Every finding on record at Bella Terra Bloomingdale

Based on observation, interview, and record review, the facility failed to protect a resident from abuse. This failure resulted in R1 experiencing a broken arm after R2 struck R1 with a plate cover. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 5. The findings include:The facility's Abuse Report Initial Form dated May 22, 2025, at 7:45 PM, by V1 (Administrator) showed On May 22, 2026, RN (Registered Nurse), [V8 (RN)], reported to Administrator, [V1], that resident [R1], reported to him that his roommate, [R2], hit him on the arm with the plate lid from his meal tray. Residents were immediately separated and [R2] was placed on one-to-one supervision. Upon assessment, [R1] was noted with a small abrasion to his left wrist, no other injuries noted. [R1] is not in pain, is in stable condition and not in distress. Attending physician, [V12 (R1's Physician)], and sister of resident were notified. Final report to follow. The facility's Abuse Report Final Form dated May 28, 2026, at 4:00 PM, by V1 showed . Based on interviews of residents and staff, the alleged incident was unwitnessed; however, resident, [R1]'s x-ray resulted in an acute complex fracture of distal ulna (left), as well as a skin tear to wrist/forearm area. The facility's documentation does not show abuse was substantiated. R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including metabolic encephalopathy, displaced fracture of left ulna styloid process, acute kidney failure, and heart failure. R1's MDS (Minimum Data Set) dated April 23, 2026, showed R1 was cognitively intact. The MDS continued to show R1 required maximal assistance with transfers to and from a bed to a wheelchair. R2's EMR showed R2 was admitted to the facility on [DATE], with multiple diagnoses including type 2 diabetes mellitus, adjustment disorder, chronic kidney disease, and heart failure. R2's MDS March 30, 2026, showed R2 was cognitively intact and did not require physical assistance for transfers between surfaces, to walk 150 feet, or to wheel his wheelchair 150 feet. R2's behavior care plan dated May 22, 2026, showed I, [R2], have a history of assaultive behavior, threatening verbalization and/or overt and aggressive acts related ineffective coping and poor frustration tolerance. Symptoms are manifested by being confrontational, argumentative with others or physical aggression toward others. The care plan continued to show multiple interventions dated May 30, 2026, including Intervene immediately if I demonstrate assaultive/aggressive behavior toward self or others. R2's manipulative behavior care plan dated May 29, 2026, showed I, [R2], present with manipulative behavior such as shift-blaming and attempting to avoid responsibility for personal choices and actions. Symptoms are manifested by making false, erroneous or misleading statements/allegations about my roommate. The care plan continued to show multiple interventions dated May 29, 2026, including Ask me to continue to share thoughts and feelings. Discuss with me what these feelings might represent. On June 10, 2026, at 9:37 AM, R1 was lying in bed and had a hard cast on his left forearm. R1 said on May 22, 2026, around 6:00 to 6:30 PM, R1 was watching TV in his room, R1's dinner had just been brought to his room, and R2 asked R1 to turn the volume down on his television. R1 said he told R2 it wasn't too late, and he would turn it down at 7:00 PM. R1 said he just wanted to finish watching his game. R1 said R2 said Turn the f*****g TV down. R1 said R2 came over to R1's bed and picked up the plate cover from R1's dinner and kept hitting R1 with it. R1 said staff eventually responded and R2 was already back in his bed. R1 said R2 eventually said R1 attacked him with a butterknife but R1 did not pick up his knife. R1 said he just put his arms up to defend himself or R2 would've hit R1 on the head with the plate cover. R1 said he never touched R2. R1 said the facility took an x-ray of his arm and he had a broken bone. R1 said the facility should be protecting R1's safety and R1's safety was compromised. R1 said he had to go to the emergency room on May 23, 2026, when the x-ray results showed R1 had a broken bone. R1 said he had a splint put on and then got a hard cast put on later. On June 10, 2026, at 9:55 AM, R2 said on May 22, 2026, around 6:00 PM, dinner arrived in R2 and R1's room and R1's TV was very loud. R2 said he asked the CNA (Certified Nursing Assistant) to ask R1 to turn it down. R2 said R1 said he wouldn't turn it down and then cussed at R2 and said he would beat R2's a**. R2 said he got in his wheelchair and went over to R1's bedside. R2 said R1 tried to hit R2 with remote and the plate cover then started slashing towards R2 with the butterknife. R2 said he then took R1's tray and threw it on the floor. R2 said the police came and spoke with R2 and R2 was fined $300. R2 said he should not have gotten out of bed and gone over to R1's bed. The local police department Incident Supplement Report dated May 23, 2026, by V13 (Police Officer) showed R1 told police [R1] stated that he was in bed watching TV that evening and eating his dinner. [R1] stated he has a hard time hearing, so his TV is usually playing loudly, when his roommate asked him to turn it down. [R1] stated that it was only [6:00 PM], so he felt it was not too loud for the time of day, and when he refused to turn the volume down, [R2] stated 'I'll kick your ass.' [R1] then stated [R2] rolled over to him in his wheelchair, picked up a tray cover from the dinner plate, and struck his wrist six to seven times. [R1] stated he then stopped, and he contact the staff. [R1] was treated for an injury to his left wrist, and they did an 'in-house' x-ray, which indicated his wrist was fractured. [R1] does wish to pursue charges over the incident. The report continued to show the police issued R2 a citation for battery against R1. On June 10, 2026, at 11:49 AM, V8 (RN/Registered Nurse) said he was the assigned nurse to R1 and R2 on the evening of May 22, 2026. V8 said he was notified by the CNA that R1 and R2 were fighting. V8 said the CNA used the word fighting. V8 said when V8 arrived in the room, R2 was in his bed by the window and R1 was in his bed by the door. V8 said R1 told V8, R2 hit R1 with the plate cover and R1 had a skin tear on his left arm. V8 said when he asked R2 what happened, R2 just rolled his eyes and said nothing happened. V8 said R2 was sent to the hospital for evaluation due to his behavior. V8 said as R2 was leaving to go to the hospital, R2 was complaining about R1's loud TV and told R1 to turn it down. V8 said R2 then said he went over to R1 and got in his face. V8 said R2 reported R1 picked up his butterknife and told R2 to get out of his face. V8 said R1 was complaining of left arm pain so V8 obtained an order for an x-ray. V8 said the results did not come back on his shift. On June 10, 2026, at 3:44 PM, V9 (CNA) said he was not assigned to R1 and R2 on May 22, 2026, but V7 (CNA) came out of their room and said R1 and R2 were arguing. V9 said he told V7 he would check it out since he has a rapport with both residents and told V7 to get the nurse. V9 said he finished picking up a meal tray from a different resident and then went to R1 and R2's room. V9 said when he got to the room, both residents were in their own beds. V9 said R1 claimed R2 got out of his bed and wheeled over to R1 and hit R1 with the plate cover. V9 said he is more likely to believe R1 over R2 because R2 is known to not like whoever his roommate is. V9 said he went over to R2 and R2 said R1 was crazy and denied hitting R1. V9 said R2 didn't say he was hit by R1 and V9 did not see any marks on R2's hands. V9 said R2 told V9 he didn't get out of bed. On June 10, 2026, at 1:59 PM, V1 said she did not substantiate or unsubstantiate abuse but something happened between the residents. A progress note dated May 22, 2026, by V8 showed Resident was allegedly hit on a forearm with a food plate cover, in the left wrist/forearm area. A small laceration was noted. First aid was performed and applied. No swelling noted at the current time. No other bruising noted. Resident requested an ice pack and ice pack was given. Doctor notified and x-ray was ordered. Emergency contact was notified as well. Resident noted of 2 out of 10 pain later and [acetaminophen] was given. R1's x-ray results dated May 23, 2026, at 6:22 AM, showed Procedure: Left wrist, 3 views. Findings: Acute complex fracture of distal left ulna. The bony mineralization is unremarkable. A change of condition note dated May 23, 2026, 8:21 AM, by V11 (RN) showed 1. The change in condition, symptoms, or signs observed and evaluated is/are: inflammation and bruising to left ulnar. 2. This started on: May 23, 2026. A progress note dated May 23, 2026, at 11:00 AM, by V10 (Nurse Practitioner) showed . He is seen today for nurse reports that patient has complained of left hand pain. He had bruising and swelling, x-ray was ordered which showed fracture of distal ulna. He was sent to emergency room, placed on a soft cast and discharged back to facility. He is seen today laying in bed, he was a sitter by bedside. He reports that he had an altercation with another resident and now has this fracture. On June 11, 2026, 11:26 AM, V12 (R1's Physician) said she was aware of the incident between R1 and R2. V12 said there was an argument between R1 and R2 about the TV, and R1 told R2 to come over and make him turn the volume down. V12 said R2 then went over to R1 and R2 hit R1 with the hard plastic plate cover. V12 said R2 hitting R1 with the plate cover is how R1 sustained the ulnar fracture. V12 said an x-ray was performed on R1's arm and there was a fracture, and R1 was sent to the emergency room for evaluation. V12 said R1 later had a follow up orthopedic appointment and received a hard cast. V12 said R1 has a follow up orthopedic appointment this Friday. V12 said her expectation is residents are free from abuse in the facility. The facility's policy titled Abuse and Retaliation Policy dated January 29, 2026, showed 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. These guidelines include compliance with the seven federal components of prevention and investigation. Definitions of Abuse, Neglect, Exploitation, and Abuse Coordinator: Abuse- Abuse is willful infliction of mistreatment, injury, unreasonable confinement, intimidation or punishment. Abuse assumes intent to harm, but inadvertent or careless behavior down deliberately that results in harm may be considered abuse. 1. Physical: Physical abuse includes but is not limited to infliction of injury that occur other than by accidental means and requires medical attention.

Based on observation, interview, and record review, the facility failed to follow the diet spreadsheet and standardized recipes to ensure satisfactory taste and palatability for residents.This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen.Findings include:The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 4/7/26 documents that the total census was 95 residents. On 4/9/26 at 2:32 PM, V4 (Food Service Director) said the facility had 2 NPO (Nothing by Mouth) residents, the other 93 residents were served from the facility kitchen.On 4/7/26 at 10:15 AM, R30 said he had been in the facility about 5 months and his only concern was the facility food. R30 said he opts for the burger from the always available menu most days because the food sucks. R30's breakfast tray was observed with scrambled eggs and a slice of bread, untouched. R30 said he doesn't like the eggs. R30 said he did not know what he was served the previous night's dinner, but he called it slop because it was mushy. On 4/7/26 at 10:20 AM, R24 said the food is a problem. On 4/7/26 at 11:22 AM, R92 said the food tastes like sh*t. On 4/7/26 at 11:33 AM, R89 said she is a resident representative and attends resident council meetings where she frequently hears complaints about the food. R89 said the food is terrible, too salty, she will not eat the eggs, and it does not seem like the cook is following any recipes. On 4/7/26 at 10:32 AM, R52 said the food sucks. R52 said the eggs are supposed to be scrambled but they are runny. R52 then started crying and apologized saying she had been in the facility for over 2 months, and she is hoping to be discharged soon because she hates the food. R52 said the food tastes like dog food, the soup is too salty, the fish is dry, and she does not think they are following any recipes. On 4/8/26 at 1:00 PM, during the surveyor led Resident Council meeting, R7, R29, and R89 said the kitchen adds too much gravy to meats, the vegetables are dry, and the hamburger, turkey, beef, and macaroni and cheese taste terrible.R30's POS (Physician Order Sheet) shows he is on a regular texture diet and his Face sheet validates he was correct when he said he had been at the facility for 5 months. R24's POS shows he is on a regular texture diet and his MDS (Minimum Data Set) dated 5/19/26 shows his cognition is intact. R92's POS shows he is on a pureed texture diet. R89's POS shows she is on a regular texture diet and her MDS dated [DATE] shows her cognition is intact. R52's POS shows she is on a regular texture diet and her MDS dated [DATE] shows her cognition is intact. R7's POS shows she is on a regular texture diet and her MDS dated [DATE] shows her cognition is intact. R29's POS shows she is on a regular texture diet.On 4/8/26 at 12:33 PM a test tray was received for lunch. The Week at a Glance Diet Spreadsheet showed the entree was Scalloped Chicken with Mushrooms. The test tray had a chicken filet with a thin yellow gravy covering it. The Scalloped Chicken with Mushrooms Corporate Recipe Number 485 shows the following ingredients: chicken thighs, 2% milk, canned cream of mushroom soup, breadcrumbs, margarine solids, salt, pepper, grated parmesan cheese, and canned pimientos. The recipe reads, Procedure:1. Dice chicken. Drain pimientos.2. Combine milk & soup. Heat and stir until well blended.3. Melt margarine. Add breadcrumbs. Mix.4. Arrange alternate layers of buttered breadcrumbs, chicken, salt, pepper, cheese and soup in 12 x 20 x 2 baking pans sprayed with non stick vegetable spray.5. End layers with breadcrumb mixture. Sprinkle with pimientos. Bake at 350F for 40-50 minutes.6. Serve 1/2 cup portions with #8 scoop.On 4/9/26 at 12:49 PM a test tray was received for lunch. The Week at a Glance Diet Spreadsheet included Homestyle Salisbury Steak, Harvard Beets, and Creamy Mashed Potatoes. The Salisbury steak was a mushy/soft unappetizing texture. Mashed potatoes were chunky and dry, not creamy. The beets had no flavor. The Turkey/Ground Beef Salisbury Steak Corporate Recipe Number 1036 shows the following ingredients: ground turkey, ground beef, ritz crackers, water, onions, green bell pepper, salt, and pepper. The recipe states: Procedure:1. Preheat Oven to 350 degrees.2. Soak cracker crumbs in water for 3 minutes.3. Peel onions and dice very fine. Wash pepper and dice very fine.4. Combine all ingredients. Portion into 4 ounce patties, place on lined sheet pans. [NAME] patties in 350 degree oven until internal temperature of 165 degrees is reached.5. Arrange cooked patties on serving pans, cover and hold until time of service.The Creamy Mashed Potatoes Corporate Recipe Number 227 shows the following ingredients: diced raw potatoes, whole milk, margarine solids, salt, and pepper. The recipe states, Procedure:1. Preheat steamer.2. In perforated steam table pans, steam potatoes until tender, 15-20 minutes.3. Combine milk and butter. Heat to 140 degrees.4. In mixer bowl with whisk attachment, beat potatoes on low speed until no lumps remain, 2-3 minutes.5. Add milk mixture, salt and pepper. Mix until well blended.The Harvard Beets Corporate recipe Number 70004 shows the following ingredients: canned, drained beets, liquid (drained from beets), granulated sugar, salt, corn starch, margarine solids, cider vinegar, and ground cloves. The recipe states, Procedure:1.Drain beets. Save required amount of liquid.2. Bring Beet juice to a rolling boil.3. Combine sugar, salt and cornstarch. Stir into boiling beet juice. Bring back to boiling. Turn off heat.4. Add margarine, vinegar and ground cloves.5. When margarine has melted, add drained beets.6. At serving time, bring to a boil, keep hot just below simmering point.On 4/9/26 at 12:21 PM, R89 was observed eating an egg salad sandwich for lunch. R89 said she opted for the egg salad because she doesn't like the Salisbury steak. On 4/9/26 at 12:22 PM, R24 was observed eating a grilled cheese. R24 said he didn't want the Salisbury Steak. On 4/9/26 at 12:26 PM R52 was observed reading the menu and telling the staff she would have an egg salad sandwich. R52 said she did not want the Salisbury steak because she had it at facility before and it was like mush. On 4/9/26 at 12:32 PM, R30 was observed eating a hamburger instead of Salisbury steak.On 4/9/26 at 1:45 PM, V17 (Cook) said he prepared the lunch on 4/8/26 and 4/9/26. V17 said he prepared the scalloped chicken by cooking the chicken in the oven and then added soup, red peppers, breadcrumbs, and parsley on top of the chicken. V17 said he did not use any milk, dice up the chicken, add butter to the breadcrumbs, or layer the ingredients as per the recipe. V17 said he knows the scalloped chicken recipe said to dice the chicken and layer the ingredients, but he just mixed all the ingredients together and put them on top of the chicken filets because it would taste the same. V17 said when he prepared the Salisbury steak he used liquid eggs, breadcrumbs, and crackers but he did not soak the crackers in water as per the recipe. V17 said he just smashed the crackers up and added them straight to the meat mixture. V17 was told liquid eggs were not part of the ingredients list for the Salisbury steak and he said he must have mixed the Salisbury steak recipe up with the meatloaf recipe because the ingredients are similar and the meatloaf uses liquid eggs. V17 said to prepare the Harvard Beets he mixed the diced beets from the can, flour, brown sugar, and some salt and butter in a tray and steamed them. V17 said he did not use the cider vinegar the beets recipe called for. When asked why he used flour instead of corn starch he said he calls the corn starch flour. V17 said it is important to follow the recipes because missing just 1 ingredient will effect the final taste of the food. On 4/9/26 at 2:32 PM, V4 (Food Service Director) said it is important to follow the standardized recipes because not following recipes can effect the nutritional value, caloric value, and the taste of the food.The facility's policy titled, Kitchen last reviewed 6/30/25 states, Policy Statement: The facility will comply with state and federal regulations in operating facility's kitchen. Procedures:.8. Menu a. All food items in the menu and recipe will be followed.

Based on observation, interview, and record review, the facility failed to ensure a qualified staff member performed wound care as prescribed for a resident (R93) with a stage 3 pressure ulcer to the right buttock.This applies to 1 of 3 residents (R93) reviewed for nursing services in a sample of 24.The findings include:R93's MDS (Minimum Data Set) dated 4/04/2026 said she was admitted to the facility on [DATE] with an unhealed stage 3 pressure ulcer. The MDS said R93 required ongoing nursing wound care services for treatment of her pressure ulcer.On 4/07/2026 at 10:25 AM, V16 (CNA/Certified Nurse Assistant) assisted R93 with toileting. R93's incontinence brief was soiled with urine. R93 also had a foam dressing on her right buttock. V16 said R93 required daily dressing changes, and she was provided with a foam dressing for R93's pressure ulcer treatment care. V16 rendered peri care to R93 with her gloved hands, then removed the soiled dressing and proceeded to clean the open wound with incontinence wipes with the same gloves. V16 said she was going to apply a new dressing and proceeded to obtain a foam dressing from her uniform's pocket predated 4/07/2026. V16 applied the dressing to R93's right buttock open pressure ulcer.R93's skin and wound progress note dated 4/08/2026 said she was receiving ongoing wound care services for her right buttock stage 3 pressure ulcer. The wound measured 1 x 0.5 x 0.1 cm (centimeters) with 100% epithelial tissue and serosanguineous drainage.On 4/09/2026 at 10:30 AM, V16 (CNA) said she changed R93's pressure ulcer dressing on 4/07/2026 because it was soiled and was instructed to change it. V16 said she was not wound care certified and had no wound care specialized training. V16 said she should not have performed wound care because it was not part of her job description.The facility's undated document titled Job Description Certified Nursing Assistant said CNAs provided residents with nursing and personal care services under the supervision of a nurse to safeguard the health, safety, and welfare of all the residents of the facility, in accordance with the facility's established policies and procedures and regulations. The document further said their duties included assisting the treatment nurse, but it did not include for the CNAs to independently perform prescribed wound care services.On 4/09/2026 at 10:40 AM, V15 (LPN/Licensed Practical Nurse) said she was R93's assigned nurse on 4/07/2026 and was not informed that her pressure ulcer dressing needed to be changed. V15 said only nurses were able to perform prescribed wound care, and the task could not be delegated to a CNA. V15 said CNAs did not have access to prescribed treatment orders and were not able to assess for wound complications.R93's wound care plan said she required nursing services for her right buttock pressure ulcer. The care plan had multiple nursing interventions, including the administration of treatments as ordered and to monitor for effectiveness. The interventions were assigned to be performed by the facility's Wound Care Nurse/WCN, Registered Nurse/RN, and LPN/Licensed Practical Nurse staff.R93's Order Summary Report showed an active physician order for her pressure ulcer to be administered by licensed nurses, RIGHT BUTTOCK everyday shift for wound care. Cleanse with NSS, pat dry. Apply Xeroform then cover with bordered foam dressing.On 4/09/2026 at 11 AM, V5 (WCN) said R93 required daily pressure ulcer care services from licensed nurses. V5 said CNAs were not qualified to perform specialized wound care and should only perform tasks within their scope of practice. V5 said if an unqualified staff member performed pressure ulcer wound care there could be risks for infection and healing complications if the wound was not cleaned and treated as ordered.The facility's policy titled Skin Care Regimen and Treatment Formulary, dated 7/03/2025, said routine daily wound care treatments/dressings changes were administered by the wound care nurse or designee, including for pressure ulcers. Also, to refer to the physician orders and TAR (Treatment Administration Record) for providing daily wound care services.

Based on the interview and record review, the facility failed to ensure physician's orders were in place for using the two ports on a resident's gastrojejunostomy tube (GJ tube). This applies to 1 of 2 residents (R102) who were reviewed for tube feeding in a sample of 24.On 04/08/2024, around 10:15 AM, V21(Family member) reported that R102 has a gastrojejunostomy tube (GJ tube) and the feeding should be given through the jejunal port, and medication administration through the gastric port. V21(R102's family) said the staff is not following the physicians' order, and R102 went to the hospital multiple times for the replacement of the GJ tube due to clogging.Review of V21's grievances forms dated 11/25/2026, 12/26/2025, and 01/22/2026 showed that V21 expressed concerns about the facility, including not following the physician's order, causing clogging, feeding through a G-tube, and not flushing.Per EMR (Electronic Medical Records), R102 was admitted on [DATE] following a hospital admission for a GJ tube malfunction, with the GJ tube placed on 10/21/2025. R102's diagnoses included malignant neoplasm of the lower third of the esophagus, esophageal obstruction, GJ tube status, gastrostomy complication, urinary tract infection, and unspecified dementia. A review of the interventional radiologist's outpatient plan of care/goals after the tube placement dated 11/19/2025 indicated feeds to be administered only via jejunal [port] and all crushed medications should be administered via the gastric [port] of the tube.Review of physician orders for 04/06/2025 showed four times a day Osmolite 1.2 at 100mL/hr. 2 hours off between bolus feeds, with instructions of 100 for 3 hours, and 2 times without instructions indicating which tube port to use for feeding and medication administration. A review of discontinued order dates 12/08/2026, 02/26/2026, and 03/09/2026 did not include instructions for feeding and medication administration tubing ports of R102's GJ tube.The hospital record dated 04/07/2026 showed that R102's gastrojejunostomy tube was changed on 11/20/2025, 12/03/2025, 02/06/2025, and 03/30/2026 due to malfunctioning.On 04/09/2026, at 02:40 PM, V19 and V20 (Registered nurses) stated they regularly care for R102 and are aware of the residents' GJ tube situation; however, for staff unfamiliar with the procedure, transcribing correct instructions in the correct order helps avoid errors.On 04/09/2026 at 11:01 PM, V18 (Registered Dietitian) said R102 comes from the hospital. She coordinates with the physician to adjust the feeding according to her needs and tolerance, and she enters orders, not specifying the G tube for medications, and the J tube for feeding was an oversight. V18 stated it's important to transcribe orders correctly to avoid errors.On 04/09/2026, at 3:30 PM, V2 (Director of Nursing) said that not transcribing the order on the Physician Order Sheet was an oversight and acknowledged that correct orders should have been transcribed for safety.The facility Physician Order Policy dated 07/03/2025 stated, in part, that upon admission and readmission, the facility will verify transfer orders from the hospital with the physician, and the order will be reflected in the medical administration records.

Based on interview and record review, the facility failed to obtain timely diagnostic imaging. This applies to 1 of 3 residents (R1) reviewed for diagnostic imaging in the sample of 7. The findings include:R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including hydronephrosis, hypertension, type 2 diabetes mellitus, diabetic foot ulcer, venous insufficiency, and congestive heart failure. R1's Order Listing Report showed an order dated February 6, 2026, for Right duplex scan, veins, extremity, unilateral/limited study. Sent for imaging February 6, 2026. One time only related to venous insufficiency. R1's Radiology Results Report dated February 13, 2026, at 5:33 PM, showed Examination Date: February 9, 2026. Reported Dated February 13, 2026, 5:33 PM. On March 24, 2026, at 3:12 PM, V2 (DON/Director of Nursing) said the facility did not receive R1's diagnostic imaging results until February 13, 2026. V2 said she reached out to the diagnostic imaging company following R1's care plan meeting on February 13, 2026, when R1's family questioned about the results of R1's diagnostic imaging. On March 25, 2025, at 2:37 PM, V12 (Radiology Company Liaison) said the radiology company received R1's order for a right duplex on February 6, 2026, the imaging was completed on February 9, 2026, and the results were sent to the facility on February 13, 2026. V12 said on February 13, 2026, the facility reached out to V12 inquiring about the results. V12 said she had to speak with the radiology doctor group to ensure they had the test because the test had not been read by a radiologist yet. V12 said the radiology company's contract with the facility shows a diagnostic imaging test should be completed within 24 hours of the test being ordered. V12 said a test results are usually available within six to eight hours and the company does quality control checks daily but this exam was missed. On March 25, 2026, at 2:56 PM, V13 (Radiology Company Territory Manager) said R1's duplex was delayed three days and the radiology company should have contacted the facility to make them aware and set up a date. V13 said there was not any communication between the facility and the radiology company regarding R1's delayed exam. V13 said per the contract, if it was going to take longer than 24 hours to conduct the exam, the facility should have been informed of when the exam could be performed. V13 said he does not know why it took so long for the exam to be resulted. V13 said that is insane it took four days to get results. The facility does not have documentation to show communication between the radiology company and the facility occurred regarding the delay in R1's right duplex being performed or the delay in receiving R1's right duplex results. The Facility Agreement between the radiology company and the facility dated November 1, 2025, showed .2. Duties and Obligations of Provider. b. Provider shall provide services within 24 business hours or schedule a time for the services. The Provider will promptly notify the Facility if services time is unable to be met.

Based on interview and record review, the facility failed to safely transfer a resident with a mechanical lift. This failure resulted in R1 sustaining a closed fracture of the distal end of his right femur and requiring surgery.This applies to 1 of 4 residents (R1) reviewed for transfers.The findings include: R1's EMR (Electronic Medical Record) showed R1 admitted to the facility on [DATE] with multiple diagnoses, including hemiplegia and hemiparesis related to cerebral infarction affecting his left side, spinal stenosis, general weakness, decreased mobility, polyneuropathy, and contractures to his lower extremities. R1's care plan with a review date of 6/18/2025 said R1 had a self-care deficit with his activities of daily living and required physical assistance of two-staff members. R1's care plan said he was dependent on bed mobility and transfers and required the use of a mechanical lift.On 8/02/2025 at 10:20 AM, R1 was in bed. R1's legs were severely contracted. R1's left lower leg was hyperextended in a fixed flexed position towards his pelvic area, and the right lower leg was in a straight fixed position. R1's right lower leg had surgical scars. R1 was unable to move his lower body. R1's memory was impaired and was he unable to provide details regarding the right femur fracture that occurred on 5/27/2025. On 8/04/2025 at 8 AM, V20 and V21 (R1's Family Members) said they had concerns regarding R1's assisted mechanical lift transfer on 5/27/2025. They said R1 informed them he had acute pain in his right lower leg after he was transferred by V4 and V5 (Certified Nurse Assistants/CNAs). V21 said she accompanied R1 to his medical urology appointment on 5/27/2025, and R1 did not have any injury or vocalized pain in his right lower leg. V21 said R1 had to be assisted back to his bed from his wheelchair after he returned to the facility. V20 said the facility called her later that evening, informing her R1 was having acute pain and swelling to his right lower leg and was going to have x-rays done at the facility. V20 said she was then informed R1 had a fracture to his right leg and had to be transferred to the hospital. V20 said she informed V1 (Administrator) about R1's transfer concern on 5/27/2025 because they were concerned about his safety. On 8/04/2025 at 2:50 PM, V5 (CNA) said V4 assisted her with R1's mechanical lift transfer when he returned from his appointment at approximately 1 PM. V5 said R1's legs were severely contracted. V5 said she maneuvered the lift machine while V4 placed his hands behind R1's back to direct him into the bed. V5 said no one was supporting or guiding R1's legs to safely position them onto the bed. V5 said R1 was complaining of pain, and she informed the nurse on duty. On 8/04/2025 at 12:30 PM, V4 (CNA) said he assisted V5 with R1's mechanical lift transfer after his appointment on 5/27/2025. V4 said he was behind R1 while V5 started to operate the machine. V4 said R1's legs went on the bed first and then his upper body. V4 said he was unable to visually see R1's legs during the transfer. V4 said R1 was severely contracted, and his legs were not supported during the transfer.On 8/04/2025 at 9 AM, V11 (CNA) said on 5/27/2025 at 3:30 PM during rounds R1 declined care, and at approximately 6 PM she attempted to provide care again. V11 said R1 reported they hurt me and was complaining of severe right leg pain. V11 said she then removed R1's sheet to assess, and his right leg was abnormally positioned and deformed. V11 said she informed the nurse on duty immediately.On 8/04/2025 at 12 PM, V23 (Restorative Nurse) said staff were expected to follow the facility's mechanical lift transfer policy to ensure the safety of residents during transfers. V23 said two staff members were required for mechanical lift transfers. V23 said one staff member was required to operate the machine while the second staff member safely guided the resident during the transfer. V23 said for residents with limited mobility in their legs, the second staff member had to safely hold their legs for support to prevent an injury during the transfer. V23 said staff were expected to report any injury or incident during transfers to ensure the safety of residents.On 8/04/2025 at 4 PM, V22 (Physician) said she was notified of R1's abnormal right lower leg x-ray results on 5/28/2025. V22 said R1 had to be transferred to the hospital and had surgical nailing of his femur. V22 said R1 was severely contracted and required staff assistance with his care. V22 said she expected facility staff to transfer residents safely as per their policy to ensure resident safety. R1's hospital records dated 5/28/2025 said R1 started to complain of acute pain and swelling in his right leg after he was transferred with a mechanical lift when he returned from a medical appointment. The records said R1 had a closed fracture of the distal end of his right femur and required an orthopedic surgical procedure on 5/29/2025.R1's progress note dated 5/28/2025 at 3 AM said R1's STAT (immediate) x-ray results were pending and was still having .right knee pain, swelling, and warmth also observed on right knee area. Immobilized right lower extremity as much as possible. R1's follow-up note at 6 AM said R1's x-ray .revealed right distal femoral fracture and R1 was transferred to the hospital for further management.R1's incident statement dated 5/29/2025 said R1 was reinterviewed regarding his statement of his injury being caused during his mechanical lift transfer on 5/27/2025 and said, It hurts.[V4] was messing with my legs in the lift. The statement said R1 was unable to provide further details regarding his statement. The facility's policy titled Mechanical Lift Transfers dated 7/02/2025, said 11. Lift resident up from the chair using lift with 1 person operating the machine while the other staff removes the resident's wheelchair/recliner.Then 2nd staff will guide resident and sling as resident is transferred and lowered back to bed. 13. Check resident's comfort after the task is completed.

