Every finding on record at Avantara Park Ridge

Based on observation, interviews, and record review, the facility failed to ensure a resident received appropriate incontinence care and repositioning that led to the development of a pressure ulcer for 1 (R85) of 3 residents reviewed for pressure ulcers in total sample of 48. This failure resulted in R85 developing stage 3 pressure ulcer to the right buttock.Findings include:R85 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Multiple Sclerosis; Major Depressive Disorder; Hemiplegia and Hemiparesis Following Nontraumatic Intracerebral Hemorrhage Affecting Left Dominant Side; and Essential (Primary) Hypertension.MDS (Minimum Data Set) assessment dated [DATE], shows R 85 is at risk of developing pressure ulcer/injuries and does not have unhealed pressure ulcers/injuries at the time of the assessment. On 07/13/2026 at 12:01 PM Upon interview R85 stated she has a new wound on her buttock. R85 observed sitting in the wheelchair, with towel beneath R85. On 07/14/2026 at 9:47 AM R85 said her wound care was done today (7/14/2026) at 6:30 AM and she doesn't wish for a surveyor to request observation of another wound care assist. R85 said she did not have wound care done on 7/13/2026. On 07/14/2026 at 1:25 PM V20 (Wound Crae Coordinator RN) said, On 7/9/2025, I was notified that when CNA was providing patient care, she discovered an open wound on R85's right buttock. I came to assess the wound immediately. The wound measured 0.5 cm x 1 cm x 0.1 cm. I staged it at stage 3 right buttock pressure ulcer. I notified R85's attending physician and V21 (Wound Care Nurse Practitioner). The attending physician recommended proceeding with facility wound care protocol, which consists of medical grade honey, calcium alginate, and covering with silicone foam dressing. V21 (Wound Care NP) assessed R85 on 7/9/2025 as well. V21's (Wound Care NP) treatment recommendation was the same. Dressing changes were initially scheduled to be done three times a week, we suggested the dressing should be done daily due to the area where it is, it could get easily soiled. R85's dressing was changed on 7/9/2026 when R85 was initially assessed, then on 7/10/2025 due to Monday, Wednesday, Friday dressing change schedule, and yesterday (7/13/2026). R85 sits in the wheelchair all day long and wears double diapers, she also uses flat sheet and bath towel over the wheelchair cushion, so there are too many layers of fabric. If there are too many layers, the crease formation of linens creates pressure and eliminates preventative cushion purpose, whereas double diapering maintains constant moisture.On 07/14/2026 at 2:09 PM V16 (Certified Nurse Assistant) said, R85 likes to be double diapered. I know residents are not supposed to be double diapered. We even told R85, this is probably why she is getting all these ulcers from. Everybody knows we place two diapers for R85, all nurses know. R85 always wears double diapers, and she gets incontinence care once per shift. I just changed her, I took off two diapers, placed another two, and she is good until evening shift.On 07/15/2026 at 12:01 PM V21 (Wound Care Nurse Practitioner) said, I assessed R85 on 7/9/2026 for a new right buttock wound, and then again yesterday (7/14/2026). On 7/9/2026, upon initial assessment, R85's right buttock wound was unstageable with 75% slough, measuring 0.5 cm x 1 cm x 0.1 cm. I recommended dressing to be changed every three days, but I changed it to daily on Monday (7/13/2026), it was indicated in the initial assessment that it can be changed as needed. On 7/14/2026, the wound was assessed to be stage 3 right buttock pressure ulcer with 100% granulation tissues, measuring 0.4 cm x 0.5 cm x 0.1 cm. My best judgement is that R85's personal behavior led to developing of the wound, lack of offloading, sparse incontinence care, double diapering, and multiple fabric layers. As far as I understand, R85 asks to be in the wheelchair, early in the day, and stays in the wheelchair until after dinner, which is concerning. I expressed my concerns to R85, I said that it is not good to sit in soiled diapers all this time. R85 has a wound and remains in the same position for extended period of times. I was aware that R85 requests to be double diapered, I was not aware that that was actually the case. The facility discovered there was increase DTI occurrence in the facility, so I did facility staff in-service in June of 2026, the training pertained to pressure ulcer prevention, proper equipment, turning schedule, and proper toileting.Wound Assessment Report dated 7/9/2026 shows R85's new wound assessed to be located in the right buttock area, measuring 0.5 cm x 1.0 cm x 0.1 cm with unstageable severity. Recommended treatment: 3 times per week, cleanse with vashe, medical grade honey, silicone bordered gauze.Wound Assessment Report dated 7/14/2026 shows R85's new wound assessed to be located in the right buttock area, measuring 0.4 cm x 0.5 cm x 0.1 cm with stage 3 severity. Recommended treatment: 3 times per week, cleanse with vashe, medical grade honey, silicone bordered gauze.Physician order sheet dated 7/13/2025 shows to provide daily cleanse with wash, pat dry, and apply medical grade honey then cover with silicone bordered gauze every day shift and as needed to R85's right buttock.Treatment Administration Record dated 7/1/2026 - 7/31/2026 confirms R85's wound care was done as per physician order.Wound care plan prior to 7/9/2026 regarding R85's right buttock wound does not show wound preventative measures other than to administer treatments as ordered and monitor effectiveness and weekly monitoring of wounds by wound care nurse or designee.The facility Ski Care Regiment and Treatment Formulary policy last reviewed 7/8/2026 reads in part, Residents who are unable to turn and reposition themselves will be turned and repositioned at least every 2 hours unless otherwise specified by the physician. Residents with stage III and/or stage IV pressure injuries will be paced in specialized air mattress like Low Air Mattress with an incontinence brief if they are incontinent only, incontinence pad which will also act as repositioning aid, and a flat/fitted sheet which are all necessary to prevent infection control issue.

Based on observation, interview, and record review, the facility neglected one resident (R146), out of 48 sampled residents; this failure negatively affected the dignity of this resident and potentially caused pain/discomfort due to being left to sleep at the dining table on their unit for the entirety of most days, as a non-verbal resident who cannot express their needs and are dependent on facility staff to anticipate their needs; this action goes against R146's care plan. R146's family member and staff members stated R146 remains in the dining room from breakfast until bedtime and is provided with a pillow on top of the dining table to sleep on instead of being returned to their room to nap. R146 appeared to be in an uncomfortable position and their family member/power of attorney has frequently requested to have R146 returned to their room and has been denied.R146 is an [AGE] year-old resident with an admitting diagnosis of bilateral osteoarthritis of the knee combined with but not limited to a diagnosis of Alzheimer's Disease with late onset. Findings:On 07/13/2026 at 12:03 PM, R146 was observed sitting in a wheelchair at a dining table in the dining room on the second-floor unit (P) with V8 (Family Member) present. This surveyor attempted to ask R146 questions, and they were incapable of responding. R146 presented with a flat affect and their facial expression did not change during this interaction.V8 stated R146 frequently falls asleep at the table in the dining room and has asked staff on multiple occasions (dates could not be recalled) for staff to return them to their room so they can nap in their bed. V8 stated they have been told since R146 requires a sit to stand device to be transferred, they are not able to always accommodate this transfer due to staffing, and the transfers have been denied. V8 stated they have stopped making this request because it's frustrating being told they are unable to provide this service to R146.V8 stated staff put a pillow on the dining table so R146 does not hit their head on the table when they fall asleep. V8 stated they feel this is taking away from R146's dignity and could be causing pain to R146's back from sleeping in that position at the table. V8 stated R146 is incapable of expressing pain and rarely changes their facial expression from a flat affect. V8 stated they hope R146 is not feeling pain by remaining up in their wheelchair and being expected to sleep with their head on the table each day.On 07/13/2026 at 1:45 PM, R146 was observed with a pillow in front of them at the table while they slept.On 07/14/2026 at 12:18 PM, V8 (Family Member) stated that after lunch on 07/13/2026, a pillow was placed on the dining room table due to R146 falling asleep and leaning forward in their chair to place their head on the table. V8 stated this is concerning because R146 cannot express if they are in pain or are wet and are left at the table from breakfast through bedtime, each day. Record review indicates a physician's order dated 06/01/2026 states in part but not limited to, Comfort-Focused Treatment: Primary goal of maximizing comfort. V8 also stated R146 has been directed by their eye doctor to always wear glasses due to their cataracts, however, due to the fear of the glasses breaking from hitting their head on the table, the glasses are not worn and V8 does not know how much R146 can see without them. V8 stated by R146 not wearing their glasses, they are being denied their right to see, just so they can remain at the table during the day.V8 stated they leave the facility at 1:00 PM each day and return to the facility around 4:20 PM and R146 is in the same spot at the table in the dining room, with a pillow in front of them.On 07/14/2026 at12:25 PM, R146 fell asleep at the dining table while speaking to V8 (Family Member). V8 stated R146 is often damp or wet when being changed for bed in the evening, and when they ask the staff if R146 was ever changed during the day, they state that R146 was sleeping and did not express needing to be changed. Record review of R146's care plan states in part but not limited to, that staff are expected to anticipate and meet the needs of the resident due to R146's diagnoses.On 07/13/2026 at 11:43 AM, V4 (Licensed Practical Nurse) was interviewed on the second-floor unit (P), and stated residents sit in the dining room from breakfast until bedtime each day. V4 stated this is their normal, on this unit, for their residents on a daily basis.On 07/13/2026 at 12:05 PM, V5 (Certified Nursing Assistant) stated the residents sit in the main dining room on the second-floor unit from breakfast until bedtime. V5 stated that some residents who request will be taken to their rooms to take naps, on occasion, but most of the residents are in the dining room for the entirety of each day. On 07/15/2026 at 12:44 PM, V1 (Administrator) was interviewed regarding R146 sleeping at the dining table on the second-floor unit (P). Regarding residents with dementia who are non-verbal, V1 stated their expectation is for staff to round on these residents to address and meet their needs.V1 stated if a dementia resident is sleeping at the table in the dining area, depending on their agitation level, the resident should be transferred to their bed. V1 stated if a non-verbal dementia resident's family member or power of attorney requests to have the resident put into their bed because they are sleeping, our staff is expected to move the resident to their bed to sleep comfortably. V1 stated if a staff member stated there are not enough staff to perform a transfer for any resident, that is inaccurate information and should not have been said. V1 stated there are always staff members available to transfer residents and, for that reason, staff should never say that to residents or their family members. On 07/15/2026 at 1:00 PM, R146 was observed sleeping in the dining room with a pillow placed in front of them on the table. R146 appeared to be attempting to hold their head up with their hand as their head would [NAME] while falling deeper into a sleeping state.On 07/15/2026 at 1:02 PM, V4 (Licensed Practical Nurse) stated staff will place a pillow on the table in front of residents who fall asleep while sitting in the chair/wheelchair in the dining room. V4 stated they place the pillow in front of the resident, so they do not hit their head directly on the table. V4 stated they only bring R146 to their room to sleep if their wife asks staff to; if V8 (Family Member/Wife) does not ask, R146 will remain at the table, sleeping. V4 stated R146's baseline is having a flat affect and cannot express if they are experiencing pain. V4 stated R146 does not offer cues or facial changes that would indicate they are in pain. This surveyor asked V4 how they would know if this resident was experiencing pain and they answered, I don't know.On 07/15/2026 at 1:10 PM, V2 was interviewed regarding residents sleeping at the dining tables. V2 stated if they came across a resident sleeping at a table, they would immediately wake them up to assess. For dignity purposes, the resident should be brought to their room, have their vital signs assessed and then be placed in their bed to sleep. V2 stated that any time a family member requests for a resident to be moved from a dining table to their room, for any reason including sleeping, their expectation is for staff to fulfill this request/need and bring the resident back to their room.V2 stated if staff members tell residents or their family members that there is not enough staff to perform a sit to stand transfer, that is incorrect information because there is always staff, on site, able to assist with transfers. V2 stated, I believe agency does this a lot, they love to do that, regarding making inappropriate claims.V2 stated it is not appropriate for staff to place a pillow in front of the resident, on the table, in the dining room. V2 stated this does not promote dignity and these residents should be taken back to their room to sleep, especially with residents who are non-verbal and cannot directly express their needs. Physician Order dated 06/01/2026 states in part but not limited to:Comfort-Focused Treatment: Primary goal of maximizing comfort. Care Plan dated 06/17/2026 states in part but not limited to:LONG TERM CARE: [NAME] has extensive care needs and requires the support/services of the LTC setting. The stay is presently identified as Long-Term. H Resident's care needs will be provided during stay at the facility through next review dateThe facility will provide care to enable the resident to function at their most practical level and support Leo's adjustment towards residence is a homelike environment.Leo risk for falls related to un/s fibrillation, fall, obstructive sleep apnea, Alzheimer's disease. H Staff to anticipate and meet residents needs.Chair Alarm in place to alert staff when resident reattempt to stand up unassisted. Educated the resident the importance of calling staff if she/he needs assistance in any way.Facility policy labeled Abuse and Retaliation Policy, dated 07/03/2026 states in part but not limited to:Types of abuse:5. Neglect7. Neglect is the failure to provide necessary and adequate (medical, physical or psychological) care. Neglect is the failure to care for a person in a manner which avoids harm and pain, or the failure to react to a situation which may be harmful. Staff may be aware or should have been aware of the service the resident requires but fails to provide that service.

