Every finding on record at Allure of Mendota

Based on interview and record review the facility failed to ensure money paid to the facility was refunded to the resident or the resident's representative/resident's estate within 30 days following the resident's discharge from the facility. This applies to 3 of 3 residents (R1, R5 and R6) reviewed for discharge in the sample of 7. The findings include: R1's EMR (Electronic Medical Record) shows that she was admitted to the facility on [DATE] and discharged on [DATE] when she expired at the facility. On [DATE] at 10:25AM V4 (Business Office Manager) stated, If someone comes in before the 20th of the month then they just pay for the remainder of the month. If they come in after the 20th then they pay for the remainder of the month plus the next month. If they leave before the month is over, then they have to wait until 10th of the next month for them (corporate) to close out the month. I send a check request to corporate, they cut a check and send it to me and then I call the family and they can either pick up the check, or I can mail it to them. For (R1) I was told that the person that processes the checks was busy with some sort of Medicare Audit and they were not able to cut the check. I don't have any control over what happens after I send the check request. (R1's Spouse) came in here several times and called me everything but a white woman- but he didn't cuss. He said he had bills to pay at the (local hospital) and I offered to call them and explain the situation. I sided with him. I called corporate multiple times. R1 was here 2/2- 2/6, (R1's spouse) would have had to wait until after 3/10 and I would have sent the check request then.V4 provided a copy of Check Request Form for R1 dated [DATE] and a second Check Request Form dated [DATE].V4 stated, I emailed corporate on 5/6 and 5/12, and I got the check on 5/15 (98 days). (R1's spouse) came and picked it up on 5/15. V4 provided a copy of the check in the amount of $6520.00 and a document showing R1's spouse's signature dated [DATE]. R5's EMR shows that she was admitted to the facility on [DATE] and expired on [DATE].R5's Check request is dated [DATE]. A check for $4860.00 shows an issue date of [DATE] and a mailing date to R5's Power of Attorney in Arizona on [DATE] (89 days). R6's EMR shows he was discharged from the facility on [DATE].R6's Check Request Form was sent on [DATE] and a check for $5940.00 was received on [DATE] (68 days).On [DATE] at 11:00AM V4 stated, (R6) is a current resident at the facility and the family wanted the money applied for his stay this time. The facility admission Contract states, Conveyance upon discharge, eviction, or death. Upon discharge, eviction or death of a resident with a resident with a personal fund deposited with the facility must convey within 30 days of the resident's funds, and a final accounting of those funds, to the resident, or in the case of death, the individual or probate jurisdiction administering the resident's estate, in accordance with State law.

Based on observation, interview, and record review the facility failed to ensure a certified dietary manager was employed as food service director which applies to all 64 residents in the facility.The findings include:The Centers for Medicare and Medicaid form 671 dated 4/27/26 showed there are 64 residents residing in the facility.On 4/27/26 at 9:00 AM V13 Dietary Manager stated she had not completed the Certified Dietary Manager (CDM) class. V13 stated she was enrolled and had to withdraw in January. V13 stated they were not currently enrolled in a new class. V13 stated they assisted with assessing residents and did a weekly call with V14 Dietitian and V1 Administrator.On 4/27/26 at 11:45 AM, V1 Administrator stated V13 does nutritional assessments in house. There is a weekly call with V14 which includes V13's resident nutritional concerns.On 4/29/26 at 10:45 AM, V14 stated they do not come into the facility to do resident assessments. V13 does the assessments. The facility team has a weekly phone call which includes V13 and V1 to go over new admission and nutritional issues with residents.The facility provided course certificates for V13 which showed V13 completed the courses of SERV Safe (food handling) and Certified Food Manager (CFM) certificate (expired).Per the Association of Nutrition and Foodservice Professionals (ANFP), there are no current certified dietary managers in the nation with the same last name as V13.The facility's undated Dietary Manager Qualifications showed the Dietary Manager must hold a current Certified Food Protection Manager certificate, should be a CDM or equivalent, and cannot perform nutritional assessments unless This Policy also showed nutritional assessments unless qualified by Illinois law.

Based on observation, interview and record review the facility failed to provide restorative services to residents with contractures and/or limited mobility for 4 of 6 residents (R41, R65, R8, R29) reviewed for mobility/range of motion in the sample of 17.The findings include: 1.R41's current care plan showed R41 resided in the facility for long term care due to a diagnosis of CVA (cerebrovascular accident/stroke) that caused paralysis to R41's left arm and left leg. The care plan showed R41 required staff assistance to complete all activities of daily living (ADLs). The plan showed no documentation R41 received restorative services. R41's quarterly restorative assessment dated [DATE] showed R41's left shoulder, left elbow, left wrist, left hand, left ankle and left foot were contracted. R41 had no mobility in these areas. The assessments showed no documentation R41 received restorative services. On 4/27/26 at 1:56 PM, R41 was in bed. R41's left hand was severely contracted. Her hand was in a tight, closed fist, lying loosely on the bed. No splint or towel roll was noted to R41's left hand. R41 stated she had no feeling or movement to her left arm or left leg due to her previous stroke. R41 stated she used to wear a splint to her contracted left hand but, not anymore. They took it away. R41 stated staff do not do passive range of motion exercises to her left arm or left leg. 2. R65's current care plan showed R65 resided in the facility for long term care due to a diagnosis of CVA that caused paralysis to R65's right arm and right leg. The plan showed R65 required staff assistance to complete all activities of daily living (ADLs). The plan showed no documentation R65 received restorative services. R65's quarterly restorative assessment dated [DATE] showed R65 had limited mobility to his right arm, right hand, right foot and right leg. The assessment showed R65 was not receiving any restorative services for his limited mobility. On 4/27/26 at 9:07 AM, R65 was seated in a wheelchair with his right arm lying in a foam arm support that was attached to the wheelchair. R65 stated he was unable to move right arm or right leg on his own due to his previous stroke. R65 stated staff do not do passive range of motion exercises to his right arm or right leg. 3. R8's current care plan showed R8 resided in the facility for long term care related to diagnoses including acquired absence of right foot toes, osteomyelitis of the right foot, reduced mobility, and difficulty walking. The plan showed R8 required staff assistance to complete activities of daily living. The plan showed no documentation R8 received restorative services. R8's restorative assessments dated 3/10/26 showed R8 had limited mobility to his right leg. The plan showed no documentation R8 received restorative services. On 4/28/26 at 10:07 AM, V3 Assistant Director of Nursing (ADON) stated R41, R65 and R8 were not receiving restorative services because we were told by corporate that only a certain number of people can get restorative services because of the budget. V3 stated any residents with contractures, limited mobility, and/or those who require staff assistance with activities of daily living should be receiving restorative services. V3 stated she did not know if R41 had or used a splint for treatment of her left-hand contracture. On 4/28/26 at 10:43 AM, V6 Director of Skilled Therapy stated any resident in the facility for long term care should receive restorative services if not on skilled therapy. V6 stated, Residents that have contractures or have had a stroke really need restorative services. They should at least be getting range of motion exercises. If residents are not on restorative, their contractures could get worse and/or their mobility could decline. The facility's Restorative Nursing Programs policy dated 1/14/26, It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Restorative nursing program refers to nursing intervention that promote a resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. The interdisciplinary team, with the support and guidance from the physician, will assure the ongoing review, evaluation, and decision making regarding the services needed to maintain or improve resident's abilities in accordance with the resident's comprehensive assessment, goals, and preferences. 4. R29's electronic face sheet shows R29 has diagnoses that include Alzheimer's and stroke. R29's facility assessment dated [DATE] show R29 has limitation to one side. On 4/27/26 at 12 PM, R29 was sitting in her wheelchair with right hand contracted in a closed-fist position in her lap, no splint noted. On 4/28/26 at 10 AM, R29 was using her left hand to position her contracted right hand in her lap. On 4/28/26 at 1:09 PM, V10 (MDS Coordinator) said R29 has contracted right hand. The previous Restorative Nurse placed R29 on restorative program that was not being done. There were no follow-throughs and no documentation regarding R29's restorative progress or decline, so V10 said she discontinued R29's restorative program. V10 said V3 Assistant Director of Nursing (ADON), who is Restorative Certified, is in the process of revamping the whole Restorative program of the facility. R29 will be one of the residents to be assessed. On 4/29/26 at 9:10 AM, V3 (ADON) said she will start the restorative program from scratch. Today, she will work on R29 to apply a cone/palm grip in her contracted right hand to prevent further decline.

Based on observation, interview and record review the facility failed to ensure required Personal Protective Equipment (PPE) was worn in rooms of residents on contact, droplet isolation and failed to ensure hands were washed and gloves were changed to prevent cross contamination during incontinence care. This applies to 6 of 17 residents (R11, R17, R40, R58, R41 and R5) reviewed for infection control in the sample of 17.The findings include:On 4/27/26 at 9:10 AM on the outside of R11, R17 and R40 doorways (R11 and R40 share a room) there were PPE containers which had gowns, masks, gloves and face shields. There were signs on the door indicating the residents were on Contact Droplet Precautions and staff should apply gowns, gloves, eye protection or a face shield and a N95 face mask. R11, R17 and R40's active physician order summaries show they have active orders for strict isolation for diagnosis of Respiratory Syncytial Virus (RSV). R11's order was dated 4/17/26, R17's order was dated 4/24/26, and R40's order was dated 4/22/26. On 4/27/26 at 12:42 PM, V4 (Certified Nursing Assistant/CNA) was delivering meal trays to residents in their rooms. She entered R17 and R40's room wearing only gloves. She did not apply a N- 95 mask, face shield or a gown. She then continued passing trays down the hallway and went into R11's room again without applying the required PPE. On 4/28/26 at 1:10 PM, V11 (Infection Control Nurse) said they use the same precaution for residents on RSV as COVID isolation. And when staff are in the room of these residents, they should be wearing gowns, gloves, N95 masks, and face shields. 2.R58's laboratory result report dated 4/24/26 showed R58 tested positive for RSV. R58's physician order dated 4/24/26 showed R58 was placed on, Strict Contact and Droplet Isolation for diagnosis RSV. On 4/27/26 at 9:15 AM, R58 was seated in a wheelchair in her room. R58's call light was on and flashing. A droplet isolation sign hung on the doorframe to R58's room. A cart containing PPE was noted in the hallway by R58's room. V4 Certified Nursing Assistant (CNA) knocked and entered R58's room without donning any PPE, including no face mask. V4 walked directly up to R58 and began speaking with R58 for 10-15 seconds. V4 picked up R58's breakfast tray with her ungloved hands and exited the room. On 4/28/26 at 11:25 AM, V7 Registered Nurse stated staff must don a protective gown, gloves, face shield and a face mask prior to entering the room of a resident on droplet isolation to prevent the spread of infection. The facility's Transmission-Based (Isolation) Precautions policy (undated) showed, Droplet Precautions refers to actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. The policy showed staff must don a gown, mask, face shield and gloves prior to entering the room of a resident on droplet isolation. 3. On 4/27/26 at 9:17 AM, V4 CNA and V5 CNA provided incontinence care to R41 as R41 was incontinent of urine and stool. V4 CNA wiped stool from R41 and removed R41's soiled brief. Without changing her soiled gloves, V4 placed a clean incontinence brief under R41. V4 then helped reposition R41, touching R41's bedding and clothing with her soiled gloves. On 4/28/26 at 10:07 AM, V3 Assistant Director of Nursing stated staff must remove soiled gloves and wash their hands prior to touching any clean surface or resident to prevent cross contamination. 4. The facility's wound list shows R5 has a stage 4 sacral wound. On 4/27/2026 at 9:47 AM, V11 Wound Nurse and V12 Wound Physician were in R5's room performing wound assessments to R5's sacral wound. V12 (Wound Physician) said R5 just completed antibiotic treatment due to wound infection (chronic osteomyelitis.) R5 was lying in bed to her side. V11 Wound Nurse was about to apply R5's wound dressing to R5's stage 4 sacral wound when she noticed R5 had a bowel movement. R5 was also noticed to be wet from head to toe. V11 then provided incontinence care to R5 and changed R5's linens, With the same soiled gloves used to cleanse R5's urine and stool and without washing her hands, V11 performed R5's wound dressing change. On 4/28/26 at 8:54 AM, V11 said soiled gloves should be removed, perform handwashing and apply new gloves prior to performing wound treatments to prevent cross contamination.

