Every finding on record at Avantara Palos Heights

Based on observation, interview, and record review, the facility failed to implement the comprehensive person-centered care plan for 2 of 3 residents (R2, R3) reviewed for skin and wound care. Specifically, facility staff failed to provide incontinence care and skin monitoring as outlined in the residents' established care plans. This resulted in residents remaining in soiled environments for over four hours, directly contradicting the care plan interventions designed to maintain skin integrity and prevent wound contamination.Findings include:R2 is an [AGE] year-old with diagnoses including but not limited to Chronic Obstructive Pulmonary Disease, Pressure Ulcer to left and right hips, back and sacral areas, and Atrial Fibrillation. R2's Care Plan (last reviewed 2/13/26): Includes an intervention to provide incontinence care every two hours and as needed and maintain clean, dry dressings for pressure ulcers.R3 is a [AGE] year-old with diagnoses including but not limited to Multiple Sclerosis, Pressure Ulcer stage 4 to Sacral Region, Major Depressive disorder, and Paraplegia. R3's Care Plan (last reviewed 2/2/26): Includes an intervention to keep skin clean and dry; check and change every two hours to prevent skin breakdown and wound infection.On 3/13/26, between 7:00 AM and 11:45 AM, facility staff failed to execute the interventions listed above for R2 and R3.During an interview on 3/13/26 at 12:10 PM, V5-CNA confirmed awareness of the residents' care needs but stated she did not perform the required incontinence care because she was waiting for the wound team.By failing to perform the specific check and change and hygiene interventions documented in the residents' comprehensive care plans, the facility failed to meet the requirement to implement care in accordance with the residents' person-centered goals and clinical needs.

Based on observation, interview, and record review, the facility failed to ensure that 2 of 3 residents (R2, R3) reviewed for wound care in the sample of 3 received the necessary treatment and services to maintain hygiene and prevent the risk of infection. Specifically, the facility failed to check and change residents for incontinence for over 4 hours, resulting in dried fecal matter remaining on wound dressings prior to treatments. Findings include:R2 is an [AGE] year-old with diagnoses including but not limited to Chronic Obstructive Pulmonary Disease, Pressure Ulcer to left and right hips, back and sacral areas, and Atrial Fibrillation. R3 is a [AGE] year-old with diagnoses including but not limited to Multiple Sclerosis, Pressure Ulcer stage 4 to Sacral Region, Major Depressive disorder, and Paraplegia. On 3/13/26, beginning at 11:40 AM, wound observations were conducted for R2 and R3 by V3 Wound Nurse and V4 Wound CNA. Upon arrival for the scheduled treatments, both residents were observed to have large amounts of dried feces from a previous bowel movement (BM) present on their skin and saturated onto their wound dressings. The fecal matter was noted to be dark and crusty, indicating it had been present for an extended period.On 3/13/26 at 12:10 PM, an interview was conducted with V5-CNA (Certified Nursing Assistant). V5-CNA confirmed she had been assigned to R2 and R3 since the start of her shift at 7:00 AM. V5-CNA stated, I checked in on them, but I didn't change either of them because I knew the wound team was going to see them later. V5-CNA admitted that neither resident had been checked or changed for incontinence since at least 7:00 AM, a duration of approximately 4 hours and 45 minutes.On 3/13/26 at 1:14 PM, the Wound Nurse (V3) confirmed that while R2 and R3 had existing wounds that were showing signs of improvement, the presence of fecal matter on a wound dressing poses a significant risk for bacterial contamination and potential setback in wound healing.A review of the facility's Wound Prevention and Skin Care Policy was conducted. The policy directs staff to provide timely incontinence care to maintain skin integrity and prevent contamination of existing wound sites. The facility failed to follow its own policy and standard nursing practices by withholding basic hygiene care based on the expectation of a later clinical treatment. The facility's failure to provide timely incontinence care for R2 and R3 resulted in a breakdown of standard hygiene protocols. While no immediate deterioration of the wounds was documented, the staff's failure to act created a significant potential for infection and compromised the residents' dignity and quality of care.

Based on interview and record review, the facility failed to immediately initiate chest compressions and call 911 for one full code resident (R1) who was found unresponsive without a pulse. This affected one of three residents (R1) reviewed for CPR. Findings include:Based on interview and record review, the facility failed to immediately initiate chest compressions and call 911 for one full code resident (R1) who was found unresponsive without a pulse. This affected one of three residents (R1) reviewed for CPR. Findings include:R1 was admitted to the facility on [DATE] with a diagnosis of type II diabetes, bradycardia, cerebral infarction, pulmonary hypertension, anemia, chronic respiratory failure, congestive heart failure, obstructive pulmonary disease and sleep apnea.R1's physician orders dated [DATE] document full code.On [DATE] at 7:13AM, V27 (Certified nursing aide, CNA) was assigned to R1 on overnight shift on [DATE]. V27 said around 4:30 she attempted to provide care to R1. V27 said she tried to wake R1 up and was not responding. V27 said she called for the nurse who came and check for pulse but could not find one. V27 said V7 (Nurse) was not sure if R1 was a full code so she went to check and came right back to confirm R1 was a full code. V27 said V7 said she did not know how to call overhead page 'code blue' so V27 went to get the other nurse on the unit. V27 said V26 (Nurse) called the code and went to room to start compressions.On [DATE] at 7:27AM, V25 (Certified nursing aide, CNA) was assigned to R1's unit on 12/30 overnight shift. V25 said she was providing care to a patient when she heard the page for a code blue. V25 said she saw V26 (Nurse) at nursing station. Other nurses came up to the unit from the elevator, V20 (Nurse) and V28 (Nurse) came up to unit asking if anyone called 911. V25 said she saw V7 (Agency nurse) on the phone and V26 went back to the R1's room. V28 told V7 that she needed to call 911 not trace ambulance. V28 called 911.On [DATE] 12:42pm, V26 was assigned to R1's unit on 12/30 overnight shift. V26 said she was in a patient's room on other side of unit when an aide came to tell her there was a code blue. V26 said she overhead paged that there was a code and went to the R1's room. V26 said no one was in the room when she arrived. V26 said she checked R1's pulses with no pulse felt and started compressions. On [DATE] at 9:31AM, V28 who was assigned to first floor on overnight shift 12/30. V28 said she heard the page for code blue. V28 said when she got to R1's unit she called 911 from the facility phone because she wasn't sure if anyone had called. V28 said she doesn't recall if V7 called other ambulance company or 911.On [DATE] at 3:36PM, V31 (MD) said she would expect staff to immediately begin chest compressions upon finding a full code resident without a pulse and unresponsive. V31 said it's important due to time and the sooner you are able to start chest compressions that helps to get the blood pumping back to the patient.On [DATE] at 1:51PM, V2 (Director of nursing) said staff should immediately start chest compressions upon finding a resident a full code resident without a pulse and unresponsive.According to the American heart association, in adult cardiac arrest, resuscitation should generally be conducted where the patient is found, as long as high-quality cardiopulmonary resuscitation (CPR) can be administered safely and effectively. After identifying an adult in cardiac arrest, a lone responder should activate the emergency response system first, then immediately begin CPR. Early, high-quality CPR and prompt defibrillation are the most important interventions associated with improved outcomes in adult cardiac arrest. The fundamental basic life support tasks of recognition of cardiac arrest, activation of emergency response, performance of chest compressions and ventilations, and use of an AED for defibrillation are critical components representing the first links of the Chain of Survival that must be optimized so persons with cardiac arrest can fully benefit from advanced cardiovascular care therapies. Immediate initiation of chest compressions is one of the most impactful interventions for survival from cardiac arrest.Facility code blue policy reviewed [DATE] documents: to maintain a well-coordinated and organized emergency care to a resident at any given time while medical interventions are managed according to the established standard of care. The assigned nurse will initiate the medical emergency interventions for full code status per facility protocol after evaluating the signs and symptoms of cardiac arrest. One staff will lead the team by assigning staff while CPR is in progress. Call 911, notify primary doctor, call family, prepares the transfer forms.Interview attempts with V7 (Agency nurse) were unsuccessful. V7 basic life support card dated [DATE] documents V7 completed American heart association basic life support (CPR and AED) program.

Based on observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that medication was not left at bedside, failed to ensure that medications were not accessible to unauthorized individuals, failed to maintain the medication refrigerator temperature within range, failed to ensure that multidose medication was dated when opened, and failed to discard multi-dose medications as directed for three of 53 residents (R85, R138, R154) in the sample. The facility failed to ensure that (3rd floor) refrigerated medications were stored at the appropriate temperature. This failure has the potential to affect 54 (3rd floor) residents. Findings include: The 9/14/25 (3rd floor) census includes 54 residents. On 9/15/25 at 10:13am, Fluticasone Propionate nasal spray was observed on R154's bedside table. Surveyor inquired if staff keep the nasal spray on the medication cart. R154 responded, They (staff) leave it here. On 9/15/25 at 10:15am, surveyor inquired why R154's nasal spray was left at the bedside. V3 (LPN/Licensed Practical Nurse) stated, It should not be there, usually it's on the cart. On 9/16/25 at approximately 8:55am, a bottle of Aspirin EC (Enteric Coated) 81mg was observed on V15's (Registered Nurse) medication cart which was unattended. V15 returned to the medication cart approximately one minute later. Surveyor inquired why the Aspirin was left on the cart and unattended. V15 responded, I just saw it and affirmed she was getting water for a resident. On 9/17/25 at 9:53am, the 1st floor (east) medication cart was inspected with V15 (RN/Registered Nurse). V15 opened the top drawer, and a yellow gel capsule was observed in a medication cup. Surveyor inquired why the medication was dispensed. V15 stated, Its benzonatate, I (V15) wanted to see if I can give it to another patient.On 9/17/25 at 10:04am, the 1st floor (south) medication cart was inspected with V27 (LPN/Licensed Practical Nurse). A vial of Lantus was observed in the top drawer in a bag which states refrigerate. Surveyor inquired about concerns with the Lantus on the cart. V27 stated, It says it's supposed to be refrigerated. V27 removed (house stock) Acetaminophen suspension from the cart (as requested) which was opened and undated. Surveyor inquired if the Acetaminophen container was dated. V27 responded, No, it's no open date on it. V27 removed (house stock) Multivite suspension from the cart (as requested) which was opened and undated. Surveyor inquired if the Multivite container was dated. V24 replied, It's no open date on here. On 9/17/25 at 12:11pm, the 3rd floor (west) medication cart was inspected with V32 (RN). Resident #138's Timolol ophthalmic solution was noted to be opened and undated. Surveyor inquired if an open date was on R138's Timolol. V32 stated, They (staff) did not put the date. When you open this one (referring to the Timolol), you have to put the date. On 9/17/25 at 12:18pm, the 3rd floor medication room refrigerator was inspected with V32 (RN). The refrigerator temperature log affirms inside temperature was 21 on 9/17/25. Surveyor inquired about the current temperature of the refrigerator. V32 inspected the thermometer and responded, It's 15. Surveyor also affirmed the refrigerator temperature was 15F (Fahrenheit) and within freezing range. Surveyor inquired about the ice buildup in the refrigerator freezer (approximately 4 inches thick). V32 replied, It's a lot. Numerous insulins and suspensions (nystatin, gabapentin Megace, vancomycin) were in the refrigerator at this time. On 9/17/25 at 12;49pm, the 3rd floor (east) medication cart was inspected with V3 (LPN). Surveyor inquired about R85's Dorzolamide ophthalmic solution which was opened and dated 6/17/25 (3 months ago). V3 stated, This one was opened 6/17, we have to discard it. R85's Brimonidine ophthalmic solution was opened and dated 8/9/25 per V3. R85's Latanoprost ophthalmic solution was opened and dated 8/7/25 per V3. Surveyor inquired when ophthalmic solutions should be discarded. V3 responded, Within 30 days after opening. The medication storage, labeling, and disposal policy (revised 7/2/25) states it is the facility's policy to comply with federal regulations in storage, labeling, and disposal of medications. Medications will be secured in locked storage areas. The (undated) administration procedures for all medications stated check expiration date on package/container before administering any medication. When opening a multi-dose container, place the date on the container. The (undated) storage of medication policy states medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medications requiring refrigeration are kept in a refrigerator at temperatures between 36F degrees and 46F with a thermometer to allow temperature monitoring.

Based on observation, interview, and record review, the facility failed to comply with proper food storage and sanitation protocols; failed to ensure residents' food items were dated upon opening; failed to properly contain and cover residents' food after opening; failed to ensure the scoops for bulk food items were stored appropriately; failed to limit storage in the dry food storage room/pantry exclusively to residents' items; and failed to utilize unexpired sanitizing test strips. These deficiencies have the potential to impact the health and safety of all 144 residents residing at the facility.Findings include:Facility census, dated 9/15/2025, documents 144 residents residing at the facility.On 09/15/25 at 9:25am, with V11 (Food Service Director), during observation of the facility's walk-in freezer and refrigerator (connected) the following was observed: An uncovered food cart containing a tray of individual serving containers of applesauce that were not covered; A clear plastic bag, observed opened and lacking a date label, contained beef patties with visible freezer burn; An undated blue bag of sausage crumble was observed with an approximate 3-inch tear in the packaging; and an undated, partially cut tomato wrapped in clear plastic.On 9/15/25 at 9:28am, V11 (Food Service Director) said, No matter how many times I (V11) tell them (staff), they (staff) still don't do things right. Food should be covered and dated in the fridge and freezer to keep the food fresh and not spoiled so the residents don't get sick.On 9/15/25 at 9:32am, with V11 (Food Service Director), during observation of the facility's dry food storage/pantry the following was observed: An uncontained, soiled bulk scoop was observed resting on the shelf adjacent to a bulk item container; Another soiled bulk scoop was observed placed directly on top of a bulk item container, also uncontained; and V17's (Dietary Aide) backpack (last name of V17 observed on backpack) was observed on a wooden tote. On 9/15/25 at 9:32am, V11 said, These scoops shouldn't be left out like this. Too many germs. This (backpack) is an employees. It (V17's backpack) shouldn't be in here. This is just for the resident's food. Employees things shouldn't be with the residents' food cause it (employee's personal items) may be dirty.On 9/16/25 at 11:20am, with V11 (Food Service Director), during observation of the 3 compartment sink and cleaning buckets, the sanitary testing strips were observed to be expired with an expiration date of August 15, 2025. V11 said, I have new ones. Let me get them (sanitary testing strips). Can't use expired strips because the reading might not be right.Facility policy titled, Kitchen, revised date 6/30/25, documents, in part, The facility will comply with state and federal regulations in operating facility's kitchen. Refrigerated food should be covered, dated, labeled, and shelved to allow air circulation. Open containers or potentially hazardous food or leftover should be dated and used within 3-5 days in the refrigerator. scoop handles in bulk items stored in such a way they do not touch bulk item. If the resident rooms have refrigerators, the facility will ensure that the daily temperature is checked to ensure proper temperature.Pamphlet titled, Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities, revised date 11/18, documents, in part, Your facility must provide services to keep your physical and mental health, at their highest practical levels. Your facility must be safe, clean, comfortable, and homelike.Facility job description titled, Cook, updated 12/01/19, documents, in part, In keeping with our organization's goal of improving the lives of the Guests we serve, the [NAME] position is responsible for providing nourishing food to Guests, and employees under sanitary conditions as directed and in accordance with established policies and procedures. The [NAME] will help to assure that the dietary department is maintained in a clean, safe and sanitary manner by providing assistance in all dietary functions and providing supervision to all dietary aides. Assure that established sanitation policies and procedures are followed at all times in accordance with federal, state and local regulations. Assure that equipment, tools and supplies are properly stored at all times. Maintains the comfort, privacy and dignity of Guests and interacts with them in a manner that displays warmth, respect and promotes a caring environment.Facility job description titled, Dietary Aide, updated 12/01/19, documents, in part, . The Dietary Aide will help to assure that the dietary department is maintained in a clean, safe and sanitary manner by providing assistance in all dietary functions as directed and in accordance with established dietary policies and procedures. Bag and store food items as directed. Scrape, wash, and rack unclean dishes and utensils. Sort and stack clean dishes and inspect for cleanliness. Discard waste/trash into proper containers in accordance with established sanitation procedures and guidelines. Assure that equipment, tools and supplies are properly stored at all times.Facility job description titled, Director of Dietary Services, updated 12/01/19, documents, in part, In keeping with our organization's goal of improving the lives of the Guests we serve, the Director of Dietary Services position is responsible for providing nourishing food to guests and employees under sanitary conditions and in accordance with established policies and procedures. Operates the dietary department in a safe and sanitary manner by ensuring compliance with Federal, State, and local regulations and following established policies and procedures. Assure that established infection control and prevention practices and standard precautions are maintained at all times.

Based on observation, interview and record review, the facility failed to ensure that the outside dumpster was closed. These failures have the potential to affect all 144 residents residing at the facility. Findings include:Facility census, dated 9/15/2025, documents 144 residents residing at the facility.On 9/15/2025 at 9:34am, during observation of the external facility dumpster area, accompanied by V11 (Food Service Director), the dumpster was observed left open and contained garbage. V11 acknowledged the issue, stating, The dumpster should be closed, and subsequently closed both covers of the dumpster. V11 further emphasized, It (dumpster) should be closed all the time to keep rodents out.V1's (Administrator) e-mail, dated 9/16/25 at 10:26am, documents, in part, . We do not have a garbage disposal policy.Facility policy titled, Pest Control, revised date 7/3/25, documents, in part, It is the facility's policy to ensure that there is an effective pest control process in the building.Pamphlet titled, Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities, revised date 11/18, documents, in part, Your facility must provide services to keep your physical and mental health, at their highest practical levels. Your facility must be safe, clean, comfortable, and homelike.Facility job description titled, Dietary Aide, updated 12/01/19, documents, in part, . The Dietary Aide will help to assure that the dietary department is maintained in a clean, safe and sanitary manner by providing assistance in all dietary functions as directed and in accordance with established dietary policies and procedures. Discard waste/trash into proper containers in accordance with established sanitation procedures and guidelines. Facility job description titled, Cook, updated 12/01/19, documents, in part, In keeping with our organization's goal of improving the lives of the Guests we serve, the [NAME] position is responsible for providing nourishing food to Guests, and employees under sanitary conditions as directed and in accordance with established policies and procedures. The [NAME] will help to assure that the dietary department is maintained in a clean, safe and sanitary manner by providing assistance in all dietary functions and providing supervision to all dietary aides. Assure that established sanitation policies and procedures are followed at all times in accordance with federal, state and local regulations. Assure that equipment, tools and supplies are properly stored at all times. Maintains the comfort, privacy and dignity of Guests and interacts with them in a manner that displays warmth, respect and promotes a caring environment. Facility job description titled, Director of Dietary Services, updated 12/01/19, documents, in part, In keeping with our organization's goal of improving the lives of the Guests we serve, theDirector of Dietary Services position is responsible for providing nourishing food to guests and employees under sanitary conditions and in accordance with established policies and procedures. Operates the dietary department in a safe and sanitary manner by ensuring compliance with Federal, State, and local regulations and following established policies and procedures. Assure that established infection control and prevention practices and standard precautions are maintained at all times.Facility job description titled, Housekeeper, updated 12/01/19, documents, in part, . In keeping with our organization's goal of improving the lives of the Guests we serve, the Housekeeper plays a critical role in providing superior customer service and housekeeping services to all Guests in the facility. The Housekeeper is responsible maintaining environmental and infection control standards.

Based on observation, interview, and record review the facility failed to follow policy procedures, failed to ensure staff were aware they cannot borrow resident medications to give to other residents, failed to ensure residents were made aware when prescribed medications were not administered, failed to ensure that (over the counter) prescribed medication was purchased/available, and/or failed to ensure that medications were administered within regulatory requirements for four of 53 residents (R61, R85, R119, R154) in the sample.Findings include:R119's (9/16/25) Physician Orders include Guaifenesin-DM (Dextromethorphan) every 6 hours for cough/congestion for 2 days. On 9/15/25 at 8:49am, V15 (Registered Nurse) dispensed R119's medications however Guaifenesin (house stock) was dispensed. Surveyor inquired if Guaifenesin-DM (prescribed medication) was available. V15 searched the medication cart to no avail and replied, No. On 9/16/25 at approximately 11:00am, V2 (Director of Nursing) affirmed that the facility does not have Guaifenesin (expectorant) with DM (cough suppressant) so the Physician was contacted and changed R119's orders to Guaifenesin which is available [The DM was prescribed for R119's cough - per order].__On 9/15/25 at 10:15am, V3 (LPN/Licensed Practical Nurse) reviewed R154's EMAR (Electronic Medication Administration Record) as requested and stated, I haven't given her (R154) meds yet. Surveyor inquired when R154's am medications are scheduled. V3 responded, We do early morning passes at 7:30am and then the window closes at 10:30am (3 hours later). It gives us (staff) until 10:30 before it turns red, that's something new that we (facility) started about a week ago. Surveyor inquired about regulatory requirements for medication administration. V3 replied, We (staff) have the 3-hour gap, they (facility) changed the (EMAR), we have until 10:30am for them (resident's) to receive the medications. Surveyor inquired about the regulatory requirement for medications scheduled for 7:30am administration, V3 stated, Usually it's an hour before and an hour after. Surveyor subsequently requested to see the EMAR for all of V3's assigned residents R61 and R85 were noted to be highlighted red (indicating late administration). Surveyor inquired if R61's medications (scheduled for 7:30am administration) were administered. V3 responded, She (R61) got her blood sugar but not her medication. Surveyor inquired if R85 received medications (scheduled for 7:30am administration). V3 replied, She (R85) got all her medications except the Allopurinol, I have to check the (Electronic Medication Dispenser) for that one. On 9/15/25 at approximately 10:20am, surveyor inquired about the regulatory requirement for medication administration. V4 (Nurse Supervisor) stated, Hour before, hour after. On 9/15/25 at 10:50am, surveyor inquired if medications were administered this morning. R85 stated, Yes, I just take whatever they give me. Surveyor inquired if R85 was told that she did not receive Allopurinol this morning (as prescribed). R85 responded, No. On 9/16/25 at 10:57am, surveyor inquired about the regulatory requirement for medication administration. V2 (Director of Nursing) stated, It's within the hour. The medication pass policy (revised 7/2/25) states it is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures. The (undated) medication administration general guidelines states right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. A triple check of these 5 rights is recommended. Medications are administered in accordance with written orders of the prescriber. Medications are administered within 1 hour before or after scheduled time, except before, with or after meal orders, which are administered based on mealtimes unless specified by the prescriber.The (undated) medication administration general guidelines state medications supplied for one resident are never administered to another resident. If a medication cannot be located, the pharmacy is contacted.

Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to implement care plan interventions, failed to ensure that staff were aware of resident required LALM (Low Air Loss Mattress) settings, failed to ensure that LALM settings were correct while in use, failed to ensure that the LALM device was clean and free of debris, failed to provide a pressure reducing cushion on the wheelchair, failed to ensure that layers of linen were not beneath residents during LALM use, failed to ensure that soiled dressings were changed timely, and failed to ensure that open wounds were covered with a dressing for five of 53 residents (R3, R11, R12, R115, R117) in the sample reviewed for pressure ulcer prevention. Findings include: 1.R11's diagnoses include type II diabetes mellitus, chronic kidney disease/stage 3, and cachexia (muscle wasting). R11's (3/7/25) care plan states resident has unstageable pressure injury to sacrum; intervention apply wound treatment as ordered by the physician. R11's (8/7/25) Physician orders include sacrum: clean with normal saline solution, pat dry, apply collage, and cover with dry dressing daily and as needed. R11's (9/10/25) wound note affirms a (stage 3) sacrum pressure ulcer/injury is present. R11's (9/21/25) functional assessment affirms resident is dependent on staff for toileting hygiene. On 9/15/25 at 11:05am, R11 was wearing an incontinence brief and lying atop of a LALM however a fitted sheet was on the mattress, and a folded sheet (4 additional layers) were beneath the resident. Surveyor inquired what's allowed on the LALM while in use. V4 (Nurse Supervisor) stated, It should be just a sheet. Surveyor inquired how many layers were beneath R11. V4 responded, We (staff) got 5 layers on the low air loss and instructed V5 (Certified Nursing Assistant) to remove the folded sheet. Surveyor inquired about R11's LALM settings (#4). V4 replied, It's on 4 surveyor inquired what 4 indicates. V4 stated, I (V4) would have to talk to the wound care nurse in regard to the setting on the pump and affirmed he was unsure. Surveyor inquired about the dried brown substance observed on R11's LALM device. V4 responded, I can tell you what I see on there, it looks like chocolate pudding to me or maybe a melted candy bar. Surveyor inquired about R11's incontinence care. V5 replied, I (V5) just changed him (R11). Surveyor inquired if R11 has a wound. V5 stated, Yes, his (R11) dressing hasn't been changed yet but I cleaned him and put cream down there. R11's sacrum dressing was soiled with a brown substance and part of the wound was exposed. Surveyor inquired about R11's wound. V4 responded, I see an old opening on his (R11) bottom, it's not covered with a dressing. On 9/17/25 at 9:07am, surveyor inquired what the #4 setting on R11's LALM indicates. V24 (Wound Care Nurse) responded, I'm (V24) really not sure because some of the boxes be different but it should match his (R11) weight. Surveyor inquired who's responsible for setting up the LALM. V24 responded, Maintenance brings the mattress and I wanna say we (Nurses) put the settings on. On 9/17/25 at 10:16am, surveyor inquired what the #4 setting indicates on the LALM. V25 (Certified Wound Care Nurse) stated, We have 2 types one goes off of the weight, and the other is based on the comfort level. I would have to get the manufacturer guidelines that's all I can tell you at the moment. The specialized mattress and appropriate layers of padding policy (revised 7/3/25) states for low air loss mattress, consider 1 fitted or flat sheet on top of the bed, 1 cloth incontinence pad, and/or 1 absorbent brief to absorb fecal and/or urinary incontinence and help with repositioning. The skin care regimen policy (revised 7/3/25) states it is the policy of this facility to ensure prompt identification, documentation, and to obtain appropriate treatment for residents with skin breakdown. On 9/15/25 at 10:25am during observation of residents in the Activity Room, the following were observed: 2. R117 was observed sitting in the wheelchair without pressure relieving cushion/devices. Again at 11:45am, R117 was still in the wheelchair without cushion. At this time, V19 (RN/Registered Nurse/Agency) was notified and stated that she (V19) is the nurse for R117 and would find a cushion for the resident. V19 added the residents should have cushions on the wheelchair to prevent pressure ulcers. 3. R3 was observed on a Low Air Loss Mattress with a weight setting of 280 pounds. R3's weight records dated 9/11/25 shows 172 pounds. 4. R12 was observed on a Low Air Loss Mattress with a weight setting of 140 pounds. R12's weight records dated 9/6/25 shows 92 pounds. 5. R115 was observed on a Low Air Loss Mattress (LALM) with a weight setting of 160 pounds. R115's weight records dated 9/15/25 shows 104 pounds. On 9/15/25 at 11:55am, all 3 residents' LALMs were observed to still be at the same wrong settings. At this time, V18 (Assistant Director of Nursing) was notified. V18 stated that the weight settings of the LALM should be as close to the resident's weight as possible to function properly to prevent pressure ulcers. V18 called V20 (Wound Care Aide) and V20 went in and changed the settings. V18 later presented the facility's document for staff in-service. This document (with several nursing staff signatures) states Check the weight settings on Low Air Loss Mattress; If unsure, ask Manager or Wound Care. R3's Records show the following: Face sheet shows diagnoses which include but are not limited to Multiple Fractures of Right-Side Ribs. POS (Physician Order Sheet) dated 6/11/25 has an order for Low Air Loss Mattress. Pressure Ulcer Risk assessment dated [DATE] shows that R3 is at risk for pressure ulcer. MDS (Minimum Data Status) section M dated 6/10/25 states that R3 is at risk of developing pressure ulcers/injuries and should have pressure-reducing device for wheelchair and bed. Care plan dated 3/19/25 states in part: R3 has an actual impairment to skin integrity. Intervention states to use Low Air Loss Mattress and apply Gel Chair Cushion to wheelchair. R12's records show the following: Face sheet shows diagnoses which include but are not limited to Age-Related Osteoporosis and Fracture of Left Femur. POS dated 9/17/25 has an order for Low Air Loss Mattress. Pressure Ulcer Risk assessment dated [DATE] shows that R12 is at risk for pressure ulcer. MDS section M dated 8/31/25 states that R12 is at risk of developing pressure ulcers/injuries and should have pressure-reducing device for wheelchair and bed.Care plan dated 8/28/25 states in part: R12 has an actual impairment to skin integrity. Intervention states to use Low Air Loss Mattress and apply Gel Chair Cushion to wheelchair. R115's records show the following: Face sheet shows diagnoses which include but are not limited to Right Hip Contusion, and Spina Stenosis. POS (Physician Order Sheet) dated 9/17/25 has an order for Low Air Loss Mattress. Pressure Ulcer Risk assessment dated [DATE] shows that R115 is at risk for pressure ulcer. MDS section M dated 7/6/25 states that R115 at risk of developing pressure ulcers/injuries and should have pressure-reducing device for wheelchair and bed. Care plan dated 9/15/25 states in part: R115 is at risk for impaired skin integrity. Intervention states in part: Apply Gel Chair Cushion to wheelchair. R117's records show the following: Face sheet shows diagnoses which include but are not limited to Gout, Osteoarthritis, Left Heel Pressure Ulcer, and Morbid Obesity. Pressure Ulcer Risk assessment dated [DATE] shows that R117 is at risk for pressure ulcer and has a pressure injury to the left heel. MDS section M dated 8/26/25 states that R117 is at risk of developing pressure ulcers/injuries and should have pressure-reducing device for wheelchair and bed. Care plan dated 1/15/25 states in part: Apply Gel Chair Cushion to wheelchair. Facility's policy titled Skin Care Regimen and Treatment Formulary dated 7/3/25 states in part: It is the policy of this facility to ensure prompt identification, documentation, and to obtain appropriate treatments for residents with skin breakdown. #10C – Prevention: Use of pressure redistribution mattress. Operation Manual for Low Air Loss Mattress machine states that the control knob should be set at the weight of the patient.

