Every finding on record at Aspyre of Waukegan

Based on interview and record review the facility failed to supervise a resident with dementia, poor safety awareness, and known exit seeking behaviors resulting in the resident eloping from the second floor of the facility through an alarmed door, walking down 14 interior steps, and going out a second alarmed door that led outside. R1 proceeded down 4 concrete steps, onto a wooden deck, turned right, and went down a wooden ramp, across the facility's parking lot, then crossed a busy 4 lane street. R1 then walked through another parking lot of an apartment complex and was found unresponsive (deceased ) near the back of the apartment building approximately 125 yards from the facility's emergency exit door on 4/8/26. This applies to 1 of 6 residents (R1) reviewed for safety and supervision in the sample of 12. The Immediate Jeopardy began on 4/8/26 when R1 eloped from the facility. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 4/10/26 at 4:24PM. The surveyor confirmed by observation, interview and record review, that the Immediate Jeopardy was removed on 4/10/26, but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R1's Physician's Order Sheet shows that R1 was admitted to the facility on [DATE] with diagnoses including Parkinsonism, Chronic Obstructive Pulmonary Disease, Dementia, Unsteadiness on Feet, Combined Systolic and Diastolic Heart Failure, Atrial Fibrillation and Cognitive Communication Deficit. On 4/10/26 at 11:49 AM, V1 (Administrator) and V2 (DON-Director of Nursing) were interviewed together and stated, (V2) found him across the street, to the left of the apartment building where the blacktop ends, (R1) was on the ground. He was not breathing. I (V2) started compressions. It was me and (V6-CNA-Certified Nursing Assistant) and (V4-RN-Registered Nurse) doing CPR (Cardiopulmonary Resuscitation) and (V3-LPN Licensed Practical Nurse) called 911. Probably took them (Emergency Medical Services) 2-3 minutes to arrive. At the same time, I (V1) was in the building calling 911 to give a description of (R1) and let them know about the missing resident and believe it or not, they put me on hold because they said they think a colleague was also calling 911. (V2) said he had a history of elopement in December when he first got here but we got him right back in the building and that is why we moved him to the second floor. We had him on increased monitoring. He has not had any incidents since. The staff have to have face checks on him every hour. The nurse (V3) had him in her line of vision most of the day. Then she went in to do wound care. (V7- Activity Aide) was supposed to be watching him. The staff all were running around when they noticed the alarm going off. Both doors are alarmed and were going off.On 4/10/26 at 12:15PM V3(LPN) stated, (V8-CNA) told me when I came in that (R1) was very agitated and wanted to go home. I talked to (R1) and was able to calm him down some. He had breakfast but then he got agitated again. He kept going to the elevator. I notified the DON and the NP (Nurse Practitioner) was here, so I talked to the NP, and he ordered blood work and a UA/C&S (Urinalysis/Culture and Sensitivity). I talked to (R1) and he agreed to give me a urine sample, and I got a little bit in the cup. I put it in the refrigerator and scheduled the lab work for the next day. He kept needing to be redirected. I tried to reach out to social service and (V9- Social Service Assistant) came up and spoke to him. I called the Administrator and the DON. He kept going to the elevator. We were taking turns watching him. We had lunch and I spoke to (R1's) son and had him speak to his son. I don't know what his son said to him, but he was not happy about it. Then they sent (V7-Activity Assistant) up and told me she was assigned to take care of him. Me and (V8-CNA) went in to do wound care on another resident and when I was done, I said, Where is (R1)? (V7) said, He went down the hall. I thought (R1) went to his room - he was in (room number) so I checked his room and he was not there, so I started checking some of the other rooms and I called down to the other nurse who was at the nurse's station in the middle of the hall and she said he was not there. I came back and found (V4-RN- Registered Nurse) coming out of the bathroom and told her I could not find (R1) and she said she had just seen him at the nurse's station, so I went back up there. Then I turned around and saw everyone running towards the other end of the hall so I started running down there too. As I got closer, I could hear the door alarm going off and then I could see his wheelchair sitting outside the stairwell door. Then I could hear the door alarm at the bottom of the stairs ringing too and I said, oh, he went out the door. I called the DON, the MD, and the Administrator and the Administrator called a Code Green. We all started looking inside and outside the building for (R1). It was a very nice day, warm outside. I was running outside; we went to the (Fast Food Restaurant), (Fast Food Restaurant), the apartments next door. Then they said that the cameras showed that (R1) crossed the street and we ran over there. (V2-DON) was in her car and she was there first and then several of us were right behind her. I called 911. V4, V6 (CNA) and (V2) did CPR and I switched out with them as they got tired. The Paramedics arrived in about 5 min. The paramedics took over and they put the machine on him and transported him to the hospital.On 4/10/26 at 1:22PM V4 (RN) stated, I had just come upstairs, and I saw (R1) in the wheelchair at the nurse's station. Then I went to the bathroom. As I was coming out (V3) said she couldn't find (R1). I looked towards the nurse's station, and I didn't see him and then under the sound of the call light I could hear this very faint dinging sound. The call light system is old so it is very loud, but I could hear another ding, ding, ding under that sound. So, I ran towards the door at the end of the hall, and I saw (R1's) wheelchair outside the door, so I booked it down the stairs and out the door. I called the Administrator at 2:26PM and she called the code green. The camera shows (R1) coming out the door at 2:24 PM. I went towards the apartments next door because there are always people outside. I don't know the exact time he was found. I ran back upstairs and got my keys and went down and got in my car and started driving around. I went to the parking lot across the street, but I went to the right because I thought it went all the way around and then I came back here. As I was getting out of my car, I saw people running across the street, so I got back into my car and drove back over there and assisted with CPR. When the paramedics got there, they took over. There were no signs of life. He was fully dressed with shoes on. It was a beautiful day, probably 70 degrees outside. I had seen him earlier in the day talking to his son, he wanted to go home.On 4/10/26 at 12:35PM Surveyor reviewed R1's exit path with V3 (LPN), V1 (Administrator) and V2 (Director of Nursing). R1 went down the hall, turned down the narrow hallway with the stairwell door at the end. R1 went out the stairwell door, setting off the alarm, went down 14 interior stairs and out the exterior door, setting off the second alarm. R1 proceeded down 4 concrete steps and onto a wooden deck. R1 turned right onto a wooden ramp that led to the side of the facility's parking lot. R1 walked across the parking lot, across a 4-lane busy street, and into the parking lot of an apartment complex. R1 turned left and followed that parking lot around to the back where he was found unresponsive on the ground near the building. On 4/10/26 at 12:45PM Surveyor assessed door alarms on the second floor. As Surveyor and V3 (LPN) were walking towards the stairwell door someone stated that the alarm was going off right now. Surveyor was unable to distinguish the door alarm over the call light system. After assessing the doors and the alarms and the areas that R1 exited the building, surveyor asked V5 (Maintenance) to trigger the alarm on the stairwell door. Surveyor walked down the hall towards the center nurse's station. About halfway down the hall, at about room [ROOM NUMBER] (before the main nurse's station, dining room and elevator) the door alarm was no longer audible to Surveyor. As Surveyor walked back towards the stairwell door, a call light came on and the door alarm was not audible to Surveyor at all, even at room [ROOM NUMBER], closer to the door alarm. On 4/10/26 at 2:35PM V9 (Social Service Assistant) stated, I went to the second floor because the nurse (V3) said (R1) was anxious. He was very anxious, worried. The nurse wanted me to talk to him. He calmed down a little bit, and I went back downstairs to do other work. I called his son and the son said he had already talked to his dad. I went back upstairs to talk to him, and he was calm, so I came back down to do other work and talk to other residents. I had worked with him a few times before. He was not trying to get on the elevator when I saw him. He didn't have any complaints. He was just anxious but did not give me any reason for his anxiety. He was just sitting in the dining room.On 4/13/26 at 9:20AM V8 (CNA) stated, I saw (R1) before (V3) and I went in to do the wound care (down the same hall as the elevator) V7(Activity Aide) was sitting by the elevator and (R1) was moving down the hallway. He was in his wheelchair. There were a few other residents in the hallway, and this was not really unusual. I think (V7) thought she was just supposed to be guarding the elevator. I told her she didn't have to stay in front of the elevator if (R1) is down the hall. After the wound care I went into (Room number) to change another resident. I heard the code green and it took me a minute to respond because I had to finish up and put the bed back in the low position and give the resident her call light. I could not hear the door alarm going off. I couldn't differentiate that from the call light bells going off since the call lights are so loud. Then I heard (R1) was missing. I ran downstairs and then I remembered seeing him in the hallway and V5 (Maintenance) and I ran back up thinking that maybe he couldn't get out of the stairwell. He wasn't there so I got in my car and started driving around and kept thinking, (R1) couldn't have gotten this far. (R1) walked pretty good. He kept saying he wanted to walk home, he wanted to walk to (his hometown) and I showed him on my phone that it would take him 15 hours to walk there (42miles from facility) and (R1) said if you people wouldn't keep stopping me. I know (R1) talked to his son, and I don't know what was said but I know it was an argument because I could hear them both yelling on the phone. (V3) calmed (R1) down quite a few times that day but he still wanted to go home.On 4/13/26 V7(Activity Aide) stated, At 1:35PM my boss (V10- Activity Director) told me to go upstairs and do the activity on the second floor. When I got up there, (V8-CNA) told me I needed to watch after (R1). I went closer to the nurse's station, and I asked the nurse with the red hair (V3) if I could sit at the nurse's station and she said it was only for the nurses. So, I sat in front of the nurse's station and (V8) and (V3) walked away. Then I went and sat in front of the elevator and (R1) went down the short hall and I brought him back and he got a cup of water and then he went down the long hallway and there were a couple other residents and another CNA and a nurse in the hallway too. Then (V9- Social Service Assistant) came up on the elevator and she asked me if I knew how to work a (Virtual Assistant Device) because (R1's) family wanted to be able to call him on it and I told her I really didn't know how. Then I saw (V8) and he told me I really didn't have to sit in front of the elevator if (R1) was down the hall so I went and sat at the long table in front of the TV and I was working on a flowerpot with one of the other residents. Then a few minutes later (V3) came and asked me if I knew where (R1) was and I told her he was in the hallway and then a few minutes after that (V4- RN Infection Preventionist) came and asked me if I knew where (R1) was and I told her the same thing. I could not hear the door alarm- but the dining room is usually pretty loud. Then everyone started running and I was left alone on the floor with all the residents in the dining room.On 4/13/26 at 2:30PM V10 (Activity Director) stated, I told (V7) to go upstairs and run the activity and watch (R1) so he doesn't get on the elevator- while she does the activity. A lot of times while we are in the dining room we are also monitoring the dining room and the elevator because we are right there. I knew (R1) was trying to elope so I thought she could do the activity and also just kind of watch the elevator to make sure he doesn't get on it. She didn't really have to guard the elevator- just watch (R1) while she was in the dining room. I don't know what she was told when she got up there.R1's EMS Report shows that the EMS call came in at 2:54PM. The report states, (City) Rescue 4 and Engine 4 called to noted location for an unresponsive/person down. Upon arrival crew waved down by a civilian and directed crew to patient. Pt was supine on the parking lot floor with a significant amount of Vomit. CPR was in progress. Crew took over checked for pulse and breathing. Crew determined that patient was pulseless and not breathing. Pt presented with Asystole on the cardiac monitor. Crew initiated CPR and began to bag patient with a BVM (Bag-Valve-Mask) supplied with oxygen. Pt suctioned and OPA (Oropharyngeal Airway) placed, attempted placement of NPA (Nasopharyngeal Airway) no success no visual signs of trauma noted. LUCAS ([NAME] University Cardiopulmonary Assist System) device place for continuous CPR. IO (Intraosseous) established in the Left Tibia. Fluids and EPI 1:10 administered per protocol. It was determined that patient is a resident of (Facility) and he had absconded from the facility. Multiple staff members on scene, it was determined that the person left the facility approximately 14:15 (2:15 pm) and they have been looking for him since. When staff found him he was unresponsive and initiated CPR and called 911. Crew continued to work patient Pt was in Asystole with no changes. Pt intubated and obtained a brief spiked reading of ETCO2.(End-Tidal Carbon Dioxide) Pt prepped for transport. ET (Endotracheal) tube checked after pt moved, still in place. Pt suctioned once again as tube became filled with frothy sputum. Unable to get a adequate ETCO2 reading. Contacted (Local Hospital) with a full report, no orders given. Continued CPR and EPI 1:10 during transport no changes noted pt remained in asystole during the entirety of the incident. Upon arrival to (Local Hospital) pt was taken to ED room report was given to RN pt care was transferred without incident. Pt remained in asystole.R1's Elopement Risk assessment dated [DATE] states, Resident at risk for elopement. IDT reported resident for an attempt to leave unattended and paces on the unit.R1's Care Plan dated 12/22/25 states, The resident is an elopement risk/wandered related to History of attempts to leave facility unattended, impaired safety awareness. New to facility. Worsening confusion during evening hours. One of the Interventions states, Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes.The facility presented an abatement plan to remove the immediacy on 4/10/26. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on 4/13/26, and the survey team accepted the abatement plan on 4/13/26.The Immediate Jeopardy that began on 4/8/26 was removed on 4/10/26 when the facility took the following actions to remove the Immediacy:1.The facility has taken the following actions concerning the IJ complaint:a. The identified exit door was monitored by staff 24/7 beginning on 4/10/2026.b. Second floor and first floor middle of the hallways alarm bells were delivered and installed on 4/11/26. An additional alarm bell was placed by the second floor nursing station/elevator area on 4/12/26. In addition to being alarmed, first and second floor middle of the hallway stairwell doors were added to the existing bells on 4/13/26.c. An emergency QAPI meeting was held with the medical director on 4/8 to review the incident and for any additional input.d. Inservices was done by administrator and/or designee to staff prior to the start of their shift regarding: code green (missing resident), what to do if a resident is exit seeking and anxious, and residents that are identified as elopement risk and placed on 1:1 care, what to do if they walk away.2.Measures the facility will take to ensure the problem will be corrected and not recur.a. The maintenance director or designee will monitor and test the alarm bells. The bells will be tested weekly on various shifts for three months.b. The maintenance director or designee will perform code green (missing resident) mock drills monthly for three months on various shifts.c. Social services will identify residents that are at risk for elopement. These assessments will be completed for current residents on 4/13/26. All new residents will be assessed for elopement risk. Interventions for elopement will be put in the residents' care plan.3.The administrator will monitor continued compliance via the following Quality Improvement programs:a. A QA tool was developed to review the alarm bells weekly and ensure they are audible for 3 months.b. A QA tool was developed to review any attempted or actual cases of elopement weekly for 3 months.c. Outcomes of bell testing and code green (missing resident) drills will be discussed at monthly QAPI. These reviews will be ongoing for 3 months and may continue based on outcome of the findings.d. Interventions for identified residents that are an elopement risk will be discussed at monthly QAPI meetings. These reviews will be ongoing for 3 months and may continue based on outcome of the findings.e. The results of the monitoring completed under this plan are submitted to the QA/QAPI committee for review and follow-up and reviewed with the Medical Director. Next QAPI meeting scheduled for April 30th, 2026.Date Removal Plan Will Be Completed: 4/10/2026

