Every finding on record at Avantara Long Grove

Based on interview and record review the facility failed to notify the state agency after a resident's missing phone could not be located. This applies to 1 of 5 residents (R4) reviewed for misappropriation in the sample of 5. The findings include: R4's Valuables Disclosure Statement dated 6/8/26 shows R4 admitted to the facility with a black cell phone. R4's grievance form dated 6/10/26 shows R4 reported missing a black cell phone. The form states the facility checked R4's room, the facility kitchen, the laundry room, and with the facility's contracted linen laundry company. On 7/29/26 at 12:33 PM, V11 (R4's Family Member) said on the night of 6/9/26, V11 called R4's cell phone and spoke on the phone together. V11 said on the morning of 6/10/26, R4's phone went missing overnight. On 7/29/26 at 12:11 PM, V1 (Administrator) and V4 (Corporate Guest Services) said because the family did not specifically state they believed R4's phone may have been stolen by staff, the facility did not notify the state agency about the missing phone and treated it as a grievance rather than a potential abuse allegation. Facility Abuse and Retaliation Policy dated 7/3/26 states, . 6. Financial/Misappropriation of Property: Financial abuse includes, but not limited to deliberate misplacement, misappropriation, exploitation or otherwise taking advantage of a resident's money or property temporarily or permanently. Per the SOM (State Operations Manual), the following are examples of non-reportable acts: -Theft of nominal items with little to no monetary or sentimental value; Lost items that are not listed under must be reported. Must be reported includes theft of personal property, including but not limited to jewelry, computer, phone, and other valuable items such as eyeglasses and hearing aids . If abuse/neglect is suspected the facility will: . 2. Notify the appropriate/designated organization/authority (State Agency) that an investigation is being initiated immediately following interventions for the resident's safety.

Based on interview and record review the facility failed to thoroughly investigate a report of a lost phone to rule out misappropriation. This applies to 1 of 5 residents (R4) reviewed for misappropriation in the sample of 5. The findings include:R4's Valuables Disclosure Statement dated 6/8/26 shows R4 admitted to the facility with a black cell phone. R4's grievance form dated 6/10/26 shows R4 reported missing a black cell phone. The form states the facility checked R4's room, the facility kitchen, the laundry room, and with the facility's contracted linen laundry company. There are no documented interviews with staff on the form. On 7/29/26 at 12:33 PM, V11 (R4's Family Member) said on the night of 6/9/26, V11 called R4's cell phone and spoke on the phone together. V11 said on the morning of 6/10/26, R4's phone went missing overnight. V11 said staff informed them that they checked R4's room, with the kitchen, in the facility's laundry, and ultimately claimed the phone to have maybe accidentally gotten sent with the linens to the company that launders the facility's linens. On 7/29/26 at 12:11 PM, V1 (Administrator) and V4 (Corporate Guest Services) said upon learning about the lost phone, the facility conducted a search within the facility, but ultimately could not locate R4's phone. V1 and V4 stated staff were interviewed, but did acknowledge the only place investigation information was documented was R4's grievance form. V4 agreed that V4 could have put more information on the grievance form. Both V1 and V4 iterated that the family did not utilize language insinuating the phone was stolen, so the facility did not treat the missing phone as an allegation of misappropriation or theft. Facility Abuse and Retaliation Policy dated 7/3/26 states, . 6. Financial/Misappropriation of Property: Financial abuse includes, but not limited to deliberate misplacement, misappropriation, exploitation or otherwise taking advantage of a resident's money or property temporarily or permanently. Per the SOM (State Operations Manual), the following are examples of non-reportable acts: -Theft of nominal items with little to no monetary or sentimental value; Lost items that are not listed under must be reported. Must be reported includes theft of personal property, including but not limited to jewelry, computer, phone, and other valuable items such as eyeglasses and hearing aids . If abuse/neglect is suspected the facility will: . 3. Conduct a careful and deliberate investigation centering on facts, observations and statements from the alleged victim and witnesses.

Based on observation, interview and record review the facility failed to identify a fall for a resident with a history of falling and failed to implement their fall policy for 1 of 3 residents (R1) reviewed for safety/supervision in the sample of 3. The findings include: On 1/22/25 at 9:41 AM, R2 had self-propelled from the dining room area, in her wheelchair. R1 was in the dining room, watching R2 leave. R1 had a clothing protector on his chest, and it fell to the floor. R1 was in a high back wheelchair, with no foot pedals. R1 reached forward and tried to pick up the clothing protector from the floor. There was not a staff member inside the dining room area. V4 (RN -Registered Nurse) was at the medication cart, outside the dining room, looking down. R1 continued to reach for the clothing protector and his buttocks came off the seat of his wheelchair. The surveyor informed V4 (RN) that R1 was reaching for something on the floor and was concerned he may fall. V4 instructed R1 to stop reaching and stated, He's always trying to pick stuff up off the floor. A staff member picked up the clothing protector and placed it on the table, in front of R1. R2 started self-propelling back to the dining room. V4 stated, [R2] can you take that away from him (R1). R2 self propelled to R1 removed the clothing protector from R1's reach, spoke to R1 and turned his chair toward the TV. R1 was nonverbal. V4 (RN) said R2 looks out for R1 and stated, They're friends. R1's Facesheet dated 1/22/25 showed diagnoses to include, but not limited to: Parkinson's disease; PVD (Peripheral Vascular Disease); dysphagia; abnormalities of gait and mobility; lack of coordination; muscle wasting and atrophy; osteoarthritis; dementia; seizures and intellectual disabilities. R1's facility assessment dated [DATE] showed he had long and short term memory problems; and required substantial to maximum assistance from staff for oral hygiene, shower/bathe/ personal hygiene, bed mobility, and transfers. R1's Fall Risk Evaluation dated 12/23/24 showed he was at High Risk for Falls. R1's Behavior Note dated 1/16/25 at 3:40 PM showed, Resident was received in the bedroom, (CNA - Certified Nursing Assistant) got him dressed and came to the dining area, writer (V4 - RN) noted resident going back to his room and was (R1) instructed to remain in the dining room, resident refused, writer then went to check on resident and noted him bending over to pick his toy and slid off the wheelchair, resident POA (Power of Attorney) was made aware, PCP (Primary Care Provider) made aware with an order to monitor. The R1's Electronic Medical Record (EMR) did not contain an Incident Report, Change of Condition, SBAR assessment, or post fall follow-up documentation related to this fall. R1's progress notes did not show an assessment was completed, vital signs were obtained, or the fall was identified. R1's Care Plan initiated 4/12/23 showed, [R1] is at high risk for falls due to impaired mobility and activity intolerance secondary to diagnosis of Parkinson's disease, osteoarthritis, metabolic encephalopathy, seizures, HTN (Hypertension - high blood pressure), and severe sepsis with septic shock. [R1] tends to reach for his stuffed animals when they fall (on) the floor that makes him a high fall risk . This care plan was not updated after the fall on 1/16/25. The facility's Fall Report printed 1/22/25 showed R1 fell on [DATE]. This report did not show R1 fell on [DATE]. On 1/22/25 at 12:40 PM, V4 (RN) said R1 always carries too many toys with him. V4 stated, If he drops his toys, then he will reach for them and he will slide out off the chair. V4 said R1 is alert and oriented to himself but is not verbal. V4 said she was working 1/16/25, when R1 slipped out of his wheelchair. V4 said the CNA (she couldn't remember the CNA's name) had dressed R1 and brought him to the dining room. V4 said R1 started to self-propel himself back to his room. V4 said she encouraged R1 to return to the dining room, but then she got busy. V4 said later she checked on R1, in his room, and noticed him leaning to pick up his snake from the floor. V4 said R1 slid from the wheelchair and landed on his buttocks, on the floor. V4 said she didn't consider R1 sliding from the chair a fall, she considered it a behavior. V4 stated, He (R1) has a behavior of dropping things (usually his toys) and reaching for them. That's why she didn't consider this a fall and she entered a behavior note. I called his POA and told her what happened. She wasn't surprised. V4 said this has happened several times but was unable to provide any details. V4 said she saw R1 slide to the floor, so she didn't consider it a fall. V4 said she didn't complete a fall incident report, nor did she report the fall to V6 (Restorative Director). On 1/22/25 at 12:51 PM, V5 (CNA - Certified Nursing Assistant) said she's familiar with R1. V5 said R1 had lots of stuffed animals. V5 said if he drops anything, then he will try to reach for it himself. On 1/22/25 at 1:23 PM, V6 (Restorative Director) said she investigates all the falls at the facility. V6 said a change of plane or surface to surface change is considered a fall. The surveyor asked if a resident reached for an item on the floor and slid from the chair to the floor, then is that considered a fall. V6 replied, Yes, that would be considered a fall. V6 said the nurses should perform a head to toe assessment, neuro checks, check ROM (Range of Motion), and assess for injuries. V6 said the nurse should notify the family, physician, and her of the fall. V6 said the nurse will complete the Incident Report and any other necessary documents (i.e. SBAR, Change in Condition, Post Fall Monitoring, Neuro Checks). V6 said she will investigate the fall by talking to the resident, staff, and possible witnesses to determine the root cause. V6 said she updates the resident's care plans and monitors the effectiveness of the interventions. V6 said she was not aware that R1 fell on [DATE]. V6 said it had not been reported to her, so she had not followed the Fall Policy and Procedure. V6 said the process should be completed to properly assess the resident and revise the care plan in an effort to prevent future falls. V6 said R1's fall on 12/23/24 was also due to him reaching for stuffed animals on the floor. V6 said R1 was sent to the hospital for evaluation but did not have any injuries. V6 stated, I'm still trying to figure out what interventions will work for him. V6 said she will need to provide education on definition of a fall. On 1/22/25 at 1:55 PM, V7 (CNA) said R1 needs frequent supervision. V7 said R1 can't stand himself and needs the staff to perform 98% of the work (to transfer). V7 said R1 carries a lot of stuff animals and toys with him. V7 said if R1 drops the toys, then he will reach for them and he will slide right out of the chair. V7 said R1 does it a lot. The facility's Fall Occurrence Policy revised 7/26/24 showed, It is the policy of this facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary. Procedure . 4. An incident report will be completed by the nurse each time a resident falls. 5. The Falls Coordinator will review the incident report and may conduct his/her own fall investigation to determine the reasonable cause of fall. 6. The nurse may immediately start interventions to address falls in the unit, even prior to the Falls Coordinator's investigation. 7. Ultimately, the Falls Coordinator may change the interventions provided by the nurse if the Falls Coordinator's investigation identifies a more appropriate interventions for the individual fall. 8. The Falls Coordinator will add the interventions in the resident's care plan. 9. The incident may be written in the nurses' notes or other parts of the resident's medical record that will remain accessible to any person who has the right to access the resident's record. 10. Interventions will be reevaluated and revised as necessary.

