Every finding on record at Bella Terra Schaumburg

Based on observation, interview, and record review the facility failed to ensure a resident's head of the bed was upright during meals (R9). This applies to 1 of 5 residents reviewed for safety in the sample of 47. The facility also failed to ensure a second-floor medication cart was locked when unsupervised. The findings include: 1. R9's face sheet printed on 1/15/26 showed diagnoses including but not limited to brain cancer, palliative care, heart disease, skin cancer, and protein-calorie malnutrition. R9's facility assessment dated [DATE] showed supervision needed for eating and on a mechanically altered diet. R9's dietary evaluation dated 12/26/25 showed dysphagia (difficulty swallowing) and dental problems of broken or fractured teeth. On 1/13/26 at 12:58 PM, R9 was lying in bed during the lunch meal service. R9 had a plate of mechanical soft food directly in front of him on the over the bed table. The meal consisted of diced carrots, pasta, and a roll. R9 had black, broken teeth in his upper mouth and missing teeth on the bottom. R9's head of the bed was declined, and he was trying to spoon food into his mouth. The room divider curtain around the bed was pulled and R9 was not visible from the hall. At 1:15 PM, R9 was still in the same position with the head of the bed declined. At 1:16 PM, V24 (CNA-Certified Nurse Aide) stated room trays get delivered to resident rooms around 12:45 PM daily. At 1:30 PM, V25 (second CNA) entered R9's room and could be heard raising the head of the bed. V25 confirmed R9 was still eating and exited the room. This surveyor entered the room and R9 was still feeding himself. On 1/15/26 at 10:55 AM, V20 and V21 (Wound Care Nurses) performed care on R9. During care V20 and V21 stated R9 does eat by himself in bed. He needs to be in an upright position, not flat. He is on a mechanical soft diet because he has dental issues and is at risk for aspiration. The head of the bed should be up to prevent choking on food. On 1/15/26 at 12:31 PM, V3 (Director of Nurses) stated R9 should have the head of the bed upright as tolerated but at least at 45 degrees or so during meals. Nothing less. He could aspirate or choke if it is any lower. R9's care plan showed a focus area initiated 4/9/25 related to compromised nutritional status due to a diagnosis of dysphagia. Goals included no episodes of choking or aspiration. Interventions included assess the resident during mealtime, utilizing safe swallowing technique and protocols. 2. On 1/15/26 at 7:40 AM, upon arrival to the second floor, the medication cart was located down the hallway outside of a resident room. The medication cart was unlocked. There was no staff present in the hallway or near the cart. This writer waited by the cart for staff to arrive. V16 Licensed Practical Nurse (LPN) stepped out of a resident room and immediately locked the cart. She said the cart should have been locked when she stepped away. On 1/15/26 at 12:12 PM, V2 (Assistant Administrator) said the medication cart should be locked whenever staff step away. They should be locking it for safety so no one can get into it. The daily census of 1/13/26 documents the second floor to have 62 residents. The facility's 7/2/25 policy for medication storage, labeling, and disposal documents 3. Medications will be stored safely under appropriate environmental controls. 4. Medications will be secured in locked storage area.

Based on interview and record review the facility failed to ensure residents were offered bedtime snacks for 5 of 5 residents (R21, R83, R88, R100, and R118) reviewed for snacks in the sample of 47. The findings include:On 1/14/26 at 10:39 AM, During the group resident meeting all 5 residents present (R21, R83, R88, R100, and R118) stated they do not receive and are not offered bedtime snacks. R21's face sheet showed she was admitted to the facility 10/02/2019. R21's facility assessment dated [DATE] showed she has no cognitive impairment. On 1/14/26 at 10:29 AM, R21 said she is the Resident Council President. R21 said she can't even get an extra cookie or dinner dessert treat to take back to her room to eat later. R21 said she has asked staff if she could have something to take back to her room and they tell her no. R118's face sheet showed he was admitted to the facility 7/16/24. R118's facility assessment dated [DATE] showed he is cognitively intact. R118 said, That is a BIG NO. R83's face sheet showed she was admitted to the facility 7/22/25. R83's facility assessment dated [DATE] showed she has no cognitive impairments. R88's face sheet showed he was admitted to the facility 9/5/24. R88's facility assessment dated [DATE] showed he has no cognitive impairments. R100's face sheet showed he was admitted to the facility 12/23/23. R100's facility assessment dated [DATE] showed he has no cognitive impairment. On 1/15/2026 at 12:42 PM, V19 (Dietary Manager) said snacks are provided only to the resident's who the dietitian tells them to. V19 said they have a list of people who get snacks, and they get delivered to the nursing station on each floor labeled with the resident name and room number. V19 said no other residents are offered snacks and there is nothing available to send up if they were to ask for it at bedtime. The facility's policy and procedure revised 6/26/25 showed, Bedtime (HS) Snacks. Policy Statement: the facility will provide the residents bedtime snacks in accordance with the federal regulations. Procedures: The facility must offer snacks at bedtime daily.The facility's policy and procedure reviewed 9/12/21 showed, Resident Food and Nutrition Services Standard Operating Procedures Manual. Policy Statement: Between meal snack/nourishments shall be made available for residents 3 times/day to ensure residents are provided adequate nourishment and hydration between meals. Snacks/ Nourishments will be provided at the following times. AM (morning) Snack. PM (afternoon) Snack. HS (bedtime) snack. All residents will be offered a snack/nourishment unless otherwise indicated in his/her plan of care.

Based on observation, interview and record review the facility failed to ensure medical records were private for 1 of 1 resident (R105) reviewed for privacy in the sample of 47.The findings include:On 1/15/26 at 7:40 AM, upon arrival to the second floor, the medication cart was located down the hallway outside of a resident room. The cart had a computer mounted on top of the cart. The computer screen was open to R105's medications. There was no staff in the hall or near the cart. This writer waited by the cart for staff to arrive. V16 Licensed Practical Nurse (LPN) stepped out of a resident room, and said she was called away to a resident room, but the screen should have been closed.On 1/15/26 at 12:12 PM, V2 Director of Nursing said when a nurse steps away from her cart the computer should be closed and no resident information exposed. That would be a HIPAA (Health Insurance Portability and Accountability Act) violation.The facility's 12/8/25 policy for Notice of privacy practices states 1. The resident has a right to secure and confidential personal and medical records. Personal and medical records include all types of records the facility might keep on a resident, whether they are medical, social, fund accounts, automated, electronic, or other.

Based on observation, interview and record review, the facility failed to ensure staff thoroughly cleaned a resident who was dependent on staff for incontinent care for 1 of 1 resident (R159) reviewed for activities of daily living (ADLs) in the sample of 47.The findings include:R159's admission Record, provided by the facility on 1/15/26, showed she had diagnoses including, but not limited to, dementia, osteoarthritis, diverticulosis of small intestine, pressure ulcer of sacral region, acute kidney failure, urine retention, and altered mental status. R159's facility assessment dated [DATE], showed she has severe cognitive impairment and is dependent on staff for all cares. R159's skin impairment care plan initiated on 11/13/25, showed she remains at high risk for skin breakdown due to a history of multiple pressure injuries. The care plan showed one of the interventions in place was Keep skin clean and dry. R159's ADL care plan initiated on 11/20/25, showed she has an ADL self-care performance deficit and is dependent on staff for her toileting and personal hygiene needs.On 1/15/26 at 10:20 AM, V20 (Wound Nurse in training/RN) and V21 (Wound Nurse/LPN) donned PPE (Personal Protective Equipment) and went in to do the wound care for R159. V21 said R159 had pressure ulcers on admission that were very large and were healed about two weeks prior to this observation. V20 said they are monitoring the areas and applying barrier cream to R159's buttocks. R159 was positioned on her left side and V20 undid R159's brief and pulled it down. R159 had been incontinent of stool. V20 grabbed the wipes and cleaned the stool from 159's buttocks area. This surveyor could see visible stool in R159's perineum area that was not cleaned. V20 removed the gloves used for incontinent care, performed hand hygiene and donned new gloves. V20 applied barrier cream to R159's buttocks and a new brief was placed on R159. V20 and V21 repositioned R159 and started placing pillows under her to offload areas of pressure. V20 had put the wet wipes back in the drawer. This surveyor asked them to please check R159's front area to make sure all the stool was cleaned off. After undoing the brief, V20 grabbed the wipes out of the drawer and wiped R159's vaginal and perineal area. Visible stool was on the wipe. The brief that was put on after incontinent care also had visible stool on it. V20 used two more wipes, and each one had visible stool on it. R159 was rolled onto her right side and V21 said she was going to make sure they got all the stool off. V21 used three wipes, one at a time and they all had visible stool on them. V21 said it is important to make sure all the stool is cleaned off of the residents when giving care to prevent infection and skin breakdown.On 1/15/26 at 10:50 AM, V3 (Director of Nursing-DON) said it is important to make sure staff are cleaning all the stool from a resident while providing care to prevent infection and skin breakdown. The facility's policy and procedure titled Incontinence and Perineal Care, with a revision date of 6/30/2025, 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.

Based on observation, interview, and record review the facility failed to prevent, identify, initiate a treatment, and notify the physician of a new skin condition for 1 of 2 residents (R140) reviewed for non-pressure skin conditions in the sample of 47. The findings include:R140's face sheet showed she was admitted to the facility 3/27/23 with diagnoses to include senile degeneration of brain, hypokalemia, hypertensive heart and chronic kidney disease without heart failure, dementia without behavioral disturbance, generalized anxiety disorder, insomnia, and overactive bladder. R140's facility assessment showed dated 12/23/25 showed she had severe cognitive impairment and dependent upon staff for all cares. R140's current Physician Order Sheet showed no orders for treatment or monitoring in place of her bilateral shins.On 1/13/26 at 1:30 PM, R140 was in her room sitting up in her wheelchair. V26 (R140's son-in-law) was present in the room with R140. R140's shins were exposed. R140 had several dark bruises on each shin and steri-strips had been applied to an area on each shin. Drainage could be visualized under the steri-strips on both of R140's shins. V6 said, Those bruises and the steri-strips has been on and off like this for months, she has had bruising or skin tears in various forms for months. R140's care plan initiated 3/27/23 showed, [R140] has potential for alteration in skin integrity related to needs assist with personal care, incontinent of bowel and bladder and extensive assist with bed mobility. Diagnosis of reduced mobility, weakness, cognitive communication deficit, dementia, hyperlipidemia. HIGH RISK -Skin check every shift. Report abnormalities to the nurse. On 1/15/26 at 9:20 AM, V20 (Wound Care Nurse) said she was not aware of R140 having any skin conditions. V20 said residents have falls sometimes and maybe the skin tears occurred from a fall and the nurses put the steri-strips on. V20 said these skin conditions could have just happened today. V20 said R140 is a hospice patient so maybe hospice placed the steri-strips. V20 said the facility staff and the hospice staff should let her know when there is a new skin condition. V20 looked at R140's shins with the surveyor and said, It doesn't even look like anything. Maybe they put the steri-strips over the bruises. V20 said steri-strips are not typically a treatment for bruising but usually used for skin tears. V20 used an alcohol swab and wiped over the steri-strips to R140's left shin. The steri-strips peeled up and there was dried blood visualized on R140's shin and on the steri-strips. V20 said, See there is nothing there. R140 did not remove the steri-strips to R140's right shin. V20 said when a new skin condition is reported to her, she would come assess the area, notify the wound care company, enter orders for treatment and monitoring, and there would be an investigation started to determine the cause of the skin condition. V20 said the resident's care plan would also be updated. On 1/15/26 at 9:30 AM, V12 (Nursing Supervisor) said she was not aware of R140's skin conditions. On 1/15/2026 at 1:34 PM, V3 DON (Director of Nursing) said, when staff notice a skin alteration they should report it to the nurse right away. V3 said the facility has a wound care nurse in the facility 7 days a week and the wound care staff should be notified. V3 said she would expect that the staff would assess the wound, open a skin/wound assessment in the electronic record, notify the doctor and the family, and make sure that there is a treatment in place. V3 said it is important to complete these steps because they don't want the wound to get worse, they want to make sure the proper interventions are in place, and it is important for the doctor to be able to determine the appropriate treatment. V3 said an investigation would be initiated to determine what caused the area and if there needs to be staff training done or other interventions put into place to prevent it from happening again. The facility's policy and procedure with review date of 7/3/25 showed, Skin Care Regimen and Treatment Formulary. Policy Statement: It is the policy of this facility to ensure prompt identification, documentation and obtain appropriate treatment for residents with skin breakdown. Procedures: 1. Charge nurses must document in the Electronic Health Record any skin breakdown upon assessment and identification. Furthermore, treatment must be obtained from the patient's physician. Treatment Protocol: . a. Skin Tears/Laceration: Film dressing (ex: Tegaderm), foam dressing. Xeroform gauze and topical antibiotic unless contraindicated.

Based on observation, interview and record review, the facility failed to ensure an insulin pen was disinfected prior to attaching the needle for 1 of 1 resident (R108) reviewed for insulin injections in the sample of 47.The findings include:R108's admission Record, provided by the facility on 1/15/2026, showed she had diagnoses including, but not limited to, dementia and type II diabetes mellitus. R108's Order Summary Report, printed 1/15/2026, showed the following active order for Humalog Kwik pen Subcutaneous Solution Pen Injector 100 units/ml. inject per sliding scale before meals and at bedtime. R108's facility assessment dated [DATE], showed she has severe cognitive impairment and requires substantial/maximal assist from staff, or is dependent on staff for all cares except eating. R108's careplan initiated on 11/7/2025, showed she is at risk for fluctuating blood sugars due to diabetes mellitus. The care plan showed the nurse should administer sliding scale per physician's order.On 01/14/2026 at 11:23 AM, V6 (Registered Nurse-RN) checked R108's blood sugar level and informed R108 she was going to get her insulin ready and be right back. When preparing the insulin, V6 removed the cap from the Humulog Injector Pen and attached the needle without disinfecting the rubber top at the end of the pen prior to attaching the needle. V6 administered the insulin to R108. V6 was asked if the rubber end of the injector pen needs to be disinfected prior to attaching the needle. V6 said she does not need to alcohol the end of the insulin pen prior to attaching the needle.On 01/14/2026 at 2:42 PM, V14 (Licensed Practical Nurse-LPN) said the nurse's do not need to alcohol the top of insulin pens before attaching the needle.On 01/15/2026 at 9:08 AM, V28 (First floor Nurse Manager) said the insulin pens should be disinfected with alcohol wipes before attaching the needle to the end of the pen for infection control.On 1/15/2026 at 10:50 AM, V3 (Director of Nursing-DON) said the nurses should alcohol the rubber end of the insulin pen before attaching the needle for infection control.The facility's policy and procedure titled Medication Pass, with a revision date of 7/2/2025, did not address disinfecting insulin injector pens prior to attaching needle, nor did it mention disinfecting the rubber stopper on insulin vials prior to inserting the needle.

Based on observation, interview and record review, the facility failed to provide incontinent care in a manner to prevent cross contamination (R45, R159) and failed to ensure staff wore the personal protective equipment (PPE) required when accessing a resident's intravenous line (R2) for 3 of 3 residents (R45, R159, R2) reviewed for infection control in the sample of 47.The findings include:1. R45's admission Record, provided by the facility on 1/15/2026, showed she has diagnoses including, but not limited to, early onset Alzheimer's disease, acute kidney failure, urine retention, major depressive disorder, and anxiety disorder. R45's facility assessment dated [DATE], showed she has moderate cognitive impairment. The assessment showed R45 is always incontinent of bowel and bladder and is dependent on staff for toileting hygiene and personal hygiene. R45's care plan initiated on 3/3/2024 showed she is dependent on staff for toilet hygiene. R45's care plan initiated on 5/18/2024 showed she was at risk for skin breakdown relating to needing assist with personal cares, and being incontinent of bowel and bladder, among other health concerns. On 1/13/2026 at 12:29 PM, R45 said she turned her light on because she is wet, and needs changed. V23 (Restorative Aide) and V27 (Certified Nursing Assistant-CNA) came in to provide incontinent care for R45. V23 and V27 removed R45's incontinent brief. The brief was soiled with urine. V27 grabbed several wipes and stacked together and wiped R45's pubic area, then right groin area, then down R45's middle vaginal area with the same wipes. V27 did not use a different section of the wipes or fold the wipes. V23 and V27 put a clean brief on R45 and assisted her with repositioning. On 1/15/2026 at 9:08 AM, V28 (First floor Unit Manager) said wet wipes should be discarded after each swipe and a clean wipe should be used when cleaning the vaginal area to prevent infection. For infection control. On 1/15/2026 at 10:50 AM, V3 (Director of Nursing-DON) said staff should use a clean wipe with every swipe. Using the same wipe to clean the resident's pubic area, groin, then vaginal area can cause an infection because that is an opening to the body. 2. R159's admission Record, provided by the facility on 1/15/2026, showed she had diagnoses including, but not limited to, dementia, osteoarthritis, diverticulosis of small intestine, pressure ulcer of sacral region, acute kidney failure, urine retention, and altered mental status. R159's facility assessment dated [DATE], showed she has severe cognitive impairment and is dependent on staff for all cares. R159's ADL care plan initiated on 11/20/2025, showed she has an ADL self-care performance deficit and is dependent on staff for her toileting and personal hygiene needs. On 1/15/2026 at 10:20 AM, V20 (Wound Nurse in training/RN) and V21 (Wound Nurse/LPN) donned PPE and went in to do the wound care for R159. R159 had been incontinent of stool. While providing care, V21 tossed three wet wipes visibly soiled with stool over the bed to try to make it into the trash can on the other side of the bed. Every time, the wet wipes landed on the floor instead of the bed. After incontinent and wound care was done, V20 picked the three soiled wet wipes off the floor and placed them in the trash bag. V20 lifted the trash bag out of the can to tie it off. While doing this, V20 was standing right over the area the soiled wipes had just been. On 1/15/26 at 10:50 AM, V3 (Director of Nursing-DON) said V21 should not have tossed the soiled wet wipes over the bed to put in trash. The trash can should be next to the staff cleaning the resident so they could just put it in the trash can. For infection control and to prevent cross-contamination. V3 said staff should use a clean wipe with every swipe. Using the same wipe to clean the resident's pubic area, groin, then vaginal area can cause an infection because that is an opening to the body. The facility's policy and procedure titled Incontinence and Perineal Care, with a revision date of 6/30/2025, 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. The procedure showed.5. Maintain clean techniques. 6. Wash the perineal area and gently dry after the procedure. 7. Discard disposable items into designated containers/plastic bag. 3. R2's Care Plan showed R2 requires Enhanced Barrier Preauction (EBP) related to IV (intravenous) medications. This care plan intervention was initiated on 12/10/25 On 1/13/26 at 11:24 AM, V13 Registered Nurse entered R2's room to administer R2's IV antibiotic. During the process of administering the IV medication, V13's clothing brushed up against R2's bedding. V13 was not wearing a gown. Posted outside V13's door was a sign showing she was in Enhanced Barrier Precautions, and a gown was required for device care or use: central line, urinary catheter, feeding tube, tracheostomy. On 1/13/26 at 12:40 PM, V13 stated she should have worn a gown when accessing the IV to prevent the spread of any protentional contamination. On 1/14/26 at 2:24 PM, V2 Director of Nursing stated enhanced barrier precautions is required for IV access. V2 stated the gown is an extra barrier of protection to prevent the spread of contamination. The facility's Enhanced Barrier Precaution policy (revised 9/16/25) showed EBP involves the use of gown and gloves to reduce transmission of resistant organisms during high-contact resident care activities for residents.with wounds and/or indwelling medical devices. The policy showed a gown is required during high contact resident care.

