Every finding on record at Alta Rehab at Fairmont

Based on observations, interviews and record review, the facility failed to ensure that one dependent resident (R10) received timely incontinence care. The facility also failed to timely provide activities of daily living (ADL) care to ensure that two residents (R1 and R3) did not have excessive facial hair and/ or debris in beard.These failures have affected three (R1, R3, R10) of four residents reviewed for quality of care which resulted in R10 experiencing psychosocial harm becoming tearful and expressing her feelings of upset and frustration for delayed incontinence care.Findings include:A. On 4/1/26 at 10:45 am, R10 observed in bed and was upset and tearful. R10 stated the following, I (R10) need to bed changed. I had a bowel movement, and I don't remember the last time that I was changed. It makes me upset when I have to wait so long just to be changed. It's not right. There are times that I've ripped off my brief because I have to wait so long to have it changed. I don't want to get bed sores. Sometimes I want to leave this place.At that time, V9 (RN/ Registered Nurse) stated that she would inform V10 (CNA/ Certified Nurse Assistant) to come and clean R10 once she (V10) is done helping another resident.On 4/1/26 at 11:40 am, V10 entered R10's room to clean her (R10) and stated the following to R10, I (V10) was with another resident. I apologize for the delay.On 4/1/26 at 12:05 pm, V10 stated that she had informed V2 (DON/ Director of Nursing) that she (V10) needed help with team two residents and was told by V2 that there was nothing that she (V2) could do.R10 is [AGE] year old with diagnosis including but not limited to: Adult failure to thrive, hypotension, type 2 diabetes mellitus with hyperglycemia, Atherosclerotic heart disease of native coronary artery without angina pectoris and iron deficiency anemia.R10's Functional Abilities assessment (Section GG) dated 3/18/26 documents, R10 is dependent on staff for toileting hygiene. R10 has a BIMS (Brief Interview of Mental Status) score of 8, which indicates moderately impaired cognition. B. On 3/31/26 at 4:00 pm, R1 was observed lying in bed with his eyes closed and filled with a wet, green substance. R1 had a full beard and mustache with hair covering his mouth, also with debris in his beard and mustache. V6 (RN/ Registered Nurse) stated the following, It looks like food in his (R1's) beard. I told the ADON (Assistant Director of Nursing) that he needs a shave.R1 is a [AGE] year old with diagnosis including but not limited to: Other reduced mobility, aphasia, abnormalities of gait and mobility, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side.R1's Functional Abilities assessment (Section GG) dated 2/6/26 documents, R1 is dependent on staff for all personal hygiene (including shaving). C. On 4/1/26 at 10:47 am, R3 was lying in bed and observed with facial hair above her lips, below her lips and on her chin. R3 was asked if she wanted to be shaved and replied, Yes, I look ugly.On 4/1/26 at 10:47 am, V9 (RN) stated the following, I would say that her (R3's) facial hair is unkempt. She definitely needs to be shaved.R3 is a [AGE] year old with diagnosis including but not limited to malignant neoplasm of endometrium, other reduced mobility, aphasia following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side.R3's MDS (Minimum Data Set) dated 2/10/26 documents R3 has a BIMS (Brief Interview of Mental Status) score of 15, which indicates cognitively intact.R3's Care Plan documents the following: R3 has an ADL (Activities of Daily Living) self-care/mobility performance deficit. On 4/1/26 at 1:53 pm, V8 (ADON/ Assistant Director of Nursing) stated the following, It is not acceptable for a resident to wait one hour to be changed. This is how residents develop infections such as UTIs (urinary tract infections) and skin breakdown. I would say that a resident shouldn't wait no more than 10-15 minutes to be changed. The CNA is usually caring for another resident.On 4/2/26 at 1:30 pm, V16 (FNP/ Family Nurse Practitioner) stated the following, If an incontinent resident that wears a brief has a bowel movement in their brief, some possible effects of not cleaning the resident within an hour could be: Skin rashes, UTI, skin and breakdown. Also, the patient could be affected mentally because they cannot do for themselves. Women residents with facial hair (beard and mustache) can be affected as well if they are alert and oriented.Facility policy titled Bathing (1/31/18) documents the following purpose, to ensure residents' cleanliness to maintain proper hygiene and dignity.Facility policy titled Incontinence Care (4/20/21) documents the following purpose, to prevent excoriation and skin breakdown, discomfort and maintain dignity.Facility policy titled Shaving Male and Female Residents (undated) documents the following purpose, to provide cleanliness, comfort and improved morale.

Based on interviews and record review, the facility has failed to provide restorative services to two contracted residents (R8 and R9). This failure has affected two of four residents reviewed for restorative services.Findings include:On 3/31/26 at 3:30 pm, R8 was noted with flaccid legs and contracted hands; R9 was noted with flaccid legs and right arm and legs. No splints or adaptive equipment were noted at that time.At that time, Both R8 and R9 were asked about restorative services.On 3/31/26 at 3:32 pm, R8 stated, No one has ever come in and help me with exercises. I (R8) would like to feed myself, but I can't because my fingers are too stiff, and I was told that I would receive some adaptive utensils. They still haven't ordered the utensils for me.At that time, R9 stated, They (staff) come and put my arm splint on sometimes but not every day. No one comes in and exercises my legs or arms. I wish I could do it myself. I don't want to become even stiffer.R8 is a [AGE] year old with diagnosis including but not limited to: Personal history of transient ischemic attach and cerebral infarction, age-related osteoporosis with current pathological fracture, chronic pain and heart failure.R8's MDS (Minimum Data Set) dated 2/13/26 documents R8 has a BIMS (Brief Interview of Mental Status) score of 15, which indicates cognitively intact.R9 is a [AGE] year old with diagnosis including but not limited to: hemiplegia and hemiparesis following cerebral infarction, muscle weakness, unspecified arthritis, reduced mobility and type 2 diabetes mellitus without complications.R9's MDS dated [DATE] documents R9 has a BIMS score of 14, which indicates cognitively intact.On 4/2/26 at 11:27 am, V15 (Restorative Registered Nurse, RN) stated the following, I am the only restorative nurse at this time. I have seven restorative aides. We don't have a set schedule of residents to see daily. If anyone had been referred by therapy, I update the residents. I assess the residents and create a program based on the therapy recommendations. If someone needs adaptive equipment, I notify V1 (Administrator) to order the equipment. I didn't know that R8 needed assistance with feeding. I did assess her but didn't know that she needed adaptive utensils. The purpose of the adaptive equipment such as feeding utensils is to maximize the resident's abilities so that they would be more independent. I don't have a QA (Quality Assurance) program to monitor the restorative program. Residents on the restorative program should exercise three to six times per week according to their program.On 4/2/26 at 12:20 pm, V12 (Restorative Aide) stated that she is assigned to R8 and R9 for restorative services; however, V12 could not recall the last time that she performed Passive Range of Motion (PROM) with R8 or R9.On 4/2/26 at 1:30 pm, V16 (FNP/ Family Nurse Practitioner) stated the following, Restorative services can prevent contraction and muscle stiffness. It is important to preserve the current functional levels.R8's Therapy to Nursing Recommendations dated 2/21/25 documents the following restorative recommendations: PROM of upper and lower extremities (BUE {bilateral upper extremities}/ BLE {bilateral lower extremities}); and Active Range of Motion (AROM) on a cycle machine.R8's Restorative Observations dated 2/13/26 documents the following: the IDT (Inter-disciplinary Team) believes R8 would benefit from AROM (Active Range of motion), PROM and Bed mobility exercises.R8's Care Plan documents the following: R8 has the potential for decline in assisting with bed mobility related to decreased endurance, decreased mobility and age-related osteoporosis; staff will cue resident to complete bed mobility exercises six times per week.R9's Therapy to Nursing Recommendations dated 5/9/25 documents the following recommendations: Passive Range of Motion exercises of bilateral upper and lower extremities.R9's Restorative Observations dated 2/11/26 documents the following: the IDT (Inter-disciplinary Team) believes R8 would benefit from PROM (Passive Range of motion) and Bed mobility exercises.R9's Care Plan documents the following: R9 has limited range of motion related to a history of CVA (Cerebrovascular Accident) and weakness; staff will conduct PROM and monitor for pain; staff will monitor progress of ROM (Range of Motion).Facility policy titled Restorative Nursing Program (dated 1/4/19) documents the following purpose, to promote each resident's ability to maintain or regain the highest degree of independence as safely as possible.

Based on interview and record review, the facility failed to follow physician order for bi-level positive airway pressure (BIPAP) use and ensure continuous positive airway pressure (CPAP) / BIPAP device (mask, tubing and exhalation port) were cleaned daily. These failures affected five (R1, R2, R3, R4 and R6) of six residents reviewed for Improper nursing care. The findings include:R1's admission record or face sheet shows initial admission date on 2/13/26 with diagnoses not limited to Acute and chronic respiratory failure, Unspecified systolic (congestive) heart failure, Acute embolism and thrombosis of unspecified deep veins of right distal lower extremity, Morbid (severe) obesity with alveolar hypoventilation, Morbid (severe) obesity due to excess calories, Type 2 diabetes mellitus with unspecified complications, Body mass index [BMI] 70 or greater, Cognitive communication deficit, Other reduced mobility, Chronic kidney disease stage 2 (mild), Autistic disorder. MDS (Minimum Data Set) dated 2/16/26 shows R1's cognition was intact.On 3/15/26 At 10:52AM Observed R1 sitting up on wheelchair by his bedside with oxygen inhalation via nasal cannula at 3Lmin, alert and oriented x 3, verbally responsive. Stated he is using BIPAP at bedtime around 9-10pm. Observed bi-level positive airway pressure (BIPAP) machine at bedside. R1 stated he was admitted to the facility in February for rehab. He said the following morning after he was admitted to the facility, he passed out and was transferred to the hospital. R1 stated the BIPAP mask was not put on his face, so he passed out the following morning. He was only using O2 via nasal cannula during that night. R1 stated BIPAP machine was available at bedside, but he did not get it, or mask was not applied on him. He stated he was admitted to the hospital for 1 day and came back again to the facility to continue rehab. R1 stated he was supposed to get BIPAP machine every nighttime around 9 - 10pm. He stated the nurse was supposed to put on BIPAP mask at nighttime. R1 stated he became responsive or came back to life in the hospital. R1 stated he is using BIPAP machine for breathing. R1's admission Summary notes dated 2/13/26 show in part: R1 is bariatric weighing 486 lbs. (pounds). R1 is on BIPAP at night.V18's (Nurse Practitioner) notes dated 2/14/26 show in part: the provider received a call from the nurse on duty reporting that R1 was not waking up and his respirations had increased to 32. The provider returned to the bedside and evaluated R1. R1 was found to be requiring increased oxygen, with a respiratory rate of 34. R1 is not waking up. Given his extensive history of acute respiratory failure with recent ICU (Intensive Care Unit) admission, the decision was made to transfer R1 out for acute evaluation via 911.R1's Nurses Note dated 2/14/26 shows in part: R1 is admitted with diagnosis: acute respiratory failure.R1's Nurses Note dated 2/17/26 07:00 shows in part: LATE ENTRY - this is for 02/14/2026 0730H: 1915H - Received R1awake in bed, saturating well at 94% in 3 lpm via nc (nasal cannula), not in respiratory distress. On 2/14/26 at 130H - placed R1 on BIPAP machine with medium size mask, saturating between 91-94%. At 0615H - Transferred R1 to nc at 3 lpm. R1 noted to be very sleepy while providing care. Rechecked spO2, noted between 89-90%. increased rate to 4 lpm and patient saturated between 94-96%.R1's physician order dated 2/13/26 shows order not limited to: BiPAP via full mask at bedtime for sleep apnea. R1's health record does not show that BIPAP machine was provided or put on at bedtime ON 2/13/26.R1's February and March MAR (Medication Administration Record), TAR (Treatment Administration Record) and progress notes do not reflect that BIPAP device (mask, tubing and exhalation port) were cleaned daily.Care plan dated 2/16/26 shows in part: R1 has altered respiratory status/difficulty breathing r/t (related to) Sleep Apnea. BiPAP via full mask with 15/5 50%.R1's hospital records dated 2/14/26 show in part: R1 with past medical history of obesity, Obstructive Sleep Apnea (OSA), Acute respiratory failure, recent pneumonia presents today with AMS (Altered Mental Status) from nursing home. R1 only opened eyes to his name and was otherwise unresponsive. Final diagnoses: Acute respiratory failure, Mobid obesity.R2's admission record or face sheet shows initial admission date on 1/3/26 with diagnoses not limited to Sepsis due to methicillin susceptible staphylococcus aureus, Obesity class 3, Body mass index [BMI] 70 or greater, Type 2 diabetes mellitus with unspecified complications, Resistance to multiple antibiotic, Epilepsy, Diabetes insipidus, Hypothalamic dysfunction, Hidradenitis suppurativa, Retention of urine, Hypothyroidism, Personal history of traumatic brain injury, Major depressive disorder, Bilateral primary osteoarthritis of knee. MDS dated [DATE] shows R2's cognition was intact.On 3/15/26 At 11:12AM Observed R2 resting in bed, alert and oriented x 3, verbally responsive. He stated he has been residing in the facility since January 2026 for therapy. Observed BiPAP machine at bedside. He stated he has been using BIPAP machine on and off since February. He stated he prefers the nasal pillow mask instead of face mask. R2 stated face mask is not really a good for him. R2's POS (Physician Order Sheet) dated 3/15/26 shows order not limited to Devices: BiPAP ON at 2100; OFF at 0700. Please assist the patient with setting up the BiPAP device each night and removing it each morning.R2's February and March MAR (Medication Administration Record), TAR (Treatment Administration Record) and progress notes do not reflect that BIPAP device (mask, tubing and exhalation port) were cleaned daily.R2's care plan dated 2/26/26 shows in part: R2 have altered respiratory status/difficulty breathing r/t Sleep Apnea. Devices: BiPAP ON at 2100; OFF at 0700. R3's admission record or face sheet shows initial admission date on 07/27/2025 with diagnoses not limited to Acute on chronic diastolic (congestive) heart failure, Essential (primary) hypertension, Radiculopathy cervical region, Morbid (severe) obesity due to excess calories, Body mass index [BMI] 70 or greater, Chronic obstructive pulmonary disease, Obstructive sleep apnea. MDS dated [DATE] shows R3's cognition was intact.On 3/15/26 At 11:27AM Observed R3 resting in bed, on moderate high back rest, with air mattress, alert and oriented x 3, verbally responsive. Observed CPAP machine at bedside. R3 said she is using her CPAP machine on and off for about a month. She said when she is using it, usually she cannot sleep, it is not comfortable. R3's POS dated 3/15/26 shows active order not limited to Auto CPAP 6-18cm H2O at bedtime for sleep apnea.R3's February and March MAR (Medication Administration Record), TAR (Treatment Administration Record) and progress notes do not reflect that CPAP device (mask, tubing and exhalation port) were cleaned daily.R3's care plan dated 10/28/25 shows in part: R3 have altered respiratory status / difficulty breathing r/t Sleep Apnea. Auto CPAP 6-18cm H2O.R4's admission record or face sheet shows initial admission date on 02/10/2026 with diagnoses not limited to Metabolic encephalopathy, Chronic obstructive pulmonary disease, Body mass index [BMI] 50.0-59.9, Morbid (severe) obesity due to excess calories, Type 2 diabetes mellitus, Anemia, Primary generalized (osteo)arthritis, Other fracture of right femur, Chronic kidney disease stage 3, Chronic atrial fibrillation, Spinal stenosis, Neuromuscular dysfunction of bladder, Chronic systolic (congestive) heart failure, Essential (primary) hypertension, Methicillin resistant staphylococcus aureus infection, Resistance to multiple antimicrobial drugs. MDS dated [DATE] shows R4's cognition was intact.On 3/15/26 At 11:36AM Observed R4 resting in bed, alert and oriented x 3, verbally responsive. Observed continuous positive airway pressure (CPAP) machine at bedside. R4 said she has been using CPAP machine at bedtime around 10pm. She said the nurse is putting the mask on her face and checking the water level. Stated she never seen any staff cleaning the device, she said the nurse would only wipe excess water on the mask, but they never cleaned it. R4 stated the device was cleaned months ago at least 2-3 months ago. She stated she did not see staff cleaning it. She said the device is supposed to be cleaned at least every week, but it has never been done. R4's POS dated 3/15/26 shows active order not limited to: CPAP via (full/nasal) mask with setting 5-20cm at bedtime for sleep apneaR4's February and March MAR (Medication Administration Record), TAR (Treatment Administration Record) and progress notes do not reflect that CPAP device (mask, tubing and exhalation port) were cleaned daily.R6's admission record or face sheet shows initial admission date 5/12/22 with diagnoses not limited to Unilateral primary osteoarthritis right knee, Morbid (severe) obesity due to excess calories, Body mass index [bmi] 70 or greater, Chronic pulmonary embolism, Chronic respiratory failure with hypoxia, Sleep apnea, Lymphedema, Major depressive disorder, Vitamin d deficiency, Gastro-esophageal reflux disease. MDS dated [DATE] shows R6's cognition was intact.On 3/15/26 At 11:41AM Observed R6 resting in bed on moderate high back rest, alert and oriented x 3, verbally responsive. Observed CPAP machine at bedside. He said sometimes he is using CPAP; he last used it about 3 days ago. R6 said the nurse has been putting it on every night around 10pm but he is removing the device at times. Stated he doesn't sleep at night at times when CPAP machine is on. He stated he is Breathing okay at night without using CPAP. R6's POS dated 3/15/26 shows active order not limited to: CPAP at bedtime for sleep apnea.R6's February and March MAR (Medication Administration Record), TAR (Treatment Administration Record) and progress notes do not reflect that CPAP device (mask, tubing and exhalation port) were cleaned daily.R6's care plan dated 4/8/25 shows in part: R6 has altered respiratory status/difficulty breathing r/t Sleep Apnea. CPAP at bedtime for sleep apnea. On 3/15/26 At 12:23PM V12 (CERTIFIED NURSING ASSISTANT / CNA) stated he was the assigned staff when R1 was transferred to the hospital on 2/13/26. He said when he rounded R1 at the beginning of the shift around 7am, he was sleeping in bed. V12 stated he can't remember if there was BIPAP machine going on. He stated that R1 was using oxygen. V12 said R1 just looked at him but did not say anything. V12 stated he passed breakfast tray in R1's room and checked on R1 again and he did not eat. V12 stated R1 just keep looking at him and was not saying anything, he was off and called the nurse (V6) right away. On 3/15/26 At 12:42AM V6 (REGISTERED NURSE / RN) stated that on 2/14/26, taking report from the previous nurse - V17 (night shift nurse). R1 was new admit, he was admitted on [DATE]. On 2/14/26 At around 7:30am, R1 was sleeping in bed with oxygen on via nasal cannula. BIPAP machine was not on. She said R1 was very sleepy, will wake up and then go back to sleep right away. V6 said she referred R1 to NP (V18) who was in the facility at that time. She stated R1 was seen by NP in R1's room. R1 was transferred to the hospital as ordered.On 3/15/26 At 1:48PM V15 (REGISTERED NURSE / RN) stated she was the nurse who admitted R1 on 2/13/26, R1 had an order for BIPAP machine at bedtime. She stated R1 is alert and oriented x 3-4, verbally responsive, not sleepy or lethargic. V5 stated R1 wanted his BIPAP machine on at around 8-9PM. She said nurse should be documented in the progress notes or signed in TAR / MAR after BIPAP was given or administered. She said standard nursing practice if it was not documented then it was not done.On 3/15/26 2:47PM V2 (DON / Director of Nursing) stated CPAP / BIPAP machine - nurses are expected to have setting order and consistent with hospital records. She stated nurses should follow the doctor's order. Administer the CPAP / BIPAP at bedtime as ordered, however residents have the right to refuse. When resident is refusing - reeducate and encouraged maybe later. V2 stated once BIPAP / CPAP machine was administered or provided, should be signed in the TAR / MAR or general progress notes. She said proper documentation should be done to validate that they followed the order or provided or BIPAP / CPAP to residents. V2 stated general nursing standard of practice, if it was not documented it was not done. She said BIPAP / CPAP device, hose or mask should be cleaned daily as stated in the policy. She said expectation to place it in MAR / TAR or progress notes to validate it was done. She said the purpose of BIPAP / CPAP helps or support with sleep apnea, it will help residents' breath. V2 stated residents could possibly have an apnea episode if not wearing BIPAP / CPAP machine at bedtime. She said the purpose of cleaning BIPAP / CPAP device for infection control to prevent infection.On 3/15/26 At 3:14PM V18 (Nurse Practitioner / NP) stated she can recall R1. It was on 2/14/26, she saw R1early morning around 7:15am - 7:30am was waking up and was not wearing BIPAP mask. She said it took a bit of time to wake him up, R1 tired and wanted to sleep. V18 stated, around 8-9am, the nurse alerted her because staff are having a hard time keeping him awake, R1 will wake up but then go back to sleep right away. She said she then evaluated R1 at bedside. V18 sated R1 was not waking up, stay asleep. R1 was sent out to hospital for further evaluation due to change in mental status. She said R1 was breathing fast, Tachypnea = 28 -32/min, R1 was on oxygen via nasal cannula and oxygen level was above 94%. V18 stated in her clinical judgement, if BIPAP machine was not provided as ordered at bedtime, it could potentially cause a change in mental status but there could be a lot of reasons as well. She said given R1's chronic condition or comorbidities such as chronic respiratory failure, CHF, OSA and he is morbidly obese could lead also to change in mental status. She said it is important to clean CPAP / BIPAP device to maintain pulmonary hygiene to prevent infection.On 3/16/26 At 8:44AM V17 (RN) stated she was working with R1 on 2/13/26, 7pm to 7am shift. She stated she received R1 alert and oriented x3, verbally responsive. V17 stated it was endorsed to her that R1 is using BIPAP at bedtime as ordered. She said she was busy that night and was able to put on BIPAP mask on R1 after 1AM. V17 said she used medium size mask, it fits on him. She stated R1 is morbidly obese, there was a large size available, but she opted to use medium size. She said she did not try to fit or use the large size mask for R1. V17 said there were 3 mask sizes available at bedside - small, medium and large and she used medium size for R1. She said in the morning, R1 was responding but not that much, R1 would look at her and close his eyes. She said R1 would respond to Verbal stimuli but it's hard for him to stay awake, he was very sleepy. V17 said at around 4am, R1 was awake so she removed BIPAP mask and changed him with oxygen via cannula. She stated R1, was sleepy and went back to sleep with oxygen via NC. V17 stated she started med pass then around 5AM, V16 (CNA) asked her for help with R1. She observed R1 slow to respond but responding to verbal stimuli, not staying awake, very sleepy. She said she switched back R1 from oxygen to BIPAP. Stated she raised R1's head of bed, Saturation checked = 90-92% with 0xygen then switched to BIPAP and saturation picked up to 96-97%. V17 said she removed BIPAP mask after 6am then oxygen via cannula was administered. V17 stated maybe R1 can't remember that BIPAP mask was put on 2/14/26 after 1AM because he was sleeping already around that time. She said R1 was slow to respond, breathing was okay early morning of 2/14/26. V17 said BiPAP mask was put on after 1 AM until around 4:30AM when he was switched to oxygen via nasal cannula. On 3/16/26 At 9:15am V19 (R1's PHYSICIAN) stated he saw R1 on day of admission and he is supposed to get BIPAP nightly. Stated given R1's BMI greater than 70, morbidly obese - typically would use large size BIPAP mask. V19 said the nurse should check the mask's seal, if it fits well or has a good seal. V19 stated if BIPAP machine was not put on at bedtime, it could potentially lead to change in mental status, but it could be that R1 was discharged too early from the hospital. V19 stated probably change in mental status would keep happening until R1 will lose weight. He said we don't know for sure what was the cause of R1's altered mental status. He stated R1's CO2 (carbon dioxide) is chronically high. V19 stated R1 would benefit with large size mask, comfort wise - large would be helpful and would have a good seal. V19 said short amount of time around 4 hours of BIPAP use could potentially lead to R1's change in mental status but R1's had prolonged intubation period in the hospital, R1 has Chronic medical condition such as CHF, obesity, OSA, are other factors that lead to his change in mental status.Facility's CPAP / BILEVEL policy dated 8/2017 shows in part: CPAP - provided continuous positive airway pressure (CPAP) to airways to spontaneously breathing residents. Delivered via circuit to nasal mask, full face mask or nasal prongs. BIPAP/BILEVEL - provides CPAP but allows for different pressures on inhalation and expiration. PURPOSE: To augment resident breathing. To treat residents with sleep disorders, obstructive sleep apnea, to correct arterial hypoxemia, to decrease work of breathing. To avoid tracheostomy and / or mechanical ventilation. To decrease atelectasis. CPAP / BIPAP must be ordered by the physician and initially set up by a respiratory therapist. Verify physician's order in the resident's chart. CPAP / BIPAP mask, tubing, and exhalation port should be cleaned daily or as needed.

