Every finding on record at Allure of Peru

Based on interview and record review the facility failed to set up a resident's dialysis treatment and transportation to dialysis upon discharge for 1 of 3 residents (R1) reviewed for discharge planning in the sample of 3.The findings include:R1's face sheet shows R1 was admitted to the facility last 3/11/26 and was discharged last 3/23/26.R1's Physician order sheet dated 3/26 show, R1 has diagnoses that include end stage renal disease and dependence on dialysis. The same POS shows R1 has an order for: R1 to receive hemodialysis three times weekly Monday, Wednesday and Friday. On 4/10/26 at 8:45 AM, V3 (Dialysis Nurse Manager) said the dialysis unit was concerned regarding R1. R1 had not been showing up to receive his dialysis treatment. R1's last dialysis treatment was 3/20/26. R1 missed his dialysis on 3/23/26 and again on 3/25/26. V3 said on 3/25/26 the dialysis unit called the facility to find out what was going on with R1. V3 said messages were left but no one at the facility returned the call. V3 said she now found out that R1 had been discharged from the facility. The facility did not notify the dialysis unit that R1 was discharged . Facilities normally coordinate with the dialysis unit when a resident is discharged home to ensure continuity of care including ensuring dialysis schedule and transport to the dialysis unit. R1's new address also needs updating in case a wellness check needs to be done. V3 said the dialysis unit found out that R1 was hospitalized after R1 was discharged from the facility due to abnormal labs. On 4/10/26 at10 AM, V4 (Reregistered Nurse- RN) said on 3/23/26 (Monday) she was informed that R1 was being discharged that day. V4 (RN) said she did not see any discharge papers. V4 said she asked the Social Services (V7) regarding R1's discharge. At that time also the dialysis was following up about R1 going to dialysis since it was a Monday. R1 was discharged that day. V4 said she did not call the dialysis unit to inform them that R1 was being discharged home. V4 said she assumed V7 Social Services had done all that (dialysis set up and transport). On 4/10/26 at 10:50 AM, V7 (Social Service) said R1 wanted to go home. V7 said she did not call dialysis to confirm a spot in the dialysis when R1 was back in the community. V7 said R1 had a friend and assumed the friend would transport R1 to the dialysis. V7 said she did not set up transport for R1 to go to dialysis when R1 was discharged .R1's Discharge summary dated [DATE] did not include instructions or confirmed arrangements for dialysis upon discharge. On 4/10/26 at 10:15 AM, V6 (Nurse Practitioner-NP) said she gave an order for R1 to discharge home on 3/23/26. R1 has kidney failure and end stage renal disease requiring dialysis. It was critically important for R1 to be discharged home with confirmed dialysis arrangements in place, as missed dialysis treatments can lead to serious complications including death. Dialysis coordination should have been part of the discharge planning process by Social Services.The facility policy entitled Discharge Summary (undated) documents, it is the policy of this facility to ensure that discharge summary is provided upon a resident's discharge. The discharge summary provides necessary information to continuing care providers pertaining to the course of treatment while the resident was at the facility and the residents plan of care after discharge. It must include accurate and current description of the clinical status of the residents and sufficiently detailed individualized care instruction to ensure that care is coordinated and the resident transitions safely from one setting to another.

Based on observation, interview, and record review, the facility failed to ensure that controlled substances were reconciled and stored appropriately. This has the potential to affect all 82 residents residing in the facility. The facility's Medication Storage policy, undated, documents to ensure all medications housed on the premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperatures, light, ventilation, moisture control, segregation, and security. This form also documents that schedule II drugs and back-up stock of schedule III, IV, and V medications are stored under double-lock and key. This form documents that schedule II controlled medications are to be stored within a separately locked, permanently affixed compartment when other medications are stored in the same area, such as in a refrigerator. The facility's Controlled Substance Administration and Accountability policy, undated, documents that all controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form. Written documents must be clearly legible with all applicable information provided. This form also documents that for areas without automated dispensing systems, two licensed nurses account for all controlled substances and access keys at the end of each shift. On 3/17/26 at 10:30am, the west wing medications cart was reconciled with V5, Registered Nurse. V5 removed a taped-up prescription bottle of Hydrocodone-Acetaminophen (Opioid) 7.5mg-325mg belonging to R2. V5 stated that since the bottle is taped up, she does not open it to count the pills left inside. V5 verified that she could not see the number of pills left in the bottle. V5 also stated that the tape could be removed and reapplied with no one even knowing. V5 also stated that it does not matter because R2 is no longer receiving the dose in the bottle. V5 entered the medication room. There were two plastic containers of class II-V medications sitting on the top of a small refrigerator. V5 verified that the containers containing the stock class II-V medications are not in an affixed locked cabinet. The facility's Control Box documents the following medications: 3-Oxycodone/Acetaminophen 5-325mg (milligram), 3-Oxycodone/Acetaminophen 7.5-325mg, 3-Oxycodone/Acetaminophen 10/325mg, Oxycodone 10mg, Oxycodone ER (extended release), Hydromorphone 2mg, Morphine Sulfate IR (immediate release) 15mg, Morphine Sulfate ER 15mg, 2 Fentanyl Patches 25mcg (micrograms), and 15ml (milliliter) of Morphine Oral Solution 20mg/ml. The second Control Box documents 1 of each of the following medications: Hydrocodone/Acetaminophen 5/325mg, Hydrocodone/Acetaminophen 7.5/325mg, Hydrocodone/Acetaminophen 10/325mg, Acetaminophen/Codeine #3 300/30mg, Alprazolam 0.25mg, Diazepam 5mg, Pregabalin 25mg, Lorazepam 0.5mg, Tramadol 50mg, and Clonazepam 0.5mg. On 3/17/26 at 11:00am, the north medication cart was reconciled with V7, Registered Nurse. V7 entered an unlocked storage closet to retrieve R3's bottle of Lorazepam 2mg/ml 30ml bottle. V7 took out the plastic bag of Lorazepam and looked at the box, then placed it back in the refrigerator. V7 did not open the box to check the bottle of Lorazepam. V7 also stated that all staff have access to the refrigerator in the stock room. V7 also stated that the stock room is not visible at all times, so it is possible for someone to walk out with the refrigerator. The facility's Midnight Census Report, dated 3/17/26, documents 82 residents residing in the facility.

Based on interview and record review, the facility failed to ensure interventions were in place to prevent misappropriation of a medication for one of three residents (R1) reviewed for misappropriation of property in a sample of three. Findings include:The facility's Abuse and Retaliation Policy Prevention Program, dated 01-2026, documents that the facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, or mistreatment. The Proof of Delivery form, dated 2/7/26, documents that a bottle of Lorazepam (benzodiazepine) 2mg/ml (milligrams per milliliter), 30ml, was delivered and signed in by V4, Registered Nurse. The facility's Final Summary of Investigation, undated, documents that R1 had an order for Lorazepam Oral Concentrate 0.25ml by mouth every two hours as needed for anxiety for 14 days. This form documents that on 2/13/26, V2, Director of Nursing, was notified by V3, Assistant Director of Nursing, that she had been made aware of an incorrect narcotic count for R1. V2 compared the remaining amount of medication in the bottle with the count sheet. V2 confirmed that the count was inaccurate. V2 investigated whether any doses had been administered and not documented; none were identified. R1's Controlled Drug Receipt/Record/Disposition Form, dated 2/7/26, documents that a vial of 30ml was delivered. This form documents that 0.25ml was signed out on 2/12/26 at 5:19pm and at 10:15pm, leaving under 1ml. On 3/18/26 at 12:00pm, V3, Director of Nursing, stated that on 2/13/26, she received a call from V6, Registered Nurse, telling her that R1's Lorazepam was missing. V3 stated that V6 stated that there was less than 1ml in the bottle, which was supposed to be full. V3 stated that V6 sent her a picture of the bottle, which showed less than 1ml of liquid inside. On 3/18/26 at 12:20pm, V2, Director of Nursing, stated that on 2/14/26, she started an investigation and interviewed all staff who had access to R1's Lorazepam. V2 stated that everyone denied giving, spilling, or accessing the bottle. V2 verified that after a very long and thorough investigation, it could not be determined what happened to R1's medication. On 3/18/26 at 2:20pm, V6, Registered Nurse, stated that she went to give R1 a dose of the Lorazepam 0.25ml when she noticed that there was less that 1ml left in the bottle that was supposed to have 30ml. V6 stated that she called V3 to notify her of the missing medication. V6 verified that she did not give or spill any of the medication; it was gone before she even gave the medication.

Based on observation, interview, and record review the facility failed to ensure a resident at risk for falls who was placed in the bathroom had access to a call light for safety. This applies to 1 of 5 residents (R1) in the sample of 5 reviewed for safety. The findings include: R1's face sheet shows she has diagnoses including pneumonia, heart failure, COPD, atrial fibrillation, abnormalities of gait and mobility, anxiety, unsteadiness on feet, dependence on supplemental oxygen, and osteoarthritis. On 9/26/25 at 9:32 AM, R1 was observed sitting in her recliner chair in her room, she was wearing oxygen, and her phone was attached to a lanyard around her neck. R1 said she was placed in the bathroom and was told to ring when she was done. R1 said she was not given the bathroom call string and waited in the bathroom for a long time. R1 said the bathroom call string to pull was broken. The string was detached from the wall unit, she never pulled the cord because the cord was on the ground. R1 said she waited on the toilet and staff did not come in to check on her. R1 said she keeps her phone attached to her lanyard around her neck and called 911 because she did not know what to do. 911 called the facility and told her no one answered so they sent the police. When the police arrived, she was still on the toilet. R1 said she has a fear of falling and needs assistance getting up. R1 said if someone seen that the cord was broken why did they not report it?On 9/26/25 at 10:52 AM, V3 (RN-Registered Nurse) said on 9/8/25, V9 (Police Officer) arrived and said they received a call a resident (R1) who was stuck in the bathroom. V3 said she didn't know that. She went to R1's room with the police officer, and V6 (CNA-Certified Nurses Assistant). R1's room door was closed. They found R1 in the bathroom sitting on the toilet. The bathroom call string was pulled from the wall on the floor. V3 said R1 appeared anxious when we found her. R1 requires assistance with transfers and said it's a safety concern if a resident does not have access to their call light.On 9/26/25 at 11:15 AM, V6 (CNA) said she was coming out of the bathroom before 7:00 PM and the police arrived and said there was a resident (R1) who called the police. V6 said she did not know what was going and notified V3. They went to R1's room and found her sitting on the toilet with the call string broken. It was not attached to the wall unit. V6 said staff should make sure the call string is given to the resident before leaving the room. On 9/26/25 at 1:31 PM, V4 (CNA) said she placed R1 on the toilet and told her to pull the call light when she was done. V4 said she did not give R1 the call light when she left her in the bathroom and left her room to assist other residents. She did not notice the call light on the floor and said no one reported to her the call light was broken. If she knew it was broken, she would have not left her in the bathroom. On 9/26/25 at 10:21 AM, V1 (Administrator) said she received a call from the police that one of their residents called 911 because she was in the bathroom and the call light was broken. 911 called the facility, but no one answered, the police came and found her in the bathroom. She said after talking to staff, R1 was placed in the bathroom about 6:30 PM and the police arrived prior to 7:00 PM. V1 confirmed R1's bathroom call light was broken. R1's fall risk assessment dated [DATE] shows she is at risk for falls. The facility's undated Call Lights: Accessibility and Timely Response Policy states, The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance.staff will ensure the call light is within reach of resident, secured, as needed. the call system must be accessible to the resident at each toilet.staff will report problems with a call light system immediately.

