Every finding on record at Alta Rehab at Wauconda

Based on interview and record review the facility failed to determine the residents' wishes upon admission for advanced directives. This applies to one of three residents (R1) in the sample of seven reviewed for advanced directives.The surveyor confirmed by observation, interview and record review that the deficiency practice occurred on [DATE] and was corrected on [DATE], prior to the start of this survey and was therefore past noncompliance.The findings include:The facility face sheet for R1 shows she was admitted to the facility on [DATE] and discharged on [DATE]. The diagnoses for R1 include but are not limited to metabolic encephalopathy, urinary tract infection and Type 2 Diabetes Mellitus. The section of the face sheet for advanced directive is blank. The admission observation form dated [DATE] shows R1 was alert and orientated to person, place, time and situation.A nursing note dated [DATE] shows R1 was admitted to the facility with altered mental status and was alert and oriented but was forgetful. No mention of advanced directives being discussed with the resident or her family.A nursing note dated [DATE] for R1 shows at 9:10AM, a nurse (V5) was summoned to R1's room with the report of being unresponsive. The nurse documented R1 was unresponsive with absent respirations and carotid pulse. The nurse then documented that she checked R1's medical record and saw an order for a full code, so CPR (Cardiopulmonary Resuscitation) was started and 911 was called. The note goes on to show CPR continued until EMS (Emergency Medical Services) arrived. The note shows at 10:05 AM, per lead Paramedic, a pulse was regained, and the resident was transferred to the hospital.On [DATE] at 4:30 PM, V8 (R1's son in law) was called and he said R1 was in the hospital, and it was decided by R1 and her daughter, R1 would be a DNR (Do Not Resuscitate). R1 had a wrist band on her wrist showing she was a DNR when she got to the facility. V8 said the admitting nurse at the facility cut off the wristband and settled R1 into her room. V8 said he and his wife stayed at the facility about an hour after R1 was admitted making sure she was settled and no staff ever asked him or his wife what R1's wishes were regarding advanced directives. V8 said the hospital told him the form showing advanced directives would be sent with R1 to the facility.On [DATE] at 9:50AM, V5 RN (Registered Nurse) said she really did not remember much about that shift when R1 coded. V5 said she was called to R1's room when other staff found her unresponsive. V5 said she checked for a pulse and respirations on R1 and when none were found, she checked R1's medical record and saw she was a full code, so she began CPR and 911 was called. V5 said it is important for the staff who admit a resident to ask about advanced directives on admission. V5 said if the resident is not aware enough, the family should be asked. V5 said the hospitals are not very good at sending advanced directives with the resident from the hospital.On [DATE] at 10:07 AM, V6 RN said she was working the morning R1 stopped breathing. V6 said CPR was being done and EMS arrived at the facility. V6 said R1 did have a heartbeat and was transferred to the hospital. V6 said when a resident is admitted to the facility, advanced directives needs to be determined so the residents wishes are granted.On [DATE] at 10:35 AM, V2 DON (Director Of Nursing) said she was notified of CPR being performed on R1 that morning. V2 said the nurse that called her said the medical record was checked to see what R1's wishes were before CPR was started and an order for a full code was noted. V2 said upon admission to the facility, the staff need to talk to the residents and their family about advanced directives.On [DATE] at 1:40PM, V7 RN said she was the nurse who admitted R1 to the facility, but she does not remember her specifically. V7 said she admitted a lot of residents to the facility. V7 said it is the protocol for the facility to ask the residents on admission what their wishes are for advanced directives, but she does not remember if she did this for R1 when she was admitted .On [DATE] at 1:49AM, V3 ADON (Assistant Director of Nurses) said the nurses must ask all residents and families on admission what their wishes are for advanced directives and it must be documented.On [DATE] at 2:16PM, V1 Administrator said after this incident he completed an in-service and audits on advanced directives. V1 said the facility needs to have a consistent process in place for advanced directives, it needs to be addressed and documented in the medical record. V1 said if the admitting nurse does not see advanced directive from the hospital, they should not assume the resident is a full code.The discharge summary from the hospital dated [DATE] shows code status on discharge as DNR. The discharge summary was a part of R1's facility medical record.The Physician Order Sheet dated [DATE] shows an order for a full code.The facility policy with a revision date of [DATE] for Advance Directive shows at the time of admission each resident will be asked if they have made advanced directives and provided educational information regarding state and federal law.Prior to the survey date of [DATE], the facility had taken the following action to correct the noncompliance:On [DATE] an in-service was completed regarding code status being verified on admission with the resident and if the resident is not able to make that decision, confirm with the POA (Power of Attorney).On [DATE] a whole house audit was completed for advanced directives.On [DATE] a Quality Assurance action plan was made to continue chart audits for advanced directives.The facility was able to demonstrate monitoring of the corrective action and sustained compliance.

Based on interview and record review, the facility failed to communicate and document a fall incident in a timely manner, failed to a complete a post fall assessment or perform any subsequent assessments following a fall, and failed to implement interventions to prevent any future incidents. This failure affects one of three residents (R1) reviewed for falls in the sample of 3.The findings include:R1's face sheet documented an admission date of 01/06/2026 from an acute care hospital where she was hospitalized from [DATE] through 01/06/2026. Her past medical history upon admission included but not limited to seizures, anemia, hypertension, anxiety, osteoarthritis to left wrist, and chronic kidney disease. (Review of R1's census record indicates she is on hospital leave.)R1's fall risk assessment with effective date 01/06/2026 (same day as admission) documented score of 8 which indicated R1 is not at risk for falls. Assessment with effective date of 01/08/2026 (signed on 01/16/2026) documented score of 14 and indicated that R1 is at risk for falls. R1's care plan documented she is at risk for falls as evident by scoring tool with date initiated of 01/08/2026 that was revised on 01/14/2026.Final facility reported incident report submitted to Illinois Department of Public Health (IDPH) with incident date of 01/12/2026 indicated that R1 was admitted to the facility on [DATE] for short-term rehab. R1 noted with discoloration on right side of face. Patient's family reports that patient sustained a fall. Physician made aware. Patient was unable to be interviewed due to cognitive deficits. Staff assigned to the patient were interviewed. V7 (Certified Nursing Assistant/CNA) reported that when he was assigned to the patient on 01/08/2026, patient did sustain a fall. V7 stated that R1 fell from the right side of her bed. V7 stated that the patient's bed was in the lowest position and landing (floor) pads were in place. V7 stated that he reported the incident to the nurse (V6-Registered Nurse/RN) and that another CNA (V3) was also present. V3 (CNA) and V6 (RN) were both interviewed and confirmed V7's statement. They both reported that R1 did sustain a fall in which she fell from the right side of her bed. All staff members stated that they did not, nor did they witness anyone be physically inappropriate toward the patient. (Per V1-Acting Administrator, incident date of 01/04/2026 on IDPH report was incorrect date.)R1's unwitnessed fall report (#761) with incident date of 01/08/2026 at 08:06 PM (20:06) indicated that R1 rolled off the right side of her bed and was found on the landing pad. Resident was restless and hard to redirect. Resident unable to describe what happened due to her cognition and that no injuries observed at time of incident. Report had no documentation under the agencies/people notified section. (Date incident report was completed was not documented.)Fall report (#761) showed V7's witness statement dated 01/13/2026 that documented he put R1 to bed and lowered bed to lowest position, set up landing (floor) pads. Did not remember exact time but when V7 went back to check on R1, she was noted on the right side of the bed, and it appeared that R1 fell or rolled off her bed onto the landing pad. Another aide (V3) was there to assist. They called the nurse right away and the nurse assessed the patient.Fall report (761) also showed V6's witness statement dated 01/13/2026 that documented she was informed by V7 that R1 was noted on the landing (floor) pad. She went in and assessed patient. V6 indicated interventions were in place but they were not specified on report.Interdisciplinary Team note dated 01/13/2026 at 01:56 PM (13:56) documented that after further investigation, the team discovered that the resident sustained an unwitnessed fall on 01/08/2025 which could have caused facial discoloration due to the use of anticoagulant (blood thinner).On 01/17/2026 at 01:12 PM, V1 (Acting Administrator) said on 01/10/2026, R1 was noted by R1's daughter and V5 (Registered Nurse) with discoloration to her right side of face that looked like a new bruise. R1 also displayed altered mental status. Per V5, the night shift nurse (V6) had reported R1 was wandering, restlessness, and trying to get up during the previous night. V5 (RN) contacted R1's primary care physician on 01/10/2026 and updated him regarding facial bruising. Physician concluded bruising was likely due to the behaviors and use of a blood thinner but ordered R1 be sent to the hospital for evaluation of her altered mental status. V1 added that during further investigation into R1's facial bruising, V1 was informed by V7 (CNA) that R1 had a fall on 01/08/2026 and V7 had informed V6 (RN) of the fall. V1 added that V6 assessed R1 but did not document her assessment or complete a report, then said it was clear the nurse failed to report the incident. V1 also said from after the fall on the 8th until the morning of the 10th, R1 had no discoloration or bruising to her face; was first noted on 01/10/2026.On 01/17/2026 at 02:04 PM, V3 (Certified Nursing Assistant) said on 01/08/2026 she was working the evening shift with V7 (CNA). R1 was put R1 into bed after supper around 6-6:30 PM. Then around 08:00 PM while walking past R1's room with V7, he saw R1 had fallen out of bed onto the floor mats. It looked like she rolled out of bed. V3 went to get the nurse while V7 stayed with R1.On 01/17/2026 at 02:30 PM, V5 (Registered Nurse) said on morning of 01/10/2026 around 08:30 AM, R1 was sitting with her daughter and husband in the main dining room by nurses' station on the 700 unit. V5 was told that R1 was not acting like herself, was not talking to the daughter and noted with a new discoloration to the side of her head. V5 said R1 was admitted a few days prior with bruising to her upper and lower extremities. V5 called the physician and informed him of the bruising upon admission, new facial bruise, and the mental status changes. Was told by physician that the bruising is most likely from her behaviors and blood thinner (Lovenox) but to send R1 out for the altered mental status to rule out infection. V5 added that R1 constantly tries to transfer herself, get up by herself, and is unstable when standing. V5 also said the night shift reported R1 was restless and made multiple attempts to get up and transfer herself the previous night (01/09/2026).On 01/17/2026 at 02:51 PM, V6 (Registered Nurse) said on 01/08/2026 at approximately 08:06 PM, she was informed by V3 (CNA) that R1 was on the landing pad (floor mat) in her room. V6 went to assess her and did not see any injury at that time or any bruising. V6 then said that she totally forgot to document the fall and my assessment. V6 was called by management on the 12th because they were investigating the facial bruising to R1's to periorbital area. V6 said she informed them at this time that R1 had an unwitnessed fall that she forgot to document and did not inform the oncoming nurse. V6 said it slipped my mind. V6 added that she was disciplined for non-documentation. V6 said she should have reported the incident, contacted family and physician, documented her assessment/vitals/neurological checks and completed an incident report that would have resulted in continued post fall assessments for R1.On 01/17/2026 at 03:07 PM, V7 (CNA), said on 01/08/2026, he and V3 put R1 into bed about 6:00 PM. V7 said they lowered the bed to the floor and placed mats to both sides. V7 then said at around 8:00 PM, R1 was on the floor mat on the right side. It looked like she had rolled out of bed. V7 said he did not see any injury, redness or bruising. V7 stayed with R1 while V3 went to get the nurse. V6 (RN) came to the room and assessed R1. After she was assessed, V7 and another aide put R1 back into bed.Fall Prevention Program policy last revised 11/21/2017 provided by facility on 01/17/2026 reads in part: purpose is 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 for falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness.The Fall Prevention Program includes the following components but not limited to: assessment time frames, use and implementation of professional standards of practice, immediate change in interventions that were successful, notification of physician, family/legal representative, communication with direct care staff members, documentation requirements.Care plan incorporates included: addresses each fall, interventions are changed with each fall, as appropriate and preventative measures.Standards included: fall risk assessment will be performed upon admission, quarterly and with each significant change in mental or functional condition and after any fall incident; safety interventions will be implemented for each resident identified at risk.

