Every finding on record at Aliya of Glenwood

Based on observations, interviews, and record review, the facility failed to follow its call light policy and ensure call light cords were kept within easy reach of residents; failed to provide assistance or notify the appropriate staff of resident's need for assistance before turning off call light. These failures affected four residents (R18, R23, R24, and R25) out of four reviewed for call lights. Findings include:On 8/14/26 at 10:10 AM, R23 was observed lying supine in bed with call light wrapped loosely around the bottom portion of the left upper side rail. Call light was not within reach. When questioned if R23 is able to reach her call light cord, V15 RN (registered nurse) was observed adjusting call light cord to top of side rail and securing in place within R23's reach. V15 stated that the call light cord must have slipped down.On 8/14/26 at 10:12 AM, R24 was observed sitting in a reclining wheelchair near the right-side of the foot of bed. R24's call light cord was observed draped over the left upper side rail. Call light was not within reach.On 8/14/26 at 10:15 AM, R25 was observed lying on his left side near the edge of his bed with call light cord lying on the floor on the right side of R25's bed.On 8/14/26 at 1:18 PM, R18 stated that he has complaints with staff answering call lights. R18 stated that once his call light has been activated, the nurse will come in immediately and turn his call light off, without giving assistance. R18 stated that with the nursing staff answering the call light the CNAs (certified nurse aides) assume the assistance for R18 has been taken care of, when it has not. R18 stated that this breakdown in communication causes a delay in his care. The facility's call light response policy, reviewed 02/2026, notes in part ensure the call light is always within the resident's reach. When the resident is in bed or confined to a bed or chair, provide the call light within easy reach of the resident. Answer the resident's call as soon as possible. Listen to the resident's request. Do what the resident asks of you. If assistance is needed, summon help to the room. After meeting the resident's needs, turn off the call light.

Based on interview and record review, the facility failed to provide incontinence care for at least two hour for a resident who was identified as dependent on staff assistance with toileting and frequently incontinence with bowel and bladder. This affected one of three residents (R7) reviewed for incontinence care. Findings include:On 8/12/26 at 11:29 AM, R7 who was assessed to be alert and oriented to person, place and time said, he has not been provided incontinence care since last night. R7 said, the certified nursing assistant told him to wait until the day shift to be provided care. R7 moved the bed sheet back to expose his adult brief area. R7 was observed with a strong smell of urine. R7's white fitted sheet was observed with a large irregular shaped yellow ring with a thickened brown irregular shape ring outlining the yellow wet/dry spot that extended from R7's middle of the back to middle posterior thigh area. R7 said, he soiled himself right before the sun came up on the night shift, he informed his assigned CNA (certified nurse aide) who informed him he had to wait for the day shift to be changed. R7 was able to describe the CNA but did not know staff's name. V2 DON (director of nursing) identified V19 (CNA) as R7's scheduled CNA on the night shift. V16 CNA and V17 CNA provided R7's incontinence care.On 8/12/26 at 11:40 AM, V17 CNA said R7 was soiled with feces and saturated with urine. V16 CNA and V17 CNA said residents are checked and changed every two hours and as needed.R7's medical record notes diagnoses including but not limited to stroke with hemiplegia affecting right dominant side, muscle disorder, spinal stenosis, and low back pain.R7's MDS (minimal data set), dated 6/10/26, notes R7's BIMS (brief interview of mental status) score of 15 out of 15 which indicates R7 is cognitively intact. R7's functional abilities documents R7 is dependent (helper does all the effort. Resident does none of the effort to complete the activity) on staff for toileting. Bowel and bladder assessment notes R7 is frequently incontinent of bowel and bladder.The facility's activities of daily living policy, reviewed 5/1/26, notes, in part, the ability of each resident to meet the demands of daily living is determined by the licensed nurse. Privacy is provided to each resident and dignity maintained. Assistance is given as required.

Based on observations, interviews, and record review, the facility failed to provide the necessary care and services to prevent the development of a new pressure ulcer for one of three residents (R7) reviewed for pressure ulcers. This failure resulted in R7 developing a new area of skin breakdown to the mid-back measuring 0.5 cm x 0.5 cm that was not identified by the facility prior to surveyor observation. Findings include:On 8/12/26 at 11:29 AM, R7 who was assessed to be alert and oriented to person, place and time said, he has not been provided incontinence care since last night. R7 said, the certified nursing assistant told him to wait until the day shift to be provided care. R7 moved the bed sheet back to expose his adult brief area. R7 was observed with a strong smell of urine. R7's white fitted sheet was observed with a large irregular shaped yellow ring with a thickened brown irregular shape ring outlining the yellow wet/dry spot that extended from R7's middle of the back to middle posterior thigh area. R7 said, he soiled himself right before the sun came up on the night shift, he informed his assigned CNA (certified nurse aide) who informed him he had to wait for the day shift to be changed. R7 was able to describe the CNA but did not know staff's name. V2 DON (director of nursing) identified V19 (CNA) as R7's scheduled CNA on the night shift. V16 CNA and V17 CNA provided R7's incontinence care.On 8/12/26 at 11:40 AM, V17 CNA said R7 was soiled with feces and saturated with urine. V16 CNA and V17 CNA said residents are checked and changed every two hours and as needed.On 8/14/26 at 12:45 PM, the surveyor observed V8 (wound care nurse) complete a head-to-toe skin assessment on R7. When R7 was turned to his left side, the surveyor observed a pale yellow stain on R7's fitted sheet on the buttocks area. A large indentation in the middle of R7's mattress was observed. V8 stated that indentation will increase the pressure to R7's back and buttocks. V8 stated that R7's mattress should not look like that. A new skin alteration was observed to R7's midback area on spinal column. V8 stated that she was not aware R7 had a wound. V8 was observed measuring the wound to be 0.5cm (centimeters) x 0.5cm. V8 applied a dressing to wound and stated that she will call the physician to obtain treatment orders. V8 stated that residents should be turned/repositioned and receive toileting assistance/incontinence care every 2-3 hours and as needed to prevent pressure ulcers.R7's medical record notes diagnoses including but not limited to stroke with hemiplegia affecting right dominant side, muscle disorder, spinal stenosis, and low back pain.R7's MDS (minimal data set), dated 6/10/26, notes R7's BIMS (brief interview of mental status) score of 15 out of 15 which indicates R7 is cognitively intact. R7's functional abilities documents R7 is dependent (helper does all the effort. Resident does none of the effort to complete the activity) on staff for toileting. Bowel and bladder assessment notes R7 is frequently incontinent of bowel and bladder.

Based on observation, interview and record review, the facility failed to follow their physician order by not having hydromorphone pain medication on hand to administer as prescribed. This affected one of three residents (R22) reviewed for physician orders. This failure resulted in R22 missing two doses of hydromorphone within twelve hours, complaining of pain level of a ten out ten to the left shoulder R22's active physician order as of 8/14/26 document: hydromorphone 4mg (milligrams). Give one tablet by mouth every six hours for pain. Controlled drug receipt record/disposition form dated 8/13/26 at 8:00 PM documents: hydromorphone 4mg tablets; amount given one; amount left zero. On 8/14/26 at 11:56 AM, R22 who was alert and oriented, said, he did not have his hydromorphone (pain) medication within the last twenty-four hours. R22 said, this is not the first time he has run out of medication.On 8/14/26 at 12:01 PM, V12 (nurse) said, R22 did not have hydromorphone pain medication on the medication cart. V12 said, R22 is to receive a scheduled dose at noon. V12 said she was going to call the pharmacy to get a code for the CASPA (medication dispensing machine) to get the medication out of it.On 8/14/26 at 1:06pm, R22 said he was having pain of a 10 out of 10 to his left shoulder. R22 said he was given Tylenol at six o'clock in the morning, was given two small pills at noon but is his not relieving his pain. R22 was unable to identify which pill he had been given. R22 said, he needs his hydromorphone.On 8/14/26 at 12:03 PM, V12 said hydromorphone medication was not in the CASPA. V12 said that V13 (unit manager) called the pharmacy.On 8/14/26 at 12:06 PM, V13 said she called the pharmacy at 10:45am this morning. V13 said she was informed that R22 had a script for ten pills that wound be filled and that R22 needed another script. V13 said, residents should not run out of medication. Medication should be reordered when a resident gets down to seven pills.On 8/14/26 at 12:49 PM, V2 (don) said, residents should not run out of medication with an active order. Medication should be ordered seven days before it runs out. R22 last dose was at 8:00pm on 8/13/26.

Based on observation, interview, and record review, the facility failed to implement its infection control policy related to transmission-based contact precautions and hand hygiene upon exiting the isolation room on the B-Wing. This deficient practice had the potential to affect all 44 residents assigned to the B-Wing included in the review for infection control practices.R15 electronic medical record dated (5/21/26) documents strict contact isolation related to c-diff.R59 electronic medical record dated (6/1/26) documents strict contact isolation related to c-diff.On 6/2/2026 at 1:29 PM Observed staff V4 (health information manager) going inside R15 and R59. R15's and R59's room entrance observed to have a contact precaution sign. V4 observed going in R15's and R59'S contact isolation room to serve lunch tray for R15 and did not don PPE (personal protective equipment) and perform hand hygiene. V4 observed bringing R15's lunch tray, touch R15's bedside table and left room without performing hand hygiene. V4 went back to the cart and grab two juice and went back to R15's room and did not don PPE upon entering the room and gave two juices to R15. V4 exited R15's room without performing hand hygiene and entered R63's room and served R63 lunch tray. V4 said that she usually does not help pass tray. V4 said that R15 has a history of C-DIFF but does not think he has it. V4 said that she knows you are suppose to wash hands in between.On 6/3/25 at 11:11 AM V3 (infection prevention nurse) said that she expects all staff going into transmission base precaution to don proper PPE and perform proper hand hygiene. V3 said that when a staff member goes into a room with someone with C-diff she expects staff to wash hands with water and soap and don proper PPE. V3 said that all medical and non-medical staff are all provided with in service regarding transmission base precautions.Facility's infection prevention and control-plan general policy revised (1/2026) documents that contact precaution intended to prevent transmission of infectious agents spread by direct or indirect contact with residents or the environment. Examples of infectious organisms requiring contact precautions are C.difficile, scabies, norovirus, et cetera and are outline in CDC (centers for disease control and preventions) Appendix A(type and duration of precautions recommended for selected infections and conditions). Use of a gown and gloves is necessary prior to room entry. Face protection may be necessary if performing activity with risk of splashing or spraying.Facility's hand hygiene policy review date of 3/2025 documents that hand hygiene is done before and after resident contact, before and after any procedure, after using a facial tissue or the rest room, before eating or handling food, when hands are obviously soiled and regardless of glove use. Hand hygiene with a waterless system is appropriate any time hand hygiene should be done, except in the hands are visibly soiled or contact with a resident with c-diff.

Based on observation, interview, and record review, the facility failed to promote the residents' rights to be treated in a dignified manner during meal service. This affects four of four (R69, R3, R79, R76) residents reviewed for dignity during meal service in total sample of 54. R69 face sheet shows diagnosis of dementia. R3 face sheet shows diagnosis of dysphagia. R79 face sheet shows a diagnosis of neuromuscular dysfunction. R76 face sheet shows a diagnosis of dysphagia. During lunch observation on 6/02/2026 at 12:08 PM, R82 and R64 was observed being assisted with their meal, R69 was seated at the same table, R69 did not have a meal tray. R69 was watching R82 and R64 eat. R69 received her tray at 12:18PM.On 6/02/2026 1:03 PM R3 received his lunch tray in his room. V23 (Certified Nursing Assistant) was observed at 1:15 pm, feeding R3, V23 was standing while feeding R3.V24 (CNA) was also observed standing while feeding R79 at the bedside, R79 is R3's room mate. During lunch observation on 6/03/2026 at 12:10 pm, R26, R86 and R76 were at the same table for lunch, R26 and R86 was eating, R76 did not have a lunch tray, R76 was watching R86 and R26 eat their meal. R76 did not get her tray until 12:14pm.On 6/04/2026 at 1:00 PM V2 (Director of Nursing) said staff should be seated at eye level when assisting residents with meals and all residents at the table must be served their meal at the same time. Reviewed the Resident rights for people living in the Long-term Care facilities shows residents have the right to be treated with dignity and respect.

Based on observation, interview, and record review, the facility failed to follow its food storage policy to ensure dented canned goods were not stored or available for use. This has the potential to affect all 136 residents who receive meals from the facility kitchen Findings include: On initial tour in the kitchen on 06/02/2026 at 9:48 AM, there were six cans of six pound of fruit salad observed on the shelf in the dry storage with the none dented cans and there was one seven pound can of chocolate pudding stored in the emergency food supply.6/2/2026 at 9:50 AM, V31 ( dietary Manager) said the dented cans should not be stored with the none dented cans, V31 said the staff can grab and use the canned food and dented cans could be contaminated with botulism. During the follow up visit in the kitchen on 6/3/26, and 06/04/2026 at 9:34 AM, the seven pound can of chocolate pudding remained stored in the emergency food supply.Dietary Policy and procedure manual dated 2026 denotes dented cans are not used and are stored in a separate area.

Based on interview and record review, the facility failed to follow its Medication Administration policy and Controlled Substances policy by not administering PRN psychotropic medications in accordance with physician orders and by not documenting the effectiveness of the medication. This affected one of three residents (R79) reviewed for unnecessary medications in a sample of 54.Findings include:On 6/2/2026 at 2:39 PM, R79 said that he does not take lorazepam (psychotropic medication) and was unaware that the nursing staff were administering this to him. R79 said that he has not asked the nursing staff for lorazepam since the month of April and was unaware of V6 LPN (licensed practical nurse) administered lorazepam with his morning medications on 6/2/2026 at 9:00 AM. R79 said that he no longer trusts the nursing staff or the facility. R79 said that when he asks the nurses what medications they are giving him, they will not tell him. R79 said that he does get upset when the staff are not providing his care to meet his needs. R79 said that he does not want lorazepam because it makes him feel drowsy. R79 said he did give consent to receive Lorazepam when he first admitted to the facility in April because he did have some anxiety admitting to a new place. R79 said that he did not give consent to receive Lorazepam 0.5mg for the order period of 5/7/2026 through 5/21/2026 and he has not asked for the Lorazepam during the timeframe of 5/7/2026 through 5/21/2026. R79's psychiatry note, dated 5/6/26, notes R79 presents with anxious and irritable mood, reporting recent emotional distress related to the loss of another nephew with whom he was very close. R79 endorsesfeelings of depression, frustration, and anger related to being unable to assist his family during this time. Plan: restart Lorazepam 0.5mg 1 tablet by mouth every 12 hours as needed for anxiety for14 Days.R79's POS (physician order sheet), dated 5/7/26, notes a new order for Lorazepam 0.5mg every twelve hours as needed from 5/7/2026 through 5/21/2026. R79's controlled drug form, dated 4/13/2026, documents lorazepam 0.5mg (milligrams) every twelve hours as needed for anxiety times 14 days. This form notes R79 received ten doses of Lorazepam 0.5mg during the timeframe of 5/7/2026 through 5/21/2026. R79's controlled drug form also notes R79 received six doses of lorazepam 0.5mg with no active physician order on 5/22/2026 at 1:00 AM, 5/26/2026 at 11:30 PM, 5/28/2026 at 9:00 PM, 5/31/2026 at 9:00 AM, 5/31/2026 at 9:00 PM, and 6/2/2026 at 9:00 AM. R79's medication administration record (MAR), dated 5/1/2026 through 5/31/2026, does not record any administered doses of Lorazepam 0.5mg. There is no documentation found in R79's progress notes related to signs/symptoms R79 was exhibiting, administration of lorazepam, or if the medication was effective in treating R79's symptoms. R79 minimum data sheet (MDS) dated [DATE], documents a Brief Interview for Mental Status (BIMS) of 15 out of 15. R79 is cognitively intact and able to make needs known. On 6/2/2026, at 1058 AM, V6 (LPN) said that she administered Lorazepam 0.5mg at 9:00 AM to R79. V6 said that she administered the last pill and needed to reorder the lorazepam 0.5mg. On 6/2/2026 at 9:10 PM, V20 (LPN) said that she would check the MAR to see if there is an active order before administering any as needed medications. V20 would check to see how often the as needed medication is given, administer the medication, sign the medication out the MAR, sign the controlled drug form, and monitor the effectiveness of the medication administered. On 6/4/2026, at 12:00 PM, V8 LPN said that when administering as needed medications, the nurse should check with the resident to see if they require the medication prescribed as needed, check the MAR for an active order, sign the medication out on the controlled drug form and document the administration on the MAR. V8 said that the nurse should follow-up for the effectiveness of the as needed medication administered for any positive or adverse reactions. V8 said that she would check for a change in condition, lethargy, altered mental status, nausea and vomiting, and drowsiness. V8 said that if the resident is administered an as needed medication without the nurse asking the resident may cause the resident to experience negative side effects of the medication. The facility's Medication Administration Policy, dated 02/2026, states in part, an order is required for administration of all medication, document as each medication is prepared on the medication administration record, document reason and response for any PRN (as needed) medication. The facility's controlled substance policy, dated 05/2025, notes in part, while a controlled substance is in use the nursing staff will maintain the following medication records: record each dose at the time of administration on the MAR noting date, time, initial of nurse administering dose, and if a PRN (as needed) order, document the effectiveness; on the controlled substance form note the date, time, signature (which includes minimum of first initials) of nurse who administered dose, and number of doses remaining.

Based on observations, interviews, and record reviews, the facility failed to follow physician orders and obtain daily weights; failed to notify the physician of weight gain of more than 5 pounds for one resident with a diagnosis of heart failure. This affected one of three residents (R1) reviewed for weight monitoring related congestive heart failure in a sample of 54.Findings include:On 6/5/26 at 12:00 PM, R1 stated that staff are not weighing her daily.On 6/4/26 at 1:00 PM, V35 (restorative aide) and V36 (restorative nurse) were observed obtaining R1's weight via a mechanical lift device. R1's weight is 261.4 pounds today.On 6/4/26 at 10:35 AM, V21 (restorative nurse) stated that the restorative aides are responsible for obtaining all weights for residents. V21 stated that she reviews physician orders to see if any residents need more frequent weights than once a month. V21 stated that residents with orders for daily weights, she documents on paper but does not enter daily weights in the resident's EMR (electronic medical record). V21 stated that she was not instructed to enter the daily weights in the resident's record. V21 stated that she is unsure if previous restorative nurse was obtaining daily weights and documenting. When questioned how physician/nurse practitioner would know the resident's weight if not documented in the resident's EMR, V21 responded she is not sure.V21 was unable to provide documentation that R1 has been weighed daily.On 6/4/26 at 3:33 PM, V37 (cardiology nurse practitioner) stated that she would expect the nurses to obtain a resident's weight per physician orders. V37 stated that she would expect the nurse to notify her if R1 gains more than two pounds in one day or five pounds in one week. V37 stated that it is important to monitor residents with a diagnosis of heart failure for weight gain, fluid intake, and for edema (swelling) to ensure R1 is not retaining fluid.R1's medical record notes R1 was admitted to this facility on 10/10/2025 with a diagnosis of heart failure.R1's medical record does not document R1's weight was monitored daily.R1's BIMS (brief interview of mental status) score, dated 4/29/26, notes R1's score is 13 out of 15. R1 is able to make needs known.R1's POS (physician order sheet), dated 11/15/25, notes an order for daily weight: notify physician if > 2 pounds in 24 hours or 5 pounds in a week, weigh in the morning.R1's weight documentation notes the following:11/17/25, weighed 287.4 pounds.11/28/25, weighed 303.4 pounds. R1 gained 16 pounds in 11 days.There is no documentation found in R1's medical record noting the physician was notified of R1's weight gain2/5/26, weighed 264 pounds.2/11/26, weighed 277 pounds. R1 gained 13 pounds in 6 days.There is no documentation found in R1's medical record noting the physician was notified of R1's weight gain.R1's medical record notes R1's weights have not been obtained in the morning per physician orders. R1's weights have been obtained between 9:41 AM and 8:43 PM.Per the American Heart Association, sudden weight gain or loss can be a sign that your heart failure is getting worse. Weigh yourself at the same time each morning, before breakfast. This will help you to see actual changes in weight from day to day. Checking your weight is key to keeping an eye on your symptoms. Weight gain is one of the first signs of retaining fluid. If your weight goes up 2 pounds in one day or 5 pounds in one week, you should notify your physician.The facility's weight management policy, dated 01/2026, notes in part residents should be weighed using the same scale, at the same time of day and in the same way each time they are weighed. All weights, upon completion will be given to the DON (director of nursing).

Based on interview and record review, the facility failed to ensure physician orders were followed for the administration of a PRN psychotropic medication (lorazepam) for one resident. Specifically, the facility administered lorazepam over a 14-day period without obtaining the resident's informed consent prior to administration and continued administering the medication after 5/21/26 without obtaining a current physician order. This affected one of three residents (R79) reviewed for chemical restraints in a sample of 54 residents. Findings include: On 6/2/2026 at 2:39 PM, R79 said that he does not take lorazepam (psychotropic medication) and was unaware that the nursing staff were administering this to him. R79 said that he has not asked the nursing staff for lorazepam since the month of April and was unaware of V6 LPN (licensed practical nurse) administered lorazepam with his morning medications on 6/2/2026 at 9:00 AM. R79 said that he no longer trusts the nursing staff or the facility. R79 said that when he asks the nurses what medications they are giving him, they will not tell him. R79 said that he does get upset when the staff are not providing his care to meet his needs. R79 said that he does not want lorazepam because it makes him feel drowsy. R79 said he did give consent to receive Lorazepam when he first admitted to the facility in April because he did have some anxiety admitting to a new place. R79 said that he did not give consent to receive Lorazepam 0.5mg for the order period of 5/7/2026 through 5/21/2026 and he has not asked for the Lorazepam during the timeframe of 5/7/2026 through 5/21/2026. R79 said that he does not trust the nursing staff or the facility with administering his medications and he has asked social services to transfer him to another facility somewhere in Chicago.R79's POS (physician order sheet), dated 5/7/26, notes a new order for Lorazepam 0.5mg every twelve hours as needed from 5/7/2026 through 5/21/2026. R79's controlled drug form, dated 4/13/2026, documents lorazepam 0.5mg (milligrams) every twelve hours as needed for anxiety times 14 days. This form notes R79 received ten doses of Lorazepam 0.5mg during the timeframe of 5/7/2026 through 5/21/2026. R79's controlled drug form also notes R79 received six doses of lorazepam 0.5mg with no active physician order on 5/22/2026 at 1:00 AM, 5/26/2026 at 11:30 PM, 5/28/2026 at 9:00 PM, 5/31/2026 at 9:00 AM, 5/31/2026 at 9:00 PM, and 6/2/2026 at 9:00 AM. R79's medication administration record (MAR), dated 5/1/2026 through 5/31/2026, does not record any administered doses of Lorazepam 0.5mg. There is no documentation found in R79's progress notes related to signs/symptoms R79 was exhibiting, administration of lorazepam, or if the medication was effective in treating R79's symptoms. R79 minimum data sheet (MDS) dated [DATE], documents a Brief Interview for Mental Status (BIMS) of 15 out of 15. R79 is cognitively intact and able to make needs known. On 6/2/2026, at 1058 AM, V6 (LPN) said that she administered Lorazepam 0.5mg at 9:00 AM to R79. V6 said that she administered the last pill and needed to reorder the lorazepam 0.5mg. On 6/2/2026 at 9:10 PM, V20 (LPN) said that she would check the MAR to see if there is an active order before administering any as needed medications. V20 would check to see how often the as needed medication is given, administer the medication, sign the medication out the MAR, sign the controlled drug form, and monitor the effectiveness of the medication administered. On 6/4/2026, at 12:00 PM, V8 LPN said that when administering as needed medications, the nurse should check with the resident to see if they require the medication prescribed as needed, check the MAR for an active order, sign the medication out on the controlled drug form and document the administration on the MAR. V8 said that the nurse should follow-up for the effectiveness of the as needed medication administered for any positive or adverse reactions. V8 said that she would check for a change in condition, lethargy, altered mental status, nausea and vomiting, and drowsiness. V8 said that if the resident is administered an as needed medication without the nurse asking the resident may cause the resident to experience negative side effects of the medication. The facility's Medication Administration Policy, dated 02/2026, states in part, an order is required for administration of all medication, document as each medication is prepared on the medication administration record, document reason and response for any PRN (as needed) medication. The facility's controlled substance policy, dated 05/2025, notes in part, while a controlled substance is in use the nursing staff will maintain the following medication records: record each dose at the time of administration on the MAR noting date, time, initial of nurse administering dose, and if a PRN (as needed) order, document the effectiveness; on the controlled substance form note the date, time, signature (which includes minimum of first initials) of nurse who administered dose, and number of doses remaining.

Based on observation, interview, and record review, the facility failed to ensure that wound care treatments were implemented as ordered. This affected one of four residents (R3) reviewed for pressure ulcers in a sample of 54 residents. R3 care plan shows R3 has diagnosis of unspecified dementia, COPD, protein malnutrition, and lack of coordination. R3 MDS dated [DATE] section c for cognition shows BIMS score of five (cognitive deficits), section E for behaviors- rejection of care, 0 is documented (behavior not exhibited), section M for skin shows one stage 3 pressure ulcer, unhealed, M1200 for skin and ulcer treatment shows pressure reducing device for bed, nutrition or hydration interventions to manage skin problem, pressure ulcer/injury care and application of nonsurgical dressing.On 6/4/26 at 1:37pm R3 was observed resting in bed, awake and alert. R3 agreeable for wound observation. R3 was observed for wound care assisted by V27 (wound tech), V30 (wound care coordinator) with support of V29( wound care director). R3 was wearing an adult brief, R3 did not have a wound treatment dressing in place. R3 was observed with a wound to the sacrum the size of a half dollar, the wound bed was pink in color, the surrounding skin was R3 skin tone. V27 said he did not remove R3's treatment dressing.V30 said she did not remove R3's treatment dressing, R3 treatment is three time a week.V29 said she did not remove R3's treatment dressing.V23 (R3 CNA) said R3 did not have a wound treatment dressing on all day, V23 said she last changed R3 after lunch, with assist for V25 (CNA), V23 said R3 did not have a treatment dressing on at that time. V23 said she did not inform the nurse that R3 did not have a treatment dressing. V25 said R3 did not have a treatment dressing on when she assisted V23 with incontinence care for R3. V25 said she did not inform the nurse or anyone that R3 did not have a dressing on. At 2:04pm, V6 (R3's Nurse) said she did not remove R3 wound treatment dressing, and the aides did not inform her that the dressing was off. V6 said the aide should notify her if the treatment dressing comes off or when there's no treatment dressing on a wound, she should be made aware so that she can complete the wound treatment. R3's physician orders show orders for coccyx: cleanse with wound cleanser, pat dry and paint peri wound with betadine, apply calcium alginate with silver to the wound bed and cover with border gauze three times week, every day shift Monday, Wednesday, Friday to promote wound healing.R3's wound evaluation completed by the wound care provider dated 6/3/2026 denotes in-part patient has wound to his coccyx and a rash, wound site 4, stage three, full thickness, etiology-pressure, duration- greater than 98 days, care goal-decrease ulcer area, granulation 100%. Dressing treatment plan- primary dressing: alginate calcium with silver, apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days; sub skin application, apply once weekly for 7 days: do not remove or disturb the wound bed. Change the secondary dressing with care as per the recommendations. The skin substitute graft will be re-evaluated by the wound physician during the indication next visit. Secondary dressing- gauze island with border three times per week and as needed: if saturated, dislodged. For 30 days. Peri wound treatment- apply betadine three times per week and as needed: if saturated, soiled or dislodged. For 30 days. V2 (Director of Nursing) presents R3 current plan of care, dated initiated 11/2/2023 it is denoted that R3 care plan for actual skin alteration and is at risk for skin complication's r/t (related to) impaired mobility, incontinence, malnutrition and wound to coccyx. Interventions are to access/ record changes in skin, avoid skin to skin contact, educate resident/ family on causative factors and measures to prevent skin injury, follow facility protocols for treatment of injury. Identify/ document potential causative factors and eliminate/ resolve where possible. Low air loss mattress, minimize pressure over bony prominences, residents will be turned and repositioned q2 hours as tolerated.Facility policy titled skin care prevention dated 1/2025 denotes in-part all resident will receive appropriate care to decrease the risk of skin breakdown.

Based on interview and record review, the facility failed to follow hospital recommendations by not ordering a BiPAP machine to be used at night for a resident (R3) for four months for one out of three reviewed for supplemental oxygen in a total sample of 11. Findings Include: R3 is a [AGE] year old with the following diagnosis: multiple myeloma, chronic obstructive pulmonary disease (COPD), immunodeficiency, end stage renal disease with dependence on renal dialysis, and asthma. On 5/12/26 at 3:16PM, R3 was lying in bed. R3 reported R3 has been using a BiPAP at night since 2009. R3 stated R3 used a BiPAP at the previous facility which R3 was admitted from but was never ordered once R3 admitted to this facility in 01/2026. R3 reported R3 has been wearing oxygen to try to help with R3's sleep apnea which is the reason R3 must wear the machine at night. R3 stated when R3 roomed with R4, R4 was on a BiPAP and staff would always put it on for R4 at night. R3 stated R3 questioned staff why R3 was not using the BiPAP and staff would always replay that there was no order but never checked into a need for a BiPAP any further for R3. R3 reported R3 has been asking staff to call the former facility or R3's physician's at the hospital since R3 admitted but no one has helped out. R3 reported the BiPAP machine that is currently in the room was brought in a couple hours ago. R3 denied knowing what took the facility so long into getting the BiPAP ordered. R3 stated R3 has had trouble sleeping without the BiPAP being used. On 5/13/26 at 9:37AM, V2 (CNA) stated R3 never used a BiPAP before but R3's old roommate used one at night. V2 reported being unaware R3 was supposed to use the BiPAP and R3 would ask to use nebulizer treatments when feeling short of breath at night. V2 stated if a resident has questions regarding their orders, then V2 will refer them to the nurse. On 5/13/26 at 10:06AM, V5 (Nurse Manager) stated R3 admitted to the facility with a different BiPAP machine but had no known orders from the previous facility so it was never used. V5 reported orders were never put in place at the facility so they could not use the BiPAP machine until yesterday. V5 stated R3 called the hospital yesterday where R3 receives care and the hospital called the facility with setting orders for the BiPAP. V5 reported V5 was aware R3 mentioned getting the BiPAP ordered to other staff but is unsure why the staff never followed up with getting the order sooner. V5 stated it is the nurse's responsibility to check the medications and orders when returning from the hospital to make sure all orders are put in place upon returning to the facility. V5 reported if the nurse does not understand an order or is unsure about any care from the hospital paperwork then the physician must be called for clarification. On 5/18/26 at 2:56PM, V20 (Administrator) stated V20 was unable to say why the BiPAP was not ordered sooner, and V20 was unaware R3 was asking to have the BiPAP ordered. V20 reported the re-admitting nurse and the IDT team work together to ensure when residents re-admit they have all recommendations and orders carried over at the facility. V20 stated the re-admitting nurse and IDT should go through the paperwork to determine what orders should be put in place at the facility. V20 reported V20 was unaware a BiPAP at night was written as part of R3's plan of care in the nurse practitioner's note. V20 stated if R3 was using the BiPAP at the hospital then it should have been ordered at the facility for R3. An Acute Care note dated 3/31/26 documents R3's chief complaint was shortness of breath which was mild and a productive cough. A plan for managing chronic obstructive pulmonary disease was BiPAP at night with supplemental oxygen as needed.A Nursing note dated 3/31/26 documents R3 went to the hospital for a follow up appointment and was admitted for pneumonia and COPD exacerbation.A Hospital Pulmonary Progress note dated 4/4/26 documents the reason for consult as COPD exacerbation. R3 has a history of COPD, asthma, and obstructive sleep apnea. R3 is utilizing 2-3L of oxygen via nasal cannula. R3 is currently at baseline. Continue current antibiotics, home inhaler and nebulizer regimen, and nocturnal BiPAP. R3's sleep apnea is documented as severe. Pulmonary signed off with these recommendations.A Follow-up note dated 4/29/26 documents R3 developed a cough with brown sputum production. R3 has been using an inhaler for shortness of breath. R3 is currently stable. Plan for COPD documented as R3 currently has a BiPAP at night. The Physician Order Sheet documents an order for BiPAP full mask with settings while sleeping was ordered on 5/12/26. All orders for care of the BiPAP mask were also ordered on 5/12/26.The Medication Administration Record was reviewed for 04/2026 and 05/2026. The BiPAP was just ordered on 5/12/26.The Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score as 15 (no cognitive impairment).The Care Plan dated 1/23/26 documents R3 has potential for difficulty breathing related to asthma/respiratory failure/chronic obstructive pulmonary disease. An intervention dated 5/12/26 documents bipap every night. The policy titled, Admission/Re-admission, dated 01/2026 documents, GENERAL: The facility will ensure that all residents have necessary assessments completed in a timely manner at the point of admission to provide the best possible, person-centered care. POLICY: . 3. The physician's order summary should reflect any standing orders specific to the resident as well as medications and treatments that are ordered throughout the stay.

Based on interview and record review the facility failed to ensure verification of license qualification was performed upon hire of a registered professional nurse for 1 of 3 (V4) reviewed for licensed professionals. Findings Include:On 5/6/2026 at 10:54 AM, V3 (Director of Human Resources) stated V4 (Registered Nurse) was hired in August 2025 as a as needed staff nurse. V3 said it was an oversight on her end for not properly verifying V4's registered nurse license upon hire. In March 2026, V3 and facility administration were notified by their corporate office that V4 did not have the license qualification as a registered nurse. On 5/6/2026 at 1:18 PM, V1 (Administrator) said V3 should have ensured nursing license was checked and verified upon hire. V4 was immediately released from her duties as staff nurse. V1 said facility has no Human Resource (HR) policy but only guidelines.Review of V4's personnel records revealed no license for registered professional nurse on file. Health care worker registry, date 8/13/25, read Work Eligibility: Eligible.Title: HR Hiring Personnel Guideline, no dateNurse licenses

Based on observation, interview and record review, the facility failed to prepare food in a sanitary manner, failed to ensure staff wear appropriate hair restraints, and failed to ensure the kitchen was regularly cleaned to remove dust, debris and grease to prevent growth of microorganisms. These failures have the potential to affect all 137 residents that consume food from the kitchen. Facility census (4/24/2026) documents 139 residents reside in the facility. Facility Diet Type Report (5/25/2026) documents 3 residents do not receive oral intake. This indicates 137 residents consume food from the facility's kitchen. On 4/24/2026, at 12:34 PM, a kitchen tour was conducted. Observed large black patches of stains on the ceiling tiles, old brownish grease/dirt over 30% of the wall of the area above the steam table, food debris stuck to the steam table, wrappers and debris near the drain by the steam table, broken ventilation vent with significant amounts of accumulated dust over the food preparation and dish area. These findings were observed confirmed with V1 (Administrator) and V17 (Dietary Manager). V1 affirmed that the kitchen needed to be cleaned. On 4/24/2026 at 12:50 PM, V25 (Cook) was observed plating food on the steam table. The kitchen had not been cleaned after the unsanitary conditions were identified. V25 looked at the ceiling tiles and walls and confirmed the observations. V25 stated, those have been there a while. That looks like old grease to me. Yeah, that isn't clean.On 4/25/2026 at 7:45 AM, V18 (Cook) was observed preparing food on the steam table. V18's face had observable facial hair and was not restrained. This observation was confirmed by V17 (Dietary Manager). V17 told V18, (V18), you need to wear a beard guard. The US Department of Food and Drug Administration Food Code (2022) documents in part, 2-402 Hair Restraints: (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES .3-304.11 Food Contact with Equipment and Utensils . FOOD shall only contact surfaces of:(A) EQUIPMENT and UTENSILS that are cleaned as specified under Part 4-6 of this Code and SANITIZED as specified under Part 4-7 of this Code; (B) Single-service and single-use articles; or (C) LINENS, such as cloth napkins, as specified under S 3-304.13 that are laundered as specified under Part 4-8 of this Code .4-301.14 Ventilation Hood Systems, Adequacy. Ventilation hood systems and devices shall be sufficient in number and capacity to prevent grease or condensation from collecting on walls and ceilings .6-501.14 Cleaning Ventilation Systems, Nuisance and Discharge Prohibition. (A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials . 4-301.14 Ventilation Hood Systems, Adequacy. If a ventilation system is inadequate, grease and condensate may build up on the floors, walls and ceilings of the food establishment, causing an insanitary condition and possible deterioration of the surfaces of walls and ceilings. The accumulation of grease and condensate may contaminate food and food-contact surfaces as well as present a possible fire hazard.