Based on observation, interview, and record review the facility failed to weigh, assess and monitor a resident with significant weight loss. This failure resulted in R137 losing 21 lbs (pounds) in 14 days without being re-weighed or assessed. The facility also failed to provide physician ordered supplements for a resident with a history of significant weight loss. This applies to 2 of 7 residents (R137 & R118) reviewed for weight loss in the sample of 30. The findings include: 1. R137's face sheet lists her diagnoses to include: senile degeneration of brain, dementia, unspecified psychosis, major depressive disorder, cognitive communication deficit and hallucinations. R137's face sheet also shows she was admitted to the facility on [DATE]. She weighed 145.6 lbs. R137's initial admission dietary evaluation dated July 31, 2024 shows, [AGE] year old female admitted from the hospital with a dx (diagnosis) of psychosis. Past medical hx (history) includes dementia, depression, hyperlipidemia. Diet: regular with thin liquids. Appetite appears fair with intake of ~50-75% of meals since admission. Current BMI (body mass index) is 22.5 which reflects weight within normal range for height, but low for age. Reviewed meds. No current labs to review. No skin breakdown noted. Visited with patient in the room during breakfast. Observed feeding herself with a good appetite. Patient was confused stating Hi Ma, will you be here all day? Patient was unable to answer any interview questions. Spoke with the POA (Power of Attorney) who reports patient's height to be 5'7 1/2 and states patient used to be ~190.6# (lbs) x ~4-5 months ago- unable to specifically quantify. POA states patient was eating well at home and did receive [NAME] (meals on wheels) for lunch, however continued to lose weight despite eating well. Obtained preferences and left meal tickets and alternative menu to fill out. Per POA, patient prefers cold cereal at breakfast, likes cheeseburgers, chicken and fish and loves anything chocolate. MNA (mini nutritional assessment) score is 12 which is normal nutritional status. Goals: PO (by mouth) intake >/=75%, weight maintenance. Patient appears well nourished at this time but will monitor weight trend and intake d/t (due to) reported wt (weight) loss. R137's progress notes dated August 4, 2024 shows, The patient refused to eat. She's always saying that I don't want to eat, I don't like the food. Spoke with POA she said that a family member will come by today to bring her burger which likes to eat. R137's electronic medical record (EMR) shows no re-weight from admission. R137's order details dated August 5, 2024 shows, mirtazapine tablet was ordered for increase appetite. R137's EMR continues to shows no re-weight from admission. R137's nutrition- amount eaten sheet shows the following percentages of food eaten: 8/3/24- 0-25% for all 3 meals, 8/4/24- 51-75% for all 3 meals, 8/5/24 & 8/6/24- 26-50% for breakfast and lunch, 51-75% for dinner, 8/7/24- 0-25% for breakfast and lunch and refused dinner, 8/8/24- 26-50% for breakfast, 51-75% for lunch and dinner, 8/9/24- 0-25% for all 3 meals and 8/10/24- breakfast refused and 26-50% for lunch. R137's weights show, she was not weighed again until August 13, 2024 (14 days later). She weighed 124.5 lbs (21 lb loss). R137's EMR and progress notes show, she was not seen by the dietitian after her initial assessment until August 20, 2024 (7 days later). Reported that resident continues to have varies to mainly poor p.o. (by mouth) intake with meals despite of assist and encourage. Diet was downgraded to Mechanical Soft on 8/19 and to Puree on 8/20 (started for Lunch) d/t (due to) continues poor intake. Per nursing provided Puree for lunch today and ate 100% of the meal with ice cream. Nursing notified MD and families regarding p.o. intake, current wt with wt loss and diet changes. Current wt is 126.6# as of 8/20 which showed 5# or 3.7% loss from last week's wt of 131.6# 8/15. Initial wt of 145.6# on 7/30 and 124.6# on 8/13 were both questionable, resident was re-weighed on 8/15-131.6#. With current wt BMI is 19.5 which remains normal status but at the low-end side. Per wound nurse today, resident has unstageable to coccyx area as of 8/19. Per nursing resident tolerates supplements well. Will recommend increasing to 120ml (milliliters) QID (four times a day) and to provide (fortified shake) which will provide 960kcal (kilocalories) and 40g (grams) of protein if all consumed. Added ice cream with lunch and dinner, super cereal at breakfast. Interventions should help with the healing process and maintain or have wt (weight) gain. Will make Rd (Registered Dietitian) aware. Will continue to monitor wt, labs and intake. On November 19, 2024 at 1:24 PM, V14 (Dietitian) stated, she asked for a re-weigh when R137 was admitted because she didn't believe she weighed 145 lbs. She did not get re-weighed until August 13, 2024. She only saw her on July 31, 2024 and August 20, 2024. New admits should have weekly weights for 4 weeks to make sure the initial weight are correct and monitor for any fluctuations. R137's care plan initiated on July 31, 2024 shows, Nutrition-Dementia focused. R137 is at risk for compromised nutritional status, related to diagnosis of Alzheimer's disease or related dementia . 2. On November 17 & 18th, 2024 both at the noon meals, R118 was not provided a magic cup. R118's dietary evaluation dated October 24, 2024 shows, Resident is seen for significant weight loss of 10.5% x 6 months. Current weight is 129.8# which is down from 145# x 6 months ago. Resident continues under hospice care w/a dx (with a diagnosis) of senile degeneration of the brain. Continues on Pureed with thin liquids, pudding at breakfast, magic cup at lunch and dinner. R118's physician orders shows, Regular diet, Puree texture, Thin liquids consistency. Magic cup with lunch and dinner, pudding at breakfast and whole milk with meals. No Straws. On November 19, 2024 at 1:24 PM, V14 (Dietitian) stated, R118 has had some weight loss. One of the interventions added was a magic cup at lunch and dinner. If he doesn't receive his magic cup, he could lose more weight. R118's care plan initiated on September 10, 2024 shows, Focus: Unintended weight loss/gain: R118 has the following conditions and risk factors that put him at risk for unintended weigh loss/gain: Alzheimer's disease/dementia. Significant weight loss x 6 months. Interventions: Proved pureed diet to meet the nutritional needs of the resident by: 1. providing fortified foods- magic cup BID (twice a day), pudding (date initiated October 25, 2024). The facility did not provide a weight loss/prevention policy.

Based on interview and record review the facility failed to ensure a resident and/or resident representative understood the arbitration agreement, and failed to educate staff providing the arbitration agreement to residents which applies to 4 of 4 (R20, R73, R144, R251) reviewed for the arbitration agreement in a sample of 30. The findings include: 1. R251's medical record showed R251 was admitted to the facility on [DATE]. R251's Health Care Arbitration Agreement (HCAA) was signed on 11/17/24 by R251. R251's medical record show R251 was assessed as being cognitively intact. On 11/20/24 at 10:00 AM, R251 stated she was in the facility a few days when a young man (V27 Guest Services Director) came into her room to have her sign some documents. R251 stated she knew one of the documents was an admissions packet. The other one had smaller writing. V27 did not explain what the other document was clearly. R251 stated they signed the papers, V27 stated if R251 had any questions to contact them. R251 stated it was not explained to her the details of what the HCAA document meant. R251 was unaware if the HCAA was signed it waived her ability to get legal assistance if something happened to her in the facility. R251 stated that was not mentioned at the time the HCAA was presented to her. 2. R20's medical record showed R20 was admitted to the facility on [DATE]. R20's Health Care Arbitration Agreement (HCAA) was signed on 10/10/24 by V28 (R20's Power of Attorney-POA). R20's medical record showed R20 has severe cognitive impairment. On 11/20/2024 at 9:45 AM, V28 (R20's POA) stated she remembered signing some documents after a careplan meeting for R20. V28 stated she was asked to sign a document (HCAA) at that time, and did not have time to review the documents. When asked if V28 understood the document waives the right to seek legal actions against the facility for malpractice related to care and services R20 may receive in the future, V28 stated that was not explained to her. V28 stated she would have taken the document with and signed it later when she had the appropriate time to look at it. 3. R73's medical record showed R73 was admitted to the facility on [DATE]. R73's HCAA was signed on 10/10/24 by R73. R73's medical record showed R73 was assessed with having moderate cognitive impairment. R73 has no POA listed in this medical record. On 11/20/24 at 10:15 AM, R73 stated someone came in after she was in the building, and had her sign a bunch of papers at the same time. R73 stated she does not remember anyone explaining what the documents (included the HCAA) meant. R73 stated she did not remember any suggestion they could not sue the facility if something bad happened to them in the facility. 4. R144's medical record showed R144 was admitted to the facility on [DATE]. R144's HCAA was signed on 11/18/24. R144's medical record showed R144 was assessed to be cognitively intact. On 11/20/24 at 11:00 AM, R144 stated she had someone come into the room and talk to her about a bunch of documents in the folder on the bedside table. R144 stated she thought an arbitration agreement had a committee work with you and the facility to resolve issues. Not that she could not get a lawyer if any problems happened during her admission. R144 stated she would of had her husband look through the documents if it was explained better to her before she signed it. On 11/20/24 11:56 AM, V26 (Admissions Director) stated the way they were taught to give out the HCAA to the residents was done by the previous admissions director. The previous admission director explained to V26 the HCAA needed to be gone over with the resident when they brought it to the room, and have the resident accept or decline the HCAA. V26 stated that is what was told to V27 (Guest Services Director) when V27 started assisting me with the HCAAs. On 11/20/24 at 11:58, V27 stated V27 agreed with R26 about being verbally told how to approach the residents with the HCAA form. V27 stated they had not received any formal education on the HCAA. On 11/20/24 at 12:30 PM, V31 (Regional Clinical Consultant) stated the facility did not have a policy on the Arbitration Agreement, but provided a power point education packet used for staff education. On 11/20/24 12:50 PM, V26 and V27 stated they had not see the education packet provided by the facility. The undated HCAA education packet showed factors which could have the HCAA be unconscionable (against good conscious) were if there was issue with a resident's age, literacy, or lack of sophistication of a party, the manner and setting in which the contract was formed, and/or whether the party had an opportunity to understand the terms of the contract. It is important to be sure the signer is not signing the agreement while being rushed, and the terms were explained to them in a manner that they can understand.

Based on interview and record review, the facility failed to ensure residents (R115 and R13) were free of resident-to-resident verbal and physical abuse. This affects 2 of 30 residents reviewed for abuse in the sample of 30. The findings include: On 11/19/24 at 3:29 PM, R115 said R13 was cursing at him. R13 rolled over in his wheelchair and grabbed R115's left wrist area and had a good grip on it. R115 said R13 dug his nails in and did break the skin, but he did not bleed. R115 said he had an Xray, but nothing was broken. R115 said he and R13 did not get along well. On 11/19/24 at 2:35 PM, V1, Administrator, said he received a call from the nurse one evening saying R115 and R13 were yelling at each other and R13 was holding R115's wrist. V1 said R115 did have an Xray following the incident on 10/1/24. On 11/19/24 at 12:30 PM, V24, Licensed Practical Nurse (LPN), said a CNA (certified nursing assistant) told her he heard some yelling and asked her to address it. V24 said she went into R115 and R13's room and saw R13 by R115's bed. R13 had a hold of R115's wrist and they were yelling at each other. V24 said it is very difficult to know what R13 is saying, but she did understand the words TV and loud. V24 said R115 told her R13 was yelling at him and then grabbed his arm. R13's Progress Notes dated 10/1/24 at 8:57 PM show R13 was observed grabbing and shaking roommate by the wrist, R13 appeared angry, with unclear speech. R13's care plan initiated on 1/22/22 shows R13 will reside in the facility free of abuse. R115's Progress Notes dated 10/1/24 at 9:06 PM shows R115 was assessed after an altercation with his roommate whereby he was grabbed by the wrist. R115's wrist appeared red, and he reported mild pain. An order was received for an Xray of the left wrist. R115's care plan initiated 6/5/23 shows R115 is alert and sufficiently oriented and coherent. The facility's Abuse and Neglect Policy (revised 7/12/24) shows the facility will provide services in an environment free from any type of abuse. Abuse is willful infliction of mistreatment, injury, unreasonable confinement, intimidation or punishment.

Based on interview and record review the facility failed to notify the resident or their representative in writing of transfer. This applies to 2 of 30 (R31, R13) reviewed for notice of transfer or discharge in the sample of 30. The findings include: 40798 1. R31's Progress Notes dated 10/20/24 at 5:15 PM show R31 is awaiting transport to the ER (emergency room ). R31's Progress Notes dated 10/20/24 at 7:00 PM show an ambulance has arrived to transport R31 to the ER. R31's Progress Notes dated 10/20/24 at 9:38 PM show R31's POA (Power of Attorney) was called and informed that R31 was being admitted to the hospital. The facility was unable to provide documentation of a written notice regarding R31's transfer to the hospital. 2. R13's Progress Notes dated 10/30/24 at 3:26 PM show R13 was admitted to the hospital. The facility was unable to provide documentation of a written notice regarding R31's transfer to the hospital. On 11/18/2024 at 12:28PM, V19 (Registered Nurse/RN) said we give documents to the paramedics but not the family. On 11/19/2024 at 10:22AM, V23 (Licensed Practical Nurse/LPN) said she contacts the family when a resident transfers but does not send a written copy to the family. V23 said documents are sent with the EMTs (Emergency Medical Technicians). On 11/19/2024 at 12:16PM, V2 (Director of Nursing/DON) said we don't send a hard copy of transfer to family. V2 said we talk to the family over the phone. The facility failed to provide a policy that addresses written notification of transfer to the resident or their representative.

Based on interview and record review the facility failed to notify the resident or their representative of the bed hold policy. This applies to 3 of 30 (R23, R31, R13) reviewed for notice of bed hold in the sample of 30. The findings include: 1. On 11/18/2024 at 3:39PM, V22 (Registered Nurse/RN) said he was caring for R23 when she went to the hospital in February of this year. V22 said he gave the paperwork to the EMTs (Emergency Medical Technicians) because the resident was confused that day. V22 said he does not recall if he notified the family of the bed hold policy. V22 said the bed is held for 10 days after a resident transfers to the hospital. V22 said he couldn't find anything in his documentation that shows he notified the family of the bed hold policy. 2. R31's Progress Notes dated 10/20/24 at 5:15 PM show R31 is awaiting transport to the ER (emergency room ). R31's Progress Notes dated 10/20/24 at 7:00 PM show an ambulance has arrived to transport R31 to the ER. R31's Progress Notes dated 10/20/24 at 9:38 PM show R31's POA (Power of Attorney) was called and informed that R31 was being admitted to the hospital. The facility was unable to provide documentation of providing a written bed hold policy to R31 or his POA. 3. R13's Progress Notes dated 10/30/24 at 3:26 PM show R13 was admitted to the hospital. The facility was unable to provide documentation of a written notice regarding R31's transfer to the hospital. The facility was unable to provide documentation of providing a written bed hold policy to R13's POA. 45540 On 11/18/2024 at 12:28PM, V19 (RN) said the bed hold policy is given to the paramedics upon transfer. On 11/18/2024 at 1:44PM, V20 (RN) said we give the paperwork to the EMTs and sent it with them. V20 said we call the resident's family to notify them about the transfer, but we don't necessarily call about the bed hold. On 11/18/2024 at 1:46PM, V21 (RN) said we give the bed hold policy to the paramedics when the resident transfers out. V21 said we tell the family the bed is held for 24 hours. On 11/19/2024 at 10:22AM, V23 (Licensed Practical Nurse/LPN) said we give a copy of the bed hold information to the EMTs when we send the resident out. On 11/19/2024 at 12:16PM, V2 (Director of Nursing/DON) said we don't send a hard copy of transfer to family. V2 said we give paperwork to the paramedics upon transfer to the hospital. The facility provided Bed Hold and Readmission policy revised 7/26/2024 states, the facility must inform the resident or family members being transferred of the duration of bed hold in writing.