Based on observation, interview, and record review the facility failed to ensure a resident was transferred in a safe manner for 1 of 3 residents (R1) reviewed for accidents in the sample of 9. This failure resulted in R1 receiving stitches to a left leg laceration. This past noncompliance occurred from 6/3/25 to 6/9/25.The findings include: The facility's initial incident report sent to IDPH (Illinois Department of Public Health) showed R1 sustained a laceration to her left lower extremity on 6/3/25 at approximately 11:15 AM. The report showed R1 was provided first aid and orders were obtained to send R1 to the local hospital emergency department. The report showed R1 left the facility with paramedics at around 1:06 PM the same day. R1's face sheet printed on 7/10/25 showed a [AGE] year-old female admitted on [DATE]. The face sheet showed diagnoses including but not limited to heart failure, cataracts, left foot drop, hypertension, venous insufficiency, and polyneuropathy. R1's facility assessment dated [DATE] showed moderate cognitive impairment and total staff assistance for chair to bed transfers. R1's care plan showed a focus area related to ADLs (activities of daily living). Interventions included: TRANSFER: (R1) requires weight bearing physical assist (full body lift) of 2 staff participation in moving between surfaces to and from bed, chair, wheelchair, standing position. Date initiated 12/05/2023. On 7/10/25 at 9:50 AM, R1 was lying in bed and covered with a light sheet. R1 was pleasantly confused and had no recall of a leg injury or emergency room visit. V3 (Registered Nurse) entered the room and removed the sheet. R1's left lower leg was wrapped in white gauze from the mid-calf to the foot and elevated on a pillow. V3 stated she had a leg injury while being transferred from her chair to the bed. Her left leg hit the side rail of the bed. She has been a mechanical lift transfer since she was admitted . The aide called me in right away after it happened. R1 was already on the bed and her leg was bleeding. The aide was in the room alone and no one else was helping him. He was very shaken up and so sorry. I applied pressure and cleansed the open wound. The wound care nurse was notified and came right in to assess it. R1 was sent to the emergency room the same day. She had to get stitches and came back the same day. V3 said all residents requiring a mechanical lift should be done with two people. The aide (V4) is a big, tall guy and he did it by himself. V4 likely thought since R1 is so small that it wouldn't be a problem. On 7/10/25 at 10:18 AM, V4 (CNA-Certified Nurse Aide) stated he was assigned to give R1 a shower on 6/3/25. V4 said resident transfer status is posted inside the closet doors and in the care plans. V4 said R1 has always been a two person assist using a mechanical lift. V4 said he wheeled R1 into her room after the shower and got her dressed in day clothes. V4 was attempting to get the lift sling under R1 while seated in her wheelchair. V4 said he pulled on the sling to get her closer to the bed and her left leg hit the side rail. V4 said he saw it bleeding and continued to transfer her by himself onto the bed. V4 said he should have done the transfer preparation and actual transfer itself with another staff member. V4 said he was in a hurry and thought he could do it alone. V4 said it is safer with two people and ensures the resident does not hit their body on anything. It is a bad idea to do it alone. On 7/10/25 at 10:50 AM, V5 and V6 (CNAs) stated R1 has been a mechanical lift since she came here. Mechanical lifts are always done with two staff members. It is for resident safety and it's the right thing to do. It helps keep residents safe. One aide guides the legs and back while the other aide works the lift. One person can't do both if they are alone. On 7/10/25 at 12:01 PM, V2 (Director of Nurses) stated she interviewed V4 after the incident of 6/3/25. V2 said V4 was preparing R1 for a mechanical lift transfer from the chair to the bed. V4 was alone and moving R1 around to get the sling underneath her buttocks. R1's leg hit the bed side rail and was cut open. V2 said V4 did transfer R1 to the bed without another staff member. V2 stated residents should never be injured during staff cares. The correct procedure would have been to follow her care plan. R1 is a two person assist for all transfers. It is facility policy to use two staff members for every mechanical lift transfer. There is the potential for the lift to fail, injury, or dropping a resident when the policy is not followed. R1's local emergency room after visit summary report dated 6/3/25 showed a left, lower leg laceration 20 centimeters in length with blunt trauma. The report showed R1 received five internal sutures and 24 external sutures to the left leg. The facility's Mechanical Lift Transfers policy revision dated 8/16/24 states: 5. There will always be 2 staff to assist resident. 1 staff will control the lift as the other will guide resident and support back and neck to transfer surface. 15.It is also a safety issue putting back the sling under a resident who is sitting on a wheelchair or a recliner. Prior to the survey date of 7/15/25, the facility had taken the following action to correct the noncompliance:On June 3, 2025, V4 received formal one on one training on mechanical lift transfers, one-person transfers, and sit to stand transfers. On June 3, 2025, a facility wide audit was done on all [NAME] brand beds for damage. On June 3 to June 9, 2025, all certified nurse aides were in-serviced on sit to stand transfers, two person transfers, and one person transfers with competency return demonstrations. The Director of Nursing or designee will conduct randoms audits for three residents to identify any issues with staff to resident transfers. The audits will continue three times per week for 12 weeks. Any identified issues or concerns be immediately addressed. Audits started 6/5/2025, ongoing for 12 weeks. A QA meeting was held with the facility Medical Director, Facility Administrator, and Director of Nursing to review the plan of correction of 6/5/2025.

Based on interview and record review, the facility failed to administer medications as ordered by the physician and as scheduled in the EMR (Electronic Medical Record). This applies to 5 of 16 residents (R1, R2, R3, R13, R15) reviewed for quality of care in the sample of 16. The findings include: 1. On May 21, 2025 at 11:26 AM, R1 was sitting in his room. R1 said on May 17, 2025 the day shift nurse left at approximately 3:00 PM, and the evening shift nurse did not arrive at the facility until 5:45 PM. R1 said he was upset because he did not receive his Velphoro (Phosphorous binder) or his carvedilol (cardiac medication) at 5:00 PM. R1 said, I receive dialysis, and I need to take the Velphoro when I eat to absorb any extra phosphorous. If I don't receive it with my meal, then it doesn't do any good. We were served dinner at 5:00 PM that night and I didn't get my Velphoro. It is just upsetting because management knew [V6] (RN-Registered Nurse) was going to be late, and they didn't bother to get anyone else to cover for her to get us our medications on time. The EMR shows R1 was admitted to the facility on [DATE] with multiple diagnoses including, COPD (Chronic Obstructive Pulmonary Disease), dependence on renal dialysis, chronic kidney disease, type 2 diabetes, bilateral vitreous hemorrhage, heart failure, hypertension, and heart disease. R1's MDS (Minimum Data Set) dated April 1, 2025 shows R1 is cognitively intact, requires setup assistance with eating, oral and personal hygiene, and supervision with all other ADLs (Activities of Daily Living). R1 is always continent of bowel and bladder. R1's care plan for congestive heart failure, initiated on September 6, 2022 shows multiple interventions initiated on September 6, 2022, including, give cardiac medications as ordered. The EMR shows the following order for R1 dated February 4, 2025: Velphoro oral tablet chewable 500 mg. Give 2 tablets by mouth three times a day to control phosphorous level. R1's May 2025 MAR (Medication Administration Record) shows R1's Velphoro is scheduled to be given at 9:00 AM, 12:00 PM, and 5:00 PM daily. V1 (Administrator) provided EMR documentation to show R1's Velphoro medication, scheduled to be administered at 5:00 PM on May 17, 2025, was administered by V6 (RN) at 21:14 (9:14 PM), more than four hours after dinner was served, and the scheduled administration time. The EMR shows the following order for R1 dated February 4, 2025: Coreg 25 mg. (milligrams) orally, twice a day for hypertension. R1's May 2025 MAR shows R1's Coreg is scheduled to be given at 9:00 AM and 5:00 PM daily. V1 (Administrator) provided EMR documentation to show R1's Coreg medication, scheduled to be administered at 5:00 PM on May 17, 2025, was administered by V6 (RN) at 21:14 (9:14 PM), more than four hours after the scheduled administration time. 2. On May 21, 2025 at 11:12 AM, R2 was lying in bed in her room. R2 said V6 (RN) arrived at the facility at approximately 5:45 PM on May 17, 2025. R2 said, She got here and just sat at the desk and didn't even bother to check on us. I had to go up to her at the desk and tell her I needed my blood sugar checked. I had to go to the desk to get my Gabapentin (pain medication) because she hadn't passed medications, and no one had filled in for her when she was late getting here. I was not having a lot of pain, but it's just the idea that we like to get our medications on time, and that was not happening. The EMR shows R2 was admitted to the facility on [DATE] with multiple diagnoses including, Type 2 diabetes, abnormal gait and mobility, sciatica, atrial fibrillation, chronic kidney disease, left eye cataract, pressure ulcer of the left heel, presence of cardiac pacemaker, depression, heart failure, pulmonary hypertension, anemia, morbid obesity, and PVD (Peripheral Vascular Disease). R2's MDS dated [DATE] shows R2 is cognitively intact, requires setup assistance with eating, oral hygiene, dressing, and personal hygiene, supervision with toilet hygiene, bed mobility, and transfers between surfaces, and partial/moderate assistance with showering. R2 is occasionally incontinent of bowel and bladder. R2's care plan for pain/discomfort initiated on July 22, 2024 shows multiple interventions initiated on April 4, 2023 including, provide analgesic as ordered. The EMR shows the following order for R2 dated September 14, 2024: Gabapentin 100 mg. Give 2 capsules by mouth three times a day for pain. R2's May 2025 MAR shows R2's Gabapentin is scheduled to be given at 9:00 AM, 1:00 PM, and 5:00 PM daily. V1 (Administrator) provided EMR documentation to show R2's Gabapentin medication, scheduled to be administered at 5:00 PM on May 17, 2025, was administered by V6 (RN) at 18:50 (6:50 PM), almost two hours after the scheduled administration time. 3. On May 21, 2025 at 11:20 AM, R3 was walking in her room with a walker. R3 was not able to recall concerns regarding medications being given late due to her cognitive status. The EMR shows R3 was admitted to the facility on [DATE]. R3 has multiple diagnoses including, Type 2 diabetes, abnormal gait and mobility, asthma, vascular dementia, obstructive uropathy, chronic diastolic heart failure, low potassium, major depressive disorder, chronic kidney disease, atrial fibrillation, and psychosis. R3's MDS dated [DATE] shows R3 has moderate cognitive impairment, requires setup assistance with eating and oral hygiene, substantial/maximal assistance with lower body dressing, and partial/moderate assistance with all other ADLs. R3 is occasionally incontinent of bowel and bladder. R3's care plan entitled chronic back pain, joint/knee pain, initiated October 4, 2023 shows R3 receives lidocaine to lower back, and gabapentin as ordered. The EMR shows the following order for R3 dated November 19, 2024: Gabapentin Capsule 100 mg. Give 1 capsule by mouth three times a day for nerve pain. R3's May 2025 MAR shows R3's Gabapentin is scheduled to be given at 9:00 AM, 1:00 PM, and 5:00 PM daily. V1 (Administrator) provided EMR documentation to show R3's Gabapentin medication, scheduled to be administered at 5:00 PM on May 17, 2025, was administered by V6 (RN) at 21:09 (9:09 PM), over four hours after the scheduled administration time. 4. The EMR shows R13 was admitted to the facility on [DATE] with multiple diagnoses including, COPD with exacerbation, polyneuropathy, spinal stenosis, Type 2 diabetes, and heart disease. R13's MDS dated [DATE] shows R13 is cognitively intact and requires setup assistance with all ADLs. The EMR shows the following order for R13 dated July 19, 2024: Gabapentin capsule 100 mg. Give 2 capsules by mouth three times a day for nerve pain. R13's May 2025 MAR shows his Gabapentin is scheduled to be given at 9:00 AM, 1:00 PM, and 5:00 PM daily. V1 (Administrator) provided EMR documentation to show R13's Gabapentin, scheduled to be administered at 5:00 PM on May 17, 2025, was administered at 20:54 (8:54 PM), almost four hours after the scheduled administration time. 5. The EMR shows R15 was admitted to the facility on [DATE] with multiple diagnoses including, acute and chronic respiratory failure with hypercapnia, COPD, atrial fibrillation, pulmonary fibrosis, hypertension, Type 2 diabetes, asthma, heart failure, and abnormal gait and mobility. The EMR continues to show R15 has an order for continuous oxygen dated March 6, 2025. R15's MDS dated [DATE] shows R15 is cognitively intact, requires partial/moderate assistance with showering, and setup and/or supervision with all other ADLs. The EMR shows the following order for R15 dated February 20, 2025: Budesonide-Formoterol Fumarate Inhalation Aerosol. Two puffs, inhale orally two times a day for COPD. R15's May 2025 MAR shows R15's Budesonide-Formoterol Fumarate inhaler is scheduled to be given at 9:00 AM and 5:00 PM daily. V1 (Administrator) provided EMR documentation to show R15's Budesonide-Formoterol Fumarate inhaler, scheduled to be administered at 5:00 PM on May 17, 2025, was administered by V6 (RN) at 21:02 (9:02 PM), four hours after the scheduled administration time. On May 21, 2025 at 3:45 PM, V8 (Pharmacist) said, Velphoro has to be given with meals. If you take the medication three hours after the meal, it will decrease the effectiveness of the medication. The manufacturer recommends it should be given with the meal. If Coreg is given an hour before or after the scheduled time, I wouldn't expect a huge change. When you go three, four, or five hours, you might experience some symptomatic results, like fluctuations in blood pressure. Gabapentin is administered for nerve pain. As compared to an opioid, it works differently. All the medications should be administered as ordered. The facility's policy entitled Physician Orders, revised on 8/16/24 shows: Policy Statement: It is the policy of this facility to ensure that all resident/patient medications, treatment, and plan of care must be in accordance with the licensed physician's orders. The facility shall ensure to follow physician orders as it is written in the POS (Physician Order Sheet). The facility's policy entitled Medication Pass, revised on 8/16/24 shows: Policy Statement: It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures.7. PO (Oral) Meds: .e. After medication is administered to each resident, sign MAR that it was given. The facility's policy entitled Oral Medication Administration, revised on 08-2020 shows: 9. Chart medication administration on the MAR (or eMAR-Electronic MAR) immediately following each resident's medication administration.

Based on interview and record review, the facility failed to administer insulin as ordered by the physician. This applies to 4 of 16 residents (R1, R2, R3, R4) reviewed for quality of care in the sample of 16. The findings include: 1. On May 21, 2025 at 11:26 AM, R1 was sitting in his room. R1 said on May 17, 2025 the day shift nurse left at approximately 3:00 PM, and the evening shift nurse did not arrive at the facility until 5:45 PM. R1 said he was upset because he did not receive his medications on time and no facility staff were asked to fill the void left by V6's (RN-Registered Nurse) [NAME] arrival. R1 said dinner was served at 5:00 PM on May 17, 2025. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including, COPD (Chronic Obstructive Pulmonary Disease), dependence on renal dialysis, chronic kidney disease, type 2 diabetes, bilateral vitreous hemorrhage, heart failure, hypertension, and heart disease. R1's MDS (Minimum Data Set) dated April 1, 2025 shows R1 is cognitively intact, requires setup assistance with eating, oral and personal hygiene, and supervision with all other ADLs (Activities of Daily Living). R1 is always continent of bowel and bladder. The EMR shows the following order for R1 dated February 5, 2025: Lyumjev KwikPen Solution pen-injector. Inject 24 units subcutaneously with meals for DM (Diabetes Mellitus). R1's May 2025 MAR (Medication Administration Record) shows R1's Lyumjev insulin is scheduled to be given at 8:00 AM, 12:00 PM, and 5:00 PM daily. V1 (Administrator) provided EMR documentation to show R1's Lyumjev insulin, scheduled to be administered at 5:00 PM on May 17, 2025, was administered by V6 (RN) at 21:14 (9:14 PM), more than four hours after dinner was served, and the scheduled administration time. 2. On May 21, 2025 at 11:12 AM, R2 was lying in bed in her room. R2 said V6 (RN) arrived at the facility at approximately 5:45 PM on May 17, 2025. R2 said, She got here and just sat at the desk and didn't even bother to check on us. R2 said dinner was served at 5:00 PM on May 17, 2025. The EMR shows R2 was admitted to the facility on [DATE] with multiple diagnoses including, Type 2 diabetes, abnormal gait and mobility, sciatica, atrial fibrillation, chronic kidney disease, left eye cataract, pressure ulcer of the left heel, presence of cardiac pacemaker, depression, heart failure, pulmonary hypertension, anemia, morbid obesity, and PVD (Peripheral Vascular Disease). R2's MDS dated [DATE] shows R2 is cognitively intact, requires setup assistance with eating, oral hygiene, dressing, and personal hygiene, supervision with toilet hygiene, bed mobility, and transfers between surfaces, and partial/moderate assistance with showering. R2 is occasionally incontinent of bowel and bladder. R2's care plan for being at risk for fluctuating blood sugars due to diabetes, initiated July 22, 2024 shows multiple interventions, including administer medications as ordered, and administer sliding scale per physician's order. The EMR shows the following order for R2 dated July 25, 2024: Lyumjev KwikPen subcutaneous solution pen-injector. Inject 25 units subcutaneously three times a day for antidiabetics. R2's May 2025 MAR shows R2's Lyumjev insulin is scheduled to be given at 9:00 AM, 1:00 PM, and 5:00 PM daily. V1 (Administrator) provided EMR documentation to show R2's Lyumjev insulin, scheduled to be administered at 5:00 PM on May 17, 2025, was administered by V6 (RN) at 18:50 (6:50 PM), almost two hours after the scheduled administration time. The EMR shows the following order for R2 dated July 22, 2024: Humalog KwikPen subcutaneous solution pen-injector. Inject as per sliding scale before meals and at bedtime for diabetes. R2's May 2025 MAR shows R2's Humalog insulin is scheduled to be given at 8:00 AM, 11:00 AM, 4:00 PM, and 9:00 PM daily. V1 (Administrator) provided EMR documentation to show R2's Humalog insulin, scheduled to be administered at 4:00 PM on May 17, 2025, was administered by V6 (RN) at 18:50 (6:50 PM), almost three hours after the scheduled administration time, and two hours after dinner was served. 3. On May 21, 2025 at 11:20 AM, R3 was walking in her room with a walker. R3 was not able to recall concerns regarding medications being given late due to her cognitive status. The EMR shows R3 was admitted to the facility on [DATE]. R3 has multiple diagnoses including, Type 2 diabetes, abnormal gait and mobility, asthma, vascular dementia, obstructive uropathy, chronic diastolic heart failure, low potassium, major depressive disorder, chronic kidney disease, atrial fibrillation, and psychosis. R3's MDS dated [DATE] shows R3 has moderate cognitive impairment, requires setup assistance with eating and oral hygiene, substantial/maximal assistance with lower body dressing, and partial/moderate assistance with all other ADLs. R3 is occasionally incontinent of bowel and bladder. The EMR shows the following order for R3 dated November 19, 2024: Lyumjev KwikPen solution pen-injector. Inject 6 units subcutaneously with meals for DM II (Type 2 Diabetes). R3's May 2025 MAR shows R3's Lyumjev is scheduled to be given at 8:00 AM, 12:00 PM, and 5:00 PM daily. V1 (Administrator) provided EMR documentation to show R3's Lyumjev insulin medication, scheduled to be administered at 5:00 PM on May 17, 2025, was administered by V6 (RN) at 21:09 (9:09 PM), over four hours after the scheduled administration time and the dinner meal was served. 4. The EMR shows R4 was admitted to the facility on [DATE] with multiple diagnoses including, cerebral infarction, unsteadiness on feet, lack of coordination, cognitive communication deficit, constipation, hemiplegia affecting left non-dominant side, Type 2 diabetes, mood disorder, atrial fibrillation, emphysema, heart failure, bilateral hearing loss, depression, and heart disease. R4's MDS was not completed at the time of this investigation. The EMR shows the following order for R4 dated May 16, 2024: Novolog FlexPen subcutaneous with meals as per sliding scale. R4's MAR shows R4's Novolog insulin is scheduled at 8:00 AM, 12:00 PM, and 5:00 PM, and R4's blood sugar reading was 150 on May 17, 2025 at 5:00 PM. V1 (Administrator) provided EMR documentation to show R4's Novolog insulin, 2 units, scheduled for 5:00 PM on May 17, 2025 was administered at 20:42 (8:42 PM), over three and a half hours after the scheduled administration time. On May 21, 2025 at 3:45 PM, V8 (Pharmacist) said, the Lyumjev insulin is a short acting insulin. V8 said, It is to be given with meals. There is a possibility of blood sugar fluctuations and symptoms when it is not given correctly. It is not meant to be given four hours late or after a meal. The sliding scale Humalog should be done before the meals is eaten, because the sliding scale is tailored to pre-meal blood sugar levels. The idea with all the insulin regimens is to keep the blood sugar stable at the level you want. Any sort of variation in timing, that is going to potentially cause more fluctuations in the blood sugar. The facility's policy entitled Physician Orders, revised on 8/16/24 shows: Policy Statement: It is the policy of this facility to ensure that all resident/patient medications, treatment, and plan of care must be in accordance with the licensed physician's orders. The facility shall ensure to follow physician orders as it is written in the POS (Physician Order Sheet). The facility's policy entitled Medication Pass, revised on 8/16/24 shows: Policy Statement: It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures. The facility's policy entitled Diabetes Management, revised on 7/26/24 shows: Policy Statement: It is the policy of this facility to provide optimal nursing care for diabetic patients to: Assist in establishing a balance between diet, exercise, oral medications, and insulin therapy. Prevent episodes of hyperglycemia/hypoglycemia and prevent recurrence. Recognize, assist, and document the treatment of complications commonly associated with diabetes. Individualize teaching according to carefully assessed resident and family needs. Procedure: .5. Blood Glucose Check: Verify physician's order for this procedure.7. Complete the MAR or the Blood Sugar Monitoring Log as per policy. 8. If resident is on a sliding scale, administer insulin as ordered.

Based on interview and record review, the administration failed to provide oversight and leadership to ensure resident nursing care assignments were revised due to a change in staffing to ensure residents received nursing care and medications as ordered by the physician. This applies to 16 of 16 residents (R1- R16) reviewed for quality of care and administration in the sample of 16. The findings include: On May 21, 2025 at 9:52 AM, V4 (Staffing Coordinator) reviewed the facility's Daily Schedule dated Saturday, May 17, 2025 and the resident room assignments for that day. V4 said day shift nurses and CNAs (Certified Nursing Assistants) work the day shift from 7:00 AM to 3:00 PM, evening shift from 3:00 PM to 11:00 PM, and night shift from 11:00 PM to 7:00 AM. V4 continued to say five nurses (V7, V9, V10, V13, and V14) worked on the day shift on May 17, 2025. V4 said V7 (LPN-Licensed Practical Nurse) worked a double shift that day and continued to work the entirety of the evening shift until 11:20 PM. V4 said any other day shift nurses who worked after 3:00 PM were not providing resident care after 3:00 PM, but were performing administrative tasks, such as charting. V4 said five nurses (V6, V7, V11, V12, V15) were scheduled to work on the evening shift on May 17, 2025. V4 said V6 (Agency RN-Registered Nurse) came to the facility late and no staff were assigned to fill the void of her absence until she was able to get to the facility. V4 reviewed the resident assignments for May 17, 2025 and said V6 (Agency RN) was assigned to care for the rooms occupied by R1 through R16. V4 provided the staffing agency invoice for V6 (Agency RN) dated May 17, 2025. The invoice shows V6 (Agency RN) worked at the facility on May 17, 2025 from 17:45 (5:45 PM) to 00:30 (12:30 AM) on May 18, 2025. The Resident Listing Report dated May 21, 2025 shows R1-R16 resided on the unit assigned to V6 (Agency RN) on May 17, 2025 from 3:00 PM to 11:00 PM. On May 21, 2025 at 8:38 AM, V7 (LPN) said he was working at the facility on May 17, 2025 from 7:00 AM to 11:20 PM. V7 said, I worked a double shift that day. One of the nurses (V6) came in late on the afternoon shift so there were two of us working the unit. No one asked us to cover her assignment (V6's residents) or administer medications to them because she was late. On May 21, 2025 at 12:24 PM, V1 (Administrator) said, We knew [V6] (Agency RN) was going to be late on May 17. We thought she would be here around 3:45 PM. At 4:15 PM she still had not shown up, and we found out she had more car trouble and was arriving later. We did not have a manager on duty at the facility on that weekend that was clinical (a nurse). We were going to call our ADON (Assistant Director of Nursing) in, but she would have gotten here about the same time as [V6] thought she would get here. [V6] didn't end up getting here until about 5:45 PM. V1 (Administrator) was unable to say why the nursing assignments were not revised or why the nursing staff present in the facility were not instructed to absorb V6's assignment until her arrival to ensure residents received any necessary nursing care or their medications as ordered by the physician. 1. On May 21, 2025 at 11:26 AM, R1 was sitting in his room. R1 said on May 17, 2025 the day shift nurse left at approximately 3:00 PM, and the evening shift nurse did not arrive at the facility until 5:45 PM. R1 said he was upset because he did not receive his Velphoro (Phosphorous binder) or his carvedilol (cardiac medication) at 5:00 PM. R1 said, I receive dialysis, and I need to take the Velphoro when I eat to absorb any extra phosphorous. If I don't receive it with my meal, then it doesn't do any good. We were served dinner at 5:00 PM that night. It is just upsetting because management knew [V6] (RN-Registered Nurse) was going to be late, and they didn't bother to get anyone else to cover for her to get us our medications on time. R1 said dinner was served at 5:00 PM on May 17, 2025. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including, COPD (Chronic Obstructive Pulmonary Disease), dependence on renal dialysis, chronic kidney disease, type 2 diabetes, bilateral vitreous hemorrhage, heart failure, hypertension, and heart disease. R1's MDS (Minimum Data Set) dated April 1, 2025 shows R1 is cognitively intact, requires setup assistance with eating, oral and personal hygiene, and supervision with all other ADLs (Activities of Daily Living). R1 is always continent of bowel and bladder. The EMR shows the following order for R1 dated February 4, 2025: Coreg 25 mg. (milligrams) orally, twice a day for hypertension. R1's May 2025 MAR (Medication Administration Record) shows R1's Coreg is scheduled to be given at 9:00 AM and 5:00 PM daily. V1 (Administrator) provided EMR documentation to show R1's Coreg medication, scheduled to be administered at 5:00 PM on May 17, 2025, was administered by V6 (Agency RN) at 2114 (9:14 PM), more than four hours after the scheduled administration time. The EMR shows the following order for R1 dated February 4, 2025: Velphoro oral tablet chewable 500 mg. Give 2 tablets by mouth three times a day to control phosphorous level. R1's May 2025 MAR shows R1's Velphoro is scheduled to be given at 9:00 AM, 12:00 PM, and 5:00 PM daily. V1 (Administrator) provided EMR documentation to show R1's Velphoro medication, scheduled to be administered at 5:00 PM on May 17, 2025, was administered by V6 (Agency RN) at 21:14 (9:14 PM), more than four hours after the scheduled administration time. The EMR shows the following order for R1 dated February 5, 2025: Lyumjev KwikPen Solution pen-injector. Inject 24 units subcutaneously with meals for DM (Diabetes Mellitus). R1's May 2025 MAR (Medication Administration Record) shows R1's Lyumjev insulin is scheduled to be given at 8:00 AM, 12:00 PM, and 5:00 PM daily. V1 (Administrator) provided EMR documentation to show R1's Lyumjev insulin, scheduled to be administered at 5:00 PM on May 17, 2025, was administered by V6 (Agency RN) at 21:14 (9:14 PM), more than four hours after dinner was served, and the scheduled administration time. 2. On May 21, 2025 at 11:12 AM, R2 was lying in bed in her room. R2 said V6 (Agency RN) arrived at the facility at approximately 5:45 PM on May 17, 2025. R2 said, She got here and just sat and the desk and didn't even bother to check on us. I told her I needed my blood sugar checked. I had to go to the desk to get my Gabapentin (pain medication) because she hadn't passed medications, and no one had filled in for her when she was late getting here. I was not having a lot of pain, but it's just the idea that we like to get our medications on time, and that was not happening. She got here and just sat at the desk and didn't even bother to check on us. R2 said dinner was served at 5:00 PM on May 17, 2025. The EMR shows R2 was admitted to the facility on [DATE] with multiple diagnoses including, Type 2 diabetes, abnormal gait and mobility, sciatica, atrial fibrillation, chronic kidney disease, left eye cataract, pressure ulcer of the left heel, presence of cardiac pacemaker, depression, heart failure, pulmonary hypertension, anemia, morbid obesity, and PVD (Peripheral Vascular Disease). R2's MDS dated [DATE] shows R2 is cognitively intact, requires setup assistance with eating, oral hygiene, dressing, and personal hygiene, supervision with toilet hygiene, bed mobility, and transfers between surfaces, and partial/moderate assistance with showering. R2 is occasionally incontinent of bowel and bladder. The EMR shows the following order for R2 dated September 14, 2024: Gabapentin 100 mg. Give 2 capsules by mouth three times a day for pain. R2's May 2025 MAR shows R2's Gabapentin is scheduled to be given at 9:00 AM, 1:00 PM, and 5:00 PM daily. V1 (Administrator) provided EMR documentation to show R2's Gabapentin medication, scheduled to be administered at 5:00 PM on May 17, 2025, was administered by V6 (Agency RN) at 18:50 (6:50 PM), almost two hours after the scheduled administration time. The EMR shows the following order for R2 dated July 25, 2024: Lyumjev KwikPen subcutaneous solution pen-injector. Inject 25 units subcutaneously three times a day for antidiabetics. R2's May 2025 MAR shows R2's Lyumjev insulin is scheduled to be given at 9:00 AM, 1:00 PM, and 5:00 PM daily. V1 (Administrator) provided EMR documentation to show R2's Lyumjev insulin, scheduled to be administered at 5:00 PM on May 17, 2025, was administered by V6 (Agency RN) at 18:50 (6:50 PM), almost two hours after the scheduled administration time. 3. On May 21, 2025 at 11:20 AM, R3 was walking in her room with a walker. R3 was not able to recall concerns regarding medications being given late due to her cognitive status. The EMR shows R3 was admitted to the facility on [DATE]. R3 has multiple diagnoses including, Type 2 diabetes, abnormal gait and mobility, asthma, vascular dementia, obstructive uropathy, chronic diastolic heart failure, low potassium, major depressive disorder, chronic kidney disease, atrial fibrillation, and psychosis. R3's MDS dated [DATE] shows R3 has moderate cognitive impairment, requires setup assistance with eating and oral hygiene, substantial/maximal assistance with lower body dressing, and partial/moderate assistance with all other ADLs. R3 is occasionally incontinent of bowel and bladder. The EMR shows the following order for R3 dated November 19, 2024: Gabapentin Capsule 100 mg. Give 1 capsule by mouth three times a day for nerve pain. R3's May 2025 MAR shows R3's Gabapentin is scheduled to be given at 9:00 AM, 1:00 PM, and 5:00 PM daily. V1 (Administrator) provided EMR documentation to show R3's Gabapentin medication, scheduled to be administered at 5:00 PM on May 17, 2025, was administered by V6 (Agency RN) at 21:09 (9:09 PM), over four hours after the scheduled administration time. The EMR shows the following order for R3 dated November 19, 2024: Lyumjev KwikPen solution pen-injector. Inject 6 units subcutaneously with meals for DM II (Type 2 Diabetes). R3's May 2025 MAR shows R3's Lyumjev is scheduled to be given at 8:00 AM, 12:00 PM, and 5:00 PM daily. V1 (Administrator) provided EMR documentation to show R3's Lyumjev insulin medication, scheduled to be administered at 5:00 PM on May 17, 2025, was administered by V6 (Agency RN) at 21:09 (9:09 PM), over four hours after the scheduled administration time and the dinner meal was served. 4. The EMR shows R4 was admitted to the facility on [DATE] with multiple diagnoses including, cerebral infarction, unsteadiness on feet, lack of coordination, cognitive communication deficit, constipation, hemiplegia affecting left non-dominant side, Type 2 diabetes, mood disorder, atrial fibrillation, emphysema, heart failure, bilateral hearing loss, depression, and heart disease. R4's MDS was not completed at the time of this investigation. The EMR shows the following order for R4 dated May 16, 2024: Novolog FlexPen subcutaneous with meals as per sliding scale. R4's MAR shows R4's Novolog insulin is scheduled at 8:00 AM, 12:00 PM, and 5:00 PM, and R4's blood sugar reading was 150 on May 17, 2025 at 5:00 PM. V1 (Administrator) provided EMR documentation to show R4's Novolog insulin, 2 units, scheduled for 5:00 PM on May 17, 2025 was administered at 20:42 (8:42 PM), over three and a half hours after the scheduled administration time. 5. The EMR shows R13 was admitted to the facility on [DATE] with multiple diagnoses including, COPD with exacerbation, polyneuropathy, spinal stenosis, Type 2 diabetes, and heart disease. R13's MDS dated [DATE] shows R13 is cognitively intact and requires setup assistance with all ADLs. The EMR shows the following order for R13 dated July 19, 2024: Gabapentin capsule 100 mg. Give 2 capsules by mouth three times a day for nerve pain. R13's May 2025 MAR shows his Gabapentin is scheduled to be given at 9:00 AM, 1:00 PM, and 5:00 PM daily. V1 (Administrator) provided EMR documentation to show R13's Gabapentin, scheduled to be administered at 5:00 PM on May 17, 2025, was administered at 20:54 (8:54 PM), almost four hours after the scheduled administration time. 6. The EMR shows R15 was admitted to the facility on [DATE] with multiple diagnoses including, acute and chronic respiratory failure with hypercapnia, COPD, atrial fibrillation, pulmonary fibrosis, hypertension, Type 2 diabetes, asthma, heart failure, and abnormal gait and mobility. The EMR continues to show R15 has an order for continuous oxygen dated March 6, 2025. R15's MDS dated [DATE] shows R15 is cognitively intact, requires partial/moderate assistance with showering, and setup and/or supervision with all other ADLs. The EMR shows the following order for R15 dated February 20, 2025: Budesonide-Formoterol Fumarate Inhalation Aerosol. Two puffs, inhale orally two times a day for COPD. R15's May 2025 MAR shows R15's Budesonide-Formoterol Fumarate inhaler is scheduled to be given at 9:00 AM and 5:00 PM daily. V1 (Administrator) provided EMR documentation to show R15's Budesonide-Formoterol Fumarate inhaler, scheduled to be administered at 5:00 PM on May 17, 2025, was administered by V6 (Agency RN) at 21:02 (9:02 PM), four hours after the scheduled administration time.