Based on observation, interview and record review the facility failed to perform nail care for two residents (R19) and (R40) of 18 reviewed for assistance with daily living in a total sample of 31. Findings Include: The facility's undated Nail Care policy documents Policy: The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health. Policy Explanation and Compliance Guidelines: 3. Routine cleaning and inspection of nails will be provided during ADL (Activities of Daily Living) care on an ongoing basis. 4. Routine nail care, to include trimming and filing, will be provided on a regular schedule (such as weekly on Wednesday 3-11 shift). Nail care will be provided between scheduled occasions as the need arises. 5. The Resident's plan of care will identify: a. The frequency of nail care to be provided. b. The type of nail care to be provided. c. The person(s) responsible for providing nail care (e.g., licensed nurse, nurse aide, podiatrist, activity professional). 6. Principles of nail care: a. Nails should be kept smooth to avoid skin injury. 7. Procedure: a. perform hand hygiene and don gloves. b. fill wash basin(s) with warm water. Soak hands/feet in wash basin for 10-20 minutes, unless resident has diabetes or circulation problems. c. Gently clean underneath nails with 'orange stick'. d. If trimming is allowed, clip nails using nail clippers straight across and even with tops of fingers/toes. e. Shape nails straight across using nail file, emery board, or the like. f. Dry hands/feet well with towel. g. Apply lotion to hands/feet h. Remove gloves and perform hand hygiene. i. Document completion of task, any complications, or if resident refuses. 1. On 4/22/25 at 1:30 PM, R19's fingernails on both hands were long with dark brown substance under all of them. R19 stated I need to do something about my nails, they are gross, I just haven't had time. On 4/23/25 at 8:30 AM, R19's fingernails on both hands were long with dark brown substance under all of them. R19 stated they are gross (indicating her nails.) R19's MDS (Minimum Data Set) assessment, dated 1/29/25, documents I. Personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene): substantial/maximum assistance. R19's CNA (Certified Nursing Assistant) Task section documented nail care as complete on 4/23/25 at 10:12 AM by V9 (CNA). On 4/23/25 at 11:30 AM V7 (Activity Aide) confirmed R19's fingernails on both hands were long and dirty On 4/23/25 at 11:40 AM V8 (Licensed Practical Nurse) confirmed R19's fingernails on both hands were long and dirty. On 4/23/25 at 1:00 PM V9 (CNA) stated she performed nail care on R19 as best as she could. V9 stated she wiped R19's hands with a washcloth. V9 denied attempting to soak, clip or clean under nails with orange stick. 33973 2. R40's Minimum Data Set/MDS, dated [DATE], documents R40 is moderately cognitively impaired and requires substantial/maximal assistance with personal hygiene. On 4/22/25, at 10:46am, R40 sat in a chair with long jagged, sharp fingernails. R40 stated I need to get them cut, but I don't know where to get that done. I am new here. On 4/23/25, at 9:53am, R40 sat in a wheelchair in the doorway of her room. R40's fingernails are still long and jagged and R40 stated, Now they are breaking off. R40's right index fingernail is partially broken off, sharp, and jagged with the other half still long. On 4/23/25, at 10:09am, R40 sat in the activity area. At this time V2 Director of Nursing/DON confirmed that R40's nails are long, broken and jagged and should be clipped.

Based on observation, interview, and record review, the facility failed to keep residents' medications securely stored for two (R12 and R174) of seven residents reviewed for medication storage during medication administration in a sample of 31. Findings include: The facility's undated Medication Storage policy documents Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. On 4/23/25, at 8:25am, V4 Registered Nurse's/RN's medication cart sat in a high traffic hallway between two dining rooms in the front portion of the facility. On 4/23/25, at 8:29am, V4 stood at the medication cart and prepared R12's medications. At this time, V4 walked over to R12 with R12's medications in a medicine cup and left two multi-dose medication bubble cards on top of the medication cart consisting of Vitamin B-12 100mcg (micrograms) and Carafate one gram. While V4 was away from the medication cart administering medications to R12, staff brought several residents out of the dining room passing by the medication cart. On 4/23/25, at 8:35am, V4 RN prepared R174's medications at the medication cart. At 8:37am V4 left the medication cart to retrieve water for R174. The medication cart had nine multi-dose medication bubble cards on top including Lipitor 10mg, Apixaban 2.5mg, Lasix 40mg, Zestril 10mg, Toprol XL 25 mg, Potassium Chloride Micro tabs 20mEq (milliequivalents), Hydrodiuril 25mg, Preservision capsules, and Zoloft 50mg. At 8:38am, V4 RN returned to the dining room and administered R174's medications to R174. During this time staff continued to bring residents out of the dining room passing by the medication cart. On 4/23/25, at 12:08pm, V4 RN confirmed she should not have left medications on top of the medication cart.

Based on interview and record review, the facility failed to ensure fingernail care was added to a resident's Care plan for one (R40) of 18 residents reviewed for Care plans in a sample of 31. 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 and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the Resident's personal and cultural preferences in developing goals of care. The facility's undated Nail Care policy documents Policy: The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health. Policy Explanation and Compliance Guidelines: 5. The resident's plan of care will identify: a. The frequency of nail care to be provided. b. The type of nail care to be provided. c. The person(s) responsible for providing nail care (e.g., licensed nurse, nurse aide, podiatrist, activity professional). R40's current Care plan does not include fingernail care. On 4/24/25, at 1:13pm, V10 Care plan Coordinator confirmed R40's current care plan does not include fingernail care. V10 stated they do not routinely add nail care to residents' care plans. On 4/24/25, at 1:16pm, V2 Director of Nursing/DON confirmed that according to the facility's Nail Care policy nail care should be on all residents' care plans.

Based on observation, interview, and record review, the facility failed to ensure glove change during pressure ulcer treatment for one (R27) of seven residents reviewed for pressure ulcers in a sample of 31. Findings include: The facility's undated Clean Dressing Change policy documents Policy: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes. Policy Explanation and Compliance Guidelines: 7. Wash hands and put on clean gloves. 9. Loosen the tape and remove the existing dressing. If needed to minimize skin stripping or pain, moisten with prescribed cleansing solution or use adhesive remover to remove tape. 10. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. 11. Wash hands and put on clean gloves. 12. Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of the wound (i.e. clean outward from the center of the wound. Pat dry with gauze. R27's Wound Evaluation & Management Summary, dated 4/23/25, documents R27 has a stage III pressure wound to her left heel. On 4/24/25, at 8:20am, R27 sat in a wheelchair in her room. V5 Registered Nurse/RN wearing a mask, donned a gown and gloves and prepared to change the dressing to R27's left heel pressure ulcer. V5 removed R27's old dressing soiled with a small amount of drainage. R27's left heel has an approximately dime sized open area. With the same soiled gloves, V5 cleansed R27's left heel pressure ulcer with gauze wet with normal saline. V5 removed V5's soiled gloves, performed hand hygiene, then completed the rest of the dressing change. On 4/24/25, at 1:30pm, V5 RN stated V5 should have changed her gloves after removing the soiled dressing and before cleansing the wound.

Based on interview and record review the facility failed to document behaviors to justify the use of psychotropic medications for two residents (R6 and R46) and failed to attempt nonpharmacologic interventions for one resident (R46) of five residents reviewed for unnecessary medications in a total sample of thirty one. Findings Include: The Facility's undated Use of Psychotropic Medications policy documents It is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. Psychotropic medications are to be used only when a practitioner determines that the medication(s) is appropriate to treat a resident's specific, diagnosed, and documented condition and the medication(s) is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). 1. R6's Medical Record documents that R6's diagnosis to include but not limited to: Alzheimer's, anxiety, depression, dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance psychotic disturbance, mood disturbance, anxiety, adjustment disorder with mixed anxiety and depressed mood. R6's Medication Administration Record for April 2025 documents she receives the antidepressant medication Mirtazapine 15 mg (milligrams) every night for adjustment disorder with mixed anxiety and depressed mood. R6's Medication Administration Record for April 2025 documents she takes the antidepressant medication Fluoxetine 10 mg every day for major depressive disorder single episode, adjustment disorder with mixed anxiety and depressed mood. R6's Care Plan dated 6/3/24 documents I have a history of feeling down, worrying, anxious, mind racing, crying, difficulty sleeping. Has orders for antidepressant medication. R6's Medication Administration Record for February, March and April 2025 document Behaviors: NO for all shift for all three months. R6's Task documentation in medical record documents behaviors: sadness, depression. R6's Task documentation did not have any documentation of any behaviors of sadness or depression for R6 for January, February, March and April 2025. R6's Psychiatric Periodic Evaluation dated 2/14/25 documents (R6) denies any concerns with depression. Per facility staff there are no acute concerns or issues nor are there any behavioral changes. On 4/24/25 at 10:15 AM V2 (Director of Nursing) confirmed that R6 was on two antidepressants with no documented signs and symptoms of depression. 2. R46's Medical Record documents R46's diagnosis to include but not limited to Alzheimer's, dementia unspecified with psychotic disturbance, unspecified dementia with unspecified severity with other behavioral disturbance, insomnia, impulse disorder, depression, insomnia, dysthymic, dementia in other diseases classified elsewhere with anxiety, unspecified mood disorder. R46's Medication Administration Record documents she takes the anti-psychotic medication Olanzapine 2.5 mg (milligrams) every day for unspecified dementia, unspecified severity with other behavioral disturbance. R46's Medication Administration Record documents she takes the antidepressant Sertraline 25 mg for unspecified mood disorder, depression, anxiety disorder. R46's Care Plan dated 11/11/2024 documents the resident has behaviors such as asking to go to the bathroom every 5 minutes, ambulating around room unattended and wants to stay in bed other than meals. R46's Medication Administration Records for February, March and April 2025 document Behaviors: NO for all three shifts for all three months. R46's CNA Task documentation documents anxiety/restlessness as behaviors to be monitored. R46's CNA Task documentation shows on 4/10/25 R46 had frequent crying, repeated movement, yelling/screaming and grabbing. R46's CNA Task documentation dated 4/18/25 documents R46 had repeated movements and yelling/screaming. Neither entry in the task documentation (4/10/25 and 4/18/25) documented any nonpharmacologic interventions attempted, if the behaviors were easily redirected or if any other reasoning for the behaviors could be identified. R46's Medical Record did not contain any other documentation about any harmful behaviors exhibited by R46 for January, February, March or April 2025. R46's Periodic Psychiatric Evaluation dated 2/14/25 documents No acute behavioral issues or concerns. Sleep and appetite OK. On 4/24/25 at 2:00 PM V2 (Director of Nursing) confirmed there were no nonpharmacological interventions related to R46's two instances of having documented behaviors. V2 also confirmed that there was no description of what R46 was doing. These are check mark lists for the CNA so I cannot say exactly what was happening.

Based on observation, interview, and record review, the facility failed to ensure medications were administered according to physician orders and pharmacy medication instructions for two (R12 and R48) of six residents reviewed during Medication Administration in a sample of 31. There were two errors out of 26 medication opportunities observed resulting in a 7.69% medication error rate. Findings include: The facility's Medication Administration policy, dated 2025, 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. 17. Administer medication as ordered in accordance with manufacturer specifications. a. Provide appropriate amount of food and fluid. 1. On 4/23/25, at 8:23am, R12 sat in the dining room eating breakfast. V4 Registered Nurse/RN administered Aspirin 81mg (milligrams) one tab, Multivitamin one tab, Metoprolol 50mg one tab, Sertraline 50mg one tab, Vitamin B-12 100 mcg (micrograms) one tab, and Carafate one gram one tab to R12. R12's current Physician Order Sheet/POS documents orders for Aspirin 81mg one tab, Multivitamin one tab, Metoprolol 50mg one tab, Sertraline 50mg one tab, Vitamin B-12 100 mcg (micrograms) one tab, and Carafate one gram one tab all to be given by mouth in the morning. The two pharmacy labels on R12's Carafate multi-dose medication bubble card read Take this product at least two hours before or two hours after your other medications. And Take medicine on an empty stomach- 1 hour before or 2-3 hours after a meal unless otherwise directed by your doctor. R12's Physician Order Sheet/POS does not indicate other directions for the administration of R12's Carafate. On 4/23/25, at 8:30am, V4 RN confirmed the pharmacy label and stated, It should be given two hours before or two hours after his other meds. V4 stated that R12 did not receive his Carafate on an empty stomach or without other medications and should have. 2. On 4/23/25, at 11:45am, R48 sat in the dining room eating breakfast. V4 RN administered Carb/Levo (Carbidopa/Levodopa) (sub for Parcopa) 25-100mg one tab and Acetaminophen 325mg two tabs to R48 whole and mixed in applesauce. R48's current POS documents orders for Carb/Levo (Carbidopa/Levodopa) (sub for Parcopa) 25-100mg one tab and Acetaminophen 325mg two tabs to be given by mouth in the morning. The pharmacy label on R48's Carb/Levo mulit-dose medication bubble card reads Place medicine on your tongue and allow it to disintegrate. On 4/23/25, at 11:48, V4 stated (R48) wants it in his applesauce. I have never given it that way to him before. V4 confirmed the pharmacy label and stated, I guess I should have given it that way.

