Every finding on record at Aperion Care Niles

Based on observation, interview, and record review the facility failed to ensure the expired multi-dose vial of tuberculin test was removed and discarded affecting 44 residents currently residing on 2nd floor.Findings Include: On 5/26/2026 at 6:48 AM on 2nd floor medication refrigerator a multi dose vial of tuberculin test with date expired on 5/11/2026. On 5/26/2026 at 6:51 AM V4 (Licensed Practical Nurse) said expired medications should be discarded and not kept in the refrigerator. The tuberculin multi dose vial has an opened date of 4/12/2026 and date expired of 5/11/2026. Vial should be removed and discarded.On 5/27/2026 at 9:30 AM V2 (Director of Nursing) stated all expired medications should be removed, discarded, and not kept in the refrigerator.Policy and ProcedurePolicy Title: Storage of Medications, no datePolicy: Medications and biologicals are stored, safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Procedures:8. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner.

Based on observation, interview and record review the facility failed to implement infection control practices during medication administration affecting 4 of 7 residents (R39, R8, R77, R72) observed for medication pass for total sample of 19.Findings Include:On 5/26/2026 at 8:05 AM - 9:30 AM during medication administration V6 (Registered Nurse), V7 (Licensed Practical Nurse), and V8 (Registered Nurse) all failed to clean and disinfect their personal blood pressure (BP) machine between each residents used. V6 checked and measured BP for R39 prior to medication administration then proceeded to R8 also measured BP using the same blood pressure machine without cleaning and disinfecting. V7 measured BP for R72 and did not clean and disinfect BP equipment after using. V8 measured blood pressure for R77, cleaned the BP machine but did not disinfect according to manufacturer's recommendation.On 5/26/2026 V6, V7, and V8 said blood pressure machine and cuff should be cleaned and disinfected between each residents used.On 5/26/2026 at 8:05 AM - 8:25 AM V6 completed medication pass for R39 and R8 without performing hand hygiene before and after medication administration. V6 said hand hygiene should be performed before and after each medication administration.On 5/27/2026 at 9:20 AM V2 (Director of Nursing) stated staff may use their personal blood pressure machine provided it is clean and disinfected between each residents used. Staff should perform hand hygiene before and after medication administration. V2 said the facility does not have policy for cleaning and disinfecting medical equipment such blood pressure equipment.Policy and ProcedurePolicy Title: Medication Administration General Guidelines, no datePolicy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration).Procedures:Preparation2. Handwashing and Hand Sanitization: The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly: a. before beginning a medication pass b. prior to handling any medication c. after coming into direct contact with a resident

Based on observation, interview and record review the facility failed to provide a dignity cover for a indwelling urinary catheter for one of two residents (R72) reviewed for indwelling urinary catheter in a sample of 19. Findings include:On 5/26/2026 at 10:30am this surveyor observed R72 in bed with her indwelling urinary catheter bag hanging on the side bed as you walk in the door from the hallway, with 400cc of urine and no privacy cover. On 5/26/2026 at 10:40am V7(Licensed Practical Nurse-LPN), observed with the surveyor R72 indwelling urinary catheter bag on the side where the door is located to hallway, filled with of 400cc of urine and no privacy cover.On 5/26/2026 at 10:45am V7 said the urinary catheter bag should have a privacy cover if it is by the door to the hallway.On 5/27/2026 at 9:40am V2(Director of Nursing-DON), said all urinary catheter bags should have a privacy cover if they are on the side of the door by the hallway.A resident information sheet indicates R72 is alert and oriented times three, non-ambulatory history of falls, and pressure ulcers, retention of the urine presence of urogenital implants, an order summary dated 5/28/2026 order dated 10/24/2025 for monitor urinary catheter output change catheter tubing every month, foley catheter care every shift, 16 French millimeter balloon 30cc to gravity for neurogenic bladder and irrigate with 100cc of normal saline.Facility Policy: Revised 4/23/2018-DignityGuidelines: The 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. The facility shall consider the residents' lifestyle and personal choices identified through the assessment processes to obtain a picture of his or her individual and preferences.Refraining from practices demeaning to residents such as leaving catheter bags uncovered, refusing to comply with a resident's request for bathroom assistance during mealtimes, and restricting residents from use of common areas open to general public.

Based on interview and record review, the facility failed to implement the restorative program recommendation for one (R77) of six residents reviewed for restorative program in the sample of 19.Findings include: On 5/27/2026 at 2:32 PM, V17 (REHAB DIRECTOR) said that V17 is familiar with R77. V17 said that R77 was under PT, OT, and Speech therapy from 3/3/2026 to 4/29/2026. V17 said that R77 was originally on her Part A USC insurance, and she was cut off. V17 said that the facility requested Part B of R77 insurance to continue therapy. V17 said that R77 part B insurance approved 6 sessions of PT and OT each. V17 said once those sections were completed, the insurance did not approve additional therapy sessions. V17 said that R77 was discharged from PT/OT and recommended that R77 continue with restorative program. V17 said that prior to R77 discharge from therapy, R77 was able to walk 50 feet with moderate assistance. On 5/28/2026 at 10:52 V17 said that after discharging a resident from therapy program, the restorative director is made aware of the restorative recommendation within 1 week of the resident discharge. V17 said that R77 recommendation was not communicated to the restorative department because V17 was aware of discussion regarding R77 discharge plan. V17 said that it is not necessary to hand over written documentation to restorative department because during the IDT weekly meeting, therapy gives reports on all the residents and discusses the functional level and their GG coding. On 5/28/2026 at 10:00 AM, V18 (Restorative Director) said that R77 was in PT and OT therapy upon admission. V18 said that while making rounds, V18 was having a general conversation with R77 to find out how R77 was doing with therapy sessions. V18 said that R77 informed V18 that her therapy session was completed. V18 said that V18 approached V17 and inquired if there are any residents that therapy department has recommended for restorative program. V18 said that V17 handed V18 R77's restorative program recommendation on 5/21/2026 which was the same day R77 was discharged . V18 said that V18 went and assessed R77 immediately. V18 said that V18 only assessed R77 based on therapy recommendation. V18 said that R77 was able to transfer from bed to wheelchair and from wheelchair to toilet.On 5/28/2028 at 12:52 PM, V2 (DIRECTOR OF NURSING) said that the facility conducts IDT meetings every morning from Monday to Friday. V2 said that both physical therapy and restorative therapy are in-house, and they both attend the meetings. V2 said that physical therapy will discuss residents that are recommended to be followed by restorative program. V2 said that physical therapy department was supposed to endorse the recommendation to the restorative department stating what program the resident should engage in.R77 is a [AGE] year-old female admitted into the facility with original admission date of 3/2/2026. The physician admission note dated 3/2/2026 at 16:08 PM, indicated that R77 was admitted for short-term stay rehabilitation following acute right pontine CVA with functional decline and recent fracture. R77 has a diagnosis not limited to primary hypertension, type 2 diabetes, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R77 physical therapy discharge summary indicated that R77 therapy session ended on 4/29/2026 and recommendation was made for R77 to continue with restorative program for bed mobility, passive, and range of motion.Restorative Nursing Program:Effective Date: 11 - 28 - 2012Department: Nursing RestorativePurpose:-To promote each resident's ability to maintain or regain the highest degree of independence as safely as possible.

Based on observation, interview, and record review the facility failed to follow facility guidelines in gastrostomy management care for one (R1) resident in the sample of 19 reviewed for gastrostomy management. Findings include:On 5/26/26 at 9:35 AM, Observed R1 gastrostomy syringe/piston hanging on pole with date 5/24/26.On 5/26/26 at 9:38AM, V6 (Registered Nurse) said that all syringes are to be changed daily by night staff, V6 checked date on syringe with date on it 5/24/26. On 5/27/26 at 11:55AM, V2 (Director of Nursing) made aware of above findings and said that she expects staff to change irrigation syringe on a daily basis.Facility Policy on Gastrostomy Tube-Feeding and Care revised 8/3/20Purpose: To provide nutrients, fluids and medications as per physician orders, to residents requiring feeding through an artificial opening into the stomach. 13. Feeding tube syringes and irrigation containers are to be changed every 24 hours.

Based on observation, interview, and record review the facility failed to conduct daily refrigerator temperature checks inside the resident's room to ensure proper temperature and food safety. This deficiency affects two residents (R10 and R84) in the sample of 19 reviewed for Resident safe food storage. Findings include:On 5/26/26 at 9:25AM, observed R10 personal refrigerator with no daily temperature checks recorded for 5/26/26 and missing daily temps, inside refrigerator with two milk cartons with expiration date 5/26/26.On 5/26/26 at 9:25 AM, V9 (Certified Nurse Aide) said that usually the temperatures are checked daily and recorded, V9 verified no temperature was recorded for R10 refrigerator and milk carton with expiration date 5/26/26. On 5/26/26 at 9:30AM, observed R84 personal refrigerator with no daily temperature checks recorded for 5/26/26 and missing daily temps, inside refrigerator with container of cut watermelon, and food container with ground meat not labeled or dated. On 5/29/26 at 10:41AM, V2 (Director of Nursing) said that refrigerators should be checked daily for temperature and recorded, all food brought in by family should be checked by nursing staff for appropriate diet, food stored in refrigerator should be labeled and dated. Facility Policy on Food Items Brought from Outside revised 6/13/19.Guidelines:Food (s) brought to a resident by a family/visitor will be permitted with authorization.4. Any food brought in is checked by nursing or food service. Food must be in a plastic container with a tight lid. It is recommended that only enough food be brought in for that visit. 5. Food stored must be labeled with the resident's name and dated. Facility Policy on Refrigerator and Freezer TemperaturesGuideline: To ensure all perishable foods stay fresh and palatable, temperatures will be recorded an all refrigerators and freezers in use, including unit refrigerators located in nourishment rooms. Procedure:Dining services will be responsible for taking temperatures on all kitchen and nourishment room refrigerators and freezers, and recording temperatures on temperatures report logs daily, during each shift. Corrective actions are taken as necessary to insure only safety stored foods as served to residents.

Based on observation, interview and record review the facility failed to ensure a person-centered comprehensive care plan was implemented for one of three residents (R72) reviewed for care plan interventions in a sample of 19. Findings include: On 5/29/2026 at 11:30am this writer was unable to locate a comprehensive care plan for R72's indwelling urinary catheter care.On 5/29/2026 at 11:38am V2(Director of Nursing-DON) said all residents with catheters should have a comprehensive care plan with interventions, staff placed a care plan in today for urinary catheter care. On 5/29/2026 at 12:07pm V18(Restorative Director) said it should be a care plan in place. A resident information sheet indicates R72 is alert and oriented times three, non-ambulatory history of falls, and pressure ulcers, retention of the urine presence of urogenital implants, an order summary dated 5/28/2026 order dated 10/24/2025 for monitor urinary catheter for pressure ulcers, monitor output change catheter tubing every month, foley catheter care every shift, 16 French millimeter balloon 30cc to gravity for neurogenic bladder and irrigate with 100cc of normal saline.Facility Policy: Baseline Care Plan revision 11-17-17Purpose: To develop a baseline care plan within 48 hours of admission to direct the team while a comprehensive care plan is developed that incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being. Guidelines:Upon admission, the admitting nurse will initiate the development of the baseline care plan as part of the admission assessment. The baseline care plan will continue to be developed by the interdisciplinary team and be completed within 48 hours of admission. The resident and or their representative shall receive a summary of the baseline care plan prior to completion of the comprehensive care plan that includes:- the initial goals of the resident- a summary of the resident's medications and dietary instructions- any services and treatments to be administered by the facility and personnel acting on behalf of the facility- any updated information based on the details of the comprehensive care plan, as necessary. The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan is developed within 48 hours of admission.

Based on observation, interview, and record review, the facility failed to follow their policy and procedures for safe and sanitary food by not ensuring resident's personal refrigerator temperatures were consistently monitored and accurately documented, failed to ensure that food stored in resident's personal refrigerators were stored and labeled properly, and failed to ensure that staff remove old and expired food items from resident's refrigerators. These failures affected four (R23, R40, R56 ad R80) of four residents reviewed for food safety. Findings include: [DATE] at 11:39 AM V2 (Director of Nursing) said that the Assistant Director of Nursing checks the temperature in the refrigerators in residents' rooms and they are documented in the temperature log attached to the refrigerator. Staff is supposed to document the temperature in the log when it is checked and that is the standard procedure. Regarding the items inside the refrigerator, there are assigned staff for different rooms who are supposed to check and make sure there are no expired items in the refrigerator. [DATE] 02:00 PM V3 (Licensed Practical Nurse) said that she is the one that documented the temperature in the refrigerator logs in resident's rooms. V3 said she made a mistake and documented a temperature before it was checked and that was not the right thing to do. [DATE] 10:13AM V13 (Dietary Manager) said that she oversees checking the refrigerator in six rooms on the second floor, she usually checks them whenever she is here on Mondays to Friday and on Sunday once every six weeks. The refrigerator is supposed to be checked every day to make sure that there is no expired food, that the temperature is okay, and that the food is appropriate for the resident's diet. V13 said that she checked one of the rooms on Friday and did not see any expired food. V13 stated that she is not sure what happens when she is not here or if anyone checks the refrigerators. V13 also said that all food items in resident's refrigerator should be labeled, as well as food brought from outside. Fresh fruits like banana or orange can be put in a container or plastic bag and labeled. Any food item not labeled can be thrown out after some days. Facility policy for food brought from outside revised [DATE] states in part: food brought to a resident by a family/visitor will be permitted with authorization. 4. Any food brought in is checked by nursing or food service. Food must be in a plastic container with a tight-fitting lid. 5. Food stored are labeled with resident's name and dated. 1.) On [DATE] 11:10AM, while conducting random observation on the second floor, noted the refrigerator in R56's room with the documentation of a temperature reading from [DATE] to [DATE] at 6:00AM. R56 stated that staff do not check the refrigerator every day, sometimes the temperature log will not be filled for days and one day someone will come and fill the whole spot with some numbers. Surveyor found the same documentation in four other rooms on the second floor, including in R23 and R80's rooms. On [DATE] at 9:34 AM surveyor observed R56's refrigerator contained multiple foods in containers with no labels or date and an orange outside of a container and without any labeling. On [DATE] at 10:40AM, R56 was observed being walked in the hallway by the restorative aide, he stated that he is doing okay today. Surveyor checked resident's refrigerator and noted several food items with no label or date on them. The temperature log was also noted with the temperature documented the previous day, 38.6, actual reading on [DATE] was 40 degrees. 2.) [DATE] at 9:45AM, the documented temperature on the log from the previous day remained the same in all the rooms. Surveyor checked the refrigerator in R23's room and noted the following items: 3 cartons of 2% milk with the following dates: [DATE]. [DATE] and [DATE]. 1 carton of 2% milk with no date on it,1 glass of juice with no date and 2 cups of pudding that were open with no cover. The puddings were all caked up with some brownish fluid at the bottom. Surveyor presented this observation to V7 (Certified Nursing Assistant/CNA) who was assigned to the room. V7 said that staff are supposed to check the refrigerators, it is not okay for residents to have expired food items in the room and the items are supposed to be labeled with resident's name and dated. 3.) [DATE] at 9:55AM, surveyor also found 1 carton of 2% milk in R80's refrigerator that was dated [DATE] and some slices of pizza wrapped in a [NAME] wrap with no name or date on the pizza. Resident's temperature log remained the same from the previous day, 38.1, actual temperature reading was 40. 4.) On [DATE] at 12:35 PM surveyor observed R40's refrigerator temperature log documented temperatures for [DATE] through [DATE]. On [DATE] at 9:34 AM surveyor observed R40's refrigerator temperature log unchanged from the previous day.

Based on observation, interview, and record review, the facility failed to ensure that proper hot water temperatures were maintained in one shower room (Second Floor East Wing). This failure has the potential to affect 22 residents that currently reside on the Second Floor East Wing. Findings include: Per facility census report received during this survey, there are currently 22 residents residing on the second-floor east wing and have access to the shower room. On 3/2/2025 at 11:15AM, R46 said the water in the shower room does not get hot enough even when it is turned as far as it goes. Sometimes I do not want to take a shower because it is too cold. On 3/2/25 at 11:30AM, V6 (Certified Nursing Assistant) said the one shower room does not get very hot. I know maintenance has tried to fix the temperature in the past, but it remains the same temperature. Second Floor East Shower room was observed with V6. V6 ran the water for around five minutes. This surveyor and V6 felt the water to not get very warm. V6 said it will not get any warmer than this. On 3/3/2025 at 11:45AM, V12 (Maintenance Director) said the water temperatures should be between 100-110 degrees Fahrenheit. V12 checked the water temperature in the second-floor shower room with a thermometer which ranged between 90-95 degrees Fahrenheit. Facility policy titled Bathing - Shower and Tub Bath with revision date of 1/31/2018 states in part but not limited to the following: The purpose is to ensure resident's cleanliness to maintain proper hygiene and dignity. Turn on water and ensure that water is at a comfortable and safe temperature. Temperature should be 100-110 degrees Fahrenheit.

Based on interviews and record reviews, the facility failed to follow their policy and procedures for psychotropic medication administration by not ensuring a gradual dose reduction evaluation was performed quarterly for a resident receiving psychotropic medications. This failure applied to one (R82) of five residents reviewed for unnecessary medications. Findings include: R82 is a [AGE] year-old male with a diagnosis history of Cognitive Communication Deficit, Generalized Anxiety Disorder, Insomnia, and Partial Paralysis due to Stroke who was admitted to the facility 05/17/2024. R82's current physician orders include active orders effective 05/17/2024 for half of 150mg tablet of Trazodone (antidepressant/sedative and SSRI inhibitor) to be given by mouth at bedtime for sleep and three 125mg for Depakote/Divalproex (Anticonvulsant) capsules by mouth three times a day for anxiety. R82's current care plan initiated 05/18/2024 includes interventions for cognitive loss/dementia. R82's care plan initiated 05/20/2024 documents he is receiving sedative/hypnotic therapy including trazadone (sedative) for insomnia. R82's care plan initiated 05/18/2024 documents he has a mood problem related to anxiety, & dementia with interventions including administer medications as ordered, monitor/document for side effects and effectiveness, and Behavioral Health consults as needed (psycho-geriatric team, psychiatrist etc.). R82's February and March 2025 Medication Administration Records documents he received Depakote and Trazadone as ordered daily. R82's Physician Progress Note dated 03/04/2025 documents he was evaluated by the psychiatrist on 05-25-2024 and does not include a GDR (Gradual Dose Reduction) assessment or determination. R82's medical records and psychiatric progress notes from admission to current do not include an assessment for a gradual dose reduction. On 03/05/25 at 02:02 PM V2 (Director of Nursing) stated Gradual Dose Reductions are supposed to be performed with resident's quarterly reviews and they are either deemed not in the best interest of the resident or they are attempted. V2 stated or we try to perform a gradual dose reduction if by a resident's behavior it's determined psychotropic medications are no longer needed and we attempt to reduce the dosage. V2 stated there is only one psychiatric progress note available for R82. The facility's Psychotropic Medication/Gradual Dose Reduction Policy received 03/05/2025 states: The purpose of the policy is To ensure that residents are not given psychotropic drugs unless psychotropic drug therapy is necessary to treat a specific or suspected condition as per current standards of practice and are prescribed at the lowest therapeutic dose to treat such conditions. Residents who use psychotropic drugs shall receive gradual dose reductions and behavior interventions unless clinically contraindicated, in an effort to discontinue or reduce the medication. A gradual dose reduction shall be encouraged at least twice yearly unless previous attempts at reduction have been unsuccessful, or reduction is clinically contraindicated.