Based on observation, interview, and record review, the facility failed to follow and serve the posted menu for residents. This applies to all 18 residents (R8, R11, R18, R14, R41, R54, R55, R57, R59, R62, R70, R76, R82, R96, R357, R360, R361, R362) who receive non-vegetarian mechanical soft and puree regular diets, and 1 resident (R22) who receives a vegetarian pureed diet from the facility kitchen. The findings include: The facility's Week-At-A-Glance menu provided on 2/25/2025 showed a roasted pork loin was to be served for lunch on Tuesday (2/25/2025). On 2/25/2025 at 12:00 PM, V11 (Dietary Server) said the menu's main entree for lunch was roasted pork loin. At 12:30 PM R14 was served mechanical soft beef, not pork. V11 said residents with a mechanical soft diet were being served beef but could have pork. V11 said she was unsure why mechanical beef was prepared instead of pork. V11 said the pork loin was soft enough to be served for residents with a mechanical soft diet. V26 (Dietary Server) said the dietary department was not provided with the facility's updated list of residents receiving mechanical soft diets to ensure enough food could be prepared in advance. The facility's posted Menu on 2/26/2025 for breakfast also said a sausage patty was to be served. On 2/26/2025 at 8:15 AM, V11 said the breakfast menu included sausage patties. At 8:20 AM, R360 was served mechanical soft ham, not a sausage patty. V11 said she was unsure why mechanical ham was prepared but possibly because there was not enough sausage patties available. V11 said the sausage patty could be cut up into small cube sizes and be served to residents with a mechanical soft diet. At 8:35 AM, R361 was served a pureed meal, which had pureed eggs, bread, and a light whitish-tan colored meal item. V11 was asked what the unidentified puree item was served. V11 said it was not sausage but was unsure what was prepared because the container was not labeled. V11 was asked to serve the surveyor a puree sample tasting plate. The unidentified light whitish-tan item tasted like poultry and not sausage or ham. At 8:45 AM, breakfast observation was continued on the other unit. R54 and R41 were also served mechanical soft ham and not a sausage patty. R18 was served a pureed meal, which also included the same light whitish-tan puree meal item. V12 (Dietary Server) was asked to serve the surveyor a pureed sample for tasting. The served sample meal had the same poultry item and no sausage. V12 was asked about the served item but was unable to say what was being served. On 2/26/2025 at 12:05 PM, R22 was served a puree meal for lunch. R22's lunch meal ticket dated 2/26/2025 said R22 was to be served a Puree Vegetarian Burger. R22's served meal did not have a puree vegetarian burger as indicated in his meal ticket. V11 (Dietary Server) said she served a puree meal as requested by the CNA (Certified Nurse Assistant). V11 said she was not informed the meal was a puree vegetarian meal. V11 also said she was not provided with a puree vegetarian burger to serve R22. Then R361 was served a puree meal, which had puree bread, mashed potatoes, and green peas. R361's lunch meal ticket dated 2/26/2025 said R361 was to be served a double portion of Puree Crispy Chicken Thigh. R361's meal did not have a puree crispy chicken thigh as indicated in his meal ticket. V11 was asked to serve the surveyor a pureed tasting sample. The served sample meal had puree bread, mashed potatoes, and green peas. The sample meal did not have puree chicken. V4 (Dietary Manager) was present during the observations for R22, R361, and the puree meal taste sampling . V4 said R22 was supposed to receive a puree vegetarian burger and R361 a puree crispy chicken thigh. On 2/27/2025 at 11:10 AM, V4 (Dietary Manager) was interviewed regarding menus. V4 said menus should be followed but at times he makes the decision to substitute items. V4 said the facility had enough pork loin, sausage patties, and crispy chicken to serve residents. V4 said the puree sausage patty was substituted because he felt the quality and appearance was poor. V4 said he was unsure what was served on 2/26/2025 as a substitute for the puree sausage patty. V4 was unable to say why the sausage patty was also a substitute for residents receiving mechanical soft diets. V4 said dietary servers serve what is requested from the staff and if a resident has specific food items, they need to be made aware to ensure the resident receives it. On 2/28/2025 at 9:00 AM, V23 (Registered Dietician) said menu substitutions needed to be done prior to meal preparation to ensure the items are of equal nutrition. V23 said on 2/25/2025 residents with mechanical soft diets were to be served mechanical roasted pork loin for lunch. V23 said she did not approve any substitutions for the pork loin and was unsure what was served for residents with mechanical soft diets. V23 said on 2/26/2025 residents with mechanical soft diets were to be served a mechanical ground sausage patty for breakfast. V23 said she was unsure why it was changed to mechanical ham. V23 said V4 (Dietary Manager) informed her during the meal service that the puree sausage was changed to puree ham because of the poor quality appearance of puree sausage. V23 said she was unsure what the served unidentified light whitish-tan puree meal item was that was served for breakfast. V23 said sausage patties can be pureed and mechanically chopped. V23 said she was unsure why R22 did not receive his vegetarian burger which was selected for his lunch menu in advance. V23 said she was also unsure why R361 did not receive his double portion of puree chicken. V23 said she was unsure if the puree food containers were labeled with the food items to ensure servers were serving all the menu items. V23 said residents should be served what is indicated in their meal tickets. The facility's Diet Type Report dated 2/27/2025 said R54, R70, R41, R59, R82, R360, R357, R96, R362, R57, R14, and R76 were receiving non-vegetarian regular mechanical soft diets. The report also said R361, R62, R55, R11, R8, and R18 were receiving non-vegetarian regular puree diets. The facility's policy titled Menus dated 10/2019, said Policy Statement It is the center policy that menus are planned in advanced, and to meet the nutritional needs of the residents/patients, will be developed utilizing an established national guideline .6. Menus are served as written, unless changed in response to preference, unavailability of an item, or a special meal .8. Menus will be posted in the Dining Services department, dining rooms and resident/patient care areas. The facility's policy titled Kitchen dated 8/16/2024, said 8. Menu a. All food items in the menu and recipe will be followed. In the event that change is needed, the dietician may be consulted first to approve the change and ensure that the change is appropriate .

Based on observation, interview, and record review, the facility failed to follow its respiratory testing policy for the management of its COVID-19 outbreak. The facility also failed to follow infection control practices for residents on transmission-based and enhanced-barrier precautions and failed to thoroughly disinfect glucometers. This applies to 13 of 13 residents (R23, R53, R307, R96, R32, R359, R103, R358, R48, R157, R26, R21, and R98) reviewed for infection control in a sample of 31. The findings include: 1. On 2/25/2025 at 9:30 AM, the facility's main entrance had signage indicating that the facility had a COVID-19 outbreak and the transmission rate for respiratory infections was high in the facility's county. On 2/25/2025 at 11:25 AM, V5 (Infection Preventionist/IP Nurse) said the facility's COVID-19 outbreak started on 2/22/2025. V5 said the facility had three cases of confirmed facility COVID-19 cases. V5 said R96 and R307 tested positive on 2/22/2025, and R23 had just now tested positive. On 2/25/2025 at 11:55 AM, R32 was wearing a hospital gown in the dining room with other residents. R32 said she felt ill because she had a sore throat. R32 said she asked the nurse to test her for COVID-19 early in the morning. R32 said her rapid COVID test was negative but she still felt ill. R32 said the facility then tested her roommate (R23) because she was also having respiratory symptoms. R32 said she was then removed from her room because R23 tested positive for COVID. R32 said that the staff had not returned to explain to her what was going to occur with her room situation. On 2/26/2024 at 8:50 AM, R32 was in bed and said her throat was still sore. 2. On 2/25/2025 at 11:45 AM, R23 was in her room receiving 3 liters of oxygen via nasal cannula. R23 said she had been feeling ill and was without an appetite for a few days and thought she had a sinus infection. R23 said overnight she felt short of breath and was placed on oxygen. R23 said the nurse tested R32 and then her for COVID-19 early in the morning. R23 said she tested positive for COVID-19. On 2/26/2025 at 12:40 PM, V5 (IP Nurse) said the facility now had two additional confirmed resident cases (R359 and R53) and one staff member V8 (Registered Nurse/RN). V5 said the facility was only testing symptomatic residents for COVID-19. V5 said she had informed V13 (IP Local Health Department) and received guidance, including a link for Preventing and Controlling ARI [Acute Respiratory Infection] Outbreaks in Skilled Nursing Facilities and Other Facilities Providing Nursing Care. On 2/26/2025 at 2:50 PM, V13 (IP Local Health Department) confirmed that the facility received guidance resources on managing respiratory outbreaks, including COVID-19, on 2/06/2025. V13 said that based on the current transmission rates in the county, facilities are to be testing for both COVID-19 and Influenza for residents showing respiratory symptoms. On 2/27/2025 at 9:50 AM, V3 (Regional Nurse Consultant) said the facility should be following their COVID-19 policies. V3 said infection control policies are developed based on CDC (Centers for Disease Control and Prevention) and Health Department regulations and guidelines. V3 said V5 has now retested R32 for both COVID and Influenza. V3 said she has also instructed V5 to now test R23, R359, R53, R96, and R307 for influenza. R32's Order for Respiratory nasal swab panel showed it was obtained on 2/26/2025 at 5:55 PM. The facility's document titled COVID-19 Residents Cases Tracker showed R307 and R96 were tested on [DATE]; and R23, R359, and R53 were tested on [DATE] only for COVID-19. The document titled Preventing and Controlling ARI Outbreaks in Skilled Nursing Facilities and Other Facilities Providing Nursing Care from IDPH (Illinois Department of Public Health), showed This guidance replaces previous COVID-19 disease-specific guidance. It is based on the CDC's guidance for the control of respiratory illnesses, including COVID-19, influenza, and other respiratory illnesses, in healthcare settings . Testing COVID-19, influenza, RSV, and other viral respiratory illnesses all have similar and overlapping symptoms. When an outbreak of acute respiratory illness is suspected, testing to determine the etiology of the disease is essential to determine the appropriate precautions needed to control the outbreak and if indicated, to implement timely treatment and chemoprophylaxis .Specimens for acute respiratory outbreaks should be collected immediately after the onset of illness .Test any resident with symptoms of COVID-19 or influenza for both viruses. The facility's policy titled Covid 19 and Influenza Virus Cocirculation policy dated 7/16/2024, said The following practices recommended by CDC should be considered when COVID 19 and Influenza viruses are found to be co-circulation based upon local public health surveillance data and testing at local healthcare facilities .2. Test any symptomatic resident for both Covid and Influenza viruses. Obtain respiratory specimens for influenza and Covid 19 testing .Test for COVID 19 by nucleic acid detection OR by COVID 19 antigen detection assay .Because antigen detection assay have lower sensitivity than nucleic acid detection assays for detecting Covid 19 in upper respiratory tract specimen, a negative Covid 19 antigen detection assay result in a symptomatic person does not exclude Covid 19 infection and should be confirmed . 3. On 2/25/2025 at 10:50 AM, R96's room door had signage for transmission-based precautions instructing everyone entering the room that N95 PLUS EYE PROTECTION AND CONTACT PRECAUTIONS were required. V10 (Physical Therapist) was observed exiting R96's room without eye protection. V10 said she just finished providing therapy services to R96. V10 said she did not don a face shield because she used her personal prescription eyeglasses as PPE (personal protective equipment). On 2/26/2025 at 9:15 AM, V6 (Certified Nurse Assistant/CNA) was observed exiting R96's room with a surgical mask, not an N95 mask. V6 said he forgot to don an N95 mask before entering R96's room. R96's Order Summary report had an order for Isolation- Droplet/Contact Reason: Active COVID initiated on 2/22/2025. 4. On 2/26/2025 at 9:20 AM, R103's room door had signage for enhanced-barrier precautions (EBP) instructing providers are required to don gloves and a gown when providing high-contact activities. V6 (CNA) transferred R103 from her wheelchair to her bed by supporting her right upper arm. V6 was not wearing a gown. R103 had a right upper arm intravenous midline and sacral wounds. R103's care plan said she was on EBP because of the potential spread of infection (initiated on 2/14/2025). The care plan said EBP interventions were required because high-contact activities provided the opportunities for transfer of [multi-drug resistant organisms] to staff hands and clothing. 5. On 2/25/2025 at 10:40 AM, R358's room door had a signage for EBP. V7 (CNA) entered R358's room with gloves and proceeded to provide him with urinary catheter care. V7 did not don a gown. R358's care plan said she was on EBP because of the potential spread of infection (initiated on 2/25/2025). The care plan interventions said precautions should be taken when being provided with high-contact activities including device care such as urinary catheters. On 2/26/2025 at 12:40 PM, V5 (IP Nurse) said staff were expected to don proper PPE when providing care to residents under transmission-base and enhanced-barrier precautions to prevent the spread of infections and protect other residents and staff. The facility's policy titled Enhanced Barrier Precautions dated 7/26/2024, said The facility will use Enhanced Barrier Precautions (EBP) to reduce transmission of multi-drug resistant organisms in the nursing homes. 31327 6. On 2/26/25 at 11:47 AM, V16 (Agency RN) took R26's blood sugar with a glucometer in her room. She then brought the glucometer to her medication cart. Instead of wiping down the surface of the glucometer and disinfecting it, she simply wrapped it in a bleach wipe and left it to air dry. At 12:30 PM, V16 went back to R26 and rechecked her blood sugar. Again V16 brought the glucometer to her medication cart and just wrapped it with a bleach wipe. R26's face sheet shows a diagnosis of type 2 diabetes mellitus with hyperglycemia. R26's POS (Physician Order Sheet) shows an order: Blood glucose check 4 times a day before meals and at bedtime. On 2/26/25 at 2:10 PM, V2 (DON) said, the nurse should wipe the surface first, then either wrap it with the bleach wipe or keep it wet continuously for however long the manufacturer's recommendations says. Facility's policy titled: Glucose Meter Cleaning (7/30/24) shows: Policy Statement-To ensure safe, convenient and proper cleaning and disinfection of blood glucose meters in accordance to CDC (Centers for Disease Control and Prevention) guidelines and manufacturer's instructions to help prevent device exposure to blood borne pathogens. Procedures: 3. Place equipment on a clean surface. 4. Clean and disinfect glucose meter with EPA-approved disinfectant including Clorox Healthcare Bleach Germicidal Wipes/Microkill Wipes/ Microdot Wipes/Avert Wipes before after each resident use. 5. Staff must keep glucometer with the disinfectant wipe for a minimum of 60 seconds The label on the back of the container and manufactures guidelines for the Clorox Healthcare Bleach Germicidal Wipes showed: Cleaning Procedure: Blood and other body fluids must be thoroughly cleaned from surfaces and other objects before applying this product. Contact Time: Allow surfaces to remain wet for 1 minute, let air dry. For all other organisms, see directions for contact times. 7. On 2/26/25 at 11:22 AM, V14 (Agency RN/Registered Nurse) took R157's blood sugar in her room with a glucometer that is used for all residents. She then brought the glucometer to her medication cart. Instead of wiping the surface of the glucometer first, she wrapped it in a Clorox Healhcare Bleach Germicidal Wipe and left it to air dry. R157's face sheet shows a diagnosis of type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye. R157's POS shows an order: Blood glucose 3 times a day before meals. 8. On 2/26/25 at 11:28 AM, V14 stated that R96 was Covid positive. V14 took R96's blood sugar in his room with a glucometer. She then brought the glucometer back out of the room and to her medication cart. Instead of wiping down the surface of the glucometer, she wrapped it in a bleach wipe and left it to air dry. R96's face sheet shows a diagnosis of type 2 diabetes mellitus without complications. R96's POS shows an order: Blood glucose check 4 times a day before meals and at bedtime. 9. On 2/26/25 at 11:34 AM, V15 (LPN-Licensed Practical Nurse) took R48's blood sugar with a glucometer. She then brought the glucometer to her medication cart. Instead of thoroughly wiping down the surface of the glucometer, she wrapped it in a bleach wipe and left it to air dry. R48's face sheet shows a diagnosis of type 2 diabetes mellitus without complications. R48's POS shows an order: Blood glucose check 4 times a day before meals and at bedtime. 40054 10. R98 is a [AGE] year-old male with diagnoses including hydronephrosis with renal and ureteral calculous obstruction, and hematuria with nephrostomy drainage tubing and foley catheter. On 02/26/2025, at 10:40 AM, observed not having enhanced barrier precaution (EBP) signage on R98's door, and V7 (Certified Nursing Assistant) drained R98's nephrostomy and urinary catheter bag. At 11:25 AM, V24 (Registered Nurse) changed R98's indwelling urinary catheter drainage bag. V7 and V24 provided direct care to R98 without using gowns per their enhanced barrier precaution policy. 11. R21 is a [AGE] year-old male with diagnoses including stenosis of the anus and rectum with a colostomy bag, anemia, and protein-calorie malnutrition. On 02/26/2025 at 10:10 AM, observed not having enhanced precaution signage on R98's door, and V7 (Certified Nursing Assistant) provided incontinence care to R98. V7 provided direct care to R21 without wearing a gown. On 02/26/2025 at 11:40 AM, V7 and V24 said they should have worn full PPEs (Personal Protective Equipment) while providing direct care to R98 and R21. 12. R359 is a [AGE] year-old female on isolation for Covid 19 positive result with diagnoses including acute gastroenteropathy due to other small round viruses, infectious gastroenteritis, and colitis. On 02/27/2025 at 10:30 AM, observed V21(Licensed Practical Nurse) administering medications without using a facial shield. R359's care plan, dated 02/25/2025, states that staff will wear a mask and face shield or goggles while providing care while in close contact with the resident. 13. R53 is a [AGE] year-old female on isolation for Covid 19 positive result with diagnoses including end-stage renal disease and chronic obstructive pulmonary disease. On 02/27/2025 at 10:30 AM, V21(Licensed Practical Nurse) was observed administering medications without a facial shield. On 02/27/2025, at 10:55 AM, V21 said she forgot to wear a face shield, which she should have. On 02/27/2025 at 2:30 PM, V5 (Infection Control Nurse) said, All staff should adhere to infection control protocol and policies.

Based on observation, interview, and record review, the facility failed to repair a resident's bed. This applies to 1 out of 3 (R103) residents reviewed for environment in a sample of 31. The findings include: On 2/25/2025 at 10:50 AM, R103 was in bed. R103 said her bed's footbard was broken. R103 said an unidentified male staff member assessed her bed in the morning and showed her that the inner side (facing her feet) of the footboard's plastic cover was detached and broken. R103 said she asked the staff member to fix it but was unsure when it would be fixed. The loose plastic cover remained hanging on the footboard. Then V9 (Agency Certified Nurse Assistant/CNA) entered R103's room and assessed the footboard's broken plastic cover. V9 said she would complete a maintenance work order request. On 2/26/2025 at 9:00 AM, R103 said her bed was still not fixed and she was unsure why. On 2/27/2025 at 8:20 AM, R103 was in bed. R103's footboard had an exposed electric connector. R103 said the plastic cover fell off completely overnight and the staff placed it up against the wall. R103 said she was still not sure when her bed was going to be fixed. On 2/27/2025 at 1:00 PM, V1 (Administrator) said she reviewed the maintenance work orders and was unable to find a work request form for R103's broken bed. V1 said she assessed the bed and the facility decided to provide R103 with a new bed. The facility's policy titled Maintenance dated 8/16/2024 said It is the facility's policy to maintain equipment and the building environment. Procedures 1. All resident care equipment and the building environment will be maintained by the maintenance department. 2. Any staff who is made aware of a malfunctioning equipment or any part of the building that is in disrepair will report the issue to the maintenance department. ===

Based on observations, interviews, and record reviews, the facility failed to provide residents with grooming and incontinent/hygeine care for residents who require assistance with ADLs (Activities of Daily Living) This applies to 3 of 3 residents (R14, R43, and R46) reviewed for ADL cares in a sample of 31. The Findings include: 1. R14 is a [AGE] year-old male admitted with severe cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. The MDS also documents that R14 is dependent on shower/bath and toileting hygiene and requires substantial/maximal assistance with personal hygiene. On 02/25/25 at 10:24 AM, R14 was observed in his bed with long, dirty fingernails with a black substance underneath the nail tip and a broken right middle fingernail. On 02/25/25 at 10:29 AM, V17 (Staffing Coordinator/Certified Nursing Assistant/CNA) stated that the CNAs are supposed to clean and trim R14's fingernails. On 2/26/25 at 12:20 PM, V2 (Director of Nursing/DON) stated that the CNAs or nurses can provide nail care/trimming. V2 also stated that they could check and offer nail trimming and grooming during shower days. A review of the facility presented Nail Care policy revised on 8/16/24 documents: 1.Nursing staff shall check the residents for nail care, which includes cleaning and regular trimming 4.Trimmed and smooth nails prevent the resident from accidentally scratching and injuring their skin . 2. R43 is a [AGE] year-old male with mild cognitive impairment as per MDS dated [DATE]. The MDS also documents that R43 is dependent on shower/bath and toileting hygiene. On 2/25/25 at 11:56 AM, R43 was observed in his bed with a strong odor of urine. On 2/25/25 at 12:00 PM, V18 (Registered Nurse/RN) checked on R43 for incontinence. R43 was observed with a urine-soaked incontinent brief and an intense urine smell. On 2/26/25 at 12:20 PM, V2 (DON) added that incontinent care should be offered at least every two hours. A review of R43's Activities of Daily Living (ADL) care plan documents that R43 is dependent on staff for toileting hygiene and requires 1-2 staff assistance for all toileting needs, including adjusting clothes, providing appropriate cleaning, and providing perineal care. A review of the facility presented incontinent and perineal care policy revised on 7/31/24 documents: 1.Do rounds at least every 2 hours to check for incontinence during the shift 39182 3. On 02/25/25 at 12:00 PM, observed R46 sitting on her bed with her nightgown on. Alert and oriented. Observed R46 had stubbles on her chin area, about half cm long and thick. On 02/26/25 at 10:08 AM, observed R46 had stubbles on her chin. R46 stated, CNA (Certified Nursing Assistant) will shave her today. V25 (RN - Registered Nurse) stated, R46 can shave on her own. On 02/27/25 at 12:45 PM, observed R46 sitting on her bed and eating lunch. Observed that there is a lot of hair on her chin area, about 1/2 to 3/4 cm long. R46 stated, facility staff will shave it today. On 02/27/25 at 12:55 PM, V22 (LPN-Licensed Practical Nurse) stated, anytime the CNAs (Certified Nursing Assistant) shower the residents, they will take care of their nails, facial hair etc. It is supposed to be done during their shower. V22 (LPN) stated, sometimes when agency staff is working, they do not pay attention to such details. On 02/27/25 at 12:59 PM, V21 (LPN) stated, it is undignified for females to be left with facial hair. It should be shaved during shower. If resident refuses, the CNAs inform the nurse & it is documented in the progress notes and care-plan. On 2/27/25 at 2:00 PM, V2 (DON) stated, facial hair, whether for males or females, should be shaved /trimmed during their shower. It is part of the resident's ADL (activities of daily living) care. If the resident refuses to be groomed regarding their facial hair, the nurse would document it in the progress notes. V2 stated, facility do not have a policy specific to the facial hair grooming. R46's Care Plan dated 1/13/25 showed R46 needed assist with ADLs. R46's MDS (Minimum Data Set) dated 1/21/25 GG showed R46 needed substantial assist for upper body dressing & shower & bathing. R46's Progress Notes did not include any note stating that R46 refused to be groomed.

Based on observation, interview, and record review, the facility failed to ensure blood glucose testing was performed as accurately as possible and failed to follow up on resident concerns with characteristics of urinary output. This applies to 4 of 4 residents (R26, R96, R98, R157) reviewed for quality of nursing care in a sample of 31. The findings include: 1. On 2/26/25 at 11:47 AM, V16 (Agency RN) wiped R26's index finger her right hand with an alcohol pad and pricked the finger with a lancet and squeezed R26's finger. Instead of using a gauze, V16 wiped away the first drop of blood with an alcohol wipe without it letting it dry. Then she squeezed R26's finger a second time and tested the second drop of blood. The glucometer machine read R26's blood glucose as 583 MG/DL. On 2/26/25 at 12:30 PM, V16 went back to R26 and rechecked her blood sugar. V16 again wiped R26's ring finger of her left hand with an alcohol pad and pricked the finger with a lancet and squeezed it. V16 wiped away the first drop of blood with the alcohol pad, and again without letting it air-dry, squeezed the finger and tested the second drop of blood. R26's blood glucose read 495 MG/DL. On 2/26/25 at 2:05 PM, V2 stated she was unaware that by wiping away the first drop of blood with an alcohol wipe that hasn't air-dried, the alcohol can affect blood glucose readings. R26's face sheet shows a diagnosis of type 2 diabetes mellitus with hyperglycemia. R26's POS shows an order: Blood glucose check 4 times a day before meals and at bedtime. Call MD if blood sugar is below 75 or above 400. R26's care plan (1/13/2025) shows: Focus: (R26) is at risk for fluctuating blood sugars due to diabetes mellitus, receives glucose monitoring, insulin and Metformin. Under the Procedures section of the facility's Diabetes management policy (revised 7/26/2024), it showed 5. Blood Glucose Check clean the selected fingertip with alcohol pad and allow it to dry completely obtain a blood sample using a lancet 2. On 2/26/25 at 11:22 AM, V14 (Agency RN/Registered Nurse) wiped R157's right middle finger with an alcohol pad and pricked it with a lancet. V14 wiped away the first drop of blood with an alcohol pad and without letting it air-dry, V14 took the second drop of blood and tested it. R157's blood glucose reading was 129 MG/DL (Milligrams/Deciliter). R157's face sheet shows a diagnosis of type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye. R157's POS (Physician Order Sheet) shows an order: Blood glucose 3 times a day before meals. Call MD (Medical Doctor) if blood sugar is below (70) or above (400). R157's care plan (2/14/25) shows: Focus: (R157) is at risk for fluctuating blood sugars due to diabetes mellitus. Interventions: Blood sugar check per physician's order. 3. On 2/26/25 at 11:28 AM, V14 wiped R96's right middle finger with an alcohol pad, pricked it with a lancet, then squeezed R96's finger. V14 wiped away the first drop of blood with an alcohol pad and instead of waiting for the alcohol to air-dry, She squeezed R96's finger ad tested the second drop of blood. The machine read R96's blood glucose as 155 MG/DL. R96's face sheet shows a diagnosis of type 2 diabetes mellitus without complications. R96's POS shows an order: Blood glucose check 4 times a day before meals and at bedtime. Call MD if blood sugar is below 70 or above 350. R96's care plan (2/11/25) shows: Focus: (R96) is at risk for fluctuating blood sugars due to diabetes mellitus. Interventions: Blood sugar check per physician's order. 40054 4. On 02/26/2025 at 10:00 AM, R98 said he was in pain and had discomfort in his penis, especially when his urine passed through, and he was scared to drink any water so as to avoid the discomfort. R98 said this has been happening for a few days and he reported it already to some staff members but nothing had been done. R98 repeatedly said that he thinks he is going to die. A review of the urinary catheter output nursing document showed that R98 had decreased urinary output ranging from 300 ml (milliliters) to 450 ml for the whole day from 02/24/2025 to 02/26/2025. On 02/26/2024 at 10:40 AM, V7 (Certified Nursing Assistant) emptied R98's indwelling urinary Foley catheter (IFC) drainage bag and nephrostomy drainage bag. R98's IFC drainage totaled approximately 50 ml of concentrated, cloudy, and foul-smelling urine that had blood in it. The 100 ml of drainage from the nephrostomy tube was a muddy brown color, and it was also cloudy and foul-smelling. V7 checked R98's temperature at 09:50 AM, which showed his temperature was elevated at 99.7 degrees Fahrenheit. V7 said R98's urinary drainage was cloudy the day before on 02/25/2025, and she reported to V21 (Licensed Practical Nurse). On 02/26/25 at 11:25 AM, V24 (Fall Nurse) said she called R98's Nurse Practitioner and received an order for a urine culture and blood lab work. V24 then changed R98's indwelling catheter tubing. V24 said she was covering the unit and did not realize she needed to assess R98 completely. R98's urinalysis with culture and sensitivities was not collected until the next day on 2/27/25, and the nephrostomy drainage sample was not collected until the day after that on 2/28/2025. R98's preliminary urinalysis report showed abnormal results of turbid urine of orange color, with the presence of protein (300 milligram/deciliter), a large amount of blood, and positive for nitrites, leukocyte large, and bacteria many (reference ranges are negative); also with red blood cells more than 900 (reference range is 0-5), white blood cells 15 (reference range 0-5), and hyaline casts 6 (reference range is 0-3). The final urine cultures/sensitivities were not ready by the end of the survey. On 02/27/2024 at 10:00 AM, V21 said the staff should monitor, document, and follow up with the physician regarding any change in the resident's conditions. The EMR (Electronic Medical Record) showed R98 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including hydronephrosis with renal and ureteral calculous obstruction, calculous of kidney, hematuria, obstructive and reflex uropathy, covid 19, diabetes type 2, acute and chronic respiratory failure with hypoxia and with a foley catheter and nephrostomy drainage tubing. R98's Minimum Data Set, dated dated dated [DATE] showed R98 cognitively moderately intact, and the care plan dated 01/18/2025 showed R98 needed monitoring for signs of elevated temperature, raised inflammatory markers, purulent urine output, pain, and burning and stinging when passing urine. On 02/28/2025 at 9:26 AM, V28 (R98's Physician) said he was unaware of R98's issue and the facility might be following up with the nurse practitioner. V28 said that if R98 has a low-grade fever, decreased urinary output, and other symptoms, the best practice is to do bloodwork and urine labs and expedite his appointment with the urologist. V28 said R98 was admitted with a indwelling catheter and nephrostomy tube. V28 said that, to his best knowledge, R98 had both tubes because of an obstruction and didn't know the details, so the urologist might decide to keep or remove at least one of the tubes when R98 goes for the follow-up. The facility's Urinary Catheter Care revised policy dated 08/24/2025, in part, stated check the urine for unusual appearances, report the complaints of residents may have tenderness or pain in the urethral area, observe for the signs and symptoms of urinary tract infection or urinary retention and report to the physician or supervisor immediately .

