Every finding on record at Bella Terra Lombard

Based on observation, interview and record review, the facility failed to respond to a resident's request for a more compatible roommate, failed to respond to a physician recommendation for a room to protect a resident's health and failed to educate a resident regarding the ombudsman program to provide an advocate for the protection of resident's rights.This failure applies to 1 of 3 residents (R1) reviewed for transfer/discharge in the sample of 5. The findings include:On August 19, 2026, at 12:26 pm, R1 stated while in her current room, she feels she has more respiratory concerns regarding her health, is taking more nebulizer treatments due to the noxious odors from feces and urine when her roommate is being changed due to incontinence. R1 stated her request for a different roommate are being ignored by facility staff. R1 stated her community physician recommended a room change that the facility did not respond to. R1 stated R5 (R1's roommate) also verbalizes cuss words toward her when R1 attempts to sing or speak. R1 stated she feels the management staff should consider roommate compatibility when determining room placement. R1 stated her community physician recommended a single room to avoid respiratory illness, but no room change was made. R1 stated she would accept a roommate if it was someone more like herself, able to use the bathroom, and interested in communicating. R1 stated when R1 had asked to open the window to air out the room or when she asked for a more appropriate roommate who is not on hospice care, her requests are ignored. R1 stated she feels staff ignore R1's rights in favor of R5's rights. When R1 was asked if she had talked to the Ombudsman regarding her concerns with resident rights, R1 replied she did not know what an Ombudsman was and never heard that word before. After describing the role of the Ombudsman, R1 replied that sounded like someone R1 needed to talk to.Census records for R1 and R5 showed they have been roommates since January 21, 2026.R1's EMR (Electronic Medical Record) showed R1was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, asthma, reactive airway disease, alcohol abuse, systemic lupus and anxiety disorder.R1's MDS (Minimum Data Set) dated July 20, 2026, showed R1 was cognitively intact, and required assistance with ADLs (Activities of Daily Living) including partial assistance with bathing, putting on footwear and walking 10 feet, lower body dressing, and supervision with upper body dressing and toilet hygiene and bed mobility and independent with eating and bed mobility. On August 19, 2026, at 3:36 PM, V8 (Social Services) stated she had been aware that R1 was requesting a change in rooms for about 3 weeks. V8 stated the facility protocol was usually the person requesting the room change would be the one to move. V8 stated she had not spoken to the Ombudsman regarding R1's concerns and was unaware if R1 had been given the Ombudsman information. V8 stated she usually consults with the Ombudsman when a resident has a concern and the facility, and resident are at an impasse regarding the resolution.On August 19, 2026, at 4:43 PM, V9 Licensed Practical Nurse (LPN) stated she had worked full time in the facility for about 5 months on R1's unit. V9 stated ever since she had worked with R1 for the past 5 months, R1 had complained about the fecal and urine odors in R1 and R5's shared room.On August 19, 2026, at 5:04 PM, V1 (Administrator) stated that roommate incompatibility may be addressed by separating both roommates if abuse between them is identified, encouraging the one who is complaining to choose a different room, or sometimes asking the roommate of the complaining resident to agree to being moved out of the room. V1 stated there was a letter from R1's community physician recommending a single room for R1, however V1 deferred the recommendation to V10 (R1's in facility NP Nurse Practitioner).On August 20, 2026, at 9:30 AM, V1 provided a copy of the letter dated July 23, 2026, written by V11 (R1's community MD Medical Doctor). The letter showed that V11 identified R1 as having chronic asthma, reactive airway disease and pulmonary edema which placed R1 at risk for respiratory illnesses and respiratory compromise. V11 recommended that R1 reside in single room or have a single occupancy room to prevent respiratory complications and decompensation. V11 addressed the letter to V4 (RN R1's Unit Manager) who was unavailable to be interviewed and closed the letter with the statement your understanding and cooperation in this very important medical matter is appreciated.On August 20, 2026, 10:08 AM, V10 stated she was made aware of the letter written by V11 on July 24, 2026. V10 stated she examined R1 that day and determined R1 was not experiencing an acute medical condition and was not in need of isolation precautions necessitating a private room. V10 stated R1's conditions of Lupus and respiratory conditions does place R1 at higher risk for infection. V10 stated she did not disagree with V11 room recommendation however V10's role was to assess acute medical conditions and base room recommendations on her exam. V10 stated room placement for other concerns would be the responsibility of facility management. V10 stated she documented on July 24, 2026, no isolation or need for private room.Review of R1's progress note documentation by facility staff showed between July 24, 2026, and August 18, 2026, there was no documentation to address R1's request for a more compatible roommate or offer of a resolution to R1's concerns regarding her room placement, or response to V11's written request regarding R1's room placement.The facility's policy titled Room Transfer dated July 8, 2026, showed the policy statement as the facility will transfer a resident to another room within the facility based on the needs of the resident. The procedures showed if conflict arises between roommates, the facility has the right to transfer the residents as necessary for safety reasons and to avoid further escalation of the situation.

Based on observation, interview and record review, the facility failed to maintain resident rooms free of mold. This applies to 15 of 17 residents (R1, R7-R12, and R15-R22) reviewed for facility environment in a sample of 22. The findings include:On 7/9/26 at 12:55 PM, R7 and R8 were sitting in their room in their wheelchairs. R7 stated approximately two hours ago she was lying in bed and felt water on her feet. R7 stated she told a nurse about the water dripping from the ceiling and the nurse was going to call facility maintenance, but she had not seen them yet. R7's bed sheet was slightly damp at the foot of her bed and the ceiling tiles above the foot of her bed had brown stains and appeared wet. Observations of R7 and R8's ceiling tiles showed 16 tiles in their room that had varying amounts of brown stains and six of those ceiling tiles contained black-colored substances. R7 and R8's bathroom contained 4 ceiling tiles that had various amounts of brown stains. V6 (CNA - Certified Nursing Assistant) stated she moved R7's bed earlier because the ceiling was leaking water on her foot, processed a work order earlier, and told facility maintenance that there was water leaking from R7's ceiling. When asked if she reported the black-colored substances on the ceiling tiles, she stated she did not notice the spots on the ceiling prior. On 7/9/26 at 1:54 PM, V5 (Maintenance Director) inspected R7 and R8's ceiling tiles and stated he was not aware of the brown stains or black-colored substances and stated he was not sure if the black-colored substance was mold.On 7/9/26 at 2:07 PM with V5, V1 (Administrator) stated the black-colored substances on the ceiling tiles were mold. On 7/9/26 at 2:08 PM, R8 stated she wanted to move out of the room because of the mold identified on the ceiling tile of her room.2. On 7/9/26 during tour of the rooms of the facility with V1 (Administrator) at 2:10 PM, the rooms of R9 and R10, R11, R12, R15, R16, R17, R18, R19, R20, R21, and R22 all had ceiling tiles in their rooms with black-colored substances identified by V1 as mold. R19 and R20's room had four brown-stained ceiling tiles (one with mold) and one missing tile which exposed water damage in the old ceiling which was covered by a newer ceiling. The paint on the wall below R11's moldy ceiling tile had paint bubbling up and rippling away from the wall and the area of the room smelled like mold. R12 stated the ceiling tiles where the mold was located had water coming from the ceiling recently. R12 stated, I had a waterfall there. One of the tiles in R12's room was bowing down from the ceiling. R18 stated the mold on his ceiling had been there a month. During the tour, V1 (Administrator) stated the stained and molded tiles needed to be replaced because the condensation of the pipes dripped on the ceiling tiles below the pipes. 3. On 7/9/26 at 11:25, V4 (Family) stated in the corner of the ceiling of R1's room there was what looked like mold on the ceiling tiles, water dripping from the ceiling tiles, and there was a mold smell in the bathroom that would not go away. V4 stated the facility replaced the moldy tiles and repainted the room but they were concerned there was still mold in the room.Maintenance policy/procedure, reviewed 7/7/26, shows, 1. All resident care equipment and the building environment will be maintained by the maintenance department. 2. Any staff who is made aware of malfunctioning equipment or any part of the building that is in disrepair will report the issue to the maintenance department. 3. The maintenance department will address the issue as soon as possible. 4. Any equipment that cannot be fixed will be replaced accordingly.

Based on observation, interview, and record review the facility failed to prevent the development of a facility acquired stage 3 pressure ulcer. This failure resulted in R1 developing a facility-acquired stage 3 sacral pressure ulcer. This applies to 1 of 3 residents (R1) reviewed for pressure ulcers in sample 5. The findings include:1.The EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including Type 2 diabetes, multiple sclerosis, hypertension, gastroesophageal reflux disease, low back pain, difficulty in walking, unsteadiness on feet and dementia. The MDS (Minimum Data Set), dated May 11, 2026, showed R1 was cognitively impaired and dependent on staff for toileting, hygiene, bathing and transfers. The MDS continued to show her skin was intact on admission. R1's care plan dated May 11, 2026, showed she had a potential for skin impairment. The care plan said she will continue to have skin intact, and interventions included to keep skin clean and dry turn and reposition at least every two hours and as needed.R1's Skin and Wound note dated May 15, 2026, by V14 (Wound Care Nurse Practitioner) showed on admission, skin was overall intact. Prior sacral ulcer was healed. Plan to continue routine skin assessments, monitor for any signs of breakdown. R1's Nursing admission assessment dated [DATE], showed no existing pressure ulcer.On June 24, 2026, at 11:01 AM, V9 (family member) stated she visited R1 on June 9, 2026, and observed that R1 appeared uncomfortable and complained of pain. V9 also stated she turned R1 to assess her skin and observed two sores on R1 sacrum area V9 further stated she immediately notified V17 (RN/Registered Nurse) that R1 was in pain and showed V17 the wounds. V9 stated V17 assessed the area and asked the CNA (Certified Nursing Assistant) to provide incontinence care and apply a barrier cream and stated that staff were unaware of the sores until she brought them to the nurse's attention.On June 25, 2026, at 11:28 AM, V17 (RN/Registered Nurse) stated that while she was sitting at the nursing station on June 9, 2026, V9 told her R1 was complaining of pain. V17 stated she immediately went to R1's room and assessed the sacral area and observed an open area with no dressing present. V17 stated she instructed the CNA to provide incontinence care and apply barrier cream V17 stated she notified the nursing supervisor who contacted the physician to obtain treatment orders. V17's progress note dated June 9, 2026, showed writer was notified by the resident's family that the resident complained of pain in the buttocks area. Upon assessing the resident, I observed what appeared to be a pressure related wound, possibly related to moisture. The CNA changed the resident and applied a barrier cream. I informed the nurse supervisor, who then notified the medical doctor. Follow up with wound care arranged to ensure ongoing treatment. will endorse the oncoming nurse to follow-up.On June 24, 2026, at 2:16 PM, V13 (CNA/Certified Nursing Assistant) stated she provided care to R1 on June 10, 2026. V13 stated she took R1 to her room to provide incontinence care and observed an skin impairment area on R1's sacral region. V13 stated she immediately reported the findings to the nurse. V13 stated the nurse advised her she would come assess the wound. V13 stated she completed R1's incontinence care and returned R1 to the dining room. V13 stated the nurse did not assess the wound while she was providing care. V13 further stated there was no dressing covering the wound at that time.On June 24, 2026, at 11:58 AM, R1 was sitting in her wheelchair. V16 (CNA/ Certified Nurse Assistant) wheeled R1 to her room. V3 (Wound care Nurses/WCNs) said R1 has a stage 3 pressure ulcer on her sacral area. V3 (WCN) removed R1's silicone boarder gauze dressing to assess the wound. R1's sacrum wound bed had approximately 10% slough, 50% granulation and 40% epithelial. V3 said R1's wound was last assessed and measured on June 24, 2026, by V14. V3 said she performs the wound dressing changes daily and the floor nurses perform any as needed daily dressing changes. V3 cleaned R1's wound with normal saline and gauze. V3 said the wound measured 1.2 cm (length) (centimeter) x 1 cm (width) x 0.1 (depth). V3 applied medi honey, calcium alginate and covered with silicone boarder gauze.On June 24, 2026, at 1:10PM, V3 (WCN) stated she was unsure of the exact date the wound reopened but believed it was around June 10, 2026. V3 stated she received a message regarding the wound during the evening and assessed the wound the following day. V3 stated R1's skin was intact upon admission to the facility. V3 stated that when she first assessed the open pressure ulcer on June 10, 2026, it was covered with slough and appeared as a cluster of two areas. V3 stated that R1 does not stand or walk independently and requires staff assistance with ADLs (activities of daily living). V3 stated R1 was previously continent of bowel and bladder but now requires staff assistance with incontinence care. V3's progress note dated June 12, 2026, showed Resident has been monitored since Wednesday for a suspected wound to the sacral area. During today's assessment, the nurse practitioner identified a Stage 3 pressure ulcer located on the sacrum in an area of previous scar tissue. The wound measures 3.0 cm x 1.3 cm x 0.2cm and presents as a cluster.On June 25, 2026, at 10:35 AM, V14 (Wound NP/Nurse Practitioner) stated the sacral wound reopened but was unsure how long the wound had been present before it was identified. V14 stated that because R1 had a previous open area prior to admission the skin in that area was more fragile and required ongoing monitoring. V14 stated R1 was at an increased risk for skin breakdown due to impaired mobility. V14 stated prolonged pressure to the sacral area and immobility contributed to the development of stage 3 pressure ulcer. V14 stated earlier identification of the wound would have prevented its progression to a stage 3 pressure ulcer. V14 stated it is her expectations that nursing staff perform routine skin assessments, provide timely incontinence care and reposition residents in accordance with the residence care plan. The facility does not have documentation to show that R1 was repositioned every 2 hours per the facility care plan interventions.On June 25, 2026, at 2:40 PM, V2 (DON/Director of Nursing) stated she became aware of R1's wound after V3 (WCN) notified her during wound rounds. V2 stated V3 informed her that the wound had reopened. V2 stated that she was unaware of who initially identified and reported the wound. V2 also stated nursing staff are expected to monitor residents skin during shower days and when completing full body assessments and to immediately report any changes in skin integrity to the wound care team so appropriate interventions can be implemented.The facility's policy titled Wound Care Guidelines dated January 24, 2024, stated the goal of this care guideline is to achieve compliance to regulatory requirements and provide evidence based recommendations for the prevention and treatment of pressure injuries that can be used by the health professionals in the facility. Under the subheading of Prevention of skin breakdown included inspection of skin every shift with care for signs of breakdown, keeping local areas of skin clean and dry and free of body waste, perspiration and wound drainage. Under the subheading of Activity, Mobility and Positioning included while in bed resident should be repositioned at least every two hours or as indicated in the care plan. Under the subheading of Skin Protection included assess and treat incontinence. As part of incontinent care, apply protective ointments.

Based on interview and record review, the facility failed to follow their policy to obtain measurements of a pressure injury during a wound evaluation. This applies to 1 of 3 residents (R1) reviewed for pressure injuries in the sample of 6. The findings include:R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including rheumatoid arthritis, chronic kidney disease, congestive heart failure, pressure-induced deep tissue damage of right buttock, unstageable pressure ulcer of sacral region, and unstageable pressure ulcer of left buttock. R1's skin integrity care plan dated January 13, 2026, [R1] has an actual impairment to skin integrity related to sacral and bilateral buttock wound unstageable pressure ulcer. The care plan continued to show multiple interventions dated January 13, 2026, including Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration, etc. to physician. On January 27, 2026, at 10:43 AM, V3 (Wound Nurse) said she assesses newly admitted residents for skin impairments with 24 hours of admission. V3 said if she is unsure how to measure the wound then she will wait for the next time the wound nurse practitioner comes to that facility. V3 said she did not measure R1's buttock pressure injuries and she is unsure why she did not measure R1's pressure injuries on her buttocks. V3 said sometimes she does not measure pressure injuries because she does not want to measure incorrectly and measure the pressure injury as larger than it is. A Skin/Wound Evaluation dated January 14, 2026, at 5:01 PM, by V3 showed R1 had a suspected deep tissue injury to the bilateral buttocks. The documentation does not show measurements of R1's bilateral buttock pressure injury. A Nursing-Admission/readmission assessment dated [DATE], at 3:57 PM, did not show measurements of R1's bilateral buttocks pressure injuries. A wound assessment report dated January 19, 2026, by V16 (Wound Nurse Practitioner) showed Date of Service: January 16, 2026. Wound 2, Location: Left glute, Primary Etiology: Pressure Ulcer/Injury, Stage/Severity: DTI (Deep Tissue Injury), Wound Status: Present on admission, Size: 6.7 cm (centimeters) by 3.9 cm by 0 cm. Calculated area is 26.13 square cm. Wound Base: 100% (percent) epithelial, Periwond: Intact, Fragile. Wound 3, Location: Right glute, Primary Etiology: Pressure Ulcer/Injury, Stage/Severity: DTI, Wound Status: Present on Admission, Size: 9.3 cm by 5.3 cm by 0 cm. Calculated area is 49.29 square cm, Wound Base: 100% epithelial, Wound Edges: Attached, Periwound: Intact, fragile. On January 27, 2026, at 3:12 PM, V2 (Director of Nursing) said when a resident is admitted to the facility, the admitting nurse will assess the resident for wounds and document what they see. V2 said V3 then comes within 24 hours to assess the resident's skin. V2 said she would think as a nurse, the pressure injuries should be measured when being assessed. V2 said without admission wound measurements, V2 cannot say if a wound had gotten larger between the time the resident was admitted to the facility and when the wound nurse practitioner comes in to assess the resident. V2 said staff should follow the policy for wound care guidelines. The facility's policy titled Wound Care Guidelines dated January 24, 2025, showed Overview of the Program: This facility adheres to the Federal and State regulatory requirements for wound care management and the care guidelines for wound care established by the National Pressure Injury Advisory Panel. The goal of this care guidelines is to achieve compliance to regulatory requirements and provide evidence-based recommendations for the prevention and treatment of pressure injuries that can be used by the heath professionals in the facility. The purpose of the prevention recommendations is to guide evidence-based care to prevent development of pressure injuries and the purpose of the treatment focused recommendations is to provide evidence-based guidance on the most effective strategies to promote pressure injury/ulcer healing. Procedures: .11. Wound assessment for pressure, diabetic, venous, and arterial wounds: Wound assessment documentation shall include but are not limited to: type of wound and/or ulcer, etiology, location, date, stage, (if applicable), length, width, and depth; wound bed description, wound edge description and if present, exudates, undermining, tunneling, and wound related pain.

