Every finding on record at Aliya on 87TH

Based on interview and record review the facility a.) failed to provide a proper transfer for a dependent resident that required a two person assist with a mechanical lift, b.) failed to communicate a resident's mode of transfer to a new employee and c.) failed to educate a staff of how to properly transfer a resident. This failure resulted in one (R4) resident sustaining an impacted transverse fracture of the right humeral neck and the greater tuberosity during the resident transfer from the wheelchair to the bed.Findings Include:R4 was admitted to the facility on [DATE] with diagnosis not limited to Dementia, Anxiety Disorder, Peripheral Vascular Disease, Gastrostomy, Hyperlipidemia, Major Depressive Disorder, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Need for Assistance with Personal Care, Reduced Mobility, Disorder of Brain and Unspecified Displaced Fracture of Surgical Neck of Right Humerus, Initial Encounter for Closed Fracture. R4's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 09 indicating moderate impairment. Section GG Functional Abilities: Mobility Devices: Wheelchair, Chair/bed-to-chair transfer: Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. or, the assistance of 2 or more helpers is required for the resident to complete the activity.R4's Care Plan document in part: Focus: R4 is at risk for alteration in Comfort. 03/12/26 readmitted to facility with right humerus fracture. Focus: R4 has history of Cerebral Vascular Accident (Stroke). Focus: ADL (Activities of Daily Living): R4 requires assistance with daily care needs r/t (Related to) Right side hemiplegia/hemiparesis and COPD (Chronic Obstructive Pulmonary Disease). Interventions: Mechanical lift with two assists for transfers. Date Initiated: 01/04/25. Focus: FALL: R4 is at high risk for falls r/t generalized weakness and left side hemi. Date Initiated: 01/14/26. Interventions: Currently uses manual wheelchair for mobility needs. Mechanical lift with two assists for transfers. Date Initiated: 01/14/26. Focus: Potential for falls, R4 at HIGH risk for injury from falls. Date Initiated: 01/16/26. Focus: SKILLED/ADL: R4 has a Self-care deficit r/t Hemiparesis, hemiplegia and CHF (Congestive heart failure). Interventions: Use mechanical lift for all surface-to-surface transfers.R4's Physician order document in part: Order: Right Humerus, 2+ Views / Right Elbow, 2 Views / Right Shoulder, Complete, 2+ Views / Right Wrist, 2 Views / Right Forearm, 2 Views / Right Hand, 2 Views Completed Imaging X-Ray 03/11/26 00:00. 1. Non weight bearing to right arm, use of sling for comfort. 2. Non weight bearing right upper extremity shoulder immobilizer for comfort. 3. Elevate and ice right upper arm extremity. Every shift for comfort measures.Radiology Results Report dated 03/11/26 document in part: Right Humerus, 2+ Views / Right Elbow, 2 Views / Right Shoulder, Complete, 2+ Views / Right Wrist, 2 Views / Right Forearm, 2 Views / Right Hand, 2 Views. Right Humerus 2+ Views. Clinical information: Pain. Findings: Right Humerus examination reveals impacted transverse fracture of the humeral neck and the greater tuberosity. Impression Right Humerus: Fracture of the humeral neck and greater tuberosity. Findings: Right Elbow: Examination reveals mild soft swelling. Findings: Right Shoulder examination reveals slightly impacted transverse fracture of the humeral neck and the greater tuberosity. Findings Right Wrist examination reveals soft tissue swelling. Findings: Right Forearm examination reveals mild soft tissue swelling. Findings: Right Hand examination reveals mild soft tissue swelling.Progress note dated 03/10/26 22:00 document in part: Summary for Providers Situation: The Change in Condition/s reported Evaluation are/were: Pain (uncontrolled). Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: - Pain Status Evaluation: Does the resident/patient have pain? Yes, Nursing observations, evaluation, and recommendations are: Complain of RUE (right upper extremity) with touch or movement. PRN (as needed) Pain medication given. rest encouraged. Primary Care Provider responded with the following feedback: A. Recommendations: Hold Tramadol while taking NORCO Start Norco 5/325 mg (milligram) tablet - 1 tab/via gastric tube/q (every) 6hr (hours)/prn for pain Order x-rays of right humerus, right forearm, right hand and wrist B. New Testing Orders: - X-ray - New or Change in Medications.Progress note dated 03/10/26 22:39 document in part: Extremity Pain History Present Illness: R4 reporting pain to the RUE that started this evening. R4 has no prior history of similar pain in the past. R4 was given Tramadol about an hour ago with no improvement in pain. States pain started as she was being transferred from wheelchair to bed and twisted arm. Per nurse and/or patient Diagnosis, Assessment/Plan: - Pain in right upper arm (Primary). Order x-rays of right humerus, right forearm, right hand and wrist.Progress note dated 03/11/26 00:27 document in part: Nursing Note: STAT X-Rays of RUE (right upper extremity) per order.Progress note dated 03/11/26 02:51 document in part: STAT X-rays of right humerus, right forearm, right hand and wrist r/t right upper extremity pain STAT X ray of right humerus, right forearm, right hand and wrist r/t pain completed on 03/11/26 at 0215.Progress note dated 03/11/26 03:01document in part: Nursing Note: occasional c/o pain to right arm with movement, x ray of right arm completed this night shift.Progress note dated 93/11/26 06:10 Diagnostics Note Text: Relayed STAT Radiology results of x ray of right humerus, right elbow, right wrist, right forearm, right hand. Impression: impacted transverse fracture of the humeral neck and the greater tuberosity with no significant displacement. Orders received to send resident to emergency department for further eval and treatment.Progress note dated 03/11/26 07:37 document in part: Radiology review: abnormal results and/or requiring provider assessment History Present Illness: Patient presenting for a radiology review. Patient started complaining of right shoulder pain during yesterday evening shift. Radiology report shows a fracture of the right humoral neck, and greater tuberosity. RN reports tenderness to area and reduced ROM (range of motion) and rate upper extremity. Exam findings per nurse and video observation: pain and guarded movements in right arm. Reduced ROM in right arm. Diagnosis, Assessment/Plan: Unspecified fracture of upper end of right humerus, initial encounter for closed fracture (Primary.) This is an acute new problem Condition is guarded Fracture of the right humoral, neck, and greater tuberosity Orders: Transfer to Emergency Department.Progress note dated 03/11/26 14:36 document in part: Nursing Note: Resident admitted to Hospital with dx (diagnosis). closed Humerus fx (fracture).Progress note dated 03/12/26 21:16 document in part: Nursing Note: resident received from Hospital via stretcher with dx. Right Humerus neck fracture. Patient with complaints of pain to right arm, Patient has sling present in hospital belongings.R4's initial reportable dated 03/11/26 document in part: date of incident 03/11/26. Time of incident 9am. R4 complain of pain in right arm. X-ray was done and noted with abnormalities. R4 was sent to the hospital for further evaluation. Resident is alert and verbally responsive with periods of forgetfulness.R4's final reportable dated 03/16/26 document in part: summary of investigation: Based on thorough investigation through staff interviews and medical record reviews. R4 was up in a wheelchair on 03/10/26 before lunch and was seated in the dining room. At approximately 2:00 pm V29 (Licensed Practical Nurse) stated that R4 requesting to go back to bed. Assigned CNA (Certified Nurse Assistant) was providing care to another resident. V29 sked another CNA to assist resident back to bed. V26 (Certified Nurse Assistant) stated that he brought R4 to room and proceeded to transfer R4 to bed with use of gait belt. Once in bed, Nurse came to assist V26 in repositioning R4. V26 then proceeded to leave room when R4 complained of pain to right wrist. Interviewed V26 and stated when he assisted R4 to stand with gait belt, R4 noted to grab the quarter rail. Xray showed slightly non-displaced fracture of the humerus. Final: Based on the known facts, interviews and medical records it was determined that during transfer, R4 grabbed the quarter rail. Xray showed slightly non-displaced fracture of the humerus.On 04/07/26 at 12:53 PM V10 (R4's Family Member) stated on 03/10/26 R4 complained to the nurse that her arm was hurting severely. R4's arm was broken, and they wanted to send R4 to the hospital. No one knew what happened. They said R4 fell out the bed but R4 was immobile. After I did some further investigations myself, I found out that it was poor transfer and they handled R4 incorrectly. They were doing the investigation but would never tell me who it was. R4 said no one dropped her and she did not fall out of the bed. R4 is very verbal and direct. I found out that R4 was mishandled when I met with, V35 (3rd floor Unit Manager) and V1 (Administrator).On 04/07/26 at 11:55 AM V8 (Restorative Director) stated R4 has had falls in the facility but none recently with injuries. R4's last fall according to risk management was 12/19/24. The injury of unknown origin, briefly R4 had a fracture but it was not due to a fall. R4 is max assistance and 2-person assistance for all transfers. R4 follows verbal commands, has a gastric tube, a history of Cardiovascular Accident, non-ambulatory and on oxygen.On 04/08/26 at 12:28 PM Per telephone interview V38 (Certified Nurse Assistant/Activity Aide) stated On 03/09/26 R4 was not in any pain and did not say anything was wrong with her. R4 is transferred using the mechanical lift with 2 persons assistance. You can find the transfer status in Point Click Care, log in and go under Kardex or you can ask restorative.On 04/08/26 at 01:11 PM V13 (Licensed Practical Nurse) stated I worked on 03/09/26 and R4 had no complaints of pain. R4 is a total assist and has a gastric tube. R4 is probably transferred using a mechanical lift but I am not 100% sure.On 04/08/26 at 11:54 AM Per telephone interview V39 (Certified Nurse Assistant) stated R4 is transferred using the mechanical lift with 2 or more assists. I was there that morning on 03/10/26 and R4 did not complain of pain. We got R4 up in the wheelchair using the mechanical lift. R4 is verbal, will make her needs known and will let you know if she is in any pain.On 04/07/26 at 03:38 PM V26 (Certified Nurse Assistant) stated I have worked here for 1 month. I don't have a permanent floor, but I mainly work on the third and sometimes on the second floor. I know R4 but I was not assigned to her. I put R4 in bed using my gait belt. It was about 1:45 PM and R4 was in the hallway. It was one of the female nurses that ask me to put R4 in bed because R4 had been up all day and was tired. R4 was in a wheelchair, and I took her into the room, put my gait belt around her and proceeded to stand and pivot. R4 grabbed on the bedrail, let it go then grabbed me and I sat R4 on the bed. When I was about to exit the room, R4 said my arm hurt. I went and notified the female nurse. The nurse said okay, I will go and assess her. The nurse did not tell me how the resident was supposed to be transferred. That was my first or second day on the floor. I was not aware that R4 was a 2 person assist with a mechanical lift. I was aware R4 was injured when they started investigating.On 04/07/26 at 03:19 PM V25 (Registered Nurse) stated I am one of the nurses that take care of R4. R4 has a gastric tube, wheelchair bound, needs staff assistance for transfers, alert and oriented x2. I am not sure how R4 is transferred but I know R4 needs staff assistance for transfers. On 03/10/26 when I came on the shift doing rounds and passing medications R4 complained of pain to her arm, and I gave her pain medication. I believe it was the right arm. R4 was in bed when I initially saw her. Subsequently, when I was passing medication that night R4 complained of more pain. The doctor ordered an Xray, so I called for a Stat Xray and endorsed it to the oncoming nurse.On 04/08/26 at 04:17 PM Per telephone interview V49 (Registered Nurse) stated I received during report R4 complained of right arm pain. The previous nurse ordered an Xray and asked me to look for the results. I received the report and received an order to send R4 to the hospital for evaluation. R4 never complained of pain to her arm before that day. I received the in-service about transfers in February. Sometimes there are things that I miss out on because I am part time. When we attend an in-service, we have to sign a sheet to verify we attended and do a return demonstration.On 04/08/26 at 12:06 PM Per telephone interview V42 (Certified Nurse Assistant) stated R4 is a 2-person assist with a mechanical lift and would be considered a total. R4 did not complain of pain prior to her injury to her right arm.On 04/08/26 at 10:50 AM Per telephone interview V18 (Former Director of Nursing) stated V25 (Registered Nurse) called me and said R4 was having pain. V25 gave R4 pain medication and R4 was still complaining. V25 called telehealth and they ordered a different pain medication and to get an Xray. The Xray came back with the impression of a fracture. The nurse called the doctor and was given an order to send R4 out for evaluation. During the investigation V29 (Licensed Practical Nurse) asked V26 (Certified Nurse Assistant) to put R4 in bed. V26 used the gait belt when transferring R4 to bed, R4 grabbed the side rail, V26 sat R4 on the bed then got R4 the rest of the way in bed. After V26 placed the rest of R4's body in bed R4 complained of pain to the arm. I don't remember which arm. V26 made R4 comfortable and said that he went and told the nurse. When I was doing the investigation V29 (Licensed Practical Nurse) said she did not know anything about R4's pain. The only person that called me about R4's pain was V25 (Registered Nurse). V26 said he told the nurse but didn't remember her name. R4 was supposed to be transferred using the mechanical lift with 2-person assistance and R4 was not properly transferred from the wheelchair to the bed. When not using the right device to transfer a resident there is a potential for injury.On 04/08/26 at 09:40 AM V29 (Licensed Practical Nurse) stated I was told the next day about R4 going out for her right arm due to the Xray that she had for a fracture to the right upper humerus. When R4 came back from the hospital R4 had a sling to be applied when out of bed and an ice pack was applied to the shoulder. R4 is alert and oriented x1 to name.On 04/08/26 at 10:37 AM V35 (3rd floor Unit Manager) stated R4 was complaining of pain and discomfort to her arm. The nurse got an Xray, received the results and R4 went to the hospital. R4 returned to the facility with a sling and ice. R4 is a mechanical lift with 2 people assist. The protocol for knowing how to properly transfer the residents is by looking at the Kardex under task or the staff should ask the nurse how to transfer the resident. If the resident is improperly transferred it can potentially cause an injury.On 04/08/26 at 04:05 PM Per telephone interview V47 (Nurse Practitioner/Physical Therapy) stated I know R4, she was referred to therapy. In my professional opinion if a resident is transferred using improper transfer techniques, there is a potential for injury. If the proper transfer techniques were used the injury could have been avoided. On 04/08/26 at 12:23 PM V1 (Administrator) stated we identified there was an issue with the resident transfer. We did the reeducation of the staff, the monitoring of the residents and we did an in-service. The PNC (Past Noncompliance) we identified with the staff, and we did a QA (Quality Assurance) form to make sure it does not happen again. The staff go to the Kardex to see what type of care needs to be provided for the residents. The failure that was recognized, the transfers of using a mechanical lift. During the investigation the root cause of the resident we noted transfer technique was the failure and the completion date was 03/13/26. The incident happened on 03/10/26 and we did competencies for the sit to stand and mechanical lift. Restorative did the in-services. When we were doing the investigation we noted R4's transfer was improper.On 04/08/26 at 01:20 PM V8 (Restorative Director) stated I did not see R4's report. I had to do the in-service about how to properly transfer, stand pivot, gait belt use and mechanical lift. We do a return demonstration.On 04/08/26 at 01:34 PM V1 (Administrator) stated all of the certified nurse assistants and nurses were in-serviced on proper transfers. On 04/08/26 at 02:11 PM V1 (Administrator) stated all staff should have been in-serviced. R4's Initial document request was emailed to V1 (Administrator) on 04/07/26 at 12:20 PM. The second request for R4's documents was emailed to V1 on 04/07/26 at 02:36 PM requesting R4's progress notes dated 03/10/26-03/12/26 and entire incident reportable dated 03/10/26 with interviews. On 04/08/26 at 02:54 PM surveyor asked V1 (Administrator) why she just presented the past noncompliance. V1 responded, yesterday was the first day of the survey and all the questioning that we were getting interviewed on that. We did recognize the issue and started working on it. On the first day of the survey, we are trying to figure out the complaint. Does it make a difference, we did our in-services and our QA (Quality Assurance) forms that are still ongoing. The completion date is 03/13/26 ongoing with in-services and QA. Surveyor asked V1 how the transfer status policy includes the certified nurse assistants. V1 responded, this is more or less the transfer of the residents. It is common sense despite, if the transfer status policy does not state it there. On orientation and orientation on the floor my staff are educated on where to find the transfer status.On 04/08/26 at 01:50 PM V14 (Licensed Practical Nurse) stated I received the in-service about how to transfer residents at the beginning of the year. We have to sign a sheet that I attended the in-service. On 03/12/26 and 03/13/26 I was here but I do not see my name on the in-service sheet.On 04/08/26 at 01:44 PM V17 (Certified Nurse Assistant) stated I can't recall when I received the transfers in-service, but I signed a sheet. Surveyor showed V17 the transfer in-service sign in sheets and V17 responded, I don't see my name.On 04/08/26 at 01:47 PM V53 (Certified Nurse Assistant) stated I received the in-service about transfers a while back last year. I think I got it in January or February. There were four different ones, and we had to sign a sheet. I did not see my signature on the in-service sheets dated 03/12/26 and 03/13/26.On 04/08/26 at 02:32 PM V54 (Certified Nurse Assistant) stated I received one in-service today and received one prior to that about last month at the beginning of March. On the signed in-service sheets there is no signature on 3/12/26 and 3/13/26. I'm a part time employee too and my signature is not on any of the in-service sheets.Past noncompliance documentation document in part: Plan of Correction document in part: Deficiency: 1. a. On 03/10/26 at approximately 02:30 PM V26 (Certified Nurse Assistant), was transferring R4 from wheelchair to bed and R4 suddenly grabbed on the rail tightly causing her arm to be overextended. During interview R4 stated that she was holding tight on rail since she felt her leg got weak and overextended her arm probably pain. b. R4 complained of right arm pain on 03/10/26 at 10 pm. Nurse practitioner was notified with order of x-ray. Xray was done which showed displaced fracture of right humerus. Medical doctor was notified with order to send R4 to hospital for evaluation. c. R4 was supposed to be transferred using mechanical lift and V26 transferred using 1 person transfer technique. d. R4 returned on 03/11/26. R1 may use sling/immobilizer for comfort. 3. The measures the facility will take or system the facility will alter to ensure that the problem will be corrected and will not recur: c. An observation audit was completed on all staff to ensure safe transfers. (See attachment C). Completion date: 03/13/26.Per the past noncompliance plan of correction 3. c. An observation audit was completed on all staff to ensure safe transfers. (attachment C). Completion date: 03/13/26. The facility provided the QA (Quality Assurance Audit) for observations being conducted after the completion date of 03/13/26.QA (Quality Assurance tool) Tool presented to the surveyor document in part: The Restorative Nurse and/or designee will conduct a random audit 3x/week for 4 weeks to ensure staff are conducting a safe transfer. (QA Tools dated 03/11/26, 03/12/26, 03/13/26, 03/15/26, 03/16/26, 03/17/26, 03/25/26, 03/26/26, 03/27/26, 04/01/26, 04/02/26 and 04/03/26 which does not indicate the name of the staff member performing the transfer, has random initials as the resident identifier and a column indicating staff performed transfer document, yes).In-Service Topic: Transfer: Hoyer Lifts, Sit to Stand, Gait Belt, Stand by Supervision. To CNAs (Certified Nurse Assistants), Nurses. Date of n-Service: 03/12/26 and 03/13/26. Document in part: All Surface-to-Surface transfer must comply with what is assigned to the resident Kardex. All resident that requires Hoyer Lifts, Sit to Stand mechanical lifts must be with 2 persons assist No exception!!!! At anytime a resident is transferred improperly will be unacceptable and disciplinary action will follow!!!! Resident stand pivot gait belt use gait belt not resident clothing!!!The in-service has a total of 56 nursing staff signatures.On 04/08/26 the Nursing staff roster was presented by the facility consisting of 152 nursing staff members.Policy:Titled Transfer Status reviewed 05/25 document in part: General: Resident/patient transfer status will be determined through a screening process provided by the restorative nurse or admitting nurse upon admission/readmission, significant change, and quarterly.Titled Mechanical Lift reviewed 05/25 document in part: General: To assist the lift and transfer of a resident from one surface to another using the mechanical lift when appropriate. Procedure: 1. Identify resident and explain procedure. 6. One caregiver is to focus on the resident's head and body positioning while the other is operating the lift.Titled Restorative Nursing Program reviewed 03/26 document in part: General: To promote each resident's ability to maintain or regain the highest degree of independence as safely as possible. 1. Each resident will be screened for restorative programs by the Restorative Nurse upon admission, quarterly and with any significant change in function. 5. Each resident involved in a restorative program will have an individualized program with individualized goals, and measurable objectives documented in the care plan. 6. Documentation of the interventions and resident's response will be completed with each implementation.

Based on interviews and record reviews, the facility failed to provide a safe environment for one [R3] of five [R7, R9, R10, R11] residents reviewed for falls. This failure resulted in R1 falling from the bed, sustaining an open area to back of head, bleeding, sent to emergency department via 911 and was admitted to the hospital diagnosed with a blunt head trauma. Findings include, R3's clinical record indicates in part: R3 was admitted on [DATE] and discharged to the hospital on 1/29/26 and did not return. R3's medical diagnosis of encephalopathy, unsteadiness on feet, dysarthria asthma, glaucoma, urinary tract infection, acidosis, anxiety, age related cataract, psoriasis, bilateral osteoarthritis, spinal stenosis, and acute cystitis. R3's minimum data set [MDS] dated 1/11/26, section [GG] indicates the following in part: R3 has impaired upper extremity range of motion. R3 requires full/extensive assistance from staff for ADL care, toileting, bed mobility, dressing and eating. MDS section [C] indicates R3 is severely cognitive impaired. R3's Hospital Emergency Department Document dated: 1/29/26-R3 Admitting diagnosis: Blunt Head Trauma; Fall from bed.Blut head trauma following fall from bed. R3's admission Fall Risk assessment dated [DATE] document in part:R3 is a high fall risk due to decrease in mobility and R3 was noted confused. R3's Care plan indicates in part:R3 requires assistance with daily care needs related to generalized weakness. Staff will anticipate and meet all of R3's needs on a daily basis through next review such as clean, dry, grooming, turning and repositioning R3. R3's Progress Notes in part:1/29/2026 7:00 PM Medical Practitioner Note [V20]Post fall assessment, ER transferR3 was seen as a nursing request for a post fall assessment. Per the nurse, she had the patient falling out of bed with CNA in attendance. Upon assessment, the patient was noted with frank bleeding from the back of her head. The patient is alert and oriented x 1. 1/29/2026 10:19 PM V33 [Licensed Practical Nurse]Nursing observations, evaluations, and recommendations are: The resident [R3] rolled out of the bed during care and sustained an open area at the back of her head.Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: Transfer the resident [R3] to the nearest hospital via 911. 1/30/2026 5:13 AM, NursingNote: Hospital called in concern of resident. Spoke with E.R. representative who informed the writer that R3 is still awaiting a bed and will be admitted with Blood head trauma and fall from bed. On 4/6/26 at 4:00 PM, V5 [R3's Family Member] stated, On 1/29/26 at 9:36PM, I received a phone call from the facility's nurse. The nurse told me while R3 was being changed, R3 was turned and kept rolling off the bed and R3 was bleeding from the back of her head. Nurse said R3 was sent to the hospital emergency room for further assessment. Later, I received a phone call from the hospital emergency department, and I was told R3 was being admitted from the nursing home. R3 had fallen from the bed and sustained a head injury but did not require sutures. I requested for R3 not to return back to that nursing facility. At the time R3 fell, her hair was braided to the scalp. Later at the new nursing facility R3 braids were taken down and there were two open areas draining with pus, oozing out of her scalp. The new nursing facility failed to keep R3's head wounds clean. Later, 2/18/26, R3 passed away. On 4/10/26 at 9:55 AM, V32 [Certified Nurse Assistant] stated, I have been a certified nurse assistant for eighteen years. I have been working at this facility for over a year. I have been assigned to R3 often. R3 is confused and needs total assistance. R3 was resting on air mattress due to her wound. R3 did not have side rails. R3 was a one person assist. I was providing incontinent care on R3. I rolled R3 to her other side to clean her up, when she kept rolling off the mattress on other side of the bed fell onto the floor. I ran around the bed, and R3 was alert, bleeding from the back of her head. I called the nurse. The nurse applied pressure to the bleeding and called 911. The bed was steady and there was no problem with the mattress. I rolled R3 to her other side, away from me, but she kept rolling so fast and fell off the bed before I could reach her. I knew I should have rolled R3 towards me, but it would have been hard to clean up all the feces. I should have got another staff member to assist me. A resident has never rolled off the bed with me during incontinent care. On 4/8/26 at 10:18 AM, V33 [Licensed Practical Nurse] stated, I was in the room caring for R3's roommate when I heard R3 hit the floor. I turned around and saw V32, ran to the other side of the bed and I saw R3 on the floor. V32 said she turned R3 to clean her, and she kept rolling off the bed. R3 was bleeding from the back of her head, I applied pressure and called 911. I could not see exactly the wound or opening because R3 had braids. R3 was admitted to the hospital due to her fall. On 4/7/26 at 2:20PM, V9 [Restorative Nurse] stated, R3 requires max assistance with ADL care and bed mobility. R3 was here for about three weeks and had a decline in her mobility. R3 lost her upper body strength. R3 fell on 1/29/26, during second shift. V32 [Certified Nurse Assistant] was providing incontinent care, when V32 turned R3 to the other side away from her [V32] when R3 kept rolling and fell off the air mattress. V32 received education on turning and repositioning during incontinent care. Nursing staff know to aways turn the resident towards them to prevent the resident from falling off the bed. 4/8/26 at 9:50 AM, V3 [Director of Nursing] stated, I just started working here two weeks ago. I am not aware of R3's fall incident. Generally speaking, while one nursing staff member is providing incontinent care, staff members should always roll the residents toward them not away from them. If the staff member rolls the resident away from them, it could potentially cause the resident to roll off the bed. On 4/7/26 at 3:00 PM, V1 [ Administrator] stated, I was not the administrator in January 2026. However, the facility policy and regulations read we only have to report an incident if the resident requires sutures or staples. No, there was no IDPH report completed related to R3's fall dated 1/29/26. Policy in part:Fall Prevention and Management dated 7/2025.This facility is committed to maximizing each resident's physical, mental, and psychosocial well-being. The facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible.

Based on observation, interview, and record review, the facility failed to follow its skin care prevention policies and procedures and failed to implement the resident's comprehensive care plan to prevent skin breakdown and wound development. This failure affected one (R1) of two residents reviewed for wound management and prevention, in a total sample of 35 residents. As a result of the facility's failure to provide timely and appropriate preventive skin care and incontinence management, R1 experienced a decline in skin integrity, evidenced by the development of a new Stage 2 pressure ulcer/injury and moisture-associated skin damage (MASD).Findings Include:On 2/4/26 at 11:09 a.m., R149 stated her roommate (R1) has not been changed since 4:00 a.m. R149 said, [R1's] been lying on that soiled diaper for hours. I've been awake since four in the morning and that was the last time the CNA [Certified Nursing Assistant] came in here to change her [R1]. They should know that she [R1] needs to be changed frequently because she has that tube feeding going and she [R1] soils herself a lot.On 2/4/26 at 11:16 a.m., R1's lying in bed alert and able to verbalize needs. R1 stated she's wet and needs to be changed. R1 said she does not remember when the last time her diaper was changed, but she feels like it's been a while. R1 said that she has a wound on her back and the wound dressing was changed yesterday morning.On 2/4/26 at 11:35 a.m., surveyor notified V6 (Certified Nursing Assistant) that R1 needs incontinence care. V6 said she will notify the CNA assigned to R1. On 2/4/26 at 11:40 a.m., V7 (Certified Nursing Assistant/CNA) stated [V7] is the CNA assigned to R1. V7 said she started at 6:00 a.m. and had not yet had the opportunity to check on R1.On 2/4/26 between 11:43 a.m. and 11:56 a.m., surveyor observed V7 (CNA) providing morning care to R1. During the observation, R1's incontinence brief and pad were noted to be saturated with urine and feces. R1's perineal area (inner thighs and groin) and perianal (buttocks) were heavily soiled with urine and feces. R1's sacral wound dressing was also soiled and not intact. Surveyor and V7 observed skin breakdown in R1's perianal area, with a scant amount of bleeding noted. Surveyor and V7 also observed an open wound on R1's left inner thigh located at the area corresponding to the edge of R1's incontinence brief. The wound was noted along the line of contact where R1's incontinence brief rests against R1's skin measuring approximately four centimeters (cm) in length and approximately less than 1 cm in width. V7 stated that the wound on R1's left inner thigh is new. V7 stated, That's from her [R1] diaper. It may be too tight on her [R1]. V7 also stated that the skin breakdown to R1's perianal area is new.On 2/4/26 at 12:11 p.m., V9 (Wound Care Coordinator/Licensed Practical Nurse) stated that R1's sacral wound dressing was last changed on 2/3/26, in the morning. V9 stated that V25 (Wound Physician) rounded on R1 with the wound care team on 2/3/26, and at that time no skin breakdown or open areas were noted on R1's left thigh or perineal area beside R1's current sacral pressure ulcer. V9 stated that R1's wound dressing should be changed as needed when soiled.On 2/4/26 at 12:15 p.m., V10 (Wound Care Nurse/Licensed Practical Nurse) stated that the last time she assessed R1 was on 2/1/26, and at that time no skin breakdown was noted other than R1's sacral ulcer.On 2/4/26 between 12:19 p.m. and 12:51 p.m., surveyor observed a wound care treatment/assessment conducted by V9 and V10 for R1. During the observation, R1's incontinence brief was noted to be soiled with feces, and no wound dressing was in place on R1's sacral wound. V9 measured R1's sacral wound as follows: 5.5 centimeters (cm) in length, 6.2 cm in width, 0.3 cm in depth, with 1.5 cm of tunneling. V9 and V10 assessed R1's perianal area and stated that R1 had developed new moisture-associated skin damage (MASD). V9 stated that MASD can develop rapidly when the skin is exposed to moisture. V9 and V10 also assessed R1's left thigh and stated that R1 had acquired a new pressure wound. V9 stated it caused by R1's shearing and friction from R1's incontinence brief and if the brief remained in place for several hours, it could result in the development of pressure wound. V9 measured the left thigh wound as 4.5 cm in length, 0.3 cm in width, and 0.0 cm in depth. V9 identified it as partial-thickness Stage 2 pressure ulcer.On 2/4/26 at 3:43 p.m., surveyor conducted a telephone interview with V26 (Certified Nursing Assistant). V26 stated that she was the CNA assigned to R1 during the night shift on 2/3/26, and that she left the faciity on 2/4/26, at 6:00 a.m. V26 stated that R1 had frequent bowel movements related to tube feeding and requires frequent incontinence care. V26 stated that R1 typically has bowel movements every one to two hours and requires frequent diaper changes. V26 stated that she last changed R1's incontinence brief at approximately 4:30 a.m., prior to leaving the facility, and that this was her last round with R1. V26 stated R149 saw V26 changed R1 because R149 was awake at that time and that whenever V26 changes R1, V26 would let R149 know. V26 stated that during her last round, [V26] did not observe excoriation to R1's perineal area and did not observe any additional wounds other than the existing sacral ulcer. V26 stated that R1 is a resident who requires incontinence care as frequently as every one to two hours, and that if care is not provided within this timeframe, skin breakdown may occur.On 2/5/26 at 9:00 a.m., V9 stated that upon admission, residents are assessed for risk of skin breakdown using the Braden Scale, which considers mobility, cognition, diet, immobility, and level of staff assistance. V9 stated that all residents at the facility are considered at risk for skin breakdown. V9 stated that a skin care plan is initiated upon admission. Preventive interventions include heel offloading, routine skin checks during care, repositioning, and application of skin barrier ointment with every incontinent episode. V9 stated these are standard interventions for residents at risk. V9 stated that incontinent residents are expected to receive incontinence care at least every two hours and be kept clean and dry, and that failure to provide care within this timeframe increases the risk of skin breakdown. V9 stated that low air loss (LAL) mattresses are used as a preventive measure and to promote wound healing, and that the wound care team updates skin care plans as needed. V9 stated that V25 rounds weekly and sees residents with Stage 2 pressure ulcers and higher, and may also see residents with complex wounds. V9 stated that R1 was admitted with a Stage 4 sacral pressure ulcer dated 8/16/25. Initial measurements were 11.0 cm length x 12.5 cm width x 0.0 cm depth, with 95% slough and 5% granulation tissue. Initial treatment included Medihoney three times per week and as needed. V9 stated that recent measurements dated 2/4/26, were 5.0 cm length x 3.5 cm width x 0.3 cm depth, and the wound remained Stage 4, with current treatment of Medihoney and alginate three times per week and as needed. V9 stated that during ADL (Activities of Daily Living) care, CNAs are expected to perform skin checks, and if abnormalities are observed, to report findings to the nurse or wound care team. V9 stated that skin assessments for R1 are performed every other day during wound treatment. V9 stated that on 2/3/26, during morning wound rounds at approximately 7:30 a.m., [V9] observed R1 with [V25] and noted only the sacral ulcer. V9 stated that at that time there was no excoriation of the buttocks and no open areas to the groin/thighs or perineal area. V9 stated that if any skin issues had been observed, they would have been addressed immediately. V9 stated that R1 experiences loose bowel movements and requires prompt incontinence care. V9 stated that R1 acquired new moisture-associated skin damage (MASD) to the perianal area and a Stage 2 pressure ulcer to the left inner thigh on 2/4/26. V9 stated that R1's left inner thigh wound was classified as pressure ulcer because it was believed to have resulted from shearing and friction caused by R1's incontinence brief. V9 stated that treatment for the MASD includes Triad cream daily and as needed, and treatment for the left inner thigh includes foam dressing three times per week and as needed. V9 stated that R1 requires frequent checks for stool and urine, and that incontinence care should not exceed two hours to prevent skin breakdown.On 2/5/26 at 12:47 p.m., V3 (Director of Nursing) stated that staff are expected to provide incontinence care as soon as possible when a resident is incontinent. V3 stated that staff conduct routine rounds, alternating with nursing staff, to assess resident safety and needs. V3 stated that during rounds, staff are expected to ensure the resident is safe, safety precautions are in place, the call light is within reach, and resident needs are addressed. V3 stated that staff are expected to check residents for incontinence at least every two hours, and that residents who are incontinent require checks at least every hour. V3 stated that incontinence care should be provided promptly when needed. V3 stated R1 requires reminders and relies on staff to meet her needs. V3 stated that R1 requires assistance with all activities of daily living (ADLs) and can sit up in a chair but requires staff assistance for repositioning. V3 stated that R1 is incontinent of both bowel and bladder and requires staff assistance for incontinence care. V3 stated that R1 has a gastrostomy tube (G-tube) and that some residents with a G-tube may experience loose stools, requiring frequent monitoring. V3 stated that staff should check R1 at least every hour. V3 stated that R1 has fragile skin and is at risk for skin breakdown, and that delays in care could impact wound healing and development of new skin breakdown.On 2/6/26 at 9:49 a.m., V19 (Registered Dietitian) stated that R1 is NPO (Nothing by Mouth) and receives tube feeding with a high-fiber formula and may experience frequent loose stools due to R1 may not be absorbing the formula well due to her current medical conditions.On 2/6/26 at 3:01 p.m., surveyor conducted a telephone interview with V25 (Wound Physician). V25 stated he began providing wound care services at the facility in October 2025 and visits the facility once weekly. V25 stated that upon residents' admission from the hospital, the facility typically implements preventive measures, including dietitian involvement, protein supplementation, heel protection, low air loss (LAL) mattresses, and proactive skin-breakdown prevention. V25 stated that if a resident is incontinent of urine or stool and remains soiled or wet for several hours, skin breakdown can occur, even in the absence of a pre-existing wound. V25 stated that prolonged moisture exposure can also delay wound healing when an existing wound is present. V25 stated that he last evaluated R1 on Tuesday, 2/3/26, during wound rounds with the wound care team. V25 stated that at that time, R1 had a sacral pressure ulcer and was being treated with a wound vacuum-assisted closure (VAC), which was discontinued to support wound healing. V25 stated that during the 2/3/26, assessment, [V25] did not observe any additional skin breakdown other than the sacral ulcer. V25 stated that he documents any skin issues observed during assessments. V25 stated that he later spoke with the wound care team and was informed that new wounds had developed following his last assessment. V25 stated that R1 has multiple risk factors for skin breakdown, including bowel and bladder incontinence. V25 stated that R1's nutritional status was also a concern, noting [R1's] albumin level was low, and that the dietitian and wound care team were working to improve her protein intake. V25 stated that R1 is currently receiving tube feeding. V25 stated that if R1 were left soiled or wet for several hours, she could develop new skin breakdown and wounds as a result.R1's clinical records show an original admission date of 7/25/26 with listed diagnoses but not limited to cerebral infarction, gastrostomy status, flaccid hemiplegia affecting left nondominant side, and adult failure to thrive. R1's Minimum Data Set (MDS) assessment dated [DATE] revealed R1 has severely impaired cognition with BIMS (Brief Interview for Mental Status) of 7. It also reveals that R1 is always incontinent of bowel and bladder, is dependent on staff's assistance for perineal hygiene, bathing, and mobility, and is at risk of developing pressure ulcers/injuries. R1's comprehensive care plan documents in part: [R1] is at risk for and has an alteration in skin integrity related to self-care deficits, impaired mobility and comorbidities with one of the interventions that reads: Provide peri-area after each incontinent episode and apply barrier cream (date initiated 7/28/25). R1's care plan also documents in part: R1 is incontinent of bowel and bladder and one of the interventions reads: Provide incontinence care at routinely timely intervals. Keep skin clean, dry and moisturized (date initiated 7/28/25).R1's Wound Assessment Details Reports printed on 2/5/26 indicate R1 has stage 4 sacral pressure ulcer date identified on 8/16/25, a facility-acquired stage 2 pressure ulcer on left inner thigh identified on 2/4/26 (measured as 4.50 cm length, 0.30 cm width, unknown depth), and facility-acquired MASD to perianal identified on 2/4/26. V25's visit report for R1 dated 2/3/26 documents existing stage 4 pressure ulcer with recommendation to keep area clean and dry and avoid direct pressure to the wound site.R149's clinical records show an original admission date of 6/20/23. R149's MDS dated [DATE] shows R149 is cognitively intact with BIMS of 15 and requires supervision with ADLs.On 2/10/26 at 11:06 a.m., V40 (Interim Administrator) emailed surveyor a Skin Condition document dated 2/4/26. The documentation, prepared by V41 (Regional Nurse Consultant), reads in part: On Wednesday February 4, 2025, during incontinence care, resident was noted with a skin alteration to the left inner thigh. At the time, this area was believed to be a stage 2 pressure ulcer. During the investigation it was noted to be an abrasion as per our in-house wound MD [Medical Doctor]. The abrasion has now healed. Additional documentation emailed to surveyor by V40 on 2/10/26, included V25's (Wound Physician) progress notes dated 2/10/26, which documented in part: 2/10/26 - Patient noted to have a wound to the left medial thigh, appears to be superficial abrasion that has epithelialized over and has now healed, no complex wound intervention indicated at this time.The facility's SKIN CARE PREVENTION policy and procedures dated 6/25 documents in part: All residents will receive appropriate care to decrease the risk of skin breakdown. Clean skin at time of soiling and at routine intervals.The facility's INCONTINENCE CARE policy and procedures dated 5/25 documents in part: Incontinence care is provided to keep residents as dry, comfortable and odor free as possible. It also helps in preventing skin breakdown.The facility's Certified Nurse Aide job description (undated) documents in part: Keep incontinent residents clean, dry and odor free; check every two hours to maintain. Review care plans daily to ensure provision of appropriate care.The Centers for Medicare & Medicaid Services (CMS) State Operations Manual (SOM), Appendix PP, F686 (Rev. 229; Issued April 25, 2025; Effective April 25, 2025; Implementation April 28, 2025) defines a Pressure Ulcer/Injury (PU/PI) as localized damage to the skin and/or underlying soft tissue, typically over a bony prominence or related to a medical or other device. The guidance states that a pressure injury may present as intact skin or an open ulcer, and that the appearance varies depending on the stage. The SOM further states that a pressure injury occurs as a result of intense and/or prolonged pressure, or pressure in combination with shear. The guidance notes that soft tissue damage related to pressure and shear may be influenced by moisture, nutrition, perfusion, co-morbidities, and the condition of the soft tissue.

