Every finding on record at Ascension Nazarethville Place

Based on observation, interview and record review the facility failed to implement its policies and procedures to prohibit and prevent abuse. This deficiency affects (R1) of three residents reviewed for Abuse Prevention Program.Findings include:On 12/31/25 at 9:12AM, V3 Family member/R1's sister said that she was notified by nurse that R1 had bruised on right hand and forearm last week. R1 had incidents of found bruises in the facility. V3 said that they are not doing anything to prevent her from having these bruises. V3 believed that R1 is being abused.On 12/31/25 at 9:27AM, V1 Administrator said that last week 12/24/25, R1 was observed to have bruises on her hand. V1 said he already submitted facility reported incident to IDPH. V1 said that R1 had incident reported last [DATE] due to unknown bruising on her left eyebrow. V3 Family member/R1's sister who is also a resident in the facility in another unit, who keeps on calling the IDPH for abuse allegations. V3 is accusing facility of abusing R1 due to her occurrences of bruises. He said that R1 has behavioral issues of agitation and physical aggression. She has tendency to resist care and swing her arms that may hit hard objects. R1 is on blood thinning medication which bruising is expected side effects.On 12/31/25 at 9:33AM, Observed R1 up in high back chair in the 2nd floor hallway near the nursing station. She is alert to herself and responsive but irritated and does not want to be bothered.On 12/31/25 at 9:35AM, V4 LPN (Licensed Practical Nurse) said that she is regular nurse assigned for R1. R1 is alert but confused and has behavioral issues of agitation and resistive to care. R1 had history of bruises due to her medication side effects and agitations. She has tendency to swing her arms when resisting care and may hit hard objects. Surveyor asked V4 to check bruises on right hand and forearm. Observed fading bruises yellow green discoloration on right dorsal hand and forearm. R1 said she did know what had happened to her hand and does not want to be bothered.On 12/31/25 at 10:17AM, Both V1 Administrator and V2 Social Service Director (SSD) said that V3 Family member called multiple time to IDPH for allegations of resident abuse to R1. All allegations are unsubstantiated. Both said that abuse /neglect assessment are done upon admission, quarterly, annually, significant change and in allegation of abuse.On 12/31/25 at 10:30AM, Reviewed R1's medical records with V1 Administrator. R1 is re- admitted on [DATE] with diagnosis listed in part but not limited to Parkinson's disease, Atrial fibrillation, Congestive heart failure, Hypertension, Type 2 Diabetes Mellitus, Stage 3 chronic kidney disease, Dementia, Anxiety disorder, Depression, Cognitive communication deficit, Psychosis, History of falling. Active physician order sheet indicated: Alprazolam 0.25mg tablet by mouth every 8 hours as needed for anxiety. Eliquis 2.5mg tablet by mouth twice a day for atrial fibrillation. Escitalopram 5mg tablet by mouth every day for Depression. Donepezil 10mg tablet by mouth every day for Alzheimer's disease. R1's facility incident report of abuse allegation dated 10/10/25 and 12/24/25. Active comprehensive care plan indicated: Cognitive loss/dementia. She demonstrates altered level of cognitive function due to unspecified dementia, depression, anxiety disorder and unknown psychosis as evidenced by intermittent episodes of verbal and physical aggression particularly during care interactions with CNA (Certified Nurse Assistant)s. Intervention: Monitor behaviors to ensure staff and resident safety while exploring appropriate interventions. She needs assistance with daily ADL ( Activity of daily livings) care, impaired functional mobility/wheelchair bound, resistive to care, 2 staff will be present to provide ADLs at all times. She is at risk for abuse and neglect. She is cognitively impaired. Diagnosis of dementia, psychosis, depression, and anxiety. Prefers to be in her room, social isolation. Reported for resistive to care verbally and behavioral aggression. Abuse care plan was not updated after allegation of abuse on 12/24/25. No abuse/neglect assessment was found for 2025. No abuse assessment was done after abuse allegation incident in October and December 2025.On 12/31/25 at 10:56AM, V6 RN (Registered Nurse) said that she is the regular nurse and the assigned nurse on the day of incident (12/24/25 3-11 shift) . Around 4pm, V7 CNA reported of observing bruise on R1's right wrist and forearm. V6 RN assessed R1's right wrist bruise measuring 4cm x 3cm and right forearm bruise measuring 2cm x 2cm. R1 denied pain upon assessment. V6 notified primary care physician and ordered x-ray of right hand. She notified V3 Family member, who is a resident in another unit and visited R1. Around 9pm, V3 informed V6 that she called police officer because she believed that the bruises are from abusing R1. Around 10pm, the police officer came and conducted investigation. V6 updated V1 and V2 of the incident. V6 said that R1 is prone to bruising due to anticoagulant medication side effects and her behavioral issues of agitations. She may swing her arms when agitated and may hit hard objects. V6 said that they used to apply Geri sleeves to protect her upper arms, but she refused. V6 did not remember if she documented it. V6 said that they used Broda chair/padded chair to R1. V6 said that they did not use padded side rails, but they use pillow to each side of the bed for protections. Informed V6 that R1 was observed today, using high back wheelchair not padded. R1's room was observed with 2 pillows only in her room. V5 CNA said that she used 2 pillows on her head and does not use pillows on bilateral side rails as protection when in bed. V6 said that they can use devices such as Geri sleeves and padded side rails or pillows as protection for R1 from injury.On 12/31/25 at 12:04PM, V2 SSD said that he did not complete abuse/neglect assessment. The last time he attempted to complete annual assessment for 8/15/25, but V3 Family member refused. V2 said that he did not document R1 or V3 refusal of abuse assessment. No abuse assessment was done in Oct and [DATE] after allegation of abuse or incident of bruising on unknown injury. There was no abuse assessment was done on MDS significant change of condition dated 11/3/25. No abuse assessment done for 2025. V1 Administrator said that they should document any refusal of assessment of abuse. Abuse assessment should be completed after each allegation of abuse and assessment corresponding to MDS/Resident assessment review.On 12/31/25 at 1:30PM, V1 Administrator said that they don't have policy on Resident safety /Prevention of injury. Facility's policy on Abuse Prevention revised 8/2025 indicated: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes, but is it not limited to, freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse and physical or chemical restraint to required to treat the resident's symptoms. The objective of the abuse policy is to comply with the seven-step approach to abuse and neglect detection and prevention. Prevention: A. The community will develop and implement policies and procedures to aid our community in prevention and prohibiting all types of abuse, neglect or mistreatment of our residents. C. Implement preventive measures to address factors that may lead to abusive situations for example: 5. Involve the resident/family group council in developing, monitoring and evaluating the community's abuse prevention program. 8. Monitor associates on all shifts to identify inappropriate behaviors towards residents9. Identification, ongoing assessment, care planning and appropriate interventions and monitoring of residents with needs and behaviors that may lead to conflict or neglect.

Based on observation, interview and record review facility failed to ensure to provide adequate supervision and develop new care plan intervention to prevent injury/bruising to resident who has history of injury of bruising. This deficiency affects one (R1) of three residents reviewed for Adequate supervision and Prevention of Injury.Findings include:On 12/31/25 at 9:12AM, V3 Family member said that she was notified by nurse that R1 had bruised on right hand and forearm last week. R1 had incidents of found bruises in the facility. V3 said that they are not doing anything to prevent her from having these bruises. V3 believed that R1 is being abused.On 12/31/25 at 9:27AM, V1 Administrator said that last week 12/24/25, R1 was observed to have bruises on her hand. V1 said he already submitted facility reported incident to IDPH. V1 said that R1 had incident reported last [DATE] due to unknown bruising on her left eyebrow. V3 Family member/R1's sister who is also a resident in the facility in another unit, who keeps on calling the IDPH for abuse allegations. V3 is accusing facility of abusing R1 due to her occurrences of bruises. He said that R1 has behavioral issues of agitation and physical aggression. She has tendency to resist care and swing her arms that may hit hard objects. R1 is on blood thinning medication which bruising is expected side effects.On 12/31/25 at 9:33AM, Observed R1 up in high back chair in the 2nd floor hallway near the nursing station. She is alert to herself and responsive but irritated and does not want to be bothered.On 12/31/25 at 9:35AM, V4 LPN (Licensed Practical Nurse) said that she is the assigned nurse for R1. She said, that R1 is alert but confused and has behavioral issues of agitation and resistive to care. R1 had history of bruises due to her medication side effects and agitations. She has tendency to swing her arms when resisting care and may hit hard objects. V4 said that R1 needs assistance with ADLs (Activity of daily living) and transfers. She needs 2-person mechanical lift transfer. V4 said that R1 has bilateral floor mats. V4 said that they are not using Geri sleeves (Protective sleeves), or side rails pad for R1. for Surveyor asked V4 to check bruises on right hand and forearm. Observed fading bruises yellow green discoloration on right dorsal hand and forearm. R1 said she did know what had happened to her hand and does not want to be bothered. Observed R1's room with V4 LPN. Observed bilateral floor mats against the wall. 2 pillows on the bed.On 12/31/25 at 9:44 AM, V5 CNA (Certified Nurse Assistant) said that she is the assigned CNA for R1. R1 is alert but confused and has behavioral issues of agitation and resistive to care. She is aware that R1 has bruised on her right hand. R1 has tendency to swing her arms when resisting care and may hit hard objects. V4 said that R1 needs assistance with ADLs and transfers. She needs 2-person mechanical lift transfer. V4 said that R1 has bilateral floor mats. V4 said that they are not using Geri sleeves, or side rails pad for R1.On 12/31/25 at 10:17AM, Both V1 Administrator and V2 Social Service Director (SSD) said that V3 Family member called multiple times to IDPH for allegations of resident abuse to R1. All allegations are unsubstantiated. Both said that abuse /neglect assessment are done upon admission, quarterly, annual, significant change or in allegation of abuse.On 12/32/25 at 10:30AM, Review R1 medical records with V1 Administrator. R1 is re- admitted on [DATE] with diagnosis listed in part but not limited to Parkinson's disease, Atrial fibrillation, Congestive heart failure, Hypertension, Type 2 Diabetes Mellitus, Stage 3 chronic kidney disease, Dementia, Anxiety disorder, Depression, Cognitive communication deficit, Psychosis, History of falling. Active physician order sheet indicated: Alprazolam 0.25mg tablet by mouth every 8 hours as needed for anxiety. Eliquis 2.5mg tablet by mouth twice a day for atrial fibrillation. Escitalopram 5mg tablet by mouth every day for Depression. Donepezil 10mg tablet by mouth every day for Alzheimer's disease. Active comprehensive care plan indicated: Cognitive loss/dementia. She demonstrates altered level of cognitive function due to unspecified dementia, depression, anxiety disorder and unknown psychosis as evidenced by intermittent episodes of verbal and physical aggression particularly during care interactions with CNAs. Intervention: Monitor behaviors to ensure staff and resident safety while exploring appropriate interventions. She needs assistance with daily ADL care, impaired functional mobility/wheelchair bound, resistive to care, 2 staff will be present to provide ADLs at all times. She is at risk for pressure ulcer and other skin related injuries. 10/11/25 left eye redness and closed linear lesion of left forehead/healed. CT of head and cervical spine done. Intervention: Observe skin for redness and breakdown during routine care. She is at risk for complications from blood thinning medication. Eliquis as ordered. Monitor for presence of absence of signs of active bleeding such as hematuria, petechiae, bruising, bloody stool or nosebleed at least daily. Total body checks for all anticoagulants except for ASA are done with baths by CNAs and once a week by licensed nurse. This will be recorded on the treatment records. She is at risk for abuse and neglect. She is cognitively impaired. Diagnosis of dementia, psychosis, depression, and anxiety. Prefers to be I her room social isolation. Reported for resistive to care verbally and behavioral aggression. Informed V1 that Abuse care last updated 10/17/25. No abuse/neglect assessment was found for 2025. No abuse assessment was done after abuse allegation incident in [DATE]. No documentation found regarding skin assessment at least daily monitoring for bruising as medication side effects of anticoagulant medication Eliquis as indicated in care plan. Skin impairment was not updated of bruises found on right hand and forearm. Last care plan conference held with V3 Family member was 9/18/25. No care plan conference with the family after V3's multiple abuse allegation against the facility leading to multiple visits from IDPH. There is no documentation of IDT meeting to develop new care plan interventions to prevent re-occurrence of bruising or protecting R1 from bruising. V1 Administrator said that care plan should be updated. V1 said that he will address all the above concerns.On 12/31/25 at 10:56AM, V6 RN (Registered Nurse) said that she is the regular nurse and the assigned nurse on the day of incident (12/24/25 3-11 shift). Around 4pm, V7 CNA reported of observing bruise on R1's right wrist and forearm. V6 RN assessed R1's right wrist bruise measuring 4cm x 3cm and right forearm bruise measuring 2cm x 2cm. R1 denied pain upon assessment. V6 notified primary care physician and ordered x-ray of right hand. She notified V3 Family member, who is a resident in another unit and visited R1. Around 9pm, V3 informed V6 that she called police officer because she believed that the bruises are from abusing R1. Around 10pm, the police officer came and conducted investigation. V6 updated V1 and V2 of the incident. V6 said that R1 is prone to bruising due to anticoagulant medication side effects and her behavioral issues of agitations. She may swing her arms when agitated and may hit hard objects. V6 said that they used to apply Geri sleeves to protect her upper arms, but she refused. V6 did not remember if she documented it. V6 said that they used Broda chair/padded chair to R1. V6 said that they did not use padded side rails, but they use pillow to each side of the bed for protections. Informed V6 that R1 was observed today, using high back wheelchair not padded. R1's room was observed with 2 pillows only in her room. V5 CNA said that she used 2 pillows on her head and does not use pillows on bilateral side rails as protection when in bed. V6 said that they can use devices such as Geri sleeves and padded side rails or pillows as protection for R1 from injury.On 12/31/25 at 11:08AM, V8 CNA said that regular CNA and the assigned CNA in the morning incident on 12/24/25. R1 is alert but confused with behavioral issues of agitation and resistance to care. She dressed R1 by herself. She did not observe any bruising not redness on R1's hand but she complaint of pain which she reported to the nurse on duty, and she was given pain medication. She said that R1 does not use Geri sleeves and did not use bilateral pillows on side rails as protection. V8 said that R1 should have skin protection devices such as Geri sleeves or padded siderails.On 12/31/25 at 12:04PM, V2 SSD said that he did not complete the abuse/neglect assessment of R1. The last time he attempted to complete annual assessment for 8/15/25, V3 Family member refused. V2 said that he did not document R1 or V3 refusal of abuse assessment. No abuse assessment was done in Oct and [DATE] after allegation of abuse or incident of bruising on unknown injury. There was no abuse assessment was done on MDS significant change of condition dated 11/3/25. V1 said that they should document any refusal of assessment of abuse. Abuse assessment should be completed after each allegation of abuse and assessment corresponding to MDS review.On 12/31/25 at 1:30PM, V1 Administrator said that they don't have policy on Resident safety /Prevention of injury. Facility unable t provide policy on Resident safety / Prevention of injury.Facility's policy on Comprehensive person-centered care plan revised 10/2021 indicated: Policy statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs, that are identified through evaluation and assessment, is developed and implemented for each resident. Policy interpretation and implementation: N. Assessment of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.Facility's policy on Abuse Prevention revised 8/2025 indicated: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes, but is it not limited to, freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse and physical or chemical restraint to require treating the resident's symptoms. The objective of the abuse policy is to comply with the seven-step approach to abuse and neglect detection and prevention. Prevention: A. The community will develop and implement policies and procedures to aid our community in prevention and prohibiting all types of abuse, neglect or mistreatment of our residents. C. Implement preventive measures to address factors that may lead to abusive situations for example: 5. Involve the resident/family group council in developing, monitoring and evaluating the community's abuse prevention program. 8. Monitor associates on all shifts to identify inappropriate behaviors towards residents9. Identification, ongoing assessment, care planning and appropriate interventions and monitoring of residents with needs and behaviors that may lead to conflict or neglect.

