Every finding on record at Alpine Care of St. Charles LLC

Based on observations, interviews and record reviews, the facility failed to prevent the physical restraint of a resident's movement per facility policy.This applies to 2 of 3 residents (R1 and R3) reviewed for falls in a sample of 4.The findings include:1. Face sheet, printed 8/15/26, showed R3's diagnoses included neurocognitive disorder with Lewy bodies, psychotic disorder with delusions, unsteadiness on feet, anxiety, mood affective disorder, cerebrovascular disease, visual hallucinations, difficulty walking, abnormalities of gait and mobility, and muscle wasting and atrophy. Review of R3's care plan showed R3 may be at risk for falls related to weakness and immobility secondary to anxiety disorder, Parkinson's disease, mood disorder, polymyalgarheumatica, and insomnia. The care plan showed R3's fall prevention interventions included wheelchair seatbelt (fastened while [R3] is sitting in her wheelchair. The care plan showed the intervention was implemented on 1/28/26. R3's behavior care plan showed, I am noted to display behavioral symptoms such as attempting to get out of my bed or wheelchair without staff assistance.On 8/14/26 at 10:45 AM with V2 (Director of Nursing), R3 was sitting reclined back in her wheelchair and R3 had a black seat belt buckled around her waist and her wheelchair. V2 asked R3 several times if she could unbuckle her seatbelt and R3 was unable to follow V2's requests. V2 stated R3 may not be able to comprehend what she was asking R3 to do.On 8/14/26 at 12:09 PM, R3 was sitting in her wheelchair in the dining room and had her seatbelt fastened around her waist and the wheelchair. R3 was fidgeting with a cloth in her lap.Facility Restorative assessment, dated 1/28/26, shows R3 was assessed for wheelchair seatbelt use. The assessment shows R3's family requested the seatbelt to decrease instances of unassisted self-transferring out of wheelchair and decrease fall risk. The assessment shows R3 was to use a seatbelt when R3 was sitting in her wheelchair especially at times of increased anxiety and restlessness to prevent incident of injury and enhance safety. On 8/14/26 at 9:39 AM, V2 (Director of Nursing) and V5 (Assistant Director of Nursing) stated R3's family requests that facility staff use a seatbelt to keep R3 in her wheelchair because R3's family is afraid R3 will fall when sitting in her wheelchair. V2 stated R3 was able to release her seatbelt herself.On 8/14/26 at 10:53 AM, V7 (Restorative) stated R3 had a seatbelt implemented while sitting in her wheelchair to protect R3 from getting out of her wheelchair and falling because she was a high fall risk. V7 stated R3 constantly attempted to get out of her wheelchair herself. On 8/14/26 at 11:23 AM, V12 (Fall Prevention Nurse) stated R3 had a seatbelt in place when sitting in her wheelchair because R3's family insisted on having the seatbelt implemented on R3's while in her wheelchair. V12 stated R3's family knew she was a fall risk, was restless, and had a potential of falling if she stood up. V12 stated R3's behaviors included standing up from her wheelchair because she was restless. V12 stated residents utilizing seatbelts while in wheelchairs should be able to release the seatbelts by themselves. V12 stated she did not think R3 would be able to fully understand the question if she was asked to release her seatbelt. On 8/14/26 at 11:02 AM with V8 (Registered Nurse), V9 (Restorative) stated R3 had a seatbelt implemented while sitting in her wheelchair because R3 leaned forward and there was a concern she would slip out of her chair. V9 stated R3 would attempt to get out of the chair to stand putting her at risk for falling and R3's seatbelt would prevent her from standing from her wheelchair. V8 stated R3 was still able to stand if she desired to do so. V9 stated R3 would pull or tug on her seatbelt so staff would place it under R3's shirt so she could not tamper with the seatbelt. V8 stated when R3 was more awake she tried to move forward and get out of her wheelchair and R3 experienced a fall after sliding from her wheelchair. V9 stated R3 no longer walked safely and the family was requesting she used the seatbelt so she did not attempt to slide out of her wheelchair and fall.On 8/14/26 at 2:45 PM, V12 stated on 5/22/26 R3 fell from her wheelchair and her seatbelt was in place but R3 unbuckled her seatbelt and crawled to her footrest and then to the floor. Fall investigation, dated 5/22/26, shows R3 was sitting in her wheelchair in the common area in front of the nursing station with her seatbelt on and a CNA (Certified Nursing Assistant) observed R3 crawl from the footrest of her wheelchair to the floor. Physician Order Sheet, printed 8/15/26, shows R3 had the following physician order: Wheelchair seatbelt - To be used while patient is sitting up in wheelchair, especially during instances of increased anxiety and restlessness. Indications: Enhanced wheelchair safety. Prevention of incident or injury.On 8/16/26 at 12:09 PM, V19 (Consultant) stated it was her expectation that the facility follow the facility policy/procedure regarding R3's seatbelt and provide education for families regarding what is best for the resident.2. Face sheet, printed 8/14/26, shows R1's diagnoses included dementia with anxiety, psychosis, muscle wasting, abnormal posture, and congestive heart failure. Review of R1's care plan showed R1 was at high risk for falls related to a history of frequent falls, anxiety and agitation, cognitive impairment related to dementia, functional debility and weakness, impulsivity, poor safety awareness, and unsteadiness on her feet. R1's fall interventions to prevent future falls included use of a chair alarm while R1 was in her wheelchair. On 8/13/26 at 6:28 PM, V4 (Family) stated the facility staff asked V4 if R1 could be strapped in her chair using a seatbelt because R1 was experiencing multiple falls. V4 stated R1 would not be able to get out of her chair if a seatbelt was implemented. V4 stated the facility was trying t restrain her by not allowing her to stand on her feet.On 8/14/26 at 9:39 AM, V1 (Administrator) stated a family member of R1 asked if the facility could place a seatbelt on R1 when in her wheelchair to prevent her from falling after experiencing multiple falls. V1 stated the family was not R1's decision maker and the facility had to seek permission from V4 before implementing a seatbelt on R1 while in a wheelchair. V1 stated the facility asked V4 if she would like to place a seatbelt on R1 while R1 was in her wheelchair to prevent further falls but V4 declined. Facility Restraint Device Evaluation document, dated 3/2021, shows Restraint use requires and evaluation, recommendation and an order and resident/legal representative permission before application. Use of restrains will be in accordance with state/federal regulations. Any device evaluated as a restraint using the Device Observation, education and Consent requires the following in the order: a When to use a restraint, b. Why it is to be used, c Specific type of restraint, d. How long to apply. 7. Make sure the restraint allows for freedom of movement.

Based on interviews and record reviews, the facility failed to prevent the use of chemical restraints. This applies to 2 of 3 residents (R1 and R3) reviewed for falls in a sample of 4. The findings include: Face sheet, printed 8/14/26, shows R1's diagnoses included dementia with anxiety, psychosis, muscle wasting, abnormal posture, and congestive heart failure. Review of R1's care plan showed R1 was at high risk for falls related to a history of frequent falls, anxiety and agitation, cognitive impairment related to dementia, functional debility and weakness, impulsivity, poor safety awareness, and unsteadiness on her feet. R1's fall care plan shows interventions included referral to psychiatry, initiated 6/21/26, due to frequent anxiety, difficulty with redirection, agitation and restlessness resulting in unassisted standing/unassisted self-transferring. On 8/13/26 at 6:28 PM, V4 (Family) stated she was concerned R1's fall interventions suggested by the facility were not appropriate. V4 stated the facility suggested R1 begin to receive trazadone to help R1 sleep but V4 stated R1 did not have difficulty sleeping. V4 stated the facility was trying to restrain her by not allowing her to stand on her feet.Review of R1's MARs (Medication Administration Records), dated 6/1/26 to 8/15/26, showed the R3 was administered the following medications while not exhibiting any behaviors at the time of administration:-Lorazepam was scheduled to be administered twice daily for anxiety between 6/12/26 and 6/30/26. The MAR showed the medication was administered 30 of 34 times as scheduled while not experiencing any anxiety at the time of administration.-Lorazepam was prescribed to be administered as needed for sleep and was administered on 6/2/26 at 4:24 PM and on 6/4/26 at 4:00 PM. The MAR showed no behaviors were occurring when the medication was administered.- Lorazepam was scheduled to be provided twice daily for anxiety and was administered twice daily on 7/1/26, 7/2/26 and 7/3/26 as ordered. The MAR documentation showed R1 was not experiencing any anxiety when the medication was administered.- Haldol was prescribed to be administered as needed for agitation was administered on 7/14/26, 7/16/26, 7/19/26, and 7/24/26. The documentation showed R1 was not experiencing agitation occurring at the time of administration.- Lorazepam prescribed to be administered as needed for restlessness and insomnia. The medication was administered on 8/3/26 at 6:47 PM and 8/10/26 at 7:32 PM. The MAR shows R1 was not experiencing restlessness/insomnia when the medication was administered.On 8/14/26 at 12:23 AM, V12 (Fall Prevention Nurse) stated after R1 returned form the hospital in June 2026 she had a physician order for lorazepam to be given every 12 hours. V12 stated she thought the use of the lorazepam and R1's falls were correlated. V12 stated R1's physician discontinued the lorazepam but the nurses stated R1 was having difficulty sleeping so the psychiatric nurse practitioner recommended the use of trazadone which V4 declined. V12 stated V4 requested R1 begiven lorazepam at bedtime and V12 told V4 that R1 might experience more falls if lorazepam were administered. V12 stated the hospital also correlated the use of lorazepam with R1 falling. Review of R1's fall investigations, dated 5/22/26 to 7/28/26, showed R1 experienced seven falls at the facility including a fall on 7/4/26 resulting in a subdural hematoma and hospitalization.2. Face sheet, printed 8/15/26, showed R3's diagnoses included neurocognitive disorder with Lewy bodies, psychotic disorder with delusions, unsteadiness on feet, anxiety, mood affective disorder, cerebrovascular disease, visual hallucinations, difficulty walking, abnormalities of gait and mobility, and muscle wasting and atrophy. Review of R3's Physician Order Sheets show R3 had physician orders for lorazepam for agitation/anxiety or agitation/restlessness from 4/7/26 to 4/21/26 and from 5/28/26 to 6/11/26.Review of R3's care plan showed R3 may be at risk for falls related to weakness and immobility secondary to anxiety disorder, Parkinson's disease, mood disorder, polymyalgarheumatica, and insomnia. Review of R3's behavior care plan showed, Behavioral symptoms such as attempting to get out of my bed or wheelchair without staff assistance. Interventions for the identified behaviors included Give psychoactive medication as ordered. Record behavioral symptoms. and refer R3 to the psychiatrist for psychiatric evaluation. R3's anti-anxiety medication care plan shows R3 was taking lorazepam related to anxiety and agitation which was associated with increased confusion, amnesia, loss of balance and cognitive impairment that looks like dementia, falls, broken hips and legs. The care plan shows R3 was to be monitored every shift for safety. The care plan fails to identify resident specific behaviors demonstrating R3 was experiencing anxiety other than R3 attempting to get out of her bed or chair without staff assistance.The facility document Chemical Restraints, dated 3/2021, shows, 'Chemical Restraint' according to federal regulations, means any chemical used primarily to modify a resident's behavior, mood or mental status. Chemical restraints should be used only as a last resort to protect a resident from injury to himself or others. Chemical restraints shall never be used to limit or control behavior for staff convenience The resident's plan of care should include: when the chemical restraint is to be used. For how long. Plans for alternative measures. Periodic evaluation of the resident . The use of chemical restraints, other intervention strategies used, and the response to the plan of care should be documented in the progress notes

Based on observations, interviews, and record reviews, the facility failed to implement fall prevention interventions per a residents' plan of care and facility policy.This applies to 2 of 3 residents (R1 and R3) reviewed for falls in a sample of 4. The findings include: 1. Face sheet, printed 8/14/26, showed R1's diagnoses included dementia with anxiety, psychosis, muscle wasting, abnormal posture, and congestive heart failure. Review of R1's care plan showed R1 was at high risk for falls related to a history of frequent falls, anxiety/agitation, cognitive impairment related to dementia, functional debility and weakness, impulsivity, poor safety awareness, and unsteadiness on her feet. R1's fall interventions to prevent future falls included use of a chair alarm while R1 was in her wheelchair. On 8/13/26 at 6:28 PM, V4 (Family) stated she visited R1 at the facility and R1's fall interventions were not implemented including her bed and/or chair alarms were not implemented and turned on when R1 was in her chair/bed.On 8/14/26 at 10:34 AM, R1 was sitting in her high back wheelchair in front of the nursing station. R1 had a chair alarm hanging from the handles of her wheelchair. The chair alarm was not blinking green indicating it was turned on and the setting of the alarm was in the off position. V21 (Wound Care) inspected the chair alarm and stated the alarm was not turned on. V21 turned on the setting of the alarm to the on position, the alarm beeped, and the green light began blinking. V2 (Director of Nursing) examined the chair alarm and stated the alarm should have been turned on when R1 was sitting in her wheelchair.On 8/14/26 at 11:02 AM, V9 (Restorative Nurse) stated she checked R1's chair alarm earlier in the morning and it was turned on. V9 stated staff took R1 to R1's room recently to change her incontinence brief and must not have turned the alarm back on after care. V9 stated the chair alarm should be on when R1 was sitting in her wheelchair. On 8/14/26 at 11:48 AM, V13 (CNA-Certified Nursing Assistant) and V14 (CNA) took R1 to her room to be toileted. R1's right foot protection boot was removed exposing a white sock on her foot. R1 had a walking boot on her left foot. R1 was wheeled to the bathroom and the staff asked R1 to stand and pivot on to the toilet and then again off the toilet to her wheelchair when she was finished. R1 was wearing the white sock on her foot during the transfers. When asked if R1's white sock was a non-slip sock, V13 and V14 examined the white sock and stated it was not a non-slip sock and only a regular sock. V14 stated R1 should have had a non-slip sock while transferring to and from the toilet and stated, I am going to get you different socks.On 8/14/26 at 1:13 PM, V12 (Fall Prevention Nurse) stated R1 experienced 7 falls between 5/22/26 and 7/28/26. V12 stated R1 fell from her wheelchair on 7/1/26 and the staff implemented a chair alarm as a fall intervention to prevent R1 from experiencing further falls. V12 stated R1 was confused, anxious and impulsive and had a history of falls including resultant hematoma injury. V12 stated it was her expectation that R1 have non-slip socks on her feet when transferring or standing on the floor. 2. Face sheet, printed 8/15/26, showed R3's diagnoses included neurocognitive disorder with Lewy bodies, psychotic disorder with delusions, unsteadiness on feet, anxiety, mood affective disorder, cerebrovascular disease, visual hallucinations, difficulty walking, abnormalities of gait and mobility, and muscle wasting and atrophy. Review of R3's care plan showed R3 may be at risk for falls related to weakness and immobility secondary to anxiety disorder, Parkinson's disease, mood disorder, polymyalgarheumatica, and insomnia. The care plan shows R3's fall interventions included use of a bed alarm during times when R3 was in bed (implemented 4/18/26).On 8/14/26 at 2:45 PM, V12 (Fall Prevention Nurse) stated R3 experienced 5 falls between 3/20/26 and 8/3/26. V12 stated on 8/3/26, R3 was observed next to her bed on the floor. V12 stated no staff heard R3's bed alarm sound when she fell and based on V12's fall investigation, R3's bed alarm was not on and implemented when R3 fell. Facility Fall Program document, effective 3/2021, showed if a resident is identified as a fall risk a care plan is developed or updated and new fall interventions are reviewed with the resident/responsible party and applicable staff. The policy shows education regarding the resident's risk for falls and interventions to prevent falls were to be provided.

Based on observations, interviews and record review, the facility failed to ensure significant medications were available and administered in accordance with physician orders. This applies to 2 of 9 residents (R3 and R8) reviewed for medications. The Findings include: 1.The EMR (Electronic Medical Record) showed that R3 is a [AGE] year-old with diagnoses that include thrombocytopenia, history of pulmonary embolism, long term use of anticoagulants, radiculopathy, to the lumbar region, sacrococcygeal disorders, and spondylosis. The MDS (Minimum Data Set) assessment dated [DATE], showed that R3's cognition was intact. The MDS also showed that R3 requires substantial amount of staff assistance for ADLs (Activities of daily Living).On May 15, 2026, at 10:30 A.M., R3 was observed lying in bed. R3 said that her Lovenox was not administered again on May 11 and 12 of 2026. R3 said that it was in the month of April that she had not also received her Lovenox and this is another episode that Lovenox was not administered again. R3 added that Lovenox was ordered for her for prevention of blood clots. R3 stated that she has history of blood clots, so she needed Lovenox for clot prevention. Review of the Medication Administration Record (MAR) and corresponding nursing documentation confirmed the medication was not administered on those dates. Further review reflected that the medication omission was documented. Review of the current POS (Physician order Sheet) for the month of May 2026 showed a physician order dated April 19, 2026, for Lovenox 40 mg every 12 hours (6:00 A.M. and 6:00 P.M.) to be given via injection subcutaneously. On May 16, 2026, at 11:45 A.M. V2 (Director of Nursing) had validated that Lovenox was not administered on May 11 and May 12, 2026, for the scheduled morning doses. V2 had no explanation of what the reason was why Lovenox was not administered. 2. The EMR showed that R8 was a [AGE] year-old with diagnoses of dependent on renal dialysis treatment, post-traumatic stress disorder, epilepsy, and metabolic encephalopathy.The MDS dated [DATE] showed that R8 was cognitively moderately impaired. R8 also requires substantial assistance from ADLs. On May 15, 2026, at 2:00 p.m., V9, (Registered Nurse) was preparing, administering, and documenting medications in accordance with physician orders. However, V9 could not administer R8's Hydroxine 50 mg tablet as this medication was not available. The order was for R8 to have Hydroxine 50 mg during the day of dialysis (Mondays-Wednesdays -Fridays). V9 said that this Hydroxine was for R8 to decrease anxiety level and lessen symptoms of urticaria (skin reaction characterized by intensely itchy welts). V9 added that R8 was on her way to the dialysis treatment. V9 further said that the Hydroxine was already ordered but was not available in the facility. During this time, R8 said can someone check my room, I felt like bugs are in my room, I am always feeling itchy. Maintenance staff was called and checked R8's room and no bugs were found.On May 16,2026 at 8:30 A.M., V3 (Nurse Practitioner) said that R3's Lovenox 40 mg. injection was significant medication as this would help prevent blood clots. V3 also said that R8's Hydroxine was ordered during the dialysis days (Monday-Wednesdays-Fridays) prior to R8's dialysis treatment to control anxiety level and continuous itchiness.The facility failed to administer R3's prescribed Lovenox medication on May 11 and 12, 2026, and failed to ensure availability and administration of R8's prescribed Hydroxyzine prior to dialysis treatment. These failures had the potential to adversely affect residents' health and well-being.The facility's policy for medication administration dated March 2021 showed to ensure that the administration of medications in a safe manner to prevent medication errors. The policy also showed that they are administered as ordered.

Based on observation, interview, and record review the facility failed to ensure a resident was free from significant medication errors. This applies to 1 of 3 residents (R1) reviewed for medications in the sample of 4. The findings include: On 4/23/26 at 9:37 AM, R1 was observed in her room lying in bed. R1 said she does not receive all her medications. They run out of my medications. R1 said she did not receive her pain patch (Fentanyl) and blood thinner injection (Lovenox) a few weeks ago. Nursing said they didn't have the medication. R1 said there's medication issues every month.R1's Medication Administration Record (MAR) dated April 2026 shows orders including Lovenox 40 mg (milligrams) inject 40 mg every twelve hours. R1's MAR shows Lovenox 40 mg was not administered for five doses. R1's MAR on 4/10 and 4/22 shows there was no documentation of the medication administered. R1's MAR shows on 4/7, 4/8, 4/11, the medication was unavailable and not administered. R1's MAR dated April 2026 shows orders including Fentanyl transdermal patch every 72 hours 50 mcg/hr (micrograms) apply one patch transdermally every 72 hours for pain. On 4/10/26, R1's fentanyl patch was unavailable and not administered. On 4/23/26 at 11:13 AM, V2 (DON/Director of Nursing) said when the medication is running low nursing should order at minimum three days in advance. Some medication we can pull from our emergency supply if the medication is not available. If the medication is not documented on the M.A.R it was not administered. V2 said there was a time when R1 did not receive her blood thinner injection because the agency nurse said she could not find it. V2 said she was not aware of any other missed doses. On 4/23/26 at 12:46 PM, V3 (ADON/Assistant DON) reviewed R1's April 2026 MAR with this surveyor and confirmed R1 did not receive her fentanyl patch on 4/4/26. V3 said the patch was ordered through pharmacy but it was not available to administer. V3 said medications should be signed off when administered. V3 said R1's blood thinner injection medication is delivered in a box supply. There should be plenty of supply for nursing to administer the medication. She is not sure why nursing is documenting unavailable. The facility's Medication Administration Policy dated 4/2026 states, To ensure that the administration of medications is performed in a safe manner to prevent medications errors.at completion of med pass, review all EMARs to assure all medications have been administered and documented.

