Every finding on record at British Home, The

Based on observation, interview, and record review, the facility failed to follow therapeutic diet orders, failed to ensure nutritional supplements ordered by the Registered Dietician were provided during meals, and failed to monitor, assess, and document meal/nutritional intake of residents. This failure affected three residents (R1, R7, R28) in a sample of 20 residents reviewed for nutrition. These failures have the potential to affect 35 residents that receive oral intake at the facility. Findings include: 1.R7 is [AGE] years of age. Current diagnoses include but are not limited to Dementia, Weakness, History of Falling, Hypothyroidism, Chronic Obstructive Pulmonary Disease, Palliative Care, Gastro-esophageal Reflux Disease. R7's comprehensive assessment section C Cognitive Patterns, dated 05/11/2026, documents a BIMS (Brief Interview for Mental Status Score) of 13, which indicates R7 is cognitively intact. On 05/11/2026 at 11:17 am, R7 was asked about her meals. R7 said, When the food comes, they don't bring what I order even when I ask them for it, they never bring it back. On 05/12/2026 at 12:20 pm, R7 is alert and oriented, while in bed. R7 is in bed with the head of the bed elevated eating her lunch. R7 was served diced bite sized pieces of chicken, lo mein noodles, stir fry carrots and broccoli, chicken noodle soup, cranberry and apple juice. R7 ate approximately 10% of her lunch and drank all 6 ounces of cranberry juice. R7 said, I always ask for my ice cream and they never bring it. R7's diet ticket on her lunch tray has ice cream circled per her request. On 05/12/2026 at 12:57 pm, R7's physician orders document 04/07/2026 Magic cup with meals- 1 cup PO (by mouth) twice a day for nutritional supplement (provide with lunch and dinner). Frequency: BID (twice a day). R7's care plan documents- I am at nutritional risk for weight loss related to medications, medical conditions, varied po (by mouth) intakes, mechanically altered diet, and impaired mobility. H/O (History of) recent swallow and chewing issues/dental issues. Malnutrition per MNA (Mini Nutritional Assessment) signed by provider 1/14/26. A) Provide diet as prescribed: Regular, regular texture, thin liquids. Provide: Boost BID (twice a day) and Magic cup BID. Please honor my food preferences with diet regimen. Review of R7 weight loss documents the following: On 01/08/2026, the resident weighed 135 lbs. On 05/01/2026, the resident weighed 125 lbs (pounds) which is a -7.41% loss. On 05/12/2026 at 2:25 PM, V1 Administrator provided R7's MNA (Mini Nutritional Assessment), dated 1/14/26, which documents a screening score of 7, which indicates she is malnourished. 2.R28's face sheet documents an admission date of 6/20/2025 with diagnoses that include but are not limited to fibromyalgia, cervical region, encounter for palliative care, adjustment disorder with mixed anxiety and depressed mood, osteoarthritis, personal history of urinary (tract) infections, and severe protein-calorie malnutrition. R28's comprehensive assessment section C Cognitive Patterns, dated 04/22/2026, documents a BIMS (Brief Interview for Mental Status) score of 11, which indicates R28 has moderate cognitive impairment. On 5/12/2026 at 11:59 am, R28 was in bed with the head of the bed elevated and being fed lunch by V17. V17 was feeding R28 cream of spinach soup. R28's tray included baked fish, lo mein noodles, and spinach cream soup. R28 only ate cream of spinach soup. The diet ticket on the lunch tray indicated Special Note (No chicken and provide magic cup with lunch). No magic cup (nutritional supplement) was on the R28's tray. R28's care plan documents in part under the nutritional status section, I am at nutritional risk related to medications, medical conditions, hospice care, poor oral intakes, weight loss, and impaired mobility. Diagnosis: malnutrition. Provide diet as ordered: regular, regular texture, thin liquids. Provide Magic cup BID (twice daily) and Boost QD (daily). On 05/13/2026 at 9:56 am, V9, Dining Director, was asked about providing nutritional supplements as ordered. V9 said, We have the magic cups in the freezer on each floor. I don't have access to the physician orders. The nurse or Dietitian enters it (the order) into Matrix (electronic medical record). It's in a separate place in there. Or they would either have to give me a written form or send an email. Nursing staff should be checking the resident's diet ticket with each meal to make sure they're getting the right diet and any special order. We don't put them on the meal tray because they're in the warming carts and it'll melt. On 05/13/2026 at 10:10 am, the 2nd floor refrigerator in the dining area has 5 magic cups in the freezer. On 05/13/2026 at 10:12 am, V22 LPN Licensed Practical Nurse was inquired of providing residents with nutritional supplements. V22 said, It's the nurse's responsibility and the CNA (Certified Nurse Assistant). The diet ticket says if the resident gets a magic cup and those are in the freezer. On 05/13/2026 at 1:34 pm, V2, DON Director of Nursing, was asked about providing nutritional supplements as ordered. V2 said, The supplements come from the Dietitian order to provide a magic cup, and the kitchen brings a supply to the nursing unit. I believe the Dietitian should inform the kitchen and nursing staff of the order or any changes to the resident's diet. Nurses and CNAs should make sure to check the residents' ticket for the correct meal, cross-check allergies and for supplements. Nurses on duty should have an order on the eMAR (electronic medication administration record) to ensure the resident receives the supplement. The nurse has to document it was given to the resident. The 3/2/2026 Therapeutic Diet Orders policy states in part: Policy: The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences.Policy Explanation and Compliance Guidelines2. Therapeutic diets, including mechanically altered diets where appropriate, will be based on the resident's individual needs as determined by the resident's assessment. Therapeutic diets may be considered in certain situations, such as, but not limited to:a. Inadequate nutritionb. Nutritional deficitsc. Weight lossd. Medical conditions such as diabetes, renal disease, or heart diseasee. Swallowing difficulty4. The reason for a therapeutic diet is to be documented in the medical record and/or indicated on the resident's comprehensive plan of care. All diet orders are to be communicated to the dietary department in accordance with facility procedures.5. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed. 3.R1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] after being hospitalized . R1's 4/6/2026 admission diagnoses included urinary tract infection, extended spectrum beta lactamase (ESBL) resistance, klebsiella pneumoniae, bacteremia, acute systolic congestive heart failure, hydronephrosis with renal and urethral calculous obstruction, muscle wasting and atrophy, atrial fibrillation, systolic congestive heart failure, toxic encephalopathy, dysphagia, difficulty walking, cognitive communication deficit, type two diabetes, chronic kidney disease stage two (mild), unsteadiness on feet, atherosclerotic heart disease, hyperlipidemia, gout, anemia, hypothyroidism, acute respiratory failure with hypoxia, essential tremor, urinary retention, essential hypertension, dysphagia, severe sepsis without septic shock, delirium due to known physiological condition, myocardial infarction, acute kidney failure, need for assistance with personal care, cognitive communication deficit, generalized muscle weakness. R1's Minimum Data Set (MDS), dated [DATE], included a Brief Interview of Mental Status (BIMS) of 9, indicating moderate cognitive impairment. MDS also indicated R1 had difficulty or pain with swallowing and needed assistance with eating set up and clean up. R1 had two pressure injuries and a weight loss of greater than five percent in the last month. R1's care plan, dated 4/6/2026, stated, I (R1) am at nutritional risk for weight loss related to medications, medical conditions, varied po intake, therapeutic diet, advanced age, mechanically altered diet, weight loss, pressure injuries and impaired mobility, plus swallow deficits. Goal was to maintain current weight plus/minus five percent times thirty days. Interventions include monitoring oral intake of food and fluids. On 5/13/2026 at 2:47 pm, V1 R1's weight obtained on 5/13/2026 at 1:08 PM was 196.6 pounds. On 5/11/2026 at 10:54 am, R1 was in the dining room reading the newspaper. R1 stated, I've been losing weight. Don't ask me how much. I haven't been trying to lose weight. I was 201 pounds. I was 231 pounds and at some point, I was as high as 260 pounds. On 5/13/2026 at 9:12 am, V3 (Assistant Director of Nursing) described the process when a resident loses weight. V10 (Dietician) reviews weights, confirms the weight is accurate, looks at resident intake, and considers possible supplements. V3 stated R1's most recent dietician note is 4/9/2026 and (Nutritional supplements) were ordered. V3 could not locate in the EHR where the nurses were documenting meal consumption. On 5/13/2026 at 10 am, V2 (Director of Nursing/DON) stated, I don't see where the nurses are documenting the percentage of meals being eaten. I will check with the nurses to see if they are documenting it somewhere else that we are not aware of. On 5/13/2026 at 10:26 am, V10 (Dietician) stated, A significant weight loss is 5% at one month, 7.5% at three months, or 10% at six months. If a resident has significant weight loss. I assess the root cause. (R1's) weight decrease from 201 pounds to197.4 pounds is a concern. I monitor (R1's) intake by going through the nurses notes to figure out what (R1's) intake was. The nurses document dietary intake in the interdisciplinary notes or the nurses notes. V3 (Assistant DON) was present and stated there is no documentation of percentage of meal consumed in the EHR. V10 stated, The nurses document, for example, appetite 75%, which is how I know how much the resident has consumed. V10 was asked what appetite 75% means. V10 stated, I am looking at the 5/12/2026 nurses note. That means (R1) ate 75% of lunch. I do not know what (R1) ate for breakfast or dinner. The nurses usually document at least one of (R1's) meals consumption. V10 and V3 stated there was no note for breakfast or dinner on 5/12/2026 and there was no documentation of appetite or meal consumption every day by nursing. V10 stated the only way V10 knows what residents are eating, is when V10 is present and sees what residents are eating at mealtime. V10 stated, Otherwise, I don't know what residents are eating. V10 stated, (R1) is declining. (R1) is starting to decline in cognition, so (R1's) weight loss is concerning. The risk of decreasing weight is malnutrition and bed sores and I know (R1) already has a wound. We don't know if (R1) is getting enough protein or calories because I don't know what (R1) is eating. V10 affirmed meal consumption should be documented within the EHR and leaders need to review weights and weight loss. We will be working on a plan of correction now. On 5/13/2026 at 12:25 pm, V2 (Director of Nursing/DON) stated, Percentage of meal consumption by residents is occasionally documented in the interdisciplinary notes in the electronic health record (EHR), otherwise it is not documented anywhere else. The concern is the facility needs documentation and proof residents are eating enough to maintain heathy recovery and promote wound healing. Because meal consumption is not being documented, the risks are malnutrition without a direct plan of action and resident specific risks such as residents with diabetes who could experience hypoglycemia. The Certified Nursing Assistants (CNA) are not documenting meal consumption. On 5/12/2026, the nurse documented appetite 75%. That may mean 75% of breakfast and lunch were consumed, but there is no identification of whether the nurse is documenting for breakfast or lunch. The morning nurse documents on the even numbered rooms. The evening nurse documents on the odd numbered rooms. (V3, Assistant DON) spoke to the CNAs. There was a change in the computer system some time ago and CNAs can no longer document meal consumption. It is important to know what residents are consuming nutritionally. On 5/13/2026 at 12:37 pm, V3 (Assistant Director of Nursing) stated, Certified Nursing Assistants (CNA) do not document meal consumption on any resident. It is not part of their charting. V3 stated, (V18, CNA) stated it is standardized that the CNAs cannot document meal consumption for any resident. It has been months that the CNAs have not been able to chart meal consumption for the residents. On 5/13/2026 at 12:42 am, V18 (Certified Nursing Assistant) stated, CNAs do not document meal consumption. Maybe a year ago the facility changed the documentation and removed that ability. The nurses ask at the end of the shift what each resident ate. They will say how much did they eat. I will say 50% for example. I assume that they mean lunch. On 5/13/2026 at 1:26 pm, V6 (Medical Director) stated, If meals are not eaten, it is noticed, but not a rule of thumb that it is documented. If we note plates have leftovers on them, the staff would document that. Other facilities document the percentage of meals eaten. This facility makes it more homelike. If a resident is not eating, the Certified Nursing Assistants (CNAs) should be documenting that. If the CNAs are not documenting, it is the nurses' responsibility. If nursing is not documenting the percentage of meals consumed, I would be concerned and if the meal is less than 50% eaten. If the amount of meal eaten is not documented, the weight loss becomes the guide that a resident is not eating. If you don't have nurses that are documenting, leadership needs guidelines that documentation should be done. The immediate indicator a resident is not eating could be dehydration, change in vital signs, decreased blood pressure or delirium. Review of R1's progress notes include on 5/13/2026 at 2:06 PM V19 (Nurse documented Appetite: 100% of breakfast, lunch. 1 bottle of ensure On 5/13/2026 at 7:18 PM V10 (Dietician) documented current body weight 196.6 pounds on 5/13/2026. Weight history: in 2 weeks, R1 had a 2.2% weight loss. In one month, R1 has been stable. In two months, R1 had a 7.8% weight loss. R1 is consuming about 75% of most meals per nursing notes. On 5/13/2026 at 7:21 PM V32 (Physician) documented in the plan daily weights. On 5/12/2026 at 2 PM V33 (nurse documented Appetite: 75%. On 5/11/2026 at 6:31PM V34 (physician) assessment and plan included daily weights. On 5/11/2026 at 4;06 PM V19 (Nurse) documented Appetite: 75%. On 5/11/2026 at 4;45 PM V34 (physician) assessment and plan included daily weights. On 5/10/2026 at 2:26 PM V35 documented Appetite: 75%. On 5/10/2026 at 6;31 PM V34 (physician) assessment and plan included daily weights. On 5/9/2026 at 3:08 PM v36 (Nurse) documented Appetite 100%. On 5/8/2026 at 2:44 PM V19 (Nurse) documented Appetite 75%. On 5/8/2025 at 11:42 PM V37 (Nurse Practitioner) assessment and plan included daily weights. On 5/7/2026 at 2:39 PM V19 (Nurse) documented Appetite 75%. There was no documentation provided by the facility which included the percentage of all three meals consumed on any given day. Facility Weight Monitoring policy (revised 2/11/2026) stated meal consumption information should be recorded.