Based on observation, interview, and record review, the facility failed to use a low air loss mattress in accordance with manufacturer guidelines, for a resident with a facility acquired, Stage 4 pressure ulcer. This failure applied to one (R3) of three residents reviewed for pressure ulcers in a sample of 33 residents. Findings include: R3 is an alert and oriented [AGE] year-old with diagnoses including but not limited to chronic obstructive pulmonary disease, asthma, heart failure, anxiety disorder and presence of a cardiac pacemaker. On 3/2/25 at approximately 9:50 AM, R3 was observed asleep in bed atop an air mattress and in a supine position (laying on his back) with his upper torso raised. On 3/4/25 at approximately 9:50 AM, R3 was observed on his backside but was awake. Surveyor asked how he was doing and R3 responded that he was fine but that his back hurt and mentioned that the bed was very uncomfortable. Surveyor asked if he made the nurse aware and if he obtained medications for his pain and R3 responded that he did. Observations of the bed showed a bed pump with 8 green lights but with no markings to designate their significance, however the bed mattress appeared to be raised up in a concave (hump) manner. On 3/4/25 at approximately 10:05 AM, R3 was observed during wound care by V10 (Wound Nurse) and V18 (Certified Nursing Assistant/CNA) who assisted. V18 turned the resident to his right side to reveal the wound to show to the surveyor. V10 removed the wound dressing which revealed a very large and deep hole on R3's left buttock. V10 described the pressure ulcer and stated, (R3) first developed this last year around November 2024 as a DTI (deep tissue injury) because the resident was noncompliant with incontinence care. I don't have the exact measurements, but I'd say it's about 4.9 centimeters (length) by 2.8 (width) by 3.2 centimeters deep. Undermining is about 3.1 centimeters and there is no tunneling. Surveyor asked R3 during the treatment if what V10 said was true and that he was not compliant with incontinence care, R3 stated, No that is not true. They always come in when it's convenient for them like when I'm trying to rest or sleep or when I'm not even wet and I would know if I was wet. Surveyor asked when he asks for staff to come back at a later time, if they do, R3 stated, Sometimes but mostly they don't. They've talked to me about this, and I've explained to them that what I want is some flexibility, but they seem to keep doing what is convenient for them and not honor my requests. Surveyor asked if he was ever explained or shown his care plan to heal his wound, R3 stated, No. Surveyor asked if he was made aware of his care plan showing his resistance to care, R3 stated, I have never seen that or been told that. I don't resist care. I just want to be changed when I asked to be changed or when I'm actually wet and not when it's convenient for the nurses. When I call for someone to change me, it takes so long for someone to come, but when they do come, it's whenever its convenient for them like I said. There were times, when I asked to be changed and I'm told the CNA is on their break. Why can't some other CNA come, you tell me? (R3 getting upset). Surveyor later asked V10 if R3's requests for CNAs to return when the resident was actually in need of changing were reasonable requests. V10 affirmed it was and indicated that R3's behavior improved and was better complying. MDS (Minimum Data Set) assessments dated 5/12/23, 8/12/23, 11/12/23, 2/12/24, and 5/12/24 all show no behaviors of resistance to care. Only until after the formation of R3's deep tissue injury on 7/8/24 does the MDS assessment dated [DATE] and consecutive MDS assessments thereafter show R3 with behavior of rejection of care occurring 1-3 days. V3 (Assistant Director of Nursing/ADON) and V10 (Wound Nurse) was asked to comment on these assessments, and both indicated they did not do the MDS assessments. After the wound treatment observation, V10 was shown the air mattress pump and was asked how the pump functioned, V10 indicated she was not aware of how the mattress pump functioned and that V12 (Maintenance Director) was solely responsible for applying the mattress when ordered and adjusting the mattress pump settings. Surveyor clarified if she was the wound nurse in charge of all wounds. V10 stated, Yes I am in charge of wounds, but I always just call V12 for the mattress and he puts the mattress on the bed. Surveyor asked what the green lights meant, and which green light was turned on. V10 said, It looks like the 5th light is on, but it's supposed to designate the weight of the resident and that's how it should be set with the resident's weight but there's no numbers on these lights to show what it's for, but I will ask V12. On 3/4/25 at 10:20 am surveyor questioned the maintenance director about his role with the air mattress application. V12 stated, We get them from storage we bought from company. I install the mattress on the bed, and I connect the pump. Surveyor asked how much pressure he sets the mattress to. V12 said, around 200 pounds to 250 pounds, maybe 300 for a heavy patient. Sometimes the nurse put on setting, sometimes the CNA. Surveyor asked if he was trained on how to apply the appropriate settings for the specialty air mattress. V12 said, No, but sometimes it's just a little button to adjust it and I adjust it to see how it looks. Surveyor clarified if he adjusted the mattress by sight only. V12 said, Yes, I look at it and I touch it too. It's like kicking a tire and if it's hard enough it's ok. Surveyor clarified again so the other surveyors heard what he stated. V12 stated, It's like kicking a tire but I don't know if it's exactly right, so I just do it too by touching the mattress to see if it's hard enough. Surveyor requested to obtain copy of the air mattress pump/mattress manual. Manual titled Alternating pressure and low air loss mattress replacement system with defined Perimeter reads in part, Weight setting buttons (=) and (-). The weight setting buttons can be used to adjust the pressure of the inflated cells based on the patient's weight. As the weight setting increases, the pressure level indicator lights up (green) with each added level of pressure. Eight pressure lights are available and indicated by increasing green light indicator. On 3/4/25 at 12:21 PM, surveyor returned to observe R3 with V3 (ADON). R3 was laying on his backside and with no appearance of any positional changes except for earlier wound observation. Surveyor asked V3 about the air mattress pump to ensure its accurate functioning. V3 stated, Yes it's fine, it looks like it's on. Surveyor asked what the lights on the pump meant and how she knew the pump was fine. V3 stated, I don't know, there's nothing on the pump but lights. I don't do anything with these beds or pumps. It's just V10 and V12's responsibility not mine. Surveyor asked if she was the assistant director of nursing and if V10 was under her supervision, V3 responded, No. I am not responsible for her. On 3/4/25 at 12:45 PM, V2 (Director of Nursing/DON) said (in the presence of survey team), I recommend residents who need to be on the air mattresses along with V3 (ADON) and V10 wound nurse. We own our own mattresses and don't rent them so (V12) puts them in position on the bed. He sets the pump and makes sure the motor works and inflates. He services them if there is an issue. Surveyor asked if V12 knows how to apply the appropriate inflation settings. V2 stated, I believe he should know how to inflate them to coincide with the resident's weight or he'll ask the nurse. Surveyor asked if there was any in-service training on how to operate the air mattresses and pumps. V2 stated, There was no in-service done. On 3/4/25 at 1:15 PM, V10 (Wound Nurse) clarified with surveyor that the light turned on R3's pump was designated to be for a 280-pound resident. Surveyor asked R3's weight. V10 stated, He's around 165 to 170 but he's never been that heavy. Surveyor asked if R3 was always on the same weight setting since he obtained the mattress over a year ago. V10 said, I think so. Surveyor asked what impact a wrong setting of too much inflated mattress could do. V10 stated, It can cause pressure on the wound. The wound can get worse with an inaccurate setting because the weight matters and the mattress is not going to sink. The mattress will be a little more pressure will increase pressure on the wound. Records showed R3 to be at 167 lbs. on 10/1/24; 169 lbs. on 11/1/24; 170.6 lbs. on 12/2/24; 173 lbs. on 1/3/25; 169 lbs. on 2/1/25 and 165 lbs. on 3/4/25. On 3/4/25 at 1:34 PM V19 (Wound Doctor) said, I've been seeing him (R3) awhile for probably several months and when I was gone there was a wound NP (Nurse Practitioner) that took over, but I just saw the resident last week. R3's wound to his buttock and I diagnosed it about 250 days ago. At the time he was having debridement (surgical removal of necrotic dead skin). I gave all the orders on how to resolve the wound and yes I ordered the offloading air mattress. Surveyor asked the importance of a properly inflated mattress. V19 said, Well it is one component in the treatment of this wound, which is multi-modal including turning and repositioning, nutrition, but it can impact other factors include albumin of 2.9 and anemia. R3's albumin ranged from about 3.8 range, and he had some behavior and anxiety issues which also affected it and reluctance of care, fear of falling out of bed. As for the albumin levels during this time, it ranged from around 3.9 at the highest down to 3.7. He had some weight loss from around 206 to 169 pounds and fecal incontinence. Surveyor asked if the pressure setting on the mattress should be adjusted to the weight loss. V19 said that it should but repeated that it is only part of a multi modal treatment and other factors he mentioned that impacted healing. On 3/4/25 at 3:00 PM, V2 (DON) later returned to the conference room to inform the survey team that R3's mattress was removed and replaced with a properly functioning mattress. R3's pressure ulcer care plan revised 10/3/24 reads in part (but not limited to), I have a potential for impairment to skin integrity related to immobility, incontinence, and refusal of care. I have pressure ulcer on left buttock. Goal: I will not develop alteration in skin integrity. Interventions: Assess/record changes in skin status. Avoid positioning in affected wound area. Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Keep skin clean and dry. Use lotion on dry skin. Low air loss mattress. Minimize pressure over bony prominences. Protective skin barrier cream as ordered. Turn and repositioning q 2 hrs. and as needed. Facility wound prevention policy revised 1/15/2018 titled Pressure Ulcer Prevention reads in part, To prevent and treat pressure ulcers/pressure injury. Maintain clean/dry skin during hygiene measures. Inspect the skin several times daily during bathing, hygiene, and repositioning measures. Change bed linen per schedule and whenever soiled with urine, feces, or other material. Turn dependent resident approximately every two hours or as needed and position resident with pillow or pads protecting bony prominences as indicated. Pressure reducing mattresses are used for all residents. Specialty mattresses such as low air loss, alternating pressure, etc. may be used as determined clinically appropriate. Specialty mattresses are typically used for residents who have multiple stage 2 wounds or more Stage 3 or Stage 4 wounds.

Based on interview and record review, the facility failed to follow R1's plan of care to provide supervision with meals (eating), ensure R1's assistive mobility device was within reach and ensure R1 was wearing appropriate footwear. R1 who is high risk for falls, was left in the room unsupervised. R1 had a fall incident on 11/13/24 that resulted in subdural hematoma. This past noncompliance occurred from 11/13/24 to 11/15/24. The findings include: R1's Admission record documented initial admitted on 7/12/22 with diagnoses not limited to Other osteomyelitis upper arm, Type 2 diabetes mellitus, Atherosclerosis of coronary artery bypass graft(s), Cognitive communication deficit, Difficulty in walking, Unspecified protein-calorie malnutrition, Metabolic encephalopathy, History of falling, Nontraumatic acute subdural hemorrhage, Essential (primary) hypertension, Solitary pulmonary nodule, Contusion of right front wall of thorax, Other dysphagia, Latent tuberculosis, Hyperlipidemia, Unspecified glaucoma. MDS (minimum data set) dated 11/13/2024 showed R1's cognition was moderately impaired. R1 needs supervision or touching assistance with eating; Substantial / maximal assistance with chair / bed and toilet transfer. On 1/12/25 At 11:40am V9 (REGIONAL NURSE CONSULTANT) informed surveyor that facility created a past noncompliance for R1's fall incident on 11/13/24 and binder was presented to the surveyor. V9 said R1 was identified as high risk for fall, the RCA (root cause analysis) has been identified, and the action plan and plan of correction were in place. On 1/12/25 At 11:45am V2 (DIRECTOR OF NURSING / DON) stated she investigated the fall incident of R1 on 11/13/24 and reported to state agency due to diagnosis of subdural hematoma. V2 said R1 came back from an appointment with son and was served her meal in her room. V2 said fall might have been prevented if R1 was placed by nurse's station or dining room for close supervision. V2 stated R1 was identified as high risk for falls. No surgery was done in the hospital and R1 was readmitted to the facility on [DATE]. On 1/12/25 at 12:48pm V13 (Licensed Practical Nurse / LPN) said he has been working R1 and was the nurse during the fall incident on 11/13/24. He said R1 went out for appointment with son and went back to the facility. V3 said she was served dinner in her room because it was late already. V13 said he was informed by V15 (Certified Nursing Assistant / CNA) that R1 was on the floor. V3 stated he was on the 2nd floor at the time of R1's fall incident. When he was informed, he immediately went to the 3rd floor and saw resident laying on the floor. V13 said there was food sitting on the table. He said walker was farther away from the bed and close to the closet. He said R1 got up from the wheelchair, lost her balance and fell . V13 said there was indication that R1 hit her head against the floor because of the bruise and skin tear on forehead. He Informed the doctor and R1 was transferred to the hospital. V13 stated R1 was admitted in the hospital with diagnoses of subdural hematoma. He stated he can't remember if R1 was toileted, did not check if R1 was wearing a proper footwear. V13 said R1 was high for fall, if R1 was placed near the nurse's station and if walker was accessible or within reach to R1 then fall might have been prevented. On 1/12/25 at 1:11pm V14 (Certified Nursing Assistant / CNA) stated has been working with R1 who can speak minimal English. He said he was working with R1 on 11/13/24. R1 came back from out on pass and was served dinner in her room. V14 said R1 was sitting up in wheelchair, call light was within reach and instructed to call for help. V14 stated he went for his break and was informed that R1 fell and was about to be transferred to the hospital. V14 stated R1 would usually eat in the dining room, and she is high risk for fall. V14 said if resident was placed in the dining room, by the nurse's station, or if R1 had called for help, the fall might have been prevented. On 1/12/25 at 1:59pm V15 (Certified Nursing Assistant / CNA) stated she had worked with R1 but was not the assigned CNA during the fall incident on 11/13/24. V15 said she heard R1 was moaning or something, saw R1 laying on the floor on her stomach , face down with a bruise and some blood on the floor. She said nurse was informed immediately. V15 stated I don't believe R1 had any shoes on because I saw her shoes on the floor. R1 was wearing socks and might have slid. V15 stated R1's walker was by the radiator/ closet and not accessible to the R1. V15 said R1 is high risk for falls. V15 said she is always eating in the dining room. If the resident was in the dining room ,closer to the nurse's station, or maybe if R1 was using a proper footwear, the fall might have been prevented. On 1/12/25 at 2:37pm V3 (ADON / Assistant Director of Nursing) stated has been working in the facility since 2015. V3 stated she was informed by the nurse that R1 fell and had Bruise and skin tear on forehead. V3 said R1 was transferred to the hospital with a diagnosis of a subdural hematoma. She said the initial report was sent to state agency. V3 stated R1 is high risk for falls. The fall could have prevented, if R1 was place in common area like dining room or nurse' station for close supervision. Care plan date initiated on 2/24/23 documented in part: R1 at High risk for falls related to weakness. History of falls on: 5/17/2023, 12/19/2023, 7/15/2024, 11/13/2024. Care plan interventions included but not limited to: R1 to use walker. Ensure R1 is wearing appropriate footwear when ambulating. Care plan date initiated 1/18/24 documented in part: R1 have an ADL self-care/ mobility performance (functional abilities) deficit. Eating: R1's usual performance is supervision. Fall-initial occurrence note dated 11/13/24 documented in part: R1 had an un-witnessed fall in resident room on 11/13/2024 8:00 PM. Forehead bruised. Nurses Note dated 11/14/2024 showed in part: confirmed R1's hospital admission with Admitting Diagnosis: SUBDURAL HEMORRHAGE. R1's CT (computer tomography) head wo contrast result dated 11/13/24 documented in part: Impression: Stable narrow caliber interhemispheric acute subdural hematoma. R1's hospital records by V5 (HOSPITAL PHYSICIAN) history and physical notes dated 11/14/24 documented in part: R1 with mechanical fall in the nursing home. Was found on the floor, fall was unwitnessed. Frontal head contusion and bruising along the left hand and wrist. CT head with slim interhemispheric acute subdural hematoma. R1 is somnolent and complaining of neck pain. Waking up on and off on sternal rub and going back to sleep. Could not answer any of the subjective answer. V4 (Nurse Practitioner / NP) progress note dated 11/20/24 documented in part: R1 was readmitted to the hospital 11/13-11/17 due to a fall, unwitnessed. R1 was found to have interhemispheric SDH (Subdural hematoma). Facility's incident report dated 11/19/24 documented in part: R1 was last observed sitting in wheelchair eating her dinner, stood up, lost her balance, and fell to the floor. R1 had bruise and skin tear on the front / middle of the forehead and was sent to hospital with diagnosis of Subdural Hematoma. Facility's fall prevention policy dated 11/21/17 documented in part: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the Individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Assistive devices such as walkers and canes will be placed within reach of those residents. The resident will be reminded as needed to call for assistance before attempting to ambulate. Residents who require staff assistance will not be left alone after being Footwear will be monitored to ensure the resident has proper fitting shoes and / or footwear is non-skid. Prior to the survey date of 1/12/25 the facility took the following actions to correct the deficient practice. Surveyor did observation, interview and record review and found the following action plans in place: 1. R1 was supervised by staff every 15 minutes and placed by the common area for close monitoring. R1's log monitoring every 15 minutes from 11/17/24 to 1/11/25. 2. R1 was evaluated by therapy upon readmission on 11/17/24. 3. V2 (DON) and V3 (ADON) in-serviced all staff on the facility's fall policy and individualized interventions. 4. Care plans updated with new interventions. 5. Fall assessment was completed upon readmission on 11/17/24. 6. R1 had no further fall after incident on 11/13/24. 7. V2 (DON) and V3 (Assistant Director of Nursing) stated that they discuss fall and interventions at morning meeting with IDT (interdisciplinary team). 8. Facility did a wide audit to ensure high risk residents care plans and interventions are up to date. 9. The facility's Quality Assurance Committee has monitored compliance through the daily and weekly internal Quality Assurance process. QA tool from 11/18/24 to 1/10/25 reviewed.

Based on observation, interview and record review, the facility failed to effectively monitor a newly admitted resident and follow the facility practice of leaving doors open for residents identified to be at risk for falls. This affected one of three residents (R1) reviewed for safety and monitoring. This failure resulted in R1 being found on the floor. R1 was sent to the local hospital and treated for a laceration that required 2 staples, and 6 sutures in frontal scalp laceration and 1 staple left superior lateral scalp laceration. Findings include: R1 had an unwitnessed fall on 3/23/24. Facility Reported incident dated 3/24/24 reads in part: R1 was self-transferring, call night not on, resident found lying on the floor behind the door. Final Report Summary: R1 was admitted to the hospital for unwitnessed fall. R1 received staples to head for laceration to be removes in 7-10 days. After review of resident's medical record and staff interviews, it has been identified that R1 did not call for help when she transferred from the bed and fell on the floor. R1 was observed sleeping prior to the fall. R1 is nonverbal at baseline and could not say what happened. R1 has diagnoses of but not limited to: Parkinson, Anxiety, Insomnia, and cerebral infarction. R1 has a care plan for high risk for fall related to confusion and actual fall due to poor balance dated 3/25/24. R1 has a baseline care plan for risk for falls dated 3/23/24. On 5/15/24 at 1045AM, V10 (Certified Nursing Assistant/CNA) stated she did her rounds beginning of her shift. V10 started in the room closer to the nurse's station and work her way down the hall. As V10 went closer to R1's room, approximately around 11:25 to 11:30PM, the door was shut and V10 tried to open the door, and V10 was having a hard time opening the door (like something was blocking the door). V10 continued to try to open R1's door and pushed it hard enough with V10 strength and then found the resident on the floor. Called and informed the nurse. As we enter, R1's bed is bed one and the one closer to the door. The blue floor mat was also blocking the door, R1 was on top of the mat, and the mat moved and blocking the door and so it was hard to open. Part of her body was on the mat and the head was off the matt and touching the floor. V10 saw blood, and the blood was not pure red, and it was not fresh, it was already dry and brown. Blood stain did not look new, it looked like it been there for a while. V10 informed V9 (Night Shift Nurse) and V7 (PM shift Nurse) were in the nurse's station charting. V9 came right away. After V9 saw R1, and then V7 went to check on R1 also. On 5/15/24 at 11AM, V9 (Nurse) stated that V10 reported to V9 that V10 cannot fully open the door of R1 because R1 was lying on the floor. V9 went and help V10 to fully open the door, both cannot open fully so both slide themselves into the bedroom slightly opened, and found blood on R1 in the head area, on the floor. R1 was away from the floor mat and the bed, lying behind the door like one or two step away from R1's bed. It was a resident blocking the door. Blood was a little bit dry and thick. It was coagulated at the time, Saline solution 4x4 gauze. And after cleaning the site, it started oozing a little bit and so V9 applied pressure. At this time V9 already called 911. R1's blood on the floor was described by V9 as semi liquid, coagulated blood on the floor. 911 came and transferred the resident to the hospital. Fire Department report dated 3/23/24 reads in part: dispatched to a nursing home for a head injury. Upon arrival the crew met a [AGE] year-old female, awake but nonverbal which was her norm. R1 was lying on her side on the floor. The staff stated the fall just happened but unwitnessed. The crew noted dried blood on R1 and the floor. The staff said they bandaged her head right before we arrived. The crew noted a 1-inch laceration with bleeding controlled on the crown of R1's head. On 5/15/24 at 12PM V11 (Paramedic) stated that all V11 can remember what was documented in their report, and it was documented that staff reported the incident just happened, but it was odd because the blood looked dry on R1 and on the floor. Hospital record on 3/24/24 at 12:35AM at ER notes reads in part: large stellate laceration frontal scalp, a second posteriorly. Per EMS, the nursing home stated the fall occurred just prior to their arrival but the patient has dried blood in it appears she may have fallen earlier. She found lying next to the bed just to the side of the pads that were placed near the bed. Hospital record reviewed and documented on 3/24/24 at 3:44AM under laceration repair documentation that R1 had 2 lacerations, on top and back of the head. Frontal scalp 4cm length and 2mm depth. 2 sutures and 6 staples. 1 cm laceration to left superior lateral scalp. On 5/15/24 at 10:45AM, surveyor went to previous room of R1. The door swing opens to the right, bed located at the right side of the wall, bed against the wall. With the door slightly open, the person passing by cannot see a full visual of a resident located in bed one (right side, bed against the wall). For someone to have a good visual of a resident that stays in bed one, the door must be fully open, or for a person to enter/peek the head into the room. On 5/15/24 at 12:50PM, V2 (Director of Nursing) stated that R1 was a hospice resident. V2 asked the nurse how badly the injury was to R1, and the nurse said it was pretty significant wound and was having a hard time to control the bleeding. Instructed to send the resident out to the hospital and then to contact the Nurse Practitioner, grandson, and hospice. V2 expectation is for staff to leave the door open for closer observation of any residents in the unit. To have visual contact and to make sure the mat is in place and bed in lowest position for those who are at risk for fall. V2's expectation is hourly monitoring and as often as possible on a new admission and for at risk for fall residents, and especially those who can't verbalized their needs. Door needs to be open. Staff cannot fully visualized if the door is not fully open. If partially open, we can only see if someone is on the floor. At risk resident needs to have their door fully open. Only resident who has preference and not at risk for fall can have their door shut closed. Fall Prevention Program policy with a revision date of 11/21/17. Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Program will monitor program to assure ongoing effectiveness. The admitting nurse and assigned CNA are responsible for initiating safety precautions at the time of admission. All assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained. Nursing personnel will be informed of residents who are at risk of falling. The fall risk interventions will be identified on the care plan. The resident will be 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 and the plan of care.

