Every finding on record at Bella Terra Wheeling

Based on interviews and record review, the facility failed to follow its abuse policy to ensure one resident (R1) remained free from physical abuse by another resident (R2) in a sample of three reviewed. This failure resulted in R1 sustaining lacerations to the forehead and swelling to the left eye. findings include: R1 is an [AGE] year-old, originally admitted on [DATE] with medical diagnoses that include and are not limited to: Parkinson's Disease, senile degeneration of the brain, and Alzheimer's disease. Minimum data set (MDS) dated [DATE] reads: Cognitive Skills for daily decision making: severely impaired. Per abuse, neglect, exploitation, and trauma assessments dated: 10-31-2019 and 3-7-2025, read: high risk for abuse: R1 has a diagnosis of delusional disorder, gets easily annoyed with others, especially during care, and will push staff and yell. R2 is a [AGE] year-old, originally admitted on [DATE] with medical diagnoses that include and are not limited to: dementia unspecified severity, with other behavioral disturbance, anxiety disorder and non-st elevation myocardial infarction. Minimum data set (MDS) dated [DATE] reads Brief interview for mental status (BIMS), results read of 4/15 impaired cognition. Per abuse, neglect, exploitation and trauma assessments dated: 6-23-2023 and 3-14-2025, read: high risk for abuse: R2 has a diagnosis of dementia, anxiety and other psychotic diagnoses. On 6-22-2025 at 1:40 pm V14 (Registered Nurse) said, on 5-31-2025, I worked 3-11 and 11-7, I had in my assignment R1 and R2. R2 was in by the nurse station after dinner and told me: My son-in-law is the owner of this place, have everything ready, I am going home. I called R2's wife without an answer, R2 appeared to be more confused than normal. I took R2 to his room, and he went to bed without any concerns. he slept well. On 6-1-2025, at about 6:00 am I was passing my medications and I went into R1-R2's room. I did not see R2 in his bed; I looked in the bathroom since R2 can ambulate to the bathroom independently, but he was not there. The curtain between the beds was pulled, and I was not able to see R1's bed. I went towards R1 bed and I saw R2 standing next to R1's bed holding a pillow in his hand R2's, I asked R2 if everything was ok. R2 answer I am going to kill him. At that time, I noticed R1 had a left eye swelling and lacerations to the forehead; the injuries were new. R1 did not have them at 4:30 am when I saw R1 and R2 sleeping. I asked R2 what he was doing by R1's bed, but he did not answer me. I asked R2 to please come with me I asked him to sit down in his bed, I immediately removed R2 from R1's proximity. I called for help without leaving the room. I applied ice to R1's face since I noticed some swelling to the left eye and a laceration to the forehead. On 6-22-2025 at 6:45 am V8 (Certified Nurse Assistant) said, On 6-1-2025 started making my rounds at about 4:00am. I went into R1 and R2 after 5:00 am. I provided incontinent care to R1. R1 did not have any bruises, scratches, or facial swelling noted. R1 was fine, and R2 was sleeping. I did not provide any care to R2 since he can get up and go to the toilet, and R2 is sleeping. I did not see anything unusual when I was in the room. On 6-22-2025 at 11:00 am, V12 (Licensed Practical Nurse) said, On 6-1-2025, I was the nurse for 7-3 shift, I received a report from V14, in regards to the altercation between R1 and R2, V14 described that at about 6:00 am observed R2 standing next to R1's bed. R2 hit R1, he developed some swelling to the left eye, and scrapes to the forehead. I saw an ice pack in R1's face. R1 is non-verbal, unable to ambulate, and dependent on staff for all activities of daily living. V12 said, R2 was observed with a staff member 1:1, I transferred R2 to a local hospital for evaluation. R2 is not back to the facility. The doctor ordered a facial x-ray to make sure R1 was ok, the results received were negative for fracture. On 6-22-2025 at 11:50 am V2, Director of Nursing, presented: skin wound evaluation dated 6-3-2025 at 7:30 am reads: R1 has bruising to left eye with abrasion to eyebrow, onset: 6-1-2025, measures: 2.0 cm X1.0 cm X 0.0, abrasion to left eyebrow. On 6-22-2025 at 12:30 pm V1 (Administrator), said on 6-1-2025 I received a call from V14 at 6:00 am, V14 reported that when she was going to give the morning medications to R1 and R2, V14 saw R2 standing next to R1's bed holding on a pillow in his hands. R1 had a skin tear to the forehead. V14 did not see any physical contact between R1 and R2. I came to see the residents after V14 reported the incident. R2 appeared very confused when interviewed. R2 was very delusional and talking about how much money his family has, and they own the facility, did not verbalize having any concerns with R1. R2 was unable to verbalize any reason why he did what he did. I called the police, sent the report to IDPH. I am aware our policy indicates: the facility will be free from any type of abuse. On 6-22-2025 at 12:00 pm V2 (Director of Nursing) said, my expectation is for the staff to immediately report, immediately ensure all the patients are safe. I expect that no abuse takes place in the building. V2 presented policy titled: Abuse and Neglect dated: 4-24-2025, reads in part: it the policy of the facility to provide professional care and services in an environment that is free from any type of abuse. Physical abuse includes but not limited to infliction of injury that occurs other than by accidental means and requires medical attention.

Based on the interview and record review, the facility failed to provide appropriate assistive devices and staff supervision while walking to two cognitively impaired, high-risk falls residents (R1, R2) out of 3 residents reviewed for incidents/accidents. These failures resulted in R1 bumping R1's nose on the hallway countertop and sustained a nasal fracture. Findings Include: R1's clinical records show an initial admitted [DATE] with included diagnoses but not limited to Unspecified Dementia Without Behavioral Disturbance, Unspecified Psychosis, History of Falling, and Altered Mental Status. R1's Minimum Data Set (MDS) dated [DATE] shows R1 has severe cognitive impairment and requires supervision or touching assistance with walking. R1's fall risk evaluation dated 9/09/24 shows R1 is at high risk for falls. This fall risk evaluation also shows R1 has unsteady gait, has memory problem, and is able to walk with assistance and/or assistive device. R1's restorative mobility evaluation dated 9/09/24 shows R1 uses a walker. R1's fall care plan initiated on 12/06/22 shows R1 is at risk for falls related to impaired balance, weakness, and activity intolerance. This care plan also shows that R1 is ambulatory and uses a rolling walker with cueing assistance. One of the fall interventions in the fall care plan reads in part, I have periods of forgetfulness. I would like staff to frequently reorient me to my surroundings (date initiated 12/06/22). R1's Activity of Daily Living (ADL) care plan date initiated on 11/30/22 shows R1 requires cueing to partial assistance with ADLs (transfers, walking), and R1 primarily utilizes a walker but oftentimes is forgetful to use a walker for ambulation; therefore, R1 is at risk for falls/injury. One of the interventions reads in part, Provide [R1] with reminders to use [R1's] walker, cue/assist if necessary (date initiated 9/09/24). The facility's final incident report sent to the state agency on 9/20/24 at 7:00 PM documents in part: On 9/13/24, at about 7:10 PM, [R1] was ambulating in the hall while holding hands with another female resident [R2]. The other resident began to fall, and as [R1] was still holding onto [R2's] hand, [R1] was pulled forward and bumped [R1's] nose on the hallway railing. [R1] did not fall or have a change in plane, [R1] was noted with swelling and skin tear measuring 0.2x0.5cm [centimeters] to the nose. Minimal bleeding noted. Abrasion was cleansed and covered with a band aid. Pain medication administered and ice pack applied. Neurochecks initiated. [V16 Advanced Practice Nurse] was notified with order to send to ED [Emergency Department] for evaluation. This report also documents that R1 was transferred to the acute hospital via emergency [911] where R1 was diagnosed with closed fracture of nasal bone and returned to the facility on [DATE] at 1:20 AM. R1's progress notes documented by V12 (Licensed Practical Nurse) indicates that per ER [emergency room ] department, R1 has a bilateral nasal bone fracture and will return to the facility. R1's hospital discharge instructions printed on 9/13/24 at 10:58 PM documents that R1's was seen for a fall and [R1] hit [R1's] nose with a diagnosis of Closed fracture of nasal bone, initial encounter. R2's clinical records show an initial admitted [DATE] with included diagnoses but not limited to Unsteadiness on Feet, Adult Failure to Thrive, Other Abnormalities of Gait and Mobility Unspecified Dementia Without Behavioral Disturbance, and History of Falling. R2's MDS dated [DATE] shows R2 has severe cognitive impairment and requires supervision or touching assistance with walking. R2's fall risk evaluation dated 8/16/24 shows R2 is high risk for fall. This fall risk evaluation also shows R2 has unsteady gait, has memory problem, is able to walk with assistance and/or assistive device, and just had a fall. R2's fall care plan initiated on 6/11/22 documents in part: R2 is at high risk for falls related to a history of falls, behaviors, current medication use, poor safety awareness, unsteady gait, and disease process. R2 ambulates with use of walker with cueing and redirection from staff due to wandering behaviors. One of the fall interventions in the fall care plan reads in part, Assist [R2] with walking, remind [R2] of safety precautions as needed. May require frequent reminders and cuing of assistance requires for ambulation (date initiated 6/21/22). Another fall care plan intervention reads in part: Use of assistive device during ambulation to prevent falls (date initiated 6/11/22). R1's behavior care plan initiated on 6/16/22 documents in part: R2 exhibits poor safety awareness and will walk without R2's walker or regard to R2's own safety which increases R2's risk for falling and/or obtain an injury. One of the interventions reads in part, Provide frequent cues and redirection to wait for staff assistance (date initiated 6/16/22). The facility's change in condition form for R2 dated 9/13/24 at 7:10 PM documents in part: R2 holding hands with another resident coming out of the room. The other resident tripped over [R2], and R2 sat down on the floor. Head to toe assessment done, no skin alteration noted, no injury. Vitals taken all within normal limits, denies pain. [R2] alert and oriented x 1, range of motion within the baseline. On 1/12/25 at 10:50 AM and 1:03 PM, interviewed V10 (Agency Registered Nurse) and stated that V10 is the nurse in charge for R1 and R2. V10 stated that R1 needs one person assistance when walking with the use of a rolling walker. V10 stated R1 is confused. V10 stated that R2 is also ambulatory using a rolling walker. V10 stated R2 needs one staff assistance with walking because R2 gets confused and forgetful and is high fall risk. On 1/12/25 at 11:02 AM, interviewed V2 (Director of Nursing) and stated that V2 witnessed the incident that happened with R1 and R2 on 9/13/24 at around 7:10 PM. V2 stated, I went to the floor to do rounds. When I came out the elevator, I turned left to go down the hall and saw [R1] and [R2] walking together. There were no staff walking with them. [R1 and R2] were not using their walkers. [R1] was holding [R2] and walking together. Back there on the third-floor unit there is a cove. There is a countertop on the hallway like an island. I saw [R2] began to fall and [R1] was holding on to [R2] they were walking face to face holding each other's both hands. [R2] was walking backwards and then [R2] lost [R2's] balance and fell backwards. [R2] kind of slid down the wall. [R2's] back was leaning on the wall. [R1] was still holding [R2's] hands and went forward hitting [R1's] face on the countertop. [R1] had a nasal bone fracture. [R1] went to [Acute] hospital. V2 stated that fall assessment is completed upon admission, post fall, quarterly, and re-admission. V2 stated that the fall assessment's purpose is to assess the resident they are high fall risk. V2 stated that the care plan would address fall interventions to prevent from residents' from falling. V2 stated fall interventions include the resident's needs, based on the fall assessment, and is updated based on the root cause analysis post fall. V2 stated that R1 ambulates by herself with a walker and is quite independent. V2 stated that R2 has a walker needs assistance with walking. V2 stated that R2 is very forgetful and needs multiple re-direction. V2 stated that R2 needs staff assistance with walking, toileting, and transfer. A follow up interview conducted with V2 on 1/12/25 at 3:47 PM and stated that there were no other staff witnesses for R1 and R2's incident. On 1/12/25 at 1:10 PM, a phone interview conducted with V12 (Licensed Practical Nurse) and stated that R1 has dementia, walks with a walker, and wanders around. V12 stated that when R1 she walks somebody has to be with [R1]. V17 stated, We have to keep an eye on [R1] and supervise [R1]. [R1] is high risk for fall. [R1] forgetful. [R1] uses a rolling walker, and [R1] needs to use that all the time. [R2] also walks with walker and is more disoriented than R1. [R2] only speaks Spanish a little bit English. [R2] needs supervision at all times when walking. [R2] is a high fall risk. [R2] also needs rolling walker at all times. Surveyor asked V12 regarding the incident that happened on 9/13/24 with R1 and R2. V12 stated, I can't recall the exact time. I was passing medication at that time. It was evening meds. I can't recall the exact time. [V2] brought to my attention that [V2] witnessed [R1] and [R2] were walking holding hands. They were not using the walkers. [R1] lost balance and bumped [R1's] nose on the countertop by the front of [R1's] room. I did a full assessment for both. I took care of [R1]. [R1] was not complaining of pain after the incident but [R1] was holding [R1's] nose. We saw discoloration on [R1's] nose, no bleeding, just a superficial cut on the bridge of [R1's] nose. At that time [R1] did not complain of pain. [R1's] vitals were stable. We called 911 and the doctor. V12 stated that R1 came back to the facility the same night with nasal fracture as R1's diagnosis. On 1/12/25 at 4:38 PM, a follow-up phone interview was conducted with V12. V12 stated that V12 cannot recall what time the last time [V12] saw R1 and R2 before the incident. V12 stated that [V12] can only remember that R1 was in the dining room and R2 was in R2's room the last time V12 saw R1 and R2. On 1/12/25 at 1:33 PM, interviewed V13 (Restorative Licensed Practical Nurse) and stated that the Section GG of the MDS shows the resident's functional assessment, including their mobility assessment. V12 stated that if the resident 's MDS is coded supervision or touching assistance for example if a resident is walking with a walker, the staff should be cuing, reminding, or guiding the resident during walking activity. On 1/12/25 at 3:37 PM, I attempted to conduct a phone interview with V14 (Former Certified Nursing Assistant/CNA). Surveyor asked about the incident with R1 and R2 on 9/13/24. V14 stated that V14 is very sick and can't talk. V14 refused to be interviewed. On 1/13/25 at 10:24 AM, a phone Interview conducted with V18 (Nurse Practitioner) and stated that V18 knows about the incident that happened on 9/13/24 between R1 and R2. V18 stated that R1 sustained the nasal fracture from the incident and was sent to the hospital. V18 stated that based on R1 and R2's cognitive and mobility statuses, R1 and R2 need staff supervision when walking and needs frequent monitoring. Surveyor asked V18 that if staff supervised and monitored R1 and R2 with walking would the incident had been prevented. V18 stated, I'm sure the incident would not happen. On 1/13/25 at 10:33 AM, a phone interview conducted with V2 and stated that for confused residents who are high risk for falls, fall interventions that the staff should be doing are frequent monitoring, re-direction, and to make sure residents are engage with activities. V2 stated that frequent rounding means the staff (Nurses and CNAs) are checking on residents every half hour. The facility's Fall Occurrence policy dated 7/26/24 documents in part: It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and reevaluated and revised as necessary. Those identified as high risk for falls will be provided fall interventions. The facility's General Care policy dated 7/30/24 documents in part: It is the facility's policy to provide care for every resident to meet their needs. Upon admission or readmission, the facility will evaluate the resident for physical and psychosocial needs. Physical needs would include, but are not limited to ADL, wound care, medical needs, etc. Psychosocial needs would include but are not limited to areas of mental and psychosocial well-being. The facility will assist the resident to meet these needs, unless it shows that the resident's needs cannot be met in the facility.

Based on observation, interview, and record review, the facility failed to ensure medications were administered as scheduled per physician orders to 3 (R3, R4, R5) out of 3 residents reviewed for medication administration. Findings Include: On 1/12/25 at 9:13 AM, I interviewed R3. R3 stated that yesterday (1/11/25), R3 received [R3's] 9:00 AM medications closed to lunch time. R3 stated they were two hours late. On 1/12/25 at 10:26 AM, the Surveyor observed V8 (Agency Registered Nurse) enter R4's room and administer two insulin injections and medication pills to R1. The Surveyor asked what [V8] had just given to R4 and stated that those were R4's 9:00 AM medications. On 1/12/25 at 10:31 AM, R4 stated that sometimes on weekends, [R4] would get [R4's] medications late, sometimes one hour to two hours late. On 1/12/25 at 10:37 AM, R5 stated that [R5] does not pay attention with the time [R5] gets [R5's] medications and is not sure if [R5's] getting them on time or not. On 1/12/25 at 10:38 AM, V11 (Agency Registered Nurse) prepared R5's 9:00 AM medications. On 1/12/25 at 10:41 AM, R5 took all R5's medications. V11 stated that [V11] documents in the resident's chart that medications were administered after and not before administering medications. V11 stated that [V11] signs off the EMAR (Electronic Medication Administration Record) what were administered. V11 stated, We have to document after just in case resident's refuse their meds. R3's face sheet listed diagnoses, including Orthostatic Hypotension and Syncope and Collapse. Minimum Data Set (MDS) dated [DATE] shows R3 is cognitively intact with BIMS (Brief Interview for Mental Status) of 15. R3's Medication Admin Audit Report printed on 1/12/25 at 10:20 AM shows that on 1/11/25, R3 had ordered and scheduled medication of Midodrine 5 mg by mouth three times a day to be administered at 9:00 AM but was documented administered at 11:48 AM, more than two hours past the scheduled administration time. A review of R3's electronic health records (EHR) does not show any documentation that the physician was notified of the late medication administration for R3. R4's face sheet listed diagnoses not limited to unspecified atrial fibrillation, chronic kidney disease, type 2 diabetes mellitus with diabetic polyneuropathy, essential hypertension, and cerebrovascular disease. MDS dated [DATE] shows R4 is cognitively intact with BIMS of 14. R4's Medication Admin Audit Report printed on 1/12/25 at 11:45 AM shows that on 1/12/25, R4 had ordered and scheduled medications of Insulin Aspart injection 22 units plus insulin sliding scale to be administered at 8:00 AM, but were documented administered at 10:27 AM and 10:28 AM, more than two hours past the scheduled administration times. R4 also had ordered and scheduled medications of Metformin 850 mg two times a day by mouth, Carvedilol 6.25 mg every 12 hours by mouth, Basaglar insulin injection 50 units two times a day, Apixaban 5 mg by mouth two times a day, Baclofen 10 mg by mouth three times a day, and Vascepa 1 gm by mouth two times a day to be administered at 9:00 AM, but were documented administered more than one hour past the administration scheduled time. A review of R4's electronic health records (EHR) does not show any documentation that the physician was notified of the late medication administration for R4. R5's face sheet has listed diagnoses but not limited to Multiple Sclerosis, Anemia, and Hyperlipidemia. R5's MDS dated [DATE] shows R5 has moderately impaired cognition with BIMS of 08. R5's Medication Admin Audit Report printed on 1/12/25 at 11:47 AM shows that on 1/12/25, R5 had ordered and scheduled medication of Ferrous Sulfate 325 mg by mouth two times a day and Methylphenidate 5 mg by mouth two times a day to be administered at 9:00 AM but were documented administered at 10:33 AM and 10:36 AM, more than one hour past the scheduled administration time. A review of R5's electronic health records (EHR) does not show any documentation that the physician was notified of the late medication administration for R5. On 1/12/25 at 11:02 AM, I interviewed V2 (Director of Nursing) and stated that medication administration is done one hour before and one after the scheduled administration times. V2 stated that nurses should follow the phsyician orders when administering medications. V2 stated that if the nurses give the medications late, they must call the doctor. V2 stated that after a resident takes their medications, the Nurses are documenting the time they administered the medications in the EMAR. V2 stated that they have to document what are given, what's missed and if it's late to call the doctor if it's a significant medication such intravenous medications, antibiotic, blood pressure medications, anticoagulant, insulins and antidiabetics. The facility's Physician Orders policy dated 8/16/24 documents in part: It is the policy of this facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician orders. The facility shall ensure to follow physician orders as it written in the POS. Medication orders entered in the POS (Physician Order Sheet) shall be reflected accurately in the MAR (Medication Administration Record).

Based on interview and record review the facility failed to notify the residents Power of Attorney (POA) of an abnormal labororatory results and change in medication/treatment to 1 of 3 residents (R1) reviewed of notification of change in the sample of 3. The findings include: On 10/25/24 at 12:27 PM, V7 (R1's POA) said she was not notified when her mom (R1) had an abnormal lab result of low potassium level and R1 was put on Potassium medications. V7 said R1 has heart failure and a change in her potassium level is significant. V7 said she was R1's POA and she should have been notified of new orders or changes in R1's medications or condition. A progress note dated 10/22/24 by V6 (Registered Nurse) showed R1 had a low potassium level (2.2) and was started on Potassium Chloride 40 meq tablet. The progress notes did not show that V7 (R1's POA) was notified. On 10/25/24 at 3:15 PM, V6 (RN) said he was not able to inform V7 R1's POA of the abnormal potassium level and R1 being started on Potassium tablets. V6 said if he did, he would have documented the notification. On 10/25/24 at 3PM, V8 (Nurse Practitioner) said V7 was very particular with R1 medications. V8 said he spoke to V7 regarding medications but that did not include R1's being on Potassium. On 10/25/24 at 3:30 PM V2 (Director of Nursing) said any abnormal labs, or any new order including new mediations or treatments the POA should be notified. The Nurses will be inserviced today. The Facility Policy of Notification of Change of Condition dated 8/16/24 show, the facility will provide notification of residents change in status.