Based on interview and record review the facility failed to ensure a resident was assessed prior to being diagnosed with a serious mental illness according to professional standards of practice. This applies to 1 of 1 residents (R99) reviewed for professional standards of practice in the sample of 30. The findings include: R99's face sheet shows, she was admitted to the facility on [DATE]. The same face sheet lists Schizophrenia as a diagnosis as of May 2, 2023 (2 years after admission). On November 20, 2024 at 10:38 AM, V25 Psychotropic nurse stated, she didn't know how R99 got that diagnosis. She has only been doing the psychotropics since May of this year. R99's progress notes dated May 2, 2023 documented by V30 R99's primary care physician (PCP) shows, .schizophrenia, continue seroquel to 25 mg (milligram) daily . The progress note does not show, any information to add diagnosis of schizophrenia. On November 20, 2024 at 2:19 PM, V30 R99's PCP stated, her understanding was that R99 came to the facility with that diagnosis. She had not done any testing to confirm the diagnosis. On November 20, 2024 at 3:17 PM, V29 Psych Nurse Practitioner stated, R99 has had that diagnosis since she has been seeing her. She has been seeing her since February 2024. R99 does have a diagnosis of dementia which she agreed R99's behaviors could be a result of her dementia diagnosis which comes with mania and psychosis. You can manage dementia with the same psychotropic medications. Schizophrenia is a big diagnosis and the gold standard is a full psych evaluation and long hours of testing. Which she has not done with R99 since she has been seeing her. R99's face sheet does also include dementia, bipolar disorder, psychotic disorder with delusions, generalized anxiety disorder, delusional disorders and major depressive disorder as diagnoses. R99's admission hospital records do not list schizophrenia as a diagnosis.

Based on observation, interview and record review the facility failed to provide ADL's (activities of daily living) for residents who require extensive assistance. This applies to 3 of 30 residents (R59, R118 & R49) reviewed for ADL's in the sample of 30. The findings include: 1. On November 17, 2024 at 1:15 PM, V6 R59's family complained, her dad doesn't get the care he needs. They don't change his clothes or his adult diaper in a timely manner. On November 18, 2024 at 10:40 AM, V8 Hospice CNA (Certified Nursing Assistant) was giving R59 a bed bath. She stated, R59 had the same clothes on from the last time she was here. She was last there on Thursday (November 14, 2024 - 4 days prior). R59's adult diaper was saturated with urine. V8 stated, he is always like this when she comes in to care for him. R59's care plan initiated on January 11, 2022 shows, Focus: R59 has an ADL self care performance deficit and impaired mobility AEB (as evidence by): impairments in over-all strength, generalized weakness, decrease activity tolerance, poor endurance secondary to Chronic complex medical diagnosis such as Gout, AFIB (atrial fibrillation), basal cell carcinoma, limited range of motion, abnormality of gait and mobility, gait unsteadiness r/t hemiplegia and hemiparesis following CVA (cerebral vascular accident), osteoarthritis, cognitive impairment such at ST (short term) memory loss, forgetfulness, confusion r/t dementia, behavioral issues, mood disturbance r/t major depression and anxiety disorder, impaired hearing. Interventions: Dressing: I require substantial/maximal assistance of 1 staff participation to put on, fastens and takes of all items of clothing, including donning/removing a prosthesis or TED hose. Toilet use: I require substantial/maximal assistance of 2 staff participation to use the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination. 2. On November 17, 2024 at 10:47 AM, 11:02 AM & 1:54 PM, R118 was sitting up in his reclining wheelchair in the same spot in the dining room. On November 18, 2024 at 9:26 AM, R118 was up in his reclining wheelchair in the dining room. At 10:19 AM - 12:44 PM, by continuous observation, R118 remained in the same spot in the dining room. At 1:56 PM, R118 was still in the dining room. At the same time, V10 Restorative CNA took R118 to his room to toilet him. V10 stated, R118 was already up in his reclining wheelchair that morning when he got there. The night shift got him up. This was the first time he was toileting R118. R118's care plan initiated November 6, 2023 shows, Focus: R118 has an ADL self care performance deficit and impaired mobility AEB: generalized weakness, easy fatigability, decrease activity tolerance, impaired mobility, limited range of motion, secondary to chronic diagnosis such as: cognitive impairment, poor safety awareness, unspecified dementia. Interventions: Toilet use: I require dependent assistance of 1-staff participation to use the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination. 3. On November 18, 2024 at 9:26 AM, R49 was asleep in her reclining wheelchair in dining room. At 10:19 AM - 12:44 PM, by continuous observation, R49 remained in the same spot in the dining room. At 2:00 PM, R49 was still in the same spot in the dining room. V11 agency CNA stated, R49 was already up this morning when she got there. She had not toileted her that day. R49's care plan initiated on August 6, 2024 shows, Focus: R49 has an ADL self care performance deficit and impaired mobility AEB generalized weakness, easy fatigability, decrease activity tolerance, impaired mobility, limited range of motion. Secondary to chronic diagnosis such as metabolic encephalopathy, unspecified fall, asthma, insomnia, autoimmune hepatitis, spinal stenosis, lumbar region without neurogenic claudication, HLD (hyperlipidemia), present of right artificial knee joint, acquired absence of right breast and nipple, UTI-E.Coli (urinary tract infection- escheria coli), AMS (altered mental status), dementia, HTN (hypertension), specified D/O (disorder of) of bone density and structure, an adult failure to thrive. Interventions: Toilet use: I require dependent assistance of 1 staff participation to use the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination. The facility's incontinent and perineal care policy dated July 31, 2024 shows, Policy Statement: It is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition. Procedures: 1. Do rounds at least every 2 hours to check for incontinence during shift.

Based on observation, interview and record review the facility failed to ensure a residents skin preventive treatment was in place per physician orders. This applies to 1 of 5 residents (R59) reviewed for non-pressure skin conditions in the sample of 30. The findings include: On November 18, 2024 at 10:40 AM, V8 Hospice CNA (Certified Nursing Assistant) was giving R59 a bed bath. R59's adult diaper was saturated with urine. His coccyx was red with a small superficial open area. V8 stated, there usually is a dressing on his coccyx but it wasn't there today. On November 19, 2024 at 2:25 PM, V12 and V13 both wound care nurses stated, R59 did not have any open pressure injuries on his coccyx. It was more like MASD (moisture associated skin damage) now. R59 does have a treatment order in place as a preventive measure every shift. R59 has really declined and is on hospice now. He doesn't even get out of bed. The preventive treatment orders are to prevent any skin breakdown or pressure injuries from developing. R59's November 2024 treatment administration record shows orders for: calamine-zinc oxide external lotion, apply to coccyx/buttocks topically every shift for skin breakdown prevention . apply duraseptine to xeroform, apply to noted areas every shift . xeroform oil emulsion gauze external pad, apply to coccyx/buttocks topically every shift for skin breakdown prevention .

Based on observation, interview and record review the facility failed to report skin alterations, identify an unstageable pressure injury prior to developing and failed to protect a resident's heel from developing a stage 2 pressure injury. This applies to 2 of 5 residents (R137 and R118) reviewed for pressure injuries in the sample of 30. The findings include: 1. R137's face sheet lists her diagnoses to include: senile degeneration of the brain, dementia, cognitive communication deficit and need for assistance with personal care. On November 18, 2024 at 9:46 AM, V13 Wound Care Nurse (WCN) was changing R137's dressing on her coccyx. R137 had an approximately a dime size elongated open area to her coccyx. V13 stated, it was approximately 1 centimeter deep. R137's initial wound assessment dated [DATE] shows, a pressure ulceration, facility acquired, unstageable measuring 3 cm (centimeters) X 5 cm X unknown to her coccyx. Current plan & Comments: noted by nursing staff, presents as an unstageable PI (pressure injury) . R137's shower sheet dated August 9, 2024 shows, a skin alteration to her coccyx. (10 days prior to initial wound assessment). On November 19, 2024 at 2:36 PM, V12 (WCN) and V13 (WCN) stated, R137's pressure injury was acquired in the facility and not found until it was already an unstageable. She was not eating or drinking at the time. She was incontinent of urine so she should have been changed at least every shift and someone should have noticed prior to it becoming an unstageable. Ideally any skin issue would be identified with redness and interventions can be put into place right away so it doesn't turn into an unstageable pressure injury. R137's care plan initiated on August 5, 2024 shows, R137 is potential for alteration in skin integrity related to needs assist with personal care, incontinent of bowel and bladder, and extensive assistance with bed mobility 2. On November 17 & 18, 2024, R118 was sitting up in his reclining wheelchair. He had heel protector boots on both feet. R118's initial wound assessment dated [DATE] shows, a pressure ulceration, facility acquired, stage 2 to his left medial heel measuring 2 cm X 1.80 cm X 0.20 cm. Current plan & Comments: left medial heel presents as a stage 2 blister that partially opened . On November 19, 2024 at 2: 36 PM, V13 (WCN) stated, R118 sits in his reclining wheelchair and his heel was resting on the foot rest which caused a blister to his heel. R118's care plan initiated on August 26, 2023 shows, Focus: R118 is potential for alteration in skin integrity related to needs assist with personal care, incontinent of bowel and bladder, and extensive assist with bed mobility. Diagnosis of depression, pneumonitis, dementia, and chronic COPD (chronic obstructive pulmonary disease). Intervention: Apply green prevalon boots as ordered to offload heel areas (date initiated August 26, 2023). The facility's wound care guidelines dated January 24, 2024 shows, Overview of the program: .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 health professionals in the facility. The purpose of the prevention recommendations is to guide evidence-based guidance on the most effective strategies to promote pressure injury/ulcer healing. Procedures: 3. Prevention of skin breakdown includes but not limited to: c. Inspection of the skin every shift with care for signs of breakdown. Activity, Mobility, and Positioning: j. Off load elbows and heels as needed.

Based on observation, interview, and record review the facility failed to monitor a resident on the toilet with a history of falls. This applies to 1 of 30 (R10) reviewed for safety supervision in the sample of 30. The findings include: 1. On 11/17/2024 at 2:20PM, shouts of Help me and Help were heard from the hallway. R10 was observed sitting on her bathroom toilet holding the grab bar to the right of toilet. No staff observed in R10's room, bathroom, or outside in the hallway. On 11/17/2024 at 2:28PM, V17 (Agency Certified Nursing Assistant/CNA) said she put R10 on the toilet. V17 said R10 is not alert and oriented. On 11/17/2024 at 2:23PM, V16 (CNA) said staff assist R10 to the toilet. V16 said, We should not leave [R10] on the toilet by herself because she is a fall risk and it's a safety issue. On 11/17/2024 at 2:31PM, V18 (Licensed Practical Nurse/LPN) said, We do not leave [R10] on the toilet alone because she's a fall risk. R10's Fall Risk Evaluation dated 4/1/2024 shows a fall risk score of 15. A score of 8 and above is considered high fall risk according to the Fall Risk Evaluation reference range.

Based on interview, and record review the facility failed to provide catheter care interventions to a resident (R119) with a history of urinary tract infection (UTI). This applies to 1 of 5 (R119) residents reviewed for catheters in the sample of 30. The findings include: 1. On 11/17/2024 at 12:05PM, R119 was observed lying in bed with a urinary catheter in place hanging on the side of his bed. On 11/19/2024 at 12:16PM, V2 (Director of Nursing/DON) said catheter care, catheter flush, and betadine should be applied every shift for R119 as ordered and documented. V2 said this is done to help prevent infection. R119's Treatment Administration Record (TAR) dated 11/1/2024 to 11/30/2024 shows an order for Betadine External Solution 10% - apply to external meatus topically every shift. No documentation provided for November 15 and 16, 2024 at 9:00AM. R119's Treatment Administration Record (TAR) dated 11/1/2024 to 11/30/2024 shows an order to flush foley catheter every shift with 60cc (cubic centimeters) of saline. No documentation provided for November 15, 2024 at 9:00AM. R119's Treatment Administration Record (TAR) dated 11/1/2024 to 11/30/2024 shows an order to provide catheter care every shift. No documentation provided for November 15, 2024 at 9:00AM.

Based on observation, interview, and record review, the facility failed to ensure there were no discrepancies between physical doses of controlled medications (including methadone) and the correlating number documented on the record of controlled substances for 1 of 30 residents (R62) in the sample of 30 reviewed for pharmacy services. The findings include: On 11/18/24 at 9:05 AM, during medication administration observations, there were 22 physical doses of R62's methadone available. R62's Individual Controlled Substance Record (date received 11/12/24) showed there should have been 23 physical doses of methadone. When V19 ( Registered Nurse) administered R62's prescribed dose of methadone, she wrote in 23, skipped that entry and signed out her dose on the next line. There was no entry made for the 23rd dose. On 11/18/24 at 9:40 AM, V19 said the off-going and the oncoming nurses do a count of the narcotics at every change of shift. V19 said they need to make sure there are no medications missing and they need to make sure the count is accurate. V19 said she will need to report the discrepancy to her supervisor. The facility's Controlled Substance Storage Policy shows at each shift change, or when keys are transferred, a physical inventory of all controlled substances is conducted by two licensed personnel and is documented. Any discrepancy in controlled substance counts is reported to the Director of Nursing immediately.

Based on interview and record review, the facility failed to ensure pharmacy recommendations were followed after being agreed upon by the physician for 1 of 5 residents (R94) reviewed for psychotropic medications in the sample of 30. The findings include: R94's Consultant Pharmacist Recommendation to Prescribed dated 8/2/24 shows the pharmacist requested R94's psychotropic medications, quetiapine and Sertraline, be reevaluated and considered for a gradual dose reduction (GDR). The physician response dated 9/24/24 shows the physician agrees with the recommendations. R94's Order Summary Report dated 11/20/24 shows R94 had an order on 4/4/24 for Sertraline 50 milligrams (mg) once a day and an order on 3/25/24 for Seroquel (quetiapine) 12.5 mg twice a day. There were no orders for the two medications at a reduced dose. On 11/20/24 at 10:30 AM, V25 (Psychotropic Nurse) said the pharmacist reviews the residents' medications and emails the recommendations to her and other leadership personnel in the facility. V25 said she is responsible to address the psychotropic medication recommendations. V25 said since the doctor agreed with the GDR for R94's Sertraline and Seroquel, she or the floor nurse should have clarified what dose of the medications the doctor wanted to prescribe.

Based on observation, interview, and record review the facility failed to ensure a resident was safely transferred for 1 of 3 residents (R1) reviewed for safety in the sample of 3. This failure resulted in R1 sustaining a laceration of 11 centimeters (cm) requiring 13 sutures. The findings include: R1's face sheet printed on 11/4/24 showed she was [AGE] years old and diagnosed with dementia, malnutrition, and peripheral venous insufficiency. A facility assessment done on 8/29/24 showed R1 had severe cognitive impairments and was dependent on staff for transfers. R1's Care Plan printed on 11/4/24 showed R1 had a self-care deficit and impaired mobility. Listed under interventions showed R1 was dependent on two staff for transfers. The same care plan showed R1 had a cognitive deficit such as poor safety awareness, decreased comprehension, and impulsiveness. Listed under intervention was to modify environment as needed. On 11/4/24 at 9:05 AM, R1 was in bed. R1's left leg near her shin showed a dark line/scar about 8 cm long. The dark line/scar was toward the outside of R1's leg towards her knee. There were two grape size swollen dark areas next to the dark line/scar. On 11/4/24 at 9:05 AM, V5 (Certified Nursing Assistant- CNA) said the dark/scar area occurred while V5 transferred R1 from a shower chair. V5 said she and V6 (CNA) were transferring R1 with a mechanical lift when R1 kicked her left leg out hitting the mechanical lift causing a laceration. V5 said every once in awhile R1 will kick her legs while being transferred. V5 said R1 will sometimes follow direction and the day of the incident R1 was not following direction. A written statement by V5 dated 10/3/24 showed on 10/2/24 while R1 was in a sling being transferred she, .accidentally bumped her left shin onto the base of the [mechanical lift] . On 11/4/24 at 10:05 AM, V6 said on 10/2/24 after R1 received a shower he was asked by V5 to assist in transferring R1 from a shower chair to a wheelchair. According to V6, he was moving the mechanical lift and V5 was guiding R1 by being positioned by R1's trunk. V6 said R1 moved her left leg during the transfer hitting the main bar of the mechanical lift. V6 said R1 was lowered back into the shower chair and R1 was moved to her room while in the shower chair. Once R1 was in her room, she was transferred with a mechanical lift into bed. V6 said once R1 was in bed, V6 and V5 noticed R1's left leg was bleeding, and they got the nurse. On 11/4/24 at 10:52 AM, V7 (Wound Care Nurse) said R1 sustained a laceration and two hematomas to her left leg during a transfer done on 10/2/24. V7 said the laceration was about 10 cm long and required 13 sutures to close. V7 added that R1 had a history of getting agitated with care. On 11/4/24 at 11:19 AM, V9 (CNA) said when transferring a resident with a mechanical lift it takes two staff members. One staff member will move the mechanical lift and the second staff member will guide the resident to ensure there are no accidents. On 11/4/24 at 1:01 PM, V10 said the hematoma found on 10/1/24 could have happened during a transfer. V10 added that R1 had dementia and can be restless a times. R1's Progress Note dated 10/2/24 showed R1 had a left shin laceration with moderate amount of bleeding. The note indicated the laceration was 11 cm x 2 cm x 3 cm and R1 was sent to the emergency room . R1's emergency room notes dated 10/2/24 showed she had 13 sutures placed to close the laceration. The same notes showed an x-ray report indicated, .soft tissue swelling anterior to the proximal tibia . R1's health care provider progress note entered by V10 (Physician) dated 10/1/24 (one day before R1 sustained a laceration) showed R1 was seen for a hematoma to her left leg that was about the size of a grape to R1's anterior shin that had swelling and bruising. Staff found the hematoma during a transfer. The note indicated that the hematoma was likely caused by, .trivial trauma . On 11/4/24 at 1:15 PM, V1 (Administrator) said after the incident on 10/2/24 where R1 sustained a laceration during a transfer, padding was added to the mechanical lifts.