Based on observation, interview and record review, the facility failed to prepare food using methods that conserve nutritive value, flavor, and appearance; failed to serve food that was palatable, attractive, and at a safe/appetizing temperature. These failures have the potential to affect all 137 residents that consume food from the facility's kitchen. Findings include: Facility census (4/24/2026) documents 139 residents reside in the facility. Facility Diet Type Report (5/25/2026) documents 3 residents do not receive oral intake. This indicates 137 residents consume food from the facility's kitchen. R4's face sheet documents in part the following diagnoses: type 2 diabetes mellitus with neuropathy, emphysema, acute respiratory failure, radiculopathy, heart failure, and hepatomegaly. R4's minimum data set documents a brief interview of mental status (BIMS) summary score of 14, indicating R4 is cognitively intact. On 4/24/2025 at 10:46 AM, R4 explained, I've been here since around 2024. The food here is not good. It's been an issue for a really long time, they have had a few different administrators at this point. I've told all of them about my food concerns, and nothing has ever changed. It's cooked too long to where its burnt, not cooked. One time they served me frozen hash browns (potatoes). I have to order outside food because I can't stand this garbage. R4 unlocked his cellular phone, and showed pictures of burnt food including but not limited to, pancakes that appeared black over 50-75% of the surface of the pancake, grilled cheese sandwich that appeared burnt/black over 50-75% of the surface of the sandwich, raw tomato/onion next to a light yellow (buttered bread), undercooked grilled cheese sandwich, and plain toast served next to hash browns. The hashbrowns were light white, unseasoned, and appeared stiff as if undercooked/frozen. Evidence that the pictures were taken inside the facility include, but are not limited to, dietary meal tickets that match the appearance facility's meal tickets with R4's name on it, matching dishware, medical records with the facility's logo seen on the meal trays in the pictures, trays that match the appearance of the facility's trays. The dates of the pictures taken inside the phone coincide with R4's face sheet/census and confirm R4 was a resident of the facility when the pictures were taken. On 4/23/2026 at 11:49 AM, observed V18 (Cook) plating food from the steam table in the kitchen. Staff were observed in the dining room serving the trays. The steam table contained a pan of polish sausages that were ununiformed varying shades of light tan, and dark golden brown/leathery (cooked and undercooked), baked beans and pureed sausages. V18 stated, I cooked the sausages and boiled them in water. The ones that are darker are more done because they were stuck to the bottom of the pan. The ones that aren't as done I don't think were by the bottom. I don't think the really done ones look appetizing. Observed no steam coming from the area around the steam table and no observable signs of heat radiating from the food. V18 denied food temperatures were checked prior to plating or serving. V18 continued to plate the food and did not check the temperature. Observed mechanically altered polish sausage, that appeared ground and dry. V18 stated, no, I did not use any gravy for the mechanical soft. I just threw a little bit of water in there and ground it up. I didn't know it had to have gravy. V18 continued to prepare plates of food and the sausages appeared undercooked and off colors with some sausages appearing brown while others appeared yellow/green in hue. This observation was confirmed with V18. Surveyor stopped the food pass and requested the temperatures of the food to be assessed. V18 and V17 (Dietary Manager) accessed a thermometer and affirmed the temperatures of the polish sausage, pureed polish sausage, and baked beans to be between 60-65 degrees F. V17 affirmed the expectation is the cook should be temping the food once finished during holding, and right before serving. V17 affirmed the food should have been held at 135 degrees. V17 stated, Yes the thermometer is working. I need to go reheat these to the correct temperature. They should not have been served to the residents. If residents eat uncooked food or if the food wasn't held correctly, they could get sick (food borne illness). V17 removed the items from the steam table and there was no water/steam underneath the trays. V17 questioned if the steam table was malfunctioning. V17 took the items to the stovetop to reheat. V18 affirmed V18 did not take temperatures of the breakfast foods that were served in the morning. R5's face sheet documents in part the following diagnoses: multiple sclerosis, anxiety disorder, asthma, and neuromuscular dysfunction of the bladder. R5's minimum data set documents a brief interview of mental status (BIMS) summary score of 15, indicating R5 is cognitively intact. On 4/24/2026 at 12:08 PM, observed 11 residents eating lunch in the dining room. No residents were observed eating any other entree/side than the polish sausage, bun, beans, tossed salad. On 4/24/2026 at 12:09 PM, observed R5 eating lunch in the dining room. R5 was eating the polish sausage in her hands with condiments covering her hands. The bun was observed on the plate, uneaten. R5 stated, The food here is not good. There's no flavor, no seasoning. It tastes so bland. It's usually not warm and it tastes like cat food most of the time. I would rather eat cat food sometimes than the food here. On 4/24/2026 at 12:09 PM, observed R6 eating lunch in the dining room next to R5. R6 stated, Yeah, the food here could be better for sure. Both the quality and the portion sizes. My meal overall isn't very warm. R12's face sheet documents in part the following diagnoses: hemepelegia/hemiparesis of right side, apraxia following cerebrovascular disease, vascular dementia, alzheimer's disease, major depressive disorder, asthma, and hyperlipidemia.R12's minimum data set (4/1/2024) documents in part a brief interview of mental status (BIMS) summary score of 12, indicating R12 has mild cognitive imapirment.On 4/14/2026 at 12:14 PM, observed R12 eating lunch. R12 stated, yeah my food isn't warm. Yes, lukewarm. Food's not good here. Doesn't taste good. Doesn't look good. It's a problem. R7's face sheet documents in part the following diagnoses: osteomyelitis of vertebra, hypertension, type 2 diabetes mellitus, anemia, neuromuscular dysfunction of bladder, and parapelegia. R7's minimum data set (1/22/2026) documents in part a brief interview of mental status (BIMS) summary score of 15, indicating R7 is cognitively intact. On 4/24/2026 at 12:15 PM, observed R7 eating lunch in the dining room. R7 stated, Yeah, my lunch today wasn't very warm today. I would say it was like lukewarm. The food here isn't good but my issue is mainly with the taste. Doesn't have a lot of seasoning. Somedays are better than the others, but overall, it's not good. On 4/24/2026 at 12:36 PM, observed the steam table after all holding pans had been removed. There was between 1/4-1/2 inch of water in the water holding areas of the steam table. On 4/24/2026 at 12:50 PM, V25 (Cook) was observed plating food on the steam table. Observed circular cuts of pork on the steam table that were desiccated and blackened/burnt around the edges. The cuts were all of different sizes varying in lengths of up to 2 inches. V25 confirmed the observation, stating, I just got here but yes they do look a little dry. They are for our renal diet residents. I wouldn't eat it. V25 confirmed the sizes of the pork looked varied and ununiform. V25 stated, We use the scooper to measure portion sizes. V25 confirmed the pork cuts couldn't be scooped in a scooper to check for the correct portion size. Surveyor requested the portions of pork to be weighed to verify the residents were getting adequate amounts of protein. V25 stated, we don't weigh the meat prior to serving. I think there's a scale somewhere, but I haven't seen it in a minute. On 4/24/2026 at 12:59 PM, V17 (Dietary Manager) confirmed the kitchen did not have a scale and that they were going to buy one right now. V17 said the facility doesn't weigh the meat products because it comes prepackaged and only has about 5% shrinkage once cooked. On 4/24/2026 at 1:18 PM, V17 tested the thermometers for accuracy by placing the thermometer in ice water. The thermometer used during the food temping was approximately 25 degrees less than the other calibrated thermometers reading 30-32 F. V17 stated, This is a brand new thermometer, I just calibrated it yesterday. Either way, the food should not have been served. When we put the food back on to reheat and used the other thermometers, our first reading after reheating was 120F. Even if the thermometer was 30 degrees lower, we know it wasn't at the right temperature because even after it was reheated it still wasn't at the right temperature. The food should not have been served. Surveyor inquired to see the temperature logs. The temperature log for 4/24/2026 was blank. V17 asked V18 if the temperatures were taken for breakfast. V18 said no. V17 stated, come on, you know better. They know to be taking the temperatures. On 4/25/2026 at 8:45 AM, a test tray of the breakfast meal was made by V25 and V24 (Regional Dietary Consultant) consisting of oatmeal, biscuit with gravy, scrambled egg, and a sausage patty. The plate was covered and the tray was added to the tray line. Surveyor stayed with test tray until 9:11 AM, when the final tray was served. V24 affirmed the thermometer was calibrated this morning and was in working condition. V24 tested the temperatures of the test tray. The biscuit was 94 F, sausage patty was 101.5 F, the eggs were 90.5 F and the oatmeal was 147.5 F. These findings were confirmed with V24. V24 stated, the temperature of the food should be palatable at serving. Surveyor tasted all items from the test tray. The biscuit was cold, and the gravy was a thin white consistency with a faint meat flavor. The eggs were cold and devoid of flavor. The sausage patty was lukewarm. The oatmeal tasted significantly hotter than the rest of the menu items served. These findings were reviewed with V24. On 4/25/2026 at 9:16 AM, V20 (Maintenance Director) affirmed a company came out and serviced the steam table in response to the temperature issues yesterday. V20 stated, The problem was they didn't have enough water in the steam table. You need like at least 3 inches of water in the bottom so it can generate enough steam to hold temperatures. They didn't have enough in there. When I saw it, there was only like a half inch of water. It wouldn't have had enough water in the bottom of the table to make any steam. The steam table generates steam from the water that keeps the food warm. The food service company did not find any issues with the steam table, so it had to have been from the lack of water.On 4/25/2026 at 11:56 AM, observed the pureed meatloaf on the steam table. The pureed meatloaf looked orange, coarse and dry resemblant of a Pate consistency. Around the edges were burnt/blackened. These observations were confirmed with V17. V17 stated, no it shouldn't look like that. I am going to go remake it. R10's face sheet documents in part the following diagnoses: congestive heart failure, type 2 diabetes mellitus, malignant neoplasm of bone, schizophrenia, anxiety disorder, monoclonal gammopathy, alzheimer's disease, hypertension, hyperlipidemia, and depression. R10's minimum data set (4/16/2026) documents in part a brief interview of mental status (BIMS) summary score of 8, indicating R10 is cognitively impaired. On 4/25/2026 at 12:13 PM, observed R10 sitting in the dining room. R10 affirmed that R10 had ate the lunch today and explained, The food here is MEDIOCRE! They don't season it, it tastes terrible. Looks terrible! I worked in food service my entire life, and I ain't never seen no (explicative, redacted) like this. The food here makes me want to just choke on it and die. I can barely eat it!. R10 began getting very agitated and told surveyor, Do something about it and get the (explicative, redacted) out of here! On 4/25/2026 at 12:17 PM, observed R7 sitting at a table in the dining room near R10. R7 stated, Yeah I think she already ate lunch but (R10) usually doesn't eat much. She's probably still hungry, that's why she is so upset. R11's face sheet documents in part the following diagnoses: cerebral infarction, hemepelegia/hemeparesis following left non-dominant side, hypertension, dysphagia, type 2 diabetes mellitus, malignant neoplasm of the skin, and major depressive disorder. R11's minimum data set (3/27/2026) documents in part a brief interview of mental status (BIMS) summary score of 15, indicating R11 is cognitively intact. On 4/25/2026 at 12:14 PM, observed R11 in dining room after R11 had been served R11's lunch tray. R11 stated, yeah the food here . not really that good. You know how they say hospital food is not good? Lousy, sometimes edible. It's like that. I don't really have an issue with the food being too hot, but it's usually not too warm. I'd say like lukewarm. Facility grievance (4/21/2026) documents that R11 filed a grievance on 4/21/2026 regarding the food being cold and the portion of the soup not being enough/came out of a can. V17 (Dietary Manager) expressed that the meal was ham salad sandwich, and marinated green bean salad and chicken noodle soup, the sandwiches/green bean salad are served cold. The chicken noodle soup was made from scratch. V7 advised if R11 did not like the meal on the menu that R11 could request a substitute. The grievance is signed by both V1 (Administrator) and V17 as resolved, however the resolutions listed did not include any action/investigative information regarding the temperature of the soup or portion size of the soup. Facility policy titled, Food and Beverage Temperature Control (2025) documents in part, Food temperatures are maintained during serving times. Purpose: To ensure residents receive safe food served at acceptable temperatures. Procedure: Food and beverage temperatures should be taken and logged upon being cooked and again prior to meal service. Food temperatures should be within the required temperatures per state and federal regulations when cooked and served. If food is not the correct temperature zone, corrections should be made or food is discarded . Log cock and service (holding) temperatures. Logs should be on file for one year. Facility policy titled Dietary- Standardize Menus (1/2026) documents in part, Policy: The facility shall provide nourishing, palatable meals to meet the nutritional needs of the residents based on the Recommended Daily Allowances (RDA) of the Food and Nutrition Board of the National Research Council of the National Academy of Sciences. standardized cycle menus are planned in advance and utilized . 1. The facility will make reasonable efforts to provide food that is appetizing and culturally appropriate for residents. Menus will be planned to meet basic nutritional needs by providing meals based on individual nutritional assessment and the individualized plan of care. 5. Menus are revised by the registered dietician and dietary manager based on resident food preferences. Reasons for change should be noted and kept on file . 15. If during meal observations, a resident's dietary intake appears inadequate, the facility will make reasonable efforts to review and/or adjust the menu and/or the individual residents food plan to meet the nutritional, religious, cultural, and ethnic needs and preferences of the resident . Facility policy titled Dietary Policy (1/2026) documents in part, It is the policy of this facility to record food temperatures daily to ensure food is at the proper serving temperatures before trays are assembled . 1. Food temperatures will be checked on all items prepared in the dietary department. 2. Hot foods will be held at 135 degrees Fahrenheit or greater . 6. measure and record the temperatures for each food product and milk at all meals. Record temperature on temperature log. 7. When holding hot foods for service, food temperatures should be measured when placing it on the steam table line. 8. If the food temperature falls into an unsafe range, immediately follow procedures for reheating previously cooked food . 11. No food will be served that does not [NAME] the food code standard temperatures . 14. Food temperatures will be verified using a thermometer which is both clean, sanitized and calibrated to ensure accuracy .

Based on observation, interview and record review, the facility failed to prepare food as indicated in the menu and failed to provide/serve the food on the written menu. This failure affected all 137 residents that consume food from the kitchen. Facility census (4/24/2026) documents 139 residents reside in the facility. Facility Diet Type Report (5/25/2026) documents three residents do not receive oral intake. This indicates 137 residents consume food from the facility's kitchen. On 4/25/2026 at 4:00 PM, V22 (Dietician) affirmed facility staff should be following all written menus and recipes. The facility menu cycle indicates on 4/25/2026, the lunch served is meatloaf, green beans, mashed potatoes, a dinner roll, bread pudding and a beverage. On 4/25/2026 at 11:31 AM, V25 (Cook) was observed temping the foods served for lunch. There were no dinner rolls in the plating areas. At 11:55 AM, observed residents served the meal in the dining room with no dinner roll on the tray. The tray ticket/menu was reviewed with V25. V25 stated, oh, I didn't know. I guess I didn't see that on the menu today. I didn't cook any dinner rolls. On 4/25/2026 at 12:04 PM, V17 (Dietary Manager) affirmed that the staff did not cook the dinner rolls. V17 stated, No they, forgot to make them. They are still in the freezer. Observed the box of frozen dinner rolls in the freezer with V17. V17 stated, They told me they had everything made and that everything was good. They should have made those. V17 explained that following the menu is important so that staff can calculate how many calories residents are receiving and ensuring they get adequate nutrition. R10's face sheet documents in part the following diagnoses: congestive heart failure, type 2 diabetes mellitus, malignant neoplasm of bone, schizophrenia, anxiety disorder, monoclonal gammopathy, Alzheimer's disease, hypertension, hyperlipidemia, and depression. R10's minimum data set (4/16/2026) documents in part a brief interview of mental status (BIMS) summary score of 8, indicating R10 is cognitively impaired.On 4/25/2026 at 12:13 PM, observed the residents eating in the dining room. No resident was served a dinner roll or an appropriate substitute for the missing roll. Observed R10 sitting in the dining room. R10 affirmed that R10 had ate the lunch today and did not receive a dinner roll. R10 affirmed that R10 would have wanted a dinner roll served with the meal. R11's face sheet documents in part the following diagnoses: cerebral infarction, hemiplegia/hemiparesis following left non-dominant side, hypertension, dysphagia, type 2 diabetes mellitus, malignant neoplasm of the skin, and major depressive disorder. R11's minimum data set (3/27/2026) documents in part a brief interview of mental status (BIMS) summary score of 15, indicating R11 is cognitively intact. On 4/25/2026 at 12:14 PM, observed R11 in dining room after R11 had been served R11's lunch tray. No dinner roll was on the tray. R11 affirmed that R11 was not served a dinner roll and would have wanted one. R7's face sheet documents in part the following diagnoses: osteomyelitis of vertebra, hypertension, type 2 diabetes mellitus, anemia, neuromuscular dysfunction of bladder, and paraplegia. R7's minimum data set (1/22/2026) documents in part a brief interview of mental status (BIMS) summary score of 15, indicating R7 is cognitively intact. On 4/25/2026 at 12:17 PM, observed R7 sitting at a table in the dining room near R10. R7 stated, Yeah I think she already ate lunch but (R10) usually doesn't eat much. She's probably still hungry, that's why she is so upset. I would have wanted a dinner roll with lunch today. Facility policy titled Dietary- Standardize Menus (1/2026) documents in part, Policy: The facility shall provide nourishing, palatable meals to meet the nutritional needs of the residents based on the Recommended Daily Allowances (RDA) of the Food and Nutrition Board of the National Research Council of the National Academy of Sciences. standardized cycle menus are planned in advance and utilized . 1. The facility will make reasonable efforts to provide food that is appetizing and culturally appropriate for residents. Menus will be planned to meet basic nutritional needs by providing meals based on individual nutritional assessment and the individualized plan of care. 5. Menus are revised by the registered dietician and dietary manager based on resident food preferences. Reasons for change should be noted and kept on file . 15. If during meal observations, a resident's dietary intake appears inadequate, the facility will make reasonable efforts to review and/or adjust the menu and/or the individual residents food plan to meet the nutritional, religious, cultural, and ethnic needs and preferences of the resident .

Based on interviews, and record review, the facility failed to follow their Staffing Policy by not having the appropriate staff available to meet the needs of the resident resulting in a resident's (R10) fall. This failure affected 1 (R1) of 3 residents reviewed for staffing.On 3/18/2026 at 11:39AM called V9 (Certified Nurse's Assistant/CNA), no answer, left a voice message.On 3/19/2026 at 10:54AM V1 (Administrator) stated the facility was staffed accordingly with eight Certified Nurse's Assistant (CNAs) to the census on 3/3/2026, but there was call offs and only had 5 CNAs.On 3/19/2026 at 9:41AM V2 states the nursing management team alternates the staffing phone for staffing call offs. V2 stated if there is a call off, the nursing management team will find coverage immediately.On 3/18/2026 at 5:18PM, V11 (CNA) stated she worked night shift 11:00PM to 7:00AM on 3/3/2026 and had 25 residents to herself and the CNAs needed more help to ensure proper nursing care was being completed for the residents, but some work was not completed. V11 stated the other two CNAs who worked the A and B unit also had 25 residents each. V2 (Director of Nursing/DON) and V8 (Assistant Administrator) stated the facilities Midnight census Report on 3/3/2026 was 136 residents. V2 and V8 stated having five CNAs for a facility census of 136 should not impede resident care.On 3/18/2026 at 10:34 AM, V2 (DON) stated the daily assignment sheet dated 3/3/2026 night shift documents three CNAs for the A and B wing each had 25 residents. The CNA for Unit C had a total of 33 residents; the CNA for Unit D had 28 residents.V2 (DON) stated there was a resident incident/fall on 3/3/2026 at 1:40AM. V2 stated there was not an appropriate number of staff available to meet the needs of the residents. The facility assessment tool documents: review updated August 2025.The facility Assessment tool provided by V1 documents other: To staffing and resource needs a holistic approach towards meeting the needs of residents is taken into account specific needs such as but not limited to acuity based on medical and clinical needs activities of daily living based on physical functions and personal choice or preference and psychosocial needs based on cognitive skills and behaviors are bases of staffing. Provide person-centered / direct care: I identified hazards and risks for residents.Facility Assessment Tool documents Direct Care Staff: CNAS Post-Acute Units Night shift 1:12 ratio, Long-Term Care Units Night shift 1:18 ratio.Facilities Staffing Policy documents:Review Date: 5/2025General: To have appropriate numbers of staff available to meet the needs of the residents.

Based on interviews and record review, the facility failed to follow their abuse policy by not investigating an incident involving alleged abuse. This deficiency affected one (R1) of three (R2, R7) residents reviewed for Abuse. R1 is an [AGE] year-old male, initial admitted to the facility 10/10/2022. R1s Minimum Data Set (MDS) dated [DATE] section C Brief Interview for Mental Status (BIMS) score is 12/15 cognitive moderately impaired. R1s medical diagnosis included, but are not limited to Chronic Respiratory Failure, disorder of the muscle, Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, Asthma, Hypertension, Type 2 Diabetes, difficulty in walking, abnormal posture.On 3/18/2026 at 9:34AM, R1 stated a few weeks ago his old roommate beat him up. R1 stated he took a broken rib. R1 stated his roommate, unable to recall his name, punched him more than six times to R1s left lower chest area. R1 stated the incident occurred at nighttime. R1 stated he was angry because R1 was transferred to another room instead of the person who beat R1 up. R1 stated the staff did not assess his left ribs. R1 stated his left ribs currently hurt.On 3/17/2026 at 10:32AM state surveyor observed that R1s incident report was not in the Facility's Abuse Reportable binder, reviewed for the months of January, February, March 2026.On 3/17/2026 at 11:22AM, R3 states he never got into a fight, punched, or slapped, anybody. R3 stated he has never hit anybody and minds his own business.On 3/17/2026 at 12:31PM, V4 (Licensed Practical Nurse/LPN) stated she was R1 and R3 nurse and confirms they were roommates. V4 (LPN) confirmed she went into R1 and R3s room because she heard them having a loud verbal altercation between R1 and R3. V4 confirmed it happened on 1/25/2026 late evening. V4 states she removed R1 from the room immediately. V4 stated R1 informed V4(LPN), R3 slapped R1. V4 stated she assessed R1 and notified the former Director of Nursing and R1s physician. V1 (Administrator) and V2 (Director of Nursing) stated they were unaware of R1s incident.On 3/18/2026 at 9:47AM, V8 (Assistant Administrator) stated an investigation for R1s incident was not started.V13 (Regional Nurse Consultant) and V8 (Assistant Administrator) stated an investigation should have been started and reported to the Illinois Department of Public Health immediately, but was not investigated.Abuse Policy and Prevention Program: The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents.VII. Internal Investigation:All incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred, was alleged or suspected.Any incident or allegation involving abuse neglect exploitation, mistreatment or misappropriation of resident property will result in an investigation.V. Internal Reporting Requirements and Identification of AllegationsAny allegation of abuse or any incident that results in serious bodily injury will be reported to the Illinois Department of Public Health immediately, but not more than two hours after the allegation of abuse. Any incident that does not involve abuse does not result in seriously bodily injury shall be reported within 24 hours.

Based on interview and record review, the facility failed to follow complete Care plan indicating need for assistive bed devices. This deficiency affects one (R5) of three residents reviewed for Patient Centered Care plan.Findings include:On 3/2/26 at 11:55AM, R5 said that she had both bilateral side rails to use in bed for bed mobility and then had had a bed changed and did not have side rails. R5 stated she received left side bed rail placed over a week ago and has asked staff for right side bed rail to help with repositioning and to be able to scoot up in bed if needed. R5 showed surveyor that she is unable to do anything with her left arm and is able to grasp with Right hand and can't turn or reposition self without right side bed rail. On 3/4/26 at 2:21pm, V7 (Restorative Nurse) said that side rails were placed per resident request on 3/3/26. V7 said no restorative assessment was completed, but it should be completed upon admission, quarterly and as needed and same with resident care plan. On 3/5/26 at 10:41AM, V15 (Occupational Therapy) said that on 2/6/26 when being treated R5 did have bilateral side rails on bed, and R5 was able to use side rails for bed mobility and did great with them.On 3/5/26 at 12:45PM, V2 (Director of Nursing) said that her expectations for Care plans should be completed upon admission, quarterly and as needed when changes occur with plan of care.R5 is a [AGE] year-old admitted to the facility on [DATE] with the following diagnosis in part but not limited to: Acute and Chronic respiratory failure with hypoxia, anxiety disorder, end stage renal disease, anemia. Occupational Therapy Treatment Encounter Note dated 2/6/26- indicated Bed mobility Roll left and Right=Partial/moderate assistance, Equipment During tasks=Using bedrail on the right, using bedrail on the left. Facility Policy on Care Plan- revised 5/1/25General: To provide the staff with guidance on completion of comprehensive person centered care baseline care planning. Protocol:The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care. The baseline care plan will be developed within 48hours of a residents admission into the facility. The baseline care plan will include at a minimum the following necessary information to properly care for a resident. e. Activities of Daily Living needs4. Person centered care means that the facility focuses on the resident as the center of control and supports each resident in making his or her own choices.

Based on interview and record review, the facility failed to complete restorative assessment upon admission. This deficiency affects one (R5) of three residents reviewed for Restorative nursing program. Findings include:On 3/2/26 at 11:55AM, R5 said that she had both bilateral side rails to use in bed for bed mobility and then had had a bed changed and did not have side rails. R5 stated she received left side bed rail placed over a week ago and has asked staff for right side bed rail to help with repositioning and to be able to scoot up in bed if needed. R5 showed surveyor that she is unable to do anything with her left arm and is able to grasp with Right hand and can't turn or reposition self without right side bed rail. On 3/4/26 at 2:21pm, V7 (Restorative Nurse) stated that side rails were placed per resident request on 3/3/26. V7 said no restorative assessment was completed, but it should be completed upon admission, quarterly and as needed.On 3/4/26 at 2:30PM, V2(Director of Nursing) stated that a restorative assessment should be completed upon admission, quarterly and as needed for any changes, and care plan should be initiated when changes occur as well.On 3/5/26 at 10:41AM, V15 (Occupational Therapy) said that on 2/6/26 when being treated R5 did have bilateral side rails on bed, and R5 was able to use side rails for bed mobility and did great with them.R5 is a [AGE] year-old admitted to the facility on [DATE] with the following diagnosis in part but not limited to: Acute and Chronic respiratory failure with hypoxia, anxiety disorder, end stage renal disease, anemia. Occupational Therapy Treatment Encounter Note dated 2/6/26- indicated Bed mobility Roll left and Right=Partial/moderate assistance, Equipment During tasks=Using bedrail on the right, using bedrail on the left. Therapy to Nursing Recommendations dated 2/16/26- Passive Range of motion to Left upper extremity at shoulder, elbow, wrist. Active Range of motion to Right upper extremity and Lower extremity with two tube number weights. Bed Mobility- rolling left and right. Facility Policy on Restorative Nursing Program- revised 5/2025General: To promote each resident's ability to maintain or regain the highest degree of independence as safely as possible. Responsibility Party:Nursing, RestorativePolicy:Each resident will be screed for restorative programs by the Restorative Nurse upon admission, quarterly and with any significant change in function. Appropriateness for the restorative program will be determined by the IDT as needed and may be determined as a continuation of care following a course of physical, occupational, and/or speech therapy. BED RAILS/SIDE- revised 5/1/25GENERAL:Bed rails may be used in order to assist with mobility to ensure that residents maintain the optimal amount of independence. These will be used only after an assessment has been completed; other alternatives have been assessed, and consent has been obtained. Policy:All residents will be assessed for the use of bed rails upon admission, quarterly, and upon significant change utilizing the Restorative Comprehensive Assessment/ RESTORATIVE: Side rail review. ACTIVITIES OF DAILY LIVING- revised 5/1/25General: A program of activities of daily living is provided to prevent disability and return or maintain residents at their maximal level of functioning based on their diagnosis. Guideline:The ability of each resident to meet the demands of daily living is determined by a licensed nurse. A program of assistance and instructions in ADL skills is care planned and implemented. Assistive device and adaptive equipment are provided by Occupational Therapy.