Based on observation, interview and record review the facility failed to provide incontinence care in a manner to prevent infection to 1 of 6 residents (R7) reviewed for incontinence care in the sample of 17.The findings include:R7's facility assessment dated [DATE] shows R7 is frequently incontinent of stool and urine.On 4/27/26 at 9:15 AM, V8 and V9 (both Certified Nursing Assistants-CNA) provided incontinent care to R7. Both V8 and V9 removed R7's incontinent pad. R7 was also noted wearing double incontinent pads that were both totally soaked with urine. V9 (CNA) stated R7 needs to have 2 incontinent pads because the incontinent pads of the facility are too thin. R7 was then turned to her side. V9 then took 3 wet wash cloth from the bathroom and said two of the washcloths were with soap and water and one was just plain water, to be used as rinse. V9 cleansed R7's buttocks and perineal area. Then R7 was positioned to her back, and a new incontinent pad was applied. There was no cleansing provided in R7's front area and thigh areas.On 4/29/26 at 9:05 AM, V3 (Assistant Director of Nursing) said there should be no double incontinent pads applied to residents. If they are heavy wetter, then they are changed more often. When providing incontinence care, residents should be cleansed thoroughly, front and the back area, to prevent infection. R7's care plan dated 8/18/25 documents, R7 has ADL self-care performance deficit r/t Confusion, Dementia, Impaired balance, and Limited Mobility. TOILET USE: Incontinent of urine/bowel, wears briefs. Dependent on staff for incontinence care The facility Policy entitled Perineal Care dated 1/14/26 shows, it is the practice of this facility to provide perineal care to all incontinent residents during routine baths and as needed to promote cleanliness and comfort, prevent infection to the extent possible and to prevent and assess for skin breakdown. Gather supplies needed. Basin filled no more than 2/3/full of warm water. Females, assist resident in bending her knees, slightly and spreading her legs. Wet wash cloth, separate resident's labia with one hand and cleanse perineum with other hand, wiping direction from front to back. Repeat opposite side. Pat dries with towel. Turn the resident on her side. Cleanse and dry anal area.

Based on interview and record review the facility failed to report an injury of unknown origin to Illinois Department of Public Health (IDPH) for a resident with bruises to her inner thigh area for 1 of 3 residents (R1) reviewed for injury of unknown origin in the sample of 6. The findings include: The Nurses Note dated [DATE] at 12:01 AM for R1 showed, the aides took the resident to the bathroom and had noticed scattered bruising to her inner thighs (yellow, green, and purple bruises). The certified nursing assistant (CNA) stated they were not sure how long they have been there due to resident being a standby assist and taking herself to the bathroom. Resident also refuses cares at times. When I asked the resident stated, it's from these and pointed to her depends. No pain or discomfort noted to the area of bruising. The facility did not report the bruises to R1's inner thighs to Illinois Department of Public Health (IDPH). On [DATE] at 10:11 AM, V1 (Administrator) stated, injuries of unknown origin could be bruises and if they can't find a reason or a conclusion as to how the bruises happened then she would investigate the bruises as an injury of unknown origin. V1 stated R1 had a bruise to her left thigh and a small mark to her right thigh. On Thursday ([DATE]) morning the nurse documented that R1 had bruises to her thighs. V1 stated they investigated the bruises and R1 would bump into things. V1 stated they thought that R1 would bump into the foot board of her bed when she was trying to get snacks that were located on a credenza at the end of her bed. V1 stated the bruises were to R1's inner thigh area on the left and a small one to inner thigh on the right. On Friday ([DATE]) night R1 fell ; she was on hospice. R1 didn't break her fall, was sent to the hospital, and came back on Saturday ([DATE]) with a diagnosis of a urinary tract infection (UTI). V1 stated that same day R1 complained of chest pain; she was restless and was acting out. Hospice was contacted and they said to send her to the hospital. V1 stated she pulled up the pictures that the hospital had in R1's chart of the bruises to her inner thigh and they did not look the same as what she saw when she observed R1's bruises. They looked different from Thursday to Friday ([DATE]). When R1 went back to the hospital on Saturday ([DATE]) they got her up to the commode, she stood up, collapsed, they put her in bed, and she died . V1 stated she looked at the hospital records and the doctor documented that she possibly died from an aortic dissection or aortic aneurysm, and this would explain the bruising. She also did have low vitamin B level and bruised easily. On [DATE] at 1:14 PM, V1 stated an injury of unknown origin is an injury that can't be explained as far as the cause or there are no witnesses to the injury. A bruise that shows up that can't be explained would be investigated. V1 confirmed if a bruise were in an unusual place they would investigate it as injury of unknown origin. V1 stated she should have reported to IDPH. The Face Sheet dated [DATE] for R1 showed diagnoses including Alzheimer's disease, palliative care, dementia with behavioral disturbance, type 2 diabetes mellitus, acute cystitis without hematuria, deficiency of B vitamins, hypomagnesemia, unspecified behavioral syndromes, anxiety disorder, and essential hypertension. The facility's Unexplained Injuries policy ([DATE]) showed, all unexplained injuries, including bruises, abrasions, and injuries of unknown source will be investigated. An injury should be classified as an injury of unknown source when both of the following conditions are met: A, the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and b. The injury is suspicious because of i. The extent of the injury or ii. The location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) Reporting and investigation procedures shall be implemented in accordance with the facility's abuse policies and procedures. The facility's Abuse, Neglect, and Exploitation policy (2025) showed, possible indicators f abuse include, but are not limited to: physical marks such as bruises or patterned appearances such as a handprint, belt or ring mark on a resident's body. Physical injury of a resident, of unknown source. Reporting of all alleged violations to the Administrator, state agency, adult protective services and other required agencies (e.g., law enforcement when applicable) within specified time frames: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on interview and record review the facility failed to ensure a thorough investigation was done by interviewing additional residents when a resident had an injury of unknown origin that consisted of bruising to her inner thighs for 1 of 3 residents (R1) reviewed for injury of unknown origin in the sample of 6. The findings include: The Nurses Note dated [DATE] at 12:01 AM for R1 showed, the aides took the resident to the bathroom and had noticed scattered bruising to her inner thighs (yellow, green, and purple bruises). The certified nursing assistant (CNA) stated they were not sure how long they have been there due to resident being a standby assist and taking herself to the bathroom. Resident also refuses cares at times. When I asked the resident stated, it's from these and pointed to her depends. No pain or discomfort noted to the area of bruising. The facility did not report the bruises to R1's inner thighs to Illinois Department of Public Health (IDPH). On [DATE] at 10:11 AM, V1 (Administrator) stated, injuries of unknown origin could be bruises and if they can't find a reason or a conclusion as to how the bruises happened then she would investigate the bruises as an injury of unknown origin. V1 stated R1 had a bruise to her left thigh and a small mark to her right thigh. On Thursday ([DATE]) morning the nurse documented that R1 had bruises to her thighs. V1 stated they investigated the bruises and R1 would bump into things. V1 stated they thought that R1 would bump into the foot board of her bed when she was trying to get snacks that were located on a credenza at the end of her bed. V1 stated the bruises were to R1's inner thigh area on the left and a small one to inner thigh on the right. On Friday ([DATE]) night R1 fell ; she was on hospice. R1 didn't break her fall, was sent to the hospital, and came back on Saturday ([DATE]) with a diagnosis of a urinary tract infection (UTI). V1 stated that same day R1 complained of chest pain; she was restless and was acting out. Hospice was contacted and they said to send her to the hospital. V1 stated she pulled up the pictures that the hospital had in R1's chart of the bruises to her inner thigh and they did not look the same as what she saw when she observed R1's bruises. They looked different from Thursday to Friday ([DATE]). When R1 went back to the hospital on Saturday ([DATE]) they got her up to the commode, she stood up, collapsed, they put her in bed, and she died . V1 stated she looked at the hospital records and the doctor documented that she possibly died from an aortic dissection or aortic aneurysm, and this would explain the bruising. She also did have low vitamin B level and bruised easily. On [DATE] at 1:14 PM, V1 stated an injury of unknown origin is an injury that can't be explained as far as the cause or there are no witnesses to the injury. A bruise that shows up that can't be explained would be investigated. V1 confirmed if a bruise were in an unusual place they would investigate it as injury of unknown origin. V1 stated residents were not interviewed as part of their investigation and should have been. V1 stated they only interviewed staff. The Face Sheet dated [DATE] for R1 showed diagnoses including Alzheimer's disease, palliative care, dementia with behavioral disturbance, type 2 diabetes mellitus, acute cystitis without hematuria, deficiency of B vitamins, hypomagnesemia, unspecified behavioral syndromes, anxiety disorder, and essential hypertension. The facility's Unexplained Injuries policy ([DATE]) showed, all unexplained injuries, including bruises, abrasions, and injuries of unknown source will be investigated. An injury should be classified as an injury of unknown source when both of the following conditions are met: A, the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and b. The injury is suspicious because of i. The extent of the injury or ii. The location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) Reporting and investigation procedures shall be implemented in accordance with the facility's abuse policies and procedures. The facility's Abuse, Neglect, and Exploitation policy (2025) showed, possible indicators f abuse include, but are not limited to: physical marks such as bruises or patterned appearances such as a handprint, belt or ring mark on a resident's body. Physical injury of a resident, of unknown source. Investigation of alleged abuse, neglect, and exploitation - an immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who may have knowledge of the allegations.

Based on record review and interview, the facility failed to verify a resident's code status prior to starting CPR/Cardio-Pulmonary Resuscitation for one of three residents (R1) reviewed code status in the sample of three. Findings include: The facility's undated Residents' Rights Regarding Treatment and Advance Directives policy documents, Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to staff. The facility's undated Communication of Code Status policy states: It is the facility's policy to adhere to residents' rights to formulate advance directives. In accordance with these rights, the facility will implement procedures to communicate a resident's code status to those individuals who need to know. Designated sections of the medical record are: miscellaneous tab under Advanced Directives. Additional means of communication of code status include: PCC/Point Click Care (the facility's electronic medical record data system) under resident's name is code status. R1's medical record documents R1 was admitted to the facility from the hospital on [DATE] with the following diagnoses: Acute Respiratory Failure with Hypoxia; Chronic Obstructive Pulmonary Disease; Chronic Kidney Disease; Congestive Heart Disease; Hypertension and Diabetes Mellitus Type 2. R1's medical record included a POLST/Physicians Order for Life Sustaining Treatment Form, signed and dated [DATE] by R1 and V16 (R1's Physician). This POLST documented R1's code status was, Do Not Attempt Resuscitation/DNR. R1's Health Status Note by V4 RN/Registered Nurse, dated [DATE] at 3:25pm, documented R1 was admitted by V4 on [DATE] at 3:25pm. V4 documented R1 was alert and oriented, able to answer all questions appropriately. V4 documented R1's code status as Full Code. R1's Health Status Note by V5 LPN/Licensed Practical Nurse, dated [DATE] at 2:25am, documents V5 found R1 unresponsive, pulseless, without respirations, and unable to auscultate an apical pulse. On [DATE] at 1:41pm, V5 LPN stated, during shift change on [DATE], V14/LPN reported that R1's code status was DNR/Do Not Resuscitate. V5 stated he did not check R1's electronic medical record for verification of R1's code status or POLST form at that time. V5 stated when they found R1 unresponsive, pulseless and without respirations, V5 did not start Cardio-Pulmonary Resuscitation/CPR, based on the verbal report V5 received when coming on duty. V5 stated he called V6 RN/Registered Nurse on a separate hall, to verify R1's death and attempted to notify R1's POA/Power of Attorney and family members of her passing. V5 stated he then called the on-call Nurse (V4 RN) to report (R1's) death. V3 ADON/Assisted Director of Nursing then called the facility and told V5 R1's code status was Full Code. At that time, V5 stated he called [DATE] (emergency services) and directed V6 RN, V7 and V8 CNAs to start CPR. V5 stated V2 DON/Director of Nursing called the facility shortly after CPR was started and informed V5 that R1's code status is DNR. V5 stated he then located R1's POLST/Physicians Order for Life-Sustaining Treatment Form in R1's electronic medical record documenting R1's DNR code status and informed staff to stop CPR. On [DATE] at 10:45am, V4 stated she was the admitting nurse for R1 on [DATE]. V4 stated she called the admitting hospital for report from R1's nurse, who stated R1's code status was a Full Code. V4 stated R1 did not voice her code status to V4 during the admission process. V4 stated on [DATE], she passed on during report to V15/LPN/Licensed Practical Nurse, the oncoming night shift nurse, that R1's code status was a Full Code. V4 confirmed R1's code status was a DNR, and she had passed on incorrect information after admitting R1. V4 stated CPR was started when R1's code status was DNR per R1's POLST form. V4 stated she did not verify R1's code status by checking R1's POLST form sent with R1 on admission. On [DATE] at 11:05am, V12 MDS/Minimum Data Set Coordinator stated R1's POLST form that R1 admitted with on [DATE] documented R1 as a DNR. On [DATE] at 11:12am V13 Social Services Director stated R1 was admitted to the facility from the hospital on [DATE] with transfer orders and a signed POLST Form documenting R1's code status as (Do Not Resuscitate) DNR. V13 stated R1 was alert and oriented when she met with R1 upon admission to the facility and confirmed R1's DNR code status with R1, personally. V13 stated R1 confirmed her code status as DNR.