Based on observation, interview and record review the facility failed to ensure ordered scheduled medications were administered for one resident (R2). This failure affected one resident out of three residents reviewed for medication administration.Findings include:R2's medical diagnoses include but are not limited to type 2 diabetes mellitus with diabetic autonomic (Poly) neuropathy, heart failure, major depressive disorder, anxiety disorder, presence of cardiac pacemaker.R2's Minimum Data Set, dated [DATE] has a Brief Interview for Mental Status score of 15, indicating R2's cognition is intact.R2's care plan dated 11/15/25 documents in part, I have Diabetes Mellitus diet manage, Insulin dependent.Diabetes medication as ordered by doctor.R2's care plan dated 11/15/25 documents in part, I am at risk for decreased cardiac output R/T (related to): atrial fib, congestive heart failure, hyperlipidemia, hypertension, pacemaker malfunction.Administer medications as orders and observe for side effects and effectiveness.On 12/08/25 at 12:20pm surveyor observed R2 being fed lunch by CNA (Certified Nursing Assistant).On 12/08/25 at 12:42pm R2 stated that she has not received any medication yet. R2 stated that she is a diabetic and has orders to have her blood glucose checked three times a day and is to be given insulin with each meal. R2 stated that she has not had her blood glucose checked all day, nor has she been given any insulin.On 12/08/25 at 12:58pm V3 (Registered Nurse/RN) stated that she had not given R2 any of her morning medications. V3 stated that R2 is a diabetic and R2 should have a blood sugar check twice on her shift. V3 stated that R2 should have had her blood sugar checked at 8am and 11:30am. V3 stated that she had not checked R2's blood sugar or given R2 any insulin. V3 stated that it is important for R2 to have her blood sugar checked because R2 is a diabetic and takes long and short acting insulin.R2's progress note dated 12/08/25 at 3:30pm documents in part, Accucheck (blood glucose) not tested. Notified V16 NP (Nurse Practitioner). Medication not given. Notified V16 NP.R2's medication administration audit record shows that V3 (Registered Nurse/RN) gave R2 insulin injection on 12/08/25 at 3:30pm. R2 physician order dated 11/10/2025 documents in part, Humalog Mix 75/25 KwikPen.Inject 16 units subcutaneously one time a day related to Type 2 diabetes mellitus with diabetic autonomic (Poly) neuropathy 9am.R2's physician order dated 01/08/2025 documents in part, Accu check before insulin, Breakfast, Lunch and Bed time before meals.R2's physician order dated 10/12/2025 documents in part, Lyumjev KwikPen.inject 7 units subcutaneously one time a day related to Type 2 diabetes mellitus with diabetic autonomic (Poly) neuropathy. One time a day with lunch if blood glucose > (greater than) 150.R2's physician order dated 12/05/2025 documents in part, Metoprolol Succinate ER (extended release) oral tablet extended release 24-hour 25 MG (milligram) give 2 tablet by mouth one time a day related to unspecified atrial fibrillation.R2's physician order dated 10/17/2025 documents in part, Furosemide tablet 40 MG give 1 tablet by mouth two times a day related to heart failure.R2's physician order dated 02/04/2025 documents in part, Eliquis oral tablet 5 MG. Give 1 tablet by mouth two times a day for blood thinner.On 12/10/25 at 1:39pm V2 (Director of Nursing) stated that medication should be given an hour before or an hour after the scheduled medication time. V2 stated that 9am medications can be given up until 10am. V2 stated that she has educated the nursing staff about time sensitive medications. V2 stated that blood pressure medication should be given every twelve hours because it is a time sensitive medication. V2 stated that it is expected that nurses follow doctor's orders. V2 stated that it is not okay for the nurse to not check a resident's blood glucose if the resident has an order for the blood glucose to be checked. V2 stated that R2's insulin should have been administered at the time of R2's meal. V2 stated that if medications are not administered on time, the physician should be notified so that a medication time adjustment could be made. V2 stated that if medications are missed and the times are not adjusted, the resident could become overmedicated.On 12/10/25 at 12:24pm V16 (Nurse Practitioner) stated that she was informed that V3 (RN) did not administer insulin as ordered. V16 stated that V3 did not inform her that R2's morning medications were not given to her. V16 stated that it is expected that all medications are given when they are due. V16 stated that if a medication is not given, it can cause a reverse action. V16 stated that if insulin doses are skipped, it can harm the resident if they are eating 100% of their meals.Facility's undated policy titled Medication Administration General Guidelines documents in part, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration) .Administration: 9. A schedule of routine dose administration times is established by the facility and utilized on the administration records. 10. Medications are administered within 1 hour before or after scheduled time, except before, with or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. 11. Medication designed to be administered over a 24-hour period are scheduled accordingly. In these cases, an order for twice daily, for example, shall be interpreted as every 12 hours.Documentation (including electronic): 7. If an electronic MAR (medication administration record) system if used, specific procedures required for resident identification, identifying medications due at specific times, and documentation of administration, refusal, holding of doses, and dosing parameters such as vital signs and lab values are described in the system's user manual.Facility's job description titled Registered Nurse (RN) dated 05/02/2017 documents in part, Summary: the RN is responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing to ensure that the highest degree of quality care is maintained at all times. Essential Duties And Responsibilities: Complete and file required recordkeeping forms / charts upon the resident's admission, transfer and / or discharge. Receive and transcribe telephone orders from physicians and record on the Physician's Order form. Chart nurse's notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to the care. Prepare and administer medications as ordered by the physician.

Based on observation, interview and record review, the facility failed to follow food item labeling practices to ensure there are no outdated food items in the kitchen for resident consumption. This failure has the potential to effect 141 residents that receive food from the kitchen.Findings include:9/9/25 at 9:23 AM, conducted initial tour of kitchen with V40 (Dietary Manager)Observed in milk cooler #1:-one carton of Thickened Lemon Flavored Water, not sealed, with no Opened date-one carton of Thickened Lemon Flavored Water, not sealed, with Opened date 8/29/25. V40 stated the flavored water is kept one week after unsealing.Observed in reach-in refrigerator:-three salad bowls labeled with prep date 9/7/25 and use by date 9/14/25-two salad bowls labeled with prep date 9/6/25 and no use by date-one salad plate with prep date 9/6/25 and no use by date-three salad plates with prep date 9/7/25 and use by date 9/14/259/10/25 at 1:07 PM, V43 (Cook) stated we have to put the open and use by date on kitchen items for resident safety. Salads should be used within three days. Other items seven days. After three days salad can get slimy, brown and no good. Residents should never get expired foods because of possible food poisoning, sickness.9/10/25 at 1:14 PM, V40 (Dietary Manager) stated V40 prefers the salads to be made daily and kept no longer than three days. It is important to label correctly so old food is not given to the residents and to describe the food. Dating the items tell when the item is to be trashed. If residents are given old food, there is potential for the resident to get food born illness. The facility has one resident that takes honey thick water.Facility policy Storage Periods, Use-By Guidelines, no date, reads in part: Food should be stored properly and used within the appropriate time period to ensure safe and high-quality food is served. The Use-By Guidelines-Posted should be used to determine a use-by date when labeling opened or unopened food that must be used within a certain time frame (i.e. not manufacturer use by dates). Foods with a manufacturer's use-by date should still require an opened-on date once the item is opened. Expired food items should be disposed of.

Based on observation, interview, and record review, the facility failed to a) perform hand hygiene before and after having direct contact with residents and ensure necessary equipment are maintained to carry out an effective infection control program for five (R14, R55, R58, R140 and R147) of five residents reviewed for infection control b) ensure that its staff follow proper personal protective equipment (PPE) protocols for one (R99) out of five residents reviewed in a sample of 29. The findings include: On 9/9/25 at 9:44 AM During medication administration observed V6 (Agency LPN / Licensed Practical Nurse) checked R58's BP (Blood Pressure) = 120/59, PR (Pulse Rate) =77/minute and administered medications to R58. V6 did not perform hand hygiene before entering / exiting R58's room, and after direct contact with R58. Standing BP device was not cleaned /disinfected / sanitized after R58's use. On 9/9/25 at 9:54 AM Observed V6 donned gloves and checked R140's BP = 133/46; PR =71/minute using the same Standing BP device used with R58. V6 did not perform hand hygiene before entering, exiting R140's room, donning and doffing of gloves, and after direct contact with R140. Standing BP device was not cleaned /disinfected / sanitized after R140's use. On 9/9/25 at 10:05 AM Observed V6 donned gloves and checked R147's BP =104/67; PR = 83 using the same standing BP device that was not sanitized or disinfected after R58 and R140's used. Observed V6 checked R147's Blood Sugar = 212. V6 removed gloves and did not perform hand hygiene and wore gloves again. V6 did not perform hand hygiene before entering / exiting R147's room, donning and doffing of gloves, and after direct contact with R147. Standing BP device was not cleaned /disinfected / sanitized after R147's use. On 9/9/25 10:20 AM During medication administration, R14's room with door signage indicated EBP (Enhanced Barrier Precaution). V28 donned PPEs (Personal Protective Equipment) gloves and gown without performing hand hygiene. V28 entered R14's room and administered medications to R14. V28 removed PPEs without performing hand hygiene. V28 did not perform hand hygiene before entering / exiting R14's room, donning and doffing PPEs, and after direct contact with R14. On 9/9/25 At 10:31 AM Observed EBP door signage on R55's room. V28 donned gloves and gown without performing hand hygiene. V28 checked R55's BP = 183/65, PR = 57/MIN Temperature = 98.1F and Oxygen saturation = 98% at room air. V28 did not sanitize / disinfect / clean standing BP device used for R55. V28 was not observed perform hand hygiene before and entering R55's room and direct contact with R55. On 9/11/25 At 9:18 AM V2 (Director of Nursing / DON) stated staff is expected to perform hand hygiene when entering and exiting resident's rooms and direct contact with resident to prevent nosocomial infection / spread of infection. V2 said reusable medical equipment such as BP, and Pulse oximeter and oxygen saturation should be sanitized, cleaned or disinfected every after use or in between in resident's use to prevent cross contamination or spread of infection. Surveyor attempted to request policy for reusable medical equipment such as BP, Thermometer, Pulse oximeter to facility but was not able to provide. V1 (Interim Administrator) and V2 (Director of Nursing / DON) said no policy for such. Facility's Hand hygiene policy dated 7/30/24 showed in part: Examples of when to perform hand hygiene: At room entry. Before exiting room. Before and after having direct contact with a patient's intact skin (taking a pulse or blood pressure. Facility's Infection prevention and control program dated 11/28/17 showed in part: All facility personnel are required to routinely wash hands. The facility shall assure that necessary equipment are maintained to carry out an effective Infection Control Program. On 09/09/2025 at 11:21 AM, CDC (Centers for Disease Control and Prevention) enhanced barrier sign outside of R99's bedroom door and PPE (personal protective equipment) supplies in a bin outside of R99's room. On 09/09/2025 at 11:31 AM, V9 (Certified Nursing Assistant) noted applying gloves, removing R99's blanket, not wearing gown. Despite this surveyor informing V9 that the surveyor will step out since the surveyor knows that V9 will need to gown up and gather supplies. Observed R99 with a disposable chuck, a flat sheet, and a brief that was not placed properly on R99. This surveyor stepped outside of R99's room and did not observe V9 don on proper PPE as V9 closed the bedroom door. V10 (Certified Nursing Assistant) opened door to throw soiled linen in a bin a few steps away from R99's room only wearing gloves, both V9 and V10 were not observed wearing a gown. As V10 opened and closed R99's door, V9 is not wearing a gown while changing R99's linen. V10 stated that she is new and is an orientee. V10 stated I was just picking up the dirty briefs and dirty linen. I threw the gloves inside dirty cart and now heading back inside the room. V10 stated I didn't provide care to R99, I just asked V9 if she needed anything else. V10 stated that she will be washing her hands after she finishes helping V9. V9 opened R99's room door and asked V10 if she can provide V9 with a clean hospital gown for R99. V9 observed not wearing a gown, only gloves. On 09/09/2025 at 11:44AM, V9 (CNA) stated that she has completed providing ADL (activities of daily living) care to R99. V9 said that she provided the following care to R99, I cleaned him, changed his sheets, washed his face again, hands. V9 stated that she didn't wear a gown because V9 was already in there. V9 stated I didn't wear it; I should have been wearing one. V9 stated that the importance of wearing proper PPE (personal protective equipment is for infection control. On 09/09/2025 at 3:01 PM, V2 (Director of Nursing) stated that enhanced barrier is the biggest one or most often used one in the facility. V2 stated because anyone that has foley catheters, intravenous (IV), urostomy tubes, gastrostomy tubes, anything that we are worried the residents getting them infected, requires to wear a gown and glove when engaging with the patient such as touching the patient. CDC (Centers for Disease Control and Prevention) enhanced barrier precaution sign reads in part providers and staff must also: wear gloves and a gown for the following high-contact resident care activities. Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting. R99's active physician order set documents in part enhanced barrier precautions for chronic wound. R99's active physician order set documents in part enhanced barrier precautions for dialysis catheter, Gtube (gastrostomy tube). Facility document dated 5/7/24 documents in part Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities, especially when care is being bundled: providing hygiene, changing linens, changing briefs or assisting with toileting.

Based on observations, interviews and record reviews, the facility failed to (a) properly date opened multi-dose insulin for three (R7, R126 and R137) residents, and (b) ensure multi-dose eye drops were properly stored at appropriate temperature for two (R35 and R67) from 4 of 8 medication carts and 1 of 2 medication rooms inspected for medication storage and labeling. The findings include: On n [DATE] at 11:26AM Team 4 Medication cart inspected with V25 (Registered Nurse / RN) and observed the following: R137's multi dose LANTUS insulin was opened with no open date. Pharmacy label showed once opened refrigerate or not discard after 28 days. R35's unopened multi dose Latanoprost eyedrop was kept inside the medication cart. Pharmacy label showed: Refrigerate unopened, store opened at room temperature discard after 6 weeks. R67's unopened multi dose Latanoprost eyedrop was kept inside the medication cart. Pharmacy label showed: Refrigerate unopened, store opened at room temperature discard after 6 weeks. V25 said once insulin was opened it should be dated to know when to discard. She said Unopened Latanoprost eyedrop should be refrigerated as it is indicated in the pharmacy label. On n [DATE] at 11:43AM Team 1 medication cart inspected with V27 (Licensed Practical Nurse / LPN) and observed the following: R7's multi-dose dose Lantus insulin pen was open with no date. Pharmacy label showed: Once opened store at room temperature for 28 days. R126's multi-dose dose Lantus insulin pen was open with no date. Pharmacy label showed: Once opened store at room temperature for 28 days.V27 said insulin once opened should be dated and discarded after 28 days.On [DATE] At 9:18AM V2 (Director of Nursing / DON) stated nurses should follow recommendation from the pharmacy for proper storage of medication. She said if the medication needed to be refrigerated then it should be kept in the right temperature. V2 said if medication is not properly stored at right temperature potentially the effect of the medication could be altered, or the potency of the medication could be affected. V2 said nurses should date insulin once opened because insulin is only good for certain days. She said if insulin is not properly dated could potentially give expired medication to the resident. V2 said Lantus insulin once opened is good for 28 days and should be discarded. R7's POS (Physician Order Sheet) dated [DATE] showed active order not limited to: Lantus solution pen injector 100unit/ml inject 32 units subcutaneously at bedtime. R35's POS dated [DATE] showed active order not limited to: Latanoprost ophthalmic solution instill 1 drop in right eye in the evening. R67's POS dated [DATE] showed active order not limited to: Latanoprost solution instill 1 drop in both eyes at bedtime. R137's POS (Physician Order Sheet) dated [DATE] showed active order not limited to: Lantus solution 100unit/ml inject 36 units subcutaneously two times a day. Facility's storage of medications policy (undated) showed in part: Medications are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. Medications requiring refrigeration are kept in a refrigerator at temperature between 36F - 46F. Certain medications or package types such as multiple dose injectables vials, ophthalmic, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. Facility's reference guide - medications with shortened expiration dates dated [DATE] showed in part: Lantus vial - once opened store below 30. Product expires 28 days after the first use or removal from refrigerator whichever comes first. Lantus pen: once opened, do not refrigerate. Store at room temperature. Product expires 28 days after the first use or removal from refrigerator whichever comes first. Latanoprost: store unopened bottles under refrigeration (36F - 46F). Once opened, product may be stored at room temperature for 42 days.

Based on interview and record review, the facility failed to complete the Quarterly Minimum Data Set (MDS) assessment using the Centers for Medicare Medicaid (CMS) specified Resident Assessment Instrument (RAI) process within the regulatory timeframe for 1 (R80) of 1 resident reviewed for quarterly resident assessment in a sample of 29.On 09/11/2025 at 12:56PM, V22 (Minimum Data Set (MDS)/Care Plan Coordinator) stated the purpose of the MDS is to describe the resident and give a picture of the care a resident will receive. V22 stated the MDS is submitted to CMS (Centers of Medicare Medicaid) every quarter (every 92 days) or more frequently if the resident has experienced significant change.V22 stated R80's ARD (Assessment Reference Date) was completed late and further stated assessment should be completed within 14 days from the ARD. V22 stated that timing completion of the MDS assessments are based on the RAI manual.The facility's RAI Version 3.0 Manual dated October 2019 page 2-17 titled RAI OBRA-required Assessment Summary indicates that Quarterly (Non-Comprehensive) MDS assessment should be completed no later than 14 days from the ARD.Assessment final validation report dated 7/24/2025 showed Message: Assessment completed late. Assessment completion date is more than 14 days.