Based on observation, interview, and record review, the facility failed to implement fall and safety interventions for residents identified at a high risk for falls. This applies to 4 of 5 (R3, R4, R5, and R6) residents reviewed for falls.The findings include:1. R3's MDS (Minimum Data Set) dated 1/15/2026 said she was severely cognitively impaired and required substantial to maximal assistance with her transfers and dressing. R3's Fall Risk assessment dated [DATE] said she had a history of falls and was at a high risk for falls.On 4/14/2026 at 1:40 PM, R3 had a fading yellow-purple bruise on her right eye's orbital area and was severely cognitively impaired. V15 (Certified Nurse Assistant/CNA) then transferred R3 to the bathroom with the use of a gait belt. R3's gait was slow and at times unsteady. V15 said R3 required extensive step-by-step cues with her care and transfers to ensure her safety. V15 said R3 was a high risk for falls. V15 continued to say R3 had recently fallen and sustained an injury to her right eye.R3's Skin/Wound Evaluation form dated 4/09/2026 said she sustained a partial laceration to the right eyebrow. The wound measured 0.5 x 1.0 x 0.1 cm (centimeters) and required the application of steri-strips.On 4/17/2026 at 2 PM, V27 (Agency CNA) said he transferred R3 to bed on 4/08/2026. V27 said he then turned away from her and walked across the room to get a gown for her. V27 then noticed R3 falling out bed and he tried to hold her from falling but was unsuccessful. V27 said R3 somehow hit her head on the furniture and sustained an injury to her right eye.R3's witnessed fall incident report dated 4/08/2026, said R3 had fallen at 8:20 PM from her bed when she was being assisted with her transfer and bedtime care by her assigned CNA. The report said R3 was unable to give a description of the event and sustained a laceration to her right eyebrow.On 4/17/2026 at 1 PM, V3 (Restorative/Fall Nurse) said she investigated R3's fall incident and determined V27 was unable to intervene in R3's fall from bed after he transferred her. V3 said V27 should have been prepared with all R3's bedtime linens, clothing, and other prior necessities prior to assisting her with her bedtime routine.R3's fall care plan showed it has not been updated since 6/29/2025. No new interventions were put in place after R3's 4/8/2026 fall.2. R4's MDS dated [DATE] said he was severely cognitively impaired. Also, he required partial to moderate assistance with his wheelchair mobility and substantial to maximal assistance with transfers. R4's Fall Risk assessment dated [DATE] said he had a history of falls and was at a high risk for falls.On 4/14/2026 at 1:15 PM, R4 was in his wheelchair. R4 had multiple skin tears on both his arms and was severely cognitively impaired. R4 was unable to say how he sustained his injuries. V15 (CNA) and V17 (Wound Care Nurse/WNC) said R4 was a high risk for falls and had sustained his skin tears after he fell on 4/03/2026. V15 said R5 had to be supervised when he was up in his wheelchair at the nurses' station to ensure he was being safely monitored. R4 was seated on a black cushion, which was neither a wedge cushion or a pommel cushion. V17 verified there was no (anti-slip material) present in R4's wheelchair either.On 4/15/2026 at 10:25 PM, V20 (Registered Nurse/RN) said R4 was a high risk for falls, and his fall prevention interventions included he be monitored at the nurses' station when up in his wheelchair. V20 said on 4/03/2026 at 2:15 PM, R4 was at the nurses' station when he propelled himself down the hallway away from the nurses' view and then slid off his wheelchair. V20 said he sustained skin tears to the left elbow and the back of his right hand.R4's unwitnessed fall incident report dated 4/03/2026 said R4 was observed on the floor in a lying position in front of the nurses' station. R4's reports showed he said he slid on the floor and hit his head slightly. The report said R4 sustained skin tears on his arms.On 4/17/2026 at 1 PM, V3 (Restorative/Fall Nurse) said she investigated R4's fall incident, and unfortunately, he was unable to describe what had occurred prior to the incident, but said he slid off his wheelchair. V3 continued to say that she determined his fall intervention was the hospital treatment he received for his chronic anemia. V3 said R4 had multiple falls and would now consider therapy fall prevention recommendations to ensure his safety.On 4/17/2026 at 12 PM, V4 (Therapy Director) said R4 was a high fall risk, and therapy had made multiple recommendations to V3 prior to his recent fall on 4/03/2026. V4 said the recommendations included an abductor pillow to be placed between R4's legs and a pommel (wedged) wheelchair cushion. V4 continued to say that even the use of a (anti slip pad) to the wheelchair could prevent him from sliding off his wheelchair.R4's therapy communication sheets dated 3/26/2026 and 4/02/2026 said they recommended he use an abductor wedge due to his poor safety awareness when up in his wheelchair.R4's fall care plan was last updated on 1/25/2026. No new fall interventions were implemented after his fall incident on 4/03/2026.3. R6's MDS dated [DATE] said she was cognitively impaired and was dependent on staff with her transfers. R6's Restorative assessment dated [DATE] said she required the use of a mechanical lift with a 2-person assist with her transfers. R6's Fall Risk assessment dated [DATE] said she had a history of falls and was at a high risk for falls. On 4/14/2026 at 3 PM, R6 was sitting in her wheelchair at the nurse's station. V19 (RN) said R6 was a high risk for falls and had to be monitored when up in her wheelchair. R6 had a mechanical lift sling underneath her and was sitting on a pommel (wedged) cushion. The cushion was worn down, and the front edge curved down and under the wheelchair's seat and not properly placed in the wheelchair.On 4/15/2026 at 11:30 AM, V21 (Dialysis Nurse) said R6's dialysis treatment was completed, and she had to be transferred into her wheelchair. R6's wheelchair was in the dialysis room, and there was a mechanical lift sling on top of the seat. V21 said V25 (CNA) had transferred R6's into the dialysis chair in the morning by himself in the dialysis room. At 11:40 AM, V25 said he transferred R6 by himself (1-person assist) because her assigned agency CNA was not scheduled to arrive until later. On 4/17/2026 at 1 PM, V3 (Restorative/Fall Nurse) said R6 had a history of multiple falls, and on 1/26/2026, she fell near the nurses' station. V3 said R6's current fall prevention cushion (pommel) was in place during her fall. V3 continued to say that staff should transfer residents based on their plan of care, and R6 required the use of a mechanical lift for safe transfers because her level of function varied due to her dialysis treatment.R6's unwitnessed fall incident dated 1/26/2026 said she fell at 2:57 PM down the hallway near the nurses' station. R6 was observed sitting on the floor with her back resting on her wheelchair. R6 was unable to describe what had occurred due to her confusion.On 4/17/2026 at 12 PM, V4 (Therapy Director) said R6 was being treated by therapy for general weakness. V4 said therapy had also made prior recommendations to the nursing team to ensure R6's was properly seated in her wheelchair to ensure proper sitting posture and placement of her cushion on the wheelchair because she had the tendency to lean forward and was at high risk for falls.R6's therapy communication sheets dated 2/19/2026, 3/23/2026, and 3/25/2026, said they recommended she be properly positioned in her wheelchair to ensure proper safe posture when up in her wheelchair.R6's fall care plan included multiple interventions, including the use of her pommel cushion (safety device), and need to be monitored at the nurses' station due to her high risk for falls.4. R5's fall care plan said she was admitted on [DATE] and was at high risk for falls due to her medical history. R5's care plan had multiple interventions, including the use of a floor mat when in bed.On 4/14/2026 at 11:20 AM, R5 was in bed, and her fall mat was not in place. The blue fall mat was in an upright position next to her chair across her bed. R5 was anxious at times and showed signs of impaired memory. R5 said she had recently fallen and broken her left hip. At 11:25 AM, V13 (Agency CNA) entered R5's room to offer her water. When V13 left the room, he failed to implement R5's fall mat intervention. Then, at 11:40 AM, V14 and V15 (CNAs) also failed to implement R5's fall mat intervention after they assisted her with her toileting needs in bed.The facility's Fall Occurrence policy, dated 6/30/2025, said it was the policy of the facility to ensure that residents were assessed for their risk for falls, that interventions were put in place, and that interventions were reevaluated and revised as necessary. The policy said those identified as high risk for falls would be provided with fall interventions. The Falls Coordinator will review the incident reports and conduct his/her own fall investigation to determine the reasonable cause of a fall. The nurse may immediately start interventions to address falls in the unit, even prior to the Falls Coordinator's investigation. But ultimately, the Falls Coordinator may change the interventions provided by the nurse if his/her investigation identifies a more appropriate intervention for the individual's fall. The Falls Coordinator will add the interventions in the resident's care plan, and the interventions will be reevaluated and revised as necessary.

Based on observation, interview, and record review, the facility failed to provide pressure ulcer prevention interventions for a resident with known risk for pressure ulcer development. This failure applies to 1 of 4 (R5) residents reviewed for pressure ulcers.The findings include:R5's EMR (Electronic Medical Record) said she was admitted to the facility on [DATE] following left hip surgery. R5's MDS (Minimum Data Set) dated 4/13/2026 said she was admitted with two pressure ulcers, an unstageable and a deep tissue injury (DTI). R5's EMR said she had an unstageable ulcer to her left heel and DTI to her left buttock.R5's skin care plan said she was at a high risk for pressure development based on her Braden assessment score of 12, known skin breakdown, and incontinence of bowel and bladder.On 4/14/2026 at 11:20 PM, R5 was in bed, lying on her back. R5 appeared confused and called out for assistance but appeared to be unsure of what she needed. R5 then requested to be toileted. At 11:40 AM, V14 and V15 (Certified Nurse Assistants/CNAs) said R5 required 2-person assistance with turning because of her left lower leg. They turned her on her right side to remove her incontinence brief. R5's brief was heavily soiled with urine and smeared feces. R5 had a DTI to her left buttock and a separate open area to her sacrum. V14 said he had last provided incontinence care to R5 at the beginning of the shift around 6 AM-7 AM (more than four hours prior) and R5 did not have an open area to her sacrum. V14 said he would inform V17 (Wound Care Nurse/WCN).On 4/14/2026 at 12:20 PM, V17 (WNC) said R5 had two pressure ulcers to her left heel and left buttock, both present on admission. V17 proceeded to assess R5's buttock and said she now had a new open wound to her sacrum, which was not present when she assessed her skin early in the morning around 6 AM. V17 said R5's sacral open wound was a stage 2 pressure ulcer that measured 5 x 1.8 x 0.1 cm (centimeters) with purple discoloration to the per-wound area.V17's skin note dated 4/14/2026 said a skin assessment was performed on R5 and was identified with a new skin alteration. The note said, sacrum was noted with superficial skin opening, measuring 5 x 1.8 x 0.1 peri-wound shows intact with discoloration. V17's note said that prior to her sacral assessment, she had also assessed R5's skin and performed wound care to her left buttock DTI and left heel unstageable ulcers.On 4/15/2026 at 9:20 AM, V17 (WCN) said R5's new sacral ulcer and admitted with left buttock DTI were being treated with (moisture barrier cream) and kept open to air. V17's said R5 had multiple skin prevention interventions, including for CNAs to apply the barrier cream when providing incontinence care. V17 said incontinence care should be provided at least twice a shift, at the beginning and end of the shift. V17 then continued to say that for residents who were cognitively impaired, like R5, they should be checked and changed at a minimum every 3 hours.On 4/15/2026 at 1 PM, V2 (Director of Nursing/DON) said nursing staff were expected to assist residents with their toileting needs as indicated in their plan of care. V2 said incontinent residents should be checked and changed at least every 2-3 hours to prevent skin breakdown, skin infections, and to relieve pressure.The facility's policy titled Incontinence Care dated 04/2026, said staff was provide care to residents who had incontinence episodes, and incontinence care should be repeated after each episode of urinary and/or fecal incontinence.The facility's policy titled Pressure Ulcer Prevention and Treatment Interventions, dated 04/2026, said the purpose of the policy was to provide guidance for pressure ulcer prevention and treatment interventions. The policy said incontinence and moisture management was required for residents, and they should be assessed and treated for incontinence care based on their needs.

Based on interview and record review, the facility failed to notify the physician of a resident's (R8) unwitnessed fall incident, who was then experiencing acute right hip pain.This failure resulted in R8 receiving delayed medical care for her right hip fracture.This applies to 1 of 7 residents (R8) reviewed for fall incidents in the sample 10. The Findings include:On 3/19/2026 at 3:00 PM, R8 was in bed, lying on a mechanical lift sling. R8 was unable to provide information regarding her fall incident on 3/01/2026 due to her cognitive impairment and communication barrier.R8's MDS (Minimum Data Set) dated 1/30/2026 said she was severely cognitively impaired.On 3/20/2026 at 9:50 AM, V11 (Certified Nurse Assistant/CNA) said she routinely took care of R8, and prior to 3/02/2026, she required minimal to partial assistance with her transfers. V11 said on 3/02/2026 at approximately 5:45 AM, when she assisted her with dressing in bed, R8 vocalized acute pain in her right leg. V11 said she became concerned and stopped rendering care and consulted V9 (Agency Registered Nurse/RN). V9 informed her that she had just administered an analgesic to R8. V11 said she then inquired if R8 had a recent incident, such as a fall, because her leg pain was new. V9 informed her that there was no incident reported or recorded in R8's EMR (Electronic Medical Record). V11 said she then proceeded to transfer R8 with a gait belt, and R8 now required extensive assistance. V11 said R8 guarded her right lower leg and was unable to bear weight. V11 said she was further concerned and updated the V10 (RN), the oncoming morning nurse, and again was instructed to continue to provide routine care to R8. V11 said she then transported R8 to the dialysis unit, and again when she transferred her to the dialysis recliner chair, she vocalized discomfort in her right leg. V11 said she then informed V15 (Dialysis RN) of R8's acute pain. V11 continued to say that at 11 AM, she again transferred R8 to her wheelchair after her dialysis treatment and transported to the therapy gym. V11 said she then informed V16 (Occupational Therapist/OT) because she was extremely concerned about R8. V11 said at 1 PM, when she transferred R8 to bed, she now required maximum to total assistance with her transfer and was still experiencing acute pain.On 3/20/2026 at 11:10 AM, V9 (Agency RN) said she was assigned to R8 on 3/01/2026 from 10 PM-6 AM. V9 said she was not notified of R8 having an incident when she received hand-off report from V8 (RN).R8's EMAR (Electronic Medication Administration Record) for March 2026 showed V9 administered Acetaminophen 650 MG (milligrams) by mouth at 4:40 AM for pain.On 3/20/2026 at 11:20 AM, V13 (Agency CNA) said he was assigned to R8 on 3/01/2026 from 10 PM-6 AM. V13 said he was instructed that R8 required minimal assistance with her transfers. V13 said R8 requested to be toileted, and she had to pivot to transfer into her wheelchair. V13 said he was not notified of R8 having an incident on the prior shift.On 3/20/2026 at 11:30 AM, V15 (Dialysis RN) said on 3/02/2026 R8 verbalized ouch when V11 transferred her into the dialysis chair. V11 then informed her that R8 was vocalizing acute pain in her right lower leg. V15 said she notified V10 (RN) and was not made aware of her having any recent incident.R8's Dialysis Communication Report sheet dated 3/02/2026 requested updated information from the nursing team, including whether R8 had any change in condition, such as a recent fall.On 3/20/2026 at 2 PM, V16 (OT) said on 3/02/2026, R8 was unable to safely stand during therapy and started to yell in pain when she removed the wheelchair's right footrest. V16 said she was not notified of R8 having any recent incidents. V16 said if a resident was experiencing acute pain and had recently sustained a fall, she would not have provided therapy services till they were fully evaluated for a possible acute injury.R8's OT Treatment Encounter Note dated 3/02/2026 said pt [patient] verbalized pain but unable to grade. Pt was screaming and holding RLE when RLE was moved.On 3/20/2026 at 12 PM, V10 (RN) said she was assigned to R8 on 3/02/2026 from 6 AM-10 PM. V10 said she was not notified of R8 having an incident when she received the report. V10 said she reported R8's right hip pain to V4 (Physician) during passing and received an order for a routine x-ray, which was done after 7 PM. V10 said that if she had been aware of R8's fall incident on 3/01/2026, she would have notified V4 to ensure an acute focus assessment was done and recommended a STAT (immediate) x-ray.R8's Radiology Report dated 3/02/2026 said her right hip x-ray was reviewed remotely at 11:30 PM and was found to have a subcapital fracture to the right femoral neck.On 3/20/2026 at 11 AM, V12 (CNA) said on 3/01/2026 at approximately 6:30 PM during rounds, she observed R8 on the floor next to her bed in a sitting position. V12 said she notified V8 (RN), and after she assessed R8, they transferred her back to bed. V12 said they carried R8 off the floor by lifting her under her arms.On 3/20/2026 at 11:50 AM, V8 (RN) said she was assigned to R8 on 3/01/2026 from 2 PM-10 PM, and R8 had an unwitnessed fall from her bed. V8 said she assisted V12 (CNA) in transferring R8 back to bed. V8 said she did not think R8 had sustained an injury. V8 said she did not document the incident in R8's EMR and did not notify V4 (Physician). V8 said in retrospect she should have notified V4 of the incident to ensure the physician could have assessed the situation and determined R8's medical care needs.On 3/20/2026 at 12:45 PM, V4 (Physician) said she was not notified of R8's fall incident on 3/01/2026. V4 said on 3/02/2026, she was still not notified of her fall incident despite her experiencing acute right hip pain. V4 said if she had been notified appropriately of R8's unwitnessed fall incident, she would have further assessed her, ordered STAT testing, or transferred her to the hospital sooner to ensure she did not have a delay in medical care. V4 said when she was notified of R8's right hip fracture, she ordered her to be transferred to the hospital for an emergency evaluation and treatment. V4 said R8 required orthopedic surgery for her right femur fracture.R8's progress note dated 3/03/2026 said X-ray result received @ 1 am, per X-ray for further evaluation. MD and DON made aware. To send to [Hospital]. [Ambulance] called @ 1:16 am. Pain complained on R hip/thigh area.Pt left with [Paramedics] @ 3:12 AM.On 3/20/2026 at 12:10 PM, V14 (RN/Fall Coordinator) said nurses were expected to notify the physician of all fall incidents as per policy. V14 said V8 (RN) received counseling after R8's acute fracture was discovered, and then afterwards identified R8 had sustained an unwitnessed fall on 3/01/2026 that was not reported.The facility's policy titled Notification of Change of Condition, dated 7/02/2025, said the facility would provide care to residents and notification of change in status. The facility would immediately inform the resident's physician of a. An accident involving the resident which resulted in injury and has the potential for requiring physician interventions, b. A significant change in a resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); c. A need to alter treatment significantly.

Based on interview and record review, the facility failed to document, report, and monitor a resident (R8) after she sustained an unwitnessed fall and was then experiencing acute right hip pain.This failure resulted in R8 not being properly assessed for post-fall complications and receiving delayed medical care for her right hip fracture.This applies to 1 of 7 residents (R8) reviewed for falls in the sample of 10. The findings include:On 3/19/2026 at 3:00 PM, R8 was in bed, lying on a mechanical lift sling. R8 was unable to provide information regarding her fall incident on 3/01/2026 due to her cognitive impairment and communication barrier.R8's MDS (Minimum Data Set) dated 1/30/2026 said she was severely cognitively impaired.On 3/20/2026 at 11:00 AM, V12 (Certified Nurse Assistant/CNA) said on 3/01/2026 at approximately 6:30 PM during rounds, she observed R8 on the floor next to her bed in a sitting position. V12 said she notified V8 (Registered Nurse/RN), and after she assessed R8, they transferred her back to bed. V12 said they carried R8 off the floor by lifting her under her arms.On 3/20/2026 at 11:50 AM, V8 (RN) said she was assigned to R8 on 3/01/2026 from 2 PM-10 PM, and R8 had an unwitnessed fall from her bed. V8 said she assisted V12 (CNA) in transferring R8 back to bed. V8 said she did not think R8 had sustained an injury. V8 said she did not document the incident in R8's EMR (Electronic Medical Record) and did not notify V4 (Physician) and the nursing team. V8 said in retrospect she should have documented and made notifications to ensure that R8 was monitored for post-fall complications and received appropriate care.R8's fall incident report dated 3/01/2026 said she had an unwitnessed fall in her room at 5:30 PM and was observed sitting next to her bed. The report said R8 was unable to provide details regarding the incident and was transferred back to bed. The report indicated that the incident document was Privileged & Confidential- Not Part of the Clinical Record- Quality Assurance Only.On 3/20/2026 at 11:10 AM, V9 (Agency RN) said she was assigned to R8 on 3/01/2026 from 10 PM-6 AM. V9 said she was not notified of R8 having an incident when she received a report from V8 (RN). V9 continued to say R8's EMR did not indicate she had a fall on the prior shift. V9 said she did not perform post-fall assessments for R8.On 3/20/2026 at 11:20 AM, V13 (Agency CNA) said he was assigned to R8 on 3/01/2026 from 10 PM-6 AM. V13 said he was instructed that R8 required minimal assistance with her transfers. V13 said R8 requested to be toileted, and she had to pivot to transfer into her wheelchair. V13 said V12 (CNA) and V8 (RN) did not notify him of R8's fall incident on the prior shift.On 3/20/2026 at 9:50 AM, V11 (CNA) said she routinely took care of R8, and prior to 3/02/2026, she required minimal to partial assistance with her transfers. V11 said on 3/02/2026 at approximately 5:45 AM, when she assisted her with dressing in bed, R8 vocalized acute pain in her right leg. V11 said she became concerned and stopped rendering care and consulted V9 (Agency RN). V9 informed her that she had just administered an analgesic to R8. V11 said she then inquired if R8 had a recent incident, such as a fall, because her leg pain was new. V9 informed her that there was no incident reported or recorded in R8's EMR. V11 said she then proceeded to transfer R8 with a gait belt, and R8 now required extensive assistance. V11 said R8 guarded her right lower leg and was unable to bear weight. V11 said she was further concerned and updated the V10 (RN), the oncoming morning nurse, and again was instructed to continue to provide routine care to R8. V11 said she then transported R8 to the dialysis unit, and again when she transferred her to the dialysis recliner chair, she vocalized discomfort in her right leg. V11 said she then informed V15 (Dialysis RN) of R8's acute pain. V11 continued to say that at 11:00 AM, she again transferred R8 to her wheelchair after her dialysis treatment and transported to the therapy gym. V11 said she then informed V16 (Occupational Therapist/OT) because she was extremely concerned about R8. V11 said at 1 PM, when she transferred R8 to bed, she now required maximum to total assistance with her transfer and was still experiencing acute pain.On 3/20/2026 at 11:30 AM, V15 (Dialysis RN) said on 3/02/2026 R8 verbalized ouch when V11 transferred her into the dialysis chair. V11 then informed her that R8 was vocalizing acute pain in her right lower leg. V15 said she notified V10 (RN) and was not made aware of her having any recent incident.R8's Dialysis Communication Report sheet dated 3/02/2026 requested updated information from the nursing team, including whether R8 had any change in condition, such as a recent fall.On 3/20/2026 at 2 PM, V16 (OT) said on 3/02/2026, R8 was unable to safely stand during therapy and started to yell in pain when she removed the wheelchair's right footrest. V16 said she was not notified of R8 having any recent incidents. V16 said if a resident was experiencing acute pain and had recently sustained a fall, she would not have provided therapy services till they were fully evaluated for a possible acute injury.R8's OT Treatment Encounter Note dated 3/02/2026 said pt [patient] verbalized pain but unable to grade. Pt was screaming and holding RLE when RLE was moved.On 3/20/2026 at 12:00 PM, V10 (RN) said she was assigned to R8 on 3/02/2026 from 6 AM-10 PM. V10 said she was not notified of R8 having a fall incident when she received the report. V10 said she did not perform post-fall assessments for R8. V10 continued to say she then reported R8's right hip pain to V4 (Physician) during passing and received an order for a routine x-ray, which was done after 7 PM. V10 said that if she had been aware of R8's fall incident on 3/01/2026, she would have further assessed R8 for post-fall complications and notified V4 to ensure an acute focus assessments were done and recommended a STAT (immediate) x-ray.R8's Radiology Report dated 3/02/2026 said her right hip x-ray was reviewed remotely at 11:30 PM and was found to have a subcapital fracture to the right femoral neck.On 3/20/2026 at 12:45 PM, V4 (Physician) said she was not notified of R8's fall incident on 3/01/2026. V4 said on 3/02/2026 that she was still not notified of her fall incident despite her experiencing acute right hip pain. V4 said if she had been notified appropriately of R8's unwitnessed fall incident, she would have further assessed her, ordered STAT testing, or transferred to the hospital sooner to ensure she did not have delay in medical care. V4 said when she was notified of R8's right hip fracture, she ordered her to be transferred to the hospital for an emergency evaluation and treatment. V4 said R8 required orthopedic surgery for her right femur fracture. V4 continued to say that she expected the facility to follow its post-fall protocol to ensure residents were being assessed and monitored for complications appropriately.R8's progress note dated 3/03/2026 said X-ray result received @ 1 am, per X-ray for further evaluation. MD and DON made aware. To send to [Hospital]. [Ambulance] called @ 1:16 am. Pain complained on R hip/thigh area.Pt left with [Paramedics] @ 3:12 AM.On 3/20/2026 at 12:10 PM, V14 (RN/Fall Coordinator) said all fall incidents had to be reported to ensure nursing staff were aware and continued to monitor for post-complications to prevent delay in care for possible acute injuries. V14 said nurses were expected to assess residents after they had fallen for 72 hours, and if unwitnessed, they had to initiate neurological assessments. V14 said all post-fall documentation assessments had to be recorded in the residents' EMR. V14 continued to say that fall incident reports were supposed to be integrated into the residents' EMR to ensure staff and providers were aware of the incident. V14 reviewed R8's EMR and said there was no documentation and post-fall assessments for R8's unwitnessed fall on 3/01/2026.The facility's policy titled Fall Occurrences, dated 6/30/2025, said an incident report would be completed by the nurse each time a resident falls. The incident may be written in the nurses' notes or other parts of the resident's medical record that will remain accessible to any person who has the right to access the resident's record. The policy did indicate the facility's procedure for post-fall monitoring and documenting.

