Every finding on record at Bella Terra Streamwood

Based on interview and record review, the facility failed to prevent and protect (R4) from physical abuse out of 7 residents reviewed for abuse. Findings include: 1.Facility reported incident (FRI) submitted 11/07/2025 documents: R3 threw a shoe at R4 and hit him in the back of the head. R3 admitted to throwing the shoe at R4 because R3 was upset with R4.R3 is a 72 -year-old resident admitted to the facility on [DATE] with the diagnoses including but not limited to cerebral infarction, myocardial infarction, genitive deficit, diabetes, and subarachnoid hemorrhage, and cognitive functions and awareness. On the MDS (Minimal Data Set) assessment of 12/05/2025, Section C, the BIMS (Brief Interviewed Mental Status) score was 10/15, indicating moderate cognitive impairment. R4 is a 69 -year-old resident admitted to the facility on [DATE] with the diagnoses including but not limited to impulsive disorder, personality disorder, cognitive communication deficit, benign neoplasm of the pituitary gland, and dysphagia. On the MDS (Minimal Data Set) assessment of 11/04/2025, Section C, the BIMS (Brief Interviewed Mental Status) score was 15/15, indicating cognitive intact. On 12/20/25 at 11:50 AM, R3 said I got upset with R4 because R4 was accusing me of stealing potato chips from the cafeteria, but I did not do it. R4 was too loud, and I threw my rubber slipper at him and accidentally hit R4 over the head, and I did not have the intention of hurting him. I just wanted R4 to stop talking and accusing me of something I did not do. I did not get hurt, and I feel safe here. I have never done things like that before. On 12/20/25 at 11:25 AM, R4 said that I was in my room when R3 threw a shoe over my head and said that I was too loud, we never had any issue in the past and I called the staff and the staff removed R3 right away and brought R3 to the first floor and R3 is still there and I have not seen him since. I feel safe here, and I am not scared of anyone. On 12/20/25 at 1:36 PM called V8 (Registered Nurse), said, I worked on 11/07/25. I was not assigned to R3 and R4. I did not witness the incident. R3 and R4 did not have any behaviors that day and were not aggressive. They were good roommate together, and when I came back to work one day, I was told that R4 and R3 were separate and R3 is now on the first floor because R3 threw a shoe at R4's head. On 12/20/25 at 11:30 AM, V4 (Certified Nursing Assistant) said, I am familiar with R3 and R4, and I never seen them having any disagreement or fighting. I found out about the incident when I came back to work. On 12/21/2025 V7 (Registered Nurse) was the nurse for R3 and R4 on 11/07/25, the day of the incident. V7 is out of the country and unable to communicate at this time, but the V7 written interview stated that V7 did not witness any incident between R3 and R4. V7 interview said, he did not know about the incident until the police came, and he said he did not receive any complaints. On 12/21/2025 at 2:02 PM spoke with V1(Administrator) via telephone and said, I am very familiar with R1 and R2; both residents have no boundaries and will just say things that are hurtful to others. Care plan in place for the behaviors. We investigate and take any abuse allegation seriously, and I reported both incidents to the state surveying agency and completed a full investigation. The facility separated all the residents and made sure that they were not together. R1 and R2 are on totally different sides of the building, and R3 was moved to the first floor, and R4 remained in his room. We are doing more education for the staff. On 12/21/2025 at 2:00 PM, V3 (Director of Nursing) said, I am aware of the incident of R1, R2, R3, and R4, but V1 was the one who completed the investigation and can better provide details. All residents have behaviors documented under their care plan, and staff members are aware to monitor them and make sure that they redirect residents and report any behavior or abuse allegation. On 12/ 21/2025 at 2:00 PM, V3 (Director of Nursing) provided facility policy titled Abuse and Neglect, revised 06/26/25. Which reads in part (but not limited to),Policy Statement:It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to presentation of abuse and timely and thorough investigation of allegations. These guidelines include compliance with the seven federal components of prevention and investigation.Abuse is the willful infliction of mistreatment, injury, unreasonable confinement, intimidation, or punishment. Abuse assumes intent to harm, but inadvertent or careless behavior done deliberately that results in harm may be considered.1. Physical AbusePhysical Abuse includes, but not limited to infliction of injury that occurs other than by accidental means and requires medical attention.2. Verbal AbuseVerbal Abuse includes, but is not limited to, the use of oral, written or gestural language. The definition includes communication that expresses disparaging and derogatory terms in language to residents within their hearing/seeing distance.

Based on interview and record review, the facility failed to honor a resident's (R4) right to refuse medication by crushing the medication and putting it into the R4's food without R4 being aware for one out of three residents reviewed for resident rights in a total sample of eight. Findings Include: R4 has the following diagnosis: generalized anxiety disorder, auditory hallucinations, catatonic disorder, noncompliance with medical treatment, and paranoid schizophrenia. On 12/2/25 at 2:18PM, R4 was sitting alone at a table in the dining room participating in the scheduled activity. R4 requested to stay in the dining room for the interview. R4 was alert and oriented times three. R4 denied any issues with medications or medication regimen. When asked if the facility forces, R4 to take scheduled medications, R4 said, no. The surveyor then asked if R4 ever found medications crushed up in R4's food and R4 said, Yes, it happened one time. R4 stated it occurred sometime in October but was unable to give an exact date or even a date range. R4 reported it happened at the lunch meal. R4 stated one day R4's food tasted funny so R4 thought the staff put R4's medication in the food. R4 report R4 saw crushed pills in the food. R4 denied reporting this allegation to anyone at the facility but called R4's guardian and the police. R4 reported R4 refuses medications because R4 doesn't need them. When asked how this makes R4 feel, R4 stated it makes R4 angry because if R4 doesn't want to take a medication then R4 shouldn't have to take it. R4 denied any other concerns at the facility. On 12/3/25 at 12:46PM, V4 (Psychotropic Nurse) stated R4 is on psychotropic medication for a diagnosis of schizophrenia but has a behavior of refusing the medications. V4 reported R4 doesn't have a reason for refusing and staff will educate or will offer the medication again to R4 if R4 refuses. V4 stated the facility never expects nurses to crush the medication and put it in food if a resident refuses. V4 reported it is a resident's right to refuse a medication. On 12/3/25 at 1:21PM, V7 (Registered Nurse/RN) stated R4 has a habit of refusing medication so V7 will offer the medication again to R4 later in the shift. V7 denied ever putting crushed medications into R4's food. V7 reported R4 is alert but has a guardian since R4 has psych diagnoses. V7 stated R4 doesn't have any behaviors if R4 refuses the medication and V7 will call to update the guardian if R4 refuses the medication. On 12/3/25 at 2:44PM, V10 (R4's Guardian) stated on 10/14/25, V10 spoke with R4 on the phone and R4 alleged a nurse crushed medications and put it in R4's food after R4 refused the medication. V10 stated V10 then called V7 and V7 admitted to crushing all the scheduled medications the day before and putting them in R4's food. V10 stated V10 told V7 that if R4 refuses the medication then they shouldn't be given to R4. V10 reported V7 apologized and told V10 that it won't happen again. The surveyor then interviewed V7 (RN) on 12/3/25 at 3:03PM to clarify statement in the previous interview. The surveyor made V7 aware of V10 statements of V7 admitting to putting the medications in food. V7 then admitted to crushing medications and putting them in R4's breakfast on 10/13/25 or 10/14/25. V7 stated V7 doesn't like when R4 refuses the scheduled medication and V7 found a way to get R4 to still take the medication. V7 reported that morning R4 refused the medication when offered earlier so all morning medications were crushed and put into oatmeal. V7 denied being aware how much of the oatmeal R4 ate. V7 reported if a resident refuses a medication, then staff should offer the medication again at a later time. V7 stated V10 spoke with V7 on the phone about consent and V7 told V10 that V7 will not put medications in R4's food again. The surveyor asked V7 what the seven rights of medication pass are and V7 was able to name five rights that were the right person, route, meds, reason, and dosage. The surveyor asked if a resident should be aware of what they are taking at all times and V7 said, yes. On 12/3/25 at 3:17PM, V11 (Administrator) stated V11 didn't make any notes about V7 giving crushed medications in food because V11 didn't think of it that way. V11 reported the facility does not teach staff to put medications in resident food if they refuse. V11 stated V11 hasn't looked at the medication policy in a while so V11 was unaware of what the medication rights were but reported R4 has a right to refuse medication. On 12/3/25 at 3:43PM, V12 (Director of Nursing) stated the facility crushed medications and put them in R4's food one time in August after getting clearance from the guardian (The guardian was not V10 at that time), but it was only one time. V12 reported the guardian's instructions were to only put the medication in the food one time then allow R4 to refuse the medication if R4 does not want to take them. V12 stated the facility cannot force a resident to take medications if they refuse. V12 reported R4 is alert and oriented but is delusional. V12 denied being aware of R4 being given any medication in food in October. On 12/3/25 at 4:03PM, V7 (RN) stated V7 called the guardian in August to get clearance to put the medication in the food then but it was only for one time. V7 reported R4 didn't notice the medication in the food in August but did notice the medication in the food when V7 did it in October. V7 said, I hope you see where I was trying to come from. I was just trying to make sure he took his meds. V7 stated V7 didn't go back and chart R4 took the medication on the Medication Administration Record because V7 didn't know how much medication R4 consumed. A General Progress note dated 8/28/25 documents R4 refused to take medication as ordered. Staff notified the state guardian and ask to call back. A state guardian called back and was made aware. The guardian gave verbal consent that medication may be mixed with food on this day.A General Progress note dated 10/13/25 documents R4 was alert but confused. R4 refused to take all medications after the nurse offered many times. R4 was educated in the importance of taking all medication but still refused. The nurse practitioner was made aware.A General Progress note dated 10/14/25 documents R4 refused all morning medication. The state guardian was made aware.A Psychotropic note dated 10/30/25 documents no behavior or mood concerns were reported by staff. R4 has had no deviations from baseline. R4 is intermittently noncompliant with medication. Today R4 was cooperative with prompting and reported doing fine. The Care Plan dated 12/25/24 documents R4 required psychotropic medication to help manage and alleviate agitation, aggressive behavior, and anxiety. An intervention includes to have the nurse carry out medication management regimen as prescribed and report any changes or complications to the physician or psychiatrist as appropriate.The Care Plan dated 7/10/25 documents R4 is challenged by mental illness and experiences psychosis. The Care Plan dated 10/14/25 documents R4 demonstrates cognitive impairment related to a diagnosis of mental illness and medical complexities. R4 has a guardian. An intervention includes staff will coordinate requests made by my guardian and will contact my guardian for appropriate treatment consent/authorization. The Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score as 15 (no cognitive impairment).The Physician Order Summary documents ordered medications. An order was placed that nurses may crush medications if appropriate and mix with soft food. There is no order that medications must be put in food if R4 refuses to take the medication.The Medication Administration Record (MAR) dated 10/2025 documents R4 had a total of five times during the month where R4 refused the medication. On 10/13/25, the morning or 9AM scheduled medications were Risperdal 1 mg tablet, Xarelto 20 mg tablet, senna-plus 8.6-50 mg tablet, and Ativan 0.5 mg tablet, and it is charted as DR- drug refused. The Psychotropic Management Program Comprehensive Evaluation date 10/27/25 documents R4 currently takes two psychotropic medications daily. R4 has poor medication compliance. Non-pharmacological interventions that should be attempted are redirect R4, remove R4 from a situation to ensure safety, allow venting, and activity involvement.The State Guardian Letter dated 1/24/25 documents R4 needs a state guardian for care management which will be permanent.The policy titled, Medication Pass, dated 7/2/25 documents, Policy Statement: it is the policy of the facility to adhere to all federal and State regulations with medication pass procedures. Procedures.7. PO meds:.b. Crushed medications must now be done separately. Each pill is crushed in an individual cup, applesauce added, and given to the resident. The cup must be completely cleaned out or it is considered an incomplete dose.e. After medication is administered to each resident, sign MAR that it was given.The State of Illinois Department on Aging Resident's Rights for People in Long-term Care Facilities was provided by the facility and documents, Your facility must make reasonable arrangements to meet your needs and choices.V12 denied having a policy that included the seven medications rights or a different policy on resident rights.

Based on interview and record review, the facility failed to supervise a resident at high risk for falls during patient care by leaving the resident alone for staff to obtain supplies and then finding the resident on the ground. The facility failed to train staff on identifying residents at risk for falls. The facility also failed to implement measures to prevent falls from happening. These failures affect 1 (R9) of 4 residents reviewed for falls in the sample of 45. These failures resulted in R9 being emergently transferred to the hospital and admitted with a left femur fracture that required surgical intervention. Findings include: R9 is an [AGE] year-old with diagnoses including but not limited to dementia, heart failure, severe morbid obesity, absence of right leg above knee amputation, and oblique fracture of left femur. Hospital records dated 3/7/25 titled Operative Reports authored by V10 (Surgeon) reads in part, Patient is obtunded and confused. Alert and oriented x 2. Notes reflect that she fell in facility 3/2/25. Had pain in the left thigh last couple of days when admitted and x-rays to left femur demonstrate distal third femoral shaft fracture. She recently had an AKA (Above Knee Amputation) on the right side, so she needed her left side to transfer to wheelchairs therefore decision was made to undergo open reduction intramedullary nailing of the left femur. On 3/18/25 at 10:25 AM, V5 (Fall and Psychotropic Nurse) stated that she had completed R9's fall investigation and conducted the interviews to get root cause of the fall. V5 indicated that during her internal investigation, she was told by V6 (Certified Nursing Assistant/CNA) that she was in the room with the resident and was told V7 (Agency Nurse) that R9's colostomy was leaking, so she went there to check and told the CNA she was going to get the supplies. While waiting for the nurse, R9 was allegedly lying flat on her bed when V6 (CNA) went to get extra linens right outside the room. V6 went to get the linens and left the resident on the bed. Surveyor asked V5 whether the CNA in question left the resident unattended. V5 stated, Yes, but she wasn't left unattended very long. Surveyor asked if she witnessed this incident to know the length of time the resident was left alone. V5 stated, No, this happened around midnight. Surveyor asked what the CNA should have done when caring for a high fall risk such as R9. V5 stated, V6 (CNA) should have prepared the supplies prior to propping the resident up to clean her and not leave her unattended. On 3/18/25 at 10:40 AM, V6 (CNA) stated, I started working at the facility about 3 weeks ago, so I did not know the resident (R9). I was making rounds, and she was sitting up in bed and the bed was already raised up and her gown had feces on it from her colostomy bag, so I went to clean her up and laid the bed flat. I went to reach for my pad to clean her so I can change the beddings and then I heard her scream. I was at the doorway reaching for a pad and I rushed back into the room and found her on the floor. Surveyor asked that if she had to rush back to the room would imply, she left the room to begin with. V6 responded, But the cart was just outside the doorway. Surveyor asked if there was any sort of padding the resident may have fallen on to cushion her fall. V6 replied, No, there was nothing under her. Her head was at the foot of the bed slightly under the bed. Surveyor clarified how she was able to reach for supplies without leaving the resident unattended. V6 stated, My linen cart was in the hall outside the door, but you can say I left her unattended, but it was very fast. Surveyor asked if she knew anything about the resident prior to working with her. V6 said, I know she is alert, and she can ask for things, but I was not told anything about her. When I got hired, I oriented for 3 days but on all floors each day. Surveyor asked if she was aware that R9 recently had a leg amputation. V6 stated, No. They said she just got back from the hospital the day before. Surveyor asked whether she knew R9 was at high risk for falls. V6 stated, When I was working with her, I was not familiar with her at all, and no one told me whether she was a fall risk or not. No one told me anything about her at all. On 3/18/25 at 10:50 AM, V7 (Agency Nurse) stated, I've worked here (referring to the facility) about a dozen times, and I float. When I worked with (R9), it was probably the second or third time. The night of her fall, I had just come in for my shift 11 PM to 7 AM and I was doing rounds and replacing oxygen humidifiers on various rooms, and I went into R9's room and found V6 (CNA) there trying to clean the resident's colostomy, but it needed to be replaced. I looked to see if there were any colostomy bags in the room but there weren't any so I told V6 to finish cleaning R9 up and that I'd be back with a new colostomy bag after finishing my rounds and replacing humidifiers. When I was about finished with my rounds, I heard the call light buzzing and it was R9's room. When I got into the room the resident was on the floor at the foot of the bed with her head under the footboard part and both legs were facing outward. Surveyor clarified if she was certain of her description as R9 had only one leg, V7 stated, Yes, she had her legs extended facing the window and her head was slightly under the bed. I asked V6 what happened, and she told me she had to get supplies to clean the resident. Surveyor asked if she was given formal training by the facility about fall prevention. V7 stated, I wouldn't call it formal training, but they provided orientation packet to take home and that was last year. Surveyor asked if she received any endorsement from the previous nurse about R9's current condition or risk for falls. V7 stated, I did not get any endorsement about R9 or that she came back with an amputated knee. I just knew she recently got back from the hospital, but I didn't know for what. On 3/18/25 at 12:02 PM, R57 (roommate of R9) said that she heard R9 screaming on the ground but did not see the resident fall. R57 stated, I was awakened around midnight when (R9) was screaming loudly. I pulled the call light so someone would come in to help her. R57 said that she had seen V6 (CNA) come into the room to take the resident's gown off and saw the same CNA again when R9 started screaming. Minutes later, R57 indicated she saw the nurse V7 come in and then later saw paramedics take the resident out. Records show the R57's BIMS (Brief Interview for Mental Status) score of 15 showing her to be cognitively intact. On 3/19/25 at 1:04, V12 (attending physician) stated that the facility called him when R9 fell so he gave the order to send the resident out and that she came back with a femur fracture. V12 stated, I don't follow the resident when they're admitted to the hospital. I was just informed by the facility about the fall which happened just days after the amputation of the right leg. They (the facility) told me she slid out of the bed and was found on the floor. (R9) is high risk for falls but she was already at risk prior to this latest fall with fracture. Surveyor asked if R9 required extra precautions due to her new amputation. V12 agreed and said that they should have taken extra precautions because she had dementia, severe morbid obesity, and was a recent leg amputee which made her more at risk and unstable (poor trunk control). R9's fall prevention care plan prior to her most recent fall of 3/2/2025 was revised last on 4/14/2023 and reads, (R9) is at risk for falls related to history of CVA, diagnosis of epilepsy, diabetes, peripheral vascular disease and overactive, osteoarthritis, psychotropic medication, and unsteady balance. Goal: Prevent further falls until next review. Interventions: Keep call light within reach when in bedroom or bathroom. Side rails up to prevent rolling out of bed. Skilled Rehabilitation Therapy evaluation and treatment as indicated. Use of Assistive device during ambulation to prevent falls. Post fall care plan dated 3/11/25 reads, (R9) is high risk for falls related to recent hospitalization with surgical intervention, right AKA (Above Knee Amputation), recent fall with fracture to left femur. Goal: R9 will not sustain serious injury through next review. R9 will be free of falls through next review. Interventions: I prefer to keep all needed items like water pitcher, tissue box, urinal, etc., within reach. I prefer to keep the bed in the low position for safety. I would like PT (physical therapy)/OT (occupational therapy) to evaluate and treat me as ordered to increase my strength and mobility and prevent further falls. Please make sure that my call light is within my reach and encourage me to use it for assistance as needed. I would like staff to address my needs with a prompt response to all requests for assistance. Facility fall prevention policy titled Know how to prevent Resident Falls reads in part, Frequent Rounding: Orient resident to the surroundings, Ensure resident is sitting properly in chair and/or bed at right height. Anticipate resident's needs. Place call light and frequently used items within reach. Assist with toileting needs, mobility, and ADL's. Pay close attention to residents at high risk for falls. They may have had an actual fall prior to admission or have a diagnosis that make them high risk for falls.