Based on observation, interview, and record review, the facility failed to maintain the privacy of residents' health information for two (R12 and R174) of 18 residents reviewed for confidentiality/privacy in a sample of 31. Findings include: The undated Residents' Rights for People in Long-Term Care Facilities documents Your rights to privacy and confidentiality - You have a right to privacy and confidentiality of your personal and medical records. Your medical and personal care are private. On 4/23/25, between 8:29am and 8:45am, V4 Registered Nurse/RN administered medications to R12 and R174 in the dining room. V4's medication cart sat in a high traffic hallway between two dining rooms in the front portion of the facility. On 4/23/25, at 8:29am, V4 RN stood at the medication cart, opened R12's electronic medical record on the lap top computer sitting on top of the medication cart, and prepared R12's medications. V4 then left the medication cart with the computer screen unlocked and open showing a view of R12's clinical record. While V4 was away from the medication cart administering medications to R12, staff brought several residents out of the dining room passing by the medication cart. On 4/23/25, at 8:35am, V4 RN changed the computer screen to R174's clinical record and prepared R174's medications. At 8:37am V4 left the medication cart to retrieve water for R174. The computer screen on top of the medication cart was unlocked and open showing a view of R174's clinical record. At 8:38am V4 RN returned to the dining room and administered R174's medications to R174. During this time staff continued to bring residents out of the dining room passing by the medication cart. On 4/23/25, at 12:08pm, V4 RN confirmed she should not have left the computer screen unlocked and open to residents' clinical records on top of the medication cart.

Based on observation, interview and record review, the facility failed to ensure accuracy of resident medical records for two (R40 and R48) of 18 residents reviewed for medical records in a sample of 31. Findings include: The facility's Documentation in Medical Record policy, dated 2024, documents Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Policy Explanation and Compliance Guidelines: 4. Principles of documentation include but are not limited to: a. Documentation shall be factual, objective, and resident centered. I. False information shall not be documented. ii. Record descriptive and objective information based on first-hand knowledge of the assessment, observation, or service provided. b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. The facility's Certified Nursing Assistant job description, dated 2023, documents Major Duties and Responsibilities: Completes flow sheets daily to indicate that the specified task was done. 1. On 4/22/25 at 10:46am and 4/23/25 at 9:53am, R40's fingernails were long, sharp and jagged. R40's Task: Inspect & Clean Fingernails, dated 3/25/25 to 4/23/25, documents on 4/22/25 at 6:07am by V6 Certified Nursing Assistant/CNA that R40's nails were trimmed. On 4/23/25, at 10:41am, V6 CNA confirmed that V6 worked day shift yesterday (4/22/25) and had charted that R40's nails were trimmed even though she didn't know that they had not been. On 4/23/25, at 1:22pm, V2 Director of Nursing/DON stated the Certified Nursing Assistants/CNAs should not chart on a resident who another CNA is taking care of unless they are charting together and knows what cares were done. 2. On 4/23/25, at 11:45am, R48 received Carb/Levo (Carbidopa/Levodopa) (sub for Parcopa) 25-100mg (milligrams) one tab with two Tylenol 325mg tabs whole in applesauce by V4 Registered Nurse/RN. The pharmacy label on R48's Carb/Levo mulit-dose medication bubble card reads Place medicine on your tongue and allow it to disintegrate. On 4/23/25, at 11:50am, V4 looked up the hospital discharge orders and confirmed that the order for R48's Carb/Levo is for an oral dose, not the dispersing type. V4 stated It was put in wrong. On 4/23/25, at 1:18pm, V2 Director of Nursing/DON stated I put the order for Carb/Levo in wrong. I should have selected the oral route not the dispersing route. I probably took it from the template.

Based on interview and record review, the facility failed to report potential allegations of theft to the local law enforcement for two (R1 and R2) of four residents reviewed for misappropriation of property in a sample of four. Findings include: The facility's Abuse, neglect and Exploitation policy, dated 7/1/24, documents Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. 2. The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations of suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. B. Possible indicators of abuse include but are not limited to: 4. Resident reports of theft of property or missing property. The facility's Grievance Logs dated November 2024 through January 2025 documents R1 and R2 made allegations of theft (missing money). 1. The facility's initial Reportable for R1, date of occurrence 1/3/25, documents Former resident (R1) contacted the facility from home and alleges that (R1) has missing money .Investigation begun, full report to follow. This report also documents Incident Category -Resident Misappropriation of Property/Theft. Police notified - no. Status of resident - discharged . The facility's undated final report for R1 summarizes that R1 had $54 and a blank check in an envelope that was locked in a medication cart's narcotic box. R1 forgot about the envelope upon discharge, called the facility from home to retrieve it and the money was not in the envelope. 2. The facility's initial Reportable for R2, date of occurrence 12/10/24, documents Incident Description - (R2) notified (V1) that (R2) had $27 missing from her change purse. Incident Category - Resident Misappropriation of Property/Theft. Police Notified - no. The facility's undated final report for R2 summarizes that R2 had $27 in R2's change purse in R2's room that went missing. On 1/17/25, at 3:13pm, V1 Administrator stated that the police were not notified. (R1) was already home and I asked (R1) if she wanted me to call the police and she said no. The police would have had to go to her house. For (R2) I did not call the police because I don't know if it was lost or maybe (R2) dropped it. (R1's) was more in our possession. On 1/22/25, at 12:10pm, V1 Administrator stated V1 was unaware of the obligation to notify the local law enforcement for allegations of theft. At this time, V1 confirmed that their Abuse policy states that law enforcement is to be notified of theft allegations.

Based on observation, interview, and record review the facility failed to utilize PPE (Personal Protective Equipment), failed to perform hand hygiene during medication pass, failed to initiate enhanced barrier precautions and failed to sanitize equipment after usage in an enhanced barrier precaution room for six residents (R2, R12, R32, R58, R14 and R281) of 24 reviewed for infection control. This has the potential to affect 79 residents residing in the facility. Findings include: The facility's Cleaning and Disinfection of Resident-Care Equipment, dated 7/1/23, documents that resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC recommendations in order to break the chain of infection. This form also documents that multiple-resident use equipment shall be cleaned and disinfected after each use. The facility red Enhanced Barrier Precautions sign from the United States Department of Health and Human Services Centers for Disease Control and Prevention, provided by V11/Infection Preventionist documents, Enhanced Barrier Precautions everyone must clean their hands, including before entering and and when leaving the room. The facility policy, Medication Administration, dated 7/1/23 directs staff, 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. Remove medication from source, taking care not to touch medication with bare hands. R32's current Physician Order Sheet documents that R32 is on enhanced barrier precautions related to wounds, MRSA (methicillin-resistant staphylococcus aureus) of the nares, and history of MRSA of the wounds. R281's current Physician Order Sheet documents that R281 is on enhanced barrier precautions related to a urinary catheter. This form also documents to cleanse the incision on the left hip and cover with a dry dressing every other evening shift. 1. On 05/14/24 at 9:00am, V15, CNA (Certified Nursing Assistant) and V16, CNA, entered R32's room with a mechanical lift, with only masks on. V15 and V16 exited the room and verified that they did not have the appropriate personal protective equipment on. V15 and V16 transferred R32 with a mechanical lift to the commode and then back to his chair. V15 exited R32's room with the mechanical lift, removed her gloves. V15 then pushed the mechanical lift down the hall to R281's room. On 5/15/24 at 9:00am, V15 verified that the mechanical lift was not cleaned or disinfected after it was used on R32. V15 stated that the facility does not have bleach or disinfecting wipes in the rooms or in the PPE carts outside of the rooms. 2. R14's current Physician Order Sheet, dated May 2024 documents R14 was admitted to the facility on [DATE] with the following diagnoses: Type 2 Diabetes Mellitus, Vascular Dementia, Personal History of Urinary Tract Infections, Current Urinary Tract Infection. On 5/11/24 a new physician's order was obtained to place an indwelling urinary catheter, due to urinary retention. On 5/13/24 at 10:04 A.M., R14 was seated in a wheelchair in her room. A urinary catheter bag was hanging from the back of R14's wheelchair with yellow urine present. No Enhanced Barrier Precaution sign was present on the door to R14's room. V8 and V9/Certified Nursing Assistants entered (R14's) room to provide assistance to (R14's) roommate without performing hand hygiene. On 5/15/24 10:30 A.M., V11/Infection Preventionist stated, The criteria for a resident to be placed in EBP (Enhanced Barrier Precautions) is any resident with an indwelling urinary catheter. At that time V11/Infection Preventionist verified that R14 should have been placed in Enhanced Barrier Precautions when the urinary catheter was placed on 5/11/24. 3. On 5/13/24 at 11:16 A.M., V6/Registered Nurse prepared to administer medications for R58. After placing medications in a plastic medication cup, V6/RN entered R58's room without performing hand hygiene, despite the fact an Enhanced Barrier Precaution sign was hanging from R58's room. On 5/13/24 at 11:20 A.M., V6/Registered Nurse prepared to administer medications for R32. After placing medications in a plastic medication cup, V6/RN entered R32's room without performing hand hygiene, despite the fact an Enhanced Barrier Precaution sign was hanging from R32's room. On 5/13/24 at 11:31 A.M., V6/Registered Nurse prepared to administer medications for R2. After placing medications in a plastic medication cup, V6/RN entered R2's room without performing hand hygiene, despite the fact an Enhanced Barrier Precaution sign was hanging from R2's room. Upon exit from R2's room, V6/RN verified she did not perform hand hygiene upon entrance to the resident's rooms despite the Enhanced Barrier Precaution sign with instructions to do so. 4. On 5/13/24 at 11:22 A.M., V6/Registered Nurse (RN) prepared to administer mediations for R12. 6/RN removed one tablet of Gabapentin 100 MG from a prepackaged bubble pack directly into a small, plastic medication cup. V6/RN then removed one tablet of Carafate 1 GM (Gram) from a prepackaged bubble pack directly into her bare hand, broke the tablet in 2 and placed both halves into the small, plastic medication cup. V6/RN then entered R12's room, handed R12 the medication cup which R12 took with sips of water. Upon exit from R12's room, V6/RN verified she had touched R12's medications with ungloved hands. The CMS (Center for Medicare and Medicaid Services) Form 671 dated 5/13/24 documents 78 residents reside in the building.

Based on observation, interview and record review, the facility failed to administer medications as ordered by the physician for two residents (R58 and R72) on the sample of 7 residents reviewed for medication pass. This failure resulted in two medication errors out of twenty- five opportunities for error, for an 8% medication error rate. FINDINGS INCLUDE: The facility policy, Medication Administration, dated (7/1/23) directs staff, 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. Ensure the six rights of medication administration are followed: right resident, right drug, right dosage, right route, right time and right documentation. 1. R58's current Physician Order Sheet, dated May 2024 includes the following medications: Carafate (anti-ulcer) 1 GM (Gram) by mouth three times daily. On 5/13/24 at 11:16 A.M., V6 Registered Nurse (RN) prepared to administer medications for R58. V6 placed one capsule of Gabapentin 100 MG (Milligrams) in a plastic medication cup. V6 then removed one tablet of Sucralafate 1 GM from a punch card, with written instructions on the card, Take 2 hours before or 2 hours after other medications, placed it in the medication cup and then added Lasix 20 MG one tablet to the same cup. V6 entered R58's room, handed R58 the medication cup with three pills to R58 who immediately took the three pills together with a drink of water, Upon exiting R58's room, V6 verified the Sucralfate should have been given 2 hours before or 2 hours after the other medications. 2. R72's current Physician Order Sheet, dated May 2024 includes the following diagnoses: Osteomyelitis Of Vertebra, Thoracic Region; Methicillin Resistant Staphylococcus Aureus Infection; Type 2 Diabetes Mellitus. This same sheet includes the following medications: Vancomycin HCl ((Hydrochloride)Intravenous Solution 2500 mg intravenously in the morning. On 5/14/24 at 8:20 A.M., V6 mixed 20 ML (Milliliters) of Sterile Water into (3) vials of Vancomycin 1 GM (Gram) powder. V6 then withdrew all 20 ML of 2 bottles and 10 ML of the third bottle and injected the mixed solution into the 500 ML bag of Normal Saline, equaling a total of 550 ML. with 2500 MG of Vancomycin. V6 entered (R72's) room and programmed (R72's) IV (Intravenous) pump for 500 ML of fluid over 180 minutes. On 05/14/24 12:08 P.M., V6 returned to R72's room to disconnect the IV (intravenous) Vancomycin and flush (R72's) PICC (Peripherally Inserted Central Catheter) line. V6 disconnected (R72's) Vancomycin bag with 50-60 ML (Milliliters) of Vancomycin mixture remaining. V6 flushed the PICC line with Normal Saline, then Heparin and disposed of the Vancomycin IV bag with the remaining fluid., in the trash can. At that time, V6 verified the remaining IV medication in the bag and stated, The directions are to infuse (the bag) (500 ML Normal Saline) at 200 CC/HR for 180 minutes. I guess that doesn't take into account the additional 50 ML of sterile water with the vancomycin in it.