Based on observation, interview, and record review, the facility failed to follow their abuse policy and failed to protect one resident (R1) from repeated verbal and psychological abuse by R2. This failure affected one (R1) of three residents reviewed for abuse. These failures resulted in R1 experiencing ongoing fear and anxiety related to being R2's roommate. Findings include: R2's face sheet documents and admission date of [DATE] and diagnoses that include but are not limited to asthma, type 2 diabetes mellitus, and chronic kidney disease.R2's BIMS (brief interview mental status), dated [DATE] is 12 which indicates R2's cognition is moderately impaired.On [DATE] at 9:31am, R2 said, We (R1 and R2) had a disagreement a few days ago. They (facility staff) keep putting me in rooms that make me sick. The residents are way sicker than me. I'm not sick like of all of them (other residents). I should have a private room or semi-private. Yeah, it was Saturday or Sunday ([DATE] or [DATE]) when our (R1 and R2) arguing got a little out of hand. His (R1) cough, his (R1) skin, and his (R1) hair is just nasty. I have to eat, and his nastiness is just no good for me. He's a disgusting fat pig. He needs to stay on his side of the room. I mean when he starts hacking, yeah, I called R1 nasty a** out. I don't call him names all the time, but it's happened a few. No, that's a lie. I never said that I would shoot anyone in the head. I came in with the BB gun. I had it ever since I was admitted here. Never took it (BB gun) out. They (facility staff) took my bag with the gun, and I called the police. I (R2) have a police report. R2 said, I've been in this room with R1 and R3 for about 3 weeks. R2's CHIRP (Criminal History Information Response Process), dated [DATE], documents, in part, Result: In Process.R2's care plan, dated [DATE], documents, in part, (R2) have a history of criminal behavior. (R2) have demonstrated stability during the admission screening process and does not appear to present at risk. I (R2) fit the criteria for an identified offender, with interventions, that document, in part, Appropriate supervision and observation. R2's (Name of Company) Live Scan Fingerprinting and Identity Services, dated [DATE], documents, in part, that R2 was fingerprinted on [DATE]. However, review of R2's electronic medical record (EMR) and interviews with facility staff revealed that R2's fingerprint results were not available and could not be located.R1's face sheet documents diagnoses that include but are not limited to chronic obstructive pulmonary disease, type 1 diabetes mellitus, and major depressive disorder.R1's BIMS (brief interview mental status), dated [DATE], is 15 which indicates R1 is cognitively intact.On [DATE] at 9:35am, R1 said, I (R1) never said anything about anyone saying that they were going to shoot me (R1) in the head. That's probably the one thing R2 hasn't said to me (R1). He (R2) did say that he's gonna slap me into next year and choke me to death. He (R2) moved in about 2 weeks ago. Nothing but problems. He doesn't like me. I (R1) think he's a germaphobe. I'm (R1) sick, I'm hospice, and I'm dying. There's nothing I (R1) can do. He (R2) wheeled past my bed the other day and kicked my bed so hard that my bed moved about 1 or 2 inches, and the bed was locked. The fight between us (R1 and R2) was real bad last Sunday ([DATE]). I (R1) went to turn up the air conditioner that is by his (R2) bed, cause it was hot as he** and he lost it. He was sitting in the doorway and started screaming, Don't go on my (R2) side of the room. Turn the air conditioner down. You fuc**** smell. He's (R2) not wrong, I am nasty because I'm dying and can't help it. I (R1) shower every day. I'm just sick. Oh yeah, V3 (Licensed Practical Nurse/LPN) and V4 (Nurse's Aide) know all about R2 going crazy on me (R1). V3 settled down R2. R2 is a scary guy. I can only take so much of him telling me I'm a fat faggot mother fuc***r . all the flies are in the room cause me (R1). He has a valid reason, but I'm sick and dying. I'm [AGE] years old. I don't need to be yelled at every day. I'm scared to death. Once he (R2) said that he (R2) was going to choke me to death. I'm (R1) scared to death. I'm (R1) constantly on edge because of him and I (R1) don't feel safe with him here. I'm scared of this guy (R2). I'm (R1) [AGE] years old and couldn't function myself out of a paper bag. Look. R1 pulls out of R1's sock, a facility menu, dated [DATE] (day after verbal altercation), that R1 wrote on documents, in part, CHOKIN TO DEATH; LIVING IN CHRONIC FEAR; R2. R1 said, I (R1) wrote on this and put it in my sock just in case R2 kills me (R1), so they know R2 did it. He's (R2) crazy.R1's active physician order, ordered date [DATE], documents, in part, Admit to Hospice Services for DX (diagnosis) of Respiratory Failure.R1's Abuse/Neglect Screening, dated [DATE], is 5 which indicates R1 is at high risk for potential future problems/ symptoms related to mistreatment. R1's care plan, dated [DATE], documents, in part, (R1) have been assessed for Risk of Abuse and Neglect, and I (R1) am at risk for abuse and Neglect, with interventions that documents, in part, Report any verbalization of abuse or neglect to administrator immediately; Immediately act and conduct abuse investigation if the resident reports any abuse or neglect; Take appropriate action(s) based upon the findings of investigation regarding abuse or neglect that is conducted; Ensure safety, if resident reports feeling unsafe.R3's face sheet documents diagnoses that include but are not limited to hypothyroidism and anxiety disorder.R3's BIMS (brief interview mental status), dated [DATE], is 15 which indicates R3 is cognitively intact.On [DATE] at 9:52am, R3 said, I (R3) don't know what their (R1 and R2) deal is. They (R1 and R2) are at each other all the time ever since he (R2) has been in this room. I (R3) just stay outta of it. He (R1) just lays there and R2 just starts with him (R1). Yeah, I (R3) try to tune it out though. He's (R2) called him (R1) a fat fuc**** pig, a sick fat fu**, and he (R2) told him (R1) to shut the fu** up or he'd (R2) choke him (R1) to death. It (arguing with R1 and R2) was real bad last weekend. The CNA (certified nurse's assistant) came in and said knocked the crap off. I (R3) don't know her (CNA) name. It was last weekend. I (R3) don't know if it was Saturday or Sunday ([DATE] or [DATE]). The days run together. Look, just keep me (R3) out of it and get R2 outta here. He's (R2) been at R1 since he (R2) came. I (R3) never seen R2 kick R1's bed. No, I (R3) never heard R2 say he (R2) was going to shoot R1 in the head.On [DATE] at 10:45am, V3 (Licensed Practical Nurse/LPN) stated that on [DATE] was V3's last day worked that week and reported that, while passing medications outside R1's and R2's room, V3 overheard the residents discussing an odor. V3 stated that V3 entered the room because of concerns about an odor being discussed by R1 and R2 and reported that, once inside the room, V3 learned the residents were discussing that one resident leaving the lid off a urinal was causing the odor. However, when asked to clarify whether the urinal was full or emitting a foul odor, V3 stated there was nothing was in the urinal or else I (V3) would have emptied it. V3 further denied hearing any yelling, arguing, fighting, or inappropriate language between R1 and R2 and characterized the interaction between R1 and R2 as fine. Despite denying the presence of an odor, denying any inappropriate behavior, and describing the interaction as normal, V3 stated V3 entered the room specifically to determine what smell the residents were discussing.On [DATE] at 10:53am, V4 (Nurse's Aide) stated that the only interaction V4 recalled between R1 and R2 occurred last weekend, Sunday ([DATE]), while V4 was picking up trays. V4 described the interaction as a normal conversation, but could not remember any details about what R1 and R2 were discussing. When asked about yelling, name-calling, arguing, or inappropriate language, V4 repeatedly responded no and offered no additional information. On [DATE] at 10:16am, while in R1's room with V1 (Administrator), R1 said, He (R2) was scary. He's (R2) worse than Dr. Jekyll and Mr. [NAME]. Every movement I (R1) made; I (R1) was afraid. I (R1) feel better now that he's (R2) not here. I'm (R1) not on pins and needles anymore. Thank you.On [DATE] at 10:19am, V1 (Administrator) stated that R2's initial CHIRP (Criminal History Information Response Process) was initially marked as held and in process. V1 stated that the facility never received the results. V1 further stated that the facility does not have the results of R2's CHIRP or fingerprints. V1 stated that the admission Director has been following up on the CHIRP. V1 also stated that the fingerprints were submitted by the previous Social Services Director, who no longer works at the facility.On [DATE] at 10:21am, V7 (Social Services Consultant) stated that the facility does not have an official CHIRP result for R2, and that the Admissions Director (V6) is responsible for managing CHIRP results. V7 stated that if a CHIRP is marked as held, there is potential for multiple hits on the resident's background, and that the Admissions Director (V6) checks once a week for 30 days, rerunning the CHIRP if results are not returned within that timeframe. V7 stated that the facility does not have R2's fingerprint results, and did not have authorization to order them, and that the previous Social Services Director had submitted the fingerprints. V7 explained that CHIRP results are managed by the Admissions Director (V6), fingerprints by Social Services, and that the purpose of the background checks is to ensure regulatory compliance, assess the resident's risk level, and determine appropriateness for placement in a skilled nursing facility.On [DATE] at 10:46am, V6 (admission Director) stated that sometimes the facility receives CHIRP (Criminal History Information Response Process) results immediately, while other times a delayed hit occurs. V6 stated that when a CHIRP is delayed, they check every day to see if the results have been returned. V6 stated that the facility received an in process result for R2 in the mail. V6 stated that sometimes CHIRP results do not come back at all and eventually expire. V6 stated that they checked R2's CHIRP status yesterday and found it had expired, so they ran another CHIRP for R2, which is currently marked as held again. V6 stated that this situation usually occurs when residents have hits from out-of-state sources.On [DATE] at 10:56am, V1 (Administrator) stated that V1 was never aware of any physical or mental/verbal abuse between R1 and R2.Evidence shows that the facility's failure to prevent, identify, and respond to verbal and mental abuse allowed R1 to experience ongoing fear, emotional distress, and a loss of safety in R1's home environment. Record review of facility policy titled, Abuse Policy and Prevention Program, dated 10/2022, documents, in part, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: conducting pre-employment screening of employees and pre-admission screening of residents; orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of abuse neglect, exploitation, and misappropriation of property; establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment, identifying occurrences and patterns of potential mistreatment; identifying concerns of residents' allegations of deprivation of goods and services by staff; immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property; implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences. his facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means (210 ILCS 45/1-103). Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident (42 CFR 483.5). This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain and/or maintain physical, mental, and psychosocial well-being. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish (42 CFR 483.12 Interpretive Guidelines). Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individuals' age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never to be able to see his/her family again (42 CFR 483.12 Interpretive Guidelines). Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation (42 CFR 483.12 Interpretive Guidelines).Record review of facility policy titled, Baseline Care Plan, dated 1/2023, documents, in part, The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care. The baseline care plan will include at a minimum the following necessary information to properly care for a resident. C. Supervision needs. D. Behavioral interventions. F. Social services. Person-centered care means that the facility focuses on the resident as the center of control and supports each resident in making his or her own choices. Person-centered care includes making an effort to understand how each resident communicates, verbally and nonverbally, identifying what is important to each resident with regard to daily routines and preferred activities, and having an understanding of the resident's life before coming to reside in the facility. The baseline care plan must reflect the resident's stated goals and objectives and include interventions that address his or her current needs. It must be based on admission orders and, information about the resident available from the transferring provider, and discussion with the resident and resident's representative, if applicable. Because the baseline care plan documents the interim approaches for meeting the resident's immediate needs, it should also reflect changes to approaches, as necessary, resulting from significant changes in condition or needs, occurring prior to the development of the comprehensive care plan. The facility will provide the resident and their representative with a summary of the baseline care plan that includes at a minimum the following: e. Any updated information based on the details of the comprehensive care plan, as necessary. If significant changes are made to the baseline care plan prior to completion of the comprehensive care plan, an updated summary will be provided to resident and resident's representative.Facility presented document 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 provide services to keep your physical and mental health, at their highest practical levels. 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 interview and record review, the facility failed to ensure that staff administer prescribed PRN (as needed) blood pressure medication for a resident; failed to assess and document vital signs for a resident with a change in condition; and failed to monitor and document a resident's blood sugar as ordered. This failure affected one (R2) of three residents reviewed for nursing care and resulted in R2 becoming unresponsive while at the facility and required hospitalization and treatment that included intubation and being admitted to the intensive care unit (ICU) for treatment of septic shock and healthcare associated pneumonia. Findings include: R2 is [AGE] years old and was originally admitted to the facility on [DATE], face sheet listed the following medical diagnosis among others: Dysphagia following cerebral infarction, type 2 diabetes, hypertensive heart and chronic heart disease, essential primary hypertension, systemic lupus erythematous, acquired absence of right leg, unspecified viral hepatitis C, etc. Hospital record dated 3/6/2025 states in part, patient brought in ALS per Emergency Medical Service (EMS). EMS called uncontrolled blood pressure, upon arrival at nursing home EMS states unresponsive and diaphoretic with shallow respirations. The same hospital record documented in part, [AGE] year-old male with past medical history of diabetes, CKD, hypertension .presents to the emergency department from nursing home via EMS for evaluation after he became unresponsive. Reportedly, his blood pressure was uncontrolled earlier, (unclear if it was low or high) and then he became unresponsive and diaphoretic with shallow respirations. Patient was intubated on 3/6/2025 at 6:01am, lab revealed positive RSV, chest x-ray with possible pneumonia, clinical impression septic shock and health care associated pneumonia. Review of physician orders showed the following: clonidine HCl Tablet 0.1 MG Give 1 tablet by mouth three times a day for antihypertensive. Hydralazine HCl Tablet 10 MG Give 10 milligram by mouth every 6 hours as needed for Elevated blood pressure. Give for SBP over 160 and DBP over 100. Blood Glucose Fingerstick Monitoring BID at breakfast & dinner. Call MD if BS is under 70___ or over _250__. two times a day for diabetic monitoring. Order date 10/25/2024. Medication administration record for the month of March 2025 showed that R2 received only one dose of the ordered PRN (as needed) hydralazine on 3/6/2025 at 0100. Last vital [NAME] documented for R2 was on 2/25/2025 prior to the one documented by V8 on 3/5/2025. Last blood sugar documented was on 2/25/2025 prior to the 3/6/2025. Per record review, R2 was observed with poor appetite for breakfast and lunch and diminished lung sounds with rumbling upon auscultation as documented in progress note dated 3/3/2025at 15:08. Medical doctor was notified and an order for respiratory panel and chest x-ray was obtained. 3/32025 at 15:10, respiratory panel was collected and placed in the soiled utility refrigerator. Laboratory result dated 3/4/32025 stated that R2's lab was canceled due to an unlabeled specimen. There was no follow up documentation to the collected sample, no assessment or vital signs documented for the resident the rest of 3/3/2024 and all three shifts on 3/4/2025. Laboratory result dated 3/4/32025 stated that R2's lab was canceled due to an unlabeled sample. Repeat lab result dated 3/5/2025, reported at 20:18 showed that R2 tested positive for RSV. 3/5/2025 at 13:04, V9 (LPN) documented the following: During med pass writer heard congestion during breathing in the resident, writer contacted Primary doctor to alert of s/s, order for Geri-tussin DM 10ML three times a day for 10 days PO (by mouth), cont. to monitor. V9 did not document any assessment or vital signs for R2 after she made this observation. On 4/2/2025 at 11:41AM, V9 (LPN) said that said that she assessed R2 and noted that he was having a respiratory issue and coughing, there was an outbreak of RSV in the facility, so she called the doctor and received an order for cough syrup. V9 said that R2 should have gone out the same day but she followed the order. Care plan initiated 12/25/2022 states that R2 have altered cardiovascular status r/t CHF, Hypertension, and heart disease. Interventions include assess for shortness of breath and cyanosis every shift as needed, monitor vital signs, notify MD of significant abnormalities, monitor/document/report PRN any changes in lung sounds on auscultation (i.e. crackles), edema and changes in weight, monitor/document/report PRN any s/sx of CAD: chest pain or pressure especially with activity, heartburn, nausea and vomiting, shortness of breath, excessive sweating, dependent edema, changes in cap refill, color/warmth of extremities. On 3/5/2025 19:07:20, V8 (RN) documented the following Writer observed that the resident refused to communicate with him when asked a question, he looks confused, refuses to take his medication and dinner. V/S (vital signs) BP.166/85. P.98. T.97.8. SPO2 87. writer assists with 2 liters of oxygen, will continue to monitor. On 4/1/2025 at 4:05PM, V8 (RN) said that he is familiar with R2, when he came to work on 3/5/2025, the outgoing nurse told him to monitor resident's respiration; V8 continued passing medications and decided to check his lab results. V8 called the doctor to report a positive RSV result for R2 but the doctor did not answer, V8 faxed the result to the doctor. V8 called the DON (Director of Nursing) to let her know and she advised him to follow up with the doctor. Night shift nurse came and V8 handed over to her, he is not sure what the blood pressure was at that time. Vital sign documented by V8 at 23:57 is as follows: B/P 166/98, Pulse 127, T-97.8 02 sat 94%, no respiratory rate charted. V8 was asked if he gave R2 any PRN (as needed) blood pressure medicine and he said, I did not know that the resident have such medication, I don't really know the resident because I hardly work that set, it was the night nurse that informed me that resident have a PRN hydralazine and I even went with her to pull it. On 3/6/2025 at 03:16, V5 documented the following: Writer observed resident sweating, lethargic, not verbally responsive with labored breathing. Vitals 160/89, Temp.99.0 Pulse 84 on oxygen, BS 90. CO -nurse called EMS. EMS arrived at the facility @ 0301. On 4/1/2025 at 1:08PM, V5 (RN) said that she is familiar with R2 and was the person that sent him to the hospital 3/6/2025. V5 came to work at 11:00PM and was notified by the outgoing nurse that R2 was not feeling well. V5 assessed the resident with the outgoing nurse and noted that his blood pressure was elevated, the outgoing nurse made some calls while V5 stayed with the resident. V5 rechecked resident's vitals and his blood pressure got higher, she medicated resident with a PRN blood pressure medicine and Tylenol for elevated temperature. V5 said that resident's blood pressure and temperature came down a little after the medication, but the respiration remains shallow, and resident was unresponsive. V5 said that the physician did not call back until early morning and she informed him that resident was sent to the hospital. V5 added that resident is usually responsive but not that night. Medication administration record for the month of March 2025 showed that R2 received only one dose of the ordered PRN hydralazine on 3/6/2025 at 0100. Last vital [NAME] documented for R2 was on 2/25/2025 prior to the one documented by V8 on 3/5/2025. Last blood sugar documented was on 2/25/2025 prior to the 3/6/2025. On 4/2/2025 at 11:22AM, V10 (Primary Physician) said that R2 was sent to the hospital immediately and his test came back positive for RSV; he was treated and he came back to the facility. Surveyor informed V10 that R2 did not return to the facility and presented the documentation by the nurse that they called with the positive RSV result and V10 did not call back until the morning after the resident has been sent out. V10 then said that he must have mistaken this admission with resident's previous hospital visit, V10 added that he keeps his phone with him all the time and always calls the facility back. If the nurse thinks that something is wrong with a patient and the doctor does not answer then they can call the DON and make the decision to send out the resident; they don't have to wait for the doctor to take an action. On 4/12025 at 3:12PM, V2 (DON) said that nurses are supposed to check blood sugar and vital signs as ordered and it should be documented in the MAR (Medication Administration Record) or in the vitals section of the medical record. On 4/2/2025 at 10:30AM, V2 (DON) said that the protocol to follow when staff cannot reach the physician is to call the medical director, all the nurses are aware of this, if they cannot reach the physician they should continue trying and inform the DON of what is going on. V2 added that the rule of thumb is to reach for the nurse practitioner first, then the attending physician and the medical director if needed. Job description for registered nurse and licensed practical nurse document (undated) states in part: The basic functions: 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: 3. Administer prescribed medications and treatments according to policy and procedure, evaluate treatment effectiveness on a continuing basis. 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.

Based on interview and record review, the facility failed to supervise one resident (R2) who was diagnosed with Dementia, cognitively impaired with a history of falls and identified as high fall risk from sustaining three falls within forty-five days. This affected one of three residents (R2) reviewed for falls. This failure resulted in R2 sustaining an unwitnessed fall with a laceration to the back of the head injury requiring suture and staple repair and sustaining another fall with a laceration to the back of the head requiring staples. Findings include: R2 was admitted to the facility on [DATE]with a diagnosis of type II diabetes, dementia, psychosis, Alzheimer's disease, anemia, encephalopathy, and history of falling. R2's Minimum Data Set, dated dated dated [DATE] documents brief interview for mental status score a 3/15 which indicate severe cognitive impairment. R2's fall risk dated 8/26/24 documents R2 at risk for falls. R2's psycho therapy progress note dated 8/15/24 documents: chief complaint: follow up on restlessness and dementia. Info gathered from staff: staff report patient is less anxious, less restless, confused, tries to get up at times with no assistance, requires close monitoring. Patient seen sitting on wheelchair by the nurses' station, appears comfortable, pleasantly confused. Denies anxiety or depression. denies sleep and appetite concerns. Patient is being continuously monitored by staff for safety due to unsteady gait and trying to get up with no help. R2's incident report dated 8/17/24 documents: Resident noted face down on the side of her bed. Resident was assessed head to toe. No injury noted. R2 assisted back to wheelchair. Under mental status: disoriented but within normal limits for this resident, oriented to person. Under predisposing physiological factor: impaired memory; Under predisposing situation factors- ambulating without assistance. On 10/3/24 at 12:32PM, V11 (Restorative nurse) R2 is confused due to diagnosis of dementia and she can be restless. V11 said R2's fall on 8/17/24 was due to R2 unaware of safety needs. V11 said R2 has dementia and may do things that are unsafe. Interventions placed were x-rays, toileting before and after meals, and floormats were added. R2 is in the busy bee program during the day and should be monitored by staff. R2 needs to be in a high visual area when out of bed. R2 will sometimes be at the nursing station after activities so staff are present. R2 has a behavior of standing up from her wheelchair. R2's incident report dated 9/1/24 documents: Writer was informed by another staff that resident was on the floor. Writer observed laceration to the back of head and resident was bleeding. Under mental status: disoriented but within normal limits for this resident, oriented to person. Under predisposing situation factors documents restless. Facility reportable dated 9/1/24 documents: R2 had an unwitnessed fall on 9/1/24 around 6:26PM at the nurse's station. Resident was unable to state what occurred. Full body assessment noted bleeding from the head. Md notified and order to the hospital for evaluation. Resident retuned with a diagnosis of laceration to the head and four staples to the area. Under Final: Based off the facility investigation, it can be determined that the resident had a fall event due to standing from her wheelchair, causing it to tilt backwards. As a precaution, antitippers were added to R2' wheelchair while remaining in visible sight of staff during wake hours. Under summary of investigation: V5 (laundry aide) was interviewed. V5 said he was pulling linen on C/D wing when R2 suddenly stood up form her wheelchair and fell backwards. V21 (nurse) said she was administrating medication on her assigned wing when she heard V5 call for help.V9 (Nurse) said she was administrating medication on her assigned wing when she was notified by peer that resident had fallen. On 10/1/24 at 2:52PM, V5 (laundry aide) said he was going to pull the soiled linen near nursing station and observed R2 sitting behind the nursing station at the desk. V5 said there were no other staff present. The nurses were in the hallways passing medication. V5 said he saw R2 start to stand up and heard another resident telling for R2 to sit down. V5 said he heard a noise and when he looked he did not see R2 anymore. V5 said he went closer and observed R2 on the floor next to her wheelchair. V5 said the wheelchair was flipped back. R2 hit her head on the floor. On 10/3/24 at 3:23PM, V10(CNA)said he was familiar with R2's care. R2 likes to stand up from her wheelchair and try to walk. R2 requires frequent checks and staff will take turns sitting with her because of her impulsive behaviors. R2 will usually sit by the nursing station so someone is with her because she is a high fall risk. On 9/1/24, V10 said he was R2's assigned aide. V10 said R2 was sitting behind the nursing desk with staff. V10 said he told staff he was going on break and when he returned he received report that R2 had fallen and was sent to the hospital. On 10/3/24 at 3:48PM, V9 (Nurse) said she was familiar with R2 care needs. V9 said R2 is agitated and restless and staff will keep her at the nurses station for close monitoring. R2 is always trying to stand up from her wheelchair to go to the store or home. V9 was one of nurses working on 9/1/24 when R2' fall occurred. V9 said she was not at nursing station when R2 fell and unsure what staff was there. R2's fall was unwitnessed and she was found behind the nursing desk on the floor with head injury. V9 said someone should have been at the nursing station watching the residents. On 10/3/24 at 12:32PM, V11(Restorative nurse) said the fall on 9/1/24 root cause was impulse, and anti-tippers added to wheelchair and therapy screen. On 10/4/24 at 10:31AM, V20 (ADON) said they do not currently have any residents on one to one monitoring. Some residents maybe on close monitoring which indicates staff are making frequent rounds and watching the residents closely. Some at risk residents are placed near the nursing station when activities are not being done for close monitoring. The nurse's station is not left unattended, and staff are always near the area. The nurses or aides are responsible for monitoring the residents. R2's fall IDT (interdisciplinary team) note dated 9/2/24 documents: Summary of incident: The writer was notified by the other nurse that the resident is on the floor. The writer assesses the resident and observes that the resident is bleeding from her head, the writer stabilizes the resident until the ambulance arrives at about 6:31pm. Root cause of fall determined by IDT: nothing documented. New interventions and/or changes suggested by the IDT at this time: Bed mat in place , call light within reach and bed in lowest position. R2's hospital record dated 9/1/24 documents under notes: R2 is alert and oriented x1 which is her baseline. R2 states she does not recall how the fall happened as it occurred very quickly. Per nurse who spoke to nursing home staff, fall was unwitnessed, but they suspect R2 fell out of her wheelchair. Under physical exam: 2 centimeters by 3 centimeter laceration in the shape of a cross with central gaping revealing skull. Under laceration repair for occipital scalp length 3 centimeters x 4 milmeters depth. Sutures and staples used. Two sutures used for gaping center and 4 staples applied to the edges. R2's therapy notes dated 9/5/24 documents under precautions: fall risk, confusion with decreased safety awareness, 1:1 supervision for safety. R2's facility state reportable dated 9/28/24 documents: R2 had witnessed fall on 9/28/24 around 11:30PM at the nurse's station. Full body assessment noted bleeding from the head. MD notified and order to send the hospital for evaluation. R2 returned with diagnosis of laceration and four staples to the area. R2's incident report dated 9/29/24 documents: Resident was observed sitting in wheelchair across from the nurses station, she stood up and tried to sit back down and missed the chair and fell on her buttocks, hit her head against the wall, a small laceration with blood was noticed from the back of her head pressures was applied, 911 called. On 10/3/24 at 1:13PM, V12 (Nurse) said he was working the night R2 fell on [DATE]. V12 said R2 has behaviors of trying to get out of bed and standing up from wheelchair. R2 has always had these behaviors and staff will take turns sitting with her during the shift to prevent her from falling. V12 said R2 was sitting across from the nursing station. V12 said R2 was attempting to get out of bed prior and that's why she was at the nursing station. V12 said they were doing change of shift report and V15(CNA) was assisting another resident with his shoes near R2. R2 stood up from her wheelchair and was instructed to sit back down but she must have moved and missed the wheelchair and fell to the ground. R2 hit her head on the floor or wall and did have an injury. R2 was sent out to the hospital. On 10/3/24 at 3:48PM, V9 (Nurse) said R2's fall on 9/29/24 was during change of shift. R2 was sitting in her wheelchair in front of the nursing station. R2 stood up from her wheelchair and staff instructed her to sit back down but she must have stepped to the side because when she sat back down she missed the wheelchair and fell hitting her head on the wall or other chair near her. There was an aide sitting near R2 who was helping another residents with his shoes but she could not see R2. Nurses were all busy doing change of shift and could not reach R2 in time. On 10/3/24 at 2:08PM, V15 (CNA) said she was familiar with R2's care needs and was present at time of fall on 9/28/24. V15 (CNA) said she was working on the unit and was near the station when another resident approached her to assist with his shoes. V15 said she took a chair that was near R2 and sat down with her back turned to R2. V15 said she assisted the resident with his shoes and during that time, R2 stood up and nursing staff was verbally instructing R2 to sit down. V15 said R2 will usually sit down when told and she was sitting but she moved and fell down to the floor by missing her wheelchair and hit her head possibly on the wall. V15 said she was not assigned to watch R2 at time of the fall. On 10/3/24 at 2:40PM, V11 (Restorative nurse) said The root cause of fall on 9/29/24 was impulse. V11 was asked where and what interventions were in place for R2's impulsive behaviors. V11 presented careplan for behavior problem manifested by attention seeking behaviors that include sitting or laying on the ground, making statements that are false. Interventions documented: administrate medications as ordered and anticipate the needs of the residents. R2's hospital record dated 9/29/24 documents under diagnosis fall, blunt head injury and scalp laceration. Under procedures laceration repair: occipital scalp 2 centimeter wound. Repaired with four staples. R2 plan of care documents: R2 is at risk for High risk falls related to impaired mobility, weakness, Diabetes, high risk medication use, impaired cognition, agitation, history of falling prior to admitted Initiated: 06/17/2024 Revision on: 06/27/2024. Interventions: Anticipate and meet The resident's needs. Date Initiated: 06/17/2024. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Date Initiated: 06/17/2024 Dycem to bed added to wheelchair Date Initiated: 06/23/2024 Revision on: 07/05/2024 Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Date Initiated: 06/17/2024 Ensure that the resident is wearing appropriate footwear shoes, non-skid socks when mobile on unit Date Initiated: 06/17/2024 Revision on: 06/25/2024 Follow facility fall protocol. Date Initiated: 06/17/2024 Medication review Date Initiated: 09/30/2024 Revision on: 09/30/2024 Placed in busy bee Activities during the day Date Initiated: 06/17/2024 Pt evaluate and treat as ordered or PRN. Date Initiated: 06/17/2024 PT screen Date Initiated: 09/01/2024 Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers as to causes. Date Initiated: 06/17/2024 Tippers to wheel chair Date Initiated: 09/01/2024 Revision on: 09/09/2024 Toilet before meals after meals, and at bed time. Date Initiated: 08/17/2024 Xray to left hand and Left knee Date Initiated: 06/25/2024 Facility policy titled Fall prevention and management reviewed 1/24 documents: The 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 preventative strategies, and facilitate as safe as an environment as possible. All residents fall shall be reviewed, and the residents existing plan of care shall be evaluated and modified as needed. Care plan to be updated with a new intervention based on root cause analysis after each fall occurrence.

Based on interviews and record reviews, the facility failed to follow its skin care prevention policy and implement effective interventions and monitoring to prevent one resident developing three facility acquired non-pressure wounds to the right foot and ankle. This affected one of three R1 residents reviewed for non-pressure wounds in a sample of 11. This failure resulted in R1 presenting to the hospital emergency roiagnom on [DATE] with sepsis secondary to a right heel wound that was infected and with acute osteomyelitis (bone infection). Findings include: On 9/5/24 at 1:40 PM, V11 (wound care nurse) stated that the staff nurses are responsible for monitoring residents' skin for any breakdown. V11 stated that V11 noted R1 with right heel bruising on 8/19/24 and obtained order for wound cleaning and the application of skin prep. V11 stated that the blister opened on 8/24/24 and V11 obtained an order for xeroform and dry dressing daily. V11 stated that the wound on the top of R1's foot was still a blister so V11 continued applying skin prep to this wound. V11 stated that V11 placed a pillow between R1's legs, because V11 was concerned that R1's left lower leg cast was putting pressure on R1's right leg and foot. V11 stated that R1 is unable to move self in bed, dependent on staff. V11 stated that R1's legs were contracted, crossed at knees, and V11 was concerned for pressure on right leg. V11 stated that R1's right foot wounds were trauma related because nothing was wrong with R1 prior to left foot fracture on 8/7/24. V11 stated that V11 performed wound care treatments six days a week and repositioned R1 during treatments. V11 stated that V11 checked to ensure she was able to insert two fingers under R1's rim of cast at toes and positive capillary refill. On 9/6/24 at 1:20 PM, V10 NP (nurse practitioner) stated that R1's legs were very contracted. V10 stated that R1 returned from the emergency room with a post mold to left tibia/fibula fractures on 8/8/24. V10 stated that V10 visited R1 on 8/12/24 and observed bruising to R1's right foot and left knee area. V10 stated that V10 would have V11 (wound care nurse) manage residents with bruising as well as open wounds. V10 stated that fractures, contractures, and poor nutrition puts R1 at risk for skin breakdown. V10 is unable to articulate how the bruising to R1's right foot and left knee could be from trauma on 8/7/24. V10 stated that if due to trauma would have been present at the time of injury on 8/7. V10 was able to review R1's current hospital record which notes right heel wound infection with osteomyelitis. V10 stated that once a wound is present, it can deteriorate very quickly to an infection. V10 stated that the mottling and increased respirations observed by nursing on 9/1 could be due to R1's body responding to the infection. On 9/6/24 at 4:26 PM, V14 (family member) stated that when she was visiting with R1 on 8/31/24, V14 noted R1's right foot wounds with a foul odor. V14 stated that V14 informed the nurse on duty of the foul odor. R1's weekly skin observation, dated 8/8/24, notes R1's skin warm, dry, within normal limits. Skin turgor is fair. Swelling observed to left foot. No skin concerns noted. There were no further weekly skin observations documented between 8/9/24 and when 9/1/24 when R1 was hospitalized . The CNAs (certified nurse aides) documentation, dated 8/8/24 -9/1/24, notes 8/8, 8/9, 8/14, and 8/21, the CNAs noted discoloration. On 8/11 and 8/18, the CNAs noted redness. On 8/21, the CNA charted skin tear. There is no documentation found in R1's medical record noting the nurse assessed R1 for these skin abnormalities. V10's NP progress note, dated 8/12/24, notes R1 with a soft cast on left leg. There are surrounding bruising and discoloration to R1's left knee and right foot. R1's wound assessment, dated 8/27/24, notes R1 was identified with a facility- acquired right dorsal foot hematoma (bruise) due to trauma on 8/27/24. It is a full thickness wound with 100% intact skin. Maceration (softening and breaking down of skin resulting from prolonged exposure to moisture) noted to periwound. Wound measured 11.10cm (centimeters) x 9.6cm. On 8/29/24, V11 initiated skin prep and gauze dressing treatment. R1's wound assessment, dated 8/27/24, notes R1 with a facility acquired right heel bruise due to trauma, identified on 8/20/24. It is a full thickness wound with 100% bright pink or red tissue. Wound measured 5.5cm x 4.5cm with serous (clear) drainage. On 8/26/24, V11 initiated xeroform and gauze dressing treatment. R1's wound assessment, dated 8/27/24, notes R1 with a facility-acquired right lower leg front bruise due to trauma, identified on 8/27/24. Wound with 100% pink or red non-granulating tissue. Wound measured 18.3cm x 3.1cm. On 8/27/24, V11 initiated application of skin prep treatment. R1's POS (physician order sheet), dated 8/20/2024, notes an order for right foot wound apply skin prep every day shift to prevent skin breakdown. There is an order, dated 8/24/24, for right ankle wound clean with wound cleaner pat dry, apply xeroform and rolled gauze every day shift for wound care. R1's TAR (treatment administration record), dated August 2024, notes R1 did not receive treatment to right ankle wound on 8/25 or 8/31. R1 also did not receive treatment to right foot blister on 8/25 or 8/31. R1's hospital record, dated 9/1/24, notes R1 presented to the emergency room at 11:07 AM. Condition is serious. R1's primary admitting diagnosis is osteomyelitis right foot. R1 with necrotic (dead tissue) right heel ulceration with foul-smelling drainage and right foot blister. R1's white blood cell count was 19.2 (normal range 4-11). X-ray of R1's right foot noted heel with soft tissue gas tracking superiorly along the achilles tendon. Impression: heel ulcer with evidence of infection by a gas-forming organism. R1 with sepsis secondary to necrotic infected right heel wound. Infectious disease physician consulted and noted severe sepsis, necrotic right heel ulcer with wet gangrene, and osteomyelitis. Along the medial ankle there appears to be tissue necrosis also. It is unlikely that the limb will be salvageable given the extensive necrosis of the heel. Antibiotics alone will not take care of the infection given the tissue damage. Very foul-smelling odor noted from the right foot. Wound dressings with small bugs noted. Podiatrist consulted and noted R1's right heel ulcer with achilles tendon exposed, limb not salvageable. Right heel wound measured 14.3cm x 12.2cm x 0.4cm. This facility's skin care prevention policy, reviewed 01/2024, notes dependent residents will be assessed during care for any changes in skin condition including redness and this will be reported to the nurse. The nurse is responsible for notifying the health care provider.

Based on interviews and record reviews, the facility failed to implement effective pressure relieving interventions to prevent one resident, who's lower extremities are severely contracted, at very high risk for skin breakdown, and dependent on staff for all ADLs (activities of daily living), from developing a facility acquired pressure ulcer on the left posterior distal thigh due to pressure from posterior mold splint on the left lower leg. This affected one of three residents R1 reviewed for pressure ulcers in a sample of 11. This failure resulted in R1 presenting to the hospital emergency roiagnom on [DATE] with a pressure wound to the left posterior distal thigh with hamstring tendon exposed. Findings include: On 9/5/24 at 1:40 PM, V11 (wound care nurse) stated that the staff nurses are responsible for monitoring residents' skin for any breakdown. V11 stated that R1 is unable to move self in bed, dependent on staff. V11 stated that R1's legs were contracted, crossed at knees. V11 stated that V11 checked to ensure she was able to insert two fingers under R1's rim of cast at toes and there was positive capillary refill. On 9/6/24 at 1:20 PM, V10 NP (nurse practitioner) stated that R1's legs were very contracted. V10 stated that R1 returned from the emergency room with a post mold to left tibia/fibula fractures on 8/8/24. V10 stated that V10 visited R1 on 8/12/24 and observed bruising to R1's right foot and left knee area. V10 stated that V10 would have V11 (wound care nurse) manage residents with bruising as well as open wounds. V10 stated that fractures, contractures, and poor nutrition puts R1 at risk for skin breakdown. R1's weekly skin observation, dated 8/8/24, notes R1's skin warm, dry, within normal limits. Skin turgor is fair. Swelling observed to left foot. No skin concerns noted. R1's left ankle down to the foot dark purple bruise, swollen and painful. Left elbow with dark purple bruising. The CNAs (certified nurse aides) documentation, dated 8/8/24 -9/1/24, notes 8/8, 8/9, 8/14, and 8/21, the CNAs noted discoloration. On 8/11 and 8/18, the CNAs noted redness. On 8/21, the CNA charted skin tear. There is no documentation found in R1's medical record noting the nurse assessed R1 for these skin abnormalities. R1's progress notes, dated 8/8/24 - 9/1/24, notes on three occasions, 8/27 at 1:18 AM, 8/28 at 00:17 AM, and 8/29 at 1:49 AM, documentation of positive capillary refill and two fingers can fit under the rim of the soft cast. There were no further weekly skin observations documented between 8/9/24 and when 9/1/24 when R1 was hospitalized . V10's NP progress note, dated 8/12/24, notes R1 with a soft cast on left leg. There are surrounding bruising and discoloration to R1's left knee. There is no documentation found in R1's medical record noting staff monitored the bruising and discoloration to R1's left knee or skin to left thigh area. R1's POS (physician order sheet), dated 8/11/2024, notes an order to monitor left lower extremity cast and surrounding areas for circulation, motion, and sensation, signs/symptoms of skin breakdown every shift, notify physician of abnormalities. R1's hospital record, dated 9/1/24, notes R1 presented to the emergency room at 11:07 AM. Condition is serious. Podiatrist consulted and noted R1's left distal thigh wound with hamstring tendon exposed related to pressure on leg from post mold splint on left lower leg. This facility's skin care prevention policy, reviewed 01/2024, notes dependent residents will be assessed during care for any changes in skin condition including redness and this will be reported to the nurse. The nurse is responsible for notifying the health care provider.

Based on observation, interview and record review the facility failed to ensure a plan of care was followed to review information on past falls, attempt to determine cause of falls, and anticipate and meet the resident's needs. The facility also failed to follow their fall protocol to ensure effective interventions for safety were in place to reduce the risk for falls for 1 of 3 resident's (R1) reviewed for safety. This failure resulted in R1 sustaining a left hip fracture of the femur head on 4/21/2024. Findings include: On 5/7/2024 at 10:30am R1 was observed at the nurse's station in his wheel-chair alert to name only. On 5/9/2024 at 12:30pm R1 was observed in his room sitting on the edge of the bed with a t-shirt, incontinent brief, no pants or socks on and with one foot half under the fall mat asking for pants. On 5/9/2024 at 12:35pm V5 (Nurse) observed with writer R1's condition and said he is a fall risk, he should be dressed and at the nurse's station for observation or in activities after breakfast. On 5/9/2024 at 12:36pm V6 (Certified Nurses Assistant - CNA) said R1 is a fall risk. I checked on him when I brought his breakfast tray in and he was in the bed. I was attending to my other residents. On 5/9/2024 at 2:30pm V8 (Certified Nursing Assistant - CNA) said on 4/19/2024 at about 8:30am upon doing morning care, R1 was very combative, guarding his leg and complained of pain. I immediately notified the nurse. On 5/9/2024 at 2:25pm V3 (Nurse) said on 4/19/2024 between 8am and 9am, V8 reported to her that R1 was guarding his left leg, complaining of pain and being combative with care. V3 said she called the physician for an x-ray and received it back on 4/21/2024 reporting that it was a fracture of the left femur. On 5/9/2024 at 12:50pm V2 (Director of Nursing - DON/Falls Coordinator) said I expect all the nursing staff to follow the safety protocol in place for each resident. R1 has a history of falls and is a fall risk. R1 is alert x1, ambulatory with a walker upon admission. R1 complained of pain on 4/19/2024, he was placed in a wheelchair and put on high risk for falls with interventions in place. R1 should have been up in his wheelchair for all meals, at the nurse's station or in activities. Never alone in his room. On 5/9/2024 at 3:00pm V1 (Administrator) said I thought R1 was dressed and in his wheelchair at the desk or activities. He's a fall risk because we do not know how R1 fractured his leg. We suspect a fall, but no one found him on the floor, so that is why we called it an injury of unknown origin. He was admitted with a history of falls. An admission record indicates R1 has an history of falls and unspecified dementia, severe with other behavioral disturbance. A care plan with a focus of a risk for falls related to impaired cognition, impaired mobility a history of prior falls prior to admission. An intervention of anticipate and meet the resident's needs, follow facility fall protocol and review information on past falls and attempt to determine cause of falls. An incident report dated 4/21/2024 of injury of unknown injury with a stat x-ray and possible fracture of left hip. A nurse's progress note dated 4/21/2024 at 14:16 indicating that R1 had a x-ray result of a positive fracture if the left femur heads. A diagnostic radiology report dated 4/21/2024 indicates that R1 had a acute fracture of the left femoral neck. Facility Policy: Fall Prevention and Management revision date 1/2024 General: 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 an environment as possible. A resident fall shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed. Guidelines: Upon Admission: 1.A fall risk evaluation will be completed on admission, readmission, and quarterly significant change and after each fall.

