Every finding on record at Aperion Care Dolton

Based on observation, interview, and record review the facility failed to keep residents free from misappropriation of funds. This deficiency affected three residents (R1, R2, R3) of eight residents reviewed for misappropriation of funds. This past noncompliance occurred from 3/23/2026 through 3/25/2026.Prior to the survey date of 3/31/26, the facility had taken the following actions to correct the noncompliance:On 3/24/26, the facility Compliance Assurance Committee developed a plan of correction for the 3/23/26 R1, R2, and R3 misappropriation of funds. On 3/24/26 All staff received an education in- service on Abuse Prevention Policy, Abuse reporting, resident rights, proper handling of funds and financial exploitation. On 3/24/26, the facility completed a facility wide audit of all resident trust fund accounts for the past 60 days to identify any additional discrepancies or unauthorized transactions. On 3/24/26, the facility conducted a facility wide audit to ensure abuse assessments are up to date and care plans/interventions reviewed. On 3/25/26, All affected residents and/or their responsible parties were notified of findings of investigation. There is no subsequent improper transfer determined by Quality Assurance Tool from 3/26/26, 3/27/26, 3/30/26, 3/31/26.

Based on interview and record review, the facility failed to follow physician order for anticoagulation medication. This deficiency affected one (R5) of nine residents reviewed for physician orders. This past noncompliance occurred on 2/11/2026.Prior to the survey date of 3/31/26, the facility had taken the following actions to correct the noncompliance:On 2/11/26, the facility Compliance Assurance Committee developed a plan of correction for the 2/11/26 R5's readmission physician orders. On 2/11/26 All staff received an education in- service on following and carrying out physician orders, 5 rights of medication administration, medication administration and verification of new admission/readmission orders. On 2/11/26, the facility completed a facility wide audit of the past 60 days to ensure physician orders have been carried out. On 2/11/26, the facility conducted an emergency QAPI meeting held with medical director. On 2/11/26, the facility completed an audit of the last 10 admissions/readmissions completed to ensure physician orders have been carried out. The facility has implemented a QA tool to audit 5 residents a week for 2 months and then 2 residents a week for 4 months to ensure physician orders are being followed. Audits on 2/12/26, 2/13, 2/16, 2/17, 2/18, 219, 2/20, 2/23, 2/24, 2/25, 2/26, 2/27, 3/2/26, 3/3, 3/4, 3/5, 3/6, 3/9, 3/10, 3/11, 3/12, 3/13, 3/16, 3/17, 3/18, 3/19, 3/20, 3/23, 3/24, 3/25, 3/26, 3/27, 3/30.

Based on observation, interview, and record review, the facility failed to ensure that a resident's indwelling urinary catheter drainage bag was covered with a privacy bag to maintain resident's right to privacy and dignity. This failure affected one resident(R3) of two residents, reviewed for privacy and dignity.Findings include:R3 was admitted to the facility on [DATE] with diagnoses which include but are not limited to Tracheostomy Status, Quadriplegia, Neuromuscular Dysfunction of Bladder, and Urinary Tract Infection (on 10/7/25).On 12/22/25 at 11:30am, R3 was observed in bed with indwelling urinary catheter drainage bag resting on the floor, and without privacy bag. The Urinary drainage bag was visible to persons passing by in the hallway. Again at 11:45am, the urinary drainage bag was still in the same position, visible to anyone walking down the hall. At this time, V3 (RN/Registered Nurse), who was observed earlier caring for R3, was asked why the drainage bag should not be resting on the floor and exposed to anyone standing or walking down the hallway. V3 stated that R3's bed is in a low position, and she (V3) did not know how to prevent the drainage bag from touching the floor. V3 added that R3 is able to understand questions and able to answer yes or no in response.On 12/22/25 at 11:55am, V2(Director of Nursing) was notified and V2 stated that the urinary drainage bag should not touch the floor and that there should be a privacy bag covering the drainage bag for the resident's privacy. V2 later informed the surveyor that V3 and other staff members were given in-service training regarding the care of indwelling urinary catheter.R3's care plan dated 11/10/25 states that R3 has an indwelling urinary catheter related to pressure injury. Goal states that R3 will be free from catheter related trauma through the review date.Facility's policy on Dignity dated 11/28/12 and latest revision on 4/23/18 states: This facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Staff Should I carry out activities in a manner which assists the residents to maintain and enhance his/her self-esteem and self-worth. Maintaining a residents' dignity should include but is not limited to the following: Refraining from practices demeaning to residents such as living urinary catheter bags uncovered, etc.

Based on observation, interview, and record review, the facility failed to ensure that a resident's indwelling urinary catheter drainage bag did not rest on the floor directly, to prevent potential contamination of the drainage bag from the floor surface. This failure affected one resident (R3) of two residents reviewed for indwelling urinary catheter care.Findings include:R3 was admitted to the facility on [DATE] with diagnoses which include but are not limited to Tracheostomy Status, Quadriplegia, Neuromuscular Dysfunction of Bladder, and Urinary Tract Infection (on 10/7/25).On 12/22/25 at 11:30am, R3 was observed in bed with indwelling urinary catheter drainage bag resting on the floor, and without privacy bag. The Urinary drainage bag was visible to persons passing by in the hallway. Again at 11:45am, the urinary drainage bag was still in the same position, visible to anyone walking down the hall. At this time, V3 (RN/Registered Nurse), who was observed earlier caring for R3, was asked why the drainage bag should not be resting on the floor and exposed to anyone standing or walking down the hallway. V3 stated that R3's bed is in a low position, and she(V3) did not know how to prevent the drainage bag from touching the floor. V3 added that R3 is able to understand questions and able to answer yes or no in response.On 12/22/25 at 11:55am, V2(Director of Nursing) was notified and V2 stated that the urinary drainage bag should not touch the floor to prevent contamination, and that there should be a privacy bag covering the drainage bag for the resident's privacy. V2 later informed the surveyor that V3 and other staff members were given in-service training regarding the care of indwelling urinary catheter.R3's face sheet and progress notes dated 10/7/25 shows that R3 was admitted to this facility on 8/20/25 and that R3 was sent to the hospital with a diagnosis of Urinary Tract Infection (UTI) on 10/7/25(about 7 weeks after admission to the facility).R3's care plan dated 11/10/25 states that R3 has an indwelling urinary catheter related to pressure injury. Goal states that R3 will be free from catheter related trauma through the review date. Intervention states to monitor for signs and symptoms of urinary tract infection.Facility's policy on Urinary Catheter Care dated 11/28/12 with latest revision date 2/14/19 states: Purpose - Established guidelines to reduce the risk of or prevent infections in residents with an indwelling catheter. #7 states: Urinary drainage bag and tubing shall be positioned to prevent either from touching the floor directly. May place the drainage bag and excess tubing in a secondary vinyl bag or other similar device to prevent primary contact with the floor or other surfaces.

Based on observation, interview, and record review, the facility failed to ensure three residents (R1, R2, and R5) were properly placed on enhanced barrier precautions, staff were adequately informed of isolation procedures and failed to follow their infection precaution guideline procedure. This failure has the potential to affect all 14 residents currently residing on the South-2 Unit.Findings include:Per facility census dated 7/9/2025 shows 14 residents residing in the South-2 Unit.R1 is a [AGE] year-old female who originally admitted to the facility on [DATE] and continues to reside in the facility. R1 has multiple diagnoses including but not limited to the following: acute myelitis in demyelinating disease of central nervous system, dementia, altered mental status, multiple contractures, need for assistance with personal care, urinary tract infection, ESBL (Extended-Spectrum Beta-Lactamase), quadriplegia, COPD (Chronic obstructive pulmonary disease), and anxiety. It is to be noted that R1 has multiple wounds and a urinary catheter. R2 is a [AGE] year-old male who originally admitted to the facility on [DATE] and continues to reside in the facility. R2 has multiple diagnoses including but not limited to the following: ESRD (End-Stage Renal Disease) dependent on dialysis, type II DM (Diabetes Mellitus), lack of coordination, pneumonia, sepsis, muscle wasting, difficulty in walking, abnormal posture, and prostate cancer. It is to be noted that R2 has a dialysis port, a central venous catheter, and multiple wounds.R4 is a [AGE] year-old male who originally admitted to the facility on [DATE] and continues to reside in the facility. R4 has multiple diagnoses including but not limited to the following: CKD (Chronic Kidney Disease), CHF (Congestive Heart Failure), type II DM, and repeated falls. It is to be noted that R4 has a VRE (Vancomycin-Resistant Enterococci) infection in his wound.R5 is a [AGE] year-old male who originally admitted to the facility on and continues to reside in the facility. R5 has multiple diagnoses including but not limited to the following: quadriplegia, depression, MRSA (Methicillin-Resistant Staphylococcus aureus), UTI (Urinary Tract Infection), anxiety, seizures, cachexia, obstructive uropathy, and psychotic disorder.It is to be noted that R5 has a urinary catheter and an active pressure ulcer.Order Listing Report dated 7/8/2025 shows R5 on Enhanced Barrier Precautions due to suprapubic catheter and wounds. R4 is on Contact Isolation for VRE of the wound. It is to be noted that R1 or R2 are not on the Enhanced Barrier Precautions list.On 7/8/2025 at 11:20AM, observed R2 and R5's room to have no enhanced barrier sign on door or isolation bin outside of door. At 11:30AM, observed V7 (Certified Nursing Assistant) changing linens to R1's bed. V7 was wearing gloves, however no gown or mask was worn. At 11:45, V6 (Certified Nursing Assistant) was asked about enhanced barrier precautions and contact isolation. V6 was noted to be confused and unable to accurately describe the differences between isolations and the expectations of CNA's regarding infection control when dealing with residents on various types of isolations.At 11:55AM, V7 (Certified Nursing Assistant) was also asked about enhanced barrier precautions and contact isolation. V7 was also unable to accurately describe the differences between isolations and the expectations of CNA's regarding infection control when dealing with residents on various types of isolations.At 1:10PM, V8 (Certified Nursing Assistant) was observed entering R4's room (who was on contact isolation) not wearing any PPE's.On 7/9/2025 at 11:16AM, V12 (Certified Nursing Assistant) was observed in R4's room assisting resident with transferring from bed to wheelchair. R4 was noted to be wearing gloves, however no mask or gown was worn. V12 assisted R4 with transferring, repositioning, and fixed wheelchair. V12 exited room wearing gloves, grabbed bag of soiled linen from hallway, and put soiled linen from R4's bed in bag. V12 then began making R4's bed with clean linen without changing gloves or conducting hand hygiene. V12 then carried soiled linen bag out to hallway and grabbed a clean sheet from clean linen cart, still wearing same gloves. V12 then grabbed R4 a soft drink off of dresser which R4 began to drink.V12 said she was unaware that R4 was on contact isolation, but she does see the contact isolation sign on his door and isolation bin outside of his room. V12 said I should have worn gloves, mask, and a gown when caring for R4. It is to be noted that V12 was also unable to adequately explain expectations of CNA's when a resident is on enhanced barrier precautions and was unable to provide this surveyor with a time she was in-serviced on isolation.At 1:30PM, V2 (Director of Nursing) said residents who have wounds or a medical device that cause an opening to the body should be on enhanced barrier precautions. This is to help prevent the spread of infection. My expectation would be that any staff providing direct patient care would be expected to wash their hands before and after and wear a gown, gloves, and a mask when providing care. Asked V2 when the last time the staff was in-serviced on isolation. V2 provided this surveyor with an in-service for enhanced barrier precautions dated 4/8/2025. V2 said staff is also trained on many things upon hire.Facility Contact Precautions sign shows providers must put on gloves and gown before entering room and discard upon exiting room. Facility Enhanced Barrier Precautions sign shows providers and staff must put on gloves and gown for the following high contact resident care activities: dressing, bathing, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care, and wound care.Facility policy titled Infection Prevention Guidelines with last revision date of 5/15/2023 states in part but not limited to the following: It is the policy of this facility to, when necessary, prevent the transmission of infections within the facility through the use of isolation precautions.

Based on interview and record review the facility failed to securely store a resident's injectable medication for 1 of 3 residents (R1) reviewed for medication storage in the sample of 3. The findings include: R1's Face Sheet shows a diagnosis of acute transverse myelitis in demyelinating disease of central nervous system. On 2/21/25 at 10:50 AM, V6 (R1's Family Member) said that she delivered three doses of R1's Enspryng injection that she had delivered to her home from a specialty pharmacy to the facility. V6 said that she received a call from the nurse on 2/7/25 and the nurse said that they could not find her third dose of the injection. V6 said that R1 was sent to the emergency room but was not able to receive the medication but they re-ordered the medication for her and the resident received the dose on 2/12/25. R1's Medication Administration Record (MAR) for January and February shows an order for: Enspryng Subcutaneous Solution Prefilled syringe 120 mg (milligrams)/ML (milliliter)-Inject 120 mg/ml subcutaneously in the afternoon every 2 weeks on Friday for neuromyelitis for 6 weeks. R1's January MAR shows that she received a dose on 1/10/25 and 1/24/25. R1's February MAR shows that she was supposed to get a dose on 2/7/25 but received it on 2/12/25. R1's Nursing Note dated 1/10/25 shows, Approached by [V6] in facility regarding order for Enspryng Three available injections in frig (refrigerator) as per [V6] she brought 3 injections R1's Nursing Note dated 2/7/25 shows, Reached out to [V6] regarding need for Enspryng Subcutaneous Solution Prefilled Syringe. Patient is due for administration this afternoon. None available. Per pharmacy is a specialty medication. Daughter provided last doses. She was made aware of need for medication at this time. On 2/21/25 at 10:39 AM, V3 (Licensed Practical Nurse) said that she was R1's nurse on the day that she needed her third injection. V3 stated that V6 had brought three doses of the injection, and they were put in the medication room refrigerator. V3 stated that they were in separate boxes and had R1's name on them. V3 stated that she administered R1's first and second dose of the medication but the day that her third injection was due, she could not find it in the fridge. V3 stated that she notified V6, V2 (Director of Nursing) and R1's Nurse Practitioner. On 2/21/25 at 12:38 PM, V2 (Director of Nursing) said that she was notified by V3 that she could not find R1's Enspryng injection. V2 stated that she searched the medication room and facility and could not find the injection. V2 stated that she then called V6 and told her that she thinks that the medication got thrown out in error. A Concern Form dated 2/7/25 for R1 shows, Staff reached out to family that a dose of Enspryng injection is missing for [R1] Summary of Pertinent Findings: Substantiated Facility was searched not able to locate. Pt (patient) monitored, sent out to hospital. No adverse reaction. Physician notified On 2/21/25 at 1:59 PM, V1 (Administrator) stated that the facility does not have a policy for when family brings in medications for the resident. The facility's undated Storage of Medication Policy shows, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier.