Based on observations, interviews, and record reviews, the facility failed to: 1. wear a hair restraint to cover a beard while in the kitchen, 2. ensure hand soap was available at the hand washing sink in the kitchen, 3. maintain sanitizing solution buckets at 200 ppm (parts per million) of Quaternary Ammonium solution for sanitizing kitchen surfaces and dishes in the three compartment sink, 4. maintain sanitizing solution in the low temperature chemical sanitizing dishwasher at ,d+[DATE] ppm (parts per million) of Chlorine solution for sanitizing kitchen dishware and utensils, 5. cover, date, and label prepared desserts in the refrigerator, and a bag of fish while stored in the freezer, 6. ensure staff are properly trained how to clean the kitchen, 7. perform hand hygiene prior to putting on gloves to prepare food and maintain infection control, 8. follow the recipe with exact measurements during food preparation, and 9. ensure food handler certificates were renewed for staff in a timely manner. This failure has the potential to affect 87 residents who received oral meals from the facility's kitchen and 23 of the residents who consume the Korean meals. Findings include: On [DATE] at 11:06 AM, upon entrance to the kitchen, V8 (Dishwasher) was observed with a full beard standing near the food prep line stacking clean food trays. V8 was not wearing a beard protector. V8 was inquired of not wearing a beard protector. V7 (Dietary Manager) entered the kitchen. V7 was inquired of V8 not wearing a beard protector while handling clean food trays. V7 said, V8 is a dishwasher, but he should have a beard cover on. V7 told V8 to put on a beard protector in English and handed one to him. V7 said, V8 doesn't speak much English. I don't remember his language. I use Google translate to talk to him. On [DATE] at 11:10 AM, surveyor approached the hand washing sink to perform hand hygiene. There was no soap in the soap dispenser at the sink. V18 (Cook) said, I used the last bit of soap. V7 (Dietary Manager) was inquired of the person responsible for checking the soap levels for the hand washing sink. V7 said, Everyone should be checking the soap. V7 was inquired of the importance of the soap at the hand washing sink. V7 said, They need the soap for cleanliness, infection control, and proper hygiene. On [DATE] at 11:19 AM This surveyor asked V7 (Dietary Manager) to test the sanitation buckets in the food preparation area. V7 was inquired of the sanitation solution used. V7 said, We use Quat (Quaternary) in the buckets. On [DATE] at 11:21 AM, V7 dipped the sanitation test strip into the sanitation bucket #1 across from the stove area. The test strip color read at the 100 ppm (parts per million). V7 was inquired of the test strip reading. V7 said, It should be at least 200 (ppm). On [DATE] at 11:22 AM, V7 dipped the sanitation test strip into the sanitation bucket #2. The test strip color read at the 0 ppm. V7 was inquired of the test strip reading. V7 said, It should be at least 200 (ppm). I'll have them change these buckets. On [DATE] at 11:23 AM, V9 (Dishwasher) was observed washing the cooking pans at the 3-compartment sink. V7 was asked to test the sanitation of the 3-compartment sink. V7 dipped the sanitation test strip into the sink area labeled sanitize. The test strip color read at the 0 ppm. V7 was inquired of the test strip reading. V7 said, It should be at least 200 (ppm). V7 began adding more sanitizing solution to the sink area. On [DATE] at 11:25 AM, V9 (Dishwasher) was inquired of checking the sanitizing solution in the 3-compartment sink. V9 said, I push the button by the sink 3 times. V9 was not able to explain how to check the sanitizing solution in the 3-compartment sink. On [DATE] at 11:30 AM, V7 was inquired of testing the sanitation of the single rack dish washing machine and the type of washer it was. V7 said, It uses chlorine. V7 put a sanitation strip on the dish rack and ran it through the dish washing cycle. The sanitation strip read at 25 ppm. V7 was inquired of the strip reading. V7 said, It should probably be around 100. I'll tell maintenance to check it or have them call the supplier. On [DATE] at 11:36 AM, review of the refrigerator identified a full cart of desserts uncovered. V7 was inquired of the desserts. V7 said, Those are cups of apple pie for lunch today, they should be covered. On [DATE] at 11:40 AM, review of the freezer identified an open bag of Tilapia fish with no open date. V7 was inquired of the bag of fish. V7 said, It's a bag of fish, it should be closed, dated, and labeled. The Korean meal had fish for dinner last night. On [DATE] at 12:14 PM, during lunch observation on the second-floor residents are being served lunch on kitchen dishware plates, coffee cups, juice cups, and utensils. The kitchen did not provide disposable dishware due to the dishwashing machine found to be out of acceptable range for the chemical sanitizing concentration. On [DATE] at 10:13 AM, V8 (Dishwasher) took the mop over to the dish washing sink sprayer and sprayed water on the mop. V8 wrung out the mop and began mopping the floor. V7 (Dietary Manager) observed V8's action. V7 was inquired of the correct procedure to mop the floor. V7 said, V8's supposed to use the bucket and the cleaning solution to mop the floor. V8 does not to appear to know the mopping procedure. V7 attempted to demonstrate how to use the mop and bucket to V8. On [DATE] at 10:39 AM, V17 (Cook) is preparing the Omu rice and cucumber salad for the Korean lunch. V17 cleaned the food preparation table with a red kitchen towel she wet with water at the food preparation sink. She threw her gloves into the garbage. She went over to the food preparation sink and rinsed her hands with water. V17 then picked up another red kitchen towel and dried her hands off with the towel and placed it onto the food preparation table. V17 did not perform hand hygiene at the handwashing sink and put the used kitchen towel she dried her hands on onto the food preparation table while preparing a meal failing to maintain infection control. On [DATE] at 10:43 AM V17 (Cook) is using a disposable plastic spoon to measure spices. V17 left the spoon in one spice container and continued preparing the dish. Then removed the spoon and used it to dispense a different spice from another container. V17 is not using appropriate measuring spoons to measure spices for the recipe. V17 is using the same spoon to dispense spices from two different containers. On [DATE] at 10:47 AM, V17 removed gloves from her hands, then picked up the red kitchen towel on the food preparation table and wiped her hands with it. V17 set the towel back on the food preparation table and put on a new pair of gloves. On [DATE] at 10:50 AM, V17 removed gloves from her hands, went over to the food preparation sink, and rinsed her hands with water. V17 picked up the red kitchen towel on the food preparation table and wiped her hands with it. V17 set the towel back on the food preparation table and put on a new pair of gloves. V17 began touching multiple surfaces then went to the food preparation sink and picked up cucumbers from a colander rinsing them with water. V17 did not perform hand hygiene at the handwashing sink and put the used kitchen towel she dried her hands on onto the food preparation table while preparing a meal failing to maintain infection control. On [DATE] at 11:14 AM, V23 (Social Services) assisted V17 (Cook) with Korean translation during interview with surveyor regarding food preparation concerns. What is the food preparation sink should be used for? V17 responded and V23 translated and said, Preparing and washing food. Is it appropriate to rinse or wash your hands in the food preparation sink? V17 responded and V23 translated and said, When I came in to work, I used the hand wash sink and washed my hands. When I rinsed the vegetables, I took off my gloves and rinsed my hands. No, I shouldn't wash them here, I should use the hand wash sink. Is it appropriate to use the kitchen towel to dry your hands and put the towel back on the food preparation table? V17 responded and V23 translated and said, I tried to dry my hands. I know I shouldn't use the towel, No. How should spices be measured appropriately? V17 responded and V23 translated and said, I used a spoon. V17 picked up a plastic spoon from under the food preparation table storage area to show this surveyor. V17 did not know she was to use measuring spoons to measure the spices for the recipe. Is it appropriate to leave a spoon inside a spice container? V17 responded and V23 translated and said, I was making two dishes, but I needed the same spices, so I put it in their temporarily. When gloves are removed from your hands what should be done? V17 responded and V23 translated and said, If something contaminates the gloves, I should wash my hands in the hand wash sink. V7 (Dietary Manager) is present during V17's interview and was inquired of V17's food preparation concerns. V7 said, V17 knows to use the hand washing sink and not to use the towels for her hands. She shouldn't put the towel on the table, it's for infection control. She knows to put it in the bin. V17 is supposed to use measuring spoons to measure the spices. On [DATE] at 11:45 AM, review of the food service certificates found 5 staff with expired certificates. V19 Cook, V20 Cook, V21 Cook, V22 Dietary Aide, and V18 Cook. V7 (Dietary Manager) was inquired. V7 said, Yes, I know some of them are expired. On [DATE] at 12:58 PM, V7 (Dietary Manager) was inquired why disposable dishware wasn't provided for the lunch meal on [DATE] when the dishwasher chemical sanitizing solution read 25 ppm. V7 said, No reason. We did use it for dinner. When was the dishwasher serviced? V7 said, It was done Tuesday ([DATE]) by an outside company. The Dining RD Guideline & Procedure Manual 2020 Hair Restraints Policy states in part: Guideline: Hair restraints shall be worn by all dining services staff when in food production, dishwashing, and serving areas. Procedure: 1. Staff shall wear hair restraints in all food production, dishwashing, and serving areas. 2. Hair restraints, hats, and/or beard guards shall be used to prevent hair from contacting exposed food. Facial hair is discouraged. Any facial hair that is longer than the eyebrow shall require coverage with a beard guard in the production and dishwashing areas. The Dining RD Guideline & Procedure Manual 2020 Sanitizing and Disinfectant Solutions Policy states in part: Guideline: Employees shall refer to the manufacturer guidelines for the proper use of sanitizer and disinfectant solutions. Procedure: 1. The employee will prepare sanitizer solution or disinfectant solution in accordance with manufacture guidelines. 2. If a dispensing system is used, appropriate concentration level will be tested at least daily. 3. If a solution must be prepared, guidelines for preparation will be posted or available to staff. The staff member will prepare the solution in accordance with posted or available instructions and test with a test tape/strip before use. 5. Bleach solution should be at a concentration of greater than or equal to 50 to 100 ppm or in accordance with label instructions for other types of sanitizers. 6. This solution can be used for sanitizing equipment and food contact surfaces. All rags used for sanitizing must be kept submerged in sanitizing solution when not in use. The Dining RD Guideline & Procedure Manual 2020 Cleaning Instructions: Floors states in part: Guideline: Floors will be kept clean and sanitary, washed daily or as needed. Procedure 2. Floors will be washed daily, using hot water and detergent: a. Fill designated mop bucket with hot water and detergent. b. Place wet floor signs around the selected area to be mopped. c. Dip mop into detergent solution, and mop one section of the floor at a time. d. If the floor is exceedingly dirty, allow solution to sit prior to mopping. e. Mop in a figure eight motion, apply pressure on the top of the mop. f. Allow the floor to air dry. The Dining RD Guideline & Procedure Manual 2020 Food Storage (Dry, Refrigerated, and Frozen) Policy states in part: Guidelines: Food shall be stored on shelves in a clean, dry area free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. Procedure: 1. General storage guidelines to be followed: a. All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. See dated marking guidelines in this section for exceptions to dating individual dry storage food items. The Dining RD Guideline & Procedure Manual 2020 Labeling and Dating Foods (Date Marking) Policy states in part: Guidelines: All foods stored will be properly labeled according to the following guidelines. Procedure: 3. Date marking for freezer storage food items. Once a package is opened, it will be re-dated with the date the item was opened and shall be used by the safe food storage guidelines or by the manufacturer's expiration date. The Dining RD Guideline & Procedure Manual 2020 Proper Hand Washing and Glove Use Policy states in part: Guidelines: All employees will use proper hand washing procedures and glove usage in accordance with State and Federal sanitation guidelines. Procedure: 6. Hands are washed before donning gloves and after removing gloves. 7. Gloves are changed any time hand washing would be required. This includes when leaving the kitchen for a break, or to go to another location in the building; after handling potentially hazardous raw food; or if the gloves become contaminated by touching the face, hair, uniform, or other non-food contact surface, such as door handles and equipment. 9. When gloves must be changed, they are removed, hand washing procedure is followed, and a new pair of gloves is applied. Gloves are never placed on dirty hands; the procedure is always wash, glove, remove, rewash, and re-glove. The Dining RD Guideline & Procedure Manual 2020 Dishwashing: Machine Operation Policy states in part: Guideline: The dining services staff shall maintain the operation of the dishwashing machine according to established procedure and manufacturer guidelines posted or contained in this guideline to ensure effective cleaning and sanitizing of all tableware and equipment used in the preparation and service of food. Procedure: 1. All dishwashing machine should be operated according to manufacturer recommendations. Tableware, utensils, pots, and pans should be cleaned and sanitized in either a high temperature dish washing machine that uses hot water, or a chemical sanitizing dish washing machine that uses a chemical sanitizing solution. 4. If the machine is found to be out of the acceptable range for either final rinse temperature or proper chemical sanitizing concentration, do not proceed to wash dishes. Empty dish washing machine, check nozzles and empty bottom screen and restart the dish washing machine. 5. After trouble shooting, if the dish washing machine is not functioning, the employee should contact the dining services manager or maintenance or outside vendor per facility guidelines to coordinate repair. The dish washing machine should be labeled out of service and not utilized until the dish washing machine is repaired. The Dining RD Guideline & Procedure Manual 2020 Standardized Recipes Policy states in part: Guidelines: Standardized Recipes will be used for all menu items, including pureed and therapeutic diets. Procedure: 1. Each standardized recipe will include the following: d. measurement and/or weight of ingredients.

Based on observations, interviews, and record review, the facility failed to follow standard infection control practices by not washing hands and not changing gloves while performing dressing change for 1 (R41) of 1 resident reviewed for pressure injury in the sample of 41. This failure may affect 10 resident who currently require dressing changes. Findings include: On 04/04/2024 at 11:30 AM V1 (Administrator) provided list of residents who require dressing changes, the list contains of 10 residents. R41 is an [AGE] year-old male admitted to the facility on [DATE] with diagnosis including but not limited to Paraplegia, Osteoporosis, Vascular Dementia, Hypothyroidism, Hypotension, and hypertension. According to R41's MDS (Minimum Data Set) section M dated 02/29/2024, R41 has one or more unhealed pressure ulcers/injuries. R41's care plan dated 10/19/2020 reads in part, Follow facility protocols for treatment of injury. R41's physician order dated 03/28/2024 reads in part, Left Lateral Leg: Cleanse wound with NSS (normal saline solution), Apply calcium alginate with silver topical, cover with layers of gauze, wrap with (brand name of gauze wrap) and secure with tape 3x per week. On 04/02/24 at 10:31 AM interviewed V27 (Licensed Practical Nurse/Wound Care Nurse) who stated in summary: R41 has left outer ankle pressure ulcer that's Stage 4 now, he acquired it on 12/24/2023. Recently, R41 developed infection in that wound that required antibiotic therapy. Order for wound care includes calcium alginate with silver, gauze, and (brand name of gauze wrap). The dressing is changed 3 times a week. We utilized an offloading device, but they were ineffective, so now we just use a pillow to elevate his legs. The wound has been stable. R41 also has an unstageable left calf pressure ulcer that was acquired in the facility as well. One of the offloading devices that was supposed to help with ankle wound, caused calf wound. On 04/03/24 at 12:44 PM observed R41 sitting up in the bed, set up to eat lunch. Pillow placed underneath his knees, heals resting directly on the bed mattress. Surveyor approached V35 (Licensed Practical Nurse/LPN) to inquire about R41 pillow placement, R35 stated in summary: I am the float nurse today, so I go between both facility units. The pillow should prevent R41's legs from crossing and his heels resting on the mattress. R41 moves a lot, so the pillow is not the best for him. We tried offloading device but R41 removes it too. On 04/03/2024 at 1:00 PM Surveyor asked V35 (LPN) to see R41's pressure injuries. V35 brought wound care cart into the room and prepared wound care supplies. V35 proceeded then to undressing R41's wound without performing hand hygiene, only donning gloves. V35 measured both wounds, applied treatment consisting of cleaning both wounds with wound cleanser, applying dressing containing calcium alginate with silver, putting gauze over it, taping gauze to the skin, and wrapping both wounds with (brand name of gauze wrap). V35 did not change gloves nor performed any sort of hand hygiene throughout dressing change procedure for both wounds. On 04/03/24 at 03:23 PM interviewed V4 (Assistant Director of Nursing) who stated in summary: Wound care, including dressing changes, are usually scheduled three a week. V27 (Wound care nurse/LPN) does it or me if V27 is not available. Floor nurses can help but it's V27's and my primary responsibility. Floor nurses are allowed to do wound care on acutely acquired wounds or when dressing gets soiled. Nurses are expected to follow physician orders, infection prevention, and resident rights while performing wound care. Infection prevention includes washing hands and wearing and changing gloves. Wound care cart should always stay outside of the residents' room. Before initiating dressing change, nurse should perform hand hygiene and put on gloves. They can then remove old dressing followed by removing gloves, performing hand hygiene, and placing new gloves on. Next, nurse should clean the wound, perform hand hygiene, and put new gloves on. Finally, nurse and can finish with a dressing change, and when done, they should perform hand hygiene. If at any point during wound care or dressing change, nurse touches contaminated area, they should perform additional hand hygiene and glove change. The facility Infection Prevention and Control Program policy dated 11/28/2017 reads in part, To comply with a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement. All facility personnel shall adhere to the Infection Control Program in the performance of their daily assignments.

Based on observations, interviews, and record review, the facility failed to provide feeding assistance in a dignified manner for 5 (R18, R33, R37, R44, R71) out of 5 residents reviewed for dignity in the sample of 41. Findings include: 1. R18 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including but not limited to Hemiplegia and Hemiparesis, Major Depressive Disorder, Malignant Neoplasm of Brain Aphasia, and Dysphasia. R18's care plan dated 11/14/2023 reads in part, The resident needs encouragement/support to be independent with eating. Allow the resident to feed self if desired, regardless of skill. On 04/02/24 at 12:40 PM observed V28 (Certified Nursing Assistant/CNA) assisting with lunch meal. V28 was standing while assisting R18 with feeding. 2. R33 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Parkinson's Disease, Dementia, Dysphagia, Anemia, and Major Depressive Disorder. R33's care plan dated 08/05/2021 reads in part, Feed slowly, stop for signs of choking and notify nurse ASAP. On 04/01/24 at 12:55 PM observed V32 (CNA) assisting with lunch meal. V32 was standing while assisting R33 with feeding. 3. R37 is an [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Hemiplegia, Abnormal Weight Loss, Major Depressive Disorder, Dysphasia, and anxiety disorder. R37's care plan dated 09/07/2022 reads in part, Provide assistance with food/liquid consumption as needed. On 04/01/24 at 01:00 PM observed V33 (CNA) assisting with lunch meal. V33 was standing while assisting R37 and R71 with feeding, feeding both residents simultaneously. 4. R44 is an [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Neurocognitive Disorder with Lewy Body, Psychosis, Depression, Barrett's Esophagus with Dysplasia, and Alzheimer's Disease. R44's care plan dated 10/20/2023 reads in part, Eating/Swallowing Program: Put resident in an upright position while sitting in (geriatric) chair during meals. Assist with opening condiments, monitor intake, and encourage resident to bring his head slightly forward and feed self, using verbal cueing during meal. Provide assistance with extensive assist of 1 staff. On 04/01/24 at 12:55 PM observed V31 (CNA) during lunch time. V31 was standing while assisting R44 with feeding. On 04/03/24 at 12:30 PM observed V25 (Registered Nurse) observed during lunch time. V25 was feeding R44 while standing up, feeding quickly, rushing R44 to swallow food. 5. R71 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including but not limited to Dementia, Anemia, Dysphagia, Anorexia, and History of Falling. R71's care plan dated 05/15/2023 reads in part, Provide necessary assistance with PO intake. On 04/01/24 at 01:00 PM observed V33 (CNA) assisting with lunch meal. V33 was standing while assisting R37 and R71 with feeding, feeding both residents simultaneously. On 04/03/24 at 12:40 PM interviewed V34 (Certified Nursing Assistant) who stated in summary: It's important to sit down and feed resident in sitting position to have face to face interaction. Also, sitting down allows you to ask if they like the food or not. I think it's also a rule to sit down while providing feeding assistance. On 04/03/24 at 03:23 PM interviewed V4 (Assistant Director of Nursing) who stated in summary: Staff providing feeding assistance to residents should be sitting down during entire mealtime. One of the reasons for providing feeding assistance while sitting down is to maintain eye contact, interaction, and safety, to make sure resident can swallow. It also makes residents feel more comfortable. The facility Contract between Resident and Facility. Attachment E: Statement of Residents Right (no date) reads in part, The right to live in an environment that promotes and supports each resident's dignity, individuality, independence, self-determination, privacy, and choice and to be treated with consideration and respect.

Based on observation, interview and record review, the facility failed to provide adequate nutrition, and follow dietary order for 2 (R18, R44) of 5 reviewed for nutrition in the sample of 41. Findings include: 1. R18 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including but not limited to Hemiplegia and Hemiparesis, Major Depressive Disorder, Malignant Neoplasm of Brain Aphasia, and Dysphasia. R18's physician order dated 02/29/2024 reads in part, General Diet. Mechanical Soft texture, Regular/Thin Consistency. R18's care plan dated 11/14/2023 reads in part, Encourage The resident's family members to bring in favorite food items from home or favorite restaurant items: [NAME] John's sandwich, sausage w/ onion pizza, pork sandwich. Give to dietary to ensure correct texture. R18's Nutrition Progress Note dated 03/04/2024 shows R18's current body weight at 92.2 lbs, BMI 15.8 (underweight) and 20.7% weight loss in 5 months. On 04/02/24 at 10:30 AM observed R18 observed, laying in the bed, appears emaciated. On 04/02/24 at 10:30 AM interviewed V27 (Licensed Practical Nurse/Wound Care Nurse) who stated in summary: The family brings R18 sandwiches. R18 is on mechanical diet, so we educated them, but they disregard our recommendations. R18 also needs assistance with feeding. On 04/02/24 at 12:38 PM observed R18's lunch tray placed and can of soda on the bedside table, in front of the R18, R18 asleep in the bed. R18' meal ticket reads in part, Mechanical Soft Diet, Thin Liquids. On 04/02/24 at 12:40 PM Surveyor V28 (Certified Nursing Assistant/CNA) come into R18's room. V28 offered lunch tray but R18 refused. V28 reached to R18's personal refrigerator and placed sandwich on the bedside table. R18 proceeded to eat the sandwich while V28 assisted with drinking soda and intermittently feeding supplemental frozen dessert. R18 able to feed self, eating sandwich and coughing periodically, observed having difficulty swallowing. Surveyor interviewed V28 who stated in summary: R18' family lives out of state, they order sandwiches from there and sandwiches get delivered to the facility. On 04/02/2024 at 01:15 PM Surveyor interviewed V29 (Registered Nurse) who stated in summary: R18's family says it's better for him to eat sandwich rather than nothing. But they don't see R18, so maybe it's hard for them to understand. R18 calls the family, tells them what he wants to eat, they order it, and it gets delivered to the facility. I educated the family that sandwiches are dangerous for him, and we have to assist him throughout the feeding, and we don't have enough staff to do that, but they don't understand that. On 04/03/24 at 11:15 AM Surveyor interviewed V30 (Dietitian) who stated in summary: R18 is on mechanical diet. Sandwiches provided by the family would not be appropriate as part of mechanical diet. Mechanical soft diet consists of sandwiches with soft lunch meat, no raw vegetables, and soft bread but and I don't know what's on the sandwiches that he eats on daily basis. On 04/03/24 at 11:50 AM Surveyor interviewed V7 (Dietary Manager) who stated in summary: R18 is on pureed food. Sandwiches provided by the family are not mechanically altered, so R18 can choke. If the sandwiches were delivered to me, and I could mechanically alter them, and make it safe for R18 to eat, but I wasn't aware that R18 eats sandwiches. 2. R44 is an [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Neurocognitive Disorder with Lewy Body, Psychosis, Depression, Barrett's Esophagus with Dysplasia, and Alzheimer's Disease. R44's physician order dated 06/23/2023 reads in part, Low Potassium Diet. Regular Texture, Regular thin liquids, consistency. Provide 1 plate in front of resident at a time during meals for improved PO intake. R44's care plan dated 10/20/2023 reads in part, I will eat enough nutrients during mealtimes. R44's Nutrition Progress Note dated 04/03/2024 shows R44's current body weight at 142.4 lbs, trending downward. On 04/01/24 at 12:55 PM observed V31 (CNA) feeding R44 with supplemental frozen dessert, no lunch tray offered to R44. Surveyor interviewed V31 (CNA) who stated in summary: R44 only eats ice cream or sweet stuff, she spits out regular meals, so we don't even try to offer it to her. R44 has been doing that for at least 2 months that I have been here. Nurses are aware. R44's meal ticket reads in part, Low Potassium/Thin Liquids/No Yogurt Pureed Diet; Pureed Turkey Tetrazzini, Pureed Parslide Bowtie Noodles, Pureed Buttered Corn, Pureed [NAME] Bread, Margarine, Pureed Apple Pie. On 04/01/24 at 01:09 PM interviewed V25 (Registered Nurse/RN) who stated in summary: R44 only eats ice cream because if we try to feed her other food, she spits it out. R44 only eats sweet treats like apple sauce, ice cream, or oatmeal w/sugar in the morning. When we see she has good apatite, we pour sugar over her plate, so she eats it. R44 has dietary supplements such as house nutrition supplement. R44 only likes to drink supplements but not water. On 04/03/24 at 11:04 AM interviewed V30 (Dietitian) who stated in summary: As of today, R44 does not display significant change in weight but there was gradual weight loss over the last 6 months. R44's diet is low potassium with house supplement three times a day and no yogurt. No yogurt is due to R44's preference. I was not aware that R44 doesn't eat her meals. Staff should document that R44 doesn't consume regular meals. If staff only gives supplemental frozen dessert, that what should be documented. Staff should be offering meal, even if R44 refuses to eat it. Nutritionally speaking, R44 won't be meeting her nutritional needs from consuming supplemental frozen dessert only. No progress note noticed in R44's electronic medical chart showing that R44 eats sweet treats only and not eating regular melas. On 04/03/24 at 11:43 AM interviewed V7 (Dietary Manager) who stated in summary: I have never heard that R44 refuses all meals. Staff should offer a meal; R44 must be offered a tray. R44 can eat what they prefer but sugary treats would not be a wholesome diet. Staff should not sprinkle sugar over R44's plate to encourage eating. There is no nutritional value in sugar. On 04/03/24 at 12:30 PM R25 (RN) observed feeding R44 during lunch time. R25 standing up, feeding quickly, rushing R44 to swallow. R44 covered mouth periodically; however, after multiple attempts of persistent cuing, R44 consumed supplemental frozen dessert, vanilla shake house supplement, and yogurt, despite no yogurt shown on R44's meal ticket. On 04/03/24 at 03:23 PM interviewed V4 (Assistant Director of Nursing) who stated in summary: Nurses and CNAs are expected to follow physician's order. It's important because it is quality of care of the resident. Physician place orders based on assessment, testing, and expertise, to come up with way to care for a resident. Nurses and CNA may have suggestions that they can communicate to a medical doctor; however, it is the doctor who makes sure all appropriate orders are carried out. The facility Diet Order policy (no date) reads in part, Each resident will have a diet order prescribed by the physician (or Registered Dietitian were allowed by State and Federal Guidelines) and documented in the health record. Diet orders are clearly communicated, using the designated diet order communication form, to Dining Services.