Based on observation, interview, and record review, the facility failed to communicate a resident's new dialysis site order to the dialysis team and assess for post-dialysis complications. This failure resulted in the resident developing acute right arm pain and swelling from his AV (Arteriovenous) fistula site and requiring hospitalization for management of an acute cephalic vein thrombosis.This applies to 1 of 3 residents (R93) reviewed for hemodialysis in a sample of 23.Findings include:On 9/23/2025 at 3:20 PM, V9 (R93's Family Member) said R93 required hemodialysis treatments. R93 was in bed with his right arm elevated on a pillow. R93's right arm had purplish discoloration throughout. R93 had an AV fistula to his right upper arm and a permcath (central vascular access catheter) to his upper chest. V9 said before R93 was discharged to the facility, he required insertion of permcath for his dialysis. V9 stated R93 experienced severe bleeding complications from his AV fistula at the hospital on 9/8/2025. R93 was then admitted to the facility on [DATE]. V9 said R93's hospital discharge instructions included for the facility to ensure R93's permcath be used for his dialysis treatments, and not the AV fistula. V9 said on 9/11/2025, after R93 received his dialysis treatment on 9/10/2025 (at the facility), she noted his right upper arm was severely swollen, and he was complaining of pain. V9 said she requested the nurse on duty to assess R93's arm. V9 said she was then informed his AV fistula was used for his dialysis treatment, rather than his permcath. V9 said R93 was transferred to the hospital and was treated with intravenous heparin because he had a blood clot (thrombosis) in his right arm.On 9/24/2025 at 12:20 PM, V11 (Dialysis Registered Nurse/RN) said [Dialysis Company] provided in-house hemodialysis services at the facility. V11 said the facility was responsible for providing the company's intake staff with current dialysis treatment orders for new residents prior to admission. V11 said the facility nurses were also responsible for completing the dialysis Communication Report sheet prior to each treatment. V11 said the form was to communicate important resident dialysis care information, including any changes from their prior treatment and identified access sites. V11 said on 9/08/2025, R93 was admitted to the dialysis company system, and his treatment order included for him to receive his treatments via his right arm AV fistula. V11 said the facility did not update the dialysis team of R93's new hospital discharge order to now receive his treatment via his new permcath. V11 also said R93's Communication Report sheet dated 9/10/2025 did not indicate he had a new catheter site, nor his updated dialysis discharge instruction. V11 said she did not have access to R93's hospital records for review, which were uploaded into the facility's EMR (Electronic Medical Record) system. V11 said on 9/10/2025 she accessed R93's AV fistula site and dialyzed him. V11 said R93's site was stable after his treatment, but he had notable swelling to his arm. V11 said then V9 (Family Member) informed her of R93's order to use his permcath, not his AV fistula, due to his last treatment complications at the hospital. V11 said R93's nephrologist (V5) was notified of R93's swollen arm and gave orders for him to be transferred to the hospital. On 9/24/2025 at 12:40 PM, V12 (admission Director) said the facility's intake staff was responsible for providing the dialysis company with dialysis treatment orders prior to a resident's admission. V12 said he assumed the nursing staff was then responsible for reviewing the hospital medical record of a new admission and updating the dialysis team of any new dialysis orders after admission. On 9/24/2025 at 12:50 PM, V2 (Director of Nursing/DON) said V11 (Dialysis RN) had limited access to the facility's EMR system. V2 said the access included progress notes, nursing assessments, and physician orders, but not attached hospital documents. V2 said nurses were expected to complete a comprehensive admission assessment and document any vascular access sites. V2 said nurses should also review and ensure hospital instructions were followed. V2 said if any discrepancies were identified, nurses should contact the physician or hospital discharge nurse for clarification. V2 said nurses should also be monitoring and assessing residents closely for complications after dialysis. On 9/25/2025 at 12 PM, V5 (Physician/Nephrologist) said he was contacted on 9/11/2025 regarding R93's post-hemodialysis complication to his right arm AV fistula site. V5 said the clinical team members involved in the resident's care should have appropriate access to their medical record to ensure important information is communicated. V5 said the dialysis team depends on critical dialysis treatment notes and orders for review to ensure residents receive their treatments as ordered. V5 said R93's complicated stenosis from his AV fistula was most likely ongoing, and that is why his permcath was placed prior to discharge from the hospital. V5 said R93's post-dialysis complication from his treatment on 9/10/2025 could have been avoided if the dialysis team had been informed of his updated treatment orders to not use his AV fistula and only use his new permcath. R93's hospital discharge documents dated 9/09/2025 included dialysis catheter care instructions. The instructions said, A catheter was placed into the large blood vessel in your neck.This catheter will be used for you to receive dialysis. R93's Nursing Admission/readmission form dated 9/09/2025, said R93 was admitted to the facility for dialysis and rehabilitation services. The forms section titled Vascular Access Evaluation did not note R93's permcath and AV fistula sites. The forms section titled Baseline Care Plan for Dialysis also did not include R93's permcath access site for his treatment.R93's Order Summary Report showed his dialysis admission orders dated 9/09/2025 did not include his order to use his new permcath for his treatments. R93's hemodialysis care plan initiated on 9/17/2025, did not include the use of his permcath for his treatments. The care plan did include the interventions of Encourage communication with dialysis center and Monitor access site.R93's dialysis Communication Report sheet dated 9/10/2025, did not communicate R93's last treatment complications and new access site.R93's progress note dated 9/11/2025 said Daughter [V9] was on the bed side earlier when she notified the [NOD-nurse on duty], that [R93] was complaining of [RT-right] arm pain and some discomfort when moving. NOD noted swelling on [R93's] RT arm with a dressing intact from his dialysis. [V5] was notified.R93's readmission hospital documents dated 9/12/2025 said R93's assessment included RUE DVT [right upper extremity, deep vein thrombosis]; RUE edema; [End-stage Renal Dialysis] Patient presented to the ED for evaluation of right arm swelling. Has RUE AVF [arteriovenous fistula] of the upper arm.Also has right chest PermCath. RUE US [ultrasound]reports acute thrombus within right cephalic vein at the mid forearm. Swelling out of proportion to the size of acute thrombus. Concern for outflow obstruction, possible stenosis .The facility's policy titled Hemodialysis dated 6/20/2025, said It is the policy of the facility to ensure that appropriate care for residents on hemodialysis is provided by facility staff.The charge nurse may enter any new physician order in the resident's record that is requested by the hemodialysis center physician.The facility's [Dialysis Company] service contract dated 11/18/2019, said the facility's responsibilities included Communication: [Dialysis Company] and Facility staff must communicate regularly through a defined and systematic process.Facility shall immediately inform [Dialysis Company] of any changes in the Resident's medical conditions relating to continued Dialysis Services. Facility staff shall participate in and have ultimate responsibility for Resident care planning. Ongoing communication, coordination, and collaboration between the nursing home and the dialysis staff shall be administered as described.(b) Physician/treatment orders.iii. Each Party's accessibility to the other Party's EMR provides information regarding physician/treatment orders.

Based on observation, interview, and record review, the facility kitchen staff failed to follow sanitary practices and safely store food items in the kitchen.This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen.Findings include:The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 9/23/25 documents the total census was 83 residents. On 9/23/25 at 10:31 AM, V13 (Dietician) said all 83 residents eat from the facility kitchen.On 9/24/25 starting at 11:46 AM, the following observations were made in the facility kitchen during lunch service preparation:1.At 12:36 PM, V17 (Dietary Manager) dropped the thermometer probe cover on the kitchen floor, then picked it up from the floor and placed it on the prep table where lunch temperatures were being checked. V17 did not clean the probe cover or the preparation counter.2. At 12:21 PM, V19 (Cook) picked up the uncovered thermometer probe off the prep table, did not clean it with alcohol wipe, and then stuck the probe into the shrimp to check temperature.3. At 12:56 PM, V17 (Dietary Manager) set the thermometer probe down on the prep table right next to the contaminated probe cover, then picked up the thermometer and brought it into walk-in freezer and placed the probe into the pasta salad without cleaning the probe with alcohol.4. At 12:38 PM, V17 (Dietary Manager) was checking the temperature of a tray of pasta salad. V17 was holding a used alcohol wipe in her left hand and the thermometer probe in her right hand, and she used the alcohol wipe to push the pasta off the thermometer probe back into the large tray of pasta salad.5. At 11:46 AM V19 (Cook) was observed wearing the hair restraint only covering the hair on the back half of her head and hooked under her ear lobes to stay on her head. V19 was noted with loose hair on the top of her head, her forehead, and her temples that was not restrained by hair net. During this time V19 was hands on with lunch preparation and was leaning over the steam table counter, checking temperatures of food items.6. Pureed dinner rolls were on top of the steam table in a medium silver container, uncovered. V18 (Regional Director of Operations) said the pureed rolls should be covered up until lunch service begins.7. At 1:04 PM, the scooper used for the thickener was seen being stored on the preparation counter next to the preparation sink, not contained and within splash distance.On 9/23/25 starting at 9:46 AM, the facility kitchen was toured in the presence of V13 (Dietician), V17 (Dietary Manager), and V18 (Regional Director of Operations) and the following was found:In the walk-in cooler8. A bag of pulled turkey in cardboard box labeled with delivery date of 8/22/25 and the bag showed a packed on date of 4/15/25. There was no expiration date, use by date, or thaw date anywhere on the pulled turkey and it was fully thawed.9. A cardboard box labeled green peppers with a zucchini inside that had multiple white fuzzy spots on it. V13 (Dietician) said, It appears moldy.10. A cardboard box of 13 green peppers with black spots all over them and mushy black areas. V13 (Dietician) said, I wouldn't eat it, and if I wouldn't eat it, I can't serve it.In the dry storage:11. A bin labeled thickener with scoop stored on top of the bin, not contained, open to environmental contaminants.12. 3-32 fluid ounce bottles of 100% prune juice with best before date of 9/20/25. V13 (Dietician) and V17 (Dietary Manager) said they can no longer serve the juice to the residents because it is past the best by date.On 9/25/25 at 1:23 PM, V18 (Regional Director of Operations) said foods in the facility kitchen are labeled and dated to maintain food freshness, safety, quality, and palatability. V18 said when a food item is pulled from the freezer and placed in the cooler to thaw, it should be labeled with a thaw date, so the staff know how many days they have left to safely serve the thawed item to the residents. V18 said scoops for dry food items should be stored outside of the food container and contained/covered. V18 said the scoops need to be covered/contained for infection control purposes and to make sure dust or debris do not get on the scoops and lead to contamination of the food item and/or illness of the residents. V18 said food items past their expiration or best-by date should be removed from storage by the end of service on the marked date so the staff don't accidentally serve the food item to the residents past the marked date, with the possibility of it leading to resident illness and/or poor quality. V18 said vegetables should not be kept in food storage when they have fuzzy white spots or mushy black spots on them. V18 said hair restraints in the kitchen need to be worn covering all of the hair on the staff member's head to prevent contamination of food from hair and sweat. V18 said if a thermometer probe is cleaned and then set down on the prep table with the probe touching the table, it needs to be cleaned again prior to being used to check temperature of food item to prevent cross contamination from the prep table into the food item. V18 said the thermometer probe cover being dropped on the kitchen floor and then placed on the prep table is a concern for cross contamination and resident illness. V18 said the probe cover should have been sanitized before it was set on the prep counter to properly prevent cross contamination. V18 said an alcohol wipe should not be used to sanitize a thermometer and then used to push pasta off the probe back into the tray of pasta because of the risk of chemical contamination which could lead to resident illness.The facility provided policy titled, Safe Standards & Procedures Food Handling last revised 3/8/24 states, 1. Purpose: To establish consistent standards and procedures when serving and delivering food.This is important because: Harmful bacteria, and physical and chemical contaminants.can be introduced into food and cause foodborne illness, injury, or allergic reactions when. Foods that need to be kept hot or cold (TCS) are not prepared, cooked, carried, shown, labeled, or served correctly. Food touches unclean or improperly sanitized equipment, containers, or utensils.3. Responsibilities 3.1 Associates: Follow service and delivery standards and procedures daily. 4. Preparation Standards and Procedures: 4.1.3 Thawing.1) Thawing in a refrigerator: Types of Products:.Ready to eat TCS foods. Thawing steps:.Remove cardboard or insulating packaging from product.Place foods in clean, sanitized containers with drip trays suitable for containing thawed water and cover the food properly.5. Production Standards and Procedures: 5.1.1. Cold Food Production.After prepping, probe all refrigerated TCS food for cold holding using a clean, sanitized digital thermometer.8 Labeling Processes Standards and Procedures: 8.1.1. Prepared Foods Definition: Inclusive of any ingredients or foods that have been washed, prepped, sliced, cooked, assembled, opened, thawed, or otherwise processed within Aramark foodservice establishments. 8.1.3. TCS Refrigerated Food Label Requirements: These food labels intended for storage must include this information: Item name, Preparation Date, Use-By Date, Employee Initials. Labeling Requirements by Food Type, Preparation/Process, and Packaging. Fresh Produce:.Discard if quality is unsatisfactory. Thawing Frozen Foods: The 7=day use-by date begins on the day thawing starts.The facility policy titled, Storage dated 6/19/2019 states, .Ensure that bulk dry food storage bins have lids and are equipped with dispending scoops stored out of the product in clean holders or containers.

Based on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) cares for residents who needs assistance.This failure effects to 4 of 4 residents (R12, R13, R22, R44) reviewed for ADLs in a sample of 23.The findings include:1.On 9/23/25 at 11:28 AM, R22 was in bed. His fingernails were long with a black substance underneath his nail tips. He said he told the CNA's (Certified Nursing Assistants) that he would like them cut. He stated, Yeah, it never happened as you can see.R22's face sheet shows diagnoses which include major depressive disorder, single episode, moderate, generalized anxiety disorder, and dementia in other diseases classified elsewhere, mild, with anxiety. R22's MDS (Minimum Data Set) dated 9/4/25 shows he is cognitively intact. R22 needs substantial/maximal assistance with personal hygiene. R22's care plan dated 3/6/25 shows he has an ADL self-care performance deficit and impaired mobility related to .dementia with mild anxiety, major depressing and unsteadiness on feet.2.On 9/23/25 at 10:35 AM, R13 was in bed and had long yellow-colored fingernails. R13 stated he would like them cut.R13's face sheet shows diagnoses of major depressive disorder, dementia in other diseases classified elsewhere, moderate, with other behavioral disturbance, bipolar disorder, current episode depressed, moderate, generalized anxiety disorder, and other schizophrenia. R13's MDS dated [DATE] shows he has moderate cognitive impairment. R13 needs substantial/maximal assistance with personal hygiene. R13's care plan dated 11/21/22 shows he has an ADL Self-Care Performance Deficit and Impaired Mobility related to anemia, difficulty walking.schizophrenia, anxiety, depression and dementia with behavioral disturbance.3. On 9/23/25 at 11:52 AM, R12 had a full beard. He stated he wanted to be shaved. He said he has told the CNA's but they have been busy.R12's face sheet shows diagnoses of cerebral infarction, cognitive social or emotional deficit following cerebral infarction, generalized anxiety disorder, psychotic disorder with delusions, major depressive disorder, and other schizophrenia. R12's MDS dated [DATE] shows he is moderately impaired in cognition. R12 is dependent with personal hygiene. R12's care plan dated 426/25 shows he requires assistance with ADLs (personal hygiene).4. On 9/23/25 at 9:45 AM, R44 had facial hair under her chin and stated she wanted to be shaved.R44's face sheet shows diagnoses lack of coordination, major depressive disorder, recurrent, Alzheimer's disease, and generalized anxiety disorder. R44's MDS (Minimum Data Set) dated 7/1/25 shows she has moderate cognitive impairment. R44 needs substantial/maximal assistance with personal hygiene. R44's care plan dated 11/8/23 shows she has an ADL self-care performance deficit related to Alzheimer's disease, generalized anxiety, and major depression.On 9/24/2025 at 3:00 PM, V2 (DON-Director of Nursing) stated that ADL's including shaving and nail care are done on shower days and as needed, or whenever the resident prefers. She said the CNA's (Certified Nursing Assistants) are responsible for providing ADL care.Facility's policy titled General Care (6/30/25) shows: It is the facility's policy to provide care for every resident to meet their needs. 1.the facility will evaluate the resident for physical and psychosocial needs. Physical needs would include, but are not limited to ADL.

Based on interview and record review the facility failed to coordinate and maintain documentation of hospice care activities and the hospice care plan.This applies to 4 of 4 residents (R10, R13, R34, and R62) reviewed for hospice care in a sample of 23.Findings include: On 09/25/2025 at 10:05 AM, V26 (Hospice RN - Registered Nurse) stated the hospice staff document their care and progress notes in their electronic computer system, not the facility's. They do not provide copies of their electronic documentation to the facility. The facility staff is updated verbally. V26 stated the only documentation provided to the facility is the admission packet, DNR (Do Not Resuscitated), POA (Power of Attorney), admission assessment, history and physical. Physician orders may be communicated verbally by the hospice doctor, ordered by the nurse practitioner, or written on an order form.On 09/25/2025 10:52 AM, V20 (RN assigned to R10 and R34) stated there should be notes in the hospice binder from the hospice nurse and hospice CNA (Certified Nursing Assistant). The hospice staff also verbally updates the facility staff. V20 states she only writes a hospice progress note when she reaches out to them. Hospice staff document in the hospice binder themselves.On 09/25/2025 at 11:11 AM, V27 (RN assigned to R62) stated the hospice staff documents in the hospice binder after their visits. V27 states the hospice nurse visits weekly and the CNAs visit twice per week. The hospice CNA will give her the shower sheet to review. The Hospice nurse places her documentation in the hospice binder and speaks to her directly. V27 stated she only documents hospice notes when she initiates contact with them.On 09/25/2025 at 12:04 PM, V28 (RN assigned to R13) stated she communicates verbally with the hospice nurse when she visits. The hospice visit notes should be kept in the resident's hospice binder. The hospice CNA will verbally provide updates of their care and any concerns. The hospice staff should be placing the care plans and visit notes in the binder themselves. V28 stated she would look in the binder for hospice staff if she had been away and didn't speak to them directly.On 09/25/2025 at 12:50 PM, V2 DON (Director of Nursing) the hospice staff provides verbal updates, and the facility nurse should document conversations and changes in the electronic medical record. The hospice staff document in their own electronic medial record not the facility record. The Hospice staff does not provide the facility copies of their documentation. The hospice nurse generally visits weekly, and the CNAs visit twice per week unless there is a change, and they need to come out more often. Hospice staff should be signing the visit log when they visit. There should be a care plan specific to hospice in the binder for staff to reference that the hospice staff should be updating.1.R10's physicians orders showed admit to hospice on 6/5/25 dated 6/17/24, The hospice binder contained her POA (Power of Attorney) for healthcare, hospice consent dated 6/5/25, a visit summary dated 5/11/25, a pre-admit evaluation dated 6/5/25, a POLST (Physician Order for Life Sustaining Treatment) signed and dated by POA on 6/5/25, and hospice physician orders dated 8/14/25. The hospice binder did not include any hospice visit notes. The facility did not provide any hospice after-visit notes. R10's facility care plan (initiated 6/5/2025) showed R10 is receiving hospice services from [hospice company], my admitting diagnosis is malignant neoplasm of the brain. The only goal on the care plan is I will verbalize comfort or be comfortable as much as possible as exhibited by lack of signs and symptoms of pain and discomfort throughout next review. Three interventions were listed on R10's facility care plan for hospice, including I am kept as comfortable as possible at all times, my (nurse/social worker) may contact [hospice company] IDT (inter-disciplinary team) for to provide update of my condition, and my nurse may provide me with pain medication if there is sign and symptom of pain or if pain is anticipated. 2.The hospice binder for R13 contained the case sheet, POA form, designation of attending physician form, hospice consent dated 5/29/25, pre-admit evaluation dated 5/29/25, hospice physician orders dated 5/29/25, a long-term care facility change in billing dated 5/29/25, the POA signed POLST dated 5/28/25 and the hospice care provider sign in log last dated 7/25/25. The hospice binder did not have any other hospice visit documentation. The facility did not provide any hospice after-visit notes. R13's facility care plan (initiated 5/29/2025) showed R13 is receiving hospice services from [hospice company], with my admitting diagnosis to hospice, senile degeneration of the brain. The only goal on the care plan is I will verbalize comfort or will be comfortable as much as possible as exhibited by lack of signs and symptoms of pain and discomfort throughout next review period. Three interventions were listed on R13's facility care plan for hospice, including I will be kept as comfortable as possible at all times, my (nurse/social worker) may contact [hospice company] regarding my care to provide update of my condition, and my nurse may provide me with pain medication if there is sign and symptom of pain or if pain is anticipated. 3.R34's hospice binder contained hospice physician orders and a sign in sheet signed only by one hospice RN (Registered Nurse) on 8/14/25. R34 did not have any other hospice documentation. The facility did not provide any hospice after-visit notes. R34's facility care plan (initiated 8/14/2025) showed R34 is receiving hospice services from [hospice company] with an admitting diagnosis of nonrheumatic aortic valve disorder. The only goal on the care plan is I will verbalize comfort or will be comfortable as much as possible as exhibited by lack of signs and symptoms of pain and discomfort throughout next review period. Three interventions were listed on R34's facility care plan for hospice, including I am kept as comfortable as possible at all times, my (nurse/social worker) may contact [hospice company] IDT to provide update of my condition, and my nurse may provide me with pain medication if there is sign and symptom of pain or if pain is anticipated. 4.The hospice binder for R62 contained the case sheet, pre-admit evaluation dated 1/19/24, hospice consent dated 1/18/24, the admission orders / hospice certification form dated 1/18/24, the declination to designate an attending physician dated 1/18/24 and the POLST dated 1/18/24. The most current plan of care review provided dated 5/29/24, a focus plan of care revision dated 7/14/24. Last physician orders dated 2/21/24 and the hospice care provider sign in log last dated 7/27/25. R62's facility care plan (initiated 1/19/2024) showed R62 is currently receiving hospice services from [hospice company] related to my diagnosis of dementia. The only goal on the care plan is my surrogate decision maker or I will verbalize comfort or be comfortable as much as possible as exhibited by lack of signs and symptoms of pain and discomfort until next review date. Three interventions were listed on R62's facility care plan for hospice, including I am kept comfortable at all times, my nurse may provide me pain medication if there is sign and symptom of pain or if pain is anticipated, my nurse/social worker may contact IDT [hospice company] to provide update of my condition. The signed facility hospice agreement dated 3/13/24 showed the hospice shall retain responsibility for ensuring that applicable requirements to hospice medical records are met. Facility shall allow [hospice company] access to appropriate medical records and permit the inclusion of the [hospice company] care plans and other appropriate documentation in the Hospice Patient's facility medical record. [Hospice company] shall coordinate with the facility to ensure documentation of services is completed as applicable for hospice patients