Based on interview and record review the facility failed to ensure a resident received a higher level of care for a resident experiencing respiratory distress. This delay in medical intervention resulted in R77's death. This applies to 1 of 21 residents (R77) reviewed for care and services in the sample of 21.The Immediate Jeopardy began on [DATE] when the resident (R77) was found having respiratory distress and died the same day.V1 (Administrator) was notified of Immediate Jeopardy on [DATE] at 2:45 PM. This surveyor confirmed by interview and record review that Immediate Jeopardy was removed on [DATE] but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.The findings include:R77's electronic face sheet shows R77 has diagnoses that include, Chronic Obstructive Pulmonary Diseases, (COPD), Congestive Heart Failure, vascular dementia and diabetes.R77's Physician Order Sheet (POS) dated 1/2026 shows R77 has an order of Oxygen 2Liters (L) per minute, titrate to 3-4L as needed every shift, for Parameters of oxygen (02) saturation. Notify Physician of O2 Sats (saturation level of blood oxygen) below 92%.R77's death certificate shows R77's cause of death was acute respiratory failure on [DATE].On [DATE] at 10:20 AM, V23 (Certified Nursing Assistant-CNA) said she was R77's CNA on [DATE] working from 11PM to 7AM. V23 (CNA) said at around 3 AM, R77 was in her doorway, gasping for air, calling out, please help, I cannot breathe call the Nurse. V23 said she hurriedly called the nurse (V20). The Nurse (V20) checked R77's oxygen level and said it was low and applied R77's oxygen. Throughout the shift, R77 continued to complain of not being able to breathe. R77 stayed in her wheelchair, by her doorway, not visible in the hallway but could be seen when passing in her room. At around 4:30 AM-5AM, R77 was in her chair unresponsive. 911 was called, Cardiopulmonary Resuscitation (CPR) was done R77 passed away that same morning.On [DATE] at 11:30 AM, V20 (Registered Nurse-RN) said she was the nurse on duty on [DATE]. V20 (RN) said at around 3AM, V23 (CNA) informed her that R77 was complaining she could not breathe. V20 said she went to check on R77, R77 was struggling to breathe. R77 was not keeping her oxygen on, she kept taking her oxygen off, she was very anxious. R77's oxygen saturation was very low, in the 60's. V20 said she increased R77's oxygen from 2L to 4L and R77's oxygen saturation went up. V20 said she called V2 (Director of Nursing-DON) who instructed her to put on a nonrebreather mask and to make sure R77's O2 sats were in the 90's. V20 said R77 continued to struggle to breathe, complaining she could not breathe. V20 said R77 was monitored and reminded to keep her oxygen on. V20 said she did not notify R77's Physician regarding R77 experiencing respiratory distress with low oxygen saturation in the 60's and continued complaints of not being able to breathe, she only notified V2 (DON). At around 5AM, R77 became unresponsive. R77 was full code, CPR was done and 911 was called. V20 said R77 died that morning. V20 said she notified R77's physician and family after R77 passed away.On [DATE] at 12:13 PM V2 Director of Nursing (DON) said V20 (RN) notified her regarding R77 having respiratory distress and that R77 won't keep her 02 on. V2 (DON) said she instructed V20 to apply a non-rebreather mask and get R77's oxygen saturation up. V2 said she also instructed V20 to notify R77's physician regarding R77's significant change in condition or send R77 out to the hospital. V2 said she did not know why V20 did not notify R77's Physician at that time for timely evaluation and medical treatment. V2 stated we call the doctor for everything, the physician can assess the severity or decide to transfer resident to the hospital, not sure why she only notified me and did not inform R77's physician.On [DATE] at 12:07 PM, V21 (Nurse Practitioner-NP) said R77 was young in her late 60's with COPD and oxygen dependent. V21 (NP) said she was at the facility early in the morning on [DATE] making rounds when R77 coded. V21 said she helped with the CPR. R77 was pronounced dead by the paramedics. V21 said she was the NP for R77 but did not get a call regarding her condition change. V21 stated If I was notified, I would have sent R77 out to the hospital to make sure R77 received the level of care without delay. Breathing problems can worsen fast and lead to respiratory failure.R77's progress notes dated [DATE] by V20 (RN) show that at 3:15 AM, R77 was found in her room doorway saying she was having trouble breathing, R77 has taken her oxygen off. (V20) gave R77 nonrebreather mask and checked oxygen saturation level (02 sats), reading very low at 60 percent (%). RN (V20) did deep breathing exercises, turned oxygen up to 4 Liters via nasal cannula (NC), R77's 02 sats went up to 90 %. Oxygen gradually decreased to 2L. R77 was assisted to bed and reminded the importance of keeping her oxygen on. R77's progress notes dated [DATE] shows that at around 4:30 AM, R77 was still breathing heavy and continues to show signs of air hunger. R77 was placed on non-rebreather mask, O2 sats level at 92 %. R77 continues to remove oxygen saying that she can't breathe, V20 (RN) informed R77 the importance of wearing mask including the risk of death. The DON was notified.R77's progress dated [DATE] shows that at around 5:30 AM, R77 was seen bent over in wheelchair, attempted to arouse R77 by yelling her name, doing sternal rub and shaking R77, - no response, no pulse felt, R77 removed from wheelchair, CPR immediately initiated, 911 was notified. 911 arrived and took over CPR. R77 was pronounced dead. R77's family and coroner were notified. Coroner gave permission to release the resident's body.The Facility Policy on Change in Condition (Your role as a Nurse-undated) shows, residents have especially high risk for developing acute conditions because they already have chronic diseases that make them susceptible to acute conditions. Do an assessment of the residents focusing on the area of change. All changes of condition should have full set of vitals. Respiratory: listen to lung sounds, pulse ox, respiratory rate, if resident has oxygen are they using? new or worsening cough. Call the Physician or Nurse Practitioner with the assessment. Practice: A resident complains of Shortness of breath, what would you evaluate? -Vital sign, including pulse ox (oxygen saturation) listen to the lungs, assess for swelling, if resident has an order for 02, apply as ordered. Call the physician or nurse practitioner with the assessment.The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy:a) All nurses scheduled for [DATE] and [DATE] have been educated on change of condition. Any unavailable nurse will be educated prior to start shift. The nurse involved has been educated individually.b) All residents with a current change of condition have been reviewed to ensure that the physician or nurse practitioner has been notified and if orders given are in place.c) An emergency QAPI meeting with the Medical Director was held last [DATE], reviewed the situation and for any additional input.2. Measure the facility will take to ensure the problem will be corrected and not recur.a) The Director of Nursing will review all changes of condition to ensure that the Physicians or nurse practitioners were notified, and orders carried out.b) All transfers to the hospital will be reviewed by the Interdisciplinary Team (DON, Wound Care Nurse, Administrator) at the time of transfer to ensure changes in conditions were not missed and that the physician or nurse practitioner were notified timely.c) All deaths will be reviewed by the Interdisciplinary Team (DON, Wound Care Nurse, Administrator) within 48 hours of the death to ensure that there were no opportunities to intervene.d) All transfers to the hospital and deaths will be discussed at the monthly QAPI with the Medical Director present for any additional input.3. The Director of Nursing will monitor continued compliance via the following Quality Improvement programs:a. A QA tool was developed and will be completed on all changes of conditions for 3 months.b. A QA tool was developed to review hospital discharges and will be done with all hospital discharges for 3 months.c. A QA tool was developed and will be done with all deaths for 3 months.d. The results of the monitoring completed under this plan are submitted to the QA/QAPI Committee for review and follow-up and reviewed with Medical Director. Next QAPI meeting will be [DATE].

Based on observation, interview and record review the facility failed to identify and assess a pressure ulcer prior to developing a new unstageable pressure ulcer and failed to implement pressure relieving interventions for a resident at risk for developing pressure ulcers. This failure resulted in R59 developing an unstageable pressure ulcer to her right ischium. This applies to 1 of 6 residents (R59) in the sample of 21 reviewed for pressure injuries. The findings include: R59's face sheet shows she has diagnoses including type 2 diabetes, unspecified dementia, hypertensive heart disease, dysphagia and bilateral hearing loss. On 2/22/26 at 9:51 AM, V10 (Licensed Practical Nurse-LPN) said R59 has an open area to her right buttock with a foam dressing. On 2/22/26 at 1:36 PM, R59 was sitting in her reclining wheelchair with no pressure relieving cushion. R59 was thin and underweight. She was yelling out, help me, help me. V10 and V23 (Certified Nursing Assistant) transferred her with the mechanical lift to her bed and provided incontinence care. A foam dressing was in place to her right buttock. V10 and V23 then transferred R59 back into her recliner chair without a cushion in place. On 2/23/26 at 12:17 PM, V10 (LPN) said R59 is dependent on staff for most cares and has a pressure ulcer to her right buttock, the wound physician is following her wound. We notify the new wounds to V2 (DON/Director of Nursing), V4 (Wound Nurse) and family. The wound is assessed, and treatment orders are put in place. On 2/24/26 at 9:25 AM, V4 (Wound Nurse) said R59 is a high risk for developing pressure ulcers and confirmed she did not have pressure relieving interventions in place prior to developing a pressure ulcer. V4 said she was not aware of R59's open area. She said R59's bottom was red over the weekend, and she had an order for foam dressing and barrier cream. New wounds should be assessed and treatment orders followed. R59's progress note dated 2/13/26 documents wound on right mid buttock with foam dressing in place, weight 96 lb. (pounds). R59's Wound Progress Note dated 2/23/26 shows unstageable (due to necrosis) of the right ischium measuring 2.4 cm (centimeters) x 0.8 cm x 0.2 cm; heavy serous exudate, 80% necrotic tissue. R59's Braden Scale dated 12/17/25 shows she is at risk for developing pressure. R59's current care plan shows she was at risk for skin impairment with no pressure relieving interventions implemented prior to 2/23/26.

Based on observation, interview and record review the facility failed to have a Water Management Plan that includes an assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread, control measures to prevent the growth of opportunistic waterborne pathogens and a system to monitor the control measures. The facility also failed to ensure residents with wounds and an indwelling urinary catheter were placed on Enhanced Barrier Precautions and facility staff failed to remove their gloves and wash their hands to prevent the spread of infection. This applies to all 77 residents residing at the facility.The findings include: 1.The Resident Roster provided on 2/22/26 shows that there are 77 residents residing at the facility. The facility provided a two page document that was titled Water Management Program. The document shows, The Water Management Program: Identifies building water systems for which legionella control measures are needed. Assesses how much risk the hazardous conditions in those water systems pose. Applies control measures to reduce the hazardous conditions, whenever possible, to prevent legionella growth and spread. Makes sure the program in running as designed and is effective. The document does not document a risk assessment specific to the building and what specific control measures need to be taken. The document does not show what control measures are needed based on the assessment and how to monitor them and actions to take if the control measures are not met. On 2/24/26 at 10:03 AM, V1 (Administrator) said that they do not have a documented risk assessment for potential areas of growth of legionella. V1 said that the facility does have ice machines, faucets and shower heads. V1 said that she is unsure if they have storage tanks or hot water heaters. V1 said that their program does not have any control measures besides flushing vacant rooms every three days. On 2/24/26 at 11:21 AM, V6 (Maintenance) said that water comes in from the city and goes to a boiler and then to two hot water holding tanks. V6 said that he is unaware of a Water Management Program and he has not seen a risk assessment that has been done. V6 said that they do run water in vacant rooms every three days. V6 said that he keeps the water temperatures between 105-110 degrees. 2. On 2/22/26 at 10:47 AM, V12 and V19 both Certified Nursing Assistants-CNAs were in R42's room providing incontinent care. V12 (CNA) removed R42's incontinent pad totally soaked with large amount of stool. V12 took disposable incontinent wipes and cleansed R42. V12 used all the incontinent wipes in the pack. With the same soiled gloved, V12 opened multiple drawers in R42's room looking for incontinent wipes until V19 brought another pack of incontinent wipes. V12 continued to provide incontinence care, turning R42 to her side to clean the back area, then applied a new incontinent brief and pants. Then V12 removed the soiled gloves but did not wash hands. On 2/23/26 at 9 AM, V3 (Infection Control Nurse) said staff should change their gloves and wash hands from dirty to clean tasks to prevent the spread of infection. The Facility Policy on Hand Hygiene date 4/2020 shows, All personnel are responsible for hand hygiene. Wash hands with soap and water when hands are visibly soiled. Wash hands: After removal of gloves (the use of gloves does not negate the need for hand hygiene). 3. On 2/22/2026 1:39 PM, R10 was sitting in his wheelchair with a leg bag. V12 CNA said R10 has an indwelling catheter. There was no Enhance Barrier Precaution (EBP) sign noted in R10's room. There was no Personal Protective Equipment (PPE) cart set up by the room. On 2/23/26 at 12:43 PM, V18 Registered Nurse-RN confirmed there was no EBP sign and no cart outside for PPE. V18 said she noticed the same, there should be a EBP sign for staff to know what PPE to use, due to the catheter to prevent infection. V18 then put the EBP sign on R10's door. R10's care plan dated 1/2026 documents, enhanced barrier precaution due to indwelling catheter ensure that gown and gloves are used during high contact resident care activities including dressing bathing showering transferring providing hygiene changing linens changing briefs or assisting with toileting. The facility Policy on Enhanced Barrier Precautions dated 12/2019 documents, Enhance Barrier Precautions (EBP) are a new approach for preventing the spread of infections in the facility. 4. A sign will be placed on the door for EBP which indicates high contact resident care activities. 5.PPE including gown and gloves are available outside the room. 4. On 2/22/26 at 9:45 AM, R8 was in her room lying in bed. She said she has a wound to her leg. There was no EBP sign posted or an isolation cart outside of her room. On 2/23/26 at 12:17 PM, R8's room did not have a EBP sign or cart outside of her room. On 2/23/26 at 12:17 PM, V10 (LPN) said residents with wounds, catheters should be on enhanced barrier precautions and staff should wear gown and gloves during direct care. R8's Wound Progress note dated 2/16/26 shows a non-pressure wound to the right leg, full thickness measuring 0.8 cm (centimeters) x 0.8 cm x 0.2 cm. R8's Physician Order Sheets dated February 2026 shows orders there are no orders for EBP precautions.

Based on observation, interview and record review the facility failed to ensure that dishware and utensils were sanitized prior to use, failed to safely store open lunch meat in the refrigerator, failed to store bulk item scoops in a sanitary manner and failed to ensure hands were washed before preparing food items. This applies to all 77 residents who reside at the facility. The findings include:The Resident Roster provided on 2/22/26 shows that there are 77 residents residing at the facility. On 2/22/26 at 9:42 AM, V5 (Cook/Dietary Aide) was using the dishwasher. V5 tested the chemical dishwasher with a test strip and it was not reading any chemical concentration. V5 tested it multiple times with the same results. V5 then primed the lines and tested again with a different set of test strips with the same results. V3 (Dietary Manager) then tested with the same results and said that she would have maintenance come and look at it. On 2/22/2026 at 9:58 AM, V5 put the dish rack of plate covers and trays away that had just been ran through the dishwasher. V5 continued to use the dishwasher to wash and put away two dish racks of plates, two dish racks of serving trays, a dish rack for plate covers, and a dish rack of silverware. At 10:14 AM, V5 tested the chemical dishwasher again and it was still reading that no chemicals were being dispensed. On 2/23/26 at 12:41 PM, V3 (Dietary Manager) said that the dishwasher is a low temperature chemical dishwasher. V3 said that the dishwasher should be tested before use three times a day. V3 said that if it is not reading the appropriate chemical concentration on the test strip, maintenance should be notified and the dishes should be soaked in a sink of sanitizer before being used.The facility's Dishwashing Machine Use Policy shows, The Dishwasher Machine temperature and/or chemical check daily and documented. If there are issues with the check, the Dietary Manager and Maintenance Director will be notified. If the temperature or chemical concentration can not be maintained, then paper products will be used. On 2/22/26 at 10:19 AM, there was an open package of lunch meat in the refrigerator. The package did not have a label on it. V3 said that the meat was bologna and should be labeled with the date opened because it is only good for one week after opening.The facility's Food Storage Policy shows, All foods should be covered, labeled and dated and routinely monitored to assure that food (including leftovers) will be consumed by their use by dates, or frozen (where applicable) or discarded.On 2/22/26 at 10:27 AM, There was a scoop in the bulk sugar bin and a scoop in the bulk thickener bin. V3 said that scoops should not be stored in the bins for sanitary reasons. The facility's Food Storage Policy shows, Scoops must be provided for bulk foods (such as sugar, flour, and spices). Scoops should be kept covered in a protected area near the containers rather than in the containers.On 2/22/26 at 12:08 PM, V8 (Dietary Aide) was prepping the noon meal carts with drinks. V8 did not have gloves on. V8 squatted down to look at a tray on the lower shelf of tray rack and when he squatted down, he placed his hands onto the floor for balance. V8 then opened a container of nutritional supplement and poured multiple cups of the supplements and put them on the lunch trays.On 2/23/26 at 12:41 PM, V3 (Dietary Manager) said that hand should be washed after touching the floor to prevent cross contamination. V3 said that staff should never touch the floor and then touch food products without washing their hands in between. V3 stated, That would be disgusting and could lead to loads of sicknesses. The facility's Hand Hygiene Policy shows, All personnel are responsible for hand hygiene.before handling food items.