Based on observation, interview, and record review, the facility failed to ensure a resident's bed had protective pieces in place for the resident's safety. This applies to 1 of 3 residents (R1) reviewed for resident injury in the sample of 6. The findings include:R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including rheumatoid arthritis, chronic kidney disease, congestive heart failure, pressure-induced deep tissue damage of right buttock, unstageable pressure ulcer of sacral region, and unstageable pressure ulcer of left buttock. R1's ADLs (Activities of Daily Living) care plan dated January 14, 2026, showed [R1] has an ADL self-care performance deficit requiring assistance in completing daily needs related to impaired mobility, pain. The care plan continued to show multiple interventions dated January 14, 2026, including Transfer: [R1] requires partial staff assist with sit to stand, chair-bed-to-chair transfer and max staff participation with toilet transfers. On January 28, 2026, at 10:18 AM, V14 (CNA/Certified Nursing Assistant) said she gave R1 a shower on January 19, 2026, and R1 wanted to be transferred back to bed immediately after her shower. V14 said she transferred R1 back to bed and noticed some redness on R1's left lower leg. V14 said she inspected the shower chair and R1's bed for the cause. V14 said she saw there were some square pieces on the middle of the bed frame which were missing the plastic protective pieces. A Skin Alteration Nursing Evaluation dated January 19, 2026, at 8:15 PM, by V15 (RN/Registered Nurse) showed R1 had a rear left lower leg skin tear. On January 27, 2026, at 1:16 PM, V7 (Admissions Director) said he had heard from V9 (Social Services Director) a resident's bed needed to be replaced due to missing plastic protective pieces. V7 said the bed was changed and is now in the basement. On January 27, 2026, at 1:20 PM, V8 (Maintenance Assistant) said the resident's bed was missing two plastic protective pieces located in the center of the bed frame. V8 showed the resident bed with the missing pieces. The bed frame had exposed metal squares with no plastic covering over the metal. On January 27, 2026, at 1:35 PM, V9 said he had a care plan meeting with R1's daughter on January 20, 2026. V9 said at the meeting, R1's daughter said there were missing pieces on R1's bed and R1 scratched her leg on the bed. V9 said he notified V7 of the issue with R1's bed. On January 27, 2026, at 2:53 PM, V1 (Administrator) said a resident's bed should have all the required pieces to ensure the resident's safety.

Based on interview and record review the facility staff failed to promptly report a resident's allegation of abuse to the facility's abuse coordinator in accordance with facility policy. This applies to 1 of 3 residents (R1) reviewed for abuse allegation.The findings include:R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including type 2 diabetes, closed fracture of the left lower leg, chronic diastolic congestive heart failure, legally blind, personal history of malignant neoplasm of the breast, hearing loss, and acquired absence of uterus and cervix, added to diagnoses on September 23, 2025. R1's MDS (Minimum Data Set) dated July 14, 2025, showed R1 was moderately cognitively impaired and required assistance with ADLs including, set up assistance with eating, substantial assistance for turning side to side in bed, and dependent on staff for oral hygiene, bathing, dressing, toileting, personal hygiene, and transfer.R1 had a care plan initiated on February 11, 2025, for the behavior of resisting ADL care due to misunderstanding caregiver requests, that could result in resistance or combative behavior. The interventions to address this concern included: emphasize soothing, kind, slow and compassionate speech when speaking to R1, do not rush or hurry her, use body language that communicates patience and understanding. On October 1, 2025, at 2:45 PM, R1 stated on Sunday evening (September 28, 2025) at 8:00 PM, V10 (CNA) while providing incontinence care, grabbed her left wrist and would not let go when R1 asked her to. R1 stated she was experiencing pain in her abdomen during the care, due to her recent abdominal surgery and she was trying to use her left arm to assist the CNAs reposition herself but V10 kept holding onto her left arm and would not let go when R1 asked her to. R1 stated she swatted at V10 with her right arm so V10 would let go of R1's left wrist. R1 stated she knew it was V10, because she recognized V10's voice and stated V10 is softspoken and R1 often had a hard time hearing V10 when she speaks. R1 stated she told V4 (RN) on the next morning September 29, 2025, when V4 asked R1 how her weekend was. On October 1, 2025, at 1:26 PM, V4 (RN) stated she was R1's nurse on September 29, 2025, during the 7:00 AM and 3:00 PM shift. V4 stated she asked R1 how her weekend was during her morning greeting and R1 told that R1 was rushed through ADL care over the weekend. V4 did not report the allegation to the abuse coordinator. V4 stated she reported the allegation to her supervisor, V3 (ADON, Assistant Director of Nursing).On October 1, 2025, at 1:37 PM, V3 (ADON) stated V4 had reported that R1 alleged she had been rushed through care. V3 stated when she spoke to V2 (Director of Nursing, DON) later in the afternoon, V2 had told V3 that R1's POA (Power of Attorney) made an allegation regarding R1 being rushed during care.On October 1, 2025, at 4:30PM, V9 (Assistant Administrator) stated V2 (DON) reported on September 29, 2025, around 3:00 PM, she received an allegation from R1's POA on a voicemail message. V9 stated V1 (Administrator) was also present when V2 reported the allegation. V9 stated she interviewed R1 and was told that R1 alleged R1 was rushed during ADL care but did not specify when or who had rushed her care. V9 stated based on her interview with R1, V9 determined R1 made an allegation of mental abuse and made an initial report to IDPH and initiated the investigation. V9 stated neither V3 or V4 reported R1's allegation to V9 or V1 when R1 had reported it in the morning. On October 2, 2025, at 1:29 PM, V10 (CNA) stated she was the assigned CNA for R1 on September 28, 2025, 2PM-10 PM shift. V10 stated she responded to R1's call light around 8:00 PM , and R1 requested assistance with incontinence care. V10 stated she gave R1 care for incontinence, assisted by V11 (Agency CNA). V10 stated she was standing on the right side of R1's bed and V11 was on the left side. V10 stated while R1 was lying on her left side, after V10 completed cleaning R1, the clean linens were placed under R1. V10 stated she did hold R1's left hand/wrist to try and assist R1 to turn to the right so the linens could be straightened out underneath R1. V10 stated R1 told V10 to let go of her hand, but V10 did not and continued to try and pull R1 to the right, holding on to R1 left hand/wrist. V10 stated she knew R1 well and knew she did not like to feel rushed through care. V10 stated V11 was able to pull the linens from underneath R1 with R1 only being partially on her right side. V10 stated R1 hit her with her right hand while she was holding R1's left hand. V10 stated she did not report that R1 had hit her until she was interviewed on October 1, 2025. V10 stated she did receive a message from V9 on Monday September 29, 2025, in the late afternoon but did not return the call. V10 stated she worked the next day on September 30, 2025, on the 2PM - 10PM shift on R1's unit and stated neither V9 nor any management staff interviewed her or requested to talk to her during that shift.On October 2, 2025, at 2:05 PM, V11 (Agency CNA) stated she assisted V10 to provide incontinence care to R1 on September 28, 2025, 2PM-10PM shift. V11 stated when V10 and V11 were providing care to R1, R1 was complaining of pain. V11 stated she did see V10 hold R1's left hand and wrist and tried to pull R1 to the right side while trying to pull the clean linens underneath R1. V11 stated R1 was complaining while V10 was holding R1's wrist and V10 did not let go. V11 stated R1 hit V10 with her right hand when V10 was holding R1's left arm. V11 stated she did not report R1 hitting V10, did not report R1 was complaining of pain and did not report V10 had been holding R1's left hand/wrist when R1 had told V10 to let go.On October 1, 2025, at 3:56 PM, V8 (Police Officer) stated the department was just notified of an allegation of abuse that occurred on September 28, 2025. V8 stated R1 had told him during the interview that a staff member had held her left wrist and hand and would not let go when asked while R1 was receiving care on September 28, 2025, during the evening.On October 2, 2025, at 3:54 PM, V14 (CNA) stated she had worked full time in the facility for four years and was very familiar with R1's care needs. V14 stated R1 is blind and deaf , however R1 had never been combative with V14 during care. V14 explained R1 needed to be treated with patience and staff need to explain what staff are going to do. V14 stated R1 likes to assist when she can. V14 stated R1's left hand is her stronger hand and prior to her recent abdominal surgery, R1 would hold the upper side rail with her left hand and scoot herself side to side or up in the bed to assist with repositioning during care.On October 1, 2025, at 4:30 PM, V9 stated it is the expectation that staff should immediately report any allegation of abuse, whether it was reported to them or witnessed by them, to the abuse coordinator. V9 stated V1 (Administrator) is the abuse coordinator however V9 is the assistant and also does abuse investigations and reporting.The facility's policy titled Abuse and Neglect dated June 26, 2025, showed If abuse/neglect is suspected the facility will: 1. Take immediate steps to assure the protection of the resident. This may involve separation from the alleged abuser .3. Conduct a careful and deliberate investigation centering on facts, observations, and statements from the alleged victims and witnesses.II. Training.Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents.Abuse identification and recognizing signs of abuse.III. Prevention.The supervision of staff to identify inappropriate behaviors, .such as rough handling. ignoring residents while giving care. V. Investigation.Interview all involved persons including the victim, perpetrator, witnesses, and others who might have knowledge of the allegation.VII Reporting .All allegations and/or suspicions of abuse must be reported to the Administrator immediately.

Based on observation, interview, and record review, the facility failed to provide timely incontinent care to dependent residents. This applies to 2 of 4 residents (R4 and R5) reviewed for activities of daily (ADL) care in a sample of 5. The Findings Include: 1. R4 is an [AGE] year-old female admitted on [DATE] with cognition intact as per the Minimum Data Set (MDS) dated [DATE]. MDS also documents that R4 is dependent on toilet hygiene. On 3/7/25 at 10:05 AM, R4 stated, They changed me this morning at around 4:30 AM. I want to be changed now. The CNA is supposed to come and change me. On 3/7/25 at 10:10 AM, V5 (CNA) stated, I started 6:00 AM today and am on my way to change R4. We should provide incontinent care to dependent residents every two hours. I was passing breakfast trays. On 3/7/25 at 10:10 AM, R4 was observed with a urine-soaked incontinent brief with brownish discoloration. A review of R4's incontinent care plan documented that the staff checks the resident for incontinent episodes every two hours and as needed and assists the resident in washing, rinsing, and drying her perineum. 2. R5 is an [AGE] year-old female admitted on [DATE] with cognition severely impaired as per the MDS dated [DATE]. MDS also documents that R5 is dependent on toilet hygiene. On 3/7/25 at 10:15 AM, R5 was observed in her bed with her daughter (V9) at the bedside. On 3/7/25 at 10:15 AM, observed V6 (CNA) checking on R5 for incontinence and observed R5 with urine and feces-soaked brief, with dark brown discoloration. V6 stated that R5 is not her resident and she is just helping out another aide. A review of R5's incontinent care plan documented that the staff checks the resident for incontinent episodes every two hours and as needed and assists the resident in washing, rinsing, and drying her perineum. On 3/7/25 at 10:20 AM, V2 (Director of Nursing/DON) stated that the staff should provide incontinent care to residents every two hours and as needed. Moisture Associated Skin Dermatitis (MASD) is developed due to prolonged exposure to moister/urine. The facility presented incontinent, and the Perineal Care policy was revised on 7/31/24 document: Procedures: 1. Do rounds at least every 2 hours to check for incontinence during the shift.

Based on observation, interview, and record review, the facility failed to follow the physician orders to provide wound care to a stage 4 sacral pressure ulcer. This applies to 1 of 3 (R1) residents reviewed for pressure ulcer and treatment in a sample of 4. The findings include: R1 is an [AGE] year-old male admitted on [DATE] with severe cognitive impairment as per the minimum data set (MDS) dated [DATE]. A review of the admission summary note dated 12/31/24 documents that R1 was admitted with an unstageable sacral wound (16.0 x 10.0 x 4.0 centimeter/cm) along with both heels and right knee wounds. The wound assessment report dated 3/6/25 by V7 (Wound Care Nurse Practitioner/NP) documented a stage 4 wound with 100% granulation (15.0 x 12.0 x 3.0 cm). On 3/7/25 at 9:40 AM, observed V3 (Wound Care Nurse) and V4 (Certified Nursing Assistant) providing wound care to R1's sacral wound. V3 stated that R1 came back from the hospital two days ago after the wound was debrided. On 3/7/25 at 9:40 AM, during wound care, R1's sacral wound was observed to have moderate drainage, and V3 cleansed the wound with saline-sprayed gauze instead of irrigating the wound. The wound was packed with hydrogel-moistened gauze instead of calcium alginate. Record review on Physician Order Sheet (POS) documented a wound care order for sacrum wound: Irrigate with normal saline (NS), apply Cavilon barrier spray to the peri-wound area, lightly pack with hydrogel-moistened kerlix, cover with 2 abdominal pads, and secure with tape. Record review on wound assessment report dated 3/6/25 by V7 documented treatment plan with calcium alginate to the base of the wound. On 3/7/25 at 10:20 AM, V2 (Director of Nursing/DON) stated that V3 should have irrigated the sacral wound and packed it with calcium alginate, as recommended by the wound nurse practitioner. On 3/7/25 at 9:45 AM, V3 stated that she didn't have individual saline vials to irrigate the wound, and she used barrier film wipes instead of Cavilon spray as she didn't have that spray. On 3/7/25 at 1:55 PM, V7 stated, I made my wound round with the wound care nurse (V3) yesterday morning, and at that time, I mentioned V3 to use calcium alginate packing as the wound was draining moderate to heavy. Calcium alginate is used to absorb exudate and thereby enhance wound healing. I also recommended calcium alginate packing in my late entry note from yesterday at 7:00 PM. I can't enter my orders into the system as I am from an outside agency. The wound care nurse should have entered the calcium alginate order under the physician's name and packed the wound with calcium alginate. If the physician's (MD) order says to irrigate the wound, they should irrigate the wound as per the MD's order.

Based on observation, interview, and record review, the facility failed to provide timely incontinent care to dependent residents. This applies to 3 of 4 residents (R2, R3, and R4) reviewed for activities of daily (ADL) care in a sample of 4. The Findings Include: 1. R2 is a [AGE] year-old female admitted on [DATE] with mild cognitive impairment as per the MDS dated [DATE]. MDS also indicates that R2 is dependent on toilet hygiene. On 7/19/24 at 9:45 AM, R2 stated, I was changed at 5:00 AM today. I am a little wet now. On 7/19/24 at 10:05 AM, per the surveyor's request, V5 (Certified Nursing Assistant/CNA) checked on R2 for incontinence and found R2 with a urine-soaked diaper and urine smell in the room. On 7/19/24 at 10:05 AM, V5 stated, I started my shift at 6:00 AM, and I didn't change her today. We should check residents every two hours for incontinent care. A review of R2's incontinent care plan documents R2's preference to check on her for incontinent episodes every two hours. R2 also prefers assistance to wash, rinse, and dry her perineum. 2. R3 is an [AGE] year-old female admitted on [DATE] having mild cognitive impairment as per the MDS dated [DATE]. MDS also indicates that R3 is dependent on toilet hygiene. On 7/19/24 at 10:00 AM, R3 stated, They changed me at 4:30 AM. I might be wet now. Upon the surveyor's request, V4 (Registered Nurse/RN) checked on R3 for incontinence. R3 was found with a urine-soaked incontinent brief (urine smell in room) with mild blackish discoloration to brief. On 7/19/24 at 10:03 PM, V4 stated that they should check on residents every two hours to offer incontinent care. A review of R3's incontinent care plan documents R3's preference to check on her for incontinent episodes every two hours. R3 also prefers assistance in washing, rinsing, and drying her perineum. 3. R4 is an [AGE] year-old female admitted on [DATE] with severely impaired cognition as per the MDS dated [DATE]. MDS also indicates that R4 is dependent on toilet hygiene. On 7/19/24 at 10:10 AM, V7 (RN) checked on R4 as per the surveyor's request, and R4 was observed with a double diaper soaked in urine, even the outer layer. On 7/19/24 at 10:45 AM, V3 (Assistant Director of Nursing / ADON) stated, We are supposed to provide incontinent care every 2 hours and as needed. Staff should offer incontinent care more frequently if the residents are on Lasix or heavy wetter. The facility presented incontinent, and the Perineal Care policy was revised on 6/6/24 documents: Procedures: 1. Do rounds at least every 2 hours to check for incontinence during the shift.

Based on interviews and record review, the facility failed to ensure that a resident was free from misappropriation of prescribed narcotic medication. This applied to 1 of 4 residents (R1) reviewed for narcotic/controlled medications. The findings include: The EMR (Electronic Medical Record) showed that R1, a [AGE] year-old with diagnoses that included dementia, alcohol dependence, bipolar disorder, pain in left shoulder, low back pain, fractured left femur, obstructive and reflux uropathy, limitation of activities due to disability, and cardiac arrythmias. R1 was admitted to the facility on [DATE]. The MDS (Minimum Data Set) dated 5/3/2024 showed that R1's cognition was severely impaired with BIMS (Brief Interview Mental Status) score of 6/15. The care plan dated 4/27/2024 showed an intervention to provide prescribed pain medications to R1 for pain management. The care plan also identified R1 with impaired cognitive function, impaired thought processes related to dementia, bipolar disorder, alcohol dependence, major depressive disorder. The POS (Physician Order Sheet) for the month of 7/2024 showed a physician order dated 5/24/2024 for R1 to have Norco 5/325 mg. (controlled/narcotic medication) 1 tablet every 4 hours as needed for pain management. The order was changed on 7/8/2024 for Norco 5/325 mg. to every 6 hours as needed from the original order of every 4 hours. The pharmacy manifest list showed that the facility had received 30 tablets of Norco 5/325 mg on 6/8/2024 and another 30 tablets on 6/28/2024 for R1. The EMAR (Electronic Medication Administration Record) for the month of 6/2024 and 7/1-7/2024 were reviewed. The EMAR showed that for the month of 6/2024, R1 had received 11 tablets of Norco 5/325. The month of 7/1 through 7/7 of 2024 showed that R1 had received 11 tablets of Norco 5/325 mg. This showed that there should still be available Norco for R1 with 60 tablets supplied and 22 tablets used. The facility's incident report dated 7/13/2024 showed that an incident of misappropriation of R1's Norco 5/325 mg. was identified on 7/7/2024 at 11:45 P.M. The report also showed that V4(LPN/Licensed Practical Nurse/routinely scheduled staff night on the dementia unit floor, (where R1 resides) had reported that R1's Hydrocodone 5/325 mg. (Norco) was identified missing during the change of shift narcotic count between her and V3 (RN/Registered Nurse from agency staffing). The facility incident report also showed that V3 was narrowed down as the alleged perpetuator. The incident report also documents that the facility notified the local police, public health and replaced the missing medication for R1. Review of the staffing schedule on 7/6/2024 and 7/7/2024 showed the following nurses on duty on the third floor. They were same nurses for the 2 days that took care of R1. -7/6/2024 and 7/7/2024 for day shift (7:00 A.M.- 3:00 P.M.) was V5 (RN/Registered Nurse/in house staff/routinely assigned to R1) -7/6/2024 and 7/7/2024 for evening shift (3:00 P.M. -11:00 P.M.) was V3 (RN/ from agency staffing) -7/6/2024 and 7/7/2024 for night shift (11:00 P.M. -7:00 A.M.) was V4 (LPN/Licensed Practical Nurse/in house staff/ routinely assigned to R1) On 7/16/2024 at 1:58 P.M., V5 said that she was routinely scheduled to the dementia unit and assigned to R1 during the day shift. V5 said she was scheduled day shift on 7/6 and 7/7 of 2024. V5 said that during the change of shift narcotic count with V3, R1's Norco 5/325 mg. of 7-9 tablets were accounted for based from the narcotic count sheet. V5 said that on 7/7/2024, at changed of shift at 3:00 P.M. again with V3, narcotic count was done. V5 said that R1's Norco was accounted and there were approximately 7-8 tablets. V5 said that since she was regularly assigned to R1, she knows how R1 was being managed with pain which was Norco daily given around early morning. V5 said it was really weird when narcotic count held at the change of shift between her and V4 on 7/7/2024 night/morning shift. V5 said that both of them (V4 and V5) have noticed that (R1) narcotic count sheet showed that (V3) signed off indicating that V3 took 3 tablets of R1's Norco 5/325 the evening of 7/6/2024 at 3:00 P.M., 7:00 P.M. and 10:45 P.M. V5 added that between change of shift on 7/6 and 7/7/2024, it was only the three of us (V3 and V4, V5) that have the access for the narcotic box where (R1's) Norco was placed. It was identified by (V4) that (R1's) Norco 5/325 mg. tablets and the Norco narcotic count sheet form were missing. This was identified during the narcotic count sheet between (V3) and (V4). I believe (V3) took (R1's) Norco but she said she does not know. How could (V3) not know if (V3) was the only one who had the access to the narcotic box prior to being noted it was missing. V5 also said that she did not administer Norco medication to R1 on 7/6 and 7/7 of 2024 during the day shift. On 7/16/2024 at 2:00 P.M., V4 said that she was routinely scheduled to the dementia unit and was assigned to R1 during the night shift. V4 said she was scheduled night shift on 7/6 and 7/7 of 2024. V4 said that during the change of shift with V3 on 7/6 at 11:00 P.M., both counted R1's Norco tablets in the narcotic box. V4 said they both counted the Norco tablets and checked with the Norco narcotic count sheet. V4 said there were approximately 7 tablets of Norco. V4 said she had noticed that R1's narcotic count sheet showed that V3 signed off indicating that she took R1's Norco 3 tablets at 3:00 P.M., 7:00 P.M. and 10:45 P.M. V4 said that she was well aware of R1's routine of taking Norco which was only once a day and was usually given early morning. V4 said it was very unusual that (V3) took 3 tablets of Norco) from (R1) based on the narcotic count sheet. This was very unusual that (R1) had Norco every 4 hours. (R1) was only having daily Norco and was comfortable with a pain patch only. V4 said that during the narcotic count at the change of shift on 7/7/2024 at 11:45 P.M. with V3, V4 noted that R1's Norco tablets and Norco narcotic count sheet were both missing. V4 said she had asked V3 what happened to R1's Norco tablets and the narcotic count sheet. V4 said that V3 kept saying follow your policy, I don't know, I don't know what happened. V4 said she immediately called V2 (Assistant Director of Nursing) due to missing controlled medication. V4 said (V3) might deny that she took the Norco, but she was the only one who had the access to the narcotic box and no one else, so how would she not know what happened to (R1's) Norco. Obviously, she took (R1's) Norco since she was the only responsible staff for that specific narcotic box during her shift. It was already strange the day before when (V5) and I have noticed that (V3) signed off from (R1's) Norco narcotic count sheet indicating she took 3 Norco tablets on 7/6/2024. On 7/16/2024 at 11:24 P.M. V2 said that she had received a call from V4 on 7/7/2024 at around 11:45-11:50 P.M. V2 said that V4 had reported to her that R1's Norco tablets and Norco narcotic count sheet were missing which V4 discovered during the narcotic count with (V3) during the change of shift. V2 said that she immediately called V1 (Administrator), and she had started asking the assigned nurses that took care of R1 (V4 and V5). V2 said that V3 left the building and did not answer her phone despite multiple attempts from V2 to contact her. V2 said that finally with staffing agency's help, V3 had called the facility on 7/9/2024 and said that (V3) kept saying I don't know, I don't know. V2 added that based on interviews, and V3's response it tells a lot without saying anything.