Based on observation, interview, and record review, the facility failed to ensure ongoing assessment and care planning for residents desiring to self-administer medications.This applies to 2 of 2 residents (R11, R55) reviewed for medications in a sample of 23.The findings include: 1.On 9/23/2025 at 11:16 AM, R11 had Artificial Tears eyedrops, Carboxymethyl Cellulose Sodium Ophthalmic eye drops, Albuterol Sulfate inhaler, and Zoryve (Roflumilast) cream on his bedside table. R11 stated the medications are always kept in his room. He stated no one taught him how to take the medications. R11 stated he knows how to take the medications. R11's MDS (Minimum Data Set) dated 7/2/25 shows that he is cognitively intact R11's POS (Physician Order Sheet) shows an order that R11 may self-administer the Artificial Tears eyedrops and Carboxymethyl Cellulose Sodium Ophthalmic eye drops. There is no order that indicates R11 can self-administer the Albuterol Sulfate inhaler and Zoryve (Roflumilast) cream. Review of R11's electronic medical record indicates there is a self-administration of medication assessment for the Albuterol Sulfate inhaler from 2/16/2021. It says the medication should be stored in the resident's drawer. The medication assessment was not updated after 4 years. There was no self-administration of medication assessment forms for the Artificial Tears eyedrops, Carboxymethyl Cellulose Sodium Ophthalmic eye drops, and Zoryve (Roflumilast) cream. On 9/24/2025 at 3:00 PM, V2 (DON—Director of Nursing) stated there should be an order from the physician to have medications brought from home and to be at the bedside. She also stated that the nurse has to do a self-administration of medication assessment to make sure the resident knows how to take the medication by themselves. V2 stated residents have to demonstrate it in front of the nurse and the assessment is filled out in the resident's electronic medical record. Review of R11's care plans show there are no care plans discussing self-administration of medications. Facility's policy titled Self-Administration of Medication (7/3/25) shows: Procedures: 1. The IDT (Inter-Disciplinary Team) will assign a staff to evaluate resident's ability to safely administer medication. A self-administration evaluation will be filled out to determine capability. A return demonstration will be done to accurately evaluate resident's ability after the health teaching. 2. The resident may store the medication at bedside if there is a physician order to keep it at bedside. 5. The resident's ability to self-administer medication will be assessed regularly by the facility to coincide with the MDS assessment or any notable change in status. The facility's Medication Storage, Labeling, and Disposal policy (rev. 7/2/2025) showed Policy Statement: It is the facility's policy to comply with federal regulations in storage, labeling, and disposal of medications .4. Medications will be secured in locked storage area . The facility's Self-Administration of Medication policy does not include how the medications at bedside should be locked and secured to prevent access by other residents. 2. On 9/23/2025 at 11:00 AM, R55 had a blue inhaler labeled Albuterol and a bottle labeled nasal spray on his bedside table. In an interview at the time, R55 stated: I take it when I think I need it. He further stated that he knows how to use both medications, and that staff allows him to keep them in his room. He reported that he does not recall any nursing staff assessing his ability to use the medications or asking him to demonstrate their usage. R55's MDS dated [DATE] shows that R55 has mildly impaired cognition. R55's Physician's Order Sheet (POS) shows an order for unsupervised self-administration of the albuterol sulfate inhaler as well as orders for fluticasone propionate nasal spray and saline nasal spray, but no orders allowing for unsupervised self-administration of either nasal spray. R55's electronic medical record showed no completed self-administration of medication assessment for any of the medications, and R55's care plan does not show any goals or interventions related to self-administration of medications.

Based on observation, interview, and record review, the facility failed to assess a resident's nutritional needs and provide their ordered supplement.This applies to 1 of 3 residents (R93) reviewed for nutrition in a sample of 23.Findings include:On 9/23/2025 at 12:30 PM, R93 was served his lunch in his room. R93 was thin and appeared frail. V8 (Certified Nurse Assistant/CNA) said the dietary staff prepared residents' meals based on their meal tickets, including supplement drinks. R93's meal ticket said he required a renal mechanical soft diet with thin liquids. R93 meal tray drinks were a cup of cranberry juice and a carton of Lactaid milk. R93's lunch did not include a nutritional supplement drink.On 9/24/2025 at 2:00 PM, R93 was served his lunch in his room. V31 said R93's served lunch included a drink was a cup of juice, as indicated in his meal ticket. V31 said R93's meal ticket did not include a nutritional supplement drink. On 9/24/2025 at 2:25 PM, V13 (Dietician) said she was responsible for assessing all residents' nutritional needs. V13 said residents were assessed, interviewed, and reviewed for malnutrition within 24-72 hours of admission. V13 said nurses completed dietary communication slips to inform the dietary staff of the residents' diet and nutritional needs, including nutritional supplement drinks. V13 said the information was then entered into the dietary computer system, which then generated the resident meal tickets. V13 said the meal tickets instructed the dietary staff to include nutritional drinks as ordered to ensure residents received their nutritional supplements. V13 said R93 was admitted to the facility on [DATE] and transferred back to the hospital on 9/11/2025, and she was unable to complete his dietary evaluation dated 9/11/2025. V13 said R93 was then readmitted on [DATE], and his dietary evaluation currently remained incomplete. V13 said R93's ordered supplement drink was not added to his meal ticket and not provided as ordered. R93's EMR (Electronic Medical Record) reviewed on 9/24/2025, showed his Dietary Evaluation form dated 9/11/2025 was not completed. The EMR also did not show any dietary/nutrition progress note showing R93's nutritional needs were assessed.R93's nutritional care plan reviewed on 9/24/2025, showed it was initiated on 9/17/2025 and remained incomplete. R93's specific diet and nutritional supplement needs were not identified.R93's Order Summary Report showed an order dated 9/18/2025 for (Supplement Drink) every day shift for supplement kitchen to provide at lunch.R93's readmission [DATE]) Diet Order & Communication Form slip did not include his ordered supplement drink. The facility's policy dated Nutritional Assessment and Care dated 10/01/2023, said All residents receive nutritional assessment for the purpose of identifying and planning care based on the needs, goals, and preferences of each resident. Purpose: To ensure all residents' nutritional status is assessed. To ensure all residents have individualized care plans reflecting their needs and preferences for care. To provide guidance for caregivers to ensure residents maintain an appropriate level of nutritional care. Procedure: 1. Upon admission, each resident will be interviewed by the Registered Dietitian/Nutritionists.within 24-72 hours.The facility's policy dated Nutritional Supplementation dated 10/01/2023, said Oral nutritional supplements (ONS) can also be utilized within the limitations of the resident's medical condition, as recommended and/or ordered by the physician.To provide nutrition supplementation for residents identified as needing additional support to maintain or improve their nutritional status.4. The order will be communicated to Food and Nutrition Services (FANs) via the EMR or appropriate diet change communication form per facility policy.

Based on observation, interview, and record review, the facility failed to secure resident medications. This applies to 3 of 3 residents (R15, R78, R95) reviewed for medications in a sample of 23.The findings include: 1.On 9/23/2025 at 10:30 AM, R78 had a medication cup containing six (6) tablets of various shapes and colors on her bedside table. The medication cup had a handwritten label with the resident's name and room number and was covered by another plastic medication cup placed on top of the medication. The contents of the cup included: 1 small orange tablet 1 small round black tablet 2 small round white tablets 1 medium-sized round white tablet 1 large oval tablet R78 stated she refused her medication, and that a nurse from a previous shift had left the medications in her room. On 9/26/2025 at 11:30 AM V2 (DON—Director of Nursing) stated that all medications should be secured and in the med cart because residents shouldn't be taking medications if they aren't assessed. V2 also stated there are residents that wander, and somebody might take another resident's medication. Facility's policy titled Medication Storage, Labeling, and Disposal dated 7/2/25 shows: 3. Medications will be stored safely under appropriate environmental controls. 4. Medications will be secured in a locked storage area. 2.On 9/23/2025 at 10:30 AM, R95 had a vial of Sooth XP eye drops lubricant on her bedside table. 3.On 9/23/25 at 11:25 AM, R15's Nystatin powder was on her bedside table.

Based on interview and record review, the facility failed to assess and assist residents in obtaining routine dental services.This applies to 2 of 3 residents (R57 and R58) reviewed for dental services in a sample of 23.Findings include:1. On 9/23/2025 at 9:50 AM, R58 said he and his wife (R57) had been residing at the facility for a long time and had not seen a dentist. R58 said they both needed routine dental care services. R58 had upper and lower missing and broken teeth, with visible decay. On 9/24/2025 at 4:00 PM, V4 (Social Services Director/SSD) said the facility provided in-house dental services for all residents identified with dental care needs. V4 said social services was responsible for following up with residents who also requested in-house dental services. V4 said the dental company provided monthly services at the facility, and they assisted residents in enrolling in their dental service program.R58's MDS (Minimum Data Set) dated 7/07/2025 showed an admission date of 10/21/2024. The MDS said R58 was cognitively intact. R58's Foot and Oral Health Evaluation form dated 7/06/2025 said R58's oral cavity was assessed, and no abnormalities were identified, including obvious or likely cavity or broken natural teeth. The form did say R58 Required Dentist evaluation- assessment may indicate need for Dental check-up as soon as possible.2. On 9/23/2025 at 3:35 PM, R58 said R57 did not eat much for lunch. R58 said his wife (R57) was confused, and he also wanted her to be seen by a dentist because her lower partial dentures were missing. R58 continued to say they did not have much income, and he was unsure how they could receive dental services at the facility. R57's upper dentures were loose-fitting, and her lower front teeth were missing.R57's MDS dated [DATE] showed an admission date of 1/25/2025. The MDS said R57's oral/dental status was assessed, and no abnormalities were identified, including Broken or loosely fitting full or partial dentures.R57's Foot and Oral Health Evaluation form dated 7/20/2025 said R57's oral cavity was assessed, and no abnormalities were identified, including Broken or loosely filling full or partial dentures. The form did say R57 Required Dentist evaluation- assessment may indicate need for Dental check-up as soon as possible.On 9/25/2025 at 10:35 AM, V3 (Assistant Director of Nursing/ADON) said nurses were responsible for accurately completing residents' routine oral assessments. V3 said based on the assessment forms, the nurses then informed social services if a resident was identified in need of dental services to ensure they received routine dental care. On 9/25/2025 at 10:15 AM, V4 (SSD) said R57 and R58 were not referred to the dentist because she was not aware of their identified dental care needs or requests. V4 said she was informed verbally of new resident dental referrals. V4 said she was not aware of the facility's Foot and Oral Health Evaluation form. V4 said she also was not sure who was responsible for completing the assessment form and how the identified need for dental services was then communicated.The facility's document titled Residents on Dental Program dated 9/25/2025 did not include R57 and R58. The facility's policy titled Dental Services Policy dated 6/30/2025, said The facility will assist all residents in obtaining dental services according to the resident's needs, subject to the federal and/or state regulations.

Based on observation, interview and record review, the facility failed to maintain and monitor residents' personal refrigerators.This applies to 3 of 3 residents (R6, R40 and R74) reviewed for personal refrigerators in a sample of 23.Findings include: 1.On 09/23/2025 at 10:20 AM, the freezer section of R40's personal refrigerator was completed filled with accumulate ice built up over the freezer door. The freezer door was frozen closed and could not be opened. The freezer log for R40's personal refrigerator had not been done on September 8th, 9th, or 10th 2025. 2.On 09/23/2025 at 10:32 AM, R6's personal refrigerator contained a 1lb (pound) 3oz (ounce) bottle of strawberry fruit spread that expired June 2023. Half of the freezer section was built up with ice. The refrigerator had a melted cup of strawberry ice cream, and the bottom of the refrigerator was dirty with un-identifiable crumbs. The refrigerator temperature log had not been completed September 5th -10th, 2025 and September 20th -22nd, 2025. On 09/24/2025 at11:22 AM, V25 CNA (Certified Nursing Assistant) stated the CNAs are not responsible for resident refrigerators. On 09/24/2025 at 11:33 AM, V21 CNA stated housekeeping is responsible for cleaning and defrosting the resident refrigerators. CNAs monitor the temperature logs. On 09/24/2025 at 11:25 AM, V22 Housekeeping Supervisor stated housekeeping is responsible for logging the refrigerator temperatures and cleaning the refrigerators. Housekeeping will notify the CNA if there is outdated or spoiled food items. The temperature range is monitored to assure the food is stored at the correct temperatures. If the temperature is not in the correct range maintenance is notified. Maintenance is responsible for defrosting the refrigerator. If there is excessive ice accumulation the staff should notify maintenance. The facility policy Refrigerator and Resident Appliance Maintenance Service dated 7/3/25 states the maintenance department or facility designee is responsible for maintaining the resident appliance e.g. refrigerators are safe, clean and operable at times. The facility will perform resident refrigerator checks. Temperature is maintained using a thermometer. Proper labeling, storage and disposition of food items. Ensure proper dating and disposition of outdated food items including food brought by family and resident from the outside. 3. On 9/24/2025 at 10:29 AM R74's refrigerator had no thermometer inside. Inside there was BBQ sauce, salad dressing, a piece of chicken breast with [NAME] dressing on a plate wrapped in saran wrap undated and unlabeled. On 9/24/2025 at 3:00 PM, V2 (DON—Director of Nursing) stated that housekeeping is responsible for checking the temperature in resident refrigerators. She said that CNA's (Certified Nursing Assistants) are responsible for labeling and dating the food. She said, CNA's are responsible for disposing expired food. Maintenance is responsible for defrosting the refrigerator. Facility's policy titled Food from the Outside (6/30/25) shows: 1. All food brought in by visitors and family members from the outside of the facility will be labeled with the date it was brought to the facility. 3. After 3—5 days, these food items will be discarded. 4. All undated food items will be discarded to ensure safety of the residents.

Based on observation, interview, and record review, the facility failed to perform hand hygiene and change gloves when rendering care, and ensure urinary drainage bags were kept off the floor.This applies to 3 of 3 residents (R44, R58, and R63) reviewed for infection control in a sample of 23.Findings include:1. On 9/23/2025 at 9:50 AM, R58 was in bed, and his full urinary catheter drainage bag was directly on the floor. Then V8 (Certified Nurse Assistant/CNA) entered the room and said she was going to assist R58 with his routine morning care. V8 donned PPE (Personal Protective Equipment), including gloves. V8 applied a new incontinence brief to R58 and assisted R58 with putting on his pants. V8 put R58's catheter tubing and bag inside his pant leg and then placed the bag directly on the floor. V8 proceeded to place R58's soiled clothing in the soiled bin and then put R58's slippers on him. V8 assisted R58 into his wheelchair and then combed his hair. V8 did not change her gloves in between R58's different care activities. 2. On 9/23/2025 at 10:35 AM, R44 was in bed. V8 and V10 (CNAs) said they were going to change R44's soiled incontinence brief. V10 cleaned R44's peri-area and removed his gloves and applied hand sanitizer. V10 then donned a new pair of gloves, which he obtained from his uniform pocket. V10 proceeded to clean R44's buttock area. V10 again removed his gloves, applied hand sanitizer, and then donned a new pair of gloves taken from his uniform pocket. V10 then applied a new incontinence brief to R44.3. On 9/24/2025 at 10 AM, R63 was in bed and her full urinary catheter drainage bag was directly on the floor. At 12:20 PM and 2 PM, R63 was still in bed, and her full urinary catheter drainage bag remained directly on the floor.Then, at 2:40 PM, V6 and V7 (CNAs) said they were going to assist R63 with her care. R63's urinary drainage bag was still on the floor. They donned PPE, including gloves. V7 obtained her pair of gloves from her uniform pocket. V6 cleaned R63's catheter tubing and removed his gloves, applied hand sanitizer, and then used a washcloth to dry the sanitizer off his hands. V6 proceeded to clean R63's peri-area and again removed his gloves, applied hand sanitizer, and dried it off with a washcloth. V6 then applied a clean brief and proceeded to dress R63 and apply her shoes. V6 did not change his gloves. V7 continued to assist V6 by repositioning R63 while he rendered her care. They then transferred R63 with a mechanical lift into her wheelchair. V6 and V7 did not change their gloves and perform hand hygiene in between R63's different care activities. On 9/25/2025 at 9:55 AM, V3 (Assistant Director of Nursing/ADON) said nursing staff were expected to perform proper hand hygiene and change their gloves when transitioning between different resident care activities. V3 said gloves should never be stored inside staff uniforms because they would no longer be considered clean. V3 said staff were also expected to properly use hand sanitizer, which required them to rub their hands together to dry off the sanitizer and should not use a towel to remove it. V3 said proper use of gloves and hygiene were important to prevent the spread of infections. V3 continued to say residents with urinary catheters were at further risk for infection, and staff were responsible for ensuring drainage bags were placed inside a protective bag and always be kept off the floor. The facility's policy titled Glove Use dated 3/23/2023, said Objectives 1. To prevent the spread of infection.When gloves are indicated, use disposable single-use gloves.Use non-sterile gloves primarily to prevent the contamination of the employee's hands when providing treatment or services to the patient.The facility's policy titled Hand Hygiene dated 6/30/2025, said Hand hygiene is important in controlling infections. Hand Hygiene consists of either hand washing or the use of alcohol gel. The facility will comply with the CDC Guidelines in regards to hand hygiene.The facility's policy dated Urinary Catheter Care dated 7/03/2025, said The purpose of this procedure is to prevent catheter-associated urinary tract infections.Infection Control.b. Be sure the catheter tubing and drainage bag are kept off the floor.

Based on observation, interview, and record review, the facility failed to investigate allegations of sexual abuse in a timely manner. The facility also failed to implement their Abuse policy and procedure and conduct a comprehensive investigation of the alleged sexual abuse and report the abuse to the state health department and police department. This applies to 1 of 5 residents (R5) reviewed for sexual abuse in a sample of 12. The findings include: The EMR (Electronic Medical Record) shows that R5, a [AGE] year-old with diagnoses of dementia in Alzheimer's disease, major depressive chronic pain, difficulty in walking, cognitive communication deficit, depressive disorder, autoimmune thyroiditis, osteoporosis, Lyme disease, hypothyroidism, anxiety disorder, hypertension, and spinal stenosis. R1 was admitted to the facility on [DATE]. R5's MDS (Minimum Data Set) dated 8/5/2024, showed R1 had moderate cognitive impairment. The progress notes dated 8/16/2024 showed that R5 was sent to the hospital related to medication regimen to address R5's aggression. The hospital record dated 8/16/2024 showed that R5 was: - A patient admitted from (nursing facility) for increased aggression, refusing to take medications. History of depression. Upon examination, (R5) was alert and oriented times 3. States that they want me on antidepressant, and I am sensitive to medications and only requires low doses. Patient needs inpatient psychiatric hospitalization for mood stabilization and safety. The hospital record also showed that on 8/17/2024, R5 was transferred to the medical floor due to acute pulmonary embolism and acute DVT (deep vein thrombosis). On 8/20/2024 at 10:30 A.M., V1 (Administrator) said that on 8/16/2024, she had received a call from V15 (hospital staff) that R5 made an allegation of sexual abuse towards a male staff working in the facility. V1 said that she did not investigate this sexual allegation because there was an open allegation regarding R1's alleged physical abuse towards a CNA (Certified Nurse Assistant), that R1 felt being rushed on 8/15/2024 at 2:30 P.M. Surveyor verified with V1 if the allegation of being rushed is the same as sexual abuse. V1 then decided to initiate sexual allegation and called the police department. On 8/20/2024 at 11:30 A.M., V18 (Police Officer) came to the facility. V18 said that this case of sexual abuse was called in by the hospital on 8/16/2024 when R5 made the allegation. V18 said that it was today (8/20/2024) that the facility had notified the police department regarding the allegation of sexual abuse. On 8/21/2024 at 11:00 A.M., V2 (Director of Nursing) said that R5 returned to the facility the evening of 8/20/2024. On 8/21/2024 at 11:30 A.M., R5 was observed sitting at the edge of her bed. R5 was calm, soft spoken, was alert and oriented times 3, but with some forgetfulness with dates. Surveyor introduced herself and asked R5 how staff are when providing care to her. R5, with teary eyes had responded around 10 days ago, there was this CNA, muscular built, tall and he was black. I never seen him before, so I assumed he was from staffing agency. He gave me his name. He came with an attitude, and at 5:00 A.M., he took me to bathroom, changed my diaper, wiped me with wipes then pinched my vagina. I slapped his hand and told him not to do that and I was worried that if he did that to me, what else can he do for other residents that cannot say something or fight back. R5 said she reported this to V17 (counselor) a few days after it happened before she went to the hospital on 8/16/2024. R5 said that V17 had advised her not to tell anyone and that V17 will follow it up. R5 said that however, to this day, V17 had not come back to her for an update. R5 also said that she had reported to a hospital staff on 8/16/2024 regarding the sexual abuse by this described CNA. Surveyor asked R5 if V1 and or V2 had already talked to her regarding this sexual allegation. R5 said that no one had interviewed her from the facility of what happened. R5 gave permission to surveyor to inform V1 and V2. Upon prompting, V1 and V19 (Director of Operation for the company organization) went to talked to R5. R5 had stated the same scenario regarding this individual CNA that had allegedly pinched her vagina. Review of the schedule for the last 2 weeks showed V6 (CNA), happened to be the only one male CNA from staffing agency that was assigned to R5 on 8/12/2024 for the night shift. On 8/21/2024 at 12:40 P.M., V6 said he introduced himself by name. V6 said that he took care of R5 on 8/12/2024. V6 also said that he had changed R5's bedding because it was wet. V6 also said that he changed R5's incontinence brief. The facility's policy titled Abuse, dated 11/28/2017 showed, POLICY STATEMENT: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse . The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of all allegations. TYPES OF ABUSE .1. Physical abuse .4. Sexual abuse . ABUSE COORDINATOR: The Administrator is the abuse coordinator in this facility and is responsible for developing and implementing the abuse prevention training curriculum and conducting the investigation in situations of alleged abuse/neglect .A report will be made to the local police department immediately and not exceeding 2 hours after forming the suspicion or allegation of sexual abuse if there is serious bodily injury, and within 24 hours of the allegation being made, if there is no serious bodily injury.