Based on Interview and Record Review, the facility failed to protect a resident (R1) from Neglect when a resident requested to be changed, and V6 (Certified Nurse Aide/CNA) did not change the resident during the V6's shift and was changed by the next shift CNA. This failure affected 1 resident (R1) of 3 reviewed for Neglect.Findings Include:On 9-2-25 at 10:24 AM, V1 (Administrator/ Human Resources) said R1 is alert, oriented, and able to make her needs known. R1 told previous Director of Nursing/DON that R1 requested V6 (Certified Nurse Aide/CNA) to change her brief and be changed for the day and return to bed. V6 replied it was too much work. V6 was already in bed. V6 told R1 that when you are back in bed (we are not getting you back up). R1's peri care was not performed until next shift. V1 said she felt the V6 intimidated R1 where R1 would feel uncomfortable in asking for help. V1 said CNA willfully held back from changing R1 when R1 wanted to be changed which is Neglect. V1 said facility investigation substantiated Neglect. V1 said R1 was terminated.On 9-2-25 at 9:50 AM, V3 (Social Service Director) said R1 told V1 (Administrator) with V3 present, R1 requested to be changed, and the CNA did not return to assist resident.Initial State Reportable dated 7-31-25 documents: Resident alleged that CNA did not provide care based on facility standards today. CNA Nina suspended. Nursing instructed to do body assessment. Investigation initiated. Family and MD notified. Final investigation to follow.Final State Reportable dated 8-8-25 documents: Following investigation, CAN openly admits to not performing peri-care checks on resident at all during her shift. When ask why, CNA stated I don't know. She will usually call for help if she needs to be changed. Administrator asked staff CNA how often peri-care checks should be completed as per facility policy, in which staff CNA replied, every 2 hours or more if necessary. Resident stated that following breakfast, she used her call light for staff CNA to please come and change her brief as well as her clothes for the day. Resident requested to be placed into bed for this, however per resident staff CNA replied with its too much work for us, once you're back in bed you're back in bed. Resident peri-care was not completed until the new CNA arrived for the PM shift around 2:30 PM when resident called for the primary nurse to inform her of the situation. After completing the above investigation, it has been determined by this administration that there was substantiated resident neglect due to a staff CNA member knowingly not attending to peri care needs for one resident during her shift stating that she didn't know why she did not check on this resident. Abuse Prevention Policy (revised 8-24) documents: Policy Statement: Our residents have the right to be from abuse, neglect, misappropriation of resident property, and exploitation. The objective of the abuse policy s to comply with the seven-step approach to abuse and neglect detection and prevention.

Based on observation, interview, and record review the facility failed to monitor and dispose of expired insulin medication per the facility policy for Insulin Pens. The facility failed to remove the insulin pen after 28 days of opening per manufacturer recommendation. This deficiency affects one of two medication carts (2nd Floor Middle Cart) reviewed for Safe Medication Storage. This failure affected 1 (R63) of 3 residents reviewed for medication label and storage. Findings include: On [DATE] at 11:00AM, surveyor observed 2nd Floor Middle Cart [NAME] with V5 (Registered Nurse/RN) and discovered an expired Lantus Kwikpen dated [DATE] - [DATE], Lot#4F9646A. When asked V5 (Registered Nurse) responded that it should have been disposed of after 28 days and wasn't sure why it was still in the medication cart. When asked if it was used recently for R63, V5 (RN) checked the EMAR and confirmed that it was used the previous night by the evening nurse. V5 (RN) did remove and dispose of the expired Lantus Kwikpen from the medication cart while in the presence of the surveyor. V5 (Registered Nurse) stated that she was going to let pharmacy know about the expired insulin medication for R63. R63's EMAR on [DATE] at 9:57PM showed she received 7units of Lantus Insulin On [DATE] at 11:30AM, informed V2 (Director of Nursing/DON), V2 states that depending on the brand of insulin pens once opened they are good for ,d+[DATE] days and newer brands can be used even longer. V2 (DON) states that nurses are educated on insulin administration and are instructed that insulin pens are only good for ,d+[DATE] days after first use. V2 (DON) states the facility had an all-nurse staff in-service within the last ,d+[DATE] weeks. When asked how often carts are audited and by whom V2(DON) states monthly audits are performed by pharmacy and shift nurse should check the medication cart for medications that are expiring the next ,d+[DATE] days to insure they are refilled. V2 (DON) states he had R63 assessed vitals, blood glucose, and all within normal limits. V2 (DON) states he called R63's POA to inform them that a expired insulin was administered. V2 (DON) states R63 reports feeling fine, no issues or concerns. On [DATE] at 1:59 PM, surveyor attempted to call V6 (Registered Nurse/RN) regarding patient care on the evening of [DATE] for R63. Left voicemail. Medication administration records from ([DATE] through [DATE]) showed evening administrations of Lantus insulin (7 units) for R63 as of start date of [DATE]. Facility's policy on Medication Storage ( Rx Insulin Pen Policy date of last review [DATE]) Policy: It is the policy of this facility to safely dispense insulin pens when prescribed in this facility. II. Purpose: The purpose of this policy is to provide guidelines for the safe dispensing of insulin pens to this facility. V. Procedure: Described in policy 4. Pharmacy will affix two auxiliary labels, the first will indicate that nursing should Refrigerate unopened pens upon receipt from the pharmacy, and the second label allows for nursing to write the date that the pen was first opened for use, and the date the pen must be discarded, based on Appendix A document.

Based on observation, interviews and record reviews, the facility failed to implement interventions in preventing the development of a pressure ulcer in relation to repositioning and skin monitoring for one (R12) of one resident reviewed for pressure ulcers in the sample of 26. This deficiency resulted in R12's stage III pressure ulcer in the coccyx area worsen to stage IV pressure ulcer with ongoing infection requiring antibiotic therapy. Findings include: R12 is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including but not limited to Hypertensive Heart Disease with Heart Failure; Paroxysmal Atrial Fibrillation; Unspecified Osteoarthritis, Unspecified Site; Dysphasia, Oropharyngeal Phase; and Unsteadiness on Feet. According to MDS (Minimum Data Set) dated 10/25/2022 under Section C, R12 has a BIMS (Brief Interview of Mental Status) score of 12 indicating a moderately impairment of cognitive functioning. According to MDS (Minimum Data Set) dated 10/25/2022 under Section G, R12 requires extensive assist of two + person physical assist in Bed Mobily including turning side to side. According to MDS (Minimum Data Set) dated 10/25/2022 under Section M, R12 is at risk for developing pressure ulcers/injuries and has one stage four pressure ulcer that was not present upon admission. On 11/14/22 at 11:04 AM Surveyor observed R12 lying in bed in supine position. R12 utilizing low air loss mattress, set up to static mode. Upon interview R12 stated, I have a wound on my behind. Per record review, progress note completed by V14 (Registered Nurse) dated 10/15/2022 reads in part, Stage III wound in coccyx area. 2cm x 3cm x 05cm. Cleaned and secured. Will endorse to next shift. No previous documentation pertaining R12's wound present. On 11/15/22 at 9:47 AM Surveyor observed R12's wound dressing change. V8 (Registered Nurse, corporate/mobile MDS) and V9 ((Licensed Practical Nurse) performed dressing change. V8 (RN) stated, Wound clinic has been following R2's wound. R12 has a stage IV pressure ulcer on coccyx. It is also infected, which R12 gets antibiotics for. I'm just helping lately with wound care, since the Assistant Director of Nursing has been gone; it used to be the ADON who took care of wounds at the facility. ADON been gone since the beginning of October of this year. V9 (LPN) stated, ADON was a wound care nurse from Monday to Friday and staff nurses would do wound care on the weekends. ADON did rounds with wound doctor as well. Wound dressing change observed, wound measurements 4cmx5cmx2.5cm appearing as tennis ball size with additional underlining and tunneling. Wound dressing changed per order. Plan of Service dated 10/21/2022 reads in part, Santyl ointment coccyx wound cleanse with normal saline, apply nickel layer of Santyl, pack with Calcium Alginate and cover with boarded foam dressing daily and PRN. On 11/15/2022 at 10:02 AM Surveyor interviewed V9 (LPN), V9 stated, Nursing staff usually checks the residents' body, including skin assessment, daily. R12 developed some skin redness at some point, and preventative dressing was utilized at that time. Surveyor clarified how could R12 develop such significant wound, V9 (LPN) stated, Lack of supplements or repositioning could cause a pressure ulcer to develop. R12 is also on antibiotic therapy for suspected osteomyelitis. There is no wound doctor in the facility, R12 has appointments every Friday with the wound doctor, and she has seen infection disease doctor as well. Plan of Service dated 11/10/2022 reads in part, Cefdinir 300mg capsule, take 1 capsule by mouth every 12 hours for 14 days. Per record review, progress note completed by V11 (wound doctor) dated 10/21/2022 reads in part, Pressure ulcer to coccyx, measurements 5cm x 4cm x 2.5cm with undermining. You need to relieve the pressure as best as possible; this is achieved by repositioning every 2 hours. Per record review, progress note completed by V11 (wound doctor) dated 10/28/2022 reads in part, The wound measures 4.8cm x 4cm x 2.6cm. There is no tunneling or undermining noted. Wound cultures reviewed and noted to have proteus mirabilis sensitive cephalosporins, refer to infectious disease for possible osteomyelitis noted on the x-ray sacrum. Cefdinir prescribed for patient. Per record review, progress note completed by V11 (wound doctor) dated 11/04/2022 reads in part, The wound measures 4cm x 4cm x 2.4cm. Per record review, progress note completed by V11 (wound doctor) dated 11/11/2022 reads in part, The wound measures 3.8cm x 3.8cm x 2.4cm. There is undermining starting at 7:00 and ending at 9:00 with a maximum distance of 2cm. Per record review, progress note completed by V13 (infectious disease doctor) dated 11/10/2022 reads in part, [R12] referred for evaluation due to concern for osteomyelitis in the sacrum. Sacrococcygeal wound pressure ulcer stage IV [with] possible osteomyelitis underlying the wound bed with bony changes on x-ray. Continue with oral Cefdinir without stopping for the next 2 to 3 weeks. On 11/15/22 at 10:18 AM Surveyor interviewed V10 (Certified Nursing Assistant), V10 stated, If I see any resident skin changes, I notify a nurse, even if it's a little redness. I check residents' skin daily, when I perform incontinence care, which is about every 2 hours. I noticed that R12 had a blister forming in late September 2022, so I notified nurse on duty. Assistant Director Of Nursing was also aware of R12's skin assessment change. V10 (CNA) further indicated that there were multiple management changes in early October 2022 and R12's wound must have gotten overlooked. On 11/15/22 at 11:48 AM Resident noted in supine position, air mattress activated in static mode. On 11/15/22 at 1:52 PM Resident remaining in supine position. Plan of Service dated 10/16/2022 reads in part, Reposition every 2 hours. Plan of Service dated 10/30/2022 reads in part, Turn and reposition every 2 hours and document the turning schedule. On 11/16/2022 at 1:43 PM Surveyor interviewed V12 (acting Director of Nursing), V12 stated, Wound can develop due to several reasons, it's based on individual case though, wounds can develop due to residents' weakness, thin skin, poor nutrient intake, supplements and medications. We look at the patient as a whole and see if they are at risk. To prevent wound development staff should make sure individually based preventative devices are in place, barrier cream is being utilized, incontinence care is provided, including every 2 hours checks for wetness, and repositioning, especially bed ridden residents. On 11/16/2022 at 2:00 PM V1 (administrator) presented Root Cause Analysis pertaining to R12's wound development, no date provided, document reads in part, What human factors were relevant to the outcome? Previous Director of Nursing and Assistant Director of Nursing did all skin assessments, evaluations, and treatments. Documentation not always completed. Was the staff properly qualified and currently competent for their responsibilities at the time of the event? [Facility] floor nursing staff were qualified to do skin evaluation and documentation but were told by previous Director of Nursing that they were not allowed to do it. On 11/16/22 at 2:50 PM Surveyor interviewed V11 (Wound Doctor), V11 stated, Stage IV pressure ulcer could develop due to lack of reposition or poor nutrition. There are other factors such as aging frail skin. Incontinence care plays a big role, especially in the sacral area where a wound gets contaminated easily. Frequent repositioning and incontinence care would help with wound deterioration. Care plan for Risk for Impaired Skin Integrity related to Decreased Mobility, Bowel and Bladder Incontinence, dated 02/21/2022 reads in part, Daily skin inspections, report any changes in skin or signs of possible skin breakdown; Assist R12 with turning and repositioning at regular intervals and as needed. Care plan for Impaired Skin Integrity as evidenced by Pressure Ulcer to Coccyx dated 10/15/2022 reads in part, Daily skin check and record; Assist with turning and repositioning at regular intervals and as needed. Pressure Injury Assessment/Treatment policy dated 12/2016 reads in part, The pressure injury treatment program should focus on the following strategies: Resolution of current pressure injuries and prevention of additional pressure injuries; Managing and preventing bacterial colonization and infection. Interventions/Care Strategies: Eliminate or reduce the source of pressure using positioning techniques; Preventative measures to reduce the risk of further tissue loss; Managing and reducing the risk of infections; Interventions that increase the potential for healing.