Based on observations, interviews and record review, the facility failed to ensure a resident's right to be free from physical harm and mental abuse for 1 (R1) of 4 residents reviewed for abuse in the sample of 5. This failure resulted in R1 being verbally and physically assaulted by staff causing bruising and lacerations during an unprovoked altercation. Findings include: R1 is a [AGE] year old female admitted to the facility on [DATE] with diagnosis including but not limited to Dementia; Suicidal Ideations; Anxiety Disorder; Major Depressive Disorder; Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris; Chronic Pain Syndrome; Chronic Obstructive Pulmonary Disease; Hypertension; and Epilepsy. According to R1's MDS (Minimum Data Set) assessment dated [DATE], under section C, R1 has BIMS (Brief Interview of Mental Status) score of 15 indicating intact cognition. According to R1's MDS (Minimum Data Set) assessment dated [DATE], under section E, R1 had not shown any psychotic behaviors. On 08/05/2024 at 10:25 AM, Surveyor observed R1 sitting in the common area, awaiting activities. R1 clean, dressed appropriately, displaying appropriate demeanor. Surveyor asked R1 to talk about an incident in private setting. Surveyor followed R1 to her room. Surveyor observed bruising and scabs on R1's right forearm. Surveyor asked what occurred between R1 and V5 (Certified Nursing Assistant) on the evening of 07/15/2024, R1 said: On that evening, I don't remember the exact time, I used a call light and V5 (CNA) came in. I asked V5 (CNA) to give my roommate (R3) an extra sheet and close the drapes in the room, V5 (CNA) said she's here until 11:00 PM and has time to do it. I pointed out that V5 (CNA) should do her job. I pointed my finger at V5 (CNA) as I was talking, I'm Italian, I talk with my hands, and I think V5 (CNA) took offense to that and said not to point fingers at her and slapped my finger. I pointed at V5 (CNA) again, and that's when she grabbed my finger. I grabbed V5's (CNA) hand and pushed it off me. Then, V5 (CNA) grabbed my arm and dug her nails into my skin. I started bleeding. We had an exchange in words and I told V5 (CNA) to get out of my room, but she wouldn't leave. V4 (Licensed Practical Nurse) came around that time, after hearing commotion in my room. V4 (LPN) told V5 (CNA) to leave the room and that's when she finally left. V4 (LPN) asked me what happened and took care of my bleeding arm. Surveyor asked if there was anybody else in the room at the time if the incident, R1 said that her roommate (R3) was in the room at the time, but she's [AGE] years old, so she was not aware of what happened. Surveyor asked if anybody talked to R1 after the incident, R1 said: that V1 (Administrator), V2 (Director of Nursing), and nurses spoke to me about what happened. I'm just glad I don't see V5 (CNA) anymore, she hasn't taken care of me since then. Surveyor asked if V5 (CNA) still works in the facility, R1 said: I think she does, but was moved to another unit. V5 (CNA) is [NAME]. She's the only one like that. Surveyor asked if R1 feels safe in the facility, R1 said: Overall, I feel safe in the facility. I have been here for over a year, and nothing like this happened to me before. I haven't heard of anything like this happen to another resident either. On 08/05/2024 at 2:38 PM, Surveyor interviewed V5 (Certified Nursing Assistant), who stated the following: On 07/15/2024, after dinner, I responded to the call light in R1's room. I went in to check on R1 and R1 said that her roommate (R3) needs to be covered. I asked R3 if she needs assistance, R3 said that she didn't use the call light, it was R1 who used it. Regardless of that, I noticed that R3 needs a flat sheet, so I decided to go get it. At the same time, R1 was accusing me of not doing my job while she was sitting on her bed, when I turned around, R1 was right in my face. R1 started scratching my neck and face, so I held her arm, turned around and ran out of the room. R1 ran out, chasing me, she was trying to hit me. V4 (LPN) was right outside R1's door. R1 then proceeded to show V4 (LPN) her bleeding arm. Surveyor asked if R1's arm was bleeding when V5 (CNA) came into the room, V5 (CNA) responded, Ma'am, I don't need to be rude, but I already told you that I don't know if her arm was bleeding before I came into the room. V5 (CNA) demonstrated what appeared to be hostility against a surveyor and also appeared to be irritable and temperamental during an interview. On 08/05/2024 at 3:05 PM, Surveyor interviewed V4 (Licensed Practical Nurse), who stated the following: I was at the nursing station at the time of the incident involving R1 and V5 (CNA) on 07/15/2024. I heard some commotion coming from R1's room. I went in there and saw V5 (CNA) and R1 standing by the foot of R1's bed. V5 (CNA) and R1 were arguing. I saw scratches on R1's right arm. R1 was repetitively asking V5 (CNA) to leave the room, so I asked V5 (CNA) to step out, and she finally left R1's room. I did not see any scratch marks on V5's (CNA) face or neck, she didn't report to me either. I did not see R1 chasing after V5 (CNA) or try to hit her. When I was providing first aid care to R1's arm, R1 said that she asked V5 (CNA) to close the drapes in the room, but V5 (CNA) responded that she has until 11:00 PM to do it. I haven't talked to V5 (CNA) after the incident, I notified the V10 (Nurse Supervisor) and, I believe, she talked to V5 (CNA). I've worked with V5 (CNA) before, she comes across as loud. I've worked with R1 for over a year now, and she has never been aggressive towards me, nor I witnessed her being aggressive with other staff or residents. On 08/05/2024 at 3:29 PM, Surveyor interviewed V10 (Nurse Supervisor), who said: I was on my break when V4 (LPN) called me to let me know that there was an incident between R1 and V5 (CNA) resulting in R1 acquiring skin tear to her right arm. I returned from my break right away and made sure V5 (CNA) is away from R1 and then I asked R1 what happened. R1 said that she used a call light, V5 (CNA) came in and was asked to close the drapes. V5 (CNA) responded that she's here until 11:00 PM and has time to do that. R1 got upset, got up from the bed, and struggle ensued. V5 (CNA) grabbed R1's right arm and that's probably how R1 acquired the skin tear. I proceeded with full assessment and wound care for R1 and then notified V3 (ADON). V3 (ADON) is who interviewed V5 (CNA). One thing about V5 (CNA) is that she is loud, but I've never heard any complaints about her, other than being loud. On 08/06/2024 at 9:57 AM, Surveyor interviewed V3 (Assistant Director of Nursing), who stated the following: On the evening on 07/15/2024, I was notified by V10 (Nurse Supervisor) that there was an incident between R1 and V5 (CNA). V10 (Nurse Supervisor) asked me to talk to V4 (LPN), she handed the phone off and had me speak to V4 (LPN). V4 (LPN) said that she heard commotion in R1's room, went in, but didn't see physical altercation between R1 and V5 (CNA). R1 was saying She did this to me pointing to her right arm. V4 (LPN) had V5 (CNA) step out of R1's room and went to notify V10 (Nurse Supervisor). Then, I asked to speak to V5 (CNA). V5 (CNA) said that she answered the call light in R1's room. V5 (CNA) was assisting R1's roommate (R3) and that's when R1 started yelling at her. V5 (CNA) said she was trying to leave the room, and that's when R1 jumped out of the bed, pointing at V5 (CNA) swatting, scratching, and spitting at V5 (CNA). V5 (CNA) tried to stop R1 from attacking her and grabbed R1's arm. Right then, V4 (LPN) came into the room and V5 (CNA) was able to leave. I also spoke to R1. R1 said that she asked V5 (CNA) to give a blanket to the roommate (R3), V5 (CNA) responded that she is here until 11:00 PM and has time to do it. R1 then got off the bed, pointed at V5 (CNA) and said that it doesn't matter that V5 (CNA) is here until 11:00 PM, she needs to do it now. R1 said she extended her arms up and that's when V5 (CNA) grabbed her. R1 yelled to show V5 (CNA) what she had done, pointing to her injured right arm, and that's when V4 (LPN) came in and had V5 (CNA) leave R1's room. Once I got R1's, V4's (LPN) and V5's (CNA) statements, I told V5 (CNA) to leave the facility. V12 (Primary Physician) and V1 (Administrator) were notified. Police was not notified. V1 (Administrator) took the investigation over from there. Surveyor asked about R1's general demeanor, V3 (ADON) said: R1 is very pleasant, can get anxious or frustrated; however, she's never been involved in physical altercation with anybody. Normally, R1 comes to staff when she gets upset. Surveyor asked how is V5's (CNA) behavior, V3 (ADON) said: V5 (CNA) hasn't been here that long and works night shift, so I'm not very familiar with her. I did have an interaction with her on the day of the incident, around 4:00 PM, she appeared to be pleasant even though she was loud. On 08/06/2024 at 11:00 AM, Surveyor observed R3 resting in the bed. Surveyor asked about the incident that occurred between R1 and V5 (CNA), R3 responded: I don't remember anything, nothing happened here. On 08/06/2024 at 11:05 AM, Surveyor approached R1 in her room and asked if R1 could answer a couple more questions in regard to the incident that occurred between R1 and V5 (CNA). R1 appeared nervous, apprehensive, and afraid. Surveyor asked R1, in the follow up interview, how does she feel about V5 (CNA) still working in the facility, R1 responded, You know, I was a little nervous when we talked yesterday, but as long as V5 (CNA) is not on this unit, I think I'm ok. I just hope V5 (CNA) doesn't have the same run-in with another resident like she had with me. I've been here for over a year now, and I would have never thought something like this could happen. On 08/06/2024 at 1:16 PM, Surveyor interviewed V1 (Administrator/Abuse Coordinator) who stated: On the evening of 07/15/2024, V3 (ADON) notified me that V4 (LPN) went into R1's room due to ongoing commotion. R1 showed her a skin tear and said that V5 (CNA) caused it. After that, I completed initial report and sent it to IDPH. The police were not called because it didn't constitute to our Abuse policy. I continued the investigation on 07/16/2024. I spoke to R1, V4 (LPN), V5 (CNA), and other staff that was present on the shift. Social services spoke to residents. The conclusion of the investigation was that abuse was not substantiated because R1 reached out towards V5 (CNA) in attempt to scratching her and V5 (CNA) held R1's arms in self-defensed. Surveyor asked if V5 (CNA) should be involved in altercation with a resident, V5 (CNA) should have not been involved in any altercation with R1 but she was attacked by R1, so it justified that V5 (CNA) held R1's arms down. Surveyor clarified whether V5 (CNA) should have stepped out of R1's room to prevent physical altercation, V1 (Administrator) said: I think V5 (CNA) should have stepped away, but as R1 attacked V5 (CNA), it was reasonable for her to hold R1's arms. Surveyor asked why is V1 (Administrator) convinced that R1 attacked V5 (CNA) not the other way around, V1 (Administrator) stated: Because R1 stated to multiple people that she attacked V5 (CNA). Surveyor asked how did R1's injury occur, V1 (Administrator) said: There is no definite conclusion but considering her fragile skin, R1 could have acquired it during interaction with V5 (CNA). Surveyor requested full investigation to collaborate V1's (Administrator) statement, V1 (Administrator) said, You have summary of that in the initial and final facility reported incident. Surveyor clarified if those are the only documents available to the surveyor, V1 (Administrator) said, Yes and refused to provide full incident investigation. On 08/06/2024 at 2:33 PM, Surveyor interviewed V12 (Primary Physician). Surveyor asked if it's a good time to talk, V12 (Primary Physician) said, Not really, but I will talk to you. Surveyor asked about the incident that occurred on 07/15/2024 between R1 and V5 (CNA), V12 (Primary Physician) said, I don't clearly recall what happened, but I think R1 was agitated and V5 (CNA) was trying to calm R1 down, but I don't know exactly. Surveyor asked if V12 (Primary Physician) knew why V5 (CNA) grabbed R1?, V12 (Primary Physician) said, R1 was agitated and V5 (CNA) grabbed her. I mean, I think V5 (CNA) grabbed R1, not sure. Surveyor asked if V5 (CNA) behavior was appropriate, V12 (Primary Physician) said, V5 (CNA) should have tried to redirect R1 and call the nurse. Surveyor asked about R1's skin tear: V12 (Primary Physician) said, I don't remember anything about R1's skin tear. On 08/07/2024 at 1:56 PM, In follow up interview, surveyor asked V1 (Administrator) whether V5 (CNA) was suspended and/or moved to another unit as a result of the incident on 07/15/2024, V1 (Administrator) said: Yes, V5 (CNA) was suspended immediately and has been since moved to another floor after the investigation was completed. Surveyor asked how long was V5 (CNA) suspended for, V1 (Administrator) said: V5 (CNA) was suspended for the length of the investigation until the final report was submitted. V5 (CNA) was moved to another floor because R1 did not want to work with her anymore even though the other residents appreciated V5's (CNA) work. The facility final incident reported dated 07/19/2024 reads in part, After review of medical records, staff, and resident interviews, the allegation of physical abuse is unsubstantiated. R1's skin assessment dated [DATE] reads in part, At around 7:20 PM, post incident, (R1) noted with 2 skin tears to right forearm with very small amount of bleeding. Areas of skin cleansed with normal saline and pat dry. Applied Xeroform and covered with dry dressing. V12 (Primary Physician) informed of incident and skin teras. The facility Abuse and Neglect policy dated 07/12/2024 reads in part, 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, negelct, or mistreatment. Abuse is willful infliction of mistreatment, injury, unreasonable confinment, imtimidation or punishment. Physical abuse includes but not limited to infliction of injury that occur other than by accidental means and requires medical attention. Mental abuse inludes but is not limited to humiliation, harassment, threat of bodily harm, punishment, isolaton (involunatry, imposed seclusion) or deprivation to provoke fear or shame.

Based on interviews and record review, the facility failed to keep a severely cognitively impaired resident at high risk for falls and with history of falls from a mechanical fall while providing routine ADLs (activities of daily living care) and failed to follow fall prevention protocols for 1 (R2) of 3 residents reviewed for accidents/hazards in the sample of 5. This failure resulted in R2's transfer to the hospital Emergency Department and diagnosis of comminuted displaced intertrochanteric right femur fracture. Findings include: R2 is a [AGE] year old female admitted to the facility on [DATE] with diagnosis including but not limited to Displaced Intertrochanteric Fracture of Right Femur; Epilepsy; Restlessness and Agitation; Abnormal Posture; Degenerative Disease of Nervous System; Delusional Disorders; Osteoarthritis; Osteophyte Right and Left Hip; and Progressive Vascular Leukoencephalopathy. According to R2's MDS (Minimum Data Set) assessment dated [DATE], under section C, R2 has memory problems and severely impaired decision making. According to R2's MDS (Minimum Data Set) assessment dated [DATE], under section GG, R2 is dependent or requires substantial/maximal assistance with majority of ADLs (activities of daily living). On 08/05/2024 at 12:41 PM, Surveyor interviewed V6 (Licensed Practical Nurse) who stated: On 06/01/2024, before breakfast time, V7 (Wound Care Technician) heard V9 (Certified Nursing Assistant) yelling for help. V7 (Wound Care Technician) stepped into R2's room and saw V9 (CNA) next to R2 who was on the floor, on the floor mat. V7 (Wound Care Technician) came to get me and that's when I went into R2's room. I saw R2 sitting on the floor, on the floor mat with her back towards the bed. I started the assessment. I checked R2's skin, there were no injuries. I also check R2's range of motion, it appeared to be at R2's baseline. I also checked R2's vital signs. It did not appear that R2 had any injury at that time, so me, V9 (CNA), and V7 (Wound Care Technician) put R2 back into the bed via mechanical lift. I kept monitoring R2 for pain as well, which R2 didn't appear to be in pain either. After R2 was placed in bed, I notified V8 (Nurse Supervisor), the doctor, and R2's power of attorney. When I asked V9 (CNA) what happened, she said that she was getting R2 dressed when incident happened. R2 had jerking movements and it was difficult to dress her in supine position, so V9 (CNA) sat R2 up on the edge of the bed, and while she was getting R2 dressed, R2 started leaning forward and V9 (CNA) had to lower R2 to the floor, onto the floor mat. Surveyor asked if R2 was strong enough to sit on the edge of the bed independently, V6 (LPN) said: I'm not sure if R2 had enough strength to be sat on the edge of the bed. I helped other CNA's with R2's transfers and we always used at least two staff and mechanical lift. On 08/05/2024 at 12:56 PM, Surveyor interviewed V2 (Director of Nursing) who said: R2's injury was discovered at nighttime, several hours after R2 fell , that's when R2 started grimacing, pointing to her right hip, and there was a change in R2's right leg appearance, it looked displaced. Surveyor asked if there was anybody else in the room at the time of the fall, V2 (DON) said, R2 had a roommate at the time of the incident but she is not intervieweable. On 08/05/2024 at 1:36 PM, Surveyor interviewed V8 (Nurse Supervisor), who said: I had just started my shift on 06/01/2024, around 7:00 AM, I was notified that R2 had fallen. When I went into R2's room, she was already in the bed. I was not familiar with R2, but I looked at her extremities, skin, and face, R2 didn't appear to be in distress or pain at the time. V6 (LPN) told me that she knew what to do and didn't need my assistance. I followed up with V6 (LPN) before the end of my shift (3:30 PM) and there were no changes and R2 appeared to be at her baseline. On 08/05/2024 at 2:12 PM, Surveyor interviewed V9 (Certified Nursing Assistant), who said: I went into R2's room, before breakfast, to get her dressed and get her up into the chair. I raised the bed up to my hip level and started with changing R2's brief and putting on her pants. R2 was laying down for that. Then, I attempted to put on R2's top. I sat R2 up on the edge of the bed. I was standing on the side of R2, slipping her arm into the sleeve of the shirt and that's when R2 started to lean forward. As she started to lean to lean forward, I put my arm out, but that didn't prevent R2 from falling off the bed and R2 fell to the floor onto her right hip. The bed was at my hip level, so R2 fell off the hip level height. I took care of R2 before, this was my routine, I always sat R2 up to put on her shirt. Nothing like this has ever happened before. R2 utilized specialty chair, with high back. Surveyor asked if utilizing specialty chair was indicative that R2 didn't have enough strength to sit up independently, V9 (CNA) responded, Yes, that would indicate that. R2 required maximum/two person assist, especially with transfers. R2's ADLs, including getting her dressed, could have been provided by one person, but sometimes, R2 resisted repositioning and then we would need 2 people to get R2 dressed. 08/06/2024 9:37 AM, Surveyor interviewed V11 (Former Fall Coordinator) who said: R2 was in the restorative program at the time of the fall, I saw her for quarterly and annual evaluations. R2 had cognitive deficit and needed maximum assist with toileting and transferring, required mechanical lift for transfers, and total assistance during meals. R2 needed moderate assistance with turning and getting dressed. R2 utilized specialty chair for safety and comfort. Surveyor clarified what does partial/moderate assistance means in regard to getting upper body dressed, V11 (Former Fall Coordinator) said: R2 was able to sit up, in order to assist with dressing. Surveyor asked about V11's (Former Fall Coordinator) fall investigation outcome, V11 (Former Fall Coordinator) said: My investigation revealed that the V9 (CNA) was assisting with changing R2, had R2 sit on the edge of the bed, noticed R2 leaning towards her and was unable to prevent her from falling. It was unusual for R2 to lean forward like that, so the doctor ordered labs after the fall; however, R2 was sent out to the hospital before nurses were able to collect urine sample. After getting labs done at the hospital, it was discovered that R2 had urinary tract infection at the time of the fall. R2 had previous falls and had a urinary tract infection around those times. The conclusion of the investigation was that R2 had an urinary tract infection and the fall was unexpected and unavoidable. On 08/06/2024 at 1:49 PM, Surveyor interviewed V2 (Director of Nursing) who said, Interventions for residents at high fall risk are bed alarms, chair alarms, floor mats, checking labs in case of ongoing infection, and staff education in regard to root-cause of a fall. Each intervention is individual to a resident. R2 didn't require bed alarm because she did not try to get out of bed. R2's fall interventions were: wing mattress due to history of seizures and fall mats. Those were the two main fall prevention interventions for R2. I don't think there was anything more that could have been done to prevent R2's fall. On 08/06/2024 at 2:20 PM, Surveyor interviewed V13 (Family Nurse Practitioner) who said: I am familiar with R2. R2 was alert but not oriented, had dementia. R2 was unable to answer any questions, not able to follow simple directions. R2 was mainly in bed, sometimes was sitting up in the wheelchair. R2 required assistance with all ADLs (activities of daily living). Surveyor asked if it was appropriate for staff to place R2 on the edge of the bed, to provide ADL care based on R2's functional ability, V13 (FNP) said, I'm not sure if it was appropriate, I used to always see her in the dining room, in the wheelchair. Surveyor asked about R2's fall, V13 (FNP) said: I remember R2 had a hip fracture, but I don't remember R2 having a fall. Surveyor asked what would be appropriate fall prevention interventions for R2, V13 (FNP) said: Fall interventions appropriate for R2 would be staff assistance, frequent monitoring, maybe a bed alarm, not sure. R2 was not very alert, I don't think she moved a lot. On 08/06/2024 at 3:28 PM, Surveyor asked V14 (Agency Certified Nurse Assistant) what some of the interventions are appropriate for high fall risk residents, V14 (Agency CNA) said, Some of the interventions for high fall risk residents are bed and chair alarm, bed in the lowest position, and frequent monitoring. Surveyor asked what it means if a resident requires maximal assistance in almost all aspects of ADLs (activities of daily living), V14 (CNA) said: Resident who is assessed to require maximum assistance, needs staff assistance with their ADLs. It means, that their mobility is very limited. Even if one of the resident's ADLs requires partial/moderate assistance, they cannot perform the task independently, and still need staff's assistance. Surveyor asked, would you sit a resident on the edge of the bed to dress them, who's functional ability is assessed as maximum assistance for dressing lower part of the body and partial/moderate assistance for dressing upper part of the body, V14 (Agency CNA) said: I would sit them up in the bed while putting on their shirt, not on the edge of the bed. Some CNAs find it more convenient to sit residents on the edge of the bed, but it is too risky. If a resident requires maximum assistance with all ADLs except dressing upper body, where they need partial/moderate assist, and they require mechanical lift for transfers, that means their mobility is very limited and there is no point to sit them up on the edge of the bed. The facility incident report dated 06/01/2024 reads in part, On 06/01/2024 while (R2) was sitting in the bed and staff were assisting her with dressing, (R2) began to lean forward, causing the staff the need to lower her to the floor on her floor mats. Post 72 (hour) incident follow up, (R2) was noted with swelling to her right hip and facial grimacing. (R2) was sent to the (local) hospital for evaluation where she was admitted with diagnosis of right hip fracture. Per record review, R2 had two prior falls within 6 months, on 01/10/2024 and 03/14/2024, to the fall on 06/1/2024. Fall Risk Evaluation dated 03/14/2024 shows R2 to be at high risk for falls. R2's Change in Condition with SBAR Form dated 06/01/2024 reads in part, The change in condition, symptoms, or signs observed and evaluated are/is: witnessed fall. R2's Post-incident 72 Hours Follow-up dated 06/02/2024 reads in part, Swelling to the right hip; right hip external rotation. Hospital record dated 06/02/2024 written by V15 (Advanced Practical Nurse) reads in part, History of Present Illness: (R2) is nonverbal at baseline and unable to provide any history but per (the facility) staff, (R2) has been exhibiting signs and symptoms of right hip pain. There is no report of any fall or apparent trauma. CT abdomen reported incidental commuted fracture of the intertrochanteric right femur with mild shortening. Hospital record dated 06/02/2024 written by V16 (Medical Doctor) reads in part, (R2's) POA aware of the natural history of this condition. This includes progression of the fracture, worsening pain, possible neurovascular injury due to displacement of the fracture. Possible skin breakdown due to bony protrusions. Hospital record dated 06/02/2024 written by V17 (Physician Assistant) reads in part, (R2) brought to the ER for evaluation and found to have right hip fracture. (R2) also has UTI (Urinary tract infection). (R2) contracted in the fetal position with both hips and knees flexed. R2's Fall care plan dated 12/22/2023 reads in part, (R2) is at high risk for falls related to: Current medication use, Poor safety awareness, Unsteady gait, Disease process (Toxic Encephalopathy, Alzheimer's Disease, Fatigue, Anxiety, Major Depressive disorder). (R2) utilizes a high back wheelchair as primary means for locomotion. (R2) may have hypotensive episodes placing her at high risk for falls/injury. (R2) is at high risk for fall, has had a hx of fall, impaired cognition requiring weight bearing to staff dependent on self-care and mobility. Interventions: ABT (antibiotic) for UTI; Bed alarm on at all times for fall precautions; Low bed with floor mat while in bed; Treat acute Infection with ABT (antibiotic). R2's ADL care plan dated 03/04/2024 reads in part, (R2) l have an ADL self-care deficit due to incomplete performance, weakness and impaired thought process related to diagnosis of Toxic Encephalopathy, Cognitive communication deficit, Lack of coordination, Fatigue, Anxiety, Major Depressive disorder and Alzheimer's disease, therefore requires extensive assistance with ADL's (bed mobility, transfers, dressing, walking, personal hygiene, eating and toileting). (R2) has a (specialty) chair for resident comfort and safety and is totally dependent on staff for locomotion. Interventions: Encourage participation in ADL's; Transfers: mechanical full body lift x2 staff assist. No documented intervention regarding getting R2 dressed. The facility Fall Occurrence policy dated 06/06/2024 reads in part, It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary. Those identified as high risk for fall will be provided fall interventions. The interventions will be reevaluated and revised as necessary.