Based on observation, interview, and record review the facility failed to provide a resident with a mirror to allow for self grooming for one (R66) of one resident reviewed for Accommodations of Need in a sample of 35. Findings include: The facility's Activities of Daily Living (ADLs) policy, dated 7/1/23, documents The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming, and oral care. On 5/13/24, at 9:40am, R66 was lying in bed with visible facial hair. R66 stated I can't see myself in the mirror from my wheelchair, only from the forehead up. It is part of the reason I haven't shaved. I know it (my beard) looks bad. R66's Care plan includes a focus of: (R66) is at risk for an ADL Self Care Performance Deficit related to Activity Intolerance, Impaired balance, bilateral AKA (Above the Knee Amputation). The goal is: (R66) will improve current level of function in Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene through the review date. The interventions include: Encourage (R66) to participate to the fullest extent possible with each interaction. On 5/14/24, at 2:20pm V13 Restorative Nurse stated (R66) is capable of shaving himself and would need a mirror to do so. V13 was unaware that R66 could not see himself in his mirror on the wall. On 5/15/24, at 3:15pm, R66 sat in his electric wheelchair facing and across from the sink with a mirror above it. R66 adjusted the position of the back of his wheelchair up higher and stated I can't see my chin no matter what.

Based on observation, interview and record review the facility failed to administer medications as ordered by the physician for one resident (R72) of seven residents reviewed for medication administration, in a sample of 35. The undated facility policy, Intravenous Therapy directs staff, The facility will adhere to accepted standards of practice regarding infusion practices. Review and verify practitioner's order for infusion solution or medication, dose, frequency and route of administration. R72's current Physician Order Sheet, dated May 2024 includes the following diagnoses: Osteomyelitis Of Vertebra, Thoracic Region; Methicillin Resistant Staphylococcus Aureus Infection; Type 2 Diabetes Mellitus. This same sheet includes the following medications: Vancomycin HCl ((Hydrochloride)Intravenous Solution 2500 mg intravenously in the morning. On 5/14/24 at 8:20 A.M., V6 (Registered Nurse/RN) mixed 20 ML (Milliliters) of Sterile Water into (3) vials of Vancomycin 1 GM (Gram) powder. V6 then withdrew all 20 ML of 2 bottles and 10 ML of the third bottle and injected the mixed solution into the 500 ML bag of Normal Saline, equaling a total of 550 ML. with 2500 MG of Vancomycin. V6 entered (R72's) room and programmed (R72's) IV (Intravenous) pump for 500 ML of fluid over 180 minutes. On 05/14/24 12:08 P.M., V6 returned to R72's room to disconnect the IV Vancomycin and flush (R72's) PICC (Peripherally Inserted Central Catheter) line. V6/RN disconnected (R72's) Vancomycin bag with 50-60 ML (Milliliters) of Vancomycin mixture remaining. V6/RN flushed the PICC line with Normal Saline, then Heparin and disposed of the Vancomycin IV bag with the remaining fluid., in the trash can. At that time, V6 verified the remaining IV medication in the bag and stated, The directions are to infuse (the bag) (500 ML Normal Saline) at 200 CC/HR for 180 minutes. I guess that doesn't take into account the additional 50 ML of sterile water with the vancomycin in it. On 5/15/24 at 9:52 A.M., V14 (Pharmacist) stated, The addition of the additional 50 ML of normal saline to the 500 ML bag, the volume of fluid to be infused needs to be adjusted to compensate for the additional 50 ML added, or the resident would not receive the full dose of Vancomycin. I would consider that a significant medication error.

Based on observation, interview, and record review the facility failed to ensure an order was placed and a resident was wearing a recommended assistive device for one (R62) of one resident reviewed for Limited Range of Motion in a sample of 35. Findings include: The facility's Prevention of Decline in Range of Motion policy, dated 7/1/23, documents 3. Appropriate Care Planning. a. Based on the comprehensive assessment the facility will provide interventions, exercises and/or therapy to maintain or improve range of motion. b. The facility will provide treatment and care in accordance with professional standards of practice. This includes, but is not limited to: i. Appropriate services (specialized rehabilitation, restorative, maintenance). ii. Appropriate equipment (braces or splints). R62's current Face Sheet documents R62 admitted on [DATE] with an admitting diagnosis of Hemiplegia and Hemiparesis following other Cerebrovascular Disease affecting left non-dominant side. On 5/13/24, at 9:28am, R62 was sitting in a reclining chair in her room with a flaccid left arm and hand at her side. A splint device is sitting on the bedside table near her. R62 stated I have a hard time getting someone to put it on. I can't do it myself. It is supposed to be four hours on four hours off. I have been up since 5 and haven't had it on yet. I had a stroke and can not move my left arm. On 5/13/24, at 11:32am, V19 Certified Nursing Assistant/CNA stated V19 assisted in getting R62 up today around 7:45am. V19 verified V19 did not put R62's splint on her hand and should have. V19 stated I guess I was in a hurry. R62's Minimum Data Set/MDS assessment, dated 3/27/24, documents splint in use 7 days/week. R62's Care Plan, dated 10/13/23, documents (R62) is a risk for an ADL (Activities of Daily Living) Self Care Performance Deficit related to Activity Intolerance, Left Hemiplegia status post stroke, Impaired balance. The interventions include: Restorative: Splint/Brace - (R62) is to wear left hand splint as ordered by therapy. Assist in donning brace. On in AM at 7:00, off at 12:00 and on in PM at 4:00, off at 9:00pm daily. The goal is to prevent left hand tendon shortening and contracture. R62's Order Request for Occupational Therapy, dated 10/13/23, documents: Reason for request/Treatment diagnosis: Prevention of tendon shortening and contracture; preventions while left hand at rest. Frequency: 2 times a day. Duration: 5 hours. To receive assistance donning left wrist hand resting hand splint. R62's current Physician Order Sheet/POS does not include an order for a splint. On 5/13/24, at 3:43pm, R62 is in a wheelchair in her room with her left arm lying at her side without a splint. R62's splint is lying on the bedside table in front of her. On 5/14/24, at 2:27pm, V12 Director of Rehab stated We give our orders to Restorative Nursing and she puts the order in. On 5/14/24, at 2:30pm, V13 Restorative Nurse stated that V13 put (R62's) splint order in on 10/13/23. (R62's) orders were discontinued in February after a hospitalization and V13 didn't see it to put it back in R62's POS (Physician Order Sheet). V13 stated that staff should be putting (R62's) splint on her.

Based on interview and record review the facility failed to ensure psychotropic medication ordered PRN (as needed) was limited to 14 days for one (R39) of three residents reviewed for Unnecessary Medications in a sample of 35. Findings include: The facility's undated policy, Use of Psychotropic Medication documents, Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record, and the medication is beneficial to the resident as demonstrated by monitoring and documentation of the resident's response to the medications(s). This policy also states 9. PRN (as needed) orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days). a. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order. R39's Physician Order Sheet/POS includes diagnoses of Dementia with Psychotic Disturbance and Adjustment Disorder with Mixed Anxiety and Depressed Mood. R39's POS also includes an order for Lorazepam Oral Tablet 0.5mg, dated 4/29/23. Give 1 tablet by mouth every 8 hours as needed for Anxiety related to Adjustment Disorder with Mixed Anxiety and Depressed Mood for 90 days. The ending order date is documented as 7/28/24. On 5/16/24, at 11:00am, V2 Director of Nursing/DON was unable to produce documentation by R39's physician for extended use of Lorazepam.

Based on interview and record review the facility failed to implement a person centered baseline care plan for two residents (R281 and R283) of five reviewed for baseline care plans in a sample of 35. Findings include: The facility's Baseline Care Plan, undated, documents that the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care. R281's admission orders, dated 5/4/24, documents the following diagnosis: fracture of the neck of the left femur, acute urinary tract infection, acute metabolic encephalopathy, dementia, hard of hearing, lacunar stroke and mild aortic insufficiency. R281's base line care plan does not address R281's personalized needs. R283's Progress Notes, dated 5/10/24 documents that R283's referral (to another facility) was denied due to R283's history of suicidal ideation's. On 05/14/24 at 2:00pm, R283 stated that she had some concerns a while back with suicidal ideation's and mental disorders. On 5/15/24 at 1:45pm, V18, Care Plan Director, stated that the base line care plans is a check off list and not personalized. V18 verified that R281 and R283's base line do not address all of their needs. On 5/15/24 at 2:00pm, V4, Social Service Director, stated that R283 has a history of suicidal ideations in the past. V4 verified that R283's current care plan does not address this issue.

Based on record review and interview, the facility failed to prevent a safe and secure transfer for one of three (R1) residents reviewed for safe transfers in a sample of three. This failure resulted in R1 falling on 11/15/2023 and receiving a Displaced oblique distal diaphyseal fracture of the left femur. Findings Include: R1's V7/ Physician Assistant History and Physical, dated 11/15/2023, documents the following,(R1's) left leg shortened and internally rotated. Motor limited due to pain. R1's Trauma Level 2 History and Physical, dated 11/15/2023, from V8/ Orthopedic Surgeon documents, [AGE] year-old female Caucasian patient who was brought into the trauma bay, who fell from her wheelchair while being transferred in vehicle. (R1) was found to have a distal left femur fracture. Patient presents with left leg internally rotated, very tender. R1's X-Ray of the left femur, dated 11/15/2023, documents, Displaced oblique distal diaphyseal fracture of the left femur. The fracture is probably acute. Distal fracture fragment is displaced anteriorly and medially. The State Agency Notification report, dated 11/20/2023, documents,(R1) was being transferred to the facility from an appointment. Because of another driver, the facility driver was forced to stop the vehicle quickly. (R1) slipped to the floor of the van. The facility van driver called 911 immediately. (R1) was sent to the emergency room . (R1) sustained a closed fracture of the left femur. On 12/16/2023 at 1PM, R1 was laying in the bed resting, eyes appear to be closed. Resident did not respond when she was spoken to. On 12/16/2023 at 12:27PM ,V6/Transportation Aide, stated, I was taking (R1) to the hospital for a blood transfusion. On the way back to the facility, I went around a curb and there was a mail track stopped in the middle of the road. I was driving about 45 miles an hour and I had to suddenly stop very fast. (R1) had slid out of her wheelchair and onto the floor. (R1) was positioned between her wheelchair and the front console. I called 911 and then released the seat belt to give the paramedics room to take care of (R1). On 12/17/2023 at 1:35PM V1/Administrator stated, I was told by (V6/Transportation Aide) that (R1) had slid out of her wheelchair, coming back from a blood transfusion. (V6) had to unexpectedly put the brakes on because there was a mail truck in front of her, so she had to stop suddenly or hit it. (R1) had a sling under [NAME] her, a personal chair alarm, and was very wet. (V6) said she had to release the seat belts and remove the wheelchair for the paramedics. (R1) was admitted to the local hospital with a fracture of the left femur. On 12/16/2023 at 11:45AM, V2/DON (Director of Nurses), stated,(V6/Transportation Aide) was taking (R1) for a blood transfusion. They were coming back and (V6) had to stop suddenly because a mail truck was parked in the way and (V6) was afraid she was going to hit the truck. (R1) slid out of her wheelchair landing on the foot pedals and must have hit the console. (R1) broke her left leg. R1's Nurses Notes, dated 11/15/2023, documents, Received a call from (V6/CNA/Transportation Aide) van driver stating that (R1) had been strapped in her wheelchair returning to the facility when the driver was forced to stop quickly. (R1) had slipped out of her chair, onto the floor. (V6) van driver states that (R1) was complaining of pain and 911 was called. (R1) was taken to a local hospital. (R1's) son was notified. The facility policy, Van Usage and Policy and Procedure, with no date, documents, When employees operate a facility van, they have inherent responsibilities to care for the vehicle and the residents, obey all state and local traffic laws and abide by drivers operating procedures. Procedure: 3.B.Wear seat belts anytime the vehicle is in motion and require all passengers to wear seatbelts. 3.C.Ensure all residents and wheelchairs are safely secured.