Based on observation, interview, and record review the facility failed to ensure residents were free of accidental hazards by not removing razors from the room of residents with dementia and within reach of residents that have dementia that wander. This applies to 2 of 2 residents (R49 & R120) reviewed for safety in the sample of 32 and 8 residents (R79, R96, R103, R109, R119, R127, R142, & R149) outside of the sample. The findings include: On 8/6/24 at 12:51 PM, in the bathroom of room [ROOM NUMBER] there was a disposable razor in a clear plastic bag on the mirror ledge. The safety cover was off of the dry razor. R49 was one of two residents that resided in room [ROOM NUMBER]. On 8/7/24 at 9:45 AM, in the bathroom of room [ROOM NUMBER] there was a disposable razor in a clear plastic bag on the mirror ledge. The safety cover was off of the dry razor. The Face Sheet dated 8/7/24 for R49 showed diagnoses including dementia, delirium, paroxysmal atrial fibrillation, lack of coordination, congestive heart failure, peripheral vascular disease, anemia, and type 2 diabetes mellitus. The MDS (Minimum Data Set) dated 6/11/24 for R49 showed severe cognitive impairment; resident uses a wheelchair and supervision or touching assistance to wheel 150 feet. The Care Plan dated 6/18/24 for R49 showed, R49 displays an acute confusional episodes and disorientation related to metabolic encephalopathy. R49 has an alteration in neurological status related to metabolic encephalopathy. R49 is on anticoagulant therapy related to atrial fibrillation. On 8/6/24 at 12:36 PM, in room [ROOM NUMBER], there was a disposable razor sitting in a plastic cup in the bathroom on the mirror shelf. The razor did not have a safety cover and had hairs in the blade. R120 was one of two residents that resided in room [ROOM NUMBER]. On 8/7/24 at 9:41 AM, room [ROOM NUMBER]'s door was open and bathroom door was open. There were two dry disposable razors in the bathroom that had the safety covers off. The Face Sheet dated 8/7/24 for R120 showed diagnoses including dementia, depressive episodes, anxiety disorders, Wernicke's encephalopathy, and delusional disorders. The Psychiatry Progress Note dated 7/12/24 for R120 showed, irritable and frustrated behavior. Poor insight, judgement, and impulse control. Impairment of short term and long term memory. Appears distractible, suspicious, distrustful, disorganized with poor boundaries and judgement. The MDS dated [DATE] for R120 showed moderate cognitive impairment; set up or clean-up assistance to walk 150 feet. On 8/7/24 at 01:28 PM, V4 CNA (Certified Nursing Assistant) was shown the razors in room [ROOM NUMBER] and 110. V4 stated residents are not supposed to have disposable razors in their bathroom for resident safety. V4 stated they have a lot of residents that wander. On 8/7/24 at 1:37 PM, V6 LPN (Licensed Practical Nurse) stated she is at the facility every day and R119 is completely demented. R119 wanders into others room. R79 is very demented. R103 is forgetful, demented, hoards, goes in and out of resident's rooms. R49 has dementia, goes into others rooms and gets angry when redirected. V6 stated razors cannot be left in resident's rooms because it is dangerous; residents can cut themselves. On 8/8/24 at 12:49 PM, V2 DON (Director of Nursing) stated razors are not to be left in resident's rooms for resident safety. The facility's Residents at Risk for Elopement/Wandering (no date) received from V1 (Administrator) on 8/8/24 at 11:30 AM showed R103, R142, R149, R119, R96, R127, R120, R79, and R109 were on the list for the 100 unit. The Face Sheet dated 8/8/24 for R103 showed diagnoses including mood disorder, dementia, anxiety, schizoaffective disorder, major depressive disorder, and psychosis. The Face Sheet dated 8/8/24 for R142 showed diagnoses including dementia and Alzheimer's disease. The Face Sheet dated 8/8/24 for R149 showed diagnoses including traumatic brain injury, mood disorder, attention deficit hyperactivity disorder, and depressive episodes. The Face Sheet dated 8/8/24 for R119 showed diagnoses including insomnia, anxiety, and dementia. The Face Sheet dated 8/8/24 for R96 showed diagnoses including Alzheimer's disease, anxiety, dementia, and major depressive disorder. The Face Sheet dated 8/8/24 for R127 showed diagnosis including dementia and bipolar disorder. The Face Sheet dated 8/8/24 for R79 showed diagnoses including metabolic encephalopathy, psychotic disorder, dementia, and insomnia. The Face Sheet dated 8/8/24 for R109 showed diagnoses including major depressive disorder, schizophrenia, schizoaffective disorder, and mental disorder. The facility's Hazards policy (7/30/24) showed, It is the facility's policy to ensure the safety of each resident in the building and remove hazardous items and correct situations to prevent accidents. Ensure that residents have no access to medications, sharps, and chemicals that would be hazardous to them.

Based on interview and record review the facility failed to ensure bedtime snacks were offered to residents for 3 of 3 residents (R58, R112, and R526) reviewed for bedtime snacks in the sample of 32 and one resident (R1) outside of the sample. The findings include: R58's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include generalized osteoarthritis, anemia in other chronic diseases, hypothyroidism, hyperlipidemia, and depression. R58's August 2024 Physician Order Sheet showed, 8/5/23 Offer Bedtime Snack. R58's Nutrition-Snacks documentation for the last 30 days was reviewed and showed he was offered a snack two times. R526's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include seizures, dysphagia, Type 2 Diabetes Mellitus, and hypertensive heart disease. R526's August 2024 Physician Order Sheet showed, 7/26/24 Offer Bedtime Snack. R526's Nutrition-Snacks documentation since admission to the facility was reviewed and showed no snacks offered. R112's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include primary generalized osteoarthritis, peripheral vascular diseases, major depressive disorder, and generalized anxiety disorder. R112's August 2024 Physician Order Sheet showed, 1/31/23 Offer Bedtime Snack. R112's Nutrition-Snacks documentation for the last 30 days was reviewed and showed one snack offered. R1's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include hypertensive heart disease without heart failure, hypothyroidism, hyperlipidemia, iron deficiency anemia, Type 2 Diabetes Mellitus without complications, major depressive disorder, and functional quadriplegia. R1's Nutrition-Snacks documentation for the last 30 days was reviewed and showed snacks were offered two times. On 8/7/24 at 10:42 AM, During the resident council meeting, R1, R58, R112, and R526 stated they do not get offered snacks often and they are unsure of where to get them. R1 stated he thinks he has seen snacks at the nurse's station, but staff eat them, so he assumes they are for staff and does not ask for them. On 8/8/24 at 11:11 AM, V11 (Clinical Care Coordinator) stated, Snacks are passed out by the floor staff each night. Not all residents are offered a snack each night, but all of the diabetic residents are offered one. Snack acceptance or refusal is documented under the physician's orders. I think the aides can also document under the tasks in the plan of care but I'm not completely sure. The facility's policy with review date of 7/26/24 showed, Bedtime (HS) Snacks . Policy Statement: The facility will provide the residents bedtime snacks in accordance with the federal regulations. Procedures; 1. The facility must offer snacks at bedtime daily .

Based on observation, interview, and record review, the facility failed to implement contact isolation precautions for a resident (R95) with methicillin-resistant Staphylococcus aureus (MRSA), failed to wear the appropriate personal protective equipment (PPE) for 3 residents (R31, R11, R154) on enhanced barrier precautions, and failed to perform glove changes during incontinence care for 1 resident (R154). These failures apply to 4 of 9 residents reviewed for infection control in the sample of 32. The findings include: 1. R95's electronic face sheet printed on 8/8/24 showed R95 has diagnoses including but not limited to fracture of head and neck of right femur, sepsis, osteomyelitis, pressure ulcer of sacral region, stage 4, flaccid hemiplegia, post laminectomy syndrome, and cord compression. R95's physician's orders dated 8/1/24 showed, Isolation: contact precautions, reason for isolation MRSA sacral wound. R95's care plan dated 4/13/24 showed, (R95) is on isolation. Contact isolation due to MRSA of sacral wound initiate proper precaution. On 8/6/24 at 10:23AM, R95's doorway had a sign showing, Enhanced Barrier Precautions. No sign was located outside of R95's room showing that she is on contact isolation. On 8/8/24 at 10:54AM, R95's doorway continued to only have a sign showing, Enhanced Barrier Precautions. No sign was located outside of R95's room showing that she is on contact isolation. On 8/8/24 at 11:11AM, V12 (Registered Nurse Supervisor) stated, (R95) should be on contact isolation for MRSA in her wound. I'm not sure why the correct sign is not outside of her door. On 8/8/24 at 11:47AM, V3 (Infection Preventionist) stated, (R95) is on contact isolation. I just checked all of the signs earlier this week so I have no idea how she couldn't have the right sign unless someone moved it. If staff aren't wearing the correct PPE in there, then they could potentially spread MRSA. Any resident on enhanced barrier precautions should be cared for with a gown and gloves and if any splashing is expected, staff should be wearing eye protection as well. The facility's policy titled, Infection Prevention and Control revised 7/31/24 showed, The facility has established a policy to Identify, Record, Investigate, Control, Test, and Prevent infections in the facility .8. A sign will be provided outside the room for residents on transmission-based precaution indicating the type of precaution (contact, droplet, EBP) . 2. R31's electronic face sheet printed on 8/8/24 showed R31 has diagnoses including but not limited to multiple sclerosis, pressure ulcer of left buttock unstageable, non-pressure chronic ulcer of right heel and midfoot, major depressive disorder, peripheral vascular disease, and dysphagia. R31's care plan dated 5/28/24 showed, (R31) is on enhanced barrier precautions due to Foley catheter use .change gown and gloves before caring for the next resident, ensure that gown and gloves are used during high-contact resident care activities (like dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, Device care or use for those with central line, urinary catheter, feeding tube, tracheostomy/ventilator, and Wound care for any skin opening requiring a dressing) that provide opportunities for transfer of MDROs (Multi Drug Resistant Organisms) to staff hands and clothing. On 8/6/24 at 10:26AM, R31's doorway had a sign showed, Enhanced Barrier Precautions: Clean hands when entering & leaving room, providers must also wear gown and gloves for the following high contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting w/ toileting. V13 (Certified Nursing Assistant) was in R31's room providing incontinence and catheter care for R31. V13 only wore gloves during R31's care. (No gown was applied at any time during cares). V13 stated R31 was not on any isolation and that she was just on precautions so no personal protective equipment other than gloves is required when caring for her. The facility's policy titled, Enhanced Barrier Precautions revised 7/26/24 showed, The facility will use Enhanced Barrier Precautions (EBP) to reduce transmission of multi-drug resistant organisms in the nursing home. EBP involves the use of gown and gloves to reduce transmission of resistant organisms during high-contact resident care activities for residents known to be colonized or infected with MDRO's as well as residents with wounds and/or indwelling devices. 34891 3. R111's face sheet printed on 8/8/24 showed diagnoses including but not limited to dementia, chronic kidney disease, schizoaffective disorder, traumatic subdural hemorrhage, and obstructive uropathy. R111's August 2024 physician order summary report showed orders start dated 6/17/24 for the use of an indwelling catheter and catheter care to be done on every shift. On 8/6/24 at 1:09 PM, signage was posted outside R111's door showing he was on enhanced barrier precautions. The sign stated gloves and gown must be worn for high-contact resident care activities. The sign listed the activities which included the use of urinary catheters. On 8/7/24 at 1:14 PM, V15 (CNA-Certified Nurse Aide) entered R111's room and donned a pair of gloves. V15 emptied R111's urinary drainage bag, adjusted the leg strap, and emptied the urine into the toilet. V15 did not don a gown at any time during the catheter care. V15 stated he does not wear a gown when he is doing catheter care for any resident. V15 said he only wears a gown if the resident has an open area on the skin. 4. R154's face sheet printed on 8/8/24 showed diagnoses including but not limited to intracerebral hemorrhage, dysphagia, and attention to gastrostomy. R154's August 2024 physician order summary report showed orders start dated 11/9/23 for NPO (nothing by mouth) and the use of a G-tube (gastrostomy tube). R154's facility assessment dated [DATE] showed severe cognitive impairment and always incontinent of urine and bowel. On 8/6/24 at 10:05 AM, signage was posted outside R154's door showing he was on enhanced barrier precautions. The sign stated gloves and gown must be worn for high-contact resident care activities. The sign listed the activities which included the use of feeding tubes (G-tubes). On 8/6/24 at 10:07 AM, this surveyor entered R154's room and V16 (CNA) was in the process of performing incontinence care. V16 wore gloves but no gown. R154 was incontinent of urine and while V16 was removing the wet brief, V4 (CNA) came to the bedside to assist with incontinence care. V4 wore gloves but no gown. R154's groin area, buttocks, and back were cleansed of urine. R154's urine-soaked shirt was removed. V16 continued wearing the urine contaminated gloves to put on a fresh brief and clean shirt. R154's G-tube was touched and adjusted repeatedly with the contaminated gloves during the process. V16 wore the same gloves to lower the bed to the floor, place fall mats down, put on heel protectors, and place a pillow to R154's side. V16 and V4 did not don a gown at any time during cares for R154. On 8/8/24 at 10:15 AM, V2 (Director of Nurses) stated staff should be following the isolation signage outside resident rooms. Any resident on enhanced barrier precautions require staff to wear gloves and a gown during care. That includes residents with catheters and feeding tubes, just as the sign shows. It helps to stop the spread of germs. V2 said gloves need to be changed once they are dirty or soiled. Urine on gloves is considered a type of contamination. Staff need to change gloves before going onto any other areas or touching anything. It is important for stopping the cross contamination of germs. The facility's Incontinent and Perineal Care policy revision dated 7/31/24 states under the procedure section: 6. Wash the perineal area and gently dry after the procedure .8. Remove gloves and dispose to designated plastic bag .9. Put on a new set of clean gloves to put on clean briefs/incontinent pads, to make resident comfortable, groom and change clothing.