Based on interview and record review, the facility failed to treat a resident with respect and dignity by providing care in a discourteous manner. This failure applied to one (R3) of four residents reviewed for resident care. Findings include: R3 is a [AGE] year-old female admitted to the facility 05/01/23 with a diagnosis history of Anxiety, Autoimmune hemolytic anemia, CAD, Depression, Hepatitis B, Hypertension, A-fib, Interstitial lung disease, Neuropathy, Pneumonia, Diabetes type II D, Venous insufficiency, oftubularadenoma, cholecystectomy, radiofrequency ablation, colostomy, left total hip arthroplasty, breast biopsy, and Peg placement. On 06/03/24 at 12:05 PM, R3 said, I had a concern with one V9 (Certified Nursing Assistant) a couple weeks ago and I reported to the nurse and V12. I asked V9 to turn to my left side and change me. I did not want to turn towards the right side. V9 said, shit while providing care. I waited until V9 came in the next day to report the incident. I have not seen V9 here since the incident. R3 said, I don't feel comfortable and did not like it. It was disrespectful. On 06/03/24 at 12:12 PM, V12 (Family Member) said, I don't have concerns about the care and my mother never mentioned concerns with the care until I reported this. My mother reported that V9 used inappropriate language during care, and I reported it to the facility. On 06/03/24 at 03:45PM, V9 (CNA) said, I was providing care to the roommate, and I went to help R3. The facility started using a new brief and R3 did not like them. I put the brief on, and secured one side of the brief and the other side was torn. I asked R3 if there is a brief in the closet. R3 had the old briefs in the closet, and I changed R3 and said good night. I did not swear or use inappropriate language during the care. I was suspended during the investigation. I got a phone call on Saturday and stayed home. I have not provided care to R3 since the incident. On 06/04/24 at 1:00 PM, V2 (Director of Nursing) said, R3 is alert and oriented x2 and forgetful. R3 forgets receiving care and would call V12. R3 is seeking attention for V12 to come to the facility. V2 said, I never received complaints of V9, and I reported the incident. V9 said, that no inappropriate language was used during care. On 06/06/2024 at 09:33AM, V1 (Administrator) provided facility policy undated, Residents' Rights for People in Long-term Care facility, reads: You have the right to . Safety and good care- Your Facility must provide services to keep your physical and mental health and sense of satisfaction.

Based on interviews and record reviews, the facility failed to follow its intravenous therapy policy and accurately assess and monitor resident's signs/symptoms/change of condition, which resulte in delay of care and resulted in MRSA spread causing decline in resident's health, with infection to knee and MRSA pneumonia for one resident's (R422) PICC (peripherally inserted central catheter) out of three reviewed for change in condition in a sample of 37. This failure resulted in R422 developing chills, elevated white blood cell count, and malaise. R422 was transported to the hospital and diagnosed with MRSA infection of PICC line causing MRSA infection of right knee and MRSA pneumonia. Findings include: On 4/26/24 at 8:56 AM, V14 RN (Registered Nurse) stated that PICC (peripherally inserted central catheters) dressing is changed weekly. V14 stated that all the needed supplies are in kit. V14 stated that when you record arm circumference and external catheter length, the previous documented result will appear so that you can compare previous result with current result. V14 stated that 1-2cm difference in arm circumference would not be considered significant but more than that would be considered significant, resident could have edema. V14 stated that the physician should be notified of any changes. V14 stated that the differences in external length catheter could signify concern with catheter position not in correct place and physician should be notified. V14 stated that PICC line insertion site is monitored for signs/symptoms of infection every shift; monitor for swelling, redness, pain at insertion site. V14 stated that when he provided care for R422 the end of February and early March, R422 was complaining of right knee pain. V14 stated that he did not report pain to physician because he believed it was chronic pain. R422's TAR (Treatment Administration Record), dated February and March 2024, notes R422's right upper arm midcircumference measurement on 2/25/24 was 33cm (centimeters), on 3/3/24 it was 23cm (centimeters); and on 3/10 it was 34cm. R422's MAR (Medication Administration Record), dated March 2024, notes R422 received Acetaminophen 650mg (milligrams) for complaints of right knee pain on 3/7, 3/8, 3/11, 3/13, and 3/14. On 4/26/24 at 9:30 AM, V15 NP (Nurse Practitioner) stated that every facility has PICC line protocol and that staff are trained on changing dressing with aseptic technique. V15 stated that when V15 saw R422, there were no signs of infection (redness or swelling) observed at PICC line insertion site. V15 stated that during R422's stay at this facility, staff informed V15 of inability to draw blood from PICC line. V15 stated that R422 was transported to the hospital for further evaluation. V15 stated that the emergency room staff were able to get PICC line working properly after flushing line. V15 stated that when R422 came back from hospital visit, R422 complained of not feeling well. V15 stated that laboratory testing was done and R422's white blood cell count was 19 (normal range is 3.9-11). V15 stated that she believes R422's PICC line became infected from the emergency room staff flushing PICC line and not using aseptic technique. V15 stated that R422 had MRSA (methicillin resistant staphylococcus aureus) infection in PICC line causing MRSA infection in right knee and in lungs. V15 stated that the hospital was unable to determine if MRSA had spread to R422's heart because heart testing was unable to be done due to R422's comorbidities. When questioned how would a PICC line become infected with MRSA, V15 stated MRSA infection due to not using aseptic technique while providing care for PICC line. R422's medical record notes the following: On 2/26/24, R422's white blood cell count was 10.1. On 2/28/24, the nurse noted R422 sent to the hospital to assess and exchange PICC line placement due to no blood return. R422 scheduled/ expected to return today with new picc line. V16 RN noted R422 returned from the hospital at 5:00 PM. The PICC line remained the same. It was flushed in the emergency room and happened to be working fine. The x-ray was done to verify the location. On 3/4/24, R422's white blood cell count was 8.2. On 3/11/24, R422's white blood cell count was 11.5. On 3/14/24, R422's white blood cell count was 19.5. R422's medical record notes the following: On 1/23/24, R422 was admitted to this facility with a right upper arm PICC line, arm circumference 28cm (centimeters). R422's TAR (Treatment Administration Record), dated February and March 2024, notes R422's right upper arm mid-circumference measurement on 2/25/24 was 33cm (centimeters), on 3/3/24 it was 23cm (centimeters); and on 3/10 it was 34cm. R422's pre-admission hospital record, dated 12/18/23-1/23/24, notes R422 was found to have cardiogenic shock secondary to acute decompensated heart failure. An echocardiogram on 1/3/2024 showed an ejection fraction of 10-15%, and a right heart catheterization indicated elevated filling pressures. Left anterior descending artery in heart showed 99% occlusion. R422's left ventricle showed severe dilation. On 2/26, the nurse practitioner noted R422's right lower extremity with 2+ edema (swelling). On 2/28, nurse practitioner noted R422 with bilateral lower extremity edema. R422's progress notes, dated 3/14/24, notes at 1:55 PM, R422 complained of body malaise, bilateral lower extremities with edema. Stayed in bed, WBC (white blood cell count) 19.5 (normal range 3.9 - 11). At 2:43 PM, R422 still complained of body malaise and bilateral lower extremity pain. R422's hospital record, dated 3/14/24-3/25/24, notes R422 presented from this facility due to laboratory abnormalities. R422 reports 48 hours prior to hospitalization she developed severe pain in right knee which interfered with her ADLs (activities of daily living). She had chills/shaking, but no fevers. It also hurts to take deep breaths. 24 hours ago developed shortness of breath. Physical examination noted lungs with poor inspiratory effort. 2+ pitting edema bilateral lower extremities. Right knee swollen, warm, effusion present. Active and passive ROM (range of motion) severely limited. R422 alert and oriented x 4. Speech clear. Generally weak, especially lower extremities. Elevated white blood cell count, suspect pneumonia as there is right perihilar fulness/haziness, pleuritic chest pain and new oxygen requirement. PICC (Peripherally inserted central catheter) inserted right arm on 1/7/24. R422 with septic knee, and MRSA (methicillin resistant staphylococcus aureus) bacteremia (likely due to PICC infection, and then causing the MRSA septic knee and MRSA pneumonia- PICC was partially displaced on arrival to hospital). PICC removed 3/16 given MRSA bacteremia. Given MRSA in the knee, taken for a right knee washout with orthopedics on 3/17. This facility's intravenous therapy policy, revised 8/7/23, notes all intravenous access will be assessed by the nurse to ensure that no signs and symptoms of infection and infiltration are left unaddressed. All central line dressings (PICC line) will be changed every 7 days. The length of the external catheter and extremity circumference will be measured weekly to monitor movement and edema (swelling).

Based on observation, interview, and record review the facility failed to ensure food containers are stored off the floor and ensure staff are employing hygienic practices during food handling in the dining room. This deficiency has the potential to affect all 165 residents receiving food from the kitchen. Findings include: On 4/23/2024 at 11:05 AM, observed 6 cans of fruit cocktail on the floor in the dry storage room during the initial tour. On 4/23/2024 at 11:05 AM, V12 (Cook) stated those cans should not be on the floor. On 4/23/2024 at 01:00 PM, V1 (Administrator) stated cans of food should be stored on the shelves when delivered. It should be off the floor. On 4/23/2024 at 12:23 PM, observed V13 (Dietary Aide) during lunch in the dining room touched and adjusted her eyeglasses with gloved hands then proceeded to continue preparing food without performing hand hygiene and changing gloves. On 4/23/2024 at 12:24 PM, V13 said I should have changed gloves before continuing to prepare food. On 4/24/2025 at 10:31 AM, V3 (Assistant Director of Nursing/Infection Control) stated V13 should have removed her gloves and performed hand hygiene after touching her eyeglasses and before continuing her task. Policy: Food Storage - Dry Goods, Revision History Date: October 2019 Policy Statement: It is the center policy to insure all dry goods will be appropriately stored in accordance with guidelines of the FDA Food Code. Action Steps: Dry Storage 1. The Dining Services Director or designee is responsible to store all items 6 inches above the floor on shelves. Facility unable to provide Food Handling Policy

Based on observation, interview, and record review the facility failed to implement appropriate transmission-based precaution and to provide the necessary personal protective equipment (PPE) supplies readily accessible for use by staff and visitors for 3 of 3 residents (R153, R47, R131) reviewed for transmission-based precaution in a sample of 37. Findings include: On 4/23/2024 at 12:05 PM, R153 identified positive COVID 19 and on isolation. Observed isolation signage outside room as Contact Precaution, no other sign identified. On 4/23/2024 at 12:05 PM, V11 (License Practical Nurse - LPN) stated R153 is on isolation for COVID 19 and should have a signage of Contact and Droplet Precaution. On 4/23/2024 at 01:00 PM, V2 (Director of Nursing - DON) said R153 should be Droplet Precaution. On 4/24/2024 at 10:31 AM, V3 (Assistant Director of Nursing/Infection Control) stated R153 should have a signage outside the room of Contact and Droplet Precaution. On 4/23/2024 at 11:45 AM, R47 and R131 on Contact Precaution with Personal Protective Equipment (PPE) bin set-up outside the room. PPE bin without the necessary glove supplies readily accessible for use by staff and visitors. On 4/23/2024 at 11:49 AM, V10 (Registered Nurse - RN) said there should be gloves on the isolation bin for immediate use. Central Supply Personnel is responsible for making sure there is PPE supplies available. V10 stated I will go look for gloves now. On 4/24/2024 at 10:31 AM, V3 (Assistant Director of Nursing/Infection Control) stated isolation bin should have the complete PPE supplies, including gloves, readily accessible for use. (R153) Order Summary Report include: Isolation Precaution: Contact/Droplet - Reason for Isolation: COVID+ (R47, R131) Order Summary Report include: Isolation- contact precautions, Reason for isolation: MRSA sacral wound Care Plan: Focus: R153 requires Droplet/Contact Precautions related to: COVID 19 Focus: Isolation Contact Precautions: R47 is on contact isolation related to MRSA of wound Focus: Isolation Contact Precautions: R131 is on contact isolation related to MRSA of wound Policy: Name: Infection Prevention and Control, Revised 10/23/23 Policy Statement: The facility has established a policy to Identify, Record, Investigate, Control, Test, and Prevent infections in the facility. The facility will also maintain a record of incidents and corrective actions implemented for 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. 8. A sign will be provided outside the room for residents on transmission-based precaution indicating the type of the precaution (Contact, Droplet, or EBP).

Based on observation, interview and record review the facility failed to identify supervision needs and implement measures to reduce fall risk for a confused resident at risk for falls, failed to implement plan of care interventions and falls policy to prevent resident's fall and injury. This failure affects 1 (R1) of 3 residents reviewed for accidents/incidents in the sample and resulted in R1 being emergently transferred to the hospital for hip fracture with surgical intervention. Findings include: R1 is a [AGE] year old male admitted to the facility on [DATE] with diagnosis including but not limited to Retention of Urine, Unspecified; Polyosteoarthristis, Unspecified; Atrioventricular Block, Second Degree; Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, and Anxiety; Altered Mental Status, Unspecified; Unspecified Symptoms and Signs Involving Cognitive Function and Awareness; Unspecified Hearing Loss; Adult Failure to Thrive; and Fracture of Unspecified Part of Neck of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing. According to most recent MDS (Minimum Data Set) before the fall (that occurred on 10/26/2023) dated 09/01/2023, under section C, R1 has BIMS (Brief Interview of Mental Status) score of 2 indicating severe cognitive impairment; under section G, R1 needs extensive assistance, one person physical assist for transfers, and R1 not steady, only able to stabilize with staff assistance moving from seated to standing position. Per record review, Fall Risk Evaluation dated 09/01/2023 reads in part, Score 4; scoring: 0-7 = low risk. Per record review, Fall Risk Evaluation dated 10/26/2023 reads in part, Score 13; scoring: 8 and above = high risk. Per record review, R1's fall care plan reads in part, R1 has unsteady balance, able to stabilize without staff assist, please monitor R1's balance and assist as needed. I (R1) would like staff to address my needs with a prompt response to all requests for assistance. On 11/13/2023 at 10:07 AM, Surveyor interviewed V8 (Licensed Practical Nurse) who related the following in summary but non-verbatim: Nurses round on residents upon beginning of their shift; however, there is no rounding schedule for nurses. Certified Nursing Assistants are our eyes and ears, and they do the rounding. When we have agency CNAs, we, floor nurses, orientate them upon beginning of their shift to familiarize them with residents. There is also a list that summarizes high fall risk residents and their needs for agency staff to review. Residents' names who are on high risk for fall are also marked with gold leaf as a visual reminder. On 11/15/2023 at 02:08 PM, Surveyor interviewed V2 (Director of Nursing/Interim Falls Coordinator) who related the following in summary but non-verbatim: The expectation on staff rounding is to have nurses and CNAs round at the beginning of their shift and at least every couple of hours throughout the rest of the shift for both, nurses and CNAs. On 11/13/2023 at 10:18 AM, V8 (LPN) provided memory care unit high risk fall residents' list. List reviewed, R1 not included on the high risk fall list. On 11/13/2023 at 10:23 AM, R1 not in the room at this time. No gold leaf observed by R1's name outside of the room. On 11/13/2023 at 10:35 AM, Surveyor interviewed V6 (Agency Certified Nursing Assistant) who related the following in summary but non-verbatim: Nurses give us verbal update on residents' needs, but I am not aware of any resident list pertaining to their specific needs, I've never seen it before. On 11/13/2023 at 02:42 PM, Surveyor interviewed V6 (Agency Certified Nursing Assistant) who related the following in summary but non-verbatim: We are vigilant when working on the third floor because it is dementia unit. I remember R1. I was the one who took care of him on the evening of 10/26/2023. R1 usually goes to bed around 7.30 pm. That evening, I came out of adjacent room, peaked into R1's room and noticed, that he was sitting on the edge of the bed, ready to be assisted to go to bed for the night. I asked R1 to give me a minute while I go to throw away the garbage. When I came back, R1 was already on the hallway floor with his walker beside him and his roommate standing next to him. R1 was complaining of left leg pain. I notified the nurse and R1 was sent to the hospital via 911. R1 is confused, requires 1 person assist with Activities of Daily Living and walking, although he often walks by himself, always with the walker. I don't consider R1 safe to walk by himself. R1 doesn't use a call light and is forgetful. R1 tends to walk out of the room when he needs something instead of using call light. Additionally, R1 is hard of hearing. On 11/13/2023 at 3:50 PM, Surveyor interviewed V9 (Licensed Practical Nurse) who related the following in summary but non-verbatim: On the evening of 10/26/2023, R1 was in the new room when he fell . R1 was not aware of new surroundings since he was moved to the new room the day before. R1's roommate thought that R1 was knocking on the door, and pushed the door as R1 was standing in the doorway. R1 might have gotten startled and fell in the hallway, right outside of the room. V6 (CNA) alerted me about the fall. I approached R1 and assessed him, including vital signs, neurological check, and checked for leg shortening as he was complaining of left leg pain. I asked R1 what happened, but he was unable to recall. R1 was just holding onto his leg, saying that it hurts. We treat all residents on memory unit as a fall risk. Fall risk resident have gold leaf by their names. R1 was ambulatory with a walker but very confused. R1 needed assistance with some Activities of Daily Living and one person assist with getting in and out of the bed. Per record review, hospital record dated 11/01/2023 reads in part, R1 presents to the hospital status post hip fracture. On 10/28 (2023) R1 underwent a left hip open reduction and internal fixation surgery and required postoperative pain management. On 11/13/2023 at 04:12 PM, R1 observed asleep in the bed at this time. Bed alarm pad underneath the resident, bed alarm monitor stored away in the drawer, in the nightstand, next to the R1's bed. On 11/14/2023 at 11:51 AM, Surveyor interviewed V2 (Director of Nursing/Interim Falls Coordinator) who related the following in summary but non-verbatim: R1's fall investigation consisted of staff and roommate interview, we also discussed R1's fall during interdisciplinary team meeting. R1's post fall precaution interventions are: reorienting to surrounding environment and bed alarm; R1's fall precaution interventions previous to the fall were: call light within reach and proper footwear. R1 wasn't a fall risk resident before the fall. We came to this conclusion based on R1's assessments including: no previous falls, whether there was significant change, additionally, we observed R1. R1 was safe to walk unassisted. We determined that the fall that occurred on 10/26/2023 was unavoidable because R1 was pushed by the door. On 11/14/2023 at 3:00 PM, Surveyor interviewed V5 (Restorative Nurse/Interim Fall Coordinator) who related the following in summary but non-verbatim: On 09/01/2023, I assessed R1's Minimum Data Set, section G -Functional Status, based on CNAs documentation, restorative aid comments, and my own assessment. For sit to stand transfer, R1's functional status was graded as 3 - extensive assistance and 2 - one person assist because the CNA placed gait belt on R1 and pulled him up, R1 needed 50% assistance from staff, was unable to complete the task independently. Before the fall on 10/26/2023, R1 wasn't high risk fall resident; however, after the incident, R1 became a high risk fall resident. R1 needs now physical and occupational therapy due to incident/fracture. R1 is not safe to ambulate with a walker like he used to, he uses wheelchair now. On 11/15/2023 at 9:50 AM, Surveyor interviewed V7 (Nurse Practitioner) who related the following in summary but non-verbatim: R1 is a [AGE] year old male who's minimally verbal, doesn't answer questions, follows minimum commands, and is confused, only able to state his name. R1 is also hard of hearing. The main issue when communicating with R1 is not so much trouble hearing, it is his progressive dementia due to old age. I last assessed R1 before the fall (that occurred on 10/26/2023), on 08/08/2023. I didn't see him walk at that time, and even before then, R1 was mostly in his bed. R1 had overall decline in health since August of 2023. I performed full assessment, including chest x-ray and blood work, but there has not been indication of an ongoing infection, R1 has been just declining due to his age. Surveyor further clarified, if I said (R1), I'll back in a minute, just wait for me would R1 be able to understand that command? V7 (NP) stated, No, I doubt R1 would understand that. On 11/15/2023 at 2:48 PM, Surveyor interviewed V10 (Nurse Practitioner 2) who related the following in summary but non-verbatim: (Nurse Practitioner) I've been taking care of R1 for the last year, I see him about once a month. The biggest communication issue with R1 is that he can't hear but just agrees with you; and it has been especially challenging with staff wearing masks. R1 would not remember to use the call light taking his BIMS score into consideration, and his dementia also plays a big role. High-Risk Fall Identification Process policy, not dated, reads in part, The visual identifier is used to identify residents who are on the program. The identifier may be in place next to the resident's name outside of the room. By making it easy to identify high-risk resident's, staff can quickly initiate action to reduce the risk of falling and injuries. Fall Occurrence policy dated 07/17/2023 reads in part: It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary. If a resident had fallen, the resident is automatically considered as high risk for falls.