Based on observation, interview, and record review, the facility failed to implement care plan interventions to prevent falls for residents with recent histories of falls. This applies to 2 of 2 residents reviewed (R14, R100) for fall and injury in a sample of 31. The findings include: 1. R100's Admission Record showed he admitted to the facility on [DATE] with multiple diagnoses including nontraumatic intracerebral hemorrhage, hemiplegia and hemiparesis afftecting the left side, adjustment disorder, insominia, encephalitis, encephalomyelitis, impaired cognition, and muscle weakness. R100's fall care plan said he was at high risk for falls. The care plan included the following interventions Bed/Chair alarm to alert staff when resident attempts to get out of bed unassisted so staff can assist resident and prevent fall initiated on 12/14/2025 and Please provide me with wing mattress whenever available initiated on 1/17/2025. On 2/25/2025 at 10:05 AM, R100 was in bed on a regular mattress. R100 did not have a wing mattress (a fall prevention mattress with a boundary perimeter) in place. R100's sensory fall alarm pad was hanging on the left side bedrail, not underneath him. R100's wife said she was concerned for his safety because he had recently fallen out of bed twice. On 2/27/2025 at 9:30 AM, V2 (DON) said she expected R100's fall interventions to be obtained and implemented, including his fall sensory alarm pad and specialty fall mattress. V2 said wing mattresses are ordered from an outside equipment company and delivered within two days. On 2/27/2025 at 10:30 AM, V24 (Fall Nurse) said she followed up regarding R100's specialty mattress and the facility was now putting it in place. R100's Fall Incident report dated 12/20/2024 said R100 had an unwitnessed fall from his bed, and a second Fall Incident report dated 1/13/2025 said R100 had another unwitnessed fall from his bed. 34410 2. On 2/26/25 at 9:27 AM, R14 was observed in his bed with a call light on the floor, floor paddings folded and leaned towards the wall (not on the floor at bedside), and an entry door name tag with no yellow star with the resident's name (indicative of a fall risk). R14 has severe cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. On 2/26/25 at 9:27 AM, V29 (Certified Nursing Assistant/CNA) stated that R14 is on fall precautions and floor padding should be on the side of the bed, and the call light should be accessible to the resident. On 2/26/25 at 12:20 PM, V2 (Director of Nursing/DON) stated the floor padding should be in place, and the call light should be accessible to the resident to call. The resident's name board should have a yellow star to reflect his high risk for falls. A review of the fall risk assessment dated [DATE] documented that R14 is at high risk for falls and the fall incident log documented that R14 had a fall he sustained on 1/26/25 with no injury. A review of the fall care plan interventions includes: providing floor mats/floor pads at my bedside, applying a yellow star sign that indicates high fall risk in his name tag by the door, and a call light within reach. A review of the facility presented Fall Occurrence policy revised on 7/26/24 documents: 1. Those identified as high risk for falls will be provided with fall interventions .

Based on observation, interview, and record review, the facility failed to to ensure urinary catheter tubing and drainage bags were positiond in a manner to prevent infection. This applies to 3 out of 4 (R358, R96, and R95) residents reviewed for urinary catheters in a sample of 31. The findings include: 1. On 2/26/2025 at 10:40 AM, R358 was in bed and he was wearing pants. R358's urinary catheter drainage tubing came out from underneath the waistband of his pants, and then was over his pants (above the level of his bladder). R358's catheter drainage bag had been placed on top of his bed and the tubing and drainage bag contained urine. V7 (Certified Nurse Assistant/CNA) said she would provide catheter care to R358. R358's catheter tubing securement device was ripped and detached from the tubing and the tubing was not secured. After V7 completed R358's care, she again brought his catheter tubing up from his front waistband and then over his pants. R358's care plan said he required the use of a Foley catheter for acute urinary retention related to hydronephrosis and benign prostatic hyperplasia with lower urinary tract symptoms. R358's care plan interventions included catheter care every shift per facility policy protocol. On 2/27/2025 at 9:50 AM, V2 (Director of Nursing/DON) said residents with urinary catheters should be checked every shift to ensure securement devices are properly in place securing the tubing. V2 said catheter tubing should never be positioned underneath and over a resident's pants waistband, it should go underneath their pant leg. V2 said drainage bags should be placed below the bladder to prevent urine backflow into the bladder. The facility's policy titled Urinary Catheteter Care dated 8/19/2024, said The purpose of this procedure is to prevent catheter-associated urinary tract infections. b. Maintain Unobstructed Urine Flow i. Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks .iii. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder .Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh) . 2. On 2/26/2025 at 10:05 AM, R96 was in bed. V6 (CNA) said he would provide catheter care to R96. R96's urinary catheter tubing was looped underneath his right upper leg. R96's catheter tubing was not secured because the securement device was wrapped around the tubing and not attached to his leg. R96's urinary catheter tubing and drainage bag contained urine. R96's care plan said he required the use of an indwelling catheter for obstructive uropathy. R96's care plan interventions included positioning the catheter bag and tubing below the level of the bladder and for staff to check the catheter tubing for kinks. 3. On 2/26/2025 at 10:25 AM, R95 was in bed. V6 (CNA) said he would provide catheter care to R95. R95's urinary catheter tubing was not secured because the securement device was not attached to her right upper leg. R95's urinary catheter's tubing and drainage bag contained urine with sediment. R95's Order Summary Report dated 2/27/2025 said she required the use of an indwelling catheter for obstructive uropathy. R95's report included orders for catheter care every shift and to monitor urinary tract infections.

Based on observation, interview, and record review, the facility failed to report a Resident fall (caused by an improper transfer) to licensed staff before assisting the Resident up from the floor, failed to transfer residents using gait belts, and failed to ensure resident tranfer status was clearly communicated. This applies to 5 out of 5 residents (R1-R5) reviewed for accidents. The findings include: 1. R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE] with multiple diagnoses including post-operative care for a lumbar L3-5 transforaminal spinal fusion surgery with complications of wound infection and dehiscence, spinal stenosis of the lumbar region with neurogenic claudication, neuropathy, abnormalities of gait and mobility, difficulty walking, and unsteadiness on feet. R1's MDS (Minimum Data Set) dated 11/30/2024 showed R1 was dependent on staff for toilet transfers. R1's hospital records dated 12/12/2024 said The patient .presents with right leg pain and numbness which has worsened since she was dropped while being assisted to the toilet at the SNF [facility] on 12/11/2024. Since then, she has had worsening back pain and radiculopathy to the bottom of her right foot. The sensation is diminished to the right leg from L3 down. R1's hospital records said R1 received treatment for acute on chronic pain. On 12/17/2024 V3 (Agency Certified Nurse Assistant/CNA) was unable to be reached for an interview. V3's facility witness statement dated 12/12/2024 regarding R1's fall said CNA stated that she was transferring Resident in the bathroom sometime after dinner and Resident lost her balance, so she lowered her to the floor. Transferred via 1 person assist. CNA doesn't remember if she notified the nurse .Requested help from another CNA to assist patient off the floor. On 12/17/2024 at 2:30 PM, V13 (CNA) said on 12/11/2024 after dinner, V3 called him into R1's bathroom for assistance. V13 said R1 was on the floor in a sitting position in front of the toilet with one leg extended forward and another with her knee bent underneath her buttocks. V13 said they then proceeded to lift R1 by placing their arms underneath her armpits to transfer her onto the toilet. V13 said he couldn't recall if a gait belt was used. V13 said he informed V3 that R1's transfer status was a sit-to-stand machine with a 2-person assist. On 12/17/2024 at 2:35 PM, V4 (Agency Registered Nurse/RN) said she took care of R1 on 12/11/2024 on the evening shift (3 PM-11 PM) and night shift (11 PM-7 AM). V4 said she did not assess R1 after her fall because V3 (Agency CNA) did not inform her of the incident. V4 said R1 started to complain of knee pain at 3 AM (12/12/2024). V4 said R1 then informed her she had fallen on the prior shift because V3 had failed to use the sit-to-stand equipment when transferring R1 to the toilet. V4 said she administered pain medication to R1 and tried to notify R1's physician. V4's Progress Note dated 12/12/2024 at 2:32 AM said, I was told that the patient fell in the pm shift, and the incident was not reported to me until now. No one was informed about the fall. The patient stated that her knee hurt and rated her pain 8 on a scale of 0-10. R1's EMR shows on 12/12/2024 at 4:23 AM she received Oxycodone HCI 5 mg (milligrams) by mouth for severe pain. On 12/17/2024 at 12:45 PM, V9 (RN) said she then re-assessed R1 on 12/12/2024 at 9 AM because R1 was now having acute pain in her back and legs, which was unrelieved with her pain medication. V9 said she notified R1's physician, and R1 was transferred to the hospital. V9's Progress Note dated 12/12/2024 at 9:57 AM showed, Resident complaining of back pain and bilateral leg pain, as needed pain medication was given but still ineffective. Resident verbalized that she would want to be sent to ER. On 12/17/2024 at 11:00 AM, V10 (Therapy Director) said R1 was receiving therapy services because she was very weak after undergoing a complex surgery on her lumbar spine. V10 said therapy had recommended R1's transfer status to be a sit-to-stand machine with a 2-person assist. V10 said therapy notifies nursing of transfer recommendations to ensure they are followed and updated in the residents' plan of care. V10 said transfer status are recommended to ensure the safety of residents and prevention of falls. On 12/17/2024 at 11:20 AM, V11 (Restorative Nurse) said restorative and therapy assess residents' transfer status during admission, quarterly, annually, or if there is a significant change. V11 said restorative nursing completes Resident's Care Profiles document when a resident is admitted and if there is a change in transfer status. V11 said Resident Care Profiles are located in each Resident's room to ensure nursing staff is aware of how to safely transfer residents. R1's Physical Therapy notes dated 12/12/2024 said R1 was at risk for falls. The notes said R1 was dependent for toilet transfers. R1's Restorative Section GG: Admission form dated 11/25/2024 showed R1's toilet transfer (the ability to get on and off a toilet or commode) was also dependent. R1's Restorative UDAs form dated 11/23/2024 showed Transfer Status a. Mechanical sit to stand lift with 2 or more person assist. R1's undated Resident's Care Profile said, R1's transfers were substantial/maximal and number of staff to assist: 1. The Resident's Care Profile did not show the transfer device of sit-to-stand was selected for R1. On 12/17/2024 at 1:50 AM, V2 (Director of Nursing/DON) said she was still investigating R1's 12/11/2024 fall incident because her fall was not reported and an incident report was not completed. V2 said she expected all fall incidents to be reported immediately to ensure the Resident is being properly assessed and safely transferred after a fall incident. V2 also said she expects Resident's Care Profile transfers to be updated and followed to ensure safe residents' transfers. V2 said she was unsure why R1's Resident's Care Profile transfer was not accurate to include R1's need for a sit-to-stand machine with a 2-person assist. The facility's policy titled Restorative Nursing Program dated 8/19/2024, said It is the policy of this facility to assess for comprehensive nursing and restorative needs upon admission .may include .b. Transfer .Nursing and restorative services shall be reflected in the resident's individualized care plan consistent to the completion of the resident comprehensive assessment .Resident assistance with ADLs will be based on the above functional assessment. The facility's 8/16/2024 Notification for Change of Condition policy showed The facility will provide care to Resident and provide notification of resident change in status .a. An accident involving the Resident which results in injury and has the potential for requiring physician intervention . b. A significant change in the Resident's physical, mental, or psychosocial status . 2. On 12/17/2024 at 9:35 AM, R2 was using the toilet. At 9:44 AM, R2 called for assistance, and V8 (RN) responded and said she would assist R2 in getting off the toilet. V8 did not use a transfer gait belt and instead pushed up on R2's mid-lower back to assist her to a standing position. R2 was able to only use her left hand to hold on to the rail for support because her right arm was flaccid and her fingers were contracted. V8 stood behind R2 while providing pericare, then R2 started to slightly squat back, and V8 used her upper leg to help support R2 to maintain her balance. V8 then pulled up R2's pants and used the back waist of her pants to guide her into a sitting position in her wheelchair. On 12/17/2024 at 11:00 AM, V10 (Therapy Director) said gait belts should be always used for residents who require 1 or 2-person transfer assistance with transfers. V10 said gait belts are used for safety to help provide residents with standing support during transfers and help prevent falls. R2's care plan reviewed on 12/17/2024, said [R2] is high risk for falls related to Gait problem, such as unsteady gait, even with mobility aide or personal assistance, slow gait, takes small steps, takes rapid steps or lurching gait. The care plan had multiple interventions including I would like staff to provide me a safe environment. R2's undated Resident's Care Profile said, R2's transfers were substantial/maximal and required the device use of a gait belt. On 12/17/2024 at 1:50 AM, V2 (Director of Nursing/DON) said she expected nursing staff to use gait belts when performing transfers to help residents maintain balance and guide them during the transfer process. V2 said staff should not be pulling on Resident's pants or pushing up on their backs to bring them to a standing or sitting position. The facility's policy titled Gait Belt dated 7/26/2024, said The facility will use gait or transfer belts to assist residents needing limited to total assistance during transfers and walking. 3. On 12/17/2024 at 9:50 AM, R3 self-transferred to the toilet without supervision. V7 (CNA) was not supervising R3 because she was stripping R3's bed linen. V7 then went to assist R3 with dressing while she was sitting on the toilet. V7 said she had stepped out of the room to get wash towels and left R3 unsupervised sitting on the toilet. V7 then returned and instructed R3 to stand and pushed up on R3's mid-lower back to assist her in a standing position. V7 did not use a transfer gait belt. V7 stood behind R3 to provide pericare and then pulled up her pants. V7 then used the back waist of R3's pants to guide her into a sitting position in her wheelchair. V7 said she reviews the Resident's Care Profiles in the residents' closets to know their transfer status. R3's care plan reviewed on 12/17/2024, [R3] is at risk for falls related to: Specific: Current medication use, Poor safety awareness, Unsteady gait . The care plan had multiple interventions including Provide DME (durable medical equipment) if needed. R3's undated Resident's Care Profile showed R3's transfers were substantial/maximal and required the device use of a gait belt. 4. On 12/17/2024 at 10:15 AM, R4 called for assistance to be transferred from the bed to the toilet. R4 said she required the use of a sit-to-stand machine for transfers. At 10:45 AM, V5 (CNA) and V6 (CNA) used the sit-to-stand machine to transfer R4 out of bed into the toilet. They said they review the Resident's Care Profiles in the residents' closets to know their transfer status. They then reviewed R4's Resident's Care Profile and said it did not indicate R4 was a sit-to-stand transfer. They said R4 had been declining and was at risk for falls and that's why they had been using a sit-to-stand machine to transfer her. R4's undated Resident's Care Profile said, R4's transfers were substantial/maximal and number of staff to assist: 1. The Resident's Care Profile did not show the transfer device of sit-to-stand was selected for R4. 5. On 12/17/2024 at 10:50 AM, R5 said she just received a shower and was transferred back into bed with the use of a sit-to-stand machine. R5 continued to say that sometimes nursing staff also uses the sliding board to transfer her out of bed. V7 (CNA) said she had just transferred R5 using a sit-to-stand because she was transferred into the shower chair, but they also transferred her using a sliding board when assisting her out of bed. R5's undated Resident's Care Profile said, R5's transfers were substantial/maximal and number of staff to assist: 2 with the use of a sliding board device. The Resident's Care Profile did not show the transfer device of sit-to-stand was selected for R5. On 12/17/2024 at 11:00 AM, V10 (Therapy Director) said she was familiar with R4 and R5 because they had recently received therapy services. V10 said R4 was treated after a fall and was discharged with a 1-staff assist transfer status recommendation on 11/8/2024. V10 said R5 was also treated and discharged last week with a recommended transfer status of a sliding board with a 2-staff assist. V10 said therapy did not make any recommendations for sit-to-stand transfers for R4 and R5. On 12/18/2024 at 12:40 PM, V2 (DON) confirmed that nursing staff had been transferring R4 into her recliner geriatric chair with the use of the sit-to-stand machine and R5 also when transferring into the shower chair. V2 said she was unsure why R4 and R5's specific transfer instructions of when to use the sit-to-stand device were not indicated in their Resident's Care Profiles. The facility said they did not have a Transfer policy or a Resident's Care Profile policy.

Based on interview and record review the facility failed to provide showers in accordance with the facility schedule and policy for residents identified as needing assistance with showers. This applies to 5 of 5 residents (R1, R2, R3, R7, R8) reviewed for showers/baths in the sample of 8. The findings include: V1 (Administrator) and V2 (Director of Nursing) were requested to provide all shower documentation for the past 30 days for R1, R2, R3, R7, and R8. 1. The EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses, including chronic diastolic congestive heart failure, chronic kidney disease stage 3B, dry eye syndrome, type 2 diabetes without complication, malignant neoplasm of the prostrate, other obstructive and reflux uropathy and dementia, unspecified. R1's MDS (Minimum Data Set), dated August 1, 2024, showed moderate cognitive impairment and required assistance with ADLs (Activities of Daily Living), including substantial assistance with oral hygiene, upper body dressing, and bed mobility. The set-up assistance with eating was also required, and R1 was dependent on staff for toileting, bathing lower body dressing, and transfer. The facility's shower documentation showed that R1 received a shower and complete bed bath on September 26 and 30, 2024, and October 3 and 10, 2024. However, R1 did not receive the shower scheduled from 9/16/24 until 9/26/2024 and did not receive a shower between October 10 and October 21, 2024. Each time frame exceeded 7 days. 2. R2's EMR showed that R2 was admitted to the facility on [DATE], and discharged from the facility on October 8, 2024. R2 was admitted with multiple diagnoses: metabolic encephalopathy, unspecified psychosis, type 2 diabetes with chronic kidney disease, neuromuscular dysfunction of the bladder, unspecified dementia, pressure ulcer to the ankle, and acute and chronic respiratory failure. R2's MDS, dated [DATE], showed R2 was moderately cognitively impaired and required assistance with ADLs, including substantial assistance with eating, oral hygiene, personal hygiene, dressing, and bed mobility, and dependent on staff for bathing and toileting. Per R2's POC (Point of Care) task documentation, the facility did not give R2 a shower or complete bed bath during his stay from September 21, 2024, to October 8, 2024. 3. R3's EMR showed R3 was admitted to the facility on [DATE], with multiple diagnoses, including chronic congestive heart failure, chronic kidney disease stage 3, diabetes type 2, legal blindness, and urinary tract infection. R3's MDS, dated [DATE], showed R3 had moderately impaired cognition and required assistance with ADLs, including substantial assistance with eating, oral hygiene, and personal hygiene and supervision with bathing and sitting up in bed, dependent on staff assistance for toileting, dressing and transfer. According to the facility's schedule, R3 was scheduled to receive a shower on September 17, 20, 24, 26, and October 1, 4, 8, 11, 15, and 18. However, R3 received a shower per POC documentation on September 27 and 28 and October 4, 8, and 13, 2024, not as often as scheduled, twice per week. On October 19, 2024, at 3:00 PM, R3's daughter stated she wanted R3 to receive her bathes twice per week as scheduled. 4. R7's EMR showed R7 was admitted to the facility on [DATE], with multiple diagnoses, including nontraumatic intracerebral hemorrhage, unsteadiness on feet, diabetes type 2, depression, ischemic cardiomyopathy, and chronic kidney disease stage 3. R7's MDS dated [DATE], showed R7 had moderate cognitive impairment, and required assistance with ADLs including set up assistance with eating, oral hygiene, upper body dressing, Supervision/light touch with bed mobility, personal hygiene, toilet hygiene, and lower body dressing, and partial assistance with bathing. Per R7's POC documentation for the past 30 days, R7 received a shower on September 27, and October 13, 2024, less than the minimum of 7 days apart. 5. R8's EMR showed R8 was admitted to the facility on [DATE], with multiple diagnoses, including unspecified atrial fibrillation, vascular dementia, obstructive and reflux uropathy, and cognitive communication deficit. R8's MDS, dated [DATE], showed R8 was severely cognitively impaired and required assistance with ADLs, including supervision with eating and oral hygiene, partial assistance with upper body dressing and bed mobility, and substantial assistance with lower body dressing, bathing, and transfer. R8's shower documentation from September 22, 2024, through October 20, 2024, showed R8 received a shower on October 10, 17, and 18, 2024. There was no documented shower given from September 22, 2024, until October 10, 2024. On October 19, 2024, at 5:36 PM, V2 (Director of Nursing) stated residents are scheduled to receive a shower twice per week and if the resident refuses the shower, staff is to document the refusal. The Facility's policy title Shower and Hygiene dated August 19, 2024, showed It is the policy of the facility to ensure that resident shower/hygienic care is provided by the nursing staff to promote cleanliness, provide comfort to the resident, and observe the condition of the resident's skin.Procedures .1 Administer the shower once weekly and/or as often as necessary. Any resident who needs hygienic care will be provided to promote hygiene.

Based on interview and record review the facility did not follow their policy for Urinary Catheter Care and failed to document the assessment of symptoms for residents with indwelling urinary catheters who developed UTIs (Urinary Tract Infections) This applies to 3 of 4 residents (R1, R2 and R8) reviewed for indwelling urinary catheter care and UTI in the sample of 8. The findings include: 1. R2's EMR (Electronic Medical Record) showed R2 was admitted to the facility on [DATE], and discharged from the facility on October 8, 2024. R2 was admitted with multiple diagnoses: metabolic encephalopathy, unspecified psychosis, type 2 diabetes with chronic kidney disease, neuromuscular dysfunction of the bladder, unspecified dementia, pressure ulcer to the ankle, and acute and chronic respiratory failure. R2's MDS (Minimum Data Set) dated September 24, 2024, showed R2 was moderately cognitively impaired, and required assistance with ADLs (Activities of daily Living) including substantial assistance with eating, oral hygiene, personal hygiene, dressing, and bed mobility and dependent on staff for bathing and toileting. R2 had an indwelling urinary catheter and was incontinent of bowel. R2's hospital record dated October 8, 2024, showed R2 arrived at the local hospital emergency department from the facility at 7:35 PM. R2's emergency department record showed R2 arrived lethargic, altered mental status with possible UTI. R2's laboratory reports dated October 8, 2024, at 9:05 PM, showed R2's urine was orange in color, extra turbid, with blood and many bacteria present. R2's symptoms documented in the emergency room note showed that R2 was lethargic and non-verbal, skin was slightly warm, clammy, and shaky. R2's hospital admitting diagnosis was a urinary tract infection with indwelling urethral catheter. On October 19, 2024, at 5:54 PM, V14 (RN) stated he was the regular evening shift nurse assigned to R2 and had been the nurse who sent R2 to the hospital on October 8, 2024. V14 stated that R2 was sent to the hospital after R2's daughter insisted that R2 be transferred. V14 stated that R2 was very lethargic and not taking in oral fluids. V14 stated he told R2's daughter he would contact R2's physician and obtain an order for IV (Intravenous fluids) and obtain a urine sample. V14 stated the daughter was told it may take a day for the initial urine results and the culture would take an additional 48-72 hours for results and the daughter insisted R2 to be sent to the hospital for evaluation and treatment. V14 stated he did not recall what the urine output in the drainage bag looked like, but there was not much in the drainage bag. There was no description of R2's urinary output, color, clarity, or unusual appearance in R2's EMR. 2. R8's EMR (Electronic Medical Record) showed R8 was admitted to the facility on [DATE], with multiple diagnoses including unspecified atrial fibrillation, vascular dementia, obstructive and reflux uropathy and cognitive communication deficit. R8's MDS (Minimum Data Set) dated September 4, 2024, showed R8 was severely cognitively impaired, and required assistance with ADLs including supervision with eating and oral hygiene, partial assistance with upper body dressing and bed mobility, and substantial assistance with lower body dressing, bathing, and transfer. R8's progress note of October 14, 2024, showed R8 had urine lab results called to the physician for notification due to the presence of bacteria noted in the urine lab result. R8's EMR showed there was no assessment of symptoms, including urine color, turbidity, or presence of pain, or evaluation for fever in R8's progress notes. R8's physician ordered Cipro 500 mg twice daily for 7 days as an antibiotic to treat UTI. R8's progress notes did not contain a description of R8's urine output except for the amount drained from the bag. R8's progress notes do not contain an assessment of R8's response to treatment of the UTI. R8's urine lab results dated October 10, 2024, showed urine described as cloudy. 3. R1's EMR showed R1 was admitted to the facility on [DATE], with multiple diagnoses including chronic diastolic congestive heart failure, chronic kidney disease stage 3B, dry eye syndrome, type 2 diabetes without complication, malignant neoplasm of the prostrate, other obstructive and reflux uropathy and dementia, unspecified. R1's MDS, dated [DATE], showed R1 with moderate cognitive impairment and required assistance with ADLs, including substantial assistance with oral hygiene, upper body dressing and bed mobility, set up assistance with eating, and dependent on staff for toileting, bathing, lower body dressing and transfer. R1 had a suprapubic indwelling urinary catheter in place. On September 3, 2024, the hospice NP (Nurse Practitioner) wrote a progress note with orders to change the antibiotic order from Macrobid to Cipro for 14 days for a UTI. R1's progress notes did not include an assessment by facility staff and no lab results indicative of a UTI to indicate why the medication was changed or what symptoms of UTI R1 was exhibiting. R1's progress notes did not contain documentation of R1's response to treatment for a UTI. On October 19, 2024, at 3:19 PM, V2 (Director of Nursing) stated it is the expectation for nursing staff to monitor urinary output from indwelling urinary catheters and document color, clarity or any unusual appearance or change in the output. The facility policy titled Urinary Catheter Care, dated August 19, 2024, showed Purpose: The purpose of this procedure is to prevent catheter associated urinary tract infections .General Guidelines . 2a. Input/output i. Observe the resident's urine level for noticeable increases or decreases .ii. Maintain an accurate record of the resident's daily output .Complications .1b Check the urine for unusual appearance (i.e. color, blood, etc.) .e. Observe for other signs and symptoms of urinary tract infection or urinary retention. Report findings to the physician or supervisor immediately .Documentation .4. Character of urine such as color (straw colored, dark, or red), clarity (cloudy, solid particles, or blood) and odor .