Based on interview and record review the facility failed to developed a resident specific care plan with interventions to address a residents drug use history. This failure resulted in R1 being found unresponsive, non-breathing and was pronounced dead at the hospital. This failure affected R1 out of 8 residents reviewed for comprehensive care plan. Findings include: R1 was [AGE] years old, was admitted to the facility on [DATE] with diagnosis of but not limited to: Anoxic brain damage, Poisoning by unspecified drugs and functional quadriplegia. R1's BIMS Score (Cognition test) was 14 meaning R1 was cognitively intact. R1's (,d+[DATE]) admission paperwork from the hospital document in part: Anoxic brain damage secondary to drug overdose. R1's ([DATE] at 2:05 pm) progress note documents in part: Resident is a [AGE] year old, male, Caucasian newly admitted to the facility on [DATE]. Resident is alert x3 and he can make his needs known. Resident was diagnosed with anoxic brain injury due to drug overdose. Resident also has protein calorie malnutrition and dysphagia. R1's ([DATE]) death certificate documents cause of death: drug overdose, due to toxic effects of Fentanyl and Cocaine. R1's ([DATE] at 10:48 am) progress note documents: Upon rounding by staff, resident observed unresponsive and non-breathing. Resident a full code, code blue called, 911 emergency services contacted and CPR (cardio pulmonary resuscitation) initiated with crash cart present. Resident last observed alert and sleeping at approximately 7:50am. CPR continued until Emergency services arrived to facility and transferred resident to the hospital. Nurse Practitioner made aware. Family contacted and made aware. On [DATE] at 9:10 am V10 (Certified Nursing Assistant) said, she is on staff at the facility and has been here little over a year. She remembers R1, was keeping to himself, had an electric wheelchair and spoke to some residents. R1 needed help with putting on clothes, he was smoking cigarettes when it was time for smoke breaks, she did not have a clue or did not see signs of drug use, if she would suspect drug use she would let the nurse on duty and V2 (Director Of Nursing) and V1 (Administrator) know. V10 said, V16 was assigned to him but she was duty on that wing also. V10 asked V16 if if R1 wanted his breakfast tray, sometimes he didn't want anything. V10 said, V16 told her she just checked on him earlier and he was sleeping but if V10 could check on R1 because R1 didn't look right. V10 said, she went into R1's room and she went over by the window (R1's bed was by the window) and he didn't respond, he slept with pillow on his face usually, she got closer and noticed his fingertips were purple and it freaked her out because his eyes were open and she never seen anything like that. V10 said, she ran towards nurses station and she yelled called blue and everyone started running, even from different wings to help. On [DATE] at 9:28 am R8 said she was a friend of R1 and they were close. R8 said, she knew something of his history of drug use however she did not suspect R1 to do drugs. R8 said, she never saw R1 doing drugs or talk about drugs. R8 did not know R1 was struggling with drugs. R8 said, she never saw residents doing drugs. R8 said, he passed on Monday morning and the last time she saw him was Saturday evening and he was his normal self. R8 said, she was supposed to see R1 on Sunday but he never come over to her room. On [DATE] at 10:13 AM with V1 (Administrator), V2 (Director of Nursing) and V12 (Social Service Director) were present for the interview. V1 said, she was here at the facility, little after 9 am, code blue was called, she went there with V17 (ADON), as she was headed down there the nurse started CPR, 911 was called and staff continued CPR, paramedics were doing CPR also even as leaving the facility, Narcan was given but unsure if it was the paramedics or the facility that gave the Narcan. V15 (RN) was R1's assigned nurse. V1 said, she was not aware of R1 cause of death until she was informed by the surveyor. V12 (Social Service Director) said R1 had history of drug use. V2 said, one of R1's diagnosis were Poisoning by unspecified drugs and it could be drug are pharmaceutical and recreational. V12 was asked what facility had in place for R1 with known history of drug use, V12 said, R1 came with history of drugs and was in no condition to inject any drugs, he was not alert and oriented on admission, he became more oriented with time, R1 made improvements in functional abilities and was able to do more by himself, and he got physical therapy and got stronger. V12 said facility monitors residents and also does constant monitoring, for unusual behavior as needed. V12 said, he believes R1 was care planned for drug use (V12 was provided copy of R1's care plan and asked by surveyor to show where the care plan documents interventions for history of drug use). V12 said, he is not seeing R1 was care planned for drug use, and in hindsight R1 should have been care planned for drug use. V12 said, resident monitoring is based on observation and staff would document if something is observed and increased monitoring if required. V1 said, R1 never presented with active drug use and never facility found any drugs on him. V12 said, R1 had his own phone that he was using. V2 said, is someone comes in and they want to leave something for a resident, it goes first to social service and it is inspected and inventoried. V1 said, if (online food delivery platform system) is delivered or dropped off the facility does not inspect/open residents food, like staff will not open the actual wrapper but will look in the bag. V1 said, if packages come thru the mail they are inventoried so facility can keep track of resident belongings and social service inspects them first. R1's care plan does not document intervention in place for history of drug use. R1's ([DATE]) community assessment documents R1 does not appear to be capable of unsupervised outside pass privileges at this time. Facility's (,d+[DATE], revXXX,d+[DATE]) Comphrensive Care Plan policy documents in part: Facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights, that includes measurable objectives and timeframes to meet a residents medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, interview, and record review the facility failed to follow their pressure ulcer prevention policy by not preventing a resident from developing a facility acquired Stage 3 pressure ulcer and failed to have effective interventions and physician orders in place for the treatment of the pressure ulcer once acquired. This failure applied to one (R3) of one resident reviewed for pressure ulcers and resulted in R3 not receiving the care and services required to aid in the healing and prevention of pressure ulcers. R3 developed a new stage 3 pressure ulcer to his left ischium. Findings include: R3 is [AGE] years old and have resided at the facility since 2/01/2023, with past medical history including, but not limited to Paraplegia, Type 2 diabetes without complication, colostomy status, acquired absence of left leg above knee, neuromuscular dysfunction of bladder, ataxia following other cerebrovascular disease, pain, major depressive disorder, hypertensive chronic kidney disease, Kidney failure, benign prostatic hyperplasia, etc. 11/27/2023 at 11:30AM, observed resident in his bed, awake and alert but said that he is tired, just came back from dialysis. Resident was noted to have a urinary catheter. R3 stated that it is supra pubic, and he also has a colostomy bag. 11/27/2023 at 1:40PM, resident was observed still lying on his back in the same position and stated that he is feeling a little better. Review of facility pressure ulcer log documented that R3 has a stage 3 pressure ulcer to left thigh back, facility acquired and identified on 9/22/2023. 11/28/2023 at 11:30AM, observed wound care for resident with V5 (Licensed Practical Nurse/LPN) and V7 (Wound Care Tech) noted a large area of excoriation on the residents back left tight with some whitish substance, resident's stoma site was noted with some brownish crusty substances and resident stated that the area is sore to touch. V5 wiped away the substances and stated that the wound doctor just changed the treatment to reduce the drainage. V5 proceeded to remove the old dressing, applied the new treatment. Neither V5 nor V7 repositioned the resident after the wound care or offered to reposition him. Surveyor presented this observation to V5 who stated that R3 refuses care and prefers to lie on his back and will not allow staff to reposition him. Surveyor pointed out that R3 was not offered an opportunity to be repositioned after the wound care treatment so how does he refuse if the care is not even offered and V5 did not have an answer to that question. 11/28/2023 at 2:30PM, R3 was observed in his room still lying in the same position since the wound care observation. Surveyor asked resident why he is still in the same position, and he said that he cannot turn, and that staff will not help him. R3 was asked if he refuses care from staff and he said no, he never refused any type of care from staff; they just don't help. Braden (pressure ulcer risk) score assessment dated [DATE] scored R3 as 11 indicating high risk for alteration in skin integrity. Minimum Data Set assessment (MDS) dated 10 /26/2023 section C (Cognition) scored R3 with a BIMs score of 14 (cognitively intact), section GG (functional abilities and goals) coded R3 as being dependent on staff for all ADL care. Care plan initiated 2/01/2023 states: I have a potential for impairment to skin integrity r/t need for assistance with mobility and HX of pressure injury, interventions include Avoid skin-to-skin contact, Encourage, and assist with turning and repositioning at regular intervals every shift as tolerated and when requested for comfort, Minimize pressure over boney prominences, etc. Pressure ulcer care plan initiated 2/01/2023 stated that resident has pressure ulcer related to immobility, LLE amputation and fragile skin. Interventions include Encourage and assist with turning and repositioning at regular intervals every shift as tolerated and when requested for comfort. Wound care note dated 10/16/2023 documented a stage 3 pressure ulcer to the left ischium measuring 2.6 X 2.0 X 0.1cm, surface area 7.54cm, >25 days duration, 70% granulation tissue and 30% skin. Recommendation: turn side to side in bed every 1-2 hours if able, offload wound, reposition per facility protocol. 11/27/2023 at 3:38PM, V5 (LPN/Wound Care) said that the doctor saw R3 today and put in an order for zinc oxide, he was previously getting treatment with zinc oxide before he went to the hospital. V5 does not have any treatment orders since the resident came back from the hospital, he does not get daily dressing change because he does not allow her to do the dressing change. V5 said, what good will it do to have an order when he will not let me change his dressing? V5 added that the previous order was for three times a week and she cannot recall when resident went to the hospital or how long he has been at the facility without a wound care order, resident has a stage 3 facility acquired pressure ulcer that was identified on 9/22/2023. 11/28/2023 at 2:05PM, V2 (Director of Nursing) said that if a resident is refusing care, everybody should be involved, the doctor, family, IDT, and they are supposed to provide education, document in the progress note and it should be care planned. V2 confirmed that V2 has never been notified by anyone that R3 refuses ADL and wound care. There was no care plan noted that addressed R3 refusing care. Pressure ulcer policy revised 1/15/2018 states its purpose as to prevent and treat pressure sores/pressure injury. Guidelines: 2. Inspect the skin several times daily during bathing, hygiene, and repositioning measures, may use lotion on dry skin. 5. Turn dependent resident approximately every two hours or as needed and position resident with pillow or pads protecting bony prominences as indicated.

Based on interview and record review, the facility failed to ensure that proper precautions were in place during therapy session for a resident who was assessed as being at risk for falls. This failure affected one resident (R3) who had a witnessed fall during therapy, was transported to the hospital where she was diagnosed with a hip fracture, requiring a surgical intervention. Findings include: R3 is a [AGE] year-old female who was admitted to the facility on [DATE], with past medical history including, but not limited to encounter for other orthopedic aftercare, acquired absence of left leg below knee, type 2 diabetes mellitus with diabetic neuropathy, presence of left artificial hip, fracture of unspecified part of neck of femur, major depressive disorder, anxiety disorder, delusional disorder, etc. On 6/12/2023 at12:35PM, R3 was observed in her room, awake, alert and oriented and stated that she was having an occupational therapy session with a staff, she was required to pick up some socks that the staff dropped on the floor using a Reacher, R3 walked to the first clothing with a walker, wanted to pick up the socks and fell , R3 said she heard a pop and knew that she had broken something. This was her first time doing this exercise, she had a gait belt on her, but the staff did not hold on to the belt, she was just standing there. R3 said that she is used to a staff holding on to her gait belt and another staff following behind with her wheelchair when she is walking with her walker, she added that she is very upset because she was getting ready to go home before this happened, and this could have been avoided if the staff was holding on to her gait belt. Hospital record documented resident's diagnosis as hip fracture requiring operative repair. Facility reported incident dated 5/24/2023 documented in part, while resident was participating in her walking therapy, resident verbalized losing her balance and falling to the floor. She remained alert and oriented, was transferred to the hospital, admitted with the diagnosis of closed displaced fracture of the left femoral neck. Fall risk assessment dated [DATE] coded R3 with a score of 11 (at risk for falls). Minimum data set assessment (MDS) section G (functional) coded R3 as requiring supervision with one-person physical assist for transfer, bed mobility for bed mobility and transfers, and limited assistance with one-person physical assist for walk in room and walk in corridor. Care plan initiated 10/9/2022 stated that R3 have functional task performance deficit related to impaired mobility generalized weakness, left BKA, etc. Interventions include lying to sitting- supervision or touching assistance, sit to lying, supervision or touching assistance, sit to stand partial/moderate assistance, etc. Another care plan initiated 9/14/2021 states that R3is at risk for falls related to cognitive impairment, new BKA, generalized weakness, pain, impaired mobility, etc. Interventions include to encourage resident to participate in activities that promote exercise physical activity for strengthening and improved mobility, PT to evaluate and treat, therapy to screen. 6/13/2023 at 12:10PM, V5 (OT Assistant and Director of Rehab) said that she has been discussing discharge plan with R3, they went to the room to do some exercise of her (V6) tossing some socks on the floor and the resident are supposed to pick them up with a Reacher while standing/walking. R3 had a gait belt on and came to the location in her wheelchair. When R3 stood up with a walker, V5 said that she would have taken the wheelchair for safety reasons, this was her first time doing this exercise with the resident, she has walked in the past but always with a walker. V5 said that when they were doing the exercise, R3 stood up from her wheelchair, her left hand was on her walker, and she was holding the Reacher in her right hand. Resident reached and picked up a sock, tried to put it in a container and lost her balance and fell to her left side. when the resident bent down, she can't recall holding on to the gait belt. R3 cannot ambulate independently only with a walker, V5 also said that for residents that are unsteady, staff is supposed to follow them with a wheelchair, she has seen restorative staff do that with R3. V5 was asked what she could have done differently to prevent the incident and she said, possibly holding on to the gait belt or with staff following her with a wheelchair, at that time, I did not think it was necessary. Occupational therapy treatment encounter notes dated 5/24/2023. Presented by V5 documented the precautions for R3 as fall risk. On 6/13/2023 at 12:39PM, V4 (LPN) said that the day R3 had a fall, she was on the phone when a therapy staff was yelling that R3 was on the floor, she ran to the area and saw the resident on the floor, the therapy staff was standing by the resident who was lying on her right side. V4 said she don't know if the staff used it or not, she has seen the restorative staff walking with R3, there are usually 2 staff, one staff will hold on to the gait belt and the other staff will be following them with a wheelchair. 6/15/2023 at 1:16PM, V27 (Restorative aide) said that she is familiar with R3, have worked with her since August of last year, when they do a restorative activity with R3, if she is already sitting in her wheelchair, staff will put a gait belt around her waist and position the walker in front of the resident. They will assist resident to a standing position to hold on to the walker, when the resident starts to walk, one staff will hold on to the gait belt, and the other will be following behind with resident's wheelchair. V27 said that the purpose of the gait belt is for safety, to enable the staff ease resident to her wheelchair if she gets weak and need to sit down. She added that she is aware that resident wears a prosthetics on her left leg, will consider her a fall risk. 6/15/2023 at 1:30PM, V28 (Restorative aide) said that she was at work the day R3 had a fall with injury but R3 was in therapy at that time. She has worked with R3 as a restorative aide with R27, it is usually 2 staff with the resident when she is walking with her walker, one holding on to her gait belt and the other following with her wheelchair. V28 said that the restorative people would not do an activity that requires resident to pick something from the floor while standing, she considers R3 to be slightly unsteady and would expect staff to hold on to her gait belt. V28 said that R3 has never been assessed as not needing chair follow and they always take that precaution with her. Facility falls prevention program revised 11/21/2017 presented by V2 (DON) states in part in its purpose; to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk for falls to provide necessary supervision and assistive devices are utilized as necessary.

Based on observations, interviews, and records reviewed the facility failed to follow the care plan interventions, failed to implement effective interventions, and conduct root cause analysis to prevent or reduce the risk of falling. This affected 3 of 4 residents (R1, R4, and R6) all reviewed for falls and fall prevention. This failure resulted in R1 falling while trying to retrieve a television remote sustaining a laceration to the right ear. This failure also resulted in R6 rolling out of bed and sustained Impression: 6.2mm oblique transverse fracture of posterior superior corner of this C4 vertebral body which appears acute, and acute appearing impacted fracture to the nasal bone. The findings include: On 3/23/23 at 11:50AM the surveyor toured the units with V19, MDS/Care Plan/ Restorative Nurse. V19 presented a binder with list of residents at risk for falls. V19 presented the list on each unit, an undated copy was presented to the surveyor. R1 is listed with interventions low bed is not indicated for R1. R4 has bilateral side rails listed as an intervention. A.R1 is [AGE] years old with diagnosis including but not limited to Muscle Wasting and Atrophy, Obstructive and Reflux Uropathy, Spina Bifidia, Protein Calorie Malnutrition, Dysphagia, retention of Urine, Functional Quadriplegia, Hyperlipidemia, Hypertension, Convulsions, History of Traumatic Brain Injury, and History of Falling (onset date 10/29/22). On 3/23/ at 9:58AM V12, Licensed Practical Nurse (LPN), said on 2/20/23 R1 had just returned from the hospital that shift and he fell . V12 said the CNA said R1 was pointing at the television and she had tried to turn it on for him, but it did not turn on. V12 said R1 was trying to get the remote, I told R1 I was going to get him the remote and left the room. V12 said before I got the remote he rolled out of the bed. V12 said I can't remember if a floor mat was in use. V12 said R1 had a cut on his head and the Director of Nursing told her to send R1 back to the hospital. R1 had a fall on 2/20/23 at 5:55PM. Incident report documents R1 observed face down on the floor next to the bed. R1's progress notes dated 2/21/23 document the cause of R1's fall is he rolled out of bed or attempted a self transfer. R1 has traumatic brain injury and has moments of impulsive behaviors. Intervention update stated R1 moved closer to the nurses' station, ensure personal items are within reach on bedside table. The care plan dated 2/20/23 keep all needed items in reach. Care plan intervention dated 10/31/22 states anticipate and meet resident needs. Intervention dated 2/13/23 states bedside matt. Hospital records obtained dated 2/20/23 documents R1 underwent a laceration repair to his right ear. Laceration documented to measure length 1.5 x depth 2. R1 received 4 sutures. On 3/22/23 at 3:10PM V5, LPN, said on 3/14/23 the CNA called for him and said the CNA had been changing R1 in bed. V5 said the CNA said she was dropping him (R1) to the floor mat. V5 said R1 was in the bed receiving care when he fell . V5 said there was only 1 CNA in the room when R5 fell . V5 said R1 is always restless. V5 said R1 was a fall risk. V5 said R1 is able to move side to side, but it is not purposeful movements, he needs staff assistance to roll for care. On 3/28/23 at 10:38AM V24, CNA, said on 3/14/23 she was replacing R1's linens with him in the bed. V24 said R1 rolled over to the side and he kept going and rolled off the bed. V24 said I have not seen a fall list or symbols to indicate who is a fall risk. R1 incident report dated 3/14/23 at 8:50PM documents the CNA said R1 rolled onto his floor mat while the CNA was changing him. R1's progress notes dated 3/16/23 document the cause of R1's fall is muscle weakness and lack of coordination. Intervention R1 will be a 2 person assist. R1's care plan for bed mobility initiated on 1/16/23 reads R1 requires assistance with bed mobility. Intervention dated 1/16/23 documents Provide assistance of 2 persons disciplines listed RN, LPN, CNA, and RN. ADL self care performance deficit care plan intervention dated 3/15/23 notes extensive assist by 2 persons. Fall intervention dated 3/14/23 documents change to 2 person assist with bed mobility tasks. (This intervention has been in place since 1/16/23.) On 3/24/23 at 11:01AM V17, LPN, said when R1 fell on [DATE] I was entering the room and saw R1 on the floor, on the right side of the bed. V17 said R1 had been in the bed when she saw him about 10 minutes earlier and he was moving some in the bed. V17 said his sheet was off his feet, I repositioned his sheet and spoke with him. V17 said R1 looked like he had rolled out of his bed, all of his body was on the floor mat. V17 said R1 was incontinent when he fell . V17 said R1 is not able to turn himself purposefully, he has control of his upper body more than his lower. V17 said R1 can't just turn himself. Incident report dated 3/18/23 at 3:15PM for R1 documents he was on floor mat on the right side of the bed. On 3/24/23 at 10:10AM V7, RN, said on 3/20/23 the CNA called my attention and I saw R1 on the side of the bed sitting, we asked him what happened. V7 said R1 said he said he wanted to get up. V7 said R1 said he fell from the bed. V7 said R1 does not roll he scoots. V7 said I had seen R1 around 2:00PM he got his medication. When I saw R1 he was ok, he was calm, he was not restless and he was not hot. V7 said R1 was a fall risk. V7 said we don't have a fall list or a fall binder. R1's progress notes dated 3/20/23 at 2:02AM document R1 observed on the floor beside his bed. On 3/20/23 at 2:38PM R1 was observed sitting on the floor by his bed. The root cause of one fall documented at 2:28PM is documented R1 restless in bed and was hot causing him to move about in bed and due to muscle weakness and lack of coordination R1 rolled self to floor. The root cause documented at 2:31PM states poor coordination with increase restlessness. On 3/24/23 at 11:20AM V18, CNA, said R1 is known for falling. V18 said I was on my 15 min break and I was told R1 had fallen. V18 said for R1 to turn in the bed he is an extensive assist. V18 said she has seen R1 put his foot on the ground or put his feet on the side of the bed. On 3/24/23 at 11:33AM V19, MDS/Care Plan Restorative Nurse, said on 3/14/23 I assessed R1 and he can move his arms and legs purposefully. V19 said R1 can turn side to side. V19 said last week R1 was having seizures and was more restless. V19 said when a fall occurs the nurse will inform the family, doctor, and add an immediate intervention. V19 said the Inter-disciplinary Team (IDT) will discuss the fall and develop appropriate interventions from the root cause. V19 said the root cause is the reason for the fall. V19 said identifying the contributing factors that caused a fall will lead to new interventions. V19 said R1 is weak with muscle atrophy and spinal bifida. V19 said diagnosis alone are not the root cause of a fall. V19 said more than a diagnosis is needed for a root cause. V19 said once the intervention is added the staff needs to follow the intervention listed on the care plan. V19 said every wing has fall list with interventions. On 3/24/23 at 12:33PM V21, Director of Rehab, said when she was working with R1 he was not able to roll in the bed independently. V21 said I have not seen R1 being restless or moving around in the bed. R1's Physical Therapy Discharge Summaries are dated 2/7/23 and 3/22/23. On 3/29/23 at 10:06 AM V19, MDS/Care Plan Restorative, said if a resident is having behavior, like restlessness, rolling, kicking, then I may not leave the resident in their bed. V19 said I may get them in a chair and take them to activities or nurses station to get them to supervision. V19 said if a resident is having behaviors during the shift the nurse should assess the resident to find out why they are having the behavior. V19 said after a fall the new intervention should be listed on the care plan. V19 said the intervention is added to the care plan during the interdisciplinary team meeting. V19 said the root cause of R1's fall on 2/20/21 was that R1 was trying to get up by himself. V19 said there was not charting about a remote related to R1's fall. V19 said bed mobility includes rolling from side to side. V19 said if the staff is changing R1's bed linens and he is in the bed, there should be 2 persons with him, one on each side of the bed. The surveyor asked V19 if R1's care plan before 3/14/23 stated 1 or 2 person assistance for bed mobility. While reviewing the care plan V19 said I am confused the care plan included both 1 and 2 person assist. V19 discussed the restorative care plan for bed mobility that states 2 person assist. V19 said all disciplines should use 2 person assistance for R1's bed mobility. While reviewing R1's care plan V19 said according to the care plan R1 should have 2 person assistance when rolling. V19 said on 3/18/23 R1 rolled out of bed because he was hot. V19 said the root cause of R1's fall on 3/19/23 was because he was restless. V19 discussed the root cause of R1's 2 falls on 3/20/23. V19 said a bedside floor mat was provided to R1 on 2/13/23. V19 said I can't prove the interventions are preventing the falls. On 3/29/23 at 12:45PM V33, Physician, said I have told the staff they need to bring R1 out to the nurses station, it could help prevent a fall. V33 said people need to pay attention to R1 so he does not fall. R1's Fall Risk assessment dated [DATE] notes he is at risk for falls with a score of 14. B.R6 is [AGE] years old with diagnosis including, but not limited to Ataxia, Lack of Coordination, Dementia, Adult Failure to thrive, Seizures, Syncope and Collapse, Protein Calorie Malnutrition, Hyperlipidemia, Bipolar Disorder, Intellectual Disabilities, Hypertension, Atherosclerotic heart Disease, and Dysphagia. On 3/28/23 during two interviews at 10:38AM and 11:05AM V24, CNA, said R6 had been in the bed when she did rounds. V24 said R6 was able to move himself in the bed. V24 said R6 was a 1 person assist with cares if he was not being combative. V24 said R1 was not having any behaviors before the fall, he was fine. V24 said if R6 had been combative or aggressive that shift she would have reported to her nurse. V24 said the nurse, V31, called her to the room and V24 saw R6 on the floor and he was bleeding from the nose. V24 said R6 became combative while she was assisting to get him off the floor. V24, CNA, said R6 was fine before the fall. V24 said if R6 was trying to be up and down or getting up on his own from the bed, I would have assisted him into a chair and probably brought him up to the nurses station for supervision. On 3/28/23 at 1:07PM V31, Registered Nurse, said I had been in R6's room giving his room mate medications. I then went out to the hallway to prepare R6's medications. V31 said I heard a bump, so I ran in, and called for help. V31 said R6's room mate said R6 was restless and fell . V31 said when I saw R6 he was on the floor in a sitting position trying to get up. V31 said R6 was sent to the hospital. V31 said when R6 came back to the facility he had a cervical collar a healing wound on his nose. V31 said R6 will get restless when he is incontinent and move from side to side. V31 said when R6 fell she had no eye vision of the room. V31 said before the fall R31 was in bed with is eyes closed, head of the bed was slightly elevated, about 30 degrees, and only the head pillow was in use. V31 said R31 had no rails in use, no floor mat, no alarm, and the call light was not on. V31 said V24 and V25, both CNAs, got R6 off the floor. V31 said before the fall, I was not told R5 was kicking. V31 said the CNAs will let me know when the patient is restless and I will check them. V31 said the CNAs will report when they are being hit or abused by residents. V31 said R6 was a fall risk before he fell . Transfer Form notes on 2/8/23 R6 was transferred to the hospital for a nose laceration. Progress Notes dated 2/2/23 note R6 has weakness and extensive assistance with bed mobility. Progress Notes dated 2/8/23 note R6 observed on floor by his bed after a fall. Laceration on nose with swelling. Progress Notes dated 2/9/23 documents R6 admitted to hospital with diagnosis of Neck Injury. Progress Notes dated 2/9/23 notes the root cause of the fall was R6 flailing and combative. R6's Functional Status assessment dated [DATE] notes he required extensive assist for bed mobility and transfer. Cognition on 2/7/23 is documented to be severely impaired. R6's fall risk assessment documents him at risk for fall with a score of 13. R6's hospital records dated collection on 2/8/23 CT Spine Cervical. Impression: 6.2mm oblique transverse fracture of posterior superior corner of this C4 vertebral body which appears acute. Spine surgical consultation is advised as the injury appears to involve least 2 columns and may be unstable. CT examination of the facial bones collected 2/8/23 impression: nasal septum is sharply angulated as the anterior aspects for acute fracture with deviation of the anterior portions of the left increased from previous exam suggestive of acute fracture with comminuted acute appearing impacted fracture of the distal aspect of the nasal bone. C.R4 is [AGE] years old with diagnosis including but not limited to Hemiplegia/Hemiparesis, History of Traumatic Brain Injury, Schizoaffect Disorder, Lack of Coordination, Fusion of Spine - Cervical Region, Seizures, Cerebrovascular Disease, Dysphagia, Abnormal Posture, Disorder of Brain. On 3/22/23 at 10:22AM R4 interviewed. R4 said when I fell the CNA was standing where you are, surveyor on side of bed at about R4's knee level. R4 said the CNA said she was going to change me. R4 said the CNA pulled on the sheet under me and then I just rolled and fell off the bed. R4 was alert to name, month, and situation when surveyor spoke with him. The surveyor observed R4 had one halo rail to the top side of his left bed and no standard style side rails. On 3/22/23 at 10:32AM R4 observed in his bed with a halo on the top left side of his bed, no siderails. On 3/22/23 at 1:45PM V3, LPN, said R4 is alert and oriented times 2 to 3 and is sometimes forgetful. V3 said R4 knows what is going on.V3 said R4 does not complain about anything. V3 said R4 fell off the bed one time. V3 said following the fall R4 requested side rails, he did not have them before the fall. V3 said when R4 fell , I was called to the room by the CNA, V2. V3 said V2 said R4 was on the floor, when I walked in R4 was on his back on the floor. V3 said R4 said I fell and he did not say any description of the fall. V3 said V2 was in R4's room, but she did not witness the fall. V3 said V2 said she was in the restroom in the room. V3 said V2 said R2 was trying to do patient care, but V2 said she did not witness him fall. On 3/22/23 at 2:03PM V2, CNA, said on 3/5/23 I was preparing to change R4. V2 said R4 was flat in the bed. V2 said I had not touched R4 and was in the bathroom getting the towels and bucket ready for bathing. V2 said I heard it (sound) and ran out and saw R4 on the floor. V2 said R4 had not asked for anything before the fall. V2 said R4's bed had not been raised for patient care. V2 said she did not see R4 roll out of bed. During a second interview on 3/24/23 at 1:19PM V2 said R4 had fallen sometime after breakfast and before lunch. V2 said she had done rounds at the start of her shift and he did not need any care at that time. V2 said she served R4 his breakfast in bed and had set him up to eat. V2 said R4 is alert and knows what is going on. V2 said R4 sometimes leans to the side. V2 said when she provided R4 his breakfast she had to reposition him in the bed. V2 said someone else helped me reposition R4 before breakfast, V2 said she did not know the name of the person who helped her reposition R4. V2 said she is not sure who collected R4's breakfast tray on 3/5/23. V2 said she later entered R4's room and stood at his bedside when letting him know she would give him a bath. V2 said she then went into the bathroom. V2 said when she initially into the room R4 was flat on the bed. V2 said I am not sure how the bed was when I saw him on the floor. V2 said R4 always has a lift sheet under him. On 3/24/23 at 11:50AM the surveyor observed, with V19, R4 with bilateral half side rails on his bed. R4 said they put the side rails on the bed the day before yesterday. On 3/24/23 at 12:23PM V20, MDS Coordinator, said with assistance R4 can roll and he can move a little with staff assistance. V20 said R4 can move slightly on his own in the bed, but not without staff assistance. V20 said R4 cannot roll without staff touching him if he is flat in the bed. V20 said R4 is alert and oriented and does not lie. V20 said when R4 tells you things it is probably accurately. V20 said they said he rolled out the bed on 3/6/23. V20 said R4 is not impulsive. At 12:55PM V20 said R4's side rails should have been put in place following his fall. On 3/24/23 at 12:33PM V21, Director of Rehab, said R4 was on therapy caseload. V21 said R4 was not able to turn unassisted in the bed. V21 said R4 has no function in his legs, he is not able to move his knees or hips. V21 said hip and knee movement is used for turning. V21 said in my opinion R4 can not roll out of bed unassisted. V21 said R4 is not impulsive and is alert and oriented, not confused or forgetful. On 3/24/23 at 1:48PM V4, Social Services, said R4's cognition is a 10 out of 15, he is moderately impaired. On 3/29/23 at 10:06AM V19, said the root cause of R4's fall on 3/5/23 is that he rolled out of bed. V19 said the root cause does not say why R4 rolled out of bed, it needs to say more. R4'sDocumentation Survey Report for March 2023 notes on 3/3/23; 3/4/23; and 3/5/23 R4 required extensive to total assistance from staff for bed mobility. R4's cognitive assessment dated [DATE] notes a score of 10, moderately impaired. Incident report dated 3/5/23 notes R4 noted on the floor next to his bed. R4 noted to be oriented to place, time, person, and situation. Progress Notes dated 3/6/23 notes R4's root cause of the fall rolled out of bed. R4's Occupational Evaluation and Plan of Treatment dated 2/28/23-3/14/23 notes R4's bed mobility assessment roll left and right = substantial/maximal assistance. R4's care plan for Activity of Daily Living assistance initiated on 8/28/19 identifies intervention bed mobility, extensive, 2 person. R4's fall care plan identifies on 3/8/23 half side rails added to the bed. On 3/24/23 at 10:10AM V7, RN, said if a fall risk resident with weakness is restless will tell staff to get them up, bring them out for us to keep an eye on them to prevent a fall. R6's fall risk assessment dated [DATE] notes he is at risk for falls with a score of 12. The facility policy Incident and Accidents review date 4/7/19 states all incident/accident reports are reviewed, signed, and investigated. The facility fall prevention program review date 11/21/17 states the program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Care plan incorporated interventions are changed with each fall, as appropriate. Preventative measures. Safety interventions will be implemented for each resident identified at risk. Fall safety interventions mentioned include, keeping resident belongings in reach, nursing personal will be informed of residents who are at risk of falling.