Based on observations, interviews and record reviews, the facility failed to ensure a medication error rate of less than 5% for three (R55, R58 and R147) of five residents with 12 errors for 35 medication administration opportunities. This resulted in a medication error rate of 34.29%. The findings include:On 9/9/2025 at 9:44AM Medication administration observation conducted with V6 (Agency Licensed Practical Nurse / LPN). Observed V6 prepare and administer the following medications to R58: Guaifenesin 400 MG (milligrams) 1 TabletJanuvia 50 MG 1 TabletClopidogrel 75 MG 1 TableNifedipine 60 MG Extended Release 1 TabletIron ferrous gluconate 27mg 1 TabletEliquis 5 MG 1 Tablet Observed R58 take prepared medications by mouth.R58's POS (Physician Order Sheet and MAR (Medication Administration Record) showed medication orders not limited to: Mucinex cough and chest congestion oral capsule 10-200mg give 1 capsule by mouth two times a day at 9AM and 9PM. Ferrous sulfate 325 MG (65 Fe) give 1 tablet by mouth two times a day at 8AM and 8PM.Observed medication errors due to wrong dose for Mucinex and Ferrous sulfate. On 9/9/25 at 10:04 AM Observed V6 (Agency LPN) prepared and administered the following medications to R147: Ferrous fumarate 325 MG 1 Tablet. Senna 1 tablet Aspirin 81 MG chewable 1 Tablet Losartan potassium 100 MG 1 Tablet. Nifedipine 90 MG Extended Release 1 Tablet. Insulin lispro 200 UNT/ML Pen Injector 5 UnitsObserved V6 injected insulin to R147's right side of the abdomen and R147 took prepared medications by mouth. R147 POS and MAR showed medication orders not limited to: Senna plus twice a day give 1 tablet by mouth two times a day at 8AM and 8PM. Nifedipine 90 MG Extended Release give 1 tablet by mouth two times a day at 9AM and 9PM. HUMALOG Kwik pen inject 5 units subcutaneously with meals at 8AM, 12PM and 5PM.Observed medication errors due to wrong time for the following medications: Senna, Nifedipine, Insulin Humalog.On 9/9/25 At 10:31am Medication administration observation conducted with V28 (LPN). Observed V28 prepared and administered the following medications to R55: Sertraline 50mg 1 tabletLinzess 72mcg 1 tabletPolyethylene glycol 1 capful mixed with waterAllopurinol 100mg 1 tabletAspirin EC 81mg 1 tabletDocusate Sodium 100mg 1 tabletMagnesium oxide 400mg 1 tabletProtonix 40mg 1 tabletRena Vite R1x 1mg 1 tabletSenna plus 1 tabletHydralazine 50mg 1 tabletSpironalactone 50mg 1 tabletCarvedilol 25mg 1 tabletNifedipine ER 60MG 1 TabletMetolazone 2.5mg 1 tabletLosartan 100mg 1 tabletObserved R55 took prepared medications by mouth.R55's POS (Physician Order Sheet and MAR (Medication Administration Record) showed order not limited: Docusate sodium 100 MG Oral Capsule [Colace] two times a day at 9AM and 5PM. Pantoprazole 40 MG Delayed Release Oral Tablet give 40mg by mouth two times a day at 9AM and 5PM. Senna oral 8.6mg give 1 capsule by mouth two times a day at 9AM and 5PM. Hydralazine hydrochloride 50 MG Oral Tablet give 1 tablet by mouth three times a day for hypertension at 8AM, 12PM and 8PM Carvedilol 25 MG Oral Tablet give 1 tablet by mouth two times a day at 9AM and 5PM. Nifedipine 60 MG Extended Release Oral Tablet give 1 tablet by mouth two times a day at 9AM and 5PM. Furosemide 80 MG Oral Tablet give 1 tablet by mouth two times a day at 9AM and 5PM.Observed medication errors due to wrong time for the following medications Docusate sodium, Pantoprazole, Senna, Hydralazine, Carvedilol, Nifedipine. Furosemide 80 MG was omitted or was not given during medication administration. On 9/11/25 At 9:18AM V2 (Director of Nursing / DON) stated nurses are expected to follow Medication administration policy by giving medications in a timely manner. She said nurses have 2-hour window one hour before and one after the ordered time. V2 said nurses should follow 5 R's (Right resident, route, dose, time, medication) in medication administration. She said if a nurse is not following doctor's order for the right time and dose in giving medication it could have a negative impact to the resident. V2 said for example Blood pressure medication was not given at the ordered time, could potentially lead to hypertensive crisis and trip to the hospital. She said If insulin was not given in a timely fashion, hyperglycemic incident could occur and potentially lead to a trip to the hospital. V2 said if medication dosage was not followed, potentially the resident could not receive therapeutic effect of the medication.Facility's administration procedure for all medications dated 8/2020 showed in part: Medications will be administered in a safe and effective manner. At a minimum, review the 5 rights at each of the following steps of medication administration. Check the MAR for the order

Based on observation, interview and records review, the facility failed to protect privacy for one (R101) resident of six residents reviewed in a sample of 29. R101's current face sheet documents R101's diagnosis to include but not limited to: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, alcoholic cirrhosis of liver without ascites, adult failure to thrive, dysphagia, oropharyngeal phase. R101's Brief Interview for Mental Status (BIMS) dated 08/22/2025 documents R101 has BIMS score of 6/15, indicating R1 has severe cognitive disability. On 09/09/205 at 12:00PM, R101 was observed wearing a wrist band from a nearby hospital on his left wrist that documented his name, age, gender, date of birth .On 09/09/2025 at 12:02PM, V14 (Registered Nurse-RN) observed R101's wrist band and stated R101 came back with it from a recent hospital visit. V14 stated the wrist band should have been removed when R101got back to the facility because the wrist exposed R1's personal information; full name, age, date of birth , and gender, and anyone can see the information on the wrist band. V14 stated this was a HIPAA (Health Insurance Portability and Accountability Act) violation. On 09/11/2025 at 10:50AM, V2 (Director of Nursing-DON) V2 stated R101 when come back from the hospital, the wrist band from the hospital should have been removed to protect R101's privacy because the wrist band showed R101's identifying private information such as date of birth , age, name and gender and was exposed where anyone could see R101's personal information which is a HIPAA concern. Policy titled Dignity dated 4-23-18 documents: -Place labels on each resident in a way that is conspicuous and respects his or her dignity.

Based on observation, interview, and record review the facility failed to obtain a physician order, develop plan of care and determine if self-administration of medication was appropriate for one (R52) of one resident observed with medication at bed side table in a sample of 29. The findings include:R52's admission record showed initial admit date on 7/26/2024 with diagnoses not limited to End stage renal disease, Dependence on renal dialysis, Benign prostatic hyperplasia, Essential (primary) hypertension, Multiple subsegmental thrombotic pulmonary emboli, Unspecified atrial fibrillation, Obstructive and reflux uropathy, Wedge compression fracture of fourth lumbar vertebra, Wedge compression fracture of second lumbar vertebra. MDS (Minimum Data Set) dated 8/6/2025 showed R52's cognition was intact. On 9/9/25 at 12:36 PM Observed R52 resting in bed, alert and verbally responsive. Appears comfortable and well groomed. Observed 2 brown with green capsules in the medication cup at bedside. R52 said it was brought by the nurse, not sure when. On 9/9/25 At 12:39PM Surveyor requested V28 (Licensed Practical Nurse / LPN) to R52's room and stated those 2 capsules are Tamsulosin / Flomax and it is scheduled at nighttime. Stated maybe the night nurse left it at bedside. On 9/11/25 At 9:18AM V2 (Director of Nursing / DON) stated nurses are not supposed to keep or leave medications at bedside. She said self-medication administration should be determined or assessed to determine if the resident is able /can safely self-administer medication and if they are cognitively appropriate to keep medication at bedside. V2 said self-administration should have a physician order and should be care planned. V2 stated if medications were left at bedside, the nurse would not know the exact time the resident took the medications, and not following medication timing of physician order and resident could possibly result in not receiving the therapeutic effect of the medication. R52's electronic health record reviewed with V2 and did not find assessment and care plan for self-administration and no physician order for medication to leave at bedside. R52's POS (Physician order sheet) dated 9/9/25 and MAR (Medication Administration Record) showed active order not limited to Tamsulosin HCl Oral Capsule 0.4 MG Give 2 capsule by mouth at bedtime at 9PM related to Benign Prostatic Hyperplasia. Facility's Self-administration of medications policy dated 8/2020 showed in part: In order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team (or equivalent) has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self- administer. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical and visual ability to carry out this responsibility during the care planning process.

Based on observation, interview and record review, the facility failed to initiate a person-centered care plan with appropriate interventions for one resident (R94) of 29.Findings include:9/9/25 at 12:11 PM, Writer observed R94 lying in bed eating lunch. R94s head of the bed was not upright, it was approximately 30 degrees high. R94 was almost lying flat. R94 was bending at the neck to put food in R94s mouth. Writer observed R94 coughing as R94 ate and drank. Writer observed signage on the wall above R94s bed that read in part: remember safe swallowing: sit upright when eating and drinking. R94 said R94 eats like this every meal. R94 said staff pull R94 up but R94 keeps sliding back down.9/10/25 at 12:22 PM, R94 said when the head of the bed is up, R94 slides down so there is no point in putting it up. 9/10/25 at 12:28 PM, V39 (Certified Nursing Assistant) stated R94 always refuses to have the head of bed up while eating. V39 stated V39 has warned R94 of the choking hazard. V39 stated V39 has not told the Director of Nursing or anyone of R94s preference.9/10/25 at 12:51 PM, V42 (Licensed Practical Nurse) stated V42 is familiar with R94. V42 stated R94 always wants to lay flat even when eating and for medication administration. V42 stated V42 has educated R94 on the choking, aspiration hazard. V42 stated V42 believes the Director of Nursing is aware of R94s preference but V42 has not notified the Director of Nursing or management.9/11/25 at 9:54 AM, V2 (Director of Nursing) stated staff have not made V2 aware that R94 eats lying down. V2 stated R94 is a picky eater as far as food preferences. V2 stated we will make a plan for R94 to help R94 stay in position, particularly when eating. V2 stated R94s preference should be care planned. V2 stated whoever is aware of the situation could care plan it. Nurses can care plan it. V2 checked R94s care plan and stated R94s lying down while eating is not care planned. R94s face sheet provided by facility indicates R94 has diagnoses that include but not limited to gastro-esophageal reflux disease; dyspepsia.Facility was not able to provide a care plan that addresses R94s preference to not be positioned upright while eating.Facility policy Comprehensive Care Plan, 11/17/17, reads in part: To develop a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview and record review, the facility failed to ensure feeding assistance was provided to a resident on aspiration precaution. This failure affected one (R83) resident reviewed for activities of daily living (ADL) care out of 29 residents in the final sample.Findings Include: On 9/9/25 at 12:18 PM, R83's in bed eating lunch independently with head of bed up to 90 degrees. R83's meal ticket reads in part: 1200 fluid restriction with 1:1 [one-to-one] feeding. Surveyor observed a signage posted on R83's closet documents in part: Feeding-Aspiration precautions. Patient requires 1:1 feeding. Small teaspoon presentation at a time. Do not provide secondary bites until patient swallows and clears mouth. Do not leave patient alone with tray.On 9/9/25 at 12:28 PM, R83 was observed still eating lunch unassisted in her room. Surveyor called the attention of V5 (Certified Nursing Assistance). On 9/9/25 at 2:28 PM, V12 (Speech Pathologist) stated that R83 was discharged from skilled speech therapy services on 7/16/25 and the recommendation was solid mechanical soft, thin liquids and one-to-one feeding assistance. V12 stated that R83 needs full staff assistance with feeding and general swallow precaution: upright posture, slow rate, slow bites and sips. V12 stated R83 is at risk for choking or aspirating if she's not assisted with meals.R83's clinical records show an admission date of 10/16/24 with included diagnoses but not limited to type 2 diabetes mellitus, Alzheimer's disease, dysphagia oropharyngeal phase, and chronic obstructive pulmonary disease. R83's order summary report with active orders as of 9/9/25 reads in part: ST [Speech Therapy] diet clarification: Diet effective 7/8/2025: mechanical soft solids/thin liquids- STRICT ASPIRATION PRECATIONS- 1:1 FEEDER. R83's ST Discharge summary dated [DATE] documents in part: one to one feeding with mechanical soft diet. R83's comprehensive care plan documents in part: Eating: My usual performance is: partial/moderate assist x 1, 1:1 feeder.Surveyor requested for the facility's policies and procedures for aspiration precaution and ADL care. V1 (Administrator) stated that the facility has no such policies.

Based on observation, interview and record review, the facility failed to follow their policy and procedure to (a) measure upper circumference and exterior catheter length, (b) change midline dressing timely, (c) provide maintenance flush, and (d) develop comprehensive care plan of midline use for 1 (R12) resident. The facility also failed to ensure physician's order was followed for a resident (R1) with aspiration precaution. These failures affected two (R1, R12) residents out of 29 residents in the final sample reviewed for quality of care.Findings Include: R12's admission record showed admit date on 5/9/25 with diagnoses not limited to Malignant neoplasm of central portion of left male breast, Secondary and unspecified malignant neoplasm of axilla and upper limb lymph nodes, Secondary malignant neoplasm of retroperitoneum and peritoneum, Secondary malignant neoplasm of pleura, Malignant neoplasm of abdomen, Malignant pleural effusion, Secondary malignant neoplasm of unspecified lung, Essential (primary) hypertension, Other ascites, Spontaneous bacterial peritonitis. MDS (Minimum Data Set) dated 8/13/2025 showed R12's cognition was intact. On 9/10/25 At 11:02AM Observed R12 resting in bed, alert and oriented x 3, verbally responsive. R12 showed single lumen midline on left upper arm, dressing was dated 8/29/25. He said midline was placed in the hospital and dressing was never replaced in the facility. R2's midline was never accessed, and no flushing was done. He said his left arm circumference and midline external catheter was never measured. On 9/10/25 at 1:32PM V31 (Licensed Practical Nurse / LPN) stated she is working with R12 today. She said R12 has a midline and dressing was dated 8/29/25. On 9/11/25 At 9:18AM V2 (Director of Nursing / DON) stated midline dressing should be changed every 7 days to prevent potential infection. She said arm circumference and exterior catheter length of midline should be measured and documented to monitor complications such as swelling / edema / infiltration or catheter migration. V2 said midline use should be care planned to establish plan of care and so staff would know how to care for the resident that would include interventions. R12's Nurses Note dated 9/8/2025 showed in part: Has IV Midline on the Left forearm. Care plan reviewed; no plan of care found for R12's midline. R12's health record reviewed with no documentation found that left arm circumference and external catheter of midline was measured. Facility's policy for IV (intravenous) access line maintenance protocol dated 2/7/20 showed in part: Midline: Maintenance flush for each lumen = 10ml NS (Normal Saline) every week. Transparent dressing changed = On admission then weekly and as needed. Measure upper arm circumference and exterior catheter length with each dressing change and prn (as needed). Facility's comprehensive care plan policy dated 11/17/17 showed in part: to develop a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences and services that are to be furnished to attain or maintain the resident's highest practicable well-being. On 9/9/25 at 10:43 AM, R1 was lying in bed alert and awake noted with bouts of confusion noted. Surveyor observed a cup of water with a straw on top of R1's bedside table within easy reach of R1. Surveyor observed a signage posted on top of R1's head of bed. On 9/9/25 at 10:59 AM, V5 (Certified Nursing Assistant) entered R1's room and stated that the signage means R1 should not be given a straw with her fluids. V5 stated the cup of water with a straw had been on top of R1's bedside table since V5 came in the morning. V5 stated, I will take it away from her. On 9/9/25 at 11:10 AM, V6 (Agency Licensed Practical Nurse) stated that it's her first time working in the facility. Surveyor showed V6 the signage that was posted on top of R1's bed. V6 stated that the signage means no straw. V6 confirmed in R1's electronic health records that R1 has an order for NO STRAW because R1 at risk for aspiration or choking. On 9/9/25 at 2:28 PM, V12 (Speech Pathologist) stated that R1 was discharged on 8/4/25 from skilled speech therapy services. V12 stated R1's discharge instruction/recommendation from speech is pureed diet and thin liquid with no straws. V12 stated staff should be giving R1 a straw because she can aspirate if they allow R1 to use a straw. R1's clinical records show an admission date of 3/25/23 with included diagnoses but not limited to hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side, dysphagia oropharyngeal phase, acute pulmonary edema, and acute bronchitis. R1's Minimum Data Set (MDS) dated [DATE] shows R1 has impaired cognition and requires supervision assistance for eating. R1's order summary report with active orders as of 9/9/25 reads in part: GENERAL * diet Pureed * texture, Thin consistency, NO STRAWS (ordered 7/8/25) and ST (Speech Therapy) diet clarification: puree/nectar to puree/THIN- NO STRAWS. Administer medications crushed in puree. STRICT NO STRAWS RESTRICTION- ASPIRATION W/STRAWS. Diet effective: 7/7/2025: Puree solids/Thin liquids- Set up assist, no straws. R1's comprehensive care plan shows R1 is at risk for aspiration date initiated on 2/21/24. Surveyor requested for the facility's policy and procedure for aspiration precaution and/or general care. V1 (Administrator) stated that the facility has no such policies.

Based on observation, interview and record review, the facility failed to implement fall interventions for two residents (R24, R151) of 29 reviewed for falls.Findings include:9/9/25 at 12:05 PM, writer observed R151 lying in bed watching television. A fall mat was observed on the floor next to R151's bed. R151's bed was observed not in the lowest position. R151's bed was approximately knee height. R151 said the bed has been like this all day. R151 said R151 needs assistance to get out of bed.9/9/25 at 12:23 PM, writer observed R24 lying in bed and the bed was not at the lowest position. 9/9/25 at 12:27 PM, V24 (Licensed Practical Nurse) stated R24s bed was raised to about knee level. The bed was not at the lowest position. V24 stated R24 tries to get up from bed. V24 stated R24 could have fallen out of bed and been injured with the bed not at lowest position. V24 stated R151's bed should be lower to prevent a fall with injury.9/9/25 at 2:04 PM, V41 (Certified Nursing Assistant) stated R151 is a fall risk because there is a fall mat on the floor by the bed. The bed should be low for fall precaution because R151 could fall out of bed. 9/11/25 at 9:54 AM, V2 (Director of Nursing) stated R24 is a fall risk. R24's bed should be in the lowest position. V2 stated R151 is a fall risk. R151's bed should be in the lowest position. The bed should be in the lowest position because it decreases the risk of significant injury. R151's face sheet provided by facility indicates R151 has diagnoses that include but not limited to dementia; repeated falls.R151's MDS (Minimum Data Set) 6/23/2025, indicates R151 has a BIMS (Brief Interview for Mental Status) score of 12 indicating moderately impaired cognition.R151 has care plan that reads in part: Potential for falls related to: confusion, history of falls, unfamiliar environment, weakness.Fall Risk Assessment, 4/28/2025, categorizes R151 as at risk for falls.R24's face sheet provided by facility indicates R24 has diagnoses that include but not limited to dementia; dysphagia, oropharyngeal phase; fall; presence of artificial hip joint, bilateral.R24's MDS (Minimum Data Set) 8/11/2025, indicates a BIMS (Brief Interview for Mental Status) score was not able to be obtained due to R24 was unable to complete the interview. R24 requires partial/moderate assistance to go from sitting to standing.R24 has care plan that reads in part: Potential for falls related to: confusion, history of falls, unfamiliar environment, weakness.Fall Risk Assessment, 8/11/2025, categorizes R24 as at risk for falls.Facility policy Fall Prevention Program, 11/21/17, reads in part: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary.

Based on observation, interview, and record review, the facility failed to ensure that the water ordered for flushes is administered per doctor orders for one (R99) out of five residents reviewed in a total sample of 29. This failure places residents at risk to be provided with inappropriate care and services to meet the resident's physical, mental and/or psychosocial needs. Findings include:On 09/09/2025 at 11:21 AM, R99 was observed laying down on his bed, head of the bed elevated, gastrostomy tube feeding rate set at 65 ml (milliliter) per hour, water flush set at 160ml every 6 hours. Noted with 599 ml fed and 160 ml flushed. R99's water flush bag dated 09/08/25 and feeding formula labeled with R99's name, room number, rate, and date 09/08/25. On 09/10/2025 at 11:12 AM, with V25 (Registered Nurse), R99 is not in his room but R99's g-tube feeding pump noted in R99's room. V25 stated that R99's g-tube is disconnected and turned off when R99 goes to dialysis. V25 stated I am the one that disconnected it this morning, it was connected when I came in to work at 7:00 AM. V25 turned on R99's g-tube pump to inform this surveyor the settings that R99's g-tube pump is set at. V25 stated that R99's g-tube feeding is set at 65ml (milliliter) per hour, and the water flush is set at 160ml every 6 hours. V25 stated that R99 is being followed by the dietician and V25 does not work regularly with R99. On 09/11/2025 at 10:39 AM, with V2 (Director of Nursing), observed R99's g-tube feeding pump on and attached to R99. V2 stated I see the water flush is set at 160ml every 6 hours, and the feeding formula is set at 65ml/hour. V2 stated that the feeding and water flush settings should be cross referenced with the resident's orders. On 09/11/2025 at 9:59 AM, V35 (Registered Dietician) stated that she is the dietician that follows the residents who are on dialysis. V35 stated that she recommended for R99 to have a decrease in water flushes because V35 increased R99's gastrostomy (g-tube) feeding rate. V35 stated that she increased his feeding because R99 was underweight. V35 stated she decreased water flushes because of heart concerns and total amount of fluid that a dialysis patient can remove. V35 stated that the feeding tube is already providing fluid. V35 stated that if R99 were to continue to receive 160ml (milliliters) every six hours of water flushes and 65ml/hour of g-tube feeding, it would be exceeding the amount of fluids and the blood sodium level will be lower than 135 milliequivalents per liter (mEq/L).On 09/11/2025 at 9:45 AM, V2 (Director of Nursing) stated that it is important to follow the enteral orders including flushing orders because it is the residents' nutritional status and it will impact their weights and overall health. R99's face sheet documents that R99 is a [AGE] year-old individual with diagnoses not limited to: unspecified protein-calorie malnutrition, gastrostomy status, end stage renal disease, dependence on renal dialysis, chronic systolic (congestive) heart failure. R99's MDS/Minimum Data Set Section C dated 07/15/2025 documents that R99 is severely cognitively impaired. R99's active care plan documents in part R99 requires tube feeding. Interventions document in part I am dependent with tube feeding and water flushes. See MD (Doctor of Medicine) orders for current feeding orders.R99's nurses note dated 09/05/2025 12:13 PM documents in part dialysis dietician recommended to decrease water flush from 160ml every 6 hours to 100 ml every 8 hours. NP (Nurse Practitioner) approved recommendation noted and carried out. R99's active physician order set documents in part state date 09/05/2025, enteral feed order every 8 hours 100 ml water flush q 6hrs. Facility document dated 8-3-20 documents in part gastrostomy tube- feeding and care. To provide nutrients, fluids and medications, as per physician orders, to residents requiring feeding through an artificial opening into the stomach. Licensed nurse will review physician's order for type of formula, concentration, rate of flow, and method of administration.

Based on observation, interview and record review, the facility failed to ensure a resident (R83) received the correct oxygen flow rate as ordered by the physician and to ensure nasal cannula tubing was applied to a resident receiving oxygen for 1 (R1) of 2 residents reviewed for respiratory care in a final sample of 29.Findings Include:On 9/9/25 at 10:43 AM, R1 was lying in bed alert and awake noted with bouts of confusion. R1's oxygen (O2) concentrator was turned on and flow rate set to 2 liters per minute (lpm). R1's nasal cannula (nc) tubing was wrapped around her left side rail; the nasal prong was on the floor and was not applied in her nose. R1 was not in distress. On 9/9/25 at 10:59 AM, V5 (Certified Nursing Assistant) entered R1's room and applied the nasal cannula tubing for R1. V5 stated that it should have been in her nose. On 9/9/25 at 10:57 AM, R83's sleeping in bed noted receiving oxygen (O2) via nasal cannula that was set to 3 liters per minute (lpm).On 9/9/25 at 11:10 AM, V6 (Agency Licensed Practical Nurse) stated that it's her first time working in the facility. V6 confirmed R83's electronic health record shows an order for continuous oxygen at 2lpm. On 9/10/25 at 11:42 AM, R83 was sleeping in bed and noted her O2 concentrator flow rate was still set to 3lpm. On 9/10/2025 at 11:52 AM, surveyor asked V14 (Registered Nurse) to check R83's oxygen and confirmed R83's O2 concentrator flow rate was set to 3lpm. V14 stated the order is 2lpm.9/11/25 at 9:43 AM, V2 (Director of Nursing) stated, When administering oxygen, the nurse is to check the doctor's order. They must administer and monitor the resident's oxygen based on the doctor's order because it is considered a medication and if the resident does not need it, it should be removed or if they need it, then it should be adjusted accordingly. It is important to follow the doctor's order because oxygen falls on medication safety practice.R1's clinical records show an admission date of 3/25/23 with included diagnoses but not limited to hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side, acute pulmonary edema, and acute bronchitis. R1's Minimum Data Set (MDS) dated [DATE] shows R1 has impaired cognition and requires staff assistance with bed mobility and transfers. R1's order summary report with active orders as of 9/9/25 shows Oxygen 2 lpm/nc every shift (ordered 6/15/25).R83's clinical records show an admission date of 10/16/24 with included diagnoses but not limited to chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia. R83's MDS dated [DATE] shows R83 has moderately impaired cognition and is total dependent on staff's assistance for transfers and bed mobility. R83's order summary report with active orders as of 9/9/25 reads in part: Oxygen via nasal cannula on 2LPM (ordered 10/17/24).The facility's Oxygen Concentrator policy (2013) documents in part: To provide Oxygen for therapeutic use by utilizing a concentrator that converts ambient air to a higher concentration level of oxygen. Verify and understand the physician's order. Know the flow rate and duration of use. Adjust the flow meter control knob to the flow setting prescribed by the physician.