Based on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program by failing to refer a resident with a newly evident or possible serious mental disorder or related condition for a level 2 review due to new mental health diagnoses. This failure applies to two (R2 and R78) of two residents reviewed for PASRR screening. Findings include: 1.) R2 is [AGE] years of age and was admitted to the facility on [DATE]. Current medical diagnoses include but are not limited to 1. Vascular Dementia, Unspecified Severity, With Other Behavioral Disturbance, 10/18/2024. 2. Nightmare Disorder, 2/27/2024. 3. Generalized Anxiety Disorder, 8/1/2023. 4. Vascular Dementia, Severe, With Psychotic Disturbance, 8/1/2023. 5. Post-Traumatic Stress Disorder, Unspecified, 12/3/2021. 6. Major Depressive Disorder, Recurrent, Unspecified, 2/8/2021. 7. Unspecified Psychosis Not Due To A Substance Or Known Physiological Condition, 2/6/2021. 8. Hallucinations, Unspecified, 2/2/2021. On 03/19/25 at 01:06 PM, V2 (Director of Nursing) was inquired of R2's PASRR (pre-admission screening and resident review) screening. V2 said, They don't have a Maximus PASRR. Since they've been here a long time, OBRA (Omnibus Budget Reconciliation Act) screening was done, instead. I thought OBRA was sufficient. I did not know Maximus had to get done. On 03/19/25 at 01:44 PM, V9 (Director of Admissions) was inquired of R2's PASRR (pre-admission screening and resident review) screening. V9 said, Both (R2 and R78) were admitted before Maximus became enacted. PASRR screenings were not a requirement for admission. If it's a bed hold of ours there is no requirement to return. Case management at hospital will not be necessary to create one. If change in condition or change in mental status, then we do create one. If they are diagnosed with a mental illness while at the facility, then we will order a PASRR screening. V9 was inquired of the need of screening for other facility residents. V9 said, Yes, I have a list of other residents that are to be screened due to having a new diagnosis. R2's OBRA-I Initial Screen: 1. Date: 02/02/2021. 2. No reasonable basis for suspecting DD or MI. 3. Screening indicated nursing facility services were appropriate. 4. Screening certified by Department on Aging. R2's pertinent medical diagnoses after admission include: 1. Vascular Dementia, Unspecified Severity, With Other Behavioral Disturbance, 10/18/2024. 2. Nightmare Disorder, 2/27/2024. 3. Generalized Anxiety Disorder, 8/1/2023. 4. Vascular Dementia, Severe, With Psychotic Disturbance, 8/1/2023. 5. Post-Traumatic Stress Disorder, Unspecified, 12/3/2021. 6. Major Depressive Disorder, Recurrent, Unspecified, 2/8/2021. 7. Unspecified Psychosis Not Due To A Substance Or Known Physiological Condition, 2/6/2021. 8. Hallucinations, Unspecified, 2/2/2021. V9 (Director of Admissions) presented a PASRR Level I screen done 03/19/2025 at 12:56 PM for R2 after being inquired of a PASRR screening. 2.) R78 is [AGE] years of age and was admitted to the facility on [DATE]. Current diagnoses include but are not limited to PTSD (Post Traumatic Stress Disorder) 01/21/2025, Vascular Dementia, Unspecified Severity, with Other Behavioral Disturbance 10/01/2022, Other Specified Depressive Episodes 04/01/2022, Delusional Disorders 08/07/2021. On 03/19/25 at 09:00 AM V1 (Administrator) provided R78's OBRA (Omnibus Budget Reconciliation Act) initial screening from the Illinois Department of healthcare and Family Services from 06/18/2021. Screening indicated nursing facility services are appropriate. The individual has been formally diagnosed with a mental illness verified by a DSM-IV (Diagnostic and Statistical Manual of Mental Disorders 4th Edition) classification which substantially impairs the person's cognitive, emotional and/or behavioral functioning, excluding organic disorders/dementia, developmental disabilities, and alcohol/substance abuse- yes. V9 (Director of Admissions) presented a PASRR Level I screen done 03/19/2025 at 12:56 PM for R78 after being inquired of a PASRR screening. On 03/19/25 at 01:01 PM, V2 (Director of Nursing) was inquired of R78's preadmission screening and resident review. V2 said, We don't have a PASRR for her (R78), only the OBRA. V9 (Director of Admissions) is putting it in now. I didn't know we had to do a PASRR (preadmission screening and resident review) screening. On 03/19/25 at 01:51 PM, V9 (Director of Admissions) was inquired of PASRR screenings for R2 and R78. V9 said, I started in August of 2023 and received training on PASRR screening. Any new admissions from the hospital case managers do the screenings. If the resident has a change in condition, a new mental health diagnosis a PASRR screening would need to be done to see if it triggers a PASRR 2 screening. I didn't know the residents that were already here needed to be screen when the new PASRR screening started. R2 and R78 need to be screened because of their new diagnoses. V9 was inquired of the need of screening for other facility residents. V9 said, Yes, I have a list of other residents that are to be screened due to having a new diagnosis. On 03/19/25 at 2:20 PM, V2 (Director of Nursing) was asked to provide this surveyor a copy of V9 (Director of Admissions) list of other residents that required a PASRR screening for review. There are 18 residents listed as requiring PASRR screening.

Based on interview and record review the facility failed to ensure a resident was free from significant medication error for 1 of 3 residents (R3) reviewed for medications in the sample of 8. The findings include: R3's Physician order sheet (POS) dated 1/25 show R3 has diagnoses that include anxiety, rheumatoid arthritis, depression, and bipolar disorder. The same POS show R3 has an order of Lorazepam (Ativan) 0.5 milligram (mg) give 1 tablet every 8 hours at: 6AM, 2PM and 10 PM for anxiety. On 1/10/25 at 9:15 AM, R3 was in bed alert and pleasant. R3 said she had missed her Ativan medications in the past. R3 said she has anxiety. On 1/10/25 at 9AM, V12 (Registered Nurse/RN) said on 1/4/25 she was R3's morning shift nurse. V12 (RN) said she got in report that R3 missed her 6AM dose of Ativan on 1/4/25. V12 said the pharmacy was wanting a signed script. V12 said she took care of the issue that day. R3's Ativan came around 4PM on 1/4/25. R3 got her Ativan dose of 2PM at 4PM (when the medication was finally delivered.) V12 (RN) who was with this surveyor reviewed R3's Electronic Medication Administration record (EMAR). R3's EMAR show on 1/3/25 timed at 2200 (10PM), R3's Ativan was marked as UV-(unavailable) R3's EMAR show on 1/4/25 timed at 0600 (6AM) marked as UV-unavailable. V12 said unavailable means the medication (Ativan) was not available, therefore the resident did not receive her anti-anxiety medications. On 1/10/25 9:49 AM, V13 (License Practical Nurse/LPN) said he was the night nurse last 1/3/25. V13 said he got in report that R3's Ativan was not available. R3 did not get her 10 PM dose. At around midnight (1/4/25), he was surprised that paramedics arrived at the facility looking for R3. R3 called 911 due to not receiving her Ativan dose. R3 said she was having withdrawals and was wanting to be sent to the hospital. R3 also said she had a full-blown anxiety attack months ago due to not taking her Ativan and she was afraid this can happen again. R3 was then brought to the emergency room (ER) via 911. R3 was discharged back to the facility in the morning of 1/4/25. On 1/10/25 at 8:50 AM, V13 (local Emergency Response Team/EMS) said he was one of the CMS that responded to R3's call. They were at the facility last 1/4/25 past midnight responding a call from a resident (R3). R3 called 911 herself and said she was having anxiety attack due to not receiving her anti-anxiety medications. R3 was anxious, nervous, and tense. R3 wanted to go to the hospital. R3 was taken to the ER for treatment. R3's Emergency Notes dated 1/4/25 show R3 was diagnosed with generalized anxiety disorder. R3 was discharged back to the facility. Discharge instructions include refill R3's antianxiety medications (Ativan). On 1/10/25 at 1PM. V2 (Director of Nursing) said staff should ensure residents medications including antianxiety were reordered with script timely. R3's care plan dated 12/13/24 show (R3) requires psychotropic medication (Lorazepam) .to help manage and alleviate anxiety and depression with bipolar disorder. The facility policy entitled Medication Pass dated 8/16/24 show, it is the policy of the facility to adhere to all Federal and State Regulations with medications.

Based on observation, interview, and record review the facility failed to provide residents weekly showers for two of three residents (R2 and R3) reviewed for showers in the sample 11. Findings include: The facility's Shower and Hygiene Policy dated 8/19/24 documents, It is the policy of this facility to ensure that resident showers/hygienic care is provided by the nursing staff to promote cleanliness, provide comfort to the resident and observe the condition of the resident's skin. Administer resident shower once weekly and/or as often as necessary. Documentation: Date and shift the shower was performed. The name/title of the nursing staff who assisted the resident with the shower/bath. 1. R2's MDS (Minimum Data Set) assessment dated [DATE] documents R2 needed staff assistance for hygiene and showers. R2's Shower/Bathing and Skin Monitoring Report dated 6/29/24 (Admission) through 7/31/24 documents R2 only received two showers within this timeframe on 7/10/24 and 7/27/24. On 9/20/24 at 4:40 PM V4 (R2's Family Member) stated, (R2) no longer resides at the facility. Whenever I would visit (R2) he was dirty, and his hair was greasy. (R2) was not getting showers. 49187 2. R3 was readmitted from the (Local Hospital) on 9/4/24. R3's MDS dated [DATE], documents R4 has a memory problem, is moderately impaired for daily decision making, is unable to ambulate, and requires maximum to dependent staff assistance with ADL's (Activities of Daily Living). R3's Shower/Bathing and Skin Monitoring Report dated 9/4/24 through 9/19/24 documents R3 only received one shower within this timeframe on 9/16/24. On 9/20/24 at 8:45 AM R3 was lying in bed. R3 did not respond to verbal stimuli. R3's hair was unkempt and all R3's fingernails were long, jagged, and had brown matter underneath. R3 was still in a facility gown and had a putrid smell. On 9/20/24 at 9:30 AM V17 (Certified Nursing Assistant) verified R3's long nails with black matter underneath them. V17 stated, I am getting ready to give (R3) a bed bath now and I will clip and clean her nails. On 9/2/204 at 2:00 PM V2 (Director of Nursing) verified R2 and R3 (according to shower reports) did not receive at least one shower per week. V2 stated, According to facility policy they should at least receive one shower per week. The staff should also be clipping and cleaning residents' fingernails on shower days at least.

Based on observation, interview, and record review the facility failed to follow their policy and procedure related to infection control by not wearing appropriate personal protective equipment (PPE) in resident rooms who required contact isolation and by not practicing hand hygiene while performing incontinence care for a resident. This failure applied to three of three (R82, R275, R277) residents reviewed during review of facility infection control practices. Findings include: Per contact isolation log dated 04/2024, shows R275 on contact isolation for MRSA in the urine and R277 on contact isolation for VRE in the urine. 1.) On 4/1/24 at 1:20PM, V9 (Dialysis Social Worker) was observed entering R275's room not wearing any PPE. V9 sat on the edge of R275's bed next to R275 to have a discussion. 2.) On 4/2/24 at 12:40PM, V11 (Director of Rehab) was observed to be in R277's room not wearing a gown. V20 (family member) was also observed entering R277's room without putting on any PPE and without performing any hand hygiene. V20 was then observed leaving the room and going to the nursing station to speak with staff without performing any hand hygiene. On 4/2/24 at 1:40PM, V21 (Infection Preventionist) was interviewed regarding contact isolation expectations. V21 said my expectation is that prior to entering the room of any resident who is on contact isolation, no matter who it is: staff and visitors should perform hand hygiene with hand sanitizer and put on a gown and gloves. Prior to exiting the room, they are to take PPE off and perform hand hygiene. Family is informed of this when a resident is put on isolation and there is also a sign and PPE placed outside of the door for them to utilize. Policy titled Infection Prevention and Control with last revision date of 10/23/23 states in part but not limited to the following: 2. Contact Precaution- intended to prevent transmission of infectious agents spread by direct or indirect contact with patient or the environment. Use of gown and gloves is necessary prior to room entry. Residents are restricted to leave the room except for medically necessary procedures and appointments. 49740 3.) R82 is a cognitively impaired [AGE] year-old resident with diagnosis listed in part, but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia following cerebral infarction, vascular dementia, and type II diabetes mellitus. On 04/03/2024 at 9:57am, V22 (Wound Care Coordinator) said R82 has poor appetite, does not eat through the mouth, is being fed via a g-tube, has low albumin levels, used to have pitting edema, which is now controlled, has moderate to severe atherosclerosis, venous insufficiency, and had sepsis that resolved with antibiotics. On 04/03/2024 at 12:15pm, surveyors observed perineal care done for R82 by V13 (Certified Nursing Assistant/CNA) and V14 (Restorative Aide). V13 and V14 donned gowns, gloves, and masks prior to entering R82's room. R82 was laying on an air mattress, which was covered by one sheet. R82 was moved toward the head of the bed by V13 and V14. The wound dressing on R82's sacrum was partially loose. R82's soiled brief was removed by V14 and thrown into a trash can. V14 placed a new disposable brief on R82 but left it open. V13 used cleansing wipes to clean R82's perineal area, then (petroleum jelly) was applied by V13 to R82's buttocks and the disposable brief was taped close. Surveyor observed every time V14 removed gloves while performing perineal care for R82 and noted that V14 did not perform hand hygiene before putting on new gloves. After the perineal care was completed, surveyor asked V14 to review the steps taken when performing perineal care for R82. V14 said, sorry for not performing hand hygiene between glove changes. V14 added that they did not have hand sanitizer at their disposal during R82's perineal care and was nervous. Per the facility's hand hygiene policy, dated 07/28/2023, hand hygiene using alcohol-based hand rub is highly recommended before and after direct resident contact, after performing an aseptic task, and before moving from work on a soiled body site to a clean body site on the same resident. Also, the policy states, the facility will comply with the CDC guidelines in regard to hand hygiene. Per CDC Website, Hand Hygiene in Healthcare Settings the following recommendations are: The Core Infection Prevention and Control Practices for Safe Care Delivery in All Healthcare Settings recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) include the following strong recommendations for hand hygiene in healthcare settings. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: -Immediately before touching a patient -Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices -Before moving from work on a soiled body site to a clean body site on the same patient -After touching a patient or the patient ' s immediate environment -After contact with blood, body fluids, or contaminated surfaces -Immediately after glove removal Healthcare facilities should: -Require healthcare personnel to perform hand hygiene in accordance with Centers for Disease Control and Prevention (CDC) recommendations -Ensure that healthcare personnel perform hand hygiene with soap and water when hands are visibly soiled -Ensure that supplies necessary for adherence to hand hygiene are readily accessible in all areas where patient care is being delivered -Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and, in the absence of a sink, are an effective method of cleaning hands.