Based on interview and record review, the facility failed to follow their policy to provide professional care and services in an environment free from misappropriation of property from one (R2) of three residents reviewed for misappropriation of property. This failure resulted to R2 missing her money in the sum of $50.00. Findings include: On 5/30/2025 at 1:37 PM, V4 (CNA) said that occasionally R2 is assigned to (V4). V4 said that R2 mentioned to her once that R2 told her that, someone stole something from her purse, it looks like $50.00 dollars. V4 said that V4 could not imagine how that could be possible because R2 always carry her purse even when V4 is giving R2 a shower. V4 said that she did not report to anyone that R2 told her that someone stole her money because V4 did not think that can be possible. V4 said that should have reported it to the administrator. On 5/30/2025 at 3:38 PM, V8 (Assistant Director of Nursing) said that V4 notified the management today that R2 complained to her that R2 lost her money. V8 said that V4 did not notify the management on a timely manner. V8 said that the facility frequently gives in - services on abuse including other topics. V8 said that the facility is immediately investigating and filing police report. V8 said that her expectation is for staff to report residents' complaint especially any form of abuse to the administrator immediately because theft is a form of abuse. On 5/30/2025 at 4:38 PM, V2 (Director of Nursing) said that it was news today to her that R2 lost her money. V2 said that V2 has called a police department to investigate. V2 said that her expectation is for staff to report immediately to the abuse coordinator. On 5/30/2025 at 4:55 PM, V1 said that as soon as she was made aware that there is an allegation of missing item, that she followed up immediately by filing a police report. V1 said that the expectation is for staff to report any allegation immediately to the administrator who is the abuse coordinator, so that investigation can be initiated promptly. V1 said the facility has initiated investigation and police department have been notified. R2 is a an [AGE] year-old female admitted on [DATE]. R2 had a BIMS score of 14. On 5/30/2025 at 11:45 AM, R2 said that she had $50.00 dollars stolen from her wallet. R2 said that she always carries her bag because she had things stolen from her before. R2 said that she told the social worker and everybody. R2 said that everybody knew about it, and she even mentioned it to the big boss upstairs. R2 said that 2 or 3 weeks ago, she walked down the hall without carrying her purse. R2 said that she saw the CNA walked towards her room. R2 said that when she returned to her room and brought out her wallet, she noticed that the wallet was not closed all the way. R2 said that when she opened the wallet, she noticed that her money was missing. R2 said that it must have been the CNA that stole her money. R2 said that $50.00 is a lot of money to her because she has no one helping her out financially. Facility Policy Name: Abuse and Neglect Revised: 4/24/25 Policy Statement: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations.

Based on observation, interview, and record review the facility failed to ensure medications were administered within one hour of their scheduled administration time for 3 of 6 residents ( R11, R12, and R13) reviewed for medication administration in the sample of 14. The findings include: On 1/12/25 at 11:15 AM, V4 RN (Registered Nurse) was passing morning medications to residents. V4 said she was late with medications because this was her first day working in the facility because she is agency. V4 said there were 6 residents left to receive their scheduled morning medications. R11's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include nonrheumatic aortic valve stenosis, multiple myeloma, pantocytopenia, hyperlipidemia, generalized anxiety disorder, essential hypertension, cerebral infarction, centrilobular emphysema, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, spinal stenosis, and urinary tract infection. R11's January 2025 eMAR showed an order for Acyclovir 400 mg twice daily for chemotherapy treatments and Gabapentin 300 mg three times daily for nerve pain. Both of these medications were scheduled to be given at 9:00 AM. On 1/12/25 at 11:15 AM, R11 was still waiting for her 9:00 AM medications to be administered. R12's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include concussion with loss of consciousness, hyperlipidemia, depression, anxiety disorder, obstructive sleep apnea, hypertension, heart failure, and pneumonia. R12's January 2025 eMAR showed an order for colace 100 mg two times daily for constipation. On 1/12/25 at 11:15 AM, R12 was still waiting to receive her 9:00 AM medications to be administered. R13's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include malignant neoplasm of breast, anemia, Type 2 Diabetes, glaucoma, paroxysmal atrial fibrillation, chronic congestive heart failure, thoracoabdominal aortic aneurysm, muscle wasting and atrophy, trochanteric bursitis, chronic kidney disease, wedge compression fracture of fifth lumbar vertebra, and macular degeneration. R13's January 2025 eMAR showed an order for Eliquis 5 mg two times daily for anticoagulant to be given at 9:00 AM, Gabapentin 100 mg two times daily for pain to be given at 9:00 AM, and Tylenol 500 mg two times a day for pain to be given at 8:00 AM. On 1/12/25 at 11:15 AM, R12 was still waiting for her 8:00 AM and 9:00 AM scheduled medications to be administered. On 1/12/25 at 3:38 PM, V7 LPN (Licensed Practical Nurse) said, Usually we expect the medications to be given on time of course. We have 3 hours to pass medications, one hour before and one hour after. We had a call off today so we put a call in to the agency group. She arrived at about 8:00 AM. Then I had to do the required orientation which took additional time and then she had to receive report from the other nurse . The facility's policy and procedure with revision date of 8/16/24 showed, Medication Pass . it is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures .

Based on observation, interview and record review, the facility failed to a.) ensure (R3's) fall risk assessment was accurate b.) failed to implement fall prevention interventions and failed to provide supervision for two ( R2, R3) of four residents reviewed for falls. These failures resulted in the following: R2 fell on [DATE] and on 7/06/24. R3 fell on [DATE] (fall without injury) and R3 also fell on [DATE] (7 days later) and sustained a subdural hemorrhage (bleeding inside the head). Findings include: R2's face sheet dated 09/15/2024 documents that R2 is a [AGE] year-old resident with diagnoses not limited to: mild cognitive impairment of uncertain or unknown etiology, anxiety disorder, unspecified, unspecified fracture of t9-t10 vertebra, subsequent encounter for fracture with routine healing, metabolic encephalopathy, acute on chronic systolic (congestive) heart failure, insomnia, unspecified, type 2 diabetes mellitus with hyperglycemia, age-related osteoporosis. R2's MDS section GG dated 8/20/2024 documents R2's interim assessment affirms R2 requires partial/moderate assistance with transfers form bed to chair, toilet transfers, and to walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. The facility fall log affirms R2 fell on [DATE] (fall without injury) and on 7/06/24 (fall without injury). R2's fall risk evaluation dated 06/20/2024 documents R2 just had a fall and that R2 is a high fall risk. R2's fall risk evaluation dated 06/29/2024 documents R2 just had a fall and that R2 is a high fall risk. R2's care plan documents in part that R2 is at risk for falls related to weakness, fibromyalgia, chronic T8 com fracture, right shoulder pain, debility. Interventions: chair Alarm in place to alert staff when R2 reattempt to standup unassisted. Educated R2 the importance of calling staff if she needs assistance in anyway. Date Initiated: 02/15/2023. 09/15/2024 11:30 AM V4 (Registered Nurse) provided surveyor with a copy of the fall risk prevention list. Facility document dated 09/14/2024 titled Fall Risk Prevention List documents in part that R2 is marked for bed alarm, chair alarm, and floor mats; R4 is marked for bed alarm and chair alarm. 09/15/2024 11:51 AM observed R2 in her room, sitting on a recliner chair with two pillows behind her, observed bedside table in front of R2, observed R2 wearing her own clothes and gym shoes on. Observed R2 wearing glasses. Observed carpet flooring. Observed bed alarm, and observed chair alarm on a wheelchair that was against R2 ' s room wall. No observation of a chair alarm under R2 or around the recliner chair that R2 was sitting on. R2 states that she has had falls here. R2 states that she last fell out of her bed, R2 states now there is pad on the floor when she is in bed. R2 states that she has had 3 episodes that they have taken her to the hospital because R2 states that she has been sick. R2 states she honestly cannot remember what happened. R2 states that another fall she had, R2 states that it was pure accident, R2 states that her leg just buckled. 09/15/2024 12:16 PM surveyor questioned V3 (Director of Nursing) which CNA was assigned to care for R2. Observed V3 review the assignment sheet. V3 states that V6 is assigned to R2. 09/15/2024 12:20 PM V8 (Certified Nursing Assistant/CNA) states that if an alarm is not placed under a resident that is supposed to have bed or chair alarm, V8 states that the resident could have a fall. V8 states that it is a split second that a fall can happen. V8 states that the bed and chair alarms do not prevent a fall, but it is just alerting staff that the resident is moving out of the chair, V8 states or they are probably uncomfortable in the chair, V8 states they could probably need to go to the bathroom, V8 states or they can be reaching for something, want water. V8 states that staff can switch the chair alarm to the recliner. V8 states that the chair alarm is connected to a pad that will be triggered with movement. 9/15/2024 12:55 PM V6 (CNA) states that she is not sure which CNA has R2. V6 states that she thinks it was V7 (CNA) who was assigned to R2. V6 states that V7 walked out of the facility. V6 states that V7 said it was too much work and walked out of the facility. V6 states that the supervisors are aware. V7 states that she is not familiar with R2's care. V6 states that she would have to go to the nurse's station to review R2's care plan and V6 states to find out how R2 transfers, if R2 is a fall risk. V6 states that the chair alarm and bed alarm are pads and are motion sensor. V6 states that the pads should be under the resident. V6 states that the chair alarms are not built in the wheelchairs. V6 states that the chair alarm should be placed under any type of seating that the resident is sitting on. V6 states that she has never worked with R1 and R3 before. 09/15/2024 12:58 PM V6 states that the change in assignment must have just happened. V6 states that she has not seen R2 today. V6 states that she was not made aware that she was just assigned to R2. R3's face sheet dated 09/15/2024 documents that R3 is a [AGE] year-old resident with diagnoses not limited to: disorder of brain, unspecified, traumatic subdural hemorrhage without loss of consciousness, subsequent encounter, unspecified fall, subsequent encounter, Parkinson's disease without dyskinesia, orthostatic hypotension, primary generalized (osteo)arthritis, benign prostatic hyperplasia with lower urinary tract symptoms, anxiety disorder, unspecified. R3's MDS/Minimum Data Set, dated dated dated [DATE] documents that R3 has a BIMS/Brief Interview for Mental Status score of 15/15, indicating that R3 is cognitively intact. R3's MDS/Minimum Data Set, dated dated dated [DATE] (post R3's falls) documents that R3 has a BIMS/Brief Interview for Mental Status score of 10/15, indicating that R3 is moderately cognitively impaired. R3's MDS section GG dated 4/24/2024 documents R3's annual assessment affirms R3 requires partial/moderate assistance with transfers form bed to chair, toilet transfers, and to walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. The facility fall log affirms R3 fell on [DATE] (documents fall without injury) and on 7/04/24 (documents fall without injury). R3's fall risk evaluation dated 06/27/2024 documents R3 did not have a fall and that R3 is a high fall risk. R3's fall risk evaluation dated 07/04/2024 documents R3 just had a fall and that R3 is a high fall risk. R3's care plan documents in part that R3 is at risk for falls related to Parkinson disease, orthostatic hypotension, past fall, lack of coordination and abnormalities of gait. Interventions: staff should anticipate and frequently round. Date initiated 04/14/2023. 09/15/2024 2:03pm V9 (Fall preventionist/RN) states that she has been working for the facility for almost 2 years. V9 states that she has been the fall coordinator for a year and 4 months. V9 states that she completes the residents' fall risk care plans. V9 states that she inputs the fall risk care plan interventions too. Surveyor inquired how V9 determines that the chair and bed alarm interventions should be put in place. V9 states that if the resident has had history of falls, diagnosis of dementia, pain, UTI, or upon admission assessment, V9 states that it determines if the residents need to have bed and/or chair alarm. V9 states that she completes assessments upon admission. V9 states that also if the residents have weakness. V9 states that the bed and chair alarm intervention can help prevent residents from falling, V9 states that the chair alarm should be placed on whatever chair the resident is sitting on. V9 states that R2 fell on [DATE]th, V9 states that R2 said that she wanted to get out of bed, V9 states that R2's bed was in a low position. V9 states that R2 was found at the side of her bed at 1:00 am. V9 states that R2 did not suffer any injuries. V9 states that this fall could have been prevented if R2 would have used her call light. V9 states that R2 had another fall on June 29th, in the morning shift. V9 states that R2 said that she was trying to ambulate to the washroom, V9 states that R2 said that she lost her balance and fell . V9 states that for this fall, she would have to say that the same still applies, V9 states that R2 is a retired nurse, and V9 states that she encouraged R2 to use the call light. V9 states that R2 can use her walker and V9 states that R2 can go by herself to the washroom unsupervised. Surveyor inquired as to why did R2 had a chair alarm and bed alarm if she is able to go by herself to the washroom unsupervised. V9 states that that she wanted to discuss the previous fall R2 had, V9 states that R2 had an infection when she had her first fall on June 20th, V9 states that to prevent R2 from falling, R2 and her family were ok with R2 having a bed and chair alarm. V9 states that R2 still wants to have the alarms in place. V9 states that she feels that it is safer for R2 to have the bed and chair alarm, V9 states because R2 has had multiple falls, and V9 states that the root cause of R2 falling is that R2 is not calling for her. V9 states that staff need to anticipate R2's needs. V9 states that staff need to make rounds and anticipate needs. V9 states that she does not do reportables. V9 states that her director does the reportables. V9 states that R3 was a long-term care resident, and V9 states that R3 was declining. V9 states that R3 fell on [DATE]th, V9 states that R3 didn't call for help. V9 states that R3 had refused to go to the hospital the first time that R3 fell . V9 states that after his fall on June 27th, V9 states that she revised R3's care plan and implemented chair alarm, and R3 was reeducated to call for help. V9 states that R3 did not suffer any injuries from his fall on 06/27/2024. V9 states that R3 did not have bed and chair alarms in place prior to his fall on 06/27/2024, V9 states because R3 became very strong, and it had resolved. V9 states that prior to R3 having a fall on 06/27/2024, V9 states that R3 wasn't much of a fall risk, V9 states that R3 could do things by himself, V9 states that R3 went out by himself, V9 states R3 was independent. V9 states that R3 was this way for 9 to 10 months. V9 states that she noticed a decline in R3. V9 states that R3 had lab work done and no new orders were given. V9 states And we continued neuro check in house after fall on 27th. Why did he fall on June 27th, he said he wanted to use the washroom, I usually have, and he tripped going past the bedside table, it was in his way, and then he fell . And he verbalized that he didn't hit his head, and didn't have any pain, and that was the fall that he refused to go to the hospital. V9 states that R3 fell again on 7/4/24. V9 states that the nursing assistant found R3 on the floor. V9 states that prior to this fall, staff saw R3 watching T.V. (television), sitting on his recliner chair. V9 states that R3 didn't call for help. V9 states that R3 fell in front of his recliner. V9 states that R3 wanted to get up. V9 states that at that time, R3 couldn't engage a lot in conversation, V9 states that R3 didn't say where he was going, V9 states that R3 had denied any pain and denied hitting his head. V9 states that she insisted that R3 needed to go to the hospital. V9 states that she was concerned that R3 was declining. V9 states that he didn't look too good. V9 states that when R3 returned to the facility from being in the hospital, V9 states I put back the floor mats, and low position, after that he returned under hospice. V9 states that she does in-services regarding fall precautions every day, V9 states that she encourages staff and reminds staff about fall precautions in place, to check that fall precautions are in place every day, V9 states that she also reminds staff to review and understand the fall precautions in place for the residents from the care book binder, V9 states that she also reminds staff to rounds and anticipate residents' needs while rounding. 09/16/24 4:01pm via telephone V12 (Nurse Practitioner) states that if a resident falls and hits their head, the resident can have Subdural hematoma, V12 states which is bleeding in the brain. V12 states that for older residents, if they have a fall, V12 states that they can potentially suffer many complications with a fall, V12 states they can break their bone, lacerations, fat embolism. Facility document dated 07/26/2024 titled Fall occurrence documents in part 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.