Based on interview and record review, the facility failed to have effective interventions in place to keep residents free from physical abuse. This failure applied to two (R4 and R5) of three residents reviewed for abuse. Findings include: R4 and R5 are the subjects of this incident investigation. R4 is a [AGE] year-old resident admitted on [DATE]. R4 has medical diagnoses that include: unspecified psychosis, Alzheimer's disease, anxiety, and unspecified dementia with other behavioral disturbances. R4's abuse assessment upon admission, dated 7/20/23, documents that R4 is at risk of abuse. Narrative section documents that R4 yells at staff and tell them to drop dead and poke her finger at them; she also spits. R4's current care plan includes a focus with date initiated 7/20/23 and reads: (R4) exhibits agitation and calls out and has hit the staff as well as bit another resident; Behavior Focus includes (R4) exhibits confusion r/t her Dementia. She has been spitting on the floor and at staff. Per son, she does this when she is in new surroundings. Interventions include: Identify if there are behaviors or factors from the past that should be considered in treatment planning and conduct appropriate assessments to promote knowledge and understanding of the resident's past. R5 is a [AGE] year-old resident admitted on [DATE]. R5 has medical diagnoses that include: other schizoaffective disorders, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and insomnia due to other mental disorder. R5's abuse assessment upon admission, dated 8/15/23, documents that R5 is at risk of abuse. Narrative section documents that R5 has a diagnosis of Alzheimer's Disease, Major Depressive d/o , Anxiety d/o and Psychotic d/o. She will grab onto others which doesn't appear to be intentional but more so due to her confusion. R5's current care plan includes a focus with date initiated 12/31/21 and reads: (R5) presents with anxious and restless behaviors and has been identified to have had a difficult or troubled past .presents with behavioral symptoms including minimizing her mental health and psychosocial issues socially inappropriate behavior such as yelling and grabbing onto others .BEHAVIOR/IMPULSIVENESS: (R5) exhibits significant confusion r/t her Alzheimer's Disease and does not appear to be oriented to her surroundings. She often attempts to get up without regard to her own safety, she also slides herself down when in her w/c and his been observed attempting to lift her legs to her chest while in her w/c. She tends to lean onto others when she does walk with assistance. She also grabs others as they walk by her and holds on tightly without letting go and will attempt to pull them closer to her. More recently, she has been dangling her legs while lying in bed between the bedrails and over the bedrails. These behaviors put her at high risk for falling, obtaining an injury, and/or abuse Date Initiated: 04/06/2022 . Interventions include: Identify if there are behaviors or factors from the past that should be considered in treatment planning and conduct appropriate assessments to promote knowledge and understanding of the resident's past. Facility submitted final incident report dated 8/25/23, submitted by V2 (Director of Nursing): On 8/20/2023 at approximately 2:15 pm, CNA (V4) reported that while in the dining room, he observed (R4) bite resident (R5) in the left hand. Both residents were immediately separated and assessed by NOD. Body check was completed on both residents and resident (R5) was noted with bite marks to her left hand, no broken skin was noted. Resident (R4) is AAOx1, confused, with diagnosis of Alzheimer's disease, anxiety disorder, blindness to right eye, and macular degeneration. She has poor Judgement and decision-making skills. POA for (R4), and MD were notified. (R4) was placed on 1:1 supervision pending transfer to ED for evaluation. POA for (R5) and NP were notified. The investigation identified that both residents have cognitive impairments and lack willful intent to harm. Resident (R5) is a [AGE] year old female who is AAO x 0 with confusion and with severely impaired cognition. She has a diagnosis of Alzheimer's Disease with early onset and Psychotic Disorder with Anxiety. She has care planed behaviors that address her attempts of reaching out to others and attempting to pull them close to her and grabbing items and not letting go. She exhibits difficulty with concentration due to her Alzheimer's disease, which makes it difficult for her to process the environment around her and her behaviors do not appear intentional but more so are related to her confusion. Post incident resident did not exhibit any psychosocial distress. Resident (R4) is a [AGE] year old female who is AAO x 1 with periods of confusion and agitation. She has a diagnosis of Alzheimer's disease, Anxiety, Depression and has right eye blindness. She scored a 1/15 on the BIMs indicating severe cognitive impairment. She has care planned behaviors that address her becoming easily annoyed with others, her agitation and poor impulse control. Based upon the investigation conducted, it has been determined that both residents lacked willful intent to harm based on their severely impaired cognition and confusion causing them to have poor Judgement and decision-making skills. Physical Abuse cannot be substantiated. 9/22/23 at 1:48 PM V4 (CNA) stated (regarding incident between R4 and R5), that they were in the dining room, and he saw R4 go towards R5 and R5 said that R4 was pulling her. Then R4 bit R5. After that, R4 was put on one-to-one supervision. V4 said that he had not witnessed these behaviors prior to this incident. V4 said he did report the incident but couldn't remember to who he reported it to and that now R4 is seated by herself at the table and is provided activities to keep her distracted. V4 did not recall other staff in the dining room who may have witnessed incident. 9/22/23 at 1:37 PM V5 (CNA) confirmed that she has worked at the facility for about a year and usually works on this floor so is familiar with the residents. V5 was not on duty during the incident between R4 and R5 but stated that she is familiar with R4's behavior of grabbing on people and spitting at people. V5 confirmed that R4 needs to be kept busy with activities but only participates when she feels like it. 9/23/23 at 3:58 PM V2 (Director of Nursing) was asked about the incident between R4 and R5 and said, we tell the staff to separate her (R4) if they see that she's reaching out to people. She is blind and so she reaches out and puts things in her mouth. Her son is here frequently to help keep her busy and give her one-on-one time. That helps. Facility provided Abuse and Neglect Policy (Effective Date: 7/14/23), which reads: Policy Statement: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. Definitions of Abuse, Neglect, Exploitation, & Abuse Coordinator Abuse Abuse is willful infliction of mistreatment, injury, unreasonable confinement, intimidation, or punishment. Abuse assumes intent to harm, but inadvertent or careless behavior done deliberately that results in harm may be considered abuse. Types of abuse. 1. Physical 2. Verbal 3. Mental 4. Sexual 5. Neglect (including medical neglect) 6. Theft/ Misappropriation of Property/Financial abuse 7. Involuntary Seclusion 8. Exploitation 9. Injury of Unknown Origin . Types of Abuse and Examples 1. Physical: Physical abuse includes but not limited to infliction of injury that occur other than by accidental means and requires medical attention. Examples: hitting, slapping, kicking, squeezing, grabbing, pinching, punching, poking, twisting, and roughly handling. Any person in a position of power or authority may potentially cause harm to a resident. Potential aggressors include but are not limited to, facility staff, other residents, state employers, family members, volunteers, students in an affiliated Nurse-training Program, students in affiliated academic institutions including therapy, social, and activity programs, guardian, and other visitors . Prevention (483.13 (b) and 483.13 (c)): Have procedures to: o Provide residents, families, and staff information on how and to whom they may report concerns, incidents, and grievances without fear of retribution: and provide feedback regarding the concerns that have been expressed. .o Identify, correct, and intervene in situations in which abuse, neglect, exploitation, and/or misappropriation of resident properly is more likely to occur. o Establish a safe environment that supports consensual sexual relationship o Develop and implement policy on abuse, neglect, theft, exploitation, and misappropriation of property o Deployment of sufficient and trained staff to deal with behaviors in the units o Identification, assessment, care planning for intervention, and monitoring of residents with needs and behaviors that might lead to conflicts or neglect .

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive fall prevention plan of care for 1 of 3 residents (R1) reviewed for fall care planning in the sample. Findings include: R1 is a [AGE] year old with severe cognitive impairment and diagnosis of dementia, major depressive disorder, atrial fibrillation and hypertension. Care Plan dated 8/9/2022 shows in part, (R1) is at risk for falls related to: Current medication use antidepressants and antipsychotics, Disease process (Polyosteoarthritis, UTI, A-Fib., HTN, Depressive disorder, Dementia). R1 utilizes a wheelchair as primary means for locomotion. R1 will be free of falls through next review date. Ensure R1 is sitting in the center of her wheelchair, offer and assist to take naps in her bedroom in between meals. Keep call light within reach when in bedroom or bathroom. Side rails to aid in bed mobility and transfers. Use of assistive device during ambulation to prevent falls. There were no interventions for assistive/preventative devices such as chair alarms and/or wedge cushions or other devices while in wheelchair to prevent further accidental falls. A fall risk assessment dated [DATE] showed R1 at high risk for falls. On 8/11/23 at 10:22 AM, R1 was observed in the dining area slumped over and asleep in a wheelchair. R1 displayed facial injuries of a swollen lip with dried blood on the right side of her mouth and a right eye that appeared to be swollen shut. R1 was slumped over to the same side she had recently fallen on and there were no preventative devices observed such as a chair alarm nor wedge cushion to prevent R1 from further falls. V5 (Memory Care Manager) stated, This is her usual place in the dining room and it was where she was seated when she fell over last week. Surveyor asked what the facility did to prevent the fall from happening to begin with, V5 stated, There is usually somebody here to watch the residents but I was told that she just ended up on the floor. Surveyor asked again if there was anything else the facility did to prevent R1 from falling, V5 stated, You would have to ask the nurses about that. Surveyor asked what her role was on the unit, V5 stated, I am the memory care manager for this dementia unit. V11 (CNA/Certified Nursing Aide) who was standing nearby was asked about R1 stated, R1 fell during the morning shift but I was not here that time. I am assigned to watch this room (dining room) today and you can see there are a lot of residents here so we can't get to all of them if they fall. Surveyor counted the number of residents in the room which showed 41 residents with only V11 monitoring the room. Surveyor asked V11 who the residents were that were at risk for falls currently in the dining room, V11 stated, I don't know, I think they all are. On 8/11/23 at 1:31 PM, V4 (LPN) stated, I am a new nurse here about 1 month. I remember when (R1) fell because that was my first time working that floor and on that day I remembered I was passing medications and (R1) was in the dining room waiting for breakfast and there was a CNA watching the residents. I didn't hear anything and the CNA just came running out and said (R1) fell and she was lying on her right side and she was bleeding on the floor. I called the DON (V2) and we do check up and everything and she helped me with my assessment. We ordered X-rays for a possible fracture and I immediately sent her 911 to hospital for further evaluation. Surveyor asked who the CNA was that was assigned to watch the dining room, V4 stated, She was agency CNA that day and was supposed to be there and she said she just heard a noise, but the resident was already on the floor Surveyor asked what preventative measures were in place to prevent R1 from falling, V4 stated, I am not sure. I am new but I know the CNA should be watching the room. Surveyor asked if she was provided any fall prevention training during her orientation, V4 stated, Not really. Surveyor asked V4 how she knew R1 did not lose consciousness since she did not witness the fall, V4 stated, I don't know. Surveyor asked if she asked R1 if she knew she lost consciousness, V4 stated, No she is too confused. On 8/12/23 at 3:09 PM, V8 (Agency CNA) stated, I'm with agency and I had just got there that day and they (facility) assigned me to be in charge of watching the dining room. I didn't see (R1) fall and I didn't even know her but I was with another patient when she fell . I think everyone else was passing trays or feeding residents when the patient fell . I just heard this loud noise. There was some other resident by her before she fell , but like I said I don't know the residents at all since it was my first time there. All I heard was just the noise of her falling hard . Surveyor asked if she ever worked another shift at the facility, V8 stated, No I haven't been back since that last time and I only was there once. Surveyor asked if she was told anything about fall interventions or fall risk of residents, V8 stated, No, I didn't know anything about her fall risk. Is she one because they didn't tell me anything? All they do like every place is give you the residents and they don't tell you anything. Surveyor asked if she received any kind of dementia or fall prevention training, V8 stated, I'm with agency, they don't do training. On 8/11/23 at 11:15 AM, V15 (Clinical Manager) stated, I am usually on the dementia floor but I am on call for the whole building. Surveyor asked what her role was in preventing falls in the building as the clinical manager, V15 stated, The only thing I did was check the wheelchair for malfunctioning. I helped the nurse with the assessments but V4 was the nurse on duty so she did most of the paperwork. Surveyor asked if she was part of the IDT (interdisciplinary team) and if they discussed fall prevention, V15 stated, I am part of the IDT and we discussed R1's incident that happened and she needed the x-rays and went to the hospital, but that is all I do. The restorative nurse manager (V7) does the root cause analysis regarding R1's fall but she's been on maternity leave. I don't do that. We do not do anything else. We don't discuss fall prevention in the meetings and the restorative nurse and her team are responsible for the fall prevention. I also do psychotropic review, I do medication review, but I do not have any input in the falls whatsoever. Surveyor asked if she saw R1's injuries or assessed R1 after she fell , V15 stated, No I did not, I was not present during the incident. Surveyor clarified what her role was for the building, V15 stated, I am an RN BSN and the clinical manager for the facility. Policy dated August 5, 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 them from falling. A fall risk assessment form will be completed by the nurse upon admission, readmission, quarterly, significant change and annually. Those identified as high risk for falls will be provided interventions to prevent falls. An interim Falls Care Plan may be started but a Fall Care Plan is necessary and required after the State required MDS was done.

Based on observation, interview and record review, the facility failed to provide care in accordance with professional standards of quality by failing to prevent falls with significant injuries, and failed to train facility nursing staff on fall preventions and provide implementation of assistive and/or preventative devices to prevent falls. This failure affected 1 of 3 residents (R1) reviewed for falls in the sample. Findings include: R1 is a [AGE] year old with severe cognitive impairment and diagnosis of dementia, major depressive disorder, atrial fibrillation and hypertension. Care Plan dated 8/9/2022 shows in part, (R1) is at risk for falls related to: Current medication use antidepressants and antipsychotics, Disease process (Polyosteoarthritis, UTI, A-Fib., HTN, Depressive disorder, Dementia). R1 utilizes a wheelchair as primary means for locomotion. R1 will be free of falls through next review date. Ensure R1 is sitting in the center of her wheelchair, offer and assist to take naps in her bedroom in between meals. Keep call light within reach when in bedroom or bathroom. Side rails to aid in bed mobility and transfers. Use of assistive device during ambulation to prevent falls. There were no interventions for assistive/preventative devices such as chair alarms and/or wedge cushions or other devices while in wheelchair to prevent further accidental falls. A fall risk assessment dated [DATE] showed R1 at high risk for falls. A facility incident report dated 8/2/23 written by V4 (LPN) reads in part, Went directly to resident (R1) and noticed her lying on her right side. Notified by CNA that resident was lying on the right side. Resident was immediately assessed. Resident was awake, no loss of consciousness. Neurological checks initiated and ongoing PERRLA (pupils equal, round, reactive to light and accommodation) . On 8/11/23 at 1:31 PM, V4 (LPN) stated, I am a new nurse here about 1 month. I remember when (R1) fell because that was my first time working that floor and on that day I remembered I was passing medications and (R1) was in the dining room waiting for breakfast and there was a CNA watching the residents. I didn't hear anything and the CNA just came running out and said (R1) fell and she was lying on her right side and she was bleeding on the floor. I called the DON (V2) and we do check up and everything and she helped me with my assessment. We ordered X-rays for a possible fracture and I immediately sent her to hospital for further evaluation. Surveyor asked who the CNA was that was assigned to watch the dining room, V4 stated, She was agency CNA that day and was supposed to be there and she said she just heard a noise, but the resident was already on the floor Surveyor asked what preventative measures were in place to prevent R1 from falling, V4 stated, I am not sure. I am new but I know the CNA should be watching the room. Surveyor asked if she was provided any fall prevention training during her orientation, V4 stated, Not really. Surveyor asked V4 how she knew R1 did not lose consciousness since she did not witness the fall, V4 stated, I don't know. Surveyor asked if she asked R1 if she knew she lost consciousness, V4 stated, No she is too confused. On 8/12/23 at 3:09 PM, V8 (Agency CNA) stated, I'm with agency and I had just got there that day and they (facility) assigned me to be in charge of watching the dining room. I didn't see (R1) fall and I didn't even know her but I was with another patient when she fell . I think everyone else was passing trays or feeding residents when the patient fell . I just heard this loud noise. There was some other resident by her before she fell , but like I said I don't know the residents at all since it was my first time there. All I heard was just the noise of her falling hard . Surveyor asked if she ever worked another shift at the facility, V8 stated, No I haven't been back since that last time and I only was there once. Surveyor asked if she was told anything about fall interventions or fall risk of residents, V8 stated,No I didn't know anything about her fall risk. Is she one because they didn't tell me anything? All they do like every place is give you the residents and they don't tell you anything. Surveyor asked if she received any kind of dementia or fall prevention training, V8 stated, I'm with agency, they don't do training. On 8/11/23 at 11:15 AM, V15 (Clinical Manager) stated, I am usually on the dementia floor but I am on call for the whole building. Surveyor asked what her role was in preventing falls in the building as the clinical manager, V15 stated, The only thing I did was check the wheelchair for malfunctioning. I helped the nurse with the assessments but V4 was the nurse on duty so she did most of the paperwork. Surveyor asked if she was part of the IDT (interdisciplinary team) and if they discussed fall prevention, V15 stated, I am part of the IDT and we discussed R1's incident that happened and she needed the x-rays and went to the hospital, but that is all I do. The restorative nurse manager (V7) does the root cause analysis regarding R1's fall but she's been on maternity leave. I don't do that. We do not do anything else. We don't discuss fall prevention in the meetings and the restorative nurse and her team are responsible for the fall prevention. I also do psychotropic review, I do medication review, but I do not have any input in the falls whatsoever. Surveyor asked if she saw R1's injuries or assessed R1 after she fell , V15 stated, No I did not, I was not present during the incident. Surveyor clarified what her role was for the building, V15 stated, I am an RN BSN and the clinical manager for the facility. Facility radiology results report interpreted by V13 (MD) shows in part, There is evidence of suspected acute subcapital fracture of the right proximal femur. The hip space is narrowed and the femoral head has abnormal contour. Impression: Subcapital fracture right proximal femur suspected. Hospital records dated 8/2/2023 and signed by V14 (Hospital Physician) shows in part, [AGE] year old female with past medical history of dementia, atrial fibrillation and anticoagulation presents status post fall. Already with outpatient X-ray showing hip fracture, will repeat X-ray of hip and chest here, CT scans of head, neck, face ordered. Will dermabond wound here (face). Will reassess but anticipate admission. Facial lacerations; X-rays of the right hip were performed; multiple CT scans for the brain without contrast, CT scan for cervical spine, CT scan for the maxillorfacial area; and finally, a CT scan of the right hip. Policy dated August 5, 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 them from falling. A fall risk assessment form will be completed by the nurse upon admission, readmission, quarterly, significant change and annually. Those identified as high risk for falls will be provided interventions to prevent falls.

Based on observation, interview and record review, the facility failed to provide adequate supervision for 1 of 3 (R1) residents with severe cognitive impairment and fall risk reviewed for accident/hazards in the sample; failed to provide an environment that was free of accidental hazards; and failed to follow R1's plan of care to prevent accidental falls. Findings include: On 8/11/23 at 10:22 AM, R1 was observed in the dining area slumped over and asleep in a wheelchair. R1 displayed facial injuries of a swollen lip with dried blood on the right side of her mouth and a right eye that appeared to be swollen shut. R1 was slumped over to the same side she had recently fallen on and there were no preventative devices observed such as a chair alarm nor wedge cushion to prevent R1 from further falls. V5 (Memory Care Manager) stated, This is her usual place in the dining room and it was where she was seated when she fell over last week. Surveyor asked what the facility did to prevent the fall from happening to begin with, V5 stated, There is usually somebody here to watch the residents but I was told that she just ended up on the floor. Surveyor asked again if there was anything else the facility did to prevent R1 from falling, V5 stated, You would have to ask the nurses about that. Surveyor asked what her role was on the unit, V5 stated, I am the memory care manager for this dementia unit. V11 (CNA/Certified Nursing Aide) who was standing nearby was asked about R1 stated, R1 fell during the morning shift but I was not here that time. I am assigned to watch this room (dining room) today and you can see there are a lot of residents here so we can't get to all of them if they fall. Surveyor counted the number of residents in the room which showed 41 residents with only V11 monitoring the room. Surveyor asked V11 who the residents were that were at risk for falls currently in the dining room, V11 stated, I don't know, I think they all are. R1 is a [AGE] year old with severe cognitive impairment and diagnosis of dementia, major depressive disorder, atrial fibrillation and hypertension. Care Plan dated 8/9/2022 shows in part, (R1) is at risk for falls related to: Current medication use antidepressants and antipsychotics, Disease process (Polyosteoarthritis, UTI, A-Fib., HTN, Depressive disorder, Dementia). R1 utilizes a wheelchair as primary means for locomotion. R1 will be free of falls through next review date. Ensure R1 is sitting in the center of her wheelchair, offer and assist to take naps in her bedroom in between meals. Keep call light within reach when in bedroom or bathroom. Side rails to aid in bed mobility and transfers. Use of assistive device during ambulation to prevent falls. A fall risk assessment dated [DATE] showed R1 at high risk for falls. A facility incident report dated 8/2/23 written by V4 (LPN) reads in part, Went directly to resident (R1) and noticed her lying on her right side. Notified by CNA that resident was lying on the right side. Resident was immediately assessed. Resident was awake, no loss of consciousness. Neurological checks initiated and ongoing PERRLA (pupils equal, round, reactive to light and accommodation) . On 8/11/23 at 1:31 PM, V4 (LPN) stated, I am a new nurse here about 1 month. I remember when (R1) fell because that was my first time working that floor and on that day I remembered I was passing medications and (R1) was in the dining room waiting for breakfast and there was a CNA watching the residents. I didn't hear anything and the CNA just came running out and said (R1) fell and she was lying on her right side and she was bleeding on the floor. I called the DON (V2) and we do check up and everything and she helped me with my assessment. We ordered X-rays for a possible fracture and I immediately sent her to hospital for further evaluation. Surveyor asked who the CNA was that was assigned to watch the dining room, V4 stated, She was agency CNA that day and was supposed to be there and she said she just heard a noise, but the resident was already on the floor Surveyor asked what preventative measures were in place to prevent R1 from falling, V4 stated, I am not sure. I am new but I know the CNA should be watching the room. Surveyor asked if she was provided any fall prevention training during her orientation, V4 stated, Not really. Surveyor asked V4 how she knew R1 did not lose consciousness since she did not witness the fall, V4 stated, I don't know. Surveyor asked if she asked R1 if she knew she lost consciousness, V4 stated, No she is too confused. On 8/12/23 at 3:09 PM, V8 (Agency CNA) stated, I'm with agency and I had just got there that day and they (facility) assigned me to be in charge of watching the dining room. I didn't see (R1) fall and I didn't even know her but I was with another patient when she fell . I think everyone else was passing trays or feeding residents when the patient fell . I just heard this loud noise. There was some other resident by her before she fell , but like I said I don't know the residents at all since it was my first time there. All I heard was just the noise of her falling hard . Surveyor asked if she ever worked another shift at the facility, V8 stated, No I haven't been back since that last time and I only was there once. Surveyor asked if she was told anything about fall interventions or fall risk of residents, V8 stated,No I didn't know anything about her fall risk. Is she one because they didn't tell me anything? All they do like every place is give you the residents and they don't tell you anything. Surveyor asked if she received any kind of dementia or fall prevention training, V8 stated, I'm with agency, they don't do training. On 8/11/23 at 11:15 AM, V15 (Clinical Manager) stated, I am usually on the dementia floor but I am on call for the whole building. Surveyor asked what her role was in preventing falls in the building as the clinical manager, V15 stated, The only thing I did was check the wheelchair for malfunctioning. I helped the nurse with the assessments but V4 was the nurse on duty so she did most of the paperwork. Surveyor asked if she was part of the IDT (interdisciplinary team) and if they discussed fall prevention, V15 stated, I am part of the IDT and we discussed R1's incident that happened and she needed the x-rays and went to the hospital, but that is all I do. The restorative nurse manager (V7) does the root cause analysis regarding R1's fall but she's been on maternity leave. I don't do that. We do not do anything else. We don't discuss fall prevention in the meetings and the restorative nurse and her team are responsible for the fall prevention. I also do psychotropic review, I do medication review, but I do not have any input in the falls whatsoever. Surveyor asked if she saw R1's injuries or assessed R1 after she fell , V15 stated, No I did not, I was not present during the incident. Surveyor clarified what her role was for the building, V15 stated, I am an RN BSN and the clinical manager for the facility. Facility radiology results report interpreted by V13 (MD) shows in part, There is evidence of suspected acute subcapital fracture of the right proximal femur. The hip space is narrowed and the femoral head has abnormal contour. Impression: Subcapital fracture right proximal femur suspected. Hospital records dated 8/2/2023 and signed by V14 (Hospital Physician) shows in part, [AGE] year old female with past medical history of dementia, atrial fibrillation and anticoagulation presents status post fall. Already with outpatient X-ray showing hip fracture, will repeat X-ray of hip and chest here, CT scans of head, neck, face ordered. Will dermabond wound here (face). Will reassess but anticipate admission. Facial lacerations; X-rays of the right hip were performed; multiple CT scans for the brain without contrast, CT scan for cervical spine, CT scan for the maxillorfacial area; and finally, a CT scan of the right hip. Policy dated August 5, 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 them from falling. A fall risk assessment form will be completed by the nurse upon admission, readmission, quarterly, significant change and annually. Those identified as high risk for falls will be provided interventions to prevent falls.