Based on interviews and record reviews, this facility failed to adequately monitor a resident receiving an anticoagulation (blood thinner) medication, recognize signs exhibited when laboratory value is critically high, implement interventions immediately to reduce risk of further bleeding, and evaluate the effectiveness of interventions. This failure affected one resident (R3) out of three residents reviewed for anticoagulation therapy in a sample of 3. This failure resulted in R3 experiencing an acute change in condition and transported to the local hospital where R3 was assessed and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the medical record notes R3 was admitted to this facility from another long term care facility on 3/25/22. R3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/5/22 at 1:40pm, V2 DON (director of nursing) stated that V2 received report on 3/28 from R3's nurse of elevated INR (international normalized ratio). V2 stated that V2 requested the laboratory result to review because R3 was receiving [MEDICATION(S)] (anticoagulation medication). V2 stated that R3's INR was greater than 11 (normal range 2.5-3.5). V2 stated that V2 notified the physician. V2 stated that physician believed there was something wrong with laboratory results; orders received to hold R3 [MEDICATION(S)] until next laboratory test redrawn on 3/31. V2 stated that R3's INR on 3/31 was greater than 11. V2 stated that on 3/31, R3's physician ordered vitamin K oral x 1 dose. On 4/1, R3 was lethargic, weaker, and oxygen saturation level was 85% on room air and R3 was transported to the hospital. V2 denied performing a head to toe assessment on R3 to assess for signs of bleeding and increase in skin discoloration. V2 stated that V2 contacted previous facility for recent laboratory results. V2 denied requested R3 anticoagulant flowsheet noting R3 INR levels and [MEDICATION(S)] dosages. On 5/5/22 at 2:15pm, V7 (nurse) stated that V7 was assigned to provide care for R3 on 3/28. V7 stated that V7 observed skin discolorations on both of R3's forearms as this was the only skin exposed when V7 administered R3's medications. V7 stated that V7 did not perform a head to toe assessment to monitor for any increase in skin discolorations. V7 stated that V7 received R3's critical high INR result from the laboratory. V7 stated that V7 did not notify R3's physician; V7 endorsed the result to the oncoming nurse. On 5/6/22 at 12:10pm, V4 ADON (assistant director of nursing) stated that V4 completed the initial assessment of R3 when R3 was admitted on [DATE]. V4 stated that R3 skin was pale, R3 had dark purple bruising to left posterior shoulder the size of her hand, and smaller dark purple bruising all over body. V4 stated that R3 denied any fall recently V4 denied performing any further skin assessment to monitor for any increase in skin discolorations. V4 stated that V4 did not receive any reports from nurses of any changes to R3's skin discolorations. On 5/6/22 at 12:25pm, V9 CNA (certified nurse aide) stated that V9 is familiar with R3. V9 stated that V9 is the regular CNA for R3 on the day shift. V9 stated that V9 observed the skin discolorations on R3's skin. V9 stated that V9 notified the nurse and was informed this may be side effect of R3's medication. V9 stated that V9 did not pursue R3's skin discolorations any further after the first time V9 questioned bruising, because the nurse had already said bruising was side effect of medication. V9 stated that R3 had large skin discoloration on right side of upper body extending to thigh. On 5/6/22 at 1:30pm, R3 stated that R3 looked like she was beaten up with a sledgehammer. R3 stated that R3's body was covered in skin discolorations when R3 went to the hospital in April. R3 denied any falls recently. R3 does not recall rough handling that would have resulted in fractures. R3 stated skin discolorations related to [MEDICATION(S)] therapy. On 5/11/22 at 1:00pm, V16 (attending physician) stated that it would be reasonable to hold R3's [MEDICATION(S)] from 3/28-3/30 for INR greater than 11 and repeat INR on 3/31 as long as no active bleeding. V16 stated that V16 was informed of R3's bruising on 3/31. V16 stated that increased bruising is subjective unless there was a hematoma present. Review of R3's laboratory results notes the following: On 3/28/22 hemoglobin 10.8 (normal range 12-15.3). INR greater than 11 (critical high; normal range when on [MEDICATION(S)] is 2-3). On 3/31, INR greater than 11. Review of prior to admission laboratory results: On 2/28, R3's INR was 2.8. Review of R3's medical record notes: On 3/25/22 at 12:52pm, V4 ADON noted R3's skin intact. Observed with multiple dark purple discolorations on right and left arms and on the back of the left shoulder. Dark discoloration noted on left lower lip. On 3/31 at 2:00pm, nurse received report of increased PT/INR - greater than 11. V2 DON notified. Received order to administer vitamin K ([MEDICATION(S)] reversing medication). R3 alert, appears weaker today in morning after being transferred from bed to wheelchair, R3 became verbally non-responsive with shallow breathing. After about 10 seconds, R3 became more responsive, was able to follow instructions, had weak verbal response. R3 placed back in bed, encouraged to take fluids. On 3/31 at 7:06pm, R3 observed with increase dark purple skin discoloration on left mid back. On 4/1 at 10:18am, speech therapist noted R3 difficult to arouse. Maximum assistance for response to noxious stimuli. Later more easily arousable with maximum assistance to maintain wakefulness. Presented with diminished attention, orientation. On 4/1 at 12:13pm, oxygen saturation 85% on room air. Oxygen at 2 liters via nasal cannula immediately administered. Oxygen saturation level increased to 95% with oxygen. R3 encouraged oral fluids. On 4/1 at 2:12pm, R3 alert and oriented 1-2, very weak, noted with increase lethargy. Physician notified, order received to send R3 to hospital. Outside ambulance service transported R3 to hospital. Review of R3's hospital record, dated 4/1/22, notes R3 presented to the emergency room from this facility for evaluation of altered mental status since yesterday. R3 is normally alert and oriented x 4. R3 was noted to be somewhat confused yesterday. Progressively worsened today and is now somnolent and slightly lethargic. Per paramedics, R3 also with low oxygen level, oxygen applied with improvement of oxygen saturation level. R3 occasionally mumbles nonsensically. Physical assessment noted: extensive bruising noted to right flank extending to the right chest wall. Bruising throughout right upper extremity at proximal humerus and proximal forearm. Significant bruising extending from axilla to right flank. Hemoglobin 4.1. CT (computerized tomography) of chest and abdomen noted, in part: large intramuscular hematoma within the right subscapularis muscle, measuring 9.4cm (centimeters) x 6.4cm, with extensive soft tissue stranding and contusions along the right upper back. This extensive soft tissue stranding and contusions with intramuscular hematomas extend along the right abdominal wall to the right inguinal soft tissues. Nondisplaced right scapular fracture, nondisplaced fracture of lateral right 7th rib, nondisplaced fracture of the manubrium (top portion of sternum). Mild to moderate left flank subcutaneous stranding. Left gluteal soft tissue hematoma, measuring 4.5cm (centimeters) x 1.7cm. Drop in hemoglobin related to bleeding. R3's hemoglobin improved to 7.2 after R3 received three units of blood. Findings concerning for trauma. Per the FDA (food and drug administration), [MEDICATION(S)] can cause major bleeding in tissues and organs. A person's INR should be monitored closely.

Based on interviews and record reviews, this facility failed to report an allegation of sexual abuse to the State Surveying and Certification Agency immediately upon being informed of the allegation on 5/5/2022. This failure affected one resident (R3) of three residents reviewed for allegations of abuse in a sample of 3. Findings include: On 5/5/22 at 10:30am, V6 (R3's guardian) stated that V6 went to the emergency room to see R3 on 4/1/22. V6 stated that the physician was insistent that R3 was abused, R3 experienced trauma. The physician stated that R3 had a fractured clavicle, sternum, and ribs. On 5/5/2022 at 2:00pm, this surveyor informed V1 (administrator) and V2 DON (director of nursing) of an allegation of sexual abuse involving R3 was made. On 5/10/22 at 10:39am, when questioned regarding the facility's investigation for the allegation of sexual abuse involving R3, V1 stated that V1 absolutely did not initiate an investigation. On 5/10/22 at 1:42pm, V15 (complainant) stated that there was concern of abuse while R3 was in hospital on 4/1/22. V15 stated that R3 exhibited bruising on rectum and other injuries that did not make sense to the physicians. V15 stated that the physician requested V15 to report an allegation of sexual abuse to the State Surveying and Certification Agency. V15 stated that when V15 interviewed R3, R3 had a flat affect and denied any abuse. Review of R3's hospital record, dated 4/1/22, notes R3 presented to the emergency room from this facility for evaluation of altered mental status since yesterday. R3 is normally alert and oriented x 4. R3 was noted to be somewhat confused yesterday. Progressively worsened today and is now somnolent and slightly lethargic. R3 occasionally mumbles nonsensically. Physical assessment noted: extensive bruising noted to right flank extending to the right chest wall. Bruising throughout right upper extremity at proximal humerus and proximal forearm. Significant bruising extending from axilla to right flank. CT (computerized tomography) of chest, abdomen, and pelvis noted, in part: large intramuscular hematoma within the right subscapularis muscle, measuring 9.4cm (centimeters) x 6.4cm, with extensive soft tissue stranding and contusions along the right upper back. This extensive soft tissue stranding and contusions with intramuscular hematomas extend along the right abdominal wall to the right inguinal soft tissues. Nondisplaced right scapular fracture, nondisplaced fracture of lateral right 7th rib, nondisplaced fracture of the manubrium (top portion of sternum). Mild to moderate left flank subcutaneous stranding. Left gluteal soft tissue hematoma, measuring 4.5cm (centimeters) x 1.7cm. Findings concerning for trauma. Review of this facility's abuse investigation and reporting policy, revised 08/2020, notes all reports of resident abuse shall be promptly reported to local, state, and federal agencies and thoroughly investigated by management. Alleged violations involving abuse will be reported immediately but no later than 2 hours.

Based on interview and record review, the facility failed to monitor and implement effective interventions to prevent one resident exhibiting physically aggressive behavior from punching another resident this affected one of three residents (R2) reviewed for abuse in a sample of 3. Findings include: On 5/6/22 at 12:25pm, V9 CNA (certified nurse aide) stated that V9 is familiar with R1 because of incident that occurred on 4/26/22. V9 stated that V9 took one of her assigned residents to the dining room. V9 stated that V9 was washing hands in sink in dining area when R1 came up to her and hit her on right side of her abdomen. V9 stated that V9 informed R1 not to do that. V9 stated that V9 has heard that R1 has hit other staff in past, but never witnessed R1 hitting anyone before. V9 stated that R1 was speaking, but V9 couldn't understand him. V9 stated that V9 walked away from R1 back to V9's assigned work area. V9 stated that R1 followed V9 to the other end of the hallway and saw what resident room V9 entered. V9 stated that V9 blocked door so R1 couldn't get in. V9 stated that when R1 stopped banging on the resident's door, V9 peaked out and saw R1 grab R2 and was punching R2 on her sides all around her waist. V9 stated that R1 hit R2 more than 5 times, not sure how many times exactly but it was more than 5. V9 stated that R1 was fighting R2 and R2 was screaming. V9 stated that staff came out when they heard R2 screaming, stated that she does not recall hearing or seeing any staff when R1 hit her or was banging on resident's door. On 5/6/22 at 12:05pm, V8 (nurse) stated that V8 was in medication room and heard R2 screaming. V8 stated that V8 came out to see what was going on. V8 stated that V8 observed R1 holding onto the front of R2's shirt with left hand and swinging at R2 with right arm. V8 stated that R1 hit R2 2-3 times and then V8 grabbed R1 to separate the residents. V8 stated that a CNA came to and took R2 back to R2's room. V8 stated that R1 came back from [CONDITION(S)] around 11:00am and was agitated; R1 stated that [CONDITION(S)] told him that his [CONDITION(S)] treatments were done. V8 stated that R1 was very upset; R1 kept saying two guys were trying to jump on him. V8 stated that V8 called social worker regarding R1 being upset over [CONDITION(S)]. V8 stated that a Spanish speaking staff member spoke with R1; R1 continued to say two men were trying to jump him. V8 stated that R1 was observed banging on residents' doors. V8 stated that the social worker contacted the [CONDITION(S)] center and was informed that R1 completed [CONDITION(S)] and there were no issues. V8 stated that R1 will have a moment then go back to room, usually re-directable by staff. On 5/6/22 at 2:34pm, V12 (nurse) stated that R1 was on 1:1 monitoring after the incident. When asked for clarification, V12 stated that V12 checked on R1 in between medication pass. V12 stated that no one stayed with R1 continuously. On 5/10/22 at 11:10am, V2 Director of Nursing (DON) stated that R1 normally ambulates in hall and does not bother anybody. V2 stated that R1 was upset about R1's [CONDITION(S)] treatment that day and punched V9 CNA in the side of abdomen. V2 stated that V9 immediately went to another resident's room for safety. V2 stated that R1 was banging on this resident's door. V2 stated that when V9 had the courage to come out of the resident's room, V9 saw R1 punching R2 and staff separating the residents. V2 stated that is when V9 informed V2 that R1 just hit V9. V2 denied V9 shouted out for staff assistance after R1 hit V9; stated V9 was running for safety. When questioned about safety of the residents on that nursing unit during this incident, V2 did not respond. V2 stated that they do not have a policy on 1:1 monitoring because this is not a psychiatric facility and R1 did not exhibit behaviors when admitted to this facility. Review of the facility's incident investigation report, dated 4/26/22 at 1:30pm, notes R1 was walking down the hallway and became combative. R1 was mumbling. R1 is Spanish speaking only, legally blind. R1 was physically aggressive towards R2. Staff unable to re-direct R1. 1:1 supervision being maintained at this time. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Psychiatrist ordered [MEDICATION(S)] 5mg (milligrams) (antipsychotic) oral every 8 hours as needed for agitation. Review of R1's behaviors documentation notes: On 3/31 at 2:58pm, resident walking in hallway, raising his voice and waving his hands. resident stated that he is having difficulty with eyesight and can no longer see. On 4/12, social services noted R1 has a history of spitting, urinating on the floor, and refusing care at times. On 4/25, social services noted R1 reporting that he was informed by [CONDITION(S)] clinic that he no longer needed [CONDITION(S)] and he was rushed out of [CONDITION(S)] clinic. R1 appeared confused and not making sense. Social services spoke with [CONDITION(S)] center, R1 received full treatment and that no issues arose at the [CONDITION(S)] center. On 4/26 at 12:38pm, social services noted R1 appeared confused and was not making sense. R1 reported two men and a woman entered his room at night. R1 denied being harmed but stated he wanted to leave. On 4/26 at 1:30pm, R1 physically attacked R2 as R2 was walking past him. R1 reached out and grabbed R2. Staff pulled them apart. R1 escorted back to R1's room. On 4/26 at 3:27pm, R1 noted upset and becoming increasingly combative towards others. On 4/27 at 3:01pm, R1 began pacing, showing increased agitation. On 4/27 at 5:45pm, R1 came out of room and was hallucinating, tried to punch the staff, [MEDICATION(S)] given. On 4/28 at 2:48pm, throughout shift R1 has displayed increased agitation, has been physically aggressive and verbally inappropriate towards staff and residents, pacing the hallway and banging on doors. unable to re-direct. On 4/28 at 4:05pm resident transported to the emergency room via outside ambulance service. Review of R1's 1:1 monitoring documentation notes: on 4/26, R1 was monitored at 2:00pm, 3:00pm, 4:15pm, 4:35pm, 4:55pm, 5:10pm, 5:45pm, and 6:00pm. On 4/27, R1 was monitored at 10:00am, 11:25am, 11:45am, 12:45pm, 1:10pm, 2:10pm, 3:10pm.5:20pm, 5:30pm, 6:00pm, 7:00pm, 8:30pm, 9:00pm, and 11:00pm. On 4/28, R1 was monitored at 8:00am, 9:00am, 10:00am, 11:00am, 11:30am, 12:00pm, 1:00pm, 2:00pm, and 3:00pm. There is no documentation found noting R1 was being monitored 1:1 continuously from the time of the incident on 4/26 at 1:30pm until transported to the emergency roiagnom on ,d+[DATE] at 4:05pm. Review of R1's BIMS (brief interview of mental status), dated 4/12/22, notes R1's BIMS score is 12 out of 15. The total possible BIMS score ranges from 00. to 15. 13 - 15: cognitively intact. 08 - 12: moderately impaired. 00 - 07: severe impairment. Review of R1's MAR (medication administration record), dated April 2022, notes R1 received [MEDICATION(S)] x 1 dose on 4/27/22 at 5:45pm. Review of R1's behaviors care plan, dated 7/30/2021, notes R1 noted urinating on floor next to his bed, spitting at bedside. On 10/26/21, R1 noted with increase in behaviors-pacing/wandering the hallway, throwing food items, attempting to rest in other residents' beds, attempting to hold hands/hug other residents. Resident with poor insight. On 4/26, R1 noted with increased agitation, banging on doors, pacing in hallways, talking to himself, and combative behaviors towards others. Difficult to re-direct. Review of R1's medical record notes R1 was admitted to this facility on 7/8/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of this facility's abuse investigating and reporting policy, revised 08/2020, notes this facility will protect the resident through increased supervision of the alleged victim and residents during the investigation.