Based on observation, interview and record review, the facility failed to remove expired medications for three (R1, R90, R121) residents from first floor medication carts and house stock medication refrigerator, failed to ensure multi-dose vials and eye drop medications for four (R28, R29, R80, R138) residents were dated upon opening and, failed to remove medications for one (R205) expired resident from the medication cart. These failures have the potential to affect all 66 residents receiving medication from the 1st floor medication carts and Medication room. Findings include: On 04/17/24 at 09:30 AM The following medications were observed for storage and labeling Sunshine Medication Cart one with V7 Licensed Practical Nurse. R121 - Tramadol 50mg tablets expired 3/38/24 verified with V7 Licensed Practical Nurse. Physician order: Tramadol 50mg 1 tab every 8 hours as need for pain. Brimonidine Tartrate 0.2% eye drops for R80 open and not labeled verified with Licensed Practical Nurse. Physician order: Brimonidine Tartrate ophthalmic solution 0.2% (Brimonidine tartrate instill 1 drop in both eye two times a day for glaucoma. First floor Medication Room Sunshine Refrigerator: Two Tuberculin multi dose house stock vials opened and not labeled in the refrigerator. Five Bisacodyl 10mg suppositories which expired 6/20/23. On 04/17/24 at 09:45 AM Sunshine Medication Cart two on the first floor: Verified with V8 Licensed Practical Nurse. R1-Pantoprazole liquid 2mg/ml expired 3/31/24. Physician order: Pantoprazole (Protonix) suspension 2mg/ml, give 20ml by mouth one time a day for GERD. R205 - Hospice patient expired 9/25/23- Hospice kit containing Benadryl/Decadron/Reglan 2 syringes. Scopolamine 25mg/ml gel 2 syringes and Bisacodyl 10mg 3 suppository observed in the medication refrigerator. R28 artificial tears eye drops opened and not labeled. R90 Hydrocodone-Acetaminophen Tablet 5-325 MG5/325mg 16 tabs expired 03/07/24. Physician order: Hydrocodone-Acetaminophen Tablet 5-325 MG5/325mg Give 1 tab by mouth every 8 hours as needed for pain. V8 stated that Norco medication is expired and should be discarded per facility protocol, and she will give to the ADON (Assistant Director of Nursing) on the floor. On 04/17/24 at 11:30 AM The following medications were observed for storage and labeling Friendship Medication Cart 1: V9 LPN R29 Olopatadine 0.2% - opened and not labeled. Physician order: Pataday Ophthalmic solution (Olopatadine HCL) Instill 1 drop in both eyes on time a day. R138 artificial tears eye drops opened and not labeled. Physician order: Refresh Tears Ophthalmic solution 5 % (Carboxymethylcellulose Sodium instill one drop in the right every 8 hours as need for redness in the right eye. V9 LPN said that medication should be labeled when opened, and she will discard medication on hand and order new medications. On 04/17/24 at 11:52 AM V2 DON (Director of Nursing) said that when residents discharge from the facility, the medications should be sent with them and or removed from the medication cart. We either send the medications with the resident or they are destroyed. Nurses are supposed to label bottles when they are opened and date it. Any open bottle without a date should be discarded. Facility provided pharmacy policy titled Storage of Medications (No revision date) states in part: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: 3. All medications dispensed by the pharmacy are stored in the container with the pharmacy label 7. outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal and reordered from the pharmacy, if a current order exists. Expiration Dating (Beyond- use dating): 1. Expiration dates (beyond-use date) of dispensed medications shall be determined by the pharmacy at the time of dispensing. 4b: Drugs dispensed in the manufacturer's original container will carry the manufacturer's expiration date. Once opened, these will be good to use until the manufacturer's expiration date is reached unless the medication is: i. in a multi-dose injectable vial, ii. An ophthalmic medication, iii. An item for which the manufacturer has specified a useable life after opening. 5. When the original seal of the manufacturer's container or vial is initially broken, the container or vial will be dated. a. The nurse shall place a date opened sticker on the medication and enter the date opened. b. If a vial or container is found without a date opened, the date opened will automatically default to the date dispensed and the expiration date will be calculated accordingly. 6. The nurse will check the expiration date of each medication before administering it. 7. No expired mediation will be administered to a resident. 8. All expired medications will be removed from the active supply ad destroyed in the facility, regardless of amount remaining, the medication will be destroyed in the usual manner.

Based on observations, interviews, and record reviews the facility failed to follow their policy and procedures for activities of daily living by not ensuring a resident received assistance with feeding and personal hygiene as required, and by not ensuring residents who require incontinence care were changed in a timely manner. This failure applies to three of four residents (R93, R121, and R135) reviewed for ADL (Activities of Daily Living) care. Findings include: 1. R93 is a [AGE] year-old female with a diagnoses history of Partial Paralysis Due to Stroke who was admitted to the facility 08/27/2020. On 04/15/24 at 11:33 AM Observed R93 lying in her bed with a towel on her chest. Observed food residue and particles left on R93's mouth and towel on her chest. R93 nodded yes when asked if she fed herself. R93's current Care Plan Initiated: 09/03/2020 documents she has an ADL (Activities of Daily Living) Self Care Performance Deficit and Impaired Mobility related to diagnoses and past medical history of Morbid obesity, hypertension, and stroke with interventions including: requiring total staff participation to eat; and requires 2 staff participation with personal hygiene. On 04/17/24 at 12:24 PM V2 (Director of Nursing) stated, if R93 was fed by staff on 04/15/2024 staff should have cleaned her up. V2 stated, if R93 fed herself and staff collected her tray they should have cleaned her up. V2 stated, if the nursing staff leaves R93 unclean it is a dignity issue. 2. R121 is a [AGE] year-old female with a diagnoses history of Partial Paralysis due to Stroke who was admitted to the facility 10/14/2022. On 04/15/24 at 11:35 AM R121 gestured that she needed her adult brief changed and pulled on her diaper. Observed most of the bottom of R121's foot resting near her adult brief was smeared with feces. V11 (Certified Nursing Assistant) stated, she last changed R121 at 7AM when she started her shift. R121's current care plan Initiated 10/14/2022 documents she requires assistance with ADL's (Activities of Daily Living) including bed mobility, transfers, dressing, walking, personal hygiene, and toileting; R121 displays bowel and bladder incontinence related to medication side effect, decreased mobility with interventions including: Nursing staff to check R121 for incontinence episode every 2 hours. On 04/17/24 12:27 PM V2 (Director of Nursing) stated it's neglectful to find a resident with an overflow of feces and having not been changed from 7AM - 11:35 AM. 3. R135 is a [AGE] year-old female with a diagnoses history of Multiple Cervical Spine Injuries and Gastrostomy Status who was admitted to the facility 10/30/2023. On 04/18/24 at 12:37 PM surveyor observed R135 with a strong urine odor. R135 stated, she was last changed at 5AM. V10 (Certified Nursing Assistant) stated he started work at 7AM and had not changed R135 yet because he was working with residents he was assigned in another area. V10 stated, R135's brief is full. Observed R135's brief to be heavily soiled with urine. V10 stated there is a need for more CNA's (Certified Nursing Assistants). V10 stated there used to be 6 CNA's on the unit he is assigned to but now there are five which increased the amount of residents that he has to care for and he has to get residents changed, dressed, and bathed. R135 current care plan initiated 11/01/2023 documents she requires assistance with ADL's (Activities of Daily Living) including bed mobility, transfers, dressing, walking, and personal hygiene; R135 displays bowel and bladder incontinence related to medication side effect, decreased mobility with interventions including: Nursing staff to check R135 for incontinence episode every 2 hours. The facility's General Care Policy received/reviewed 04/18/2024 states: It is the facility's policy to provide care fore every resident to meet their needs. The facility will assist the resident to meet these needs, unless it shows that the resident's needs cannot be met in the facility.

Based on Observations and Interview and Record Review the facility failed to have a five percent (5 %) or lower medication error rate. There were eight (8) medications error out of 31 opportunities, resulting in a 25. 81% medication error rate. These failures affected four (R46, R105, R136, R203) residents observed for medications not administered as ordered. Our findings include: On 04/16/24 at 04:29 PM V6 RN (Registered Nurse) was observed administering medications. When passing medications to R136, V6 omitted Diclofenac Sodium External Gel 1 % Apply to 4GM (grams) to affected area topically four times a day for pain. Administered medications were reconciled against the current (April 2024) Medication Records (MAR). Physician Order: Diclofenac Sodium External Gel 1 % Apply to 4GM TO AFFECTED AREA topically four times a day for PAIN-Scheduled to be given at 5:00 PM. On 04/16/24 at 05:00 PM For R203, V6 held (did not administer) medication Senna-Plus Tablet 8.6-50 milligrams Give 1 tablet via G-Tube two times a day times, scheduled for 5:00 PM. Administered medications were reconciled against the current (April 2024) Medication Records (MAR), Medication was omitted during medication administration. Physician Order: Senna-Plus Tablet 8.6-50 milligrams Give 1 tablet via G-Tube two times a day times for constipation. Scheduled to be given at 05:00 PM. On 04/17/24 at 9:06AM. V7 LPN (Licensed Practical Nurse) was observed during medication administration, when administering to R46, V7 held (did not give) order for Metoprolol Succinate Extended Release 25mg tablet- Give one tablet by mouth one time a day for hypertension and Lisinopril Oral Tablet 5mg- Give 1 tablet by mouth one time a day for hypertension for a blood pressure result of 101/52. Administered medications were reconciled against the current (April 2024) Medication Records (MAR) and the Progress notes, care plan and physician's orders sheets were reviewed and there was no indication that the physician was notified, and no interventions were in place after holding medications. V7 administered Polyethylene Glycol 3350 Powder ordered as- Give 17 grams by mouth one time a day for constipation, however V7 was observed to measure less than 17grams when preparing the medication. Physician Order: Metoprolol Succinate ER 25 MG Tablet extended release 24 HR GIVE 1 TABLET BY MOUTH ONE TIME A DAY FOR hypertension. (Active 01/20/2024). Lisinopril Oral Tablet 5 MG (Lisinopril) Give 1 tablet by mouth one time a day for hypertension (Active 01/20/2024). GlycoLax Powder Give 17 gram by mouth one time a day for constipation (Active 02/26/2024). V7 was next observed administering medications to R105. V7 held (did not give) order for Metoprolol Tartrate Tablet 25mg- Give 1 tablet by mouth every 12 hours related to essential hypertension. V7 also held (did not give) Losartan Potassium Tablet 50 MG- Give 1 tablet by mouth one time a day related to essential hypertension for blood pressure of 99/62. Additionally, V7 was observed to give Calcium Vitamin D 600mg/400 units 1 tablet, however the order was for Calcium-Vitamin D 500mg/400mg-unit. Administered medications were reconciled against the current (April 2024) Medication Records (MAR) with discrepancies. Progress notes, care plan and physician's orders sheets were reviewed and there was no indication that the physician was notified, and no interventions were in place after holding medications. Physician Order: Metoprolol Tartrate Tablet 25 MG Give 1 tablet by mouth every 12 hours related to ESSENTIAL (PRIMARY) HYPERTENSION. (Active 07/20/2021). Losartan Potassium Tablet 50 MG Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (Active 07/21/2021): Calcium-Vit D 500mg/400mg-unit 1 tab by mouth two times a day. Supplement. (Active 07/07/2022) On 04/18/24 2:22PM V2 DON (Director of Nursing) stated, when residents have vital signs (blood pressures) that are high or low and you don't have parameters to hold or give medications, they are expected to call the provider right away. On 4/18/24 at 2:40PM V2 DON stated, there were no parameters documented or ordered for the blood pressure medications to be held. V2 said that V6 and V7 did not call the physician at the time they held the medications, nor did they document the reason the medication was held in the electronic medical record. Additionally, V7 gave the wrong dose of Calcium and will be in serviced accordingly. The facility provided a list of house stock medications, which included Calcium 500mg/400units was available and ordered by the facility. Facility Policy Titled: Medication administration General Guidelines (Pharmascript) Policy # 7.2. 6) Five Rights- Right resident, right medication, right dose, and right time, are applied for each medication being administered. A triple check of these 5 rights is recommended at three steps in the process of preparation of the medication for administration. (1) when the medication is selected, (2) when medication is removed from the container, and finally when (3) just after the dose is prepared and the medication is put away.