Based on observation, interview, and record review, the facility failed to recognize the immediate need for transferring a Covid-19 positive resident to the hospital for necessary medical treatment for one (R26) of four residents reviewed for hospitalization in the sample of 29. This failure resulted in delay of treatment resulting in R26 expiring in the emergency room . Findings include: The facility's Guidelines for Physician Notification of Change in Resident Condition policy, revised ,d+[DATE], documents: Purpose: to define resident care situations that require physician notification. Standard: Staff observe, document and communicate to the physician changes in resident condition promptly .If the nurse is unable to contact the physician, the nurse may, by his/her informed judgment and professional discretion, transfer the resident to the hospital of record for evaluation and treatment. On [DATE], at 3:10pm, R26 sat in R26's isolation room in a wheel chair with his head and upper body leaning over the bed with eyes closed. On [DATE], at 3:30pm, V13 Registered Nurse/RN stated the following: I worked on Tuesday ([DATE]) from 6am-6:30pm. I took care of (R26) the last two days. Tuesday he was already Covid positive. No symptoms, just his blood pressure was a little lower than normal (,d+[DATE]s) for his baseline. I let (V12 R26's Nurse Practitioner/NP) know. On Wednesday, (R26) got up and had breakfast, but was really tired, exhausted. I noticed (R26) was a little confused but vitals were the same; blood pressure ,d+[DATE]s, no cough. I let (V12 NP) know. I noticed (R26) said he wasn't short of breath, but he looked it. (R26) was a little more confused. I told all this to (V12 NP). After spoke with (V12 NP) earlier (V12) gave an order for Lasix and IV (intravenous) fluids. Later in evening on my shift (R26) perked up and was more awake. (R26) started with a congested cough. I listened to his lungs and he had congestion to right lung and his blood pressure was ,d+[DATE]. I called (V12 NP) again close to end of my shift and told (V12) this. She said to give an extra Lasix 20mg (milligrams) and order stat chest xray. This was right after I gave report. Then I put the orders in. (V15 RN) relieved me and was going to give the Lasix. I put the order in as stat for the chest xray. I told (V15) before I left that (V12 NP) wanted to be called with (R26's) xray results and a condition report. (V15) asked if (R26) was to have more fluids after this bag and I said no, that (V12 NP) would make that decision after a condition update. R26's Progress note, dated [DATE] at 6:55pm by V15 Registered Nurse/RN, documents Biotech here to do chest x-ray. R26's Progress note, dated [DATE] at 10:00pm by V15 RN Respirations are now 36. Spo2 (Saturation of peripheral oxygen) 89% on 3L (liters). Resident complained of 'feeling anxious'. Oxygen titrated to 4L. Gave albuterol inhaler. R26's Progress note, dated [DATE] at 10:00pm by V15 RN, documents Received chest xray results. Results indicate cardiomegaly with CHF (Congestive Heart Failure), pulmonary edema, right sided pleural effusion, underlying infiltrate/atelectasis involving the lung bases. Results sent to (V12 Nurse Practitioner/NP). Awaiting call back. On [DATE], at 1:28pm, V15 RN stated the following: I worked 6pm-10:30pm ([DATE]) last night. I took care of (R26) and got report from (V13 RN). (V13) told me (R26) was dehydrated, getting a liter of fluid and a chest xray, and had increasing edema. (V13) said (R26) had a cough and was confused on day shift. (R26's) chest xray results came back at 10pm. I gave report to (V14 Licensed Practical Nurse/LPN). (V14) took a picture of the results and texted it to (V12 R26's Nurse Practitioner). I did not listen to (R26's) lungs. At 8pm (R26) seemed alert and oriented talking to me. I did hear (R26) coughing kind of congested sounding. I did not listen to (R26's) lungs then or on my shift. At shift change at 10pm his breathing was faster and his oxygen saturation dropped to ,d+[DATE]%. I upped (R26's) oxygen from 3 to 4lpm (liters per minute) and gave (R26) Ventolin inhaler. A CNA (Certified Nursing Assistant) said (R26) was asking for an anxiety pill but it was too soon. I reported off to (V14 LPN). Maybe I should have listened to (R26's) lungs. I told her about these things in report. I did read the chest xray results. We did not hear back by the time I left around 10:30pm. I thought (V14) was going to call (V12 NP) if (V14) hadn't heard back from the text (to V12 NP). That's what I would have done. I would have waited 20 minutes or so then called (V12 NP) or the doctor. On [DATE], at 12:33pm, V14 LPN stated the following: I took care of (R26) for four hours from 10pm till 2am. I got report from (V15 RN). (V15) said (R26) had Covid. (V15) gave (R26) an anxiety pill about 8:30pm. (R26's) oxygen saturation had dropped so (V15) bumped it up to 4 liters .After report maybe around 10:45 or 11pm I think, (R26) had put (R26's) call light on. CNAs said (R26) was feeling anxious and didn't know where (R26) was at earlier when I got report, (V15) said that (R26's) chest xray results just came in. I saw the results and sent it to (V12 R26's NP). I sent it by text to (V12's) work phone shortly after 10pm. I did not hear back from (V12). I did not try (V12) again and didn't think there was reason to (R26) called CNAs a lot and wanted fan turned on then a little while later wanted it off, then back on a little while later (V15) did report to me that (V15) gave (R26) Albuterol and that (R26's) oxygen saturation was 89%. (V15) said (V15) bumped him (R26's oxygen) up to 4 and he (R26's oxygen saturation) went up. I don't recall (R26's) respirations being at 36. (R26) fell asleep and was asleep when I left - it seemed like anxiety to me. R26's Progress note, dated [DATE], at 3:38am by V11 LPN, documents Resident is noted to be yelling out multiple times starting at 0300 (3:00am). At 0325 (3:25am), O2 (oxygen) 96% 3L, no abdominal breathing at this time, head of bed elevated and resident repositioned. Resident is verbalizing that he is SOB (short of breath) and can't breath and wants to go to hospital. Resident denies pain at this time; PRN (as needed) Norco given at 0043 (12:43am) and Hydroxyzine given at 2037 (8:37pm) [DATE]. Resident verbalized 'Just give me something to sleep or be able to breath, just send me to hospital!' 911 called at 0331 (3:31am), MD (Medical Doctor) notified at 0333 (3:33am). On call notified at 0334 (3:34am), POA (Power of Attorney) called and notified at 0335 (3:35am) and verbalized understanding and would like to be updated with any news, EMT (Emergency Medical Technicians) arrived at 0341 (3:41am). When entering room with EMTs resident is noted to be abdominal breathing and verbalizing 'I feel like I'm dying'. EMTs left with resident at 0355 (3:55am). R26's Progress note, dated [DATE], at 4:57am by V11 LPN, documents Nurse at (local hospital) notified this nurse at 0445 (4:45am) that resident passed away in ER. Nurse at ER verbalized that she would call and notify (R26's) POA (Power of Attorney). (V1) Administrator notified at 0455 (4:45am). (V12 R26's NP) notified at 0500 (5:00am) and verbalized understanding. On [DATE], at 9:28am, V11 LPN stated the following: I came on duty at 2am today. I got report from (V14 LPN) After that (R26) was call light happy - on the call light every 5 min. I asked the CNAs each time what he needed. I asked if he seemed more anxious than usual and they said yes. (R26) wanted the fan on then off then back on again. At 3:25am (R26) started complaining of shortness of breath, his oxygen saturation was ,d+[DATE]%, oxygen was running, bubbler was fine. No abdominal breathing. Head of bed was elevated. It was just verbal that he was short of breath. I said I could send (R26) to the hospital, he agreed and didn't refuse. I offered (R26) prn (as needed) Albuterol inhaler and (R26) refused and just wanted to go to the hospital. I saw the chest x-ray results after my assessment at 3am sitting on the desk. I knew (R26) had one done but didn't know we had the results back until I saw them. I did not know they had been reported to (V12 NP) already. I didn't have time to notify (V12) because I was trying to get (R26) out to the ER (emergency room ). On [DATE], at 9:50am, V12 (R26's Nurse Practitioner) stated (R26) probably should have been sent out yesterday. (V13 RN) called me yesterday ([DATE]), not sure what time (10am?), and said (R26) seemed confused, weak, his blood pressure was still low, and his lungs and urine were clear. I ordered one liter of fluids at 125 lpm (liters per minute) and to monitor (R26's) blood pressure. I also ordered Lasix 40mg oral in addition to his usual Lasix 40 dose. (V13) called back later around 6pm and said (R26) seemed perkier but (R26's) right lung is congested. I ordered a chest x-ray. (V13) said (V13) would put it in stat. (V14 LPN) texted the results to me at 10:10pm but I was sleeping. I woke up at 12:30am and saw the results. I did not text back or call them. (V13 RN) was worried. (V13) said (R26)was weak, confused and not himself. That isn't like him, but I thought (R26) was dehydrated and kidney function was failing. (V14 LPN) texted me at 10:10pm with xray results but I was sleeping and saw them at 12:30am. I didn't' know (R26's) respirations were 36 and oxygen saturation was 89% at 10pm .I'm hesitant to send residents out. They are sending them here really sick then expect me to keep them out of the hospital. I totally trust (V13's) assessment. If (R26) had been sent out earlier (R26) would have gotten more diuretics but was urinating. It's a hard line. R26's X-ray Patient Report, dated [DATE], documents Impression: Postop changes in the chest. Cardiomegaly with CHF (Congestive Heart Failure), as well as early/subtle interstitial pulmonary edema. Right-sided pleural effusion. Obscured lung bases may be secondary to pleural fluid, but underlying infiltrate/atelectasis involving he lung bases would also have to be considered. Follow-up chest radiographs recommended after medical management. On [DATE], at 3:53pm, V2 Director of Nursing/DON stated the following: V2 was unaware of (R26's) 10pm condition of rapid respirations and low oxygen saturation when the xray results were received. I think they should have phoned (V12 R26's Nurse Practitioner/NP) with results. They normally would call. (V12 NP) likes the text. The nurses shouldn't wait very long before calling (V12NP) to be sure (V12) got the results. On [DATE], at 8:59am ,V16 Medical Director stated the following: I think they should have called the nurse practitioner. Texting does not replace a phone call. Technically they should have an order to have an ER (emergency room ) visit, but (V15) could have sent him out without it. An ER visit at 10pm would have been warranted. The nurse is trained to send patients to the ER. It's possible they could have done more for (R26) and tried other things. ER generally prefers to get people before they crash. V16 confirmed that knowing R26's condition and xray results, the nurse (V15 RN) should have reached (V12 NP) by phoning. R26's Emergency Department Note, dated [DATE], documents Exam Narrative: Patient having agonal breathing, is ashen, and his respirations are down to 10. He is not alert. He is not responding. Chest has fairly decent air movement when he takes in a breath. Pupils are still reactive. Discharge Patient Disposition: Expired. Probable Cause of Death: Pulmonary Embolism. Expired Date/Time: [DATE] 04:37am.

Based on observation, interview, and record review, the facility failed to identify and assess a pressure ulcer at admission for one of two residents (R42) reviewed for pressure ulcers in the sample of 37. This failure resulted in R42's wound worsening in condition from admit to a Deep Tissue Injury then to a Stage 4 pressure ulcer. Findings include: The facility's Wound and Ulcer Policy, dated 1/10/18, documents, When a resident is found to have a wound a licensed nurse will complete, either on admission or during their stay, the following: Document assessment of the wound/ulcer in the medical record. Initiate the treatment protocol appropriate for the stage of ulcer or for the wound assessed. Document wound/ulcer treatment provision on the treatment administration record. Notification of the physician, documenting, and initiating ordered treatment. Transcribing, documenting, and initiating written and/or verbal orders of the physician. The policy also documents, Ulcer treatment protocols: Pressure ulcer-stage 1 Non-blanchable [CONDITION(S)]-intact skin with nonblanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. A reddened area should be rechecked after pressure is relieved to see if the area is non-blanchable. Protocol: Implement positioning to relieve/reduce pressure on the affected area (pressure reduction and/or pressure relief measures). Cleanse: Normal saline or wound cleanser. Prep: Apply no sting protectant wipes to surrounding tissue. Let skin protectant dry prior to application of a [MEDICATION(S)] or transparent dressing. Treat: If the wound is located on a high friction area: apply [MEDICATION(S)] or transparent film dressing. The policy documents, Suspected deep tissue injury (DTI): Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. On 05/16/22 at 01:35 PM, R42 was alert sitting up in a chair in his room. R42 stated, I have an ulcer on my left foot. It's just not getting better, so I'm not able to walk very much. I can't put my shoes on because it hurts too bad. Staff will tell me I need to walk but I can't walk with that on my heel. R42's Clinical Admission Evaluation, dated 2/16/22, documents that upon admission R42 had redness to his bilateral heels. R42's Skilled evaluation, dated 2/21/22 at 9:08 a.m., documents, Skin location #10: Left heel. Issue type: Pressure ulcer/ injury. Skin tissue: Mushy. Skin tissue: Boggy. Skin tissue: Painful. R42's Skilled Evaluation, dated 2/22/22 at 2:05 a.m., documents, Skin location #10: Left heel. Issue type: Pressure ulcer/ injury. Skin tissue: Painful. Skin tissue: Mushy. Skin tissue: Boggy. R42's Braden Risk (Risk for Developing Pressure Ulcers) Assessment, dated 2/22/2022, documents that R42 had a score of 17 putting him at risk for developing pressure ulcers. R42's Skilled Evaluation, dated 2/23/22 at 12:39 a.m., documents, Skin location #10: Left heel. Issue type: Pressure ulcer/ injury. Skin tissue: Painful. Skin tissue: Mushy. Skin tissue: Boggy. R42's Wound Physician Evaluation, dated 2/24/22, documents, Unstageable DTI of the left heel partial thickness. Wound size: 5.5 cm x 5.5 cm x not measurable. R42's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R42's Current Medical record has no documentation of a wound assessment nor staging of R42's left heel until 2/21/22. R42's Wound Documentation, dated 3/30/22, documents that R42 has a facility acquired Stage 4 pressure ulcer to his left heel that measures 4.5 cm x 4.5 cm that was identified on 2/18/22. R42's wound physician evaluation, dated 5/11/22, documents, Stage 4 Pressure wound of the left heel full thickness. Wound size 2.5 cm x 3 cm x 0.1 cm. Duration greater than 70 days. Wound Progress: No change. On 05/18/22 at 01:40 PM, R42 had a light pink circular open area with minimal clear drainage on the back of R42's left heel. On 05/19/22 at 09:40 AM, V2 (Director of Nursing) stated, (R42) did not have a full wound assessment completed prior to 2/21/22. The assessment should have included a description and staging of the wound. The admitting nurse noted that (R42's) heels were both red. However, she did not do an assessment of the wounds or obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The worsening of the wound was caused by him putting pressure to that area, but there was no redirection to help with that because the wound had not been formally identified and put in (R42's) plan of care.