Based on observation, interview, and record review the facility failed to ensure food preparation equipment was sanitized prior to preparing food. This has the potential to affect all 138 residents receiving food from the kitchen. The findings include: The CMS 671 dated 6/24/24 shows there are 139 residents residing in the facility. Facility provided Diet Type Report shows that there is only one resident with an order of NPO (nothing by mouth) and does not receive food from the kitchen. On 6/24/24 at 10:37 AM, V18 (Chef) said that he had just finished pureeing the chicken for lunch and had to finish pureeing the noodles and broccoli. On 6/24/24 at 10:42 AM, V18 went to the prep sink where water was running onto a soiled food processor container, food processor lid, food processor blade, and spatula. V18 grabbed a rag from a green bucket next to the sink and proceeded to use it to wash the items in the prep sink. When finished, V18 returned the rag to the green bucket, removed the items from the sink, and brought all the items to the prep table to begin his puree process. V18 placed the spatula on the prep table and assembled all the food processor components before placing them onto the food processor base. The items were still wet from being washed and were not sanitized. On 6/24/24 at 10:46 AM, V18 returned to the prep table where he began to puree the broccoli. At 10:52 AM, V18 picked up the un-sanitized spatula that was on the prep table and used it to scoop the pureed broccoli out of the food processor pitcher and into a serving pan. At 10:55 PM, V18 brought the food processor components and the spatula back to the prep sink where he continued the same process as before, washing all the items in the prep sink and returning them to the prep table without sanitizing and air drying. On 6/24/24 at 10:55 AM, V17 (Food Service Director) confirmed that the contents of the green bucket were only water with soap. On 6/24/24 at 10:59 AM, V18 began to puree the pasta. At 11:03 AM, V18 finished with the pureed pasta and used the un-sanitized spatula to scoop the pureed pasta into a serving pan. On 6/24/24 at 12:10 PM, V17 said that no additional purees were made for lunch and the ones used for service were the ones made by V18. On 6/25/24 at 1:24 PM, V17 said that V18 should have brought the food processor pitcher, lid, blade, and the spatula to the dish room to wash, rinse, and sanitize the parts. He (V18) . needs to wash, rinse, sanitize, and air dry before starting the next puree. V17 said in a perfect world, the facility would have two or more complete food processor pitchers for the puree process.

Based on observation, interview, and record review the facility failed to ensure a wound was assessed and the wound nurse practitioner notified of a new wound. The facility failed to ensure pressure relieving interventions were in place for residents who are at risk for pressure ulcer for 4 of 5 residents (R98, R105, R121 and R240) reviewed for pressure injuries in the sample of 29. The findings include: 1. On 6/25/24 at 10:59 AM, R98 was lying in bed. R98's left heel was laying directly on the bed. R98's heel protector boots were sitting in the wheelchair in her room. R98 was provided incontinence care. R98 had an open area on her sacrum that was approximately 3 centimeters (cm) x 3 cm x 0.2 cm. The wound was covered in white appearing cream. R98 had scar tissue present in the same area. On 6/25/24 at 11:27 AM, V6 (Wound Care Registered Nurse) said that R98 is at high risk for pressure ulcers. V6 said that R98 has a history of a very large unstageable pressure ulcer on her bottom and has had heel pressure ulcers in the past as well. V6 said that intervention put in place to prevent pressure ulcers for R98 include: an air mattress, frequent incontinence care, repositioning and offloading her heels when in bed. V6 said that the staff notified her of an area they were concerned about on her bottom. V6 said that she went and assessed the area and found that she had a skin tear in the same area as her previous pressure ulcer. V6 said that the flap of skin was still intact, so they kept the piece of skin there but eventually it came off and exposed pink tissue. V6 said that once the skin tear was found, an order to apply zinc cream was obtained and that is the treatment that has been in place daily since. On 6/26/24 at 10:30 AM, V13 (Wound Nurse Practitioner) said that she comes to the facility to see residents two times per week. V13 said that she sees all wound types. V13 said that if she is notified of a new wound, she would see the resident at her next visit to the facility. V13 said that she would do a wound assessment that included the type of wound, description of the wound and measurements of the wound. V13 said that she would ensure that the treatments in place were appropriate for the wound. V13 said that she would then see the resident weekly to do another assessment to ensure that the wound is healing and provide new treatment interventions if it is not healing. V13 said that she was not notified to see R98's wound. V13 said that the last time she saw R98 was in March, and she did not have any sacral wounds. V13 said that she has been to the facility multiple times since 6/7/24. On 6/26/24 at 10:40 AM, V14 (Registered Nurse) performed a wound assessment. The sacral wound measured 3.5 cm x 4 cm x 0.5 cm. The wound bed was pink with two areas in the middle of the wound that had whitish/yellow tissue present. V14 tried to clean the areas off to ensure that it was not cream present. The areas remained after cleaning. On 6/26/24 at 1:00 PM, V2 (Director of Nursing) said that she would expect her staff to report any new wounds to the physician or nurse practitioner to get orders for the wound and report the wound to the wound nurse. V2 said that the wound nurse would then do an assessment of the wound and document the assessment on the skin alteration form. V2 said that the wound nurse would then notify the wound Nurse Practitioner to see the resident on their next visit. V2 said that the wound should be assessed at least weekly or whenever the wound has a deterioration or change. V2 said that the assessments should be documented in the resident's medical record. On 6/26/24 at 1:24 PM, V7 (Nurse Practitioner) said that she went and saw R98's wound today and it looks like a stage 2 to 3 pressure ulcer now. V7 said that the wound bed was pink with a couple areas of yellowish fat tissue present (The National Pressure Injury Advisory Panel says stage 3 pressure injuries are full thickness loss of skin, in which adipose (fat) is visible in the ulcer). V7 said that to her it sounds like the wound started as a skin tear and then developed into a pressure ulcer. V7 said that the nurse should be monitoring and assessing any open area and if it gets worse, they should notify the physician or nurse practitioner. V7 said that R98 had zinc cream previously ordered but now that it is worse, she does not want zinc on it and put in a new order for collagen ointment and a dry dressing. V7 said that they do not do measurements for skin tears but once the wound changed to an open wound, an assessment should have been done at that time and the physician notified. R98's Nursing Notes dated 6/7/24 shows, Called to see pt (patient) due to the CNA (Certified Nursing Assistant) noted skin friction tear, upon assessment noted skin flap intact and pulled over, base of the wound pink and dry. Site is of healed wound area and over scar tissue. Pt already on air mattress, and seen by NP (Nurse Practitioner), treatment ordered. R98's Nurse Practitioner Note dated 6/07/24 shows, The pt was noted to have a new shearing/skin tear on her sacrum Skin: skin tear over sacrum, shearing-new .Plan: Wound care nurse to evaluate; zinc oxide added . No other assessment of R98's wound was documented in her clinical records from 6/7/24 to 6/25/24. There were no skin alteration forms completed in R98's clinical records between 6/7/24 and 6/25/24. There were no measurements or other descriptions of the wound documented until 6/26/24. R98's Quarterly Skin Evaluation Form dated 4/1/24 shows that she is at risk for pressure ulcer development. R98's Care Plan shows she has a history of a stage 4 sacral pressure ulcer and a stage 2 left heel pressure ulcer with intervention to include: off load heels as ordered. The facility's Wound Care Guidelines Policy revised on 1/24/24 shows, Elevate resident heels off the bed as indicated (place pillows under calf .or use heel protectors that offload the heel from the bed surface .The resident's skin alteration/breakdown (pressure ulcer, arterial, diabetic, venous ulcer and etc.) shall be documented in the resident's clinical records Pressure Injury treatment .Timely referral to the facility's Wound Care Specialist for all pressure injuries and/or wounds Wound assessment documentation shall include but are not limited to: type of wound and/or ulcer, etiology, location, date, stage (if applicable), length, width, and depth; wound description, wound edge description and if present, exudates, undermining, tunneling, and wound related pain. 35119 2. On 06/24/24 at 10:25 AM, R240 was in bed with a pillow under her left side. R240's heels were flat on the bed. On 06/24/24 at 12:10 PM, R240 remained in the same position in bed with a pillow under her left side. R240's heels were flat on the bed. On 06/25/24 V6 Wound Registered Nurse said to reduce pressure on heels, interventions of heel boots or offloading the heels with pillows can be used. V6 said R240 does not like heel boots so pillows are used to float her heels off the bed. R240's Skin and Wound Note dated 6/21/24 shows R240 has an unstageable pressure injury to her right hip and shows float heels while in bed with use of foam boots. 3. On 06/24/24 at 12:20 PM, R105 was in bed on her back with her heels flat on the bed. On 06/25/24 at 9:43 AM, R105 was in bed on her back with her heels flat on the bed. R105's Skin and Wound Note dated 5/31/24 shows R105's pressure injury to her left heel is resolved and shows preventative measures: Float heels while in bed with use of heel boots. The facility's Wound Care Guidelines Policy dated 1/24/24 shows Elevate resident heels off the bed as indicated (e.g., place pillows under calf, not under ankles or use heel protector that offloads the heel from the bed surface) to raise heels off the bed. 37232 4. On 06/25/24 at 10:30 AM, 11:25 AM, 12:56 PM, and 2:37 PM, R121 was in bed with his heels resting directly on the mattress. R121's heel protector boots were in the corner of R121's room sitting next to the television. On 06/25/24 at 11:51 AM, V6 (Wound Care Nurse) said R121 had fragile skin and wearing heel protector boots was one of the pressure injury interventions in place for R121. R121's Order Summary Report showed to apply heel boots to bilateral lower extremities for skin protection. R121's care plan showed R121 was at risk for skin breakdown.

Based on observation, interview and record review the facility failed to ensure residents received their range of motion (ROM) exercises as ordered and failed to ensure splints were placed for a resident with contractures as ordered for 4 of 10 residents (R5, R14, R28 and R79) reviewed for restorative services in the sample of 29. The findings include: 1. On 6/24/24 at 10:10 AM, R28 was transferred from his bed to the wheelchair with two person assist. R28 was unable to stand up straight and required maximal assistance to pivot transfer to the wheelchair. R28 was not provided a walker to transfer. On 6/24/24 at 9:53 AM, R28 said that he used to be able to walk but can now barely get out of bed and it takes two people to get him up. On 6/25/24 at 1:38 PM, V3 (Restorative Nurse) said that all residents should receive their ordered restorative services. V3 said that it should be charted under that task section in the computer. V3 said that if the resident refuses, it should still be charted. V3 said that if it was not charted, then it was not done. On 6/25/24 at 2:00 PM, V10 (Restorative Certified Nursing Assistant) said that R28 is in the restorative program. V10 said that they stand him on the side of the bed with two persons daily to help with his leg strength and she either does arm exercises with him or has him use the arm bike for upper extremity strength daily. V10 said that when she performs the exercises, she documents it under the tasks in the computer program. V10 said that she would also document if he refuses. V10 said that she is not able to perform her restorative duties if she is pulled to work the floor but another restorative aide or the restorative nurse should be doing the residents who require restorative services. On 6/25/24 at 2:05 PM, R28 said that they do not have him stand on the side of the bed with his walker because he can't do it anymore. R28 said that he does not ever recall using an arm bike for exercise. R28's Physical Therapy Discharge Summary dated 4/12/24 shows that R28 requires moderate assistance for transfers and can currently ambulate 20-40 feet with his rolling walker. R28's Discharge Recommendations include: restorative range of motion, bed mobility and transfer program. R28's Physician's Order Sheet shows orders dated 5/2/24 for: upper extremity bike range of motion exercises daily for 15 minutes and sit to stand to rolling walker/grab bar as tolerated up to 7 days/week. R28's Electronic Task History shows that R28 is to complete sit to stand with rolling walker or grab bar to strengthen bilateral lower extremities up to 7 days/week. The task history from 5/28/24 to 6/26/24 shows that this was performed 9 times and refused one time. R28's Electronic Task History shows that R28 is to complete upper extremity bike range of motion exercises to increase strength and endurance daily for 15 minutes. The task history from 5/28/24 to 6/26/24 shows that this was performed 7 times. 45540 2. On 6/25/2024 at 12:15PM, V3 Restorative Nurse said R14 has been receiving restorative services since 6/14/2024 since she finished physical therapy. V3 said we try to provide restorative services daily, but it hasn't been daily. V3 said sometimes restorative staff forget to chart when services are provided. V3 said R14 has not had a decline since beginning restorative services. R14's Task: Nursing Rehab: Active ROM and Active Assisted ROM lists recommendations for 15 min sets 2 times per day. R14's task documentation for the last 14 days does not show restorative services documentation for 6/15/2024, 6/18/2024, 6/19/2024, 6/20/2024, 6/21/2024, 6/22/2024, 6/23/2024, 6/24/2024. 37232 3. R79's Face Sheet showed R79 was diagnosed with hemiplegia of his left side. A facility assessment done 4/4/24 showed R79's mental status was intact. On 6/24/24 at 10:29 AM, R79 was in bed with a splint on his left hand. R79 said he had a stroke and could not move his left hand/arm. R79 attempted to move his left hand/arm but was unable to move it. R79 said the facility did not provide range of motion (ROM) everyday. R79 said he goes several days without getting ROM. R79 added that he has gone as long as a week without receiving ROM. R79's Order Summary Report showed R79 was to get passive ROM to his left upper and lower extremities with staff assistance daily as tolerated. R79's Care Plan showed he was on a passive ROM program and R79 was to receive ROM with his daily care. A review of R79's task passive ROM documentation for the last 30 days showed there was no documentation for 5/28/24, 5/30/24, 5/31/24, 6/1/24, 6/2/24, 6/3/24, 6/4/24, 6/5/24, 6/6/24, 6/7/24, 6/8/24 and 6/22/24 (missing 12 out of 30 days). 6/9/24 and 5/27/24 had Not Applicable documented for the ROM. The documentation did not indicate R79 had refused ROM. On 6/24/24 at 1:11 PM, V3 (Restorative Nurse) said he was familiar with R79 and R79 did not refuse ROM. V3 added that R79 was to get ROM to his left upper and lower extremities daily and once the ROM was provided it was to be documented in the task passive ROM. 4. R5's Face Sheet showed R5 was diagnosed with a stroke, hemiplegia, and contractures of the left and right hands. On 6/24/24 at 10:34 AM, R5 was in bed. R5 had a splint to his left hand and a carrot splint in his right hand. R5's right hand/fingers were closed around the carrot splint in a fist like shape. R5 was non-verbal and did not follow directions when asked. R5's Care Plan showed R5 had a self care deficit and impaired mobility related to contractures. Listed under interventions was for staff to provide gentle range of motion as tolerated with daily care and for splints to be applied daily. R5's Order Summary Report showed R5 was to get passive ROM to all extremities up to 7 days a week, a right hand splint, and a left carrot splint to manage contractures. A review of R5's task passive ROM documentation for the last 30 days showed there was no documentation for 5/28/24, 5/30/24, 5/31/24, 6/1/24, 6/2/24, 6/3/24, 6/4/24, 6/5/24, 6/6/24, 6/7/24, 6/8/24, and 6/22/24 (12 out of 30 days). For 5/27/24 and 6/9/24, Not Applicable was documented. On 06/24/24 at 01:11 PM, V3 said he was familiar with R5. V3 described R5 as pleasant, non-verbal and did not refuse ROM or his splint application. V3 added that R5 was to get ROM to all extremities daily and should have his splints placed daily. V3 said that once the ROM and splints were applied it was to be documented in the Tasks. V3 said the restorative aides were to provide the ROM and apply the splints. A review of R5's task splint application for 30 days showed No the splints were not applied on 5/28/24, 5/31/24, 6/1/24, 6/2/24, 6/5/24, 6/6/24, and 6/7/24. On 5/27/24, Not Applicable was documented for the splint application. On 6/25/24 at 1:45 PM, V3 said the floor certified nursing assistants (CNA) were documenting that the splints for R5 were not applied. On 6/25/24 at 11:50 AM, V4 (CNA) said she was familiar with R5 and normally takes care of R5. V4 said floor CNAs do not provide ROM, put on splints, or document about ROM/splints. V4 added that restorative will provide ROM and apply splints. On 6/25/24 at 11:59 AM, V5 (Restorative Aide) said she was the one that provides ROM and applies splints to R5 and R79. V5 confirmed R5 and R79 did not refuse ROM or their splints. V5 said there should be documentation that the ROM was done, and splints were applied. The facility's Restorative Nursing Program policy with a revised date of 6/6/24 showed appropriate nursing and restorative services consistent to the resident's functional needs must be provided. If the assessment showed the resident needs therapy, then therapy should be provided. Restorative programs shall be reflected and indicated in the resident's electronic restorative log in order to document the provision of services and the frequency by the nurses, CNAs and/or restorative aides.