Based on interview and record review, the facility failed to ensure that staff were aware of care plan interventions for residents at risk for falls and failed to ensure that a resident who required staff assistance with ambulation was provided with assistance while ambulating in the hallway. This failure affected two (R3, R4) of four residents reviewed for falls and resulted in R3 having an unwitnessed fall in room and being admitted to local hospital with a diagnosis of subdural hematoma and resulted in R4 having a fall while ambulating without staff assistance, which resulted in an inter trochanteric fracture, requiring surgical intervention. Findings include: R3 is a [AGE] year-old male who was admitted to the facility on [DATE], with medical history including but not limited to: Traumatic subdural hemorrhage without loss of consciousness, unsteadiness on feet, dysphagia oropharyngeal phase, weakness, other lack of coordination, history of falling, muscle wasting and atrophy hemiplegia and hemiparesis following unspecified cerebrovascular disease, etc. R3 was not at the facility at the time of the investigation, per progress note dated 2/3/2023, resident had an unwitnessed fall and was taken to the hospital by 911. Facility reportable dated 2/8/2023 stated that resident was observed lying on the floor in his room beside his bed facing the wall, rolled out of bed, time of incident 23:18PM. Same document stated that follow-up report from the hospital documented that CT of the head was positive for subdural hematoma, no significant midline shift. Fall risk assessment dated [DATE] scored R3 as (12) at risk for falls, interim care plan dated 1/31/2023 stated that resident is at risk for fall, goal; I will not sustain any serious injury through the review date, the only intervention was to follow facility fall protocol. Minimum Data Set (MDS) assessment dated [DATE] section C (cognitive) scored R3 with a BIMs score of 2 (severe cognitive impairment), G (functional) coded R3 as requiring extensive assistance with 2-person physical assist for bed mobility, transfer, dressing, toilet use and personal hygiene, extensive assistance with one-person physical assist for eating, locomotion in room and off unit. Section H (bowel and bladder) of the same assessment documented that R3 is always incontinent of bowel and bladder. 2/21/2023 at 3:29PM, V6 (LPN) said that the day R3 fell was her first time working with the resident, he was okay during medication pass, maybe around 5:00PM, then she heard a yelling from resident's room, ran to the room and saw resident on the floor by the bed facing the wall. She got resident up with the help of other staff, assessed resident and noticed an old wound to his hip, there was no bleeding, but resident was grimacing to touch as if he is in pain, cannot tell if resident hit his head. V6 said that she does not know if resident is a fall risk, or if he has any fall interventions, she did not get any report from the outgoing nurse, resident is a new admit, they may have given report, but she cannot remember. V6 said she is not sure how resident takes his medication or the type of assistance he needed from staff, resident was alert but confused by the time he was sent to the hospital, his vitals were okay, and his neuro check seems to be normal. V6 does not remember who the C.N.A was and not sure the last time herself or the C.N.A saw resident before the fall. R4 is a [AGE] year-old male who was admitted to the facility on ,d+[DATE].2021, with history of Chronic obstructive pulmonary disease, dysphagia oropharyngeal phase, cellulitis left lower limb, unsteadiness on feet, essential primary hypertension, other lack of coordination, etc. R4 was no longer at the facility; was sent to the hospital on 2/4/2023 for coffee ground emesis as documented in medical record. Review of facility reportable showed that R4 had a fall on 1/17/2023 at approximately 10:30am while ambulating in the hallway with a cane. R4 was sent to the hospital was admitted and treated for a right hip fracture. Hospital record dated 1/17/2023 states, patient is from nursing home after a fall, states he was walking and lost his balance, fell , complained of right hip pain, denies dizziness. X-ray show displaced inter trochanteric fracture. Resident had a surgical procedure (right hip pinning-ORIF) on 1/18/2023. R4 also had a documented fall in his room on 10/2/2022 while walking in the room and complained of pain to his left elbow as stated in resident's progress note. Fall risk assessment dated [DATE] score resident as 12, at risk for falls. MDS assessment dated [DATE] section G (functional) coded R4 as requiring supervision (oversight, encouragement, or cueing) with one- person physical assist for walk in room and supervision with set up for walk in corridor. R4 was also coded as requiring supervision to limited assistance with one-person physical assist for all other ADL cares. Fall care plan initiated 10/9/2018 and revised 7/7/2022 states that R4 is at risk for falls related to impaired mobility. Interventions include call light within reach, ensure resident is wearing appropriate footwear when ambulating or mobilizing with wheelchair, bed in low position at night, even floors free from clutter and spills, etc. ADL care plan initiated 1/8/2019, revised 10/6/2022 states that resident requires assistance with ADLS due to weakness and debility, under locomotion on unit; it states supervision, one person. On 2/22/2023 at 10:28AM, V9 (LPN) said that the day R4 fell , she was at the nursing station, the C.N.A called her stating that resident fell , she saw the resident on the floor in the hallway, in front of the conference room. R4 was going to an appointment, he was ambulating with a cane, 3 staff members were already with the resident before V9 got there, V9 assessed resident and noted a blood spot on his head, she cleaned the area and placed resident on a wheelchair. V9 was asked what type of assistance resident needed from staff and she said that he will ask for water sometimes, he does not look like a fall risk and V9 is not sure if resident has any fall precautions. At 12:40PM, V11 (MDS/Care Plan) said that nurses do a fall risk assessment on residents upon admission and after every fall, based on the score, the MDS will develop a fall care plan which have to be updated after every fall. V11 said that R4 ambulates with a cane; all residents are to be supervised by staff. The day R4 fell , V11 was told that R4 was supposed to go to an appointment, something happened, and he was going back to his room when he fell . V11 added that she is not sure if someone was with the resident when he fell ; she was not present at the time. At 2:06PM, V12 (ADON) said that she has worked at the facility for a few months. For resident care needs or those that are risk for falls, communication is done in stand up and during shift change, the precautions with interventions in place should be communicated to the C.N.A. As by the nurses. V12 also said that resident's needs are also documented in the task section of the medical record. Document presented by V1 (Administrator) titled, Fall Prevention Program (revision date 11/21/2017), states: Purpose .to assure safety of all residents in the facility when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary .Standards .the admitting nurse and assigned C.N.A are responsible for initiating safety precautions at the time of admission. All assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained.

Based on observation, interview. and record review, the facility failed to ensure that staff provide timely incontinence care in a manner consistent hygiene standards of practice for residents dependent on staff for care. This failure applied to six (R1, R4, R5, R6, R7, and R8) of seven residents reviewed for incontinence care and resulted in R1 requiring interventions for newly acquired MASD (moisture associated dermatitis); R6 requiring current treatment for a facility acquired UTI (urinary tract infection); and R7 has experienced emotional distress as a result of having to wait for an extended amount of time to be provided with incontinence care. Findings include: R1 is a [AGE] year-old female who has resided at the facility since 2020, with past medical history of other specified arthritis, chronic obstructive pulmonary disease, abnormal posture, schizoaffective disorder bipolar type, other benign neoplasm of skin, morbid severe obesity due to excess calories, essential primary hypertension, iron deficiency anemia, etc. 1/23/2023 at 12:45PM, observed R1 in her room in bed, awake, alert and oriented x 3, stated she does not get changed very often; they will tell her that they are coming back but never do. R1 said that when she gets cleaned, staff do not clean inside vagina, they just clean around the area. R1 said that staff get upset when she has a bowel movement because it is loose and sticky; she even refuses her stool softener because she does not need them, though she takes Norco for pain, but she never gets constipated. R1 said that she has not been changed today, the last time she was changed was yesterday. Surveyor asked R1 if it is okay to observe her incontinence care and she said yes. At 1:58PM, observed incontinence care for R1 with V4 (CNA) and noted resident's incontinence brief visibly soaked with urine and brown in color, resident's bed sheet was also noted very wet with brown colored marks from dried urine all around the sheet. An open area was noted to the resident's sacral area actively bleeding. V4 (CNA) said that due to the number of people they need to care for, sometimes it takes a while before getting to some of the residents. V4 was observed wiping resident's front and vaginal area with a gloved hand using one wet towel, after removing the wet incontinence brief and sheets, then wiped resident's bottom area with another wet towel, removed the wet incontinence brief and sheets and proceeded to put clean sheets and a clean incontinence brief on the resident without changing her gloves or performing any hand hygiene. V4 also applied Vaseline and powder all over resident's body with the same pair of gloves. When V4 was about to put a clean brief on R1, R1 complained of itching in her vaginal area. V4 told R1 that she must go and get another towel. V4 covered R1 with a clean sheet, brought a clean towel and wiped resident's vaginal area and some dark/brownish substances that looked like bowel movement was noted on the towel. V4 said that this must have been left there from before because the resident does not have any bowel movement at this time. 1/24/2023 at 11:16AM, R1 was observed again in her room, awake and alert and states that she was not changed again last night, the staff did not change her because they said that she ran out of incontinence briefs. R1 stated that the facility provides the incontinence briefs but they keep a particular size for her in her drawer, but some staff will use them for her roommate. R1 said that she is wet right now and just had a bowel movement. 1/24/2023 at 12:25PM, observed staff providing incontinence care to R1, V8 (CNA) said that she is the assigned staff and had not yet changed R1 today. At this time, observed with V8 that R1 had a bowel movement and her brief was heavily soiled. V8 was not sure if R1 was changed last night. V8 asked R1 if she was changed last night and she said no. R1 was still noted with an open area in her bottom that was actively bleeding. At 12:30PM, V7 (Nurse Consultant) said that R1 (currently) has a laceration on her left buttocks due to moisture. V7 was asked what the cause of the moisture was and she said it might be urine. V7 added that she will apply some barrier cream to resident now and call the doctor for some orders. Review of physician orders for R1 shows an order to apply dermaseptin to gluteal folds q (every) shift and each incontinent care every shift for incontinent care and as needed, order date 1/24/2023. Care plan dated 7/11/2018 and revised 7/08/2022 states that R1 is incontinent of bowel and bladder. Interventions include to check resident frequently and as needed for incontinence, change incontinent brief frequently and as needed, etc. Facility MDS section C (cognitive pattern) coded R1 with a BIMS score of 13, section G (functional) coded R1 as requiring extensive assistance with two persons physical assist for dressing toilet use bed mobility and personal hygiene. Section H of the same MDS coded R1 as always incontinent for bowel and bladder. 1/23/2023 at 12:35PM R6 was observed in her room awake and alert, stated that she is doing okay, she was asked if she has been changed and she said no, the last time she was changed was yesterday. R6 said that this happens most of the time, she finishes eating lunch before being changed. At 12:50PM, observed incontinence care for R6 with V3 (CNA), resident was noted with an incontinence brief that is saturated with urine and brown in color with a very strong smell. R6 was noted to be lying on top of two draw sheets, which were wet. Staff wiped resident's frontal area with a wet cloth, and wiped the back area with a wet cloth, did not clean the labial area. V3 proceeded to put clean linens and a clean incontinence brief on resident without changing her gloves or performing any type of hand hygiene. V3 added that she still has some people to change, she is not sure how many. Review of R6's medical record shows a urine culture dated 1/22/2023 with a positive result for ESBL, physician orders for R6 shows that she is currently receiving Bactrim DS Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim), give 1 tablet by mouth every 12 hours for UTI for 7 Days. Review of medical records showed the following care plan initiated 1/8/2020, I have had functional, bladder and bowel incontinence due to Impaired mobility, generalized weakness. Interventions include Brief use: resident uses, disposable briefs. Change frequently and prn. Check resident frequently and as needed for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes, etc. MDS assessment dated [DATE] coded R6 as requiring extensive assistance with 2 persons physical assist for dressing, toilet use and personal hygiene, section H coded resident as always incontinent of bowel and bladder. 1/23/2023 at 12:55PM, R7 was observed in the same room with R1, awake and alert and stated that she is waiting to get up, she was left in bed since Friday, she has not been changed either and is wet right now. At 1:30PM, observed incontinence care for R7 with V3 (CNA) and V4 (CNA) and noted resident with what looked like like two incontinence briefs, when surveyor asked if resident was wearing two briefs, V3 said that it is an inserted pad, both the pad and brief were visibly saturated with urine, brown in color and has a strong smell. R7 was asked the last time she was changed, and she said, Yesterday afternoon, the night shift staff here don't do sh**, they don't even come into the room. R7 added that she wears the insert in addition to her brief because she is a heavy wetter. V3 provided the incontinence care while V4 was assisting with holding the resident because resident is a two person assist. V3 removed the dirty brief and linen, wiped the resident with a wet cloth and proceeded to apply a clean brief, some powder and deodorant and clean linens to the bed without changing her gloves or performing any type of hand hygiene. Care plan dated 3/5/2021 and revised 5/28/2022 states that R7 is incontinent of bowel and bladder, interventions include check resident as required for incontinence, wash, rinse, and dry perineum after incontinence episode. Facility MDS assessment section G (functional status) coded R7 as requiring extensive assistance with two persons physical assist for bed mobility, dressing, toilet use and personal hygiene, section H coded R7 as always incontinent of bowel and bladder. 1/24/23 at 1:00PM while surveyor was interviewing V5 (CNA), R7 approached and asked V5 when she could be changed because she had been waiting for a while. V5 informed R7 that she was busy but would find another staff to assist when possible because R7 is a two person staff assist. R7 said to surveyor, I asked a little while before and I was told I couldn't get changed right away. At 2:17PM R7 approached another surveyor in the hall and said, I am not happy. I have a feeling that they'll make me wait until after 3'o clock when the next shift comes to be changed. It has happened before. I haven't been changed since 6am today when they got me up and put me in the chair. R7 began crying and said, I know I am a two person assist and she needs help but why is that my problem? Why should I have to suffer and wait? V5 came in and changed both of my roommates, what about me? When I have a bowel movement it goes up into my pubic hair and vagina because I'm sitting and can't get up because I'm paralyzed. It's gotten to the point where I want to go somewhere else. The nurses don't help either. I ask the nurses for help and they say they don't know where the CNA is. At 2:33PM V15 (LPN) informed surveyor that V5 (CNA) told her that she had been waiting to be changed 15 minutes prior and did not know she had been waiting long before that. V15 said, the nurses help when we have time, but right now, I have been running around like crazy because we are short a nurse and two CNA's and it's the end of the shift. At 2:34PM, V5 (CNA) was heard behind the nurse's station loudly saying to another CNA, I don't have no help! I shouldn't have to beg nobody to help me V5 and the other CNA were then observed telling R7 they would change her. R4 is a [AGE] year-old male who was admitted to the facility 12/7/22 with diagnoses that include Multiple Sclerosis and paraplegia. According to R4's health record, MDS (Minimum Data Set) dated 1/3/23 indicates R4 has full cognition and requires extensive 2-person physical assistance with bed mobility, extensive one person assist with personal hygiene and is always incontinent of bowel and bladder function. According to wound care notes R4 arrived to the facility with multiple wounds and was initially assessed by V19 Wound Care Physician on 12/12/22. V19 weekly assessment dated [DATE] indicated all wounds present on admission were resolved. On 1/18/23 the facility identified two newly acquired wounds: a Stage 3 Pressure Ulcer to the left lateral lower leg, and Stage 3 pressure ulcer to the right medial knee. On 1/23/23 at 12:52PM V5 and V9 CNAs (Certified Nursing Assistants) were observed providing incontinence care for R4. Before securing the incontinence brief, V5 placed an additional folded brief inside the front and said, I put an extra brief because sometimes R4 urinates so much it soaks the brief. No one told me to do this, this is just something that I do. On 1/23/23 at 1:08PM, R4 was observed alert and oriented in bed and said during an interview, I get changed at least once per shift. I urinate more than that but they come when they come. Sometimes I wait so long for them to come that I have to ask or pull my light which also takes a while for them to answer. R4's health record contained a care plan for incontinence initiated 12/9/22 and revised 12/14/22 which stated check R4 s required for incontinence; Wash, rinse, and dry perineum; Change clothing as needed after incontinence episodes. 1/24/2023 at 11:10AM, observed incontinence care for R8 with V9 (CNA) who tried to wash resident up in her bed. R8 was alert with confusion and continuously asking unrelated questions. V8 wiped resident's face with one end of a bath towel soaked in water, used the same towel to wipe resident's upper body and went down to wiping the vaginal area with the same towel. Surveyor asked V8 if she is using only one towel to wash and dry the entire body and she said yes. V9 was asked if that is the standard or that they do not have any towels and she said sometimes they don't have enough towels. Facility Minimum Data Set (MDS) assessment dated [DATE] coded R8 as requiring extensive assistance with one-person physical assist for transfer, bed mobility, dressing, toilet use and personal hygiene. Care plan for R8 dated 2/22/2022, revised on 10/11/2022 states that resident is incontinent of bowel and bladder related to moderate to severe cognitive impairment and impaired mobility. Interventions include but not limited to provide peri care after each incontinent episode, apply barrier cream after each incontinent episode, etc. R5 is an [AGE] year-old male admitted to the facility 4/20/2012 with diagnoses that include cerebral infarction with hemiplegia and hemiparesis affecting left side, dysphagia, dementia, and contracture of the left hand. According to R5's medical records, MDS dated [DATE] indicated R5 has mild cognitive deficits with a BIMS (Brief Interview for Mental Status) score of 09. R5 is incontinent of bowel and bladder and requires extensive 2-person assistance with bed mobility, transfers, and hygiene. On 1/23/23 at 1:17PM R5 was observed in bed alert and oriented. R5 said during an interview, I have to use the brief to relive myself. Sometimes I must wait an hour or more which is quite a time to sit in urine or feces. I like to be clean, and I just have to sit and wait. R5's health record contained a care plan for incontinence initiated 10/28/21 and revised 1/19/22 stating that R5 is incontinent f bowel and bladder and requires staff assistance with toileting task due to diagnoses of Parkinson's, Arthritis, Neuropathy and Hemiplegia. Care plan Interventions include checking R5 as required for incontinence; Wash, rinse, and dry perineum; Change clothing as needed after incontinence episodes. 1/24/2023 at 3:54PM, V2 (ADON) said that she has not provided any in-services on incontinence care since she started at the facility about six weeks ago. Her expectation from staff during incontinence care is for them to clean residents using proper cleaning solution, making sure they are cleaning from front to back. If providing a bath, they are supposed to use soap and water but for changing incontinent briefs, a wet wipe is okay. V2 said that staff should have at least two towels when providing ADL care, one for the face and the other for the body. When providing incontinence care for a female resident, staff are supposed to clean from front to back as well as the vaginal/labial area. Staff are supposed to perform hand hygiene before and after care and between soiled and clean surfaces. Residents should be checked and changed every two hours and as needed. A resident not having any incontinence briefs in the room should not be an excuse for not changing a resident, the facility provides the briefs, and they always have some in storage. V2 said that MASD (moisture associated dermatitis) on an incontinent resident is probably from being wet and soiled all the time. Incontinent care policy dated 11/28/2012 and revised 1/16/2018 provided by V1 (Administrator) stated its purpose as to prevent excoriation and skin breakdown, discomfort and maintain dignity. Under guidelines, the policy states that incontinent residents will be checked periodically I accordance with the assessed incontinent episodes or every two hours and provided perineal and genital care after each episode. Under procedure, the policy states in part; soap one cloth at a time to wash genitalia using a clean part of the cloth for each swipe, wash the labia firs, then groin areas, in the female resident, separate labia, wash with strokes .each side separately with a clean cloth or clean .keep labia separated with one hand. Clean/rinse inner/upper thigh areas to remove urine moisture, change gloves and perform hand hygiene, apply clean incontinence brief or incontinence pad, do not touch any clean surfaces while wearing soiled gloves, etc.

Based on observation, interview, and record review, the facility failed to follow their pressure ulcer prevention policy by failing to ensure that interventions were carried out, including turning and repositioning, in order to prevent residents from developing new pressure ulcers while in the facility. This failure applied to three (R3, R4, and R5) of three residents reviewed for pressure ulcers and resulted in (R3, R4, and R5) developing multiple stage 3 pressure ulcers while in the facility. Findings include: R3 is a [AGE] year old male who was admitted to the facility 9/3/21 with diagnoses that include Cerebral Infarction, Adult Failure to Thrive, Dementia and Dysphagia. According to R3's health record, MDS (Minimum Data Set) dated 1/9/23 notes R3 to have impaired cognition as with a BIMS (Brief Interview for Mental Status) score of 07. The MDS also indicated R3 required Extensive two person staff assist for bed mobility, toileting, and hygiene. On 1/23/23 at 12:36PM, R3 was observed sleeping in bed, presented with contractions of both legs and a urinary catheter hanging from the bed frame. Surveyor periodically observed R3 between 12:36PM and 3:15PM and R3 was noted to be in the same position as evidenced by position of head, body positioning wedge and urinary catheter bag which had not been emptied. Medical records indicate R3 is seen weekly by V19 Wound Care Physician and is being treated for a Stage 4 pressure wound on the right hip identified in the facility 11/15/22, Stage 3 pressure wound to the left hip identified in the facility 12/21/22 and Stage 3 pressure wound to the right lateral fifth toe identified in the facility 1/16/23. According to most recent Wound Care Physician assessment dated [DATE], left hip and right toe are healing and the right hip wound did not change in status. On 1/26/23 at 2:29PM, V19 Wound Care Physician said, some of the wounds I am currently treating for R3 are healing based on my notes so I wouldn't consider them to be unavoidable. On 1/24/23 at 2:07PM V8 CNA (Certified Nursing Assistant) said, I work with R3 regularly during the morning shift. He has wounds and should be repositioned every two hours because he has sores. When we are short staffed, it can be hard to turn and change every body within that time. R3's care plan for alterations in skin integrity initiated 10/9/22 and revised 1/19/23 include interventions that state: Follow facility policies/protocols for the prevention/treatment of skin breakdown; Assist and encourage turning and repositioning every two hours as tolerated every shift. R4 is a [AGE] year old male who was admitted to the facility 12/7/22 with diagnoses that include Multiple Sclerosis and paraplegia. According to R4's health record, MDS (Minimum Data Set) dated 1/3/23 indicates R4 has full cognition and requires extensive two person physical assistance with bed mobility, extensive one person assist with personal hygiene and is always incontinent of bowel and bladder function. According to wound care notes R4 arrived to the facility with multiple wounds and was initially assessed by V19 Wound Care Physician on 12/12/22. V19 weekly assessment dated [DATE] indicated all wounds present on admission were resolved. On 1/18/23 the facility identified two newly acquired wounds: a Stage 3 Pressure Ulcer to the left lateral lower leg, and Stage 3 pressure ulcer to the right medial knee. On 1/23/23 at 1:08PM, R4 was interviewed, and said, I developed new sores on my legs while in the facility. I can't turn on my own because I can't move my lower body. I need help from staff to turn and sometimes I'm in the same position for a while. Sometimes, I don't see a CNA regularly or every two hours in the evening or night. Care Plan for R4 initiated 12/14/22 revised 12/19/22 state R4 has potential for impairment to skin integrity related to impaired mobility and requires turning and repositioning frequently and as needed. R5 is an [AGE] year old male admitted to the facility 4/20/2012 with diagnoses that include cerebral infarction with hemiplegia and hemiparesis affecting left side, dysphagia, dementia and contracture of the left hand. According to R5's medical records, MDS dated [DATE] indicated R5 has mild cognitive deficits with a BIMS (Brief Interview for Mental Status) score of 09. R5 is incontinent of bowel and bladder and requires extensive two person assistance with bed mobility, transfers and hygiene. According to R5's wound care notes, the facility identified a Stage 3 pressure ulcer to the left lateral calf on 11/7/22. On 1/23/23 at 1:17PM R5 said, I have a pressure sore on my left leg that they change every day. I've had it for a while, and they say it is healing but I can't see it. I have occasional pain, and a while back the pain was too much for me about a month ago. It would sometimes prevent me from wanting to get up out of bed. The CNA's don't help me to change position and most of the time I lay in the same spot. R5 Care plan for Impaired Skin integrity initiated 7/21/22 and revised 7/28/22 include interventions that states, assist with turning and repositioning as needed. On 1/24/23 at 3:54PM V2 Assistant Director of Nursing said, CNAs should be turning and repositioning dependent residents every two hours and charting once per shift. The (electronic record) where they chart does not prompt every two hours, so it is unclear if the task is completed. I am not aware of any where else they would document this. I wouldn't know that turning and repositioning is happening if it isn't documented. Facility policy titled, Pressure Ulcer Prevention (revised 1/15/18) states in part: The purpose to prevent and treat pressure sores/pressure injury. 3. Turn dependent resident approximately every two hours or as needed and position resident with pillow or pads protecting bony prominences as indicated.

Based on observation, interview, and record review, the facility failed to have sufficient staff to provide necessary care and services to residents required to meet their plan of care. This failure applied to six (R1, R4, R5, R6, R7, and R8) of seven residents reviewed for nursing care and resulted in R1 requiring interventions for newly acquired MASD (moisture associated dermatitis); R6 requiring current treatment for a facility acquired UTI (urinary tract infection); and R7 has experienced emotional distress as a result of having to wait for an extended amount of time to be provided with incontinence care. Findings include: R1 is a [AGE] year-old female who has resided at the facility since 2020, with past medical history of other specified arthritis, chronic obstructive pulmonary disease, abnormal posture, schizoaffective disorder bipolar type, other benign neoplasm of skin, morbid severe obesity due to excess calories, essential primary hypertension, iron deficiency anemia, etc. 1/23/2023 at 12:45PM, observed R1 in her room in bed, awake, alert and oriented x 3, stated she does not get changed very often; they will tell her that they are coming back but never do. R1 said that when she gets cleaned, staff do not clean inside vagina, they just clean around the area. R1 said that staff get upset when she has a bowel movement because it is loose and sticky; she even refuses her stool softener because she does not need them, though she takes Norco for pain, but she never gets constipated. R1 said that she has not been changed today, the last time she was changed was yesterday. Surveyor asked R1 if it is okay to observe her incontinence care and she said yes. At 1:58PM, observed incontinence care for R1 with V4 (CNA) and noted resident's incontinence brief visibly soaked with urine and brown in color, resident's bed sheet was also noted very wet with brown colored marks from dried urine all around the sheet. An open area was noted to the resident's sacral area actively bleeding. V4 (CNA) said that due to the number of people they need to care for, sometimes it takes a while before getting to some of the residents. V4 was observed wiping resident's front and vaginal area with a gloved hand using one wet towel, after removing the wet incontinence brief and sheets, then wiped resident's bottom area with another wet towel, removed the wet incontinence brief and sheets and proceeded to put clean sheets and a clean incontinence brief on the resident without changing her gloves or performing any hand hygiene. V4 also applied Vaseline and powder all over resident's body with the same pair of gloves. When V4 was about to put a clean brief on R1, R1 complained of itching in her vaginal area. V4 told R1 that she must go and get another towel. V4 covered R1 with a clean sheet, brought a clean towel and wiped resident's vaginal area and some dark/brownish substances that looked like bowel movement was noted on the towel. V4 said that this must have been left there from before because the resident does not have any bowel movement at this time. 1/24/2023 at 11:16AM, R1 was observed again in her room, awake and alert and states that she was not changed again last night, the staff did not change her because they said that she ran out of incontinence briefs. R1 stated that the facility provides the incontinence briefs but they keep a particular size for her in her drawer, but some staff will use them for her roommate. R1 said that she is wet right now and just had a bowel movement. 1/24/2023 at 12:25PM, observed staff providing incontinence care to R1, V8 (CNA) said that she is the assigned staff and had not yet changed R1 today. At this time, observed with V8 that R1 had a bowel movement and her brief was heavily soiled. V8 was not sure if R1 was changed last night. V8 asked R1 if she was changed last night and she said no. R1 was still noted with an open area in her bottom that was actively bleeding. At 12:30PM, V7 (Nurse Consultant) said that R1 (currently) has a laceration on her left buttocks due to moisture. V7 was asked what the cause of the moisture was and she said it might be urine. V7 added that she will apply some barrier cream to resident now and call the doctor for some orders. Review of physician orders for R1 shows an order to apply dermaseptin to gluteal folds q (every) shift and each incontinent care every shift for incontinent care and as needed, order date 1/24/2023. Care plan dated 7/11/2018 and revised 7/08/2022 states that R1 is incontinent of bowel and bladder. Interventions include to check resident frequently and as needed for incontinence, change incontinent brief frequently and as needed, etc. Facility MDS section C (cognitive pattern) coded R1 with a BIMS score of 13, section G (functional) coded R1 as requiring extensive assistance with two persons physical assist for dressing toilet use bed mobility and personal hygiene. Section H of the same MDS coded R1 as always incontinent for bowel and bladder. 1/23/2023 at 12:35PM R6 was observed in her room awake and alert, stated that she is doing okay, she was asked if she has been changed and she said no, the last time she was changed was yesterday. R6 said that this happens most of the time, she finishes eating lunch before being changed. At 12:50PM, observed incontinence care for R6 with V3 (CNA), resident was noted with an incontinence brief that is saturated with urine and brown in color with a very strong smell. R6 was noted to be lying on top of two draw sheets, which were wet. Staff wiped resident's frontal area with a wet cloth, and wiped the back area with a wet cloth, did not clean the labial area. V3 proceeded to put clean linens and a clean incontinence brief on resident without changing her gloves or performing any type of hand hygiene. V3 added that she still has some people to change, she is not sure how many. Review of R6's medical record shows a urine culture dated 1/22/2023 with a positive result for ESBL, physician orders for R6 shows that she is currently receiving Bactrim DS Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim), give 1 tablet by mouth every 12 hours for UTI for 7 Days. Review of medical records showed the following care plan initiated 1/8/2020, I have had functional, bladder and bowel incontinence due to Impaired mobility, generalized weakness. Interventions include Brief use: resident uses, disposable briefs. Change frequently and prn. Check resident frequently and as needed for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes, etc. MDS assessment dated [DATE] coded R6 as requiring extensive assistance with 2 persons physical assist for dressing, toilet use and personal hygiene, section H coded resident as always incontinent of bowel and bladder. 1/23/2023 at 12:55PM, R7 was observed in the same room with R1, awake and alert and stated that she is waiting to get up, she was left in bed since Friday, she has not been changed either and is wet right now. At 1:30PM, observed incontinence care for R7 with V3 (CNA) and V4 (CNA) and noted resident with what looked like like two incontinence briefs, when surveyor asked if resident was wearing two briefs, V3 said that it is an inserted pad, both the pad and brief were visibly saturated with urine, brown in color and has a strong smell. R7 was asked the last time she was changed, and she said, Yesterday afternoon, the night shift staff here don't do sh**, they don't even come into the room. R7 added that she wears the insert in addition to her brief because she is a heavy wetter. V3 provided the incontinence care while V4 was assisting with holding the resident because resident is a two person assist. V3 removed the dirty brief and linen, wiped the resident with a wet cloth and proceeded to apply a clean brief, some powder and deodorant and clean linens to the bed without changing her gloves or performing any type of hand hygiene. Care plan dated 3/5/2021 and revised 5/28/2022 states that R7 is incontinent of bowel and bladder, interventions include check resident as required for incontinence, wash, rinse, and dry perineum after incontinence episode. Facility MDS assessment section G (functional status) coded R7 as requiring extensive assistance with two persons physical assist for bed mobility, dressing, toilet use and personal hygiene, section H coded R7 as always incontinent of bowel and bladder. 1/24/23 at 1:00PM while surveyor was interviewing V5 (CNA), R7 approached and asked V5 when she could be changed because she had been waiting for a while. V5 informed R7 that she was busy but would find another staff to assist when possible because R7 is a two person staff assist. R7 said to surveyor, I asked a little while before and I was told I couldn't get changed right away. At 2:17PM R7 approached another surveyor in the hall and said, I am not happy. I have a feeling that they'll make me wait until after 3'o clock when the next shift comes to be changed. It has happened before. I haven't been changed since 6am today when they got me up and put me in the chair. R7 began crying and said, I know I am a two person assist and she needs help but why is that my problem? Why should I have to suffer and wait? V5 came in and changed both of my roommates, what about me? When I have a bowel movement it goes up into my pubic hair and vagina because I'm sitting and can't get up because I'm paralyzed. It's gotten to the point where I want to go somewhere else. The nurses don't help either. I ask the nurses for help and they say they don't know where the CNA is. At 2:33PM V15 (LPN) informed surveyor that V5 (CNA) told her that she had been waiting to be changed 15 minutes prior and did not know she had been waiting long before that. V15 said, the nurses help when we have time, but right now, I have been running around like crazy because we are short a nurse and two CNA's and it's the end of the shift. At 2:34PM, V5 (CNA) was heard behind the nurse's station loudly saying to another CNA, I don't have no help! I shouldn't have to beg nobody to help me V5 and the other CNA were then observed telling R7 they would change her. R4 is a [AGE] year-old male who was admitted to the facility 12/7/22 with diagnoses that include Multiple Sclerosis and paraplegia. According to R4's health record, MDS (Minimum Data Set) dated 1/3/23 indicates R4 has full cognition and requires extensive 2-person physical assistance with bed mobility, extensive one person assist with personal hygiene and is always incontinent of bowel and bladder function. According to wound care notes R4 arrived to the facility with multiple wounds and was initially assessed by V19 Wound Care Physician on 12/12/22. V19 weekly assessment dated [DATE] indicated all wounds present on admission were resolved. On 1/18/23 the facility identified two newly acquired wounds: a Stage 3 Pressure Ulcer to the left lateral lower leg, and Stage 3 pressure ulcer to the right medial knee. On 1/23/23 at 12:52PM V5 and V9 CNAs (Certified Nursing Assistants) were observed providing incontinence care for R4. Before securing the incontinence brief, V5 placed an additional folded brief inside the front and said, I put an extra brief because sometimes R4 urinates so much it soaks the brief. No one told me to do this, this is just something that I do. On 1/23/23 at 1:08PM, R4 was observed alert and oriented in bed and said during an interview, I get changed at least once per shift. I urinate more than that but they come when they come. Sometimes I wait so long for them to come that I have to ask or pull my light which also takes a while for them to answer. R4's health record contained a care plan for incontinence initiated 12/9/22 and revised 12/14/22 which stated check R4 s required for incontinence; Wash, rinse, and dry perineum; Change clothing as needed after incontinence episodes. 1/24/2023 at 11:10AM, observed incontinence care for R8 with V9 (CNA) who tried to wash resident up in her bed. R8 was alert with confusion and continuously asking unrelated questions. V8 wiped resident's face with one end of a bath towel soaked in water, used the same towel to wipe resident's upper body and went down to wiping the vaginal area with the same towel. Surveyor asked V8 if she is using only one towel to wash and dry the entire body and she said yes. V9 was asked if that is the standard or that they do not have any towels and she said sometimes they don't have enough towels. Facility Minimum Data Set (MDS) assessment dated [DATE] coded R8 as requiring extensive assistance with one-person physical assist for transfer, bed mobility, dressing, toilet use and personal hygiene. Care plan for R8 dated 2/22/2022, revised on 10/11/2022 states that resident is incontinent of bowel and bladder related to moderate to severe cognitive impairment and impaired mobility. Interventions include but not limited to provide peri care after each incontinent episode, apply barrier cream after each incontinent episode, etc. R5 is an [AGE] year-old male admitted to the facility 4/20/2012 with diagnoses that include cerebral infarction with hemiplegia and hemiparesis affecting left side, dysphagia, dementia, and contracture of the left hand. According to R5's medical records, MDS dated [DATE] indicated R5 has mild cognitive deficits with a BIMS (Brief Interview for Mental Status) score of 09. R5 is incontinent of bowel and bladder and requires extensive 2-person assistance with bed mobility, transfers, and hygiene. On 1/23/23 at 1:17PM R5 was observed in bed alert and oriented. R5 said during an interview, I have to use the brief to relive myself. Sometimes I must wait an hour or more which is quite a time to sit in urine or feces. I like to be clean, and I just have to sit and wait. R5's health record contained a care plan for incontinence initiated 10/28/21 and revised 1/19/22 stating that R5 is incontinent f bowel and bladder and requires staff assistance with toileting task due to diagnoses of Parkinson's, Arthritis, Neuropathy and Hemiplegia. Care plan Interventions include checking R5 as required for incontinence; Wash, rinse, and dry perineum; Change clothing as needed after incontinence episodes. 1/24/2023 at 3:54PM, V2 (ADON) said that she has not provided any in-services on incontinence care since she started at the facility about six weeks ago. Her expectation from staff during incontinence care is for them to clean residents using proper cleaning solution, making sure they are cleaning from front to back. If providing a bath, they are supposed to use soap and water but for changing incontinent briefs, a wet wipe is okay. V2 said that staff should have at least two towels when providing ADL care, one for the face and the other for the body. When providing incontinence care for a female resident, staff are supposed to clean from front to back as well as the vaginal/labial area. Staff are supposed to perform hand hygiene before and after care and between soiled and clean surfaces. Residents should be checked and changed every two hours and as needed. A resident not having any incontinence briefs in the room should not be an excuse for not changing a resident, the facility provides the briefs, and they always have some in storage. V2 said that MASD (moisture associated dermatitis) on an incontinent resident is probably from being wet and soiled all the time. Incontinent care policy dated 11/28/2012 and revised 1/16/2018 provided by V1 (Administrator) stated its purpose as to prevent excoriation and skin breakdown, discomfort and maintain dignity. Under guidelines, the policy states that incontinent residents will be checked periodically I accordance with the assessed incontinent episodes or every two hours and provided perineal and genital care after each episode. Under procedure, the policy states in part; soap one cloth at a time to wash genitalia using a clean part of the cloth for each swipe, wash the labia firs, then groin areas, in the female resident, separate labia, wash with strokes .each side separately with a clean cloth or clean .keep labia separated with one hand. Clean/rinse inner/upper thigh areas to remove urine moisture, change gloves and perform hand hygiene, apply clean incontinence brief or incontinence pad, do not touch any clean surfaces while wearing soiled gloves, etc. 44570 Based on observation, interview, and record review, the facility failed to have sufficient nursing coverage in order to provide adequate resident care and support. This failure effected 3 (R4, R5 and R7) out of 4 residents reviewed for lack of staff and has the potential to affect all 125 residents residing in the facility. Findings include: On 1/23/23 at 1:08PM, R4 said, CNA (Certified Nursing Assistant) staff can be low. It seems like they are sparse; like you don't see them as the day gets long. It usually takes two CNAs to change me because my legs are stiff. I get changed at least once per shift. I urinate more than that but they come when they come. Sometimes I wait so long for them to come that I have to ask or pull my light which also takes a while for them to answer. On 1/23/23 at 1:17PM R5 said, I have to use the brief to relive myself. Sometimes I have to wait an hour or more which is quite a time to sit in urine or feces. I like to be clean, and I just have to sit and wait. We usually don't have a problem in the morning but in the evening and night, it is more common that CNAs don't come in to check. They don't come and turn or reposition me regularly if they aren't even coming in the room. I don't put my light on or complain because I don't want to get anyone upset or retaliate against me. On 1/24/23 at 2:10PM V8 CNA said, I am having a hard time getting staff to help me change a resident (R7) that requires two staff assist to use the mechanical lift because we are short staffed. We are working with three CNA's today and we should have five. At 2:33PM V15 LPN said, when we are short CNAs; the nurses do help with care but today I am running and busy because we are also short a nurse. On 1/24/23 at 3:54PM V2 ADON (Assistant Director of Nursing) said I am currently responsible for the nursing schedule. A fully staffed shift is four to five nurses and 10 CNAs (Certified Nursing Assistant). The building is organized as A/B wing and C/D wing. A fully staffed day and evening shift has five CNAs for each wing and three CNAs for night shift. The A/B wing has three medication carts and can staff three nurses and the C/D wing is staffed with two nurses per shift. Staffing is challenging due to multiple call offs and because of that I am working the floor today. This is the second time that I have had to work the floor and I am a new employee to the facility. There is a registered nurse scheduled to work every shift and there is at least one working every day. On 1/25/23 at 12:10PM V1 Administrator said, the facility budget allows us to staff 13 nurses and 30 CNAs every day for direct patient care. We don't utilize any agency for staffing at this time. We hire some under contract but after the contract ends, often they don't stay. I think that the high turnover and the increased call ins are impacted by the fact that they really need a leader. We have had three DONs (Director of Nursing) in the past year and a new one just started today. When we don't have enough people to do what we need, we have to do the best we can. During the course of this survey, residents were observed to be soiled with feces and urine and in need of incontinence care for several hours. V1 was asked if lack of staff has contributed to delays in care and V1 stated, I can't answer that. We want them to be checked and changed and if that is not happening, we are looking at why. Nursing Assignment sheet dated for 1/23/23 and 1/24/23 were reviewed and included the following: 1/23/23 A/B wing: 7am to 3pm - 2 nurses, 3 CNAs - 3pm to 11pm, 3 nurses 2 CNAs C/D wing: 3pm to 11pm -2 nurses, 2 CNAs - 11pm to 7am, 2 nurses 2 CNA's 1/24/23 A/B wing: 7am to 3pm - 2 nurses 3 CNAs; 3pm to 11pm 2 nurses 2 CNAs; 11pm to 7am 1 nurse 3 CNAs C/D wing: 7am to 3pm - 2 nurses 3 CNAs; 3pm to 11pm 2 nurses 2 CNAs; 11pm to 7am 2 nurses 2 CNAs During the course of this survey, facility cited for concerns related to incontinence care not being provided (F690) and pressure ulcers (F686), with staffing as a contributing factor.