Based on observation, interview and record review, the facility failed to ensure there was no trash on the ground surrounding the dumpster. This deficient sanitation practice has the potential to affect all 191 residents who reside in the facility.Findings include:On 02/04/26 at 10:45 AM, during initial tour of kitchen traveled outside with V17 (Dietary Manager) to view outside dumpster area. The lid of dumpster was closed. Observed a lot of trash, garbage and debris all around the ground near the dumpster including food scraps, empty cans of soda, used plastic cups, used gloves, used face masks, empty bottles of cleaning containers. V17 said, it is a mess out here and stated there should not trash all around the dumpster. V17 stated it is nasty and will attract rodents. V17 stated they want to keep rodents away from the facility, not attract them toward the building. Also, observed by the entry of the back door two bottles of used culture vials in a plastic bag. V17 stated looked at the vials and said, that is a hazard.On 02/06/26 at 8:14 AM, V42 (Environmental Services Director) stated the outside dumpster is used by housekeeping and dietary departments. V42 stated the housekeeping department is responsible for picking up garbage on the ground outside and to make sure the whole area around the dumpster is kept clean and free from trash. V42 said, the expectation is to clean up whatever we see. V42 stated if anything falls on the ground it should be picked up. V42 stated it is important to pick up the garbage on the ground so little critters like rodents and pests do not come close to the building. V42 stated the used culture bottles should have been put in the hazard compactor, it should not have been left on the ground.Facility provided policy titled, Trash Disposal undated documents in part, the dietary department should dispose of trash appropriately and maintain the dumpster area for cleanliness and prevention of rodents, purpose is to prevent the spread of infection and deter pests and rodents, and that no trash is on the ground surrounding the dumpster.

Based on observations, interviews, and record reviews, the facility failed to a.) ensure food items were properly labeled and dated, b.) store food items according to manufacturer recommendations, c.) discard expired food based on use by date and guidelines, d.) store food at least six inches off the floor. These failures have the potential to affect all 185 residents receiving food prepared in the facility's kitchen. Findings include:On 02/04/26 at 9:35 AM, during initial kitchen tour V17 (Dietary Manager) stated all items should be labeled with a delivery date, an open date and use by date. V17 stated it is important for food items to be properly labeled with an open and use by date, so the staff knows when to throw out the food items, so they do not get served to the residents. V17 stated the use by date differs depending on what the food item is and manufacturer storage guidelines are followed as listed on the product.On 02/04/26 at 9:40 AM, observed in the walk-in refrigerator 12 unopened 8-ounce cartons of whole milk labeled with best by date 02/02/26 which were mixed in with other cartons of whole milk labeled with best by date 02/14/26. V17 stated the cartons dated 02/02/26 must have been left over from an older delivery and mixed in with the newest delivery. V17 stated the whole milk cartons with the best by date 02/02/26 should have been thrown out on or before 02/02/26. V17 stated if the expired milk was to be served to a resident it could make them sick.On 02/04/26 at 9:45 AM, in the walk-in freezer the shelving units appeared to be less than six inches off the floor with many boxes of frozen food stored on the lowest shelf. Surveyor requested for Maintenance Department to be contacted to bring a measuring tape to the kitchen.On 02/04/26 at 10:35 AM, V30 (Maintenance Director) provided V17 with a measuring tape and V17 measured the distance from the floor to the bottom shelf. This distance was five inches in three of the six shelving units measured. V17 stated the distance should be at least six inches from the floor.On 02/04/26 at 9:48 AM, observed in the prep area the following opened items stored at room temperature (not refrigerated):Opened 1-gallon container of Barbeque Sauce labeled with delivery date 01/22/26 and opened date. 01/22/26. There was no use by date written on the product. On the container manufacturer printed For best flavor, refrigerate after opening.Opened 1-gallon Soy Sauce labeled with open date 09/17/25. There was no use by date written on the product. On the container manufacturer printed Refrigerate after opening for quality,On 02/04/26 at 9:55 AM, V17 stated all the items should be labeled with a use by date and the items should be stored in the refrigerator not left out at room temperature based on the manufacturer storage guidelines printed on the items.On 02/06/26 at 10:10 AM, V19 (Regional Registered Dietitian) stated the best by date on the milk means that it is the last day it is good to drink; the milk should be consumed on or before the best by date. V19 stated the milk should have been thrown out and not consumed. V19 stated if the expired milk was served to a resident, it could have gotten them sick. V19 stated it is the kitchen staff's responsibility to check the best-by dates on the milk and not serve any past the best by date. V19 stated when a shelf-stable item gets opened it should be labeled with an open and use by date. V19 stated the staff would know if the item needed to be refrigerated by checking the use-by guidelines posted in the kitchen and following the manufacture guidelines printed on the item. V19 stated the barbeque sauce, and the soy sauce should have been stored in the refrigerator after opening.On 02/04/26, facility provided list of diet orders for all residents in the facility. The diet order list indicates there are six residents receiving nothing by mouth (NPO). This was confirmed with the V19 (Regional Registered Dietitian).Facility provided policy titled Storage Periods, Use-By Guidelines undated documents in part, food should be stored properly and used within the appropriate time period to ensure safe and high-quality food is served, and the Use-By Guidelines Posted should be used to determine a use by date when labeling opened or unopened food that must be used within a certain time frame.Facility provided policy titled, Use-By Guidelines Handout documents in part, the following guide can be used to determine a use-by date when labeling opened or unopened food that must be used within a certain time frame.Facility provided handout titled, Use-By Guidelines - Posted which indicates in part, opened BBQ sauce refrigerate after opening, unopened milk adhere to best use-by date on carton, and opened soy sauce refrigerate after opening.Facility provided policy titled, Food Storage undated documents in part, food should be stored and prepared in a clean, safe, sanitary manner that complies with state and federal guidelines to minimize contamination and bacteria, and food is stored at least six inches from the floor.Facility provided policy titled, Cold Storage Areas undated which documents in part, store food products on slated shelves, six inches off the floor and away from the walls to allow proper air circulation.

Based on interviews and record reviews, the facility failed to have sufficient staffing to provide adequate care and assistance for residents. This has the potential to affect all the residents residing in the facility.Findings Include:On 2/4/26 at 10:58 AM, R101 stated he's been in the facility for a year and a couple of months. R101 said facility is always short on staff. R101 said sometimes he does not get his medications on time and is mostly short on weekends. On 2/4/26 at 11:07 AM, V6 (Certified Nursing Assistant) started working in the facility full time for two years. V6 said she works morning shifts and every other weekend. V6 said sometimes facility is short on CNAs (Certified Nursing Assistants). V6 said morning shift needs five CNAs but sometimes there are only 4 CNAs working the floor. On 2/4/26 at 11:09 AM, R149 stated she's been in the facility for two years. R149 said sometimes facility is short nurses and CNAs on weekends. R149 said care is delayed sometimes and call lights answered more than 10 minutes. On 2/4/26 at 12:54 PM, R2 stated she's been in the facility for six months. R2 said sometimes facility is short staff mostly on weekends. R2 said her medications would be late more than an hour and staff are delayed on answering call lights would wait for 45 minutes sometimes can take up to two hours.On 2/5/26 at 9:58 AM, resident council meeting was held. R82, R94, R95, R149, and R203 were in attendance. They all stated that they do not feel like the staffing is always sufficient to provide the needs of the residents. All stated that facility has lack of staff. R149 stated, On the third floor we have 74 residents and sometimes there's only 2 or 3 CNAs from 10:00 PM to 6:00 AM. Call lights are not answered timely. Sometimes we have to wait more than an hour. R94 and R203 said they don't get changed timely when wet and soiled. R149 said that her roommate (R1) is only being changed once during the day and once in the evening.On 2/5/26 at10:49 AM, V18 (Staffing Coordinator) stated that she is responsible for scheduling both licensed nurses and certified nursing assistants (CNAs). V18 stated that the facility does not utilize agency staffing and uses a staffing application, which generates the master schedule and identifies open shifts. V18 stated that staffing assignments may vary by shift. V18 stated that the facility has three resident floors. V18 stated that staffing levels by shift are as follows: Morning shift: 5 CNAs on each floor and 2 nurses on each floor. Evening shift: 4 CNAs on the first floor, 5 CNAs on the second floor, 5 CNAs on the third floor, and 2 nurses on each floor. Night shift: 4 CNAs on each floor and 2 nurses on each floor. V18 stated that staffing is adjusted based on the facility daily census, which she calculates each morning. V18 stated that the staffing ratio described applies when the census is between 186 and 200 residents. V18 stated that the facility has a licensed bed capacity of 204. V18 stated that on the day of interview, the census was 192 residents. V18 stated that census is multiplied by 1.7 and divided by 7.5 hours, resulting in a total of 43 CNAs scheduled from 6:00 AM to 6:00 AM. V18 stated that licensed nurse staffing remains the same regardless of census, while CNA staffing may be reduced if the census is below 186, at which time 42 CNAs would be scheduled for the entire day. V18 stated that the facility maintains a minimum of 14 CNAs per shift and reported no issues with weekend staffing.R2's clinical records show an initial admission date of 7/11/25 and minimum data set (MDS) dated [DATE] shows R2 is cognitively intact with Brief Interview for Mental Status (BIMS) of 15.R82's clinical records show an initial admission date of 7/13/18 and MDS dated [DATE] shows R82 is moderately impaired with cognition with BIMS of 12.R94's clinical records show an initial admission date of 2/22/21 and MDS dated [DATE] shows R94 is moderately impaired with cognition with BIMS of 11.R95's clinical records show an initial admission date of 3/4/18 and MDS dated [DATE] shows R95 is cognitively intact.R101's clinical records show an initial admission date of 8/2/24 and MDS dated [DATE] shows R101 is moderately impaired with cognition with BIMS of 12.R149's clinical records show an initial admission date of 6/20/23 and MDS dated [DATE] shows R149 is cognitively intact with BIMS of 15.R203's clinical records show an initial admission date of 5/11/23 and MDS dated [DATE] shows R203 is moderately impaired with cognition with BIMS of 10.Surveyor reviewed facility's timecard reports and showed inadequate CNA staffing on some days and multiple weekends from 7/1/25 to 9/30/25 and 1/24/26 to 1/25/26.PBJ (Payroll Based Journal) staffing data report FY (Fiscal Year) Quarter 4 2025 (July 1 - September 30) showed: TRIGGERED for Excessively low weekend staffing and one star staffing rating.A review of randomly selected facility census records revealed the following daily census totals: 7/4/25: 191 residents, 7/5/25: 186 residents, 7/6/25: 185 residents, 1/24/26 to 1/25/6: 198 residents, and 2/4/26: 191 residents residing in the facility.The facility's STAFFING policy dated 5/25 documents in part: To have appropriate numbers of staff available to meet the needs of the residents. Staffing is based on the IDPH [Illinois Department of Public Health] formula for determining numbers and levels of staff. Staffing is then increased based on the needs of the resident population.The facility's FACILITY ASSESSMENT TOOL dated 11/25 documents in part: Facility will utilize new CMS [Centers for Medicare & Medicaid Services] staffing rule to meet the requirements. Licensed Nurses (LN) includes RN [Registered Nurse] and LPN [Licensed Practical Nurse] providing direct care. Long term care units: 1:20 LN ratio (all shifts). Direct care staff: CNAs long term care units 1:12 ratio days, evenings, and nights.

Based on observation, interview and record review the facility failed to (a) ensure staff cleaned and disinfected shared equipment between 3 (R29, R128, R181) residents use; (b) perform hand hygiene prior and place on a pair of gloves while obtaining one (R181) resident's blood glucose; (c) ensure proper Personal Protective Equipment (PPE) was worn by staff upon entry to resident's (R150) room on contact precautions; and (d) post an Enhance Barrier Precautions (EBP) sign for a resident (R135) with an indwelling medical device. The facility also failed to ensure proper Personal Protective Equipment (PPE) was worn by staff when providing high contact resident care activities to a resident (R1) on Enhanced Barrier Precaution (EBP). This failure has the potential to affect all 74 residents residing on the third-floor unit. The findings include: R150's admission record / face sheet showed admit date on 1/22/26 with diagnoses not limited to Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Type 2 diabetes mellitus, Chronic obstructive pulmonary disease, Enterocolitis due to clostridium difficile, Partial intestinal obstruction, Thrombocytopenia, Dementia in other diseases classified elsewhere, Primary generalized (osteo)arthritis, Other specified polyneuropathies, Malignant neoplasm of overlapping sites of left female breast, Other heart failure, Hypertensive heart disease with heart failure, Chronic kidney disease stage 3 unspecified, Gastro-esophageal reflux disease. MDS (Minimum Data Set) dated 1/19/26 showed R150's cognition was severely impaired. MDS indicated R150 was in isolation for active infectious disease. On 2/4/26 At 11:47AM R150's room observed with contact precautions by the door and PPE (Personal Protective Equipment) supplies by room entrance. Observed R150 sitting on the side of the bed, alert and verbally responsive. On 2/4/26 At 12:02 PM Observed V32 (Certified Nursing Assistant / CNA in training) went inside R150's room to pass meal tray without wearing proper PPE. V32 did not wear gloves and gown upon entry to R150's room. R150's door signage indicated Everyone must clean their hands, including before entering and when leaving the room; Providers, and staff must put on gloves and gown before room entry. Observed V32 went out of R150's room and did not perform hand hygiene. Observed V32 went inside other residents' rooms passing meal trays. V32 said she is CNA in training for almost a month and works with V33 (CNA). On 2/4/26 at 12:16PM V33 (CNA) said she is working with V32 (CNA in training). She said V32 can make the bed, answer call lights, pass water, pass meal trays. V33 said their room assignment is from room [ROOM NUMBER] to 107 with 12 residents. On 2/5/26 at 9:49AM V4 (IP / Infection Preventionist NURSE) said R150 is on contact precautions for C-diff stool. There should be a bin outside for PPE supplies, contact precautions signage to inform staff / visitor what to do. V4 said all staff / visitor should perform good hand hygiene, wear gown and gloves before entering the room on contact precautions to ensure no cross contamination for the safety of the residents and staff. She said C-diff is highly contagious so proper PPE should be worn. Going into the room of the resident with contact precautions, staff / visitor should wear proper PPE gown and gloves and remove PPEs before coming out of the room to prevent spread of infection or cross contamination. On 2/5/26 At 1:06PM V3 (DON / DIRECTOR OF NURSING) stated R150 has an order for contact precautions for C-diff stool. Staff are expected to implement contact precautions. V2 said Staff / visitor are expected to wear proper PPE (Gown and gloves) to go into the room of residents on contact precautions to help prevent spread of germs or cross contamination. R150's POS (Physician Order Sheet) dated 2/4/26 showed order not limited to: Contact isolation Diagnosis: C-diff. Care plan dated 1/23/26 showed in part: R150 is on contact isolation related to C-diff. Facility's daily assignment showed V33 (CNA) assignment is from room [ROOM NUMBER] to 107-2. Facility's midnight census report dated 2/4/26 showed 12 residents assigned to V33. Facility's list of isolation showed R150 on contact precautions for diagnosis of C-diff. Facility's Transmission Based Precautions policy dated 1/1/23 showed in part: Contact: Gloves and gown required upon entry to room, must be removed before exiting, followed by hand hygiene. Facility's Infection Prevention and Control Plan policy dated 7/2025 showed in part: Contact Precaution – intended to prevent transmission of infectious agents by direct or indirect contact with residents or the environment. Examples of infectious organisms requiring contact precautions are C-difficile. Use of a gown and gloves is necessary prior to room entry. Facility's contact precautions signage showed in part: Everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also: put on gloves and gown before room entry and discard before room exit. Findings include, Surveyor observed V15 [Licensed Practical Nurse] during medication administration: On 2/4/26 at 9:22 AM, V15 [Licensed Practical Nurse] placed the blood glucose machine in the glucose caddy [basket that held all the blood glucose supplies] and entered R181's room. V15 placed the glucose caddy on R181's bedside table. V15 placed on one glove onto her left hand and did not perform hand washing nor any usage of alcohol gel cleansing. V15 used the auto-disabling lancet on R181 finger for a blood return. However, R181 finger did not produce an adequate blood supply. V15 used her right un-gloved hand to rub R181 finger to produce the blood. V15 obtained R181 blood glucose sample that read 79mg/dl and wiped the blood off R181 finger with an alcohol wipe. V15 picked up the used blood-stained alcohol wipe, removed the used blood glucose strip out of the glucose machine with her right un-gloved hand and placed the items into her left gloved hand, removed the left hand gloved with the items in the glove and placed the glove into the garbage on her med cart. V15 took the glucose caddy off R181's bedside table and placed the caddy on top of the medication cart then placed the caddy into the bottom drawl of the medication cart. V15 did not wash her hands or use alcohol cleansing. At 9:31AM, V15 enter into R181's room with a wrist blood pressure device and placed the device on R181's left wrist, blood pressure resulted 165/79. V15 did not clean the blood pressure device before or after use. V15 placed the blood pressure device back on top of the medication cart. On 2/4/26 at 9:50 AM, V15 [Licensed Practical Nurse] entered R128's room with the uncleaned wrist blood pressure device and placed the cuff on R128's left wrist, resulting 117/64. V15 did not sanitize the device and sat the blood pressure device back on top of the medication cart. On 2/4/26 at 10:04 AM, V15 [Licensed Practical Nurse] entered R29's room with the unclean blood pressure device and placed the cuff on R29's left wrist, resulting in 112/63. V15 did not sanitize the device and sat the blood pressure device back on top of the medication cart. On 2/4/26, at 10:15 AM, V15 [Licensed Practical Nurse] stated, I should have used two gloves while obtaining R181's blood glucose. I don't know why I only used one glove; I was nervous. I forgot to clean the glucose caddy off, and the blood pressure device, I was rushing and was not thinking clear. If I don't wear two gloves, sanitize the glucose caddy and blood pressure device, it could potentially spread infection. On 2/5/26 at 1:00 PM, V3 [Director of Nursing] stated, Before obtaining a resident's blood glucose measurement, the nurse must wash their hands, gather equipment, a place on a pair of gloves. The glucose caddy should not enter the resident's room. The supplies should be removed from the glucose caddy to be taken into the resident's room. The blood pressure shared devices between residents must be sanitized between each use. If the nurse is not wearing a pair of gloves during blood glucose monitoring, and not sanitizing the blood pressure device between residents, it could potentially cause the spread of infections from one resident to another. Policy document in part Blood Glucose Monitoring dated 1/2025 Obtain needed equipment and supplies, such as gloves Perform hand hygiene and gloves. Routine Cleaning and Disinfection dated 1/2025 It is the policy of this facility to ensure the provision of routine cleaning and disinfection In order to provide a safe, sanitary environment and to prevent development and Transmission of infections to the extent possible. Resident's chairs, blood pressure cuffs, chairs etc Findings include: On 02/04/26 at 11:53 AM, observed R135 sitting in bed with two nephrostomy tubes draining light yellow color liquid into collection bags. R135 stated the staff always wears gloves and a mask when they come in to empty her bags, but they do not wear a gown. On 02/04/26 at 11:55 AM, upon leaving R135's room observed that there was no Enhanced Barrier Precautions (EBP) signage posted outside R135's room. Did not find an EBP sign on the floor near R135's doorway or inside her room. On 02/04/26 at 12:01 PM, V21 (Registered Nurse) stated R135 has bilateral nephrostomy tubes and there should be an Enhanced Barrier Precaution sign posted outside R135's door. V21 stated the purpose of posting the EBP sign outside R135's door is to inform anyone going into the room that the resident is on EBP, so they wear the appropriate personal protective equipment (PPE). V21 stated the potential problem with the EBP signage not being posted outside R135's room is that people will not perform hand hygiene or wear appropriate PPE which can be an infection risk for R135 because staff/visitors coming into R135's room can transmit bacteria to her. On 02/04/26 at 12:03 PM, V20 (1st Floor Unit Manager/Licensed Practical Nurse) stated if the EBP sign is not posted outside R135's room that means if a CNA (Certified Nursing Assistant) went into R135's room to give her care the CNA would not know they needed to wear PPE before giving care. V20 stated everyone entering and leaving the room should be doing hand hygiene and for staff doing direct care activities such as emptying nephrostomy tubes they need to wear gown and gloves. V20 stated it is important for the staff to wear the appropriate PPE to protect R135 because she has an indwelling medical device and is at a higher risk for acquiring an infection. On 02/05/26 at 9:35 AM, V4 (Infection Preventionist/2nd Floor Unit Manager/LPN) stated EBP are needed if a resident has any indwelling medical catheter such as nephrostomy tube to reduce the risk of the staff introducing infection into the openings. V4 stated residents on EBP have an EBP signage outside their door to make the staff aware that the resident's immune system is compromised and what PPE they need to wear. V4 stated if the staff are doing any kind of resident care, they need to wear a gown and gloves and do hand hygiene before and after entering the room. V4 stated if the EBP signage is not posted outside the resident's room the staff could be inadvertently exposing the resident to an outside organism, bacteria and/or infection. V4 stated R135 has bilateral nephrostomy tubes and is on the EBP list. V4 stated R135 should have had an EBP sign posted outside her door. On 02/06/26 at 8:25 AM, V3 (Director of Nursing) stated the purpose of the EBP signage is to let anyone who comes into the room know what PPE they should be wearing when they take care of the resident. V3 stated anyone with nephrostomy tubes should be on EBP and should have EBP signage posted outside their door. V3 stated the potential problem if the EBP sign is not posted is then the staff coming into care for the resident could contaminate the resident if they do not perform hand hygiene and wear a gown and gloves when performing ADL activities. R135's diagnosis included but not limited to Malignant Neoplasm of Endometrium, Other Hydronephrosis, Other Obstructive and Reflux Uropathy, Generalized Abdominal Pain, Chronic Kidney Disease Stage 2, Unspecified Protein-Calorie Malnutrition, Urinary Tract Infection, Sepsis, Other Artificial Openings of Urinary Tract Status, Congestive Heart Failure. R135's Order Summary Report dated 02/04/26 documents in part drain nephrostomy tubes PRN as needed for urinary drainage, monitor bilateral nephrostomy tubes every shift for signs/symptoms of infection and functionality/placement every shift for infection control monitoring, R135's MDS (Minimum Data Set) from 01/16/26 documents in part, R135 has an indwelling catheter and requires partial/moderate assistance with toileting hygiene, shower/bathing self and transfers. R135's care plan documents in part (R135) has the potential risk for complications related to bilateral nephrostomy tubes and (R135) is on enhanced barrier precautions per applicable infection prevention and control standards and regulation with goal to prevent the spread of infection and intervention to maintain precautions as indicated. Reviewed Enhanced Barrier Precautions List provided by facility on 02/05/26 which lists R135 name and reason for EBP is listed as indwelling. Facility provided policy titled, IC - Enhanced Barrier Precautions (EBP) dated 01/2026 which documents in part, EBP are indicated for wound and/or indwelling medical devices and an EBP sign should be posted for each resident on EBP. Facility provided copy of Enhanced Barrier Precautions sign by the U.S. Department of Health and Human Services Center for Disease Control and Prevention which documents everyone must clean their hands, including before entering and when leaving the room and providers/staff must also wear gloves and a gown for the following high-contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use – central line, urinary catheter, feeding tube, tracheostomy. Findings Include: On 2/4/26 at 11:16 AM, an enhanced barrier precautions signage was noted posted on R1's door that reads in part: Everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for the following high-contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing brief or assisting with toileting. On 2/4/26 from 11:43 AM to 11:56 AM, surveyor observed V7 (Certified Nursing Assistant) provided morning care to R1. V7 wiped R1's face, arms, and upper body. V7 changed R1's incontinence product, changed R1's gown and incontinence pad. V7 did not wear protective personal gown the entire time [V7] provided morning/incontinence care to R1. Surveyor asked V7 if she was aware what type of transmission-based precaution R1 is on. V7 stated R1 is on enhanced barrier precaution but was not aware that [V7] was supposed to wear gown while providing care to R1. V7 stated she is assigned to approximately 13 to 15 residents on the third floor but still helps with attending to others residents' needs for the entire floor. On 2/5/26 at 9:25 AM, V4 (Infection Preventionist/Licensed Practical Nurse) stated that residents who have any opening such as central lines, any wounds, tube feeding, and indwelling catheters are placed on EBP. V4 said the purpose of EBP is to ensure that staff don't infect the residents and that infection is not introduced into their openings. V4 said staff should be wearing gowns, gloves and masks when doing high contact activities such as incontinence care, whenever they are touching the patient, during bathing, changing diaper, wound care, and enteral tube feeding care. V4 said if staff does not wear the proper PPE, it would increase the risk of infection to the resident and other residents they take care of and also would put employees at risk for infections. V4 said R1 is on EBP for wounds and tube feeding. On 2/5/26 at 12:47 PM, V3 (Director of Nursing) stated that staff are required to wear appropriate personal protective equipment (PPE), including gloves and gowns, when providing personal care such as dressing, bathing, grooming, wound care, or any activity involving direct contact with the resident. V3 stated that proper PPE use is important to prevent the spread of bodily fluids and potential cross-contamination to staff and other residents. The facility's IC-enhanced Barrier Precautions (EBP) policy dated 1/25 documents in part: EBP requires the use of gowns and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs [Multidrug-resistant Organisms] and XDROs [Extensively Drug-Resistant Organisms] to staff hands and clothing. High-contact resident care activities requiring gown and glove use among residents that trigger EBP use include: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing brief or assisting with toileting, Wound care. The facility's residents' roster dated 2/4/26 shows a total of 74 residents residing on the third floor.

Based on observation, interview and record review the facility failed to place oxygen cannula tubing in a bag when not in use for one (R78) of two residents reviewed for respiratory care in a sample of 35. Findings include:On 02/04/26 at 11:30 AM, observed in R78's room oxygen tubing attached to an oxygen concentrator with the nasal cannula end of the tubing lying in an opened drawer. The nasal cannula was lying on top of an opened bag of cookies, and a used plastic urinal bottle was hooked on the edge of the opened drawer close to the nasal cannula. The nasal cannula was not stored in a bag or container. The oxygen concentrator was not turned on and R78 was not in the room.On 02/04/26 at 11:33 AM, V20 (1st Floor Unit Manager/Licensed Practical Nurse) came into R78's room and observed the uncovered nasal cannula tubing in the open drawer and stated the oxygen tubing should be stored in a bag when not in use for infection control reasons. V20 stated the oxygen tubing should not be touching other things because the nasal cannula tubing goes directly into the resident's nose. V20 stated she is going to throw the oxygen tubing set out and get a new one for R78 to use. On 02/06/26 at 8:22 AM, V3 (Director of Nursing) stated when not in use the oxygen tubing should be stored in a plastic bag to protect it and keep it from not being infected. V3 stated putting the oxygen tubing in a plastic bag when not in use is a protective measure for infection control reasons.On 02/06/26 at 12:54 PM, observed R78 sitting in wheelchair at bedside in room. Observed R78's nasal cannula tubing wrapped around the grab bar of his bed. The oxygen tubing was not in a plastic bag or covered in any way. The oxygen concentrator was not on. R78 stated he turns his oxygen on/off when he feels like he needs it. R78 stated the last time he used his oxygen was last night. R78 stated no one told him that he should store the tubing in a plastic bag or container when not in use. R78 stated he just wraps it around the bed rail when he is not using it.R78's diagnosis included but not limited to Anemia in Other Chronic Diseases Classified Elsewhere, Pleural Effusion, Encounter for Screening For Malignant Neoplasm Of Prostate, Hypertensive Heart Disease Without Heart Failure, Heart Failure, Other Artificial Openings Of Urinary Tract Status, Secondary Malignant Neoplasm Of Bone, Insomnia.R78's Order Summary Report printed 02/05/26 document in part, oxygen at two liters/minute PRN per nasal cannula, maintain oxygen saturation at 92% or greater as needed for SOB dated 01/20/26.R78's MDS (Minimum Data Set) dated 01/22/26 indicates intact cognition based on BIMS (Brief Interview for Mental Status). R78's oxygen care plan dated 02/05/26 documents in part R78 has oxygen therapy related to congestive heart failure. Facility provided policy titled Oxygen Safety/Use dated 05/2025 which documents in part, oxygen sources will be provided that ensure ready access and safe distribution of oxygen to patients/residents and oxygen tubing will be changed weekly and appropriately stored to prevent contamination when not in use.

Based on observations, interviews, and record reviews, the facility failed to provide one-to-one (1:1) feeding assistance for two residents (R84 and R192) with aspiration and swallowing precautions and failed to include the aspiration and swallowing precautions in their comprehensive care plan for two out of a total sample of 35 residents.Findings include: R84's 'admission Record' documents in part diagnoses of Parkinson's disease, lack of coordination, and dementia. R84's speech therapy discharge summary signed by V37 (Speech Language Pathologist) on 10/02/2025 documents in part: Compensatory Strategies/Positions: close supervision and the following swallowing precautions: only feed when alert, upright at 90 degrees for all intake, aspiration precautions, monitor for [signs and symptoms] aspiration related illness, alternate liquids and solids, slow rate, 'monitor for pocketing', provide oral care, discontinue feeding and clear mouth if [patient] demonstrates pocketing or [signs and symptoms] aspiration and notify nurse/[medical doctor]. R84's 1/02/2026 Quarterly MDS (Minimum Data Set) assessment documents in part that R84 had severely impaired cognition during the assessment period. R84 had loss of liquids and solids from mouth when eating or drinking. R84 was on a mechanically altered diet. R84 needed supervision or touching assistance when eating. R84's 'Order Summary Report' documents in part dietary orders for mechanical soft-textured diet with thin liquids. R84 has an order for 1:1 (one-to-one) assist with aspiration and swallowing precautions. The order date for the dietary orders was 9/09/2025. R84's 'Order Summary Report' also had a separate order for 1:1 feeder three times a day active since 12/08/2024. R84's 'Care Plan Report' documents in part focuses for R84's nutritional risk, impaired memory, and potential complications with Parkinson's including but not limited to dysphagia and drooling. However, R84's comprehensive care plan does not contain focuses or interventions related to R84's aspiration and swallowing precautions. R192's 'admission Record' documents in part diagnoses of traumatic brain injury, dementia, and mild cognitive impairment. R192's speech therapy discharge summary signed by V37 (Speech Language Pathologist) on 8/29/2025 documents in part: Compensatory Strategies/Positions: [speech language pathologist] recommends diet advancement to [patient] to [mechanical] soft/thin with 1:1 assistance and the following precautions: upright at 90 degrees for all intake, aspiration precautions, monitor for [signs and symptoms] aspiration related illness, alternate liquids and solids, slow rate, monitor for pocketing, 1:1 assistance. R192's 11/04/2025 Quarterly MDS assessment documents in part that R192 had severely impaired cognition during the assessment period. R192 needed partial/moderate assistance with eating. R192 was on a mechanically altered diet. R192's 'Order Summary Report documents in part dietary orders for mechanical soft texture with thin liquids. R192 has an order for 1:1 assist with swallowing precautions. The order date for the dietary orders was 8/19/2025. R192 also had a separate order for 1:1 feed with meals for nutritional intake active since 6/30/2025. R192's 1/29/2026 progress note by V39 (Nurse Practitioner) documents in part strict aspiration precautions related to dysphagia. R192's 'Care Plan Report' documents in part a focus for R192 being malnourished. Intervention includes providing 1:1 feeding assist (initiated 7/01/2025). However, R192's comprehensive care plan did not contain focuses on aspiration or swallowing precautions. During random lunch observations on 2/04/2026 at 12:09 PM, V12 (Nurse Manager) dropped off R192's lunch tray in front of [R192]. R192's meal ticket on the tray read 1:1 assist, swallowing precautions. R192 began eating. No staff sat 1:1 with R192 during the lunch meal. During same lunch observation, R84 was eating at the nearby table. R84's meal ticket on the lunch tray read 1:1 assist, aspiration precautions, swallowing precautions. No staff sat 1:1 with R84. V13 (Certified Nurse Aide) was standing in between the two tables. At 12:21 PM, V13 stated [V13] was watching everyone on that side of the room to make sure residents weren't sleeping or trying to get up from their chairs unassisted. V13 stated [V13] was not doing 1:1 feeding assist because role was to watch everyone in the room. At approximately 12:36 PM, R192 put tissue onto the plate, put hands under the blanket that was across [R192's] lap and brought it up to the chest. R192 closed eyes and stopped touching food from meal tray. R192 ate half of the turkey pot pie, half of the vegetable medley, half of the pudding and a cookie from V11 (2nd floor Activity Director). No staff provided 1:1 assist to R192 during continuous observations of R192's lunch meal. At approximately 12:42 PM, R84 finished all of lunch meal. No staff provided 1:1 assist to R84 during continuous observations of R84's lunch meal. On 2/05/2026 at 1:15 PM, V3 (Director of Nursing) stated 1:1 assist with feeding means a staff member should sit down and help feed the resident during meals. V3 stated residents that require 1:1 feeding assist are residents who need more assistance during meals to make sure they eat. V3 also stated it can be for safety reasons such as aspiration precautions when residents are at risk for aspirating food or water. Attempted telephone interview with V37 (Speech Language Pathologist) on 2/06/2026 at 12:22 PM; however, no answer. Survey team received facility's Feeding Assistance policy (1/2023) as it applies to residents who are unable to feed themselves. Policy did not address residents who require 1:1 feeding assistance with aspiration or swallowing precautions. Facility's Comprehensive Care Plan policy (1/2023) documents in part: The facility must develop a comprehensive person-centered care plan for each resident. The care plan will include a focus, measurable goal, and interventions specific to the resident's medical, nursing, mental, and psychosocial needs. The comprehensive care plan should drive the care and services provided for the resident and allow for the highest level of physical, mental, and psychosocial function based on the comprehensive MDS assessment.