Based on observation, interview and record review the facility failed to ensure a resident was free from physical abuse. This applies to 1 of 6 (R1) residents reviewed for abuse in the sample of 12. The findings include: The facility's Final Abuse Report dated 6/15/23 documents on 6/10/23 (R1) reported to V13 (Nurse Supervisor) that he was involved in a resident-to resident altercation with (R2). (R1) was noted with an abrasion above his upper lip. (R2) is alert and oriented to self, confused with diagnosis of dementia, delusion disorder and anxiety. (R2) has poor judgement and decision-making skills .(R2) was sent out for further evaluation. R1's Minimum Data Set assessment dated [DATE] shows he's cognitively intact. R1's nurse's note dated 6/10/23 documents, notified by (V13) (R1) had an altercation with another resident (R2) that resulted in (R1) bleeding in the upper lip. On 6/30/23 at 9:10 AM, R1 was observed in his room. He said on 6/10/23, R2 was wandering into another resident's room. I told him he was not supposed to be in there. I held on to his wheelchair and started [NAME] him out and that's when he hit me in the face by my lip and drew blood. I told him to stop, and I did not engage back. He attacked me. R9 was there and saw what happened. I reported the incident to V13. R2 has been physical before, and he wanders into other resident's room. On 6/30/23 at 9:27 AM, R9 said (R2) was in another resident's room going thru all his things. R1 went in the room to get him out of there. R1 held onto R2's wheelchair handles and started getting him out of the room and that's when R2 hit R1 in the face by his mouth. I saw it happen. R2 doesn't speak English and he wanders into other resident rooms and has been physical with other residents. On 6/30/23 at 12:34 PM, V13 (Nurse Supervisor) said she was alerted of the incident with R1 and R2. She said R1 reported R2 hit him the face. He was trying to get R2 out of another resident's room. R1 had an abrasion to the top of his lip. After the incident R2 was very agitated, he was pointing his finger at R1. R2 was sent out for his behaviors, he was a history of physical abuse towards others. Staff should be monitoring him. She spoke with R9 who saw the incident and he told me the same thing. R2 hit R1 in the face. R2 hit R1 purposely. R2's face sheet shows he is a [AGE] year-old male with polish as his primary language. His diagnosis include hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, unspecified psychosis, cognitive communication deficit, unspecified dementia with other behavioral disturbance, restlessness and agitation, delusional disorder, anxiety and history of falling. R2's nurses notes dated 5/8/23 documents verbally aggressive to staff and roommate, attempting to be physically aggressive to staff. R2's nurses note dated 5/9/23 documents behaviors of verbal aggression, refusal of cares and hitting staff. R2's nurses note dated 5/13/23 documents he is verbally and physically aggressive towards staff, trying to hit and punch staff and other residents. R2 is also screaming and yelling. R2's nurses note dated 5/31/23 documents he is yelling at staff and other residents. Attempting to bite the writer (V11) RN. On 6/30/23 at 9:40 AM, V11 (RN) said R2 has history of wandering, agitation, physical and verbal behaviors. On 6/30/23 at 9:03 AM, V12 (Certified Nursing Assistant-CNA) said R2 does not speak English, he wanders into other resident's room and get confused. We have to follow him and try to redirect him because a lot of the residents get upset that he goes into their rooms. On 6/30/23 at 11:41 AM, V14 (Clinical Manager) said R2 has several psych diagnosis and frequent behaviors of agitation, restlessness, and verbal behaviors. He has history of physical altercations. V14 confirmed R1 was hit in the face by R2. The facility's Abuse and Neglect Policy states, It is the policy of the facility to provide care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment Abuse is willful infliction or mistreatment, injury types of abuse 1. Physical .physical abuse includes but not limited to infliction of injury that occur other than by accidental means .

Based on observation, interview and record review the facility failed to ensure incontinence care was provided in a manner to prevent infections for 1 of 3 residents (R4) reviewed for incontinence care in the sample of 12. The findings include: R4's Hospital Admission Report dated 5/12/23 shows that she was admitted to the hospital with a diagnosis of urinary tract infection. On 6/30/23 at 9:45 AM, V17 (Certified Nursing Assistant) provided incontinence care to R4. V17 pulled up R4's gown and there was a large amount of stool coming out of the top of R4's incontinence brief. The stool went up to her belly button. V17 cleaned R4's front perineal area with disposable wipes. V17 cleaned the groin area and the outer part of the labia. V17 did not spread the labia apart and clean in between. V17 then turned R4 to her side and cleaned her buttock. With the same gloves on, V17 applied barrier cream to R4's buttock and front perineal area. On 6/30/23 at 11:35 AM, V3 (Assistant Director of Nursing) said when providing female incontinence care, it is important to spread the labia and clean in between to make sure all fecal matter is removed to prevent contamination and an infection. V3 also said that gloves should be removed and hands should be washed and new gloves applied before applying barrier cream or whenever a staff member is moving from a clean area to a dirty area. The facility's Incontinent and Perineal Care Policy revised on 7/28/22 shows, It is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation .

Based on observation, interview and record review, the facility failed to discard expired medications from two of five medication carts and one of two medication rooms. This deficiency could potentially affect all 162 residents in the facility. Findings include: On 03/15/2023 at 10:30 AM, during observation with V12 (Registered Nurse-RN), first floor refrigerator was observed with: 1. Ziplock bag with label that reads Influenza vaccine 2022-2023 with 3-milliliter (ml) syringe with clear liquid inside. 2. 3 opened and undated Influenza vaccine 2022-2023 vials 3. 1 opened Influenza vaccine 2022-2023 vial with open date of 10/19/2022 At 10:50 AM, during observation with V10 (RN), second floor medication cart 2 was observed with the following: 1. Opened and undated R90's insulin lispro 100 units (u)/ml vial - label reads Discard after 28 days 2. Opened and undated R60's insulin glargine 100u/ml pen - label reads Once opened store at room temperature for 28 days 3. Opened and undated R16's insulin lispro 100u/ml vial - label reads Discard after 28 days 4. Opened R94's fluticasone propionate and salmeterol 250-50 micrograms/dose inhalation powder with open date 2/8/23 - label reads Discard 1 month after opening foil protection pack At 1:20 PM, during observation with V11 (Licensed Practical Nurse-LPN), second floor cart 3 was observed with the following: 1. House stock Vitamin D 400 international units with expiration date 4/2022 2. House stock Fish Oil 1000 milligrams with expiration date 12/2021 At 1:45 PM, during observation with V11, second floor refrigerator was observed with opened and undated Tuberculin purified protein derivative 5 units/0.1ml. On 03/15/2023 at 10:50 AM, V10 said that there should be an open date on insulins and inhalers. On 03/15/2023 at 1:20 PM, V11 said that expired medications should have been removed from the medication cart. At 1:45 PM, he said that the Tuberculin purified protein derivative should have an open date. On 03/17/2023 at 9:30 AM, V2 (Director of Nursing) stated that all expired medications are expected to be surrendered to the nursing supervisors or sent back to facility to be destroyed. She also added that Tuberculin purified protein derivative and influenza vaccine vials should be dated. Influenza vaccine literature: 16.2 Storage and Handling - Once the stopper of the multi-dose vial has been pierced the vial must be discarded within 28 days. Facility Policy: Title: Medication Storage, Labeling, and Disposal Revised 10/24/22 Policy Statement: It is the facility's policy to comply with federal regulations in storage, labeling, and disposal of medications. Procedures: 2. House stocks designed for multiple administration will be labeled with . and expiration. 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 maintain sanitizer levels in the three-compartment sink and two sanitizer buckets. This failure has the potential to affect 160 residents receiving meals from the facility's kitchen. Findings include: On 3/14/23 at 9:55 AM, the quaternary level measured 100 ppm (parts per million) in the three-compartment sink and two sanitizing buckets in the kitchen. On 3/14/23 at 10:19 AM, V17 (Dietary Manager) said (quaternary) should measure 150 ppm in the sink and sanitizer buckets. The facility provided a Pot Sink Sanitation Record that indicates Standards PPM .150-200 Quaternary. The facility provided a diet tally that indicated that 160 residents received meals from the facility kitchen on 3/14/23.

Based on observation, interview and record review, the facility failed to provide a privacy cover on urinary drainage bag and failed to knock on the door and ask permission before going inside the room for three (R64, R115, R135) of 13 residents reviewed for dignity in a sample of 32. Findings include: 1. On 03/14/2023 at 10:40 AM, during observation, R115 was observed sitting on her wheelchair in the dining room with an uncovered urinary drainage bag. On 03/14/2023 at 10:55 AM, R115 was observed with V6 (Agency Registered Nurse) and stated that she will ask if it is their policy to have it covered. At 11:20 AM, she said that all urinary drainage bags should be covered. On 03/15/2023 at 9:32 AM, V2 (Director of Nursing) stated that all urinary drainage bags should have a cover. R115's Order Summary Report dated 03/17/2023 indicated admitted [DATE], and diagnoses of but not limited to extended spectrum beta lactamase (ESBL) resistance and obstructive and reflux uropathy. Facility Policy: Title: Privacy and Dignity Revised: 7/28/22 Policy: It is the facility's policy to ensure that resident's privacy and dignity is respected by the staff at all times. Procedures: 2. Knocking prior to entering resident's room will be done by all staff. 4. Urine bags will be covered with the use of privacy bags. 45316 2. On 03/14/23 at 11:30 AM, surveyor was in the room interviewing R64, V4 (Registered Nurse) opened the door without knocking at the door and waiting to be invited in. On 3/14/23 at 11:43 AM, V4 (Registered Nurse) said that he should have knocked and waited to be invited in. On 3/15/23 at 09:50 AM, V3 (Director of Nursing) said that she expects staff to knock and wait for acknowledgment before entering in residents' rooms. R64 is a [AGE] year old female admitted on [DATE] with a diagnosis not limited to difficulty in walking, type 2 diabetes mellitus, weaknesses, and myocardial infarction 3. On 03/14/23 at 10:30 AM, surveyor observed R135 with V3 (Registered Nurse). R135 was lying in his bed with his urinary catheter exposed. On 3/14/23 at 10:30 AM, V3 said that R135's catheter should have been in a privacy bag. On 3/15/23, V2 (Director of Nursing) said that the urinary catheter should be in the privacy bag. R135 is a [AGE] year old male admitted on [DATE] with a diagnosis not limited to aphasia following unspecified cerebrovascular disease, Alzheimer's disease with early onset, essential hypertension, and pressure ulcer of sacral region. Review of care plan of 2/10/2023 documents: Please position catheter bag and tubing below the level of the bladder and away from entrance room door. R135 has a roommate and at the window door. When the curtain divider is pulled, R135 Foley Catheter is exposed.

Based on interview and record review, the failed failed to ensure adequate supervision is provided to one resident (R1) who is at risk for falls and has had history of multiple falls in the past out of 3 residents reviewed for supervision. This failure resulted to R1 sustaining laceration on right forehead which required sutures and resulted to subarachnoid hemorrhage, displaced fracture right zygomatic arch, fracture of the right inferior orbital wall, fracture of the right superior orbital wall and fracture of the right frontal sinus. R1 was admitted to the facility on [DATE]. R1's Minimum Data Set with a Target date of 12/28/2022 under Brief Interview for Mental Status documents a score of 3/15 which indicates cognitive impairment. R1's Progress notes dated 12/7/22 documents in part: At around 7:15 PM, Resident fell in the dining room, was found on the floor of the dinning (sic) room in the prone position, He was assessed for injuries, bleeding on face was noted with a 3 cm deep cut on R eyebrow, ice pack and sterile gauze were applied on wound site until bleeding stopped. 911 called at 7:18 PM, and resident has been transported to xxx hospital at 7:30 pm. R1's Fall Risk assessment dated [DATE] documents a score of 14 which indicates that R1 is a high fall risk. R1's Fall List documents that R1 had a fall incident on the following dates: 12/7/22, 8/29/22, and 6/17/22 within the last 6-8 months. R1's Fall Care Plan with 12/7/22 revision date documents in part: R1 is at high risk for falls related to: recent fall, Cognitive impairment, Anxiety, Anemia, History of falling, Altered mental status, Left hemi post subdural hemorrhage, Dementia, anemia, cardiac dysrhythmias, CHF, anxiety, depression, schizophrenia, violent behavior, current medication orders for antipsychotics and antidepressants, and incontinence. Due to R1's diagnosis of psychosis, he is noted with periods of agitation and delusional thoughts placing him at high risk for fall/injury. R1 is noted with increase anxious behaviors placing him at risk for fall/injury. Hospital records document result of CT of the brain under Findings in part as: There is a small amount of subarachnoid hemorrhage and intraparenchymal hemorrhage in the right anteroinferior frontal lobe. CT of the facial bones under Findings also document: There is a dispalced fracture of the right zygomatic arch. There is a fracture of the right inferior orbital wall without herniation of the intraorbital contents. There is also a fracture of the right superior orbital wall that extends to involve the frontal sinus. The inner table of the right frontal sinus is fractured and there is pneumocephalus. R1 also had laceration of the right forehead which was sutured in the emergency room . On 2/10/22 at 11:17 AM, R1 observed sleeping in bed, bed on low position, with bed alarm, landing pads on both sides of the bed, white noise player on. R1's wheelchair was observed with bolsters on both hand rails. When asked if he recalls his fall incident on 12/7/22, R1 did not respond. Further questioning still did not yield any response from R1. R1 was murmuring something unintelligible. When asked if he is in any pain, R1 did not respond. On 2/10/22 at 12:45 PM, V13, Certified Nursing Assistant/CNA, assigned to R1 at the time of the fall stated, I was the CNA assigned to R1 that shift. Dinner usually starts around 6:00 PM. I fed R1 his dinner, R1 is a feeder. R1 ate everything. I was cleaning up the dining room so R1 stayed in the dining room. There were other residents in the dining room. At that time, I don't really know who was watching the residents in the dining room. Usually one of us is usually there. I can't remember who was in charge of supervising the residents in the dining room at that time. R1 is high risk for falls. R1 shouldn't be left in the dining room unsupervised. I was in and out of the dining room. I did not witness R1 falling. The last time I saw R1 was around 7 PM and then I proceeded to pick up the trays from the other residents' rooms. On 2/10/22 at 12:05 PM, V12, Restorative Nurse stated, I am in charge of investigating fall incidents and updating care plans. For R1, based on my investigation, his fall could be more because of his diagnosis or his behaviors that contributed to him falling. R's fall occurred in the dining room around 7:30 PM. We did put R1 on behavior monitoring when he returned from the hospital. V13 was the CNA in charge of R1 at that time. The CNA said that she put R1 in the dining room around dinner time which would have been around 6 PM. The CNA was there when it happened. She didn't witness the fall because she was putting trays away. For R1 if he is calm, he usually stays in the dining room after dinner. When there's people in the dining room, there should be a staff member supervising the residents. My root cause analysis showed that his behavior contributed to the fall occurrence. On the behavior monitoring for 3 days, I didn't observe any new behaviors that might have contributed to that fall. On 02/10/2023 at 1:38 PM, V11, R1's Physician when asked if she was informed about R1's fall incident on 12/7/22 stated, I'm sure I was informed about R1's fall incident. During my last assessment with R1, all I remember was that the patient was in a wheelchair and he was trying to get up and he was sliding from his chair constantly. And you cannot talk to him, about the dangers, about his surroundings. I tried to call the CNA to pull him back up on the chair. R1 was doing it constantly. You cannot keep patient in bed all the time. I think he (R1) will benefit from social interaction and activities. When he (R1) was on the chair, he (R1) constantly gets up. He (R1) is calmer when he is in bed. When he (R1) is in the chair, he needs constant supervision. In his wheelchair, he (R1) probable needs 1:1. I am told there is always somebody sitting there in the dining room. When I visit the facility, I usually see the breakfast service. During meal time, there's always somebody in the dining based on my observation. I am usually there during breakfast, there is always at least 4 staff members in the dining room. I don't know how can R1 be left unattended. But I am not there during dinner time. On 2/10/22 at 2:02 PM, V7, Licensed Practical Nurse/LPN stated, I was the nurse assigned to R1 on 12/7. R1 was in the dining room when he fell . I was passing medications and then I was told by one of the nurses that R1 had a fall. R1 was bleeding, we put ice pack on him and I went and called 911. R1 got admitted with Subarachnoid hemorrhage. R1 usually eats dinner in bed, most of the time he eats in bed but that day he ate in the dining room. The incident happened after dinner. There's always somebody in the dining room to watch the residents in the dining room. I did not witness the fall. When asked why that day R1 ate dinner in the dining room, V7 responded, I don't know but when the assigned CNA asked me if R1 should get up and go to the dining room for dinner, I told the CNA to get him up. On 2/10/22, during interviews, V5, V8 and V9, CNA's who worked on 12/27/22 3-11 shift, all denied they were assigned to supervise R1 while he was in the dining room. V5, V8 and V9 all stated that were not assigned to supervise the residents who were still in the dining room after dinner time. On 2/10/22 at 2:21 PM, V10, Certified Nursing Assistant/CNA stated, When R1 fell , I was in the dining room but I was asking another resident if she wants to go back to bed. No I was not assigned to supervise in the dining room after dinner, I had already watched the dining room before that time, I don't know who was assigned to watch the dining room at time. It wasn't me who was assigned to watch the dining room, I had already watched the dining room earlier. Surveyor told V10 that on the 12/27/22 Assignment Sheet which the facility provided to me, her name was listed as the CNA in charge of watching the dining room from 7-7:30 PM, which was the time R1 fell . V10 stated, Yes, I was in the dining room but like I said I was there but I was talking to another resident and by the time I turned around R1 was already on the floor.