Based on observation, interview, and record review the facility failed to ensure physician prescribed medications were administered as ordered for 1 of 2 residents (R1) reviewed for medication administration in the sample of 32. The findings include: R1's face sheet printed on 8/8/24 shows diagnosis including but not limited to neuropathy, heart disease, asthma, schizoaffective disorder, dysphagia, gout, anemia, depression, pancreatitis, diabetes mellitus, and functional quadriplegia. R1's facility assessment dated [DATE] showed no cognitive impairment or memory problems. On 8/6/24 at 11:04 AM, R1 was seated in a wheelchair in his room. Four medication cups were on the bedside table next to him. One cup contained a blue liquid, one contained three capsules, one contained a single blue tablet, and one contained six assorted colored tablets. R1 stated the nurse dropped those off a while ago. They are my 9:00 medicines. I asked her to just leave them. They do it all the time. R1's MAR (medication administration record) was reviewed and showed 12 assorted medications were signed off as been given at his 9:00 AM medication pass. On 8/7/24 at 2:24 PM, V2 (Director of Nurses) stated residents are allowed to take their own medication if they have been assessed to be safe. They need a safety assessment, physician order to leave at bedside, and care plan interventions in place before they can self-administer their own medications. R1's EMAR (electronic medical record) was reviewed, and no documentation of the required forms were found. On 8/8/24 at 10:10 AM, V2 reviewed R1's EMAR and verified the required safety assessment, physician order, and care plan were not present. V2 said they are important to ensure residents can properly manage their own medications. The facility's Self-Administration of Medication policy revision dated 6/6/24 states: 1. The IDT will assign a staff to evaluate resident's ability to safely administer medication. A Self-Administration Evaluation will be filled out to determine capability. A return demonstration will be done to accurately evaluate resident's ability after the health teaching. 2. The resident may store the medication at bedside if there is a physician order to keep it at bedside.

Based on observation, interview, and record review, the facility failed to provide dignity during personal cares for 2 of 2 residents (R31, R97) reviewed for dignity in the sample of 32. The findings include: 1. R31's electronic face sheet printed on 8/8/24 showed R31 has diagnoses including but not limited to multiple sclerosis, pressure ulcer of left buttock unstageable, non-pressure chronic ulcer of right heel and midfoot, major depressive disorder, peripheral vascular disease, and dysphagia. R31's facility assessment dated [DATE] showed R31 has mild cognitive impairment. On 8/6/24 at 10:26AM, V13 (Certified Nursing Assistant) provided incontinence care to R31. R31 was rolled onto her left side with her buttocks uncovered, facing the window. R31's window had clear exposure to the parking lot where people could be seen walking by vehicles within view of R31's window. V13 stated, We don't close her blinds because she doesn't like the dark room. Normally we would but for her we don't. R31 then stated, It bothers me a little bit that my blinds were open because I'm a modest person and I wouldn't want anyone seeing me without clothes on coming to their car. I asked her to close it, but she still left it part way open. On 8/8/24 at 11:11AM, V11 (Clinical Care Coordinator) stated, When staff are providing personal cares for a resident, they should be ensuring that the door, privacy curtain, and window curtains are all closed so there are no opportunities for their privacy to be violated. This would also be a dignity concern as our residents are from a generation where they are very modest. The facility's policy titled, Privacy and Dignity reviewed 6/6/24 showed, It is the facility's policy to ensure that resident's privacy and dignity is respected by the staff at all times .1. During care that requires privacy such as incontinence care, the resident will be placed in bed and the privacy curtain will be drawn to provide full visual privacy. If the privacy curtain is not sufficient to provide full visual privacy, the combination of the privacy curtain and privacy screen will be used .door may also be closed to provide additional layer or privacy during care . 39537 2. On 8/7/24 at 10:46 AM, V8 (Wound Care CNA - Certified Nursing Assistant) and V9 (CNA) were wearing gown and gloves to perform R97's incontinence care. R97 was instructed to roll toward V8. V8 assisted R97 with staying on his right side. R97 was wearing a gown that was open in the back. When R97 was turned, his back, buttock, scrotum and posterior legs were exposed. R97's door was open to the hallway. V7 (Wound Care Coordinator) was outside the door preparing his wound care supplies. At 10:50 AM, V7 entered the room and shut the door. After R97's care was completed, he said he wouldn't want people seeing him like that. R97 said that would be embarrassing. R97's Facesheet printed 8/8/24 showed R97 had diagnoses to include, but no limited to: general muscle wasting and atrophy; dysphagia; lack of coordination; chronic pain; chronic respiratory failure; obstructive sleep apnea; morbid obesity; diabetes; congestive heart failure; peripheral vascular disease; and generalized edema. R97's facility assessment dated [DATE] showed he had moderate cognitive dysfunction and was dependent on staff for rolling left and right. On 8/8/24 at 11:32 AM, V2 (DON - Director of Nursing) said the staff should ensure the door and privacy curtains are pulled to prevent the residents from being exposed. V2 said this is done for resident privacy and dignity. The facility's Incontinent and Perineal Care Policy reviewed 7/31/24 showed, It is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition. Procedures: .2. Provide privacy. Avoid unnecessary exposure of the resident .

Based on observation, interview, and record review, the facility failed to administer oxygen as ordered by a physician for 3 of 4 residents (R34, R95, R519) reviewed for oxygen therapy in the sample of 32. The findings include: 1) R34's electronic face sheet printed on 8/8/24 showed R34 has diagnoses including but not limited to hemiplegia and hemiparesis, chronic respiratory failure, dysphagia, hypertensive heart disease, and heart failure. R34's facility assessment dated [DATE] showed R34 receives oxygen therapy. R34's physician's orders dated 11/23/21 showed, Oxygen at 2L/min (liters per minute) via nasal cannula at bedtime. R34's care plan dated 7/1/19 showed, (R34) is on oxygen therapy related to ineffective gas exchange, heart failure. She is on oxygen continuous on 2L/min (liters per minute) via nasal cannula .give oxygen as ordered by the physician. On 8/6/24 at 10:18AM, R34 was in bed sleeping with her oxygen applied via nasal cannula. The oxygen concentrator was set at 3 liters. On 8/8/24 at 10:57AM, R34 was sitting up in bed with her oxygen cannula laying on her chest (not in her nose) and the oxygen concentrator was set at 3 liters. On 8/8/24 at 11:11AM, V12 (Registered Nurse Supervisor) stated, We do rounds on all of the residents every 2 hours. During those rounds, we should be checking the oxygen concentrators to ensure they are functioning and set at the correct liter flow. R34 cannot change her own liter flow so I'm not sure why it would be set incorrectly. Oxygen should be set per physician's orders for all residents. On 8/8/24 at 11:27AM, V11 (Clinical Care Coordinator) stated, Oxygen should be given as ordered by the physician because that is what has been determined to be therapeutic. If it is discovered during rounds that the oxygen is not set correctly, it should be corrected immediately. The facility's policy titled, Oxygen Therapy and Administration reviewed 6/6/24 showed, Oxygen therapy shall be administered to patients as indicated and upon a physician's order . 2) R95's electronic face sheet printed on 8/8/24 showed R95 has diagnoses including but not limited to fracture of head and neck of right femur, sepsis, osteomyelitis, pressure ulcer of sacral region, stage 4, flaccid hemiplegia, post laminectomy syndrome, and cord compression. R95's physician's orders dated 8/1/24 showed, Oxygen continuous 2L/min via nasal cannula. R95's care plan dated 8/2/24 showed, (R95) has pneumonia-oxygen therapy as ordered. On 8/6/24 at 10:23AM, R95 had her oxygen applied via nasal cannula with her oxygen concentrator set at 4.5 liters. On 8/8/24 at 10:54AM, R95 had her oxygen applied via nasal cannula with her oxygen concentrator set at 4 liters. 3) R519's electronic face sheet printed on 8/8/24 showed R519 has diagnoses including but not limited to metabolic encephalopathy, dysphagia, generalized anxiety disorder, bipolar disorder, hypertensive urgency, and acute respiratory failure. R519's physician's orders dated 7/12/24 showed, Oxygen at 2-3L/min via nasal cannula. R519's care plan dated 7/14/24 showed, (R519) has an altered respiratory status/difficulty breathing related to anxiety and acute respiratory failure .give oxygen as ordered by the physician (oxygen continuous 2-3l/min via nasal cannula). On 8/6/24 at 10:42AM, R519 had her oxygen applied via nasal cannula with her oxygen concentrator set at 4 liters.

Based on interview and record review, the facility failed to obtain weights as ordered by a physician for 1 of 2 residents (R34) reviewed for quality of care in the sample of 32. The findings include: R34's electronic face sheet printed on 8/8/24 showed R34 has diagnoses including but not limited to hemiplegia and hemiparesis, chronic respiratory failure, dysphagia, hypertensive heart disease, and heart failure. R34's physician's orders dated 3/26/21 showed, Weekly weights: monitor for increased edema notify MD for weight gain of 5lbs in a week. R34's monitor record showed R34's weight was not obtained on 7/19/24, 7/28/24, and 8/2/24. R34's care plan dated 4/5/24 showed, Risk for fluctuating weights: (R34) has the following conditions and risk factors that put them at risk for fluctuating weights: diuretic use and diagnosis of heart failure .monitor weights per physician's orders. On 8/8/24 at 11:11AM, V11 (Clinical Care Coordinator) stated, Weights for residents are done on a monthly basis and as ordered by a physician. The nurses can see on the monitoring record when residents are due to be weighed so they can ensure the task is done. It would be especially important to weigh a resident with heart failure to determine if they are retaining fluid or not. The facility's policy titled, Weights reviewed on 6/6/24 showed, It is the facility's policy to obtain residents monthly weight unless otherwise ordered differently by the physician .

Based on Observation, Interview, and Record Review the facility failed to ensure an indwelling urinary catheter drainage bag was not placed on a resident's bed or lifted above the level of the resident's bladder for 1 of 4 residents (R53) reviewed for catheters in the sample of 32. The findings include: On 8/7/24 at 1:52 PM, V4 CNA and V5 CNA went into R53's room to provide catheter care. V5 completed the catheter care and put a clean incontinence pad and incontinence brief under R53. V5 lifted the drainage bag and laid it on R53's bed. V4 picked up the drainage bag, held it up above the level of the resident's bladder as she moved the bag to his left side of the bed and attached it to the side rail. V4 and V5 adjusted the incontinence brief and incontinence pad under part of the resident's bottom. V5 turned R53 towards her. V4 unhooked the drainage bag from the side rail, lifted the drainage bag approximately a foot above the resident's bladder as she passed it over to V5 who attached the bag to his lower right side of the bed. V5 stated the drainage bag shouldn't be placed on the bed for infection control reasons. V4 and V5 both stated the catheter drainage bag should be kept below the level of the bladder. On 8/7/24 at 2:05 PM, V6 LPN (Licensed Practical Nurse) stated the catheter drainage bag should not be on the bed for infection control. The drainage bag should be kept below the level of the bladder otherwise the urine can back up and cause infection. The Face Sheet dated 8/8/24 for R53 showed medical diagnoses including retention of urine, benign prostatic hyperplasia with lower urinary tract symptoms, obstructive and reflux uropathy, urinary tract infection, hypokalemia, muscle wasting, type 2 diabetes mellitus, transient ischemic attack, dementia, and hypertensive heart disease. The Physician Orders dated July 2024 for R53 showed, indwelling catheter, 18 French, 10 cc balloon. Reason for use: due to obstructive and reflux uropathy. The Antibiotic Note dated 7/17/24 for R53 showed he was on amoxicillin 500 mg, three times per day for 10 days due to a urinary tract infection. The Care Plan dated 6/10/24 showed, R53 has indwelling urinary catheter due to obstructive uropathy. No interventions in place for keeping the urinary drainage bag below the level of the bladder. The facility's Indwelling Catheter policy (7/31/24) showed, indwelling catheter bag will always be positioned below the bladder region to prevent backflow if the catheter bag has no anti-backflow valve.