Based on observation, interview and record review the facility failed to ensure medications were stored in a locked area, failed to ensure medications were stored in a manner to not compromise the integrity of the medication and failed to have schedule II controlled substances double locked. This applies to 5 of 5 residents (R29, R13, R48, R50 and R64) reviewed for medication storage in the sample of 21. The findings include:On 2/22/26 at 11:51 AM, the medication room on the first floor was not locked. There was a bag of fluconazole tablets on the counter in the room. The refrigerator was not locked and contained multiple insulin pens for R29, R13 and R48 and a box of Trulicity for R50. There was a container in the refrigerator containing an insulin pen for R50, a box of acetaminophen suppositories and a box of bisacodyl suppositories for R64. The container had a 1/4 inch of liquid in the bottom of it and the boxes were saturated. On 2/22/26 at 1:07 PM, The second floor west medication cart was reviewed. The narcotic box inside of the cart was not locked and was able to be opened with a key. The narcotic box contained norco (schedule II controlled substance) for R48. On 2/23/26 at 12:35 PM, V2 (Director of Nursing) said that medication rooms should be locked at all times. V2 said that controlled substances should be locked in the lock box that is in the locked medication cart at all times. V2 said that she thinks that the water in the container was from when the refrigerator was defrosted or from the door not being closed properly.The facility's Medication Storage Policy shows, The facility maintains proper store of a variety of medications in accordance to the pharmacy recommendations and regulatory guidelines. The facility acknowledges that medications can be stored in a variety of storage areas located within the nursing unit and under lock and key. The medication room is locked and only nurses are allowed to hold the key.Each individual patient room has a lockable cabinet for medications and a double lock for narcotics.

Based on observation, interview and record review, the facility failed to ensure residents with limited range of motion had splints in place for 4 of 12 residents (R63, R6, R16, R32) reviewed for range of motion in the sample of 21.The findings include: 1. On 2/22/26 at 9:52 AM, R63 was reclined back in his chair, his left hand was curled inward indicating he had a contracture to the hand. There were no splints or braces on his hands or legs. R63 was also observed at 11:30 AM, 11:44 AM and 12:40 PM and he did not have splints on. R63's face sheet shows he has diagnoses including aphasia, hemiplegia and hemiparesis following a cerebral infarction and has contractures to the left knee, left elbow, left shoulder and left hand. R63's Physician Order Summary shows an active order for him to have a left hand and elbow brace on for 4 hours on with morning care, and off at lunch time. R63's restorative charting for February 2026 shows the facility should apply R63's splints as ordered. On 2/23/26 at 12:18 PM, V11 (Restorative Nurse) said that it is in residents medical records or (POC) who need to have range of motion and splints applied and the Certified Nursing Assistants (CNA's) are the staff who apply them. V11 verified that R63 has an order for a hand splint due to having a contracture and it should have been on in the morning. 2. On 2/22/26 at 10:09 AM, R16 was lying in bed. She was using only her right hand to move her covers. R16's left hand was partially visible under the covers and was flaccid. R16 said she has a brace for her left hand but they don't put it on her very often. R16's face sheet shows she has diagnoses including wrist drop to her left wrist. R16's Physician Order Summary shows an active order for her to have a brace on her left hand for 4 hours a day on with morning care, and off after lunch. R16's restorative charting for February 2026 shows she should use a brace to her left hand for 4 hours daily. There are no staff initials in the charting for the month of February to indicate the brace was applied. On 2/23/26 at 12:18 AM, V11 verified that R16 has an order for a hand splint to prevent a contracture and it should have been on in the morning. 3. On 2/22/26 at 9:56 AM, 11:31 AM, 11:44 AM and 12:40 PM, R6 was lying in bed and had no splint on her hands. V2 (Director of Nursing) and V4 (Wound care Nurse) were both present with this surveyor in R6's room at 11:44 AM and 12:40 PM. R6's face sheet shows she has diagnoses including a cerebral infarction, and contractures to her right wrist, and her right and left hands. R6's Physician Order Summary shows she has an active order for a bilateral hand splints to be worn for 2 hours daily, on with morning care and off before lunch. (R6 is fed via a Gastrostomy tube). R6's Restorative charting for February 2026 shows she should have splints applied to her hands for 2 hours in the morning on with morning care and off before lunch. There are no staff initials in the charting for the month of February to indicate that R6 had splint applied. On 2/23/26 at 12:18 PM, V11 verified that R6 has an order for hand splints due to having contractures and they should have been on in the morning. The facility provided Restorative Nursing policy revised on 3/2021 shows the facility will implement and monitor restorative needs of the residents and follow the plan of care. 4. R32's face sheet shows he has diagnoses including dementia, weakness, contracture of right hand and chronic pain. On 02/22/2026 at 10:10 AM, R32 was in his room lying in bed. R32's right hand was in a closed position without his hand splint on. On 02/23/2026 at 9:22 AM; R32 was in his room lying in bed. His right hand in a closed position without a splint in place. R32 said sometimes they put a splint on my right hand. A hand splint was not located in his room. At 12:17 PM, R32 was in his reclining chair near the nurse's station, his right hand on his lap without his hand splint on. On 02/23/26 at 12:17 PM, V10 (Licensed Practical Nurse-LPN) said she is not sure if R32 has a splint she would have to ask V11 (Restorative Nurse). On 02/23/26 at 1:24 PM, V11 said R32's restorative services include a right resting hand splint on for two hours in the morning. Restorative aides or CNAs should apply the splint. On 02/24/26 at 9:40 AM, R32 was in the dining room in his recliner chair with his right hand resting on his lap without his hand splint on. On 2/24/26 at 9:43 AM, V10 said R32's hand splint should be in his room. This surveyor and V10 looked in R32's room for his hand splint, opened all the drawers and checked the closest and could not locate his splint. At 9:45 AM, V12 (Restorative Aide) R32's hand splint should be in his drawer. V12 checked R32's room, drawers and could not find his splint. R32's Restorative Planning assessment dated [DATE] shows his program includes passive range of motion and splint/brace program. Right resting hand splint to be worn for two hours before and after AM care. R32's current care plan shows he requires a splint to right hand due to contracture and interventions include to apply splint as ordered.

Based on observation, interview and record review the facility failed to ensure the pureed rice was in the form to meet the resident's needs for 6 of 6 residents (R5, R23, R37, R39, R49 and R64) reviewed for pureed diets in the sample of 21. The findings include:The facility's Diet Type Report printed on 2/23/26 shows that R5, R23, R37, R39, R49 and R64 are on pureed diets.2/22/26 at 12:55 PM, a pureed diet tray was sampled. The pureed rice was very thick and had chucks of rice throughout. At 12:57 PM, V3 (Dietary Manager) tasted the pureed rice. V3 was observed chewing the rice. V3 said that the rice was not the right consistency. V3 said that it was too gritty. V3 said that pureed food should be smooth like baby food and not have chunks in it. The Facility's Pureed Diet Sheet shows, A Pureed diet is food with a very smooth consistency or foods that have been well processed in a food processor or blender to a very smooth consistency or texture. No solid pieces or parts can be noticed in the food.

Based on observation, interview and record review, the facility failed to safely transfer a resident and failed to ensure fall interventions were in place for 2 of 21 residents (R73, R32) reviewed for safety in the sample of 21.The findings include:1.R73 has diagnoses that include traumatic subdural hemorrhage, dementia and unsteadiness of feet. On 2/22/26 at 10:12 AM, R73 was in bed alert and pleasant. V17 (Certified Nursing Assistant-CNA) was also in the room assisting R73 up from bed to wheelchair. V17 (CNA) placed R73's wheelchair at the side of the bed. Then assisted R73 to sit at the edge of the bed. V17 placed R73's walker in front of him and instructed R73 to get up. R73 placed both of his hands in the walker, leaned forward and used the walker to pull himself up, but he was not able to. R73 stated ok, I'll try one more time. Again, R73 leaned forward and use the walker to pull himself up. V17 put his hands under R73's armpits and lifted R73 in standing position. V17 then instructed R73 to use his walker to turn and sit in his wheelchair. V17 went behind R73's wheelchair, pulled the back of R73's pants to sit R73 in his wheelchair. V17 took his gait belt from his pocket and said he did not use his gait belt because R73 wanted to do things himself. On 2/23/26 at 12:45 PM, V18 (Registered Nurse-RN) said R73 is 1 to 2 assist for safe transfers. A gait belt should be used for safety. R73's care plan dated 11/5/25 shows, R73 utilizes a sit to stand lift for transfers, requires two staff members for transfers. 2. R32's face sheet shows he has diagnoses including dementia, weakness, COPD, Alzheimer's disease, bipolar, schizophrenia, chronic pain and weakness. On 2/22/26 at 10:10 AM, R32 was lying in a low bed with his eyes closed. His head was resting on right side rail. There were no floor mats placed on the floor. On 2/23/26 at 9:22 AM, R32 was lying in a low bed eating his breakfast. R32's floor mats were folded at the foot of his bed. On 2/23/26 at 12:17 PM, V10 (CNA) said R32 is a fall risk, he tries to get out of bed. His fall interventions include a low bed, placed in a supervised area and floor mats. R32's current care plan shows he is a high risk for falls, he is unaware of his safety needs and has attempts to self transfer. R32 had a fall on 12/7/25 of sliding of the bed. Interventions include to have a floor mat in place.

Based on observation, interview and record review the facility failed to administer medications as ordered at ordered times. There were 26 opportunities with 2 errors resulting in a 7.6% error rate. This applies to 1 of 4 residents (R6) observed in the medication pass.On 2/22/26 at 11:00 AM, V13 (Licensed Practical Nurse-LPN) prepared R6's morning medications including Amiodarone 200 mg (milligrams) give via g-tube two times a day for arrhythmia and Metoprolol 25 mg give half of tablet two times a day for hypertension. R6 crushed the medications separately and administered the medications through R6's g-tube. At 11:30 AM, V6 said R6 was her last resident for morning medication pass. On 2/26/26 at 10:51 AM, V16 (LPN) said morning medication pass should be from 8:00 AM to 10:00 AM. R6's Medication Administration Record dated February 2026 shows orders to administer at 9:00 AM; amiodarone 200 mg one tablet via g-tube two times a day and metoprolol 25 mg give half of tablet two times a day. The facility's Medication Administration Policy dated 3/24 states, To ensure that the administration of mediations in a safe manner to prevent medication errors.medications preparation/Administration a. five rights.right time 60 minutes before or after the scheduled time unless otherwise specified.

Based on observation, interview and record review the facility failed to ensure nutritional supplements were given for a resident with significant weight loss. This applies to 1 of 8 residents (R11) reviewed for weight loss in the sample of 21. The findings include: 1. R11's face sheet shows she has diagnoses including major depressive disorder, unspecified dementia, severe psychotic disturbance, weakness, cognitive communication deficit, and post-traumatic stress disorder. On 2/22/26 at 10:10 AM, R11 was sitting in the dining room with her breakfast tray in front of her. She was served eggs, oatmeal and milk and her nutritional supplement was not provided. At 11:57 PM, R11 was in the dining room sitting at the same table. At 12:41 PM, lunch trays were delivered to the 2nd floor, R11 was served her noon meal, and her nutritional supplement shake was not provided. On 2/23/26 at 12:51 PM, R11 was sitting in the dining room during the noon meal. She was served a regular tray feeding herself. R11 was not given her nutritional shake during the noon meal. On 2/23/26 at 12:17 PM, V10 (Licensed Practical Nurse-LPN) said nursing gives nutritional shakes to the residents and documents on the MAR (Medication Administration Record) the shake was given. V10 said we have a couple of residents who receive nutritional shakes and did not include R11 receiving a nutritional shake. On 2/24/26 at 10:36 AM, V9 (Dietitian) said R11 triggered a significant weight loss of 6.2% in one month and her nutritional shake was increased to 120 ml (millimeters) three times a day. She puts in the order and nursing documents in the resident's medical record the supplement was given. On 2/24/26 at 2:45 PM, V2 (Director of Nursing-DON) said nutritional shakes are signed off by nursing on the MAR. R11's Dietitian Evaluation report dated 02/03/26 shows she is underweight at 91 lb. which is a decrease of 6.2% since 12/31 and the weight loss is not planned or desired and recommendations include to increase nutritional shake to 120 ml three times a day. R11's Weight Report dated 2/23/26 shows: 12/31/25: 97 lb.1/30/26: 91 lb. R11's February 2026 M.A.R. does not show the nutritional shake 120 ml three times a day ordered or signed off as given. The facility's Weight Management Protocol dated 3/2021 states, To provide an accurate baseline and ongoing reading of the resident's weight management. report triggers need for additional follow up/assessment.

Based on interview and record review the facility failed to ensure a PASRR (Preadmission Screening and Resident Review) was completed for a resident with a SMI (Serious Mental Illness diagnosis for 1 of 6 residents (R54) reviewed for PASRR in the sample of 21.The findings include: R54's face sheet shows he was admitted to the facility on [DATE] with diagnoses including Other Schizophrenia, Major Depression Recurrent, and anxiety disorder.The facility provided an Interagency Certification of Screening results (OBRA) dated 4/16/15 for R54 which does not identify R54 as having a Serious Mental Illness diagnosis and shows the screening is good for 90 days. There was no PASRR for R54 in his Electronic Medical Record.On 2/23/2026 at 12:40 PM, V15 (Social Services Director) and V14 (Admissions and marketing) said the admission department looks for PASRRs when a resident is admitted . 02/23/2026 1:24 PM, V1 (Administrator) said the PASRR for R54 was ordered by the facility today. The facility provided PASRR screening policy dated 8/2022 shows no residents will be admitted to the facility without a PASRR level 1 and if there is a diagnosis of a Severe Mental Illness a PASRR 2 will be completed.

Based on interview and record review the facility failed to ensure a PASRR (Preadmission Screening and Resident Review) was completed after a Serious Mental Illness (SMI) diagnosis change for 1 of 6 residents (R4) reviewed for PASRR in the sample of 21. The findings include:R4's face sheet shows she was admitted to the facility on [DATE] with a primary diagnosis of Hemiplegia affecting the left side. A diagnosis of schizoaffective disorder was added to her diagnoses on 12/13/19. A PASRR screening was requested from the facility by this surveyor and what was provided was an Interagency Certification of Screening Results (OBRA) dated 5/13/19 and does not identify R4 as having a SMI diagnosis.On 2/23/2026 at 1:24 PM, V1 (Administrator) said the PASRR for R4 was ordered to be done today. The facility provided PASRR screening policy dated 8/2022 shows that a PASRR level 2 should be completed if a resident has a SMI diagnosis.

Based on interview and record review the facility failed to ensure an antibiotic was given as ordered for 1 of 3 residents (R2) reviewed for medications in the sample of 6. The findings include: R2's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include pneumonia, major depressive disorder, osteoporosis, weakness, unsteadiness on feet, severe protein calorie malnutrition, hypothyroidism, pain in right shoulder, chronic obstructive pulmonary disease, hypotension, legal blindness, dysphagia, generalized anxiety disorder, decreased white blood cell count, and bipolar disorder. R2's Hospital Discharge instructions dated 12/18/25 showed an order for doxycycline 100 mg (milligrams) to be given daily for 3 days starting 12/19/25.R2's December 2025 eMAR (electronic Medication Administration Record) showed and order for doxycycline monohydrate. give 1 capsule by mouth one time only for 3 days. R2's same December eMAR showed R2's doxycycline was administered only once on 12/19/25. R2's record showed the order for the doxycycline was entered incorrectly as a one time order rather than for the full 3 days as ordered.On 12/31/25 at 11:45 AM, V2 DON (Director of Nursing) said R2 got her doxycycline on the 19th. V2 said the order was entered for doxycycline 100 mg, 1 capsule by mouth one time only for 3 days. V2 said the doxycycline should have been scheduled one time a day for the duration of 3 days. V2 said R2 received just one dose on the 19th. V2 said it looks like the order was entered wrong. It should have been for 3 days.The facility's policy and procedure effective 3/2021 showed, . Medication Administration. Guideline: To ensure that the administration of medications is performed in a safe manner to prevent medication errors.