Based on observation, interview and record review, the facility failed to properly administer physician ordered continuous oxygen to an immunocompromised resident dependent on supplemental oxygen and monitor oxygen saturation level for 1 (R290) of 1 resident reviewed for oxygen therapy in sample of 41. Findings include: R290 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Hemiplegia and Hemiparesis, Progressive Leukoencephalopathy, HIV, Cytomegaloviral Disease, Acute Flaccid Myelitis, and Dependence on Supplemental Oxygen. R290's care plan dated 03/28/2024 reads in part, Monitor for s/sx (signs and symptoms) of respiratory distress and report to MD PRN: Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, Skin color. R290's Physician orders dated 03/28/2024 reads in part, Oxygen at 3LPM via N/C continuous every shift for Pneumocystosis. On 04/01/2024 at 01:28 PM observed R290 laying supine in the bed. Nasal Cannula observed to be laying around R290's neck, not inserted into R290's nostrils, not delivering oxygen. R290 noticed to be diaphoretic breathing at an increased rate. On 04/01/24 at 01:31 PM V25 (Registered Nurse/RN) entered R290's room. Surveyor pointed to R290's nasal cannula and asked if this is an accurate nasal cannula placement, wrapped around R290's neck, V25 denied and placed nasal cannula's prongs in R290's nostrils. Surveyor proceeded to interview V25 who stated in summary: R290's nasal cannula is off but when I came in earlier, around 10:00 AM, the nasal cannula was on. Surveyor asked how is R290's oxygen saturation monitored and whether it is important to monitor it for residents depending on continuous oxygen therapy. V25 stated: R290's oxygen saturation level is checked once per shift with vital signs. R290 is a critical care resident, so we have to monitor her oxygen saturation. R290 also has some abnormal breathing, so chest x-ray was done yesterday, and we are currently waiting for the x-ray results. Surveyor clarified if a resident has acute respiratory issue, should oxygen saturation level be monitored even closer, V25 agreed. On 04/01/2024 at 1:40 PM V25 (RN) left R290's room, obtained oxygen saturation measuring device, measure R290's oxygen saturation at 94%. Per 290's electronic medical record, last oxygen saturation level checked on 03/29/2024 noted to be at 96%. No documented oxygen saturation level found between 03/29/2024 and 04/01/2024. On 04/01/24 at 01:45 PM V25 (RN) stated: I will notify R290's nurse practitioner about the decreased oxygen saturation level. On 04/01/2024 at 2:00 PM interviewed V4 (Assistant Director of Nursing/ADON) who stated in summary: I think we should have order set for oxygen level monitoring for residents on continuous oxygen therapy. Residents like R290, would require vital signs, including oxygen saturation, check at least once every shift. I worked with R290 yesterday, and heard some wheezing when I assessed her, so chest x-ray was ordered. R290 definitely needs oxygen monitoring. On 04/03/24 at 10:55 AM interviewed V26 (Physician Assistant) who stated in summary: Resident requiring continuous oxygen therapy mostly require at least once a shift oxygen saturation level check. On 04/03/24 at 03:23 PM interviewed V4 (ADON) who stated in summary: Nurses and CNAs are expected to follow physician's order. It's important because it is quality of care of the resident. Physician place orders based on assessment, testing, and expertise, to come up with way to care for a resident. Nurses and CNA may have suggestions that they can communicate to a medical doctor; however, it is the doctor who makes sure all appropriate orders are carried out. R290's chest x-ray report dated 04/01/2024 reads in part, Findings: The lungs demonstrate patchy right-sided pneumonia. Oxygen Therapy policy not provided by V1 (Administrator) upon surveyor's request.

Based on interview and record reviews, the facility failed to follow its abuse policy and immediately report an allegation of physical abuse to the regulatory agency within two hours. This affected one of three (R1) residents reviewed for reporting allegation of abuse. Findings Include: On 1/23/24 at11:45AM, R1 stated that R1 reported to V1 (Administrator) the allegation of physical abuse by V7 (Registered Nurse/RN) to R1 via phone around 4 or 5am on 1/3/24. On the same morning, V1 came and talked to R1 in person. They also called the Police Department to report the incident. Facility reported incident report confirmation, reads that the incident was reported to regulatory agency on 1/3/24 at 11:39 AM. On 1/24/24 at 10:30AM, V1 stated that he was made aware by R1 about the abuse allegation probably around 5am on 1/3/24 via phone. The nurse called V1 and gave the phone to R1. V1 spoke to R1 and R1 reported an alleged abuse from V7. When asked if V7 was escorted out of the facility once the allegation was reported to V1, and V1 stated that V7 was not escorted out of the facility. V1 said that the third floor would not have had a nurse. It would have been maybe only an hour or so that V7 stayed in the facility. V1 stated that V1 is not in the facility 24/7 and did the best that V1 could with the situation. V1 stated that V1 was not in the facility to escort V7 out at that time and V1 wanted to make sure that other residents are being taking care of, and to have a nurse on the 3rd floor. V1 stated if there is a crime made, we have 24 hours to report it to the regulatory agency. I don't know what else to tell you. We have abuse policy, but I cannot tell you at this time what was exactly said in our abuse policy. Abuse Prevention and Reporting policy with a revision date of 10/24/22, reads 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. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment of residents. Any allegation of abuse or any incident that results in serious bodily injury will be reported to (regulatory agency) immediately but not more than two hours after the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours.

Based on interview and record review, the facility failed to follow their abuse policy and immediately remove the alleged staff from resident care. This affected one of three (R1) residents reviewed for abuse policy. Findings Include: On 1/23/24 at 11:45AM, R1 stated that R1 went to the third floor looking for someone who can assist him to look for his nurse. R1 went to the back by the med room and knocked, a male voice from the inside answer saying he is not the nurse but will look for my nurse. I just want to make sure, so I know who I was talking to, so I opened the med room door and found V7 (Registered Nurse/RN) inside. V7 stood up from a chair, kneed me with his right knee to my left knee and put his hands on my shoulder and pushed me away from the med room. I told him, take your hands off me. Stated that there were no other staff or residents witnessed the incident. V7 then went back inside the med room and R1 went back to his floor. I checked the 2nd floor med room. R1 reported the incident to V1 (Administrator) via phone around 4 or 5am, and same morning V1 came and talked to R1 in person, they also called the Police Department to report the incident. On 1/24/24 at 8:30AM, interview with V7 (RN) reported that V7 was made aware of the abuse allegation when V7 was already home on 1/3/24, after V7 completed his shift. V7 stated that he received a call from V1 (Administrator) informing him of the abuse allegation and that V7 will be suspended pending the investigation. V7 was scheduled to work on 1/2/24 (11-7 shift, night nurse). Timecard reviewed and showed that V7 clocked in to work that shift at 10:57PM and clocked out at 7:28AM. V7 was not on the schedule 1/3/24 and 1/4/24 due to the investigation. On 1/24/24 at 10:30AM, V1 stated that he was made aware by R1 about the abuse allegation probably around 5am on 1/3/24 via phone. The nurse called V1 and gave the phone to R1. V1 spoke to R1 and R1 reported an alleged abuse from V7. When asked if V7 was escorted out of the facility once the allegation was reported to V1, and V1 stated that V7 was not escorted out of the facility, that the third floor would not have had a nurse. It would have been maybe only an hour or so that V7 stayed in the facility. V1 stated that V1 is not in the facility 24/7 and did the best that V1 could with the situation. V1 stated that V1 was not in the facility to escort V7 out at that time. V1 wanted to make sure that other residents are being taking care of, and to have a nurse on the 3rd floor. V1 stated if there is a crime made, we have 24 hours to report it to the regulatory agency. I don't know what else to tell you. We have abuse policy, but I cannot tell you at this time what was exactly said in our abuse policy. Abuse Prevention and Reporting policy with a revision date of 10/24/22, reads 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. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment of residents. Employees of this facility who have been accused of abuse, neglect, exploitation, mistreatment, or misappropriation of property will be removed from resident contact immediately. The employee shall not be permitted to return to work until the result of the investigation have been reviewed by the administrator and it is determined that any allegation of abuse, neglect, exploitation, mistreatment, or misappropriation of property is unsubstantiated.

Based on observation, interview, and record review the facility failed to supervise a resident at high risk for falls for 1 of 3 residents (R1) reviewed for falls in the sample of 3. This failure resulted in R1 sustaining a fractured left hip from a fall. The findings include: R1's admission record shows he was admitted to the facility on [DATE] and readmitted [DATE] following a hospital stay from 7/9/23 to 7/13/23. The same document shows R1 to have multiple diagnoses including dementia, history of falling, and difficulty in walking. R1's care plan initiated on 3/25/23 documents he is a high risk for falls related to weakness and being non-compliant with using his walker during ambulation. R1's quarterly resident assessment and care screening of 7/4/23 shows he has severe cognitive impairment. The same assessment documents he requires extensive assist of one person for transfers between surfaces, walking in his room, and walking in the corridor. The facility's final incident report of 7/13/23 shows R1 was in the dining room for activities, attempted to transfer himself, lost balance, and slid to the floor in a supine position (face up). The report shows R1 sustained a left hip fracture. R1's nursing progress note of 7/9/23 documents at 2:35 PM, R1 was on the floor of the dining room, resident complaining of pain in back of his head, noted bump on back of head, left leg pain, no swelling, no change in ROM (range of motion), MD notified, and order for transfer resident to hospital. On 7/10/23, the notes show R1 was admitted to the hospital with a diagnosis of fall with left hip fracture. On 8/12/23 at 9:15 AM, V4 (Activity Aide) said he was working on 7/9/23, and R1 was present in the dining room. V4 said V5 (Certified Nursing Assistant/CNA) was assigned as the monitor and was to watch over the residents. V4 said while conducting activities he had witnessed R1 standing up from his wheelchair, caught him, and placed him back in his chair. V4 said he did not see R1 when he fell . V4 said R1 was a fall risk, and that is why he was in the group. On 8/12/23 at 9:40 AM, V5 (CNA) said she was in the dining room on 7/9/23, assisting another resident with bingo. She said R1 was in the dining room in his wheelchair, he had no pedals on the chair, and his was not able to propel himself. V5 said she was in the corner of the dining room, and was not watching R1, but she believes he was trying to get up on his own, and that is why he fell . She said that was why he needed extra supervision, because he tries to get up by himself. V5 said she did not see him attempting to stand prior to his fall, and V4 never reported to her R1 was trying to stand up on his own. V5 said if V4 had communicated with her regarding R1's attempts to get up, she would have changed what she was doing, or move to monitor him any closer. On 8/12/23 at 11:30 AM, V7 (Registered Nurse/RN) said when residents are at a high risk for falls, they are placed in the dining room and staff are assigned to watch over them. R1 was a high fall risk, he would try and stand and walk without assistance. V7 said R1 has dementia, and if he gets up once, he will do it again. She said staff should report to each other when a resident tries to get up, and staff should sit with them to ensure they do not fall. On 8/12/23 at 12:00 PM, V8 (Corporate Nurse) said residents are assessed for fall risk upon admission and fall prevention interventions are based upon their individual needs. She said residents with dementia are re-directed and require close monitoring. The high fall risk residents are placed in activities, and a CNA is to monitor them. If the aide leaves the room, the nurse will take over monitoring the room. V8 said if V4 saw R1 getting out of his wheelchair, he should have communicated that information to V5 so she could move closer to R1 and sit with him. On 8/12/23 at 9:00 AM, R1 was observed sitting up in a geriatric chair at the nurse's station. He had was alert and confused. He had no complaints of pain per the nurse translating for him while she was feeding him breakfast. The facility's 11/21/17 policy for fall prevention documents the purpose of the policy is to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized, as necessary.

Based on interview and record review, the facility failed to follow their policy and ensure that effective interventions were identified and implemented to prevent one resident (R49) of three residents reviewed in a sample of 19 from falling. The facility also failed to ensure that all staff are aware of fall risk status and interventions. This failure resulted R49 falling and suffering an injury to her head that required three staples. Findings include: Review of R49's final incident report dated 6/7/2023 documents resident was found sitting on the floor by her bathroom door. Resident did not know the cause of the fall. Laceration found to the back of the head and resident was sent to the emergency room . R49 was diagnosed with a head laceration and received 3 staples. Review of R49's hospital discharge instructions dated 6/4/2023 document the following: diagnosis: Fall, Injury of head, and Laceration of scalp. Follow up in 10 days to have staples removed. On 6/14/23 at 9:40 AM with V19 (Director of Korean Service) interpreting, R49 states she doesn't remember the circumstances of the fall. Observed 3 staples in the back right side of R49's head. On 06/15/23 03:31 PM V27 (Registered Nurse/RN) states V27 doesn't think she (R49) can comprehend if you tell her something. V27 states that sometimes in the evening R49 gets up once or twice and comes to the nurse's station. V27 states that last week was the last time she saw R49 come from her room to the nurse's station without assistance. V27 states R49's gait is not stable. V27 states, R49 doesn't need to have assistance with ambulation. V27 states R49 does not speak English. V27 states she has not received communication from therapy about their recommendation for R49 assistance while ambulating. V27 states someone should communicate with evening shift the therapy recommendations. On 06/15/23 03:40 PM V21 (Certified Nurse Assistant/CNA) states on 6/4/2023 he was in another resident's room and heard a thump. V21 states, he came out and found R49 on the floor by her bathroom. V21 states R49 is very confused at times. V21 states the more confused R49 is the more she tries to move around. V21 states that R49 walks with supervision, no hand-on assistance. V21 states he is not sure if R49 understands them when they tell her things. V21 states he can redirect R49 and then later she will come out of her room again after redirection. V21 states he only redirects her when she comes out of the room. On 06/15/23 03:52 PM V6 (CNA) states R49 hates to sit. V6 states R49 likes to be out and moving. V6 states R49 was an elopement risk before the 6/4/2023 fall. V6 states she was not aware R49 was a fall risk before the 6/4/2023 fall. V6 states no one ever told her that R49 was a fall risk just an elopement risk and she was not giving R49 any assistance for ambulating before the 6/4/23 fall. V6 states R49 tries to get up to go to restroom or get up when she is hot. V6 states I don't think she really understands us, so they use gestures. V6 states she would gesture for her to use light; however, she never has seen the resident use the call light. V6 states, she doesn't believe R49 understands how to use the call light and is forgetful. V6 states that no one has ever directed her to frequently remind R49 to use her call light or call for help. On 06/15/23 10:56 AM V18 (Physical Therapy Director of Rehab) states they started seeing R49 on 5/15/23 after R49's elopement and they are working on balance, strengthening, and cognition for speech, ADL training and toilet transfer. V18 states, R49 was having balance issues. When she stood, she would fall back or sideways. V18 states, the week before the 6/4/23 fall R49 required one person touch assist with ambulation. V18 states they inform nurses what we recommend verbally. V18 states R49 is forgetful. V18 states, R49 would Definitely, forget to do the things we asked her to do. V18 states R49 is not safe ambulating alone as of 5/15/2023 until now. Review of facility's falls log documents five falls since October 2022 for R49. R49 fell on [DATE] (documented left arm fracture per progress notes), 11/25/22, 1/2/23, 4/1/23, and 6/4/2023. Review of fall assessments dated 1/6/23 and 4/1/23 documents resident was at risk for falls. Fall occurrence form dated 1/2/23 documents CNA saw resident falling backwards. Fall occurrence form dated 4/1/23 documents resident trying to transfer herself from chair and slid to the floor. R49's fall risk care plan documents the 1/2/23 fall intervention as follows: Remind patient on asking for assistance, frequent monitoring, and redirection. R49's fall risk care plan documents the 4/1/23 fall intervention as follows: Continue frequent monitoring and frequently reminding resident to ask for help. On 6/15/23 01:19 PM V2 (Director of Nurses) states R49 tries to get up on her own. V2 states that the interdisciplinary team including herself determine interventions after each fall. The facility's Fall Prevention Program policy dated 11/21/17 documents the following: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized, as necessary. Care plan incorporates: Identification of all risk/issue, addresses each fall, interventions are changed with each fall, as appropriate, preventative measures.

Based on interviews and record reviews, the facility failed to provide adequate supervision for a cognitively impaired resident assessed to be at high risk for elopement and failed to ensure the resident did not leave the facility without staff knowledge or supervision. This failure affected one (R3) of four residents reviewed for elopement risk and supervision. This failure resulted in R3 leaving the facility unsupervised. R3 was found by a bystander. R3 had fallen on the ground and sustained a right facial contusion which required hospital evaluation. The Immediate Jeopardy began on 5/14/23 when the facility failed to monitor R3, who was assessed to be at high risk for elopement, which resulted in the resident leaving the building unsupervised. V1 (Administrator) was notified of the Immediate Jeopardy on 5/25/23 at 10:43AM. The survey team verified by observations, interviews, and record review, that the Immediate Jeopardy was removed, and the deficient practice corrected on 5/24/23. Findings include: R3 is an [AGE] year-old, female, initially admitted in the facility on 11/03/2018 with diagnoses of Mild Cognitive Impairment of Uncertain or Unknown Etiology; Anxiety Disorder, Unspecified; and Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. R3's Wandering Risk Scale dated 03/16/23 scored 18.0 which means high risk to wander. MDS (Minimum Data Set) dated 04/05/23 documented that R3's BIMS (Brief Interview for Mental Status) score was 4, which means severe cognitive impairment. R3's Elopement Risk and Community Survival Skills assessment dated [DATE] recorded the following: 7.) Recommendations: Elopement risk decision. The resident presently appears to be: d.) At risk to elope and should be placed on the elopement risk protocol. A care plan for elopement is indicated. e.) Comments - high risk According to progress notes dated 05/14/23, R3 left the facility around 8:12 PM, unattended. Facility's Incident report dated 05/15/23 documented that R3 was last seen in her room at 7:45 PM resting comfortably with no signs and symptoms of distress or behaviors noted. The incident also indicated that when she was found missing, code pink was called immediately in the facility and search was made. R3 was seen outside on sidewalk; and was sent to the hospital for evaluation. Ambulance report dated 05/14/23, time stamped 7:55 PM, documented that R3 was found on the ground near a nursing home facility. She was seen a block away from the facility. A bystander stated R3 was crawling on the ground thus paramedics were called and R3 was then transported to the hospital. Per hospital records dated 05/14/23, it was recorded that R3 was brought in by paramedics after she was found outside facility, on the ground on all fours. R3 was disoriented, believed she was in her home country. Physical examination findings revealed that R3 sustained right facial contusion. Her hospital diagnoses were fall, initial encounter and facial contusion. She was discharged to the facility on [DATE]. V3 (Registered Nurse/RN) was asked on 05/22/23 at 12:30 PM regarding R3. V3 verbalized, she is alert, ambulatory, speaks her native language but confused. She walks back and forth in the hallway, goes to other residents' rooms. We always redirect her. She wanders a lot. During the day, I didn't see her use or touch the elevator. Exit doors are all working, one on the end of each hallway. V4 (RN) also mentioned during interview, she wanders, we do monitor her. She is usually in the dining room and walks back and forth in the hallways. I don't think she knows how to use the elevator. I did not see her use the elevator, open exit doors, or use the stairs during my shift. I am not aware the exit doors are not working. On 05/22/23 at 12:41 PM, R3 was observed in the dining room. R3 is ambulatory, able to verbalize needs but speaks foreign language. An interpreter is needed to communicate with R3. V20 (Activity Aide) acted as interpreter. R3 was asked what happened when she was found outside the facility and was brought to the hospital. R3 stated she does not know and doesn't remember any incident. Per V20, R3 has an impaired memory. R3 stated she goes from room to room to check up on something and arrange chairs and tables; picks up litter and puts aside television remotes. R3 said she does not know how to use the elevator. She also stated that exit doors have stop signs so no one can touch it and should not be used. R3 was also observed making several attempts to follow surveyor around but she (R3) was redirected by V20 to stay in the dining room. During interview with V7 (Certified Nursing Assistant/CNA) on 05/22/23 at 2:57 PM, he stated that R3 does wander on the unit but normally stays in the hallway. V7 added, from my experience with her (R3), she did not try to elope, she stays in the dining room. But when the dining room empties out with residents, she starts pacing back and forth in the hallway. I have not seen her attempting to use the elevators or exit doors. Exit door alarms were working at the time. On 05/14/23, I saw her around 7:15 PM to 7:30 PM and she was in the dining room. I was the one supervising residents at the time. I took my residents to their rooms and V19 (Agency CNA) came to supervise them. Later, V2 (Director of Nursing/DON) told me that she was missing. And she (V2) called the code for missing person. On 05/23/23 at 10:14 AM, V10 (RN) was also asked regarding incident on 05/14/23 regarding R3's elopement. V10 stated, on 05/14/23, I was working on the floor, but I didn't notice her that much because I was the floater that time. On 05/23/23 at 11:24 AM, V2 (DON) was asked about R3's incident on 05/14/23. V2 stated, on 05/14/23, I worked on the third floor, 3-11 shift. I was the nurse assigned to R3 that time. From 3 PM to 7 PM, she was in the dining room, she had her dinner. At 7 PM, she went to her room and went to sleep early. Around 7:45 PM, she came to the nurses' station, I asked and figured out what she wants. I gave her water, and she took it then went back to her room. Around 8 PM, I was starting to do my medication pass. I passed by in her room and noticed she was not there. I called CNAs (V7 and V19). She (V19) was on the East Wing and V7 was at the nurses' station. We all started looking for her (R3), room to room and we couldn't find her on the unit, so I went to go outside the facility. When I came outside, by the parking lot, a police car was parked in front. So, I came back inside and asked police why they were here. The police showed me R3's picture to confirm if she was a resident in the facility and was told that she (R3) was on her way to the hospital. I don't know who called paramedics. I called the hospital emergency room to give reports and asked police to submit her (R3) paperwork to the hospital. She came back later to the facility during the 11 PM to 7 AM shift. I couldn't figure out how she got out of the building, it happened so fast. She ambulates very well. That time, it was me, V7 (CNA) and V19 (CNA) on the floor. I was not sure if V10 (RN) was on the floor or on the second floor. It was a busy day, there were a lot of visitors before dinner time due to Mothers' Day. It kind of slows down after dinner. There were other family members still visiting other residents on that West wing where she (R3) resides. V2 was also asked about what interventions are implemented on R3 for supervision. V2 replied, prior to this incident, she was not monitored every 15 minutes. During the day, we keep her in the dining room, and she sits there the whole time. In the evening, she goes to bed around 7-7:30 PM. We do frequent rounding - could be every 30 minutes or every hour. We do it by opening doors and check on residents or answer call lights. She (R3) never tried to open exit doors. But she can open exit doors. I have never had any episode of elopement on her (R3), but she is an elopement risk. She is redirected all the time since she goes to other residents' rooms. We keep her (R3) in the dining room for activities. She was assessed as high risk for elopement and was placed on the elopement risk protocol. According to the protocol, her risk factors are cognitive impaired individual who is a follower. She is very nice to strangers, and she follows them around. Sometimes, when other residents' family members come around, she follows them and talks to them. Another risk factor is inability to differentiate safe from unsafe situations due to her Dementia diagnosis. We don't provide personal alarm or ankle bracelet; we did not do the 15 minutes to one-hour observations; and one on one observation on her (R3) prior to incident. That incident on 05/14/23 happened so fast and I have no idea how it happened. I kept asking myself. She walks very fast. On 05/23/23 at 10:35 AM, V13 (Social Services) was interviewed regarding R3 and elopement risk assessment protocol. V13 replied, we do the elopement assessment during admission and quarterly and anytime it happened. Assessing residents for risk factors for elopement and wandering. Once we identified a resident as high risk, we talk to IDT (interdisciplinary team) and let them know about the risk. Social Services do the care plan for elopement and wandering. Part of care plan interventions is to follow facility protocol. Facility protocol interventions includes faces of residents at risk posted by the staircase. Their faces are covered with paper, so staff must flip it to identify the residents. Other interventions include every 15-minute monitoring and a sheet for CNAs to sign; redirection; medications; activities; in services on staff about elopement. Everything on the elopement risk assessment protocol interventions should be implemented on each residents identified as wanderer including R3. R3 does not have an alarm on the arm but she should be provided with one on one. Usually, the one on one is implemented in the dining room that is why all residents high risk for elopement are placed in the dining area. After dinner time, residents are redirected to go into their own rooms. When they are in their rooms, one on one is still implemented by CNA or nurses who go to their rooms and make sure these residents stay in their rooms the whole time. CNA or nurses stay in residents' rooms also. R3 is alert most of the time but she does not remember things. She has a Dementia and confuse at times. She can go to her room by herself; use the bathroom by herself. She wanders around the unit, go to other residents' rooms and clean everything. She is ambulatory but unable to use the elevator or use exit doors and stairs. I have no idea how she got out of the facility. I was not working at the time it happened and off the following day too. I asked her on the day when I came back, and she does not remember. She was physically strong enough to push doors. Sometimes I went to her room, and I saw her pushing chairs and nightstands. I was assuming she was able to push exit doors and got out or that time it was Sunday and Mothers' Day, a lot of visitors came in the facility to visit other residents. She probably was able to join family in the elevator and got out. Door's alarm and at times, staff don't pay attention that much. She (R3) never eloped before. This was the first time. She wanders and talks to strangers/visitors. She is very nice to people, and she talks to strangers, always smiling, helping others. R3's care plan documented the following: Date initiated 02/07/23: Attempting to leave the facility without responsible escort (elopement) was identified: Interventions - Make room checks per facility protocol to minimize chance of unauthorized leave. Date initiated 10/26/20: I am an elopement risk. I sometimes attempt to leave the facility without a responsible escort. I have a diagnosis of mild cognitive impairment and sometimes realize what I am attempting and sometimes not. Interventions - Elopement risk; Staff will make rounds/room checks per facility protocol. 05/25/23 at 9:07AM V21 (Medical Director) was asked regarding R3 and prevention of elopement. V21 stated, I was told she was missing and how it happened was because the alarm system was not working. You know, you can't easily leave the floor because it alarms. You can't easily use elevators because you need to do some forms of tricks to use it. You can't easily leave the first floor because door will alarm. We spoke to other staff to make sure all alarms are working. My expectations on staff in preventing elopement to occur from happening is if they hear any alarm, check where the alarm is coming from right away, faster. Notify supervisor and alert front desk. I was not sure if there was somebody at the front desk that time. When we discussed about R3 missing, I was told the alarm did not work that time. If it's not technical alarm issue, then once staff heard any noise, they need to listen and ask each other, and find out where alarm is coming from. Inspect and see, take time out to check where noise was coming from. Staff must also follow the interventions in the facility protocol regarding risk assessment in preventing elopement. On 05/22/23 at 1:32 PM, V6 (Maintenance Director) was asked if there were issues regarding exit door alarms. V6 stated, in the months of February, March, April and May, there were no repairs pending for the exit door alarms on all floors in the facility. All exit doors alarm when opened. Daily maintenance records dated 05/11/23 to current showed that all exit door alarms are functioning properly. Interview with V1 (Administrator) on 5/24/23 at 1:17PM, V1 confirmed that he is the person responsible for monitoring the facility camera surveillance videos. Surveyor asked to view footage of 5/14/23 - when R3 eloped from the facility and V12 (Regional Nurse Consultant/Registered Nurse) stated that they are not allowed to show video footage. V1 was then asked if he watched the video to determine how R3 left the building and he confirmed that he did. V1 was then asked to please walk surveyor along the path that R3 was seen leaving the building. At this time, V1 led surveyor up to the third floor and both surveyor and V1 walked out of the exit door on the 3west side of the unit. The door had a stop sign banner hanging across the door. V1 was asked when that was added to the door, and he did not remember. The alarm sounded off when the exit door was opened, as V1 and surveyor exited the door. It was noted that when the door closed behind, it did not shut all the way. It required to be pushed to catch the lock and close properly. Upon exiting the 3west door, it leads to a stairway that goes down to the first floor (ground level). V1 and surveyor walked out of the ground level door and ended up outside the facility, towards the back of the building. There were no exit alarms noted to go off when the door was opened, and it did not require any security codes to open. V1 was asked if anyone can just walk out this door and V1 said that life safety doesn't require that door to be alarmed. Upon walking out of the door, it was noted that there is a surveillance camera around the corner in the direction of the parking lot. V1 confirmed that he saw (via the camera footage) that R3 came around the back - meaning from the west exit door - so on the camera he saw her walking past the front entrance on over to the sidewalk and that was as far as he could see from the camera. On 5/25/23 at 10:45AM, V1 (Administrator) informed survey team that on yesterday afternoon maintenance installed an alarm doorbell on the ground level exit door on the west side of the building - which is the door that R3 exited the facility from. Surveyor confirmed that the door was alarmed at that time. Facility's policy titled, Elopement Risk Assessment, undated, documented in part but not limited to the following: Purpose: to identify residents who may be potentially at risk for elopement and at risk for harm. To use as a baseline to maintain a secure resident environment. Procedure: 6. The Social Service Department will notify Facility Staff and initiate interventions necessary to protect the resident. Interventions include, however, are not limited to the following: e. Personal Alarm Arm or Ankle Bracelet f. 15 minute to 1-hour observations g. One on one observation The Immediate Jeopardy that began on 5/14/23 was removed on 5/24/23 when the facility took the following actions to remove the immediacy and correct the noncompliance. 1. All staff were in-serviced including agency staff on elopement precautions and how to know residents who are at risk for elopement along with their elopement interventions. Initiated on 5/14/23 and ongoing. 2. All residents were assessed for elopement risk, residents that have a high risk of elopement were care planned with resident centered interventions. Care plans will be reviewed for effectiveness on each resident during scheduled care plan reviews and as needed. Initiated on 5/14/23 and ongoing. 3. Door alarms being checked q shift for 90 days and then weekly. Initiated on 5/14/23 and ongoing. 4. Code pink drill to be done on each shift and weekly times 6 months than according to policy. Initiated on 5/15/23 and ongoing. 5. Elopement binders at the nursing stations and front desk were updated. Initiated on 5/14/23 and ongoing. 6. Audit will be conducted daily to ensure doors are alarmed and discussed in IDT, and during QAPI meetings for at least 6 months. Initiated on 5/14/23 and ongoing. 7. All door secured with alarm system were checked for functionality and are in working order. Initiated on 5/14/23 and ongoing. 8. Nursing management assessed current residents for elopement precautions. Initiated on 5/14/23 and ongoing. 9. New safety alarm placed on door. Completed on 5/15/23. 10. Affected resident will be assessed for any injuries. Completed on 5/14/23. 11. Emergency QAPI plan has implemented. Any IDT member unavailable will be call via phone. Completed on 5/15/23. 12. All staff has had comprehensive elopement Quiz, staff not at facility were called over the phone and quiz given before start of next shift. Initiated on 5/15/23 and ongoing. 13. Resident to be evaluated by speech for change of condition for cognition. Completed on 5/15/23. 14. Sign placed at all elevators making visitors aware the need to be aware of residents entering elevator. Completed on 5/20/23. 15. Alarm placed on lower-level exterior door motion sensor placed by alarm on door which alarms at the nurse's station. Completed on 5/24/23.