Based on observation, interview, and record review the facility failed to ensure food service dishes were handled in a way to prevent cross-contamination. This has the potential to affect all residents that receive food from the kitchen. Findings include: Centers for Medicare and Medicaid Services form 671 dated 12/1/25 shows there are 134 residents that reside in the facility. Facility diet report dated 12/1/25 shows two residents have diet orders of nothing by mouth (NPO) and do not receive foods from the kitchen. On 12/1/25 at 9:54 AM. V6 (Dietary Aide) was at the three-compartment sink washing pots, pans, and utensils. V6 went to the dish pit, across the kitchen, and rinsed a large food service pot. At 10:01 AM, V6 returned to the three-compartment sink, put the pot into the sanitizer sink, and removed all the dishes from the sanitizer sink to place them on a rack to dry. V6 did not perform hand hygiene before removing the dishes from the sanitizer sink. V6 returned to the washing sink and continued to wash, rinse, and sanitize dishes without performing hand hygiene before removing the sanitized dishes from the sanitize sink. On 12/1/25 at 10:06 AM, V6 left the three-compartment sink, placed bare hands onto the garbage can to move it, then immediately grabbed a food-service cart and wheeled it to the other end of the kitchen to place sodas onto the cart. V6 again walked to the back of the kitchen, rolled up the garbage bag in the garbage can, then completed hand hygiene. On 12/1/25 at 10:09 AM, V4 (Food Service Director) said the process of completing dishes in the three-compartment sink starts by washing the dishes in one sink, rinsing them in the following sink, then placing the dishes into the last and final sink to sanitize. V4 said the dishes must remain in the sanitize sink for a minimum of 60 seconds. V4 said staff should perform hand hygiene prior to removing the dishes from the sanitize sink to prevent cross-contamination. Facility Hand Washing Dietary Policy and Procedure states, Staff should wash their hands before handling food (even between tasks), clean dishes, upon arrival and return to the kitchen from outside and the bathroom .

Based on observation, interview and record review the facility failed to ensure a resident was transferred in a safe manner to 1 of 27 residents (R85) reviewed for safe transfers in the sample of 27Findings include:R85's Physician Order Sheet dated 11/25 show R85 has diagnosis of hemiplegia and hemiparesis affecting left dominant side due to stroke.On 12/2/25 at 9AM, R85 was sitting in his wheelchair, his left arm was elevated with sling. R85 was using his right arm to move his left arm. R85 said he had a stroke, and he cannot move his left side.V10 (Wound Nurse) and V9 (Certified Nursing Assistant -CNA) wheeled R85 near his bed. V9 (CNA) applied a gait belt to R85's waist. V9 said R85 need two staff using the gait belt to transfer R85. V10 (Wound Nurse) positioned herself behind R85 who was still sitting in the wheelchair. V10 then lifted R85 from behind the wheelchair by pulling the gait belt up. V9 who was in front of R85 lifted R85 from under his right arm not using the gait belt. R85 was not able to stand, R85 was leaning to the left side. V9 continued to lift R85 under his right arms, still not using the gait belt while V10 was behind the wheelchair trying to hold unto R85 with the gait belt until finally R85 was transferred to bed. On 12/3/25 at 12:08 PM, V11 (Physical Therapy Director) said R85 has left sided impairment due to stroke. For safety reasons, it was not safe to transfer a resident under their arms, it can cause injury to the resident particularly the shoulder. Proper transfer is to use the gait belt, and staff should position themselves correctly for safe transfers.R1's care plan dated 9/26/25 show R85 has impaired balance due to left sided weakness due to stroke with intervention of Sit to stand = Substantial/maximal assistance Chair/bed-to-chair transfer.The facility policy on Transfers dated 1/19/18 documents, in order to protect the safety and wellbeing of the staff and residents, and to promote quality of care, 9. Use of gait belt for all physical assist transfers is mandatory.

Based on observation, interview, and record review the facility failed to ensure R165 received treatments and services to heal and prevent pressure ulcers for 1 of 4 residents (R165) reviewed for pressure ulcers in the sample of 27.Findings include: On 12/01/2025 at 11:10 AM, R165 was lying on back in regular bed. R165's left, and right heels were lying directly on the regular mattress. R165's right heel boot was on the floor under a chair in the corner of the room by the foot of the bed, the other heel boot was on a chair, opposite corner of the room, under a stack of pillows. On 12/01/2025 at 11:15 AM, R165 stated, I have a wound to my bottom. On 12/01/2025 at 1:17PM, R165 was lying on back. V10 Wound Nurse and V15 Wound Nurse assisted R165 in removing clothing to provide wound care. R165 did not have a dressing to the wound that was on the left buttock. On 12/01/2025 at 1:17 PM, V10 Wound Nurse said, residents that are admitted with pressure ulcers are considered high risk for pressure ulcer development. Pressure reduction heel boots are applied by the CNA-Certified Nursing Assistant when the resident is in bed and documented under tasks. R165 has a stage 2 pressure ulcer to the left buttock. On 12/01/2025 at 1:43 PM, V15 Wound Nurse said, I did not see a dressing on R165 when we provided wound care. The dressing protects the wound from becoming worse. It protects the wound from episodes of incontinence reducing the risk of the wound becoming infected. On 12/01/2025 at 1:43 PM, V16 CNA said, I changed R165 before lunch (Noon). R165 did not have a dressing on the wound. R1's Physician's Orders on 12/01/2025 shows, treatment to left buttock wound, cleans with normal saline, apply (anti-septic) paste and cover with foam dressing (change dressing) Tuesday, Thursday, Saturday and as needed. R165's Medical Record-Wound Rounds on 12/01/2025 shows, Pressure Ulcer Risk Assessment-High Risk. Active Wound: Left Buttock, Pressure Ulceration, active stage 2. Intact Skin 50% Epithelial tissue 50%. The facility policy revised 01/15/2018 shows, use positioning devices or pillows, rolled blankets, and other things to reduce pressure and friction/shearing from heels, toes, and malleoli as indicated.

Based on observation, interview and record review the facility failed to provide incontinence care to residents that needed extensive assist of Activities of Daily Living (ADLs) to 2 of 27 residents (R63, R98) reviewed for ADL care in the sample of 27.Findings include:1.R63's facility assessment dated [DATE] show R63 is incontinent of bowel and bladder functions On 12/1/25 at 11:57 AM, R63 was sitting in her wheelchair during lunch. R63 was yelling, I am wet! I need to be changed! R63's frontal area was visibly wet including the bottom part of her shirt. V9 (Certified Nursing Assistant-CNA) said (R63) was so wet, it's probably just water spilled all over her. R63 was wheeled to her room. R63 was noted to have a strong smell of stool and urine. R63 was transferred to bed. R63's chair cushion was visibly soiled. When V9 and V12 (both CNAs) removed R63's incontinent pad, it was saturated with large amount of stool and urine that soaked thru her pants and lower bottom of her shirt. At 2:00 PM V13 (CNA) said R63 was gotten up this morning around 8AM to-8:30 prior to breakfast. R63 was not checked and changed until 11:57 AM (approximately more than 3 hours.)R63's care plan dated 10/21/25 showed, I have an ADL self-care/mobility performance due to morbid obesity, fatigue, dementia. I have functional bladder incontinence with intervention of check and change every 2 hours.2. R98's Facility assessment dated [DATE] show R98 is incontinent of bowel and bladder functions. On 12/1/2025 at 1:13 PM, R98 was in bed. V13 (CNA) removed R98's incontinent pad totally soaked with urine. R98 had indented marks of her bottom. V13 said she got R98 around 8:30 AM. V13 said she had not changed R98 until now, (almost 5 hours ago).R98's care plan dated 9/10/25 show, I have an ADL self-care/mobility performance (functional abilities) and deficits due to Hemiplegia with intervention of Check and change Q2-3H and PRNOn 12/3/25 at 8:45 AM, V14 (Registered Nurse) said incontinent residents should be checked and changed every 2 hours to keep them clean and dry and comfortable to prevent infections.The facility policy on Incontinence care dated 4/21/21 documents, to prevent excoriation and skin breakdown discomfort and maintain dignity, incontinent residents will be checked periodically in accordance with the assessed incontinence episodes for approximately every two hours and provided perennial/genital care after each episode.

Based on observation, interview, and record review the facility failed to ensure the daily nursing staffing census was posted and kept on record for up to 18 months. This failure has the potential to affect all residents residing in the facility. Findings include: Centers for Medicare and Medicaid Services form 671 dated 12/1/25 shows there are 134 residents residing in the facility. On 12/2/25, this surveyor was unable to locate the daily nursing staffing census throughout the facility. On 12/2/25 at 11:59 AM, V7 (Certified Nursing Assistant Supervisor) said the daily census is done daily and it used to be posted by the old entrance. V7 had a binder of previous censuses that were completed, but there were no censuses held on hand after November 2024. V7 did provide this surveyor a copy of a completed daily census for 12/2/25 in V7's office, but the census was not seen posted throughout the facility. On 12/2/25 at 12:05 PM, V8 (Receptionist) said she has never had any part in completing or displaying the daily staffing census at the front desk of the facility. On 12/2/25 at 12:34 PM, V2 (Director of Nursing) said V7 was unable to locate any previously completed censuses for 2025. The dates in the binder include censuses from January 2024 to November 2024. V2 said V7 currently is posting the census by the nursing station on the town hall unit and V7 should start putting the census by the front reception desk as well.