Based on observation, interview, and record review, the facility failed to ensure a resident was propelled safely in the facility parking lot to avoid a fall. The resident fell forward out of her wheelchair and landed on the asphalt, sustaining progression of an existing neck fracture, a shoulder dislocation, and a hematoma on her forehead. This applies to 1 of 5 residents (R1) reviewed for falls in the sample of 5. The findings include: The facility incident reported to the Illinois Department of Public Health on 6/27/23 (occurring on 6/26/23) showed R1's incident occurred at 10:46 AM while R1 and fell ow residents were being escorted around facility property by CNAs [Certified Nursing Assistants]. R1's front wheelchair became stuck in grated manhole cover causing R1 to lean forward and fall from her wheelchair Resident was admitted (to local hospital) with a [fracture] of C2 [cervical- second bone in the neck] R1's 6/29/23 Physical Therapy referral showed R1 was readmitted with a diagnosis of C2 fracture from a fall in the facility compound while CNAs were pushing [R1] for a morning walk. Patient fell forward out of her [wheelchair] and no leg rests were in place . R1's hospital discharge summary (6/26/23 result date) included her Computerized Tomography (CT) of her spine and it showed IMPRESSION: Unstable complete transverse base of the dens fracture of C2 [second bone in neck] this fracture has progressed from the prior CT scan dated 12/11/2022 . The narrative section in R1's hospital discharge summary also showed a left shoulder Xray from 6/26/23 with probable AC joint separation [collar bone separating from the shoulder blade] . R1's 6/26/23 brain CT findings showed There is a small left lateral frontal scalp hematoma, measuring 0.5 centimeters in thickness. On 7/6/22 at 11:51 AM, V12 (Maintenance Assistant) assessed the area in the parking lot where R1 fell out of her wheelchair. The area had a round metal manhole cover V12 measured as approximately 22 inches across and it was painted yellow. The manhole cover was set down three-quarters of an inch below the surrounding asphalt, and the surrounding asphalt gradually sloped down toward the cover. V12 measured over 10 feet of clearance on one side between the manhole cover and the parking spaces, and six feet 10 inches of clearance between the manhole cover and the lawn on the other side. On 7/5/23 at 10:36 AM, R1 was lying in bed wearing a hospital gown and sleeping. R1 was wearing a cervical collar. R1's July 2023 Physician Order Sheet showed a 7/5/23 order of NURSING REHAB: Cervical neck brace- keep neck brace in place at all times for at least 12 weeks from date of re-admission OR until re-evaluated by orthopedics . On 7/6/23 at 9:46 AM, R1 was in bed in a hospital gown and had discoloration on her left forehead. R1 stated she recalled falling outside. R1 stated she did not have leg rests on her wheelchair at the time of her fall and she did not want to get out of bed because it hurts to move. R1's 6/10/23 Minimum Data Set 6/10/23 showed R1 is cognitively intact and required limited assistance with locomotion off the unit. R1's 7/5/23 V14 NP (Nurse Practitioner- Hospice/Palliative) note from 1:21 PM showed R1 suffered a fall last month, with head injury. She was sent to the hospital, and it has been determined that she has a progression of her dens fracture She had been mobile prior to the fall and had been able to wheel herself around the hallways but has become primarily bed bound On 7/5/23 at 11:31 AM, V5 (Restorative Aide) stated on 6/26/23 at about 9:30 AM, she and V4 (Restorative Aide) were escorting R1 with two other residents on a walk around the building through the parking lot. V5 stated they were all walking side by side, and she was the one pushing R1 in her wheelchair. V5 stated they were talking to the residents as they were walking. V5 stated R1's back left wheel caught the edge of the manhole cover and R1 fell forward out of the wheelchair before she could grab her. V5 stated R1 fell on her left side and a bump formed on R1's left forehead. V5 stated every resident has foot pedals in their room. It is part of their (staff's) job to assure residents have leg rests available when they go out. On 7/5/23 at 10:55 AM, V4 (Restorative Aide) confirmed she and V5 were walking outside the facility with R1 and two other residents. V4 stated she was pushing one resident's wheelchair, and another resident was walking on her left. V4 stated V5 was on her right, pushing R1 in her wheelchair. V4 stated V5 pushed R1 over the manhole cover and R1 went forward, falling out of her wheelchair. V4 stated R1 hit her left head and left side. V4 stated when residents are transported by staff, they should have leg rests in place on their wheelchairs. On 7/7/23 at 3:15 PM, V16 (Occupational Therapist- Registered) stated residents should have leg pedals on if they are in the parking lot because of the uneven surfaces. V16 explained the use of leg pedals on a wheelchair helps position the hips back if there is a sudden jerk while in motion. V16 stated leg pedals keep the knees up and keep the person back in their seat. V16 added that when residents go out for appointments, they must use leg pedals for traveling on the bus for safety. V16 stated, It's a standard. V16 stated since the fall, R1 has primarily been on bedrest except for therapy at the bedside. V16 stated, It's a big change for her (R1) .it's her preference right now. V16 added R1 does not want to get out of bed and she says it is too much discomfort and pain, adding R1, knows she fell out of the chair. On 7/7/23 at 3:10 PM, V6 PT (Physical Therapist / Director of Physical Therapy) stated that on 6/26/23 when R1 fell , she heard a commotion out front and went to the parking lot. V6 stated she saw R1 on her back and R1 said something like, take me, I'm hurting. V6 stated residents do not need leg pedals on their wheelchairs if they are just sitting in the front entrance because staff is always there. On 7/5/23 at 2:23 PM, V6 stated when she saw R1 on the ground in the parking lot, her wheelchair did not have leg rests in place. V6 stated leg rests are important to prevent falls from the wheelchair. On 7/5/23 at 3:36 PM, V3 ADON (Assistant Director of Nursing) stated R1 had swelling on her right forehead and an abrasion on her left knee. V3 stated R1 has a bag on the back of her wheelchair for her leg rests, but he did not recall if the leg rest or a seat cushion were in use. V3 stated when R1 is being transported outside of the facility, there should be leg rests in use. On 7/6/23 at 11:31 AM, V11 CNA (Certified Nursing Assistant) stated if she is taking a resident outside, they need to have their leg rests in place. V11 stated the leg rests provide balance and safety. On 7/7/23 at 10:37 AM, V13 NP (Nurse Practitioner) stated R1's current C2 (cervical) fracture post-fall was a progression of a previous fracture she sustained at the end of last year. V13 stated there was enough space outside to avoid pushing R1 over the manhole cover. On 7/7/23 at 3:05 PM, V15 RN (Registered Nurse) stated she heard about R1's fall and that staff should have used leg pedals for R1, adding, I think they should have avoided the manhole cover. On 7/7/23 at 11:58 AM, V2 DON (Director of Nursing) stated the facility does not have a policy for transporting residents, but it is the facility's practice for residents to have leg rests in use when being escorted by staff. V2 stated staff should make sure the wheelchair is in working condition, the footrests are in place, make sure it's not raining or windy, and avoid potholes or any dips in the ground. R1's fall risk care plan (initiated 10/11/18) showed a 10/11/18 person-centered care plan intervention of: I would like staff to provide me a safe environment: even floors, free from spills and/or clutter .

Based on observation, interview, and record review, the facility failed to supervise R1, a male resident with known history of sexually inappropriate behaviors. The facility also failed to develop and implement a comprehensive care plan with specific interventions and instructions regarding 1:1 monitoring to prevent R1 from touching and fondling female residents' breasts who were unable to give consent due to cognitive impairment after an incident involving R6 and R7 on [DATE]. R1 was noted with another incident on [DATE], involving R5. The final incident was on [DATE], when R1 was left unsupervised and touched R4's breast. This applies to 4 of 4 residents (R4, R5, R6 and R7) who were severely cognitively impaired female residents who were unable to give consent and were touched by R1 in a sexual manner. This resulted in an Immediate Jeopardy. The IJ (Immediate Jeopardy) began on [DATE] at 11:30 A.M., when R1 fondled R4's breast while left unsupervised. V1 (Administrator) and V21 (Regional Director of Operation) were notified of the IJ on [DATE] at 11:52 A.M. The surveyor confirmed by interview and record review that IJ was removed on [DATE] at 4:24 P.M., but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The EHR (Electronic Health Record) shows R1, a [AGE] year-old, was originally admitted to the facility on [DATE]. R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission medical provider notes dated [DATE] show that R1 was admitted to facility from hospital on [DATE] due to covid-19 and altered mental status. The notes showed that R1's CT (Computerized Tomography) of head was done at the hospital and result was negative. R1 was ultimately transferred to facility for rehab services. During the examination from the provider, R1 had reported he was okay and stated that he likes being in the facility because everything is done for him. The medical provider noted that R1 was poorly motivated with therapy treatment and likes staying in bed. The notes show that R1 is a current smoker, with history of [CONDITION(S)], and was alert and oriented times three. The assessment/plan made for R1 was to monitor him for his mood and behavior. The SW (Social Worker) notes dated [DATE], show R1 had secondary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The SW assessed R1 on [DATE] for BIMS (Brief Interview Mental Status) and PHQ-9 (Patient Health Questionnaire-9-Mental Disorders Screening). The assessments show that R1 was alert and oriented x 3 and able to make his needs known. R1's BIMS score was 15 out of 15 indicating he is cognitively intact. The assessment also shows that R1's hearing was adequate, and he can understand as well as make himself understood. R1's PHQ-9 score was a 12 out of 27 indicating moderate depression. (Total scores of 5,10,15 and 20 represent cut points for mild, moderate, moderately severe, and severe depression). It was also in the notes that R1 reported little interest in activities and indicated he prefers to schedule his own leisure time. R1 had reported feeling down at times, having trouble with sleep, and added he naps frequently throughout the day. The medical provider notes dated [DATE] and 29 of 2021, [DATE] of 2021, [DATE], 25 of 2021, [DATE], show R1 was alert and oriented times 3 spheres. The EHR (Electronic Health Record) shows multiple occurrences of R1's outburst of negative behavior that includes physical altercation and sexual altercation that were explicit in nature. The documentation as described below, and interviews held showed R1's inappropriate behavior: 1. The medical provider notes dated [DATE] show that R1 had an altercation with another resident. The notes show that R1 hit a female resident. It also shows that when R1 was asked by the medical provider the reason of this altercation R1 responded I do not like her. 2. R1 had physical altercation with a female resident on [DATE] as documented on: - The General Progress notes dated [DATE] at around 9:20 A.M., the nurse had heard a resident screaming in the dining area close to the courtyard. There were other nurses who also came because of someone screaming from this location. Upon investigation, R10 (a female resident) stated that R1 had grabbed her arm and caused scratches on her right arm. - The medical provider notes dated [DATE] showed that R1 grabbed a female resident's right arm because the female resident had kicked R1 while going outside to smoke. R1 had long nails and this caused scratch marks on the female resident's arm. 3. The SW notes dated [DATE] show SW talked to R1 regarding an occurrence from [DATE] before the police were involved. The facility's incident report dated [DATE] shows R10 (female resident) reported to the abuse coordinator (V1, Administrator) an incident that occurred on [DATE] which occurred in the morning and again in the afternoon. The report states R10 reported R1 was inappropriately touching a female residents' breasts. The report states R10 reported that V19, (CNA/Certified Nurse Assistant) stated that V17 (CNA) had witnessed R1 touched R7's breast. The report states V19 saw R1 touch R6's arm, then touch R6's shoulder area/chest area. This report shows that R10 yelled at R1 and said, Remove your arm from her (R6)! The facility investigated this sexual abuse allegation. However, the facility found it unsubstantiated. The conclusion from the facility was that R1's BIMS score was 15; that R1 was alert and oriented; that R1 denied he touched R6 and R7's breasts and that R6 and R7 had not reported any abuse. The MDS (Minimum Data Set) dated [DATE] shows R6's BIMS score of ,d+[DATE]; and MDS dated [DATE] BIMS score was ,d+[DATE] in which means R6's cognition was severely impaired. The MDS dated [DATE] shows R7's BIMS score of ,d+[DATE], which means moderately impaired for cognition. Observation on [DATE] at 2:45 P.M., R6 was sitting in her wheelchair. R6 was in the dining room. R6 was not verbally responsive and was mumbling incomprehensible words. Review of record shows R7 was transferred to the hospital on [DATE]. R7 was not observed during the survey as R7 had expired. On [DATE] at 4:10 P.M., V6 (Registered Nurse) said that R1 had episodes of touching female resident's breasts, staff's breasts, and rear ends prior to the incident of [DATE] with R6 and R7. V6 said she had not seen R1 touch female residents, however, it was reported to her that R1 displayed inappropriate behavior at times. V6 said that routine monitoring/observation (every 2 hours) of R1's behavior was in place. V6 said it was inappropriate to touch others, especially those residents (R6 and R7) who were not able to give their consents. V6 said, though R1 was occasionally forgetful, (R1) was alert enough to know what was going on, he knows the place, time events and especially the time for smoking period. (R1) would remind staff that it is smoking period/time. On [DATE] at 11:04 A.M., V17 said R1 has a behavior of touching female residents' breasts, female staff's breasts and rear ends and all of it was inappropriate. V17 said she saw R1 inappropriately touch R6's and R7's breast on [DATE], and that R1 had stroked, caressed, and fondled their breasts. V17 said it happened twice the same day ([DATE]), once in the morning and once in the afternoon. It was not appropriate at all, and I don't want that happening to me or any other female, especially elderly who cannot give their consent. (R1) actions were sexually motivated and were inappropriate. (R1) was coherent enough to know what he was doing. On [DATE] at 4:30 P.M., R10 said she saw R1 touch female residents' breast. R10 said she does not remember the residents' name. R10 also said I felt it was very inappropriate, so I yelled at him (R1) to stop. I don't want (R1) doing that to me or to any other resident. He is a dirty old man. I reported (R1) to the administrator. The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The notes show R1's neurological assessment was grossly intact and psychiatric evaluation showed R1's affect was flat. The plan of care was to continue with same medication ([MEDICATION(S)]) and monitor behavior. It was noted that physician documented dementia without behavior. There was no evaluation assessment /revised plan of care that addressed R1's inappropriate sexual behavior. The psychiatric nurse practitioner's evaluation report dated [DATE] shows R1 was alert and oriented times three spheres, with poor boundaries and grabbing females inappropriately. The notes show the psychiatric nurse practitioner had discussed this behavior with R1 and that R1 was educated on respecting people's personal space and expected social norms. The assessment shows R1's insight was fair and abstract reasoning was intact. 4. The SW (Social Worker) Behavior Notes dated [DATE] show R1 has been observed talking with a female resident and they appear to have started a romantic relationship. The notes show that R1 had been observed holding the hand of the female resident and fixing her coat at times. The SW explained to R1 that R1 may have female friends; however, he needs to refrain from touching them. The notes show that R1 had verbalized understanding and was able to track what was being talked about. 5. The General Progress Report dated [DATE] shows that R1 was observed touching a cognitively impaired female resident (R5). The Attending Physician was informed, psychiatric evaluation was ordered. The facility's incident report dated [DATE] at 10:21 A.M., shows V15 (Activity Director) saw R1 place his hands on top of R5's hands and was moving R5's hands towards R5's breasts. The report shows that R5 was sitting in her wheelchair in the dining room when this happened. The report shows that R5 is cognitively impaired. The MDS (Minimum Data Set) dated [DATE] and [DATE] shows that R5's cognition is severely impaired. On [DATE] at 11:45AM, R5 was observed sitting in her wheelchair in the dining room. R5 was not able to verbalize, had a flat affect and only stared. Review of record shows that on [DATE], the social worker met with R1 regarding report of inappropriate boundaries with peer. R1 was placed on 1:1 for on-going monitoring and the local police department was involved. R1 was sent to the hospital for evaluation on [DATE] and returned to the facility on [DATE]. R1 was placed on 1:1 care. R1 was described as alert and oriented times 2, and able to follow directions. 6. The psychiatry nurse practitioner notes dated [DATE] show that V3 (ADON/ Assistant Director of Nursing) reported to the psychiatric nurse practitioner that R1 continues to exhibit inappropriate behavior despite recent inpatient hospitalization . The notes show that on [DATE], R1 attempted to grab the breast of a nursing staff. The social worker notes dated [DATE], document that SW spoke with R1 and his daughter, regarding the continuous exhibition of sexually inappropriate behavior including inappropriate touching. The progress notes show that on [DATE] R1 attempted to grab CNA's chest during care. The CNA pulled back and informed R1 that behavior is not acceptable. This behavior was reported immediately to V1, who gave instruction to file a report with police department. The psychiatry nurse practitioner notes dated [DATE], show R1 was exhibiting inappropriate sexual behavior. The notes show R1 was alert and oriented times two and the plan of care was discussed with the nurse on duty and V3. The notes document the plan was to continue to monitor R1 and to communicate any further inappropriate behaviors. The general progress notes dated [DATE] show R1's daughter was notified of R1's inappropriately touching a CNA's breast with his hand. The notes show that police were notified. The Behavior Notes dated [DATE] show at approximately 09:30 on [DATE], the NOD (Nurse on Duty) witnessed R1 reach out and grab a CNA's rear end. The CNA was standing by wound treatment cart at the time. R1 was being pushed back to room by his assigned 1:1 monitoring aid at the time. 8. The General Progress notes dated [DATE], show around 11:30 A.M., R8 (female resident) witnessed R1 inappropriately touch R4 (female resident) while in the dining room. The notes show R8 reported this to V4 (CNA), who then reported to the Administrator. The notes show R1 was sent to the hospital for psychiatric evaluation with an involuntary petition for admission to the hospital. The incident report dated [DATE], shows on [DATE] at approximately 12:10 PM, V4 notified the abuse coordinator that R8 informed V4 that R8 saw R1 touch R4's breast. The police were notified. Review of this facility's investigation shows that R1 had a BIMS of 9 (moderately impaired for cognition) is aware and oriented. Review of the investigation shows this incident was substantiated for sexual abuse. The Police Report dated [DATE] shows the facility's social worker had called police department on [DATE] at 1:02 PM to report battery between 2 residents identified as (R1 and R4). The report shows R8, as a witness, was the only resident interviewed. The report shows R8 reported to the police that there were no staff around when R8 saw R1 fondling (R4's) breast repeatedly. Per report, the social worker informed the police that R1 and R4 both have severe dementia. The social worker had no answer when the police asked why R1 was left alone unsupervised. It was documented on the police report that the social worker had informed the police that R1 had numerous problems battering, fondling female peers' breast and female staff. Further review of the report shows the facility is currently contacting (R1 and R4's) family and all they wanted from us (police) was to document the incident. There was no further action. R4 was observed on [DATE] at 12:10 PM in the dining room. R4 was noted not to respond to questions but was awake. The EHR shows R4 is a [AGE] year-old female resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A BIMS score for R4 was not attainable due to severe impairment. On [DATE] at 2:35 PM, R8, an alert, oriented, female resident. R8's BIMS assessment dated [DATE] was ,d+[DATE], indicating R8 is cognitively intact. R8 said: On [DATE], there were 4 of us in the Providence Dining room (myself, R9, R1 and R4). There was a table next to my table. (R1) and (R4) were at that table, sitting in their wheelchairs. They were sitting next to each other, like elbow to elbow. I saw that dirty old man (R1) fondling, caressing (R4's) breast. (R4) is so confused and cannot speak for herself, she just mumbles. I yelled at (R1) to STOP!!!, then he looked at me, then he stopped for few seconds and started to do it again and again. He did it fondling (R4's) breast repeatedly ,d+[DATE] cycles and each cycle had stroked her breast ,d+[DATE] times. I yelled and screamed at the top of my lungs for staff to come. There were no staff around. It was very scary situation what this dirty old man did to this helpless female resident (R4). I was so traumatized and up to this day, it's been more than 2 weeks since it had happened, and I still cry about it and felt so scared. I don't even want to see women being sexually exploited. It was very scary to see that. How about if no one was there to ask for help, if I was not there, since there was no staff, then this dirty old man (R1) can just take advantage and sexually assault women that cannot speak for themselves and are helpless. It is not right at all. We are supposed to be protected. On [DATE] at 1:23 P.M., V4 (CNA/sitter, a female staff) said she was the assigned sitter as 1:1 monitoring/supervision for R1 the morning shift on [DATE]. V4 said she took R1 to smoke around 11:30 A.M. and left him at the patio to smoke. V4 said V5 (Activity Aide) was on the patio but was supervising other residents that were smoking. V4 said she left R1 on the patio without 1:1 supervision, and she proceeded to go inside the facility. V4 said that as far as she knows, her job as a sitter was to supervise, and report R1's negative behavior to the nurse. V4 said during supervision, she just sits behind R1. According to V4, R1 can easily touch female residents if he wanted to because during the supervision R4 sits behind R1. V4 said. there was no caution for distancing from female residents allowing R1 the ability to touch others within R1's arms reach. When asked if she could prevent R1 from touching female residents, V4 responded she will just have to remind him not to do it. V4 said R1 was alert and oriented and able to verbalize his needs, was aware of his surroundings and events, especially smoking time. V4 confirmed that she left R1 unsupervised on [DATE] when the incident happened between R1 and R4. On [DATE] at 3:23 P.M., V5 (Activity Aide) said that on [DATE], around 11:40 A.M., she propelled R1 into the dining room and left him there at the table in his wheelchair with no supervision. V5 said there was no staff or other residents in the dining room at that time. V5 was very upset during the interview and said that she should have not left R1 alone. On [DATE] at 4:10 P.M., V6 (Registered Nurse) said she was on duty on during the morning shift of [DATE]. V6 said she was passing medications and was not aware that R1 was not supervised as 1:1. V6 said R1 was alert and oriented. V6 said when R1 was asked why he touched R4's breast, R1 said I don't know and shrugged his shoulders with somewhat of a smirk on his face. R1's plan of care was reviewed for the dates of: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. The care plans show the same non-specific interventions, were generalized and vague. The care plans did not address detailed instructions how the 1:1 monitoring should be implemented to ensure and protect female residents from inappropriate touching and sexual abuse. The care plans addressed R1's problem as SEXUALLY ORIENTED BEHAVIOR: I exhibit sexually inappropriate behavioral symptoms which may be manifested by my diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions: -Have male CNA's provide cares to me when available. -Intervene and redirect when any inappropriate behavior is observed. Communicate assertively that I must exercise control over impulses and behavior (Social Skills). Remind me to refrain from inappropriate touching (Please keep your thoughts and your hands to yourself). -Use creative refocusing to alter behavioral patterns (e.g. distraction techniques with food, drink, or another activity) to redirect me. SEXUALLY ORIENTED BEHAVIOR: I exhibit sexual behavior symptoms which are manifested by: my diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . I am easily redirected. -I will comply with staff redirection and behave in a safe and respectful manner, daily by next review period. -I suffer from dementia and a TBI. Use creative refocusing to alter behavioral patterns (e.g., distraction techniques with food, drink, or another activity to redirect my attention. -Implement limit setting. Specify appropriate versus inappropriate behavior. If I try to touch inappropriately, gently but firmly remove my hand and redirect me. -Intervene and redirect when any inappropriate behavior is observed. Communicate assertively that I must exercise control over impulses and behavior. Remind me to refrain from inappropriate touching (Please keep your hands to yourself). On [DATE] at 9:30 A.M., V1 said the facility has no policy regarding 1:1 staff monitoring and supervision. -On [DATE] at 1:13 P.M., V7 (female CNA/sitter) said she was the assigned sitter as 1:1 monitoring/supervision with R1. V7 said that as far as she knows, her job as a sitter was to supervise, and report R1's negative behavior to the nurse. V7 said that during supervision, she sits behind R1 and when she propelled R1, they pass by other female residents. V7 added that during these periods of supervision, there was no caution for distancing, therefore, R1 can easily touch anyone if he wanted to since the distance was only within R1's arms reach. When asked if she could prevent R1 from touching female residents, V7 responded that she will just have to remind him not to do it. V7 said R1 was alert and oriented and able to verbalize his needs, was aware of his surroundings and events, especially smoking time. - On [DATE] at 1:25 P.M. V8 (female sitter/CNA) said that she was the assigned sitter as 1:1 monitoring/supervision with R1. V8 said that as far as she knows, her job as a sitter was to supervise, and report R1's negative behavior to the nurse. V8 said that during supervision, she just sits behind R1 and when R1 being propelled by her, R1 passes by female residents. V8 added that during these periods of supervision, there was no caution for distancing, therefore, R1 can easily touch female peers if he wanted to since the distance was only within R1's arms reach. When asked if she could prevent R1 from touching female residents, V8 responded that she will just have to remind him not to do it. V8 said that R1 was alert and oriented and able to verbalize his needs, was aware of his surroundings and events, especially smoking time. V8 added that there was an incident that when her daughter (V14/Restorative Aide/female sitter) approached her and R1 at the reception area/hallway. R1 attempted to grope my daughter, but my daughter was very quick and had avoided being touched inappropriately. - On [DATE] at 1:25 P.M., V11 (female sitter/CNA) said that multiple times that R1 had grabbed her rear end while providing R1 incontinence care. V11 said that I know (R1) intentionally touched me with sexual intentions. (R1) knows what he was doing. V11 said during supervision of R1 she sits behind R1 and when R1 being propelled by her, R1 passes by female residents. V11 added that during these periods of supervision, there was no caution for distancing, therefore, R1 can easily touch female residents since the distance was only within R1's arms reach. When asked if she could prevent R1 from touching female residents, V11 responded that she will just have to remind him not to do it. - On [DATE] at 10:45 A.M., V13 (female CNA/sitter) said that R1 also touched her inappropriately in her rear end. V13 said R1's touch was sexually explicit in nature. I told him to stop, then he stopped, smiled and did it again. V13 said that during supervision, she sits behind R1 and when R1 is being propelled by her, R1 passes by female residents. V13 added that during these periods of supervision, there was no caution for distancing, therefore, R1 can easily touch female residents since the distance was only within arm's reach. When asked if she could prevent R1 from touching female residents, V13 responded that she must remind him not to do it. -On [DATE] at 10:30 A.M., V14 (female Restorative aide/sitter, daughter of V8) said that she was inappropriately touch in her rear end by R1. V14 added that R1 did it on purpose, told him to stop and did it again. V14 said that during the periods of 1:1 monitoring/supervision, there was no caution for distancing, therefore, R1 can easily touch female residents since the distance was only within R1's arms reach. When asked if she could prevent R1 from touching female residents, V14 responded that she just must remind him not to do it. -On [DATE] at 3:25 P.M., V9 (Registered Nurse) said she was aware of R1's sexually inappropriate touching of female residents. V9 added that R1 had a sitter since the ,d+[DATE] incident. V9 said the sitter was supposed to supervise and intervene. V9 said she did not provide detailed instructions for the sitters/CNA. -On [DATE] at 3:15 P.M., V10 (female nurse) said she was aware of R1's sexually inappropriate touching of female residents. V10 said R1 had a 1:1 sitter/CNA since the ,d+[DATE] incident. V10 said the sitter was supposed to supervise and intervene. V10 added that she did not provide detailed instructions -On [DATE] at 1:25 P.M., V18 (Psychiatric Nurse Practitioner) said R1 was alert and oriented times three. V18 said he examined R1 once a month and as needed. V18 said the last time R1 was examined by him was on [DATE]. V18 said he was not aware R1 was touching female staff inappropriately. V18 said he was not told R1 was touching female residents inappropriately. V18 said the plan of care for R1 included structured activity to divert R1's attention. V18 said it was okay for R1 to be with other residents playing card games for socialization if there was a sitter next to him. However, if V18 was aware of R1 touching female peers inappropriately then the plan would have been modified to the extent that R1 and female residents have a caution distance. R1 would not be able to reach out and touch them inappropriately. V18 said his expectation was he would have been made aware of R1's behavior of touching female residents. V18 said he should have been notified when R1 was sent out for this behavior. V18 said that no one told him that R1 was in the hospital for this behavior. V18 said based on his examination with R1, R1 knows where he is at, the time, and events. The facility Abuse Prevention Policy dated [DATE], with a revision date of [DATE] shows, It is the policy of the facility to provide professional care and services, in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect or mistreatment. Types of abuse; physical, verbal, mental, sexual, neglect, theft, involuntary seclusion, exploitation, and injury of unknown origin. Sexual abuse includes but is not limited to harassment, coercion, disparaging remarks or sexual assault. The IJ began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy. 1) R1 is no longer at the facility and is not returning to this facility 2) R1 was immediately separated from R4 and placed on a 1:1 staff monitor 3) IVD (Involuntary Discharge) emergency basis issued to resident and POA (Power of Attorney) on [DATE] 4) R4 was immediately assessed by the nurse on [DATE] upon being informed of this incident and was found without any physical injury (no swelling, no skin injuries of the entire head to toe assessment and right and left breasts) and had no sign or symptom of anxiety or fear. 5) R8 and R10 were provided wellness checks by social services/and or designee on [DATE] and continued once a week until [DATE] with no reported concerns and will continue as needed. This will be documented in the social service wellness check log. 6) All residents in the facility are being re-assessed on [DATE] for abuse/neglect, to identify if any residents are sexually inappropriate or sexually aggressive. This audit will be completed by [DATE]. 7) Any residents, if identified to be sexually inappropriate or sexually aggressive, will be audited once a week to ensure compliance starting on [DATE]. This audit will continue for one month, then reviewed at the monthly QAPI (Quality Assurance Performance Improvement) meeting by the IDT (Interdisciplinary Team) including the medical director. 8) Any residents if identified to be sexually inappropriate or sexually aggressive will have their care plans revised accordingly by [DATE]. 9) New admissions since [DATE] until current to be reviewed and assessed for any sexually inappropriate behaviors and this will be completed by [DATE]. 10) New admissions will be assessed for any sexually aggressive/inappropriate behaviors upon admission and if identified having these behaviors, appropriate interventions such as a 1:1 staff monitor will be implemented immediately and audited once a week to ensure compliance. 11) 1:1 re-education on the abuse policy and the 1:1 monitoring policy with the Activity Aide (who forgot to ensure R1 was supervised at all times) was done on [DATE] by the Administrator and on the 1:1 monitoring policy on [DATE]. 12) 1:1 re-education with the assigned C.N.A. to ensure that R1 was provided supervision always was done on [DATE]. 13) A QA (Quality Assurance) audit will be conducted three times per week for 12 weeks starting [DATE] to ensure there are no sexually aggressive residents and/or residents with inappropriate behaviors. If this is identified, ensure proper interventions are in place. This will be done by Administrator or designee and reviewed at the monthly QAPI meeting by the IDT, including the medical director. 14) The incident and abatement plan has been discussed and reviewed with the facility medical director on [DATE] and the medical director agreed with the plan of correction and abatement plan. 15) This incident was re-reviewed with the medical director, including the Abatement plan with the medical director by the Regional Director of Operations on [DATE] at 11:30 am, the Medical Director was in agreement with the Abatement plan and steps facility has taken to ensure compliance. 16) On [DATE] during the incident review with the Medical Director by the Regional Director of Operations, the Medical Director suggested interventions for the staff that were inappropriately touched by R1. Discussed the Human Resource procedures in place to address work- related incidents that are already in place at the facility to address this, the medical director was in agreement with this. 17) The facility has initiated implementing and review of a policy addressing 1:1 monitoring and interventions for inappropriate behavior on [DATE]. 18) All staff have been re-educated on the 1:1 staff monitoring policy as of [DATE] and is ongoing until [DATE]. 19) All agency staff will be educated on the 1:1 staff monitoring policy at the beginning of their shifts, by the manager on duty and/or designee starting on [DATE]. This will be audited daily for 12 weeks by the Human Resource Director and/or Designee to ensure compliance and will be reviewed at the monthly QAPI committee meeting. 20) The 1:1 staff monitoring policy education is ongoing and will be completed by [DATE] with an emphasis on what to do in certain circumstances (listed in the policy) when assigned as a 1:1 staff monitor. 21) Re-education on abuse is ongoing and will be completed by [DATE]. Emphasis will be placed on even if two residents are cognitively impaired and engage in a sexual inappropriate activity, this is still considered abuse and should be immediately reported to the abuse coordinator for investigation. 22) A full house audit has been conducted and all residents as of [DATE] have been re-assessed for abuse/neglect, whether they are at risk or at low risk, or not at risk. The reasons have been identified for the level of risk they are at with proper care plan revisions and interventions.