Based on observation, interview, and record review the facility failed to ensure fall interventions were in place for a resident who is a HIGH risk for falls and failed to ensure a resident was safely transferred. This failure resulted in R135 falling on the floor in the dining room sustaining a right femoral neck fracture and requiring surgical intervention. This applies to 1 of 2 residents (R135, R459) reviewed for safety in the sample of 31. The findings include: 1. R135's face sheet shows he is a [AGE] year old male with diagnosis including fracture of the right femur neck, unspecified dementia without behavioral disturbance, unsteadiness on feet, cognitive communication deficit, weakness, monoplegia of upper limb following cerebral infarction affecting right dominant side, hydronephrosis, urine retention and aphasia. R135's Final Incident Report dated 9/19/23 documents on 9/13/23, (R135) stood up from chair in the dining room and lost his balance and fell hitting the right side of his body on the floor. A staff member from a distance observed him fall. He was kept immobilized until the paramedics arrived. (R135) was transferred to the local hospital and admitted for right acute femoral neck fracture and required surgical intervention. R135's Minimum Data Set assessment dated [DATE] shows his cognition is impaired, requires extensive assist with bed mobility, transfers, tolieting. He is not steady and only able to stabilize with staff assistance when moving from seated to standing position, walking, moving on and off the toilet, and surface to surface transfers. R135's Fall Risk assessment dated [DATE] shows he is HIGH risk for falls. On 10/22/23 at 9:25 AM, R135 was observed in his room in a low bed near the nurses station. On 10/24/23 at 10:27 AM, V16 (RN) said she was R135's nurse on 9/13/23 when he fell . She was on break and was alerted by staff he was on the floor. Last time she observed R135 was about 6:30 PM, in the dining room he was self propelling in his wheelchair. R135 is alert to self, sometimes he can verbalize his needs and is unable to follow direction. He had a fall a week prior getting up without assistance. V17 (CNA) was the only staff in the dining room. He told me there were so many residents in the dining room at that time who were at high risk for falls and could not watch them all. When she entered the dining room he was laying on the floor on his right side complaining of pain. She called the ambulance and did not move him, he was admitted with femur fracture. V16 said V18 was his assigned CNA (Certified Nursing Assistant) that day and was in another residents room. There's supposed be two staff supervising the dining room for safety. On 10/24/23 at 1:08 PM, V18 (CNA) said R135 is alert to person, does not follow direction. He was R135's CNA on 9/13/23 when he fell . He's supposed to be toileted every two hours, that day he toileted him about 3:30 PM and did not take him to the bathroom after dinner. At the time of the fall he was in another residents room. Residents should be toileted before and after meals, when awake, and before bed to prevent them from getting up on their own. There should be two staff in the dining room to help supervise the residents for safety reasons. On 10/25/23 at 9:59 AM, V2 (DON) said V17 is no longer an employee at the facility. She said R135 has dementia and poor safety awareness. He got up from the chair and fell and fractured his femur. She confirmed R135 was not assisted to the toilet after the dinner meal and that was an intervention they put in place after his fall on 9/8/23. It doesn't matter if there was only one CNA in the dining room that's considered supervision. We in-serviced the staff to offer tolieting to residents every two hours and frequent monitoring. On 10/25/23 at 2:21 PM, V22 (R135's Nurse Practitioner) said R135 has dementia and is alert to himself, he has poor safety awareness, and is at high risk for fall. Staff should be monitoring him closely. and he needs staff assistance for his activities of daily living. She confirmed he fell and sustained a femur fracture. R135's Post Fall Investigation Report dated 9/9/23 shows on 9/8/23 he had a fall in his room, he was attempting to stand without staff assistance. The interventions included to re-educate staff to offer toileting to the resident upon rising in the morning, before and after each meals and at bedtime. The facility's Falls Policy revised 8/20 states, The Fall Prevention Program is designed to ensue a safe environment for all residents. Each resident will be evaluated upon admission, quarterly and as needed .to assess his/her individual fall risk .implementing an individualized Plan of Care designated to meet the resident's needs. To ensure the consistency in the implementation of preventive measures to assist with the reduction of falls . 35541 2. R459's Admission Restorative assessment dated [DATE] showed R459 required maximum assistance from staff for transferring and toileting. On 10/23/23 at 9:15 AM, V5 Certified Nursing Assistant (CNA) transferred R459, from her bed to a wheelchair, by lifting R459 under her armpits and sliding her into the wheelchair. No gait belt was used. V5 CNA wheeled R459 in her wheelchair, into the bathroom. Again, V5 CNA transferred R459, from her wheelchair onto the toilet, by lifting R459 under her armpits. No gait belt was used. Once R459 was finished going the bathroom, V5 CNA lifted R459 off the toilet by her armpits and asked her to hold onto the bar on the wall by the toilet. R459 grasped the bar and began yelling Help me! Help me! as V5 CNA briefly let go of R459 to wipe her. Once V5 CNA had finished wiping R459, V5 placed his hands under R459's buttocks and guided her into the wheelchair. No gait belt was used. On 10/24/23 at 11;45 AM, V2 Director of Nursing stated gait belts are to be used to transfer any resident that requires staff assistance to ensure resident safety. The facility's Gait Belt policy dated 7/28/23 showed, The facility will use gait or transfer belts to assist residents needing limited to total assistance during transfers and walking.

Based on observation, interview, and record review the facility failed to ensure intravenous therapy to central venous catheters was performed in accordance with standards or practice; failed to ensure staff were qualified and trained to provide care for central venous catheters (long, flexible tubes inserted by providers that lead directly to vena cava, near the heart); and failed to implement policies for the administration of medications and maintenance of the central venous catheter site for 2 of 3 residents (R1, R2) reviewed for intravenous access in the sample of 7. These failures resulted in R1's implanted port (central line) becoming infected, requiring hospitalization and surgical removal of the infected port. R1 developed bacteremia (infection of the blood stream). The findings include: 1. On 5/5/23 at 7:38 AM, V22 (R1's Power of Attorney) said [R1] had the implanted port in place since 2018 and never had any issues with it prior to it becoming infected. The port was placed because [R1] needed frequent lab draws and medications and she was a hard stick. The port was implanted, under her skin in her upper chest. V22 stated, I don't think it was ever flushed at the facility. In December 2022, [R1] started getting weird and hallucinating. She would see dogs in her bed at night. The doctor said she probably was dehydrated and ordered IV fluids. The nurse called me to report that they were attempting to access [R1's] port and gook came out. The nurse said she called the doctor back right away and [R1] was sent to the emergency room . [R1's] port was infected and had to be removed. She was in the hospital for several days for a very aggressive infection. The doctor toil me there wasn't much more we could do, so [R1] went back to the facility in early January 2023. A PICC (Peripherally Inserted Central Catheter) was inserted for IV antibiotics, fluids, and blood draws. R1 never got better, and she was placed on hospice care. [R1] passed away on 2/24/23 at the facility. I had a care meeting with the facility staff when it was obvious that [R1] wasn't improving. They discussed her decline, due to a UTI (Urinary Tract Infection). That frustrated me because the issue was her port became infected and caused an infection in her blood. I asked when [R1's] port had been flushed and none of them could answer me. I requested to see the documentation and it was never provided to me. R1 was doing poorly, so my focus was on her, and I wasn't the best at following-up. The staff never provided in the information about the port care and when I remembered to ask them, they would say, I'll ask, but no one got back to me. I can't remember names, but I know how they made me feel. R1 was alert and oriented prior to this infection, but at the end she didn't seem to know who I was. R1's Face sheet dated 5/9/23 showed diagnoses to include, but not limited to: CKD (Chronic Kidney Disease - Stage 4); dysphagia; reduced mobility; need for assistance with personal care; severe protein-calorie malnutrition; MRSA (Methicillin Resistant Staphylococcus Aureus) infection; local infection due to central venous catheter; hyperparathyroidism; hypokalemia; noninfective gastroenteritis and colitis; real tubulo-interstitial disease; sleep apnea; bullous pemphigoid; diabetes; chronic respiratory failure; adult failure to thrive; hypothyroidism; anxiety; anemia; COPD (Chronic Obstructive Pulmonary Disease); major depressive disorder; and Crohn's Disease. R1's facility assessment dated [DATE] showed R1 was cognitively intact; required extensive assistance from staff for bed mobility, dressing, toilet use, and personal hygiene; and had limited ROM (Range of Motion) to one upper extremity. R1's November 2022 TAR (Treatment Administration Records) showed, If the port has not been accessed: Access the port monthly and flush with 5 ml normal saline followed by 5 ml Heparin (100 Units/ml) every night shift starting on the 15th of every month. This entry was signed out as completed by V18 (LPN - Licensed Practical Nurse). (The care and use of port (central venous catheter) is beyond the scope of practice for LPNs). This document showed, Implanted port (lumen is used for blood draws). For blood draws: flush before, draw 10 ml blood then waste; draw 10 ml for blood draw. For patency: flush with 10 ml NS daily every day shift. This was signed out as completed on 19 of the 30 days in November. (During this investigation, the facility and staff interview were unable to prove when R1's port was accessed with a needle and dressing in place and unable to report how long the needle was left in place. They were unable to explain the conflicting orders for the care of the port.) This document showed, Only if in use, change dressing and the non-coring needle on day shift on Saturday for right chest mediport. This was signed out on 11/5 (by V12, RN - Registered Nurse), 11/12, and 11/26. (This entry was left blank on 11/19. R1's December 2022 TAR showed on 12/15/22 the port was not accessed by V19 (LPN). The document showed the initials NN, which means there should be a nurses' note explaining why the port was not accessed and flushed, as ordered. There was no nurse note entry by V19 on 12/15/22. The document showed the facility nurses documented the blood draw flushes and flushes were performed 21 of 30 days. The document showed, Only if in use, change dressing and non-coring needle on day shift every Saturday for right chest mediport. This was signed out on 12/3 (by V12, RN) and 12/17 by V20 (Agency LPN). During interviews, V12 (RN) reported she was uncomfortable providing care for implanted ports. A dressing change and needle chart of a mediport requires sterile procedure to prevent the risk of infection and should only be performed by qualified, competent staff. V20 is an LPN and care of an implanted port is beyond the scope of practice. R1's Progress Notes dated 12/27/22 showed, Patient appeared lethargic and had loose stools. V17 (R1's PCP - Primary Care Physician) was notified. V17 ordered labs, IV fluids, and antifungal medication. R1's Medical Professional Progress Note dated 12/27/22 showed R1 was seen for a change in condition. CNA (Certified Nursing Aide) felt R1 had an altered mental status. V17 (R1's PCP) saw R1 and found her to be complaining of loose stools, nausea, and no appetite. R1's diaper was filled with loose, mucoid, liquid, foul-smelling bowel movement. There were orders placed for immediate labs and IV fluids for an acute flare up of her Crohn's disease. R1 had an implanted port in place due to difficult IV access. R1's Change of Condition (SBAR) report dated 12/27/22 at 4:16 PM showed R1 had purulent (infectious) drainage from the implanted port and diarrhea. R1 had a low-grade temperature and was lethargic. V17 was notified at 2:45 PM and orders were given to send R1 to the emergency room . R1's Admission Summary dated 1/6/23 at 7:41 PM, showed R1 was readmitted to the facility from the local hospital. R1 was placed on contact isolation for MRSA in her blood. Per the hospital nurse, the right chest (chemo) port was infected, and the port was removed. R1 is on IV antibiotics every 48 hours for 10 days, for the infected port. R1's port removal incision area was seen by the wound nurse. R1 had a PICC line with 2 lumens to the left upper arm. R1's Progress Notes showed R1 continued to decline, upon return to the facility. R1 was refusing to eat, drink, and take some medications. A Palliative Care Consult was performed on 1/20/23. R1 continued to refuse to eat/drink and take medications. R1 was placed on hospice on 1/26/23 and passed away on 2/24/23. R1's EMR (Electronic Medical Record) did not contain a Care Plan for the implanted port prior to R1 being readmitted to the facility, after her port became infected. R1's Care Plan was updated on 1/6/23 and showed, Resident requires Contact Precautions related to MRSA in the blood. and resident has potential for infection related to chemo port removal incision; and resident is on antibiotic therapy. R1's hospital records faxed on 5/8/23 showed R1 was admitted to the hospital from 12/27/23 - 1/6/23 for an infected right chest port. The port was scabbed over with puss noted. R1's wound culture and blood cultures were both positive for the same organism, MRSA. MRSA is a drug-resistant bacteria. R1 was placed on isolation and an Infectious Disease Consult was in place. R1's medi-port was removed on 12/29/23. R1 had a PICC placed on 1/5/23 and returned to the nursing home on 1/6/23. R1's emergency room Record dated 12/27/23 showed R1 reported to the emergency room for a possible port infection. R1 stated that a nurse at the nursing home accessed the port, and she thinks she did it wrong. Since then, she has had pain, redness, and discharge from the area. R1's chest assessment showed port with overlying redness and crusted lesion. R1 was alert and oriented to person, place, and time. R1 was diagnosed with cellulites over the port and concerns of bacteremia (systemic infection of the blood stream). On 5/9/23 at 12:09 PM, V4 (RN) she usually works second shift, on second floor. She said she had taken care of R1. R1's port was used for medications, IV fluids, and blood draws. If the RN is activating (accessing) the port, then they should be performing flushes according to facility protocol. The nurses should be following the correct orders for flushing and care of a central venous line (port or PICC). V4 stated, There are special nurses that have been trained to access the ports. I've never done it. The managers usually do it. I went on leave for a couple months. When I left R1 was fine and when I came back, she was declining and on hospice. R1 had a poor appetite and often refused to eat/drink or take medications. On 5/9/23 at 12:59 PM, V12 (RN) said she was not comfortable with implanted ports. V12 stated, I was working the day R1 started to be lethargic and have increased diarrhea. V17 (R1's PCP) went to see R1 and ordered labs and IV fluids. I had never accessed a port before, so I had V13 (RN/Nursing Supervisor) come with me. I gathered the supplies, and we went in the room. R1 had teeny scab over the port area. V13 picked at it and purulent drainage came out. We didn't continue with accessing the port. I called V17 (R1's PCP) and got orders to send R1 to the emergency room . R1 had been having severe diarrhea so V17 wanted us to try IV fluids and obtain labs at the facility. R1 refused the medications. She was lethargic and her hands were twitchy. I was glad V17 sent R1 out. I think R1's port was infected and had to be removed. I saw her a couple times after she came back. She seemed depressed and was refusing to eat/drink and take medications. On 5/9/23 at 1:19 PM, V14 (ADON - Assistant Director of Nursing/Unit Manager) said central venous catheters should only be cared for by RNs. LPNs are not allowed to provide care for central venous access. R1 had a port. The nurses should follow facility protocol for flushes and blood draws. There is a set of orders in the EMR that the nurse can chose. The RN should make sure the proper orders are entered for the proper use of the central venous catheter. The RN should be checking the site daily to assess for any changes and ensure they are not developing an infection. The proper maintenance of a port depends on if the site is accessed (needle in place) or not. The RNs should be following facility protocol for flushing and maintaining the port. The port should only be accessed by an RN that is trained. Most of the supervisors can access the port and have received training. I'm not sure who provided the training or when it was done. There should be records of the RNs training. The surveyor requested to see the specialized training. On 5/9/23 at 2:17 PM, V17 (R1's PCP) said R1 had several chronic illnesses that required close monitoring and treatment. R1 had a port because she was a difficult stick, and required frequent infusions and blood draws. R1 did not have an implanted port for the typical reason most residents do. R1's port was not used for chemo or dialysis. R1 had [NAME] syndrome, a kidney disorder that causes imbalances of potassium and magnesium. R1 had Crohn's and would have flare ups and become dehydrated, required IV fluids administration. Generally, the RN would access the port for the chemo or blood draw, administer the flushes, and remove the needle. The fluctuations in R1's labs and IV fluids resulted in R1's needle needing to be left in for a short time. The RN would usually change the needle every 4-5 days, but the maximum a needle could be left in place is 7 days. R1 was seen at least monthly by myself and my NP. I remember seeing R1 with the port accessed, needle in place and dressing covering it. R1 was in and out of the hospital for flare ups, from chronic Crohn's and bullous pemphigoid (autoimmune pruritic skin disease). In December, the nurse called me to report that R1 was lethargic and was having severe diarrhea. I ordered STAT (immediate) labs, IV fluids, and some medications. A little while later I received a call from the nurse that R1's port may be infected. There was pus noted at the port site and R1 was complaining of pain when the area was touched. I went to assess R1 and decided to send her to the emergency room . When I sent her to the emergency room , I was more concerned about the diarrhea and need for treatment. The next day I rounded on R1 at the hospital and found out R1's port culture and blood culture were positive for the same organism (MRSA). That was concerning. When the cultures grow same organism, then it is likely the port was the source of R1's blood infection. Then the focus shifted to the infected port. R1 was placed on isolation and followed by several specialties at the hospital. R1's port was removed at the hospital due to infection. The facility should be following protocol for the care central venous catheters. I would expect they were following the standards of practice. If they were not, then it is possible the port could become clogged or infected. The nurses should call me if there are any issues with the central venous access. The nurses should be documenting the care and maintenance of the port, as well as any assessments or changes in assessments. If it's not charted, then how do we know what is going on. On 5/9/23 at 3:11 PM, V13 (RN/Nursing Supervisor) said she has [AGE] years of experience at the facility. The nurses will call me if they are uncomfortable with something. They usually call me to access an implanted port. There are order sets in the EMR for the proper care of the central venous lines and the nurse must enter the orders. The orders will then populate on the MAR or TAR for the RN to chart the assessments, dressings, and flushes. A port should only be accessed by an RN. Not everyone is comfortable, so they usually call the supervisors or managers. There isn't any proper training, for the central lines, but there had been in-services in the past. There was a change in ownership a couple years ago. That was the last time I remember having training on central venous catheters. I accessed R1's port. I'm not sure how long R1's needle would remain in place. Normally we access the port to draw blood and de-access it after flushing. The day R1 was sent to the hospital (12/27/23) I was asked to assist with accessing R1's port because the nurse was uncomfortable. When we looked at the port site, we noticed there was a white dot with pus over the port. We called the doctor because it looked infected. The skin over the port was red and R1 had facial grimacing and complained of pain when we touched it. The port was not accessed. R1 was sent to the emergency room . V13 reviewed R1's November and December 2022 MARs and TARs. V13 said the port site should be assessed daily. I'm not sure if R1's port was access on the 15th? This charting is confusing. If there is any abnormal finding or I can't access the port, then I enter a progress note. On 5/9/23 at 3:39 PM, V2 (DON) said LPNs are not allowed to access or care for central lines, only peripheral lines. The RNs are the only ones that should be taking care of R1's port. I'm not sure if there has been any specialized training for central lines at the facility. The RN is certified for central lines access as part of their licensure, but they may not see them often and be uncomfortable. If they are uncomfortable, they can call someone for help. I'm not sure if there has been an formalized in-services or training for central venous lines at the facility. I'd have to look. The EMR has order bundles for the proper care of the central lines. The nurse must enter the appropriate orders and follow the facility protocol. There should be clear orders in the Physician's Order Sheet and the care should be documented on the MAR or TAR, and possible the progress notes. On 5/10/23 at 3:13 PM, V2 (DON) was asked to review R1's November and December 2022 MAR and TAR with the surveyor. V2 said a checkmark with initials means the care was provided. On 11/15/22 the care was provided and signed out by V18 (LPN). The surveyor asked if LPNs were allowed to provide care to R1's port. V2 stated, No, and I'm not sure he's the only LPN that accessed that. He's not supposed to do that. The surveyor read the order for the blood draw flushes to V2 and asked how often the flush was performed, as the order has conflicting information. V2 stated, if it was signed as completed, then I would think the flushes were done. That order should be separated, so it's not confusing. V2 said R1's port was not accessed on 12/15/22 but is unsure why. V2 stated, I can't find any information in the nurses notes. NN, means there should be more information in a nurses' note. On 12/17/22 R1's TAR showed V20 (Agency LPN) completed R1's port access, flushes and dressing changed. V2 was asked how often the port was accessed. V2 had difficulty providing information about when R1's port was accessed for blood draws, medication infusions, and IV fluids. The facility's undated Order Set Screenshot showed the type of port and the picklist of orders for the nurse to add. The nurse must check the orders to enter them into the MAR and TAR. The facility's Competency Skills Forms for Central Line Dressing Change Skilled were dated 2021 and only provided for 3 RNs. 2. On 5/5/23 at 1:34 PM, V3 (RN) gathered R2's IV antibiotic and NS flushes. R2's room had a sign for Enhanced Barrier Precautions on the door and an isolation cart, stocked with gowns and gloves outside the door. V3 donned a gown and gloves before entering R2's room. V3 used the add-a-vial set to mix the antibiotic medication. R2 was sitting up in the recliner with a dual lumen PICC inserted in his right upper arm. The dressing was dry and intact and both lumens were capped. V3 primed the tubing for the antibiotic and set up the infusion pump. V3 cleansed both ports with alcohol swabs and flushed each port with 10 ml NS, after obtaining blood return. V3 said the facility has a lot of IV lines and she is familiar with PICC lines. The PICC lines are flushed before and after use with 10 ml NS. The NS flushes should be entered in the R2's orders because it's considered a medication. After completing the NS flushes, the nurse will sign them off on the MAR or TAR. If the flushes are not documented, then there is no way of knowing when it was done. The RNs are responsible for care and management of the central lines, including Port-a-caths, midline catheters, and PICCs. R2's Face-sheet dated 5/9/23 showed R2 was admitted to the facility on [DATE]. R2 had diagnoses to include, but not limited to abdominal wall abscess, pleural effusion, other bacterial infections, candidiasis, iron deficiency anemia, mild protein-calorie malnutrition, esophageal varices, peritoneal abscess, alcoholic cirrhosis of the liver, hepatic encephalopathy, weakness, fatigue, reduced mobility, and presence of other specified devices for long-term use of antibiotics. R2's Physician's Order Sheet dated 5/9/23 did not show any orders for NS flushes to R2's PICC line. There were no documented PICC line flushes on R2's April or May 2023 MARs (Medication Administration Records). R2's Care Plan dated 4/14/23 showed, Resident has potential for infection at IV site (on IV ABT (antibiotics) due to abdominal abscess. Interventions: Initiate proper precaution per facility protocol. On 5/5/23 at 1:19 PM, V14 (ADON/2nd floor manager) said only RNs can completed IV infusions and dressing changes for PICC lines. The NS flushes should be done before and after each use. There should be an order for the flushes, so the nurse is aware it is due. I don't see any orders for NS flushes to R2's PICC line. I only see dressing change orders and the measurements. There should be an order because NS is a medication. It's important to perform the flushes as order to keep the line open, prevent clotting issues, and reduce the risk of infection. The facility's Intravenous Therapy revised 7/28/22 showed, It is the facility's policy to ensure that intravenous policy and procedures are complaint to federal standards of care. Procedures: All IV access will be assessed by the nurse to ensure that no signs and symptoms of infection and infiltration are left unaddressed. 2. Dressing Change: b. All Central line dressing (PICC lines, single and multi-lumen central catheters inserted in subclavian, Juglar, or inguinal area) will be changed every 7 days and PRN (as needed). c. Implanted ports such as Portacath (PAC) dressing will be changed every 7 days and PRN during Huber needle change. 3. Flushing: B: Central line including PICC lines are flushed with 5 to 10 ml NSS. c. Implanted ports including Portacath will be flushed with 5 to 10 ml of NSS before and after infusion. If implanted port is not accessed, flush with 5 ml NSS followed by 5 ml of Heparin (100 Units/ml) every month.