Based on interview and record review, the facility failed to thoroughly assess and consistently monitor pain for a resident (R1) who was cognitively impaired and had verbalized had a recent fall incident. The facility also failed to follow physician order for pain medication administration and failed to notify the physician of severe pain. This failure resulted in R1 waiting more than 24 hours experiencing pain and a delay in treatment for the right hip fracture. This applies to 1 of 3 residents (R1) reviewed for injuries of unknown origin. The findings include: The EHR (Electronic Health Record) shows R1 was admitted to the facility on [DATE] at 2:20 P.M. R1 came from another facility. R1's diagnoses include NPH (Normal Pressure Hydrocephalus), with s/p (status post insertion of VP shunt (Ventricular-Peritoneal), UTI (urinary tract infection), diabetes mellitus type 2, adjustment disorder, anxiety, syncope, collapse, and ataxia. The EHR also showed that R1 was sent to the hospital on 4/16/2023 at 2:52 P.M. for further evaluation and treatment due to pain to hips and knees. R1 was admitted to the hospital with right hip fracture. The facility's incident report dated 4/16/2023 shows that on 4/15/2023, upon admission, R1 was alert and oriented with bouts of confusion and forgetfulness. The report showed that V11(R1's spouse) informed V3 (Licensed Practical Nurse) that R1 fell 2 days ago at previous nursing facility. V11 stated that V3 was told that the previous facility was unaware of the fall. The report also shows that R1 had complained of pain to the left rib cage area. A portable X-ray to the left rib cage was done at the facility on 4/15/2023 with result of negative for fracture. The incident report also showed that on 04/16/2023, R1 was sent to the hospital due to pain to his hips and knees and was admitted with right hip fracture. The left rib cage X-ray report showed it was done on 4/16/2023 at 12:00 MN and the report was reported to the facility on 6:48 A.M. R1 continued to verbalize pain, yet the EHR shows that there was no assessment to determine cause of continued pain. The progress notes for the night shift show no entries documenting R1's condition and assessment of pain. R1's progress notes document: -4/15/2023 documented at 4:42 P.M. by V3 shows that R1 admitted to facility. Upon assessment resident reported to his family (V11) that he fell at (previous nursing facility) but did not report it to the staff. R1 reported right rib pain. Family would like X-ray. Writer called (Attending Physician) requesting an order for an Xray. Waiting for orders.'' -4/15/2023 documented at 8:23 P.M. by V4 (Licensed Practical Nurse/LPN) shows that (R1) admitted ., alert and oriented x 1-2 with bouts of confusion and forgetfulness. Resident told the spouse at bedside who reported to this nurse that he fell at (previous nursing facility) 2 days ago and did not tell the staff and now is c/o left rib pain. This writer assessed resident, upon touching the left rib cage, resident grimaced of pain. (Attending Physician) was paged, received call back .with an order for X-Ray of left rib cage. -4/16/2023 documented at 11:51 A.M. by V5 (Registered Nurse/RN) shows that Results: Left Ribs, Unilateral 2 Views; Relayed Results to (Attending Physician); Follow up: R hip X-ray due to complaints of pain. -4/16/2023 documented at 1:31 P.M. by V5 shows that: (R1) alert responsive, forgetful, and confused. (R1) is not on any form of distress, complains of pain to Left leg. (R1) is inconsistent with pain site. At times he points to hip area, and sometimes to above the knee. No redness, no swelling, no bruising noted. Per wife, resident fell about 3,4 days ago at (previous facility) X-Ray relayed to MD with no findings and (V11) was updated. New orders for X-ray of R hip and R leg due to pain. (V11) refuses to wait for X-ray to be done at the facility as explained by this writer. (V11) insists that she wants (R1) resident to be sent out to the ER for X-ray (Attending Physician) is made aware that (R1) is being transferred to ER (emergency room ) at (hospital) per (V11's) request . -4/16/2023 documented at 2:12 P.M. by V5 that: (R1) is being sent out to (hospital) per family request. (V11) at bedside and refusing to wait for X-ray be done at the facility. (V11) expressed that she does not trust portable X-ray results and wants (R1) to go out to ER. (R1) continues to be inconsistent with pain site, at times points to R hip, then R knee, and then at times he starts pointing at opposite extremity. -4/16/2023 documented at 2:51 P.M., by V5 shows: (R1) left the facility via stretcher at 2:52 P.M. Wife left with resident. -4/16/2023 documented at 8:43 P.M. by V4 shows that This writer called (hospital) ER for an update. Report received that (R1) is admitted with closed right hip fracture. The facility Admission Evaluation notes dated 4/15/2023 shows that R1 had verbalized pain at a numeric scale rate of 6/10, which indicated a moderate pain (numerate rating scale as 0/10 for no pain; 1-3/10 for mild pain; 4-6/10 for moderate pain; 7-9/10 for severe pain and 10/10 as excruciating pain). However, the same pain evaluation shows that R1 had verbalized that he was on severe pain. The pain was also described as on and off pain. The Physician Order Sheet (POS) for the month of April 2023 shows a physician order dated 4/15/2023 for Tylenol 325 mg. 2 tabs every 6 hours as needed for mild pain; Seroquel 1 tablet every 24 hours as needed for agitation for 14 days, monitor pain every shift. The EMAR (Electronic Medical Administration Record) for the month of April 2023 shows that on the evening shift of 4/15/2023 (time unspecified), R1 had a pain of 4/10. The EMAR shows that Tylenol was not administered as ordered. Furthermore, when the Admission Evaluation was done dated 4/15/2023, R1 verbalized that he has a severe pain. There was no documentation that shows a physician was notified for R1's severe pain. The EHR that included the progress notes, assessments, and EMAR for month of April 2023 shows that R1 was not consistently monitored for pain to determine its cause and location. The EMAR shows there was only one documented entry that R1's pain complaint with mild pain on 4/15/2023. On 7/13/2023 at intermittent times from 11:39 A.M. through 2:40 P.M., staff that took care of R1 were interviewed: V3 (Admitting nurse for R1) was interviewed on 7/13/2023 at 11:39AM said that she just did not assess R1 upon admission. V3 added that R1 had verbalized generalized pain but mostly pointing to the left rib cage area. V3 said she just listened of what R1, and spouse told her and failed to conduct a head-to-toe assessment on R1. On 7/13/2023 at 2:40 P.M., V4 (LPN/took care of R1 for 3-11 P.M. shift of 4/11/2023) said that she did not do head-to-toe assessment on R1 to determine possible site of pain. V4 said that R1 and V11 said that R1 has pain all over his body. On 7/13/2023 at 2:13 P.M., V5(RN-Registered Nurse) said that V11 was upset because R1 was in pain from the time of admission and up to the time when she visited around afternoon of 4/16/2023. V5 also said that there was no way that V11 would wait for portable x-ray and insisted for R1 be sent to the hospital for immediate evaluation and determine what was causing R1's pain. On 7/13/2023 at 2:33 P.M., V8 (CNA/Certified Nurse Aide) said that R1 was in constant pain and complained of body pain throughout the time he was on duty. V8 said he had informed the assigned nurse (V10/LPN). Review of the EMR documented no pain assessment or evaluation for R1 during the night shift. This was verified by V2 (Director of Nursing/DON) on 7/23/2023. V2 also stated that there was no comprehensive assessment done during the time R1 was at the facility. V2 also stated that thorough assessment should be done upon admission and for three consecutive days/every shift post-admission. V2 explained that pain assessment should be done every shift and as needed to determine pain management was effective. V2 had also verified that R1 was assessed with pain the evening of 4/15/2023, and pain level was 4/10 (mild pain) and was not medicated with Tylenol as ordered. V2 also said that after R1 was assessed with 4/10, time not indicated when it was done, there was no follow up with pain assessment after that. V2 also said that the Admission Evaluation assessment dated ,d+[DATE] showed that R1 had verbalized severe pain. V2 said there was no follow up with physician for a stronger pain medication since there was only one order for pain, which was the Tylenol for mild pain. On 7/13/2023 at 9:11 A.M., V11 said that R1 was complaining of pain and having changes in behavior such as clinching, grabbing to rails, and holding bars upon R1's admission to the facility. V11 also stated that if she did not insist on sending R1 to the hospital, R1 would have to wait for portable X-ray again. V11 added that R1 had already waited long enough since the day he arrives at the facility. V11 added that R1 had hip surgery because of the fracture to the right hip and was done the same day he was admitted to the hospital. The facility's policy for admission, dated 7/27/2022, shows the policy was to ensure the facility complies with federal regulations in terms of admission and readmission of resident. The facility also shows to Assess the resident . The facility's pain policy dated 7/28/2023 shows It is the policy of the facility that all residents as assessed for pain in every situation where there is potential for pain. For pain complaints and for situations/incidents that might result to pain (fall incident, altercation, cuts, bruises, wound care etc.), the nursing staff may document it in any part of the resident's medical records that includes Nurses Notes, Incident Report, and Medication Administration Record . The policy also shows that the nurse should assess the resident for pain, and when pain was identified, to call physician for pain order, administer medication and reassess for effectiveness and call physician for lack for relief. On 7/13/2023 at 12:31 P.M., V7 (Nurse Practitioner for V12, R1's Attending Physician) said that as a clinician, the acceptable standard of practice was to assess the resident comprehensively and thoroughly upon admission and when there was identified pain. If a resident was confused, then the more, we must do thorough assessment from head-to-toe including touching/palpate parts of the body to identify any injury, such as fracture. A resident that is confused and had verbalized pain might be displacing pain so a head-to-toe thorough assessment is a must. When palpated, the confused resident will show grimaces, might even jump from pain. Also, must check for any limitation with range of motion to see misalignment of limbs such as rotation or shortening. The pain assessment should be continued to be monitored, as this is an indication that something was going on. It was also expected that facility should have called when the pain was described as severe when Tylenol was only ordered for mild pain, then a stronger pain medication, maybe Tramadol could have been ordered. We only order what the nurse had relayed to us, if the assessment was done thoroughly, the nurse would have seen sign of fracture/injury/abnormality and the resident would have been sent to the hospital sooner for further evaluation and treatment, such as imaging or surgical intervention as appropriate.

Based on observation, interview, and record review, the facility failed to safely transfer a resident in a mechanical lift, failed to safely reposition a resident in bed, and failed to safely position a resident in bed to prevent from sliding out of bed for two of 22 residents (R21, R6) reviewed for safety and supervision in the sample of 22. This failure resulted in R21 obtaining an extensive hematoma to her forehead. The findings include: 1. R21's Order Summary report dated 4/25/23 shows R21 was admitted to the facility on [DATE] with diagnoses including hemiplegia, cerebral infarction, diabetes mellitus 2, aphasia, gastrostomy status, dysphagia, major depressive disorder, and contracture. R21's Care Plan initiated 9/13/22 shows R21 has an ADL (Activities of daily living) self-care performance deficit and impaired mobility related to stroke. Interventions initiated 9/13/22 shows R21 requires total assistance of two staff participation to reposition and turn in bed. R21 requires total assistance of two staff participation with transfers. R21's MDS (Minimum Data Set) dated 2/9/23 shows R21 is not cognitively intact. R21 requires two-person physical assistance with bed mobility and transferring. The facility's Post Fall Investigation/RCA (Root Cause Analysis) Investigation report dated 2/12/23 shows Root Cause analysis: Upon investigation, resident was transferred with one assist resulting resident (R21) to fall. Resident is a full body lift with transfer with a minimum 2 assist. Patient was sent to the (local hospital) via 911. Interventions to address incident: I would like staff to make sure that they transfer me at least 2 persons assist using full body lift properly for my safety. R21's cat scan final report from the local hospital dated 2/11/23 shows, There is a large frontal scalp hematoma measuring 1.4 cm in depth and up to 10 cm across. On 4/24/23 at 2:07 PM, V33 (Fall Prevention Nurse) said the agency CNA transferred the resident with one assist. R21 was a full body transfer (mechanical lift for transfer). V33 said R21 was transferred with one staff member when it should have been two staff members. V33 said R21 went to the local hospital with a hematoma on her face. V33 said both of R21's eyes were bruised. On 4/24/23 at 11:37 AM, V4 (Certified Nursing Assistant/CNA) repositioned R21 in bed multiple times during incontinence care. R21 was not able to assist V4 in her repositioning. The facility's Mechanical Lift Transfers policy revised 7/28/22 shows, There will always be two staff to assist resident. One staff will control the lift as the other will guide the resident and support back and neck to transfer surface. 22499 2. On 4/24/23 at 12:51 PM, R6 stated, Last Tuesday I fell out of bed. The CNA (V19-Cerified Nursing Assistant/CNA) went to change me, and she rolled me to the right- I have MS (Multiple Sclerosis) and I am weak on my right side. V19 said to me, 'Why didn't you tell me you peed and pooped?' and she walked out of the room to go get a diaper. My legs fell off the bed, and my knees hit the ground. My arm was all wrapped up in the rail. Then the CNA (V19) came back in the room and said, 'R6 what are you doing?' and she went to get help. (V19 and V17-CNA) came back in and they decided they couldn't get me up by themselves so V19 went to get more help. I told them I can't hold on anymore, so can you please put my head on the floor. Then I let go and (V17) put her hand under my head so I wouldn't hit my head. She told them that they laid me on the floor. (V19) went and got 4 other people and they turned me around and got the sling under me and lifted me into bed. I got a bruise on my foot, a cut on left foot and right knee. My left knee hurts when they touch it. My Left hip hurts really bad and they took X-rays, but they were negative. R6's Incident Report dated 4/18/23 states, Staff called nurse to room. Resident noted on her right side on the floor near her bed. Staff reported resident was holding onto rail and they lowered her to the floor. Resident stated before she knew anything she was sliding down to the floor. Resident stated she was holding on until the girls came in. Then they lowered her to the ground. Resident noted with a small skin abrasion to her right knee. Resident began to complain of pain to her right knee. This same document states, Skin tear to right (knee) cleansed dressing applied. X-ray ordered for both knees. R6's X-ray Reports show that R6 had X-rays to right and left knee of 4/18/23 and X-rays to her left hip and right ribs on 4/19/23. All x-rays were negative of fractures. On 4/25/23 at 1:51 PM, V19 (CNA) stated, I had just finished changing someone else. I went in to check her and she didn't have a diaper on. I left to get her a diaper and when I came back her feet were falling off the bed. Her head and torso were still on the bed. Her original bed was not working- PM shift put her wrong bed -B, she is supposed to be in A. V17 (CNA) came and her and I decided we could not get her off the floor, so I ran to the back to get some help. (V17) stayed with R6. When we came back with everyone her knees were on the floor and she was lying on the floor. I do a lot of things for her- she can't move her legs. She always moves her torso to the right, and then her legs slide to the left. One of her knees got hurt- had a scab and was bleeding a little bit. Complained of pain to her knee when she was on the floor. Wanted to go to activities afterwards. On 4/25/23 at 1:41 PM, V17 (CNA) stated, I was in the process of doing a room transfer with another resident. When I was in the hallway, the other CNA yelled for me to come in here. R6's top half of her body was still in the bed; she was sliding to the right. Her knees are on the floor. R6 requested that we put her on the floor, so I put my arms under her head, and she let go of the rail. I didn't want her to hit her head. She had a skin tear on her right knee. We got the (mechanical lift) pad under her and put her back in the bed- with the help of a few other people. She was in a normal bed, not on the air mattress she is usually on. She was laying in B bed- she was in the incorrect bed. R6's Progress Notes dated 4/18/23 state, Patient was hanging from her bed with the torso on the bed and knees on the floor. Staff had to Lower resident to the floor. Staff then had to assist her to the bed. Resident has a skin tear to the left knee by 1 cm. Area cleansed dressing applied. Resident has pain to her right knee . and At 11:15 AM, Aides noted resident with her knees on the floor. Resident was holding herself up by holding the bed rail. Staff could not lift her up. Staff lowered her to the floor. Resident suffered an abrasion/skin tear to the right knee. Treatment done to right knee. X-ray done to both knees due to pain. R6's Minimum Data Set assessment dated [DATE] shows that R6 has no cognitive impairment and requires extensive assist of 2 staff for bed mobility. R6's Care Plan dated 3/10/23 states, R6 is extensive assistance of staff for repositioning and turning in bed. This Care Plan also states, R6 is at risk for falls related to . Disease Process (Multiple Sclerosis). Neither of these care plans were updated with interventions following R6's fall out of bed on 4/18/23.

Based on interview and record review, the facility failed to protect a cognitively impaired resident from sexual abuse by another resident. This failure resulted in R8 experiencing sexual abuse at the facility when R9 provided a bed bath to R8, and R8 displaying psycho-social symptoms of emotional upset when discussing the incident. R8's medical diagnosis makes assessing the effects of sexual abuse difficult. A reasonable person would not want to be bathed by another facility resident. This applies to 1 of 3 residents (R8) reviewed for resident-to-resident abuse in the sample of 9. The findings include: The facility's Abuse Report Final Form dated February 6, 2023, shows an allegation of sexual abuse occurred at the facility on January 31, 2023. The alleged victim was R8 (female resident), and the alleged perpetrator was R9 (male resident). The form continues to show, On 1/31/2023, V13 (RN-Registered Nurse) reported that R9 was seen in R8's room and R9 stated he was in her room to assist her with a bed bath. The EMR (Electronic Medical Record) shows R8 is a [AGE] year-old female resident. R8 was admitted to the facility on [DATE], with multiple diagnoses, including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, hypertension, anemia, depression, chronic respiratory failure, and cerebrovascular disease. R8's MDS (Minimum Data Set), dated December 15, 2022, shows R8 has severe cognitive impairment, requires limited assistance by one facility staff member with eating, extensive assistance with bed mobility, transfers between surfaces, dressing, and toilet use, and is totally dependent on facility staff for locomotion off the unit, personal hygiene, and bathing. R8 is always incontinent of bowel and bladder. R8's MDS continues to show R8 has a functional limitation in range of motion of her upper and lower extremities on one side of her body. The EMR shows R9 is a [AGE] year-old male resident. R9 was admitted to the facility on [DATE]. R9 went on therapeutic leave on September 22, 2022 and returned to the facility on [DATE]. R9 has multiple diagnoses including COPD (Chronic Obstructive Pulmonary Disease), opioid dependence, alcohol abuse, anxiety, seizures, and depression. R9's MDS dated [DATE], shows R9 is cognitively intact, requires physical help limited to transfer only for bathing, is independent with eating, and requires supervision with all other ADLs (Activities of Daily Living). R9 is occasionally incontinent of urine and always continent of stool. R9's Illinois State Police criminal background check, dated June 8, 2022, shows R9 has a criminal history of disorderly conduct, bad checks/obtain control of property, and attempted forgery/make/alter document. On February 1, 2023, at 12:57 PM, V1 (Administrator) said she received an allegation of sexual abuse regarding R8 and R9 on January 31, 2023. V1 said, The CNA (Certified Nursing Assistant) went into R8's room and noticed that she was unclothed, and her hair was wet. R9 gave her a bed bath. I reported it to IDPH (Illinois Department of Public Health) because R8 is not decisional. On February 1, 2023, at 2:18 PM, R8 said, R9 and I are engaged. It happened last week. We stay at the same place (resident could not name the facility). He tells me he loves me. He hugs me. On shower days we get a bed bath. He decided to clean me up and it was my shower day. He gave me a new gown. R8 was tearful while discussing the incident. On February 1, 2023, at 1:44 PM, R9 was sitting in his room. R9 said, I proposed to the girl down the hall (R8) and gave her a ring. She complained she did not get a bath. I helped wash her up. She was wearing a hospital gown and had food all over her chest. I was able to get the food off. She wears an [incontinence brief] or pull-up type of underwear. On February 1, 2023, at 2:18 PM, V16 (Certified Nursing Assistant/CNA) said, After dinner last night, R9 came to get me to tell me [R8] needed a clean brief. I noticed R8's hair was wet. She was lying in bed, covered by a blanket. I asked the other CNA (V15) if she gave R8 a bed bath, and she said no. I lifted the blanket off of R8 and she was completely naked underneath the blanket. No gown and no incontinence brief, and she was wet all over her body from head to toe. She had been washed everywhere. When I asked her why her hair was wet, she told me it was because the male resident had helped her with a bed bath. On February 1, 2023, at 4:02 PM, V1 (Administrator) said, We will be doing the investigation for the abuse allegation from last night. I asked R8 who disrobed her, and she said she did that herself. On February 2, 2023, at 10:46 AM, V11 (SSD-Social Service Director) said, I am currently working on finding placement for R9 at another facility. He said his daughter has a plane ticket for him to move to Massachusetts, and I sent two more referrals out there, but he is on the wait list. I was never aware he and R8 had a relationship. He never talked about it. He never requested to share a room with her. I have never seen him speak to other residents. He did not tell me he gave her a ring. He has never asked me to make plans to transfer his fiance (R8) with him when he leaves the facility. On February 7, 2023, at 11:43 AM, V16 (CNA) said, That night, just after dinner, R9 walked out of R8's room. R8 was wet everywhere. R8 said, My husband gave me a bath. I was assigned to R8 that night. I worked from 3:00 PM to 7:00 AM the next morning. It was not her night to receive a shower. R8 cannot remove her own clothes or her incontinence brief by herself. Her left arm does not work, and her left leg does not work. She is not able to cover herself with a blanket. She is able to feed herself with her right hand, but she will make a mess. When I saw her naked and all wet in the bed, I asked her who gave her a bath, and she said R9 gave her a bath. R8 was wet on her breasts, her genital area, and from her head down to her toes. I never removed her clothes that evening, and I did not give her a bed bath. No one ever told me the two residents were married or engaged. On February 7, 2023, at 12:10 PM, V14 (RN) said, I regularly care for R9. No one has ever told me he and R8 were engaged or married. That night (1/31/2023), he started saying that she was his wife and then later, he said she was his fiance. I told him he was not allowed to go in R8's room. He said he was just trying to help her, and then he started swearing and went in the room and threw a garbage bag at a CNA in the other hallway. On February 7, 2023, at 12:20 PM, V13 (RN) said, I was taking care of R8 that night (1/31/2023). The CNA came and told me the resident received a bed bath from a resident. I was passing medication, and the CNA came up to my cart and said the patient was naked. R8 said, I just received a bed bath by R9. She had a stroke, and she is unable to move her left side and is not able to remove her clothes by herself. I did not remove her clothes or give her a bed bath that night. After the bed bath situation, she said they were engaged. On February 7, 2023, at 1:48 PM, V19 (CNA) said, I was not taking care of R8 that night. I was at the nurse's station. I was doing my charting. V16 asked me to follow her into R8's room. R8 was lying in the bed completely naked. The bedding was wet. The resident used her right arm to cover her breasts, and her left arm was lying on top of her body, with her left hand resting on her genital area. The resident was not able to move her left hand or arm. R8 said R9 cleaned her up. There was a disposable razor on the table. The resident had a small cut on her hip between her waist and her hip. She kept rubbing it. R9 came into the room and I asked him why would he give a bath to a resident? He said he shaved her legs. When I finished dressing her, she showed me a ring on her right hand and said he proposed to her. I was never aware they had any type of relationship going on. This resident cannot remove her own clothes by herself. She is fully dependent. None of us were aware there was any type of relationship between these two residents at the time. On February 7, 2023, at 1:25 PM, R8 was lying in her bed. R8 had a brace on her left forearm. R8 said, I had a stroke, and I am completely paralyzed on my left side. R8 was wearing a long-sleeved shirt and elastic waist pants. R8's shirt had a dried, white substance in the middle of her chest area. R8 said she spilled yogurt on her shirt, and she was unable to change her shirt by herself. V16 (CNA) came to R8's room to provide incontinence care to the resident. V16 asked R8 to try to remove her pants without assistance. R8 was unable to move her left arm or leg and used her right arm to attempt to remove her pants. R8 tried for approximately five minutes to remove her pants, without staff assistance, but was unable to do so. V16 assisted R8 to remove her pants and then asked R8 to remove her soiled incontinence brief. R8 was able to unfasten the tabs of the incontinence brief from her right hip area but was unable to unfasten the tabs securing the left side of the brief. V16 continued to encourage R8 to remove the incontinence brief, but R8 was unable to remove the brief without assistance, stating, I cannot do it. V16 encouraged R8 to remove her long-sleeved shirt without assistance. R8 was unable to remove the shirt. V16 assisted with removing R8's shirt. V16 provided a hospital gown for R8 to wear. R8 was unable to put the hospital gown on without assistance. V16 then asked R8 to reach the top sheet on the bed and cover herself with the sheet. R8 was unable to sit up and bend at the waist to reach the top sheet. R8 used her right foot to bring the top sheet closer to herself but was unable to reach the top sheet and cover herself completely without the staff assisting her. R8 said, On the evening R9 gave me the bed bath (1/31/2023), R9 covered my body with the sheet. On February 2, 2023, at 11:00 AM, V17 (Nurse Practitioner/NP) documented she did a head-to-toe assessment on R8 on February 1, 2023, at 12:00 PM, following the allegation of sexual abuse on January 31, 2023. V17's examination included a vaginal exam. V17 documented, Vaginal area with no erythema, bruising present . On December 30, 2022, V18 (Psychiatrist) documented the following regarding R8: Mental Status Examination: Orientation: Alert and oriented to self only. Patient is not oriented to specific day, date, or location. Speech: Dysarthric. Volume: Normal. Rate: Normal but sparse. Thought Process: Confabulatory with expressive word finding deficits. Insight: Poor. Patient cannot describe the patient's current conditions or treatments. Judgment: Poor. Patient is unable to describe what to do with a stamped addressed envelope. Recent Memory: Patient cannot describe how the patient came about to be at [the facility] or what she did this morning. Intellectual Capacity: Impaired. Patient has cognitive impairments with deficits in memory, orientation, calculation, and language, and is unable to care for self. On February 3, 2023, V18 (Psychiatrist) documented the following regarding R8: Mental Status Examination: Orientation: Alert and oriented to self only. Patient is not oriented to specific day, date, or location. Speech: Dysarthric. Volume: Normal. Rate: Normal but sparse. Thought Process: Confabulatory with expressive word finding deficits. Insight: Poor. Patient cannot describe the patient's current conditions or treatments. Judgment: Poor. Patient is unable to describe what to do with unpaid bills. Recent Memory: Patient cannot describe how the patient came about to be at [the facility] or what she ate yesterday. Intellectual Capacity: Impaired. Patient has cognitive impairments with deficits in memory, orientation, calculation, and language, and is unable to care for self. On February 1, 2023, at 4:13 PM, V18 (Psychiatrist) said that R8 has been under his care, and he is familiar with the resident. V18 continued to say, In general, R8 has cognitive impairments, and she would need a family member or POA (Power of Attorney) to make important decisions for her. She has cognitive impairment, and we do not want anyone to take advantage of her. In general, she is not capable of making decisions on her own. I do not think she is capable of making decisions on her own. On February 7, 2023, at 4:15 PM, V1 (Administrator) said, R8 and R9 are not married, and the facility does not allow non-married residents to reside in the same room. V1 continued to say male residents are not allowed to provide bed baths to female residents. The facility's Abuse and Neglect policy, effective 10/24/22 shows: 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. These guidelines include compliance with the seven (7) federal components of prevention and investigation.5. Sexual: Sexual abuse is defined as non-consensual sexual contact of any type with a resident. Even if there is capacity to give consent, consent obtained through intimidation, coercion, or fear is considered sexual abuse .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 unsecured catheter tubing from causing a pressure injury. This failure resulted in a Stage 3 pressure wound/injury for 1 of 3 residents (R97) reviewed for pressure ulcers. Findings include: Physician order [REDACTED]. On 2/13/18, 2/14/18 and 2/15/18 R97 was observed with an intact indwelling urinary catheter. Wound assessment dated [DATE] indicates R97 was identified with a facility acquired Moisture Associated Skin Damage (MASD) due to incontinence pelvic region/right buttock. Assessment Note indicates Noted MASD on right buttock due to incontinence as evidenced by partial thickness skin loss with redness and skin irritation around periwound to perianal area. Quarterly MDS (Minimum Data Set) dated 1/11/18 Section H/Bowel and Bladder indicates R97 uses an indwelling urinary catheter and is frequently incontinent of bowel. On 2/15/18 at 2:16pm R97 was transferred to bed from a wheelchair and assisted with bowel incontinence by V4, CNA (Certified Nursing Assistant). Upon inspection, R97 was found to have diffuse, scattered widespread reddened open areas across lower buttocks and groin, linear demarcation of catheter tubing across right ischium, lower buttock - dark red/purple. Entire perineum, ischium and lower buttocks appeared raw. R97's left ischium was also noted with recent indentation and demarcation of catheter tubing. V3, LPN (Licensed Practical Nurse/Wound Care Nurse) stated The area is worse than when seen last week. Looks like the wound is from mechanical trauma from the catheter tubing. At that time, V11 (CNA Preceptor) stated R97 should have a catheter legstrap to keep (R97) from sitting on the catheter tubing. R97 did not have catheter tubing securement device in place and tubing was noted to be exactly consistent in size to wound. Physician order [REDACTED]. Urinary Catheter Care Plan (effective 10/12/17) indicates staff are to ensure that indwelling catheter securement device is in place. Wound assessment dated [DATE] at 3:27pm indicates R97 with right buttock wound from catheter. Note indicates wound classified as a Stage 3 pressure wound - full thickness due to Medical Device Related Injury. Note indicates Tissue 40% Non-Granulating, 60% Slough with small amount of serous exudate and reddened surrounding tissue. Note indicates Upon assessment, noted trauma wound right buttock with excoriation, redness and skin irritation around periwound and perianal. Note indicated wound measured 2.50cm and 0.40cm. Clinical Notes Report 2/15/18 at 4:28pm indicates a pressure wound was found on R97's right buttock today. On 2/16/18 at 9:30am V3, LPN stated that R97 is High Risk for pressure ulcers and skin was already weakened in area that trauma occured. V3 stated nurses who are doing daily skin treatments should notify Wound Care if the wound or skin changes or declines. Braden Scale For Predicting Pressure Sore Risk dated 1/11/18 indicates R97 at High Risk. Physician order [REDACTED]. No documentation was found or presented to indicate R97's wound was identified prior to surveyor request to assess skin on 2/16/18 and staff that were providing care every shift did not report skin changes. Facility Guidance (undated) indicates: Staff must ensure (urinary) catheter tubing is secured with proper device. Anytime a resident is positioned in his wheelchair, bed, etc. tubing must be checked to ensure it is tension free and resident is not laying on the tubing. This is to help prevent catheter from becoming dislodged and pressure injuries. Facility Policy/Skin Management dated 8/10 indicates: Head to toe observation of the resident's skin will be conducted on admission, readmission, weekly and during care.

Based on interview and record review the facility failed to ensure a heating pad was placed in a manner and according to policy to prevent a second degree burn. This applies to 1 of 3 (R1) residents reviewed for accidents and supervision. This failure resulted in R1 obtaining a second degree burn and pain to the left shoulder and a smaller blistered area to the right shoulder. The findings include: R1 has a medical history of [REDACTED]. R1's MDS (Minimum Data set) July 27,2016 documents R1 to have a BIMS (Brief interview for Mental Status) score of 15 out of 15. This indicates R1 is cognitively intact and interviewable. On 7/28/16 the therapy room was observed to have a large container with hot water that housed multiple large hot packs. The water temp was checked and shown to be 163.7 degrees using the facility thermometer. R1 stated she had therapy on July 22,2016 with Z2 (COTA, certified occupational therapist assistant). R1 stated after therapy she received a hot pack for her shoulder and neck pain. R1 stated it was placed on her neck and shoulder area and Z2 had remained in the department but not right with her. R1 stated after approximately 20 minutes the hot pack was removed and R1 was taken to her room. R1 ststed no one checked her skin on her neck and shoulders when the hot pack was removed. or any time during the treatment. R1 stated the therapists never do that. They just remove it and that's it. R1 also stated she did not have pain with the hot pack but always has pain in her shoulder. On July 28,2016 at 10:25 AM, Z2 stated R1 was in therapy at approximately 2:00 PM on July 22, 2016. Z2 stated it was her first time working with R1. Z2 sated R1 requested a hot pack after therapy. Z2 demonstrated how the hot pack was placed. Z2 placed the hot pack in the holder, which is made out of a thin towel type of material. The holder has a pouch that the heating pack goes into and then the top is folded over. The heating pack is large enough to fit around the neck a nd both shoulders. Z2 then took a towel and folded it over once and stated she put that between R1 and the heating pack. Z2 stated the Velcro tabs to secure the hot pack were not placed and R1 sat in the wheel chair holding the hot pack on each end over her shoulders. Z2 stated maybe the hot pack slipped out of the holder. Z2 stated she checked R1's neck after and it was light pink in color. R1's shoulders were not checked. The areas were also not checked during the treatment. On July 28,2016 at 11:35 AM, Z1 (Physician) stated R1's history of polyneuropathy and age would increase her risk of a burn without sensing the pain. The Rehab policy dated July 3, 2012 and titled Hydrocollator Packs documents the Hydrocollator packs contain inert silica gel which absorbs and holds large quantities of water. The heat is released slowly over 30 minutes. The contraindications are documented as peripheral vascular disease and patients with impaired sensation. The precautions are listed state to take caution with elderly residents they may need more toweling due to fragile skin and scar tissue as it may be more sensitive than normal skin. The utilization section of the policy documents: 3. Inspection of the body part to be treated must be performed and checked for sensation to light touch, hot and cold and presence of scars or burns. R1 has a large scar directly next to the blistered area. 4. Appropriate layers of toweling (at least 6 layers of towels)with 2-3 hot pack covers on top of each other. Z2 demonstrated only one towel folded over. 7. Make sure the pack is secure and the patients position is correct. Do no leave the resident unattended. check the skin after the first 5 minutes to ensure it is not to hot and to adjust the number of towels as needed. These interventions on the policy were not followed as well as the consideration of R1's polyneuropathy as a risk factor for burns and decreased sensation. R1 also has a large visible scar right next to the blistered area. On July 28, 2016 at 10:15 AM, Z3 (Therapy department manager) stated multiple towels should be used between the hot pack and the resident. Z3 also provided Z2's competency record showing Z2 was competent with use of hot packs in 2012 upon hire . No inservice since that time.