Based on observation, interview, and record review the facility failed to thoroughly investigate an allegation of abuse for 1 of 3 residents (R1) reviewed for abuse in the sample of 4. The findings include: The facility's Incident Report for R1 shows on 12/23/24 resident was overheard in the dining room (during breakfast) stating that she was abused by a CNA on the previous day. Social Service Designee interviewed the resident who claimed that the day before she overheard a CNA and an Activity Aide arguing in the hallway. According to the resident, she tried to intervene and tell them to stop, and the CNA allegedly pointed her finger in the resident's face and used profanity at her. On 12/30/24 at 9:20 AM, V1 Administrator said the incident was determined to be a 2 staff verbal altercation witnessed by R1. V1 said the initial report said R1 used profanity at her, but as they interviewed staff, the profanity was toward the other staff and not the resident. V1 said they did not substantiate abuse. On 12/30/24 at 9:47 AM, R1 was in her room re-arranging her things on her bed. R1 said on 12/22/24 after breakfast, she heard yelling in her hall. R1 said she went out of her room and as she got closer to the people yelling, she saw V6 Certified Nursing Assistant (CNA) was yelling at V5 Activity Aid. R1 said V5 was pushing a resident down the hall from the nursing station and V6 was yelling at V5. R1 said V5 wasn't saying anything and V6 was harassing V5 about how V5 was a little person on the grapevine and her position was on the bottom. R1 said V6 was saying V5 was dumb and stupid and V5 just kept pushing the resident down the hallway and not saying anything back. R1 said she got involved and told V6 to knock it off and to get out of here it wasn't her hall. R1 stated V6 yelled at me to back off and to shut up you bitch. R1 said she felt bad for V5 and again told V6 to get out of here, you don't belong here. R1 said she was wanted V6 to leave V5 alone. R1 said V6 was yelling at her and at V5 and pointing her finger at them. R1 said at some point it went from V6 yelling B*** to her saying F*** You. R1 said V5 was able to get away and she reported what happened to V7 Manager on Duty. R1 said she talked to V4 Social Services about what happened the next day. R1 said R2 saw and heard the yelling as well. On 12/30/24 at 9:56 AM, R2 said on that day, she was in her room watching TV and heard yelling in the hall. R2 said it was loud, she heard it over the TV. R2 said she wheeled herself to the hall and saw V6 yelling at V5. R2 said she heard no words from V5. R2 said V5 was pushing another resident down the hall and V6 was just raging calling V5 a B***. R2 said V5 kept pushing the resident down the hallway, trying to get away from V6. R2 said she was not sure who the resident that was being pushed was. R2 said V6 was getting so close to V5 that she thought it was going to get violent. R2 said R1 was nearby, somewhat behind V5. R2 said V6 was yelling at R1 to go back to her room. R2 said V6 called V5 and R1 a B****. R2 said R1 told V6 to get out of there and V5 again told R1 to go back to her room. R2 said V6 kept on yelling to V5 about how V5 was just a little activity person, and she was a CNA. R2 said it was not right and she was going to call the state about it. On 12/30/24 at 11:37 AM, R3 said V5 was pushing her back to her room and the other one came up and started talking loudly about V5 talking about her behind her back, childish stuff like you do in school. R3 said V6 kept on and on down the hall and was yelling loud enough for people to hear. R3 said she couldn't remember all that was said and couldn't see behind her to know who else was there. R3 said V5 kept pushing her down the hall to her room and the other one went away. On 12/30/24 at 10:39 AM, V6 said she had a verbal disagreement with another staff member. V6 said the disagreement did get loud and R1 did come out of her room. V6 said R1 was behind V5 who was pushing another resident down the hallway. V6 said she did call V5 a B*** and R1 assumed that she was talking to her. V6 said R1 kept propelling toward her and she told R1 to back away. V6 said she was not assigned to that unit and her assignment was in a hall on the other side of the building. V6 said that the situation was not appropriate to do in the hallway with residents present. V6 said she was not sure if any other staff was present, but there were other residents in the doorways of the rooms. On 12/30/24 at 10:24 AM, V1 Administrator said V7 was home sick and was not available. V1 said V7 was the manager on duty that day and had started the interviews about the incident. V1 said V7 told her no other residents or staff were present and the incident happened at the nurse's station. V1 said she was told no one had overheard anything, so she did not interview anyone else based on V7's report of the situation. V1 said V6 did get disciplinary action for swearing and leaving her assigned unit. V1 was not aware of any other residents overhearing the incident nor that the incident continued down the resident hallway from the nurse's station. On 12/30/24 at 10:54 AM, V4 Social Services said R1 reported to her (12/23/24) that two employees (V5 and V6) were fighting in the hallway and she had tried to intervene. V4 said R1 reported V6 swore at her and told her to stay out of it. V4 said she had only talked to R1 and had not done any other interviews. V4 said R1 did not want to call the police. The facility's Statement from V5 regarding the 12/22/24 incident shows Several residents witnessed the incident and urged her to stop and leave me alone. At one point, V6 yelled at a resident, telling them to mind their business. The facility's Statement from V6 regarding the 12/22/24 incident shows walking and shouting down the hallway (not just at the nurse's station). The facility's Abuse Prevention and Reporting Policy dated 10/24/22 shows Implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making necessary changes to prevent future occurrences. The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked, will be interviewed to determine whether any one has witnessed any prior abuse, neglect, exploitation, mistreatment or misappropriation of resident property by the accused individual.

Based on observation, interview, and record review the facility failed to ensure a resident was free from verbal abuse for 1 of 3 residents (R1) reviewed for abuse in the sample of 4. The findings include: The facility's Incident Report for R1 shows on 12/23/24 resident was overheard in the dining room (during breakfast) stating that she was abused by a CNA (certified nursing assistant) on the previous day. Social Service Designee interviewed the resident who claimed that the day before she overheard a CNA and an Activity Aide arguing in the hallway. According to the resident, she tried to intervene and tell them to stop, and the CNA allegedly pointed her finger in the resident's face and used profanity at her. On 12/30/24 at 9:47 AM, R1 was in her room re-arranging her things on her bed. R1 stated on 12/22/24 after breakfast, she heard yelling in her hall. R1 stated she went out of her room and as she got closer to the people yelling, she saw V6 Certified Nursing Assistant (CNA) was yelling at V5 Activity Aid. R1 stated V5 was pushing a resident down the hall from the nursing station and V6 was yelling at V5. R1 stated V5 wasn't saying anything and V6 was harassing V5 about how V5 was a little person on the grapevine and her position was on the bottom. R1 stated V6 was saying V5 was dumb and stupid and V5 just kept pushing the resident down the hallway and not saying anything back. R1 stated she got involved and told V6 to knock it off and to get out of here it wasn't her hall. R1 stated V6 yelled at me to back off and to shut up you b***h. R1 stated she felt bad for V5 and again told V6 to get out of here, you don't belong here. R1 stated she wanted V6 to leave V5 alone. R1 stated V6 was yelling at her and at V5 and pointing her finger at them. R1 stated at some point it went from V6 yelling B***h to her saying F*** You. R1 stated V5 was able to get away and she reported what happened to V7 Manager on Duty. R1 stated she talked to V4 Social Services about what happened the next day. R1 stated R2 saw and heard the yelling as well. On 12/30/24 at 9:56 AM, R2 stated on that day (12/22/24), she was in her room watching TV and heard yelling in the hall. R2 stated it was loud, she heard it over the TV. R2 stated she wheeled herself to the hall and saw V6 yelling at V5. R2 stated she heard no words from V5. R2 stated V5 was pushing another resident down the hall and V6 was just raging calling V5 a B***h. R2 stated V5 kept pushing the resident down the hallway, trying to get away from V6. R2 stated she was not sure who the resident that was being pushed was. R2 stated V6 was getting so close to V5 that she thought it was going to get violent. R2 stated R1 was nearby, somewhat behind V5. R2 said V6 was yelling at R1 to go back to her room. R2 said V6 called V5 and R1 a B****. R2 stated R1 told V6 to get out of there and V5 again told R1 to go back to her room. R2 stated V6 kept on yelling at V5 about how V5 was just a little activity person, and she was a CNA. R2 said it was not right and she was going to call the state about it. On 12/30/24 at 10:24 AM, V1 Administrator stated V6 did get disciplinary action for swearing and leaving her assigned unit. On 12/30/24 at 10:39 AM, V6 stated she had a verbal disagreement with another staff member. V6 stated it started in the dining room and continued to the nurse's station and down the hallway. V6 stated the disagreement did get loud and R1 did come out of her room. V6 stated R1 was behind V5 who was pushing another resident down the hallway. V6 stated she did call V5 a B*** and R1 assumed that she was talking to her. V6 stated R1 kept propelling toward her, and she told R1 to back away. V6 stated she was not assigned to that unit and her assignment was in a hall on the other side of the building. V6 stated that the situation was not appropriate to do in the hallway with residents present. On 12/30/24 at 10:54 AM, V4 Social Services stated R1 reported to her (12/23/24) that two employees (V5 and V6) were fighting in the hallway, and she had tried to intervene. V4 stated R1 reported V6 swore at her and told her to stay out of it. On 12/30/24 at 11:04 AM, V5 stated V6 had approached her in the dining room and accused her of talking about V6 behind her back. V5 stated V6 followed her down the 200 hall to the 300 hall and then continued down the 300 hall while V5 was pushing R3. V5 stated V6 was calling me irrelevant and downgrading my job and her age. V5 stated she kept walking away and V6 kept on and was calling her a B***. V5 stated R1, R2, and R3 heard everything. V5 stated V6 yelled at R1. V5 stated you are not supposed to talk to residents that way. V5 stated she told V6 to go back to her unit and kept walking to try to get away from V6. V5 stated V6 finally left, and she called her supervisor who advised her to talk to V7. V5 stated she gave her statement to V7. V5 said she went and apologized to the residents. V5 stated V6 was very loud, and her tone was disrespectful to her and the residents. V5 stated V6 was very disrespectful to R1 and was using her hands and pointing at R1 while yelling at her. On 12/30/24 at 11:37 AM, R3 stated V5 was pushing her back to her room and the other one came up and started talking loudly about V5 talking about her behind her back, childish stuff like you do in school. R3 said V6 kept on and on down the hall and was yelling loud enough for people to hear. R3 said she couldn't remember all that was said and couldn't see behind her to know who else was there. R3 said V5 kept pushing her down the hall to her room and the other one went away. On 12/30/24 at 1:10 PM, V1 said residents should not be yelled at by staff. R1's Progress Note by V4 dated 12/24/24 shows Resident was overheard in dining room, stating a CNA was inappropriate. Said writer discussed with resident what had happened, R1 stated a CNA was inappropriate to an activity aide and R1 stated she asked the CNA to stop, and then CNA was verbally inappropriate to her. Said writer informed Administrator. R1's Minimum Data Set, dated dated dated [DATE] shows R1 is cognitively intact. The facility's Statement from V5 regarding 12/22/24 incident shows As V6 was walking away she called a B**** and then returned and repeated her insults. Several residents witnessed the incident and urged her to stop and leave me alone. At one point, V6 yelled at a resident, telling them to mind their business. The facility's Abuse Prevention and Reporting Policy dated 10/24/22 shows Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability.