Based on observation, interview and record review the facility failed to ensure supervision of residents who had a history of falls. The facility also failed to implement fall interventions for high fall risk residents to prevent fall reoccurrence. The facility also failed to update fall care plans after fall incident to prevent future falls in a timely manner. This deficiency affects 3 of 6 residents (R1, R4 and R5) who are reviewed for fall prevention management in a total sample of 6. This failure resulted R1 sustaining a laceration on right orbital area which required suturing at the hospital. This failure also resulted in R1 sustaining a nondisplaced left nasal bone fracture and right periorbital hematoma. Findings include: 1. R1 was readmitted on [DATE] with diagnosis to include Parkinson's Disease, Unsteadiness on feet, Abnormality of gait and mobility, Abnormal posture, Spondylosis with myelopathy lumbar region, Wedge compression fracture of fourth lumbar vertebra, History of falling, Restless and agitation. R1's initial admission assessment dated [DATE] and most recent fall assessment dated [DATE] indicated he is at high risk for fall. R1's care plan indicated he is at risk for falls related to poor safety awareness, unsteady gait, history of falls, requires assistance for transfers, incontinent of bowel and bladder, cognitive impairment and medical diagnosis of Parkinson's disease and anxiety disorder. He utilizes a wheelchair as a primary mode of locomotion at this time. He is ambulatory with extensive assistance from the staff using a rolling walker. He has a self-care deficit due to weakness, impaired balance and poor coordination therefore requires assistance with ADLs (bed mobility, transfers, dressing, walking, personal hygiene, bathing and toileting). He has impaired mobility. He has extensive care needs. R1's fall incidents: 6/20/21- Observed fall. Observed resident eating in the dining room when he decided to get up to get more food then lost his balance. 6/28/22- Unwitnessed fall. Heard alarm sounding, observed R1 sitting on the floor in front of his wheelchair in the hallway. R1 was sent to the hospital for evaluation due to anti-coagulant usage. 7/11/22- Unwitnessed fall. Observed R1 lying on the floor on his right side in the dining room. R1 was sent to the hospital for evaluation. 8/30/22- Observed fall with injury. Observed by another resident, R1 got up from his wheelchair and attempted to walk and fell in the lounge area. Nurse observed R1 lying on the floor on his right side. R1 said that he got up from his wheelchair to walk to the dining room without assistance and lost his balance. R1 sustained laceration to the right eye area. R1 was sent out to the hospital for suturing. R1 returned to the facility with diagnosis of right eye laceration repair, nondisplaced left nasal bone fracture and right periorbital hematoma. Root cause analysis done but fall care plan was not updated. R1's hospital record dated 8/30/22 indicated: Laceration repaired of right orbital area. CT Brain without contrast final result listed in part: Nondisplaced left nasal fracture, right periorbital hematoma. Review R1's facility incident reported to IDPH indicated: On 8/30/22 at 6pm, alarm was sounding and R1 was noted laying on the floor outside of the resident lounge. R1 stated I got up from my wheelchair to walk to the dining room and fell. Head to toe assessment completed and R1 was noted with laceration to the right eye. Area was cleaned and pressure dressing was immediately applied. Neuro checks initiated. No other injuries noted. Vital signs include: BP 122/68, PR 72, RR 20, T 97.2F, O2 98%. Physician made aware and received orders to send R1 to the hospital for evaluation. Family notified. R1 returned with sutures to the right eye and nasal bone fracture. Care plan reviewed and updated. R1's Physical medicine and rehabilitation progress notes indicated on 8/4/22 documented by V26 Physician Assistant: Plan/recommendation: He is supervision for bed mobility, supervision for transfers, supervision for ambulation. High fall risk. Fall precaution were reviewed. On 10/25/22 at 10:27 am, V18 LPN said that she has taken care of R1. He is alert and oriented but forgetful. He has poor safety judgement. He tries to ambulate without his walker. He needs constant supervision. He is at risk for fall. He has unsteady gait. He propels himself on wheelchair. She said that he had fall incident on 8/30/22 during evening shift/dinner time. Review R1's progress notes with V18. He was sent out to the hospital for evaluation due to injury to right eye that need suturing. He returned to the facility. On 10/25/22 at 4:31 pm, V25 RN said that she is assigned to R1 when he had fall incident on 8/30/22 at 6pm. She said she was busy with passing medication with another resident, when she was called to the lounge area and observed R1 was on the lying on floor on his right side. R1 said that he got up from his wheelchair to walk in the dining room. He sustained laceration to his right eye area. He was sent out to the hospital for suturing and came back. V25 said that R1 is high fall risk and needs supervision. V25 said that she instructed V27 Agency CNA to monitor R1 because he is high risk for fall. V25 said that when she talked to her after R1 was sent to the hospital, V27 told her that she does not know who is R1. V25 told her that she should asked her if she does not know who is R1. On 10/26/22 at 8:30 am, V27 Agency CNA said that V25 RN did not gave report to her about R1. One of the CNA gave her list of her resident assignment. She does not know that R1 was in her list. She was busy passing tray in the dining room. She did not know that R1 was one of her assigned residents not until R1 was transferred to hospital. She said that if they told her that R1 is high risk for fall, she will monitor him and will place him in the dining room to be supervised. On 10/26/22 at 10:03 am V8 Restorative Nurse said she review the incident report and conduct her own fall investigation to determine the reasonable cause of fall/root cause analysis. Fall intervention is updated after the fall to address preventive measures. V8 said that she did the root cause analysis and updated the care plan for R1 when she came back from the hospital on 8/31/22. Showed printed copy of R1's fall care plan that was provided by V2 DON, no new fall intervention was updated. On 10/27/22 at 9:55 am, V2 DON said that if a resident is in the lounge area there should be staff with them to monitor. On 10/27/22 at 2:03 pm, Informed V8 of above interview with V25 RN and V27 Agency CNA. V8 said that if there is an Agency Nurse or Agency CNA, the floor nurse will endorse who are the residents on monitoring for high fall risk and the list is in the communication binder for both nurses and CNAs. V8 said that both agency nurses and CNAs should check the binder if they have assigned residents on high fall risk for monitoring. R1 was on the list for resident monitoring for high fall risk. 2. R4 is re-admitted on [DATE] with diagnosis to include Fibromyalgia, Low back pain, Malignant neoplasm of colon, Type 2 Diabetes Mellitus, Pain in shoulder, right knee and ankle, Spondylosis lumbosacral region, Osteoporosis. R4's care plan indicated: at high risk for falls and related injuries due to history of fall, supervision cuing with walking, locomotion, transfer, use of diuretics, complaint of pain right knee, fibromyalgia, Chronic Obstructive Pulmonary Disease (COPD), and advance age. Intervention: Staff to encourage supervision during showers. She has Activity of Daily Living (ADL) self-deficit care performance related to lack of coordination, other abnormalities of gait mobility and pain. R4 fall assessment indicated she is at high risk for falls. R4's fall incidents: 9/9/22- fall witnessed by roommate's family member. R4 tripped and fell, hitting her head, sustained laceration to her head. R4 was sent to hospital via 911. MD and family notified. R4 returned to facility with sutures to left eyebrow. 10/22/22- witnessed fall. R4 was observed ambulating from her room to the hallway when she suddenly tripped over her foot causing her fall before the nurse can get to her. R4 was not using assistive device at that time. R4 did not hit her head. R4 said that she was walking, tripped and lost her balance. R4 was sent to hospital for evaluation due to anti-coagulant usage. Root cause analysis done. Care plan was not updated. On 10/25/22 at 10:42 am, Review 2nd floor endorsement log with V18 LPN, noted R4 is on fall follow up due to fall with left eyebrow laceration. V18 said that R4 is assigned to V20 Agency Nurse. V20 said she does not know who is on fall prevention monitoring or who had recent fall, no one endorsed to her. On 10/25/22 at 10:47 am, Rounds made with V18 LPN looking for R4. R4 found in shower room taking bath by herself. V18 said that R4 is ambulatory, she goes to the shower and bathroom independently. On 10/25/22 at 10:59 am, Informed V8 Restorative Nurse of above observation that R4 was found taking bath in the shower room by herself without supervision. V8 said that staff should supervised her. V8 said that she is not aware R4 is not being supervised during shower. On 10/26/22 at 10:15 am, Review R4's fall incidents with V8 Restorative Nurse. Informed V8 that R4's root cause analysis for fall incident on 10/22/22 was done but care plan was not updated. 3. R5 is re-admitted on [DATE] with diagnosis to include Cerebral infarction, Bilateral age-related cataract, History of falling, Stage 3 Chronic kidney disease, Diabetes Mellitus. R5's POS (physician order sheet) indicated: Dycem to wheelchair- check placement every shift for safety. R5's care plan indicated: At risk for falls related to current medications use, poor safety awareness, unsteady gait, Disease process (BPH (Benign Prostatic Hypertrophy), Gout, Anemia, Diabetes, Hypertension) and pain. He is noted with impaired balance and weakness therefore utilizes a wheelchair as a primary mode of locomotion at this time. He is noted with behavior of removing his no skid socks related to he prefers to be barefoot placing him at high risk for fall and or potential for injury. Interventions: Dycem ( non-slip mat) to wheelchair. Encourage to wear nonskid socks when up in wheelchair. Encourage not to lay at the edge of the bed for safety. He has self-care ADL deficit due to impaired balance, therefore requires limited assistance with ADL's (bed mobility, transfers, dressing, personal hygiene, bathing and toileting, set up with eating and walking. He has extensive care needs and requires support and services of the LTC setting. R5 fall assessment indicated at high risk for fall. R5's fall incidents: 6/14/22- unwitnessed fall. Observed leaning on his left side on the floor in his room. R5 said that he slipped and landed on the floor. Sustained small superficial scratch on his left lateral ankle. R5 was sent out to the hospital for evaluation due to anti-coagulant usage. 10/13/22- unwitnessed fall. Observed R5 lying on the floor, face down in front of his locked wheelchair, on the left side of the bed. R5 said he was trying to get back into bed from wheelchair but lost his balance, fell and hit his head. Noted scant left nostril bleeding and controlled. R5 was sent out to the hospital for evaluation. R5's progress notes indicated PT and OT recommendation after fall by V21 Nurse Practitioner dated 10/14/22 and V22 R5's PCP dated 10/17/22. No follow up documentation nor order made regarding recommendation made. On 10/25/22 at 12:57 pm, Observed R5 lying in bed, closer to the edge of the bed. Not wearing nonskid socks. Observed towel on the floor on his right side of the bed. R5 said that he placed the towel on the floor because its slippery. R5 said he does not have nonskid socks. R5 said that he goes to the bathroom by himself using his wheelchair. Observed no dycem on his wheelchair. R5 said that the staff does not answer his call light. Showed to V8 Restorative nurse observation made. V8 said R5 has nonskid socks in his bedside drawer. V8 said that the CNA need to apply it. V8 said that R5 needs assistance with putting his nonskid socks. On 10/26/22 at 11:09 am, Observed R5 sitting at the edge of his bed, having difficulty to put his pants on. He does not wear nonskid socks. He does not have Dycem on his wheelchair. Called V8 Restorative nurse to R5's room and showed observation. V8 assisted R5 to don his pants and his nonskid socks. R5 is compliance and allowed V8 to put his socks on. Informed V8 that dycem was not applied to R5's wheelchair since yesterday. V8 said that dycem is place to R5's wheelchair to prevent him from sliding. V8 unable to locate dycem in his room. Facility's policy on Fall occurrence indicates: It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place and interventions are re-evaluated and revised as necessary. Procedure: 5. Fall coordinator will review the incident report and may conduct his/her own fall investigation to determine the reasonable cause of fall. 6. The nurse may start interventions to address falls in the unit, even prior to the Falls coordinator's investigation. 7. Ultimately, the Fall coordinator may change the interventions provided by the nurse if the Fall coordinator's investigation identifies a more appropriate intervention for the individual fall. 8. The Fall coordinator will add the intervention in the resident's care plan. 10. The interventions will be reevaluated and revised as necessary. Facility's policy on Fall prevention Program Guidelines indicates: Fall prevention guidelines shall be implemented to promote safety of all residents in the facility. This program shall measure to determine the individual needs of each resident by assessing the risks for fall and the implementation of evidence-based prevention interventions. Procedure: 2. Safety interventions shall be initiated and implemented for each resident identified at risk for fall. 3. All assigned nursing personnel and facility staff shall be responsible for ensuring ongoing precautions are put into place and consistently maintained. 8. An individualized evidence-based plan of care shall be created to reflect fall prevention interventions which could be put but not limited to: N. consider placing confused resident or difficult to redirect resident by the nurse's station or within eye contact. R. May consider PT/OT evaluation.

Based on interview and record review, the facility failed to supervise 1 of 3 residents (R68) reviewed for accidents in the sample of 35. This failure resulted in R68 falling from a scale and obtaining a nondisplaced femoral fracture. Findings include: On 5/19/22 at 1:39 pm, V2 DON (Director of Nursing) said R68 is alert and oriented x1, able to make simple needs known, and has Dementia with confusion. R68 has poor safety awareness due to Dementia. R68 is a high fall risk due to Dementia and lack of safety awareness. R68 has a history of falls. R68 was getting weighed near dining room. When Certified Nursing Aide (CNA) was weighing R68, CNA saw another resident starting to fall. CNA left R68 to tend to the other resident to prevent a fall and subsequently R68 fell . CNA was unable to prevent R68's fall. No findings of injury, MD was notified and gave orders to send to local hospital. Hospital x-ray revealed a left femoral fracture. On 5/18/22 at 2:29 PM, V16 (LPN) said R68 is alert oriented x 2 and able to make her needs known. R68 needs redirection and supervision. R68 requires supervision to prevent falls. CNA said she was taking R68's weight. Another resident was in the room and started to fall, CNA went to tend to other resident and R68 tried to get up from scale and fell . R68 was admitted for left hip fracture. On 5/19/22 at 12:55 PM, V17 (Restorative Nurse) said R68 is alert oriented x1. R68 is able to make simple needs known. R68 has dementia and is confused at times. R68 lacks safety awareness and has history of wandering behavior. R68 requires redirection and cuing due to poor safety awareness, wandering behaviors, and diagnosis of dementia. R68 is a high fall risk due to wandering behavior, lack of safety awareness, and history of falls. CNA was weighing R68 on standing scale (monthly) and there was another resident nearby. The other resident was attempting to get up from her chair. CNA went to attend to the other resident at the same time R68 attempted to get off the scale without assistance. CNA was tending to other resident when R68 fell from scale. CNA was unable to prevent R68's fall. Hospital x-ray determined R68 had a left femoral fracture. Fall Risk Assessment (dated 5/3/16, 7/18/21, 6/19/21, 6/1/21 4/7/21, and 1/25/21) documents High Risk for falls. MDS (Assessment Reference Date 4-2-22) documents: Brief Interview for Mental Assessment documents 3, Transfer- (self) limited assistance, (support) one person assist, Locomotion: (self) supervision, (support) 1-person physical assist, Balance- not steady, only to stabilize with staff assist, Walking- not steady, but able to stabilize with staff assist. Diagnoses (Not Limited To:) Non-Alzheimer's dementia, anxiety, depression, [CONDITION(S)], and history of falls. Hospital Record dated 5/3/22 documents Impression: Nondisplaced fracture of the femoral neck remainder the femur is intact. Impression: A nondisplaced left femoral neck fracture is present. Surveyor requested Fall Prevention Policy and facility presented Fall Occurrence Policy.

Based on observation, interview, and record review, the facility; failed to provide ongoing supervision and monitoring of cognitively impaired residents considered high risk for falls with history of falls; failed to supervise a resident per facility protocol and resident's plan of care. These failures affected two (R3, R4) of two residents reviewed for supervision/falls. These failures resulted R3 being outside in cold winter temperature unsupervised; R4 had multiple falls with most recent fall resulting in emergent transfer to hospital and stitches to the head as a result of injury. Findings include: 1. R3 is an alert and oriented [AGE] year-old with diagnoses listed in part with absence of right below-the-knee amputation, [CONDITION(S)], diabetes, and end-stage kidney disease. On 1/22/22 at 9:55 AM, R3 was observed outside the patio adjacent to the facility parking lot facing the main road. R3 had a red waist-length winter coat and was seated in her wheelchair against a patio table. R3 was observed smoking in cold winter temperature that read 18 degrees as it appeared in surveyor's vehicle reading. At 10:45 AM surveyor walked past an empty dining room area and found the exit to where R3 went out to the patio area and found R3 still outside smoking cigarettes. A sign on the door inside the dining room area leading to the patio read, Patio closed. Door alarmed. There were no staff present to monitor or supervise R3 while she was outside in the freezing temperatures. Surveyor returned back to the main area to look for staff and requested for a supervisor. V4 (nursing supervisor) accompanied surveyor to the patio area and identified the resident and stated, That's (R3) she's a smoker but I don't know how she got outside because this door should be locked. V4 was observed pushing the unlocked patio door open with no alarms triggered as shown on the sign the patio was closed and door was alarmed. Surveyor asked about this, V4 stated, I don't know, this door should be locked and alarmed. Surveyor asked if there were any cameras outside to monitor any residents, V4 stated, I don't see any but there should be someone with her. Surveyor asked R3 how she was able to go outside, R3 stated, I always come out here on my own to smoke and the door is never locked. Surveyor asked if staff were to accompany her whenever she goes outside, R3 responded, I was never told that and there's never anyone that ever accompanies me or even asks me where I'm going. On 1/24/22 at 1:39 PM interview with V4 (RN) stated, R3 is alert and oriented x 4 she is very with it. She usually goes out to smoke but there should be someone assigned to supervise her while she is outside smoking. I know the other day there was no one with her but some activity aide or the activity director who was here at the time should have assigned someone to supervise her. Surveyor asked whether R3 was considered a fall risk, V4 stated, I know she needs assist for transfers from bed to her wheelchair because she is an [CONDITION(S)] and she is wheelchair- bound but we never considered her a fall risk. A care plan dated 4/13/21 reads in part (but not limited to), (R3) requires supervision with walking in corridor, walking in room, locomotion, toilet use, related to: right below knee amputation, low back pain, use of prosthesis. A fall risk care plan dated 11/18/19 reads in part (but not limited to): (R3) is at risk for falls and related injuries due to: amputation of right leg below the knee, uses prosthesis, diagnosis low back pain, gait and balance impairment. A smoking care plan dated 8/25/20 reads in part (but not limited to): (R3) is a smoker and expresses the desire to smoke at this facility. Interventions: Remind the resident that staff will be observing and supervising smoking-related behavior. 2. R4 is an alert an oriented [AGE] year-old with diagnoses listed in part with multiple [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], diabetes and hypertension. Care plan dated 10/29/21 reads in part, (R4) is at high risk for falls related to: recent fall, current medication use of diuretics, antihypertensives. Poor safety awareness, unsteady gait, disease process (Multiple [CONDITION(S)], unsteadiness on feet, A-Fib., [CONDITION(S)], [CONDITION(S)], diabetes) and history of falls. Interventions: Bed alarm, Chair alarm, Educated resident to ask for assistance with toileting and self-catheterization setup. Keep call light within reach when in bedroom or bathroom; Use of assistive device during ambulation to prevent falls. On 9/3/21 at 08:45 AM, V14 (LPN) wrote in the progress notes, Incident Summary: Prior to the incident the nurse on duty went to check the resident's blood sugar at 8:10 AM, the resident was lying in his bed with call light and personal belongings within easy reach. At 845 AM, the assigned aide reported R4 is on the floor. Nurse on duty went to the R4's room and saw the resident lying on his left side, on the floor, on the left side of his bed with head towards the footboard, side and legs towards the head side. Head to toe assessment done no visible injury noted on his head or any part of the body. R4 denies hitting his head on any hard surface and denies any pain on any part of the body. R4 refused to use mechanical lift, assisted resident back to bed with four person assist. Notified NP with order to initiate neuro check, Left message for doctor. On 10/29/2021 at 2:28 AM V13 (LPN) wrote in progress notes: Incident Summary: R4 last seen around 1 am sleeping in his bed. Around 1:25 am alarm was sounding from R4's room and resident was noted lying on his right side beside his bed. Head to toe assessment revealed a laceration to the forehead. Moderate bleeding was noted, and pressure was applied to stop bleeding. MD and POA were made aware. R4 was sent to ER via 911 for evaluation. On 11/27/21 at 11:03 AM V14 (LPN) wrote a third incident note that read, Incident Summary: At 09:30 AM, assigned CNA (certified nurse aide) reported R4 is on the floor. The writer went to the resident's room, saw resident sitting on the floor leaning on his bed and holding the side rail with left hand, wheelchair was behind him. Head to toe assessment done resident denies any pain or discomfort. Resident denies hitting his head on any hard surface. Assisted the resident to his bed with the two persons assist. R4 said, he tried to transfer himself from bed to chair by himself, forgot to lock the wheelchair and sat on the floor. Called the on-call doctor and notified him, he advised to monitor the resident for any symptoms an start Neurocheck, Neurocheck started. On 1/24/22 at 11:20 AM, Surveyor visited resident in his room and R4 was observed sitting in his wheelchair with his call light that was attached to his bed away from R4's reach. Surveyor asked if he was able to reach his call light, R4 stated I can't reach it but good luck getting anyone to answer it. They are very short staffed here. Surveyor asked about his falls and most recent fall, R4 stated, I was catheterizing myself because I could no longer wait for a nurse that night and the next thing I know is I was in the hospital. I had a huge black eye, several stitches to my head, and face and I was in a lot of pain. I fell straight on my face on the hard floor, I must have slipped because of my own urine and I must have hit my face and head pretty hard because I only remember being in the hospital next. Surveyor asked what the nurses were doing to prevent him from falling again, R4 stated, Well not much because I still have to catheterize myself even after I fell . I know they'll tell you that it's my preference but it really isn't. I'm doing it myself out of sheer frustration with getting anyone to come do it in time. Surveyor asked about the wheelchair alarm that was observed behind his chair, R4 stated, What's that going to do. It will ring when I'm already on the floor. They also claim to put an alarm on my bed but most the time it doesn't work but just wakes me up when I shift my body. It's also what rang when I was already on the floor unconscious when I remember being in the hospital next. It's another convenience for them, not for me. On 1/24/22 at 11:35 AM interview with V14 (LPN) stated, Yes I'm (R4)'s nurse today. I take care of him often. He catheterizes himself but we normally don't do that for him. He has all his supplies to do this at bedside. Surveyor asked whether R4 was considered a fall risk, V14 stated, No he does things by himself and we just watch him a lot. Surveyor asked about the falls R4 sustained, V14 stated, I'm sorry, I wasn't on duty when he fell . Surveyor clarified whether she was the nurse on duty when R4 fell on [DATE] and 11/27/21, V14 replied, Yes I recall he fell those times. Surveyor asked again whether R4 would be considered a fall risk since falling 3 times, V14 stated, Yes, I guess he is. Surveyor asked again what she did to prevent R4 from falling and sustaining further injury, V14 stated, We monitor him often and not just me but everyone that passes by his room should be monitoring him. On 1/24/22 at 2:00 PM, V3 (Assistant director of nursing)ADON stated, I know (R4) has been self-catheterizing himself for many years and he wants to maintain his independence in doing so. Surveyor asked about R4's lack of safety awareness based on the facility's own assessment, V3 stated, I see what you mean. The nurses should be present when R4 is self catheterizing himself or assisting him with this for safety reasons and to prevent any further fall incidents. We can reevaluate this later on. Interviews for V5 (former DON), V6 (former staff LPN), V9 (Former maintenance director) could not be conducted as all were no longer employed with the facility. Interviews for V2 (current Director of Nursing)DON, could not be obtained due to being on vacation and V19 (Restorative Director) being on leave for 3 months according to V3 (assistant director of nursing)ADON. On 1/24/22 at 10:35 AM with V12 (Medical Director) stated, I am the medical director for this facility. I attended the monthly QA meeting just last month. We always talk about all the falls and injuries that occur in the building and we follow our general policies pertaining to this. From my recollection the facility will conduct a full fall risk assessment upon admission, after an accidental fall occurs or when any injuries occur and are care planned. This is also conducted on a quarterly basis. As a general statement I can give you is that any of these falls will be directed to receive PT (physical therapy) evaluation and also for OT (occupational therapy) evaluations. They also conduct pharmacy review of medications to see if it might cause unsteadiness and requires any changes. Overall, these are my general expectations but otherwise, I don't know if there are a lot of falls but that we do discuss them. Facility policy dated 7/28/21 titled Fall Occurrence reads in part (but not limited to): 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 them from falling. A fall risk assessment from will be completed by the nurse or falls coordinator upon admission, readmission, quarterly, significant change, and annually. 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. The nurse may immediately start interventions to address falls in the unit.