Based on observation, interview, and record review the facility failed to follow policy procedures, failed to follow physician orders, failed to ensure that humidification was provided when administering high flow oxygen, failed to date respiratory equipment, and failed to contain respiratory equipment in a bag after use for four of 53 residents (R10, R18, R38, R85) in the sample. Findings include: 1. R85's diagnoses include COPD (Chronic Obstructive Pulmonary Disease). R85's (6/10/25) physician orders include oxygen 3 liters nasal cannula. R85's (7/4/25) BIMS (Brief Interview Mental Status) determined a score of 15 (cognition intact). On 9/15/25 at 10:50am, R85 was wearing a nasal cannula with oxygen set at 4 liters. R85 affirmed she uses 3 liters. R85's oxygen humidifier was empty. R85's nebulizer mask and CPAP (Continuous Positive Airway Pressure) mask were observed sitting on the dresser (uncontained). On 9/15/25 at 11:00am, surveyor inquired about R85's oxygen setting. V3 (Licensed Practical Nurse) inspected the concentrator and stated, She's (R85) up to 4 liters and the bubbler (referring to humidifier) is empty this needs to be changed it's from the 11th. Surveyor inquired if R85's CPAP mask was dated. V3 responded, There's no date on it. Surveyor inquired if R85's nebulizer mask was dated. V3 replied, The neb is dated 9/4 (11 days ago – therefore not discarded within 7 days). Surveyor inquired when nebulizer masks are supposed to be changed. V3 replied, I think weekly. Surveyor inquired if R85's nebulizer mask and/or CPAP mask were contained. V3 stated, No, it should be inside a bag, and they should both be put up. On 9/15/25 at 12:03pm, R85's oxygen humidifier remained empty. Surveyor inquired if R85's bubbler was changed. V3 responded, No, I (V3) haven't had a chance to change it. The respiratory therapy equipment use policy (revised 7/3/25) states it is the facility's policy to ensure that oxygen and nebulizer equipment use is compliant with the acceptable standards of practice. All oxygen equipment including nasal cannula, humidifier, and nebulizer mask will not be reused. Once opened, this equipment will be dated and discarded after 7 days of use, whether used continuously or on a prn (as needed) basis. 2. R10's diagnoses includes but are not limited to morbid obesity and diabetes 2 mellitus. R10's Order Summary Report, dated 9/17/25, documents, in part, Supplemental O2 = 2l by nasal cannula titrate to SPO2 over 94% every 8 hours as needed. On 9/15/25 at 10:53am, R10's oxygen face mask and tubing were observed lying on a white table, unlabeled with a date and not properly contained. 3. R38's diagnoses includes but are not limited to heart failure and chronic kidney disease. R38's care plan, date initiated 1/03/23, documents, in part, Prefers (not to attend group activities/limited group activities) due to: covid 19 restrictions. O2 (oxygen) Need for individualized visit program for stimulation of patient senses and for social contact. with interventions that document, in part, Monitor for sob and the need for O2 (oxygen) notify nurse if in distress and encourage deep breathing exercises, monitor for side effects of psychotropics and for depression and agitation notify nurse if any changes. R38's Order Summary Report, dated 9/17/25, documents, in part, Apply oxygen to keep O2 sat greater than or equal to 90% as needed for hypoxia or SOB (shortness of breath). On 9/15/25 at 10:57am, R38's oxygen nasal cannula and tubing, connected to an oxygen humidifier bottle, were observed lying on the bedside table, not properly contained and lacking a date label. 4. R18's diagnoses includes but are not limited to chronic obstructive pulmonary disease and pneumonia. R18's care plan, date initiated 1/01/25, documents, in part, R18 is at risk for alteration in respiratory functioning related to: COPD (chronic obstructive pulmonary disease) with interventions that document, in part, Administer oxygen and other medications and respiratory treatments as ordered. R18's Order Summary Report, dated 9/17/25, documents, in part, O2 (oxygen) at 2-6L/NC PRN for O2 sat <92%. On 9/15/25 at 10:58am, R18's oxygen face mask and tubing were observed lying on a table, unlabeled with a date and not properly contained. On 9/15/25 at 11:20am, while in R38's room with V2 (Director of Nursing/DON), V2 said, R38's oxygen tubing should be in a bag. I'll (V2) throw it out. Oxygen masks and tubing should be changed weekly. When it (oxygen equipment) is changed the nurse puts a date on it (oxygen equipment), so they (nursing staff) know when to change it (oxygen equipment). When the oxygen masks and tubing aren't in use, they (oxygen equipment) should be kept in a bag. It's (oxygen equipment in a bag when not in use) done for infection control and to prevent cross contamination. Facility policy titled, Oxygen Therapy and Administration, revised date 7/02/25, documents, in part, Oxygen setups should be changed every seven days and as needed if heavy soiling is present. Pamphlet titled, Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities, revised date 11/18, documents, in part, Your facility must provide services to keep your physical and mental health, at their highest practical levels. Your facility must be safe, clean, comfortable, and homelike.

Based on observation, interview, and record review, the facility failed to conduct hand hygiene prior to passing meal trays. This failure has the potential to affect affected four residents (R67, R101, R111, and R129) reviewed for infection control on the sample of 53 residents.Findings include:On 9/15/25 from 12:46pm to 12:54pm, V9 (Activity Aide) was observed preparing and arranging beverages for the residents. On 9/15/25 at 12:54pm, V9 was observed arranging beverages and then retrieving a food tray from the food cart without performing hand hygiene. V9 served the tray to R11, making direct contact with the resident while assisting with meal setup. Without performing hand hygiene, V9 returned to the food cart, retrieved another tray, and served it to R101, again making physical contact while assisting with the meal and cutting the resident's hot dog. V9 continued this pattern by retrieving a tray from the food cart for R129 without performing hand hygiene, served R129 the food tray, cutting the hot dog in half, and placing the R129's hand on the food. V9 then walked back to the food cart, did not perform hand hygiene, retrieved another tray of food from the food cart, walked to the table R67 was at and served R67 the food tray, without hand hygiene and with direct resident contact during meal setup.On 9/17/25 at 9:19am, V2 (Director of Nursing/DON) said, Staff should wash hands or use hand sanitizer between each resident while serving food. V2 affirmed, staff should perform proper hand hygiene between each resident while serving meals to prevent the spread of infection.Facility policy titled, Hand Hygiene, revised date 6/30/25, documents, in part, Hand hygiene is important in controlling infections. Hand Hygiene consists of either hand washing or the use of alcohol gel. The facility will comply with the CDC Guidelines in regards to hand hygiene. Hand Hygiene using alcohol-based hand rub is recommended during the following situations: Before and after direct resident contact. Before and after assisting a resident with meals.Facility policy titled, Infection Prevention and Control, revised date 6/30/25, documents, in part, The facility has established a policy to Identify, Record, Investigate, Control, Test, and Prevent infections in the facility. The facility will also maintain a record of incidents and corrective actions implemented for the identified infection. Hand hygiene will be performed by staff and contracted workers before and after direct patient contact and after each situation that necessitates hand hygiene. Alcohol-based hand rubs or hand washing x 20 seconds will be used. The facility shall comply with infection control recommendations provided by the IDPH or certified local health department. Standard Precaution: . Infection prevention practices include hand hygiene.Facility policy titled, Kitchen, revised date 6/30/25, documents, in part, Staff will wash hands prior to handling food for 15-20 seconds.Pamphlet titled, Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities, revised date 11/18, documents, in part, Your facility must provide services to keep your physical and mental health, at their highest practical levels. Your facility must be safe, clean, comfortable, and homelike.

Based on observation, interview, and record review the facility failed to follow policy procedures and failed to review/revise a comprehensive care plan for one of 53 residents (R64) in the sample reviewed for restorative care. Findings include:R64 was admitted to the facility on [DATE] (almost 2 years ago). The (undated) facility splints/brace/prosthetic log includes R64's name. However R64's comprehensive care plan (received 9/16/25) excludes splints, brace and/or prosthetics. On 9/15/25 at 12:02pm, R64's hands were noted to be severely contracted however splints were not in use. Surveyor inquired if R64 uses hand splints R64 affirmed that she does. On 9/17/25 at 12:27pm, surveyor inquired if R64 uses a restorative device V4 (Restorative Nurse) stated, She (R64) has a left palm protector. Surveyor inquired why R64's restorative device was excluded from the comprehensive care plan (received 9/16/25). V4 responded, It's in there. V4 accessed R64's care plan (via EMR/Electronic Medical Records) which states, I am on a splint program. However, this was not included in the care plan received. Surveyor inquired when R64's splint program was added to the care plan. V4 accessed the history on the EMR (as requested) which affirms this was not initiated until 9/16/25. The care plan policy (revised 6/30/25) states the baseline care plan at minimum should include initial goals based on admission orders, physician orders, dietary orders, and therapy services. After the comprehensive assessment (state/federal required MDS) is completed, the facility will put in place person-centered care plans outlining care for the resident within 7 days. These will be periodically reviewed and revised by a team of qualified person after each assessment.

Based on observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that staff were aware of resident required restorative devices, failed to include restorative devices in the care plan, failed to ensure that required devices were included in facility tasks, and failed to ensure that restorative devices were applied as directed for one of 53 residents (R64) in the sample reviewed for restorative care. Findings include:The (undated) facility splints/brace/prosthetic log (received 9/16/25) includes R64's name however which required restorative device - was excluded.R64's comprehensive care plan (received 9/16/25) excludes splints, brace and/or prosthetics. On 9/15/25 at 12:02pm, R64's hands were noted to be severely contracted however splints were not in use. Surveyor inquired if R64 can move her left fingers (which were in a fixed position - almost touching the palm of her hand), however R64 was unable to do so. Surveyor inquired if R64 can move her right fingers (which were angled towards the lateral side of her hand) she was to move the fingers, however unable to bend the knuckles. Surveyor inquired if R64 receives restorative therapy to maintain range of motion for both hands. R64 stated, I (R64) try to do this myself but lately its (referring to her left fingers) bending down. Surveyor inquired if R64 uses hand splints. R64 responded, I thought I would order another one because I can't find the one, I had. Surveyor inquired if R64 requires hand splints. V3/Licensed Practical Nurse (assigned to R64) responded, I would have to check. On 9/15/25 at 2:13pm, surveyor inquired if R64 requires hand splints. V2 (Director of Nursing) stated, I will have to check, I don't remember. The (9/17/25) Nursing Rehab: assistance with splint or brace removal log (also) excludes R64's name. On 9/17/25 at 12:27pm, surveyor inquired if R64 uses a restorative device. V4 (Restorative Nurse) stated, She (R64) has a left palm protector, we (staff) keep that on and monitor for redness. Surveyor inquired how staff are aware of which residents require restorative devices. V4 responded, It's in the tasks (referring to the EMR/Electronic Medical Records). Surveyor inquired if V4's required restorative device was in the tasks. V4 reviewed R64's EMR and replied, I didn't see it in the tasks. Surveyor inquired why R64's restorative device was also excluded from the comprehensive care plan (received 9/16/25). V4 stated, 'It's in there. V4 accessed R64's care plan (via EMR) which states, I am on a splint program however this was not included in the care plan received. Surveyor inquired when R64's splint program was added to the care plan. V4 accessed the history on the EMR (as requested) which affirms this was not initiated until 9/16/25. R64 was admitted to the facility on [DATE] (almost 2 years ago). The restorative nursing program (revised 7/3/25) states it is the policy of this facility to assess for comprehensive nursing and restorative needs upon admission. Nursing and restorative services may include the following: splint/orthotic management. Nursing and restorative services shall be reflected in the resident's individualized care plan. Restorative programs shall be reflected and indicated in the resident's electronic restorative log in order to document the provision of services and the frequency by the nurses, CNAs (certified nursing assistants), and/or restorative aides.

Based on interview and record review, the facility failed to implement fall prevention measures as indicated on the care plan, failed to ensure bed alarms were in use, and failed to ensure residents received adequate supervision to prevent falls and prevent repeated falls. This failure affected 3 residents (R2, R4, R10) reviewed for falls in a sample of 53 residents. This failure resulted in R2 sustaining radial, ulnar, and femoral fractures due to an unwitnessed fall.1. R4's records show the following: R4 had unwitnessed falls on 9/2/25 and on 9/4/25 and was sent to the hospital for each fall. Face sheet shows diagnoses which include but are not limited to Dementia, History of Falling, Anxiety Disorder, Obesity, Encephalopathy, Gout, Polyosteoarthritis, and Leg Pain. MDS section GG dated 8/13/25 states R4 needs assistance for mobility/functional ability. Care plan dated 9/1/25 states R4 is at risk for falls. Intervention states in part to use bed/chair alarm to alert staff when residents attempt to get out of bed unassisted so staff can assist residents and prevent falls. On 9/17/25 at 12:00pm, V8 (Fall Nurse) was asked why resident's falls were unwitnessed if they have bed/chair alarms and staff were alerted when resident attempts to get out of bed. V8 stated staff try to monitor residents more frequently by constantly rounding, especially for residents with Dementia. 2. R10's diagnoses include fracture of right femur (5/3/25) and right artificial hip joint. R10's (8/27/25) BIMS (Brief Interview Mental Status) states resident is rarely/never understood, inattention and disorganized thinking are present/fluctuate. R10's (8/27/25) functional assessment affirms resident requires substantial/maximal assistance with bed to chair transfers. R10's (5/3/25) care plan states resident is at high risk for falls, interventions bed alarm to alert staff when resident attempts to get out of bed unassisted, so staff can assist resident and prevent falls. (9/2/25) Morning shift staff to get resident up early before breakfast. R10's (9/2/25) fall risk evaluation (post fall) determined a score of 16 (high risk). On 9/15/25 at approximately 11:32am, R10 was lying in bed atop of a bed alarm. Surveyor inquired if R10's bed alarm was working. V3 (Licensed Practical Nurse) responded, It works because its constantly beeping. Surveyor requested V3 remove the bed alarm from beneath R10 to determine if it was working. V3 removed R10's bed alarm (as requested) however it was not sounding - as warranted. V3 stated, It's not beeping then inspected R10's bed alarm device and affirmed It's actually off. On 9/16/25 at approximately 2:30pm, V2 (Director of Nursing) affirmed the facility does not have a policy for bed alarms. On 9/17/25 at 11:50am, surveyor inquired about R10's fall prevention interventions. V8 (Fall Risk Nurse) stated, He does have a bed/chair alarm, he has a visual prompt in his room to use the call light. I know he's like confused and has intellectual disability. Surveyor inquired about R10's (9/2/25) fall. V8 responded, This happened at 7:30am, the Nurse on Duty was doing rounds after report and observed the resident walking towards the foot of the bed and suddenly fell to his knees on top of the bedside floor mat. ( R10) stated he was trying to go to the bathroom, but the CNA (Certified Nursing Assistant) just took him to the bathroom at 7:20am. The doctor ordered x-rays for the bilateral knees and the results came back with no fractures. Surveyor inquired what fall prevention interventions were added to R10's care plan (post fall) to prevent additional falls. V8 replied, We (facility) added for the morning staff to get the resident up in the wheelchair and in the dining room to be monitored however on 9/15/25 at 11:32am R10 was observed lying in bed and R10's care plan excludes monitoring in the dining room – as stated. The fall occurrence policy (revised 6/30/25) states it is the policy of the facility to ensure residents are assessed for risk for falls, interventions are put in place, and interventions are reevaluated and revised as necessary. Those identified as high risk for falls will be provided fall interventions. The interventions will be reevaluated and revised as necessary. 3. On 9/15/2025 at 10:52 AM, observed R2 sitting in a wheelchair in R2's room with V31 (Family Member) at the bedside. R2 was attempted to be interviewed but was unable to answer questioning due to cognitive deficits. V31 (Family Member) stated, You'll have to talk to me, (R2) has dementia and is very impaired mentally. R2 has lost most memories at this point and requires a lot of care and supervision. I don't think the facility has enough staff to supervise (R2), (R2) is constantly getting up if you aren't here with (R2). I spend so much time here (at the facility), this is my (family), I have to take care of (R2). So, I am here all the time trying to keep eyes on (R2) so (R2) doesn't fall again. V31 recalled about a month ago, V31 was visiting in the facility and R2 fell, sustaining a hip fracture. V31 explained V31 was visiting R2 in R2's room for a lot of the day and had left to get R2 ice from the ice machine. When V31 came back, R2 was on the ground in the bathroom and R2's wrist was swollen. The nurse came and checked R2 out and they sent R2 to the ER. The ER diagnosed R2 with wrist and hip fractures. V31 stated, See what I mean? I can't leave (R2) alone here at all; they don't have someone to sit with (R2) and supervise (R2). R2's face sheet documents in part the following diagnoses: unspecified fracture of the right femur, fracture of the left radius, fracture of the left ulna, fracture of the left femur, history of falling, unspecified dementia, polyneuropathy, chronic kidney disease, and type 2 diabetes mellitus. R2's admission assessment (6/17/2025) documents in part R2 was assessed for fall risk and has been determined to be a high risk for falls. R2's minimum data set (8/17/2025) documents in part a brief interview of mental status summary score of 7, indicating R2 has severe cognitive impairment. R2's care plan (6/5/2025) identifies R2 is a high fall risk, has a goal of preventing falls through next review, and has multiple interventions including, but not limited to, a Bed/chair alarm to alert staff if resident gets up, dining room during the day, maximizing time out of bed, visual prompts, educating R2, family/caregivers on safety measures need to be taken to reduce risk of falls, keeping needed items within reach. Additionally, the care plan identifies R2 needs extensive physical assistance with transfers, assist from staff to use the toilet, and is to only ambulate with the therapy team. R2's progress notes document in part on 8/7/2025, R2 had a fall in R2's bathroom. R2 was observed sitting in a wheelchair with a swollen left wrist and decreased range of motion. R2's POA and physician were notified and R2 was sent to the hospital for evaluation. R2 returned to the facility after hospitalization on 8/11/2025. R2's hospital records and physician notes (8/7/2025-8/11/2025) document in part R2 has a history of falls and was brought to the hospital ER on [DATE]. (Family Member) was visiting with the patient on the day of (R2's) fall. Earlier today, patient stood up from (R2's) wheelchair unsupervised and walked to the bathroom while (family member) was busy in adjacent room. By the time (family member) returned to the room (family member) found (R2) on the floor outside of the bathroom. EMS was called and patient was brought to the ED for further evaluation. In the ED, patient was afebrile and hypertensive (175/98) . XR L wrist and forearm with mildly displaced distal radius and ulnar styloid fractures. Moderate tissue swelling. XR L hip and pelvis showed acute mildly impacted subcapital fracture of the left femoral neck. Orthopedic Surgery was placed on consult, and (R2) was admitted for operative repair of new L hip fracture. Upon my interview, (R2) remembers (R2) fell but is unable to provide any further context. Per (family member), (R2) may have hit (R2's) head during the fall. Patient notes 5/10 left hip pain and 5/10 left wrist pain. Pt complains (R2's) L wrist appears swollen and mildly deformed. Pt fell at (R2's) rehab facility on 8/7. Got up from (R2's) wheelchair without supervision and fell on the way back from the bathroom. R2 underwent left femoral neck closed reduction and percutaneous pinning on 8/8/2025 to repair the femoral fracture. On 9/17/2025 at 10:39 AM, V2 (Director of Nursing) affirmed it is the expectation the facility staff follow resident care plans. V2 stated if there is a deviation from the care plan, or not implementing certain interventions, a progress note should be documented to explain why there was a deviation from the care plan. V2 affirmed V2 was familiar with R2. V2 stated R2 has dementia, poor safety awareness, and is a high fall risk. V2 affirmed V2 completed the investigation related to R2's fall on 8/7/2025. V2 recalled from the investigation the fall was unwitnessed and happened in R2's room/bathroom. V2 explained a family member was with R2 and left to go get ice and when the family member returned, R2 was on the ground. R2 was self-ambulating with no one else in the room. After, the family member picked up R2 from the ground, placed R2 in the wheelchair and called for help. The nurse assessed R2 and noted left wrist swelling/decreased range of motion so R2 was sent for evaluation. V2 reviewed R2's progress notes and affirmed R2 has a fall prevention intervention within the care plan to have R2 in the dining room during the daytime. V2 stated based on how the care plan reads, R2 should have been in the dining room during the time of the fall. V2 explained the intervention should say dining room unless if family is visiting. V2 was unsure if V31 was ever educated to not leave R2 alone in the room, educated on when to notify the nurse, or other supervisory measures. V2 affirmed if education was provided, it would be documented within the medical record. Surveyor requested this documentation related to education of V31, and no documentation was received prior to the exit of the survey. On 9/17/2025 at 11:58 AM, V30 (Agency Registered Nurse) affirmed V30 was the staff member assessed R2 after the fall. V30 recalled V30 received a phone call from a family member on the facility line saying R2 had fell. V30 went to the R2's room and R2 was already back in R2's wheelchair. V30 completed a head-to-toe assessment and denied there were any signs of injury to R2's hip. V30 affirmed R2's left wrist was swollen and looked displaced. V30 called V33 (Physician) and sent R2 to the ER. On 9/17/2025 at 12:25 PM, surveyor requested to interview V33 (physician) regarding the incident. V1 (Administrator) affirmed V1 asked V33 to speak with surveyor about the incident, but V33 refused to be interviewed. V1 explained V33 stated V33 cannot participate in any survey activity unless V33's risk management department allows. V33 was unable to be interviewed prior to the exit of the survey. On 9/17/25 at 2:32 pm, surveyor inquired what the potential harm to a confused resident is that has an unwitnessed fall. V29 (Medical Director) stated, You (staff) have to do a thorough evaluation if the person cannot say what's going on. There has to be a thorough assessment of the patient to see if there's any bruising, head pain, or other things. We do imaging studies as needed. If they (resident) hit their head and are on blood thinners, I (V29) would send them out for head CT (Computed Tomography) to check for a bleed. We would implement things like bed/chair alarms, look at their meds. Record review of the facility's HIGH RISK FALL IDENTIFICATION PROGRAM (undated) documents in part, .The High-Risk Fall Identification Program goes beyond the fall risk identification score and identifies the residents in the facility with the highest risk for falling. It is important to remember many residents are at risk for falling and should have care plan interventions accordingly, even if the resident is not on the high-risk identification program. To determine residents appropriate for this program, consider the following: 1. PCC risk evaluation (most recent) a. Low Risk = 7 and below b. High Risk = 8 and above. Preventing a fall may include, but is not limited to: - making sure call light, assistive device and personal items are close to the resident – reminding the resident to ask for assistance – calling for nursing to assist the resident and waiting with them until qualified staff arrive . -providing mobility, toileting and ADL assistance. – Close supervision of high risk residents.

Based on observation, interview, and record review the facility failed to ensure that the enteral feeding pump was functioning properly, failed to follow physician orders, failed to provide enteral nutrition as directed, and failed to prevent weight loss for one of 53 residents (R10) in the sample reviewed for tube feeding management. Findings include:R10's diagnoses include severe protein-calorie malnutrition and gastrostomy status.R10's (5/5/25) care plan includes risk for alteration in nutritional status related to dysphagia, intervention g (gastrostomy) tube feeding as ordered.R10's physician orders include (7/30/25) NPO (nothing by mouth) diet. (8/5/25) Enteral feed order: Jevity 1.2 rate: 75ml (milliliters)/hr (hour) start at 2pm and infuse until 1,500ml formula total volume is reached per day. On 9/15/25 at 11:18am, R10 appeared frail and notably thin. R10's Jevity 1.2cal hung on 9/15 at 9:30am (per container) was set to be infused at 75cc/hr (cubic centimeters/per hour) via pump however the pump was noted to be alarming and 1,000ml (milliliters) remained in the (1,000ml) container. Upon further inspection R10's enteral feeding pump stated, pump has been idle for 10 minutes. Surveyor inquired why R10's enteral feeding was not infusing. V3 (Licensed Practical Nurse) stated, The pump has been having an error we (staff) let the lady in charge of ordering know. I'm (V3) not sure if this pump is new but it keeps beeping and stops, stating it kinks. Surveyor inquired how much Jevity R10 received within in the past hour. V3 accessed the pump and affirmed 0 milliliters was infused. 96ml was infused over 2 hours, 110ml was infused over 3 hours and 182ml was infused over 4 hours - therefore not 75 ml/hr as ordered. Surveyor inquired how much Jevity R10 received over the last 24 hours. V3 affirmed, 1,029ml was infused over 20 hours therefore R10 will not receive 1,500ml within 24 hours - as prescribed. Surveyor inquired if R10 receives oral nutrition. V3 responded, No, he's (R1) NPO.On 08/06/2025, R10 weighed 114.2 pounds. On 09/03/2025, R10 weighed 112.2 pounds which is a -1.75% loss in 1 month. On 06/29/2025, R10 weighed 118.3 pounds. On 09/03/2025, R10 weighed 112.2 pounds which is a -5.16% loss in roughly 2 months. On 9/17/25 at 2:20pm, surveyor inquired if a resident is NPO and receives enteral feedings what may be the cause of weight loss. V29 stated, It depends, we can't just pinpoint one thing, the dietician should have looked at the diet goal and how many calories he (resident) needs in a day to meet the calorie needs. The enteral tube feeding policy (revised 6/30/25) states enteral tube is an avenue of feeding and hydration nutritional support via gastrostomy route. Procedure: Nurse to check in the POS (Physician Order Sheet) / MAR (Medication Administration Record) the order for enteral feeding interventions: feeding formula, type; bolus, continuous, rate, duration.

Based upon observation, interview, and record review the facility failed to follow policy procedures and failed to ensure that prescribed medications were available for one of 5 residents (R119) reviewed for medication administration. Findings include:R119's Physician Order Sheets include (9/16/25) Benzonatate 100mg three times daily for 5 days and Guaifenesin -DM (Dextromethorphan) 100mg/10ml (milliliters) give 10 ml every 6 hours for 2 days.On 9/15/25 at 8:49am, V15 (Registered Nurse) dispensed R119's medications (scheduled for 7:30am administration - per EMAR/Electronic Medical Administration Record) however the prescribed Benzonatate was unavailable. V15 stated, The Benzonatate, that's a new order so I have to call the pharmacy for that. V15 then affirmed that she was prepared to administer the medications however Guaifenesin (house stock) was dispensed. Surveyor inquired if Guaifenesin - DM (prescribed medication) was available V15 searched the medication cart to no avail and replied, No.On 9/17/25 at 9:16am, surveyor inquired who places the order for facility house stock medications. V2 (Director of Nursing) stated, We (Facility) have an ancillary person (V23/Central Supply). Surveyor inquired how V23 knows which medications need to be ordered. V2 responded, They (V23) follow the list. The (undated) central supply list (received 9/17/25) excludes Guaifenesin DM.On 9/17/25 at 9:53am, surveyor inspected the 1st floor (east) medication cart with V15 (Registered Nurse). V15 opened the top drawer, and a yellow gel capsule was observed in a medication cup. Surveyor inquired why the medication was dispensed V15 stated, Its benzonatate, I (V15) wanted to see if I can give it to another patient (R119) to see if I can use it. V15 affirmed the benzonatate was dispensed from R25's medications due to R119's benzonatate not received from the pharmacy. The (undated) medication administration general guidelines state medications supplied for one resident are never administered to another resident. If a medication cannot be located, the pharmacy is contacted.