Based on observation, interview, and record review, the facility failed to ensure a resident's indwelling urinary catheter bag included a privacy cover and the catheter tubing was off the floor for one (R22) of one resident reviewed for indwelling urinary catheters in a sample of 26. Findings include: The facility's undated Catheter Care policy documents, Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Policy Explanation: 2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use. R22's current Physician Order Sheet/POS documents R22 has an indwelling urinary catheter due to urinary retention. On 11/12/24, at 10:23am, R22 sat in his room with no privacy cover on his indwelling urinary catheter bag. On 11/12/24, at 12:40pm, R22 sat at a dining room table with no privacy bag on his indwelling urinary catheter bag and the catheter tubing was touching the floor. On 11/12/24, at 1:07pm, V6 Certified Nursing Assistant/CNA confirmed that R22's indwelling catheter bag is not in a privacy bag and should be covered. V6 also confirmed that R22's catheter tubing was touching the floor and should not be. On 11/13/24, at 8:30am and 11:58am, R22 sat at a dining room table with an indwelling catheter bag hanging underneath his wheelchair. R22's catheter bag did not contain a privacy covering. On 11/14/24, at 1:21pm, V2 Director of Nursing/DON stated that catheter bags are to be covered with privacy covers and catheter tubing should not be touching the floor.

Based on observation, interview, and record review, the facility failed to ensure medications were administered according to physician orders and medication instructions for two (R6 and R56) of seven residents reviewed during Medication Administration. This failure resulted in two medication errors out of 26 opportunities resulting in a 7.69% (percent) medication error rate. Findings include: The facility's undated Medication Administration policy documents, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and compliance Guidelines: 10. Ensure that the six rights of medication administration are followed: a. Right resident b. Right drug c. Right dosage d. Right route e. Right time f. Right documentation. 1. On 11/13/24, at 8:45am, R56 sat on her bed. V5 Registered Nurse/RN administered Vitamin D 25mcg (micrograms) one tablet to R56. R56's current Physician Order Sheet/POS documents an order for Vitamin D3 oral tablet give 125mcg by mouth in the morning. On 11/13/24, at 2:40pm, V5 RN confirmed that V5 gave the wrong medication to R56, that V5 pulled the wrong Vitamin D from the drawer of the medication cart. 2. On 11/13/24, at 9:04am, R6 was in bed. V4 RN gave R6 his Albuterol inhaler in which R6 inhaled two puffs orally. Next V4 gave R6 his Arnuity Ellipta 50mcg (micrograms) inhaler and R6 inhaled one puff orally. This inhaler was followed by his Stiolto 2.5mg (milligrams) inhaler in which R6 inhaled two puffs. V4 took the three inhalers and left R6's room. R6's current Physician Order Sheet/POS documents an order for Arnuity Ellipta Inhalation Aerosol Powder Breath Activated 50 mcg/act (micrograms/actuation) (Fluticasone Furoate (Inhalation) one puff inhale orally in the morning related to Chronic Obstructive Pulmonary Disease, Unspecified. The facility's undated Full Prescribing Information for Arnuity Ellipta documents Dosage and Administration: Administration: After inhalation, the patient should rinse his/her mouth with water without swallowing to help reduce the risk of oropharyngeal candidiasis. On 11/13/24, at 2:43pm, V4 RN confirmed that V4 should have had R6 rinse and spit after inhaling the Arnuity Ellipta as it is a steroid.

Based on observation, interview, and record review the facility failed to safely perform a mechanical lift transfer and failed to follow their policy and procedure after a fall for 1 of 3 residents (R1) reviewed for safe transfers in the sample of 7. This failure resulted in R1 falling to the floor, sustaining a right hip fracture, and requiring surgical repair of the fracture. The findings include: On 11/6/24 at 10:44 AM, R1 was lying in bed. R1 said there were two CNAs (Certified Nursing Aides) putting her back to bed, after lunch (on 8/23/24). R1 said the wheelchair was parked, facing the bed, near the middle of the bed. R1 said the CNAs applied the sling under her arm, she held onto the grab bar, and they used the lift to stand her up. R1 stated, I don't know what the problem was, but they were taking too long, and I told them I couldn't stand anymore. They pushed the lift over near the bed, but my legs weren't against the bed. They were trying to take of my pants, so I could lay down. It was taking too long, and I told them. Then my legs just gave out. I was hanging there, by my arms. The sling was pulling under my armpits and shoulder, and I was hanging on to the handles. They tried to sit me on the edge of the bed, but I was slipping. I landed on my butt on the floor. My right arm was sore right away and later on my right hip stated to really hurt. R1 said a nurse did not complete a head to toe assessment after she fell . R1 said the CNAs used the total lift to get her back in bed without the nurse checking her first. R1 said the facility did X-rays a couple days after she fell , but they told her there wasn't a fracture. R1 said she was having hip pain for two weeks before she was sent to the hospital. R1 said she had to have her hip repaired surgically. R1 said she wasn't able to do her regular therapy because her right hip was hurting too bad. R1 said she tried the sit to stand one more time, but it hurt so bad, and they had to stop. R1 said after that, she only did therapy in her bed, and it hurt when she did the leg exercises. R1 stated, I think someone made a mistake. I don't like to think about the fall. It was such an awful experience. I was just hanging from that sit to stand lift, by my arms for a long time and then I fell on my butt. R1's Facesheet dated 11/6/24 showed diagnoses to include, but not limited to: right hip fracture and orthopedic aftercare (9/9/24); CHF (Congestive Heart Failure); COPD (Chronic Obstructive Pulmonary Disease); peripheral venous insufficiency; stroke with right sided weakness; major depressive disorder; morbid obesity; lymphedema; GERD (Gastro-Esophageal Reflux Disease); chronic pain syndrome; pain in right shoulder and right hip (9/9/24); reduced mobility; unsteadiness on feet; generalized muscle weakness; lack of coordination; and need for assistance with personal care. R1's facility assessment dated [DATE] showed she was cognitively intact; and was dependent on staff for toileting, shower/bathing, and transfers. R1's Progress Notes and Assessments were reviewed for 8/23/24. There were no notes or assessments (vital signs, neuro checks, ROM, pain, skin check) completed by R1's nurse (V18 - Agency RN). There were late entries created on 8/30/24 by V2 (DON - Director of Nursing) and V30 (MDS Coordinator). R1's Post Fall Evaluation dated 8/23/24 showed R1 had a witnessed fall in her room when she was being transferred to bed with a sit to stand mechanical lift, by V19 and V20 (CNAs). R1's Progress Note dated 8/25/24 showed, Resident complained of pain with ROM (Range of Motion) to right shoulder, right hip, and right lower extremity . The doctor was notified and orders for X-rays were obtained. (This note was 2 days after R1's fall). R1's portable Right hip X-ray report 8/25/24 showed there was no fracture or dislocation seen and she had moderate degenerative changes. R1's Health Status Note dated 9/5/24 showed R1 continued to complain of right hip pain after a fall on 8/23/24. The doctor was notified, and orders were received to send R1 to the hospital. R1's Orthopedic Pre-operative Report dated 9/8/24 showed R1 had a surgical nailing of her right hip to repair the fracture. This note showed R1 fell at the nursing home 2 weeks ago and continues to have pain in her right hip and inability to perform ADLs (Activities of daily living) including sitting to stand and stand to sit. The document showed, . The X-rays at the time of the nursing home showed a minimally displaced greater trochanteric hip fracture. The patient was then admitted to the hospital for continued right hip pain in order to get an MRI of the right hip. MRI of the right hip was done yesterday (9/7/24) which showed a greater trochanteric hip fracture with intertrochanteric extension to greater than 50% of the intertrochanteric region. The fracture was due to a combination of trauma from a fall and pathologic bone due to osteoporosis . On 11/6/24 at 2:59 PM, V20 (CNA) said R1 was in the wheelchair, and we were trying to get her back to bed, after lunch. V20 said V19 (CNA) was helping her. V20 said R1 was seated in the wheelchair, the sling was placed under her arms, and they started to use the sit to stand lift to raise R1's bottom out of the wheelchair. V20 said they were having difficulty with R1's wheelchair being in the way and the transfer was taking a little longer than usual. V20 said R1 can't stand on the sit to stand platform very long. V20 said they moved R1 toward the bed as fast as they could, but R1's right side gave out. V20 said R1 is a large lady and part of her bottom was on the bed. V20 said she was managing the lift and from where she was standing, she thought R1 was on the edge of the bed. V20 said V19 told her that she was trying to hold the resident in place with her knee and she needed to get help. V20 said she ran to the hall for help. V20 stated, It was chaos. Everyone was busy V20 said R1 was hanging from the sit to stand lift by her arms, with her hands still holding on to the hand grips, and her arm stretched over her head. V20 said R1 was hanging like that for a couple of minutes. V20 said V21 (CNA) came to help. V20 said V19 (CNA) was on R1's right side, using her knee to wedge R1 into the bed and keep her from slipping, but it was getting too hard, and they had to lower her to the floor. V20 said R1 just slipped to the floor. V20 said R1 still was holding onto the handles, the sling was still attached to the lift, and R1's bottom was on the floor. V20 said they didn't think it was a fall because she slipped from the bed to the floor. V20 said they removed R1's sit to stand sling and used a sling to lift R1 off the floor and back into bed. V20 did not report the fall to the nurse immediately and the nurse did not assess R1 before she was removed from the floor. V20 said she didn't work for a couple weeks after R1's fall. On 11/6/24 at 3:46 PM, V19 (CNA) said she was the CNA helping V20 transfer R1 to bed on 8/23/24. V19 said they were transferring R1 from her wheelchair to bed and tried to change her incontinence brief before sitting her down on the edge of the bed. V19 said R1 said she couldn't hold herself up any longer, her legs went week, and she collapsed. V19 said she placed her knee behind R1 to try to keep her from sliding off the bed. V19 said some of her bottom was on the bed, but not all of it. V19 said she told V20 to get help because she couldn't hold R1 for long, her knee was starting to hurt. V19 said V20 thought we could push R1 into the bed, but I told her that wouldn't work, and we needed help. V19 stated, [V20] left the room to go get help. I don't how long she was gone but felt like a long time. I told [R1] we were going to have to lower her to the floor because my knee was hurting. We lowered her to a seated position on the floor. One of her legs was in an awkward position. It was a little twisted. I don't remember which one. She seemed scared because we got scared. She was complaining of pain, but I don't remember exactly what she said. She was hanging from the lift for quite a while. All of it was so sudden. She said, I can't, my feet. By the time [V20 and V21 (CNAs)] came back in the room, I was already lowering R1 to the floor. [V20] and I got the total lift, and we got her back to bed. The nurse didn't come in and assess her before we got her back to bed. [V20] and we got write ups for this. I was surprised the nurse didn't come. [V20] said the nurse isn't coming because she's pregnant. I know we shouldn't have gotten her up until the nurse assessed her. On 11/7/24 at 8:38 AM, V21 (CNA) said she was providing care to another resident when V20 said they needed help in R1's room. V21 said when she went in the room, V19 had her knee underneath R1 and R1 was hanging from the sit to stand lift. V21 stated, There's no way [V19] could have held R1 for long. V21 said she and V20 help lower R1 to the floor. V21 said she left R1's room after that. V21 said when a resident falls the nurse should be notified right away. V21 said the nurse does an assessment and tells us if it's safe to transfer the resident. V21 said we don't want to hurt the resident if they have injuries already. On 11/7/24 at 12:01 PM, V18 (Agency RN) said she was R1's nurse on 8/23/24 but she had no idea R1 fell . V18 said the CNAs didn't tell her R1 fell . V18 said she was charting at the nurses' station, and she was approached by therapy. V18 said therapy reported that R1 had a rough transfer. V18 said she went to R1's room about 30 minutes later. V18 said the CNAs were in R1's room and she asked if there was an incident. They said it was a rough transfer. V18 said no one reported a fall to her, she didn't complete an assessment of R1 after the fall, and there wasn't any documentation because she wasn't aware R1 fell . V18 stated, If I knew about a fall, then I would have started the assessments and paperwork immediately. If you're going to have a fall, a witnessed fall is the easier one to have. It's less paperwork. All R1 said was she didn't want to use the sit to stand anymore, she stated, I don't want to do that again. Then I heard a few days later she told someone else she fell , and she was sent out to the hospital. V18 said she didn't take care of R1 again until she returned from the hospital after she had surgery on her broken hip. On 11/7/24 at 9:55 AM, V23 (PTA - Physical Therapy Assistant) said prior to R1 falling, they had been working training with the sit to stand. V23 said a sit to stand lift was performed in the therapy gym successfully and he had completed in room training with the CNAs on sit to stand transfers for R1. V23 said R1 was doing well with the training and could bear weight for several minutes during the transfer. V23 said he was surprised when he heard there was a rough transfer on 8/23/24 (Friday). V23 said he saw R1 the following Monday or Tuesday and attempted the sit to stand lift and R1 could not bear weight. V23 said R1 complained of right hip pain and demanded to stop. V23 said he didn't attempt the sit to stand lift with R1 again and after that her therapy consisted of exercises in the bed or wheelchair and the staff used a total lift for transfers. V23 said R1 often had pain with ROM and exercises with her right leg. On 11/7/24 at 12:42 PM, V30 (MDS Coordinator) said she did not witness R1's fall, nor did she assess R1 on 8/23/24. On 11/7/24 at 1:02 PM, V2 (DON) said she was at the facility on 8/23/24. V2 said she didn't witness R1's fall, was not in R1's room after the fall and didn't not complete an assessment on R1 on 8/23/24. V2 said the CNAs did not report a fall. V2 said she was in the hall and overheard V19 talking. V2 said V19 reported a rough transfer, but not a fall. V2 said she didn't ask any other questions and went to deal with another issue. V2 said on 8/25/24 she got a call from V1 (Administrator). V2 said she was told R1 was having pain all over, and was asked if there had been an incident. V2 stated, I told her that I heard there was a rough transfer but wasn't aware of an incident. She (V1) said [R1] did go on the floor and that's considered a fall. They got orders for X-rays. I didn't come in that day or do an assessment. The nurses should be documenting a fall and their assessment in the progress notes. The purpose is to ensure there is continuity of care and communicate with other staff what has been happening with the resident. On 8/30/24 we had a fall meeting and were reviewed R1's documentation and realized there was no charting on 8/23/24 about the fall. V2 said after a fall she expects the CNAs to report the fall immediately, the nurse to perform a full head to toe assessment of the resident and determine if it is safe to transfer the resident from the floor. If a resident is complaining of pain with ROM after falling, then the resident shouldn't be moved and sent out 911 to the hospital. I don't have X-ray vision. I can't tell if there is a fracture by looking at them. The nurses should have charted all of that information, but the CNAs didn't report a fall. On 11/7/24 at 3:08 PM, V28 (Orthopedic Surgeon) said it's very likely that the initial portable X-ray completed on 8/25/24 did not capture the fracture due to R1's body size and positioning with portable X-ray machines. V28 said an MRI would be needed for more sensitive results. V28 said inability to bear weight, pain in the hip area, or pain with ROM/movement of the affected limb are signs of a fracture. V28 said the facility should report these concerns to the physician and obtain an order to send the resident to the hospital for further evaluation. V28 said he wasn't clear how R1 fell . The surveyor explained the fall from the sit to stand lift. V28 replied, It's very likely that caused her fracture, and the original X-ray missed it. If she was complaining of continued pain and hadn't returned to baseline physical functioning, they should have sent her to the hospital. She ended up having surgery to repair her hip. The pain she was having was likely from the fracture and she needed stabilization (surgery) on her hip to reduce the pain. V19 and V20's Employee Disciplinary Forms dated 8/29/24 showed R1's fall was not reported to the nurse. They were provided education and in-servicing. The facility's undated Safe Resident Handling/Transfers Policy showed, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines . The facility's undated Fall Prevention Program showed, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Definitions: A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force (e.g. resident pushes another resident). The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere . 9. When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of injury. The facility's undated Fall Checklist showed, #1. Complete assessment/VS, initial neuro checks as indicated. If any injury noted or suspected keep resident still and do not transfer to bed or chair. Contact 911 and send to ED for evaluation and treat .