Based on interview and record reviews, the facility failed to follow their practice and perform weekly skin assessments for one resident R6, out of 4 residents reviewed for pressure ulcer prevention in a sample of 21. This failure resulted in R6 developing an unstageable pressure ulcer to his coccyx, a deep tissue pressure injury to the left buttock and a left medial upper thigh full thickness wound. The facility also failed to properly assess one resident's (R8) wounds and order wound care treatments for 5 days after R8 was admitted with 3 wounds. This failure led to the worsening of R8's sacral wound. Findings Include: 1. R6 is a [AGE] year old admitted on [DATE] with a diagnosis not limited to major depressive disorder, unspecified hemiplegia and hemiparesis, essential (primary) hypertension, and multiple sclerosis. R6's admission skin assessment indicates that R6's skin was intact. MDS section G indicates that R6 needs extensive assistance, and is total dependence with activities of daily living. R6's Wound assessment dated [DATE] documents 3 new wounds identified on 10/27/2022: 1) Coccyx- unstageable, size 7.5 x2.5 x unknown, and 70% slough 2) Left buttock- deep tissue pressure injury. 6.00 x 5.00 x unknown, deep [NAME] 60% 3) Left medial upper thigh- full thickness On 12/30/22 at 2:24 PM V8 (MDS) states she looked for all assessments for R6 and was only able to find one assessment and handed surveyor an admission assessment dated [DATE]. Surveyor Reviewed R6's electronic records for wound assessments and there were no skin/wound assessments documented. Review of R6's Braden observation dated 6/2/2022 documents R6 as a moderate risk for development of pressure ulcers. On 10/07/2022, skin assessment documentation indicated wound observation on right knee (front), and sacrum. Review of R6's progress notes by the previous director of nursing documents the following: Resident observed with 3 new skin issues: unstageable wound to coccyx, DTI to left buttock, and skin tear/shearing to left inner thigh. 2. Review of R8's face sheet documents a [AGE] year old male with diagnoses including the following: Complete traumatic amputation at level between left hip and knee, sepsis, malignant neoplasm, diabetes mellitus, pressure ulcer of sacral region unstageable, and end stage renal disease. R8's Discharge wound care recommendations from the hospital dated 11/2/222 documents wound treatments for a Left Knee Amputation site, a Sacral Wound, and a Right Foot Wound. Review of R8's Braden observation dated 11/2/2022 documents R8 as at risk for development of pressure ulcers. Review of R8's admission skin integrity assessment is absent of any wounds and documents R8 to have potential for impairment to skin integrity. The admission skin assessment also documents R8 has a pressure ulcer, but does not specify a location of any wound or pressure ulcer or any measurements. Review of R8's wound assessment dated [DATE] documents a pressure ulceration that documents an unstageable sacral wound measuring 6.50 x 9.00 x unknown with 80% slough and no tunneling. The only other wound assessment is dated 11/15/2022, the day R8 was discharged and it documents the sacral wound with the same measurements and 100% slough and tunneling present. Review of R8's Physician orders documents he did not have any wound care orders for 5 days from admission 11/2/2022 through 11/6/2022. The first wound care orders are dated 11/7/2022. Review of R6's care plan does not document his new 3 wounds or any new interventions. On 01/03/2023 at 10:15 am, V14 (Nurse) said that R6 had a wound on his sacrum and coccyx. V14 said that she started taking care of R6's wound after the wound care nurse left. V14 said that the facility wound care doctor does not see VA residents in the facility. V14 said R6 was never assigned to her because R6 resides on D-Wing, and she works on C-Wing. V14 said that weekly assessments are done when it pops up on the medication administration record or the treatment administration record. V14 said that weekly assessments are supposed to be done on all the residents and it could pop up to be done on different shifts. On 12/30/2022 at 1:03 pm, V32 (Previous Wound Nurse) said that she recalled taking care of R6. She said that R6 is 1 - 2 assist but she does not recall seeing any wounds. V32 said that if she notices any wounds on the residents, she tells the nurse and also document in the POC. On 12/30/2022 at 2:00 PM V18 (Nurse) said that she remembered that R6 had wounds but she cannot recall the location of the wounds. V18 said that R6 is not ambulatory, can only turn with assistance, and as such, is at high risk for developing a wound. V18 said that when she notices a wound on residents, she cleans the wound, covers it and notify the doctor for orders. V18 said that the wound care nurse is responsible for all wound care. V18 said that the nurses perform baseline skin assessment upon admission and on a weekly basis to ensure that the resident's skin integrity is intact or notify the doctor to initiate treatment for any skin breakdown in a timely manner. On 1/3/2023 at 09:58 AM, V18 said that she took care of R6 every day she worked. V18 said that the nurse does the skin assessment if it shows up on the medication administration record (MAR) or the treatment administration record (TAR). V18 said that she does not recall performing a skin assessment on R6, but if she did, it would be charted. On 1/3/2023 at 2:30 PM V2 (ADON) states upon admission all residents should have a skin assessment. V2 states, the admitting nurse documents the wounds and refers the resident to the wound care nurse. The nurse will then notify the doctor of wounds. V2 states, you want to document whatever skin condition is there on admission to have a baseline of where they are and that is standard practice. V2 states nursing staff should do skin assessments weekly. V2 states that nursing staff should be documenting skin or wounds on a skin assessment form or some nurses put it in the progress notes. V2 states, nurses should be documenting skin assessments weekly in the weekly skin assessment tool in the electronic medical record. Wound care team does the measurements of wounds. V2 states that within 72 hours the wound care team should see wounds and measure and assess the wounds. V2 states, orders for wound care should come with admission and immediately be put into the system. V2 states, she can't see any reason to wait 5 days to get wound care orders on a person with wounds and/or unstageable wounds. V2 states, If there are empty spaces on the Treatment Administration record (TAR) and it is not initialed, then it is not done. V2 states, the C.N.A.'s should be doing skin checks and documenting it when providing care to a resident. The facility's Pressure Injury and Skin Condition assessment dated [DATE] documents the following: 2) Residents identified will have a weekly skin assessment by a licensed nurse. 4) Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. Changes shall be promptly reported to the charge nurse who will perform the detailed assessment. 10) Pressure injuries and other ulcers will be measured at least weekly and recorded in centimeters in the resident clinical record.

Based on interviews and records reviewed the facility failed to ensure that one resident (R5) of 4 residents reviewed was free from abuse from a CNA in a total sample of 21. This failure resulted in R5 being screamed at and threatened to be hit with a cane by a CNA and R5 feeling afraid and unsafe at the facility. Findings include: The facility's final Incident reported dated 10/17/2022 documents the following: R5 stated on Monday 10/17/2022 that a C.N.A. on the night shift the night before threatened to hit him with a cane. He described her as a young lady with a nice physique who was African American with blonde curly hair. No one with that description worked on that day. R14 was the roommate of R5 and is alert and oriented. R14 states that he does not know why, but a C.N.A came in the room and waved the cane at R5 and said she was going to hit him with it. Report also documents 2 staff members being interviewed: V29 (nurse) and V22 (CNA) Review of R5's face sheet documents a [AGE] year old male with history of the following diagnoses: Encounter for Surgical aftercare following surgery on the digestive system, Encounter for attention to colostomy, Type 2 Diabetes Mellitus Without complications, Obesity, hypertension, Benign Prostatic Hyperplasia, personal history of Transient Ischemic Attack and Cerebral Infarction Without Residual Deficits, Colostomy status, long term (current) use of anticoagulants. R5's Minimum Data Sheet (MDS) dated [DATE] section C documents R5's mental status was intact as noted in the Brief Interview for Mental Status (BIMS) score of 14 out of 15. R5's Admission observation dated 9/28/2022 documents R5 Alert and oriented to person, place, time and situation. On 10/3/2022 V34 (FNP) document R5 to be alert and oriented. On 12/29/22 at 12:55 PM V1 (Administrator) states that she is the abuse coordinator. V1 states that on 10/17/2022 R5 asked to see her and family called and said go see him because he had a concern. V1 states that R5 said the CNA threatened to hit him with a cane the previous night. V1 states, R5 said it was an African American with light curly hair. V1 states we had no one with that description. V1 states then someone told her that V22 (CNA) wears a light colored wig. V1 states on the video she saw she could see the room and did not see a CNA go into his room. V1 states that on 10/15/2022 she saw that V22 was on the unit and saw her wearing light colored hair on 10/15/2022. V1 states she never saw V22 go into R5's room. Surveyor asked for clock-ins for V22 for that week. V22's time clock in report documents she did not work on 10/15/2022. After pointing that out to V1 that V22 did not work 10/15/2022, V1 states she doesn't remember the day she saw V22 in the light colored wig on video and she no longer has the video. V1 states V22 was suspended pending investigation. We had figured out it was V22 that R5 was talking about. V1 states R5's Roommate, R14 added info that helped her figure it out. V1 states something wasn't sitting right with her about the allegation and R14 had corroborated it, so they suspended V22 on 10/20/22 pending the investigation. Incident reported on 10/17/22 documents that she was suspended on 10/20/22. V1 states she interviewed V22 on the 20th and suspended her on the same day. Then when surveyor states that V22 worked the night shift on 10/20/22 then V1 stated it was probably the 21st that we suspended her. V1 states V22 agreed she was assigned to R5 then we let V22 go. On 1/3/2023 at 10:33 AM V1 states that R5 said young lady who threatened him had blonde hair. V1 states she looked at the video from 10/16/2022 from 11pm to 7 am at the nurse's station only for who fit that description. V1 states, she did not look at who was going in and out of R5's room for that time period. V1 states she does not know if V22 went into R5's room because she did not look on the video by his room. V1 states several people working that unit that evening and she interviewed V29 (nurse) and the V22 (CNA) only. Video lasts only one week. V1 states she found video of V22, fitting the description that R5 gave on a different day, but she does not know what day that was. V1 states, when they figured out that it was V22 R5 was talking about they told V22 she was no longer employed. V1 states R5 had never had any allegations about any staff or residents before. On 12/28/2022 at 12:27 PM R14 states R14 that he remembers the situation with R5 and a CNA in October. R14 states the facility fired the CNA. R14 states that R5 was sitting up at the side of the bed and he had a colostomy bag. R14 states the CNA came into the room and she never said anything about emptying the bag or what she wanted to do. R14 states she just told R5 to lay down and R5 said no that he did not have to lay down. The CNA was then screaming lay down, lay down! she said if you don't I will hit you with this cane. V14 states, he saw her shadow and heard the commotion and he got up. R14 states the CNA was screaming lay down, lay down right now or I'll hit you with this cane, and she had the cane holding it up like she was going to hit him. R14 states he told the administrator what happened when she came and asked him about it. R14 states, I felt like it was wrong. R14 states R5 wasn't in the best of health, and R14 states he felt like the CNA was taking advantage of R5. R14 states he had back surgery but he got up to see what was going on. R14 states R5 was mad. The CNA had his cane in her hand and holding it up above his head like she was going to strike him. After that happened the CNA went to work on A&B for about a week and then I didn't see her again. The incident happened about midnight. I had my T.V on and the CNA was saying Lay down, I said lay down right now, If you don't lay down I'm going to hit you with this cane. R14 states, I thought she was going to hit him (R5) for real. On 12/28/2022 at 2:53 Pm V30 (family of R5) states that when she went to the facility on [DATE], they said they had started the investigation. V30 states V1 told her they would review the camera's because they didn't find anyone that fit the description R5 gave. V30 states that R5's roommate explained to them that the CNA wears different wigs and had a had a short wig that night. V30 states a few days later, V1 called and said I have good news, we found out who the CNA was and we terminated her on the spot. V30 put R5 on the phone and R5 assessed to be alert to person, place, event, and states in the middle of the night I was sitting on the side of the bed and the CNA came in and wanted me to lay back. R5 states the CNA didn't say why she wanted me to lay down. R5 states, she wanted me to lay down like a kid. She made it sound like I was a child. R5 states he told the CNA, You can't make me get in the bed. I'll get in the bed when I'm ready. R5 states, she took his cane and said I am going to hit you with this cane if you don't lay down. R5 states, I said please don't hit me. I felt like she was wrong. I was afraid. I was scared. I put my hands up so she wouldn't hit me in the head. The facility said no one fit the description with short hair. R5 states, I didn't feel safe after that, because I couldn't believe they would do that to me. I don't think they would fire her for nothing. R5 states he did not want to hit her, but was feeling like he would have to protect himself if she hit him. Review of staffing schedule and assignment sheet for 10/16/2022 documents V22 working the night of 10/16/2022 and was assigned to R5. Review of R5's clock in sheet document she worked the 3rd overnight shift (11PM to 7:30 AM) on 10/16/2022, 10/17, 2022, 10/18/2022, 10/19/2022 and 10/20/2022. Review of staffing schedule also documents V29 (nurse D wing), V35 (CNA), V36 (CNA), and V37 (CNA) working on C and D wings on 10/16/2022 . On 12/30/22 at 6:22 AM V29 (Nurse) states he has never heard of any situation with a resident and staff threatening with cane. V29 states he does not remember R5 and no one has interviewed him regarding R5. On 1/2/2023 at 11:45 PM V37 (CNA) states she doesn't remember R5. V37 states no staff has interviewed her regarding any situation or allegation of abuse with R5. The facility's Abuse Prevention and Reporting policy dated 10/24/2022 documents the following: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment.

Based on interview and record review, the facility failed to conduct daily glucose as prescribe by the physician and failed to assess a diabetic resident experiencing a change in level of consciousness by not performing blood glucose monitoring. This applies to one of 4 residents (R5) reviewed for improper nursing care. As a result, R5 experienced a critical blood glucose level of 50mg/dl (milligrams/deciliter) and had to be transferred to the hospital for medical treatment. Findings include: R5 is [AGE] years old. Current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5 admitted to the facility on [DATE]. R5's census indicates a hospital leave on 8/22/22 through 8/26/22. On 10/25/22 at 12:20 PM, R5's family was interviewed about his hospitalization . V11 (family) stated R5's blood sugars were going to be checked twice daily and V35 (MDS Minimum Data Set Nurse) informed the family his last reading was September 24th. V11 and V12 (family members) stated today was R5's first care plan since he's been admitted . V11 and V12 reported R5 had to go to the hospital about a month ago because his blood sugar was in the 50's. V11 and V12 reported the facility just put R5's order in for blood sugar readings. R5's POS Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Call MD Medical Doctor if BS blood sugar is under 70 or over 400. If less than 70 give [MEDICATION(S)] 1mg then notify MD. Review of R5's Blood Sugar Summary indicates the last blood glucose monitor was performed at 6:04 AM on 8/22/22 with result of 82 mg/dl (milligrams/deciliter). Progress note by V19 ( Registered Nurse/RN) from 8/22/22 at 4:12 PM indicates: Upon rounds resident noted to have a change in LOC (Level of Consciousness); resident usually has a LOC of 3, now only oriented to self and when speaking gurgling noted. Resident has no drooping of face grasping bilateral within normal limits for resident V/S (vital signs) within normal limits. Doctor made aware orders sent to hospital to R/O (rule out) stroke. Orders received and carried out. R5's 8/22/22 change in condition form by V19 (RN) indicates no recent blood glucose value obtained during R5's change in his level of consciousness. R5's 8/23/22 progress note indicates: R5 is being admitted at the hospital with a DX (diagnosis) of [CONDITION(S)]. The hospital emergency room report indicates: R5 was brought from the nursing home for [CONDITION(S)], glucose 50 on EMS (Emergency Medical Service) arrival. R5 does not recall details of hypoglycemic episode. Says this glucose has not ever been that low. Plan: Admit to observation. On D5W (intravenous solution) at 100cc/hr. Accu checks (blood glucose monitoring) every 2 hours. R5's care plan dated 8/16/2022 indicates I have Diabetes Mellitus. Interventions: Monitor/document/report PRN (as needed) any s/sx (sign/symptom) of [CONDITION(S)]: sweating, tremor, increased heart rate ([CONDITION(S)]), pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait. On 10/27/22 at 1:45 PM, V2 (Director of Nursing/DON) was interviewed regarding blood glucose monitoring and change in condition of a resident. V2 stated, I believe R5 was on oral medicine for diabetes. If they are diabetic, I check a blood glucose and do vital signs. I usually check a blood sugar regardless with any change in condition. What are the symptoms of [CONDITION(S)]? V2 stated, Diaphoresis, lethargy, cold clammy skin, increased respirations and altered mental status. What interventions can be used to treat [CONDITION(S)]? V2 stated, If the resident is alert, we can give them juice with sugar packets, any protein shake, or offer food and liquids. If they have altered nutrition, R5 had thicken liquids, he would just need them thickened. If the doctor is not responding, call 911. There are no standing orders. What documentation would be done for this incident? V2 stated, The change in condition form. What information is listed on the change of condition form? The form auto generates the last set of vital signs. If you want to put in a new one, there's an option to put in the new set of vitals. There should be the most recent vital signs put in. I always use the vital signs I took. At 2:38 PM, V19 RN was interviewed regarding R5's change in condition. Are you familiar with R5? Is he diabetic? V19 stated, Yes I am familiar. He is diabetic.What happened with R5's change in condition? V19 stated, He wasn't responding correctly. I thought he may have had a stroke because his left side was of his face was drooped. His hand grip was not as strong, so I called the doctor and told him what I found. He was sent out 911 at that time. Did you notice any signs of [CONDITION(S)]? What are the signs of [CONDITION(S)]? V19 stated, No, he didn't have any sweating or diaphoresis; nothing like that. What is done when there is a change in a resident's condition? What treatment is performed when a resident is hypoglycemic? V19 stated, We usually do vital signs. His family was there. I did his vital signs. A blood glucose would be a part of his vital signs, I can't tell what it was at the time. We have sugar, or a spray into their nostrils if they have an order. Then we recheck it in 30 minutes. Did you complete any documentation during R5's change in condition? V19 stated, Yes in the nurse's notes. I document in the notes his change in condition. Did you check R5's blood glucose during this time? V19 stated, I can't remember, everything I do I put in the chart. The revised 1/16/18 Glucose Testing Policy states: Policy: To supplement lab glucose testing. To provide an immediate glucose value for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .uidelines: 1. Review physician order. 13. Record results in EMAR (electronic medication administration record).

Based on interview and record review, the facility failed to monitor and supervise a resident on aspiration precautions with moderate cognitive impairments during meal times by allowing the resident to eat alone, unsupervised in the resident's room for one of three (R3) residents reviewed for supervision of residents with difficulty swallowing in a total sample of nine. This failure resulted in R3 choking on the dinner meal and being transferred to the local hospital unresponsive later expiring with a contributing cause of aspiration pneumonia. Findings Include: R3 is a [AGE] year old with the following Diagnosis: [REDACTED]. R3 admitted to the facility on [DATE]. A Nursing note dated [DATE] documents R3 observed unresponsive, pale and noted to be choking on food. [MEDICATION NAME] maneuver performed by staff, CPR in progress, and 911 called. R3 transferred to the hospital and left facility breathing on own. R3 admitted to the hospital with [REDACTED]. A Nurse Practitioner note dated [DATE] documents R3 returned to facility after inpatient stay at the hospital with a [DIAGNOSES REDACTED]. Aspiration precautions. A Swallow Study dated [DATE] documents R3 as aspiration precautions on a regular diet while working with speech. A Physician note dated [DATE] documents speech therapy is working with the R3. R3 is tolerating mechanical soft diet. R3 is on mechanical soft diet due to aspiration. Continue aspiration precautions. The Minimum Data Set Sections C, E, and G dated [DATE] reviewed. The Brief Interview for Mental Status score is a 12 (moderate cognitive impairment). The Functional Status in the MDS documents R3 with needing one person physical assist while eating and supervision during meals. A Nurse Practitioner note dated [DATE] documents R3 seen for monthly follow up. Continue with current treatment plan and aspiration precautions. A Nursing note dated [DATE] documents CNA went to answer the call light for R3 and CNA heard calling for help from staff. Noted CNA doing [MEDICATION NAME] maneuver. CNA informed the nurse that R3 had light on, and when the CNA answered the light, R3 was sitting on the side of bed. R3 moved the dinner plate to side and gestured to R3's neck, and [MEDICATION NAME] maneuver was started. Nurse noted that R3 started to cough when trying to examine R3's mouth and was unable to due to R3 clinching teeth. Second nurse arrived and assisted to put R3 in recovery position. R3 noted to have no change in color or blueness noted in any area. CPR was not started due to R3 continued to breath and have a pulse. 911 was called and took over care. The Ambulance Run Sheet dated [DATE] documents on arrival an unconscious patient found in the room seizing. Staff found R3 in the room with R3 ' s tray and identified that R3 was choking on food from the tray. A large amount of food found in R3's airway. R3's oxygen level 70% (normal oxygen range ,[DATE]%) prior to beginning resuscitation. The Hospital records dated [DATE] documents R3 arrived in [MEDICAL CONDITION]. EMS called because R3 was choking on dinner around 6:55PM. R3's vital were absent with no pulse on the monitor. R3 intubated and pupils were fixed and dilated. R3 pronounced dead at 7:33PM. Final impression of aspiration on food and [MEDICAL CONDITION]. The Final Incident Report dated [DATE] documents CNA passing dinner hall trays noticed call light on for R3. Upon entering room, R3 attempting to place dinner plate on the bedside table. CNA noticed R3 in distress pointing to upper body. Staff attempted to perform a mouth sweep, but unable due to R3 clinching mouth. EMS called immediately, and R3 placed in recovery position until EMS arrived. The Death Certificate dated [DATE] document the cause of death as [MEDICAL CONDITION] disease and aspiration pneumonia. On [DATE] at 3:32PM, V10 (CNA) stated, I was never told of R2 being on aspirations precautions. I don't ever think R2 was on aspiration precautions. For residents that are aspiration precautions, they have to eat in the dining room or they have to get fed one on one by an aide in their room. The CNAs pass out the dinner trays. I can't remember if I passed R2's tray out or not. I was feeding the people in the dining room, and R2 put his call light on. I went in R2 room and R2 was doing the sign for choking- like hold R2's neck with R2's hands. I started the [MEDICATION NAME] maneuver with R2 still in the bed and started to yell for help. We tried doing a finger sweep of R2's mouth, but R2 had R2's teeth clenched so we couldn't get back there. On [DATE] at 3:46PM, V11 (LPN) stated, V10 went to answer the light and I heard V10 yell for help. I walked in the room and R3 was sitting on the bed, and V10 was giving R2 the [MEDICATION NAME] maneuver. I don't know if R2 was on aspiration precautions. We have a staff member with them while they eat if they are on aspiration precautions. We try to get them in the dining room, but sometimes it doesn't always happen. I don't know if R2 had any special recommendations by speech therapy. On [DATE] at 12:44PM, V14 (Speech Therapist) stated, R3 had weaker muscles in R3's esophagus and R3's tongue which was causing R3 to aspirate on food so we were doing exercises to strengthen those muscles as well as working on techniques to properly chew and swallow food. R3 was on aspiration precautions during therapy and after R3 was discharged from therapy from what I recommended. Residents that are on aspiration precautions should be eating up in the dining room and should be supervised while eating. On [DATE] at 11:45AM, V16 (medical doctor) stated, R3 initially had a choking episode over last summer. He was brought back here after the hospital and worked with speech therapy. Yes, R3 did have aspiration precautions just based on R3's history. R3 had weaker neck muscles so that caused issues with swallowing. With the condition R3 had, R3 should have been up in the dining room eating to be monitored. On [DATE] at 1:36PM, V9 (DON) stated, Residents that are on aspiration precautions are never supposed to be eating alone. The ones that eat in the dining room are fed first and monitored by the staff. Then they are moved in the hallway to sit, and the residents that want to stay in their rooms are fed or supervised while they eat. We talk about the residents that are aspiration precautions in morning meeting, and then we update the staff on the floor. It's put into the computer charting system so it can be seen by everyone there. We don't have a policy on aspiration precautions.

(A) Based on interview and record review the facility failed to provide a resident with a mechanical soft diet as ordered, supervise a resident with a behavior which puts the resident at risk for choking during meal time and have a staff member within the dining room to immediately start procedures to dislodge food from a resident throat while choking. This applies to 1 of 1 resident (R5) with a modified diet in a sample of 17 residents. As a result, R5 who was identified with swallowing difficulties, choked on regular food served to him. R5 expired soon after the choking incident. This was identified as an immediate jeopardy that began on (MONTH) 2, 2019. On [DATE] at 11:52 am V1 (administrator) was informed of the immediate jeopardy. On [DATE], the facility presented a removal plan for the immediate jeopardy. The surveyor observed implementation of the removal plan on [DATE]. The immediacy was removed on [DATE] The facility took measurements to remove the immediacy; however, the non-compliance remains at the second level, as the facility completes the staff in-services: Findings include: R5 was [AGE] years admitted to facility on [DATE] with [DIAGNOSES REDACTED]. R5 ' s brief interview for mental status (BIMS) dated [DATE] scored 5 out of 15 and his mental status was severely impaired. According to his Minimum Data Set ((MDS) dated [DATE], R4 required extensive assistance of one staff for eating. R5's (MONTH) 2019 physician's order [REDACTED]. Nurses' notes for R5 documented on [DATE] at 5:30PM, R5 was served a meal to include fried chicken sandwich (Regular diet). According to the notes, the tray was placed in front of him and he started to stuff a lot of the food in his mouth. He was then noted by staff to be choking and staff summoned the nurses. The [MEDICATION NAME] maneuver was performed by two nurses, one of whom was able to take out some food from his mouth. The facility's incident report dated [DATE] received by the state agency read: On [DATE] at approximately 5:50PM; nursing staff was notified by CNA (Certified nurse aide) that R5 seemed to be choking in the main dining room. Two nurses responded immediately, and initiated the [MEDICATION NAME] maneuver, where particles of food were expelled. R5 became unresponsive and 911 was called. CPR was initiated until EMS arrived and EMTs continued CPR as R5 was transferred to the hospital. On [DATE] the facility was notified from the hospital the R5 had expired in the emergency department of the hospital. On [DATE] at 11:00AM, V2 (director of nursing) said for the residents who needed supervision or assistance for eating, she expected that when the tray was placed in front of the residents, the staff sat down right away to supervise or feed them. On [DATE] at 2:30PM, V11 (CNA) said she was the staff who saw R5 stuffing the food in his mouth. She said the staff knew R4 had a problem of stuffing food in his mouth and then he would start to spit out the food when his mouth was too full. She said All the staff knew about it. V11 said the tray was in front of R5 and no staff member was at the table to supervise him. In addition she said she told him to stop but he did not and she moved him away from the table when he spat food on her face accidentally. She said she left to wash her face and when she returned she noticed he did not look good, so she called the nurse. When asked about the risk faced by R5 with his mouth full with food she said he could choke. She did not answer when asked why she did not alert someone that R5's mouth was full of food. She said she did not check to see what he had on his tray. V11 said she had no knowledge who gave R5 his tray. On [DATE] at 11:30AM, V10 (Dietary supervisor) said R5 should have never been given a chicken sandwich when his diet was mechanical soft. He said the mechanical soft diet should have been Ham and Beans, Mashed potatoes and greens. He said the regular diet was Chicken (fried) patty on a bun, fried potatoes, mixed greens and corn bread. On [DATE] at 2:50PM, V12 (CNA) said all the staff knew that R5 had a problem of stuffing food in his mouth and had a potential for choking and that was why he was supposed to be assisted with meals On [DATE] at 3:25PM, V19 (Speech Therapist) said any resident on a modified diet should at least be supervised and if the resident was to be supervised for eating then he should not have given a tray without supervision. On [DATE] at 3:15PM, V14 (attending physician) said if the patient required supervision or assistance for eating, his tray should not have been placed in front of him unattended. He also said he should have been served the prescribed diet. Hospital records for R5 dated [DATE] documented: Pt (patient) arrived from nursing home for witnessed choking that led to [MEDICAL CONDITION]. Pt was given Epi X 4 by EMS. Upon arrival pt. was unresponsive and in [MEDICAL CONDITION]. Facility's undated policy on Diet Standardization noted: Mechanical Soft diet documented: The texture and consistency of the general/ regular or therapeutic diet is modified. Food may be served as ground or chopped. Whole food may only be served if it is soft in consistency. The facility took the following measures to remove the Immediacy; however, the non-compliance remains at the second level, as the facility completes the staff in-services: - A QAPI (quality assurance) committee held a meeting on (MONTH) on 02, 2019 to address the root cause analysis concerning the incident with R5. The Medical Director was informed of the situation and agreed to the committee's planned changes to address the immediacy. -An audit was conducted to ensure that diet tickets matched physician's orders [REDACTED]. In the future the dietary manager will be informed during the daily manager meeting of any changes either upgrades or downgrades of any resident's diet. The dietary manager will ask for a dietary communication slip that has the physician order [REDACTED]. -The facility changed the method in which nurse aides delivered food trays and diet cards procedures for the residents in the dining room. On [DATE] an in-service was initiated for nursing, dietary and all department heads regarding these changes. The in-service will continue until all staff members have been in-serviced and any new employee will be trained upon hire. The administrator to monitor compliance -The new diet card procedural changes were implemented on [DATE] and will continue to be implemented. The administrator will monitor for compliance weekly for 1 month, then afterward quarterly using a QA dining room audit tool. -All residents with an altered texture diet were identified as a potential to be affected on [DATE]. Table assignments were re-assigned based on level of assistance required by residents. Those needing direct supervisor or physical assistance were put at specific tables. Completion date [DATE], the administrator will monitor for compliance weekly for 1 month, then afterward quarterly using a QA developed tool. -Staff members trained in the [MEDICATION NAME] maneuver will be in the dining room for all meals, the QA audit tool will be filled out at every meal by a predetermined member of the IDT. This will be initiated on [DATE] and to continue. The administrator will monitor for compliance weekly for 1 month, then afterward quarterly. -Dining rooms will be monitored by IDT (interdisciplinary team) management staff member, each meal ongoing to ensure proper diets are served. This was started on [DATE] and to be on going. -Signs will be posted and a sample food plate set up with food items to be served for modified texture diets for all dietary and staff members serving food to all residents in the dining room. Initiated on [DATE] an ongoing, the administrator will monitor for compliance weekly for 1 month, then afterward quarterly using a QA developed tool. (B) Based on interview and record review the facility failed to plan and implement fall interventions to avoid a resident fall or decrease possible injury due to a fall, for a resident who was at risk for fall. This applies to one of three residents (R4) reviewed for fall in a sample of six. As a result, R4 a confused resident, sustained some broken ribs and a punctured lung as a result of a fall. Findings Included: R4 was [AGE] years old admitted to facility on [DATE] at 7:00PM with [DIAGNOSES REDACTED]. Nurse notes on [DATE] upon admission documented: R4 was a fall risk and was confused and provided with floor mats. On [DATE] at 5:48AM, nurse wrote, noted R4 crawling on carpet next to her bed. On [DATE] at 7:43PM, nurse wrote, Resident was combative with staff, destroying phone wires and trying to knock down the computer, daughter was called and verbalized she will be there. On [DATE] at 8:33PM, nurse documented V15 (Family) left facility and notified her that R4 was asleep. According to nurses' note of [DATE] at 8:37PM, call light was clipped to covers on bed of R4 by V13 (family member). On [DATE] at 8:37PM, V9 wrote R4 was observed on floor sitting upright in between the sink and the toilet seat. R4 was then observed holding on to her right side and complained of pain. She was subsequently sent out to community hospital. The nurses' notes of [DATE] had no documentation that floor mats were next to bed and there was no documentation that added interventions were implemented after the first observation of R4 being on the floor. R4's baseline care plan for the admission of [DATE] was not individualized and did not include any safety measures for falls. R4's hospital records dated [DATE] noted, Multiple right sided rib fractures with adjacent chest wall [MEDICAL CONDITION]. Suspicious for right pneumothorax. On [DATE] at 2:30PM V9(Nurse) said she could not remember if any fall intervention was in place for R4 who was at risk for falls. She said when the family left ([DATE]), they clipped the call light to the covers of R4.When asked if R4 was able to use the call light, V9 said Maybe not. She said she should have pinned the call light to R4's clothing. On [DATE] at 3:10PM, V29 (Nurse) said upon admission he documented R4 was a fall risk because hospital papers stated she had bilateral side rails. He said he did not speak with family in relation to falls of R4. On [DATE] at 12:40PM, V27 (Certified Nursing Assistant/CNA) said she could not remember if R4 had any fall interventions in place when she fell . Facility's policy on falls dated [DATE] noted, Provide ongoing risk reducing interventions and, Identify and implement related care link interventions.