Based on observation, interviews and record reviews, the facility failed to ensure that call lights are answered in a timely manner per policy. This deficiency affects four (R1, R12, R13 and R14) of four residents reviewed for accommodation of needs. Findings include: 1.) R1 was admitted on [DATE] with diagnoses of Displaced Fracture of Base of Neck of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing; Difficulty in Walking, Not Elsewhere Classified; Unsteadiness on Feet; Need for Assistance with Personal Care and End Stage Renal Disease. R1's MDS (Minimum Data Set) dated 05/25/23 under Section C indicated that her BIMS (Brief Interview for Mental Status) score is 15 which means intact cognition. R1 was discharged to home on 06/02/23. According to concern form dated 05/28/23, she (R1) complained of poor call light response during night shift. V1 (Administrator) stated during interview on 06/13/23 at 2:59 PM that R1 was talking about call light responses that she waited for longer periods of time because she wanted staff to respond quicker. V1 continued, It happened more on the night shift. She mentioned that night shift did not respond quicker. I did education on call light. 2.) R12 was initially admitted in the facility on 05/23/23 with diagnoses of End Stage Renal Disease; Shortness of Breath; Difficulty in Walking, Not Elsewhere Classified and Unsteadiness on Feet. On 06/14/23 at 12:26 PM, R12 was observed in her room, alert and oriented. Her call light was observed within her reach. R12's BIMS score is 15 which means intact cognition, per MDS dated [DATE]. R12 was asked regarding issues on call lights. R12 stated, This early morning, I pushed the call light around 3, 3:30 AM and no one came to my room until around 5:00 AM. I waited for an hour and a half to two. No staff cared to respond to my call light. Concern form dated 05/29/23 documented R12 complained that she was not satisfied with the call light responses from staff. 3.) R13 was admitted with diagnoses of Nondisplaced Zone 1 Fracture of Sacrum, Subsequent Encounter for Fracture with Routine Healing and Dependence on Supplemental Oxygen. On 06/14/23 at 12:35 PM, R13 was observed in her room, lying in bed, on continuous oxygen at 3 lpm (liters per minute) via nasal cannula. Her call light was within her reach, by bedside rail. Per MDS dated [DATE], her BIMS score is 9 which means moderately impaired cognition. R13 was asked if she has any concern with staff responding to her call light. R13 stated, It was during night shift, staff don't come when I pushed the call light. I need to go to the bathroom, but no one came so I just got up and walked to the bathroom. And I have this oxygen in me. It was 2:30 AM that I used my call light, but no one checked on me and came to my room until next shift came. According to concern form dated 06/12/23, she (R13) complained that it took too long for staff to respond to her call light. 4.) R14 was admitted on [DATE] with diagnoses of Other Specified Arthritis, Left Shoulder, and Other Muscle Spasm. On 6/14/23 at 12:41 PM, R14 was observed in room, lying in bed, alert, oriented and verbal. Her call light was at bedside and within her reach. R14 was asked if she must wait longer time for staff to come to her room when she pushed her call light. R14 replied, Sometimes staff come to my room when I pushed the call light but a lot of times they don't. I waited and waited for an hour or more. It depends on who the CNA (Certified Nurse Assistant) is assigned to me. R14's MDS dated [DATE] indicated a BIMS score of 9 which means moderately impaired cognition. On 06/14/23 at 12:57 PM, V2 (Director of Nursing) was asked regarding call light response time. V2 replied, All staff is responsible to respond to call lights. It should be responded within 5-10 minutes, the acceptable time because some staff or CNAs are still assisting other residents. I expect that anybody who could see the call light on, it should be responded. Even when staff is walking the hallway, call light should be responded in a timely manner. Facility's policy titled Call Light Policy revised date 7/27/22 stated in part but not limited to the following: Policy Statement: It is the policy of this facility to ensure that there is prompt response to the resident's call for assistance. The facility also ensures that the call system is in proper working order. Procedures 1. Facility shall answer call lights in a timely manner.

Based on observation, interview and record review the facility failed to have the State inspection survey results available and accessible to the residents. This deficiency affects four residents (R12, R39, R75 and R110) in the sample of 28 reviewed for Resident right to Survey results. Findings include: On 11/2/22 at 10:23am, Resident council meeting held with 4 residents in attendance. R12, R39, R75 and R110. During the resident council meeting all 4 residents said that they don't know where the results of the State Inspection is located. All said that they have not seen the signage for the location of the survey results. All said that there is no posting or signage on the facility's bulletin board. On 11/2/22 at 11:10am, V1 Administrator informed of above concerns. V1 said that due to construction the posting or signage is not in place at the front deck. They usually place the signage and the location of the State Inspection/Survey results on the front desk. She said she will take care of it. On 11/2/22 at 12:54pm, Round made to the all bulletin boards on units and front desk. No posting/signage indicating the location of State inspection survey result. On 11/2/22 at 3:38pm, Rounds made with V1 Administrator to the front desk to show that there is no postage /signage indicating the location of State inspection survey result. V15 Receptionist said she does not know where the State Inspection Survey result binder is. V1 said that is supposed to be in here but due to construction she does know where it is located. Unable to locate the Survey result binder in the front desk. V1 said that she will have it available by tomorrow. Facility's policy on Resident Rights Long Term Care indicates: As a long term care resident in Illinois, you are guaranteed certain rights, protections and privileges according to state and federal laws. *You have the right to see reports of all inspections by the IDPH from the last five years and the most recent review of your facility along with any plan that your facility gave to the surveyors saying how your facility plans to correct the pro

Based on observation, interview and record review the facility failed to implement fall care plan interventions for residents who are at high risk for falls. The facility also failed to formulate new fall care plan interventions based on root cause analysis of resident fall incident. This deficiency affects all three (R15, R20, R39 and R79) residents in the sample of 28 reviewed for Fall prevention management. Findings include: 1. R79 is readmitted on [DATE] with diagnosis to include Wedge compression fracture of first lumbar vertebrae, Systemic involvement of connective tissue, Unsteadiness on feet, Need for assistance with personal care, Reduced mobility, Low back pain, Repeated falls, Contusion of right knee, Pain in hip, Fusion of spine lumbar region, Deforming dorsopathies, Collapse vertebra thoracic region, Fracture of shaft of right fibula, Fracture of part of right clavicle, nondisplaced fracture of acromial process right shoulder, [CONDITION(S)], History of falling, Primary [CONDITION(S)]. R79's most recent fall assessment dated [DATE] indicates at high risk for falls. R79's care plan indicates she is at high risk for falls related to anxiety disorder, cognitive impairment, decline in functional status, hearing impairment, impulsivity or poor safety awareness. Intervention: Keep the bed in the low position for safety. R79 has 5 fall incidents dated 6/5/22, 6/16/22, 7/1/22, 7/25/22 and 8/28/22. On 11/1/22 at 10:38am, V9 LPN said that R79 is on high risk for fall monitoring. R79 had several fall incidents. On 11/1/22 at 11:45am, Observed R79 lying in bed in a high position. Called V9 LPN and showed observation. V9 said that R79's bed should be on the lowest position. V9 put the bed on the lowest position. On 11/1/22 at 12:13pm V13 Agency CNA said that she fed R79 for breakfast. She probably forgot to put down the bed after she feds her. V13 is aware that R79 is at high risk for fall. On 11/1/22 at 2:30pm, V5 Fall coordinator informed of above observation, V5 said that they are expected to follow the fall intervention prevention. 2. R39 is readmitted on [DATE] with diagnosis to include Bilateral primary [CONDITION(S)] of knee, Difficulty walking, Pain in bilateral knee, Type 2 Diabetics Mellitus, Anxiety disorder, [CONDITION(S)]. R39's fall risk assessment dated [DATE] indicated at high risk for falls. R39's care plan indicates at high risk for falls related to depression, impaired balance, impulsivity or poor safety awareness, [CONDITION(S)]. R39 had fall incident on 9/22/22. R39's post fall investigation root cause analysis completed by V5 Fall coordinator indicated that on 9/22/22 at 1:30pm Therapist reported that R39 had a fall incident outside the facility (front door) and before they could get to him, he already got inside the cab. (Per V5 Fall coordinator, the therapist saw it from the window). R39 returned to the facility at 3:30pm. Assessment was done, noted abrasion on his right knee lateral side, no active bleeding. R39 said that the car arrived in front of the building to take him to his dental appointment. R30 told to the cab driver that he was bringing his wheelchair inside and will come right out. The driver started driving away and resident tried to go after the cab, walking too fast. R30 took a stumble and got up by himself. R30 able to catch up with the cab by the side of the street and got inside the cab to go to his appointment. R30 has poor functional mobility related to bilateral knee [CONDITION(S)] and poly [CONDITION(S)]. He has impulsive behavior related to [CONDITION(S)], [CONDITION(S)] disorder and restlessness and agitation contributing to his risk. Intervention to address incident: R39 was reminded to use his assistive device at all times. He was referred to PT/OT to evaluate and treat as ordered to increase his strength and mobility and prevent further falls. Fall intervention formulated not related to the root cause analysis. R39 does not have staff supervision/assistance when going into the cab/taxi for his medical appointment. On 11/2/22 at 9:53am Informed V2 DON (Director of Nursing) of above concern regarding R39's fall incident, root cause analysis and fall interventions. R39 was not supervised getting into a cab when going out for his dental appointment. V2 said that staff should physically be present to supervise resident getting into a cab or any transportation going to medical appointments for safety. On 11/2/22 at 10:28am, R39 said that he had a fall last Sept when going to his dental appointment. He said that he tried to catch up with the cab driver and stumbled and fell . He said no staff assisted him. 3. R20 is readmitted on [DATE] with diagnosis to include Nontraumatic intracerebral hemorrhage, [CONDITION(S)] with behavioral disturbance, History of falling, Type 2 Diabetes Mellitus. Most recent fall assessment done on 10/18/22 indicated at high risk for falls. R20's care plan indicates resident is at high risk for falls related to Anxiety disorder, Cognitive impairment, impulsivity or poor safety awareness, Dementia, [CONDITION(S)]. R20 had 2 fall incidents: 9/3/22 unwitnessed fall with injury. R20 found in the dining room lying on the floor. R20 sustained a hematoma above her right eyebrow. She was sent out to the hospital and admitted with intracranial Hemorrhage. R20 returned to the facility on [DATE]. On 10/18/22 R2 had an unwitnessed fall without injury. R20 found sitting on the floor next to her bed. She was sent out to the hospital and admitted with [CONDITION(S)]. R20 returned on 10/25/22. On 11/1/22 at 11:36am, Observed R20 up in B**** chair (Tilt in space positional chair) in the dining room. She is confused and unable to be interviewed. On 11/2/22 at 11:00am, V5 Fall coordinator said that they evaluated R20 for B***** chair (Tilt in space positional chair) on 10/28/22 for safety because she always leaning forward attempting to pick up from the floor. V5 said that R20 was placed on the chair on 10/28/22. Informed V5 that R20's fall care plan was not updated of new intervention implemented. V5 said that she thought V6 Restorative Nurse updated it because she is the one who evaluated the chair for R20. Facility's policy on Fall occurrence indicates: It is the policy of the facility to ensure that resident is assessed for risk for falls, that interventions are put in place and interventions are re-evaluated and revised as necessary. Procedures: 5. The Falls Coordinator will review the incident and may conduct his/her own fall investigation to determine the reasonable cause of fall. 8. The Fall coordinator will add the intervention in the resident's care plan 4. On 11/2/2022 a Post Fall Investigation/RCA Investigation indicated that R15 had an unwitnessed fall on 10/22/2022 at 7:15pm resulting in R15 sustaining a bump/swelling to her right forehead with minimal bleeding. The certified nursing assistant-cna had assisted the resident to the toilet after dinner and the resident was brought back to her bedroom. The cna placed R15 in front of her television-tv with her call light in reach in her wheelchair. An Admission Record indicated that R15 has a diagnosis of Non-traumatic Subdural Hemorrhage Unspecified, Repeated Falls, [CONDITION(S)], Unspecified Severity, with-other Behavioral Disturbance. A care plan dated 9/27/2022 for R15 had a focus of high risk for falls, and an Intervention of (I would like staff to move me close to the nurses' station for closer observation). On 11/3/2022 at 11:30am V5(Fall coordinator) said that all interventions should be followed as placed on the care-plan. On 11/3/2022 at 12:00pm V4(Director of Nursing-DON) said if a resident has an intervention to place at the nurses' station, I expect staff to follow all interventions as placed on the care plan and recommended.

Based on observation, interview, and record review, the facility failed to dispose of expired house stock medications on first floor team 1 medication cart, dispose of opened enteral feeding and medication for R19 in second floor medication refrigerator, and failed to document the open date on an inhaler for R42 in second floor team 1 medication cart. This observation was made in two of three medication carts and one of two medication rooms observed for medication storage and labeling. Findings include: On [DATE] at 1:00PM during observation, first floor team 1 medication cart was observed with the following: 1. House stock [MEDICATION(S)] sodium 8.6mg (milligrams) tablet with manufacturer's expiration date of ,d+[DATE] 2. House stock Guaifenesin 400mg tablet with manufacturer's expiration date of ,d+[DATE] 3. House stock Ibuprofen 200mg tablet with manufacturer's expiration date of ,d+[DATE] On [DATE] at 1:15PM during observation, second floor medication refrigerator was observed with the following: 1. R19's aluminum hydroxide 3.15 grams mouthwash suspension with note that reads Do not use after [DATE] 2. Tube feeding formula 1500 mL (milliliters) bottle with open date of ,d+[DATE] On [DATE] at 11:55AM during observation, second floor team 1 medication cart was observed with R42's [MEDICATION(S)], [MEDICATION(S)], vilanterol inhalation powder 100 mcg (micrograms)/62.5 mcg/25 mcg with no open date and label that reads Discard 6 weeks after opening foil tray. On [DATE] at 1:10PM, house stock medications were observed with V3 (Director of Nursing) and stated that it should have been removed from the medication cart as soon as it expired. On [DATE] at 1:20PM, tube feeding formula bottle and aluminum hydroxide mouthwash suspension were observed with V9 (Licensed Practical Nurse) and stated that it should have been discarded as soon as it expired. On [DATE] at 11:55AM, [MEDICATION(S)], [MEDICATION(S)], vilanterol inhalation powder was observed with V17 (Registered Nurse) and state that there should be an open date to determine the discard date. R19's face sheet dated [DATE] indicated admitted [DATE] and discharge date and time of [DATE] 18:00 (6:00PM). R42's Order Summary Report dated [DATE] indicated admitted [DATE]. Facility Policy: Title: Medication Storage, Labeling, and Disposal Revised:[DATE] Policy Statement: It is the facility's policy to comply with federal regulations in storage, labelling, and disposal of medications. Procedures: 1. Medications from pharmacy will be labeled by the pharmacy to include . expiration date when applicable. 2. House stocks designed for multiple administration will be labeled with the name of the medication, the strength, instruction, and expiration. The information from the manufacturer is enough to meet this requirement And the medication automatically expires based on the expiration date based on the manufacturer's guidelines.