Based on observation, interview, and record review the facility failed perform assessments, failed to continue to monitor a resident's change of condition, failed to communicate changes in a resident's condition, and failed to provide treatment of a fracture in a timely manner for 1 of 3 residents (R1) reviewed for quality of care in the sample of 7. These failures resulted in experiencing continued pain after a fall on 8/23/24 and a delay in her being sent to the hospital for evaluation and treatment. R1 was transferred to the hospital on 9/5/24 (2 weeks after she fell ) and had surgery for a right hip fracture. The findings include: On 11/6/24 at 10:44 AM, R1 was lying in bed. R1 said there were two CNAs (Certified Nursing Aides) putting her back to bed, after lunch (on 8/23/24). R1 said the wheelchair was parked, facing the bed, near the middle of the bed. R1 said the CNAs applied the sling under her arm, she held onto the grab bar, and they used the lift to stand her up. R1 stated, I don't know what the problem was, but they were taking too long, and I told them I couldn't stand anymore. They pushed the lift over near the bed, but my legs weren't against the bed. They were trying to take of my pants, so I could lay down. It was taking too long, and I told them. Then my legs just gave out. I was hanging there, by my arms. The sling was pulling under my armpits and shoulder, and I was hanging on to the handles. They tried to sit me on the edge of the bed, but I was slipping. I landed on my butt on the floor. My right arm was sore right away and later on my right hip stated to really hurt. R1 said a nurse did not complete a head to toe assessment after she fell . R1 said the CNAs used the total lift to get her back in bed without the nurse checking her first. R1 said the facility did X-rays a couple days after she fell , but they told her there wasn't a fracture. R1 said she was having hip pain for two weeks before she was sent to the hospital. R1 said she had to have her hip repaired surgically. R1 said she wasn't able to do her regular therapy because her right hip was hurting too bad. R1 said she tried the sit to stand one more time, but it hurt so bad, and they had to stop. R1 said after that, she only did therapy in her bed, and it hurt when she did the leg exercises. R1 stated, I think someone made a mistake. I don't like to think about the fall. It was such an awful experience. I was just hanging from that sit to stand lift, by my arms for a long time and then I fell on my butt. R1's Facesheet dated 11/6/24 showed diagnoses to include, but not limited to: right hip fracture and orthopedic aftercare (9/9/24); CHF (Congestive Heart Failure); COPD (Chronic Obstructive Pulmonary Disease); peripheral venous insufficiency; stroke with right sided weakness; major depressive disorder; morbid obesity; lymphedema; GERD (Gastro-Esophageal Reflux Disease); chronic pain syndrome; pain in right shoulder and right hip (9/9/24); reduced mobility; unsteadiness on feet; generalized muscle weakness; lack of coordination; and need for assistance with personal care. R1's facility assessment dated [DATE] showed she was cognitively intact; and was dependent on staff for toileting, shower/bathing, and transfers. R1's Progress Notes and Assessments were reviewed for 8/23/24. There were no notes or assessments (vital signs, neuro checks, ROM, pain, skin check) completed by R1's nurse (V18 - Agency RN). There were late entries created on 8/30/24 by V2 (DON - Director of Nursing) and V30 (MDS Coordinator). R1's Post Fall Evaluation dated 8/23/24 showed R1 had a witnessed fall in her room when she was being transferred to bed with a sit to stand mechanical lift, by V19 and V20 (CNAs). R1's Progress Note dated 8/25/24 showed, Resident complained of pain with ROM (Range of Motion) to right shoulder, right hip, and right lower extremity . The doctor was notified and orders for X-rays were obtained. (This note was 2 days after R1's fall). R1's portable Right hip X-ray report 8/25/24 showed there was no fracture or dislocation seen and she had moderate degenerative changes. R1's Health Status Note dated 9/5/24 showed R1 continued to complain of right hip pain after a fall on 8/23/24. The doctor was notified, and orders were received to send R1 to the hospital. R1's progress notes do not show continued assessments of R1 after her fall. R1's notes do not reflect that she was unable to bear weight in therapy, could no longer use the sit to stand lift, had pain with ROM/exercises with right leg, and was complaining of right hip pain from 8/25/24 until 9/5/24 (when she was sent to the hospital for continued right hip pain after a fall on 8/23/24.) R1's August and September 2024 MARs showed R1 took Norco (opioid pain medication) 5-325 mg 1 tablet 2-4 times a day for pain rated 3-9 on a 1-10 scale. R1's Occupation Therapy Notes dated 8/23/24 (before she fell ) showed R1 was currently using the sit to stand machine for lifts and was completing tasks to increase her upper arm strength. On 8/26/24 R1's notes showed the therapist discussed attempting to get R1 up with a sit to stand lift tomorrow and R1 said she would try and wanted to work towards using the sit to stand again. R1's note on 8/27/24 showed she was a total lift transfer. R1's Physical Therapy Discharge Summary dated 5/20/24 to 9/6/24 showed R1's prior equipment was a sit to stand lift and wheelchair. This summary showed R1 was discharged to the hospital. This note showed, .Progress & Response to Treatment: The patient had been demonstrating good stability on the sit to stand lift for functional transfers but had fallen off the lift when transferring with the CNAs in her room. Patient had been complaining of RLE (right lower extremity) pain, was admitted to the hospital . R1's Physical Therapy Recertification, Progress Report and Updated Therapy Plan dated 8/20/24 to 9/29/24 showed R1 was able to perform bed to wheelchair transfers with sit to stand lift with good stability but required more skilled therapy to ensure safety on sit to stand lift and to trial toilet transfers with sit to stand lift for safety. R1's Physical Therapy Progress notes dated 8/22/24 (before she fell ) showed she performed a sit to stand from the bed to the wheelchair and the wheelchair to the bathroom. R1's Physical Therapy notes do not include R1's sit to stand performance after the fall on 8/23/24. R1's Orthopedic Pre-operative Report dated 9/8/24 showed R1 had a surgical nailing of her right hip to repair the fracture. This note showed R1 fell at the nursing home 2 weeks ago and continues to have pain in her right hip and inability to perform ADLs (Activities of daily living) including sitting to stand and stand to sit. The document showed, . The X-rays at the time of the nursing home showed a minimally displaced greater trochanteric hip fracture. The patient was then admitted to the hospital for continued right hip pain in order to get an MRI of the right hip. MRI of the right hip was done yesterday (9/7/24) which showed a greater trochanteric hip fracture with intertrochanteric extension to greater than 50% of the intertrochanteric region. The fracture was due to a combination of trauma from a fall and pathologic bone due to osteoporosis . On 11/7/24 at 12:01 PM, V18 (Agency RN) said she was R1's nurse on 8/23/24 but she had no idea R1 fell . V18 said the CNAs didn't tell her R1 fell . V18 said she was charting at the nurses' station, and she was approached by therapy. V18 said therapy reported that R1 had a rough transfer. V18 said she went to R1's room about 30 minutes later. V18 said the CNAs were in R1's room and she asked if there was an incident. They said it was a rough transfer. V18 said no one reported a fall to her, she didn't complete an assessment of R1 after the fall, and there wasn't any documentation because she wasn't aware R1 fell . V18 stated, If I knew about a fall, then I would have started the assessments and paperwork immediately. If you're going to have a fall, a witnessed fall is the easier one to have. It's less paperwork. All R1 said was she didn't want to use the sit to stand anymore, she stated, I don't want to do that again. Then I heard a few days later she told someone else she fell , and she was sent out to the hospital. V18 said she didn't take care of R1 again until she returned from the hospital after she had surgery on her broken hip. On 11/7/24 at 9:55 AM, V23 (PTA - Physical Therapy Assistant) said prior to R1 falling, they had been working training with the sit to stand. V23 said a sit to stand lift was performed in the therapy gym successfully and he had completed in room training with the CNAs on sit to stand transfers for R1. V23 said R1 was doing well with the training and could bear weight for several minutes during the transfer. V23 said he was surprised when he heard there was a rough transfer on 8/23/24 (Friday). V23 said he saw R1 the following Monday or Tuesday and attempted the sit to stand lift and R1 could not bear weight. V23 said R1 complained of right hip pain and demanded to stop. V23 said he should have documented that in his notes. V23 said he didn't attempt the sit to stand lift with R1 again and after that her therapy consisted of exercises in the bed or wheelchair and the staff used a total lift for transfers. V23 said R1 often had pain with ROM and exercises with her right leg. V23 said he did not communicate R1's complaints of right hip pain with ROM/exercises and inability to bear weight to the nursing staff. V23 stated, I thought since the X-ray didn't show a fracture that her pain would eventually go away. I was under the assumption that the nurses' knew about her right hip pain. That's my fault. I thought they knew, but I should have told them. She was doing pretty good with the sit to stand transfers before the incident, but after the failed sit to stand attempt, her therapy consisted of more seated or in the bed exercises due to her pain in the right leg. On 11/7/24 at 11:03 AM, V26 (RN - Registered Nurse) said she was familiar with R1 and verified that she had worked R1's hallway between 8/23/24 (R1's fall) and 9/5/24 (R1's transfer to hospital - 2 weeks later). V26 said R1 was alert and oriented. V26 said R1 had chronic issues of pain and had complained of hip pain occasionally. V26 said she gave R1 Norco and tried to stay on top of her pain. V26 said she was not aware that R1 was not able to bear weight in therapy and was having right hip pain with movement of her right leg. V26 stated, They don't always tell us stuff. If I knew R1 fell and she was having those problems, I'd assume her hip was broken and call the doctor to send her to the hospital as soon as possible. But no one told me that. On 11/7/24 at 8:54 AM, V22 (RN) said she was working 9/5/24 (when R1 was sent to the hospital). V22 said she was not assigned to R1 but was the supervisor working that day. V22 said V25 (R1's nurse) came to her because she didn't know what to do. V22 said V25 reported R1 had a fall on 8/23/24 and was complaining of right hip pain rated at a 10 on a 1-10 scale. V22 said she told her to call the nurse and helped call 911. V22 said that's why she entered a note on 9/5/24. V22 said if a resident had a fall and is complaining of severe hip pain, they need to be sent out as soon as possible because there may be a fracture. On 11/7/24 at 1:02 PM, V2 (DON) said she was at the facility on 8/23/24. V2 said she didn't witness R1's fall, was not in R1's room after the fall and didn't not complete an assessment on R1 on 8/23/24. V2 said the CNAs did not report a fall. V2 said she was in the hall and overheard V19 talking. V2 said V19 reported a rough transfer, but not a fall. V2 said she didn't ask any other questions and went to deal with another issue. V2 said on 8/25/24 she got a call from V1 (Administrator). V2 said she was told R1 was having pain all over, and was asked if there had been an incident. V2 stated, I told her that I heard there was a rough transfer but wasn't aware of an incident. She (V1) said [R1] did go on the floor and that's considered a fall. They got orders for X-rays. I didn't come in that day or do an assessment. The nurses should be documenting a fall and their assessment in the progress notes. The purpose is to ensure there is continuity of care and communicate with other staff what has been happening with the resident. On 8/30/24 we had a fall meeting and were reviewed R1's documentation and realized there was no charting on 8/23/24 about the fall. V2 said, If a resident is complaining of pain with ROM after falling, then the resident shouldn't be moved and sent out 911 to the hospital. I don't have X-ray vision. I can't tell if there is a fracture by looking at them. The nurses should have charted all of that information, but the CNAs didn't report a fall. V2 said the nurses should have performed and documented continued assessments of R1 after she fell to ensure there wasn't an injury. V2 said she was not aware that R1 was having pain with movement of the right leg and was no longer able to bear weight. V2 said therapy did not report that to her. V2 said if she had known, then she would have sent R1 out to the hospital sooner for further evaluation. V2 said R1's progress notes and assessments should reflect a timeline of R1's injuries and complaints. V2 said R1's progress notes did not contain the pertinent nursing assessments to demonstrate a thorough assessment. V2 said the purpose of continued assessments, documentation of findings, and interdisciplinary communication of resident's change of condition is to ensure the resident is receiving proper care and continuity of care can be maintained. On 11/7/24 at 11:26 PM, V27 (NP - Nurse Practitioner) said she is familiar with R1 and took care of her before she was admitted to the facility. V27 said she would expect the staff to complete a head to toe assessment after a fall, continued assessments of the resident, and to document their assessments. V27 said the nurses will notify her or the physician of falls. V27 said if there is an injury then they call right away, but if not, injury they may send a message. V27 said she wasn't sure when she was notified of R1's fall. V27 said she doesn't document her phone communication with the facility. V27 stated, The facility is responsible for maintaining that documentation. V27 said she had not done an assessment on R1 between 8/23/24 - 9/5/24. V27 said she expects the staff to perform and assessment and notify her of any changes in the resident condition. V27 said she isn't an orthopedic doctor, but inability to bear weight, increased pain upon palpation of the right hip area, or increased pain with movement of the right leg could be indications of a fracture. V27 said she would expect the staff to notify her immediately with these symptoms, so the resident can be transferred to the hospital for further evaluation. V27 said it's possible that R1's fall on 8/23/24 contributed to her right hip fracture, but she was not an orthopedic doctor. On 11/7/24 at 3:08 PM, V28 (Orthopedic Surgeon) said it's very likely that the initial portable X-ray completed on 8/25/24 did not capture the fracture due to R1's body size and positioning with portable X-ray machines. V28 said an MRI would be needed for more sensitive results. V28 said inability to bear weight, pain in the hip area, or pain with ROM/movement of the affected limb are signs of a fracture. V28 said the facility should report these concerns to the physician and obtain an order to send the resident to the hospital for further evaluation. V28 said he wasn't clear how R1 fell . The surveyor explained the fall from the sit to stand lift. V28 replied, It's very likely that caused her fracture, and the original X-ray missed it. If she was complaining of continued pain and hadn't returned to baseline physical functioning, they should have sent her to the hospital. She ended up having surgery to repair her hip. The pain she was having was likely from the fracture and she needed stabilization (surgery) on her hip to reduce the pain. The facility's undated Safe Resident Handling/Transfers Policy showed, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines . The facility's undated Fall Prevention Program showed, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Definitions: A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force (e.g. resident pushes another resident). The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere . 9. When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of injury. The facility's undated Fall Checklist showed, #1. Complete assessment/VS, initial neuro checks as indicated. If any injury noted or suspected keep resident still and do not transfer to bed or chair. Contact 911 and send to ED for evaluation and treat .