Based on observation, interview and record review the facility failed to ensure a resident with eczema was assessed and treated in a timely manner. This applies to 1 of 6 residents (R1) reviewed for quality of care in the sample of 6. The findings include: On May 14, 2024, at 10:10 AM, R1 was lying in bed. The entire top of her head/scalp was dry with yellow/red crusty scabs. Her hair appeared greasy and/or wet. She stated, They say it's eczema on my head. It's been there for a while. On May 14, 2024, at 10:56 AM, V3 Certified Nursing Assistant (CNA) stated, R1's head has been like that for 2-3 months. They are not doing anything for it. She has been putting A&D ointment on it until R1's friend (V5 power of attorney of financial (POA)) brought her a medicated shampoo. She was washing her hair with regular shampoo, but it was drying it out more. She didn't know what it was on her head. It started off small and has gotten bigger. When she tries to scrape off the crusty scabs, R1 says it hurts so she doesn't scrub it too hard. On May 14, 2024, at 10:58 AM, V5 R1's POA was visiting her. She stated, her head has been like this since December. She showed this surveyor a picture taken on December 13, 2023, of R1's head. It had a small round yellow crusty scab on the top of her head. It was approximately the size of a quarter. (The yellow crusty area now covers the entire top of her scalp/head). There were two red/purple lines on each side of the yellow scab. It looked like scratches. She stated, they told her it was psoriasis. So, she went and bought her a medicated shampoo. R1 had a bottle of [NAME] psoriasis shampoo in her room that was purchased by V5. They have only been putting on ointment (A&D ointment) and using the medicated shampoo V5 bought her last week. V5 also showed this surveyor another picture she took last Thursday (May 9, 2024) of R1's head. R1's head had a thick yellow, red crusty scabs all over the top of her head. On May 14, 2024, at 11:00 AM, V8 Wound Care Nurse and V7 Wound Care Nurse Practitioner (WCNP) were seeing residents in the facility. V8 stated, he didn't know about R1's head until last week when V10 Social Services reported it to him. V7 stated, he first saw R1's head last week on May 8th. He recommended a medicated shampoo (Ketoconazole). V7 stated, he has been seeing her weekly because she has a rash on her back and coccyx. He has not been seeing her for her head/scalp. At 2:15 PM, V7 stated, A&D ointment is a petroleum ointment. He would not recommend that because it acts like a barrier. She needs the medicated shampoo. On May 14, 2024, at 11:10 AM, V9 Registered Nurse (RN) stated, she was the full-time nurse on day shift for R1. She didn't know anything about the eczema on R1's head. She did not see it when she was passing medications this morning. I just thought she had a shower, and her hair was wet. The CNA's will report to the nurses if they see skin alterations. On May 14, 2024, at 1:24 PM, V10 Social Services stated, V6 R1's power of attorney of healthcare called her last week and reported her concerns with R1's scalp/head. She wanted to know if there was a treatment plan and what they were doing for it. R1's electronic medical record does not show anything about eczema until May 12, 2024. R1's progress notes dated May 12, 2024, shows, Updated daughter V5 of R1's scalp eczema and current tx (treatment) plan, daughter states she understands and agrees with plan of care. There is no assessment or description. R1's Minimum Data Set, dated dated dated [DATE], shows, she is cognitively intact. R1's ADL (activities of daily living)- Shower/bathing and skin monitoring task list shows, she had a bed bath on May 4th, 6th & 9th, 2024 with no skin alterations. R1's care plan date-initiated December 21, 2021 shows, Focus: R1 has potential for pressure ulcer development related to Braden score: 12, immobility, L (left) hip fx (fracture), anemia, anxiety d/o (disorder), psychosis, fx of L rib, use of psychotropic, incontinence of bowels and bladder, low air loss mattress weight setting higher than current weight for resident's comfort, L lower back rash, scalp eczema . Interventions: Notify nurse immediately of any new areas of skin breakdown, such as redness, blisters, bruises, discoloration noted during bath or daily care. The facility's skin care regimen and treatment formulary last reviewed January 24, 2024, shows, Policy Statement: It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate treatment for residents with skin breakdown. Procedures: .5. Refer any skin breakdown to the skin care team and physician including wound physician/NP for further review and management as indicated.

Based on interview and record review, the facility failed to provide oxygen therapy according to professional standards for a resident (R1) experiencing low oxygen levels. This applies to 1 of 3 residents reviewed for oxygen therapy in the sample of 4. The findings include: R1's electronic face sheet printed on 1/10/24 showed R1 has diagnoses including but not limited to surgical amputation, chronic respiratory failure with hypoxia, generalized anxiety disorder, peripheral vascular disease, congestive heart failure, and ischemic cardiomyopathy. R1's facility assessment dated [DATE] showed R1 had mild cognitive impairment, respiratory failure, and heart failure. R1's care plan dated 1/2/24 showed, (R1) has an altered respiratory status/difficulty breathing related to chronic respiratory failure .give oxygen as ordered by the physician, elevate head of bed, monitor/document/report abnormal breathing patterns to physician . R1's nursing progress notes dated 1/5/24 showed, This writer was attending to resident's roommate and heard the resident breathing loudly with shallow breaths. Upon investigation, the resident's face was pale and displayed signs of shortness of breath with labored breathing patterns vitals were immediately taken and oxygen saturations fluctuating between 80-82%. R1's local emergency medical services (EMS) run report dated 1/5/24 showed, Upon arrival patient was found lying in bed .in respiratory distress on a non-rebreather at 4LPM (liters per minute) with pulse oximetry reading of 54% .crew increased patient's oxygen to 15LPM .with the increase in oxygen patient's status did improve, patient was more alert and responding to questions . On 1/10/24 at 10:49AM, V7 (Licensed Practical Nurse-LPN) stated, If a resident is found with difficulty breathing, I would immediately check their oxygen levels. If their oxygen levels are dropping, I would place them on a non-rebreather mask at 15LPM. It would not be effective at 4LPM because you're not providing enough oxygen to them. I was the one who placed the mask on (R1) and I'm sure I would have put it on at 15LPM, but I don't see it documented anywhere . (R1's medical record showed no documentation that V7 placed her on 15LPM of oxygen while utilizing the non-rebreather mask) On 1/10/24 at 1:16PM, V11 (Nurse Practitioner) stated, I don't know what the exact number is for a non-rebreather mask, but I know it has to be at least 12LPM to achieve proper oxygenation. The resident should have been placed on the mask, oxygen increased to at least 12LPM and then (V7) should have continuously monitored her oxygen levels until EMS arrived to ensure she was getting enough oxygen and keeping her oxygen saturation levels up. She was at a critical level when they arrived and seemed to improve for a while with the increased oxygen level . On 1/10/24 at 10:34AM, V5 (LPN) stated, If a resident's oxygen levels begin to drop, I would increase their oxygen and then recheck their oxygen saturations. If the levels continue to drop, I would place them on a non-rebreather mask at 12LPM and then recheck the levels again to ensure they are improving. If you put a non-rebreather mask on at 4LPM that's not effective because they aren't going to get the full amount of high flow oxygen that they need to increase their oxygenation. The facility's policy titled, Oxygen Therapy and Administration dated 7/28/23 showed, Oxygen therapy shall be administered to patients as indicated and upon a physician's order .Purpose: To assure adequate oxygenation to all spontaneously breathing and ventilator dependent patient .Non-Rebreather flow rates: 8-12LPM.

Based on observation, interview and record review the facility failed to supervise a resident with dementia and a history of wandering for 1 of 9 residents (R2) reviewed for safety in the sample of 9. The findings include: On 11/1/23 at 9:45 AM, R2 was sitting in a dining room chair sleeping. R2 had dark purple bruises above his left eyebrow, on his left eyelid, and below his left eye. R2 had gauze wrapped around both hands and wrists. V10 Central Supply was sitting next to R2 and said he was asked to sit with R2 today. On 11/1/23 at 9:52 AM, V6 Licensed Practical Nurse said no one really knows what happened to R2's eye, it happened on the weekend. V6 said R2 wanders around the hallway and goes into other residents rooms. V6 said staff usually follows R2 and redirects him. V6 said R2 has had 1:1 observation since he moved down here from the unit upstairs. V6 said R2 ambulates but can't follow commands and is very confused. V6 said when R2 starts roaming around you really have to watch him. V6 said staff are supposed to be with him at all times when the family is not here. On 11/1/23 at 11:10 AM, V1 Administrator said R2's daughter noticed bruises on R2's left eye and hand and notified the nurse. V1 said the nurse was not sure how the bruises happened, and the resident wasn't able to tell her. V1 said the injury happened sometime Saturday morning. V1 said a staff member was assigned to sit with R2 on the evening but V1 was not sure if someone was assigned to monitor R2 on Saturday morning. V1 said we knew from admission reports that R2 needed supervision and extra help. On 11/1/23 at 11:45 AM, V12 Certified Nursing Assistant said he worked on Saturday morning and was providing care to R2's roommate when he saw R2 get up out of bed by himself and walk to the bathroom. V12 said there was no 1:1 person in the room with R2 and the nurses were passing medications in other resident rooms. V12 said he was not sure what happened to R2, but he did notice a red area under R2's eye around breakfast time. On 11/1/23 at 1:30 PM, V1 Administrator said there was no sitter assigned to R2 for 1:1 on Saturday. On 11/1/23 at 1:39 PM, V13 Licensed Practical Nurse (LPN) said she was the nurse on duty Saturday morning, and she was not aware of a person being assigned to be the 1:1 with R2. V13 said staff reported to her, bruising to R2's eye and some bruising to his hand. V13 said she had no idea where the injuries came from. On 11/2/23 at 9:04 AM, V3 LPN said R2 wanders all over the unit. V3 said R2 has been on 1:1 monitoring ever since he moved down to this unit. R2's Progress Note dated 10/28/23 at 7:42 AM, shows R2 slept well the entire night with one and one caregiver, fall precaution observed, will continue to monitor. R2's Change in condition form dated 10/28/23 shows Notified by a staff member, noted bruise on the left eyebrow and above the eyelid, abrasion on the right hand with some bruise. Unwitnessed skin alteration, no fall or no physical altercation noted with other resident.

Based on observation, interview and record review the facility failed to ensure cookware was handled in a sanitary manner. This applies to all 163 residents residing at the facility. The findings include: The Resident Census and Conditions of Residents Form (CMS-672) dated 6/26/23 shows there were 163 residents residing at the facility. On 6/26/23 at 11:52 AM, V9 (Cook) loaded soiled pans into a tray and ran them through the dishwasher. With the same gloves on, V9 took the cleaned pans from the dishwasher rack and placed them on the storage shelf. On 6/27/23 at 2:00 PM, V8 (Dietary Manager) said that gloves should be removed, and hands should be washed after loading dirty dishes and before touching the clean dishes. The facility's undated Dishwashing Machine Use Policy shows, Wash hands before and after running dishwashing machine, and frequently during the process.

Based on observation, interview, and record review the facility failed to ensure resident rooms were clean and homelike for 4 of 32 residents (R23, R45, R88, R138) reviewed for environment in the sample of 32. The findings include: 1. 06/26/23 10:01 AM R45 was sitting in her room in her wheelchair. R45 stated I've been here 5 weeks. I transferred here from another facility because this place had 5 stars. Housekeeping only comes to clean my room every 2-3 days to sweep and mop. There is a hole in the wall in the bathroom and when I asked when it's being fixed, I was told next year. They last cleaned my room on Friday and haven't been here yet today so probably won't come today. I have accidents. Sometimes I can't help my bladder, so the floor gets dirty. This is 5 stars? R45's floor had various debris scattered around the floor, and several sticky spots. R45's bathroom wall, next to the shower wall had paint off, with the drywall cracked and exposed in plain sight when entering the bathroom. On 06/26/23 at 12:55 AM, R45's floor was still dirty. On 06/27/23 at 8:49 AM, R45 said she had not seen housekeeping yet and the debris was still on the floors. 2. On 06/26/23 at 10:55 AM, R138's bathroom had dried stool on the front edge of toilet and there were two spots of stool smeared on the floor. On 06/26/23 11:27 AM, R138 was walking in the hallway back to her room carrying a cloth. R138 said she liked things clean. R138 was alert and oriented to person, place, and time. On 06/26/23 at 02:03 PM, in R138's bathroom, the dried stool remained on the toilet and floor. On 06/27/23 at 08:37 AM, in R138's bathroom, the dried stool remained on the toilet and floor. 3. On 06/26/23 at 10:55 AM, R88 (R138's roommate) shared the bathroom that had dried stool on the edge of toilet in front and on the floor with R138. R88 said she was able to do most things for herself and liked her room clean and organized. R88 was alert, oriented, and answered questions appropriately. 4. On 06/26/23 at 10:14 AM, R23 was in bed sleeping. R23 had large softball size holes in the drywall behind R23's bed. On 06/28/23 at 08:48 AM, V10 Housekeeping said the resident rooms are cleaned every other day. V10 said the bathrooms, floors, tables are cleaned, and the garbage is taken out. V10 said there is 1 housekeeper for the 200 hall and there is no housekeeper after 2:30 PM. On 06/28/23 at 11:07 AM, V11 Housekeeping Director said they are short staffed and only have one housekeeper per unit. V11 said staff is supposed to clean half the rooms in the unit one day and the other half the next day. V11 said staff should clean rooms if needed even if not on the scheduled day. V11 said there is housekeeping staff on weekends that should clean the resident rooms. The facility's General Housekeeping Policy dated 7/28/22 shows facility will ensure that the facility and resident rooms will be clean, orderly, and sanitary through housekeeping services. The housekeeping staff will clean the resident rooms and bathrooms daily using approved sanitizing agents.