Based on observation, interview, and record review, the facility failed to ensure portion sizes were adequate, failed to ensure portion sizes were served according to the recipe, and failed to weigh food products to ensure correct serving sizes prior to serving in accordance with professional standards. These failures affect all 35 residents that consume food from the kitchen. Findings include: Facility census (5/11/2026) documents 37 residents reside in the facility. Facility nothing by mouth (NPO) list (undated) documents 2 residents do not consume oral nutrition. Facility menu (5/11/2026) documents the lunch meal is chicken noodle soup, Italian beef sandwich, roasted potato wedges, marinated mushrooms and peppers, and a peanut butter cookie. Recipe for the Italian beef sandwich (5/11/2026) documents, Serve 3 oz (ounce) slice of beef with a Side Cup of Hot Beef Broth for dipping. Portion according to serving size. A picture of the sandwich is on the recipe and appears like a beef sandwich on a long sub roll that occupies approximately half of the plate. There were several portions of beef that fill the roll to the degree which would not allow the roll to close. On 5/11/2026 at 11:21 am, V11 (Cook) and V13 (Cook) began to plate meals from the steamtable for the skilled rehab residents. Observed uniform pieces of sliced beef in the steam table in a beef broth. V11 and V13 were putting one to three slices of beef on a small roll. The roll appeared approximately 4 inches in length. V11 was unsure of the portion size of beef and explained the staff used to have the recipe available but V11 did not have the recipe for the beef. V11 showed surveyor the dietary spreadsheet which indicated the portion of beef was 0.5 each. V11 was unsure what was meant by the 0.5 each and referred surveyor to speak with V9 (Dietary Director). V13 prepared an Italian beef sandwich and placed one slice of beef on the roll. V13 was unsure the exact portion size that was to be used. V13 explained servings of meat are generally between two and four ounces of meat. V13 explained, The portion of meat every resident gets, yes, it varies by the resident. We sometimes don't put as much because then they will get scared and not eat as much. A lot of times they will ask for half orders. V11 and V13 affirmed the beef came pre-sliced in portions. V11 and V13 denied the cooks in the facility never weigh meat prior to serving. On 5/11/2026 at 11:34 am, V9 affirmed the cooks did not have access to the recipes because they hadn't been printed yet. V9 obtained the kitchen's scale from the Dietary Manager's office. A test plate was prepared by V13. 3 slices of beef were placed on the roll. V9 explained the beef was pre-packaged and each slice was about 1 ounce of beef. Observed V9 calibrate (zero) the scale. V9 removed the portion of beef and placed it on the scale. The scale read 1.9 ounces. Confirmed observation with V9. V9 affirmed the portion size should have been around three ounces and the amount served was not enough beef. V9 instructed V13, (V13) you need to be putting more (beef) on there (the sandwich). You need like double the amount of meat. V13 and V11 continued plating and did not weigh any of the meat portions during plating. V9, V11, and V13 did not replate or reweigh any of the food already prepared to ensure the correct portion of beef was served. On 5/11/2026 at 11:41 am, V10 (Registered Dietician) affirmed V10 is the consultant Dietician for the facility. V10 explained, Beef is the protein component of the lunch served. Protein is an essential nutrition as it helps with muscle healing and wound healing. If residents no not receive enough protein, they can experience muscle wasting or retention of fluids. V10 affirmed 1.9 ounces of beef served is way less than it is supposed to be. V10 affirmed the Dietary staff should be weighing meat products prior to serving to ensure the correct portion size is served. V10 observed V13 plating food for the residents in the skilled nursing facility. V13 was putting 3 slices of beef on the sandwiches and was not weighing the meat prior to making the sandwich. Confirmed observed with V10. V10 affirmed, Yes, (V13) should be weighing the meat and (V13) isn't. V10 reviewed the picture of the sandwich on the recipe, and affirmed the sandwiches being served have less beef and the roll is smaller than the picture. V10 described the picture on the recipe of the sandwich as taking up a lot of the plate, like at least a third. V10 confirmed the facility's sandwich did not look like the sandwich on the recipe. Facility policy titled, MEAL/TRAY ASSEMBLY PROCEDURES (Revised 1/2025), documents, Meal service is prompt and accurate to ensure temperatures and nutrient content of food is preserved. PROCEDURES: Ensures current diet extension is available and followed at each meal period . Checks meals for accuracy .

Based on observation, interview, and record review, the facility failed to label/store food items in accordance with professional standards, failed to discard expired or undated food products, failed to clean non-food surfaces to prevent the build-up of grease, failed to repair walls of the kitchen to ensure the wall was able to be cleaned in accordance with professional standards, and failed to complete regular quality assurance monitoring of sanitization procedures in the kitchen. These failures affected all 35 residents that consume nutrition from the kitchen. Findings include: Facility census (5/11/2026) documents 37 residents reside in the facility. Facility nothing by mouth (NPO) list (undated) documents 2 residents do not consume oral nutrition.On 05/11/2026 at 9:18 am, completed initial tour of the kitchen with V9 (Dining Director). V9 affirmed V9 is the Dietary Manager for the skilled nursing facility. Observed crushed red pepper container in the food preparation area, with a good by date of 8/8/2025. The taco seasoning was unlabeled. V9 confirmed these observations. V9 stated, Yeah, you can see how often we don't use the red pepper flakes. The taco seasoning looks like it washed off or something. We will have to relabel it. Observed a pitcher of an unidentifiable tan, milky colored liquid, that separated into a dark brown and light brown liquid. There was no label/date on the liquid. Confirmed observation with V9. V9 was unsure what the liquid was or when it was made. V9 smelled the liquid and explained it smelled like milk/dairy with a hint of cinnamon. V9 affirmed the liquid should have been dated. V9 dumped the liquid into the sink within the food preparation area. Observed the filters over the ovens, range, griddle and deep fryer. The filters hood and wall behind the appliances had think large, dried grease stains/droppings approximately 60% of the wall and the filters. Confirmed observations with V9. V9 explained, That is grease, it is just hard to get to. There's a bit of grease build up and splatters. If it is on the filters that is okay, it means the ventilation is doing its job. Observed the freezer with V9. Observed plastic bags containing deli-style ham with a use by date of 4/30/2026. V9 confirmed this observation, stated, Yeah these bags of ham are past date, I'll address it now. Observed a bag of deli-style turkey slices in the freezer that was undated and unlabeled. V9 confirmed this observation. V9 affirmed the turkey should be dated and labeled so staff know when it can be used by. V9 removed the turkey from the freezer. Observed a hole in the wall of the kitchen next to the ice machine, that was approximately six by six inches. V9 stated, I don't know how long that hole has been there or what exactly was the reason for the hole. I think that hole is from when we had a fly infestation. Maintenance is aware of it, yes, they were the ones that cut a hole in the wall. Observed V12 (Kitchen Utility) in the kitchen area cleaning. V12 had a visible beard/facial hair and was not wearing a facial hair restraint. V9 confirmed this observation. V9 stated, (V12) should be wearing a beard net. V9 instructed V12 to put on a facial hair restraint.On 5/11/2026 at 11:08 am, observed V12 utilize the dish machine. V12 completed the quality assurance process for the dish machine using a test strip. V12 accessed the Test Strip Results log for 5/2026 and affirmed there was no test strip placed for 5/10/2026, indicating the testing was not completed. The other sanitation quality assurance logs including the dish machine temperature log (5/2026), pot-sink temperature sanitizer log (5/2026), red bucket log (5/2026), sanitizer solution from dispenser log (5/2026) had no data collected for 5/10/2026. Confirmed these observations with V12. V12 stated the testing was not completed because V12 did not work on 5/10/2026.On 5/11/2026 at 11:12 am, the sanitation quality assurance logs (5/2026) were reviewed with V10 (Registered Dietician). V10 confirmed there was no data collected for 5/10/2026. V10 stated the staff should be monitoring sanitizer and temp levels. V10 affirmed the monitoring is important because it makes sure bacteria and viruses are killed and dishes/utensils are sanitized properly to prevent food-borne illness.On 5/11/2026 at 12:15 pm, kitchen tour completed with V5 (Maintenance Director). Observed the six-by-six-inch hole in the wall by the ice machine. V5 operated a flashlight and shined the flashlight into the hole. Observed a second hole inside the wall of the first hole that was approximately 4 inches by 3 inches. V5 confirmed these observations and explained the hole was caused by electrical work that was completed by electricians a while ago. V5 could not recall exactly when the work was completed. V5 affirmed the wall was not patched after the work was completed, and the second hole inside was caused by the saw going too far into the wall and damaged the second wall. V5 observed the grease over the walls and appliances of the food preparation area/appliances and explained, I only complete maintenance on the hood itself with the ventilation company. The filers and the walls and such are maintained by the Dietary staff. Observed a puddle of yellow tinged grease approximately 7 inches in length near the griddle area. Confirmed observation with V5. V5 stated, Yeah, that is grease. It needs to be cleaned up. V5 asked V9, how often should the grease be cleaned on the filters?, V9 replied, We clean the filters like every 2 weeks. V5 confirmed grease can be a fire hazard.Facility policy titled, CLEANING OF FOOD AND NONFOOD CONTACT SURFACES (1/2025) documents, The food-contact surfaces of all cooking equipment shall be kept free of encrusted grease deposits and other accumulated soil. Nonfood contact surfaces of utensils and equipment must be made of materials that are safe, corrosion resistant, nonabsorbent, smooth and easily cleanable, and maintained in good condition.Nonfood contact surfaces of equipment, such as handles on reach-in units, sides of sinks, gaskets on cooler and freezer doors, tracks of sliding doors on equipment, and the exterior of ice machines, shall be cleaned as often as is necessary to keep the equipment free of accumulation of dust, dirt, food particles, and other debris.The United Stated Food and Drug Administration Food Code (2022) documents, (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination. A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES . Non-FOOD-CONTACT SURFACES shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance . (A) Utility service lines and pipes may not be unnecessarily exposed. (B) Exposed utility service lines and pipes shall be installed so they do not obstruct or prevent cleaning of the floors, walls, or ceilings. contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.Walls and ceilings that are of smooth construction, nonabsorbent, and in good repair can be easily and effectively cleaned. Special requirements related to the attachment of accessories and exposure of wall and ceiling studs, joists, and rafters are intended to ensure the cleanability of these surfaces.

Based on observation, interview, and record review, the facility failed to complete an accurate facility assessment, failed to ensure all requirements of the facility assessment were reviewed and addressed, failed to ensure residents/their representatives were involved in the completion of the facility assessment, failed to identify any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services, failed to consider specific staffing needs for each resident unit and shift in the facility, and failed to identify utilized agency nursing contracts to provide agency nursing staffing services during normal operations. These failures has the potential to affect all 37 residents that reside within the facility.Findings include: Facility census (5/14/2026) documents 37 residents reside in the facility. On 5/11/2026 at 9:45 am, V1 (Administrator) affirmed the facility had 2 floors/units during the entrance conference. V1 affirmed the units were both mainly short-term rehab but the upstairs unit was a locked unit that required a keycode to leave the unit. V1 identified the facility utilizes third party contracts/vendors for Dietary department services, Housekeeping services, Maintenance services, Rehab services, Minimum Data Set completion/care plan development, and licensed nursing staff/certified nursing assistants. V1 affirmed the facility utilizes 4 staffing agencies to staff the facility with licensed nurses and certified nursing assistants. Record review of facility assessment (reviewed 2/11/2026) documents the following: A) Racial/ethnic make-up of resident needs is not identified, documents all races/ethnicities are represented. The assessment does not identify the cultural or ethnic needs or services residents require or the facility is providing, including food/nutrition services and activities. Disability, socioeconomic status, preferred language, health literacy, other factors that affect access to care and health outcomes related to health equity is blank B) Facility resources (staff) does not identify staffing needs per shift and per unit. C) The utilization of contract licensed nursing services and certified nursing assistants provided in the facility is not identified. Additionally, the staffing agencies utilized for nursing staffing are not identified on the facility assessment. D) Residents/their representatives were not included in the development of the facility assessment. E) Inform contingency planning for events that do not require activation of the facility's emergency plan, but do have the potential to affect resident care, such as, but not limited to, the availability of direct care nurse staffing or other resources needed for resident care. On 5/13/2026 at 11:42 am, V1 (Administrator) affirmed V1 last reviewed the facility assessment with the governing body in February 2026. V1 explained the purpose of the facility assessment is to provide the most up-to-date information about the facility, and determine what resources are needed to adequately care for the residents. V1 accessed the facility assessment on the computer. Reviewed facility assessment with V1. V1 explained the facility has a diverse population and consists of African American residents, Asian American residents, residents that are of Latin decent. V1 affirmed the facility celebrates diversity and had completed events like Chanukah, Cinco de Mayo, Greek Easter, Chinese New Year, Kwanzaa, Mexican Mother's Day and other holidays depending on census and resident needs. V1 reviewed the facility assessment and affirmed these ethnic needs were not identified or addressed within the facility assessment. V1 affirmed the staffing for the facility is 1 nurse per floor with around 2 certified nursing assistants (CNAs) on each shift. V1 reviewed the facility assessment and affirmed the staffing is not identified by unit and shift needs. V1 stated, I must have misread that (the requirement to consider specific staffing needs for each resident unit per shift in the facility and adjust as necessary based on changes to its resident population). V1 affirmed the facility uses agency staffing to supplement licensed nursing staff and CNAs. V1 reviewed the assessment and confirmed these agencies are not identified on the assessment. V1 stated, I am putting it now under the HVAC contract. V1 explained when there are variations in the staffing needs of the facility, the facility uses agency staff to cover those needs. If unable to get agency staff, V1 would get staff from other sister facilities to help cover the staffing needs. V1 affirmed these contingency staffing plans were not identified in the facility assessment. V1 reviewed the signatures of all who participated in the development of the facility assessment. V1 confirmed the resident representative/family members portion was blank. V1 stated, We had a resident participate, but we did not include any family members. Facility policy titled, Facility Assessment (Revised 2/11/2026) documents, This facility conducts and documents a facility-wide assessment to determine what resources are necessary to care for our residents competently during both day-to-day operations (including nights and weekends) and emergencies. The purpose of this policy is to establish responsibilities and procedures for the facility assessment process. 1. The facility assessment will, at a minimum, address or include: . v. Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services. b. The facility's resources, including but not limited to; . v. Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies . In conducting the facility assessment, the facility will ensure: . iii. The facility must also solicit and consider input received from residents, resident representatives, and family members. 3. The facility will use the facility assessment to: a) Inform staffing decisions to ensure that there are a sufficient number of staff with the appropriate competencies and skill sets necessary to care for its residents' needs as identified through resident assessments and plans of care. b) Consider specific staffing needs for each resident unit in the facility and adjust as necessary based on changes to its resident population. c) Consider specific staffing needs for each shift, such as day, evening, night and adjust as necessary based on any changes to its resident population. d) Develop and maintain a plan to maximize recruitment and retention of direct care staff. e) Inform contingency planning for events that do not require activation of the facility's emergency plan, but do have the potential to affect resident care, such as, but not limited to, the availability of direct care nurse staffing or other resources needed for resident care. 4. The Administrator is responsible for ensuring the completion of the facility assessment and maintaining all documents that pertain to the assessment. The Administrator serves as the leader of the facility assessment process, or may designate someone to lead the process . 8. Based on the assessment of resident characteristics, the facility will determine what care/services, staff competencies, and staffing needs are required to meet the needs of our residents. This will be compared to the specific care/services, including by contract, and training that we provide. Action plans will be implemented as necessary . 10. The facility assessment will be reviewed and updated as necessary and at least annually, whenever there is, or the facility plans for, any change that would require a substantial modification to any part of the assessment. Additionally, the facility will consider specific staffing needs for each shift (e.g., day, evening, night, weekend shifts) and for each resident unit in the facility based on changes to resident population. Any changes to the assessment will be documented, along with a revision history.