Based on interview and record review the facility failed to provide sufficient staffing to meet resident's needs. This has the potential to affect all residents in the building. The findings include: The facility's resident roster dated 11/6/24 showed 67 residents reside in the facility. R1's face sheet dated 11/6/24 showed diagnoses including but not limited to right femur fracture, orthopedic after care, right side paralysis, morbid obesity, and history of falls. R1's facility assessment dated [DATE] showed no cognitive impairment and total staff assistance for transfers and toileting. The same assessment showed R1 is always incontinent of urine and bowel. R3's face sheet dated 11/7/24 showed diagnoses including but not limited to urinary tract infection, clostridium difficile, use of an ostomy bag (for collection of stool via the intestines), and muscle wasting. R3's facility assessment dated [DATE] showed no cognitive impairment and total staff assistance for transfers and toileting. The same assessment showed R1 is frequently incontinent of urine. R5's face sheet dated 11/7/24 showed diagnoses including but not limited to diabetic peripheral angiopathy, lumbar region disc degeneration, peripheral venous insufficiency, chronic kidney disease, osteoarthritis of knee, and muscle wasting. R5's facility assessment dated [DATE] showed moderate cognitive impairment and total staff assistance for transfers and toileting. The same assessment showed R5 is frequently incontinent of urine and bowel. R7's face sheet dated 11/7/24 showed diagnoses including but not limited to diverticulosis of intestine, obesity, gastric ulcer, osteoarthritis, malaise, and muscle weakness. R7s facility assessment dated [DATE] showed no cognitive impairment and total staff assistance for transfers and toileting. The same assessment showed R7 is frequently incontinent of urine and occasionally incontinent of bowel. On 11/6/24 at 10:44 AM, R1 was lying in her bed. R1 said sometimes she must wait over two hours for her call light to be answered. R1 said it's worse at night. R1 said if they don't come in time then we just have to go to the bathroom in our pants. R1 stated, It's so embarrassing. On 11/6/24 at 11:08 AM, R6 self-propelled her wheelchair down the hall, into her room. R6 said the staff that works at the facility is wonderful, but they need more help and more slings. R6 stated, I blame that on the owners. They should make sure there is enough people working and enough slings. The other night I was stuck in bed all day and night because they didn't have the help or a sling to get me up. I have to use a total lift. On 11/6/24 at 11:30 AM, R3 was lying on her bed and stated the aides take too long to answer my call light. R3 said, Sometimes it is over an hour. I have to wait so long I end up going to the bathroom in my pants. Sometimes I just transfer to the toilet alone. They (staff) frown on that but I can't wait any longer. It takes a long time to get help to change me too. It seems like there is a lot of staff calling off and not coming in to work. There isn't any one particular shift that is bad, they are all bad. There just isn't enough help. On 11/7/24 at 9:10 AM, R5 was lying in bed and stated she needs help to walk or get out of bed. R5 said, They (staff) make me wait around to get me up or lay me down. I just have to lay here and wait till someone shows up. Most of the time I have already wet or went number two in my pants. They take too long to get me out of bed and into the bathroom. On 11/6/24 at 2:35 PM, R7 was seated in an upright recliner and stated call light response time varies depending on what is going on in the building. R7 said it is frequently a long wait time and many times she goes to the bathroom in her pants. R7 said there are a lot of times more CNAs (Certified Nurse Aides) are needed so she isn't sitting and waiting so much. R7 said staff leave her on the toilet way too long and it gets annoying. R7 said the evening wait times are even longer. She can't get into bed when she wants to. R7 stated she uses a mechanical sit to stand to transfer. Aides do it with only one person a lot of the time because they can't find a second aide to help. R7 said only one aide is used at least 50% of the time. On 11/6/24 at 2:40 PM, V9 (CNA) and V10 (CNA) were interviewed together. V9 stated it is difficult to find coworkers to help with resident care at times. V9 said a few disappear when call lights go off. V9 said two CNAs are required for all mechanical lift transfers. On 11/7/24 8:38 AM, V21 (CNA) said she comes in at 5:00 AM for the day shift. V21 said there are days that are very hectic, and many residents are soiled (in urine or feces) when she comes in. V21 said she doesn't work nights, so she doesn't know what it's like. V21 said maybe there were call offs. On 11/7/24 at 9:50 AM, V13 (CNA) stated there is absolutely not enough staff for resident care. V13 said CNA staffing numbers were reduced by administration about three weeks ago, but it has been a problem since early spring. V13 stated some aides are forced to transfer residents without two people. The evening cares can't get done on time. Wet or soiled residents have to wait longer until they can be changed. V13 said the overnight rounds don't get done on time because there isn't enough staff. V13 said several other CNAs are having the same issues. Three other evening or night CNAs were attempted to be reached for interview. Calls were not returned before the end of the survey. On 11/7/24 at 11:00 AM, V2 (Director of Nurses) stated it is a facility expectation that call lights are answered in 3-5 minutes. V2 said, Staff should at least be addressing the resident and let them know they will be back if they are busy. It is a safety thing. They can't know if it is an emergency if they don't go check on the resident. It is unsafe to be transferring residents without two staff and unsafe for residents to do it by themselves. It is embarrassing for residents to have to go to the bathroom in their briefs. It makes them feel horrible, like anyone would feel. V2 stated long call light response times could be an indication more staff are needed. The facility was unable to provide any policy related to staffing. The facility's Resident Rights policy last review dated 7/1/24 stated under the respect and dignity section: c. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents. The policy stated under the self-determination section: b. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident.