Based on observation, interview and record review the facility failed to ensure R162 was provided with incontinent care as directed by her care plan and failed to ensure R50 was positioned and provided with care planned interventions during mealtimes for two of thirty-two residents reviewed for ADL's-Activities of Daily Living. The findings include: On 06/27/23 at 1:19PM, R162 was lying in bed on her back. R162 had a strong smell of urine. V14 CNA-Certified Nursing Assistant turned R162 without the assistance of another staff. R162 yelled out, made facial grimace, and grabbed her left arm when V14 CNA rolled R162 to her right side by himself. V14 CNA removed R162's incontinent brief, it was saturated with urine and loose stool. R162 had redness to her labia, redness to her right medial thigh, and multiple 1-centimeter red circular areas diffusely spread throughout her inner thighs and posterior buttocks. On 06/27/23 at 1:19PM, V14 CNA said, I last changed R162 at 9:00AM, (over 4 hours). On 06/27/23 at 1:34PM, V4 Wound Care Nurse said, R162 was seen by the Wound Nurse Practitioner yesterday for a wound on her abdomen. I was not aware R162 had any other skin issues. This looks like a fungal infection; it can be caused by a variety of things including moisture. R162's MDS-Minimum Data Set, dated dated dated [DATE], shows, Bed Mobility: Extensive Assistance of two-person physical assist. Toilet use: Total dependence-full staff performance every time with two-person physical assist. Urinary Continence: Always incontinent. Bowel Continence: Always incontinent. R162's Current Care Plan on 06/27/23 shows, R162 displays frequent occasional bladder incontinence related to impaired mobility; I will remain free from skin breakdown due to incontinence and brief use; I would like the staff to check me for incontinence episode every 2 hours. The facility's Skin Care Treatment Regimen policy revised 07/28/22 shows, residents who are not able to turn and reposition themselves will be turned and repositioned every 2 hours. 2. On 6/26/23 at 12:30 PM, the head of R50's bed was elevated 30 degrees. R50 was lying on her back with her shoulders and hips flat on the mattress. R50's neck was hyper-flexed with the back of her neck in the crease of the mattress where the head of the bed elevates. R50 said, I usually sit up in bed to eat. R50 attempted to sit-up further in bed but was unable to. R50's meal tray consisted of chicken noodle soup, chicken and biscuit, mashed potatoes, broccoli, and ice cream. R50 did not receive a grilled cheese sandwich with lunch. No staff were present to assist R50 with eating. R50 could not reach the ice cream on her tray that is listed in her Care Plan as an intervention to prevent weight-loss. On 06/27/23 at 2:05PM, V5 Restorative Nurse said, R50 can move from side to side in bed but cannot push herself up in the bed. R50 requires set up and supervision for eating, staff to set up food, ensure correct diet, cut food as needed, and the head of the bed should be elevated 45 to 90 degrees to eat. On 6/28/23 at 10:47 AM, V13 (Registered Dietitian) said, R50 should have received a grilled cheese with lunch on 6/26/23. R50's MDS dated [DATE] shows, R50 requires one-person physical assistance and supervision during meals. R50 requires extensive assistance of one person for bed mobility. R50's Meal Ticket dated 06/26/23 shows, Note: Send: Ice-Cream, Grilled Cheese Sandwich, Soup. (R50 did not receive a grilled cheese sandwich with her lunch tray.) R50's Dietary Notes dated 04/14/23 shows, R50 experienced a 10.2% significant weight loss between October 2022 and April 2023. R50's current Care Plan on 06/26/23 shows, R50 has an ADL self-care performance deficit related to impaired mobility, weakness, and fatigue. Bed Mobility: extensive two staff participation to reposition and turn in bed. Unintended Weight Loss: R50 has the following conditions and risk factors that put her at risk for unintended weight loss. Diagnosis of dementia, bilateral primary osteoarthritis of knee, muscle wasting and atrophy, cognitive communication deficit .History of significant weight loss related to varied oral intake. Body Mass Index low for age. Intervention: Provide ice cream at lunch and dinner, extra sandwich at lunch.

Based on observation, interview and record review the facility failed to assess, identify and provide treatment for an open area on a resident with a history of pressure ulcer and failed to ensure pressure relieving interventions were in place for residents with pressure ulcer injuries and residents who a high risk for developing pressure. This applies to 2 of 5 residents (R98, R147) reviewed for pressure ulcer in the sample of 32. The findings include: 1. R98's face sheet shows he is [AGE] year old male with diagnosis including osteoarthritis of knee, muscle wasting, type 2 diabetes, morbid obesity, peripheral vascular disease and cellulitis of right lower limb. R98's Minimum Data Set assessment dated [DATE] shows his cognition is intact, requires extensive assist with bed mobility and toileting and total dependent with two person assist for transfers. R98's Braden Score dated 6/12/23 shows he is HIGH risk for acquiring pressure wounds. On 6/26/23 at 9:28 AM, R98 was observed lying in bed. He said he has a pressure sore on the back of his right leg from being in bed and new wounds on his groin. He said he has not been out of bed in 10 days. At 9:45 AM V7 (Certified Nursing Assistant-CNA) was providing incontinence care to R98. R98 was soiled with urine. Excoriation and redness were observed to his scrotum and groin. R98 moaned in discomfort while being cleansed he stated, my skin is really sore. An open area was observed under his right gluteal fold with skin discoloration and without a dressing in place. On 6/26/23 at 12:51 PM, R98 remained in bed, a wheelchair was observed in his room without a pressure relieving cushion. He said he would like to get out of bed. His wheelchair does not have a cushion, they lost it. They brought me a different wheelchair because the previous one broke and lost my cushion. On 6/27/23 at 10:43 AM, V4 (Wound Nurse) said R98 has moisture associated skin damage (MASD) on his right posterior thigh, that he was informed of yesterday 6/26/23. R98 has a history of pressure ulcers but did not have MASD prior. He said R98 would like to get out of bed but does not have a pressure relieving cushion. Restorative should know where his cushion is. At 11:33 AM, V4 said his moisture is related to incontinence issues and he should be changed frequently. Staff should report any skin concerns right away. On 6/27/23 at 10:50 AM, R98 was lying in bed, he said he has reported the sore on his bottom several times to the staff. His sore feels better with the dressing on. On 6/27/23 at 11:59 AM, V5 (Restorative Nurse) said he changed R98's wheelchair about a week ago because it was broken. I'm not sure what happened to his cushion, but he should have it. Maybe the cushion was taken with the broken wheelchair. If the staff cannot find the cushion, they should notify nursing. On 6/27/23 at 1:06 PM, V7 (CNA) said R98 is alert and oriented, he is incontinent and should be changed every two hours. He said R98's had skin issues to his bottom. He said he's had that area on his right leg/bottom since last week and he was applying the barrier cream, it's hard to keep him dry. R98's Wound assessment dated [DATE] documents Right Posterior Thigh facility acquired moisture associated skin damage, classification incontinence measuring 0.5 cm (centimeters) x 0.4 cm x 0.10 with new orders, dressing initiated. R98's current care plan shows he has a potential for pressure ulcer development related to high Braden score, edema, morbid obesity, frequent incontinence and limited joint mobility. R98 has a history of right gluteal deep tissue injury with interventions including he requires a wheelchair cushion and low air loss mattress, notify nurse immediately of any new skin breakdowns, such as redness ., turning and repositioning . 35178 2. On 6/26/23 at 10:29 AM, R147's Pressure reduction heel boots were sitting in a chair at the foot of R147's bed. R147's right and left lateral heels were resting on the bed. No off-loading interventions were in place. On 6/27/23 at 9:03 AM, V18 Restorative Aide said, pressure to the heel of the foot is reduced by elevating the feet off the bed with pillows or applying heel protectors. On 6/27/23 at 11:30 AM, R147 was in bed lying on his back. R147's heels were resting on the bed. R147 did not have heel boots or a pillow to off-load pressure from his heels. R147's current Care Plan on 6/26/23 shows, R147 has potential for pressure injury related to assessed as moderate risk (for pressure ulcers), limited joint mobility, incontinent, diabetes, Cerebral Vascular Accident with hemiplegia, anemia, sacral to groin moisture acquired skin disorder, history of a Stage three pressure ulcer. Intervention: Off-loading of bilateral heel when in bed every shift and as needed.

Based on observation, interview and record review the facility failed to ensure aspiration precautions were maintained for a resident with dysphagia, failed to provide thicken liquids and failed to ensure fall interventions were in place for a resident at risk for falls. This applies to 2 of 32 residents (R151, R10) reviewed for safety in the sample of 32. The findings include: 1. On 6/26/23 at 9:21 AM, R151 was observed lying in bed during the breakfast meal. The head of the bed was not positioned upright. It was approximately at a 45 degrees angle. A cup of non-thicken orange juice was on his tray half consumed. A bright colored sign was posted on the wall Aspiration Precautions with instructions to have the head of the bed upright. At 12:55 PM, during the noon meal, R151 was positioned at a 45 degree angle. He was served a mechanical ground tray with regular liquids. R151's diet card on his tray shows a mechanical ground and nectar thicken liquids. On 6/27/23 at 1:06 PM, V7 (Certified Nursing Assistant-CNA) said R151 is a little confused, he can have regular liquids. On 6/28/23 at 9:11 AM, V6 (Speech Therapist) said R151 has moderate to severe dysphagia, he has poor bolus control and aspirates on thin liquids. He was discharged from speech and referred to hospice and is now on a mechanical diet with nectar thick liquids. It is not safe for him to have thin liquids. R151's Physician Order Sheets shows he is an [AGE] year old male with diagnosis including pneumonia, unspecified psychosis, dysphagia oral phase, cognitive communication deficit, and encephalopathy. The P.O.S. shows orders for mechanical soft texture and nectar thick liquids. R151's Barium Swallow Study dated 4/26/23 documents moderate to severe oropharyngeal dysphagia .he is at extremely HIGH RISK of Aspiration due to severe amounts of pharyngeal residue . The report shows the recommendations include strict aspiration precautions, multiple swallows per bite/sip, meds crushed . R151's current care plan and does not show he is at risk for aspiration and does list his precautions in place. 35178 2. On 6/27/23 at 9:15 AM, R10 was sitting in a wheelchair in the dining/activity area. R10 moved his wheelchair from the table then towards the center of the room using his arms and feet. R10 was wearing socks that did not have non-skid soles. On 6/27/23 at 9:16 AM, V21 CNA-Certified Nursing Assistant said, R10 is a fall risk, he does not need non-slip footwear in the wheelchair. On 6/27/23 at 2:05 PM, V5 Restorative Nurse said, R10 is a fall risk. He needs to wear shoes or non-skid socks when up in the wheelchair. R10's Fall Report dated 4/19/23 at 2:25 AM, shows, resident half sitting half lying with head up, on the floor at bedside, leaning on his right arm. R10's Care Plan updated 4/20/23 shows, R10 is high risk for falls, ensure that R10 is wearing appropriate footwear, non-skid shoes/socks, when mobilizing in wheelchair. The facility's Fall Occurrence policy revised 5/17/23 shows, those identified as high risk for falls will be provided fall interventions.

Based on observation, interview and record review the facility failed to ensure perineal care was provided in a manner to prevent infections for a resident with a history of urinary tract infections. This applies to 1 of 9 residents (R98) reviewed for bladder services in the sample of 32. The findings include: 1. On 6/26/23 at 9:45 AM, V7(Certified Nursing Assistant) was providing incontinence care to R98. V7 cleansed R98's penile area from the base towards to the tip of the penis and used the same area of the contaminated wipe cleansing his scrotum and groin. On 6/28/23 at 9:33 AM, V2 (Director of Nursing) said staff should be cleansing the top of the penile area downward to prevent infections and should be using a different area of the wipe for cleansing. R98's face sheet shows he is an [AGE] year old male with diagnosis including morbid obesity, chronic kidney disease with heart failure, congestive heart failure, benign prostatic hyperplasia and history of malignant neoplasm of the bladder. R98's care plan initiated on 6/13/23 shows he has a urinary tract infection with interventions including check at least every two hours for incontinence care. Wash, rinse and dry soiled areas and caregiver teaching should include good hygiene practices. The care plan also shows he is incontinent and would like the staff to check for incontinence care every two hours and requires extensive assist with toileting The Facilities Incontinent and Perineal Care Policy revised 7/2022 states, It is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition maintain clean techniques .