Based on interview and record review, the facility failed to adequately supervise a resident who is at risk for aspiration and requires staff assistance during meals (R3) and failed to provide adequate staff supervision for a resident during smoking (R4). These failures affected two (R3, R4) of four resident reviewed for accidents and supervision and resulted in R3 sustaining an injury during mealtime, while in her room unsupervised and required treatment of two sutures; R4 was found on the floor while out on the patio, unsupervised, during a smoke break and required transfer to local hospital for evaluation of swelling to forehead. Findings include: R3 is a [AGE] year-old female who has resided at the facility since 2020, past medical history includes, but not limited to other lack of coordination, cerebral infarction, unsteadiness on feet, dysphagia oral and oropharyngeal phase, type two diabetes, abnormal posture, hyperlipidemia, difficulty walking, other symptoms and signs concerning food and fluid intake, etc. On 9/24/2024 at 1:40PM, R3 was observed in her room, awake, alert, and oriented with some confusion sitting in her wheelchair. R3 answers yes or no to questions but was speaking in what appears to be a different language. R3's Minimum Data Set (MDS) assessment dated [DATE] section C (cognitive patterns) scored resident with a BIMS score of 00, section GG (Functional status) of the same assessment documented that R3 requires partial/moderate assistance to substantial / maximal assistance to being dependent on staff for all ADL care needs including eating. R3's Care plan initiated 5/27/2020, revised 9/20/2024 documented that R3 requires assistance with meal consumption related to diagnosis of dementia, decrease in strength and endurance, and lack of coordination. Interventions includes provide cueing as needed, offer substitutes, and provide socialization during meals. R3's Care plan initiated 4/21/2020 and 1/02/2024 states that R3 is at risk for nutritional problem related to current diet and diagnosis. Interventions include Monitor/document/report as needed any signs and symptoms of dysphagia: Pocketing, Choking, Coughing, Drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals. Facility reported incident dated 6/27/2024 documented in part: the evening of 6/27/2027, resident was observed in her room asleep in front of her bedside table bleeding from her mouth. Resident was sitting up with her bedside table in front of her having dinner, resident had nodded off and bumped her chin on the bedside table, sustaining the lip wound and bruised area to her chin. Progress note documented by V4 registered nurse (RN) dated 6/27/2024 17:41:15 states as follows: Writer's attention called into resident's room notifying of a bleeding gum, upon assessment bleeding noted to resident's upper mouth/gums as well the bridge of the mouth. Resident's mouth was cleaned out and attempt made to stop the bleeding. Writer unable to stop bleeding currently. Nurse Practitioner (NP) made aware, and orders received to send resident to a local hospital emergency room . 9/24/2024 at 2:44PM, V5 certified nursing assistant (C.N.A) stated that she was at work the day R3 injured herself, R3 was in her bed around 5 to 5:30PM and was eating dinner. V5 stated she was not in the room with resident, her roommate was there eating too, when V5 came back, she saw blood on resident's cover, V5 could not see where the blood is coming from and R3 could not open her mouth. V5 called the nurse who came and assessed resident and noted that she was bleeding from her mouth. V5 added that R3's roommate was in the room at the time but did not see anything, both were eating dinner when V5 saw them last. R3 eats by herself and does not require staff assistance, she only require supervision if she does not eat. V5 added that she was not in the room and cannot explain how R3 got her injury. 9/24/2024 at 3:54PM, V4 (RN) stated that she was assigned to R3 the day she had an incident, she was called by the C.N.A, when she got to the resident's room, she noted that she was bleeding in her mouth. V4 stated she could not stop the bleeding she called the NP and received an order to send the resident to the hospital. V4 added that R3 was sitting up in bed, there was nothing in front of her or on the floor, the blood was on the resident, no blood was noted on the bed or floor. V4 stated that she doesn't usually work that set, R3 eats by herself and does not require staff supervision except when she refuses to eat, then staff will assist her. V4 then stated that she thinks R3 feeds herself with supervision, V4 was not sure the last time she saw R3 before the incident. V4 stated that she was passing medication at the time. Feeding assistance policy provided by V1 (Administrator) (undated) states its purpose as to assist the resident to obtain nutrients and hydration. Under procedures, #20 states: report all pertinent observations and resident preferences for food to the charge nurse. Swallowing, chewing, choking episodes, bite and gag reflex, lip closing, poor tongue control, etc. to be recorded in the nursing notes by a licensed nurse. R4 is an [AGE] year-old male admitted to the facility on [DATE], past medical history includes orthostatic hypertension, unspecified psychosis due to a substance or known physiological condition, pain in unspecified joint, history of falling, laceration without foreign body of scalp, other fracture of left femur initial encounter for closed fracture, hyperlipidemia, type 2 diabetes, etc. On 9/24/2024 at 2:06PM, R4 was observed in his room sitting in a wheelchair, awake and alert with some confusion. R4 was asked if he recalls going to the hospital and what happened. He stated that he remembers going to the hospital but not sure why, surveyor asked R4 if he recalled falling in his room and he (R4) said that he remembers falling outside not in his room. R4's Facility MDS dated [DATE] section C, scored R4 with a BIMs of 08, section GG of the same assessment coded R4 as requiring staff assistance for all ADL care. R4's Smoking care plan initiated 8/20/2024 states, I am a smoker, I will not smoke without supervision through the review date. Interventions include - Instruct about smoking risks and hazards and about smoking cessation aids that are available, observe clothing and skin for signs of cigarette burns, etc. An incident report dated 9/22/2024 18:43:17, by V7 (RN) states: Resident had an un-witnessed fall 09/22/2024 6:00 PM Location of Fall: outside patio writer was called outside (patio) and observed resident sitting in the floor next to his wheelchair on 09/22/2024 6:00 PM. 9/25/2024 at 3:30PM, V7 (RN) stated that she was called by a staff because someone fell outside, she went there and saw R4 on the floor with the rest of the residents, they were supposed to be monitored by the activity aide, but she was not there at the time. They assisted resident back to his wheelchair, V7 assessed resident with no injuries. 9/25/2024 at 3:58PM, V8 (Activity Aide) stated she was supposed to be monitoring the residents that were outside smoking the day R4 fell . V8 stated she had just stepped out to go to the cart and get more cigarettes. V8 stated she came back and R4 was on the floor. V8 stated the incident occurred around 5:30PM there were about seven residents outside at that time. V8 stated that she was the only one monitoring the smoke break, it was the last smoke break, and she (V8) usually monitors it before she leaves. V8 stated that she did not inform anyone that she was going inside so no one was monitoring the residents while she was gone. Facility smoking policy revised 10/24/2022 states its purpose as to provide a safe and healthy living environment with respect for the health and well-being needs of each resident, staff member and visitor. It is also the objective of this policy to communicate to each resident that they are responsible for following each rule and on-going compliance with this policy. Under safety measures, the policy states that a Smoking Safety Assessment will be completed to determine the level of assistance and supervision needed during smoking, the ability to carry and store smoking materials, and if a smoking apron is indicated. The plan of care shall reflect the results of this assessment. This assessment will be completed upon admission, quarterly and with significant change.

Based on observation, interview, and record review the facility failed to ensure a resident was free from sexual abuse from a resident (R4) with a history of sexual inappropriate behaviors. This applies to 1 of 2 residents (R3) reviewed for abuse in the sample of 11. The findings include: R3's face sheet shows R3 is a [AGE] year-old female with diagnoses including degenerative disease of basal ganglia, unspecified psychosis, diabetes mellitus, and hypertension. R4's face sheet shows R4 is [AGE] year-old male with diagnoses including cerebral infarction, high risk heterosexual behavior, vascular dementia with other behavioral disturbance, and personality disorder. On 8/2/24 at 10:05 AM, R3 was observed in her room sitting in her wheelchair. R3 stated last month she was touched by R4. R3 stated we (R3 and R4) were in the dining room, he (R4) was rubbing my right leg/thigh area, I told him (R4) to stop. R4 then touched my right breast, I (R3) moved his hand, and told him (R4) to stop again. I reported to a staff member the incident and wanted to move to another table. R3 stated she does feel comfortable sitting at the same table with R4. On 8/2/24 at 11:18 AM, R3 was in the dining room sitting at the same table with R4. At 11:27 AM, R3 and R4 remained seated at the same table. On 8/2/24 at 11:05 AM, V16 (Resident Liaison) stated on 7/11/24, she saw R3 in the dining room upset she was trying to move from her table. V16 stated R3 reported to me R4 touched her leg/thigh and was trying to touch her chest. R3 stated people can't touch you without your permission, R3 was upset. V16 stated she separated the residents and spoke to R4. R4 stated he didn't do anything. R11 was at the table who witnessed the incident. R4 had some behaviors of hypersexual activity recently, he pulled out his private parts in the dining room and exposing himself. V16 stated we keep R3 and R4 separated while in the dining room. V16 stated I don't think it was abuse because R3 moved herself from R4. On 8/2/24 at 11:20 AM, R11 stated she was sitting at the same table when she saw R4 rubbing on R3's leg. R4 was putting his hand on her bosoms trying to get into her shirt. R3 told him to stop, and she moved away. On 8/2/24 at 11:48 AM, V1 (Administrator) stated she was notified about the incident with R3 and R4. V1 stated it was reported R3 and R4 were in the dining room. V1 stated R3 alleged R4 touched her leg/thigh and her chest. V1 stated she spoke with R3, and she said no one should be touched without their permission, she was upset. V1 stated when she spoke with R4, he said R3 was being friendly to him, and he touched her leg. R4 has an issue with boundaries and a history of sexual behaviors. V1 stated she did not substantiate the abuse, but it was an invasion of her privacy. V1 stated going forward we will make sure R3 and R4 are not seated at the same table, that's what R3 was comfortable with. On 8/2/24 at 9:46 AM, V15 (LPN/ Licensed Practical Nurse) stated R4 has a mental health disorder, and he does not say much. V15 stated R4 has childlike behaviors. V15 stated R4 is horny he has pulled out his private parts in the dining room and will shake and dance inappropriately. When you talk to him and tell him that's inappropriate, he puts his head down and says, I'm sorry. On 8/2/24 at 10:10 AM, V18 (CNA/Certified Nursing Assistant) stated R4 is confused, acts like a big kid, just looks at you and laughs when you talk to him. V18 stated R4 has sexual tendencies and he used to pull his thing out. V18 stated When you tell him not to do that, he would say I'm sorry. The Final Abuse Incident dated 7/16/24 documents on 7/11/24 an incident with R3 and R4 occurred .On 7/12/24, V1 interviewed R3, she alleged that she was touched by somebody (R4) on her leg and her chest, on her shirt, while she was about to have dinner. R3 stated she told the person to move away, she is alert and oriented in 3 spheres. On 7/12/24, R4 stated while at dinner, he thought the young lady (R3) was moving towards him, being friendly or she needed help, and he was just being playful, nothing more to it. R4 is observed alert and oriented to person and place. R3 was reassured of her security during the entire process of this investigation, and she persistently expresses she feels safe and wants to continue to reside at the facility. R4 was educated on the definition of personal spaces and the need to respect such. He voiced his understanding. He was referred for Psych Consult. Both residents' care plans were reviewed and updated. R4's Psychiatric Nurse Practitioner note dated 7/18/24 documents he is high risk for sexual behavior, major neurocognitive disorder without behavioral disturbance, vascular dementia. R4 has been having sexually acting out behavior, touching himself and exposing his privates in the dining room, trying touch other females' breasts while touching himself. She recommends close monitoring when in public area. R4's care plan dated 7/5/24 shows he has maladaptive behaviors at times manifested by exposing himself in appropriate areas such the dining room dated 7/5/24; interventions include to counsel on inappropriate behaviors and proper social skills. The same care plan dated July 11, 2024, documents he has a behavior problem related to poor boundaries, invasion of privacy and touching other inappropriately, with interventions resident monitored by staff, divert attention, remove from situation, and take to alternative location. The facility's Abuse Prevention and Reporting Policy revised 2022, states, This facility affirms the right of our residents to be free abuse .sexual abuse is non-consensual contact of any type with a resident .unwanted intimate touching of any kind especially of breasts or perineal area .sexual contact is nonconsensual if the residents either does not want the contact to occur .

Based on interview and record review the facility failed to protect the resident right to free from mental abuse by staff when needing assist. This affected one of three residents (R1) reviewed for abuse. V1 told R1 that she would not fit in the shower chair. This failure results in R1 feeling dehumanized and humiliated. Findings include: 1.R1 MDS (Minimum Data Set) dated 3/2/2024 denotes in-part section C BIMS/brief interview for mental status score of 15 (cognitively intact. Section GG for functional abilities and goals denotes shower/ bathing, (02) R1 requires substantial/ maximal assistance, helper does more than half the effort. Facility final report to the department denotes in-part, around 1140hr on 3/21/24, the Administrator interviewed R1. She (R1) alleged that on 3/19/24, V1 (CNA/certified nursing assistant) was her assigned staff; she brought a bowl of wash water and towels for her bed bath and told her to wash up, knowing she needed help. She (R1) stated (V1) did not render assistance to her and was very unprofessional when she asked her for help. Which she didn't do, adding it took an hour for her to return to her. Also, on 3/20/24, V1 placed her breakfast tray where she couldn't reach it. When she (R1) called her back to help, she had an attitude with her. It was her (R1) shower day and during their conversation, V1 told her rudely, 'either you want this shower, or you don't'. While she (R1) was being showered, she reported V1 being very unprofessional and snappy with her. After the shower, she (R1) heard V1 saying she was not going to deal with R1 anymore. V1 was interviewed on 3/21/24. She (V1) stated that on 3/19/24, she handed a pail of water to R1 and asked her to 'wash up' she'll be back to do the rest. She (V1) said it took an hour to convince R1 to do her shower on 3/20/24 and admitted to saying to her either you do, or you don't at this point, referencing the shower. V2 (resident liaison) and V6 (CNA) were two of the staff members that helped V1 transfer R1 to the shower chair on 3/20/24 and they both stated they did not witness the alleged unprofessional acts towards R1, from V1, while they were present there. V3 (restorative aide) was one of the staff that helped render care to R1 on 3/20/24 and she stated she heard V1 in the hallway venting to herself about how she does not want to work with R1 anymore. A complete assessment was immediately performed for R1. There was no findings of bruise or trauma. R1 denies being any pain, discomfort, or being fearful R1 was reassured of her continued safety at the facility. V1 was terminated for unprofessional conducts and poor customer service. On 4/13/24 at 10:21am R1 agreeable to interview. R1 observed alert, orient to person, place, and time. R1 said the incident happened on a Wednesday, her shower day. R1 said V1 came in the room and she (R1) informed V1 that it was her shower day, and V1 said I know and turned and left the room. R1 said around 10:00am she put the call light on and V1 responded and R1 asked about her shower and V1 began to explain to R1 that we have to get you up in the chair, transfer you to the shower room, then transfer you to the shower chair. R1 said V1 left and came back about 11:00am and told her (R1) you won't fit in the shower chair. R1 said she asked V1 to bring the shower chair so that she could see if she could fit. R1 said V1 brought the chair in the room and R1 said she told V1 that my big *** will fit. R1 said V1 then said do you want a shower or not very rudely. R1 said she told V1 yes. R1 said V1 and other staff transferred her to the wheelchair and took her to the shower room. R1 said when she was in the shower room V1 gave her soap and towel and left the shower room. R1 said an aide name V4 (CNA) stayed in there with her. R1 said she washed her upper body as best as she could. R1 said V1 returned at some point, and she asked V1 if she could wash her perineal area and buttocks and V1 responded no one wants to touch the water on you, R1 said V1 did not wash her perineal area or buttocks. R1 said V1 assisted with washing her legs because she could not reach her legs. R1 said the towel was not warm that V1 used to wash her legs with. R1 said while they were in the shower room, V1 said to V4 I'm not working next week, if they put me on the schedule I'm calling off. R1 said V1 was trying to engage V4 in conversation but V4 would not respond to V1's comments. R1 said V1 made the statement multiple times. R1 said I know why V1 said she would call off, its so that she would not have to give me a shower on Wednesday. R1 said V1 was rude towards her. R1 said V1's behavior was not necessary, V1 was rude and unprofessional. R1 said she does not like some of the staff that help. On 4/12/24 at 12:00pm V2 (liaison) said on 3/21/24 she was going to talk to R1 about her care plan meeting and R1 mentioned to V1 that V1 was nasty toward her yesterday. V2 said R1 mentioned that she heard the aide say she was going to call off next Wednesday and she knows it's so that she doesn't have to give R1 a shower. On 4/13/24 at 2:10pm V3 (restorative aide) said she assisted V1 with repositioning R1 when R1 was in the shower chair. V3 said V1 was upset that she had to give R1 a shower on 3/20/24. V3 said V1 said she didn't want to give R1 a shower because she had already washed R1 up. V3 said V1 had an attitude about giving R1 a shower. V3 said after assisting with repositioning R1 in the shower chair, she left the shower room. V3 said V1 was in the hallway, and as she was passing V1, she heard V1 saying to herself that she wasn't happy working on that unit and that she should have taken a mental health day. V3 said she responded by saying take a deep breath and pray. V3 said she walked away. On 4/14/24 at 11:09am V4 (CNA) said she did assist V1 with transferring R1 from the bed to the wheelchair and to the shower chair. V4 said after the shower she assisted V1 with transferring R1 back to bed. V4 said she is aware that R1 and V1 had some issues, she knows this because news travels around that facility very quickly. On 4/13/24 at 9:59pm V5 (Administrator) said she was made aware of R1's allegation on 3/21/24 and she responded quickly. V5 said she concluded her investigation and determined that V1's behavior was not professional and V1 was terminated. V5 said she in-serviced her staff on abuse prevention. V5 said V1's behavior is not acceptable, and it does not align with the culture of the facility. The facility policy Titled Abuse Prevention and Reporting- Illinois with last revision date 10/24/2022 denotes in-part the facility affirms the right of our residents to be free from abuse neglect exploitation misappropriation of property deprivation of goods and services by staff or mistreatment. This will be done by establishing an environment that promotes resident sensitivity resident security and prevention of mistreatment. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury unreasonable confinement intimidation or punishment with resulting physical harm pain or mental anguish to a resident. This also includes the deprivation by an individual including a caretaker of goods or services that are necessary to attain and or maintain physical mental psychosocial well-being. This assumes that all instances of abuse of residents even those in a coma cause physical harm or pain or mental anguish. The term willful in the definition of abuse means the individual must have acted deliberately not that the individual must have intended to inflict injury or harm. Mental abuse is the use of verbal or nonverbal conduct which causes or has a potential to cause the resident to experience humiliation intimidation fear shame agitation or degradation. Verbal abuse may be considered a type of mental abuse verbal abuse includes the use of oral written or gestured communication or sounds to a resident within hearing distance regardless of age ability to comprehend or disability. Facility policy titled dignity with last review/revision date of 4/23/18 denotes in part the facility shall promote care for residents in a manner and in an environment that maintains or enhance the resident's dignity and respect and full recognition of his or her individuality. The facility shall consider a resident lifestyle and personal choices identified through the assessment processes to obtain a picture of his or her individual needs and preferences. Staff shall carry out activities in a manner which assists the resident to maintain and enhance his or her self-esteem and self-worth. The facility policy titled Dignity with last review date of 4/23/2018 denotes in -part residents have the right to a dignified existence self-determination and communication with and access to persons and services inside and outside the facility resident has the right to exercise their right as a resident in the facility and as a citizen for resident in the United States. Residents have a right to be free from sexual abuse physical abuse mental abuse corporal punishment neglect and involuntary seclusion. Residents have the right to be free from verbal abuse.