Based on observation, interview and record review the facility failed to ensure that the isolation cart was stocked with adequate (Personal Protective Equipment-PPE) for 4 of 7 residents (R13, R14, R23, R114) and the facility also failed to ensure hand hygiene was performed in between changing gloves for 2 of 3 residents (R23, R102) reviewed for infection control in a sample of 28. Findings include: 1. On 11/1/2022 at 11:30am the surveyor observed R13 Isolation sign on door indicating contact isolation, the isolation cart outside the door did not have gloves or hand gel, only isolation gowns. On 11/1/2022 at 11:50am V4(Assistant Director of Nursing-ADON) said the Isolation cart should be stocked before entering the room and began to place supplies on the cart. On 11/3/2022 at 9:30am V3(Director of Nursing-DON) said all Isolation carts should be always stocked with Personal Protective Equipment-PPE. On 11/4/2022 An Order Summary Report dated 11/1/2022 indicates R13 is on Contact precautions for (ESBL-Extended spectrum beta-lactamase) of the urine. A care-plan intervention dated 3/22/2021 contact precautions include (gloves, gown, goggles, and biohazard supplies). On 11/1/2022 at 11:33am the surveyor observed R14's Isolation sign on door indicating contact isolation, the isolation cart outside the door did not have gloves or hand gel, only isolation gowns. An Order Summary Report dated 11/1/2022 indicates an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A care-plan Intervention dated 10/18/2022 Contact precautions include Gloves, gown, mask, goggles, and biohazard supplies. On 11/1/2022 at 11:36am the surveyor observed R23 Isolation sign on door indicating contact isolation, the isolation cart outside the door did not have gloves or hand gel, only isolation gowns. An Order Summary Report dated 11/1/2022 indicates that R23 has an order dated for 6/28/2022 for Isolation-Single room/contact precautions, reason for isolation: ([CONDITION(S)] [CONDITION(S)]-resistant Staphylococcus aureus) in the wound. A care-plan Intervention dated 6/29/2022 Contact precautions include: (gloves, gown, mask, and biohazard supplies). On 11/1/2022 at 11:40am the surveyor observed R114's Isolation sign on door indicating contact isolation, the isolation cart outside the door did not have gloves or hand gel, only isolation gowns. An Order Summary Report dated 9/30/2022 Isolation-contact precautions, reason for isolation (VRE-[MEDICATION(S)]-Resistant Enterococcus) of the urine. A care-plan intervention dated 10/22/2022 Contact precautions include gloves, gown, mask, goggles, and biohazard. Facility Policy: Infection Prevention and Control Dated: revised on 7/28/2022 Policy Statement: The facility has established a policy to identify, record, investigate, control, test, and Prevent infections in the facility. The facility will maintain a record of incidents and corrective actions implemented for the identified infection. Procedures: 7. A transmission-based precaution set up will be provided outside the resident's room to provide Personal Protective Equipment (PPE) like gown and gloves to staff and visitors entering the resident's room. 2. Contact Precautions-A. Single room is required. B. Use of Gown and gloves is necessary for all interactions. 2. On 11/02/2022 at 11:51AM during observation, V17 (Registered Nurse) was observed administering medication to R42 with gloves on. After giving R42's medication, she removed her gloves and came out of the room. She was then observed wearing another set of gloves and prepared to perform a blood glucose check on R102. After performing the blood glucose check, V17 was observed removing gloves and went out of the room. She then wore another pair of gloves to wipe the glucometer machine with disinfecting wipe, removed gloves, donned another pair of gloves and wrapped the glucometer machine with disinfecting wipe. She was observed removing her gloves and putting on another set of gloves to retrieve result on another glucometer machine and wiped the second glucometer machine with disinfecting wipe. She removed her gloves and donned another pair of gloves to wrap the second glucometer machine with disinfecting wipe. She again removed her gloves. She then proceeded to push her medication cart to R23's room door. She wore gloves and prepared the blood glucose check supplies to be used for R23. She went into the room and performed blood glucose check on R23. She then discarded the used supplies, and removed her gloves. She donned another set of gloves and wiped the glucometer machine with disinfecting wipe and wrapped the glucometer machine with another disinfecting wipe then removed her gloves without performing hand hygiene afterwards. On 11/02/2022 at 12:13PM, V17 said that she should have performed hand hygiene in between changing gloves but failed to do so. On 11/02/2022 at 2:16PM, V3 (Director of Nursing) stated that hand hygiene should be performed in between changing gloves. R23's Order Summary Report dated 11/04/2022 indicated admitted [DATE], diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R42's Order Summary Report dated 11/04/2022 indicated admitted [DATE], diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R102's Order Summary Report dated 11/04/2022 indicated admitted [DATE], diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility Policy: Title: Hand Hygiene Revised: 7/28/22 Policy Statement: Hand Hygiene is important in controlling infections. Hand Hygiene consists of either hand washing or the use of alcohol gel. Procedures 1. Hand Hygiene using alcohol-based hand rub is recommended during the following situations: i. After removing gloves .

Based on observation, interview and record review the facility failed to ensure the indwelling urinary bag was placed in a dignity bag for 1 of 2 residents (R282) reviewed for indwelling urinary catheter in a sample of 28. Findings include: On 11/1/2022 at 10:30am R282 was observed in bed with an indwelling urinary bag hanging on side of bed by the door with-out a dignity bag covering. On 11/1/2022 at 10:45am V16 (Registered Nurse-RN) observed with the surveyor R282 indwelling urinary bag not covered with a dignity bag. V16 said the urinary bag should be covered for privacy. On 11/3/2022 at 9:45am V3(Director of Nursing-DON) said all indwelling urinary bags should be covered for privacy. An Order Summary Report dated active as of 11/1/2022 indicated that R282 has an Indwelling Catheter size 16 French with a 30-milliliter balloon, reason [CONDITION(S)]. Facility Policy: Privacy and Dignity Revised: 7/28/2022 Policy Statement: It is the facility's policy to ensure that resident's privacy and dignity is respected by the staff at all times. Procedures: 4. Urine bags will be covered with the use of privacy bags.

Based on observation and interview and record review, the facility failed to place the call light within resident's reach for two of fourteen residents (R33 and R123) reviewed for accommodation of needs in a sample of 28 residents. Findings include 1. During observation on 11/1/22 at 11:30 am, R123's call light was observed underneath R123. R123 stated I need someone to boost me up in bed, but I cannot find my call light. During an interview on 11/1/22 at 11:30 am with V16 (Registered Nurse), V16 stated that the call light should be within the resident's reach. On 11/2/22 at 9:30 am in the conference room, V3 (Director of Nursing) stated that the call light should be within the resident's reach. Facility policy revised 7/27/22 Titled: Call Light Policy reads; Policy Statement, it is the policy of this facility to ensure that there is prompt response to the resident's call for assistance. The facility also ensure that the call system is in proper working order. Procedure; 5. Be sure call light are placed within reach of the residents who are able to use it at all times . 2. On 11/01/2022 at 11:07AM during observation, R33 was observed lying in bed with bed alarm. Wheelchair was observed with chair alarm and call light was observed on the other side of the room on a dresser, out of sight and reach of R33. On 11/01/2022 at 11:10AM, R33 was observed with V18 (RN) with call light out of R33's sight and reach. V18 said that it should be placed within R33's reach and clipped it on R33's gown. On 11/01/2022 at 2:00PM, V3 (Director of Nursing) said that the call light should always be within resident's reach. R33's Order Summary Report indicated admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Care plan last reviewed 09/27/2022 indicated that R33 is high risk for falls and interventions include to please make sure that call light is within R33's reach.

Based on observation, interview and record review, the facility failed to provide privacy while performing a blood glucose check for one (R71) of three residents observed for privacy in a sample of 28. Findings include: On 11/01/2022 at 12:06PM during observation, V18 (Registered Nurse) brought R71 to her room via wheelchair to perform blood glucose check. V18 placed the resident by the wall on the left side across the bathroom just right after passing the door going into the room. She then proceeded with performing the blood glucose check with the door wide open. On 11/01/2022 at 1:25PM, V18 said that it is okay to perform blood glucose check on a resident if the resident is inside the room. She also added that closing the door is not necessary. On 11/01/2022 at 2:00PM, V3 (Director of Nursing) stated that the door should be closed if procedure is to be performed on a resident like a blood glucose check. R71's face sheet indicated admitted [DATE] and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility Policy: Title: Privacy and Dignity Revised: 07/28/22 Policy Statement: It is the facility's policy to ensure that resident's privacy and dignity is respected by the staff at all times. Procedures: 1. During care that requires privacy ., . the privacy curtain will be drawn to provide full visual privacy. Door may also be closed to provide additional layer of privacy during care.

Based on interview and record review the facility failed to provide written notice of a bed hold for three residents (R30, R73, and R94) of six residents reviewed for hospital transfer in the sample of 28. Findings include: R30's progress note on 7/17/22 indicates .patient was sent to (hospital) for sob (shortness of breath) at 1pm on 7/16/22. Patient was also admitted with of Dx (diagnosis) of respiratory distress, ams (altered mental status), and pna (pneumonia). There is no indication that notice of bed hold was sent. R73's progress note of 9/9/22 indicates, resident admitted for further evaluation post fall. The progress note of 9/12/22 indicate, resident admitted to (hospital) 9/9/22 with Dx. (diagnosis) altered mental status, episodes of hallucinations, [CONDITION(S)] HR (heart rate) less than 40, and [CONDITION(S)] (end stage renal diagnosis). There is no indication that notice of bed hold was sent. R94's progress note of 8/7/22 indicates, resident was picked up by ambulance at around 9:30 AM to be evaluated at (hospital). R94's progress note of 8/8/22 indicates, resident's av (arterial-venous) fistula is clogged per np (nurse practitioner) writer is sending resident out to (hospital) emergency room . There is no indication that notice of bed hold was sent. On 11/2/22 at 10:15 AM V3 (Director of Nursing) said, SBAR (situation, background, assessment, recommendation) and interact form is filled out. The nurse calls the doctor for an order to send the resident to the hospital. The family is notified. We notify the family that the bed is held for 10 days. I don't think that we send a notice. Usually the nurses document in the progress notes. A policy titled Bed Hold and Readmission indicates, the facility must inform the resident or family members being transferred of the duration of bed hold in writing.

Based on observation, interview and record review the facility failed to ensure that the oxygen tubing and humidifier bottle was dated and labeled for 1 of 2 residents (R282) reviewed for oxygen in a sample of 28. Findings include: On 11/1/2022 at 10:30am the surveyor observed R282's oxygen tubing and humidifier bottle without a date or label. On 11/1/2022 at 10:40am V16 (Registered Nurse-RN) said the oxygen tubing and the humidifier bottle should be labeled and dated. On 11/3/2022 at 9:40am V3 (Director of Nursing-DON) said all the oxygen tubing and humidifier bottles should be labeled and dated every Sunday and as needed. On 11/3/2022 An Admission record indicated that R282 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An Order Summary Report dated with an order of 10/20/2022 documents Continue 1.5L/min via nasal cannula every shift for [CONDITION(S)]. Facility Policy: Respiratory Therapy Equipment Use Dated:7/28/2022 Policy Statement: It is the facility's policy to ensure that oxygen and nebulizer equipment use is complaint with the acceptable standards of practice. Procedures: 2. Once opened, this equipment will be dated and discarded after 7 days use, whether used continuously or on a prn (as needed) basis.

Based on interviews and record reviews, this facility failed to provide safe transfer assistance to prevent an avoidable fall incident for 1 of 3 (R1) residents reviewed for safe transfers. This failure resulted in R1 being involved in a fall incident while being assisted by staff to the toilet. This fall resulted in R1 sustaining a left distal fibula fracture with subluxation of the left ankle. Findings include: On 10/7/22 at 12:55pm, V7 (Director of Rehabilitation) stated that skilled therapy was working with R1 on bed mobility and transfers. V7 stated that R1 would fatigue very fast during therapy. V7 stated that R1 required two person assist with ADLs (Activities of Daily Living) because R1's level of assistance needed fluctuated between moderate and extensive assistance. V7 stated that skilled therapy recommended staff transfer R1 using a mechanical lift device for R1's safety. V7 stated that this facility does use raised toilet seats for residents as needed. V7 stated that the raised toilet seat sits on top of toilet; it does not attach securely to toilet. On 10/12/22 at 10:00am, V3 DON (Director of Nursing) stated that there is a caregiver book kept at each nurses' station. V3 stated that this book is updated every Friday and as needed to reflect the resident's status. V3 stated that it provides information on each resident, including information on how resident transfers/walks. V3 stated that R1 needed one person assistance with walking. V3 stated that R1's legs gave out and that is the reason R1 fell and fractured an ankle. On 10/12/22 at 11:20am, V25 (Falls Prevention Nurse) presented this surveyor with R1's OT (Occupational Therapy) discharge summary. V25 stated that per OT's discharge summary, dated 8/17/22, R1 required only partial/moderate assistance with toilet transfers. R1's PT (Physical Therapy), OT, and progress notes, dated 8/14/22 through 8/17/22 reviewed with V25. PT and OT noted R1 fatigues easily and required moderate assistance of two persons to take a few small steps from bed to wheelchair. V25 stated that V14 CNA (Certified Nurse Aide) transported R1 to the bathroom door via wheelchair and then walked R1 to the toilet with a rolling walker. V25 stated that V14 should have had another staff member present for R1's safety due to R1's increased fatigue. R1's falls risk assessments, dated 7/23/22 and 8/17/22, were reviewed with V25. V25 stated that on 8/17/22 R1's post falls risk assessment notes R1 was high risk for falls. V25 stated that if a resident has a fall, the resident is automatically a high risk for falls. V25 stated that R1's admission falls risk assessment, dated 7/23/22, notes R1 was at low risk for falls. When asked for clarification on fall history section question, did the resident just have a fall, a recent fall or fall incident that occurred in the past 3 months? V25 was informed R1 fell at home on 7/14/22 and was admitted to this facility on 7/23/22. V25 stated that if R1 fell within past three months, that question should have been marked 'yes' and R1 would have been an automatic high fall risk and fall interventions would have been in place. V25 was informed that R1 had a new diagnosis of [CONDITION(S)] and started on medication for it on 7/19/22 while in hospital. When asked for clarification on medication change section question: has the resident's medication changed in the last 5 days? V25 stated that the nurse should have been marked 'yes' to that question. When questioned if staff check orthostatic blood pressures on residents, V25 stated that the nurse checks and documents in the admission vital sign section. V25 reviewed the admission vital signs documentation, and it does not note R1's vital signs were checked lying down in addition to sitting. When questioned how would the nurse be able to answer the question: Is there a drop in the systolic blood pressure of 20 points or more; if blood pressure is not checked in two different positions per the instructions listed on the assessment? V25 acknowledged that staff should be checking blood pressure lying and standing/sitting before completing this section on the falls risk assessment. When questioned if R1's admission falls risk assessment was accurate, V25 stated 'no'. V25 stated that R1 was high risk for falls and fall interventions should have been in place. On 10/12/22 at 12:30pm, V26 COTA (Certified Occupational Therapist Aide) presented a document, dated 8/4/22, noting R1 required one person assistance and a rolling walker with transfers. V26 stated that after reviewing V26's therapy notes, V26 was unable to find documentation supporting R1 required one person assistance with walking. V26 stated that R1 did exhibit a decline in functional abilities starting on 8/14. V26 stated that this document should have been updated when R1's ability declined. Review of R1's document of skilled therapy's recommendations for ADLs for CNAs, dated 8/4/22, notes R1 required mobility assistive device (rolling walker) for transfers. The section for walking is blank. Review of R1's PT (Physical Therapy) treatment record, transfers refer to: moving from bed to chair and chair to bed. Review of R1's medical record notes R1 was admitted to this facility on 7/23/22 with diagnoses including: polyneuropathy, reduced mobility, lack of coordination, [CONDITION(S)], new onset [CONDITION(S)] (7/19/22), [CONDITION(S)], and history of falling (fall 7/14/22). Review of R1's restorative ADL evaluation, dated 7/23/22, notes R1 is totally dependent on two plus persons physical assistance for transfers. Review of R1's MDS (Minimum Data Set), dated 7/29/22, notes R1's BIMS (Brief Interview of Mental Status) score is 11 out of 15. R1 is always incontinent of bowel and bladder. R1 requires extensive assistance with bed mobility and incontinence care. R1 is totally dependent on two staff members for transfers. Review of R1's PT treatment encounter, dated 8/15/22, notes R1 reports not feeling well and declined to walk. Bed mobility from supine to sit and transfers from bed to wheelchair at moderate/maximum assistance with rolling walker, stand step pivot. On 8/17/22, PT noted R1 seen for continued therapy of bilateral lower extremities in supine position x 20 repetitions with rest period in between due to R1 fatigues easily. R1's sitting balance at edge of bed with increased fatigue for 5 minutes. Sit to stand from edge of bed with rolling walker with moderate assistance of two persons due to increased fatigue, R1 took small steps from bed to wheelchair with rolling walker with moderate assistance of two. Review of R1's OT treatment encounter, dated 8/16/22, notes R1 performed bed mobility, rolling, and scooting up in bed. R1 complaining of not feeling well. R1 sleeping half the day requiring multiple attempts for skilled therapy, discussed with nursing and physician. On 8/17/22, OT noted skilled interventions focused on bed mobility training to increase functional skills, training in supine/side lying to/from sitting edge of bed and training in safe sit to stand/stand to sit mobility. R1 expressed feeling tired today and does not want to get up in wheelchair at this time. Review of R1's progress notes, dated 7/25/22, the physician noted R1 was admitted to the hospital after a fall at home on 7/14/22. Review of R1's falls care plan, initiated 7/23/22, notes R1 is at low risk for falls related to decline in functional status. Interventions identified include: PT/OT evaluation and treatment to increase R1's strength and mobility and prevent further falls and make sure call light is within reach. Review of R1's medical record, dated 8/17/22 at 2:30pm, V15 (Agency Nurse) noted: R1 complained of left ankle pain at this time. R1's physician notified and ordered left ankle x-ray. Order noted and carried out. Outside diagnostic imaging company notified. At 7:25pm, nurse received a call from the diagnostic imaging company that R1 sustained a fracture to the left ankle. Physician made aware and ordered to send R1 to the hospital for evaluation. R1's family member made aware. R1 was transported to the hospital via outside ambulance company. R1 was admitted with fracture to the left ankle. Review of R1's hospital medical record, dated 8/17/22, notes R1 presented to the hospital after a fall in the bathroom this morning. Staff at this facility stated they received a verbal report that x-rays showed a left ankle fracture. Unable to bear weight after the fall. R1 has pain with movement. X-rays noted a left distal fibula fracture with subluxation of the left ankle joint. R1 was admitted for pain management and orthopedic evaluation and treatment. Review of this facility's fall incident report dated 8/18/22, notes R1 was being assisted to the bathroom by V14 CNA when R1 started sliding off the raised toilet seat when R1 tried to sit down. R1 was lowered to the ground. Review of this facility's falls policy revised 5/17/22, notes those identified as high risk for falls will be provided fall interventions.