Based on observation, interview, and record review the facility failed to ensure a resident was transferred in a safe manner for 1 of 3 residents (R2) reviewed for safety in the sample of 3. The findings include: On 12/9/24 at 12:55 PM, R2's room had handwritten signs above her bed and on the wall by the bathroom that said, Fall Risk, Use Gait Belt. On 12/9/24 at 12:57 AM, R2 was sitting in her wheelchair at the dining room table. R2 stated when she first got to the facility she walked to the bathroom with her walker. R2 stated when she was coming out of the bathroom, V13 Certified Nursing Assistant (CNA) was with her, and she started to fall. R2 stated V13 assisted her to the floor. R2 stated V13 did not put a gait belt on her. R2 stated they should use a gait belt, now I make sure! On 12/9/24 at 1:34 PM, V13 stated R2 had walked with the walker to the bathroom by herself. V13 stated she assisted R2 to walk out of the bathroom with the walker and R2's legs got weak. V13 stated she assisted R2 to the floor. V13 stated she was holding R2's pants and did not have a gait belt on R2. On 12/9/24 at 11:17 AM, V3 Assistant Director of Nursing stated R2 had a fall where she was assisted to the floor. V3 stated V13 was helping R2 walk with a walker out of the bathroom and R2's knees gave out. V3 stated V13 did not use a gait belt. R2's IDT Fall Committee Meeting Note dated 11/29/24 shows R2's knees gave out as she was ambulating back to her bed from the bathroom with assist of one CNA and use of a walker and was lowered to the ground by the CNA. No injuries observed. R2 fell during ambulation due to knees giving out as well as weakness, impairments in strength, mobility, and balance likely due to recent illness. The facility's Ambulation Assistance Policy dated 1-15-18 shows Place transfer belt around resident's waist and hold securely with one hand.

Based on observation, interview, and record review the facility failed to assess and monitor a resident after a fall for 1 of 3 residents (R1) reviewed for quality of care in the sample of 3. The findings include: R1's Final Incident Report shows that R1 had an assisted fall on 10/11/14. R1 had an X-ray done on 10/14/24 that showed an acute nondisplaced oblique distal radial fracture with soft tissue swelling. On 11/4/24 at 9:19 AM, R1 was sitting in her wheelchair in her room. R1 had a brace on her left wrist and was unable to move her left arm. On 11/4/24 at 9:19 AM, R1 stated that she had a fall in the bathroom. R1 stated that she must have hit her left arm on the wheelchair when she fell . R1 stated that after she fell , the nurse came in and helped her back up into the wheelchair. R1 stated that it did not appear that the nurse did any type of assessment after the fall. R1 stated that she had pain and tingling in her left arm right after the fall. On 11/4/24 at 1:32 PM, V6 (Registered Nurse) stated that she was the nurse on duty when R1 fell . V6 stated that she was alerted by the Certified Nursing Assistant (CNA) that R1 was on the floor in the bathroom. V6 stated that she went into the bathroom and R1 was sitting on the floor and her left arm was holding her body up. V6 stated that she looked her over from head to toe and asked her if she hurt anything and she (R1) stated, no so they lifted her back into the wheelchair. V6 stated that she did not consider the incident a fall because the CNA stated that she was lowered to the ground. V6 stated that she did not notify the physician or the family of the incident. On 11/4/24 at 3:09 PM, V10 (Nurse Practitioner) stated that on 10/14/24 she was asked by V14 (R1's Spouse) to see R1 due to her having pain in her left wrist after a fall. V10 stated when she examined R1, she had tenderness to her wrist area when palpated. V10 stated the tenderness in her wrist area was new for R1 so she ordered an X-ray. V10 stated that the X-ray came back showing a fracture. V10 stated that R1 told her that her wrist had a constant ache ever since the fall. R1's Electronic Medical Record (EMR) does not document the fall incident that happened on 10/11/14 in the Nursing Notes. There was no initial assessment of the resident after the fall incident documented in R1's Nursing Notes. There was no documentation of assessments of the resident post fall until V10 (Nurse Practitioner) saw R1 on 10/14/24 in R1's EMR. There was no documentation in the Nursing Notes that R1's physician and family was notified immediately after the fall. On 11/4/24 at 3:00 PM, V3 (Assistant Director of Nursing) stated that a fall is when a resident has a change in elevation and did not get to their intended spot. V3 stated that even if a resident is assisted to the floor, it is still considered a fall. V3 stated that once a resident falls, the nurse should immediately do a full head to toe assessment, check range of motion, assess pain and do a full set of vitals. V3 stated the physician and the family should be notified of the fall and it should be documented in a Fall Occurrence Assessment Form in the EMR. V3 stated that after a fall, the resident is assessed by the nurse every shift for the following 72 hours to ensure there is not a change in condition. V3 stated that R1 did not have a Fall Occurrence Report done after her fall. V3 stated that she could not find an assessment documented of any type immediately after R1's fall. V3 stated that she could not find any documentation that the physician or family was immediately notified after the fall. V3 stated that she could not find any 72-hour post fall assessments in R1's EMR. V3 stated that she was aware that R1 had fallen after V10 saw R1 on 10/14/24. The facility's Fall/Incident Occurrence-Assessment and Documentation Guidelines revised on 1/4/16 shows, The following information needs to be documented in the service notes: Date and time of Incident; Change noted in resident's physical and mental condition; skin conditions including pain, swelling, change in temperature, site, size, depth, color and breaks; pain, site and intensity; Notification of resident's attending physician, responsible party and Administrative Staff; The facility's Incidents and Accidents Policy dated 11/28/12 shows, Documentation in nurses' notes to include A description of the occurrence, the extent of injury (if any), the assessment of the resident, vital signs, treatment rendered, and parties notified. A minimum of seventy-two (72) hours (longer, if indicated) of documentation by all three shifts on resident status after the incident. Vital signs, mental and physical state, follow-up, tests, procedures, and findings are to be documented.

Based on interview and record review, the facility failed to ensure a resident was positioned in a safe manner for one of three residents (R1) reviewed for safety in the sample of three. This failure resulted in R1 experiencing a fall which required sutures and resulted in R1 obtaining a small subdural hematoma. The findings include: R1's Face Sheet shows he was admitted to the facility on [DATE], with diagnoses including alcohol abuse, fall from bed, mood disorder, vascular dementia, generalized anxiety disorder, Parkinson's disease, and malnutrition. R1's Fall Risk assessment dated [DATE], shows that R1 is at risk for falls. R1's Significant Change in Status Minimum Data Set, dated dated dated [DATE], shows R1 is not cognitively intact, has an impairment on both upper and lower extremities, is dependent (helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity) on staff for toileting, personal hygiene, putting on/taking off footwear, sit to lying, and lying to sitting on the side of the bed. R1's Progress Notes dated August 10, 2024; shows he was transferred to the local emergency room after a fall. R1's Progress Notes dated September 4, 2024; shows he experienced another fall while ambulating. R1's Care Plan initiated February 26, 2024, shows R1 is resistant to ADL (Activities of Daily Living) care such as dressing and changing. He is also combative, hitting, pushing, holding onto and punching staff during care. This generally occurred almost daily. He has a diagnosis of dementia. Work in pairs when providing care if necessary for safety of resident or staff. R1's Care Plan initiated February 26, 2024, and revised September 9, 2024, shows R1 is at risk for falls related to confusion, incontinence, poor communication/comprehension. Falls were noted on April 29, 2024, May 20, 2024, June 16, 2024, August 2, 7, and 10, 2024, September 4, 2024, and September 7, 2024. The facility's Facility Reported Incident shows that on September 7, 2024, at approximately 9:00 AM, [R1] fell from the edge of his bed while in a seated position. R1 returned from the local emergency room . CT (computed tomography) of the brain showed a possible tiny subdural hemorrhage. The emergency room physician spoke to the power of attorney (POA) and discussed goals of care. The POA declined treatment and wanted the resident transferred back to the facility. The resident has sutures in place on the left side of his forehead with order to remove in seven days. Conclusion: The CNA was next to the resident and was reaching for his shoes when the resident fell forward and sustained the fall but was unable to stop the fall. On September 10, 2024, at 10:11 AM, V5 CNA (Certified Nursing Assistant) stated she was the CNA taking care of R1 when he fell on [DATE]. V5 stated R1 was sitting on the side of the bed with his left hand holding the side rail. V5 stated R1 fell face first to the floor when V5 went to the foot of R1's bed to grab R1's shoes. V5 stated that R1 hit his head on the ground. V5 stated that when R1 wants to do something he will. V5 stated that R1 is impulsive. V5 stated that R1 tries to get out of the wheelchair by himself. V5 stated that prior to R1's recent fall, R1 was able to ambulate on his own. V5 stated that in the last month or so, R1 would cross his legs when he tried to stand up. V5 stated that R1's legs would get tangled. V5 stated that R1 has not really walked since his fall. V5 stated that when R1 fell forward from the bed, she immediately called for R1's nurse. V5 stated that R1 is pretty much nonverbal, but when R1 fell , he was moaning. V5 stated that R1 had a little blood coming from his forehead when he fell . V5 stated that R1 went to the hospital via 911. On September 10, 2024, at 10:29 AM, R1 was sitting in a high back wheelchair at the nurses' station. R1 had 5-6 sutures to his left forehead with fading bruising. R1 was nonverbal. On September 10, 2024, at 9:40 AM, V2 DON (Director of Nursing) stated that it was Saturday when R1 fell . V2 stated that R1 was sitting on the edge of the bed when V5 turned around to pick something up. V2 stated that R1 has been declining. V2 stated that R1 has agitative behaviors and is very cognitively not intact. At 11:34 AM, V4 RN (Registered Nurse) stated she was the nurse taking care of R1 the day he fell . V4 stated that R1 was on the floor when she came into R1's room. V4 stated that R1 had a bump on his head and there was a small amount of blood. V4 stated that R1 has severe dementia. V4 also stated that R1 is able to ambulate but does not have good balance. R1's Hospital Records dated September 7, 2024, shows, Impression: New small right temporal subdural hematoma likely subacute in nature. Patient's laceration was repaired using sutures. The facility's Fall Prevention Program policy revised on November 21, 2017, shows, 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. Safety interventions will be implemented for each resident identified at risk.

Based on interview and record review the facility failed to ensure a resident received their routine medication for 1 of 27 residents (R2) reviewed for pharmacy services in the sample of 27. The findings include: A facility assessment done on 6/14/24 showed R2's cognition was intact. R2's Order Summary Report showed R2 had an order for morphine (pain medication) to be given three times a day scheduled for pain. On 08/19/24 at 09:45 AM, R2 said the facility ran out of her morphine because they did not reorder the medication in time. R2 said she missed two doses of the morphine. R2's August 2024 Medication Administration Record (MAR) showed she was to receive morphine at 5:00 AM, 1:00 PM and 9:00 PM. The MAR showed on 8/5/24 R2 was not given her 1:00 PM or 9:00 PM doses. V5 (Licensed Practical Nurse- LPN) was the nurse that documented R2 did not received the 8/5/24 1:00 PM dose. On 08/19/24 at 11:57 AM, V5 could not recall why R2 did not receive her scheduled morphine. A progress note entered by V5 dated 8/5/24 at 1:36 PM, 36 minutes after the 1:00 PM dose of morphine was due, that a script for morphine was sent to the pharmacy. A progress note dated 8/5/24 at 9:25 PM, 25 minutes after the 9:00 PM dose of morphine was due, showed the morphine was not available and the facility was waiting for morphine to be delivered. R2's morphine Controlled Drug Administration Record dated 7/26/24 - 8/5/24 showed R2 received a dose on 8/5/24 at 5:00 AM and had no remaining doses on hand. On 08/19/24 at 02:17 PM, V15 (Pharmacy Technician) said the pharmacy received a script to refill R2's morphine on 8/5/24 and it was delivered to the facility on [DATE] at 4:24 AM. On 08/20/24 at 12:28 PM, V8 (Registered Nurse) said medications should be reordered to ensure they do not run out of a resident's medication. R2's Care Plan showed she was at risk for alteration in comfort related to pain. Listed under interventions was to administer pain medication as ordered. The facility's Pharmaceutical Services policy showed, Refill prescription drugs when needed, in order to prevent interruption of drug regimens.