Based on interview and record review, the facility failed to ensure adequate pain management was provided for 1 of 5 residents (R2) reviewed for pain control in the sample of 5. This failure resulted in R2 experiencing unrelieved pain after a fracture. The findings include: On 4/24/23 at 9:52 AM, V2, Director of Nursing (DON), said R2 has a lot of pain due to advanced cancer. R2 had increasing pain on Saturday (4/15/23). On 4/24/23 at 12:21 PM, V9, Licensed Practical Nurse (LPN), said she was R2's nurse on the day shift (7 AM to 3:30 PM) on 4/15/23. V9 said R2 requested pain medication around 8:00 AM and she administered it. V9 said R2 has bone cancer and they have to be very careful with R2's care due to his cancer and chronic pain. V9 said around lunch, R2 still had pain. V9 said R2 had a BM and they were unable to clean his backside due to his pain. V9 said she told the evening shift nurse they were unable to change R2 due to his pain not being relieved by the narcotics she gave around 8:00 AM and again around lunch. V9 said she called R2's doctor for an X-ray. V9 said the following day (4/16/23), the night shift nurse told her R2 had been in too much pain during the night to wait for the in house x-ray results, so they sent him to the hospital. On 4/24/23 at 2:55 PM, V16, LPN, said she was R2's nurse on the evening shift (3 PM to 11:30 PM) on 4/15/23. V16 said R2 complained of pain in the left knee. V16 said she spoke with R2's daughter and was told not to change R2 because he was in too much pain. V16 said she did not contact R2's doctor during her shift. V16 then said R2 told her he was not in pain. On 4/15/23 at 6:54 PM, V16 documented an eMAR note which rated R2's pain a 0. However, V16 said she gave R2 pain medication around 9 something. V16 said when she gives pain medication, she documents it on the Medication Administration Record (MAR). R2's MAR provided by the facility for 4/1/23-4/30/23 (printed 4/24/23) does not show any documentation of R2 receiving PRN (as needed) Oxycodone (narcotic pain medication) after 3:30 PM on 4/15/23. There is no correlating documentation in R2's Progress Notes to explain why or when R2 may have received pain medication while V16 was his nurse on 4/15/23 nor was there documentation regarding R2's doctor being contacted during that time. On 4/24/23 at 2:41 PM, V15, Registered Nurse (RN), said she was R2's nurse during the night shift on 4/15/23 going into 4/16/23. V15 said she went to check on R2 and R2 told her he was in pain and did not want to be touched. V15 said R2 complained of pain when they tried to change him or give him care. V15 said she believes R2 had been rating his pain a 7 or 8 on a 0-10 scale. V15 said R2 was not comfortable. V15 said she did not administer any pain medications to R2. V15 said when pain medication is given, it is documented on the MAR. V15 said she contacted R2's doctor and was told to send him to the hospital because they could not control his pain. R2's Progress Notes written by V15 on 4/15/23 at 11:15 PM show V15 attempted to call R2's doctor and was waiting for a return call and R2 was refusing care due to pain of his left knee and left hip. V15 noted swelling to R2's left knee. V15's documentation on 4/16/23 at 2:15 AM in R2's General Progress Note shows V15 spoke to R2's doctor and received an order to send R2 to the hospital for further evaluation. R2 was sent to the hospital at 3:20 AM and at 2:16 AM R2 continued to complain of pain to his left leg. No other pain interventions were documented as being attempted. On 4/24/23 at 1:30 PM, V18, Emergency Medical Personnel (EMS), said he went to the facility on a 911 call and the nurse said R2 could not be moved due to being in so much pain. V18 said R2 was in a lot of pain and no one called EMS until 3 AM. V18 said they gave R2 pain medication in the ambulance. R2's Admission Record dated 4/24/23 shows R2's diagnoses include, but are not limited to, pathological fracture of the left femur, weakness, fatigue, reduced mobility, malignant neoplasm of the lung, pain in left hip, and malignant neoplasm of unspecified bones. R2's MAR shows he received Oxydocone on 4/15/23 at 8:20 AM and a last documented dose at 3:30 PM. On 4/15/23 at 3:52 PM, V9 documented that R2's pain medication was ineffective and rated R2's pain a 5. R2's Physician's Order Sheets (POS) dated 4/24/23 does not show any new medication ordered in April of 2023. The facility's Pain Policy (Revised 7/28/22) shows, After the administration of PRN pain medication, the resident will be assessed for the effectiveness of the pain medication. If the resident is still unrelieved of pain despite pharmacologic and nursing measures, the resident's physician will be called to refer to the lack of relief. It is important that pain medication will be administered to residents prior to repositioning. If despite the administration of pain medication. The resident still complains or shows signs of pain. The staff will stop the procedure and allow more time. If the resident continues to exhibit signs of pain afterwards, the nurse will call the physician and obtain additional pain relieving interventions.

Based on interview and record review the facility failed to ensure a resident (R1) was transferred, via a mechanical lift, in a safe manner. This failure resulted in R1 falling out of a mechanical lift on August 30, 2022. R1 was emergently sent to a local hospital where she was subsequently admitted to the intensive care unit (ICU) with diagnoses of a scalp laceration and subarachnoid hemorrhage (brain bleed). This failure had the potential to affect all 13 residents (R1, R2, R7-R17), on the third floor of the facility, that required the use of a mechanical lift for transfers. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy started on August 23, 2022, when V3 Certified Nursing Assistant (CNA) and V8 CNA knowingly used the third-floor mechanical lift with a broken/missing part, to transfer residents. V3 and V8 CNA each stated they continued to use the broken mechanical lift to transfer residents from August 23, 2022, until August 30, 2022, when R1 fell out of the broken mechanical lift. The Immediate Jeopardy was identified on September 21, 2022. V1 (Administrator) was informed of the Immediate Jeopardy on September 26, 2022. This surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on September 26, 2022, however, noncompliance remains at a Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: A Facility Incident Report for R1, dated August 30, 2022, showed R1 was being transferred by a mechanical lift when she slipped out of the lift and fell to the ground, striking the left side of her head. R1 sustained a laceration to the left side of her head. R1 was immediately sent to a local hospital for an evaluation. R1's hospital History and Physical report dated August 30, 2022, showed R1 presented to the hospital due to a fall from mechanical lift during transfer, laceration noted to left scalp. The report showed R1 was diagnosed with a subarachnoid hemorrhage and required 5 staples to close the laceration to her scalp. R1 was admitted to the ICU. R1's current care plan showed R1 was severely cognitively impaired related to her diagnoses of dementia and intellectual disabilities. The care plan showed R1 was totally dependent on staff for transfers which included the use of a mechanical lift. The Operating Manual for the facility's mechanical lift, dated November 2017, showed for resident transfer, the resident was to be placed on a fabric sling and then attached to the mechanical lift by four loops on the sling. The mechanical lift had four hanger rods (metal hooks), where each of the loops of the fabric sling attached to the lift. The manual showed that each hanger rod had a grommet (hanger rod clip/metal clip) attached to the rod to ensure the loops of the fabric sling stayed in place during a resident transfer. The Manual showed, Inspect the lift and sling to make sure they are undamaged and in good working order prior to use. The Manual also showed, Verify hanger rods and grommets (metal clips) are present and in working condition. On September 21, 2022, at 8:50 AM, V3 CNA stated she was providing cares to R1 on August 30, 2022, when R1 fell out of the mechanical lift. V3 stated, The (mechanical) lift on the third floor had been missing a metal clip on one of the hooks (hanger rods) for a while. We had no other lift to use on the third floor, so we had to use it. (V8 CNA) and I went to transfer (R1) from the bed to her wheelchair when the lower left part (hanger rod) of the lift dipped down and the sling came apart from lift. The lower left (hanger) rod was missing the metal clip. (R1) fell out of the lift, falling onto the floor, hitting her head on the lift .Everyone knew the lift was missing a clip. On September 21, 2022, at 12:45 PM, V3 CNA stated, I reported verbally to (V7 Third Floor Manager) sometime in August (2022) that the lift was missing a metal clip, but I never put in a work request to have maintenance look at it. I can tell you that I worked on, August 23, 2022. From that date on, the lift had been missing the clip. Even after (R1) fell out of the lift on August 30, 2022, we asked (V2 Director of Nursing/DON) if we should continue to use the lift with the missing clip and she told us we could. We (V3, V8) tried to tell her (V2 DON) that (R1) fell out of the lift because the clip was missing. (V2 DON) told us to stop blaming the fall on the missing clip. We then used the lift to transfer (R7) and (R8). V3 CNA's August 2022 timecard showed V3 worked August 23, 24, 25, 26, 30, and 31, 2022. On September 21, 2022, at 9:10 AM, V8 CNA she was providing cares to R1 on August 30, 2022, when R1 fell out of the mechanical lift. V8 stated, One of the clips on the third floor (mechanical) lift had been missing for a while. The clips were used to lock the sling in place on the hooks of the lift. It was the only lift on the third floor, so we had to use it. (R1) fell out of the lift when the sling came away from the lift, down by (R1's) left leg. That was the hook on the lift that was missing the metal clip. V8 CNA stated she notified V2 DON verbally of the missing metal clip sometime in August but stated she never filed a work request to have maintenance fix/evaluate the mechanical lift. On September 21, 2022, at 12:48 PM, V8 CNA stated, I can also verify I worked August 23, 2022. From that date on, the lift was missing the metal clip. There was no other lift on the floor, so we had to keep using it. After (R1) fell on [DATE], I tried to tell (V2 DON) that she fell because the lift was missing a clip. (V2 DON) told me (R1's) fall did not happen because of the missing clip. She told us we could still use the lift to transfer residents. We then transferred (R7) and (R8). V8 CNA's August 2022 timecard showed V8 worked August 23, 24, 25, 26, 30, and 31, 2022. On September 21, 2022, at 1:00 PM, V18 Registered Nurse (RN) stated, I was here on August 30, 2022, when (R1) fell out of the lift. I overheard (V2 DON) tell (V3 and V8 CNAs) that they could continue to use the lift with the missing clip to transfer residents. On September 21, 2022, at 10:55 AM, V2 DON stated she was unaware that the mechanical lift on the third floor was missing a grommet/metal clip until after R1 fell out of it on August 30, 2022. V2 stated, I know (R1) fell out of the lift when the sling, by her left leg, came off the hook of the lift. V2 stated, If the staff didn't feel that lift was safe to use, they shouldn't have used it. V2 DON denied telling V3 CNA and V8 CNA they could continue to use the lift with the missing clip, after R1's fall on August 30, 2022. On September 21, 2022, at 2:00 PM, V7 Third Floor Manager stated she was unaware that the mechanical lift on the third floor was missing a grommet/metal clip until after R1 fell out of it on August 30, 2022. V7 stated the mechanical lift was taken out of service on August 30, 2022. On September 21, 2022, at 12:30 PM, V10 Maintenance Director stated he was unaware that the mechanical lift on the third floor was missing a grommet/metal clip until after R1 fell out of it on August 30, 2022. V10 stated, When equipment is broken or something is wrong, staff are to put a work order in the computer, so I know it needs to be looked at. I would then take the equipment out of service until I can look at it. If a metal clip is broken off one of the hooks of the lift, the lift should not have been used. The clips serve as a locking mechanism for the lift. V10 denied ever receiving a work order/request to fix the third-floor mechanical lift. V10 stated the mechanical lift on the third floor was taken out of service on August 30, 2022. On September 21, 2022, at 11:18 AM, V14 (Quality Assurance Manager for the mechanical lift company) stated, The hanger rod clip, on the mechanical lift, is a double-check mechanism to make sure the loops of the cloth sling stay in place on the hooks of the lift. If the clips are not in place, the loops of the sling could slip off the hooks of the lift, causing a person to fall. If a rod clip is broken or missing, the lift should not be used. The facility's Mechanical Lift Transfers policy dated July 28, 2022, showed. 1. Follow Manufacturer's guidelines on how to operate machine. The facility's Maintenance policy dated July 28, 2022, showed, 2. Any staff who is made aware of a malfunctioning equipment or any part of the building that is in disrepair will report the issue to the maintenance department. The Immediate Jeopardy that began on August 23, 2022, was removed on September 26, 2022, when the facility took the following actions to remove the immediacy: 1. On 8/30/22, the Maintenance Director inspected the mechanical lift that R1 used and replaced the retention clip that was missing. 2. Since R1's return from the hospital on 8/31/22, R1 has been transferred safely using a mechanical lift that is in safe, working order. 3. There are 23 residents that require a mechanical lift for transfer. All 23 residents that require a mechanical lift transfer were identified by Nursing Administration (See Attachment 1), and all 9 mechanical lifts were reconciled and inspected by the Maintenance Director and were determined to be in safe, working order with no missing retention clips. (See Attachment 2) This was completed on 9/26/22. 4. There has been no further incidents/accidents that have occurred during a transfer since 8/30/22 due to broken/malfunctioning equipment such as a mechanical lift. 5. On 8/30/22, a 1:1 in-service was conducted with the 2 Certified Nursing Assistants that transferred R1 with the mechanical lift. This in-service included the process to do a visual check of the mechanical lift, prior to each use, and to note that is retention clips are missing, immediately remove the lift from service and notify the Nursing Supervisor. (See Attachment 3) 6. On 9/26/22, the Director of Nursing was in-serviced by the Regional Nurse Consultant that the DON must consult with the Director of Maintenance/Designee before determining whether or not to deem mechanical equipment safe to use after receiving a concern from staff about the respective piece of equipment. DON/Designee must remove the respective equipment out of service until the Maintenance Director/Designee inspects and deems safe to be back in operation. (See Attachment 9) 7. All staff will be educated by the DON/Designee on reporting if a mechanical lift is in safe, working order. This includes visually inspecting the lift, prior to each use for retention clips, and in cases where clips are missing, immediately removing the lift from service and notify the Nursing Supervisor. Agency staff will be educated prior to the start of their shift to visually inspect the lift, prior to each use for retention clips, and in cases where clips are missing, immediately removing the lift from service and notify the Nursing Supervisor This will be completed by 9/26/22. (See Attachment 4) 8. Newly hired staff will be in-serviced by Restorative/Designee prior to the start of their shift to visually inspect the lift, prior to each use for retention clips, and in cases where clips are missing, immediately removing the lift from service and notify the Nursing Supervisor. 9. On 9/26/22, all Nursing Supervisors will be in-serviced on reporting to the Maintenance Director via Mpulse 9 (software application) used to enter and communicate work orders, any mechanical lift needing repair, including any missing retention clips. (See Attachment 5) 10. A log will be initiated effective 9/26/22 and ongoing to ensure that staff are completing visual checks, prior to use, to ensure that the mechanical lift is in safe, good, working condition. (See Attachment 6). 11. A QA (Quality Assurance) tool will be initiated on 9/26/22 by the Maintenance Director and/or Designee to check weekly for 12 weeks, to ensure that all mechanical lifts are in safe, good, working condition. Upon completion of 12 weeks of the QA tool, Maintenance Director/Designee will continue to inspect monthly in accordance with the manufacture's guidelines (See Attachment 7A). This QA tool will then be initialed by the Maintenance Director/Designee after completion of the inspection. (See Attachment 7) 12. The Maintenance Equipment policy has been updated on 9/26/22 to ensure that staff are aware that he/she must tag and remove from service if equipment is deemed not functioning properly. (See Attachment 8). 13. Reviewed with QA Committee on 9/26/22 and committee decided that the 2 above QA tools will be added indefinitely into monthly review QAPI process. (See Attachment 10) 14. Medical Director, was notified via phone on F689 citation and the basis behind it on 9/26/22.