Based on interview and record review, the facility failed to follow the Comprehensive Class Member Transition Program Informed Consent and schedule a Neuropsychological evaluation appointment. This affected 1 of 3 (R4) residents reviewed for resident rights. Findings include: On 10-11-22 at 10:37 AM, V2 (Assistant Administrator/ Social Worker) said R4 is alert, oriented x3, and able to make her needs known. Ombudsman informed V2 about Neuropsychological evaluation re-scheduled for November 7th. V2 could not find R4's transportation form for Neuropsychological evaluation dated 9-12-22. On 10-12-22 at 10:46 AM, V2 (Assistant Administrator) said R4 has a consent decree. Consent decree is for residents who are able to live in the community under a lower level of care such as assisted living or supportive living or senior apartments. V2 did not hear from the previous Social Worker that R4 had a consent decree. With a consent decree, the facility would be able to assist the outreach coordinator and resident with coordinating services in the community and assisting with the discharge plan. V2 said moving forward, social services will establish communication with the outreach coordinator and facility team. V2 said she would reach out to the [NAME] Williams Program and get a copy of the Consent Decree. V2 presented R4's Comprehensive Class Member Transition Program Informed Consent. On 10-12-22 at 12:00 PM, V2 said (based on an email) R4's outreach coordinator was in contact with the previous Social Service Director about R4's scheduled neuropsychological evaluation for 9-12-22. That Social Services Director transferred to a sister facility and new social worker designee took over. The previous Social Service Director or designee did not mention R4's [NAME] Decree to the other staff. On 10-11-22 at 1:50 PM, V3 (DON) said R4 is alert, oriented x 3-4, and able to make her needs known. R4 did not make staff aware of the Neuropsychological evaluation on 9-12-22. R4 did not attend her Neuropsychological evaluation on 9-12-22. An agency LPN took the order for R4's Neuropsychological evaluation for 9-12-22. The Neuropsychological evaluation was needed by the [NAME] Williams Program. Medicaid residents require 72 hours or more (business days) to arrange transportation. The facility should have notified the ordering MD that transportation requires more time to schedule. V3 said she was not aware of R4 having a [NAME] Williams Consent Decree. On 10-11-22 at 12:52 PM, V18 (Ombudsman) said R4 needed a Neuropsychological Evaluation because it was needed by the [NAME] Williams Program. V18 is aware R4 missed her initial Neuropsychological Evaluation on 9-12-22 and was rescheduled for November 7th. V18 said R4 has a [NAME] Williams Decree, and the case manager was trying to contact the facility social services. V18 is aware of the new social services staff at the facility and will help facilitate the [NAME] Williams case worker geting in touch with facility social workers. On 10-11-22 at 11:51 AM, R9 (Resident Council President) said he heard some complaints about transportation and rides not showing up. Facility will do everything they can do. Facility was using a very unreliable medical transportation in the past. On 10-11-22 at 1:06 PM, R10 (Resident Council [NAME] President) said she has not missed outside appointments personally but has heard of other residents missing their appointments. An email dated 9-14-22 documents the case manager submitted a complaint to the state agency for missing the original appointment. Email documents: Case manager sent R4's original appointment letter to previous facility social worker through MedTunnel on 5-16-22 and she verified she received it and would have it taken care of. Case manager attempted to give a courtesy reminder to facility but was having difficulty getting through to anyone, so they talked to the receptionist on Friday. On 10-7-22, surveyor asked V2 (Assistant Administrator) for a copy of R4's [NAME] Williams Consent Decree and V2 said they did not have a copy. On 10-12-22, the facility provided a faxed copy of R4's Comprehensive Class Member Transition Program Informed Consent dated 2-5-22. R4's Comprehensive Class Member Transition Program Informed Consent dated 2-15-22 was reviewed.

Based on interview and record review the facility 1) failed to supervise a resident who is a high risk for falls. This failure resulted in R3, sustaining a subdural hematoma (brain bleed) and laceration at the back of her head requiring staples. Based on interview, observation and record review the facility 2) failed to put interventions in place for a resident who is a high risk for falls. This failure resulted in R4 sustaining a lumbar fracture requiring hospitalization . This applies to 2 of 4 residents (R3 and R4) reviewed for falls in the sample of 6. The findings include: 1. R3's Physician Order Sheet dated 8/22 show R3 has diagnoses that include dementia of Alzheimer type and [CONDITION(S)]. R3's facility assessment dated [DATE] show R3 is severely cognitively impaired and needs extensive assist with bed mobility and transfers. A Fall Risk assessment dated [DATE] show R3 was a high risk for falls. A progress notes dated 7/2/22 timed at 9:18 PM, V10 (Registered Nurse) documents The writer heard the bed alarm going off .In the hallway while walking towards resident's room heard the sound that she fell . Noted resident on the floor laying on her back and noted moderate bleeding from her head, kept her in same position and placed a pillow under head, Resident stated that she is feeling dizzy but no pain at this time. Vitals done and called 911, [Physician] notified of the fall and POA notified of the fall and injury. Sent to ER. A hospital record dated 7/3/22 show [AGE] year female presented to the emergency department., .[CONDITION(S)], Chronic renal failure, renal transplant known dementia aware of family members but confused as baseline per report, brought in after found on floor in nursing home. Pt had lacerated wound on back of her head. A Radiology report dated 7/3/22 show R3's CT of the head results 13-millimeter mm thick subdural hematoma (brain bleed). R3's hospital admitting diagnosis dated 7/3/22 shows R3 was admitted for traumatic subdural hematoma and scalp lacerations with staples. A Facility Reported Incident-Final, sent to the state agency dated 7/8/22 show that R3 is a [AGE] year old memory care resident .alert and oriented x 1, forgetful and confused. R3 has multiple complex medical diagnoses including [CONDITION(S)] MWF .On 7/2/22 the nurse on duty heard an alarm going off and upon entering [R3's] room, noted resident lying supine (on back) on the floor next to bed with bed on the lowest position. Head to toe assessment was done, noted with bleeding from back of her head. Pressure applied to help stop bleeding .911 was called .No loss of consciousness observed. Resident was sent to the hospital via 911. Staff interview and record review were completed. The same report documents that R3 has poor safety awareness, poor insight on current placement and situation and has impulsive behavior contributing to her risk. R3 was admitted to the hospital with diagnosis of subdural hematoma and laceration with metallic skin staples. On 8/12/22 at 10:30 AM, V10 (Registered Nurse) said she was R3's nurse when the incident happened on 7/2/22. V10 said she was at the nurses station when she heard an alarm going off. V10 said she was not sure where the alarm was coming from. V10 said as she was walking in the hallway, she checked the room by the nurses station where she thought the alarm was coming from but the alarm was not coming from the room. V10 said she continued to walk towards the end of the hallway to R3's room, she heard the sound that R3 fell . By the time she got to R3's room, R3 was already on the floor lying on her back. R3's head was bleeding. V10 said she called 911 and notified R3's physician and family. V10 said R3's room was located quite a way from the nurses station and R3 cannot be observed when staff are in the nurses station. On 8/12/22 at 9:18 AM, R3 was in the [CONDITION(S)] unit receiving treatment. When asked how she was doing, R3 just nodded. At 10:45 AM, R3 was in her room in the Memory Care Unit sitting in her wheelchair. R3 was very agitated trying to wheel herself towards the hallway saying, I am paid, I want to go to the Cafeteria., I want to go to the cafeteria! Help, help I need to go there! repeatedly. R3's room is located at the back of the right side of the 3rd floor hall near the exit door. R3's room is approximately 4 rooms away from the nurses station. R3's room is not visible from the nurses station. This surveyor walked towards the nurses station to look for staff. V7 (Certified Nursing Assistant-CNA) was at the nurses station. V7 (CNA) said she was not aware that R3 was already back from [CONDITION(S)]. V7 also said R3's room is located far from the nurses station and R3 cannot be observed from the nurses station. V7 said R3 has a tendency to transfer herself unassisted to bed so R3 needs to be supervised and R3 cannot be left in her room by herself. V7 said R3 again had a fall less than a week ago. R3's latest care plan show that R3 is high risk for falls due to cognitive impairment, impaired balance during transition, impulsivity, poor safety awareness and muscle weakness. With intervention to include: I would like staff to move me close to the nurses station for closer observation. On 8/12/22 at 10:58 AM V3 (Director of Nursing-DON) said R3 is high risk for falls due to history of having multiple falls. R3 is very confused and very hard to redirect. V3 (DON) said R3 was in the hospital from 7/2/22 to 7/14/22 (12 days) in the ICU for treatment of R3's subdural hematoma. V3 said R3 continues to be impulsive. R3 had another fall after coming back from the hospital. V3 said R3's room is near the nurses station now compared to her previous room. V3 said R3's room used to be in the farthest back on 3rd floor. V3 and this surveyor went to 3rd floor to check R3's room location in relation to the nurses station. V3 confirmed to this surveyor that R3's room is located at the right side of the hallway, near the exit door. R3's room is 4 rooms away and cannot be observed/not visible from the nurses station. On 8/12/22 at 12:22 PM, V15 (Nurse Practitioner) said residents who have a history of falls including falls with injury should be placed in a room near the nurses station where staff can supervise the resident more frequently. The facility policy entitled Fall Occurrence dated 5/17/22 show, It is the policy of the facility to ensure that residents are assessed for risk for falls, that intervention are put in place and intervention are revised and reevaluated as necessary. 2. On 8/12/22 at 9:01 AM, R4 was lying in bed with her electronic tablet. R4 was unable to answer questions related to her falling in June 2022. R4 denied having a fall. There was a disconnected alarm on the floor next to R4's bed. R4's bed was not in a high position, but it was not at the lowest level to the floor. On 8/12/22 at 8:45 AM, V12, RN (Registered Nurse) said R4 is a fall risk and she fell two months ago. V12 said R4 does not have alarms initiated for fall prevention. On 8/12/22 at 11:04 Am, V13, CNA (Certified Nursing Assistant) said R4 is a fall risk. V13 said R4 does not have fall interventions in place, she does not have a chair or bed alarm, she does not use a bed near to the floor and there are no mats to place on the floor next to her bed. V13 said after a resident falls, the nurses verbally inform them, or they look at the Help Book for newly implemented fall interventions. On 8/12/22 at 11:32 AM, V11, Restorative RN, said she is not the second floor manager, but she acts as a resource and has some managerial duties. V11 said R4 is a fall risk and should have a bed alarm and a chair alarm. V11 said R4 is in their falling star program, therefore, R4's bed should be in the lowest position, staff should do frequent rounding on R4 and R4 should have the alarms (bed or chair) in place. V11 said when they implement fall interventions, the interventions are updated every Friday and put in the CNA Help Book. V11 said R4 had a back injury after a fall. On 8/12/22 at 11:59 AM, V14, Fall Prevention Nurse, said R4 had fallen multiple times at home prior to admission to the facility, therefore, she was a high fall risk upon admission. V14 said a care plan would need to be initiated with a focus on fall risk for a patient at high risk for falls. On 8/12/22 at 1:04 PM, V16, RN, said the paramedics brought R4 back from the hospital on 6/16/22 and left the bed in high position. V16 said she was R4's nurse when she returned from the hospital on 6/16/22. V16 said R4 tried to get up, and within seven minutes of her return, the CNA found her on the floor. V16 said R4 had fallen previously, went to the hospital, had a lumbar fracture with surgical repair, and then returned to the facility (on 6/16/22). V16 said she assessed R4 after she fell following her return on 6/16/22 and found no visible injury, but R4 complained of more pain at her surgical site and on her knee, therefore, she sent R4 back to the hospital. On 8/12/22 at 1:19 PM, V3, DON, said when transportation brings the resident to their room, the nurse and CNA need to go there to do vital signs and welcome the patient. V3 said it is the nurse's responsibility to make sure the resident has a call light and the bed is in low position. The facility's CNA Help Book includes the following information: Fall Interventions List 8/5/22 shows R4 should have a bed and chair alarm. Falling Star/Frequent [NAME] List as of 8/5/22 lists R4. R4's Admission Record dated 8/12/22 shows she was initially admitted to the facility on [DATE] and her diagnoses include, but are not limited to, Wedge Compression Fracture of the first lumbar vertebra (onset date 6/20/22), low back pain, repeated falls, Unspecified fracture of unspecified lumbar vertebra, fusion of spine, lumbar region (onset date 6/16/22), and history of falling (onset date 3/1/22). R4's Minimum Data Set (MDS) dated [DATE], shows she has moderate cognitive impairment and requires extensive assistance with bed mobility, transfers, dressing, and toilet use, and is completely dependent on staff for her personal hygiene. R4's Care Plan, not initiated until 6/21/22, shows she is a high risk for falls and interventions include use of a bed alarm to alert staff when resident attempts to get out of bed unassisted, so staff can assist resident and prevent falls. On 7/2/22 the following intervention was added: chair alarm to alert staff when resident attempts to get out of chair unassisted, so staff can assist resident and prevent falls. R4's care plan includes a focus of impaired cognitive function (initiated 3/8/22). R4's Incident Note dated 6/5/22 at 11:37 AM shows R4's husband went to the hall to summon help. R4 was found lying on the floor on her back with her head towards the foot of the bed and her feet towards the head of the bed. R4 complained of lower back pain, and she was sent to the hospital for evaluation. At 11:21 PM on 6/5/22, R4's Progress Note shows staff spoke with the hospital, and was informed R4 was admitted with a diagnosis of a L1-L2 (lumbar) compression fracture. On 6/16/22 at 11:55 PM, V16, RN, documented R4 was found on the floor by an unnamed CNA. V16 documented that R4 was observed sitting on buttocks on floor and complained about having pain on both knees and at her lower back surgical site. V16 sent R4 back to the hospital. On 6/17/22 at 2:15 AM, R4's Progress note shows she was admitted to the hospital with a diagnosis of spinal fracture. On 6/21/22 at 11:10 PM, R4's Physician Progress Note shows the following: .admitted to (hospital) on 6/16/22 after a fall from bed the day she was discharged from the hospital where she was from 6/5-6/16 (2022) .This patient is recently status post pedicle screw fixation (a procedure that stabilizes and connects vertebrae in the spine to bone grafts to certain types of spinal surgery. These connections allow the bone grafts to fuse with the existing bone) for compression fractures, burst fracture T12-L3 . Within hours of discharge, she had a fall at the nursing home and returned to the hospital .the radiologist notes a transverse process fracture of L3 .no further neurosurgical intervention is indicated. R4's Admin Census/Rates document dated 8/12/22 shows she went to the hospital on 6/5/22 and returned to the facility on [DATE], then went back to the hospital on 6/16/22 and did not return to the facility again until 6/20/22. R4's Hospital Records from 6/16/22 titled Clinical Discharge Summary show .Visit Reason- Fall; L1-L2 compression fractures with retropulsion (a retropulsed fragment is any vertebral fracture fragment that is displaced into the spinal canal) .Encounter diagnoses 1. Hip pain: Retropulsion: Spinal compression fracture .Procedures: Spine Lumbar Laminectomy (6/15/22) . R4's Hospital Records from 6/20/22 titled Clinical Discharge Summary show .Visit Reason- Knee pain-swelling; fracture .Encounter diagnoses 1. Knee contusion; 2. Fracture of transverse process of lumbar vertebra .