Based on interviews and record reviews, the facility failed to prevent an injury for one (R1) of five residents reviewed for accidents and supervision. The facility failed to follow the resident's care plan for bed mobility. This deficiency resulted in R1 being found to have a bump and swelling on the left thigh that required R1 to be transferred to local hospital, then diagnosed with fracture of the left femur. Findings include: R1 was admitted in the facility on 03/01/21 with diagnoses of Dementia in other Diseases Classified Elsewhere, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety; Vascular Dementia, Severe, Without Behavioral Disturbance, Mood Disturbance, and Anxiety. Per face sheet also, she was diagnosed with Age Related Osteoporosis without Current Pathological Fracture on 02/04/23 and Unspecified Fracture of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing on 02/06/23. R1's MDS (Minimum Data Set) dated 01/03/23 documented: Sec G: Total dependence on two persons physical assist during bed mobility; transfer; toileting; total dependence from one physical assist during dressing; personal hygiene; bathing. Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture R1's Care plan documented: I require assistance with bed mobility related to decreased mobility, dementia - initiated 10/17/22, revision on 01/06/23 - Interventions: Providing assist of 2 persons assist (initiated 10/17/22; revision 01/16/23). According to incident report dated 02/04/23, R1 was noted with left hip swelling and redness. R1 was unable to explain how it occurred. R1 was sent to the emergency room for X-ray. Hospital notified facility that there is a left hip fracture. On 02/07/23 at 3:21 PM, V5 (Registered Nurse/RN) was interviewed regarding R1. V5 replied, On 02/04/23 around 4:15 PM, V6 (Certified Nurse Assistant/CNA) asked me to check on R1 because he had seen the swelling on the left leg became bigger. He (V6) was the CNA last Friday and he already noticed the swelling which he notified V8 (RN). When he notified her (V8), X-ray was ordered. It was not done, I don't know. When V6 (CNA) told me to check on R1, I noticed swelling on the left thigh and lump on the mid lateral thigh. V6 told me that it got bigger since yesterday. I followed up with X-ray, was told they might be coming late in the evening or early morning. I informed V3 (Assistant Director of Nursing) and V9 (Nurse Practitioner/NP) and ordered for her (R1) to be sent out to the hospital. On 02/07/23 at 3:46 PM V6 (CNA) was interviewed regarding R1. V6 verbalized, I worked on 02/03/23, afternoon shift - I came at 3 PM, we are checking the residents around. I set up the dinner for her (R1), she was awake and alert. I repositioned her from the right side to supine and I used the sheet and put a pillow on the back. I did not touch the leg. Did not notice anything. Around 8:30 PM, she (R1) was in supine position. I prepared to change her when I noticed that her left leg was loose and not contracted, no swelling, no bruises or anything. She was not in pain. I called V7 (Licensed Practical Nurse/LPN) and have her (R1) checked. He assessed her (R1) and was told that he had not seen anything relevant. But still, I suggested him to call V8 (RN), the other nurse who is in house. When she (V8) came to the floor, I asked her to assess R1. She (V8 RN) did the assessment, contacted V2 (Director of Nursing) or whoever and ordered a stat X-ray. But no X-ray done. The next day when I came back, afternoon shift, I told V5 that she (R1) was still in the facility, and X-ray was never done. I showed her (V5 RN) that her swelling got bigger. She (V5) called somebody, and she (R1) was sent to the hospital. On 02/08/23 at 10:30 AM, V8 (RN) was asked regarding R1's left leg. V8 stated, On 02/03/23 around 7 PM, I got called by V6 (CNA), said that they needed a second opinion for R1. He (V6) said that he found a bump on her left thigh. He and V7 checked it but unsure what had happened. I went to her room, I assessed her and saw a bump on her left thigh, upper part, like the size of about three to four centimeters. The site was not warm, no discoloration. He (V6) said she (R1) does not have the bump the day before. Now that he was changing her, he noticed it. Also, when he (V6) tried to lift her legs up to check for movements, she (R1) made a sound like she was guarding the leg. I notified V3 (Asst Director of Nursing) via text. She called, said that she talked to V9 (Nurse Practitioner) and a stat X-ray need to be done. R1's progress notes documented the following: 02/04/23: V6 (CNA) asked me (V5 RN) to check on patient's (R1) left leg as he had noticed yesterday that the leg was hypermobile and a lump was found on the thigh, which was reported to V3 (Assistant Director of Nursing/ADON) and V9 (Nurse Practitioner) yesterday, and they had ordered a left thigh X-ray stat (immediately) that was not still done today. Upon assessment of the area, left leg was swollen and bump was still present, and had gotten larger as observed by V6. X-ray company was contacted for an update and status, still unknown if today or tomorrow so as per advice of V3 and V9, R1 was sent out to the hospital. Hospital Records Emergency Department dated 02/04/23 documented: Chief Complaint: Leg swelling. Imaging: CT (Computerized Tomography) lower extremity without contrast left. Impression: Oblique fracture of the mid femoral diaphysis with displacement and angulation. Imaging: XR (X-Ray) Femur Left. Impression: Oblique fracture of the left femur with angulation and displacement. On 02/08/23 at 12:02 PM, V3 (ADON) was interviewed regarding R1 and left left leg swelling. V3 replied, When she was in the facility, she never had fall incidents. She is alert, oriented to person, bed bound, total care. She went to the hospital last weekend due to fracture. They texted me Friday evening, 02/03/23 about her (R1) having a bump on the left thigh. I asked V8 (RN) if she had fallen, or if bruise was noted. I notified V9 (NP) right away and ordered a stat X-ray. I was home, then Saturday, 02/04/23, I received a text that X-ray was not done so me and V9 decided to send her (R1) to the hospital for further evaluation. The cause of her (R1) fracture - she has a wound, and we reposition her every two hours. She has contractures on both legs. Because of her poor nutrition and Osteoporosis, when staff reposition her, maybe it could cause a break in the bones, like a spontaneous fracture. Staff should be gentle when repositioning her. Two staff is needed, pull the draw sheet gently and put a wedge pillow on her back. As much as possible, avoid pushing R1 while turning. I expect staff to provide two person assists during repositioning for bedbound residents and use minimum force/pushing on residents while turning. R1's POS (Physician Order Sheet) dated 11/08/22 recorded: Turn and reposition while in bed (refer to clock schedule). Offload heels at all times, every two hours for wound treatment. R1's progress notes documented the following: 11/25/22: Weekly Skin observations: R1 has a wound in the sacrum area. R1'S progress notes dated 02/06/23 documented: After discussing and investigating resident has protein calorie malnutrition. Anemia, osteoporosis labs: RBC (red blood cells) 3, 32, Hgb (hemoglobin) 9; calcium 8.6; sacrum pressure ulcer, resident (R1) is turned and repositioned often that increases her risk for fracture even with minimal impact. Resident (R1) does not have any known fall incident. On 02/08/23 at 12:27 PM, V9 (NP) was interviewed regarding R1 and incident on 02/04/23 causing a fracture. V9 verbalized, I have been taking care of her (R1) since admission. She is alert to herself, she has Dementia. She has a different language, never talk to me, unable to follow commands. She is bed bound, total care, dependent on staff. She was found to have femoral fracture on the left hip. Cause: we need to turn her every two hours because of the sacral wound, she has Osteoporosis. Looks like she has spontaneous fracture, maybe during turning and repositioning it happened. Because there was no fall incident at all. Her legs have contractures, immobile and does not move at all. I am sure staff are in-serviced on how to turn residents properly. I expect staff that they received proper training and education related to turning repositioning. On 02/08/23 at 12:49 PM, V10 (Admissions Director/Administrator in Training) mentioned during interview, I am finishing up interviewing everyone involved in her (R1) care and also looking into the results with her (R1) diagnosis of Osteoporosis, Anemia, lower levels of Calcium. Last 02/03/23, around 1 PM, wound care did a full assessment on her, no bruises, no redness, no bump. They also did wound treatment. V6 observed the bump in the evening. He reported it to the nurse. The nurse reported it to V9, and stat X-ray was to be taken. Cause of her (R1) fracture - it came back like an oblique fracture, could be caused by Osteoporosis. And with her being turned and repositioned every two hours, likely could have break her bones. 02/08/23 at 1:00 PM, V1 (Administrator) was also asked regarding R1 and the cause of her fracture. V1 stated, She has fracture on the femur, left. She is bedbound. She is elderly, [AGE] years old, has Osteoporosis, a lot of comorbidities. She was not in pain. She is being repositioned frequently, for wound, which is every two hours or during peri care. Possibly during movement of resident (R1) from side to side, which should be done in a proper way, and should be performed by two persons for assist. We actually did annual competency last Thursday 02/03/23, turning and repositioning is part of the skills they need to be trained well. I expect my staff to be cautious during provision of care, if they need proper training on certain skills, let facility know and we can provide the needed training. V5 (RN) also mentioned during interview, R1 is alert, oriented, non-verbal; bed bound. Since she is bed bound, we have to do the turning schedule while in bed. When we do turn her, we do log rolling, one assist but if there are available staff, we have two assists. But since she is small, one person can do the turning. V8 (RN) was also asked regarding R1's turning and repositioning. V8 stated, She (R1) is bedbound, we do turn and repositioning on her every two hours. I have done the turning before with CNA. She never had incidents of fall during my shift. Very difficult to move her legs because it is flexed, bent but it can be moved by staff. When we do the turning and repositioning: she does have a flat sheet under her lower back. Me and the CNA are on both sides, rolled her to the side where she is going to be moved. The CNA will pull the sheet towards her, I am on the other side holding her back and legs and move her back towards me. V6 (CNA) also verbalized, Her (R1) legs are contracted. When turning, I pull the sheet towards me, unfortunately since we are short of staff, I always do the turning by myself, and she is turned to the other side. Same thing during changing of briefs. She has contracted legs and arms. On 02/07/23 at 3:03 PM, V4 (CNA) was also asked regarding R1's turning and repositioning. V4 replied, I am her usual CNA. Most of the time, she is in bed. During changing of incontinent brief, she can hold the halo attached to bed while I change the brief and reposition her. She helps me in turning. Most of the time, I am the only one turning and changing her. When I changed her, I give her a little push on the back, and she holds the halo. When repositioning, I grab the draw sheet and pull it towards me and turn her to the other side and put the pillow under the back. V11 (CNA) also verbalized, We turn and reposition her (R1) every two hours. I call other CNA to help me in turning. We pull that sheet under her bottom. We pull together the flat sheet towards us, she is a heavy set. We turn her to the other side. We roll her body together to the other direction. We hold the shoulders and the hip and push it together so she could go to the direction we want to. On 02/08/23 at 1:49 PM, V2 (Director of Nursing) was asked regarding R1 and prevention of injury on bed bound residents. V2 stated, She (R1) is being turned and reposition every two hours and as needed because of the pressure ulcer on the sacral area. Very high risk for fractures when turned. She is bedbound. There should be two persons assist, one on each side of the bed, use a draw sheet to turn to the other side while the other person putting the pillow on the back and between the knees to maintain comfort. We have to offload the heels with a pillow. My expectations on staff in preventing fractures or injuries on bedbound residents are to expect them to work as a team, help each other and report to the nurse, to us, if there are changes in functional level. There should be proper endorsements between nurses and CNAs. Report to me ASAP (as soon as possible) on any changes observed on a resident. Staff has to follow the facility procedures when turning a resident. Facility's procedure titled Turning Patients Over In Bed, undated, documented in part but not limited to the following: Turning A Patient The following steps should be followed when turning a patient: Get as close to the person as you can. You may need to put a knee on the bed to get close enough to the patient Place one of your hands on the patient's shoulder and your other hand on the hip. Standing with one foot ahead of the other, shift your weight to your front foot (or knee if you put your knee on the bed) as you gently pull the patient's shoulder toward you. Then shift your weight to your back foot as you gently pull the person's hip toward you. You may need to repeat steps 4 and 5 until the patient is in the right position. Facility's checklist titled Bed Mobility and Positioning Competency dated 08/2012, documented in part but not limited to the following: Performance Criteria: 1. Turning in bed a. Assess resident's ability to turn b. Lower head of bed as appropriate c. Turning a resident toward you i. Cross the resident's arms over his/her chest ii. Cross the leg near you over the far leg iii. Raise side rail on opposite side of bed as appropriate iv. Lower the rail on the side of the bed towards where the resident will be turning v. Place one hand on the resident's far shoulder and the other on the resident's far hip vi. Gently roll the resident toward you d. Turning a resident away from you i. Cross the resident's arms over his/her chest ii. Cross the leg near you over the far leg iii. Place one hand on the resident's near shoulder and the other on the resident's near hip iv. Gently roll the resident away from you v. If the side rail is up, ensure that the side rail is padded to prevent injury 3. Logrolling a. Ensure assistance of 2 to 3 persons b. Move the person as a unit to keep the spine straight