Based on observation, interview and record review the facility failed to identify a facility acquired pressure injury prior to it becoming unstageable for 1 of 3 residents (R1) reviewed for pressure in the sample of 6. The failure resulted in R1 developing an unstageable pressure injury to her ischium. The findings include: R1's facility assessment dated [DATE] shows her cognition is intact and she requires extensive assistance of 2 staff for her bed mobility. R1's face sheet shows she has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's care plan shows she is at risk for impairment of skin integrity with an intervention to check skin every shift and report any abnormalities to the nurse. R1's pressure ulcer risk assessment completed on 2/22/2022, 2/27/2022 and 3/6/2022 by V9 (Wound Care Nurse) shows that R1 is at moderate risk to develop pressure injuries. R1's nursing progress notes show she has a recently acquired left arm humerus fracture and as a result R1 has been bed bound since 2/19/2022. A facility Wound Assessment Details Report completed by V9 on 3/8/2022 at 12:16 PM, shows that R1 has a new facility acquired pressure injury to her left ischium. The wound is 3.70 centimeters (cm) long by 2.30 cm. wide by unknown depth. An area of 8.51 cm.² the wound is classified as unstageable and has 70% slough tissue. On 3/10/2022 at 9:35 AM, V9 removed the dressing to R1's left ischium. R1's pressure injury is approximately the size of a fist. The top layer of skin is gone and there is a white area in the center of the wound bed. V9 said that due to the slough tissue in the wound bed it is not possible to determine how deep it is underneath so the pressure injury was classified as unstageable. V9 additionally said that R1 is incontinent of urine and has been remaining in bed so she should be receiving incontinence care and turning and repositioning every 2 hours. On 3/10/2022 at 11:51 AM, V9 said that R1's wound would have initially started out as skin irritation and it should have been reported much sooner. V9 said he thinks that R1's wound was just not reported early enough and the process broke down and slipped through the cracks. Sooner reporting is the key and at some point this wound was just a skin irritation. And treatment could have been initiated sooner, it was just too far along to justify not being reported sooner. There is no documented skin abnormalities in R1's nursing progress notes prior to 3/8/2022 for R1's ischium. On 3/10/2022 at 9:40 AM, V10 (Certified Nursing Assistant/CNA) said residents are turned and repositioned every 2 hours and incontinence care is provided. V10 said R1 is incontinent of urine and is supposed to be checked, turned and repositioned every 2 hours. V10 said she had not worked with R1 in a couple of weeks and she was the one who reported R1's pressure injury to the nurse. V10 said any changes to a residents skin even just redness or irritation should be reported immediately. V10 said that R1 has been feeling a little down lately. On 3/10/2022 at 9:50 AM, R1 said she has been in bed due to her having a broken arm. R1 said and now I have a sore on my bottom that has been hurting for a while now. R1 said she likes to be up out of bed in her wheelchair and not in bed. On 3/10/2022 at 10:20 AM, V11 (CNA) said all residents skin should be looked at during incontinence care which is done every 2 hours, during showers, and anytime they are doing care for a resident. V11 said any abnormal findings needs to be reported to a nurse immediately even just pink or irritated skin. On 3/10/2022 at 10:46 AM, V3 (Assistant Director of Nursing/ADON) said that any skin abnormalities should be reported immediately. A nursing progress completed by V14 (Nurse Practitioner) on 3/9/2022 at 8:31 PM, says that R1 has a newly acquired ischial ulceration. The same note states, Aides reports on going crying and she (R1) reports feeling depressed. V14 was attempted to be contacted by phone and a message was left by the facility and again by the surveyor on 3/10/2022 at 1:27 PM, with no return phone call. The facility's Wound Care Program Care Guidelines with a reviewed date of October 3, 2021 says, 3. Prevention of skin breakdown includes but not limited to: b. daily regular skin hygiene. C. inspect the skin every shift with care for signs of breakdown .

Based on interview and record review the facility failed to ensure a resident was safely transferred using 2 staff members, for 1 of 3 residents (R1) reviewed for safety/supervision in the sample of 6. This failure resulted in R1 sustaining a left arm humerus fracture during the transfer. The findings include: R1's face sheet updated and printed date of 2/24/2022 shows she has diagnoses including: Unspecified fracture of shaft of humerus left arm, initial encounter for closed fracture, [CONDITION(S)], and pain in left arm. R1's facility assessment dated [DATE] shows her cognition is intact, and she requires extensive assistance of 2 staff members to transfer. R1's active care plan shows she has a self-care deficit and impaired mobility and requires 2 staff members physical assistance and the use of gait belt, using the stand pivot method for transfers. R1's nursing progress notes show an entry written by V6 (Registered Nurse/RN) on 2/17/2022 at 3:01 PM that states Resident complained of pain to left arm after transfer her from bed to chair, given pain medicine as per PRN (as needed) order, MD aware with new order for left arm x-ray STAT (as soon as possible). A entry in R1's nursing progress notes on 2/18/2022 also by V6 says, R1's X-ray was normal and no fracture the Nurse Practitioner (V14) was notified, R1 c/o pain 6/10 given pain medication as per order, resident stay in bed because of left arm pain. R1's nursing progress notes show on 2/19/2022 at 4:30 PM, the facility received a call from the x-ray company that they are sending a tech to redo R1's x-ray. The x-ray was completed at 5:50 PM. At 8:20 PM the facility received a call that R1's x-ray shows she has a fracture to her left arm. The facility notified a nurse practitioner who then notified the family and R1 was sent to the emergency room for treatment of a left arm humerus fracture. R1's emergency room records from a local community hospital on 2/19/2022, show R1 was being evaluated for a left arm injury that occurred during a transfer on 2/17/2022 where R1's arm was squeezed tightly. A radiology report from the local community hospital dated 2/19/2022 shows R1 has a subacute spiral fracture to her distal third left humeral shaft. R1 was discharged from the emergency roiagnom on [DATE] with an arm sling and recommended to have orthopedic follow up. An Orthopedic note written by V15 (Orthopedic Physician) shows that R1 was seen by him on 3/1/2022. The same note shows she has a non-displaced spiral fracture of the shaft of the humerus on the left arm. The notes shows that R1 is having constant pain to the left shoulder. On 3/10/2022 at 9:50 AM, R1 said her arm was broke during a transfer when an agency CNA (identified as V12) transferred her alone with no gait belt and without a mechanical lift. R1 said the CNA asked her how she is usually transferred and R1 told her with a lift. R1 said the CNA told her I don't think we need that I can lift you into the chair. R1 said the CNA was alone, did not apply a gait belt, and lifted her under the arms and it happened so fast the next thing she knew she was in excruciating pain and called out that something was not right. R1 said when she was sat down in her wheelchair the pain was terrible and she could not lift her shoulder up. R1 said her roommate R4 was present in the room when the incident occurred. R1 also said since the incident she has been bed bound and that makes her upset because she likes to be up in her wheelchair. On 3/10/2022 at 9:57 AM, R4 said she witnessed the incident when the CNA (V12) came into the room and asked R1 how she usually transferred. R4 said V12 did not use a lift to transfer R1 and she was the only CNA in the room. R4 said she heard R1 calling out ouch this is too much. R4 said no one from the facility interviewed her about witnessing the incident. R4's facility assessment dated [DATE] shows her cognition is intact. On 3/10/2022 at 9:40 AM, V10 (CNA) said they always use 2 staff to safely transfer residents when using a sit to stand. V10 said that R1 had some weakness to her lower extremities but her upper body was strong and she could hold on to the lift. V10 said R1 has been feeling a little down lately, since the injury to her arm. On 3/10/2022 at 10:20 AM, V11 (CNA) said R1 was supposed to be transferred with 2 staff and using a sit to stand lift. V11 said R1 would not be safe to transfer with 1 staff person. V11 said R1 is also not safe to do a stand/gait belt transfer with 1 person. V11 said R1 should not have been transferred alone. On 3/10/2022 at 10:46 AM, V3 (Assistant Director of Nursing/ADON) said she interviewed V12 after the incident to R1 and V12 told her she used the sit to stand lift alone to transfer R1. V3 said their policy is 2 staff are required to be present when using a lift on a resident On 3/10/2022 at 11:02 AM, V6 (Registered Nurse/RN) said she was called to assess R1 on 2/17/2022 after she was transferred by V12 and complained of arm pain. V6 said both R1 and R4 are alert and oriented. V6 said an ordered was received for R1 to have an x-ray of her left arm. On 3/10/2022 at 11:23 AM, V8 (Restorative Nurse) said that they highly recommend 2 staff during a sit to stand transfer. V8 said even though manufacturer guidelines for a sit to stand lift says you can use 1 staff we prefer 2 because, look at the mess we are in now if something goes wrong. V8 also said the guidelines also indicate when more than 1 staff are recommended for transferring. On 3/10/22 at 11:35 AM, V12 said on the date in question 2/17/2022 it was the first time she had taken care of R1. V12 said she went into R1's room and asked her how she transferred and R1 told her with a sit to stand lift. V12 said she went and got the lift and while transferring R1 she began grimacing in pain, and during the transfer R1 was telling her she was having severe pain. V12 said R4 was asking R1 if she was okay during the transfer. V12 said she could transfer R1 with only 1 person. On 3/10/2022 at 10:40 AM, V5 (RN) said R1 and R4 are both alert and oriented. A nursing progress completed by V14 (Nurse Practitioner) on 3/9/2022 at 8:31 PM, says that R1 has a newly acquired ischial ulceration. The same note states, Aides reports on going crying and she (R1) reports feeling depressed. R1's investigation report completed by V2 (Director of Nursing) has no witness statement from R4. The same report says that V14 (Nurse Practitioner) consulted with R1's primary care physician and indicated the residents (R1) fracture is pathological in nature and caused by the resident's fragility due to long term use of steroids and immobility and the resident has [CONDITION(S)]. In the same investigation report a witness statement completed by V12 says she was the only staff present during the transfer and says she used a sit to stand lift alone and R1 began grimacing in pain during the transfer. V14 was attempted to be contacted on 3/10/2022. 2 messages were left one by V2 and one by the surveyor with no return call. On 3/10/2022 at 12:55 PM, V15 (Orthopedic Physician) was attempted to be contacted. V15 was out of town so V4 (Orthopedic Physician Assistant) took the call and said he is V15's assistant. V4 said that a spiral fracture is not a pathological fracture. V4 said the type of fracture R1 has is consistent with trauma to R1's arm. V4 said an arm would not just fracture on its own without there being a tumor or mass present pushing on it. The facility's Mechanical Lift Transfers with a revised date of 7/28/2021 says to follow the manufacturer's guidance on how to operate machine. The manufacturer guidance states, Though one person can perform patient transfers, certain patients or situations may require the help of one or more additional staff members .