Based on observation, interview, and record review, the facility failed to ensure adequate ventilation of steam released above the dish machine which caused water damage and degradation of the ceiling tiles above the dish machine/dishwashing area. These failures have the potential to affect all 35 residents that consume food from the kitchen. Findings include: Facility census (5/11/2026) documents 37 residents reside in the facility. Facility nothing by mouth (NPO) list (undated) documents 2 residents do not consume oral nutrition.On 5/11/2026 at 11:08 am, observed V12 utilize the dish machine. V12 completed the quality assurance process for the dish machine using a test strip. Observable steam was produced above the dish machine which rose and hit the ceiling tiles above the dish machine. The ceiling above the dish machine was bowed, peeling and had yellow foam/insulation hanging from the ceiling. The ceiling around the ventilation duct from the machine left approximately a 4-inch rectangular hole the length of the duct and was in disrepair. Confirmed observation with V12 (Kitchen Utility). V12 stated, The ceiling gets like that (warped); it's the steam. On 5/11/2026 at 12:15 pm, kitchen tour completed with V5 (Maintenance Director). Observed the warped ceiling above the dish machine with V5. V5 affirmed the ceiling tiles were in disrepair, and the yellow foam insulation was exposed was from the degradation of the ceiling tiles. V5 affirmed the insulation within the tiles was fire-rated to prevent fire damage. V5 explained the degradation of the ceiling tiles was caused by inadequate ventilation of steam over from the dish machine. V5 recalled repeatedly having to exchange and repair ceiling tiles in that area due to the steam. V5 affirmed the ceiling tiles damaged can cause issues if the insulation falls into the area of the clean dishes. Facility policy titled, Building Ventilation (Updated 12/01/2025) documents, The purpose of this policy is to ensure proper throughout the facility in order to maintain a safe, comfortable, and healthy environment for residents, staff, and visitors. Proper ventilation helps reduce odors, airborne contaminants, humidity. and heat buildup while supporting indoor air quality standards. This policy applies to all facility areas including resident rooms, common areas, offices, kitchens, laundry rooms, restrooms, maintenance areas, and storage spaces. PROCEDURES 1. General Ventilation Requirements All occupied areas shall have adequate airflow and ventilation .Exhaust systems shall be used in bathrooms, kitchens, and in laundry areas to reduce moisture and odors . Staff shall monitor for excessive heat, humidity, odors, dust, or poor air circulation . Department supervisors shall ensure ventilation concerns are reported promptly .Facility policy titled, Equipment Maintenance Program (revised 1/2026) documents, Proper maintenance of the physical plant and all equipment in the Department is the responsibility of the Director in cooperation with the Maintenance Department and subject to policies and procedures set forth by the facility's administration. The Director is directed or has knowledge of all routine, periodic, and critical maintenance work done to the physical plant or equipment in the Department. Jointly with the Maintenance Department, plans in writing a program of preventive maintenance for all Food and Nutrition equipment requiring regular maintenance. Cover: o Regular inspection/maintenance by maintenance department, o Periodic servicing by service companies contracted through the Maintenance Department. Reviews the effectiveness of the Preventive Maintenance program annually with the Maintenance Department, and document meetings .

Based upon observation, interview, and record review, the facility failed to ensure that the correct date was documented on resident dry erase boards and failed to ensure call lights were within reach for six of 20 residents (R15, R25, R31, R33, R34, R43) in the sample reviewed for accommodation of needs. Findings include: 1.R15's diagnoses include dementia and weakness. R15's (4/29/26) functional assessment affirms the resident requires partial/moderate assistance with rolling left and right. On 5/11/26 at 11:42am, R15 was observed lying in bed leaning towards the (right) side rail, however, the call light was dangling from the (left) side rail - out of reach. R15 attempted to locate the call light, however was unable to do so. On 5/11/26 at 11:47am, V15 (Registered Nurse) entered the room and stated, It (call light) should be within his reach. V15 then moved the call light near R15's (left) shoulder, however, failed to secure the call light and/or place it within reach. 2.R31's face sheet documents diagnoses that include but are not limited to cognitive communication deficit, unsteadiness on feet, need for assistance with personal care, and muscle weakness. R31's BIMs (Brief Interview for Mental Status), dated 4/01/26, is 11, which indicates R31's cognition is moderately impaired. R31's care plan, dated 5/12/26, documents, Cognitive Loss/Dementia: I (R31) have cognitive loss deficits related to my short-term memory problems as evidenced by my inability to recall three words in a short period of time even with cues. Dx: vascular dementia. I (R31) would like to maintain and/or improve my current level of cognitive functioning as evidenced by showing orientation to significant persons like family and/or staff members and I would like to remain mentally active through next review. On 5/11/26 at 10:34am, a dry erase board was hanging on the wall in R31's room that documents, Today is Friday May 8th 2026. R31 was asked what the date was today. R31 replied, The day is Monday. The actual date, well. ummm. It's not the 8th like the board says. That board is good for someone like me because things get to be the same every day. 3.R34's face sheet documents diagnoses that include but are not limited to insomnia, cellulitis of left lower limb, and bacteremia. R34's BIMs (Brief Interview for Mental Status), dated 3/09/26, is 14, which indicates R34 is cognitively intact. R34's care plan, dated 5/12/26, documents, I (R44) am HOH (hard of hearing). On 5/11/26 at 10:45am, a dry erase board was hanging on the wall in R34's room that documents, Today is Thursday, May 7, 2026. R34 was asked what the date was today. R34 looked behind R34 at the dry erase board and replied, Well, I don't think it's Thursday. Sunday?? No, it's Monday. Don't ask me who the president is because I know who he is, and I just don't want to say his name. I really like that they have that (dry erase board) up, and they do at times fix the date, but not all the time. I am not too concerned about the staff being right because I know most of them (staff). No, I do like the board with the date. I look at it (dry erase board) a lot. 4.R25's face sheet documents diagnoses that include but are not limited to cognitive communication deficit and muscle weakness. R25's BIMs (Brief Interview for Mental Status), dated 4/16/26, is 15, which indicates R25 is cognitively intact. R25's care plan, dated 5/08/26, documents, Resident (R25) has hearing deficits uses left ear amplifier. Son brought in new hearing aids. Please establish meanings of non-verbal cues with me. On 5/11/26 at 10:56am, a dry erase board was hanging on the wall in R25's room that documents, Today is May 7, 2026. R25 was asked what the date was today, R25 replied, Oh honey. They all run together. R25 looked at the dry erase board and saids, Oh it's the 7th (5/7/26). Anyways, can I get a pain pill for my neck? 5.R33's face sheet documents diagnoses that include but are not limited to cognitive communication development, osteomyelitis of vertebra, sacral and sacrococcygeal region. R33's BIMs (Brief Interview for Mental Status), dated 5/03/26, is 14, which indicates R33 is cognitively intact. On 5/11/26 at 11:14am, a dry erase board was hanging on the wall in R33's room that documents, Today is Thursday, May 4, 2026. R33 was asked what the date was today. R33 replied, Well, that's a question that I don't have the answer to. It's 2026. I do wish they (staff) would remember to change the date every day, but they do have other important stuff they're doing. 6.R43's face sheet documents an admission date of 4/29/26. R43's face sheet does not document R43's diagnoses nor does R43's EMR (electronic medical record). R43's BIMs (Brief Interview for Mental Status), dated 5/5/26, is 10, which indicates R43's cognition is moderately impaired. R43's care plan, dated 4/30/26, documents, Cognitive Loss/Dementia: I (R43) have cognitive loss deficits related to my short-term memory problems as evidenced by my inability to recall three words in a short period of time even with cues. I (R43) would like to maintain and/or improve my current level of cognitive functioning as evidenced by showing orientation to significant persons like family and/or staff members and I would like to remain mentally active through next review. R43's care plan, dated 4/30/26, documents, Resident (R43) has impaired functional abilities. Assist with functional abilities ambulation, stairs, transfer, bed mobility, set up, and toileting. On 5/11/26 at 11:22am, R43's call light was observed behind R43, hanging over R43's table, not within reach. R43 said, Hmmm. I'm not sure where my light is at to get help form the nurses. Well, I don't always need help, but sometimes I do. Yes, I do need it (call light). On 5/11/26 at 11:25am, V18 (Certified Nursing Assistant/CNA) said, I did not realize I did not put her call light back. I just got her back to bed a few minutes ago. No, she cannot reach it (call light). V18 took the call light and put it within reach to R43. V18 said, We're supposed to change the date and put the names of the staff working that day every morning. The CNA or the nurse usually changes it. Got a little busy today so some of them (dry erase boards with date) didn't get changed. On 5/13/26 at 11:50am, V2 (Director of Nursing/DON) said, Call lights should be within reach and available to the resident so they don't fall out of bed and get care if needed. The boards are supposed to have the correct date on them as a reminder to the residents. It's (dry erase boards with the date) to keep the residents alert and oriented. Some (residents) are forgetful, and some have dementia. Record review of facility policy titled, Call Lights: Accessibility and Timely Response, dated 2/11/26, documents, Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Staff will ensure the call light is within reach of resident and secured, as needed. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. Record review of pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis. Your facility must be safe, clean, comfortable, and homelike. You may participate in developing a person-centered care plan which states all the services your facility will provide to you and everything you are expected to do. This plan must include your personal and cultural choices. Your facility must make reasonable arrangements to meet your needs and choices. You should receive the services and/or items included in the plan of care.

Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles. This failure has the potential to affect all 21 residents residing on the second floor reviewed for labeling of medications and biologicals.On 5/13/2026 at 10:30 am, surveyor inspected the 2nd floor medication storage room with V22, LPN (Licensed Practical Nurse). In the inside door of the refrigerator, one multi-dose vial of Tuberculin 5T/0.1 ml (milliliters), stored in the original packaging box, was opened and not dated. V22 (LPN) affirmed there was no open date on the Tuberculin vial. V22 (LPN) stated generally Tuberculin is good for 45 days and then discarded. On 05/13/2026 at 1:59 pm, V2 Director of Nursing (DON) was asked about labeling of medications. V2 (DON) stated, Medications need to be dated with a use by date, so we know how long the medication is effective for. Review of the facility's Medication Storage Policy, dated 2/11/26, documents, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Review of the Symbria Rx Services Medication Storage Policy in The Facility ID1: Storage of Medications, dated July 2024, documents, Expiration Dating (Beyond-use dating) section D. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1) The nurse shall place a date opened sticker on the medication (if dedicated area not on label/container) and enter the date opened and the new date of expiration (NOTE: the best stickers to affix contain both a date opened and expiration notation line). The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating.

Based on interview and record review, the facility failed to ensure the Advance Directives care plan was congruent with the POLST (Practitioner Order for Life-Sustaining Treatment) and/or Physician Orders for one of 20 residents (R15) in the sample reviewed for resident rights. Findings include:R15's ([DATE]) POLST states NO CPR (Cardiopulmonary Resuscitation): Do Not Attempt Resuscitation.R15's ([DATE]) Physician Order states Resuscitate: No; DNR (Do Not Resuscitate) for both Pre-Arrest Emergency & Full-Arrest Emergency. R15's ([DATE]) care plan states CATEGORY: Social Service. Resident has chosen to not make any Advance Directives: FULL CODE. R15's Advance Directives care plan was initiated on [DATE] - the same date physician orders were received for Advance Directives.On [DATE] at 3:19pm, V3 (Assistant Director of Nursing) reviewed R15's ([DATE]) POLST and stated The POLST says no CPR do not attempt resuscitation. V3 was asked about R15's code status per Physician Orders. V3 responded, It says DNR. V3 was asked if resident code status is on the care plan. V3 replied, I don't think that's actually something they put in the care plan. V3 subsequently accessed R15's care plan and stated, It does say he has chosen to not make any directives: Full Code. That is not accurate, due to the POLST or orders that we have on file. The care plan is not up to date. V3 was asked why Social Service documents code status on the care plan. V3 responded, She's (Social Service) the one that actually does the POLST with the family and reviews it at the care conference.The ([DATE]) residents' rights policy regarding treatment and advance directives states upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff. Decisions regarding advance directives and treatment will be periodically reviewed as part of the comprehensive care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care.

