based on observation, interview, and record review the facility failed to follow their Medication Administration Policy by not notifying the physician that a resident's anti-seizure medications were not available in a timely manner. This failure resulted in R10 having a seizure the next morning and being sent out to the hospital. This failure affected 1 (R10) of 3 residents reviewed for Quality of Care/Treatment.Findings include: On 2/18/2026 at 3:09PM, V2 (DON-Director of Nursing) stated pharmacy notified the DON the delivery hours for medication had a cut off time after 4:00PM on 12/24/2025 due to the holiday. V2 stated the facility nurses use the (medication dispensing system) machine to retrieve medications that have not been delivered from the pharmacy and are given to the residents as ordered by the doctor. V2 states if the medication is not available in the (medication dispensing system) machine the nurse should call and notify the doctor and family, but R10's nurse did not notify V35. V2 stated Dilantin was the only anti-seizure medication in (medication dispensing system) out of the 3 anti-seizure medications R10 takes for the seizure diagnosis. V2 states R10 was given Dilantin pulled from (medication dispensing system) the next day on 12/25/2025.On 2/19/2026 at 12:38PM, V35 (Nurse Practitioner) states on 12/24/2025 around 6:00PM, V35 was notified by R10's nurse of R10's admission into the facility. V35 stated he was not notified that the facility did not have 2 of R10's seizure medications in the (medication dispensing system) machine. V35 stated he was unaware of the pharmacy's cut-off hours because of the holiday. V35 stated R10's nurse did not call V35 on 12/24/2025 in the late evening to notify V35 that R10 did not take any of her anti-seizure medications. V35 stated if he was notified that R10's anti-seizure medications were not delivered and R10 did not take any anti-seizure medications the evening of 12/24/2025, V35 stated he would have placed an order to send R10 back to the hospital that same night.Record Review of R10's December 2025 Medication Administration Record (MAR) Topiramate Oral Tablet 200 MG give 1 tablet by mouth two times a day for Epilepsy , Phenytoin Sodium (Dilantin) Extended Capsule 100 MG give 2 capsule by mouth two times a day for Epilepsy, Oxcarbazepine Oral Tablet 600 MG give1200 mg by mouth two times a day for Epilepsy, were not administered on 12/24/2025 as instructed by R10's Hospital Discharge Medication list.Record review of R10s progress note dated 12/25/2025 at 9:55AM, documents V23 (R10's concerned party) insisted R10 go out 911 because R10 had a seizure.Record review of R10s progress note dated 12/25/2025 at 4:45PM documents R10 was admitted to (local) Hospital with seizure activity.V2 stated the evening of 12/25/2025, V2 provided an in-service to the nurses. The topic states when a new admission arrives to the facility and medications are not available, nurses are to attempt to pull from (medication dispensing system) and if not in the (medication dispensing system) notify MD (physician) and get an order to give medication upon arrival. State Surveyor observed the in-service /meeting is signed by nurses and dated 12/25/2025.On 2/18/2026 at 12:16PM, V20 (Former Administrator), states if family notifies her of a concern V20 would have addressed it right away or informed the DON right away.During Observation, on 2/19/2025, Surveyor and V2 reviewed the list of medications available on the (medication dispensing system) machine, only Phyentoin100mg capsule was available, but V2 stated it was not given to R10 until 12/25/2025. V2 stated the nurse did not notify V35 the evening of 12/24/2025 that the anti-seizure medications were not given.V2 provided R10s Hospital Discharge Medications, documents topiramate 200mg tablet (Take 200mg by mouth in the morning and 200mg in the evening) dose was given on 12/24/2025 at 8:23AM in the hospital, next scheduled dose in the evening time at 11:00PM. Hospital Discharge Medication Documents Phenytoin 100mg ER capsule (Take 200mg by mouth in the morning and 200mg in the evening) last dose 200mg on 12/24/2025 at 8:24AM, next scheduled dose for 11:00PM. Hospital discharge medication Oxcarbazepine 600mg tablet (Take 1,200mg by mouth in the morning and 1,200mg in the evening) last dose 1,200mg on 12/24/2025 at 8:23AM, next scheduled dose 11:00PM.During record review no progress note was written by R10's nurse to notify V35 that R10's antiseizure medications were not delivered and R10 was not given any of R10's anti-seizure medications the evening of 12/24/2025 as directed by the hospitals discharge medication list scheduled time.Facility Policy Titled Medication Administration Review date 5/2025, documents: General: Medications are administered safely and appropriately to aid residents to overcome illness relieve and prevent symptoms and help in diagnosis.Guideline:22. If medication is not given as ordered document the reason on the MAR (Medication Administration Record) and notify the health care provider.26. If the medication is ordered but not present check to see if it was misplaced and then call the pharmacy to obtain the medications. If available obtain it from the contingency or convenience box27. If the physician's order cannot be followed for any reason the physician should be notified in a timely manner depending on the situation and a note should reflect the situation in the residence medical record.

Based on interviews and record reviews, the facility failed to follow their interventions of ensuring residents were adequately supervised who were identified as high risk for falls when left unattended, failed to modify fall prevention interventions post fall and failed to ensure a resident who is at high risk for falls whom repeatedly exhibited unsafe behaviors when in a reclining chair, was safely positioned in a reclining chair and adequately supervised during care. This failure applies to three of three (R1, R2 and R3) residents reviewed for accidents and resulted in R1 sustaining a facial fracture and intracranial hemorrhage from a fall. Findings include: 1. R1 is a [AGE] year-old female with a diagnoses history of Dementia, Insomnia, Muscle Wasting and Atrophy, and a history of falling who was admitted to the facility 07/04/2023. R1's Functional Abilities Minimum Data Sets dated 07/09/2024, 10/09/2024, 01/07/2025, and 03/30/2025 document she is dependent on staff for all activities of daily living and mobility activities. R1's current Fall care plan initiated and created 12/08/2024 documents she is at risk for falls due to functional deficits with the intervention initiated and created on 04/06/2025 of staff to monitor resident frequently to ensure proper reposition and safety in chair or bed. R1's current ADL (Activities of Daily Living) care plan initiated and created 12/16/2024 documents she requires assistance with daily care needs related to dementia, and muscle wasting and atrophy at multiple sites with interventions including one person assistance with bathing, toileting, dressing, and eating; and the intervention initiated 03/31/2025 and revised 04/14/2025 of mechanical lift with two-person assistance for transfers. R1's Restorative Comprehensive assessment dated [DATE] documents her fall risk factors included a history of falls or post fall fracture in the past 1-6 months, a fall risk score of 10 or above indicates high fall risk, and a final score for her of 21. R1's progress notes from February - April 2025 document multiple observations of behaviors. R1's progress note dated 04/06/2025 at 4:47 AM created by V8 (Registered Nurse) on 04/06/2025 at 6:28 AM documents she had a fall at 4:47 AM. CNA (Certified Nursing Assistant) notified writer that resident was in the chair and she turned to get blanket and resident tried to get up and fell , hitting head on bed. Resident assessed by this writer and noted cut to right cheek and under chin. Resident also noted bleeding from nose and mouth. Physician made aware and stated to send resident out to the hospital emergency room . R1 sent out via ambulance. R1's progress note dated 4/6/2025 at 12:01 PM documents she was admitted at Christ Hospital with a facial fracture and Intracranial hemorrhage. R1's Fall Risk Management Incident Report dated 04/06/2025 documents that at 4:47 AM she had a fall, V9 (Certified Nursing Assistant) reported that while she was providing care and placed R1 in a chair she turned around to grab something and the resident fell from the chair to the floor hitting her head on the bed, she was observed with bleeding in her face including from the nose and mouth and complained of pain; she requires total assistance with activities of daily living and transfers and the root cause of her fall is noted as having poor trunk control, and when placed in her geriatric chair by staff she fell out of the chair head first hitting the bed frame then the floor; her mental status was documented as not being oriented or oriented to person only; predisposing factors were noted to include confusion and impaired memory, gait imbalance, and weakness; the physician was notified and ordered she be sent out to the hospital emergency room for evaluation and her Power of Attorney [NAME] Fields was also notified; Interventions implemented in response to the fall included monitor her frequently to ensure proper repositioning and safety in chair. The facility's Incident Investigation report received 04/15/2025 documents on 04/06/2025 at approximately 4:47 AM R1 was observed on the floor in her bedroom by the facility aide and was unable to verbalize what occurred in the room. R1 was admitted to the Hospital with a facial fracture and intracranial hemorrhage. It is determined that R1 attempted to get up from her wheelchair and had a fall. Staff were interviewed and reported that R1 was sitting in the wheelchair and attempted to get up and fell forward. Witness statement from V9 (Certified Nursing Assistant) dated 04/06/2025 documents she was assigned to work with R1, when finished putting on R1's clothes she transferred her to the chair and then turned around to get a plastic bag to place the dirty linen in which was on the other bed in the room and heard a noise then turned her head and observed R1 on the floor. V9 stated she immediately called the night nurse and told her that R1 had fallen. Witness statement from V8 (Registered Nurse) dated 04/06/2025 documents the CNA (Certified Nursing Assistant) informed her at 4:47 am that R1 fell from her wheelchair, the CNA reported that she turned around to grab something and R1 fell when trying to get up; R1 fell forward out of chair. On 04/16/2025 at 10:23 AM V11 (Certified Nursing Assistant) stated she has worked with R1. V11 stated she would position R1 in her (Reclining) chair at a slightly tilted angle because if the chair is lowered too far back it could be considered a restraint. V11 stated R1 would like to sit straight up on the edge of her (Reclining) chair. V11 stated when R1's (Reclining) chair was tilted back she would sometimes attempt to sit up however if her chair is tilted back she couldn't get up. V11 stated R1 would attempt to sit up once or twice when receiving incontinence care. V11 stated she uses a sit to stand most of the time to transfer R1 and needs assistance with transferring her. On 04/16/2025 at 11:15 AM V6 (Therapy Director) stated (Reclining) and Geriatric chairs are used for reclining due to cognition and for residents who require two-person assistance or a mechanical lift. V6 stated there should not be one person assistance for residents who use a (Reclining) or Geriatric chair. On 04/16/2025 at 11:54 AM Observed with V7 (Minimum Data Set Director) when a care planned intervention of keep clean and dry was entered in the facility's electronic medical record system to R1's care plan; the intervention was automatically categorized as initiated and created for the date it was entered of 04/16/2025. Observed in the facility's electronic medical record system the intervention in R1's care plan of mechanical lift with two-person assistance for transfers was categorized as initiated 03/31/2025 and revised 04/14/2025. On 04/16/2025 at 1:47 PM V5 (Restorative Nurse) stated the mechanical lift was implemented for R1 due to the extensiveness of her fall and her total dependence. V5 stated since R1 is totally dependent, she should be a two-person assistance however she feels one person assistance is adequate to transferring R1. V5 stated a (Reclining) chair should be reclined and if it is reclined it is not impossible but highly unlikely that the resident will fall out of it. V5 stated she isn't sure if R1's (Reclining) chair was reclined on the day she fell because she fell forward and injured her face which may indicate the chair was in an upright position however she couldn't confirm this. On 04/16/2025 at 2:41 PM V3 (Vice President of Clinical) stated if a mechanical lift is being used there should be two people assisting. V3 stated mechanical lifts are used for resident's who require total assistance and are dependent however this intervention is used on a case-by-case basis. V3 stated what could have been done differently to prevent R1's fall was having the necessary items close by so the staff would have what they needed for the resident. On 04/17/2025 at 12:09 PM In response to surveyor's request for information on what behaviors was R1 being monitored for and documented as being observed by staff in several behavior progress notes between February 02 and April 03, 2025 V1 (Administrator) replied per the CNA's (Certified Nursing Assistant) R1's behavior can range from swinging her arms in the air to leaning forward. On 04/15/2025 at 3:20 PM V5 (Restorative Nurse) stated R1 requires full assist with all activities, she can lift either of her arms and has range of motion but can't lift her arms on cue, and doesn't do anything on her own. V5 stated R1 is 79 pounds and light however we have her in a (Reclining) chair because her trunk support isn't there and for this reason shouldn't be sitting up in a wheelchair. 2. R2 is a [AGE] year-old female with a diagnoses history of Central Nervous System Cancer, Muscle Wasting and Atrophy, Morbid Obesity, Spinal Stenosis, and Stage 3 Chronic Kidney Disease who was admitted to the facility 01/31/2025. On 04/16/2025 AT 9:12 AM Observed R2 in the unit 2 Long Term Common/Dining Area without other residents present and staff walking around the surrounding area. Observed R2 sitting in a (Reclining) chair slightly reclined. R2 stated she had fallen out of bed 2-3 months ago onto a mat, then fell again about a month later while sitting on the edge of her bed when she started to slide and couldn't stop herself. R2's Current Fall Care Plan initiated and created on 01/31/2025 documents she is at high risk for falls related to repeated falls with an intervention initiated 02/08/2025 including staff to monitor resident frequently to ensure safety. R2's Fall Risk Assessment Incident Report dated 02/05/2025 documents she was observed on the floor in the dining room and reported she was trying to sit up in the wheelchair; the root cause was determined to be she has poor thought process, very impulsive, and stood up from her wheelchair and fell with an intervention implemented of encouraging staff to continue to monitor and redirect her; there was no one identified to have witnessed the fall. R2's Fall Risk Assessment Incident Report dated 02/08/2025 documents she was observed on the floor near her bed during rounds and reported she was trying to get out of the bed and she sustained an abrasion on her right knee; there was no one identified to have witnessed the fall; the root cause was determined to be her having poor thought process and being very impulsive with an intervention implemented of encouraging staff to continue to monitor and redirect her. R2's Fall Risk Assessment Incident Report dated 02/27/2025 documents she was observed on the floor next to her bed and she reported she needed to get up and she slid on her bottom; her assigned CNA (Certified Nursing Assistant) reported she left he with her breakfast tray; the root cause was determined to be poor though process and being very impulsive with an intervention implemented of educating staff to bring her to the common area for close monitoring. 3. R3 is an [AGE] year-old male with a diagnoses history of Dementia, Generalized Muscle Weakness, and Difficulty Walking who was admitted to the facility 11/30/2024. R3's Current Fall Care Plan initiated and created on 12/09/2024 documents he is at risk for falls due to diagnoses of functional deficits, muscle weakness, and dementia with interventions created on 01/22/2025 of staff to monitor him frequently. R3's Fall Risk Assessment Incident Report dated 01/19/2025 documents he had an unwitnessed fall, with an intervention implemented of staff monitoring him more frequently. R3's Fall Risk Assessment Incident Report dated 02/01/2025 documents he was in the common area and slid out of his chair onto his buttock, while V12 (Certified Nursing Assistant) was observing in the dining room he stood up from his chair in the day room and was observed sitting on the floor with an intervention implemented of staff monitoring him more frequently. R3's Fall Risk Assessment Incident Report dated 03/16/2025 documents he was observed sitting on the floor on his buttocks in front of the (Reclining) chair in the dining room and when he was asked what happened he stated he slid out of the chair, there was no one identified to witnessed the fall; an intervention was implemented of reminding staff to monitor him more frequently; he was not receptive to education due to a diagnosis of dementia. R3's Fall Risk Assessment Incident Report dated 03/20/2025 documents he stood up from the (Reclining) chair and fell on to his buttocks in the dining room and the fall was unwitnessed; the writer of the report was alerted by the CNA (Certified Nursing Assistant) that he stood up from the (Reclining) chair and fell on to his buttocks in the dining room; the root cause was determined to be R3 standing up out of his chair unassisted and not making safe decisions due to dementia with an intervention implemented of reminding staff to monitor him more frequently. On 04/15/2025 at 3:53 PM V5 (Restorative Nurse) stated she is the fall coordinator. V5 stated she and physical therapy perform assessments to determine if residents need to use a (Reclining) chair. V5 stated residents are assessed for (Reclining) chair use on admission and if there are any significant changes in their physical ability. V5 stated upon admission therapy screens all residents and will give recommendations and she performs a follow up assessment and most of the time she uses their recommendations because they are more skilled in that area. V5 stated R2 and R3 use (Reclining) or geriatric chairs. V5 stated if a resident can't sit up safely or doesn't have proper trunk control in a wheelchair, they are placed in a (Reclining) or Geriatric chair. V5 stated the restorative assessment is used to determine if a resident needs a (Reclining)/Geriatric chair. V5 stated when R1 is sitting in the (Reclining) chair it should be tilted back and should not be sitting up for because of her poor trunk control. On 04/16/2025 at 12:23 PM V5 (Restorative Nurse) stated R3 is at high risk for falls. V5 stated R3 had an unwitnessed fall on 01/19/2025 that occurred in the hall and it was his first fall in the facility since his admission in November. V5 stated R3's first few falls were attempts to self-transfer or get up on his own. V5 stated fall interventions are updated after reviewing fall incidents and when needed. V5 stated the intervention implemented after this fall was for staff to monitor R3 more frequently. V5 could not explain what more frequently meant and stated every one to two hours was adequate monitoring for him. V5 stated R3's next fall was on 02/01/2025 where he slid out of a chair in the common area, and this was witnessed by V12 (Certified Nursing Assistant) who was written up for not actively attending to him during sitting time. V5 stated sitting time includes staff monitoring in the dining/common areas for 30-minute intervals. V5 stated R3's next fall was on 03/16/2025 in the common area when he got out of his chair. V5 stated the intervention implemented was reminding staff to monitor him more frequently because he was not receptive to education on asking for assistance due to his dementia. V5 stated R3's next fall was on 03/20/2025 when he stood up out of his chair in the dining room and the intervention was staff being reminded to monitor him. V5 stated she doesn't know how to answer the surveyors question of was R3 being adequately supervised however he should have been. V5 stated she doesn't believe there were any other interventions required for R3 and in order to move you have to be raising up to do so if there was someone there watching him they should be intervening when he attempts to ambulate or transfer. V5 stated R2 fell on [DATE] in the dining room when she slid from her wheelchair while trying to sit up in the chair. V5 stated the intervention for this fall was encouraging staff to monitor and redirect the resident. V5 stated R2 fell on [DATE] and was observed on the floor in her room near her bed during rounds. V5 stated R2 is at high risk for falls and she attempts to transfer herself. V5 stated the intervention for this fall was to have a floor mat in place when in bed. V5 stated R2 had a fall on 02/27/2025 in her room while sitting on the edge of her bed. V5 stated the CNA (Certified Nursing Assistant) had left the room to get her clothes from another area and when she returned R2 was on the floor and reported that she wanted to get out of bed. V5 stated the intervention for this fall was educating staff to bring her to the common area for close monitoring and she shouldn't have been left because she tries to get things on her own. V5 stated the CNA was educated not to leave R2 by herself. V5 stated it had already been established that R2 would attempt to self-transfer prior to this last fall for R2. The facility's Fall Prevention and Management Policy, dated January 2023 documents: The facility is committed to maximizing each residents physical well-being. The facility will facilitate as safe an environment as possible. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventative strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed.