Based on observation, interview and record review, the facility failed to provide privacy during blood sugar check for one (R59) of two residents reviewed for blood sugar monitoring. The facility also failed to empty and cover a urinary collection canister for one resident (R329) of eight residents reviewed for dignity in a sample of 20 residents. Findings Include: During medication administration on 3/21/24 at 12:00pm with V4 (Registered Nurse) performed blood sugar check on R59 with a resident and family member sitting opposite R59 in the 400-hall dining area. R59's room was being cleaned at the time blood sugar check was due. On 3/21/24 at 12:30pm, V4 stated that the blood sugar check should have been done in a private area to provide privacy to R59. On 3/21/24 at 1:42pm, V2(Director of Nursing) stated that all patients should be provided privacy during blood sugar check. Review of records indicates R59 was admitted on [DATE] with diagnosis of type 2 Diabetes Mellitus with orders for Novolog Flex Pen Subcutaneous solution injector 100 unit/ml (Insulin Apart) 3units with meals and inject per sliding scale before meals. Care plan dated 5/12/22 indicates, I have Diabetes Mellitus. Facility unable to provide patient privacy policy for blood sugar monitoring. 35546 On 3/19/24 at 12:30 PM R329 was observed in a wheelchair eating lunch. The tray was placed on the overbed table in front of her. A canister half filled with urine was on top of the bedside table. R329 said that the canister was connected to her external female catheter overnights. R329 said that she used the catheter at night and took it off in the morning. The canister was not covered. On 3/20/24 at 11:00 AM the urine canister was observed on the bedside with a small amount of urine, the canister was not covered. R329 said that it is hit or miss if they empty the urine. Sometimes it is not emptied. On 3/20/24 at 12:04 AM V2 (Director of Nursing) said the urine collection should be covered. The urine should be emptied when the catheter is removed in the mornings. The Order Summary Report indicates catheter care every shift and as needed. The Care Plan indicates I have a female external catheter in place related to potential for incontinence episodes of bladder and skin issues on right medial thigh. Policy Urinary Catheter Care, Revision 2/14/19 12. Catheter drainage bags will be emptied one time on each shift or as needed, using a separate collecting container for each resident's drainage bag. Dignity, Revision 4/23/18 Maintaining a resident's dignity should include but is not limited to the following: Refraining from practices demeaning to residents such as leaving urinary catheter bags uncovered, refusing to comply with a resident's request for bathroom assistance during meal times, and restricting residents from the use of common areas open to the general public, such as lobbies and restrooms, unless they are on transmission-based isolation precautions or are restricted according to their care planned needs.

Based on observation, interview and record review, the facility failed to provide professional standards of care by failing to prime an insulin Flex pen prior to administering insulin to one resident (R59) of two residents reviewed for insulin administration in a sample of 20 residents. Findings include: During medication administration on 3/21/24 at 12:20pm with V4 (Registered Nurse), V4 removed R59's flex pen from a plastic bag, turned it to 1 unit with no needle attached to the pen. V4 then proceeded to attach the needle to the pen and turned it to seven (units to be administered). V4 proceeded to administer seven units of Aspart insulin to R59 for a blood glucose of 277mg/dl. On 3/21/24 at 1:00pm, V4 stated that the Flex pen should have been primed before administering to R59. On 3/21/24 at 1:45pm, V2(Director of Nursing) stated that the Flex pen should have the needle attached to the pen before priming with 2units. Review of records indicates R59 was admitted on [DATE] with diagnosis of type 2 Diabetes Mellitus with orders for Novolog Flex Pen Subcutaneous solution injector 100 unit/ml (Insulin Aspart) 3units with meals and inject per sliding scale before meals. Care plan dated 5/12/22 indicates, I have Diabetes Mellitus. Facility policy updated 2/2024 indicates: Brand, Novolog U-100 Flex Pen, Generic; Aspart. Pen Priming Requirements: 2 units.

Based on observation, interview, and record review the facility failed to provide grooming for three residents (R5, R25, and R57) of eight residents reviewed for activities of daily living in the sample of 20. Findings include: On 3/19/24 at 11:45 AM R57 was observed in his room with untrimmed beard growth. R57 said they were supposed to shave me, but they never did. On 3/20/24 at 10:00 AM R57's beard growth had not been trimmed or shaved. R57 said (Certified Nursing Assistant unnamed) kept saying that she was going to shave me. Every time that I asked, she said that she would come back and do it. She never came back. On 3/19/24 at 11:48 AM R5 was observed with untrimmed beard growth. R5 said, I asked them to shave me, but it hasn't happened yet. On 3/20 24 at 10:05 AM R5's beard growth was unchanged. R5 said (Certified Nursing Assistant unnamed) said that she was going to shave me yesterday, but she never came back. On 3/19/24 at 11:50 AM R25 said I need a shave. R25's beard is untrimmed and overgrown. On 3/20/24 at 10:55 AM R25's beard growth remains unchanged. R25 said they never came back to shave me. She (Certified Nursing Assistant unnamed) said that she was coming back. On 3/20/24 at 12:04 PM V2 (Director of Nursing) stated the residents should be shaved the same day that they ask. Policy Activities of Daily Living reviewed 1/2023 Grooming: Maintaining personal hygiene, including planning the task and gathering supplies, combing and/or styling hair, face and hands, brushing teeth, shaving or applying makeup, oral hygiene, self-manicure (safety awareness with nail care), and/or application of deodorant or powder.

Based on observation, interview and record review, the facility failed to follow its infection control policy by failing to disinfect an intravenous tubing valve for 30 seconds for one (R330) of one resident reviewed for intravenous medication administration in a sample of 20 residents. Findings include: During medication administration on 3/19/24 at 2:00pm, V3(Registered Nurse) was observed wiping the valve of an intravenous tubing. V4 did not disinfect the valve for 25 to 30 seconds. On 3/19/24 at 2:00pm, V3 stated that the valve should be cleaned for at least one minute to prevent the growth of bacteria. V3 stated that she should have waited a bit longer. On 3/20/24 at 1:45pm, V2(Director of Nursing) stated that the valve should be cleaned for 25 to 30 seconds. R330's face sheet indicates an admitted [DATE] with a diagnosis of history of Diabetic Foot Ulcer, a physician order for Cefazolin Sodium Injection Solution with start date of 3/23/24 and end date of 4/18/24 to be given three times a day for DM (Diabetes Mellitus) foot ulcer. Care plan dated 3/13/24 indicates; I have a PICC (Peripheral Inserted Venous Catheter) line and have the potential risk for infection at the site. PICC line site will remain free from sing and symptoms of infection. Facility policy dated 12/2014 title; Administration Procedures: Intermittent Infusion Administration. 11. Disinfect valve with alcohol swab, .

Based on interview and record review the facility failed to offer pneumococcal immunization to one resident (R57) of five residents reviewed for immunizations in the sample of 20. Findings include: On 3/20/24 at 4:00 PM surveyor conducted a review of the immunizations for five residents. R57 did not have any documentation related to the pneumococcal immunization education, consent, or refusal. V2 (Director of Nurses/Infection Preventionist) stated that she did not know if R57 had a pneumococcal immunization. On 3/21/24 at 11:00 AM V2 said I don't know why R57 was missed for pneumonia. We have a clinic coming this month and he will be offered the pneumonia vaccine then. Policy: Influenza and Pneumococcal Immunizations revision 4/21/22 Pneumococcal Immunization: Before offering the pneumococcal immunization each resident or the resident's representative will be provided education regarding the benefits and potential side effects of the immunization. Each resident is offered a pneumococcal immunization per CDC (Center for Disease Control) recommendations (see CDC Pneumococcal Vaccine Timing for Adults reference table) unless the immunization is medically contraindicated, or the resident has already been immunized: A second pneumococcal vaccine will be offered only when necessary, according to CDC guidelines. The resident or the resident's representative has the opportunity to refuse immunization. The resident's medical record includes the documentation that indicates, at a minimum, the following: That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and That the resident either received or did not receive the pneumococcal immunization due to medical contraindications or refusal.

Based on observation, interview, and record review, the facility failed to check placement of a gastric tube immediately before starting a feeding for one (R3) of two residents reviewed for gastric tube feedings in the sample of three. Findings include: On 2/28/24 at 2:15 PM V4 (LPN-Licensed Practical Nurse) was observed in R3's room. V4 was noted turning on the gastric tube feeding at 75 ml/hour. V4 was asked if the tube placement had been checked. V4 responded I checked it about twenty minutes when I gave medicine. I always check them early. I check the residual and listen for the air blowing. On 2/29/24 at 1:05 PM V2 (DON-Director of Nursing) said I expect the nurses to check the placement of a g-tube when they get ready to start the feedings and before they do the flushes. They can pour a small amount of water in the tube and listen for the swoosh. Policy: Gastrostomy Tube-Feeding and Care revised 8-3-20 Procedure: 7. Observe for tube placement before: a. Starting feeding. b. Water Flushes and Hydration, and c. Medication Administration. CHECKING FOR TUBE PLACEMENT a. Aspirate to visually verify stomach contents. NOTE: Auscultation is no longer recommended for checking placement of the feeding tube. Movement of air would likely be heard whether the tube was in the correct or incorrect location.

Based on observation, interview and record review, the facility failed to provide appropriate treatment and services for care of a resident with a clinically justified indwelling catheter that affected 1(R1) of 3 residents in the sample of 3 reviewed for catheter care. This failure resulted in R1's emergent transfer to an acute care hospital where resident was diagnosed and treated in the ICU for septic shock and injury to the urethra. Findings include: R1 is a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including but not limited to Quadriplegia; Neuralgia and Neuritis; Neuromuscular Dysfunction of Bladder; Major Depressive Disorder; and Hypertension. According to R1's MDS (Minimum Data Set) assessment dated [DATE] under section C, R1 has BIMS (Brief Interview of Mental Status) score of 14 indicating intact cognition. According to R1's MDS (Minimum Data Set) assessment dated [DATE] under section H, R1 voids through an indwelling urinary catheter. R1's care plan dated 06/16/2023 reads in part, I have Indwelling Catheter related to sacral wound. Goal: I will be free from catheter related trauma through review date. Interventions: Monitor and document intake and output as per facility policy. Monitor for signs and symptoms of discomfort on urination and frequency. Monitor/document for pain/discomfort due to catheter; Monitor/record/report to MD for signs and symptoms of Urinary Tract Infection: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, Urinary frequency, foul smelling urine. Physician orders dated 6/14/23 shows, Foley catheter. Per record review, no other indwelling urinary catheter orders with start date before 08/12/2023 noticed in R1's medical electronic record. On 01/24/2024 at 2:57 PM V1 (Administrator/Abuse coordinator) stated, There is no complete urinary indwelling catheter physician order and urinary catheter care for every shift physician order for R1 between June 2023 and August 2023. A review of MARs (medication administration records) from June 2023 through August 2023 showed no maintained records of input/output that would demonstrate any ill-effects due to urine retention or presence of blood in urine. emergency room hospital record dated 8/13/2023 authored by V8 (emergency room doctor) reads in part, (R1) is a [AGE] year-old with previous medical history of neurogenic bladder and quadriplegia presents with evaluation of hematuria after improperly inserted urinary catheter in the nursing care facility. The patient states that a urinary catheter was placed earlier in the day. The patient began having abdominal discomfort. When the nursing care staff removed the catheter, they noticed that the patient had bleeding from his urethra. R1 was transferred from the Emergency Department to the ICU with admitting diagnosis of 1. Septic Shock and 2. Injury of urethra. V8 (ED emergency room doctor) continued with ICU records which read in part, Total critical care time 60 minutes. Due to a high probability of clinically significant, life-threatening deterioration, the patient required my highest level of preparedness to intervene emergently, and I personally spent this critical care time directly and personally managing the patient. This critical time included urgent treatment with development of a management plan, evaluation of patient's response to treatment, and discussion with other providers. On 01/24/2024 at 10:10 AM Surveyor interviewed V3 (Licensed Practical Nurse) who related the following in summary: R1 had a chronic urinary catheter and pain medication pump due to the accident that he suffered before his admission to the facility. On 08/12/2024, R1's assigned nurse asked me if I could change his catheter per R1's request. I used a urinary catheter kit. There are different sizes of urinary catheters, I look at what the size that resident has inserted, and based on that, I reinsert the same size. If it is a first time that a resident is getting urinary catheter, I start with the smallest size and see if it works. If it too small, it's going to leak, so it needs to be observed for at least 24 hours. R1 wanted to change it due to catheter leakage. He was concerned about urine getting into his wounds and getting them infected. I heard R1 say that for a few days before I reinserted it on 08/12/2023. Urinary catheter insertion is a sterile procedure. I wash hands with soap and put on sterile gloves that are included in the kit. Clean the area, with iodine swabs, get a cup/tray to catch the initial urine return, put some lubricant, and insert it. When catheter is in the place, urine comes out right away. Next, I inject normal saline to inflate the balloon to secure the catheter in the bladder. I believe it takes 30 ml of saline to inflate the balloon. I connect the catheter to the collection bag and secure the tubing. In R1's case, there was a mist of urine in the tubing upon insertion, but then, I felt resistance, and couldn't insert the catheter any further. R1 didn't indicate any discomfort during the procedure. Later in the day, he started bleeding, and was sent out to the hospital. Progress note dated 08/12/2023 at 1:00 PM written by V3 (LPN) reads in part, Resident c/o (complaining of) (urinary catheter) was leaking urine, writer changed (urinary catheter) 16f without any difficulty with urine return, will continue to monitor. Progress note dated 08/12/2023 at 2:03 PM written by V10 (Licensed Practical Nurse) reads in part, Resident observed with new (urinary catheter) with no urine return. Per resident, voiced uncomfortable, writer checked the urine return and the bag was empty. NP (Nurse Practitioner) made aware, (urinary catheter) was removed and there was blood noted. On 01/24/2024 at 12:45 PM Surveyor interviewed V2 (Director of Nursing) who related the following in summary: There should always be an order for urinary catheter, it usually gets put in upon admission and readmissions. Order should include when to reinsert it, flushing intervals, bag change or when to do urinary catheter care. Urinary catheter order set includes accident dislodgement and there is no need for a new order for reinsertion; however, nurses should let the doctor know and follow their recommendations. The order is individual for each resident. When there is an issue with a urinary catheter, for example, when it is leaking, nurse should let the doctor know for further guidance. Urinary catheter balloon should be inflated with 10 ml of saline, that's what's included in the urinary catheter kit. Any licensed nurse is trained appropriately to insert the urinary catheter, for example Licensed Practical Nurse, Registered Nurse, or even Nurse Practitioner. Urinary catheter care is established between CNAs and nurses. CNAs render perineal care and empty the bag. CNAs should empty the bag at least once a shift and PRN, and need for perineal care should be checked at least every 2 hours and done at least once a shift. Urinary catheter care is charted in the MAR (Medical Administration Record) or TAR (Treatment Administration Record). If CNAs notice any changes of urine appearance, they should let the nurse know. On 01/24/2024 at 1:48 PM Surveyor interviewed V6 (Nurse Practitioner) who related the following in summary: I've been taking care of R1 since October 2023, so I was not part of the medical team during the time when he had traumatic urinary catheter insertion followed by the hospitalization . R1 had a chronic urinary catheter because he was quadriplegic. Every resident needs a complete physician order if they have a urinary catheter. There is an order set with urinary catheter maintenance that can be adjusted to resident's needs. Additionally, there should be an order for each time when urinary catheter is reinserted. If a urinary catheter is leaking, that means balloon might be deflated. In such case, I would suggest reinflating balloon and if that doesn't help, reinsertion of a urinary catheter. If a nurse feels resistance or any difficulty during reinsertion of a urinary catheter, doctor should be notified, and resident would be sent out immediately to the hospital for further evaluation. Often, residents with neurogenic bladders have spasm upon urinary catheter insertion, followed by lack of urine return, in that case, urinary catheter needs to be removed right away and doctor should be notified. Facility policy dated 02/14/2019 titled Urinary Catheter Care, reads in part, Purpose: To establish guidelines to reduce the risk of or prevent infections in resident with an indwelling catheter. Guidelines: Urinary catheter and tubing may be removed or reinserted when any of the following are observed: Inability to observe urine contents in the urinary drainage bag or tubing; Upon physician's orders; The date of catheter insertion shall be documented in the nurses notes and Treatment Record.