Based on interview and record review, the facility failed to refer one resident (R4) with a possible serious mental disorder for Screening and Resident Review to the appropriate state-designated authority for further assessment as required. This failure affected one resident (R4) reviewed for pre-admission screening in the sample list of 37 residents.Findings include:R4's face sheet documents an admission date of 2/23/26 and diagnosis that includes but is not limited to bipolar disorder.R4's BIMs (Brief Interview for Mental Status) score, dated 3/26/26, is 15 which indicates R4 is cognitively intact.R4's care plan, dated 3/4/26, documents, At risk for changes in mood due to diagnosis of Bipolar.R4's physician order, start date 2/23/26, documents, Trazadone 200mg by mouth every night for bipolar disorder.On 5/13/26 at 1:12pm, V25 (Medical Records) said, Yes, I take care of the PASARRs (Pre-admission Screening and Resident Review) for the facility. (R4's) PASARR was done prior to coming here and her bipolar diagnosis was added later, after admission. Yes, a PASARR II should have been initiated after the bipolar diagnosis.Record review of R4's Notice of PASRR Level I Screen Outcome, dated 2/18/26, documents, PASRR Level I Determination: No Level II Required - No SMI/ID/RC.On 5/13/26 at 2:55pm, V25 (Medical Records) said, PASARR IIs are initiated when a resident has a mental health or intellectual disability. Other services may need to be provided for these residents. I initiated a PASARR II for (R4) today (5/13/26).On 5/13/26 at 3:45, V1 (Administrator) stated, The breakdown occurred (reason for R4's PASARR II not being completed) because the psych provider saw (R4) after the initial PASARR was completed, diagnosed (R4) with bipolar disease, but never notified us (facility) so that a new screening can be done.Record review of pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis. Your facility must be safe, clean, comfortable, and homelike. You may participate in developing a person-centered care plan which states all the services your facility will provide to you and everything you are expected to do. This plan must include your personal and cultural choices. Your facility must make reasonable arrangements to meet your needs and choices. You should receive the services and/or items included in the plan of care.

Based on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care to one of 20 dependent residents (R16) in the sample reviewed for quality of life.Findings include:R16's (3/31/26) BIMS (Brief Interview Mental Status) determined a score of 14 (cognition intact).R16's (3/31/26) functional assessment affirms resident is dependent on staff for toileting and personal hygiene.On 5/11/26 at 11:08am, a strong urine odor was noted while interviewing R16. R16 was asked when R16's incontinence brief was last changed. R16 stated, Yesterday, I haven't seen her (staff) yet. I'll take that back they did change me, I just forgot. R16 was asked if R16's incontinence brief was wet. R16 responded, A little bit. Long, thick hairs were observed on R16's upper lip and chin. R16 was asked about concerns with R16's long facial hair. R16 replied, It's hard to get an appointment to take care of it because there's only one beautician here (facility). On 5/11/26 at 11:15am, V17 (Certified Nursing Assistant) affirmed she's assigned to R16. V17 was asked when R16's incontinence brief was last checked and/or changed. V17 stated, This morning when I came in around 8:00. V17 was asked when incontinent residents should be checked and/or changed. V17 responded, Normally I try to change them three to four times before I go. V17 inspected R16's incontinence brief. The front of R16's brief appeared saturated, and the lines were blue (indicating the brief was wet). V17 subsequently removed R16's brief, which was saturated with urine. Upon further inspection, R16's toenails were noted to be thick, long, and broken. V17 was asked about the appearance of R16's toenails. V17 replied, Long. Thick dry scaly skin was observed on both of R16's shins. V17 was asked about the appearance of R16's skin on lower extremities. V17 stated, A little bit ashy and dry, and proceeded to apply lotion. On 5/12/26 at 12:45pm, V22 (LPN/Licensed Practical Nurse) affirmed he's assigned to R16. V22 was asked about concerns with R16's facial hair. V22 subsequently inspected the resident and stated, Well, she needs that taken care of, its long hair. V22 was asked about the appearance of R16's toenails. V22 replied, The toenails are long and dry. V22 was asked if R16's toenails were also thick. V22 stated, Yes ma'am she needs to be added to the podiatry list. The ADL policy (reviewed 2/11/26) states care and services will be provided for the following activities of daily living: grooming, toileting. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and record review, the facility failed to ensure that hospice orders/hospice care plan was accessible to staff, failed to identify resident change in condition, failed to notify the physician of change in condition timely, failed to document an accurate physical assessment and failed to obtain physician orders for two of 20 residents (R16, R28) in the sample reviewed for quality of care.Findings include: 1.R16's diagnoses include the following: eye abnormalities: ectropion (a condition where eyelid, typically the lower lid, turns outward and sags away from the eye, exposing the inner eyelid surface) of unspecified eye and presbyopia (age-related loss of eye's ability to focus on close objects). R16's (3/31/26) BIMS (Brief Interview Mental Status) determined a score of 14 (cognition intact). On 5/11/26 at 11:08am, both of R16's lower eyelids were red, and notably swollen. Yellow crust was also observed on R16's bilateral lower eyelashes. Surveyor inquired about R16's eyes R16 stated, It's kind of an inflammation. On 5/11/26 at 11:15am, V17 was asked about concerns with R16's eyes. V17 (Certified Nursing Assistant) stated. I think that's just the color of her eyes. On 5/11/26 at 12:11pm, V15 (Registered Nurse) affirmed she's assigned to R16. V15 was asked about R16's eyes. V15 replied, She gets red eyes a lot, the conjunctiva (a thin, clear, mucous membrane that lines the inner eyelids and covers the white part of the eye). V15 reviewed R16's EMR (Electronic Medical Record) and stated, She does have issues like presbyopia. V15 was asked if any medications and/or treatments were prescribed for R16's eyes. V15 responded, No, when the doctor comes, I'll have them take a look at her. V15 was asked about the current appearance of R16's eyes. V15 subsequently entered the room and stated, It's a little red on the bottom lids and crust a little bit on the corners. R16 proceeded to touch her right eye. V15 responded, She's picking at it, does your eye itch? R16 nodded her head yes. R16's (5/11/26) progress note states 3:19pm, resident is alert to self, has red eyes referring to MD (Medical Doctor) when rounding. [documentation excludes lower eyelid redness/swelling/yellow crust, itching, vital signs, physician notification, and/or orders received]. On 5/12/26 at 12:00pm, no additional documentation regarding R16's change in condition was found in the progress notes. [An entry was created by V34/Physician on 5/11/26 at 8:03pm, however nothing was documented – the entry was blank]. On 5/12/26 at 12:41pm, R16's lower eye lids were notably red and swollen. A yellow crusty substance was also observed on R16's bilateral lower eyelashes. R16 was asked how R16's eyes feel. R16 responded, Gritty, and affirmed they were also itchy. R16 was asks if R16 was seen by the physician yesterday. R16 replied, No, I don't think so. R16 was asked if medications were prescribed for R16's eyes. R16 stated, I don't think it's been ordered. On 5/12/26 at 12:43pm, V22 (Licensed Practical Nurse) affirmed he's assigned to R16. V22 was asked if R16 is prescribed eye medication. V22 stated, She's just getting regular eye drops. V22 subsequently accessed R16's EMR and added, Just the refresh liquid gel eye drops. On 5/12/26 at 12:45pm, V22 assessed R16's eyes and stated, I see that she has, sometimes they are a little crusted with like eye boogers. V22 was asked what crusted eyes and eye boogers are indicative of. V22 responded, An infection, an eye infection. On 5/12/26 at 12:52pm, V22 was asked if R16 was seen by the provider (Physician or NP) yesterday or today. V22 accessed R16's progress notes and stated, I don't see a note, it's nothing from the physician. Shedoesn't have a note here yet. On 5/12/26 at 1:49pm, V6 (Medical Director) was asked about staff requirement for resident change in condition. V6 (Medical Director) stated, We expect the CNAs (Certified Nursing Assistants) to let the Nurses know if there's a problem and expect the Nurses to inspect them (residents). We also have the NP (Nurse Practitioner) who is here Monday through Friday (9am to 1pm). The NP can assess them during the hours they are onsite but during the hours they (NP) are not onsite, they would call the Physician to relay concerns. V6 was asked about potential harm to R16 if eye abnormalities (discharge, redness, inflammation) are not addressed. V6 responded, If it's an infection and it's not addressed on time, then there's a risk for worsening condition. If this is a chronic condition this would be in the practitioner's note. R16's (5/11/26) progress notes (received on 5/12/26 at approximately 3:00pm) were timestamped 20:03 (8:03pm) and include HEENT (Head, Eyes, Ears, Nose, Throat): MMM (Moist Mucous Membranes), no pharyngeal exudates, no JVD (Jugular Vein Distension). The entire entry was also noted to be redacted (each entry was crossed out). The 5/11/26 (8:03pm) documentation was modified by V34 (Physician) on 5/12/26 at 2:17pm. The (2/11/25) notification of changes policy states the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. Circumstances that require a need to alter treatment. 2.R28's face sheet documents an admission date of 6/20/2025, with diagnoses that include but are not limited to fibromyalgia, cervical region, encounter for palliative care, adjustment disorder with mixed anxiety and depressed mood, osteoarthritis, personal history of urinary (tract) infections, and severe protein-calorie malnutrition. R28's comprehensive assessment section C Cognitive Patterns, dated 04/22/2026, documents a BIMS (Brief Interview for Mental Status) score of 11, which indicates R28 has moderate cognitive impairment. On 5/11/2026 at 9:45 am, R28 was asleep in bed, with head of bed raised with oxygen at 4 liters per nasal canula. Reviewed R28's hospice binder which did not have hospice standing orders nor hospice care plan. R28's plan of care in the electronic records system (Care Plan Type: MEDREC) reviewed on 5/11/2026 at 1:30 pm documents care interventions and oxygen therapy were excluded. On 5/12/26 at 9:50am, V3 (ADON/Assistant Director of Nursing) was asked if oxygen was ordered for R28. V3, ADON (Assistant Director of Nursing), subsequently reviewed R28's EMR (Electronic Medical Records) and hospice binder then stated, The hospice standing orders and hospice care plan should be on the hospice binder, and they are not here. Let me call and check with the hospice group taking care of her and I will get back to you. R28's plan of care provided to the surveyor on 5/12/2026 at 10:41 am by email from V3 (ADON) indicates resident is on hospice in the electronic records system and noted oxygen therapy was not identified in the care plan. R28's plan of care plan sent and dated 5/12/2026 at 10:41 am documents, Category 200: Hospice (G ) Resident will receive care and support services by nursing and coordinate all care needs with hospice to meet and maintain a maximum comfort level through next reviews. These interventions were dated 2/03/2026. There was no mention of interventions for oxygen therapy. On 5/13/2026 at 11:30 AM, reviewed R28's hospice binder and the resident's hospice care plan and physician order were not in the hospice binder. Review of the facility's Coordination of Hospice Services, dated 1/10/2025, documents, The facility will coordinate and provide care in cooperation with hospice staff, in order to promote the resident's highest practicable, physical, mental, and psychosocial well being. Review of the facility's contract with R28's hospice provider, dated 8/2/2023, documents, The Hospice Plan of Care is maintained for each individual and reflects hospice philosophy, policies, and practice related to an individualized hospice patient's/family needs, with input provided by facility staff. The Hospice Plan of Care will be integrated with the facility's Plan of Care for that patient. Record review of pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, Your facility must provide services to keep your physical and mental health, at their highest practical levels.