Based on observation, interview and record review, the facility failed to assess the risk versus benefits of using side rails and review them with the resident prior to use and failed to implement person-centered comprehensive care plan addressing the use of the side rails. These failures affected two (R4, R52) out of three residents reviewed for side rails in a final sample of 29. Findings Include: On 9/9/25 at 11:47 AM, R4 was sitting on the side of the bed and noted with two upper half side rails up. R4 stated she gets out of bed by herself and uses a wheelchair to get around. On 9/10/2025 at 11:37 AM, R4 was sleeping in bed and noted with two half upper side rails up. On 9/10/25 at 10:43 AM, V22 (MDS Coordinator) stated that the purpose of the care plan is to notify the staff how to provide care for the residents. V22 stated if the resident has a change in condition the care plan should be updated as soon as possible. V22 stated that comprehensive care plan should be initiated on admission MDS (Minimum Data Set), annually, significant change, and with any change in condition. V22 stated that the needs of the resident should be addressed in the care plan and how to provide the care for the residents. V22 stated the use of side rails should be addressed in the care plan. V22 confirmed in R4's electronic health records that R4 had no side rails care plan. V22 also confirmed that there was no side rail assessment completed for R4, and that the last one was done on 6/28/24 from R4's previous admission. On 9/10/25 at 3:11 PM, V32 (Restorative Nurse) stated that side rail risk assessment should be completed before using the side rails for the residents. V32 stated that the purpose of the assessment is to determine for risk of injury when they are using the side rails, to determine if the resident can use the side rails safely and the benefits of the side rails. V32 stated that a consent obtained from the resident or responsible party prior using the side rails is incorporated in the side rail risk assessment. V32 stated that side rail risk assessment is completed upon admission and reviewed on a quarterly basis or if there is a significant change or as needed. V32 stated that the use of side rails needs to be incorporated in the ADL (Activity of Daily Living) care plan as part the bed mobility performance. V32 stated that the side rail assessment needs to be re-evaluated for continued use or for any changes. R4's clinical records show an admission date of 6/25/25 with included diagnoses but not limited to dementia, essential hypertension, and chronic kidney disease. R4's Minimum Data Set, dated [DATE] shows R4 is cognitively impaired and requires substantial maximal assistance from staff for bed mobility and transferring from bed. R4's physician orders do not have an order for use of side rails. R4's electronic health records revealed no side rail/s assessment since the admission date of 6/25/25. R4's comprehensive care plan does not address the use of side rails. R52's admission record showed initial admit date on 7/26/2024 with diagnoses not limited to End stage renal disease, Dependence on renal dialysis, Benign prostatic hyperplasia, Essential (primary) hypertension, Multiple subsegmental thrombotic pulmonary emboli, Unspecified atrial fibrillation, Obstructive and reflux uropathy, Wedge compression fracture of fourth lumbar vertebra, Wedge compression fracture of second lumbar vertebra. MDS (Minimum Data Set) dated 8/6/2025 showed R52's cognition was intact. He needed total assistance with toileting hygiene, shower / bathe self, lower body dressing; Partial / moderate assistance with upper body dressing and personal hygiene, roll from lying on back to left and right side, sitting on side of bed to lying flat on the bed; Dependent with chair / bed transfer. On 9/09/2025 at12:36PM Observed R52 in bed, alert and verbally responsive, with 2 upper side rails up. R52 said rails are always up. On 9/10/25 At 3:22PM V32 (Restorative nurse) stated side rails should have a care plan. Surveyor reviewed R52's EHR (Electronic Health Record) with V32 and stated there is side rail assessment indicated for bed mobility. Stated no care plan found for Side rail use. On 9/11/25 At 9:18AM V2 (Director of Nursing / DON) said use of bedrails should have an assessment and usually it is being used to enhance bed mobility. Stated bedrail use should be planned for safety of the resident and so staff would be able to know the use of bed rails for positioning. The facility's Side Rails/Bed Rails policy dated 10/24/22 documents in part: The facility shall ensure that prior to the installation of bed rails, the facility has attempted to use alternatives. After alternatives to bed rails have been attempted and determined that these alternatives do not meet the resident's needs, the facility shall assess the resident for the risks of entrapment and possible benefits of bed rails. In addition, the resident assessment should include an evaluation of the alternatives to the use of a bed rail that were attempted and how these alternatives failed to meet the resident's assessed needs. The facility shall also assess the resident's risk from using bed rails. The following includes potential risks regarding the use of bed rails: Accident hazards, barrier to residents from safely getting out of bed independently, physical restraint, other potential negative physical outcomes, and other potential negative psychosocial outcomes. After alternatives have been attempted and prior to installation, the facility shall obtain informed consent from the resident or if applicable, the resident representative for the use of bed rails. The care plan shall be developed on an individual basis, and may include but is not limited to the following related to use of bed rails: Which medical need would be met through the use of bed rails; How often the bed rail is applied, duration of use, and the circumstances for when it is to be used; How monitoring is provided, and when and how often the bed rail is to be released and assistance provided for use of the bathroom, walking and range of motion; What the resident's functional ability is, such as bed mobility and ability to transfer between positions, to and from bed or chair, and to stand and toilet and staff required for each function that requires assistance; Identification of interventions to address any potential complications such as physical and/or psychosocial changes related to the use of the bed rails, such as increased incontinence, decline in ADLs or ROM, increased confusion, agitation, and depression; Identification of interventions to minimize or eliminate the use of the bed rails; and Who monitors for the implementation of the use of the bed rails, and who evaluates and assesses the resident to determine the ongoing need for bed rails, whether the bed rail use should be gradually decreased, and how the modifications.

Based on observation, interview and record review, the facility failed to properly position one resident (R24) of 29 reviewed for activities of daily living. Findings include:9/9/25 at 12:23 PM, writer observed R24 lying in bed with the head of the bed not in an upright position, approximately 30 degrees. R24 was not pulled up in the bed. R24s lunch tray was on the bedside table across the bed. Writer observed the tray had been eaten from. Writer observed R24 take spoonsful from the tray and eat them. 9/9/25 at 12:27 PM, V24 (Licensed Practical Nurse) stated R24s head of bed was almost flat. V24 stated R24 feeds self. V24 stated R24 could have choked, aspirated with the head of bed low and R24 not positioned upright.9/9/25 at 2:04 PM, V41 (Certified Nursing Assistant) stated residents should not be flat to eat because they could aspirate. V41 stated V41 placed R24s meal tray down and R24 reached for the food to eat. V41 stated next time V41 will reposition R24 first before giving the meal tray.9/11/25 at 9:54 AM, V2 (Director of Nursing) stated when setting up a resident to eat, the CNA will set them up. They sit them up in the bed. Elevate the head of the bed to at least 45 degrees. They put the bedside table in front of the resident with the food tray and drinks and position everything in their reach. They assess for any other needs before leaving the resident. R24 needs assistance to prop-up in bed. R24 should not be lying in bed to eat.R24s face sheet provided by facility indicates R24 has diagnoses that include but not limited to dementia; dysphagia, oropharyngeal phase; fall; presence of artificial hip joint, bilateral.R24s MDS (Minimum Data Set) 8/11/2025, indicates a BIMS (Brief Interview for Mental Status) score was not able to be obtained due to R24 was unable to complete the interview. R24 requires setup or clean-up assistance for eating. R24 requires partial/moderate assistance to go from lying to sitting on the side of the bed.R24 has care plan that reads in part: I have a swallowing problem related to swallowing assessment results; with intervention including: Instruct resident to eat in a upright position, to eat slowly, and to chew each bite.Writer requested policies for choking, aspiration precautions. V1 (Administrator) stated there are no policies of this subject.V2 (Director of Nursing) stated we do not have a policy for feeding setup in bed.

Based on interview and record review, the facility failed to ensure Discharge Instruction was completed and provided to a resident upon discharge to ensure a safe and effective transition of care. This failure affected 1 (R5) resident reviewed for discharge requirement in the total sample of 12 residents. Findings include:On 09/02/2025 at 12:09pm, V9 (Assistant Administrator) stated when a resident discharges, there is a Discharge Assessment the nurse prints out at the time of discharge. Nursing will print the Discharge Assessment and the resident or family signs the Discharge Assessment. On 09/02/2025 at 12:14pm, this surveyor opened R5's EHR (Electronic Health Record). V9 stated the Discharge Assessment is on the Assessment tab. Upon opening R5's Discharge Instruction on Assessment tab, Sections A and B were highlighted 'Green', and Sections C, D, E and G were not highlighted. V9 stated if the section is completed it will be in 'green'. V9 checked R5's Discharge Instruction and stated his (R5) Discharge Instruction is not yet completed. V9 stated the process remains the same, the facility will open up the Discharge Assessment and IDT (Interdisciplinary Team) complete their part. Based on what is showing on the Discharge Instruction, she (V7 -Social Services Director) did her part, but nursing did not complete their part. The Discharge Instruction should be completed before his discharge; and nursing will be the one printing it and give the Discharge Instruction to the resident or his family member and on this case to (V24-R5 family member). The importance of completing the Discharge Instruction is for the continuity of care because Discharge Instructions include the resident's medications, appointments, and the resident's diet; and instruction for the continuation of care for wherever the resident is discharged to, which is his home. On 09/02/2025 at 12:35pm, V7 (Social Services Director) stated she opened a Discharge Assessment in electronic health record system and completed two sections and nursing department does the rest. Sections A and B are already completed, and Sections C, D, E, F, and G are not completed. 'Section F' was highlighted yellow because she wrote a note that the Durable Medical Equipment are already available in his home where he would be discharged . Nursing is in charge of making sure all the sections on the discharge assessment is completed. The Dietary Section, the Dietary Department can fill out that Section, but nursing also knows the diet order so they can, too, fill out that Section. The importance of completing the Discharge Assessment is for the continuity of care. On 09/03/2025 at 9:57am, V25 (Licensed Practice Nurse) stated she did not remember giving the Discharge Instruction to (R5). She did not remember filling out the Discharge Instruction form for him (R5). V25 stated nobody reminded her to complete the Nursing Sections of the Discharge Instruction. On 09/02/2025 at 1:09pm, V15 (Medical Records/Transportation) stated the facility has discharge papers the resident or the POA (Power of Attorney) signs and she (V15) is responsible for uploading the discharge document to the electronic health record. On 09/02/2025 at 1:10pm, V15 checked R5's electronic health record and stated the discharge paper that is signed by the resident or the POA is still not uploaded. The nurses usually put the discharge paper in a 'scan' box to be uploaded to the system. V15 stated if he (R5) was discharged on 08/14/2025 then she (V15) should have uploaded the discharge paper already because she checks the scan box every other day. On 09/03/2025 at 10:23am, V15 (Medical Records/Transportation) stated she was not able to find the discharge paper for (R5). That she looked at the scan box and there is no document to upload. V15 stated it means the nurse did not print the discharge instruction for him to sign. On 09/03/2025 at 10:51am, V26 (RN-Registered Nurse/Night Shift Supervisor) stated the facility has Discharge Assessment on the 'Assessment' tab in EHR system. The nurse, who will discharge the resident, is expected to complete the Discharge Assessment in EHR system. The night shift nurse assigned to the resident is responsible for completing the Medications Section of the Discharge Assessment. The nurse, who is discharging the resident, should print the completed Discharge Assessment because there is a section on the Discharge Assessment where the resident has to sign. Signing the Discharge Assessment is an acknowledgment that the resident or the POA receives the medication and the discharge instruction. Each section of the Discharge Assessment will turn green once completed. If it did not turn green, it means that section is not completed or answered yet. Discharge Assessment should be completed prior to discharge. A complete Discharge Assessment gives instruction to the resident or family how they will take the medication and the purpose of the medication. It also explains the follow up appointments that are scheduled. If not completed and not given to the resident, the resident may miss the appointments and or may not take the medications appropriately. R5's admission Record documented that R5's diagnoses (include but not limited to) hemiplegia and hemiparesis, sequelae of cerebral infarction, and morbid obesity due to excess calorie. R5's Census list documented that R5 was readmitted on [DATE] and was discharged on 8/14/2025. R5's (06/30/2025) care plan documented, in part I wish to be discharged home w/family. Will verbalize/communicate an understanding of the discharge plan and describe the desired outcome by the review date. The resident needs written instructions, as required, to ensure care continuity post-discharge. R5's (08/10/2025) Discharge Instruction documented, in part discharge date and time: 08/14/2025 11:00(am). Of note, Sections A and B were completed by V7 (Social Services Director). Sections C. Medications, Section D. Diet/Nutrition - Dietary, Section E. ADL/Bowel & Bladder/Restorative Nursing, Section F. Education/Appointments, Section G. Skin Condition on Discharge & Treatments - Nursing were not completed. Space provided for Name of Person Completing the Sections and Resident/Responsible Party Signature, as applicable, has no entry.The (09/04/2025) email correspondence with V28 (Regional Nurse Consultant) documented, in part Referring to the Discharge Instruction on the 'Assessment' tab in EHR system. What is the expectation? The expectation is for staff to complete prior to discharge and provide a copy upon discharge. The (undated) Discharge/Transfer of Resident documented, in part Purpose: To provide safe departure from the facility. To provide for continuity of care and treatment. Equipment: Discharge Notice. Procedure: 1. Explain discharge procedure to resident and family. Provide additional health education or medication instruction information for resident or family as indicated in lay(man) terms. 7. Complete Transfer Form Accurately and completely. Rationale/Amplification. Ensure that resident's current physical and psychosocial assessment, medications and current treatment is completely describe. 11. Document discharge summary. Include notes on specific instruction given (medications) to resident and responsible party in lay(man)'s terminology.

Based on observation, interview and record review, the facility failed to protect the residents' rights to be free from physical abuse. These failures affected 2 residents (R1 and R2) resulting in R2 grabbing R1's thumb causing R1 pain; and R1 grabbing R2 in the chest causing multiple scratches and pain to R2. Findings include: The final for FRI (Facility Reported Incident) that occurred on 12/20/24, dated 12/24/24, documents, in part, . (R2) alleged that (R1) grabbed on to her shirt. (R2) reported that she asked (R1) to let loose of the shirt, but she would not. (R2) reported she removed (R1's) hand from her shirt . (R1) alleged that (R2) came out of the bathroom, approached her bed, made contact with her head, bit her arm and then grabbed her thumb. (R1) reported grabbing (R2's) shirt and accidentally scratched her . Later in the evening, (R1) reported to the nurse that she had pain in her left thumb. The doctor was notified, and an x-ray was ordered. Diagnosis of an acute fracture is inconclusive due to history of pathological fractures and Xray report stating: acute versus old ununited cortical fracture at the ulnar margin of the base of the left 1st metacarpal. The provider ordered ace bandage and follow up with ortho. Resident scheduled to see ortho on 12/30/2024. On 1/24/25 at 12:46pm, R1 said, My thumb is still broken. R1 showed surveyor R1's left thumb/hand. Surveyor observed R1's left thumb/hand without a splint or ace wrap, and R1's left thumb appeared swollen. R1 stated, I (R1) can't wear that wrap for my thumb, it just don't feel right. It's (ace wrap) not comfortable. It (left thumb) still hurts. I'll (R1) tell you what happened with (R2). (R2) violated me. She (R2) had issues with her (R2) previous roommate before me. (R2) is the problem. (R2) was in the bathroom complaining about the (V3, Assistant Administrator). I (R1) was tired of listening to it, so I (R1) told her (R2) to shut up. She (R2) then came out of the bathroom and physically and verbally assaulted me. She (R2) bit me in the arm. I (R1) grabbed her (R2) shirt to defend myself and she (R2) grabbed my thumb, bent it back and broke it. It (R1's thumb) hurt like a b****! I (R1) called her a C-*-*-*! I (R1) am not going to deny that. The police came and if I (R1) go to jail, she (R2) goes to jail too. The truth hurts. I (R1) don't feel safe with her (R2) here. She's (R2) going around the facility physically and verbally assaulting people. R1's face sheet documents, in part, diagnosis that include but are not limited to bipolar disorder; major depressive disorder; age-related osteoporosis with current pathological fracture, right ankle and foot, subsequent encounter for fracture with routine healing; and Human Immunodeficiency Virus (HIV). R1's Minimum Data Set (MDS), dated [DATE], documents, in part, a brief interview of mental status (BIMS) score of 14 which indicates R1 is cognitively intact. R1's progress note per V4 (Registered Nurse/RN), dated 12/20/2024 at 10:43pm, documents, in part, 9:20pm the patient (R1) had a physical altercation with her roommate (R2). The patient stated that she (R1) has a broken left thumb but refused to go with the ambulance to be checked in the hospital. NP (nurse practitioner) . made aware of the situation. The administrator was made aware of the situation . R1's progress note per V4 (Registered Nurse/RN), dated 12/20/2024 at 10:45pm, documents, in part, The patient (R1) refused to go to the hospital to get her thumb checked. the patient is showing her thumb but refused to be touched for examination. R1's progress note per V5 (Social Worker) dated 12/21/24 at 12:10pm, documents, in part, Well-being Note: Writer checked in on pt (patient) today. Pt was tearful and became upset when discussing an altercation between her and her former roommate (R2). Pt reports to be in pain and that she is awaiting to have an x-ray done of her hand. Writer sat with pt until she (R1) became calm. Pt began to ask if she'd be able to get her belongings from her old room with writer. Writer informed her that it would be best to allow staff to retrieve her (R1) belongings to keep things cordial. She (R1) verbalized understanding. Writer retrieved all pt's belongings and assisted pt with putting them away in her new room. R1's progress note per V6 (Medical Records), dated 12/26/2024 2:54pm, documents, in part, Appointment for Orthopedic consult ASAP. I (V6) made an appointment for (R1) it was for the 30th of December at 1:45. She (R1) canceled the appointment. She (R1) made another appointment, and she (R1) also made her own transportation arrangements. This is what the resident stated when I (V6) went to ask her for the new information about her appointment to facilitate transportation. R1's progress note per V7 (Licensed Practical Nurse/LPN), dated 12/26/2024 6:35pm, documents, in part, (R1) cancelled her Ortho appt and said, no one schedules my appt! I'll (R1) do it myself! I (R1) have my own doctor! I (R1) don't want any doctors that's associated from here!! R1's Care plan, revision date 10/21/24, documents, in part, At Risk For Abuse/Neglect: Pt (patient/R1) scored low (2) on Abuse/Neglect Screening Assessment; however, there was an allegation of abuse while she (R1) was in the hospital. According to the patient (R1), a police report was done but claimed she (R1) did not file a complaint, with goal that documents, in part, Pt (patient/R1) will be cared for in a safe manner and verbalize to staff any incidences of abuse or neglect through review date, and with interventions that document, in part, Ensure safety if feeling unsafe.R1's Care Plan, revision date 12/26/24, documents, in part, Pt (patient/R1) is non-compliant with application of ace wrap to left hand due to fracture. Patient educated on importance of application however still reluctant. R1's Care Plan, revision date 10/22/24, documents, in part, I (R1) use psychotropic medication, with interventions that document, in part, Monitor/record occurrence of for target behavior symptoms (inappropriate response to verbal communication, violence/aggression towards staff/others. etc.) and document per facility protocol. R1's Abuse/Neglect Screening, dated 10/21/24 (most recent assessment done prior to the physical altercation between R1 and R2 on 12/20/24), documents, in part, Score:2. R1's Abuse/Neglect Screening, dated 10/21/24, documents, in part, B. Risk measure. Risk measure for likelihood for a history of previous/ . mistreatment and/ or potential future problems/ symptoms related to mistreatment. 0. Low= 0-2, Moderate = 3-4, High = 5 +. On R1's Abuse/Neglect Screening, dated 10/21/24, the following was answered NO 4. Psychiatric history and /or present mental health diagnosis: including psychotic symptoms (e.g. delusional thinking, hallucinations) and possible misinterpretations of events and the intentions of others. R1's face sheet documents, in part, diagnosis that include but are not limited to bipolar disorder and major depressive disorder, which are both mental health diagnosis. Answering NO put R1 at low risk for potential further abuse, however if the question was answered correctly as Yes, R1 would have a score of 3 which would put R1 at Moderate risk for potential further abuse. R1's Order Summary Report, dated 1/24/25, documents, in part, order date 1/3/25: ORTHO CONSULT - DIAG; LEFT THUMB FRACTURE. R1's Order Summary Report, dated 1/24/25, documents, in part, order date 12/21/24: STAT X-Ray of left thumb due to pain/swelling. R1's x-ray of left thumb, dated 12/21/24, documents, in part, acute versus old ununited cortical fracture at the ulnar margin of the base of the 1st metacarpal. On 1/24/25 at 11:47am. R2 said, (R1) was saying something to me while I (R2) was in the bathroom. I (R2) couldn't hear her (R1), so I (R2) told her (R1) to hold on. When I (R2) came out of the bathroom, I (R2) went up to her (R1) and asked (R1) what she (R1) was saying. (R1) then yelled What do you think? I'm (R1) stupid. She (R1) then grabbed my shirt. I (R2) gave (R1) to count of 3 to let go of my shirt. I (R2) counted to 3 and (R1) said what are you going to do now, so I (R2) grabbed her (R1) hand to stop her (R1) from grabbing my shirt and I (R2) must have hurt her (R1) thumb. I (R2) didn't mean to break it (left thumb), but I (R2) did intentionally grab her (R1) hand in self-defense. I (R2) grew up in a not so good neighborhood. I (R2) think she (R1) thought I (R2) was just going to stand there and let her (R1) hurt me, and then (R1) told the nurses I (R2) bit her (R1). Why would I (R2) bite someone with HIV (Human Immunodeficiency Virus)? I'm (R2) not stupid. She's (R1) a liar. She (R1) gave me scratches all over my chest. Those scratches hurt. It looked like I (R2) was attacked by a rabid cat. R2's face sheet documents, in part, diagnosis that include but are not limited to anxiety disorder, depression and bipolar disorder. R2's Minimum Data Set (MDS), dated [DATE], documents, in part, a brief interview of mental status (BIMS) score of 15 which indicates R2 is cognitively intact. R2's progress note per V4 (Registered Nurse/RN), dated 12/20/2024 at 10:48pm, documents, in part, At 9:20pm, the patient (R2) had a physical altercation with her roommate (R1). She (R2) was grabbed by her roommate (R1) in the chest that caused some scratches. She (R2) then grabs her roommates (R1) hand so that she (R1) will let go . causes pain to the roommate. Both patients were separated and put in different rooms. NP (nurse practitioner) . and Administrator made aware of the situation. R2's progress note per V10(Licensed Practical Nurse/LPN), dated 12/21/24 at 7:20pm, documents, in part, . Scratch marks still noted on resident chest area . R2's Abuse/Neglect Screening, dated 10/16/24 (most recent assessment done prior to the physical altercation between R1 and R2 on 12/20/24), documents, in part, Score:3, which puts R2 at MODERATE risk for potential further abuse. R2's Care plan, revision date 10/16/24, documents, in part, I (R2) am at risk for abuse/neglect ., with interventions that document, in part, Assess resident for risk for abuse . Observe resident when in company of peers. R2's Care plan, revision date 7/22/24, documents, in part, I (R2) use antidepressant medication, with interventions that document, in part, Monitor/document/report PRN (as needed) adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition . On 1/24/25 at 2:05pm, V8 (Social Service Director) affirmed that she (V8) is familiar with R1 and R2. V8 affirmed that she (V8) is aware of the altercation that occurred between R1 and R2 on 12/20/24 and that R1 and R2 rooms were changed. V8 said, It was a he said she said type of thing since the minute it happened. On 1/24/25 at 2:11pm, V5 (Social Worker) affirmed that both R1 and R2 were separated immediately, and their rooms were changed the same day due to a physical altercation. V5 said, I (V5) couldn't tell what actually happened. They (R1 and R2) had different stories . On 1/24/24 at 2:21pm, V3 (Assistant Administrator) said, . The incident with (R1) and (R2) was not substantiated because both residents were telling different stories. The stories were not coinciding. We (staff) ensured both were safe. I (V3) followed up with both (R2) and (R1). I (V3) followed up with them (R1 and R2) and I (V3) asked them if they (R1 and R2) feel safe and they (R1 and R2) both said yes. On 1/24/25 at 2:44pm, V2 (Director of Nursing/DON) said, I'm (V2) aware of the incident with (R1) and (R2). The thing I (V2) know is that (R1) was lying in bed and (R2) was coming out of bathroom. (R2) was upset and angry and kept talking and talking. (R1) said to stop talking. (R2) suddenly jumped on her (R1) and then (R1) had to defend herself. They (R1 and R2) were separated right away, and the administrator was called. They (R1 and R2) both had injuries. I (V2) feel most injuries can cause pain, some worse than others. On 1/24/24, surveyor called V4 (Registered Nurse/RN) for an interview, but V4 did not pick up call. On 1/24/25 at 3:15pm, V9 (Medical Director) said, I'm (V9) familiar with them (R1 and R2), but I (V9) don't follow them. When asked if grabbing someone's hand or scratching someone can cause pain, V9 replied, Possibly. When asked if a fractured thumb can cause pain or harm to resident, V9 replied, Well, yes. On 1/25/24, surveyor called V4 (Registered Nurse/RN) for an interview, but V4 did not pick up call. Facility's policy titled, Abuse Prevention and Reporting- Illinois, revised date 10/24/22, documents, in part, This facility affirms the right of our residents to be free from abuse, neglect, exploitation misappropriation of property deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse neglect exploitation, misappropriation of property and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse neglect exploitation misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: . Establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment . Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means (210 ILCS 45/1-103). Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident (42 CFR 483.5) . Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention (77 Ill. Adm. Code 300.330). Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment (42 CFR 483.12 Interpretive Guidelines) . Resident-to-resident altercations that include any willful action that results in physical injury, mental anguish or pain must be reported in accordance with regulations . Resident Assessment: As part of the resident's life history on the admission assessment, comprehensive care plan, and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, history of trauma or misappropriation of resident property, who have needs, triggers and behaviors that might lead to conflict . Facility's policy titled, Quality Assurance Performance Improvement Program (QAPI), revised date 10/24/22, documents, in part, Quality of care will be monitored and evaluated in areas of resident care and services at each QAA meeting, including but not limited to: Abuse/Resident Rights .