Based on interview and record review the facility failed to follow the plan of care and provide three persons assist with activities of daily living care during bed mobility for a dependent resident. This affected one of three residents (R1) reviewed for avoidable accidents. This failure resulted in R1 falling out of bed when provided one person assist, V1 pushed the linen under R1's body, pushing R1 out of bed. R1 complained of pain, sent to the hospital diagnosed with non-displaced left, 11th rib fracture. Findings include: R1 face sheet shows diagnosis of generalized osteoarthritis, repeated falls, hereditary and idiopathic neuropathy, adult failure to thrive, morbid obesity, muscle weakness, difficulty in walking, unspecified lack of coordination, venous insufficiency, chronic pain, vitamin D deficiency. R1 MDS dated [DATE] section for cognitive pattern shows score of 15 (cognitively intact), section GG for functional status shows mobility-roll from left to right- 01 is entered (01-dependent, helper does all the effort, resident does none of the effort to complete the activity or the assistance of or more helpers is required for the resident to complete). Section K shows R1 is 67 inches in height and weigh 376 pounds. Facility final report to the department dated 9/28/24 denotes in part date of occurrence 9/28/24, R1 observed laying on the floor by side of hospital bed in bedroom. R1 complained of pain to left shoulder and left knee. Pain medication offered by nurse and refused by R1. She is placed back in bed by facility staff. MD (Medical Doctor), family were made aware of findings and orders to send R1 to ED (Emergency Department) for further evaluation was received and carried. Upon further investigation, it has been determined that R1 experienced a fall while receiving ADL care from facility staff aide. R1 is alert, orient x four, verbal and able to tell writer what happened at time of fall. R1 stated she slid out of bed while laying on her side receiving care from facility aide. Facility staff aide was interviewed: stated that R1 was receiving ADL care in bed, she was trying to change bed sheets when R1 slid out of bed. R1 complained of pain to left shoulder and left knee. Pain medication offered by Nurse and refused by R1. She (R1) is placed back in bed by facility staff. MD, family were made aware of findings to send R1 to the hospital for further evaluation was received and carried out. R1 noted with left eleventh rib non-displaced fracture in hospital, she (R1) returned to the facility with no new orders. R1's plan of care is updated, MD and family aware. This shall serve as the final report. On 11/15/24 at 12:07pm observed sitting in her wheelchair, R1 observed alert to person, place, time, and situation. R1 said she was receiving ADL (Activity of Daily Living) care, she was on laying on her right side, R1 said when the aide pushed the linen, she rolled out of bed. R1 said she fell on the side of the bed between the wall and bed frame. R1 said the aide summons the Nurse, the Nurse assessed her. R1 said she was having pain. R1 said she was sent to the hospital and was diagnosed with left shoulder contusion, left rib fracture, and sprain left knee. R1 said the fall caused her to have a set back in function abilities. R1 said her shoulder is painful, to move, her right knee is better, and the bruising from the fractured ribs has resolved. On 11/15/24 at 1:57pm V1 (CNA) she was R1 aide on 9/28/24, V1 said she had provided R1 with ADL care and was changing R1's bed linen. V1 said R1 was laying on her right side facing the wall. V1 said she put the linen on the bed, and as her pushed the linen to get it under R1, R1 fell out of bed. V1 said R1 landed on the floor on the side of the bed. V1 said she summons the nurse right away. V1 said the Nurse and other staff picked R1 up from the floor. On 11/15/24 at 3:20pm V5 (Restorative Nurse) said R1 requires two assists with bed mobility, V5 said R1 required 2 persons assist with bed mobility on 9/28/24. V5 said staff should review the care card prior to providing care. During follow up interview on 11/19/24 at 11:00am V5 said staff should provide the level of assistant that the resident has been assessed to need during care. V5 said this is for patient and staff safety, it helps reduce risk falling out of bed, reduce skin tears, and reduce risk for resident getting hurt. V5 said 2A on the baseline care plan means 2 persons assist. On 11/15/24 at 3:00pm V2 (Director of Nursing) said he conducted the investigation for R1's incident of 9/28/24. V2 said R1 fell out of bed during care. V2 said R1 is 2-person assist with bed mobility now (11/15/24). V2 said when R1 fell out of bed on 9/28/24, R1 required three persons assist with bed mobility. V2 said V1 should have checked the resident care card prior to providing care, V2 said V1 should have asked the Nurse on duty what was R1 functional status with ADL care/ bed mobility prior to giving care to R1. V2 said the resident care card is placed in their closet and the aides should check the care card prior to proving care. V2 said R1 or any residents should not fall from bed during care. 11/19/24 9:58am V4 (Restorative aide) said R1 was a three person assist with bed mobility on 9/28/24. V4 said all the staff including the aide are to check the care card before giving care to the resident. On 11/19/24 at 11:29am V6 (Rehab Director) said on 9/28/24 R1 required max assist with bed mobility. V6 said staff provided 75% to 90% of support for bed mobility. V6 said staff assist with the turning left to right and should be there to hold R1 in place to keep R1 in that position. R1 baseline care plan dated 9/24/24 shows ADL assistance, will receive ADL assistance as needed, 2A (2 assist) with bed mobility. R1 post fall observation dated 9/28/24 at 12:14pm denotes in part fall to the floor, witnessed by (V1), what was resident doing prior to fall- in bed, what was resident trying to do just before they fell - turn to side, resident usual ambulatory status- mechanical lift, review contributing factors- amount of assistance in effect, evaluation; what appears to be the root cause of the fall-need more assistance. Facility Activities of Daily Living policy with effective date of 2/2023 denotes in part our collaborative professional team, together with the resident and/ or resident representative: develop and implement interventions in accordance with the residents evaluated need, goals for care, and preference and will address the identified limitation in an ability to perform ADLs. Revise the approach to care as appropriate. Facility policy Titled Falls and falls risk, managing with revised date 8/2008 denotes in part based on previous evaluation and current data, the staff will identify interventions related to the residents' specific risk and causes to try to prevent the resident from falling and try to minimize complications from falling. R1 face sheet shows diagnosis of generalized osteoarthritis, repeated falls, hereditary and idiopathic neuropathy, adult failure to thrive, morbid obesity, muscle weakness, difficulty in walking, unspecified lack of coordination, venous insufficiency, chronic pain, vitamin D deficiency. R1 MDS dated [DATE] section for cognitive pattern shows score of 15 (cognitively intact), section GG for functional status shows mobility-roll from left to right- 01 is entered (01-dependent, helper does all the effort, resident does none of the effort to complete the activity or the assistance of or more helpers is required for the resident to complete). Section K shows R1 is 67 inches in height and weigh 376 pounds. Facility final report to the department dated 9/28/24 denotes in part date of occurrence 9/28/24, R1 observed laying on the floor by side of hospital bed in bedroom. R1 complained of pain to left shoulder and left knee. Pain medication offered by nurse and refused by R1. She is placed back in bed by facility staff. MD (Medical Doctor), family were made aware of findings and orders to send R1 to ED (Emergency Department) for further evaluation was received and carried. Upon further investigation, it has been determined that R1 experienced a fall while receiving ADL care from facility staff aide. R1 is alert, orient x four, verbal and able to tell writer what happened at time of fall. R1 stated she slid out of bed while laying on her side receiving care from facility aide. Facility staff aide was interviewed: stated that R1 was receiving ADL care in bed, she was trying to change bed sheets when R1 slid out of bed. R1 complained of pain to left shoulder and left knee. Pain medication offered by Nurse and refused by R1. She (R1) is placed back in bed by facility staff. MD, family were made aware of findings to send R1 to the hospital for further evaluation was received and carried out. R1 noted with left eleventh rib non-displaced fracture in hospital, she (R1) returned to the facility with no new orders. R1's plan of care is updated, MD and family aware. This shall serve as the final report. On 11/15/24 at 12:07pm observed sitting in her wheelchair, R1 observed alert to person, place, time, and situation. R1 said she was receiving ADL (Activity of Daily Living) care, she was on laying on her right side, R1 said when the aide pushed the linen, she rolled out of bed. R1 said she fell on the side of the bed between the wall and bed frame. R1 said the aide summons the Nurse, the Nurse assessed her. R1 said she was having pain. R1 said she was sent to the hospital and was diagnosed with left shoulder contusion, left rib fracture, and sprain left knee. R1 said the fall caused her to have a set back in function abilities. R1 said her shoulder is painful, to move, her right knee is better, and the bruising from the fractured ribs has resolved. On 11/15/24 at 1:57pm V1 (CNA) she was R1 aide on 9/28/24, V1 said she had provided R1 with ADL care and was changing R1's bed linen. V1 said R1 was laying on her right side facing the wall. V1 said she put the linen on the bed, and as her pushed the linen to get it under R1, R1 fell out of bed. V1 said R1 landed on the floor on the side of the bed. V1 said she summons the nurse right away. V1 said the Nurse and other staff picked R1 up from the floor. On 11/15/24 at 3:20pm V5 (Restorative Nurse) said R1 requires two assists with bed mobility, V5 said R1 required 2 persons assist with bed mobility on 9/28/24. V5 said staff should review the care card prior to providing care. During follow up interview on 11/19/24 at 11:00am V5 said staff should provide the level of assistant that the resident has been assessed to need during care. V5 said this is for patient and staff safety, it helps reduce risk falling out of bed, reduce skin tears, and reduce risk for resident getting hurt. V5 said 2A on the baseline care plan means 2 persons assist. On 11/15/24 at 3:00pm V2 (Director of Nursing) said he conducted the investigation for R1's incident of 9/28/24. V2 said R1 fell out of bed during care. V2 said R1 is 2-person assist with bed mobility now (11/15/24). V2 said when R1 fell out of bed on 9/28/24, R1 required three persons assist with bed mobility. V2 said V1 should have checked the resident care card prior to providing care, V2 said V1 should have asked the Nurse on duty what was R1 functional status with ADL care/ bed mobility prior to giving care to R1. V2 said the resident care card is placed in their closet and the aides should check the care card prior to proving care. V2 said R1 or any residents should not fall from bed during care. V2 said during his investigation, V1 informed him that she did not know where R1 care card was located, thats why she did not check the care card. 11/19/24 9:58am V4 (Restorative aide) said R1 was a three person assist with bed mobility on 9/28/24. V4 said all the staff including the aide are to check the care card before giving care to the resident. On 11/19/24 at 11:29am V6 (Rehab Director) said on 9/28/24 R1 required max assist with bed mobility. V6 said staff provided 75% to 90% of support for bed mobility. V6 said staff assist with the turning left to right and should be there to hold R1 in place to keep R1 in that position. R1 baseline care plan dated 9/24/24 shows ADL assistance, will receive ADL assistance as needed, 2A (2 assist) with bed mobility. R1 post fall observation dated 9/28/24 at 12:14pm denotes in part fall to the floor, witnessed by (V1), what was resident doing prior to fall- in bed, what was resident trying to do just before they fell - turn to side, resident usual ambulatory status- mechanical lift, review contributing factors- amount of assistance in effect, evaluation; what appears to be the root cause of the fall-need more assistance. Facility Activities of Daily Living policy with effective date of 2/2023 denotes in part our collaborative professional team, together with the resident and/ or resident representative: develop and implement interventions in accordance with the residents evaluated need, goals for care, and preference and will address the identified limitation in an ability to perform ADLs. Revise the approach to care as appropriate. Facility policy Titled Falls and falls risk, managing with revised date 8/2008 denotes in part based on previous evaluation and current data, the staff will identify interventions related to the residents' specific risk and causes to try to prevent the resident from falling and try to minimize complications from falling. Facility policy titled baseline care plan with revised dated 10/19/24 denotes in part nursing homes are required to develop a baseline care plan within the first 48 hours of admission which provides instructions for the provision of effective and person-centered care to each resident. The facility staff must implement the interventions to assist the resident to achieve care plan goals and objectives.