Based on interview and record review, the facility failed to safely transfer 1 of 7 residents (R1) in the sample of 7 reviewed for safety. This failure resulted in R1 sustaining a distal right femur fracture. On 11/3/22 at 9:49 AM, V4, Licensed Practical Nurse (LPN), said on Sunday, 10/23/22 around 3:20 PM, she was doing her charting and R1 was sitting in the dining room. V4 said she noticed R1's leg was not even with her other leg and R1's right leg was also swollen. V4 said she endorsed the findings to the oncoming nurse, V5, Registered Nurse. V4 said R1 is not able to get up by herself, R1 is a two person assist and she does not try getting up by herself and she is not restless. V4 said if R1 had fallen, she would not have been able to get up by herself; she is very heavy, she needs two people to help her. V4 said R1 does not self-propel in her wheelchair. V4 said R1 does not have any behavior issues, she is very mellow. V4 said she does not know how R1 could have injured her leg. On 11/3/22 at 10:28 AM, V9, R1's son-in-law said R1 did not propel herself in her wheelchair. V9 said R1 had two bad knees and could not use them to propel herself. On 11/3/22 at 11:26 AM, V11, Orthopedic Physician Assistant (PA) said R1 came to the emergency room with leg pain; R1 fractured her distal femur. V11 said R1 most likely had some type of trauma to cause her fracture like a fall or a bad transfer. V11 said she does not feel that R1's femur fracture was from her getting her legs stuck under the wheelchair with movement. On 11/3/22 at 12:15 PM, V5, Registered Nurse (RN), said she was R1's nurse from 3:00 PM to 11:00 PM on 10/23/22. V5 said she noticed R1 had redness and swelling on her lower leg which had not been previously reported. V5 said R1 does not try to get up by herself from her bed or wheelchair. V5 said R1 is resistive to care and yells during care and when sitting in the dining room for no reason. V5 said R1 does not propel herself in her wheelchair and if she had fallen, R1 would not have been able to get herself back into bed or her wheelchair by herself. V5 said R1 was a two person assist for transfers. V5 said R1 would pivot transfer with a two person assist from bed to the wheelchair and back. On 11/3/22 at 12:33 PM, V6, Certified Nursing Assistant (CNA), said he was R1's CNA on 10/23/22. V6 said he got her up and dressed that morning and dressed then transferred R1 from her bed to her wheelchair via a one person pivot transfer. V6 said R1 was fine and did not seem to have any pain. V6 said he put R1 back to bed and changed her mid-shift, then later, he alone got her back up to her wheelchair for dinner. V6 said he later put R1 back to bed by himself. V6 said R1's nurse (he did not remember the nurse's name) asked him to come back to R1's room while she assessed R1's leg. V6 said that is when he saw a bruise on R1's upper leg. V6 said he didn't know anything about it. V6 said he is not sure if R1 is a one- person transfer or requires two people. V6 said there is instruction above the resident's headboard which tells the caregiver how the resident transfers. On 11/3/22 at 12:56 PM, V10, CNA said no one told him that R1 had anything going on with her leg. V10 said he got R1 up Monday morning (10/24/22) and R1 was normal. V10 said he transferred R1 from her bed to her wheelchair with a one person pivot transfer using a gait belt. The facility's Daily Staffing Sheet provided by the facility shows V6 was scheduled from 7:00 AM until 11:30 PM on R1's unit on 10/23/22 and V10 was scheduled from 11:00 PM to 7:30 AM on R1's unit on 10/23/22 ending on 10/24/22. On 11/3/22 at 1:11 PM, V1, Administrator, said there is no accident or fall of record for R1. On 11/3/22 at 1:14 PM, V12, CNA, said we know how a resident transfers by looking at the sticker that is above their bed or the POC (Kardex). V12 said therapy does an evaluation and they let us know how to transfer. V12 said you should follow the care plan for safety reasons for the residents and staff. On 11/3/22 at 1:50 PM, V3, Director of Nursing (DON), said R1 is a two person transfer and has always been. V2 said R1 has no history of falls and if she had fallen, she would not be able to get herself back up. R1's Progress Notes show the following documented on 10/23/22 at 5:20 PM .Notice a swelling from her right leg, it's not warm to touch, it's not symmetrical from the other leg. Called her Primary physician and order Venous Doppler in the right Leg STAT. noted and endorsed. R1's Admission Record dated 11/3/22 shows her diagnoses include but are not limited to displaced intertrochanteric fracture of right femur with an onset date of 10/25/22, abnormalities of gait and mobility, history of falling, diabetes and dementia. R1's Minimum Data Set (MDS) dated [DATE] shows her cognitive skills for daily decision making are severely impaired and she requires extensive assistance by two persons with bed mobility, transfers, and toilet use. R1's Physicians Order Review Report dated 11/3/22 shows R1 has an order dated 12/01/21 for Fall Precautions: Due to history of fall. R1's current care plan provided by the facility shows she has cognitive impairment related to a diagnosis of dementia and an ADL (activities of daily living) self-care deficit and requires extensive two assist to turn and reposition in bed, for toileting, and with transferring. R1's care plan shows R1 is noted with combative behavior at times and is high risk for falls. R1's care plan shows she requires staff assistance to be propelled and requires extensive two person assist with surface to surface transfers. The facility's Restorative Nursing Program Policy (last revised 7/28/22) shows, .3. Nursing and Restorative Services may include the following: .a. Ambulation b. Transfer .4. Nursing and restorative services shall be reflected in the resident's individualized care plan consistent to the completion of the resident comprehensive assessment .9. Resident assistance with ADLs will be based on the above functional assessment .

Based on interview and record review the facility failed to assess a resident (R1) with [MEDICAL CONDITIONS] who was exhibiting increased signs of excerbation of [MEDICAL CONDITION]. This failure contributed to a delay in medical intervention, R1's condition continued to decline resulting in hospitalization and subsequently expiring at the hospital. This applies to 1 of 3 residents (R1) reviewed for quality of care in the sample of 3. The findings include: R1's facility's SBAR (Situation, Background, Assessment, Recommendation) Report dated (MONTH) 12, 2109 at 3:46 PM, showed R1 was found by staff to be in respiratory distress and subsequently sent to a local emergency room via emergency medical services (EMS). R1's Emergency Department (ED) Provider Notes dated (MONTH) 12, 2019 showed R1 arrived to local emergency room via EMS in respiratory distress. R1 was intubated and placed on a ventilator. R1's ED Triage Note dated (MONTH) 12, 2019 at 4:02 PM, showed R1 had [MEDICAL CONDITION] to bilateral legs with significant redness/warmth noted upon arrival to the emergency room . R1's hospital History and Physical Exam Report dated (MONTH) 13, 2019 showed R1 had +3 [MEDICAL CONDITION] to his lower extremities with redness and wounds to both lower extremities. R1's hospital Inpatient Discharge Summary printed (MONTH) 3, 2019, showed R1 expired in the hospital on (MONTH) 14, 2019 at 5:15 PM, with discharge [DIAGNOSES REDACTED]. R1's Care Plan dated (MONTH) 5, 2019 showed R1 had [DIAGNOSES REDACTED]. R1's Care Plan showed R1 has potential for shortness of breath and altered fluid balance related to [MEDICAL CONDITION] with interventions including monitor/document/ report to MD (medical doctor) PRN (as needed) any signs or symptoms of [MEDICAL CONDITION]: dependent [MEDICAL CONDITION] of legs and feet . R1's Admission Record printed (MONTH) 4, 2019, showed V4 was the physician for R1. R1's Electronic Medical Record was reviewed and showed the last comprehensive physical examination completed on R1 by a medical professional (physician, nurse practitioner, physician assistant) was (MONTH) 29, (YEAR). On (MONTH) 4, 2019 at 1:30 PM, V3 CNA stated, I am very familiar with (R1). I took care of him a lot after he switched rooms. The last time I cared for him was the last week of (MONTH) (2019). I remember his lower legs were red and swollen then. I didn't report the swelling to anyone because I thought that wasn't anything new for him . On (MONTH) 4, 2019 at 11:30 AM, V5 Licensed Practical Nurse (LPN) stated, I took care of (R1) on (MONTH) 10, 2019. I remember I walked into his room and (R1) was sitting on the side of his bed. Both of his legs were swollen from the knees down to his feet. The skin to his lower legs has stretched and hard to the touch. When V5 LPN was asked if he reported R1's leg swelling to R1's physician, V5 stated, No, I didn't report (R1's) leg swelling because I thought that was normal for him. On (MONTH) 4, 2019 at 9:50 AM, V7 Registered Nurse (RN) stated, I took care of (R1) that day ([DATE]). I usually don't work that floor and I didn't know (R1) real well. I knew he had a history of [REDACTED]. It wasn't until the CNA (Certified Nursing Assistant) came and got me later that afternoon to tell me (R1) was having trouble breathing, that I pulled back the covers of his bed to assess him and found also that both of (R1's) lower legs were red and swollen. V7 RN stated she didn't really do a thorough assessment on R1 on (MONTH) 12, 2019 until after he developed shortness of breath. On (MONTH) 4, 2019 at 11:20 AM, V2 Director of Nursing (DON) stated nurses should be assessing each resident, head to toe, daily, unless a resident refuses the assessment. If a resident refuses the assessment, it should be documented in a progress note. On (MONTH) 4, 2019 at 11:15 AM, V1 Administrator stated R1 had not had a comprehensive examination by a physician since (MONTH) of (YEAR) because he (R1) never had any concerns but I should have called (R1's) physician and reminded him that (R1) needed to be seen. V1 also stated, Any change in a resident's condition, including skin changes, should be reported to the physician immediately. I should have made sure (R1's) physician knew about his leg swelling. On (MONTH) 4, 2019 at 1:00 PM, V4 Physician stated, I have not seen (R1) since (YEAR) because he is no longer under my care. I don't come to that facility. Any resident in a facility should be seen and monitored by a physician or the nurse practitioner at least every three months because of their ongoing medical conditions. This includes routine lab work such as a complete blood count (CBC) and a comprehensive panel (CMP) to look at kidney function. If a resident has a history of [MEDICAL CONDITION], they should probably have a chest X-ray done also. R1's physician orders [REDACTED]. No orders for a CBC, CMP, or chest X-ray for R1 were noted during that time frame. R1's 2019 Skin Check Forms dated (MONTH) 29, (MONTH) 5, (MONTH) 12, and (MONTH) 10, 2019, each showed R1 had [MEDICAL CONDITION] and swelling to his bilateral lower legs.