Based on observation, interview, and record review the facility failed to ensure the dishwasher was sanitizing dishes and failed to ensure kitchen staff washed hands to prevent cross contamination to clean dishes which applies to all 77 resident in the facility reviewed for kitchen sanitation. The findings include: The Facility Data Sheet dated 6/17/25 showed the facility had census of 77 residents. On 6/17/25 at 9:20 AM, V4 Dietary Aide was using the dishwasher in the kitchen. V4 was not wearing gloves. V4 unloaded a clean rack of dishes, loaded a dirty rack of dishes, and the moved the clean dishes and rack without washing their hands. At this time the sanitizer 5 gallon bucket under the dirty tray line was empty. On 6/17/25 at 10:00 AM, V3 Dietary Manager retrieved test strips from their office and checked the dishwasher. The test strip stayed white showing no sanitizing agent in the dishwasher. V3 noted the 5 gallon sanitizer bucket was empty. V3 stated acceptable levels for chlorine is 50-100 parts per million (PPM) and Quaternary Ammonium (QUAT) sanitizer levels should be 150-200 PPM to sanitize dishes. V3 stated the dishwasher should be checked 3 times a day to make sure it is working correctly. V3 stated if you are washing dishes you need to wash your hands going from dirty dishes to clean to prevent cross contamination. On 6/17/25 at 10:15 AM, V7 Infection Control Nurse stated the dishwasher needs to be sanitizing dishes and utensils residents use to reduce the chance of spreading any food borne illness and/or gastrointestinal viruses. The facility's dishwasher sanitizer check sheet (June 2025) showed no entries of sanitizer checks for 6/15/25 breakfast and lunch, 6/16 lunch, and 6/17/25 breakfast checks prior to dishwasher use. The facility's undated dishwasher policy showed dish machines will be checked prior to meals to assure proper function and appropriate temperature for cleaning and sanitizing. This policy also showed when loading dishes will not handle the clean dishes unless they wash their hands before moving from dirty to clean dishes.

Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in a manner that would prevent foodborne illnesses. This applies to 71 residents who ate food from the kitchen. The findings include: On January 10, 2025 at 2:35 PM, V2 (DON/Director of Nursing) said two residents were NPO (Nothing By Mouth) and did not receive trays from the kitchen. On January 7, 2025 at 10:28 AM, during the initial tour of the kitchen, the dry food storage area was observed to have the following: -5 cartons of [Brand] tomato Juice from concentrate with a best if used by date of September 11, 2024. -16 packets of [Brand] creamy classic mashed potatoes with no 'received on' dates or expiration dates. -5 packets of tortillas with no 'received on' dates. -An opened 25-lb box of instant food thickener, left open to air, with no 'opened on' date. -An opened box of long grain rice with a bag within it, open to air, with no 'opened on' date. On January 7, 2025 at 10:50 AM, the milk refrigerator was checked, and did not contain a thermometer within the refrigerator. There were 32 cartons of 2% milk which were undated. On January 7, 2025 at 10:50 AM, V11 (Cook) said he would not serve the undated milk because there were no dates on them. On January 7, 2025 at 12:20 PM, several residents in the first-floor dining room were served the undated milk. On January 8, 2025 at 3:07 PM, the milk refrigerator still did not have a thermometer inside of it. On January 9, 2025 at 9:46 AM, the milk refrigerator did not have a thermometer inside of it. On January 7, 2025 at 11 AM, the kitchen cooler was checked. The cooler had a disposable, plastic cup with coffee and a straw within it, and a plastic bag with water bottles and a canned beverage, which belonged to staff. The cooler also had the following: -12 cups of juice in the cooler without a plastic cover over it. At 11 AM, V11 said the cups should be covered in plastic and dated. -Opened cheese, wrapped, but not dated. -Opened bologna, wrapped, but not dated. -Cut beets and cauliflower in stainless steel steam table pans, without plastic covers or dates on them. On January 7, 2025 at 11:12 AM, the kitchen freezer had the following: -Raw, frozen pork chops on the top shelf -Tray of tator tots placed on the shelf below the pork chops, not completely covered in plastic and undated. -Frozen sausages in an undated Ziploc bag. -Cooked sausage crumbles in packaging that was open and exposed to air, and no date on the packaging. -Undated Ziploc of beef hotdogs. -Undated frozen pancakes wrapped in plastic wrap. -Undated raw, frozen chicken in plastic wrap. On January 7, 2025 at 11:25 AM, the second kitchen freezer had the following: -A tray of cooked enchiladas, not properly covered and undated. V11 said the enchiladas had been here a minute. -An opened and undated bag of corn. -An undated tub of vanilla ice cream with a broken lid, exposed to air. On January 8, 2025 at 12:27 PM, the food carts were delivered uncovered to the first and second floor dining halls. The carts contained trays with open cups. On January 9, 2025 at 12:15 PM, V13 said the food on the carts should not be exposed to air and should be covered when delivered to the units. The facility's Food Receiving and Storage dated May 2020 showed Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in-first out system. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Wrappers of frozen foods must stay intact until thawing. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the food and nutrition services manager or designee and documented. Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables, and other ready-to-eat foods. Refrigerators must have working thermometers and be monitored for temperature according to state-specific guidelines. Open containers of food and liquid must be dated and resealed/covered. The facility's undated Storage of Food and Supplies policy showed Prepared foods stored in the refrigerator until service will be covered, labeled, and dated with an expiration date. TCS (Time/Temperature Control for Safety) foods prepared on site must be labeled with the name of the food, the date it should be sold, consumed or discarded. All foods will be covered, labeled, and dated. Items should be stored in original packaging. If removed from its original packaging, wrap in clean moisture-proof material, or place it in a clean sanitized container with a tight fitting lid. All packaging and contaienrs should be labeled with the name of the food and expiration date. Refrigerators and freezers will be equipped with an internal thermometer and monitored. Temperatures will be documented.

Based on observation, interview, and record review, the facility failed to label and store medications for residents receiving insulins and eye drops. This applies to 5 out of 5 (R61, R23, R44, R71, and R42) residents reviewed for medication storage in a sample of 19. Findings include: 1. On 1/08/2025 at 9:30 AM, the medication storage task was done with V4 (Licensed Practical Nurse/LPN) on the 2-East and 1-East medication carts. V4 remained present during the following observations: R44's Levemir insulin vial was opened and undated. R44's Levemir medication package bag said it was dispensed on 12/22/2024 and was also undated. R44's Order Summary Report dated 1/08/2025 showed an active order for Levemir Solution 100 UNIT/ML (Insulin Detemir) Inject 26 units subcutaneously in the morning for DM (Diabetes Mellitus). 2. R42's Humulin R insulin vial was open and dated with an open date of 11/11/2024. R42's Humulin R medication package had instructions to MUST DISCARD W/ IN 31 DAYS after opening. R42's Order Summary Report dated 1/08/2025 showed an active order for HumuLIN R Solution 100 UNIT/ML (Insulin Regular Human) .subcutaneously two times a day for Diabetes. 3. R61's Fiasp insulin vial was unopened at room temperature. R61's Fiasp medication package bag said it was dispensed on 1/03/2025 and had instructions of HIGH ALERT, REFRIGERATE UNTIL OPEN. R61's Order Summary Report dated 1/08/2025 showed an active order for Fiasp 100 UNIT/ML Solution Inject as per sliding scale .subcutaneously before meals and at bedtime for Diabetes. 4. R23's two Glargine insulin pens were opened, unbagged and undated. R23's Lantus and Lispro insulin vials were also opened and unbagged. R23's insulins were stored in an open multi-resident use container with other residents' opened insulins. R23's Order Summary Report dated 1/08/2025 showed active orders for Insulin Glargine Subcutaneous Solution Pen-Injector 100 UNIT/ML (Insulin Glargine) Inject 17 units subcutaneously one time a day for DM and Insulin Lispro Solution 100 UNIT/ML Inject as per sliding scale .subcutaneously before meals for Diabetes. 5. R71's Latanoprost eye drop container was open and undated. R71's Latanoprost medication package bag said it was dispensed on 9/24/2024 and had instructions to DISCARD AFTER 6 WKS after opening. R71's Order Summary Report dated 1/08/2025 did not show an active order for Latanoprost eye drops. On 1/09/2025 at 9:40 AM, V2 (Director of Nursing/DON) said insulin and eye drop medications should be stored inside their packages and package instructions for storing should be followed for safety storage. V2 continued to say multi-dose medications should be labeled when opened and discarded as indicated to ensure medication safety administration. The facility's policy titled Medication Storage dated 3/2021, said The facility maintains proper store of a variety of medications in accordance to the pharmacy recommendations and regulatory guidelines.

Based on observation, interview, and record review, the facility failed to dispose of controlled medication and verify the accuracy of controlled medication logs for residents with controlled medications. This applies to 4 out of 4 (R57, R5, R26, and R44) residents reviewed for controlled medications in a sample of 19. Findings include: 1. On 1/08/2025 at 9:30 AM, V4 (Licensed Practical Nurse/LPN) was asked to verify the controlled medications located in the 2-East medication cart. V4 said nurses confirmed they completed the end-of-shift handoff count of controlled medications by signing the accountability record log. V4 reviewed the log and confirmed the log for the AM shift on 1/08/2025 was not signed by the incoming morning nurse. V4 said R26 had an open medication bottle of Clonazepam 0.5 mg (milligrams) with 42 tablets. V4 then said R26 did not have an Individual Controlled Drug Administration Record log to verify the medication's quantity. V4 said that nurses should ensure that all controlled medications have Individualized Controlled Drug Administration Record logs to verify the proper count of each medication. R26 had another bottle of Clonazepam 0.5 mg with 9 tablets. V4 reviewed and confirmed that the medication's Individual Controlled Substance Record log said the last removed tablet was on 1/07/2025 and there should be a total of 10 tablets available. V4 said nurses needed to log every removed controlled medication in their Individual Controlled Substance Record logs when removed to ensure accuracy and prevent discrepancies. The document titled Shift Change Accountability Record for Controlled Substances for January 2025 showed multiple omitted nurses' signatures including for the 1/08/2025 AM shift. R26's Individual Controlled Substance Record log for Clonazepam 0.5 mg tablets dated 12/24/2024, showed the last logged removed tablet was on 1/07/2025 at 6 PM and there should be an amount remaining of 10 tablets. The log also had missing signatures for tablets removed on 1/03/2025 at 9 AM and 12:00 PM. R26's MAR (Medication Administration Record) for January 2025 said R26 last received Clonazepam 0.5 mg by mouth at 9 AM. R26's Order Summary Report dated 1/08/2025 showed an active order for clonazepam Oral Tablet 0.5 MG (Clonazepam) Give 1 tablet by mouth three times a day for anticonvulsant. 2. V4 continued to remain present during the following observations: R5's Hydrocodone-APAP 5-325 mg medication punch card was observed with the #7 pill slot punched open with a pill inside, the slot was covered with a piece of cloth tape. R5's Order Summary Report dated 1/08/2025 showed R5 did not have an active order for Hydrocodone. R5's Controlled Drug Administration Record Tablet log for Hydrocodone showed the medication was dispensed on 8/21/2024 and R5's last removed tablet was on 8/23/2024. 3. R57's Lorazepam 0.5 mg medication punch card was observed with the #5 through #8 pill slots punched open with pills inside, the slots were covered with a plastic band-aid and clear pieces of tape. R57's Order Summary Report dated 1/08/2025 showed R57 did not have an active order for Lorazepam. R57's Controlled Drug Administration Record Tablet log for Lorazepam showed the medication was dispensed on 10/04/2023 and R57's last removed tablet was on 2/6 (year unknown). The log showed the following instructions TAKE 1 TABLET BY MOUTH EVERY 8 HOURS AS NEEDED FOR ANXIETY FOR 14 DAYS. 4. On 1/08/2025 at 9:50 AM, V4 (LPN) was asked to verify the controlled medications located in the 1-East medication cart. The cart's accountability record log for controlled medications was not completed. The document titled Shift Change Accountability Record for Controlled Substances for January 2025 showed multiple omitted nurses' signatures including for the 1/08/2025 AM shift. R44's Tramadol 50 mg medication punch card was observed with the #17 and #26 pill slots punched open with pills inside, the slots were covered with tape. R44's Order Summary Report dated 1/08/2025 showed R44 did not have an active order for Tramadol. R44's Controlled Drug Administration Record Tablet log for Tramadol showed the medication was dispensed on 4/02/2024 and R44's last removed tablet was on 6/04/2024. On 1/09/2025 at 9:40 AM, V2 (Director of Nursing/DON) said all controlled medications need to be accounted for to ensure medication safety and prevent variances. V2 said nurses were expected to count controlled medications with the oncoming shift nurse and sign the accountability record log. V2 said that when a medication is removed from the controlled box it needs to be logged immediately in the resident's individual medication log. V2 continued to say controlled medications need to be disposed of appropriately when discontinued or not used. V2 said removed medications should not be placed back into the punch card slots and taped. The facility's policy titled Medications-Controlled dated 3/2021, said Controlled substances are signed out upon dispensing of the medication. A count of controlled drugs is maintained by nurses of the off-going and oncoming shifts. Any irregularities are reported to the director of nursing .Controlled medication documentation: a. A separate controlled substance administration control record is kept on all scheduled II or higher drugs. It contains the amount verifiable inventory .Disposition of unused portion or prescriptions is documented .a. Do not place in container b. Record refusal as per policy c. Destroy drug in accordance with policies of facility for destruction of refused controlled medications.

Based on observation and interview, the facility failed to maintain a homelike environment. This applies to 8 of 8 residents (R7, R11, R17, R24, R43, R47, R50, R58) reviewed for environment in a sample size of 19. The findings include: On 1/7/25, during initial tour the following observations were made: 1. At 11:04 AM, surveyor went to R11 and R17's room. Both of them were not in their room. Next to R11's bed, there was hole in the wall and paint was peeling from various parts of the wall. On 1/8/25 at 10:23 AM, R17 stated, I want that hole fixed and wall repainted. On 1/8/25 at 10:25 AM, R11 stated, I don't like that hole and I want it fixed. R11's MDS (Minimum Data Set) dated 12/5/24, shows a BIMS (Brief Interview for Mental Status) score of 11, which means she is moderately impaired in cognition. 2. At 11:07 AM, inside R47's room, there was paint peeling from various parts of the room. Some parts of the floor were also missing base boards. R47 stated, It doesn't look nice like that, but it's no [NAME]. R47's MDS dated [DATE] shows a BIMS score of 9, which means he is moderately impaired in cognition. 3. At 11:09 AM, surveyor went to R24's room. She shared a bathroom with R7 who was in the adjacent room. The paint was peeling in various parts of the wall in the bathroom. Both R24 and R7 were not in the room. On 1/8/25 at 10:30 AM, R24 said in broken English, It would be good if some one cleans the wall in my bathroom. On 1/8/25 at 10:33 AM, surveyor asked R7 what she thought of the paint peeling in her bathroom. She was unable to understand surveyor because her primary language was Spanish. 4. At 11:14 AM, there was paint peeling in various parts of the wall in R58's room. R58 stated, Yes, it would look better if it was repainted. R58's MDS dated [DATE] shows a BIMS score of 9, which means she is moderately impaired in cognition. 5. At 11:33 AM, surveyor went to R43's room. She was sleeping. Her bathroom was shared with R50 who was in the adjacent room. R50 was not in her room. In their bathroom, there were big areas of paint peeling on the wall. On 1/8/25 at 10:48 AM, R43 stated she wanted the bathroom repainted. On 1/8/25 at 11:40 AM, R50 stated, All the bathrooms are like that. They are all peeling. I would love for them to repaint it. It would look much better. R43's MDS dated [DATE] shows a BIMS score of 13, which means she is cognitively intact. R50's MDS dated [DATE] shows a BIMS score of which 12, which means she is moderately impaired in cognition. On 1/18/25 at 10:14 AM, V10 (Maintenance Director) stated, This is a big issue, an ongoing issue with paint peeling, wallpaper peeling, holes in wall, and missing base boards. We are planning on remodeling our building. So, I'm hesitant to do all this work now. I'm not sure when or if we will remodel. We are waiting for an answer from corporate. I can't find a policy on this.