Based on observation, interview, and record review, the facility failed to ensure a safe environment to prevent resident to resident sexual abuse, and failed to implement an immediate intervention(s) to assure safety of a resident which affected three (R2, R3, R9) of six residents reviewed for Abuse in a sample of 10. This failure caused R2 to experience psychological harm which was exhibited by increased anxiety/fear, increased nervousness, and difficulty sleeping at night due to R3 residing on the same resident unit. Findings include: R2's Admission Record documents an admitted [DATE]. R2's pertinent medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff indicated R2 is alert and oriented to person, place and time. R2's Minimum Data Set (MDS), dated [DATE], documents a cognitive score of 13 out of 15, which indicates that R2 is cognitively intact. This MDS also documents R2 requires extensive assistance from staff for bed mobility. On 8/16/21, staff that regularly care for R2 indicated R2 does not usually complain, and if R2 says something, it's reliable. R3's Admission Record documents an admitted [DATE]. R3's pertinent medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff indicated R3 is alert and oriented to person and place. R3's MDS, dated [DATE], documents a cognitive score of 12 out of 15, which indicates R3 is cognitively intact. This MDS also documents R3 is able to walk independently on unit without assistance. R3's Act(ivity) care plan, dated 5/31/21, documents: (R3) may need to be monitored while being out in halls. It also has been reported that he demonstrates wandering or pacing behaviors. R3's wandering in and out of resident rooms was not addressed and not care planned. R3's Sexually oriented behavior care plan, dated 5/6/21, documents: (R3) has exhibited sexually inappropriate behavioral symptoms such as masturbating in the dining room. On 8/16/21 at 11:50 AM, R2 recounted the sexual abuse incident with R3. R2 stated, I was assaulted. It happened in July, less than a month ago. A man that lives at the end of the hallway came into my room at night and sat on the end of my bed. I've never seen him before the assault, but I have seen him since. He came in at about 3:00 AM. Sat on my bed. I thought he was someone that comes in at 5:00 AM to change diapers. He lifted up my dress and put his hands on both my thighs. And when I realized it wasn't the diaper guy, I screamed at him and said, Stop doing what you're doing. He got scared and left. On 8/16/21 at 11:53 AM, R9 (R2's roommate) stated, The man came in. I saw him. I woke up and saw him sitting on (R2's) bed at the end. I saw a figure there but I didn't see exactly who it was. I've seen him since. From my vantage point you can see everyone in the hallway. He walks by quite a few times a day and looks into the room. (R2) was able to identify him and she pointed out who he was to me. I haven't seen him in here since but who's to say it won't happen again? She doesn't feel safe and I don't blame her. They should move him but instead they asked (R2) to move. It's not her fault. Why should she move? R9's MDS, dated [DATE], documents R9 scored a 15 out of 15 for mental status and is cognitively intact. On 8/16/21, R2 stated, Since the incident, R3 has come and looked in the room but hasn't come in. Not yet at least. It makes me nervous. I really don't feel safe. I'm scared to go to sleep at night. I want to know why he still lives on this floor. This building has multiple floors. I'm afraid. I don't want to run into him. So I stay in my room. At night, I'm scared to fall asleep. And then they have come to me and asked me to be moved out of my room when I am where I want to be with a roommate that I get along with. They're making me feel like it's my fault that this happened. R2 indicated R3 can walk in the hallways by himself and come into her room anytime, and staff is not always watching him. R2 stated, I can't sleep at night because I feel like I have to stay awake to see if he comes in. The staff says that they can watch him but how can they? This man is allowed to walk around the floor. We've seen him, so how are they keeping me safe. My headaches have gotten worse because my anxiety has gone up and because I'm not sleeping. I'm nervous. I'm just a mess. I wish they would do something more. According to R2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's June MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's July MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's July/August MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . And V12's (Nurse Practitioner) progress note, dated 8/4/21, documented R2 requested to remain on [MEDICATION(S)] three times a day for anxiety. R2's medical record has multiple entries documenting R2 felt nervous and anxious due to R3 being seen in the hallway outside of her bedroom. It is also documented V3 and V4 asked R2 if she would like to move rooms. On 8/4/21, V12 (Nurse Practitioner) documented, (R2) reports that she feels anxious, nervous and upset when she sees the resident who touched her ambulating in the hallways. She does not want any medications for anxiety. She reports that she will feel better if (R3) is relocated off (the unit) and she does not have to see him. On 8/16/21 and 8/17/21, V2 (DON-Director of Nursing) and V3 (ADON-Assistant Director of Nursing) indicated they both watched video surveillance of the unit on the night of the alleged sexual assault. Both agreed R3 was seen wandering in the hallway leading to R2's room during the exact time frame of the alleged sexual assault. V2 stated, (R3) was the only gentleman walking in the hallways at that time. V3 stated, (R3) was wandering in and out of rooms that weren't his. He was wearing the clothing and flip flops that (R2) described. V3 indicated R3 moved towards R2's room and moved off camera, but it matched the timeframe that she said that it happened. V3 stated, We corroborated that it probably was him and we showed that to the police as well. At this point, I believe that something happened. On 8/16/21 and 8/17/21, V3 and V4 (Social Services Designee) indicated they were, respectively, manager and social services personnel for the unit that R2 and R3 resided on. V3 and V4 indicated R3 had exhibited sexually explicit behaviors. V3 stated, (R3) has some sexual behaviors that we have care planned, masturbation, sometimes not in the privacy of his own room. V4 stated, (R3) was found masturbating when he initially moved down to (unit) in March 2021., and it is also documented R3 had another episode in May 2021. V4 also indicated a CNA (Certified Nurse Assistant) saw R3 in the shower room with woman's panties on his head. On 8/17/21, V10 (RN-Registered Nurse) and V11 (CNA) indicated they are regular staff on R3's unit on the evening shift and/or night shift. V10 and V11 indicated R3 had wandering behaviors even before the sexual abuse incident. V10 stated, I know I have heard that he masturbates in the dining area. And he's been caught a few times by the nurses. It happened once or twice early morning hours, 5 AM - 6 AM. As of 8/17/21, R3 continues to reside at the end of the hallway, four rooms away from R2. This has caused R2 fear, nervousness, anxiety, [CONDITION(S)] and an increase in requiring medication for headaches caused by the increased anxiety and [CONDITION(S)]. R2's Census sheet documents that her room was not changed after the sexual assault. R3's Census sheet documents that his room was not changed after the sexual assault. On 8/16/21 and 8/17/21, V1 (Administrator/Abuse Coordinator), V2 (DON), V3 (ADON) and V4 (Social Services Designee) were all asked why R3 was not moved to another unit, and still allowed access to R2. V1, V2, V3 and V4 all stated R3 was not appropriate for 3rd floor because he does not have Dementia and not appropriate for 1st floor because R3 is an elopement risk. V1 and V2 also indicated they were not aware that R2 was still nervous about the situation. V2, V3 and V4 indicated the intervention put into place was to request R3 not walk down the hallway towards R2's room, and to have staff monitor R3 hourly. Hourly rounds documentation specific for R3 were requested and not submitted. On 8/17/21, V2 was asked how hourly monitoring of R3 was going to ensure that he did not go to R2's room again. V2 did not answer the posed question. On 8/17/21 at 9:51 AM, V12 stated, (R2) does report that she's very anxious when she sees this resident in the hallway. If this (R3) was moved off of the unit, I think it would greatly help (R2's) anxiety. I don't take any part in moving resident's from room to room. But it would help. V12 was asked if she told any staff regarding R2's request, and V12 stated she spoke to V4. On 8/17/21 at 10:44 AM, V1 stated, I agree with you from a psychological standpoint that if (R2's) still anxious, then we definitely should have moved (R3) to another floor. We should have separated them to let (R2) feel safe. V1 was asked why V4 and V12 did not report to administration R2's request to have R3 moved to another unit. V1 did not have an answer. On 8/18/21 at 12:16 PM, V22 (Psychiatrist) indicated he was not notified regarding the sexual assault involving R2 until 8/18/21. V22 stated, I have provided her psychiatric care for two years now. I was not aware of the sexual assault. I was just told by (V2) at the facility today. (R2) is nervous. She was told yesterday that (R3) was moved to another floor. She said that she was able to sleep. She was nervous due to the incident. She said that she used to feel safe in the home but the last three weeks she has not felt safe. But she feels like she will get better now that he is moved. On 8/18/21, V2 indicated that staff should have notified V22 at the time of the allegation. On 8/18/21 at 12:37 PM, V24 (Psychiatrist) stated, After the sexual assault allegation, I started (R3) on [MEDICATION(S)] to mainly reduce the sexual impulsivity because I believe that incident was due to impulsive behaviors. Per V24's visit notes, dated 5/17/21 and 7/5/21, V24 was not aware of the increase in R3's sexually oriented behavior in regards to masturbation. It is documented in both notes dated 5/17/21 and 7/5/21, There have been no reported incidents of inappropriate behaviors or perceptual alterations. Per V2 and V3, V24 should have been notified on the behaviors. It is noted V24 was not notified about R3's sexual behaviors until 7/26/21, after the alleged sexual abuse incident with R2. R3's medical record documents he does have a dementia with behavioral disturbance diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . V1 and V2 confirmed the facility utilizes electronic monitoring bracelets for elopement risks, have staff around the clock on the first floor, and that the first floor door is a secured door requiring a code to get to the lobby area, which would have made him appropriate for the 1st floor. On 8/18/21, V22 indicated R2 feels she will get better now R3 was moved to another unit. Per V22, R2 slept better the night before. A facility policy dated May 17, 2021 and titled, Abuse and Neglect documents: If abuse/neglect is suspected the facility will: 1. Take immediate steps to assure the protection of the resident(s). This may involve separation from the alleged abuser and/or provision of medical care. III. Prevention: Have procedures to: Establish a safe environment that supports consensual sexual relationship.

Based on observation, interview, and record review, the facility failed to provide an immediate intervention to assure safety/ of a resident after a resident to resident sexual abuse and failed to provide corrective action to prevent further abuse which affected three (R2, R3, R9) of six residents reviewed for Abuse in a sample of 10. This failure caused R2 to experience psychological harm which was exhibited by increased anxiety/fear, increased nervousness and difficulty sleeping at night due to R3 residing on the same resident unit. Findings include: R2's Admission Record documents an admitted [DATE]. R2's pertinent medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff indicated R2 is alert and oriented to person, place and time. R2's Minimum Data Set (MDS), dated [DATE], documents a cognitive score of 13 out of 15, which indicates R2 is cognitively intact. This MDS also documents R2 requires extensive assistance from staff for bed mobility. On 8/16/21, staff that regularly care for R2 indicated R2 does not usually complain and that if R2 says something, it's reliable. R3's Admission Record documents an admitted [DATE]. R3's pertinent medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff indicated R3 is alert and oriented to person and place. R3's MDS, dated [DATE], documents a cognitive score of 12 out of 15, which indicates R3 is Cognitively Intact. This MDS also documents R3 is able to walk independently on unit without assistance. R3's ACT(ivity) care plan, dated 5/31/21, documents: (R3) may need to be monitored while being out in halls. It also has been reported that he demonstrates wandering or pacing behaviors. R3's wandering in and out of resident rooms was not addressed and not care planned. R3's sexually oriented behavior care plan, dated 5/6/21, documents: (R3) has exhibited sexually inappropriate behavioral symptoms such as masturbating in the dining room. On 8/16/21 at 11:50 AM, R2 recounted the sexual abuse incident with R3. R2 stated, I was assaulted. It happened in July, less than a month ago. A man that lives at the end of the hallway came into my room at night and sat on the end of my bed. I've never seen him before the assault but I have seen him since. He came in at about 3:00am. Sat on bed. I thought he was someone that comes in at 5:00am to change diapers. He lifted up my dress and put his hands on both my thighs. And when I realized it wasn't the diaper guy, I screamed at him and said Stop doing what you're doing. He got scared and left. On 8/16/21, R2 stated, Since the incident, he has come and looked in the room but hasn't come in. Not yet at least. It makes me nervous. I really don't feel safe. I'm scared to go to sleep at night. I want to know why he still lives on this floor. This building has multiple floors. I'm afraid. I don't want to run into him. So I stay in my room. At night, I'm scared to fall asleep. And then they have come to me and asked me to be moved out of my room when I am where I want to be with a roommate that I get along with. They're making me feel like it's my fault that this happened. R2 indicated R3 can walk in the hallways by himself and come into her room anytime and that staff is not always watching him. R2 stated, I can't sleep at night because I feel like I have to stay awake to see if he comes in. The staff says that they can watch him but how can they? This man is allowed to walk around the floor. We've seen him, so how are they keeping me safe. My headaches have gotten worse because my anxiety has gone up and because I'm not sleeping. I'm nervous. I'm just a mess. I wish they would do something more. According to R2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's June MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's July MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's July/August MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . And V12's progress note, dated 8/4/21, documented R2 requested to remain on [MEDICATION(S)] three times a day for anxiety. R2's medical record has multiple entries documenting R2 felt nervous and anxious due to R3 being seen in the hallway outside of her bedroom. It is also documented V3 and V4 asked R2 if she would like to move rooms. On 8/4/21, V12 (Nurse Practitioner) documented, (R2) reports that she feels anxious, nervous and upset when she sees the resident who touched her ambulating in the hallways. She does not want any medications for anxiety. She reports that she will feel better if (R3) is relocated off (the unit) and she does not have to see him. On 8/16/21 at 11:53 AM, R9 (R2's roommate) stated, The man came in. I saw him. I woke up and saw him sit on (R2's) bed at the end. I saw a figure there but I didn't see exactly who it was. I've seen him since. From my vantage point you can see everyone in the hallway. He walks by quite a few times a day and looks into the room. (R2) was able to identify him and she pointed out who he was to me. I haven't seen him in here since but who's to say it won't happen again? She doesn't feel safe and I don't blame her. They should move him but instead they asked (her) to move. It's not her fault. Why should she move? R9's MDS, dated [DATE], documents R9 scored a 15 out of 15 for mental status and is cognitively intact. R2's Census sheet documents that her room was not changed after the sexual assault. R3's Census sheet documents that his room was not changed after the sexual assault. On 8/16/21 and 8/17/21, V2 (DON-Director of Nursing) and V3 (ADON-Assistant Director of Nursing) indicated they both watched video surveillance of the unit on the night of the alleged sexual assault. Both agreed R3 was seen wandering in the hallway leading to R2's room during the exact time frame of the alleged sexual assault. V2 stated, (R3) was the only gentleman walking in the hallways at that time. V3 stated, (R3) was wandering in and out of rooms that weren't his. He was wearing the clothing and flip flops that (R2) described. V3 indicated R3 moved towards R2's room and moved off camera, but it matched the timeframe that she said it happened. V3 stated, We corroborated that it probably was him and we showed that to the police as well. At this point, I believe that something happened. On 8/16/21 and 8/17/21, V3 and V4 (Social Services Designee) indicated they were, respectively, manager and social services personnel for the unit that R2 and R3 resided on. V3 and V4 indicated R3 had exhibited sexually explicit behaviors. V3 stated, (R3) has some sexual behaviors that we have care planned, masturbation, sometimes not in the privacy of his own room. V4 stated, (R3) was found masturbating when he initially moved down to (unit) in March 2021. and it is also documented R3 had another episode in May 2021. V4 also indicated a CNA (Certified Nurse Assistant) saw R3 in the shower room with woman's panties on his head. On 8/16/21 and 8/17/21, V1 (Administrator/Abuse Coordinator), V2 (DON), V3 (ADON) and V4 (Social Services Designee) were all asked why R3 was not moved to another unit and still allowed access to R2. V1, V2, V3 and V4 all stated R3 was not appropriate for 3rd floor because he does not have Dementia, and not appropriate for 1st floor because R3 is an elopement risk. V1 and V2 also indicated they were not aware R2 was still nervous about the situation. V2, V3 and V4 indicated the intervention that was put into place was to request that R3 not walk down the hallway towards R2's room, and to have staff monitor R3 hourly. Hourly rounds documentation specific for R3 were requested and not submitted. On 8/17/21, V2 was asked how hourly monitoring of R3 was going to ensure that he did not go to R2's room again. V2 did not answer the posed question. On 8/17/21, V10 (RN-Registered Nurse) and V11 (CNA) indicated they are regular staff on R3's unit on the evening shift and/or night shift. V10 and V11 indicated R3 had wandering behaviors even before the sexual abuse incident. V10 stated, I know I have heard that he masturbates in the dining area. And he's been caught a few times by the nurses. It happened once or twice early morning hours, 5am - 6am. As of 8/17/21, R3 continues to reside at the end of the hallway, four rooms away from R2. This has caused R2 fear, nervousness, anxiety, [CONDITION(S)] and an increase in requiring medication for headaches caused by the increased anxiety and [CONDITION(S)]. On 8/17/21 at 9:51 AM, V12 stated, (R2) does report she's very anxious when she sees this resident in the hallway. If this (R3) was moved off of the unit, I think it would greatly help (R2's) anxiety. I don't take any part in moving resident's from room to room. But it would help. V12 was asked if she told any staff regarding R2's request, and V12 stated she spoke to V4. On 8/17/21 at 10:44 AM, V1 stated, I agree with you from a psychological standpoint that if (R2's) still anxious, then we definitely should have moved (R3) to another floor. We should have separated them to let (R2) feel safe. V1 was asked why V4 and V12 did not report to administration R2's request to have R3 moved to another unit. V1 did not have an answer. On 8/18/21 at 12:16 PM, V22 (Psychiatrist) indicated he was not notified regarding the sexual assault involving R2 until 8/18/21. V22 stated, I have provided her psychiatric care for two years now. I was not aware of the sexual assault. I was just told by (V2) at the facility today. (R2) is nervous. She was told yesterday that (R3) was moved to another floor. She said that she was able to sleep. She was nervous due to the incident. She said that she used to feel safe in the home but the last three weeks she has not felt safe. But she feels like she will get better now that he is moved. On 8/18/21, V2 indicated that staff should have notified V22 at the time of the allegation. On 8/18/21 at 12:37 PM, V24 (Psychiatrist) stated, After the sexual assault allegation, I started (R3) on [MEDICATION(S)] to mainly reduce the sexual impulsivity because I believe that incident was due to impulsive behaviors. Per V24's visit notes, dated 5/17/21 and 7/5/21, V24 was not aware of the increase in R3's sexually oriented behavior in regards to masturbation. It is documented in both notes dated 5/17/21 and 7/5/21, There have been no reported incidents of inappropriate behaviors or perceptual alterations. Per V2 and V3, V24 should have been notified. It is noted V24 was not notified about R3's sexual behaviors until 7/26/21, after the alleged sexual abuse incident with R2. On 8/18/21, V22 indicated R2 feels she will get better now that R3 was moved to another unit. Per V22, R2 slept better the night before. R3's medical record documents he does have a dementia with behavioral disturbance diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . And V1 and V2 confirmed that the facility utilizes electronic monitoring bracelets for elopement risks, have staff around the clock on the first floor, and that the first floor door is a secured door requiring a code to get to the lobby area, which would have made him appropriate for the 1st floor. A facility policy dated May 17, 2021 and titled, Abuse and Neglect documents: If abuse/neglect is suspected the facility will: 1. Take immediate steps to assure the protection of the resident(s). This may involve separation from the alleged abuser and/or provision of medical care. III. Prevention: Have procedures to: Establish a safe environment that supports consensual sexual relationship.

Based on interview and record review, the facility failed to follow the plan of care for one resident (R1), which required supervision with eating, and failed to have one person physical assist with eating as assessed (per MDS - Minimum Data Set). This failure resulted in R1 eating alone in room, then found five minutes later gasping for air and blue in the face. Findings include: R1's Progress notes entered by V7 (Licensed Practical Nurse), dated 8/24/2019, state in part; at 6pm resident's dinner tray was brought into his room. CNA stated that resident did not want to get out of bed for dinner, so CNA left resident in bed with head elevated at 90 degrees and call light within reach. At 6:05pm this writer went to check on resident and found resident gasping for air and blue in the face. The writer called for help and other nurse on duty and began the [MEDICATION NAME] Maneuver At 6:15PM other nurses on duty came to the floor and began assisting with [MEDICATION NAME] Maneuver and suctioning the resident, brown vomit liquid was being suctioned out of the mouth of the resident At 6:30pm paramedics pronounced resident dead. R1's Detailed Incident Summary; stated in part; On Saturday at 1800 he was served his diet (General/Thin liquids) consumed 100% of the turkey and 100% of the cake. The nurse was rounding and observed resident to be bluish gasping for air. R1's Minimum Data Set (MDS), dated [DATE], Section G: Functional Status Eating: Self performance- Supervision oversight encouragement or cueing. Support: One person physical assist. R1's Care plan, effective 8/19/2019, state is part; R1 requires total assist with bathing .supervision with eating, due to Dementia with behaviors, obesity . On 8/25/2020 at 12:44 PM, V3 said that supervision is just cueing resident to take small bites, and reminding resident that food is in front of them, making sure that they are eating. At least three times somebody has to go and check on the resident. If it is noted that residents are not swallowing or pocketing food, they are referred for speech evaluation. On 8/25/2020 at 1:35 PM, V14 (Speech Therapist) was asked what supervision means, V14 said supervision means someone is in view of somebody. And cueing is to get them to eat or follow directions. During the course of this survey, facility was asked for, and did not provide, any policies related to resident supervision during meals.