Based on observation, interview and record review, the facility failed to ensure timely incontinence care was provided to one (R1) out of two residents reviewed for activities of daily living (ADL) care in a final sample of 35. Findings Include:On 2/4/26 at 11:09 a.m., R149 stated her roommate (R1) has not been changed since 4:00 a.m. R149 said, [R1's] been lying on that soiled diaper for hours. I've been awake since four in the morning and that was the last time the CNA [Certified Nursing Assistant] came in here to change her [R1]. They should know that she [R1] needs to be changed frequently because she has that tube feeding going and she [R1] soils herself a lot.On 2/4/26 at 11:16 a.m., R1's lying in bed alert and able to verbalize needs. R1 stated she's wet and needs to be changed. R1 said she does not remember when the last time her diaper was changed, but she feels like it's been a while. R1 said that she has a wound on her back and the wound dressing was changed yesterday morning.On 2/4/26 at 11:35 a.m., surveyor notified V6 (Certified Nursing Assistant) that R1 needs incontinence care. V6 said she will notify the CNA assigned to R1. On 2/4/26 at 11:40 a.m., V7 (Certified Nursing Assistant/CNA) stated [V7] is the CNA assigned to R1. V7 said she started at 6:00 a.m. and had not yet had the opportunity to check on R1.On 2/4/26 between 11:43 a.m. and 11:56 a.m., surveyor observed V7 (CNA) providing morning care to R1. During the observation, R1's incontinence brief and pad were noted to be saturated with urine and feces. R1's perineal area (inner thighs and groin) and perianal (buttocks) were heavily soiled with urine and feces. R1's sacral wound dressing was also soiled and not intact.On 2/4/26 at 3:43 p.m., surveyor conducted a telephone interview with V26 (Certified Nursing Assistant). V26 stated that she was the CNA assigned to R1 during the night shift on 2/3/26, and that she left the faciity on 2/4/26, at 6:00 a.m. V26 stated that R1 had frequent bowel movements related to tube feeding and requires frequent incontinence care. V26 stated that R1 typically has bowel movements every one to two hours and requires frequent diaper changes. V26 stated that she last changed R1's incontinence brief at approximately 4:30 a.m., prior to leaving the facility, and that this was her last round with R1. V26 stated R149 saw V26 changed R1 because R149 was awake at that time and that whenever V26 changes R1, V26 would let R149 know.On 2/5/26 at 12:47 p.m., V3 (Director of Nursing) stated that staff are expected to provide incontinence care as soon as possible when a resident is incontinent. V3 stated that staff conduct routine rounds, alternating with nursing staff, to assess resident safety and needs. V3 stated that during rounds, staff are expected to ensure the resident is safe, safety precautions are in place, the call light is within reach, and resident needs are addressed. V3 stated that staff are expected to check residents for incontinence at least every two hours, and that residents who are incontinent require checks at least every hour. V3 stated that incontinence care should be provided promptly when needed. V3 stated R1 requires reminders and relies on staff to meet her needs. V3 stated that R1 requires assistance with all activities of daily living (ADLs) and can sit up in a chair but requires staff assistance for repositioning. V3 stated that R1 is incontinent of both bowel and bladder and requires staff assistance for incontinence care. V3 stated that R1 has a gastrostomy tube (G-tube) and that some residents with a G-tube may experience loose stools, requiring frequent monitoring. V3 stated that staff should check R1 at least every hour. V3 stated that R1 has fragile skin and is at risk for skin breakdown, and that delays in care could impact wound healing and development of new skin breakdown.On 2/6/26 at 9:49 a.m., V19 (Registered Dietitian) stated that R1 is NPO (Nothing by Mouth) and receives tube feeding with a high-fiber formula and may experience frequent loose stools due to R1 may not be absorbing the formula well due to her current medical conditions.R1's clinical records show an original admission date of 7/25/26 with listed diagnoses but not limited to cerebral infarction, gastrostomy status, flaccid hemiplegia affecting left nondominant side, and adult failure to thrive. R1's Minimum Data Set (MDS) assessment dated [DATE] revealed R1 has severely impaired cognition with BIMS (Brief Interview for Mental Status) of 7. It also reveals that R1 is always incontinent of bowel and bladder, is dependent on staff's assistance for perineal hygiene, bathing, and mobility, and is at risk of developing pressure ulcers/injuries. R1's comprehensive care plan documents in part: [R1] is at risk for and has an alteration in skin integrity related to self-care deficits, impaired mobility and comorbidities with one of the interventions that reads: Provide peri-area after each incontinent episode and apply barrier cream (date initiated 7/28/25). R1's care plan also documents in part: R1 is incontinent of bowel and bladder and one of the interventions reads: Provide incontinence care at routinely timely intervals. Keep skin clean, dry and moisturized (date initiated 7/28/25).R149's clinical records show an original admission date of 6/20/23. R149's MDS dated [DATE] shows R149 is cognitively intact with BIMS of 15 and requires supervision with ADLs.The facility's SKIN CARE PREVENTION policy and procedures dated 6/25 documents in part: All residents will receive appropriate care to decrease the risk of skin breakdown. Clean skin at time of soiling and at routine intervals.The facility's INCONTINENCE CARE policy and procedures dated 5/25 documents in part: Incontinence care is provided to keep residents as dry, comfortable and odor free as possible. It also helps in preventing skin breakdown.The facility's Certified Nurse Aide job description (undated) documents in part: Keep incontinent residents clean, dry and odor free; check every two hours to maintain. Review care plans daily to ensure provision of appropriate care.

Based on interview and record review, the facility failed to follow their policy to develop a comprehensive person-centered care plan for each resident. This failure affected 2 (R104 and R178) residents on anticoagulant medication use in a sample of 35. The findings include:R104's admission record / face sheet showed admit date on 4/29/25 with diagnoses not limited to Paroxysmal atrial fibrillation, Type 2 diabetes mellitus, Hypertensive heart disease with heart failure, Presence of cardiac pacemaker, Other heart failure, Primary generalized (osteo)arthritis, End stage renal disease, Hypertensive heart and chronic kidney disease, Atherosclerotic heart disease of native coronary artery, Dependence on renal dialysis, Gout, Mixed hyperlipidemia.On 2/04/2026 At 11:57AM R104 observed up and about, ambulatory with cane with steady gait. Alert and oriented x 3, verbally responsive, stated he is getting blood thinner medication. R104's POS (Physician Order Sheet) dated 2/5/26 showed order not limited: Apixaban Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth every 12 hours for Thrombosis.MDS (Minimum Data Set) dated 11/4/25 showed R104 received anticoagulant medication.Reviewed R104's EHR (Electronic Health Record), no care plan was found for anticoagulant medication use. R178's admission record / face sheet showed admit date on 4/16/25 with diagnoses not limited to Heart failure, Alcoholic cirrhosis of liver without ascites, Alcohol dependence, Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, Other arterial embolism and thrombosis of abdominal aorta.R178's POS dated 2/5/26 showed order not limited to: Eliquis Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth every 12 hours.MDS dated [DATE] showed R178 received anticoagulant medication.Reviewed R178's EHR (Electronic Health Record), no care plan found for anticoagulant medication use. On 2/5/26 At 1:06PM V3 (DON / DIRECTOR OF NURSING) said Residents on anticoagulant medication, care plan should be completed. She said care plan is a generalized plan of care of the residents that includes interventions to guide staff how to care for the residents. She said if there is no care plan completed there is no discussed plan of care / interventions for the residents.On 2/6/26 At 9:40PM V36 (MDS DIRECTOR) she said part of her responsibility is to do care plan as well. She said Care plan provides patient's centered care, individualized for each resident based on their needs. V36 said care plan is done by IDT (Interdisciplinary Team). It can include problems / concerns, medications such as insulin, anticoagulant medication. She said Care plan includes goals and interventions. V36 said residents on anticoagulant medication should have a care plan because of the Potential or risk for bleeding. She said care plan helps the staff to care for the residents. Reviewed R104 and R178 EHRs with V36 and said both residents are on anticoagulant medication and care plan should be in place. Reviewed R104 and R178's care plan with V36, no care plan found for anticoagulant medication use.Facility's Comprehensive care plan policy dated 5/1/25 showed in part: The facility must develop a comprehensive person-centered care plan for each resident. The care plan will include a focus, measurable goal, and interventions specific to the resident's medical, nursing needs. The comprehensive care plan should drive the care and services provided for the resident and allow for the highest level of physical, mental, and psychosocial functions based on the comprehensive MDS assessment.

Based on observations, interviews, and record reviews, the facility failed to follow physician's orders for R129's IV (intravenous) dressing, failed to ensure that R129's IV dressing was secure and intact, failed to perform hand hygiene while handling R129's IV dressing, and failed to address R129's IV site in the comprehensive care plan for 1 out of 1 resident reviewed for IVs out of a total sample of 35 residents. Findings include: R129's 'Order Summary Report' documents in part that facility may insert a midline or PICC (peripherally inserted central catheter) line on 01/23/2026. There is an active order to Monitor [intravenous] insertion site, ensure dressing and placement is intact every shift. Notify [medical doctor] of any abnormalities every shift. The order date was 1/26/2026. There was an additional order to monitor the right arm for signs and symptoms of infection, infiltration, and/or dressing placements every shift dated 12/22/2025. R129's 'Order Summary Report' did not have any current medications or fluids to be administered intravenously. R129's 'Care Plan Report' did not include a focus on R129's intravenous line. On 2/04/2026 at 11:33 AM, R129 was sitting in the day room. R129 had an intravenous line near the crease of the right arm (antecubital). The medial side of the dressing was peeling off. The date on the dressing read 1/24/26. On 2/04/2026 at 11:34 AM, V11 (Activity Director for the second floor) stated the date on the dressing was 1/24/26. On 2/05/2026 at 11:05 AM, R129 was sitting in the day room. R129's intravenous line remained with a date of 1/24/26. The dressing was not intact on the medial side. On 2/05/2026 at 11:10 AM, R129's Medication Administration Record (MAR) documents in part that nursing staff including V15 (Nurse) charted monitoring the right arm for signs and symptoms of infection, infiltration, and/or dressing placements. However, the dressing remained with a date of 1/24/26 and was not intact. On 2/05/2026 at 11:14 AM, V15 (Licensed Practical Nurse-LPN) stated R129 was getting an antibiotic at some point. V15 stated doesn't know why R129 remained with intravenous line. V15 stated no due medications or fluids to R129's intravenous line during morning shift. V15 did not know when the last time staff used R129's intravenous line. V15 stated the facility has V27 (IV Nurse) who usually deals with residents PICC lines and midlines. V15 was not sure who oversaw changing of intravenous line dressings. V15 stated maybe the overnights. V15 stated normally, the overnight nurse would reinforce the intravenous dressing if it were coming loose. V15 stated most intravenous dressings should be changed every 72 hours overall but was not sure what the facility protocol was. V15 was not sure if LPNs could change the dressings. At 11:17 AM, surveyor and V15 went to observe R129's intravenous dressing. V15 did not perform hand hygiene or don gloves (V15 was charting at the nurses' station prior to this interview). With bare hands, V15 touched R129's single lumen and intravenous dressing stating the dressing was coming off on one side. V15 read the dressing date as 1/twenty something/26. After interview, V15 then went to the nurses' station. On 2/05/2026 at 11:22 AM, V4 (Second Floor Unit Manager and Infection Preventionist) stated staff nurses do the intravenous dressing changes. V4 stated nurses are to follow the physician orders which show up on the residents' MAR. The nurses are supposed to change the dressing when it's due, date it, and sign it. During a follow-up interview, at 11:49 AM, V4 stated R129 needed the intravenous line for antibiotics but R129 is no longer on it. V4 and surveyor observed R129's intravenous dressing. V4 stated nursing staff should have addressed R129's intravenous dressing. V4 stated nurses are to change the dressing every seven days and as needed when dressing is not intact. V4 stated staff should also perform hand hygiene and wear personal protective equipment including gloves while handling intravenous lines. On 2/05/2026 at 1:10 PM, V3 (Director of Nursing) stated R129 has a midline intravenous line. V3 did not know when it was last used. V3 stated nursing staff are to change the transparent dressing every seven days or as needed when the dressing is not intact. V3 stated any nurse that has a license can change the intravenous dressings. V3 stated V27 (IV Nurse) is a contracted company to insert midlines and PICC lines; however, when it comes to dressings and pulling the intravenous lines out, it is the facility nurses' duties. Attempted telephone interview with V27 on 2/05/2026 at 11:34 AM, 11:36 AM, and 11:42 AM; however, no answer. Facility's Midline Catheter-Dressing Change policy (date 1/2023) documents in part: The catheter insertion site is a potential entry site for bacteria that may cause a catheter related infection. This policy provides guidance on completing a midline catheter dressing change. The policy reads to perform dressing changes every seven days or when the integrity of the dressing has been compromised such as when it is loose. Staff are to perform assessment of venous access at least once every shift when not in use. Assessment is to include the integrity of the transparent dressing. Facility's Comprehensive Care Plan policy (1/2023) documents in part: The facility must develop a comprehensive person-centered care plan for each resident. The care plan will include a focus, measurable goal, and interventions specific to the resident's medical, nursing, mental, and psychosocial needs. The comprehensive care plan should drive the care and services provided for the resident and allow for the highest level of physical, mental, and psychosocial function based on the comprehensive MDS assessment.

Based on observation, interview and record review, the facility failed to implement care planned, fall risk interventions for a high fall risk resident (R2); failed to provide 2 person assist during activities of daily living (ADL) care for a dependent resident in bed (R2); and failed to notify the practitioner of the nurse's assessment of a resident's pain post fall incident for one resident (R2) in the total sample of 8. These failures affected R2 who suffered a fall in the facility on 1/4/2026 from the bed to the floor sustaining a 3 centimeter left head laceration and exhibiting pain signs immediately post fall with the nurse's palpation of R2's left leg which was not communicated to the practitioner; and after increased pain signs, R2's left hip X-ray was performed on 1/6/2026 showing a proximal left femur fracture. Findings include:R2's admission Record documents, in part, diagnoses of Alzheimer's disease, dementia, chronic kidney disease, major depressive disorder, anorexia, hypotension, atherosclerotic heart disease of native coronary artery without angina pectoris, cough, hypertensive heart disease without heart failure, pressure ulcer of sacral region stage 4, gastrostomy status, simple chronic bronchitis, arthropathies, shortness of breath, hypoxemia, psychosis, insomnia, pneumonia, and displaced subtrochanteric fracture of left femur.R2's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 00 which indicates that R2 has severe cognitive impairment. R2's Functional Abilities indicate that for oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing and personal hygiene, R2 is dependent coded as Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. For R2's bed mobility to roll left and right, sit to lying, and lying to sitting on side of the bed, R2 is coded as dependent. R2 utilizes no mobility devices per this MDS.On 1/21/2026 at 3:19 PM, V11 (Certified Nursing Assistant, CNA) stated that the V11 was assigned as R2's primary CNA on 1/4/2026 for the 2:00 pm to 10:00 pm shift. V11 stated that V11 is nonverbal, bedbound, and contracted on both arms and legs and had a floor mat next to R2's bed. V11 stated that on 1/4/2026, around 9:00 PM, V11 was making the last resident rounds. V11 stated, Whenever I (V11) want to make easier for whoever is coming behind me (night shift CNA), I was getting all of (R2's) linens made and change the bed with clean linens. (R2) kinda like drools a little bit on the bed. V11 stated that V11 had laid out the clean linens and rolled them into a linen roll. V11 stated that V11 was the only staff member rendering R2's care and moved R2's bed away from the wall, positioning V11's self in between R2's bed and the wall. V11 stated that V11 then turned R2 to the right side away from V11. V11 stated that V11 tucked the clean linen roll under R2's body as R2 is turned to the right side and realized that V11 did not have the new incontinence brief. V11 stated that V11 reached over R2's body toward the foot of the bed to retrieve the incontinence brief and in this process leaned with V11's arm on R2's low air loss mattress, which started R2 to move further away from V11's side of the bed, and R2 started to fall. V11 stated, (R2's) contracted and I grabbed (R2's) leg and it felt like it was making matters worse and I didn't want to extend it worse. I can see (R2) was in pain. V11 stated that V11 grabbed R2's leg to try to keep R2 from falling to the floor. V11 stated that as R2 was falling from the bed to the floor, R2 made no noises when R2 hit the floor, but only when I was grabbing (R2's) leg, I realized I was hurting (R2). V11 stated, I see that, the pain in (R2's) face. (R2) went from no emotion and you could see it. It was hurting. When asked if R2 fell on the bare floor or the fall mat, V11 stated, Kinda both. The mat and floor, it was both. V11 stated that R2 was laying on R2's left side, contracted arms and legs on the floor mat, and R2's head was slightly off the floor mat. V11 stated, I wanted to make sure (R2) was still alive. I didn't want to move (R2). I wanted to get the nurse. V11 stated that V11 left R2's room and went to the nurse's station and informed V8 (LPN) who was the nurse covering for V7 who was on break. V11 stated that V8 performed an assessment of R2 on the floor prior to the lift transfer back to the bed. V11 stated that V11 told V8 what had occurred during V11's care of R2. V11 stated that V11 provided a written statement of R2's care on 1/4/2026, and I learned to never lean on an air mattress.In V11's (CNA) signed statement for R2's witnessed fall when V11 was working on 1/4/2026 on the shift 2:00 PM to 10:00 PM, V11 documents, in part, I (V11) was entering the room to do patient care on (R2); (R2) was facing the window. As I was tucking the clean linen under the patient, I leaned on the mattress to reach for the brief. I saw (R2) begin to slide headfirst off the mattress; I attempted to keep (R2) from falling but was unsuccessful (R2) landed on the mat next to the bed. I called for help and the Nurse came in.On 1/21/2026 at 11:02 AM, V8 (LPN) stated that V8 was working on R2's floor for the 3:00 pm to 11:00 pm shift and that V8 was not assigned as R2's primary nurse during this shift. V8 stated that if a resident has a fall occurrence, V8 will perform an assessment to see if there are physical injuries or if resident is complaining of pain. When asked what the post fall assessment by a nurse entails, V8 stated that it's done prior to moving the resident, and V8 starts at the resident's head looking for bruising or discoloration. V8 moves down to the shoulders and arms, having the resident move extremities to see if there's pain or discomfort. V8 stated that V8 will perform passive range of motion for a resident that cannot actively move as baseline. When asked if a resident is contracted on the arms and legs, how will V8 assess the extremities, and V8 stated that if passive range of motion can't be done due to the contractures like R2, V8 looks at the joints to see if there is swelling or discoloration and will feel the extremity for heat, all while looking at the resident's face for grimacing or if making noises for nonverbal residents. V8 stated that R2 is total care, bedbound, and is nonverbal. V8 stated that on 1/4/2026 around 9:30 PM, V8 was covering V7's assignment while V7 was off the floor on V7's break. V8 stated that V11 (CNA) came to the nurse's station and stated, You (V8) are not going to like it but (R2) is on the floor. V8 stated that V8 immediately went into R2's room and observed R2 on R2's left side, on the floor mat with R2's head that had went on the floor but was no longer in contact with the floor. V8 stated that V8 assessed R2 for physical injuries seeing blood coming from R2's left forehead where V8 applied pressure with a gauze and did R2's remaining assessment. V8 stated that with R2's contractures to both arms and legs, V8 touched and squeezed along R2's arms and legs. V8 stated that when V8 touched with V8's hand along R2's left leg, V8 did notice that R2 grimacing, having pain on the left leg. V8 also stated that R2 made moaning noises when V8 touched R2's left leg. V8 demonstrated to this surveyor how V8 checked R2 on 1/4/2026 by V8 palpating in a slight squeezing motion with V8's hands along the left upper leg from knee up to the hip. V8 stated that V8 assisted V11 with the lift transfer of R2 to the bed and continued to clean R2's left head laceration and placed 2 adhesive tape strips over the skin opening. V8 stated that V7 was returning from V7's break, and V8 was medicating R2 with Acetaminophen for pain (already a PRN, whenever needed, order was present). When asked if V8 communicated V8's findings of new left leg pain post fall to V7, V8 stated that V8 informed V7 that R2 was in pain on R2's left side and that V11 said that R2 rolled over and slipped out of bed. V8 stated that V7 contacted V31 (Advance Practice Nurse, APN) and during this call, V8 only spoke to V31 about R2's blood thinning medication status. V8 stated that V8 did not inform V31 of R2's post fall assessment of the new left leg pain upon palpation. When asked did V11 inform V8 that as R2 was falling off the bed, V11 tried to catch R2, and V8 stated that V11 could have said that to V8. When asked did V11 tell V8 that V11 grabbed R2's leg as R2 was falling off the bed and that R2 moaned out in pain, V8 stated that V8 didn't recall that statement from V11.On 1/21/2026 at 9:09 AM, V7 (LPN) stated that V7 was R2's primary nurse on 1/4/2026 for the 3:00 pm to 11:00 pm shift. V7 stated that for high fall risk residents, V7 communicates to the CNAs who the high fall risk residents are and monitoring checks are performed at a minimum of every 2 hours. V7 stated that if a resident has a fall, V7 will first assess the resident for changes, then reposition the resident with another nurse or CNA, take vital signs, and will call the doctor, family and V2 (DON). V7 stated that V7 is very familiar with R2 and that R2 is nonverbal so V7 watches (R2's) body movements to get communication. V7 stated that R2's call light device is an adaptive, flat pad that V7 places near R2's jaw on the pillow for R2 to lean head on the call light. V7 stated that R2 is a 2 person assist for ADL care and that R2 is contracted both arms and legs. V7 stated that V7 returned from break on 1/4/2026 to find several staff coming from R2's room. V7 stated that R2 was back in bed at this point, where R2 had 2 adhesive tape strips on the left forehead. V7 stated that V8 informed V7 that V11 was take care of R2 when R2 fell from the bed. V7 stated that V7 took R2's vital signs and called V31 (APN). V7 stated that when V31 asked about R2's pain, V7 stated, This client is nonverbal and we do not know (R2's) degree of pain. V7 stated that V7 informed V31 that R2 had a PRN Tylenol order present and that R2 was medicated with a dose. V7 stated that V31 informed V7 to perform 72 neurological checks and to notify a practitioner with any change in R2's condition. V7 stated that V7 gave V31 the secondhand report from V8 about the witnessed fall for R2 on 1/4/2026 and that V31 relies on the information that V7 is telling V31. V7 stated that V7 questioned V11 about what occurred with R2's fall. V7 reiterated to V11 that 2 people are needed to care for R2. When asked during report at beginning of shift, did you tell V11 that R2 was a 2 person assist, No, not at the beginning of shift. I told (V11) that after the fall. (V11's) new. In R2's Fall Incident Report, dated 1/4/2026 at 9:45 PM, V7 (LPN) documents, in part, for the incident description (nursing), at approximately 9:30 AM, V11 stated that R2 was on the floor; upon entering R2's room, R2 observed lying on left side on floor mat; and per V11, ADL care was being rendered when R2 slid from bed and V11 was unable to stop R2 from sliding to the floor. For incident description (resident), R2 was unable to give any description. For the immediate action taken description, V7 (LPN) who is assigned to R2 was on lunch break and V8 (LPN, second nurse on R2's floor) went to R2's room immediately and observed R2 on the mat with skin alteration noted on R2's left forehead with a small amount of bleeding where V8 applied pressure, cleansed with normal saline and applied adhesive tape strips to R2's forehead skin laceration. In V31's (Advanced Practice Nurse, APN) Progress Note, with date of service 1/4/2026 at 10:16 PM, V31 documents, in part, that details are provided by nurse, V7, with primary chief complaint of fall with head strike. History of present illness is noted as R2 with a witnessed fall resulting in small laceration on head treated with adhesive tape strips and no active pain, bleeding or complaints. In R2's Comprehensive Pain Evaluation, dated 1/4/2026 at 11:45 PM, V7 documents, in part, that only R2's skin alteration diagnosis is the reason for R2 is experiencing pain; that pain is increased during R2's incontinence care; that R2's nonverbal indicators are facial grimaces (furrowed brow, narrowed eyes, tightened lips, dropped jaw, clenched teeth, or distorted expression); and in the category for possible workup needed/doctor ordered the following tests, the space is blank (no imaging tests ordered). On 1/15/2026 at 11:49 AM, V9 (R2's Healthcare-Power of Attorney, HC-POA) stated that on 1/4/2026 around 10:30 PM, V9 received a phone call from V7 (LPN) saying that R2 had fallen and has a head laceration. V9 stated that V9 and V10 (R2's Family Member) arrived at the facility within 15 minutes, and they see R2 in bed with blood dripping on the left side of R2's head. V9 stated that V9 and V10 questioned V7 about sending R2 out to the hospital to be examined, and V7 replied that R2 was stable and that V7 spoke to a practitioner who recommended to monitor R2 in the facility. V10 arrived in-person during this surveyor's interview with V9, and V10 stated on 1/4/2026 when V10 arrived with V9, V10 asked the nurse are you going to do a body examine to see if there are any broken bones, and the nurse said that they will do it. V9 stated, (R2) is nonverbal and (R2) can't speak up for (R2's) self. (R2) is contracted with (R2's) arms and legs and (R2) can't defend (R2's) self. V9 stated that on 1/6/2026, the nurse practitioner (V24) called V9 and said R2's breathing is labored, that they had R2 on Acetaminophen ordered every four hours; and were ordering an X ray of R2's hips. V9 stated that R2's resting heart rate and blood pressure were more elevated than R2's normal now. V9 stated, I was terrified of what's going on with (R2). V9 stated that the hip X-rays were done later on 1/6/2026, and I wish they had taken better care of (R2). V9 stated that on 1/6/2026 around 10:25 PM, V2 (Director of Nursing, DON) phoned V9 saying that X-ray results were back, and both of R2's hips are dislocated. V9 stated that V9 came to the facility within 15 minutes that evening on 1/6/2026, and R2 was in lots of pain, making loud noises saying ohhhhh. V9 stated that V9 and V10 went to the hospital where R2 was transported to on the night of 1/6/2026-1/7/2026, and the emergency room doctor told us that R2's left femur was broken, and we were told the doctor that V2 (DON) had told us both hips were dislocated. V10 stated that V9 and V10 were getting conflicting information from the facility. V9 stated that emergency room doctor said that the left femur was like a wish bone and due to R2's current medical status, R2 wouldn't sustain the surgery needed to repair the left femur. V9 stated, This has impacted (R2). It's not fair to (R2). (R2) has suffered lots of pain and discomfort. It's life changing. On 1/20/2026 at 10:42 AM, R2 observed in bed in room with R2's adaptive call light hanging down over the headboard of R2's bed toward the wall away from R2, and R2's bed height is visibly higher than this surveyor's observation of R2 in the lowest bed position on 1/15/2026. This surveyor called V14 (LPN) to R2's room and asked about the current height of R2's bed. V14 stated that the height of R2's bed should be lower. V14 stated, I (V14) would bring it (bed height) down more than this to prevent injury if (R2) falls. V14 used the bed control and lowered R2's bed height down to the lowest position towards the floor. When asked about the location of R2's call light, V14 retrieves the call light cord that is hanging over R2's headboard towards the wall and pins it to the pillow near R2's head saying that it is a modified call light for R2. V14 stated that R2 can't use it with her hands and they are keeping it near R2's head. On 1/20/2026 at 1:39 PM, V3 (Restorative Nurse, Licensed Practical Nurse, LPN) stated that V3 is the restorative nurse for R2's floor and sometimes works as a floor nurse on R2's floor. V3 stated that as the restorative nurse, V3 performs assessments for residents to determine what proper devices are needed for transfers and mobility, and the number of staff members needed to safely perform ADL (Activities of Daily Living) care. V3 stated that V3 also performs the fall risk assessment within the comprehensive restorative assessment to determine if a resident is a high fall risk with a score of 10 or higher. V3 stated that V3 will then care plan for interventions for the high fall risk resident and update the high fall risk resident list on the floors. V3 stated that for bedbound residents in their rooms, staff keep the bed in the lowest position and the call light within residents' reach. V3 stated that the bed is to be maintained in the lowest position, so if they do fall, they don't fall from a high plane. V3 stated that the call light is kept close to residents in bed for their safety so if they need help, they can activate the call light. V3 added that for bedbound residents, the staff must make sure to position the resident in the center of the bed, so when the resident is rolled to the side, the resident will not roll off the edge of the bed. V3 stated that when CNAs are performing 2 person assist while rendering care to a dependent resident in bed, one CNA will be on one side of the bed and the other CNA will be on the other side of the bed and both CNAs will log roll the resident in the center of the bed during care. V3 stated that R2 is alert to R2's name, nonverbal, receives gastrostomy tube feedings, is incontinent and depends on staff for ADL care and repositioning in bed. V3 stated that prior to R2's fall incident on 1/4/2026, R2 was at a high fall risk and was assessed as a 2 person ADL assist (dependent). V3 stated that on 1/5/2026, V3 learned of R2's fall from 1/4/2026, and V3 talked to V11 (CNA) who was rendering care for R2 during the fall incident. V3 stated that V8 responded to R2 immediately post fall. V3 stated that V3 must collect the details of R2's fall incident to be able to determine what new fall interventions to put in place in the care plan to prevent further falls. V3 stated that V3 visited R2 on 1/6/2026, and R2 was making a lot of noise and was in pain. V3 stated that V3 confirmed with the primary nurse, V14 (LPN), who had stated that V14 had given R2 the Acetaminophen. V3 stated that V9 arrived late morning on 1/6/2026, seeing R2 in pain. V3 stated that V3 informed V9 that V14 had already given R2 the pain medication (Acetaminophen), but V9 was asking for help since R2 was so uncomfortable. V3 stated that V3 would let V24 (Nurse Practitioner, NP) know. V3 stated that V3 informed V24 to come to evaluate R2, and V3 was present with V24 during V24's assessment where the left leg is more swollen than the day before. V3 stated that V24 provided STAT X-ray orders for bilateral hips and chest X-ray, since R2's respirations and heartrate were elevated. V3 stated that V3 knows R2 well, and since R2's pulse was faster than normal and that was in pain, it was a concern for V3. R2's Vitals Summary indicate R2's heart rate readings on 1/6/2026 were 102 beats per minute (bpm) at 5:39 AM and 100 bpm at 10:37 PM. On 1/21/2026 at 1:28 PM, V24 (NP) stated that V24 is familiar with R2 and routinely visits R2 in the facility. V24 stated that R2 is nonverbal, contracted muscles on all 4 extremities, normally is on 2 to 3 liters/minute of oxygen with nonlabored breathing, has eyes open but does not track, and R2 gives nonverbal cues so you can tell if something is wrong. V24 stated that on 1/5/2025, V24 did not see R2 in the facility, and on 1/6/2026, V24 ran the 72 hour report and could see that R2 had a fall incident on 1/4/2026. V24 stated that prior to seeing R2 on 1/6/2026, V3 (Restorative Nurse, LPN) came asking for V24 to assess R2 for moaning in pain during care. V24 stated that V24 did a full assessment seeing R2 breathing faster and moaning while R2 is exhaling, looked distressed. V24 stated that R2's contracted left leg normally is stationary upwards at hip joint but was leaning down and to the left side. V24 stated that when V24 touched R2's left upper leg, R2's moaning would get louder. V24 stated that V24 ordered Acetaminophen every 4 hours around the clock and STAT X-rays of hips and chest on 1/6/2026. V24 stated that the imaging results came back after V24's shift ended on 1/6/2026, and R2 was sent to the hospital later on that night with a left femur fracture. V24 stated that if the nurse had palpated R2's leg post fall, the nurse must notify the on call practitioner because R2 cannot verbally tell the nurse if there is an injury, so the nurses are trained in assessment skills for nonverbal signs of pain. V24 stated that if a fall resident is assessed with new pain immediately post fall, there is a risk of an unknown fracture. V24 stated that for R2's fall incident, V24 would have been concerned with R2 possibly developing compartment system and R2's pain. V24 stated, A nurse should recognize nonverbal cues of pain.In V24's (Nurse Practitioner) Progress Note, dated 1/6/2026 at 11:45 AM, V24 documents, in part, that R2's baseline is alert with eyes open, does not tract and oriented times zero; R2 is non-verbal and unable to make R2's needs known; and R2's past medical history includes contractures of multiple joints and functional quadriplegia. V24 documents that per nursing documentation, R2 has a witnessed fall during patient care in which R2 landed on the floor mat next to the bed sustaining a skin alteration to the forehead. V24 documents that upon assessment today (1/6/2026), R2 is moaning with exhalation and moaning when LLE (left lower extremity) was palpated. V24 documents that R2's LLE was noted to be slightly abducted while R2 noted to have knee bent at approximately 90 degrees with STAT X-rays ordered of bilateral hips and pelvis. V24 documents for V24's assessment of R2's extremities as the following: LLE contracted at approximately 90 degrees, unable to extend but does have some movement when abducted; RLE (right lower extremity) contracted at 90 degrees, unable to abduct, adduct or extend; RUE (right upper extremity) shoulder contracted and unable to fully abduct, arm contracted at the elbow at approximately 90 degrees and unable to extend, and fingers are contracted; and LUE (left upper extremity) shoulder contracted and unable to fully abduct, arm contracted at the elbow at approximately 90 degrees and unable to extend, and fingers are contracted. On 1/20/2026 at 2:34 pm, V14 (LPN) stated that on 1/6/2026, V14 worked the day and evening shifts as R2's primary nurse. V14 stated that V24 (NP) had ordered the X-rays for R2's STAT X-rays, and when the X-ray technician was performing the X-rays for R2, V14 said the technician could see possible bilateral hip fractures as a preliminary reading, but the radiologist must read the X-ray film to confirm this. V14 stated that V14 then phoned V2 (Director of Nursing, DON) with this information who then relayed to V14 that V34 (Physician) is ordering R2 to be sent to the hospital for further evaluation. V14 stated that R2 was grimacing a lot, and R2 was receiving the Acetaminophen every 4 hours. V14 stated that R2's heart rate would elevate to 99 bpm, then would come down to 80 after the Acetaminophen was given. Facility document titled Radiology Results Report documents, in part, with date of service 1/6/2026, R2's left hip X-ray (unilateral with pelvis, 2 to 3 views) results are fracture of the proximal left femur with overriding of the fracture fragments. R2's hospital records, dated 1/7/2026, document, in part, that R2 experienced fall at the facility on 1/4/2026 and hit head sustaining a 3 centimeter laceration that was repaired with adhesive tape strips, and R2 received X-ray in facility on 1/6/2026 showing possible bilateral hip fractures. R2 does grimace with movement of left leg. R2's hospital CT (computerized tomography) without contrast results of left hip (dated 1/7/2026) indicate comminuted displaced left intertrochanteric femur fracture with soft tissue swelling around the left hip with probable left hip joint hemarthrosis and intramuscular hematoma in the left proximal thigh. On 1/21/2026 at 1:55 PM, V2 (DON) stated that if a resident falls in the facility, V2 expects the nurses to follow this procedure: enter the area where resident is on the floor; do an assessment to see if the resident is injured; see if the resident is able to tell you what happened; assess for change in body function structures; and if there are no changes, then the nurse can assist the resident off the floor to a safe area. V2 stated that V2 expects for the nurse to follow up with practitioner, family and V2, and after making the notifications, to then document. V2 stated that the nurse must document using the risk management form (fall incident report) that allows for further information to be added in the risk management form as the fall investigation continues. V2 stated that nurses must notify V2 who will help guide the nurse on how to follow the facility's protocol post fall. V2 stated that the protocol for falls with suspected injuries is that the nurse gathers the information from the assessment. If the resident had a fall and resident complains of new pain, the nurse will report to the practitioner where the resident is having pain and recommend an X-ray. V2 stated that once there is a confirmed injury with an X-ray, the resident will be ordered by the physician to be sent to the hospital. For a resident who has fallen and is nonverbal and contracted, V2 expects that the nurse performs a full body assessment by looking and touching the resident's body while seeing if there are any facial grimacing or moaning/grunting sounds. V2 stated that nurses should not assume there is no pain if there are no facial changes, because there could be teeth grinding, jaw barring down, body shaking or resident who is trying to move. V2 stated that if the pain assessment findings are different from the resident's baseline, the nurse must inform the practitioner and recommend for possible X-ray if in pain. V2 stated that R2's fall incident occurred on 1/4/2026, and on 1/6/2026, V3 (Restorative Nurse, LPN) touched R2's left leg with R2 being in discomfort. V2 stated that V3 relayed this pain assessment to V24 (NP) who ordered the hip X-ray. V2 stated that V2 reported R2's left femur fracture to the State agency with a corresponding investigation. V2 stated that V11 informed V2 that V11 turned R2 to the right side in bed when rendering care by V11's self; V11 tucked the clean linen roll under R2; and as V11 moved V11's arm to reach for the incontinence brief, V11 pressed into air mattress, and R2 began to slide off the opposite edge of the bed. V2 stated that V11 informed V2 that when R2 was sliding off the bed, V11grabbed R2's left leg and got a hold of it, but it was not successful and R2 continued to slide off the bed to the floor. her and she fell down on her side. When asked was V2 informed on 1/4/2026 about R2's pain to the left leg with palpation by nurse (V8) performing post fall assessment, V2 stated no. V2 stated that the restorative nurse assesses residents to determine the number of staff needed to perform safe ADL care, and V2 expects for CNA staff to follow each the interventions from each resident's assessment.In R2's Order Summary Report for orders from 1/4/2026 to 1/6/2026 document, in part, orders as follows: monitor left forehead and report any changes or signs/symptoms of infection report to primary care physician every shift and as needed (order date 1/5/2026); Acetaminophen 500 milligrams (mg) via gastrostomy tube every morning and at bedtime for pain/elevated temperature (order date 1/5/2026); and Acetaminophen 500 mg every 4 hours for pain (order date 1/6/2026). No new orders listed on 1/4/2026.R2's Medication Administration Record (MAR) for January 2025 shows R2 was not medicated with Acetaminophen for pain prior to R2's fall incident on 1/4/2026 at 9:30 pm, and R2 received 6 doses of Acetaminophen (3 doses of 500 milligrams and 3 doses of 650 milligrams) post fall until transfer to hospital on 1/6/2026.R2's Care Plan, with created on date of 1/23/2019 and date initiated 8/23/2024, documents, in part, a focus that R2 is high risk for falls and is at risk for injury from falls related to weakness with interventions of maintain bed in the lowest position; use approved techniques for repositioning (R2); and call light within (R2's) reach when in room.On 1/15/2026, V9 and V10 presented to this surveyor photographs of R2 on 1/4/2026 with R2's left forehead laceration with 2 adhesive tape strips with blood staining noted on the strips and residual blood that has run down R2's scalp past R2's left ear and a small blood stain on R2's tile floor (with R2's oxygen tubing and gastrostomy tube pole base noted in photograph).Facility document titled (R2's Floor) High Fall Risk dated 12/24/2025 documents, in part, that R2 is a high fall risk with HF next to R2's name. V3 (Restorative Nurse, LPN) retrieved this list from R2's floor nurse's station on 1/20/2026 at 3:08 PM, and V3 stated that it's kept here for all staff to review who the high fall risk residents are.Facility Daily Assignment Sheet dated 1/4/2026 for the 2nd shift (evenings) on R2's floor, documents, in part, 2 (V7 and V8) nurses working with V7 assigned to R2's room, and V11 (CNA) assigned to R2's room. Facility policy titled Fall Prevention and Management dated July 2025 documents, in part, General: 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 preventive strategies, and facilitate as safe and environment as possible. All resident falls shall be reviewed, in 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. 2. Residents at risk for falls will have fall risk identified on the interim plan of care with interventions implemented to minimize fall risk. Facility Guideline following a fall incident: 1. Evaluate the resident for any injury and notify the physician and emergency contact. 2. Complete a fall incident report in the (electronic medical record system) risk management portal. 3. A fall risk evaluation is completed by the nurse. A score of 10 or greater indicates the resident is at high risk for falls.Facility policy titled Activities of Daily Living dated 5/1/2025 documents, in part, General: 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. Responsible Party: All Nursing Personnel. Guideline: 1. The ability of each resident to meet the demands of daily living is determined by a Licensed Nurse. 2. A program of assistance and instructions in ADL skills is care planned and implemented.Facility policy titled Call Light Response dated 5/1/2025 documents, in part, General: To provide the staff with guidance on responding to residents' requests and needs . Protocol: . 3. Ensure the call light is always within the resident's reach. 4. When the patient or resident is in bed or confined to a bed or chair, provide the call light within easy reach of the patient or resident. Facility policy titled Pain Management dated May 2025 documents, in part, General: To facilitate and provide guidance on pain observations and management. To facilitate resident independence, promote resident comfort and preserve resident dignity. This will be accomplished through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life environment. Responsible Party: Nursing, DON. Guideline: The pain management program is based on a facility wide commitment to resident comfort. Pain is defined as whatever the experiencing person says it is and exists whenever he or she says it does . Pain management is a multidisciplinary care process that includes the following: Observing the potential for pain. Effectively recognizing the presence of pain. Identifying the characteristics of pain. Addressing the underlying causes of the residents pain . Policy: 1. Pain is assesse