Based on observation, interview, and record review, the facility failed to follow policy procedures, failed to ensure that prescribed medications were available, failed to ensure that the correct medication was dispensed, and failed to ensure that unauthorized medications were not administered. There were three medication errors out of 25 opportunities, resulting in a 12% medication error rate. Two of five residents (R25, R119) in the medication administration sample were affected. Findings include:R25's (9/8/25) POS (Physician Order Sheets) include Hydrocodone 7.5/325mg (milligrams) tablet every 6 hours as needed for severe pain 7-10.On 9/16/25 at approximately 8:35am, R25 requested pain medication. V15 (RN/Registered Nurse) dispensed Hydrocodone 7.5/325mg then requested R25's pain level. R25 rated current pain level a 4. V15 responded the Hydrocodone is prescribed for pain above 7 (which affirmed V15 was aware), however administered Hydrocodone to R25 (unauthorized). R119's POS includes (9/16/25) Benzonatate 100mg three times daily for cough for 5 days and Guaifenesin -DM (Dextromethorphan) 100mg/10ml (milliliters) give 10 ml every 6 hours for cough/congestion for 2 days.On 9/15/25 at 8:49am, V15 (RN) dispensed R119's medications (scheduled for 7:30am administration - per EMAR/Electronic Medical Administration Record), however the prescribed Benzonatate was unavailable. V15 stated, The Benzonatate, that's a new order so I have to call the pharmacy for that. V15 then affirmed that she was prepared to administer the medications however Guaifenesin was dispensed (incorrect medication). Surveyor inquired about R119's Guaifenesin discrepancy V15 reviewed the EMAR and responded Oh, the combination Dextro? Surveyor inquired if Guaifenesin DM was available. V15 searched the medication cart to no avail and replied, No.The medication pass policy (revised 7/2/25) states it is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures. The (undated) medication administration general guidelines state: right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. A triple check of these 5 rights is recommended. Medications are administered in accordance with written orders of the prescriber. If a medication with a current active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility (other units) are searched, if possible. If medication cannot be located after further investigation, the pharmacy is contacted, or medication removed from the emergency kit.

Based on observation, interview, and record review the facility failed to follow policy procedures and failed to ensure that one of five residents (R25) reviewed for medication administration remained free from significant medication errors. Findings include: R25's (9/8/25) Physician Order Sheet includes Hydrocodone 7.5/325mg tablet every 6 hours as needed (for severe pain 7-10). On 9/16/25 at approximately 8:35am, R25 requested pain medication. V15 (RN/Registered Nurse) dispensed Hydrocodone 7.5/325mg then requested R25's pain level. R25 rated current pain level a 4. V15 responded the Hydrocodone is prescribed for pain above 7 (which affirmed V15 was aware) however administered Hydrocodone to R25 (unauthorized). R25's (September 2025) Medication Administration Record affirms Hydrocodone 7.5/325mg was also administered on 9/9 for pain level 4, on 9/13 for pain level 6, on 9/14 for pain level 5 and on 9/15 for pain level 5 therefore administered 4 additional times - unauthorized. The medication pass policy (revised 7/2/25) states it is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures. The (undated) medication administration general guidelines state medications are administered in accordance with written orders of the prescriber.

Based on observation, interviews and record reviews, the facility failed to implement intervention related to use of bed alarm; and failed to follow manufacturer's recommendation for safety use of reclining chair in preventing fall for one (R1) of three residents reviewed for accidents. This deficiency resulted in R1 who is cognitively impaired fell out of bed and sustained a large bruise on the left side of neck and jaw. Findings include: R1 is a [AGE] year-old, male, originally admitted in the facility on 06/21/23 with diagnoses of Unspecified Dementia, Unspecified Severity, with Psychotic Disturbance; Psychotic Disorder with Delusions due to known Physiological Condition; and Delusional Disorders. R1's MDS (Minimum Data Set) dated 04/23/25 and 06/17/25 documented the following: Sec C - memory problem for short-term and long-term; cognitive skills for daily decision making is severely impaired. Sec GG - dependent on toileting, personal hygiene and mobility Sec J - no falls since admission/entry/reentry or prior assessment R1's fall risk evaluations documented the following: 03/25/25 - 17, high risk 05/12/25 - 17, high risk 06/22/25 - 15, high risk R1's care plans on high risk for falls related to decline in functional status, difficulty maintaining standing position, fatigue, weakness, gait problem, such as unsteady gait, even with mobility aid or personal assistance, slow gait, takes small steps, takes rapid steps, or lurching gait, impulsivity, poor safety awareness, muscle weakness, other dementia, history of falls, potential medication side effects documented the following interventions: Bed/chair alarm to alert staff when resident (R1) attempts to get out of bed unassisted, so staff can assist resident (R1) and prevent falls. Check resident (R1) frequently while in bed I would like to staff to provide me a safe environment: even floors, free from spills and/ or clutter; adequate, glare-free light; a working and reachable call light; the bed in low position at night; side rails as ordered; handrails on walls. (3/25/25) According to incident report dated 05/12/25 at approximately 10 AM, R1 was observed sitting on the floor in front of his reclining chair. R1 was being transferred to the outside patio by the CNA (Certified Nurse Aide). Staff noticed him sitting upright on the floor on his bottom as alarm was sounding. R1 was being transferred by CNA in his reclining chair and fell out of the chair when reclining chair went over the bump of the door threshold. On 06/30/25 at 3:25 PM, V5 (CNA) was asked what happened to R1 on 05/12/25. V5 stated, Around 11:00 AM after breakfast. We were putting residents out to the patio at the time. I was bringing him (R1) outside first. I grabbed the chair's push handle. I positioned myself behind the reclining chair and started to wheel it backwards. I am not tall enough to see what was going on with him while I try to pull the reclining out when the door alarm went off so loud and when I saw him, he was already sitting on the floor. Since the door alarm was so loud, I didn't hear the chair alarm. On 07/01/25 at 1:59 PM, V19 (Licensed Practical Nurse, LPN) was asked regarding R1's fall on 05/12/25. V19 stated, I do know it's towards the end of my shift. Lunch was completed, like 1 or 2 PM. We were going to take residents out of the patio. The CNA (V5) started to take him out. I didn't see him fall. When I turned around, he was on the floor already. I talked to (V2, Director of Nursing) and they reviewed the cameras. I was told that when he was taken out, when she (V5) was pulling him out, he must have grabbed the door and fell. I was there with other staff, but we were attending to other residents, and it was only her (V5) who started taking R1 outside. According to progress notes dated 06/22/25, time stamped 11:04 PM, V18 (Licensed Practical Nurse, LPN) was made aware by V4 (CNA) that R1 had a fall. R1 was observed on the floor mat lying on the right side in a fetal position. He (R1) was unable to give verbal statement. Physical assessment completed. Bowel movement at the time of fall noted. He (R1) is alert with confusion. Neuro assessment completed and log initiated. ROM (range of motion) with all extremities within normal limits. No new skin alteration. Apparent injury is not present. On 06/30/25 at 11:41 AM, R1 was observed in the dining room, attending activities. R1 was sitting in a high reclining chair. A working chair alarm was hanging at the back of his (R1) chair. R1 responded to name calling, alert with confusion. R1 speaks Spanish, was asked on how is he doing and stated he is doing very well. R1 was asked if he had fallen recently but he was unable to answer. A purplish skin discoloration was noticed on the left side of his neck and jaw, which appeared to be a bruise. R1 was asked how he got the bruise, stated I don't know. V15 (Certified Nurse Aide, CNA) was asked regarding R1's bruise. V15 stated she does not know. R1 was also observed trying to get out of his chair. R1 appeared agitated, leaning forward and backwards, attempting to stand up. Around 1:15 PM, he (R1) appeared restless, kept leaning forward with several attempts made to stand up. V15 verbalized that he (R1) gets fidgety when he is wet and needs to get changed. On 06/30/25 at 3:00 PM, incontinence care was provided to R1 by V4 and V15. Prior to putting R1 to bed, the alarm was left in the reclining chair. There was no alarm placed under R1 while in bed. On 06/30/25 at 3:15 PM, V4 was asked regarding R1's fall on 06/22/25. V4 replied, It was around 8:00 PM that I put him to bed. I changed him, he had a bowel movement. Then, I left. Then, around 8:55 PM, I came back to check on him (R1), he was sitting on the mat, his right leg was under the back wheel of his reclining chair. When I saw him, I called the nurse, V18. The nurse assessed him and then use the mechanical lift to put him back to bed. We found out he had bowel movement again. When he is wet or has bowel movement, he gets agitated. Residents are monitored every two hours. He (R1) does not know how to use call light. I was in room (next door), just next door, and providing care. V4 was asked if she heard R1's bed alarm go off. V4 verbalized, I didn't hear any alarm. It's because the batteries were not working. Any staff is responsible to check the alarm to make sure it is properly working. At this time, V4 took the alarm from R1's reclining chair and placed it under his (R1) lower back. The alarm was placed after surveyor asked about alarm. On 07/01/25 at 10:42AM, V18 was interviewed regarding R1's fall incident on 06/22/25. V18 stated, It was towards the end of my afternoon shift. I actually had just came from his room like 40 minutes ago when I checked him (R1), and he was okay. I went back to my desk, 40 minutes after, the CNA (V4) told me that he had a fall. I went in, I assessed him. He was okay. I checked his brief, and he had a bowel movement. His bed alarm didn't go off but when I checked it. It seems like it was working so I asked her (V4) to change the batteries. No bruising, vital signs were checked. I called the eye doctor, the family and supervisor. I did not hear any alarm prior to fall. R1's eye health note dated 06/22/25, time stamped 11:52 PM documented: fall without injury. Patient (R1) is at risk for falls due to the following; recurrent falls, unwitnessed fall. Rolled down to the floor from the bed/recliner. The bed is at the lowest level. Did not hit the head. No skin tears or acute pain. Not on anticoagulation. On exam, no head injury, and no overt physical signs of trauma. No reports of syncope, chest pain, nausea or vomiting. Neuro checks are being performed. Orders: assess pain per protocol; monitor with neuro-checks per facility protocol; fall precautions per facility protocol; notify a clinician of a change in condition; R1's NP (Nurse Practitioner) progress notes dated 06/23/25, time stamped 3:13 PM recorded that he (R1) was seen due to recent fall. Review of systems showed negative bruising, abrasions, skin tears, lacerations and pressure ulcers. Progress notes dated 06/25/25, time stamped 6:57 PM documented a bruise on R1's left side of neck was observed. Skin and Wound note dated 06/26/25, time stamped 1:50 PM recorded: Patient (R1) seen today at request of staff for skin alteration to left face/neck. Exam revealing for ecchymoses in late stages of healing without edema and with overlying skin intact. On 06/30/25 at 3:40 PM, V7 (Family Member) was asked about R1's bruise on the left side of his neck and jaw. V7 verbalized, He had a big bruise on the left side of his neck because of the fall last Sunday, 06/22/25. I was told that he was trying to get up and hit his neck on the chair. On 07/01/25 at 10:55 AM, V8 (Wound Care Nurse) was interviewed regarding R1's bruise on the left side of neck and jaw. V8 verbalized, I was first notified last Thursday, 06/26/25 about his bruise on neck, face and jaw, on his left side. They just wanted us to come and take a look. Bruise is not much about wound care to do something about it in terms of treatment but (V20 Wound Nurse Practitioner, NP) seen R1. We could have not given any details. I know they said that he (R1) had a fall, could be related to that. On 07/01/25 at 11:33AM, V2 (Director of Nursing/Fall Coordinator) was interviewed regarding R1 and falls. V2 stated, He is alert, oriented to self, confuse all the time, He has very advanced Dementia. He is Spanish speaking. He is combative during care and during assistance. The fall incident on 05/12/25 could possibly be prevented by making sure he did not make sudden movements and having another person to supervise during the transport. There were staff present during that time watching other residents. Because of the sudden movements by R1, staff could not get to him right away. The 06/22/25 fall incident happened around 10 PM. They observed him (R1) on the floor mat next to his bed. He (R1) was seen 15 minutes prior to fall. The bed was low, and he was positioned correctly in the center of the bed. He was not sleeping, moves around. He probably woke up, maybe he had a bowel movement and tried to go to the bathroom. There were no injuries at the time as assessed by nurse. The bruise on the neck and jaw could be related to the fall. On 07/01/25 at 12:23 PM, V9 (Nurse Practitioner) was interviewed regarding R1. V9 replied, I have been seeing him more than 3 years now. He uses a reclining chair because he always climbs up from the wheelchair. I was notified with his fall incident on 05/12/25 and saw him on 05/14/25. There was no injury. He had a fall while he was transported to the patio. This fall could be prevented by assisting the patient or making sure resident is secure in the reclining chair. He has a behavior that he appears calm then suddenly become agitated, so staff needs to hold him to prevent him from falling or injuring himself or hurting other staff. I know his behavior, staff knows his behavior also, so staff should anticipate and make sure he won't fall. With the fall incident on 06/22/25, bed alarm is part of the intervention and staff make sure it is functioning. The bruise on the left side of his neck/jaw might be from the fall. On 07/03/25 at 9:54 AM, V20 was interviewed regarding R1's bruise. V20 stated, I saw him on 06/26/25 for the bruise on left face/neck/jawline. There was ecchymosis and discoloration of yellow, purple and green indicating late stages of healing for a bruise. Looks like it's been there for a couple of days. He had a fall Sunday, 06/22/25, the bruise could be related to the fall, possibly related to fall because of the appearance of the bruise when I did the assessment. There was no edema, generally caused by hitting onto something which could be related to fall. Facility just have to follow their fall protocol. Facility's policy titled Fall Occurrence dated 7/26/24 stated in part but not limited to the following: Policy Statement: It is the policy of the 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. R1's (Name of reclining chair) Operating Manual, documented in part but not limited to the following: 2 Safety Requirements 2.5 Hazards 2.5.6 Unintended Movement - Danger of Falling or Collision We recommend (name of reclining chair) chairs for indoor use within a long-term care institution and where there is not enough slope to cause the chairs to move unaided. Chairs used where the surface is uneven or sloped are at risk of unintended movement and could become a serious danger to the resident, caregiver (s) or a third party. We recommend that (name of reclining chair) chairs are located away from stairwells, elevators, and exterior doorways within a long-term care institution. Outdoor use is appropriate only under the strict supervision and full attention of a caregiver who is physically capable of preventing any unintended movement over any surfaces that are to be traveled on. We recommend that a second caregiver assist when the chair is moved over surfaces that could cause significant unintended movement.

Based on observation, interviews and record reviews, the facility failed to follow their policy related to incontinence and perineal care for one (R1) of three residents reviewed for incontinence care. This failure resulted in R1 developing incontinence associated dermatitis (IAD) on the scrotal area. Findings include: R1 is a [AGE] year-old male, admitted in the facility on 09/26/24, with diagnoses of: Unspecified Dementia, Anemia, Acute Kidney Failure, Benign Prostatic Hyperplasia, and History of Cerebral Infarction. According to R1's MDS (Minimum Data Set) dated 06/17/25, R1's BIMS was not conducted due to R1's severe cognitive impairment. According to Section GG, R1 is dependent on staff for eating, toileting and hygiene, toilet transfer, mobility. Section H indicated that R1 is always incontinent of urine, and frequently incontinent of bowel. On 06/30/25 at 11:41am, R1 was sitting in the reclining chair in front of the dining table. Alert, not interviewable. Activity on-going, however R1 doesn't appear to participate. Chair alarm and star symbol were attached to the reclining chair. R1 was observed leaning forward and touching the table. On 06/30/25 at 12:48pm, surveyor observed R1 in the same location and position at the dining table. Surveyor observed R1 mumbling Spanish words. On 06/30/25 at 1:10pm, R1 remains sitting at the same area in the dining room. At 1:15pm, before R1 had his lunch, V5 (Certified Nurse Aide, CNA) and V15 (CNA) brought R1 to the washroom which is located at the corner of the dining room area. Surveyor observed the changing process in the washroom. V5 put anti-skid socks on R1, then using the standing lift, both V5 and V15 were instructing R1 to stand up, to which R1 was not able to follow. R1 was having difficulty standing up. Attempt to transfer to toilet, and brief changing was not done. V15 brought R1 back to the dining table to have lunch, without his brief checked and changed. When V5 and V15 were asked by this surveyor as to when R1 was changed last, they said when R1 got up this morning around 8:00am. On 06/30/25 at 2:59pm, V5 and V15 brought R1 to his room to check and change R1's brief in bed. V5 and V15 pivot transferred R1 from reclining chair to the bed with scooped mattress. Brief was completely soaked with urine and feces. Scrotal lesion observed. V5 and V15 cleansed R1's perineal area with cloth towel with soap and water. On 06/30/25 at 4:00pm, V7 (Family Member) came to visit. V7 said that she visits every night and that R1 is soaking wet with double briefs almost every time she visits. V7 stated she has informed the staff about the wound on scrotal area. V7 noticed the scrotal wound when she was giving care to R1 on 6/26/25, she stated she's unsure how long the wound has been there. On 07/01/25 at 12:41pm, wound care observation with V8 (Registered nurse, RN/Wound Care Nurse) and V17 (CNA) was performed. R1's eyes were closed, non-verbal. V8 explained the process to R1. Hand Hygiene observed. V8 described the scrotal area as 100% granulation, no staging, about 0.3 x 0.2 mm (millimeters) in size full thickness. There was no bleeding or drainage. BPOC ([NAME] and [NAME] Oil)/Venelex ointment was applied after cleansing the wound area with normal saline. Sacral area observed with scar tissue. Perineal care was rendered, and brief was changed. TAR (Treatment Administration Record) showed administration of treatment per V8. On 07/01/25 at 10:55 am, interviewed V8 who has been working at this facility for 7 years, with 3 years working as the wound care nurse. When surveyor asked V8 regarding R1's skin condition, V8 said that currently he's following R1 for MASD (Moisture-Associate Skin Damage) of scrotum, this was reported to him on Friday, 6/27/25. V8 stated, I went and did my assessment, it was MASD, all measurements and pictures are through Healing Partners. We don't have access to it. There's one small area on the left side of scrotum. Venelex Treatment ointment daily was ordered by V12). When asked about other interventions and prevention of skin breakdown, V8 said Stay clean and dry, since it is moisture related, according to WNP it is MASD rather than IAD (Incontinence Associated Dermatitis). R1 has co-morbidities and fragility, also keep patient clean and dry, making sure staff are doing their check and change at least every two hours. On 7/01/25 at 12:12 PM, V2 (Director of Nursing) regarding policy on incontinent and perineal care, stated, They should check patients every 2 hours, do the rounds then check and change. We use cloth towels with soap and water for perineal care. On 7/1/25 at 12:25 PM, interviewed V9 (Nurse Practitioner, NP). I was notified about the scrotal skin tear on same day he got the skin tear, on 6/27/25. I asked the staff to apply protective cream and follow up with the resident. When surveyor asked about the cause, V9 said, Sometimes from wet briefs. (R1) has very fragile skin, moisture and incontinence, there should be protective skin care, and change brief ideally every two hours or per facility policy. For this resident (R1), should have at least two staff when changing, should be changed in bed ideally. On 7/01/25 at 3:03PM, phone interview with V12 (Wound Nurse Practitioner). When asked about wound status, she said it was the first time she saw it on 6/30/25. V12 stated, The wound nurse said the family told them about the scrotal area. I categorized it as (IAD) Incontinence Associated Dermatitis, moisture skin damage. The patient is incontinent. This is due to the repeated exposure to body fluids. When V12 was asked what her expectations are from the staff when it comes to incontinence care, V12 said she would refer to the facility policy, for the facility to follow the incontinence care protocol. Progress Notes dated 6/30/2025 per V12 reads in part: Information necessary for today's visit was obtained from nursing staff, per patient's medical record. Reason for visit: new skin and wound consult on current resident (R1). Patient unable to participate in full Review of Systems (ROS) related to altered mental status. Gastrointestinal: fecal incontinence, Genitourinary: urinary Incontinence. Musculoskeletal: Generalized weakness, multiple contractures. SKIN: warm and dry, thin, fragile, wound/skin condition noted. WOUND ASSESSMENT: Location: Scrotum Primary Etiology: Incontinence Associated Dermatitis (IAD). Stage/Severity: Partial Thickness. Wound Status: New; Odor Post Cleansing: None Size: 0 cm x 0 cm x 0 cm. Calculated area is 0 sq cm. Wound Base: 100% epithelial Exposed Tissues: Dermis Wound Edges: Attached Periwound: Dermatitis Exudate: None amount of None ASSESSMENT: Irritant contact dermatitis due to fecal, urinary or dual incontinence. PLAN: Wound # 17 Scrotum Incontinence Associated Dermatitis (IAD) Treatment Recommendations: 1. Cleanse with soap and water, pat dry. 2. apply Venelex/BPCO to base of the wound. 3. Leave open to air. 4. Daily, and PRN (as needed). PREVENTATIVE MEASURES: The resident is incontinent of bowel and bladder. Use appropriate moisture barrier creams per formulary to provide thorough skin care with each incontinent episode. Use formulary briefs when indicated to manage moisture and assess often. R1's care plan on incontinence dated/initiated on 06/29/23, reads in part: Resident has an actual impairment to skin integrity IAD to scrotum and is at risk for further skin breakdown related to recent surgery, impaired mobility, weakness, cognitively impaired, falls, anemia, and malnutrition. Interventions read in part: Call light placed within easy reach. Commonly used items placed within easy reach. The staff will check resident for incontinence episode and provide peri care as needed every shift. Kept clean and comfortable. Provide assistance with toileting needs as needed. Skin check and barrier cream applied as necessary. The facility's Incontinent and Perineal Care Policy dated 7/31/24, reads in part, 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 include doing rounds at least every 2 hours to check for incontinence during shift. Provide privacy. Avoid unnecessary exposure of resident. If the resident refuses the procedure - inform the charge nurse. Perform hand hygiene before the procedure. Put on gloves and appropriate personal protective equipment if indicated. Maintain clean techniques. Wash the perineal area and gently dry after the procedure. Discard disposable items into designated plastic bag. Wash hands. Put on new set of clean gloves to put on clean briefs/incontinent pads, to make resident comfortable, groom and change clothing. Complete hand washing after the procedure and do after care of equipment per facility protocols.

Based on observation, interview, and record review the facility failed to ensure resident safety by failure to provide 2 persons assist when providing incontinence care. This failure resulted in resident (R61) to fall from bed required visit to emergency hospital for evaluation due to bruising, swelling and pain on forehead. The facility also failed to ensure fall preventive measures were being implemented for residents who are at high risk for falls. This deficiency affects five (R13, R33, R61, R105, R392) residents in the sample of 27 reviewed for Fall prevention program. Findings include: R61 On 10/29/24 at 10:35AM, Observed R61 lying in bed with dark blue purple discoloration /bruising and swelling on face which is more prominent on forehead, bilateral eyes, cheeks, and right side of neck. R13 can barely open her eyes because of the swelling. R61 said she was pushed out of the bed by CNA during providing care. She has bilateral floor mats on the sides of her bed, but her bed in not in low position. V9 LPN (Licensed Practical Nurse) said R61 is at high risk for fall due to her recent fall. V9 said R61's bed should be in the lowest position. V9 adjusted the bed to the lowest position using the bed control at the foot part of the bed. On 10/29/24 at 10:38AM, Informed V7 Restorative Nurse of above observation made. R61 was readmitted on [DATE] with diagnosis listed, in part but not limited to, Paroxysmal Atrial Fibrillation, Gastrointestinal hemorrhage, Needs assistance with personal care, Disorder of the muscle, Muscle spasm of back, Stage 3 chronic kidney disease, Congestive heart failure, History of falling, Old myocardial infarction, Alzheimer's disease. Re-admission fall assessment dated [DATE] and most recent fall assessment dated [DATE] indicated R61 is at high risk for fall. MDS section GG Functional abilities and goals: GG0130 Self-Care indicated Personal hygiene, Toileting hygiene and Shower/bathe were coded 01- Dependent, Helper does all the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity. Comprehensive care plan indicates: R61 is at risk for falls related to Current medication use, Poor safety awareness, Unsteady gait, and Generalized weakness. She has ADL self-care performance deficit and impaired mobility. She has impaired cognitive function/dementia or impaired thought processes (forgetful, short term memory impairment) related to diagnosis of dementia as evidenced of BIM (brief interview for mental status) score of 9. R61's progress notes dated 10/26/24 at 6:50AM documented by V21 LPN indicated: V23 Agency CNA reported to V21 R61 was confused and not following commands when asked to turn on her side while changing her diaper (brief). Upon rounding, observed R61 swaying her legs out of the bed stating, CNA pushes me out of the bed. V21 LPN and V23 Agency CNA together redirected and reposition R61, reassuring her she did not fall out of bed, safety measures are in place. Endorsed to oncoming nurse and CNA. R61's fall incident report dated 10/26/24 at 8:55AM completed by V12 Unit Manager indicated: When CNA delivered breakfast tray, R61 mentioned she has a headache and pointed to her right forehead. CNA observed some swelling and called for the nurse. R61 stated when the CNA was changing her, she was placed on her right side and slipped off the bed. R61's progress notes dated 10/26/24 at 8:55AM documented by V12 Unit Manager a change of condition form indicated: R61 stated she fell out of bed during ADL care. R61 reporting pain to right hip and headache 6/10. She has light purple bruising and swelling to right forehead. Neuro checks initiated and WNL (within normal limit). She can move all extremities without difficulty. R61 was sent to the hospital for evaluation. R61's concerns/response form dated 10/26/24 completed by V12 Unit Manager indicated: R61 stated, I was pushed out of bed, right before the sun came up, it happened. R61 said, She (V23 Agency CNA) turned me while changing me and before I knew it, I was on the floor. She went to get help and they each took a side, one at my head and one at my feet and lifted me into bed. R61's hospital record dated 10/26/24 indicated: This is a [AGE] year-old female with a history of dementia presents emergency room for fall. Patient was turned onto her side while they were changing her. Patient then apparently went over the rail, landed on her right side. She is anticoagulated. She has bruising on her forehead. She does have a history of dementia, is difficulty to obtain history from. X-rays were done, negative for fractures. CT (computed tomography) scans were done negative for intracranial hemorrhage and traumatic injury. R61 returned to facility. R61's progress notes documented by V12 Unit Manager dated 10/26/24 at 4:06PM indicated: Discussed with R61's daughter fall intervention would be she will be changed with 2 staff now, one on each side of bed, floor mat upon her return, bed to be in low position except during transfers which also be with two staff. R61 agreed. On 10/30/24 at 10:33AM, Observed R61 lying in bed still with dark blue purple discoloration /bruising and swelling on facial more prominent on forehead, bilateral eyes, cheeks, and right side of neck. Observed floor mat on bilateral side of the bed but the bed is not on low position. Called V7 Restorative nurse and showed observation made. V7 lowered the bed to the lowest position using the bed control located at the foot part of the bed. On 10/30/24 at 12:54PM, V21 LPN said she was the nurse for R61 on 10/25/24 11-7 shift. She was not aware R61 fell out of bed when V23 Agency was providing care. She said around 6:00AM, V23 Agency CNA asked her help to pull up R61 from bed. She observed R61 hanging her legs out of bed. R61 told V21, She (CNA) pushed me out of bed. V21 asked V23 what happened but denied allegation of R61. V21 said, she did not notice any bruises nor swelling on her face at time. She assumed R61 is confused. V21 did not complete an incident report and did not notify the supervisor or DON (Director of Nursing) of R61's allegation that V23 Agency CNA pushed R61 out of bed. V21 endorsed it to the next shift. When V21 got home around 10:00AM, she received calls from V2 DON and V1 Administrator regarding the incident. V21 said she should notify them and complete an incident report because it is an allegation of abuse. On 10/30/24 at 12:29PM, Reviewed R61's medical records with V2 DON. Informed V2 of concerns regarding V23 Agency CNA providing 1 person assist instead of 2 persons assist with R61 during personal hygiene/incontinence care. R61's MDS section GG Functional abilities and goals: GG0130 Self-Care indicated Personal hygiene, coded 01- Dependent, Helper does all the effort. R61 does none of the effort to complete the activity and the assistance of 2 or more helpers is required for the resident to complete the activity. Informed V2 the fall intervention was not implemented. R61 was observed for 2 days 10/29 and 10/30/24 with bed not in low position. Informed V2 R61 reported to V21 LPN V23 Agency CNA pushed her out from bed. V2 did not investigate allegation made. V21 assumed R61 is confused. V12 Unit Manager started investigation when R61 complained of pain and purplish discoloration/bruise started to occur. On 10/29/24 at 10:38AM, V7 Restorative Nurse provided surveyor list of residents on high fall list on 3rd floor updated 10/17/24 with indication of fall prevention measures such as bed/chair alarm, floor mats, wide mattress, bolsters, dining room. Rounds made to the residents listed with V7. R13 On 10/29/24 at 10:40AM, Observed R13 lying in bed not in low position. Showed observation made to V7 Restorative Nurse. V7 adjusted R13 bed to lowest position using the bed control at the foot part of the bed. On 10/29/24 at 12:29PM, Reviewed R13's medical records with V2 DON. R13 was admitted on ,d+[DATE] 23 with diagnosis listed, in part but not limited to, Epilepsy, Anxiety disorder, Injury of head, Abnormality of gait and mobility, Reduced mobility, Dementia, Encephalopathy, Syncope, and collapse. Admission fall assessment dated [DATE] and most fall assessment dated [DATE] indicated at high risk for fall. Comprehensive care plan indicates she is at high risk for falls related to decreased strength, endurance, balance, epilepsy, anemia, dementia, cardiac issues, and possible untoward effects related to medications. R13 has multiple falls dated: 2/15/24, 3/11/24, 3/23/24 and 10/20/24. All unwitnessed fall in her room. Most recent fall dated 10/20/24 indicated she was observed lying in left lateral position near bed and nightstand with wheelchair position to the right side of the resident. R13 is unable to give description. R13 was sent to the hospital for evaluation and was admitted . Informed R105 On 10/29/24 at 10:43AM, Observed R105 lying in bed. The bed is not in low position. V7 Restorative Nurse checked for bed alarm, but no alarm was found. Facility's list of high fall risk indicated R105 is on bed alarm. V7 said R105 should have bed alarm as indicated in the list as fall preventive measures. V7 adjusted the bed to the lowest position using the bed control located at the foot part of the bed. On 10/30/24 at 10:36AM, Observed R105 lying in bed is not on low position. V7 adjusted the bed to the lowest position using the bed control located at the foot part of the bed. On 10/31/24 at 10:40AM, Review R105's medical records with V2 DON. R105 is admitted on [DATE] with diagnosis listed in part but not limited to Acute post hemorrhagic anemia, Anxiety disorder, Need for assistance, Dementia, history of transient ischemic attack and cerebral infarction. Admission falls assessment and most recent assessment indicated she is at high risk for fall. Comprehensive care plan indicates she is at high risk for fall related to impaired mobility, weakness, CHF, Atrial fibrillation, and Dementia. Informed V2 DON of above observation made on 10/29/24 and 10/30/24 to R105 without bed alarm and not bed not in low position. R392 On 10/29/24 at 10:47AM, Observed R392 lying in bed is not in low position. V7 adjusted the bed to the lowest position using the bed control located at the foot part of the bed. On 10/31/24 at 10:45AM, Review R392's medical records with V2 DON. R392 is admitted on [DATE] with diagnosis listed, in part but not limited to, Myopathy, Muscle wasting and atrophy, Epilepsy, History of transient ischemic attack and Cerebral infarction. Admission falls assessment and most recent fall assessment indicated she is at high risk for fall. Comprehensive care plan indicated she is at risk for falls related to Cardiac dysrhythmias, Chronic or acute condition resulting instability, Congestive heart failure pulmonary edema, decline in functional status, Use of cardiovascular medications, Use of other medications cause lethargy or confusion. Informed V2 DON of above observation made bed was not in low position. R33 On 10/29/24 at 10:54am, Observed R33 lying in bed. V7 Restorative Nurse checked for bed alarm, but no alarm was found. Facility's list of high fall risk indicated R33 is on bed alarm. V7 said R33 should have bed alarm as indicated in the list as fall preventive measures. On 10/31/24 at 10:59AM, Review R33's medical records with V2 DON. R33 is admitted on [DATE] with diagnosis listed, in part but not limited to, Dementia, Cognitive communication deficit, History of falling, Anxiety disorder, Psychosis, Chronic Obstructive Pulmonary Disease, Malignant neoplasm of bladder. Admission falls assessment and most recent fall assessment indicated she is at high risk for fall. Comprehensive care plan indicates R33 is at risk for falls related to Anemia, Anxiety disorder, Arthritis, Cognitive impairment, Dementia, Gait problem, such as unsteady gait, even with mobility aid or personal assistance, slow gait, takes small steps, takes rapid steps, or lurching gait, history of falls, incontinence, pain, poor safety awareness. Informed V2 of above observation made she does not have bed alarm. On 10/31/24 at 11:10AM, V2 DON said resident who was assessed as high risk for falls was placed on fall prevention program list. Surveyor showed the high fall list on 3rd floor given by V7 Restorative Nurse. V2 said the high fall list was updated by the Fall nurse before she left. The interventions placed were individualized and not necessary in care plan. V2 said they don't have procedure guidelines in turning resident during incontinence care for dependent resident. V2 said resident should be turned towards the CNA, not away. Facility's policy on Fall Occurrence revised 7/26/24 indicated: Policy statement: It is the policy of the facility to ensure residents are assessed for risk for falls interventions are put in place, and interventions are reevaluated and revised as necessary. Facility's policy on High-risk fall identification program indicates: Purpose: This program is intended to aide nursing home staff with easy identification of residents with a heightened risk of falling. A visual identified such as yellow star, is placed close to the resident. This allow staff to be diligent with safety measures, response times and fall prevention measures for these residents. The high-risk fall identification program goes beyond the fall risk evaluation score ad identified residents in the facility with the highest risk for falling. It is important to remember many residents are at risk for falling and should have care plan interventions available accordingly, even if the resident is not on the high-risk identification program.