Based on interview, observation and record review, the facility failed to properly implement fall prevention interventions for 1 of 4 residents (R1-R4) reviewed for falls. The resident (R1) suffered two falls with fractures within a two month span of time;a fractured wrist 2/21/14 and a fractured hip 4/20/14. Findings include: R1 a 93 yo resident, was admitted to the facility 12/28/11. Documentation available shows R1 to be alert and oriented with moderately impaired cognition. R 1 did not have a history of falls prior to the fall she suffered in February. E2 (DON) said that R1 had gone out on 2/21/14 with the activity department for lunch. R1 was in a wheelchair and rode on the bus to the destination. On arrival, R1 was taken off the bus by wheelchair and was being wheeled into the restaurant by E4 an activity aide who is also a trained CNA. E4 was interviewed and said that as she was pushing R1 up to the door in the chair R 1 suddenly got startled by the "sound of the concrete" and leaned forward. R1 was in a highback wheelchair and E2 was not able to reach down and stop her fall. She said that R1 had been on outings before and was always calm and had not ever acted like this before. She (E4), said she immediately called the facility who had them return R1 to the facility for evaluation. After return to the facility it was observed that R1's R hand was swollen. It was elevated on a pillow and the doctor notified. An X-ray was ordered and showed a "minimally displaced distal radial fracture." E4 was asked if there were footrests on the wheelchair at the time of her fall and she stated that there were not any on at that time. E4 said that in the facility R1 would peddle herself around the facility, so she did not have them on there. Even though R1 was being taken out and would be transported by someone else at the location, no footrests had been placed on the chair for the trip. Review of staff inservices dated 8/21/13, show that the policy of the facility was discussed concerning foot and leg rests. The information discussed was that :"All patients or residents who use a wheelchair must have a legrest/ footrest unless otherwise specified in their careplan." There is no evidence that this exclusion was present for R1, especially when being taken outside the facility. E4 said that R1 had put her feet down on the pavement while she was pushing her which caused R1 to fall forward. After this incident, R1 is documented in the nursing notes as needing extensive assist with transfers and toileting. The MDS dated [DATE] that was done for a significant change in condition scored R1 as 3/3 for toileting needs. This translates to extensive assist by two persons. On 4/10/14, R1 had her cast removed by the orthopedic doctor and replaced by a splint. In the next week between 4/17/14 and 4/19, R1 showed signs of a GI problem that E2 (DON) said caused loose stools, nausea and vomiting. E2 said that this resulted in R1 being weaker than ususal. On 4/20/14, E7 (CNA) assisted R1 to the bathroom by herself. According to E2, the facility investigation documented that E7 claims that while she was changing the incontinence garment of R1, R1 was holding the grab bar. R1's knees buckled and she (E7) assisted R1 to the floor. This fall resulted in R1 suffering a fracture to the R hip. One of the first people to respond to E7's calls for help was the shift nurse, E6. E6 was interviewed as to what he saw when responding to the room. E6 said that he saw E7 behind R1 supporting her back. He recalled R1's legs being straight out in front of her. E6 claimed he did ROM on R1 and did not notice any problem. E6 said once placed back in bed, R1 expressed pain to the R hip area and X-ray was done that confirmed an intertrochanteric hip fracture. Surgery was required to repair the fracture. E7 failed to use two person assist with toileting as identified by MDS of 3/27/14. R1 was interviewed on 5/1/14 about her injuries. She was alert and verbal but unable to relate what had occurred with either incident. R1 was in bed with a splint to the R wrist and an abductor pillow between her knees. She was not aware of the purpose of either device.

Based on observations, interviews and record review the facility failed to transfer one resident (R2) out 3 residents reviewed for transfers with a two person transfer and as a result, R2 suffered a fracture to the left knee after an improper transfer. The facility also failed to transfer R6 from wheel chair to the toilet with a two person assist as per the MDS (Minimum Data Set) from a total sample of 6. Findings include the following: 1. R2 ' s physician's orders [REDACTED]. R2's care plan dated 8/30/2013 indicates R2 requires extensive assistance and two people for transfers. R2's fall risk assessment done on 8/30/2013 shows R2 score 21 (High Risk) for falls. E2 (Director of Nursing) stated during interview of 1-22-14 at 10:55am that R2 fell on [DATE]. According to E2, R2 fell while being transferred by one staff person from bed to wheel chair. E4 (Nurse Aid) was terminated from the facility after the incident since E4 admitted to E2 that she had transferred R2 by herself with no assistance. E2 stated during the interview that E4 had verbalized that she knew that R2 needed a two person transfer. E3 (Nurse Manager) stated on 1-22-14 at 10:15am that R2 was, "extensive assist times two person with a gait belt." E3 also stated that R2's injury occurred because of a one person transfer. R2 ' s care plan dated 8-30-13 documents that R2 is extensive assistance with 2 person transfer. Facility policy titled, " Transfer, Ambulation and Re-positioning (TARP) " revised 2-10 documents the following, " 3. Transfer status will be based on the number of staff needed to perform the task and or if a mechanical lift, slide board or other adaptive equipment is required as required. This information is recorded on the care giver alert and medical record. " On 1/22/2013 at 10:55AM, E2 (DON) Director of Nursing states that on or about 9/5/2013 (the date R2 fell ) E4 (CNA) Certified Nurse Assistant was attempting to transfer R2 by herself from her bed to her wheelchair when R2 slid off the bed and was lowered to the floor. E2 also states that E4 was hired on 8/7/13 and was subsequently terminated from facility on 9/13/2014 following this incident. On 1/22/2014 at 10:15AM, E3 (Nurse Manager) states, R2 required extensive assist with 2 people to transfer. R2 was sent out to the hospital on [DATE] and a CT (Cat Scan) was done and showed R2 had a fracture to the left knee. 2. R6 admitted on [DATE] with [DIAGNOSES REDACTED]. R6's Care assessment indicates R6 requires 2 persons to transfer. R6 has 27 staples to right hip. R6 observed on 1/21/2014 at 4:00PM, E5 (CNA) Certified Nurse Assistant and E6 (CNA) Certified Nurse Assistant transferred R6 from bed to wheelchair. E6 stayed outside the bathroom while E5 assist R6 from wheelchair to the toilet. 1/21/2014 at 4:00PM E5 states that R6 requires two people to transfer as stated on the care alert sheet posted on her closet door. 3. R5 ' s most recent MDS dated [DATE] documents that R5 has multiple [DIAGNOSES REDACTED]. R5 is alert and oriented. R5's MDS indicates that R5 score 14/15 on BIMS (Brief Interview for Mental Status) R5 also requires extensive assist and 2 persons to transfer. On 1/21/2013 at 4:24PM, R5 states that only 1 person gets her in and out of bed.

Based on observation, interview and record review, the facility failed to address R 4 ' s risk factors in developing two areas of facility acquired pressure ulcers. Develop and consistently implement interventions specific to the needs of R 4 in order to promote healing. This applies to three (R4, R 14, and R 11) of three residents reviewed for pressure ulcer development in the sample of twenty four residents. Findings include: Review of R 4 ' s nurses notes dated 02-26-13 reads: resident was noted with Stage II pressure ulcer on the left and on the right sacrum. Is incontinent of bowel and bladder, requires total assist with Activities of Daily Living, toileting and transfer . On 02-28-13 at 3:00 PM, the Treatment Nurse (E3) stated on 02-26-13 during incontinence care, the CNA noted a skin opening one on his left and one on the right sacrum both a Stage II ' s. The wound assessment details report dated 02-26-13, (1) the left sacrum was measured at 2.0 cm X 1.0 cm- Stage II and (2) right lower sacrum measured at 1.5 cm X 1.0 cm- Stage II. Review of R 4 ' s clinical record showed no comprehensive assessment that was done for R 4. On 02-28-13 at 3:00 PM, E3 confirmed and stated what we use is the wound assessment where we document the measurement, site and description of the wound, the nurse ' s notes were we document that we call the family and the doctor and we also use the Braden scale. We don ' t really assess the cause and how the sores develop. That ' s all we have as for pressure ulcer documentation. For him we didn ' t analyze if these pressure ulcers are avoidable or unavoidable. R 4 ' s left and right sacrum pressure ulcer care plan was not individualize and specific to the problem identified. R 4 ' s approach includes: elevate heels off of bed, provide medications as ordered and bilateral heel protectors . When this finding was discussed with 02-28-13 at 3:00 PM, E 3 stated we have a template - a computerize program.

Based on observations, interviews, and record reviews, the facility failed to ensure that one resident (R14), who has impaired cognitive status, weak physical condition and at risk for falls, received the appropriate safety measures (assistance of two staff members), while being transferred. This failure resulted in the resident having an avoidable accident, sustaining a right ankle fracture, and requiring medical treatment. This failure applies for 1 out of 10 residents reviewed because of their fall occurrence. Findings included: Review of R14 ' s Admission Face Sheet documented that R14 is a [AGE] year old female, who was original admitted to the facility on [DATE]. R14 has [DIAGNOSES REDACTED]. Review of R14 ' s Fall Risk Assessment, dated 11/23/2012 and 2/20/2013 documented R14 as assessed for being at risk for falls. Review of R14 ' s MDS (Minimum Data Set) Assessment, dated 11/27/2012, documented that R14 required extensive assistance from 2 staff member to transfer. Review of R14 ' s plan of care documented that she (R14) required the extensive assistance form 2 staff members. R14 ' s had a Resident/Patient Transfer Status Form , dated 11/23/2012, which documented the following instruction for staff: Assist of 2 (staff members) . Review of the facility ' s Incident Report documented the following for R14: R14 requires extensive staff assistance x 2 for all transfers. On 1/23/2012 resident ' s right ankle was noted to be swollen with discoloration . The X-ray result showed a spiral fracture involving the distal tibial diaphysis with modest displacement, joint . When R14 was interviewed she stated her leg may twisted upon transfer but later she stated her leg may have caught in the leg rest. When the CNA (certified nurses aide identified as E8) who was assigned to care for the resident on January 23, 2013 morning shift was interviewed she stated that she did transfer the resident by herself . Injury may have occurred during the transfer . Review of the facility ' s policy on Transfer, Ambulation and Re-Positioning documented the following: Procedure . Transfer status will be based on the number of staff needed to perform the task . This information is recorded on the Care Giver Alert and in the medical record. When R14 was transferred on 1/24/2013, the CNA did not transfer R14 with the number of staff identified in R14 ' s medical record. On 2/28/2013 at 9:40 AM, R14 was observed and interviewed in her room. R14 was alert to self and place. R14 ' s right foot was swollen and she was wearing a splint. The treatment nurse (E3) was present. E3 stated that R14 had a spiral ankle fracture, which caused her pain. E4 is the hospice nurse working with R14, and she (E4) was interviewed on 2/27/2013 at 11:33 PM. E4 said, It was the hospice CNA who discovered R14 ' s leg red and swollen, and was later found to be broken. After R14's fractured ankle, E4 stated that she (R14) required 2 weeks of bed rest, and treatment with round the clock doses of Narco to control her pain. The nursing manager (E5), who conducted R14 ' s 1/24/2013 investigation, was interviewed on 2/28/2013 at 1:33 PM. E5 said that her investigation found that E8 (CNA) transferred R14 on 1/24/2013 using only one person. E5 stated that R14 required assistance from 2 person/staff member. E5 said R14's accident may not have happened, if E8 transferred R14 using 2 people. E8 was interviewed on 3/01/2013 at 2 PM. E8 stated she transferred R14 without any assistance on 1/24/2013. E8 said she did not review the transferred requirements on R14 ' s Care Alert Card, which is maintain in R14's closet. E8 did not follow the safety measure based on her (R14 ' s) assessments as documented in her Care Alert and medical record.

Based on observation, interview and record review, the facility failed to address R 4 ' s risk factors in developing two areas of facility acquired pressure ulcers. Develop and consistently implement interventions specific to the needs of R 4 in order to promote healing. This applies to three (R4, R 14, and R 11) of three residents reviewed for pressure ulcer development in the sample of twenty four residents. Findings include: Review of R 4 ' s nurses notes dated 02-26-13 reads: resident was noted with Stage II pressure ulcer on the left and on the right sacrum. Is incontinent of bowel and bladder, requires total assist with Activities of Daily Living, toileting and transfer ... On 02-28-13 at 3:00 PM, the Treatment Nurse (E3) stated " on 02-26-13 during incontinence care, the CNA noted a skin opening one on his left and one on the right sacrum both a Stage II ' s. " The wound assessment details report dated 02-26-13, (1) the left sacrum was measured at 2.0 cm X 1.0 cm- Stage II and (2) right lower sacrum measured at 1.5 cm X 1.0 cm- Stage II. Review of R 4 ' s clinical record showed no comprehensive assessment that was done for R 4. On 02-28-13 at 3:00 PM, E3 confirmed and stated " what we use is the wound assessment where we document the measurement, site and description of the wound, the nurse ' s notes were we document that we call the family and the doctor and we also use the Braden scale. We don ' t really assess the cause and how the sores develop. That ' s all we have as for pressure ulcer documentation. For him we didn ' t analyze if these pressure ulcers are avoidable or unavoidable. " R 4 ' s left and right sacrum pressure ulcer care plan was not individualize and specific to the problem identified. R 4 ' s approach includes: elevate heels off of bed, provide medications as ordered and bilateral heel protectors ... When this finding was discussed with 02-28-13 at 3:00 PM, E 3 stated " we have a template - a computerize program. "

Based on observations, interviews, and record reviews, the facility failed to ensure that one resident (R14), who has impaired cognitive status, weak physical condition and at risk for falls, received the appropriate safety measures (assistance of two staff members), while being transferred. This failure resulted in the resident having an avoidable accident, sustaining a right ankle fracture, and requiring medical treatment. This failure applies for 1 out of 10 residents reviewed because of their fall occurrence. Findings included: Review of R14 ' s Admission Face Sheet documented that R14 is a [AGE] year old female, who was original admitted to the facility on [DATE]. R14 has [DIAGNOSES REDACTED]. Review of R14 ' s Fall Risk Assessment, dated 11/23/2012 and 2/20/2013 documented R14 as assessed for being at risk for falls. Review of R14 ' s MDS (Minimum Data Set) Assessment, dated 11/27/2012, documented that R14 required extensive assistance from 2 staff member to transfer. Review of R14 ' s plan of care documented that she (R14) required the extensive assistance form 2 staff members. R14 ' s had a " Resident/Patient Transfer Status Form " , dated 11/23/2012, which documented the following instruction for staff: " Assist of 2 (staff members) " . Review of the facility ' s Incident Report documented the following for R14: " R14 requires extensive staff assistance x 2 for all transfers. On 1/23/2012 resident ' s right ankle was noted to be swollen with discoloration ... The X-ray result showed a spiral fracture involving the distal tibial diaphysis with modest displacement, joint ... When R14 was interviewed she stated her leg may twisted upon transfer but later she stated her leg may have caught in the leg rest. When the CNA (certified nurses aide identified as E8) who was assigned to care for the resident on January 23, 2013 morning shift was interviewed she stated that she did transfer the resident by herself ... Injury may have occurred during the transfer ... " Review of the facility ' s policy on Transfer, Ambulation and Re-Positioning documented the following: " Procedure ... Transfer status will be based on the number of staff needed to perform the task ... This information is recorded on the Care Giver Alert and in the medical record. When R14 was transferred on 1/24/2013, the CNA did not transfer R14 with the number of staff identified in R14 ' s medical record. " On 2/28/2013 at 9:40 AM, R14 was observed and interviewed in her room. R14 was alert to self and place. R14 ' s right foot was swollen and she was wearing a splint. The treatment nurse (E3) was present. E3 stated that R14 had a spiral ankle fracture, which caused her pain. E4 is the hospice nurse working with R14, and she (E4) was interviewed on 2/27/2013 at 11:33 PM. E4 said, " It was the hospice CNA who discovered R14 ' s leg red and swollen, and was later found to be broken. " After R14's fractured ankle, E4 stated that she (R14) required 2 weeks of bed rest, and treatment with "round the clock " doses of Narco to control her pain. The nursing manager (E5), who conducted R14 ' s 1/24/2013 investigation, was interviewed on 2/28/2013 at 1:33 PM. E5 said that her investigation found that E8 (CNA) transferred R14 on 1/24/2013 using only one person. E5 stated that R14 required assistance from 2 person/staff member. E5 said R14's accident may not have happened, if E8 transferred R14 using 2 people. E8 was interviewed on 3/01/2013 at 2 PM. E8 stated she transferred R14 without any assistance on 1/24/2013. E8 said she did not review the transferred requirements on R14 ' s Care Alert Card, which is maintain in R14's closet. E8 did not follow the safety measure based on her (R14 ' s) assessments as documented in her Care Alert and medical record.

Based on observation, record review and interview the facility failed to: - Ensure that the call light was readily accessible, - Develop and implement individualized and specific interventions to monitor R15 to prevent falls. As a result: R15 fell on [DATE] at 10:25 PM from his bed to the floor when reaching for his television remote control. On 9/6/11 at the hospital it was determined that R15 sustained a non-displaced left ankle fracture. This is for one resident (R15) in the sample of 24 residents who are at risk for falling. Findings include: On 1/19/12 at 10:30 am R15 was seated in his adult high back chair stationed in his room, he leaned to his left side watching TV. R 15 was alert, but could not recall what happened on 8/24/11, but was able to say he had severe pain for a long time. R15 could not explain where his nurse call cord was. R15's nurse call cord was on the floor between his chair and bed. On 1/20/12 at 10:45 am R15 was seated in his high back chair, he had dark eye glasses, was alert when called his name. R 15 had no nurse call cord accessible, he did not know what happened to it. The call cord was between the wall and head board of his bed. E3 (Assistant Director of Nurses) verified the observation. E3 also verified the nurse call cord was not accessible to his room mate who was lying in his bed; his call cord was also behind his head board. E 3 said she will speak to direct care staff about keeping the call light available all the time. E 3 confirmed that R15 is capable of using nurse call light. R15's 8/24/11 at 10:25 PM it was noted in the nurses notes indicating staff found him on the floor beneath the bed lying on his right side. R 15 holding the battery cover of the TV remote at the right. R 15 complained of pain on his back and right hip. The facility sent R 15 to Hospital at 11:00 PM and he returned back to the facility on [DATE] 4:15 am. After R 15 had fallen on 8/24/11 the following entries were made in his nurses notes: On 8/26/11 R15 moving around more than usual, when asked is he in pain, he moaned and had facial grimacing; receive acetaminophen with hydrocodone 5-325 mg for pain in addition to a regular dose of acetaminophen 325 mg three times daily. R 15 continued to receive acetaminophen with hydrocodone 5-325 mg for pain on 9/2/11, 9/4/11, 9/5/11 and 9/6/11. R 15 continued to receive acetaminophen 325 mg three times daily and acetaminophen with hydrocodone 5-325 mg from from 8/25/11 to 9/5/11. R15 on 9/5/11 at 8:00 PM complained of left ankle pain to family members. R15's family requested to do X-Ray of left ankle. R 15 received acetaminophen with hydrocodone 5-325 mg for pain. On 9/6/11 the staff made a late entry to reflect R15's left ankle which indicated 'R 15 complained of left ankle pain, ankle found to be swollen, facial grimacing noted. On 9/6/11 10:30 am X-Ray of R15's left ankle was done, which indicated he sustained a non-displaced fracture of left distal tibia and fibula. On 9/8/11 a short cast was placed on his left foot. On 1/20/12 at 10:45 am E3 stated during her investigation of the incident the nurse stated that she did not conduct assessment of R15's left foot because he did not complain of pain. E 3 stated the nurse should have conducted a complete assessment of R15 when has complained on pain after he returned from the hospital. The facility documented an incident on 8/24/11 to indicate R15 had had fallen, sent to the hospital. R15's 8/24/11 investigation noted he stated to his sister to indicate the TV remote control flipped when attempted to reach it. On 9/6/11 after it was diagnosed R15 sustained left ankle non-displaced fracture, the investigation report indicated the fracture was related to his falling on 8/24/11. R15's 7/26/11 Resident Assessment Protocol (RAP) summary noted he is at risk of falling due to impaired mobility, decreased safety awareness and use of psychotropic medication and care plan to have interventions to prevent fall. R15's plan of care interventions for falls prior to his falling on 8/24/11 is not specific or individualized to his risk factors (mobility, decreased safety awareness and use of psychotropic medications) identified in his 7/26/11 RAPs. The examples are: (a) frequently used items are within reach at all time; (b) keep call light within reach at all times and answer promptly. These interventions are not implemented on 1/19/12 and 1/20/12. The facility failed to implement specific and individualized interventions and monitor R 15 to prevent from falling. As a result R 15 sustained a preventable non-displaced left ankle fracture.

Based on observation, interview and record review the facility failed to monitor, maintain and update their infection control program which led to systemic failures . Infection control applies to all residents at risk for potential spread of blood borne infections. E 2 identified on 02-16-11 that almost all residents in the facility are immunocompromised, 34 residents were identified with diabetes,32 residents on blood sugar monitoring, 10 on hospice care, 2 receiving intravenous therapy, 8 on respiratory therapy & 20 residents with health care associated infections (acquired), 5 with clostridium difficile , 8 with urine infection. Facility failed to: (1) implement & maintain infection control measure to prevent a 2nd norovirus outbreak. The facility had 2 norovirus outbreaks (a) on 01-12-11, 58 residents were affected & (b) on 02-09-11 with 9 residents affected with the virus. (2 ) Show that the data from the facility precaution/infection report log was analyzed & the origin of the infection was determined. (3) Develop, implement & maintain infection program in order to recognize, prevent & control the onset & spread of infection. (4) Prevent & control outbreaks using transmission based precaution in addition to standard precaution. (5) Establish & compare trends & pattern of health care associated infections. (6) Analyze the justification for the use of antibiotic therapy. (7) Wash hands before & after performing finger stick blood sampling for R 11 & to R 1 who was in isolation precaution for ESBL (Extended Spectrum Beta Lactimase). (8) Implement hand hygiene practices consistent with the standard of practice for R 11, R 1 & R 66. (9) Properly dispose biohazard materials such as lancets, blood glucose strips, bloody alcohol wipes & contaminated PPE ' s (personal protective equipment) for R 11, R1 & R 66. (10) Have a policy & procedure for effective cleaning & disinfecting the glucometer machine before & after use. (11) Provide a dedicated medical equipment (glucometer machine) to be use for residents on isolation precaution for 5 of 24 sampled residents R1, R3, R12, R11,and R25 and three supplemental residents R66, R104, and R156. (12) ensure new employees receive the Mantoux test within ten days of employment and repeated 21 days following the first test. If positive, the employee must follow up with a chest x ray for 5 of 11 newly hired staff E32, E33, E34, E35 and E36. These failures resulted in an immediate Jeopardy, E 1(Administrator) & E 2 (DON) was identified on 02-16-11 at 5:00 PM. While the immediate Jeopardy was removed on 02-17-11,at 12:00p.m. The facility remains out of compliance at a severity level 2. Additional time is needed to monitor & evaluate the effectiveness of the facility revised infection control program. Findings include: (1) Review of the influenza binder & interview with the Administrator on 02-14-11 showed that the facility has 2 outbreaks of norovirus. The report sent to the Department reads: during the period of 01-02-11 - 01-10-11, the facility experienced 58 cases of residents with gastro intestinal symptoms- most often diarrhea & vomiting. On 02-16-11 at 11:00 AM the Director of Nursing/Infection Preventionist (E2) claimed " I remember there was a visitor, can ' t remember who, the nurses said she (visitor) has a stomach flu & when she comes in the facility she always uses the bathroom, you know norovirus is airborne. We asked her to be careful and wash her hands after bathroom use. " Review of the facility surveillance log for the 1st outbreak showed that the first resident (R 152) showed symptoms of (abdominal) cramping, stomach pain, chills & diarrhea on 12-31-10 followed by R 18 on 01-01-11 with fatigue, dizziness, vomiting, headache, muscle pain, light diarrhea then # of residents with same symptoms increased in daily basis until 01-10-11 with 58 documented cases. On 02-09-11 a second norovirus outbreak was identified involving 9 residents, 2 (R104 & R 3) of which were sent to the emergency room for evaluation& treatment. From 01-06-11 thru 01-09-11 there were 17 facility staffs identified with symptoms of diarrhea, nausea, and vomiting & stomach pain. There were no documentation provided which department they ' re from and how long the symptoms lasted & if they continued to work with the symptoms or when they return back to work. On 02-16-11 at 11:00 AM E2 claimed " I ' m not sure about the staff. " Review of the facility investigation report/log failed to show evidence that the facility evaluated where in the facility the illness was occurring. The final report submitted to the Department showed that the Medical Director ordered 2 residents for blood work & stool for virus testing which came positive. Interview with the Medical Director (E40) on 02-17-11 at 12:15 PM, E 40 stated " we could not identify the cause, it could be a lot of reasons, we don ' t know! I wish I could give you an answer. " ( 2 ) On 02-14-11 at 7:25 AM, during the medication pass observation with the Nurse (E 26), E 26 was observed to wipe the glucometer (blood sugar) machine with alcohol pad then inserted the strip, wore a pair of gloves, went to R 11 ' s room & proceeded with the procedure. E 26 was not observed to wash hands prior to procedure. E 26 was observed pricking R 11 ' s finger with a lancet, dab a small amount of blood on the strips, wiped off R 11 ' s bloody finger with an alcohol pad. After this procedure E 26 was observed to throw all of the biohazard material in R 11 ' s waste basket, these are the lancet, alcohol pad, strip, & gloves. E 26 went to R 11 ' s bathroom & washes her hands for 9 seconds. E26 then went back on her med cart & wiped the top of the glucometer machine with one alcohol pad. (3 ) At 7:45 AM, E 26 prepared R 1 ' s 2 tablets ([MEDICATION NAME] & [MEDICATION NAME]) for 6:00 AM dose & to obtain finger stick blood sample. R 1 was identified with cognitive impairment, incontinent of urine & on isolation for ESBL of urine, no indwelling catheter noted & confirmed by E 26. E 26 wore a gloves & gown & entered R 1 ' s room. E26 was not observed to wash hands before entering the room or prior to performing the procedure to R 1. After E 26 obtained the blood sample E 26 disposed the lancet, the glucometer blood strip, and alcohol pad with blood in R1 ' s bedside waste basket, removed her gown & gloves & threw it in the regular garbage can in R 1 ' s bathroom then went out of the room & proceeded in the medication cart & wiped the glucometer machine with an alcohol pad. (4) At 7:55AM, E 26 was noted to put a drop of hand sanitizer in her hand, E 26 put her hands together & rub the top of her left & the right hand once, a 3 second procedure. E 26 applied gloves on entered R 66 's room that was in isolation room with R 1(with active infection) & applied R66 's pain patches on his left & right hip flushed the gastrostomy tube. E 26 removed her gloves disposed it in R 66 's bedside waste basket, no hand washing was observed went back to her medication cart & wiped the glucometer machine with alcohol pad. 5. 2/15/11 at 11:30am, E31(RN) placed a glucometer machine and a bottle of glucometer strips on a thin paper tissue . E31 carried the thin paper tissue, glucometer machine and bottle of glucometer strips to R25's room and sat the items on top of an isolation cart inside of R25's room. Surveyor asked E31 if R25 was in isolation and E31 responded "yes-for[DIAGNOSES REDACTED]." E31 performed the blood glucose level, sat the glucometer machine and the bottle of glucometer strips back onto the same thin paper tissue, threw the used lancet and gloves into the isolation garbage container. E31 then picked up the thin paper tissue by the corners and carried the items to her medication cart, setting them on top. E31 then wiped the glucometer machine with an a germicidal wipe for 30 seconds and sat the glucometer machine back onto the thin paper tissue. E31 said she was hazy about how long to wipe the glucometer machine. -Interview with E28(LPN) on 2/15/11 at 12:15pm, E28 said she takes the glucometer machine and one glucometer strip on a paper towel, takes it to the resident and obtains the blood glucose level. The glucometer machine is then wiped with an alcohol wipe for 30-45 seconds and then let it dry for 5 minutes. -Observation on 2/17/11 at 1:45pm E32(CNA) was observed performing incontinence care for R25. After performing incontinence care for R25, E32 did not remove the soiled gloves. E32 continued to wear the soiled gloves-replacing the adult diaper and clothing, covering R25 up with the linens and then rubbed R25's left arm. R25 is in isolation for[DIAGNOSES REDACTED] and during incontinence care expelled a large amount of watery, foul smelling feces. -On 2/15/11 at 10:00am E9 (CNA) and E10 (CNA) were observed providing personal care (pericare) to R12. When the incontinence care was completed on R25, E10 did not remove her soiled gloves before pulling the privacy curtain closed. Interview with E10, E10 said she was should have removed her gloves and washed her hands after the continence care before touching the privacy curtain. Review of the facility's policy and procedure for hand hygiene shows to use soap and water after removing gloves and /or handling contaminated objects or linen. On 02-15-11 at 9:10 AM, E 26 stated " I clean the machine before & after with disinfecting wipes or alcohol swab at the edges of the machine & the back. The alcohol swab is the only one available yesterday so that ' s what I used. Most often I throw the lancets in the patient ' s garbage can, I think I should throw it in the red (biohazard container) container in my cart & my used gown & gloves for isolation residents should be in the big red isolation bin. " When E26 was told that she was not observed to wash her hands before & after performing procedures to residents specially patients on isolation rooms E 26 claimed " you guys makes me nervous! " E 26 verbalized that the facility administrative staff supply each medication carts with disinfecting wipes for the glucometer machines. On 02-15-11 at 11:00 AM, when the Assistant Director of Nursing (E 3) was asked on the procedure of cleaning & disinfecting glucometer machine E 3 disclosed " after I used the machine I will use a Clorox wipe to clean the machine. I will wipe the entire machine with the Clorox (wipe) then leave it opens to air for 5 minutes. " On 02-16-11 at 11:00 AM, the Director of Nursing (E2) stated " the CDC guidelines recommends washing hands for at least 20 seconds, the facility policy is to wash hands for 30 seconds. " On several days of the survey starting on 02-14-11 the facility policy & procedure for cleaning & disinfecting glucometer machine was requested to the Administrative staff (Administrator (E1), Director of Nursing (E2) & facility Consultants). The facility was unable to present such policy & procedure, instead a (microdot glucose meter) guidelines was presented on 02-16-11. E 2 claimed the facility has no hard copy of the policies & procedure in the facility. E2 stated " Our policy & procedures are all in the computer, the staff doesn ' t have access to it, and they need to inform the supervisors. " E 1 said " there ' s access issues that we don ' t want the nurses to get confuse with because there ' s still old P/P in there. " When the surveyors access the computer for the policy, the facility has none developed. 6. After observing the treatment nurse (E18) changing a residents dressing on 2/15/2011, surveyor accompanied her to the dirty utility room. E18 had a red bag, containing dirty wound dressings to be put in the large waste bin. Because there were so many red bags on top of the bins for the infectious waste, E18 could not place her red bag into the container. Surveyor observed E18 laid her red bag on top of the garbage can with several other red bags. Surveyors prompted E18 to ensure that red bags are appropriately contained in garbage bins. Later on the environmental tour on 2/17/2011 at 2:30 PM with E21 (director of housekeeping) and E22 (director of maintenance), surveyors observed two red bags on top of the garbage containers for the infectious waste. Surveyor asked E21 should red bags be just left on the top of the garbage containers. E21 told surveyor that all red bags should be placed in the container. When asked why, E21 said that the infectious waste should be contained in the red bag. E21 also said it's possible that the outside of the bag could be contaminated, and should be put in the garbage bin. -On 2/17/2011 at 2:00 PM, surveyor accompanied a housekeeper (E29) to an isolation room. The resident in this room was on contact isolation for MRSA (Methicillin Resistant Staph. Aureus) Infection. Surveyor observed E29 clean a shower chair seat, and clean down the sides of the shower chair legs. Then, surveyor observed E29 take the same cloth and cleaned the door knob to the bathroom door. Surveyor asked E29 should she have cleaned the door knob last. E29 indicated that she should not cleaned the bathroom door knob after cleaning the shower chair. Also, surveyor did not observe E29 clean the side rails to the bed in the room. In the janitor's closet with E21 and E29, surveyor discussed observations with them (E21 and E29). When informed of the above observations, E21 told E29 she (29) should clean from clean to a dirty area, from the the bathroom door knob to the shower chair seat. E21 also told her that the bed rails are always done as part of the daily cleaning in isolation rooms. Review of Center for Disease Control and Prevention (CDC) website had guidelines for cleaning isolation rooms, which were developed by CDC and Healthcare Infection Control Practice Advisory Committee (HICPAC). These Guidelines for Environmental Infection Control in Health-Care gave the following recommendation: "...Housekeeping surfaces can be divided into two groups those with minimal hand-contact and those with frequent hand-contact (high touch surfaces)... High touch housekeeping surfaces in patient-care areas (e.g., doorknobs, bedrails, light switches, wall areas around the toilet in patient's room and the edges of privacy curtains) should be cleaned and/or disinfected more frequently than surfaces with minimal hand contact." However, E29 did not followed these CDC guidelines. She failed to clean a "high touch" area such as the bedrails. E29 also failed to appropriately clean another "high touch" areas such as the bathroom door knob appropriately. Interview on 2/17/2011 with E1 (administrator) and E2 (acting director of nursing), E1 provided insevices done for staff. But, he did not present any evidence to indicate that staff cleaned the isolation according to CDC guidelines. 7. E32 Certified Nursing Aide (CNA), hired 9/22/2010 review of the employee files no documentation of Mantoux testing available. E33 Medical Secretary, hired 11/19/10 initial Mantoux conducted 11/19/2010. A positive result of greater than 10 mm in diameters is recorded on 11/22/11. No results of a chest x-ray in the files. E34 CNA hired 10 /13/ 2010; no information of Mantoux testing is available in health file. E35 Housekeeping, hired 1/30/11, No information of Mantoux testing in health record. The [MEDICATION NAME] screening sheet is not complete. E36 Dietary Aide, hired 1/11/2011, initial Mantoux test conducted 1/14/2011 has a negative reading recorded 1/17/2011. No second step conducted as per policy. Interview with E3 (Acting Director of Nursing) on 2/20/2011 stated she was in charge of monitoring the Mantoux testing and she thought she had 90 days to start the testing. The facility submitted a statement that " The facility changed its procedure for maintaining Mantoux records, transferring the responsibility from HR to nursing. During the transition, the processes of monitoring completion had not been completely implemented, causing a few gaps. The responsibility has been transferred back to HR department and they will suspend any employee not completing their health exam requirements." On 02-16-11 the Director of Nursing/Infection Preventionist (E2) presented all of infection control documentations/surveillance which includes (a) 6 months of facility monthly report, that identifies the types of infection (urinary tract infection, Upper/Lower respiratory tract infection, Gastro-Intestinal Tract Infection-without diarrhea, Pressure ulcer/wounds, Blood stream infection & others), # of patients on contact precaution, # of admitted or acquired per unit, total for the month. (b) Precaution report- this includes the room #, name of residents, Doctor ' s name, Type (of isolation), admit/acquired, culture organism, location, start date, treatment (antibiotic), follow up culture. (c)Infection Report -room #, name, Medical Doctor, Admit/acquired, infection, organism, start date, treatment, follow up. Interview with E2 on 02-16-11 at 11:00 AM, showed & explain the facility system of investigating health care associated infection (acquired in the facility). E 2 stated " basically the Assistant Director of Nursing, me & the Supervisors collects the data from the staff on who ' s on antibiotic therapy, they write info on the precaution report (b). " E 2 claimed the log is completed monthly by the Assistant Director of Nursing & the Supervisors, and then presented to her. Interview with the Nurses on the floor (E 28, E 30 & E13) disclosed that they are not familiar on how the facility tracts the infections. E 28 claimed " sometimes they just asked the nurses on who ' s on antibiotic therapy. " E 2 confirmed that the facility did not summarize trending & patterns such as over 3 months period. When E 2 was asked how does the facility analyze the justification for the use of antibiotic therapy, E 2 stated " that ' s a problem, we have a doctor in the facility that will prescribed antibiotic right away even without culture. We talk with him already but it didn ' t do anything, he ' s very difficult to work with. No it wasn ' t documented but we ' re trying not to give him any more patients. " E 1 & E 2 was notified of the immediate Jeopardy on 02-16-11 at 5:00 PM related to (1) the occurrences of 2 norovirus infection outbreaks on (01-12-11, 58 residents were affected & (b) 02-09-11 with 9 residents affected with the virus.) (2) Implement & maintain infection control measure to prevent 2nd norovirus outbreak. (3) Prevent & control outbreaks using transmission based precaution in addition to standard precaution. (4) Not disinfecting glucometer machines before & after its use for R 11 & to R 1 who was in isolation for ESBL (Extended Spectrum Beta Lactimase). (5)Properly dispose biohazard materials such as lancets, blood glucose strips, bloody alcohol wipes & contaminated PPE ' s (personal protective equipment), for R 11 & R 1, R 66. (6)Have a policy & procedure for effective cleaning & disinfecting the glucometer machine before & after use. ( 7) Provide a dedicated medical equipment (glucometer machine) to be use for residents on isolation precaution. (8) Develop, implement & maintain infection prevention & control program in order to recognize prevent & control the onset & spread of infection. (9) Establish & compare trends & pattern of health care associated infections. (10) Show that the data from the facility precaution/infection report log was analyzed & the origin of the infection was determined. (11) Analyze the justification for the use of antibiotic therapy.(12)ensure new employees receive the Mantoux test within ten days of employment and repeated 21 days following the first test. If positive, the employee must follow up with a chest x ray. For 5 of 11 newly hired staff E32, E33, E34, E35 and E36 The facility took the following steps to removed the immediacy of the situation: 1. Corrective Actions taken for those residents alleged to have been affected by the deficient practice are: No residents specifically identified Immediate actions taken Implemented in-servicing as indicated below Implemented house wide sweep of soiled utility rooms and precaution rooms To ensure infectious waste disposed of properly Ordered additional equipment for precaution rooms as indicated below 2. Actions taken to identify other residents that have the potential to be affected by the same deficient practice: All residents are at risk for this alleged deficient practice. 3. The measures the facility will take to ensure the problem will be corrected and will not reoccur: Facility will consult with the Medical Director to review infection control log, surveillance log, and antibiotic use for last 90 days. The facility will review infection control program with the Medical Director and make changes as indicated. Facility will consult an Infectious Disease Physician within the next 48 hours to review those residents with current infections and those on precautions. The facility will secure an ongoing contract with Infectious Disease Physician for services to include surveillance review and P and P review. Infection control policy and procedure manuals placed at each nurse's station and each department. The facility will complete a house wide audit of residents receiving accuchecks to identify any resident on precautions. Individual glucometer's ordered with ETA 2200 2/16/10 and will be provided to residents who are receiving accuchecks and on precautions. The facility will in-service licensed nurse staff regarding the cleaning and disinfection of the glucometer and the disposal of lancets and glucose strips with return demonstration. The facility will in-service staff on hand hygiene to include pericare, medication pass and wound care, and with return demonstration. The facility will in-service the CNA's on incontinent /pericare to include competency and return demonstration. Facility will in-service staff on storage of infectious waste in resident rooms and soiled utility rooms. Staff will be in-serviced on using personal protective equipment when indicated and proper disposal of PPE. The facility will in-service staff on designated place for infection control manual in each department. The facility will in-service housekeeping staff with return demonstration on cleaning of precaution rooms. The facility will provide education to visitors and physicians in regards to infection control by signage reminder at entry to facility and by precaution sign on resident room doors, and by placing proper hand washing technique instructions in precaution rooms. The facility will orientate new staff, volunteers and students to infection control practices during orientation process and also by signage reminder at entry to facility, by precaution sign on resident room doors, and by placing proper hand washing technique instructions in precaution rooms. 4. Quality Assurance plans to monitor facility performance to make sure corrections are achieved. The facility has developed a QA audit tool to monitor compliance. Director of Nursing or designee will randomly monitor with return demonstration with 5 nurses daily for 2 weeks then three times a week for 2 weeks then weekly times 4 weeks to ensure licensed nurses are cleaning and disinfecting the glucometer and disposing of lancets and test strips appropriately. Director of Nursing or designee will randomly monitor with return demonstration 5 CNA's performing incontinent care daily for 2 weeks then three times a week for 2 weeks then weekly times 4 weeks to ensure providing incontinent care appropriately to maintain infection control. Director of Nursing or designee will randomly monitor with return demonstration 5 staff members daily for 2 weeks then three times a week for 2 weeks then weekly times 4 weeks to ensure staff are using proper hand hygiene technique and PPE use and disposal. Director of Environmental Services or designee will monitor soiled utility room and precaution rooms daily for 2 weeks then three times a week for 2 weeks then weekly times 4 weeks to ensure infectious wasted are disposed of and stored properly. Director of Environmental Services or designee will randomly monitor housekeeping staff cleaning of precaution rooms 5 staff members daily for 2 weeks then three times a week for 2 weeks then weekly times 4 weeks. Results of audit will be reviewed by QA committee. QA committee will determine continued frequency of monitoring.