Based on interviews and record reviews, facility failed to follow their policy and did not notify resident's legal representative/guardian about a fall incident for one resident (R1) in the final sample of 8 residents reviewed for quality care/treatment.On 1/20/2026 during complaint investigation for allegation of quality care, record review, and interviews showed in part, that R1's legal guardian was not notified of R1's fall incident on 4/8/2025, and instead, R1's second emergency contact was left a phone message, and no other notification was documented.On 1/20/2025 at 10:05 AM, confirmed that R1 no longer resides in the facility.R1 was discharged [DATE].On 1/20/2026, R1's admission record sheet showed in part that R1 was admitted to the facility on [DATE] from acute care hospital and that R1's contacts information included, but not limited to a family member as a second emergency contact and V25 (Legal Guardian/Case Manager) as R1's state appointed legal guardian and a case manager.R1's admission record (12/23/2024) showed in part R1's diagnosis included but not limited to Dementia without behavioral disturbance; Difficulty in walking; Lack of coordination; Dysphagia; Protein-calorie malnutrition; Dehydration; Muscle Weakness; Hypertensive heart disease; Iron Deficiency and Adult Failure to thrive.R1's Care plan (Initiated 12/24/2025) showed in part, that R1's had a surrogate decision maker and as of 3/31/2025, R1 had appointed state guardian and to contact adult guardianship division.R1's Progress notes (3/31/2025 at 13:14 AM), documented by V30 (Social Worker) showed in part that V30 was notified that R1 has been appointed a public guardian with notes documenting the guardian's information.R1's Progress notes (4/9/2025 at 02:10 AM), documented by V7 (LPN), showed in part that R1 was sent out to the emergency room). Progress notes do not show documentation that R1's legal guardian was notified of R1's fall or transfer to hospital.R1's Progress notes (4/9/2025 at 02:19 AM), documented by V7 (LPN), showed in part that V7 left voice message with R1's second emergency contact about R1's fall and that R1 was in the hospital for observation. Progress notes do not show documentation that R1's legal guardian was notified of R1's fall.R1's Progress notes (4/9/2025 at 6:12 AM), documented by V18 (LPN), showed in part a noted that V7 called hospital and R1 is on the way back to facility and that CT Scan was negative. Progress notes do not show documentation that R1's legal guardian was notified of updated status.R1's Progress notes (4/9/2025 at 6:40 AM), documented by V18 (LPN), showed in part, that R1 returned from hospital with no additional new orders and that R1 had alteration of skin to left eyebrow without redness or swelling, no pain, stable vital signs and that safety measures were maintained. Progress notes do not show documentation that R1's legal guardian was notified of updated status or the fall incident. No other documentation of legal guardian notification was noted in R1's progress notes related to R1's 4/8/2025 fall incident.On 1/20/2025 at 3:02 PM, V15 (LPN), stated that if resident has a fall incident, V15 should notify resident's first emergency contact and if resident has a legal guardian on file, then V15 should notify the legal guardian of incident first, before other emergency contact and document the notification in the resident's electronic record. V15 was not sure if R1 had a fall on 4/8/2025 because the incident happened so long ago but V15 recalled R1's fall on 5/10/2025 where R1 ended up with left hip fracture. On 1/21/2026 at 9:05 AM, V7 (LPN) stated, that V7 is somewhat familiar with R1 and after presenting V7 with V7's progress notes, V7 recalled R1 having a fall incident on 4/8/2025 around 11 PM. V7 stated R1 was found lying on the left side in the bathroom, when V7 responded to a call light bell. V7 stated, that when came to the room, R1 was observed by V7 on the floor in the bathroom and said that R1 did not remember what happened, when R1 stand up from using a bathroom. V7 stated, that R1 had a minimal skin tear on R1's left eyebrow and V7 cleaned it and applied gauze dressing. V7 stated, that V7 notified the physician, and the resident was sent out to the emergency room for evaluation. V7 stated, that V7 thinks that V7 called the legal guardian, but is not sure and confirmed when looking at the charted progress notes, that V7 did not documented the notification to legal guardian on file but documented leaving message with the second emergency contact instead. V7, when presented and looked at R1's admission Record with R1's contact information, then stated that V7 should have contacted the legal guardian and document in R1's chart. V7 stated, that if resident has a power of attorney (POA) or a legal guardian contact information on file, the legal guardian or the POA should be notified with any resident's changes. V7 also said, that when resident is received back from hospital, the legal guardian should also be notified with an update and conversation should be documented.On 1/21/2026 at 10:48 AM, V18 (LPN), stated, that V18 does not remember R1's 4/8/2025 fall incident, because it was long time ago and R1 was in the facility only for short time. V18 stated, that if R1's progress notes showed, that V18 documented that R1 came back from hospital, then legal guardian should be notified, but is not sure that V18 notified R1's legal guardian with the update status. V18 stated, that when resident returns from hospital, the legal guardian should be still notified about resident's status and the conversation should be documented.On 1/21/2026 at 11:35 AM, V20 (Second Floor Unit Manager), stated, that when resident have a fall, the nurse should notify the physician, the nursing director or V20 and the legal guardian . V20 stated, that the if resident has a legal guardian on a file and emergency contact, the legal guardian should be always notified first and then the emergency contact and the notification should be documented in the resident's chart. V20 also stated, that the legal guardian should be notified with changes or updates on resident any time of the day and should be left a message if notification is in late hours. V20 is not familiar with R1, and is not aware of R1's falls, because V20 just started working at the facility on the end of April of 2025 and the resident was discharged few days after.On 1/21/2026 at 12:10PM, V22 ( Third Floor Unit Manager/LPN), stated that when resident has a fall, the nurse should assess resident and check vital signs, place resident safely back to bed and then notify the physician, the resident family and the nursing director or the unit manager. V22 stated, that if resident has a legal guardian appointed, then the guardian should be notified before the family and the notification should be documented in resident's chart. V22 also stated, that notification should be also documented when resident returned from a hospital.On 1/21/2026 at 12:19 PM, V23 (Social Work Director) stated, that resident's legal guardian should be notified first, then notify the next emergency contact on the list of contacts. V23 stated, that there should be a documentation in resident's chart if the nurse tried to contact or left message with the legal guardian. V23 stated, that V23 is not familiar with R1, because the resident was discharged prior V23 started working at the facility.On 1/21/2026 at 1:55 PM, V2 (Director of Nursing/DON) stated, that V2 is somewhat familiar with R1 and that R1 was a resident with Dementia diagnosis and that R1 loved to move around. V2 stated, that R1 could not ambulate without assistance, but was attempting to get up. V2 stated, that V2 was notified of R1's fall on 5/10/2025 at 8 Am by V15 (Licensed Practical Nurse/LPN) and was informed that R1 was found lying on the floor in R1's room, on the right side, next to R1's bed. V2 stated, that V2 was not familiar if R1 had a fall on 4/8/2025 but is aware of the fall incident with injury on 5/10/2025. V2 was presented a progress note documentation and a risk assessment about R1's fall on 4/8/2025 and then V2 stated, that the fall on 4/8/2025 was not needed to be reported to the agency because the resident did not have a serious injury, but the fall on 5/10/2025 should be reported to the state agency and presented initial and final incident report from 5/10/2025. V2 confirmed that R1 had two falls in the facility and one with injury and stated, that the legal guardian should be notified first before emergency contact. V2 stated, that the legal guardian should be notified about the 4/8/2025 fall incident first and the notification documented, instead of the family member emergency contact. On 1/21/2026 at 3:32 PM, V26 (LPN), stated, that when V26 has a resident that would be going to the hospital, V26 should notify whoever is the responsible party for that resident. V26 stated, that if resident has multiple emergency contacts on the chart, the legal guardian should be notified first and then the other emergency contacts. Facility's Document titled Fall Incident Description (4/8/2025 at 10:20 PM), showed in part R1's fall description and that family member was notified on 4/9/2025 at 07:05AM documentation by V7 (LPN). Document does not show that legal guardian was notified of R1's fall.Facility's presented document titled Letter of Instruction, Office of the [NAME] County Public Guardian (3/31/3035), showed in part that R1 has been appointed Plenary or Temporary Guardian by the Circuit court of [NAME] County and that in the event of an emergency the staff should notify the appointed guardian and that the compliance with the procedure is mandatory. The document also showed in part, that the letter should be placed in resident's chart and all personnel should be advised of the guardian role and expectations. Facility's document titled Physician-Family Notification-Change in Condition (1/1/2025) showed in part, that the purpose is to ensure that medical care problems are communicated to the attending physician or authorized designee and family in a timely, efficient, and effective manner and it is responsibility of the Licensed Nursing Personnel and Social Services. The document further showed in part, that the facility should inform the resident and notify the resident's legal representative or an interested family member when the resident is involved in accident that resulted in injury, a significant change in resident's physical status and when decision to transfer or discharge of resident was made.

Based on interviews and record reviews, facility failed to follow their policy to ensure residents are free from accidents and hazards by planning for preventative strategies and facilitate as safe as an environment as possible for one (R4) out of three residents reviewed accidents and hazards in a sample of four. This failure resulted in R1 sustaining an acute subdural hematoma to the left frontotemporal region of her head.Finding include:R4's Minimum Data Sheet Section C (12/8/2025) documents in part: R4 has a Brief Interview of Mental Status (BIMS) of 10. R4 is mildly cognitively intact.R4's Facesheet documents in part: R4 has a medical diagnosis of cerebrovascular disease, delirium due to known physiological condition, difficulty in walking and unspecified lack of coordination.Per R4's Facesheet R4 was admitted to facility on 11/6/2025.R4's fall risk assessment on 11/7/2025 documents in part: R4 scored a fall risk assessment of 23. 10 or above is high fall risk.On 12/11/2025 at 11:16 AM, V11 (Falls Coordinator/Licensed Practical Nurse) stated that she is familiar R4. Fall risk assessments are quarterly and post fall. V11 stated that the initial assessment is completed upon admission. If they score above 10, they are a high fall risk, and if they are below a 10, then we put standard fall precautions in place. V11 stated that R4 did not fall on 12/8/2025 but instead had a seizure overnight.On 12/11/2025 at 11:18 AM, V7 (Restorative Nurse) stated that R4 was a high fall risk. High fall risk interventions include floor mats in place, increased rounding, high staff supervised area such as dining room during activities because the expectation is to monitor them frequently. V7 stated that herself and V11 investigate all falls that take place. V7 stated that R4 fell on [DATE]. V7 stated that V7 was found sitting in front of her wheelchair in her bedroom. V7 stated that the incident happened at noon. V7 stated that activities go on during the day. This was an unwitnessed fall. V7 stated that R4's nurse on 11/29/2025 was V16 (Licensed Practical Nurse). We redirected her to use her wheelchair. She was a high fall risk upon admission. V7 stated that R4 went out on the 11/29 and came on the 12/6. She was added to the fall star program which was the added intervention after R4 came back to the facility. V7 stated that R4 did not fall on 12/8/2025, but instead had a seizure where she slouched in her wheelchair.On 12/11/2025 at 12:59 PM, V14 (Licensed Practical Nurse) stated that she is familiar with R4. V14 stated that she was R4's nurse the night she was sent out on 12/8/2025. V14 stated that she doesn't remember R4 having floor mats or seizure preventative bed bolsters. On 12/8/2025 around 9:30 PM, R4 had a seizure in the cafeteria. She was in the wheelchair when she had the seizure. She fell into her chair. The CNA told her that R4 was slumped over in her chair. R4 stayed in the wheelchair. We took her out of her chair and moved her into the Geri chair so she doesn't keep slumping over. V14 stated that she notified the doctor about R4's uncontrolled tremors. V14 stated that the doctors were suspecting seizures, so they told her to just monitor R4 through the night. Her vitals were normal.On 12/11/2025 at 2:00 PM, V2 (Director of Nursing) stated that she is familiar R4. V2 stated that on 11/29/2025, R4 did not fall in her room but instead fell in the dining room during lunch hours. V2 stated that R4 was being monitored by a CNA but that CNA was asked to help feed a resident. As she went to feed another resident, she took her eyes off R4 and in that moment R4 had fallen. V2 stated that V16 was R4's nurse that day R4 had fallen. V2 stated that as that CNA went to feed that other resident, another staff member or the nurse should have monitored R4 in the dining room. The nurse was at her medication cart in the hallway.On 12/12/2025 at 12:25 PM, V17 (Certified Nursing Assistant) stated that she was not R4's CNA on 11/29/2025 when fell in the dining room. V17 stated that she was in the dining room cutting up another resident's food. V17 stated that it was her assigned task that day to monitor the residents in the dining room. V17 stated that as she was cutting up another resident's food, she heard another resident say R4 is standing up. V17 stated that she was the only staff in the dining room at that time. V17 stated that by the time she got to R4, she had already fallen.On 12/12/2025 at 12:28 PM, V18 (Nurse Practitioner) stated that she was R4's nurse practitioner. V18 stated that she had already left the facility when R4 had fallen. V18 stated that she was notified of the fall after she left. V18 stated that she did not see R4 when she was readmitted in the facility. V18 stated R4 came back with hospital records. V18 stated that from R4's hospital record, it looks like R4 had an acute subdural hematoma overlying left frontotemporal region. V18 stated that it looks like they ordered a repeat Computed Tomography (CT) scan of the head, and they usually do that when they see something small. V18 stated that the hospital did document that it was acute subdural hematoma, but she is not hundred percent sure that it resulted from the fall. V18 stated that signs and symptoms of subdural hematoma can be change in mental status, not responding physical or verbal stimuli, involuntary muscle movement, also patients can have seizure depending on where the subdural is. V18 R4 was sent out on 12/9/2025 because R4 did have a change in mental status. V8 stated that she assessed R4. R4 was breathing and had a pulse but was not responsive to stimuli. V18 stated that when did a sternal rub then R4 responded by pushing her hand away. V18 stated that subdural hematomas are typically causes from some sort of injury. There are some cases where subdual hematomas can be spontaneous, but they are usually from sort of injury.R4's fall care plan does not contain appropriate interventions for someone who is a high fall risk. R4's care plan documents in part: Keep room free of clutter. Round at a minimum of 2 hours.Per R4's risk management report on 11/29/2025, R4 fell on [DATE] in the dining room. V16's statement states that R4 fell while attempting to get up out of her wheelchair without assistance after multiple attempts of redirection had been given. R4 requires extensive staff assist with all transfer and uses a wheelchair for mobility. R4 observed on floor in dining room. Written statement by R5 quotes, I was sitting in the back eating my lunch. I looked over and she was leaning on the side of her wheelchair again after the CNA helped her to scoot back. Next thing I know is she was on the floor. Mild swelling noted to bilateral sides of face.R4's hospital record on 11/29/2025 documents in part: Diagnosis, acute subdural hematoma overlying left frontotemporal region, right eye hematoma. Plan repeat Computed Tomography (CT) of head scan at 6 hours.Facility's fall prevention policy (07/2025) documents in part: This facility is committed to maximizing each resident's physical, mental and psychosocial well-being. The facility will identify and evaluate those residents at risk for falls, plan for preventative strategies, and facilitate as safe an environment as possible. Residents at risk for falls will have fall risk identified on the interim plan of care with interventions implemented to minimize fall risk. A score of 10 or greater indicates the resident is at high risk for falls.

Based on interview and record review, facility failed to follow their policy to ensure residents are free from physical and verbal abuse by not providing necessary care, resulting in a staff worker being physically rough during activities of daily living (ADL) care and being verbally abusive to one resident (R1) out of three residents reviewed for abuse in a sample of four.Findings include:On 12/09/2025, surveyor observed R1, R2 and R3 share a room. On 12/09/2025 at 10:00 AM, surveyor observed R1 in his room. R1 stated that this past Saturday night a CNA comes into my room because apparently the light was on. She comes in and says, What is it that you want?. R1 replied saying, I don't like to be treated that way. The CNA then says, I don't have time to fool around with you. I have other patients to see. Are you going to be pushing that call button all night because I don't have time for you? R1 replies saying that the call button wasn't even near him and that he didn't push the call button. R1 stated that he told her to get the F*** out. The CNA then says, Don't be cursing at me. R1 stated that the CNA left and came with the nurse and the nurse says I shouldn't curse at the CNA. And as soon as the nurse left, the CNA says, B**** let me change you. R1 then states that the CNA grabbed him and pulled him. R1 stated that he told her to leave him alone. The CNA then says, What are you going to do now? R1 stated that the CNA grabbed his leg and threw it. R1 stated that the CNA began making sexual comments at him about having erectile dysfunction and how his dad should F*** his mom. R1 stated that he repeatedly kept asking her to leave. R1 stated that the CNA then began hitting his chest, stomach, arm because he wouldn't turn for her. She then grabbed his arm and turned him. R1 stated that he felt horrible at the incident. R1 stated that he called for help from his roommate and his roommate opened the curtain. R1 stated that as soon as he opened the curtain the CNA stopped and left. R1 stated that he doesn't know who that CNA or nurse was.On 12/09/2025 at 10:10 AM, surveyor observed R2 in his room. R2 was sitting on his wheelchair next to his bed. R2 stated that he witnessed V3 (Certified Nursing Assistant) being rough with R1. R2 stated that on the night of the incident between R1 and V3 (Certified Nursing Assistant), the curtain that separated his bed from R1's bed, was closed. So, the CNA didn't realize he was behind the curtain. R2 stated that he heard the CNA yell and curse at R1. R2 stated that R1 yelled his name when the CNA was being rough with him. R2 then looked over to see what was happening and he saw the CNA take R1's legs and throw it.On 12/09/2025 at 10:15 AM, surveyor observed R3 in his room. R3 was laying on his bed watching TV. R3 stated that he heard yelling between the resident and CNA, but he didn't see what was happening. R3 stated that he tries to stay out of it. R3 stated that both V3 and R1 was yelling back and forth. R3 stated that he has concerns of being abused by staff members. R3 stated that he gets water and drinks from the staff throughout the day.On 12/09/2025 at 12:23 PM, V1 (Administrator) stated that he is familiar with R1. V1 stated R1 reported that the CNA was rough during ADL care during 3:00 PM to 11:00 PM shift Saturday 12/06/2025. V1 stated that the CNA was V3 (Certified Nursing Assistant). V1 stated that R1 didn't report it to the nurse till later. V1 stated that R1 reported the incident to V5 (Licensed Practical Nurse) later in the night. V1 stated that V5 (Licensed Practical Nurse) then called him around 01:30 AM on 12/07/2025 to notify him of the incident. V1 stated that he spoke to R1 and R1 told him that the CNA was rude to him and rough during activities of daily living (ADL) care. During patient care, the CNA was rough moving his legs and body. V1 stated that he spoke to the R2. V1 stated that R2 told him that he heard their interaction, and when he opened the curtain, R2 saw the CNA moving R1's legs roughly. V1 stated that V3 is currently on suspension pending the investigation. V1 stated that he submitted the initial immediately has he found out of the incident. V1 stated that R1 has not made any abuse allegations in the past.On 12/10/2025 at 1:10 PM, V2 (Director of Nurse) stated that she is familiar with R1. V2 stated she is not familiar with the incident specifically but something along the lines that the CNA was rude and rough. But V1 had reported it. V2 stated the CNA was V3 (Certified Nursing Assistant). V2 stated that V3 (Certified Nursing Assistant) should have stopped care, notified the nurse. Let the nurse take over the situation, or if the nurse wanted to switch off the patients. There should have not been any arguing to begin with. No residents should be abused in this facility. V2 stated that she doesn't have any reason to believe R1 is lying about the situation. He has not made any abuse allegations in the past.On 12/10/2025 at 2:39 PM, V3 (Certified Nursing Assistant) stated that he is familiar with R1. V3 stated that she was R1's CNA on 12/6/2025 from 3:00 PM to 11:00 PM. V3 stated that she went in to change R1 and R1 was being disrespectful. V3 stated that she was called very horrible names. V3 stated that she let him disrespect her. V3 stated that the nurse stated to R1 that R1 was talking to her very disrespectfully. V3 stated that she did not yell back at the resident. V3 stated that she did not hit him. V3 stated that she gave him the benefit of the doubt. V3 stated that she couldn't see it in her nature doing that. V3 stated that she ended up cleaning him up because she had to. V3 stated that she still cleaned him up even if R1 didn't want her to because no other CNA was free.On 12/10/2025 at 2:45 PM, V10 (Licensed Practical Nurse) stated that he is familiar R1. V10 stated that he as R1's nurse on the night R1 had an incident with V3 (Certified Nursing Assistant) on 12/6/2025 from 3:00 PM to 11:00 PM. V10 stated that V3 informed him that R1 did not want to perform ADL care. V10 stated that he went to speak to R1. V10 stated that R1 was angry. R1 was calling her names. V10 stated that he told R1 not to call R1 names. R1 did not like V3's attitude. He didn't want her. V10 stated that he asked R1 if he wants to switch CNAs'. R1 stated, No. As long as she does her work. There was no yelling between them. V10 stated that V3 ended up cleaning R1. V10 stated that R1 did not bring up to him about V3 hitting him or being rough during ADL care.On 12/10/2025 at 11:15 AM, V5 (Licensed Practical Nurse) stated that she is familiar with R1. V5 stated that there was any incident that took place between R1 and the CNA this past Saturday. V5 stated that when she went in to do her rounds at 11:00 PM, R1 told V5 that V3 was rude with him and rough changing him. V5 stated that she then called the administrator to notify him of what R1 is saying. V5 stated that she has no reason to believe that R1 would make this up.R1's Minimum Data Sheet Section C (12/5/2025) documents in part: R1 has a Brief Interview of Mental Status (BIMS) score of 12. R1 is cognitively intact.R2's Minimum Data Sheet Section C (10/4/2025) documents in part: R1 has a Brief Interview of Mental Status (BIMS) score of 12. R1 is cognitively intact.R3's Minimum Data Sheet Section C (10/1/2025) documents in part: R3 has a Brief Interview of Mental Status (BIMS) score of 12. R3 is cognitively intact.R1's care plan documents in part: On 12/06/2025, R1 expressed staff allegedly verbally and physically abused him. No updated interventions after incident.R1's progress note on 12/7/2025 by V5 (Licensed Practical Nurse) documents in part: MD was notified of alleged abuse allegation and gave orders to follow facility protocol, Family made aware of alleged abuse.Facility's abuse policy (undated) 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. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention (77 Ill. Adm. Code 300.330). Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families or within hearing distance, regardless of an individual's age, ability to comprehend, or disability (42 CFR 483.12 Interpretive Guidelines).

Based on observations, interviews, and record reviews, facility failed to ensure activities of daily living (ADL) are provided for dependent residents by getting them out of bed for one (R1) out of three residents reviewed for ADL care in a sample of four. Findings include: On 12/09/2025 at 10:00 AM, surveyor observed R1 in his room. Surveyor did not see R1's wheelchair in his room or near his room. R1 was lying in bed still with his night gown on. R1 stated that he wants to get out of bed, but they won't put him in his wheelchair. R1 stated that he doesn't know where his wheelchair is.On 12/10/2025 at 10:30 AM, surveyor again observed R1 lying in bed with the same night gown on. R1 stated that he wants to get out of bed, but no one has gotten him up.R1's Minimum Data Sheet Section C (12/5/2025) documents in part: R1 has a Brief Interview of Mental Status (BIMS) score of 12. R1 is cognitively intact.On 12/10/2025 at 11:15 AM, V5 (Licensed Practical Nurse) stated that she is familiar with R1. V5 stated that R1 can get out of bed but he usually refuses to get out of bed.On 12/10/2025 at 11:58 AM, V7 (Restorative Nurse) stated that she is familiar with R1. V7 stated that R1 has poor trunk control. V7 stated that R1 has weakness on one side so he has a Geri chair. V7 stated that R1 does have a Geri chair, and it was in a storage room near his room. They are getting him up right now. V7 stated that all residents should be getting up unless they refuse. V7 stated that any care or order that they carry out they are expected to document it in the residents' plan of care.On 12/10/2025 at 12:10 PM, V9 (Assistant Director of Nurse) stated that she is familiar with R1. V9 stated that the expectation is to get up the residents. But the residents have right to say no. The CNA will notify the nurse and social worker if the resident refuses to get up out of bed. V9 stated that the nurse will do education on importance of getting up out of bed so they don't develop wounds. Any time a resident refuse to get up out of bed, there is supposed to be documentation of resident's decision and education provided. V9 stated that R1 usually refuses getting out of bed.On 12/10/2025 at 1:10 PM, V2 (Director of Nurse) stated that she is familiar with R1. V2 stated that the expectation is to get up all the residents out of bed. V2 stated that the residents have right to say no. V2 stated that when a resident refuses to get up then the CNA will notify the nurse and social worker, and they will do education on importance of getting up out of bed, so they don't develop wounds. Any time a resident refuse to get up out of bed, there is supposed to be documentation of resident's decision and education provided.Reviewed R1's progress notes from 12/05/2025 to 12/09/2025. No documentation of resident refusal or education on the importance of getting out of bed, provided.Reviewed R1's Bed Transfer care POC from 11/12/2025 to 12/11/2025. No documentation of refusal for getting out of bed, on 11/16/2025, 11/18/2025, 11/26/2026, 11/27/2025, 11/29/2025, 11/30/2025, 12/2/2025, 12/3/2025, 12/4/2025, 12/7/2025, 12/8/2025, 12/9/2025 and 12/10/2025.Facility did not provide any policies specific to the importance of getting residents out of bed.

Based on observation, interview, and record review, the facility failed to provide the fall prevention interventions for cognitively impaired residents who are also at risk for falls. This failure has the potential to affect 5 residents, R3, R4, R5, R6, and R7 out of 7 reviewed for proper footwear as a fall prevention intervention. Findings include: On 5/27/25 at 11:20am during observation of residents in the second-floor dining room, the following were observed: R3 was observed sitting in the wheelchair in the day room with white socks that are smooth on the bottom. R4 was observed sitting in the wheelchair in the day room with other residents with grey/white socks that are smooth on the bottom. R5 was observed sitting in the wheelchair in the day room with other residents with grey/white socks that are smooth on the bottom. R6 was observed sitting in the wheelchair in the day room with other residents with dark grey socks that are smooth on the bottom. R7 was observed sitting in the wheelchair in the day room with other residents with black socks that are smooth on the bottom. Again on 5/27/25 at 11:45 AM, all 5 residents still had the same socks on. At this time, V6(CNA/Certified Nurse Assistant) was notified. V6 stated We will get the non-skid socks for them. The non-skid socks are needed to prevent falling. On 5/27/25 at 12:10pm, V7(Restorative Nurse) stated All residents need to wear nonskid socks so keep them from falling. I will make sure. Please, can you give me the names of the residents? On 5/27/25 at 12:15pm, V8 (Unit Manager) stated I am the unit manager; they told me that some residents don't have the nonskid socks. We have some in the storage and we will make sure that the residents wear the socks. On 5/27/25 at 2:15 PM, V2(Director of Nursing) stated I have in-serviced all of them. I don't know why they did not put the non-skid socks on for the residents because we have them in the storage. At this time, V2 presented the facility document titled Maintaining Proper Footwear. This document dated 5/27/25 states All residents must have skid proof footwear on at all times when out of bed to increase safety and comfort. No exceptions. Please notify management with any questions or concerns. R3's records reviewed are as follows: Fall Risk assessment dated [DATE] states that R3 is at high risk for falls. Face sheet show diagnoses which include but are not limited to Dementia, Generalized Anxiety Disorder, Major Depressive Disorder, and Altered Mental Status. Care plan dated 12/31/24 states in part that R3 is at risk for falls due impaired cognition. Basic Interview for Mental Status (BIMS) Score dated 5/2/25 could not be assessed due to Severe Cognitive Impairment. R4's records reviewed are as follows: Face sheet shows diagnoses which include but are not limited to Dementia, Major Depressive Disorder, Altered Mental Status, Unsteadiness on Feet, And Generalized Muscle Weakness. Fall Risk assessment dated [DATE] states that R4 is at high risk for falls. Care plan dated 2/27/24 states in part that R4 is at risk for falls due to history of repeated falls, unsteady gait, decreased safety awareness, confusion due to dementia, incontinence and lower extremity muscle weakness. BIMS Score dated 5/27/25 is 4 out of 15(Severe Cognitive Impairment). R5's records reviewed are as follows: Face sheet shows diagnoses which include but are not limited to Dementia, Major Depressive Disorder, Slurred Speech, Gait Abnormality, And Generalized Muscle Weakness. Fall Risk assessment dated [DATE] states that R5 is at high risk for falls. Care plan dated 5/26/25 states in part that R5 is at risk for falls due to history of repeated falls, unsteady gait, decreased safety awareness, confusion due to dementia, incontinence and lower extremity muscle weakness. BIMS Score dated 5/6/25 is 6 out of 15(Severe Cognitive Impairment). R6's records reviewed are as follows: Face sheet shows diagnoses which include but are not limited to Dementia, Major Depressive Disorder, Abnormal Posture, Aphasia, Lack of Coordination, Hemiplegia and Hemiparesis, And Cerebral Infarction. Fall Risk assessment dated [DATE] states that R6 is at high risk for falls. Care plan dated 1/9/23 states in part that R6 is at risk for falls. BIMS Score dated 5/1/25 could not be assessed due to Severe Cognitive Impairment. R7's records reviewed are as follows: Face Sheet Shows Diagnoses Which Include but Are Not Limited to Dementia, Difficulty Walking, Alzheimer's Disease, and Generalized Muscle Weakness. Fall Risk assessment dated [DATE] states that R7 is at high risk for falls. Care plan dated 10/28/24 states in part that R7 is at risk for falls due to history of falls, unsteady gait, decreased safety awareness, confusion due to dementia, incontinence and lower extremity muscle weakness. BIMS Score dated 5/6/25 is 6 out of 15(Severe Cognitive Impairment). Facility's Fall Prevention and Management Program with latest review date 2/2025 states in part: 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. #2: Residents at risk for falls will have fall risk identified on the interim plan of care with interventions implemented to minimize fall risk. #4: Care plan to be updated with a new intervention based on root cause analysis after each fall occurrence.