Based on interviews and record reviews, this facility failed to follow their policy and thoroughly investigate an allegation of sexual abuse upon being informed of the allegation on 5/5/2022. This failure affected one resident (R3) of of three residents reviewed for allegations of abuse in a sample of 3. Findings include: On 5/5/22 at 10:30am, V6 (R3's guardian) stated that V6 went to the emergency room to see R3 on 4/1/22. V6 stated that the physician was insistent that R3 was abused, R3 experienced trauma. The physician stated that R3 had a fractured clavicle, sternum, and ribs. On 5/5/2022 at 2:00pm, this surveyor informed V1 (administrator) and V2 DON (director of nursing) of an allegation of sexual abuse involving R3 was made. On 5/10/22 at 10:39am, when questioned regarding the facility's investigation for the allegation of sexual abuse involving R3, V1 stated that V1 absolutely did not initiate an investigation. On 5/10/22 at 1:42pm, V15 (complainant) stated that there was concern of abuse while R3 was in hospital on 4/1/22. V15 stated that R3 exhibited bruising on rectum and other injuries that did not make sense to the physicians. V15 stated that the physician requested V15 to report an allegation of sexual abuse to the State Surveying and Certification Agency. V15 stated that when V15 interviewed R3, R3 had a flat affect and denied any abuse. Review of R3's hospital record, dated 4/1/22, notes R3 presented to the emergency room from this facility for evaluation of altered mental status since yesterday. R3 is normally alert and oriented x 4. R3 was noted to be somewhat confused yesterday. Progressively worsened today and is now somnolent and slightly lethargic. R3 occasionally mumbles nonsensically. Physical assessment noted: extensive bruising noted to right flank extending to the right chest wall. Bruising throughout right upper extremity at proximal humerus and proximal forearm. Significant bruising extending from axilla to right flank. CT (computerized tomography) of chest, abdomen, and pelvis noted, in part: large intramuscular hematoma within the right subscapularis muscle, measuring 9.4cm (centimeters) x 6.4cm, with extensive soft tissue stranding and contusions along the right upper back. This extensive soft tissue stranding and contusions with intramuscular hematomas extend along the right abdominal wall to the right inguinal soft tissues. Nondisplaced right scapular fracture, nondisplaced fracture of lateral right 7th rib, nondisplaced fracture of the manubrium (top portion of sternum). Mild to moderate left flank subcutaneous stranding. Left gluteal soft tissue hematoma, measuring 4.5cm (centimeters) x 1.7cm. Findings concerning for trauma. Review of this facility's abuse investigation and reporting policy, revised 08/2020, notes all reports of resident abuse shall be promptly reported to local, state, and federal agencies and thoroughly investigated by management. The individual conducting the investigation will, at a minimum: review documentation, review the resident's medical record, interview person reporting incident, interview any witnesses, interview the resident, and interview staff on all shifts who have had contact with the resident during the period of the alleged incident.

Based on interviews and records reviewed the facility failed to ensure that staff utilized the mechanical lift for a resident assessed to require mechanical lift for transfers. This failure affected 1 of 3 (R1) residents reviewed for safe transfers. This failure resulted in R1 suffering an acute left medial malleolus fracture (closed fracture of the left ankle). This past noncompliance occurred on 3/17/22. Finding include: R1 is [AGE] years old with diagnosis including but not limited to Alzheimer's Disease, [CONDITION(S)], Major Depressive Disorder, [CONDITION(S)], Essential Hypertension, Age Related [CONDITION(S)], Anxiety, and [CONDITION(S)]. Cognitive pattern assessment dated [DATE] notes R1 has long and short-term memory impairments and is severely cognitively impaired. On 4/2/22 at 10:28AM surveyor observed R1 sitting in a wheelchair in a small group. A mechanical lift sling is visible under her. R1 has cast on her left foot from foot to mid lower leg. R1 has a wedge in between her legs while sitting and her left leg is elevated and extended out in front her with the wheelchair pedal. R1 did not verbally respond to the surveyor. On 4/2/22 at 10:48AM V2, Director of Nursing, said CNA reported to nurse that R1 complained of pain. The nurse went to assess R1. V2 said R1 does have chronic generalized pain. V2 said I assessed R1 myself and noted her ankle was swollen. V2 said I was preparing to assist in transferring R1 back to bed when I saw she did not have a lift sheet under her. I asked the CNA why she did not use a lift when it is clearly written in the room on the care card. V2 said R1 has been a mechanical lift for transfers since at least 2 years. We have ordered increased acetaminophen for pain. V2 said R1 is non-weight bearing at this time. V2 said V6 had been coming to the facility since November 2021 as agency staff. On 4/2/22 at 1:02PM via phone interview V6, CNA, said I transferred R1 out of her bed into a wheelchair by standing her. V6 said she supported R1's legs with her leg in between R1's legs. V6 said she has taken care of R1 often and has always transferred her the same way. V6 said she has been working in the facility since February 2022. V6 said before 3/17/22 she did not know about the care cards or that R1 required a mechanical lift for transfers. V6 said after she assisted R1 into her wheelchair she notified the nurse and V2 that R1 was complaining of leg pain. Staff Orientation Packet for V6 dated 11/2/21 notes V6's signature and care cards are located in the closet of each resident's room. It will give you the information about how to meet the care needs of the resident. R1's care plan dated 1/5/21 notes requires mechanical aid for transfers with 2 staff personal. R1's Functional Status assessment dated [DATE] notes she totally dependent on 2 persons for transfers. R1's Safe Patient Mobility and Movement Risk assessment dated [DATE] notes lift as ordered full body mechanical lift. R1's left ankle x-ray dated 3/17/22 notes acute medial malleolus fracture. A final report dated 3/23/22 conclusion notes R1 has a closed fracture of the left ankle. Report notes that the resident might have sustained injury due to improper transfer technique. Investigation notes V6 admits she failed to use lift for transfer. The facility Safe Lifting and Moving of Patients policy revised on 12/2019 notes Nursing associates, in conjunction with the rehabilitation associated, shall assess individual resident's needs for transfer assistance on an ongoing basis. Associates will document resident transfer and lifting needs in the care plan. Based on record review and interview the facility took the following corrective actions prior to the survey to correct the non-compliance: -R1 returned to the community on 3/18/2022. Assessment completed by assigned nurse and Director of Nursing (DON). Care plan reviewed and updated by interdisciplinary team as indicated. -Other current residents requiring the use of a mechanical lift for transfer have the potential to be affected by the identified practice. Community review completed by the DON. No further residents identified as being affected by the identified practice. -QAPI meeting was held by the interdisciplinary team on 3/18/2022 and this plan of correction was developed and implemented. -Medical Director was notified by DON on 3/18/2022. -One on one education completed with the associate involved by DON on following resident care plan to identify proper and safe transfer technique. -Current associates will be re-educated by the DON or designee on 3/18/2022 or prior to working next scheduled shift on Safe Lifting and Moving of Patients policy and will require return demonstration to evaluate competency. -Interdisciplinary team has reviewed Safety Lifting and Moving of Patients policy and procedure and it is in compliance with the CMS regulation F689. -During weekly Resident at Risk meetings, the interdisciplinary Team will review the clinical record of residents who have had a change in condition or change with assistance level. The review will be documented in the Resident's clinical record. -Routine reviews will be completed by the DON or designee on safe transfer technique with use of a mechanical lift. Reviews will be reported during routine clinical huddles. If discrepancies are identified immediate one on one education will be provided. -Monthly review of completed routine review results and trends will be completed by the DON or designee and reported to the facility's QAPI Committee for the next 3 months and then re-evaluated to determine if further monitoring is indicated.

Based on observation, interview, and record review, the facility failed to prevent and/or contain the spread of COVID-19 by failing to follow their policy and procedures for wearing PPE's (Personal Protective Equipment) including universal mask usage and hand hygiene; failed to provide available PPE's to staff as per CDC recommendations; and failed to train all staff including agency personnel on masking and isolation procedures. This failure caused R1 to contract COVID-19 infection who was then emergently transfer to the hospital; and died due to complications related to pneumonia and the COVID-19 virus. This failure also has the potential to affect all 64 residents currently residing in the facility. Findings include: On [DATE] at 10:10 AM, V1 (Manager on Duty) provided surveyor with a facility roster showing 64 current residents in the facility. V1 could not respond to the questions pertaining to COVID-19 and was not aware of the number of residents currently on isolation. Surveyor clarified V1's role, V1 stated, I am the manager on duty today but I'm not clinical so I can't answer any of your questions regarding care but I suppose I should have. On [DATE] at 10:20 AM, V4 (RN) stated, I'm the nursing supervisor on the second floor but I also pass medications on that floor too. I think we have 2 to 3 residents on isolation and they are on droplet precautions so we have to wear full PPE (personal protective equipment), wash our hands, wear gloves, mask, and gown before we go in and care for these residents. On [DATE] at 10:40 AM, V6 (CNA) and V7 (CNA) were observed in a small area across from the nurses' station both seated next to each other. V6 had her mask below her chin looking at her phone and V7 wore her mask under her nose and also was staring at her phone. Surveyor approached the two CNA's and asked which side of the hall each worked on. V6 stated while continuing to have her mask below her chin, We're on our breaks, who are you.? Surveyor identified self and asked again, V6 stated, We're on break and I'm from the agency. V7 stated, I'm with the agency too but not the same as hers (referring to V6). Surveyor asked about masks and COVID-19 precautions, V6 and V7 both got up, and walked away not answering the surveyor's questions. V6 walked over to V4 (RN) and was overheard telling V4 that she was going to finish her break off the floor. V4 affirmed to the surveyor that both V6 and V7 were contracted out from an agency. V4 stated, They should both still be wearing masks and the agency should have trained them about infection control. Surveyor asked V4 to accompany surveyor to an isolation room to observe and speak with a resident. V4 approached the isolation room with a PPE cart outside the room. V4 opened the drawer of the isolation bin and could not find any gloves or masks. V4 stated, There should be PPE's in this drawer but there are only gowns inside but there should be masks and gloves too. Asked how staff were to use full PPE's if the bins had no gloves and masks, V4 stated, I know, I will get more. Went to another isolation cart for another resident on isolation and found similar absence of PPE's inside the isolation bins. Asked V4 about biohazard bins inside the room of each resident on isolation, V4 stated, We don't have those red biohazard bins inside the resident isolation rooms. Our corporate office said it's okay to just use the regular garbage bins but we already told them they were too small to fit all the used gowns, gloves, and masks after we take care of the resident. I will let them know your concern though. On [DATE] at 10:55 AM, approached the end of the hall where a group activity program was being held. V8 (Activity aide) was seated close to the center of the room, her mask off and was occupied with her phone. Seated next to her were 3 other residents who were not masked or prompted by V8 to wear their masks. 10 other residents were in seated at tables with all residents slouched in their chairs and most were asleep and only 4 residents were observed wearing masks. V8 stated, I'm the activity person. We're doing puzzles but most of them are just waiting for lunch to be served. Inquired when lunch was, V8 stated, I know its only 11:00 but sometimes it gets here early. Surveyor asked about masking and COVID-19 infection control procedures, V8 stated, I know I briefly took my mask off but it should be on. I should be reminding these residents too to wear them. On [DATE] at 12:52 PM, V2 (Director of Nurses) stated, We had a COVID outbreak in December when we had R1 in the facility. I believe there were about 20 or so residents that were positive and sent to the hospital. We also had a lot of staff that were positive too. We did contact tracing and the results came back that the source of the outbreak were mostly the CNA (certified nursing aides) who worked multiple jobs and facilities and more than likely brought the virus into the facility. We also traced it back to an event that happened when there was a dietary party and it ended up as a 'COVID-spreader' event. I will provide you with the contact tracing information and give you the details of all the residents and staff with COVID. Facility contact tracing records provided to surveyor show in part (but not limited to): 1.) 21 total residents tested positive for COVID-19 including (R1 tested positive [DATE]) 2.) 4 out the 21 residents died of COVID-19. R1 was one of the four that died . 3.) 32 facility staff were found to test positive for COVID-19. Hospital records dated [DATE] reads in part (but not limited to): [AGE] year old female with a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She resides at a nursing home where she was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Coli. She originally tested positive for COVID on [DATE] . Patient found to be septic due to COVID-19 pneumonia. Patient has been treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's death certificate shows: 1.) date of death : [DATE] 2.) Cause of death: Acute hypoxic respiratory failure, pneumonia, Novel Corona (COVID-19) [CONDITION(S)] infection. Facility policy and procedures dated ,d+[DATE] titled COVID-19 Infection and Prevention Guidelines state in part (but not limited to): Perform hand hygiene at a minimum before starting the shift; before and after contact with a resident; Whenever putting on or taking off gloves; When hands are visibly soiled; Prior to leaving sift. Universal masking: Keep mask on at all times, covering the nose and mouth; Do not hang mask around the neck; Replace mask if wet, soiled or damaged. The purpose of universal masking is that the CDC has identified that there are people who carry COVID-19 and do not have symptoms. The residents that we serve live in a communal environment, the highest risk comes from associates and visitors entering the community. Universal masking limits the risk of transmission to the residents. Transmission-Based Precautions: Covid Positive: Droplet and Contact Precautions + Eye protection upon entry to the community and already initiated for current residents when they were a Person Under Investigation (PUI). PUI/Symptomatic Resident: Droplet precautions + Eye Protection initiated with any observation of a positive respiratory observation; Admission/Readmission and frequently out of the building for treatment (e.g. hemodialysis). Universal Masking: Used to prevent transmission from asymptomatic or pre symptomatic residents and healthcare personnel. Keep well fitting mask at all times, covering the nose and mouth, while in the community including break rooms or other spaces where coworkers are encountered. Remove only to eat or drink when physically distanced. Activities: Group actinides may occur while adhering to the core principles of Covid-19 Infection Prevention for residents not requiring transmission based precautions. Social distancing, hand hygiene, and use of well-fitting face coverings are practiced. Dining: Residents that are capable of eating and feeding themselves without assistance. Provide in-room meal service using trays, plate covers, and normal china and silverware. Associates perform hand hygiene prior to picking up the food tray and prior to leaving the resident's room. Associates perform hand hygiene prior to donning PPE and after removing. When assisting residents with meals, change gloves and perform hand hygiene between residents.