Based on observation, interview, and record review the facility failed to ensure safe resident transfers for two (R1 and R2) of three residents reviewed for falls with transfers in a sample of three. This failure resulted in R1 and R2 being sent out to the hospital. R1 suffered from pain and a left hip fracture requiring surgery. R2 suffered from pain and a left hip sprain and sacral contusion. Findings include: The facility's undated Safe Resident Handling/Transfers policy documents, Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Policy Explanation: All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used. Compliance Guidelines: 3. Mechanical lifting equipment or other approved transferring aids will be used based on the resident/s needs to prevent manual lifting except in medical emergencies. 4. Mechanical lifts may include equipment such as full body lifts, sit to stand lifts, or ceiling track mounted lifts (add any others that may apply). 5. Handling aids may include gait belts, transfer boards, and other devices (specify as applies). The facility's undated Use of Gait Belt policy documents, Policy: It is the policy of this facility to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety. Policy Explanation and Compliance Guidelines: 1. Each nursing department employee will be given a gait belt during orientation .3. It will be the responsibility of each employee to ensure they have it available for use at all times when at work. The facility's undated Fall Prevention Program policy documents, Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. 1. R1's current Face Sheet documents diagnoses including, but not limited to: Fracture of Unspecified part of neck of left femur; Diabetes Mellitus Type II; Unspecified Dementia, Unspecified severity with other behavioral disturbance; Weakness; History of falling; and Unsteadiness on feet. R1's Fall Risk Evaluation, dated 7/30/24, documents R1 is a high risk for falls. R1's Minimum Data Set/MDS Assessment, dated 7/30/24, documents R1 is cognitively intact and is dependent on staff for toilet transfers. R1's current Care Plan includes but is not limited to (R1) requires extensive assist of 1 (one) with toileting and ileostomy cares and (R1) is at risk for falls related to Confusion, Gait/balance problems, and Unaware of safety needs . R1's Fall Nursing Progress note, dated 8/31/24 at 10:30am by V7 Licensed Practical Nurse/LPN, documents, Fall occurred on 8/31 at 9:45am in the resident's bathroom. Resident (R1) was transferring from toilet to sink with gb (grab bar) and walker. While transferring, (R1's) left leg gave out and (V6 Certified Nursing Assistant/CNA) caught resident's head from hitting the floor. Resident landed on L (left) hip. When nurse (V7) walked in the room, resident (R1) was sitting on her bottom laying against the bathroom wall. Full assessment initiated. Full range of motion in upper and lower extremities. Resident able to move both legs up and down along with her arms. Slight pain noted in L (left) hip. (V6 CNA) and nurse (V7) helped resident (R1) up to walker, no complaints of pain during that time. Resident (R1) walked back to her bed from bathroom. VS (vital signs) WNL (within normal limits). (V6) CNA denies resident hitting her head. No visible injuries noted at the time. Assisted resident back to bed. R1's Progress note, dated 8/31/24 at 3:00pm by V7 LPN, documents, Reassessed resident's pain and rates 8/10 pain. Noted pain in L (left) groin area. Notified V12 R1's Nurse Practitioner/NP and new order to obtain STAT (immediate) x-ray of L (left) hip/femur and Tramadol 50mg (milligrams) TID (three times per day) x (times) 3 days. R1's Progress note, dated 8/31/24, at 7:40pm by V7 LPN, documents, X-ray results came back and noted L (left) femoral neck fracture. Notified (V12) NP. Administered Tramadol 50mg for pain. New order to send resident to ER (emergency room ) for evaluation and treatment. R1's Progress note, dated 9/5/24, documents, Resident arrived to facility via ambulance from (named hospital) at 5:45pm, primary diagnosis closed left hip fracture, WBAT (weight bearing as tolerated) to LLE (left lower extremity). C/o (complains of) pain 8/10, received PRN (as needed) Tramadol at 6:30pm. Resident received a Norco prior to arrival at 4:25pm. Colostomy changed today at hospital. Surgical incision to left lateral thigh with 9 staples, dry blood on dressing . The facility's Reportable for R1's fall on 8/31/24, documents V6 CNA's statement as, (V6) states resident was transferring from toilet to sink with grab bar and walker. While transferring (R1's) left leg gave out and I caught her head from hitting the floor. (R1) landed on her left hip/leg. (V6) states the nurse did a full ROM (range of motion) assessment and resident c/o (complained of) minimal soreness. (R1) was pulling and trying to get up so they assisted (R1) and (R1) said I have no pain and ambulated with no difficulty. R1's radiology report of left femur, dated 8/31/24, documents, Results: There is a fracture involving the left femoral neck with minimal to no displacement. The joint shows no dislocation. Pubic rami are intact. Osteopenia is present. R1's Witness Fall Investigation report, dated 8/31/24, documents, Resident was transferring from toilet to sink with gb (grab bar) and walker. While transferring, her left leg gave out and CNA caught resident's head from hitting the floor. Resident landed on L hip. When nurse walked in the room, resident was sitting on her bottom laying against the bathroom wall. Full assessment initiated. Full range of motion in upper and lower extremities. Resident able to move both legs up and down along with her arms. Slight soreness noted in L hip. CNA and nurse helped resident up to walker due to resident insisting on getting up and was pulling at that time we assisted to prevent further incident, no complaints of pain during that time. Resident walked back to her bed from bathroom. VS WNL. CNA denies resident hitting her head. No visible injuries noted at the time. Assisted resident back to bed. Administered PRN (as needed) Tylenol for pain. 'I turned too fast, and my leg gave out.' On 9/10/24 at 11:25am, R1 sat in a wheelchair in the therapy room. R1 stated the following occurred on 8/31/24: I went to the bathroom with (V6 Certified Nursing Assistant/CNA) and my walker. (V6) did not put a gait belt on me. There were none in my room and (V6) did not bring one with him. He stayed in the bathroom with me while I was on the toilet. I stood up holding the grab bars and (V6) pulled my pants up. I went to use hand sanitizer and he asked if I wanted to wash my hands. I turned around and did that. I shook my hands off. Then I think I turned too quickly to get paper towels and I hit the wall with my back. I slid down and couldn't grab the bar. I slid down the wall and hit the floor. (V6) caught my head as it was only about six inches from the stone floor. I couldn't get up and needed two people, so he (V6) and a nurse (V7 Licensed Practical Nurse/LPN) got me up and walked with me to the bed. Later, I went to the lobby, but by 4pm I couldn't take the pain. I went to the (local) hospital then they transferred me to (named) hospital for surgery for a left hip fracture. On 9/10/24 at 3:05pm, V6 CNA stated the following: She (R1) needed to use the restroom and empty her colostomy bag. She was in her wheelchair, and we went down to her room. (R1) was dumping out her stool into a measuring cup and I said, 'hey, let's wash our hands' and I got her up to the sink. I tried to reposition the wheelchair behind her while she washed her hands. I was in visual view of her but was hands off. She turned and then did a weird jerk and I said, 'oh snap'. (R1) fell on her left side. I was able to catch her head. The moment (R1) was on the floor I went to get my nurse (V7 LPN). (R1) insisted she could get up on her own and with a walker, so we helped her. I should not have let go of (R1) to get the wheelchair. I should have grabbed the (mechanical lift) instead of letting her walk to the wheelchair after the fall. Protocol is we (mechanical lift) after a fall. (R1) insisted and felt good to get up. V6 could not recall for sure if V6 used a gait belt for R1's transfer. On 9/10/24 at 3:19pm, V7 LPN stated the following, I did not witness (R1's) fall (on 8/31/24). I was doing med pass and (V6 CNA) came and grabbed me. (V6) explained that (R1) turned around to wash her hands too fast and went down. (V6) said he caught (R1's) head before hitting the floor. I went with him and assessed (R1). I should have used a (mechanical lift) to get (R1) up, but (R1) insisted on getting up with me and (V6's) help. V7 confirmed that gb in the progress note V7 wrote meant grab bar. V7 said, (R1) was not wearing a gait belt. After the fall we got her up without a gait belt by going under her arms to lift her up then walked her to her bed. A gait belt would be ideal, give resident more time to wash her hands, not let go of her or have her out of site. If I'd known she had that injury I would have used the (mechanical lift). (V1) told me we are a no lift facility which means everybody is a (mechanical lift) after a fall. I did know that, but in the heat of the moment we thought it was just easier to help her up. (R1's) transfer status was a stand-by one assist so a gait belt should be used. On 9/10/24 at 11:35am, V4 Physical Therapy Assistant/PTA stated that prior to (R1's) fall on 8/31/24, (R1) was receiving therapy and was a one assist with walker. (R1) was walking 75-100 feet. V4 confirmed that a gait belt is to be used for transfers and is the house-wide facility policy. On 9/11/24 at 9:25am, R1 was lying in bed with a mechanical lift sling under her. V5 and V11 CNAs prepared to transfer R1. V5 brought the mechanical lift into R1's room. V5 and V11 hooked the lift to the sling, V5 supported R1's left leg while they lifted her up then lowered her into her wheelchair. R1 grimaced and stated her left hip hurts right where the staples are. On 9/11/24, at 12:30pm, V1 Administrator confirmed a gait belt should have been used for R1's transfer. V1 stated that after a resident fall the staff are to use a mechanical lift to get the resident up. V1 confirmed that when V6 and V7 didn't use a mechanical lift they should have then used a gait belt to assist R1 to get off the floor. V1 stated, We are a no lift facility, and we train staff to use a mechanical lift and they understand that. 2. R2's current Facesheet documents diagnoses including, but not limited to Diabetes Mellitus Type II; Unspecified Dementia, Unspecified severity; Obesity; Unsteadiness on feet; and Muscle Weakness (generalized). R2's Fall Risk Evaluation, dated 7/3/24, documents R2 is a high risk for falls. R2's Minimum Data Set/MDS Assessment, dated 7/3/24, documents R2 is moderately cognitively impaired; uses a wheelchair and walker; requires substantial/maximal assistance for sit to lying - the ability to move from sitting on side of bed to lying flat on the bed; and partial/moderate assistance for chair/bed-to-chair transfer - the ability to transfer to and from a bed to a chair (or wheelchair). R2's current Care Plan documents R2 has an ADL (Activities of Daily Living) self-care performance deficit related to Limited Mobility, confusion, multiple comorbidities and Dementia with interventions including but not limited to Transfer: Requires extensive assist of 1-2 with gait belt and wheeled walker for stand and pivot transfers and (R2) is at risk for falls related to Confusion and Gait/balance problems. R2's Progress note, dated 9/3/24 and signed by V8 Licensed Practical Nurse/LPN, documents, Summoned to the resident room on 9/2/24 at 7:10pm. (V9) CNA (Certified Nursing Assistant) was transferring resident stand and pivot from wheelchair. When CNA was moving wheelchair out of the way resident slid out of bed onto left side of the floor and did not hit head. This note states that V12 (R2's Nurse Practitioner) ordered to send (R2) to ER (emergency room ) to evaluate and treat .Resident was transferred with the assist of four to stretcher and left for ER at this time. R2's Progress note, dated 9/3/24 at 00:10am by V8 LPN, documents, Resident returned from (named ER) had left hip and lumbar spine (back) x-ray with DX (diagnoses): left hip sprain and contusion of sacrum. No complaints of pain or discomfort at this time. R2's Witness Fall Investigation report, dated 9/2/24, documents, Resident was transferring to bed and was sitting on the side of bed. CNA (V9) moved the wheelchair out of the way to help resident put legs in bed. When CNA was moving the wheelchair, resident slip out of the bed onto her left side. Complained of left hip pain .Resident unable to give description. This report documents V9's statement as, I was transferring resident to bed from the wheelchair stand and pivot. Resident was sitting on the side of the bed, and I moved the wheelchair out of the way so I could help resident get her legs in bed. As I was moving the wheelchair resident slid off bed and landed on her left side. Did not hit her head. On 9/10/24 at 3:48pm, V8 Licensed Practical Nurse/LPN stated the following, I was getting report and (V9 CNA) came up to me and said (R2) just fell . (V9) said she was transferring and (R2) was sitting on her bed. (V10 Registered Nurse/RN) and I went down there. (R2) complained of a lot of pain, back, hip and whole left side which she was laying on. (V9) did not use a gait belt and (V9) should have. (R2) is a stand and pivot. (V9) had (R2) on the bed and went to move the wheelchair to make room for (R2's) legs and as (V9) moved the wheelchair (R2) went down. (V9) should not have left (R2) to move the wheelchair. (V9) could have just pushed it out of the way. The wheelchair was over by the closet door when I walked in. (R2) had a sprain of the hip and a contusion to the sacrum. We had ordered her Tylenol 1000 mg every 6 hours as needed and I felt she needed something stronger, so we got an order for Norco. On 9/11/24 at 10:13am, V9 CNA stated the following: I had taken (R2) back to bed and had her on the bed sitting. (R2) usually has to scoot back a little bit when she sits on the bed. We hadn't got back to that part. I pulled the wheelchair away to the end of the bed. Maybe she was reaching for the remote or something. (R2) fell off the bed. I turned a little bit, but was right next to her, but the wheelchair was in front of me. I helped transfer (R2) from her wheelchair to her bed. I did not have a gait belt on her. I should have used it and usually do. I had left it in the resident's room prior. When I use a gait, I usually keep my hands on the gait belt. I could have kept the wheelchair there or given her the remote. (R2's) legs were bad that day and (R2) has a hard time standing. Possibly could have prevented (this fall) if I wouldn't have taken my eyes off her. I hadn't taken care of her for a long time either. V9 confirmed that the facility policy is to use gait belts on all transfers. V9 stated, (R2) self-transfers but needs one assist and that's where the use of the gait belt comes in. I don't trust her. I feel awful. I stayed with her until ambulance came and got her. She had pain at first in one of the hips. R2's hospital After Visit Summary, dated 9/2/24, documents, Reason for visit: fall. Diagnoses: Fall in elderly patient; Hip sprain, left, initial encounter; Contusion of sacrum, initial encounter. Imaging Tests: Left Hip X-ray, Lumbar Spine (Back) X-ray. R2's September 2024 Medication Administration Record/MAR documents R2 received Tylenol 650 mg (milligrams) on 9/3/24 at 5:49am for 10/10 pain and Tramadol HCl (Hydrochloride) 50 mg at 7:35pm for 9/10 hip pain. On 9/10/24, at 10:40am, R2 sat in a wheelchair in her room. R2 stated that she had fallen off the bed. R2 said, I must have wanted to get up to go to the bathroom or something. The ambulance came and took me away. I hurt my buns. It still hurts when I sit. On 9/11/24, at 12:30pm, V1 Administrator stated that a gait belt should have been used for R2's transfer; (V9 CNA) got written up for not using a gait belt. The facility's Employee Disciplinary Form, dated 9/2/24, documents that V9 CNA received a verbal warning for Transferred a stand a pivot resident without the use of a gait belt.