Based on interview and record review the facility failed to treat a resident in a dignified manner. This applies to 1 of 29 residents (R9) reviewed for dignity in the sample of 29. The findings include: On 6/24/2024 at 9:53AM, R9 said on Sunday (6/23/2024) in the morning he put his call light on. R9 said his call light was on from approximately 6:20AM until 8:20AM. R9 said he had soiled himself with stool and urine, requiring staff assistance. R9 said he didn't receive help until after 8:20AM from the nursing staff. On 6/25/2024 at 1:50PM, V9 Registered Nurse (RN) said R9 is very alert and oriented. V9 said R9 is aware of when he needs to be cleaned up and lets staff know. V9 said residents should be checked every 2 hours or as needed. V9 said residents should be cleaned up right away when they are soiled. R9's Minimum Data Set section C dated 5/30/2024 shows a BIMs score of 14, cognitively intact. R9's Task B&B - Bowel charting does not show any documentation on 6/23/2024. R9's Care Plan dated 6/7/2024 states, [R9] is always incontinent of bladder and bowel related to multiple sclerosis . interventions include . I would like staff to check me for inconvenience episode 2 hours. The facility's Privacy and Dignity policy dated 6/6/2024 states, . it is the facility's policy to ensure that resident's privacy and dignity is respected by the staff at all times .

Based on observation, interview, and record review the facility failed to ensure fall interventions were in place for residents with a history of falls for 2 of 29 residents (R108, R33) reviewed for safety in the sample of 29. The findings include: 1. On 6/24/24 at 9:56 AM, R108 was in bed with fall mats on each side of the bed. R108's bed was not in the lowest position. R108 said he fell and broke his hip and leg. On 6/25/24 at 9:46 AM, R108 was in bed (not in lowest position) with the call light on the floor near the head of the bed. On 6/25/24 at 1:55 PM, R108 was yelling out help me. R108's bed was not in the lowest position and his call light was wrapped around the bed rail and dangling down towards the ground, not within R108's reach. On 6/26/24 at 10:48 AM, V3 Restorative Nurse said after R108's fall he implemented the interventions of bed alarm, floor mats, and bed in lowest position. The facility's Post Fall Investigation dated 6/16/24 for R108 shows R108 got up from bed and fell . The same form shows interventions to address incident: Provided resident with bed alarm to alert staff when resident attempted to get up from bed unassisted and provided floor mats on both side of bed, position bed at lowest position. 37232 2. On 6/24/24 at 12:22 PM, R33 was in bed. Hanging on the bed frame was a bed alarm box. The sensor pad for the bed alarm was hanging behind the headboard of R33's bed. The sensor pad cord was unplugged from the bed alarm box. No staff were present in R33's room. On 6/24/24 at 12:32 PM, V4 (Certified Nursing Assistant) confirmed the bed alarm sensor pad was not under R33 and was unplugged from the bed alarm box. V4 said the pad should be under R33 and plugged into the alarm box. R33's Care Plan showed R33 was at risk for falls and requires a bed alarm to prevent falls. The facility's Fall Prevention Program Guidelines policy with a reviewed date of 12/5/23 showed safety interventions shall be initiated and implemented for each resident identified at risk for falls. Place call device within reach at all times and respond to call lights promptly. May utilize personal alarms when appropriate such as bed alarms.

Based on observation, interview, and record review the facility failed to ensure resident nebulizer equipment was stored in a manner to prevent cross contamination for 3 of 6 residents (R3, R26, R69) reviewed for oxygen in the sample of 29. The findings include: 1. On 6/25/24 at 11:52 AM, R3's nebulizer mask/tubing was in an opened plastic bag on the nightstand next to the bed. The plastic bag was dated 4/22/24. R3's June 2024 Medication Administration Record (MAR) shows an order for Ipratropium-Albuterol Inhalation Solution nebulizer treatment was administered on 6/9/24. 2. On 6/24/24 at 10:08 AM, R26's nebulizer mask/tubing was in an open plastic bag on nightstand next to the bed. The plastic bag was dated 4/22/24. On 6/25/24 at 10:32 AM, R26's nebulizer mask/tubing was on the nightstand, still dated 4/22/24. R26 said she uses the nebulizer once in a while. R26's June 2024 MAR shows an order for Ipratropium-Albuterol Solution nebulizer treatment was administered on 6/9/24. 3. On 6/24/24 at 10:07 AM, R69 stated she was short of breath yesterday and received a nebulizer treatment. R69's nebulizer mask was sitting on the base of the nebulizer (not in a plastic bag) and the edges of the mask (which are secured around the resident's mouth and nose) were touching the privacy curtain. The mask/tubing was not dated. On 6/25/24 at 9:55 AM, R69's nebulizer mask remained in the same position, still touching the privacy curtain. On 6/25/24 at 1:00 PM, V16 Registered Nurse said nurses change nebulizer tubing and mask. V16 the tubing should be dated and stored in a plastic bag to prevent contamination and for infection control. V16 said usually there are orders to change the tubing weekly. V16 said if the nebulizer tubing is dated in April, it should be discarded and not used. R69's June 2024 MAR shows an order for Ipratropium-Albuterol Inhalation Solution every 6 hours as needed for shortness of breath/congestion. The facility's Oxygen Therapy and Administration Policy dated 6/6/24 shows Oxygen setups should be changed every seven days and as needed if heavy soiling is present.

Based on observation, interview and record review the facility failed to reorder a resident's medication. This applies to 1 of 29 residents (R340) in the sample of 29 reviewed for pharmacy services. The findings include: On 6/24/2024 at 9:42AM, R340 was observed lying in bed in his room. R340 said he was waiting on the facility to reorder his morphine. On 6/24/2024 at 12:18PM, V8 Registered Nurse said the prescription from the hospital had a requested quantity of 60 but the pharmacy only sent 6 of the morphine tablets. On 6/26/2024 at 10:36AM, V2 Director of Nursing (DON) said the hospital prescription was electronically signed, but the pharmacy requires an actual signature for the medication. V2 said this is why the pharmacy sent only 6 pills and didn't fill the entire script. On 6/24/2024 at 1:39PM, V7 Nurse Practitioner (NP) said the prescription could have been filled over the weekend by the covering provider. V7 said [R340] had oxycodone ordered as well for pain control. V7 said she did refill his prescription for the morphine on 6/24/2024. R340's Medication Administration Record (MAR) dated 6/1/2024 shows an order for Morphine Sulfate ER 60 milligram (mg) give 1 tablet by mouth every 12 hours scheduled for pain. R340's MAR shows the medication was unavailable starting on 6/22/2024 at 9:00AM until 6/24/2024 at 9:00 AM. R340's MAR shows an order for oxycodone 30mg give every 6 hours as needed for pain. R340's MAR shows oxycodone given on 6/22/2024 at 8:31PM, 6/23/2023 8:17AM and 4:18PM for pain management. R340's Morphine prescription from the hospital had a quantity of 60. The facility's prescription quantity shows a quantity of 6 on the morphine label sent by the pharmacy.

Based on observation, interview and record review the facility failed to ensure staff wore personal protective equipment (PPE) when providing direct resident care for residents on enhanced barrier precautions (EBP) for 2 of 29 residents (R28 and R97) reviewed for infection control in the sample of 29. The findings include: 1. R97's current Care Plan shows that R97 is on EBP related to having a gastrostomy tube. The Care Plan shows interventions of: Ensure that gown and gloves are used during high-contact resident care activities (like dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting). On 6/24/24 at 11:14 AM, V15 (CNA) went into R97's room to provide incontinence care and reposition R97. V15 put gloves on but did not don a gown. V15 performed incontinence care and repositioned R97. R97 was observed to have a gastrostomy tube. 2. R28's current Care Plan shows that R28 is on EBP related to an indwelling foley catheter and a surgical wound. The Care Plan shows interventions of: Ensure that gown and gloves are used during high-contact resident care activities (like dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting). On 6/24/24 at 10:05 AM, R28 was observed to have an indwelling urinary catheter. At 10:10 AM, V15 (Certified Nursing Assistant/CNA) went into R28's room and applied gloves. V15 did not don a gown. V15 assisted R28 to sit on the side of the bed. V15 applied a gait belt to R28 and assisted him to his wheelchair. V15 then removed the gait belt and put it around her waist. On 6/26/24 at 9:06 AM, V20 (Infection Preventionist) said that any resident that has a gastrostomy tube, indwelling urinary catheter or wound need to be on EBP. V20 said that the staff need to don gloves and a gown if they are going to have any type of contact with the resident if they are on EBP. The facility's EBP Policy revised on 6/6/24 shows, EBP involves the use of gowns and gloves to reduce transmission of resistant organisms during high-contact resident care activities for residents know to be colonized or infected with MDROs as well as residents with wounds and/or indwelling medical devices .EBP will be used for any resident in the facility: With open wounds .urinary catheter, feeding tube .Examples of high-contact resident care activities requiring gown and glove use among residents that trigger EBP use include: .Transferring, providing hygiene .,Changing briefs

Based on observation, interview, and record review, the facility failed to provide timely incontinent care to dependent residents. This applies to 4 of 5 residents (R1, R3, R4, and R5) reviewed for activities of daily (ADL) care in a sample of 9. The Findings Include: 1. R1 is a [AGE] year-old female admitted on [DATE] with severely impaired cognition as per the MDS dated [DATE]. MDS also indicates that R1 is dependent on toilet hygiene. On 4/9/24 at 9:22 AM, R1 was observed with V5 (Certified Nursing Assistant/CNA) and R1 was observed with an inner liner inside an incontinent brief soaked with urine and feces. V5 stated on 4/9/24 at 9:22AM, I started my shift at 6:00 AM, and I checked her around 6:20 AM, and R1 was dry then. We are supposed to check residents for incontinence every two hours. A review of R1's incontinent care plan documents R1's preference to check on her for incontinent episodes every two hours. R1 also prefers assistance to wash, rinse, and dry her perineum. 2. R3 is an [AGE] year-old female admitted on [DATE] with severely impaired cognition as per the MDS dated [DATE]. MDS also indicates that R3 is dependent on toilet hygiene. On 4/9/24 at 9:35 AM, R3 was observed with V4 (CNA) and R3 was observed with a urine-soaked inner pad inside the incontinent brief. On 4/9/24 at 9:35 AM, V4 stated that R3's preference for an inner pad is care planned, and she will change R3 even though she was not assigned CNA for R3. A review of R3's incontinent care plan documents R3's preference to check on her for incontinent episodes every two hours. R3 also prefers assistance in washing, rinsing, and drying her perineum. 3. R4 is a [AGE] year-old female admitted on [DATE]. As per the MDS dated [DATE], her cognition is intact. The MDS also indicates that R4 is dependent on toilet hygiene. R4 was observed on 4/9/24 at 9:42AM in her bed with a double-layered incontinent brief with inner padding soaked with urine. R4 stated on 4/9/24 that the staff changed her earlier, at around 5:50 AM. Later, V4 provided care and R4 was compliant with incontinent care without refusal. A review of R4's incontinent care plan documents R4's preference to check on her for incontinent episodes every two hours. R4 also prefers assistance in washing, rinsing, and drying her perineum. 4. R5 is a [AGE] year-old female admitted on [DATE] with cognition intact as per the MDS dated [DATE]. MDS also indicates that R5 dependent on toilet hygiene. R5 was observed in her room on 4/9/24 at 9:50AM and stated that the last time she was provided personal care was around midnight. On 4/9/24 at 9:52 AM, V6 (Registered Nurse/Wound Care) checked R5's brief and observed a heavily soaked, blackish-colored incontinent brief with urine and stool smeared all over her buttocks. V6 stated that she is going to change R5. A review of R5's incontinent care plan documents R5's preference to check on her for incontinent episodes every two hours. R5 also prefers assistance in washing, rinsing, and drying her perineum. On 4/9/24 at 12:00 PM, V2 (Director of Nursing/DON) stated, Our staff supposed to check and offer Incontinent care to residents every two hours and as needed. The facility presented incontinent, and the Perineal Care policy was revised on 7/28/23 document: Procedures: 1. Do rounds at least every 2 hours to check for incontinence during the shift.

Based on interview and record review the facility failed to ensure a resident who is dependent on staff received assistance with incontinence care. This applies to 1 of 4 (R1) residents reviewed for activities of daily living in the sample of 4. The findings include: R1's face sheet shows he is [AGE] year-old male with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, morbid obesity, generalized anxiety, and major depression disorder. On 4/2/24 at 9:10 AM, R1 was observed lying in a bariatric bed. He said on 3/28/24 during third shift, V9 (Agency Certified Nursing Assistant/CNA) did not change him during her shift from 10 PM to 6 AM. R1 said he pressed his call light on a few times in the morning and someone answered and said they would come. V8 (CNA) the day shift CNA answered his call light after 6:00 AM to change him. R1 said he was soaked with urine and stool and had not been changed from the night before about 8:30 PM. On 4/2/24 at 9:41 AM, V5 (CNA) said there has been times when she comes in for her shift in the morning and she finds residents who have not been changed. It happened three days ago and its usually agency staff. On 4/2/24 at 11:54 AM, V8 (CNA) said she was R1's CNA on 3/29/24, during day shift at 6:00 AM. When she came in R1's call light was on. He said he needed to be changed. He said he was aggravated with one of the rentals )that's what he calls the agency staff.) R1 was soaked with urine and stool, I had to change the complete bed because it was soiled. R1 is alert and oriented when he voids, he is a heavy wetter. When a resident is soaked it usually means they have not been changed. I had a couple of residents that shift who were soaked. V9 did not give her report in the morning. V8 said, Agency staff they just leave when their shift is over. Residents should be checked and changed every two hours for incontinence care. On 4/2/24 at 1:38 PM, V2 (ADON) said R1 has reported to her concerns with agency staff. A previous time he did report not being changed during a shift and it was true. We try to keep him with our regular staff because he does not like agency staff. R1's current care plan dated through April 2024 shows he is always incontinent of bladder and bowel with interventions for staff to check me for incontinence episodes every two hours. The facility's 2nd floor Assignment Sheet for night shows V9's assignment including R1's room. The Incontinent and Perineal Care Policy reviewed July 2023 states, It is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident to prevent infection and skin irritation and to observe the residents skin condition. Do rounds at least every two hours to check for incontinence during shift.

Based on observation, interview, and record review, the facility failed to provide incontinence care to residents' dependent on staff for care for 5 of 5 residents (R1-R5) reviewed for incontinence care in the sample of 5. This failure resulted in psychosocial harm as evidenced by R2 being upset and angry for lying in a soiled incontinence brief for over four hours and stating it makes her pissed and disgusted, R1sitting in a soiled incontinent brief for over six hours and stating he felt like a second class citizen, and R4 stated in the morning she is soaked through to the bed linens and can't feel like a person when this happens. The findings include: 1. R4's face sheet showed an [AGE] year-old female with diagnosis of rheumatoid arthritis, chronic kidney disease Stage 3, hypertension, heart failure, urinary tract infection, and falls. On 8/24/23 at 10:50 AM, R4 said she urinates a lot and uses incontinence briefs. They put a pad inside my brief too to help. Nobody usually comes in during the night to check and change me. This morning, I was soaked through to the bed linens. I can't move to assist them. It makes me worry about the residents that can't speak for themselves. It's terrible. I can't feel like I'm a person. I have a sore on my bottom that I didn't have before I got here. At 12:22 PM, V4 Director of Nursing said residents should be checked and changed every two hours whether they are alert or not. Some residents want to be independent so may not request assistance. If incontinent care is needed and not given you could have skin issues, infection, and their dignity can be affected. To provide appropriate care for the residents, the staff need supplies and access to supplies. Central supply has a key to the supply area, the receptionist and shift supervisors do as well. At 2:12 PM, V2 facility Medical Director said incontinent residents should be checked and changed every couple hours. That would be appropriate and his expectation. Complications that may occur if incontinence care is not done include UTI (urinary tract infection), sepsis, skin infections, bed sores and worsening of bed sores. Staff should always have access to the needed supplies to provide care to the residents. R4's 7/7/23 facility assessment showed she was cognitively intact, required extensive assistance of one plus persons to physically assist with transfers and toileting. This assessment showed R4 was frequently incontinent of bladder and bowel. R4's care plan showed she was at risk for skin breakdown and to keep her skin clean and dry. R4's ADL care plan showed a self-care deficit and impaired mobility related to a UTI (urinary tract infection), gout, and myeloplastic syndrome. This care plan showed R4 required extensive staff participation to toileting. R4's incontinence care plan showed for staff to check on her every two hours and that she requires assistance to wash, rinse, and dry her perineum. R4's physician order sheet showed a 6/4/23 approval of the care plan. The facility's 7/28/23 Incontinent and Perineal Care Policy showed it is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition. Do rounds at least every two hours to check for incontinence during shift. The facility's 7/28/23 General Care Policy showed it is the facility's policy to provide care for every resident to meet their needs. The facility will evaluate the need for physical and psychosocial needs. Physical needs would include ADL, wound care, medical needs, etc. Psychosocial needs would include but are not limited to areas of mental and psychosocial well-being. The facility will assist the resident to meet these needs. 2. R1's face sheet showed a [AGE] year-old male with diagnosis of right sided hemiplegia and hemiparesis following a cerebral infarction, dementia, heart failure, urinary tract infection, major depressive disorder, anxiety disorder, bilateral deep vein embolism and thrombosis, morbid obesity, hypertension, and acute respiratory failure. On 8/24/23 at 9:45 AM, R1 was lying in bed on his back. R1 said he was currently sitting in a soiled incontinent brief. R1 said he was last changed around 4:00 AM. R1 said the staff were aware but did not have the supplies available to change him. R1 said if they can't get to me, how many others aren't getting care? It happens a lot. It makes me feel like a second-class citizen. At 10:25 AM, V8 Certified Nursing Assistant (CNA) said she's waiting on the big diapers. V8 said there are four resident who use bariatric diapers and identified R1, R2, and R3 as those that do. V8 said R4 wears a 2XL incontinent brief and had been given incontinence care her shift (6 AM-2 PM). V8 said R1-R3 had not been given incontinence care this shift because there were no bariatric incontinent briefs available to use. V8 said this has been going on for weeks and management gets mad when we ask for supplies and reprimand us if we talk to you. Another CNA made a list of each resident's incontinent supply needs (on the second floor) and gave it to V1 Administrator about a week ago. At 10:45 AM, V8 entered R1's room to provide incontinence care. R1's 7/14/23 facility assessment showed he could make himself understood and was able to understand others, required extensive assistance of two plus persons to physically assist for bed mobility and toilet use. This assessment showed R1 had upper and lower extremity impairment on one side and was always incontinent of bladder and bowel. R1's care plan showed he was at risk for skin breakdown related to impaired mobility and incontinence. Keep skin clean and dry. R1's 6/7/22 care plan showed antibiotic use related to recurrent UTI (urinary tract infection). R1's ADL (activity of daily living care plan) showed he requires extensive assistance of two staff for peri care. R1's incontinence care plan showed staff to check every two hours for incontinence and aid wash, rinse, and dry his perineum. R1's physician order sheet showed a 7/12/23 order for certification and approval of the care plan. 3. R2's face sheet showed a [AGE] year-old female with diagnosis of morbid obesity, chronic kidney disease Stage 4, chronic obstructive pulmonary disease, heart failure, type 2 diabetes, and major depressive disorder. On 8/24/23 at 10:07 AM, R2 was lying in bed with a sheet and incontinent brief on. R2 said she was incontinent and asked to be changed at 7:00 AM. It's absolutely friggin ridiculous. It makes me extremely pissed and disgusted. R2 said the CNAs don't have access to the supplies so it's not their fault. I wouldn't treat my dog like this. This happens almost daily. R2 said she called V3 Assistant Administrator several times to complain. V3 didn't respond until I told her I was going to call the state. After that, diapers appeared and now it's starting over again. At 10:30 AM, V8 accompanied this surveyor to the clean utility room. There were no bariatric incontinent briefs on the shelf and one open package of 2XL briefs. V9 Central Supply was in the clean utility room stocking incontinent supplies. V9 said bariatric briefs are locked in the medication room and staff must ask the nurse for those supplies. V9 accompanied this surveyor into the medication room and there were no bariatric incontinent briefs available. At 10:46 AM, V9 said supplies used to be kept in resident rooms but it was a fire hazard to store the briefs on the top shelf near the sprinklers. Staff were using the bariatric briefs on the wrong residents, so none were available when a bariatric resident needed them. So now, the nurses restricted them. Staff must ask the nurse for the bariatric briefs. At 11:17 AM (four hours after R2 asked to be changed), V8 CNA removed R2's two incontinence briefs. There was a 2XL and a bariatric brief on R2. Urine had soaked through the 2XL brief (closest to R2's skin) and the bariatric brief. R2's skin was intact to her buttocks. R2 and V8 said R2 needs to be changed at least four times a shift. At 11:37 AM, incontinence care and supplies concerns were discussed with V1 Administrator. V1 said staff were not using briefs inappropriately so the 3XL (bariatric) briefs were locked in the med room. At 12:37 PM, V14 Registered Nurse (RN) said V8 asked her for some 3XL incontinent briefs this morning and there were none available. V14 said she didn't notify anyone that they needed supplies because there's no one to call until V9 gets here after 8:00 AM. V14 said even after 8:00 AM, she did not call anyone. R2's 6/15/23 facility assessment showed she was cognitively intact, required extensive assistance of two plus persons to physically assist with bed mobility and toilet use. This assessment showed R2 was always incontinent of bowel and frequently incontinent of bladder. R2's care plan showed she was at risk for skin breakdown related to incontinence and to keep skin clean and dry. R2's ADL care plan showed she required two staff to assist with peri care. R2's incontinence care plan showed for staff to check her for incontinence every two hours, and she required assistance to wash, rinse, and dry her perineum. 4. R3's face sheet showed a [AGE] year-old female with diagnosis of morbid obesity, polyosteoarthritis, Asperger's syndrome, and hypertension. On 8/24/23 at 10:20 AM, R3 was laying in her bed uncovered with a hospital gown and incontinent brief on. R3 said she was currently laying in a wet brief. R3 said she's used to it as she's had incontinence and a lot of leakage for about [AGE] years. R3 said sometimes she calls to be changed and sometimes she doesn't. R3 said she hasn't complained although she sometimes waits over an hour for someone to change her. R3's 7/8/23 facility assessment showed she was cognitively intact, required extensive assistance of two plus persons to physically assist to toilet and transfer. This assessment showed R3 was always incontinent of bowel and bladder. R3's care plan showed she was at risk for skin breakdown related to muscular disorders, obesity, osteoarthritis, and abnormal gait and mobility. Keep skin clean and dry. R3's ADL care plan showed she required 2 staff to participate in toileting and transfer. R3's incontinent care plan showed for staff to check her for incontinence every two hours and needing assistance to wash, rinse, and dry, her perineum. 5. R5's face sheet showed a [AGE] year-old female with diagnosis of multiple sclerosis, depressive disorder, hypertension, type 2 diabetes, moderate protein-calorie malnutrition, and obsessive-compulsive disorder. On 8/24/23 at 11:15 AM, R5 was laying supine in bed. R5 said she wears incontinent briefs and is not checked or changed during the night unless she puts her light on. I'm always wet in the morning. Sometimes I wear two diapers and soak through both by morning. They don't have supplies. Sometimes they're out of diapers, pads and wipes. The staff look just not happy when they don't have the supplies to care for you. It's not the CNAs fault. R5's 8/15/23 facility assessment showed she was cognitively intact, dependent on staff for toilet use, and required extensive assistance for bed mobility and transfer. This assessment showed R5 was frequently incontinent of bladder and bowel. R5's care plan showed she was at risk for skin breakdown related to immobility and incontinences. Keep skin clean and dry. R5's care plan showed impaired mobility related to multiple sclerosis. R5's ADL care plan showed she required total staff participation to use the toilet and two staff to transfer. R5's incontinence care plan showed for staff to check for incontinence every two hours, and she required assistance to wash, rinse, and dry her perineum.