Based on observation, interview, and record review the facility failed to maintain privacy of medical information on two units (Second Floor North, Second Floor South) of four units reviewed for privacy and confidentiality. This failure has the potential to affect 28 residents on Second Floor North and Second Floor South. Findings include: On 10/5/21 at 11:55 AM R52 walked to the nurses station on the second floor and started looking at papers on a clipboard that was on top of the counter. R52 asked, is my name here? The clipboard contained forms titled B/M (bowel movement) and [MEDICATION(S)] chart with the names of all the residents on Second Floor North and Second Floor South. The form was dated 10/3/21-10/8/21. On 10/5/21 at 12:15 PM V5 (CNA-Certified Nursing Assistant) said, we keep the sheet here so we can write when a resident has a BM (bowel movement). V6 (LPN-Licensed Practical Nurse) said, we keep it here to check on the BMs every shift. We turn it over. On 10/7/21 at 2:40 PM V2 (DON-Director of Nursing) said, the nurse left the clipboard on the counter that day. It is kept behind the desk. The information should not be where it can be seen. A document titled Standards of Conduct- Compliance with Laws and Regulation, undated, reads maintain privacy and security of protected health information in keeping with HIPAA (Health Insurance Portability and Accountability Act). Do not access, use, disclose or discuss protected health information with others unless permitted to do so or required by law. A document titled Joint Notices of Privacy Practices, revised January 2020, reads we are required by law to: have reasonable safeguards in place to discourage improper use or access to your health information; maintain and protect your privacy and the confidentiality of your health information and records. The census provided by the facility for 10/5/21 listed a total of 28 residents on Second Floor North and Second Floor South.

Based on interview and record review the facility failed to update the care plan for one of two residents reviewed for falls in the sample of 18. This is failure resulted in a fall for R44 on 9/18/2021. Findings include: R44's care plan was revised with interventions to decrease fall risk on 11/14/2020, 2/15/2021, and 9/18/2021. The care plan was not revised after the fall in 7/8/2021. The facility's fall incident log indicated that R44 had falls on 11/14/2020, 2/15/2021, 7/8/2021 and 9/18/2021. 7/8/2021 A resident incident report description, R44 is alert and oriented times three, was found sitting on the floor by her room door waving. R44 said she went to the bathroom and came from the bathroom and felt dizzy held on to the bathroom door and ease herself down to the floor, denies hitting her head. Immediate action an assessment, no visible injury, ROM (range of motion) intact, R44 denied pain, neuro (neurological) checks initiated has an history of falls. On 10/7/2021 at 1:00pm V4 (MDS/Care Plan Coordinator, MDS-Minimum Data Set) said that all care plans should be updated after every fall incident, and I don't know why this one was not. On 10/8/2021 at 9:40am V2 (Director of Nursing) said' I expect the care plan coordinator to update care plan after every fall or change in condition I don't know why that was not completed. Facility Falls-Policy 01/2018 1. The [NAME] 11 Fall Risk form (or similar fall risk evaluation) should be completed quarterly, with significant change MDS Assessment and after every fall 2. The falls should be reviewed at the daily stand -up meeting following the fall for identification of any additional individualized interventions to reduce risk of falls.

Based on interview and record review the facility failed to ensure effective interventions were in place to reduce the risk of falls for one resident (R44) of two residents reviewed for falls in the sample of 18. This deficient practice resulted in R44 falling on 7/8/2021 and 9/18/2021 resulting in R44 complaining of right-side rib and right hip pain. Findings include: On 10/6/2021 at 11:30am R44 said I have had some falls, but I take care of myself and I don't hurt myself when I fall. On 10/8/2021 at 9:35am V7 (registered nurse) said on 7/8/2021 at about 4:15pm, she was passing medication and heard someone call out help and it was R44 she was sitting on the floor between the bathroom door and room entrance door. R44 said that she sat on the floor because she felt dizzy. I immediately assessed R44 and assisted her to the chair she did not have any injuries. I reported it to the Director of Nursing and did called the physician, family member and started Neuro (neurological) checks for an unwitnessed fall. On 10/7/2021 at 1:00pm V4 (MDS/Care Plan Coordinator, MDS-Minimum Data Set) said that all care plans should be updated after every fall incident, and I don't know why this one was not. On 10/8/2021 at 9:40am V2 (Director of Nursing) said, I expect the care plan coordinator to update care plan after every fall or change in condition I don't know why that was not completed. On 10/8/2021 10:05am V8 (licensed practical Nurse) said on 9/18/2021 at about 3:00pm, I was on [MEDICATION(S)] to do an blood pressure and heard some screaming it was R44, she was standing in front of the window with her back to the door and her food tray all over the floor. R44 said that she had pain to right side ribs and her right hip. I never witnessed R44 on the floor, she said she fell . On 10/8/2021 at 10:20am R44 has a Physician order dated October 2021 that indicates a diagnosis of Unspecified [CONDITION(S)] , benign [CONDITION(S)] [CONDITION(S)], sciatica, spondylosis, intervertebral disc, degeneration, lumbar region. A fall risk assessment dated on 7/9/2021 indicates that R44 has risk factors of symptomatic depression, dizziness/[CONDITION(S)], any prescribed benzodiazepines. R44 had a score of 5 which means that she is at high risk for falls. A fall risk assessment dated [DATE] indicates that R44 has risk factors of confusion/disorientation, symptomatic depression, any prescribed benzodiazepines. The risk score of 8 means that R44 is at high risk for falls. A care plan initiated 7/22/2019 that indicates R44 is high risk for falls related to decreased safety awareness, impulsiveness secondary to cognitive deficit, unsteady gait, impaired balance, high-risk medications, and a history of falls. On 7/8/2021 R44 did not have a care plan update after the fall. After the fall on 9/18/2021 the care plan was updated to check edges of bed for any loose wires/edge/and or cracks. Coordinate with maintenance if bed is defective. 7/8/2021 A resident incident report description, R44 is alert and oriented times three, was found sitting on the floor by her room door waving. R44 said she went to the bathroom and came from the bathroom and felt dizzy held on to the bathroom door and ease herself down to the floor, denies hitting her head. Immediate action an assessment, no visible injury, ROM (range of motion) intact, R44 denied pain, neuro (neurological) checks initiated has an history of falls. A resident incident of 9/18/2021 at 3:36pm indicates that V8 went into R44 room for a blood sugar check. R44 was standing facing her bed, screaming, barefoot. Tray and dishes on the floor. V8 did a body check no swelling nor discoloration noted. Complained of pain at a level of eight out of ten. An Xray of right ribs and right hip was ordered. R44 was alert and oriented times two with a history of falls. Facility Falls-Policy 01/2018 1. The [NAME] 11 Fall Risk form (or similar fall risk evaluation) should be completed quarterly, with significant change MDS Assessment and after every fall 2. The falls should be reviewed at the daily stand -up meeting following the fall for identification of any additional individualized interventions to reduce risk of falls.