Based on interview and record review the facility failed to assist one resident (R8) assessed to be in need of extensive assistance for toileting to the bathroom for one of eight residents (R8) reviewed for accidents in a sample 33. This failure resulted in R8 getting up on own and falling causing severe pain and a sprained left knee. Findings include: The facility's Fall Assessment, Risk Identification and Management Policy, revised 3/20/2012, documents that the potential for injury will be care planned when appropriate, based on the results of the Fall Assessment. The interdisciplinary care plan will be individualized to reflect the specific needs and risk factors of the resident. This form also documents that all staff providing care to the resident will have access to the care plan and interventions. On 03/18/19 at 1:30pm, R8 stated that she was in the dining room and asked for help to the bathroom. R8 stated that V5, CNA (Certified Nursing Assistant), pushed her to her room, and left the room without assisting her to the bathroom. R8 stated that she attempted to transfer herself to the toilet, because she could not hold it any more, then lost her balance and fell to the floor. R8 stated that she hurt her left knee, and is afraid to walk now. R8 stated that she hit her back on the sink, when she fell . R8's Fall Scale, dated 2/27/19, documents that R8 has a score of 90, a high risk for falls. R8's Minimum Data Set, dated dated [DATE], documents that R8 requires extensive assistance of two for transfers, and extensive assist of one for toileting. R8's current care plan documents that R8 requires one assist, gait belt, and rolling walker for transfers. R8's Progress Notes, dated 3/2/19 at 9:20am, documents that V9, Registered Nurse, heard R8 yell My legs. My knees. Help. Help. My legs and my knees. V9 then quickly went to resident's room, and was informed that resident was on the floor. This form documents that R8 was observed sitting on her left hip with legs flexed under her buttock, and her walker was laying on the floor around R8. R8 told V9 that That girl left me in here standing up cause I needed to use the restroom. I was pulling down my pants and my left leg gave out. I fell and hit my head on my walker. R8's legs were extended due to resident experiencing severe pain with them flexed. R8 was transferred to her bed via a mechanical lift, because R8's complaint of pain greater than 10/10 to left knee. R8 also complained of pain to her lower back and bilateral hips. This form documents that R8 was transported to the emergency room for an evaluation. R8's Progress Note, dated 3/2/19 at 12:55pm documents that R8 has a left sprained knee. R8 is to follow up with V12 (Orthopedic Physician). V5's, CNA, signed interview, dated 3/2/19, documents that V5 walked R8 to her room, from the dining room. V5 documented that R8 requested to used the bathroom, but V5 told R8 she couldn't take her, that she needed to call one of the CNA's in her hall. V5 documented that R8 stated that she insisted that she had to go to the bathroom. V5 documented that R8 was given her call light. On 3/20/19 at 11:10am, V7, Registered Nurse, verified that R8 needs assistance to transfer, and to use the bathroom. On 3/21/19 at 9:35am, V2, Director of Nursing, verified that V5 should have assisted R8 to the toilet when she asked. V2 stated that V5 was disciplined for her actions.

Based on interview and record review, the facility failed to provide adequate hydration based on current fluid needs and to notify the physician of significant decreased oral intake in a timely manner for one of four residents (R5) reviewed for hydration in the sample of 13. This failure resulted in R5 being admitted to the hospital with [REDACTED]. Findings include: The Order Summary Report for June 2014 documents R5's [DIAGNOSES REDACTED]. Nurse's Notes dated 6-17-14 document R5 is "dependent on staff for all care." On 8-22-14 at 1:22pm and on 8-26-14 at 11:30am, respectively, E16 and E6, Certified Nurses Assistants (CNAs) both stated that R5 was "a total assist" (for meals and hydration). E17, CNA, stated on 8-26-14 at 11:25am that "we had to feed her (R5) and give her fluids." R5's Nutritional Intake Flowsheet dated 6/8/14 - 6/18/14 documents oral intake of "25%" meal intake decreasing to "bites" and "refused," and a 24 hour intake of fluids ranging from 390 to 150 milliliters per day. R5's Nutritional assessment dated [DATE] documents that R5's estimated daily fluid need is 1320 milliliters. The Nurse's Notes dated 6-18-14 at (4:45pm) document that Z1, R5's physician, was "Notified of residents I&O (intake and output)" and at (6:00pm) that Z1 "called wants resident sent to ER for evaluation." R5's Hospital History & Physical Examination dated 8-21-14 documents R5's [DIAGNOSES REDACTED]. Hospital laboratory test documents R5's Final Cumulative Report for Chemistry on 6-18-14 as: Sodium 179 mmol/L (millimoles per liter) (Reference Range is 137-147 mmol/L) Chloride 130 mmol/L (Reference Range is 98-107 mmol/L) BUN (blood urea nitrogen) 72 mg/dL (milligrams per deciliter) (Reference Range 7-17 mg/dL) Creatinine 1.56 mg/dL (Reference Range is 0.50-1.00 mg/dL) The Final Cumulative Report for Hematology dated 6-18-14 documents R5's results as: HGB (Hemoglobin) 16.8 g/dL (grams per liter) (Reference Range 11.5-15.8 g/dL) HCT (Hematocrit) 56.1% (Reference Range 34.0-45.0%) E2, Director of Nursing (DON) stated on 8-26-14 at 1:10pm that she did not realize (R5) had poor intake of fluids and did not notify R5's physician Z1. E2 then stated "It's my fault for the nurses not knowing the process when a resident her age is declining." The Hydration Policy (1/10) documents: "Policy: Adequate hydration will be promoted with the provision of fluids in amounts to meet the needs of each resident."

Based on record review and interview, the facility failed to notify the physician and the resident legal representative in a timely manner of significant, unplanned weight loss and significantly decreased fluid intake for one of four residents (R5) reviewed for weight loss and hydration in a sample of 13. This failure resulted in R5 being admitted to the hospital with [REDACTED]. Findings include: R5's Weight and Vitals Summary documents the following weights and weight loss: 5/19/14- 98.8# (pounds) 5/27/14- 95.4# weight loss 3.5#, 3.5 % 6/2/14- 95.2# weight loss 3.6#, 3.6% 6/9/14- 90.6# weight loss 8.2#, 8.3% 6/15/14- 85.8# weight loss 13#, 13.2% 6/17/14- 84.4# weight loss 14.4#, 14.6% R5's Nutritional Intake Flowsheet dated 6/8/14 - 6/18/14 documents oral intake of "25%" meal intake decreasing to "bites" and "refused," and a 24 hour intake of fluids ranging from 390 to 150 milliliters per day. R5's Nutritional assessment dated [DATE] documents that R5's estimated daily fluid need is 1320 milliliters. On 8/21/14 at 3:30pm, E2, Director of Nursing (DON), stated that she reviews residents' weights weekly. E2 confirmed that R5 had a significant weight loss, and that E2 did not notify Z1, R5's physician, or Z4, legal representative. On 8/26/14 at 11:30am, E2 stated that she did not realize that R5 had such a decrease in oral intake. On 8/22/14 at 1:35pm, Z1 stated that he was not notified of R5's weight loss or decreased oral intake of fluids until 6/18/14. Z1 stated that R5 was admitted to the hospital with [REDACTED]. R5's Hospital History and Physical Report dated 6/19/14 documents R5's admitting [DIAGNOSES REDACTED]." R5's Blood Chemistry Report dated 6/18/14 documents R5's Sodium as 179 mmol/L (millimoles per liter), critically elevated , (Reference Range 137-147 mmol/L), and Blood Urea Nitrogen as 72 mg/dL (milligrams per deciliter) (Reference Range 7-17 mg/dL). The facility's Height and Weight Protocol (1/10) directs that "The physician will be notified of any significant weight change."

Based on interview and record review the facility failed to assess, develop interventions, and inform the physician in a timely manner of significant weight loss for one of four residents (R5) reviewed for weight loss in the sample of 13. This failure resulted in a 14.6% unplanned significant weight loss and abnormal laboratory test values for R5. Findings include: The Order Summary Report for June 2014 documents R5's [DIAGNOSES REDACTED]." The Minimum Data Set (MDS), dated [DATE] documents R5 as being severely cognitively impaired. Nurse's Notes dated 6-17-14 document R5 is "dependent on staff for all care." On 8-22-14 at 1:22pm and on 8-26-14 at 11:30am, respectively, E16 and E6, Certified Nurses Assistants (CNAs) both stated that R5 was "a total assist (with meals)." E17, CNA, stated on 8-26-14 at 11:25am that "we had to feed her (R5) and give her (R5) fluids." The Weights and Vitals Summary documents R5's weights and weight loss as: 5-19-14- 98.8# (pounds) 5-27-14- 95.4# weight loss 3.5#, 3.5% 6-2-14- 95.2# weight loss 3.6#, 3.6% 6-9-14- 90.6# weight loss 8.2#, 8.3% 6-15-14- 85.8# weight loss 13#, 13.2% 6-17-14- 84.4# weight loss 14.4#, 14.6% R5's Nutritional assessment dated [DATE] documents the DWR (Desired Weight Range) for R5 as 103-125 (lbs). R5's care plan (review completed 3-28-14) documents the intervention "document weight, report variance of 5% in 30 days...to the physician." R5's Nutritional Intake Flowsheet dated 5-19-14 to 5-31-14, documents R5's breakfast intake at 25% for eight out of 13 days; 25% lunch intake for seven out of 13 days; and 25% or less ("bites") supper intake for 12 out of 13 days. R5's Nutritional Intake Flowsheet dated June 2014 documents R5's breakfast intake of 25% for eight out of 18 days; 25% or less ("bites" or "refusal") lunch intake for 16 out of 18 days; and supper intake for five out of 18 days as refusal, zero or bites for six out of 18 days, and 25% for the remaining seven out of 18 days. R5's Nurse's Notes dated 6-18-14 at (4:45pm) document that Z1, R5's physician, was "Notified of residents I&O (intake and output)" and at (6:00pm) Z1 "called wants resident sent to ER for evaluation." R5's Hospital History & Physical Examination dated 8-21-14 documents R5's admitting [DIAGNOSES REDACTED]. On 8-22-14 at 1:30 pm, Z1 stated that he was not notified of R5's significant weight loss and that R5 was admitted to the hospital with [REDACTED]. Hospital laboratory test documents R5's Final Cumulative Report for blood Chemistry on 6-18-14 as: Sodium 179 mmol/L (millimoles per liter) (Reference Range is 137-147 mmol/L) Chloride 130 mmol/L (Reference Range is 98-107 mmol/L) BUN (blood urea nitrogen) 72 mg/dL (milligrams per deciliter) (Reference Range 7-17 mg/dL) Creatinine 1.56 mg/dL (Reference Range is 0.50-1.00 mg/dL) The Final Cumulative Report for Hematology dated 6-18-14 documents R5's results as: HGB (Hemoglobin) 16.8 g/dL (grams per liter) (Reference Range 11.5-15.8 g/dL) HCT (Hematocrit) 56.1% (Reference Range 34.0-45.0%) E2, Director of Nursing (DON) stated on 8-22-14 at 11:30am that E2 did not notify Z1, Z5 (Registered Dietician)(RD), or Z4 (R5's Power of Attorney) (POA) that R5 had a significant weight loss from 5-19-14 through 6-18-14. On 8-26-14 at 10:25am E18, Dietary Manager, stated that she was aware of R5's significant weight loss and reported it to E2 and Z5. E18 stated that she could not remember the date she notified E2 and Z5. E2 stated on 8-26-14 at 3:10pm that "there is no record of the RD (Registered Dietician) seeing this resident (R5)" from 5-19-14 through 6-18-14 and that "she (R5) wasn't on the list to be seen." On 8-26-14 at 10:55am E15, Medical Records staff confirmed that there are no dietary assessments or recommendations from Z5 from 5-19-14 through 6-18-14. The facility's Height & Weight Protocol (1/10) documents "Any resident with a significant or severe weight change will be referred to the dietician for assessment of the residents' condition," and "The physician will be notified of any significant weight change and be made aware of any recommendations made by the dietitian."