Based on observations, interviews and records reviewed the facility failed to follow fall prevention interventions to include supervision/monitoring and use of assistive/safety devices to prevent the risk of falling. This affected three of three residents (R1-R3) reviewed for falls and fall prevention interventions. This failure resulted in R1 being involved in a fall incident sustaining a fracture of the L4 and L5, Lumbar Spine, and R3 being involved in a fall incident resulting in an Oblique Fracture of the Left Fifth Metatarsal and of the Neck of the Right Radius. Findings include: A.R3's diagnosis include but are not limited to Spinal Stenosis, Anemia, Dementia, Osteoarthritis, Difficulty in Walking, Age Relate Physical Debility, Altered Mental Status, Lumbago with Sciatica, Right Side, and Radiculopathy - Lumbar Region. R3's Cognitive assessment dated [DATE] indicates mildly impaired. On 10/29/23 at 2:49PM The surveyor observed a star on the door, near R3's name, door closed. V3, Restorative Aid, in the room with the roommate. V3 sitting a chair near roommate. R3 opened the door and greeted the surveyor. R3 walking in the room then to sink to finish washing. R3 hanging washcloth on towel rack and then stumbled while turning, but regained balance, loud squeaking sound from shoe, before sitting on his bed. R3 said yes, I fell I was up alone in my room. R3 said I did not call for help. R3 said I was ashamed and did not call for help. R3 said I don't call for help when I need to use the bathroom or get something. No alarms sounding with the resident in the room. On 10/29/23 at 3:15PM V3, Restorative Aid, said I was in R3's room working with R3's roommate. V3 said I work with R3 for range of motion. V3 said R3 can walk with a standby. V3 said R3 was using the washroom I was in the room. V3 said I did not see him stumble. V3 said I would not have gotten to R3 from where I was if he was falling. V3 said R3 does not have alarms on and he should. V3 said I did not [NAME] R3's alarms off when I went in the room. On 10/30/23 at 9:52AM V9, Fall Nurse, said R3 is a fall risk. R3's diagnosis include Spinal Stenosis, Arthritis, Debility, Lack of Coordination, and Altered Mental Status. V9 said R3 had one fall on 10/17/23. V9 said R3 should be supervision for ambulation. V9 said this means R3 should have a person in the room while ambulating. V9 said R3 is not stand by assist for ambulation. V9 said Staff should be standing when supervising residents. V9 said staff don't need to sit so they can move faster for staff. V9 said R3 complained about the alarms being too loud so I stopped them. V9 said R3 is alert and can call for assist with the call light. V9 said she was unsuccessful in reaching the night shift agency staff to interview about R3's fall. V9 said it is unknown if the alarm was answered or if the alarm was in place and on at the time of R3's fall. V9 said R3 sustained a fracture on right foot. On 10/30/23 at 11:30AM V11, Therapy Director, said R3 is currently supposed to be walking with a walker and supervision, including yesterday. V11 said prior to R3's fall on 10/17/23 R3 required supervision for ambulation. V11 said supervision means staff should be in eyesight during ambulation. R3's Fall Risk Evaluation dated 10/17/23 score is 13, high risk. R3's care plan dated 9/15/23 identifies R3 at risk for falls related to Spinal Stenosis with Radiculopathy, Right Hip, Osteoarthritis, Altered Mental Status, Dementia, Depression, and Debility. Interventions dated 9/15/23 include bed alarm and chair alarm. R3's care plan for Activity of Daily Living and Fall Risk do not address R3's ambulation ability/status. R3's Functional Status dated 9/21/23 indicates he needs staff assistance during transfers and was not ambulating at the time. Incident Report dated 10/17/23 documents R3 notified staff he fell during the night and did not report or call for help. Resident statement, in part, reads I was trying to use the rest room and fell . The facility Incident Report dated 10/18/23 documents after hospital evaluation R3 findings include Oblique Fracture of the Fifth Metatarsal and of the Neck of the Right Radius - initial encounter. R3's hospital record dated 10/17/23 states oblique fracture through the fifth metatarsal shaft. Closed non-displaced fracture of fifth metatarsal bone of left foot and closed non-displaced fracture of neck of right radius. B. R1's diagnosis include but are not limited to Fracture of Left Femur, Anemia, and Hypertension. On 10/29/23 at 1:27PM V2, Licensed Practical Nurse, said R1 fell because he had a Urinary Tract Infection and may have had a behavior change. V2 said R1 could not walk. V2 said I was called to the room and saw R1 on the floor. V2 said I don't know what CNA was assigned to him. V2 said I was not assigned to R1. On 10/29/23 at 2:08PM V12, Nurse Supervisor said on 9/11/23 when I went to R1's room I saw him on the floor. V12 said R1 either pulled the light or the alarm sounding. V12 said R1 did not know he was on the floor. V12 said when I asked R12 about the fall, he said oh, I'm on the floor. V12 said I am not sure of R1's his mental status at the time. V12 said R1 was on isolation at the time and his room door was closed. V12 said R1 was on his back. He was right next to the bed. V12 said R1 was not a fall risk. V12 said I did not see him fall and I do not know what he was trying to do. On 10/30/23 at 9:52AM V9, Fall Nurse, said V5,Nurse, and V13, CNA, were interviewed and said R1 tried to transfer without assistance. V13 said she did not see the fall, V13 said to V9 I was providing care to another resident. V9 said V5, Nurse, said V12, Nurse Supervisor, called me and said R1 was on the floor. V9 said she was told V12 was rounding and saw the call light on and when he entered the room R1 was on the floor. V9 said R1 is always in bed, he had not tried to get up. V9 said R1 was on antibiotic and could have been confused causing him to fall. V9 said R1's baseline was incontinent of urine. V9 said I don't know what R1 was trying to do when he fell . V9 said R1 required a mechanical lift for transfer, and he was not strong enough to stand. V9 said R1's door was closed for isolation. V9 said there was no other cnas involved in R1's care, V13 was the assigned CNA. V9 had no additional interviews for R1's fall. While reviewing R1's incident report/investigation with V9, she was unable to say when R1 was last turned, repositioned, or received incontinent care. V9 was unable to say who assisted in repositioning R1 during the shift. On 10/29/23 at 11:32AM V8, R1's wife, said R1 had fractures of the L4 and L5 in his back he did not have those before the fall. R1's care plan dated 2/18/2023 states R1 is at risk for falls related to left femur fracture status post surgery, anemia, abnormal gait and mobility. Interventions for R1 include bed alarm in place chair alarm in place, requires two staff participation to reposition and turn in bed. Incident report for R1 dated 9/11/2023 reads R1 verbalized pain to the right leg and facial grimacing was noted level of pain is 6 out of 10. Review of R1's medication administration record and physician orders for September 2023 do not include treatment of urinary tract infection. Physical therapy discharge summary dated 8/13/2023 documents R1 to require partial/moderate assistance with sitting to standing. Transfers from chair to bed require partial/moderate assistance. Substantial/Maximal assistance for toilet use and patient was unable to ambulate. The facility's incident report to IDPH on 9/11/23 reveals R1 was transferred to the hospital on 9/11/23. R1 was admitted to the hospital with lower back trauma. A CT of the spine revealed L4 and L5 compression deformities that are new compared to 9/25/2022 and represent acute fractures. C.R2's diagnosis include but are not limited to Fall, Compression Fracture of Vertebra, Anemia, Difficulty in Walking, Weakness, and Osteoporosis. On 10/29/23 at 10:33 AM R2 called for the nurse in the dining room and asked V2, LPN, to check his blood sugar. V2 said in 2 minutes I will be there. The surveyor remained monitoring R2 until 10:45AM and V2 did not return him. On 10/29/23 at 1:27PM V2, LPN, said R2 is very alert but we must help him. V2 said R2 requires 2 person assistance to get from wheelchair to the bed we use the mechanical lift. On 10/29/23 at 3:32PM V4, Registered Nurse, said R2 used the call light around 6:45AM. V4 said R2 said he wanted to get up and sit in the wheelchair. I asked him to wait for the CNA. V4 said R2 called again, he said I want to get up, I just need some help, he did not want to wait. V4 said on the third time R2 called I helped him to get up. V4 said I helped him lower his feet from the bed, I held his arms, he was helping, but then his feet were shaking, he got weak. V4 said I was about to fall. V4 said the safest thing to do was to put him on the floor. V4 said this was my first time working with the resident. The surveyor asked V4 how she knows the transfer status of the residents she is assigned to. V4 was unable to answer. V4 said R2 is 1 assist. V4 said R2 said he is going to help me, and he said he can help. On 10/30/23 at 9:52AM V9, Fall Nurse, said R2 is high risk for falls because he has fractures in the spine, lack of coordination weakness, and history of falls. V9 said R2 is a 2 person assist with a mechanical lift for transfers. V9 said to use the commode R2 is a 2 person assist. V9 said R2 has required 2 person since his admission. V9 said the cause of the fall on 10/12/23 was related to R2 asking to transfer out of bed. V9 said the Staff Care Binder is used to notify staff of resident transfer status. V9 said the V4 can look at the binder to know what care to provide. V9 said R2 is cooperative with the mechanical lift. Incident report dated 10/12/23 reads R2 requested to get out of bed and into his wheelchair. This writer, V4, told him to wait for his CNA. Report reads I still want to sit in my wheelchair. At 7:00AM writer attempted to transfer R2 from bed to wheelchair. R2's legs began to shake and R2 became unsteady. R2 assisted to the floor. Review of R2's Incident Reports identify falls on 9/16/23; 9/29/23; and 10/12/23. R2's care plan dated 9/18/23 states R2 require 2 staff participation with mechanical lift transfers to prevent fall. On 10/30/23 at 9:52 AM V9, Fall Nurse, said a resident's diagnosis can increase the risk for falls such as Hypertension, Diabetes, Parkinson's, Impaired Memory, Dementia, Alzheimer's, Weakness, Debility, Seizure, and Syncope. V9 said the Root Cause Analysis is what led to the fall. V9 said the plan is developed from the cause. On 10/30/23 at 2:32PM V15, MDS Coordinator, said the purpose of the care plan is so the nurses can find the intervention for the plan of care of the resident. V15 said I expect the nurses to follow the careplan. V15 said when an intervention is no longer needed we do review and update the care plan. V15 said we can add and remove interventions or resolve them. The facility fall prevention program guidelines dated December 5th 2022 states fall prevention program guidelines shall be implemented to promote safety of all residents in the facility. safety interventions shall be initiated and implemented for each resident identified at risk for fall. All assigned nursing personnel and facility staff shall be responsible for ensuring ongoing precautions are put into place and consistently maintained. All file incidents shall be monitored, analyzed, root causes identified. The facility Fall Occurrence policy dated 7/17/23 reads 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. If a resident has fallen, the resident is automatically considered as high risk for falls. The falls coordinator will add the intervention in the residence care plan. The interventions will be reevaluated and revised as necessary.