Based on observation, interview and record review, the facility failed to use two staff members to assist a resident with bed mobility and dressing. This applies to one of three residents (R2) in a sample of 5 reviewed activity of daily living. This failure resulted in R2 sustaining a [MEDICAL CONDITION] tibia. Findings Included: R2 was [AGE] years old who was first admitted to facility on 2/14/2014 and readmitted on [DATE]. His [DIAGNOSES REDACTED]. According to the MDS, R2 needed 2 staff members for dressing and transfer. Section G0400 documented R2 had limited movement to one upper extremity and to both lower extremities. Care plan for R2 noted he had contractures to the right shoulder, right elbow and right fingers. There was no care plan for R2 for transfers. Fall risk assessment for R2 dated 12/7/2018 scored 11 considered moderate risk for falls. Incident report for R2 dated 10/24/2018 documented R2 was observed lying on floor on back next to bed. According to report, there were two Certified Nursing Assistants (CNAs/ V20,V21) at bedside. R2 was sent to community hospital for complaint of pain to the leg. He was diagnosed with [REDACTED]. On 1/11/2019 at 1:25PM, V20 (Certified Nursing Assistant/CNA) said R2 rolled out of the bed on the left side when he turned too quickly. She did not answer when asked if there was another staff to help her. On 1/15/2019 at 3:00PM, V21 said she was not in the room when R2 fell . She said she went into room to assist V20 to transfer R2 in chair with a mechanical lift. V21 said V20 dressed R2 by herself and was not finished. She said she left the room to return. According to V21, when she returned, R2 was on the floor on the left hand side. On 1/17/2019 at 11:40AM, V22 (Nurse) said she was the nurse on duty when R2 fell . She said when she was called to the room, V20 (CNA) was the only staff present with R2 who was on the floor on the left side of the bed. According to V22, R2 required 2 staff members for bed mobility and dressing and he could not turn by himself. On 1/10/2019 at 11:20AM, R2 laid in bed. V2(Director of Nursing/DON) and V8 (Nurse) assisted to turn R2 in bed. R2 could not move his upper body without assistance. He was repositioned to the right side with extensive effort by staff. R2 was able to initiate the turn to the left side by staff extensive assistance to help him reach the rail on the left side, His grip was loose on the rail. R2 fell out of bed on the left side on 10/24/2018. On 1/9/2019 at 10:15AM, R2 was alert, awake and was in power wheelchair in room. His right hand was contracted by the elbow and right fingers were also bent. When asked to move his legs he said he could not move them. He said he could not turn by himself but can hold on to the siderail on the right side with his left hand and someone had to assist him. According to him he could turn to the right side better than the left. R2's bed had two bar rails which were about 12 inches wide and were on the upper ends of the bed. He said the reason why he fell out of bed on the left side in (MONTH) was because he tried to hold on to the left siderail with his right hand which was contracted and V20 who stood on his right side picked up his feet and threw them over to the left side so far that he slid right out of the bed. He said she was by herself and dressed him by herself.

Based on observation, interview and record review, the facility failed to provide a protective covering to the indwelling central venous catheter, placed in the left upper chest for [MEDICAL TREATMENT] purposes, for one resident, (R118), of three residents reviewed for [MEDICAL TREATMENT] care. Facility failed to conduct a resident assessment, failed to notify the physician of change in condition, and failed to follow physician orders [REDACTED]. R67's (10/21/18) stat chest x-ray was abnormal the results and/or treatment were not obtained until 10/22/18 (after surveyor inquiry). facility failed to: place splints on contracted hands, and provide restorative care as stated in care plan and occupational plan of care to prevent further contractures and decline in range of motion affecting 2 of 2 residents (R33 and R85) reviewed for limited range of motion in a total sample of 30 residents.R67's (10/21/18) x-ray affirms bilateral lung infiltrate. Findings include: On 10/22/18 during initial tour of the C-Wing, R118 was observed in her room, and after conversing with R118, R118 indicated that she has to do [MEDICAL TREATMENT]. R118 pushed back the lapel to her blouse, and revealed her [MEDICAL TREATMENT]. R118 pointed to her indwelling central venous access catheter, you could see it directly inserted into the left upper chest wall, where there was no protective dressing covering the area of insertion. V20 [MEDICAL TREATMENT] Technician expressed during interview on 10/22/18 at 11:38am, that the dressing covering the insertion site should remain until the next treatment. V2 DON (Director of Nursing) stated during interview on 10/22/18, at 12:10pm, cover the insertion site with gauze kept in place until the resident returns to [MEDICAL TREATMENT]. Review of the facility's Policy for [MEDICAL TREATMENT] state in the Responsibility section that It is the responsibility of nursing to provide care for the [MEDICAL TREATMENT] resident. The Procedure section of the policy state in number 4. Nursing will monitor the access site for signs and symptoms of infection or bleeding. The facility failed to monitor and protect the [MEDICAL TREATMENT] for R118. R67's (10/21/18) stat chest x-ray was abnormal the results and/or treatment were not obtained until 10/22/18 (after surveyor inquiry). R67's (10/21/18) x-ray affirms bilateral lung infiltrate. R67's (10/22/18) antibiotic medication(s) were not administered as ordered. On 10/24/18 at 4:20pm, V18 (Medical Director) affirmed that harm for infections not timely addressed include pneumonia [MEDICAL CONDITION]. On 10/22/18 at 11:55am, R67's eyelashes were coated with dried yellow discharge and her eyes adhered shut. R67 opened her eyes (after V3/Certified Nursing Assistant washed her face) and purulent discharge was observed in her left eye. R67 coughed and sounded congested. Surveyor inquired about R67's eyes V4 (Licensed Practical Nurse) stated It needs to be washed and cleaned. It has drainage that is sticky like an eye infection. We are running some tests on her cause of her cough. On 10/22/18 at approximately 12:25pm, R67's (October (YEAR)) POS (Physician order [REDACTED]. R67's progress notes include; (10/8/18) History of present illness: cough mild congestion. Plan: will monitor cough for now. (10/21/18) 12:17, Temperature 101F (Fahrenheit). Coughing a lot. Lung sounds congested on auscultation. New orders: stat CXR. (There is no documentation concerning the stat CXR result and/or eye infection). On 10/22/18 at 1:38pm, surveyor inquired about R67's (10/21/18) CXR result V5 (Minimum Data Set Coordinator) stated I just called about that, medical diagnostics says she has to find it. Surveyor advised that R67's CXR was ordered stat V5 responded I know, it should have been here. On 10/22/18 at 2:31pm, surveyor inquired about R67's eye infection which was not addressed V4 stated I came in at 7:00am she was sleeping and had her eyes closed. It wasn't mentioned to me in report. They ordered a chest x-ray and nebulizer, those things were in place. Surveyor inquired about the turnaround time for stat orders V4 responded The turnaround time is something that needs done right away. On 10/24/18 at 11:24am, an additional review of R67's POS was conducted. The following was now inclusive; [MEDICATION NAME] 875/125mg (milligrams) twice daily for bilateral lung infiltrate for 10 days (start date: 10/22/18). [MEDICATION NAME] 0.3% (2) drops in both eyes twice daily for [MEDICAL CONDITION] for 10 days (start date: 10/22/18). R67's MAR (Medication Administration Record) affirms that [MEDICATION NAME] and [MEDICATION NAME] were not administered until 10/23/18 at 9:00am. On 10/24/18 at approximately 10:30am, V2 reviewed R67's progress notes (documented 10/22/18 at 8:43pm) and stated The medication was on order. On 10/24/18 at 4:20pm, surveyor inquired about the standard of care for a fever, cough, and eye infection V18 stated If having symptoms I would get a chest x-ray, and basic blood tests like a CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Profile). (R67's labs were last drawn on 6/7/18 per documentation provided during this survey). V18 stated the turnaround time for reporting stat chest x-ray results is 4-6 hours. V18 affirmed the expectation for medication administration is The same day orders are received. Surveyor inquired about harm to a patient if infections are not addressed timely V18 stated I can't predict what will happen but the blood may get infected or end up with pneumonia or [MEDICAL CONDITION] that would be the harm. R67's (10/21/18) CXR obtained at 4:22pm, states mild [MEDICAL CONDITION] vascular congestion is noted in both lower lung fields with early interstitial infiltrate in the left lung base. The (6/17/15) acute condition changes policy & procedure includes but not limited to; the nurses and physician must recognize acute condition change and identify its nature, severity, and cause(s). Before contacting a physician about someone with an acute change of condition, the nursing staff will make pertinent observations and collect appropriate information to report to the physician using the SBAR (Situation Background Assessment Recommendation) assessment. Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected pertinent information, including the resident's current symptoms and status. 10/22/18 10:55 AM R33 in bed with no splints on R33s contracted hands. 10/23/18 09:03 AM R33 is being fed with no splints on R33s contracted hands. 10/23/18 02:39 PM R33 is lying in bed with both hands contracted with no splints on hands. 10/24/18 09:30 AM R33 in day room sitting in wheel chair with no splints on R33s contracted hands. 10/24/18 11:08 AM V2 DON (director of nursing) states if resident refuses splint as ordered for contractures the residents physician would be notified and if the resident still refuses to use the splint a declination of care would be completed. V7 ADON (assistant director of nursing) states V7 believes R33 was supposed to use a splint but wasn't sure. 10/24/18 11:59 AM V19 Rehab Clinical Leader states CNAs are given restorative sheets to provide care. I don't see residents unless they are on my work load. V19 states R33 has not been referred to V19 for therapy. 10/24/18 03:00 PM V2 DON (director of nursing) states there is no restorative nurse and V2 can't produce any training of CNAs for restorative care. Care plan revised 08/09/18 documented R85 has decreased strength and decreased mobility and has been observed to need assistance with some portion of her passive range of motion. Interventions for R85 include participation in passive range of motion restorative program 7 days per week for at least 15 minutes a day, stabilization of each extremity that is to receive passive range of motion on a pillow etc. as much as possible prior to the procedure. Pharmacy medication review report dated 10/24/18 documented order dated 08/11/18 for applying bilateral hand rolls daily to prevent further contractures and decline. An order dated 02/07/18 documented R85 may have restorative nursing if warranted. Care plan revised 10/26/17 documented R33s interventions include hand brace daily and prn after prom, and R33 will participate in passive range of motion as tolerated 15 minutes a day 6 - 7 days per week by 1 - 2 staff. Occupational therapy plan of care dated 06/20/18 documented R33 refused to participate and refused to allow therapy services and R33 has not received occupational therapy for this same condition of positioning in the past year; R33 has a right hand splint for proper positioning. Physician order [REDACTED].

Based upon observation, interview and record review the facility failed to provide care and services according to accepted standards of practice to one of 33 residents (R67) in the sample. R67's (10/21/18) stat chest x-ray affirms bilateral lung infiltrate the results and/or treatment were not obtained until 10/22/18 (after surveyor inquiry). R67's (10/22/18) antibiotic medication(s) were not administered as ordered. On 10/24/18 at 4:20pm, V18 (Medical Director) affirmed that harm for infections not timely addressed include pneumonia [MEDICAL CONDITION]. Findings include; On 10/22/18 at 11:55am, R67's eyelashes were coated with dried yellow discharge and her eyes adhered shut. R67 opened her eyes (after V3/Certified Nursing Assistant washed her face) and purulent discharge was observed in her left eye. R67 coughed and sounded congested. Surveyor inquired about R67's eyes V4 (Licensed Practical Nurse) stated It needs to be washed and cleaned. It has drainage that is sticky like an eye infection. We are running some tests on her cause of her cough. On 10/22/18 at approximately 12:25pm, R67's (October (YEAR)) POS (Physician order [REDACTED]. R67's progress notes include; (10/8/18) History of present illness: cough mild congestion. Plan: will monitor cough for now. (10/21/18) 12:17, Temperature 101F (Fahrenheit). Coughing a lot. Lung sounds congested on auscultation. New orders: stat CXR. (There is no documentation concerning the stat CXR result and/or eye infection). On 10/22/18 at 1:38pm, surveyor inquired about R67's (10/21/18) CXR result V5 (Minimum Data Set Coordinator) stated I just called about that, medical diagnostics says she has to find it. Surveyor advised that R67's CXR was ordered stat V5 responded I know, it should have been here. On 10/22/18 at 2:31pm, surveyor inquired about R67's eye infection which was not addressed V4 stated I came in at 7:00am she was sleeping and had her eyes closed. It wasn't mentioned to me in report. They ordered a chest x-ray and nebulizer, those things were in place. Surveyor inquired about the turnaround time for stat orders V4 responded The turnaround time is something that needs done right away. On 10/24/18 at 11:24am, an additional review of R67's POS was conducted. The following was now inclusive; [MEDICATION NAME] 875/125mg (milligrams) twice daily for bilateral lung infiltrate for 10 days (start date: 10/22/18). [MEDICATION NAME] 0.3% (2) drops in both eyes twice daily for [MEDICAL CONDITION] for 10 days (start date: 10/22/18). R67's MAR (Medication Administration Record) affirms that [MEDICATION NAME] and [MEDICATION NAME] were not administered until 10/23/18 at 9:00am. On 10/24/18 at approximately 10:30am, V2 reviewed R67's progress notes (documented 10/22/18 at 8:43pm) and stated The medication was on order. (There is no documentation that the physician was notified). On 10/24/18 at 4:20pm, surveyor inquired about the standard of care for a fever, cough, and eye infection V18 stated If having symptoms I would get a chest x-ray, and basic blood tests like a CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Profile). (R67's labs were last drawn on 6/7/18 per documentation provided during this survey). V18 stated the turnaround time for reporting stat chest x-ray results is 4-6 hours. V18 affirmed the expectation for medication administration is The same day orders are received. Surveyor inquired about harm to a patient if infections are not addressed timely V18 stated I can't predict what will happen but the blood may get infected or end up with pneumonia or [MEDICAL CONDITION] that would be the harm. R67's (10/21/18) CXR obtained at 4:22pm, states mild [MEDICAL CONDITION] vascular congestion is noted in both lower lung fields with early interstitial infiltrate in the left lung base. The (6/17/15) acute condition changes policy & procedure includes but not limited to; the nurses and physician must recognize acute condition change and identify its nature, severity, and cause(s). Before contacting a physician about someone with an acute change of condition, the nursing staff will make pertinent observations and collect appropriate information to report to the physician using the SBAR (Situation Background Assessment Recommendation) assessment. Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected pertinent information, including the resident's current symptoms and status.

Based upon observation, interview and record review the facility failed to provide necessary care and services to ensure that one of 33 residents (R67) in the sample was free from neglect. R67's (10/21/18) stat chest x-ray affirms bilateral lung infiltrate the results and/or treatment were not obtained until 10/22/18 (after surveyor inquiry). R67's (10/22/18) antibiotic medication(s) were not administered as ordered. On 10/24/18 at 4:20pm, V18 (Medical Director) affirmed that harm for infections not timely addressed include pneumonia [MEDICAL CONDITION]. Findings include; On 10/22/18 at 11:55am, R67's eyelashes were coated with dried yellow discharge and her eyes adhered shut. R67 opened her eyes (after V3/Certified Nursing Assistant washed her face) and purulent discharge was observed in her left eye. R67 coughed and sounded congested. Surveyor inquired about R67's eyes V4 (Licensed Practical Nurse) stated It needs to be washed and cleaned. It has drainage that is sticky like an eye infection. We are running some tests on her cause of her cough. On 10/22/18 at approximately 12:25pm, R67's (October (YEAR)) POS (Physician order [REDACTED]. R67's progress notes include; (10/8/18) History of present illness: cough mild congestion. Plan: will monitor cough for now. (10/21/18) 12:17, Temperature 101F (Fahrenheit). Coughing a lot. Lung sounds congested on auscultation. New orders: stat CXR. (There is no documentation concerning the stat CXR result and/or eye infection). On 10/22/18 at 1:38pm, surveyor inquired about R67's (10/21/18) CXR result V5 (Minimum Data Set Coordinator) stated I just called about that, medical diagnostics says she has to find it. Surveyor advised that R67's CXR was ordered stat V5 responded I know, it should have been here. On 10/22/18 at 2:31pm, surveyor inquired about R67's eye infection which was not addressed V4 stated I came in at 7:00am she was sleeping and had her eyes closed. It wasn't mentioned to me in report. They ordered a chest x-ray and nebulizer, those things were in place. Surveyor inquired about the turnaround time for stat orders V4 responded The turnaround time is something that needs done right away. On 10/24/18 at 11:24am, an additional review of R67's POS was conducted the following was now inclusive; [MEDICATION NAME] 875/125mg (milligrams) twice daily for bilateral lung infiltrate for 10 days (start date: 10/22/18). [MEDICATION NAME] 0.3% (2) drops in both eyes twice daily for [MEDICAL CONDITION] for 10 days (start date: 10/22/18). R67's MAR (Medication Administration Record) affirms that [MEDICATION NAME] and [MEDICATION NAME] were not administered until 10/23/18 at 9:00am. (There is no documentation that the physician was notified). On 10/24/18 at 4:20pm, surveyor inquired about the standard of care for a fever, cough, and eye infection V18 stated If having symptoms I would get a chest x-ray, and basic blood tests like a CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Profile). (R67's labs were last drawn on 6/7/18 per documentation provided during this survey). V18 stated the turnaround time for reporting stat chest x-ray results is 4-6 hours. V18 affirmed the expectation for medication administration is The same day orders are received. Surveyor inquired about harm to a patient if infections are not addressed timely V18 stated I can't predict what will happen but the blood may get infected or end up with pneumonia or [MEDICAL CONDITION] that would be the harm. R67's (10/21/18) CXR obtained at 4:22pm, states mild [MEDICAL CONDITION] vascular congestion is noted in both lower lung fields with early interstitial infiltrate in the left lung base. The (6/17/15) acute condition changes policy & procedure includes but not limited to; the nurses and physician must recognize acute condition change and identify its nature, severity, and cause(s). Before contacting a physician about someone with an acute change of condition, the nursing staff will make pertinent observations and collect appropriate information to report to the physician using the SBAR (Situation Background Assessment Recommendation) assessment. Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected pertinent information, including the resident's current symptoms and status. The abuse prevention policy & procedure (revised 7/22/15) includes; this facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. This will be done by: identifying occurrences and patterns of potential mistreatment.

Based on interview and record review the facility failed to follow their policy and procedure for Accidents and Incidents and failed to properly assess and treat 1 of 3 residents (R6) reviewed for falls in a total sample of 11. This failure resulted in a delay in treatment and R6 being sent to the local hospital with a fractured left hip 2 days after a fall. Findings Include: The Face Sheet documents that R6 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Incident Report dated 7/3/17 at 6:55pm documents that R6 was observed sitting on the floor in the dining room next to the resident's wheelchair. The Nurse's Notes dated 7/3/17 at 8:14pm documents that a nursing assessment was done and there were no injuries noted but the resident was medicated for pain. The Medication Administration Record [REDACTED]. The Nurse's Notes dated 7/5/17 at 10:30am documents that R6 had complaints of pain to the left leg and was noted with a slight protrusion to the left hip. A stat x-ray was done and indicated that R6 had suffered a fracture to the left hip. The MD was notified and R6 was transferred to the local hospital for evaluation and treatment. On 7/20/17 at 3:15pm E6 (Nurse) stated I was the nurse and I was told that the resident had fallen in the dining room by one of the CNA's. By the time I made it to the Dining Room they had already gotten the resident up to the chair. We put the resident back to bed and I did an assessment. I did not notice any injuries but the resident had a complaint of pain on the left side. The resident was confused and kept trying to get out of bed so we had to monitor R6 closely. I did believe that the pain was new for the resident so I tried to contact the MD for orders. I paged the Physician about 4 times that evening and didn't get a call back during my shift. There was no x-ray or anything done during my shift. I did report it to the DON because I felt like the resident needed an x-ray because R6 kept pointing and pulling at the hip. On 7/21/17 at 12:00pm E2 (DON) stated The nurse did contact me regarding the fall. It was never reported to me that the resident was having hip pain and was pulling at the hip. Had that information been reported, I would have requested an x-ray right away. On 8/1/17 at 12:20pm Z1 stated I was not notified of the fall on 7/3/17 with the resident complaining of pain and pulling at the hip. I would have ordered a stat x-ray. The Accident/Incident Policy documents that the nurse must conduct an immediate investigation of the accident/incident and implement immediate appropriate interventions to the affected parties.

Based on record review and interview, the facility failed to assess and implement safety measures to reduce the risk of injury for one of three residents (R1) reviewed for fall in a sample of 4 residents. This failure resulted in R1 being hospitalized and treated for [REDACTED]. Findings Included: Medical Record for R1 noted a [AGE] year old admitted to facility on 11/25/2015 with [DIAGNOSES REDACTED]. R1's face sheet generated at the facility did not list the [DIAGNOSES REDACTED]. On 3/24/2016 at 10:20AM, E4(Admitting Registered Nurse,RN) said she was aware that R1 had an Intracranial bleed and Craniotomy in October, 2015. She said she did not know why the [DIAGNOSES REDACTED]. Fall risk assessment completed on 11/25/2015 scored 25. Fall risk scale presented by facility noted 0.0 to 5.0 was low risk; 6.0 to 15.0 was moderate risk and 16.0 to 60.0 was high risk for falls. Completed admission assessment done on 11/25/2015 noted R1 had multiple falls, non-ambulatory, unable to use call light, exhibited behavior problems like spitting on staff, had orders for anti-seizure, antihypertensive and sedative medications, incontinent of bowel and bladder and memory and recall ability was never. On 11/25/2015, Interim care plan for R1 had no interventions in place based on the assessment and [DIAGNOSES REDACTED]. of bed unassisted. According to care plan of 11/28/2015, bed and chair alarms were initiated on 11/27/2015 and ,the bed in low position at night. There was no other documentation in the medical record about interventions to keep R1 from injury. On 11/27/2015 at 10:16PM, R1's gastrostomy tube came out and R1 was sent to the hospital according to medical record. On 11/28/2015 at 6:45AM, nurse wrote, Resident received via ambulance from St James Hospital with a [DIAGNOSES REDACTED]. Side rail assessment done on 11/25/2015 noted no side rails. On 11/28/2015 at 12:38PM, nurse's notes documented,Resident noted supine position bedside spitting, kicking, punching and screaming. R1 was sent to acute care facility in the community after the unwitnessed fall from the bed. On 11/28/2015 at 9:35PM, nurse wrote,R1 admitted to hospital into Critical care unit with [DIAGNOSES REDACTED]. On 3/17/2016 at 12:30PM, E5(Certified Nursing Assistant, CNA) said she was the staff taking care of R1 on 11/28/2015. She said R1 was agitated and verbally aggressive to staff so she assisted her in the bed. E5 said that R1 calmed down and she went to assist in the dining room. However, E5 said when she returned from the dining room, R1 was on the floor on her back. E5 said she summoned the nurse right away. When asked about the bed alarm, E5 said,I only heard the alarm when I went into the room because the battery was low. Medical record from hospital on [DATE] noted,Hyperdense blood collection within the subdural space along the left frontal bone measured 4mm. Findings are comparable with acute subdural hemorrhage. On 3/17/2016 at 1:30PM, Z1(Physician) said he spoke with the Neurosurgeon when R1 was in the hospital. He said the bleeding would have been caused by the fall. Facility's policy on Falls dated 1/12/2013 documented,Review hospital records for fall related information. Facility's policy on admitted d 7/21/2015 documented that to qualify for admissions,all of the needs of the resident can be met at the facility. Facility's policy on Care Planning revised on 8/3/2015 noted that the goal should be resident centered and reflect the problem focus.

Based on record review and interview the facility failed to immediately implement measures to protect a resident from further abuse after being sexual assaulted by another resident and immediately report a crime of sexual assault to local law enforcement as required by the facility's abuse policy. On 7/18/2015 R2 (male resident) sexually assaulted R1 (female resident) as witnessed by E5 (certified nurse aide). After the sexually assault the facility staff allowed R2 to remain on units A and D without constant direct supervision until the time R2 was transferred to a local hospital. R2 remained in a room next door to R14 and R15 (R1 ' s roommates), after the sexual assault and sometime after the first shift, R2 was transferred to another room on the D unit without constant direct supervision from staff until the local law enforcement intervened on the morning of 7/20/15. The facility ' s failure to implement measures to protect a resident and call law enforcement when a crime is committed has the potential to affect 131 of 131 residents within the facility. An immediate jeopardy was identified on 7/18/2015 when the facility failed to have R2 removed from facility or have one to one direct supervision until he was transferred out. On the morning of 7/20/15 the local law enforcement placed an officer within a room with R2 and provided one on one to one supervision until R2 was transfer to a hospital for an evaluation. On 7/23/2015, E1 (administrator) was informed of the immediate jeopardy. The immediacy began on 7/18/2015 and was removed on 7/24/2015. Findings include: The facility's abuse prevention program dated 9/15/1998 and revised 8/01/2014 states: The facility shall immediately contact local law enforcement authorities (i.e. telephoning 911 where available) for sexual abuse of a resident by a staff member, another resident, or a visitor. The facility's accident/incident reported dated 7/18/15 at 2:15am documented a certified nurse aide (E5) reported that she observed a male resident (R2) on bed with the resident (R1) partially disrobed. A written statement by E5 certified nurse aide (CNA) reads: I was just coming back from off break, and was about to do my round and heard R1 screaming. So I walked into her room and saw R2 was on top of her. R2 had his pants all the way down to his feet and his shoes were off. R2 had R1's dress all the way up with her legs open and having sex with her. After that I walked back to the door and called the nurse so she could see. By the time she got down to the room he was pulling his pants up and just walked out the room. All of this happened around 2:25a.m. A written statement by E4 (nurse) reads: This writer was in the nursing station writing incident report on another resident. I did not see resident coming out of his room because the laundry cart in the hallway is blocking the two rooms involved. On 7/20/2015 at 1:40pm E3 (social service director) reported she was the person designated to receive abuse allegation in the absence of the administrator. E3 stated on 7/18/2015 she received a call from the facility's director of nurses/ DON (E2) informing her about the incident involving R1 and R2. E3 was unable to provide the time of the call. E3 said she reported the incident to the Administrator (E1), the Regional Director and the nurse consultant. E3 stated instructions were given to put R2 on one to one monitoring. The surveyor asked E3 when this occurred. E3 replied, approximately at 3am. E3 reported she arrived to the facility later at 7:45am, in which a local police detective was at the facility. E3 stated, the facility did not report the incident to the police and the hospital called the police. On 7/20/2015 at 5:05pm, E2 (DON) reported she was not on duty at the time of the incident involving R1 and R2. She was called on the phone by E4 (nurse) who was the designated night supervisor for 7/18/2015. E4 just before 3am called E2 and stated a CNA (E5) found R2 on top of R1. E4 wanted to know who was the abuse coordinator since E1 (administrator) was on vacation. E2 informed E4 it was E3 (social service director). E2 after speaking to E4 called E3 and reported the incident. E3 wanted to know what the CNA saw. E2 then called back to the facility to interview E5 (CNA) and called E3 with the details. At that point E3 took over. E2 stated, as she was arriving to the facility, she was re- routed to go to the police station sometime between 9-10am on 7/18/2015. The surveyor asked E2, what is the procedure for an allegation of rape or sexual assault? E2 stated the resident should be examined and checked for injury, the physician should be informed; an incident report generated and send the resident out for a rape kit. The surveyor asked if this was a part of the facility's abuse policy. E2 stated I don't know but that should be the procedure. E2 stated she instructed E4 to do just that (check R1 for injury) before she called E3. Next, the surveyor asked what should happen to the aggressor in this situation. E2 stated the abuse coordinator or the doctor determines what happen to the aggressor. E2 further stated, R2 was placed on every 15 minute check and a sheet was placed on his door. There is a paper log of who did the well-being checks. E2 said she would provide the surveyor with the documentation for the monitoring. On 7/21/2015 at 11:30am via phone, E4 reported she wanted to send R1 out and call the police but E2 told her not to call (the police) until the test (rape kit) comes back positive. On 7/21/2015 at 11:45am via phone, E5 reported she came back from break at 2:15am and she heard R1 screaming from the room. She went to the room. R2 was on top of R1, her (R1) gown was all the way up. R2 was having sex with R1. Once R2 saw her, R2 got off R1, pulled his pants up and walked out the room. E5 also reported after the incident occurred she continued taking care of the residents. She did not do one to one monitoring for R2. E5 stated she checked on both residents (R1 & R2) during rounds. Also, she was not continuously stationed in the hallway or the resident's room. E5 stated there were two CNA assigned to unit on the third shift. On 7/21/2015 at 2:05pm via phone, E6 (second CNA working the morning 7/18/2015) reported she did not know what happened with R1 and R2. She checked on him twice during the shift. She did not sit with him and was not continuously watching him during the shift. According to a face sheet R2 is a [AGE] year old male resident with [DIAGNOSES REDACTED]. R2's progress notes documented the following: -7/18/2015 08:22 hour documented: Upon arrival resident observed standing at the nursing station. When asked to return to room or go to the dining room for breakfast while nurse to nurse report given, resident stated, I'm not going nowhere! Resident on 15 minute monitoring by all staff on wing. Resident in room lay in bed at this time. -7/18/2015 14:56 hour documented: resident noted to become agitated upon asking resident to go to his room resident unable to be re-directed by staff. According to R2's minimum data set assessment ((MDS) dated [DATE] R2 had moderate cognitive impairment, had verbal behavioral symptoms directed toward others and needs oversight for transfer and walking. According to the minimum data set assessment dated [DATE] R2 is 68 inches tall On 7/20/2015 at 1:50pm, R2 was present in a room with a local police officer presented. The surveyor attempted to ask questions. However, every question was answered with no. R2 was noted to ambulate within the room without any problems. According to a face sheet R1 is a [AGE] year old female resident. R1 [DIAGNOSES REDACTED]. R1's progress notes documented the following: -7/18/2015 11:21 hour documented: At about 2:45am the CNA notified this writer that she observed a male resident on bed with a female resident. Upon writer entering the room the male resident was walking out the room with clothes on. The resident observed on the bed partially disrobed, legs opened. Assessment completed and indicated no visible bruise, no bleeding from the vagina and no signs and symptoms of pain to note at this time. DON notified, Doctor page, Family member made aware. Resident transferred to hospital via ambulance for further evaluation/ exam. -7/18/2015 14:45 hour documented: Resident arrived from hospital via ambulance. Resident alert and oriented to self. Resident returned with [DIAGNOSES REDACTED]. Awaiting return call from doctor. According to R1's minimum data set (MDS) assessment dated [DATE] R1 is moderately cognitive impaired, had no activity for walking, needs extensive physical assistance for transfer and totally dependent on staff for dressing. Also R1 was 64 inches tall and weighed 110 pounds. On 7/20/2015 at 2:58pm, R1 was returned to her room transported by E7 (CNA) via wheel chair. When asked if anyone hurt her, R1 said yes and pointed a finger to her pelvic area. R1 was unable to provide specific details. R1 had two roommates R14 and R15at the time of the survey. According to a MDS assessment dated [DATE], R15 is moderately impaired, unable to walk and needs two people to assistance for transfer and bed mobility. According to a MDS assessment dated [DATE], R14 is also moderately cognitively impaired. According to the facility ' s census on 7/19/15 these two residents were present on the A-wing next door to R2, until he was transferred. The resident location monitoring log presented by E2 (DON) had dates of 7/18, 7/19 and 7/20/2015. On 7/18/2015 the time monitoring sheet is initially documented at 7:15am. The monitoring is documented in 15 minute intervals during the listed day. Surveyor noted monitoring the log sheet was not filled out completely. It lack some initials indicating checks were done, for the morning of 7/20/2015. The sheet did not indicate the location of the R2. On 7/23 and 7/30/15 the surveyor watched parts of the facility ' s video tape surveillance of the resident ' s A and D units from 7/18-7/19/2015. The tape had footage of times in which R2 ambulated in the hallways or going to the nurse ' s station without staff accompanying him. On 7/21/2015 at 4:22pm via phone Z1 (detective) reported: at or about 5:10am the morning of 7/18/2015 the local police department was contacted by hospital personnel, who reported R1 was sexually assaulted by someone. Police officers viewed the facility's video tape and observed R2 entering R1's room during the 2am hour. R2 stayed in the room appropriately 9 minutes according to the time on the tape before a staff member entered the room. Z1 stated, he was initially told on 7/18/2015 by E3 (social service director) R2 was being monitored every 15 minutes. Later, Z1 received a called from E1 (administrator) stating R2 was being monitored one to one. Z1 report, the hospital doctor reported there was the present of sperm in R1's vaginal and the morning 7/20/2015 R2 was officially arrested. On 7/20/2015 between 9am-9:30am, Z1 with police officers came and arrested R2. Z1 stated because he was in under arrest an officer had to remain with R2 at all times. The facility took the following actions to removal the immediacy. Although the immediacy was removed on 7/24/2015 the deficiency harm level remains at the second level. -On 7/19/2015 an in-service was initiated for all managers and direct care staff member regarding following the facility ' s policy for calling law enforcement when a crime is commented. This in-service is to continue until all staff has been in-serviced. -On 7/23/2014 the facility had a meeting QA meeting with member to discussed and revolved the situation. Facility will plan and scheduled yearly training for staff member to address all types of abuse and interventions for each. -The facility ' s policy has been revised to include procedures detailed actions to taken by staff if there is an occurrence of abuse. Completed on 7/23/2015. The staff in-services on the policy modification began on 7/24/2014 and will continue until all staff members have been in-serviced. -A log for continuous 1:1 monitoring will be added to the abuse prevention policy. Completed on 7/23/2015 -All new employees will be in-serviced on the abuse prevention policy during general orientation, and all current employees will be re-in serviced quarterly. Dated of completion: ongoing. -All residents will have an abuse risk assessment completed to begin on 7/23/2015, starting with residents on the unit where the incident occurred. All the resident ' s risk assessments to be completed by 7/24/2015. The abuse risk assessment will be completed upon admission, quarterly and as needed. -Each resident ' s care plan will address the abuse risk factors. Completed by 7/24/2015 and on- going process as needed. -A resident ' council meeting will be held on Monday 7/27/2015 to educate residents on how to report abuse. -All current staff will be in-serviced on new mock abuse drill procedure to be initiated by 7/23/2015 and completed by 7/24/2015. -During weekly QA rounds, the IDT (interdisciplinary team) will observe residents for signs and symptoms of abuse. Any observations will be reported to Social Services Director and Administrator/Designee. Date of completion 7/23/2015 and on-going.