These failures resulted in two deficient practice statements. 1. Based on observation, interview, and record review, the facility failed to follow their care plan interventions to monitor and supervise a cognitively impaired resident with a history of falls. These failures affect one (R2) of four residents reviewed for falls and resulted in R2 having an unwitnessed fall, then not being monitored according to the plan of care. R2 was subsequently found unresponsive and pronounced dead at the facility. 2. Based on observation, interview, and record review, the facility failed to provide required assistance with bed mobility during incontinence care for one (R1) of four residents in the sample. This failure resulted in R1 rolling out of bed and sustaining a knee fracture and emergent transfer to an acute care hospital. Findings include: 1. R2 was a [AGE] year old cognitively-impaired resident with diagnoses including but not limited to [CONDITION(S)] with behavioral disturbance, right leg below the knee amputation, and end stage [CONDITION(S)]. Care plan dated 3/22/21 states in part: (R2) is high risk for falls related to cognitive impairment, decline in functional status, impaired balance during transitions, missing limbs. Interventions: visually check me every hour, or more frequently as determined by care team; make sure that my call light is within my reach and encourage me to use it for assistance as needed. Records document R2 with a previous unwitnessed fall that occurred on 3/21/21 where R2 was found on the floor beside the bed and on 4/6/21 where R2 was again found on the floor beside the bed. On 6/30/21 at 10:10 AM, V2 (Director of Nursing) stated, (R2) was found unresponsive by the nurse (V11/Registered Nurse/RN) at around 6:00 in the morning and wasn't informed by the previous nurse (V12) that R2 had fallen. (V11) didn't continue any neuro-checks (brief neurological exam) on the resident which the nurse (V11) should have continued. He also didn't inform the doctor or the family {of the fall}. On 6/30/21 at 11:45 AM V12 (RN) stated, (R2) was on the bathroom floor in an empty bedroom at the end of the hall. I was the only nurse on duty and was at the opposite end of the unit from where R2 was found. V18 (Certified Nursing Assistant/CNA) told me she found R2 on the bathroom floor and there was stool on the toilet bowl. I tried to do an assessment of R2 and checked him for injuries, but he is confused so he couldn't tell me what happened. We put him back in his wheelchair and brought him back to his room and put him back to bed. I started neuro-checks on him. Surveyor asked if he heard any alarm go off that drew him to find R2. V12 stated, No, he was heard yelling for help and V18 went in and saw (R2) on the ground in the bathroom and so she called me to tell me and we picked him up from the ground back to his wheelchair. Surveyor asked if he informed the doctor of R2's unwitnessed fall to obtain further orders. V12 stated, I didn't call the doctor or the family because the phones weren't working. I also forgot to endorse (inform) to the next shift nurse (V11) about the fall incident. Surveyor asked what fall prevention measures were in place for R2. V12 stated, I know he's a fall risk and has to be supervised. We just have to watch him more closely that's all. On 6/30/21 at 1:35 PM, V11 (RN) stated, When I started my shift that night at around 11:20 (PM) I didn't get a report from the previous nurse (V12) who was on duty and he already left the building. V12 never told me that R2 fell earlier, so I didn't conduct any neuro-checks or was told anything that happened to him. I found (R2) at 6 AM and he was unresponsive and was drooling. I immediately checked his blood sugar because I knew he was diabetic and received [CONDITION(S)]. I then called 911 and when the paramedics came, I overheard them saying he's already gone. Nursing progress note by V12 (RN) on 6/11/21 at 7:51 PM (written over 13 hours after R2's death) stated in part, This is a late entry of incident on June 10, 2021 at about 8:30 PM to allow for further investigation. As per CNA report, resident was noted calling for help. Staff went immediately to the resident to check. Resident was noted inside the washroom. Resident was in sitting position beside the toilet bowl facing the door. Head to toe assessment done. No visible injuries or bumps noted. Neuro-check every 15 minutes was initiated with resident denying pain when asked upon each assessment. Resident was assisted back to the wheelchair. Resident was assisted back to bed. Neuro-check was continued, initial blood pressure was elevated 172/111 at about 8:30 PM. Blood pressure was monitored and it went down to 139/79 at about 8:45 PM. Resident with no further complaints and slept until the end of the shift. There were no nursing entries written by V12 (RN) to show that he immediately informed the doctor, family, or any facility staff member of the of R2's unwitnessed fall incident that occurred on his shift. Emergency Medical Services record dated 6/11/21 at 6:11 AM stated in part, Responded for the full arrest at facility. Upon arrival paramedics assessed patient to determine no further resuscitation was needed and medical control contacted for a time of death. Scene/body left in care of Police Department Officers. Policy dated 8/2020 titled Fall Occurrence states in part, It is the policy of the facility to ensure that residents are assessed for risk for falls and interventions are put in place to prevent the resident from falling. Those identified as high risk for falls will be provided interventions to prevent falls. If a resident had fallen, the resident is automatically considered as high risk for falls. An incident report will be completed by the nurse each time a resident falls. The falls coordinator will review the incident report and may conduct his/her own fall investigation to determine the reasonable cause of fall. 2. On 7/1/21 at 11:20 AM, V2 (Director of Nursing) stated, We had a fall incident (6/23/21) that I reported to your office regarding (R1). She (R1) is currently in the hospital and we are aware that she got a fracture. V16 (Certified Nursing Assistant/CNA) was changing her brief and (R1) was in a side-lying position when she asked to get some more lotion put on her legs. When V16 reached for the lotion, R1 slid down from the bed and fell to the floor. There was only V16 in the room with her as she only needs one person assist for bed mobility. Facility incident report completed by V10 (Falls Prevention Nurse) wrote (in part), At around 4:40 am, CNA (V16) was changing resident's brief while resident was in bed. Resident was positioned on her right side and had asked the CNA to apply more lotion on her legs before lying on her back. While CNA reached for the lotion, resident was observed sliding off the side of the bed landing on her buttocks. Nurse on duty was notified immediately and upon entering the room, resident was observed sitting on the floor on the right side of her bed with head resting on the side of the bed. Head to toe and range of motion assessments were completed, resident complained of pain to left hip area. 911 was called. Hospital follow-up was done, and resident was admitted with diagnosis of left knee fracture. V16 (CNA) was not available for interview and did not return any calls from surveyor and V2. R1 is an alert and oriented [AGE] year old with diagnoses including but not limited to [CONDITION(S)] disease, Alzheimer's disease, and chronic obstructive pulmonary disease. MDS (Minimum Data Set) dated 4/15/21 documents R1's bed mobility required a 2-person staff assistance to turn and reposition while in bed. Fall risk assessment dated [DATE] documents R1 with a score of 19 and considered high risk for falls (according to the risk assessment provided). There were no prior fall risk assessments shown in the records or provided to surveyor. Care plan revised on 5/19/21 by V17 (Restorative Nurse Director) documents, Resident requires assistance with activities of daily living (bed mobility, transfers, dressing, walking, personal hygiene, eating and toileting). Transfers with mechanical lift & 2-person assist from bed to wheelchair. Bed mobility maximum assist. On 7/1/21 at 11:45 AM, V17 stated, (R1) required a 2-person staff assist to turn left and right while in bed. She is limited in her ability to scoot up the bed and she still needs that 2-person assist. I was informed of her fall out of bed and was told she slid out of bed, but we did not consider her a fall risk. There should have been 2 CNA's (Certified Nursing Assistants) when they were changing her brief. I did hear that there was only one aide. It's possible that the bed was high up too when she was being changed. The one aide had to roll her to her side so that's when she rolled out of bed and fell to the ground. I do not believe she slid to the floor given her injury. emergency room records dated June 23, 2021 at 3:18 PM documents in part, The patient (R1) is an [AGE] year old female who was dropped out of her bed this morning when they were attempting to change her [brief]. She rolled over and fell to the floor, complained of some discomfort to the lower back and buttocks. Diagnostic results: 1. Fracture/dislocation of the distal left femur/proximal tibia (bone above knee/shin bone). Procedure: Fracture/Dislocation. Technique: attempted reduction with traction counter-traction as well as manipulation; without success. Critical Care Note: Patient is unstable at presentation and required my full and direct attention, intervention and personal management for 60 minutes of critical time including time spend performing procedures. There is imminent risk of deterioration of the cardiovascular systems.

Based on observation, interview and record review, the facility failed to ensure that a resident was safely transferred by staff. This resulted in (R1) sustaining a Right Distal Femur Fracture. This applies to 1 of 16 residents (R1) reviewed for falls in the sample of 16. The findings include: R1's Face sheet shows resident is a [AGE] year old female with the following Diagnoses: [REDACTED]. R1's Minimum Data Set (MDS) assessment dated (MONTH) 10, (YEAR) shows R1's cognitive status is severely impaired. The MDS also shows R1 is totally dependent on (2) staff members for transferring resident with mechanical lift. R1's Care Plan dated (MONTH) 1, 2019 shows R1 requires total assistance with transferring related to pain, cognitive deficits and fatigue and requires (2) person assist with mechanical lift related to a decrease in physical activity, weakness and [DIAGNOSES REDACTED]. The Facility's Incident Investigation Report faxed to the Illinois Department of Public Health shows R1 was transferred from her wheelchair to her bed by R1's assigned CNA (Certified Nursing Assistant). Investigation revealed the transfer was done and injury most likely occurred at that time. On (MONTH) 5, 2019 at 10:00 AM, V2 Director of Nursing/DON) stated, R1 is to be transferred via mechanical lift which requires (2) staff members. V10 (Certified Nursing Assistant/CNA) was the one who transferred R1 by himself using the mechanical lift. V2 stated V10 (CNA) transferred R1 on (MONTH) 28, 2019 on his 3 PM-11 PM shift from the wheelchair to her bed and the fracture likely happened then. V2 stated on (MONTH) 28, 2019 on the 11 PM-7 AM shift V11 (CNA) was R1's assigned CNA and noticed R1's right leg was bigger than her left leg and a red mark was on the right side of her right knee. V2 stated V11 told the nurse on duty. V2 stated V12 (Licensed Practical Nurse/LPN) did not do a physical assessment on R1 to determine what the cause of her leg swelling was. V2 stated it was on (MONTH) 29, 2019 at 7:45 AM when R1 was noted with right knee swelling and complaining of pain in the shower room; it was then that an assessment was done. V2 stated R1's change in condition was not reported to the family until (MONTH) 29, 2019 at 7:53 PM, when R1's X-Rays determined R1 had a Right Femur Fracture. R1's X-Ray report dated (MONTH) 29, 2019 shows R1 has an Acute Complete displaced spiral [MEDICAL CONDITION] femoral shaft. R1's Hospital Records dated (MONTH) 31, 2019 shows resident sustained [REDACTED]. On (MONTH) 5, 2019 at 3:55 PM, V4 (R1's Physician) stated R1's injury could have been prevented if the proper handling/standing manipulation was done. V4 stated R1's fracture was not a spontaneous fracture. V4 stated, We see these displaced fractures as being caused by trauma, such as falls, dislocation or some type of mechanical injury that now a resident has to undergo surgery. The Facility's Transfer, Ambulation and Re-Positioning Policy and Procedure dated (MONTH) 2010 shows the facility will promote safety for residents and staff during transfers, ambulation, and re-positioning through the use of body mechanics and safety devices .Transfer status will be based on the number of staff needed to perform the task and/or if a mechanical lift, slide board or other adaptive equipment is required. This information will be recorded on the Caregiver Alert and in the medical record. The Change in Condition Policy and Procedure undated shows: To keep the physician, who is in charge of medical care, and family members/legal representatives, responsible for health care decisions, informed of the resident's medical condition so they may direct the plan of care as needed Notification of the physician, legal representative, or interested family member, should occur promptly, according to federal regulations, when there is a change in the resident's condition.

Based on interview and record review, the facility failed to respect the right to refuse treatment for one (R39) resident reviewed for resident rights in the sample of 30. This failure resulted in R39 feeling a loss of control, anxiety, and emotional distress. Findings include: R39 is an [AGE] year old resident originally admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. According to R39's most recent Minimum Data Set (MDS) assessment completed on 3/21/18, R39 has a BIMS (Brief Interview for Mental Status) score of 14 out of a possible score of 15 (indicating the resident is cognitively intact). R39 is her own guardian and decision maker. In the event R39 is unable to make decisions for herself, R39 has documented Advanced Directives on file which includes designated Power of Attorney (V13) for health care. On 5/22/18 at approximately 1:22pm, R39 was observed sitting in the room watching television. When R39 was greeted by a member of the survey team, R39 said, You know, I wanted to talk to you about something that has been bothering me. A few days ago one of the nurses with blonde hair came and inserted something into me (pointing at the indwelling urinary catheter between her legs). I told her no, but she inserted it anyway. I told her to call my daughter first. She told me she already called my daughter and my daughter said it's ok. The nurse did not call my daughter because after the procedure I called my daughter and she told me no one called her from the facility. R39 stated, I still did not consent to her putting it in me, but she did it anyway. While telling her story R39 started crying saying, I don't think that is right because it's my right and I don't want them putting things into my body (referring to private area) without me agreeing to it. R39 was asked whether the procedure was explained to her. R39 replied, Yes but I don't want anything put in me unless I agree to it. The surveyor asked R39 if anyone was made aware of what happened. R39 stated, The only one I told was V12 (Occupational Therapy Assistant). When this was brought to V1 (Administrator) and V2 (Director of Nursing/DON) they identified the nurse involved as V3 (Registered Nurse/RN). V1 stated this incident was not reported (to V1) and no follow up was done. On 5/23/18 at approximately 12:10pm, V12 stated during interview (R39) told him that a nurse put something in her. (R39) told the nurse not to put it in, but she did it anyway. R39 told the nurse to call V13 (family) but the nurse said, 'I've called V13 and V13 said it's okay.''' V12 explained that R39 then called V13 and V13 said no one called her. When V12 was asked whether this was reported, V12 stated, I did not report this because I thought R39 was talking about a suppository medication. V12 was asked about the facility protocol if a resident verbalizes a concern. V12 replied, I will first ask the nurses or tell the nurses what the resident said and also report it to my direct supervisor and the administrator. On 5/23/18 at between 1:10pm and 1:15pm, both V10 (nurse supervisor) and V11 (Licensed Practical Nurse/LPN) stated, When a resident refuses any treatment and/or medication the physician and the family are notified and the refusal is documented in the resident's progress notes. On 5/24/18 at approximately 9:48am, V3 stated, On 5/18/18 R39 needed an indwelling catheter to be inserted for urine retention after a bladder scan was done. A message was left for V13 (Family) on an answering machine asking V13 to call back. Then the procedure was explained to R39. R39 then asked whether V13 (family) had been informed. V3 explained to R39 that a message was left for V13 on an answering machine. R39 asked what number did V3 leave the message on. V3 stated she went back to the computer and gave the number to R39. V3 further explained that R39 gave her V13's cell number. V3 stated that R39 never said No. V3 stated after the procedure R39 called V3 and wanted V3 to speak with V13 on R39's phone. V3 stated R39 told V13 that an animal was inserted into R39's vagina. V3 stated, I explained the procedure to V13. V3 stated V13 explained that (R39) is confused about the procedure because R39 said an animal was inserted in R39's private part. On 5/30/18 at approximately 12:50pm, upon reaching V13 (family) by phone, V13 stated that R39 is an [AGE] year old lady. V13 stated, Maybe at the time the nurse (V3) was trying to insert the catheter (V3) did not fully explain the procedure to (R39) in a way she (R39) could understand. V13 explained that R39 has gone through traumatic events in her life that has affected her. V13 further explain that the only thing the nurse (V3) could have done differently in her opinion is to have called her (V13) to have her explain the procedure and calm (R39) down. V13 stated R39 is now very upset about the situation and felt she was abused. V13 explained that when R39 called her, R39 was terrified and hysterical, stating an animal was inserted in her private part and that V3 told her V13 gave consent to put the animal in R39's private area. Later when V13 had a talk with V3, V3 explained that she left a message on V13's answering machine but did not know about the cell phone number. Review of R39's behavior care plan (effective 7/13/17 -10/6/2017) list interventions that include but are not limited to, conducting 1 to 1 visits to identify specific thoughts, to educate on resident rights, and validate feelings. R39's care plan for periods of anxiety, verbal distress, and paranoia (effective date 1/2/2018) list interventions that include but are not limited to, conducting 1 to 1 visits that will help R39 identify specific thoughts/ideas that cause anxiety. The facility presented a copy of Illinois Long Term Care Ombudsman Program pamphlet that states, residents of Long Term Care facilities have numerous rights that includes but not limited to rights to refuse treatment.

Based on interview and record review the facility failed to follow its policy for transferring residents and failed to use the recommended sling size and techniques for mechanical lift transfer. This failure resulted in R2 falling to the floor during a mechanical lift transfer and sustaining [MEDICAL CONDITION] that required hospitalization . This applies to 1 of 3 (R2) residents reviewed for falls in the facility from a total sample of 6. The findings include: R2 was admitted to the facility on (MONTH) 17, 2010 with [DIAGNOSES REDACTED]. R2's MDS (Minimum Data Set) dated (MONTH) 10, (YEAR) showed R2 was severely cognitively impaired and R2 was totally dependent on 2 plus staff persons for transfers. R2's fall risk assessment dated (MONTH) 5, (YEAR) showed R2 at high risk for falls;R2 scored 12 on a scale of 10 and above is high risk. R2's care plan for falls showed R2 had balance problems and problems with strength. R2 has cognitive impairment and impaired safety awareness. R2 reaches out for things that are not there. R2's care plan for activities of daily living showed R2 to be dependent on 2 staff persons for transfers. R2's caregiver alert last updated (MONTH) 13, (YEAR) showed staff to use a full body mechanical lift with sling size medium (Red). On (MONTH) 30, (YEAR) at 2:51pm V16 (Restorative Nurse) stated during interview that she performed an assessment on R2 on (MONTH) 13, (YEAR). V16 stated she recommended R2 be transferred using a mechanical lift with a medium sling because R2's weight was 150 pounds. V16 added that the red sling was recommended per the manufacturer recommendations because of R2's weight. V16 also stated that R2 has poor trunk control and V16 cannot tell what could happen if staff used a larger sling size. V16 stated that she would expect that staff use the recommended sling size for R2. V16 stated that while transferring R2, one staff member can operate the machine and the other staff should cradle R2's body in support during transfer using the mechanical lift. On (MONTH) 1, (YEAR) at 2:00 PM V16 stated R2 had a behavior of leaning forward. On (MONTH) 1, (YEAR) at 3:30 PM V15 (R2's Primary Care Physician) stated R2 had very weak upper extremity muscles and poor trunk control. R2 had a behavior of reaching forward. On (MONTH) 23, (YEAR) R2 was hospitalized and admitted to Intensive care unit because of a bleed in the brain due to a hard fall during transfer. On (MONTH) 26, (YEAR) at 3:35 PM V4 CNA (Certified Nurse Assistant) stated on (MONTH) 23, (YEAR) she was assigned to work with R2 and provide care for R2 during the 7:00 AM and 3:00 PM shift. V4 stated that she was transferring R2 from the bed to the wheelchair with the assistance of V11 CNA (Certified Nurse Assistant). V4 stated she placed a sling (blue) under R2 while R2 was on the bed. V4 stated she held R2 at the feet as V11 operated the mechanical lift at the back of the machine. V4 stated that as V11 raised R2 off the bed and brought R2 away from the bed she saw R2 lean forward towards the right side and R2 fell over the right side of the sling to the floor. V4 stated she was not sure if R2 hit her head on the leg of the mechanical lift but R2 was bleeding from the back of her head. V4 stated she did not check R2's care card for the appropriate sling size for R2 when she transferred R2. V4 stated the correct sling for R2 was medium (Red). On (MONTH) 1, (YEAR) at 2:00PM V16 stated she encourages the staff to only use the cross loop connection method when applying the sling. On (MONTH) 1, (YEAR) V2 (Director of Nursing) stated it was expected that the staff use the correct sling size for the resident. V2 said it was expected that nursing staff check R2's care card for the correct sling size and use the sling size that was recommended for R2. The manufacture's procedure guide for the mechanical lift used by the facility dated (MONTH) 2014 showed the cross loop connection method: a) the patient must have predictable, cooperative behavior . The manufacture's recommendations in the sizing and positioning the sling showed that when the correct size of the sling has been determined for the patient, the information should be documented in the patient's record and the information should be communicated to the nursing staff so the proper size sling is used in each transfer of the resident. The mechanical Sling/Belt color chart showed size medium (Red) 110 to 190 pounds average user weight and the size large (Blue) 180 to 250 pounds average user weight. The facility's policy on Mechanical Full Body Lift Safety and Use Procedure #1 (L) showed the lift requires two people to transfer patients. One employee will push the lift and one employee will hold onto the handles of the sling.