Based on observations, interviews, and record reviews, the facility failed to prevent an accident by not ensuring R1 was adequately supervised based on his history of behaviors and accidents, mobility limitations, and health status which resulted in R1 self-transferring and sustaining multiple fractures. This failure applies to one (R1) of three residents reviewed for accidents/supervision. Findings include: R1 is an [AGE] year-old male with a diagnoses history of Parkinson's Disease, Dementia, Major Depressive Disorder, Muscle Wasting and Atrophy, Psychotic Disorder with Delusions, Diverticulitis, Cardiomegaly, Atherosclerotic Heart Disease, Encephalopathy, Malignant Neoplasm of Spinal Cord, and chronic kidney disease who was admitted to the facility 01/27/2020. On 10/02/2024 at 11:21 AM Observed R1 sitting in a wheelchair in the dining room. Observed R1 wearing a sling on his right arm. Observed R1's right arm covered in bruises and observed bruises on R1's left arm. R1's progress note created by V12 (Licensed Practical Nurse) dated 9/22/2024 at 12:30 PM documents he was noted with bruising and swelling to his right upper arm, he is unable to move extremity without pain. Abuse Coordinator notified. Note created by V13 (Registered Nurse) at 1:30 PM documents writer was notified that resident has a new bruise and swelling to right upper arm. Resident noted guarding right arm, not allowing writer to assess for range of motion. Called and spoke with V27 (Physician) with new orders to send resident to the ER for evaluation. R1's progress note created on 9/22/2024 21:27:28 by V11 (Agency Licensed Practical Nurse) documents note is a late entry for 9/21/2024 21:30; and states during rounds noted resident with legs hanging over the footboard of his bed, entered the room to observe and called CNA (Certified Nursing Assistant) for assistance in repositioning. R1's hospital report dated 09/22/2024 documents he was admitted to the hospital due to suspicion of elderly abuse in light of family discovering bruising on his skin at the nursing home. There was a high suspicion for elderly abuse at nursing home after family found him in pain and were not notified of any falls drawing suspicion for abuse having received no reports of falls and found with evidence of rib fractures and humeral (upper arm) fracture. Patient was seen today by family member who noted upon hugging patient that he winced in pain and upon further evaluation family member found significant body bruising and shoulder deformity with no reported falls from nursing home which he has been residing for over 2 years. Family has high suspicion for elderly abuse at nursing home, of note he is on Eliquis for Deep Vein Thrombosis and prophylaxis (illness prevention) and has a history of falls. Patient is at his dementia baseline however seems uncomfortable due to pain. He is typically wheelchair bound and usually needs help with assistance to bathroom. Imaging revealed impacted right humeral (upper arm bone) fracture, and 10th and 11th rib fractures. R1 was observed with a small abrasion to his right knee and bruising on his right upper extremity. The facility's Final Abuse Investigation Report dated 09/27/2024 documents on 09/22/2024 while providing care staff observed bruising to R1's upper right arm. He was unable to provide any information about what the source of the bruise was. He was sent to the hospital for evaluation, and it was found via emergency room x-ray that R1 sustained an impacted right humeral (right upper arm bone) fracture, and nondisplaced fractures of the right 10th and 11th ribs; multiple interviews were taken from staff working during varying shifts from 09/21/2024 - 09/22/2024. Witness statement from V11 (Licensed Practical Nurse) dated 09/22/2024 documents on the evening of 09/21/2024 while passing medications after dinner time he observed R1 was in his room in his bed with his feet hanging over the foot of his bed. R1 was sliding down his bed and hanging his feet over the end of the bed. V11 stepped into the hallway and asked V14 (Certified Nursing Assistant) to assist him with repositioning R1. R1 denied any pain and he did not observe anything unusual during this interaction. Witness statement from V14 dated 09/22/2024 at 1 PM documents V14 was assigned to work with R1 on 09/21/2024 during the PM shift. V14 recalls assisting V11 (Licensed Practical Nurse) with repositioning R1 in bed that evening and observed R1's legs hanging off the bed when she entered the room. R1 did not exhibit any signs or indications of pain or discomfort during repositioning or throughout the remainder of her shift. Witness statement from V15 (Certified Nursing Assistant) dated 09/22/2024 at 11AM documents he worked during the day shift on 09/22/2024. V15 dressed R1 and brought him to the dining room, noticed R1 was guarding his arm but he did not show any signs of pain or distress. Witness statement from V12 (Licensed Practical Nurse) dated 09/22/2024 at 12 PM documents she was assigned to R1 on 09/22/2024. V12 was not aware of any incidents/accidents involving R1 during her shift or any other day. V12 provided R1 with his morning medications and did not notice him with any distressing or unusual behavior and did not observe him to show any signs of distress. V12 was then notified by the assigned CNA (Certified Nursing Assistant) that R1 was guarding his arm during ADL (Activities of Daily Living) care. Upon assessment R1 was found with bruising to his right upper extremity. Based on the type of injuries sustained, collected data, and staff interviews, it is believed that R1's injuries were most likely due to trauma sustained during the process of transferring himself into his bed. R1's current care plan documents he is at risk for behavior symptoms related to dementia due to Parkinson's with behavior. Continues to reach for items on the floor and has a tendency to bump into doorway frame and bed frame. He has an alteration in his self-care of Activities of Daily Living related to decreased strength, endurance, balance, Parkinson's, Dementia, and cardiac issues with interventions including ambulating him from the bed to the bathroom on day and evening shifts. Encourage and/or assist to reposition frequently. R1 has impaired mobility related to Parkinson's and Dementia with intervention including guiding him to position his legs and place safety gait belt around his waist during transfer. R1 requires assistance with activities of daily living including bed mobility and transfers. R1 is at high risk for falls related to fatigue, weakness, current medication use, poor safety awareness, unsteady gait, disease process related to Dementia, history of falls, and stroke. On 10/08/2024 at 9:15 AM V19 (Family Member) stated he and another family member usually visit R1 every Sunday morning to have breakfast with him. V19 stated when he came to the facility on Sunday 09/22/2024 around 12:30 PM he found R1 in the common room where he's always seated with other residents. V19 stated as soon as he touched R1's arm R1 screamed louder than he ever heard him scream in his life and then saw bruising on him and noticed his shoulder had swelling and bruising. V19 stated he asked the nurse in the corner of the room what happened to his father, and she said we don't know what happened to your father. V19 stated he doesn't know how they got R1 dressed that morning. V19 stated he took his father R1 out of the common room and took him to his room and performed more of an assessment of him. V19 stated that's when he noticed R1 couldn't breathe and couldn't tolerate any touch to his mid-section when he attempted to palpate him. V19 stated R1's had swelling of his neck, deformity and swelling of his clavicle (collar bone), bruising to his upper shoulder area down through his back and arm just above his elbow. R1's arm was swollen, and he could not move his arm. V19 stated R1 was holding his right arm tight to himself and was using his other hand to hold his right arm. V19 stated he also found bruising on R1's hips on the right side as well as the left and he had an open avulsion (skin tear) below his right knee. V19 stated its possible they left R1 alone and he was not supposed to be left alone. V19 contemplated whether R1 fell or did somebody drop him. V19 stated no one has ever advised us of R1 having osteoporosis or any other conditions that make his bones vulnerable to breaking. V19 stated for someone R1's age, his injuries could be life threatening. V19 stated R1 needs constant supervision, and they usually place him in bed, and he stays there until the morning. V19 stated if R1 is sitting in his wheelchair, he has Parkinson's and will sometimes attempt to reach down to the floor and pick up something. V19 stated his father hasn't gotten up on his own in years now. V19 stated during the meeting on Monday after R1's incident they told him that the nurse on duty 09/22/2024 didn't see R1 fall but noticed his feet were hanging from the bed abnormally but they didn't think anything of it. On 10/08/2024 at 9:50 AM V13 (Nurse Supervisor/Registered Nurse) stated on 09/22/2024 she was told that R1 had a new bruise and asked her if she would go look at it. V13 stated she came in around noon and she was informed a few minutes after she arrived. V13 stated she went up to see R1. V15 (Certified Nursing Assistant) was trying to show her R1's arm. V13 stated she brought R1 into his room to tried and take R1's shirt off, but R1 wouldn't allow them to really look at because he was guarding his arm. V13 stated R1 had his arm bent towards himself just as if giving a hug with one arm and he would tighten it anytime you attempted to move his shirt. V13 stated she was trying to roll up the short sleeve of R1's right arm but he was tightening it. V13 stated she was able to see bruising in front and back of R1's arm, then she left the room and started making phone calls because she could tell something was wrong. V13 stated she called V1 (Administrator) because she is the abuse coordinator, then called V17 (Physician) and called and arranged for transportation for R1 to go to the hospital. V13 stated R1 wasn't yelling in pain and had a flat affect during this incident but he was guarding his arm. V13 stated R1 had no facial expressions which was surprising to her. On 10/08/2024 from 2:02 PM - 3:20 PM V1 (Administrator) stated upon review of the facility's camera footage she observed on Saturday 09/21/2024 at 7:38 PM R1 self-propelled to his room. At 7:48 PM V11 (Agency Licensed Practical Nurse) entered R1's room. At 7:49 PM V11 called V14 (Certified Nursing Assistant) into R1's room and at 7:52 PM V11 walked out of R1's room. At 7:53 PM V14 walked out of R1's room. V1 (Administrator) stated the position R1 was found in after propelling himself to his room indicates he attempted to self-transfer. V2 (Director of Nursing) stated V11 told her he didn't really think much about the incident of how he found R1 positioned in his room. V2 stated when V13 (Nurse Supervisor/Registered Nurse) was notified of R1's bruises, she began investigating and there was no report. The morning nurse wasn't aware of any incident or accident that happened, and she looked at documentation and didn't find anything about R1. V18 (Restorative Nurse) stated a gait belt is required for transferring R1. V18 stated R1 cannot transfer himself from one surface to another and always needs someone there with him. V1 stated she didn't think at the time of R1's incident there was any communication about how R1 got into his bed. When asked by surveyor should V14 have attempted to determine how R1 got himself into his bed and in the position, V1 stated, yes, the expectation is that V11 should have done so. V14 stated on Saturday 09/21/2024 she observed R1 laying on his right side and his legs were lying across the top of the foot board of his bed. V14 stated R1's head and torso were closer toward the foot of his bed. V14 stated she did not place R1 in bed. V14 stated she did not have any concerns about how R1 got in the bed on his own. V14 stated no one else stated they placed R1 in the bed that night. V14 stated prior to V11 finding R1 in the bed he was sitting in the front of his room. V1 stated she observed R1 on the camera footage from 09/21/2024 sitting in front of his room right outside the doorway before propelling himself into his room. V14 stated R1 needs assistance transferring from one surface to another. V14 stated she wasn't concerned about how R1 got in his bed because she saw V11 with him and thought he put him to bed. V14 stated she didn't ask V11 if he put R1 in the bed and V11 did not mention to her that he found R1 in the bed already. V2 stated the position R1 was found in could put him at risk for injuries with his legs hanging across the footboard and if they were positioned that way for some time there could be some pressure. V2 stated V11 should have investigated further as to what occurred with R1 because R1 is dependent on staff, he didn't put him in the bed and no one else put him in the bed.

Based on observation, interview and record review the facility failed to have effective interventions in place to monitor/supervisor a resident identified to be high risk for falls. This affected one of four residents (R1) reviewed for fall prevention. This failure resulted in R1 falling from wheelchair on 12/31/23 while in dining/group room, R1 complained of right-hand pain. On 1/2/24 R1 Xray showed 5th metacarpal fracture with mild displacement, R1 sent to hospital for evaluation and treatment. Findings include: R1 face sheet shows R1 has diagnosis of displaced fracture of base of fifth metacarpal bone (12/31/23), right hand unspecified dementia with other behavioral disturbance, other specified muscle disorders, Parkinson's disease without dyskinesia, hypertension, orthostatic hypotension, repeated falls. R1 radiology report dated 1/2/24 denotes in-part procedure - hand 2V (views) pain in right hand, findings-fifth metacarpal fracture with mild displacement, soft tissue appears swollen. Acute appearing fifth metacarpal fracture. Facility final report to the department dated 1/8/24 denotes in-part: Prior to the fall around 2:30 pm, resident was noted sitting in the dining room watching TV with chair alarm in place and functional. Few minutes later, staff responded to the alarm sounding and observed resident sitting in the dining room on his buttocks in front of the wheelchair. Resident unable to say what he was trying to do at the time of the fall. Resident assessed for injury and safety. Full body assessment completed with resident complaining of right shoulder and wrist pain. No discoloration or swelling observed. Doctor was notified of the fall with orders for STAT x-ray of right shoulder, elbow, and wrist. X-ray results received on 12/31/2023 and showed no acute fracture or dislocation, degenerative changes only. Resident medicated for pain with scheduled and PRN medication with relief. He was monitored by staff post fall. Today, 01/02/2024, resident was noted with swelling to right hand fingers and discoloration to the right hand. Nurse Practitioner was present on the unit and assessed the resident. STAT x-rays to right hand and fingers were ordered with result showing right hand 5th metacarpal fracture with mild displacement. Resident denies pain upon assessment; area was immobilized. Nurse practitioner notified of the results and ordered to send resident to ED for further evaluation and treatment. Wife notified of orders and present in the facility at this time. Resident still in the emergency room at the time of the reporting. Staff interviews were conducted, and clinical review was completed by the Director of Nursing. Resident was re- admitted to the facility on [DATE] for short -term rehabilitation from (hospital name) after he was discharged home from skilled nursing facility and fell at home. He has PMH of metabolic encephalopathy, Parkinson's disease, repeated falls, dementia, insomnia, depression, orthostatic hypotension, HTN, benign prostatic hyperplasia, disorder of muscle, history of Covid, history of UTI and dysphagia. Per wife and hospital records patient's Parkinson's disease has been getting progressively worst over months and she reports that resident has multiples falls at home. Resident saw neurologist couple weeks ago, who referred him to the specialist for 2nd opinion and has an appointment after discharge back to the community. Resident is alert, oriented x 2 with periods of forgetfulness and very poor safety awareness. His BIMS is 13/15. He requires partial/moderate assistance with most ADL care. Per therapy notes, he is able to ambulate 50 feet with moderate assistance, but his gait is very unsteady due to Parkinson disease. He is incontinent of B/B, but able to make his needs known to staff. Resident is repeatedly observed by staff trying to get up and ambulate on his own. He is not accepting his limitations and progressive illness and often overestimates his physical abilities. On 12/31/2023 resident was noted sitting in the dining room watching TV with chair alarm in place and functional. Wife visited in the morning and left prior to the incident. Around 14:30 staff was at the door of the dining room and heard chair alarm sounding. Patient attempted to walk and fell in front of his wheelchair. Resident was immediately assessed for injury and safety. He complained of right shoulder, wrist, and hand pain and after serious of x-rays he was diagnosed with right hand 5th metacarpal fracture with mild displacement. 01/03/2024, resident returned from (hospital name) emergency department with orders to follow up with (proper name) Orthopedics- (Doctor proper name). Appointment scheduled for Monday, 01/08/2024. He has immobilizer in place. NWB (non-weight bearing) status to right hand until ortho appointment. Resident is receiving scheduled Norco for pain with relief. Wife is aware of all orders. Based on the investigation, prior to the fall, staff provided necessary care for the resident, including incontinence care. He has been clean and dry at the time of fall and had his shoes on. He was sitting in the dining room, watching TV and within staff sight with chair alarm in place and functional. Care plan updated. MD and wife were updated and agreeable of current interventions. Full investigation completed, no abuse or neglect substantiated. On 1/27/24 at 1:08PM V1 (LPN) said on 12/31/23 she heard R1's chair alarm sounding and residents saying it's R1 he fell , V1 said she and V3 went into the dining room, and she observed R1 sitting on the floor on his buttocks, R1 complained that his right hand hurt. V1 demonstrated the right hand below the wrist. V1 said she notified the provider, and the provider gave orders for Xray of the right shoulder, right arm, and right hand. V1 said she doesn't remember giving R1 anything for pain. V1 explained it was toward the end of the shift and she was helping the other nurse V2 (LPN). V1 said she and V3 (RN) lifted R1 up using the mechanical lift and placed R1 back in the chair. V1 said she assessed from R1 head to toe. V1 said she placed R1 at the nurse station for monitoring. V1 said there was no aide in the dining room when R1 fell . V1 said the aide had left and did not wait for her relief. V1 said it was only a couple minutes. V1 explained that a fall can happen quickly, V1 explained that R1 has a lot of falls, and it's like as soon as the staff turn their back, R1 falls. V1 said the aides are in the dining room to monitor/supervise the residents and high fall risk resident. V1 said they monitor the residents to try and prevent them from falling, or so that they can intervene if the resident is trying to get out the chair. R1 X-ray dated 12/31/23 reviewed with V1, V1 verified there was not an Xray completed for the right hand but instead the right wrist. V1 explained that when the technician takes the images of the wrist the hand is placed down, and she thought that the entire right hand would be X-rayed. V1 said the report does not denote that R1 right hand was X-rayed, there are no results for the right hand. On 1/27/24 at 3:04PM V3 (RN) said on 12/31/23 she was in the office when she heard commotion and she went to the area of the commotion. V3 said when she got to the dining room, she observed R1 on the floor, in a sitting position. V3 said she assisted with lifting R1 with the mechanical lift and placed R1 in the wheelchair. V3 said V1 took R1 away for assessment. V3 said she stayed in the dining room to monitor the residents because there was no aide there to monitor. V3 explained the shift was changing. On 1/27/24 at 12:35pm V2 (LPN) said she was the R1's Nurse on 12/31/23 when R1 had the first fall and second fall. V2 said V1 handled the first fall because she was managing another situation with another family. V2 said V1 informed her that R1 had a fall in the dining room during shift change. V2 said V1 informed her that R1 had an injury of bruising to the head and swelling or pain to the hand. V2 said she was not sure if it was the right or left hand. V2 said when R1 had the second fall she was summons to the dining room by the aides. V2 said when she got there, R1 was back in his chair. V2 said she don't know how R1 got back in the chair. V2 said R1 complained of right-side rib pain. V2 said she observed R1 right hand swollen and bruising to the forehead. V2 said she did her assessment and placed R1 at the nurse's station for monitoring. V2 said she was not concerned about the bruise to the head and swelling to the hand because that happened on the first fall, it was not due to the second fall. V2 said she doesn't remember what the aides said about how they got R1 back into the chair. V2 said she doesn't remember who the aides were that was in the dining room for the second fall. On 1/27/24 at 3:28PM V4 (fall coordinator) said the root cause of R1's falls are due to R1 being impulsive. V4 said R1 is a high fall risk. V4 said R1 had 20-22 falls at home and that's why he was admitted to the facility. V4 said R1 fell in the bathroom on 12/26/23 when he got up from the commode and tried to walk to the sink to wash his hands. V4 said the aide was on the other side of the door and when she heard the noise she went into the bathroom and observed R1 on the floor. V4 was asked who assisted R1 with peritoneal care, who helped R1 pull his clothes up. V4 said she doesn't know if R1's clothing was down when the aide found R1 on the bathroom floor. V4 said the intervention is to maintain visual supervision while using the bathroom to prevent falls. V4 said R1's second fall was on 12/29/23 and R1 was assisted to the floor by staff. V4 said the aide was in the dining room, however the manager on duty was speaking to the aide and back was to R1 so she could not see R1. V4 was asked how the monitoring is effective if the aide is distracted by the conversation with the manager. V4 said the aide is in the dining room to monitor residents, to keep a visual on the residents to intervene if the resident tries to get up from their chair. V4 explained R1 is impulsive, and R1 will wait until no one is looking and try and get up from the chair. V4 said first fall on 12/31/23 was due to R1 impulsive behaviors. V4 said staff was in the dining room when R1 fell from the wheelchair and his hands went out in front of him. V4 said she thinks staff said they were in the dining room. V4 said R1 complained of pain to the right hand and the physician ordered and Xray of the right hand, right shoulder, and right arm. V4 reviewed the Xray report of 12/31/23. V4 said she doesn't see that an Xray of the right hand was completed. V4 said the Xray on 1/2/24 showed R1 had a fracture of the right fifth metacarpal. V4 said the Xray of the right hand should have been completed on 12/31/23 as ordered by the physician. V4 said R1 second fall on 12/31/23 occurred in the dining room also. V4 said R1 was agitated that his wife had left for the day and fell from the wheelchair. V4 said staff was there and assisted R1 back to the wheelchair. V4 was asked how the monitoring and supervision is effective if R1 continues to fall in the presence of the staff. V4 said R1 doesn't like staff too close to him. V4 said the facility is doing everything they can for fall prevention. V4 said R1 discharged on [DATE] and R1 last fall was 1/8/24. V4 was asked if the facility reviewed the records and noted that R1 had 20-22 falls at home, how did the facility plan for this admission and develop fall interventions. V4 said R1 had a lot of interventions in place. V4 said part of the issue is that R1 wants to keep his independence. On 1/27/24 at 4:50pm V6 (Director of Nursing) said the facility can't offer 1 to 1 monitoring more than 48 hours. R1 fall risk evaluation dated 12/31/23 denotes a score of 19 (high risk for falls). R1 fall incident report dated 12/31/23 at 4:03pm completed by V2 denotes in-part informed by second nurse and CNA that an unwitnessed fall occurred in the group room. Resident unable to give description. Resident had second fall, an hour later this time complaining that his head hurts, his wrist hurts and his back hurts, MD (medical doctor) aware initial orders for Xray of right hand from initial fall. R1 comprehensive Plan of Care present by V6 (Director of Nursing) with initiated date of 12/23/23 denotes in part, R1 is high risk for falls related to difficulty maintaining standing position. Fatigue, weakness, gait problem, such as unsteady gait, even with mobility aid or personal assistance, slow gait, takes small steps, takes rapid steps, or lurching gait, Impaired balance during transitions, Incontinence, Muscle weakness, other dementia, Parkinson's disease, Recent fall in last 2-6 months. Recent fall in last month. Use of Other medications that cause lethargy or confusion. R1 will resume usual activities without further incident through next review initiated 12/26/23. Interventions denotes, bed/chair alarm to alert staff when resident attempts to get out of bed unassisted, so staff can assist resident and prevent falls. Ensure patient is using leg rest for wheelchair. Ensure that R1 is wearing appropriate footwear (Specify and describe correct client footwear i.e., brown leather shoes, tartan bedroom slippers, black non-skid socks) when ambulating or mobilizing in w/c. Ensure that R1 is able to use the call light. If the light is difficult to press, consider giving him a foam pad call light or other adaptive call lights. Ensure that R1 visitors are aware of the use of assistive and adaptive devices. Frequently remind R1 to ask for assistance to stand or transfer to prevent falls. I would like PT/OT to evaluate and treat me as ordered to increase my strength and mobility and prevent further falls. Instruct spouse to activate call light prior to leaving room during visitation to prevent falls, so resident can be brought to common area for monitoring. Keep all needed items like water pitcher, tissue box, urinal, etc. within R1 reach. Maintain visual supervision while using bathroom to prevent falls. Offer R1 toileting at bedtime and when he is up at night. Offer toileting at bedtime and when patient is awake at night. Patient to stay in common supervised area when visitors are not present or when patient is awake. Place chair alarm in wheelchair. Provide me with activities to minimize the potential for falls while providing diversion and distraction to prevent falls. Room moves closer to the nurses' station for closer observation. Please make sure that my call light is within my reach and encourage me to use it for assistance as needed. I would like staff to address my needs with a prompt response to all requests for assistance. R1 medical provider progress notes dated 12/30/23 denotes in-part- note is previous and discussed with the staff to monitor closely for any issue or concerns including fall prevention. Overall looks comfortable. Fall precaution/skin care and other preventive measures per facility policy. R1 progress note dated 1/2/24 denotes in-part send to (hospital name) ER (emergency room ). R1 change in condition progress note dated 1/2/24 denotes in-part the change in condition, symptom or signs observed and evaluated is /are fracture to right metacarpal. R1 progress note dated 1/3/23 denotes in-part patient returned from ER, bed alarm in place and functioning, no s/s (signs/ symptoms) of distress, ACE wrap to right fourth and fifth finger. R1 physician progress note dated 1/3/24 denotes in-part fell and had been to the ER, noted with fifth digit fracture and will be given a splint to assist with healing and pain control and fall prevention discuss with RN. Facility policy titled Fall occurrence with last revised date of 7/17/2023 denotes in-part it is the policy of the facility to ensure that resident is assessed for risk for falls, that interventions are put in place, and interventions are revaluated and revised as necessary. Facility policy titled general care with last revised date of 7/28/23 denotes in-part it is the facility's policy to provide care for every resident to meet their needs. Facility policy titled care plan with last revised date of 7/27/23 denotes in-part it is the policy of the facility to ensure that all care plans including baseline care plans are in conjunction with the federal regulations. After the comprehensive assessment is completed, the facility will put in place person centered care plans outlining care for the resident with-in 7 days. These will be periodically reviewed and revised by a team of qualified person after each assessment. On 1/27/24 during survey tour staff was observed in dining room when residents were present. At 238pm when first shift was over V5 (activity aide) observed in dining room/group room with residents. Aides were observed giving report to the oncoming aides.