Based on interview and record review the facility failed to prevent a facility acquired pressure ulcer from developing, failed to develop and implement a care plan with pressure relieving interventions to prevent a pressure ulcer from developing, failed to develop and implement a care plan with interventions to address a pressure ulcer once developed, and failed to do skin checks for one of three residents (R4) reviewed for pressure ulcers in the sample of five. These failures resulted in R4, who was admitted to the facility without pressure ulcers, developing a stage two pressure ulcer to the right heel that progressed to an unstageable infected pressure ulcer that required R4 to be hospitalized and treated with intravenous antibiotics. Findings include: The facility's Wound Care Program policy dated 7-1-22 documents, It is the policy of this facility to ensure that residents whose clinical conditions and medical diagnosis potentiate the risk for skin breakdown and development of pressure ulcers are properly identified, assessed, and managed according to current regulatory guidelines and standard of care. Procedures: 1. Timely identification of residents assessed to be at risk for skin breakdown. Each risk factor and potential causes identified with the Braden scale (wound risk assessment) should be reviewed individually and addressed into the resident's care plan. Facility shall develop a plan of care and implement interventions according to the resident's Braden score and/or identified individual risk factors. Prevention of skin breakdown: Inspection of the skin every shift with care for signs of breakdown. Activity, Mobility, and Positioning: Establish an individualized turning and repositioning schedule of the resident if immobile or with impaired physical functioning. The resident's care plan shall be evaluated and revised based on resident's response to treatment, treatment goals and outcomes. Pressure Ulcer Treatment: Initiate wound care treatment upon identification of the wound with physician's order. Develop a care plan with appropriate interventions. R4's Admission Record documents R4 was admitted to the facility on [DATE] with the diagnoses of Spinal Stenosis, Need for Assistance with Personal Care, Weakness, Lack of Coordination, and Mild Intellectual Disabilities. R4's Progress Notes dated 9-28-22 document R4 was discharged to the hospital on 9-28-22 and did not return to the facility. R4's MDS (Minimum Data Set) assessment dated [DATE] documents R4 was a [AGE] year-old admitted to the facility on [DATE]. This same MDS documents R4 was moderately cognitively impaired, required extensive assistance of one staff for bed mobility, transfers, dressing, and toileting. R4's Admission Skin Evaluation dated 8-19-22 documents R4 was admitted with normal, warm skin and had no pressure ulcers upon admission. This same evaluation documents R4 had a non-pressure skin condition to the right great toe, is assessed to be at risk for pressure sore development related to fragile skin, incontinence, and impaired mobility, and should have heels offloaded with pillow while in bed. R4's Wound Risk assessment dated [DATE] and 8-27-22 documents R4 is at risk for developing pressure ulcers. R4's Wound Summary and Wound Assessment Details Report dated 8-25-22 through 9-27-22 documents R4 developed a partial thickness pressure ulcer to the right heel on 8-25-22 that measured 5.0 cm (centimeters) by 3.0 cm by an unknown depth and had a scant amount of sero-sanguineous (clear pinkish) exudate (drainage). R4's Progress Notes dated 8-26-22 and signed by V31 (LPN/Licensed Practical Nurse) documents, Writer spoke to (V32/R4's Power of Attorney) to give them an update on resident's skin integrity and wound care consultant visit from 8-25-22. Writer also addressed right heel blister that was noted on 8-25-22. (V32) was made aware. Writer will continue to monitor resident. R4's Care Plan dated 8-19-22 through 9-8-22 (hospital admission) does not include a plan of care to address R4's pressure ulcer to the right heel identified on 8-25-22. This same Care Plan does not include pressure relieving interventions to prevent the development of a pressure ulcers before the development of R4's pressure ulcer to the right heel on 8-25-22. R4's Electronic Health Record does not include documentation of skin checks being performed every shift by the nurses or CNAs (Certified Nursing Assistants) as directed by the facility policy and does not include documentation of daily or weekly skin checks being performed by the nurses. R4's Physician's Order Sheet and Treatment Administration Records dated 8-19-22 (Admission) through 8-31-22 document R4 did not receive an order, or a treatment for the right heel until 8-27-22 (two days after discovery). R4's Physician's Order dated 8-27-22 documents, Right heel: Cleanse with normal saline, pat dry, apply bacitracin plus xeroform and cover with border gauze every day shift every Tuesday, Thursday, and Saturday. R4's Arterial Duplex Scan Radiology Results Report of the lower bilateral extremities dated 9-2-22 documents Clinical Information: Right lower extremity wound to the right heel. Impressions: No evidence of hemodynamically significant luminal stenosis (narrowing of the blood vessels) in visualized vessels. R4's Hospital History and Physical dated 9-9-22 and signed by V30 (R4's Hospital Physician) documents, (R4) is sent to the emergency room because of wound on the right foot with infection there. Leukocytosis (high white blood count) admitted with antibiotics for right lower extremity wound infection and wound care on consult. admitted for further evaluation and treatment. (R4) given IV (Intravenous Meropenem/Antibiotic) in the emergency department. Assessment and Plan: Unstageable pressure ulcer right heel. Recommend betadine dressing changes twice a day per nursing. In addition to foam offloading boots, would keep pillows under his calf to float the heel. On 6-16-23 at 12:15 PM V32 (R4's Power of Attorney) stated, (The facility) did nothing to prevent (R4's) pressure ulcer to the heel. Every time I would go to the facility, staff would not re-position (R4) or do anything for (R4). That is why I had (R4) move to a different facility and had (R4) sent to the hospital. When (R4) went to the facility he did not have any pressure ulcers. On 6-16-23 at 5:35 PM V14 (Nurse Consultant) stated, (R4's) pressure ulcer to the right heel was facility acquired. On 6-16-23 at 6:00 PM V2 (Director of Nursing) stated that CNAs are supposed to do skin checks every shift and document them on the residents. V2 stated R4 does not have skin checks documented every shift and did not have a plan of care for pressure relieving interventions developed or implemented prior to R4 developing the pressure ulcer to his right heel, and R4 did not have a care plan implemented with interventions to address and treat R4's pressure ulcer once developed.

Based on interview, observation, and record review the facility failed to use an appropriate mechanical lift sling per manufacturer's instructions during a transfer and failed to transfer a resident safely, as directed by the facility's policy, using a mechanical lift for one of three residents (R3) reviewed for falls in the sample of five. These failures resulted in a mechanical lift tipping over with R3 during a transfer from the bed to the wheelchair, resulting in the mechanical lift falling on R3's left arm, fracturing the left radial head (knobby area of the radius where it meets the elbow) of R3's left arm. Findings include: The facility's Mechanical Lift Transfers policy dated 1-14-13 documents, Procedures: 1. Follow manufacturer's guidelines on how to operate machine. 4. Use sling compatible with mechanical lift and appropriate size. 5. There will always be two staff to assist resident. One staff will control the lift as the other will guide resident and support back and neck to transfer surface. 11. Lift resident up from the chair using lift with one person operating the machine while the other staff removes the resident's wheelchair/recliner out of the way while resident is suspended in the air. For a brief second, the second staff won't be able to put hands on the sling as staff removes the wheelchair or recliner. 12. The second staff will guide resident and sling as resident is transferred and lowered back to bed. 14. When lifting resident from bed to chair, one staff will also operate the machine while one staff guides the sling. The (Manufacturer's) User Manual for the Mechanical Lift Model dated 10-1-18 documents, Ensure the legs of the lift with patient in the sling are in the open position. Press the legs open button until maximum open position. Do not use slings and patient lifts of different manufacturers. Slings are made specifically for use with mechancial lifts. Injury or damage may occur. Warning: When using an adjustable base lift, the legs must be in the maximum opened/locked position before lifting the resident. R3's MDS (Minimum Data Set) assessment dated [DATE] documents R3 is at [AGE] year-old that is cognitively intact. This same MDS also documents R3 requires extensive assistance of two plus physical assist of staff for bed mobility and requires total assistance of two plus staff for transfers. R3's Incident Note dated 1/24/2023 at 2:42 PM and signed by V3 (LPN/Licensed Practical Nurse) documents, Incident Summary: Prior to the incident 11:50 AM, resident (R3) was in bed. Around 1:50 PM two CNAs (Certified Nursing Assistants) were transferring (R3) from the bed to the wheelchair with Hoyer lift (mechanical lift). CNAs called for help and three other staff went in to assist in re-positioning (R3) upright in the wheelchair. (R3) alert and oriented times three. (R3) was asked what happened and resident stated the (mechanical) lift was toppling over and l hit my left arm to the (mechanical lift). Body assessment done. No apparent injuries noted. No swelling noted to the arm. Resident complained of mild pain to the left arm. Tylenol 650 mg (milligrams) given. No other complaints. V17 (Nurse Practitioner) was notified with an order for x-ray to left arm/hand. R3's Left Elbow X-Ray report dated 1-25-23 documents, Impression: Small left elbow effusion, Cortical step-off of radial head, concerning for non-displaced left radial head fracture. V21 and V20's (Agency CNAs) Statement Forms dated 1-24-23 document around 12:15 PM on 1-24-23 both V20 and V21 were transferring R3 from the bed to the wheelchair using the (mechanical lift). During the transfer the mechanical lift toppled over and V20 and V21 supported R3 to the wheelchair. R3 landed in the wheelchair leaning toward the left. On 6-16-23 at 9:45 AM R3 was lying in a bariatric bed. R3 was holding his left arm. R3 stated, On (1-24-23) two agency staff were transferring me from my wheelchair to the bed. The two staff did not know what they were doing and were moving the Hoyer (mechanical lift) to fast and was jerking the lift. The lift tipped over with me in it and I fell hard into my wheelchair. The (mechanical lift) fell on top of me, hitting my left arm and my head. The lift broke my left arm. It hurt for a little while. The staff tipped the lift over on me sometime last year also. The lift tipped forward while I was in the wheelchair and pinned me against the wall, scratching my face. On 6-16-23 at 10:30 AM V15 (CNA/Certified Nursing Assistant) and V16 (CNA) transferred R3 from the bed to the wheelchair using a bariatric mechanical lift and sling labeled with another manufacturer name. During the transfer V16 raised R3 off of the bed with the mechanical lift and transferred, R3 with the mechanical lift from the bed to the wheelchair that was located 10 feet from the bed. R3 was suspended in the air, without staff support behind his back, head, or neck during the transport from the bed to wheelchair. V15 was standing beside R3's wheelchair during the transfer from the bed to wheelchair. On 6-16-23 at 12:48 PM V3 (LPN) stated, The (mechanical lift) was toppling over and fell on (R3), hitting (R3) on the shoulder. Two CNAs were transferring (R3). I assessed (R3) and he had some pain in his left shoulder. We got an order for an x-ray, and they found (R3's) arm was fractured. On 6-16-23 at 12:56 PM V23 (Building Maintenance Director) stated, I have always ordered 'Drive' brand mechanical lift slings for the mechanical lifts. I thought 'Drive' slings were compatible to use with the lifts. On 6-16-23 at 1:55 PM V21 (Agency CNA) stated, On (1-24-23) me and V20 (Agency CNA) were transferring (R3) from the bed to the wheelchair. During the transfer, the (mechanical lift) started to tip over, and the back wheel came off of the floor. We had to hold (R3) up and get him into the wheelchair. (R3) had hit his arm on the (mechanical lift) when the (mechanical lift) started to topple over. I am not sure why the (mechanical lift) tipped. On 6-16-23 at 4:00 PM V24 (Mechanical Lift Manufacturer's Representative) stated, (The Manufacturer) cannot guarantee the safety of residents during a transfer with our (mechanical lift) model unless the facility uses our manufacturer's slings. Any other manufacturer's slings are not guaranteed to be safe. On 6-16-23 at 4:05 PM V2 (Director of Nursing) stated, Two staff should do a mechanical lift transfer. While the resident is suspended in the air and being transferred to the wheelchair from the bed, so one will control the lift and the other staff will support the resident behind the resident's head and neck until they get the resident close to the wheelchair. One staff will then lower the resident with the lift, while the other maneuvers the resident into the wheelchair. I know (R3) got fracture to the left arm from the (mechanical lift) tipping over on him.

Based on interview and record review, the facility failed to ensure a resident was properly seated in her wheelchair during wheelchair transport. This affected 1 of 3 residents R2 reviewed for safety while transporting in a wheelchair. This failure resulted in R2 falling forward while being pushed in the wheelchair by facility staff, this fall incident resulted in R2 falling onto R2's face sustaining a facial laceration a treated at the local hospital with stitches. Findings include: On 12-27-22 at 12:00 PM, surveyor observed R2 in dining room during lunch meal under staff supervision. R2 was seated in her reclining high-back wheelchair with leg rests and footboard in place. R2 is confused and unable to carry conversation with surveyor. R2 was noted with resolving discoloration below her left eye. R2 was not showing any attempts to get up by herself. On 12-27-22 at 1:43 PM,V2 (Director of Nursing) said R2 is a fall risk. R2 had dementia and confusion. R2 is not directable due to cognitive deficits. R2 has poor safety awareness due to dementia and confusion. When CNA was bringing R2 back to her room via wheelchair, CNA stated R2 leaned forward. CNA was unable to prevent R2 from falling forward and sustaining facial laceration requiring stitches. Fall coordinator in-serviced CNA on safely transporting wheelchair residents. On 12-27-22 at 3:37 PM, V13 (CNA) said R2 is confused and forgetful. R2 is unable to make her needs known. R2 has poor safety awareness and will lean forward in wheelchair. During a transport to R2's room via wheelchair, R2 leaned forward and fell from the wheelchair. V13 said R2 hit her head on the floor and V13 saw R2's blood on the floor. The nurse came immediately. Nurse cleaned the blood, placed towel under the head, and called 911. On 12-27-22 at 2:59 PM, V12 (LPN) said R2 is alert and oriented x1 with confusion and forgetfulness. R2 is unable to make her needs known. R2 has poor safety awareness because she is impulsive and tries to get up by herself. R2 has to be re-directed and monitored. R2 needs to be re-directed several times. V12 said after dinner (after 6:00 PM), V13 was transporting R2 to her room via wheelchair. V12 was at nursing station and heard a crash and chair alarm. In dining room, V12 saw R2 in the floor in front of the wheelchair. V12 saw blood on the floor. V12 left R2 on the floor to lessen any trauma and V12 called 911. V12 saw blood on the bridge of R2's nose on the side where R2 was laying. 911 came right away and transported to the hospital. R2 had no indication of pain. The hospital records indicated fracture to nose R2's nose was treated with steri-strips. R2 had 5-6 stitches on the side of her forehead. R2 returned to facility that same night. R2 is a fall risk. On 12-27-22 at 2:51 PM, V11 (RN) said R2 is alert, oriented x 1-2, and mostly unable to make her needs known. R2 is confused and forgetful. R2 has no safety awareness. R2 is impulsive, will try to get up by herself, and takes multiple times for re-direction. V11 has seen R2 leaning forward in her wheelchair during transport in the past. On 12-27-22 at 2:43 PM, V10 (CNA) said R2 is confused and forgetful. R2 is unable to make her needs known and carry conversation. R2 requires feeding assistance most of the time. R2 is a high falls risk. R2 has chair alarm, bed alarm, floor mat, reclining high back wheelchair, and foot board. R2 will attempt to get up by herself and R2 is not able to be re-directed. V10 said she sees R2 leaning forward in her wheelchair. V10 says she will ensure R2's back is upon the back of the wheelchair. CNA will not transport R2 unless her back is up on the back of the wheelchair. V10 will do this several times as needed. Initial State Reportable dated 12-1-22 documents: Description of what happened: On 11-30-22 prior to fall, resident was up in her wheelchair in dining area and around 6:12 PM, assigned nurse stated the CNA was wheeling resident to her room and resident tipped forward and landed on the floor with face down. No loss of consciousness. Neuro checks was done and no deficit. Resident was noted with scant bleeding from right forehead and sustained a cut to the right forehead and superficial skin tear was noted to the bridge of the nose. Range of motion to all extremities were within resident's baseline. Resident unable to relay the cause of the fall due to cognitive impairment. Vital signs were with resident's baseline. 911 was called. Nursing supervisor was notified. Resident was sent to ED for further evaluation and returned to facility same day with stitches to forehead and steri-strips to the bridge of the nose. Final State Reportable dated 12-6-22 documents: Final Investigation/Conclusion: Imaging done in ED as follows: CT Facial bone without contrast: Mildly comminuted fractures of the tip of the nasal bone without significant displacement. Resident Care Plan has been reviewed and updated upon returning to the facility. Hospital Record dated 11-30-22 documents: Reason For Exam: facial laceration/nasal bone contusion/ laceration. Impression: Mildly comminuted fractures of the tip of the nasal bone without significant displacement. Fall Risk Assessments (dated 1-10-22, 2-11-22, 5-12-22, 11-9-22, and 12-15-22) document: R2 is high fall risk.