Based on interview and record review, the facility failed to place effective fall prevention interventions to include monitoring to reduce or prevent the risk of falling for a cognitively impaired resident with a behavior of getting out of bed unassisted. This affected one of three residents (R1) reviewed for fall prevention. This failure resulted in R1 being involved in a fall incident suffering resulting in a hematoma to the left eye. Findings Include: R1 is an [AGE] year-old with the following diagnosis: Alzheimer's Disease, Dementia, and Adult Failure to Thrive. A Fall note dated 12/5/23 documents around 4:35 AM R1 was found in R1's room on the floor. The physician was notified and ordered to send R1 out to the hospital for an evaluation. The ambulance arrived around 7:15 AM. R1 was alert but confused. A large hematoma to the left eye was noted. The Fall Occurrence note dated 12/5/23 documents the fall occurred around 4:35 AM. The fall was unwitnessed in R1's bedroom. During rounds, R1 was observed on the floor with a bump to the left eyebrow. R1 was assessed for other injuries none were noted. R1 was safely transferred back into the bed. R1 was unable to give an adequate description of what occurred but stated, I hurt myself. I didn't mean to hurt myself. I am sorry. R1 has a gait imbalance and is confused. The physician was notified and ordered to send R1 to the emergency room for further evaluation. R1 is alert and oriented per baseline. There is no documentation of when R1 was last monitored by staff before the fall. The Hospital Records dated 12/5/23 documents R1 presented to the emergency room for an evaluation of a head injury after an unwitnessed fall. R1 has left periorbital edema and bruising. R1 is alert and oriented times one at baseline. A CT (computed tomography) scan of the head and C spine were negative for fractures or brain bleeds. Left periorbital soft tissue swelling is noted. Family is at the bedside and plan to discharge R1 home. The photos submitted by the complainant were reviewed. The second picture of R1 with a hematoma covering the entire left eye. There is a large bump to the upper left eyelid. R1's eye is closed. On 12/6/23 at 2:16PM, V3 (Restorative/Fall Nurse) stated when R1 was initially assessed, R1 was lethargic and would not respond verbally. V3 endorsed a family member was at the bedside during the assessment and endorsed R1 was ambulatory before going to the hospital. V3 reported R1 was a high fall risk because R1 was a new admission, not able to get up and walk, and had decreased cognitive function. V3 stated fall mats were put in place as an intervention. V3 denied R1 was able to follow any directions. V3 endorsed R1 rolled out of the bed onto the floor on the floor mat per the report from staff. V3 stated V3 asked the family member at the bedside if they wanted to put the bed bolsters on at the time of assessment, but the family denied. V3 reported R1 did not need the bed bolsters at that time because R1 was not actively trying to get out of bed when the assessment took place. V3 stated if V3 was aware that R1 was more active after the assessment, then bed bolsters would have been put into place as an intervention to help prevent any falls. On 12/6/23 at 2:42PM, V2 (DON) stated R1 fell and bumped R1's head. V2 endorsed residents are rounded on every two hours, but when a new admission is in the facility, staff should check on them every time they walk by the room. V2 denied being aware of when the last round was made on R1 before R1 was found on the floor. V2 stated R1 was a high fall risk due to a history of falls, and R1's cognition level. V2 denied being aware of any behavior of R1 continuing to attempt to get out of bed without assistance. V2 stated if a resident is having a behavior where they're getting out of bed constantly, then staff should be making restorative or V2 aware. V2 endorsed the care plan would then be reviewed to see if any additional interventions could be added. On 12/6/23 at 2:52PM, V4 (Nurse) stated R1 was able to roll from side to side in the bed without any assistance. V4 endorsed R1 was a high fall risk based on the history of Dementia and a fall history. V4 reported seeing R1 being taken away by ambulance the morning of the fall. V4 stated there was a large knot on R1's left eyebrow that was about the size of a golf ball. V4 endorsed R1 had a habit of staying up all night and sleeping during the day. V4 reported this made R1 higher fall risk because R1 was more active when less staff were in the building for monitoring. On 12/6/23 at 4:32PM, V5 (Nurse) stated R1 was alert to self only and denied R1 being able to follow any directions. V5 endorsed R1 did attempt to get out of bed without assistance on the day of admission. V5 reported redirecting R1 back to bed, but R1 did not follow directions and kept attempting to get out of bed. V5 stated R1 was then put in a wheelchair and taken into the nurse's station for closer monitoring. V5 endorsed R1 is a high risk for falls because R1 does not have good mobility and has a decreased cognition level. V5 reported if a new resident does not want to stay in the bed, then staff should get them up and set them in an area where more staff is available to monitor them. V5 stated V2 or the restorative department should be made aware of the behavior so new interventions can be put in place. On 12/7/23 at 8:05AM, V6 certified nursing assistant (CNA) stated V6 was assigned to R1 the day before the fall. V6 endorsed on this day R1 kept hanging R1's feet off the side of the bed where R1 would be half in the bed and half out of the bed. V6 reported other staff would be calling for help from R1's room because they caught R1 attempting to get out of bed without any help. V6 stated the nurse staff decided to put R1 in a wheelchair and take R1 to the dining room to be monitored more closely. V6 denied R1 being able to follow any directions. V6 stated when residents continue getting out of the bed, staff bring them to an area that has more people to be more closely monitored. V6 endorsed telling the nurse that R1 kept getting out of bed but is unaware if the nurse told anyone else to put in further interventions. V6 reported R1 is a high fall risk because R1 was confused and could not stand alone. On 12/7/23 at 10:31AM, V7 (CNA) stated R1 was found in R1's room on the floor but V7 was not able to remember an exact time R1 was found. V1 reported sometime between 2AM and 4 AM R1 was found on the floor mat. V7 endorsed staff was checking on R1 every two hours but they would try to check on R1 every hour. V7 reported R1 would hang R1's legs over the side of the bed and staff would reposition R1 back in the bed. V7 endorsed R1 was able to move without assistance in the bed. V7 denied R1 was able to explain how the fall occurred because R1 is confused. V7 stated V9 (Nurse) knew R1 kept trying to get out of bed and was moving around a lot that night. V7 endorsed staff would put R1 back to sleep when they found her attempting to get out of bed alone and direct R1 to stay in bed. V7 reported R1 would get back in bed when redirected but when checked on again, R1 would be attempting to get out of bed alone. V7 denied R1 followed the direction to stay in bed. V7 denied remembering when V7 rounded last on R1. On 12/7/23 at 11:00AM V1 (Administrator) stated R1 was able to move from side to side in the bed alone. V1 endorsed the fall was unwitnessed. V1 reported R1 was a high fall risk due to being a new resident and having bouts of confusion. V1 stated the staff was still trying to assess R1's baseline because R1 was a new resident. V1 stated if R1 was not at the previous baseline that R1 was admitted at, then that should have been reported to the next nurse or V2 to follow up with the physician and the care plan should have been reviewed for any new intervention needed. On 12/7/23 at 1:50PM, V8 (Primary Physician) stated R1 had intermittent confusion probably due to being in a new environment along with generalized weakness. V8 endorsed sometimes residents are more confused after coming to a new facility when they have dementia, and the confusion can be worse until they get settled into a new place. V8 stated, with these types of residents, staff should keep them near the nurse's station with a low bed, and if they have anyone available to be sitting with them while they're awake, then they should be doing so. V8 denied being aware of R1's behavior of getting out of the bed unassisted before the fall. V8 endorsed if V8 was made aware of the behavior a psych consult would have been ordered to see if they could have evaluated R1 to manage the behavior with medication. On 12/7/23 at 2:12PM, V9 (Nurse) stated V7 found R1 on the floor mat next to the bed. V9 reported R1 had a bump to the left forehead. V9 reported when R1 was asked what happened the only thing R1 could say was I'm sorry I hurt myself. V9 endorsed the fall happened around 4 AM. V9 stated R1 was a high fall risk due to being a new resident and being confused. V9 endorsed the night of the fall R1 kept sitting up at the edge of the bed. V9 reported while doing rounds, V9 would lay R1 back down to try to get R1 to sleep. V9 stated V9 repositioned R1 two or three times before the fall. V9 endorsed being assigned to R1 on the 2 PM to 10 PM shift and the 10 PM to 6 AM shift. V9 stated during the evening shift, R1 was in a wheelchair sitting by the nurse's station because R1 kept trying to get out of bed alone during the dayshift. V9 reported putting R1 back to bed because staff did not want R1 falling asleep and falling out of the chair. V9 was not able to answer how the left eyebrow bump occurred if R1 fell on to the floor mat next to the bed. V9 stated there is a possibility R1 fell off the mat when R1 fell out of bed. V9 reported if a resident is having a behavior where they are trying to get out of bed unassisted then it should be passed onto the next nurse or to the restorative department. V9 endorsed the restorative department would put in new interventions for a resident, and they are in charge of putting in interventions unless it is an emergency situation. V9 reported V9 could have called V2 to get access to the bed bolsters that night, but staff instead kept redirecting R1 back to sleep. V9 stated R1 would go back to sleep for an unknown amount of time before getting up again. V9 endorsed the size of the bump on the left eyebrow was about the size of a walnut and it did grow a little bit bigger by the end of the shift. V9 denied remembering the time R1 was last rounded on before the fall. V9 stated between V7 and V9 they were attempting to round on R1 every hour. The Admission Hospital Records dated 11/19/23 document R1 was admitted to the hospital for Acute on Chronic Encephalopathy Versus Worsening Dementia and Adult Failure to Thrive. R1 is alert and oriented times one at baseline and is able to follow one step commands with reinforcement. R1 has decreased balance, upper extremity/lower extremity strength, and impaired cognition. The Admission Observation dated 11/30/23 documents R1 arrived from the hospital with a diagnosis of Failure to Thrive. R1 is total dependence for bed mobility, transfers, and all ADL (activities of daily living) care. The skin assessment documents the only skin alteration is to the sacrum, which is a small, excoriated area. The Fall Risk assessment dated [DATE] documents R1 is at risk for falls due to intermittent confusion, history of falls, medical history, and being chairbound. The Fall Risk assessment dated [DATE] documents R1 is still at risk for falls for the same reasons listed as above. The SBAR Communication Form dated 12/5/23 documents R1 fell , and a bump is noted in the skin evaluation, but is not documented where on the body. The Brief Interview for Mental Status dated 12/4/23 documents the score as zero (severe cognitive impairment). The Care Plan dated 12/4/23 documents R1 is at high risk for falls related to a decrease in strength and endurance, gait/balance problems, incontinence, and adult failure to thrive. All interventions were documented on 12/4/23. There are no interventions documented before the fall addressing R1's behavior of continuously attempting to get out of bed. There is no documentation on the care plan regarding what kind of monitoring R1 requires as a high fall risk actively attempting to get out of bed. The IDT Fall Committee Meeting dated 12/5/23 documents during rounds, R1 was observed on the floor mat with a bump to the left eyebrow. Contributing physiological factors to the fall are documented as gait imbalance, incontinence, weakness, confused, impaired memory, forgets to use call light, and declining cognitive skills. The root cause of the fall was determined to be R1 rolled out of the bed onto the floor mat. Interventions in place at the time the fall were floor mats. The policy titled, Fall Prevention Policy, dated 11/21/17 documents, Standards: . All assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained .Inform family of risk factors and reinforce interventions as needed . In addition to the use of Standard Fall Precautions, the following interventions may be implemented for residents identified at risk: the resident will be checked, approximately every two hours, or as according to the care plan, to assure they are in a safe position. The frequency of safety monitoring will be determined by the resident's risk factors in the plan of care.