Based on observation, interview, and record review, the facility failed to assist residents needing assistance with eating, oral care, and grooming. This applies to 4 out of 4 residents (R57, R1, R28, and R26) reviewed for activities of daily living in a sample of 19. Findings include: 1. R57's EMR (Electronic Medical Record) showed she had multiple diagnoses including Alzheimer's disease, left-hand contracture, dysphagia, cognitive communication deficit, stage 4 pressure injury to the sacrum, seizures, and anemia. R57's MDS (Minimum Data Set) dated 12/04/2024 said she required substantial to maximal assistance with eating and was dependent on staff for her personal and oral hygiene needs. On 1/07/2025 at 11:30 AM, R57 was sitting in her reclining wheelchair in the dining room. R57 was confused and non-interviewable. R57 had overgrown facial hair on her upper lip and chin areas. R57's teeth were unkept they had food residue and had a foul mouth odor. At 12:30 PM R57 was trying to feed herself a folded slice of bread with a slice of a barbeque pork tenderloin, unsupervised. R57 was unable to feed herself because she had a surgical mask covering her mouth which was soiled with sauce. Then V8 (Certified Nurse Assistant/CNA) went to R57 to pull her surgical mask down to her chin and handed her the folded slice of bread with the pork tenderloin again. R57 was still having difficulty feeding herself and then V8 guided her with her hand to put the food in her mouth. At 12:45 PM V8 returned to R57 and started to feed her but then stopped and left her unsupervised again. On 1/08/2025 at 12:12 PM, R57 was again in the dining room for lunch. R57 continued to have overgrown facial hair. V9 (CNA) served R57 her lunch meal and did not feed her. R57 was trying to feed herself but was having difficulty. Then at 12:30 PM V6 (Restorative Aide) sat next to her and started to feed her. V6 said R57 was unable to feed herself and had to be fed by the staff. R57's Restorative Observation and Planning form dated 12/04/2024, said R57 was unable to state needs to have needs met .Resident is dependent of staff with all ADL's requires a feeder for meals. 2. R1's EMR showed she had multiple diagnoses including Alzheimer's disease, bilateral hand contractures and pain, weakness, dysphagia, cognitive communication deficit, and generalized osteoarthritis. R1's MDS dated [DATE] said she required supervision to touching assistance with eating and was dependent on staff for her personal and oral hygiene needs. On 1/07/2025 at 10:55 AM, R1 was sitting in her wheelchair in the dining room. R1 was wearing bilateral hand splints. R1 had two cups of thickened water and cranberry juice untouched in front of her. At 12:35 PM V7 (CNA) served R1 her lunch meal and removed the previously served cups of liquids which remained untouched. V7 said R1 was sometimes able to feed herself and did not assist her. R1 started to try to feed herself but her surgical mask was covering her mouth. R1's surgical mask was soiled with pureed food. V7 returned to remove R1's surgical mask and then left her unsupervised again. On 1/08/2025 at 12:25 PM, R1 was trying to feed herself lunch. R1 was having difficulty at times and spilled food on the side of her partially removed surgical mask and clothing protector. R1 had two cups of thickened water and milk untouched. Then at 12:58 PM, V6 (Restorative Aide) came to assist R1 with her drinks. V6 said R1 was able to feed herself food most of the time but required supervision and assistance with her drinks. V6 said R1 was unable to grip drinking cups with her hands because of her contractions and splints. V6 fed R1 her milk which she drank the entire serving and then proceeded with her water. R1's Restorative Observation and Planning form dated 1/02/2025 said R1 had contractions to her hands and cannot state needs to have needs met .Resident is dependent of care on all ADL's, including feeding. 3. R28's EMR showed he had multiple diagnoses including hemiplegia and hemiparesis following an intracranial hemorrhage affecting his right dominant side, dysphagia, right hand and elbow contractions, and other musculoskeletal system symptoms. R28's MDS dated [DATE] said he was dependent on staff for his oral hygiene care. On 1/07/2024 at 11:07 AM, R28 was in bed. R28's teeth were unkept and they had a thick build up of food residue. On 1/08/2024 at 12:20 PM, R28 again had a thick build-up of white residue substance on his teeth. V9 (CNA) was asked to inspect R28's mouth and said his teeth were dirty. V9 said CNAs brush residents' teeth at least daily. V9 said sometimes R28 would not allow for daily oral care but was seen by the dentist. R28's Restorative Observation and Planning form dated 11/12/2024, said R28 had weakness to his right side and requires one assist for ADLs. R28's Dentist consultation report dated 11/11/2024 said Extremely heavy, generalized plaque and heavy calculus present on pt's teeth. Assistance with daily OH (oral hygiene) recommended. 4. R26's EMR showed he had multiple diagnoses including hemiplegia and hemiparesis following an intracranial hemorrhage affecting his right dominant side, malignant neoplasm of the brain, cognitive impairment, seizures, and adult failure to thrive. R26's MDS dated [DATE] said he was dependent on staff for his oral hygiene care. On 1/07/2025 at 10:55 AM, R26 was sitting in his reclining wheelchair in his room. R26's teeth were unkept, had food residue, and were stained with an orange substance. On 1/08/2024 at 12:15 PM, R26 again had a thick white food substance on his front lower teeth. V5 (Registered Nurse/RN) was asked to assess R26's mouth and with her gloved finger, she removed a thick white chunk of white substance from his left gum area. V5 said it appeared to be food residue. V5 said CNAs provide daily oral care to the residents. On 1/09/2025 at 9:50 AM, V2 (Director of Nursing/DON) said she expects staff to assist residents with their ADLs (Activities of Daily Living) including feeding, oral hygiene, and grooming care. V2 said residents who are unable to feed themselves should be assisted if not they can be at risk for improper nutrition, weight loss, choking, or aspiration pneumonia. V2 said residents should be assessed and assisted daily with their grooming needs, including shaving. V2 said it was appropriate to assume that female residents would expect to be assisted with the removal of unwanted facial hair. V2 also said oral care should be provided to residents in the AM, PM, and any time in between if needed. V2 said for residents who may be resistant to oral care staff should at a minimum attempt to swab their teeth and mouth to assist them in promoting healthy oral hygiene. The facility's policy titled Maintaining ADL's dated 3/2021, said Guideline: The facility provides the necessary care and services to attain or maintain the highest practical physical, mental, and psychological wellbeing for the resident in accordance to the comprehensive assessment and plan of care.

Based on interview and record review the facility failed to ensure a resident (R1) was free from sexual abuse from a resident (R2) with known sexual behaviors. This failure resulted in R1 being sexually abused by R2. These failures apply to 1 of 9 residents (R1) reviewed for abuse in the sample of 9. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy started on 9/6/23 when R2 with a known history of sexually inappropriate behaviors started displaying inappropriate sexual behaviors and the facility failed to put interventions in place, and to notify his physician or nurse practitioner of the behaviors. This led to R2 behaviors escalating and R2 sexually abusing R1. V2 (Director of Nursing/DON) was notified of the Immediate Jeopardy on 9/25/23 at 2:00 PM. This surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 9/26/23, however, noncompliance remains at a Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R2's admission records dated 8/23/23 showed R2 was admitted to the facility, with diagnoses including a traumatic brain injury (TBI) and schizoaffective disorder, after being transferred from a sister facility. R2's admission records consisted only of R2's demographic sheet and background checks from the previous (sister) facility. No care plan, progress notes, resident assessments, or any documented information, identifying R2's behavioral history, was sent with R2, upon his admission to the facility. A Nurse Practitioner Progress Note dated 9/1/23, for R2, showed R2 was a temporary patient as the facility he was staying in is being fixed . The note showed R2's history and physical admission assessment, completed by the nurse practitioner, was limited due to no medical records available from the transferring facility. The note showed R2 was alert, oriented, able to follow commands, and had the ability to propel himself around the facility in his wheelchair. A Behavior Note dated 9/6/23, for R2, showed, Provided patient education on keeping hands to self and not trying to poke staff and make them uncomfortable . A Behavior Note dated 9/7/23, for R2, showed, CNA (certified nursing assistant) reported to this writer that resident would tell her sexual stuff in Spanish that translates in I want to get between your legs. Resident also tries to touch CNA in an inappropriate way. Staff continuously educates him to stop but resident just laughs. A facility incident report dated 9/18/23 showed V7 CNA witnessed R2 touching R1's breasts, in R1's room, on 9/13/23. R2 was immediately removed from R1's room by V7 CNA. The local police, facility administration, and appropriate physicians were notified. The report showed R1 was cognitively impaired due to her diagnosis of Alzheimer's disease. The report showed R1 is typically not able to make her needs known. R2's nurses notes dated 9/13/23-9/15/23 showed R2 was transferred to another floor in the facility and placed on 1:1 staff supervision until his discharge from the facility on 9/15/23. On 9/25/23 at 9:25 AM, a telephone interview was conducted with R2. R2 stated he remembered the incident with R1 on 9/13/23. R2 stated he entered R1's room and touched R1's breasts. On 9/25/23 at 9:50 AM, an attempt to interview R1 was unsuccessful due to her cognition. When R1 was asked questions, she would provide repetitive verbal responses of no, no, no or ok, ok, ok. On 9/25/23 at 10:12 AM, V7 CNA stated R2 would poke at me with his finger and tell me I was pretty prior to the incident on 9/13/23. V7 CNA stated she reported R2's behaviors to V6 Registered Nurse (RN). V7 stated, On 9/13/23, I saw (R2) propelling himself down the hallway, towards the dining room, but he never made it to the dining room. I walked down the hall to look for him. I saw him in (R1's) room so I walked into her room. (R1) was lying in bed. (R2) was in wheelchair, next to (R1's) bed. (R2) had one hand on (R1's) breast and his other hand was going down between her legs. I immediately wheeled (R2) out of the room and told the nurse. (R1) can't consent to anything. She just babbles. On 9/25/23 at 9:19 AM, V6 RN stated she was notified by V7 CNA, on 9/6/23, that R2 was touching/poking V7. V6 stated, I talked to (R2) about it and told him to stop. He just started laughing. V6 stated she reported the incident to V2 DON and documented the behaviors in R2's medical record. V6 stated she did not report R2's behaviors to his physician or nurse practitioner. On 9/25/23 at 11:45 AM, V14 CNA stated, (R2) would touch my leg. He always made (sexually) inappropriate comments to me. This happened multiple times. I would tell him to stop. V13 stated she reported R2's behaviors to a nurse. On 9/25/23 at 1:50 PM, V3 Licensed Practical Nurse (LPN) stated on 9/7/23, A CNA reported to me that (R2) was trying to touch her and speak to her sexually in Spanish. I reported this to the DON (V2). (V2) just told me to redirect him. No other interventions were put into place. V3 stated she did not report R2's behaviors to his physician or nurse practitioner. On 9/25/23 at 11:30 AM, V2 DON stated R2 was an emergency admission from a sister facility. V2 stated, We didn't get any verbal report on him. Our corporate just called and asked us to take him. We didn't get his care plan or any behavioral records from the previous facility. V2 stated she had no idea if R2 displayed any sexual behaviors at his previous facility. V2 stated she was informed of R2's sexual behaviors towards facility staff on 9/6/23 and 9/7/23. V2 stated she did not initiate close monitoring of R2 or 1:1 supervision of R2, after learning of his behaviors, because R2 hadn't done anything to residents at the time, so I told the staff to redirect him and set boundaries. I talked to (R2) about his behaviors. He was laughing. He just said, I'm a man. I got eyes. I can look. V2 stated she did not report R2's behaviors to his physician or nurse practitioner. On 9/25/23 at 11:59 AM, V16 Social Services Director stated she was not aware if R2 exhibited sexually inappropriate behaviors at his previous facility. V16 stated, When (R2) was admitted , we never got a care plan or records from his previous facility. After his behaviors on 9/7/23, I did place a referral to psych for him. We just told staff to keep any eye out for him. V16 stated she did not report R2's behaviors to his physician or nurse practitioner. V16 stated, In the future, we should report these behaviors right away to the physician. We also need to make sure we get report from the transferring facility before we accept a new admission. On 9/25/23 at 11:20 AM, V13 Psychiatric/Social Director, from R2's previous facility, was interviewed via phone. V13 stated, (R2) was transferred out of here due to our building no longer being habitable. Our air conditioning stopped working. We had to transfer all our residents out to other facilities. I know (R2) well. He had a brain injury due to an accident. He has schizophrenia. He was care planned for behaviors of verbal aggression, physical aggression, and for being sexually inappropriate towards staff. He has poor impulse control. V13 stated, I wasn't involved with the actual process of calling report and getting (R2) transferred out. I don't know what records were sent with him when we transferred him out. I don't know if verbal report was called on (R2). We were just in a hurry to get everyone evacuated. V13 stated he did not know if R2's behaviors had been reported to R2's new facility, prior to his transfer. On 9/25/23 at 10:36 AM, R2's Behavioral Notes dated 9/6/23 and 9/7/23 were reviewed with V12 (Nurse Practitioner for R1 and R2). V12 stated, This is the first of me seeing these notes. No one reported (R2's) inappropriate behaviors to me. I saw him on 9/8/23. No one reported anything to me even then. I was not aware of any sexual behaviors exhibited by (R2) until his incident with (R1). Had I been notified of his behaviors towards staff, I would have sent him out of the facility, for a psych evaluation, immediately. I would have been concerned about him being a threat to other residents . V12 also stated, (R1) does not have the mental capacity to give consent. On 9/25/23 at 11:50 AM, V15 (Family of R1) stated, (R1) does not have the mental capability to consent. If she did, she would have never consented to letting that (incident with R2) happen. The facility's Abuse policy dated March 2022 showed, This facility affirms the right of our residents to be free from verbal, physical, sexual, mental abuse, neglect, exploitation, misappropriation of property, involuntary seclusion, or mistreatment .This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property, involuntary seclusion, or mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals .This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish . The Immediate Jeopardy that began on 9/6/23 was removed on 9/26/23, when the facility took the following actions to remove the immediacy: 1. The facility has taken the following action concerning the IJ component a) R2 was placed on a 1:1 supervision from 09/13/2023 until discharge on [DATE]. b) R2 is no longer in the facility. 2 .Statement regarding residents that have the potential of being affected. a) Resident R1 has been identified as having been affected. 3 .Measures the facility will take or systems to ensure the problems will be corrected and will not recur. a) Social services will do daily rounds to monitor residents for change in behaviors. Daily rounds will continue for 90 days. b) Nurses and CNAs will complete a tracking sheet for any residents that are presenting with any worsening sexual behaviors, to be monitored 1:1, by their location to prevent any sexual abuse. This tracking sheet will be utilized for 90 days. c) The facility's Behavior Management policy was updated to include notification of the physician for worsening resident behavior. Staff in-services, regarding the policy change, was conducted by the administrator. The in-service was initiated 9/26/23 and will be completed by 9/27/23. PRN staff will be in-serviced prior to their next scheduled shift. d) All facility staff were educated on the abuse prevention policy with emphasis on sexual abuse and the reporting requirements. Staff in-services were conducted by the administrator. The in-services were initiated on 9/25/23 and will be completed by 9/27/23. PRN staff will be in-serviced prior to their next scheduled shift. e) The facility admissions IDT (interdisciplinary team), including the DON, admissions coordinator, and social service director were educated on the facility admission process to include screening of all potential admissions to ensure proper placement. The in-services were facilitated by the administrator. The in-services were initiated on 9/25/23 and completed on 9/26/23. 4. The SSD (Social Service Director) or designees will monitor continued compliance via the following Quality Improvement Programs: a) Daily, the Administrator or designee, will audit all referrals to ensure the admission screening was completed to include medical and psychiatric history for proper placement. Monitoring initiated on 9/26/23. This audit will be completed daily for 90 days. b) Referral packets and care plans reviewed for resident admissions over the last 30 days. Resident care plans updated as appropriate. c) Daily, the administrator or designee, will review the tracking sheets to monitor all residents exhibiting worsening sexual behavior, to ensure they are placed on immediate supervision to prevent abuse. This audit will be completed for 90 days. The physician will be notified of resident behavioral changes and consulted for further direction and interventions. d) The results of the monitoring completed will be submitted to the QA/QI Committee for review and follow-up, monthly, by administrator. e) An emergency QA meeting was held on 9/26/23. f) Medical Director notified about the incident on 9/13/23 by the DON.