Based on observation, interviews, and record reviews, the facility failed to conduct a thorough wound assessment, obtain wound treatment orders from physician, implement interventions and ensure proper functioning of low air loss mattress in preventing the development and deterioration of pressure ulcer for two (R13 and R273) of eight residents reviewed for pressure ulcers. This failure resulted in R13's intact skin to develop a facility acquired stage 2 pressure ulcer on the sacral area which deteriorated to unstageable pressure ulcer; and R273's intact skin to develop a facility acquired stage 3 pressure ulcer on the sacrum. Findings include: R13 is a [AGE] year-old female, initially admitted in the facility on 09/04/21 with diagnoses of Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood disturbance, and Anxiety; Alzheimer's Disease, Unspecified; and Pressure Ulcer of Sacral Region, Stage 2 (on 09/04/21, history). According to progress notes dated 02/22/23, R13 has an Unstageable pressure ulcer on the sacrum, treated with med honey, alginate and dry dressing daily and as needed. On 02/27/23 at 10:30 AM, R13 was observed sitting in a reclining chair in the dining room, eating breakfast without assistance. She was observed eating 90-95% of foods served. At 11:15 AM, she was still in the dining room for activities. At 1:20 PM, she was still observed in the dining room eating lunch, sitting in her reclining chair. She was not observed repositioned while in the chair. Checking and or changing of her incontinence brief was also not observed. On 02/28/23 at 9:57 AM, R13 was observed eating breakfast in the dining room, sitting in her reclining chair. At 1:30 PM, she was again observed in the dining room eating lunch. At 4:07 PM, she was still in the dining room, sitting in her reclining chair. V11 (Certified Nurse Assistant, CNA) was asked regarding R13. V11 stated that she is going to put her (R13) to bed and change her brief. There was no cushion or any pressure redistributing device observed on her (R13) wheelchair. At 4:15 PM, incontinence care was observed on R13. It was noted that she (R13) was using a regular mattress, cased with a fitted sheet and a white blanket folded into four layers placed under her lower back. An intact wound dressing on her sacral area was also observed. R13 was asked what time she is put into bed every day. R13 tried to recall the time but did not respond to the question. V11 responded, She usually sits in this reclining chair in the morning. She should be put into bed after lunch. The night shift got her up like around 6 to 6:30 AM and should be in bed after lunch. I check her brief when I bring her to bed like 3 PM and check her every two hours. R13's POS (Physician Order Sheet) dated 01/25/23 recorded: Sacrum: Clean with normal saline solution, apply med honey with calcium alginate, and cover with dry dressing daily and as needed, as needed and every day shift. On 03/01/23 at 10:00 AM, wound care was observed on R13, provided by V3 (Wound Care Nurse) assisted by V13 (Wound Care Tech). R13 was observed on a low air loss mattress (LAL) with pump on. A flat sheet was seen directly over the mattress. A white blanket folded into four layers was placed on R13's lower back. V3 was asked on why R13 was using a regular mattress the previous day. V3 replied, They might have switched it out last night or this morning. She has to be given a low air loss mattress for the pressure ulcer. There should be a flat sheet, draw sheet. This white blanket is the draw sheet. R13's progress notes documented in part but not limited to the following: 12/22/22: R13 has new wound on the sacral, Stage 2, has slough, 1 cm (centimeter) x 1.5 cm. Adhesive foam dressing applied. 12/27/22: Wound care nurse was notified that R13 has open area to sacrum. Wound care nurse to assess. 12/29/22 Wound note: R13 seen for new skin alteration to sacrum. During assessment, new wound noted. Wound is Unstageable with slough. Site cleaned, picture taken, and treatment implemented. New treatment of med honey with dry dressing daily and as needed. R13's POS dated 12/27/22 recorded: Wound care to eval/treat. R13 was seen by V3 on 12/29/22. V3 was asked on when R13's sacral wound was first identified. V3 stated, When staff first alerted me with her wound on the sacrum, it was already Unstageable. They are supposed to tell me if they identify any skin breakdown on residents. I don't recall staff informing me on 12/27/22 but on the 29th when I received it, I assessed it and provided treatment. Skin and wound evaluation dated 12/29/22 documented that R13 has Unstageable pressure ulcer on the Sacrum, in-house acquired, with measurements 3.0 cm x 1.4 cm. V12 (Wound Nurse Practitioner) was also interviewed on 03/01/23 at 10:00 AM regarding R13's pressure ulcer on the sacrum. V12 verbalized, The wound is Unstageable. She is [AGE] years old, has advanced age, has Dementia and Alzheimer's, pretty frail. Pressure ulcer prevention is to do peri care every two hours; turning and repositioning while in bed and in chair every two hours; she is okay to get up; she gets nutritional treat twice a day, supplement, and multivitamin with minerals. Her sacral wound was identified on 12/29/22 as Unstageable. I saw her since she was admitted for skin issues. She had history of MASD (moisture associated skin damage) prior to her pressure ulcer. Her history of MASD puts her at risk to develop pressure ulcer. Peri care every two hours and repositioning should be implemented. R13's progress notes also recorded the following: 05/11/22: Wound Progress Notes - MASD to sacrum, wound bed is 100% epithelial tissue, current treatment is a (skin barrier ointment); measurement: 3.9 cm x 3.6 cm x 0.1 cm. 06/15/22: Wound Progress Notes - MASD to sacrum is closed. Progress notes dated 03/01/23 documented that R13 has Unstageable pressure wound to sacrum measuring length 0.5 cm x width 0.5 cm. Moist exudate, 80% slough 20% epithelization tissue. On 03/01/23 at 11:01 AM, V2 (Director of Nursing) was asked regarding expectations on staff in prevention of pressure ulcers. V2 stated, I give them in-services regarding skin care and peri-care. Peri care is done as needed when patient is soiled. Upon arising, every two hours that they have to check them and change when needed or if they need to go to the bathroom; showers - two times a week if soiled and when requested; moisture barrier cream application for prevention. For excoriations, zinc is available and nurses has to apply it; turning and repositioning every two hours and as needed while in bed or even sitting in a chair; hydration is also important for skin care; nutrition; we need to put cushions on wheelchair for high-risk residents; the use of low air loss mattress. The high risk and those residents with pressure ulcers need to have the low air loss mattress. We have two types, the regular air mattress for high risk; which has also a pump. The low air loss mattress is for residents with pressure ulcers. For LAL mattress, fitted sheet is to be used or just one flat sheet. R13's care plans regarding pressure ulcer to sacrum related to impaired mobility and generalized weakness dated 12/29/22 documented: Interventions: incontinence management; repositioning during ADLs (activities of daily living). R13's care plan regarding risk for alteration in skin integrity related to lack of mobility, incontinence, indwelling catheter, respiratory issues, impaired cognition, and possible untoward effects related to medications, revised date 01/22/22 also documented: Encourage to reposition as needed; use assistive devices as needed; pressure redistributing device on bed and chair; provide preventative skin care routinely and prn (when needed); use pillows/repositioning devices as needed. On 03/02/23 at 10:02 AM, V3 was asked why R13 had no cushion or any pressure redistributing device on chair. V3 stated, I just put the chair cushion this morning. She should have one before. Facility's policy titled Skin Care Treatment Regimen revised date 7/28/22 stated in part but not limited to the following: Policy Statement: It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate topical tx for residents with skin breakdown. Procedures: 1. Charge nurses must document in the nurse's notes and /or the Wound Report form any skin breakdown upon assessment and identification. Furthermore, topical skin treatment must be obtained from the patient's physician. 5. Refer any skin breakdown to the skin care coordinator for further review and management as indicated. 6. Residents who are not able to turn and reposition themselves will be turned and repositioned every two hours unless specified in the POS. 10. Topical treatment protocol: Unless otherwise indicated by the attending physician. Topical agents based on cost effectiveness, immediate availability, and insurance preferred topical formularies. Examples of these treatment medications are: b. Pressure ulcers ii. Stage 2: Xenaderm ointment, Aloe Vesta Cream, A and D Cream or Ointment, Xeroform Dressing daily, Foam dressings (Hydrocolloid and Alginate dressings to fill the wound base daily and PRN), Hydrogel Gauze or gel. iii. Stage 3 and 4: 1. Clean wound base: Ca Alginate, Hydrocolloid Gauze/gel daily, Xeroform Gauze 2. Necrotic areas: Santyl ointment daily 3. Radiation Sites: Wet to Dry Dressings 4. Use of Low Air Loss Mattress/Alternate Pressure Mattress LAL mattress manufacturer's guidelines documented in part but not limited to the following: Nursing procedures: To ensure the system is operating correctly, the mattress and control unit should be checked during patient repositioning, scheduled per facility protocol. Recommended Linen: Based upon the patient's specific needs, the following may be utilized: Draw or slide sheet to aid in positioning and to further minimize friction and shearing Incontinence barrier pad for urine and/or stool and patients with heavily draining wounds Top sheet, blanket, and/or bedspread as needed for patient comfort Minimal padding between the patient and the surface to provide optimum performance. 40920 R273 is a [AGE] year-old female who was admitted to the facility on [DATE] with past medical history including, but not limited to fracture to unspecified part, type 2 diabetes, hyperlipidemia, anemia, cognitive communication deficit, depression, etc. On 02/27/23 10:48AM, R273 was observed in her room, awake and alert and was saying that she is in pain, she just came back from therapy and her neck just started hurting when she came back to the room. R273 added that she has sore on her bottom, and it is painful. She rated the pain on her neck as a 10 on a scale of 1 to 10, and an 8 for the pain to her sacrum. R273 said that she did not come in with the sore, it started here, she went to the hospital for a hip surgery and came here after that. She has been complaining of this and all the facility is doing is putting a cream on her and it doesn't help. Resident was noted to have a regular mattrass on her bed. 02/27/23 11:10AM, observed wound care for R273 with V3 (wound care nurse). Noted some redness to resident's bottom and an area about a quarter size that looked open. V3 stated that the area is not open so there is no treatment for it right now, they are just using a barrier cream but if the treatment she is currently getting is not working, he will let the nurse practitioner (NP) know and see if she can order something different. At 12:30PM, V3 approached the surveyor and said that he reached out to the NP and NP will assess the resident tomorrow. For right now NP said to use skin prep and a foam dressing three times a day. Review of resident's progress note dated 3/1/3023 showed the following documentation: Patient seen for wound rounds. Right buttock stage 3 pressure ulcer. Measurements 1.0cm x 2.0cm, with a depth of 0.1cm. Small serous sanguineous drainage noted with 100% granulation tissue. Viable wound edges with intact peri wound and no odor. Treatment order given for calcium alginate and foam dressing 3x a week and as needed. Left heel DTI, deep tissue injury. Measurements 2.0cm x 2.0cm. No drainage. 100% epithelization tissue/purple color. Attached wound edges with intact peri wound and no odor. Will continue with current treatment of skin prep daily. No further issues noted. Will continue to monitor. Braden score assessment for predicting pressure ulcer dated 2/15/2023 coded R273 with a score of 18, indicating at risk for pressure ulcer. Care plan dated 2/16/2023 stated that resident is at risk for alteration in skin integrity related to impaired mobility, incontinence, recent surgery and diabetes, Interventions include to observe skin conditions with ADL care daily, report abnormalities, provide preventive skin care routinely and as needed, barrier cream to buttocks as needed.

Based on interview and record review, the facility failed to have effective interventions in place to adequately supervise a resident with a diagnosis of dementia and a history of wandering and falls. This failure resulted in one resident (R98) having a fall that resulted in (R98) sustaining a subdural hemorrhage. The facility also failed to transfer a resident in a safe manner, consistent with the assessed needs of the resident. This failure applied to one (R59) of one resident and resulted in (R59) sustaining a fracture to the left clavicle after being transferred to bed. Findings include: R98 is a [AGE] year-old female who was originally admitted to the facility on [DATE] with multiple diagnoses including but not limited to the following: COVID-19, depression, anxiety disorder, traumatic subarachnoid hemorrhage, laceration of scalp, scoliosis, dementia, and history of falling. It is to be noted that R98 sustained multiple falls since admitting to the facility including on 12/3/22, 12/12/22, 1/10/23, 2/3/23, and 2/23/23. Facility general progress note written on 12/12/22 states in part but not limited to the following: Heard a boom sound and ran to the area where the noise came from. R98 was lying on the floor face down bleeding heavily on the right side of the forehead above the eye. R98 admitted to the hospital for fall and laceration to the forehead and loss of consciousness. Facility incident report dated 12/12/22 states in part but not limited to the following: Description of incident: R98 was going to the bathroom when she fell face down and hit her forehead, bleeding. Hospital discharge paperwork from 12/14/22 states in part but not limited to the following: Chief complaint: laceration, closed head injury, and fall. Clinical impression: Subarachnoid hemorrhage, laceration of scalp, and history of dementia. History of present illness: R98 fell out of bed and hit the right side of her head. She has a laceration with staples. Summary of Admission: R98 presents with dementia, frequent falls, presenting from SNF after unwitnessed fall. Possibly multifactorial due to poor safety awareness, dementia, and chronic imbalance. History obtained by V19 (family member) who states that R98 has had multiples falls, as she loses her balance when ambulating without assistance. V19 says it is always a mechanical fall and tripping. On 2/28/23 at 11:00 AM, R98 and V19 (family member) were interviewed regarding care within the facility. V19 says R98 has had multiple falls since admitting to the facility and she feels as if they do not provide her with adequate supervision. R98 is ambulatory and has wandered off the unit and gotten on the elevator without anyone seeing her on multiple occasions. Due to the fall on 12/12/23, she now must wear a helmet. She has fallen and hit her head on multiple different occasions. On 3/1/23 at 9:45 AM, V15 (Nurse Supervisor) was interviewed regarding R98. V15 says R98 tends to go to the washroom on her own, not use her call light, and leave her walker behind when ambulating. We have attempted to educate her on using her call light and ask for assistance on multiple occasions. However, she does not follow assistance and is impulsive. There have been multiple times where she has left the unit and went to the second floor. She will get on the elevator and has made it to activities on a different floor without anyone seeing her get on the elevator. Attempted to interview V19 x 4, however was unable to get a hold of during the survey. Facility care plan with creation date of 12/14/22 states in part but not limited to the following: Focus: Resident is noncompliant with use of walker when ambulating. Goal: Resident will use walker for ambulating with assistance through next review. Interventions: Monitor resident every hour for safety and toilet as needed; Provide resident with walker and assist resident as needed for safety. Facility care plan with creation date of 1/20/23 states in part but not limited to the following: Focus: Exit seeking / elopement i.e., risk going on elevator related to cognitive impairment. Goal: Will not leave center unattended. Interventions: Accompany to meals and scheduled activities; calmly redirect to an appropriate area. Facility care plan with creation date of 11/28/22 states in part but not limited to the following: Focus: At risk for falls due to muscle weakness and potential medication side effects. Goal: Minimize risk for falls. Interventions: Call light within each reach and close patient monitoring; provide assistance to transfer and ambulate as needed. Facility policy titled Fall Occurrence with last revision date of 5/17/22 states in part but not limited to the following: Policy statement: It is the policy of the facility to ensure that residents are assessed for risk for falls, interventions are put in place, and interventions are reevaluated and revised as necessary. R59 is a [AGE] year-old female who originally admitted to the facility on [DATE] with multiple diagnoses including but not limited to the following: Cardiomyopathy, tachycardia, syncope, left clavicle fracture, type II DM, history of falling, pain in right knee, repeated falls, CHF, muscle weakness, anxiety, and osteoarthritis. Facility progress note dated 2/11/23 states in part but not limited to the following: R59 complained of pain to left shoulder after being transferred via sit to stand from wheelchair to bed. Range of motion to extremity not tolerated well. Orders received for x-ray of left shoulder. Facility progress note dated 2/12/23 states in part but not limited to the following: Acute fracture involving left distal clavicle with modest displacement on X-Ray. On 02/27/23 at 12:30 PM, R59 was interviewed regarding incident on 2/11/23. R59 said she was being transferred back to bed using the sit-to-stand machine and on the way down, she felt something crack in her shoulder. R59 said she does not feel comfortable in the sit-to-stand machine. She feels smooshed while using the machine and cannot put pressure on her leg because she has is in pain and has a blood clot. On 3/1/23 at 9:45AM, V15 (Nurse Supervisor) was interviewed regarding incident with R59 on 12/11/23. V15 says he was notified of the incident afterwards. Says the family requested to get her out of bed. The patient requested to go back to bed during shift change. V24 (Certified Nursing Assistant) went in to assist her. It is to be noted that V15 said V24 was the only employee present at time of transfer. R59 expressed to V24 after the transfer that her neck/shoulder area was in pain. R59 has only been out of bed one time since the incident and that was to go to an appointment. She is now fearful of the sit-to-stand machine. On 2/28/23 at 12:00 PM, V17 (Certified Nursing Assistant) and V18 (Certified Nursing Assistant) were observed doing a sit-to-stand transfer. V17 said there should always be two CNA's present during a mechanical transfer. At 11:15 AM, V21 (Director of Rehab) was interviewed regarding R59 and transfers. V21 said R59 was admitted as private pay and was not screened by therapy upon admission. The nursing staff did a functional assessment to determine her status. V21 said if a resident has a recommendation for stand and pivot: total assistance, this typically means two person transfer if they can bear weight on their legs. If they cannot bear weight, typically a device would be recommended for that transfer. A sit-to-stand would be recommended if they can hold on with both of their hands and bear weight on their legs. If a resident is fearful of the device, we will not recommend it. If a resident cannot bear weight on both legs and hold on to the device, a mechanical lift would be recommended. Facility Care Plan with creation date of 2/23/23 states in part but not limited to the following: Focus: Requires assistance/potential to restore function for transferring from one position to another; Goal: Will be able to transfer with assistance of device; Interventions: Therapy evaluation and treatment as ordered; Use gait belt to facilitate safe transfer. Minimum Data Set, dated dated dated [DATE], Functional Status and Functional Abilities and Goals state in part but not limited to the following: Transfer- How resident moves between surfaces including to or from: bed, chair, wheelchair, standing position: Self Performance: Extensive assistance; Support: Two+ persons physical assist; Functional Limitation in Range of Motion: Upper extremity: Impairment on one side; Lower extremity: Impairment on both sides; Mobility: Sit to stand: the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed: Not attempted due to medical condition or safety concerns. Facility Patient Transfer Worksheet dated 2/9/23 states in part but not limited to the following: Patient is able to tolerate bearing weight on legs: No Skilled Nursing Facility discharge paperwork dated 2/8/23 states in part but not limited to the following: Physical Medicine Rehabilitation Evaluation dated 2/1/23: Patient states that she still has the lower left extremity pain below her knee. States when she gets out of bed her left leg buckles. Currently in therapy the patient is stand and pivot total assistance.

Based on observation, interviews, and record review, the facility failed to assure that agency staff received training on the safe utilization of mechanical lifts prior to be use with any resident resulting in physical injury to one resident (R2) who required emergency transfer to a local hospital and was diagnosed with laceration to the right lower extremity. This failure affected one resident (R2) out of 4 residents (R4, R5, and R6) reviewed for improper mechanical transfer. Findings include: R2 is a [AGE] year old woman admitted to facility on 8/30/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . BIMS score is 09 per MDS dated [DATE]. Patient Transfer Screening Worksheet dated 1/21/2022 indicated R1 requires assistance for transferring using a mechanical lift and sling with a 2 person assist. On 1/20/2022 at 8:12 pm, V12 Registered Nurse was called into R2's room by V13 Certified Nursing Assistant (CNA). R2 was lying in bed with a bleeding laceration to her right lower leg. V12 cleansed and dressed wound then notified MD who gave orders to monitor for bleeding. At 9:10 V12 checked on R2 and noted the wound dressing was saturated with blood. V12 notified MD who ordered R2 be sent to local hospital for evaluation and treatment. On 1/21/2022 at 3:23 am, R2 returned from hospital with laceration repair to right lower extremity. Orders received and carried out to remove sutures in 14 days, and to perform daily dressing changes with triple antibiotic cream and non-adherent dressing. On 2/18/2022 at 2:40 PM, R2 was observed with V6 Nurse Manager and V11 Wound Care Nurse. R2's right lower leg was dressed with roll gauze clean and intact. Surrounding skin was noted to be reddened, edematous and scaly. On 2/18/2022 at 2:42 PM, V11 Wound Care Nurse said, R2 had to be sent out for sutures because the wound wouldn't stop bleeding. I later removed the sutures because they were falling off and we added some treatment orders to assist with the closure. The wound became infected and has delayed the healing process a bit. Right now there is minimal to small drainage and we are applying a debridement treatment daily. On 2/18/2022 at 2:45 PM, V6 said on the 3-11 evening shift, two CNA's were transferring R2 to the bed from the wheelchair. I am not sure how the injury occurred and neither do they according to their statements. The CNA guiding the machine should have been the one to ensure that no parts of the body came in contact with the machine. At 4:14PM V13 CNA said, I had never used this type of lift prior to working at this facility. It is similar to the others that I have worked with, but this one is different because of the way that it positions the resident while up in the air. The facility never provided any instruction on how to use the machine and we didn't get any in-service or safety briefing after the incident happened. At 5:06 PM V2 DON (Director of Nursing) said, the facility doesn't provide teaching or orientation about the use of the mechanical devices to agency staff because it is an expectation that they know how to use the equipment as a condition of their employment. We only provide an orientation to the unit when they arrive. There were no in services completed on the safe use of the mechanical lift after the incident occurred. On 2/19/2022 at 11:13 am, V2 DON said, we don't have a separate policy for using the mechanical lifts for agency staff, our expectations are the same as staff certified nursing assistants. Facility provided mechanical lift policy and procedure reviewed. Nurse Aide Essential Job Functions reads: Safety and Sanitation: .uses safety equipment and supplies when indicated and properly trained to use.

Based on interviews and record review, the facility failed to immediately address a high blood sugar and failed to notify a doctor of the high blood sugar in a resident (R1) with a history of type 1 diabetes for one of three residents reviewed for improper nursing care. The failure resulted in R1 being admitted to the hospital with mild diabetic ketoacidosis. Findings Include: R1 is a [AGE] year old with the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 admitted to the facility on [DATE]. A Nursing note dated 4/26/21 documents R1 found on the floor on R1's back. R1 reported attempting to sit in the wheelchair due to vomiting in R1's bed and lost footing when R1 stood up. R1 reported being too nauseous to move and requested to be sent to the emergency room . Unit manager made aware and nurse practitioner ordered to send R1 to the hospital. A Nursing note dated 4/26/21 documents R1 was admitted to the hospital for [CONDITION(S)]. Blood sugars were as follows: 4/25/21 at 5:45PM - 75mg/dL, 4/25/21 at 9:44PM - 75mg/dL, 4/26/21 at 5:27AM - 394 mg/dL, 4/26/21 at 9:25AM - 511 mg/dL (normal range is 70-110 mg/dL). An eMAR note dated 4/26/21 documents R1 was given 7 units of [MEDICATION(S)] at 9:25AM (approx 4 hours after reading of 394 mg/dl at 5:27 am). The laboratory report dated 4/26/21 documents R1's glucose was elevated at 488 mg/dL. The Hospital Records dated 4/26/21 document R1 was sent to the emergency room from the facility for elevated blood sugars and multiple emesis this morning. R1 is in mild diabetic ketoacidosis (DKA). Per endocrinology, R1 is to start on an insulin drip with intravenous fluids and then will transfer back to insulin injections. R1 admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/6/21 at 1:05PM, R1 stated, I got my blood sugar taken that morning before 6AM. I don't remember what it was but I started to get really nauseous after that. I knew it was going to be high so I checked it with the machine I have and it was over 400. I threw up at around 6AM. I started to feel terrible. I knew my sugar was too high and I needed to go to the hospital. I have been dealing with this since I was little so I know when it's too high. I always get nauseous and start throwing up when it's too high. I kept yelling out for the nurse but I don't think she could hear me. Then shift changed happened. The next nurse came in here around 7:30AM and I told her I threw up. I kept dry heaving at that point because I had nothing left in me. I started sweating really bad and I wanted to lay on the floor where is was cooler and there was puke all over my bed. The day nurse finally came in around 9AM to check on me and my blood sugar. I told her I wanted to go to the hospital then because my sugar was so high. They gave me some insulin around that time and then the ambulance came and took me to the hospital. I was diagnosed with diabetic ketoacidosis. I only have been in that 1 other time in the last like [AGE] years. I have to get an IV insulin with a fluid bag and then I was sent back here a couple days later. On 5/6/21 at 2:09PM, V2 (Nurse) stated, That morning he complained of elevated blood sugar. I took his blood sugar and it was in the 500s. I gave him some insulin that was scheduled. This was around 9 I think. (MAR documented at 9:25 am) He was sweating in bed. I called the nurse practitioner and we were already in the process of sending him out when the doctor called and said to send him out for the high blood sugar. Everyone's order is different when to call the order. I think for him it was over 300 then you call to let them know. I had no report from the previous nurse before me that his blood sugar was that high. She should have called the doctor for a blood sugar that high. After an hour, you call back to try to let them know what is going on. I saw 2 emesis in his bed. His admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/6/21 at 3:51PM, V3 (Nurse) stated, Everyone's order is different on when to call the doctor. I don't remember what his order was. Some are call after 250, some 350, and some 400. If you call and the doctor doesn't call back within an hour then I would page again. On 5/6/21 at 6:35PM, V4 (Nurse) stated, I don't remember having any problems with his blood sugar that morning. Every order is different for every resident on when to call the doctor. If I call the doctor, I put a note in. I think I called the doctor to tell them the blood sugar that morning. I don't remember. I started at the end of the hall in room [ROOM NUMBER] and worked my way to the front. I started going to the other rooms and finished with the residents I needed to see that morning. I never called the doctor back about the blood sugar. On 5/7/21 at 9:36AM, V5 (Nurse Manager) stated, I wasn't made aware of the blood sugar until I heard there was a fall. That occurred around 8:30AM. Each resident is different for when to call the doctor about how high their blood sugar is. If the doctor doesn't call back then you repage them. There really isn't a timeframe; it depends on what is going on. He was admitted to the hospital for [CONDITION(S)]. On 5/7/21 at 11:26AM, V6 (Endocrinologist) stated, If his blood sugar was that high then he should have been given insulin right away to prevent it from going higher. If he wasn't given insulin then he is at risk for the blood sugar going higher and developing DKA. DKA is a very serious complication of high blood sugar. It starts shutting down organs if you don't catch it in time. People can end up in a coma. The brain can swell; the kidneys start to shut down. There is a whole list of things that can happen. Every person body is different. Some people go into DKA with a blood sugar at 300 and other people don't going in DKA until they hit 600. It just depends on the person. Just like the blood sugar, every person has different symptoms they are in DKA. Some can be increased urine production, nausea and vomiting, abdominal pain, confusion. Type 1 diabetes also needs to be taken more seriously when a high blood sugar reading is received because their bodies don't make insulin. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order for [MEDICATION(S)] sliding scale is documented as if the blood sugar is greater than 350mg, give 8 units of insulin and call the doctor. The Care Plan dated 4/18/21 documents R1 has diabetes mellitus and an intervention of monitoring/reporting signs or [CONDITION(S)] is documented. The Minimum Data Set - Section I dated 4/23/21 documents R1 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] There is no documentation of a doctor being notified when R1's blood sugar was 394 mg/dL at 5:27AM that morning. The policy titled, Change in Condition, dated 11/2016 documents CMS requires, a 'facility must immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident's representative when there is: an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications); a need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment); a decision to transfer or discharge the resident from the facility.' According to the American Medical Directors Association (ADMA) Clinical Practice Guidelines - Acute Changes in Condition in the Long Term Care Setting, - immediate notification is recommended for any symptom, sign or apparent discomfort that is acute or sudden in onset and a marked change in relation to usual symptoms and signs, or is unrelieved by measures already prescribed.