Based on observation, interview, and record review, the facility failed to ensure a LALM (Low Air Loss Mattress) was turned on while in use, failed to identify a skin integrity impairment, failed to implement preventive interventions, failed to notify the physician/nurse practitioner of change in skin condition, failed to document a wound assessment for two days and administered dressings without physician orders, and failed to obtain treatment orders for two of 20 residents (R15, R25) in the sample reviewed for pressure ulcers. These failures resulted in R25's right heel wound identified by surveyor on 5/11/26. Findings Include: 1.R25's medical history is significant for colon cancer with liver metastasis, congestive heart failure, peripheral vascular disease, falls with compression fractures of the thoracic vertebrae (at level T5-T6), and atrial fibrillation. R25 was admitted to the facility 4/10/2026, however, had a one-night hospital stay 5/7/2026 to 5/8/2026 due to an exacerbation of her heart failure. R25's Minimum Data Set (MDS), dated [DATE], includes a Brief Interview for Mental Status (BIMS) of 15, indicating R25 is cognitively intact, and MDS documents R25 requires partial/moderate assistance for rolling left to right in bed as well as bed-to-chair transfers. On 5/11/2026 at 11:02am, R25 was observed lying in bed on her back. No interventions were in place to offload the heels. Protective boots were in the corner of the room, not on the patient. Low air loss mattress was on the bed. On 5/11/2026 at 3:42PM, R25 was observed lying on her back. No interventions were in place to offload the heels, nor protective boots on the resident. Heels were in direct contact against the mattress. Patient was stating she is uncomfortable and wanting to get up. V28 (Certified Nursing Assistant/CNA) was present and assisting R25. As R25 turned to her left side, surveyor observed a purple blistered area to the posterior right heel, approximately the size of a quarter. V28 (CNA) denied seeing the skin alteration previously. V27 (Registered Nurse/RN) came to the room and assessed the resident's heels. V27 (RN) denied seeing any impairment to the right heel previously. V27 (RN) described the area as a blister, likely a deep tissue injury. V27 (RN) confirmed the location of posterior heel wound aligned where the heel rests against the mattress. The left heel wound (previously examined by the wound physician) did not have a dressing on as ordered (order entered for left heel wound dressing on 5/11/2026) and was open to air. V27 (RN) cleansed both heels and applied a vaseline gauze with adhesive foam dressing to each heel. A sacral dressing was noted; V27 (RN) removed the soiled dressing during incontinence care and no wound was noted in that location. Scant excoriation noted under the abdominal fold on the left side of abdomen. On 5/12/2026 at 3:00om, R25 was resting in bed, lying on her back. Bilateral legs were flush against the bed, no offloading of heels. Heel protective boots were not on the resident; boots were present in the corner of the room. On 5/13/2026 at 11:00am, V16 (CNA) was at bedside, assisting R25 into sitting position. Bedsheet was noted to be stained with moderate amount of serosanguinous fluid. V16 (CNA) removed R25's socks, bilateral foam dressings were noted on R25's heels. V16 (CNA) confirmed that both dressings were dated today (5/13/26). Dressings both appeared to be clean and dry. On 5/13/2026 at 1110am, V19 (Registered Nurse/RN) confirmed both heel dressings were changed prior to the start of the day shift today, however, the left heel wound had been leaking fluid, so V19 (RN) changed that dressing. On 5/13/2026 at 11:41am, V2 (Director of Nursing/DON) confirmed when a new skin alteration is discovered, the staff nurse should be notifying the DON and/or the Assistant Director of Nursing (ADON); a physician should also be contacted to obtain orders for the wound treatments. V2 (DON) stated V3 (ADON) assists the wound physician weekly during rounds and is more familiar with the wound documentation and residents receiving wound treatments. V2 (DON) affirmed the only wound locations noted in R25's medical record are on the left heel and the right forearm. V2 (DON) denied being notified regarding a new right heel wound. On 5/13/2026 at 11:55am, V3 (ADON) affirmed there was no notification to her regarding a new skin alteration on the right heel: This was not brought to my attention and is a problem. V3 confirmed wound doctor visits R25 weekly (last assessment was 5/5/2026) and the doctor classified the left heel wound as arterial and unavoidable due to the resident's diagnoses. V3 (ADON) stated the physician completed doppler ultrasound at bedside during assessment and that arterial studies were ordered for the legs but not yet completed due to her hospital stay. On 5/13/2026 at 1:25pm, V26 (Wound Physician, vascular surgeon) confirmed via telephone he has been treating R25 for a right arm wound and left heel wound. V26 denied being notified of a new wound to the right heel. V26 stated the left heel was classified as an arterial wound due to patient's diagnoses metastatic cancer, coronary artery disease, peripheral vascular disease, heart failure, malnutrition, anasarca, and atrial fibrillation. Doppler ultrasound was performed by V26 at bedside to evaluate pedal pulses during his last assessment, which showed impaired circulation/no signals. Per V26, order for arterial dopplers was entered on 5/5/2026 but not yet completed. The expectation of when the order should be completed depends on who they have to complete the test and was not intended to be ordered immediately (STAT). In discussion of the cause for the new right wound, V26 (physician) stated the wound could have multiple etiologies, she has poor blood circulation and the cause could be multifactorial. V26 acknowledged R25 is not exempt from risk of pressure wounds despite extensive medical history, but relayed her left wound was classified as arterial due to the findings in bedside doppler ultrasound despite the location. V26 affirmed pressure relief measures are ordered and are expected to be followed, treatment orders are to be completed as ordered, and a provider should be contacted for new orders when a new skin integrity issue is found. V26 was asked what potential harm could come to a patient is a skin integrity issue is not addressed timely. V26 replied, 1. Nothing, 2. It could stay the same, 3. It could worsen. On 5/13/2026 at 3:00pm, V3 (ADON) performed an assessment of the bilateral heel wounds in R25's room. Heel protector boots were on, as well as heels offloaded with pillows at the start of the assessment. Bilateral heel dressings were removed. Right heel was described by V3 (ADON) as a closed blister, approximately 2 centimeters (length) by 2 centimeters (width). The location of the wound was confirmed by V3 (ADON) to be the right posterior heel and that yes, that area is the part of the foot that rests on the bed when heels are not being offloaded. The left heel wound was the source of the serosanguinous fluid noted in previous observation, as V3 (ADON) confirmed the blistered wound appears much more deflated than in previous assessment. Braden Score on 4/30/2026 reflects a score of 14 (No response in diagnosis section that would influence skin integrity). Braden score on 5/9/2026 documents a score of 14 with a response of 1 in the diagnosis section that may influence skin integrity. Per the instructions on the form Braden Scale for Predicting Pressure Sore Risk, If diagnosis tab response is 1, consider advancing to the next level of care. This advancement to the next level of care would indicate that resident is at risk for skin breakdown. readmission orders on 5/8/2026 document, Turn and reposition resident every two hours as tolerated, Barrier cream to periarea and buttocks three times a day (TID) and as needed (PRN) after incontinence episodes, Offload resident's heels when in bed as tolerated every shift, and Wound care physician to evaluate and treat as needed. Additional orders on 5/11/2026 include Low Air Loss (LAL) Mattress in place, monitor for proper inflation and functioning, Clean wounds to Right Forearm (RFA) and Left (L) heel with Normal Saline solution (NSS), pat dry, apply xerofoam (vaseline gauze) and cover with dry dressing three times a week, and may apply abdominal (ABD) pad to extremities and secure with kerlix (rolled gauze) if extremity is weeping, monitor for breakdown. Review of records shows there were no wound orders in place for the known left heel arterial wound and right forearm skin tear, nor order for a LAL mattress for wound prevention for 5/8/2026, 5/9/2026, and 5/10/2026. On 5/11/2026, there was no order obtained for the new right heel wound care. Prior to the evaluation of the wound with V3 on 5/13/2026 at 300pm, there was no order obtained for right heel wound treatments. There was a dressing applied by V27 on Monday 5/11/26 when the wound was discovered. There was also a dressing over the right foot wound (dated 5/13/26) noted during observation on 5/13/26 at 11:00am. Treatment Record for 4/2026 was reviewed: Heel Protectors on while in bed; there was no documentation that heel protectors were on from 4/12/2026 through 4/30/2026, nor any refusals documented in treatment record. Treatment Record for 5/2026 was reviewed: LAL Documentation began on 5/11/2026 after order received (No LAL mattress ordered on 5/8/2025, 5/9/2026, 5/10/2026). Cleanse wounds to Right Forearm and Left Heel with Normal Saline Solution, pat dry, apply xerofoam and cover with dry dressing three times per week – treatment was not documented on Treatment Record, was scheduled for 6am, however order was obtained after this time. Wound care on left heel was not completed until right heel wound was discovered at 342pm on 5/11/2026. No documentation of those dressings is present in the treatment record nor progress note. Skin Evaluation Form on 5/11/2026 at 747am documents the presence of a Right forearm Full thickness wound, skin tear as well as a Left Heel partial thickness wound, arterial ulcer, fluid filled blister. There is no documentation of a Right Heel Wound. Initial Wound Evaluation & Management Summary on 4/14/2026 documents, a stage II pressure wound on the sacrum as well as a skin tear wound on the right arm. No heel wounds were present on this date. Wound Evaluation & Management Summary on 5/5/2026 documents, a skin tear wound of the right arm and an arterial wound of the left heel. Ankle Brachial Index (ABI) is recommended. There is no mention of a right heel wound present on this date. V26 (Wound Physician) confirmed no notification was made of new right heel wound prior to interview with surveyor 5/13/26 at 125pm. V26 affirmed when there is a new skin integrity issue, the staff nurse is to notify the Assistant Director of Nursing or the Director of Nursing, and then the physician (either the wound physician or the attending/oncall physician) would be notified to obtain temporary orders until the wound physician evaluates the wound. At 1150am on 5/14/2026, both V2 (Director of Nursing) and V3 (Assistant Director of Nursing) confirmed they were not made aware of the new wound to the right posterior heel and therefore did not make a notification to the wound doctor. There were no progress notes from any staff nurses which document a notification to either the wound doctor not attending doctor/nurse practitioner following the discovery of the wound 5/11/2026. Resident care plan (printed 5/13/26) documents R25 is at risk for skin breakdown due to previous wounds and diagnosis of Peripheral Arterial Disease (PAD). Goal of care plan is to receive no new skin breakdown through review and wounds will resolve. Interventions include: .assist with turning and repositioning often while in bed, ensure proper offloading and pressure distribution is occurring often, LAL initiated per orders.Perform daily skin checks, notify nurse if new areas of redness are seen. Monitor left heel and skin tear site for signs/symptoms of infection and/or worsening.heel protectors per orders. There is no revision to the care plan noted on 5/11/26, 5/12/26, or 5/13/26 that reflects the monitoring or treatment of a new wound to the right heel. Interdisciplinary Notes Reviewed: 5/12/2026 10:53PM (Nursing) – Skin condition: No new findings. No resident refusals of preventative measures documented 5/11/2026 11:38PM (Nursing) – Skin condition: No new findings. No resident refusals of preventative measures documented 5/10/2026 3:36PM (Nursing) – No resident refusals of preventative measures documented 5/9/2026 4:51PM (Nursing) – No resident refusals of preventative measures documented 5/4/2026 3:48PM (Nursing) – Observed to have purplish fluid filled blister at the left and right heel. Left heel blister is bigger than the right. Dr. Shen made aware. Protective foam placed to bilateral heels, feet elevated with pillows. No subsequent note entries nor skin assessments addressed the right heel wound, nor treatment orders obtained. Skin Evaluation Form charted on 5/13/2026 at 3:45pm by V3 documents, right heel blister, fluid filled in addition to resident's refusal to wear the protective boots at that time. No prior refusals of preventative measures were noted in skin assessments nor interdisciplinary notes. The facility policy Notification of changes, dated 2/11/2025, documents, The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include.3. Circumstances that require a need to alter treatment. This may include: a) New Treatment. Facility policy Pressure Injury Prevention and Management (dated 2/11/25) documents, Avoidable means that the resident developed a pressure ulcer/injury and that the facility did not do ONE or more of the following: .define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; .or revise the interventions as appropriate. 2.R15's diagnoses include metabolic encephalopathy, dementia, weakness, signs/symptoms involving musculoskeletal system and cognitive communication deficit. R15's (4/29/26) BIMS (Brief Interview Mental Status) affirms resident was unable to complete the interview. 05/11/2026 at 11:42am, R15 was lying on a LALM, however, the mattress was not turned on. On 5/11/26 at 11:48am, V15 (Registered Nurse) was asked if R15's LALM was turned on. V15 (Registered Nurse) inspected R15's LALM device and stated, I don't see anything go on (while pressing several buttons), I'll call maintenance. The (2/11/26) Low Air Loss Mattress policy states the mattress pump must be set according to the manufacturer's instructions based on the resident's current weight. Staff must check that the mattress is functioning (plugged in, working properly) every shift.

Based on observation, interview, and record review, the facility failed to ensure that an opened gallon of distilled water used for tube feeding flushes was labeled with an open date for one resident (R33). This failure affected one resident (R33) reviewed for tube feeding management in the total sample of 37 residents.Findings include:R33's face sheet documents diagnoses that include but are not limited to artificial opening of digestive tract, dysphagia, and osteomyelitis of vertebra, sacral and sacrococcygeal region.R33's BIMs (Brief Interview for Mental Status), dated 5/03/26, is 14 which indicates R33 is cognitively intact.R33's care plan, dated 4/28/26, documents, Potential for complications related to the use of GJ (gastrojejunostomy) due to dysphagia, recent displacement.R33's physician order, order date 4/27/26, documents, Enteral feeding: Flush with 250ml of sterile water every 6 hours, four times daily.On 5/11/26 at 11:14am, observed a gallon of distilled water on R33's bedside dresser that was opened and not labeled with a date.On 5/11/26 at 11:15am, R33 said, I'm not sure what that water (pointed to the opened gallon of distilled water) is for. I don't drink anything.On 5/11/26 at 11:17am, V19 (Registered Nurse/RN/Agency) said, Oh, there should be an open date on that (R33's gallon of distilled water). It's dated to see how new it is.On 5/13/26 at 11:50am, V2 (Director of Nursing/DON) said, The sterile water for tube feeding is usually dated to make sure how old the water is. It's beneficial to date the water once opened to prevent cross contamination.Record review of facility policy titled, Care and Treatment of Feeding Tubes, dated 2/11/26, documents, Policy: It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible.Record review of pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis. Your facility must be safe, clean, comfortable, and homelike. You may participate in developing a person-centered care plan which states all the services your facility will provide to you and everything you are expected to do. This plan must include your personal and cultural choices. Your facility must make reasonable arrangements to meet your needs and choices. You should receive the services and/or items included in the plan of care.

Based on observation, interview, and record review, the facility failed to ensure policy procedures include storage for respiratory devices when not in use and failed to contain respiratory equipment when not in use for two of 20 residents (R16, R23) in the sample reviewed for quality of care. Findings include:1.On 5/11/26 at 10:51am, R23's incentive spirometer was observed on the windowsill and uncontained. On 5/11/26 at 11:02am, V15 (Registered Nurse/RN) was asked about R23's (uncontained) incentive spirometer. V15 stated, She had pneumonia that's why we're using it. V15 was asked if R23's incentive spirometer was contained while not in use. V15 responded, We need to have (brand name) bags and affirmed the device was not contained at this time.2.R16's (10/30/24) physician orders include CPAP (Continuous Positive Airway Pressure) at bedtime. R16's (2/17/25) care plan includes CPAP however the interventions exclude containment when not in use. On 5/11/26 at 11:08am, R16's CPAP mask was observed (uncontained) behind the dresser and touching the curtain.On 5/11/26 at 11:15am, V17 (Certified Nursing Assistant) was asked about concerns with R16's CPAP mask. V17 (Certified Nursing Assistant) state,d It's behind here (referring to the dresser), and there's no bag on here.On 5/12/26 at 12:45pm, R16's CPAP mask was on the dresser and (uncontained). V22 (Licensed Practical Nurse/LPN) was asked about concerns with R16's CPAP mask. V22 (Licensed Practical Nurse) stated, When it's not in use, we can have the mask in a (name brand bag). V22 was asked if R16's CPAP mask was contained in a bag. V22 responded No ma'am.On 5/13/26, surveyor requested the facility policy for containment of respiratory equipment when not in use. Surveyor received the noninvasive ventilation (CPAP, BiPAP) policy (revised 2/11/26) which states, It is the policy of this facility to provide noninvasive ventilation as per physician's orders and current standards of practice however storage/containment of respiratory equipment when not in use is excluded.