Based on interview and record review the facility failed to ensure safe practices when turning a resident in bed. This resulted in the resident falling out of bed and sustaining a [CONDITION(S)]. This applies to 1 of 3 residents (R1) reviewed for falls during bed mobility from a total sample of 16. The findings include: According to the Electronic Health Record (EHR), R1 had diagnoses including heart failure, hypertension, [CONDITION(S)], diabetes, [CONDITION(S)], arthritis, depression, other orthopedic conditions, morbid (severe) obesity, [CONDITION(S)], irritable bowel syndrome, long term use of insulin, personal history of [CONDITION(S)], bilateral primary [CONDITION(S)] of knee, long term (current) use of aspirin, chronic pain, body mass index [BMI] 50.0-59.9, hereditary [CONDITION(S)], [CONDITION(S)], and fracture of neck of left femur. The Minimum Data Set (MDS) dated [DATE], showed R1 needed extensive assistance of two people for bed mobility, dressing, and toilet use. R1 was always incontinent of bowel and bladder. The MDS showed R1's cognition was intact. The MDS showed R1 was five feet six inches tall and weighed 335 pounds. A care plan showed R1 had an Activities of Daily Living (ADL) self-care deficit and impaired mobility with interventions including R1 required two staff participation to reposition and turn in bed initiated 11/25/2018; and R1 was totally dependent on staff for toilet use initiated on 05/27/2020. The Incident information provided to Illinois Department of Public Health (IDPH) showed R1 was alert and oriented times two, able to follow directions, was non-ambulatory, and transfers using a total body mechanical lift. (R1) requires extensive to total assistance of two persons for ADLs and used a trapeze and grab bars for repositioning. On 08/06/2021 around 12:48 PM, CNA (Certified Nursing Assistant) was providing peri care when R1 repositioned herself to her right side, crossed her left leg over her right leg as she turned to the right side, lost trunk control and rolled all the way out of bed landing on both knees. R1 was grabbing the half bed rail at the time and had a low air loss mattress. On 08/23/2021 at 1:00 PM, R1 was awake lying in a bariatric bed with an air mattress, approximately one foot away from the wall. The bed was elevated with the top of the mattress approximately 36 inches from the floor. R1 said she was recovering from hip injury from falling out of bed. When asked how she fell out of bed, R1 said she wasn't sure, but Maybe the CNA wasn't paying attention. R1 said she was in a different room with a different air mattress which was not as wide as the current mattress. R1 said only one person was changing her incontinence brief and the CNA told me to roll onto my side. R1 said when she rolled to the side, she just kept rolling off the bed, her knees hit the floor, and she had to let go of the side rail she had been holding onto. R1 said now she won't let anyone help change her unless they have at least two people in the room to help. R1 said before sometimes they would use two or three people to assist her when turning in bed. On 08/23/2021 at 1:31 PM, V6 (CNA/Activities Aide) said on 08/06/2021 approximately 2:00 PM R1 had put on the call light and said she needed the incontinence brief to be changed. V6 looked for another staff member to help but was unable to find anyone to assist her. V6 said R1 was on an air mattress, possibly a bariatric size mattress. V6 said R1 was laying on her back and was able to roll to her left side (toward the wall) better. V6 said she had R1 roll to the left side, V6 cleaned R1's bottom while standing behind R1 on the right side of the bed, then had her roll to her back. V6 went to R1's left side of the bed and told R1 Now we need to roll over. V6 said R1 had crossed her legs, R1 grabbed the right quarter side rail, and started rolling over. V6 said (R1) just kept rolling and I told her to stop rolling and tried to grab (R1) but was unable to stop (R1) from rolling out of the bed. (R1) landed on her knees then rolled onto her bottom in a sitting position with her back leaning against the bed. V6 asked R1 if she was ok and R1 yelled Get help! Get help! V6 said R1 wasn't complaining of pain right away while she was on the floor or while the staff had gotten her into the total body mechanical lift sling, however R1 did start complaining of left hip pain when R1's leg touched the bed while lowering the lift sling to the mattress. On 08/23/2021 at 1:49 PM, V7 (Registered Nurse/RN) said when she arrived to R1's room, (R1) didn't say anything when I asked what happened. (R1) has a tendency to keep quiet when she is upset. V7 said at first R1 was quiet, not complaining of any pain while she was on the floor or while the staff was moving her to put the sling underneath R1 to move her into the bed. V7 said once they were lowering R1 to the bed was when R1 started complaining of pain on the left hip. V7 said normally R1 would have two or three people for assist with her care, especially since R1 was heavier. R1 needed assistance with one CNA on either side of her when turning her in bed for safety. V7 said R1 didn't have two people assistance and only one CNA was assisting her for incontinence care. V7 said, The CNA should wait for assistance from another CNA. On 08/23/2021 at 3:24 PM, V1 (Administrator) and V2 (Director of Nursing/DON) said R1 was on a 42-inch low air loss/alternating pressure mattress bed prior to her fall. On 08/23/2021 at 3:49 PM, V8 (CNA) said during the night shift prior to the fall, R1 would activate her call light when she needed to be changed, usually around 3:30 AM or 4:00 AM. V8 said she would always bring in another CNA for assistance with the other CNA standing on the opposite side of the bed from V8. V8 said she didn't want to take any chances with R1 falling. On 08/23/2021 at 4:01 PM, V9 (CNA) said she would usually bring another CNA to help hold R1's legs while the other person was cleaning. V9 said It was easier and to prevent her from falling off the side of the bed. V9 said R1 was about halfway capable of turning herself over and was able to hold the side rail. V9 said she may have only changed R1 once without assistance from another CNA and V9 would have turned R1 away from V9, not toward her. A hospital X-Ray left hip radiograph dated 08/06/2021 showed R1 had an impacted fracture of the region of the left femoral neck with resultant migration of the left femur. A hospital Computerized Tomography (CT) dated 08/07/2021, showed R1 had an acute comminuted fracture of the base of the left femoral head and extending into the neck. There is impaction and anterior apex angulation. A hospital Operative Note dated 08/07/2021, written by V10 (MD/Medical Doctor Orthopedic Surgeon) showed R1 slid out of bed suffering an impacted left femoral neck fracture. Surgery was aborted and R1 was treated non-operatively due to R1's comorbidities and the inability to safely accommodate R1's size for surgery. On 08/24/2021 at 12:02 PM, V13 (Attending MD) said R1's fracture happened from falling out of bed. V13 said R1 had pretty much zero mobility on her own and would need to use the total body mechanical lift. V10 reiterated saying he was not aware of R1 complaining of hip pain prior to the fall, so I would think that the fall was the cause of the fracture. On 08/24/2021 at 1:19 PM, V14 (RN/V10's nurse RN) said according to V10, R1's fall caused the fracture, and the osteopenia would have been a factor in exacerbating it. V14 said V10 decided not to proceed with surgery due to R1's morbid obesity and underlying conditions. On 08/24/2021 at 11:08 AM, V12 (Assistant Therapy Director/Physical Therapist PT) said she recommended two people for assistance with rolling and changing even prior to R1's fall from bed. V12 said she would recommend two-person assistance because R1 was on an air mattress and it would be a safety concern. V12 said R1's movement was very restricted, she had a history of polio, and [CONDITION(S)]. R1 needed a lot of help for positioning and moving due to the air mattress and her size. V12 said even with the trapeze she would try to help with positioning, but she needed help with her lower extremities. R1 was very limited in mobility of her lower extremities, plus she had eversion (a condition of the foot being turned or rotated outward). V12 said R1's bed was in the high position and V12 does not recommend the bed being in the high position. V12 said she also felt the bed should be against the wall instead of being away from the wall due to a safety issue. V12 said from a therapy standpoint R1 should always have two people to assist with bed mobility and repositioning. V12 would always recommend the nursing staff to roll the resident toward the staff member, not away from them for safety concerns. On 08/24/2021 at 1:53 PM, V15 (Licensed Practical Nurse/LPN Restorative Nurse) said if it is recommended to use two people for bed mobility and positioning, then the staff should use two people. V15 said the staff should pull the resident towards them, not roll them away from the staff member because they wouldn't be able to stop them if the resident kept rolling. V15 said residents who are using an air mattress should always have two staff members to turn them in bed due to the slippery nature of the air mattress material and having only one sheet on it. V15 said, The air mattresses are just too slippery even for residents who can provide more assistance. The United States National Library of Medicine [MEDICATION(S)] Plus dated 10/09/2019, showed the following steps should be followed when turning a patient from their back to their side or stomach: Explain to the patient what you are planning to do so the person knows what to expect. Encourage the person to help you if possible. Stand on the opposite side of the bed the patient will be turning towards and lower the bed rail. Move the patient towards you, then put the side rail back up. Step around to the other side of the bed and lower the side rail. Ask the patient to look towards you. This will be the direction in which the person is turning. The American Congress of Rehabilitation Medicine Caregiver Guide and Instructions for Safe Bed Mobility dated 2017, included bed mobility refers to activities such as scooting in bed, rolling (turning from lying on one's back to side-lying), side-lying to sitting, and sitting to lying down. It also includes scooting to sit on the edge of the bed when preparing to stand or transfer. The instructions include to decide which side of the bed the patient should get out from based on their strength and position yourself to that side of the bed. The patient should always roll toward you not away from you. Patient safety included to assist the patient on their weaker side and if you are ever unsure, get needed help.