Based on observation, interview, and record review the facility failed to utilize safety devices during a mechanical lift transfer and failed to safely transfer a resident for 2 of 3 residents (R1 and R2) reviewed for transfers in the sample of 4. This failure resulted in R1 receiving a fracture to her left femur (thigh) bone. The findings include: R1's Face Sheet (dated 1/12/23) showed an Initial admitted [DATE] with diagnoses to include left sided hemiplegia (paralysis or weakness to the left side;) muscle weakness; lack of coordination; repeated falls; severe obesity; gait and mobility abnormalities; need for assistance with personal care. R1's 10/28/22 Minimum Data Set showed she required extensive assistance for transfers. During interviews on 1/11/23 at 1:35 PM and 1/12/23 at 10:00 AM, R1 was alert and oriented to person, place, time, and her current condition. R1 responded to questions appropriately and in detail. On 1/12/23, R1 was able to recall details from her interview on 1/11/23. R1's 12/30/22 Inpatient Hospital Note showed, V3 R1's Inpatient and Long-Term Care physician, assessed her as being Alert & Oriented x (times) 4. R1's Inpatient Occupation Therapy assessment from 1/2/23 assessed her as being alert and oriented times 4 and she was aware of her deficits and limitations. The facilities Initial and Final Incident Report (The initial and final were sent as a singular document by V1 Administrator) emailed 12/30/22 at 12:48 PM showed on 12/28/22, During [R1's] transfer from bed to w/c (wheelchair) on 12/28/22, resident heard a pop to her left knee during the process and was lowered to the floor. Physician called and orders received for a STAT X-Ray. Upon X-Ray results it was found that an oblique fx (fracture is not at a right angle to the bone) was found at the distal femoral diaphysis (shaft of the thigh bone closer to the knee than the hip.) Resident was hospitalized for further evaluation. On 1/11/23 at 1:35 PM and 1/12/23 at 10:00 AM, R1 was laying on her back, wearing a hospital gown, and the lower half of her body was covered with a bed sheet. A splint/boot was visible through the sheet to her left leg. R1's left hand; at the area between the base of her thumb and the base or index finger; she had several small scabs and discolored skin indicating remnants of a fading bruise. On 1/11/23 at 1:35 PM, R1 stated It was two weeks ago. I was getting dressed and I normally need help. I need the sit-to-stand (a mechanical lift that takes a resident from the seated to standing position and then back to seated.) and I wasn't on it quite right. The left foot was slipping to the left side. It was never on the machine quite right from the start [of the transfer.] R1 stated the Certified Nursing Assistant was getting her dressed while she was up in the sit to stand, and it was during that time that her left leg slid out of the machine. R1 stated after her left leg slid out of the machine, she collapsed under her own weight, and she was hanging by her arms and shoulders. R1 stated when she collapsed, she heard two pops in her left leg. R1 stated, I was afraid it broke. That's what I thought happened and that's what I told the nurses. It was painful; it hurt. R1 stated, My legs were not strapped in [to the sit-to-stand], if they were [strapped in] it wouldn't have happened. They never strap in my legs. R1 stated, since the fracture she has not gotten out of bed, and she still has pain with movement. On 1/12/23 at 11:04 AM, V2 Director of Nursing (DON) stated We were made aware that the sit-to-stand made a funky maneuver, [R1] heard a pop or crack, she wasn't in any pain, and a STAT X-Ray was ordered. We talked with [V13, (CNA doing R1's transfer)] who affirmed that the sit-to-stand malfunctioned; it jerked her. So that was the conclusion of the investigation .the machine stopped and restarted and made an abnormal movement while the patient was in the machine . On 1/11/23 at 1:15 PM, V11 Registered Nurse (RN) stated she was walking by R1's room on the first floor when V13 asked her for help. V11 stated, It happened so fast. V11 stated, for certain, R1 went to the floor as she entered the room. V11 stated, R1 was laying in front of her wheelchair and V11 believed R1 slid out of the wheelchair. V11 stated, she could not recall if the sit-to-stand machine was in the room. V11 stated she could not understand V13 well; however, she believed he stated R1 slid out of the wheelchair. V11 was not aware of any statements from R1 regarding what happened.V11 stated R1 was not having pain and R1 could move her left leg. V11 said herself and V13 used a crane type mechanical lift and transferred R1 off of the floor and to the bed. V11 said she then notified V12 Licensed Practical Nurse (LPN, R1's Nurse on 12/28/22.) On 1/11/23 at 1:00 PM, V12 stated R1 was already in bed when she arrived at R1's room. V12 stated R1 was having pain and she couldn't move her leg. V12 stated R1 told her she was in the sit-to-stand and she needed to move her leg, it twisted and she heard a pop. V12 stated, In the back of my mind I thought she broke something . On 1/12/23 at 10:00 AM, R1 stated I am 100 percent certain my leg popped while I was standing in the sit to stand. I never told anyone it popped while I was still sitting in bed. My foot slipped off of the sit to stand .they definitely did not have my legs strapped in. On 1/12/23 at 1:40 PM, V12 reiterated (R1) told me the pop happened while she was up in the sit-to-stand, not before. She (R1) said it twisted and popped while she was up in the stand. R1's Progress Note for 12/28/22 at 11:56 AM (Authored by V12) showed, .resident was being transferred from bed to wheelchair, the resident heard a pop to her left knee in the process and was lowered to the floor . On 1/12/23 at 11:29 AM, V1 stated she does not have a statement from V13 himself or V12 regarding the incident with R1. V1 stated a thorough investigation should have those statements. V1 stated, The way it was explained to me, was that when she (R1) was repositioning herself at the edge of the bed her knee popped, and she didn't tell [V13] and when [V13] got her up he lowered her to the ground. V1 stated, the Final Incident Report sent to the State Health Department sounds as if the pop happened during the transfer, not before the transfer. V1 stated At the time I wrote that statement, I got the impression that it popped while she was standing up because that came from my own mind. That's how I thought it happened. The facility's Incident Investigation showed, Resident Description: Resident stated that during transfer using the sit to stand she heard a pop to her left knee, she also complained of pain . The investigation also showed, Statement: Resident was being transfer[ed] from bed to wheelchair using sit to stand, resident heard a pop to her left knee and she was lowered to the floor. The investigation showed she was oriented to person, place, time, and situation. The investigation showed R1 .wasn't able to move her left knee and it was painful . R1's Hospital physician note by V3 from 12/30/22 showed, fall and left femur fracture. R1's Hospital Occupation Therapy Evaluation note from 1/2/23 showed, .presents with left femur fracture. Patient states she was being helped into clothes when she felt her left leg twist and heard a snap . On 1/11/23 at 2:25 PM, the first-floor sit-to-stand was in a storage room on the first floor. The sit to stand had a padded leg brace for the resident to place their shins against. There's a strap that wraps behind their calves and secures the resident's legs tight to the shin pad. On 1/11/23 at 2:25 PM, V15 stated The leg strap does not work anymore. We use the leg strap if we need to. We don't use the leg strap on everyone. [R1], we don't have to use the leg strap on her. She can hold herself up. As long as they can hold themselves up, we don't have to use the strap . On 1/12/23 at 11:04 AM, V2 DON stated the purpose of the leg strap on the sit-to-stand is to keep the legs stable. V2 stated the leg strap is a safety device and the machine should not be used without it. On 1/12/23 at 10:20 AM, V8 Physical Therapist stated The leg straps should always be used; it's standard of care. It would keep the legs in place. On 1/12/23 at 10:21 AM, V9 Occupation Therapist stated, in regard to using or not using the leg strap on a sit-to-stand, I didn't even think it was an option. It is standard of care to use the leg straps to keep the resident secure. On 1/13/23 at 12:10 PM, V3 Physician stated he is her doctor at the facility as well as the hospital. V3 stated he is not aware of any pathological (pertaining to any diseases R1 has) reason for R1's fracture. V3 stated it is certainly possible that R1 fractured her leg at the moment she heard the pop and R1's leg slipping and/or twisting off of the sit-to-stand could have caused her fracture. The sit-to-stand manual showed 2. Position the unit in front of the patient. 3. Have patient place feet on foot plate and position their shins into the shin pad. The shin pad should be positioned below the knees. (See Figure 6) Use of Shin Pad Strap: If a caregiver deems it necessary to keep a patient's shins or feet on the foot plate, secure the shin strap around the patient's legs. Figure 6 shows the person's legs strapped tight to the shin pad with no room to shift laterally or behind the resident. The facility's policy Safe Patient Handling Protocols (effective 4/2020) showed, Lift Transfer .Questions regarding the transfer of a resident can be directed to therapy or the nursing supervisor for clarification or assistance. R2's Face Sheet showed an admitted [DATE] with diagnoses to include stroke, paralysis to his right side, and overweight. On 1/12/23 at 1:15 PM, R2 was transferred from his high-back wheelchair to his bed using a sit-to-stand mechanical lift. V15 and V16 Certified Nursing Assistants (CNA's) performed the transfer. During the transfer, the CNA had difficulty moving the sit-to-stand. The wheels of the lift took significant force to begin rolling, such that when the wheels broke free and began to roll it caused the resident to swing side to side. On 1/11/23 at 2:25 PM, V15 stated she had notified maintenance regarding the lift's wheels. On 1/12/23 at 1:20 PM, V15 and V16 stated the sit-to-stand does not roll well. V15 and V16 stated it is unsafe to move residents with the sit-to-stand because it does not roll easily. On 1/12/23 at 1:49 PM, V6 Maintenance Supervisor stated, I was told about the wheels a couple of months ago. V6 said he told the corporate maintenance supervisor about the wheels and honestly, after that, we kind of dropped the ball and didn't follow up on the wheels.

Based on observation, interview, and record review the facility deprived a resident of a STAT X-Ray for 40 hours, failed to notify the physician of the delay, and the facility deprived the resident of assessments after a transfer incident. The neglect began on 12/28/22 at 8:00 PM, when the facility was aware of a delay in imaging and ended on 12/30/22 at 4:30 AM (approximately 32 hours later) when the resident was transported to a local area hospital. This applies to 1 of 3 residents (R1) reviewed for nursing care in the sample of 4. This failure resulted in R1 being in bed without a leg splint and experiencing pain. The findings include: R1's Face Sheet (dated 1/12/23) showed an Initial admitted [DATE] with diagnoses to include left sided hemiplegia (paralysis or weakness to the left side;) muscle weakness; lack of coordination; repeated falls; severe obesity; gait and mobility abnormalities; need for assistance with personal care. R1's 10/28/22 Minimum Data Set showed she required extensive assistance of two staff for transfers and extensive assistance of one for toilet use. During interviews on 1/11/23 at 1:35 PM and 1/12/23 at 10:00 AM, R1 was alert and oriented to person, place, time, and her current condition. R1 responded to questions appropriately and in detail. On 1/12/23, R1 was able to recall details from her interview on 1/11/23. R1's 12/30/22 Inpatient Hospital Note showed, V3 R1's Inpatient and Long-Term Care physician, assessed her as being Alert & Oriented x (times) 4. R1's Inpatient Occupation Therapy assessment from 1/2/23 assessed her as being alert and oriented times 4 and she was aware of her deficits and limitations. The facilities Initial and Final Incident Report (The initial and final were sent as a singular document by V1 Administrator) emailed 12/30/22 at 12:48 PM showed on 12/28/22, During [R1's] transfer from bed to w/c (wheelchair) on 12/28/22, resident heard a pop to her left knee during the process and was lowered to the floor. Physician called and orders received for a STAT X-Ray. Upon X-Ray results it was found that an oblique fx (fracture is not at a right angle to the bone) was found at the distal femoral diaphysis (shaft of the thigh bone closer to the knee than the hip.) Resident was hospitalized for further evaluation. On 1/11/23 at 1:35 PM and 1/12/23 at 10:00 AM, R1 was laying on her back, wearing a hospital gown, and the lower half of her body was covered with a bed sheet. A splint/boot was visible through the sheet to her left leg. R1's left hand; at the area between the base of her thumb and the base or index finger; she had several small scabs and discolored skin indicating remnants of a fading bruise. R1's 12/28/22 Incident Note from 11:56 AM showed, .resident was being transfer from bed to wheelchair, the resident heard a pop to her left knee in the process and was lowered to the floor, used the [mechanical lift, crane type] lift to bring her back to bed, resident complained of pain to her left knee, she was assessed and she stated that she cannot move her left knee, called the physician got an order for STAT left knee X-Ray . On 1/11/23 at 1:35 PM, R1 stated after she heard her leg pop during the transfer, I was afraid it broke. That's what I thought happened and that's what I told the nurses. It was painful; it hurt. R1 stated she had pain when her leg was moved, and her leg was not immobilized until she went to the hospital. R1 stated she did not have surgery at the hospital, instead a boot/splint was applied to her left leg. R1 stated from the time of the incident and until she was sent to the hospital, I couldn't get out of bed .The [acetaminophen] worked as good as it could but I would have wanted something stronger. I had to stay on my back for those two days .I normally get up into the wheelchair for meals but during that time, I couldn't. The facility's schedule showed V12 Licensed Practical Nurse (LPN) worked a double 8-hour shift (AM and PM shift), approximately 6:00 AM to 10:00 PM. On 1/11/22 at 1:00 PM, V12 stated R1 .was having pain. I don't know how bad, but maybe 5 out of 10. She (R1) could move it a little, but she was scared to move it .I thought in the back of my mind she broke something that's why we called for the X-Ray. I called for stat X-Ray, but I was not sure when they would come .STAT X-Ray means it should be done within 4 hours and when I called back to follow up, they said they were backed up. I didn't call [V3 R1's Inpatient and Long-term care physician] to let him know . On 1/12/23 at 11:04 AM, V2 Director of Nursing (DON) stated STAT means they should come immediately. V2 state she was not aware R1 had pain with leg movement R1 would have been sent to the emergency department immediately. V2 stated it would be her expectation of staff to notify providers if a STAT X-Ray was not able to be done immediately and the notification should be documented. On 1/13/23 at 12:10 PM, V3 said, .A STAT X-Ray; it should happen pretty immediately in an urgent manner. I ordered stat because there was pain and swelling, so I was concerned about the patient; concerned that something needed to be done. I was not notified that the X-Ray could not be done immediately. From noon on 12/28/22 until 12/30/22 at 3:00 to 4:00 AM is too long; that is not STAT. If I order a STAT X-Ray and it cannot be done STAT, I expect to be notified. If I had been told of pain with movement, limited movement with the leg, and the X-Ray could not be done I would have told them to send her to the hospital. I would have told them [to send R1] as soon as they knew it couldn't be done STAT. I would have her sent to the hospital for pain control and to assess the situation. She was experiencing a change in condition, and she needed to be assessed. Her change in condition was a concern. I was concerned that this could be a fairly significant. R1's December 2022 Medication Administration Record (MAR) showed R1 was given acetaminophen for pain on 12/28/22 and twice on 12/29/22. The MAR showed R1 had not taken acetaminophen prior to 12/28/22. The MAR showed R1 was not given any other pain medication, except acetaminophen. R1's 12/28/22 Incident Note from 11:56 AM showed, .resident was being transfer from bed to wheelchair, the resident heard a pop to her left knee in the process and was lowered to the floor, used the [mechanical lift, crane type] lift to bring her back to bed, resident complained of pain to her left knee, she was assessed and she stated that she cannot move her left knee, called [V3] and got an order for stat left knee x-ray . R1' 12/28/22 Incident Note from 8:54 PM showed, .around 8:00 PM called [X-Ray contractor] again to f/u (follow up) about the X-Ray, spoke with [X-Ray] and she said that it will be done tomorrow due to their back orders, and they are still trying to catch up, resident was given a [acetaminophen] for pain with relief, will continue to monitor. (Note does not indicate R1's provider was notified of the delay.) R1's Progress Notes showed no nurses notes or assessments on 12/29/22. R1's 12/30/22 Daily Skilled Note from 3:36 AM showed, X-Ray here. X-Ray of left knee/femur done . R1's 12/30/33 Daily Skilled Note from 4:53 AM showed, R1 left the building at 4:30 AM and she was transferred to a local area emergency department. On 1/12/23 at 3:30 PM, V1 Administrator/Nurse stated, while reviewing R1's Electronic Health Record, I don't see any assessment on 12/29/22 or 12/30/22. It should be documented in Forms or in Progress Notes and there are none. I would expect the staff to contact the physician and let him know that a stat X-Ray was not able to be done and that a resident was having pain with movement. I would expect that notification to be documented and any new orders or changes to orders to be documented. The facility's Abuse Policy, dated March 2021, defines neglect as .the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain or mental anguish. Neglect means a facility's failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness of a resident. The policy showed, This facility affirms the right of our residents to be free from verbal, physical, sexual, mental abuse, neglect, exploitation, misappropriation of property, involuntary seclusion, or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents.