Based on observation, interview, and record review, the facility failed to follow their policy for transferring residents using a gait belt or mechanical lift device. This failure resulted in R8 sustaining an arm fracture (left humerus fracture) following a fall, due to an improper transfer. This applies to 3 of 3 residents (R2, R6, and R8) in the sample of 9. The findings include: 1. On April 14, 2022, at 9:16 AM, R8 was sitting in his bed. R8 had an arm sling loosely hanging over his left arm. R8's left arm hung limp at his side. Bruising was visible on R8's upper left arm. R8 said he has a history of a stroke and has no use of his left arm. R8 demonstrated his inability to use his left arm and used his right hand and arm to reposition his left arm to a comfortable position. R8 said he fell to the floor recently after an employee tried to transfer him from his bed to a wheelchair without the use of a mechanical lift device. R8 said, [V12] (CNA-Certified Nursing Assistant) was trying to move me off of my bed to a wheelchair. I didn't understand it, but for some reason they were moving me to a new room that day. [V12] was getting me up off of the bed. He did not use the mechanical lift. He did not put a gait belt around my waist. He uses that belt to hold up his own pants. He said he was in a hurry because they wanted the room change right away. He did not bring anyone else in the room to help him. He got me to the edge of the bed and wrapped me in a great big bear hug and tried to pick me up. Since I cannot use my left arm, I really couldn't hold onto him at all or help. I was almost up to a standing position, but I was too heavy for [V12] and we both fell down to the floor at the same time. My left arm just flew up in the air because I do not have any control over that arm, and my left arm hit me in the head. They did an X-ray on my left shoulder because I was having a lot of pain, and they found my upper left arm is broken. Now I have to wait and see if I will need surgery to fix it. The EMR (Electronic Medical Record) shows R8 was admitted to the facility on [DATE]. R8 has multiple diagnoses including, cerebral infarction, contracture of the left hand, [CONDITION(S)] affecting the left non-dominant side, major depressive disorder, and [CONDITION(S)]. R8's MDS (Minimum Data Set) dated April 1, 2022, shows R8 is cognitively intact. R8 is totally dependent on facility staff for transfers between surfaces, requires extensive assistance with bed mobility, and is independent with eating. R8's MDS continues to show R8 has functional limitation in range of motion, with impairment on one side of his body for both his upper and lower extremity. R8 requires a wheelchair for mobility. R8's care plan for ADL (Activities of Daily Living) self-care performance deficit and impaired mobility, related to cerebral infarction and [CONDITION(S)] affecting R8's left non-dominant side, was initiated on August 25, 2021. Interventions dated August 25, 2021, include: [R8] requires [mechanical lift] 2-person assist for transfers. The facility's fall investigation report dated April 5, 2022, shows R8 experienced a fall on April 5, 2022, at 1:00 PM during a transfer between surfaces by V12 (CNA). The report shows there were no predisposing environmental factors. Predisposing physiological factors include left [CONDITION(S)], lower extremity weakness, and reduced range of motion. The report continues to show the predisposing situation factors were unsafe transfer without assist. On April 14, 2022, at 12:01 PM, V12 (CNA) said, [R8] was having his room changed the day he fell (April 5, 2022) because his roommate and he were having disagreements, I believe. It was in the middle of lunchtime, and we were getting food ready for all the residents, and they were telling me to get him ready to go because the person that was switching rooms with him was on the way to the room already. Everyone was busy passing trays and helping, so I went in and tried to transfer him quickly and by myself. I was getting ready to transfer him by myself, and he fell . That was the first time I cared for him in quite a while. I'm a permanent CNA on that floor, but I have not cared for [R8] in a long time. I did not check his transfer status. I didn't think to. He was supposed to be transferred with a two-person mechanical lift. I didn't think about checking his transfer status, and I didn't think about asking the nurse. I just wanted to get him from the bed to the wheelchair and to his new room before the other resident got there. I tried to lift him to a standing position by myself, and he slipped down to the floor. I realized when he was on the floor, this wasn't the right way to transfer him. After the situation I realized I messed up. They used to post a paper on the inside door of the resident's closet showing the resident's transfer status. I didn't even think about looking at it. On April 14, 2022, at 11:31 AM, V15 (NP-Nurse Practitioner) said, [R8] has a left humerus fracture caused by the fall he had on April 5, 2022. That's his bad side. He has no strength in his left arm. He cannot hold onto a staff member or assist with a transfer between surfaces due to the weakness on his left side and inability to use his left arm. He has full cognitive function and safety awareness, but he was trying to not rock the boat and went with the flow and let the CNA transfer him inappropriately. His arm fracture was caused by this fall and the inappropriate transfer by facility staff. On April 14, 2022, at 1:09 PM, V1 (Administrator) and V2 (DON-Director of Nursing) said R8's fall with fracture was caused by improper transfer and R8 should have been transferred using a mechanical lift device and two staff members. 2. On April 13, 2022, at 9:24 AM, R6 was sitting in his bed while the nurse administered his medications. R6 had just finished eating breakfast. R6 was not able to answer questions regarding his fall in February 2022 due to his cognitive status. The EMR shows R6 was admitted to the facility on [DATE], with multiple diagnoses including, cerebral palsy, [CONDITION(S)] (Urinary Tract Infection), norovirus, unsteadiness on feet, lack of coordination, abnormal posture, left hand contractures, hypertension, [CONDITION(S)], major depressive disorder, dementia without behaviors, cerebral infarction, Alzheimer's disease, and diabetes. R6's MDS dated [DATE], shows R6 has severe cognitive impairment, requires supervision with eating, is totally dependent on facility staff for bathing, and requires extensive assistance with all other ADLs including bed mobility and transfers between surfaces. R6's care plan, initiated January 11, 2022, shows R6 is at high risk for falls related to current medication use, poor safety awareness, unsteady gait, disease process cerebral palsy, [CONDITION(S)], weakness and dementia. R6's care plan for ADL self-care performance deficit and impaired mobility, initiated October 4, 2021, shows multiple interventions dated October 4, 2021, including, [R6] requires mechanical sit-to-stand lift with 2-person assist for transfer. R6's fall risk assessments dated June 19, 2021, and February 16, 2022, show R6 is a high risk for falls. The facility's fall investigation for R6, dated February 16, 2022, shows the following: Incident Description: At 6:20 PM, notified by CNA that resident on the floor. Resident was observed sitting position next to his bed. Per CNA, The wheelchair rolled back while I was assisting him to stand. I got him to the edge of bed, but he started moving and sliding down. Couldn't get to the wheelchair and secure him at same time, so I eased him to the floor. Resident wheelchair was locked and wearing non-skid socks. V16 (LPN-Licensed Practical Nurse) documented on February 16, 2022, at 11:08 PM, At 6:20 PM, notified by CNA that resident on the floor. Resident was observed sitting position next to his bed. Per CNA, I was putting him to bed, got him to the edge of bed, he started moving and was about to fall off. I couldn't get to wheelchair and secure him at same time, so I eased him to the floor. Nursing documentation continues to show R6 did not sustain any injuries. On April 14, 2022, at 1:09 PM, V2 (DON-Director of Nursing) said, [R6's] fall was due to improper transfer. The CNA should have been using a sit-to-stand mechanical lift with another staff person present. She did not use the mechanical lift and was attempting to transfer the resident by herself. 3. On April 14, 2022, at 11:14 AM, V14 (CNA) transferred R2 from the wheelchair to her bed. V14 looked around R2's room for a gait belt. R2 said, I've never seen a gait belt in my room, and no one has ever used a gait belt on me, except during therapy sessions. V14 was unable to locate a gait belt to use for R2's transfer. V14 proceeded to place his hands under R2's armpits and lifted the resident to a standing position next to her wheelchair. Once R2 was in the standing position, facing the bed, V14 held onto R2's hands and asked R2 to pivot before assisting R2 to a sitting position. Multiple times during the transfer, R2 said, I'm scared, I don't want to fall. The EMR shows R2 was admitted to the facility on [DATE]. R2 has multiple diagnoses including, heart failure, weakness, unsteadiness on feet, lack of coordination, abnormal posture, anxiety disorder, major depressive disorder, [CONDITION(S)], and dementia. R2's MDS dated [DATE], shows R2 is cognitively intact, requires extensive assistance for transfers between surfaces, and has a functional limitation in range of motion, with impairment on one side of her upper body. R2's MDS continues to show R2 had one fall since her admission to the facility and did not sustain an injury due to the fall. R2's care plan for ADL self-care performance deficit with interventions, initiated March 4, 2022, shows, Transfer: [R2] requires extensive staff participation with transfers. R2's fall risk assessment dated [DATE], shows R2 is a high risk for falls. On April 14, 2022, at 10:47 AM, R2 said she fell in the shower at the facility in mid-March 2022. R2 said, I was sitting on the shower chair in the shower. We were finished with the shower, and the CNA pulled on the shower chair from the front of the chair. The whole chair tipped forward and I fell right out of the chair onto the wet floor. I was unable to stand up with just the one CNA, so someone else had to come and help me stand. On April 14, 2022, at 1:09 PM, V2 (DON) said, facility staff should use a gait belt when transferring R2 from the wheelchair to the bed. Facility documentation dated March 13, 2022, shows, At around 07:13 AM, CNA reported that resident was sitting in the shower chair, and she was drying the resident when the chair moved, and resident slid forward. CNA was able to catch resident, but she was not able to bear residents weight and assisted her down to the floor. CNA then informed this writer. Resident was immediately assessed, no injury noted upon assessment. Resident did not hit her head. She is able to move all of her extremities within her normal limits. Resident was assisted back to the shower chair with 2-assist. Then back to her room and back to her bed. The facility's policy entitled Gait Belt, revised on July 28, 2021, shows: Policy Statement: The facility will use gait or transfer belts to assist residents needing limited to total assistance during transfers and walking. Procedures: 1. Staff will use a gait/transfer belt on residents who need limited to total assistance with transfer or walking. 2. 1-2 staff might also assist a resident while using a gait belt during transfers and ambulation. 3. Residents who need extensive to total assistance of 1 or more staff might also need the aid of a mechanical lift transfer. 4. If a mechanical lift is used on a resident, 2 staff members are needed during the procedure. The facility's policy entitled Mechanical Lift Transfers, revised on July 28, 2021 shows: Procedures: .5. There will always be 2 staff to assist resident. One staff will control the lift as the other will guide resident and support back and neck to transfer surface.