Based on interview and record review the facility failed to ensure necessary care and services for a resident who was experiencing a decline in her condition. The facility failed to complete and document ongoing assessments, failed to monitor a resident's urine output who was receiving intravenous fluids, and failed to assess a resident after they became unresponsive. These failures contributed to the resident deteriorating and developing Septic Shock, R1 was admitted to the hospital for Septic Shock. R1 expired on [DATE], two days after admission to the hospital. This applies to 1 of 3 residents (R1) reviewed for necessary care and services. The findings include: The Physician order [REDACTED]. The Minimum Data Set assessment dated [DATE] shows R1's cognition is intact, she requires two persons assist for transfers, setup and supervision during meals, and is frequently incontinent. The nurse's notes dated [DATE] at 9:30 PM, documents R1was complaining of not feeling well. Vital signs BP (Blood Pressure) ,[DATE], P (Pulse) 78, R (Respiration) 78, T (Temperature) 100.7, O2 86%RA (Room Air). O2 applied at 2L. R1 was complaining of urinary burning and discomfort. V3 (Nurse Practitioner) was notified with new orders received for a UA & CS (Urinalysis and culture & sensitivity). The nurse's notes dated [DATE] at 6:30 PM, V15 (Registered Nurse-RN) documents R1 is complaining of nausea. Vital signs BP-,[DATE], P-90, R-20, T-101.7, O2 sats 88%RA. O2 applied at 3L (liters). Tylenol given. At 10:15 PM, R1 is alert and verbally responsive. R1 denies pain or discomfort. R1 verbalized she feels better. Temperature 100.1 F. Continue to monitor. The nurse's notes dated (late entry) [DATE] at 8:20 A.M., V9 (,[DATE] AM Nurse) documents received report from V15 to closely monitor resident for any health status changes. At 11:45 PM R1 in her bed, alert, awake and confused. R1 with yellow drool from her mouth. R1's vitals BP ,[DATE], P-95, R-22, Temp- 98.4 and O2 90% 3LNC (Liters per Nasal Cannula). R1 is non-verbal, able to answer questions by nodding her head yes and no. An hour later at (12:45A.M.) R1 has yellow drool from her mouth again. R1 stated, please leave me alone. V9 closely monitored R1 through the remaining of the shift. There is no documentation that R1's physician was notified with R1's change of condition. At 6:00 A.M., R1 is alert, awake and confused. R1 has sunken eyes and pale colored skin. Called and notified V3 (Nurse Practitioner) received orders to start intravenous fluids (IV) and STAT (Immediate) lab orders. Updated day shift nurse about R1's condition and to closely monitor R1. On [DATE] at 10:15 AM, V17 (Laboratory Employee) said the facility staff called and ordered STAT (Immediate) lab orders at 8:54 AM (2 hours and 54 minutes later) after V3 ordered STAT lab orders on [DATE] for R1. The Laboratory report dated [DATE] shows R1's lab results were communicated with V9(LPN) at 1:51 PM. R1's W.B.C. (White Blood Cell) is 31.0 (Critically High). The nurse's notes document on [DATE], at 2:17 P.M. V9 documents R1 is sweating profusely; her skin is warm to the touch. Vitals BP- ,[DATE], P-104, R-18, SpO,[DATE]% at 3LNC, Temp-100.4. R1 allowed staff to feed her. R1 consumed 8oz of juice and dessert. R1's lab results relayed to V3 (N.P.) The nurse's notes on [DATE] at 10:35 P.M., V7 (RN) documents R1 is awake, alert and has intermittent confusion. R1 is weak and pale looking. R1 has a poor appetite. R1's husband here visiting and updated on current condition. Medicated for a Temp of 99.5 The nurse's notes on [DATE] at 8:00 AM, V8 (LPN) documents received R1 awake at 11:00 PM. V8 in and out of R1's room medicating her with IV antibiotics (treatment for [REDACTED]. R1 was alert and responsive to verbal and tactile (touch) stimulation. R1 laying with her head of the bed in a upright position. At 3:30 AM, R1 is unresponsive and unable to arouse. 911 called. The facility's Criteria for Infection Report dated [DATE] shows the date infection was suspected with [DATE] (5 days prior). On [DATE] (R1) complaining of urinary burning, discomfort and general weakness. Urine culture showed no growth. CBC (Complete Blood Count) done on [DATE] and noted critical high WBC of 31. Resident noted continued decline in condition. On [DATE] noted fever of 104.6. Resident suddenly became unresponsive and was sent to the local hospital via 911. The facility's Urinary/Bladder report shows R1 did not have any documented urinary output for (38 hours and 5 minutes) from [DATE] at 2:00 PM until she was transferred to the hospital on [DATE] at 4:05 AM. The Nursing home to Hospital Transfer Form dated [DATE] shows at 3:30 AM, R1's vitals BP-,[DATE], HR-56, R-18, O2 sats 92% 3LNC. There is no documentation of continued assessment or care provided while waiting for EMS to arrive. The Emergency Medical Service (EMS) arrived at the facility at 3:38 AM. On arrival R1 was unresponsive. At 3:43 AM, R1's BP- 90/ (there was no diastolic reading) P-180 (weak), Resp- 24 and 76 % 2LNC. The hospital records dated [DATE] shows on arrival to the emergency department R1 was still unresponsive. Per EMS R1 was [MEDICAL CONDITION] irregular into the 180's. R1 was hypoxic 76% placed on a non-rebreather by EMS. On arrival began to bag the patient intubated. R1 was directly admitted to the ICU (Intensive Care Unit). The ER report showed R1's condition was discussed with V16 (R1's husband) explaining she (R1) is very sick. The hospital medical records showed R1's [DIAGNOSES REDACTED]. The same report showed on [DATE] R1 did not have any urine output after a foley catheter was placed in the hospital. A bladder scan was also performed and showed no urine in the bladder. R1 went into MSOD (Multi symptom organ dysfunction) and expired at the hospital on [DATE]. On [DATE] at 9:09 AM, V9 (LPN) said she was R1's nurse on [DATE]. V9 said R1 was declining at that time. R1 would open her eyes briefly and say a few words and close her eyes again. R1 was weak, lethargic and she was on IV fluids. R1 was not looking good. R1 would normally feed herself, but now needed staff assistance. V9 said she did not assess or monitor R1's urinary output. On [DATE] at 1:35 PM, V15 (RN) said he was R1's nurse on [DATE]. V15 said he was not aware of any changes with R1's urinary output. V15 said staff should monitor a resident's intake and urinary output. V15 said he did not monitor or assess R1's urinary output. On [DATE] at 7:40 AM, V4 (RN) said she was R1's nurse on [DATE]. V4 said she noticed R1 was more sleepy and lethargic. R1 was confused she couldn't remember my name. She had yellow drool on the side of her mouth and was not speaking. I think because she was sleepy. V4 said she called V3 (Nurse Practitioner) on [DATE] V3 ordered IV fluids for R1 and labs. R1 needed to be closely monitored. V4 said she did not know if R1 had any urine output. V4 said she did not assess R1's urine or urinary output. CNA's (Certified Nursing Assistant's) document when a resident voids or changes their incontinent brief. V4 said the staff are expected to monitor a resident's output. On [DATE] at 9:45 AM, V7 (RN) said she was R1's nurse on [DATE] (2nd shift). V7 said R1 stayed in bed during her shift. V16 (R1's husband was visiting). R1had a fever and elevated WBC's (white blood cells). R1 seemed like herself. On [DATE] at 1:00 PM V16 said he visited R1 on [DATE]. R1 had been running fevers over a few days and was having a difficult time breathing. She was wearing oxygen (normally she did not), and she had a change in appetite. R1 was not her normal self. V16 said he questioned the staff about R1's condition a few times. He was told she had an infection. V16 said R1 did complain to him of having right lower abdominal pain.V16 said They (staff) took to long to send her (R1) to the hospital. On [DATE] at 2:05 PM, V8 (LPN) said she was R1's nurse the day she was transferred to the hospital on [DATE]. V8 said it was reported to her by the previous nurse to closely monitor R1 because she had a critical lab value (WBC=31) and she (R1) was running high temperatures. R1 was warm, weak, had a cold compress and moaning. V8 said I was in out of R1's room administering IV antibiotics and IV fluids. V8 said she was not too familiar with R1's baseline. R1 looked clammy and pale and had trouble breathing. At 3:30 AM, R1 became unresponsive and she called 911. V8 said she assessed R1 when she became unresponsive. There is no assessment of R1's condition documented in the medical record. On [DATE] at 10:30 AM, V2 (Director of Nursing) said if a resident has a condition change staff should do an assessment. Staff are not expected to monitor a resident's output unless there is a physician's orders [REDACTED]. R1 had a WBC of 31 indicating an infection that's too high. V2 said with a WBC of 31 she would not expect a resident to be acting like themselves. On [DATE] at 9:30 AM, V3 (Nurse Practitioner) said she could not recall what information was relayed to her regarding R1's condition. V3 said she ordered IV fluids for R1 to keep her hydrated. V3 said she would not expect staff to monitor a residents output who is receiving IV fluids. There is no way to monitor output unless a resident is on a urinary catheter. V3 said she would expect staff to notify her if a resident has no urinary output for greater than 24 hours. On [DATE] at 9:00 AM, V3 said she did not make a visual assessment of R1 when she (R1) started to have changes in her condition. V3 did not assess R1 when her WBC was reported at a crticial high value of WBC-31. V3 said it was the weekend and she does not make rounds during the weekends. On [DATE] at 11:30 AM, V19 (Medical Director) said it is the standard of care and protocol to monitor a residents intake and output who is receiving IV fluids. A WBC count of 31 is pretty high indicating an infection. That high of a count could [MEDICAL CONDITION]. If a resident is showing clinical symptoms (change in mental status, low blood pressure, and critically high WBC count) with elevated WBC count they should be sent to the hospital immediately. According to CDC (Centers for Disease and Control and Prevention)[MEDICAL CONDITION] is the body's extreme response to an infection. It is life-threatening, and without the timely [MEDICAL CONDITION] can rapidly cause tissue damage, organ failure and death. On [DATE] at 2:25 PM, V18 (Hospital Physician) said R1 was very sickwhen she came to the hospital on [DATE]. V18 said he was surprised they kept R1 at the facility on [DATE] (the day she had a critical high WBC of 31) they send residents to the hospital for less acute reasons. V18 said anytime a resident is administered IV fluids it standard of care to monitor their intake and output. R1 might have had a different outcome if things were identified earlier. V18 said R1 expired due to Septic Shock related to a kidney stone normally this is treatable.

Based on observation, interview and record review the facility failed to ensure a resident's safety during a transfer.The facility also failed to ensure that 2 staff members are present when transferring a resident with a mechanical lift. This failure resulted in R1 sustaining a fractured left ankle on 3/16/13. This applies to 1 of 3 residents (R1) reviewed for mechanical lift transfers in a sample of 6. The findings include: The physician's orders [REDACTED]. R1's care plan dated 3/8/12 states, "Transfers with 2 assist. Extensive assist use (mechanical) lift." The facility Occurrence Report dated 3/16/13 states, Injury/Outcome: "Left ankle, mild swelling and redness to left ankle. Complains of pain. Resident verbalized, "It hurts a lot." and noted with facial grimacing." Actions: " Continue to observe; 3/17/13 7:30 AM noted with increased swelling and redness to left ankle." Description of Occurrence: Assigned CNA approached writer that while he was removing (R1's) pants, (R1) complained of left leg pain. Upon assessment when writer touched (R1's) left thigh, (R1) verbalized pain. Writer asked (R1) where exactly the pain was and (R1) stated, "My whole entire left leg hurts.".... Outcome: Further assessment was done on 3/17/13; noted with increased swelling (severe) to left ankle and redness. " On 3/26/13 at 1:00 PM, E3 (CNA) stated, "I came to work and I asked the nurse for report on my people. The nurse didn't know. I asked another CNA (don't know her name) , and she said (R1) was an extensive assist of 1 for transfers.. When I went to get her up before lunch I transferred her with a gait belt into the wheelchair in her room. It seemed to go okay. (R1) had an old skin tear on her leg and it started bleeding so I went and got the (E4 LPN). E4 came in and treated the skin tear. I told (E4) that (R1's ) foot looked strange, it looked twisted. (E4) told me it was fine. Then E4 told me that (R1) is supposed to transfer with a (mechanical lift). (E4) thought that (R1) looked uncomfortable in the wheelchair so (E4) said we would transfer (R1) to the new (reclining) wheelchair that was in her bathroom. You can put a mechanical lift sling under her while she is in the wheelchair but (E4) said we would just transfer (R1) (with a gait belt). I was following the direction of my nurse. (E4) barely assisted with the transfer. I bared most of the weight. We got her into the (reclining) wheelchair and I told (E4) again that her foot looked strange. (E4) said her foot is fine so I believed her. " A written statement by E3 states, "I transferred (R1) from the bed to the wheelchair. I noticed that (R1) had blood dripping from her leg and that her foot appeared to look strange. I asked E4 to come into the room right away. (E3) used some type of treatment to clean up the small little wound. ...(R1)appeared to be uncomfortable in the wheelchair I put her in. (E4) stated that (R1) appeared uncomfortable and (E4) shared with me that (R1) was a (mechanical lift for transfers). (There was no (mechanical lift sling in sight, no mechanical lift sling for (R1). There was no indication to me that (R1) was a (mechanical lift for transfers). (E4) stated that we would transfer (R1) from the wheelchair to the (reclining wheelchair). During the transfer process between me and (E4), I supported most of (R1's ) weight. E4 didn't really help me during the transfer. I struggled to keep (R1) from falling and finally I got (R1) in the (reclining wheelchair). I asked E4 if (R1's) foot was okay because it looked appeared strange.(E4) told me there was nothing wrong with (R1's) foot so I took her word because she is the nurse and I'm the CNA without nursing experience as far as LPN or RN. ....3/17/13 for AM shift. (R1) was sent to the hospital. A few hours later (E5-LPN) asked if I had (R1) yesterday and I told her exactly wheat happened. It was the understanding from E5 that I and E4 had (mechanically lifted) (R1). This is not true at all." The hospital diagnostic X-ray dated 3/17/13 states: "There are fractures seen involving the distal shafts of the tibia and fibula. There is some mild comminution on the fracture fragments and mild impaction without significant displacement or angulation. On 3/26/13 at 9:50 AM, E2 (Director of Nursing) was asked how the CNAs receive information about the residents they are caring for. E2 stated, "Most of the CNAs have a permanent position on a unit. Then we have some float CNAs to cover all units on staff days off. CNAs can get report from the nurse on the unit or from other CNAs on the unit. We have a cardex system but it is not in use right now because it is being revamped. If CNA doesn't know how do care for a resident they should ask another CNA on the unit." On 3/26/13 at 11:30 AM, E6 (CNA) stated, " I replace whoever is off. Sometimes I don't know how to care for a resident so I ask another CNA or the nurse. We just started a new thing that whoever is leaving is responsible for telling whoever is coming in, what is going on. It is not working too well. Sometimes when we come in in the morning the night shift is punching out so we can't get report from them. It depends on the CNA. Some of them don't want to give or get report. " 2. The physician's orders [REDACTED]. R1's care plan dated 3/8/12 states, "Transfers with 2 assist. Extensive assist use (mechanical) lift." On 3/26/13 at 10:50 AM, Z1 (Hospice CNA) transferred R1 with the mechanical lift from the bed to the (reclining wheelchair). No other facility/hospice staff were present during the transfer. Z1 stated, "Sometimes there are two of us. I have to get a CNA from the facility to help." On 3/26/13 at 11:45 AM, E7 (CNA) stated, "You have to have 2 people for the (mechanical lift) transfer. You should never do it alone. So you have a witness in case something happens and also for the safety of the resident." The undated facility policy entitled Mechanical Lifts states, "During the actual lifting and moving of the resident, two staff persons are to be available to assist. Both persons will transfer the resident in accordance with the manufacturer's operating instructions." IL