Based on observation, interview and record review, the facility failed to follow their policy on implementing a care plan for 1 (R2) of 3 residents reviewed in the sample for care plans. This failure caused R2 to fail to maintain dignity and psychosocial wellbeing. Findings include: R2 is [AGE] years of age. Current diagnoses include but are not limited to Cerebral Infarction due to Embolism of Right Middle Cerebral Artery, Lack of Coordination, Abnormal Posture, and Quadriplegia. On 8/29/23 at 11:51 AM, R2 is alert and oriented to person, place, and time. He is resting in bed with the call light. R2 was inquired of his incontinence care. R2 said, I'm soaking wet now! They changed me at 3:30 in the morning. My aide is V3 CNA Certified Nurse Assistant. I refused her because we are always having problems. Her attitude. When I ask her to do something she doesn't do it and has a smart mouth. When I ask her to roll me over or pull me up in bed, she says she has to find someone to help her, and she never comes back. I told the nurse; I can't think of her name. She said it's my right. She said everybody refused to take care of me. This is not the first time this has happened. R2's incontinent brief appears to be wet. At 12:09 PM, V3 CNA was inquired of R2 refusing her care. V3 stated, R2 refused me today, he does it every day when I work. He doesn't want me to take care of him. I told V4 RN and I informed V2 DON Director of Nursing and the administrator that R2 doesn't want me to give him any care. The nurse V4 fed him breakfast this morning. I documented that he refused me to take care of him this morning. At 12:26 PM, V4 RN Registered Nurse stated, This is not the first time this has happened. R2 will refuse care if he doesn't like you, he will refuse you to care for him. It was about 8am in the morning and V3 CNA went to pass him his breakfast tray. That was the only time she came to me. V3 said R2 refused for her to feed or care for him. I went and fed R2 his breakfast and talked to him. He didn't respond today. I charted a note that he was refusing care this morning. It's hard to find someone to help R2. I haven't told anyone yet. I still have to go in and feed him lunch. I will ask R2 again if he will allow V3 to care for him. At 12:58 PM, V5 CNA is in R2's room. R2 is speaking with V5, he agreed to allow her to care for him with V4 RN. V5 CNA stated, No one asked me about helping R2 this morning. I already knew what was going on. I have an understanding with R2. At 1:12 PM, V4 RN and V5 CNA are providing ADL (activities of daily living- eating, bathing, grooming and toileting) and perineal care (cleaning the genital area) and applying a clean incontinence brief for R2. R2 is wearing an incontinent brief that is soaked with urine at this time. At 1:32 PM, V2 DON was inquired of V4 being made aware that R2 refused care from V3 CNA. What should V4 RN have done when R2 refused care from V3 CNA? V2 stated, I was not informed today that R2 refused care from V3 CNA. V4 should have looked at the schedule of CNAs to see who could go to R2 and provide care. Most of the time if we can't find anybody, we will get social services to go in and speak with R2. They can help point out the concerns and inform him that there is staff here willing to help him. We do a check and change at least every 2 hours. Our heavy wetter's we try to get them changed more frequently. On 8/31/23 at 10:02 AM, V2 DON was inquired of R2's care plan and interventions being carried out. V2 stated, For his care plan for incontinence of the bladder because of his condition of quadriplegia he isn't aware to perceive, he doesn't know when he has to urinate. The intervention to call for assistance when feeling the urge isn't measurable. He wasn't assigned an aide by V4 RN after refusing. He didn't get toileted. His care plan for resistance to care should have been carried out according to his interventions. At 10:38 AM, R2 was asked if staff put him on the toilet every 2 hours. R2 stated, They don't put me on the toilet. They said it dangerous; they don't want to do it because I'm a mechanical lift. R2's comprehensive assessment section C for cognitive patterns dated 6/11/23 documents a brief interview for mental status score of 13/15. A score of 13-15 indicates the person is cognitively intact. R2's comprehensive assessment section G for functional status dated 6/11/23 documents toilet use- how a resident uses the toilet room, commode, bedpan, or urinal; transfers on/off the toilet, cleanses self after elimination; changes pad; manages an ostomy or catheter; and adjusts clothes. The resident's self-performance indicates a 4- total dependence. Full staff performance every time. The support provided indicates a 3- two plus persons physical assistance needed. V2 DON provided V3 CNA's POC (point of care) documentation for 8/29/23 regarding R2 refusing care from V3. On 8/29/23 at 9:48 AM, V3 documented resident refused all AM care. Resident said he does not want me to feed him or do any care for him and I told the nurse. At 11:50 AM, V4 RN Registered Nurse documented- resident refused all morning ADL's (activities of daily living- eating, bathing, grooming and toileting) with CNA despite patient teaching and encouragement. There is no documentation of V4 RN returning to speak with R2 regarding his refusal of care by V3 or of V4 offering another staff to provide him with care. R2's care plan for incontinence of the bladder is not measurable due to his Quadriplegia diagnosis. The care plan acknowledges R2's absence of perception to void. The intervention listed states to encourage resident to call for assistance when feeling urge to void (urinate) or have a bowel movement. R2 is not being toileted every two hours by staff as documented in his care plan intervention. On 8/29/23, R2 was not assigned another CNA to provide his care to be toileted by V4 RN causing him to be soiled in urine from 3:30 AM until 1:12 PM when V4 RN and V5 CNA provided his incontinence care. The care plan for R2 being resistive to care and refusing care was not implemented V4 RN. The interventions state, if possible, negotiate a time for ADL's (activities of daily living- eating, bathing, grooming and toileting) so that the resident participates in the decision-making process. Return at the agreed upon time. If resident resists with ADL's, reassure resident, leave, and return 5-10 minutes later and try again. The revised 11/17/17 Comprehensive Care Plan policy states in part: Purpose: To develop a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Guidelines: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, interview and record review, the facility failed to follow their policy on incontinence care for 1 (R2) of 3 residents in the sample reviewed for incontinence care. This failure caused R2 to not have his basic needs met as well as a loss of dignity. Findings include: R2 is [AGE] years of age. Current diagnoses include but are not limited to Cerebral Infarction due to Embolism of Right Middle Cerebral Artery, Lack of Coordination, Abnormal Posture, and Quadriplegia. On 8/29/23 at 11:51 AM, R2 is alert and oriented to person, place, and time. He is resting in bed with the call light. R2 was inquired of his incontinence care. R2 said, I'm soaking wet now! They changed me at 3:30 in the morning. My aide is V3 CNA Certified Nurse Assistant. I refused her because we are always having problems. Her attitude. When I ask her to do something she doesn't do it and has a smart mouth. When I ask her to roll me over or pull me up in bed, she says she has to find someone to help her, and she never comes back. I told the nurse; I can't think of her name. She said it's my right. She said everybody refused to take care of me. This is not the first time this has happened. R2's incontinent brief appears to be wet. At 12:09 PM, V3 CNA was inquired of R2 refusing her care. V3 stated, R2 refused me today, he does it every day when I work. He doesn't want me to take care of him. I told V4 RN and I informed V2 DON Director of Nursing and the administrator that R2 doesn't want me to give him any care. He likes the younger CNAs to take care of him. V2 DON and V1 Administrator said I can switch him with another resident when I work. The other aides don't like to care for R2, he can be a difficult patient. He accuses the other aides of stealing or something and the other staff are burned out from caring for him. The nurse V4 fed him breakfast this morning. I documented that he refused me to take care of him this morning. At 12:26 PM, V4 RN Registered Nurse stated, This is not the first time this has happened. R2 will refuse care if he doesn't like you, he will refuse you to care for him. I worked with R2 as a CNA as well. It was about 8am in the morning and V3 CNA went to pass him his breakfast tray. That was the only time she came to me. V3 said R2 refused for her to feed or care for him. I went and fed R2 his breakfast and talked to him. He didn't respond today. I charted a note that he was refusing care this morning. It's hard to find someone to help R2. I haven't told anyone yet. I still have to go in and feed him lunch. I will ask R2 again if he will allow V3 to care for him. This is like every day, there are 3 CNAs on this wing. At 12:58 PM, V5 CNA is in R2's room. R2 is speaking with V5, he agreed to allow her to care for him with V4 RN. V5 CNA stated, No one asked me about helping R2 this morning. I already knew what was going on. I have an understanding with R2. At 1:12 PM, V4 RN and V5 CNA are providing ADL (activities of daily living- eating, bathing, grooming and toileting) and perineal care (cleaning the genital area) and applying a clean incontinence brief for R2. R2 is wearing an incontinent brief that is soaked with urine at this time. At 1:32 PM, V2 DON Director of Nursing was inquired of being informed R2 refused care by V3 CNA this morning. V2 stated, I was not informed today that R2 refused care from V3 CNA. Last week he made a request that V3 not give care to him, but he didn't give a reason. It was told to me by V3 CNA that R2 didn't want her to be his care giver. I play a part in CNA scheduling. V3 has R2's section and we do a tradeoff R2 to another CNA. When I came in nothing was reported to me. We had morning meeting and there was no concern. When V1 Administrator was trying to print off the POC documents for V3 CNA, that's when I found out there was a concern with R2 refusing care from V3. When we do a trade off with V3 CNA, sometimes R2 will say no, he'll rather keep V3. The staff say they don't want to care for R2 by themselves because R2 makes it very difficult to care for him. What should V4 RN have done when R2 refused care from V3 CNA? V2 stated, V4 should have looked at the schedule of CNAs to see who could go to R2 and provide care. Most of the time if we can't find anybody, we will get social services to go in and speak with R2. V3 is one of a handful of staff that will care for R2 because of his comments to them. We have CNA's that are uncomfortable taking care of R2. They can help point out the concerns and inform him that there is staff here willing to help him. We do a check and change at least every 2 hours. Our heavy wetter's we try to get them changed more frequently. R2's comprehensive assessment section C for cognitive patterns dated 6/11/23 documents a brief interview for mental status score of 13/15. A score of 13-15 indicates the person is cognitively intact. R2's comprehensive assessment section G for functional status dated 6/11/23 documents toilet use- how a resident uses the toilet room, commode, bedpan, or urinal; transfers on/off the toilet, cleanses self after elimination; changes pad; manages an ostomy or catheter; and adjusts clothes. The resident's self-performance indicates a 4- total dependence. Full staff performance every time. The support provided indicates a 3- two plus persons physical assistance needed. V2 DON provided V3 CNA's POC (point of care) documentation for 8/29/23 regarding R2 refusing care from V3. On 8/29/23 at 9:48 AM, V3 documented- resident refused all AM care. Resident said he does not want me to feed him or do any care for him and I told the nurse. At 11:50 AM, V4 RN Registered Nurse documented- resident refused all morning ADL's (activities of daily living- eating, bathing, grooming and toileting) with CNA despite patient teaching and encouragement. There is no documentation of V4 RN returning to speak with R2 regarding his refusal of care by V3 or of V4 offering another staff to provide him with care. R2 is not being toileted every two hours by staff. On 8/29/23, R2 was not assigned another CNA to provide his care to be toileted by V4 RN causing him to be soiled in urine from 3:30 AM until 1:12 PM when V4 RN and V5 CNA provided his incontinence care. The revised 4/20/21 Incontinence Care policy states in part: Purpose: To prevent excoriation and skin breakdown, discomfort and maintain dignity. Guidelines: Incontinent residents will be checked periodically in accordance with the assessed incontinent episodes or approximately every two hour and provided perineal and genital care after each episode.

Based on interview and record review, the facility failed to safely transfer 1 (R1) of 3 residents (R2 and R3) in the sample reviewed using a mechanical lift. This failure caused the arm of the lift to hit R1 on the head causing a laceration which required medical attention. Findings include: R1 is [AGE] years of age. Current diagnoses include but are not limited to Primary Osteoarthritis Right Shoulder, Fracture of Lower End of Right Femur, Obesity, Lack of Coordination, Abnormal Posture. On 8/29/23 at 1:57 PM, R1 has a dark burgundy colored dime sized bruise to her left forehead area. There are 5 staples to the top left side of her head. R1 was inquired of her accident. R1 stated, I don't walk. They were getting me up to put me in my wheelchair. This happened in the morning. My regular girl V6 CNA Certified Nurse Assistant was here, she's a CNA. I think it was 3 of them, CNA's, I don't remember. They were all talking. They put the pad under me. They had the lift machine and hooked me up to it. They were busy talking to each other and they should have been paying attention to what they were doing. When they tried to get me up, the machine came down on my head. The aides started hollering, one of them went to get the nurse. My head was bleeding bad, it was bleeding profusely. The staff was trying to soak up the blood. The nurse called the ambulance. I don't remember what the aides said to the nurse because I was in pain. The ambulance came and took me to the hospital. They did a CT (Computed Tomography) scan to see how much damage was caused. They found a hole in my head. They worked on me most of the night, then they did what they could. I think it was that night when they sent me back here. On 8/30/23 at 9:40 AM, V7 CNA regarding R1's accident with injury. V7 stated, I was R1's CNA that day, it was 1st shift later in the day. It was me and V6 CNA in the room. I can't remember who the nurse was. Once R1's ADL's (activities of daily living- eating, bathing, grooming and toileting) were done I asked V6 to help me put R1 into her chair. We put the mechanical lift sling underneath R1. We hooked it onto the lift machine. We lifted her and guided the lift over to R1's wheelchair. We had the legs of the lift open to fit over the wheelchair. V6 had the control of the lift. I can't remember if it was myself or V6. The lift control only has 2 buttons, 1 to go up and 1 to go down. The lift goes down slow. Once R1's bottom touched her wheelchair, we made sure to pull her back in the wheelchair and the whole lift machine tipped over with R1 in the wheelchair. The top bar of the lift hit R1 one on the front left side of her head. R1 had her head leaning forward. We were struggling to get R1 to sit back and unhook the sling from the lift machine. We were trying to reposition her. I went and told V8 LPN know we were putting R1 into the wheelchair and it tipped over and hit her in the head. When we got her off the lift is when we saw that she was bleeding from her head. What position were the wheels of the machine in? Were they locked? V6 stated, The wheels were on the floor, and they were locked. The grey lock buttons were down, that means the wheels were locked. How did R1's get hit with the top part of the lift machine? Who was using the lift controls? V7 stated, As long as you press the down button on the lift it'll keep lowering down until you remove your thumb off of it. It has to be let down far enough to release the sling from the hooks. At 10:08 AM, the Proactive medical product mechanical lift labeled number 1 indicates a weight limit of 500 pounds maximum load. The machine appears to be in good repair. R1's electronic medical record indicates her weight as 237 pounds. At 11:15 AM, a telephone call was attempted to contact V6 CNA regarding R1. Unable to leave a message due to the voicemail being full. V2 DON attempted to call with no response. At 11:17 AM, V11 stated the manufacturer was inquired of proper usage of the mechanical lift. V11 stated, In order for the patient be lifted from the bed, the mast should not be tilted. The lift is supposed to go under the bed to lift the patient from the bed, then moved to the desired surface. The base of the machine has to be widened and the wheels have to be locked. The staff should not be pulling the patient, that will add more weight to the lift and cause the lift to move forward. The staff should only be guiding the patient to the surface they are transferring them to. If they are repositioning or pulling the patient while connected to the lift machine it could cause an injury to the patient. At 11:47 AM, V9 LPN Licensed Practical Nurse was inquired of R1's accident with injury. V9 stated, I was not present during R1's transfer. I think V6 CNA told me to come into R1's room. V6 and V7 were in R1's room. R1 was in the chair. Both of them explained it to me. They said the top bar hit R1 in the head. The only thing they said was after seating her in the chair they were trying to situate R1 in the wheelchair and trying to unhook the sling from the machine and it swung and it her in the head. That's what I was told. Did R1 sustain an injury? She had a laceration to her head and a bump to her forehead. I think it was the left side. R1 was bleeding from the laceration to her head. I did my assessment and cleaned the laceration with normal saline. R1 said she didn't want anything on her laceration. She allowed me to clean it. R1 said she wanted to go to the hospital. I checked her vital signs and range of motion they were stable, same as her baseline. I assessed her head, and she said it was hurting. I gave her Tylenol because of the pain; she had a PRN (as needed) order. I called the doctor and let him know and he gave an order to send R1 out to the hospital. I started neurological checks (an evaluation of a person's nervous system) on R1 after her vital signs (temperature, heart rate, respirations, and blood pressure) and every 15 minutes. R1 didn't lose consciousness. I contacted her family and V2 DON. Usually the aides use the lifts, I have had in-services on how to use it. I left the building after R1 was sent to the hospital. I think the staff said she came back later in the day. They said she had stitches. At 12:34 PM, V7 CNA was inquired of repositioning R1 during the transfer using the mechanical lift. V7 stated, R1 was sitting on the wheelchair. I repositioned her while she was still hooked to the lift to make sure she was seated back in her wheelchair. When should a resident be repositioned when using a mechanical lift to prevent injury? V7 stated, Once R1 is unhooked, move the lift out of the way. Each person uses the sling to slide her back in the wheelchair. I'm not sure but it could have been because she was still connected. At 12:57 PM, a second telephone call was attempted to contact V6 CNA regarding R1. The voicemail is full and there was no response. V2 provided R6's witness statement of the incident for review. At 1:07 PM, V2 DON Director of Nursing was inquired of R1's accident with injury. V2 stated, V9 LPN informed me of R1's accident on that Saturday 8/19/23. She called me and said V6 CNA called her to R1's room and upon arriving, R1 was sitting in her wheelchair, and she observed blood from the left side of her head and a raised bump on the temporal area. V9 LPN said R1 was alert and oriented, no change in cognition. She did first aid, like a pressure dressing and proceeded to contact R1's doctor. She got the order to transfer R1 to the hospital. V9 said according to V6 CNA it was after the transfer from the bed to the chair when they repositioned R1 the lift bar swung, and they couldn't catch it. It hit R1 on the side of the head. Was R1 still connected to the lift machine from the sling? V2 stated, Yes, R1 was still connected when they noticed R1's back was not properly against the back of her wheelchair. When should a resident be repositioned when using a mechanical lift? V2 stated, After you disconnect the Hoyer (mechanical lift) sling from the lift. It should be disconnected from the spreader bar where the hooks are and then the resident should be repositioned. I'm picturing that the lift should not have been in the way while repositioning. V2 and surveyor both looked at the Proactive Protect power lift manual. Could the staff repositioning the resident while still connected to the mechanical lift machine cause harm/injury to the resident? V2 stated, Yes, if the resident is still connected to the lift and staff are repositioning the resident they could be harmed. At 1:13 PM, V12 Maintenance Director was inquired of the mechanical lift maintenance. V12 stated, Mechanical lift number 1 is the new lift. I have Proactive number 2 and Reliant E. We have 3 mechanical lifts being used by staff. I look them over and do the checklist monthly. V12 provided the monthly checklists for review. The mechanical lift monthly checklists appear to be completed timely. No concerns identified. At 3:12 PM, V2 DON was inquired of training for the mechanical lift. V2 stated, The first form (unlabeled) is a return demonstration check list. Human resources gave V13 Restorative Nurse the validation of competency for mechanical lift to use for in-service competency. The form hasn't been used for staff. Going forward we will use this form. I will have them add once the resident is seated and the lift machine is moved away from the resident, then reposition the resident. At 3:18 PM, V13 Restorative Nurse was inquired of the teaching material used during in-service training. V13 stated, We have a checklist and I just go down the list and explain each step and do a demonstration. If they don't understand, we do a return demonstration. If needed, we do one on one training. We use the first form (unlabeled) to do return demonstrations. V6 and V7 CNAs were provided in-service training on 7/17/23 and 8/21/23 by the restorative department for the mechanical lift. R1's comprehensive assessment section C for cognitive patterns dated 7/26/23 documents a brief interview for mental status score of 15 out of 15. A score of 13-15 indicates the person is cognitively intact. R1's comprehensive assessment section G for functional status dated 7/26/23 indicates how R1 transfers- moves between surfaces including to or from bed, chair, wheelchair and standing position. The resident's self-performance indicates a 4- total dependence. Full staff performance every time. The support provided indicates a 3- two plus persons physical assistance needed. R1's mobility device indicates a wheelchair. The 5/17/23 care plan indicates: R1 has an ADL (activities of daily living- eating, bathing, grooming and toileting) self-care deficit related to impaired balance, limited mobility, limited range of motion (the totality of movement a joint is capable of doing), shortness of breath and musculoskeletal impairment. Interventions indicate transfer- total dependence, two plus persons physical assistance needed. R1 requires a mechanical lift with two staff assistance with transfers. 8/21/23 R1 has a surgical site to the left scalp with staples. Interventions indicate keep incision site clean/dry. Monitor site for signs and symptoms of infection (i.e., increased drainage, foul odor, redness, warmth etc.). The progress note dated 8/19/23 by V9 LPN states in part- called into resident's room by aide to assess resident due to incident that occurred during her transfer into the chair from her bed. R1 observed in chair with a bump noted on the left side of her forehead and laceration on the left side of her head; bleeding from laceration cleaned and kept dry. R1 complained of pain and as needed pain medication administered. Vital signs are stable. R1 informed she would be going out to the emergency room for further evaluation, and she stated she would prefer further treatment at the hospital. Nurse practitioner, V2 Director of Nursing, and R1's family notified. R1's 8/19/23 skin condition report by V9 LPN indicates a new skin condition. Laceration on the left side of the head and a bump on the left side of the forehead. Treatment/pain assessment- first aid, initiation of neurological checks, notification of the doctor with transfer to the emergency room for further evaluation and notification of the ambulance for transport. Witness statement from V6 CNA on 8/21/23 states in part We had just completed R1's transfer from bed to her wheelchair and as we (another aide) repositioned her in chair the Hoyer (mechanical lift machine) bar swung and before I could stop it the bar hit R1's left side of her head. The hospital assessment documentation dated 8/19/23 indicates a left parietal 4-to-5-centimeter linear laceration with no [NAME] apparent, bleeding controlled with local tamponade. Laceration repaired with 5 staples. The Transfers Manual Gait Belt and Mechanical Lift policy dated 1/19/18 states in part: Purpose: In order to protect the safety and well-being of the staff and residents, and to promote quality care, this facility will use mechanical lifting devices for the lifting and movement of residents. Responsibility: Licensed Nurse, CNA Certified Nurse Assistant, Restorative and Therapy. Guidelines: 1. Mechanical lifting devices shall be used for any resident needing a two person assist, or who cannot be transferred comfortably and/or safely by normal transfer technique. Except during emergency situations or unavoidable circumstances, manual lifting is not permitted. 2. Staff responsible for direct resident care will be trained in the use of mechanical lifting devices annually and as needed. Refer to the manufacturers guide for proper instructions for use of equipment for transfer and weighing.