Based on record review and interview the facility failed to follow their abuse policy for two residents (R1,R2,) out of four residents reviewed for abuse. This failure resulted in staff members not immediately intervening in a situation where residents became abusive to each other. Staff did not intervene in time resulting in R1 and R2 engaging in a physical altercation that lead to them both putting scratches/abrasions on each other's faces. Finding Include: R1's wound assessment sheet dated 4/25/25 reads upon assessment writer noted skin alteration to face. Classification abrasion. Doctor made aware , staff to continue to monitor. R1s Nursing Note 4/25/2025 08:35 reads: was notified of the situation that occurred and will notify the rest of her family. MD has also been notified.MD wants wound care to evaluate and treat. Resident does not need to go out to the hospital at this time. Resident was separated and in stable condition. No c/o(complaints of) pain or discomfort at this time. First aid applied. R2's wound assessment sheet dated 4/25/25 reads upon assessment writer noted skin alteration to face. Classification abrasion. Doctor made aware , staff to continue to monitor. R2'S Nursing Note4/25/2025 15:42 reads: MD wants wound care to evaluate and treat. Resident does not need to go out to the hospital at this time. Resident was separated and in stable condition. No c/o pain or discomfort noted. First aid applied. On 5/6/25 at 10:45 am V3 (Certified Nurse Aide) stated she was sitting at the nurses station and saw R1 wandering down the hall and redirected her to sit down in the hallway by the nurses station. V3 stated R2 rolled to where R1 was sitting and heard them talking and heard R1 tell R2 to move her hand away. V3 stated as she was getting up from the nurses station when R1 stood up over R2 then they started wailing their hands at each other. V3 stated she separated them both and the nurse (V6) came and assessed them. V3 stated after they were separatedshe noticed scratches on both of their faces. On 5/7/25 at 10:10 amV6 (Licensed Practical Nurse) stated she was getting off the elevator and saw R1 and R2 wailing their arms at each other while V3 was separating them. V6 stated they separated them and took them to their rooms. V3 stated she noted after assessing R1 and R2 they both had small scratches on their face. V3 stated she gave them first aide by cleaning the scratches with normal saline. V3 stated she has worked on the Dementia unit for five years. V3 stated R1 had been on that unit for about a year and a half, while R2 had lived up there for about three years. V3 stated she has never witnessed them getting into an altercation before like the one she had witnessed. V2 (Wound Nurse) stated on 5/6/25 at 11:15 am stated she was told by V6 to look at R1 and R2 faces because they had gotten into a little scuffle. V2 stated noticed R1 had two small superficial scratches/abrasions under her right eye and that R2 had a small scratches/abrasions on her top lip . V2 stated neither needed extensive treatment only they were cleaned and monitored for any signs of an infection. V2 stated since the incident both resident scratches/abrasions have healed. Facility's abuse policy reads the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. The facility prohibits abuse, neglect, misappropriation of property, and exploitation of its residents, including verbal, mental, sexual or physical abuse; corporal punishment; and involuntary seclusion. Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish.

Based on observations, interviews, and record reviews the facility failed to notify a resident's responsible party about a room change prior to being moved to a new room on a different unit within the facility. This affected one (R1) of one resident reviewed for resident rights. Findings include: R1 was initially admitted to 1st floor nursing unit on 12/03/24 and has diagnosis which includes but not limited to Neurocognitive Disorder with Lewy Bodies, Type 2 Diabetes Mellitus, Cerebral Infarction, Personal History of Transient Ischemic Attack, Unspecified Dementia With Other Behavioral Disturbance, Age-Related Osteoporosis, Unspecified Severe Protein Calorie Malnutrition, Difficulty Walking, Lack of Coordination, Dysphasia, Generalized Anxiety, Unspecified Psychosis. R1's MDS (Minimum Data Set) assessment dated [DATE] documents in part, resident is rarely/never understood. BIMS (Brief Interview for Mental Status) was not able to be conducted. R1's electronic health record (EHR) lists R1's daughter, V16 as R1's Power of Attorney. Per R1's EHR's Census List indicates R1's room was change from the 1st floor to the 2nd floor on 04/07/25. A nursing note on 04/07/25 time stamped 14:48 documented in part, received resident at 2:30 PM from the first floor . Upon initial review of R1's EHR on 04/15/25 there was no documentation in R1's record indicating R1's POA was notified about the room change and/or the reason for the room change. Upon later review of R1's EHR V13 (Social Service Coordinator) entered a late entry progress note time stamped 04/15/25, 14:45:38 backdated to 04/07/25, 19:20:00 which documented in part, this worker informed daughter (V16) due to dementia dx (diagnosis) and by (R1) being considered a long-term resident, is the reason why (R1) was moved to the 2nd floor . On 04/16/25 at 11:46 AM, via phone interview V16 (R1's Power of Attorney) stated she did not receive any notification either verbally or in writing about R1 being moved from the 1st floor to the 2nd floor. V16 stated she found out about the move when another family member came to visit R1 on 04/07/25 around 4:30 PM and the family member could not find R1 on the 1st floor. V16 stated the residents in the 1st floor day room are the ones who informed the family member that R1 had been transferred to a different unit, not the staff. V16 stated on that same day (04/07/25) she had called the facility around 3:15 PM to get an update on her mom (R1) and the nurse did not mention anything about R1 being moved to a different unit. V16 stated they transferred my mother (R1) to a new floor, and V16 received no notification about the change which is why V16 knew nothing about it. V16 stated the 2nd floor is a dementia unit and if the facility had notified her about their decision to change R1 to the dementia unit before it happened, she (V16) would have had the opportunity to express her concerns so the facility could understand her reasoning for why she preferred R1 to stay on the 1st floor. V16 stated they could have a discussion about it, but the facility made the move without even notifying her (V16) before they moved R1. On 04/15/25 at 3:20 PM, V13 (Social Service Coordinator) stated the resident's family/POA/guardian are notified when a resident will be transferred to a different room or unit and this notification is documented in the resident's EHR in a progress note section by a social service staff member. V13 stated the facility can let the family know about the transfer the day before and/or the day of but the family/POA must be notified prior to when the transfer occurs. V13 stated the only time they do not notify the family is if the resident is responsible for themselves, and/or they do not have a Power of Attorney or guardian. V13 stated it is important to notify the POA/guardian about the room change so the family/POA/guardian is aware of the change. V13 stated on 04/07/25 in the afternoon, R1's family member came in to visit R1 and by that time R1 had already been transferred to the 2nd floor. V13 stated R1's family member who was visiting then called V16 (R1's POA) and then V16 called V13. V13 stated V16 was upset that R1 was transferred to the 2nd floor but V13 stated she had educated them when R1 was initially admitted that the 1st floor was not for long-term placement so V13 felt the family knew this transfer was coming eventually even if they did not know the specific day/time it was going to happen. V13 stated notification of the transfer was not addressed prior to the change happening. On 04/16/25 at 10:00 AM, V14 (Social Service Director) stated we normally figure out the room/unit the resident will be transferred to and then we notify the POA/guardian/next of kin verbally by telephone before the transfer occurs and we also notify them in writing by giving them a form called Notification of Room Change form. V14 stated the Notification of Room Change form specifies the date the notification was given and the reason for the room change. V14 stated it is important that the facility notify the POA/guardian ahead of the move when a change is going to be made so that they are aware that their loved one is going to be moved. On 04/17/25 at 9:10 AM, V2 (Director of Nursing) stated a resident's POA/guardian or responsive party should be notified verbally prior to the transfer and written documentation can be provided later when the POA/guardian is in the building. V2 stated it is important that they are notified ahead of time so they know where their loved one will be located before they come to visit the resident, so they know where to find them. V2 stated this is a resident's right and they should be provided with an explanation of why the transfer will be happening. V2 stated notification should be documented somewhere in the EHR about the verbal notification to the resident's responsible party about the pending transfer. V2 stated all documentation should be done in the EHR, the facility does not keep paper records and therefore, if it is not in the EHR there is no proof that it was done. On 04/17/25 at 12:59 PM, V1 (Administrator) stated for any resident getting transferred to a different room the POA/guardian should be notified before the transfer/change happens. V1 stated that is part of resident rights. V1 stated the notification can be done verbally in which case the conversation should be documented in the progress note section to prove that it happened. V1 stated if it is not documented in the resident's EHR there is no proof that it happened. V1 stated it was an oversight that R1's POA was not called ahead of time and V13 should not be backdating information in the progress notes. V1 stated it is his expectation that she (V13) enters the information in EHR when it occurs. R1's Notification of Room/Roommate Change form dated 04/07/25, 12:44 is blank for the section on notification for the name of the resident/resident's representative notified, date written notification provided and reason for change. Facility provided policy titled, Room Change/Transfer within Facility dated 01/2025 documents in part, to assure the resident and/or their representatives are appropriately notified of room transfers, when a resident is being moved to a new room at the request of the facility, the residents, family or resident representative shall receive an explanation in writing of why the move is required. Facility provided document titled, Illinois Long-Term Care Residents' Rights for People in Long-Term Care Facilities documents in part, you have the right to be told in advance and in writing if your room is being changed and you have the right to receive notice, including the reason for the change before your room or roommate in the facility is changed.

Based on interviews, and record reviews the facility failed to follow their wound prevention policy to ensure one [R1] of two [R2, R3] residents did not develop pressure wounds. This failure resulted in R1 developing a facility acquired stage [3] pressure ulcer to the sacrum. Finding include, R1's clinical record indicates in part; R1 is a seventy-year-old admitted on [DATE], with the medical diagnosis include but not limited to osteoarthritis of left shoulder, atrial fibrillation, cardia pacemaker, acute respiratory failure, and difficult walking. Minimum data set [MDS] section [C] Brief Interview Mental Status Score Indicates R1 is cognitively impaired. MDS section [GG] indicates R1 is dependent for all ADL's, bed mobility, turning, repositioning, and transfers. MDS section [M] dated 12/9/24 indicates, R1 did not have a pressure ulcer. R1's Care plan document in part: R1 is at risk for alteration in skin integrity related to self-care deficits, impaired mobility and comorbidities, dated 12/4/24. Interventions: Check skin daily during routine care, dated 12/4/24. Provide peri-care after each incontinent episode and apple barrier cream dated 12/4/24. R1's emergency room document indicates in part: 2/4/25 at 5:27 AM note: R1 has a large sacral wound that has likely causing acute sepsis possible tracking into R1's spine causing osteomyelitis. R1's skin assessment: R1 has Large sacral wound noted with purulent drainage, covered with foam dressing measured: 10cm x 10cm stage 4 decubitus ulcer filled with stool, is erythematous. (R1's wound was filled with stool when R1 arrived to the emergency room ) R1's Hospital Admission document: 2/5/25 R1's neurosurgical evaluation after CT scan done there showed extensive decubitus ulcer with osteomyelitis and extending into spinal canal, no spinal abscess noted. 2/5/25, R1's medical plan; R1 remains alert and oriented x1, bedbound. There are at this point, no plans for surgical intervention. Wound recommend a discussion in regard to goals of care and continue intravenous antibiotics for now. The plan for intravenous antibiotics seven-day course, for skin and soft tissue infection, the risk of on-going antibiotics outweighs the benefits of R1's sacral osteomyelitis without surgical intervention. Would consider discussion in regard to palliative care. R1's Wound Care Assessment reports indicates in part: 12/4/24, V8's wound assessment, sacrum pressure ulcer measures 5.5 x 7.0 x 0.20cm. V8 documented: Incorrect documentation, refer to current image. [The image of sacrum shows no open area]. Outcome: Maintenance. 12/11/24, V8's wound assessment, sacrum area measures 0x0x0cm. No further treatment needed at this time. Outcome: healed. 1/7/25, V13 [Former Wound Care Licensed Practical Nurse] assessment; Writer [V13] made aware of skin alteration on the buttocks. Assessment reveals: Facility acquired re-opening of stage #3 sacrum wound pressure ulcer, no slough. Sacrum wound measured: 7.0x 8.0x unknown cm. V10 [R1's Family Member #2] made aware of re-opening of stage #3, all questions answered. Outcome: Probable Decline. 1/14/25- V5 [Wound Care Coordinator] assessment; R1 noted with 50% slough, primary medical doctor aware, orders received and carried out. Wound measures 7.0x 8.0x unknown cm. Preventative measures in place, heels off loaded, reposition as needed and skin checks, and skin barrier after each incontinent episode. [The wound declined, with 50% of slough noted]. On 1/15/25 V3 [Wound Physician] R1 visit has been rescheduled. R1 at dialysis. (wound doctor did not see R1) 1/21/25 V13 [Former Wound Care Licensed Practical Nurse] assessment; R1 noted with 50 % slough in sacrum wound. Assessment completed; no changes noted this week. Sacrum wound measures 7.0 x 8.0x unknown cm. Primary physician made aware. 1/23/25 V3 [Wound Physician] assessment; R1's noted with 50% of slough in sacrum wound. Measures 7 x8 x unknown cm, depth is unmeasurable due to presence of nonviable tissue and necrosis. No labs for this visit. 1/28/25 V11 [Wound Care Nurse Licensed Practical Nurse] assessment; R1 noted with 90% slough in sacrum wound. Wound is stable, primary care made aware, no new orders at this time. Wound measures 7.0 x 8.0x unknown. [The wound declined with 90% of slough, no new orders noted.] 1/29/25 V3 [Wound Physician] R1's noted with 50% of slough in sacrum wound. Measures 6.5 x 8 x 0.4cm. Dressing plan Iodosorb gel. Apply once daily for 24 days. Gauze sponge sterile, apple once daily and as needed for 24 days. Gauze island with boarder apply daily and as needed for 24 days. Sharp selective debridement procedure to remove biofilm, remove devitalized tissue at margins of wound. [R1's wound was debrided] R1's progress notes: 2/3/2025 22:27 Nursing Note: Writer called hospital to check on the status of R1. Writer was informed that they are searching for a hospice to relocate R1 where she will be treated for a spinal infection. Interviews: On 2/27/25 at 9:50 AM, V4 (R1's Family Member) stated, R1 is currently in the hospital due to bed sore that has went to the spine and set up infection. R1 had a stroke and is total dependent for assistance. R1 had a bed sore but healed before being admitted to the facility. The area re-opened back up due to the facility staff not turning and repositioning. I was made aware R1's butt sore had re-opened at the beginning of January, but I was not made aware R1's wound had worsened. On 2/27/25 at 12:56 PM, V8 [Licensed Practical Nurse/Wound Care Nurse] stated, On 12/4/24, I completed R1's skin assessment. R1 did not have any open wounds. The sacrum was noted an old scar from a previous pressure ulcer. I measured the scar surface area and placed in those measurements on R1's body assessment. I placed a note on R1's assessment stated I placed incorrect documentation, refer to current image. The image showed no open areas. There was an order placed for a protective dressing only, to apply to the old, healed area as a preventative measure. On 12/11/24 skin assessment, again R1 did not have any open areas on her sacrum. I entered on R1's assessment 'healed' due to the previous wrong documentation. Once R1 wound healed in December 2024, the wound care team does not monitor the resident's skin. The nursing staff, and certified nurse assistances monitor all the resident's skin during incontinence care and bathing. If noted any skin alteration or skin openings, the staff nurse will open a new skin assessment in the electronic chart, notify the physician and family of any changes. Then I was promoted and no longer assessed R1's wound, I was on longer on the wound care team. On 2/27/25, at 1:14 PM, V11 [Wound Care Nurse/License Practical Nurse] stated, I am familiar with R1 wounds. R1 is alert and oriented x1, not able to voice her needs, and is total dependent for assistance. On 1/28/25 I completed R1's skin assessment, no changes in the wound size and the wound were stable. I did document the wound was noted with 90% slough and the previous assessment on 1/28/25 there was 50% of slough noted, so yes there was a decline in R1's wound. When there is an increase in slough means the wound not healing properly. If R1 was sleeping or refused to be repositioned, then the nursing staff was not allowed to turn and reposition R1. I remember R1 not wanting to be repositioned at times, and she had that right. On 2/27/25 at 2:28 PM, V5 [Wound Care Coordinator] stated, I assessed R1's wound on 1/14/25, the sacrum wound was noted with 50% slough, and the measurements were the same as the previous assessment on 1/7/25. The slough was new, I notified the primary physician. The wound measurements were the same, and there was no change in the wound, the wound was stable. Yes, the wound developed slough, but there were no signs of infection. I think her wound declined due to dialysis, sitting in the chair. The facility has a dialysis unit here, where R1 received her treatment. On 2/28/25 at 11:08 AM, V12 [Director of Operations of Dialysis Unit] stated, The dialysis unit in the facility runs six days a week. If a resident needs their scheduled modified, chair time length, time or day of treatment, is always accommodated. The dialysis chair is a big recliner with specialize pressure reducing cushion. Also, if a resident has a cushion in their wheelchair, the dialysis staff places that cushion in the dialysis chair as well. According to R1's dialysis record she has received services with this company starting 8/14/24. Our company also treated her at another nursing facility prior to her coming here. I have not received any concerns regarding her dialysis chair time or concerns about wound healing. The dialysis unit would have been able to accommodate R1's needs. On 2/27/25 at 1:44 PM, V3 [Wound Physician] stated, I'm currently at the airport, and only can talk for a minute. I assessed R1's wound on 1/29/25, and my documentation should answer all your questions, my assessment speaks for itself. I missed assessing R1's wound due to her attending dialysis treatments. The wound care team are aware the dates and times I will be at the facility, it was their responsibility to ensure R1 was available for her wound care assessment. On 1/29/25, I completed a bed side debridement on R1's sacrum wound to remove the slough, I did not order any labs or wound cultures. I must end the interview and board my airplane. I feel the decline in her sacrum wound came from dialysis. Policy document in part: Skin Management dated 1/2024. It is important that the Facility have a system in place to assure that the protocols for daily monitoring, frequency of assessments, documentation are implemented consistently throughout the facility. The presence of possible complications, such as signs of increasing area of ulceration or soft tissue infection such as increase in redness, swelling around the wound, increase drainage from the wound or pain. If the wound shows no signs of healing after three weeks, a reevaluation of the treatment plan including determining whether to continue or modify the current interventions is done. If the decision is made to retain the current regimen, documentation of the rational for continuing the current plan will occur.

Based upon observation, interview, and record review the facility failed to follow policy procedures, failed monitor blood glucose levels, failed to ensure that medication administration records include actual times for administration, failed to follow physician orders, and/or failed to ensure that medications/supplements were administered and documented within regulatory requirements for nine of thirteen residents (R1, R3, R5, R6, R7, R8, R9, R10) in the sample. The facility also failed to ensure that (R2's) Humalog was ordered and administered before meals, this failure resulted in R2's frequent blood glucose levels above 200. On 9/2/24, R2's blood glucose level was 399 (critical high). Findings include: On (9/24/24) IDPH (Illinois Department of Public Health) received allegations that medications are not administered at the facility as ordered and there's no set schedule for when medications are given. In addition, blood glucose and blood pressure are not being monitored at the facility. R2's diagnoses include type II diabetes mellitus and metabolic encephalopathy. R2's POS (Physician Order Sheets) include (4/2/24) blood glucose check before meals. (4/7/24) Humalog (Insulin) per sliding scale one time a day. R2's (September 2024) MAR (Medication Administration Record) affirms blood glucose level was above 200 on 9/1, 9/2, 9/3, 9/6, 9/8, 9/9, 9/11, 9/12, 9/13, 9/14, 9/16, 9/17, 9/18, 9/19, 9/22, 9/23, 9/25, 9/26, 9/27, and 9/29 [20 days]. R2's (9/2/24) 11:00am blood sugar was 399. On 10/8/24 at 12:12 pm, surveyor inquired if blood glucose checks are ordered before meals and a resident is prescribed Humalog how often should the Humalog be administered V11 (Medical Director) stated Usually whenever they check the blood sugar, it depends on how the physicians order it. Usually, we check the blood sugar before meals and try to cover that. Surveyor inquired if prescribing Humalog only once a day is appropriate for a resident with blood glucose levels frequently above 200 V11 responded It can be that way depending on the patient. We might need to adjust the dose or the frequency, it depends on the patient. Surveyor inquired about Humalog insulin V11 replied It's not a long acting one, it doesn't last a long time. Surveyor inquired about potential harm to a resident with a blood sugar of 399 that's not treated, V11 stated If it's a one time reading probably nothing but if it's a persistent reading over a couple weeks, it can start causing dehydration or frequent urination. Long term non-controlled diabetes can affect the kidneys. R1's diagnoses include type II diabetes mellitus. R1's (9/27/24) BIMS (Brief Interview Mental Status) determined a score of 9 (moderate impairment). On 10/2/24 at 9:49am, surveyor inquired if medications are received (at the facility) as ordered R1 stated I don't know. On 10/2/24 at 2:50pm, surveyor inquired about medication administration concerns at the facility V6 (Family) stated When my mother (R1) got there, they (facility) didn't have her medication. The Nurse said the medication wasn't there. R1 was admitted to the facility on [DATE]. R1's POS (Physician Order Sheets) include the following medications with (9/20/24) start date: Atorvastatin Calcium 80mg (milligrams) at bedtime, Gabapentin300mg three times daily, Metformin (Hypoglycemic) 500mg twice daily, Metoprolol Succinate ER (Extended Release) 25mg at bedtime, Pantoprazole Sodium 40mg twice daily, and Sacubitril Valsartan 24-26mg twice daily. [Blood Glucose orders are excluded however hypoglycemic medication is prescribed]. R1's MAR (Medication Administration Record) affirms the following medications (scheduled for 9/20/24 administration) were marked 9 (see Nurse notes): Atorvastatin Calcium, Gabapentin Metformin, Metoprolol Succinate ER, Pantoprazole Sodium, and and Sacubitril Valsartan. In addition, several of R1's medications were noted to be scheduled for morning, afternoon, or evening therefore not specified times - as warranted. R1's (9/20/24) Nursing Progress Notes affirm at 4:23pm resident was received for admission. (11:41-11:43pm) EMAR (Electronic Medication Administration Record): pharmacy to deliver Metformin, Pantoprazole Sodium, Atorvastatin Calcium, Gabapentin, and Metoprolol Succinate ER [R1 was admitted roughly 7 hours prior]. On 10/7/24 at 12:49pm, surveyor inquired about the requirements for receiving medication orders V2 (Director of Nursing) stated In that order you have to have the name of the medication, the milligrams or the dosage, how often it's to be given, it needs to be verified with the doctor and have a diagnosis. The schedule depends on what the doctor orders, if it's ordered daily, usually daily is scheduled for 9am. Surveyor requested the actual times for R1's medication administration V2 reviewed R1's (September 2024) MAR and responded It says for Atorvastatin bedtime, I don't actually see a time on there, it just says bedtime. Metoprolol just says given at bedtime. Metformin it says give by mouth 2 times a day, it says morning and evening. Pantoprazole it says morning and evening, it's not giving a specific time. Surveyor inquired about the regulatory requirement for medication administration, V2 replied It should be given a time, so if its 9:00 we have a hour before and a hour after to administer the medication. Surveyor inquired if staff should be monitoring blood sugars if residents are receiving hypoglycemic medication, V2 stated If they (residents) are on anything for diabetes, we (staff) should call and get orders for checking blood sugars once or twice a day. On 10/8/24 at 12:19pm, surveyor inquired about potential harm to a resident receiving oral hypoglycemics if blood sugars are not monitored, V11 (Medical Director) replied Potential harm is they can get all sorts of high or low blood sugars, this can cause coma. On 10/2/24 at 10:29am, surveyor stated that medication administration will be monitored this morning V4 (Registered Nurse) responded Actually, I'm done for now unless you want to see the 12:00. V4 accessed the EMAR (Electronic Medication Administration Record) as requested however R3's name was highlighted red (indicating late administration). Surveyor inquired why R3's name was highlighted red V4 replied Right now I (V4) need to see about getting the medicine from the c (convenience) box. The Metoprolol (ER) 25 milligrams, its scheduled for 9:00 but we got 1 hour after and 1 hour before to give it. Surveyor inquired why R3's Metoprolol (scheduled for 9am administration) was not administered V4 stated I believe that was a new order. [R3's POS affirms Metoprolol ER 25 milligrams was prescribed 7/26/24 therefore not a new order]. Surveyor inquired what time it is V4 responded It's after 10:00. On 10/2/24 at 11:34am, V5 (Licensed Practical Nurse) was observed passing R4's AM medications per EMAR [actual time of administration was excluded}. Surveyor inquired if all V5's assigned residents received their AM medications today V5 stated Yes. Surveyor inquired what residents highlighted red on the EMAR indicates V5 responded The red? this means late. Surveyor inquired why R5, R6, R7, R8, R9 and R10 were highlighted red on the EMAR V5 responded These are done I just haven't signed em out yet. V5 reviewed the EMAR with surveyor and affirmed that R5's supplement (scheduled for 10am administration) was not documented. Surveyor inquired if R6's scheduled Haldol, Morphine, and Lorazepam were administered this morning V5 replied The 9am Morphine is the only one I gave. Surveyor inquired when prescribed medications are not given (as scheduled) what's the requirement V5 stated When I (V5) don't give em, I just put the reason why I didn't give it however nothing was documented for R6's Haldol and Lorazepam (scheduled for 10am administration). R7's (10/2/24) 7:30am blood sugar and Humalog administration were not documented. Surveyor inquired why R7 did not receive Humalog this morning V5 responded When we checked his blood sugar it was like 110 however appeared unsure. Surveyor inquired if R7's (10/2/24) 7:30am blood sugar was documented in the EMAR V5 affirmed it was not. Surveyor inquired if R7's blood sugar was documented on paper V5 stated No. R7's MAR (received after interview) affirms 10/2/24 7:30am blood sugar result states N/A (not applicable). Surveyor inquired if R8 received 9am medications this morning V5 stated Yes, I haven't signed em out yet. Surveyor requested to inspect R8's medications V5 removed R8's medications from the cart (which are labeled individually - including date and time) however the 10/2/24 medications (scheduled for 9am administration) remained in the packages. V5 stated Oh no, his (R8's) I (V5) didn't get to yet. I thought I did his, this is the 2nd (October 2nd). Surveyor inquired if R9 received Nifedipine ER (Antihypertensive) scheduled for AM administration, V5 responded I didn't give it yet. Surveyor inquired if R10 received Sacubitril Valsartan (Antihypertensive) scheduled for AM administration, V5 replied I didn't give that one yet because I didn't check his blood pressure for today. The medication administration policy (reviewed 1/2024) states verify that the medication is being administered at the proper time. If the medication is not given as ordered, document the reason on the MAR and notify the Health Care Provider if required. Vital signs are taken as required prior to medications and documented on MAR. The diabetes management policy (reviewed 1/2024) states residents with a diagnosis of diabetes will be managed per physician orders. Physician's orders for diabetic management may include but are not limited to specialized diet, oral medications, insulin injections, and blood glucose monitoring.