Based on observation, interview and record review, the facility failed to implement pressure ulcer prevention interventions for a resident identified at risk of skin breakdown and failed to complete weekly skin assessments for one of one resident (R8) reviewed for pressure ulcers in the sample of 24. This failure resulted in R8 developing unstageable pressure ulcers to R8's bilateral heels. Findings include: The facility's undated Pressure Injury Prevention and Management Policy documents, Policy - This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Avoidable is defined as, The resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. A section titled Policy Explanation and Compliance Guidelines documents, 2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. 3. Assessment of Pressure Injury Risk: a. Licensed nurses will conduct a pressure injury risk assessment, using the (Pressure Ulcer Risk Assessment) tool, on all residents upon admission/re-admission, weekly x (times) four weeks, then quarterly or whenever the residents' condition changes significantly. 4. Interventions for Prevention and to Promote Healing a. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. b. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). c. Evidenced based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but are not limited to: i. Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.); ii. Minimize exposure to moisture and keep skin clean, especially of fecal contamination; iii. Provide appropriate, pressure-redistributing, support surfaces; iv. Provide non-irritating surfaces; and v. Maintain or improve nutrition and hydration status, where feasible. f. Interventions will be documented in the care plan and communicated to all relevant staff. g. Compliance with interventions will be documented in the weekly summary charting. 5. Monitoring: a. The RN (Registered Nurse) Unit Manager, or designee, will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance at least weekly, and document a summary of findings in the medical record. The facility's undated Skin Assessment Policy documents, It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment. This policy further documents Compliance Guidelines as, 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. R8's Admission Record documents R8 was most recently admitted to the facility on [DATE] with diagnoses to include: Type 2 Diabetes Mellitus, Age-Related Osteoporosis, Need for Assistance with Personal Care, Unspecified Dementia, Chronic Kidney Disease Stage 3B, Heart Failure, Unspecified Urinary Incontinence and Weakness. R8's Minimum Data Set Assessment, dated 8/23/23 documents, R8 has moderately impaired cognition; is at risk of developing pressure ulcers/injuries; requires extensive assistance by two (plus) persons physical assist in the areas of bed mobility, transferring, dressing, toileting, and personal hygiene. R8's current Care Plan documents, R8 is at risk for skin breakdown due to limited mobility, incontinence, diagnosis of diabetes and chronic kidney disease; R8 has an ADL (Activities of Daily Living) self-care performance deficit related to Dementia, Impaired balance, Limited Mobility, Disc Degeneration, Osteoporosis and Osteoarthritis; Needs assist to turn and reposition at least every two hours and as needed; Requires extensive assistance of one to reposition in recliner chair; R8 has cognitive impairment; and is malnourished. R8's Predicting Pressure Ulcer Risk Evaluation, dated 7/21/23, documents R8 is at risk for developing pressure ulcers. This same Pressure Ulcer Assessment contains Clinical Suggestions for pressure ulcer prevention interventions to be implemented. R8's clinical suggestions are all blank and not marked as implemented on this evaluation tool. R8's Predicting Pressure Ulcer Risk Evaluation, dated 8/22/23, documents R8 is at moderate risk for developing pressure ulcers. A section titled Activity documents R8 is Chairfast: Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. A section titled Mobility documents R8 is Very limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. A section titled Nutrition documents R8 Probably Inadequate: Rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. A section titled Friction and Shear documents Problem: Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. This Pressure Ulcer Assessment has Clinical Suggestions for pressure ulcer prevention interventions to be implemented. R8's clinical suggestions are all blank and not marked as implemented on this evaluation tool. R8's Mini Nutritional assessment dated [DATE] documents the following: R8 is bed/chair bound and R8 is with severe dementia or depression. R8's Progress Note dated 9/11/23 at 1:21 am documents, (R8) continues to receive (hospice) services for heart failure. Periods of lethargy. Dependent upon all aspects of care. Transfers per (two) staff assist and (mechanical) lift. Mobility and positioning per (geriatric)-chair propelled by staff. (Two) staff assist required with bathing, personal hygiene, dressing, toileting, and post-use hygiene cares. (Bowel and bladder) incontinence with brief worn. Staff assist of one with feeding. Intake varies. R8's Progress Note dated 10/16/23 and written by V14 (Registered Nurse) documents R8 continues with (local hospice) for CHF (Congestive Heart Failure); transfers with two assist and (mechanical lift); Uses (reclining chair with wheels) for mobility, assist of one to two with bathing, dressing, and grooming; Assist of two with toilet use and post-use hygiene; Incontinent of bowel and bladder with brief worn at all times. R8's Client Coordination Notes Report dated 10/17/23 and written by V12 (Hospice Aide) documents, During this (visit, I) found a very large blister on (R8's) left hill (heel), black in the middle . (Manager, V13) notified of changes. R8's Client Coordination Notes Report dated 10/18/23 and written by V13 (Hospice RN) documents, (R8) is a [AGE] year-old living (at present facility) with primary diagnosis of CHF (Congestive Heart Failure) with senile degeneration of the brain. This same note documents (R8) was asleep in her (mobility) chair; R8 would mumble occasionally; R8 is a total assist with her ADLs (Activities of Daily Living); R8 will not eat without being fed, and even then, only taking in 25% (percent). (V12) had called earlier and said (R8's) left heel had a blister on it from pressure. Heel protectors were ordered and new wound care order. It was covered with Hydrogel at this visit. R8's Progress note written by V14 (Registered Nurse) on 10/17/23 at 7:44 pm documents, Hospice CNA (V12) summoned this nurse to (R8's) room. Hospice CNA (V12) notified Hospice RN (V13) awaiting call back. (R8) presents with a left (heel) ulcer black colored noted to heal (heel). Treatment in place for foam boarder dressing M/W/F (Monday, Wednesday, Friday) and PRN (as needed) until healed. (Pressure Ulcer Preventative soft boots) in place for left foot. R8's Wound Observation Tool dated 10/17/23 documents, R8 has a (facility) acquired ulcer measuring four centimeter by three centimeter area to R8's left heel. R8's Care Plan was revised on 10/18/23 to include R8 had a wound to R8's left heel. There are no interventions added for pressure relieving device to R8's heel(s). R8's Physician Order Sheet dated October 2023 documents an order for (pressure relieving) boots at all times to left foot with an order start date of 10/17/23. R8's Progress Note dated 10/19/23 at 7:25 pm states, (Hospice) CNA/Certified Nursing Assistant noted a pressure sore starting to R8's right heel when giving (R8) a bath. Dark soft area (one centimeter in diameter) noted with surrounding skin red. Hospice to bring air mattress and (pressure relieving boot) applied with new order for skin prep. R8's Wound Observation Tool dated 10/19/23 documents R8 developed a (facility) acquired pressure area to R8's right heel discovered on 10/19/23. This same Tool documents R8's pressure ulcer as a dark circle measuring one centimeter by one centimeter. On 10/17/23 at 10:35 am, R8 was observed in R8's bedroom, sitting upright in a (wheeled mobility) chair with R8's knees bent and R8's feet flat, directly on the chair rest. No chair cushion was noted to R8's chair or pressure relieving interventions were noted to R8's bilateral heels. On 10/17/23 at 12:06 pm, R8 was observed in R8's (wheeled mobility) chair inside her room. R8 remained upright in her chair with her knees bent and feet resting directly on the footrest. R8 appeared asleep and did not respond when surveyor knocked on her open door. No chair cushion was noted to R8's chair or pressure relieving interventions were noted to R8's bilateral heels. On 10/17/23 at 2:30 pm, R8 was observed lying in bed on her back. R8's feet were not elevated off the bed and no pressure relieving devices were in place. On 10/18/23 at 10:30 am, R8 was noted to be in R8's (wheeled mobility) chair. R8 was sitting slightly reclined with her knees bent and feet flat on the footrest of her chair. No chair cushion was noted to R8's chair or pressure relieving interventions were noted to R8's bilateral heels. On 10/19/23 at 11:28 am, R8 was noted to be in bed with facility staff performing incontinence care. At this time, an approximate two centimeter by one centimeter open area was noted to R8's right heel. 10/19/23 at 1:23 pm V2 (Director of Nursing) confirmed R8 is at moderate risk for developing pressure ulcers; R8's left heel pressure ulcer was discovered on 10/17/23; R8 was ordered a heel protector for R8's left foot only; R8 developed a new pressure ulcer to R8's right heel on 10/19/23; pressure reducing interventions had not been implemented prior to R8's bilateral heel skin breakdown; and R8 did not have a chair cushion to offload pressure when R8 was out of bed. V2 stated V2 ordered offloading supplies today (10/19/23) and R8 now has bilateral heel protectors. At this time, V2 verified skin assessments should be performed by the nurses weekly. V2 verified V2 was only able to provide one Weekly Skin Assessment conducted by a licensed nurse which was dated 8/27/23. As of 10/20/23, R8's medical record did not contain documentation that weekly skin assessments were completed on R8 since R8's admission to the facility other than the one obtained on 8/27/23 and R8's medical record did not contain documentation that pressure ulcer prevention interventions were implemented for R8's bilateral heels prior to the development of R8's pressure ulcers.

Based on observation, interview, and record review the facility failed to ensure the designated Infection Control Preventionist completed the specialized training in infection prevention and control. This failure has the potential to affect all 66 residents residing in the facility. Findings include: The facility's current Infection Control Line List for COVID-19 documents, as of 10/14/23, 14 residents have tested positive for COVID-19 with outbreak beginning on 10/8/23. As of 10/19/23 there are 18 residents who have tested positive for COVID-19. On 10/17/23 at 9:00 am, signage was posted on the facility entrance door indicating the facility was experiencing an outbreak of COVID-19. A table to the right of the facility entrance held surgical masks and an automatic dispenser of hand sanitizer was positioned next to the table. On 10/17/23 at 9:15 am, V1 Administrator stated the facility is in a COVID-19 outbreak and V3 ADON (Assistant Director of Nursing) was the designated facility's ICP (Infection Control Preventionist). V3 ADON/ICP was responsible for the facility's Antibiotic Stewardship Program. On 10/20/23 at 9:22 am, V3 ADON stated she is the Infection Preventionist for the facility and does all the antibiotic stewardship and tracking of infections. V3 stated she has not taken the Infection Control Class yet. On 10/20/23 at 10:16 am, V2 DON stated she did take the Infection Control Course but has not yet taken the exam. On 10/20/23 at 9:55 am, V1 Administrator stated the ICP Certificates are in the Infection Control Book. V1 Administrator stated V3 ADON/ICP has not signed up for the class yet and V2 DON took the class and has not yet taken the test. The facility's Infection Control Logbook does not contain an Infection Control Infection Preventionist Certificate for V3 ADON/ICP. The Resident Census and Condition of Residents (Centers for Medicare and Medicaid Services/CMS 672) form, dated 10/17/23, documents 66 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to revise resident Care Plans for two (R17 and R59) of 18 residents reviewed for Care Plans in a sample of 24. Findings include: The facility's undated Comprehensive Care Plans policy, documents, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .Policy Explanation and Compliance/Guidelines: 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1. On 10/17/23, at 10:44am, R17 was lying in bed with oxygen flowing per nasal cannula via oxygen concentrator with a humidifier bubbler in use. R17's current POS includes a diagnosis of Chronic Diastolic (Congestive) Heart Failure with an order dated 3-22-23 for oxygen as needed. R17's current Care plan does not include any cares for R17's oxygen humidifier and tubing. On 10/20/23, at 11:12am, V4 Care Plan Coordinator stated the cares for R17's oxygen is not on R17's Care Plan and should be. 30678 2. The current Order Summary Report for R59 documents a physician order, dated 7/24/23 for antipsychotic medication Quetiapine 37.5 mg (milligrams) at bedtime related to Mood Affective Disorder. The Pharmacy Recommendation for R59, dated 8/8/23, documents, Antipsychotic Justification needed for R59's use of Quetiapine. An appropriate diagnosis must accompany each antipsychotic order, and it must also have documented justification for continued use. This recommendation lists new diagnosis as: Behavioral and Psychological Symptoms of Dementia (BPSD). The current Care Plan for R59 documents, R59 is receiving an antipsychotic medication related to mood disorder. On 10/20/23 at 11:15 am, V4 CPC (Care Plan Coordinator) confirmed R59's current Antipsychotic Care Plan documents a diagnosis of Mood Disorder. V4 CPC stated she was unaware of the 8/8/23 Pharmacy Recommendation with new diagnosis for R59's Quetiapine. V4 CPC stated V2 DON (Director of Nursing) does all the Pharmacy Recommendations and did not notify her of the new diagnosis or she would have updated it.

Based on observation, interview, and record review, the facility failed to assist with a resident's need for toileting in a timely manner for one (R5) of 18 residents reviewed for resident rights in a sample of 24. Findings include: The facility's undated policy, Helping a Resident with Toileting Needs documents: Policy: It is the practice of this facility to assist residents with toileting needs in order to maintain the resident's dignity as well as proper hygiene. The facility's undated Resident Rights policy documents, Resident Rights. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 2. Planning and implementing care. The resident has the right to be informed of, and participate in, his or her treatment, including: b. iv. The right to receive the services and/or items included in the plan of care. On 10/17/23, at 10:56am, R5 was in bed and stated, On second and third shift I have to wait two hours or even three for the bed pan then same amount of time to get off. It's ridiculous. I feel like a two-year-old sh***ing the bed. It happened a couple of months ago .I can hear them giggling and laughing in the hall until I pull the cord, then silence. If you bang on things it takes longer because it makes them mad, I guess. R5's Minimum Data Set/MDS assessment, dated 9/11/23, documents R5 is cognitively intact, requires extensive assist of two for toileting, and is frequently incontinent of bowel. R5's current Care plan documents, (R5) has an ADL (Activities of Daily Living) Self Care Performance Deficit related to Impaired balance, Limited Mobility, obesity, COPD (Chronic Obstructive Pulmonary Disease) osteoarthritis and weakness. Interventions include: TOILET USE: Requires extensive assist of 1-2 with toileting. The facility's Resident Council meeting minutes, dated 5/18/23, document, Old business: Any unresolved issues from last month: Waiting for bathroom after meals can take time. The facility's Resident Council meeting minutes, dated 7/25/23, document, New Business: Waiting for the bathroom at times can take a long time. The facility's Resident Council meeting minutes, dated 8/24/23, document, New Business: Bathroom waits are long than hoped. The facility's Resident Council meeting minutes, dated 9/28/23, document, Old Business: Bathroom wait times ongoing especially after mealtime. New Business: Nursing - longer waits for toileting after meals especially at night. They don't see night crew in evenings. On 10/19/23, at 10:45 am, V2 Director of Nursing/DON confirmed the Resident Council meeting minutes state there is an ongoing issue with bathroom wait time. V2 stated that the expectation is for the call device to be answered and acknowledged in five minutes, 15 minutes top for answering it to assist with a need like toileting.