Failures at this level required more than one deficient practice statement. A. Based on interview and record review, the facility failed to utilize two persons assist for bed mobility (R1), failed to utilize a gait belt to assist with transfers (R18), failed to ensure wheelchair leg supports were in place during transport (R9), and failed implement an effective plan to prevent or reduce the risk of falling with injury for a resident identified to be at risk for falling out of bed (R13). This affected (R1, R9, 18, and R13) reviewed for safety during care and fall prevention interventions on the sample list of 21. This failure resulted in R1 rolling off the bed onto the floor while staff was providing care. R1 sustained an impacted/displaced fracture to the left upper arm with abrasion to the left knee and toe. R9 sustained a closed nondisplaced fracture of the metatarsal bone of the right foot while being transported in the wheelchair by staff, and R13 being involved in an unwitnessed fall incident sustaining a closed displaced fracture of the right femoral neck and closed fracture of the orbital of the right zygomatic bone. B. Based on interview and record review, the facility failed to supervise and monitor a resident with a history of wandering behavior (R12). This affects two of three residents reviewed for supervision and safety on the sample list of 21. This failure occurred when (R12) wandered into (R11's) room and resulted into a resident-to-resident altercation, R12 hit R11's arms with a remote control, and R11 hit R12 back on the hand. Findings Include: a) R1 had the diagnosis of need assistance with personal care, reduced mobility, muscle wasting and atrophy, dizziness and giddiness. Minimal data set dated [DATE] documents: section C (cognitive pattern) documents a score of fifteen which indicates cognitively intact. Section G (function status) documents: R1 required extensive assistance with two person physical assist with bed mobility (how resident moves to and from lying position, turns side to side and position body while in bed) and toilet use. R1 care plan dated 1/25/23 documents: R1 is at risk for fall due to general weakness. On 10/20/23 at 11:28am, R1 who was assessed to be alert to person, place and thing said, she had diarrhea, V4 (cna) was providing incontinence care. V4 rolled her over but she was not over far enough. R1 said, she did not having any bed rails. V4 rolled me over little more, R1 said, her legs started too slid off the bed. R1 said, she fell out the bed, hit the radiator then the floor on her left side. R1 said, she hit her head, skinned her knee and fractured her shoulder and elbow. R1 said, her pain was a ten out of ten. R1 said, staff caused her more pain by trying to get her up off the floor. R1 said, she could not straighten up her left arm. On 10/24/23 at 10:15am, V9 (nurse) said, V4 (cna - certified nursing assistant) informed me, R1 had fallen off the bed. R1 was on the floor against the wall and complaining of shoulder pain, we could not get R1 up off the floor based on R1's position. V9 said, she had to call 911. V4 was the only cna in R1's room providing care. R1 required two person assist with being changed/ incontinence care and transfers. On 10/24/23 at 11:24am, V10 (ADON- Assistant Director of Nursing) said, if a resident requires two person assistance with bed mobility and toileting means two staff members need to assist with those items/bed mobility and toileting. Progress note dated 4/13/2023 documents: (V9) Writer was called into (R1) patient's room by (V4) cna. V9 went into room and observed R1 lying on the floor against the wall next to bed on her left side. V9 asked R1 what happened and R1 stated, I was lying on my side while V4 was changing me and when I was going to lay back my hand gave out and I fell off the bed. R1 said, she hit the back of her head and complained of left shoulder pain ten out of ten. Unable to get R1 off the floor with mechanical lift due to position R1was lying on floor. 911 called. Event Report dated 4/13/23 documents: witnessed fall. Location of injury: left should pain, range of motion painful/limited in upper extremity and rotation/deformity of upper left extremity. First aid-immobilize/splint area. Sent to emergency room for evaluation. Incident Investigation: R1 explanation of the incident: slid of the bed. Mode of transfer: two staff maximum. Fall observation dated 4/13/23 documents: V4 was present in room at the time of fall. R1 fell off the bed. Two person assist. Fall root cause analysis form dated 4/13/23 documents: root cause determination: slid out of bed during changing. New Interventions and recommendations need to be implemented: Staff educated to use two person assist with transfer and change. Facility reportable dated 4/20/23 documents: R1 expressed, I'm sliding, I'm sliding and reached out to brace herself on the wall that was a few feet from the bed. Hospital paperwork 4/13/23 documents: R1 presented with to the emergency room after a fall causing injury to head and left shoulder. R1 rolled on the bed on her side with the help of the side earlier this morning. R1 rolled over all the way, left shoulder, left side of forehead to floor with no loss of consciousness but R1 complained of pain to left shoulder with decreased movement. Chest x-ray of R1's left should showed evidence of an acute fracture was noted in the humeral head (upper arm) extending from the humeral tuberosity (the bump of bone at top of the upper arm that serves as the attachment for two rotator cuff muscles) to the humeral neck which is impacted and displaced (shift out of placed). R1 also had an abrasion to anterior left knee and left toe. R9 was diagnosed with generalized osteoarthritis, intervertebral disc degeneration (lumbar region) difficulty walking and restless leg syndrome. On 11/02/23 at 2:21PM, R9 who was assessed to be alert to person, place and time said, she was being pushed in her wheelchair to physical therapy by V27 (restorative aide). R9 said, she had one foot crossed over the other with both of her legs raised/extended out in front of her. R9 said, her legs got tired, her right leg slipped down, buckled underneath the wheelchair and she fell forward landing on her knee. On 11/7/23 at 2:41PM, V26 (restorative nurse) said, R9 was being pushed in the wheelchair by the V27. R9 was holding her feet up. R9's foot drop while she was being pushed causing her to fall forward out of the wheelchair. R9 did not have any leg rest because she normally self -propel. R9 should have had leg rest while being pushed. On 11/7/23 at 3:02PM, V27 said, she was pushing R9 from unit one to unit two, R9 normally does not get tried. R9 was holding her legs out and up in front of her, flipped over and fell out the chair hitting her knee first on the ground. Progress note dated 9/7/23 documents: R9 stated, I fell . I fell right knee first, my right ankle twisted a little bit but I'm fine I didn't hit my head or anything my brain is still intact, my right foot got stuck under the chair as I was being pushed by restorative (V27). R9 denied pain, I get a pain pill in couple of hours. NP (nurse practitioner) made aware ordered x-ray of the right knee/ankle. Post fall observation dated 9/7/23 documents: root cause of the fall: R9's right foot got stuck under her wheelchair while being pushed down the hall. Witnessed V27. Additional fall follow-up questions dated 9/7/23 documents: V27 was pushing R9 in wheelchair, told R9 to hold legs up and let V27 know if legs get tired. V27 was pushing R9, R9 placed her foot on the floor and fell forward without warning landing on the floor. X-ray results dated 9/8/23 documents: right knee: soft tissue swelling with uncomplicated revised right knee arthroplasty. Right ankle: findings are concerning for an acute to subacute, avulsion fracture of the avulsion fracture of anterior talus. Hospital paperwork dated 9/8/23 documents: Reason for visit: fall, knee/ankle injury. R9 said, she is wheelchair-bound for issues with mobility and that she was being wheeled by a CNA yesterday. R9 states, that her feet were not resting on the foot rest and that they got dragged under her and she fell forward onto her knees and twisted her right ankle. R9 denied utilizing her hands to stabilize herself. R9 said, she was feelings pain mainly at the top of her foot where her shoes lay. X-ray right foot documents: Closed oblique nondisplaced fracture of metatarsal bone of right foot (5 digit). Assisting a client to use the wheelchair not dated given was created after R9's fall. Employee in-service dated 9/10/23 documents: All residents must have leg rest on their wheelchair during transport. R18 was diagnosis with Dementia, cognitive communication deficit, hemiplegia and hemiparesis following unspecific cerebrovascular disease affecting right dominate side, abnormalities of gait and mobility, repeated falls, need for assistance with personal care, muscle wasting and atrophy. Minimal data set section C (cognitive pattern) brief interview for mental status dated 10/12/23 document a score of eleven which indicated moderately impaired. Section G (functional status) dated 4/11/23 document: R18 need extensive assistance with one person physical assist with transfers. Balance during transitions and walking documents: surface to surface transfer (transfer between bed and chair or wheelchair) not steady, only able to stabilize with staff assistance. Quarterly Observation dated 4/18/123 documents: R18 was at high risk for falls. On 11/2/23 at 12:56PM, R18 who was pleasantly confused, said, she was in the shower by herself, had a fall and an unknown female co-peer helped her up off the floor. On 11/3/23 at 1:13PM, R18 was observed being transferred from the wheelchair to the bed safely by one staff member who used a gait belt. On 11/7/23 at 1:08PM, V25 (cna) said, she transfers R18 safely by herself utilizing a gait belt. On 11/07/23 at 1:22PM, V23 (cna) said she, (on 6/16/23) was transferring R18 from her wheelchair to the shower chair, She instructed R18 to hold on to the shower bar, told R18 they were getting ready to turn/pivot, as R18 turned, R18 fell down. V23 said, she did not use a gait belt with R18's transfer. On 11/7/23 at 2:55PM, V2 (DON- Director of Nursing) said, CNA's must use a gait belt for all transfers to help support the resident and break falls. Nursing note dated 6/16/23 documents: V23 (cna) notified writer that while assisting R18 to the shower chair the R18's knees buckled. V23 helped lower R18 to the ground. R18 complained of leg pain. Event report dated 6/16/23 documents: While assisting R18 to shower chair, R18's knees buckled and V23 help lower R18 to the ground. Fall root cause analysis dated 6/16/23 documents: R18 knees buckled during transfer to shower chair. Incident Investigation documents: Resident's explanation of incident: My legs gave out. Activity: getting ready for shower. Aide with resident at the time of event. Gait belt policy dated 2/23 documents: a gait belt is a safety device made of cloth that buckles securely around a resident's waist. The device provides a secure grasping surface to aid during transfer and ambulation. Commonly used for residents who are at risk for falls and those who require assistance during transfers. A gait belt can support a lower to the floor if the resident begins to fall or loses balance during transfer or ambulation. If the resident has one side weakness, position the destination surface (wheelchair, commode or chair) on the resident's unaffected side, grasp both side of the using an underhand grip. 39340 R13 was admitted to the facility on [DATE] with a diagnosis of anemia, hypothyroidism, hypertension, atrial fibrillation, history of falling, and osteoporosis. R13's minimum data set dared 6/6/23 under functional status bed mobility (how a resident moves to and from a lying position, turns side to side, and positions body while in bed documents a score of 4 for self-performance which indicates total dependence- full staff performance every time during entire seven day period under support a score of two which indicates one person physical assist R13's point of care charting dated 7/13/23 documents under how resident moves in bed a score of four which indicates total dependence; Staff support provided for bed mobility documents a score of two which indicates one-person physical assist. R13's fall care plan interventions dated 9/8/22 documents: implement exercise program that targets strength, gait and balance; increased staff supervision with intensity based on resident need; obtain order for vitamin D, provide individualized toileting interventions; assessment and treatment for postural hypotension. R13's fall investigation dated 7/14/23 documents: was the cause of the fall known- No resident was in bed during sleep hours; Activity at time of fall- laying in bed; what fall interventions are listed on care card- documents not applicable for all except low bed which is not checked and documents error. floormat which documents started intervention placed on care card; were the interventions in place working at the time of the fall documents not applicable. What did the resident say they were trying to do or where were they going- she did not know how she fell . Under incident investigation documents resident explanation of incident- Roll out of bed. R13's fall risk assessment dated [DATE] documents a score of 13. Total score of 10 or above deems client at risk: initiate precautions R13's physical therapy plan of care dated 4/12/23 documents under mobility roll left to right prior level substantial/maximal assist-helper does more than half the effort. Helper lifts or holds trunk limbs and provides more than half the effort; under current level resident refused. R13's final fall reportable dated 7/25/23 documents: Upon further investigation, it has been determined that R13 experienced a fall while attempting to self-reposition and resident rolled over causing a change in plane. Staff were interviewed and were able to confirm that R1 was laying in bed with her call light within reach prior to fall. Per staff interviews R13 had received peri care 15 minutes prior. Upon interview R13 was unable to recall how she fell and was not able to communicate additional events surrounding the fall. R13 was heard yelling out by CNA while rounding and upon entry to the room R13 was observed lying on her right side on the floor parallel to the bed on top of the metal base of bedside table wrapped in bed linen. CNA notified nurse for further assessment. R13 was immediately assessed, and first aid care rendered. R13 was sent to emergency room for further evaluation and treatment. R13 returned to the facility with diagnosis of closed displaced fracture of the right femoral neck, nondisplaced fracture along the temporal process of the right zygoma, and adjacent fracture of the right lateral orbital wall. On 11/7/23 at 1:44PM, V26 (restorative nurse) said R13 had been provided incontinence care about 15 minutes prior to fall. Staff was in the next room when they heard R13 fall. R13 was wrapped in her sheets and rolled out of bed. No side rails on bed and unclear if any halo bar in place. When asked how did R13 roll out of bed when she needs assistance with bed mobility, V26 said she was unsure. On 11/7/23 at 3:42PM, V28 (Certified nursing assistant,CNA) said she provided incontinence care to R13 and roommate between four and five in the morning. R13 preferred to sleep in a fetal position and said R13 was in the middle of bed and bed in lowest position upon leaving the room. V28 said she went to the next room across the hall and heard help me and saw R13 on the floor in fetal position on top of bedside table base. Nurse came and she was assisted back to bed. She had a call light and can use it if she needs assistance, no behaviors that day, no changes observe that shift. On 11/8/23 at 12:34PM, V32 (rehab director) said R13 was dependent on staff for transfer and bed mobility in April of 2023. Rolling R13 refused but previously required a maximum assist. On 11/21/23 at 9:27AM, V49 (nurse) said she was nurse on duty at time of incident. V49 said staff informed her that R13 had a fall and when she entered the room, R13 was on the floor next to her bed on the bottom part of the bedside table. V49 said R13's bed was not in the lowest position but was not super high, unable to give any further details. R13's hospital record dated 7/14/23 documents under visit diagnosis: closed displaced fracture of right femoral neck and closed fracture of orbital portion of right zygomatic bone According to national library of medicine dated 6/27/22 fracture of zygoma is the second most common fracture of the face which can cause significant cosmetic and functional deformity. Fractures of the zygoma are almost always the result of high impact trauma. The most common mechanisms are assault, motor vehicle collisions, falls and sporting injuries. 41156 b. Facility Initial reported incident, dated 8/25/23 reads in part: R11 was sitting in R11's room reading and R12 independently wheeled in and approached R11's table that was next to R11. R12 started reaching for things and R11 reports that R12 hit R11, so R11 hit R12 back. R11 yelled for help and the staff immediately intervened and came to help R12 out of R11's room, R11 has a broken fingernail. Body checked refused by R11 and R12 will be completed. No other injuries noted at this time. Investigation initiated. Final report reads in part: R11 claims R12 came in to R11's room and hit R11 with remote control and the bedside table was between them, it was also being pushed at R11. R11 claims she was defending self and hit R12 on the hand. R12 is blind and R12 was not aware R12 was in wrong room. R11 has had daily follow up with nursing and did develop a slight bruising to R11's right forearm. On 11/8/23 at 11:30AM, R11 reported that back in August, R11 was in her room, up on her wheelchair, next to her bed; and bedside table was in front of her. R11 stated she was reading and dozed off and when R11 opened her eyes, R11 saw R12 on his wheelchair in her room, right in front of her, and dragging R11's cup on R11's table. R11 yelled and told R12, it is my cup, don't take it. R12 said to R11 this is my cup and my room. R11 then reported that R12 grabbed the remote and hit R11's right arm, and so R11 reported in hitting the arm of R12 to stop R12 from hitting R11 with a remote. Maintenance passed by and saw the incident and reported it to the nurse. The nurse then took R12 away of R11's room. R11 also reported that two month prior to this incident, approximately Month of May 2023, same resident (R12) wandered in R11's room. R11 coming from her shower, R11 entered her room and saw R12 in her bed, asleep. R11 yelled and asked the staff to take R12 off R11's bed. R11 reported that there were two separate occasions when R12 wandered in R11's room. On 11/8/23 at 11:10AM, V14 (Unit Manger) stated that nurses are around and other staff to keep a close look and monitor R12. Our intervention is to toilet or ask R12 if R12 needs to lay down back to bed if observed wandering the unit. Staff would ask R12 if he needs to use the toilet or assist him back to bed. On /9/23 at 915AM V1 (Administrator) stated that R11 reported the incident to V1. I think R12 may have wandered in R11's room few times before, With R11 as soon as R12 enters room R11 was able to redirect R12, except from the last incident when R11 I believe reported she fell asleep and did not see R12 came in her room. Staff knew R12 is a wanderer. My expectation is for staff to monitor all of our wandering residents. Staff to redirect R12 if noted wandering in the hallway. R12 was going in the dining because it was about the time for dinner, nurse thought R12 was going in the dining for dinner but somehow ended up in R11's room. On 11/9/23 at 9:30AM, V2 (DON) R12 has blindness and staff to redirect. Continue to guide R12. Able to move around and to keep his independence but for staff to redirect if observe with wandering behavior in the unit. We also encourage R12 to participate in activity to be able to monitor and R12 to stay occupied and not wanders the unit. Care plan for R12 dated 8/25/23 reads R12 often wanders in his wheelchair and goes into other resident rooms. Intervention: Staff will provide activities for R12, activity boards, folding clothes. Music therapy etc. Care plan for R12 dated 5/17/23 reads R12 experiences wandering and at times takes things that are not his. Interventions: Maintain calm environment and approach R12, and remove R12 from non-patient areas and return items that R12 may pick up. Care plan for R12 dated 5/15/23 reads R12 experiences wandering (moves with no rational purpose, seemingly oblivious to needs or safety). Interventions: Wander guard for safety. Check placement every shift; Approach from the front. Walk in step with R12 first before redirecting; If R12 looks for family/significant other, reassure that others know where to find him/her; Maintain a calm environment and approach with R12; When R12 begins to wander, provide comfort measures for basic needs such hunger or toileting; And when R12 becomes physically abusive, stop and try later. Do not force to do task. Care plan for R12 dated 3/2/23 reads R12 experiences wandering by entering rooms of his peers and attempt to lay in their beds. Interventions: Approach from the front. Walk in step with R12 first before redirecting; and when R12 begins to wander, provide comfort measures for basic needs (e.g., pain, hunger, toileting, too hot/cold, restless etc). R12 progress notes reviewed dated 3/1/23 and reads in part: R12 was seen in the bed of another resident. Incident was reported to R12's nurse. Other resident was not in the room at the time of this incident.