Based on observation, interview, and record review the facility staff neglected to operationalize their policy on full body (mechanical) lifts and create an environment of safety for one of three residents (R1) in the sample of three. E3,Certified Nurse Aide (CNA) knowingly disregarded facility policy and transferred R1 without using a mechanical lift. R1 received a fractured femur and subsequent amputation of the leg. The facility neglected to operationalize their policy on reporting falls for one of three residents (R2) sampled for falls in a total sample of three. E5 CNA knowingly falsified R2's fall from bed for over 24 hours until confronted about R2's bruising. R2 fell from the bed during cares sustaining facial fractures and subdural hematoma. E5, CNA neglected to follow the facility policy on reporting falls and moved R2 back to bed without alerting the nurse first. Findings include: 1. Admission Data Sheet for R1 documents the date of admission as 10/13/10 with the following Diagnoses: [REDACTED]. Facility Resident Handling Policy "No-Lift" dated 02/07/12 and signed by E3, Certified Nurse Aide (CNA) on 11/10/11 documents the following: The Resident Handling Policy exists to ensure a safe working environment. Resident transfer status will be reviewed via care plan time frame and on an as needed basis. This policy will be reviewed and signed by all staff that perform or may perform resident handling. This policy is to be followed at all times." The care plan for R1 dated 03/01/12 documents the following: "Transfer with assistance of two and full body lift (mechanical lift)." Nurses notes for R1 dated 10/23/12 at 10:55AM and signed by E4, Registered Nurse(RN) document the following:" Upon CNA transferring resident into wheelchair resident complained of left leg pain. Left knee visibly swollen. Doctor notified and resident given [MEDICATION NAME] as ordered for pain. Order received for resident to be seen in ER (emergency room ). POA (Power of Attorney) notified." Facility Incident Investigation Report for R1 dated 10/23/12 documents the following: (E3/CNA) self reported she had done a pivot transfer with (R1) rather than using the required full body (mechanical) lift. Post transfer resident complained of pain in the left knee. (E3/CNA) immediately notified the nurse as well as (E2 /Director of Nursing {DON}). Both nurses assessed the knee and noted slight swelling with no discoloration and no loss of movement. (R1's) physician was notified as well as the POA. (R1) was transferred to the ER for evaluation and admitted to (hospital) with a [DIAGNOSES REDACTED]. (E3/CNA) admitted she did not follow care plan regarding transfer of (R1)." On 11/21/12 at 2:30PM E1, Administrator stated, "In October (E3/CNA) did not use the lift (mechanical) and did pivot transfer (R1). (R1) has [MEDICAL CONDITION] so when (E3) transferred the resident using a pivot transfer it caused the fracture. (E3) received a suspension for this." On 11/27/12 at 10:15AM E4, Registered Nurse (RN) stated, "(E3) came to me and said she inappropriately transferred (R1) and that the residents left knee was swollen. I gave (R1) a pain pill and notified the doctor who had us send (R1) to the emergency room . (R1) returned later that day with a cast on that leg due to a fracture." Nurses notes for R1 dated 10/23/12 document that R1 was returned to the facility at 1:00PM with a cast from "groin to toes." Nurses notes for 11/20/12 at 1:40PM documents the following: "CNA notified nurse of cast assessment that shows medial aspect of left knee cast showing 2cm (centimeter) by 1cm irregular discoloration to cast area. Cast remains hard and dry. Physician notified. POA notified." Same nurses notes document that at 2:45PM R1's physician called back with orders for R1 to be sent to ER for evaluation. Same nurses notes for R1 document that at 6:00PM hospital notified facility that resident was admitted , cast was removed due to pus formation under the cast from open an wound at the fracture site. Hospital history and physical examination (R1) was brought to the emergency room , the cast was removed and (R1) was found to have about a 2cm hole to skin with a large amount of blood pustular drainage to the distal femur(thigh) over the fracture site. (R1) continues to have a nonunion (not healed) at the distal aspect of the tibia as well which was from approximately six years ago. At this point it was recommended the patient be admitted to the hospital on surgical floor and be placed NPO (nothing by mouth) with consent for above the knee amputation on 11/21/12." On 11/27/12 at 10:00AM Z1, R1's Surgeon stated, "Moving this resident without using the mechanical lift caused the fracture given the resident's severe [MEDICAL CONDITION] (brittle bones). Even though this recent fracture did not help (R1's) situation, I spoke with the family prior to this most recent fracture because the old fracture of this resident's lower leg had never healed, the family was going to make a decision after the holiday when this most recent fracture occurred. This hastened the family to make a decision and they decided to have the amputation done now." On 11/27/12 at 9:00AM R1 was lying in the hospital bed. R1 was awake but confused. R1 had received an above the knee amputation of the left leg. A dry dressing was in place covering the amputation site. On 11/27/12 at 10:00AM E3, CNA stated, "I stood and pivoted (R1) from the bed to the wheelchair. I was aware that I was supposed to use a (mechanical lift) and have received training on the (mechanical lift) and the no lift policy. (R1) did bear weight during the transfer. (R1) complained of pain in the left knee when I went to put that foot on the wheelchair pedal. I could hear a popping sound when I moved (R1's) foot. It was like a grating sound. I went to the nurse and told her what I did then went to (E2, DON) and also told her. I don't know why I didn't use it (mechanical lift). I knew I was supposed to I just didn't. We weren't short staffed that day so I had plenty of help. I should have gotten help like I was supposed to. I knew (R1) had a bone problem and had weak bones. I got a two day suspension for not following the care plan and the policy." On 11/28/12 at 10:20AM E1, Administrator stated, "(E3/CNA) showed negligence when she didn't follow the lift protocol and the resident's care plan. Our policy on those states a warning and/or suspension. Even though (E3) came forward immediately, she received a written warning and a three day suspension." 2. The Admission Face Sheet for R2 documents date of admission as 10/08/05 with the following Diagnoses: [REDACTED]. Facility "Fall Assessment,Risk Identification and Management Policy/Post Fall Assessment" dated 03/20/12 documents the following: "After a fall, the resident will not be moved from their position until a licensed nurse determines it is safe to do so." Facility Resident Handling Policy "No Lift" dated 02/07/12 and signed by E5, CNA documents the following: "Should a resident fall to the floor, the resident will be first assessed by a nurse." The care plan for R2 dated 05/13/12 documents that R2 is to be transferred using a mechanical sit to stand lift and that R2 is a one person assist for bed mobility. Nurses notes for R2 dated 06/27/12 at 12:30PM document the following: "noticed purple bruising below right eye. CNA states resident pulled on CNA's name tag and bumped nose." Occurrence Report for R2 dated 06/27/12 documents the following: "CNA came to nurse stating that the resident received a skin tear. Upon entering the room noted a 1cm skin tear to the bridge of the resident's nose. Resident was laying in bed. CNA stated that she was leaning over the resident and the resident grabbed at the CNA's name tag. When the CNA went to pull it back the resident let go and the name tag hit the resident in her nose. After breakfast the resident had a dark purple bruise under the left eye, after lunch the resident was noted to have a dark purple bruise under the right eye and some light purple bruising to the left cheek. Physician and POA (Power of Attorney) notified." Nurses notes for R2 dated 06/28/12 at 9:00AM documents the following: "Midnight CNA (Certified Nurse Aide) reports bruising to right hip. Deep purple bruise on right Iliac Crest (upper hip). Noticed also a faint purple (bruise) to right trochanter (upper thigh), right side of head, an abrasion on second toe of right foot and right knee swelled. Complete head to toe assessment completed. Contacted (Z2,R2's physician) and (R2's) POA. Orders received to send (R2) to hospital for X-ray of knee." Nurses notes for R2 dated 06/29/12 document the following "Late entry for 06/28/12. CNA reports that on 06/27/12 (over 24 hours later) resident rolled out of bed onto floor with no apparent injuries so CNA put resident back to bed. (Z2, R2's physician) aware that resident rolled out of bed onto floor. Resident's sister also notified." Occurrence Report for R2 dated 06/28/12 and signed by E2, DON documents the following: "On 06/27/12 it was reported that (R2) had cut nose with a CNA's name tag. On 06/28/12 (R2) presented with several more areas of discoloration, two areas on the iliac crest and one on the right trochanter. Resident was lying to close to the edge of the bed. A CNA (E5) entered the room and attempted to pull (R2) back toward the center of the bed and the resident rolled out. The CNA (E5) then to placed the resident back in the bed without calling a nurse and reported to the nurse only that the resident had cut her face with the CNA's name tag." Incident Report to Illinois Department of Public Health (IDPH) for R2 dated 06/28/12 and signed by E1, Administrator documents the following: "...(R2) is severely impaired and non-interviewable. She requires assistance of one and a sit to stand lift for all transfers. She is dependent on staff for all ADL's (Activities of Daily Living). On 06/28/12 was notified of bruises of unknown origin noted on (R2). A nursing assessment was completed. Bruises were noted on right hip and right knee. An abrasion to right side of head and swelling of right knee was also noted. POA and physician were notified. (R2) was sent to the hospital for an X-ray of right knee returning to the facility with no findings. Upon investigation, (E5/CNA) stated she observed (R2) roll out of bed onto the floor on 06/27/12. (E5) stated she returned (R2) to bed. Per (E5's) signed statement, she did not report the occurrence to the nurse or any other staff. (E5) has been terminated." On 11/27/12 at 9:30AM E2, DON verified that E5 knowingly falsified how the resident injury occurred and knowingly kept knowledge of the residents fall from the bed until confronted. On 11/27/12 at 9:30AM E2 stated, "Initially when I talked to E5 she told me that (R2) received a cut on her nose when she pulled on E5's name tag. Then the next day when we saw more bruising on R2's knee and leg I pulled E5 back into my office and confronted her, again asked if anything else had happened to cause the bruising to (R2). That's when E5 admitted to me that she had went to move the resident more to the center of the bed and (R2) rolled out of bed and landed on the floor. E5 then said she didn't see anything wrong with the resident and picked her up and put her back to bed, telling the nurse the laceration on the nose was from the name tag." Statement signed by E5/CNA dated 06/28/12 documents the following: "I went in to get (R2) up. She was close to the edge (of bed). I raised her bed a few inches. I moved the pad. She started to roll and I tried to catch her, but she fell on the floor and rolled over. She landed on her face on the floor. I picked her up and put her to bed. I was trying to wash her up and she tried to pull my name tag and it cut her nose. I reported the cut to the nurse but not the fall." On 11/27/12 at 9:50AM E5, CNA stated, "I was getting (R2) ready to get up. She was close to the edge of the bed so I pulled on the sheet to move her and she rolled off the bed onto the floor. I picked her up and put her back to bed. She had a scratch on her nose. I told the nurse she got that from my name tag. I knew what the policy was and I was supposed to go get the nurse when (R2) fell . I just didn't do it. I take responsibility for what I did." Nurses notes for R2 dated 06/30/12 at 7:00AM document the following: "CNA called nurse to residents room. Noted resident to be up in chair, leaning to the right. Resident mouth is open and drooping to the right side. Bottom teeth (dentures) had fallen out and resident was drooling. Resident transferred to bed. Apical pulse irregular. Resident noted to use abdominal muscles with breathing. Resident's extremities are flaccid and laying straight our in the bed. No response to verbal or tactile stimuli. Pupils equal and reactive. Discoloration remains to both eyes (dark purple) and left side of face light purple. Notified (Z2, R2's physician) and received orders to transfer to hospital. Ambulance called and resident transferred. POA notified." Hospital Head Computerized Tomography (CT) for R2 dated 06/30/12 documents a large subdural hematoma (area of bleeding in the brain) with significant mass effect (pressure) upon the right hemisphere (side) causing greater than 2cm (centimeters) midline shift of the brain to the left side with impending herniation of the brain. Hospital CT of facial bones for R2 dated 06/30/12 documents nondisplaced comminuted (spiral) nasal bone fractures. Nurses notes for R2 dated 07/03/12 at 12:45PM document that R2 was readmitted to the facility from the hospital. R2 had no verbal or tactile response noted. Nurses notes continue to document that R2's POA was contacted in regards to R2's condition and NPO (nothing by mouth) status. POA does not want hospice at this time, declined feeding tube and wants comfort measures only. Nurses notes for R2 dated 07/03/12 at 8:00PM document the following: "Condition remains poor. Repositioned for comfort." Nurses note for R2 continue to document that R2 was monitored throughout the night. Nurses notes for R2 dated 07/04/12 at 4:25AM document the following: "CNA reported change in condition Resident stopped breathing. No apical pulse and no blood pressure heard. Pupils dilated. Death verified by two nurses. (Z2/R2's physician) and POA notified of (R2's) death." On 11/27/12 at 6:00PM Z2, physician for R2 stated "I was involved in this investigation. It created quite a mess. She (E5) should have reported what happened from the beginning. I gave orders for X-ray. At that time the resident's neurological assessment was within normal limits so a CT of the head was not indicated. The facility continued to monitor the resident's neurological status and it remained within normal limits until the morning she was found unresponsive. We don't routinely do head CT's without indication (signs and symptoms) and since this resident did not have any indication I did not order one. The facility followed the appropriate protocol." On 11/28/12 at 10:20AM E1, Administrator verified E5, CNA was negligent and stated, "We discussed what happened with (E5). She lied to us until we confronted her. I couldn't trust her anymore so I terminated her. She showed absolutely no remorse for what she did. I had to let her go."