Based on interview and record review, the facility failed to provide supervision, and an environment that is free from accidents and hazards for one (R1) of five residents reviewed in a total sample of four residents. This deficiency resulted in R1 falling from bed and sustaining a right femur fracture and swelling to the forehand. Findings include: R1's current face sheet documents R1 is a [AGE] year-old individual admitted to the facility on [DATE]. R1's medical conditions include but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, aphasia following cerebral infarction, other sequelae of cerebral infarction, foot drop, left foot. R1's MDS (Minimum Data Set) 3.0 Brief Interview for Mental Status (BIMS) dated Jun 10, 2024, documents R1 has a BIMS score of 13/15, indicating she has intact cognitive function. Section GG - Functional Abilities and Goals documents: R1 requires setup or clean-up assistance with eating/oral hygiene and is dependent with toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on side of bed, chair/bed-to-chair transfer and sit to stand, toilet transfer, tub/shower transfer was not attempted due to medical condition or safety concerns. R1 has Functional limitation in range of motion, and R1 has lower/upper impairment on one side and is always incontinent of bladder and bowel and uses a wheelchair. On 10/10/2024, at 2:56PM, V9 (Certified Nursing Assistant-CNA) stated via phone that she had just taken care of R1 who was not able to move her body except move her the right hand but was not able to turn left to right or get out of bed by herself. V9 stated as she was getting out of the door, she heard a sound of someone falling and went back to R1's room and found R1 face down on the floor. V9 stated she had just prepositioned R1 to face the window side, and R1 was not able to move by herself. V9 stated maybe she left R1 at the edge of the bed, and V9 does not know if R1 was at risk for falls.V9 said she then called for help and all staff came to the room to rescue R1. V9 stated fall risk residents have a sign on the door to let staff know who is on fall but does not know if R1 had sign on the door for risk for falls. V9 stated she worked for a few more weeks and then somebody from the facility told her she was fired. On 10/10/2024, at 3:32 PM, V2 (Director of Nursing-DON) said R1 was a potential for risk of falls related to limited mobility. When transferring or changing R1, there should be two staff because R1 was not able to move her body to reposition herself or assist staff with turning herself or repositioning. V2 stated V9 should not have been cleaning R1 by herself because R1 was a two person assist resident, and maybe turning and repositioning R1 alone could have contributed to R1 falling and swelling (hematoma) on the forehead. V2 stated R1 was sent to the local hospital. Later that day, V8 (Licensed Practical Nurse-LPN) called the local hospital and was informed R1 was admitted with diagnosis of right femur fracture. V2 stated the facility staff are supposed to follow residents care plans and keep the residents safe and prevent falls.V9 was in-serviced about repositioning R1 in the middle of the bed after R1 fell . On 10/10/2024, at 1:28 PM, V10 (Advanced Nurse Practitioner) said R1 was a new patient for her and had just started providing services to R1 and V10 further stated that the morning of 7/15/2024 when R1 fell , V10 had just seen R1 for a cough, and V10 had observed R1 in bed awake with no bruises or swellings.V10 stated she was still in the building when she received a call that R1 had fallen. V10 stated she went back to R1's room and found R1 on the floor on the right side of the bed. R1 had a large hematoma on her forehead and a small amount of blood was observed on her gums. V10 stated the large hematoma was secondary to the fall because V10 had just seen R1 that morning and R1 did not have a hematoma. V10 said after she assessed R1, she gave orders to V8 (LPN) to call 911 to transport R1 to the local hospital for further evaluation and later found out R1 was admitted to the hospital with a femur fracture on the right leg, and R1 was also on blood thinners. V10 stated R1 had left side hemiparesis (paralysis) due to a stroke. She had never seen R1 get out of bed by herself or turn or reposition herself in bed. But V10 has seen R1 eat things like popcorn by herself using the right hand. R1 might have slid out of bed if she was not positioned properly. V10 stated R1 did not complain she was in pain before the ambulance got to the facility, but R1 might have been in shock due to the fall. She was also on scheduled gabapentin 100mg (milligrams) three times a day. V10 stated she hopes staff monitor residents, so they do not fall to prevent any resident injuries. R1 should have been monitored to prevent falls. On 10/09/2024 at 12:25PM, V6 (Director of Rehabilitation) stated R1 was referred to therapy on 05/18/2023, for Physical Therapy/ Occupation Therapy (PT/OT) related decline in strengthen and balance, positioning and safety while seated in wheelchair. V6 stated R1's bed/wheelchair mobility evaluation/assessment was done on May 18th, 2023. The evaluation determined R1 was dependent on bed/wheelchair mobility, meaning she needed 100% assistance with bed/wheelchair mobility, and staff have to do all the work. V6 said R1's PT ended on June 14th, 2024. R1 did not show any improvement and continued to be dependent on 05/18/2024. R1 was working on bed/wheelchair mobility, but R1 was not able to turn or reposition herself and remained dependent on staff for bed/wheelchair mobility. Therefore, R1 was discharged from therapy. V6 stated for dependent residents, when positioned by staff, the resident will remain the same until repositioned again because the resident cannot move her/himself. Therefore, staff have to move the resident. V6 stated he was familiar with R1 and she could not move or reposition herself independently in bed or in wheelchair. On 10/10/2024, at 12:56PM, V7 (Restorative Director) stated the Fall Risk Assessment shows which resident is at a high risk for falls and stated R1's fall risk assessment on 07/17/2024, two days after the fall. V7 stated the fall risk assessment is supposed to be completed on the day of the resident fall. V7 stated R1's initial fall risk assessment was completed on 12/28/2023, and R1's score was 10. V7 said a score of 10 indicates the risk for falls is high and fall precautions are put in place such as the blue star program where a blue star is put on the door of the at fall risk resident to let staff know the resident is at a high risk for fall. V7 stated R1 was a blue star resident. Her bed should have been in low position. R1 was not ambulatory, was a two person assist with toileting, needed the mechanical lift from bed to wheelchair and vice versa. V7 stated R1 was on a high back wheelchair, meaning the wheelchair could be reclined at a slight angle. V7 stated R1 was on the restorative program and was receiving Passive Range of Motion for left upper and left lower extremity because R1 has left side weakness and had a splint on her left ankle and left hand. V7 said R1 was receiving active range of motion for her right upper and lower extremities. V7 stated R1 could not roll from left to right or right to left by herself unless assisted by two staff. V7 stated R1 was dependent moving from chair to bed, putting on upper/lower body dressing, laying to sitting on the side of the bed, to shower, sit to laying, and toilet hygiene. V7 stated dependent means the staff do all the work. V7 stated a dependent resident like R1 cannot fall out of bed if positioned properly because R1 would need staff to do the movement for her. V7 stated R1's Resident Functional Ability was conducted on 6/11/2024, and documents R1's detailed summary of R1's abilities as: Eating-setup or cleanup assistance, oral hygiene, R1 needs supervision/touching, for toilet hygiene, shower/bathing self, upper/upper body dressing, putting on/taking off footwear-dependent, roll left/right-dependent, sit to laying, laying to seating on edge of bed, Chair/bed to chair transfer, toilet transfer, R1 is dependent. Car transfer, walk 10 feet, walk 50 feet, walk 150 feet- was not applicable. Wheelchair wheeling dependent. Sit to stand was not attempted due to medical condition or safety concerns. R1's Facility Reported Incident Report sent to Illinois Department of Public Health on 07/15/2024 documents: - On 7/15/24 at 11:00 AM, R1 was observed lying on the floor beside her bed. R1 sustained a bumped to the forehead and a skin tear to the mouth, R1 sent to the local hospital. At around 7:38 PM, follow up made to the hospital and informed that R1 was admitted with a diagnosis of right femur fracture. R1's progress notes document: 7/15/2024, 2:05 PM-Fall Description: R1 had an un-witnessed fall 07/15/2024 11:00 AM Location of Fall: At bedside. R1 was noted face down on the floor between the bed and the wall by the window, responsive to verbal stimuli. 7/15/2024, 7:38 PM-R1 was admitted to local hospital with diagnosis of Right femur Fracture. 7/17/2024 11:10 AM-V9 (certified Nursing Assistant-CNA) was in-serviced on positioning resident in the center of the bed and with proper level of assistance. R1's care plan dated: 03/26/2024 documents: -R1 has Potential for falls related to: decreased mobility, incontinence, weakness, -Goals- R1 will have no significant injuries related to falls thru next review date, will have no falls thru next review date. -Interventions: Assess for fall risk per facility, assess for toileting, half rails to assist with transfers, keep bed in locked position, keep frequently used items in reach, Non-skid footwear when up. Fall policy titled Fall Prevention Program dated 11/21/17 documents: -The bed will be maintained in position appropriate for resident transfers. -The bed locks will be checked to assure they are in locked position at all times -The resident's personal possessions will be maintained within reach when possible. -Residents will be observed approximately every two hours to ensure the resident is safely positioned in the bed or a chair and provide care as assigned in accordance with the plan of care. -Nursing personnel will be informed of residents who are at risk of falling. The fall risk interventions will be identified on the care plan. -the resident will be reminded as needed to call for assistance before attempting to ambulate.

Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that (R2's) monthly weights were documented, failed to ensure that resident dietary preferences are included on nutritional assessments and failed to ensure that two of five residents (R1, R2) in the sample remained free from significant weight loss. These failures resulted in R2 sustaining 7.1% weight loss in 1 month and R1 sustaining 11.6% weight loss within 6 months. Findings include: R2 is [AGE] years old with diagnoses which include end stage renal disease and protein-calorie malnutrition. R2's POS (Physician Order Sheets) include (1/25/24) general diet, whole milk with meals. House Nutrition Supplement 8 ounces TID (three times daily). (2/15/24) Multivitamin with minerals daily. (6/17/24) Prostat AWC (advanced wound care) 30 cc (cubic centimeters) TID for nutritional supplement. R2's (6/24/24) BIMS (Brief Interview Mental Status) determined a score of 15 (cognition intact). On 9/4/24 at 11:26am, surveyor inquired about dietary concerns, R2 stated We get 3 meals, but the portions have gotten really small since December when a new owner took over this place. Half of the time I'm ordering food out because I'm not full (a restaurant bag was observed in R2's trash can at this time). I've lost weight since then. Surveyor inquired if R2's weight loss was planned, R2 responded No. They used to give you menus and you could select what you want and even get double portions if you want. Now, we just get what they put in front of us. We don't get a choice of food or a choice of a size. Surveyor inquired if the facility offers alternate menu items, R2 replied No, they used to, but they don't anymore. R2's weights are as follows (8/7/23) 132.4# (pounds). (10/4/23) 133.6# (gain). (12/8/24) 133# (loss). (1/5/24) 122.9# (loss). (7/4/24) 117.8# (loss). (8/13/24) 109.4# (23# loss in 12 months). R2's required (monthly) weights (per facility policy) were not documented for September, November, February, March, April, May, and June (2024). [R2's weight loss started in December - as stated]. R2's (8/19/24) nutrition progress notes include general diet. PO (Oral) intakes 75-100% per nursing records occasionally less. House supplement 8 oz (ounces) TID, Prostate AWC 30ml (milliliters) TID. Multivitamin with minerals. Current body weight reflects significant weight loss 7.1% x 1month. Plan: whole milk with meals, staff to encourage compliance with supplement intake [food preferences and/or double portions are excluded]. R2's (August 2024) MAR (Medication Administration Record) affirms the house supplement was refused 37 times, Prostate AWC was refused 66 times and Multivitamin with minerals was refused 25 times. On 9/12/24 at 1:49pm, surveyor inquired about R2's unplanned weight loss V16 (Registered Dietician) stated I know that I follow her (R2) for impaired skin (stage 4 sacral area). She (R2) did have significant weight loss. I (V16) did see her in August for the original weight loss. We had her on supplements already for weight management and wound healing, and I added whole milk with meals. Surveyor inquired what R2's weight loss is attributed to, V16 responded She does have CKD (Chronic Kidney Disease) and a wound. It is documented that she's eating 75-100% so were just monitoring her intakes and her weights. Surveyor inquired when resident's weights are supposed to be done, V16 replied They're done monthly [R2's weights were not documented monthly]. Surveyor inquired if R2's dietary preferences are included in the Nutrition progress notes and/or assessments, V16 stated The food service manager updates the resident food preferences. Surveyor inquired if double portions were recommended for R2, V16 responded Not by me, no. Surveyor inquired why whole milk was recommended for R2, V16 replied It's just to increase the calories with her meals and add protein. Surveyor inquired if V16 comes to the facility and/or speaks directly with the resident during Nutritional assessments, V16 stated Its' hybrid, so sometimes its remotely and just communicating with staff in the building. R1 is [AGE] years old with diagnoses which include hypertension secondary to other renal disorders. R1's POS includes (1/29/24) Nepro (Supplement) 8 ounces BID (two times daily) and (4/18/24) LCS (Low Concentrated Sweets), NAS (No Added Salt) diet, no orange juice, banana, potato, tomato. R1's (7/14/24) BIMS determined a score of 13 (cognition intact). On 9/3/24 at 1:42pm, surveyor inquired about dietary concerns, R1 stated They have me on a kidney diet which I don't need anymore. They feed me the regular stuff and I get sick for the past year. I get nauseous just looking at the stuff or smelling it. I asked them (staff) to just bring me cottage cheese because you can't screw that up but rarely, they give it to me. They have lemon pudding or soup I can eat; they're getting better with bringing me a small salad but that's not gonna do it long term. I just need more protein to increase my muscles and stamina. I've lost 112 pounds since last August. I depend on Ensure if I don't get anything to eat and sometimes, they run out. Surveyor inquired if R1 has orders for Ensure, R1 responded No. Surveyor inquired if R1 was seen by the Dietician, R1 replied I've asked to see a Dietician they have one, but she's just totally useless. The thing is, you ask for something, and they acknowledge the issue but there's no follow through. The attitude is, isn't it great she lost all that weight, and it is but I'm starving. Meals go by and I don't get anything I can eat. Surveyor inquired if R1's weight loss was planned, R1 stated No. R1's weights include but not limited to: (8/2/23) 262# (pounds). (11/9/23) 225# (37# loss in 3 months). (2/6/24) 203.5# (58.5# loss in 6 months). (8/7/24) 196# (66# loss in 12 months). On 9/3/24 at 1:58pm, surveyor inquired how much weight R1 lost in the past 12 months, V3 (Licensed Practical Nurse) stated About 60 pounds [R1 lost a total of 66 pounds]. Surveyor inquired what R1's weight loss was attributed to, V3 responded The doctors are aware of this; I think she wanted to lose weight [R1 affirmed that she did not want to lose weight]. Surveyor inquired if R1 was assessed by the dietician, V3 reviewed R1's electronic medical records, affirmed she was last seen on 7/9/24 and sustained significant weight loss of 7.9% in 3 months. Surveyor inquired about R1's current diet, V3 replied She has LCS/NAS diet no orange juice, potato, tomato [double portions and/or food preferences were excluded]. Surveyor inquired if R1 receives a supplement, V3 stated She's on Nepro 2 times a day but I don't think she likes this one. R1's (August 2024) MAR affirms Nepro was refused 3 times and not documented 1 time. R1's nutrition progress notes include (6/5/24) Significant weight loss 11.6% x 6 months. Intakes typically, 50-100% per nursing records, varies occasionally. Goal to maintain current body weight. Diet; NAS/LCS, no banana, tomato, potato. Nepro 8 oz BID. No recommendation [food preferences and/or double portions are excluded]. (7/9/24) Significant weight loss 7.9% x 3 months. Diet; NAS/LCS, no banana, tomato, potato. Nepro 8 oz BID, Proteinex. No recommendation [food preferences and/or double portions are again excluded]. On 9/12/24 at 1:56pm, surveyor inquired about R1's unplanned weight loss, V16 stated She has been stable since I've been seeing her in April. Surveyor inquired if R1 sustained significant weight loss, V16 responded She did but she's stabilizing. She's also on a diuretic which causes weight fluctuations. Surveyor inquired what R1's significant weight loss is attributed to, V16 replied I didn't know her that long ago. She's been in the 190s since I'm working with her, and the diuretic will cause weight fluctuations. We have her on Nepro and been maintaining her weight. Surveyor inquired if R1's dietary preferences are included in the Nutrition progress notes and/or assessments for R1, V16 stated Those will be updated by the food service manager and on her meal ticket. Surveyor inquired if resident food preferences are recommended by the Dietician so physician orders can be obtained and followed, V16 responded Not for food preferences, those just go on their meal ticket. Surveyor inquired if V16 recommended double portions for R1, V16 replied I did not, sometimes Nursing or the Doctor can do that, but I haven't. On 9/16/24 at 1:34pm, surveyor inquired if a resident is eating meals but however refusing nutritional supplements, what should be implemented to increase caloric intake, V15 (Medical Director) stated Appetite stimulant sometimes help, we can also offer different meal options. We also go over all the patients with weight loss at the monthly meetings and look at individual approach how to solve the issue. Surveyor inquired about potential harm if a resident sustains significant weight loss, V15 responded Malnutrition can worsen the patient's chronic medical condition and increase wounds. The weights policy (revised 10/17/24) states each resident shall be weighed on admission and at least monthly thereafter, or in accordance with Physician orders or plan of care. Residents identified at nutritional risk may be weighted weekly or bi-weekly as per physician order or Interdisciplinary Team recommendation. Undesired or unanticipated weight gains/loss of 5% in 30 days, 7.5% in 3 months, or 10% in 6 months shall be reported to the Physician, Dietician and/or Dietary Manager as appropriate.