Deficiency requires two deficient practice statements. 1. Based on observation, interview, and record review, the facility failed to ensure that residents were free from falls by not implementing interventions according to the resident centered care plans and facility protocols for supervision. These failures applied to three of three (R47, R90, and R92) residents reviewed for accidents and supervision and resulted in R90 experiencing repeated falls; R92 requiring three staples to the back of the head as a result of a head injury from a fall; and R47 sustaining a right femoral neck fracture as a result of a fall. 2. Based on interview and record review, the facility failed to supervise a resident with known wandering behaviors and failed to prevent a resident from to wandering into another resident's room and relieving himself. This failure applied to two (R15 and R22) of two residents reviewed for supervision. Findings include: 1.A. R47 is an [AGE] year-old female who originally admitted to the facility on [DATE]. R47 has multiple diagnoses including but not limited to the following: nondisplaced fracture of right fibula, cerebral infarction, hemiplegia, dementia, muscle wasting, abnormalities of gait and mobility, need for assistance with personal care, lack of coordination, and type II DM. On 4/11/23 at 10:15AM, R47 was observed to be lying in bed with facial grimacing. R47 said she was having pain to her right hip and wanted to get out of bed. Attempted to interview R47 about fall incident on 4/1/23. R47 said she knows she recently hurt her hip from a fall, but she does not remember what had happened. At 10:30AM, V19 (Licensed Practical Nurse/LPN) was interviewed regarding R47. V19 said she was not present when R47 fell , but she knows she fell in the dining room during dinner shift, and she broke her hip. Facility progress note dated 4/1/23 at 6:41PM states in part but not limited to the following: R47 was observed on the floor in the dining room near the table, lying on R47 back with knees bent next to resident wheelchair and complaining of right-side hip pain. R47 said she was reaching for something for another resident and slipped and fell . On 4/12/23 at 2:42PM, V29 (Restorative Licensed Practical Nurse) was interviewed regarding incident with R47. V29 said R47 fell in the dining room during dinner time on 4/1/23. She said she was reaching for something that had fallen on the floor. Says no staff were in the dining room at this time. V2 (DON) interjected and said actually V28 (Certified Nursing Assistant/CNA) was in the dining room charting at the time of the fall, but her view was obstructed. On 4/13/23 at 10:29AM, V28 was interviewed regarding incident on 4/1/23 with R47. V28 said she was standing outside the dining room charting on a mobile laptop by the nursing station. V28 heard a loud bang and looked behind but did not see anything. A couple minutes later, I walked in the dining room to check what happened and I saw R47 on the floor screaming. She was on her bottom with her knees bent. I asked her what happened and R47 said she was reaching for something and fell . This happened around the end of dinner time. I was not assigned to supervise the dining room; I was charting near the nursing station. There was no other CNA present in the dining room at the time of the fall. At the end of the meal, the CNA assigned to the dining room will transport residents back to their rooms. There are times when a CNA may not be present in the dining room during this time. Hospital Inpatient Discharge Summary dated 4/1/23-4/6/23 state in part but not limited to the following: Active Hospital Problems: Closed right hip fracture; Summary of admission and hospital course: [AGE] year-old female who presented to the emergency department with a mechanical fall. In the emergency department, she was found to have acute subcapital right femoral neck fracture with posterior angulation. R47 care plan with start date of 10/20/22 started in part but not limited to the following: Problem: R47 is at risk for falls due to weakness, impaired balance, decreased cognition, on psychotropic medication, and incontinence. Goal: R47 will be free of falls Approaches: Increased staff supervision with intensity based on resident need. Per Minimum Data Set Section G and GG with date of 1/19/23 states in part but not limited to the following: Balance during transitions and walking: moving from seated to standing position: not steady, only able to stabilize with staff assistance; Mobility: picking up object: the ability to bend/stoop from a standing position to pick up a small object: dependent- helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers required for the resident to complete the activity. On 4/11/23 at 11:40AM, ten residents were observed in the dining room, with no CNA or supervision. At 11:55AM, R61 was observed assisting residents and putting clothing protectors on residents. No staff observed in dining room at this time. At 12:20PM, V18 (Certified Nursing Assistant/CNA) came in the dining room to help serve lunch. V18 was interviewed regarding supervision in the dining room. V18 said there should be one CNA in the dining room during meals; however, we have to transport the residents back to their rooms after meals. There may not be supervision in the dining room when we are transporting people. There are some residents that need assistance during mealtimes as well. I do not feel as if one CNA is enough to supervise the residents. At 1:10pm, it was observed to have six residents in the dining room with no staff present. At 1:20PM, R47 stopped this surveyor and asked if she could go back to her room. No staff present in the dining room at this time. On 4/12/23 at 2:50PM, V2 (DON) was interviewed regarding supervision. V2 said, my expectation of supervision during mealtimes is that a staff member is present throughout the entire meal while residents are in the dining room. If a resident is requesting to be transported elsewhere, they should notify another CNA or staff member to supervise while they are not present. 1.B. On 04/10/23 at 11:32 AM, observed R90's bed not in lowest position. R90 stated the remote to his bed doesn't work. R90 stated he is getting tired of calling them to ask for his bed to be adjusted. R90 stated he fell out of bed the other day while asleep, so they try to keep his bed low to the floor. R90 stated his bed should be lower but he can't adjust it. On 04/11/23 at 3:25 PM, observed R90's bed raised approximately 1.5 to 2 feet from the floor. Observed V30 (Licensed Practical Nurse/LPN) lower R90's bed manually from his foot board because his bed remote control was not working. Fall Log Received 04/11/24 from Facility Documents R90 had falls 12/01/22 at 10:27 AM, 12/07/22 at 10:27 AM, 12/24/22 at 10:00 PM, 12/28/22 at 7:33 AM and at 2:02 PM, and 04/02/23 at 10:52 PM. R90's current care plan documents he is at risk for falls with interventions including ensure (trade name) a tool aid for picking up things that are out of reach, is within reach, educate resident to use (trade name) tool aid as needed, and use call light for assistance, and ensure the bed height is at its lowest position, Increased staff supervision with intensity based on resident need, resident is educated on using proper body mechanics when repositioning in bed, ensure floor mat is in place, be sure resident call light is within reach and encourage the resident to use it for assistance as needed. The residents prompt response to all requests for assistance. R90's progress note dated 12/01/2022 at 09:57 PM documents writer was made aware by CNA (Certified Nursing Assistant) that resident was on the floor on the side of the bed. Fall was unwitnessed, and resident stated that he was trying to sit in the chair. R90's progress note dated 12/24/2022 10:15 PM documents at approx. 10pm resident was observed by CNA laying on the floor. Resident stated he had a fall while trying to reposition for comfort. R90's progress note dated 12/28/2022 07:45 AM documents at approximately 7:10 AM, resident was observed on the floor in prone position by staff. Resident stated he didn't fall but slid out of bed to the floor; at 02:15 PM CNA staff reported to writer that resident was on the floor, writer noted resident lying on the floor next to bed. R90's progress note dated 04/02/2023 10:40 PM documents writer called to room and witnessed resident on hands and knees on the floor. Writer asked resident what he was trying to do, and he stated, I was reaching for something on my dresser and ended up on my hands and knees. I really didn't even fall. I never touched the floor fully my body didn't hit anything. The resident stated he was reaching for something on his dresser when he fell . On 04/12/23 at 02:57 PM, V29 (Restorative Licensed Practical Nurse/Fall Coordinator) and V2 (Director of Nursing/DON) stated that staff needed to be educated on R90's specific needs and ensuring staff observe his care plan for fall interventions. V29 and V2 agreed that R90's bed should be in the lowest position. V29 stated if a resident is at risk for falls and their bed is not in lowest position as included in their fall interventions, they could fall, and anything can happen. On 04/13/23 from 1:51 PM - 2:09 PM, V2 (DON) stated a root cause analysis should be completed after each fall. V29 (Restorative Licensed Practical Nurse/Fall Coordinator) stated R90 has a behavior of adjusting his bed with his remote. V29 stated this behavior would contribute to his fall risk factors as well as him attempting to reposition himself in bed and transfer himself. V29 stated R90 does need increased supervision based on his fall history which would include frequent every hour - hour and a half. 1.C. 04/10/23 11:50 AM, R92 was not in his room during resident screening and was later seen at the dining area sitting with about five other residents. No staff member noted in the dining area. Resident was awake and alert but unable to answer any questions. 04/11/23 at 10:05AM, R92 was observed in the dining area with other residents, there were no staff members in the dining area with the residents. 04/12/23 11:45AM, R92 was observed in the dining area with other residents from 11:30AM to 11:45AM, there were no staff in the dining area or the nursing station. Review of facility fall log showed that R92 had an unwitnessed fall in his room on 1/3/2023 with no injuries, the intervention for that fall incident was to increase staff supervision and redirect as needed. On 3/21/2023, facility documented another unwitnessed fall in the resident's room with a head injury, was sent to the hospital and returned to facility with three staples to the back of his head. Writer was alerted to patient's room by therapy staff. Writer observed patient lying supine on floor next to his wheelchair. Writer asked resident what happened. Resident stated, I was reading my daily chronicles, one of them fell on the floor and I reached to pick it up, then I fell on the floor. Resident placed into bed with a mechanical lift. Head to toe body assessment done and noted 2cm cut to back of head and bleeding noted. Pressure and ice pack applied to back of head. bleeding stopped. (Trade Name) wound closure tape applied. No loss of consciousness. No complaints of pain voiced. Vitals taken: 145/66,62,17,98.0,97% O2 room air. Neuro checks initiated. Writer notified Hospice and ok to send to hospital for further evaluation. NP made aware. left voicemail for patient's son(s). DON made aware. (ambulance) called for pick up. (ambulance) arrived and pt exited facility on stretcher. will try again later to call son(s). R92's medical record includes documentation, 03/21/2023 07:29 PM: Resident alert and verbally responsive. Behavior calm and cooperative. Resident denies pain or discomfort at this time. Skin assessment completed revealing a laceration with 3 staples to back of head s/p fall. No swelling, drainage, or other s/s of infection at this time. Resident returned to a position of comfort with bed in lowest position and call light attached. Resident arrived back on the unit alert and in stable condition via ambulance. Neuro check WNL and all vitals stable. No signs nor complaints of any distress. Able to move all extremities. R92 arrived on the unit with three staples that was placed to posterior head and orders to leave in place for 7-10 days. Both (son) and NP made aware of arrival on unit and resident clinical situation. Monitor closely, frequent rounds, and all safety measures in place. Will continue to monitor. Facility policy titled Falls and Fall Risk, managing with revision date of 3/2019 states in part but not limited to the following: Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident-centered approaches to managing falls and fall risk: The staff will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. 2. R22 is a [AGE] year-old male who was admitted to the facility 11/16/2021 and has diagnoses that include: dementia, lack of coordination and a history of falls. On 4/10/23 at 09:37 AM, R15 said one-time R22 came into her room, urinated in a cup, and left it on her table. Another time he came into her room and defecated on the floor and smeared it all over. Facility Concern Form: dated 3/20/23 states R15 complained about another resident going into her room. Summary of Findings determined that the confused resident is in the same room down a different hall. This resident wanders, gets confused, and then goes into R15's room and starts to clean up or remove items that are unfamiliar. Resolutions signed by V1 Administrator) said that family of this resident was contacted and asked to find a dementia unit what would better meet the needs of the resident as he is unable to be redirected easily and is upsetting the alert residents. 04/12/23 04:18 PM, V7 (Assistant Administrator) confirmed the wandering resident to be R22 and said there were concerns with R22 going into R15's room and care plans were updated to reflect that provided redirection. His room was equidistant to R15's room, and there was at least one incident where he used her toilet and missed. We had to get housekeeping to clean it up. Progress note dated 03/15/2023 at 12:34 PM stated: This writer made several attempts and left [Voice Mail] messages on 3.14.23 and 3.15.23 to son of resident (R22) regarding his increased wandering. Writer will [follow up] with another phone call. [Social Services] will continue to provide therapeutic services as needed. 04/12/23 02:52 PM, V2 (DON) stated, I think given certain residents and staff attempts to do. The residents have the right to manipulate themselves. If a resident is cognitively impaired, rounding, supervision, meaningful activities, asking for family to be more active. We expect for the residents to be supervised by staff ideally at all times. According to our payroll-based journal (PBJ) we have enough staff to provide this supervision. 40920 46344 44570