Based on interview and record review, the facility failed follow their fall algorithm and develop a plan of care to include supervision and interventions to reduce or prevent the risk of falling and strategies to prevent future falls for 1 of 4 (R3) residents reviewed for fall and fall prevention protocol. This failure resulted in R3 having multiple falls subsequently resulting in a fall to the floor sustaining a left [MEDICAL CONDITION]. Findings Include: R3 was admitted with the [DIAGNOSES REDACTED]. R3's minimal (MDS) data set [DATE] documents: R3 had a brief interview for mental status score of ten which indicate moderated impairment. Section G (functional status) documents: R3 required limited assistance with one person physical assist with locomotion on the unit. R3's balance during transitions and walking was not steady without staff assistance. R3 had impairments bilaterally for the lower extremities. Walking in the room or corridor did not occur. On 1/13/2021 at 1:07pm, V9 (nurse) said, R3's family told the facility, that R3 was a fall risk. I did not see the actual fall on 2/18/19 On 1/15/2021 at 2:58pm, V16 (unit manager) said, R3 was at high risk for falls on admission due a [DIAGNOSES REDACTED]. R3 could not have been expected to remember to call for help based on her cognition. R3 would not wait for assistant based on her anxiety. R3's interventions that were put in place for the falls on 2/12, 2/18, 3/6, 8/21 and 12/3 were not effective to prevent future falls. Interventions are put in place to prevent future falls. R3's fall incident on 2/12/2019 does not document R3 was reaching for anything. On 1/19/2021 at 2:16pm, V17 (nurse) said, R3 was at high risk for falls. R3 would try to get up from the wheelchair with an unsteady gait without locking the wheelchair. R3 did not use the call light. R3 would forget she had the call light on her side. R3 would only remember instruction for a second. I don't remember the incident on 3/6/19, I use my charting as a factual documentation. On 1/20/2021 at 4:26pm, V18 (nurse) said, R3 required supervision. R3's short term memory was not intact. R3 had a fall on 8/21/2019 that resulted in a fracture. R3's wheelchair was lodged between bed and the dresser. R3 got up and fell . I don't know what (FYI) means as a fall intervention. I don't know what happened with R3's fall on 12/3/2019. R3 was usually trying to transfer self. Progress note dated 2/12/2019 documents: R3 was observed lying on floor next to the bed. R3 had a small hematoma to right side of the forehead. R3's fall incident dated 2/12/19 documents: R3 had cognitive impairment, difficulty maintaining sitting balance and standing position, decline in functional status, history [MEDICAL CONDITION] and low levels of physical activity. R3's care plan initiated on 2/12/2019 documents: R3 is at risk for falls due to decline cognition, history of falls, incontinence, muscle weakness, difficulty walking, impaired vision and use of [MEDICAL CONDITION] medications. Intervention initiated on 2/12/2019 was fall risk (FYI) and have commonly used articles within easy reach. Progress note dated 2/18/2019 documents: Staff noted another female resident assisting R3 with reposition in wheelchair when R3 fell forward. R3's fall incident dated 2/18/2019 documents: Another resident was attempting to help R3 move her wheelchair when R3 fell forward on the floor before staff could be warned to assist. R3 was unable to recall the event. Risk factor: R3 has poor sitting balance. R3 has poor safety awareness, loss of arm or leg movement, musculoskeletal problems and fatigue weakness. Summary of critical information: Both residents have cognitive impairment and were not aware of their limitation. R3's care plan intervention initiated 2/18/2019 documents: R3 will be seated within reachable distance. Progress note dated 3/6/2019 documents: R3 was yelling for help. R3 was noted on the bathroom floor in the toilet. Summary of critical information: R3's fall incident dated 3/6/2019 documents: R3's disease and conditions: [MEDICAL CONDITION]. Physical limitation documents one leg appears shorten then the other. R3 risk factors for potential falls: cognitive impairment, poor judgement for safety due to Dementia. Root cause: R3 went to the bathroom without help and fell . R3 did not realize her limitation due to cognition impairment. R3's care plan intervention initiated 3/6/2019 documents remind R3 to call for assistance. Progress note dated 8/21/2019 documents: R3 was standing at the foot of her bed with wheelchair next to R3. R3 slipped to the floor before staff could reach R3 resulting in left [MEDICAL CONDITION]. R3's fall incident dated 8/21/2019 documents: R3 was standing by bed holding on to the foot of the bed and slid down before staff could reach R3 due to the wheelchair being between R3 and staff. R3's care plan intervention initiated 8/28/2019 documents monitor limbs for swelling, skin changes, signs and symptoms of [MEDICAL CONDITION] complications, infection and pain. Hospital paperwork dated 8/22/2019 documents: R3 presents with pain in the left hip. R3 fell out of the wheelchair. R3 has a closed displaced intertrochanteric [MEDICAL CONDITION] femur (hip). Progress note dated 12/3/2019 documents: Resident was observed lying on floor in her room. R3's care plan intervention initiated 12/4/2019 documents: Accompany to room for needs. Fall algorithm dated 2011 documents: Develop/revise care plan and implement ongoing fall prevention strategies.

Based on interview and record review the facility failed to follow their Falls Practice Guide, and failed to properly assess and notify a Physician after a fall for 1 of 3 residents (R3) reviewed for falls in a total sample of 7. This failure resulted in R3 not being assessed for over 12 hours after a fall. R3 was hospitalized and diagnosed with [REDACTED]. Findings Include: The care plan dated 3/12/19 documents that R3 is a fall risk related to decreased strength, endurance, balance, and history of a right [MEDICAL CONDITION]. Interventions include staff assisting R3 with ambulation and transfers. The Minimum Data Set ((MDS) dated [DATE] documents that R3 was cognitively intact but required extensive assistance and 1 person physical assist with toileting related to lower extremity weakness. The Fall Report dated 3/2/20 at 12:22am documents that R3 had a fall on night shift related to gait problems and impaired balance. There was no documentation of a full body assessment done at the time of the fall and no documentation of Physician and family notification. The Medication Administration Record [REDACTED]. The Nurse's Notes dated 3/3/20 at 1:42pm documents that R3 had pain while getting dressed and informed staff of a fall that took place at night on the previous shift. R3 was left alone in the bathroom and stated that the fall occurred while trying to get back into the wheelchair after using the bathroom at bedtime. The family was made aware and requested that the resident be sent out for evaluation. The Physician was notified and R3 was transferred to the local hospital for evaluation. The hospital records dated 3/3/20 documents that R3 was admitted after a fall the evening prior and has complaints of pain to the left hip that radiates up the back. R3 is unable to ambulate due to pain related to the fall. R3's x-ray of the hips showed an inferior and superior rami (pelvis) fracture on the left. A CT scan was done of the abdomen and pelvis and showed a large displaced [MEDICAL CONDITION] iliac bone (pelvis) extending to the iliac crest (pelvis) and the roof of the acetabulum (hip) with bilateral fractures of the sacrum. R3 also has a compression [MEDICAL CONDITION] spine. On 10/13/20 at 11:40am, V1 (Administrator) stated The incident with R3 occurred on the night shift. The Nurse caring for the resident at the time was aware of the fall and did not notify anyone that the resident had fallen. The Nurse just put R2 back in bed after the fall. The Nurse was terminated for failure to notify the administrative staff or the Physician. The Nurse did not follow our Fall Protocol. The Nurse was a really good staff member that just made a very poor decision. It is outlined clearly in the computer that the Physician should be notified after a fall but the Nurse did not follow those prompts. On 10/16/20 at 3:20pm, V8 (CNA) stated At the start of the morning shift I went in to see the resident. I remember seeing blood on the top of the resident's underwear. I tried to move R3 but the resident complained of hip pain. R3 told me that there was a fall that took place on the night shift. R3 was transferred to the bathroom and fell trying to get back into the wheelchair. I informed the night Nurse at that time. I'm not sure what the Nurse did after that. That Nurse no longer works here. On 10/16/20 at 2:10pm, V6 (Physician) stated This was not my resident but the Nurse should definitely call the Physician caring for the resident after a fall. There is a fall protocol for the Nurse to inform the Physician so that the resident can be assessed for pain, or x-rays and also notify the family. This is the normal protocol after a fall. The Falls Practice Guideline documents that an evaluation is completed timely following a fall or change in patient condition that increases the patient's risk for falls. Upon the completion of the evaluation, the Physician is notified and orders are documented, noted and implemented, as indicated. The family and responsible party is notified of the fall event or change in fall risk factors and the patient's current condition.

Based on interview and record review the facility failed to follow their Falls Practice Guide, failed to keep the resident safe while toileting, and failed to properly assess and notify a Physician after a fall for 1 of 3 residents (R3) reviewed for falls in a total sample of 7. This failure resulted in R3 being left alone in the bathroom where the resident attempted to ambulate resulting in a fall. R3 was hospitalized and diagnosed with [REDACTED]. Findings Include: The care plan dated 3/12/19 documents that R3 is a fall risk related to decreased strength, endurance, balance, and history of a right [MEDICAL CONDITION]. Interventions include staff assisting R3 with ambulation and transfers. The Minimum Data Set ((MDS) dated [DATE] documents that R3 was cognitively intact but required extensive assistance and 1 person physical assist with toileting related to lower extremity weakness. The Fall Report dated 3/2/20 at 12:22am documents that R3 had a fall on night shift related to gait problems and impaired balance. There is no documentation of a full body assessment done at the time of the fall and no documentation of Physician and family notification. The Medication Administration Record [REDACTED]. The Nurse's Notes dated 3/3/20 at 1:42pm documents that R3 had pain while getting dressed and informed staff of a fall that took place at night on the previous shift. R3 was left alone in the bathroom and stated that the fall occurred while trying to get back into the wheelchair after using the bathroom at bedtime. The family was made aware and requested that the resident be sent out for evaluation. The Physician was notified and R3 was transferred to the local hospital for evaluation. The hospital records dated 3/3/20 documents that R3 was admitted after a fall the evening prior and has complaints of pain to the left hip that radiates up the back. R3 is unable to ambulate due to pain related to the fall. R3's x-ray of the hips showed an inferior and superior rami (pelvis) fracture on the left. A CT scan was done of the abdomen and pelvis and showed a large displaced [MEDICAL CONDITION] iliac bone (pelvis) extending to the iliac crest (pelvis) and the roof of the acetabulum (hip) with bilateral fractures of the sacrum. R3 also has a compression [MEDICAL CONDITION] spine. On 10/13/20 at 11:40am, V1 (Administrator) stated The incident with R3 occurred on the night shift. The Nurse caring for the resident at the time was aware of the fall and did not notify anyone that the resident had fallen. The Nurse just put R2 back in bed after the fall. The Nurse was terminated for failure to notify the administrative staff or the Physician. The Nurse did not follow our Fall Protocol. The Nurse was a really good staff member that just made a very poor decision. It is outlined clearly in the computer that the Physician should be notified after a fall but the Nurse did not follow those prompts. On 10/16/20 at 3:20pm, V8 (CNA) stated At the start of the morning shift I went in to see the resident. I remember seeing blood on the top of the resident's underwear. I tried to move R3 but the resident complained of hip pain. R3 told me that there was a fall that took place on the night shift. R3 was transferred to the bathroom and fell trying to get back into the wheelchair. I informed the night Nurse at that time. I'm not sure what the Nurse did after that. That Nurse no longer works here. On 10/16/20 at 2:10pm, V6 (Physician) stated This was not my resident but the Nurse should definitely call the Physician caring for the resident after a fall. There is a fall protocol for the Nurse to inform the Physician so that the resident can be assessed for pain, or x-rays and also notify the family. This is the normal protocol after a fall. The Falls Practice Guideline documents that an evaluation is completed timely following a fall or change in patient condition that increases the patient's risk for falls. Upon the completion of the evaluation, the Physician is notified and orders are documented, noted and implemented, as indicated. The family and responsible party is notified of the fall event or change in fall risk factors and the patient's current condition.

Based on the unprecedented coronavirus global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 3/13/20, the Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS) Memo QSO-20-14-NH revised on 3/13/20, Nursing Home guidance from the Centers for Disease Control (CDC), and observation, interview, and record review, the facility failed to ensure that staff: 1) used full personal protective equipment (PPE) every time staff entered an isolation room including serving meals; 2) used N95 respirator masks properly by not using a cloth mask underneath; 3) refrained from touching the front part of the mask; and, 3) had readily available PPE for use (face shield, masks, gowns) as needed to care for persons under investigation (PUI) and with orders for isolation. This failure had the potential to expose six non-isolation residents to the COVID-19 virus under the care of the staff. The IJ began on 5/13/20 at 12pm, when Nursing Assistant (NA)1 who was wearing a cloth mask under the N95 respirator, entered R1's room, an isolation room, without wearing a gown or gloves to serve the lunch tray, and when interviewed, kept on adjusting the N95 mask by touching the front part of the mask. In addition, there was no adequate PPE set up that was readily available for use in three isolation rooms (R1, R2 and R3). The facility had six current staff and 16 residents who tested positive for COVID-19. The Administrator was notified of the Immediate Jeopardy on 5/14/20 at 2:52pm. According to https://www.nih.gov/news-events/news-releases/new-coronavirus-stable-hours-surfaces National Institute of Health (NIH) Tuesday, March 17, 2020 New coronavirus stable for hours on surfaces [DIAGNOSES REDACTED]-CoV-2 stability similar to original [DIAGNOSES REDACTED] virus. [MEDICAL CONDITION] that causes coronavirus disease 2019 (COVID-19) is stable for several hours to days in aerosols and on surfaces, according to a new study from National Institutes of Health, CDC, UCLA and Princeton University scientists in The New England Journal of Medicine. The scientists found that severe acute respiratory syndrome coronavirus 2 ([DIAGNOSES REDACTED]-CoV-2) was detectable in aerosols for up to three hours, up to four hours on [MEDICATION NAME], up to 24 hours on cardboard and up to two to three days on plastic and stainless steel. The results provide key information about the stability of [DIAGNOSES REDACTED]-CoV-2, which causes COVID-19 disease, and suggests that people may acquire [MEDICAL CONDITION] through the air and after touching contaminated objects. The study information was widely shared during the past two weeks after the researchers placed the contents on a preprint server to quickly share their data with colleagues. The NIH study attempted to [MEDICAL CONDITION] being deposited from an infected person onto everyday surfaces in a household or hospital setting, such as through coughing or touching objects. The scientists then investigated how long [MEDICAL CONDITION] remained infectious on these surfaces. The scientists highlighted additional observations from their study: If the viability of the two coronaviruses is similar, why is [DIAGNOSES REDACTED]-CoV-2 resulting in more cases? Emerging evidence suggests that people infected with [DIAGNOSES REDACTED]-CoV-2 might be spreading virus without recognizing, or prior to recognizing, symptoms. This would make disease control measures that were effective against [DIAGNOSES REDACTED]-CoV-1 less effective against its successor. In contrast to [DIAGNOSES REDACTED]-CoV-1, most secondary cases of virus transmission of [DIAGNOSES REDACTED]-CoV-2 appear to be occurring in community settings rather than healthcare settings. However, healthcare settings are also vulnerable to the introduction and spread of [DIAGNOSES REDACTED]-CoV-2, and the stability of [DIAGNOSES REDACTED]-CoV-2 in aerosols and on surfaces likely contributes to transmission of [MEDICAL CONDITION] in healthcare settings. According to: https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html .To prevent infectious disease transmission, elimination (physically removing the hazard) and substitution (replacing the hazard) are not typically options for healthcare settings. However, exposures to transmissible respiratory pathogens in healthcare facilities can often be reduced or possibly avoided through engineering and administrative controls and PPE. Prompt detection and effective triage and isolation of potentially infectious patients are essential to prevent unnecessary exposures among patients, healthcare personnel (HCP), and visitors at the facility. N95 respirators are the PPE most often used to control exposures to infections transmitted via the airborne route, though their effectiveness is highly dependent upon proper fit and use. The optimal way to prevent airborne transmission is to use a combination of interventions from across the hierarchy of controls, not just PPE alone. Applying a combination of controls can provide an additional degree of protection, even if one intervention fails or is not available . According to https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html updated on April 15, 2020 revealed: Given their congregate nature and resident population served (e.g., older adults often with underlying chronic medical conditions), nursing home populations are at the highest risk of being affected by COVID-19. If infected with [DIAGNOSES REDACTED]-CoV-2, [MEDICAL CONDITION] that causes COVID-19, residents are at increased risk of serious illness. COVID-19 cases have now been reported in all 50 states and DC; with many areas having wide-spread community transmission. Given the high risk of spread once COVID-19 enters a nursing home, facilities must take immediate action to protect residents, families, and healthcare personnel (HCP) from severe infections, hospitalization s, and death. Visitors and HCP continue to be sources of introduction of COVID-19 into nursing homes. To protect the vulnerable nursing home population, aggressive efforts toward visitor restrictions and implementing sick leave policies for ill HCP, and actively checking every person entering a facility for fever and symptoms of illness continue to be recommended . Findings include: During the entrance interview on 5/13/20 at 11am, the Administrator confirmed the facility had confirmed cases of residents with COVID-19 in the designated unit called COVID-19 AIRBORNE ISOLATION UNIT (CAIU) on second floor and residents who are considered PUIs on the third floor. During the tour and review of the resident list, the facility had 16 positive cases in the designated CAIU unit and three PUIs in the non-COVID-19 floor of the facility. During the tour of the non-COVID unit on 5/13/20 at 12pm, revealed that there were three residents' rooms (room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]) that had STOP SIGN SEE NURSE BEFORE ENTERING posted on the door. An isolation set-up was hanging on room [ROOM NUMBER] (R3's room) door. The isolation set-up had boxes of gloves but no other PPE. In the hallway across from room [ROOM NUMBER](R1's room), in between rooms [ROOM NUMBERS], a plastic bag containing a yellow gown was hanging by the handrail. Hanging right outside room [ROOM NUMBER] (R2's room) by the hand rail was a blue gown. At approximately 12:20pm, NA1 entered room [ROOM NUMBER](R1's room) with a lunch tray. NA1 was wearing an N95 mask but underneath the mask was a cloth mask. NA1 was not wearing a gown or gloves. NA1 was heard telling R1 that she would come back later to turn off the call light since she was not wearing a gown. NA1 brought R1's lunch tray (non-disposable utensils) back to the cart when R1 indicated he did not want to eat. Then NA1 took the yellow gown out of the plastic bag that was hanging across from R1's room. NA1 donned gown and gloves and entered R1's room. After a few minutes, NA1 came out of R1's room and doffed the gown and put it back in the plastic bag and left it hanging across from R1's room. When asked, why R1 was on isolation, NA1 stated the resident was exposed to his roommate who was moved to the COVID unit. When asked what PPE should be worn when entering the room, NA1 stated that she should wear a mask, gown and gloves when entering the room. When asked why she was wearing a cloth mask underneath the N95mask, NA1 did not answer. At this time, the Unit Manager joined the interview. When asked about the cloth mask, NA1 confirmed that the cloth mask underneath the N95 mask was her personal mask. During this interview, NA1 was observed adjusting her N95 mask by touching the front part of the mask. The surveyor intervened and told NA1 not to touch the front part of the mask. NA1 sanitized her hands after prompting from the Unit Manager. The Unit Manger confirmed that R1, R2 and R3 were considered PUIs and were placed on isolation. The Unit Manager also confirmed that the isolation rooms were not set up with available PPE for staff to use in case they needed to enter the room. During an interview with the Director of Nursing (DON) on 5/13/2020 at 2:30pm, the DON was asked about required PPE set-up and use for airborne isolations. The DON stated that PUIs were placed on airborne isolation, and staff were expected to wear the same PPE as though they were caring for COVID-19 residents which included N95 masks, gowns, gloves and face shields. The DON also clarified that the COVID unit required the use of shoes protectors. Review of the Daily Deployment Sheet dated 5/13/19 revealed there were seven residents (R1, R4, R5, R6, R7, R8 and R9) assigned under NA1's care from 6am to 2pm. Except for R1, the six residents under NA1's care were not on isolation precautions. Review of R1's physician's orders [REDACTED]. Review of R1's progress notes dated 5/15/20 revealed Writer spoke to patient's sister-in-law (name of sister in law) about the room move since patient is positive for Covid-19. Patient and family agreeable to move. Review of R10's (R1's roommate) electronic record revealed Effective Date: 5/12/2020 11:36 (Name of Nurse Practitioner (NP), NP notified of Covid19 positive test results .New room # and phone number for the son provided .5/12/2020 15:22 Patient transferred to 2nd floor . (COVID unit) in stable condition with all medications and belongings. Report given to receiving nurse. Review of R2's POS revealed airborne isolation dated 5/12/20 Review of R3's electronic record dated 5/12/20 revealed Np (for name of MD) updated of patients status-elevated temp and about roommate who tested positive for Covid19. Patient started on Z-pack (an antibiotic), Zinc (supplement) daily and Vit C 500 (Vitamin supplement). Orders carried on, first dose of Z-pack given .Effective Date 5/13/20 11:26 Patient notified of positive Covid 19 test results and that will have to transfer to second floor for airborne isolation. Voiced understanding .Patient already started yesterday on ABT (antibiotic) . Review of R6's COVID-19 test result done on 5/5/20 and reported on 5/11/20 revealed a negative result. Review of R4's COVID-19 test result that was done on 5/12/20 and reported on 5/15/20 revealed a positive result. R4's POS dated 5/15/20 revealed an order for [REDACTED].>Review of R5, R8 and R9's laboratory order indicated specimen collection for [DIAGNOSES REDACTED]-CoV-2, the coronavirus associated with COVID-19 testing dated 5/12/20. Review of R7's electronic record revealed no indication for COVID-19 testing. R7's [DIAGNOSES REDACTED]. The Administrator was notified that the immediacy was removed as of 5/14/20 when the acceptable removal plan was accepted and after the surveyor verified that the removal plan was implemented. Verification of the removal plan on 5/19/20 included: 1. Observation of staff wearing N95 and facemasks properly throughout the facility. 2. Observation of isolation set-up and availability of PPE in the isolation rooms. 3. Observed staff donning and doffing PPE when entering and leaving isolation rooms. 4. Review of in-service dated 5/13/20, 5/14/20, 5/15/20, 5/16/20, 5/17/20, and 5/18/20 provided to all staff regarding the use of N95, Donning/Doffing PPE, and PPE Usage Guide. 5. The specified employee was taken off from schedule for monitoring for 14 days 6. Interviews were conducted to assess staff knowledge of the PPE usage. 7. Review of the facility audits on proper use of PPE and availability of PPE supplies After removal of the Immediacy, the non-compliance remained at the level of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy until sustained compliance is verified.

Based on interview and record review, the facility failed to follow their Pain Practice Guide, and evaluate and monitor for side effects for a resident (R4) after administering [MEDICATION NAME] (pain medication) for one of four residents (R4) reviewed for reassessment after administering pain medication in a total sample of eight. This failure resulted in R4 having an unreported change in baseline of feeling groggy, then being found on the floor with a laceration to the forehead and absence of vital signs. Findings Include: A note dated [DATE] at 12:56PM documents R4 visited by the hospice nurse and educated on need and use for ordered opioid pain medication. R4 understands this medication is for mild pain and shortness of breath. A note dated [DATE] at 10:43PM documents R4 found lying face down on the floor on the right side of the bed without movement or respirations at 5:10PM. R4's head was lying in blood due to a left [MEDICAL CONDITION]. R4's call light and bed control were lying underneath R4. Vital signs assessed and were absent. R4 lifted back into bed. The Fall Report dated [DATE] documents R4's medications as antianxiety, antidepressant, and narcotic [MEDICATION NAME]. R4's disease and conditions are the following: cardiac [MEDICAL CONDITIONS], decline in functional status, incontinence, muscle weakness, and fatigue putting R4 at risk for falls. The Investigation Report dated [DATE] documents R4 found on the side of the bed expired. On [DATE] at 11:09AM, V13 (LPN) stated, I know activities was doing rounds and went down there and found R4 on the floor. I walked in and saw R4 face down on the floor. There was blood around her face and when we flipped R4 over we then saw it was coming from a laceration on R4's left forehead. Before we decided to move R4, we called R4's name and checked for a pulse and couldn't find one. R4 was blue when we flipped her over and not moving at all. I was with R4 since 7am that morning and R4 was her normal self. R4 had a visit from hospice and the hospice person told me R4 was complaining of pain and shortness of breath. I went down there and around one I gave her [MEDICATION NAME] for pain and shortness of breath. R4 normally took the [MED] for pain because R4 told me before R4 didn't like the way the [MEDICATION NAME] or [MEDICATION NAME] made R4 feel. R4 said it made R4 feel funny but that is all I know. R4 really didn't say more about that. I last saw R4 at 1 P.M. when I gave the [MEDICATION NAME] to R4. I never got a chance to check on R4 again. If R4 was still having pain or something the CNA that checked on R4 would tell me. There wasn't a change after R4 got the [MEDICATION NAME] that I know of. R4 was always A&O (alert & oriented) X3 (Alert to person, place, & time). R4 could tell you exactly what R4 wanted and have a conversation with you. R4 liked to control the bed. R4 knew how to make the bed go up and down and she knew how to use the call light too. R4 liked the head of her bed raised because it helped R4's breathing. That day when I went in the room it was maybe 45 degrees and the bed was probably 3 to 3 and a half feet off the ground. I know the call light was on when the activity person went in the room. R4 didn't have side rails on the bed. No one has side rails on their bed here. On [DATE] at 11:27AM, V12 (Activity Aide) stated, I was doing my rounds. I saw the call light on and I went in to see if the first lady needed anything she told me no and I looked around the curtain and found R4 on the floor. She was not calling out or moving at all. R4 was face down. As soon as I saw R4 and the blood I ran and got the nurse. I know the head of the bed was raised but I couldn't tell you how much. R4 always had R4's bed like that; it was R4's preference. I did see R4 earlier that day and when I saw her R4 was sleeping. The last time I saw her she was sleeping around 2 or 2:30PM. R4 was never confused. I didn't talk to R4 that day though. The light was already on when I started my rounds. I'm not sure how long the light was on for before that. On [DATE] at 11:54AM, V14 (CNA) stated, I last saw R4 at 4:45PM. I went in R4's room to help take her roommate to the bathroom. When I came out I checked on R4 too since I was in the room. I know they were giving R4 [MEDICATION NAME] that day. R4 was more groggy than usual. R4 was talking to me telling me what R4 wanted but R4 wasn't opening her eyes when R4 talked to me. R4 was speaking with a softer voice too this time. Normally, R4 would talk to you with her eyes open when you were helping R4 get comfortable. R4 was always alert times 3. I didn't tell anyone R4 was like that. I tried to put R4's head of the bed down a little when I was leaving. It was close to being all the way up but R4 told me R4 wanted it up because it made R4's breathing better. R4 always sat with the head of the bed up. The height of the bed was to my mid-thigh probably and I am 5'6. R4 didn't have any side rails on the bed. On [DATE] at 1:52PM, V15 (Physician) stated, I remember I got a call from hospice that evening tell me the resident expired and was a DNR so I gave the order to release the body to the funeral home. I think hospice or someone called me the next day wanting me to sign the death certificate. I found out that R4 fell and was found down and R4's death might not have been from natural causes so I didn't feel comfortable signing it. I never saw this patient in my life. I have no idea what she was like and then hearing what happened I didn't want to put my name on that. Like I said I can't really say what the person was like because I didn't know R4. The least they should have done is notify hospice if R4 showed a change from R4's baseline. There are many side effects of [MEDICATION NAME]. It is a powerful medication for someone that doesn't get it often. Some side effects are depressed respiratory and cardiac function, a change in mental status or an increase in confusion. It could have made her more sleepy than usual. The Death Certificate dated [DATE] documents the cause of death as subdural hematoma and probable fall. The manner of R4's death is ruled an accident. The Physician order [REDACTED]. The Medication Administration Record (MAR) for ,[DATE] documents R4 received an ordered as needed opioid pain medication on [DATE] and [DATE]. No documentation of reassessment noted on [DATE]. The Minimum Data Set ((MDS) dated [DATE] reviewed. Section C of the MDS documents R4's Brief Interview for Mental Status (BI[CONDITION]) score as a 13 (no cognitive impairment). Section G of the MDS documents R4's functional status as needing extensive assistance with two person physical assist. The Pain Practice Guide, dated ,[DATE] documents, FYI - Obtain pain scale scores daily and before and after administration of PRN [MEDICATION NAME]. Scores are documented on the MAR. Patients receiving opioid [MEDICATION NAME] are routinely evaluated and monitored for side effects which include, but are not limited to: confusion/[MEDICAL CONDITION], constipation, hallucinations, myoclonic jerking, nausea/vomiting, pruritis, respiratory depression, and sedation. If adverse side effects are noted, the physician is promptly notified for additional orders or interventions. The policy titled, Change in Condition, dated ,[DATE] documents, C[CONDITION] requires, a facility must immediately inform the resident; consult with the resident's physician; and notify consistent with his or her authority, the resident representative when there is: a significant change in the resident's physical, mental, or psychosocial status (that is a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). According to the American Medical Directors Association Clinical Practice Guideline - Acute Changes in Condition in the Long Term Care Setting, immediate notification is recommended for any symptom, sign or apparent discomfort that is acute or sudden in onset and a marked change in relation to usual symptoms and signs, or is unrelieved by measures already prescribed.