Based on observation, interview, and record review, the facility failed to follow their policies and procedures for grievances by failing to replace essential medical devices (hearing aids) in a timely manner to accommodate one (R1) of three residents reviewed for resident rights. This failure prevented R1 from hearing his immediate surroundings and caused exacerbation of R1's [MEDICAL CONDITION] and overall psychosocial well being. Findings include: R1 is an alert and oriented [AGE] year old with [DIAGNOSES REDACTED]. Facility's form dated 2/9/21 signed by V4 (Social Service Director) titled Notification of Concern/Complement states, (R1) Resident's hearing aids are missing. Actions taken: searched residents room, searched garbage, spoke to kitchen, still unable to find. Called niece on 1/29/21 to inform her facility is working on getting an amplifier for resident. Power of attorney requested for facility to replace hearing aids. Comment written on form by V4 states, Not sure if we're replacing. We can't find them. A letter sent to R1's family almost a month later by V1 (administrator) dated 2/23/2021 states in part, Dear family member, Please accept this letter as acknowledgment of your correspondence. I would like to thank you for reaching out to us with your concern and bringing this issue to my attention. At facility we strive to provide the best care and experience for all those we serve and we are sorry that we did not meet your expectations. The concern referenced in your correspondence is being reviewed and a response will be provided to you in writing within 30 days from January 27, 2021. Facility record dated 2/23/21 titled Investigative summary states in part, The following is a summation of the investigation regarding (R1) for allegation of neglect of care: On 1/27/21, R1's family reported to social worker (V4) R1's hearing aids were missing and he had trouble. Resident is alert, oriented and own person. Resident was interviewed by the social worker and had no concerns. Could not find his hearing aids. Administrator and Director of Nursing were notified around 2/9/21. Search was started on 1/28/21. Executive director reviewed the grievance on 2/5/21. An estimate was obtained form hearing aid center. The community staff continued to search for missing hearing aids and is unable to find them. Executive director met with the resident discuss the concerns and the community's investigation results. Community purchased and assigned R1 an amplified phone. Family was grateful for it but asking what will be done about the lost hearing aids. Based on the above information, the community is not able to locate the lost hearing aids for R1. The family feels it is the responsibility of the community to replace the lost hearing aids. On 3/19/21 at 10:10 AM, surveyor asked V3(RN) the procedure for using and storing resident hearing aids. V3 showed and stated to surveyor, In the evening, the PM nurse would store the hearing aids in their cases labeled with the resident's name and room number and the morning nurse would place them in the ears of the resident. Surveyor asked if she was aware of R1's hearing aids being lost by the facility, V3 stated, Yes, I wasn't here when it happened but I know that they searched for them but couldn't find them. Surveyor asked if she knew R1, V3 stated, Yes, he's a very nice man. He stays pretty much in his room. He is very hard of hearing. Asked when he had the hearing aids if he was still hard of hearing, V3 stated, No he was fine with them. It helped him a lot so I don't know why he did not get them replaced. Surveyor asked if she communicated this concern to administration, V3 stated, No, I just thought they were going to take care of it. Surveyor asked how long R1 has been waiting for his hearing aids, V3 stated, I don't know, but I think it's been several months now. Interview with V4 (Social Service Director) at 10:10 AM stated, I'm in charge of following up with any resident concerns and missing items and I did the investigation along with V1 (administrator). On 1/26/21 V5 (CNA) took out R1's hearing aids and placed them in a case and gave them to the nurse (V6) for safe keeping behind the nurses station. The next morning, the nurse could not find the hearing aids to place in R1's ears so that was when it was reported to me as missing. We did a thorough search and could not find them. I've had numerous conversations and emails with R1's family to try to get them replaced and I asked V1 about 3 weeks later what was going on with the hearing aids and we still did not get them for R1. After 4 weeks waiting for a replacement, we got a special telephone for R1 so he could hear his family when he was on the phone. Surveyor asked if there was any other amplified hearing device the facility tried to offer R1 so he could hear his television or the nurses that were caring for him, V4 stated, No I'm sorry we did not consider that but I've been trying to get V1 to get these hearing aids for him as soon as possible. Asked if waiting over 2 months for a hearing aid that a resident required was acceptable timeframe, V4 stated, No it definitely is not acceptable. Interview with R1's family on 3/19/21 stated, I had ordered hearing aids myself for (R1) because the audiologist said that he was very hard of hearing. I gave them to the facility and I was told they lost them and couldn't find them. I've been calling and emailing the administrator and social worker and all I get is them telling me its on order, it's on order, but when I called the hearing aid company myself, they tell me that they were still waiting for payment in order to even start to make the hearing aid devices. After they get payment, the hearing aid company said it would take another week to two weeks. I called them this past Friday on 3/12/21 and was told there was still no payment made. Mind you this has been since late January and I informed the administrator (V1) and all he says to me is that they were taking care of it and that it'll be on the way. I'm at my wit's end because (R1) tells me he desperately needs it and that he already feels imprisoned because of this pandemic and even more so because he can't hear a thing, he can't hear when the nurses come in to his room, he can't hear his own television to enjoy his shows and he's really depressed about it. I told this to V1 and it doesn't seem to sink in. Facility records of R1's visit to the audiologist on 7/30/20 show R1 with bilateral (both ears) moderate-to-severe hearing loss. Interview with R1 on 3/19/21 at 10:50 AM stated, I can't hear you please talk louder. Surveyor asked how he was doing, R1 stated, They lost my hearing aids months ago and they still did not replace it for me. I can't hear anything. I can't hear my own TV. I can't hear the nurses when they talk to me. I can't hear anything, please help me. I'm very upset and depressed about it. I feel already trapped inside here like a prisoner and it has made it worse that I can't hear anything. I get startled when someone walks in my room because I just see them all of a sudden in my room can you imagine how that would make you feel? I already have to stay in my room most of the time because of [MEDICAL CONDITION] and this makes it worse. Have you ever tried watching television with no volume because that's what I feel like when I watch TV. I have to put the volume way up and then someone comes in to my room and says it's too loud and to turn it down. It's very upsetting to me. Why can't they find me another pair of hearing aids? When asked if he expressed his concerns to the nurses, R1 stated, I told my niece and I keep asking the nurses about my hearing aids but the nurses don't even listen to me. Interview with V6 (RN) at 11:30 AM (with V2 (Director of Nursing) present) stated, I was the nurse that took R1's hearing aids from the CNA that evening. The next morning I was told that it was lost so I don't know anything about that. Surveyor asked if she was the regular nurse for R1, V6 stated, Yes, I know (R1) pretty well, I've been working here for 5 years. Surveyor asked if she noticed any concerns with R1, V6 stated, Well, he's alert and oriented to himself only and he always has his TV turned up. He speaks Spanish but I don't but he seems to understand me though. Surveyor asked if she noticed any behavior change from R1 after not having his hearing aids, V6 stated, Not really. After the interview, V2 stated, R1 is not alert and oriented to himself only. He has periods of confusion but he is very 'with it', so I don't think V6 knows (R1) at all. As for his TV being turned up, that should have told her (V6) that he was having hearing problems. Interview with V1 (Administrator) at 12:10 PM stated, I talked to staff to see if they could find the missing hearing aids and a case was found in another patient's room but no hearing aids, so we kept looking for it. I reached out to our corporate offices to see if we could get payment for reimbursement for the hearing aids because we were at fault for losing them and am waiting for approval for them. Surveyor asked how R1 could hear his nurses or enjoy his leisurely activities, V1 stated, I know the nurses gesture to him and I think he understands but I did not consider the other aspects. I know (R1) can still read and follow instructions. Asked if the staff used any communication board to assist R1, V1 stated, I don't think he needs one. Surveyor asked when the new hearing aids were arriving for R1, V1 stated, I contacted the hearing aid company last Friday and they said once they get payment it would take 1 to 2 weeks. Surveyor asked if payment was made, V1 stated, I will have to check. when asked if waiting several months to get essential hearing aids for R1 was acceptable to him, V1 stated, I know, you're right. We should have replaced them right away. Interview with V2 at 1:30 PM (Director of Nursing) stated, I just spoke to V1 and he told me that payment was not even made yet for the hearing aids but he said he was going to use his own credit card this time. I'm sorry I've been telling him to get this done and that it was going to be a problem. We were at fault and we should have replaced those hearing aids right away because (R1) really needs them. I didn't realize he felt more isolated and depressed because the nurses did not tell me otherwise I would have let V8 (psychiatrist) know. Surveyor asked when V8 last visited to see R1, V2 stated, I know he was here several months ago in January. When asked V2 for V8's progress notes but the notes were not found in the medical record. No records were received from V2 after several requests. Surveyor asked V2 to get a hold of V8 and for his contact information. After several attempts, V8 did not return any of surveyor's messages. Interview with V7 (Activity director) at 1:40 PM stated, R1 is a bit hard of hearing but I am aware he is missing his hearing aids for awhile now. When things started opening up during the pandemic, I was conducting group activities in the large dining room and R1 would attend the group exercises to get him out but I know he mainly likes to watch television and he cranks up the volume. When asked how long she was aware R1 was missing his hearing aids, V7 stated, Yes, I thought they would have been replaced by now. It's been going on for several months now I think. Interview with V9 (Physician) at 2:15 PM stated, I am the physician for R1. He's hard of hearing and I do have to raise my voice to talk to him. Surveyor asked whether he was aware that R1 was having difficulty hearing because he had no hearing aid for 2 months, V9 stated, I was not aware of that and no one told me because he needs his hearing aids to hear. When asked if it was essential for R1 to be able to hear, V9 stated, I can't argue with that as being able to hear is essential and if you are not able to hear, it impacts his mental well being and overall quality of life. I will follow up with the administration because this is very important for (R1) to get these especially now (referring to the pandemic). Facility policy dated 11/2017 titled Complaints and Grievances states in part (but not limited to): Each community must designate a Grievance Official to oversee and ensure responses to complaints and grievances in accordance to the policy. The Grievance official or designee will be responsible for the complaint and grievance process through their conclusion to include: Review and provide acknowledgement of receipt of grievances to complainant. Coordinating the investigation by the community to include but not limited to reviewing reports for any reportable issues, interviewing complainant, staff and or witnesses, reviewing medical records and coordinating with other departments when needed; Acknowledging the grievance within 7 working days from receipt; issuing a final written grievance decision to the resident and/or family members within a reasonable time frame but not to exceed 30 days. Facility's policy dated 11/2017 titled Resident Rights states in part (but not limited to): It is the policy of facility to promote and protect the rights of residents residing in our ministry. Residents are entitled to exercise their personal and legal rights and privileges to the fullest extent possible. Our ministry will make every effort to assist the resident in exercising his/her rights and to assure that the resident is always treated with respect, kindness and dignity.

Based on observation, interview, and record review, the facility administration failed to timely replace essential medical device (hearing aids) for one (R1) of three residents reviewed for hearing services. Findings include: R1 is an alert and oriented [AGE] year old with [DIAGNOSES REDACTED]. Facility record dated 2/23/21 titled Investigative summary states in part, The following is a summation of the investigation regarding (R1) for allegation of neglect of care: On 1/27/21, R1's family reported to social worker (V4) R1's hearing aids were missing and he had trouble. Resident is alert, oriented and own person. Resident was interviewed by the social worker and had no concerns. Could not find his hearing aids. Administrator and Director of Nursing were notified around 2/9/21. Search was started on 1/28/21. Executive director reviewed the grievance on 2/5/21. An estimate was obtained form hearing aid center. The community staff continued to search for missing hearing aids and is unable to find them. Executive director met with the resident discuss the concerns and the community's investigation results. Community purchased and assigned R1 an amplified phone. Family was grateful for it but asking what will be done about the lost hearing aids. Based on the above information, the community is not able to locate the lost hearing aids for R1. The family feels it is the responsibility of the community to replace the lost hearing aids. Interview with V4 (Social Service Director) at 10:10 AM stated, I'm in charge of following up with any resident concerns and missing items and I did the investigation along with V1 (administrator). On 1/26/21 V5 (cna) took out R1's hearing aids and placed them in a case and gave them to the nurse (V6) for safe keeping behind the nurses station. The next morning, the nurse could not find the hearing aids to place in R1's ears so that was when it was reported to me as missing. We did a thorough search and could not find them. I've had numerous conversations and emails with R1's family to try to get them replaced and I asked V1 about 3 weeks later what was going on with the hearing aids and we still did not get them for R1. After 4 weeks waiting for a replacement, we got a special telephone for R1 so he could hear his family when he was on the phone. Surveyor asked if there was any other amplified hearing device the facility tried to offer R1 so he could hear his television or the nurses that were caring for him, V4 stated, No I'm sorry we did not consider that but I've been trying to get V1 to get these hearing aids for him as soon as possible. When asked if waiting over 2 months for a hearing aid that a resident required was acceptable timeframe, V4 stated, No it definitely is not acceptable. Interview with R1's family on 3/19/21 stated, I had ordered hearing aids myself for (R1) because the audiologist said that he was very hard of hearing. I gave them to the facility and I was told they lost them and couldn't find them. I've been calling and emailing the administrator and social worker and all I get is them telling me its on order, it's on order, but when I called the hearing aid company myself, they tell me that they were still waiting for payment in order to even start to make the hearing aid devices. After they get payment, the hearing aid company said it would take another week to two weeks. I called them this past Friday on 3/12/21 and was told there was still no payment made. Mind you this has been since late January and I informed the administrator (V1) and all he says to me is that they were taking care of it and that it'll be on the way. I'm at my wit's end because (R1) tells me he desperately needs it and that he already feels imprisoned because of this pandemic and even more so because he can't hear a thing, he can't hear when the nurses come in to his room, he can't hear his own television to enjoy his shows and he's really depressed about it. I told this to V1 and it doesn't seem to sink in. Facility records of R1's visit to the audiologist on 7/30/20 show R1 with bilateral (both ears) moderate-to-severe hearing loss. Interview with R1 on 3/19/21 at 10:50 AM stated, I can't hear you please talk louder. Surveyor asked how he was doing, R1 stated, They lost my hearing aids months ago and they still did not replace it for me. I can't hear anything. I can't hear my own TV. I can't hear the nurses when they talk to me. I can't hear anything, please help me. I'm very upset and depressed about it. I feel already trapped inside here like a prisoner and it has made it worse that I can't hear anything. I get startled when someone walks in my room because I just see them all of a sudden in my room can you imagine how that would make you feel? I already have to stay in my room most of the time because of [MEDICAL CONDITION] and this makes it worse. Have you ever tried watching television with no volume because that's what I feel like when I watch TV. I have to put the volume way up and then someone comes in to my room and says it's too loud and to turn it down. It's very upsetting to me. Why can't they find me another pair of hearing aids? When asked if he expressed his concerns to the nurses, R1 stated, I tell told my niece and I keep asking the nurses about my hearing aids but they don't even listen to me. Interview with V1 (Administrator) at 12:10 PM stated, I talked to staff to see if they could find the missing hearing aids and a case was found in another patient's room but no hearing aids, so we kept looking for it. I reached out to our corporate offices to see if we could get payment for reimbursement for the hearing aids because we were at fault for losing them and am waiting for approval for them. Surveyor asked how R1 could hear his nurses or enjoy his leisurely activities, V1 stated, I know the nurses gesture to him and I think he understands but I did not consider the other aspects. I know (R1) can still read and follow instructions. When asked if the staff used any communication board to assist R1, V1 stated, I don't think he needs one. Surveyor asked when the new hearing aids were arriving for R1, V1 stated, I contacted the hearing aid company last Friday and they said once they get payment it would take 1 to 2 weeks. When asked if payment was made, V1 stated, I will have to check. Surveyor asked if waiting several months to get essential hearing aids for R1 was acceptable to him, V1 stated, I know, you're right. We should have replaced them right away. Interview with V2 at 1:30 PM (Director of Nursing) stated, I just spoke to V1 and he told me that payment was not even made yet for the hearing aids but he said he was going to use his own credit card this time. I'm sorry I've been telling him to get this done and that it was going to be a problem. We were at fault and we should have replaced those hearing aids right away because (R1) really needs them. I didn't realize he felt more isolated and depressed because the nurses did not tell me otherwise I would have let V8 (psychiatrist) know. Interview with V9 (Physician) at 2:15 PM stated, I am the physician for R1. He's hard of hearing and I do have to raise my voice to talk to him. Surveyor asked whether he was aware that R1 was having difficulty hearing because he had no hearing aid for 2 months, V9 stated, I was not aware of that and no one told me because he needs his hearing aids to hear. When asked if it was essential for R1 to be able to hear, V9 stated, I can't argue with that as being able to hear is essential and if you are not able to hear, it impacts his mental well being and overall quality of life. I will follow up with the administration because this is very important for (R1) to get these especially now (referring to the pandemic).