Based on observation, interview, and record review, the facility failed to identify and assess acute changes in condition to include and determine complaints of severe leg pain and assess and identify acute mental or neurological changes that required activation of 911. These failures affected 2 of 4 residents (R1, R7,) reviewed quality of care related to acute changes in condition. These failures resulted in R1 complaining of severe leg pain. R1 was sent to the local hospital and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . R7 was admitted and treated at the local hospital for acute [CONDITION(S)]. Findings include: 1. R1 Review of R1's medical record notes, R1 was admitted to this facility on 1/29/22 for orthopedic aftercare of right femur fracture. R1 had a right total hip arthroplasty while in the hospital. Review of R1's physical therapy documentation notes the following: On 2/7/22, V22 (Physical Therapy Aide/PTA) placed 1.5-pound weights on R1's lower legs while R1 was lying in supine position with instructions on [MEDICATION(S)] and isometric exercises to increase range of motion, mobility, flexibility, muscle strength, and endurance. Afterwards, R1 performed gait training with a rolling walker, 9 feet to 14 feet minimum assistance, with decreased stride length, toeing off, a significant leg length discrepancy and an antalgic gait (a limp caused by pain in lower legs). On 2/8/22, V23 (Physical Therapist/PT) noted: R1 complained of right hip pain, 8 out of 10 post medication. R1 requires constant redirection due to increased anxiety and easily gets distracted. R1 instructed to increase foot clearance and step length. Rest breaks taken due to complaints of fatigue and pain. On 2/9, therapy session spent consulting with R1's nurse about R1's bulging right hip, swelling, increased back pain, and pain traveling down R1's leg to R1's toes, describing pain as lightning. R1 observed internally rotating right foot. On 9/15/22 at 11:00am, V5 (Director of Rehabilitation Services) vaguely recalls R1. After reviewing R1's physical therapy documentation, V5 stated that weights are applied to a resident's legs when doing exercises to improve the resident's stability. V5 stated that 1 1/2 pounds weights were used during R1's therapy session on 2/7. V5 stated that the therapist noted R1 was distracted during session, needed redirecting. V5 stated that the therapist also noted a leg discrepancy-right leg shorter than left; R1 was unable to do much in therapy due to pain. On 9/15/22, V8 (Nurse) stated that on 2/9/22 R1's right hip was very swollen. V8 stated that she ordered a right hip x-ray. V8 does not recall if x-ray was urgent or not. V8 denied contacting the outside diagnostic imaging company and receiving an estimated time of arrival for x-ray to be done. V8 stated that V8 endorsed to next shift. On 9/15/22 at 3:00pm, V2 (Director of Nursing/DON) stated that the nurse is expected to call the outside diagnostic imaging company with all X-ray orders. V2 stated that the outside diagnostic imaging company will provide the nurse with a confirmation number with an estimated time of arrival at this facility to perform X-ray. When asked if it is appropriate for a resident who had been admitted to this facility for care after a right total hip arthroplasty to wait 10 hours for an X-ray of the right hip that was observed bulging, swollen, and with increased pain, V2 declined to answer. V2 stated that V2 would assess the resident and determine best course of action. Review of R1's right hip X-ray results, dated 2/10/22 at 1:06am, notes R1 with dislocation of right total hip replacement with the femoral head displaced superiorly. Review of R1's hospital record, dated 2/10/22 at 4:25am, notes the emergency room physician attempted to reduce R1's right hip dislocation, but was unsuccessful. R1 was taken to the operating room. A second attempt to close reduce R1's right hip dislocation was unsuccessful. R1 required surgical intervention, a right total hip revision, to obtain proper alignment of R1's right hip. Review of R1's physical therapy evaluation, dated 1/29/22, notes R1's activity tolerance, sitting and standing, is 0-15 minutes. Range of motion to right leg: completes up to 25% of normal range. Strength of left leg is 3 out of 5. Strength of right leg is 2 out of 5. Physical therapy recommended 5 times a week for 4 weeks. Review of this facility's change in a resident's condition or status policy, revised 03/2019, notes the nurse will notify the resident's attending physician when there has been a discovery of injuries of an unknown source, significant change in the resident's physical condition, need to transfer the resident to a hospital. The nurse will record in the resident's medical record information relative to the changes in the resident's medical condition or status. 2. R7 R7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/16/22 at 1:27PM, V16 (Certified Nursing Assistant/CNA) said R7's baseline was alert, oriented and able to express needs. V16 said she observed R7 having difficulty talking and R7 was unable to communicate what she wanted to say. R7 was confused and not herself. V16 unable to recall time of events but reported it to V10 (nurse). On 9/16/22 at 12:08PM, V10 (Nurse) said she recalls staff reporting R7 was not herself at some point during her shift. V10 said R7 was not talking a lot. V10 was unable to recall the time or vital signs at time of assessment. V10 said she does not recall if she called the doctor or if she just called private ambulance. V10 said she called an ambulance due to vomiting and checked on the resident two additional times prior to the ambulance arrival. V10 said she did not call 911 because R7 did not need to go out immediately. V10 said she documented events and vitals but unsure why they are not recorded in R7's medical record. On 9/27/22 at 11:44AM, V10 (Nurse) said signs and symptoms of a stroke would include slurred speech, drooping of the face, and weakness in an extremity. You would call 911 for any of those signs. R7 was not sent out via 911 because she was stable. R7 started exhibiting signs of slurred speech and low vital signs when EMS was already present on site. On 9/16/22 at 10:59AM, V15 (Nurse Practitioner/NP) said resident showing slurred speech or facial droop should be sent put 911 due to the possibility of stroke. Time is critical and needs to be evaluated immediately. On 9/16/22 at 2:57PM, V2 (Director of Nursing/DON) said 911 should be called for any resident experiencing changes in mental status or slurred speech. R7's transfer form dated 7/13/22 at 5:59PM with completion date 7/13/22 at 6:39PM documents: send to hospital due to vomiting, altered mental status, slurred speech, low heart rate and oxygen saturations. There were no vitals documented on form. V10 was unable to recall vitals when asked about information that was presented in transfer form. R7 medical record does not document any nursing notes or progress notes after 7/12/22 at 7:16am. The next progress notes dated 7/14/22 at 1230AM. R7's ambulance report dated 7/13/22 documents: dispatch notified 18:49, on scene 18:56, at destination (local Hospital) 19:46. Under primary impression altered mental status. Secondary impression: stroke. Vitals at 19:02 document: blood pressure 149/68, pulse 45, respirations 20 and oxygen saturation 100. Under initial assessment: positive for facial droop. Under narrative documents: upon arrival crew found patient laying supine in facility bed. Patient only responsive to verbal stimuli. Patient assessed and vitals taken. According to patient's nurse. Patient last known normal was approximately 3pm this afternoon, when she began having bouts of emesis, patient is normally alert and oriented x4. R7 local hospital record documents arrival on 7/13/22 at 19:46 via local ambulance company with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Under chief complaint documents: altered mental status. Patient las known normal by nursing home staff was 3 PM, developed right sided weakness and became nonverbal. Under physical exam: NIH stroke scale 24- indicates severe stroke. Lethargic not moving all extremities. Under impression of CT head documents: there is a 6 cm acute intraparenchymal hemorrhage in the left parietal white matter with significant surrounding vasogenic [CONDITION(S)]. According to the American Stroke Association website documents: Call 911 if these signs are present: face dropping, arm weakness and speech difficulty. Stroke is the number 5 cause of death and a leading cause of disability in the United States. On average 1.9 million brain cells die every minute that a stroke goes untreated. Stroke is an emergency. Call 911 immediately. Early treatment leads to higher survival rates. Calling 911 lets first responders start treatment on someone experiencing stroke symptoms before arriving at the hospital. (https://www.stroke.org/en/about-stroke/stroke-symptoms) Review of this facility's change in a resident's condition or status policy, revised 03/2019, notes the nurse will notify the resident's attending physician when there has been a discovery of injuries of an unknown source, significant change in the resident's physical condition, need to transfer the resident to a hospital. The nurse will record in the resident's medical record information relative to the changes in the resident's medical condition or status.

Based on observation, interview and record review, the facility failed to follow fall prevention protocols and remove tripping hazards to prevent the risk of falling and failed to implement fall prevention recommendations. These failures affected 2 of 3 (R3, R8) residents reviewed for falls and fall prevention. This failure resulted in R3 tripping and falling to the floor sustaining a closed fracture of the left side rib. Findings Include: Facility reported incident dated on 6/27/22 documented that R3 reported pain to R3's left side with increased pain and tenderness during movement. R3 reported a fall in the bathroom, R3 hit R3's side on the toilet and that R3 crawled back to the bed. Diagnostics revealed mildly displaced 11th rib fracture. R3's notes reviewed and documented on 6/23/22 by V29 (Nurse) reads in part: R3 discovered on the floor at bedside, not sure if R3 fell or just laid on the floor, abrasion noted to right elbow. On 9/16/22 at 1pm, V11 (Restorative Nurse) stated Restorative aide reported to me that R3 is having pain on R3's left side where the left rib area was at. I went to see R3. My assessment was, R3 was in pain and could not move because there was more pain when moving. Pain only with movement. I asked R3 what happened. R3 reported R3 was out with the son couple of days ago, then the sister of R3 walked in and I asked if R3 was out of the building with R3's son and the sister said NO. Sister then reported to me that R3 had fallen on the 23rd. the sister of the resident reported that the sister received a call from the nurse on the 23rd about the fall incident of R3. I talked to R3 on how did he fall and R3 said he was in the bathroom, lost balance and hit his side on the toilet. R3 stated I crawled back to my bed. I asked if R3 called after the fall and R3 said R3 yelled out and the nurse came to check on R3. On 9/16/22 at 1:45pm, V17 (Restorative Aide) stated I asked if R3 is in pain and if he had a fall, when and where did R3's fall happened. R3 stated In the bathroom and I think it was the other day. I may have tripped and lost my balance. Hospital record of 6/27/22 reviewed and CT abdomen pelvis with IV contrast was done and it shows minimally displaced posterior left 11th rib fracture. R3 is at risk for fall due to weakness, impaired balance and dementia with a revision date of 8/11/22. Goal for R3 is to be free of falls. Interventions: Increased staff supervision with intensity based on resident need. Provide individualized toileting interventions based on needs/pattern. R3 was assessed on 3/23/22, Physical Therapist and discharged summary: Balance Dynamic Standing as Minimal assist to maintain, dynamic cannot move trunk without loss of balance. Walk 10 feet and 50 feet with two turns: Helper assist only prior to or following the activity. Walk 150: Supervision or touching assistance-helper provides verbal cues or touching steadying assistance as resident completes activity or intermittently. Walking 10 feet uneven surfaces: not attempted due to medical condition or safety concerns. Risk for fall: R3 will demonstrate improved balance to 41/56 as evidence by Berg Balance test result with improvement in safe transfer and gait. Status: Goal not met on 3/23/22. Explanation: reached highest functional level. End of goal status as of 3/23/22: Goal not met R3 medium fall risk as evidence by Berg Balance test result. Analysis of functional outcome/Clinical impression: R3 continues to demonstrate right foot drop and R3 dragging right foot with R3 able to correct with verbal cues given. Precautions but not limited to falls. On 9/14/22 at 2pm, observation of R3's room conducted and noted duct tape on the floor by the doorway, bedroom to washroom transition. On 9/16/22 at 11am, R3's room recheck and the same duct tape on the floor was observed. Doorway floor bedroom to washroom transition. On 9/16/22 at 1130am, V3 (Maintenance Director) stated I communicated this concern with the V1 (Administrator) and the management team first time it was observed by a surveyor during this survey on 6/14/22. I mentioned to them that in order for me to fix the floor issue, the resident in the room must be moved to another room. It would have been more of a trip hazard if the duct tape is not there, however having the duct tape is still a hazard. The floor needs to be fixed in order to make the area safe and not a hazard. I have everything/items to fix the floor, I am just waiting for the facility to move the resident who is present now in R3's former room. Fall and Fall Risk Management with a revision date of 3/2019 reads in part: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Policy interpretation and implementation: According to the MDS, fall is defined as: Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Fall Risk Factors: Environmental factors that contribute to the risk of fall include: Obstacle in the floor path. Resident conditions that may contribute to the risk of falls include: Lower extremity weakness. R8 R8 was admitted to the facility on [DATE] with diagnoses of unsteadiness on feet, history of falling, lack of coordination and [CONDITION(S)]. R8's brief interview for mental status dated 9/2/22 documents a score of 15/15, which indicates cognitively intact. R8 minimum data set section G, documents under bed mobility, Resident requires extensive assistance with one-person physical help. R8's nutritional assessment dated [DATE] documents a weight of 235 pounds. On 9/14/22 at 1:53PM, R8's mattress was observed hanging over the frame of her bed and was not flush to the bed frame. R8 had no positioning rails observed on bed. R8 post fall observation dated 9/14/22 documents an observation date of 9/5/22, staff relayed that R8 had slid between the mattress and wall, lodging herself. Staff carefully lowered her to the floor and used mechanical lift to return her to bed. The mattress was changed out; there were no further incidents or injury. What appears to be the root cause for this fall is that mattress did not fit the bed. Initial intervention documents: mattress changed. Additional information documents: assessed R8's bed mattress and still needs change and positioning rails on bed; informed maintenance. R8 Progress Notes dated 9/4/22 documents: Resident was observed in bed, alert and able to make needs known. CNA was doing ADL care while resident was lying in bed on an air mattress and when turning to the side, the resident turned and got stuck between the bed and wall. R8 Therapy Notes dated 9/6/22 under notes: Patient on an extra-large air mattress and agreeable to bed positioning device to increase bed mobility On 9/15/22 at 2:46PM, V11(Restorative Nurse) said it was recommended for R8's mattress to be changed following an incident on 9/4/22. V11 said the mattress was too big for the frame and was not changed until 9/14/22. V11 said she was unaware of therapy recommendations for positioning rails for R8.