Based on record review and interview the facility failed to have staff present at a table to implement the assessed requirement for one person physical assist for a resident while drinking. This applies to one resident (R1) in the sample of 17. This failure resulted in R1 not receiving required supervision while seated in the dining room. R1 had an unwitnessed fall and sustained bilateral femur fractures. Findings include: R1 is a [AGE] year old with [DIAGNOSES REDACTED]. R1 was admitted to the facility [DATE]. Resident's assessments including Minimum Data Set (dated [DATE]) scores R1 needing extensive assistance with activities of daily living. This includes Section G (eating ) scores ,[DATE], one person physical assist for drinking. Resident is alert and oriented X,[DATE] with forgetfulness. R1 lived on the 3rd floor (Memory Care) floor. R1's fall assessment dated [DATE] scored as a high risk for falls. R1 was care planned for at risk for falls due to [DIAGNOSES REDACTED]. Interventions include to remind R1 to call when needing assistance. This care plan failed to include interventions while R1 was seated in wheelchair during day time. Clinical note dated [DATE] reveals at 10:50AM Activity staff (V12) stated that resident (R1) had a fall in the dining room. V18 (nurse) went to the dining room and observed the resident in front of the dining room table, in front of her wheelchair, sitting by her footrest with her knees bent. R1 stated she was trying to reach for the juice and slid off her chair and landed on the floor. [DATE] 1:25PM V12 (Activity Aide) stated, I was in the 3rd floor dining room before lunch. I don't recall how many staff were in the room. There were ,[DATE] residents. I was preparing hot chocolate. I looked back after I heard a noise. R1 was on her knees one foot away from the table. The table in front of her had cranberry juice spilled on it. R1 was confused but didn't display pain. I called the nurse from outside the dining room. The nurse starting assessing her. ,[DATE] other nurses came in and helped R1 back to her chair. Clinical note dated [DATE] 8:43PM stated called hospital ER (emergency room ) for follow up, patient admitted with [DIAGNOSES REDACTED]. Death Certificate reveals R1 expired on [DATE]. Cause of death Complications Of Bilateral Femur Fractures Due to fall from wheelchair. [DATE] 11:20AM R1's Physician (V6) stated, I don't agree with cause of death being Complications of Bilateral Femur Fractures. We could have done surgical intervention but elected not to. R1 was put on Hospice at the hospital due to Alzheimers Disease, [MEDICAL CONDITION] Fibrillation and [MEDICAL CONDITION].

Based on observation, interviews and record review the facility failed to avoid hitting a resident's leg while transporting the resident in a wheelchair for one of five resident (R1) reviewed for accidents and supervision. This failure resulted in R1 sustaining a right tibia and fibula fracture. Findings Include: June 10, 2015 at 12:40 pm, R1 is sitting in special wheel chair in the dining room. Chair back was at a 30 degree angle. R1 has a right leg cast that extends from the foot to the knee. R1 had heel booties on both feet. R1 is severely contracted with the left leg and upper extremities. R1 has a [DIAGNOSES REDACTED]. June 11, 2015 at 9:50 am, R1's was lying back in the special wheel chair while at the table with other residents during activities. R1 was asked to be interviewed and agreed. R1 stated I can't hear so well in my left ear, I can hear you better in my right ear. R1 was wearing a hearing aid in the right ear and responded to questions asked appropriately. R1 was asked what happened to your leg. R1 responded E4 was pushing me in my chair while looking back and talking to another staff. E4 was not looking at what she was doing when E4 ran into the door and hit my foot and leg. E4 is always talking and bumping into something when she pushes me back and forth. It was not intentional. R1's Minimum Data Set (MDS) assessments dated, April 30, 2015 and February 4, 2015 indicated R1 had no significant cognitive impairment and requires two person assist for all activities of daily living. Care Plan - Dated 4/30/15, Self Care Deficit denotes, R1 is a total assist and requires 2 staff assistance for transfer and repositioning. R1 is totally dependent on staff to meet all Activities of Daily Living (ADL) needs. June 10, 2015 at 1:40 pm, E2 (Director of Nursing /DON) stated I did not do the actual interviews with staff in the investigation. E3 (Assistant Director of Nursing (ADON) asked the questions. I did the report to Illinois Department of Public Health (IDPH). E2 was asked how the incident happened; E2 stated I was aware that R1 stated foot was hit by E4 certified nurse aide/CNA). I did not state in the report to IDPH that E4 bumped R1's foot into the door. June 11, 2014 at 10:53 am, E3 stated E4 said while trying to fix R1's booties, E4 noticed R1's right leg was bigger than the left leg. E3 stated E4 took R1 to the nursing station so the nurse could assess R1's leg. E3 stated R1 was interviewed twice to see if R1 would change the story on how the injury happened. E3 stated R1 said E4 ran into the door and hit my foot on the door. E3 stated R1 said E4 and E5 (CNA) were involved in the incident. E3 stated both E4 and E5 was suspended pending investigation. June 10, 2015 at 12:25 pm, E4 (CNA who started working at 7am) stated; I fixed the sling to transfer R1 into the chair like I do every morning. I got help from another CNA to transfer R1, when we transferred R1 into the chair I noticed one of R1' s leg looked bigger than the other. I pulled back the sock to check for redness or bruising. I did not see anything. I put the sock back on R1; I gave R1 glasses and took R1 to the nurse ' s station. I asked the treatment nurse does R1 ' s leg look bigger than the other. The treatment nurse grabbed the foot of R1 a little but R1 pulled back leg indicating pain. The nurse said I am going to call the doctor for an x-ray. That day I was really sick so I did not put R1 back to bed, I went home about 9:30 am. The next day E3 called me and stated I was being suspended for what happened to R1. E3 said R1 stated every time E4 takes me to the dining room I am always bumping R1 ' s feet into the door. Sometimes I will be pushing R1 and looking back answering or talking to someone; the chair rolls all over the place so I will lock the wheels on one side to have better control of the chair. June 10, 2015 at 12:50 pm, E5 (CNA) stated as I was going down the hallway, E4 asked me to help with transfer of R1. R1 was on isolation so I gowned up and went in to help. R1 was already lying on the sling for transfer when I arrived in the room to help. E4 took control of the lift remote, I was guiding R1's feet onto the broad chair; I made sure R1 ' s feet were in good position on the chair and I left the room with E4 still in the room with R1. E5 was asked if the special wheel chairs is hard to control. E5 stated yes the chair goes all over the place and is hard to control. E5 stated we lock the chair on one side to control it better. June 10, 2015 at 1:10 pm, E6 (Treatment Nurse), stated at the beginning of my shift about 7:15 am; E4 asked me to look at R1 ' s right foot and stated that R1 ' right foot looked weird. I went to assess R1 ' s foot but R1 jerked back when I attempted to touch leg. I stopped and told R1 ' s nurse to call the doctor and ask for order to x-ray R1 ' s foot. June 10, 2015 at 1:25pm, 2:50 pm and 3:15 pm several attempts were made to contact nurse on duty. Was not able to reach nurse, several messages were left to contact writer. Clinical Note: Dated June 4, 2014 at 2:09 pm. E4 reported right ankle to be swollen in the a.m. Assessment completed right ankle noted swollen and warm to touch. R1 noted to retract leg when touched. Doctor notified of R1's symptoms. STAT x-rays were ordered to right ankle. Physician ordered Tylenol for pain. Doctor's office called back at 1:45 pm to request resident be sent directly to hospital emergency room (ER) for evaluation. Power of Attorney (POA) notified. June 4, 2014 at 1:05 pm, Z1 (Primary Physician) stated I feel R1 is a good historian at times. I feel R1 did get hurt during a transfer or repositioning. R1 is totally dependent on staff for transfer and all care. No one told me about the CNA bumping R1 only that R1 was found by CNA with swollen ankle. Policy entitled Transfer Ambulation and Repositioning (TARP) revised 2/10 denotes: Investigation of resident injuries which occur during transfers or ambulation should include information regarding the use of all safety devices and safe transfer techniques prior to the incident.

Based on observation, interview and record review the facility failed to identify and prevent facility acquired pressure sores for one resident (R15). The facility also failed to notify the wound care nurse in a timely manner to assist in the prevention and healing of R15's Pressure sores. This resulted in R15 acquiring a stage 3 pressure sore to the right buttocks / thigh area; a stage 2 pressure sore to the coccyx area; and multiple open draining areas on his back and the need for oral antibiotics. This applies to one resident (R15) of 5 residents reviewed for pressure sores in a total sample of 26. The findings include: R15's admission electronic medical record showed he is a [AGE] year old male, has [MEDICAL CONDITION] with [MEDICAL CONDITION] and [MEDICAL CONDITION] of the right arm. R15 also has a history of [MEDICAL CONDITION], chronic indwelling catheter due to [MEDICAL CONDITION] bladder and obesity and has been in the facility since 1997. R15 is shown to be cognitively intact with a score of 15 on his Brief Interview for Mental Status (BIMS) on the 3/19/15 Minimum Data Set (MDS). R15's functional status on the same MDS documents him to need extensive assist from two people with dressing and an extensive assist with one assist for personal hygiene. On 5/27/15 at 10:00 AM, R15 was in his room in bed sitting up finishing breakfast. There was a very strong foul odor in the room. R15 stated the staff have not come to clean him up or change his bedding. R15 stated they usually come in the morning and change his bedding and cleaning once a day. On 5/27/15 at 10:10 AM, E6 (Certified Nurse Aide - CNA) came in R15's room and stated she was going to change his bedding. E6 proceeded to assist R15 with turning on his left side. R15 was noted to be saturated in a foul smelling brownish green fluid from his shoulders to mid thighs on both sides. There were two thick absorbent dressing on R15's right buttock that were also completely saturated with this foul smelling fluid. Under these dressings there were open wounds on the coccyx area and multiple open areas on the right buttock. R15's posterior skin from his shoulder to his mid thighs was completely discolored a dark brown color and open oozing areas. All the linen and mattress were completely saturated with foul smelling fluid. R15 stated he had not been cleaned up since yesterday. E6 stated, I don't know I wasn't here yesterday. E6 then began saying, I can't do this, I can't do this, and began to walk out of R15's room to get assistance while leaving R15 exposed, until called back to cover him. E6 was also asked if R15's nurse could come with her to assess him. On 5/27/15 at 10:10 AM, E6 (CNA), E7 (Licensed Practical Nurse - LPN), E8 (CNA) came back to R15's room. They turned him on his left side. When asked E7 how long R15 had been like this, she (E7) stated she didn't know. E7 stated she need to go and get medicine for R15's wounds and left. E6 proceeded to take a wash cloth and wipe down R15's back when pieces of R15's skin on his back was coming off and bleeding. R15 then stated, Keep going down the spine, it itches. E7 and E9 (Registered Nurse) arrived in R15's room. E9 donned gloves and began washing R15's back and buttocks and sores with the same wash cloth. There was no protective cloth to cover the mattress. E7 also donned gloves and began wiping with a dry cloth across the buttock / coccyx wounds and R15s back. E7 then changed her gloves, no handwashing and began applying an antifungal cream to R15's back. E9 (RN) stated he had been using that anti-fungal cream for at least 2 years. The May 2015 Physician order [REDACTED]. E7 then changed her gloves again, without handwashing, and applied a barrier cream to R15's buttocks and then placed dry absorbent dressings on the area. R15's sheets were then changed and the mattress was never cleaned. R15 had an indwelling urinary catheter. No one provided catheter care or washed his groin area. R15 stated they are supposed to wash the groin area every shift and they don't do it. R15 stated, I get a shower twice a week but I could use it more often, they just don't do it. On 5/27/15 at 10:45 AM, E11 (wound nurse) came into the room and stated, she has not seen R15 in a long time. E11 stated the nurses will ask her to see a resident if they have wounds. E11 stated R15 has had problems with friction and shearing in the past because he refuses to get up and change position. The facility wound Assessment dated 2/3/14 documents the wound was initially identified on 7/19/13. The wound was documented as Moisture Associated Skin Damage (MASD) facility acquired and measured 5.0 cm x 4.5 cm x 0.05 (L x W x D). The last wound Assessment documented 3/14/15 documents the wound size as 10.0 cm x 5.0 cm x 0.05 cm (L xW x D). R15 was not seeing the wound physician at that time. E11 stated the staff nurses were taking care of R15's skin and wound after that and was not diagnosed with [REDACTED]. There is no documentation in the nurses notes concerning R15's skin, malodorous drainage from his wounds and there is also no documentation on what the wounds looked like, the measurements or what type of care was provided to them. R15 had been using the same topical cream to his back for two years and there is no documentation of improvement or worsening of the area and if the medication is effective after this period of time. There is also no documentation to support whether R15's primary physician was aware of the decline in wound status. On 5/28/15 at 10:30 E2 (DON) stated she did not know why the staff nurses did not alert E11 (Wound Nurse ) of R15's worsening wounds. E2 stated it was obvious he didn't get the care he needed yesterday. E2 also stated she did not know why R15 had been on the same topical medication for two years with unknown results and also was not aware of R15's worsening skin condition. On 5/27/15 at 2:35 PM, Z1 (Physician) stated, R15 Refuses care a lot and if he was cooperative this wound could be prevented. Z1 also stated he was aware R15 had a wound caused from a mix of sliding or pressure. Z1 stated he hasn't seen the wound in awhile but would assess it the next day during rounds. It was documented R15's Nurses Notes indicating he refuses ADL care, turning and repositioning, but there is no documentation to show if any one explained and educated R15 with the risks and benefits so R15 could make informed decision to accept or decline care and services. The facility care plan with a goal date of 6/11/15 ( Per E2 on 5/29/15 at 10:00 AM, the care plans are written quarterly so if the goal date is June then the care plan would have been written in April 2015) documents Alteration is skin integrity MASD on ___ Right lower buttocks / Right upper thigh____ related to alter intertriginous. It is unknown what the blank spaces are for and this is repeated in the care plan three times. The interventions listed are to educate resident, treatment as ordered with weekly documentation and bed linen changing. Monitor and report skin changes, changes in drainage , odor or surrounding tissue. Notify physician of failure to respond to treatment. These interventions were not followed. The facility care plan with a goal date of 6/11/15 also documents seven different problems for, At risk for skin breakdown. R15 already had a breakdown in skin integrity and it is unknown if these interventions were re-assessed if not working. The care plan does not mention R15's impaired skin on his back or intervention to improve or promote healing. R15 was seen by the wound physician on 5/28/15 and documented R15 has a stage II pressure sore on the sacrum measuring 8.0 cm x 2.0 cm with moderate serous drainage. R15 also has a stage III pressure sore to the right buttock measuring 9.5 cm x 10.5 cm x 0.2 cm with moderate serous drainage. The treatment was also changed at that time. R15's name was not in the facility list of pressure sores that was given to the survey team on the survey entrance date, 5/26/15. It was on 5/27/15 when the surveyor observed R15's ADL's care, R15's pressure sore was identified for the first time. It was on 5/28/15 when the wound care physician saw R15, his (R15's) Sacral pressure sore was identified as a Stage II (8.0 cm x 2.0 cm) and right buttocks pressure sore was identified as a State III (9.5 cm x 10.5 cm x 0.2 cm). On 5/29/15 R15 was also seen by Z1 (primary physician) and started on oral antibiotics. The facility policy titled Skin Management with a date of 8/2010, documents resident will have a Braden scale done (to determine risk assessment) on admission, re-admission, quarterly, or following a change in status. The earliest documented Braden Score is 4/20/14 and documents R15 to be moderate risk with a score of 14. On 3/11/15 the Braden score was documented at 13, moderate risk. On 5/15/15 the Braden score was documented to be 15, at risk. The skin management policy also documents a head to toe observation will be done on admission, readmission, weekly and during care and areas of concern will be reported to the nurse and physician. The May 2015 treatment notes for the head to toe skin check documents on 5/4/15 no impairment. On 5/11/15 PM shift excoriation and 5/25/15 PM shift impairment. The heading under the skin check states,If skin is impaired, please write a note explaining. There are no notes explaining R15's impaired skin condition. On 5/28/15 at 10:00 AM E2 stated she did not know why it was documented as no skin impairment on 5/4/15 and also does not know why further documentation was not done.