Based on observation, interview, and record review, the facility failed to ensure a resident was free from the use of side rails as a restraint, failed to assess a resident for the need of side rails, and failed to provide other less restrictive interventions prior to the application of side rails. This failure resulted in R1 becoming entrapped in the side rail and sustaining a 20 centimeter (7.8 inch) long, gaping laceration, down through the muscle to the bone. This failure resulted in Immediate Jeopardy. The immediate jeopardy was noted to begin on (MONTH) 28, 2019 when V9 (RN-Registered Nurse) placed two siderails in the upright position to keep R1 from exiting the bed. V1 (Administrator) was notified of the Immediate Jeopardy on (MONTH) 26, 2019 at 12:24 PM. Although the immediacy was removed on (MONTH) 21, 2019, the facility remains out of compliance at Severity Level 2 due to the need to evaluate the implementation of new policies and procedures and Quality Assurance monitoring. This applies to 3 of 4 residents (R1, R2, R3) reviewed for restraints in the sample of 4. The findings include: 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on (MONTH) 28, 2019 at 4:30 PM with multiple [DIAGNOSES REDACTED]. R1 was transported from the facility to the local hospital by paramedics on (MONTH) 29, 2019 at 1:00AM. R1 did not return to the facility. R1's MDS (Minimum Data Set) dated (MONTH) 5, 2019 shows R1 had required extensive assistance with bed mobility. All other ADLs (Activities of Daily Living) showed activity occurred only once or twice or activity did not occur during the observation period. R1 was occasionally incontinent of bowel and bladder. Other areas of the MDS were not completed due to the limited amount of time R1 was in the facility. R1's interim care plan dated (MONTH) 29, 2019, failed to include a care plan or interventions for bed mobility and did not have any interventions in place for the use of assistive rail devices, side rails, or a pad sensor alarm. Facility documentation shows R1 was admitted to the facility with four wounds including: a skin tear on the right upper shin measuring 2 cm. long x 1 cm wide x no depth documented (0.78 inches x 0.39 inches), a right lower shin skin tear measuring 3.5 cm long x 3.0 cm wide x 0 cm deep (1.37 inches x 1.1 inches x 0 inches), a right lateral lower extremity skin tear measuring 1.0 cm. x 1.0 cm. x no depth documented (0.39 inches x 0.39 inches), and a left upper shin skin tear measuring 3.0 cm x 2.0 cm. x no depth documented (1.1 inches x 0.78 inches). R1's Nursing Admission assessment dated (MONTH) 28, 2019 and completed by V9 (RN) shows R1 was oriented to person only and had garbled speech. R1's range of motion was within normal limits, and R1 had no assistive devices. R1 had bilateral lower extremity weakness. R1's Fall Risk Assessment, completed during the admission assessment shows R1 had intermittent confusion, had a history of [REDACTED]. The fall risk assessment showed R1 had a balance problem while standing and walking and decreased muscular coordination. R1 had multiple predisposing diseases. R1's fall risk score was 16, meaning R1 was a high risk for falls. R1's nursing admission assessment did not have any documentation to show a side rail assessment was completed for R1. On (MONTH) 19, 2019 at 11:49 AM, V9 said, When we admit a resident, if we notice the resident is only alert times one we put the side rails up, and a pad sensor bed alarm on. It is at the discretion of the nurse as to how we put the side rails. On (MONTH) 21, 2019 at 9:55 AM, V9 said, I did (R1's) assessment around 5:00 PM on (MONTH) 28, 2019 and that is when I put up the side rails because she had tried to get out of the bed while I was doing the assessment. On (MONTH) 19, 2019 at 11:11 AM, V2 (DON-Director of Nursing) said the facility does not have a policy regarding the use of side rails. Usually therapy or restorative will make the determination if side rails are needed. We don't have side rails here, we call the side rails assistive devices. All the beds in the facility have side rails and it's just a matter of if the side rail is up or down. I think the side rail assessment is part of the admission nursing assessment. On (MONTH) 19, 2019 at 2:16 PM, V5 (Restorative Nurse) said, Typically we aren't supposed to use side rails. Side rails are more for restraints. As a restorative nurse, I don't have any sort of assessment for the use of side rails. Per policy, both siderails aren't supposed to be up because that's considered a restraint. I don't do anything as far as the use of a side rail. The side rails are already attached on the bed the way they are. When someone comes from the hospital, there's no assessment per se to see who goes into the room with the side rails. On (MONTH) 19, 2019 at 4:24 PM, V7 (Director of Rehab) said, The side rails are ordered by the facility. We work with what's in place on the bed, we don't make the recommendations. We do assess for bed mobility, but we do not do an assessment for the safety or use of a side rail assistive device. On (MONTH) 20, 2019 at 9:31 AM, V1 (Administrator) said, the facility does not have any documentation to show an assessment had been completed for the use of the side rail assist devices for R1. V1 could not say what specific criteria had been met to determine the need for the side rails for R1. On (MONTH) 29, 2019 at 2:05 AM, V8 (Nurse) documented: Around 12:30 AM, while doing rounds to (R1's room), noted patient screaming. Went to check on her. Noted large amount of blood on the floor near her bed. She was sitting on the bed. Her right leg was caught on the assistive device (bottom part) and her left leg caught on the middle part. Bed alarm was not sounding. Her right leg skin was scraped. Called for help right away. Co-nurses and supervisor came. 3-11 RN able to move assistive device up to release legs. Supervisor applied pressure dressing to right leg. Bleeding stopped and applied steristrip. (R1) verbally responsive. Open area 20 x 4. Depth 1 cm., blood pressure 158/79, pulse 104. While supervisor doing (applying treatment) to her right leg, patient noted resisting. 3-11 RN notified (V12-Physician) and called family. Patient out to ER thru 911 per MDs order. Paramedic documentation shows they arrived at the facility at 12:59 AM on (MONTH) 29, 2019 and transported R1 to the local hospital at 1:12 AM. Hospital documentation dated (MONTH) 29, 2019 at 1:35 AM by V16 (Physician) showed, R1 Got her legs caught in a bar causing extensive lacerations to her right lower extremity, which go all the way down to the bone, and involved the muscle, and she also has lacerations to the anterior aspect of her left lower extremity and right calf area. There is a very deep right anterior lower leg laceration extending almost the entire length of the tibia on the right side and down through the muscle down to the bone, no foreign bodies identified, the wound is gaping open and actively bleeding. This laceration is approximately 20 cm (7.87 inches), there is a 4 cm (1.57 inches) U-shaped skin tear on the right calf which is superficial, epidermis only. There are 9 cm (3.5 inches) worth of lacerations to the anterior aspect of the left leg which extends through the dermis, one is proximal, and one is distal, distal pulses and distal motor and sensory function grossly intact, and there is bruising and hyperpigmentation to the lower legs bilaterally. Emergency Department Patient Summary dated (MONTH) 29, 2019 shows, Laceration repair: Simple (single layer only) repair of bilateral lower extremity lacerations were performed. Total length of wounds repaired was 29 cm (11.4 inches). Greater than 20 sutures were placed to reapproximate the wounds. Final Diagnosis: [REDACTED].#2 dementia, #3 bilateral lower extremity contusions. On (MONTH) 19, 2019 at 11:49 AM, V9 (RN-Registered Nurse) said, I remember the situation with (R1). I was the admitting nurse that day, so I did her admission assessment, but I was not assigned to her care. The night nurse found her, and she called us and we all went to the room to help her. When we went in the room, there was a lot of blood on the floor, and a cut on the left side of her lower leg on her shin. Her legs were caught in the side rail. Her head was at the head of the bed, and that's why the alarm didn't go off. We cleaned her legs and removed them from where they were caught. After we cleaned her we called 911 and sent her to the hospital. We called 911 because there was a lot of blood on the floor, not due to any behaviors she was having. I don't know when the last time was that someone saw her. On (MONTH) 19, 2019 at 3:28 PM, V9 (RN) went to an empty resident room and demonstrated the type of bed R1 was using at the facility and the type of side rails that were in place when her legs became entrapped in the side rail. V9 demonstrated the side rail placement on R1's bed at the time of the incident. V9 showed bilateral side rails and said R1's side rails were in the up position on each side of R1, with both rails extending from approximately her chest to her mid-thigh or knee. V9 said, We found her in the bed with her legs caught between the rails. Her legs were very skinny and fit between the rails. Her one leg was hanging down low and was hitting the sharp part of the side rail and it was bleeding a lot. Mostly in this facility everyone gets side rails and the rails will be half rails like we used on (R1). It is up to the nurse's discretion how to place the rails, especially if we think they will try to get out of bed. She could not remove the side rail on her own. At 4:18 PM, V9 said, The 20-centimeter laceration that happened from the side rail was not one of the same skin tears I assessed when I did (R1's) initial assessment, it was a new wound. On (MONTH) 19, 2019 at 3:33 PM, V8 (Nurse) said, I remember (R1). I was the incoming nurse. I heard her screaming. She was sitting at the edge of the bed with her legs between the rails of the side rail. There was a lot of blood all over the floor. I called a bunch of other nurses. They had to release the side rail to get her legs out. On (MONTH) 20, 2019 at 2:52 PM, V14 (RN) said, We heard someone calling out for help, with her foot caught underneath the siderail. I do remember there being a lot of blood. I was one of the people who put the steri-strips on to control the bleeding. I remember the wound was deep. I know the incident happened over an hour after nurse handoff. She had dementia. I do remember asking to move her to a bed closer to the nurse's station, so I could keep an eye on her and I was told that the bed we had available was for a resident coming the next day. I wanted her closer to me because she was a fall risk and I didn't want her getting out of the bed. The bed she was in was behind a wall and I could not directly see the resident from the hallway. On (MONTH) 20, 2019 at 3:07 PM, V12 (Physician) said, I came and saw the resident the night R1 was admitted to the facility, and I talked with the family. I believe I saw R1 around 9:00 PM. R1 was not acting aggressive or inappropriate at that time. R1 was easily confused, and R1 was trying to get out of the bed, so the side rails were used. I think the nurse used his own judgement to put up the side rails. R1 did get up and go to the bathroom on R1's own. I don't know the details of the facility's protocol for the use of side rails. I think it's not a bad idea to have a protocol, so all nursing staff are on the same page with using the side rails and trying less restrictive measures like mattress bolsters, low beds or floor mats. The laceration on R1's leg was caused by the rail or something on the bed. On (MONTH) 20, 2019 at 3:20 PM, V13 (RN) said, I was the supervisor that night of (R1's) accident in March. When I came that night they had a bunch of admissions. I was checking to see what I can help with, and they said help with the care plans. Somebody called me to see (R1), and they said the patient was stuck in the side rail. I got to the room, and both of R1's legs were stuck in the side rails. One was in the upper part of the rail, and the other leg was stuck in the lower part. There was a lot of blood everywhere. The one leg was caught in the lower, section that was tight; the leg with the biggest laceration. I yelled for them to get the treatment cart. Someone had to pull the side rail off to free R1's leg. I tried to put the steri-strips on, but they wouldn't stick because it was a big laceration. I could see some white in the deep wound, but I'm not sure if it was the bone. I could see some ligaments. They said R1 was confused when R1 arrived. I told them to call 911 because it was a lot of bleeding and they will stitch it right away at the hospital. I think that when R1's leg got caught, it was rubbing and rubbing, and it caused the laceration. R1 was sitting nicely in the middle of the alarm, so it wasn't making a sound. The side rails were up because R1 had a history of [REDACTED]. That's just an intervention we put in place, put up the side rails and put on a bed alarm. They tell us if they have a history of falls, or try to get up without assistance, that's what we should do. When R1's legs were through side rails, R1's foot was not touching the ground. The hospital told us that it was an acute laceration injury. I don't remember R1 being combative. R1 was combative when we were trying to treat R1's laceration. 911 was called strictly for the laceration, not due to R1's behavior. The bed and the floor were full of blood. The whole side of the bed on the floor, the side rails and the side of the mattress were full of blood. R1 had a lot of blood on R1's hands. Alert residents can have one side rail up to help them move about their bed and bathroom. If the resident isn't alert, two side rails will be more appropriate, the half side rails, to keep the resident in the bed. We don't have to do any special documentation for the use of a restraint. Both side rails were up, full rails from R1's chest to R1's thighs. 2. On (MONTH) 19, 2019 at 3:23 PM, R2 was sitting in the wheelchair next to R2's bed with family at R2's bedside. V4 (family member) said R2 sleeps in the bed all the time with the side rails up, from R2's shoulders to R2's thighs. The side rails and pad sensor alarm have been in place since the day (R2) was admitted . I don't remember signing any consents for the side rails or pad sensor alarm, but I was told they were in place to prevent (R2) from falling or getting out of the bed. (R2) cannot move the side rail by (R2's) self. R2 was confused, not interviewable, and not able to demonstrate the use of the bed side rails. On (MONTH) 20, 2019 at 12:05 PM, R2 was lying in bed. R2's bilateral side rails were up on both sides of R2's bed, from R2's shoulders to R2's thighs. The EMR shows R2 was admitted to the facility on (MONTH) 3, 2019 with multiple [DIAGNOSES REDACTED]. walking. R2's MDS dated (MONTH) 16, 2019 shows R2 has severe cognitive impairment, is totally dependent on facility staff for bathing, and requires extensive assistance with all other ADLs. R2 is incontinent of bowel and bladder. The MDS shows R2 walked in the room and corridor only once or twice. The MDS does not show the use of a bed rail or sensor alarm for R2. As of (MONTH) 19, 2019, at 5:58 PM, the facility did not have interventions on R2's care plan for the use of assistive side rails or a sensor pad alarm in the bed. R2's care plan for extensive assistance for bed mobility, transfers, locomotion, dressing, eating, toileting, personal hygiene, and bathing, effective (MONTH) 13, 2019, shows interventions with a goal date of (MONTH) 13, 2019 that include: While in bed, assist R2 to turn/reposition self. Use pillows and foam wedges to maintain position. Transfer using the transfer board/lift devices (specify) (no device specified). PT to evaluate; set goals for distance/support; provide appropriate assist devices. R2's admission nursing assessment, dated (MONTH) 3, 2019 shows R2 is a high fall risk. R2's nursing admission assessment did not have any documentation to show a side rail assessment was completed for R2. 3. On (MONTH) 20, 2019 at 8:22 AM, R3 was lying in bed. Bilateral side rails were in the up position, extending from R3's chest to R3's upper thighs. V15 (CNA-Certified Nursing Assistant) was present in the room delivering a meal tray. V15 said, The side rails are in place like that to keep (R3) from getting out of the bed. Sometimes (R3) puts his legs over and tries to get out of the bed and to stand up. The EMR shows R3 was admitted to the facility in (MONTH) (YEAR) with multiple [DIAGNOSES REDACTED]. R3 was recently readmitted to the facility on (MONTH) 4, 2019 from the local hospital with [DIAGNOSES REDACTED]. R3's MDS dated (MONTH) 17, 2019 shows R3 has moderate cognitive impairment, is totally dependent on facility staff for transfers between surfaces and bathing, requires extensive assistance with bed mobility, locomotion on and off the unit, dressing, toilet use, and personal hygiene. R3 is always incontinent of bowel and bladder. The MDS does not show the use of a side rail for this resident. As of (MONTH) 20, 2019, at 3:07 PM, the facility did not have care plan interventions for R3 for the use of side rails, or any other interventions to prevent R3 from exiting the bed. The bed manufacturer's undated User Manual shows: Patient entrapment with Assist Bar may cause injury or death. Mattress must fit snugly within the mattress keepers to prevent patient entrapment. Use only a mattress of recommended specifications with the bed. Monitor patient frequently. Assess the needs of the resident prior to using the Assist Bar. Patient Safety: Patients who have problems with memory, sleeping, incontinence, pain, uncontrolled body movement, or who get out of bed and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm, such as falling. Assessment by the patient's health care team will help to determine how best to keep the patient safe. Historically, physical restraints (such as vests, ankle or wrist restraints) were used to try to keep patients safe in health care facilities. In recent years, the health care community has recognized that physically restraining patients can be dangerous. Although not indicated for this use, bed rails are sometimes used as restraints. Regulatory agencies, health care organizations, product manufacturers and advocacy groups encourage hospitals, nursing homes and home care providers to assess patients' needs and to provide safe care without restraints. Potential risks of bed rails may include: Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress. More serious injuries from falls when patients climb over rails. Skin bruising, cuts, and scrapes. Inducing agitated behavior when bed rails are used as a restraint. Feeling isolated or unnecessarily restricted. Preventing patients who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet. When bed rails are used, perform an on-going assessment of the patient's physical and mental status; closely monitor high-risk patients. Consider the following: Lower one or more sections of the bed rail, such as the foot rail. Use a proper size mattress or mattress with raised foam edges to prevent patients from being trapped between the mattress and rail. Reduce the gaps between the mattress and side rails. The facility's undated Admission Contract shows: Every resident will be individually assessed upon admission regarding the need for appropriate safety measures and will be periodically reassessed as their needs change throughout their stay at Facility. Facility does not use side rails as a restraint. Side rails have been removed from the bed as a result of a government recommendation regarding the dangers of bed entrapment. Some of our residents benefit from an assist device which enhances the residents' need for mobility to turn in bed without assistance or exit the bed on their own. These assist devices meet requirements to prevent entrapment; however, these are only used if the Resident's assessment results meet specific criteria and are not considered a restraint. Resident or Resident's Representative understand and agrees with this policy. The facility's Physical Restraints Policy, revised (MONTH) 28, 2014 shows the facility, Supports the resident's right to be free from physical restraints. Further, the facility will assess and determine that a device is required to treat a resident's medical symptom prior to application and periodically thereafter. Procedure: 1. Complete the Restraint Assessment prior to application of the device. 2. Obtain a physician order [REDACTED]. [NAME] The type of physical restraint. B. The interventions utilized or considered prior to the physical restraint and the impact of these interventions. C. The length of time the physical restraint is to be applied. 3. Notify the family and provide education regarding the risks and benefits related to the use of restraint. 4. Assess the effectiveness of the restraint quarterly and with a change of condition. Make changes to insure the least restrictive device is utilized. 5. Develop the care plan to identify restraint use, risks, benefits, timeframe for use, restraint reduction and interventions to prevent decline and/or to maintain the highest practicable physical, psychosocial and mental well-being. 6. The resident will be routinely released from the device based on the plan of care to provide: a. 1:1 supervision, b. Repositioning and pressure relief, c. To meet toileting or other care needs, d. During meals and activities as indicated by the plan of care. Through observation, interview and record review, the surveyor confirmed that the facility took the following actions to remove the immediacy of the situation: Nursing staff was provided training on restraint use by the Nurse Consultant, DON, or designee starting on (MONTH) 21, 2019 that included: device assessment, proper use of side rails and assistive devices, definition of a restraint, and review of the Physical Restraint policy. As of (MONTH) 21, 2019, at 3:30 PM, approximately 40 percent of the nursing staff had been provided training. V1 (Administrator) said all staff will be provided training as they report to the facility for their next shift and prior to working with the residents. No staff will be allowed to work until the staff has completed training. Education will be provided upon hire and quarterly for one year, then annually thereafter. 1. The facility revised the restraint policy and also developed a quality improvement tool to trend compliance with side rail use on (MONTH) 21, 2019. 2. The facility ensured no new resident has been placed in a bed with the center rail, effective (MONTH) 21, 2019. 3. A review, including current orders, was completed of all residents in the identified bed with a center rail. Individual orders and care plans were updated as needed on (MONTH) 21, 2019. 4. The facility identified a way to maintain the rail in the upright position for patients or residents who who have been assessed to require an assist rail as indicated by the Device Assessment. Due to the fact that there is no product that can be retro-fitted to this bed according to the manufacturer, side rail removal for all others not requiring an assist rail was done on (MONTH) 21, 2019. 5. Quality improvement checks for the use of rails was completed by the facility on (MONTH) 21, 2019, and individual findings were addressed 1:1 with staff. 6. The outcomes of quality improvement tool for use of side rails was implemented as part of the daily manager's meeting reporting effective (MONTH) 20, 2019 with Performance Improvement Plan initiated through Abaqis (quality management system) on (MONTH) 21, 2019. 7. On (MONTH) 21, 2019 the updated quality improvement tool developed for monitoring of side rail use was implemented and will continue three times a week ongoing until the QAPI (Quality Assurance and Performance Improvement) committee deems resolved. 8. On (MONTH) 21, 2019 the DON or designee initiated use of the updated Quality Improvement tool to identify trends, provide 1:1 counsel as needed, and communicate compliance and any further need for follow up to the Administrator. 9. On (MONTH) 21, 2019 New Admission chart checks were completed by the nursing management team to identify new patients and monitor policy and procedure compliance with side rail use. 10. On (MONTH) 21, 2019 the Quality Assurance committee reviewed the results of the Quality Improvement review during the monthly meeting. The DON will evaluate audits for trends and report to the QAPI committee and will meet additionally at the discretion of the Administrator until the issue is resolved. Trends requiring additional revision of existing policy or procedure will be implemented as indicated.