Based on observation, interview, and record review, the facility failed to supervise two of three residents (R1, R3) reviewed for falls. This deficient practice resulted in R1 falling and breaking her pelvis. Findings include: 1)R1's medical record (Face Sheet, Physical Therapy Notes) document R1 is a [AGE] year-old admitted to the facility on [DATE] with diagnoses including but not limited to: Diverticulitis of Intestine, Syncope and collapse, Open angle glaucoma, Muscle weakness (generalized), Other abnormalities of gait and mobility (03/04/2023), and Other lack of coordination (03/04/2023). R1's MDS (Minimum Data Set, 03/10/2023) notes a BIMS (Brief Interview for Mental Status) of 8 denoting R1 was moderately cognitively impaired. On 04/01/2023 at 7:14 PM-7:33 PM, V3 (RN-Registered Nurse) said she was the nurse working the 7:00 PM-7:00 AM shift on 03/04/2023 when R1 fell the morning of 03/05/2023. So, what happened, the patient (R1) had a fall. She was coming out into the hallway from her room, she was a little unsteady on her feet. She fell backwards, she hit her head on the wall. She complained of pain to her back. She was always complaining of pain, she was a hypochondriac with a psych history. When asked if R1 was a fall risk, V4 said Oh, yeah, she was a fall risk, she was a new admit, and unsteady on her feet. I checked on her frequently, at least every hour, there should be documentation in her progress notes. I asked R1 what she was doing; R1 said she was going to the bathroom. We would monitor R1 frequently, assist with toileting needs, ensure R1 was clean and dry; we kept the call light close to R1 but she didn't use it. I'm sure she was getting up on her own (to go to the bathroom), we probably didn't see her. On 03/05/2023 at 7:49 PM, Progress Note documents in part, Describe Incident in Detail: 03/04/2023 7:00 PM Resident observed in bed. No c/o (complaint) voiced. 9:00 PM All due meds given. 10:00 PM Resident assisted with toileting needs by CNA. 03/05/2023 12 MN (midnight) Sleeping in bed. 2:00 AM Resident observed walking out of room in hallway. Gait unsteady. Assisted back to bed. Instructed resident to use call light and to call nurse for assistance. 4:00 AM Sleeping on rounds. 5:20 AM Resident observed walking out of room into hallway. Gait unsteady. Observed resident falling to the floor. Resident was obsrved in supine position. C/O (complaining of) back and stated, I hit the back of my head. Ask resident where was she going or doing. Resident stated I was trying to go to the bathroom. 04/03/2023 at 9:27 AM-9:43 AM via telephone, V4 (CNA-Certified Nursing Assistant) said, she was the CNA responsible for R1's care on 03/04/2023 from 11 PM-7 AM when R1 fell on the morning of 03/05/2023. V4 said R1 was a fall risk. V4 said R1 wasn't in bed at the beginning of the shift; R1 was sitting up in the dining area watching TV. Around 12 (midnight) V3 (RN-Registered Nurse) told me to put R1 back in bed. I put R1 back in bed and covered her. I don't remember toileting her; I assumed we changed her in the bed since she had a diaper on. Prior to the fall, R1 was getting up all the time on her own, we couldn't keep her sitting. We kept the bed locked in the low position, call light within reach. We encouraged R1 to use the wheelchair, but she would get up on her own all the time without the wheelchair. I don't remember a walker. On 04/03/2023 at 1:18 PM-1:25 PM via telephone, V5 (PT-Physical Therapist) said, Before I saw R1 (for physical therapy evaluation), both the nurse and the CNA said R1 kept getting up on her own and walking into the hallway. I remember when I saw her that day, on Saturday, that she kept walking by herself in the hallway; her gait was unsteady. When the session was over, I put her back to bed; the bed was locked and in the lowest position; the call light was within reach; her walker was near her bed within reach. I spoke with the CNAs and Nursing, I told them R1 needed to ambulate with the walker; the walker should be within R1's reach. I also left the door (to her room) open so that everyone could see what was going on. It was really unsafe for R1 to be left alone. She definitely needed supervision and to use the walker. On 04/01/2023 at 6:29 PM-6:31 PM, V1 (Administrator) said, R1's son informed the facility, during a care plan meeting, that R1 fell last year and broke her pelvis. V1 said the fracture found on R1's X-ray on 03/05/2023 was an old fracture from previous fall. X-ray of pelvis report of 12/02/2022, documents, under diagnoses, Closed fracture of other parts of pelvis. X-ray of pelvis report of 03/05/2023, documents, under findings, There are fractures of the left superior and inferior pelvic rami and under impression, Fractures of the left pubic rami. On 04/03/2023 at 5:27 PM-5:38 PM via telephone, V6 (Nurse Practitioner) said, she saw resident (R1) three times while at facility, the last time she believes was when R1 was discharged from the facility. V6 said she is aware of the x-ray result for fall of 3.5.23 but does not know anything about x-ray results from 12.22.2022. V6 said, I would like to review the record before I give you an answer (are the fractures seen on 3.5.2023 x-rays the same fractures seen on 12.22.2022 x-ray?). V6 said she will call back within an hour; will call to speak with administrator to get x-ray results of 12.22.2022). On 04/03/2023 at 6:33 PM-6:36 PM via telephone, V6 said, I do not have a lot of information. R1 was primarily at the facility for diverticulitis. I spoke with the Administrator (V1), he would not provide information related to R1's fall on 12.22.2022. I can't answer your question about R1's x-ray results of 12.22.2022. V7 (R1's Physician) was not available for interview. On 04/03/2023 at 4:20 PM-4:30 PM, V8 1620 (RN/ Fall Nurse) said, fall interventions that were put into place prior to R1's fall included: call light within reach, bed in low position, answering call light in timely manner, the basic interventions you would do for anyone. 2)R3's medical record (Face Sheet) document R3 is a [AGE] year-old admitted to the facility on [DATE] with diagnoses including but not limited to: Parkinson's disease, Fall on same level from slipping, tripping and stumbling with subsequent striking against other object, Closed head injury, and Severe dementia. R3's MDS (Minimum Data Set, 03/30/2023) notes a BIMS (Brief Interview for Mental Status) of 9 denoting R3 is moderately cognitively impaired. Progress Note of 03/23/2023 at 5:43 PM documents: Weight Bearing Status: 1 person assist Falls Care Plan Potential (effective 03/25/2023) documents under interventions, Assist resident in transfers and ambulation. On 04/03/2023 at 1:00 PM, R3 was observed getting out of his wheelchair, unassisted, pants sliding down partially exposing his buttocks. R3 continued to ambulate down hallway while pushing wheelchair. There were no staff in or around common area to assist or re-direct R3. On 04/03/2023 at 4:32 PM-4:40 PM, V9 (RN-Registered Nurse) said, R3 can use a walker or a wheelchair (self-propel); he's unsteady on his feet. When R3 is ambulating, it would be best if one person is assisting him.

Based upon observation, interview and record review the facility failed to follow the fall prevention policy, failed to ensure that staff are aware of resident fall prevention interventions, and failed to implement fall preventions for four of four residents (R1, R2, R3, R4) reviewed for falls. The facility also failed to score (R1's) fall risk assessment properly and failed to timely transfer (R1) to the hospital post fall. These failures resulted in R1's ([DATE]) fall with subarachnoid hemorrhage and death. R1's ([DATE]) cause of death includes subarachnoid hemorrhage. Findings include: R1 was admitted to the facility on [DATE], transferred to the hospital on [DATE] and expired [DATE]. R1's ([DATE]) BIMS (Brief Interview Mental Status) determined a score of 14 (Cognitively Intact). R1's ([DATE]) functional assessments affirms (1 person) physical assist is required for bed mobility, transfers, and toilet use. Mobility devices: walker. R1's ([DATE]) care plan includes fall potential related to unsteady gait, poor muscle strength, and status post fall. Interventions include assist resident in transfers and ambulation. R1's ([DATE]) fall risk assessment determined a score of 4 (if the score is 6 or greater, the resident should be considered high risk). Gait and Balance is marked normal 0 however R1's care plan affirms unsteady gait and poor muscle strength were identified. Requires assistive devices (walker) was also not selected (as warranted) therefore the score is incorrect. On [DATE] at 9:51pm, surveyor inquired about R1's ([DATE]) fall risk assessment. V8 (Restorative Nurse) stated, in part Gait and balance they scored her zero as normal. Predisposing diseases, they scored her a zero. Surveyor inquired about R1's gait/balance. V8 responded, During her assessment she did have good balance when standing with an assistive device, a walker. Surveyor inquired why the walker was not selected on the assessment. V8 replied, I'm not sure what the nurse's thought process was when she was doing the assessment. Maybe she just made an error. Surveyor inquired what a score of 6 indicates. V8 stated, That they are not a high fall risk. Surveyor inquired about R1's ([DATE]) fall prevention interventions which may prevent harm from falls. V8 stated, anticipate needs, maintain safe environment. Surveyor inquired what fall prevention intervention would be appropriate for a resident with prior falls resulting in harm. V8 responded, I don't know if you're like referring to a landing pad, but we typically need to see if they are ambulatory because it's a tripping hazard however (1 person) physical assist was required to transfer R1. R1's initial incident report states on [DATE], resident was noted on the floor on her side in front of her bed. Resident was assessed and noted alert to self, unable to make needs known and unable to follow commands. Doctor notified order received to send to ER (emergency room ) for further evaluation. Resident was admitted with subarachnoid hemorrhage, [CONDITION(S)] and [CONDITION(S)]. On [DATE] at 11:17am, surveyor inquired about R1's ([DATE]) fall V10 (Director of Human Resource) stated I was manager on duty. I was doing rounds and saw her (R1) on the floor. She (R1) was laying on her right side with her hands under her head, it looked like she was sleeping. She was a little further than the bed, she may have been walking. She responded when I asked her if she was ok, she said yes. Surveyor inquired if floor mats were in use V10 replied I cannot remember. I ran in the room pressed call light and the CNA (Certified Nursing Assistant) came with a cup of water. He (V9/CNA) said I just left her on the bed and brought water for her. I called for the Nurses. Surveyor inquired if R1 was transferred to the hospital immediately V10 stated I left when the Nurses arrived and affirmed she was unsure. On [DATE] at 11:35am, surveyor inquired about R1's functional status prior to ([DATE]) fall V9 (CNA) stated Before the incident happened, I don't really work with her cause normally I work with section 5. It was the first time I seen her and affirmed he was unsure. Surveyor inquired if V9 was aware of R1's required fall prevention interventions V9 responded Nope, I know the commode was nearby. Surveyor inquired if V9 was aware that R1 was at risk for falls V9 stated Normally the nurse will let you know if the persons a fall risk they'll tell you to mind this person. No, I wasn't told. Surveyor inquired about R1's ([DATE]) fall V9 responded When I went around with the water, she was lying on the bed she didn't say she needed anything. I went down the hall to change somebody's diaper and then I was called up by (V10) to see what was happening in the room. When I came to the room, she was lying on the floor on the right side perpendicular to the bed. She was mumbling, I could only make out the word pee. (V10) called two other nurses there to come see what happened. We got her back to the bed and when the Nurse in charge of the section came on, she called the hospital and booked an appointment for her I think they came around 10:20am or so and took her out. Surveyor inquired if a floor mat was in use prior to R1's fall V9 replied There was no floor mat. On [DATE] at 1:51pm, surveyor inquired about the importance of scoring fall risk assessments accurately. V12 (Medical Director) stated, It is important to prevent the fall. Surveyor inquired about potential harm to a resident who sustains an unwitnessed fall. V12 responded, The injury, broken bones or head injuries. Surveyor inquired about an appropriate time frame for transferring a resident (post unwitnessed fall) to the hospital for evaluation. V12 replied, We always call 911 for every fall and evaluate that, as soon as 911 arrives the patient is being transferred. R1's ([DATE]) progress notes exclude the incident and/or calling 911. R1's ([DATE]) progress notes (entered the following day) state on call doctor notified and gave order to send resident to hospital for evaluation. Writer called report to registered nurse at ER. Ambulance notified gave estimated time of arrival 20 minutes [911 notification and/or actual time of these events were not documented]. On [DATE] at 1:56pm, surveyor inquired about R1's ([DATE]) incident. V15 (Licensed Practical Nurse) stated, When I got that assignment (around ,d+[DATE]:30am) the resident was in the bed. The RT (Respiratory Therapist) had said to me that she was off of her baseline (alert x1) not x3 her usual. I called the doctor to get a order for her to be sent out to the emergency room . I called ER to give report to the nurse. Then I called (Ambulance Service) to have her picked up, I told them that she had a reported fall and that she was off of her baseline. Surveyor inquired if 911 was called V15 responded, No. R1's ([DATE]) unusual occurrence report affirms the incident occurred at 8:30am. R1's neurochecks were documented by facility staff from 8:,d+[DATE]:15, therefore roughly 1 hour and 45 minutes elapsed before the transfer occurred. R1's ([DATE]) history & physical states patient presents from nursing home after being found unresponsive on the floor next to bed. Patient arrived unresponsive. [CONDITION(S)] mostly left arm/leg shortly after arrival. Upon return from first CT (Computed Tomography) more [CONDITION(S)] activity. Doctor requests CTA (Computed Tomography [MEDICATION(S)]) head/neck but SAH (Subarachnoid Hemorrhage) pattern more likely traumatic. R1's ([DATE]) Neurosurgery consult states she came to ED with SAH and a small left frontal contusion without significant mass effect or midline shift. Repeat head CT shows worsening hemorrhage: massive enlargement of left frontal contusion encompassing the speech area causing moderate mass effect ,d+[DATE] millimeters midline shift. Patient is medically unstable for surgery and the prognosis even with surgery remains very poor. R1's ([DATE]) Certificate of Death affirms death occurred in a hospital (inpatient). Cause of Death: subarachnoid hemorrhage, [CONDITION(S)]. __ R3's ([DATE]) BIMS (Brief Interview Mental Status) determined a score of 6 (severe impairment). R3's ([DATE]) functional assessments affirms (2 person) physical assist is required for bed mobility and transfers. R3's ([DATE]) fall risk assessment determined a score of 10 (high risk). R3's ([DATE]) fall care plan states alert and oriented x2. Unsteady standing balance/coordination, poor safety awareness. Tripping hazard: g-tube tubing. Intervention; maintain call light within reach while in bed. On [DATE] at 1:30pm, R3 was lying in bed without call light access. R3's call light was dangling from the over bed light and out of reach. On [DATE] at 1:35pm, surveyor inquired about the location of R3's call light V 4 (CNA) entered the room and stated I didn't put it up there, it's up on the light. Maybe the cleaning lady put it up there or something. R3's bed was notably elevated (thigh high). Surveyor inquired if R3's bed was in the lowest position. V 4 stated, No, it was kinda up the way I had it and proceeded to lower the bed. Surveyor subsequently inquired about R3's required fall prevention interventions V 4 stated, lower bed. I never seen a mat in there. I never seen bolsters or anything it's just her in the bed. __ R2's ([DATE]) BIMS (Brief Interview Mental Status) determined a score of 99 (unable to complete interview). Cognitive skills for daily decision making; severely impaired. R2's ([DATE]) functional assessments affirms (2 person) physical assist is required for bed mobility and transfers. R2's ([DATE]) fall risk assessment determined a score of 14 (high risk). R2's ([DATE]) fall care plan states alert and oriented x2 with confusion. Poor standing balance/coordination. Intervention: maintain call light within reach while in bed. On [DATE] at 1:11pm, surveyor inquired about R2. V3 (CNA/Certified Nursing Assistant) responded, She's not able to walk and affirmed (R2) is somewhat confused. R2 was subsequently observed lying in bed without call light access. Surveyor inquired about the location of R2's call light. V3 stated, It's right here on the table, it's supposed to be connected to her then placed the call light button within reach. R2 responded, Where did you find that at? (Referring to the call light). V3 replied, On the table. Surveyor inquired about R2's required fall prevention interventions. V3 stated, She got the landing pads. __ R4's ([DATE]) BIMS (Brief Interview Mental Status) determined a score of 3 (severe impairment). R4's ([DATE]) functional assessments affirms (2 person) physical assist is required for bed mobility and transfers. R4's ([DATE]) fall risk assessment determined a score of 10 (high risk). R4's ([DATE]) fall care plan states alert and oriented x1. Poor muscle strength. Intervention: provide personal alarms while resident is in bed or up in chair. On [DATE] at 1:50pm, R4 was lying in bed. A large mattress was adjacent R4's right side of bed however a floor mat on the left side of the bed was absent. On [DATE] at 1:56pm, surveyor inquired about R4's fall prevention interventions V7 (CNA) stated Use the belt to pull her up and extra bed to save her (referring to the large mattress on the floor). Surveyor inquired if there was a floor mat on the other side of R4's bed. V7 responded, No. Surveyor inquired if R4 has a history of falls. V7 replied, That one, I'm not sure. I'm never permanent on this floor. R4 was subsequently assessed however an alarm was not in use. The fall occurrence prevention policy (revised [DATE]) states a fall risk form will be completed on all residents upon admission readmission, quarterly, annual, post fall and on significant change of condition. It includes a fall history and a list of risk factors. The main purpose of which is to prevent injury from falls. A resident identified being at risk for fall shall have a potential for fall care plan addressing risk for fall. Plan of care with goals and intervention will be communicated to staff.