Based on observation, interview, and record review the facility failed to ensure a resident was free from sexual abuse (R1) and failed to ensure the perpetrator (R2) of the sexual abuse did not have access to other residents (R6). This applies to 2 of 6 residents (R1, R6) reviewed for abuse in the sample of 6. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on October 27, 2021 when the facility moved R2 (perpetrator) into a resident room with R6 during an ongoing abuse investigation. The Immediate Jeopardy was identified on October 28, 2021. V1 (Administrator) was informed of the Immediate Jeopardy on November 2, 2021. This surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on November 2, 2021, however, noncompliance remains at a Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: 1. The facility's Preliminary Investigation Report dated October 26, 2021 showed at 6:00 PM (on 10/26/21), R1 called the local police alleging R2 sexually assaulted him around 2:00 AM on October 26, 2021. R1's resident assessment dated [DATE] showed R1 was cognitively intact. R1's Admission Record dated November 2, 2019 showed R1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R1's Progress Note dated October 26, 2021 showed R1 told facility staff he was sexually abused by R2 around 2 am on October 26, 2021. On October 28, 2021 at 9:30 AM, R1 stated, I called the police. (R2) sexually assaulted me. It was not consensual. I woke up about 3:15 AM that morning (10/26/21) and (R2) had his hands on my penis . I told him to knock it off . R2's resident assessment dated [DATE] showed R2 was mildly cognitively impaired but able to make his needs known. R2's Admission Record dated March 11, 2020 showed R2 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R2's Progress Note dated October 26, 2021 showed facility staff asked R2 about the incident with R1. The note showed, (R2) said his roommate (R1) was masturbating around 2 am and (R2) felt his roommate was having a hard time doing it and he needed help, so (R2) helped his roommate do it . On October 28, 2021 at 12:05 PM, R2 stated, Yea, I helped (R1) masturbate that night (10/26/21). It was the middle of the night. I looked over at (R1) and I could tell he was masturbating. He kept doing it and looked like he was having a hard time so I offered to help. I thought he said yes. I went over to his bed and used my hand to help him out. Yes, I touched his penis . On October 28, 2021 at 11:35 AM, V10 Registered Nurse (RN) stated she was caring for R1 and R2 on October 26, 2021. V10 stated, Around 6:00 PM that night, the police showed up and asked to speak with (R1). That was the first I had heard of the sexual abuse allegation . I talked to both (R1) and (R2) that night . (R1) told me he was abused by (R2) . (R2) told me helped (R1) masturbate because (R1) was having a hard time doing it .I reported all of this to my supervisor . On October 28, 2021 at 12:33 PM, V1 Administrator stated, I am the abuse coordinator .The abuse investigation involving (R1 and R2) is still ongoing . I have not interviewed (R2) or (V10 RN) yet about the incident on October 26, 2021 . V1 stated he was aware R1 had called the police and made an allegation of sexual abuse against R2 but that no facility staff had reported to him that R2 admitted to helping R1 masturbate. 2. R2's Room Transfer form dated October 27, 2021 showed R2 was transferred into resident room with R6. The facility's Daily Census report dated October 28, 2021 showed R2 resided in bed A and R6 resided in bed B. On October 28, 2021 at 9:10 AM, the door to R2 and R6's room was closed. Their room was located at the end of the second floor hallway. This surveyor knocked on the door and entered the room. R2 was seated on his bed, eating breakfast. R6 was lying in bed, directly next to R2. R6 stated, I got a new roommate. He (R2) moved in yesterday. R2 then got up from his bed and walked into the bathroom to brush his teeth. On October 28, 2021 at 9:50 AM, when V1 Administrator was asked why R2 currently had a roommate, V1 stated, I don't know. He was moved into that room yesterday with (R6). I will have to find out . He (R2) shouldn't have had a roommate. The abuse investigation isn't complete. He should be supervised or in a private room. On October 28, 2021 at 10:20 AM, V3 RN stated, If a resident is accused of abusing another resident, the accused resident should not have a roommate to make sure that resident doesn't hurt someone else. They should be separated at least until the abuse investigation is done. On October 28, 2021 at 10:20 AM, V12 RN stated, If a sexual abuse allegation is made against a staff member, they are suspended until the investigation is complete. If the allegation is resident to resident, the accused resident is put in a private room and is watched closely . On October 28, 2021 at 10:30 AM, V4 RN stated, To make sure the residents are safe, if a resident did abuse another resident, the accused resident needs to be separated and in a room by themselves. On October 28, 2021 at 11:30 AM, V7 Memory Care Manager stated, I don't know why (R2) is in a room with a roommate. On November 1, 2021 at 9:15 AM, V14 Physician stated she was R1's primary care physician. V14 stated, (R1) has dementia and psychiatric behaviors .If there is an allegation of abuse, the residents need to be separated and examined by physicians. The accused resident, the perpetrator, needs to be supervised by staff and placed in a private room, while in the facility, until the abuse investigation can be done. The problem is that with residents that have dementia, they can develop hypersexual behaviors. If the accused resident has dementia, he may need to be in a private room for a few months to make sure he is not developing hypersexual behaviors. I told the facility this. Because of (R1's) and (R2's) dementia and their risk for developing hypersexual behaviors, (R1) and (R2) both need to be supervised for a while, to protect the residents and staff as well. The facility's Abuse and Neglect Policy dated May 21, 2021 showed, It is the policy of the facility to provided professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations .Sexual abuse includes but is not limited to harassment, coercion, disparaging remarks or sexual assault .Sexual abuse also includes non-consensual sexual relationship between residents . The policy also showed, If abuse/neglect is suspected the facility will: 1. Take immediate steps to assure the protection of the resident(s). This may involve separation from the alleged abuser and/or provision of medical care . The policy showed the facility will have procedures to protect residents from physical and psychosocial harm during the investigation . The Immediate Jeopardy that began on October 27, 2021 was removed on November 2, 2021, when the facility took the following actions to remove the immediacy: 1. Both residents, R1 and R2, were immediately separated and on 1:1 monitoring. Abuse coordinator, Attending Physicians, representatives, local law enforcement were all notified on 10/26/21. Both residents were transported to a local hospital for follow up on 10/26/21. 2. R1 and R2 were placed in separate rooms on separate floors upon return to the facility on [DATE]. Both residents returned in stable condition. 3. On 10/28/21, R2 was placed in a private room and will remain in a private room until completion of the investigation. 4. Abuse and neglect policy was updated on 10/28/21 to include additional measures to protect all residents during an abuse investigation. - In-services performed by abuse coordinator and designee, began with all staff on 10/28/21, focusing on the updated abuse and neglect policy, including who the abuse coordinator is, immediately reporting abuse allegations, the different types of abuse, supervision and protection of other residents during the course of the investigation, preservation of crime scene, reporting to police agency, notification of family and physicians, and sending residents to the hospital for further evaluation if applicable. - On 10/28/21, in-service started by the abuse coordinator and designee, inclusive of the entire facility staff on all shifts. The facility will ensure that new hires, staff on leave, and agency staff will be in-serviced prior to their first shift including list of residents with sexual behavior, who to immediately report abuse allegations, the different types of abuse, supervision and protection of other residents during the course of the investigation, preservation of crime scene, reporting to police agency, notification of family and physicians, and sending residents to the hospital for further evaluation if applicable. - This in-service was started on 10/28/21 and completed on 11/2/21. 5. Inservice done with V1 Administrator on 10/28/21 by the Regional Director of Operations on updated abuse policy, placing residents accused of abuse in a private room (if available) until the investigation is completed. If a private room is not available, place resident on 1:1 supervision. When investigation is complete, review resident's care plan based on results of investigation and update if needed. 6. An audit was done and completed on 10/28/21 by the Administrator and Social Services Director of residents with sexual behaviors. There are 3 residents with sexual behavior care plans. The care plans of those residents were reviewed and updated. The list of residents identified with sexual behaviors was placed on each unit on 10/28/21 so every staff is aware that these residents with sexual behaviors need to be monitored based on their plan of care. List will be reviewed and updated weekly or as needed based on changes by abuse coordinator or designee and will be ongoing. 7. All incidents of abuse allegations will be discussed with the Abuse Coordinator starting 10/28/21. 8. An audit began to check any residents, weekly for 12 weeks, that were accused of abuse and not cleared of allegations are in a private room and receiving supervision in order to protect the residents in the facility. Audits started on 10/28/21 and will be completed on 1/28/22. 9. An audit began to randomly interview 5 employees weekly for 12 weeks to ensure they know the facility's abuse policy and protocol with emphasis on timely reporting, protection of residents, and what to do if a resident is abusing another resident. Audit started on 10/28/21 and will be completed 1/28/22.

Based on interview and record review, the facility failed to provide safe environment by not checking the temperature of the coffee prior to serving to cognitively impaired residents. This deficient practice resulted in R1 sustaining second [MEDICAL CONDITION] bilateral inner thighs. This applies to 1 of 3 residents (R1) reviewed for safety/incidents. The findings include: The EMR (Electronic Medical Record) shows that R1 was admitted to the facility on (MONTH) 16, (YEAR) with multiple [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) dated 12/12/2018 showed that R1's BIMS (Brief Interview mental Status) score was 3 (severely impaired). R1 also requires supervision and assistance for all aspects of ADLs (Activities of daily living). The facility's incident report dated 1/4/2019 at 10:45 A.M., showed R1 sustained a thermal burn with redness and blisters to bilateral inner thighs due to hot coffee that was served and spilled on her lap. The coffee was served in a Styrofoam cup by V11 (Activity Aid). V11 placed the hot coffee on top of the table within R1's reach. The hot coffee spilled on R1's lap when another resident (R2) was playing with a ball. R2 rolled the ball across R1's side making the hot coffee tip and its hot contents spill onto R1's lap. R1 sustained burn wound went from redness to blisters in a matter of five minutes over the bilateral inner thighs. The measurement shows 3.0 cm x 2.0 cm. The coffee temperature was tested after it was made by V11. The temperature was 198 degrees Fahrenheit. V11 placed the coffee in a non-regulated coffee carafe then V11 proceeded to serve the coffee to the third floor residents which was a designated dementia unit. V11 failed to check the coffee temperature before serving it to the third floor residents to ensure the temperature would not cause scalding or burn in case of spills. The staff members during the time of the accident were V11 and V5 (CNA, Certified Nurse Assistant). R1 and R2 resides on the designated dementia unit floor. R2's [DIAGNOSES REDACTED]. R2's MDS dated [DATE] showed that R2's BIMS was 4 (Severely impaired). R2's requires supervision to extensive assistance for different aspects of ADLs. On 1/15/2018 at 10:00 A.M., V5(Nurse Aide) stated she was in the dining room on 1/4/2019 at around 10:45 A.M. observing residents. V5 said she heard R1 yell and saw that the coffee had spilled onto R1's lap. V5 stated that R2 rolled a ball that tipped over R1's coffee. V5 stated she was not sure how R2 obtained the ball. R2 was ambulatory with a walker. On 1/15/2019 at 10:30 A.M., R1 was in the dining room attending an activity. After R1 was taken to her room by V5, V7 and V5 provided burn treatment to R1. R1's bilateral inner thighs have burn wounds with redness around the wound perimeter. There was also slough at the center of the wound. V7 measured the burn wounds as follows and classified it as a second degree burn as follows: 11 x 4.8 cm for the right inner thigh; 4.4 cm x 1.4 cm for the left inner thigh. On 1/15/2019 at 3:25 P.M., V11(Activity Aide) stated that she made coffee and placed it in a non-regulated carafe container. V11 stated that the temperature of the coffee was 198 Degrees Fahrenheit. V11 added that she brought the coffee immediately to the third floor dementia unit. V11 immediately served the coffee to the third floor residents by pouring the coffee in a Styrofoam cup. V11 stated that both she and V5 were in the dining room. V11 added that when she served coffee to R1 and R2 were at same table. V11 said that when she turned her back, she heard R1 yell and saw that the coffee had spilled on R1's lap. V11 said R2 had rolled a ball towards R1 which tipped the Styrofoam cup with the hot coffee. V11 said the activity was coffee and Snacks but was not sure how R2 was able to get hold of the ball. V11stated that she did not check the coffee temperature prior to serving it to the third floor residents including R1 and R2. On 1/15/2019 at 4:00 P.M., V19 (Activity Director) stated that V11 did not follow facility's protocol when V11 failed to check the coffee temperature prior to serving it to residents. V19 added that the coffee temperature should be between 135- 150 Degrees Fahrenheit prior to serving to [MEDICAL CONDITION] scalding in case of spillage. V19 further added that this was a preventable accident if the coffee temperature was checked and ensure it was at a safe temperature before serving to residents. On 1/16/2019 at 10:20 A.M., V20 (Registered Dietician) stated that coffee temperature should be 120 and no more 130 degrees Fahrenheit to serve to residents to ensure safety and [MEDICAL CONDITION] case of spillage. V20 stated that the carafe was an insulated carafe and the temperature was not regulated. V20 further added that the temperature of the coffee should have been checked prior to serving it to the residents. V20 said that if the temperature is 120 degrees it was safe, but if it is 120 degrees or higher, it could possibly cause a burn. On 1/16/2019, V8 (Wound Certified Treatment Nurse/ RN, Registered Nurse) stated R1 sustained a second degree burn on bilateral inner thighs caused from a hot coffee spillage. V8 added that the burn wound was provided treatment with wound care specialist physician. V8 added that the burn wound was getting better. On 1/17/2019 at 10:15 A.M., V9 (Wound care specialist physician) stated that R1 sustained a second degree burn from the hot coffee spillage and added that the wound burn shows healing and no signs of infection. The facility's policy Hot Liquids dated 8/28/2018 shows: Purpose: To safely serve hot liquids such as hot water, coffee and soup . 1. Hot liquids such as hot water, coffee and soup should be served between 135-155 Degrees Fahrenheit. 2. Hot liquid temperature will be recorded prior to meal service. 4. Additional resident supervision may be necessary for those found to be at high risk of liquid spills.

Based on interview and record review, the facility failed to ensure a safe environment that is free from abuse for one resident (R6) reviewed for abuse in a sample of 15 residents. Additionally, the facility failed to follow their policy and procedure to safeguard the resident from continued threats of abuse from her perpetrator. This failure resulted in R6 experiencing fear, mental anguish and isolation. Findings include: R6 is a [AGE] year old resident originally admitted to the facility on [DATE] per facility face sheet dated 10/17/17 and with [DIAGNOSES REDACTED]. R6's most recent MDS (Minimum Data Set) dated 9/26/17 shows a BIMS (Brief Interview for Mental Status) scored at a 15 for cognitively intact. This same MDS assessment shows R6 with no behaviors impacting care. Progress notes show R6 to be alert and oriented to person, place, and time. On 9/10/17 at 6:45 AM, R6 complained to her nurse (E18-Licensed Practical Nurse) that CNA (E17) was rough in the bathroom and hit (R6) on the shoulder several times when she was in the hallway and told her to move. According to R6, she saw E17 back to work on the floor days later giving her dirty looks. This frightened R6 and prevented her from coming out of her room in the early morning hours like she normally likes to do. Interview with R6 on 10/17/17 at 11:00 AM states, I go outside my room to the hallway like I normally do because I get up early and can't sleep anymore. I sat by the nursing station when this CNA came from behind me and hit me on my shoulder several times. I recognized her and she was the same one that was rough with me in the bathroom. She said she was trying to wake me up and told me to move because I was in the middle of the hallway or something. I complained to the nurse about it and told her she was rough with me too when I was in the bathroom. While in the bathroom, I think around 4:00 in the morning, she was telling me to hurry up and I think she was angry with me because I was too slow. I have [MEDICAL CONDITION] so I can't help moving slow. She (E17) said she had a lot of people to do but that's not my fault they don't have enough staff here. R6 demonstrated how (E17) hit her by slapping surveyors arm several times when asked how she was hit on her shoulders. R6 stated, I don't like that (E17) is still around. I see her in the halls and she gives me dirty looks. I don't like going out of my room now like I used to because I'm afraid she's going to hit me again or something. I can tell she's angry with me and it scares me and it makes me very nervous. (R6 became visibly upset, started shaking and her eyes became watery while she's describing her situation). R6 stated, The administator is the one that doesn't believe that CNA (E17) hit me. That's why she's still up here isn't it? Review of facility staffing schedules (September 2017 through current schedule of October 2017) show E17 returning to work and assigned to the same floor and wing after the abuse investigation. 10/17/17 at 11:30 AM, E2 (DON-Director of Nursing) was asked about the abuse investigation, E2 stated in part, I didn't do the investigation, that would be (E1) the administrator. I knew about it though. E2 stated, Well they didn't find any injuries on R6 and she is on [MEDICATION NAME] (blood thinner) so that would show if R6 was hit because we'd see a bruise. When asked if [MEDICATION NAME] always causes bruising, E2 stated, No, not always. I guess you have a point. E2 stated, E17 is on the same floor but we switched her team. E2 stated, No, I have not followed up with R6 after the incident to check on her overall well being. Interview on 10/18/17 at 9:30 AM with E17 (CNA-Certified Nurses Aide), states, I've been working here 10 months. I got her ready around 4:30 AM and I guess she came out to the hallway by herself and she was sleeping in the middle of the hallway. She is a deep sleeper and I tried to wake her up and shake her shoulder. I was standing on her right side and she didn't respond so I called the nurse (E18) because she was sliding back on her wheelchair. I couldn't boost her up so E18 (LPN) and E19 (CNA) boosted her up and she still didn't wake up. E17 stated, I took her to the bathroom earlier but there was no problem, I'm not sure when but it was early on in my shift. Another CNA took her later too. (E17's initial statement dated 9/12/17 provided to E1 (administrator) states in part, (E17) also clarified that she did not toilet the resident between 2:30 AM and 6:45 AM.) E17 continued, They (Administration) told me I hit (R6) and the police and the administrator interviewed me. No one else from the facility interviewed me. The administrator called me later and said you can come back to work because there was no bruising on her. After I came back I saw (R6). She recognizes me because she watches me. My feeling is that she hates me. She (R6) is pretty alert but she takes her time to move. Asked if it bothers her that R6 moves slowly, E17 stated, No but we get very busy in the morning. E17 tried to clarify, I mean it doesn't bother me, we help each other out when there's only 3 of us working. Asked how many aides were working the night of the incident, E17 stated, We started with four but someone went home and they made me take her side. Interview at 10/18/17 at 10:00 AM with E19 (CNA) states, I can't say I was a witness because I only helped resident go to the bathroom approximately between 6 or 6:30 AM. R6 was sitting by the hall in her wheelchair and she was sliding so the nurse asked me to boost her up. Asked again if she took (R6) to the bathroom prior to 6 or 6:30 in the morning, E19 stated, No, just that one time at 6 or 6:30 AM. 10/18/17 at 10:00 AM interview with E10 (RN) states, I was asked by the administrator to assess (R6) so I did a full body check on her to look for injuries but didn't see any bruising. Asked when she conducted the full body check, E10 stated, I think a couple of days after the incident. E10 stated, I looked at the area where she was hit (back of the shoulder and neck) but didn't see any bruising because she was on [MEDICATION NAME] (blood thinner). E10 stated, [MEDICATION NAME] medication will not necessarily always cause bruising, It depends on how hard R6 was hit. Asked if she looked anywhere else on R6 for any signs of injury, E10 stated, No just her shoulder area. Interview with E1(Administrator) on 10/18/17 at 2:30 PM stated that he received a call early Sunday morning of 9/10/17 from his night shift nursing supervisor informing him of an allegation of physical abuse inflicted on (R6) by E17 (C.N.A.-Certified Nurses Aide). E1 then went to the facility and initiated the investigation. E1 states in part, I determined, based on my investigation and from interviews with my nurses, there was no physical abuse. (E6) is on [MEDICATION NAME] (blood thinner) and according to my nurses should have had bruising where she was hit. Asked if he was aware of any previous complaints of abuse logged by R6 since being admitted (2011), E1 stated, No, this is the first time I am told but I have heard from staff of other complaints but there is nothing documented. Asked if he was aware that E17's personnel file showed that she did not allow anyone to contact previous employers, E1 responded, Well that was from the previous human resource person and I know legally we can't contact them, plus everything came back fine. Asked if he interviewed R6's room mate or any other residents on the floor taken care of by E17(CNA), E1 stated, No, this incident happened in the hallway. Asked if a social worker or anyone followed up with (R6) to see how she was doing, E1 stated, Well, I make it a point to see all the residents and see how they are all doing, just general conversation, and I would hear if there was an issue because they'd tell me. Asked again if there was anyone else that followed up with R6's well being, E1 stated, I had (E10-RN) check her several days after the incident to see if she had any injury, but no, not again after that. Review of facility records show no follow up documentation from a social worker or other health care professional after the abuse incident to assess R6's overall well-being. 10/18/17 at 3:00 PM, second interview with R6 states in part, Yes I'm sure she hit me. I'm not confused and I wouldn't make this up, please believe me. She's still out there and she watches me and is angry that I accused her. Now what am I supposed to do? Facility policy dated 2/7/17 titled Abuse Prevention Program states: Facility affirms the right of our residents to be free from abuse, neglect, exploitation, mistreatment of [REDACTED]. This includes but is not limited to freedom from corporal punishment, and involuntary seclusion and any physical or chemical restraint not required to treat resident symptoms. The purpose of this policy is to assure that the facility is doing all that is within its reasonable control to prevent occurrences of abuse, neglect, exploitation, mistreatment of [REDACTED]. This will be implemented by: orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of mistreat, neglect and abuse; Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment; identifying occurrences and patterns of potential mistreatment; immediately protecting residents involved in identified reports of possible abuse; implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively and making the necessary changes to prevent future occurrences. Physical abuse: includes hitting, slapping, pinching, kicking, pushing and controlling behavior through corporal punishment. Mental Abuse includes but is not limited to humiliation, harassment, and threats of punishment or deprivation. Indicators of verbal and/or mental abuse include, but are not limited to: Expressions of fear due to the threat of staff reprisal, hesitation to speak openly about treatment and services, implausible stories, anger, and expressed feelings of helplessness. Regardless of the specific nature of the allegation the investigation activities may include: If the accused individual is an employee, review the personnel file to check references, background check and documentation or orientation and training;Where appropriate, documented interviews with the resident's roommate, family members, visitors or others who were in the vicinity of the incident; documented interviews with other residents to which the accused individual has regular contact; Documented interviews with other employees to determine if they have ever witnessed other incidents of mistreatment involving the accused individual; documented interview with the accused individual or individuals with a witness present.