Based on observations, interviews and record reviews, the facility failed to -Identify and analyze all the risk factors, causes of the resident's falls, and ensure interventions used were effective. -Ensure timely implementation of an effective and comprehensive plan of care. -Monitor for the effectiveness of the interventions and change/modify the interventions as necessary to prevent recurrence of falls. -Provide safe environment, and adequate supervision to prevent resident to resident altercations For 5 of 24 sampled residents R1,R6,R7,R8,and R24 and 8 supplemental residents R46,R54,R69,R79,R83,R98,R103 and R112 who live in the facility's Memory Care Unit -Provide adequate supervision/monitor for six residents (R4, R17, R19, R21 and R1) out of 128 identified as high risk for falls in a sample of 24. These six residents experienced multiple falls with serious injuries, requiring hospitalization s. These failures resulted in; 1. R19 sustaining an avoidable fall resulting in Cervical One Fracture of the vertebral on 1/29/2011. R19 sustaining 9 falls in the facility in a period from 4/10/2010 thru 1/28/2011 R19 at risk for possible paralysis from not receiving adequate supervision to wear neck collar 2. R17 sustaining an avoidable falls resulting in a nasal bone fracture, two lacerations to her head and a large hematoma on her left hip and sustaining 10 falls in the facility from 1/30/2010 thru 2/20 2011. 3. R4 sustaining an avoidable fall on 1/5/2011 resulting in a laceration to the head and fracture. 4. R21 sustaining injuries three times to her face . 5. 12 Resident to resident altercations in the New Town area from 1/4/2010 thru 2/22/2011. E 1 & E 2 were notified of an immediate Jeopardy excisting at F323 on 02-21-11 at 5:00 PM involving resident injuries, and resident to resident altercations related to inadequate supervision by facility staff. Example include:: 1) Review of R19's Minimum Data Set ((MDS) dated [DATE] documented that R19's cognitive skills for daily decision making skills as "moderately impaired." R19's ability to understand others is "usually understands, may miss some part/intent of message." R19 need direct supervision of one assist for transfers and ambulation. R19 need partial physical assistance for balance while standing and sitting, and is dependent on her wheel chair for mobility. Review of R19's nursing notes documented that R19 was admitted to the facility on [DATE] at 5 PM. The nursing notes dated 4/10/2010 at 12:05 AM documented "noted room call light on, attended immediately found resident (R19) sitting on the floor attempting to get up holding wheel chair. When asked what happened, (R19 said) I sat on the floor..." Review of R19's IDT (Interdisciplinary Team) Fall Review Sheet documented that R19 went on to have multiple unwitnessed falls in her room on the following dates: 06/02/2010 at 07:50 AM, 06/21/2010 at 03:30 AM, 08/03/2010 at 06:15 AM, 08/21/2010 at 02:50 AM, 10/09/2010 at 6:30 AM, 11/15/2010 at 07:10 PM, 12/29/2010 at 05:30 PM and 01/28/2011 at 11:45 AM. All of the above falls had no injury, expect for the fall occurring on 12/29/2010 and 1/28/2011. R19 sustained a bruise on the right buttocks on 12/29/2010. The resident sustained [REDACTED]. Most of the IDT Reviews were documented as done over 24 hours after a fall occurrence. Review of R19's care plan documented use of low bed, winged mattress, floor pads, bed and chair alarm. However, R19 continued to fall with the use of these safety devices. Staff did not document any alternative or additional safety device being tried. Staff identified toilet her early, and placing her in the day room for close observation. However, R19 continued to experience unwitnessed falls in her room. However, no clear and consistent toileting program was developed for R19. R19 was receiving psychotropic medication, such as Zoloft and Xanax. This was another area in R19's care that was not addressed in the evaluation of R19's falls. On the consent for for Zoloft and Xanax, the following side effects, which made R19 prone for falls, were documented: "... sedation, drowsiness, hangover effect, increased falls, depression, dizziness and memory impairment..." During several days of the survey on 2/16/2011, 2/17/2011 and 2/18/2011, R19 was observed sitting in the day room, with her cervical collar not around her neck. R19 was observed wearing the cervical collar at her forehead, on her shoulder, or off her body. At times direct care staff was observed placing R19's collar on and at other times just allowed her to keep the cervical collar off. On 2/18/2011, R19 was observed from 10 AM until 12 PM. At times, the activity aide would put the cervical collar on and at other times no one would put it back. Also, no one got the the nurse to put the collar back on R19. The nursing staff caring for R19 were aware she was noncompliant with wearing her cervical collar. However, the following interviews of the nursing staff did not provide a consistent or effective plan of care to monitor/supervise R19 to ensure she kept the cervical collar on: -The nurse responsible for R19's care was interviewed on 2/21/2011. E4 told surveyor, "I call (R19's) neuro surgeon last weekend. I asked could we put a different collar on her. The doctor told me: "I'm not going to be liable and you are not going to be liable. It has to be kept on at all times." When surveyor asked why, E4 replied: "R19 has to have it on at all times because if she hyper extend her neck backward she can get a paralysis." Then surveyor asked E4, who is responsible for ensuring R19's cervical collar stays on. E4 said, "Nurses, nurses should be applying the cervical collar." -The nurse (E26) that worked with R19, during the night shift, was interviewed on 2/18/2011 at 2 PM. When asked, E26 said that R19 required 1:1 monitoring at times to ensure she wears the cervical collar. E26 said R19 needed to wear the collar to stabilize her neck and prevent disabilities. -The nurse caring for R19 on 2/18/2011, during the day shift, was interviewed. E28 reported that R19 did not like wearing her cervical collar. She (E28) reported that R19 should be checked on every hour to ensure she was wearing the cervical collar. -The certified nurses aide (CNA/E10) observed caring for R19 on 2/18/2011 was interviewed. E10 also reported that she checked on R19 every hour to ensure she was wearing the cervical collar. However, R19 was observed frequently having the collar off before E10 came back to check on her with in the hour. The nurse (E26) working the night R19 fell (on 1/28/2011) was interviewed by phone on 2/18/2011 at 2 PM. E26 said that the CNA (certified nurses aide) taking care of R19 was in another room taking care of a resident and heard the bed alarm. E26 stated: "That happened approximately 11:45 PM. We just finish report. When they heard the bed alarm and went to the resident's room. They (certified nurses aide) found her on the floor. ...She had a cut on the top of her forehead." When asked, E26 said R19 may have fell forward from the bed because she had a habit of sitting at the edge of the mattress. E26 stated: "R19 is stubborn. She is always trying to get out of bed by herself. She (R19) says, I don't need help leave me alone." During interviews on 2/18/2011 and 2/22/2011 with administrative staff (E1/administrator, E3/acting director of nursing), E3 identify that by the time staff response to the chair and bed alarms, R19 had already fallen to the floor. E3 could not identify or provide any other safety interventions being used. E1 and E3 provided updated plan of care for R19, which placed R19 on 1:1 monitoring. E1 and E3 provided additional evaluation form other disciplines, such as pharmacy and psychiatrist looking at R19's medications. . This analysis, revision of care interventions and identify of causes of R19's falls was not presented until 2/22/11. 2) Review of the most recent Minimum Data Set ((MDS) dated [DATE] shows that R17 is [AGE] years old and admitted to facility on 4/15/09 with [DIAGNOSES REDACTED]. This MDS shows R17 has short-term and long- term memory problems and is moderately impaired with decision making and supervision is required. R17 requires extensive assistance of one person with transfers and the use of the toilet. MDS also notes R17 utilizes a wheelchair for ambulation. The Resident Assessment Protocol (RAP) dated 9/21/10 shows R17's risk complications & risk factors include the use of antipsychotic and antianxiety med's and no safety awareness. R17's RAP also documents increased fall risk. The following is a list of falls R17 sustained between 1/30/10 through 2/20/11 and are obtained from facility's event reports and nursing notes: 1. 1/30/10- 9:25pm- R17 was being wheeled to room by - she suddenly leaned forward, falling forward and fell to floor. Observed bruise on her left eyebrow. No new interventions to care plan. 2. 2/12/10-10:50pm- found on floor- laceration on forehead and bridge of nose-sent to the hospital-x-ray- fracture to nose-sent to the hospital-remained in the hospital until 2/14/10. Increased monitoring was intervention to care plan. 3. 2/18/10-9:55am-found on floor-fresh redness above the bump from the previous incident (2/12/10) Increased monitoring-labs-medication. 4. 6/5/10- 8:20am- unknown red/purple (6.5cm X 4 cm)observed on left hip. No new interventions. 5. 6/13/10- 7:00pm-observed lying on floor- no injury-new new intervention 6. 6/18/10- 2:30pm- R17 sitting up at table in wheelchair, turned the wheelchair around attempted to get up, fell to her knees. Nurse saw her go to her knees on the floor in front of the wheelchair. No injury- no new interventions. 7. 7/17/10- 12:45pm- observed R17 sitting on the floor in dining room-complained of left arm pain. No new interventions developed. 8. 7/17/10- 1:00pm- observed R17 to attempt to stand up and tried to walk and fell on buttocks.-no injury-no new interventions. 9. 9/17/10- 8:00am-In dining room sitting in wheelchair, agitated, tried to get up and slid off to the floor. R17 landed on her knees and left ear hit chair. No injury- no new interventions. 10. 10/5/10- 10:45am- In dining room-observed on floor laying on her left side in dining room. R17 sustained approximately 2 cm. x 0.2cm laceration on her left eyebrow. New intervention - increased monitoring. 11. 11/20/10- 2:45pm-observed on floor- laceration on left eyebrow approximately 2.2 cm. -steri-strips applied. New intervention- increase monitoring. 12. 11/24/10- 7:00am-found on floor-no injury-no new interventions. 13. 2/6/11- 3:15am-observed on floor-no injury- New intervention-limited 1:1 monitoring. 14. 2/20/11- 6:15am-observed on floor- no injury- New intervention- Hospice to evaluate. Observations were done throughout the survey from 2/14/11 through 2/23/11. R17 was observed at various times in the dining room and her room attempting to stand up while in adult reclining chair. R17 was appeared to be restless, anxious, grimacing, and yelling. Direct care staff was observed to attempt to sit her down in the adult reclining chair, stroke her arm, and/or give a doll. No other interventions were observed to assess R17's attempts to stand, anxiety or grimacing. Review of R17's fall care plan dated 12/20/10 documents in the area of falls that R17 is at high risk for falling due to unsteady gait, use of psychotropics, impaired safety awareness, impaired cognition, forgetful, confused, episodes of agitation, and repeat fall incidents in the last 6 months. The goal for R17 to remain free of injury through 3/20/11. There are multiple approaches listed on the care plan such as observe frequently, and place in supervised area when out of bed, call light within reach, equip with device that monitors rising, low bed, winged bed, and bed/chair alarm but these approaches had not been updated or evaluated. These approaches have been ineffective as evidenced by R17 continuing to fall. There is no indication in the record that shows these approaches were monitored for their effectiveness. Interview with E3 on 2/18/11 at 3:35pm, E3 said R17 is high risk for falls and has had multiple falls. 3) On 2/15/2011 at 10;47 AM, R1 was observed sitting on the toilet in her bathroom calling for help. Chair alarm sounding, but no one was responding. A housekeeper was cleaning a room across the hallway and was not observed to get nursing staff. A facility staff nurse was observed walking toward R1's room. E28 assisted the resident off the toilet. E28 described R1 as confused and at risk for falls. E28 also said that R1 is on fall precautions and recently had a fall. E28 said to monitor R1, staff took R1 to the toilet every hour to half hour. But E28 could not explain how R1 got to the toilet unassisted and no one readily responded to her chair alarm. Review of R1's MDS Assessment, date 11/24/2010, documented that R1 is a [AGE] year old female with the following active [DIAGNOSES REDACTED]. Review of R1's IDT Review Form and Incident Reports documented that R1 fell on the following days: 03/02/2011, 02/03/11, 02/06/2011 and 02/12/2011. On 02/03/11, R1 sustained a left eye brow hematoma. Review of R1's care plan identified that R1 required supervision and monitoring because she was at risk for falls. One of the approach identified was to "Assist with toileting". Other approaches were not appropriate for R1 because she had Dementia and was confused at times, such as: "Remind resident to call for help and wait..." Review of the Fall Management Policy documented the following: "(facility)... assesses each resident to identify factors that place them at risk for falling. A care plan was is developing defining those risks and interventions are implemented. The care plan is developed on a multi-disciplinary level to address acute and recurrent falls. Procedure: ...4. Regardless of the score, the assessment is reviewed to identify the specific areas which may require intervention. 5. The facility will assess for the intervention of safety devices as indicated, always selecting the least restrictive device to meet the individualized needs of the resident. 6. The care plan is developed to address the areas identified on the assessment and on the observations of the resident. 7. If a fall occurs:... Interventions reassessed and revised as indicated. Follow-up recommendations and monitoring as indicated." But staff failed to follow and implement this policy. E8 (nurse) was interviewed on 2/18/2011 at 11 AM. She reported that the floor nurses start the investigation into resident's falls when they occur by completing incident report. E3 said the nurse will also identify some interventions. But, E8 reported that the IDT completed the comprehensive assessment and implement additional nursing interventions. Surveyor asked how often did the IDT meet, and E8 reported that the IDT met weekly. Surveyor asked who were the team members. E8 did not give a clear answer. However, important members of the care team reported they did not participate in the IDT meetings. E16 the restorative nurse was interviewed on 2/17/2011. E16 said she did not participate in any of the IDT Meetings, or gave input into resident's care after a fall occurrence. 4) Review of R4's medical record ,R4's hospital record dated 12/9/10 reads R4 has fallen at least twice within the last week and has fallen at least 4 or more times over the past 2 months. Review of R4's medical record/ fall assessment dated [DATE] indicates not all components of the assessment are filled out resulting in a score of 14 which is not considered high risk for falls. Areas under gait, balance, cardiovascular, orthopedic and cognition are blank. Answering the blank areas would increase R4's score above 14 making R4 at high risk for falls. Review of rehab note for R4 dated 12/30/10 by E25 (physical therapy) reads, " Pt. demonstrates poor standing balance from today secondary to swelling in bilateral feet. " Note dated 1/5/11 reads according to the nurse pt. fell this morning. " Review of incident report dated 1/5/11 indicates R4 found lying on the floor at 11:10 am. R4 was bleeding from a 2.5-centimeter laceration on the right parietal side of the head. Steri strips applied. A follow to this incident dated 1/12/11 reads on 1/5/11 at 11:10 am R4 was in his wheelchair at the entrance to his room and tried to stand and fell in the doorway hitting his head on the entrance to his room. R4 tried to stand and fell into the doorway hitting his head on the bottom of the doorframe. Staff placed a clip alarm on the wheelchair after the fall. Review of nurse note dated 1/7/11 R4 is noted to have bruising and swelling of the right arm. Staff notified Physician and an x ray completed. This x ray dated 1/7/11 notes R4 to have a fractured right wrist. Interview with E1 (administrator) on 2/22/11 at 6:15pm in the facility basement class room regarding R4's fracture E1stated; " It was not reported or treated as a fracture. That was the way it was communicated. The nurses felt it wasn't treated as a fracture. Nurse does not know exactly what happened." 5) Review of R21's medical record R21 has Hip Fracture (prior to admission). R21's nurse notes and incident reports dated 2/5/10; 2/18/10 and 4/18/10 indicate R21 had falls on: 2/5/10 resulting in R21 bleeding from the nose. 2/18/10, fell to the floor hitting her head and sustained a large bruised and swollen area to the right eyebrow. On 4/18/10, R21 observed on the floor with a bump on her right outer eyebrow. 6) On 2/18/2011 in the presence of staff, one activity aide and two CNA's and surveyor R46 was observed to slap another resident in the face and R43 was setting off alarms to chair and doors During interview of R6 on 2/22/2011 at 9:30a.m., R6 stated she had an altercation on Monday with a resident and this was not the only time. R6 stated it is always something happening in the unit. R6 lifted her pant leg to show a bandage to her left shin. R6 stated she got the injury a few months ago when a resident kicked her. R6 stated she is fussy but has to take care of herself. A review of the clinical record a statement dated 2/21/2011 that while staff was passing the small dining room, staff heard a commotion and saw R6 punched R83 in the arm. R83 then threw constructions paper at R6. A review of the facility ' s incident reports documents: R6 on 12/7/2010 was observed by staff kicking the leg of another resident after this resident was in her room. R6 sustained a skin tear to the left leg during this altercation. And R6 on 7/28/2010 had an altercation in the dining striking R112 on the shoulder after R112 pushed the table into the wall catching R6's finger. The New Town dinning room on 2/18/2011 at 10:15 a.m. was full with approximately 42 residents. Two staff (CNA) were scattered with the residents. The residents were in large groups with the activity person A review of the reportable incidents reports of the facility from 1/4/2010 thru 1/13/2011 the facility has reported 16 incidents of resident to resident ' s altercations. This area is identified by the facility to be the memory care sections and has approximately 42 residents who reside there. On 1/4/2010, R103 was punched in the face by another resident who was observed by staff to be irritable and yelling while in the dining area... R103 sustained a minor abrasion to the lower lip with minimal bleeding. R7 on 5/1/2010 was observed by staff to slap R83 on the right cheek. The report documents R83 was observed touching R7 before the slapping incident. R7 on 5/14/2010, pushed R79 causing R79 to fall backwards hitting her on a door jam and sustaining a 3.0 cm x 4.0cm hematoma to the back of the head and an abrasion to the right elbow. R98 on 5/15/2010 had physical aggression and pushing of R8 who wandered into R98's room. Staff observed the incident where the two residents were hitting each other after R8 started pushing R98's wheel chair. R8 on 6/4/2010, repeatedly struck R54 on the left arm staff to provide ongoing supervision R8 on 6/21/2010 struck R6 on the foot while going into R6's room. R24 reported that R6 on 3/29 2010 was struck several times by R6 during the night. R112 on 9/9/2010 was observed by staff being grabbed and having his armed squeezed by another resident R1 on 7/12/10 had an altercation with R69 as R69 blocked the doorway of the dining room R1 punched R69 in the arm While the immediate Jeopardy was removed on 02-22-11. The facility remains out of compliance at a severity level 2. Facility took the following steps to abate the Immediate Jeopardy. 1. Corrective Actions taken for those residents alleged to have been affected by the deficient practice are: R17 pharmacy review of medications completed 2/22/11, comprehensive interdisciplinary team meeting held to review falls since 1/1/10 with care plan review and update completed, psych consult ordered 2/22/11 to determine if continued use of medication. R19 pharmacy review of medications completed 2/22/11, comprehensive interdisciplinary team meeting held to review falls since 1/1/10 with care plan review and update completed, psych consult ordered 2/22/11 to determine if continued use of medication. 2. The measures the facility will take to ensure the problem will be corrected and will not reoccur. The facility provided an in-service to licensed nurse and CNA staff related to accident prevention, supervision and monitoring, plan of care is individualized to prevent falls and reoccurrence of falls. The facility provided and in-service to IDT to include but not limited to nurse managers, NSM, SSD, memory care, activity director, administrator, therapy and restorative therapy on IDT/A&I fall meeting process, fall prevention, fall management, identifying root cause, develop, implement, and revising POC to prevent A&I's, and to ensure they are consistently analyzing for root cause of serious A&I and to prevent reoccurrence of falls. 3. Quality Assurance plans to monitor facility performance to make sure corrections are achieved: The facility has developed a QA audit tool to monitor compliance. Director of Nursing or designee will complete audit daily for 2 weeks then weekly for 4 weeks to ensure residents plan of care is individualized to prevent falls and IDT/A&I fall meeting process is comprehensive and constantly analyze for root cause of serious A&I to prevent reoccurrence. results of audit will be reviewed by QA committee. QA committee will determine continued frequency of monitoring.

Based on record review and interview the facility failed to: Investigate injuries of unknown origin, and failed to notify the Illinois Department of Public Health of these incidents in a timely manner. As a result,the facility failed to conduct thorough investigations on multiple unwitnessed falls to rule out mistreatment or improper delivery of care for 3 of 24 sampled residents R17, R4, R21 There was avoidable injury to one resident (R17) who sustained ten falls from 1/30/10 through 2/20/11, with a fractured nasal bone, lacerations, and hematoma on left hip on 2/12/2010. Examples include: Review of the facility's incident reports documents R17 was found on the floor 10 times, fell out of adult reclining chair with staff present 3 times, and one large bruise of unknown origin was found between 1/30/10 through 2/20/11. R17 previously sustained a fractured nasal bone and one laceration on 2/12/10. R17 was found with one large red/purple bruise (6.5 cm X 4 cm) of unknown origin on left hip 6/5/10. R17 sustained a laceration to her left eyebrow on 11/20/10. The information relating to these incidents was obtained from facility's incident reports and nursing notes and did not give an analysis of the root cause of the falls and bruises. R17 sustained a left scalp hematoma and midline displaced right nasal bone fracture as a result of the fall on 2/12/10 at 10:50 PM. R17 was found on floor with a laceration on forehead and bridge of nose. R17 was sent to the hospital and an x-ray completed indicating a fracture to her nose. R17 remained in the hospital until 2/14/10. The fall incidents were not thoroughly investigated to rule out abuse or to assess contributing factors. There were no new interventions developed or implemented after R17's falls, or upon return from the hospital. R17 found with one large red/purple bruise (6.5 cm X 4 cm) of unknown origin on left hip 6/5/10. This injury of unknown source was not observed by any person or the source of the injury could not be explained by the resident. The injury was extensive and unexplained without a documented fall . This injury of unknown origin was not reported to IDPH or investigated by the facility. Review of the most recent Minimum Data Set ((MDS) dated [DATE] shows that R17 has short-term and long- term memory problems and is moderately impaired with decision making and supervision is required. R17 requires extensive assistance of one person with transfers and use of the toilet. The Resident Assessment Protocol (RAP) dated 9/21/10 shows R17's risk complications & risk factors include the use of antipsychotic and antianxiety med and no safety awareness. R17's RAP also documents increased fall risk. Interview with E3(DON) on 2/18/11 at 3:35 PM, E3 said R17 is high risk for falls and has had multiple falls. 2. Nurses note dated 1/5/11 indicate R4 had a unwitnessed fall with a laceration to the right parietal side of his head with bleeding per nurse note. This fall with laceration to R4's head is not reported to the Illinois Department of Public Health. On 1/7/11 R4 is observed to have bruising and swelling to his right arm. Results of the X ray report dated 1/7/11 indicates R4 has a fracture to the right elbow and an MRI (magnetic resonance imaging) is recommended. An incident report was not initiated after it was discovered R4 developed a fracture of unknown origin to the right arm. Interview with Z1 (R4 ' s MD) at the facility on 2/22/11 at 6:05 PM in the facility basement classroom stated, " The treatment plan for R4's fractured elbow is ice and Tylenol. Even if he had a larger fracture up the arm, we would use a sling. A little chip is there in the elbow. The x ray is saying it is a fracture. " Interview with E1 (administrator) on 2/22/11 at 6:15 PM E1 sated, " It was not reported because it was not treated as a fracture. That was the way it was being communicated from nursing. There was not a sense or need to report it to the State. We did not report it. The nurse does not exactly know how it happened." There is no documentation in R4's medical record or incident investigation related to how the fracture to R4's left elbow occurred. 3. A review of nursing notes dated 2/5/10, 2/18/10 and 4/18/10 as well as incident reports indicate R21 had 1 unwitnessed fall, and 2 witnessed falls- all with injuries. None of these incidents were reported to the Illinois Department of Public Health. These injuries include: 2/5/10 at 10:00 PM in the dining room, R21 was found sitting on the chairs legrest. The wheelchair flipped over and R21 hit nose on the edge of the table in front of her with bleeding from her nose. 2/18/10 at 3:25 PM in the dining room R21 attempted to stand, fell to the floor on her right side hitting her head and sustained a large bruise, with swelling to the right eyebrow. R21 was sent to the hospital for an evaluation.. 4/18/10 R21 is found at 2:45 PM sitting on the floor during an activity on her right side with a bump/laceration on her right outer eyebrow. Per incident reports, R21 is confused and unable to verbalize what happened for any of the incidents.. Review of R21's medical record noted that R21 was admitted [DATE] with [DIAGNOSES REDACTED]. Per nurses notes dated 3/26/10 at 2:00 PM, R21's left hand is noted slightly swollen. On 3/31/10 at 10:50 PM, R21 is noted on the floor on the floor pad. On 4/1/10 at 6:45 am R21's left index finger is swollen. Review of R21's medical record and facility incident reports show that these multiple incidents have not been investigated to rule out improper care or abuse as well as determine risk factors to minimize further injury.