Based on observation, interview, and record review the facility failed to ensure a resident was assessed after a change in condition was reported to staff. This failure resulted in R1 being found approximately 24 hours later, grimacing in pain, with swelling to her bilateral knees and ankles, with subsequent X-rays/radiology reports showing fractures to her right fibula (lower leg) and left femur (upper leg). This applies to 1 of 3 residents (R1) reviewed for quality of care in the sample of 5. The findings include: R1's current care plan showed R1 was severely cognitively impaired related to her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Incident Note dated April 4, 2022, at 6:02 PM, showed V16 Registered Nurse (RN) was notified by V19 (Daughter of R1) that R1's bilateral knees and ankles were swollen. The note showed that upon assessment, V16 RN found R1's bilateral knees and ankles to be swollen with R1 grimacing in pain with movement of her lower extremities. R1's physician was notified of V16's assessment and X-rays were ordered. R1's Lab/Rad (Radiology) note dated April 4, 2022, at 10:30 PM showed. Received X-ray result: Impression .Distal right fibular fracture .Subtle fracture to the (left) medial femoral epicondyle . The note showed R1 was then sent to a local hospital for an evaluation of the fractures. On April 11, 2022, at 10:30 AM, V19 (Daughter of R1) stated, I am upset. When I visited (R1) in the afternoon of April 3 (2022), I noticed she was limping. Her knees and ankles were swollen. I asked (V11 Licensed Practical Nurse/LPN) that day to take a look at (R1) to see what was going on because she was limping. When I came back for a visit the next day (April 4, 2022), I find out (V11 LPN) never looked at her so I asked the other nurse to look at her .No one knows what happened to (R1). No one knows what caused these (fractures). On April 12, 2022, at 10:50 AM, V11 LPN stated, Yes, that afternoon (April 3, 2022), (V19 Daughter of R1) did stop me and ask me to take a look at (R1) because she was limping. When I went down to look at (R1), she was asleep in bed. I didn't want to bother her, so I didn't assess her or look at her legs. We got busy. I didn't report the limping to the doctor or the next nurse .I feel bad. I should have assessed her that day. Normally, I would have done an assessment and reported anything abnormal to the doctor . On April 13, 2022, at 8:00 AM, V16 RN stated, That afternoon (April 4, 2022), (V19 Daughter of R1) came up to me and said (R1's) knees and ankles were swollen. (R1) was seated in a wheelchair in the dining room. I went and assessed her. Both of her knees and ankles were swollen .She would grimace with any movement of her legs, so I called the doctor right away and got orders .(V19 Daughter of R1) stated she had told the nurse the day before about (R1's) limping and no one did anything about it .No staff had reported any limping or swelling to me. On April 12, 2022, at 12:05 PM, V4 Physician stated, Any change in condition, including any limping or new swelling, should be reported to me immediately so I can initiate treatment as needed. I was first notified of (R1's) leg swelling on April 4 (2022) . On April 12, 2022, at 2:10 PM, V18 Chief Clinical Officer stated staff are to promptly notify the physician of any change in resident condition so care and treatment can be provided immediately if needed. V18 stated, If a family member and/or resident complains of new swelling to an area or any injury, I would expect the nurse to go and assess the resident immediately and then call the physician with any findings. The facility's Change in Condition policy dated March 2021 showed, GUIDELINE: To keep the physician or extender, who is in charge of medical care, responsible party, responsible for health care decisions, informed of the resident's medical condition so they may direct the plan of care as needed. STANDARD: Notification of physician or extender, legal representative, or responsible party, should occur when there is a change in the resident's condition. Change in condition is defined as .An incident or accident, that involves the resident which results in injury and requires physician or extender intervention. A change in the resident's physical, mental or psychosocial status. A need to alter treatment. A decision to transfer or discharge the resident from the facility. PROCEDURE: 1. Determining When To Call - Evaluate the condition and determine when it is an emergency, medical situation or a non-emergency situation .

Based on observation, interview, and record review the facility failed to provide a safe environment for a resident which resulted in R1 sustaining unwitnessed injuries in the facility. R1's injuries resulted in fractures to her right fibula (lower leg) and left femur (upper leg). This applies to 1 of 5 residents (R1) reviewed for safety and supervision in the sample of 5. The findings include: R1's current care plan showed R1 was severely cognitively impaired related to her diagnoses of Dementia and Alzheimer's Disease. R1's Incident Note dated April 4, 2022, at 6:02 PM, showed V16 Registered Nurse (RN) was notified by V19 (Daughter of R1) that R1's bilateral knees and ankles were swollen. The note showed that upon assessment,V16 RN found R1's bilateral knees and ankles to be swollen with R1 grimacing in pain with movement of her lower extremities. R1's physician was notified of V16's assessment and X-rays were ordered. R1's Lab/Rad (Radiology) note dated April 4, 2022, at 10:30 PM showed. Received X-ray result: Impression .Distal right fibular fracture .Subtle fracture to the (left) medial femoral epicondyle . The note showed R1 was then sent to a local hospital for an evaluation of the fractures. On April 11, 2022, at 10:30 AM, V19 (Daughter of R1) stated, I am upset. When I visited (R1) in the afternoon of April 3 (2022), I noticed she was limping. Her knees and ankles were swollen .No one knows what happened to (R1). No one knows what caused these (fractures). (V1 Administrator) told me he was looking into what happened. V19 stated when she visited with R1 on April 2, 2022, R1 was not limping or complaining of any leg swelling. V19 stated she notified V11 Licensed Practical Nurse (LPN) of R1's limping and lower leg swelling on April 3, 2022. On April 12, 2022, at 10:50 AM, V11 LPN stated she was notified of R1's leg swelling and limping on April 3, 2022, by V19 (Daughter of R1). V11 LPN stated she had no knowledge of what caused R1's injuries. V11 LPN denied any knowledge of recent falls for R1. V11 stated she did not assess R1 on April 3, 2022, because she was in bed sleeping. I didn't want to bother her. On April 13, 2022, at 8:00 AM, V16 RN stated, That afternoon (April 4, 2022), (V19 Daughter of R1) came up to me and said (R1's) knees and ankles were swollen. (R1) was seated in a wheelchair in the dining room. I went and assessed her. Both of her knees and ankles were swollen .She would grimace with any movement of her legs, so I called the doctor right away and got orders .No staff had reported any limping or swelling to me. I was not told of any recent falls or injuries for her . The facility's Nursing Schedule dated April 2 and April 3, 2022 (afternoon/second shift) showed V9 Registered Nurse (RN) was assigned to provide cares to R1. On April 12, 2022, at 2:30 PM, V9 RN stated, I am not sure I was even assigned to her those days. I don't recall seeing her walking at all .I have no idea what happened to (R1). The facility's Nursing Schedule dated April 3, 2022 (day shift) showed V14 LPN was assigned to provide cares to R1. On April 12, 2022, at 1:30 PM, V14 LPN stated, I didn't see (R1) walking around at all that day. I only saw her in her wheelchair or lying-in bed. No one reported any falls or injuries to me. I didn't do an assessment on her that day because I didn't see any reason too . V14 stated she had no knowledge of what caused R1's injuries. On April 12, 2022, at 11:00 AM, V12 Certified Nursing Assistant (CNA) stated she provided cares to R1 on April 1-3, 2022. V12 stated, I have no idea what happened to (R1). She didn't fall for me. I don't remember her limping . On April 12, 2022, at 12:05 PM, V4 Physician stated, I assumed (R1's) injuries were the result of a fall but no one reported any falls .If she had fallen, she would have never been able to get herself back up off the floor, by herself, with those fractures, especially the one to her right leg. She wouldn't be able to walk with those fractures .We really don't know for sure what happened. Something traumatic happened to cause her injuries, we just don't know what .

Based on observation interview and record review, the facility failed to supervise a resident who has history of repeated falls and failed to put fall interventions in place for these repeated falls. This failure resulted in R1 falling and sustaining a fracture in her right ankle. Findings include: R1's Physician order [REDACTED]. R1's facility assessment dated [DATE] shows R1 is severely cognitively impaired. The same assessment shows R1 needs assistance of 1 person physical assist for bed mobility and transfers. R1's fall risk assessment dated [DATE] shows R1 is at high risk for falls. R1's medical record also shows R1 had fallen repeatedly on the following dates: 12/2/20, 12/15/20, 12/17/20, 1/21/21, 2/7/21 and 2/17/2021. The facility Incident Report dated 2/17/2021 sent to the state agency shows resident was heard crying. Nurse entered the room and observed the resident on the floor with her right ankle caught in the legs of the broada chair. Her right ankle was noted to be reddened and swollen. Resident was sent for evaluation. Returned to the facility with [DIAGNOSES REDACTED]. The facility's final investigation report regarding R1's fall with injury dated 2/19/2021 shows the resident was attempting to get into her reclined chair and got her foot caught in the frame of the chair. R1's emergency room (ER) note dated 2/17/2021 shows R1 was diagnosed with [REDACTED]. R1's ER discharge shows R1 needs to see V8. (Orthopedic Physician) On 2/22/2021 at 9:45 AM, R1 was sitting in her reclined chair watching TV. R1 was wearing a CAM boot (Controlled Ankle Motion) to her right foot. R1 was alert but non verbal. On 2/22/2021 at 9:30 AM, V2 (DON) said that on 2/17/2021, R1 was found on the floor. V2 said R1 transferred herself unassisted to her chair. V2 said R1 sustained an ankle fracture due to the fall. V2 said R1 has history of repeated falls. On 2/22/2021 at 5:15 PM, V3 (Registered Nurse) said she was R1's nurse when the incident happened. V3 (RN) said the incident happened at around 4:30 AM (night shift). V3 said she heard R1 yelling. V3 said when she entered R1's room, R1 was on the floor holding unto R1's chair. R1's right foot was caught between R1's reclined chair and R1's chest of drawers. V3 said R1's reclined chair and chest of drawers were on the opposite side of the room. V3 said R1 transferred herself unassisted and fell . V3 said R1's right foot was reddened and swollen. V3 said she informed R1's physician and R1 was sent to the emergency room (ER). R1 was diagnosed with [REDACTED]. V3 said R1 has history of multiple falls due to unassisted transfers in her room. V3 said R1 should have been monitored more closely. V3 said staff gets busy at night. V3 said R1 is unable to use her call light. V3 said R1 has no device to let staff know she R1 was getting up from bed unassisted. On 2/22/2021 at 10:55 AM, V4 (Certified Nursing Assistant-CNA) said she was the CNA when the incident happened. V4 (CNA) said she was busy taking care of other residents when her nurse (V3) alerted her to let her know that R1 was on the floor. V4 said when she entered R1's room, R1 was on the floor on the opposite side of the room by R1's reclined chair and chest of drawers. V4 said R1's right foot was tangled around the base of R1's reclined chair. V4 said R1's right leg was black and swollen. V4 said V5 sent R1 out to the ER. V4 said R1 gets up from bed unassisted. and then falls. V4 said R1 needs closer monitoring as she transfers herself and that is the main reason why R1 was falling. On 2/22/21 at 12:17 PM, V6 (RN) said she is R1's day shift nurse. V6 said R1 needs closer supervision and monitoring due to repeated falls. V6 said R1's room cannot be visualized in the nurses' station. V6 said there is nothing to alert staff when R1 is getting out of bed. V6 said by the time staff can make it to R1's room, R1 had fallen on the floor. V6 said R1 still gets up unassisted even when R1's bed was in the low position. V6 said an alarm would be good or other fall interventions to prevent further falls. V6 said R1's latest fall fractured R1's right ankle On 2/22/2021 at 10:00 AM, V5 (CNA) said R1 is total care. V5 said R1 needs 1 staff when she walks because R1 is unsteady. V5 said R1 is known to transfer without assistance. V5 said R1 falls a lot but staff cannot watch R1 at all times since staff get busy with other residents. R1's latest careplan did not address the repeated falls on: 12/2/20, 12/15/20, 12/17/20, 1/21/21, 2/8/21 and 2/17 2021. Per R1's medical record accessed on 2/22/2021, most of R1's falls occurred in R1's room due to unassisted transfers. The falls on 12/17/20, 2/7/2021 and 2/17/2021 happened early mornings in R1's room due to unassisted transfers. On 2/22/2021 at 2:30 PM, V2 (DON) said we were told that R1 was known to be an early riser in the past. V2 said that should have been added to her careplan fall interventions. V2 also said R1's low bed does not stop R1 from getting up from bed and ambulating unassisted then falling. V2 said R1's fall intervention should have also been updated. R1's Ortho note by V7 (V8's Physician Assistant-PA) dated 2/19/2021 shows R1 was evaluated due to right ankle fracture. The same note shows R1 has distal fibula avulsion fracture. On 2/23/2021 at 11:14 AM, V7 (Ortho PA) said R1's right ankle fracture (Distal Avulsion Fracture) shows that R1's right ankle was twisted hard enough that have caused R1's right ankle to fracture. This fracture can occur due to a fall. V7 said R1 was prescribed a CAM boot to her right foot to be worn at all times except bathing. V7 said R1's right ankle fracture will be followed up in 4 weeks for additional X-rays to see the progress of healing on R1's right ankle. V7 said it was important for R1 not to have further falls. The facility policy entitled Fall Program dated 4/2020 shows, When a fall occurs: f. Fall will be reviewed with the Interdisciplinary Team. Discussion will include any trends, education needed or recommendations .Review of interventions and care plan occurs.