Based on observation, interview, and record review, the facility failed to prevent and/or contain COVID-19 by failing to follow their policy and procedures for wearing PPE's (Personal Protective Equipment) including taking on and off of gowns and mask usage; failed to use CDC recommended disinfectant chemicals that kill Covid-19 on floors and surfaces requiring disinfecting; and failed to train all staff including agency personnel on isolation procedures. This failure has the potential to affect all 57 residents residing in the facility. Findings include: 12/21/20 at 9:50 AM, surveyor met with V1 (Administrator) who stated that the facility currently had 57 residents with 10 COVID positive residents and one person on isolation for PUI (Persons Under Investigation) for COVID. Surveyor asked about staff, V1 stated, my director of nursing is furloughed starting last Friday and I have 10 other staff who are out due to COVID. At 10:10 AM, surveyor went up to the COVID-19 floor and observed V3 (ADON) hurriedly stocking the isolation carts. V5 (CNA) was observed coming out of two resident rooms that were under strict isolation wearing the same gloves and gown and then disappeared into another room without washing her hands or putting on a new set of gloves or a new gown. V3 stated, I currently have 9 COVID-19 residents under my care. I sent a resident to the hospital this morning because the fever wouldn't go down. Surveyor asked about the isolation precautions, V3 stated, we have to use full PPE before we go in and have to take all that off before we leave the room and also do proper hand hygiene. Surveyor asked how many CNA's she had with her in the unit, V3 stated, I only have one and the other nurse has two on the other side. Surveyor asked about her aide, V3 stated, (V5) is agency but she's been here long enough and she knows the floor well. Asked if she should be putting a new set of PPE upon entering each resident room, V3 stated, Yes, like I said, anytime we go into the isolation rooms (they're all on isolation in this COVID unit), she has to put on a gown, glove, and of course a mask and all those have to be taken off and put on a new one before exiting each of the rooms. At 10:15 AM, V6 (RN) was asked about her side of the COVID floor, V6 stated, I have those rooms over there (pointing to rooms directly outside of the plastic curtain that separated the COVID positive residents). Those are just PUI but they are also on contact and droplet isolation. Surveyor asked what precautions are taken with the PUI residents, V6 stated, we have to wash our hands first or disinfect them and then we put on our gown and gloves and mask before we go in. Before we leave the room, we have to take off our gown, change our gloves and wash our hands. At 10:20 AM, V7 (CNA) and V8 (Housekeeper) walked in to R2's room with only masks worn. At 10:30 AM, V7 came out of the room and went though the double doors into the other wing of the COVID floor. V6 was asked about this section of the floor as the surveyor observed isolation carts placed outside most of the resident room doors. V6 stated, oh, these residents on this side are also on isolation for contact and droplet isolation. We do the same thing with PPE here so we have to put on a gown and gloves and cannot wear the same one we wore inside the room. At 10:30 AM, V9 (Housekeeper) was observed outside one of the isolation rooms and asked about his duties, V9 stated, I'm going to clean these rooms now; I just finished the other side (pointing to the other wing designated as the PUI wing). I'm going to do this side now (COVID side). Surveyor asked to see the chemicals used to clean rooms, floors, bathrooms and high-touch areas, V9 showed surveyor a bottle of glass cleaner, toilet bowl cleaner, and bottle of unlabeled spray bottle. Surveyor asked about the spray bottle, V9 stated he used it for the bed and side rails. Surveyor asked what was in the mop bucket, V9 stated, I used hot water. Surveyor asked if there was anything added to the mop water to clean the floors and V9 stated, It is just hot water; I don't add anything. At 11:15 AM, V4 (QA/Infection Control Nurse) was asked to confirm the number of COVID infections and PUI isolations in the facility. V4 stated, we have 57 residents from last night so for today we have 9 because one of the residents we moved down to another floor. We have 3 PUI's on the second floor we treat like they have COVID. Surveyor asked to confirm the number of contact and droplet isolations because the number provided earlier by both V3 and V6 were different than what V4 was claiming. V4 stated, I'll have to check with V2 (Director of Nursing) because she's really the infection control person. Asked who would be next to take over as the infection preventionist since V2 was isolating at home, V4 stated, that would be me but I will still call (V2) at home to speak with you. At 11:30 AM ,V10 (Housekeeper) was observed coming out of one of the resident rooms and asked about her duties, V10 stated, I clean the rooms down here. Surveyor asked to show her the cleaning supplies used to clean and disinfect the rooms she cleaned, V10 showed surveyor a bottle of glass cleaner, bottle of toilet bowl cleaner, and a pink labeled bottle that V10 described as cleaning the side rails and bathroom hand rails. Surveyor asked about how she cleaned the floors, V10 pointed to her mop bucket and stated, I put hot water there and I mop the floor with that (pointing to a rectangular shaped mop head). Surveyor asked if she added anything to her mop water. V10 stated, I use just hot water. Sometimes I put in a teaspoon of this (showing a bottle of bathroom spray cleaner with bleach). Surveyor asked if she sprayed it in the water or measured it out on a spoon, V10 stated, No, sometimes I spray it in the water but I don't put too much in it. Surveyor asked if she was instructed to measure out the spray cleaner to place in the mop water, V10 stated, No, most of the time it's just hot water I use. At 11:35 AM, V2 (Director of Nurses) with V4 present in the room, stated, We didn't have COVID until recently. We now have 10 residents that tested positive for COVID and I know we had one death and I reported that to public health. Once we had those residents turn positive, I made the north wing of the second floor a COVID unit so everyone in there is under contact/droplet isolation. Everyone else on the floor is also placed under isolation for PUI (Persons Under Investigation) and so we treat them all like we would anyone with COVID. Surveyor asked about contact tracing for the residents, V2 stated, Yes, so I have a booklet we use to trace any of the residents who test positive and go back to trace which staff took care of that particular resident. We traced one resident for example who tested positive and traced it back to the beautician who she saw about 7 days ago. There can be only the staff that could bring in COVID because none of our residents leave the facility so the only possible explanation is contracting it from our staff and I realize this. We do a lot of in-service training of all staff. Surveyor asked about their outsourced agency staff, V2 stated, We try to in-service them when I see a new face on the floor. Surveyor asked whether they are in-serviced before going on to the care floors. V2 stated, Well, no, because sometimes the agency will send me someone and they don't show up so I have to call and get someone else .we should be in-servicing them on infection control before they even start or go up to the units. Surveyor later asked V4 (Quality Assurance/Infection Control Nurse) how agency staff were trained or in-serviced on the facility's infection control policies, V4 stated, I don't do the training; that would be the DON but I know that when the agency CNA's go on the unit, they are supposed to sign in and read the infection control book. Asked if this is considered training, V4 stated, I guess not. Surveyor asked what time the agency CNA staff started in the morning, V4 stated, They are supposed to be here by 6 AM but a lot of them don't show up until 7:30 sometimes. Surveyor asked who ensures that these agency staff are properly in-serviced regarding infection control before coming on to the unit, V4 stated, I can't tell you if there is anyone at all but the nurses should be doing it. Surveyor asked for a copy of all staff infection control in-service training including outside agency staff. V4 presented a book but could not provide any agency staff who had been given any training. V4 stated, It's the responsibility of the agency company to do all that, I think. At 11:45 AM, V1 (Administrator) presented surveyor with a re-inservice of two housekeeping staff (V9 and V10) on PPE usage and general use of cleaning supplies but could not provide specific instructions given to his staff as to exact proportions of chemicals needed to be mixed in their mop water and/or whether to use any chemicals at all. Surveyor asked about this and V1 stated, this was the in-service (training) that my housekeeping director provided. At 12:15 PM while observing the lunch time meals being distributed, V7 (Agency CNA) was observed wearing the same gloves with no gown worn, going room to room passing lunch trays to 6 resident rooms. Surveyor approached V7 and after V7 confirmed that Surveyor was with IDPH, took a gown out of one of the isolation carts and put on a gown, changed her gloves and continued to distribute food trays but with gown and new gloves on and taking the gown and gloves off before going into another isolation room. At 12:18, V11 (Activity Aide/CNA) was walking up and down the hall with a yellow gown with a food tray in hand. Surveyor asked what she was doing, V11 stated, I'm in activities today and I'm helping pass the food. Surveyor asked if she was supposed to be wearing a gown coming out of resident rooms, V11 stated, No I will change now. At 1:38 PM, V12 (Receptionist), seated in the front lobby reception area and the first point of contact for anyone entering the facility, was on the phone with her mask worn below her chin while a resident sat in front of the desk waiting to meet with the Administrator. Surveyor alerted V1 and V1 immediately told V12 to place her mask back on. 12/22/20 at 10:15 AM, V1 (Administrator), stated, I immediately told V12 to place her mask back on and I in-serviced all receptionist staff including weekend receptionists sitting at the desk that masks should be worn at all times when manning the desk and with residents around. I also made mention that eating snacks or otherwise while sitting at the desk will no longer be tolerated. V12 said she was eating at her desk as the reason she had her mask off but that is not acceptable when manning the desk. Facility policy and procedures dated 5/2020, titled, COVID-19 Infection and Prevention Guidelines, includes: Perform hand hygiene at a minimum before starting the shift; before and after contact with a resident; Whenever putting on or taking off gloves; When hands are visibly soiled; Prior to leaving shift. Universal masking: Keep mask on at all times, covering the nose and mouth; Do not hang mask around the neck; Replace mask if wet, soiled or damaged. The purpose of universal masking is that the CDC has identified that there are people who carry COVID-19 and do not have symptoms. The residents that we serve live in a communal environment, the highest risk comes from associates and visitors entering the community. Universal masking limits the risk of transmission to the residents. Transmission-Based Precautions: Covid Positive: Droplet and Contact Precautions + Eye protection upon entry to the community and already initiated for current residents when they were a Person Under Investigation (PUI). PUI/Symptomatic Resident: Droplet precautions + Eye Protection initiated with any observation of a positive respiratory observation; Admission/Readmission and frequently out of the building for treatment (e.g. [MEDICAL TREATMENT]). Dining: Residents that are capable of eating and feeding themselves without assistance. Provide in-room meal service using trays, plate covers, and normal china and silverware. Associates perform hand hygiene prior to picking up the food tray and prior to leaving the resident's room. Associates perform hand hygiene prior to donning PPE and after removing. When assisting residents with meals, change gloves and perform hand hygiene between residents.

Based on observation, interview, and record review, the facility failed to use a mechanical lift with two staff members while transferring a resident from bed to wheelchair and back. This failure affected one (R1) of four residents reviewed for transfers and resulted in R1 sustaining a left femur (thigh bone) fracture requiring hospitalization and surgical intervention. Findings include: R1 is an alert and oriented [AGE] year old resident with [DIAGNOSES REDACTED]. A facility fall risk assessment dated [DATE] shows R1 with a total score of 5 signifying that she is at high risk for falls. A facility incident report dated 6/15/20 written by V2 (Director of Nurses) at 12:40 PM states, On 6/15/20 at 8:30 am, resident (R1) was being transferred by (V5) assigned CNA (certified nurses aide) from bed to wheelchair, resident complained of left leg weakness, and CNA eased her down on the floor, and called out for assistance. Assessment done, no physical injury noted, resident complained of left knee pain 2/10: [MEDICATION NAME] given. Resident was transferred to bed via hoyer (mechanical) lift with 2 assist. MD informed, order received to do X-ray left hip and left knee. 6/15/20 at 12:24 PM, X-ray result shows acute fracture left distal femur. MD informed and order received to send resident to hospital for evaluation. 9:24 PM Nurse on duty called hospital ER and was informed resident's admitting [DIAGNOSES REDACTED]. Investigation: Based on resident's medical record, staff's and resident interview, on 6/15/20 at approximately 8:30 AM, assigned CNA was transferring resident from bed to wheelchair, resident complained of left leg weakness, resident was eased to the room floor and CNA called out for assistance. Resident is alert and oriented x 4. When asked what happened, she stated, I think the screws in my knees are getting weak, I told the aid, and she sat me down slowly on the floor, I did not hit my head. Medical records recieved form the hospital shows resident has prosthesis in her left femur and she sustained Supracondylar periprosthetic fracture left distal femur. Interview with V3 (LPN) on 11/16/20 at 11:14 AM stated, I was working on the floor doing a medication pass around 8:30/9:00 AM when the CNA (V5) came over and called me and says that (R1) is on the floor so I went to her room and saw her sitting upright on the floor leaning against the dresser drawer. I did the assessment and I checked her body and legs for any injury. I asked the resident if she was in pain and she denied any pain. She (R1) said to me I fell . I asked her if she hit her head and she said she did not. Surveyor asked how many staff was required to lift and transfer (R1), V3 stated, She is a hoyer (mechanical) lift times 2 person assist .Normally 2 staff are required to safely transfer someone (using a lift). Asked what V5 told her as to how R1 fell , V3 stated, She said that during the transfer (R1) lost her balance and so V5 eased her down to the floor but she (V5) admitted she did not get help which she should have for R1. Asked what R1's current level of transfer assistance is needed, V3 stated, She requires extensive assist times 2 persons and we use the hoyer (mechanical) lift to transfer her. 11/16/20 at 11:35 AM, R1 stated, There was this young girl who got me up or at least she tried to get me up. She said, I'm going to get you dressed now. I said to her, Okay and I didn't think much of it when she was going to try to get me up to get dressed but I was concerned because she was by herself so I asked her if she could get someone to help her. She said that she could do it fine herself and she was in a bit of a hurry, but I let her do it anyway because she insisted. I told her again before she started that I was just dead weight and that she needs to get some help, but she just went about what she was going to do and ignored my requests. Surveyor asked if she recalled V5 using a belt or any mechanical device to try to assist in transferring her. R1 stated, Oh no, she just took her arms and put them under mine and tried to lift me up. There was no belt that she used on me. When she got me up and tried to maneuver me over to the bed was when I knew I was going down, because like I said I'm dead weight, and I just dropped down and fell to the ground. My feet fell under the bed and I hit my head against this table (pointing to the bedside table). Surveyor asked if staff ever used a mechanical device to move her which required her to be placed on a sling. R1 stated, No, see that blue thing (sling used for mechanical lift) sitting on the chair, that's been sitting there and never been used except maybe one time. Surveyor asked whether V5 lowered her to the ground as stated in the incident report. R1 stated, I was not lowered to the floor, I was dropped by that girl otherwise I wouldn't have my legs under the bed, would I? There were about 3 girls that came in when I was on the ground and one of them looked me over. Then some man came in and took X-rays of me and then a couple of hours later, 2 ambulance men came and took me to the emergency room and that's when I stayed in the hospital for couple of days and then I had to go back again and I had to get surgery. I was in so much pain and to this day I still have to go to therapy all because that girl was in a hurry and didn't get help like I asked her to. 11/17/20 at 9:45 AM, V5 (CNA) (with V2 present) stated, I was trying to help (R1) get ready and I took all her clothes out and sat her at the edge of the bed. When I pivoted her to transfer her to the wheelchair was when I couldn't hold her and she fell down to the ground. I went down the hall and got the nurse (V3) who assessed her and we transferred her using a hoyer (mechanical) lift back to bed and then ambulance people came about an hour later to take her to the emergency room . Asked how R1 was situated on the ground when she fell , V5 stated, She was parallel to the bed and I leaned her against the bedside table .I didn't use anything (to help transfer R1). V5 also stated that she did not use a gait belt and did not have one; there was one (gait belt) in the hall but I didn't use it. Surveyor asked if she was educated on the type of transfer requirements R1 needed to safely transfer and V5 stated, I know I was told she needed only one person to transfer and there was a sheet in her drawer that says this. Asked if anyone discussed with her R1's plan of care related to transfers, V5 stated, Well just the sheet in the drawer and also stated that she did not look at the sheet in question. 11/17/20 at 10:15 AM, surveyor entered R1's room in search of above mentioned sheet that V5 referred to earlier and asked V7 (CNA) who was currently in the room geting R1 ready. Surveyor asked about a sheet of paper with R1's care information, V5 stated, I don't know of any sheet. Asked if she's ever referred to any type of sheet or card pertaining to R1's care, V7 stated, I don't know what that is. At 10:30 AM, V7 (CNA) called surveyor back to R1's room and volunteered to demonstrate transfer technique with R1. V7 stated that she found the sheet and it was in R1's closet. The sheet of paper showed R1's name and room number with Transfer with Hoyer (mechanical lift) that was checked as device needed to safely transfer R1. V7 began the demonstration and started putting a gait belt around R1's waist, however, did not use the belt to lift and transfer R1. Asked about the gait belt, I don't need it, I use it because the DON (V2) just told me to use it. R1 stated, They never use that either on me, I don't know why they are doing it now. Surveyor asked V7 where the mechanical lift was to transfer R1 and she stated that (R1) doesn't use that .there is one (mechanical lift) on the second floor but we don't even have one here. 11/17/20 at 11:00 AM, V2 stated, All CNA's have to use their gait belts whenever they are transferring any resident. R1 used to be a 1 person assist but now she needs two people and a mechanical lift transfer. Asked how many people are required to safely use a mechanical lift and V2 stated, One person. Asked again if one person can safely place a resident on a sling then lift them with the mechanical lift, V2 stated, She needs two people. 11/17/20 at 11:30 AM, V9 (Minimum Data Set and Care Plan Coordinator) stated, I create the MDS (Minimum Data Set assessment) and do the care plan with the help of the interdisciplinary team. (R1) needs extensive assist in transfers and she is coded as a 3 which means a two person assist. 11/25/20 at 10:30 AM, V9 stated, In order to safely transfer any resident using the mechanical lift, you will need two people. You need two because you still have to place the resident on the sling, secure the sling on to the mechanical lift and one staff to run the control device. It's not safe for just one person to use. MDS dated [DATE] documents that R1 is totally dependent on staff for transfers from bed to wheelchair and with 2 or more persons physical assistance as support in performing this task. The most current MDS dated [DATE] shows R1 requiring extensive assistance with staff providing weight-bearing support but still requiring 2 or more persons physical assistance as support in performing the task. Care plan for R1 dated 10/29/2019 (prior to fall with sustained fracture) includes: (R1) is at risk for falls related to impaired balance during transfers, limited physical mobility secondary to chairbound status; medication side effects and use of mobility device. Goal: (R1) will not have fall related injuries through the next review date. Approaches: Ensure that wheelchair brakes are locked prior to transferring; prefers wearing tennis shoes, needs a night light on to help see at night, monitor for changes in condition that may warrant increased supervision/assistance. There were no specific interventions pertaining to safe transfer.