Based on observations, interviews, and record review the facility failed to: Conduct reviews and revisions of the plan of care with a team of qualified persons after each assessment for falls, in order to safeguard residents from further falls for 2 of 24 sampled residents (R17 and R19). The failure to assess, analyze and update ineffective fall measures, led to serious injuries to R19 who on 1/28/2011 sustained a fracture to the right anterior and posterior arch of the cervical one (C1) vertebrae. R19 had 7 falls in the facility, occurring from 6/02/2010 to 1/28/2011, and R17 was found on the floor 10 times while in the facility. R17 sustained a fractured nasal bone and laceration on 2/12/10. Findings include: 1. From record review and review of facility incident reports, R19 had 7 falls in the facility, occurring from 6/02/2010 to 1/28/2011. All of R19's falls occurred in her room. R19 sustained a bruise on the right buttocks on 12/29/2010. Then, R19 sustained a laceration on top of the forehead, abrasion on the left knee and a fracture to the right anterior and posterior arch of cervical one (C1) vertebrae on 1/28/2011. Review of the IDT(Interdisciplinary Team) Review Form and Incident Reports did not have documentation of an comprehensive assessment of R19's condition after each fall occurrence. There is no clear review/assessment of R19's antianxiety medication ([MEDICATION NAME]), or behaviors of sitting on side of bed and resistance to assistance from staff. The team did not show how the professional disciplines will work together to provide the greatest benefit to R19 The nursing interventions were not consistently reviewed to prevent further fall for R19. On 2/18/2011 and 2/22/2011 with administrative staff (E1/administrator, E3/acting director of nursing), E3(DON) said, the use of a bed alarm was not effective, because the pad did not sense her movement. E3 stated the use of a narrow bed sensor would have been more effective in alarming and alerting staff. 2. Review of the facility's incident reports between 1/30/10 through 2/20/11 documents, R17 was found on the floor 10 times. R17 fell out of an adult reclining chair with staff present 3 times. R17 sustained a fractured nasal bone and a laceration on 2/12/10. R17 was found with one large red/purple bruise measuring (6.5 cm X 4 cm) of unknown origin on left hip 6/5/10 and sustained a laceration to her left eyebrow on 11/20/10. R17 sustained a left scalp hematoma and midline displaced right nasal bone fracture as a result of the fall on 2/12/10 at 10:50 PM. R17 was found on floor with a laceration on forehead and bridge of nose. R17 was sent to the hospital and an x-ray completed indicating a fracture to her nose. The facility's IDT failed to analyze the root cause of R17's fall. There were no new interventions developed or implemented after R17's return from the hospital. Review of the most recent MDS dated [DATE] shows that R17 has short-term and long- term memory problems and is moderately impaired with decision making and supervision is required. R17 requires extensive assistance of one person with transfers and the use of the toilet. MDS also notes R17 utilizes a wheelchair for ambulation.and has fallen in the past 30 days. Review of R17's fall care plan dated 12/20/10 documents in the area of falls that R17 is at high risk for falling due to unsteady gait, use of [MEDICAL CONDITION], impaired safety awareness, impaired cognition, forgetful, confused, episodes of agitation, and repeat fall incidents in the last 6 months. The goal for R17 to remain free of injury through 3/20/11. There are multiple approaches listed on the care plan such as observe frequently, and place in supervised area when out of bed, call light within reach, equip with device that monitors rising, low bed, winged bed, and bed/chair alarm but these approaches had not been updated or evaluated. These approaches have been ineffective as evidenced by R17 continuing to fall. There is no indication in the record that shows these approaches were monitored for their effectiveness. R17's falls were not analyzed by the facility's IDT to determine the effectiveness of the interventions developed in an attempt to prevent R17 from further falls. Interview with E3 on 2/18/11 at 3:35 PM, E3 said R17 is high risk for falls and has had multiple falls. The IDT meets weekly to discuss the facility's falls for the week. The interventions that are in place for R17 are appropriate and the care plans are updated. There was no comprehensive review/assessment of R17's [MEDICAL CONDITION]/antianxiety/pain medications ([MEDICATION NAME]), behaviors (attempting to stand, grimacing, leaning forward in adult reclining chair, yelling), or nursing interventions implemented to prevent R17 from falling found in the plan of care.

Based on observations, interviews and record reviews the facility failed to provide consistent and effective care and services to ensure R19's cervical collar is worn correctly for 1of 24 sampled residents (R19) This failure to monitor and address the noncompliance and apply the collar put R19 at further risk for harm to the cervical fracture of C-1 sustained in a 1/28/2011 fall. Findings include: During several days of the survey (on 2/16/2011, 2/17/2011, and 2/18/2011) observed R19 sitting in the day room, with her cervical collar not around her neck. R19 was wearing the cervical collar at her forehead, on her shoulder, or off her body with improper placement. Staff observed putting the collar on and at other times, just allowed her to keep the cervical collar off. On 2/18/ , surveyor followed R19 from 10 AM until 12 PM. At times, the activity aide would put the cervical collar on and at other times left it off. On 2/21/2011, E4 (RN) stated, "I called (R19's) neuro surgeon last weekend. I asked could we put a different collar on her. The doctor told me: "I'm not going to be liable and you are not going to be liable. It has to be kept on at all times." E4 states, "R19 has to have it on at all times because if she hyper extends her neck backward she can get a paralysis." E4 said, "Nurses should be applying the cervical collar." The night shift nurse (E26) was interviewed on 2/18/2011 at 2:00 PM. , E26 said, R19 required 1:1 monitoring at times to ensure she wears the cervical collar. E26 said, R19 needed to wear the collar to stabilize her neck and prevent disabilities. On 2/18/2011, E28(LPN) said, R19 did not like wearing her cervical collar. (E28) reported that R19 should be checked on every hour to ensure she was wearing the cervical collar. -The certified nurses aide (CNA/E10) observed caring for R19 on 2/18/2011 was interviewed. E10 reported that she checked on R19 every hour to ensure she was wearing the cervical collar. However, R19 frequently had the collar off before E10 came back to check on her within the one hour time frame. Review of R19's most recent MDS (Minimum Data Set) Assessment, dated 2/22/2011, documented that R19 is a [AGE] year old female with the following Active [DIAGNOSES REDACTED]. Review of R19's Physician order [REDACTED]." Review of R19's care plan : "2/03/2011 Resident (R19) needs neck collar due to: Diagnosis: [REDACTED]. Needs: To stabilize neck." The goal : "Resident (R19) will tolerate wearing neck collar daily as ordered with assist..." The nursing interventions/services are: "Place collar properly to neck... Remove/check collar as ordered... Reapply collar when resident removes it. Educate resident on importance of wearing neck collar." However, these nursing interventions/services were not consistently given or effective for R19. E26 said that R19 had a habit of sitting on the side of the bed at night, and that's how she fell out of the bed on 1/28/2011 and suffered the injury . The plan of care to ensure that R19 received the monitoring and supervision needed to prevent fall occurrences did not address this habit or attempt other measures to assure compliance with device.

Based on observation, interview and record review the facility failed to : (1) Prevent the development of facility acquired pressure ulcers (2) Monitor the progression of facility acquired pressure areas (3) Develop & implement a prevention plan for residents identified as high risk for developing pressure ulcer. (4) Develop a specific plan to improve or prevent worsening pressure ulcers. (5) consistently Identify the stages pressure ulcer, for 4 of 4 sampled residents with pressure ulcers R4,R11,R17,R40 These failures resulted in the development of avoidable pressure ulcers to (1) R11 Stage I pressure ulcer on the anterior aspect of the 2nd, 3rd, 4th & 5th digital phalanges of R 11 ' s right foot that progressed to a deep tissue injury. . (2) Development of facility acquired Unstaegeable pressure ulcer on R 4's bilateral heels, stage I on R 17's left bunion, and R40's Stage I of the sacrum. Examples include: (1) Review of R 4's admission documentations (face sheet), R 4 was admitted on [DATE] with no alteration in skin. Interview with E18 (treatment nurse) on 2/17/11 at the nurses station stated, " he (R4) acquired the bilateral heel pressure sores while in the facility. His heel pressure sores were noted on 12/23/10. He (R4) also developed a pressure sore on his Ischium on 1/16/11 it resolved on 2/7/11." On 2/15/11 at 3:35 pm R4 was observed in bed with heels not elevated. R4 is observed to have unstageable bilateral heel pressure sores during the dressing change. E18 (treatment nurse) stated on 2/15/11, " his right heel is 100% covered with slough and is unstageable, " and the left heel has eschar, is dark with red around the edges, both Unstageable." The faclity had not developed & implement specific interventions to R 4 in order to promote healing & prevent worsening. (2) On 02-15-11 at 11:35 AM, R 11 was observed up in her wheelchair with her shoe dangling on her right foot. At 1:20 PM, the C.N.A (E 13) was observed providing care to R 11. R 11 ' s right toes were observed with contractures & noted with pinkish discolorations. On 02-16-11 at 10:08 AM, R 11 was observed in the dining room sleeping in her wheelchair during activities with shoes dangling on her feet. There was no staff intervention noted. At 2:15 PM, R 11 was observed in bed. R11's bed sheets/comforter tucked tight under the mattress. There were no positioning devices noted while R 11 was in bed & this was confirmed by E 13. R11 ' s digital phalanges (5th, 4th, 3rd, & 2nd) of the right foot were observed with darker color at this time. On 02-17-11 at 3:35 PM, skin assessments were requested with the Treatment Nurse (E 18). E 18 stated, " on 01-05-11 these started as pink discolorations, I ' m not aware of the changes in color. The nurses are supposed to notify me for any changes. I see it ' s darkening in color (maroon), it is a skin trauma, and it ' s in the bony area. " On 02-16-11, E 18 measured and documented the following: (1) 2nd (right) toe - 0.7 cm X 0.5 cm. (2) 3rd toe - 0.6 cm X 0.6 cm(3) 4th toe - 0.5 cm X 0.6 cm (4) 5th toe - 0.5 cm X 0.6 cm. Review of R 11 ' s skin integrity care plan showed that R 11 ' s high risk for skin breakdown relate to decreased mobility. R 11 ' s Minimum (MDS) data set [DATE] disclosed R 11 ' s rarely/never has the ability to express ideas & wants, unable to interview due to cognitive deficit, totally dependent (full staff performance) with two or more persons physical assist with mobility. Minimum Data Set also showed that R11 has functional limitation in range of motion, impairment on one side on her upper & lower extremities. On 02-17-11 at 3:35 PM, E 18 stated, the pinkish discoloration (Stage I) were identified on 01-05-11. Review of R 11 ' s clinical records showed there was no preventative plan of care developed and implemented. The facility has not assessed why and how these pressure ulcers developed on R 11. These findings were confirmed by E18. (3) On 2/15/11 at 10:30am ,R17 was observed with a red, non-blanchable area on her left bunion. E11(CNA) said he did not observe the red, non-blanchable area on R17's left bunion. E18(treatment nurse)said she was unaware of R17's red, non-blanchable area on her left bunion. E18 said after assessing R25's red, non-blanchable area on her left bunion, it was a facility acquired Stage I pressure sore measuring 1.6cm. X 2.2 cm. Review of R17's plan of care dated 2/20/11, documents R17 is high risk for falls, decreased mobility, and history of previous skin breakdowns. On 2/16/11 E18 documented on R17's plan of care the following, "resident has pressure wound at the left bunion; provide soft slippers until discoloration clears at the left foot." Review of R17's comprehensive wound assessment developed after surveyor notified E18 on 2/16/11, shows R17 has a wound on her left bunion, measuring 1.6cm X 2.2 cm., date of onset 2/16/11. R17's facility acquired left bunion pressure sore is assessed as an unavoidable skin condition related to continuous urinary incontinence or chronic voiding dysfunction and chronic bowel incontinence. R40 was admitted to the facility on [DATE] with one pressure sore to his coccyx area. Review of R40's comprehensive wound assessment developed 2/14/11 shows R40 has a Stage II pressure sore on his coccyx, measuring 2.1 cm. X 1.8 cm.< 0.2 cm. present on admission. On 2/17/11 at 1:45pm during the observation of R40's coccyx dressing change, a newly acquired pressure sore on R40's sacral area was observed. On 2/17/11, E18 said, she was unaware of R40's Stage I pressure sore, it is a newly acquired Stage I sacrum pressure sore. E18 assessed R40's newly acquired pressure sore as a Stage I pressure sore measuring 0.6 cm. X 0.4 cm. Review of R40's plan of care dated 2/14/11 documents R40 is moderate risk for skin breakdown related to decreased mobility and episodes of incontinence. Review of the facility's policy and procedure dated 8/10 documents the following: Observation: A head to toe observation of the residents' skin will be conducted on admission, readmission, weekly and during care. Areas of concern will be reported to the nurse and the physician. Clinical note: Using touch to assess red areas or heels can reveal early stages of pressure ulcer formation. Red areas the do not blanch and soft or boggy heel tissue require interventions to prevent further damage. Interventions: off-loading pressure points

Based on observation, interview and record review the facility failed to: (1) complete an accurate and thorough assessment of factors/causes of residents urinary incontinence.(2) Identify the type of urinary incontinence and analyze whether these were reversible or irreversible. (3) Develop a specific Bowel & Bladder program based on resident ' s individual assessment. (4) Develop a plan to promote dignity & to improve or maintain resident's current bladder functioning. (5) Utilize the bowel & bladder diary to implement a specific program . (6) Obtain tests or studies indicated to identify the type(s) of urinary incontinence.(7) Discuss & document education provided to residents or responsible party of the risks and benefits of catheter use. (8) Properly demonstrate appropriate perineal care and catheter care (9) Follow facility policy & procedure in catheter care and (10) Develop & implement a bowel & bladder program, for 5 of 24 sampled residents R4, R9, R12, and R17 and three supplemental residents R19, R36, R31. These failures resulted in R19's decline in bladder functioning from continent to always incontinent. Findings include: (1) On 02-16-11 at 9:25 AM, R19 was observed in the dining room sitting on a wheelchair waiting for activities. At 9:30 AM , R19 said, " I want to go to the bathroom. " At 9:40 AM, the C.N.A (E11) took the resident back to her room & toileted R19. R19 was observed able to stand by holding at the bathroom handrail & assisting E11 to remove her adult disposable brief. E11 stated, " she (R19) is usually able to verbalized needs to go to the bathroom. C.N.A (E10) came & assisted E11. E10 said, " I ' m her (R19) permanent C.N.A, she can verbalize her needs to go to bathroom & when she wants to go to bed. She can walk with assistance. " When E10 was asked why does R19 wears diaper if she's able to verbalize the need to use the washroom? E10 stated. " just in case she have accidents, sometimes she gets wet when not toileted immediately." The initial Minimum (MDS) data set [DATE] showed, R 19 was totally continent upon admission. R19 was scored " 0 " (on bladder) " continent- complete controls. Quarterly Minimum (MDS) data set [DATE] showed a decline in bladder to frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent of voiding.) Minimum (MDS) data set [DATE] showed further decline in R19's bladder function, always incontinent ( no episodes of continent voiding). " There was no individualized plan of care developed for R19 & this was confirmed by E16. On 02-16-11 at 1:30 PM, the Bowel & Bladder Coordinator (E 16) stated, R19 was totally incontinent of urine. Review of the bladder diary conducted on 02-03-11 thru 02-05-11 showed that R19 has periods of both continence & incontinence episodes. This assessment was not analyze for the causes and types of incontinence in order to prevent R19's further decline in Bowel & Bladder functioning. E16 stated, " she can't verbalized her need to use the bathroom " , C.N.A interviews (E10 & E11) on 02-16-11 indicated otherwise. When E16 was asked on how the facility identifies the type of incontinence? E16 stated, " we base it on the diagnosis. Like her (R19) she's diabetic so she's automatically overflow. (2) Review of R31's toileting restorative program plan of care shows R31's [DIAGNOSES REDACTED]. R31's bladder diary shows on 8/25/10 through 8/26/10 she was aware of the need to void, she is incontinent two times during the night and one or two times during the day. R31's urinary incontinent assessment dated [DATE] indicates she is a good candidate for toileting schedule(usually prompt voiding of habit training) and has functional incontinence related to impaired vision. R31's plan of care documents: scheduled toileting plan, assist to toilet, assist on schedule times: 6-7 am, 9-10am, 1-2 pm, 5-6pm, 9-10pm, 12-1am and as needed, R31 wears adult diapers. R31's urinary incontinence care plan does include an assessment or interventions to assist in identifying reversible causes of incontinence nor does it reflect the information obtained from the bladder diary. Interview with E16 (Restorative nurse) on 2/16/11 at 1:30 pm, E16 stated the facility does a 3-day bladder diary on each resident upon admission, gathers information relating to their incontinence which includes the diagnosis. E16 said she talks to the direct care staff and families. If the resident is a good candidate for an incontinence program then a plan of care is developed. The type of incontinence is based on the residents diagnoses, not the urinary incontinence assessments. The facility does not have a bladder scanner nor does the facility obtain any type of diagnostic testing to determine the type of urinary incontinence. 3. Review of R36's toileting restorative program plan of care shows R36's [DIAGNOSES REDACTED]. R36's bladder diary shows on 6/11/10 through 6/13/10 she is aware of the need to void and is sporadically incontinent throughout the day and night. R36's urinary incontinent assessment dated [DATE] indicates she is a good candidate for toileting schedule (usually prompt voiding of habit training) and has mixed incontinence with related conditions that cause urge and stress incontinence. R36's plan of care documents: scheduled toileting plan, assist to toilet, assist on schedule times: 7-8am, 9-10 am, 11-12 PM,1-2pm, 3-4pm,5-6pm,7-8pm,10-11pm, 1-2 am,4-5 am and as needed and R36 wears adult diapers. R36's urinary incontinence care plan does include an assessment or interventions to assist in identifying reversible causes of incontinence nor does it reflect the information obtained from the bladder diary. 4. Observation on 2/15/11 at 10:10 am during perineal care for R12, E10(CNA) wiped R12's labia and rectum back and forth several times. E10 wiped R12's labia and rectum with a paper clothe sprayed with perineum spray. Neither E9(CNA) or E10 cleansed R12's buttock or perineal area, nor did they dry the area, apply moisture barrier before applying an adult diaper. 5. Observation on 2/15/11 at 10:30am during perineal care for R17, E12(CNA) wiped R17 back and forth several times - labia to rectum. E12 wiped R17 labia and rectum with paper clothe sprayed with perineum spray. Neither E11 or E12 cleansed R17's buttock or perineal area, nor did they dry the area, apply moisture barrier before applying an adult diaper. Review of the facility's policy and procedure for perineal care-female dated 8/10 documents the following: *use warm water and soap to wash the perineum from front to back *spread the labia and cleanse the sides and middle with downward [MEDICAL CONDITION] using a clean portion of the cloth with each stroke. *rinse well and pat dry *spread the buttocks and wash the anal area from front to back using a clean portion of the cloth with each stroke *rinse the buttocks and anal area with warm water and pat dry *apply barrier cream as necessary 6. On 2/15/11 at 9:45 am surveyor observed E27(CNA) conduct indwelling catheter care for R9. E27 washed R9's buttock (not perineal area) with warm water. E27 sprayed a paper clothe with perineum spray and wiped the shaft of R9's penis and scrotum. E27 picked up another paper clothe and sprayed it with perineum spray then wiped R17's meatus and shaft of penis. E27 wiped the tubing of the indwelling catheter with a paper clothe that had been sprayed with the perineum solution. E27 did not secure the tubing to R9's thigh nor did he empty the collection bag. Review of the facility's policy and procedure for indwelling catheter care documents to observe the following: *using soap and water, cleanse around the urethral meatus and adjacent catheter junction working from the meatus outward. *remove all exudates from and around the meatus and catheter junction. *rinse well *secure the tubing to prevent tension on the bladder neck urethra *empty the collection bag every shift. Interview with E27 on 2/15/11 at 10:15am, E27 said he always uses the paper clothes and perineum spray to cleanse the meatus, scrotum and catheter tubing. E27 said he knows he needed to secure the collection bag on R9's thigh. Interview with E3(DON) on 2/15/11 at 2:00a.m, E3 verified that E27 should have used soap and water to cleanse the perineal area and secured the collection bag to R9's thigh. 7. Review of the census and conditions (HCFA-672) shows the facility has 78 residents out of 143 residents who are occasionally or frequently incontinent bowel and 95 residents out of 143 residents who are occasionally or frequently incontinent of bladder. The facility has no individually written bladder training program. No thorough and specific policy and procedure has been developed or implemented. 8. Review of R4's medical record R4 had an indwelling urinary catheter inserted on 2/14/11. R4 is an [AGE] year old male. R4's [DIAGNOSES REDACTED]. Review of the assessment provided by the facility dated 12/17/10 there is no comprehensive assessment for the use of the indwelling catheter. No indications for risks and benefits of the insertion of this indwelling urinary catheter. In addition, there is no documentation in R4's medical record that either R4 or R4's designated power of attorney were informed and educated in relation to any benefits and/or possible side effects of the insertion of the indwelling urinary catheter.

Based on interview, observation, record review, the facility failed to: 1) Monitor for unnecessary drugs,which includes excessive dosages and lack of medical justification for administering [MEDICAL CONDITION] and narcotic medications; 2) Develop a medication reduction plan for [MEDICAL CONDITION] medication; and 3) Develop a comprehensive assessment to monitor physical and psychosocial needs and administration of prn(as needed) drug usage. For 2 of 24 sampled residents R17 and R19 evaluated for drugs monitoring and reduction. This facility failure resulted in R17 and R19 experiencing increased confusion, sedation, and increased falls directly related to drug usage and side effects. Examples include: Review of the Resident Assessment Protocol (RAP) dated 9/21/10 shows R17's risk complications & risk factors include the use of antipsychotic and antianxiety meds and no safety awareness. R17's RAP also documents increased fall risk. Review of R17's clinical record shows between 1/30/10 through 2/20/11, R17 was found on the floor 10 times, attempted to stand up in the dining room and falling to the floor 2 times with staff present , leaned forward while being wheeled to room by staff falling to the floor 1 time, and 1 injury of unknown origin- large bruise found on her hip. R17 sustained a fractured nose and 2 lacerations from these incidents Observations were done randomly throughout the survey from 2/14/11 through 2/23/11. R17 was observed at various times in the dining room and her room attempting to stand up while in adult reclining chair. R17 appeared to be restless, anxious, grimacing, and yelling. Direct care staff was observed to attempt to sit her down in the adult reclining chair, stroke her arm, and/or give a doll. No other interventions were observed to assess R17's anxiety or grimacing. . . Review of R17's physician order [REDACTED]. 11/1/10- 11/30/10- -[MEDICATION NAME] 1ml. (2 mg.) every 2 hours for severe anxiety- 96 doses administered. - [MEDICATION NAME] 0.25 mg. (5 mg.) every 3 hours PRN for severe pain-10 doses administered. 12/1/10- 12/31/10- -[MEDICATION NAME] 1ml. (2 mg.) every 2 hours for severe anxiety- 62 doses administered. - [MEDICATION NAME] 0.25 mg. (5 mg.) every 3 hours PRN for severe pain-7 doses administered. 1/1/11-1/31/11- -[MEDICATION NAME] 1 ml. (2 mg.) every 2 hours for severe anxiety- 15 doses administered. - [MEDICATION NAME] 0.25 mg. (5 mg.) every 3 hours PRN for severe pain- 3 doses administered. 2/1/11-/2/18/11- -[MEDICATION NAME] 1 ml. (2 mg.) every 2 hours for severe anxiety- 21 doses administered. - [MEDICATION NAME] 0.25 mg. (5 mg.) every 3 hours PRN for severe pain- 3 doses administered. In addition to above, R17 was also receiving scheduled [MEDICATION NAME] 5 mg. every 6 hours and at 9:00pm. R17 receives [MEDICATION NAME] 25 mg. at bedtime. There was not a verbal or written consent from R17's power of attorney (POA) to receive [MEDICATION NAME] 1ml. (2 mg.) every 2 hours. Review of R17's clinical record revealed there was no documentation of any comprehensive assessment to determine the medical justification for the use of either the anti-anxiety agent or narcotic agent. Review of R17's clinical record failed to show that the facility completed an assessment of pain and response after R17 was administered PRN pain medications. Interview with E8(Nurse) on 2/22/11 at 9:30am, E8 confirmed that R17 was receiving [MEDICATION NAME] 1ml. (2 mg.) every 2 hours for severe anxiety and [MEDICATION NAME] for severe pain. Interview with E11(CNA) and E12(CNA) on 2/15/11 at 10:30am, said, R17 calms down when you hold her hand, sit with her, pat her head or give her a baby doll. Review of R17's [MEDICAL CONDITION] medication documentation dated from 1/10 through 1/11 does not show the facility monitored the use of medications to track progress towards therapeutic goals and/or detect the emergence or presence of any adverse consequences. There was no evidence documented that the facility developed or implemented a medication reduction plan for R17's multiple use of antipsychotic medications based on symptoms and response ,or evaluated adverse effects of the drugs after R17's frequent falls. The facility failed to analyze or monitor the effectiveness of the multiple [MEDICAL CONDITION], behavior, and pain medications administered to R17 have on her falls . Review of the facility's [MEDICAL CONDITION] Drug Reduction and Elimination policy and procedure which they failed to follow includes: any drug that is used in excessive dose, excessive duration, inadequate monitoring, indication for its use and adverse consequences. The facility is responsible for completing a pre-admission assessment to determine that status of any [MEDICAL CONDITION] medication for the resident. This shall include a review of antianxiety, antipsychotic, antidepressants and hypnotic medications. The medications are to be evaluated at least quarterly to evaluate the possibility of elimination or reduction, discontinuation of PRN medication, evaluate the dose to assure appropriate parameters for the geriatric resident, associated [DIAGNOSES REDACTED]. Per the Geriatric Dosage Handbook (2007), [MEDICATION NAME]([MEDICATION NAME]) is an Anxiolytic, Sedative/Hypnotic and is a potentially inappropriate medication for the geriatric population. These drugs have a long half-life in elderly patients (often several days), producing prolonged sedation and increasing the risk of fall and fractures. Adverse reactions include (but not limited to) dizziness, unsteadiness, and weakness. [MEDICATION NAME] is promptly absorbed with the half-life of 10-16 hours, oral daily dosage 0.5 mg- 4.0 mg. Dose selection should generally be on the low end of the dosage range. [MEDICATION NAME] is a Narcotic/Opoid [MEDICATION NAME] and is used for severe and chronic pain. Drug interactions with antipsychotic medications may increase hypotensive effects-need to monitor. CNS depressants: may increase the effects/toxicity of [MEDICATION NAME]; monitor. [MEDICATION NAME]'s half-life is 2-4 hours (immediate release) with peak time of one hour. The daily dosage is 10-30 mg every 3-4 hours but use caution; may require reduced dosage in the elderly and debilitated patients. Adverse reactions include (but not limited to): CNS depression, sedation, constipation drowsiness, dizziness and confusion. [MEDICATION NAME] ([MEDICATION NAME]) is an Anxiolytic, Sedative/Hypnotic medication with a long half-life in elderly patients (often several days), producing prolonged sedation and increasing the risk of fall and fractures. Adverse reactions include (but not limited to) dizziness, unsteadiness, and weakness. This medications ha a long half-life of 30-60 hours which may lead to accumulation in elderly patients. Daily dosage is 1-2 mg. 1-2 times/day; increase gradually as needed, rarely need to use >10 mg a day. [MEDICATION NAME] is an atypical antipsychotic medications used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] disease. [MEDICATION NAME] is not approved for treating [MEDICAL CONDITION] in the elderly with dementia. Treating the elderly patients with dementia-related [MEDICAL CONDITION] (having lost touch with reality due to confusion and memory loss) are at an increased risk of death. Side affects include(not limited to): new or worse anxiety, feeling very agitated or restlessness. Reference: Semla, T.P., Beizer, J.L., & Higbee, M.D., & . (2007). Geriatric Dosage Handbook (12th ed.). Hudson, Oh.: Lexi-Comp. Review of R19's POS (Physician order [REDACTED]. R19 has a physician order [REDACTED]. Review of the Consent For Treatment Form documented that R19 was receiving this [MEDICAL CONDITION] drug as an anti-anxiety agent, which cause the following possible side effects: "... sedation, drowsiness, hangover effect, increased falls, depression, dizziness and memory impairment..." Review of R19's most recent MAR (Medication Administrative Record) documented that R19 was given 0.25 mg of [MEDICATION NAME] on 2/04/2011 at 8:45 AM, 2/07/2011 at 1 AM, 2/08/2011 at 12:30 AM and 2/10/2011 at 5 AM. The reason given for the use of the [MEDICATION NAME] each time was: "Anxiety/Agitation." R19's results/response to the use of [MEDICATION NAME] was documented as asleep or sleeping on 2/07/2011, 2/08/2011 and 2/10/2011. However, the note for 2/07/2011 did not have an assessment of R19's response to the use of [MEDICATION NAME]. Documentation of R19's response to [MEDICATION NAME] did not indicate if the [MEDICATION NAME] was making her too drowsy, or other side effects. Also, no other assessment tool, nursing notes, physician notes indicate an review of the need for [MEDICATION NAME] in R19's care. Review of the R19's Interdisciplinary Team (IDT) Review Form and Incident Reports document that R19 had multiple falls in the facility. There was no consistent or clear documentation in the IDT Review Forms or Incident Reports assessing the impact [MEDICATION NAME] may have on her physical and medical conditions. On 1/28/2011, R19 fell and sustained a [MEDICAL CONDITION], but no documentation of a review of this drug was done. Two nurse observed caring for R19 were interviewed. E28(Nurse) was interviewed on 2/17/2011, E28 reported she would monitored R19 for drowsiness. E4(Nurse) was also interviewed on 3/03/2011 at 2 PM. E4 also she would monitor R19 to make sure she was not too sedated. However, assessment of R19's condition after receiving [MEDICATION NAME] may indicate inadequate monitoring after getting a dose. E1 (administrator) and E3 (assistant director of nursing) presented on 2/23/2011 documentation that pharmacy and psychiatrist reviewed R19 use of [MEDICATION NAME] after prompting. The pharmacy documented on 2/22/2011: "If not recently done, recommend a psychiatric evaluation to determine if this continued use of this medication ([MEDICATION NAME]) is still necessary. If this medication must continue please be sure the patient is monitored for excessive Central Nervous System depression after given a PRN dose." R19's psychiatrist evaluated the continued use of [MEDICATION NAME] on 2/22/11.