Based on record review and interview the facility failed to ensure safe transfer. This applies to 1 of 3 residents (R1) reviewed for falls in a sample of 3. This failure resulted in R1 falling from the sling of a mechanical lift and sustaining multiple spinous process fractures. Findings include: The Face Sheet documents the following [DIAGNOSES REDACTED]. The POS (physician's orders [REDACTED]. The MDS (Minimum Data Set) 10/31/17 documents: BIMs (Brief Interview for Mental Status score) 8/15 indicating some cognitive impairment; transfers- totally dependent on staff requiring 2 person physical assistance; Range of motion limitation on left upper extremity and both lower extremities; and wheelchair bound. The Care Plan documents: R1 has ADL (Activities of Daily Living) deficits related to functional, perceptual, neurological, emotional issues; Dementia, depression, anxiety, impaired vision, hearing, and communication. Remote CVA with left [DIAGNOSES REDACTED], heart disease, and chronic kidney disease III. Full body lift for transfers- unable to walk related to limitations of both legs, and left upper extremity. Interventions- full body lift X 2-3. physician progress notes [REDACTED]. The facility incident report dated 11/10/17 (Provided by E2/Director of Nursing on 11/15/17 at 11:52am) reads: As CNA was positioning the patient to put in the chair patient slipped out of the lift. What was resident doing when last observed: transferring to or from bed, chair. However, this computerized report was not finalized and still showed (EDIT) functions. E2 stated this is the incident report, but is not finalized until the entire investigation is completed. The Serious Injury Incident Report sent to the State Surveying Agency reads: Fall with physical harm or injury. The written statement by E4 (Certified Nursing Assistant/CNA) reads: I placed the sling under R1; the full lift was in the resident's room. I placed the sling on the full body lift and went to look for assistance. The written statement by Z3 (CNA/Agency) reads: I went to the resident's room, and I observed staff hooking the last sling hook onto the machine. The nurse's notes dated 11/10/17, 5:52 PM reads: At approximately 7:50 AM, patient was sent to emergency room for evaluation and treatment due to fall and patient complain of pain to head and back. Spoke with local emergency room , informed that patient was admitted with acute multiple fractures to lumbar spine. On 11/14/17 at 11:34am, Z3 (Agency Certified Nursing Assistant/CNA) stated E4 (CNA) asked her to come help transfer R1 via mechanical lift. Z3 stated I came in the room and the patient was already hooked up and everything. I asked if she needed help with hooking and E4 stated No, I'm OK. So she started lifting R1 up. R1 is a heavy patient. R1's medical record documented weight 11/8/17- 214#. Z3 stated While I was pulling R1's butt back, E4 was turning the machine. As soon as we got directly on the side of the chair R1's hands went up, the hook came up and R1 came down. Only one of the hooks was off, the left side. I had R1's butt and E4 was guiding the machine. When I came in, I didn't touch nothing (sic). R1 was already hooked. The only time when I touched the sling was when I grabbed the butt, next thing I know, it's like R1's top part came out. R1 is heavier at the top. R1's top came out then R1's head hit the wheelchair. R1 slid out of the sling. The foot hook came out. R1's left leg was still on the machine. Z3 added The back of R1's head was bleeding. R1 had confusion and was screaming my head hurts. Z3 stated the policy for transfers via mechanical lift is you need to get 2 people to roll them on the sling and hook them up. Like I said, it was already hooked. I never touched the sling. No one else was in there. Z3 stated this company doesn't in-service any one but their staff, but my company (Agency) in-serviced me. You need 2 people to hook up the sling. The statement was read back to Z3 who just kept repeating the sling was already hooked to the machine before I came in the room. On 11/14/17 at 2:19pm, E4 was interview with E2 (Director of Nursing) witnessing per E4's request. E4 stated she worked with R1 on the day shift when the fall occurred. E4 stated I hooked the sling to the mechanical lift. Then Z3 came. E4 stated Z3 was at the feet guiding R1 and I was at the head of the lift. I had the controller. After we already started lifting R1, R1 was sitting up over the bed. I was bringing the machine out from the bed moving it towards the wheel chair and one of the slings like dropped and R1 just went with it. R1's ear was bleeding. I think R1 hit R1's ear on the wheelchair, the back of R1's head was wet with blood but I think it was from the ear. R1 fell out of the sling. E4 stated the policy is for 2 people to hook the sling up. E4 again admitted she was the only one who hooked the sling up. E4 stated she had received an in-service on transfers and mechanical lifts prior to the incident. When asked if E4 had followed the policy, E4 stated I guess not, but I thought it was ok. E2 stated we don't allow them to sign statements. The statement was read back to E4 who voiced no changes. On 11/14/17 at 2:35pm, E3 (Restorative Nurse) stated she is responsible for in-servicing all staff on transfers and mechanical lifts. E3 stated she had recently in-serviced all staff as part of annual training on transfers. E3 stated R1 had left sided weakness. E3 stated R1 could raise the left arm to shoulder level. R1 can't really raise it that high. R1 can't raise the arm above R1's head, the extremity is weak. E3 added We tell them you need 2 persons before you could hook the sling up. We don't want nobody or 1 person in the room prior to hooking the sling up. E3 stated all staff are in-serviced to have 2 people hook the sling to the mechanical lift prior to lifting residents. E3 stated she in-serviced nursing staff and they signed the attendance sheet. E3 stated staff had to complete return demonstration with 2 people hooking up the sling and transfer the patient to pass the in-service. On 11/4/17 at 3:01pm, E2 stated E3 is responsible for in-servicing all staff for transfers. E2 stated I expect the CNA to call somebody else to hook them up. E2 stated the policy for mechanical lift transfers requires 2 person assist. E2 stated Z3 and E4 followed the policy because 2 people transferred R1. The facility was then asked to provide all staff in-servicing on mechanical lifts. Documentation showed Z3 was in-serviced on 3/21/17 with return competency, and E4 was in-serviced on 12/08/16. On 11/14/17 at 3:30pm, Z1 (Geriatric Nurse Practitioner/Provider) stated R1 had a CVA with left [DIAGNOSES REDACTED]. Z1 added R1 was pretty compromised. R1 had a contracture of the left upper extremity. On 11/14/17 at 3:57pm, Z2 (Medical Doctor/Provider) stated he was aware R1 sustained a fall because R1 came to the hospital where Z2 is also on staff. Z2 stated R1 sustained a scalp hematoma and left small laceration, a contusion to the left flank, and spinous process fractures of L2, L3 and L4. On 11/15/17 at 9:08am E1 stated R1 has left sided neglect and right sided weakness. The left side extremity is weak. There's no way R1 could unhook the straps while in the sling. R1 really doesn't have strength capacity to unlatch that strap. I saw R1 at the hospital. R1 was weak. On 11/16/17 at 12:30pm, Z2 verified R1's [DIAGNOSES REDACTED]. Z2 stated R1 was hypotensive with fluid volume depletion related to bruising/bleeding from the flank injury. This according to Z2 led to acute kidney failure and elevated Potassium. The bleeding also led to the lower hemoglobin in which R1 received blood transfusion per Z2. Z2 also added that R1 has chronic shortness of breath with COPD (Chronic Obstructive Pulmonary Disease) and Asthma. Z1 stated the hospital treated R1 for COPD flare with steroids. The policy for Mechanical Full Body Lift Safety and Use documents: This lift requires two people to transfer patients. One employee will push the lift, and one employee will hold onto the handles on the sling to prevent the patient from swinging. The policy for Transfer, Ambulation and Re-Positioning (TARP) documents: -TARP training will include the safe use of mechanical or electronic lifts and a competency demonstration.

Based on observation, interview and record review facility failed to ensure that a resident was safely transferred by staff. The facility also failed to ensure that the wheelchair monitoring devices are kept working condition. The failure to safely transfer a resident (R9) resulted in a traumatic fall causing a complete displaced spiral fracture involving the distal left femoral shaft, This applies to 1 of 8 residents (R9), reviewed for falls in a sample of 24 and one resident (R33) in the supplemental sample of 1. The findings include; 1) R9's [DIAGNOSES REDACTED]. R9's minimum data set assessment (MDS) dated [DATE] includes: R9 requires extensive assistance of two staff with transfers and bed mobility and requires extensive assistance of one staff with dressing and personal hygiene. A final incident report dated April 7, 2017, timed 8:15 AM documents that R9 sustained a fall at bedside, during A.M. care. The report further describes After receiving a.m. care at bedside, the resident reported sitting at the edge of the bed as staff attempted to transfer the resident he started sliding to the floor, staff attempted to break the fall, unable to do so and lowered the resident to the floor. Z1's (Agency Certified Nursing Assistant), R9's assigned caregiver, in a written statement, stated I got him dress this morning; he was helping me do that. He was able to put his legs down to sit to the side of the bed when I was transferring him from the bed to the wheelchair, while sitting in the wheelchair he was at the edge of the wheelchair, he (R9) told me that he could not turn because his knee hurt. When he couldn't move in the wheelchair I lowered him to the floor. I did not look at the care giver alert because I had that group in the past. I was educated on this process with care giver alert and I didn't look because I thought I knew the residents on that assignment. I didn't know where my gait belt was because I left it in the room and couldn't find it after I returned. He was my last resident I got up. I didn't need to use the gait belt with anyone else after that incident. No one helped me with my resident's transfer today, I transferred those who needed to be transferred by myself. The resident was wearing regular shoes at the time of fall. On August 17 2017, at 9:30 am, Z1 (by telephone) affirmed the accuracy of her written statement by stating that she transferred R9 from his bed to his wheelchair and R9 was sitting at the edge of his wheelchair and R9 stated he could not pivot (turn) because his knee hurts, so she lowered R9 to the floor. Z1 further stated that she transferred R9 by herself. Z1 also stated that the care cards were either in the door of the resident's closet or in his medical record and she did not check to see what R9's transfer status was. R9's progress note dated April 7, 2017 at 2:19 PM documents R9 has left knee swelling and lower leg pain. Stat x-ray was ordered and the result was displaced left femur fracture, the physician was notified and R9 will be sent to the local hospital for Orthopedic evaluation. The transfer form from the local hospital dated April 12, 2017, documents a primary [DIAGNOSES REDACTED]. On August 17, 2017 at 12:30 PM, Z6 (R9's physician) stated by telephone, the spiral fracture is consistent with an attempt to pivot. He further said that there has not been a decline in R9's health of condition since the fall. 2. R33's face sheet showed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R33's initial minimum data set (MDS) dated [DATE] showed R33 with brief interview for mental status (BIMS) of 13 which means R33's cognition is intact. R33's MDS also showed R33 requires extensive assistance of two or more staff for transfer, bed mobility, and toilet use. R33's initial fall assessment dated [DATE] showed R33 with total fall risk assessment score of 12 (High risk). Review of R33's fall risk care plan initiated June 2, 2017 with a goal date of September 2, 2017 showed R33 with history of falls since admission or prior to admission in last two-six months. The goal is to maintain current level of mobility with no increase in the incidence of fall/injuries in the incidence of falls/injuries over next ninety days. The fall risk care plan also showed, Use alarm to monitor attempts to rise as ordered and check for proper functioning when in use. On August 17, 2017 at 9:35 AM, R33 was sitting in the wheelchair in his room. Z5 (Occupational Therapist) was working with R33 on a puzzle. Z5 stated today she just started working with R33 today. R33's chair alarm would not sound when R33 got up from the chair twice. At 9:45 AM, E14 (Nurse) came in to R33's room. E14 tested R33's chair alarm but it was non-functional. E14 stated the alarm was non-functional. R33's chair alarm pad was changed for a new one. R33 has history of falls according to his electronic medical record (EMR). Review of facility's fall incidents showed R33 had falls on June 12, 2017- (observed on the floor leaning against wheelchair), June 15, 2017- (observed on the floor in front of wheelchair), July 21, 2017-(observed on the floor next to bed) and July 30, 2017-(observed on the floor in room). On August 17, 2017 at 10:20 AM, E7 (CNA) stated she got up R33 from bed to chair this morning with the help of another staff. E7 stated she was not aware R33 is on fall risk and not sure if R33 had a chair alarm. On August 17, 2017 at 10:55 AM, E2 (Director of Nursing/ DON) stated nursing staff are expected to check the chair alarm's function every shift. E2 further stated applying the chair/bed alarms are part of the interventions put in place for falls. Review of facility's policy titled, Fall Management with a revised date of June 4, 2014, showed The facility will observe for the use of safety devices, always selecting the least restrictive device to meet the individualized needs the resident.

Based on observation, interview and record review facility failed to assure a resident was safely transferred by staff. This failure resulted in a traumatic fall causing a displaced supracondylar femur fracture. This applies to 1 of 5 residents (R3), reviewed for falls with injury in a sample of 5. The findings include; R3's [DIAGNOSES REDACTED]. R3 resides on facilities cognitively impaired unit Memory Care Unit. R3's January 28, 2017 minimum data set assessment (MDS) includes: R3 requires extensive assistance of two staff with transfers, bed mobility, dressing, toilet use and personal hygiene. R3 has severe cognitive impairments and decreased range of motion to bilateral upper and lower extremities. R3's January 27, 2017 nurses notes include; Unable to do a brief interview of mental status (BIMS), staff need to anticipate resident's needs because R3 is unable to express needs with severe impaired cognition. R3's February 01, 2017 12:18PM restorative nurse progress note include: Transfer program discontinued due to resident requires a sit to stand lift for transfers and the residents active range of motion changed to passive range of motion due to limited range of motion and impaired cognition. R3's physician progress notes [REDACTED].> August 31, 2016 resident has severe dementia, incontinent of bladder, has gait disturbances, activity of daily life (ADL) impairment and wheel chair bound. November 29, 2016 requires significant ADL assistance with bathing, dressing and transfer activities. Resident had previous fall with hip fracture, has advance dementia, gait instability and is on fall precautions. January 25, 2017 generalized weakness, poor gait and balance, advance dementia and requires advance ADL support and care. R3's July 23, 2016 fall assessment scored 17. Fall risk scores at or greater than ten equates resident is a high risk for falls. R3's January 31, 2017 fall care plan include at risk due to decrease in functional mobility, with history of falls, receiving psychotropic medications, impaired mobility, incontinence, confusion, forgetful and with [DIAGNOSES REDACTED]. R3's February 06, 2017 incident report investigation includes; On February 06, 2017 at around 2:00PM R3 slid off chair during a transfer from wheel chair to a shower chair. R3 was being transfer by only one staff member (Z2 - an agency nurse aide), without the use of a gait belt or use of sit to stand lift as care planed. R3's February 6, 2017 incident report and nurse's note include: Assessed by E4 (nurse), on floor in shower room in front of wheel chair. R3's right leg noted with minimal deformity, resident unable to explain what events occurred resulting in fall and denied having any pain. At 6:44PM R3's right thigh-hip area assessed to be swollen, bigger than the left thigh-hip area. R3 assessed by facilities nurse practioner and X-rays ordered. At 7:30PM X-ray of right lower extremity completed. R3's right leg X-ray's revealed presence of a displaced supracondylar femur fracture. On February 6, 2017 R3 was sent to the hospital and admitted with [DIAGNOSES REDACTED]. R3 readmitted to facility February 8, 2017 with right lower extremity brace immobilizer in place and to be worn at all times. R3's incident investigation included February 6, 2017 written statements by Z2 and E4 to include: - Z2 stated while attempting to transfer R3 from the wheel chair to the shower chair, R3 slid to the floor from wheel chair. Z2 admits to not using a gait belt on R3 during this transfer and attempting transfer of R3 without any other staff assistance. Z2 stated that she did not have her gait belt with her at the time of R3's fall but Z2 stated she does not always use a gait belt with resident transfers. Z2 said there was not any other staff in proximity at time R3 taken into shower room. Z2 also stated I was not aware of the residents transfer status. - E4's statement includes: Z2 observed taking R3 into the shower room, a few minutes after E4 went into the shower room to perform skin assessment on R3. E4 observed R3 sitting on the floor in front of her wheel chair with her legs slightly bent back against the wheel chair. Z2 was trying to transfer R3 from wheel chair to shower chair by herself and without use of a gait belt on resident. R3's February 10, 2017 physician progress notes [REDACTED].>Patient found to have a right femur fracture supracondylar region with displacement and a thoracic vertebral compression fracture of spine possibly acute in nature. During February 14, 2017 review of R3's February 6, 2017 fall incident investigation with E2 (director of nurses), E2 validated information documented in incident investigation reports. E2 also stated he conducted the interviews with Z2 and E4 February 6, 2017. During February 15, 2017, 1:30PM interview E4 validated information documented in her written statement included in R3's February 6, 2017 fall investigation report. E4 also stated Z2 attempted to transfer R3 in the shower room by herself, without any assistance and without using a gait belt on R3. E4 said R3 was a two person assist with a sit to stand lift during transfer activities. R3 would have difficulty standing without physical assistance of staff. During February 16, 2017, 9:35AM telephone interview, Z3 (R3's attending physician); Z3 stated that R3 requires assistance with transfers and has history of previous hip fractures. Prior to R3's February 6, 2017 fall the resident could self-propel her wheel chair around the unit but not since the fall with new fracture. R3's current functional abilities are below her baseline status as a result of this new fracture. R3's healing process will be affected due to increased age, weight and co-morbidities. Z3 stated that facility nurse aides should know the residents transfer abilities and needs prior to caring for them. On February 15, 2017, at approximately 4:50PM, R3 observed in bed, alert but confused, unable to be interviewed. R3 had an indwelling urinary catheter, left leg immobilizer in place and continuous oxygen per nasal cannula in place. Prior to R3's February 6, 2017 fall incident resulting in a new femur fracture, R3 was up and self-propelling wheel chair daily and did not require an indwelling urinary catheter or continuous oxygen administration.

Based on interview and record review, the facility failed to implement individualized fall risk interventions for a resident identified as a high fall risk. This applies to one of four residents (R4) reviewed for falls. This failure resulted in R4 sustaining spinal cord injury. The findings include: R4 is no longer in the facility. The facility's face sheet for R4, dated May 11, 2016 shows R4 was admitted to the facility from a local hospital on May 9, 2016 at 1:00 PM, with multiple diagnoses, including: history of falling, other abnormalities of gait and mobility, pain in right knee, [DIAGNOSES REDACTED] following cerebral infarction, muscle weakness and low vision one eye. The facility's handwritten hospital report sheet, unsigned, and undated shows R4 had sustained a fall at home with no injury, had a history of [REDACTED]. emergency room documentation dated May 9, 2016 at 10:12 AM shows, [AGE] year old male with multiple medical problems including prior CVA. He has had difficulty ambulating since February 2014 due to right leg weakness. More recently he has basically been in a wheelchair with minimal transfer/ambulation.At 4:00 AM R4 fell in his bathroom trying to get from wheelchair to toilet. He landed on his bottom. E8's (RN-Registered Nurse) admission assessment of R4, dated May 9, 2016 shows R4's last fall was on May 9, 2016 and R4's fall risk score was 10. The fall risk assessment shows High Risk if score of 10 or above. Fall prevention protocol initiated. E8 did not document R4's history of CVA or any musculo-skeletal weakness. R4's care plan created by E8 on May 9, 2016 at 3:52 PM shows: At risk for falls related to DM (diabetes), HTN (hypertension), history of head injury. Interventions included: Use alarm to monitor attempts to rise as ordered and check for proper functioning when in use, remind R4 to call when needing assistance, place call bell/light within easy reach. On May 10, 2016 at 4:05 PM, E4 (RN-Registered Nurse) was standing in the hall by the nurses station, in the center of the unit. E4 pointed to R4's room at the far end of the hall. E4 said, R4 was admitted on [DATE] before I started my shift. I was told in shift report R4 came from the local hospital as a direct admit because he fell at home, and he was a high fall risk. The nursing assessment done on the shift before me shows he has a fall risk score of 10, which means he is a high fall risk, so the fall prevention protocol should have been initiated. That means bed and chair alarms should be put in place. We try to get alarms put on residents so if they try to get up we know. R4 did not have a bed or chair alarm. R4 did not use the call light before he ambulated to the bathroom. My shift started at 3:00 PM, and I know of three times R4 tried to ambulate by himself. R4 fell on the third attempt, and that was when he hurt himself. On May 9, 2016 around 5:00 PM, I was standing in the hallway by the nurse's station and saw him laying on the floor in front of his bathroom door. When I got to his room he was laying between the bathroom door and the doorway to his room with a pool of blood under his head. He seemed paralyzed. He could not feel painful stimuli. We called 911. R4 did not use the call light before he fell . He would have benefited from a room closer to the nurse's station (a dining room, storage room and 6 residents rooms are located between the nurse's station and R4's room). E4 acknowledged no new interventions were put in place for R4 after his multiple attempts of ambulating without assistance. On May 10, 2016 between 5:10 PM and 5:33 PM, E5 (CNA-Certified Nursing Assistant) said, I started at 2:00 PM on May 9, 2016. I did not know R4's transfer status. Usually the nurse informs me how a resident transfers, but no one reported that to me on that day. I only knew what R4's daughter told me; that he needed a wheelchair or walker and assistance. I was helping a CNA in a different resident's room, and E7 (Restorative Nurse) came and told me she was getting an alarm for R4 because he kept getting up. That was about 90 minutes before R4 fell . She never put the alarm on. I thought it would have been done already. If he had an alarm on, I would have known he was out of bed. R4 was up out of bed without assistance 3 times that I was aware of from the time I started at 2:00 PM until he fell around 5:00 PM. Two times he used the call light but then got up anyway before I got there. I did not try giving him a urinal. The fourth time he fell was the time when we found him on the floor. E5 stood in R4's room and demonstrated the position R4 fell , stating R4 was found on the floor between the bathroom door and the entry door to the room. E5 said R4 was laying in a pool of blood (E5 drew a 3 foot circle with her finger to indicate where the blood was located under R4). E5 said R4 had walked to the bathroom by himself, but left his walker over the toilet, had his pants pulled down around his ankles and had socks on. On May 11, 2016 at 9:07 AM, E7 (Restorative Nurse) said R4's daughter was walking into the facility on [DATE]. She had two pairs of shoes with her. We saw R4 was standing up in the bathroom, and I assisted him to bed. I explained to R4's daughter to use the shoes with good grip on the bottom. I told the daughter I was going to tell the nurse R4 needs an alarm. I informed E8 (RN) and E9 (Supervisor) that R4 needed an alarm. I informed E5 (CNA) that R4 had an unsteady gait and he was a fall risk. I could tell by R4's unsteady gait and confusion he was a fall risk. When I informed E8 and E9 about the alarm, they should have retrieved the alarms. I clocked out around 3:35 or 3:40 PM. On May 11, 2016 at 9:25 AM, E2 (DON-Director of Nursing) said the facility lacks a high fall risk protocol for nurses to follow. The nurses should use the interventions on the fall care plan as the fall protocol. E2 provided a copy of a policy entitled Fall Management dated June 4, 2014. The policy shows: The facility observes the physical and cognitive function of each resident to identify factors that place them at risk for falling. A care plan is developed defining those risks and interventions are implemented. On May 11, 2016 at 8:08 AM, Z1 (Physician) said, R4 has been a resident at the facility before. Last time I saw him was November 2015. He had right leg weakness and he ambulated with a walker. I know he fell at home on May 9, 2016 on his butt. He did not have a head injury. R4's daughter wanted him admitted to the facility for rehabilitation. Later that day he fell at the facility and sustained a spinal cord injury. In hindsight, an alarm should have been in place and they would have caught him sooner before he fell . The spinal cord injury was a direct result of the fall. On May 11, 2016 at 9:47 AM, Z2 (Physician) said, I was the admitting physician for R4 in the emergency room after his fall at the facility. He came in with a laceration on his forehead, spinal cord shock and a spinal cord injury. He incurred severe, permanent harm and is now a quadriplegic due to the fall. I was told by Z3 (family member) that she witnessed R4 getting up without assistance at the facility, alerted nursing staff and was assured a safety alarm would be put in place, so she went home. On May 11, 2016 at 9:59 AM, Z3 (family member) said, R4 fell on the morning of May 9, 2016 at home and he was going to the facility because he was a fall risk, was weak, and wanted long-term care. I went home to get slippers and when I came back, I saw him walking alone to the bathroom. I yelled and E7 (Restorative Nurse) ran down to the room and helped him back to bed. E7 told me she was getting an alarm for him. I left at 3:00 PM thinking he was safe, and two hours later they called me and told me he was being taken to a trauma center. They said they could try to surgery on him but he would end up being ventilator-dependent and require a feeding tube. He is paralyzed from the neck down and we had to put him in hospice.