Based on interview and record review, the facility failed to follow the physicians order and add 10 units of Regular insulin to TPN (Total [MEDICATION NAME] Nutrition) for 1 of 3 resident (R1) reviewed for physician orders [REDACTED]. Findings include: E6 (Registered Nurse) said during interview (11.20.24, 6:56 p.m.-7:10 p.m., via telephone) she had to add 3 medications to R1's TPN prior to hanging, including insulin. She said she collected the necessary supplies including two 10 cc syringes (to withdraw [MEDICATION NAME] and [MEDICATION NAME]) and a 3 cc syringe to withdraw insulin. E6 said: "In general an insulin syringe should be used to withdraw insulin, however, an insulin syringe has a very small needle and doesn't go into the bag (TN), so I used a 3 cc syringe because it has a longer needle." E6 said she left the facility "around 5:00 p.m." She said before she left the facility she heard a nurse saying that R1's blood sugar has dropped, she offered to call the Nursing Supervisor and after 5 minutes she left. E6 said she arrived home ("around 6:00 p.m.") and realized that she had used the wrong syringe to withdraw the insulin. She called E4 (Registered Nurse, Supervisor) and said: "I want you to stop the TPN." E6 said this was the first time she had hung TPN and that she did not ask for help prior to hanging it. She also said, in retrospect, she "would have used the insulin syringe and taken my chances." Review of E6's "Trigger Investigation Report" statement (signed and dated 11.14.2014) documents: "I called the supervisor to report that I had not used insulin syringe for insulin and I was in doubt that I had added more insulin than stated amount in TPN bag. I do not recall the exact amount of insulin drawn out." E5 (Registered Nurse) said during interview (11.20.2014, 6:20 p.m.-6:32 p.m., via telephone) she "believed the incident happened on 11.13.2014 around 4:45 p.m." She said R1 was in bed with ongoing TPN (that the day shift had hung), was diaphoretic (cold and clammy), complained of not feeling well and her blood sugar was 25 mg/dl (normal range is 60 mg/dl-99 mg/dl). The facility's Diabetic Protocol was initiated, however, R1 continued to experience episodes of [DIAGNOSES REDACTED] despite these interventions. E5 said that E6 was present when R1's blood sugar first dropped. She said E6 told her: "keep doing what you're doing and I'll call the supervisor" and that E6 never said that she might have given the wrong dose of insulin. E4 confirmed during interview (11.20.2014, 4:30 p.m.-5:21 p.m. in the Welcome Room) that E6 had notified her (11.13.2013, at approximately 5:00 p.m.) of R1's multiple low blood sugars and that she later received a call from E6 stating that she was unsure how much insulin she had added to R1's TPN. Z1 (Pharmacist) said during interview (12.02.2014, 1:25 p.m.-1:36 p.m. in the Welcome Room) an insulin syringe must be used to draw up insulin to ensure the proper dose because insulin is measured in units and other syringes don't have those markings. She also said if too much insulin is added to TPN "it's very dangerous." Z2 (Physician) said during interview (12.02.2014, 2:06 p.m.-2:22 p.m. in the Welcome Room) that she was notified multiple times of R1's change in condition. When informed that E6 admitted to using a 3 cc syringe to draw up insulin, Z2 said the resident received the incorrect amount of insulin and a regular syringe shouldn't be used because insulin is measured in units and the dose wouldn't be correct. Z2 said if sustained, [DIAGNOSES REDACTED] is bad and could cause [MEDICAL CONDITION] and neurological deficits. Review of R1's TPN order documents under "Nurse Additives," "Insulin Regular ([MEDICATION NAME]) 10 units." Per "Pearson Nurses Drug Guide" (copyright 2011, page 803, Insulin Regular), under Administration: "Use an insulin syringe." Review of the facility's Incident Report documents the following: "While the PM Nurse was reassessing the patient, the facility received a call at approximately 6:30 p.m. from the previous shift nurse asking for the supervisor to discontinue R1's TPN as she couldn't recall the amount of insulin delivered to the TPN solution. This nurse stated she didn't use an insulin syringe because she felt the needle would be too small to inject in the TPN bag."

Based on interview and record review, the facility failed to ensure the prescribed amount of insulin was added to TPN (Total [MEDICATION NAME] Nutrition) intravenous administration for 1 of 3 residents reviewed for medication administration. This medication error resulted in R1 having episodes of [DIAGNOSES REDACTED] and requiring emergent transfer to the hospital for evaluation and treatment. . Findings include: E6 (Registered Nurse) said during interview (11.20.24, 6:56 p.m.-7:10 p.m., via telephone) she had to add 3 medications to R1's TPN prior to hanging, including insulin. She said she collected the necessary supplies including two 10 cc syringes (to withdraw [MEDICATION NAME] and [MEDICATION NAME]) and a 3 cc syringe to withdraw insulin. E6 said: "In general an insulin syringe should be used to withdraw insulin, however, an insulin syringe has a very small needle and doesn't go into the bag (TN), so I used a 3 cc syringe because it has a longer needle." E6 said she hung R1's TPN "around 3:00 p.m.-3:15 p.m. and left the facility "around 5:00 p.m." She said before she left the facility she heard a nurse saying that R1's blood sugar has dropped, she offered to call the Nursing Supervisor and after 5 minutes she left. E6 said she arrived home ("around 6:00 p.m.") and realized that she had used the wrong syringe to withdraw the insulin. She called E4 (Registered Nurse, Supervisor) and said: "I want you to stop the TPN." E6 said this was the first time she had hung TPN and that she did not ask for help prior to hanging it. She also said, in retrospect, she "would have used the insulin syringe and taken my chances." Review of E6's "Trigger Investigation Report" statement (signed and dated 11.14.2014) documents: "I called the supervisor to report that I had not used insulin syringe for insulin and I was in doubt that I had added more insulin than stated amount in TPN bag. I do not recall the exact amount of insulin drawn out." E5 (Registered Nurse) said during interview (11.20.2014, 6:20 p.m.-6:32 p.m., via telephone) she "believed the incident happened on 11.13.2014 around 4:45 p.m." She said R1 was in bed with ongoing TPN (that the day shift had hung), was diaphoretic (cold and clammy), complained of not feeling well and her blood sugar was 25 mg/dl (normal range is 60 mg/dl-99 mg/dl). The facility's Diabetic Protocol was initiated with R1 receiving glucotabs and [MEDICATION NAME] but resident's blood sugar remained low at 40 mg/dl. R1's physician was notified and ordered 1/2 vial of D50 to be given. Resident's blood sugar was 161 mg/dl 15 minutes later. E5 said "around 6:15 p.m." resident complained of not feeling well and her blood sugar was 40 mg/dl. She said she stopped the TPN, replaced it an IV (intravenous) solution of D5W, called R1's physician and gave a whole dose of D50 and R1's blood sugar rose to 161 mg/dl. E5 said resident's blood sugar continued to drop and resident was sent to the hospital via 911 for treatment as per physician's orders [REDACTED]. E5 said that E6 was present when R1's blood sugar first dropped. She said E6 told her: "keep doing what you're doing and I'll call the supervisor" and that E6 never said that she might have given the wrong dose of insulin. Review of E5's "Trigger Investigation Report" statement (signed, 11.13.2014) reiterates E5's interview as noted above. E4 confirmed during interview (11.20.2014, 4:30 p.m.-5:21 p.m. in the Welcome Room) that E6 had notified her (11.13.2013, at approximately 5:00 p.m.) of R1's low blood sugar. She said the PM nurse followed the facility's protocol for [DIAGNOSES REDACTED] and R1's blood sugar went up to 163 mg/dl, however, resident continued to have episodes of [DIAGNOSES REDACTED] despite interventions by nursing staff. E4 said she discontinued R1's TPN and replaced it with D10W. She said she later received a call from E6 stating that she was unsure how much insulin she had added to the TPN. Z1 (Pharmacist) said during interview (12.02.2014, 1:25 p.m.-1:36 p.m. in the Welcome Room) an insulin syringe must be used to draw up insulin to ensure the proper dose because insulin is measured in units and other syringes don't have those markings. She also said if too much insulin is added to TPN "it's very dangerous." Z2 (Physician) said during interview (12.02.2014, 2:06 p.m.-2:22 p.m. in the Welcome Room) that she was notified multiple times of R1's change in condition. She initially said R1 was either intolerant to insulin or received the incorrect dose of insulin. When informed that E6 admitted to using a 3 cc syringe to draw up insulin, Z2 then said the resident received the incorrect amount of insulin. She also said a regular syringe shouldn't be used because insulin is measured in units and the dose wouldn't be correct. Z2 said if sustained, [DIAGNOSES REDACTED] is bad and could cause [MEDICAL CONDITION] and neurological deficits. E2 (Director of Nursing) was interviewed on 12.02.2014, from 4:12 p.m. to 4:18 p.m. in the Welcome Room. She said that she was notified by E4 of the incident involving R1 and E6 and what the staff had done in response to R1's multiple episodes of [DIAGNOSES REDACTED]. E2 said she was alarmed R1 had a blood sugar of 26 mg/dl and said a blood sugar that low could lead to diabetic coma and even death. Review of R1's TPN order documents under "Nurse Additives," "Insulin Regular ([MEDICATION NAME]) 10 units." Review of the facility's Incident Report documents the following: "R1 presented with an episode of [DIAGNOSES REDACTED] approximately one and a half hours after her TPN began infusing. She was administered a [MEDICATION NAME] x1 and glucose tabs by the PM Nurse while the day nurse observed and monitored. R1's blood sugar stabilized after treatment without incident. After about 30 minutes, patient bean to complain of feeling dizzy and nauseated in which another hypoglycemic episode occurred. Facility diabetic protocol initiated with MD and POA notification. While the PM Nurse was reassessing the patient, the facility received a call at approximately 6:30 p.m. from the previous shift nurse asking for the supervisor to discontinue R1's TPN as she couldn't recall the amount of insulin delivered to the TPN solution. This nurse stated she didn't use an insulin syringe because she felt the needle would be too small to inject in the TPN bag. Due to continued fluctuating blood sugars, probable medication variance, and use of TPN, MD gave order to sent patient to ER via 911. R1 was admitted with hypoglycemic reaction..."

Based on observations, interviews, and record review, the facility failed to monitor and supervise residents to prevent falls. This failure applies to two of nine residents (R2 and R4) reviewed for falls in a sample of nine. As a result, R2 who is cognitive impaired was left unattended while in the toilet room and fell hitting her head. This caused a traumatic brain hemorrhage and skull fracture. Findings include: 1. R2's admission face sheet on 10/9/14 notes: R2 was admitted to facility on 9/15/13 with [DIAGNOSES REDACTED]. The incident report dated 6/24/14 notes: R2 was left unattended on the toilet by E5 (certified nursing assistant - CNA). While E5 was attending to another resident in the adjacent room, E5 heard a door slam and noted R2 in the hallway falling. R2 fell before staff could reach her. R2 struck the back of her head sustaining a 3 centimeters (cm) X 3 cm bump to the back of her head and a 2 cm X 2 cm bump to the right forehead. R2 was transferred to the hospital. R2's hospital records dated 6/24/14 notes: R2 was diagnosed with [REDACTED]. R2's care plan on 10/17/14 notes R2 requires extensive assistance with activities of daily living (ADL) such as bathing, toileting and ambulating; due to decreased strength, decreased endurance, and impaired balance. R2 requires 1 person physical assist for ambulation and toileting. R2's care plan also notes R2 requires verbal cues and supervision with ADL's due to visual deficit and poor cognitive skills. R2's Restorative Nursing Program Evaluation dated 5/21/14 notes: R2 requires a lots of cueing, redirection, and prompting to participate and complete a task. R2 also requires extensive assistance with bed mobility, transfer, dressing, toileting, and personal hygiene due to poor cognitive skills, decreased strength, and decreased endurance. R2 needs human assistance to stabilize during transitions and ambulation. On 11/5/14 at 11am, E5(CNA) stated she was assigned to provide care to R2 at the time of the incident. E5 stated she was not aware that R2 could get up and walk independently. E5 stated she was not familiar with R2's level of functioning. E5 stated that following this incident she was told by E2 (DON /director of nursing) that R2 should only be toileted in the bed, not on the toilet. On 11/5/14 at 2:05pm, Z1 (attending physician) stated R2 is confused and that someone should have been watching R2 to prevent fall. 2. R4's admission face sheet on 10/17/14 notes R4 was admitted to facility on 6/16/14 with [DIAGNOSES REDACTED]. The facility's incident log for the period of 6/1/14 through 10/31/14 notes: R4 with history of multiple falls (9). On 6/19/14, 7/7/14 and 9/13/14, R4 slid out of her wheelchair onto the floor. Incident report dated 10/27/14 states R4 was sleeping in her wheelchair in the activity room and was observed falling forward from her wheel chair onto the floor sustaining bump on her left parietal area. R4 was sent out to the emergency room for evaluation. Review of R4's care plan on 11/5/14 at 2:45pm notes R4 has impaired cognition, poor balance and requires extensive assistance with activities of daily living. Review of R4's Falls Risk assessment dated [DATE] notes score of 14. Review of the facility's fall management policy revised 6/4/14, notes "The facility observes the physical and cognitive function of each resident to identify factors that place them at risk for falling." This policy also notes a Fall Risk score of 10 or higher is indicative of a risk for falls. On 11/5/14 at 1:25pm, E6 (Certified Nurses Aid - CNA) stated she was assigned to monitor approximately 42 residents in the activity room and assist E7 (activity aide) with regrouping these residents for activities. E6 stated that she was aware R4 was asleep in wheelchair with her head bent forward; but continued to regroup the other residents for activities. E6 stated R4 needed to wait for her turn to be transport by one of the other CNAs that were attending to other residents in their room. When she noted R4 was falling out the wheelchair, she hurried over to R4 but could not reach her in time. E6 stated that housekeeping had just finished mopping the floor. E6 stated the floor was wet and she (E6) almost fell while trying to reach R4.

Based on record review and interview, the facility failed to correctly transcribe a physician order [REDACTED]. This failure resulted in R3's decline in physical condition requiring emergency hospitalization . The admitting [DIAGNOSES REDACTED]. Findings include: R3 is a [AGE] year old male with multiple medical [DIAGNOSES REDACTED]. Recent hospital admission from 1/9/13 to 1/23/13, shows that R3 was admitted for acute [MEDICAL CONDITION] due to [MEDICAL CONDITION], and then was also found to have a Rectus sheath hematoma wherein his anticoagulant medication was temporarily held. R3 was restarted on the anticoagulant medication prior to discharge to the facility on [DATE]. R3 has also hx (history) of embolic stroke approximately 2 years ago. R3 was not in the facility at the time of the survey. R3 was admitted to the facility on [DATE] for [MEDICAL CONDITION] rehabilitation. R3 per hospital Discharge Medication Reconciliation Physician order [REDACTED]. under the Consultant physician's orders [REDACTED]. a) an anticoagulant medication to be administered twice daily b) Cardiology consult to be ordered for R3's anticoagulant medication management . On 2/21/13 at 10am, E2- Director of Nursing stated that the nurses made a physician transcription error regarding anticoagulation management for R3 during his admission to the facility. R3 was not given an anticoagulation medication, nor was a cardiology referral was done while the resident was in the facility from 1/23/13 to 2/8/13. E2 discussed their protocol on new admissions as follows: 1. the admission nurse transcribed the admission orders [REDACTED] 2. the shift nursing supervisor and the on-coming shift charge nurse reviews the admission orders [REDACTED] 3. the facility admitting physician is notified for approval of the admission orders [REDACTED] 4. the admitting nurse fax approved orders to pharmacy. On 2/21/13 at 11am, E5 (oncoming shift charge nurse) stated that he can not recall R3's admission medication profile. E5 further stated that he was made aware that the admission nurse "missed" the anticoagulant medication orders when R3 had already transferred to the hospital. On 2/25/13 at 2pm , E4 (admitting nurse), E3 (shift nurse supervisor) both stated that "they missed " the anticoagulation management orders for R3 on 1/23/13. On 2/21/13 at 3pm, Z1(family member of R3) stated that R3 did not receive anticoagulant medication while at the facility. The anticoagulant medication was held in the hospital due to development of rectal sheath hematoma, but was restarted prior to discharge from the hospital. R3 has to be on anticoagulation medication to prevent another " stroke " as explained by the cardiologist. On 2/21/13 at 10:30am, Z2 and Z3 (Pharmacy consultants) both stated that the pharmacy did not receive orders for anticoagulation medication from the facility's faxed admission orders [REDACTED]. On 2/21/13 at 1:50pm, Z4 (attending physician) of R3 in the facility stated that he was not made aware of any anticoagulation medication management for R3 during admission on 1/23/13. On 2/26/13 at 2:30pm, Z5's NP (Nurse Practitioner) stated that R3 has to be on long term anticoagulation medication.. On 2/8/13, R3 was admitted to the hospital for urosepsis and also recent onset of: Acute [MEDICAL CONDITION] (Left popliteal [MEDICAL CONDITION] with PE (Pulmonary embolism). The resident transferred to a different facility after discharge from the hospital.