Based on interview and record review, the facility failed to follow their policy addressing pressure injury and skin assessment. This failure affects one (R1) out of three residents reviewed for pressure injuries and resulted in a delay in treatment and assessment for R1 who developed a Stage III pressure ulcer to the sacrum and deep tissue pressure injury to the left heel. Findings include: R1 is a [AGE] year-old female admitted to the facility 8/30/2016 for long term care. According to nursing progress notes the evening of 6/5/23, R1 was sent to the emergency room for evaluation after a fall and returned to the facility several hours later the following morning. Upon return, facility staff did not indicate any pressure injuries were present. On 8/15/23 at 1:32PM, V7 (Wound Care Coordinator) said, we determined that R1 developed a pressure injury from the hospital transfer. V7 said that they were certified in wound care and were able to accurately provide classifications to pressure wounds. V7 said, that when they assessed R1, it was determined that R1 had developed a Stage III pressure ulcer to the sacrum, and a deep tissue pressure injury to the left heel. V7 said, that the nursing staff are expected to assess all the resident's skin upon readmission to the facility so that orders and treatment could be initiated as necessary. On 8/16/23 at 10:41AM V9 Wound Care NP (Nurse Practitioner) said that wounds could develop within a couple of hours in the circumstances of pressure, moisture, and other risk factors. Stage III pressure injuries are openings in the skin that penetrate multiple layers, meaning it is more than just the top superficial portion. Because of this, Stage III pressure injuries are at greater risk of becoming infected and require immediate treatment. Depending on the location and time, without proper treatment, the opening could further decline and cause additional concerns. The facility was unable to provide documentation that R1 was assessed for having any pressure injuries upon readmission from the hospital on 6/6/23. Additionally, the first documentation for pressure injuries was written by V7 on 6/13/23. In the assessment, V7 wrote that R1's representative was informed of the wound that day. Physician Order Sheet created 6/13/23, included a treatment order for the coccyx/sacrum: clean with normal saline and apply Medi honey, skin prep and cover with foam dressing. Treatment Administration Record (TAR) indicated that no treatments for the sacrum and heel were rendered to R1 from the date of transfer on 6/6/23 until 6/15/23. During a skin observation with V7 on 8/16/23 at 1:45PM V7 said, that Medi honey would be used as an antimicrobial agent applied directly to the wound. On 8/15/23 at 3:38PM, V2 Director of Nursing said, CNA's (Certified Nursing Assistants) are expected to round every two hours to check on the status of the residents. When they are providing incontinence care, they should note the skin condition of the resident and report to the nurse any unusual findings. I cannot say why the wounds for R1 were not documented at the time she returned from the hospital, or why there are no skin assessments in the electronic health record available. Looking at the TAR (Treatment Administration Record), it indicates that the treatments were not completed as the order implies. Facility Policy Titled Pressure Injury and Skin Condition Assessment revised 1/17/18 stated 1. A skin condition assessment and pressure ulcer risk assessment will be completed at the time of admission/readmission. 3. A wound assessment will be initiated and documented in the resident chart when pressure and/or other ulcers are identified by licensed nurse. 4. Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA (Certified Nursing Assistant). Changes shall be promptly reported to the charge nurse who will perform the detailed assessment.

Based on observations and interviews, this facility failed to provide the necessary services, identify a decline, implement interventions, and evaluate the effectiveness of interventions for one resident (R64) with a decline in range of motion bilateral hands out of three reviewed for a decline in functional abilities in a sample of 20. R64 has developed a contracture of bilateral hands, left worse than right, and is unable to extend fingers fully. Findings include: On 12/20/22 at 10:00am, R64 was observed lying in bed with both hands closed. On 12/21/22 at 8:40am, this surveyor observed V2 DON (director of nursing) extend R64's fingers on both hands. V2 stated that V2 is unable to fully extend the fingers on either hand. V2 stated that the left hand is stiffer than the right hand. On 12/21/22 at 9:40am, this surveyor observed V6 (restorative aide) perform PROM (passive range of motion) exercises with R64. R64 was observed crying when her fingers on both hands were extended. On 12/21/22 at 9:15am, V4 (restorative nurse) stated that R64 does not need splints as her hands are not contracted. V4 stated that R64 tenses up and clenches her hands. V4 stated that R64 is able to extend fingers fully on both hands. On 12/21/22 at 9:35am, V5 LPN (licensed practical nurse) stated that R64 is totally dependent on staff for all ADLs (activities of daily living). V5 stated that the restorative staff apply splints to R64's hands daily to prevent contractures. When questioned where R64's hand splints were, V5 did not respond. On 12/21/22 at 9:40am, V6 (restorative aide) stated that R64 does not have any contractures in her extremities. V6 stated that R64 receives PROM (passive range of motion) exercises daily. After completion of exercises, V6 stated that R64 has contractures.

Based on interview and record review, the facility failed to ensure a resident was properly in her wheelchair. This failure affected one resident (R49) reviewed for falls in a total sample of 20. This failure resulted in R49 suffering from a subdural hematoma after falling. Findings include: On 12-21-22 at 9:17am, R49 state 2 CNAs placed R49 in the wheelchair using mechanical lift and R49 slid out of the chair and hit her head. On 12-21-22 at 10:24am, V2 (director of nursing) stated 2 CNAs (V7 and V6) used the mechanical lift to put R49 in the wheelchair. When R49 was in the wheelchair, V7 (CNA) went to get a washcloth for R49 and V16 (CNA) left to provide care to other residents. As V7 came back with washcloth, R49 slid out of her chair and ended up on the floor. V2 stated R49 is a fall risk and staff were using a mechanical lift for transfers (2 person) assist prior to incident. R49 was given nonslip pad and a pommel cushion to her wheelchair after the incident. On 12-21-22 at 10:46am, V7 (CNA) stated she transferred R49 to the wheelchair with the mechanical lift using another CNA. V7 stated R49 was on top of the wheelchair with mechanical lift sling under her. After the transfer, the other CNA left to take care of other residents and V7 went to get a washcloth for R49. When V7 returned, V7 saw R49 on the floor in front of her wheelchair. V7 did not see the fall. V7 asked R49 if she was OK and R49 said she hit her head. Initial State Reportable dated 11-8-22 documents: Description of Occurrence: Reported to nurse that resident had slid out of the wheelchair and bumped her head on the floor. No LOC. Resident is alert and oriented x 3 and reports sliding to the floor and bumping her head. Complete body assessment rendered and ROM (range of motion) to AE (adverse event) WNL (within normal limits) of resident's baseline. Resident assisted back to bed with no complaints. During NP rounding later that morning, resident verbalized the start of blurred vision. NP gave the order to transfer resident to the ER for the further medical evaluation. Injuries: Hospital diagnosis: Initial encounter of fall with possible head injury. Final State Reportable dated 11-11-22 documents: Follow Up/Final Report Summary: Hospital records is revealing stable right frontal ventriculoperitoneal shunt and stable vascular stent in the right carotid area. No shift of midline structures. No mass lesions. No skull fracture or suspicious focal osseous lesion. There is a small low-density right subdural fluid collection, approximately 0.4 cm in thickness, age, indeterminate, indicative of a subdural hematoma. Hospital Record dated 11-8-22 documents: History of Present Illness: R49 is a 60 yrs.-old female with past medical history/PMX of cerebral vascular accident/CVA with left hemiplegia who presents to ED for medical evaluation status post/s/p mechanical fall from a wheelchair. Per EMS, nursing home/NH staff patient/pt. slipped out of her chair. Currently complaining of dizziness. Denies loss of consciousness/LOC, neck or backpain, visual disturbances, changes in weakness, or any other symptoms at this time. Clinical Impression: 1.Subdural hematoma. R49's MDS (assessment reference date/ARD 11-4-22) documents: BIMS= 12, Transfers: Self= total dependence, Support= 2+ person. Fall Risk Assessments dated 11-8-22 and 11-4-22 documents R49 is at risk for falls. R49's Fall Care Plan reviewed.