Based on observation, interview, and record review, the facility failed to ensure a physician ordered assistive device was used for a resident's contracted hand for one (R36) of one resident reviewed for contractures in a sample of 24. Findings include: On 10/17/23 at 10:29am and 10/18/23 at 11:44am, R36 sat in a wheelchair of her doorway without any assistive device in R36's contracted right hand. R36's current Physician Order Sheet/POS includes an order dated 6/28/22: Place rolled up washcloth to right hand BID (twice per day) as tolerated. On 10/19/23 at 11:18am, V8 Certified Nursing Assistant/CNA confirmed that V8 was taking care of R36 yesterday and the day before. V8 stated she didn't know R36 needed any assistive device in R36's hand. V8 stated, I'm a float and work prn (as needed). V8 stated she did not place one in R36's hand or offer it either of those days that V8 took care of R36. R36's Treatment Order Administration/TAR sheet, dated 10/1/23-10/31/23, does not include any direction for signing off on R36 wearing an assistive device in her right hand. On 10/19/23 at 11:25am, V3 Assistant Director of Nursing/ADON, stated, (R36) will refuse the assistive device at times, but staff should still offer it. (R36) should be wearing it or at least at least attempted to be worn by staff offering it.

Based on interview and record review, the facility failed to follow its policy and procedure for obtaining weights on new admissions for three of three residents (R116, R117 and R366) reviewed for new admissions in the sample of 24. Findings include: The facility's undated Admission of a Resident policy and procedure documents, The admission process is intended to obtain all the information possible about the resident, for the development of comprehensive plans of care, and to assist the resident in becoming comfortable in the facility. Residents are admitted to the facility under orders of the attending physician. The facility's undated Admission Checklist documents upon arrival to the facility the CNA (Certified Nursing Assistant) get HT (height) and weight and Weight daily x3 (times three) days then weekly x4 (times four) weeks, then monthly in the computer task area. The facility's undated Weight Monitoring policy and procedure documents, A comprehensive nutritional assessment will be completed upon admission on residents to identify those at risk for unplanned weight loss/gain or compromised nutritional status. Assessments should include the following information: a. General appearance (e.g., robust, thin, obese, or cachectic). b. Height. c. Weight. d. Food and fluid intake. e. Fluid loss or retention. f. Laboratory/Diagnostic Evaluation. A weight monitoring schedule will be developed upon admission for all residents and Newly admitted residents - monitor weight weekly for 4 weeks. On 10/19/23 at 1:21 pm, V2 DON (Director of Nursing) stated new admission residents should be weighed every day for three days, then weekly for four weeks, and then monthly. Weights are documented on the MAR (Medication Administration Record) or in the Vital and Weight tab in the computer system. 1. The Face Sheet for R116 documents R116 was admitted to the facility on [DATE]. The Weight and Vitals Summary for R116, documents a weight was obtained for R116 on 10/10/23, 10/11/23 and 10/18/23. This Summary does not include a day three admission weight on 10/12/23. On 10/19/23 at 1:21 pm, V2 DON (Director of Nursing) stated there should be more weights than what is documented in R116's medical record. V2 DON stated, (R116) is a new admission and should have had weights done for the first three days and then weekly. 2. The Face Sheet for R117, documents R117 admitted to the facility on [DATE]. The current Order Summary Report for R117, documents a physician order dated 9/27/23 to do Weekly weights x4 (times four) weeks every Wednesday for 4 (four) weeks. The MAR dated 9/1/23 through 9/30/23 and the Weight Summary for R117, documents there were no weights obtained during the first three days of R117's admission to the facility. The Weight and Vitals Summary for R117 documents the initial weight for R117 was obtained on 9/30/23, four days after R117 admitted to the facility. On 10/19/23 at 1:22 pm, V2 DON confirmed R117 was not weighed until day four of being admitted to the facility. 33971 3. R366's current Face sheet documents R366 admitted to the facility on [DATE]. R366's Weights and Vitals Summary documents weights were obtained on the following days: 10/3/23, 10/4/23, and 10/6/23. As of 10/19/23, R366's medical record did not contain documentation that a third daily weight was obtained on 10/5/23 or that weekly weights were obtained thereafter.

Based on interview and record review, the facility failed to supervise a confused resident in order to prevent recurrent falls for one of three residents (R1) reviewed for falls in a sample of three. This failure resulted in R1 falling and sustaining a fractured 4th lumbar vertebra. Findings include: The facility's Fall Assessment, Risk Identification and Management Policy (revised 3/20/12) documents the following: It is the policy of this facility to assess each resident's fall risk on admission. This will help facilitate an interdisciplinary approach for care planning to appropriately monitor, assess and ultimately reduce injury risk. Factors related to the risk will be addressed and care planned, and Interventions to manage falls: A. Interventions will be based on the resident assessment and the circumstances surrounding the risk for injury or actual injury or fall. Some examples may be: 2. Falls related to confusion. R1's face sheet documents R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's Admission Nursing Assessment and Care Plan dated 2/23/19 documents the following: memory problem with recall after five minutes, confusion, requires assistance of two staff to walk, assistive devices of gait belt and walker, two assist with all transfers, and make sure call light is always within reach. R1's Fall Scale dated 2/23/19 documents R1 is at high risk for falling and that R1 Overestimates or forgets limits of their abilities to ambulate safely. R1's Resident Occurrence Reports document R1 fell on [DATE] at 8:40pm and 2/24/19 at 7:40pm. The report dated 2/23/19 documents R1 was alone in her room, stood up from the recliner in her room when she thought she heard her daughter's voice, used the walker to walk out to the hallway and fell , hitting her head and sustaining a bump to back/right side of head. The report documents the intervention put into place following this fall was Slipper socks at HS (hour of sleep) and while in bed. On 3/1/19 at 9:10am V9, Licensed Practical Nurse (LPN) stated on 2/23/19, R1 self transferred out of the recliner and used the walker to walk out into the hall (where R1 fell ), but forgot to call for assistance. V9 stated R1 couldn't remember where she was, and the call light was still in reach on R1's recliner. On 3/1/19 at 10:10am, V11, Certified Nursing Assistant (CNA), stated she cared for R1 the evening of 2/23/19. V11 stated R1 was alone in her room, got herself up out of the recliner and walked out into the hall, and (R1) did not turn on the call light, (R1) forgot to. (R1's) confusion seemed to get worse as the evening got later. R1's Resident Occurrence Report dated 2/24/19 documents R1 was again alone in her room, stood up from her recliner chair in her room, walked to the doorway of her room (without her walker) where she fell and landed on her back. The report documents that the call light was in reach but had not been used. R1's Progress Notes dated 2/24/19 at 9:35pm document R1 complained of right/mid back pain and was transferred to the local Emergency Department. R1's Progress notes dated 2/25/19 document R1 was admitted to the hospital with [REDACTED]. On 3/1/19 at 9:10am V9, LPN, stated on 2/24/19 R1 had transferred out of the recliner and was lying on the floor in the doorway of her room. V9 stated R1 had forgotten to use the call light to call for help and had also forgotten to use the walker. On 3/1/19 at 10:30am, V12. CNA, stated on 2/24/19 she walked past R1's room, saw R1 sitting in her recliner with her feet raised on the leg/foot rest, with call light in reach on the recliner. V12 stated when she came back down the hall about five minutes later, she saw R1 on the floor in the doorway of her room. V12 stated after R1's fall, the foot/leg rest of the recliner was still raised and the call light was still on the recliner. On 3/1/19 at 9:20am, V10, LPN who completed the Admission Nursing Assessment and Care Plan dated 2/23/19, stated R1 could not remember where (R1) was and could not recall events R1 relayed to V10 five minutes earlier. V10 confirmed she documented R1's Fall/Safety Care Plan only as Make sure my call light is always within my reach. V10 stated the fall prevention/personal safety teaching she provided to R1 included only using the call light for assistance, and using the walker with staff assistance to walk. R1's current fall care plan documents the following interventions for R1: Make sure my call light is always within my reach; assist me to keep non-skid footwear on at all times while I am up; 2/23/19 (following the first fall on 2/23/19) Slipper socks while in bed. R1's care plan also documents I need two staff assistance to walk, and I require two assist with all transfers. On 2/28/19 at 2:10pm, V3, Care Plan Coordinator, reviewed R1's care plan and stated R1's mental status (confusion, memory problem after five minutes, overestimating or forgetting limits) is not addressed in R1's plan of care, but should have been considered when developing fall interventions. R1's X-ray of the lumbar spine dated 2/24/19 documents Contour irregularity of the superior endplate of L4 as well as anterior cortex suggesting acute compression fracture. 10-15% loss vertebral body height. R1's Emergency Department Provider Notes dated 2/24/19 document Closed fracture of fourth lumbar vertebra, unspecified fracture morphology, initial encounter.

Based on observation, interview, and record review, the facility failed to assist a resident to turn and reposition in bed for one (R29) of four residents reviewed for pressure ulcers in a sample of 21. This failure resulted in the resident acquiring two pressure ulcers. Findings include: The facility's Wound and Ulcer Policy and Procedure, revised 1/10/18, documents It is the policy of this facility to provide nursing standards for assessment, prevention, treatment, and protocols to manage residents at any level of risk for skin breakdown and for wound management. This policy continues to state High Risk Protocol: Residents with existing ulcers will be deemed as high risk for impaired skin integrity despite the Braden Risk Assessment Score. The resident may be placed on a turn and position schedule if clinically indicated. Approaches will be placed in the resident's care plan. It also states Care interventions for staff involved in the resident's care are communicated via the resident care plan. R29's Braden/Skin Assessment, dated 7/25/18 documents R29 is at high risk for skin breakdown. R29's Minimum Data Set/MDS assessment, dated 6/8/18 documents R29 is cognitively intact, and requires total dependence with 2 assist for transfers and bed mobility; R29 has [DIAGNOSES REDACTED]. R29's Ulcer/Wound documentation, dated 7/30/18, documents R29's initial assessment with an in-house acquired stage II pressure ulcer measuring 1.0 cm (centimeters) x 1.0 cm x 0.1 cm. On 08/07/18, at 11:02 AM, R29 lay supine in bed. On 08/08/18 at 01:52 PM, R29's left buttock wound care was performed by V3/Registered Nurse/RN. R29's open area to R29's left coccyx was irregular in shape, red with granulation tissue and no drainage. A smaller, irregular, pink open area was also noted just above coccyx, in the midline, with scant drainage. At this time, V3/RN stated that V3 believed that the smaller wound above the coccyx is new as of today. R29 remained in supine position after R29's wound care was completed. On 08/08/18 at 03:00 PM, V3/RN confirmed that the smaller wound above R29's coccyx is new today measuring 0.6 cm x 0.2 cm and is a Stage II, superficial wound. V3 stated I know he doesn't like certain positions. He can't turn himself and needs assistance to turn. R29's Ulcer/Wound documentation, dated 8/8/18, documents R29 with a Stage II pressure ulcer on R29's other-coccyx with measurements of 0.6cm x 0.2cm x 0.1cm and developed in-house. On 08/09/18 at 9:47 AM, R29 stated the air mattress was just put on R29's bed today. On 08/10/18 at 12:45 PM, R29 lay supine in bed. R29's air mattress power unit is not lit up while in the on position, flattened and visibly low on air. On 08/10/18 at 12:50 PM, R29 stated that staff have not turned him every two hours; and no one has turned him off his back side since or before he got his wounds. R29 stated Not at all has two people come in to get me off of my bottom except for last night. And I think it was an accident because I asked for a bigger pillow and then it got me off of my bottom and it didn't hurt. On 08/10/18 at 01:05 PM, V3/RN confirmed that R29's air mattress was unplugged from the wall. V3 doesn't not know how or when it happened. On 08/10/18 at 01:10 PM, V5 (Certified Nursing Assistant/CNA) stated that V5 is unaware of R29 having any wounds. V5 asks R29 about repositioning when rounding every two hours. R29 doesn't always want to be turned. On 08/10/18 at 01:15 PM, V6/CNA stated that V6 is unsure if R29 has any wounds. At this time, V6 pulled up the CNA documentation in R29's electronic medical record and it did not show where R29 is supposed to be turned and repositioned every two hours. V6 stated I have put a pillow under him at times, but sometimes he says it hurts his leg. R29's Care Plan, dated 7/30/18, documents that R29 has an open area to R29's coccyx with an intervention of (R29) needs extensive assist of 2 to turn/reposition every 2 hours or as needed or requested. On 08/10/18 at 01:35 PM, V2 (Director of Nursing/DON) stated that the CNAs are told in report from the nurses about residents who have wounds every shift. V2 confirmed at this time that according to R29's care plan, R29 is to be turned and repositioned every two hours. V2 stated (R29) should be able to tell you if they are turning him.