Based on observation, interview and record review the facility failed to ensure resident's safety by failure to follow its fall prevention policy. The facility failed to implement R2's fall care plan interventions to prevent another fall which caused her to sustain a left hip fracture that requires hospitalization . The facility also failed to revise the care plan based on the IDT (Interdisciplinary team) recommendations after the incident investigation. The facility failed to complete the fall assessment accurately and failed to complete the fall assessment after each fall occurrence as indicated in the policy. This deficiency affects all five (R1, R2, R3, R4 and R5) residents reviewed for resident safety and fall prevention program. Findings include: 1.) R1 was admitted on [DATE] with diagnosis listed in part but not limited to fracture of upper end of left humerus, Dementia, Psychotic, Mood and Anxiety disturbance, Age related osteoporosis without pathological fracture, Contracture left knee, Dysphagia following cerebral infarction. R1's care plan indicates that she is at risk for falls. Intervention: follow fall protocol. R1 has ADL self-care deficit AEB: Dressing total dependence- 1 person assist, Toilet use total dependence- 1 person assist, Personal hygiene total assist - 1 person assist (dated initiated and revised 12/21/22). R1 has incident report dated 12/2/22 for Injury of unknown origin resulting to age indeterminate left proximal humerus surgical neck fracture. Incident report submitted to IDPH has Quality Improvement plan: In-serviced and re-educated staff on policies and procedures for transfers, repositioning, changing and ADLs. Care plan updated for 2 persons dependent care at all times. On 1/4/23 at 10:53am, R1 in left side lying position in bed with oxygen via nasal cannula connected to oxygen concentrator. She has gastrostomy tube feeding connecting to feeding pump. She is on low air loss mattress with bed not in the lowest position. R1 has floor mat on the left side of the bed. R1 is verbally unresponsive. The surveyor called V11 (Registered Nurse/RN) and showed R1's bed position. V11 used the bed control to adjust the bed in lowest position. V11 said that this is not a low bed, but it should be in the lowest position. V11 said that R1 was recently hospitalized due to left upper arm fracture from unknown origin, she came in with left arm sling but there is no order. R1 does not have left shoulder sling. R1's medical record indicates no order of left arm sling. On 1/5/23 at 10:29am, the surveyor observed R1 in right side lying position with bed in high position with V15 (Certified Nurse Assistant/CNA). V15 adjusted the bed to its lowest position using bed control. V15 said that bed should always be in the lowest position when they are in bed for safety. R1 has left arm sling on. On 1/5/23 at 1:00pm V2 (Director of Nurses/DON) informed of above observation. V2 said that bed should be in the lowest position. The CNA probably left the bed up after providing personal care. V2 said that that R1 does not have order for left arm sling. She does not know who put it on. V2 said that after each fall or any incident of injury of unknown occurrence the root cause analysis is discussed by IDT (interdisciplinary team) and formulates new care plan interventions to prevent future falls or injury of unknown occurrence. V2 said that care plan intervention is updated by either V4 (Restorative Nurse/Fall Coordinator) or V6 (Minimum Data Set {MDS}/Coordinator). At 1:20pm V6 said that she did not update R1's care plan, V4 should update that care plan. V4 said that she updated R1's care plan but did not revise it based on IDT recommendations after the investigation of injury of unknown. 2.) R2 was admitted on [DATE] with diagnosis listed in part but not limited to displaced intertrochanteric fracture of left femur, History of falling, Age -related osteoporosis wit pathological fracture left hand, Nondisplaced fracture of proximal phalanx of left middle finger, Major Depressive disorder, Nontraumatic subarachnoid hemorrhage from middle cerebral artery, orthopedic aftercare, Cerebral infarction, Fracture of neck right femur, Heart failure. R2's care plan indicates: She has limitations with ADLs (activities of daily living) related to behavioral issues, muscle weakness, Hypertension, Diabetes Mellitus and Dementia. She is resistive to care. She is at risk for fall and needs supervision during mealtime. She is high risk for falls and injury because she is very private and used to be independent and do not like asking for help, sometimes get confused and unaware of safety measures. Education and use of call light don't apply to her related to impaired cognition. She is often disoriented. She has episode of agitation and delusions and has tendency to be non-compliant of safety measures despite of education. Call light was identified at risk for injury when bed. In the past she had hx (history) of falls and sustained injury. She has history of ambulated without assistance, lost her balance. She has history of urge to walk without assistance when she feels that she is strong enough to walk. She has history of getting up from geriatric chair, lost her balance and fell . She has an actual fall on 7/21/21, 8/21/21, 8/15/22 and 12/6/22. Most recent fall she sustained left hip fracture. R2's incident reported to IDPH dated 12/6/22 indicated: Time of occurrence: 6:05am. Description of occurrence: R2 was self-transferring from geriatric-chair lost her balance and had a fall/Injuries: Swelling to the left side of her face and pain to left hip. Action taken: A head to toe assessment was completed by the nurse, pain medication offered, and resident was sent to hospital via 911. Physician and family notified. Final report 12/9/22. R2 has returned to facility, no surgical intervention was done. Hospital records indicate resident is at elevated risk due to R2's advance age and history of Congestive Heart Failure. Voltaren gel and acetaminophen have been ordered for pain management. Also, WBAT (weight bearing as tolerated) to Left Lower Extremity. Non-slip pad has been applied to the geriatric chair and frequent round is in place. On 1/4/23 at 10:47am, V11 (RN) said that R2 is alert and oriented x 1 with confusion. She speaks mainly Korean language. She needs total care with ADLs and transfers. She has behavioral issues. V11 said that R2 has fall incident on 12/6/22 in the night shift. V13 (Agency CNA) placed R2 in a geriatric chair due to restlessness and left in the hallway for supervision instead of leaving in her room. R2 fell from geriatric chair when she tried to get up. R2 has history of multiple falls with injury. On 1/5/23 at 12:00pm, the surveyor observed R2 siting in the geriatric chair waiting for lunch to be served. She is confused. The surveyor observed R2 with V11 (RN) that non-slip pad is not applied on R2's geriatric chair. On 1/5/23 at 12:11pm, round made to R2's room with V15 (CNA) and V3 (ADON) no laser sensor alarm is in place in R2's room for safety. V3 said that it was broken and was not replaced. On 1/4/23 at 1:37pm, review R2's medical records with V2 (DON). V2 said that on 12/6/22 R2 unwitnessed fall. Found lying on the floor with head against the wall in front of her geriatric chair at 6:05am by the hallway. R2 is gets up by night shift. She has behavioral issues at times such as restlessness. R2 is confused. V12 (Agency RN) assessed R2 and observed swelling on left side of the face and pain to left hip. Staff transferred R2 back to geriatric chair. R2's PCP and family were notified. R2 sent to hospital via 911. R2 admitted with acute nondisplaced intertrochanteric fracture of left hip. R2 is readmitted on [DATE]. No surgical intervention was done. R2's care plan was updated: Voltaren gel and acetaminophen have been ordered for pain management. WBAT (weight bearing as tolerated) to Left Lower Extremity. Non-slip pad has been applied to the geriatric chair and frequent round is in place. Informed V2 that R2's care plan interventions were not updated based on root cause analysis IDT recommended written in R2's incident report submitted to IDPH. V2 said that V4 (RN/Fall Coordinator) should update the care plan. Informed V2 that previous fall interventions were not implemented: Monitor and sit in chair outside the room for close monitoring. Re-educate staff regarding maintaining 1:1 observation. Laser sensor alarm. Pain care plan was not revised after the fall injury for pain management. Pain assessment for cognitively impaired was not done. R2's fall assessment done on 8/15/22 after fall incident indicated not at risk for fall. V2 said that V4 (RN/Fall coordinator) is new to her position. V2 said that she will address concerns presented. On 1/6/23 at 8:35am V3 (ADON) said that if the resident is restless/agitated, resident should not be left unattended and should be in within vision. Numerous calls attempted to both V12 (Agency RN) and V13 (Agency CNA) who were assigned for R2 at the time of incident dated 12/6/22 but no response. Both V1 and V2 are aware and tried to contact too but failed. 3.) R3 was admitted on [DATE] with diagnosis of Parkinson's disease, Dementia, Age related osteoporosis, Major depression, Difficulty walking, Gait abnormality, Fracture of left acetabulum, Fracture of left pubis, Fracture of left clavicle, Osteoarthritis, Intervertebral disc degeneration lumbar region, Osteoporosis, History of falls. R3 has unwitnessed fall incident on 6/19/22. No fall assessment was done on 6/19/22 after fall incident. 4.) R4 was admitted on [DATE] with diagnosis listed in part but not limited to Difficulty walking, Dementia with behavioral disturbances, need for assistance with personal care, Dysphagia, Lack of coordination, generalized anxiety disorder, Major depressive disorder, Psychosis, Osteoarthritis, Age related osteoarthritis, Mild cognitive impairment. R4's care plan indicates: She requires psychotropic meds to help manage and alleviate conditions: Psychosis/ paranoid/delusions, Agitation/periods of restlessness/, Depression, Mood swings/mood lability, Anxiety/neurosis, Disruptive behavior as evidenced by resistance to care. She requires assistance with walking r/t impaired balance, unsteady gait. She has potential to lose balance and stumble because she takes some medications that can make her dizzy, tired, confused, or weak. She prefers to sit next to bed sitting on her fall mat. She is crawler. She grew up in a culture that likes to sleep and sit on the floor. She is not compliant to safety measures and refusing to use rolling walker as her assistive device and gait belt on. Education does not apply to her r/t cognitive impairment. She has history of wandering at times in hallways and walk very fast. She refused to wear appropriate footwear when transferring and ambulating, she sometimes removes it. She requires redirection and assist to dining room or in room right away. She has ADLs self-care deficit r/t impaired balance, dementia, arthritis. She has been yelling and scratching staff without provocation. She has been talking to herself, screaming, and arguing/angry with someone that does not exist, hitting shoe on floor. She sometimes experiences delusions and hallucinations and become agitated and have the tendency to hit other resident or staff. She is at risk for fall r/t unsteady gait, confusion. She has an actual fall on the following dates: 7/22/22, 8/20/22, 9/27/22, 11/6/22, 12/20/22 at 7:20am and 12/20/22 at 2:30pm. On 1/5/23 at 12:11pm the surveyor observed R3 sitting in a geriatric chair in the dining room waiting for lunch to be served. She is confused. No verbal response. R4 most recent unwitnessed fall incident dated 12/20/22 at 7:20am indicated that R4 was found sitting on the floor inside the washroom facing the toilet. Assessed R4 and noted cut on the left eyebrow with dried blood noted to surrounding area. Cleanse affected area and applied dressing. Also noted dried blood on her blanket and a small towel next to bed. Also noted bump on the back of her head with no bruise noted at this time. No other skin issues or any further injuries. R4 able to move all extremities. Denied any pain. R4 is alert and oriented x 1, as her baseline. R4 unable to give description of what had happened. R4's physician and family were notified. At around 4:30pm, the nurse saw R4 holding a pillow, stumble across the hallway into the room across. The nurse ran to R4 and called for help. V2 (DON) who was at the nursing station. Both entered the room and saw R4 lying I her left side with left arm extended and head on the floor. R4 was heard saying it hurts in Korean. Nurse lifted the head and put the pillow under and R4 was sent out to the hospital for evaluation. On 1/5/23 at 12:13pm observed R4 in the dining room sitting in geriatric chair with both legs upon the table. R4 is confused. No verbal response. On 1/5/23 at 1:13pm Review R4's medical record with V3 (ADON). R4's fall care plan was not updated after 2 fall incidents on 12/20/22. V4 said that V4 should updated the care plan after each fall occurrence to prevent future fall. V4 said that R4 should be on 1:1 supervision or the frequent monitoring done by staff should be documented in the chart. 5.) R5 was admitted on [DATE] with diagnosis to include but not limited to mild cognitive impairment, Age related osteoporosis without pathological fracture, Major depressive disorder, Anxiety disorder, Dementia, Difficulty walking, Fracture left wrist and hand, history of falling. R5's care plan indicates: She requires psychotropic meds to help manage and alleviate feeling of fear. Depression/behavior with depressive features, Mood swings/mood liability due to dementia and Anxiety/neurosis/anxiety disorder related problems. She requires the use of splint due to fractured left wrist from fall. ADLs self-care deficit. She is at risk for fall due dx of syncope and psychotropic meds. She has impaired cognitive function/dementia or impaired thought processed r/t dementia. Impaired decision making, psychotropic drug use, short term memory loss. She has senile dementia, education and reminders does not apply to her due forgetfulness. Requires re-direction and repetitive staff demonstration. She has history of falling in other resident's room. She missed the chair while attempting to sit loss balance and fell . She had fall incidents on 7/6/22, 10/3/22, 12/12/22 and 1/2/23. V4 (RN/Fall Coordinator) recent fall intervention for recent fall 1/2/23 indicates: Re-educate on patient on asking for assistance, frequent monitoring, and re-direction. R5's fall assessment done after fall incident on 11/25/22 and 1/2/23 indicated not at risk for fall. R5's most recent witnessed fall incident dated 1/2/23 indicates: CNA said that he saw R5 falling backward as he approached another resident who was trying to get out of her chair. He turned around and R5 was sitting on the floor. The nurse assessed R5 and felt bump on the back of her head. Nurse asked R5 if her head hurts and she stated in Korean that it hurts a little. Nurse took vital signs BP-150/74, PR- 72, RR-20. R5 denied feeling dizzy. Family and physician notified. On 1/5/23 at 12:15pm, observed R5 sitting in chair in the dining room. She is confused. Ambulates without assistive device (walker). She does not have left hand splint. R5 was observed not wearing left hand splint since yesterday. On 1/5/23 at 2:10pm, review R5's medical records with 4 (RN/Fall Coordinator). Informed V4 that R5 does not wear left hand splint. R5 has an order and care planned for Left hand splint due to recent left wrist/hand fracture from fall. V4 does not know if R5 still need to wear her splint on left wrist. V4 said that there is no restorative assessment done for usage of left-hand splint after fall incident of 10/3/22. Informed V4 of 2 fall assessments done to R5 after each fall coded at not at risk for fall. V4 said that R5's fall assessment should be coded as at risk for fall. Informed V4vthat fall care plan interventions written after fall incident of 1/2/23 is inconsistent with the R5 care plan. Care plan indicated that she has senile dementia, education and reminders does not apply to her due forgetfulness. V4 said that on the incident of R5 on 1/2/23 in the dining room, there is only 1 CNA monitoring the residents in the dining room. The CNA was attending to another resident who was trying to get up that's why the CNA could not prevent the fall of R5. Facility's policy on Fall prevention program indicates: Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized, as necessary. The Quality assurance program will monitor the program to assure ongoing effectiveness. Guidelines: *Use and implementation of professional standards of practice. *Immediately change of interventions that were unsuccessful *Care plan incorporates interventions are changed with each fall, as appropriate. Preventive measures. *All assigned nursing personnel are responsible for ensuring ongoing precautions are in place and consistently maintained. *Accident/incident reports involving falls will be reviewed by the interdisciplinary team to ensure appropriate care and services were provided and determine possible safety interventions. Standard: *Fall risk assessment will be performed at least quarterly and with each significant change in mental functional condition and after any fall incident. In addition to the use of standard fall precautions, the following interventions may be implemented for residents identified at risk: *The frequency of safety monitoring will be determined by the resident's risk factors and the plan of care. *In the event safety monitoring is initiated for 15-20 minute periods, a documentation record will be used to validate observations. Assigned nursing personnel are responsible for completing the safety checks and documenting the same on the record. Safety monitoring will be discontinued when the risk factors requiring monitoring is no longer evident as determined by the supervising nurse or interdisciplinary care team.

Based on observation, interview, and record review, the facility failed to ensure that the resident's plan of care included the most recent hospice plan of care and coordination of care between the facility and hospice agency in order to maintain the resident's well-being and management of pain. This failure applied to one (R1) of three residents reviewed for hospice and resulted in delayed treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R1 is a cognitively impaired with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/1/22 at 9:30 AM, V3 (Assistant Director of Nursing/Nursing Supervisor) stated upon interview, R1 is on hospice and (R1) was sent out Sunday 1/30/22 due to a fracture. Surveyor asked how often hospice came to care for R1. V3 stated, I know they keep a hospice binder upstairs, but I think they haven't been here awhile. On 2/1/22 at 9:45 AM, surveyor asked V5 (LPN/Licensed Practical Nurse) about R1. V5 stated, (R1) is hospice and (R1) is mostly total assist. I always check on (R1) and hospice comes too. Surveyor asked how often hospice came to care for R1. V5 stated, I'm not sure because sometimes they come when I am not here, but I have not seen the nurse for a while. Hospice binder presented to surveyor showed the last visit by the hospice CNA was on 1/19/22 at 6:30 AM and was provided a bed bath, lotion, nail care and transfer to the chair. This same hospice binder showed the last visit occurred 10 days prior by the hospice nurse RN to be on 1/22/22. Surveyor asked V5 who the nurse's signature that was dated 1/22/22. V5 stated, That's V16 (RN) Further review of R1's hospice binder and facility progress notes show no coordination of care between hospice agency and the facility. R1's care plan dated 12/15/21 reads in part, Terminal condition and currently under the care of hospice. Goal: (R1) will be kept comfortable as manifested by no signs or symptoms of pain. Approaches: Monitor for complaints of pain or discomfort and reposition or medicate PRN as needed. CNA to report signs and symptoms of discomfort to nurse. Assess pain level using 1-10 scale and then reassess and document effectiveness; Reposition every 2 hours if unable to reposition or move themselves; Nurse to assess and start treatment and call MD as per protocol. On 2/2/22 at 7:46 PM, V6 (RN) readmitted R1 back to the facility and wrote in part, Transported by ambulance via stretcher. AOX2 and verbal. Patient has right arm sling on for right elbow fracture and to be worn at all times. Right elbow bruise is yellow in color and the swelling has decreased. patient still complaining of pain of both arms and hurts more on the right elbow fracture. Hospice will be here tomorrow to re-admit patient back on hospice as per son and hospital report. Efforts to contact V17 (Physician) on 2/3/22 and 2/4/22 were left unanswered. On 2/3/2022 at 3:03 PM, V17 (physician) wrote in R1's progress note that read in part, physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Alert and oriented x 2 at baseline who presented to nursing home for evaluation of right elbow fracture. As per nursing home staff, patient was getting changed and rolled to (R1's) side and accidentally rolled into the wall as (R1's) bed is against the wall. X-ray done at the nursing home showed right elbow fracture and patient was transferred to ER for further evaluation. On 2/4/22 at 10:45 AM surveyor visited R1's room to interview the resident. R1 was in bed that was parallel to the wall. A light green mattress was placed upright on its side and was wedged in between R1's bed and wall. R1 appeared uncomfortable and was audibly moaning. Surveyor asked how R1 was doing. R1 stated, I'm still in pain. I was shoved up against that wall. That thing is new (motioning with (R1's) head about the greenish mattress). Surveyor asked whether the nurse gave R1 pain medications. R1 stated, Yes but it still hurts. Surveyor asked if R1 knew who pushed R1 against the wall. R1 stated, I don't know, I know she's white and she has black hair. Surveyor asked when this happened, R1 stated, I don't know but I've been complaining of pain and they didn't do anything. Finally, I went to the hospital I remember telling them at the hospital too. Surveyor asked how long R1 has been complaining of pain. R1 stated, I don't know, days, hours, a long time. Surveyor asked if R1 was given pain medications when R1 complains of pain. R1 stated, Sometimes but they don't work enough. They keep telling me I'm fine. On 2/4/22 at 10:50 AM, V8 (CNA/Certified Nursing Aide) was asked about R1. V8 stated, Yes she is my patient today. I saw her earlier and she complain of pain but the hospice CNA was here earlier, so I didn't tell anyone because I thought the hospice CNA already told the nurse. Surveyor asked what she's done with the resident so far this morning, V8 stated, She was still in bed when I got here. I think the hospice CNA already took care of her so I didn't have to do anything, so I took care of my other residents. On 2/4/22 at 10:55 AM, V5 (LPN) was asked whether she saw R1 for her pain this morning, V5 stated, I saw her earlier, but she got pain medications from the night shift nurse. Why is she complaining of pain again? Surveyor informed V5 to assess the resident directly, V5 stated, Yes I will do that. Surveyor asked whether there was any conversation with the hospice physician to reevaluate R1's pain regimen and medications, V5 stated, I have not seen them for a while, but I will find out. On 2/4/2022 at 10:58 AM, V2 (Director of Nursing) wrote in R1's progress notes, Follow up call to hospice to inquire why nurse has not arrived yet. Spoke with hospice director of nursing who stated RN will be coming and this nurse (V2) requested immediate response. On 2/4/22 at 11:05 AM, surveyor asked about R1's hospice, V2 (Director of Nursing) stated, I know that I have been having issues with them coming here and I'm aware of this and I've already put a call out to them. I know they should be here weekly or at least the hospice c.n.a should be. Hospice contract presented to surveyor on 2/4/22 reads in part, Services provided to me (R1) will be as follows: Routine home care: expected frequency and duration: Daily. Respite care: as needed; General inpatient care: As needed; Continuous care: As needed. Interview with V6 (RN on 2/4/22 at 12:30 PM stated, V16 is usually the nurse that comes here to visit R1, but I have not seen her in a while. On 2/4/22 at 1:00 PM, V3 (ADON) provided surveyor contact information for hospice agency. Calls to the hospice agency were met with no return calls.

Based on observation, interview, and record review, the facility failed to assess and manage a resident's pain consistent with the plan of care and failed to follow-up on pain interventions for one (R1) of three residents reviewed for pain management. This failure resulted in R1complaining of extreme pain for multiple days without adequate pain relief related to a fractured elbow. Findings include: R1 is a cognitively impaired with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's care plan dated 12/15/21 reads in part, Terminal condition and currently under the care of hospice. Goal: (R1) will be kept comfortable as manifested by no signs or symptoms of pain. Approaches: Monitor for complaints of pain or discomfort and reposition or medicate PRN as needed. CNA (Certified Nurse Assistant) to report signs and symptoms of discomfort to nurse. Assess pain level using 1-10 scale and then reassess and document effectiveness; Reposition every 2 hours if unable to reposition or move themselves; Nurse to assess and start treatment and call MD as per protocol. Interview with V6 (Registered Nurse/RN) on 2/4/22 at 12:30 PM stated, I was told by the CNA (V4) that the resident was complaining of pain earlier during the start of my shift (3-11) on Friday (1/28/22). I assessed R1's arm because (R1) pointed to it that (R1) was in extreme pain. (R1's) arm was very bruised, purple colored and it was swollen. I notified the hospice agency, the doctor and son to let them know. V14 (physician assistant) ordered to get x-ray of the resident and so I called the x-ray company and they said they'd come out that same night. I left for my shift at 11 PM and I found out the next day because I worked again (3-11 shift) that the x-ray company never came. The x-ray company kept telling us they would come but they still didn't, so we informed the son, hospice and the doctor know again, and we just waited. The next day Sunday, I worked again the 3-11 shift and the resident still had not gotten an x-ray to find out where the pain and swelling was, so I contacted the hospice nurse (V16) who called her supervisor. I pleaded with them that we need to send the resident to the hospital to get x-rays, but they said she couldn't go out because she was hospice. I told them this was about patient comfort and that (R1) had been complaining for days about pain, so they finally were able to send an ambulance to go to the hospital for treatment and x-rays. Before I could send (R1) out, the x-ray people came to the building and took the x-ray and so we waited again for the results which showed (R1) got a fracture so (R1) then I was finally able to send (R1) out to the hospital. Surveyor asked why it took several days for R1 to get x-rays and if anyone else from the facility followed up with the x-ray company. V6 stated, I'm not sure why. I just know that when I left for my shift, I thought the other nurse would follow up. Surveyor asked if a doctor gives orders, when these orders need to be carried out. V6 stated, They should be carried out right away when you get the order and there should be a follow up to make sure it was carried out. Facility's interviews with staff showed R1 was complaining of severe pain beginning on 1/25/22 and with the facility attributing this pain as R1's usual behavior: A statement from V9 (CNA.) taken by facility, read in part, Last time resident seen: 1/25/22 at 3 AM, (R1) usually complain of pain on right shoulder. (R1) always scream at me and say, don't touch me and sometimes (R1) hits (R1's) right elbow with (R1's) stronger side to the wall because (R1) doesn't want to be touched, even you're not touching (R1) yet. Review of pain assessments on 1/25/22 show 0-zero listed pain during both afternoon and night shifts with no other additional PRN (as needed) pain medications as ordered or interventions provided to alleviate R1's pain. A statement from V11 (CNA) taken by facility reads in part, 1/26/22. 3-11 shift CNA Facility asked V11 if R1 complained of pain and V11 stated no but her usual behavior was that she does scream. Facility asked V11 whether R1's incontinence brief was changed during her shift on 1/26/22 and V11 replied in her statement that resident had refused (R1's) diaper change at that time. The facility did not inquire further with V11 as to the reason R1 refused to be changed or whether it was due to not being moved due to R1's pain. Review of pain assessments on 1/26/22 show 0-zero pain for both 3-11 PM shifts and 11-7 night shifts and R1 was not provided any additional PRN pain medications as ordered or other interventions to alleviate R1's pain. A statement from V7 (CNA) taken by facility read in part, 1/28/22-AM shift. After lunch, transferred resident to bed via (mechanical lift). Resident usually screams when transferring (R1) and that's usual for (R1) when moving (R1). I also noticed that (R1) was still holding (R1's) right arm/elbow. Review of pain assessments on 1/28/22 show 0-zero listed pain during both morning shift when R1 screaming and holding R1's right arm and elbow. The afternoon shift was also recorded as 0-zero for no pain. The night shift recording pain of 9 out of 10 for severe pain but had no additional medications provided as ordered or other interventions to alleviate R1's pain. A review of R1's medication administration records for January 2022 showed on 1/7/22 R1's pain level was at a 7 out of 10; 1/8/22 pain level was 8 out of 10; 1/10/22 pain level was 8 out of 10; 1/24/22 pain level was at a 9 out of 10; and 1/28/22 pain level of 9 out of 10. Of these days, no PRN (as needed) pain medication was provided to R1; yet on 1/27/22 pain level was recorded at 5 out of 10 and PRN pain medication was given; 1/29/22 pain level was 8 out of 10-PRN pain medication given. 1/30/22 pain level 7 out of 10--PRN pain medication given. Hospital records dated 1/31/22 show R1 was admitted to the hospital with right elbow fracture (Proximal ulnar acute fracture). On 2/2/22, R1 was readmitted back to the facility. On 2/4/22 at 10:45 AM surveyor visited R1's room to interview the resident. R1 was in bed that was parallel to the wall. A light green mattress was placed upright on it's side and was wedged in between R1's bed and wall. R1 appeared uncomfortable and was audibly moaning. Surveyor asked how R1 was doing. R1 stated, I'm still in pain. I was shoved up against that wall. That thing is new (motioning with R1's head about the greenish mattress). Surveyor asked whether the nurse gave R1 pain medications. R1 stated, Yes but it still hurts. Surveyor asked if R1 knew who pushed R1 against the wall. R1 stated, I don't know, I know she's white and she has black hair. Surveyor asked when this happened, R1 stated, I don't know but I've been complaining of pain and they didn't do anything. Finally I went to the hospital I remember telling them at the hospital too. Surveyor asked how long R1 has been complaining of pain. R1 stated, I don't know, days, hours, a long time. Surveyor asked if R1 was given pain medications when R1 complains of pain. R1 stated, Sometimes but they don't work enough. They keep telling me I'm fine. On 2/4/22 at 10:50 AM, V8 (CNA) was asked about R1. V8 stated, Yes she is my patient today. I saw her earlier and she complain of pain but the hospice CNA was here earlier so I didn't tell anyone because I thought the hospice CNA already told the nurse. Surveyor asked what she's done with the resident so far this morning, V8 stated, She was still in bed when I got here. I think the hospice c.n.a. already took care of her so I didn't have to do anything so I took care of my other residents. On 2/4/22 at 10:55 AM, V5 (Licensed Practical Nurse/LPN) was asked whether she saw R1 for R1's pain this morning. V5 stated, I saw (R1) earlier but (R1) got pain medications from the night shift nurse. Why is (R1) complaining of pain again? Surveyor informed V5 to assess the resident directly. V5 stated, Yes I will do that. Surveyor asked whether there was any conversation with the hospice physician to reevaluate R1's pain regimen and medications, V5 stated, I have not seen them for awhile but I will find out. On 2/4/22 at 10:58 AM, V2 (Director of Nurses) wrote in R1's progress notes, Follow up call to Hospice to inquire why nurse has not arrived yet. Spoke hospice Director of Nursing who stated RN will be coming and this nurse (V2) requested immediate response. On 2/4/22 at 11:47 AM, V1 (Administrator) wrote in the nursing progress notes that read in part, Notified by (V5) LPN of resident complaints of pain 9 of 10 in both shoulders in spite of 5 mg [MEDICATION(S)] given at 11:08 PRN (as needed) and 6:45 [MEDICATION(S)] PRN for 10/10 both arms, shoulders, and buttocks. V5 notified NP and ordered for hospice to give baseline orders. I assessed the resident and (R1) was resting calmly in bed with left arm over right arm, no shortness of breath, no brow furrowing, no agitation, does not appear in pain. Hospice was called by V2 (Director of Nursing). On 2/4/22 4:00 PM R1 was provided new orders for increased pain medications. V5 (LPN) wrote in progress notes that read in part, Communication with Physician. Spoke with hospice nurse/ hospice doctor to clarify medication for resident due to resident in pain. New order received and noted: Discontinue [MEDICATION(S)] 5/325 mg and [MEDICATION(S)] 10/325 mg PO PRN, start [MEDICATION(S)] 10/325 mg PO TID (6AM, 2PM, 10 PM) for moderate to severe pain; start [MEDICATION(S)] 1 mg PO at bedtime for agitation and restlessness. Efforts to contact V17 (Physician) on 2/3/22 and 2/4/22 were left unanswered. On 2/3/22 at 3:03 PM, V17 (Physician) wrote in R1's progress note that read in part, physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Alert and oriented x 2 at baseline who presented to nursing home for evaluation of right elbow fracture. As per nursing home staff, patient was getting changed and rolled to (R1's) side and accidentally rolled into the wall as (R1's) bed is against the wall. X-ray done at the nursing home showed right elbow fracture and patient was transferred to ER for further evaluation.