Based on observation, interview, and record review, the facility failed to ensure a resident who required a mechanical lift with two assist for transfers was transferred safely. This failure resulted in a resident sustaining a laceration which required sutures in a local emergency room . This applies to 1 of 3 residents (R1) reviewed for safe transfers in the sample of 4. The findings include: R1's Face Sheet showed she is [AGE] years old and was admitted to the facility on [DATE]. R1's January 25, 2020 Minimum Data Set (MDS) showed she was severely cognitively impaired and was totally dependent on the assistance of at least two persons for transfers. On February 28, 2020 at 2:05 PM, V5 RN (Registered Nurse) stated that on February 18, V7 CNA (Certified Nursing Assistant from a staffing Agency) came out of R1's room and said R1 was bleeding. V5 stated she saw R1 lying in bed with a left lower leg gash laceration. V5 stated R1's leg was visibly open and actively bleeding. V5 stated R1's wound was bleeding a considerable amount, and she called 911 because she was concerned about a hemorrhage and she did not think the bleeding could be controlled at the facility. On March 3, 2020 at 2:30 PM, V5 described the bleeding as like a faucet; not a drip, but continuous flowing. V5 stated V14 (RN, Wound Care Certified Nurse) came in to assist. On March 3, 2020 at 2:35 PM, V14 (RN, Wound Care Certified Nurse) described R1's laceration as a smooth slit. V14 stated she guessed the laceration was 0.4 to 0.5 centimeters deep, but blood was still inside R1's wound. V14 described R1's injury as a clean fresh cut with blood in the middle. V14 stated she investigated the incident at the time and she did not think R1 was bleeding before the transfer because there was no blood on the floor, on the leg pedal, or on the wheelchair. V14 stated if R1's injury occurred because her leg had fallen off her leg pedal, the scene would have been a bloody mess. R1's February 18, 2020 progress note from 2:01 PM showed .Vital signs were unable to be obtained at that moment due to urgency of stopping bleeding and paramedics approaching . Around 1:30 PM CNA notified nurse of laceration to patient's left leg after being transferred from wheelchair to bed . On February 28, 2020 at 1:35 PM (10 days after the injury), V6 (Wound LPN-Licensed Practical Nurse) removed the dressing from R1's left lower leg. On the outside of R1's mid-calf was a scabbed line with eight sutures. R1's February 19, 2020 Wound Assessment Details Report showed the laceration was nine centimeters long. On February 28, 2020 at 8:55 AM, V12 (R1's Daughter and Power of Attorney) stated R1 lived with her and her husband for two and a half years until R1 was hospitalized in mid-January for an infection. V12 stated because R1 was no longer standing and pivoting, she could not care for her any longer so she brought her to the hospital and then she came to the facility. V12 stated R1 was transferred by staff with a sit-to-stand lift when she was admitted , and Physical Therapy (PT) tried to work with her to stand and pivot. On February 28, 2020 at 10:05 AM, V17 (Physical Therapist) stated R1 had received therapy when she was first admitted to the facility, and R1 was discharged from PT on February 12, 2020 (eight days before her injury). R1's PT Missed Visit Details showed she had refused PT on February 5th, 6th, 11th, and 13th, and her February 14, 2020 PT Discharge Summary showed she was functioning at her maximum capacity and did not make any progress toward her set goals. V17 stated even when we were seeing (R1) we recommended a lift machine .(R1) was always a sit-to-stand lift or (full-body) lift. V17 added there's no way you can transfer R1 with one or two people. V17 continued R1 has never been NOT a mechanical lift of some kind. She is not capable .she has to follow commands, task segmentation .with her cognition, she can't solve. V17 stated if R1 was transferred with one person, there could be complications, stating it's unsafe .falls, skin tears, injuries . On February 28, 2020 at 1:35 PM, V20 (Occupational Therapist) stated R1 was changed from a sit-to-stand lift to a (full-body) lift the first week she was here. V20 stated R1 has no balance and it's not appropriate to make her stand. On March 3, 2020 at 9:15 AM, V7 (Agency CNA) stated she transferred R1 from her wheelchair to her bed by herself without a mechanical lift on February 18, 2020. V7 stated that on February 18, R1's pantleg was not wet (with blood) when she lifted R1's left leg up to remove the leg pedal prior to the transfer, nor did she see any blood on R1's clothes prior to the transfer. V7 stated when she transferred R1 to bed, she was facing her and turned R1 to R1's left to get her on the bed. V7 stated she kept the outside of R1's left leg braced with the inside of her own right leg, and then she moved her to the bed. V7 added she's not that heavy. V7 stated she had worked with R1 before, and she transferred R1 both times by having R1 grab V7 by her shoulders or waist and helping her stand. V7 stated R1 helped a little, but not as much as when I transferred her before. V7 stated when she lifted R1's legs into bed, she noticed blood on the white stripe on R1's left pantleg and the side of R1's white left sock. V7 stated blood was just coming out and started leaking all over the bed. V7 stated R1 may have bumped my leg. I can't say she didn't. V7 was asked how she knew how to transfer R1. V7 stated staff can usually tell at other facilities by a paper in the resident's closet or they can ask the nurse. V7 stated when she transferred R1 the first time by herself, a PM shift nurse had told her how. On February 28, 2020 at 10:15 AM, V15 (another Agency CNA) was asked how staff know how residents transfer. V15 stated staff have to ask a nurse if they don't know. V15 stated the facility does not have resident directions posted in the resident closets, and even if you work regularly, you don't know if something has changed because any changes aren't posted. Under Functional Status in R1's February 1, 2020 Nursing-Daily Evaluation assessment form (completed 17 days before R1's injury), it showed R1's transfer status is total dependence, she uses a mechanical lift, and needs the full body lift with two or more assist. R1's Activities of Daily Living (ADL) care plan (revised February 7, 2020) showed she requires assistance with transfers and other ADLs with a goal for R1 to be assisted as needed. R1's ADL care plan interventions do not include mention of a mechanical lift or how many assist are needed for her to transfer. The Tasks section in R1's Electronic Medical Record does not show how R1 should be transferred. R1's February and March 2020 Physician order [REDACTED]. On March 3, 2020 at 12:55 PM, V3 RN (Director of Nursing) verified R1's transfer status was not written anywhere and stated the facility does not have a policy related to resident trasnfers. At 3:20 PM, V3 stated she expects CNAs to transfer residents safely and expects them to connect with the nurse and the resident's care plan.

Based on interview, and record review, the facility failed to ensure a resident received physician-ordered narcotic pain medication. This failure resulted in R10 stating he was experiencing excruciating pain. This applies to 1 of 3 residents (R10) reviewed for pain in the sample of 12. The findings include: On (MONTH) 8, 2019 at 3:20 PM, R10 was sitting in a wheelchair in his room. R10's bilateral lower legs were wrapped in white gauze from just below his knees to his feet. The dressings were dated 10/8 and appeared to have a light brown drainage on the dressings. R10 said, I am having excruciating pain in my lower legs and my pain is eight out of ten on a scale of zero to ten. I did not receive my pain medication today. My legs have sores on them, and the pain is burning and painful all the way down to my feet. It's just terrible. A review of R10's MAR (Medication Administration Record) shows R10 did not receive the physician-ordered [MEDICATION NAME] 5/325 mg. on (MONTH) 8, 2019 at 10:00 AM and 2:00 PM. On (MONTH) 8, 2019 at 4:00 PM, V11 (ADON-Assistant Director of Nursing) said R10 is out of his [MEDICATION NAME]. The EMR (Electronic Medical Record) shows R10 was admitted to the facility in (MONTH) (YEAR). R10 has multiple [DIAGNOSES REDACTED]. R10's MDS (Minimum Data Set) dated (MONTH) 3, 2019 shows R10 is cognitively intact, and requires extensive assistance with bed mobility, transfers between surfaces, dressing, toilet use, personal hygiene, and bathing. R10 is frequently incontinent of urine and always continent of bowel. R10's POS (Physician order [REDACTED]. orally every 4 hours around the clock. The POS shows an order dated (MONTH) 27, 2019 for [MEDICATION NAME] (Concentrate) 20 mg/ml. Give 0.25 ml by mouth every 2 hours as needed for pain or shortness of breath. The POS shows an order dated (MONTH) 27, 2019 for [MEDICATION NAME] (Concentrate) Solution 20 mg/ml. Give 0.5 ml by mouth every 2 hours as needed for pain or shortness of breath. The POS also shows an order dated (MONTH) 19, 2019 for [MEDICATION NAME] Suppository 650 mg. Insert 1 suppository rectally every 4 hours as needed for pain/fever. The POS also shows an order dated (MONTH) 27, 2019 for Tylenol Tablet ([MEDICATION NAME]) Give 650 mg. by mouth every 6 hours as needed for fever or pain. R10's care plan for pain initiated on (MONTH) 29, 2019 shows R10 is at risk for pain related to impaired skin integrity, impaired mobility and is under the care of hospice. Interventions include Administering [MEDICATION NAME] as ordered. Review of (MONTH) 2019 and (MONTH) 2019 MARs (Medication Administration Records) and nursing progress notes shows R10 did not receive [MEDICATION NAME] as ordered due to the resident sleeping on: (MONTH) 13, 14, 15, 24, 25, 26 and 29 at 2:00 AM, and (MONTH) 4, 5, 6, 8, and 9 at 2:00 AM. The MAR indicated [REDACTED]. R10 did not receive the [MEDICATION NAME] 5/325 mg. orally due to the medication not being available at the facility on (MONTH) 16 at 10:00 PM, (MONTH) 17 at 2:00 AM, 10:00 AM, and 2:00 PM, (MONTH) 30 at 6:00 AM, 10:00 AM, 2:00 PM, 10:00 PM, and (MONTH) 1 at 2:00 AM, 10:00 AM, 10:00 PM, (MONTH) 2, at 2:00 PM, and (MONTH) 8 at 10:00 AM, 2:00 PM, and 6:00 PM. The MAR indicated [REDACTED]. The facility did not have documentation to show R10 was provided with the physician-ordered [MEDICATION NAME] 0.25 to 0.5 ml orally or the [MEDICATION NAME] 650 mg. for pain on (MONTH) 2, 2019 at 2:00 AM after complaining of 8 out of 10 pain. The facility did not have documentation to show R10 received [MEDICATION NAME] on (MONTH) 24 and 25 at 2:00 PM. R10's MAR indicated [REDACTED]. On (MONTH) 8, 2019 at 10:41 AM, V9 (Nurse) said regarding R10 I am pretty sure I gave the medication ([MEDICATION NAME]) because that's my job to give medications. A review of R10's (MONTH) 2019 MAR indicated [REDACTED]. R10's MAR indicated [REDACTED]. The controlled substance sheet for R10's [MEDICATION NAME] 5/325 mg. dated (MONTH) 23, 2019 through (MONTH) 29, 2019 does not show V9 documented the removal of a [MEDICATION NAME] tablet at 2:00 PM on (MONTH) 25, 2019 to administer to R10. On (MONTH) 9, 2019 at 9:45 AM, V14 (Pharmacist) said R10's refill of the [MEDICATION NAME] was ordered by the facility on (MONTH) 8, 2019 at 9:45 AM and delivered to the facility at approximately 6:45 PM the same day. V14 said the facility should not wait until the medication runs out to order the medication. V14 said the pharmacy usually sends 30 tablets of [MEDICATION NAME] at a time, but can send more medication to the facility if the nurse requests an increase in the number of tablets, preventing the facility from running out of the medication. V14 said, Without the prescribed pain medication, the resident will not have good pain control. On (MONTH) 9, 2019 at 10:41 AM, V15 (Hospice Nurse) said the order for R10's [MEDICATION NAME] shows to take 1 tablet by mouth every four hours around the clock. The order does not show to hold the medication while the resident is sleeping. V15 said the [MEDICATION NAME] medication should be given as ordered to prevent the resident from experiencing pain.

Based on observation, interview and record review the facility failed to prevent the development of pressure ulcer/ injuries for one resident and failed to treat the pressure ulcer for one resident as ordered. This applies to 2 of 3 residents (R42, R67) reviewed for pressure ulcer in the sample of 21. R42 developed two Stage 3 pressure ulcers to her right upper and lower back from a life vest wearable defibrillator. The findings include: 1. R42 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 6/11/19 at 10:00 AM, V4 (Wound Treatment Nurse) was observed for R42's sacral wound care. At 10:15 AM, after V4 finished treating R42's sacral pressure ulcer, V4 was requested to check the skin condition underneath R42's life vest wearable defibrillator. V4 stated the nurses were the ones who would be monitoring and checking the life vest. V4 turned R42, who was in bed, on her left side. The vest on R42's back was heavily stained with black substance. R42 stated she spilled coffee on herself about 3 days ago. R42 was alert and oriented x3. V4 removed the life vest, assessed the skin, and stated there were two pressure ulcers on the back and abrasions under both breasts which were not there previously. R42's entire upper back, the shape of the vest area was reddened. R42's chest area was also reddened. R42 stated that she informed staff that the vest was too tight and painful 4 or 5 days ago. V4 measured the wounds, cleansed them with normal saline and covered with foam dressing until treatment orders were obtained. The Wound Assessment Details Report done on 6/11/19 showed the following facility acquired wounds: Right lower back - pressure ulcer, Stage 3, measurements 0.80 cm (centimeter) x 1.0 x 0.10 cm. Light serous exudate. Right upper back - pressure ulcer, Stage 3, measurements 2.0 cm x 6.0 x 0.10 cm. Light serous exudate. Right breast - abrasion, measurements 3.0 cm x 8.0 cm Left breast - abrasion, measurements 4.0 cm x 2.5 cm The report showed R42's Braden Score as 10 (High Risk). On 6/12/19 at 10:50 AM, on a telephone interview with V19 (Attending Physician) stated R42 has the life vest wearable defibrillator due to cardiac arrhythmia when she was in the hospital. He saw R42 at the facility one month ago. V19 stated the staff should be checking the vest and skin condition 1-2 times daily to ensure the vest is operating properly and to prevent the development of pressure ulcer. The facility policy titled, Wound Care Program, (MONTH) 1, (YEAR), requires, 3. Prevention of skin breakdown. c. Inspection of the skin every shift with care for signs of breakdown. d. Inspection of the skin under devices used daily. 2. R67's MDS dated [DATE] section C for cognitive skills and section G for functional status showed that R67 is alert and oriented and totally dependent with grooming/hygiene and eating, in addition R67 also has limitation to both upper and lower extremities. R67's active care plan and physician order [REDACTED]. On 6/10 19 from 9:45 AM through 3:00 PM R67 was monitored every hour to an hour and a half. R67 was positioned in a semi upright position in her bed without any off loading to her bottom. On 6/10/19 at 12:03 PM, R67 was resting in bed in a semi-upright position, there was no offloading pillow under her bottom. V18 provided incontinence care to R67 who had a large bowel movement. R67's wound dressing which was dated 6/8/19 was detached from stage 4 pressure ulcer and was heavily saturated with wound discharge. After completing the care R67 was placed back to semi-upright position. On 6/10 19 at 01:16 PM V4 (Wound Care Nurse) and V5 (Physician) provided wound care to R67 who was in bed in semi upright position. V4 and V5 both stated that R67's wound dressing should be changed daily and as needed when it is soiled. After completing the wound care, R67 was placed back to semi-upright position with no offloading. R67's active care plan showed that she has stage 4 pressure ulcer to left buttock. R67's care plan interventions shows the following: Avoid positioning the resident on the left ischial tuberosity. Educate the resident and/or family/caregivers as to causes of skin breakdown, including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Monitor dressing daily to ensure it is intact and adhering. Report loose dressing to Treatment nurse. The resident needs assistance to turn/reposition at least every 2 hours, more often as needed or requested. R67 is a 2 person total assist for bed mobility and transferring.

Based on record review and interview the facility failed to ensure a resident is protected from mistreatment by another resident. This resulted in R17 experiencing threat for safety, R17 afraid of R13, and R17 underwent emotion distress. This applies to one of one resident (R17) reviewed for an allegation of mistreatment in the sample of 18 residents. The findings include: On August 20, 2015 at 12:15 PM, R17 stated R13 had come into her room during the night a few weeks ago and he was undressed at the bottom. R17 said R13 had come in her room before but she always told him to get out. R17 stated R13's room was across the hall from her room. I told the nurse's aide (CNA) about it and the aide said not to worry, he (R13) was probably disoriented. The aide confronted him though. But he came in anyway that night with no pants. (R17 stated she did not want to identify the CNA for fear of getting her into trouble. The aide is good worker.) R17 stated no one came in to ask her about the incident for at least a few days. It was E1 (administrator) who spoke with her and R17 said she told him in no uncertain terms what was going on. She was very emotional, scared and felt as a threat for her safety. R17 said after R13 came in partially naked, she barricaded herself in her room for a few nights using a chair under the door handle. She realized putting her chair against the door would interfere with the nurses work but had to do something. He (R13) stayed in the room across from her until he was discharged about two weeks later. On August 20, 2015 at 3:15 PM, R17 said she hadn't told her daughter about what happened until three days ago because she would be so upset. A review of the most recent MDS (minimum data set) dated June 5, 2015 shows R17 is alert and oriented with no cognitive deficits. Her [DIAGNOSES REDACTED]. E12 (social service aide and medical records) stated on August 20, 2015 at 12:50 PM on the morning of July 30, 2015 R17 looked very upset. A few minutes later, E12 got a chance to go to R17's room but when she attempted to enter after knocking, she found the door barricaded. R17 opened the door when she knew it was E12 who then asked R17 what was going on. R17 told her, There's this man who comes in my room at night. I don't know who it is. He was undressed last night. E12 said she was going to the morning meeting after that and reported what R17 had told her. E12 stated E1 (administrator and abuse coordinator), E2 (director of nursing) and E11 (social service director) had all been present at the meeting. E12 stated R17's door was barricaded the next morning also. E1 stated on August 20, 2015 at 3:45 PM he did not conduct an investigation into R17's allegation of abuse when he was informed on July 30, 2015 at the morning meeting. An investigation into R17's allegation of abuse was not submitted to the Department of Public Health. E1 stated he did speak with R17 regarding the situation and informed R17 the facility was aware of R13's wandering and the facility would monitor and redirect him. E1 said there was no documentation regarding this interaction or the stated interventions. E1 also stated R17 had said she did not feel sexually abused therefore he did not conduct an investigation. E1 attributed R13's behavior to confusion, not a deliberate act. Review of R13's BIMS (brief interview mental status) dated July 25, 2015 is 13, indicating intact cognition. E2 (director of nursing) stated on August 20, 2015 at 1:10 PM, R13 was an alcoholic who had been admitted to the facility for five days in June 2015. R13 was readmitted to the facility July 25, 2015 after decompensating at home from alcoholism, was admitted back to the hospital, then sent to the facility again for rehab where he remained until August 12, 2015 when he was discharged home again. E2 said he recalls E12 reporting in the morning meeting on July 30, 2015 R17 was extremely upset about R13's behavior toward her and had barricaded her door. E2 said he thought R11 (SSD) spoke with R17 that day. Nurse's note dated 7/30/15 at 8:36 AM states R17 reported to me this morning that (R13) has been either naked from the waist down or fully naked and entering her room at night. When asked why he was doing this he stated I don't know where my room is. I thought this was mine. The night shift nurse took a piece of of paper and wrote his name largely and taped it to the door. Even after this he is continuing to enter her room.

A. Based on record review and interview the facility failed to provide the necessary care and services to assist a resident (R31) who was choking on food . This resulted in R31 subsequently suffering a respiratory arrest and death. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ began on [DATE]. Although the immediacy was removed on [DATE], the facility remains out of compliance at a level 2 due to the need to evaluate the facility's training to staff, the effectiveness of the revised policies and procedures and their maintenance program to keep all emergency equipment in working order. Findings include: R31 was a [AGE] year old resident with [DIAGNOSES REDACTED]. R31 had lived in the facility since ,[DATE]. On the morning of [DATE], at approximately 8:15am, while eating breakfast, R31 started to choke. According to his tablemate (R32), he tried coughing it out and it didn't come out so he tried drinking some liquid ( milk) and kept trying to cough it up. Only the milk came up. He kept coughing. R32 got the attention of a dietary aide to come and help R31. The dietary aide (E15) saw that R31 was red in the face and having difficulty. Milk with some food particles was "spewing from his mouth." E15 said he patted him on the back. About 10 seconds later he told the nurse (E17) that R31 needed her help and she took over. E17 (RN) was interviewed on [DATE] and said that she encouraged R31 to keep coughing. Some liquid and food particles came up. E17 said that R31 was able to say : "I'm okay." After less than a minute, R31 was still coughing. At this time E17 asked E18 (CNA) to help her take R31 out of the dining room and back to his room. E17 said she was talking to him telling him to try and clear it again as they went. By the time they got to the room he was getting weaker. E17 stated that :" I tried to get E16(CNA) to do the [MEDICATION NAME] since she was bigger." R31 was still seated in the wheelchair while E16 attempted to reach around and do the [MEDICATION NAME]. E17 said that : "Got some liquid, some yellow and white food particles with saliva. Trying more was not helping. Didn't seem effective so I said lie him on the floor." R31 had "started loosing it, getting weaker and red in the face." E17 said that once R31 was on the floor, they started doing abdominal thrusts. E17 said she straddled R31 and did thrusts. E17 then said that she got E16 to continue the thrusts while she ran out to the crash cart and get the suction machine and told the pharmacy nurse to get E13 (nurse) for her, she needed help. During E17's interview, she was asked about looking into R31's mouth. E17 responded that: "I just tried to look and hope it would come out with thrusts." E17 was asked if she could do a mouth sweep. E17 said: "No, I would not do that." When E13 was interviewed, she stated that she never entered the room of R31, she only knew that she was asked to call 911 and she did. While E13 called, E3 the DON, (director of nursing) went to take an oxygen tank to the room and was told by "someone" that he was better, "he's pink and has a pulse." At this point E3 called E13 and told her to cancel the 911 call, R31 was good. E13 did as requested and then E3 went into R31's room and saw for herself "he did not look good and he was unresponsive and he was pale and bluish." E3 then said to recall 911. The fire department run sheet shows that they were dispatched at 8:32 am. On [DATE] a conference call was held with the responding fire department and paramedics (Z1,Z3-Z7). Z6 described the scene at the facility as it was observed upon their arrival. Z6 said: "They entered the facility and were directed to R31's room. On entering the room they saw 6 staff members in the room. No one was doing CPR. One staff (E17) was doing the [MEDICATION NAME] to R31 who was on the floor." Z6 was asked to evaluate the manner in which the [MEDICATION NAME] was being done. "It was not being done effectively as I observed it." Z6 continued :" The resident was pale. No movement, no pulse. There were two suction machines in the room by the head of the patient. Neither were in working order. There was a nasal cannula on the patient. Did not check to see if oxygen was coming through it." Z6 continued : "(R31) was checked for pulse. No pulse was felt. Chest compressions were started immediately. I tilted R31's head, opened his mouth and saw scrambled egg. I removed it doing a finger sweep. It was visible as soon as the mouth was open, it was about a spoonful of scrambled egg. Anyone trained to do CPR could've done the same thing." Z6 explained that they continued with compressions and ventilations with an Ambu bag. He said they got good chest rise. R31 was hooked up to the paramedics monitor and showed good oxygenation to the lungs. At this point Z6 said that he rechecked the mouth and used their suction equipment to get the rest of the egg out of the mouth. "Facility staff were working on their suction machine trying to get them to work." While compressions and ventilations were being done, a DNR (do not resuscitate ) order was presented. The monitor showed R31 to be in asystole, so the hospital medical control was contacted for a decision of whether to "run the incident as an arrest that involved choking or honor the wishes of a DNR. The order was given to honor the DNR and the resuscitative efforts were stopped. R31's time of death was pronounced by Z9 at 8:45am. Z1 interviewed E3 (DON) regarding the call to 911, then the cancellation. Z1 said that the dispatcher who had taken the call was very experienced and called Z1 to advise him of the situation. Z1 advised the dispatcher that he should go ahead and dispatch them and he would determine if anything was needed. So the team was dispatched. By the time they arrived, the facility had made another call for help to 911. Z1 stated that E3 told him that when she herself went into the room and observed R31 he had a bad color so she called the second time. Z6 said that he also asked E17 how long had R31 "been down"? None of the staff members, including E17, were able to give a definite time. Z6 estimated that based on the amount of time it takes to take out the truck once a dispatch order is received and when they arrived at least 7 ,[DATE] minutes had elapsed from notification to arrival. This does not count the time lost between the original call, the discussion between Z1 and the dispatcher and the actual dispatch order. The Patient Care Record from the ambulance run documents the "Estimated Time of Arrest" as greater than 20 minutes. Interview on [DATE], with the coroners office staff (Z8) provided the information that in addition to the fact that the paramedics had removed a golf ball size lump of egg (according to their report), the autopsy showed "egg of lesser amount in the trachea and lungs." Review of the employee files showed that at the time of the incident; E16, E17, and E14 had current CPR (cardiopulmonary resuscitation) certification, E4's certification had expired in April, 2013 and E15 had not been certified. R31's clinical record was reviewed as well and the [DATE] MDS (minimum data set) that evaluates a residents care needs showed that the section for functional status showed R31 to be in need of supervision while eating and set up help for the meal itself (i.e. cutting food, opening cartons...) R31 also had hand tremors and used weighted tableware and had been identified by staff and co-resident R32 as a fast eater. No careplan had been developed to address these needs at the time of R31's incident. The lack of effective and timely medical assistance by facility staff contributed to R31 suffering a respiratory arrest followed by [MEDICAL CONDITION] and death. On [DATE] the survey team confirmed through observation, interview and record review the facility took the following actions to remove the immediacy of the situation: 1. Education conducted with staff from nursing and ancillary departments on ,[DATE] - [DATE] covering the following areas: Mock Code Demonstration, Swallowing inservicing presented by SLP and performing CPR and the [MEDICATION NAME] performed by an outside CPR instructor. 2. Enhanced laminated signage was posted in prominent locations and dining areas that demonstrates the [MEDICATION NAME]. 3. House audit conducted of patients with swallowing difficulties and care plans reviewed to ensure they were reflective of the resident individualized needs. 4. Dining rooms are monitored by CPR certified staff at all meals. 5. An audit of the crash carts was implemented to ensure was in proper working order and properly stocked. B. Based on observation, interview and record review facility failed to provide necessary care and services to a resident with bilateral Nephrostomy tubes as documented in plan of care, physician orders [REDACTED]. This applies to 1 of 1 residents (R12), reviewed for Nephrostomy tube care in the sample of 18. Findings include; On [DATE] at 11:00 AM and 3:07PM, R12 observed in a low bed with bilateral Nephrostomy tube drainage bags lying directly on the floor. R12's bilateral Nephrostomy tubes were unsecured to skin (to prevent pulling out) and the site dressings were compromised ( edges rolled up and lifted away from the skin). The left Nephrostomy tube had thick sediment in the tubing. R12's bedside table with cups of fluids were out of R12's reach (not accessible). R12 was initially admitted to facility [DATE] from the hospital with [DIAGNOSES REDACTED]. R12's [DATE] hospital record includes; that on [DATE], bilateral percutaneous Nephrostomy catheters (8 french size), were surgically placed due to bilateral severe - massive hydro[DIAGNOSES REDACTED], proximal hydroureter with distal urethral obstruction. On [DATE] R12 diagnosed with [REDACTED]. R12's [DATE] physician orders [REDACTED]. Empty Nephrostomy tube drainage bags every shift and record. Secure Nephrostomy tube to skin to prevent pulling of tubes. Change Nephrostomy tube dressings and flush tubes with 10cc saline daily on evening shift. R12's current care plan included; - Nephrostomy tubes- assess urine clarity, color and character, secure tubing to residents flank to prevent pulling, encourage and evaluate fluid intake and hydration status, apply clean dressings to sites daily, monitor output and notify physician (MD) if any decrease in output. Keep drainage bags below the kidneys. - Fall risk = keep things in reach. On [DATE] at 10:30AM, E4 (ADON), stated that facility uses "Mosby's Skills for care of Nephrostomy tubes care and flushing," as facilities Nephrostomy tube care protocol. E4 also said that facility has no formal policy and procedure for Nephrostomy tube care and maintenance. R12's medical record contained a copy of this "Mosby's skills for Nephrostomy tube care and flushing" documentation and it included; - securing the tubing to the patients flank with tape ensures that no stress is placed on the Nephrostomy tube. Stress on the tube can result in accidental dislodgement of the tubing. - expected outcomes = urine output of 30 - 60cc per hour. R12's medical record contained no intake monitoring and outputs ranged between 0 to 60cc per 8 hour shift. On [DATE], at 11:00AM, E5 (long term care MDS nurse), stated " R2 is on Hospice and Hospice patients are only here for comfort measures and we don't do intake and outputs (I and O) on them. This morning ([DATE]), I called R12's attending physician and obtained orders to stop I and O monitoring and if the Nephrostomy tubes become dislodged , do not send to the hospital.