Based on observations, interviews, and record reviews, this facility failed to ensure 2 staff members performed bed mobility while providing direct care to a dependent resident requiring who was assessed to require two staff for ADLs (activities of daily living) care. This affected 1 of 4 residents reviewed for supervison during ADL care. This failure resulted in R1 falling from the bed while being bathed by facility staff and sustaining a 4cm (centimeters) laceration to left side of forehead requiring 8 sutures. Findings include: On 2/8/22 at 10:30am, R1 was observed making slight movements with both hands and lifting forearms off bed minimally. R1 did not make any attempts to reposition self in bed. R1 was not observed moving legs. On 2/9/22, this surveyor made continuous observations of R1 from 9:00am-9:30am. R1 was observed making slight movements with both hands and lifting forearms off bed minimally. R1 was not observed moving legs. R1 was observed to be alert and oriented x 1. R1 was unable to follow simple commands and did not make any attempts to reposition self in bed. On 2/9/22, this surveyor made continuous observations of R1 from 9:30am-9:50am during R1's bed bath. There were two staff members assisting with R1's care. When turned R1 did not make any attempt to extend arms away from body grab/hold on to side rail. R1 did not attempt to assist staff with turning. Both of R1's hands remained closed throughout this observation. Resident was observed moaning when turned side to side. On 2/9/2022 at 11:00am, V2 DON (director of nursing) stated, V6 CNA (certified nurse aide) providing care for R1 on 1/18/22 at the time of the fall is an agency CNA. V2 stated, V6 has not worked at this facility since R1's fall. On 2/9/22 at 11:15am, V5 (unit manager) stated, V5 was present in this facility on 1/18/22 when R1 fell out of bed. V5 stated, V5 was informed by R1's nurse, and V7 (nurse) of the incident. V5 stated,R1 was already placed back in bed when she went to R1's room. V5 stated, R1 is not alert/oriented, R1 is unable to make needs known. V5 stated,V5 has not witnessed R1 attempt to turn self in bed. V5 stated, R1 will sometimes cross legs at ankles, but R1 does not make any significant position changes. Review of R1's medical record, dated 1/18/2022 at 11:59am, V7 (nurse) noted R1 was observed in R1's room on the floor laying on her right side on the floor. R1 was changed at the time of the fall. Physical assessment was completed. Vital signs: blood pressure 147/91, heart rate 80 beats/minute, respirations 18/minute, temperature 97.9 degrees Fahrenheit, and oxygen saturation level 95% on oxygen. R1 is alert and oriented x 1-2. Neurological assessment is completed and is negative. R1 confirms pain level 5 out of 10. New skin alteration on the forehead, is bleeding and with open laceration. Laceration was cleaned and covered with gauze. R1 was transferred out of facility to the hospital. Notified R1's attending physician regarding the fall. Spoke with R1's family member about the fall. R1 returned to facility via ambulance from the hospital at approximately at 1:30pm. Review of R1's hospital record, dated 1/18/2022, notes R1 presented to the emergency room after falling out of bed. R1 is alert and oriented x 1 per R1's normal. Physical examination noted a 4cm (centimeters) laceration to forehead requiring 8 sutures to close. Review of this facility's fall incident investigation, dated 1/19/2022, notes V6 CNA statement of the event: V6 was giving R1 a bed bath. R1 had a bowel movement which required V6 to change gloves. As V6 went behind the drawn curtain, R1 rolled out of bed. Review of R1's fall risk assessment, dated 1/18/2022, notes R1 is at risk for falls. Review of R1's MDS (minimum data set), dated 4/19/21, notes R1's cognitive status for daily decision making is moderately impaired. R1 requires extensive assistance of two staff members with bed mobility. R1 is totally dependent on one staff member for bathing. Review of R1's MDS, dated [DATE] and 10/20/21, note R1's cognitive status for daily decision making is moderately impaired. R1 requires extensive assistance of two staff members with bed mobility. R1 is totally dependent on two staff members for bathing. Review of R1's ADL (activities of daily living) flowsheet, dated 10/14/21-10/20/21, notes R1 is totally dependent on staff for bed mobility. R1 is totally dependent on two staff members for bathing. Review of R1's MDS, dated [DATE], notes R1's speech is unclear; R1 rarely/never is understood; and rarely/never understands others. R1 requires extensive assistance with bed mobility and is totally dependent for bathing. Review of R1's restorative look back documentation, dated 1/15-1/17/22, notes R1 is totally dependent on staff for ADLs. Review of R1's hospice note, dated 1/19/2022, notes R1 is oriented to person only. R1 is bedfast and completely immobile. Hospice notified by nurse on 1/18/22 that R1 fell out of bed during bed bath requiring sutures. Review of R1's care plan, notes R1 requires extensive assistance with turning/repositioning in bed. R1 will be turned/repositioned with the assistance of two people. It also notes R1 is rarely/never understood in ability to express ideas and wants. R1 rarely/never understands others. Review of this facility's CNA training/education notes make sure before bathing the resident, gather all supplies. Supplies needed for bathing include, but not limited to, gloves. If the resident is bedridden, have a second staff member on the opposite side when repositioning from side to side. Always get the assistance of another staff member when bathing, repositioning, or performing any task on a resident that is bedridden.

Based on interviews, and record reviews, the facility failed to prevent an accident for 2 residents (R3 and R6) by: 1. Failed to provide safe bed mobility-turning while providing incontinece care by a staff member, R3 rolled off the bed onto the floor resulting in a nasal fracture. 2. Failed to provide the assistance of two staff members when performing a mechanical lift transfer for one resident (R6) while using a mechanical lift device resulting in R6 falling from the mechanical lift onto the floor. Findings include: On 12/27/21 at 12:48 PM, V2 ADON (Assistant Director of Nursing) and V13 DON (Director of Nursing) regarding R3's fall incident on 12/10/21. V13 DON said, V14 (Certified Nurse Assistant) attempted to provide R3 incontinent care, V14 instructed the resident to roll over to change the incontinent brief, V14 said, resident shifted her weight while rolling over. R3 rolled in the opposite direction of the staff. V2 ADON said, according to the MDS (Minimum Data Set) R3 was only a 1 person assist for bed mobility. We don't use bed rails. R3 had redness and bruising to her face. She was transferred to the hospital. She had a CT (Computed Tomography) scan that said she had a facial fracture. V13 DON said, during the investigation we decided for bed mobility R3 requires a 2 person assist due to her impaired cognition. Verbal education was provided to V14. V14 (Certified Nurse Assistant) via phone said, regarding R3's fall incident. R3 was on her way to the hospital, I was there to change her. I turned her over on her side away from me, maybe she turned too fast and rolled off the bed. I assisted her, it wasn't expected. We decided the best thing to do, have to get two people to assist. Make sure the bed is close to the wall and my hand is on her so she doesn't roll off. Review of the 12/10/21 progress notes by nursing read: Per CNA in the process of getting the resident ready to go to the hospital when turned R3 on her right side facing the wall R3 fell to the floor. Writer did not witness the fall. When writer was told R3 had fell R3 was on a stretcher walking out of the door. The facility fall/incident report was reviewed. Incident reads: CNA completing incontinence care assisted resident in log roll to change adult brief, resident shifted body weight during turn to right side resulting in change of plane. Intervention: 2 person assist. Root cause: Resident inability to follow directions due to impaired cognition. Review of the electronic comprehensive care plan dated effective 12/6/21 indicates: R3 requires assist with bed mobility as evidenced by the following limitations and potential contributing diagnosis: [CONDITION(S)] disease. Interventions read: Assist in turning and repositioning every two hours, use draw sheet if necessary. Encourage R3 to assist with repositioning as much as possible. R3's MDS (Minimum Data Set Comprehensive Assessment) section C Cognitive Patterns dated 11/30/21 reads: BIMS (Brief Interview for Mental Status) score of 14 out of 15, indicates the resident is cognitively intact. R3's MDS section G Functional Status dated 11/30/21 reads: bed mobility self-performance -2. Limited assistance. Support provided- 2. One-person physical assist. R3's care plan indicates: turning/positioning in bed (bed mobility) R3 requires limited assistance. Interventions include: while in bed, assist R3 to turn/reposition self. Use pillows and foam wedges to maintain position. 12/09/21 emergency room records indicates: Per EMS (Emergency Medical Services) patient initially called for abdominal swelling from her liver [CONDITION(S)], upon arrival they found patient on the floor from a fall. Patient having pain to nose, face and left arm. Wound to nose and left elbow. Patient is very limited in ability to explain what is going on. CT (Computed Tomography) scan findings: A comminuted fracture is demonstrated along the nasal bone bilaterally. R3 did not return to the facility, unable to be interview. R6 is a [AGE] year old female with the diagnosis of [CONDITION(S)], chronic [CONDITION(S)] and [CONDITION(S)]. R6 has a BIMS (Brief Interview for Mental Status) of 15 and is able to be interviewed about events that occurred on 12/15/2021 the night of her fall. R6's Progress notes and the facility fall reports read on 12/15/2021 R6 had a fall from the mechanical lift while staff was assisting her with a transfer from her chair to the toilet. On 12/28/2021 at 10:05am R6 said, it was about 8:30pm -9:00pm, at night, it was just me and her (C.N.A). The C.N.A was taking me to the bathroom we got across the room and the belt that hold's me up came loose from the machine and I tried to hold myself up with the other side but it didn't help, and I went down to the floor and she ran so fast to get me help I told them I didn't hit my head so they got me up and put me in the bed. On 12/28/2021 at 11:09am V2 ADON (Assistant Director of Nursing) said, CNA that was working with R6 was using the lift to transfer her when the strap came loose and R6 fell . CNA was re-educated on using the lift safely. No she should not have been using the lift on her own, she should have had a second person with her. On 12/29/2021 at 2:43pm V19 (Certified Nursing Assistant) said, I was taking R6 to the bathroom, I put her on the sit to stand as we were going into the bathroom one of the straps snapped out. I ran to get the nurse and we lowered her to the floor we used the Mechincal Lift to get her up. I should have had someone with me but R6 was adamant about going to the bathroom so I just tried to take her so she wouldn't have accident. R6's MDS (Minimum Data Set Comprehensive Assessment) section G / Functional Status for transfers and toilet use reads that R6 requires two plus persons physical assist. Facility presented policy titled: Safe Lifting and Movement of residents dated March 2019 reads under policy statement: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Facility presented Mechanical Total lift skill Validation Form that reads: Place mechanical lift in position with the assistance of a 2nd caregiver.(position lift directly in front of the client seated in a wheelchair. Position lift perpendicular -right angle- to a client in bed). Letter D states: Demonstrate/verbalize safety awareness of the 2nd caregiver responsibilities during lift procedure. Do not proceed without assistance of a 2nd caregiver.

Based on interview, and record review, the facility failed to follow their visitation policy by restricting visitation times and visits for three of three residents (R1, R3, R5) reviewed for visitation. This failure resulted in R3 expressing a feeling of being depressed, sad and also feeling unsafe due to visitation restrictions. Findings include: R1 was admitted to the facility on [DATE] at 7:50PM, with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set, dated dated dated [DATE] documents a brief interview for mental status score 15/15 which indicates cognitively intact. R1's care plan dated 8/6/21 documents R1 has mild symptoms of depression. R1 states she has felt down, has low energy trouble sleeping and poor appetite, feeling unsafe due to visitation restriction. Intervention includes: Encourage family support, and visits to facility. On 8/31/21 at 4:53PM, R1, who was alert, and oriented at time of interview as well as tearful, states she feels like her family is being held from her. R1 said the changes in visitation has caused her more stress and sadness, and feeling unsafe due to visitation restriciton. R1 said her husband who she has been married to for over [AGE] years was not able to visit before 4:30PM during the week due to work. R1 said her husband had to change his work schedule and start work at 4:00AM so he can visit R1 in the afternoon during the week. R1 stated not seeing her husband makes her feel uncomfortable and feel unsafe. R1 said she and her husband did not receive any notice of changes in visitation until after 8/16/21. On 8/26/21 at 12:07PM,, V1 (Administrator) said he made changes to the visitation policy starting 8/16/21 due to noncompliance of families during visits V1 said prior to 8/16/21 families did not have to make an appointment, they were able to visit in a room with no time restrictions. The new policy limits in room visits to end of life, or bed bound patients. We shorten the time frame for visits in the evening due to staffing. Visits during the week are from 1:00PM to 4:30PM and on weekends from 1:00PM to 3:00PM with 20 minute time limits. V1 said all families were notified via email of changes to visitation policy and staff passed out the updates when families arrived for their visits.When asked how he ensured all families received an email, V1 said the guidelines are posted on the door. V1 said he banned V23 (R3's family) from visitation for 2 weeks after she went into R3's room for a visit unauthorized. V1 said he had no other incidents of noncompliance with V23 but she did not follow the rules and went to R3's room. R3 was admitted to facility on 6/18/21 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's minimum data set 6/21/21 documents a brief interview for mental status score 15/15 which indicates cognitively intact. On 8/31/21 at 4:26PM, R3, who was alert, and oriented at time of interview said he was upset that his wife has been banned from visiting the facility. R3 reported they have been married for [AGE] years and this is the longest they have been apart since being admitted to the facility. R3 said he feels depressed, misses his wife and feels he is being punished for something. On 8/31/21 1:13PM, V23(R3's family member) said she went to see R3 on Sunday (8/20/21). V23 said she had an appointment but when she was at the back door there was no receptionist present. V23 stated, someone finally buzzed her into the building. V23 said she waited by the back entrance and there was no staff present or at the nursing station. V23 said she finally saw a female CNA, she was told she could go to R3's room to drop off items. After a few minutes, a different staff member informed me that I could not visit in the room and I left. The next day V23 said she received a call from V1 (Administrator) informing her that she was not following guidelines and was banned from visiting the facility for two weeks. V23 said she felt afraid and embarrassed. V23 said she did not try to visit again because she was unsure of what would happen and feared any retaliation towards her husband or herself. V23 said with the new visiting times it is difficult to come see R3 during the week because V23 works until 5:30PM. On 8/26/21 at 12:07PM, V1 (Administrator) said he made changes to the visitation policy starting 8/16/21 due to noncompliance of families during visits. V1 said prior to 8/16/21 families did not have to make an appointment, families were able to visit in room with no time restrictions. The new policy limits in room visits to end of life, or bed bound patients. We shorten the time frame for visits in the evening due to staffing. Visits during the week are from 1:00PM to 4:30PM and on weekends from 1:00PM to 3:00PM, with 20 minute time limits. V1 said all families were notified via email of changes to visitation policy, and staff passed out the updates when families arrived for their visits.When asked how he ensured all families received an email, V1 said the guidelines are posted on the door. V1 said he banned V23 (R3's family) from visitation for 2 weeks after she went into R3's room for a visit unauthorized. V1 said he had no other incidents of noncompliance with V23 but she did not follow the rules and went to R3's room. On 8/26/21 at 1:20PM,, V6 (Assistant Administrator) said there was not a receptionist on Unit 2 that day. On 8/26/21 at 2:19PM, V7 (Admissions) said she was working on 8/22/21 and was on Unit 2 and observed R3 was not in the dining room for his visit. V7 said she went to R3's room and found V23 who stated R3 did not want to get out of bed and that she knew the policy and was leaving. V7 said V23 had on a mask and left willingly when notified that visitation could not take place in the room with no concerns. R5 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's minimum data set 7/15/21 documents a brief interview for mental status score 7/15 which indicates severely impaired. On 8/27/21 at 2:28PM, V16 (R5's family member) said she is R5's power of attorney. I was told R5 wasn't coming out to visit (on 8/27/21) and we would have to go into R5's room. During the visit, my mask slid down due to the ear loops being too large. V16 said she was confronted by V1 (Administrator) who said, this is the very reason, I stopped in room visits. I can stop you from visiting R5. I can make it so you can't come in to visit. You have to get out of R5's room. I don't allow room visits. Normally when I come, I take R5 outside for fresh air. The receptionist said, no outside visits today. Visits are from 12:00 PM,-4:00PM, which is an inconvenience time for me. V1 (Administrator) said, we can only come from 12:00PM,-4:00PM, for twenty minutes increments. I did not have privacy in the dining room or enough time to visit. Im unable to visit R5 tomorrow because I would have had to make the appointment before noon today even if the slots are open for tomorrow. It's frustrating when I can't see R5. R5's care plan documents R5 has verbalized mild symptoms of depression. Under interventions documents: Encourage family support and visits. Updated visitation policy dated 8/13/21 documents all visitation except end of life ends at 8:00PM. General visitation guidance- required visitation documents: facility shall not restrict visitation without reasonable clinical or safety cause. A nursing home must facilitate in person visitation consistent with applicable CMS regulations. According to CMS guidance, visitation should be person centered; consider the residents physical, mental and psychosocial well-being and support their quality of life. On 9/1/21at 12:04PM, V1 (Administrator) said there has been no banned visits for any families except for R3. V1 said R5's family received a verbal warning after being found in R5's room without wearing a mask properly. When asked why R5's family was given a verbal warning and R3's family was banned, V1 replied R5's family was instructed to go to the room by staff and R3's family went into unauthorized area without waiting for staff. On 9/1/21 at 1:29PM, V1 (Administrator) presented an email that was sent to families on 8/16/21 but was unable to show all the recipients.