Based on interview and record review the facility failed to notify the physician for five hours after a resident (R1) had an episode of vomiting which caused a decline in respiratory status for one of three residents reviewed for improper nursing care in a total sample of three. This failure resulted in R1 aspirating the vomit; R1 experiencing increased secretions, increased respiratory rate, decreased oxygen levels; and R1 needing to be admitted to the intensive care unit and placed on a ventilator. Findings Include: R1 is an [AGE] year old with the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 admitted to the facility on [DATE] and discharged on [DATE]. A Nursing note dated 6/18/22 at 6:41 AM documents R1 had a large amount of emesis and the feeding was put on hold. [CONDITION(S)] care was provided and R1 was suctioned. Thick white secretions were suctioned. Vital signs are documented as stable but no values are noted. A Nursing note dated 6/18/22 at 3:05 PM documents [CONDITION(S)] care was provided to R1 at around 10:30 AM. Vital signs are stable but no values are documented. R1's family requested R1 be sent to the hospital due to the amount of [MEDICATION(S)]. 911 was called. The doctor and the DON when were made aware. The SBAR Communication Form dated 6/18/22 documents R1 has no changes in respiratory status observed and vital signs are within normal limits. The Ambulance Run Sheet dated 6/18/22 documents the paramedics were dispatched for low oxygen saturation. Upon arrival, R1 was showing shallow breathing at 50 to 60 times for a minute with no muscle tone. Oxygen saturation was 83% on 5 L via [CONDITION(S)] mask and there was audible gurgling from the [CONDITION(S)] with a stick/yellow [MEDICATION(S)] in the oxygen supply tubing. R1 was suctioned immediately with approximately 50 through 75 mL of [MEDICATION(S)] removed. The oxygen was increased to 15 L per minute and the oxygen saturation increase to 98%. Additional suctioning continues to show improvement in [MEDICATION(S)] change from yellow to clear. Reassessment shows R1 to still be tachypneic with an additional drop in oxygen saturation to 88% The decision to divert to the closest facility was made at that time and respirations were given via bag valve mask to [CONDITION(S)]. On scene, the nurse never came to the room and when asked when the last time R1 was checked on, the nurse reported R1 was fine. The Hospital Records dated 6/18/22 document R1 presented from the nursing home by ambulance for evaluation of respiratory distress. R1 is [CONDITION(S)] dependent and the paramedics reported being called due to difficulty breathing. The paramedics did suction R1 and had a large return of yellow sputum. Oxygen saturation did improve but R1 needed to be bagged through [CONDITION(S)] upon arrival. R1 was placed on mechanical ventilation. R1 is with decreased air movement in the lungs. R1 has bilateral infiltrates in the lungs on the chest x-ray. R1 did have a hemorrhagic stroke in 04/2022 where a [CONDITION(S)] and gastrostomy tube were placed. R1 was able to be weaned off the ventilator prior to coming in today. R1 was brought in for respiratory failure in significant [MEDICATION(S)] production. Given the respiratory distress and despite significant suctioning, R1 had to be placed back on the ventilator. R1 had a normal white blood cell count but it was significant for bandemia (too many white blood cells being released into the blood stream indicating an infection or [CONDITION(S)] process) with elevated lactic acid and procalcitonin indicating an infectious process. R1 was transferred to the intensive care unit. R1's admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/09/22 at 1:25PM, V2 (Nurse) stated, V4 (Nurse) said the family was concerned that R1 was having trouble breathing. They said they wanted R1 to be sent to the hospital. It didn't look to me like she was struggling to breathe. Signs of that would be increased respiratory rate, shallow breathing, or lower oxygen level. I believe when we checked her level (oxygen saturation) it was in the 90s. I can't remember exactly what it was but I don't think it was low. I know R1 was suctioned once that I know of. The family refuse for R1 to be suctioned anymore. R1 was on a concentrator. I don't remember how much oxygen R1 was getting but we did not turn it up. R1 was not on a ventilator. The family was concerned that R1 had aspirated on R1's vomit and wanted R1 to be evaluated. We called the doctor and he told us to send R1 out. We called 911 then. I know the nurse (V4) told me V4 got a phone call after that from EMS saying that the oxygen level dropped so they had to reroute R1 to a closer hospital. No, they did not say why it dropped to. If you think someone aspirated then you should stop the feeding, suction them as much as you can, and just keep an eye on them to make sure they are still breathing OK. On 07/09/22 at 1:37PM, V3 (DON) stated, I was told that the family requested to transfer R1 because they thought R1 was in distress. The nurse (V4) told me that V4 suctioned R1 but R1's family still wanted R1 to be sent out for an evaluation. I was not made aware that R1 was in any distress while R1 was here. I know that R1 ended up having to be put back on a ventilator in the ICU when R1 went to the hospital. They did not say why. That's the only update we received. I was not told that R1 had any vomiting. A resident with a [CONDITION(S)] that vomits you need to suction what you can, keep the head of the bed elevated, and monitor them for any changes from their baseline with the respiratory status. I was only told that the family wanted R1 to leave. I was never told R1 was in distress or that R1 vomited. Staff should notify me and the doctor if there are any changes. On 07/09/22 at 4:18PM, V4 stated, I just came on that morning and the other nurse (V5) told me that R1 had just vomited. R1 never vomited for me so I didn't actually clean R1 up or suction R1 then. R1 was doing fine for me but there was a little bit of [MEDICATION(S)] on R1's chest when R1's family came to visit and they called in more family and after that they just started demanding R1 be sent out. I did suction R1 one time and it was thick and white. It wasn't a lot. I can't say how much but I only need to suction R1 one time and it was clear. This was only my second time taking care of R1 so I wasn't really familiar with R1 but from what the family was saying it wasn't like R1 to have that much [MEDICATION(S)]. R1 did not seem to be in any respiratory distress. R1 did have a little bit of gurgling right before I suctioned R1 but after that it was fine. I didn't listen to her with a stethoscope. I just was listening to see if R1 needed to be suctioned more. I called the doctor when the family kept requesting that R1 go out and V6 (Primary Physician) told me just send R1 out. No I did not call V6 before. I didn't think I needed to because R1 was fine. I don't know if the nurse before me called the doctor to tell him that R1 vomited. I know we called 911 because the family wanted R1 out of there as fast as possible. They came and picked R1 up and they did call me to tell me that they had to take R1 to the closest hospital because R1 had desatted when R1 was in route to the hospital the family wanted R1 to go to. On 07/11/22 at 3:256PM, V6 (Primary Physician), stated, It is difficult for [CONDITION(S)] patients to aspirate because that is what the [CONDITION(S)] is there for but it's not 100% guarantee. Residents with a G-tube feeding and a [CONDITION(S)] still can aspirate. If a resident like that does vomit, they should check the respiratory status to make sure they are breathing on and monitor the pulse ox. Just look out for any changes. If there does seem to be a change or they aren't doing well then 911 should be called. They may need further intervention at the hospital that we cannot provide here. They should also be suctioned. You want to try to get out as much as you can before it does go down into their lungs. If the family ever complains that something is not right with the resident then I send them out immediately if I am not there. I listen to what the families telling me because they usually can tell me more about what is going on. If the aspiration is massive you will be able to see that on a chest x-ray immediately. For a smaller aspiration it could take days to develop infiltrates in the lungs. The most important thing to monitor is the resident's clinical status. I want to be notified when a resident does aspirate. They call me at 2 AM for a skin tear so something like this I would want to be notified about that could change the resident's condition. If they don't notify me about the vomit, then they should immediately notify me once they see any changes in condition. You would watch for increase respirations, a decrease in oxygen saturations or a need for more oxygen than they are normally getting, increased secretions that need to be suction more frequently, if it appears they are struggling to breathe, and a fever. On 07/11/22 at 9:46PM, V5 (Nurse) stated, I was giving R1 morning medications right around shift change. The next nurse (V4) walked into the room and saw that I was cleaning up R1's vomit. R1 vomited just as I was giving R1 medication through her G-tube. I held the feeding and sat R1 up more. I suctioned everything out that I could and both me and the nurse coming on did the [CONDITION(S)] care. That is supposed to be done once a shift. I can't say how much the vomit was but I would say it's a decent amount. R1 did not seem to be struggling to breathe at all after we suctioned R1. I wasn't there that long so I can't tell you what happened after that but for the couple minutes I was in the room and we cleaned R1 up she did not seem like she was in any respiratory distress then. No I did not call the doctor. I was working with the morning nurse to clean R1 up so I assumed the morning nurse would have called him. If a resident starts showing signs of a change of condition then you call the doctor right away. If the vital signs are off or if there's something new that wasn't happening before then you call them to notify them to get orders and see what you need to do. The vital signs for 06/2022 were reviewed. There is only a temperature documented on 6/18/22 which was normal at 97.1°F. No other vital signs are documented on 6/18/22. The average documented respiratory rate for R1 is 18 through 20 breaths per minute. All other vital signs are documented within normal range. The Admission Respiratory Therapy note dated 6/6/22 documents R1 was admitted from the hospital. R1 has vital signs and oxygen saturation within normal limits. R1 suctioned once within yellow secretions. Respiratory therapy will work with patient to begin decannulation process in the future. The Care Plan dated 6/6/22 documents R1 requires tube feedings related to dysphasia. The following are documented interventions: listen to lung sounds each shift and document/monitor/report any signs or symptoms of aspiration, shortness of breath, and abnormal breath/lungs sounds. The Care Plan dated 6/14/22 documents R1 has a [CONDITION(S)] related to impaired breathing mechanics. The following are documented interventions. Monitor/document respiratory rate, depth and quality and suction as necessary. The Minimum Data Set, dated dated dated [DATE] documents R1 does not display any shortness of breath or difficulty breathing during this assessment. The Respiratory Infection Screener dated 6/17/22 at 10:42 PM documents the oxygen saturation is 98%. R1 does not display any difficulty breathing and breath sounds are clear. R1 does not have a cough and [MEDICATION(S)] production has not been increased. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy titled, Physician - Family Notification - Change in Condition, dated 11/13/18 documents, Purpose: To ensure that medical care problems are communicated to be 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 residence physician or authorized designee such as nurse practitioner; and if known, notify the residence legal representative or an interested family member when there is: (A) An accident involving the resident which results in injury and has a potential for requiring physician intervention; (B) A significant change in the residents physical, mental, or psychosocial status (I.e., A deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);

Based on interview and record review the facility failed to appropriately assess a resident's (R1) respiratory status after an episode of vomiting. This failure resulted in R1 aspirating the vomit; R1 experiencing increased secretions, increased respiratory rate, decreased oxygen levels; and R1 needing to be admitted to the intensive care unit and placed on a ventilator. Findings Include: R1 is an [AGE] year old with the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 admitted to the facility on [DATE] and discharged on [DATE]. A Nursing note dated 6/18/22 at 6:41 AM documents R1 had a large amount of emesis and the feeding was put on hold. [CONDITION(S)] care was provided and R1 was suctioned. Thick white secretions were suctioned. Vital signs are documented as stable but no values are noted. A Nursing note dated 6/18/22 at 3:05 PM documents [CONDITION(S)] care was provided to R1 at around 10:30 AM. Vital signs are stable but no values are documented. R1's family requested R1 be sent to the hospital due to the amount of [MEDICATION(S)]. 911 was called. The doctor and the DON were made aware. The SBAR Communication Form dated 6/18/22 documents R1 has no changes in respiratory status observed and vital signs are within normal limits. The Ambulance Run Sheet dated 6/18/22 documents the paramedics were dispatched for low oxygen saturation. Upon arrival, R1 was showing shallow breathing at 50 to 60 times for a minute with no muscle tone. Oxygen saturation was 83% on 5 L via [CONDITION(S)] mask and there was audible gurgling from the [CONDITION(S)] with a stick/yellow [MEDICATION(S)] in the oxygen supply tubing. R1 was suctioned immediately with approximately 50 through 75 mL of [MEDICATION(S)] removed. The oxygen was increased to 15 L per minute and the oxygen saturation increase to 98%. Additional suctioning continues to show improvement in [MEDICATION(S)] change from yellow to clear. Reassessment shows R1 to still be tachypneic with an additional drop in oxygen saturation to 88% The decision to divert to the closest facility was made at that time and respirations were given via bag valve mask to [CONDITION(S)]. On scene, the nurse never came to the room and when asked when the last time R1 was checked on, the nurse reported R1 was fine. The Hospital Records dated 6/18/22 document R1 presented from the nursing home by ambulance for evaluation of respiratory distress. R1 is [CONDITION(S)] dependent and the paramedics reported being called due to difficulty breathing. The paramedics did suction R1 and had a large return of yellow sputum. Oxygen saturation did improve but R1 needed to be bagged through [CONDITION(S)] upon arrival. R1 was placed on mechanical ventilation. R1 is with decreased air movement in the lungs. R1 has bilateral infiltrates in the lungs on the chest x-ray. R1 did have a hemorrhagic stroke in 04/2022 where a [CONDITION(S)] and gastrostomy tube were placed. R1 was able to be weaned off the ventilator prior to coming in today. R1 was brought in for respiratory failure in significant [MEDICATION(S)] production. Given the respiratory distress and despite significant suctioning, R1 had to be placed back on the ventilator. R1 had a normal white blood cell count but it was significant for bandemia (too many white blood cells being released into the blood stream indicating an infection or [CONDITION(S)] process) with elevated lactic acid and procalcitonin indicating an infectious process. R1 was transferred to the intensive care unit. R1's admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/09/22 at 1:25PM, V2 (Nurse) stated, V4 (Nurse) said the family was concerned that R1 was having trouble breathing. They said they wanted R1 to be sent to the hospital. It didn't look to me like she was struggling to breathe. Signs of that would be increased respiratory rate, shallow breathing, or lower oxygen level. I believe when we checked her level (oxygen saturation) it was in the 90s. I can't remember exactly what it was but I don't think it was low. I know R1 was suctioned once that I know of. The family refuse for R1 to be suctioned anymore. R1 was on a concentrator. I don't remember how much oxygen R1 was getting but we did not turn it up. R1 was not on a ventilator. The family was concerned that R1 had aspirated on R1's vomit and wanted R1 to be evaluated. We called the doctor and he told us to send R1 out. We called 911 then. I know the nurse (V4) told me V4 got a phone call after that from EMS saying that the oxygen level dropped so they had to reroute R1 to a closer hospital. No, they did not say what it dropped to. If you think someone aspirated then you should stop the feeding, suction them as much as you can, and just keep an eye on them to make sure they are still breathing OK. On 07/09/22 at 1:37PM, V3 (DON) stated, I was told that the family requested to transfer R1 because they thought R1 was in distress. The nurse (V4) told me that V4 was suctioned R1 but R1's family still wanted R1 to be sent out for an evaluation. I was not made aware that R1 was in any distress while R1 was here. I know that R1 ended up having to be put back on a ventilator in the ICU when R1 went to the hospital. They did not say why. That's the only update we received. I was not told that R1 had any vomiting. A resident with a [CONDITION(S)] that vomits you need to suction what you can, keep the head of the bed elevated, and monitor them for any changes from their baseline with the respiratory status. I was only told that the family wanted R1 to leave. I was never told R1 was in distress or that R1 vomited. Staff should notify me and the doctor if there are any changes. On 07/09/22 at 4:18PM, V4 stated, I just came on that morning and the other nurse (V5) told me that R1 had just vomited. R1 never vomited for me so I didn't actually clean R1 up or suction R1 then. R1 was doing fine for me but there was a little bit of [MEDICATION(S)] on R1's chest when R1's family came to visit and they called in more family and after that they just started demanding R1 be sent out. I did suction R1 one time and it was thick and white. It wasn't a lot. I can't say how much but I only need to suction R1 one time and it was clear. This was only my second time taking care of R1 so I wasn't really familiar with R1 but from what the family was saying it wasn't like R1 to have that much [MEDICATION(S)]. R1 did not seem to be in any respiratory distress. R1 did have a little bit of gurgling right before I suctioned R1 but after that it was fine. I didn't listen to her with a stethoscope. I just was listening to see if R1 needed to be suctioned more. I called the doctor when the family kept requesting that R1 go out and V6 (Primary Physican) told me just send V5 out. No I did not call V6 before. I didn't think I needed to because R1 was fine. I don't know if the nurse before me called the doctor to tell him that R1 vomited. I know we called 911 because the family wanted R1 out of there as fast as possible. They came and picked R1 up and they did call me to tell me that they had to take R1 to the closest hospital because R1 had desatted when R1 was in route to the hospital the family wanted R1 to go to. On 07/11/22 at 3:256PM, V6 (Primary Physician), stated, It is difficult for [CONDITION(S)] patients to aspirate because that is what the [CONDITION(S)] is there for but it's not 100% guarantee. Residents with a G-tube feeding and a [CONDITION(S)] still can aspirate. If a resident like that does vomit, they should check the respiratory status to make sure they are breathing on and monitor the pulse ox. Just look out for any changes. If there does seem to be a change or they aren't doing well then 911 should be called. They may need further intervention at the hospital that we cannot provide here. They should also be suctioned. You want to try to get out as much as you can before it does go down into their lungs. If the family ever complains that something is not right with the resident then I send them out immediately if I am not there. I listen to what the families telling me because they usually can tell me more about what is going on. If the aspiration is massive you will be able to see that on a chest x-ray immediately. For a smaller aspiration it could take days to develop infiltrates in the lungs. The most important thing to monitor is the resident's clinical status. I want to be notified when a resident does aspirate. They call me at 2 AM for a skin tear so something like this I would want to be notified about that could change the resident's condition. If they don't notify me about the vomit, then they should immediately notify me once they see any changes in condition. You would watch for increase respirations, a decrease in oxygen saturations or a need for more oxygen than they are normally getting, increased secretions that need to be suction more frequently, if it appears they are struggling to breathe, and a fever. On 07/11/22 at 9:46PM, V5 (Nurse) stated, I was giving R1 morning medications right around shift change. The next nurse (V4) walked into the room and saw that I was cleaning up R1's vomit. R1 vomited just as I was giving R1 medication through her G-tube. I held the feeding and sat R1 up more. I suctioned everything out that I could and both me and the nurse coming on did the [CONDITION(S)] care. That is supposed to be done once a shift. I can't say how much the vomit was but I would say it's a decent amount. R1 did not seem to be struggling to breathe at all after we suctioned R1. I wasn't there that long so I can't tell you what happened after that but for the couple minutes I was in the room and we cleaned R1 up she did not seem like she was in any respiratory distress then. No I did not call the doctor. I was working with the morning nurse to clean R1 up so I assumed the morning nurse would have called him. If a resident starts showing signs of a change of condition then you call the doctor right away. If the vital signs are off or if there's something new that wasn't happening before then you call them to notify them to get orders and see what you need to do. The vital signs for 06/2022 were reviewed. There is only a temperature documented on 6/18/22 which was normal at 97.1°F. No other vital signs are documented on 6/18/22. The average documented respiratory rate for R1 is 18 through 20 breaths per minute. All other vital signs are documented within normal range. The Admission Respiratory Therapy note dated 6/6/22 documents R1 was admitted from the hospital. R1 has vital signs and oxygen saturation within normal limits. R1 suctioned once within yellow secretions. Respiratory therapy will work with patient to begin decannulation process in the future. The Care Plan dated 6/6/22 documents R1 requires tube feedings related to dysphasia. The following are documented interventions: listen to lung sounds each shift and document/monitor/report any signs or symptoms of aspiration, shortness of breath, and abnormal breath/lungs sounds. The Care Plan dated 6/14/22 documents R1 has a [CONDITION(S)] related to impaired breathing mechanics. The following are documented interventions. Monitor/document respiratory rate, depth and quality and suction as necessary. The Minimum Data Set, dated dated dated [DATE] documents R1 does not display any shortness of breath or difficulty breathing during this assessment. The The Respiratory Infection Screener dated 6/17/22 at 10:42 PM documents the oxygen saturation is 98%. R1 does not display any difficulty breathing and breath sounds are clear. R1 does not have a cough and [MEDICATION(S)] production has not been increased. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review the facility failed to provide a plan of monitoring and/or supervision interventions for a resident with a known history of wandering and inappropriate social behavior for 1 of 9 residents (R5) reviewed for supervision. This failure resulted in R5 being found naked in bed with R6, a severely cognitively impaired resident. This failure has the potential to cause negative emotional and psychosocial harm to a reasonable person in the same situation. Findings include: R6 has the [DIAGNOSES REDACTED]. R5 was admitted on [DATE] with the [DIAGNOSES REDACTED]. R5's BIMS dated 12/29/2020 documents a score of ten, which indicates moderate impairment. Progress note dated 1/8/2021 documents V15 (Nurse) was made aware by V14 (Certified Nursing Assistant/CNA) that R5 was in R6's bed. R5 was sent to the hospital for altered mental status change. On 2/9/2021 at 1:01pm, V14 (CNA) stated, R5 would wander the hallway naked. R5 walked with an unsteady gait. I noticed R5 was not his room. R5 was observed in R6's bed naked. R6's gown was up by her navel. R6 did not have on an adult {incontinence brief}. R6 was confused. I looked at R6's hands, thighs and did not notice anything. I was not sure what to look for in R6's vaginal area. Residents don't wear {incontinence briefs} overnight. There was water on R5's floor. There was a puddle with a streak leading away from the puddle as if R5 slid in the water. R6's bed sheets were wet. R5's left side of the body was wet. R5 had a fall. On 2/9/21 at 1:30pm, V2 (Social Service) stated, We sent R5 to the hospital for being naked in the bed with R6. R5 was a constant wanderer. R5's cognition was off. We discharged R5 because R5 was not appropriate for this facility. R5 needed constant supervision. R5 wandered into R6's room. On 2/10/21 at 9:30 am, R6 was pleasantly confused. R6 was unable to report what happened on 1/8/21. On 2/10/21 at 10:03am, V14 (CNA) stated, R6 had barrier cream/white paste in between her thighs on her vaginal area and on her buttock. R5 had white paste on his fingertips. On 2/10/21 at 10:05am, V15 (Nurse) stated, I could not rule out or confirm whether R6 had vaginal penetration. R6 was sent to the hospital for a medical evaluation. On 2/11/21 at 2:48pm, V2 (Social Service) stated, R5 was severely impaired, very confused and wandered aimlessly. On 2/11/21 at 2:55pm, V20 (Nurse) stated, R5 was aggressive, refused medication, could not be redirected and required constant supervision for safety. R5's social service aggressive behavior dated 12/22/20 documents R5 had moderate problems with self-destructive statements/behavior and threats. R5 has a [DIAGNOSES REDACTED]. Admission/Re-Admission Observation dated 12/23/2020 documents R5 has wandering behaviors that occurred one to three days. R5 has socially inappropriate behavior. R5's care plan dated 12/23/2020 documents R5 is a wanderer. Goals include R5's safety will be maintained. Interventions include to distract R5 from wandering, identify patterns of wandering, and intervene as appropriate. R5's fall occurrence dated 1/8/2020 documents R5 had an unwitnessed fall. R5 was found by staff in room. R5 did not know what happened. R5's section G functional status dated 12/29/2020 documents R5 needed limited assistance with one person physical assist with transfers, walking in room/corridor and locomotion on/off the unit. The hospital paperwork dated 1/8/21 documents R6 was confused, found in bed with a male resident (R5) from the facility who was unclothed. R6 was reported to not have been wearing any briefs. R5 was a confused demented patient. Final Abuse Investigation Report dated 1/15/21 documents V14 (CNA) was passing trays and observed R5 in the bed with R6. R5 had a history of [REDACTED]. V14 said she immediately helped R5 out of R6's bed. V14 noticed R5's knee bleeding and R5 was naked. V14 said R6's gown was pushed upward and did not have a brief on. R5 will be discharged to another facility that has a locked unit for wandering. Behavior Management Policy dated 11/28/12 documents Implementing appropriate intervention consistent with the individualized plan of care and to ensure each resident received appropriate treatment and services to attain the highest practicable mental and psychosocial well-being.