Based on interview and record review, the facility failed to prevent a significant medication error for one resident (R2) out of 7 reviewed for medications. This failure led to R2's Intensive Care Unit admission due to [DIAGNOSES REDACTED] secondary to receiving medications not ordered by physician. Findings include: R2's progress notes as follows: On 9/11/19 at 07:28 AM, documented by V9 (Registered Nurse) Sleep well most of the shift. and took due medicines in early AM at 5.30 am and back to sleep. At 6.15 am resident noted very sleepy, responding verbally but slow. Vitals taken and read as follows. B/P = 160/70 P 61. R=16 Spo2 room air= 95 %. Respiration regular and easy. Temp=97.9 temp. Skin warm and dry to touch. At 6.40 am (V12- Physician) office called, and he is an on call but not available. Message left as his office phone prompt says. Next shift update for follow up. Resident sleeping, saturation re checked = 94 -95 % room air. On 9/11/19 at 08:09 AM, documented by V9: .Called V12 (Physician) at 7.45am again. Resident blood sugar checked , still sleepy, 31 mg/dl. Waiting MD return call. [MEDICATION NAME] 1 mg injected IM. Resident on oxygen for comfort, Respiration non labored. Skin warm and dry.ON DNR code status On 9/11/19 at 10:34 AM, documented by V8 (Nurse) Resident is able to verbalize self, more alert & oriented. Not in any distress. Denies of any pain and discomfort as of this moment. Assisted by staff to get ready for breakfast. Ate & consumed 100% of meal served From (V12's) office called back and was informed as well. Rechecked Glucose level @ 10 AM, 106 mg/dl. Will continue to monitor and refer as necessary. On 9/12/19 10:16 AM, change in condition, as documented by V6 (Registered Nurse): Situation: 1. The change in condition, symptoms, or signs observed and evaluated is/are: After breakfast around 945 am patient up in wheelchair and non-verbal, blank stare and not verbally responding, noted with pallor. Confused and checked BS level=162 mg/dl , put to bed right away and VS checked, O2 given. Unable to follow commands, flat affect when tried to shake him, smiled crookedly when asked to. Noted making sounds in his throat. Skin cool to touch. 2. This started on: 09/12/2019 2a. Since this started, it has gotten: Worse 3. Things that make the condition or symptom worse are: BS level went down from 162 to 30 when paramedics arrived. 4. Things that make the condition or symptom better are: 5. This condition, symptom, or sign has occurred before? Yes 5a. treatment for [REDACTED]. 6. Other relevant information: Pulse rate kept coming down==100, then 78 and 40 when paramedics came and patient more sleepy. On 9/12/19 at 2:34 PM, documented by V6: Called (local hospital) and also spoke with (V17), patient is admitted for [DIAGNOSES REDACTED] --he elaborated that they will do a series of test related to his pancreas /endocrinology system since after given D50 IV , BS level went up to 150 and pt. was alert again and after a few minutes, BS level just went down to 35mg/dl R2's hospital records, titled All results under (lab) miscellaneous test, dated 9/12/19 at 2330 PM, document: ([MEDICATION NAME]) - positive Intensive Care Medicine Resident Admission History and Physical, dated 9/12/19, document: History of Present Illness: presenting with severe [DIAGNOSES REDACTED] Further history gathered from patients nursing home .Per evening nurse, patient was shaking and had Altered mental status in the morning. Had low glucose level so gave oral glucose. Blood sugar rose to 162 then dropped to 30. Also initially [MEDICAL CONDITION] and then bradycardic to the 40's .This has not happened before, patient is not diabetic, usually eats all meals, no recent medication changes and no sick contacts. In Emergency Department .transferred to ICU for continued monitoring. Intensive Resident admission note, dated 9/19/19, document: Of note: he was admitted to the ICU with [DIAGNOSES REDACTED], likely secondary to receiving his roommates sulfonylurea (positive screen). R2's facility investigation, dated 9/18/19, documents: Family meeting - the (DON), and SS Director, met with V17 (R2's son) at 1530 on Wednesday 9/19/19, this meeting was requested by the son. He expressed concerns that his father may have been given the wrong mediations as indicated at by the hospitalist at (local hospital). The resident's medical records are not accessible to us at this time and updates via telephone are password protected. The son is willing to share the hospital record to complete our ongoing investigation . Medical records became available on 9/25/19 and were reviewed, It did indicate that (R2) had unintentionally, or accidentally ingestion of ([MEDICATION NAME]) A timeline was completed, and the Nurse was identified as making the error. R2's resident information form lists the following Diagnosis: [REDACTED]., [MEDICAL CONDITION], [MEDICAL CONDITIONS], Chronic Diastolic Heart Failure, [MEDICAL CONDITION], ORrthostatic [MEDICAL CONDITION], GERD, [MEDICAL CONDITIONS], [MEDICAL CONDITIONS] There is no [DIAGNOSES REDACTED]. R2's (MONTH) 2019 Physician order [REDACTED]. R2's order review report authorization date: 09/01/19 - 10/31/19 does not list ([MEDICATION NAME]). (R3's resident information lists room/bed: 119-B. According to R3's (MONTH) 2019 Physician order [REDACTED].) On 10/15/19 at 1:50 PM, V6 (Registered Nurse) was interviewed and stated that R2 was not diabetic, there were no sugar checks needed for him, but had taken it because he had low blood sugar the day before. V6 stated that on 9/12/19, resident was unfocused and pulse was dropping so 911 was called. V6 stated that blood sugar dropped from time she checked and result was 130 to 30 when paramedics came. V6 stated that R2 was admitted to hospital for [DIAGNOSES REDACTED] and was informed by (V17) that more tests will be done for pancreas because blood sugar was unstable. On 10/15/19 at 2:21 PM, V2 (Director of Nurse) was interviewed and stated incident investigation was done for R2. The first one was prompted due to R2's [DIAGNOSES REDACTED] where nothing was founded and second one - reopened investigation due to (V17) bringing up concern from hospital. V2 stated that medication variance form was done and basing off the second investigation, medication error was made, from hospital record of positive ([MEDICATION NAME]) screen and time line of medication effects, nurse working was identified and was suspended and terminated. On 10/15/19 at 3:55 PM, V7(Human Resources Director) was interviewed and stated that V8 was a previous employee, had a reprimand record, was initially suspended pending investigation and terminated on 10/2/19, due to failure to follow policy and procedure for safe medication administration. V7 stated that V8 never returned to work after suspension. V7 stated that V8 declined to make any statement or sign anything. On 10/16/19 at 10:36 AM, V2 stated the (V8) had statements and did not clearly state or admit to making the medication error, but she was probationary and had been counseled for several instances of her pre pouring medications and labeling them with room numbers, and was reported to be on her phone while doing medication pass, and that would be a distraction. V2 stated that it is not facility practice to be pre pouring meds, it should be go to the room, prepare medications, give medications and sign them after. On 10/17/19 at 9:57 AM, V15 (Medical Director) was interviewed that incident was a mistake of administering roommates medication to this resident. V15 stated on review, this patient had no diabetes and no medications for it. V15 stated [DIAGNOSES REDACTED] resulted from wrong medication and ICU admission was appropriate for closer monitoring and for a person with [MEDICAL CONDITION] - any medication would have prolonged effects in the body as the kidneys are not effectively metabolizing and getting rid of the drug in the system. Attempted to contact V8 (Former Employee - Nurse) and V12 (R2's Primary Care Physician) were unsuccessful. ([MEDICATION NAME] - [MEDICATION NAME]) Clinical Pharmacology documents: Description: is an oral blood-glucose lowering drug of the sulfonylurea class. Indications and usage: is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Precautions: may be slowed in patients with impaired renal and/or hepatic function. [DIAGNOSES REDACTED]: renal or hepatic insufficiency may cause elevated blood levels of ([MEDICATION NAME]), both of which increase risk of serious hypoglycemic reactions. (Pharmacy) titled: Medication Administration General Guidelines document under Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Procedures: 6. FIVE RIGHTS - Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication is put away Administration: 2. Medications are administered in accordance with written orders of the prescriber. 3. When medications are administered by mobile cart taken to the resident's location (room, dining area, etc.) medications are administered at the time they are prepared. Medications are not pre-poured either in advance of the med pass or for more than one resident at a time .6. Residents are identified before medication is administered using one method of identification. Methods of identification include: a) checking photograph attached to medical record, b) Calling resident by name (except in residents with cognitive impairment) c) having resident verify his/her last name d) if necessary, verifying resident identification with other facility personnel.

Based on document review and interview the facility failed to follow the transfer policy and use a gait belt while assisting a resident with a transfer for 1 of 3 residents R2 reviewed for safe transfers. This failure resulted in R2 knees giving away during a transfer and landing on the floor while being assisted by the facility staff without the assistance of a gait belt. Findings include: Facility incident report dated 7/24/18 states on 7/19/18 at 1:30PM R2 was assisted by V4 and V5 ( Certified Nurses Aids) who were supporting her on both sides as they were changing her brief. The resident was holding onto her walker and her knees gave out and the resident fell to her knees. An Xray was done that showed supracondylar [MEDICAL CONDITION] femur. Hospital record dated 7/24/18 stated left distal femur fracture. R2s Minimum (MDS) data set [DATE] states 2 person physical assist for Transfer, Dressing and Hygiene/Bathing. V5 ( Certified Nurses Aid ) 11/15/18 2:40PM stated We stood her up . We were holding her . She told us her leg was giving out. She started to go down so we lowered her to the floor . We were supposed to use a gait belt but she refused so we didn't use one. R2 11/19/18 10AM stated The two certified nurses aids stood me up from the bed and I held onto my walker. My knees gave out and I went down on both knees to the floor. I layed on my side. I broke my left leg. I have my gait belt in my drawer. A gait belt was not used. V6 ( Assistant Director Of Nursing) 11/19/18 10:40AM stated gait belts are to be used at all times. During incident R2 refused gait belt. No gait belt was used. Facility policy/procedure titled Transfer, Ambulation and Re-positioning states Gait belts are provided by the facility and are to be used during ambulation and /or transfer of a resident.

Based on observation, interview and record review, the facility failed to: properly identify a pressure sore, properly categorize a pressure sore, notify the wound care physician when the wound worsened, implement interventions as recommended by the wound care physician and ensure that a nutritional assessment was performed. These deficient practices affected one resident (R9) of five residents reviewed for pressure sores in a sample of 27. This failure resulted in R9 developing a worsening pressure sore on the coccyx area. Findings include: On 1/11/16 at 10:15 AM, E15 (CNA-Certified Nurse Assistant) performed R9's incontinence care. As E15 removed R9's incontinence brief, a wound was noted on R9's coccyx area. E15 stated, (R9's) had this a long time. R9's name was not listed on a facility document that was submitted on 1/10/16 and titled, Wound Analytics - Active Wounds. R9's name was listed on the document which indicated all wounds in the facility. R9's wound was categorized as MASD (moisture-associated skin damage) due to incontinence with a start date of 10/27/15. On 1/11/16 at 11:30 AM, Z6 (Wound Care Physician) stated, (R9) has a Stage 3 pressure sore on the coccyx. Slow healing. She has had it for 2-3 months. As Z6 performed R9's wound care, Z6 stated, It's worse from last week. We'll have to change treatment. On 1/11/16, R9's wound care treatment order was changed from [MEDICATION NAME] once a day to [MEDICATION NAME] 0.75% twice a day. Z6 stated, I suspect fecal matter is infecting the wound. [MEDICATION NAME] is [MEDICATION NAME], antibiotic. R9's Wound Care Evaluation Notes dated 10/27/15 documents that R9's pressure sore is a Stage 3. On 1/11/16 at 2:10 PM, E20 (Wound Care Nurse) stated, What happened was (R9's) wound started as moisture related. It transformed into a pressure ulcer. All my assessments were coming under the category of MASD versus pressure. On the first page of my weekly assessments, I have to indicate pressure versus MASD. I did not do that so her wound remained categorized as MASD. (R9's) wound (dressings) should have been changed by me. The (evening) floor nurses would do the wound care whenever scheduled. E20 continued, Stage 3 daily wound treatment should be done by wound care nurse. I performed her dressings weekly, not daily. There were no notifications to the wound doctor for the times when the wound worsened. Because I'm certified, I would've noticed the change in the wound sooner and notified (Z6). On 1/11/16 at 11:00 AM, E2 (DON-Director of Nursing) stated, The wound nurse gives an updated wound list weekly. (E20) admitted that she totally forgot to convert (R9's) MASD wound in our computerized assessment into pressure sore category. According to R9's Treatment Administration Records from September 2015 through January 2016, there was no continuity in floor nurses providing treatment to R9's coccyx wound. R9's Wound Care Evaluation Notes document an increase in the size of R9's wound from 0.4 cm (centimeters) length X 0.4 cm width x 0.1 cm depth on 11/30/15 to 1 cm X 0.5 cm x 0.1 cm on 12/7/15. Z6 had not been notified of the wound's worsening. On 12/7/15 during wound rounds, Z6 changed the treatment order from [MEDICATION NAME] daily to Medi-honey daily. R9's Wound Care Evaluation Notes document an increase in the size of R9's wound from 1.0 cm length X 1.0 cm width x 0.1 cm depth on 12/21/15 to 1.2 cm X 1.0 cm x 0.1 cm with slough on 12/28/15. Z6 had not been notified of the wound's worsening. On 12/28/15 during wound rounds, Z6 changed the treatment order from Medi-honey daily to [MEDICATION NAME] daily. R9's Wound Care Evaluation Notes document an increase in the size of R9's wound from 1.5 cm length X 1.0 cm width x 0.1 cm depth on 1/4/16 to 2.2 cm X 2.0 cm x 0.5 cm with on 1/11/16. Z6 had not been notified of the wound's worsening. On 1/11/16 during wound rounds, Z6 changed the treatment order from [MEDICATION NAME] daily to [MEDICATION NAME] twice daily. On 1/11/16 at 12:10 PM, Z6 stated, What do I expect of the nurses when treating a pressure wound? Follow orders, preventative measures, nutritional evaluation/assessment. Z6 indicated that R9's wound is unavoidable. Z6 stated, But, even if unavoidable, we have to treat to try to prevent worsening. If there's significant change in the wound, then I would expect that the wound care nurse measures the wounds and updates me. Z6's Wound Care Evaluation Notes dated 10/27/15 document: Today's recommendations/Preventative Measures for the Nursing Facility: Stage appropriate Pressure reduction mattress. Mattress - High Risk, IV, III = LAM (low air mattress). 4. Nutrition - Continue Dietary Follow-up of Nutritional Needs. On 1/12/16 at 1:40 PM, E20 (Wound Care Nurse) was standing outside of R9's room. E20 stated, No, she's not on an air mattress. She was at one point. But not right now. Will take care of that right away. On 1/12/16 at 2:58 PM, E2 (DON) indicated that the dietitian was going to see (R9) today. E2 stated, Since she triggered for macerated wound versus pressure sore, there was no orders or evaluation from a nutritional standpoint regarding pressure sore. On 1/12/16 at 3:00 PM, Z7 (Dietitian) stated, The RD (Registered Dietitian) will see anyone with pressure sores or upon request. If triggered as a pressure sore (on weekly report), I will see those residents monthly because they are high risk. If Stage 1 or 2, the dietary tech can see them. If more than one pressure ulcer or Stage 3 or 4, I would be the only one allowed to see the resident. I saw (R9) on 1/7/15 for follow up due to tube feeding. Pressure ulcer not triggered. It should be one gram per kilogram (of protein) with pressure ulcer. I would've increased her to 1.2 grams per kilogram. I was informed today regarding(R9's) pressure sores. I put a new order in to increase tube feeding to one hour more a day and I recommended Promod twice a day to promote wound healing. R9's Care Plan documents, in part: Problems: (R9) at risk for further skin breakdown Interventions: Perform nutritional screening. Adjust diet /supplements as indicated to reduce the risk of skin breakdown. Monitor skin daily during care and report changes. Use pressure-reducing mattress and cushion when sitting. Notify physician of changes as needed. An updated Care Plan to reflect the Stage 3 pressure ulcer on R9's coccyx was created on 1/11/16. The facility's Job Description for Wound Care Nurse documents: Accurately measures and stages wounds, Conducts regular wound measurement rounds to assess for wound healing progress, Demonstrates initiative in assessing wound needs for all patients/residents and takes ownership in implementing necessary follow-up. The facility's Clinical Practice Guidelines dated May, 2011 documents, in part: Stage III Pressure Ulcer Clinical Strategies: Employ pressure reduction devices (mattress replacements, specialty beds, cushions). Ensure adequate nutrition and hydration. The facility policy dated 4/14 and titled, Pressure Ulcer Weekly Assessment documents: POLICY: Pressure ulcers will be assessed weekly and PRN (as needed) to identify the effectiveness of the treatment plan and the progression of the healing process. PROCEDURE: 8. Assessment of Treatment Efficacy. b. Notify the physician if the wound worsens or remains static for more than three weeks. C. Adjust the treatment plan accordingly.

Based on interview and record review, the facility failed to assess, identify, treat and update physician's orders for one of one residents (R1) reviewed for diabetic ulcers. These deficient practices resulted in R1 requiring hospitalization for excisional debridement of left toe [MEDICAL CONDITION] and intravenous antibiotic therapy for Staph aureus (Staphylococcus aureus). Findings include: R1 (per review of Admission [DIAGNOSES REDACTED]. E6 (LPN-Licensed Practical Nurse, 5/6/15 at 2:00 p.m., 5/7/15 at 10:18 a.m.) said all assessments (including skin) are to be completed by the nurse upon the resident's admission to the facility and there is an admissions check list that is utilized. E6 said she is unaware of any admissions policy and procedure. E6 said she has worked at the facility for 4 years and she knows what needs to be done when a resident is admitted . E6 admitted that she did not complete a skin assessment for R1 because he refused. E6 said she believes she documented in the 24 hour shift report R1's refusals for skin assessment. E2 (Director of Nursing, 5/7/15 at 3:10 p.m.) said skin assessments are part of the admission process. The assessment is to be completed in the EMR (Electronic Medical Record) in addition to completing an admission check list. E3 (Assistant Director of Nursing, 5/6/15 at 12:15 p.m.) said skin assessments should be completed upon the resident's admission to the facility. E3 said reviewed R1's EMR and said the skin assessment had not been completed. Both E2 and E3 said R1's refusal should have been documented in the 24 hour shift report and endorsed to the next shift to complete. Review of R1's medical record (Progress Notes 4/25 and 4/30/15, Assessments) document an incomplete skin assessment. Review of the 24 hour reports (4/25/15 hand dated by E3) document that skin assessment was not completed upon admission and the need for next shift to follow up. E6 said she did not perform a skin check on R1 when he received a shower on 4/27/15 because she was in the middle of something; the CNA (Certified Nursing Assistant) completed the skin check. E6 said it is the nurse's responsibility to complete a skin check before the resident leaves the shower. E2 (5/7/15 at 3:10 p.m.) said a nurse should complete a skin check during a resident's shower. She said E6 did not complete a skin check for R1. E3 (5/6/15 at 12:15 p.m.) said a nurse must complete a skin check before the resident leaves the shower. Review of R1's Skin Observation Worksheet (Shower Log, 4/27/15) documents R1 received a shower and skin check was completed with no changes. Z1 (DPM-Doctor of Podiatric Medicine, 5/6/15 at 3:31 p.m.) said he did a debridement of the tip of the 4th toe of R1's left foot on 4/27/15 for a Grade I ulcer. Wound care was to include daily bathing and dressing change with application of [MEDICATION NAME] or [MEDICATION NAME] ointment. Z1 said he was notified by the facility that R1 did not have any paperwork when he returned to the facility. Z1 said he faxed the information to the facility the following day (4/28/15). Z1 said R1, who has a history of [MEDICAL CONDITION] and toe amputation, developed a very significant foot/toe ulcer while at the facility. He said if he had known that R1 had any symptoms of infection and that wound care was not being done, he would have sent R1 immediately to the hospital. When asked by the surveyor, what could happen if wound care was not done, Z1 responded: "what could happen, did happen." Per review of R1's Report of Consultation (4/27/15) a debridement of the tip or R1's left 4th toe was done for a Grade I ulcer measuring approximately 0.25 cm in diameter. R1's wound care status [REDACTED]. Z3 (Physician, 5/7/15 at 2:56 p.m.) said he was not informed by the facility that R1 had been seen by a podiatrist and had a debridement of the left 4th toe for Grade I ulcer nor was not contacted regarding podiatrist's wound care instructions. He said if wound care is not done (as is the case of R1), a wound could potentially get worse. It could get larger, deeper, become infected and spread to surrounding tissue. Z1 said he agreed with Z2 regarding sending R1 to the hospital. Review of R1's medical record (Progress Notes 4/25 and 4/30/15) doesn't document: that paperwork was or was not received from Z1; any further attempts to obtain paperwork from Z1; any assessment of R1's feet before or after his visit to Z1; doesn't document any notification of R1's physician regarding R1's visit to Z1/debridement of R1's left 4th toe/wound care instructions nor does it document any wound orders for resident's left 4th toe. E3 (5/2/15 at 1:20 p.m.) said staff missed wound to R1's left foot and toe. E7 (Nurse, 5/6/15 at 4:20 p.m.) said he was approached by R1's wife on 4/30/15 stating R1 has an infection somewhere because his blood sugar is high. E7 said he looked at R1's right great toe and it was red. E7 said he knew R1 saw the foot doctor on 4/27/15, but didn't see any new orders in his chart. Review of E7's Progress Note of 4/30/15 documents R1's wife told him resident's uncontrolled blood sugar was due to a possible infectious disease of the "right big toe", therefore she is taking him to the foot doctor. The note does not document any assessment of R1's feet. In a late entry created on 5/2/15, E7 documents on 4/30/15, before wife and resident left the facility, the wife called him to assess R1's feet. E7 assessed R1's feet and "found redness towards the big toe." Review of R1's hospital record (Daily Progress Note 5/2/15, Infectious Disease Progress Note 5/2/15) documents R1 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. An excisional debridement of the left toe [MEDICAL CONDITION] was performed. Culture of foot drainage was positive for Staph aureus.

Based on interview and record review, the facility failed to provide for a safe transfer and assistance for one (R1) of three residents reviewed for transfers. This failure resulted in R1 sustaining a fracture of the tibia when R1 slid from an unlocked wheel chair during a transfer. Findings include: R1 is a [AGE] year old female resident with [DIAGNOSES REDACTED]. R1 is alert and oriented x3. R1 ' s 9/28/13 weight is 291 pounds and R1 is 59 inches tall. R1 uses a wheelchair for ambulation. R1 ' s current Minimum Data Set. (9/6/13) scores R1 for transfer at 3/3 extensive assistance/two plus persons physical assist. R1 ' s 9/7/13 Care Plan includes a history of falls and requires assistance with transfers and ambulation. Review of R1 ' s clinical notes documents the following: 9/24/13, 5:35PM, "Resident was on the floor complaining of pain. According to staff this occurred during transfer from bed to wheelchair. Resident was lowered to the ground by sliding down." Resident complained of pain. R1 was sent to the hospital (911). 9/29/13 clinical notes document R1 was readmitted back to the facility on [DATE] with a right leg tibia plate fracture. 10/4/13 at 9:40AM, R1 stated, "I was being transferred from my bed to my wheelchair by 2 Certified Nurse Staff (E4, E5). "The wheelchair was not locked so I slid out of the CNA ' s arms." 10/4/13 at 12:05 PM, E5 (Certified Nurse Aid) stated (E4) (Certified Nurse Aid), " asked me to help her. We gave incontinent care to R1. After that we needed to transfer her from her bed to the wheelchair to go to lunch. (E4) said I needed to lock the wheelchair. (R1) said not to lock the wheelchair. The wheelchair was not locked. (E4) told me to grab her under the left arm pit and grab her pants to stand her up on the floor. (R1) stood up with her back to the wheelchair. We tried to hold (R1) but she started to slide down to the floor. The wheelchair slid out. She slid to the floor. (R1) complained of pain in both legs. I called for help. I ran from the room to get help. " 10/4/13 at 11:20AM, E4 (Certified Nurse Aid) stated, " This was my first day on the floor. I have been employed here 3 weeks. We gave (R1) incontinence care in her bed. I asked E5 (Certified Nurse Aid) if she could help transfer R1 from the bed to the wheelchair. I locked my side of the wheelchair. I don ' t think E5 locked her side of the wheelchair. We stood her up. We were both holding her from under the arm. She started to slide to the floor. The wheelchair moved away from (R1). We just sat her on the floor. We called for help. " 10/17/13 at 10:58AM, E3 (Licensed Practical Nurse) stated that she was called to R1 ' s room by E5. R1 was on the floor visibly in pain. We kept her immobile. We called 911. E4 and E5 said R1 slid to the floor. I don ' t think they performed the transfer correctly. Facility policy documents " the facility will promote safety for residents and staff during transfers, ambulation and re-positioning through the use of body mechanics and safety devices. This policy is called (TARP) Transfer, Ambulation and Re-Positioning. The transfer in-services sheet indicates E4 and E5 were trained on proper transfer techniques. " The facilities internal final investigation dated 9/27/13 documents the following; it was substantiated R1 was transferred inappropriately resulting in injury. It was determined that E4 (Certified Nurse Aid) failed to adhere to company transfer protocol. The facility elected to terminate the employment relationship with E4.