Based on interviews, and record review, the facility failed to timely provide pain medication to one (R1) resident following post-operative procedure to her left knee. This failure resulted in the resident being in pain 10/10 for over 12 hours for one of three residents reviewed for pain. Findings include: R1 was admitted to the facility on [DATE] at 7:50PM, with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set, dated dated dated [DATE] documents a brief interview for mental status score 15/15 which indicates cognitively intact. R1's admission nursing assessment dated [DATE] under pain documents: Is the client experiencing pain? Yes; Pain Intensity 10/10 which indicates worst possible pain; please describe pain. Sharp pain in her left leg. R1's wound assessment dated [DATE] documents: admitted with left leg surgical site measuring length 30cm x width 30cm. R1's admission note dated 7/28/21 9:00PM, R1 was discharged from local hospital. R1 is alert and oriented times four, able to verbalize needs, complaining of pain to left knee 10/10. Left knee with non-removable surgical dressing, with wound vac and left knee brace. On 8/31/21 at 4:53PM, R1 who was alert, and oriented at time of interview said on admission she was having pain 10/10 in her left leg. R1 reported her last pain medication was given at the hospital around 2:00PM. R1 said she was begging staff for any pain medication and was told they were waiting for orders, or they did not have orders for pain medication. R1 said she was not able to sleep due to the pain. R1 reported she finally received medications sometime in the late morning the following day. On 8/31/21 at 2:11PM, V2(DON) Director of Nursing, said they need an prescription to have medication released from the pharmacy and/or convenience box. V2 said they were waiting for a script and once the script was sent, the pharmacy notified facility that R1 had an allergy to [MEDICATION(S)] and needed an ok from the doctor to dispense the oxycodone. Once they received the ok the medication was sent and taken from the convenience box. V2 said she is unsure why medication was not documented when given or if they the nurse informed the doctor of the delay of pain medications or if any alternatives were given or offered besides Tylenol. V2 was unable to provide any pain assessment for R1 after 7/28/21 to 7/30/21. On 8/31/21 at 3:22PM, V24 (pharmacist) said they received oxycodone prescription for R1 at 8:00PM on 7/28/21. At 11:00PM, they attempted to call facility due to [MEDICATION(S)] allergy to see if it was ok to send oxycodone but there was no answer. At 2:48AM, facility nurse said R1 received medication in the hospital and it was ok to be dispensed. V24 said they did not need a doctor to clarify an allergy since resident was taking it at the hospital. R1's pain medication was removed from convenience box on 7/29/21 at 9:44AM. R1's progress noted dated 7/29/21 at 4:30AM, documents: Received R1 in bed. R1 is new admit had knee replacement surgery was given Tylenol for pain at 1:00AM, was somewhat effective. Pharmacy called to check on status of oxycodone, stated they had to verify allergies to [MEDICATION(S)], resident stated she was taking oxycodone in the hospital, pharmacy informed said they will be sending it out with next delivery. All needs met. No signs of pain or distress. R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record documents first dose of oxycodone was given on 7/30/21 at 4:15AM. There was no documentation of any pain medications given prior to 7/30/21 at 4:15AM R1's admission hospital paperwork documents: R1 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Under medications dated 7/28/21, documents last oxycodone was administered at 13:56. Pharmacy notes dated 7/28/21 documents R1 prescription for oxycodone dated 7/28/21 from local hospital. Pharmacy notes dated 7/28/21 at 11:45PM, attempted to call facility about [MEDICATION(S)] allergy no answer for four minutes. On 7/28/21 at 2:48AM, spoke to facility nurse that R1 received oxycodone in the hospital. Pharmacy notes dated 7/29/21 at 9:46AM, document R1 needs pain medication urgently removed one oxycodone tablet (from convenience box at the facility). Facility pain policy titled Pain- Clinical Protocol dates 3/2019 documents: The nursing staff will assess each individual for pain upon admission, at quarterly review, whenever there is a significant change in condition and when there is onset of new pain or worsening of existing pain. The staff and physician will identify the characteristics of pain such as location. Intensity, frequency, pattern and severity. Staff will use a consistent approach and standardized pain assessment instrument appropriate to the resident's cognitive level. The staff will reassess the individual pain and related consequences at regular intervals at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. The staff will evaluate and report residents use of standing and as needed analgesics.

Based on interview, record review, and observation the facility failed to provide care and services that ensures a resident's dignity, self-esteem and self-worth is maintain by not immediately removing biliary fluids from a resident's clothing and bed linen and not knocking before entering a resident's room. This applies to 2 of 24 sampled residents (R46 and R148). As a result, R46 experienced psychosocial distress by having to wait for assistance from staff to provide care and service due to a leaking biliary drainage (fluid from ostomy) bag. Findings include: 1. On 1/26/2021, at 12:42p.m, R46 was observed laying in bed, holding his sheets in his hand. R46's gown and bed linen were observed with a green substance. R46 showed the surveyor that his drainage bag was leaking, R46 said he reported this to the aide, and she reported this to the nurse, and when the nurse came in the room she said she did not know how to change it and that she needed to find some who knew how to change the bag. R46 said he feels sad that he has to sit in the soiled linen and wait for someone to change the leaking biliary bag. R46 put the call light on and V16 (CNA) arrived, V16 immediately said this bag has been leaking since breakfast trays arrived and I reported this to V23 (Nurse) around 9:30a.m- 10:00a.m. V16 said she does not know how to change this drainage bag. On 1/21/2020, at 1:00p.m, V23 (Nurse) said she went in R46's room at around 12:00 p.m and she knew the drainage bag is leaking, V23 said she has not changed the bag because she is prioritizing her tasks. V23 said the fluids leaking from R46's drainage bag can cause skin breakdown. V23 said the bag should be changed immediately when leaking. On 1/28/2021, at 10:38a.m, V3 DON- (Director of Nursing) said R46 has a biliary drainage bag, and it should be emptied when it's half full and changed right away if it's leaking. V3 said allowing the drainage to remain on the skin could cause skin breakdown. V3 said a leaking biliary drainage bag is a priority and V23 should have changed the bag when she noticed it leaking. The Facility policy titled Quality of life-Dignity, dated March 2019, shows in-part that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. The Resident shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. The Facility policy titled Resident Rights dated March 2019, shows in-part, employees shall treat all residents with kindness, respect, and dignity. These resident rights include a dignified existence. 2. R148 is a [AGE] year-old female originally admitted on [DATE] with medical [DIAGNOSES REDACTED]. R148 is alert and oriented able to verbalized her needs. On 01/26/21, at 11:40AM, observation was made that a light was illuminated over R148's entry door and R148 was calling out I need the nurse. R148 said, I have the call light on for over 20 minutes and no one is answering it, sometimes it takes more than 30 minutes before they come. At 11:56 AM, V15 (Certified Nursing Assistant), came into the room and turned the light off, then asked R148 did you call, what can I do for you? At 12:00 PM, V15 said, I came to the room to answer the call light, the door was open, I do not need to knock or ask for permission, I came as soon as I had time to answer it. At 12:15 PM, V12 (licensed Practical Nurse) said, we are responsible to answer the call light as soon as we possibly can, within 10-15 minutes. It is not acceptable to come into the patient's room without knocking and asking for permission, that is the part of the respect and dignity that we need to observe when caring for all the patients. On 01/28/21, at 11:40 AM, V3 (Director of Nursing) said, V3 said my expectation is that anyone from any department is able to answer call lights. The call light is the way the patient lets us know they need help. We need to answer the call light as soon as possible, knock on the door, ask for permission to enter, wait for response, and identify yourself, call the patient by his/her name, turn the light off, and assist the patient with the requests. It is disrespectful and unacceptable to go into the patient's room without knocking and asking for permission to enter. V1 (Administrator) presented: Answering the Call Light dated 3-2019. It reads: The purpose of this procedure is to respond to the resident's requests and needs, answer the call light as soon as possible, knock on resident's room, ask for permission to enter, identify yourself, turn off the call light, and attend to resident's requests.

Based on observation, interview and record review, the facility failed to implement safety measures for a resident at risk for falls, to reduce the risk of injury for one of two residents (R6) reviewed for a serious injury in a sample of six residents (R6). This failure resulted in R6 being hospitalized and treated for [REDACTED]. Findings Include: According to a face sheet R6 was admitted to the facility on [DATE] with admitting [DIAGNOSES REDACTED]. According to the electronic physicial therapy evaluation- with a certication start date of 2/02/2016: R6 had a prior hospitalization from ,[DATE] to 2/01/2016. R6 presented to the hospital with subdural acute hematoma status [REDACTED]. An emergency right sided craniotomy and evacuation of subdural hematoma, stripping of membrane was conducted 1/25/2016. R6's caraniotomy for subdural hematoma done on 1/25/2016 was also document of the hospital's transition of care report printed on 1/29/2016. An occurrence Report dated Tuesday 2/2/2016 at 4:40am documented the following information: Type of occurrence Fall, Location -Hallway/Corridor, Activity Sitting Witnesses) None. Cognition prior to occurence oriented x 1 and after occurence oriented x 1. Injuries None Noted. Immediate Actions Taken Neuro checks intiated, alarm applied, monitor resident closely, use gait belt for transfers/ambulation redirect, placed in wheelchair, family called to assist with behavior, ROM within normal limits for resident, Non-slip socks or shoes and Physician called. Notes: Nurse's note of what happened written by E7 (nurse) on 2/02/2016 07:47- CNA (certified nurse aide) E6, notified writer patient fell , visually observed patient on the floor on the back, assist to chair, assessed patient , notified MD (medical doctor) and POA (power of attornery) Z4,neuro checks intitiated, resident had no complaints of pain or discomfort, will continue to monitor, endorsing to 7-3 nurse. A follow-up Report entered on 2/04/2016 10:09 documented; 2/02/2016 4:40am E6 (CNA) notified E7 (nurse) R6 fell out of his wheelchair. R6 in therapy today with family. Family notified significant change in R6. He was droooling unable to follow directions as well as before and could not swallow medicine/ pudding. Family requested to send to hospital. Clinical note entry dated 2/02/16at 3:19pm documented, Resident in therapy today with family (Z4) Family noticed significant change in resident. R6 was drooling at the mouth, unable to follow simple direction and could not swallow medicine or pudding. Family requested to send to hospital. The hospital emergency room Records dated 2/2/2016 contained a CT head scan without IV contrast revealed changes in the postoperative area of R6's brain that was in line with an acute subdural hemorrhage. R6 was transferred to another hospital which could provide treatment for [REDACTED]. 3/30/2016 at 12pm, E8 (Registered Nurse/RN) was interviewed. E8 reported she admitted R6 to the facility 2/1/2016. R6 was admitted for physical therapy after suffering a fall at home. The fall caused R6 to have Craniotomy for a subdural bleed in the brain. At admission, R6 could answer simple 'yes and no' questions. R6 was not agitated. E8 did the initial assessment of R6. E8 said that upon admission to the because of R6's history of falls, R6 was placed in a low bed, mats of the floor and a bed sensor. E8 was asked if any safety measures were taken for R6's recent head injury. E8 said all bed rails were down, floor mats were in place on both sides of the bed and the night stand was removed. R6 was not admitted to the facility with a helmet, nor was there an order for [REDACTED]. E8 said R6 had become agitated by the end of her shift. R6 was sitting up in bed. R6 was told that it was time to go to sleep and he would lay back down for a short time then would again sit up in bed. R6's behavior had escalated by the end of the 3 to 11pm shift. E8 said she verbally endorsed over to the 11 to 7am shift that R6 needed increased monitoring due to agitation. 3/30/2016 at 11am, E6 (CNA)was interviewed. E6 reported she was the direct care staff for R6 on the 11 to 7am shift, 2/1/2016. E6 said that after R6's family left. R6 started yelling out for his daughter and trying to get out of bed. After the 3rd or 4th time R6's bed sensor went off. E6 told E7 (nurse) about his behavior. E7 told E6 to get R6 out of bed and place him by the nurse's station. E7 gave E6 no special precautions to take for R6's head injury. E6 got R6 dressed and transferred him to a wheelchair with a chair alarm. R6 was place at the nurse's station with at least 5 other residents who were up in wheelchairs for similar reasons. E7 said residents having behavior problems at night are dressed and set up at the nurse's station in a wheelchair. Nothing was added as a safety precaution for R6's head injury. E6 went to chart but was in visual control of R6. E6 said R6 was at first quiet but then started to rocked side to side and back and forth in the wheelchair. R6 fell forward out of the wheelchair on his knees. The wheelchair fell on top of him. E6 said R6's head did not hit the floor. After R6 was assessed for injuries while he was lying on the floor, E6 was told to put to R6 back to bed and monitor R6 1:1 until the shift was over. I didn't help with any other residents until shift ended. After the fall, R6 was quiet the rest of the shift. 4/4/2016 at 9:42am, Z2 (Attending Physician for R6) was interviewed. Z2 said he was R6's Attending Physician in the facility. Z2 was unfamiliar with R6's previous hospitalization for his original subdural hematoma and Craniotomy. Z2 confirmed that R6 suffered a subdural hematoma 2/2/2016 but said, Staff in the emergency room [DATE] had no reference to say if it was the same bleed as the first or a new bleed in the brain. Z2 was asked if R6's head being jerked back and forth cause a bleed in the brain. Z2 said, Any sudden trauma to the head causing the brain to move in the skull could cause a bleed. 4/4/2016 at 3pm, the surveyor observed the location where R6's fall occured while accompanied by E13 (vice president of clinical development). E13 pointed out where the CNAs chart in the hallway and where residents are positioned around the nurse's station. R6 was a minimum of 6 feet away from E6 with at least 5 other residents.