Based on observation, interview and record review the facility failed to implement resident specific fall prevention interventions for a resident with severe cognitive impairment for 1 (R6) of 5 residents reviewed for falls in the sample of 42. This failure resulted in R6 being transferred to the hospital's emergency department where he was diagnosed with a hip fracture and had subsequent hip surgery. Findings include: R6 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including but not limited to Chronic Obstructive Pulmonary Disease, Unspecified Asthma, Hypertension, Alzheimer's Disease, Major Depressive Disorder, and Dementia. According to MDS (Minimum Data Set) dated 05/18/2022 under section C, R6 has BIMS (Brief Interview of Mental Status) score of 4 indicating severely impaired cognition. According to MDS (Minimum Data Set) dated 05/18/2022 under section G, all shows R6's functional status for transfers requires extensive assistance with one-person staff assist to transfer, walk in the room, and toilet use. Fall risk assessment dated [DATE] shows R6's fall risk evaluation score of 12, indicating very high risk for falls. On 12/12/22 at 01:17 PM Surveyor observed R6 in his room. Bed placed against the wall, fall mat present on the right side of the bed. Bed in the lowest position with upper side rails up. Call light within R6's reach. R6's speech unintelligible, surveyor unable to conduct interview. On 12/14/22 at 11:51 AM Surveyor interviewed V16 (Registered Nurse/ fall preventionist), V16 stated, One of the reasons why R6 suffered multiple falls withing this year (2022) is that R6 has gait imbalances and is very impulsive. R6 is often displaying unpredictable behaviors, like trying to remove his clothes while being assisted to the bathroom. R6 was evaluated for urinary tract infections several times; however, all came back with negative result. V16 stated, When R6 was on the initial unit, he was placed right across from the nursing station. Additionally, R6 was encouraged to participate in day-care program to keep him occupied with multiple activities throughout the day. V19 (Psychiatrist) and the family were also involved in R6's care. Evenings and nights appeared to be the culprit of R6's fall problem. R6 had 12 fall incidents from the beginning of 2022. The hip fracture was suffered during one of his episodes of impulsiveness on 06/14/2022. R6 was attempting to get up without assistance. V17 (Certified Nursing Assistant) just rounded on R6 and offered toileting; around 1:50am V17 (CNA) and V18 (Licensed practical Nurse) found him on the floor. V16 stated, R6 would ask at times to take him to the bathroom, and he used his call light, but it was inconsistent. V16 further indicated that R6 was transferred to secured memory care unit for more effective monitoring. On 12/14/22 at 12:54 PM Surveyor interviewed V14 (LPN/ secured memory care unit staff), V14 stated, R6 was transferred to the secured memory care unit about six months ago. R6 is on fall preventions that include bed in lowest position, fall mats, upper side rails up, frequent monitoring, at least every 2 hours but with him it's usually every 45 minutes to 1 hour, bed and chair alarm in place, and call light within reach. Additionally, R6 resides in the room right across from the nursing station. On 12/14/22 at 12:54 PM Surveyor interviewed V15 (Certified Nursing Assistant/ secured memory care unit staff), V15 stated, R6 is on fall precautions. I check on him every 10 min, the door to his room is almost always open, so we can look at him pretty much constantly. R6 has fall mat beside his bed and chair alarm and bed alarm are in place. Fall care plan dated 03/10/2020 reads in part, R6 is at risk for falls, with interventions: educate R6 of the importance of calling staff if he needs assistance, create signs with instruction reminding R6 to use call light for assistance, keep call light within reach, remind R6 to ask for assistance. Resisting Care care plan dated 09/16/2020 reads in part, R6 exhibits symptoms of resisting care which is manifested by: getting up to go to the bathroom, with interventions: educate and remind resident to utilize call light, remind resident to ask for assistance form staff. Per record review, R6 fell on [DATE], 02/18/2022, 03/10/2022, 03/14/2022. 04/28/2022, 05/07/2022, 05/13/2022, 06/10/2022, 06/14/2022 while in the initial unit. R6 suffered hip fracture during 06/14/2022 fall incident. Additionally, R6 fell on [DATE], 07/22/2022, and 10/10/2022 while in the secured memory care unit. Per record review, hospital records dated 06/14/2022 at 01:01 PM reads in part, [R6] sustained mechanical fall at nursing home earlier today resulting in left hip fracture. Orthopedic surgery has been consulted and plan is for operative repair later today. On 12/15/2022 at 09:49 AM, 10:54 AM, and 12:44 PM Surveyor attempted to interview V17 (Certified Nursing Assistant) via phone, no answer, voicemail left. On 12/15/2022 at 09:51 AM, 10:56 AM, and 12:46 PM Surveyor attempted to interview V18 (Licensed Practical Nurse) via phone, no answer, voicemail left. On 12/15/2022 at 09:53 AM Surveyor attempted to interview V19 (Psychiatrist), message left with receptionist, waiting for a call back. On 12/15/2022 at 10:16 AM Surveyor received call back from V19 (Psychiatrist), V19 stated, R6 is not cognitively appropriate to respond to fall preventions such as [but not limited to] educating of the importance of calling staff if he needs assistance, creating signs with instruction reminding to use call light for assistance, or reminding to ask for assistance. R6 is not cognitively aware and cannot retain information and process through what's appropriate and what's not. Legacy Healthcare Fall Occurrence Policy dated August 3, 2016, reads in part, 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. Ultimately, the Falls Coordinator may change the interventions provided by the nurse if the Falls Coordinator's investigation identifies a more appropriate intervention for the individual fall. The interventions will be reevaluated and revised as necessary.

FACILITY Based on observations and interview, the facility failed to safely maintain proper freezer and food temperatures, failed to follow facility policy and department regulations for safe food temperatures to prevent food-born illness. This failure has the potential to affect all 134 residents who reside at the facility. Findings include: On 12/12/22 at 10:54 AM, observed temperature log on freezer labeled ice cream freezer for December 2022 that showed from 12/1-12/8, the logged AM and PM temperatures were all above 0 degrees Fahrenheit, and the AM temperature logged on 12/13/2022 showed 10 degrees F. Temperature log also showed acceptable freezer temps as below 0 degrees F. Also observed a Temperature Requirements For Potentially Hazardous Foods that showed for Hot Food Holding, temperature of 135 degrees F and freezing temperatures of 0 degrees F. At 10:56 AM, V6 opened ice cream freezer door and said the internal freezer temperature read 18 degrees F. Surveyor began checking food items within freezer and noted 2 opened boxes of ice cream cups that were soft to touch and not frozen. V6 then said he will have maintenance look at the freezer and/or thermometer. On 12/12/22 at 11:05 AM, food temperatures for lunch meal items on steam table were checked with V8 (Dietary Supervisor) as follows: Pan of roast beef temperature showed 140.6 degrees F. V8 said the temperature should be 160 degrees F. V8 then said there was a temperature issue with a second pan of roast beef which was previously placed back in the oven. On 12/13/22 at 10:42 AM, V6 (Temporary Dietary Manager) said the ice cream freezer has a compressor issue and he is awaiting a quote to repair/replace from the outside vendor. Freezer temperature at this time read 16 degrees F. V6 then said he had an in-service that morning with V8 (Dietary Supervisor) regarding previous day food temperatures. On 12/13/2022 at 11:00 AM, lunch food items were temped again with V8 (Dietary Supervisor) that showed honey ham temperature at 202.5 degrees F. At 12:22 PM, test tray plated by V8 and placed on the unit cart. At 12:31 PM, the test tray left the kitchen and taken to the unit per caregiver. At 12:43 PM, test tray temped by V8 (Dietary Supervisor) that read 131.3 degrees F (holding temperature). Per V8, holding temperature for the honey ham should be at 135 degrees F. Reviewed kitchen policy last revised 07/28/22 provided by V6 (Temporary Dietary Manager) that showed under policy statement, the facility will comply with state and federal regulations in operating facility's kitchen. Under procedures, policy showed, food storage: frozen food frozen and hard. Under food temperature, policy showed, hot food temperature should be 135 degrees F and above.

Based on observation, interview, and record review, the facility failed to follow pharmacy medication labeling policy by not noting and implementing open date labels. This applies to 8 of 54 (R6, R27, R40, R51, R54, R68, R266, and R318) residents' medications in four of five medication carts during the medication storage and labeling task. Findings Include: On [DATE] at 03:00 PM Surveyor conducted inspection of medication cart (,d+[DATE]) on Friendship unit. Surveyor observed opened and undated or dated inappropriately medications for: R54 - Ventolin HFA Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) - open date ,d+[DATE] (no year) R27 - ProAir HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) - no open date R51 - Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) MCG/ACT - no open date On [DATE] at 03:50 PM Surveyor conducted inspection of medication cart on Love Pod unit. Surveyor observed opened and undated or dated with expired date medications for: R40 - Breo Ellipta Inhalation Aerosol Powder Breath Activated ,d+[DATE] MCG/ACT (Fluticasone Furoate - Vilanterol) - No open date Insulin Glargine Solution 100 UNIT/ML vial no open date - [NAME] R266 R68 - HumaLOG KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML - dated [DATE]-[DATE] (expired) and Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML - no open date On [DATE] at 12:02 PM Surveyor conducted inspection of medication cart on Pathways unit. Surveyor observed opened and undated medications for: R318 - Anoro Ellipta Inhalation Aerosol Powder Breath Activated 62XXX,d+[DATE] MCG/ACT (Umeclidinium-Vilanterol) - no open date On [DATE] at 12:16 PM Surveyor conducted inspection of medication cart on Faith Place unit inspected. Surveyor observed opened and undated medications for: R6 - Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) MCG/ACT - no open date On [DATE] at 12:37 PM Surveyor interviewed V14 (Licensed Practical Nurse), V14 stated, Medications like insulin should be dated upon opening because there is a limited time to use it, for insulin it is 28 days. I'm not sure about inhalers and other medications. On [DATE] at 09:24 AM Surveyor interviewed V2 (Director of Nursing), V2 stated, Open dates should be placed on medications because we don't always use expiration dates as a guide to dispense those medications. One of the examples would be insulin; insulin is good for 28 days. If medication is used past its approved use date, it can lose its potency. Nurses should not administer medications that go beyond approved use date. Other medications, like inhalers, may have different time windows to use them, for example, it could be 30, 45, or 60 days. My expectation for the nurses is to date medications upon opening. Medications with Shortened Expiration dates policy dated [DATE] reads in part, Fluticasone propiante inhalation powder should be discarded 2 months (100- and 250- strengths) after removal from moisture-protective overwrap pouch. Albuterol [should be discarded] 12 months after removal from protective pouch. Insulin lispro injection KwikPen expires 28 days after first use or removal from refrigerator. Insulin Glargine injection - Lantus vial expires 28 days after first use or removal from refrigerator. Insulin Glargine injection - SoloStarPen expires 28 days after first use or removal from refrigerator. The opened date should be noted on each container/vial of medication known to have a shortened beyond use date or expiration date.

Based on interview and record review, the facility failed to implement their fall and ADL (activities of daily living) care plans to prevent 1 (R1) of 3 residents in the sample from falling. Findings include: R1 is an [AGE] year old, cognitively impaired resident with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's fall care plan dated 5/9/22 reads in part, (R1) has an ADL (Activities of Daily Living) self care performance deficit and impaired mobility related to Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions: Transfer: (R1) requires 2 staff participation with a sit to stand for transfers. On 10/16/22 V12 (Agency LPN) wrote in the progress notes that read (in part), 10/16/2022 08:40 AM Incident Summary: Resident received AM care in her room prior to incident. Approximately at 8:40 AM writer alerted to residents room by V13 (CNA/Certified Nursing Aide). Writer immediately went to residents room.Upon entering residents room, observed resident lying on the floor on the left side of the bed on her left side.V13 (CNA) stated when she was done transferring resident in the wheelchair, she turned her head for a second so she could grab her leg rest to place on the wheelchair and she tipped over. Per V13 (CNA) she couldn't react fast enough to catch her while falling. Per V13 (CNA), resident did not hit her head. Resident unable to state why this happened due to cognitive impairment.Resident assessed from head to toe with no injuries noted. vital signs assessed. Neurocheck initiated with no deficit. No shortening of either lower extremity noted. No facial grimacing noted. Order to send emergency room for evaluation. MDS ([NAME] Data Set) assessment dated [DATE] shows R1 requiring extensive assistance with a minimum 2-person assist to transfer from bed to wheelchair. On 10/16/22 V13 (Agency CNA) was the only staff member present in the room when transferring R1, turned around to obtain wheelchair device, and R1 fell face forward to the ground. Several efforts to contact V13 (Agency CNA) on 10/5/22 and 10/6/22 but could not be reached for interview. Per V1 (administrator) V13 had not taken a shift since the 10/16/22 fall incident involving R1. On 11/5/22 at 9:50 AM, V12 (Agency LPN) stated, The day R1 fell was the first time I was scheduled there. I'm an agency nurse and I did conduct some orientation before my shift but it was just forms I filled out and initialed. No one really told me anything about that unit. It was their dementia unit I think. Asked whether she was informed specifically abour R1's care needs or fall risk status, V12 stated, Not really. I think they all were fall risk in there (referring to the unit). Surveyor asked whether there were any other aides that assisted V13 to transfer R1 from bed to wheelchair, V12 stated, I don't know. I just know that it was only V13 because she was the one that called me and said R1 was on the ground.