Based on interview and record review, the facility failed to ensure a physician's order was written and in the electronic medical record physician orders for one (R29) resident of one resident reviewed for dialysis care. Findings include:R29 is [AGE] years of age. Current diagnoses include but are not limited to End Stage Renal Disease, Dependence on Renal Dialysis, Type 2 Diabetes Mellitus, Hypertension, Hypothyroidism, Benign Prostatic Hyperplasia, and Malignant Neoplasm of Prostate.R29's comprehensive assessment section C Cognitive Patterns, dated 05/06/2026, documents a BIMS (Brief Interview for Mental Status Score) of 11, which indicates R29 has moderate cognitive impairment.On 05/11/2026 at 10:50 am, R29 was in his room asleep in bed. He has oxygen in place via concentrator set at 1.5ml/min humidified via nasal cannula. Noted dialysis port to his chest wall. On enhanced barrier precautions related to his dialysis access. Will attempt to interview at a later time.On 05/11/2026 at 2:00 pm, during review of R29's electronic medical records, there is no physician's order documenting his dialysis treatment and transportation.On 05/12/2026 at 12:23 pm, R29 is sitting up in bed eating his lunch with a friend at his bedside alert and oriented. R29 said, They take me to the hospital for my dialysis. It's on time, but I missed yesterday because I wasn't feeling good. R29 appeared to be clean in no distress. He did not complain of pain or SOB (shortness of breath). He didn't have any concerns with his dialysis treatment or transportation. Oxygen remains at 1.5ml/min via concentrator humidified per nasal cannula. On 05/13/2026 at 1:40 pm, V2, DON/Director of Nursing, was asked about R29's dialysis order. V2 said, There should be an order for dialysis in the computer. It's to make sure he's (R29) on schedule, gets the right dialysis, at the right place for the right amount of time. We have a dialysis folder for the nurses to communicate with the dialysis staff. Our doctors and nurse practitioners have access to enter orders into our system. The hospital would send the order for dialysis and the nurse on duty would be responsible for putting the order in. V2 reviewed R29's physician orders and said, I don't see the order.On 05/13/2026 at 2:20 pm, V2, DON, brought a physician order for R29's dialysis to this surveyor. The physician order states- order date 05/13/2026, start date 05/13/2026. Order text- Dialysis twice a week on Monday and Friday. Physician name and contact number. R (Right) Chest CVC (Central Venous Catheter). Hospital name and contact number. Ambulance to transport back and forth. No fluid restriction. Changed on 12/17/25.The Hemodialysis policy, dated 05/01/2025, states: Policy: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the residents' goals and preferences, to meet the special medical, nursing, mental, and psychological needs of residents receiving hemodialysis.Purpose: The facility will ensure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. this will include:The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.Compliance guidelines:13. The facility will ensure that the physician's orders for dialysis include:a. The type of access of dialysis (e.g. graft, arteriovenous shunt, external dialysis catheter) and location.b. The dialysis schedule.c. The nephrologist name and phone number.d. The dialysis facility name and phone number.e. Transportation arrangements to and from the dialysis facility.f. Any medication administration or withholding of specific medications prior to dialysis treatments.g. Any fluid restriction if ordered by the physician.

Based on observation, interview, and record review the facility failed to maintain accurate records and document administration of controlled substances for one (R51) of one resident reviewed for pharmacy services in a sample of 21 residents residing on the second floor.Findings include: On 05/11/26 at 9:30am, V1 (Administrator) stated the facility census is 37 residents residing at the facility. On 05/13/2026 at 10:45 am, surveyor inspected accounting of controlled substances for the medication cart for rooms (#). The controlled substances count on 5/13/26 at 10:45 am with V22 (Licensed Practical Nurse/LPN) for medication cart for rooms (#) was inaccurate for one resident (R51). R51 has an order for Pregabalin 100 mg (milligrams) capsule, 1 capsule by mouth twice daily. The controlled drug receipt/record disposition form for R51 listed 17 capsules of Pregabalin 100 mg (milligrams) capsule but 16 capsules remain in the package. V22 stated, I gave one this morning and did not sign it yet. R51 was admitted on [DATE] with current diagnoses that include but are not limited to acute systolic congestive heart failure, acute kidney failure, chronic kidney disease, polyneuropathy, and rheumatoid arthritis. On 05/13/2026 at 1:59 pm, V2, DON (Director of Nursing), was asked about the process of accounting for controlled substances. V2 (DON) stated, After administering controlled medications, the nurse needs to sign the Controlled Drug/Receipt Record Disposition Form immediately for accuracy of medication given. Review of the facility's Controlled Substance Administration and Accountability Policy dated 3/2/2026 documents in section 1. f. ii. All controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form. Written documentation must be clearly legible with all applicable information provided. Review of the facility's Symbria Rx Services Pharmacy Policy II A7: Controlled Substances, dated July 2024 documents in section E. the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR):1) Date and time of administration (MAR, Controlled Drug/Receipt Record Disposition Form)2) Amount Administered (Controlled Drug/Receipt Record Disposition Form)3) Remaining quantity (Controlled Drug/Receipt Record Disposition Form) 4) Initials of the nurse administering the dose, completed after the medication is actually administered (MAR, Controlled Drug/Receipt Record Disposition Form)

Based on observation, interview, and record review, the facility failed to follow policy and procedure and failed to ensure a resident was free from significant medication errors. These failures affect one resident (R33) in a sample of 37 residents reviewed for medication administration. Findings include:R33's face sheet documents diagnoses that include but are not limited to osteomyelitis of vertebra, sacral and sacrococcygeal region.R33's BIMs (brief interview for mental status) score, dated 5/03/26, is 14 which indicates R33 is cognitively intact.R33's care plan, dated 4/28/26, documents, in part, I (R33) have an infection OM (osteomyelitis). My infection will be resolved after the completion of my antibiotic course. I (R33) will take my antibiotic as prescribed.R33's physician order, order date 5/5/26, documents, in part, Vancomycin 1G/250ml in 0.9% sodium chloride intravenous (IV) twice a day for osteomyelitis.On 5/11/26 at 11:14am, observed R33's Vancomycin IV (antibiotic medication) being administered through R33's left PICC line and infusing at 132ml/hr. Record review of R33's Vancomycin IV label documents, in part, Compounded: Infuse 250ml (1G) 125 ml/hr. over 120 minutes twice a day for osteomyelitis. Once activated product expires.On 5/11/26 at 11:15am, R33 said, I get that IV (Vancomycin antibiotic) for my infection.On 5/11/26 at 11:17am, V19 (Registered Nurse/RN/Agency) said, Its R33's Vancomycin medication supposed to go at 125 ml/hr. I was trying to change the rate, and it kept going to 175ml/hr. I should have gotten another pump. This pump was working fine before. No, never had this issue before. No, there is something wrong with this pump. I will get a working one (IV pump) and put a tag on it (IV pump that is not working properly) so it (IV pump that is not working properly) gets checked out. Running it (R33's Vancomycin medication) at the wrong rate can cause an adverse reaction to the resident.On 5/13/26 at 11:50am, V2 (Director of Nursing/DON) stated that the purpose of administering Vancomycin IV at the ordered rate is to ensure the body can handle the medication, there is a timing window for when it will expire, and lab troughs have to be done and are based of the timing of the last dose.Record review of facility policy titled, Medication Administration, dated 2/11/26, documents, in part, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Administer medication as ordered in accordance with manufacturer specifications. Correct any discrepancies and report to manager.Record review of facility policy titled, Provision of Physician Ordered Services, dated 2/11/26, documents, in part, Policy: The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality. Definition: Professional Standards of Quality means that care and all services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting.Record review of CMS's RAI (Resident Assessment Instrument) 3.0 Manual Chapter 3 MDS Items (N), dated October 2025, documents in part the following: N0415: High-Risk Drug Classes: Use and Indication: Antibiotic.Record review of pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, in part, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis. Your facility must be safe, clean, comfortable, and homelike. You may participate in developing a person-centered care plan which states all the services your facility will provide to you and everything you are expected to do. This plan must include your personal and cultural choices. Your facility must make reasonable arrangements to meet your needs and choices. You should receive the services and/or items included in the plan of care.

Based on observation, interview, and record review, the facility failed to ensure essential equipment was maintained in safe operating condition when an IV pump identified as malfunctioning continued to be used for resident care. These failures affect one resident (R33) in a sample of 37 residents reviewed for medication administration. Findings include:R33's face sheet documents diagnoses that include but are not limited to osteomyelitis of vertebra, sacral and sacrococcygeal region.R33's BIMS (Brief Interview for Mental Status), dated 5/03/26, is 14, which indicates R33 is cognitively intact.R33's care plan, dated 4/28/26, documents, I have an infection OM (osteomyelitis). My infection will be resolved after the completion of my antibiotic course. I will take my antibiotic as prescribed.R33's physician order, order date 5/5/26, documents, Vancomycin 1G/250ml in 0.9% sodium chloride intravenous (IV) twice a day for osteomyelitis.On 5/11/26 at 11:14am, observed R33's Vancomycin IV (antibiotic medication) being administered through R33's left PICC line and infusing at 132ml/hr. Record review of R33's Vancomycin IV label documents, Compounded: Infuse 250ml (1G) 125 ml/hr. over 120 minutes twice a day for osteomyelitis. Once activated product expires.On 5/11/26 at 11:15am, R33 said, I get that IV (Vancomycin antibiotic) for my infection.On 5/11/26 at 11:17am, V19 (Registered Nurse/RN/Agency) said, It's (R33's) Vancomycin medication supposed to go at 125 ml/hr. I was trying to change the rate, and it kept going to 175ml/hr. I should have gotten another pump. This pump was working fine before. No, never had this issue before. No, there is something wrong with this pump. I will get a working one and put a tag on it (IV pump that is not working properly) so it gets checked out. Running it at the wrong rate can cause an adverse reaction to the resident.On 5/13/26 at 11:50am, V2 (Director of Nursing/DON) stated the purpose of administering Vancomycin IV at the ordered rate is to ensure the body can handle the medication, there is a timing window for when it will expire, and lab troughs have to be done and are based on the timing of the last dose. V2 said, No, an IV pump that is not working properly should not be used on a resident. The nurse should get a new pump from central supply and put a ticket in to have the pump looked at and fixed. We have plenty of pumps. We rent some and own some. There is no need to use a pump that is not working properly.Record review of facility policy titled, Safety and Equipment Maintenance, dated 1/26, documents, Proper maintenance of the physical plant and all equipment in the Department is the responsibility of the Director in cooperation with the Maintenance Department and subject to policies and procedures set forth by the facility's administration. The Director is directed or has knowledge of all routine, periodic, and critical maintenance work done to the physical plant or equipment in the Department.Record review of Infusion Pump Instructions For Use, dated 2017, documents, (Name Of IV Company) will assume no responsibility for any incidents that may occur if the device is not utilized strictly in accordance with its product labeling. CAUTION: Always verify displayed infusion parameters (Primary Rate, Primary VTBI, Secondary Rate, Secondary VTBI) with the prescription before starting infusion. If a (Manufacturer Name) Pump fails to respond as described in this Instruction for Use and the cause cannot be determined, do not use the affected instrument. Contact qualified service personnel.Record review of pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis. Your facility must be safe, clean, comfortable, and homelike. You may participate in developing a person-centered care plan which states all the services your facility will provide to you and everything you are expected to do. This plan must include your personal and cultural choices. Your facility must make reasonable arrangements to meet your needs and choices. You should receive the services and/or items included in the plan of care.