Based on interview and record review, the facility failed to provide proper bed mobility assistance for turning in bed to avoid physical harm to one (R1) of four (R1, R2, R3, R5) residents reviewed for resident injury. This failure resulted in R1 sustaining injuries of an acute comminuted fracture of the left proximal humerus extending from the humeral diaphysis through the humeral neck and involving the humeral head. Findings include: R1's Face Sheet documents, in part, R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set (MDS), dated [DATE], documents, in part, that R1's Brief Interview for Mental Status (BIMS) score is a 99 which indicates that R1 was unable to complete the interview. R1's Staff Assessment for Mental Status indicates that R1's Short-term and Long-term memory is a 1 for Memory problem and that R1's Cognitive Skills for Daily Decision Making is a 2 for Moderately impaired - decisions poor; cues/supervision required. R1's Functional Status for Activities of Daily Living (ADL) Assistance documents, in part, Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed with a Self-Performance code of 4 for Total dependence - full staff performance every time during entire 7-day period and Support code of 3 for Two + (plus) persons physical assist. R1's Functional Abilities and Goals for Mobility documents, in part, A: Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed is coded as 1 for Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. R1's Bladder and Bowel Status for Urinary Continence documents, in part, a code of 3 for Always Incontinent (no episodes of continent voiding), and for Bowel Continence which is documented as a code of 3 for Always Incontinent (no episodes of continent bowel movement). R1's Care Plan, dated 2/1/21, documents, in part, a focus of ADL: Resident requires assist with: Bed mobility . Related to: Limited mobility, Poor Cognition, Difficulty making needs know . Due to Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Moderate large right temporo-parietal stroke with an intervention of provide assistance with repositioning in bed. R1's Care Plan, dated 2/26/21, documents, in part, a focus of Bed Mobility Program: Resident with impaired bed mobility as evidence by: Difficulty in repositioning self in bed . Related to: weakness, debility, poor cognition and easily gets tired/poor endurance. No goals or interventions exist for this focus. On 10/24/22 at 12:47 pm, V3 (Registered Nurse, RN) stated, I (V3) am familiar with (R1). (R1) is oriented times one, only to (R1's) self, confused and bed bound. (R1's) left side, (R1's) not able to move it, not at all. On 10/24/22 at 3:23 pm, V3 (RN) stated, CNA's do the (incontinence brief) changing and turning. V3 stated, R1 speaks in Korean and understands English, but (R1) can't communicate back to you in English. R1's Left Humerus (2 + views) X-ray results, dated 10/2/22 at 7:57 pm, documents, in part, Impression: Acute comminuted fracture of the proximal humerus extending from the humeral diaphysis through the humeral neck and involving the humeral head. R1's Left Shoulder (2 + views) X-ray results, dated 10/2/22 at 7:53 pm, documents, in part, Impression: Comminuted acute fracture, of the proximal humerus including the proximal humeral diaphysis extending through the humeral neck and into the humeral head at the level of the greater tuberosity. Facility documents dated 10/1/22 (Saturday) and titled (Facility) Staff Daily Assignment, document, in part, that for the CNA room assignments for R1 were as follows: 7:00 to 3:00 pm shift with V20 (CNA); 3:00 pm to 11:00 pm with V8 (CNA) and 11:00 pm to 7:00 am with V7 (CNA). On 10/25/22 at 1:28 pm, V20 (CNA) stated that V20 was R1's CNA on 10/1/22 for the 7:00 am to 3:00 pm shift and that V20 was assigned as R1's CNA the one time. V20 stated, (R1) is a total, basically. I (V20) have to do everything for (R1). V20 stated that V20 did not get R1 out of bed during V20's shift on 10/1/22. When asked about V20 providing incontinence care for R1 in bed, V20 stated, I (V20) lay (R1) flat. Turn (R1) left and right and left. Did by myself (V20's self). (R1) didn't do anything (to help). When asked how is V20 to know how many persons are needed for bed mobility assist like a 1 person assist versus 2 persons assist. V20 stated, It depends on the weight. If the resident is real heavy, I (V20) will get someone else. On 10/24/22 at 5:25 pm, V8 (CNA) stated that V8 was R1's CNA on 10/1/22 for the 3:00 pm to 11:00 pm shift and that V8 was assigned as R1's CNA a couple of times a month ago. V8 stated, (R1) can't move very good. Had a stroke. (R1) is confused and can't talk very good. V8 stated, V2 (Director of Nursing, DON) and V3 (RN) had spoken to V8 after V8's care of R1 on 10/1/22. V8 stated, I (V8) told them (V2, V3) that I (V8) changed (R1's) (incontinence brief) and at that time, (R1) was in a cranky mood. V8 stated, I (V8) was able to change (R1) by myself. (R1) was like (R1) doesn't want be bothered. (R1) was telling me (V8) that (R1) didn't want to be changed. (R1) was very cross. I (V8) told (R1) that I (V8) have to change (R1) because (R1) was wet, so (R1) don't want skin to be broken. V8 stated, (R1) can't turn by (R1's) self. The right side of (R1's) bed was open (to the room). Left side of (R1's) bed was against the wall. To turn (R1), I (V8) push (R1) by the shoulder and under (R1's) arm with one hand and take (R1's) hip part with other hand and turn (R1's) towards the wall. V8 stated, When I (V8) am turning (R1) towards me (V8), I (V8) am on the right side of the bed. I (V8) take under (R1's) left arm. I (V8) am putting my (V8's) one hand under (R1's) arm pit but not directly on (R1's) shoulder blade. I (V8) have to be very careful. Some residents have [CONDITION(S)]. When asked if R1 had spontaneous movement of R1's left arm, V8 stated, I (V8) didn't work much with (R1). (R1) didn't move (R1's) left arm. (R1's) paralyzed. I (V8) move (R1) towards me (V8) on right side of bed. I (V8) reached over (R1's) body and under (R1's) left arm with my (V8) left hand and move (R1's) hips with right hand. When asked if V8 used the draw sheet to turn R1 in bed, V8 stated, Very seldomly do I (V8) use it (draw sheet) to turn side to side. I (V8) don't use that (draw sheet). On 10/24/22 at 5:12 pm, V7 (CNA) stated that V7 was R1's CNA on 10/1/22 for the 11:00 pm to 7:00 am shift and that V7 is usually assigned as R1's CNA. V7 stated, (R1) is total care. (R1) is in and out a little bit but mostly alert. (R1) speaks some English and understand it when I (V7) speak to (R1). (R1) talks to me (V7), if (R1) don't want something or is in pain. V7 stated, (R1) is bed bound on the night shift. I (V7) change (R1's incontinence brief). Clean (R1). Do everything for (R1). When asked about V7 performing care for R1 in bed on 10/1/22 from 11:00 pm to 7:00 am, V7 stated, I (V7) did do my rounds. (R1) will say apayo. Apayo means pain (in Korean). If you turn (R1) too hard, (R1) will let you know. (R1) had (R1's) gown on and could see (R1's) arm was hurt. V7 stated, It was on my (V7) last rounds at 4:30 am (10/2/22). I (V7) go to push to (R1) over. (R1) likes to have (R1's) moments when (R1) doesn't want to be bothered. With (R1's) good hand (right hand), (R1) can swipe at you. When asked about the 4:30 am rounds on 10/2/22, V7 stated, I (V7) went to change (R1). I (V7) told (R1), I (V7) have to change you. We had to pump (oral) fluids in you. When I (V7) turned (R1), (R1) said apayo. I (V7) turned (R1) by myself. I (V7) usually get somebody. (R1's) a 2 person (assist). V7 stated, If we have help, then I (V7) use 2 people. Using the pad to turn (R1). Bed side rail is up. As soon as I (V7) touched (R1), (R1) said apayo. I (V7) lifted up (R1's) gown and saw a bruise on left arm. V7 stated that R1's bruise was observed on the upper and outer part of R1's left arm. When asked to describe R1's left arm bruise, Red bruise. Burgundy color. Size of small [NAME] or apple. On 10/26/22 at 3:15 pm, V9 (Nursing Supervisor/RN) stated that V9 was R1's assigned nurse on 10/1/22 from the 7:00 pm to 7:00 am shift. V9 stated, (R1) stays in bed. (R1's) full assistance. V9 stated that on 10/2/22 around 5:30 am, V7 (CNA) informed V9 about R1's left upper arm bruise. This surveyor asked V9 when did V9 document the assessment R1's left arm bruise, and V9 stated that V9 corrected the documentation on 10/11/22; however, V9 originally documented R1's progress note on 10/2/22 around 8:00 am. V9 stated, (R1) couldn't turn by (R1's) self in the bed. When asked V9 if V9 has assisted with turning R1 in bed, V9 stated, No, I (V9) haven't helped (R1) turn. Usually, the CNA will assist with turning. When asked V9 how many persons are needed for bed mobility for R1, V9 stated, I think one person. When asked how can V9 find out how many persons are needed for R1's bed mobility, V9 stated, The computer system (electronic medical record, EMR) at the top which assigns on (resident's) wrist band. On (resident's) wrist band, it specifies a '1' or '2' which depends on how many staff are needed. V9 stated that CNAs can see how many persons are needed to turn a resident on the resident's wrist band and in their CNA charting. When asked if a resident's wrist band signifies a '2' for 2-person assistance, how is that '2' generated for that resident, and V9 stated, They are evaluated by the rehab restorative nurse. When asked what's the importance of following the restorative nurse's assessment for a resident for bed mobility, V9 stated, It's for the safety of the patient. When asked what effect to the resident is if the resident was assessed as a 2 person assist for bed mobility and then a 1-person assist was provided instead, V9 stated, The instructions are there and (we) have to follow the instructions from the evaluation by restorative to prevent; it's for the safety of the patient. In R1's Progress Notes, dated 10/11/22 at 11:41 am with type of note as Correction, V9 (Nursing Supervisor/RN) documented, in part, Notified by CNA (V7) while rendering patient care, resident (R1) complained of left upper arm pain. Assessed resident arm noted upper arm swelling with bluish discoloration of the skin. Resident verbalized pain 6/10 (6 out of 10) scale. On 10/25/22 at 10:09 am, V12 (Restorative Nurse) stated that V12 performs restorative assessments on residents at admission and quarterly to put in the amount of care that we think is needed for them transferring and bed mobility, and the amount of staff that is needed for the patient. V12 stated, restorative assessment is documented in the EMR where nursing staff can identify how many staff are needed for bed mobility. V12 stated that if the restorative assessment for bed mobility is assessed for 2 person bed mobility, then staff must have two people to assist the patient during bed mobility. V12 stated that V12 performed R1's 9/15/22 restorative assessment. V12 stated, (R1) is totally dependent. Pretty much a total assist. (R1) can move right arm. Bilateral legs cannot move. Left arm, the tenacity is stiff. When asked to describe the 2-person assist for bed mobility, turning a resident side to side, V12 stated one staff member will stand on each side the resident's bed. V12 stated, You would use the draw sheet to turn the patient. V12 stated, the staff members would encourage the resident to hold onto the bed rail if possible and that the staff member (who is on the side of the bed where the resident is turned) would then hold with the draw sheet if they (resident) can't hold the side rail. V12 stated, the same staff member would then hold onto the resident while the staff member behind then turned resident gently lowers the draw sheet to perform care. V12 stated that this process would be repeated to roll the resident in bed to the opposite side. V12 stated that staff will roll (resident) side to side using the draw sheet. Not physical movement of the body; use draw sheet. When asked what the purpose of a draw sheet is for in bed mobility, V12 stated, It helps with bed mobility, so you don't touch the patient or injure the patient by touching their body when pulling their body up. When asked about a 1 person assist for bed mobility, V12 stated the resident must be actively participating in bed mobility. You wouldn't use a 1 person assist if the resident is not actively able to participate in bed mobility. When asked if R1 is able to participate in bed mobility, V12 stated, No, (R1) total assist. (R1) needs 2 person assist. V12 was asked if V12 would expect nursing staff to use a 1-person assist when V12 has coded that resident for a 2-person assist, and V12 stated, No. It could cause injury to the resident and cause injury to yourself (staff). When asked if V12 would expect nursing staff to turn a resident side to side in bed without using a draw sheet, V12 stated, No, a draw sheet must be used to turn side to side in bed. When asked if V12 would expect the nursing staff to go under a resident's arm pit to turn a resident in bed, V12 stated, Never. Never are they (staff) to go under someone's arm. In R1's Restorative Functional Assessment, dated 9/15/22, V12 (Restorative Nurse) documented, in part, that R1's functional assessment type was Quarterly with R1's cognitive status as Alert, Confused, Oriented to person, and Forgetful. V12 documented, in part, R1's Bed Mobility: Repositions self in bed: Self Performance: 3=Extensive assistance. Repositions self in bed: Support Needed: 3=2 + (plus) person physical assistance. Turns to right side: Self Performance: 3=Extensive assistance. Turns to right side: Support Needed: 3=2 + person physical assistance. Turns to left side: Self Performance: 3=Extensive assistance. Turns to left side: Support Needed: 3=2 + person physical assistance. In R1's Restorative Program Quarterly Notes, dated 9/15/22, V12 documented, in part, (R1) requires total dependence with ADLs. R1's Skin Risk Assessment Tool, dated 9/17/22, documents, in part that R1's Range of Motion Extremity Mobility is scored as at 4 which is Immobile-passive ROM, unable to reposition self. On 10/25/22 at 10:31 am, V13 (CNA Scheduler/CNA) stated that CNAs can look in the EMR, look at the resident ID band or ask a nurse to find out how many staff are needed for bed mobility. V13 stated that a 2-person assist is listed on the ID band, and the person assist is determined by the restorative assessment. V13 stated with a 2-person bed mobility assist, the 2 staff members will turn with the pull (draw) sheet. V13 stated, If you push on (a resident's) body, you could injure them or bruise them. Pull sheet is more supportive. R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/25/22 at 3:50 pm, V2 (DON) stated that CNAs would find out in the EMR, from the nurses or from the resident's ID band about how many staff are needed to perform a resident's care. V2 stated a 2 person assist would be listed on resident's ID band. V2 stated, It's visible and goes with the restorative nurse's assessment. V2 stated, I expect my CNA staff to look at the (resident's) ID band to see what assistance level is needed. When asked what the effect is of turning a resident who is coded as a 2-person assist and staff performs bed mobility with 1-person assist, V2 stated An accident could happen if they (staff) don't follow what they are supposed to follow. Accident can mean, injury or fall. V2 stated that with bed mobility for a 2-person assist when positioning a resident in bed, staff are to use the draw sheet to turn the resident side to side in bed. On 10/27/22 at 1:23 pm, when asked if V2 would expect the nursing staff to move or turn a resident in bed by placing their hand or arm under a resident's arm pit to move the resident, V2 stated, No. V2 was asked why not that process. V2 stated, The mechanism can injure the resident or the staff. It's not the proper way of doing it. On 10/25/22 at 3:24 pm, V14 (Nurse Practitioner) stated, (R1's) total care. When asked if V14 is expecting that nursing staff follow the restorative assessment for R1 for a 2-person assist in bed mobility, V14 stated, Well, yes. I (V14) am assuming that they (staff) are doing what they are supposed to be doing. V14 stated with R1's X-rays showing osteopenia, With care provided, it is possible with care that a fracture could happen. However, V14 stated, If (R1) is rolled in bed and (R1's) arm gets tucked under the hip, a fracture could have occurred. Facility policy undated and titled Mobility Policy: Bed Mobility; Transfer; Ambulation, documents, in part, Policy: All residents will be assessed on admission and quarterly, or more often as change of condition warrants it, for their mobility. A program will be developed based on the individual resident's needs. This program will be reflected on the interdisciplinary care plan and consistently carried out by staff. Purpose: To be able to establish baseline mobility function of resident. To be able to assess and address resident's mobility needs. To be able to assist resident reach highest level of functioning in mobility. To be able to preserve function in mobility . To promote safety. To minimize deterioration in mobility within the limits of normal aging and/or recognized disease process . This policy and procedure covers bed mobility . Procedure: 1. Upon admission, the nurse will assess resident's ability to move as part of functional assessment . 2. When mobility is triggered for required further assessment, the nurse will complete the further assessment utilizing the designated functional assessment . 7. Functional assessment in relation to mobility will be completed quarterly . utilizing the MDS and supplemental assessment tool. Facility policy dated September 2021 and titled Repositioning, documents, in part, Purpose: The purpose of this procedure is to provide guidelines of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed- or chair-bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. Preparation: 1. Review the resident's care plan to evaluate for any special needs of the resident . 3. Repositioning is critical for a resident who is immobile or dependent upon staff repositioning . Steps in the Procedure: Repositioning the Resident in Bed: 1. Check the care plan, or the communication system to determine resident's specific positioning needs including special equipment, resident level of participation and the number of staff required to complete the procedure. Facility policy dated September 2021 and titled Restorative Nursing Services, documents, in part, Policy Statement: Residents will receive restorative nursing care as needed to help promote optimal safety and independence. Policy Interpretation and Implementation: 1. Restorative nursing care consists of nursing interventions . 3. Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's care plan. Facility policy titled Activities of Daily Living (ADLs), Supporting and dated March 2018, documents, in part, Policy Statement: Residents will (be) provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation: . 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming and oral care); b. Mobility (transfer .) c. Elimination (toileting) . 5. A resident's ability to perform ADLs will be measured using clinical tools, including the MDS . e. Total Dependence - Full staff performance of an activity with no participation by resident for any aspect of the ADL activity. Resident was unwilling or unable to perform any part of the activity over entire 7-day look-back period. 6. Interventions to improve or minimize a resident's functional abilities will be done is accordance with the resident's assessed needs, preference, stated goals and recognized standards of practice. Facility Job Description, titled Certified Nursing Assistant and undated, documents, in part, Position: Certified Nursing Assistant . Position Duties & Responsibilities: 1. Follows daily assignments per charge nurse. 2. Keeps residents dry and clean . 3. Performs personal care such as baths, showers, oral hygiene, skin care and hair care on assigned residents . 11. Answers call lights in a timely manner regardless of the assignment to ensure safety and proper service to residents . 18. Provide for resident's physical, psychological, social, safety and other needs. Actively works towards the promotion of Improved Quality of Life. 19. Perform nursing care according to the established facility standard.

Based on observations, interviews and review of records, the facility failures are as follows: Failed to follow policy to assess before transferring the resident. As a result, resident (R2) sustained left lower leg wound with multiple stiches. Failed to provide required assistance according to assessment to a resident (R1) who sustained left arm (humerus) fracture after being transferred from bed to wheelchair. Failed to use gait belt for 2 residents with history of multiple falls that requires extensive assistance during transfers (R4 and R5). Per care plan, R4 fell on [DATE] and sustained hematoma in the head. And failed to provide 2-person assist extensive assistance on bed mobility for 2 residents (R1 and R4). Failed to follow (R1)s Care Plan Provide 2 person assist with transfers. Failures applies to 4 out of 4 residents (R1, R2, R4 and R5) reviewed for accidents, hazards, falls and resident injuries. These failures resulted in R1 falling and sustaining a left arm fracture. Findings include: R1 is [AGE] years old with medical diagnosis of [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting left non-dominant side. R1's brief interview of mental status dated 9/20/2022 scored 13. Per assessment, R1 ' s cognitive status is intact. And that R1 needs 2-person extensive assistant on transfers and bed mobility. R1 ' s most current Fall Risk assessment dated [DATE] was 10 which means that R1 was high risk for falls. On 10/11/2022 at 1:38 PM, R1 said, It was during a CNA (Certified Nursing Assistant) transfer that I slipped. I did not fall but I slipped. A CNA was helping me transfer. Yes, it was only 1 CNA who helped me. Because if they used gait belt on me, I only need 1 CNA. Or else I need 2 CNA. When I slipped. Yes, I slipped, I cannot do much because my left foot was paralyzed (points at her left leg. R1 was seen with left leg immobilizer). She pulled me up. Then I was able to lay on the floor. I slipped because the floor was slippery. The CNA was holding on to me, and I heard (R2 was performing a cracking sound). I said to the CNA, that my left shoulder had a popping or cracked sound. Yes, I am sure, there was only 1 CNA during that time that helped me. After the cracking sound, I felt pain right away (R1 was grimacing). And was telling her that I have pain. I ' m sorry, I don ' t know the name of the CNA. Yes, my arms still hurting. Oh yes, I can say it hurts often very much. I am not sure if I received pain medicine. On 10/12/2022 at 12:45 PM, V2 (Director of Nursing) said, It was R1's son that called me, that R1 told her that she (R1) had a pop on her shoulder. R1 was on a wheelchair that time because she (R1) was being transferred from bed to wheelchair. I went to R1 and assessed her shoulder. She (R1) complained of pain during movement. So, I notified the Nurse Practitioner/NP or doctor and X- Ray was done here at the facility. After I received the X-Ray result that showed R1 had a sub-acute fracture of her left humerus. I think it ' s right here (pointing on her left upper arm). V2 was informed that R1 said it was only 1 CNA that was helping her during transfer. V2 said, I was informed that there were 2 CNAs helping R1. V7 (Certified Nursing Assistant) and another CNA. But I was not there, so I did not see them transferring. V2 was asked why the name of the CNA that helped V7 was not mentioned on the report. V2 said, V7 was assigned to R1 and not the other CNA. I did not include the other CNA statement because the other CNA was not assigned to R1. I can't remember when R1 saw V16 (Orthopedic Doctor), but I think it was earlier than 10/12/2022 or 9/15/2022 (referring to the notes by V12 (Licensed Practical Nurse). On 10/12/2022 at 1:50 PM, V13 (Restorative/Licensed Practical Nurse) said, Transfer means that a resident is from one place to another like wheelchair to bed or [NAME]-versa. Extensive Assist means that assistance given includes weight bearing assistance. Bed mobility means that resident is moving while on bed left to right. Like when changing a resident taking off her shirt and putting gown on. Yes, that is bed mobility. With regards to R2, R3 and R5, I just made their fall assessments yesterday. Although I back dated their assessment on the past dates. I understand that fall assessments are important in determining the status of resident risk of fall. And it will help with planning their care to prevent fall. Yes, I also understand that it must be on resident ' s chart so that nurses on the floor can access the fall assessment and will know if a specific resident is at risk for falling. On 10/13/2022 at 3:11 PM, V7 (Certified Nursing Assistant) stated that she was the staff that transferred R1 from bed to wheelchair after changing her clothes. V7 confirmed that she changed R1 by herself. And that she does not know that R1 has left-sided weakness and needs 2-person extensive assistance on bed mobility. Further stated that none of the staff including nurses informed her of R1 ' s ability while on bed. V7 said, Yes, I changed her (R1) by myself. R1 was on laying on the bed so I changed her by myself. I did not know that R1 has left side weakness and needs 2-person to help her change. V16 (Orthopedic Doctor) was paged twice but did not call back. R1 ' s progress notes dated 9/13/2022 for 9/12/2022 (late entry charting) reads: during transfers to wheelchair, R1 called family and claimed that she heard a popping sound on her left shoulder and complains of pain on the site. On 10/13/2022 at 9:24 AM, V2 stated that there was no thorough pain assessment done after she was informed by the son that R1 (his mother) called complaining of pain. R1 ' s September 2022 Medication Administration Record (MAR) where pain assessment scheduled every shift shows that pain range 0-10 was left blank although it was signed by nurses on the floor. Medication Administration Record (MAR) reads: Monitor for pain every shift. Pain Intensity are as follows: 1-3 mild pain, 4-6 moderate pain and 7-10 severe pain. V2 said, Yes, there should be a numeric number that should reflect on the MAR in that section. I will check if they assessed R1 for pain but as for now I cannot tell you. Per the same MAR, R1 has an order for 2 pain medications: [MEDICATION(S)] 5 MG - 325 MG tablet to give every 12 hours for pain which does not reflect that it was given for the whole month of September. And Acetaminophen 325 MG to give 2 tablets every 6 hours as needed which was never given on the day R1 sustained left arm fracture 9/12/2022. And was not given until 9/13/2022 6:55 AM. V2 said, It seems that is showing on the MAR. Yes, that is the way it was documented. I will look into it. I will check if they were putting notes on R1 ' s pain. At 1:05 PM V2 returned, and no notes were presented. Review of R1 ' s progress notes for the month of September shows no documentation of pain on the left arm due to fracture was addressed. R1 ' s Clinical Records are as follows: X-Ray Result on the left shoulder dated 9/13/2022 document that R1 sustained left humerus subacute fracture. R1 ' s Care Plan on Activities of Daily Living/ADL dated 5/23/2021 documents that R1 needs assist on Bed Mobility. Provide 2-person assist with transfer. No pain management was documented on R1 ' s full most current care plan other than medicate as needed for pain/discomfort. Orthopedic Consultation Report is as follows: V16's (Orthopedic Doctor) Physician progress notes dated 9/14/2022 : R1 was being evaluated for left humerus pain present for a couple of days ago. R1 states the nursing staff tried to lift her up and she heard crack. R1 resides at nursing home facility after a stroke from a year ago which affected her entire left side. Per V16's diagnoses, R1 sustained closed fracture 3-part proximal end of left humerus. R2 is [AGE] years old with medical diagnosis of laceration on left lower leg and [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting left non-dominant side. R2's brief interview of mental status dated 9/26/2022 scored 15. Per assessment, R2 ' s cognitive status is intact. And that R2 needs 2-persons extensive assistant on transfers and bed mobility. R2 ' s most current Fall Risk assessment dated [DATE] backed dated to 9/19/2022 by V13 (Restorative/Licensed Practical Nurse) was scored as 7 which means that R2 was high risk for fall. On 10/11/2022 at 1:20 PM, R2 said, It happened about 2 weeks ago when I first came here. They were transferring me from wheelchair to bed that my left leg was caught. There are 2 of them (staffs) present but only 1 of the staff helped me. And I don't think she knows what she was doing. The lady saw my leg that was caught and did not respond. The other staff was just looking. When my leg was caught. I told them but I did not know if they hear me. Or my English was not good. On 10/11/2022 at 2:00 PM, with R2 ' s consent, V10 (Licensed Practical Nurse) was requested to open dressing wrap of R2's left leg. On the wrap was dried light yellow mixed with red brownish dried fluid (removed was) seen on the wrap gauze. Wound was still with stitches and swelling on the left side. V10 said it was approximately 6 inches. V10 said he was not sure if his measurement was accurate. On 10/12/2022 at 11:27 AM, V8 (Nurse Supervisor/Licensed Practical Nurse) stated that she did the incident report of R2. And that R2 sustained abrasion about 10 inches long on left leg or shin because of the transfer. V8 said, I was working as the floor nurse and helping with admission. The CNAs (Certified Nursing Assistant), V14 and V9 and another CAN, V15 was present. V14 got my attention and said R2 was bleeding on her leg. When I went inside the room, I saw R2 was on the bed already, I said what happened she was bleeding on the leg. I grabbed gloves and placed a cloth. R2 was alert and oriented, I called V19 (Wound Nurse) and V18 (Nurse Practitioner). V18 was an in-house Nurse Practitioner, and he took over. V14 said they really don't know what happened during transfer from wheelchair to the bed. V14 told her to stand up and 3 of them (V14, V9 and V15) helped R2. I did not see them transferring R2, there was no nurse present during transfer of R2. I was not inside the room , for the actual transfer of R2. When I asked R2, she said that she bumped her leg on the bed. R2 came from another nursing home. She (R2) was accompanied by the driver. It was not an ambulance but medicar. When a new admission comes, the nurse should be there and assess the patient for transfers. R2 was not yet assessed by any nurse when they transferred her to bed. During this time, we have not assessed R2 yet. Including how she (R2) can transfer from wheelchair to bed. Yes, I agree that it would be safer if the nurse assessed the resident first before transferring the resident. And it will also be safer for the nurse to be present during transfer. I don't know if they transferred her with 2-person assisting. But if R2 said that only one of them transferred then I feel bad to R2. R2 is alert and oriented she can tell you what happened. As to gait belt, it is like a part of their uniform and must be used with all transfers. V9 should have placed a gait belt to R4 and R5 when transferring them to bed. R2 ' s progress notes dated 9/19/2022 by V8 admission notes reads in part that R2 ' s weight bearing status was left blank during admission. On 10/12/2022 at 12:25 PM, V9 (Certified Nursing Assistant) stated I was called by V14 (Certified Nursing Assistant) and asked me to help her transfer R2 to bed. I am not familiar with R2. I saw her with the lady that was driving a car like an ambulance. I never saw her before or took care of her before. V14 did not inform me how to transfer her. And I was not informed by any nurse how to transfer R2. I don't know if she can stand on her own. But we were able to let her stand. After we transferred her to bed. I saw a lot of blood on the floor. And then I saw her leg with wound and skin flap. V14 called V8 and I just left the room. On 10/12/2022 at 12:45 PM, V2 (Director of Nursing) said, When a CNA (Certified Nursing Assistant) transfers any resident they must use a gait belt. V9 should have used the gait belt during transfers of R4 and R5. As to R2, nurses on the floor must inform the CNA about resident's ability to transfer because they are the one receiving report. I understand what you mean, since R2 was new admit. Nursing staff was not familiar with her ability to transfer. And CNA's does not assess but nurses. Nurses should have instructed the CNAs on transferring R2. On 10/14/2022 at 12:28 PM, V14 (Certified Nursing Assistant) confirmed that she was assigned to R2 and helped R2 transfer from wheelchair to bed. V14 said that she was not familiar with the resident ability to transfer because it was the first time the R2 came in the facility. V14 said, That was the first time I met R2 because she was a new resident. I do not know her ability to transfer, or she has left side weakness. It was only during transfer that I noticed she was weak on one side. Nobody told me how she transferred. I agree, it would be safer if I was given instruction how to transfer R2. Or I knew that she (R2) was weak on her left side. Facility wound care notes and assessments dated 9/21/2022 documents that R1 sustained skin tear with a length of 16 centimeters, 0.1 centimeters width and 0.1 centimeters depth. Hospital assessment dated [DATE] documents that R1 sustained traumatic tibial anterior wound with a length of 15 centimeters, 3 centimeters width and 0.1 centimeters depth with 16 sutures. R2 ' s care plan for mechanical lift dated 9/22/2022 documents that R2 requires the use of Hoyer lift for transfers related to weakness. And that R2 needs 2-persons assist from caregivers. On 10/11/2022 at 12:40 AM, V9 (Certified Nursing Assistant) was seen wheeling R4 on her wheelchair then entered a room. Upon entering the same room, writer saw R4 was already in bed. V9 said she just transferred R4 on bed because both R4 and R5 who was sitting on her wheelchair next to a bed wants to go back to bed right away after lunch. V9 was seen changing R4 by taking off her shirt and putting a gown. Turning R4 from left to right. V9 was asked if she usually performs transferring and changing R4 by herself. V9 replied, Yes. V9 then left the room and took multiple trays out of multiple rooms. At 1:32 PM, after 52 minutes of leaving R5 sitting on the wheelchair on the bedside, V9 was seen transferring R5 from wheelchair to bed holding on the back of R5's pants with her right hand and with her left hand holding R5 ' s upper left arm. During this time R5 was in standing position. When V9 saw the writer entering the room, V9 put back R5 on the wheelchair. V9 said, Oh I need to find something. V9 left the room and after few minutes came back with gait belt wrapped around her waist. V9 said, I forgot my gait belt from another room. I did not use my gait belt when I transferred R4 to bed earlier. I know I need to use my gait belt all the time when transferring resident. I think both R4 and R5 only need 1-person assist but with gait belt in all transfers. R4 is [AGE] years old with medical diagnosis of repeated falls. R4 have history of multiple falls per care plan. Per the same care plan, R4 recently fell on [DATE] and sustained hematoma in the head. R4 was transferred to the hospital due to fall. R4 ' s most current Fall Risk assessment dated [DATE] was scored 17 which means that R4 was high risk for fall. R5 is [AGE] years old with medical diagnosis of [CONDITION(S)] and [CONDITION(S)] following [CONDITION(S)] disease affecting right dominant side. R5 has history of multiple falls per care plan. Per the same care plan, R5 has [CONDITION(S)] due to history of head trauma and has [CONDITION(S)] medications. Per transfer care plan review date 10/12/2022, R5 needs gait belt during transfers. R5 ' s fall care plan dated 10/21/2019 documents that R5 is high risk for falls due to following factors: R5 has unsteady gait with foot drop, has balance impairment especially on standing. R5 has unsafe/unpredictable behaviors - tries to stand, transfer, walks alone in spite constant reeducation and reminders. R5 has history of traumatic [CONDITION(S)] resulting to memory and mental impairments, impaired judgment, changes in attention, cognition, impacting ability to comprehend. R5 has [CONDITION(S)] and taking anticonvulsant medication and antidepressant. R5 has prior history of falls. And R5 is impulsive and diminished safety awareness, poor recall and judgment. R5 ' s most current Fall Risk assessment dated [DATE] backed dated to 8/3/2022 by V13 (Restorative/Licensed Practical Nurse) was scored 7 which means that R5 was high risk for fall. Per Fall Assessment Instructions, if score is 6 or greater, the resident should be considered at HIGH RISK for potential falls. Facility's policy on safe lifting and movement of residents not dated, in part reads: In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents. Manual lifting of residents shall be eliminated when feasible. Nursing staff in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Fall Occurrence Prevention Policy dated as revised on 8/16/2021 in part reads: This facility is committed to minimizing residents falls and/or injury so as to maximize each resident's physical, mental and psychosocial well-being. It is this facility's policy to act in a proactive manner to identify and assess those at risk for falls, plan for preventative strategies, and facilitate a safe environment as possible. Under fall prevention protocol: Assessment, a fall risk assessment form will be completed on all residents upon admission, readmission, quarterly, annual, post fall and on significant change of condition. It includes a fall history and a list of risk factors. The main purpose of which is to prevent injury from falls. (See Fall Risk Assessment). Under Fall Investigation Report, Fall Investigation Report shall include the following: Witness and Staff Interviews. Admission Assessment and Follow Up: Role of the Nurse policy dated 12/2021. In part reads: The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan and completing required assessment instruments, including Minimum Data Set. Under steps in the procedure, conduct supplemental assessments (following facility forms and protocol) including. Activity level, Fall Risk Assessment and Functional Assessment- ability to perform Activity of Daily Living ADLs.