Based on observation, interview and record review, the facility failed to follow their fall prevention protocols, failed to follow the functional assessments for transfers for 1 (R1) of 3 residents in the sample. Findings include: R1 is an [AGE] year old, cognitively impaired resident with diagnosis of Alzheimers disease, dementia, physical debility, and with a history of multiple falls. On 11/4/22 at 10:50 AM, R1 was observed on a wheelchair in the center of the unit with other residents watching television. V5 (activity aide) was seated several feet away and stated to surveyor, I'm here to watch the residents. Surveyor asked about R1, V5 stated, She fell not long ago so we have to watch her a lot and we put alarm on her so she don't fall. Attached to R1's wheelchair was an wheelchair alarm that was blinking green. V5 stated, That means it is on. She (R1) can't tell you anything, she's really confused. On 11/4/22 at 11:00 AM, V4 (LPN/Licensed Practical Nurse) stated, This is the dementia unit. Everyone here is pretty much a fall risk. Surveyor asked what interventions were done for residents at risk to fall, V4 stated, We put alarms on them, keep their call light within reach, and we monitor them a lot, bed at low position. Surveyor asked about R1, V4 stated, I think she's in her room. (V4 unaware that R1 was in the center of the unit and not currently in her room contraditicting her monitoring). On 10/16/22 V12 (Agency LPN) wrote in the progress notes that read (in part), 10/16/2022 08:40 AM Incident Summary: Resident received AM care in her room prior to incident. Approximately at 8:40 AM writer alerted to residents room by V13 (CNA/Certified Nursing Aide). Writer immediately went to residents room.Upon entering residents room, observed resident lying on the floor on the left side of the bed on her left side.V13 (CNA) stated when she was done transferring resident in the wheelchair, she turned her head for a second so she could grab her leg rest to place on the wheelchair and she tipped over. Per V13 (CNA) she couldn't react fast enough to catch her while falling. Per V13 (CNA), resident did not hit her head. Resident unable to state why this happened due to cognitive impairment.Resident assessed from head to toe with no injuries noted. vital signs assessed. Neurocheck initiated with no deficit. No shortening of either lower extremity noted. No facial grimacing noted. Order to send emergency room for evaluation. MDS ([NAME] Data Set) assessment dated [DATE] shows R1 requiring extensive assistance with a minimum 2-person assist to transfer from bed to wheelchair. On 10/16/22 V13 (Agency CNA) was the only staff member present in the room when transferring R1, turned around to obtain wheelchair device, and R1 fell face forward to the ground. R1's fall care plan dated 5/9/22 reads in part, (R1) has an ADL (Activities of Daily Living) self care performance deficit and impaired mobility related to diagnoses:: hypertension, Alzheimer's disease, anxiety disorder, falls, [CONDITION(S)], cerebral infarction, osteopenia lumbar spine, [CONDITION(S)] and squamous cell skin cancer, Left wrist fracture status post ORIF (surgical operation). Goal: R1will remain free of complications related to immobility, including contractures, skin-breakdown, fall related injury through next review date. Interventions: Transfer: (R1) requires 2 staff participation with a sit to stand for transfers. On 11/5/22 at 9:50 AM, V12 (Agency LPN) stated, The day R1 fell was the first time I was scheduled there. I'm an agency nurse and I did conduct some orientation before my shift but it was just forms I filled out and initialed. No one really told me anything about that unit. It was their dementia unit I think. Asked whether she was informed specifically abour R1's care needs or fall risk status, V12 stated, Not really. I think they all were fall risk in there (referring to the unit). Surveyor asked whether there were any other aides that assisted V13 to transfer R1 from bed to wheelchair, V12 stated, I don't know. I just know that it was only V13 because she was the one that called me and said R1 was on the ground. Several efforts to contact V13 (Agency CNA) on 10/5/22 and 10/6/22 but could not be reached for interview. Per V1 (administrator) V13 had not taken a shift since the 10/16/22 fall incident involving R1.

Based on interview and record review, the facility failed to ensure a resident was securely seated in wheelchair while being transported to her room and fell forward from the wheelchair. This failure affected 1 resident (R1) of 3 reviewed for falls. This failure resulted in 1 cm laceration to R1's forehead. Findings include: On 8-9-22 at 11:28 AM, R1 is up to her wheelchair and seated at a table in the dining area with supervision. She has a table in front of her with a pillow. R1 was seen resting her head on the pillow at times. R1 was seen frequently leaning forward and resting her head on the pillow. She is alert and unable to carry meaningful conversation. R1 has purple/yellowish discoloration to bilateral lower periorbital areas. On 8-9-22 at 1:17 PM, V2 (Acting DON/Regional Nurse Consultant) said R1 is alert, oriented x 1-2, and not able to make her needs known. R1 has Alzheimer's and dementia with behavior disturbance. R1 is fall risk and has poor safety awareness. R1 has a behavior to lean forward in wheelchair. Staff use a pillow when she is seated at the table. R1 leaning forward can be a fall hazard in the wheelchair. Prior to incident, R1 has a chair alarm, table in-front with pillow, and placed in common area for supervision. V2 said R1's primary nurse instructed V4 (agency CNA) on how to transfer R1 by pushing wheelchair and securing R1's shoulder to keep resident back to seat back of wheelchair. R1 was not secured to back of wheelchair, leaned forward, and fell out of the wheelchair. V4 was unable to prevent R1's fall. After this incident, facility is using 2 person transfers for R1. One person will be pushing the wheelchair and another person will be on the side of wheelchair to ensure R1 is upright and secure in her wheelchair. On 8-9-22 at 10:25 AM, V3 (Nurse) said V4 (agency CNA) was getting R1 ready for bed, transferring R1 by wheelchair to her room. V4 was pushing R1 in dining area to her room and R1 fell forward. R1 is high fall risk due to memory. R1's footrests were on the wheelchair. V3 was at nurse station when she heard the R1's fall in dining area. V3 saw R1 on floor and on her side. There was bleeding on the left side of forehead. V3 cleaned R1, controlled bleeding, and called 911. R1 was unable to say what happened. V4 said R1 fell forward from wheelchair. V3 said R1 can have difficulty holding herself upright in wheelchair. V3 instructed V4 on how to transport R1 via wheelchair. When pushing the R1 in the wheelchair, you must ensure R1's back is against the seat back of the wheelchair and hold R1's shoulder. During this transfer, R1 fell out of the wheelchair and V4 was unable to prevent fall. V3 noted laceration and blood to R1's forehead. V3 did see footrests on R1's wheelchair. V4 was unable to maintain R1 upright in wheelchair. On 8-10-22 at 9:24 AM, V4 (agency CNA) said V4 was in the process of returning R1 to her room after dinner. During transport, R1 leaned forward in wheelchair while V4 was pushing the wheelchair. R1 was not aware of this leaning behavior. The staff did not tell V4 about this behavior and V3 (Nurse) did not instruct V4 on how to transport R1 in wheelchair. When R1 leaned forward CNA was unable to stop R1 from falling. This was the first time working with this resident. V4 did not know R1 was a fall risk and is not sure if R1 can make her needs known due to her confusion. V4 said R1 had footrests in place. When R1 fell , V4 saw R1 with laceration to her forehead. On 8-9-22 at 11:38 AM, V5 (CNA) said R1 is alert, confused, and unable to make her needs known. R1 is a high risk for falls because she is confused and demented. R1 is impulsive and will try to get up by herself and lean forward in wheelchair. The dementia and confusion make it difficult to redirect R1. R1 will always lean forward when transferring in wheelchair. V5 will ensure R1 has her back against the back of the wheelchair and V5 keeps her hand on R1's shoulder to keep resident back against the wheelchair back. All staff transfer R1 this way. If R1 leans forward during transfer, V5 will stop pushing, redirect and ensure R1's back is against the seat back of the wheelchair before proceeding forward. After the incident, there should be 2 staff during the transfer back to room. On 8-9-22 at 11:51 AM, V6 (Nurse) said R1 is alert, oriented x 1-2, and can sometimes make her needs known. R1 has Alzheimer's disease and dementia. R1 leans forward in her wheelchair. R1 is a high fall risk with history of falls. When transporting R1 by wheelchair it takes 2 staff because she is totally dependent. R1 is 2 person assist for safety reasons. On 8-9-22 at 12:43 PM, V7 (Fall Nurse) said R1 is alert, oriented x 1-2, and can sometimes make her needs known. R1 is a high fall risk. R1 has a lack of safety awareness at this time. R1 will try to get up by herself from wheelchair and leaning forward in wheelchair. R1 requires frequent redirection and verbal cues. When transporting R1, R1 would have leg rests on her wheelchair, staff ensure R1 is properly upright in chair with back against the seat back of wheelchair, and not leaning to the side. If needed, staff may support shoulder against the back of chair. After this incident, facility uses 2 staff when transporting R1 via wheelchair. One staff pushes R1's wheelchair that the other staff walking along side as a spotter to ensure she is not leaning forward and remains upright. There was one CNA assisting R1 at the time of the incident. This was an agency CNA who was not aware of supporting R1's shoulder to the wheelchair backrest during turning or initiating movement. R1's Face Sheet documents: Diagnosis Information (not limited to): difficulty in walking, unspecified lack of coordination, abnormal posture, need for assistance with personal care, dementia with behavioral disturbance, major depressive disorder, anxiety disorder, Alzheimer's disease, and age-related physical debility. R1's MDS (ARD 7-8-22 and 8-4-22) documents: BIMS Summary Score= 99 (unable to complete interview), Transfer (Self) 3= Two+ persons physical assist, (Support) 3= Two+ persons physical assist. R1's Falls Risk Assessments (dated 11-4-20, 12-4-20, 12-27-20, 12-31-20, 3-23-21, 7-27-21, and 7-25-22) document R1 is high risk for falls. R1's Initial State Reportable (dated 7-26-22) documents: Around 6:50 PM, the CNA on duty was pushing R1 in the wheelchair and R1 fell forward from the wheelchair and the CNA was unable to break the fall. A small amount of bleeding is noted from the left side of forehead. R1 was treated, bleeding controlled, and dressing applied. 911 was called and R1 was transferred to local hospital for evaluation. R1's Final State Reportable (dated 7-30-22) documents: Final Investigation/Conclusion: R1 was being transported from the dining area to her room. CNA was standing behind R1's wheelchair and begin to roll the wheelchair. when R1 leaned forward suddenly and the CNA was unable to break the fall. Hospital Record dated 7-25-22 documents: HPI: [AGE] year-old adult presents with a fall from wheelchair. This [AGE] year-old is brought by paramedics, who states that she fell forward out of her wheelchair striking her head on the ground. She sustained a small 1 cm laceration with well approximated skin on her forehead without foreign body. After cleaning the skin, MD approximated the skin using the fingers and secured it with cyanoacrylate glue. Patient tolerated procedure well. Clinical Impressions: Fall from wheelchair, initial encounter.