Based on interview and record review, the facility failed to follow its policy in conducting background checks for 1 of 10 residents (R34) reviewed for admission screening, and nine of ten (V9, V15, V16, V17, V18, V19, V20, V21, and V23) employees prior to hire. This failure has the potential to affect all 36 residents residing in the facility. Findings include: Census report for February 24, 2025 documents 36 residents currently residing in the facility. Per facility list, R34 is an identified offender. R34 is an [AGE] year-old male resident admitted to facility on 10/2/2024 with diagnoses including but not limited to blindness one eye, cognitive communication deficit, and adjustment disorder with depressed mood. His CHIRP (Criminal History Information Response Process) was checked on 10/18/2024, more than two weeks after admission. His CHIRP resulted in multiple hits and required fingerprints to be requested. V9, CNA (Certified Nursing Assistant), with a hire date of 2/12/2025. Illinois Department of Public Health, Health Care Worker Registry was checked 2/25/2025, and background checks were completed 2/17/2025, which was after hire date. V15 (CNA), with a hire date of 4/16/2024. Illinois Department of Public Health, Health Care Worker Registry was checked 4/23/2024, and other background checks were completed 4/23/2024, except Illinois Sex Offender background check, which was done 2/25/2025; all were after hire date. V16 (CNA) with a hire date of 8/20/2024. Illinois Department of Public Health, Health Care Worker Registry was not checked until 8/30/2024. All other background checks were completed on 8/30/2024, which is after hire date. V17 (CNA) with a hire date of 7/24/2024. Illinois Department of Public Health, Health Care Worker Registry was not checked until 7/30/2024. All other background checks were completed 7/30/2024 which is after hire date. V18 (CNA) with a hire date of 3/22/2024. Illinois Sex Offender background check was completed 2/25/2025. V19 (Receptionist) with a hire date of 8/17/2023. Illinois Department of Public Health, Health Care Worker Registry was not checked until 2/15/2024. All other background checks were done on 2/15/2024, except Illinois Sex Offender background check, which was completed 2/25/2025, which are all after hire date. V20 (Scheduler) with a hire date of 1/14/2025. Illinois Department of Public Health, Health Care Worker Registry was not checked until 2/25/2025. V21, RN (Registered Nurse), with a hire date of 2/27/2024. Illinois Department of Financial and Professional Regulation website was checked on 3/4/2024. V23, RN (Registered Nurse), with a hire date of 11/16/2022. Illinois Department of Financial and Professional Regulation website was checked on 12/13/2022. On 02/25/25 at 11:44 AM, V6 (Director of Admissions) and V7 (Receptionist) came to do Identified Offender background check review with files. V6 and V7 both stated they do not know why CHIRP was not run for R34 until 10/18/2024. V6 stated they should have been run within 24 hours of admission. On 02/25/25 at 12:44 PM, V6 stated, When we commit to someone coming in, we set up profile, send out notification, pull records into chart and verify insurance. Then reception team does CHIRP, Custody and Illinois sex offender background checks. If reception is not here, my coworker and myself do the checks. Reception uploads into the resident's electronic medical record. If there are hits, Administrator gets notified, I get notified, and my coworker gets notified. From there, we check what the charge is against the list we have and see if we need fingerprinting. We have 5 days to do fingerprinting, but we get that done right away. Once we receive that we upload into the Identified Offender system and email to Administrator, my coworker, and myself. Once that is done, we wait to see if someone is going to come out and interview the resident. Then once the person is discharged , we discharge the resident out of the system and paperwork is filed. I have just been taught that those are the 3 background checks we do. I am not sure why (R34's) CHIRP was done late. We did find that it was done late via audit and administration was aware. On 02/25/25 at 01:52 PM, V1 (Administrator) stated, Everybody will have a national sex offender background check done. This will be done immediately today. And going forward National sex offender background check will be done on every admission. We already do weekly audits since last year around May 1st, 2024. (R34's) CHIRP being done late got missed as receptionist was not here and was caught in the audit. On 02/25/25 at 02:47 PM, V5 (Human Resource Support) stated, For (V9) - Registry was checked today. Her hire date was 2/12/2025. The background checks were done 2/17/2025. All of the checks were done late. I do not know why they were done late. I do not do them, my coworker does them. For (V15), her hire date 4/16/2024. Her registry was done today. Her background check for Illinois Sex Offender was done today. Remaining background checks were done 4/23/2024. For (V16), her hire date was 8/20/2024. Her registry was checked 2/25/2025. All of her background checks were done 8/30/2024. For (V17), her hire date was 7/24/2024. Her registry was checked 2/25/2025. All of her background checks were also checked late on 7/30/2024. For (V18), she was hired 3/22/24. Her registry was checked 3/22/24. Her Illinois Sex offender was checked on 2/25/25. All other background checks were done 3/22/24. For (V19), his hire date was 8/17/23. His registry was done 2/15/2024. Illinois Sex Offender background check was done on 2/25/2025. All other background checks were done 2/15/2024. For (V20), her hire date was 1/14/2025. Her registry was done 2/25/2025. Her background checks were done 1/8/2025. (V21's) hire date was 2/27/2024. IDFPR website was checked on 3/4/2024. For (V23), her hire date was 11/16/22. IDFPR website was checked on 12/13/2022. On 02/25/25 at 03:18 PM, V4 (Medical Director) stated, My expectation of staff is that all of the background checks are done prior to hire or prior to admission. It is important to do the background checks prior to admission/hire to keep residents charged in our care safe from abuse/neglect/exploitation. On 02/26/25 at 09:10 AM, V8 (Human Resource Support Supervisor) stated, We were doing an audit in December to correct some of the things we were missing. After that audit, I was unaware of any further issues. I am unsure of why the items were missing or done late. We rely on the leadership team to tell us when the staff start. We are working towards better communication. We are trying to get leadership to understand the why no one can start until all paperwork is done. This should be done for safety and risk to the residents. It is our obligations to our residents to ensure safety of the residents. Facility Poicy Employee and Health Care Worker Background Check Policy and Procedure with Effective date of October 1,2016 and Revision Date of 2/1/2025 documents: Purpose: To ensure compliance with the Illinois Department of Public Health (IDPH) and the Centers for Medicare & Medicaid Services (CMS) regulations, this policy establishes the procedures for conducting background checks on all prospective and current employees who provide direct patient care or have access to patient records. Scope: This policy applies to all employees, contractors, volunteers, and affiliates who have direct access to patients or patient information within our organization. Policy 1. Pre-Employment Background Checks Health Care Worker Registry (HCWR) Clearance: o All prospective employees must undergo an HCWR clearance before hire to determine if they have a reported criminal background check result, a disqualifying criminal conviction, an IDPH waiver for a disqualifying conviction, or substantiated findings of abuse or neglect. o If no background check results are found in the HCWR, the employee must complete a fingerprint-based criminal background check using an IDPH-approved livescan vendor within 10 working days of hire. o The required livescan form will be printed from the IDPH Web Portal and must be provided by the hiring department to the employee. Registry and Background Check Verification: o The organization will verify each new hire's status on the HCWR before allowing them to start employment. o Employees with disqualifying convictions will not be hired unless an IDPH waiver has been granted o Individuals with substantiated findings of abuse, neglect, or financial exploitation will not be eligible for employment. 4. Compliance and Record Maintenance Documentation: o All background check results and HCWR clearance verifications will be maintained in the employee's personnel file. o Documentation must be readily available for audit or regulatory review. Ongoing Compliance Monitoring: o The HR department will conduct routine audits of background check records to ensure ongoing compliance with IDPH and CMS regulations. o Employees who fail to comply with background check requirements will be subject to disciplinary action, up to and including termination. Procedure: 1. Pre-Hire Screening: o HR will verify the applicant's HCWR status through the IDPH Web Portal. o If the applicant's background check is not listed, HR will provide the livescan form and require fingerprint submission within 10 working days of hire. 2. Record Maintenance: o HR will securely store background check results, waivers, and registry clearance records. o Records must be retained in compliance with state and federal regulations. By adhering to this policy, our organization ensures patient safety and regulatory compliance while maintaining high standards for employee integrity Identified Offenders Policy and Procedure with a reviewed date of 1/4/24 documents in part: PURPOSE To comply with the Illinois Department of Public Health Identified Offender law (Public Act [PHONE NUMBER]) and to ensure the safety of all residents of our community. PROCEDURES 1. Criminal Background and Sex Offender Checks will be completed on all residents admitted to the BHRS Health Center within twenty-four (24) hours from the admitted . The Admissions Coordinator or designee will request a Uniform Criminal Information Act (UCIA) name-based criminal history record from the Illinois State Police using the Criminal History Information Response Process (CHIRP) and verify the resident with the Illinois State Police Sex Offender Registry and the Illinois Department of Corrections Parole Sex Offender Registry to determine if the resident is a registered sex offender. If the resident is determined to be a registered Sex Offender, the Administrator and IOP must be informed immediately. 2. All background checks will be kept in a secure file and maintained for at least 3 years. 3. In the event that a resident has a hit response, the Administrator will be notified immediately. 4. The Administrator will review the UCIA Criminal History Record to determine if the resident is an identified offender.

Based on observation, interview, and record review, the facility failed to ensure food is prepared and served under the sanitary conditions, failed to ensure food items were labeled and dated per facility policy, and failed to ensure high-temperature dishwasher final rinsing cycles gauge temperature worked properly during final rinse. These failure applies to 37 residents who receive food prepared in the facility kitchen. Findings include: On 2/24/2025 at 09:29 AM, during the initial rounds in the kitchen with V12 (Director of Dining Services), surveyor observed a box of twenty-four cucumbers, box of broccoli, and a box of tomatoes sitting directly on the floor. V12 said, The delivery just got to the facility, and I expect the staff not to place directly on the floor, and use the cart next to the produce. On 02/25/2025 at 09:45 AM, surveyor checked the temperature for the dishwasher with V12. Surveyor observed the final rinse temperature gauge was not working. V12 said, I already placed a work order, and the facility is waiting for the technician to come and fix it. The facility is using the temperature strip. I could not tell for sure if the final temperature could hold the temperature up above 180 Fahrenheit, and not washing dishes properly can cause infection. The ice machine was observed to have dust and hard water marks built up around the outside on the left side of the leakage area. V12 said, The facility does monthly maintenance cleaning, and staff are expected to wipe out and clean it (ice machine) daily at the end of the shift, but it was not done. The ice cream freezer had six-3 gallons of ice cream half full, with no open date or best buy date. V12 said, I expect staff to date the ice cream as soon as each gallon is opened. A garbage container without a lid was observed half full of garbage across from the ice machine. V12 said, I expected the garbage containers to always have a lid to prevent contamination. On 02/25/2025 at 2:00 PM, V1 (Administrator) said, I was not aware of the dishwasher temperature final rinse gauge not working. The Kitchen will switch and start using (white foam) plates and disposable silverware until the machine is fixed. I expect the staff to follow facility policy and protocol and follow infection control to prevent food poisoning. On 02/26/2025 at 09:10 AM, V12 said, The technician already fixed the dishwasher. The final rinse gauge temperature was working, and surveyor able to observe two rinse cycles, and the temperature was 182 degrees Fahrenheit. On 02/27/2025 at 1:00 PM, V3 (Infection Preventionist) said, I expect the garbage to always have a lid, equipment to be fixed and cleaned. If the dishwater final wash temperature gauge is not working, the kitchen staff need to use (white foam) disposal plates and silverware. Food should be handled properly per facility policy to prevent germ contamination and infection. Facility policy titled, Sanitation and Infection Prevention Control, Dishwasher Temperature dated 1/24, reads: Multi-tank conveyor, multi-temperature machine-Final rinse temperature 180F-194F. Production, Purchasing, Storage dated 1/25, Which reads in part (but not limited to), The words sell by, best buy, enjoy by or used by, should proceed a date on the product. Food past the sell by, best buy, enjoy by date should be discarded. Refrigerator storage Store food 6 above the floor, the bottom shelf must be solid to protect the product from splash and dust. Frozen storage Once the packaging around the food has been opened, food must be used within 3 months. Sanitation and Infection Prevention Control, Solid Waste Disposal dated 1/25, Which reads in part (but not limited to), Garbage containers are clean, lined, and covered at all times.

Based on interview and record review, the facility failed to properly position a resident (R1) in bed to prevent the resident from falling out of bed onto the floor, failed to properly assess R1 after his fall incident and prior to moving the resident post fall, and failed to follow facility policy by leaving resident unattended during fall event. These failures resulted in the resident being sent out emergently to a local hospital in pain, and R1 was diagnosed with dislocation to his right hip which required surgical intervention. This failure affected one (R1) of three residents reviewed for accidents. Findings include: R1's electronic medical record indicated resident admitted to the facility on [DATE], was discharged on [DATE], and readmitted on [DATE]. R1 has a past medical history not limited to dislocation of right hip, encephalopathy, acute and chronic respiratory failure, acute osteomyelitis of right ankle and foot, hypotension, and peripheral vascular disease. R1's care plan, dated 08/04/2023, reads, resident is at risk for falls related to gait instability and poor balance. R1's Minimum Data Set (MDS) Section G for functional status, dated 08/08/2023, indicated R1 requires two-person assist for bed mobility, which includes turning side to side and body positioning in bed. R1's incident report, dated 08/08/2023, indicated R1 was being changed by (V4) a male certified nursing assistant (Certified Nursing Assistant/CNA) when R1 kept pulling on side rail and was hanging out of the bed. R1 was told to stop pulling on rail, but did not listen, and was then in a kneeling position on the floor. When the CNA (V4) walked around the bed, R1 fell face forward. R1 was sent to a local hospital emergently via ambulance. Page three of this same report, indicated R1 was lying in bed on his side and was holding on to the side rail when R1 unexpectedly and unpredictably dangled his legs beyond the edge of the mattress, and with the forward momentum of his legs, slid out of bed onto his knees then subsequently let go of the side rail and slid the rest of the way to the floor. (V4) CNA called out for help and the nurse immediately went to assist and completed a full head to toe assessment, where she observed a skin tear to his right arm and R1 complained of pain rated 6/10 on a numerical scale. R1 was emergently sent to a local hospital for further evaluation and treatment per physician's orders. R1 was admitted to the hospital and diagnosed with right hip dislocation with no acute fracture. R1's progress note, dated 08/08/2023 created by V5 (Registered Nurse), indicated R1 had a fall incident and sustained a skin tear to his right arm, but V5 was unable to assess (R1) fully as paramedics in room (R!) on to stretcher. Note continued with, (R1) denies pain, but was requesting to go to hospital. R1's hospital records, printed on 08/25/2023, indicated while in hospital, R1 had two unsuccessful attempts at a closed reduction to his right hip and had an open reduction procedure to his right hip with orthopedics on 08/11/2023. On 09/01/2023 at 11:32 AM, R1 said on day of his fall incident, I fell . R1 then said a male staff member, V4, was helping him get into bed, when he began slipping out of his arms, and almost fell to the floor. R1 added he kept slipping and sliding out from the male aide's (V4) hold, was face down when his hands went down to the floor. R1 then said the male aide, V4, was trying to hold the rest of his (R1) body up, but eventually his whole body ended up on the floor. R1 added he had pain all over, and he (V4) could not get me up from the floor, so the paramedics came and took me to the hospital. On 09/01/2023 at 2:44 PM, V4 (Certified Nursing Assistant/CNA) said as far as he knew, R1 was a two-person assist for transfers in and out of bed but to provide care; it was okay with one person. V4 then said while providing care to R1 on day of incident (08/08/2023), he used the turning pad underneath R1; pulled it towards him to turn R1 onto his side. V4 added after he had turned R1 onto his side, he noticed that the resident was a little too close to the edge of the bed. V4 (CNA) said R1 became anxious because he was on the edge, and he was unable to calm him when his legs then went over the side of the bed. V4 added he tried to hold on to R1 from the opposite side of bed, but was unable to, and R1 then slid out of bed to the floor onto his knees while he was holding on to the side rail with his arms. V4 then went over to R1's side (right side) of the bed, and tried to hold his upper body up so that R1 would not completely go onto the floor. He added R1's call light wasn't working, so he walked over to the other bed and pressed the call light, and when he returned to R1's side, he was face down on the floor and was hollering. V4 said he didn't notice any injury to R1 other than bleeding from his right arm. After the nurse (V5) assessed R1, he and another aide used the mechanical lift to get R1 off the floor and back onto bed, while the nurse left to make phone calls, then returned approximately ten minutes later and said R1 was being transferred out. V4 (CNA) did not indicate if the nurse (V5) assessed R1's range of motion to his lower extremities and whether they could move R1. When asked why he didn't initially reposition R1 away from the edge of the bed when he saw that R1 was close to the edge, V5 said I don't know, I should have repositioned him, but everything just happened so fast. On 09/01/2023 at 3:01 PM, V5 (Registered Nurse) said on day of incident at approximately 6:30 AM, V4 (CNA) was providing care to R1, when he came out of the room, informed another aide (V8), who informed her R1 was on the floor. When she walked into R1's room, she observed the bed to be waist level high, and R1 was face down on the right side of bed on the floor between the bed and wall. V5 saw blood on the floor, then asked R1 if he had hit his head. She indicated R1 said no, but it looked like he did in her opinion, so she left the room due to observing the blood, and R1 didn't complain of any new pain. When asked if she assessed R1's range of motion to lower extremities, V5 said it was communicated to her R1 was sitting on the floor, but that was not how she observed R1 to be, and she knew that R1 needed to be transferred out to the hospital emergently. V5 said after calling 911 along with R1's physician and family, she went back to his room, and R1 was in bed. V5 said she did not verbally instruct the aides to transfer R1 from the floor back into to bed. She added R1 did not complain of any hip pain, just the chronic pain to his right heel, which he had received scheduled pain medication for at approximately 6:00 AM. V5 added she didn't recall when the last fall in-service was, and a resident's level of care is communicated during shift to shift report that is done by both nurses and aides. Reviewed first floor report sheet provided by V2 (Assistant Director of Nursing/ADON) indicated R1 is a assist of one, with activities of daily living and bed mobility which is documented within his Minimum Data Set (MDS) Section G-functional status.as a two-person physical assist. On 09/02/2023 at 10:26 AM, V2 (Assistant Director of Nursing) said her expectations for nursing post fall is for a staff member to stay with the resident to prevent further injury, and for the nurse to do a full head to toe assessment to determine level of injury and if resident requires further evaluation. The aides are not to move the resident until the nurse completes an assessment and determines whether there is any injury or not. Staff should refer to a resident's chart regarding their level of care and assistance. On 09/02/2023 at 12:40 PM, V8 (Certified Nursing Assistant) said while leaving another resident's room, she saw R1's call light on and V4 (CNA) standing in R1's doorway saying he needed something, but she couldn't hear what it was. She added while heading towards R1's room, V4 began walking towards her and said, (R1) is on the floor. V4 then said when she entered R1's room, R1 was in between the bed and the radiator almost in a fetal position, saying please help me. She saw some blood on the floor, but was unsure where it came from. V8 then left the room and went to get the nurse (V5). Upon entering R1's room, the nurse began looking for injury and asking him questions, but said she did not personally see the nurse assess R1's range of motion because she was moving things about room out of the way. After the nurse left to make the phone calls, R1 was asking to get off the floor, so V4 got the mechanical lift and they got R1 up off the floor. V8 added the nurse (V5) did not directly instruct them to get R1 up. When asked when the last in-service on fall policy and procedures was that she had attended, V8 (CNA) said they are frequent and mandatory; believes the last one was a week ago, but she does not recall when the last in-service was prior to R1's fall. Reviewed bed mobility policy labeled turning resident on side away from you last revised October 2010 that reads: Purpose: provide comfort to the resident, to prevent skin irritation and breakdown, and to promote good body alignment. Preparation: review the resident's care plan to assess for any special needs of the resident Steps in the procedure: 5. slide both your arms under the resident's back to his/her far shoulder. 6. slide the resident's shoulders toward you on your arms. 7. slide both your arms under the resident's buttocks. 8. slide the resident's buttocks toward you. 9. slide both arms under the resident's feet and ankles. 10. slide the resident's feet toward you. 11. cross the resident's arms over his/her chest. 12. cross the resident's leg nearest you over the leg farthest from you. 15. place one hand on the resident's shoulder nearest you. 16. place your second hand under the resident's buttocks. 17. gently turn the resident away from you Reviewed fall-clinical protocol policy, revised March 2018, that reads: Assessment and Recognition: 2. the nurse shall assess and document/report the following: a. vital signs c. musculoskeletal function, observing for change in normal range of motion, weight bearing, etc. e. neurological status Reviewed fall prevention in-service agenda and attendance logs that showed V4 (CNA) attended on 07/23/2023 and 08/24/2023.V8 (CNA) attended on 08/24/2023. V5 (RN) was not listed on either attendance logs.