Based on interview and record review, the facility failed to follow manufacturer's guidelines on mechanical lift sling removal for one resident (R1) out of three reviewed for falls and transfer. This failure led to R1 falling from his recliner chair and obtaining a cerebral hemorrhage. Findings include: R1 is a [AGE] year old female who was present in the facility during this incident investigation survey. R1 ' s physician order [REDACTED]. R1 ' s minimum (MDS) data set [DATE] denotes that under functional status, R1 was assessed as 3/3 (extensive assistance) during transfers. R1 ' s occupational therapy notes denote R1 is a 100% total assist with activities of daily living and functional transfers. On 9/23/14 at 1:02pm, E2 (Director of Nursing) stated, " There were two CNA ' s (Certified Nursing Assistants)(E6,E7) that were transferring (R1) from the bed to the recliner chair using a mechanical lift. One CNA was attempting to remove the mechanical lift sling from behind (R1) and the other CNA was in front of R1 while she was in the in recliner chair. One CNA pulled the sling from the back very hard several times. The recliner chair tipped back and (R1) slid back and hit the bottom of her head on the floor, while the other half of her body was still on the recliner chair. They are not supposed to pull the sling from behind. They are supposed to turn (R1) side by side and then remove the sling. Both CNA ' s were disciplined and they and the rest of the house were retrained on proper transferring and how to correctly remove the mechanical lift sling by the restorative aide. (R1) was sent to the hospital. R1 had a bleed in the weak part of the brain where she had the CVA. So the doctor stopped the Coumadin. " E2 submitted sign in sheets by the facility ' s employees for the in-services on proper way to apply and remove a mechanical lift sling from a resident without the appropriate literature attached to the sheets. E2 submitted the facility ' s policy on mechanical lifts which does not indicate how full body slings should be removed. At 1:20pm, E2 stated, " We don ' t have a policy on how mechanical lift slings should be removed from a resident. " E2 submitted the incident report for R1 ' s incident of 9/23/14. Incident report denotes the following: " At 6:45am, E6 called that (R1) was on the floor. On arrival, (R1) was observed to be on her side behind the recliner chair. When asked what happened, E6 and E7 stated that while they were removing the sling from underneath (R1), the recliner chair tilted backward, and (R1) slid off while being held slowly to the floor. (R1) was assessed, repositioned, and assisted back to the recliner chair. Staff was instructed on proper positioning techniques. " Nursing notes dated 9/23/14 indicate Z1 (Medical doctor) gave order to send R1 to nearest local community hospital at 10:29am. At 2:59pm, facility followed up with emergency room staff who stated that R1 was admitted with a [DIAGNOSES REDACTED]. On 9/25/14, R1 was readmitted back to facility with a [DIAGNOSES REDACTED]. Computerized Tomography scan reports indicate that R1 suffered an intercranial hemorrhage on the right temporal lobe in the area of encephalomalacia from a previous stroke. On 9/30/14 at 3:00pm, E5 (Assistant Director of Nursing/ Second Floor Clinical Manager) submitted the initial and final reports of R1 ' s incident of 9/23/14. Final report by E5 denotes the following: " Per staff investigation and reenactment of incident, two staff was in the room performing the transfer. R1 ' s recliner chair was locked. E6 was standing behind the recliner chair and was the one who tried to pull the mechanical lift sling underneath her. E7 was standing in front of R1 and used her foot to hold the bottom part of the chair. As per her observation, E6 pulled the sling a little harder causing the chair to fall backwards. Per demonstration of the incident, staff observed not following appropriate way in removing sling from R1. Root cause of fall: staff not following appropriate way in removing sling from R1. Staff instructions and counseling/disciplinary action was provided immediately, staff involved were retrained on TARP (Transfer, Ambulation and Re-Positioning) trained by Restorative aide for appropriate transfer technique especially with removing the mechanical lift sling out from R1. Facility wide inservice is ongoing on how to properly remove the sling from a resident to prevent further incidents. Random audits to be rendered to determine if staff was following appropriate technique in removing the sling from the resident. " On 9/30/14 at 3:46pm, E5 stated, " I came in early that day. I had E6 and E7 do return demonstrations how they transferred and removed the mechanical lift sling from R1. They never brought R1 forward in the chair and E6 kept pulling and pulling really hard which made the chair fall backwards. On 9/30/14 at 1:20pm, telephone interview was conducted with E3 (LPN, Licensed Practical Nurse). E3 stated, " I was working as the nurse that night. I went to room and I saw (R1) on the floor. Her lower part was on the recliner chair. I called my supervisor who came and checked on her. According to E6, she pulled the sling from the back of her head. The chair started to tilt and (R1) fell . I was told later that the correct way of removing the sling is to turn (R1) side by side. " On 9/30/14 at 2:00pm, Z1 (medical doctor) stated the following: Yes, this accident could have been prevented if the proper transfer techniques were followed. (R1) fell and had a small bleed (cerebral hemorrhage) in the space of the brain where she had a prior stroke. I discontinued her Coumadin. " On 9/30/14 at 2:40pm, E2 came into the conference room and stated, " I ' m sorry. I was wrong. Moving the resident from side to side to remove the mechanic lift transfer sling is not the proper way. The correct way is to come behind the resident and pull straight up to remove the sling. I just talked to the restorative nurse and she ' ll come down in a few to talk to you. Sorry about that. " On 9/30/14 at 2:48pm, E8 (Restorative Nurse) stated the following: " I ' ve been here for three months. The correct way to remove a mechanical lift transfer is to have the resident lean forward. One person should be in front of the resident. The second person should be behind the resident and pull the sling straight up. Based on my restorative knowledge, I know that sling should cover the buttocks of a resident halfway and not entirely. I was not here when (R1) fell , but my best guess would be that sling covered her buttocks entirely. I don ' t have a policy on how to remove a sling. I will try to find one. " At 3:00pm, E2 submitted manufacturer ' s guidelines entitled Care Lift Operations which denotes in part the following: 1.) To position sling, gently lean patient/resident forward. Position sling handles so they face away from patient/resident. Tuck the sling behind the patient/resident until it comes in contact with seating surface. 2.) The sling should touch the seat of the chair, conforming to patient ' s/ resident ' s tailbone area. The top of the sling should rest on patient ' s/resident ' s shoulders, and the center positioning handle should be centered between the patient ' s/resident ' s shoulder blades. " On 10/1/14 at 8:56am, telephone interview was conducted with E6. E6 stated, " Yes, I removed the mechanical lift sling the improper way. E7 and myself did not lean (R1) forward. The sling covered the entire buttocks. It should have gone down, but not covering the entire buttocks. I pulled the sling straight up and the chair fell backward. And R1 slid and hit her head. I was re-inserviced the correct way of removing the sling by E5. " On 10/1/14 at 9:10am, telephone interview was conducted with E7. E7 stated, " I helped transfer (R1) with E6 to the recliner chair from her bed using the mechanical left. I was in front of her. E6 pulled a little too hard on the sling, and the chair fell backwards. (R1) fell down and hit his head. I was re-inserviced by E5 that the correct way is to roll (R1) side to side and remove the sling through the side instead of pulling straight up from behind. " Based on investigation, facility staff did not follow manufacturer's guidelines on removing a mechanical lift sling for R1. This resulted in R1 falling and obtaining a cerebral hemorrhage. Furthermore, there were many inconsistencies from staff interviews in how to correctly remove a mechanical lift sling.

A.) Based on observation, interview, and record review, the facility failed to ensure that 2 of 28 sampled residents ( R23 and R26) do not have multiple falls, have individualized monitoring programs; and the facility failed to revise/review the care plan for effective interventions. This failure resulted in the development of cerebral hemorrhage of one resident (R26) who died . Findings include: 1. R26 was a [AGE] year old who was admitted to the facility on [DATE]. R 26 was able to ambulate independently, though slow and steady. R26 was alert and forgetful at times, continent of bowel and bladder and independent with ADL's (activities of daily living). The [DIAGNOSES REDACTED]. Upon admission, the medications included: Haldol [DATE]mg intramuscular every 3 weeks, Lasix 20mg by mouth daily, Ativan 0.5mg intramuscular or by mouth twice daily as needed for agitation and Tylenol 650mg by mouth as needed for pain. R26 received one dose of Haldol on [DATE] and on [DATE], the doctor ordered Cogentin 2mg intramuscular or by mouth as needed if R26 developed dystonic reaction to the Haldol. R26 received one more injection of Haldol DEC on [DATE]. On [DATE], the physician noted a shuffling gait which the physician stated could have been due to the Haldol or Parkinson's. The physician discontinued the Haldol. It was first documented on [DATE] that R26 was restless,wandering, confused and complained of bilateral leg pain. R26 was given Ativan for restlessness and Norco for pain. On [DATE] at 6:40 AM, R26 was restless and wandering around the nurse's station. On [DATE] at 6:30 AM, the nurse documented that R26 was very restless throughout the night; repeatedly would would get out of bed despite redirection per staff. When R26 had the first fall on [DATE] it was unwitnessed. R26 told the CNA (Certified Nurse Aide), " My roommate was singing. I got up to request her to stop singing, then I fell ." The intervention in place at that time was, having personal items in reach. R26 sustained a laceration to the left eyebrow and left knee abrasion. R26 went to the emergency room for stitches. Added interventions following the fall were : increased monitoring, bed, chair and tab alarm, close to nursing station, non-skid footwear and toileting schedule. On [DATE] at 5AM the nurse documented that the tab alarm was in place but noted that R26 knew how to remove it. There was consistent documentation on R26 being confused and restless with bilateral leg pain. On [DATE], the second fall occurred. R26 was noted lying on the floor near her bed by a CNA. R26 sustained a small abrasion to the right knee. The added interventions following this fall were: low bed, floor pads, psych and physical therapy evaluations and divisional activity. R26 did not go to the E R that night. However, R26 was having difficulty swallowing, anorexia and mental status changes the next day and was admitted to the hospital. The CT scan done on [DATE] stated in part, "There is no acute intra or extra-axial hemorrhage." The third fall occurred on [DATE] at 4:00 PM when R26 was up in the dining room with staff. The nurse documented that the tab alarm went off but CNA unable to reach resident before fall. R26 sustained abrasion to the upper lip. The added interventions were, medication review and a helmet while up, off at bed and mealtimes and a psych evaluation. The half tray was added to the wheelchair on [DATE] On [DATE], the nurse documented that R26 refused to wear the helmet despite encouragement. The helmet was discontinued on [DATE] due to refusal to wear. On [DATE] at 12:25 PM, Z1 was questioned per telephone about the CT scan results and if R26 was at increased risk should she have another fall without a helmet. Z1 said that R26's CT scan was done while hospitalized and would have been managed by another doctor. Z1 said the family also refused the helmet. The fourth fall occurred on [DATE] at 7:50 AM in the dining room. R26 was found lying on the floor on the left side. There was no mention of the alarms / half tray being in place. R26 sustained a 1cm laceration to the upper lip and an abrasion to the left cheek. R26 was not sent to the hospital. Added interventions: medication review and psych evaluate. The lap tray was discontinued on [DATE] due to R26's ability to flip the tray and continue to stand. The lap buddy replaced the half tray on [DATE]. The lap buddy was to be off at mealtimes and activities. The fifth and final fall was on [DATE] at 1:10 PM. On [DATE], 3:55 PM, E9, CNA gave this account of the incident: At around 1:30 the CNA's were cleaning the dining room tables when E9 noticed that R26 had removed one side of the lap buddy. E9 replaced the lap buddy and pushed R26 up to the table. E9 said she moved over 2 tables with her back to R26 and heard R26 fall. E9 stated, "She got up just that fast." E9 said R26 was lying on her back. On [DATE], 3:05 PM, E10,Charge Nurse said R26 was very confused and unable to follow directions. E10 said R26 had been restless since admission, was non compliant with the lap buddy and kept removing it. On [DATE], 2:45 PM, E12 (Clinical Nurse Manager) said that R26 was often anxious, always wanted to walk, pace. E12 said that R26 could remove the lap buddy. E12 said of the last fall, "There was always staff present in the dining room. There were 3 - 4 staff in there that day and they all stated that R26 was facing the window and they all with their backs to her. On [DATE], R26 sustained 2 (2 and 3 cm) lacerations to the back of the head and was admitted to the hospital A CT scan revealed increased hemorrhaging in the left temporal lobe now measuring 3.8 x 2.5cm with an approximate 3mm midline shift to the right. R26 was in the hospital from ,[DATE] - [DATE] when she was transferred to another hospital Hospice Unit and died on [DATE] while in Hospice care. 2. R23 is a [AGE] year old with [DIAGNOSES REDACTED]. One staff present and another entered the room behind surveyor. According to staff, the resident understands little English and speaks Spanish. During a review of incident/accident reports, it is found that R23 has sustained several unwitnessed falls since [DATE] to [DATE]. With four of them occurring within a three month period of time from [DATE] to [DATE] ([DATE], [DATE], [DATE] and [DATE]). Per review of incident reports: - [DATE] at 9:00am, unwitnessed fall in bathroom; - [DATE] at 17:15, unwitnessed fall. Resident noted lying down flat on blue pad next to the right side of bed on the floor; - [DATE] at 10:10, "staff called by family who was with resident and informed that residents slid off the toilet seat" and four days later on; - [DATE] at 7:30am, unwitnessed fall in resident room. Incident report states, "heard alarm and resident calling out for assistance. Upon entering room noted resident on R23's bottom on top of floor mat." One of the incidents ([DATE] at 17:15), resulted in a visit to the hospital for R23. Nurse's notes as written in part states, "[DATE] 5:15pm, resident notes lying down flat on blue pad next to 3rd on floor. [DATE] 8am, resident noted to be groggy. Pupils equal, slow reaction to both pupils noted, weak motor ability to extremities noted." The physician was notified, orders received to send resident to the emergency room . R23 sent to the hospital and admitted [DATE] with [DIAGNOSES REDACTED]. Review of the current (fall) care plan, one of the approaches is "frequent monitoring." The "hourly rounding ticket (s)" for [DATE] to [DATE] different shifts were reviewed, and R23's name is not noted on each of the shift logs. The [DATE] Minimum Data Set (MDS) depicts the resident has cognitive impairment, requires assistance with transfers and toilet use. And needs assistance with activities of daily living. A review of nurses notes from [DATE] at 1:30pm to [DATE], there in no consistent documentation related to frequent monitoring in the notes. There is not an effective intervention and monitoring program for the frequent falls R23 sustained. Interview with E4 (nurse manager) on [DATE] at 2:35pm about R23's frequent fall episodes. E4 states in part, "R23 has a history of frequent/re-current UTI's (urinary tract infection). R23 has ad frequent falls. R23 has confusion and is forgetful at times. R23 continues to try to be independent with activities of daily living, meaning transfers, toileting, things of that nature. Now we have low bed, bed alarm, frequent staff monitoring, tab alarm. Three P's is a rounding tour where the staff make rounds." Surveyor interviewed E1 (administrator) on [DATE] at 3:00pm about making rounds. E1 states, "We did rounds as a campaign and motivation for staff; and we continue to do those will be documented in nursing notes. You (surveyor) won't see them on the rounds sheets." B.) Based on observation and interview the facility failed to eliminate envirnomental factor that expose any of the facility's ambulatory residents to hazards by not ensuring there are non-slipped surfaces in 3 of 3 shower rooms and that a room with a nursing cart is locked or attended by staff. As a result of the facility's failure, one resident (R22) slipped and fell in one of the facility's shower room. Findings include: On [DATE] between 11:10am and 12:09pm, the surveyor conducted an envirnomental tour, while accompanied by E5 (maintenance supervisor) and E6 (corporate maintenance). The following was noted: -The community shower area on the first, second and third floor does not contain any non-slip surfaces in the shower. The surveyor reviewed the facility's incident reports for the last year. [DATE], according to one incident report for R22 documented, R22 fell while in the shower. The summary of what happen documented: CNA (certified nursing assistant) reported that resident fell in the shower room. Resident replied I just slipped and fell but I'm all right. Per CNA, she tried to catch resident but was only able to grab resident on her brief and arm, hence resident still fell on her buttocks and slightly hit her head on the corner of a cubicle frame. -The surveyor with the facility staff entered a room used for the medical supply for the dialysis unit. This room contained multiple boxes of needle sets. The surveyor noted one box of syringe needle was open. In addition, there was a crash cart in the middle of the room. The cart was not locked. The cart also contained needles.