A. Based on interview and record review the facility failed to to follow their Fall Care Plan intervention for 1 resident (R17) with a skull fracture. This failure resulted in R17 falling again and sustaining a laceration to the back of her head with active bleeding, requiring her to be sent to the emergency room . This is for 1 resident (R17) out of 9 reviewed for falls in the sample of 26. The findings include: R17 was admitted to the facility on [DATE] status [REDACTED]. R17's Care Area Assessment (CAA) Summary triggered for falls due to R17's history of falls, impaired balance during transitions, diuretic use and being in a new environment, according the CAA narrative dated 10/3/11. R17 was assessed to be at moderate risk for falls according to the 9/22/11 fall assessment. R17 required supervision (Oversight, encouragement or cueing) for walking in her room, according to the 9/28/11 MDS. On 10/15/11 at 4:00 AM R17 slipped on water that she had spilled on the bathroom floor and sustained a laceration to the back of her head according to the occurrence report. Prior to the fall R17 was observed to be unsteady and was advised to use the call light to assist with ambulation according to the facility's investigation. R17 was sent to the emergency room and was diagnosed with [REDACTED]. R17 was re-admitted to the facility on [DATE] at 3:39 PM. A bed alarm was ordered and the care plan was updated per the following "10/18/11 bed alarm ordered upon readmit." On 10/19/11 at 3:10 AM R17 fell again according to the nursing notes and occurrence report dated 10/19/11. R17 sustained a laceration to the back of the head with active bleeding and was sent to the emergency room , according to the 10/19/11 nursing notes. The investigation report dated 10/19/11 documents that the bed alarm was not in place. On 11/10/11 at 10:50 AM, E6 (Restorative Nurse) stated that the bed alarm was ordered but was not in place at the time of R17's fall on 10/19/11. E6 said that the bed alarm should have been in place when R17 was re-admitted on [DATE]. E6 said that the order was put in the computer in a manner that did not require the nurse to sign off on the application of the alarm. E6 said that the night nurse (E21) was not aware that R17 had an order for [REDACTED]. The facility's Fall Prevention and Risk Assessment policy and procedure dated 9/1/11 documents "Risk factors and fall prevention measures for individual residents will be documented on the resident's comprehensive care plan and communicated to the direct care staff for implementation" (emphasis added). B. Based on observation and interviews the facility failed to train the staff in the "fire watch" procedures and inform the staff that a "fire watch"was in effect while the fire detection system was being updated. This failure has to potential to affect all 66 residents in the secured unit on the first floor of the facility. The findings include: On 11-7-2011 at approximately 10:00am., E1, (Administrator), provided a roster identifying sixty-six residents residing on the locked unit of the facility. On 11/7/11, during the initial meeting, E1 (Administrator) told the survey team that there were wires being "pulled" into the ceiling. He (E1) further stated that these wires are being "pulled" in order to upgrade the fire detection system in the building. When asked if there was a disruption of service to the existing system, E1 replied no. When further questioned as to whether the facility was on fire watch, E1 said, "No". At 2:45 pm E16 (Maintenance) stated that the secured door which prevents residents from leaving the the 100 wing unit, would unlock in the event that the fire alarm was activated. When tested , this door did not unlock. On 11/7/11, in the facility conference room 3:00pm, with E1 present, Z2 (Supervisor of Fire System Upgrade) stated that while the upgrade work was being done, the audible signal and the door release (for the secured unit) are disabled. He (Z2) added that the work began on 11/1/11 and the crew works from 7:00am to 4:00pm. Z2 further stated that at the end of the working day, the existing fire detection system is restored to full function. At the end of the discussion E1 said that the facility was on a "fire watch" the time the fire detection system was not fully functional. E1 presented the facility's "fire watch" policy and documentation that "fire watches " had been conducted from 11/1/11 - 11/7/11. During interviews on 11/8/11 between 9:00am and 9:15am E22 (RN), E23 (LPN) E24 (RN) and E25(Activity Aide) all stated that they were unaware that the facility was under a fire watch. E25 stated that she had never been trained about the procedures pertaining to a fire watch.. E22 stated that he was unsure as to what a "fire watch" was. All four of these staff members are assigned to work in the 100 unit of the facility. The 100 unit is in the form of of the letter T. The exterior doors are located at the Northeast and Southeast ends of the unit The secured door is located on west end of the unit During the interviews with E22, E23, E24, all stated that there is a staff member assigned to the West Hallway of the unit. This was verified by E25, who stated that her assignment was to monitor activities in the west hallway. At 4:00pm E1 presented the facility's "Fire Watch" policy. The facility's policy includes the IDPH requirements for a "Fire Watch". This document lists the facility's requirements when implementing a Fire Watch". 1) A Prominent Sign shall be posted at nurse's stations and/or staff rooms stating that the fire protection system was not working. On 11/7/11 and 11/8/11 there were no signs posted. 2) A brief inservice for all staff shall be conducted at the beginning of each shift to inform them of the situation and to review fire plan procedures. Staff members E22, E23, E24, and E25 all stated that the had never participated in any inservice about a "Fire Watch" within the last month. 3) .....The facility Administrator shall also notify the local IDPH regional office that a fire watch is being established..... As of 11/8/11 IDPH had not been notified.

Based on observation, record reviews and interviews, the facility failed to provide appropriate staff assistance for safe transfer, failed to assess the usage of mechanical transfer lift device to determine appropriateness when this transfer lift device is to be used and failed to ensure specific interventions in the care plan are in placed to ensure safety transfer for 1 of 3 residents in the sample (R1). The facility also failed to implement the facility's policy for "post fall" by failing to assess R1 immediately after fall prior to moving to avoid causing any possible further injury. These failures resulted in an unsafe transfer that occurred on 4/7/2011 and R1 sustained a right femur fracture. Findings include: Record review showed that R1 is a [AGE] year old with multiple [DIAGNOSES REDACTED]. Incident report dated 04/07/10 at 6:30 A.M. reflect that R1 was assisted by 1 staff (E3-CNA, certified nurse assistant) to the toilet. During this time of assistance, R1's knees "buckled" after standing from the toilet seat. Further review of the report indicated that R1 complained of knee pain and now experienced new difficulty from sit to stand on transfer in which R1 had not have this problem prior to the incident. This report also showed that R1's attending physician was notified with an order for [REDACTED]. Xray was done at the nursing facility and the result showed supracondylar fracture distal femur, right ankle with suspicious faint incomplete fracture of distal fibula. R1's attending physician was notified of the Xray result and had given an order for [REDACTED]. Record showed that R1 was seen by orthopedic doctor on 4/11/2011 at doctor's clinic outside the facility. R1 was directly admitted to the hospital from the orthopedic clinic. R1 was admitted to the hospital with [REDACTED]. R1 was treated at the hospital with pain control and immobilization of the right leg. R1 was returned back to the facility on [DATE] with conservative/palliative treatment as per family's request. R1 was observed on 4/19/2011 at 12:10 P.M. in the 200 unit dining room. R1 was sitting in a reclined wheelchair. R1 was quiet, barely verbally responsive with yes and no answer and was not able to response to questions appropriately. R1 was observed wearing a bandage ace wrap around her right leg and was also placed on a leg immobilizer. When interviewed on 4/19/2011 at 11:00 A.M., E3(CNA-Certified Nursing Assistant) reported she assisted R1 to the toilet by herself on 4/7/2011 at around 6:30 am to 6:45 A.M. E3 also stated that R1 was assisted from sitting position from the toilet seat into a standing position while R1 was holding unto a grab bar next to the toilet. During this process, while R1 was standing holding on the grab bar, E3 was cleansing R1's perineal area. At this time, E3 stated that R1's knees "gave up, buckled and weak" and this resulted to R1's fall. E3 stated that she "eased down (R1)" to the floor. E3 also stated that R1 ended up on the floor with bilateral knees bent and flexed towards R1's chest area. E3 continued to state that when R1 was sitting on the floor, E3 went out of the bathroom to the hallway and summoned for help. E3 also stated that E4 (CNA) was in the hallway and was able to help. As E3 continued to state, both E3 and E4 moved and transferred R1 into the wheelchair by lifting R1's underarms and by using a piece of towel placed under R1's behind knee. E3 also stated that after R1 was placed on a sitting position in a wheelchair, E3 then called E5 (nurse) and informed him of the incident. E3 further stated that R1 complained of pain non specific of origin during the transfer, however, R1 had voiced of an increasing pain into the right knee area few minutes after the incident while R1 was being propelled in a wheelchair to the dining room. E3 further stated that a mechanical standing lift is use on some occasions while R1 is being transferred from sitting to standing/ vice versa and or during toilet needs. E3 also indicated that this mechanical standing lift is used depending on R1's "mood" or level of compliance of care. When interviewed on 4/19/2011 at 2:00 P.M., E4 stated that she had helped E3 transferred R1 from the floor to the wheelchair on 4/7/2011 at around 6:45 A.M. E4 also stated that before the transfer, R1 was found sitting on the floor with bilateral knees bent and flexed towards the chest area. When interviewed on 4/20/2011 at 10:20 A.M., E5 stated that E3 informed him that R1 ended up on the floor while being toileted on 4/7/2011. E5 added that R1 was already sitting in her wheelchair when E5 went to check R1 after being prompted by E3. E5 indicated that R1 had always complained of chronic back pain and shoulder pain, did not see any abnormalities after the fall, however E5 confirmed had not documented any assessment after the fall incident. When interviewed on 4/19/2011 at 2:30 P.M., E6 (restorative nurse) stated that R1's ADL(activities of daily living) had recently shown declined sometimes around March 2011 related to poor endurance and shoulder pain. E6 also stated that R1 was not being walk beginning month of March related to pain on the left arm. As E6 added, prior to fall incident(4/7/2011), R1 needed extensive assistance for transfers, being assisted for transfer using a "pivot transfer " using 1 or 2 person assist depending how tired R1 was during the day and uses the mechanical stand lift during night time as ability to function varies. Review of R1's 2 most recent MDS (Minimum Data Set) dated 3/14/2011 and 12/27/2011, showed that R1 was coded for 3/3 for transfers. This showed that R1 was assessed as needing extensive assistance with 2 person physical assist for transfer needs. Review of recent restorative notes dated 3/17/2011 indicated that R1 has limited range of motion on the left arm/shoulder and has long standing history of bilateral knee joint pain. It was also indicated that these limitations interfere with daily function that risk injury. This notes also indicated that R1's endurance during transfer is poor related to pain and that R1 needed 2 person physical assist for transfer to provide weight bearing support during transfers. Review of care plan showed that there was no specific interventions to ensure safety transfer for R1. It was not indicated how R1 be safely transfer in case her ability to function declined and not in an optimum functioning when it occurs in a moment while in the midst of providing care like toileting needs. Review of record including care plan showed that there was no assessment for the use of mechanical standing lift nor was it addressed in the plan of care when to use this lift in specific circumstances. Review of facility policy for post fall showed that an assessment is indicated immediately post fall and prior to moving the resident /transferring in order to determine any injury or abnormalities and to avoid possible further injury. These concerns were discussed with E1 (administrator) and E2 (Director of Nursing) during the daily status meeting on 4/19/2011 and 4/20/11.