Based on observation, interview, and record review, the facility failed to provide care and assistance in accordance with the resident's plan of care and to meet the resident's need to have two staff assist with transfers and other ADL's (activities of daily living) for one (R1) of three residents reviewed for accidents. This failure resulted in R1's emergent transfer to local hospital, where R1 was diagnosed with an acute elbow fracture. Findings include: R1 is a cognitively impaired with diagnosis listed in part with [CONDITION(S)], anxiety disorder, hypertension and chronic pain. R1's most recent quarterly MDS (Minimum Data Set) assessment dated [DATE] shows R1 to have a BIMS score of 5 demonstrating severe cognitive impairment. This same assessment shows R1's activities of daily living in regard to bed mobility and transfer ability as totally dependent requiring a minimum of 2-person assist to reposition in bed and transferring between surfaces (i.e. bed to chair). R1's ADL (activities of daily living) care plan initiated 2/2/21 reads in part, I have limitations with my ADLs because I have arthritis, [CONDITION(S)], anxiety, and right shoulder pain. Approaches: Transfer me with dependent staff assistance via mechanical lift; Reposition me in bed with extensive/dependent staff assistance of 2; Assist me with my toileting needs with extensive/dependent staff assistance of 2 to be changed when in bed. R1's skin care plan initiated 9/21/21 reads in part, I am at risk for skin tear due to fragile skin. I've had history of skin tear on my left leg, scraped it on the edge of chair. Approaches: Use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface; Use long sleeves clothing for extra protection of the limbs; Use padding such as pillows, extra linen or other devices to protect limbs during transfers and turning and repositioning. A facility incident report reads in part, Description of occurrence: 1/31/22, 8:22 PM-X-ray result of the right elbow: proximal ulnar acute fracture. Orders to transfer resident to hospital via ambulance. Hospital records read in part, Date of service: 1/30/22 11:47 PM. Patient is a [AGE] year old female with past medical history of Parkinson disease, depression, recurrent urinary tract infections, dementia. Alert, oriented x 2 at baseline the present to emergency department for evaluation right elbow fracture from the nursing home. Per nursing home staff, patient getting changed and getting rolled to her side and is excellently rolled into the wall as her bed abuts the wall. Patient complained of pain in her right elbow, x-ray performed today shows fracture and she is sent in for further evaluation. On 2/1/22 at 9:30 AM, V3 (Assistant Director of Nursing/Nursing Supervisor) stated upon interview, I sent public health the initial investigation of R1's incident but the administrator and director of nursing are also doing the investigation in to how R1 got a fracture. We are interviewing all the nursing staff to see who took care of (R1) to find out how it happened. Surveyor asked whether the facility determined whether this was a fall or any form of abuse, V3 stated, We don't know yet. Surveyor asked how R1 is generally assisted with ADLs (activities of daily living). V3 stated, (R1) is pretty much extensive assist with everything. We normally get (R1) up every day and place (R1) on (R1's) chair (geriatric recliner) and then (R1) goes back to bed after lunch. Surveyor asked how this is done. V3 stated, We use a (mechanical) lift. Surveyor asked how many people are required to do this for R1. V3 stated, There should be 2 staff. Surveyor asked if R1 was able to move in bed by self. V3 stated, No (R1) cannot move by herself, (R1) needs 2 people. On 2/1/22 at 9:45 AM, surveyor went to R1's previous bedroom after R1 transfer to the hospital. R1's room was situated near the furthest end of the hall. In the room were two metal beds that were both aligned and propped against the wall. The metal frame of the bed was exposed and had a blue foam mattress that appeared stripped down after R1 was hospitalized . The wall adjacent to R1's bed was marred with stains, scratches, holes and peeling paint. V5 (LPN/licensed practical nurse) was asked to identify which bed R1 was in. V5 pointed to the bed closest to the window and stated, That was (R1's) bed. We have always put the bed right next to the wall so (R1) don't fall on the right side and we put a mat on the other side so (R1) don't fall. There is no one in the other bed because (R1) was on isolation. Surveyor asked whether R1 ever rolled out of bed to warrant the bed being wedged against the wall and fall mat. V5 stated, No I don't think so, (R1) does not move very much. Surveyor asked whether there was any type of padding used to protect the resident as the bed appeared to have exposed metal parts, V5 stated, We have long sleeves on the resident all the time. Surveyor asked about R1's ADLs. V5 stated, (R1) is hospice and (R1) is mostly total assist. I always check on (R1) and hospice comes too. Surveyor asked to clarify what total assist meant. V5 stated, (R1) need 2 people to help (R1) with everything. On 2/1/22 at 9:55 AM, interview with V4 (Certified Nurse Assistant/CNA) stated, I work with (R1) often. (R1) was in bed when I bring (R1) food and I put (R1) up in bed. Most of the time (R1) we put (R1) in (R1's) chair (geriatric recliner) because it is easier to feed (R1) when (R1) is up. When (R1) is in bed I will use (R1's) draw sheet to move (R1) in bed, that's when (R1) screamed in pain when I turned (R1). (R1) wore sleeve so I looked at it and it was red and swollen so I told nurse. Surveyor asked how she normally transfers R1 from the bed to geriatric-chair. V4 stated, I use a sling and put it on (R1) in bed, then I use the (mechanical lift) to transfer (R1) to the geriatric-chair. Surveyor asked if anyone helped her do this. V4 stated, No, I did it myself. Surveyor asked when R1 is in bed, how many staff it took to move R1 in bed. V4 stated, I did it myself. I move (R1) with the sheet and (R1) turn and I change the diaper this way or when I have to put sling under (R1). We always do it this way. On 2/1/22 at 10:20 AM, interview with V7 (CNA) stated, I worked with R1 2 days ago on the 7-3 shift. (R1) was in (R1's) chair (geriatric recliner) already when I saw (R1) because the night shift CNA dresses (R1) up and puts (R1) on the chair already. I saw (R1) one time when (R1) was sliding down from (R1's) chair and (R1) was screaming help. I pulled (R1) back up and I put (R1) back in bed so (R1) don't fall. Surveyor asked how she did this. V7 stated, I used the (mechanical) lift. Surveyor asked whether anyone assisted her with the mechanical lift. V7 stated, No I did this myself. (R1) didn't fall or anything and I didn't bang (R1's) arm or anything when I did it. Surveyor asked if she noticed the swollen arm when providing R1 care. V7 stated, No I didn't see anything, when I change R1 (incontinence brief) R1 didn't say anything. (R1) just shouts that (R1) is in pain but (R1) always complain of pain. Surveyor asked if she moves R1 herself when she changes R1 in bed. V7 stated, Yes, I do it myself all the time. Interview with V6 (RN) on 2/4/22 at 12:30 PM stated, I was told by the CNA (V4) that the resident was complaining of pain earlier during the start of my shift (3-11 Friday 1/28/22). I assessed R1's arm because (R1) pointed to it that (R1) was in extreme pain. (R1's) arm was very bruised, purple colored and it was swollen. Surveyor asked if she knew how R1 could have been injured. V6 stated, I don't know. (R1) always is in chronic pain and especially when (R1) is moved by the CNAs to get cleaned up or whenever. Surveyor asked how R1 is generally handled with transfers, toileting, and other ADLs. V6 stated, (R1) is hospice so mostly when they are not here, the CNAs will clean (R1) up and put (R1) in (R1's) chair (geriatric recliner) and then put (R1) back to bed. Surveyor asked what type of assistance R1 required in performing all of these ADLs. V6 stated, (R1) is extensive assist so there should be two people to move (R1) to (R1's) chair but the staff are supposed to use the (mechanical lift). Surveyor asked when R1 is cleaned up as she mentioned. V6 stated I know that the CNAs will change (R1) in (R1's) bed but there's also just one hospice CNA that does this by herself too when she is here. I don't think it needs two people. Efforts to contact V17 (physician) on 2/3/22 and 2/4/22 were left unanswered. On 2/3/2022 at 3:03 PM, V17 (physician) wrote in R1's progress note that read in part, Physician Progress Note: History & Physical: [AGE] year old female with Primary history of [CONDITION(S)], depression, anxiety, [CONDITION(S)], coronary artery disease without history of stroke, recurrent UTIs, dementia. Alert and oriented x 2 at baseline who presented to nursing home for evaluation of right elbow fracture. As per nursing home staff, patient was getting changed and rolled to (R1's) side and accidentally rolled into the wall as (R1's) bed is against the wall. X-ray done at the nursing home showed right elbow fracture and patient was transferred to ER for further evaluation.

Based on interview and record review, the facility failed to provide timely interventions and care for a resident who complained of pain for multiple days for one (R1) of three residents reviewed for nursing care. This failure resulted in R1 being in severe pain while waiting three days for an x-ray, then being emergently transferred to local hospital, and diagnosed with an acute right elbow fracture. Findings include: R1 is a cognitively impaired with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's progress notes of 1/28/22 at 9:28 PM written by V6 (Registered Nurse/RN) read in part, Late Entry: patient was asked about what happened to (R1) right elbow to be bruised, patient states (R1) does not remember anything and denies anybody hurting (R1). Patient also refused (R1's) hand to be immobilized in a sling to prevent pain with movements especially when repositioning a patient. Will continue to monitor. X-ray service company showed date of service on 1/30/22 at 7:16 PM, three days after V6(RN) called for x-ray company to x-ray R1's arm and elbow area. X-ray result interpreted by V18 (doctor) showed Impression: Proximal ulnar acute fracture. Interview with V6 (RN) on 2/4/22 at 12:30 PM stated, I was told by the cna (V4) that the resident was complaining of pain earlier during the start of my shift (3-11) on Friday 1/28/22. I assessed R1's arm because (R1) pointed to it that (R1) was in extreme pain. (R1) arm was very bruised, purple colored and it was swollen. I notified the hospice agency, the doctor and son to let them know. V14 (physician assistant) ordered to get x-ray of the resident and so I called the x-ray company and they said they'd come out that same night. I left for my shift at 11 PM and I found out the next day because I worked again (3-11 shift) that the x-ray company never came. The x-ray company kept telling us they would come but they still didn't, so we informed the son, hospice and the doctor know again, and we just waited. The next day Sunday (1/30/22), I worked again the 3-11 shift and the resident still had not gotten an x-ray to find out where the pain and swelling was, so I contacted the hospice nurse (V16) who called her supervisor. I pleaded with them that we need to send the resident to the hospital to get x-rays, but they said she couldn't go out because (R1) was hospice. I told them this was about patient comfort and that (R1) had been complaining for days about pain, so they finally were able to send an ambulance to go to the hospital for treatment and x-rays. Before I could send (R1) out, the x-ray people finally came to the building and took the x-ray and so we waited again for the results which showed (R1) got a fracture, so then I was finally able to send (R1) out to the hospital. Surveyor asked why it took several days for R1 to get x-rays and if anyone else from the facility followed up with the x-ray company. V6 stated, I'm not sure why. I just know that when I left for my shift, I thought the other nurse would follow up. Surveyor asked if a doctor gives orders when these orders need to be carried out. V6 stated, They should be carried out right away when you get the order and there should be a follow up to make sure it was carried out. Records from the hospital showed the ambulance arrived at the facility on 1/30/22 at 10:29 PM to transport R1 to the hospital emergency department. Hospital records read in part, Date of service: 1/30/22 11:47 PM. Patient is a [AGE] year old female with past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Alert, oriented x 2 at baseline the present to emergency department for evaluation right elbow fracture from the nursing home. Per nursing home staff, patient getting changed and getting rolled to her side and is excellently rolled into the wall as her bed abuts the wall. Patient complained of pain in her right elbow, x-ray performed today shows fracture and she is sent in for further evaluation. Facility records show on 2/2/22, R1 was readmitted back to the facility. Efforts to contact V17 (physician) on 2/3/22 and 2/4/22 were left unanswered. On 2/3/22 at 3:03 PM, V17 (physician) wrote in R1's progress note that read in part, physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Alert and oriented x 2 at baseline who presented to nursing home for evaluation of right elbow fracture. As per nursing home staff, patient was getting changed and rolled to her side and accidentally rolled into the wall as her bed is against the wall. X-ray done at the nursing home showed right elbow fracture and patient was transferred to ER for further evaluation.

Based on interview and record review, the facility failed to implement planned monitoring intervention to prevent a fall for 1 of 4 residents (R1) with a history of falls from falling and sustaining injuries. This failure resulted in R1 being sent to an acute care hospital for surgical repair for a right [MEDICAL CONDITION] due to a fall. Findings include: R1 is a [AGE] year old resident with [DIAGNOSES REDACTED]. MDS (Minimum Data Set) dated 7/2/20 shows R1 required one person physical assistance to ambulate as she was totally dependent on staff to perform this function. R1's Care plan dated 7/25/20 states, Need/Preference: Because I sometimes get confused have a [DIAGNOSES REDACTED]. 5/31/20. Approach: Place resident close to monitoring staff in dining room, educate staff to closely monitor resident in dining room. Goal: Stay safe while I'm moving about. Records document previous unwitnessed and unsupervised falls prior to 5/31/20 occurred two previous times on 5/25/20 and 1/21/20. Prior to these unwitnessed and unsupervised falls R1 fell another 5 times on 12/4/2019, 10/15/2019, 6/25/2019, 4/28/2019, and 3/5/2019. Incident report dated 5/31/20 stated, Time of Incident 3:10 PM. Type of Incident: Right Hip Closed Fracture. Description of occurrence: Alert and oriented x1-2. Ambulates with walker one staff assist. At 3:10 PM, found resident walking by herself, lost her balance and fell on the floor. Reported to nurse immediately. Head to toe assessment done. No visible injury. Complained of right hip pain. Immobilized affected area. Tylenol given for pain. MD (medical doctor) notified, order received to send resident to Lutheran General Hospital. admitted with [DIAGNOSES REDACTED]. Conclusion: After thorough investigation, it was determined that the root cause of the fracture was due to resident ambulated without staff assist, became weak and lost her balance. Interview with V6 (Wound Care Nurse) on 9/16/17 at 11:05 PM stated, I do a lot of things here, not just wound care. I did the fall investigation for R1 and my director of nursing (V2) reviews it. When asked who was assigned to be the dining room monitor when R1 fell , V6 stated, It was V15 (c.n.a. /certified nurses aide). Surveyor asked about the conclusion of the investigation as it was written, V6 stated, We concluded (R1) tried to ambulate without staff assist and that's why she fell . When asked V6 who R1 was supposed to ask for help when she's confused, she had no call light for her to use in the dining room, and there were no staff in the dining room to ask for that assistance, V6 stated, I'm not sure. On 9/16/20 at 12:20 PM interview with V14 (RN) stated, I remember (R1) and yes I took care of her. She is alert and oriented times 1-2 and she is confused and speaks mostly Russian. She is a frequent faller and I think she has fallen more than 3 or 4 times since I've been there. We try to prevent her from falling by reminding her to ask for help and we moved her to a room closer to the nursing station. She has a bed alarm but no she does not have a chair alarm but I guess we should have one on her. I was at the nursing station that day when she fell . I did not see her fall because she is usually placed around the left side of the dining room.Where the nurses sit and where I sit, we can't see around the corner but there is supposed to be a c.n.a sitting there to watch the residents. I was taking an endorsement from V3 (LPN) and around 3:15 PM or something like that, V15 came and said to come to the dining room because R1 on the floor. I went right away and I checked her. She complained of pain when we got her up so I called the doctor and got order to send her to the hospital. Surveyor asked what precautions she took to prevent R1 from falling, V14 stated, I check on her frequently and we put an alarm on her when she's in bed. We always remind her to use the call light to ask for help and we constantly try to educate her to ask for help. When asked how R1 could use a call light in the dining room, V14 stated, There wasn't one put on her in the dining room. When asked if R1 could be reminded or taught to ask for help since she was confused, V14 stated, No, I guess you can't so, we must watch her more closely. On 9/16/20 at 12:30 PM interview with V15 stated, Yes I remember R1. I was there the day she fell but I really didn't see her fall because she was already on the ground when I got to the dining room, so I ran to her right away to make sure she was okay. Surveyor asked if there were any other residents or staff in the dining room, V15 stated, I think there were about a couple of residents in the dining room but I'm not sure. But no, there wasn't any staff. When asked where she was when R1 fell , V15 stated, I was doing my rounds first before I went to the dining room because I was assigned to sit there. When asked how she was supposed to sit in the dining room and do her other nursing aide duties, V15 stated, Well we're supposed to get someone to sit there while I do my work or go on break. That doesn't always happen because we run short staffed a lot and especially on weekends, so it's not always like that there. Attempts to reach R1's attending physician were met with referrals back to the physician extender (V14). On 9/16/2019 at 1:45 PM interview with V14 (Advanced Practice Nurse) stated, I am familiar with R1's injury and fall with fracture but I don't recall getting a call for that so it could have been my partner since it was on a Sunday. I know I was not on duty on Sunday. Surveyor informed V14 that she was listed on the 5/31/20 fall incident report a being notified of the fall. V14 stated, I remember being informed about previous falls but I just don't remember about this last one. When asked whether R1 was at risk for falls, V14 stated, She is definitely at risk for falls because I recall she has fallen several times in the past from what the facility tells me. R1's progress records show in part (but not limited to): 5/31/20: 6:23 pm transferred to: Emergency Department per MD order. TIME: 4:16 PM. Reason for transfer: Fall at 3:10 pm, C/O (complain of) moderate pain on right hip pain. Treatments prior to transfer: medications: [REDACTED]. 6/4/20 7:20 pm readmitted from: Acute care hospital 6/4/20 8:34 pm muscle/skeletal findings: generalized weakness right hip FX (fracture), Right interchanetric [MEDICAL CONDITION]. muscle/skeletal pain: Moderate pain on right hip. Lower extremity range of motion: Right leg very limited movement due to surgery.

Based on observation, interview and record review , the facility failed implement turning and repositioning a resident to prevent the development and worsening of pressure sores for 1 (R3) resident of 3 residents reviewed for pressure ulcers. This failure resulted in R3 sustaining a facility-acquired pressure sore that became infected and necrotic (dead tissue). Findings include: R3 is an [AGE] year old resident with [MEDICAL CONDITION], hypertension, diabetes, and dysphasia. R3's physician orders [REDACTED]. MDS (Minimum Data Set) dated 6/3/20 show R3 requiring extensive assistance to move while in bed and is totally dependent on staff for transfers to be performed by two or more staff. MDS also shows R3 with no pressure sores upon admission to the facility and that current pressure sores were facility-acquired. R3's skin care plan dated 7/28/20 stated intervention shows, I need my aides to help me reposition at least every 1 hour when I'm in a chair. On 9/14/20 at 10:55 AM, R3 was observed in a high back recliner seated on the left hand corner against the window. R3 was asleep and lying upright in a 45 degree angle with R3 looking up towards the ceiling. R3 was fully dressed and appeared to be on top of a blue netted sling bunched up under her buttocks. On 9/14/20 at 12:05 PM, R3 remained lying in a high back recliner on the left hand corner of the main dining room waiting to be assisted in eating her pureed diet meal that was on a tray. R3 appeared uncomfortable and the sling that was left under her, the sling was still visible and her reclining position remained unchanged. At 12:35, V4 (LPN) sat down next to R3 and started to feed R3 lunch. R3 appeared to be agitated and refusing to eat what V4 was spooning in R3's mouth. V4 stood up and walked away from R3 and returned to the nurse's station. V4 went back to sit and offer R3 more food but did not adjust or reposition R3 to address her discomfort. On 9/14/20 at 1:50 PM, R3 was observed in her room on her recliner and placed next to her bed however was not placed back in bed. R3 remained in the same position on her backside with her head elevated at over 45 degrees. The same plastic nylon mechanical lift sling remained under her with no evidence of any repositioning devices such as wedges or pillows to relieve pressure from her buttocks. On 9/15/20 at 9:50 AM, R3 was lying upright in a recliner in the same corner of the dining area. She was seated atop the same plastic nylon mechanical lift sling that was used to transfer her from her bed to the recliner. V6 (Wound Nurse) was present in the dining room and when asked about R3, V6 stated, We usually get her up first thing in the morning and keep her in the recliner until after lunch when the staff put her back to bed. Surveyor asked about the plastic nylon mechanical lift sling observed under R3, V6 stated, It's okay to have it under her because the staff use it to transfer her to her recliner. When asked if the sling affected R3's wound to her sacral area, V6 stated, No It's okay, we keep the sling there because it is easier for the staff to transfer her back to bed. Asked if the sling should be removed from under R3 after each use, V6 stated,No, I think it's fine. R3's wound notes written on 9/10/20 by V6 (Wound nurse) state Weekly assessment: Onset/discovery 8/16/2020. Source: Acquired. Location: Sacrum. Original wound type: Stage 2. Current wound type: Unstageable. 3.5 centimeters length x 1.5 centimeters width x undetermined depth. Treatment: Cleanse wound with 0.9% Normal saline solution Apply ointment then top with calcium alginate, cover with bordered foam dressing/gauze daily until resolved. Comments: Wound became Worse. Wound consultation noted. Replaced mattress to low air loss mattress, cushion, repositioning every hour from side to side only. On 9/15/20 at 1:10 PM. R3 was lying in bed fully dressed atop a flat sheet that was folded up in 4 layers. Under the layered sheet was a fitted sheet wrapped tightly around the specialty air mattress. R3's wound was observed with V6 and V7 (Nurse aide) assistance. Surveyor asked V6 to describe the wound while showing the surveyor, V6 (Wound nurse) stated, The wound is on her sacrum. She got it here about a month ago. It's 90% slough and 10% necrotic (dead) tissue with redness in the surround skin area. Edges of the wound are attached and it measures approximately 3 centimeters by 1.5 centimeters and the depth is undetermined because it is not stageable. This is when I contacted V12 (wound consultant) because it worsened last week and got infected. V12 ordered a new ointment medication and we also added an air mattress. Surveyor asked V6 how long R3 would lie in bed, V6 stated, Well after lunch she's placed back in bed and she's pretty much there until bedtime because we don't get her up again until breakfast. When asked about the linens R3 laid on, V6 stated, They use this folded flat sheet to turn her and the fitted sheet is on the mattress but they should just be using the flat sheet and we shouldn't be layering the sheet under her so I see what you mean. I will ask the staff to put her in her gown when she is in bed. Interview on 9/15/20 at 2:07 PM with V12 (Wound Consultant) stated, I have not seen this patient yet but I will. I just advise them about not putting pressure on the area as much as possible and not to place her in bed as much as possible, because when you sit down there is sheer pressure that can arise. I am called upon to do wound debridements (surgical removal of dead tissue) but like I said I have not seen her yet but I was told she has necrotic tissue. When I see her I will schedule this. I do expect that the staff turn and reposition the patient frequently as much as possible and to keep pressure off that wound. (R3's) case is really tricky because she needs to be on a low air loss mattress, frequent repositioning and there should only be a flat sheet on her bed. I understand minimizing linens and I have read that but more important is keeping pressure off her pressure sore. Interview on 9/16/20 at 1:45 PM with V13 (Advanced Practice Nurse) stated, I do see (R3) and just saw her today in fact. I consult on wounds and I give doctors orders for patients R3 is not as mobile as she was before and we are trying to get her nutritional requirements up again. I have been telling the staff there to try to get her up from bed and to reposition her as much as possible to keep pressure off her pressure sore. When she is in her recliner they must keep her off her pressure sore by using pillows or wedges. When she is in bed she must be repositioned as much as possible. I don't know why they kept her up in the dining room for the amount of time you say. I just spoke to the nurse when I was there and told them that she must be placed back in the bed after meals and then to reposition her as often as possible when she is in bed. Surveyor asked if this was an avoidable pressure sore, V13 stated, I don't know if I can answer that but I know that it is healing now When asked if R3 is capable of her wound healing then if it's possible to avoid it, V13 stated, Again, I know that we are doing our best to heal the wound and I have told the staff to not put her in her recliner for long periods and place her back in bed after meals so they are correcting this. Interview on 9/16/20 at 3:15 PM with V6 (Wound Care Nurse) stated, We are supposed to reposition (R3) every hour from side to side when in bed and when she's on the multi-positional chair (recliner). Surveyor asked how staff reposition R3 while in the recliner, V6 stated, Well we can increase or decrease the incline of the back and it changes her position. When asked how this takes pressure off R3's buttocks, V6 stated, I guess it doesn't. When asked to provide any documentation that demonstrate repositioning is conducted for R3, V6 stated, On the TAR Treatment Administration Record) the nurses sign off on each shift that R3 is turned on each shift. Surveyor asked V6 what the doctor's order, V6 stated, The order says to reposition hourly from side to side. Surveyor asked who transcribed the doctor's order to the TAR, V6 stated, I thought it was a recommendation only so I put it as every shift and not every hour. Surveyor asked if the wound was avoidable, V6 stated, Yes if she was turned and repositioned like we're supposed to she would not have acquired that wound.