Based on observation, interview, and record review the facility failed to ensure residents receiving a pureed diet received a 5.33-ounce (oz) portion of the pureed stuffed shells. This applies to 2 of 2 residents (R390, R81) reviewed for pureed diets in the sample of 27. The findings include: Facility provided Diet Type report dated 8/19/24 shows that R390 and R81 receive a pureed diet. On 8/19/24 at 11:31 AM, V11 (dietary aide) began to check temperatures and prepare for the lunch service on the 500, 600, and 700 units. V11 asked V12 (dietary aide) to grab the pureed meals and a few requested alternates from the kitchen. V12 returned from the kitchen at 11:45 AM with three pre-plated puree plates that were wrapped and covered along with the requested alternate items. On 8/19/24 at 11:53 AM, V12 removed the cover to the first puree plate which included a pre-plated serving of pureed stuffed shells and a pre-plated serving of pureed zucchini already on the plate. V12 then scooped a serving of mashed potatoes and gravy onto the plate before handing it to the nursing staff. V12 proceeded to serve the second puree plate right after the first following the same process. Facility provided diet spreadsheet shows the serving size for the pureed cheese stuffed shells was supposed to be a #6 scoop, which provides 5.33 total ounces. On 8/19/24 at 11:45 AM, V12 stated he was the one who pre-plated the pureed plates. V12 said he used a #8 scoop for the pureed stuffed shells, which provides 4 total ounces: 1.33 ounces less than the required portion size. On 8/20/24 at 9:24 AM, V9 (Food Service Director) said staff can use the diet spreadsheet found in the kitchen to confirm the scoop sizes to be used at service. V9 said the cook on duty usually pre-plates the puree plates before sending them to the units. If the incorrect scoop is used, a resident may not receive the correct amount of nutrients which may lead to malnutrition. Facility Pureed Food Preparation policy dated 2020 states, Pureed foods will be prepared using standardized recipes to ensure quality, flavor, palatability, and maximum nutritive value . Procedure: . 5. Serve with appropriate scoop number or divide equally to provide an equal number of portions. All of the pureed food must be used in order to deliver the correct nutrient density to each resident.

Based on observation, interview, and record review the facility failed to safely transfer a resident by preventing the resident's head from hitting the mechanical lift, failed to safely transport a resident and failed to update a resident's care plan after a fall. This applies to 2 of 27 residents (R19 and R5) reviewed for safety in the sample of 27. The findings include: 1. R19's Face Sheet showed R19 was a [AGE] year-old female with the diagnoses of dementia and anxiety. On 08/19/24 at 10:10 AM, R19 was sitting in her wheelchair. R19 had bruising to the left side of her forehead. The bruising started at R19's hairline and extended down to her left eyebrow. The bruising was about the width of R19's eyebrow/eye. The bruised area had a darker purple area about the size of a quarter near R19's hairline. R19's Skin- Other Skin Condition Report dated 8/14/24 showed R19 hit her forehead on a mechanical lift resulting in a red area to R19's forehead and ice was applied. On 08/20/24 at 09:01 AM, V4 (Certified Nursing Assistant- CNA) stated she and V6 (CNA) transferred R19 on 8/14/24 when R19 hit her head on the mechanical lift during resulting in the bruised forehead. V4 said R19 got, excited during the transfer. V4 explained R19 raised her head during the transfer hitting her head on the mechanical lift. V4 added R19 had a history of getting agitated and moving her head during transfers. On 08/20/24 at 01:33 PM, V6 said he and V4 were transferring R19 with a mechanical lift. V6 said they accidentally hit R19's head with the mechanical lift when the sling was being unhooked. 08/20/24 at 12:32 PM, V7 (CNA) said a resident's head should not hit the mechanical lift during a transfer. R19's Care Plan showed she was at risk for developing bruises. Listed under interventions was, Extreme care with resident handling: when assisting with transfers, mobility, dressing, and bathing. 34490 2. R5's Minimum Data Set assessment dated [DATE] shows that she uses a wheelchair and needs substantial/maximal assistance to wheel 50 feet with two turns and is dependent on staff to wheel 150 feet. On 8/19/24 at 12:33 PM, R5 was laying in bed. R5 had a bruise under her right eye, forehead, and bilateral knees. R5's Fall-Initial Occurrence Form dated 8/10/24 shows, Was being wheeled down to dining room by CNA (Certified Nursing Assistant) and she put her foot down and fell forward off of chair. Braced her fall by putting her arms out but still hit her face on the ground. R5's Fall Committee Meeting Notes dated 8/13/24 shows, Resident was up in her wheelchair and staff was wheeling resident when she put her feet down and she fell out of her wheelchair .What interventions were in place at the time of the fall? Make sure to apply wheelchair footrest prior to transporting .What interventions were put in place immediately after the fall to prevent further falls? Applied foot rest What new interventions and/or changes are suggested by the IDT at this time? Refer to therapy for evaluation Care Plan reviewed and updated with new interventions the Yes box checked. On 8/20/24 a 1:28 PM, V6 (Certified Nursing Assistant) said that around breakfast time he was wheeling R5 in her wheelchair to the dining room. V6 said that R5 then put her foot down and went forward out of her wheelchair and fell to the ground. V6 said that R5 is typically transported to the dining room by staff. V6 said that R5 did not have foot rests on her wheelchair at the time of the fall. On 8/20/24 at 2:12 PM, V19 (Therapy Director) said that if staff are pushing a resident's wheelchair, they should have foot pedals on. V19 stated that it is a safety hazard if not. V19 said that their feet could get stuck under the wheelchair and they could fall. On 8/21/24 at 11:35 AM, V3 (Assistant Director of Nursing) said that R5 is forgetful at times. V3 stated that they educated all of the staff after R5's fall that if they are transporting a resident, they should have foot pedals on. On 8/21/24 at 11:48 AM, V19 said that he hears about resident falls during the morning meetings or from the nurses and likes to do an evaluation of the resident within 24-48 hours after the fall to see if they would benefit from therapy services to prevent future falls. V19 said that he was not aware that R5 had had a fall prior to yesterday (8/20/24). R5's Fall Care Plan provided on 8/21/24 does not document any new interventions after her fall on 8/10/24.

Based on observation, interview, and record review the facility failed to follow occupational therapy recommendations for a resident with a contracted hand. This applies to 1 of 4 residents (R70) reviewed for range of motion/restorative in the sample of 27. The findings include: R70's face sheet lists his diagnoses to include hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. On August 19, 2024, at 10:30 AM, R70 was lying in bed. All 4 of his fingers were bent in a fist like shape on his right hand. He stated, he can open his fingers some but not all the way. His hand was not like that when he came to the facility and has gotten worse. He tries to do hand exercises. The facility does not do any exercises/anything with his hand. On August 20, 2024, at 9:20 AM, R70 was lying in bed. His hand was in the same position as the day before. On August 21, 2024, at 9:34 AM, V17 Occupational Therapy (OT) Assistant stated, R70 has a non-fixed contracture to his right hand. They were working on exercises, range of motion and weight bearing exercises when he was doing therapy. He has been discharged from OT. His recommendation to the nurse was to have a rolled-up towel in his right hand and to continue to do range of motion exercises. R70's restorative observations dated July 10, 2024, shows, he does not have any contractures, no ROM (range of motion) or braces/splints. R70's occupational discharge summary dated July 26, 2024, shows, Discharge Recommendations: 24/7 care and restorative. Restorative Program Established/Trained = Restorative Range of Motion Program. Range of Motion Program Established/Trained: BUE (bilateral upper extremity) AROM (active range of motion) . Prognosis to Maintain CLOF (current level of functioning) = Excellent with consistent staff support . Patient will be discharged to this LTC (long term care) with therapy recommendations for 24-hour care and restorative. On August 21, 2024, at 10:05, V18 Restorative Aide stated, there are 3 restorative aides for the residents/facility. He does R70's hallway. He does not see R70. R70 is not on any restorative program at this time. R70's electronic medical record does not show any orders or documentation for restorative therapy. R70's Minimum Data Set, dated dated dated [DATE] shows, he is not receiving any restorative therapy. R70's care plan does not show any plans of care for restorative or range of motion. The facility's restorative nursing program policy dated January 4, 2019 shows, Purpose: To promote each resident's ability to maintain or regain the highest degree of independence as safely as possible. Includes, but is not limited to, programs in waling/mobility, dressing and grooming, eating and swallowing, transferring, bed mobility, communication, splint or brace assistance, amputation care and continence programs. Guidelines: Appropriateness for a restorative program will be determined by the interdisciplinary team as needed and/or may be determined as a continuation of care following a course of physical, occupational and/or speech therapy . Each resident involved in a restorative program will have an individualized program with individualized goals and measurable objectives documented on the plan of care.

Based on observation, interview, and record review the facility failed to implement pressure ulcer prevention interventions for a resident who is at risk for developing pressure ulcers for 1 of 5 residents (R9) reviewed for pressure ulcers in the sample of 27. The findings include: On 8/19/24 at 10:12 AM, R9 was laying in bed. R9 did not have blankets on and R9's heels were observed directly on her mattress (not a low air loss mattress). R9 stated that she is not sure if she has wounds on her heels or not, but they are a little tender. R9 also stated that she is supposed to wear pressure relieving boots but sometimes they do not put them on. R9's pressure relieving boots were sitting in the chair in R9's room. At 11:45 AM, R9's heels were still directly on the bed and her boots were still in her chair. On 8/20/24 at 1:03 PM, V20 (Wound Registered Nurse) stated R9 is at risk for developing pressure ulcers and should have her heels offloaded to prevent pressure ulcers. V20 stated that R9's heels should not be directly on the bed. R9's Physician's Order Sheet printed on 8/21/24 shows an order dated 5/14/24 to keep both heels off loaded when in bed, may use pillows every shift and as needed. R9's Pressure Ulcer Risk assessment dated [DATE] shows that she is at moderate risk for acquiring pressure wounds. R9's Skin Integrity Care Plan shows, Elevate heels off the bed. The facility's Pressure Ulcer Prevention Policy revised on 1/15/18 shows, Use positioning devices or pillows, rolled blankets, etc. to reduce pressure and friction/shearing from heels, toes, and malleoli as indicated.