Based on interview and record review, the facility failed to develop fall risk interventions to reduce the risk of falling for a resident with a cognitive impairment and known impulsive behavior for one of four (R3) residents reviewed for falls in a total sample of eight residents. This failure resulted in R3 falling sustaining a left [MEDICAL CONDITION] after falling while attempting to get out of bed Findings Include: A note dated 1/9/20 documents R3 attempted to get up alone while in the bathroom and fell hitting R3's head. R3 is not to be left in the bathroom alone. R3 sent to the hospital for evaluation. A note dated 1/11/20 documents R3 had an unwitnessed fall. R3 denied pain or injury at the time of the fall. R3 noted with a bruise to the left thigh. R3's family member called the nurse notifying the nurse that R3 called the family member reporting R3 was in pain. R3 complained of pain when reassessed and complained of severe pain with movement in the left leg. R3 was sent to the hospital. The Ambulance Run Sheet dated 1/11/20 documents R3 appears in some distress wincing in pain. R3 rated pain to the left leg 9 out of 10. R3 reported changing clothes to get ready for bed when R3's left leg slipped form under R3 and R3 fell on to the left hip. R3 reported falling into kind of a splits position. Bruising noted to left medial thigh. The Hospital Records dated 1/11/2020 document R3 reported getting ready for bed and slipped and fell on to the left side. Left leg appears shortened. X-ray of the pelvis shows a left displaced fracture through the left femoral neck. On 2/6/2020 at 2:31PM, V7 (CNA) stated, I was coming out of my resident's room I was taking care of and I saw R3 on the floor. The call light was not on. R3 was sitting up near the foot of her bed but R3 was facing the head of her bed. R3's legs were kind of in a folded position away from the bed. R3 was a fall risk. All fall risks have to be monitored either in the lounge area or in front of the nurse's station until they go to bed for their safety. That is our protocol here for fall risks. R3 was in R3's room at the time of the fall. I don't know who put her in R3's room. I know R3 didn't get back there alone because R3 wasn't able to maneuver the wheelchair alone. I don't know any of R3's interventions because R3 wasn't on my set. I just know R3 was a fall risk and R3 wasn't supposed to be in R3's room alone. On 2/6/2020 at 3:04PM, V8 (CNA) stated, I gave R3 the night time care and put R3 in bed around 8 to 8:30PM. This is the only fall I know of that R3 had. R3 was not a high fall risk. They have a band on their wrist if they are a high fall risk. R3 didn't have one on. We always put the high fall risks at the nurse's station because they need to be watched until the night shift comes on. R3 is confused at times. R3 won't listen to directions if you give them to R3. I can't think of any risk factors that R3 would be a fall risk. We are told for all residents that have a fall they go in front of the nurse's station until the night staff comes because they will get up from their bed. If you put a high fall risk in bed you must stay with them so they do not get out of bed. The only interventions we have for high fall risk is watching them at the nurse's station until it is time for bed. On 2/6/2020 at 3:22PM, V9 (Agency LPN) stated, The CNA came to get me and told me the patient was on the floor. I asked R3 what R3 was trying to do and R3 told me trying to get back in bed but R3 couldn't tell me what R3 was doing before then. R3 was a high fall risk because R3 was on neuro checks for a previous fall like a day or 2 before. I can't tell you what interventions they had in place for R3. I just remember being told in report R3 fell like 2 days before. It was my first time in the building as well so I didn't really know R3 or what they do there. I only knew the residents that had a fall recently from report. No, I wasn't told about her needing to be monitored because of R3 being a fall risk. I'm not sure but I know R3 was probably supposed to be at the nurse's station from other nursing homes I have been to. That is what they do. They watch the high fall risks until they are all put to bed. On [DATE]20 at 9:56AM, V10 (Nurse Supervisor) stated, I was not here during the time of the fall. We usually have the nurse doing the paperwork put in an intervention right away. If the nurse is some an agency they are put in by me the next day. The intervention we put in depends on the circumstances of the fall. We gear it to what the root cause of the fall was. I know the first fall she was put in the bathroom and R3 got up alone. I felt R3 was confused. I interviewed R3 after the first fall and R3 couldn't answer the questions I was asking. R3 was alert enough to feel more independent and felt R3 could do a little more than R3 could. We have hired extra staff to sit with them until they go to lie down for the night. We have all the residents that we need to watch that can't follow directives to call for help. I don't know when that was started when R3 was here or not. I didn't think R3 was able to follow the direction to use the call light. That was twice R3 didn't wait for help. There is nonstop movement in the halls and constant eyes moving down the halls to check on the residents so we really don't have a set time on when they should round. On [DATE]20 at 10:45AM, V11 (Physician) stated, I don't remember this patient at all. I don't know what the facility policy is on their falls so I cannot say what else could have been done to prevent something like this. From what you told me, R3's comorbidities do make R3 more prone to falls more specifically because R3's inability to function independently. The Investigation Report dated 1/16/20 documents V8 (certified nurse aid) put R3 to bed after providing care around 8:30PM. V7 (CNA) found R3 on the floor sitting next to the bed. No call light was on. This was R3's second fall. Both falls R3 got up without waiting for assistance from staff. The Minimum Data Set ((MDS) dated [DATE] Section C of the MDS documents R3's Brief Interview for Mental Status (BI[CONDITION]) score as an 11 (moderate cognitive impairment). Section G of the MDS documents R3's functional status as needing extensive assistance with two person physical assist. The Care Plan dated 1/11/2020 documents an intervention for R3 after the fall on [DATE] as the following: staff will wait outside the bathroom door when R3 is in the bathroom. R3 is not to be left alone in the bathroom. The Physical Therapy Evaluation dated 1/3/20 documents R3's safety awareness as impaired. During the evaluation, R3 demonstrates left upper and lower extremity weakness, poor standing balance, poor trunk control, and requires max assist with transfers. R3 is at risk for: compromised general health, decreased ability to return to prior living environment, decrease in level of mobility, decrease leisure task participation, decrease participation with functional tasks, falls, immobility, pressure sores, and limited out of bed activity. The facility reported not having any specific policy or protocols for residents that are cognitively impaired and a high fall risk.

Based on record review and interview the facility failed to notify the physician of a change in condition to include change in baseline condition with signs of frequent urination, weakness; change in hemodynamics to include increased temperature, heart rate and decreased oxygen saturation for 1 of 3 residents R2 reviewed for change in condition. This failure resulted in a insidious decline in R2's condition throughout the shift resulting in a fall incident, and becoming unresponsive requiring CPR. Findings Include: Review of the incident report dated [DATE] at 7:50 pm described, R2 was trying to put self into the bed from W/C when R2 slipped from the W/C onto the floor. The incident report documents that the nurse conducted a full body assessment with no noted injury. C/O back pain, able to move all extremities with gait belt assistant of other staff members. R2 was placed in bed this report was completed by V12 (nurse). A review of the R2's nursing notes dated [DATE] at 18:00 V12 was called to room to find R2 on the floor near bed, that R2 was trying to get out of W/C when R2 slipped on to the floor. Full body assessment done with no injury noted, able to move all extremities, vital signs recorded as temp 99.2, heart rate 110bpm, Respirations 20 per minute. The report documents that R2's family and physician was notified. On [DATE] at 18:05, a nursing note by V12 documented R2 Neuro checks initiated with vital signs recorded as temp 99.2, heart rate 110bpm, respirations 20 pm, oxygen saturation 92% on oxygen per nasal cannula at 2 liter, Denies pain at this time. Nursing note [DATE] at 19:00 V12 documented, R2 very restless oxygen saturation at 88% oxygen administered at 4 liters nasal cannula, R2 noted to refuse to take pain meds. V12 documents will continue to monitor. Nursing notes dated [DATE] at 20:30 V12 documents V12 was called to the room to find R2 lying on the floor, with no respirations and no B/P, 911 called and CPR was initiated. R2's family members was noted to be at the bedside. The note documents that V25 (physician) was notified about R2 status and change in condition. R2 was transferred to local hospital via 911 paramedics. On [DATE] at 3:30pm, V12 said that she recalls R2. V12 said that R2 was alert and orient times ,[DATE]. R2 knew what was going on, R2 usually used a walker to ambulate. V12 said that R2 went out to a local hospital 911 and that V12 had sent R2 out after becoming unresponsive. V12 said I remember the aide telling me to come right away and when I arrived in R2's room R2 was unresponsive on the floor and staff member was doing CPR. V12 said that she then took over and ordered staff member to call a code and bring the crash cart. V12 said that R2 was a little weaker and asked for the washroom all evening and that R2 had fallen earlier so I put R2 at the nurses station. V12 said that once R2's family member arrived R2's family member said that R2 did not look right, R2 just doesn't look good to. V12 said I thought R2 looked okay and all vitals where good. V12 said that she didn't recall staff informing her that R2 appeared weak that shift. V12 said earlier that day R2 slipped out of her wheelchair onto the floor while trying to get into bed. V12 said that R2 usually uses a walker to ambulate and that R2 being in the wheelchair was not R2's normal baseline. V12 said that no one informed her that R2 was weak, and that she didn't conduct any assessments based on the knowledge. V12 said that I don't usually do an assessment unless there is a problem. V12 said because R2 fell earlier in the shift she placed R2 in the wheelchair next to nurses station so she could watch her, and because R2 usually can ambulate with a walker. V12 said it was after the 6pm fall. V12 said that she didn't recall R2 having an order for [REDACTED]. the physician of R2's vital signs and requiring oxygen. V12 said that she felt R2 needed the oxygen so she applied it. Nursing note dated [DATE] at 19:00 was reviewed with V12. V12 said that R2 was becoming restless and her oxygenation level was worsening so she adjusted the oxygen to 4 liters per nasal cannula with a saturation of 88%. V12 said that she may have notified the physician, but didn't document. V12 said the physician didn't give any new orders after relaying R2's status. V12 said that the times in the electronic medical record may not be true but these are all things that I did. V12 said that she charted when time allowed. V12 said she called the physician but it wasn't in the charting because there was a lot going on. On [DATE] at 4:15 pm via phone, V25 (Physician) said that he was not made aware of R2's condition declining to include complaints of weakness, new increased urgency to urinate. The survey team reviewed R2's clinical notes with V25 via phone and V25 said that R2 was not hemodynamically stable and that R2 should have been sent out hours before the incident occurred if he had been notified. On [DATE] at 2:00pm, via the telephone V25 said that he now recalls he was notified of R2's fall at 7:43pm on [DATE], V25 was unable to state acknowledgement of R2's change in condition as V12 documented on [DATE] starting at 6:00pm to include change in vital signs and decrease in oxygen saturation. V25 said that he didn't give an order for [REDACTED]. However V25 never supplied the survey team the documented accounts of the times that the facility paged him on [DATE] for R2. Review of R2's hospital record dated [DATE] at 9:17 pm, documents Chief compliant -[MEDICAL CONDITION] R2 arrived initially unconscious. Shortly after cardiac meds are given with high quality CPR R2 has a carotid /femoral pulse. Hospital records 10:05 pm documents INR>20 and PTT >100. R2 has extreme coagulopathy and cannot place a central line given this finding. According to the facility change in condition policy the attending physician should be notified when the resident's baseline changes to include heart rate above 110 beats per minute, temperature above 99 degrees fahrenheit.

Based on interview and record review the facility failed to ensure that an initial physician ordered PT/INR lab was drawn ([MEDICATION NAME] time/international normalized ratio) to determine the effectiveness of the anticoagulant therapy and failed to follow the verbal order of the attending physician to have the PT/INR redrawn after an initial refusal, and failed to obtain a lab result prior to continued administration of [MEDICATION NAME] for (7) consecutive doses for 1 of 3 residents (R2) reviewed for anticoagulant therapy. The facility also failed to conduct a comprehensive assessment for a change in baseline condition with signs of frequent urination, weakness, and failed to notify the physician of change the baseline changes and a change in hemodynamics to include increased temperature, heart rate and decreased oxygen saturation for R2 and failed to obtain a physician order [REDACTED]. Theses failure resulted in a R2 having complaints of weakness and experiencing a fall, having abnormal vital signs and decreased oxygen saturation for 1.5 hours and then became unresponsive without breath or pulse and CPR ( Cardiopulmonary resuscitation) was initiated. R2 was taken to the local hospital and was treated for [REDACTED]. Findings include: Review of R2's hospital record dated [DATE] at 9:17 pm documents Chief compliant -[MEDICAL CONDITION] R2 arrived initially unconscious. Shortly after cardiac meds are given with high quality CPR R2 has a carotid /femoral pulse. Hospital records 10:05 pm documents INR>20 and PTT >100. R2 has extreme coagulopathy and cannot place a central line given this finding. R2 was admitted to the facility on [DATE], a review of the admitting hospital records dated [DATE] documents a lab anticoagulant report with at PT-25.8 / INR2.6 ([MEDICATION NAME] 8.0 13.0 time/International Normalized Ratio 2XXX,[DATE].5) A review of the admitting Physician orders [REDACTED]. A review of admitting Physician orders [REDACTED]. A review of Physicians note signed and documented by V25 (Attending Physician) dated [DATE] at 21:56 Documents [MEDICATION NAME] dose will be adjusted according to INR. A review of the requisition on [DATE] of PT\INR refusal note and at bottom of lab documented V25 made aware. A review of Outpatient Lab services on [DATE] CBC, CMP, TSH, was drawn and documents PT/INR refused. A review of nursing note dated [DATE] through [DATE] there was no physician notification or R2's refusal of the lab draw of the PT/INR documented in the notes. A review of R11/R12 also reviewed for [MEDICATION NAME] Therapy there was a document titled PT/INR [MEDICATION NAME] ([MEDICATION NAME]) flow sheet located in both residents clinical record, however a review of R2's clinical record there was no flow sheet available. On [DATE] V4 (nurse) said that the nursing staff use these forms on all residents receiving [MEDICATION NAME] to review current dosing and record and review INR levels prior to administration of [MEDICATION NAME] and to know when the next PT/INR lab draw is due. On [DATE], V26 (nurse) said that staff track PT/INR results on the PT/INR tracking sheet and that's how we know what to do when there have been a dosage change or the next lab draw due. On [DATE] at 10:00 am V5 (Director of Nursing) said the PT/INR [MEDICATION NAME] ([MEDICATION NAME]) Flow Sheet is an internal document, and that the facility destroyed R2's flow sheet after discharge. A review of the (EMAR) electronic Medication Administration Record [REDACTED]. On [DATE] [MEDICATION NAME] 5mg was administered by V12 (nurse) according to the (EMAR). On [DATE] [MEDICATION NAME] 6mg was administered by V12 according to the (EMAR). On [DATE] [MEDICATION NAME] 5 mg was administered by V12 according to the (EMAR). On [DATE] [MEDICATION NAME] 6 mg was administered by V4 (nurse) according to the (EMAR). On [DATE] [MEDICATION NAME] 5 mg was administered by V12 according to the (EMAR). On [DATE] [MEDICATION NAME] 6 mg was administered by V12 according to the (EMAR). On [DATE] [MEDICATION NAME] 5mg was administered by V12 according to the (EMAR). Review of the incident report dated [DATE] at 7:50 pm described, R2 was trying to put self into the bed from W/C when R2 slipped from the W/C onto the floor. The incident report documents that the nurse conducted a full body assessment with no noted injury. C/O back pain, able to move all extremities with gait belt assistant of other staff members R2 was placed in bed this report was completed by V12 (LPN). A review of the R2's nursing notes dated [DATE] at 18:00 V12 was called to room to find R2 on the floor near bed, that R2 was trying to get out of W/C when R2 slipped on to the floor. Full body assessment done with no injury noted, able to move all extremities, vital signs recorded as temp 99.2, heart rate 110bpm Respiration 20pm. The report documents that R2's family and physician was notified. On [DATE] at 18:05 nursing note by V12 documented R2 Neuro checks initiated with vital signs recorded as temp 99.2, heart rate 110 bpm, respirations 20 per minute, oxygen saturation 92% on oxygen per nasal cannula at 2 liter, Denies pain at this time. Nursing note [DATE] at 19:00 V12 documented, R2 very restless oxygen saturation at 88% oxygen administered at 4 liters nasal cannula, R2 noted to refuse to take pain meds. V12 documents will continue to monitor. Nursing notes dated [DATE] at 20:30 V12 documents that V12 was called to the room to find R2 lying on the floor, with no respirations and no B/P, 911 called and CPR was initiated. R2's family member was noted to be at the bedside. The note documents that V25 was notified about R2 status and change in condition. R2 was transferred to local hospital via 911 paramedics. On [DATE] at 4:15 pm via phone V25 (physician) said that R2 came to the nursing home needing therapy and R2 also had a urinary tract infection. V25 said that he was made aware that R2 refused a lab draw. V25 was unable to recall when he was made aware of the refusal. V25 said that he spoke to R2 about refusing the lab draw. V25 said that he didn't document the conversation. V25 said that the INR is best method to determine the efficacy of the anticoagulant therapy. V25 said I could have put R2 on [MEDICATION NAME] but I didn't because I didn't know R2 levels.V25 was asked did staff make V25 aware of R2 refusal? V25 said that the PT/INR is the only way for him to evaluate and make dosage adjustments based on the results, V25 said that it may have been harmful to just stop the medication. The hospital lab result was reviewed with V25 noting a INR>20.0 flagged as (H) high, PTT>100.0 was flagged as (HH) double high, after reviewing the lab results with V25, V25 indicated that the results are dangerous, he also said that it was dangerous to stop the [MEDICATION NAME]. V25 said that he attempted to send R2 the hospital to get the lab drawn but R2 refused. V25 said that he didn't document the conversation with R2 in the notes or clinical record. When asked if it was safe to continue R2's current dosage of [MEDICATION NAME] without a PT/INR V25 said he didn't say it was safe, but said it could be more harm if he stopped the medication completely. V25 didn't respond when asked about decreasing the dose rather than stopping the medication completely. On [DATE] at 10:46am, via phone, V25 said that a verbal order to draw PT/INR was given and that V25 was not made aware of R2 condition declining, and after reviewing records R2 was not hemodynamically stable and that R2 should have been sent hours before the incident occurred. On [DATE] at 2:00pm via telephone, V25 said that he would provide records of the times he was paged by the facility on [DATE] on the status of R2. However V25 never supplied the survey team the accounts of the documented times that the facility paged him. A review of V25 physician progress notes [REDACTED]. R2 is on [MEDICATION NAME] and is not feeling well R2 doesn't want blood work, spoke to R2 about that R2 is on [MEDICATION NAME] and R2 would be at high risk [MEDICAL CONDITION] bleed, plan is to continue [MEDICATION NAME] and will adjust dose according to INR. On [DATE] at 10:10 am, V1 (Administrator) said the facility does not have an anticoagulant policy or protocol, V1 said we follow physician orders. V1 was asked did they have a corporate policy on anticoagulant therapy. V1 said we do not have a corporate policy on anticoagulant therapy, and that R2 always refused labs. On [DATE] at 10:35 am, V5 said that the facilities practice is to follow the doctor's order for anticoagulant therapies. V5 said that R2 was alert and oriented and refused lab draws, V5 said the physician was made aware of the refusal, and that R2 was informed of the risk of not allowing the lab draw. V5 said that the facility nursing staff did continue to follow physician orders [REDACTED].V5 said that when residents refuse lab work we notify the physician. On [DATE] at 2:45 pm V4 (nurse) was asked do you remember R2? V4 said yes. What do you remember about R2? V4 said I remember R2 needing therapy and refusing labs. The staffing schedule for [DATE] was reviewed with V4, and V4 noted that he worked on [DATE]. V4 said that nursing is responsible for notifying the physician when a resident refused a lab draw. V4 said that he notified the physician but V25 didn't give any new orders because V25 said that he would be coming into the facility later on [DATE], however V4 said that he notified the on-coming nurse of R2's refusal. V4 said that he couldn't recall if he documented R2 refusal and documented notifying the physician of the refusal. V4 said that it not be safe to administer [MEDICATION NAME] without a current PT/INR level.V4 said he didn't administer [MEDICATION NAME] to R2 between [DATE] through [DATE]. The electronic Medication Administration Record [REDACTED]. V4 said that something was wrong because he don't recall working that day. V4 said that the facility has a protocol that includes a [MEDICATION NAME] Level flow sheet which to be reviewed for current lab levels, [MEDICATION NAME] dosage, and when the next lab draw is due. V4 said that he can't recall a flow sheet on R2. But there is usually one for all residents receiving [MEDICATION NAME]. On [DATE] at 4:30pm, V26 (Nurse) was asked how did they monitor anticoagulant levels? V26 said , 'The lab book and the PT/INR tracking sheet. How do the nurses know what to do when the dosage change? V26 we check the PT/INR [MEDICATION NAME] flow sheet, we check the computer. If you do not have a PT/INR level what do you do? V26 said 'I haven't seen that happen but I would call the medical doctor and get a level before administering the medication. V26 said she doesn't feel it is safe to administer the medication without a current PT/INR. On [DATE] at 8:43 am, V48 (lab tech) via phone interview at the local outpatient laboratory, was asked what is the policy when a resident refuses labs? V48 said we notify the nurse and get them to sign the requisition. On [DATE] at 3:30pm, V12 said that she recalls R2. V12 said that R2 was alert and orient times ,[DATE] R2 knew what was going on, R2 usually used a walker to ambulate. V12 said that R2 went out to a local hospital via 911 and that V12 had sent R2 out after becoming unresponsive. V12 said I remember the aide telling me to come right away and when I arrived in R2's room R2 was unresponsive on the floor and staff member was doing CPR. V12 said that she then took over and ordered staff member to call a code and bring the crash cart. V12 said that R2 was a little weaker and asked for the washroom all evening and that R2 had fallen earlier so I put R2 at the nurses station. V12 said that once R2's family member arrived R2's family member said that R2 did not look right, R2 just doesn't look good to. V12 said I thought R2 looked okay and all vital signs where good. V12 said that she didn't recall staff informing her that R2 appeared weak that shift. V12 said earlier that day R2 slipped out of her wheelchair onto the floor while trying to get into bed. V12 said that R2 usually uses a walker to ambulate and that R2 being in the wheelchair was not R2's normal baseline. V12 said that no one informed her that R2 was weak, and that she didn't conduct any assessments based on the knowledge. V12 said that I don't usually do an assessment unless there is a problem. V12 said because R2 fell earlier in the shift she placed R2 in the wheelchair next to nurses station so she could watch her, and because R2 usually can ambulate with a walker. V12 said it was after the 6pm fall. V12 said that she didn't recall R2 having an order for [REDACTED]. the physician of R2's vital signs and requiring oxygen. V12 said that she felt R2 needed the oxygen so she applied it. Nursing note dated [DATE] at 19:00 was reviewed with V12. V12 said that R2 was becoming restless and her oxygenation level was worsening so she adjusted the oxygen to 4 liters per nasal cannula with a saturation of 88%. V12 said that she may have notified the physician, but didn't document, V12 said the physician didn't give any new orders after relaying R2's status. V12 said that the times in the electronic medical record may not be true but these are all things that I did, V12 said that she charted when time allowed. V12 said she called the physician but it wasn't in the charting there was a lot going on. V12 said that she was aware of [MEDICATION NAME] and that it is a blood thinner. V12 said that in her opinion that it is not safe to administer [MEDICATION NAME] without a recent PT/INR level result on file. The electronic Medication Administration Record [REDACTED]. V12 said that she was not aware that R2 had refused the lab draw PT/INR. V12 said that she doesn't deal with lab draws, V12 said I wouldn't know if a resident refused a lab draw. V12 said she was aware of the PT/INR flow sheet and that the facility uses the form to track current [MEDICATION NAME] dosages, PT/INR results and to track when the next lab should be drawn. V12 didn't respond when asked if she reviewed the PT/INR flow sheet prior to administering the [MEDICATION NAME]. On [DATE] at 10:46am, V25 notified Surveyor and said that a verbal order to draw PT/INR was given and that V25 was not made aware of R2 condition declining, and after reviewing records R2 was not hemodynamically stable and that R2 should have been sent hours before the incident occurred.

Based on interviews and record reviews, this Facility failed to have an individualized plan of care for monitoring and supervising a cognitive impaired resident at risk for a fall and failed to provide visually or direct supervision for re-directing a resident who had behaviors that put the resident at risk for a fall. This applies to one resident R2 at high risk for falls in a sample of 13. This failure resulted in R2 sustaining a femur fracture due to a fall and requiring hospitalization . Findings include: According to R2's medical record, R2 has [DIAGNOSES REDACTED]. R2's initial MDS (minimum data set) assessment dated [DATE] denotes: R2 requires extensive assistance of 2+ staff members with transferring and toileting. R2's MDS's also note R2 frequently incontinent of bowel and bladder. R2's falls care plan, initiated 1/6/17 denotes: R2 is at high risk for falls in regards to decreased strength, endurance, balance, history of fall, low back pain, [MEDICAL CONDITION] joint disease, [MEDICAL CONDITION], and possible untoward effects related to medications. Initial 1/6/2017 interventions identified include: administer Calcium and Vitamin D per protocol, administer medication per physician's orders [REDACTED]. 1/14/2017 initiated interventions included: Reinforce wheelchair safety as needed such as locking brakes, have commonly used articles within easy reach, provide assist to transfer and ambulate as needed, reinforce need to call for assistance. 1/20/2017 initiated interventions included: Report development of pain, bruised, change in mental status, ADL (activities of daily living) function, appetite, or neurological status per facility guidelines post fall and evaluate medications if patient demonstrates charges in mental status, ADL function, appetite, neurological status etc 2/10/2017 initiated intervention: Fall risk- offer toileting during frequent rounding. 2/20/17 initiated intervention: Family educated to not leave resident alone in room. 2/24/2017 initiated intervention: Send to ER (emergency room ), On 3/6/18 at 1:40pm, V22 (family member) stated that R2 was evaluated by a neuropsychologist that informed V22 that R2 should never be left alone. A neuro-psychology evaluation dated 2/01/2017 was completed for R2. The evaluation had the following information: Identifying Information and Reason for Referral include-R2 is at the facility for physical rehabilitation after a fall at home. R2 nurse reports he is frequently confused and has trouble sleeping making him a safety risk as he often tries to get out of bed on his own. Summary included-Altogether, his profile is characteristic of both [MEDICAL CONDITION] and [MEDICAL CONDITION] related dementia, exacerbated by depression. In light of R2 's difficulties with memory and executive functioning, his ability to safely function independently is impaired. He will benefit from 24-hour supervision and managing of medication and meals. Recommendations- In light of R2's difficulties with memory and executive functioning, he requires 24 hour supervision and management of meals and medication. R2's progress notes dated 2/23/17 denotes: R2 is alert and oriented x1. V23 CNA (certified nursing aide) entered room when V23 heard R2 ask for help. R2 was sitting on floor, became agitated when asked what happened. R2 complained of pain in left knee but no visible injury noted, R2 had legs straight out in front of R2 with left leg bent up. R2 put back to bed with mechanical lift. When R2 laid in bed, the left lower leg was rotated internally. R2 was transported to hospital, Diagnosis: [REDACTED]. R2's fall initial investigation report, dated 2/23/17, notes V23 CNA exited another resident's room and heard R2 calling out. R2's door was closed. V23 proceeded to R2's room and opened the door, R2 was by the foot of the bed sitting on buttocks. V23 called for assistance and V24 CNA came. V23 had taken R2 out of room [ROOM NUMBER] minutes prior. V16 LPN (licensed practical nurse) was notified R2 goes into room and closes the door. R2 stated left knee hurt. V16 came to R2's room and performed a head to toe assessment. R2 was assisted back to bed with a mechanical lift device. V16 notified after R2 in bed that R2's left leg was internally rotated. V24 stated V24 last saw R2 at 7:00pm watching television. There is no documentation of when V16 last saw R2. The timeline of events notes at 8:00pm, R2 was observed in R2's room and V23 brought R2 out of room; at 8:10pm, R2 was observed on floor sitting on buttocks; at 8:30pm, R2's physician and family member were notified; and at 9:30pm, R2 was transported to the hospital for evaluation and treatment. On 2/25/17, the summary of critical information obtained during the investigation notes on the dementia nursing unit R2 wanders around the unit into R2's room and will close the door. R2 is impulsive and has poor awareness of safety. On 3/9/18 at 2:50pm, V12 CNA stated that she considers all residents on the dementia nursing unit to be at high risk for falls. V12 stated that residents are supervised at all times while in dining room or television area/nurses station. V12 stated that staff rotate throughout the shift supervising residents in the dining room and nurses station. V12 stated that if a resident needs toileting assistance, another staff member is notified to monitor residents while V12 assists that resident. On 3/13/18 at 3:45pm, V16 LPN (licensed practical nurse) stated that she does not recall R2 or any details related to fall on 2/23/17. V16 stated that for residents that frequently get out of bed or wheelchair and try to ambulate unassisted, she will do frequent rounds or sit outside of resident's room watching resident. V16 stated that residents on the dementia nursing unit are supervised continuously. V16 stated that one staff will be with the residents in the dining room, one will be in television area/nurses station with those residents, and one staff will round on residents in their rooms. Residents are not left unattended in the dining room or television area.