Based on observation, interview, and record review, the facility failed to use a mechanical lift as determined necessary by the resident's comprehensive plan of care during a transfer for one (R1) of three residents (R2, R3) reviewed for accidents. This facility failure resulted in R1 sustaining two, separate left lower leg fractures. Findings include: R1 is a [AGE] year old, nonverbal resident with [DIAGNOSES REDACTED]. 2/3/20 at 9:30AM, V1 (Administrator), stated, R1 has a fracture, and we (the facility) did report that to the State. We did an investigation of it, and it was found that the CNA's (Certified Nursing Assistants) involved (V3 and V8) had improperly transferred R1 on 1/18/20 before giving him a shower. Asked what type of transfer was recommended for R1 per his care plan, and what was performed by the CNA's, V1 stated that they did a two-person stand/pivot transfer instead of a two-person mechanical lift as ordered. 2/3/20 at 10:43AM, observed R1 lying supine in bed, sleeping, with the head of the bed elevated at approximately 35 degrees. R1's left lower leg had a [MEDICATION NAME] splint with cotton batting and ace wrapping applied to the leg, and was elevated on a pillow. 2/3/20 at 2:00PM, V2 (Director of Nursing/DON) stated, V3 told me she had improperly transferred R1. R1 is supposed to be a two-person mechanical lift. V3, with V8 assisting her, performed a two-person stand/pivot transfer from the bed to the shower chair with R1. Once V3 told me she did an improper transfer with R1, I didn't interview further because I knew what the cause of R1's injury was - it was due to the improper transfer. 2/3/20 at 3:00PM, V3 (CNA) stated, so we (V3 and V8) used a sheet under R1's knees while he was sitting on the side of the bed. We put our arms underneath each of his arms, and both of us took a side of the sheet from under his knees and then lifted him to the shower chair from the bed. Asked V3 why did you transfer R1 using a sheet instead of using the mechanical lift? - V3 stated, because I was looking for a mechanical sling, and I couldn't find one. I suggested using a sling under his knees to help move him. I know now that it was wrong, and I shouldn't have done that. On 2/4/20 at 11:20AM, V14 (Physical Therapist) stated R1's transfer status is a mechanical hoyer lift with two-persons and that R1's status was poor prior to his injury too. Transferring R1 as a stand/pivot versus his recommended two-person mechanical lift could harm R1, he does have osteopenia/[MEDICAL CONDITION]. With a comminuted and spiral fracture, the injuries could of been caused as a result of an improper transfer. Some [DIAGNOSES REDACTED]. 2/4/20 at 12:30PM, Asked V9 (Physician) if R1's type of fractures (a comminuted [MEDICAL CONDITION], and a spiral [MEDICAL CONDITION]) could have spontaneously occurred? V9 stated, R1's medical condition is fragile, he is bedridden - these (the fractures) had to have been caused by mishandling. I presumed the nursing staff mishandled R1 during care, the fractures are not going to occur spontaneously - these types of fractures have to have an extraneous force. Informed V9 of R1's transfer status being a mechanical lift with two staff persons assisting - V9 stated, Oh, I agree - he (R1) shouldn't be weight bearing, he is fragile. Review of R1's quarterly Minimum (MDS) data set [DATE], Section G (Functional Status) documents R1's transfer status as total dependence on staff assistance, and his current care plan documents R1's transfer method as an extensive assist of two-persons using a mechanical lift. Review of R1's medical chart notes R1 was being monitored for trace (slight) [MEDICAL CONDITION] to his left lower leg on 1/18/20 and 1/19/20. A portable x-ray of R1's left lower leg/foot was obtained on 1/19/20 which indicated an age-indeterminate tibia fracture, and V9 was notified of the results. R1 began to exhibit discomfort and bruising to his left lower leg, and was sent to the hospital emergency room for evaluation on 1/20/20, returning to the facility on [DATE]. Hospital x-ray report dated 1/20/20 notes R1 sustained a left lower leg fracture, stating the fractures as, Acute, mildly displaced comminuted [MEDICAL CONDITION] tibial diaphysis and Acute, mildly displaced spiral [MEDICAL CONDITION] fibula.

Based on interviews and record review the facility failed to implement interventions and adequate supervision for 1 of 3 residents (R3) to reduce the risk of choking/aspiration. (1). The facility allowed R3, to be fed on an unsupervised unit by (Z6) spouse who had no knowledge of who/how to contact the nursing staff during a medical emergency. (2.) The facility failed to facility failed to implement interventions consistent with R3's needs, goals, plan of care and current standards of practice. This failure resulted in R3, choking while being fed by Z6 on the 4th floor. R3 was taken by Z6 via the elevator to the 2nd floor to get emergency help. When Z6 arrived to the second floor and got off the elevator R3 was unconscious, pale with blue lips and head leaning forward. Z6 stated he must have fed her too fast, that R3 would not swallow food. R3 was transported to the local hospital and died of Aspiration, cardiac arrest and severe anoxic brain injury. Findings Include: Facility's Incident Report: Dated [DATE], completed by E3 (nurse) Where did this occur: on the 4th floor How did this occur: Z6 (spouse), I don't know, I was feeding her, I fed her too fast and she did not swallow. I brought her down to the nurse. Report to Illinois Department of Public Health (IDPH): [DATE] at 12:30 pm, R3 was brought from the 4th floor to the 2nd floor nursing station sitting in a special wheel chair, unconscious, leaning forward with blue lips by Z6 (spouse) who was feeding resident on an unsupervised 4th floor. The final report faxed over to IDPH noted that the root cause of the choking episode was due to Z6 feeding R3 outside food. Social Service Note: Dated [DATE] Ask family to provide cultural/ethnic foods, encourage activity participation. Z6 was asked to bring outside food into the facility to feed R3. Nursing Notes/Interviews: R3 a 77 y/o, was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R3 refused to wear her dentures during meals. R3 was at risk for choking/aspiration. R3 was carried to the 4th floor by Z6 daily to be fed lunch. The facility was aware that R3 was being carried off the unit daily by Z6 to an unsupervised floor to be fed lunch. Dietary recommendation Sheet, dated [DATE]: Resident having difficulty chewing, husband requested diet to be downgraded from a general diet to a mechanical soft diet. Dietary Progress Notes - dated [DATE] at 1:28 pm: Resident family here yesterday and noticed resident (R3) was having difficulty chewing chicken, they discussed their concerns with Russian Coordinator and wish the diet to be downgraded from general to mechanical soft. Diet changed Physician order [REDACTED]. Downgrade diet from general to mechanical soft. [DATE] at 12:15 pm, writer requested of (E1) to speak with the dietician who recommended the downgrade on [DATE]. Writer was told dietician is no longer employed and there was no contact number for her. E1 was asked why a care plan was not initiated to address the concerns/risk of R3 eating slowly, difficulty chewing and eating without dentures in mouth. E1 stated she does not know. Care plan dated, [DATE] - date of choking incident stated I have upper and lower dentures but I usually refuse to wear lower dentures, I spit them out despite encouragement. [DATE] at 12:30 pm, E1 (Director of Nursing - DON) was asked during interview why the interdisciplinary team did not address the concerns for the diet downgrade. E1 stated that the practice of the facility is to give the resident their chose of diet. Z6 fed R3 daily on another floor away from monitoring of staff and asked that (R3)'s diet be downgraded because of complications with chewing. No dietary assessments or nursing notes were initiated to see if R3 was having a chewing or swallowing problem. There was no documentation that the facility considered the development of care planning interventions for the risk of choking/aspiration. Feeding Policy and Educating families feeding residents: Family members wishing to participate in the feeding of their loved ones will be educated as to safe feeding techniques by the nurse, dietician, speech therapist or food service manger. Education may be interpreted for non English speaking families. February 11, 2014 at 1:30 pm, E1 was asked for the education/documentation regarding feeding residents and aspiration precaution risk for Z6. E1 did not have any documented information that Z6 received education on feeding and aspiration precautions. February 13, 2014 at 11:55 am, the Russian Coordinator (E10) was interviewed and stated she is the only one who is able to communicate in Russian for Z6, who speaks only Russian. (E10) stated she was on vacation when the choking incident happened. (E10) stated that she would often come back up to the fourth floor about 1:20 pm when she finished helping with residents during lunch on the second floor and would find (Z6) feeding her still on the 4th floor. (E10) stated she often would remind (Z6) not to put too much food in her mouth and wait for her to swallow. (Z10) was asked if there is any documentation of evidence that Z6 assumes all responsibility for taking R3 off the unit during meal time to feed her. Z10 responded no she does not have anything documented. Physician Interview: February 13, 2014 at 1:45 pm, Z7 (Primary Physician) was asked why an order was given to downgrade R3 from a general diet to a therapeutic diet (mechanical soft). Z6 stated because the patient was not able to chew her food per the call he received on [DATE]. The woman has dementia and would not understand. "The woman requires 100% feeding by staff or someone to be done. " She does not take solid foods well, I have heard it before and when I got the call this time. I gave the order for soft foods because she does not wear her denture. [DATE] at 12:55 pm, E3 (nurse) stated that Z6 was feeding R3 on the 4th floor by the patio. E3 nurse stated that Z6 would take R3 up to the 4th floor for lunch every day. E3 stated that around lunch time, the nursing assistants (E4, E6 and E7) brought R3 to the nursing station. E3 stated that Z6 brought R3 down from the 4th floor to the 2nd floor. E3 stated that R3 was unresponsive, and pale with blue lips. February 11, 2014, E5 (nurse) stated he came from the 3rd floor via stairs to the second floor in response to a code blue. E5 stated when he arrived he saw E3 suctioning R3. E5 stated he asked what happened and was told by E3 that R3 choked on food. E5 stated that R3 was unresponsive, pale with blue lips and head leaning forward. E5 stated that R3 did not respond to verbal and tactile stimuli. February 11, 2014 at 12:20 pm, E4 stated that Z6 came off the elevator with R3 from the 4th floor where Z6 was feeding R3. E4 stated that R3 was slumped forward in the wheel chair, lips were very blue and face was pale. E4 stated that Z6 said he doesn ' t know what happened that he must have fed R3 too fast, and that R3 would not swallow. February 21, 2014 at 3:35pm, E1 (Nursing Director) and E14 (Administrator) was asked if the facility has a safety mechanism in place to protect/identify residents at risk for choking/aspiration from being fed in an unsupervised area. E1 and E14 responded no. February 21, 2014 at 3:45 p.m. E14 and E1 stated that the 4th floor bathroom has a call cord that will buzz at the 3rd floor nursing station. E14 and E1 were asked is there any posted information that the visitors would know to go to the 4th floor bathroom and pull the cord for medical emergencies. E14 and E1 responded no they would not know and no we do not have anything posted.

Based on record review and interview, the facility failed to provide adequate supervision and implement adequate fall prevention measures for 1 (R1) of 3 residents from the sample of 3 reviewed for falls. This failure resulted in R1 receiving a hematoma and pubic remus bone fractures. Findings include: R1 is a [AGE] year old female, originally admitted to the facility on [DATE], with the following Diagnoses: [REDACTED]. R1's MDS (Minimum Data Set) dated 8/17/12 (Annual), and 2/1/13 (Quarterly) documents: Walk in room- requires supervision Walk in corridor- requires supervision Locomotion on unit- requires supervision Mobility device: walker The facility's Incident reports and Investigation summary for R1 documents the following falls: R1 sustained a fall on 6/15/11 at 10:15am, while trying to get out of bed to go to the bathroom. The investigation summary documents that R1 was sent to hospital, and returned on 6/21/11 with the [DIAGNOSES REDACTED]." R1 sustained a fall on 11/26/11 at 9:22pm. The report documents that R1 got up too fast, and lost her balance. R1 was able to stand and ambulate with assistance; however, the facility implemented a low bed after this fall. R1 then sustained a fall on 12/12/11, sliding off the bed. At this time the facility documented the following intervention: " Correct height of bed applied, currently on low bed with 2 mattresses." On 7/14/12, R1 sustained a fall while trying to go to the bathroom. On 11/20/12 the facility's incident report/summary documents that the Certified Nursing Assistants (C.N.A's) heard a crash, and found R1 lying next to the door and bathroom. The report further documents that R1 was bleeding from the back of her head and stated she was sleep walking. The summary of the investigation documents that the fall was attributed to medications, and R1 was just administered Dilaudid 4 mg at 10pm, Xanax 0.25mg, Wellbutrin XL 300mg and Elavil 50mg at 9pm. R1's care plan documents that the facility implemented a bed alarm, however, R1 refused the alarm. R1's MAR (Medication Administration Record) and POS (physician's orders [REDACTED]. R1 sustained another fall on 2/1/13 which documents that E9 (Certified Nursing Assistant/C.N.A) was making rounds and heard R1 calling for help. Upon entry into R1's room, E9 noted her sitting on the floor at her bedside. The conclusion of the investigation documents: "It was determined that the root cause of the occurrence that resulted to left SDH (subdural hematoma) and left pubic rami fracture can be attributed to the internal risk factor-medications (resident received Morphine Sulfate 15mg, Percocet 10-325mg, Xanax 0.25mg 2-5 hours before the incident). R1's MAR and POS dated 2/1/12 documents the following medications: [REDACTED]. On 3/5/13 at 1:07 pm, E11 (Licensed Practical Nurse/LPN) stated that R1 had floor mats and a bed alarm. E11 stated that R1 would get up and fold the mats and remove the alarm and walk in her room. On 3/6/13 at 3:26pm, E7 (C.N.A) stated that R1 sustained a fall on 11/20/12, and he was the first respondent to her room. E6 stated that R1 told him she wanted to use the bathroom. E6 added "she is a fall risk". E6 also stated "I always complain to the nurse because one day, I saw her disconnect the alarms." E6 stated that R1 has to be monitored closely because she knows how to disconnect the alarms. E6 stated that R1 can walk and "we sometimes we ask if she wants to go to the bathroom, but she is not on a set schedule". On 3/6/13 at 3:10pm, E6 (LPN) confirmed that R1 slid off her mattress in Dec/2011. On 3/7/13 at 10:02am, E9 (C.N.A) stated that she is R1's regular C.N.A. E9 added that every time R1 fell , she would have slipped while walking. E9 stated that she has never assisted R1 to the bathroom. E9 stated that on 11/20/12 she had walked past R1's room and saw her walking. E9 stated "the door was a little bit opened and I saw her walking. I didn't see where she was going." E9 stated she did not enter the room to assist R1. E9 stated she was making rounds of the residents on the unit and that when she came back to R1's room, she was on the floor. E9 stated that R1 gets up and walks by herself a lot. E9 stated that on 2/1/13, she was making shift rounds and R1 was calling for help. E9 said that when she entered the room, R1 was on the floor; "the problem is she removes all the alarms and walks." On 3/7/13 at 10:47am, E10, (LPN) stated that on 11/20/12, the staff found R1 lying on the floor right behind the door. E10 stated "It was hard to get into the room because she was right behind the door." E10 added that R1 had blood behind her head and was complaining of pain in her left hip. E10 stated "she walked by herself quite a bit, but we did help her occasionally. She walked alone at first, but after this incident we said we have to help her, she was on a lot of narcotics." E10 stated "once in a while she would be sitting watching TV, and 20 minutes later she would be sleep with her mouth open." On 3/7/13 at 12:48pm via phone conversation, E8 (Registered Nurse/RN) stated that on 2/1/13, she found R1 on the floor yelling and complaining of hip pain. E8 added that the "staff is supposed to stand by and assist R1 when ambulating because she uses a walker and is a fall risk." "She knows how to remove the alarms." On 3/7/13 at 2:47pm via phone conversation Z3 (Psychiatrist) stated R1 was suffering from depression and always wanted to stay in her room a lot, but it was not safe for her. On 3/7/13 at 3:00pm, E2 (Director of Nursing) stated "she needs supervision outside of the room, not inside." Then E5 (Director of Quality Assurance) said "R1 stated in her dreams she was trying to go to the bathroom." On 3/11/13 at 10:45am via phone conversation, Z2 (Medical Doctor) stated that he explained to R1 that all of the medications could cause "balance problems." Z2 stated it was difficult to balance R1's level of comfort and pain relief. Z2 did not state the medications had been reviewed and re-evaluated. On 3/11/13 at 12:55pm, Z1 (Medical Doctor) stated that R1's pain medications were necessary. However, Z1 stated that the facility informed him that R1 had some falls related to her medications. Z1 did not state whether any medication changes had been implemented. The facility was asked to provide documentation of R1's restorative programs from May/2012 - Feb/2013. Although staff and the facility's incident reports indicated that R1 fell while attempting to go to the bathroom on at least 3 occasions, R1 was not on a toileting program. R1's care plan for the fall she sustained on 7/21/12 documents that she was on a walking program. R1's restorative assessment dated [DATE] documents: "Restorative programs will be discontinued." R1's care plan interventions for the falls on 11/20/12 and 2/6/13 documents restorative re-assess for functional status. There were no restorative assessments located in R1's medical record for these dates. On 3/7/13 at 1:18pm, E4 stated that R1 was not on a restorative program since they were discontinued on 11/14/12. R1's fall risk assessment dated [DATE] documents that R1 is at risk for falls. There was no fall risk assessment located in R1's medical record after she sustained the fall on 11/20/12. After R1 sustained a fall on 2/1/13, the fall risk assessment was completed on 2/4/13 (3 days after the fall). On 3/7/13 at 2:22pm, E3 (MDS/ Care Plan Coordinator/LPN) stated that the fall risk assessment dated [DATE] applies to the fall R1 sustained on 11/20/12 (six days after the fall). On 3/7/13 at 1:18pm, E4 (Assistant Administrator/LPN) stated that the facility's policy is to complete a fall assessment for each resident on admission, quarterly and after each incident and for adding care plan interventions. E4 stated that R1 requires minimal assistance with ambulation. E4 stated that when R1 fell on [DATE], she wanted to go to the toilet and she rolled off the bed. "R1 is on a lot of pain medications which contributed to her fall. " E4 stated that the facility gave R1 a bed alarm but she refused. E4 was then asked, what interventions were added after R1 refused the alarm? E4 stated the facility offered R1 a laser sensor alarm, but she refused that as well. E4 stated "I have a background in pharmacy and with all this medication, she would be euphoric. In my opinion this is causing these accidents". R1's radiology report from the local hospital dated 6/17/11 documents the following impression: Right inferior pubic remus fracture and possible fracture of the right superior pubic remus laterally. R1's physical exam from the local hospital dated 11/20/12 documents: Head is with contusion and with laceration. R1's imaging results from the local hospital dated 11/20/12 documents: head laceration - staple X 1. R1's radiology report from the local hospital dated 2/2/13 documents the following impression: -Acute left pubic rami fractures. - Subacute fracture of the left superior pubic remus. R1's CT (Computed Tomography) from the local hospital dated 2/2/13 documents: Clinical indication- Parenchymal contusion; subdural hematoma Impression- there is evidence for a trace amount of acute extra-axial hematoma in the left temporal region. The facility's policy regarding incidents- Reportable and Non-Reportable documents: All resident falls will be assessed and the resident ' s existing plan of care will be evaluated for needed changes. The resident's Fall risk Assessment shall be reviewed and revised as needed. The resident's plan of care shall be updated if additional care interventions are necessary.

This REQUIREMENT is not met as evidenced by: Medication records shall include or be accompanied by recent photographs or other means of easy, accurate resident identification. Medication records shall contain the resident's name, diagnoses, known allergies [REDACTED]. Based on interview and record review the facility failed to ensure 1(R3) out of 4 residents reviewed for abuse remained free from a significant medication error. As a result of this medication error R3 was hospitalized and treated for [REDACTED]. Findings Include: Transferral and Referral Record dated 11-24-2011 documents that R3 was transferred on 11-24-2011 at 10:14AM to the hospital reason: "Lethargic, arousable by verbal and tactile stimuli, audible wheezing." Hospital Record History and Physical Form dated 11-24-2011 states, "R3 was transferred to the hospital due to increasing lethargy. The patient was given 2 Milligrams of [MEDICATION NAME](Opioid antagonists) Intravenously and immediately woke up and was found to be extremely agitated. R 3 was sent for a Computerized Axial Tomography(CAT) scan of the brain and when R3 returned from the CAT scan of the brain was again found to be very lethargic with pinpoint pupils. R3 was given another 2 Milligrams of [MEDICATION NAME] and woke up and got agitated again. R3's urine Tox screens were negative. No clear etiology for R3's behavior could be explained. There was no history of using any narcotics or any known drug abuse. R3 was admitted to the Intensive Care Unit." Transferral and Referral Record dated 11-26-2011 and 11-27-2011 documents "R3's urine toxicology is positive for benzodiazepines and opiates" and in the Plan section the record documents "It is still unknown how the opiates got in her system, however, it is too late to do another toxicology evaluation." Patient Information and Transfer Form dated 11-29-2011(hospital discharge record) documents a [DIAGNOSES REDACTED]. Physician order [REDACTED]. On 1-10-2012 at 3:08PM in the conference room E2(Director of Nursing, DON) stated that this incident was investigated as abuse. One of the nurses made a medication error and gave R3 [MEDICATION NAME] which was the roommates medication. The nurse did not realize that it was a error until R3 returned from the hospital several days later and the same nurse readmitted R3. On 1-11-2012 at 3:51PM in the conference room, E9(Nurse) stated, "I apologize, I made a mistake and gave [MEDICATION NAME] to R3 and I gave [MEDICATION NAME] a few hours earlier. I did not realize it until I readmitted R3 with a narcotic overdose diagnosis, I then realized that I gave the wrong medication on 11-23-2011 and R3 went to the hospital on 11-24-2011. I reported the medication error on 11-30-2011." On 1-12-2012 at 1:08PM via telephone Z3(Pharmacist) stated, "[MEDICATION NAME] with [MEDICATION NAME] can cause increased drowsiness, that's about it. [MEDICATION NAME] has a small amount of [MEDICATION NAME] which could cause some dizziness or drowsiness. Both medications can be taken together. [MEDICATION NAME] and [MEDICATION NAME] together given at one time will not likely cause an overdose even if the person was not prescribed [MEDICATION NAME]." .