Based on interview and record review the facility failed to notify a physician prior to and after holding a blood pressure medication. This applies to 1 of 27 residents (R84) reviewed for notification of changes in the sample of 27. The findings include: R84's August 2024 Medication Administration Record (MAR) shows, Hydrochlorothiazide 12.5 mg (milligrams), give 1 tablet by mouth one time a day related to essential hypertension (high blood pressure) and Lisinopril 20 mg tab, give 1 tablet by mouth one time a day related to essential hypertension. The same report shows, both medications were held on August 1st, 5th & 18th, 2024. R84's electronic medical record shows, her physician was not notified on August 1st, 5th or 18th, 2024 of her blood pressure medication being held. On August 19,2024 at 10:17 AM, V16 LPN stated, whenever they hold a medication, they contact the doctor and let them know. The facility's physician-family notification-change in condition dated November 13, 2018 shows, Purpose: To ensure that medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, efficient, and effective manner. Guidelines: The facility will inform the resident; consult with the resident's physician or authorized designee such as Nurse Practitioner; and if known, notify the resident's legal representative or an interested family member when there is: .A need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences (e.g., an adverse drug reaction), or commence a new form of treatment to deal with a problem (e.g., use of any medical procedure, or therapy that has not been used on that resident before.) .

Based on interview and record review the facility failed to ensure a resident's opioid pain medication was administered as prescribed to avoid a significant medication error. This failure applies to 1 of 4 residents (R1) reviewed for medication administration errors in the sample of 4. The findings include: The Facility Reported Incident Report dated 6/4/24 showed, On 6/3/24 at approximately 11:30 AM, the patient (R1) was seen by the NP (nurse practitioner) due to increased confusion. Nurse continued to monitor the patient, reviewed his meds (medications), and noted that Norco 10/325 (opioid pain medication) PO (by mouth) 1 tablet was given 3 hours from last dose. Patient has an order for Norco 10/325 1 tablet PO every 6 hours as needed for pain. NP was notified and gave an order for 1x (on time) dose of Narcan (medication to reverse the effects of opioids) and if no improvement of mental status to send to a (local emergency room ) . The report showed no significant change in R1's mental state after he was administered Narcan. R1 was sent to a local hospital for an evaluation. R1 was admitted to the hospital with diagnoses of urinary tract infection (UT1) and encephalopathy (altered mental state). R1's (physician) Order Summary Report dated 5/31/24 showed an order for R1 to receive Norco 10/325 mg (milligrams); one tablet by mouth every 6 hours as needed for moderate pain. R1's June 2024 (electronic/computerized) Medication Administration Record (MAR) dated June 2024 showed V7 Registered Nurse (RN) administered one tablet of Norco 10/325 mg to R1 at 9:27 AM on 6/3/24. The MAR showed no documentation R1 had been administered any doses of Norco from 12:00 AM-9:26 AM on 6/3/24. R1's Controlled Drug Administration Record (written/paper charting/narcotic log) for June 2024 showed V8 Licensed Practical Nurse (LPN) administered one tablet of Norco 10/325 mg to R1 at 6:45 AM on 6/3/24. On 6/17/24 at 10:05 AM, V7 RN stated she was assigned to R1, from 7:00 AM-7:00 PM, on 6/3/24. V7 stated, I was passing morning medications when (R1) asked for a pain pill. I looked in the MAR on the computer and saw that no one had given him a Norco in a while, so I gave him one tablet around 9:30 AM. I didn't sign out or look at his narcotic log prior to giving him a Norco. I just checked the MAR . By noon, (R1) was definitely becoming more sleepy. He seemed a little off. That's when I checked the narcotic log and saw that the night nurse (V8 LPN) had already given him a Norco at 6:30 AM that morning. The night nurse (V8) signed off he gave the med in the narcotic book but didn't document it in the computer. I notified the nurse practitioner immediately. She gave an order to give Narcan. I gave it. There was really no change in (R1) so we sent him to the hospital for an eval/evaluation. I should have checked both, the MAR and the narcotic book, prior to giving (R1) a Norco. On 6/17/24 at 10:26 AM, V8 LPN stated he gave R1 one Norco tablet around 6 AM on 6/3/24 due to R1's complaint of pain. V8 stated he signed out that he gave R1 the Norco only on the narcotic book. V8 stated he did not sign out that he gave R1 a Norco in the MAR. V8 stated, That is my fault. I forgot to sign out that I gave (R1) a Norco on the MAR in the computer. I should have documented the administration in both places (MAR and narcotic log). On 6/17/24 at 11:46 AM, V3 Assistant Director of Nursing stated when staff administer opioid pain medications, staff are to document each administration in two places, the MAR and the narcotic logbook. V3 stated in the incident related to R1 on 6/3/24, both staff members involved made mistakes. (V8 LPN) did not document (R1's) Norco administration in the computer. (V7 RN) did not check both the MAR and the narcotic logbook prior to giving (R1) a Norco. On 6/17/24 at 10:07 AM, V6 (R1's Physician) stated he expects staff to follow physician orders and administer medications as he prescribes them. When V6 was asked if the extra Norco given to R1 on 6/3/24 caused the change in R1's mental status, V6 stated, It is difficult for me to ascertain the actual cause of (R1's) change in mental status. The UTI he was diagnosed with (on 6/3/24) could have caused his change in mental status just as much as the extra Norco could have . On 6/17/24 at 11:30 AM, V1 Administrator stated the facility did not have a medication administration policy related to the administration/documentation of opioid pain medications.

Based on observation, interview, and record review the facility failed to supervise residents receiving medications and failed to administer medications as ordered for seven of ten residents (R1, R2, R3, R7, R8, R9, R10) reviewed for medication administration in the sample of ten. The findings include: 1. R10's Admission Record shows she was admitted to the facility on [DATE], with diagnoses including unspecified right bundle branch block, constipation, cellulitis of right lower limb, unstable angina, edema, asthma, hypertension, and pain. R10's Weights and Vitals summary shows R10's blood pressure was 120/54. R10's pulse is not documented. R10's Order Summary Report shows an order for losartan 100 mg (milligrams) one time daily related to high blood pressure hold if blood pressure is less than 110/60. R10's Order Summary Report shows an order for metoprolol succinate 50 mg ER (Extended Release) one time a day related to high blood pressure. There are no parameters for when to hold the metoprolol. R10's Order Summary Report shows an order for senna with docusate sodium 8.6/50 MG give one tablet by mouth two times a day related to constipation. On April 10, 2024 at 10:07 AM, V4 LPN (Licensed Practical Nurse) was performing a morning medication pass for R10. V10 stated that she is holding R10's ordered metoprolol and losartan because her blood pressure was 120/54. V4 administered sennosides 8.6 MG instead of the ordered senna with docusate sodium 8.6/50 MG. On April 10, 2024, at 1:26 PM, V8 RN (Registered Nurse) stated R10's physician orders show that there were no parameters to hold R10's metoprolol. V8 stated she would have called the nurse practitioner to obtain parameters before she held the medication. V8 stated R10's losartan had ordered parameters to hold the medication if R10's blood pressure was less than 110/60. V8 stated she would have given R10 her losartan if her blood pressure was 120/54. V8 stated that senna with docusate sodium has an extra stool softener in it. 2. On April 10, 2024, at 9:32 AM, R2 stated that the nurse drops off her medications in the morning but does not watch her take them. R2 stated the nurse comes back later to ask her if she took her medications. At 9:40 AM, V7 R1's daughter was sitting at R1's bedside. V7 stated that R1's nurse just came in and handed her a cup of medications and told R1 to take them but did not watch R1 take her medications. On April 10, 2024, at 9:53 AM, R3 stated that the nurse drops off her medications. R3 stated that the nurse does not watch her take her medications because the nurse knows that R3 will take them. R3 state she takes 21 medications in the morning. On April 10, 2024, at 1:35 PM, R8 stated that the nurse drops off her medications. R8 stated the nurse only watches her take her medications sometimes but not all the time. On April 10, 2024, at 1:37 PM, R7 stated that the nurse does not always watch her take her medications. There are times when the nurse just drops off her medications. On April 10, 2024, at 1:43 PM, R9 stated that she is usually at breakfast when the nurse is performing medication pass, so the nurse drops off her medications on her tray in her room. R9 stated she takes her medications when she gets back to her room after she's done eating in the dining room. R1-R3 and R7-R9 did not have a self-administration of medications assessment in their electronic medical records prior to April 10, 2024. On April 10, 2024, at 11:18 AM, V3 LPN (License Practical Nurse) stated I think I have left medications at residents bedside once to help someone somewhere else. V3 said she has not been counseled in regards to leaving medications at residents' bedside. V3 said there was a time when she went to give R1 her medications and R1 was sleeping so V3 left R1's medication at her bedside to prepare medications for another resident. V3 said R1's family (V6) approached V3 and told V3 that R1 has a tendency of trying to put medications in her coke can and not taking them. [R1] has a tendency of pocketing medications. V3 said she wasn't sure if R1 does it all the time. V3 said that R1's family asked V3 to make sure staff watches R1 to make sure she is taking her medication. V3 said it is important to watch residents take their medications so that the medications are effective. V3 said if certain medications are not taken, the blood pressures could go higher, or behaviors could escalate. V6 (R1's Daughter) said that the nurse that worked on Easter Sunday (March 31, 2024-V3) dropped off R1's medications and did not watch her take them. V6 said she brought the medication cup back to the nurse and told her that R1 is throwing the medications out and that staff need to watch R1 take her medications. V6 said the same nurse that worked Easter Sunday (V3) left R1's medications again on April 6, 2024. V6 said she saw R1 put the medications in R1's pop can. On April 10, 2024, at 2:38 PM, V2 DON (Director of Nursing) said R1's family noticed that R1 was not taking her medications. V2 said she put in an order for the nurses to ensure R1 was taking her medications. V2 said she does not recall R1's family bringing up concerns in regard to R1's medications being left at R1's bedside, but V2 said she told R1's family that she was shocked that nurses were leaving medications at bedside. V2 said that nurses should follow up with the resident to ensure they are taking their medications. V2 said, staff can leave the medication on residents' tables and the staff should follow up with the resident in five minutes or so. When V2 was asked if staff are not visually watching the residents taking their medications, then how do staff know that the resident is taking their medications? V2 said That is a good question. V2 said that the staff is trusting the resident to take their medications. The facility Pharmaceutical Services policy revised December 2015 shows, It is the policy of this facility to provide assistance with medication administration as needed or requested. Residents may keep and use prescription and non-prescription medication in their apartment after being evaluated for safety in self-administration of medications and must keep their apartment locked at all times when unattended. Residents must keep medications secured from other residents. Over the counter medications, prescription drugs, and biologicals used in the facility must be labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions and the expiration date.