Based on interview and record review the facility failed to isolate, monitor, and test residents with COVID-19 symptoms per the facility's policy and the CDC guidelines for two (R2, R3) residents of four residents reviewed for infection control in a total sample of six residents. This failure resulted in R2 being admitted to the hospital with [REDACTED]. Findings include: 1. R2 is an [AGE] year old with the following Diagnoses: [REDACTED]. R2 was admitted to the facility on [DATE]. A Physician Note dated [DATE] documents R2 with a temperature of 102.9 degrees Fahrenheit and currently receiving an antibiotic for a urinary tract infection [MEDICAL CONDITION]. A nursing note dated [DATE] documents R2 has been febrile all afternoon into the evening with a fever. Tylenol given twice. The doctor ordered STAT labs and a chest x-ray. A nursing note dated [DATE] documents R2's temperature 100.0 degrees Fahrenheit and Tylenol given as ordered. A nursing note dated [DATE] documents R2 is lethargic, slow to respond, and skin is ashen. R2 had a large semi-loose stool. R2 now on oxygen 2 L and a 500 ml bolus of 0.9 normal saline given wide open for low blood pressure of ,[DATE]. Blood pressure ,[DATE] after the bolus. A nursing note dated [DATE] documents R2's blood pressure ,[DATE]. The nurse practitioner ordered continuous IV fluids to be administered at 30 ml/hour. Blood pressure returned to ,[DATE] after continuous IV hydration. A nursing note dated [DATE] documents R2's blood pressure ,[DATE], lethargic, and a change in mental status. R2 sent out to the hospital for evaluation. A Nursing note dated [DATE] documents R2 returned to the facility on hospice and is COVID positive. A nursing note dated [DATE] documents CNA noticed R2 stopped breathing. A nurse went to check R2 and R2 had expired. The Care Plan for R2 dated [DATE] documents interventions as: observe for signs and symptoms of COVID-19 - document and promptly report signs and symptoms of fever, coughing, sneezing, sore throat, and respiratory issues, and follow facility protocol for COVID-19 screening and precautions. The vital signs document R2's first fever was on [DATE]. R2 remained in the same room from [DATE] until R2 expired. Low blood pressures began on [DATE]. Vital signs documented once a shift or less. R2 never resided in the COVID unit. Hospital Records document R2's [DIAGNOSES REDACTED]. R2 arrived to the hospital febrile with low blood pressure. Chest x-ray shows left lower lobe atelectasis. R2 COVID positive. Death Certificate dated [DATE] documents cause of death as novel corona (COVID-19) virus infection. 2. R3 is a [AGE] year old with the following Diagnoses: [REDACTED]. R3 was admitted to the facility on [DATE]. Progress notes for [DATE]/2020 were reviewed. An Infection Charting note dated [DATE] documents R3 is receiving antibiotics as a [MEDICATION NAME] for having a fever. A nursing note dated [DATE] documents R3's oxygen level was 72% and R3 was placed on 2L of oxygen via nasal cannula. A nursing note dated [DATE] documents R3 noted with a change in condition. R3 appears very lethargic and is groaning/moaning while moving R3's body around in bed. R3's oxygen level on 6L of oxygen is 89%. R3 sent to the hospital via 911. A nursing note later on [DATE] documents R3 admitted to the hospital with [REDACTED]. A Nursing note dated [DATE] documents R3 expired on [DATE]. The Care Plan for R3 dated [DATE] documents interventions as: observe for signs and symptoms of COVID-19 - document and promptly report signs and symptoms of fever, coughing, sneezing, sore throat, and respiratory issues, and follow facility protocol for COVID-19 screening and precautions. R3's vital signs for ,[DATE] reviewed. Vital signs were documented once daily except for temperature. Temperature checked on R3 two or three times a day due to fevers. R3's first fever noted on [DATE] at 99.7 degrees Fahrenheit. Next fever documented on [DATE] at 99.3 degrees Fahrenheit. R3 febrile again on [DATE] at 100.4 degrees Fahrenheit. R3 with a high heart rate of 101, low blood pressure of ,[DATE], and low oxygen level of 89% when sent to the hospital. Hospital Records dated [DATE] documents R3 admitted to the hospital with [REDACTED]. R3's COVID swab is positive. R3 is in mild respiratory distress. Blood pressure is ,[DATE], respirations are 36, pulse is 103, and oxygen level is 95% via nasal cannula with an overlying non-rebreather mask. The Census dated [DATE] - [DATE] documents R3 never moved rooms and three beds were available in the COVID unit during these days. On [DATE] at 12:38PM, V4 (Nurse) stated, I don't remember taking care of R3 the days before but I was working overnight then. I remember R3 kept yelling out for help so I went down there and took R3's vitals and R3's oxygen was low in the 80s. I called the PPHP insurance to tell them what was going on and they said to increase R3's oxygen and give R3 pain medication. I did that then came back like 30 minutes later to see if R3 was better and R3 wasn't. R3's oxygen dropped even lower after I put it up to 3 or 4 liters. R3 was grabbing my hand weak so I called them back and they said if I don't feel comfortable, send R3 to the hospital. I called 911 and R3 left. This wing has always been the COVID unit since the beginning. No, I don't think we have ever been full that I know of. We monitor residents that aren't on this unit with vital signs once a day and if they have any symptoms. If anything is new or looks like it might be COVID I call the doctor and let them know. I also tell the DON and the administrator so they can move them away from the others. I don't know if R3 was having any signs of COVID. I did have to increase R3's oxygen. I don't know if R3 had a fever. On [DATE] at 1:10PM, V1 (Administrator) stated, We monitored the residents by doing their vital signs once every shift. If anyone started showing signs or symptoms, they were moved down to the COVID unit as soon as possible. Signs and symptoms would be a fever or cough or respiratory issues. We would expect that nurse to call the DON or me to let us know. We have never been to full capacity in the COVID unit. R2 was in a private room so R2 didn't have a roommate. She was sent to the hospital and came back the next day, I think. R2 didn't have any respiratory symptoms if I remember. I know we were trying to manage R2 at the facility and kept the doctor updated on R2's status. R3 did have a roommate. I was out so I can't say what was done for R3. Maybe the facility was full at that time and that is the reason R3 wasn't moved. We had the whole building on lockdown at that time so I'm not sure R3 would have needed to be transferred. On [DATE] at 10:36AM, V6 (former Director of Nursing/DON) stated, Yes, I was acting DON and in charge of COVID at that time. When a resident started showing signs of COVID they would be moved to the COVID unit. Fever, cough, respiratory distress were some of the signs that would cause us to think they had it. On that unit they have their vital signs done every 4 hours. We monitor them more often in case there is a significant change in condition we can catch it. Everyone was getting vitals done every 4 hours then. It should be documented in PCC every time. It was the nurses' responsibility to tell me if their resident was having any signs and symptoms or changes. I couldn't watch everyone. I did the best I could. We would test a resident if the doctor told us to. Not everything was COVID related so we did a mass testing sometime in March then they decided when to test after that. If we had to send them out they got tested at the hospital too. We did a line list for tracking residents. I don't remember a COVID screening form. The nurses would tell me if someone was having a problem and the doctors ordered the test if they wanted. We did go on lockdown in March. We didn't allow any visitors in and the residents had to stay in their rooms as much as possible. We only have fall risks out at the nurse's station to watch them. When we went on lockdown everyone went on isolation too. They were contact and droplet precautions. R2 was in a private room. I don't remember R2 having any signs or symptoms of COVID. I think R2 was on hospice, but I don't remember R2 being positive. R3 had a roommate. I remember R3 went out to the hospital, but I don't remember being told anything before about R3. I don't know if R3 had a fever or what was going on with R3. I honestly don't remember why they weren't moved to the COVID unit. Like I said, I did the best I could but I don't remember being told anything about COVID for either of them. On [DATE] at 3:53PM, V5 (R3's Primary Physician) stated, I don't remember being called about any symptoms R3 was having or a chest x-ray. I could have been called; I just don't remember. Everything was changing so early in the beginning so I can't tell you about protocols or testing or anything because the standards now are so different. They would have to refer to what their management was telling them. If R3 were showing signs of COVID, R3 should have been monitored more frequently if that is what the guidelines reported. This way they could have monitored for a deterioration in condition. I can't say if a test should have been ordered for her or not because I can't remember the specific situation. Moving R3 to a private room immediately would have decreased her chances of spreading it to others. The policy titled, Infection Control - Interim Policy Addressing Healthcare Crisis related to Human [MEDICAL CONDITION], dated [DATE] documents Outcome Surveillance: Infection Preventionist will track all residents with fever and/or respiratory symptoms and utilize the laboratory testing algorithm to determine if these individuals should be considered a person under investigation. Any trends or patterns will be evaluated and addressed as deemed appropriate. Residents with known or suspected COVID-19 should be cared for in a single person room OR cohorted with another positive COVID-19 patient (this does not include PUI) with the door closed. The resident should have a dedicated (not shared) bathroom. The resident that is a PUI or confirmed positive will be assessed at least every 4 hours; This assessment should include but is not limited to: full set of V/S - B/P, pulse, temperature, respirations, and oxygen saturation %; respiratory assessment - lung sounds, presence or absence of cough, sputum production, shortness of breath; Physician or Nurse Practitioner should be notified immediately of any change in condition; dedicated or disposable noncritical resident-care equipment. The CDC guidelines advise Resident with new-onset suspected or confirmed COVID-19: Ensure the resident is isolated and cared for using all recommended COVID-19 PPE. Place the resident in a single room if possible pending results of [DIAGNOSES REDACTED]-CoV-2 testing - Cohorting residents on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected residents (e.g., residents who have fever, for example, due to a non-COVID-19 illness could be put at risk if moved to a COVID-19 unit). If cohorting symptomatic residents, care should be taken to ensure infection prevention and control interventions are in place to decrease the risk of cross-transmission; If the resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit.

Based on interview and record review the facility failed to prevent a staff member from using inappropriate language and tone while talking to 1 of 3 sampled residents, R1. Findings include: On 8/18/10 at 1:45pm via telephone Z1(power of attorney for R1), said that on 7/5/10 R1 was in the dining room and needed to use the bathroom. Z1 said that he inquired which certified nurse aide was providing care for R1. Z1 said that he was told E4(certified nurses aide), was resposible for caring for R1, and that she was on break. Z1 said they waited about 10 minutes and E4 came and told Z1/R1 that she was on break and would there in a minute. Z1 said that they waited another 10 minutes, and E4 did not come. Z1 said that he took R1 back to the room so she would be close to the washroom when E4 arrived. Z1 said that when E4 arrived to the room to provide care for R1, E4 was very irate. Z1 said that E4 took R1 to the washroom and after about 1 or 2 minutes he heard E4 hollaring at R1. Z1 said that E4 was yelling out at R1 about "you made me cut my break short to take you the washroom, and you don't have to use it." Z1 said that he had to intervene because he said that he felt that E4 was disrespecting R1, and that R1 could not defend herself. Z1 said that he told E4 not to hollar or yell at his wife. Z1 said that E4 was out of control and staff tried to intervene but E4 kept yelling. Z1 said that E4 was verbally abusive to R1 and was hollaring and screaming at him. Z1 said that E4 was as abusive to the nursing staff as she was to R1/Z1. On 8/18/10 at 12:30pm via telephone E3 (nurse) said on 7/4/10 that Z1 approached her regarding R1 wanting to use the washroom and wanted to know who was the certified nurse aide caring for R1. E3 said that she informed Z1 that E4 was the aide for R1. E3 said that she was coming down the hall and heard E4 yelling and came in R1's room and observed E4 yelling and screaming at Z1. E3 said that she tried to get E4 out of the room, but E4 kept yelling and talking inappropriately to Z1 and being insubordinate to E3. E3 said that after separating E4 from R1's room, she returned and Z1 told her that E4 was yelling at R1 about asking to go the washroom, but did not use it when E4 took R1 there. E3 said that she attempted to notify E2 (director of nursing) of the incident and said that E2 told her that E4 already texted her about it. E4 said that E2 refused to listen to the details of E4 verbal abuse toward R1/Z1. On 8/11/10 E5 (nurse), said that she was leaving the building, but heard E3 calling E4 out of R1's room. E5 said that she heard E4 yelling but cannot recall who E4 was talking to or what E4 was yelling about. E5 said that she does recall E3 directing E4 to the nurses' station. E5 said that she heard from E3 that E4 was being disrespectful to R1/Z1. E5 said that she recalled notifying E2 on Monday 7/5/10. On 8/11/10 during the daily status meeting E2 said that she was aware of the incident of involving E4. E2 said that on 7/4/10 E4 texted her phone about the incident that occurred between E4 and R1/Z1. E2 said that E5/E6 did mention the incident on Monday 7/5/10. E2 said that she did not investigate the incident as verbal abuse, but thought it was a personality conflict. E2 said she did not talk to Z1 regarding the incident reported to her from E5/E6. On 8/18/10 during the daily status meeting, E1 said that she did not investigate the allegations or incident because E2 was responsible for following up the incident. According to the facility's abuse policy "verbal abuse" is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents, within their hearing distance regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include but not limited to threats of harm saying things to frighten a resident.