Based on interview and record review the facility failed to accurately assess the use of side rails, failed to identify a medical symptom for the use of a restraint, and failed to obtain consent for side rails for a resident with a cognitive impairment. This failure resulted in a resident being entangled in the side rails resulting in a right arm Humerus fracture. This applies to 1 of 5 residents (R1) reviewed for abuse in the sample of 5. The findings include: R1's face sheet shows she was admitted to the facility on [DATE] with diagnoses that include: [MEDICAL CONDITIONS] arthritis, abnormalities of gait and mobility, muscle wasting and weakness, lack of coordination, [MEDICAL CONDITION], unspecified dementia without behavioral disturbances, unspecified [MEDICAL CONDITION], hypertension, rhabdomylosis, overactive bladder, and a history of falls. R1's physician's orders [REDACTED]. R1's Minimum data set (MDS) assessment of 1[DATE] shows she has a score severe cognitive impairment. The same assessment shows R1 has impaired mobility to both upper and lower extremities, and requires extensive assistance of 2 people for transfers, bed mobility, and turning and repositioning. R1's current careplan with a revision date of 1/2/2020 shows that R1 requires extensive to total care with ADL's (activities of daily living). The same care plan shows that the intervention for padded side rails was not added until [DATE]. There is no earlier intervention in the care plan that shows that R1 was using side rails on her bed. A bed rail consent form dated [DATE] (R1's admitted ) has the following categories checked for clinical indication for use of bed rails: To provide the resident with sense of security due to fear of falling, position aid to enable resident to reposition self and assist with entering/exiting bed and for safety for resident to decrease risk for slipping out of bed due to [MEDICAL CONDITION] or neurological disorders. (There is no [DIAGNOSES REDACTED]. R1's side rail assessments dated 12/5/19 and [DATE] shows boxes checked as a yes for the following areas: that R1 has a history of falls, is able to get out of bed without assistance, able to express their choice about side rail use, (R1's facility assessment shows that her cognition is severely impaired), and that the use of side rails would keep the resident from voluntarily getting out of bed. The facility's IDPH (Illinois Department of Public Health) Incident Report Form completed by V2 (Director of Nursing) with an incident date of [DATE] shows, V19 CNA (Certified Nursing Assistant) reported that the resident (R1) had her arm in the side rail and was lying cross wise in her bed, she states as she was helping the resident to free her arm the resident pulled her arm free and she said oh, it's broken. The CNA states she called the nurse to assess the resident right away. Resident noted with deformity and swelling to right upper arm. Resident transferred by Elite ambulance to (a local) ER (emergency room ) for evaluation. The facility's incident description document dated [DATE] at 9:13 PM, completed by V2, shows that R1 was twisted in her bed laying across it and had her arm through a 1/2 side rail and her legs through the opposite 1/2 side rail. V19 was assisting the resident to free her arms and legs from the side rails, and the resident pulled her arm out and said oh it's broken. The same document shows that R1 was sent to a local community hospital emergency room for evaluation and admitted with a [DIAGNOSES REDACTED]. On 2/25/2020 at 12:47 PM, V19 said on [DATE] she had put R1 to bed and was completing care for her when V2 called her out of the room to assist another resident. V19 said R1 was lying on her back in bed with her head on a pillow lying on her side with her legs pulled up towards her chest like in a fetal position and her siderails were both up as she exited the room. V19 said she cared for another resident for about 15 minutes and then returned to R1's room. When she entered the room she saw that R1 was twisted in bed and lying across the bed with both legs through the side rail on the left side of the bed and her arms intertwined in the side rail on the right side of the bed. V19 said she was lying almost kiddy corner in the bed. V19 said she went around to the left side of the bed and was able to get her legs out of the rail easily. She then took her hips and lifted them trying to move her. She said she got one arm free when she was lifting her hips up but she couldn't get the other arm free so she was going to come around to the right side of the bed to attempt to free the arm when the resident suddenly pulled the other arm out of the bed rail and said oh its broken. V19 said she looked at R1's arm and knew something was not right so she left the room to get help. V19 said she normally was transferring and repositioning R1 by herself because she was so small and other aides were transferring and repositioning her alone. V19 said You should never assume you can do it yourself, I should have went out and got V2 instead of me trying to do it alone. V19 said she was alone in the room the entire time. She did not leave to go get help because I thought I could get her out myself so I didn't go get help. On 2/25/2020 at 11:45 AM, V2 said she was R1's nurse on [DATE] when R1 sustained an arm fracture. V2 said that V19 came and told her that R1 was twisted in her bed, and something was wrong with her arm. When V2 entered the room she noticed that R1 was guarding her arm, she palpated the arm, immobilized it the best she could, and R1 was sent to a local emergency room . R1 was diagnosed with [REDACTED]. V2 said she leaves some autonomy with the staff to determine how many people they need to transfer or reposition a resident, but the facility Minimum Data Set (MDS) is the most accurate indicator of how many staff are needed. R1's 1[DATE] MDS shows she requires 2 people to turn and reposition in bed. V2 also said she does not see anything indicated on R1's care plan about the use of restraints/side rails that restorative should have addressed. There is nothing documented in R1's progress notes showing that R1's family representative gave verbal consent for the use of bed rails. She didn't care for the bed anyway that R1 was using, and a new bed without side rails and low to the ground was being delivered to the facility for R1. On 2/25/19 at 1:45 PM, V12 (CNA) said that R1 is not able to use the side rails to turn herself. On 2/25/2020 at 2:00 PM, V13 (Restorative CNA) said that R1 was supposed to have 2 staff assisting her with bed mobility and transfers and that she has no idea why R1 had the side rails because she wasn't able to use the side rails to turn and was always trying to get up on her own. On 2/25/2020 at 3:05 PM, V2, V19, this surveyor, and another surveyor were present and went to the room and the bed R1 had been in when the incident occurred. V19 showed us how R1 was positioned in the bed when she found her. She described that R1 was on her back with her upper body turned toward her right side and her arms through the side rail. R1's legs were through left side rail. V19 demonstrated, she walked around the bed to the left side and freed R1's legs. She said she (from the left side of the bed) lifted R1's hips to try to free her arms and then suddenly R1's arm flopped on her chest and R1 said Oh its broken. V19 then walked around to the right side of the bed to ask R1 what she had said. V19 said that her arm didn't look right so she left the room and got help. There were partial side rails on both sides of the bed, which were in the middle 1/3 of the bed, and approximately 2-3 feet long. The side rails had multiple bars parallel to each other with (approximate) 4 inch gaps in between each bar. The openings in between the bars of the side rails would allow for a residents arms and legs to go through them. Both sides of the bed were open at the head and foot area. V19 had to use both of her hands to pull the knob that was on the outside of the siderail to put it up and down. On 2/26/20 at 10:00 AM V3, (Director of Therapy) said that R1 had severe [MEDICAL CONDITION] arthritis and deformities to her hands which limited her movements and ability to grab/hold items. He additionally said that due to R1 being cognitively impaired it could prevent her from figuring out how to get her body out of the side rails. On 2/26/2020 at 1:20 PM, V15 (R1's physician) said I always thought her side rails were to prevent her from getting up. V15 also said with the description that is being described to her it is highly possible the fracture resulted from that action itself, of the CNA pulling on R1's hips while trying to free her from the rail. V15 stated, for sure she should have gotten help to free her from the bed rails she is so tiny and fragile. R1's records from a local community hospital transcribed on [DATE] show that R1 presented after her arm was caught in a railing at the nursing home and was found to have a right humeral fracture and orthopedics were being consulted. Additional records from the same hospital titled *Preliminary Report* performed by V21 (Orthopedic Physician Assistant) and electronically signed by V20 and V21 (Orthopedic Physician) show, Pt. presents with deformity to right upper arm. Per nursing home staff, pt has a history of falls, but had her arm stuck in the railing tonight. Assessment/Plan: [MEDICAL CONDITION] Humerus maintain sling. Diagnostic Results show R1 has a right Humerus displaced and angulated fracture. V20 and V21 were attempted to be contacted on 2/26/2020 with no return call. The facility's 12/2017 Bed Rails Policy shows, Every resident will have a safe and comfortable sleeping environment and bed. Therefore bed rail(s) use is discouraged due to the risks for injury and death. However, if a resident (or resident's representative) chooses to have bed rails of any form installed on the bed in the facility, he or she may do so with the appropriate consent. Procedure: A written consent is obtained from the resident or his/her representative via bed rails consent form. The facility may use a phone consent until a written consent is attained from the representative. A care plan will be written addressing the resident's needs/request for the bed rails and reviewed quarterly.

Based on observation, interview, and record review the facility failed to ensure residents were transferred in a safe manner for two of three residents (R1 and R2) reviewed for transfers in the sample of four. These failures resulted in R1 requiring 20 stitches on her right leg. The findings include: 1. R1's computerized face sheet showed [DIAGNOSES REDACTED]. R1's facility assessment dated (MONTH) 31, 2019 showed no cognitive impairment. The facility assessment showed R1 required extensive staff assistance with bed mobility, transfers, dressing, toilet use, and hygiene. R1's progress notes showed an incident note dated (MONTH) 10, 2019 stating: At 7:45 PM, CNA summoned this writer to report that the resident's right leg is bleeding. Resident was sitting on her bed, her right lateral lower leg sustaining a long cut and is bleeding moderately .The cut measured 15cm (centimeters) in length, unable to assess how deep . R1's (MONTH) 2019 physician order [REDACTED]. On (MONTH) 17, 2019 at 10:15 AM, R1 was lying in bed and not covered with any blankets. R1 had a white gauze bandage wrapped around her right lower leg. The bandage covered her calf from the bottom of her knee to the top of her ankle. R1 stated her leg was injured while being transferred out of the wheelchair and into bed. R1 said just one CNA (Certified Nurse Aide) moved her. R1 stated she told the aide to use the machine (mechanical lift) or get another staff member to help. R1 said the aide replied, No, I can do it. R1 said the aide picked her up and put her on the bed. R1 said her leg hit the metal bar of her bed and started bleeding all over the place. On (MONTH) 17, 2019 at 10:45 AM, V3 (CNA) stated R1 is transferred using a mechanical lift. V3 said R1 cannot bear weight on her feet at all. V3 said R1 has declined in her ability to stand and has used a mechanical lift for all transfers for about the last one month. V3 said the restorative nurse (V4) determines transfer needs for residents. On (MONTH) 17, 2019 at 11:00 AM, V4 (restorative nurse) stated R1 needs a mechanical lift for all transfers because she cannot bear weight due to chronic back pain. V4 said R1 is very sharp cognitively and definitely able to make her needs known to staff. On (MONTH) 17, 2019 at 12:45 PM, V5 (CNA that transferred R1) stated she moved R1 by herself (on (MONTH) 10, 2019). V5 said she grabbed R1 by the elastic waist band on her pants and bear hugged her. V5 said she lifted R1 up slightly by her pants to get her body onto the edge of the bed. V5 said R1 was not able to stand on her feet. V5 said she was unaware R1 was bleeding until R1 said, 'Ouch my leg. V5 said she saw blood on R1's right leg and the skin was torn open about the length of a pencil. V5 said she believed R1's leg hit the metal side rail when V5 lifted R1 onto the bed. V5 said she thought R1 was a one assist for transfers and she moved R1 into bed by herself. On (MONTH) 17, 2019 at 1:50 PM, V3 (CNA) stated all residents' capability levels for ADLs (activities of daily living) are documented on their daily ADL check list, which is completed daily for every shift. R1's ADL check list was reviewed with V3 for the month of (MONTH) 2019. The check list showed R1 marked as a 3/3 for transfers (extensive assist with staff providing weight-bearing support/ two person physical assist) for 8 of the 19 entries including (MONTH) 9, (the day before the leg injury). V3 said ADL performance levels are charted on resident care cards so aides know exactly how to care for residents. R1's care card was reviewed with V3 present and was blank for all care areas, including transfers. V3 said the care card has been blank since R1 was admitted in (MONTH) of 2019. On (MONTH) 17, 2019 at 2:00 PM, V4 (restorative nurse) was shown R1's ADL check list and care card. V4 said she did not realize R1's care card was blank. V4 said the care cards are used to communicate to staff how to safely and correctly care for residents. V4 said the 3/3 documentation of R1's ADL checklist indicates she needs a mechanical lift for transfers. V4 said R1 cannot put the pressure of standing on her legs or feet due to pain. On (MONTH) 17, 2019 at 2:50 PM, V2 (Director of Nurses) stated resident care cards are important so staff know individual resident needs. V2 said it is an important form of communication and every resident should have one. The facility's Transfer Techniques policy dated 5/10 states under the general instructions section: 4. Obtain help when necessary, or as identified on care plan/care card. R1's fall care plan was reviewed and did not show any interventions indicating how R1 should be transferred. R1's skin care plan was reviewed and showed a focus area related to fragile skin and precautions needed. Interventions included: Mechanical lift to transfer. Date initiated (MONTH) 15, 2019 (five days after R1's leg injury). R1's (MONTH) 10, 2019 emergency room instructions showed a discharge [DIAGNOSES REDACTED]. R1's facility Final Investigative Report dated (MONTH) 16, 2019 showed R1 was transferred to the ER for further evaluation where she received 20 stitches and was then returned . (on (MONTH) 10, 2019). 2. R2's Admission Record printed 10/17/19 by the facility shows [DIAGNOSES REDACTED]. The facility assessment dated [DATE] shows R2 has severe cognitive impairment and requires extensive assist of one staff member for bed mobility, dressing, toileting, personal hygiene and bathing. The assessment shows R2 requires extensive assist of two for transfers and his balance is not steady; only able to stabilize with staff assistance. On 10/17/19 at 11:44 AM, V6 Certified Nursing Assistant (CNA) was transferring R2 from his wheel chair to his bed via a sit to stand mechanical lift. As V6 was raising R2, R2 raised and bent both legs so his feet were about one foot off of the stand lift. V6 instructed R2 to put his feet back down. R2 put his feet down, however, both feet were hanging halfway off of the tray of the stand lift. V6 pushed the stand lift over to R2's bed and lowered him down. At 12:22 PM, V4 (Restorative Nurse) said during a sit to stand transfer, the resident's feet should not be hanging half-way off the stand. The resident could get an injury from doing that. V4 said when transferring a resident using the sit to stand lift, their feet should be all the way on the stand. At 2:52 PM, V2 Director of Nursing said the resident's feet should be on the stand during a sit to stand transfer. At 3:00 PM, V6 said when transferring a resident by the sit to stand lift, the resident's feet should be completely on the stand tray, not hanging half-way off the tray. R2's Activities of Daily Living care plan with a revision date of 8/13/19 shows Transfer: The resident requires mechanical aid sit to stand for transfers. The facility's undated Transfer Program Policy and Procedure show To ensure safe and appropriate transfer techniques for resident per regulatory guidelines and professional standards of practice .Mechanical Assisted Transfers: Sit to Stand Lift Transfer: B. To be transferred with a sit to stand lift, the resident must have no medical contraindications for using the lift. The resident should have the following characteristics: Alert .Able to follow simple commands.

Based on interview and record review the facility failed to ensure a resident was transferred from her wheelchair to her bed using a mechanical lift in a safe manner. This failure resulted in R1 sustaining a fractured right distal humerus on April 24, 2017. This applies to 1 of 3 residents reviewed for falls in a sample of 5. The findings include: The facility Incident Report dated April 24, 2017 states, CNA (Certified Nursing Assistant) transferred resident{R1} to bed. When CNA moved the lift away from the bedside the resident rolled over. Before the CNA could reach the resident she fell from the bed to the floor. Noted to have a laceration to her inner, upper lip, slight swelling to nose and complaints of pain to right arm . order to send to ER for evaluation. April 27, 2017 Resident returned to facility on April 24, 2017 with [DIAGNOSES REDACTED]. On May 10, 2017 at 9:45AM, E2 (Director of Nursing) stated, E3 (CNA) was transferring {R1} to bed. She turned to move the chair and the lift away from the bed and {R1} rolled off the bed. She had a laceration to her lip, was bleeding from her nose and her right arm was swollen. {E3} acknowledged that she did not use a second person during the transfer like she was supposed to. E2 then stated that R1 was recently admitted to the hospital for pneumonia and was currently not in the facility. On May 10, 2017 at 10:15AM, E3 stated, I put {R1} in the mechanical lift and put her to bed. She was positioned towards me (on her left side with her back to the wall) and the wheelchair was between me and the bed. I turned to push the chair away and {R1} rolled forward off of the bed. {R1} was bleeding from her lip and nose. E3 then stated that the transfer happened after lunch and they were busy. E3 stated that she transferred R1 by herself but they are supposed to have two staff for all mechanical lift transfers. R1's May physician's orders [REDACTED]. The Minimum Data Set of March 21, 2017 shows that R1 is totally dependent on two staff for transfers. The Physician's Progress Note dated May 1, 2017 states, Right distal humerus fracture. Sling for comfort. Non-weight bearing to right upper extremity. Occupational therapy for right elbow fracture. Return to clinic in 2 weeks. The facility policy entitled Mechanical Lift or Total Lift dated June 2013 states, A properly trained staff member cannot operate the mechanical lift/total lift by him or herself. A minimum of 2 staff members is required to operate the mechanical lift/total lift for a resident's transfer.