Based on interviews and record reviews the facility (A) failed keep one resident [R1] head of the bed elevated, and failed to provide one to one feeding assistance, (B) failed to follow their code blue policy to call 911, R1 was unresponsive and having difficulty breathing, (C) failed to notify the physician in a timely manner of an acute change in condition, and failed provide an accurate report to the physician, (D) failed to relay STAT (immediate) laboratory and diagnostic test results to the physician. These failures resulted in R1 higher level of care being delayed, R1 experiencing an acute change in condition and subsequently expiring on [DATE] in the facility. This was identified as an Immediate Jeopardy which began on [DATE]. On [DATE] at 9:14 AM, the administrator was notified of the immediate jeopardy. The immediate jeopardy was removed on [DATE] at 12:24 PM. However, the deficiency remains at the second level of harm until the facility determine the effectiveness of the implementation of the removal plan. Findings Include: R1's clinical record indicated in part; R1 was admitted to the facility on [DATE] with medical diagnosis of pneumonitis due to inhalation of food and vomit, dysphagia, cerebral infarction due to thrombosis of right middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, visuospatial deficit and spatial neglect, memory deficit, , protein-calorie malnutrition, muscle weakness, cognitive communication deficit, dysphagia, essential (primary) hypertension, attention-deficit hyperactivity disorder, weakness, gastrostomy, and generalized anxiety disorder. R1's care plan dated [DATE]: -R1 needs the head of bed elevated 45 degrees during and thirty minutes after tube feeding. -Monitor R1 and report to physician if noted aspiration, shortness of breath, abnormal lung sounds, abnormal lab values, nausea or vomiting. R1's physician orders: -[DATE] - Aspiration Precautions: Keep HOB elevated during and 30min after G/T Feedings and 1:1 Feed with Pureed Diet and HTL [Honey think liquid] every shift. -[DATE]- four times a day flush enteral tube QID with 150 mL [milters] of water after feeding. -[DATE] - four times a day enteral feeding: Jevity 1.5 360ml bolus QID [four times per day]. -[DATE]- general diet, pureed texture, honey thick consistency with one-to-one feeding assistance. -[DATE] -Oxygen at ,d+[DATE]L/nasal cannula as needed to maintain O2 Sat at 93% or greater every shift. -[DATE] (14:42)- - Oral Suction at bedside. Suction PRN [as needed]. -[DATE] (14:40) - Robinul Oral Tablet 1 MG, give 1 mg via G-Tube every 12 hours for drooling /excessive secretions. -[DATE]- CBC, BMP, Magnesium level STAT - [DATE] Chest Xray STAT - [DATE]- Monitor vital signs every shift for 30 days then daily R1's laboratory reported dated [DATE] indicated the lab results were faxed to the facility on : -Complete Blood Count [CBC] at 11:16 PM. -Basic Metabolic Panel [BMP] at 11:47 PM. [Lab Results was never Relayed to a Physcian] R1's progress notes documented in part: V8 [Speech Pathologist/Therapist] Note documented in part: On [DATE]- Recommendations for R1, to continue puree diet, with 1:1 assistance and to follow R1's swallowing precautions: only feed when alert, up right at 90 degrees for all meals, reposition as needed, aspiration precautions, monitor or pocketing, small bites, small sips, alternate liquids, and solids, monitor for signs and symptoms of aspiration related illness. V3 [Nurse Practitioner] Note: [DATE] at 3:51 pm CHIEF COMPLAINT: R1 is a [AGE] year-old male seen today for a follow-up skilled SAR visit to manage multiple medical conditions. R1 had a PEG placed on ,d+[DATE] 2024. R1 stabilized transferred here from inpatient rehab to subacute rehab. Pt seen today alert, nonverbal, not following commands. Pt in NAD [No Apparent Distress]. Scattered Rhonchi and cough noted during my exam. Pt appeared to have difficulty clearing his airway. I [V3] ordered bedside suction and Robinul for excessive secretions. V5 nursing progress note: [DATE] 7:19 pm Note: R1 is breathing easy. V/S [Vital Signs] 98.7,89,18,,d+[DATE],02 R.A @ 92%. V31 instructed to maintain R1 in an upright position to prevent reflux.MD order CXR & magnesium level stat with CBC/differential. Orders carried out. V5 [Registered Nurse] nursing progress note [DATE] 9:19 pm Note: V31[Certified Nurse Assistant] found R1 shaking and called nurse-observed pt having secretions coming out of nose and mouth. R1 regurgitated. Having difficulty breathing. Congestion noted on listening to lung sounds. V3 [Nurse Practitioner] was in house earlier on today and ordered oral suction at bedside PRN [as needed]. R1 was suctioned and stabilized. Respiration even non labored. [Nurse failed to document code blue was initiated] V30 [Telehealth Physician] Note: [DATE] at 9:03 pm telehealth evaluation (other) Date of Service: [DATE] 8:09 PM CT Details: Nurse Name: V24 [ Nurse Supervisor/Licensed Practical Nurse] Patient Name: R1 Primary Chief Complaint: General: Chills History Present Illness: [AGE] year-old male with past medical history of dysphagia status post G-tube, hypertension. Earlier today got his bolus feed. Nurse performed bedside suctioning but has lot of secretions, mucus coming out of nose and mouth had chills per CNA [Certified Nurse Assistant-V31], no AMS [altered mental status] Vital Signs: T [temperature]: 98.7 ( F), HR [heart rate]: 89 (bpm), BP [blood pressure]: ,d+[DATE] (mm/Hg), RR [respirations rate]: 18 (rpm), SpO2: 92 (%), Pain Level: 0) Physical Exam: Exam findings per nurse Physical Exam - Notes: GEN NAD [ No apparent distress] Respiratory: congested on room air, Diagnosis, Assessment/Plan: Chills (without fever) (Primary) The patient's condition is stable. This is an acute new problem. Nurse performed patient concern is aspiration pneumonia although he is not having any respiratory stress at time of this evaluation. Will order labs and chest x-ray. Technology Used: Audio and video with patient and nurse present. Statement of Medical Necessity. [V24 failed to tell the Physician: Code Blue was initiate, R1 was found laying flat, R1 was self-feeding, R1 has an emesis with food particles projecting out of his nose and mouth, and started on supplemental oxygen to sustain oxygen levels of 92%.] V29 [Agency Registered Nurse] Nurse Progress note: [DATE] 07:50 AM Note: Received R1 in bed awake and alert lying upright in bed verbally responsive. Notified by CNA [V31-Certified Nurse Assistant] that R1 was unresponsive patient found lying upright in the bed pulselessness code blue called, CPR initiated and 911 called, blood sugar 171 BP ,d+[DATE] CPR continued until fire department arrived. There was no documentation on ([DATE]) 7AM-11PM from V4 [Licensed Practical Nurse] no progress note, no vital signs. There was no documentation on ([DATE]) 11PM-7AM V36 [Agency Registered Nurse], no progress note, no vital signs. Interviews: On [DATE] at 4:21 PM, at V6 [R1's Family Member] stated, On [DATE] I went to the facility approximately 5:30 PM. Upon arrival to the facility R1's door was closed; I thought the staff was changing his under brief at the time. Then I saw nursing staff going in and out of his room running pass me and no one said a word to me. A few seconds later, I heard over the intercom speaker code blue for R1's room number. I asked V5 [Registered Nurse] coming out of R1's room what was going on. V5 told me that R1 was lying flat down in bed eating and aspirated. When V5 went back into the room I went in the room with him. I saw R1 foaming at the mouth and nose, not responding with his eyes closed and V4 [Licensed Practical Nurse] was suctioning R1. Another young lady brought in oxygen and V4 started oxygen on R1. A few minutes later R1 opened his eyes and was looking around. V4 and V5 left out the room, and I asked R1 was he okay, he turned his head side to side meaning no. R1 can usually say simple words like yes or no, but R1 could not talk. After staying with R1 for a few hours, he continued coughing, drooling, and I can hear his chest rattle when he breaths in and out. I asked V5 at the nursing station was my father going to be alright, V5 said yes, he will be okay, for me to go home and rest. On [DATE] at 8:42 AM, a nurse called me from the facility and said she was sorry R1 passed away 45minutes ago. On [DATE] at 12:44 PM, V8 [Speech Pathologist/Therapist] stated, I completed R1 speech evaluation and worked with him. R1 had a medical diagnosis of dysphagia with moderate oral phase. R1 would have oral phase trace residue 4 out of 4 exercises. R1 would have a little food left on his tongue. With drinking honey thick liquid, R1 would have some liquid come out of his mouth that he did not swallow. My recommendations for R1 were to continue puree diet, honey thick liquid, one-to-one feeding assistance and follow aspiration precautions. On [DATE], I placed R1's aspiration precautions at the head of his bed under a privacy cover. The top cover read 'Please see attached swallowing precautions', underneath I listed the following: [only feed when R1 is alert, feed him in an upright 90-degree position, and reposition as needed, due to R1's past stroke he would lean to the side, small bites, and small sips of liquid]. During mealtime if R1 was noted coughing, chest congestion, rattle, or difficult breathing staff was notified to stop oral intake and notify R1's provider for further instructions. On [DATE] at 6:26 PM, V5 [Registered Nurse] stated, On [DATE] around 5PM, V4 [Licensed Practical Nurse] yelled out for my help and said code blue in R1's room. V4 was the assigned nurse for R1. When I went into the R1's room I saw R1 lying flat down in the bed throwing up food, out of his nose and mouth, with his dinner tray in front of him, not responsive and having a hard time breathing, R1 was weak and limp. V4 sat R1 up in bed, and I ran and got the crash cart while V4 was suctioning R1. I sent V31 [R1's Certified Nurse Assistant] to get the oxygen tank. R1's oxygen level was reading in the 70's percentile. After suctioning and started oxygen R1 started to come back around. R1 started breathing and looking around. R1 continued to cough, and I could hear chest congestion, but he was back breathing and stopped vomiting. I did not call 911 when R1 was unresponsive because R1 was left lying down in bed and aspirated, that situation could be managed by nursing interventions. When I left out the room, V6 [R1's Family Member] asked me what was going on with R1. I explained R1 was left flat and aspirated, but he was okay now. I spoke to V31 and gave her education that no one with a gastric feeding tube should ever be laid flat in bed, and R1 was a one-to-one feed assist, R1 was not to receive a dinner tray to eat alone. V31 said she understood, and that she did not see the sign above R1's head. I documented a brief note in R1's chart to help out V4, because she [V4] was having a rough night with her set of residents. I documented vital signs after R1 was stable in my progress note, not on the electronic medication sheet. I did not document the vital signs during his code blue. I thought V4 would chart a complete progress note and assessment to what happened with R1, V4 was his assigned nurse. I worked [DATE] night shift, but I did not have R1 on my assignment. On [DATE] at 1:01 PM, V9 [Certified nurse Assistant] stated, I worked with R1 on [DATE] morning shift. R1 was alert but nonverbal, he understood what I would say by following commands and nodding his head yes or no. R1 had a gastric feeding tube, and he received a food tray. I did not remember if I fed R1 on [DATE]. R1 had a post at the head of his bed with his feeding instructions. R1 needed to be sitting up, fed slowly one to one, with small bites of food. I do remember R1 being congested, I could hear a rattle in his chest, and I notified the nurse [V4-Licensed Practical Nurse]. The next day, I worked with R1 on [DATE] day shift. During rounds, I notice R1's breathing was off, with his lips curled back in his mouth and his mouth was open. I reported my findings to the nurse [V29- Agency Registered Nurse]. V29 told me R1 was lying down in bed and aspirated on his food yesterday evening ([DATE]), and he was awake all night needed suctioning throughout the night, and R1 was okay he was just tired. After I passes the breakfast trays, I went to collect the trays around 9AM. I went to collect R1 breakfast tray and noticed he was not breathing. I ran and got the nurse. V29 [Agency Registered Nurse] started CPR, I called the code, and other nurse called 911. Then I went out in the hallway assisting other residents. I did not attempt to feed R1 any breakfast, because he was sleeping. On [DATE] at 12:10 PM, V7 [Physician] stated, I am R1's physician, V3 [Nurse Practitioner] and I manages R1's care. The rule from the facility and Third Eye, told me if I receive a phone call from the facility staff not to answer the phone after 7PM during the weekdays and not to answer after 7PM on Friday until Monday morning. I only seen R1 one time, he was alert and non-verbal on a pureed diet. R1 also received nutrition via gastric tube due to poor oral intake. I was notified on [DATE], there was mild episode of R1 coughing earlier that day, but R1 lung sounds were clear, and R1's oxygen level did not drop, he was not receiving supplemental oxygen. The second episode later that evening ([DATE]) when there was a code blue for R1 due to him vomiting, coughing and need suctioning. R1 became stable with ,d+[DATE] liters of oxygen and suctioning, R1 was okay to remain in the facility, with the chest x-ray ordered. A chest x-ray would have ruled out aspiration pneumonia or any mechanical issues. I was not made aware of R1's blood work results or chest Xray that was ordered from V30 [Third Eye Physician]. However, If R1 continued to cough, could hear chest rattle congestion sounds, and need frequent suctioning that lasted at least four hours, then V30 should have been notified and R1 should have been sent out the hospital emergency room for further evaluation. On [DATE] at 2:50 PM, V31 [Certified Nurse Assistant] stated, I took care of R1 on [DATE] during second shift. I made rounds and R1 was resting in bed. Dinner trays came up and I passed out the food trays, and I gave R1 a dinner tray as well. I did not reposition R1 or raise the head of bed up. Approximately around 5:30 PM, I was walking down the hallway picking up the dinner trays. I went into his room and saw half of his food missing from the food tray and he was making gurgling gasping sounds with vomiting coming from his nose and mouth. The vomit looked like it was his dinner, with food particles. R1 was lying down in bed and leaning on his side, shaking like he was having a seizure, and his eyes was rolled back into his head. I ran out and got the nurse V4 [Licensed Practical Nurse]. V4 went into R1's room and yelled out for help. V4 said R1's is aspirating and get the crash cart. V5 [Registered Nurse] came running into the room to help with the crash cart. V5 called over the speaker system code blue to R1's room, and other nurses came to help. I passed R1 his dinner tray, I did not know R1 needed one to one feeding assistance. I thought he could feed his self. After the code, V5 asked me if I gave R1 a food tray and did R1 feed himself alone. I told V5 I did give R1 his food tray, but I did not know R1 was a one -to-one feed assist. V5 told me that R1 was lying down too far and aspirated on his dinner while eating alone. V5 told me that R1 should have sitting up 90 degrees due to his aspiration precautions, and I needed to feed R1. [Survey showed V31 the sign that read 'Please See Attached Swallowing Precautions'] V31 stated, I saw the sign that was on the wall, above R1's head of bed after R1 coded, I did not pay attention to the sign before he aspirated. I did not read the swallow precautions. On [DATE] at 3:50 PM, V24 [Nurse Supervisor-Licensed Practical Nurse] stated, I was working on the second floor and heard code blue to R1's room around 5PM. When I peeped my head into R1's room V4 and V5 was working on R1. I did not go into R1's room. I went back to my floor. A few minutes later there was another code blue called for another room on the first floor. I went to that code and assisted with CPR. I do not remember video calling Telehealth physician for R1. I do not remember what happened to R1. [Surveyor showed V24 her progress nursing note dated [DATE] at 8:09 PM with the Telehealth physician.] V24 stated, I see the documented progress noted dated [DATE] at 8:09 with my name, but I cannot remember. To access a call with a Telehealth physician, each nurses have their own individual log in and passwords to access the video call. No one could document or call the Telehealth Physician under my name; I must have called the Telehealth Physician. I am so confused, and I do not recall the code for R1 on [DATE]. I do not know why I called the physician three hours after the code blue, and V4 did not call, she was R1's nurse not me. I am not trying to give you [surveyor] a hard time, I just cannot remember. It does not make any sense that I would call the physician and did not know what happened to R1, I had no information. I don't know what to say, because I was not in the room with R1's code. I have no more information to give you. On [DATE] at 4:48 PM, V30 [Telehealth Physician] stated, I received a request for telehealth visit at 8:09 PM for R1. V24 explained that R1 had some mucus, chills, with stable vital signs, no fever, and no respiratory distress. V24 told me she had concern of aspiration pneumonia, but R1 was stable without any respiratory distress noted, I ordered blood work and a chest x-ray to be completed as soon as possible, meaning STAT. I knew the test would be completed by an outside agency to perform the test, so STAT would mean to complete soon as possible. I was not made aware that code blue was called in the facility for R1 at 5PM, three hours prior to calling me. I was not made aware that R1 was found lying flat in bed, unresponsive, oxygen level in the 70's percentile, threw up food particles out of his nose and mouth, having difficulty breathing, needed to be suction, started oxygen, and needed continuous oxygen to sustain a blood oxygen of 92%. If V24 gave me a complete accurate report of R1's condition, I would have given an order to send R1 to the hospital. I did not know R1 labs came back, and his white blood count was 15, and chest Xray showed early infiltrates in the right lung base. No one from the facility notified me or my staff at the Telehealth of the test results. Those results indicated R1 aspirated, and now developing pneumonia. If I would have received the test results, I would have sent R1 to the emergency room . On [DATE] at 1:22 PM, V29 [Agency Registered Nurse] stated, I worked on [DATE], with R1 and received in report from V36, that R1 had aspirated the day before [[DATE]]. During making rounds at the start of my shift, R1 was awake, and alert sitting upright in bed. A little while later, V9 [certified nurse assistant] came and told me R1 was not looking right. I went immediately and noted R1 was sitting up in bed, nothing coming from his mouth or nose. R1 was not breathing and did not have a pulse. I started CPR, called code blue, and 911. I notified the physician, and family. 911 was unable to resuscitate R1. 911 did not remove the body, R1's family had the funeral home pick up R1. On [DATE] at 3:20 PM, V3 [Nurse Practitioner] stated, R1 has a gastric feeding tube and oral pureed diet with honey thick liquids. I assessed R1 earlier in the afternoon on [DATE], I was in the facility, he had some rhonchi and coughing. I did not order a chest Xray because R1 had the same symptoms in the hospital, it was his baseline. I ordered a medication called Robinul for excessive secretions, and a suction machine at the bed side. I felt the medication would assist with drying up the secretions. The evening of [DATE], was on a Saturday, the facility policy is during the week after 7PM, and on weekends the nursing staff is to call Telehealth Physicians on call service for assistance and change of conditions with residents. I was not notified on [DATE], that code blue was initiated for R1. If the facility staff called code blue, and R1 oxygen decreased in the 70's percentile, 911 should have been called. I did not receive any test results from R1's labs or chest x-ray from [DATE]. On [DATE] at 1:45PM V2 [Assistant Director of Nursing] stated, Residents with a gastric feeding tube should never be lay down flat, the head of bed should be elevated at all times at least 45 degrees. R1 had a gastric feeding tube and received oral diet with specific swallow aspiration precautions. R1's physician order dated [DATE], aspiration precautions, to keep head of bed elevated during and 30-minutes after gastric tube feedings and 1:1 feed assistance with all meals. The speech therapist places an instruction sheet on the wall above resident's bed that is on swallowing precautions as a reminder for staff. 1:1 feed assistance means R1 needed to receive assistance with all meals, R1 needs to be fed by a nursing staff member and to follow the swallow aspiration precautions. If a resident with a gastric feeding tube lays flat in bed, the resident could potentially aspirate. If a resident with 1:1 feed assists with meals, self-feed the resident could potentially aspirate. Whenever the nursing staff calls a code blue, 911 should have been phoned. Any change of condition, once the nurse cares for the resident, the nurse should call the physician right away. If a change of condition occurs around 5PM, it is unacceptable for the nurse to notify the physician 3-hours later at 8PM. STAT Labs (blood work), and chest Xray abnormal results, should be relayed to the physician right away. Not relaying results, is delaying potential treatment. The agency nurses and our staff nurses all have access to look up the lab results. If the results were not available, the nurse could call the lab for the results. Each nurse has their own Telehealth log in username and password. No one should share their passwords, log in information with anyone it is against HIPPA. On [DATE] at 4:48 PM, V4 [Licensed Practical Nurse] stated, I worked with R1 on [DATE], I worked first shift 7AM to 3PM and second shift 3PM-11PM. Around 5:30 PM, V31 [Certified Nurse Assistant] came to me in the hallway and said R1 was not breathing and was throwing up food out of his nose and mouth. I entered the room and R1 had difficulty breathing, not responsive, eyes were half open his eyeballs were rolling up and he was vomiting lying down in bed. V5 [Registered Nurse] came in to help me and called code blue. I pulled R1 up in bed and started to suction him and V5 applied oxygen. I did not remember R1's blood oxygen level, or his vital signs during the code I did not write them down or input the vitals in R1 electronic chart, I was busy. After suctioning and giving him oxygen, R1 came back around, alert, and looking around, R1 became stable and was okay. I did not chart on R1, V5 and V24 [Nurse Supervisor] help me chart that day because there were a couple of code blues on the same day and same time. I did not call the Telehealth Physician, V24 called telehealth and spoke with the physician. I do not know what time V24 called the physician. V24 called in labs and chest x ray to be completed STAT. No, I did not receive any test results, maybe the results came in on 11PM-7AM shift. [Surveyor asked V4 why she did not call 911.] V4 stated, I did not call 911, because R1 was stable after I suctioned him and started him on oxygen. I was able to handle the situation. On [DATE] at 1:05 PM, V2 stated, her investigation showed V24 did call the Telehealth Physician and gave report to V30. On [DATE] at 12:11 PM, V38 [Certified Nurse Assistant] stated, I been working at the facility for five months. I worked on [DATE] from 10PM to 6AM. R1 was cleaned and changed twice that shift. During ADL incontinent care, I left R1 head elevated, he was never laid down flat. R1 was woke through the night, coughing, and I could hear chest congestion like a rattle, and V36 [Agency Registered Nurse] kept suctioning him. R1 looked normal but was sweating and clammy. Other than R1 sweating, he looked okay, and R1 was non-verbal as usual. I did not take R1's vital signs, the night shift aides don't take the vital signs the day shift aides take the vitals. On [DATE] at 11:50 AM, V36 [Agency Registered Nurse] stated, I worked at the facility twice. I've been a registered nurse for ten years. On [DATE] I worked 11PM to 7AM, and that was my last time working at the facility. I got report from V4. She [V4] told me, on second shift, R1 aspirated while lying flat in bed feeding himself, and she suctioned R1 very well, the physician was notified, order blood work and chest x-ray. I received R1 sitting up in bed, awake, alert, non-verbal and he was sweating. I kept a cold face towel on his forehead to keep him cool and removed the cover off his feet. I made sure R1 was sitting straight up in bed, because he was coughing, I could hear chest congestion, and secretions coming out of his mouth. R1 needed frequent suctioning, at least a couple times per hour. I did not call the physician because V4 said she already called the physician. I did not receive R1's blood work or chest x-ray report. I am an agency nurse and do not have access to check the results. It did not occur to me to ask another staff nurse to print of R1's results, I was so busy with the other residents and suctioning R1 that I did not have time to ask another nurse. I did not chart on R1 because I was too busy taking care of the other residents. I took one set of vital signs, but I did not place the vital signs in R1's electronic chart, I just ran out of time and forgot to put them into the system. I do not remember the vital signs; I am sure they were normal. On [DATE], was my last time working at that facility. V2 placed me on the DNR [Do Not Return] list. V2 did not give me any reason why I could not return to the facility. I did not go back into the system and place in any vital signs later after I left the faciity on [DATE], I did not have access to the facility's system. On [DATE] at 10:26 AM, V9 stated, I started work on [DATE] at 6AM. I started making rounds around 6:,d+[DATE]:30 AM. When the food trays came to the floor, all staff assist with passing out food trays. I did not pass R1 his breakfast tray, but someone gave him a breakfast tray. When I was walking on the unit to collect the breakfast trays around 9:30 AM, R1 was sitting up in bed, leaning to the side and was not breathing. R1 was not throwing up, nothing was coming up from his mouth or nose. I called for the nurse, and she started CPR, called code blue, and called 911. R1's food tray was untouched. R1 was in deep sleep and did not wake up to eat anything. On [DATE] at 11:01 AM, V3 stated, During the weekdays from 7PM to 7AM, and from Friday 7PM to Monday 7AM the Telehealth Physicians are on call. If a nurse reaches out to the Telehealth Physician on call service, that physician is responsible for the resident's care. Any resident that is lying flat down that has a gastric tube feeding, has the potential to aspirate. If any resident that has high risk for aspiration, swallowing precautions, and must have one to one feeding assistance, is given a meal tray and the resident self-feed alone, has a potential to aspirate. On [DATE] at 10:48 AM, V7 stated, Telehealth Physicians are responsible for that resident's care and making health decisions during that on call time. If R1 was feeding himself alone, and he was on swallowing precautions one to one feed it could potentially cause R1 to aspiration. If R1 was lying flat, he has a potential to aspirate. On [DATE] at 12:26 PM, V37 [Director of Nursing] stated, I been working here since [DATE]. I been a registered nurse since 2007, and six years of director of nursing experience. If nurse calls out code blue, the nursing staff should check advance directives, start CPR, and to call 911. If a resident that has a gastric feeding tube lays flat, they could potentially aspirate. The staff should never give or place a food tray to a resident that is 1:1 feed assist, due to aspiration swallow precautions, the resident could potentially aspirate. The laboratory can call or fax the lab results. The nursing staff can also call the lab for results as well. Our nursing staff and agency nurses all have access to the computer system to look up lab results as well. When there is a change in condition, the assigned nurse should notify the physician to give a accurate report of the resident's condition and document the change, orders, and vital signs. R1's care plan dated ([DATE]) documents in part: -R1 needs the head of bed elevated 45 degrees during and thirty minutes after tube feeding. -Monitor R1 and report to physician if noted aspiration, shortness of breath, abnormal lung sounds, abnormal lab values, nausea or vomiting. Facility's Policy Code Blue dated ([DATE]) Documented in part: -A code is initiated for all residents requiring emergency medical attention -If a resident requires emergency medical attention, then a code blue should be announced -As staff arrive staff should, call 911, notify the physician and family Facility's Policy Change in Resident Condition: dated ([DATE]) documents in part: -It is the policy of the facility, except in a medical emergency, to alert the resident's physician and resident's responsible party of a change in condition. -Nursing will notify the resident's physician or nurse practitioner when there is a significant change in the resident's status; when there is s significant change in the resident's status, when it is deemed necessary or appropriate in the best interest of the resident. -Communication with the physician will be documented in the resident's medical record Facility's Policy Documentation dated (,d+[DATE])documents in part: -Documentation should include any change of condition of the resident -Any communication with the physician, or nurse practitioner should also be documented. Facility Assessment Tool dated (,d+[DATE]) documents in part: Licensed Staff: Identification of resident changes in condition - identify medical issues appropriately, how to determine if symptoms represent problems in need of intervention, how to identify when medical interventions are causing rather than helping relieve suffering and improve quality of life. Facility policy Critical Lab Results Reported dated ([DATE]) documents in part: The facility will communicate the results of test considered critical to the patient care to the responsible licensed caregiver in a timely and reliable manner. The surveyor confirmed through observation on [DATE], interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: the facility completed all measures on the abatement plan. Therefore, the abatement plan could be approved on ,d+[DATE]//2024. Abatement Plan: 1A. The Director of Nursing [V37], Assistant Director of Nursing [V2] and Administrator [V1] educated all nursing staff on [DATE] that all residents that need 1:1 feeding assistance must be provided 1:1 assistance and that the head of the bed will be elevated, and residents properly position during and after fe [TRUNCATED]

Based on interview and record review the facility staff failed to provide necessary treatment and services to promote healing and prevent infection of an existing pressure ulcer for 1 (R2) of 4 (R4, R7, R8) residents. R2 was admitted to the facility on [DATE] with a pre-existing pressure ulcer, however the facility was unable to provide consistent documentation that the physician ordered treatments for R2's sacral pressure ulcer was documented on from 03/06/24 through 03/11/24 and 03/12/24 through 03/17/24. The deficient practice resulted in R2 sacral wound becoming infected. Findings Include: During record review R2's sacral wound initial assessment documentation dated 03/05/24 with the second assessment dated [DATE] during which time R2 sacral wound evolved with no further wound documentation. R2 was admitted to the hospital on 03/17/24 with a diagnosis of Infected Decubitus Ulcer and received IV (Intravenous) antibiotics. R2 was admitted to the facility on [DATE] with diagnosis not limited to Paroxysmal Atrial Fibrillation, Essential (Primary) Hypertension, Hyperlipidemia, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Dysarthria Following Cerebral Infarction, Fall, Ataxia, Cerebral Infarction, Fracture of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing, Chronic Atrial Fibrillation, Acute Kidney Failure, Repeated Falls, Encounter for Other Orthopedic Aftercare, Muscle Weakness, Dysphagia, Difficulty in Walking, Cognitive Communication Deficit, Weakness, Urinary Tract Infection, Pressure Ulcer of Sacral Region, Unstageable, Pressure-Induced Deep Tissue Damage of Left Heel, Disruption of External Operation (Surgical) Wound, Pressure induced Deep Tissue Damage of Right Ankle and discharged to the hospital on 03/17/24. R2's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 13 indicating intact cognitive response. Order Summary Report document in part: Complete weekly skin checks to ensure no new skin alterations are present. Sacrum/Xeroform one time a day every Tue, Thu, Sat cleanse with ns (normal saline) pat dry apply treatment cover with dry dressing order date 03/05/24. Sacrum/Medihoney & Silver Ag (Alginate) one time a day every Mon, Wed, Fri cleanse with ns pat dry apply treatment cover with dry dressing order date 03/13/24. Cefdinir Oral Capsule 300 mg (milligram) give 1 capsule by mouth every 12 hours for 7 days order date 03/11/24. Collagenase Ointment 250 Unit/GM (gram) Apply to sacrum topically as needed for itching order date 03/12/24. Collagenase Ointment 250 Unit/GM (gram) Apply to sacrum topically everyday shift for itching cleanse with ns (normal saline) pat dry apply treatment cover with dry dressing order date 03/12/24. Treatment Administration Record: document in part: Sacrum/Xeroform one time a day every Tue, Thu, Sat cleanse with ns pat dry apply treatment cover with dry dressing -D/C (discontinue) Date- 03/17/24 with missing initials on 03/09/24 and 03/16/24. Sacrum/Medihoney & Silver Ag one time a day every Mon, Wed, Fri cleanse with ns pat dry apply treatment cover with dry dressing -D/C Date- 03/17/24. Care Plan document in part: Focus: Nutritional Status: Focus: Skin: At risk for skin complications. Focus: R2 is at Risk for alteration in skin integrity R/T (related/to) self-care deficits, Impaired mobility, and comorbidities. Interventions: Remind/Assist resident to reposition frequently. Provide peri-care after each incontinent episode and apply barrier cream. Focus: R2 has a pressure injury R/T self-care deficits, Impaired mobility, and comorbidities. Site: Sacrum Site: Left heel Site: Right medial knee Date Initiated: 03/06/2024. Focus: R2 has an alteration in skin integrity R/T self-care deficits, Impaired mobility, and comorbidities Date Initiated: 03/06/24. Patient Risk Profile dated 03/05/24 document in part: Braden score 14 (Moderate Risk). Most Recent Risk Assessment: Braden Score: 14 (Moderate Risk) dated 03/11/24. Wound Assessment Details Report assessment date 03/05/24 document in part: Wound: Sacrum, Status: Active, Type: Pressure, Classification: Ulceration, Source: Present-on-admission, Date identified: 03/05/24, Clinical Stage: Deep Tissue Pressure Injury. Tissue Types: Deep Maroon = 65%, Bright Pink or Red = 25%, Slough loosely Adherent 10%. Size: 8.50 x 15.00 x unknown. Resident is incontinent of b/b (Bowel/Bladder) and able to verbalize needs. Wound Assessment Details Report assessment date 03/12/24 document in part: Wound: Sacrum, Status: Active, Type: Pressure, Classification: Ulceration, Source: Present-on-admission, Date identified: 03/05/24, Clinical Stage: Unstageable. Tissue Types: Bright Pink or Red = 20%, Slough loosely Adherent = 80%. Size: 8.00 x 14.00 x unknown. DTI (Deep Tissue Injury) evolved, wound site 70% slough and 30% non-granulation. Progress note dated 03/04/24 18:21 document in part: Nursing Note: Uses Condom foley. Incontinent of bowel. Progress note dated 03/04/24 19:48 document in part: Medical Practitioner Note HPI: Pt (patient) seen today to manage multiple medical conditions. Sacrum 03/05/24 Pressure Ulceration Active Unstageable Sacral wounds - Consult wound care. Progress note dated 03/11/24 14:37 document in part: Skin/Wound Note Text: Received call from (R2 family member) gave a wound update, advised (R2 family member) that writer would know more on tomorrow after assessment is complete. Progress note dated 03/13/24 16:38 document in part: Social Service Note: IDT (interdisciplinary team) met with (R2 family member) via phone. Wound nursing and MD (Medical doctor) reviewed wounds, treatments, stage (unstageable). Progress note dated 03/17/24 17:51 document in part: Nursing Note: Brought to writer's attention by residents' (family members) that they want their father sent out of the facility because R2 wound is not healing to them and that they feel like R2 got an infection in the wound. Progress note dated 03/17/24 19:35 document in part: telehealth evaluation (other) Date of Service: 03/17/24 6:34 PM CT Primary Chief Complaint: Skin: Pressure Wound History Present Illness: Family believes that patient is not getting good care and think the wound has worsened. They want R2 transferred back to the hospital. They believe it is infected and do not want to wait to talk to primary or wound care. Physical Exam: Exam findings per nurse and video observation. SKIN: Patient with large sacral wound Diagnosis, Assessment/Plan: - Pressure ulcer of sacral region, unstageable (Primary) The patient's condition is worsening. Transfer patient to hospital per requests of family. Hospital record dated 03/17/24 document in part: Specimen Information Culture: wound collected 03/18/24: Moderate Corynebacterium species. Moderate Escherichia coli. ESBL (Extended Spectrum Beta-Lactamase) positive status. Skin: Comments: Stage 2 ulcer across his (R2) sacrum, warm tender, erythematous margins with purulent discharge. History of Present Illness: Patient's ulcer does appear infected. Clinical Impression 1. Infected decubitus ulcer. The patient was started on antibiotics in the ED (Emergency Department). Assessment: Sacral Decubitus/gluteal ulcer wounds, present on admission, with concern for skin and soft tissue infection/cellulitis. Principle Problem: Soft tissue infection. Assessment: Infected sacral decubitus ulcer. On 03/26/24 at 10:43 AM V11 (R2's Family Member) stated R2 was admitted to the facility on [DATE]. On Tuesday 03/05/24 we spoke to two certified nurse assistants and when they flipped R2 over he had an area on his buttocks. R2 wound traveled and on the last day 03/17/24 last day the wound ended up with an infection, was sore, spreading, and full of pus. R2 is now on IV (intravenous) antibiotics. On 03/26/24 at 12:19 PM V7 (Physician) stated R2 had a wound, but I am not sure where it was or if there was drainage. On 03/27/24 at 08:55 AM V16 (Wound Care Doctor) stated I saw R2 one time. R2 had a pressure relate wound from the sacral extending to the buttock. When R2 was admitted he had a DTI (Deep Tissue Injury) and it had evolved and progressed. It was unstageable. On 03/13/24 the sacral wound was unstageable pressure with a combination of tissue types; a quarter granulation tissue, a quarter to a third slough tissue, and half of the area was still epithelial. R2 sacral tissue was damaged on admission and evolving over the next week or two. Some DTI's resolve and some become stage 4. There were no signs of infection when I saw the wound. Physiologically when you get a DTI the tissue has been damaged and it can take a while to break down because the tissue has to necrose. The thing is if someone is wet and there is pressure that has the potential for causing further damage to the wound. If those things happen that will make the wound worst. The protocol is there to prevent those factors from convening. When showing V16 the hospital records V15 responded, Cultures show that there are bacteria present. E. coli is part of the flora of our gut because it is in proximity of the anus. The erythema will indicate an infection if the hospital says the sacral wound was infected it was infected. If the hospital had R2 there and there was a change in the wound, warm tender, and purulent drainage it evolved and became infected. If R2 was incontinent of stool and urine it is possible for the sacral wound to become infected. On 03/27/24 at 09:23 AM V17 (Certified Nurse Assistant) stated When we would come in the morning R2 would tell us the night shift did not come in the room. I did witness R2 being wet or soiled. On 03/27/24 at 09:30 AM V18 (Licensed Practical Nurse) stated I was here the day that R2's family members came and said R2 has a wound that is not getting better. I called the third eye zoom call and the doctor offered to do a culture, but the family refused. I did not remove R2's sacral wound dressing. I never physically saw or smelt R2's sacral wound. At times I had to reinforce R2's dressing because it was draining through with a light pink in color drainage. R2 had a bowel movement, and I changed the dressing one time. On 03/27/24 at 11:33 AM V13 (Wound Care Coordinator) stated R2 was admitted to the facility on [DATE]. I did R2 initial skin assessment on 03/05/24. When R2 first got here R2 had a DTI (Deep tissue injury) to the sacrum. A DTI and ulceration are under the same category. R2 had 25% granulation which is more healthier pinkish reddish tissue. 65% deep maroon where the epidermis is not open but there is something going on underneath and 10% slough, bad tissue until you clear away the slough you don't know what is going on underneath. The slough tissue was within the open area. The treatment R2 started with on 03/05/24 was Xeroform. The Xeroform is like a Vaseline gauze 3 times a week. The only time documentation that is done is every 7 days when the wound assessment I done. I saw R2 a couple of times between the assessments and there was nothing major going on. I can't remember the other days that I saw R2. The Xeroform order was discontinued on 03/12/24. With the Xeroform we wanted to remove the deep maroon tissue and remove all the tissue on top of the wound. The 20% granulation was the good tissue and the 80% slough was the bad tissue. The sacral wound was not close to R2's rectum. The meaning of the wound evolving is until the maroon tissue breaks away the wound is changing. It is an expectation of the wound evolving/changing. We expected for the wound to look like it did on 03/12/24 compared to 03/05/24. Unfortunately, we are to document every 7 days on the assessment. There is no further documentation after 03/12/24. The last time that I saw R2 wound was on 03/13/24 with the wound care doctor. While showing V13 the hospital records V15 responded, E. coli is related to stool. Purulent discharge would be signs of infection. On 03/27/24 at 02:23 PM V32 (Certified Nurse Assistant) stated R2 was incontinent of both bowel and bladder and was a total assist. R2 had a dressing on his bottom, it was brown/tan like a band aid. The last time I saw R2 his (R2) daughter peeled off the sacral wound dressing. I held R2 so that the daughter could go get the nurse. V5 (Registered Nurse) came in the room and helped me change R2. I had not seen R2's wound before. The dressing had a little red drainage on it with no odor. V5 cleaned the wound and put another dressing on. On 03/27/24 at 03:06 PM V5 (Registered Nurse) stated I don't remember what R2's wound look like or if there was any drainage. On 03/17/24 I do recall putting the dressing back on R2 sacral wound. On 03/27/24 at 03:30 PM per telephone interview V3 (Nurse Practitioner) stated I did not see R2's wound aside from seeing pictures from the wounds nurse. The picture with slough, redness around sacral area, the buttocks with an open area where it was kind of pink and slough. The family was concerned that R2 did not have any wounds. The goal is to remove eschar and slough, keep the pressure relieved, and turn every 2 hours. There is a high probability that E. coli could have been in R2 sacral wound. Given the position of the wound the E. coli lives near the butt. The purulent discharge is indicative of an infection. If the hospital found R2's sacral wound was infected upon being admitted the sacral wound became infected at the facility. On 03/27/24 at 04:06 PM V35 (Certified Nurse Assistant) stated I change R2 and sometimes I did the wound dressing. The gauze dressing was dirty with stool and wet. I changed R2 sacral wound dressing 2 or 3 times. I did not see the nurse, so I changed the dressing.' When asked by the surveyor was, she (V35) trained to do wound dressing changes V35 responded the nurse went for her break, and I was changing R2. I looked for nurse and just managed to do the best I can to protect R2's wound. I work the night shift and R2 was always urinating. R2 would urinate 2 - 3 times while I was changing him. On 03/27/24 at 04:33 PM V2 (Assistant Director of Nursing) stated my expectations for wound care and prevention are upon noticing any skin breakdown to notify the family and physician. My expectation for documentation is for the nurse to document correctly and what treatment that they are providing. On 03/28/24 03:03 PM V25 (Wound Care Nurse) stated R2 came to us admitted with a DTI to the sacrum. It evolved if I am not mistaking to an unstageable covered in mostly yellow to white slough. I don't recall what R2 wound looked like. I don't know what the wound care order was. R2 wound did not have any signs and symptoms of infection or drainage that I can recall. We don't document as we do a bandage change and do not do daily documentation. The facility protocol is to turn and reposition the residents as needed, and it depends on the patient. R2 is incontinent of both bowel and bladder. Policy: Titled Skin Care Prevention reviewed 01/24 document in part: All residents will receive appropriate care to decrease the risk of skin breakdown. Guideline: 2. Dependent residents will be assessed during care for any changes in skin condition including redness, (non-blanching erythema), and this will be reported to the nurse. The nurse is responsible for alerting the Health Care Provider. 3. All residents will be evaluated for changes in their skin condition. 5. All residents unable to reposition themselves will be repositioned as needed, (minimum of every 2 hours). 9. Clean skin at time of soiling and at routine intervals. Titled Skin Management: Monitoring of Wounds and Documentation reviewed 01/24 document in part: It is important that the facility have a system in place to assure that the protocols for daily monitoring and for periodic documentation of measurements, terminology, frequency of assessment, and documentation are implemented consistently throughout the facility. General Guidelines: An evaluation of the status of the dressing, if present (whether it is intact and whether drainage, if present, is or is not leaking); The status of the area surrounding the PU/PI (Pressure Ulcer/Pressure Injury) (that was observed without removing the dressing); General Monitoring Guidelines: With each dressing change or at least weekly (and more often when indicated by wound complications or changes in wound characteristics), and evaluation of the PU/PI should be documented. At a minimum, documentation should include the date observed and: location and staging:

Based on interviews and record reviews the facility staff [A] failed to have the necessary skills and competencies to meet one [R1] resident health care needs [B] failed to keep the head of bed elevated, and [C] failed to provide 1:1 feeding assistance. These failures resulted in R1 experiencing an acute change of condition and subsequently expiring on 3/3/24 in the facility. Findings Include: R1's clinical record indicated in part; R1 was admitted to the facility on [DATE] with medical diagnosis of pneumonitis due to inhalation of food and vomit, dysphagia, cerebral infarction due to thrombosis of right middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, visuospatial deficit and spatial neglect, memory deficit, , protein-calorie malnutrition, muscle weakness, cognitive communication deficit, dysphagia, essential (primary) hypertension, attention-deficit hyperactivity disorder, weakness, gastrostomy, and generalized anxiety disorder. R1's care plan dated 2/27/24: -R1 needs the head of bed elevated 45 degrees during and thirty minutes after tube feeding. -Monitor R1 and report to physician if noted aspiration, shortness of breath, abnormal lung sounds, abnormal lab values, nausea or vomiting. R1's physician orders: -2/27/24 - Aspiration Precautions: Keep HOB elevated during and 30min after G/T Feedings and 1:1 Feed with Pureed Diet and HTL [Honey think liquid] every shift. -2/27/24- four times a day flush enteral tube QID with 150 mL [milters] of water after feeding. -2/27/24 - four times a day enteral feeding: Jevity 1.5 360ml bolus QID [four times per day]. -2/27/24- general diet, pureed texture, honey thick consistency with one-to-one feeding assistance. R1's progress notes documented in part: V8 [Speech Pathologist/Therapist] Note documented in part: On 2/29/24- Recommendations for R1, to continue puree diet, with 1:1 assistance and to follow R1's swallowing precautions: only feed when alert, up right at 90 degrees for all meals, reposition as needed, aspiration precautions, monitor or pocketing, small bites, small sips, alternate liquids, and solids, monitor for signs and symptoms of aspiration related illness. V5 [Registered Nurse] nursing progress note 3/2/2024 21:19:40 Note: V31[Certified Nurse Assistant] found R1 shaking and called nurse-observed pt having secretions coming out of nose and mouth. R1 regurgitated. Having difficulty breathing. Congestion noted on listening to lung sounds. V3 [Nurse Practitioner] was in house earlier on today and ordered oral suction at bedside PRN [as needed]. R1 was suctioned and stabilized. Respiration even non labored. [Nurse failed to document code blue was initiated] On 3/26/24 at 4:21 PM, at V6 [R1's Family Member] stated, On 3/2/24 I went to the facility approximately 5:30 PM. Upon arrival to the facility R1's door was closed; I thought the staff was changing his under brief at the time. Then I saw nursing staff going in and out of his room running pass me and no one said a word to me. A few seconds later, I heard over the intercom speaker code blue for R1's room number. I asked V5 [Registered Nurse] coming out of R1's room what was going on. V5 told me that R1 was lying flat down in bed eating and aspirated. When V5 went back into the room I went in the room with him. I saw R1 foaming at the mouth and nose, not responding with his eyes closed and V4 [Licensed Practical Nurse] was suctioning R1. Another young lady brought in oxygen and V4 started oxygen on R1. A few minutes later R1 opened his eyes and was looking around. V4 and V5 left out the room, and I asked R1 was he okay, he turned his head side to side meaning no. R1 can usually say simple words like yes or no, but R1 could not talk. After staying with R1 for a few hours, he continued coughing, drooling, and I can hear his chest rattle when I breath in and out. I asked V5 at the nursing station was my father going to be alright, V5 said yes, he will be okay, for me to go home and rest. On 3/3/24 at 8:42 AM, a nurse called me from the facility and said she was sorry R1 passed away 45minutes ago. On 3/26/24 at 12:44 PM, V8 [Speech Pathologist/Therapist] stated, I completed R1 speech evaluation and worked with him. R1 had a medical diagnosis of dysphagia with moderate oral phase. R1 would have oral phase trace residue 4 out of 4 exercises. R1 would have a little food left on his tongue. With drinking honey thick liquid, R1 would have some liquid come out of his mouth that he did not swallow. My recommendations for R1 were to continue puree diet, honey thick liquid, one-to-one feeding assistance and follow aspiration precautions. On 2/29/24, I placed R1's aspiration precautions at the head of his bed under a privacy cover. The top cover read 'Please see attached swallowing precautions', underneath I listed the following: [only feed when R1 is alert, feed him in an upright 90-degree position, and reposition as needed, due to R1's past stroke he would lean to the side, small bites, and small sips of liquid]. During mealtime if R1 was noted coughing, chest congestion, rattle, or difficult breathing staff was notified to stop oral intake and notify R1's provider for further instructions. On 3/27/24 at 2:50 PM, V31 [Certified Nurse Assistant] I took care of R1 on 3/2/24 during second shift. I made rounds and R1 was resting in bed. Dinner trays came up and I passed out the food trays, and I gave R1 a dinner tray as well. I did not reposition R1 or raise the head of bed up. Approximately around 5:30 PM, I was walking down the hallway picking up the dinner trays. I went into his room and saw half of his food missing from the food tray and he was making gurgling gasping sounds with vomiting coming from his nose and mouth. The vomit looked like it was his dinner, with food particles. R1 was lying down in bed and leaning on his side, shaking like he was having a seizure, and his eyes was rolled back into his head. I ran out and got the nurse V4 [Licensed Practical Nurse]. V4 went into R1's room and yelled out for help. V4 said R1's is aspirating and get the crash cart. V5 [Registered Nurse] came running into the room to help with the crash cart. V5 called over the speaker system code blue to R1's room, and other nurses came to help. I passed R1 his dinner tray, I did not know R1 needed one to one feeding assistance. I thought he could feed his self. After the code, V5 asked me if I gave R1 a food tray and did R1 feed himself alone. I told V5 I did give R1 his food tray, but I did not know R1 was a one -to-one feed assist. V5 told me that R1 was lying down too far and aspirated on his dinner while eating alone. V5 told me that R1 should have sitting up 90 degrees due to his aspiration precautions, and I needed to feed R1. [Survey showed V31 the sign that read 'Please See Attached Swallowing Precautions'] V31 stated, I saw the sign that was on the wall, above R1's head of bed after R1 coded, I did not pay attention to the sign before he aspirated. I did not read the swallow precautions. On 3/28/24 at 4:48 PM, V4 [Licensed Practical Nurse] stated, I worked with R1 on 3/2/24, I worked first shift 7AM to 3PM and second shift 3PM-11PM. Around 5:30 PM, V31 [Certified Nurse Assistant] came to me in the hallway and said R1 was not breathing and was throwing up food out of his nose and mouth. I entered the room and R1 had difficulty breathing, not responsive, eyes were half open his eyeballs were rolling up and he was vomiting lying down in bed. V5 [Registered Nurse] came in to help me and called code blue. I pulled R1 up in bed and started to suction him and V5 applied oxygen. I did not remember R1's blood oxygen level, or his vital signs during the code I did not write them down or input the vitals in R1 electronic chart, I was busy. After suctioning and giving him oxygen, R1 came back around, alert, and looking around, R1 became stable and was okay. I did not chart on R1, V5 and V24 [Nurse Supervisor] help me chart that day because there were a couple of code blues on the same day and same time. I did not call R1's physician; we must use Telehealth Physician on call service on the weekends. I did not call the Telehealth Physician, V24 called third eye and spoke with the physician. I do not know what time V24 called the physician. V24 called in labs and chest x ray to be completed STAT. No, I did not receive any test results, maybe the results came in on 11PM-7AM shift. [Surveyor asked V4 why she did not call 911.] V4 stated, I did not call 911, because R1 was stable after I suctioned him and started him on oxygen. I was able to handle the situation. On 3/26/24 at 6:26 PM, V5 [Registered Nurse] stated, On 3/2/24 around 5PM, V4 [Licensed Practical Nurse] yelled out for my help and said code blue in R1's room. V4 was the assigned nurse for R1. When I went into the R1's room I saw R1 lying flat down in the bed throwing up food, out of his nose and mouth, with his dinner tray in front of him, not responsive and having a hard time breathing, R1 was weak and limp. V4 sat R1 up in bed, and I ran and got the crash cart while V4 was suctioning R1. I sent V31 [R1's Certified Nurse Assistant] to get the oxygen tank. R1's oxygen level was reading in the 70's percentile. After suctioning and started oxygen R1 started to come back around. R1 started breathing and looking around. R1 continued to cough, and I could hear chest congestion, but he was back breathing and stopped vomiting. I did not call 911 when R1 was unresponsive because R1 was left lying down in bed and aspirated, that situation could be managed by nursing interventions. When I left out the room, V6 [R1's Family Member] asked me what was going on with R1. I explained R1 was left flat and aspirated, but he was okay now. I spoke to V31 and gave her education that no one with a gastric feeding tube should ever be laid flat in bed, and R1 was a one-to-one feed assist, R1 was not to receive a dinner tray to eat alone. V31 said she understood, and that she did not see the sign above R1's head. I documented a brief note in R1's chart to help out V4, because she [V4] was having a rough night with her set of residents. I documented vital signs after R1 was stable in my progress note, not on the electronic medication sheet. I did not document the vital signs during his code blue. I thought V4 would chart a complete progress note and assessment to what happened with R1, V4 was his assigned nurse. I worked 3/2/24 night shift, but I did not have R1 on my assignment. On 4/9/24 at 11:01 AM, V3 [Nurse Practitioner] stated, Any resident that is lying flat down that has a gastric tube feeding, has the potential to aspirate. If any resident that has high risk for aspiration, swallowing precautions, and must have one to one feeding assistance, is given a meal tray and the resident self-feed alone, has a potential to aspirate. On 4/9/24 at 10:48 AM, V7 [Physician] stated, If R1 was feeding himself alone, and he was on swallowing precautions one to one feed it could potentially cause R1 to aspiration. If R1 was lying flat, he has a potential to aspirate. On 3/27/24 at 1:45PM V2 [Assistant Director of Nursing] stated, Residents with a gastric feeding tube should never be lay down flat, the head of bed should be elevated at all times at least 45 degrees. R1 had a gastric feeding tube and received oral diet with specific swallow aspiration precautions. R1's physician order dated 2/27/24, aspiration precautions, to keep head of bed elevated during and 30-minutes after gastric tube feedings and 1:1 feed assistance with all meals. The speech therapist places an instruction sheet on the wall above resident's bed that is on swallowing precautions as a reminder for staff. 1:1 feed assistance means R1 needed to receive assistance with all meals, R1 needs to be fed by a nursing staff member and to follow the swallow aspiration precautions. If a resident with a gastric feeding tube lays flat in bed, the resident could potentially aspirate. If a resident with 1:1 feed assists with meals, self-feed the resident could potentially aspirate. On 4/9/24 at 12:26 PM, V37 [Director of Nursing] stated, I been working here since 4/1/24. I been a registered nurse since 2007, and six years of director of nursing experience. If a resident that has a gastric feeding tube lays flat, they could potentially aspirate. The staff should never give or place a food tray to a resident that is 1:1 feed assist, due to aspiration swallow precautions, the resident could potentially aspirate. Record review: R1's care plan dated (2/27/24): -R1 needs the head of bed elevated 45 degrees during and thirty minutes after tube feeding. -Monitor R1 and report to physician if noted aspiration, shortness of breath, abnormal lung sounds, abnormal lab values, nausea or vomiting Certified Nurse Assistant Job Description: -To provide assigned residents with routine daily nursing care in accordance with established nursing care procedures, state, and federal guidelines. -Position residents maintaining good body alignment. -Prepare resident for meals, assist serving food trays or feed as necessary and record or report residents' intake or acceptance of food. -Follow established safety precautions in performance of all duties. -Review care plans daily to ensure provision of appropriate care. -Adhere to all facility and department policies and procedures. -Ability to read, write, and spell and to understand and follow both written and oral directions. Registered Nurse/Licensed Practical Nurse Job Description -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. -Recognize significant changes in the condition of residents and take necessary action -Document nursing care rendered, resident response, and all other pertinent and necessary data as outlined in facility's policies and procedures. -Function as a charge nurse by problem solving and making decisions relevant to resident care. -Participate in the development and implementation of an individualized patient care plans for the resident with allied health team members Facility Assessment Tool dated (1/24) documents in part: Licensed Staff: Identification of resident changes in condition - identify medical issues appropriately, how to determine if symptoms represent problems in need of intervention, how to identify when medical interventions are causing rather than helping relieve suffering and improve quality of life.

1. Based on observation, interview, and record review, the facility failed to supervise ten residents (R2, R9, R10, R11, R12, R13, R14, R15, R16, R17) in the sample. This failure also affected R2 who had an unwitnessed fall which resulted in R2 sustaining a fractured nose. This failure has the potential to affect all residents on the first and second floor of the facility. The facility failed to ensure that the emergency cart on the 3rd floor was safely locked when not in use and failed to ensure that a full oxygen tank for the emergency cart was stored securely in the oxygen rack. These failures have the potential to affect all the resident on the 3rd floor. Findings include: R2's admission records documented admitted as 10/30/23 with diagnosis that includes but not limited to End Stage Renal Disease, Fracture of nasal bone, Fluid overload, Anxiety Disorder, Unspecified Dementia, Dependence on Renal Dialysis and Other specified Diabetes Mellitus. R2's MDS (Minimum Data Set) dated 11/09/23 scored R2's BIMS as 07 indicating that R2 is cognitively impaired. R2's plan of care initiated 05/03/23 showed R2 has a wanderer behavior with goal R2's safety will be maintained. According to facility investigation report incident date 10/28/2023 and time of incident 8:44pm. R2 was observed lying on the floor in the dining area none of the staff knows what happened to R2 on 10/28/23. Upon assessment R2 was noted with a skin alteration on the nose and complained of pain to right shoulder. R2's medical record progress note dated 10/28/2023 22:02 (10:02pm) V8 LPN (licensed Practical Nurse) identified as the nurse assigned to R2 documented in part Writer (V8) sitting at nursing station charting and heard resident in dining room yelling help. Writer went into dining room and noted resident laying on the floor with bloody nose stating someone pushed him out his w/c (wheelchair), no staff present in the dining room when writer arrived at the dining room. Resident stated someone pushed him out his w/c. Writer assessed resident for injuries, no visible injuries noted, small laceration on the bridge of nose, area cleansed with NS, V/S obtained, myself and another nurse on the unit assisted resident into w/c. Pt c/o pain 7/10, Writer called third eye and spoke with (V28) and informed her of incident that occurred and that fall was unwitnessed, and neuro checks are in place also requested orders for pain medication, orders rec'd for Tylenol 650mg p q6 hours prn for pain, (family)made aware, Writer called Elite ambulance for p/u dispatch stated they have no availability, writer then called ATI ambulance eta 4 hours. Pt sitting at nursing station being monitored closely, pt shows no s/s of respiratory distress, bleeding subsided, no discharge or drainage noted from nose or ears, neuro checks in progress will cont. to monitor. 167/91-20-75-98%-97.8. R2's hospital record documents R2 was transferred to another hospital for trauma evaluation and management. R2's hospital records presented dated 10/28/23 timed 23:59 (11:59pm) and electronically signed by V29 (Medical Doctor) showed CT head without contrast, CT cervical Spine without contrast and Maxillofacial CT without contrast was done and the impression under Cervical documented in part that there may be a nondisplaced avulsion, fracture at the medial aspect of the left occipital condyles. Additionally, there may be nondisplaced avulsion fractures arising from the lateral masses of C1. These are age indeterminant. MRI may be helpful in determining acuity. Head impression showed there is no intracranial hemorrhage, midline shift, or calvaria fracture. Parenchymal volume loss and chronic microvascular ischemic changes of cerebral hemispheres are present. Mild chronic Crooner infarctions are seen within the right basal ganglia.Maxillofacial impression showed there is a mildly displaced right nasal bone fracture. On 12/04/23 at 1:25pm, V2 DON (Director of Nurse's) stated, V7 CNA (Certified Nurse's Aide) worked directly with R2 on the day of the incident and is no longer working at the facility. On 12/04/23 at 12:35pm, V13 LPN (Licensed Practical Nurse) and 2nd floor unit manager stated, R2 needs staff supervision constantly. V13 stated, Staff are supposed to monitor the areas where residents are gathered like the dining room, but whose to say R2 did not go back there after everyone had left. I'm just saying. On 12/04/23 at 12:56pm, V16 (Activity Director) identified as the 2nd floor activity director stated, all the staff are responsible for monitoring the resident but the schedule for monitoring is activities staff monitors from 7:30am to 1:00pm and after that nursing staff monitors from 1:00pm to 2:00pm and this is worked into the nursing staff schedule daily. On 12/04/23 at 1:01pm, surveyor observed nine residents sitting in the first-floor dining room area without any staff monitoring or supervision. Surveyor observed R13 crying and appeared confused. Surveyor asked V11 (Unit Manager) and V20 (Case Manager) to come to dining room to identify the residents in the dining room. V11 and V20 identified the resident as: R9, R10, R11, R12, R13, R14, R15, R16, and R17. V20 stated, There should be staff with the residents supervising/monitoring. V11 further stated there was a call off from a nurse today so she (V11) had to work the cart (referring to passing medication). V11 identified V9 as the CNA (Certified Nurse's Aide) who should have been supervising and monitoring the residents according to the daily dining room monitoring assignment sheet. On 12/04/23 at 1:06pm V17 (Activity Director) for the first floor stated, there should be staff monitoring the dining room when the residents are present. V17 stated, the CNA's (Certified Nurse aides) monitors every thirty minutes whether there is an activity or not. V17 stated, the residents are to be supervised and not to be left alone. V17 stated, the daily schedule is for activity to monitor from 10am to 11am and from 2:00pm to 3:30pm. On 12/04/23 at 1:08pm, V9 (CNA) stated, she was busy assisting another resident. V9 stated, it has being chaotic changing the residents and assisting in changing bandages. V9 stated, the previous staff supervising should not have left the residents without her (V9). On 12/04/23 at 1:25pm, V2 DON (Director of Nurse's) stated, V7 CNA (Certified Nurse's Aide) worked directly with R2 on the day of the incident and no longer is working at the facility. V2 stated, rounds are to be made frequently at least every hour. On 12/18/23 at 3:09pm, V26 NP (Nurse Practitioner) stated, she is aware of R2's fall. V26 stated, R3 was found on the floor and was sent to the hospital and after R2 came back she saw (referring to assessment of R2) R2. V26 stated, she cannot say R2's nasal fracture was due to the fall of 10/26/23 because R2 is very impulsive, and it can be due to another incident. V26 stated, the hospital record she reviewed showed that R2 had a nose fracture. As of 12/18/23 at 3:45pm, the facility was unable to provide the policy for hazard and supervision after several request. During the course of the survey, V7 was unable to be contacted. 2. On 12/04/23 at10:04am, on the 3rd floor in the hallway surveyor observed emergency red and white cart unlocked and unattended and a green oxygen tank unsecured and being stored on the bare floor. V12 LPN (Licensed Practical Nurse) identified as the unit manager stated, they (referring to oxygen tank) should be hooked up to the emergency cart and the cart should be locked with the breakaway plastic tag lock. V12 stated the cart lock is broken and cannot be locked with the breakaway tag lock. V12 stated storing the oxygen tank on the floor unsecured is a fire hazard. V12 opened the cart with the surveyor and stated, there were needles (referring to IV needles), scissors, lancets, IV solutions that were stored in the cart. V12 tried to fix the black belt attached to the cart for holding the cart and the belt was broken. On 10/04/23 at 10:40am, V2 DON (Director of Nurse's) stated, the crash cart on each floor should be locked after use with the oxygen tank attached. On 12/05/23 at 2:01pm, V2 stated, the emergency cart should be locked with the plastic tag (referring to the breakaway tag lock) and oxygen tank attached to the emergency cart. Facility policy on Crash Cart and AED dated 1/2023 presented documented in part that in general the policy is to provide the staff with guidance on the crash cart contents and monitoring. Responsible party listed includes the DON (Director of Nurse's, RN (Registered Nurses), LPN (Licensed Practical Nurses), and maintenance. Listed items in the crash cart includes but not limited to sharp IV (Intravenous) needles, suture removal kit, lancet, and scissors. Facility protocol includes but not limited to making sure that the drawer to the crash cart is always locked to ensure contents remain intact. Securing that the cart is locked using breakaway tag lock.

Based on interview and record review the facility failed to safely transfer a resident to prevent a fall for one of three residents (R1) reviewed for falls. Staff failed to utilize a gait belt during transfer from toilet to wheelchair. This failure resulted in R1 sustaining a subarachnoid hemorrhage (bleeding in the space that surrounds the brain) and a left zygomaticomaxillary complex fracture (fracture involving the cheekbone and the surrounding bones). Findings include: R1's medical record (Face Sheet) documents R6 is a [AGE] year-old admitted to the facility on 8.2.2023 with diagnoses including but not limited to: Metabolic Encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), Difficulty in Walking, Acute Kidney Failure, Repeated Falls, Weakness and Chronic Kidney Disease. R1's MDS (Minimum Data Set, dated dated dated 8.9.2023) documents the following: -BIMS (Brief Interview for Mental Status):3 of 15 (severely cognitively impaired) -Functional Status: Toilet use: 3/2 (Extensive assistance/ One-person physical assist), Moving on and off toilet-2 (not steady, only able stabilize with staff assistance Facility's Final Incident Report (8.29.2023) documents in part: On 8.22.2023 at 6:40 AM the nurse entered the room on the request of staff and observed the patient lying supine on the floor next to the toilet. When questioned, the patient was unable to explain how the fall occurred. The patient was noted with a skin tear to her left eyebrow. 911 was contacted and the MD and family were made aware of the fall and subsequent transfer to the hospital. While in the hospital the patient was diagnosed with a subarachnoid hemorrhage and a left zygomaticomaxillary complex fracture. Interview with the assigned nursing assistant revealed that while helping the resident to the bathroom the resident fell while completing the toileting task. During the IDT (Interdisciplinary Team) meeting it was determined that the fall was caused by the patient's ongoing delirium and impulsiveness. Hospital Progress Note (electronically signed on 8.23.2023 at 7:25 AM) documents in part: This is a [AGE] year-old female with past medical history of CKD, dementia, hypertension, hyperlipidemia who presents for fall. Clinical impression: 1. Fall, 2. Subarachnoid hemorrhage, 3. Closed fracture of left zygomaticomaxillary complex. CT Brain Final Result (8.22.2023 at 9:09 AM) documents in part: Indication: Head trauma. fell at nursing home. Impression: 1. Tiny subarachnoid hemorrhage noted in the right sylvian fissure, likely posttraumatic in nature. 2. Left zygomaticomaxillary complex fracture. On 10.24.2023 at 1:35 PM, V2 (LPN/Nurse Case Manager/Fall Nurse) said, V4 (CNA-Certified Nursing Assistant) was interviewed but never said how R1 fell during transfer. V2 said a resident should never fall during a transfer. On 10.26.2023 at 10:07 AM, V2 (LPN/Nurse Case Manager/Fall Nurse) said, V4 said while transferring the patient, the resident fell . The IDT completed the investigation (V1, V2-Director of Nursing, and V6-Administrator). We determined that there was some error in the transfer that resulted in the resident falling. On 10.26.2023 at 2:51 PM via telephone, V1 (DON-Director of Nursing) said, we (IDT) discussed R1's fall. To our knowledge and after speaking with the CAN (V4), the resident lost her footing when the CNA was getting the resident off the toilet. They (CNAs) should use gait belts when completing transfers. We did ask her (V4) if she used a gait belt (during the transfer) and she said no. V4 (CNA-Certified Nursing Assistant) was not available for interview.

Based on observation, interview and record review, the facility failed to ensure ADL (Activities of Daily Living) care was provided for dependent residents who required assistance with bladder and bowel incontinence for one of two residents (R6) reviewed for ADL care. Findings include: R6's medical record (Face Sheet) documents R6 is an [AGE] year-old admitted to the facility on 11.16.2022 with diagnoses including but not limited to: Anemia, Hyperlipidemia, Essential (Primary) Hypertension, Chronic Kidney Disease, Muscle Weakness, and Difficulty in Walking. R6's MDS (Minimum Data Set, dated dated dated 8.23.2023) documents the following: -BIMS (Brief Interview for Mental Status):14 of 15 (cognitively intact) -Functional Status: Bed Mobility: 3/2 (Extensive assistance/One-person physical assist) and Toilet use: 3/3 (Extensive assistance/Two persons physical assist) -Bladder and Bowel: 3/3 (Always incontinent of urine/Always incontinent of stool) On 10.26.2023 at 1:20 PM, R6 was observed awake and alert, sitting up in bed. A fecal odor was noted. R6 said she is wet and needs to be changed, was last changed on the 11-7 shift. R6 said she put the call light on several times to let staff know that she is wet but still hasn't been changed. On 10.26.2023 at 1:36 PM V11 (CNA-Certified Nursing Assistant) came to R6's room to change resident. V11 said that she last changed R6 at 6:00 AM. The front of R6's brief was saturated with urine; large amount of brown feces was noted to the back of brief. On 10.26.2023 at 1:50 PM, V12 (ADON-Assistant Director of Nursing) said, it actually should be every two hours and as needed (that residents are checked/changed for incontinence). We try to identify our heavy wetters. We don't have a set time frame to check on heavy wetters, but they should be checked on more frequently then every two hours. The 3rd Floor is our heaviest floor, but we could always have more staff. On 10.26.2023 at 2:51 PM via telephone, V1 (DON-Director of Nursing) said, Staff should be checking at least every two hours (for incontinence) or more frequently if needed. Heavy wetters should be checked on more frequently.

Based on interview and record review the facility failed to follow their fall policy by not using preventive strategies for one resident (R1) out of three residents reviewed for falls. This failure resulted in R1 falling from his bed, hitting his head on the floor subsequently sustaining a laceration above his right eyebrow requiring 9 sutures. R1's fall strategies that were written on R1s' care card and documented on R1's minimum data sheet,were not applied. Findings Include: Facility's fall policy denotes 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 environment as possible R1's care card dated 10/13/21 denotes R1 as a fall risk. Safety interventions include the use of a bed side mat. While dressing, grooming, transfers, R1 is a 2 person assist. R1's Current Activities of Daily Living (ADL) assistance dated 10/20/21 Section G. denotes: Total dependence, Two+ person physical assist. Bed mobility- how resident moves to and from lying position and turns side to side: Extensive assistance, Two + person physical assist. R1's Health Status/Progress Note Text dated 10/21/2021 01:00 reads : Was made aware by coworker that resident had fallen, upon entering room observed resident in room on floor by bed in sitting position with cna at his side and noted blood on floor and on resident. Resident alert verbally responsive with confusion. CNA stated he slid off bed to floor during care being provided, Resident assisted to bed. Upon full body assessment noted right eye with open area, site cleansed with normal saline and pressure dressing applied, PROM performed, Denies any pain/discomfort. VS T98.2, P79, R20, BP 164/84, spo2 97% on room air. Doctor notified made aware of incident, orders received to send resident out for eval r/t eye injury. 911 called and awaiting arrival. Wife made aware of incident and that he was sent out for eval. R1's ambulance run sheet dated 10/21/21 denotes staff indicated they were providing care when R1 rolled out of bed onto linoleum floor. 1 ½ inch laceration over right eyebrow. R1 denies any pain. No other obvious signs of trauma. R1's hospital record dated 10/21/21 denotes [AGE] year-old male with previous stroke presented to emergency room after fall from bed. Normal range of motion. Head: right periorbital [CONDITION(S)], 4-centimeter laceration over the right eyebrow -Skin Closure: Patient tolerated the procedure well with no complications; 9 sutures During interview on 12/7/21 at 12:15pm, V2 (Restorative Nurse)stated based of the activities of daily living (ADL) assessment, a care card is written up for that specific resident which the aides should read so they know the type of ADL care that specific resident needs. V2 also stated from the ADL assessment, a care card is written and placed inside the closet of each resident in their room to be used by any staff member providing care to that particular resident. V2 stated R1 had a care card in his closet in his room with pertinent information for staff to use. V2 stated V4 Certified Nurse Aide (CNA) was trained and should have known where R1's care card was and used the information on his care card to provide him care. On 12/7/21 at 1:05 pm, V3 (Fall Coordinator) stated he has been the fall coordinator for three years. V3 stated part of his duties are to update care plans after falls and speaks with Interdisciplinary team (IDT) to find the root/cause of a fall. V3 stated with any fall HE has to speak to the nurses and aides involved. V3 stated after R1s' he fall spoke to the aide (V4) assigned to R1 on 10/21/21. V3 stated he was told by V4 that she was changing R1's diaper and had R1 centered in the middle of the bed when R1 suddenly slid off the bed onto the floor. V3 stated V4 informed him that after R1 fell out of the bed she ran to get the nurse. V3 stated V4 told him that she was cleaning R1 by herself. V3 stated care cards are in all the resident's rooms inside the resident's closet for staff to use and to refer to so they know what care to provide to that particular resident. On 12/7/21 at 2:20pmV4 (CNA) stated she has worked at the facility for three months on the night shift. V4 stated came in to work that night (10/21/21) around 10pm making rounds and providing patient care to those residents that needed it. V4 stated R1 was one of the last residents on her side that she had got to and noticed that he was wet. V4 stated she removed the sheets and told R1 that she was going to provide care to him and R1 verbalized that he understood. V4 stated removed R1's gown, wiped his stomach, turned him on his side left side and had him in the center of the bed. V4 stated she was holding R1 with one arm, R1 was holding onto the mattress. V4 stated suddenly while wiping R1's back R1 started sliding off the bed and she could not grab him in time before he fell out of the bed onto the floor. V4 stated that when R1 fell on to the floor their were no floor mats on the floor by his bed. V4 stated was not aware that R1 was supposed to have floor mats next to his bed. V4 stated she got R1's nurse and she assessed him and saw R1 had a cut on the side of his head by his eyebrow. V4 stated they cleaned R1 and got him ready for the ambulance to take R1 to the hospital. V4 stated she was told about a care card being in the closet of the resident's room but was not aware of a care card for R1 being his room. V4 stated was not told in any shift change report that R1 required two people to turn him in the bed or wash him in the bed. V4 stated if had been aware that R1 required two people to turn or get washed up would have gotten another staff member to help her. V4 stated she told R1 that she was sorry and R1 responded that it was not her fault. On 12/7/21 at 3:20pm V5 Licensed Practical Nurse (LPN) stated she was R1's nurse since he has been admitted to the facility. V5 stated she worked the night shift and did not ever see R1 getting up. V5 stated she came to work on the night of 10/21/21 and was helping another patient out. V5 stated V4 (CNA) called to her and reported that R1 fell out of the bed while she was cleaning him up. V5 stated she assessed R1 and noted he had laceration above his eye. V5 stated she then called R1's doctor and got order to send R1 to the hospital. V5 stated there are green care cards is the residents room put in by the restorative team to tell staff what a resident need are, like one or two people to provide ADL or help with transfers. On 12/9/21 at 9:30amV9 (Doctor) stated R1 did sustain laceration from the fall. V9 stated the laceration that R1 sustained over his right eyebrow could be attributed from the fall that he had from the bed on 10/21/21.

Based on observation, interview and record review, the facility failed to provide supervision and failed to implement fall prevention interventions for three of three residents (R2, R3, R4) reviewed for falls/injury. These failures resulted in R3's (10/3/21) right femur fracture, R2's (9/21/21) left 9th rib fracture and R4's (10/20/21) right thumb dislocation. Findings include: 1. R3's diagnoses include dementia. R3's Brief Interview for Mental Status (BIMS) score of 5 indicates R3 is cognitively impaired. R3's 8/10/21 functional assessment affirms R3 requires extensive assistance (1 person physical assist) with transfers. R3's 10/3/21 incident report states patient complained of pain to right knee. Patient stating that [R3] knee was bumped during transfer. Interviews were conducted, staff denying any incidents/bumping of leg. R3's 10/3/21 x-rays include: Right Knee impression: impacted, acute distal femoral shaft fracture. Right Femur impression: There is a complete acute oblique fracture through the distal medial femoral condyle cleaning it from the lateral femoral condyle and femoral shaft. There is approximately 5 mm (millimeters) of proximal displacement of the fracture fragment. There is soft tissue swelling of the right knee. R3's fall care plan includes the following interventions; (4/27/20) Frequent monitoring due to covid 19 restrictions. (6/19/20) encourage patient to ask for assistance with transfers. Which were implemented prior to 10/03/2021 fall. R3's care plan also states: (10/8/21) Resident requires use of a gerichair due to poor balance, poor sitting posture and poor trunk control. (10/26/21) Potential for injury due to history of falls. Interventions: check on resident frequently and place resident in visible view of staff when up in chair as resident will allow. Call light within resident's reach when in room. On 10/26/21 at 2:37pm, V5 (Certified Nursing Assistant) was observed exiting R3's room. R3 was left in the room. unsupervised, sitting in an upright gerichair and leaning forward. R3's call light was observed on the bed out of sight/reach. Surveyor inquired where R3's call light was located R3 responded I don't know anything about that and affirmed (R3) was unable to locate it. On 10/26/21 at approximately 2:39pm, surveyor inquired where R3's call light should be located V5 responded It should be next to [R3] or on [R3]. Surveyor inquired about R3's fall prevention interventions V5 stated [R3's] sitting up, we normally don't have the chair sitting up. I know [R3's] chair should be sitting back. V5 exited R3's room again without reclining the chair. On 10/27/21 at 2:55pm, surveyor inquired about R3's 10/3/21 injury. V8 (Nurse Case Manager) stated [R3] accused a specific CNA, [R3] said it was a male CNA. As [R3] put it, he was from [NAME] and said he had wild hair. We were able to narrow it down to [V9] who had [R3] the previous day (3-11 shift). Surveyor inquired about the root cause analysis of R3's injury and V8 stated The outcome was that something did happen because [R3] has a fracture but we don't know what happened. [R3's] memory is very poor and [R3] has dementia. Something obviously happened because there was a fracture he (V9) is denying that he bumped her leg during the transfer and [R3] is saying that he (V9) did. I don't know who to believe because of [R3's] history but it is possible that he (V9) did not know that her leg was bumped. 2. R2's diagnoses includes altered mental status. The 9/4/21 functional assessment affirms R2 requires extensive assistance (1 person physical assist) with transfers. R2's 9/21/21 incident report states patient was observed lying supine on the floor near the foot of (R2's) bed. Patient unable to state how fall occurred due to altered mental status. Interviews were conducted with staff but the incident was not witnessed. R2's 9/21/21 Chest CT (Computed Tomography) includes a non-displaced indeterminate age fracture of the left lateral 9th rib. R2's 9/2/21 care plan includes the following fall prevention interventions: call light within resident's reach when in the room. Apply floor mats when resident is in the bed. On 10/26/21 at 2:25pm, R2 was lying in bed. The call light button was observed beneath R2's left knee out of sight/reach. Surveyor inquired where the call light was located R2 responded I'm not sure. Surveyor inquired about the scab observed on R2's left elbow R2 stated I fell about two or three times in here. I was on a whatchamacallit, the wheelchair yeah. I was on it and when I got out it seemed like it wanted to walk away from me . On 10/26/21 at 2:29pm, V4, CNA (Certified Nursing Assistant) entered the room surveyor inquired about the location of R2's call light V4 stated [R2] is lying on it right now surveyor inquired where R2's call light should be located V4 responded Clipped to [R2's] shirt. Surveyor inquired about R2's fall prevention interventions V4 stated We have [R2's] floor mat put down, that's pretty much it. Surveyor inquired where R2's floor mat was currently located R2 responded Right now it's behind [R2's] bed and removed it from behind R2's headboard. Surveyor inquired if R2 requires staff assistance for transfers V4 stated I believe [R2] is a one person. Surveyor inquired if R2 received staff assistance getting into the bed R2 stated Not today. R2's wheelchair was adjacent to the bed and within reach. 3. R4's diagnoses include dementia. R4's 9/27/21 functional assessment affirms R4 requires 1 person physical assist with transfers. R4's 6/22/21 care plan includes the following fall prevention intervention: encourage and assist as needed to wear non-slip footwear. R4's 10/20/21 incident report states patient observed lying supine on the bathroom floor. Noted right thumb out of alignment with pain during palpation. Patient was noted wearing worn out slides with slipper socks. On 10/26/21 at 2:45pm, surveyor inquired about the 10/20/21 fall and R4 stated I twisted my thumb. I got up from the bed to use the bathroom. I usually hold the wall right up here (pointing to the bathroom door frame) I couldn't reach the bar (adjacent the toilet). I fell and hit my hand on the toilet. Surveyor inquired if staff was present when [R4] fell . R4 responded No. R4's 10/20/21 right fingers x-ray includes reason for exam: right thumb subluxation. Impression: dislocation of the interphalangeal joint of the thumb has been reduced. On 10/26/21 at 2:59pm, surveyor inquired about the root cause of R4's 10/20/21 fall V6 (Licensed Practical Nurse) stated It was the shoes [R4] had on, so we (facility) changed [R4's] shoes. On 11/1/21 at 12:30pm, surveyor inquired about appropriate fall prevention interventions for residents at risk for falls and V11 (Physician) responded With a high fall risk there's gonna be a call light within reach that's generally the case. Surveyor inquired about potential harm to a resident (at risk for falls) if fall prevention interventions are not implemented and the resident is unsupervised V11 stated With any fall the potential harm is fractures. If there's any head trauma they could have intracranial bleed. The facility falls management policy (reviewed 6/21) states residents at risk for falls will have fall risk identified on the interim plan of care with interventions implemented to minimize fall risk.