Based on observations, interviews and record reviews, the facility failed to provide two confused residents, who have a history of multiple falls and at risk for harm, with interventions from staff to supervise and monitor them. These failures resulted in the residents experiencing multiple unwitnessed falls, resulting in one resident (R3) requiring treatment for [REDACTED]. This applies to 2 of 3 residents (R3 and R5) in the sample of 5 residents, who were identified as experiencing falls in the facility. The findings include: 1. Review of R5's Face Sheet showed R5 is a [AGE] year old female with [DIAGNOSES REDACTED]. R5's Clinical Notes for social services, dated 1/16/14 and 1/17/14 documented that R5 had mental health issues or behaviors that put her at risk for harm. R5 was resistive to care and not getting along with others. The note documented the need to monitor R5's behavior. Review of R5's nursing noted showed the following falls for R5: "11/27/13 at 9 AM R5... slid out from her wheel chair and landed on her right side. Noted bruise and redness on right elbow ... 12/27/2013 at 2 AM CNA (certified nurses aide) heard a loud noise from the resident ' s (R5's) room... noted resident lying on the floor ... lying on the floor face down ... 12/27/2013 at 10:21 PM Resident was transferred to ... (hospital) still at ER (emergency room ) at this time will be admitted with [DIAGNOSES REDACTED]. 1/18/2014 at 3:46 PM Undersigned was making rounds and observed resident lying on the floor sleeping besides her bed ... 1/24/2014 at 7:45 AM Around 5:45 AM, while doing med pass, undersign heard somebody calling for help. Responded to room and noted resident sitting on the floor in front of wheel chair ... 1/24/2014 at 7:55 PM Called to resident ' s room (at 4:05 PM)... noted resident sitting on the floor inside of the bathroom in front of her wheel chair. Wheel chair was not locked when checked ... 1/25/2014 at 8:17 AM Noted with hematoma of right side of forehead ... 1/28/2014 at 4:27 PM observed resident sitting on the floor in the bathroom. Resident attempted to take herself to the bathroom without assistance ... 1/30/2014 at 5:33 PM Heard somebody calling for help. Responded to room and noted resident sitting on the floor in front of her wheel chair ... 3/05/2014 3:30 PM Noted resident ' s forehead swollen with purplish discoloration on forehead and occipital areas, complaining of pain when touched, puffy on right eye lid ... 3/05/2014 at 4:14 PM ambulance staff here to pick up resident ... 3/05/2014 at 9:50 PM Resident admitted to hospital with [DIAGNOSES REDACTED]." Review of R5's hospital Admission Face Sheet, dated 3/05/14, showed: "Diagnosis/Chief Complaint: Head Pain, Fall, C2 Fracture..." R5's ED (Emergency Department) Summary, dated 3/05/14 at 5:05 PM, "R5 was found with her head leaning forward close to her knees, with an estimated time of 8 hours in that position. Patient (R5) has echymosis (bruising) to her forehead and right eye with edema..." Review of R5's hospital CT scan of her (R5's) Cervical Spine, dated 3/05/14, documented the following findings: "Impression: Bilateral fractures of C2. On the right the fracture is through the right lateral mass of C2..." R5's hospital Final CT scan Report, dated 3/05/14, showed: "Clinical Indication: Head trauma,..." R5's primary physician (Z1) documented the following about her condition at the hospital: "3/06/14... Impression: 1. Presumed fall with cervical C2 fracture, mechanism of fall is not clear and was not witnessed at the nursing home." The facility's Fall Management Policy, dated 8/10, showed: "The care plan is developed on a multi-disciplinary level to address acute and recurrent falls... 6. The care plan is developed to address the areas identified on the assessment and on the observations of the resident." Review of R5's Care Plan, dated 1/18/2014, showed R5 was at risk for falls due to physical limitations: Balance problems, gait, strength, endurance and psychotropic drug (S) ordered. The goal for R5 is " to be free of injuries related to a fall." Some of the approaches documented by staff were not specific in ensuring that R5 did not fall. The plan of care showed: "Educate patient on fall risks to ensure compliance with plans ... Remind to call when needing assistance ..." R5 has cognitive impairment and was forgetful so these interventions would not be effective, or specific for addressing what was causing her to fall. Several of the nursing interventions were noted to be written in a different manner as R5 continued to fall. R5's care plan showed: 12/28/2013 Encourage R5 to call for assistance ... 1/18/2014 Frequent reminder to use call light, 1/29/2014 monitor and assist with dressing ... 1/28/2014 Skilled physical and occupational therapy ... 1/30/2014 Call for assist prior to ADL's. The fall care plan showed on 5/17/2013 that staff had already implemented the above interventions, such as: "reminders to call when needing assistance, physical and occupational therapy evaluation and treatment." R5's care plan showed staff was directed to observe for medication side effects. R5 care plan did not identify the side effects that staff should be monitoring which put R5 at risk for falling. R5's care plan did not show any interventions that directed staff in the manner in which to supervise and monitor R5, which would prevent her from falling. R5's care plan, undated, also documents she (R5) will yell at staff and peers. R5's nursing approaches did not show documentation of staff need/method to supervise R5 for these behaviors. Z4 is an emergency room nurse working in a local hospital. Z4 was interviewed on 3/07/2014 at 2:02 PM. Z4 said she took care of R5 when she presented to the emergency roiagnom on [DATE]. Z4 said the facility reported that R5 had facial bruising, but experienced no traumatic event. Z4 said the paramedics told her that facility staff reported R5 had been sitting in a wheel chair for 8 hours. Z4 stated that R5 presented with signs of trauma, such as: bruising to top of her head, forehead, right eye and side of head. Z4 said she knew that R5 needed a CT scan done. Z4 stated R5 bruising, indicated trauma, and the need to rule out head and neck injury. Z3 was the emergency room physician who initially examined R5 on 3/05/2014. Z3 was interviewed on 3/12/2014 at 11:36 PM. Z3 said R5's CT scan showed she had a fractured neck. Z3 stated we did not get the details about the cause of her injury. Z3 said she had experienced trauma, which caused the fractured to her neck. Z3 stated R5's neurologist and primary physician could give more details about her condition. The physician (Z2), treating R5 at the local hospital, was interviewed on 3/07/2014 at 2:19 PM. Z2 said she examined R5 when she was admitted to the hospital on [DATE]. Z2 stated R5 was confused and unable to tell what happened to her. Z2 said R5 had a "hang man fracture" , which was completely broken and partly attached. Z2 stated R5's injuries of bruising (top of head, forehead and side of head) and fractured neck were more consistent with falling. Z2 said the paramedics reported that the facility staff told them (paramedics) R5 was sitting in a wheel chair for 8 hours. Z2 stated R5 could have fallen from the wheel chair and hit her (R5's) head on something on the way down. Z2 said R5 was also on psychoactive medications that could make her more susceptible to falling. Z2 also stated R5 had a history of [REDACTED]. R5 was observed in the intensive care on 3/07/2014 at 3:30 PM. R5 was wearing a neck collar because of her injury. She still had bruising on the top of her head, forehead, right eye and side of head. R5 said she knew she had a serious injury, but she could not remember what caused them. E11 (CNA/certified nurses aide) was interviewed on 3/06/14 at 2:59 PM. E11 said she usually took care of R5. E11 described R5 as being confused at times and was at risk for falls while in the wheel chair. E11 stated R5 always lean forward, and could fall out or slid out of the wheel chair. E11 said that R5 did not always want to leave her chair and sometimes slept in the wheel chair. E12 (CNA) was interviewed on 3/06/14 at 3:33 PM. E12 said R5 was confused. E12 stated R5 was at risk for falling because she tried to get up from her wheel chair and could not stand or walk. E13 (nurse) was interviewed on 3/06/14 at 3:46 PM. E13 said she recently admitted R5 from the hospital on [DATE]. E13 said R5 was started on Geodon (psychoactive medication). E13 stated the nurse, who transferred R5 from the hospital, told her the Geodon put R5 at risk for falling. E13 stated the hospital nurse told her the Geodon would make R5 sleepy and could cause her to fall. E13 said the Geodon could contribute to R5 falling. E13 was asked if she updated R5's care plan to show the added risk factor for R5. E13 reviewed R5's care plan, then said R5's care plan did not get updated R5's plan of care to show the fall risk from Geodon. Another one of R5's nurses (E14) was interviewed on 2/06/14 at 2 PM. E14 also said R5 was confused at times. E14 said R5 would try to get up to the bathroom or stand by herself, and would not ask for the help she (R5) needed. E14 said R5 had chair and bed alarms to prevent her from falling, but E14 did talk about method to supervise and monitor R5. During interview with E15 on 3/27/14 at 12 PM, E15 said R5 could be resistive to care. E15 said R5 slept in her wheel chair and he (E15) was concern she may fall out of it (wheel chair), so he asked E11 to put R5 to bed. E15 said R5 became resistive to care while being transferred by E11 on 3/03/2014. E24 is a physical therapy assistant. E24 was interviewed on 3/13/14 at 1:55 PM. E24 said she had assessed and provided services to R5. E24 stated R5 could not ambulate without assistance. E24 said R5 needs supervision because of her posture, which is flexed and forward leaning. The director of nursing (E1) was interviewed on 3/07/14 at 11:20 AM. E1 said she was responsible for investigation the resident's fall occurrences. E1 said she investigated each of R5's fall occurrences. E1 stated R5 was becoming more confused, and having multiple falls in the facility. E1 was asked to identify what interventions were put into place when R5 fell on [DATE], 1/18/14, 1/24/14, 1/28/14 and 1/30/14. E1 said interventions such as: to remind R5 to use her call light, or call for staff assistance. E1 did not provide explanation of any nursing interventions being put in place for staff to monitor/supervise R5 to prevent possible falls. E1 said she analyzed R5's falls after each occurrences. E1 said an investigation was conducted into R5's neck fracture of 3/05/14. The facility staff identified R5 was at high risk for falls/harm because of multiple factors (mental confusion, trying to get up by herself, resisting care from staff, sleeping, leaning forward in her wheel chair, and sliding out of her wheel chair) and had several unwitnessed falls. Yet, E1 said the facility did not have any knowledge of when/how R5 had fractured her C2. The nurse consultant (E21) was interviewed on 3/27/14 at 11:14 AM. E21 said staff were interviewed and asked who did they (staff) think could have harm R5. E21 said several of the staff identified R6, who was observed being verbally abusive to R5. (However, R5's care plan did not address method use to supervise R5 with R6.). E21 said the facility could not determine the cause of R5's injury. The facility's staff lack of knowledge did not provide evidence of staff giving R5 the monitoring and supervision her physical and mental condition required. 2. R3 is a [AGE] year old female with a [DIAGNOSES REDACTED]. Review of the facility's Accident Log showed R3 had unwitnessed falls on the following days: 2/10/14 at 4:41 PM, 2/06/14 at 3:13 PM and 2/05/14 at 8:45 PM. Review of R3's Fall Occurrence Report, dated 3/03/14, showed: "R3 is a long term resident, ...is alert ...periods of confusion. Staff hear alarm sounding in the dining room, responded and observed R3 lying on the floor in supine position with a lacerated wound to the back of the head... R3 was sent to the hospital... R3 returned to the facility the same day with sutures intact to on the back of the head." Review of R3's care plan, dated 5/18/2014, showed R3 is at risk for falls due to decrease in functional mobility and history of falls. The goal was to keep R3 free of falls and injury. The nursing interventions were not specific in providing R3 with the supervision and monitoring she needed. The interventions were: remind R3 to call for help, use the call light, and report any decline in mobility. R3 is confuse. R3 will not remember to use the call light or ask for help. R3 already had a decline in mobility and was not able to be mobile without assistance from staff. E1 was interviewed on 3/07/14 at 11:20 AM. E1 reviewed each fall occurrence for R3, and interventions put in place to prevent R3 from possible falls or harm. E1 did not identify any method put in place for staff to monitor and supervise R5 to prevent falls or possible harm.

Based on observations, interviews and record reviews, the facility failed to have a consistent plan to ensure one resident (R2 in a sample of three residents) received consistent care and assessments to maintain adequate hydration and identify complications. This failure resulted in staff not effectively identifying the resident required emergency care for "fluid resuscitation" in response to his altered mental status and hypertension. Findings include: Review of R2's clinical record at the acute care facility documented the following: "ER (emergency room ) Chart... 23 July 2011 16:33 (4:30 PM)... CHIEF COMPLAINT: Altered Mental Status, Hypertension... emergency room caveat invoked due to patient with mental status changes. Patient Status: Critical... NOTES: ..XXX[AGE] year old male was brought from the nursing home because of altered mental status and hypertension EMS as that the patient was unresponsive since this morning. Blood pressure dropped prior to them being called... NOTES: received report from ...(facility's staff) RN (Registered Nurse) patent being sent for being unarousable all day... Patient has [DEVICE], ...catheter with little output for the past 24 hours... LABORATORY DATA: Laboratory values revealed a urinalysis consistent with urinary tract infection. His white blood cell count is 23.5. His creatinine is 2.88 mg/dL (normal range 0.05-1.30 mg/dL with a BUN of 77 mg/dL (normal range 10-20 mg/dL). (Previous labs reviewed by ER staff from hospitalization of 7/11/2011, and documented as the following: "BUN 22, creatinine 1.48 and white blood cell count 11.6".) The laboratory results of 7/27/2011 documented that R2's BUN improved to 36 mg/dL and creatinine 1.25 mg/dL. IMPRESSION: ...We would recommend continuing the antibiotics from the direction of infectious disease and fluid resuscitation under the direction of Renal Services.... [DIAGNOSES REDACTED]." At the facility on 8/03/2011 and 8/05/2011, the surveyor reviewed R2's clinical record. -R2's Dehydration Prevention Risk Assessment, dated 7/11/2011, documented staff assessed R2 at risk for dehydration. But, this assessment for R2 failed to consider R2 was assessed with [REDACTED]. R2 also has [MEDICAL CONDITION], renal problems and use of g tube, which indicate his fluid intake was important in his care. The approaches identified to prevent dehydration in R2 was left blank. -Review of R2's care plan identified he was at risk for dehydration because of [DEVICE]. The goal was for R2 to: "tolerate tube feeding without physical or metabolic complication such as... hydration, abnormal labs. But R2's care plan failed to identify clinical symptoms for staff to monitor that would indicate R2 had problems or complications with dehydration or volume depletion. Clinical symptoms such as: [MEDICAL CONDITION], dry mucus membrane and condition of skin. -Review of R2's laboratory documented on 7/18/2011 his BUN and Creatinine were elevated and the nurse practitioner was informed on 7/15/2011. When informed, the nurse practitioner ordered fluids increased. -Review of R2's POS documented R2's flush was increased from 250 cc to 300 cc three times a day on 7/15/2011. On 8/04/2011 at 10 AM, Z2 (Paramedic, who transferred R2 to the hospital on [DATE].) was interviewed by phone. Z2 told surveyor: "When we got there, the nurse told us he had been like that since breakfast... The patient looked terrible... His blood pressure was 70/30...Heart rate in the 80's... I put him on oxygen at 15 liters. We gave him two [MEDICATION NAME] of fluid about 400 cc. That got his blood pressure up. At the hospital they gave him the rest of the fluids, another 600 cc and it stabilized him. When we arrived at the facility he was on two liters of oxygen per nasal cannular... When I put him on 15 liters his oxygen saturation came up to 98%, and his respirator rate went down." Z2 also describe R2 as sweating, and with rapid respirations. E5 (the nurse who cared for R2 on 7/23/2011 on the day shift.) was interviewed on 8/23/2011 at 2:30 PM. E5 told surveyor R2 received water flushes to maintain hydration. When asked, E5 could not explain why R2's I & O (Input & Output) did not consistently document how much fluid R2 was given. In the care of R2 on 7/23/2011, E5 described R2 as drowsy during the morning meal and not eating breakfast. E5 said she assessed R2 and called the nurse practitioner on 7/23/2011. E5 and the nurse practitioner thought R2's change in condition was caused by use of a sedative. E5 said she held the sedative. E5 said she monitored R2's mental status and vital signs as it pertains to R2's use of this sedative. E5 said staff stayed at R2's bedside to monitor him. However, Z2 reported observing R2 in bed, and with only two other residents in the room with him. (E5 documented that R2 became hypotensive and unresponsive at 2:10 PM. But, the nursing notes documented that R2 was not sent to the hospital until 3:55 PM). E6 (Nurse, who came on duty after E5's shift on 7/23/2011, and transferred R2 to the hospital.) was interviewed on 8/03/2011 at 3:05 PM. E6 said, he got report and went to see R2 on 7/23/2011. E6 stated, "His (R2's) blood pressure was a little low. ...I tried to shake him but he did not opened his eyes. I called his name and shaked him ,but no response. ...I went to the room and no one else was there." E6 also reported that he observed R2's nasal cannular not in his nasal passage, and when he put in the appropriate place. Then, E6 observed R2's oxygen saturation went up. But, R2 was not being consistently monitored. R2's son and wife were observed visiting him on 08/05/2011. Surveyor interviewed them in a sitting area on the third floor. R2 reported that his father was admitted to the hospital with [REDACTED]. R2's primary physician was interviewed by phone on 8/05/2011, he told surveyor he increased R2's fluid in response to R2's BUN and creatinine level. During the Daily Status Meeting with the administrative staff (administrator/E1 and nurse consultant/E11, the surveyor expressed concerns that R2 did not receive consistent service/care to maintain to adequate hydration. E11 presented evidence that facility's staff were thinking that R2 was over sedated and the nurse practitioner called. But, E11 did not present evidence that R2 was consistently assessed and monitored for other medical problems on 7/23/2011, such as adequate hydration or volume depletion.