Based on observation, interview, and record review the facility staff transferred (R1) utilizing a pivot transfer instead of using a mechanical lift as care planned for one of three residents (R1) in the sample of three. (R1) sustained a fractured leg and subsequent amputation of that leg. Facility staff failed to provide safety during repositioning for one of three residents (R2) in the sample of three. During repositioning of R2, E5(CNA) pulled on the sheet causing R2 to roll out of bed. E5 returned R2 to bed and failed to notify the nurse of the fall at the time of the occurrence. R2 received nasal fractures and a subdural hematoma (bleeding within the brain). Findings include: 1. Admission Data Sheet for R1 documents the date of admission as 10/13/10 with the following Diagnoses: [REDACTED]. The care plan for R1 dated 03/01/12 documents the following: "Transfer with assistance of two and full body lift (mechanical lift)." Nurses notes for R1 dated 10/23/12 at 10:55AM and signed by E4, Registered Nurse (RN) document the following: " Upon CNA transferring resident into wheelchair resident complained of left leg pain. Left knee visibly swollen. Doctor notified and resident given Norco as ordered for pain. Order received for resident to be seen in ER (emergency room ). POA (Power of Attorney) notified." Facility Incident Investigation Report for R1 dated 10/23/12 documents the following: "(E3/CNA) self reported she had done a pivot transfer with (R1) rather than using the required full body (mechanical) lift. Post transfer resident complained of pain in the left knee. (E3/CNA) immediately notified the nurse as well as E2 (DON/Director of Nursing). Both nurses assessed the knee and noted slight swelling with no discoloration and no loss of movement. (R1's) physician was notified as well as the POA. (R1) was transferred to the ER for evaluation and admitted to (hospital) with a [DIAGNOSES REDACTED]. (E3/CNA) admitted she did not follow care plan regarding transfer of (R1)." On 11/21/12 at 2:30PM E1, Administrator stated, "In October (E3/CNA) did not use the lift (mechanical) and did pivot transfer (R1). (R1) has Osteoporosis so when E3 transferred the resident using a pivot transfer it caused the fracture. (E3) received a suspension for this." On 11/27/12 at 10:15AM E4, RN stated, "(E3) came to me and said she inappropriately transferred (R1) and that the resident's left knee was swollen. I gave (R1) a pain pill and notified the doctor who had us send (R1) to the emergency room . (R1) returned later that day with a cast on that leg due to a fracture." On 11/27/12 at 10:00AM E3, CNA stated, "I stood and pivoted (R1) from the bed to the wheelchair. I was aware that I was supposed to use a (mechanical lift). (R1) did bear weight during the transfer. (R1) complained of pain in the left knee when I went to put that foot on the wheelchair pedal. I could hear a popping sound when I moved (R1's) foot. It was like a grating sound. I went to the nurse and told her what I did then went to (E2, DON) and also told her. I got a two day suspension for not following the care plan." Nurses notes for R1 dated 10/23/12 document that R1 was returned to the facility at 1:00PM with a cast from "groin to toes". Nurses notes for 11/20/12 at 1:40PM documents the following: "CNA notified nurse of cast assessment that shows medial aspect of left knee cast showing 2cm (centimeter) by 1cm irregular discoloration to cast area. Cast remains hard and dry. Physician notified. POA notified." Same nurses notes document that at 2:45PM R1's physician called back with orders for R1 to be sent to ER for evaluation. Same nurses notes for R1 document that at 6:00PM hospital notified facility that resident was admitted , cast was removed due to pus formation under the cast from an opened wound at the fracture site. Hospital history and physical examination (R1) was brought to the emergency room , the cast was removed and (R1) was found to have about a 2cm hole to skin with a large amount of blood pustular drainage to the distal femur over the fracture site. (R1) continues to have a nonunion at the distal aspect of the tibia as well which was from approximately six years ago. At this point it was recommended the patient be admitted to the hospital on surgical floor and be placed NPO (nothing by mouth) with consent for above the knee amputation on 11/21/12." On 11/27/12 at 9:00AM R1 was lying in the hospital bed. R1 was awake but confused. R1 had received an above the knee amputation of the left leg. A dry dressing was in place covering the amputation site. On 11/27/12 at 10:00AM Z1, R1's surgeon stated, "Moving this resident without using the mechanical lift caused the fracture given the residents severe Osteoporosis. Even though this recent fracture did not help (R1's) situation, I spoke with the family prior to this most recent fracture and recommended amputation because the old fracture of this resident's lower leg had never healed. The family was going to make a decision after the holiday when this most recent fracture occurred. This hastened the family to make a decision and they decided to have the amputation done now." 2. The Admission Face Sheet for R2 documents date of admission as 10/08/05 with the following Diagnoses: [REDACTED]. The care plan for R2 dated 05/13/12 documents that R2 is to be transferred using a mechanical sit to stand lift and that R2 is a one person assist for bed mobility. Nurses notes for R2 dated 06/27/12 at 12:30PM document the following: "noticed purple bruising below right eye. CNA states resident pulled on CNA's name tag and bumped nose." Occurrence Report for R2 dated 06/27/12 documents the following: "CNA came to nurse stating that the resident received a skin tear. Upon entering the room noted a 1cm skin tear to the bridge of the resident's nose. Resident was laying in bed. CNA stated that she was leaning over the resident and the resident grabbed at the CNA's name tag. When the CNA went to pull it back the resident let go and the name tag hit the resident in her nose. After breakfast the resident had a dark purple bruise under the left eye, after lunch the resident was noted to have a dark purple bruise under the right eye and some light purple bruising to the left cheek. Physician and POA (Power of Attorney) notified." Nurses notes for R2 dated 06/28/12 at 9:00AM documents the following: "Midnight CNA (Certified Nurse Aide) reports bruising to right hip. Deep purple bruise on right Iliac Crest (upper hip). Noticed also a faint purple (bruise) to right trochanter (upper thigh), right side of head, an abrasion on second toe of right foot and right knee swelled. Complete head to toe assessment completed. Contacted (Z2, R2's physician) and (R2's) POA. Orders received to send (R2) to hospital for X-ray of knee." Nurses notes for R2 dated 06/29/12 document the following "Late entry for 06/28/12. CNA reports that on 06/27/12 resident rolled out of bed onto floor with no apparent injuries so CNA put resident back to bed. (Z2, R2's Physician) aware that resident rolled out of bed onto floor. Resident's sister also notified." Occurrence Report for R2 dated 06/28/12 and signed by E2, Director of Nursing (DON) documents the following: "On 06/27/12 it was reported that (R2) had cut nose with a CNA's name tag. On 06/28/12 (R2) presented with several more areas of discoloration, two areas on the iliac crest and one on the right trochanter. Resident was lying too close to the edge of the bed. A CNA (E5) entered the room and attempted to pull (R2) back toward the center of the bed and the resident rolled out. The CNA (E5) then placed the resident back in the bed without calling a nurse and reported to the nurse only that the resident had cut her face with the CNA's name tag." Incident Report to Illinois Department of Public Health (IDPH) for R2 dated 06/28/12 and signed by E1, Administrator documents the following: "... (R2) is severely impaired and non-interviewable. She requires assistance of one and a sit to stand lift for all transfers. She is dependent on staff for all ADL's (Activities of Daily Living). On 06/28/12 was notified of bruises of unknown origin noted on (R2). A nursing assessment was completed. Bruises were noted on right hip and right knee. An abrasion to right side of head and swelling of right knee was also noted. POA and physician were notified. (R2) was sent to the hospital for an X-ray of right knee returning to the facility with no findings. Upon investigation, (E5/CNA) stated she observed (R2) roll out of bed onto the floor on 06/27/12. (E5) stated she returned (R2) to bed. Per (E5's) signed statement, she did not report the occurrence to the nurse or any other staff. (E5) has been terminated." Statement signed by E5, CNA dated 06/28/12 documents the following: "I went in to get (R2) up. She was close to the edge (of bed). I raised her bed a few inches. I moved the pad. She started to roll and I tried to catch her, but she fell on the floor and rolled over. She landed on her face on the floor. I picked her up and put her to bed. I was trying to wash her up and she tried to pull my name tag and it cut her nose. I reported the cut to the nurse but not the fall." On 11/27/12 at 9:50AM E5, CNA stated, "I was getting (R2) ready to get up. She was close to the edge of the bed so I pulled on the sheet to move her and she rolled off the bed onto the floor. I picked her up and put her back to bed. She had a scratch on her nose. I told the nurse she got that from my name tag." Facility Neurological assessment Flow Sheet for R2 from the dates of 06/28/12 through 06/29/12 document neurological assessments were done on R2 and all assessments were within normal limits. Nurses notes for R2 for the same time period document no change in condition or level of consciousness. Nurses notes for R2 dated 06/30/12 at 7:00AM document the following: "CNA called nurse to residents room. Noted resident to be up in chair, leaning to the right. Resident mouth is open and drooping to the right side. Bottom teeth (dentures) had fallen out and resident was drooling. Resident transferred to bed. Apical pulse irregular. Resident noted to use abdominal muscles with breathing. Resident's extremities are flaccid and laying straight out in the bed. No response to verbal or tactile stimuli. Pupils equal and reactive. Discoloration remains to both eyes (dark purple) and left side of face light purple. Notified (Z2, R2's physician) and received orders to transfer to hospital. Ambulance called and resident transferred. POA notified." Hospital Head CT (Computerized Tomography) for R2 dated 06/30/12 documents a large subdural hematoma (area of bleeding in the brain) with significant mass effect (pressure) upon the right hemisphere (side) causing greater than 2cm (centimeters) midline shift of the brain to the left side with impending herniation of the brain. Hospital CT of facial bones for R2 dated 06/30/12 documents nondisplaced comminuted (spiral) nasal bone fractures. Nurses notes for R2 dated 07/03/12 at 12:45PM document that R2 was readmitted to the facility from the hospital. R2 had no verbal or tactile response noted. Nurses notes continue to document that R2's POA (Power of Attorney) was contacted in regards to R2's condition and NPO (nothing by mouth) status. POA does not want hospice at this time, declined feeding tube and wants comfort measures only. Nurses notes for R2 dated 07/03/12 at 8:00PM document the following: "Condition remains poor. Repositioned for comfort." Nurses note for R2 continue to document that R2 was monitored throughout the night. Nurses notes for R2 dated 07/04/12 at 4:25AM document the following: "CNA reported change in condition Resident stopped breathing. No apical pulse and no blood pressure heard. Pupils dilated. Death verified by two nurses. (Z2,R2's physician) and POA notified of (R2's) death." On 11/27/12 at 1:30PM E1, Administrator stated, "(E5/CNA) should have told the nurse when (R2) fell to the floor. We did follow up and monitor this resident as the physician ordered. We involved the physician in all aspects of the residents care. We kept in constant contact with (R2's) family. I had to terminate E5. She lied to us about what happened and I could not trust her after that." On 11/27/12 at 6:00PM Z2, R2's physician stated, "I was aware of the fall that occurred when (R2) rolled out of bed. I was involved in the investigation. I gave orders for the facility to sent the resident to the emergency room for X-rays. At that time the residents neurological assessment was within normal limits so a CT of the head was not indicated. The facility continued to monitor the residents neurological status and it remained within normal limits until the morning she was found unresponsive. We don't routinely do head CT's without indication (signs and symptoms) and since this resident did not have any indication I did not order one. The facility followed the appropriate protocol for post fall resident care."