Based on observation, interview and record review the facility failed to put interventions in place to prevent falls and failed to provide supervision for one of four residents (R1) reviewed for falls. This failure resulted in R1 being hospitalized with a distal humerus fracture with possible radial head fracture, and acute bilateral nasal bone and nasal septal fractures with mild leftward angulation. Findings Include: R1's face sheet [DIAGNOSES REDACTED]. On [DATE] at 10:28 am, Z1 (R1's family) stated that R1 expired on [DATE]. Z1 stated that he received a call on [DATE] at around 9:30 pm informing him that R1 had fallen and was being transferred to the hospital. Z1 stated that he had spoken with staff on several occasions concerning R1's risk for falling. Z1 stated that the family requested restraints or alarms for R1's safety and was informed that the facility is restraint and alarm free. Z1 stated that he was notified on two occasions that R1 was observed walking around with the rolling bedside tray without calling for assistance. Z1 stated that he is concerned because the facility did not put safety measures in place after R1's family expressed concerns for R1's safety. R1's incident report dated [DATE] indicates R1 was face down on the floor; face was bloody; unable to assist up; called 911 emergency. On [DATE] at 2:46 pm, E12 Certified Nursing Assistant (CNA) stated that R1 would constantly get up alone to go to the bathroom. E12 stated that R1 would be re-directed to call for assistance when getting up. E12 stated that R1 was sometimes confused and did not always seem to understand. E12 stated that R1 pushed himself into the bathroom using the rolling bedside tray table approximately one week prior to falling. On [DATE] at 9:41 am, E9 CNA stated that R1 was sitting up in the chair in his room and the nurse had just given him medication. E9 stated that on [DATE] around 9:30 pm she was doing rounds to check the residents when she observed R1 lying on the floor in his room in a puddle of blood. E9 stated that R1 seemed confused and stated, get me up. E9 stated that R1 was a fall risk and was always getting up without assistance. E9 stated that she would check on R1 every 30 minutes while he was awake in his room because he often tried to get up. The facility could not provide documentation of frequent rounds. E9's written statement dated [DATE] includes the following: E7 Registered Nurse (RN) went in to give R1 medication; he was sitting in his chair; when E9 made rounds R1 was found face down on the floor; he tried to get up on his own, which he has been doing lately and was told repeatedly not to get up without help. R1's hospital records dated [DATE] includes the following: R1 states that he slipped and fell on to his face and right side; R1 is complaining of right elbow, right shoulder and left knee pain; R1 was bleeding from the nose profusely initially; x-ray to right elbow revealed a distal humerus fracture with possible radial head fracture. R1's computated tomography scan (CT scan) of sinus facial bones indicates R1 suffered acute bilateral nasal bone and nasal septal fractures with mild leftward angulation. On [DATE] at 1:25 pm, E7 RN stated that on [DATE] she was the nurse for R1. E7 stated that she had just given R1 his evening meds and asked him if he needed anything, which he did not. E7 stated that R1 was sitting up in the wheelchair when she left the room. E7 stated that approximately ,[DATE] minutes after she left R1's room, E9 CNA informed her that R1 had fallen. E7 stated that R1 was observed face down on the floor with blood appearing to be coming from his nose. E7 stated that R1 seemed dazed but stated, I'm ok. E7 stated that she could not get vitals or do an assessment on R1 because he was too heavy to move. E7 stated that 911 emergency was called and R1 was taken to the hospital. E7 stated that R1 never tried to get up without assistance while she was caring for him. R1's patient admission/readmission screen undated indicates that R1 has a history of falls. R1's skilled nursing note dated [DATE] at 4:42 pm includes the following: R1 has a fear of falling and his family was concerned. The family said he never said that at the hospital. Writer was informed by the family that we get him up a lot for therapy, toileting, and meals and that it is a valid concern that patients have. R1 also has dementia and forgot what we were discussing as he started to make jokes. On [DATE] at 9:30 am, E2 Director of Nursing (DON) stated that R1 had increased visual supervision due to his fall risk. The facility did not provide documentation to support increased visual supervision for R1. On [DATE] at 3:50 pm, E2 DON stated that all residents are at risk for falls and the facility does not use a scale to rate residents level of fall risk. E2 stated that each residents plan of care is individualized to the meet the needs of the resident.

Based on interview and record review, the facility failed to provide a safe physical transfer for a resident according to care plan and policies governing resident transfer. This applies to one resident (R1) reviewed for injury in a sample of three. This failure resulted in R1 sustaining a right shoulder dislocation. Findings include: R1 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. On 11/13/15 at 11am, R1 was observed with a sling on her right arm. R1 stated On 11/3/15, the day nursing assistant pulled my right hand to get me out of bed. R1 stated I told her not to do that. You are going to hurt me. I was the one who got hurt. She pulled my shoulder out of its socket. Everyone thinks they are so strong. It hurt for a long time. I don't want the girl to get in trouble. Now, I have to be fed. It is my right shoulder. R1's BIMS (Brief Interview Mental Status) score dated 10/29/15 was 15 out of 15. R1 was alert and oriented to time, person and place on 11/13/15 at 11 am. On 11/13/15 at 11:20am, E2 (Licensed Practical Nurse) stated that she cared for R1 on 11/3/15 during the day shift. E2 stated that Z1 (Physical therapist) came to her on 11/3/15 in the morning and stated that R1 was complaining of pain in her right arm. Z1 stated that R1 told her that the nursing assistant who was caring for her in the day (E6) pulled her right hand to get her out of bed on 11/3/15. E2 stated that E6 (Certified Nursing Assistant) told her that she pulled R1's right hand to get her out of bed. E2 stated that she told E6 that she cannot get someone out of bed by pulling on the resident's hand. E2 stated that she did an incident report, notified the daughter and Z2 (Attending Physician) of the incident. E2 stated that there was no swelling the day of the incident. E2 stated that R1 did not want to take any pain medication for the pain in her right arm. E2 stated that when she came back to work on 11/4/15, she contacted Z2 for an x-ray order because E2 stated that she assessed R1's right shoulder on 11/4/15 and R1's shoulder was super flexed and looked abnormal. R1's right shoulder x-ray was done on 11/4/15 and R1's x-ray results dated 11/4/15 showed a right shoulder dislocation. E2 stated that R1 went for an orthopedic appointment on 11/5/15 and is currently wearing a sling. On 11/13/15 at 12 noon, Z1 (Physical Therapist) stated that R1 told her on 11/3/15 that the morning nursing assistant pulled her hand while transferring her out of bed. Z1 stated that R1 told her that the pain started after E6 pulled her out of bed using R1's right hand. Z1 stated that R1 was not able to ambulate on 11/3/15 during therapy due to the pain. Z1 stated that she reported this incident to E2 (Nurse). On 11/13/15 at 3:20pm, E7 (Assistant Director of Nursing) stated that she conducted the investigation regarding the incident on 11/3/15 with R1 and E6. E7 stated that R1 told her that E6 got her out of bed in the morning on 11/3/15 by pulling her right hand. E7 stated that E6 was the only nursing assistant in R1's room for the transfer. On 11/13/15 at 3:30pm, E6 stated that when she assisted R1 in the morning of 11/3/15, R1's right arm hurt and she reported this to the nurse. E6 stated that she did use R1's arm to get her out of bed. On 11/17/15 at 9:30am, Z2 (Attending Physician) stated that R1 told her that when an nursing assistant was getting her out of bed after morning care on 11/3/15, the nursing assistant snapped her arm. R1's care plan dated 10/23/15 reads Self care deficit related to needs extensive assistance with her bed mobility and transfer and most of her adls, incontinence of bowel and bladder, muscle weakness, recent hospitalization , [DIAGNOSES REDACTED]. R1's care plan goal for this problem reads Will receive assistance necessary to meet activity of daily living needs. R1's MDS (Minimum Data Set) dated 10/29/15 reads 2 person physical assist with transfers, extensive assist with transfers between surfaces including to or from: bed, chair, wheelchair, standing position. The facility's investigation report dated 11/3/15 reads R1 is a x2 max assist during transfer. E6 was transferring R1 to the wheelchair. When E6 assisted R1 to sitting position, E6 accidentally pulled on R1's arm. R1 complained of pain to right shoulder. X-ray was done which showed dislocation of right shoulder. Ice packs applied. MD gave order for R1 to see orthopedist. R1's radiology report dated 11/4/15 reads The humerus is anteriorly and inferiorly dislocated with respect to the glenoid. There is no fracture. Conclusion: Anterior shoulder dislocation. The facility's transfer policy: bed-chair/wheelchair policy dated 1/2011 reads The purpose is to move safely from bed to chair or wheelchair and back again. The policy reads to instruct resident to lean forward to get body weight over hips. The policy does not read to pull resident's hand to get them out of bed and into the wheelchair. On 11/17/15 at 9:30am, E8 (Director of Nursing) stated that the facility does not have a policy for 2 person transfer. E8 stated that the facility only has a transfer policy.

Based on interview and record review facility failed to follow the manufacture instruction's for the use of a lift and injury-reducing devices for one resident out of three residents (R1) reviewed for falls in a sample of four. This failure resulted in the facility not following their lifts device manual policy and not reading the manufacturer ' s operating instructions for the sit-stand mechanical lift which subsequently resulted in R1 sustaining an oblique fracture. Findings include: R1's nurse note dated 2-15-15 written at 11:55 pm denotes R1 is alert and oriented times one with Dementia. CNA stated that when she was transferring R1 using the sit stand lift, R1 buckled her knees and let go of hand rails at 8:15 pm R1 was transferred to the bed and not moved any further. R1 had increased pain to right arm with noted swelling, 911 called at 8:18 pm Doctor was made aware at 8:25 pm and stated to notify emergency department of R1 ' s condition. E7 (Registered Nurse) stated on 4-16-15 at 11:00 am she was working on 2-15-15 and was walking down the hall when the CNA (E1) had called for help. E7 stated she entered R1's room and saw E1 holding R1 around her waist and noted R1 next to the machine being held by E1 around her waist. E7 stated was told by E1 that R1 had let go and her arms went up and had slid thru the machine. E7 stated they laid R1 down assessed and noticed that R1 ' s right arm was swollen and red. Called the doctor and sent R1 to the hospital. E7 stated R1's normal status was alert times 1-2 with some confusion. R1' s hospital x-ray report dated 2-15-15 denotes X-ray with 2 views the right humerus were obtained. Findings: A commuted fracture is demonstrated involving the mid shaft of the right humerus. The distal fracture is displaced laterally approximately 1.3 centimeters. Per nursing home record, they were trying to lift the patient (R1) when her left arm got stuck and they noticed the deformity of the right arm. Consultation report right arm pain secondary to fracture right humerus. R1's incident report dated 2-15-15 denotes R1 sustained injury to left arm during transfer with sit-stand lift. R1 ' s knees buckle. Z1 (Doctor) stated on 4-15-15 at 1:20 pm the cause of R1's fracture in her right arm was more than likely from it getting stuck in the lift machine when the certified nurse aide (CNA) was transferring her. E1 (Certified Nurse Aide) stated on 4-10-15 at 3:30 PM R1 was not able walk or stand by herself. E1 stated she was in R1 ' s room on 2-15-15 by herself getting R1 ready for bed. E1 stated R1 was sitting in her wheel chair and approached R1 with the sit to stand to machine. E1 stated she told R1 that she was going to put her on the machine and placed the sling around her waist-lower back. E1 stated she pulled ropes to tighten sling and placed R1 ' s feet on the foot rest. E1 stated there were no straps for the feet/legs and was not aware of any lower leg straps. E1 stated she instructed R1 to hold on to the poles. E1 stated she stood in front of R1 and started to lift R1 up with the remote control to the lift. E1 stated was lifting from R1 from the wheel chair R1 next the bed when R1 suddenly started screaming saying she was dying . E1 stated moment's later R1 knees gave out her, feet slipped off the foot rest and legs were separated from the knee rest (not leaning against the knee board). E1 stated R1 was dangling thru the waist strap when she went around the machine to grab her and R1 had already let go of the poles and slid down thru the waist strap and her arms were up in the air. E1 stated grabbed R1 by her waist before she slid all the way to the floor. E1 stated she called for help and E7 came to their aide. E1 stated before that incident on 2-15-15 she thought because R1 needed staff to support her when standing she believed that R1 should had been using the other mechanical lift (full sling) no the sit-stand but was just doing what she was told and what was written on the Kardex. E1 stated she did not read the sit-stand lift operating instructions and was not told do by her managers to do so either. Facilities Minimum data Set Manual instructions for activities of daily living assistance steps for assessment denotes talk with direct care staff from each shift that has cared for the resident to learn what the resident does for him/herself during each episode of each ADL activity as well as the type and level of staff assistance provided. R1's minimum data set section ((MDS) dated [DATE] and 2-14-15 denotes transfer from bed, chair, wheelchair standing position extensive assistance staff provide weight bearing support and Two + person physical assist. Section G0303-moving from seated to standing position not steady, only- able to stabilize with staff. R1's minimum data set Section C- Cognitive Patterns dated 11-14-14 and 2-14-15 denotes R1 unable to complete interview score-99. Section C0700 short term memory problem. Section C0800 long term memory problem. E8 (Minimum Data Set Coordinator) stated on 4-16-15 at 10:15 am section G does denote that R1 required two + people for physical assist when transferring from the chair to the bed and to stabilize R1. E8 stated does not know why two people were not transferring R1, which would be a question for nursing manger to answer. E8 stated that R1 was coded to need two + physical assist which meant a minimum of two people were required to assist R1 to stand but if she required more it would be up to staff discretion. E8 stated R1 ' s care plan is supposed to be updated by nursing. E6 (Registered Nurse Manager) stated on 4-16-15 at 10:50 am was the nurse supervisor over the floor that R1 was residing on. E6 stated she did not know the MDS had coded R1 as needing two + person assist to stabilize her with transfer form bed to chair. E6 stated if known that would have questioned the MDS staff about their assessment. E6 stated R1's care plan and Kardex should have been updated by the MDS staff to reflect their assessment. E6 stated she never read the operating instructions manual for the sit-stand mechanical lift and was not aware that R1 needed to be assessed for leg straps. E6 stated had no knowledge of who who did R1's transfer screening assessment worksheet because the facility does not keep a record or copy of it. E6 stated that whoever did the R1's transfer assessment put their results on the Kardex and care plan and that was what they follow. E5 (Director of Nursing) stated on 4-10-15 at 4:15 PM that she never read the Operating instructions for sit-stand lift and was not aware that leg straps could be used or that a resident needed to be assessed for them. E5 stated did not know if R1 was assessed for leg straps because there is no documentation in R1's record about assessment for leg straps. E5 stated there is no patient transfer assessments in R1 records for the sit-stand mechanical lift. E5 stated the lift assessment was done but the record of it was not kept. E5 stated R1's patient transfer assessment sheets were thrown away so the facility has no record of R1's assessment for the sit-stand mechanical lift. E5 stated staff did not need to read the operating instruction manual for the sit-stand mechanical lift because the in-service that staff receives from the facility is enough training. E5 stated that their policy is to do the patient transfer assessment and then record results on the residents Kardex. Facility's operating instructions for sit-stand mechanical lift denotes Warning: Only use this or other methods after a satisfactory professional assessment has been carried out on the individual patient. Warning: Determine whether the patient requires the lower leg straps. Failure to understand and obey this warning may result in injury to you or to others. Lower leg straps an optional accessory used to ensure the lower parts of the patient ' s leg stay close to the knee rest (proactive pad) for correct lifting procedure. Facility's lift and injury-reducing devices manual denotes Patient-Care Employees: during performance or patient-handling tasks, use proper body mechanics techniques, and operate mechanical lifts, friction-reducing devices and other approved equipment/aids according to manufacturer's operating instructions. Number of employees required when operating a lift: Although one person can operate most models of hydraulic lift, it ' s advisable to have two staff members present to stabilize and support the patient. As such, a two-person lift is required when using lift equipment. Under special circumstances and proper assessment of the patient, a one-person lift may be acceptable. The care plan team must determine and approve the procedure for less than two-person. When a patient' s mobility or ability to assist may vary throughout the course of day or from day to day, this change in mobility status is noted in the patient ' s Care Plan. The nurse supervisor assist with ongoing patient screenings on admission and with change of condition. Manage patient identification of lifts and friction-reducing devices on Kardex. R1's care plan denotes is at risk for falls due to decreased safety awareness unsteady gait, muscle weakness incontinence and two person transfers initiated 8-2-09 and last updated 11-4-14 interventions provide assist to transfer, report change in mental status and ADL functions; R1's Kardex dated 11-5-15 denotes ADL (activity of daily living) assist-usually one person.

Based on interview and record review, the facility failed to comprehensively assess, identify and implement effective fall interventions after repeat falls and failed to supervise 1 of 5 residents (R1) reviewed for falls in a sample of 9 residents. This failure resulted in fractures requiring hospitalization and surgical treatment for [REDACTED]. Findings include: The Medication Review Report documents R1 as a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, last completed 4/11/13, documents R1 required extensive assist of one person physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed), transfer and dressing. The facility nursing Admission Screen, 3/12/13, documents R1 as at risk for falls due to unsteady gait, muscle weakness, urinary incontinuce, diuretic medication, psychotropic mediction, cardiovascular medication and undrlyging health conditions. R1's mental status is documented as moderately impaired, decisions poor and cues/supervision required. The Physical Therapy Summary, completed by E18 (Physical Therapy Assistant) on 4/9/13, documents bed mobility as moderate assist to roll and turn. R1's Care Plan documents a self care deficit. This care area was initiated on 3/13/13 with the only revision occurring on 5/10/13. The interventions were to transfer with a gait belt for safety (implemented 5/10/13) and assist with activities of daily living care (implemented 3/13/13). R1's Care Plan documents her at risk for falls due to impaired balance/poor coordination, dementia, muscle weakness and infection initiated on 3/13/13. On 3/12/13 interventions initiated were bed in low position, have commonly used articles within easy reach, reinforce need to call for assistance, and reinforce wheelchair safety as needed, such as locking brakes. On 3/22/13 interventions initiated were therapy evaluation and treatment and administer medication per physician orders. There are no interventions or changes placed for falls after 3/22/13. The facility Incident Report, On 4/4/13 at 7:50am, documents R1 as found on the floor of her bedroom. The facility Investigation Report, 4/4/13, documents R1 was not able to describe how she fell . The Summary of Critical Information Obtained During the Investigating documents R1 with contributing factors of impaired balance during transition, impaired standing balance and no awareness for safety and limitations due to impaired cognition, assist with transfers and use of wheelchair. A stat X-ray of the left shoulder, left arm and lumbar spine were completed and negative. The Conclusion documents no abuse or neglect is substantiated after the investigation and will continue to monitor patient safety and continue therapy for rehabilitation. The facility Incident Report, 4/15/13 at 6:45pm, documents R1 was found laying on the floor next to her wheelchair in another residents bedroom. The facility Investigation Report 4/15/13 until 4/16/13, documents the Timeline of Events as R1 was last seen at nurses station prior to the fall and then she was found in another residents room next to her wheelchair. "R1 must have wandered away from her room and went into the another residents room." The Summary of Critical Information Obtained During Investigation documents R1 was admitted with [DIAGNOSES REDACTED]. R1 does not realize her limitations and gets up and ambulates without assistance. "(R1) needs constant supervision and reminders to sit in her chair. (R1) needs one assist with Activities of Daily Living, transfers and ambulation.. We will continue to monitor the patient frequently and assist with her needs. R1 is currently receiving therapy." Action taken was documented as "Complete body assessment and neuro check. No injury. MD and Power of Attorney Notified." The conclusion documents no abuse or neglect is substantiated after the investigation. The facility Incident Report, 5/9/13 at 10:10am, documents R1 had a fall with a head injury. The facility Investigative Report, 5/9/13 until 5/17/13, documents R1 was observed on the floor in her room beside her bed. Nursing Assistant reported she was providing morning care. Patient in bed completely dressed, bed in low position, nursing assistant setting up wheelchair then discover patient lying on her right side on the left side of the bed. The investigation packet included interviews of staff members interviewed by E4 (Nurse Manager). The staff interviewed were Z4 (Nurse Practitioner), E7 (Nursing Assistant), E18 (Physical Therapy Assistant), E17 (Nurse). E7 was interviewed a second time. On 6/18/13 at 2:15pm, E2 (Administrator) stated "A second interview with (E7) was completed because we just wanted to make sure facts were accurate and nothing was missed." The Summary of Critical Information Obtained During Investigation documents, "(R1) was identified upon admission with fall risk factors such as gait problems, difficulty maintaining standing position, dehydration, poor safety awareness related to dementia. (R1) has poor oral intake, based on re-enactment of the fall it was determined (R1) rolled on her left side on the right side of body. Root cause determined to be ongoing decline in (R1's) condition as noted in physician and nurse practitioner progress notes. Facility continued to work on interventions (appetite enhancer, nutritional supplement, possible insertion of tube feeding, intravenous hydration, hospitalization ) for (R1's) decline family refused recommended tube feeding insertion. Family undecided about code status and palliative care. Nurse Practitioner, Physician Therapy and Nursing Assistant reports through interview patient keeps eyes closed through care, therapy and feeding. Will open eyes only when verbally directed by staff to open eyes during feeding, care and therapy." Action Taken During Investigation documents, "Resident evaluated by Nurse Practitioner as first responder. Medical Record, fall risk and care plan reviewed and Investigation initiated." Conclusion documents, "Upon conclusion no abuse substantiated. It was determined through investigation, interview, re-enactment and record review (R1) was experiencing an acute change in condition with active infection and treatment. Despite physician, Nurse Practitioner, family and facilities effort to improve (R1's) condition and make her comfortable and safe she continued to be at risk for falls." On 6/19/13 at 9:37am, a phone interview was conducted with E7 (Nursing Assistant). E7 stated R1 was in a private room and had no roommate. The only individuals in the room at the time R1 fell was R1 and E7. E7 stated around 8:00 to 8:15am E7 requested assistance from another nursing assistant to position R1 in bed for breakfast. E7 stated she passed all other residents trays first then served R1 last. R1 needed assistance to eat and only took a few bites. R1 said she was done and E7 exited room. When E7 returned to the room an employee from Therapy was assisting R1 to eat the remainders of breakfast. R1 ate approximatly 10%. E7 then returned to R1's room later to provide care and to get R1 into a wheelchair. R1 was dressed completely except for socks and shoes. E7 stated she then lowered the bed again and then moved towards the foot of the bed to move the wheelchair closer to the bed to transfer R1. E7 stated the wheelchair would not move, a rubber therapy band was stuck in the chair. E7 stated she then checked R1 and she was fine. E7 stated she then tipped over the wheelchair to pull out the band. E7 stated her back was to R1 for the time period of "2-3 minutes, but no longer than 5 minutes." E7 said she heard a noise and turned around to find R1 on the floor. R1 was laying on her right side, on the window side of the bed (R1's left side of the bed if laying supine in the bed). E7 reported she then went to the door and yelled for help. E7 reported E17 and Z4 responded. E7 stated R1 did not have mats on the floor. E7 stated the bed was at her knee level, approximately 8 inches. E7 stated R1 was at risk for falls and was to utilize a low bed at all times. R1 did not have siderails on the bed. On 6/19/13 at 2:30pm, Z4 stated she was at the nurses station when E7 called for help. E7 stated she went to the room with nurses and R1 was on the floor with her head resting on the bottom area of the nightstand. Z4 directed E5 (Nurse) to go call for an ambulance. Z5 stated the bed was in low position but couldn't recall how low. "I remember thinking the bed was low, at least (R1) didn't fall from a high area." Z4 reported, "There was a gray mat on the floor, I think. But if so, I am not sure if she was laying on it." Z4 stated R1 had been able to turn in bed, stand and walk but had declined. "Z4 stated, I don't believe R1 would have been able to stand on own, but possibly roll. R1 was confused." Z4 stated E7 didn't provide any details surrounding the circumstances of the fall in her presence. On 6/19/13 at 9:07am, E17(Nurse) stated she had provided wound care to R1 the morning of the fall on 5/9/13 for excoriation to the buttock area which required turning R1. "(R1) needed help initially during the treatment to turn but could help." E17 reported being at the nurses station when she heard E7 call for help. E17 stated she entered the room. E17 remembered Z4 was also present. R1 was on the floor next to the bed on the window side of the room. E17 stated the bed was down, approximately 5-6 inches from the floor. E17 stated the beds do not sit flush to the floor because they roll and must be elevated slightly off of the floor to lock. E17 stated she left the room several times to obtain supplies as directed by Z4. E17 stated E7 didn't provide any details of the cause of the fall while she was in the room. E17 didn't remember if mats were present. On 6/19/13, at 9:50am, E18 (Physical Therapy Assistant) stated R1 was not feeling well the day of the fall on 5/9/13. R1 was in bed at approximately 9:20am and spent about 30 minutes with R1. As E18 assisted R1 with breakfast, R1 kept eyes closed but would respond when asked to. That morning E18 assisted R1, R1 required more assistance than usual and was "shaky." R1 had declined since admission and wasn't sure if R1 would be able to roll independently in bed on this day. E18 stated R1 had Clostridium Difficile which was treated after admission and then required a second round of treatment for [REDACTED]." R1 previously would move around in bed and would turn herself to left side. R1 made no attempts to reposition self in E18's presence that morning. E18 stated she left R1's bed in low position, approximately 12 inches from the floor with the call light in her left hand after tucking the covers around R1. On 6/19/13, Z3 (Attending Physician of R1/Facility Medical Director), stated "Yes, it is possible someone could incur fractures with a complex medical [DIAGNOSES REDACTED]. Bones must be weak. I was not there but (R1) was progressively declining. If your asking, yes, it could happen but I cannot say for certain if this was the reason because I was not there." R1 required surgery for [REDACTED]. On 6/19/13 at 1:15pm, E4 (Nurse Manager) stated the facility assesses all newly admitted residents for falls and a care plan and interventions are implemented. Once a fall occurs the first responders assess the problem, handle the injuries and interview the resident. The fall is analyzed for the root cause and documented on the fall form. The interdisciplinary team reviews all falls the next working day, troubleshoots and makes changes to the care plan as needed. On the off shifts the nurse is responsible to immediately implement interventions. E4 stated after the unwitnessed fall on 4/4/13, frequent monitoring was initiated with every 30 minute rounds. E4 stated they are documented on a form. R1 was also to continue therapy and the low bed which were implemented at the time of R1's admission due to being at risk for falls. E4 stated 4/15/13 R1 was found on the floor in another residents room. The interventions were to reinforce wheelchair safely. E4 stated R1 had dementia and was confused so she was redirected in order to reinforce wheelchair safety. No new interventions were implemented because "she hadn't declined yet, had the same risk factors and monitoring continued." E4 stated R1 could reposition herself at one time, but the week prior to the fall she was declining and the ability to reposition herself was fluctuating. E4 stated a low bed is less than 12 inches from the floor. On 6/19/13 at 2:40pm, E4 stated R1 was frequently supervised, not constantly supervised as documented on the Investigation Report, 4/15/13. Supervision is documented on the 30 minute monitoring tool. E4 stated constant supervision would require a sitter. On 6/19/13 at 3:45pm, E4 stated she was still looking for the monitoring sheets. The facility was unable to provide evidence of enhanced monitoring (frequent or constant) which was required per the Investigative Report completed by E4 on 4/15/13. On 6/19/13 at 8:48am, E3 (Director of Nursing) stated, the facility doesn't have a policy for supervision. Supervision needs are individualized. The hospital Report of Examination, 5/9/13, documents R1 as having a minimally displaced fracture of the distal clavicle and a suspicious non-displaced fracture of the right hip. The facility Fall Practice Guide, 2011, documents Change in Condition or Fall Occurrence an interdisciplinary care plan team reviews the patients most recent fall evaluation to determine if the patients present condition or status has changed. The care plan is revised as clinically indicated to meet the patients current needs. The facility was unable to provide evidence R1's care plan was reviewed by an interdisciplinary team after two previous falls with a thorough analysis of the root cause, evaluation of recommended needs for supervision and measures instituted to prevent further falls. Review of the facility policy for provision of Morning Care, 12/2009 was reviewed. In the procedure after the completion of care activities the resident is repositioned for comfort.