Based on observation, interview, and record review, the facility failed to prevent and/or contain COVID-19 by failing to properly wear masks to cover both nose and mouth; failed to screen all staff and visitors entering the facility; and failed to use EPA (Environmental Protection Agency) approved disinfectants on floors and surfaces requiring disinfecting. This failure has the potential to affect all 62 residents currently in the facility. Findings include: 11/16/20 at 10:10 AM V1 (Administrator) was asked the number of residents currently in the facility and stated, We are at 62 residents. We have no current Covid residents or PUI (Persons Under Investigation) or anyone on isolation. Interview with V2 (Director of Nurses) at 10:20 AM concurred with V1, stating, We had had about 15 to 16 Covid residents during the pandemic but we currently have none now or any PUI's or anyone on isolation. During the initial tour of resident floors on 11/16/20 at 10:30 AM, there were two residents placed on isolation on each floor. V13 (RN) on the first resident floor stated, R2 is on isolation for droplet precautions because she goes in and out for [MEDICAL TREATMENT]. V14 (RN) stated, I'm the nurse on this floor (2nd floor) and I have one person who is on isolation for PUI (R4). 11/16/20 at 2:30PM, V2 was asked whether there was any changes to the number of residents that were on isolation to prevent the spread of Covid-19, V2 stated, Yes, I'm sorry those two you are referring to are on isolation, I thought you were referring to actual Covid isolation. 11/16/20 at 2:50 PM, V12 (Receptionist) was observed wearing her mask below her nose while allowing staff to enter the facility without any COVID screening questions similar to what the surveyor was required to answer prior to entering. V12 was observed removing her mask while answering the phones. At 3:00 PM, facility staff entered the facility, signed her name in the visitor log and was not given a temperature reading by V12 as per facility policy. Surveyor asked V12 where the questionnaire was that she was supposed to ask the staff member who just walked by, V12 pointed to her staff log in sheet of all who had entered the facility so far during the day. V12 counted the number of staff/visitors who already entered and stated, There were 31 people who have signed in. Asked how many questionnaires she currently had, V12 stated, 6 including your questionnaire (referring to the screening questionnaire the surveyor took). Surveyor asked where the other questionnaires were that were supposed to be filled out by staff and visitors? V12 stated, I don't have any more, they didn't fill out any. V1 (Administrator) who noticed the surveyor talking with V12, walked over to the reception desk and informed V12 that she needed to use the COVID screening form. V12 responded to V1, Oh I didn't know we were doing that again. 11/16/20 at 12:50 PM, V8 (Housekeeper) was observed mopping floors on the second floor. Surveyor asked what he did, V8 stated, I'm the housekeeper on this floor. I do the whole floor, I sweep, mop, and clean toilets. Surveyor asked what chemicals if any were used in the mop water and V8 stated, I use soap and water. 11/16/20 at 1:10 PM, V15 (Housekeeper) was observed coming out of an adjacent room then entering R2's isolation room without washing her hands or donning an isolation gown. Surveyor asked what she was supposed to do before entering R2's room, V15 stated, I'm supposed to wear this (pointing to plastic isolation gown that was inside an isolation bin outside R2's room.) Asked if she washed her hands prior to entering the room, V15 stated, No. Surveyor asked what she used in her mop water, V15 stated, soap and water and walked surveyor to the housekeeping closet where V15 showed what she placed in the water. The plastic bottle was white with no apparent label outside the bottle to distinguish the contents of the bottle. Surveyor asked what was inside the plastic bottle and V15 stated, soap I add to mop water. 11/16/20 at 1:15 PM, V10 (Plant Operations Director) stated, I'm in charge of operations of the building and I am over all the housekeepers and maintenance. Surveyor asked what his housekeepers use to clean floors, V10 stated, They are given a citrus neutral cleaner. It's a soap but does not contain any bleach to clean the floors. Asked if this neutral cleaner is used for all floors including rooms on isolation, V10 stated, Yes we use the neutral cleaner for all rooms. Per EPA (Environmental Protection Agency) guidelines, the EPA expects all products on List N to kill the coronavirus [DIAGNOSES REDACTED]-CoV-2 (COVID-19) when used according to the label directions. Above mentioned cleaner was not noted to be found on EPA list N. Facility policy titled Covid-19 Infection and Prevention Guidelines dated 5/2020 states in part (but not limited to): Screening: Associates, contracted providers, agency, vendors and visitors screening. Identified screeners are educated on completing the screening questions and who to contact if there is a positive response to the screening questions or elevated temperature. Screeners should be wearing a face mask and have alcohol based hand sanitizer available at their station. Screened each time that they enter the community. Visitors, vendors and agency: Each community has designated one entry point for deliveries, visitors, vendors and agency staff. Screening occurs before the visitor enters a resident care area. Initiation of Precautions: Covid positive: Droplet and Contact Precautions plus eye protection (upon entry to the community and already initiated for current residents when they were a Person Under Investigation (PUI). PUI/Symptomatic Resident: Droplet precautions plus eye protection with any observation of a positive respiratory observation. Admission/Readmission and Frequently out of the building for treatment (e.g. [MEDICAL TREATMENT]): Droplet Precautions upon entry to the community.

Based on observations, interviews and record reviews, the facility failed to follow their Food Purchasing and Storage policy. The facility failed to date opened food item and failed to discard expired food items. This deficient practice can affect all 68 residents in the facility for the review of kitchen food storage. Findings Include: On [DATE] at 9:45am, kitchen observation was conducted with V4 (Dietary Manager). Walk-in freezer was observed with unboxed, unbaked round apple pie with plastic wrap loosely placed on top of the apple pie. It was observed with no written opened date and best thru date. V4 stated It's supposed to be dated, I will throw it away. On [DATE] at 9:50am, walk-in cooler #1 was observed with opened plastic bag of shredded cheese with label, opened date of [DATE] and a best thru date of [DATE]. V4 stated It supposed to be discarded already, I will put it in the garbage bag. Same walk-in cooler was also observed with unopened beef base with no date-in label. V4 stated There is no specific person assigned to label when the delivery comes. Most of the time I label it myself or whoever received the delivery should write the delivery date using the date-in sticker. On [DATE] at 10:00am, walk-in cooler #2 was observed with 3bags of lettuce, 2 romaine lettuce bags, and 2 whole uncut squash not in a box and no date-in sticker. In addition, observed 1 box of baby spinach with no date-in sticker. On [DATE] at 10:10am, dry storage room observed with 2 chocolate fudge in white buckets (11 pounds bucket), first bucket with opened date of [DATE] and a best thru date of [DATE], and second bucket with opened date of [DATE] and a best thru date of [DATE]. V4 stated These chocolate fudge buckets should have been discarded, it has already expired. Food Purchasing and Storage policy with the revised date of ,[DATE] reads: It is the policy of Ascension Living that the Nutrition and Dining Services Director is responsible for food purchasing and storage based on the menu and current census. Food must be date marked if it is prepared on site and refrigerated, or commercially processed after the original container is opened. Food shall be dated with the current date and be used or discarded per State Food Code regulations. If potentially hazardous, ready-to-eat food is frozen, the food shall be dated with the current date and used or discarded per State Food Code Regulations.

Based on observation, interview and record review, the facility failed to ensure that staff safely utilized a mechanical lift which affected one resident (R3) of ten residents reviewed for falls and accidents/supervision in a sample of 15. These failures resulted in R3 sustaining an intracranial hemorrhage after slipping out of a mechanical lift sling and hitting her head on the floor. This injury required a seven day hospital stay. Findings include: R3's Face Sheet documents, in part, the following medical Diagnoses: [REDACTED]. On 9/25/17 at 10:35am, R3 was asked if she had any issues with staff. R3 shook her head and stated, Except when they dropped me on my head. It happened two months ago. They didn't think I would make it. I was on Hospice and the whole nine yards. Hospice made me feel helpless. Like they were just waiting for me to die. R3's Minimum Data Set ((MDS) dated [DATE] documents: Transfer. R3 is coded as a 4 (Total dependence) for Self Performance and a 3 (Two + persons physical assist) for Support. R3's MDS dated [DATE] documents a BIMS (Brief Interview of Mental Status) score of 15 out of 15 which indicates that R3 is Cognitively Intact. R3's Care Plan indicates, in part: Problem: Multiple Sclerosis, needs mechanical lift for transfers due to contractures, [DIAGNOSES REDACTED] LE (lower extremities). Is non-ambulatory and needs extensive assist with bed mobility. 7/11/17 - fell while being transferred with (mechanical) lift, hit head. Sent to hospital. A facility generated Resident Incident Report denotes that on 7/11/17 at 9:30am, R3 experienced a fall while being transferred via manual lift by E5 (CNA-Certified Nurse Assistant) and E6 (CNA). The report documents the following: Narrative of incident and description of injuries: (R3) was being transferred via (mechanical) lift from bed to wheelchair, slipped out of sling on to floor hitting her head. Abrasion on left occipital area of head approximately 2 (two) centimeters in diameter. Immediate actions taken: Pressure applied to head to stop bleeding and ice pack applied, assisted to bed with four (4) assists. This report indicates that R3 was transferred to a local hospital emergency roiagnom on [DATE] at 11:16am. The transfer is also documented in R3's Departmental Notes. On 7/11/17 at 10:27pm, the following is documented in R3's Departmental Notes: Verified at (local hospital emergency room ) resident admitted with a [DIAGNOSES REDACTED]. R3's head injury required a seven day hospital stay. R3's Departmental Note dated 7/18/17 at 9:01pm documents that R3 was readmitted to the facility from the local hospital. On 9/26/17 at 10:04am, E6 (CNA) indicated that on 7/11/17 she requested assistance from E5 (CNA) for the mechanical lift transfer of R3 from the bed to the wheelchair. E6 stated, I stood on (R3's) left side. (E5) did not hook the right side (of mechanical lift) sling correctly. We picked (R3) up off the bed using (mechanical lift). When we swung her from the bed, the top right loop came undone. Because of the loop, the right side came loose. (R3) fell to the left and hit head on the floor but her legs were still looped in the sling by the leg part. Head started bleeding. Me and (E5) got blood on both of us. E6 continued, So, the first thing we should do before we mobilize the resident is check the hooks. I pulled on my side but I didn't pull on (E5's) side. This is how we make sure the loops are secure. On 9/26/17 at 10:11am, E5 confirmed that she assisted E6 with R3's transfer using a mechanical lift. E5 stated, One hook on my side came loose. I thought I hooked it correctly. But when (R3) shook it came loose. E8 (RN-Registered Nurse) confirmed that she was the float nurse on 7/11/17 and responded to R3's incident. On 9/26/17 at 9:52am, E8 confirmed that the E5 and E6 told her that one of the straps came off the mechanical lift. On 9/26/17 at 10:35am, E2 (DON-Director of Nursing) demonstrated how the loops should be secured on the actual mechanical lift that was used for R3's transport on 7/11/17. E2 indicated that the mechanical lift was removed from the unit after the incident. E2 stated, It can actually be in use because it was no fault of the machine. E2 demonstrated that a spring loaded black rubber washer has to be pushed down, the loops placed on hook while the rubber piece is pressed down and when released, E2 demonstrated that the straps remain secured and cannot move. E2 stated, We concluded that the one strap was not secured fully. E2 confirmed that R3's fall incident occurred because of operator error. E2 confirmed that the mechanical lift was functionally sound. E2 stated, Moving forward, staff should check all straps before moving the resident in (a mechanical lift). Now CNA's are responsible for checking each other's straps. On 9/26/17 at 11:25am, Z1 (Physician/Medical Director) indicated that R3 suffered a subdural hemorrhage after the incident. Not sure of her prognosis so she was placed on Hospice. Initially on Hospice due to lethargy and decline from Intracranial Hemorrhage. She just wanted to be left alone, no treatment, no surgery. Z1 acknowledged that it was an avoidable accident. After the incident, R3 was placed on Hospice on 7/17/17 with a primary [DIAGNOSES REDACTED]. On 9/26/17 at 2:25pm, R3 stated, The staff dropped me on my head when they used the machine. That was horrible and it almost did me in. On Hospice afterwards because I couldn't eat, drink, move. I really declined. On 9/27/17, both Z3 (OT-Occupational Therapy) and Z4 (PTA-Physical Therapy Assistant) confirmed that R3 declined greatly after the fall and it took one month for R3 to regain her strength to baseline. R3's emergency room Notes dated 7/11/17 document a service time of 2:36pm. R3's admitting [DIAGNOSES REDACTED]. Discharge Disposition: Admit to SICU (Surgical Intensive Care Unit). R3's Computerized Tomography of the brain without contrast which was performed on 7/11/17-IMPRESSION: Right subdural hematoma and small left subarachnoid hemorrhage. Z5's (Neurosurgeon) Consultant Notes dated 7/11/17 confirm that R3 was admitted to a local hospital with a Right Acute Subdural Hemorrhage. Z1's (Physician) Notes dated 7/11/17 document that R3 was diagnosed with [REDACTED]. On 9/27/17, E2 indicated that the facility does not have a policy that outlines how to use a mechanical lift. E2 indicated that staff are trained annually and upon hire. A facility policy dated 1/7/13 and titled, Safe Patient/Resident Handling and Movement documents, in part: 4. Employee Responsibility for Safety: b. Use mechanical lifts, devices and other approved aids in accordance with instructions and training.