Based on interviews, and record review, the facility failed to follow their Abuse Policy for R1, one of three residents reviewed for abuse. This failure resulted in R1 being physically assulted by V10 (Certified Nursing Assistant- CNA). During a phone interview on 06/24/2020 at 2:30 pm, R1 stated V10 (Certified Nursing Assistant - CNA) sent V4 a new (CNA) to my room with a tray of food that I don't eat. V4 was not aware that I don't eat pork, V10 was aware of it. I told V10 you know I don't eat pork. I told her just leave my room; V10 started going back and forth with me. I told V10 just go that's all right. I told my nurse (V9) about the incident and he told V10 to leave the room. This was a day or two before V10 came back into my room and said Bi*ch, I am about to bust you upside your Mother Fu**ing head. On the day of the incident V10 was called into the office, my daughter called Management and complained about me being served pork. I reported the incident with V10 to the charge nurse (V5). I was in my room, R4 my roommate was getting cleaned up by V4 the curtains were drawn. I was on the phone talking to my spouse when V10 entered the room yelling you and your daughter caused me to get fired and took food out of her and her family's mouth. She is walking toward me, and I am in a wheel chair. She said Bi*ch I am about to bust you upside your Mother Fu**ing head. She came toward me with her right hand. She had something in her left hand. I jumped out of the wheelchair leaping onto my bad leg to pick up a chair to defend myself. I turned the chair toward V10 to keep her up off of me. When I turned toward her with the chair my other leg gave out and I fell back into my wheelchair. V4 came over and put herself between me and V10. V4 told V10 to stop it. V10 took both hands and forcefully knocked my TV to the floor, the TV almost hit my feet that were hanging out when I fell back into my wheelchair. V10 ran out of the room, V4 went and reported the incident to the nurse. My feet were hanging out because I was hanging off the wheelchair when I fell back; I snatched my feet back as fast as I could to keep the TV from falling on my feet because I only wear footies no shoes. The staff heard loud noises and came to my room, V7 (maintenance) came into the room and asked if I was alright. V4 came back and helped me get situated in my wheelchair. V4 picked up my TV and put it back on the dresser. (V3) Unit manager went down the back stairs and said she could see V10 running down the street. I found out V10 was fired a few minutes before she came into my room and was not supposed to come back up the stairs. My room was changed to the room near the nursing station. I was in severe pain after that incident of applying all my weight to one leg which gave out me during the incident. I had to be medicated for pain. During a phone interview on 6/26/2020 at 11:20 am with V9 (nurse), I asked V9 what happened between R1 and V10 (Certified Nursing Assistant). V9 said V10 came and told me that R1 didn't want the dinner served that was pork. I went down to talk to R1 and R1 said V10 served me pork and know I don't eat pork. R1 told me she didn't like V10's attitude because V10 refused to get her some other food to eat. I asked V9 if there was documentation about the incident between R1 and V10. (V9) said I told the oncoming nurse that I reassigned V10 because of the altercation with R1 earlier and that V10 is not allowed to work with R1. I asked V9 for the name of the oncoming nurse; V9 said I can't remember who it was that was so long ago. I did not think much of it since I reassigned V10. During a phone interview on 6/25/2020 at 3:23 pm with V4 (CNA) , I asked V4 what happened on that day. V4 said I was in the room giving care to R4. The curtains was pulled, V10 came in the room uninvited and saying loudly B**ch you playing with my money. I heard a lot of noise and I felt the situation was escalating. V10 was coming toward R1 in a threatening way, I stepped in between V10 and R1 who had a chair holding it between herself and V10. I told to V10 to stop this and leave the room. V10 took both of her hands and knocked R1's TV to the floor and ran out the room down the stairs. I told the nurse (V5) what happened. I helped R1 get repositioned up in her wheelchair and made sure she was O.K. I kept checking on my resident R4 who was very upset because of the incident. During a phone interview on 6/25/2020 at 2:56 pm with V3 (Unit Manager) V3 said I called V10 into the 3rd floor medication room at the beginning of her 2:00 pm shift. I explained to her due to tardiness, calling off and not doing her charting that she was being terminated. V10 said that's fine and asked to get her belonging. V10 left out of the med room to get her belonging while I completed the exit paperwork to give her a copy. I asked V3 if the facility allows staff that has been terminated to roam through the building without an escort. V3 said we don't escort them out of the building. Once I came out of the med room V5 (nurse) told me V10 had knocked R1's TV to the floor. V5 and V4 said V10 had ran down the back stairs. I came down on the elevator and looked outside and could see V10 walking down the street. I came back in, called the police and gave them a description of what V10 was wearing and the direction V10 was walking in. The police came and a report was made. I spoke with R1, the social worker (V11) was in the room to make sure she felt safe. I moved R1 to a room by the nursing station. During a phone interview on 6/25/2020 at 2:15 pm, I asked V11 (Social Service) about the incident with R1 on 3/26/2020. (V11) said on 3/26/2020 at 2:58 pm, R1 was approached by V10 (CNA) a disgruntled employee (former) upon their exit from the facility. R1 expressed that (V10) came into her room (uninvited) and aggressively demanded Why you playing with my money?? (in regards to R1 reporting her behavior the previous day). R1 went on to say that she picked up a chair to create space between her and (V10) due to her feeling threatened; upon which V10 slammed R1's TV on the ground and stormed out. This incident was reported to the administrator, nursing manager and the local police have been contacted as well. I also documented this information in my notes. Review of R1's record dated 3/26/2020 at 2:58 pm by V11 was documented. During a face-face interview on 6/24/2020 at 10:50 am with V1 (Administrator), V1 said there was a nursing assistant V4 who was providing care to R4, the roommate of R1 . (V4) was able to intervene and stepped in between R1 and V10. V4 told V10 she needs to stop confronting/badgering R1 and leave the room. I asked V1 is it the practice of the facility to let staff that's been terminated walk around the facility without being escorted. V1 said we don't escort our employees who resign or have been terminated if they ask to gather their personal belongings. We had no reason to think something like this would happen. Facility's Abuse Policy: Abuse Prevention dated 09/2018 -Training of new employees: - How to assess, prevent and manage aggressive, violent and or catastrophic reactions of residents in a way that protects both the residents and staff - How to recognize and deal with burnout, frustration and stress that may lead to inappropriate responses or abusive reactions to residents. Establishing a Resident Sensitive Environment: This facility desires to prevent abuse, neglect, mistreatment and misappropriation of resident property by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive quality management approach involving concern identification and Follow-up. Resident and family concern will be recorded, reviewed, addressed and responded to using the facility's concern identification procedures. Based on interview and record review the allegation is substantiated

Based on interview and record review, the facility failed to provide safety interventions for one resident (R1) with mobility limitations. This failure resulted in R1 sliding off the bed onto to the floor and sustaining a fracture of the clavicle. This failure applies to one resident (R1) out of four reviewed for falls. Findings Include: R1 was admitted to the facility on [DATE] per the admission face sheet. The physician orders [REDACTED]. The nursing note dated December 29, 2016 showed that at 7:50pm E4 RN (Registered Nurse) was called to R1's room by E3 CNA (Certified Nursing Assistant). E4's note showed that R1 was found on the floor on the left side of the bed lying on her right side. R1's nursing notes showed that at 9:15pm the ambulance picked R1 up and transported to the community hospital emergency room for evaluation and treatment. A nursing note dated December 30, 2016 showed that R1 was returned to the facility at 4:15am with her right arm in a sling and a hematoma to the right side of her head. An incident note written at 12:14pm in the progress notes for R1 showed that R1 complained of pain to the right fractured clavicle when she tried to move it. A note written at 12:17pm showed that R1 had an appointment to see a physician regarding the right clavicle fracture. The appointment is scheduled for January 10, 2017. The MDS (Minimum Data Set) dated December 12, 2016 in R1's clinical record showed that R1 needed the assistance of two for bed mobility. The MDS showed that R1 was unable to hold herself in a sitting position. The current care plan for falls or assistance with daily living in R1's clinical record did not show interventions for bed positioning or assistance with bed mobility. R1's admission fall risk assessment dated [DATE] showed R1 to be at high risk of falls. A full occurrence report dated December 29, 2016 showed that R1 was found on the floor by E4 after being notified by E3 that R1 fell to the floor. The report showed that the facility determined that the fall occurred due to R1 lying close to the edge of the bed. The recommendations from this report showed that staff was educated on ensuring residents are properly positioned after ADL (activity of daily living) care. The report showed R1 had impaired mobility. On January 5, 2017 at 1:50pm R1 said that she fell off the bed over a week ago. R1 stated, The aide went to get something and I tried to straighten out and I just went off the bed onto the floor. R1 said that she is unable to lift and use her right arm and was unable to stop the fall. On January 5, 2017 at 3:14pm in the conference room E3 CNA said that R1 was not able to hold herself up. E3 said that R1's bed did not have side rails or go down to the floor. E3 stated, I turned R1 to her left side to give incontinent care. R1 had soiled a dressing. I put E3 flat and I had to leave the room to get the nurse for a new dressing. I heard a thump. I went back to the room and noticed R1 was on the floor. I was pretty sure she was in the middle of the bed but I don't know. On January 6, 2017 at 10:04am E2 Director of Nursing said that R1 could have bed baths or showers but was not aware of how much assistance were required for R1 assist. After review of the MDS E2 stated, A score of three under bed mobility does indicate the need for two staff to assist R1. E2 said that all staff is to use proper positioning and have all items in the resident's room while providing care.

Based on interview and record review the facility failed to assess and treat complaints of pain for 1 of 3 residents (R24) reviewed for pain in the sample of 28. This failure resulted in the discovery of a left ankle fracture 9 days after the initial complaint of pain was reported to the facility. Findings include: Closed record documents R24 was admitted to the facility on [DATE] and then admitted to hospice on 1/24/13 with [DIAGNOSES REDACTED]. R24 was bedbound and dependent on staff for all care. Hospice Communication Log 3/21/13 documents "patient having pain on her left leg, told nurses." Hospice Aide Visit Note 3/21/13 documents "Patient having pain on her left leg." On 6/5/13 at 12:20pm Z12 (Hospice Aide) stated that on 3/21/13 she told the facility nurse aide and the day nurse that R24 complained of pain in her left leg. Facility Investigation Form (undated) documents Z12 informed another aide and nurse that resident was complaining of pain to left leg. On 6/5/13 at 10:55am E52 (Nurse Aide) stated that abnormal findings are reported to her by the hospice aide. "I know to report them right away. I don't remember which nurse I told" about (R24)'s left ankle pain on 3/21/13. On 6/5/13 at 11:45am E15 (Nurse) stated that Z13 (hospice nurse) told her R24 had right leg pain on 3/25/13, not left. "I did not do a pain assessment or compare the right leg to the left leg." E15 stated she did not medicate R24 for pain on either 3/21/13, 3/25/13 or 3/26/13. E15 stated that on 3/26/13, Z13 changed her assessment to left leg pain. Hospice Communication Log 3/25/13, Z13 documents "during movement of left (crossed out) right lower extremity, patient displays 5 out of 10 pain."Hospice Communication Note 3/26/13, Z13 documents pain, swelling decreased to left lower extremity." Hospice Note 3/25/13 documents right lower extremity pain and swelling, discussed with (E15)." Hospice Note 3/26/13 documents pain and swelling to left lower extremity, E15 notified and educated on new order, pain management, and comfort care including keep left lower extremity elevated. This note also documents that the pain medicine [MEDICATION NAME] just arrived to the facility during that visit. Hospice Clinical Chart Addendum 3/26/13 5:10pm documents corrected information to Z13's charting for 3/25/13 and 3/26/13 for R24's left lower extremity, not right lower extremity. Facility Investigation Form 4/2/13 documents "documentation and miscommunication between hospice nurse and facility staff" regarding the care of R24. R24's March 2013 Medication Record documents a current order from 1/25/13 for the pain medicine [MEDICATION NAME] 5 milligrams (mg) as needed for pain. R24 did not receive any pain medicine from 3/21/13 through 3/30/13 with any of the complaints of left leg pain. Controlled Substance Administration Log documents [MEDICATION NAME] was given to R24 on 4/9/13. On 6/5/13 at 4:30pm E31(Unit manager) stated that there were no narcotic logs in March 2013 for R24. "That means (R24) didn't receive any narcotics in March 2013." Hospice Communication Log 3/25/13 by Z13 (Hospice Nurse) documents "during movement of left lower (crossed out), right lower extremity. Patient displays 5 out of 10 pain. Hospice Communication Log 3/26/13 documents "visit to follow up with patient pain and physician orders, 2 out of 10 pain, swelling decreased to left lower extremity." Physician Telephone Orders 3/25/13 documents "elevate right lower extremity" crossed out and "left lower extremity " is written next to it, and there is an order for [REDACTED]. The next telephone order is on 3/30/13 for x-ray of left lower extremity. X-ray report 3/31/13 documents left lateral ankle fracture and R24 was sent to the hospital. An investigation was started on 3/31/13 after the fracture was discovered. Facility Investigation Form 4/1/13 written and signed by Z13 documents the pain R24 experienced was in the left lower extremity, not the right. Facility Investigation Form (unsigned and undated) documents "On 3/25/13 hospice nurse (Z13) noted swelling to the left extremity, elevated left leg on a pillow. (R24) was grimacing and guarding left leg." Z13 cannot be interviewed because she is unreachable out of the country. On 6/5/13 at 11:10am Z3 (Hospice Clinical Director) stated that the facility called a meeting with Z12 and Z13 after the fracture was discovered. The meeting was to clarify the discrepancy of right versus left leg of R24. Z3 stated that hospice conducted their own investigation and the facility took statements from Z12 and Z13. Z3 stated "All of (Z12) and (Z13)'s statements are consistent with each other and with their documentation." On 6/4/13 at 3pm E1 (Administrator) stated that once R24's ankle fracture was discovered, an investigation was started. A meeting was called with hospice staff that cared for R24 and reported the pain. E1 stated that Z13 changed the charting from right leg to left leg. "It's legal to change your charting." On 6/5/13 at 12pm Z1(Physician) stated that R24 had pain and swelling to the left ankle. Even when a resident is on hospice, pain should be assessed by asking the resident or looking for other signs like guarding the area, moaning, or grimacing. The staff should also compare left to right sides to assess for redness, swelling, deformity, or temperature changes. Z1 stated "(R24)'s painful area should have been looked at and compared to the other side. That would have clarified right versus left. Pain should be assessed every shift. (R24) should have been given pain medicine if there was a complaint of pain. The facility has a policy to assess and treat new areas of pain." Z1 stated R24 should not have gone 9 days without a pain assessment or pain medicine. Nurse Notes from 3/21/13 through 3/30/13 do not consistently document a pain assessment of R24, in general or specific to the left or right lower extremities. R24's Pain Care Plan was initiated on 1/21/13 and updated on 3/31/13 upon discovery of the left ankle fracture. There are no interventions between 3/21/13 and 3/31/13 for the new complaint of left leg pain. Interventions dated 1/21/13 include monitor, report and record any complaints of pain: location, duration, quantity, quality, alleviating factors, aggravating factors; monitor, report and record any non-verbal signs of pain (crying, guarding, moaning, restlessness, grimacing, diaphoresis, withdrawal). The most recent Pain Assessment was completed on 10/18/12. March 2013 Medication Record does not show evidence of an order for [REDACTED]. "There was an order but it was discontinued on 12/2/12 and I don't know why." E31 stated the pain care plan should be updated with new interventions when a resident has new complaints of pain. Facility policy Management of Pain documents "promptly and accurately assessing pain; aggressively assessing pain in non-verbal and cognitively impaired residents; pain will be assessed and managed in a timely fashion, especially if it is of recent onset; thorough communication with the physician will ensure an appropriate pain management plan. Pain Screening - upon change of condition or when pain is suspected, the pain screening will be filled out. Physical Examination - the nurse will complete a physical evaluation of the resident that includes...objective observation of the painful area."

Based on interview and record review the facility failed to follow their pain policy, assess and treat complaints of pain for one of three sampled residents (R24) reviewed for pain in the sample of 28. In addition, the facility failed to implement a policy for identifying resident's personal items, to prevent the misappropriation of property for one supplemental resident (R69). As the result of the facility's failure, R24's investigation to identifiy the source of the pain was not completed in timely manner. R24's left ankle fracture was not identified until nine days after the first complaint of pain and swelling. Findings include: 1.) Facility policy Management of Pain documents "promptly and accurately assessing pain; aggressively assessing pain in non-verbal and cognitively impaired residents; pain will be assessed and managed in a timely fashion, especially if it is of recent onset; thorough communication with the physician will ensure an appropriate pain management plan. Pain Screening - upon change of condition or when pain is suspected, the pain screening will be filled out. Physical Examination - the nurse will complete a physical evaluation of the resident that includes...objective observation of the painful area." Closed record documents R24 was admitted to the facility on [DATE] and then admitted to hospice on 1/24/13 with [DIAGNOSES REDACTED]. R24 was bedbound and dependent on staff for all care. Hospice Communication Log 3/21/13 documents "patient having pain on her left leg, told nurses." Hospice Aide Visit Note 3/21/13 documents "Patient having pain on her left leg." On 6/5/13 at 12:20pm Z12 (Hospice Aide) stated that on 3/21/13 she told the facility nurse aide and the day nurse that R24 complained of pain in her left leg. Facility Investigation Form (undated) documents Z12 informed another aide and nurse that resident was complaining of pain to left leg. On 6/5/13 at 10:55am E52 (Nurse Aide) stated that abnormal findings are reported to her by the hospice aide. "I know to report them right away. I don't remember which nurse I told" about (R24)'s left ankle pain on 3/21/13. On 6/5/13 at 11:45am E15 (Nurse) stated that Z13 (hospice nurse) told her R24 had right leg pain on 3/25/13, not left. "I did not do a pain assessment or compare the right leg to the left leg." E15 stated she did not medicate R24 for pain on 3/21/13, 3/25/13 or 3/26/13. E15 stated that on 3/26/13, Z13 changed her assessment to left leg pain. Hospice Communication Log 3/25/13, Z13 documents "during movement of left (crossed out) right lower extremity, patient displays 5 out of 10 pain." Hospice Communication Note 3/26/13, Z13 documents pain, swelling decreased to left lower extremity." Hospice Note 3/25/13 documents right lower extremity pain and swelling, discussed with (E15)." Hospice Note 3/26/13 documents pain and swelling to left lower extremity, E15 notified and educated on new order, pain management, and comfort care including keep left lower extremity elevated. This note also documents that the pain medicine [MEDICATION NAME] just arrived to the facility during that visit. Hospice Clinical Chart Addendum 3/26/13 5:10pm documents corrected information to Z13's charting for 3/25/13 and 3/26/13 for R24's left lower extremity, not right lower extremity. Facility Investigation Form 4/2/13 documents "documentation and miscommunication between hospice nurse and facility staff" regarding the care of R24. R24's March 2013 Medication Record documents a current order from 1/25/13 for the pain medicine [MEDICATION NAME] 5 milligrams (mg) as needed for pain. R24 did not receive any pain medicine from 3/21/13 through 3/30/13 with any of the complaints of left leg pain. Controlled Substance Administration Log documents [MEDICATION NAME] was given to R24 on 4/9/13. On 6/5/13 at 4:30pm E31(Unit manager) stated that there were no narcotic logs in March 2013 for R24. "That means (R24) didn't receive any narcotics in March 2013." Hospice Communication Log 3/25/13 by Z13(Hospice Nurse) documents "during movement of left lower (crossed out), right lower extremity. Patient displays 5 out of 10 pain. Hospice Communication Log 3/26/13 documents "visit to follow up with patient pain and physician orders, 2 out of 10 pain, swelling decreased to left lower extremity." Physician Telephone Orders 3/25/13 documents "elevate right lower extremity" crossed out and "left lower extremity " is written next to it, and there is an order for [REDACTED]. The next telephone order is on 3/30/13 for x-ray of left lower extremity. X-ray report 3/31/13 documents left lateral ankle fracture and R24 was sent to the hospital. An investigation was started on 3/31/13 after the fracture was discovered. Facility Investigation Form 4/1/13 written and signed by Z13 documents the pain R24 experienced was in the left lower extremity, not the right. Facility Investigation Form (unsigned and undated) documents "On 3/25/13 hospice nurse (Z13) noted swelling to the left extremity, elevated left leg on a pillow. (R24) was grimacing and guarding left leg." Z13 cannot be interviewed because she is unreachable out of the country. On 6/5/13 at 11:10am Z3 (Hospice Clinical Director) stated that the facility called a meeting with Z12 and Z13 after the fracture was discovered. The meeting was to clarify the discrepancy of right versus left leg of R24. Z3 stated that hospice conducted their own investigation and the facility took statements from Z12 and Z13. Z3 stated "All of (Z12) and (Z13)'s statements are consistent with each other and with their documentation." On 6/4/13 at 3pm E1(Administrator) stated that once R24's ankle fracture was discovered, an investigation was started. A meeting was called with hospice staff that cared for R24 and reported the pain. E1 stated that Z13 changed the charting from right leg to left leg. "It's legal to change your charting." On 6/5/13 at 12pm Z1(Physician) stated that R24 had pain and swelling to the left ankle. Even when a resident is on hospice, pain should be assessed by asking the resident or looking for other signs like guarding the area, moaning, or grimacing. The staff should also compare left to right sides to assess for redness, swelling, deformity, or temperature changes. Z1 stated "(R24)'s painful leg should have been looked at before 3/30/13 when the fracture was discovered and compared to the other side. That would have clarified right versus left. Pain should be assessed every shift. (R24) should have been given pain medicine if there was a complaint of pain. The facility has a policy to assess and treat new areas of pain." Z1 stated R24 should not have gone 9 days without a pain assessment or pain medication. Nurse Notes from 3/21/13 through 3/30/13 do not consistently document a pain assessment of R24, in general or specific to the left or right lower extremities. R24's Pain Care Plan was initiated on 1/21/13 and updated on 3/31/13 upon discovery of the left ankle fracture. There are no interventions between 3/21/13 and 3/31/13 for the new complaint of left leg pain. Interventions dated 1/21/13 include monitor, report and record and complaints of pain: location, duration, quantity, quality, alleviating factors, aggravating factors; monitor, report and record any non-verbal signs of pain (crying, guarding, moaning, restlessness, grimacing, diaphoresis, withdrawal). The most recent Pain Assessment was completed on 10/18/12. March 2013 Medication Record does not show evidence of an order for [REDACTED]. "There was an order but it was discontinued on 12/2/12 and I don't know why. "E31 stated the pain care plan should be updated with new interventions when a resident has new complaints of pain. 2.) 6/11/2013 at 3pm, the surveyor interviewed Z14 (R69's Daughter) by telephone. Z14 said R69 was admitted to the facility on [DATE] at 3:30pm, she was not present however another relative of R69 was. That relative reported "The facility staff admired how my mother was dressed, especially her leather boots." When R69 was discharged from the facility, she did not have the leather boots. The facility's clothing list policy states: Upon entry into the facility, a clothing list is to be filled out and signed by both staff and resident (or the resident's family). R69's clothing list did not list a pair of leather boots and was not signed by either R69 or a family member. On 6/13/2013, this concern was brought to facility staff in a meeting, E1 (Administrator) stated that R69 and family refused to sign the clothing list, there was no documentation of refusal to sign.

Based on record review and interview, the facility failed to implement timely and appropriate fall interventions for 2 (R5, R7) of 5 residents reviewed for falls in a sample of 13. These failures resulted in R5 being hospitalized for [REDACTED]. Findings include: 1. R5 was admitted to the facility on [DATE]. R5's Physician's History and Physical form documents the following Diagnoses: [REDACTED]. R5's Minimum Data Set (MDS) documents: Cognition: Moderately impaired cognitive skills, inattention, disorganized thinking, altered level of consciousness, and psychomotor retardation. Transfers: Extensive assistance with self performance (resident involved in activity, staff provide weight-bearing support) and two person physical assist for support. Locomotion on and off unit: Total dependence for self-performance (full staff performance) and one person physical assistance. Balance during transitions and walking: Not steady, only able to stabilize with staff assistance when moving from seated to standing position, moving on and off toilet, and surface-to-surface transfer (transfer between bed and chair or wheelchair). Mobility device: Wheelchair. R5's physician (Z5) physician progress notes [REDACTED]. R5's medical record also documents that R5 had a subarachnoid hemorrhage, forehead laceration, orbital fractures, and subdural hematoma. The facility's Fall Event report and nursing progress notes for R5 documents the following falls: 10/16/12, 6:07pm: Noted to have attempted to stand and tripped on leg rest, hit bottom on the floor. 10/16/12, 10:35pm: Tipped himself over in chair. 10/18/12, 4:13pm: Sitting in his wheel chair (w/c), rocked to the side and tipped over. 10/24/12, 2:22pm: Sitting on floor in dining room, unable to verbalize what happened. 10/27/12, 1:48am: C.N.A (Certified Nursing Assistant) alerted writer that R5 had fallen, while still seated in wheel chair, noted lying on right side. R5's medical records contained no immediate interventions after the falls occurred. There were also no interventions located in R5's medical record related the fall R5 sustained on 10/16/12 at 6:07pm. R5 sustained a second fall the same day as he tipped over in the wheel chair. R5's care plan documents that anti-tippers were ordered the next day 10/17/12 for R5 ' s wheel chair. R5 sustained three more falls from his wheelchair within a two week period, two of which involved tipping the chair over/falling on his side (10/18/12 and 10/27/12). After R5 sustained a fall at 1:48 a.m. on 10/27/12, R5's nursing notes document that R5 was transferred to the hospital at 8:23 a.m. (7 hours later). On 12/6/12 at 12:48 p.m., E7 (Quality Assurance/Falls Coordinator) stated that she ordered anti-tippers to be placed on the sides of R5's wheel chair. E7 stated that the manufacturing supply company informed her that there were no side anti-tippers, and the order was not filled. E7 stated she did not add alternate interventions for R5. When inquiry was made about interventions correlating with R5 standing and tripping over the chair leg rest on 10/16/12, E7 stated she added no interventions. As a result of the fall on 10/27/12, R5 was transported to the local hospital where he was diagnosed with [REDACTED]. On 12/6/12 at 3:30pm, Z2 (Physician) stated that the subdural hematoma R5 sustained at the facility was non-life threatening. However, per Z2, it was not the same hematoma documented in R5's hospital records prior to admission the facility. On 12/7/12 at 9:29am, E7 stated she knew R5's admitting [DIAGNOSES REDACTED]. On 12/7/12 at 2:00pm E23 (C.N.A) stated he left R5 alone on 10/27/12, to put another resident to bed. E23 stated he then heard R5's chair alarm sounding as R5 was falling. E23 added that R5 keeps rocking in his wheel chair and always tips the chair over. On 12/7/12 at approximately 2:30pm (phone conversation) E24 (LPN) stated she was the nurse on duty when R5 sustained a fall on 10/27/12 at 1:48am. E24 stated that E23 had left R5 alone knowing that R5 needed monitoring. E24 stated that R5 was not to be left alone. E24 added that R5 had a scrape on the side of his head with some bleeding. E24 stated she did not transfer R5 to the local hospital until 8:23am. E24 stated that the facility's policy for emergency transfer to the hospital is for the staff to call the primary physician and dial 911 concurrently. E24 stated that for non-emergent situations, the policy is to notify the Primary Care Physician. E24 stated that if the primary physician does not respond to a page within 15 minutes to try again two times. E24 stated if no response after 3 pages, the policy is to call the facility ' s Medical Director. E24 added that she did call the Medical Director, and was not aware of the facility ' s policy on 10/27/12. On 12/7/12 at 3:30pm, E2 (Director of Nursing) stated the facility's policy in non-emergent medical situations is to page the primary physician. According to E2 if the physician does not return the call within 15 minutes, the staff is to page him again. E2 added that if there is no return call after the second page, the Medical Director is to be paged. R5's physician progress notes [REDACTED]. R5's radiology report from the local hospital after facility transfer (dated 10/27/12) documents: small extra-axial bleed along the right parietal lobe. The facility's policy for fall intervention and documentation reads: "Anytime a resident sustains a fall an intervention must be immediately put into place and documented in the medical record. The intervention must be related to the reason for the fall." 2. R7 was admitted to the facility with the following Diagnoses: [REDACTED]. The facility's incident report dated 6/10/12 documents that R7 sustained a fall and was unable to state exactly what happened. The summary of investigation report documented by E7 (RN/falls coordinator) documents that the staff observed R7 on the floor, complaining that he was in unbearable pain; when he rolled over on his side he was too close to the edge and rolled on the floor. R7's care plan approached dated 11/10/11 documents the following approaches: avoid clutter; maintain bed in lowest position, call light in reach, maintain needed items within reach, non-slid footwear, and toilet per resident ' s needs. However, R7's falls care plan dated 6/10/12 documented the following post fall interventions: "Give pain medication per resident's request, and bed alarm-refused. There were no further documented safety interventions upon R7's refusal of the bed alarm". R7 sustained a second fall on 6/14/12 and was subsequently sent to the hospital. R7's CT (Computed Tomography) scan from the local hospital dated 6/14/12 documents: Impression- There is evidence of lytic metastasis to the C5 and T1 vertebral bodies with compression fractures. On 11/9/12 at 1:15pm, E7 stated that R7 sustained a fall on 6/10/12 because he misjudged his distance related to pain. E7 added that the facility implemented a bed alarm in which R7 refused. E7 stated she also informed the staff that if they walk down the hall to "stick their heads" in R7's room. E7 stated there was no documented frequency of how often the staff should check on R7. E7 Stated he should have had a therapy screen after the fall on 6/10/12. E7 added that if the residents refuse interventions, the facility should try alternate interventions. On 11/9/12 at 2:30pm, via phone conversation, E8 (LPN) stated she was the nurse on duty when R7 sustained the fall on 6/14/12. E8 stated she could not recall the interventions implemented for R7. On 12/5/12 at 1:23pm, E12 (therapy program manager) stated that all residents are screened post fall. E12 was asked to provide all assessments/screens for R7. E12 then stated that " all therapy screens are online with a different company and we don't have access to them." E12 then returned at 1:38 p.m. and stated that the screens are actually done on paper and placed in the resident ' s medical records. E12 provided a blank form titled "Fall Screen" and stated this is the form that is supposed to be in the chart. E12 was presented with R7's medical records and asked to locate the fall screen. E12 looked through the medical records and stated "I don ' t see any." E12 exited and returned at 3:01 p.m. and presented a computerized physical and occupational evaluation for R7 dated 7/8/12 (1 month after the initial fall). On 12/6/12 at 3:30pm, Z2 (Physician) stated "the fall contributed to the fracture, but he has mushy bones." The facility's "Fall Prevention Program" policy documents: "Notify therapy department after a fall. In addition to other interventions, therapy department will screen the resident and determine additional interventions if appropriate course of treatment. Therapy department will screen the resident and determine appropriate course of treatment."

Based on observations, record reviews and interviews the facility failed to implement bed mobility and activities of daily living for 1 of 20 sampled, (R9) who rolled out of the bed and sustained a fracture of left hip. Findings Include: R9 was observed on 4-18-12 lying on a air mattress as one nurse's aide (E26) was giving her a bed bath. R9 is nonverbal, has a tracheotomy, rectal tube and an indwelling urinary catheter. R9 has no voluntary movements and her body is flaccid. E26 was the only nurse's aide providing care to R9 with bed mobility and activities of daily living. Review of R9's admission records say: R9 is a [AGE] year old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the facility's incident report dated 2-17-12 notes the following: " On 2-17-12 at 7:35 p.m., while activities of daily living care was being rendered, CNA turned R9 over onto her left side in an attempt to put clean linen on the bed. R9's weight shifted causing her to roll off of bed on top of the CNA's chest. CNA was unsure if resident had bumped her head. Upon assessment nurse noted some redness and swelling to the right side of R9's face. R9 was unable to communicate needs/how incident occurred". R9 was transferred to the hospital on 2-17-12 with x-rays of her left hip, right wrist and CT scan of her head. The x-ray dated 2-22-12 noted a left femur non displaced fracture. Review of R9's care plan dated 1-22-12 and revised on 2-22-12 did not indicate that 2 plus persons are required for bed mobility to prevent injuries and care for resident in a safe manner. Review of R9's Minimum Data Set ((MDS) dated [DATE] noted bed mobility was assessed at a level 4/3, meaning that total assistants with two plus person physical assist. E24 (Nurse's Aide) stated on 4-18-12 at 11:00 a.m. in R9's room while repositioning, "I always care and clean while repositioning her by myself." E2 (Director of Nursing) stated that the Medical Director is aware of this because the family requested a change from the pervious physician related to the care that was rendered concerning the fall.

Based on observation, interview, and record review the facility failed to perform daily skin checks for 6 of 6 residents reviewed for pressure sores (R1-R6). All six residents had changes in their skin integrity. Of the six sampled residents, two residents (R3 and R4) developed pressure ulcers. Findings include: The facillity submitted a plan of correction that was to be completed by 12/23/11. An exerpt from this plan reads as follows: "The facility has taken the following steps to ensure that this problem is corrected and will not recur: 1.) Daily skin checks will be completed for all residents at high risk for developing pressure ulcers. 2.) Weekly skin checks will be completed for all other residents." Nursing note for R4 dated 12/31/2011 documents, "small open areas to the coccyx are seen." There is no other documention in the nursing notes describing an assessment of the skin to that area after that date. On 1/3/12 a wound care assessment by treatment nurse (E2) documents an open area to the coccyx area measuring 2.0 by 1.0. There is no further documentation regarding the skin integrity of and or around the coccyx. The nursing notes for R3 dated 1/3/12 documents " open areas to the right buttock inner fold." There are two documentations in the wound and skin notes for January 4, 2012. The wound and skin note for 1/4/12 documents the skin openings as "Right buttock multiple open blister 4cm X4cm, no drainage. Right inner thigh open area 1X 0.3cm pink, no drainage." There is no daily documentation of skin checks found in the clinical record or provided by the facility. R1,2,3,4,5and 6 all have outdated careplans for wound care and skin integrity.. There is no documentation in all of these resident's clinical records, or that can be provided by the facility that daily skin checks were obtained. E1, DON (Director of Nursing) stated on 1/4/12 at 1 pm that they do not have any documentation for the daily skin checks. E1 DON, E2 Treatment Nurse were asked again together if they had any documentation to show that the daily skin checks were being done. E1 DON and E2 Treatment Nurse reported no. E2 treatment Nurse stated "we do it all the time we just don't write it down." When asked how the facility can assess a worsening or improvement of a skin change E2 Treatment Nurse stated " It just goes away and we know it is better." On 1/4/12 at 1:15pm E1, DON states, "The treatment nurse is supposed to update the care plans when there is a change in skin integrity." On 1/4/12 at 1:15pm E2 (licensed practical nurse, treatment nurse) states "I have not updated the care plans yet. I don't measure excoriated areas, only reddened areas. I check those once a week." R4 observed in physical therapy. R4 is sitting in a wheelchair that has a cushion device in the seat. When asked about her sore R4 states "They changed the dressing this morning. It hurts real bad when I am in bed. They put a pillow behind me last night and that helped a lot." On 1/5/2012 at 11:00am and again at 12:45pm at the exit meeting, E1 DON was asked again for any documentation showing assessment of skin on a daily basis. E1 DON stated "no, we don't have anything."