Based on record review and interview the facility failed to provide one to one monitor for a male resident (R2) after he sexually assaulted a female resident. This failure affected 1 of 6 residents (R1) reviewed for abuse, in a sample of 15 On 7/18/2015 R2 (male resident) sexually assaulted R1 (female resident) as witnessed by E5 (certified nurse aide). Upon the discovery the facility staff allowed R2 to remain on units A and D without constant direct supervision until the time R2 was transferred to a local hospital. R2 remained in a room next door to R14 and R15 (R1 ' s roommates), after the sexual assault and sometime after the first shift, R2 was transferred to another room on the D unit without constant direct supervision from staff until the local law enforcement intervened on the morning of 7/20/15. The facility ' s failure to implement measures to protect a resident and call law enforcement when a crime is commented has the potential to affect 131 of 131 residents within the facility. An immediate jeopardy was identified on 7/18/2015 when the facility failed to have R2 removed from facility or have one to one direct supervision until he was transferred out. On the morning of 7/20/15 the local law enforcement placed an officer within a room with R2 and provided one on one to one supervision until R2 was transfer to a hospital for an evaluation. On 7/23/2015, E1 (administrator) was informed of the immediate jeopardy. The immediacy began on 7/18/2015 and was removed on 7/24/2015. Findings include: The facility's accident/incident reported dated 7/18/15 at 2:15am documented a certified nurse aide (E5) reported that she observed a male resident (R2) on bed with the resident (R1) partially disrobed. A written statement by E5 certified nurse aide (CNA) reads: I was just coming back from off break, and was about to do my round and heard R1 screaming. So I walked into her room and saw R2 was on top of her. R2 had his pants all the way down to his feet and his shoes were off. R2 had R1's dress all the way up with her legs open and having sex with her. After that I walked back to the door and called the nurse so she could see. By the time she got down to the room he was pulling his pants up and just walked out the room. All of this happened around 2:25pm. A written statement by E4 (nurse) reads: This writer was in the nursing station writing incident report on another resident. I did not see resident coming out of his room because the laundry cart in the hallway is blocking the two rooms involved. On 7/20/2015 at 1:40pm E3 (social service director) reported she was the person designated to receive abuse allegation in the absence of the administrator. E3 stated on 7/18/2015 she received a call from the facility's director of nurses/ DON (E2) informing her about the incident involving R1 and R2. E3 was unable to provide the time of the call. E3 said she reported the incident to the Administrator (E1), the Regional Director and the nurse consultant. E3 stated instructions were given to put R2 on one to one monitoring. The surveyor asked E3 when this occurred. E3 replied, approximately at 3am. E3 reported she arrived to the facility later at 7:45am, in which a local police detective was at the facility. E3 stated, the facility did not report the incident to the police and the hospital called the police. On 7/20/2015 at 5:05pm, E2 (DON) reported she was not on duty at the time of the incident involving R1 and R2. She was called on the phone by E4 (nurse) who was the designated night supervisor for 7/18/2015. E4 just before 3am called E2 and stated a CNA (E5) found R2 on top of R1. E4 wanted to know who was the abuse coordinator since E1 (administrator) was on vacation. E2 informed E4 it was E3 (social service director). E2 after speaking to E4 called E3 and reported the incident. E3 wanted to know what the CNA saw. E2 then called back to the facility to interview E5 (CNA) and called E3 with the details. At that point E3 took over. E2 stated, as she was arriving to the facility, she was re- routed to go to the police station sometime between 9-10am on 7/18/2015. The surveyor asked E2, what is the procedure for an allegation of rape or sexual assault? E2 stated the resident should be examined and checked for injury, the physician should be informed; an incident report generated and send the resident out for a rape kit. The surveyor asked if this was a part of the facility's abuse policy. E2 stated I don't know but that should be the procedure. E2 stated she instructed E4 to do just that (check R1 for injury) before she called E3. Next, the surveyor asked what should happen to the aggressor in this situation. E2 stated the abuse coordinator or the doctor determines what happen to the aggressor. E2 further stated, R2 was placed on every 15 minute check and a sheet was placed on his door. There is a paper log of who did the well-being checks. E2 said she would provide the surveyor with the documentation for the monitoring. On 7/21/2015 at 11:30am via phone, E4 reported she wanted to send R1 out and call the police but E2 told her not to call (the police) until the test (rape kit) comes back positive. On 7/21/2015 at 11:45am via phone, E5 reported she came back from break at 2:15am and she heard R1 screaming from the room. She went to the room. R2 was on top of R1, her (R1) gown was all the way up. R2 was having sex with R1. Once R2 saw her, R2 got off R1, pulled his pants up and walked out the room. E5 also reported after the incident occurred she continued taking care of the residents. She did not do one to one monitoring for R2. E5 stated she checked on both residents (R1 & R2) during rounds. Also, she was not continuously stationed in the hallway or the resident's room. E5 stated there were two CNA assigned to unit on the third shift. On 7/21/2015 at 2:05pm via phone, E6 (second CNA working the morning 7/18/2015) reported she did not know what happened with R1 and R2. She checked on him twice during the shift. She did not sit with him and was not continuously watching him during the shift. According to a face sheet R2 is a [AGE] year old male resident with [DIAGNOSES REDACTED]. R2's progress notes documented the following: -7/18/2015 08:22 hour documented: Upon arrival resident observed standing at the nursing station. When asked to return to room or go to the dining room for breakfast while nurse to nurse report given, resident stated, I'm not going nowhere! Resident on 15 minute monitoring by all staff on wing. Resident in room lay in bed at this time. -7/18/2015 14:56 hour documented: resident noted to become agitated upon asking resident to go to his room resident unable to be re-directed by staff. According to R2's minimum data set assessment dated [DATE] R2 had moderate cognitive impairment, had verbal behavioral symptoms directed toward others and needs oversight for transfer and walking. According to the minimum data set assessment dated [DATE] R2 is 68 inches tall On 7/20/2015 at 1:50pm, R2 was presented in a room with a local police officer presented. The surveyor attempted to ask questions. However, every question was answered with no. R1 was noted to ambulate within the room without any problems. According to a face sheet R1 is a [AGE] year old female resident. R1 [DIAGNOSES REDACTED]. R1's progress notes documented the following: -7/18/2015 11:21 hour documented: At about 2:45am the CNA/ certified nurse aide (E5) notified this writer that she observed a male resident on bed with a female resident. Upon writer entering the room the male resident was walking out the room with clothes on. The resident observed on the bed partially disrobed, legs opened. Assessment completed and indicated no visible bruise, no bleeding from the vagina and no signs and symptoms of pain to note at this time. DON (director of nursing) notified, Doctor page, Family member made aware. Resident transferred to hospital via ambulance for further evaluation/ exam. -7/18/2015 14:45 hour documented: Resident arrived from hospital via ambulance. Resident alert and oriented to self. Resident returned with [DIAGNOSES REDACTED]. Awaiting return call from doctor. According to R1's minimum data set (MDS) assessment dated [DATE] R1 is moderately cognitive impaired, had no activity for walking, needs extensive physical assistance for transfer and totally dependent on staff for dressing. Also R1 was 64 inches tall and weighed 110 pounds. On 7/20/2015 at 2:58pm, R1 was returned to the room transported by E7 (CNA) via wheel chair. When asked if anyone hurt her, R1 said yes and pointed a finger to her pelvic area. R1 was unable to provide specific details. R1 had two roommates R14 and R15at the time of the survey. According to a MDS assessment dated [DATE], R15 is moderately impaired, unable to walk and needs two people to assistance for transfer and bed mobility. According to a MDS assessment dated [DATE], R14 is also moderately cognitively impaired. According to the facility ' s census on 7/19/15 these two residents were present on the A-wing next door to R2, until he was transferred. The resident location monitoring log presented by E2 (DON) had dates of 7/18, 7/19 and 7/20/2015. On 7/18/2015 the time monitoring sheet is initially documented at 7:15am. The monitoring is documented in 15 minute intervals during the listed day. Surveyor noted monitoring the log sheet was not filled out completely. It lack some initials indicating checks were done, for the morning of 7/20/2015. The sheet did not indicate the location of the R2. On 7/21, 7/23 and 7/30/15 the surveyor watched parts of the facility ' s video tape surveillance of the resident ' s A and D units from 7/18-7/19/2015. The tape had footage at times in which R2 ambulated to and from his room, in the hallways or going to the nurse ' s station without staff accompanying him. On 7/21/2015 at 4:22pm via phone Z1 (detective) reported: at or about 5:10am the morning of 7/18/2015 the local police department was contacted by hospital personnel, who reported R1 was sexually assaulted by someone. Police officers viewed the facility's video tape and observed R2 entering R1's room during the 2am hour. R2 stayed in the room appropriately 9 minutes according to the time on the tape before a staff member entered the room. Z1 stated, he was initially told on 7/18/2015 by E3 (social service director) R2 was being monitored every 15 minutes. Later, Z1 received a called from E1 (administrator) stating R2 was being monitored one to one. Z1 report, the hospital doctor reported there was the present of sperm in R1's vaginal and the morning 7/20/2015 R2 was officially arrested. On 7/20/2015 between 9am-9:30am, Z1 with police officers came and arrested R2. Z1 stated because he was in under arrest an officer had to remain with R2 at all times. The facility took the following actions to removal the immediacy. Although the immediacy was removed on 7/24/2015 the deficiency harm level remains at the second level. -On 7/19/2015 an in-service was initiated for all managers and direct care staff member regarding following the facility ' s policy for calling law enforcement when a crime is commented. This in-service is to continue until all staff has been in-serviced. -On 7/23/2014 the facility had a meeting QA ( quality assurance) meeting with member to discussed and revolved the situation. Facility will plan and scheduled yearly training for staff member to address all types of abuse and interventions for each. -The facility ' s policy has been revised to include procedures detailed actions to taken by staff if there is an occurrence of abuse. Completed on 7/23/2015. The staff in-services on the policy modification began on 7/24/2014 and will continue until all staff members have been in-serviced. -A log for continuous 1:1 monitoring will be added to the abuse prevention policy. Completed on 7/23/2015 -All new employees will be in-serviced on the abuse prevention policy during general orientation, and all current employees will be re-in serviced quarterly. Dated of completion: ongoing. -All residents will have an abuse risk assessment completed to begin on 7/23/2015, starting with residents on the unit where the incident occurred. All the resident ' s risk assessments to be completed by 7/24/2015. The abuse risk assessment will be completed upon admission, quarterly and as needed. -Each resident ' s care plan will address the abuse risk factors. Completed by 7/24/2015 and on- going process as needed. -A resident ' council meeting will be held on Monday 7/27/2015 to educate residents on how to report abuse. -All current staff will be in-serviced on new mock abuse drill procedure to be initiated by 7/23/2015 and completed by 7/24/2015. -During weekly QA rounds, the IDT (interdisciplinary team) will observe residents for signs and symptoms of abuse. Any observations will be reported to Social Services Director and Administrator/Designee. Date of completion 7/23/2015 and on-going. Based on record review and interview the facility failed to have two staff member present while giving a resident incontinence care in the bed to prevent a fall. This failure applies to one of three residents (R10) reviewed for falls in a sample of 15 Findings include: Incident Report Form 7/29/15 R10 rolled out of bed onto the floor while a nurse aide was providing morning care. R3 sustained a laceration to the right side of the forehead. First aid was administered to R10, R10 was assessed for pain and injuries, range of motion to all 4 extremities was within normal limits. The nurse called 911, the family and physician were notified, and R10 was transferred to the emergency room . R10 returned to the facility the same day after glue was applied to close the laceration. Investigation Follow Up 7/29/15 documents R10 rolled out of bed while nurse aide provided incontinent care. New interventions are to increase R10 to an extensive 2 person assist with bed mobility and tilting needs. The fall care plan was updated. Handwritten and signed statement by E 20 (Nurse Aide) while tucking R10's incontinent brief , R10 spontaneous rolled out of the bed. On 8/3/15 at 11 am, R10 propelled himself very slowly in the wheelchair down the short hall between the A-B Nurses Station and dining room using only his arms. At this time, staff assisted R10 to his room by pushing the wheelchair. R10's legs are stiff and rigid, not bending when he sits in the wheelchair. R10 cannot answer questions, engage in conversation, or follow directions. On 8/3/15 at 11:05am, E 19 (Nurse Aide) stated R10 gets turned side to side to change the incontinent brief. E 19 stands on the open side of the bed, the other side of the bed is blocked by the wall. E 19 stated R10 cannot assist with turning or incontinent care and E 19 does not know what precautions have been put in place after the fall. On 8/3/15 at 11:45am, by phone, E 20(Nurse Aide) stated that R10 rolled out of bed while being changed. E 20 stated R10 was turned on the side facing away from the wall, E 20 was by R10's feet and tried to pull the brief out from under R10, toward the wall. R10 rolled away from the wall, off the bed, and onto the floor. R10 had a cut on the forehead. E 20 stated she gave a statement to the police. On 8/3/15 at 11:50am, by phone, E 21(Nurse) stated E 20 called her to the room and R10 was on the floor. E 20 tole E 21 that she pulled something out from under R10 and he rolled off the bed. E 21 assessed R10 for other injuries and pain, applied pressure and an ice pack to the forehead, initiated neurological checks, called 911, family, and physician, and sent R10 to the emergency room . On 8/5/15 at 12pm, E14(Wound Nurse) stated R10 is now a 2 person assist, has floor mats, and a lower bed in place after the fall. On 8/5/15 at 12:15pm, E 27(Restorative Nurse) stated as the nurse aide was pulling the incontinent brief from under R10, R10 rolled out of the bed. E 27 stated E 20 could have call for assistance because R10 cannot help turn or move, R10 cannot turn self or roll out of bed on his own. R10 is now a 2 person assist, and has a lower bed and floor mats in place.

Based on interview and record review, the facility failed to follow physician orders, the policy for drawing [MEDICATION NAME] levels, and the procedure for entering physician telephone orders for 1 of 3 residents (R1) reviewed for physician orders [REDACTED]. This failure resulted in R1 receiving 5 milligrams of the blood thinner [MEDICATION NAME] for 2 days when the level was higher than the recommended limit. R1 had nosebleeds and had to be transferred to the hospital and admitted to the intensive care unit for blood [MEDICAL CONDITION] and intravenous vitamin K to reverse the high [MEDICATION NAME] level. Findings include: On 6/8/15 at 8:30am, by phone, Z4 (Family) stated R1's blood got so thin, it caused a nosebleed. Closed record documents R1 was admitted to the facility from the hospital on [DATE] with the [DIAGNOSES REDACTED]. R1 was transferred to the hospital 10 days later on 2/03/15 because of a nosebleed, a high [MEDICATION NAME] level, and worsening circulation to the feet. [MEDICATION NAME] Lab results document elevated levels: 1/30/15 8.66 (normal range 2-3), hold [MEDICATION NAME] 1/30/15 and 1/31/15, resume [MEDICATION NAME] on 2/1/15, draw a level on 1/31/15. On 1/31/15 5.66, hold [MEDICATION NAME] 1/31/15 and 2/1/15, draw a level on 2/2/15. Progress Note documents R1's [MEDICATION NAME] level is elevated at 5.65, new orders given to hold [MEDICATION NAME] until Monday 2/2/15 and redraw 2/2/15. There are no lab results for 2/2/15. February 2015 Medication Administration Record (MAR) documents R1 received [MEDICATION NAME] 5 mg on 2/1/15 and 2/2/15 at 6pm. Physician order [REDACTED]. Progress Note 2/3/15 3:58pm, documents R1 was observed with nose bleeds off and on throughout the shift, Vitamin K 2.5 mg given orally, and an abnormal [MEDICATION NAME] level is noted (without a specific value). Lab results 2/3/15 document an elevated [MEDICATION NAME] level of 7.48. Notation to the bottom of the lab report documents R1 was sent to the hospital. R1's facility records do not contain a [MEDICATION NAME] Flow sheet. Hospital Physician Consult 2/4/15 documents R1 was discharged to this facility on 1/24/15 after a filter placement for the blood clots and being started on [MEDICATION NAME], a blood thinner. R1 was admitted to the intensive care unit and received blood [MEDICAL CONDITION] for a low blood level of 5.5 (normal range for R1 8-9) and intravenous vitamin K to reverse the elevated [MEDICATION NAME] level of greater than 11 (normal range 2-3). R1 is diagnosed with [REDACTED]. On 6/8/15 at 12pm, E3(Nurse) stated staff follow the anticoagulation policy and [MEDICATION NAME] is given in the evening. The following interviews took place on 6/9/15: At 10:40am, Z3(Nurse Practitioner) stated R1 was on [MEDICATION NAME] for blood clots in the legs. At 2:15pm, Z3 stated R1's [MEDICATION NAME] level should have continued to decrease if [MEDICATION NAME] was not given on 2/1/15 and 2/2/15. R1's level should have been checked as ordered. Checking the [MEDICATION NAME] level a day later and after receiving 5 mg for 2 days in a row with an already elevated level, Z3 would expect the level to be even higher, increasing R1's risk of bleeding. On 2/3/15, Z3 ordered oral vitamin K to counteract the high [MEDICATION NAME] level. R1 bled because the [MEDICATION NAME] level was very high. Z3 stated she did not know R1 received the 2 doses of [MEDICATION NAME] when they should have been held. At 3:10pm, E2(Director of Nursing) stated nurses write up a lab requisition when labs are ordered. E2 asked why R1's [MEDICATION NAME] level was not drawn on 2/2/15 and the lab did not know why. E2 stated when a nurse takes a telephone order from a physician, they are responsible for entering it into the computer as an order. If the order is to hold a medication, the order automatically populates to the Medication Administration Record (MAR) and an H is recorded in the box for the days the medication is not to be given. A held medication will not appear on the screen during administration times. E2 stated she will look for R1's [MEDICATION NAME] Flowsheet. At 3:15pm, by phone, E6(Nurse) stated the most recent order overrides the last order. E6 remembers R1's lab order but does not remember if the order to hold [MEDICATION NAME] was entered into the computer. E6 stated nurses are to wait for the next [MEDICATION NAME] level before giving [MEDICATION NAME] in the evening. At 3:35pm, E7(Nurse) stated R1 had nosebleeds on and off throughout the day shift 2/3/15. The nosebleeds would stop and start, but were not uncontrollable. E7 stated R1 had an abnormally high [MEDICATION NAME] level, Z3 ordered oral vitamin K, E7 gave the vitamin K, and R1 was sent to the hospital. E7 stated if [MEDICATION NAME] was scheduled on the [DATE]/2/15, it was administered. E7 reviewed the February 2015 MAR and confirmed R1 received 5 mg of [MEDICATION NAME] on 2/2/15 and E7 confirmed the computer initials. At 4pm, by phone, E8(Nurse) stated if R1 had [MEDICATION NAME] scheduled and the initials are on the MAR, then [MEDICATION NAME] was given on 2/1/15. Anticoagulation Therapy Policy - All residents on anticoagulation therapy shall have their medications monitored monthly, unless otherwise ordered by a physician. All residents on [MEDICATION NAME] should have an order for [REDACTED]. The facility does not have a policy regarding telephone orders.

Based on record review and interview the facility failed to develop individualized interventions to decrease risk of falls and provide adequate supervision for one resident (R2) who experienced 3 out of 4 unwitnessed fall incidents with major injury in the sample of four residents reviewed for falls with major injury. This failure resulted in R2 sustaining facial trauma. Findings include: 1. R2 was a [AGE] year old resident with [DIAGNOSES REDACTED]. R2 has a personal history of falls while living in the community. The accident/incident report dated [DATE] indicates at 3:40pm, R2 was observed on the floor in a sitting position, face against the wall on the right side. R2 sustained a quarter sized hematoma over the right eye. The Health Status Note dated [DATE] indicates R2 developed swelling and bruising dark in color noted to right side of face with eye closed. R2 informed E4 (nurse) he fell the previous night when he got out of the chair. The fall assessment dated [DATE] indicates a score of 11.0, moderate risk. The fall assessment dated [DATE] indicates a score of 13.0, moderate fall risk. The physician's orders [REDACTED]. The fall assessment dated [DATE] indicates R2 is a high risk, score of 19.0 Individualize the care plan intervention On [DATE] at 1:15pm E3 (assistant director of nursing/ADON) stated, "we assessed him. A clip alarm was tried before the soft belt. The clip alarm wasn't effective. He would get up and want to walk. The belt was a (brand name) hook and loop belt. He could take it off sometimes." When asked what medical symptom is being treated by using this belt, E3 stated, "confused state of mind. It helped him stay seated." The care plan (initiated [DATE]) has interventions for safe environment, anticipate and meet needs of the resident, ensure call light within reach, low bed with bilateral floor mats, refer to therapy, educate resident family and caregivers, ensure resident wears appropriate footwear, follow facility fall protocol. The incident note and incident/accident report both dated [DATE] indicate it was brought to E6's (night nurse supervisor) attention that R2 was sitting down in the middle of the hallway. No shoes or socks noted on his feet. R2 was assisted back to bed. MD (medical doctor) paged, awaiting return call. There is no documentation to indicate if the MD answered the page. This was R2's second unwitnessed fall. On [DATE] at 7:10pm E2 (director of nursing) stated, "I'm the fall coordinator. The first thing the nurse is to do after a fall is an assessment, determine the severity of the injury, neuro checks, assist the resident back to bed or chair and if there are injuries, get physician's orders [REDACTED]. The revised care plan interventions dated [DATE] are: 1) educated D wing staff on the importance of ensuring resident has proper footwear on 2) educated staff on importance of ensuring that residents call light is attached to his chair or side rail for easy access. There is no intervention listed for increased monitoring of R2. The readmission fall assessment dated [DATE] indicates a score of 15.0, moderate fall risk. The incident note dated [DATE] at 7:45am indicates upon entering the room R2 was noted in chair, back on chair against the floor, head on the wall. R2 noted to have shoes, floor free from clutter. R2 assessed, no injuries noted. The fall assessment dated [DATE] indicates a score of 14.0, indicating R2 is a moderate fall risk. The care plan intervention dated [DATE] indicates "added anti-tippers to resident's wheelchair to prevent resident from leaning backwards while sitting in the wheelchair, recommend MD (medical doctor) evaluate resident for any un-diagnosed medical condition, which might contribute to falls. There are no interventions listed for increased monitoring of R2. On [DATE] at 9:45am E2 stated, "he (R2) was leaning backwards in his chair. He was in a wheelchair. The back of the chair was on the floor and his head was against the wall. The anti-tippers for the wheelchair was the only intervention added to the careplan. That was for the staff. There is no intervention for the resident." The incident note dated [DATE] at 6:50pm indicates R2 was found on the floor by his roommate. R2 was attempting to walk to bathroom and fell to floor. R2 sustained a hematoma to the right forehead and complained of head pain. Resident assessed, given acetaminophen 650mg for pain. The fall assessment dated [DATE] indicates a score of 19.0, high fall risk. The care plan intervention dated [DATE] is neuro checks initiated, ice pack applied to site of hematoma. All of the care plan interventions do not include the information from the fall assessments to aid in developing and implementing a individualized care plan for R2. On [DATE] at 9:45am E2 stated, "he (R2) got out of bed with the nasal cannula attached to the concentrator. It drew him backwards and he fell to the floor near the roommate's foot of the bed. At 4:35pm E9 (CNA/certified nurse aide) stated, "he (R2) used to try to crawl out of the bed. I usually sit in his doorway so I could monitor him He wasn't steady." The Health Status Note dated [DATE] indicates at 7:45am R2 was noted upon assessment with right pupil fixed and dilated. R2's primary physician was notified and gave orders to send R2 to the hospital for evaluation and treatment related to change in LOC (level of consciousness). The next Health Status note entry at 3:36pm indicates R2 was in CCU (cardiac care unit) admitted with intracranial bleeding. Review of the hospital records dated [DATE] - [DATE] indicate R2 was admitted to the CCU (coronary care unit) with [DIAGNOSES REDACTED]. R2 went into cardiac arrest and expired on [DATE] at 3:08am. The Certification of Death Record indicates the immediate cause of death as Cerebral Injuries due to Fall. On [DATE] at 12:50pm via telephone Z1 stated, "the hospital staff told us if he (R2) could have been sent out sooner, they could have drained the fluid off his brain and maybe he wouldn't have died so quickly. They couldn't do anything else, it was too late." Several unsuccessful attempts were made to interview Z2 regarding R2's falls. The Facility Fall Program (dated [DATE]) includes several interventions including Update Fall Assessment, Initiate Fall Interventions and Update Care Plan. On [DATE] at 12:20pm via telephone, E2 (director of nursing) was asked if the Facility Fall Program document is considered their fall policy and procedure. E2 stated, "no, I can fax a copy to you." E2 faxed a copy of the facility's Accident's & Incidents policy and procedure. Review of this policy and procedure does not specifically indicate nursing staff's responsibility related to fall incidents. At 2:25pm via telephone, E1 (admnistrator) was asked if the Accidents & Incidents policy and procedure is considered the fall policy and procedure. E1 stated, "that's what we use for falls. The fall check off is what we use also. It's a mirror of the Accident & Incident policy."

Based on record review and interview the facility failed to ensure one resident (R2) in the sample of four reviewed for falls with injury received immediate care and services after a change in medical conditon after two separate fall incidents which resulted in major injuries to R2's right eye and face and altered mental status. This failure resulted in the delayment of treatment and services and subsequent hospital admission. Findings include: 1. R2 is a [AGE] year old resident with [DIAGNOSES REDACTED]. R2 has a personal history of falls while living in the community. The incident note and incident/accident report both dated [DATE] indicate it was brought to E6's (night nurse supervisor) attention that R2 was sitting down in the middle of the hallway. No shoes or socks noted on his feet. R2 was assisted back to bed. MD (medical doctor) paged, awaiting return call. There is no documentation to indicate if the MD answered the page. This was R2's second fall. The health status note dated [DATE] at 2:16am indicates R2 received alert with periods of confusion. Receiving oxygen at 4 liters per nasal cannula. Oxygen saturation at 90% At 3am, E6 noted R2 with labored breathing, unresponsive to tactile stimulation. Vital signs checked, Temperature 97.8, pulse 88, respirations 26, blood pressure ,[DATE], oxygen saturation 78% at 3 liters via nasal cannula. Oxygen increased to 6 liters. There is no indication E6 notified R2's physician or E2 (director of nursing) of R2's change in condition. **MD interview At 7:05am, E4 (nurse) documents received R2 in room up in wheeled recliner warm to touch with eyes closed, labored breathing, responding slowly to verbal commands with jerking motions to upper and lower extremities. Oxygen nasal cannula in place, oxygenation 80%. Staff assisted R2 to bed. At time time R2's primary physician was notified. Orders were received to send R2 out to the hospital for evaluation. R2 was admitted to the hospital with [REDACTED]. The written statement dated [DATE] by E10 (CNA/certified nurse aide) indicates in part that R2 was not feeling well on the 11pm-7am shift. E10 informed the nurse (E6) what was going on. Written statements by E9 (dated [DATE]) and E11 (dated [DATE]) both CNAs (certified nurse aide) indicate E6 was made aware of R2 being slow to respond to stimulation and having difficulty breathing and E6 did not address R2's change in condition. The Employee Memorandum (Progressive Disciplinary Form) dated [DATE] indicates: E6 violated a general conduct rule when she neglected to ensure that a resident (R2) SBAR (Situation Background Assessment Response) assessment was completed, due to the resident having a change in his condition. In addition to that, the resident (R2) continued to decline throughout the night, yet employee did not intervene and treat appropriately. Moreover, the resident had to be sent to the hospital by the relieving nurse (E4) and was admitted to ICU (intensive care unit). E6 was terminated shortly thereafter and was not available for interview. The policy and procedure for Physician Notification of Resident Change of Condition indicates: Policy: The resident's attending physician will be notified of changes that occur in the residents condition by Licensed Personnel as warranted. Physician notification is to include, but not limited to the following: b. significant change in /or unstable vital signs. d. Any Accident or Incident with or without injury. i.e. falls, skin tears, bruising, etc. j. Change in Level of Consciousness Responsibility: It is the responsibility of the Charge Nurse to notify the physician of any changes in a resident's condition. Procedure: When a change has been noted in a resident's condition, the Charge Nurse must assess the resident, document the change in the resident's medical record and notify residents attending physician. 2. The incident note dated [DATE] at 6:50pm indicates R2 was found on the floor. R2 sustained a hematoma to the right forehead and complained of head pain. The Health Status Note dated [DATE] indicates at 7:45am R2 was noted upon assessment with right pupil fixed and dilated. R2's primary physician was notified and gave orders to send R2 to the hospital for evaluation and treatment related to change in LOC (level of consciousness). At 7:55am the ambulance was called. ETA (estimated time of arrival) of 20 minutes. The investigation Report ([DATE]) indicates at 8:03am E8 (night shift supervisor) called the hospital and spoke to the ER (emergency room ) nurse who stated to hang up the phone and call 911. On [DATE] at 4:20pm via telephone, E8 stated, "my last time seeing him (R2) was around 6:30am for meds. All he said was ok." After reading E8's written statement and was asked why 911 wasn't called initially, E8 stated, "we have the liberty to call 911. I was following the doctor's order to sent him out to the hospital. Yes, I did speak to the ER (emergency room ) nurse at the hospital. She did say call 911. To be honest, everything was moving pretty fast." At 8:15am, the ambulance was canceled, 911 called. R2 was transported via stretcher at documented time of 8:30am. Unresponsive to verbal stimuli. A total of 25 minutes passed before 911 was called. An additional 20 minutes passed before R2 was transported out of the facility. On [DATE] at 12:50pm via telephone Z1 stated, "the hospital staff told us if he (R2) could have been sent out sooner, they could have drained the fluid off his brain and maybe he wouldn't have died so quickly. They couldn't do anything else, it was too late." Review of the hospital records dated [DATE] - [DATE] indicate R2 was admitted to the CCU (coronary care unit) with [DIAGNOSES REDACTED]. R2 went into [MEDICAL CONDITION] and expired on [DATE] at 3:08am. The Certification of Death Record indicates the immediate cause of death as Cerebral Injuries due to Fall.

Based on interview and record review, the facility failed to implement their smoking and contraband/search policy to prevent an accident for 1 of 3 residents (R1) reviewed for supervised smoking in a sample of 3. This failure resulted in R1 possessing a cigarette lighter to read a paper and subsequently catching his beard and body on fire. R1 was admitted to the hospital for treatment of [REDACTED]. Findings include: R1 was admitted to the facility on [DATE], according to the clinical record safe smoking assessment dated [DATE], R1 was evaluated to require supervision while smoking, the assessment also notes that R1 may not manage smoking materials. R1 is noted on the assessment to have anxiety and forgetfulness. A review of R1's plan of care dated 10/4/2012 notes that R1 has been assessed to require supervision while smoking. The interventions to include safety awareness and rules, family to be made aware of supervision to ensure compliance. R1's social service progress notes dated 10/2/12 denote "Writer also assessed resident and reviewed facility's smoking policy, with resident (R1) and that he has been assessed as a supervised smoker. R1's sister is involved in R1's care, and was informed that R1 was unable to have smoking materials because he was assessed to require supervision while smoking. Review of the facility's surveillance video dated 11/8/12 at 14:13 (2:13pm) showed staff (E2-Social Service Director, E5-Activity Aide Director) talking to R1, cigarettes being removed by R1 from his shirt then R1 go to his room. On 11/14/12 at 2:45 PM E5 stated, saw R1 sitting in wheelchair with cigarettes in his shirt pocket. E5 states she asked R1 for the cigarettes and told E2. E5 states we educated R1 on the risk of having cigarettes and asked him did he have any more and R1 said "No". E5 states she did not do body check for smoking contraband, it was social service responsibility to do body check, which is done in residents' room. Review of the facility's surveillance video dated 11/8/12 at 14:58:35 (2:58pm) E2 entered R1's room then left the room at 14:58:51, 16 seconds later. On 11/14/12 at 2:10pm E2 stated she went to R1's room later after being informed that R1 had cigarettes in his possession. E2 stated that it is a facility practice to search for contraband after a resident is found with unauthorized smoking materials. E2 stated the room search was quick because R1 did not have many items in his possession. E2 stated she searched his dresser drawers, closets and asked R1 to empty his pockets. E2 stated she did not check inside R1's pockets. E2 stated she did not check R1's back pockets of his pants, socks, shoes and/or undergarments for smoking contraband, because R1 told her that he did not have anything in them. Review of facility's Policy on Smoking, dated September 2012, denotes "Residents requiring supervision during smoking sessions may not store their own smoking materials". Review of facility's policy on room searches, contraband items and removal of contraband denote "This organization reserves the right to conduct inspections if there is a reason to suspect/believe that a resident has contraband items/materials in his/her possession. These items include, but are not limited to, alcohol, illicit (street) drugs, weapons, and smoking materials. The following items are not allowed in the residents' possession if he/she has been assessed as an unsafe smoker-cigarettes, cigars, rolling papers, matches and lighters. According to the policy the mentioned items cause the risk of exposing self, peers to a dangerous situations. Residents are responsible for cooperating with room and personal searches. Residents may also be required to empty all their pockets, remove jackets, vests, shoes and socks and demonstrate that they are not hiding anything in undergarments." Review of the facility's surveillance video dated 11/8/12 at 15:38:09 PM (3:38pm) showed a resident in front of R1's room in hall yell to the nurses' station. E3, Social Service Assistant ran out of the office into R1's room. E1, Assistant Director of Nursing (ADON) and another staff member running to R1's room within seconds. E10, Wound Nurse ran to B nurses' station and pull fire alarm and then ran to R1' room. Review of the facility's video surveillance video from 11/8/12 at 15:41 (3:41 PM) a conscious R1 being wheeled out of his room. The local fire department was noted arriving to the facility at 15:41 (3:41 PM). On 11/14/12 at 2:25 PM E10 stated, heard staff yell fire, pulled fire alarm and then went to R1's room saw smoke and pulled off R1's shirt, noticed that R1's right arm was red. E10 stated we put him in the wheelchair and pushed him to the front door where ambulance and police were there. E10 stated she heard E1, ADON ask R1 what happened and R1 responded that he was trying to read the paper with a lighter. Review of the facility's accident/incident report dated 11/8/12 denotes "A resident yelled there a man on fire here, 2 nurses and social service assisted immediately rushed to scene with fire extinguisher yelling directions to call emergency services. All residents removed and accounted for. Emergency services arrived post code red." Record review of facility's follow up to resident incident denote " Upon questioning by the fire department, the resident (R1) stated he was trying to utilize his lighter to read a document in the room and caught his beard on fire." On 11/21/12 at 11:15 AM E1, ADON stated, rushed to R1's room to assist staff in putting out fire that was on R1's right arm and clothes. E1 stated after fire was put out staff and her put R1 in a wheelchair and rolled him to the front lobby where the ambulance was. E1 states R1 still had a cigarette lighter in his hand when they rolled him to the front lobby. E1 stated, asked R1 what happened and R1 told her that he was trying to read a paper in his room and his beard caught on fire. E1 stated R1 told her that his brother brought him cigarettes and a lighter yesterday. E1 stated R1's sister was involved in his care and was aware of the smoking restrictions. Record review of R1's nurse's notes dated 11/8/12 written at 6:00 PM denotes "Resident's (R1) Brother In-law called to facility to check on status of resident (R1). Informed brother in-law that resident had a family member bring him smoking materials when resident is an supervised smoking program at this facility. Brother In-law stated that on 11/7/12 he brought cigarettes and lighter to resident and was not aware of all smoking regulations." Record review of reporting officers report dated 11/8/12 denotes "Reporting officer later spoke with assistant nurse manager (E1-ADON) and she advised reporting officer that the victim (R1) was trying view a sheet of paper in front of his face while using a cigarette lighter for light. The manager (E1) went on to state that the victims beard caught on fire and then his clothing. Reporting officer later learned from the ambulance crew that victim suffered second degree burns on various parts of his body. The victim was treated on scene and later transported to a nearby hospital for treatment." Review of R1's hospital record dated 10/8/12 denote Clinical Impression: 2nd degree burn-superficial thickness right upper extremity, right lower extremity, trunk and face 25-30 % total body surface area. On 11/27/12 at 9:25 AM Z1, Medical Doctor stated R1 is confused at times and noncompliant with his medicine sometimes. Z1 stated R1 sometimes believes what others say then will do what he wants to. Z1 stated R1 was not suppose to have the lighter, and should have been supervised or monitored by facility staff while using smoking materials. R1 used the lighter and caught himself on fire. Z1 stated the fire caused by the lighter caused the second degree burns not the fire extinguisher.