Based on record review and interview, the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], R1 fell , sustained a large subdural hematoma and hemorrhagic brain contusions. R1 expired on [DATE]. These failures resulted in an Immediate Jeopardy (IJ). Findings include: R1's ([DATE]) progress notes state around 10:30pm, CNA (Certified Nursing Assistant) noted resident's door opening and immediately went to assist resident. The resident lost her balance and attempted to grab onto the door handle however was unable to maintain her balance and fell to the floor. CNA was unable to reach the resident to assist her to the floor however witnessed resident falling to the floor and hitting her head. Neuro check initiated and noted WNL (Within Normal Limits). No change in LOC (Level of Consciousness). Vital signs assessed and noted as follows: BP (Blood Pressure) ,d+[DATE], HR (Heart Rate) 64, Respirations 18, SpO2 97%, Temp (Temperature) 97.7. Notified Telepage MD (Medical Doctor), order received to send the resident to (Hospital) for evaluation. Resident left facility around 11:15pm by ambulance. R1's ([DATE]) Telemedicine Consultation Note includes; Subjective: Patient had a witnessed fall. Patient did hit their head. Patient is confused at baseline but concerned for increased confusion. Patient demented and increased confusion noted. Objective: (Nurse Assisted Exam) Vitals reviewed, stable. BP ,d+[DATE], Pulse 64, RR (Respiratory Rate) 19, SpO2 97% on room air [However aforementioned vital signs were documented at 8:36pm - prior to falling]. Fall Assessment/Plan: Witnessed fall, elderly patient with increased confusion. Patient requires stat ER (emergency room ) comprehensive exam and head CT scan to rule out [CONDITION(S)]. Advised staff to prepare for ER transfer. On [DATE] at 11:02am, surveyor inquired about R1's ([DATE]) fall V7 (Licensed Practical Nurse) stated She fell and hit her head. Surveyor inquired who was notified of R1's fall V7 responded First I called the family they are not answering, then I called the doctor (within 5 minutes after assessing R1) and he said send her out. Surveyor inquired which transport service was requested BLS (Basic Life Support) or ALS (Advanced Life Support) V7 stated I called the ambulance services (,d+[DATE] number). I asked them that I need a stretcher of course because she is not gonna be stable in the wheelchair. I called the direct number of the ambulance and told them I have to send out a patient to the hospital so I need an ambulance. Surveyor inquired why 911 was not called for emergency transport due to fall with potential head injury V7 responded Because she was stable, the doctor just told me to call the ambulance [Stat ER exam and head CT were ordered by the physician, and the physician advised staff to prepare for ER transfer], I didn't see any changes in her so far. [Increased confusion noted was documented by the physician during Nurse assisted exam]. On [DATE] at 2:43pm, surveyor inquired about R1's ([DATE]) fall V8 (Certified Nursing Assistant) stated I wanted to check and make sure that she's in bed but before I could get to her she was out of bed and she fell . I went to check to see if she was alright and then she wasn't responding so I went to get the Nurse. She was breathing but she just wasn't responding. She just kept like saying uh uh real lightly. I was with the Nurse and (V10/Activity Aide) we carried her to the bed. I was trying to tell this lady (R1) that she's going to the hospital and she wasn't responding at all. She was breathing and her eyes were a little bit open but she just had no response. On [DATE] at 10:39am, surveyor inquired about R1's ([DATE]) fall V10 (Activity Aide) stated I saw a lady was lying down on the floor. When we moved her to the bed she was lying there saying aiya aiya not too loud and affirmed she was unable to move without assistance. The (undated) change in resident's condition or status policy states prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider. R1's ([DATE]) Ambulance Run Report includes; Call Type: BLS (Basic Life Support) dispatch notify: 11:26pm (approximately 1 hours after fall). At patient: 11:43pm. In summary; was dispatched to (facility name) for an 80 y/o male [R1 was an 85 y/o female] that fell out of bed [R1 did not fall out of bed]. Being transported to hospital ER. Crew met with patient nurse to gather paperwork and information on what happen to patient. Patient nurse was little confused on what actually happen [R1's fall was witnessed by staff]. Patient is unresponsive. Patient is alert and oriented x0. Patient only withdraw from sensation. Blood Pressure ,d+[DATE], pulse 100 (weak), respiratory 20 normal, 96% on room air. Transport 11:55pm [not 11:15pm as stated in the progress notes]. At destination: 12:04am [1.5 hours after fall]. On [DATE] at 1:16pm, surveyor inquired if a resident falls and hits their head what's an appropriate plan of care V9 (Physician) stated The expectation would be to evaluate the patient, have telemedicine evaluate the patient, and monitor any change in behavior. Surveyor inquired about potential harm to a resident that falls and hits their head V9 responded It may be nothing or it could be bleed. That's the reason you do the neuro checks and assess the patient. The neuro checks have to be done. The neurological assessment policy (revised ,d+[DATE]) states neurological assessments are indicated: following a fall or other accident/injury involving head trauma; or when indicated by resident's condition. When assessing neurological status, always include frequent vital signs. Particular attention should be paid to widening pulse pressure (difference between systolic and diastolic pressures). This may be indicative of increasing intracranial pressure. Any change in vital signs should be reported to the physician immediately. Notify the physician of any change in a resident's neurological status. R1's ([DATE]) neurological assessments were conducted at 10:30pm, 10:45pm, 11:00pm and include the following documentation; level of consciousness 5 (indicating resident was oriented) however Physician documentation affirms she was demented with increased confusion noted. Stimulus response 5 (indicating resident responds to commands) and motor ability 2 (indicating all extremities were strong) however V8 affirmed she wasn't responding at all. Pupils size 3 (indicating pupils are equal) and pupils reaction 2 (indicating brisk response), however R1's ER pupil assessment (see below) is also incongruent with this assessment. The Neurological flow sheet includes the following instructions; vital signs every 15 minutes (x 4), 30 minutes (x 4). On [DATE] at 12:34pm, surveyor inquired about the neurological assessment protocol V2 (Director of Nursing) replied Were doing it every 15 minutes times 4. Then 30 minutes times 4. V2 reviewed R1's ([DATE]) neurological flow sheet and affirmed 10:30, 10:45, and 11:00pm assessments were documented [EMS arrived at patient 11:43pm therefore an additional assessment was required at 11:15pm]. Surveyor inquired what the number 5 indicates under level of consciousness V2 responded The 5 means the patient is conscious and oriented. [The Physician documented Patient demented and increased confusion noted therefore incongruent with V7's assessment]. Surveyor inquired what the number 5 indicates under stimulus response V2 replied Patient was responsive I would say [V8 affirmed She wasn't responding at all]. R1's ([DATE]) history & physical states she unfortunately comes in after an unwitnessed fall at the nursing home and found in the ER to be non-responsive to verbal, tactile and deep pain stimuli. Eye Exam: doll's eyes in ER and on arrival. Non-reactive pupils bilateral. Family is unable to give any additional details to the fall, and Nursing Home did not witness. On head CT there was massive bleeding found on right side with mass effect and midline shift to the left. She required intubation in the ER. Clinical signs of non-reactive pupils, doll's eyes, spontaneous muscle spasm, inability to draw breath without a vent, and non-responsive to all stimuli all support likely brain death. Unclear what caused the fall, what she may have struck or where exactly the fall occurred. The (undated) emergency transfer policy states should it become necessary to make an emergency transfer to a hospital or other related institution, our facility will implement the following procedures: notify the receiving facility that the transfer is being made. Assist in obtaining transportation. [There is no documentation that the hospital received report on R1's [DATE] status and they were unaware her fall was witnessed]. R1's ([DATE]) head CT affirms there is a large subdural hematoma overlying the entire right cerebral hemisphere, measuring 2.5cm in thickness. There is significant mass effect upon underlying brain with severe right to left midline shift. There is also a smaller subdural hematoma overlying the left frontal lobe measuring 7mm in thickness. There are hemorrhagic brain contusions in both frontal lobes and anteriorly in both temporal lobes with blood in the cortical sulci. R1's ([DATE]) certificate of death states death includes; Cause of death: subdural hematoma, fall. Manner of death: accident. The fall occurrence prevention policy (revised [DATE]) states if there are signs of life threatening injury call 911 and let the paramedics transport resident to the emergency room . The director of nursing will investigate all unusual occurrences and necessary intervention will be implemented immediately. The Immediate Jeopardy (IJ) was identified during review of R1's medical records on [DATE]. The IJ began on [DATE] when R1 fell at 10:30pm. Stat ER transfer/CT orders were received however she did not arrive at the hospital until 12:04am approximately 1.5 hours after fall because 911 was not immediately called and stat transfer was not requested as directed. Upon EMS arrival R1 was unresponsive and her blood pressure was ,d+[DATE] (both of which significant changes from her baseline status). On ([DATE]) at approximately 3:45pm, surveyor relayed concerns to V1 (Administrator) and V2 that V7's documentation and ([DATE]) interview concerning R1's ([DATE]) assessments were incongruent with hospital records and V8's interview. Also, 911 was not called due to head trauma and significant change in condition. V1 and V2 affirmed an investigation was conducted however they were unaware of said findings. On [DATE] at 12:16pm, the V1 (Administrator) was notified of the Immediate Jeopardy. The surveyor confirmed through record review and interview that the facility took the following actions to remove the Immediate Jeopardy: On [DATE], Nurses and CNA's were provided education on fall prevention, reporting of falls to medical staff, protocols for resident falls with/without injury, and neurological check protocols. On [DATE] V7 was terminated for failure to call 911 per doctor's order. On [DATE], additional education was provided to all nursing staff; assessing residents (with head trauma) for neurological changes correctly. Providing accurate account of residents (witnessed) fall/status to medical staff. Ensuring stat Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], education was provided to all other staff (ie: dietary, housekeeping, etc.) on fall prevention, and reporting a fall to nursing staff. The following changes were made to the process by which resident incidents are evaluated; the charge nurse must notify the nursing supervisor of all falls as they occur so he/she can ensure that necessary interventions are put in place. Any patient who has an unwitnessed fall will be sent to the ER via 911 for further evaluation. Compliance will be monitored by conducting QA (Quality Assurance) audits. If 100% compliance is not achieved at the end of 30 days, the employee(s) not following the protocols will be re-educated and/or disciplined and the QA audits will continue for another 30 days. The facility will enforce usage of the 24 hour report in the EMR (Electronic Medical Record) to give a shift to shift report to ensure that proper endorsement from the out-going nurse to the incoming nurse takes place. The facility implemented a care path tool to assess residents post fall to ensure proper interventions are implemented during assessment. All newly hired nurses will receive the same education during orientation noted above prior to working independently, including any agency nurses or CNA's. The Immediate Jeopardy was removed on [DATE], however noncompliance remains at level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training and new processes.

Based on record review and interview, the facility failed to conduct skin assessments as ordered, failed to identify skin integrity impairments, and failed to obtain treatment orders (before necrosis occurred) for one of four residents (R2) reviewed for pressure ulcers. These failures resulted in R2 sustaining multiple DTPI (Deep Tissue Pressure Injuries) with necrotic/eschar tissue and gangrene of her right great toe identified at a doctor's appointment on 12/10/20. Findings include: R2 was readmitted to the facility (11/16/20) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's (11/16/20) Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's (11/18/20) ADL (Activities of Daily Living) care plan states; report signs/symptoms of skin breakdown to MD (Medical Doctor). Check resident every 2 hours and change as needed. R2's wound history includes the following (facility acquired) wounds (identified) on said dates; (11/30/20) right heel DTPI (Deep Tissue Pressure Injury) 3.0 x 6.0 x 0.0cm (centimeters) with 100% necrotic/eschar tissue. (12/10/20) Right heel extending right lateral foot DTPI, 9.5 x 4.5 x 0.0cm with necrotic/eschar tissue. (12/10/20) Right lateral foot DTPI, 3.0 x 2.2 x 0.0cm with necrotic/eschar tissue. (12/10/20) Right medial great toe arterial wound, 1.3 x 1.4 x 0.0cm with necrotic/eschar tissue. (12/10/20) Left heel DTPI, 5.5 x 10.0 x 0.0cm with necrotic/eschar tissue. (12/10/20) Left gluteal crease extended to left buttock pressure wound (stage 2) 5.0 x 5.5 x 0.2cm. R2's (12/10/20) progress notes state; spoke with daughter in regards to the acquired wounds of the resident (discovered by the daughter during the resident's appointment at the hospital, as she was with her mother at that time). Writer was notified that new skin alterations were discovered upon arrival at the physician's appointment. On 8/16/21 at 9:38am, surveyor inquired about R2's (12/10/20) wounds. V2 (Director of Nursing) stated When they were at the doctor appointment, that's when they (Daughter/Physician) noticed the wounds. When they returned, the wound care assessed the patient. Surveyor inquired why the facility was unaware of R2's wounds (most of which were necrotic) V2 responded I guess the morning she was going to the appointment, she had her heel protectors on and the CNA (Certified Nursing Assistant) sent her out without noticing it before she left (R2 also had a wound on her gluteal crease/left buttock, and her 11/23/20 care plan affirms she was totally incontinent of bowel and bladder). Surveyor inquired how long it takes for necrosis/eschar to develop V2 replied This can take days before it happens. R2's (12/10/20) vascular surgeon consult includes history of present illness: she is currently at nursing home and developed bilateral heel pressure sores. She also has right 1st toe open wound [Right great toe dry gangrene]. On 8/16/21 at 2:01pm, surveyor inquired about the protocol for skin integrity impairments V19 (Wound Care Coordinator) stated If they notice something, they would notify the floor nurse or would notify wound care. Surveyor inquired how a wound develops gangrene V19 responded Gangrene usually forms from necrotic tissue over time. On 8/16/21 at 3:40pm, surveyor inquired about potential harm to a patient if wounds are not identified and/or reported immediately to the physician V18 (Wound Physician) stated It depends on the wound really. If they are infected then there is a problem but if they are stable there's not. Surveyor inquired how long it took for R2's tissue to become necrotic V18 responded Probably was going on for at least 1 day or so because the necrosis does not develop so fast, for necrotic tissue it takes at least 24 hours. The (undated) pressure ulcer prevention policy states any new ulcer or significant changes must be reported to the skin care coordinator, physician and family. Comprehensive assessment is required. The skin care coordinator or designee will inform the physician of the assessment and treatment option. The physician may recommend treatment if needed.

Based on interview and record review, the facility failed to develop a plan of care with fall prevention interventions to reduce or prevent risk of falls for 1 of 3 residents R1 reviewed for fall prevention. This failure resulted in R1 having a subsequent fall hitting his head and being evaluated at the local hospital and diagnosed with [REDACTED]. Findings include: On 4-16-19 at 10:51 AM, R1 stated the fall on 3-20-19 caused him to hit his head and caused him to have a brain bleed. On 4-16-19 at 11:15 AM, V2 (Director of Nursing) stated R1's active fall care plan (re: Fall Incident dated 11-8-18) does not show updated intervention to prevent further falls. On 4-16-19 at 11:16 AM, V3 (Restorative Nurse) stated R1's fall care plan (re: Fall Incident dated 11-8-18) does not document any new intervention to prevent further falls. R1's Fall Care Plan dated 11-8-18 documents Intervention post fall: Monitor for any increase in pain on the affected area and notify AP for any new orders. No updated interventions to prevent future falls noted. Fall Occurrence Prevention Policy (revision date 6-8-2011) documents the resident's care plan will be updated with each incident occurrence with or without injury sustained. New interventions are added under approaches. R1's Hospital Record dated 3-22-19 documents R1 presents after unwitnessed fall with concern for small amount of interhemispheric and peritentorial SDH (subdural hematoma) for which neurosurgery was consulted. Hospital Record dated 3-22-19 also documents CT Head: Impression: suggestion of trace amount of interhemispheric and bilateral peritentorial subdural hemorrhage. Head CT here suggests density along the tentorium and, to a lesser extent, interhemispherically, concerning for subdural hemorrhage. Care Plans, Comprehensive Person- Centered Policy (revision date 12-2016) documents assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The Interdisciplinary Team must review and update the care plan: when there has been a significant change in the resident's condition. R1's (re-admission) Progress Note dated 3-22-19 documents R1 was found to have trace subdural hematoma.