Based on observation, interview, and record review the facility failed to ensure pressure reducing interventions were in place for residents with pressure injuries for 2 of 8 residents (R106, R183) reviewed for pressure injuries in the sample of 28. This failure resulted in R106's coccyx excoriation progressing to an unstageable pressure injury and R183's Stage 3 coccyx pressure injury advancing to an unstageable pressure injury. The findings include: 1. On 07/24/23 at 10:34 AM, R106 was in her room, sitting up in her wheelchair on a flattened pillow. R106 said she has a dressing on the sore on her bottom. R106 said the wound doctor comes, but her wound is not getting better. R106 said the wound doctor did a procedure the last time and her bottom is very inflamed and burns. R106 did not have a pressure reducing cushion in her wheelchair or a pressure reducing air mattress on her bed. On 07/24/23 at 12:57 PM, R106 was sitting in her wheelchair in the dining room on a flattened pillow. R106's Most Recent Skin assessment dated [DATE] shows pressure ulcer coccyx, Stage: Unstageable, Length:3.5 cm Width: 3 cm, Appearance: moist, color: gray, Drainage amount: small, Exudate: Purulent. On 07/25/23 at 9:40 AM, V5 Wound Registered Nurse said wound assessments are done weekly and include measuring the wounds, assesses the treatment orders to determine whether to continue or change them, and looking at the pressure reducing interventions in place. V5 said pressure reducing intervention used are turn/reposition every 2 hours, low air loss pressure reducing mattress, protein supplements, and wheelchair cushions or roho cushions. V5 stated any resident comes in with a pressure wound should have an air mattress. They should have some sort of pressure reducing cushion on their wheelchair. R106 has an unstageable pressure to her coccyx, it started out as just excoriation. R106 should have an air mattress and a wheelchair cushion. On 07/26/23 at 11:15 AM, V13 Wound Doctor stated R106 has an unstageable pressure wound to her coccyx. I just debrided it last week; it was the first time seeing her and it was at unstageable. R106 should have low air loss mattress, nutritional supplements, and a wheelchair cushion in place. I believe I ordered one. The low air loss mattress and wheelchair cushion helps wounds from deteriorating by reducing the pressure by redistributing the pressure off the wound. R106's Physician Orders do not contain orders for a pressure reducing wheelchair cushion or air mattress. R106's Care Plan shows R106 was readmitted on [DATE] with excoriation on the buttocks and is at risk for impaired skin integrity with interventions: pressure reduction support surface in bed and pressure reduction sitting/wheelchair surface. The same Care Plan was updated 7/12/23 and shows resident has actual open area: unstageable coccyx due to worsened excoriation. R106's Skin assessment dated [DATE] shows excoriation/blistering to both buttocks. R106's Skin assessment dated [DATE] shows Moisture Associated Skin Damage (MASD) Excoriation on bilateral buttocks and coccyx with increased skin redness. R106's Skin Assessments on 6/27/23 and 7/4/23 shows worsening MASD excoriation. R106's Progress Note from V13 dated 6/28/23 shows discussed care and course of treatment and obtained general consent to evaluate and treat. Patient not seen, up in chair. R106's Skin Assessment on 7/12/23 shows pressure ulcer, site: coccyx, Stage: unstageable, Length 6 cm, Width 6 cm, Appearance: slough, Color: yellow. R106's Progress Note from V13 dated 7/19/23 shows unstageable pressure injury sacrum, 3.5 cm Length x 3 cm width. 100% slough. Post Debridement Wound Bed 3.5 cm length x 2.5 cm width x 1/1 cm depth. Removed some slough today, able to better determine depth but still 100% slough left on wound bed. Treatment Order: Preventative Wound Recommendations: Low air loss mattress recommended. The facility's View Delivery Order Form dated 7/25/23 shows a low air loss mattress was ordered for R106 on 7/25/23. 2. On 07/24/23 at 9:41 AM, R183 was in bed (on a regular mattress) with V7 (R183's husband) at bedside. V7 stated R183 has a sore on her bottom that causes her pain, she cries like a baby. They have not been changing the dressing. They didn't change it on Friday, Saturday, or Sunday. I'm here from 8 AM to 8 PM and they say they will take care of it, but they don't. They change it when they remember. On 07/24/23 at 9:41 AM, V8 Certified Nursing Assistant (CNA) lowered R183's saturated brief and R183's dressing to her right buttock was undated, saturated with yellow/tinged with pink drainage, and was rolled up (not on wound) in the brief. R183 had a large golf ball size wound with immeasurable depth on her coccyx. R183's brief was completely saturated with urine. R183 had an open excoriated area on her left buttock. R183 winced when moved during incontinence care. V8 said she had checked R183's brief at 8 AM and she saw a dressing in the brief but did not change R183 at that time. On 07/24/23 at 11:45 AM, R183 was up in the wheelchair at bedside with V7. V7 said R183 was crying like a little girl, she is in so much pain from her bottom. V7 said he was there when V8 came in and checked R183 earlier, but V7 only looked at R183's brief and didn't check the dressing at all. On 07/25/23 at 9:27 AM, R183 was in bed on her back. There was no air mattress on the bed. On 07/25/23 at 1:30 PM, R183 was up in the wheelchair at the bedside with V7. There was an air mattress on the bed. V7 stated they just put that mattress on the bed now. I've been asking for a month for that bed! She had one like that in the hospital. R183's Physician Orders shows R183 was admitted on [DATE]. R183's Skin assessment dated [DATE] shows sacrum: stage 3, length: 4.5 cm, width: 2.5 cm, depth: 0.5 cm, Appearance: dry, pink, no drainage or exudate. R183's Skin assessment dated [DATE] shows sacrum: unstageable, Appearance: necrotic, Color: gray, Drainage: moderate, Exudate: sanguineous. R183's Physician Progress Note by V13 dated 7/19/23 shows Unstageable Coccyx pressure injury. Post Debridement Wound Measurement 3 cm length x 3 cm width x 0.8 cm depth with 50% slough remaining. Treatment Order: Every Day and as needed cleanse wound with normal saline, santyl nickel thick layer, cover with moist gauze. On 07/26/23 at 11:15 AM, V13 Wound Doctor stated R183 has an unstageable on her coccyx. She should have an air mattress. It off loads to decrease the pressure on the wound to help heal. In general, all pressure wounds that are stage 2 or greater should have air mattress and wheelchair cushions to reduce pressure. On 07/25/23 at 9:40 AM, V5 Wound Registered Nurse said wound assessments are done weekly and include measuring the wounds, assesses the treatment orders to determine whether to continue or change them, and looking at the pressure reducing interventions in place. V5 said pressure reducing intervention used are turn/reposition every 2 hours, low air loss pressure reducing mattress, protein supplements, wheelchair cushion or roho cushion. V5 stated any resident comes in with a pressure wound should have an air mattress. They should have some sort of pressure reducing cushion on their wheelchair. I thought R183 had an air mattress, I'll have to double check. If a dressing is rolled or not in place it should be changed right away. R183's Care Plan dated 6/26/23 shows R183 has an alteration in skin integrity and lists pressure reduction support surface in bed. R183's Physician Orders shows R183 was admitted on [DATE] and contains no order for a low air moss mattress. The facility's Prevention of Pressure Ulcers/Injuries Policy dated 9/2021 shows review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Conduct a comprehensive skin assessment including areas of impaired circulation due to pressure from positioning. Select appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion, body weight, and overall risk factors. Review the interventions and strategies for effectiveness on an ongoing basis.

Based on observation, interview, and record review the facility failed to ensure residents are free from significant medication errors for 1 of 3 residents (R1) reviewed for medications in the sample of 6. This failure resulted in R1 having a hypoglycemic episode with stroke like symptoms, requiring hospitalization for 6 days. The findings include: On 7/19/23 at 10:15 AM, R1 was sitting in his room, talking on his phone. R1 was alert and orient and able to answer questions appropriately. R1 stated I've been back here for a few days now; I was in the hospital a couple times. The last time, they sent me out, I couldn't talk. I was in the hospital a few days because they gave me the wrong medication. The hospital found out I was given diabetes medication, I'm not diabetic. It was very scary. I could have had a stroke! On 7/19/23 at 10:50 AM, V6 Nurse Practitioner said R1 went to the hospital for a hypoglycemic episode and was there for a few days. V6 stated R1 is not diabetic and is not on any diabetic medications. V6 said if a diabetic medication is given to a non-diabetic patient hypoglycemia can occur. V6 said she gave orders to check R1's blood sugar twice a day to monitor R1's blood sugars for hypoglycemia since he came back. On 7/19/23 at 12:22 PM, V2 Director of Nursing said V7 Registered Nurse (RN) was the nurse on duty 7/2/23 for R1 and V7 was currently on vacation in the Philippines and not available. V2 was not aware of any medication errors reported to her and had not been told about R1's hospital test results showing R1 had been given a wrong medication. On 7/19/23 at 12:24 PM, V7's phone was not accepting calls at this time. On 7/19/23 at 12:25 PM, V8 RN Supervisor said he was the supervisor on duty when R1 was sent to the hospital. V8 said V7 RN came to him and asked him to check on R1 because V10 (R1's wife) said R1 was not acting himself and insisted something was wrong. V8 said he looked at R1 and new R1 was not himself. V8 said R1 could not talk to him and was unable to follow commands. V8 said he activated 911 and R1 was sent to the hospital. On 7/19/23 at 12:37 PM, V6 said if R1's sulfonylurea blood test (done in the hospital) is positive that would indicate that R1 was given a medication containing sulfonylurea which is found in diabetic medications. V6 said the test results would be helpful to know how to move forward in treating R1 and figuring out why R1 had a hypoglycemic event. On 7/19/23 at 1:35 PM, R1 said the hospital called his wife (V10) at home and told her the test results showed he had been given the wrong medications. On 7/19/23 at 1:47 PM, V11 Hospital Critical Care Doctor was paged and did not return the call. On 7/19/23 at 2:35 PM, V9 Social Service at Hospital said her coworker called in the complaint as a mandated reporter. V9 said R1's blood test for sulfonylurea came back positive for glimepiride. V9 said R1 is not a diabetic and had not been prescribed that drug so they reported it. V9 said they called R1's wife and spoke with her about the test result and what it meant. On 7/20/23 at 8:44 AM, V10 said she was at the facility the evening R1 was sent to the hospital. V10 said V7 brought in medications for R1 and poured all of them in R1's mouth at the same time. V10 said R1 couldn't swallow the pills or move his mouth or lips at all. V10 said she told V7 something was wrong and V7 kept trying to get R1 to swallow pills giving him Glucerna and pudding. V10 said she told V7 again that something was wrong, R1 was not himself, he couldn't move his lips at all, and his eyes were huge. V10 said two other nurses came into the room and V8 said to call 911. V10 said R1's face was drooping like he was having a stroke. V10 stated I was so scared; I rode in the ambulance with him. I thought he was having a stroke! V10 said when they arrived in the hospital R1's blood sugar was 17 in the emergency room and they were telling her that something was wrong, R1's sugar shouldn't be that low. V10 said R1 was admitted to the Intensive Care Unit where she stayed with him for several days while R1 received intravenous fluids with sugar in them. V10 said R1 was discharged back to the facility after his sugars were better. V10 said she received a call from the hospital a few days ago and they told her that the test results show R1 got medication for diabetes. V10 said the hospital was going to let the facility know what happened. On 7/20/23 at 9:06 AM, V2 Director of Nursing said she did receive the test results from the hospital for the sulfonylurea test and the results shows glimepiride positive with a result of 16. V2 said she was able to pull pharmacy records and there were residents in that hallway that were diabetic and had that prescribed medication. V2 said the resident's medications come in packets, sometimes with multiple drugs in each packet. V2 said the nurses are supposed to verify the resident name on the packet and check the medication order in the Medication Administration Record, verifying the medication and dosage before giving to the resident. V2 stated this is a disturbing mess! The nurse must have given the wrong medications in the morning and R1 started having signs and symptoms later that day around supper time. On 7/20/23 at 10:42 AM, V12 Social Service at Hospital said when R1 was at the hospital, the doctors and pharmacist thought something was off that R1 was having this hypoglycemic episode since he was not a diabetic and his records showed no order for diabetic medications, so they ordered a drug panel. V12 said the results did not come back until after R1 was already discharged back to the facility. V12 said the drug panel came back positive for glimepiride and confirmed the result of 16 indicating the drug was given to R1. V12 said she spoke with V10 and then reported to IDPH as a mandated reporter. R1's Minimum Data Set, dated dated dated [DATE] shows R1 is cognitively intact with diagnoses of: anemia, atrial fibrillation, coronary artery disease, gastroesophageal reflux disease, septicemia, hyperlipidemia, arthritis, respiratory failure, aftercare following joint replacement surgery, presence of left artificial knee joint, osteoarthritis, partial intestinal obstruction, Crohn's disease, ileus, and chronic combined systolic and diastolic heart failure. R1's Physician Order Activity Report dated 7/19/23 shows from 6/18/23 to 7/19/23 there are no orders for glimepiride or any other diabetic medication. R1's Nursing Home to Hospital Transfer Form dated 7/2/23 shows R1 was transferred to the hospital for facial droop and altered mental status on 7/2/23 at 7:30 PM. R1's Hospital Discharge Instructions dated 7/8/23 shows R1 was in the hospital from 7/2/23 to 7/8/23. The same instructions show a pending lab of sulfonylurea screen blood sent out 7/3/23. R1's Hospital History and Physical dated 7/2/23 shows [AGE] year-old male with recent left total knee replacement. Today, he was in his usual state of health. He ate dinner, he was given his evening meds. Shortly after, he began having alerted mentation. He developed slurred speech, facial droop, and he was not following commands. Accucheck per Emergency Medical Services (EMS) was 75. Upon arrival here accucheck was 17 and 18 on recheck. He was given dextrose 50 and blood glucose level increase Neuro symptoms have resolved. He feels back to baseline. He has no history of diabetes and is taking no meds for diabetes. R1's CarePort-Printable Review Referral Paperwork dated 7/8/23 shows R1's blood glucose lab result of 49 LL on 7/2/23 at 8:41 PM (normal range 70-99). The same paperwork contains a Critical Care Physician Progress Note dated 7/3/23 at 1:15 AM shows He presented to hospital emergency room (ER) late on 7/2/23 with facial droop and aphasia. Per notes upon arrival blood glucose was 17 and 18 on initial checks and he was given intravenous dextrose 50 (D50) with rise in blood glucose and a normalization of neuroexam. Repeat blood glucose in ER again noted to be low at 18. Additional D50 given and placed on infusion and admitted to intensive care unit for continued care. He has no history of diabetes and takes no oral hypoglycemic medications and is not on insulin. Elevated insulin and c-peptide levels were noted and raise concern for inadvertent administration of sulfonylureas while at rehab. Check sulfonylurea levels. V11's Progress Note dated 7/3/23 at 1:55 PM shows Active Problem: hypoglycemia- no history of diabetes, not on antihyperglycemics, erroneous sulfonylurea administration at skilled nursing facility? Sulfonylurea lab pending. Acute metabolic encephalopathy secondary to hypoglycemia, present on admission-resolved, confusion and altered state was due to his low glucose, with normalization of glucose, his mentation has normalized. R1's sulfonylurea screen from the hospital dated 7/3/23 shows glimepiride-positive result of 16. The facility's Physician Order Activity Report dated 7/2/23 shows R6 had an order for glimepiride 4 mg. The facility's Census for 7/2/23 shows R1 was in room XXX and R6 was in room YYY. The facility's Schedule for 7/2/23 shows V7 was the nurse assigned to the wings (including both R1 and R6). The facility's Administering Medications Policy dated 9/2021 shows medications must be administered in accordance with the orders, including any required time frame. The individual administering medications must verify the resident's identity before giving the resident his/her medications. The individual administering the medications must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method(route) of administration before giving the medications.