Based on observation, interview and record review the facility failed to supervise one resident while being toileted (R1) of three residents reviewed for falls. This failure resulted in R1 falling off the toilet, hitting her head and sustaining a subdural hematoma and hospitalization . Findings include: R1 was admitted to the facility 12/16/15 with [DIAGNOSES REDACTED]. Clinical Note Entry dated 12/24/15 at 9:06am indicates that at 5:15am (on that date) CNA (Certified Nursing Assistant) reported a fall in R1's room. Note indicates I stepped away to the night stand. Note indicates R1 starting to lean and then hit head on sink. Note indicates that R1 was found lying on left side, laying under sink. Note indicates that R1 was transferred to the hospital #1, then later transferred to hospital #2 with Brain Bleed. On 1/5/16 at 9:40am E11, CNA stated that (on 12/24/15 at 5am) R1 was transferred from her wheelchair to the toilet. E11 stated she then left R1 on the toilet and left the bathroom to go into R1's bedroom to get her dentures. E11 stated that while getting (R1's) stuff together she heard a noise in the bathroom and when she looked in the bathroom she found R1 on the floor and went out of the bathroom to get help. E11 acknowledged she was not supposed to leave R1 unattended on the toilet and should not have left R1 unattended on the bathroom floor to get help. R1 also admitted to transferring R1 by herself from the wheelchair to the toilet without a gaitbelt. Client Care Guide dated 12/17/15 indicates that R1 transfers with extensive assist with gait belt, 2 person assist and identifies R1 as a fall risk. On 1/6/16 at 3:15pm Z2, Physician stated I agree. This resident (R1) should not have been left unattended. Staff should have been there.

Based on observation, interview and record review, the facility failed to follow the plan of care and utilize two person assist while using the mechanical lift for one of three residents (R1) reviewed for mechanical lift transfers. This failure resulted in R1 falling from the mechanical lift and sustaining a cervical fracture. Findings include: R1s face sheet denotes, R1 is an [AGE] year old who was admitted to the facility with diagnoses, in part of paralysis, unspecified fracture of the lumbar spine, and Parkinson' s disease. The facility' s initial incident report dated 8/26/2015 denotes, E3 (certified nursing assistant) was attempting to transfer R1 from a reclining chair to a bed utilizing a mechanical lift. During the transfer, R1 fell to the floor and sustained an abrasion to the left scalp area. The facility' s final incident report dated 8/27/2015 was also reviewed. After reviewing the facility' s initial and final incident report, it was determined that E3 did not have assistance from another staff member while transferring R1 with a mechanical lift. R1 was transferred to a local hospital where it was determined that R1 sustained a cervical fracture. Hospital emergency room records dated 8/26/2015 denotes, R1 sustained an acute nondisplaced fracture of the cervical 2 vertebrae (neck). Radiology report dated 8/26/2015 denotes, There is an acute fracture of the C2 vertebrae (hangman' s fracture). R1 was placed in a cervical collar and transported to a different hospital for trauma evaluation and further care. On 8/28/2015 at 2:10 PM, R1 was observed in bed and was wearing a cervical neck collar. R1 was deemed non-interviewable. On 8/28/2015 at 12:45 PM, E3 CNA (certified nursing assistant) stated that E4 LPN (License practical nurse) asked her to get a weight for R1. E3 stated that she placed the mechanical lift pad under R1, hooked the pad to the mechanical lift, and proceeded to lift R1 with the mechanical lift. E3 stated that after R1's weight was recorded, she attempted to lower R1 in bed. E3 stated that one of the hooks on the mechanical lift pad became detached from the mechanical lift which caused R1 to fall to the floor. E3 stated that she noted a small bruise to R1's head. When E3 was asked if it was the facility' s policy for one person to operate a mechanical lift, E3 stated no. E3 stated that the mechanical lift should be operated in the presence of two staff members. On 8/28/2015 at 1:05 PM, E4 stated that on 8/26/2015, E3 was asked to obtain R1's weight. E4 stated that E3 did not ask for staff assistance before operating the mechanical lift. E4 stated that after the incident with R1, E3 was re-educated on the use of the mechanical lift and received a written write up for not following the facility' s mechanical lift policy. Corrective Action Notice dated 8/26/2015 denotes, E3 transferred a resident that is a mechanical lift with two person assistance. E3 has previously been educated on use of equipment and has received transfer training. E3 failed to follow safety procedure, including but not limited to the failure to use the mechanical lift. On 9/2/2015 at 12:40 PM, Z3 (witness) stated that E3 came in the room to get R1's weight. Z3 stated that E3 was alone and was attempting to transfer R1 from a chair to a bed with a mechanical lift. Z3 stated while R1 was suspended in the air, a hook became detached from the mechanical lift. Z3 stated that R1 fell to the floor and hit her head on the mechanical lift. Z3 stated that there was a bruise noticed on the left side of R1s head as well after the fall. On 9/2/2015 at 11:02 AM, Z2 (medical doctor) stated that R1 has degenerative cervical changes such as cervical spondylosis. Z2 also stated that R1 did experience some minor neck trauma status [REDACTED]. Z2 stated, R1's cervical collar was prescribed after the fall. R1s quarterly resident assessment dated [DATE] denotes, R1 requires a two person extensive assist for transfers including to or from bed, chair, wheelchair and a standing position. R1s care plan dated 6/15/2015 denotes that R1 requires a two person extensive assist for activities of daily living and transfers. The facility' s mechanical lift policy dated 10/2008 was reviewed. The policy denotes the mechanical lift transfer is to be operated with two caregiver supervision.

Based on interview and record review the facility failed to immediately assess the reason for a new complaint of severe pain and monitor the effectiveness of pain medication for one of four residents (R2) reviewed for pain in the sample of nine. This failure resulted in R2 remaining in severe left hip pain for 3 days due to a left [MEDICAL CONDITION]. Findings include: Clinical Notes Report 2/12/15 12:02am documents R2 tried to go to the bathroom by herself and was noted half way off the bed. On 2/26/15 at 1:25pm, E7(Nurse) stated E9(Nurse Aide) told him R2 tries to get up by herself to go to the bathroom. By the time E7 went into the room, E9 had helped R2 back into bed, R2 was laying half way across the bed. E7 stated R2 didn't like to use the call light and thought she could do things without help. Minimum Data Set (MDS) assessment dated [DATE] documents R2 was not on scheduled pain medication. February 2015 Medications documented between 2/09 and 2/17/2015, R2 received [MEDICATION NAME] (strong pain relief medication) 10-325 milligram (mg) ordered every 6 hours scheduled for pain. There is no documentation of R2's pain level before or after the administration of [MEDICATION NAME]. R2's care plan for pain initiated on 2/9/15 had interventions of: document effectiveness, review pain assessment and pain medication effectiveness and notify physician of any abnormal findings, monitor medications for effectiveness, and notify physician of significant changes in or any abnormal findings. Physical Therapy Note 2/13/15 documented: R2 complained of new left hip pain being 9 on a scale of 1-10 (10 being the worst pain and 1 being one pain), exercises were completed with bilateral hip pain, R2 required assisted active range of motion with left leg exercises, which was not needed prior to this date. On 2/26/15 at 1pm, Z2(Physical Therapist) stated on 2/13/15 during therapy R2 complained of left hip pain 9 on a scale of 10. R2 needed assistance to do exercised with the left leg that she did not need help with the day before. Z2 stated she did not tell anyone that R2 has the new left hip pain. R2 still had left hip pain on 2/16/15, rated 10 out of 10, Z4 told the nurse on 2/16/15. At 1:35pm, Z3(Physical Therapist) stated R2 told her on 2/17/15 that she fell "a few days ago" injuring her left side and someone helped her get back into bed. Z3 told the nurse on the floor that day and an x-ray was ordered. Reportable Incident Initial and Final Report 2/18/15 documents R2 complained of pain to the left hip on 2/16/15 in the evening. Physician Telephone Orders 2/16/15 9:40pm document an order for [REDACTED]. Physician Note 2/17/15 6:44pm documents an order for [REDACTED]. On 2/26/2015 at 1:30pm, E2(Director of Nursing) stated, When there is a change in condition, a fall, new or worsening pain, the physician and responsible party are notified as soon as possible. On admission, residents are assessed for risk of falls and care planned and interventions are put into place to help prevent falls. After a fall, the care plan is updated with a new intervention, a post fall assessment including pain and an incident report are completed. After a fall, the resident is assessed by a nurse before being moved. This assesses for an injury. Pain is assessed on admission and with any change in pain or new complaint of pain. If it is a new area of pain, the physician is notified and orders received. When pain medications are ordered, nurses can choose characteristics to monitor with the administration. E2 stated R2's new left hip pain was not assessed, the order does not specify how to monitor the effectiveness of the pain medication, and there is no documentation of R2's fall, behaviors to remove alarms or not use call light, a fall care plan, a behavior care plan, and physician or power of attorney (POA) notification of the pain, fall or behaviors. Clinical Notes Report 2/17/15 7:47pm documents R2 was seen by Z1(Physician) at 6pm for left hip pain, an x-ray was completed at 7pm with the results of a fractured left femoral neck (left [MEDICAL CONDITION]), R2 was being sent to the hospital for the fracture; 7:45pm R2 left the facility. On 2/26/15 at 2pm, Z1(Physician) stated on 2/16/15 R2 told him about the left hip pain and the fall a few day earlier. Z1 stated if he knew R2 fell or had new left hip pain, he would have come to evaluate her sooner, asked questions, and inquired if she fell or hurt herself. Z1 would have done an x-ray but nothing extensive. Z1 stated he did not know about the left hip pain until 2/16/15. If a nurse assessed R2's pain and found out that R2 fell , Z1 would have ordered an x-ray sooner and would have had the pain monitored. Z1 stated if R2 was found out of bed and nearly on the floor, it is obvious she had a fall. A hospital emergency room note 2/17/15 documents R2 sustained the left [MEDICAL CONDITION] as a result of the fall. The facility's policy for Change in Condition Notification - In the event of a significant change, accident or injury, or at the request of the resident, family or Power of Attorney (POA) for Health Care, the attending physician is notified. In the event of an unanticipated transfer or discharge, the attending physician and family/POA is notified. Pain Assessment and Management - Clients are assessed for pain upon admission, re-admission, if a change in condition, quarterly, and after a fall. Pain is addressed on the care plan and managed by the nurse and medical staff. Documentation of pain relief is done upon reassessment after pharmacological interventions on the MAR (Medication Administration Record). Reports of client pain by facility staff requires prompt assessment by licensed staff.

Based on interview and record review, the facility failed to ensure that safety precautions were implemented during a mechanical lift transfer involving one (R3) of four residents, reviewed for transfers from the sample of 24. This failure resulted in R3 sustaining a head laceration, a hospitalization , and nine sutures to the head. The facility also failed to assess for the use and safety of the specialty reclining wheelchair for two residents (R32, R19) from the sample of 24 reviewed for assistive devices and 12 residents (R3, R35, R40, R42-R50) in the supplemental sample. Findings include: 1. R3 is a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R3's client care guide dated 11/19/12 indicates that R3 requires the use of a total mechanical lift for transfers. R3's fall risk assessment dated [DATE] indicates that R3 was at risk for falls. An occurrence report dated 3/1/13 at 12:15 PM, indicates that R3 had a fall onto the floor during a transfer from the bed to the chair, by E13 (Certified Nurse Assistant) and E14 (Certified Nurse Assistant) and incurred a laceration to the left side of the back of the head and a bruise to the left side of the rib cage. Nurse's note dated 3/1/13 at 2:51 PM, indicates that R3 slid out of a mechanical lift sling, hit her head on the floor, and incurred a 1 centimeter laceration to the back left side of the head that had a moderate amount of bleeding. The area was cleaned with normal saline and a pressure dressing was applied, there was no loss of consciousness, and the physician and a family member were notified. Physician order [REDACTED]. Nurse's note dated 3/1/13 at 11:00 PM, indicates that R3 returned from the local hospital at 5:30 PM, received 9 sutures to the back of the head. All computerized tomography (CAT) scans and x- rays were negative. Physician order [REDACTED]. Review of R3's treatment record, indicates documentation that R3 received the ordered treatment from 3/1/13 to 3/18/13. On 4/3/13 at 1:32 PM, during an interview, E13 stated that E14 was assisting me with transferring R3 back to the chair from the bed. We were transferring her with the mechanical lift machine. Somehow when we transferred her from the bed to the chair, something came apart and she slid to the floor. She had a sore on her head from the fall and they sent her out to the hospital. E14 was holding the pad where her upper body was and I was guiding the machine. We train on the mechanical lift machine twice a year. We practice on each other. We were trained this year on the mechanical lift. I don't remember the date of training. On 4/3/13 at 3:32 PM, during an interview, E14 stated that E13 came and asked me to spot her with R3. Spot means that when you move a patient, you need two people. E13 put the lift pad under R3 and lifted her up with the lift. I was by the chair and I was helping guide the lift. As she was turning R3 in the mechanical lift machine, somehow she just slipped out of the lift pad. I was trying to hold the chair and help guide the machine. My hands were not on the pad underneath the patient. My hands were over the latch on the back of the pad. She did have a laceration on the back of her head. I was trained on the mechanical lift. We were trained in January. They do training two to three times a year. On 3/6/13, E2 (Assistant Administrator) presented an email to indicate that the mechanical lift machine will be inspected for proper working order dated 3/1/13 at 12:56 PM. Review of an email dated 3/1/13 at 1:51 PM, indicates that the mechanical lift machine was inspected and is in proper working order. On 3/19/13 at 4:31 PM E2 and E3 (Director of Nursing) stated we do competency twice a year for staff on the mechanical lift, sit to stand machine, and gait belt training. They lift each other and review the policy. The facility's limited lift safe client movement program policy doesn't document procedures on how to secure the resident within the sling on the mechanical lift machine while transferring a resident from one surface to another. 2. The following residents use a specialty reclining wheelchair: R32, R35, R40, R42, R43, R44, R45, R46, R47, R48, R49 and R50. No assessment for use, monitoring or care plan was done for the use of these specialty reclining wheelchairs prior to survey. On 4/11/13 at 2:00pm E3 (Director of Nursing) stated hospice usually orders the specialty reclining wheelchair and its delivered to the facility. E3 also stated she was not sure if the the physical therapy department preforms an assessment for the use of these assistive devices. If so the documentation would be in the physical therapy notes. No assessments found for the use of these assistive devices. On 4/11/13 at 2:03pm E3 also stated was not aware if the residents are fitted for the use of this specialty reclining wheelchair.