Based on observation, interview and record review the facility failed to perform comprehensive assessments and implement effective and timely interventions to prevent pressure ulcers or promote healing of pressure ulcers per facility protocol and plan of care for 2 of 3 residents reviewed for pressure sores, (R1 and R3) in the sample of 18 These failures resulted in R3's area of redness noted on admission worsening to an unstageable wound. It also resulted in R1 acquiring 2 different pressure ulcers in 17 days. Findings include: According to the medical record R3 is an [AGE] year old alert and oriented male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R3's admission skin assessment notes blanchable redness to the coccyx area. R3's Braden Scale for Predicting Pressure Sore Risk was a score of 18 (high risk for pressure sores). A nurse's note dated 06/14/13 listed an area of denuded skin to the coccyx area upon R3's admission. R3 was also complaining of loose stools at that time. On 07/07/13 nurses notes document blanchable redness to the coccyx. On pressure redistribution mattress and chair cushion as preventative measures. A wound assessment report dated 07/13/13 notes that a pressure ulcer was discovered to R3's sacral area on 07/10/13 that was not present upon admission. The wound was described as unstageable due to slough/eschar with a small amount of serous drainage. The measurements are documented as 1.0 cm (centimeters) length by 1.0 width by 0.10 depth with red, indurated surrounding skin. Although R3 was admitted with redness to the coccyx on admission of 06/12/13, his careplan notes a potential for skin breakdown with a later date of 06/19/13 as the date of onset. R3's careplan wasn't updated again until 07/13/13, 3 days after he was noted with an unstageable pressure ulcer. R3's treatment order was the only new intervention added to the careplan and an order for [REDACTED]. ulcer increased in size from the original measurements of 1.0 cm length by 1.0 cm width by 0.10 depth (on 07/10/13) to 1.5 cm length by 1.0 cm width by 0.1 cm depth (on 07/21/13). No new interventions are documented in the record after the assessment of 07/21/13. On 07/24/13, E10 (treatment nurse) was observed completing R3's dressing change. E3 measured R3's wound as 1.6 cm in length by 1.5 cm wide with no measurement of depth. These measurements show another increase in the size of the wound. As of 07/26/13 there are no new interventions in the record to help heal R3's pressure sore or prevent it from worsening. On 7/23/13 at 12:20pm and again at 3:20PM, R1 observed lying in bed, turned to her left side with the right heel sitting directly on the bed surface. R1's right posterior heel observed to have an un-dressed, 1cm un-blanchable dark purple area. R1 had a flat pillow under her thighs. R1's left leg is contracted approximately 90 degrees in hip and knee. R1 was readmitted to facility 5/30/13 with [DIAGNOSES REDACTED]. R1's 5/06/13 minimum data set assessment (MDS) and current care plan include document that R1 requires extensive assistance with bed mobility, activities of daily living and transfers. R1 is assessed as high risk for impaired skin integrity related to limited mobility, skin desensitized to pain or pressure related [MEDICAL CONDITION] left [MEDICAL CONDITION]. R1's 6/19/13 Braden's score was 12 = High risk for break down. This Bradon assessment documents that R1's mobility very limited, makes occasional slight changes in body extremity position but unable to make frequent or significant changes independently. Requires moderate to maximum assistance in moving . Skin care plan includes the following intervention to "Float heels off bed surface with pillows or specialty devices." On 7/24/13 at 10:15am, E10 (Wound treatment Nurse) stated, "We just found (R12) right heel deep tissue injury (DTI), wound today (7/24/13). I wasn't here (at the facility) yesterday (7/23/13). If nurses find a wound while I'm not here, they should assess and document it." R1's medical record documents the development of a stage 2 sacral pressure ulcer on 7/06/13 and a DTI to the right heel on 7/24/13. No documentation of the right heel wound on 7/23/13. On 7/24/13 at 1:30 PM, R1 observed, in bed A pillow was observed under the right calf and the left foot was resting on the pillow as well. The pillow was too thin to provide any discernable off-load of pressure to the heel-wound. E10 was also present. A review of the Care Plan finds that it includes instruction to use a pillow to raise the heels from the bed. Review of Nurses notes for past month finds no reference to lower extremity wound assessment or care.

Based on observation, interview and record review facility social services failed to assess, identify and provide timely interventions to address roommate problems. This failure resulted in the resident sustaining prolonged mental distress. This applies to 1 of 18 residents (R12), reviewed for social services in the sample 18. Findings include; R12 was initially admitted to facility 7/22/13 with [DIAGNOSES REDACTED]. R12 was under Hospice care. On 7/18/13, R12, had bilateral percutaneous nephrostomy catheters (8 french size), surgically placed due to bilateral severe - massive hydro[DIAGNOSES REDACTED], proximal hydroureter with distal urethral obstruction. R12 is under Hospice care due to her terminal status. On 7/25/13, at 11:00AM, E5 (long term care MDS nurse), stated that Hospice patients are only here for comfort measures and pain control. R12's plan of care includes to provide comfort, alleviate or control pain, management of multiple signs of the dying process and provide emotional / spiritual support. On 7/23/13 at 11:00AM, during initial tour with E7 (MDS nurse), R12 was observed in room 306, in bed and continuously crying. R12 stated that her roommate (R19), was very loud, yelling, singing and making noise throughout the entire night. R12 said "I was unable to sleep all night due to (R19's) yelling." R12 also said that when she complained about the noise to the night shift nursing staff, the staff responded by saying that R19 is always like this. On 7/24 and 7/25/13 R12 was observed in bed, with R19 as her room mate. On 7/25/13 at 10AM, R12 said "last night I did not get any sleep again, because of my room mates yelling." On 7/25/13, R12's medical records reviewed and failed to include any social service assessments or social service progress notes. On 7/25/13 at 11:30AM, E1 (Administrator), stated that R12's records do not contain a social service assessment or progress notes. R12's nurses notes include: - 7/22/13 11:15PM = admitted from hospital. Alert and oriented x 3 and able to make needs known to staff. - 7/23/13 5:47AM, R12 resident upset since she was not able to sleep well due to roommate's constant mumbling. Alert and oriented and able to make needs known. - 7/23/13 2:33PM, "Resident complains about her roommate, verbalized not able to sleep well during the night because roommate talks all night." - 7/24/13 11:16AM "Late entry for 7/23/13: Resident complained of inability to sleep all night due to roommate's near constant talking, singing, coughing. Resident will be moved to another room when a room is available in 1 - 2 days. - 7/24/13 4:04PM, R12 requested "please move her room. She seems worried that her roommate will start yelling again. Social service explained that she will be moved next week after the other room is repainted." On 7/25/13 at 11:30AM, E2 (DON), stated that on 7/25/13, R12 complained that she was unable to sleep the night before again due to roommates noise making. On 7/26/13 at 11:00AM, R12 observed new room. (new room assignment as of 7/25/13). When asked if her new room assignment was better, R12 stated "Happy Happy Happy! I'm blessed now and could not have gotten a better roommate than this new one. I'm so thankful." R12 had sleepless nights and mental distress of roommate assignment 2 of her 3 days in facility. Room change was not initiated until 7/25/13 after surveyor questioned staff about what facility was doing about her concern.

A. Based on observation, interview and record review, the facility failed to provide supervision and follow the fall policy to update care plan to prevent further falls. This applies to 1 of 6 residents (R9 ) reviewed for falls in the sample of 18. R9 was sent to the hospital on [DATE] due to a fall and which resulted in R9 sustaining a left hip fracture. Findings include: R9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R9 had left side weakness due to her diagnosis. Review of incident reports documented that R9 had the following falls on the following dates: 1. On 12/15/11 at 3:30 PM: CNA (Certified Nursing Assistant) reported to the nurse resident on floor -- upon entering room -- found on floor alert oriented X 3 -- ROM ( Range of Motion) good to right upper and lower extremities -- left sided paresis -- denies pain. 2. On 12/16/11 at 8:00 PM: Resident found on bathroom floor calling for help at 2000 (8:00 PM). Left elbow bleeding. Resident states she slightly hit her head on the wall. She indicated that she was trying to get off her wheelchair onto the toilet and fell . 3. On 12/28/11 at 11:21 AM: Nurse entered room the resident's and she was on the floor sitting up right next to bed with legs extended. Resident undid alarms she stated. Denies hitting her head. No change in LOC (level of consciousness). CNA and nurse used mechanical lift and put in w/c (wheel chair). Clip alarm intact. 4. On 01/16/12 at 6:15 PM: Resident found on floor in bathroom laying on left side with head against wall. Alarms were sounding. Stated she slightly hit her head. No change in LOC. Unable to move her left leg without pain. Swelling noted near hip. R9 was sent to hospital and this incident resulted with a left hip fracture. Preventive recommendation included. "Resident educated on not going to the bathroom or self transferring without assistance. Resident educated on use of a call light. Sensor alarm and floor mat alarm supplied to resident due to decreased safety awareness. Clip alarm remains in effect. Staff educated to toilet resident prior to meal and immediately after meals. Staff educated to provide 15 minutes checks due to decreased safety awareness." 5. On 03/26/12 8:10 PM: Resident found on Left side and Left arm near her roommates bed. Alarm was sounding. Resident c/o (complained of) left arm pain at wrist and left elbow. Noted purple discoloration on left wrist. Also L (left ) knee and R (right) toe abrasion. No other preventive measures were implemented. The alarms have not prevented any fall episodes. 6. On 05/18/12 6:45 PM: CNA heard an alarm at 6:45 PM, CNA responded and observed Resident sitting in front of the toilet. Resident stated she got up by herself and fell and hit left arm to the trash can. Sustained small discoloration to her left arm and 2 small hematomas. No intervention added. 7. On 05/20/12 1:10 PM: CNA heard an alarm and again observed resident on the floor face down. Resident stated that she got up from the toilet and was trying to wash her hands at the sink and lost her balance. Abrasion to right elbow noted. Cleanse with wound cleanser and covered with steri strips. No intervention added. 8. On 05/22/12 11:00 AM: Informed by CNA-- assisted to floor after leg giving away-- Alert oriented x 3. C/O ( complained of ) pain to left hip region-- No redness no swelling. Skin tear on her right forearm. Per facility's investigation: This fall occurred while resident was standing being transferred by staff to toilet. Resident fell while staff was lowering resident's (R9) pants. Facility did not assess whether gait belt was in use. The incident report recommended the use of mechanical lift transfer. 9. On 06/25/12 at 9:25 AM: Slipped in BR (bathroom) while being assisted from toilet to wheelchair, struck left temple on towel bar. No intervention added. On 08/28/12 at 8:45 AM, R9 was observed propelling her wheel chair in her room to the bathroom. E 17 (CNA) transferred R9 to the toilet without using gait belt. E17 was observed with gait belt on her (E17) waist. E17 was asked why she did not use the gait belt while transferring R9. E17 said that R9 was in a hurry to use the bathroom. On 08/28/12 at 1:30 PM, R9 was observed in bed with call light not within reach. E11 (Nurse) was informed and found the call light was under the bed. On 08/29/12 at 3:00 PM, R9 was observed up in wheel chair. E22 ( Hair Dresser ) was pushing R9 with no foot rest and both feet were dangling. E11 was informed and told E22. It was also observed that R9 did not have the non skid pad on the wheel chair. E21 (CNA) was also interviewed on 08/29/12 at 1:00 PM regarding the incident dated 06/25/12. E21 stated, "I was assisting R9 from toilet to wheel chair and R9 bumped her head on the towel bar and then slipped in the bathroom. E21 was asked if she was aware how many assist does R9 needed to transfer. E21 stated, "I thought 1 assist." E21 was asked again how would she know if R9 needed 1 assist. E21 said that there is a care plan behind R9's closet door. Resident care plan behind R9's closet door documented to transfer R9 with 1- 2 assist with gait belt and with quad cane. Apply anti skid pad. Care plan intervention included: - Keep equipment within reach (call bell, phone). - Encourage resident to ask for assistance with transfer. - Continue to monitor risk factor. - Orient resident to environment and how to call for assistance. The above care plan was not followed. E11 stated on 08/29/12 at 3:00 PM, "the staff are aware that R9 is high risk for falls. R9 uses one arm to propel her wheel chair and the other arm had stroke." E11 stated that R9 is confused at times and probably when you asked R9 the date, R9 won't know." Minimum Data Set Assessments ((MDS) dated [DATE] showed R9 was dependent on staff for bed mobility, transfer and toilet use. R9 has poor safety awareness due to moderate cognitive impairment. MDS dated [DATE], 12/20/11 and 4/27/12 documented that R9 needed extensive assistance with 2 persons physical assist. Review of nurses notes dated 12/29/11, 1/24/12, 3/31/12, 4/09/12 and 5/21/12 documented that R9 is alert with confusion, forgetful and with poor safety awareness. B. Based on observation, record review and interview the facility failed to provide a safe environment by having water and beverage dispensed in resident contact locations at high temperatures, without facility supervision. This has the possibility to affect 1 resident (R5) in the sample of 18 and 5 residents (R19, R20, R21, R22 and R23) in the supplemental sample. These residents were identified by the facility as ambulatory and confused as well as other residents who have an unsteady gait or may be unable to read, understand or follow precautionary instructions affixed to the beverage machines by their manufacturer. Findings include: The facility has a main dining room and a small dining room on both the Providence and Heritage wings. In the Providence dining room there is a coffee and hot water dispenser. This dispenser is positioned for self service with the hot water and coffee spigots at about four feet from the floor. There is no physical barrier to prevent access to the dispenser. At 2:00 pm on August 27, 2012, the water from this machine was tested with a dial stem thermometer. The temperature was found to be 165F.. The machine has a precautionary sign, affixed by the manufacturer, that reads, "Caution, Hot Liquids. Release handle when cup is 3/4 full". At this time the lunch meal service had ended. There were no staff members in the Providence dining room, but residents were present. The thermometer was immediately calibrated, using the ice water bath method and was found to be reading accurately. The Heritage dining room has a similar machine that dispenses coffee. At about 2:10pm, the temperature of the coffee was checked with the same dial stem thermometer and was found to be 170F..Again, residents were present, but not staff. At 2:15pm, on August 27, 2012, E1 (Administrator) was asked about the beverage dispensers. E1 said he was aware of the coffee and hot water dispensers. He also said the facility had an unwritten policy to turn off the machines after meal times when staff was not present and residents could not be supervised. E1 was asked for a list of residents who were ambulatory and confused. He presented a facility roster with R5, R19, R20, R21, R22 and R23 highlighted.

Based on Observation, Record Review and Interview the facility failed to supervise one ( R1 ) resident in a sample of three residents reviewed for accidents. This failure resulted in R1 receiving severe burns to both inner thighs and groin area. This had the potential to affect any of the 93 residents in the facility who consume hot beverages. Findings include: R1's face sheet documented that R1 is a [AGE] year old resident ,who was admitted on [DATE]. R1's Medication Administration Record ( MAR ) for November 2011 documented that R1 had [DIAGNOSES REDACTED]. The facility Resident Incident Report dated 11/15/11 at 06:45am documented ," resident (R1 ) was sitting at a table in the TV area with a cup of coffee. A therapist notified staff.. Resident was taken to her room to have pants changed, upper thighs near groin were light pink and cold to the touch. Over time the resident began to develop scattered blisters in the groin area and down the left inner thigh. scattered fluid filled blisters in the inner groins and thighs." During an investigation of the incident, the facility was unable to determine how R1 obtained a cup of coffee. At 12:15pm on 11/29/11 E5, Physical Therapist, during an interview, stated, " about 06:45am I came to the common area to pick up another resident for therapy. R1 was also my resident. I noticed a trail of brown liquid leading to R1. This liquid was brown, and did not appear to contain cream or milk. R1 was looking at me. I noted that her pants were wet. At this time there were only two residents in the common area. ( it is about 15 feet from the nursing station). The view from the station is slightly obscured by the birds. There were no other staff members in the common area. I do not know how long R1 had been drinking the coffee or how long it had been spilled on her pants." On 11/29/11 at 12:35pm E6, Nurse was interviewed regarding R1's spilling of coffee. She stated that this was the first time she had cared for R1. " I was told that R1 was wet and there was coffee on the floor. The Certified Nursing Assistant ( CNA ) placed R1 in bed. I assessed her. I noted that her inner thighs were pink. No other injuries were noted. The night nurse was sitting at the nurses' station and did not see R1 spill her coffee. I did not see anyone give her coffee. After breakfast on 11/15/11 R1 developed blisters on the burned areas. I notified the physician and received orders for treatment of [REDACTED]. On 11/15/11 at 02:45pm during an interview with E4, Certified Nursing Assistant, regarding R1's spilling her coffee in her lap, E4 stated," After naps, therapy, or other activity, R1 can be very confused. She will get up and wants help right away. R1 needs supervision during meals. We put her drinks where she can reach them and make sure her food is cut up. We then tell her the location of each food on her plate." On 11/15/11 at 10:40am E1, The Director of Nursing stated, " Over the two days following the spill incident blisters "popped " up. Now R1's burn areas are red-open and have a" little" slough. E2, the Directory of Food Service in an interview on 11/29/11 at 11:20am stated, " We keep hot beverages at 170-180 degrees Fahrenheit.(F ). It is our policy and procedure to keep them at a target range of 180 degrees F. On 11/15/11 the temperature of the coffee in the coffee dispenser was about 175 degrees F. A physician's orders [REDACTED]. This order was canceled on the same day per request. On 11/29/11 at 02:00pm R1's burns were observed with E3, Treatment Nurse. Large burn wounds were noted to bilateral inner thighs and the groin area. These wounds had thick brownish-tan slough covering the majority of the wounds. The Right Thigh wound measured 8.1 centimeters (cm ) x 12.5cm; the left thigh wound was 12.5cm x 13.6cm; the groin wound measured 0.9cm x 3cm. R1 stated that she got these injuries from spilled coffee. She could not remember when or what happened that caused the accident. R1's Minimum (MDS) data set [DATE] assessed the area of eating as requiring limited assistance with one person helping her. R1's current Care Plan dated with onsets between 11/16/11-11/18/11. A problem of vision impairment. R1 was legally blind. This is to be addressed by telling R1 what food items are on her tray and where they are. The assessed problem of potential weight loss has the approach of providing supervision at meals when consuming hot beverages. The problem of feeding self documented that R1 is legally blind and has poor safety awareness. An Activity Assistant note dated 11/16/11 documented," Resident ( R1) greeted this staff member. She stated, " I'm blind... all I can see the outer shape of your pretty hair... Resident needs redirection, assistance and cues to complete activity - related tasks...."