Based on interview and record review, the facility failed to comprehensively assess, monitor and update physician timely in order to obtain immediate medical intervention for the treatment of [REDACTED]. This failure resulted in R1 being admitted to local hospital with [DIAGNOSES REDACTED]. This applies to one resident of three residents (R1) reviewed for skin alteration and hydration. The findings include: According to the Physician order [REDACTED]. Admission nursing notes dated 12/23/14 showed R1 with sheering and ecchymosis to bilateral lower extremities, dressings to bilateral heels and rashes to perineal area. There was no identified issues with R1's coccyx on admission according to R1's admission assessment to the facility on [DATE]. R1's admission nursing assessment dated [DATE] showed R1 needed extensive assistance with transfer, dressing, toileting, hygiene and bathing. On 2/18/15 at 9:50am, Z1 (Family member) stated she was in R1's room on 12/30/14 when she noticed the excoriation to R1's buttocks. Z1 stated the nursing staff informed her R1 had a bad rash from her diarrhea. Z1 stated she was not informed of R1's diarrhea. The facility failed to document the persistent diarrhea episodes R1 had at the facility but the report from the hospital records showed R1 had persistent diarrhea for few weeks at the facility. Review of R1's best practices wound care consultation note dated 12/30/14 failed to show a treatment order for R1's coccyx area. Nursing notes dated 12/31/14 showed R1 with "bloody stool with mucous and excoriation on buttocks". Neither the wound care nor the nursing notes adequately described the excoriation area on R1's buttocks. There was no measurement of the area in any of the progress notes. The only order in R1's POS was dated 1/6/15, seven days after the initial identification, for "[MEDICATION NAME] 1%-0.05% topical cream. Cleanse with normal saline and pat dry, apply [MEDICATION NAME] to buttocks/gluteal folds and perineum twice daily for 7 days". On 2/18/15 at 2:40pm, E3 (Wound nurse) stated R1 got the excoriation of the skin from her constant diarrhea and that she applied barrier cream to the area. E3 stated the wound specialist saw R1's buttocks on 1/6/15 and ordered the [MEDICATION NAME]. Review of facility's policy on skin assessment last revised 8/2011 showed to "document findings on skin assessment in electronic medical record (EMR). It also showed that "when a new change in skin condition must be reported to skin care coordinator, physician, and family, and that "a comprehensive assessment is required". Review of facility's undated policy and procedure on Resident Condition Changes showed when there is a skin breakdown, the facility should write descriptive notes of the sores including size, depth, and drainage if any and complete unusual occurrence report per policy. On 2/18/15 at 9:50am, Z1 also stated R1 did not look right and she asked the nursing staff to check R1's potassium level on 12/30/14. The potassium critical level result of 6.6 was called back to facility on 12/31/14. Nursing notes dated 12/31/14 showed nursing left message for the Physician at 2:07pm. R1's Nurses notes showed a follow-up call was made to the physician on 1/1/15 at 8:13am. Nurses note showed R1 was not treated for [REDACTED]. Z1 also stated she kept visiting R1 and found on 1/10/15 that something was very wrong with R1. Z1 stated she insisted R1 should be sent out to the hospital. Z1 stated when R1 got to the hospital she was admitted to the intensive care unit. Z1 stated R1 was dehydrated, and was also put on "isolation for stool infection". Review of hospital record dated 1/11/15 showed R1 was admitted to the hospital with [REDACTED]. On 2/19/15 at 12:30pm, E2 Director of nursing (DON) stated nursing staff should have called the medical director if there was no response from the Primary Physician regarding a critical laboratory value. On 2/19/15 at 1:00pm, Z2 (Medical Director) stated he should have been notified right away about the critical laboratory value. Z2 stated the nurses have full access to him and he should have been notified promptly. Z2 stated he would have ordered Kayaxalate right away and also order a repeat laboratory for the next day.

Based on observation, record review and interview, the facility failed to maintain a mechanical lift in safe condition for 1 of 3 residents reviewed for resident transfers. This failure resulted in R1 receiving a head laceration being sent to the emergency room and receiving 13 sutures. Finding includes: Review of facility's final report submitted to IDPH dated 8/13/13 shows R1 was being transferred from her bed to a shower chair using a total body lift by two nurse's aides, E3 and E4. The lift dropped suddenly while R1 was being lowered into the shower chair. The lift hit the head of the resident resulting in a laceration of 6 cm. R1 remained alert and oriented with no change in consciousness. R1 was sent to the ER and returned a few hours later with 13 stitches to the scalp. E3 and E4, nurse's aides who were involved in this transfer, were interviewed on 8/15/13 at 12:50pm and a re-enactment was performed using the same pieces of equipment, the total body lift and the shower chair. E3 stated R1 was placed in the sling while in her bed, lifted and moved toward the shower chair. E3 demonstrated how R1 was in the lift, directly over the shower chair with E4 behind the chair, guiding R1. Suddenly, the overhead bar holding the sling dropped. The lift then tipped backwards and the overhead bar hit R1 on the back occipital area causing a laceration. Other staff were immediately called and assisted in lifting the lift off of R1. On 8/15/13 at 11:45am, R1 stated she did recall the incident and that it happened so fast. R1 stated it was not anyone's fault and she does not currently have any discomfort from the accident. Review of facility's weekly lift and ceiling hoist maintenance log shows this lift, #2, (the facility has 3) was taken out of order from 6/4/13 through 6/11/13 for a " lift replacement handle. " E7 (Activity/Rehab aide) stated this is the same piece of equipment that failed on 8/10/13. E7 said the lever that locks the base slipped due to a worn locking mechanism, causing the overhead bar to drop. E1 (administrator in training) stated on 8/15/13, the mechanical lift has been permanently taken out of service.

Based on observations, interview and record review the facility failed to address a resident's poor positioning and failed to identify a rash resulting from the resident's poor position. These failures resulted in 1 resident (R15) developing a neck rash with fungus. The sample size is 24. The findings include: R15 is an [AGE] year old, severely cognitively impaired resident who was re-admitted to the facility on [DATE] with multiple diagnoses, including [MEDICAL CONDITION], according to the most recent Minimum Data Assessment ((MDS) dated [DATE]. R15 is totally dependent on staff for bed mobility, transfers, locomotion, dressing, eating and personal hygiene, according to the 9/14/11 MDS. R15 was observed in her wheelchair with her head down and her chin touching the right side of her upper chest on 10/24/11 at 2:10 PM; 10/25/11 at 8:45 AM, 9:10 AM, 11:00 AM, 12:55 PM and 4:05 PM; and 10/26/11 at 8:45 AM, 10:05 AM, 10:20 AM, 10:41 AM and 10:55 AM. On 10/26/11 at 10:55 AM E6 (Restorative Aide) said that R15 usually keeps her head down and her eyes closed. E6 lifted up R15's head slightly and held it. A deep red rash was noted in the skin folds of R15's neck. E3 (Restorative and Wound Nurse) was present at this time. E3 said that she was not aware that R15 had a rash on her neck. On 10/26/11 at 11:10 AM Z1 (Doctor) examined R15's neck. Z1 said that R15 had a rash with fungus. Z1 said that he ordered anti-fungal cream. On 12/26/11 at 12:36 PM E7 (CNA) said that she noticed that R15 had a rash on her neck in the morning but did not tell the nurse because she thought the nurse new about it. On 12/26/11 at 11:20 AM E8 (Nurse) said that she was not aware that R15 had a rash on her neck.