Based on interview and record review the facility failed to ensure a resident was free of acquired pressure injury to 1 of 3 residents (R1) reviewed for pressure injury in the sample of 8 The findings include: R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The same POS show R1 has a indwelling catheter and [CONDITION(S)]. On 6/30/22 at 4:50 PM, V8 (R1's daughter) said R1 was admitted to the facility with intact skin. V8 said a little over a week after admission at the nursing facility, R1 already developed a pressure ulcer (blisters) at the back of his thighs. V8 said when she visits R1, R1 had an incontinent pad. V8 said she would ask the staff to remove the incontinent pad. V8 said R1 does not need them. R1 had a catheter and [CONDITION(S)]. V8 said on one of her visits, she asked the staff to turn R1, she noticed large blisters to R1's upper thighs. V8 said the blisters were large and very noticeable. V8 said she is a Registered Nurse and knew blisters are pressure. V8 said R1 had no reason to develop pressure since R1 had a catheter and a [CONDITION(S)]. V8 said R1 was not being turned and repositioned when in bed would be the caused of the pressure injury. V8 said she was the one who reported the blister to the Director of Nursing (V2) On 7/1/22 at at 11:23 AM, V2 said she was informed by R1's daughter that R1 had a pressure ulcer. V2 said she went to check R1. V2 said R1 again was on the incontinent pad. V2 said there was no reason for him to have the incontinent pad because he had a catheter and [CONDITION(S)]. V2 said she removed R1's incontinent pad., turned R1 to his side, R1 was noted to have large blisters on his left thigh. V2 said she noticed that R1 was laying under his catheter tubing that was causing the pressure under his thighs that had caused the blister. V2 said she does not know how long R1 was on his back. If staff would have turned R1, they would have noticed the catheter was under him instead of over the thighs. R1's admission assessment dated [DATE] show R1 was admitted to the facility with skin intact warm skin and normal skin turgor. A wound assessment dated [DATE] show: Wound inner thigh, classification- blister, facility acquired measuring 1.5 centimeters (cm) x 7.00 cm. On 7/1/22 at 11:03 AM, V10 (Wound Nurse) said she was asked by V2 to assess R1. R1 had large blisters from the back towards the left inner thighs. V10 said R1 was lying under the catheter tubing long enough to cause the pressure. V10 said residents should be turned and repositioned every 2 hours. The facility policy entitled Wound Care Program dated 8/12/21 show the purpose of this policy is to provide evidence based recommendation for the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review the facility failed to transfer a resident from the bed to a chair in a safe manner. This applies to 1 of 3 resident (R1) reviewed for safety in a sample of 3. The findings include: R1's Nurse's Notes dated 3/7/22 at 10:10 PM state, Resident is a [AGE] year old female admitted to the facility on stretcher via (local)ambulance around 10:00 PM from (Local) hospital Diagnoses: [CONDITION(S)] secondary to severe [CONDITION(S)]. Alert and oriented x3 and cooperative. No signs of respiratory distress, breathing is easy and non-labored, resident denies any SOB( Shortness of breath) ,and is afebrile. No complaints of pain at time of assessment. Head to toe assessment complete. VS: 131/84, P 63 ,T 96.6 02 95% RR 18. Hand Grips equal, Capillary refill less than 3 second, no [CONDITION(S)] swelling noted on the lower extremity. Incontinent of bowel and bladder. Abdomen soft, non-tender with active bowel sounds, non-ambulatory, fall precaution in place, call light within reach. Skin with a few bruises on left upper extremity and toes are reddish. Resident is stable, no sign of distress. R1's Progress Notes dated 3/8/22 at 1:30 AM state, Resident is a new admission with diagnoses of [CONDITION(S)] and severe [CONDITION(S)]. Resident came around 10:00 PM. Was in bed, stable. At around 12:30 AM, Resident put the call light on, writer (V3- LPN) went to check the resident. Resident claimed My chest hurts, call my son, I'm in pain. Assessment was done, vitals within (normal) range. Resident was sent (out) via 911. Left the facility around 12:50 AM . On 4/1/22 at 10:40 AM V4 (LPN) stated, (R1) came in as a late admission. Her room was close to the nurse's station, and she was brought in by 2 paramedics. I went in to check on her and show her things and get her acquainted with the facility. I did my assessment and asked her questions, trying to get to know her. She denied pain and SOB. We transferred her out of bed with the help of the CNA. She was a 2 assist for transfer. She did fine. We transferred her from the bed to the weight chair. She didn't say anything about using a hoyer. We have hoyers, we could have used one. Physical Therapy had not assessed her yet so we always use 2 assist until they can evaluate her. (R1) had a leg boot on and we took that off to get her weight. Then we transferred her back to the bed. About 12:30 AM she had her call light on, and I went in to see what she needed as the CNA was busy. She said she was having pain- chest pain- sharp pain- radiating to her left side. She said, call my son. I got my supervisor and I called the paramedics while my supervisor called (R1's) sons and left messages for both of them. The paramedics came in about 10 minutes and I told them she was having chest pain. I let the doctor know that we had to send her out again. I don't think I ever talked to the hospital. She never returned to the facility. The Facility's (unsigned) Hospital Report Sheet dated 3/7/22 shows an area for Ambulatory and Activity- this area is blank and does not show how R1 transfers or what R1's weight bearing status is. R1's Hospital Discharge Summary Notes dated 3/3/22 written by the hospital social worker state, (R1) is non-ambulatory and uses hoyer lift. R1's Hospital Discharge Physical Therapy Assessment states, Patient uses a hoyer lift at assisted living facility. The facility Referral form (sent to the facility from the hospital prior to admission) states, Patient is hoyer lift bound at baseline. On 4/1/22 at 1:40 PM V5 (Director of Rehabilitation) stated, Physical Therapy will assess new residents within 24 hours of admission 99% of the time. Usually if they come in at night we follow the orders from the hospital and they will be seen first thing in the morning for the eval. Our priority in the AM is always the evaluations. For some diagnoses there are special precautions like hip, Non-weight bearing, Spine precautions etc. If they don't have orders from the hospital they can call and ask and try to get as much information as possible. Or if the resident is alert and oriented and they can tell you then we can talk to the resident. My recommendation would be if they don't know how to transfer a resident then they should wait until the morning to get the weight. It is not going to change overnight. On 4/1/22 at 1:40 PM V1 (Administrator) stated, The nurse will take the report from the hospital and we go by that until physical therapy can evaluate the resident. Since they did not get that information in the report and it is not marked on the report sheet then they should have called for clarification.

Based on Interview and Record Review the facility failed to provide direct supervision for one resident with known history of falls. This failure affected (R1) of four residents reviewed for falls. As a result, R1 had injuries from the fall and was transferred to a local hospital via emergency services (911) and diagnosed with acute displaced right greater trochanteric fracture. Findings include: R1 is an [AGE] year old male originally admitted on [DATE] with most recent readmission on 1-14-2022 with medical diagnosis that include and are limited to: frequent falls, [CONDITION(S)] and dementia. R1 is no longer a resident at the facility. Minimum Data Set, dated dated dated [DATE] reads: Brief Interview for Mental Status score: 2/15 severe cognitive impairment. R1 needs extensive assistance of one person for: bed mobility, transfer, locomotion in and off unit, dressing, toileting and personal hygiene. R3 is dependent on mobility devices: wheelchair. Care plan reads; R1 is at risk for falls related to [CONDITION(S)] disease, [CONDITION(S)], [CONDITION(S)], dementia and cognitive communication deficit. Interventions dated: 12-19-2021, bed and chair alarms, educate R1 on importance of calling staff if he needs assistance, staff to anticipate an meet R1's needs, staff to keep R1'd wheelchair and bed in locked position during transfer and nursing care. 1-11-2022 R1 may be situated in common area while maintaining social distance Nursing Admission assessment dated [DATE] reads: Call light evaluation: 1. Is the resident cognitively able to use the call light? no. 2. Does the resident have a medical condition that can potentially affect R1 from pulling the call light string or pressing the call light button? yes. R1 is at risk for falls related to poor safety awareness, unsteady gait and disease process. Progress notes dated: 1-11-2022 at 15:34 read: noise was heard from resident's room and staff including nurse on duty immediately went to the resident's room. Nurse on duty observed resident face down on the floor with his legs out behind him lying outside his bathroom door with his wheelchair close by his feet. Resident who is Alert and oriented X1-2 with periods of confusion and forgetfulness was unable to state what happen due to cognitive communication deficit. Local Hospital History and physical dated: 1-12-2022 reads: (R1) presented in the emergency room after he fell , it was unwitnessed, and x-ray showed acute mildly displaced right greater trochanteric fracture. On 3-4-2022 at 3:00pm V5 (Certified Nurse Assistant) said R1 was confused and everyday he was different. On 1-11-2022 R1 was in the dining room because he was a fall risk. I took (R1) to the toilet maybe by 2:00pm. I will never leave R1 in the bedroom alone because R1 is a high risk for falls. I only leave R1 in the bedroom if the family is visiting and they are supervising. I did not put R1 in his room and leave him alone, that is a big no,no On 3-5-2022 at 9:45am V2 (Director of Nursing) said, my expectation is: patient safety first. R1 was left unsupervised in the bedroom that is inappropriate, (R1) is known to be a risk for falls. Residents that are at risk for fall should not be left unattended in the bedroom, the patients need to be in the common area for staff supervision. When we leave any patients in the bedroom they are going to try to transfer to the bed or go to the bathroom and that is when the falls happened, because they forget their limitations. I do not know who left R1 in the room by himself. Leaving a high risk for fall resident in the bedroom without supervision is a big no. On 3-5-2022 at 11:40am V6 (Certified Nurse Assistant) said, All the residents that are at risk for falls need to be kept under supervision, never left alone in the bedroom, because they can fall to the floor easily. On 3-5-2022 at 9:45am V1- (Administrator) there is no specific supervision/monitoring policy. Fall occurrence Policy dated: 7-28-2021 (Revised) reads: Is the policy of the facility to ensure that residents are assessed for risk for falls. If a resident had fallen, the resident is automatically considered as high risk for falls. Therefore, the nurse does not have to fill out the fall risk assessment to determine if the resident is high risk for fall or not after the resident had fallen.

Based on interview and record review, the facility failed to protect a vulnerable and incapacitated resident (R1) from being sexually abused by a staff member (V5) which required R1 being emergenctly transferred to local hospital for evaluation and initiation of local police investigation which resulted in the arrest of V5. There were also allegations of sexual harassment (R2) and verbal abuse (R3) against (V5). This failure affected three (R1, R2, and R3) residents reviewed for abuse. Findings include: R1 is a [AGE] year old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility incident report written by V1 (Administrator) dated 7/9/21 includes: (R1) mental state: alert and oriented x 0 (severe cognitive impairment). On 7/9/21 at approximately 5:40 AM, (V7) nursing supervisor reported to V1 that nurse on duty (V6), believes she observed certified nurses aide (V5) kissing resident with his hand between her legs. Resident unable to be interviewed due to cognition. Full body assessment completed with no signs of injury. Ambulance called for resident transfer to the emergency department for further assessment. Police, husband and physician notified. V5 (Certified Nurse Aide) left the facility when confronted by V6. 7/11/21 at 7:45 AM, V6 (RN) stated, On July 9th around 5:30 AM, during my shift I saw V5 kissing R1. His mouth was on R1's mouth and I saw him fondling her breasts and touching her private parts in between her legs. R1 is totally incapacitated and she periodically opens her eyes and probably has a cognitive level of a 3 or 4-year-old. I immediately called my supervisor (V7) and I was in total shock and I could not even believe this was happening to this poor woman. As soon as V5 saw me, he got up and just ran out of the room. 7/11/21 at 8:00 AM, V7 (Night Shift Supervisor) stated, I'm the night supervisor and was in charge of the facility. That night, I was on duty on the first floor when I got a call from V6 (RN) to come up to the floor right away because there was some sort of commotion on the floor. When I got there, V6 was crying and shaking and I tried to calm her down so she could tell me what was wrong. She said that when she went back to R1's room to give her her insulin, she saw V5 kissing and putting his hands in between R1's legs through her incontinence brief. We called 911 and the police came; then the ambulance came but they waited for a detective to arrive and then they took her to the emergency room . We were looking for V5 and thought he was probably hiding somewhere in the building so I asked the maintenance man to check the security camera. We saw that he (V5) left the building around 5:36 AM. Ambulance report dated 7/9/21 documents emergency 911 dispatch called to facility at 6:05 AM about a sexual abuse. Ambulance crew met with law enforcement at nursing home. Crew advised not to make contact with patient until detective arrived on scene. Registered Nurse states that the offender is a staff member. Patient is non-verbal has feeding tube and urinary catheter and is alert and oriented to person only. Police followed crew to emergency room . Police were present upon arrival. emergency room triage report dated 7/9/21 8:14 AM documents: Patient presents to emergency room from nursing home for possible sexual assault. Husband states staff saw another staff member kissing and fondling patients breasts and vulva. Upon facility abuse investigation related to R1, it was determined that two other residents had allegations of abuse against V5. 7/10/21 at 2:10 PM, V8 (Social Service Director) stated, I conducted the interviews of interviewable residents that were cared for by V5. I interviewed R2 and she stated that V5 said sexual things to her and that he said he liked thick girls. I also interviewed R3 and she told me that she was scared of V5 and that he yelled and swore at her. R3 said V5 also never came back when she used her call light and waited on the commode for over two hours. V5 also told R3 that he had a 'hot date' one night and couldn't take her to the bathroom because he was in a rush to get to his date. Surveyor asked whether a complete and thorough screening of employees would have helped catch V5 sooner, V8 stated, I guess but I just do the resident abuse assessments. Per V8, R2 and R3 had not previously reported these allegations against V5 to anyone in the facility. R2 and R3 were not interviewable during the course of this survey. Facility Abuse and Neglect policy (effective May 21, 2021) documents: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse. Policy also documents that sexual abuse includes but is not limited to harassment, coercion, disparaging remarks or sexual assault and gives examples that include: implied or actual contact between a caregiver and a resident of sexual nature .Any sexual behavior or relationship instigated by a staff member with a resident will be viewed as an allegation of sexual abuse, unless there is a pre-existing relationship between the caregiver and the resident prior to admission to the facility .Sexual abuse also includes non-consensual sexual relationship between residents or a consensual relationship involving a resident/s who wants the sexual relationship but has no cognitive ability to make a consent.

Based on observation, interview, and record review the facility failed to prevent a resident from falling out of the wheelchair while being transported by staff, and also failed to document a root cause analysis identifying the cause of the fall for one of five residents (R262) reviewed for falls in a sample of 25. This failure resulted in R262 falling from the wheelchair sustaining a right humeral head fracture. Findings include: A Fall Occurrence policy dated 2/20/17 states, It is the policy of the facility to ensure that residents are assessed for risk for falls and interventions are put into place to prevent them from falling. The Falls Coordinator will review the incident report and may conduct his/her own fall investigation to determine the reasonable cause of fall. On 5/22/18 at 12:37p.m., R262 was laying in bed with a sling to R262's right arm. R262 stated that during the previous week a therapist was wheeling R262 in her wheelchair down the hall. R262 slipped out of the wheelchair causing R262 to fracture R262's right upper arm. R262 stated that R262 had been having a problem with slipping forward in the wheelchair and that facility staff frequently need to reposition. R262's fall investigation dated 5/19/18 documents that therapy staff was transporting R262 back to her room following therapy when R262 slid from the wheelchair and landed on R262's right side on the floor. The investigation documents that when R262 was asked what happened R262 stated, I slid down from my wheelchair. The investigation also documents that R262 was sent to the emergency room for evaluation and treatment. The investigation does not document a root cause to the fall was identified, however, the investigation documents that a non-slip pad was then added to R262's wheelchair to prevent her from sliding out of the wheelchair in the future. R262's emergency room X-ray report dated 5/19/18 documents that after R262 fell she sustained, An acute, nondisplaced, mildly impacted, non-angulated right humeral head fracture. On 5/24/18 V4 (Registered Nurse Fall Coordinator) stated that V4 investigated R262's fall on 5/19/18. V4 verified no root cause analysis was documented on R262's fall investigation however, V4 stated that R262 slipped out of the wheelchair as a result of gravity because R262 was not positioned correctly in the wheelchair.