Based on observation, interview, and record review, the facility failed to follow their policy and procedure for pain management and medication administration by not administering the scheduled pain medication as prescribed. This failure applied to one (R133) of one residents reviewed for pain management. This failure resulted in R133 experiencing pain rated at a 9/10 as a result of being given her pain medication two hours late related to her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: On 02/07/22 at 10:18 AM, surveyor observed R133 in R133's room moaning and grimacing in pain. R133 stated R133 was admitted to the facility last Wednesday. R133 stated R133's pain level is at a 9, and R133 has been waiting since 8:45 AM to receive R133's scheduled analgesic pain narcotic as prescribed. R133 stated R133 last received R133's pain medication at 2AM, instead of midnight as scheduled. R133 was groaning and stated R133's pain feels like electrical shocks going through R133's legs. R133 stated R133 is at the facility to receive therapy so R133's health can improve, but due to the facility not administering R133's pain medication timely, R133 can't get up and go to therapy or do anything else as R133 normally would. R133 stated some staff don't even know when R133's pain medication is scheduled, and believe it is to be administered as needed. R133 stated R133 should be receiving R133's pain medication every six hours. R133 stated it takes an hour for R133's pain medication to kick in, therefore, receiving it late causes R133 to experience a significant amount of pain. R133 stated during a Care Plan meeting on Thursday 2/03/2022, with V16 (R133's Power of Attorney) and V2 (Director of Nursing) present, R133's pain medication regimen was discussed, and it was decided R133's pain medication would be scheduled every 6 hours, after R133 reported it had not been administered timely. R133 stated V2 (DON Director of Nursing) assured R133 her pain medication would be scheduled and administered on time. V15 (Licensed Practical Nurse, LPN) stated the previous nurse from overnight administered R133's analgesic pain narcotic at 2:30 AM, which should have been administered earlier. On 2/7/22 at 10:29 AM, R133 was reviewed during medication administration. Review of the MAR Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Administered late. Upon review of R133's Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/07/22 at 3:11 PM, V2, DON Director of Nursing, was asked about the 7AM-12 Noon medication administration times. V2 stated, The (electronic health record system) defaults some medications to that time. It doesn't give a time frame for twice a day medications. We have a window to accommodate the resident. V2 was inquired of the medication administration times and stated, We prefer one hour before and one hour after. V2 was inquired of R133's scheduled pain medication administration. V2 stated, (R133's) [MEDICATION(S)] ([MEDICATION(S)]) is scheduled every 6 hours. After we had a care conference with her, she prefers to have it scheduled to help with pain management for her therapy. It's scheduled 6AM, 12 Noon, 6PM, and 12AM. The nurses should be administering the medications as scheduled. (R133) told me it was working fine until she got the [MEDICATION(S)] late last night at 2AM. She was concerned because she was supposed to get it at 8AM. When it was close to 9AM she rung her call light for her medicine. My plan is to find out why the night nurse gave the medication late. I will address the nurses to give the medication on time. The pain medicine has got to be on time. Review of R133's care plan indicates: Pain- I have pain due to surgical site on my lower back. (G) My pain will be controlled with my current pain medications. (A) Notify my physician/NP (nurse practitioner) of pain medication effectiveness. (A) Medicate me with [MEDICATION(S)] 10mg po (by mouth) every 6 hours PRN (as needed), [MEDICATION(S)] 2mg po every 6 hours PRN. Monitor me for possible S/E (side effects) nausea, dizziness, confusion, [CONDITION(S)], muscle weakness, drowsiness, headache, notify my MD (medical doctor)/ NP (nurse practitioner). Review of R133's MAR (Medication Administration Record) indicates: V15, LPN, documented administering R133's [MEDICATION(S)] 2mg (milligrams) by mouth every 6 hours for severe pain at 12 noon. Review of the R133's Controlled Drug Receipt indicates: V15, LPN, administered the [MEDICATION(S)] 2mg (milligrams) by mouth every 6 hours for severe pain at 10:29 AM on 02/07/22. V15 did not document a nurse's note indicating the medication administration not given as scheduled. V15 also documented R133's pain level as a 7 out of 10 on the MAR. During interview, R133 stated R133's pain level was at a 9, and R133 had been waiting since 8:45 AM to receive R133's scheduled analgesic pain narcotic as prescribed. There were multiple nursing staff documentations of R133 not receiving the [MEDICATION(S)] 2mg (milligrams) by mouth every 6 hours for severe pain as scheduled on the Controlled Drug Receipt. The 10/2021 Pain Management policy indicates: Policy: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Policy Explanation and Compliance Guidelines: The facility will utilize a systematic approach for recognition, assessment, treatment and monitoring of pain. Recognition: 1. In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will: a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. b. Evaluate the resident for pain upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs (e.g after a fall, change in behavior or mental status, new pain or an exacerbation of pain). c. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. 2. Facility staff will observe for nonverbal indicators which may indicate the presence of pain. These indicators include but not limited to: b. Loss of function or inability to perform activities of daily living (ADLs) (e.g. rubbing a specific location of the body or guarding a limb or other body part). c. Fidgeting, increased or recurring restlessness. i. Negative vocalizations (e.g. groaning, crying, whimpering, or screaming). 3. Facility staff will be aware of verbal descriptors a resident may use to report or describe their pain. Descriptors include but are not limited to: d. Hurting or aching. h. Numbness, tingling, shooting or radiating. Pain Management and Treatment: 1. Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or the resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission. 4. Factors influencing the choice of treatments include: a. The cause, location and severity of resident's pain b. The resident's current medical condition c. The resident's current medications d. The resident's desired level of relief and tolerance for adverse consequences (e.g. partial pain relief for fewer significant adverse consequences). 6. Pharmacological interventions will follow a systematic approach for selecting medications and doses to treat pain. The interdisciplinary team is responsible for developing a pain management regimen that is specific to each resident who has pain or who has the potential for pain. The following are general principles the facility will utilize for prescribing analgesics: a. Evaluate the resident's medical condition, current medication regimen, cause and severity of the pain and course of illness to determine the most appropriate analgesic therapy for pain. c. Consider administering medication around the clock instead of PRN (pro re nata/on demand) or combining longer acting medications with PRN medications for breakthrough pain. f. Reassess and adjust the medication dose to optimize the resident's pain relief while monitoring the effectiveness of the medication dose to optimize the resident's pain relief while monitoring the effectiveness of the medication and work to minimize or manage side effects. h. Opioids will be prescribed and dosed in accordance with current professional standards of practice and manufacturers' guidelines to optimize their effectiveness and minimize their adverse consequences. Monitoring, Reassessment and Care Plan Revision: b. If re-assessment findings indicate pain is not adequately controlled, the pain management regimen and plan of care will be revised as indicated. The 2006 Preparation and General Guidelines 11A2: Medication Administration- General Guidelines states: Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. Procedures: A. Preparation: 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 Five 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 put away. B. Administration: 2. Medications are administered in accordance with written orders of the prescriber. 10. A schedule of routine dose administration times as established by the facility and utilized on the administration records. 11. Medications are administered within 60 minutes of scheduled time, except before, with or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. D. Documentation: 6. If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time (e.g, the resident is not in the facility at scheduled dose time, or a starter dose of antibiotic is needed), the space provided on the front of the MAR (Medication Administration Record) for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record. If a vital medication is withheld, refused, or not available the physician may be notified. Physicians should always be notified or any change of condition. Nursing documents the notification and physician response.

Based on interview and record review, the facility neglected to ensure that all certified nurse aide staff were trained on the safe use of the mechanical lift/Sit to Stand lift and neglected to follow the facility Policy, Safe Lifting and Movement for the use of the mechanical lift for 1 of 3 residents R2, reviewed for falls/safety. This failure resulted in R2 falling and being evaluated in the local hospital and assessed to have a right femur fracture requiring surgery. R2 had a difficult course after femur fracture repair, R2 expired, V15 MD (Medical Doctor) Hospitalist stated, R2's death was caused indirectly from the femur fracture. Finding Include: R2 was an [AGE] year old with [DIAGNOSES REDACTED]. R2 was hospitalized on [DATE] for a femur fracture. The facility Incident Report for R2 dated [DATE] at 6:10 PM documents CNA (Certified Nursing Assistant, V6) finished giving patient shower, was transferred from shower chair with sit to stand when patient started slipping and was lowered to the floor. Having extreme pain of right knee. Staff assisted patient from floor with mechanical lift into bed. Medicated with Tylenol for comfort, vital signs in normal range. Call doc (Medical Doctor) V13 ice to affected area. Final Report to IDPH (Illinois Department of Public Health) RE: R2 On Friday (MONTH) 27, (YEAR) at 6:10 PM agency CNA V6 called for assistance from shower room. Nurse and another CNA arrived in shower room to find R2 sitting on the floor dressed in a gown with R2's trunk supported by the CNA and R2's feet on the base of the sit to stand (device). During assessment the resident complained of right knee pain. Per agency CNA, the resident was being transferred from shower chair to wheelchair when resident slid to floor. Nurse notified physician who ordered STAT (immediate) x-ray of right knee. Right knee Xray received early morning which indicated an acute distal femur osteoporitic fracture with lateral displacement. Result related (relayed) to physician who ordered R2 be sent out to the hospital. R2's POA (Power of Attorney) notified. While at the hospital R2 underwent ORIF for femur fracture. On [DATE] at 1:30 PM, via telephone, Agency CNA V6 stated, I was working with R2, I gave R2 a shower. I applied sling under arms. R2 had a bowel movement in the shower, I wanted to clean R2 up before R2 sat down. R2 was on the sit to stand and I was wiping R2. R2 slowly slid out of the sling under her/his arms. I called for help,I put my body against R2 to support R2. When help came, R2 was already on the floor. I knew R2 can't stand to long, I believe it was under two minutes R2 was in the sling. I was alone during the transfer. R2 didn't say anything until R2was on the floor, then complained of right leg pain. I did the same thing with R2 the prior week with no problems. The nurse assessed R2 while on the floor. It happened around 6:00 PM. On [DATE] at 1:10 PM V14 RN (Registered Nurse) stated, Someone called for help, the ADON V3 (Assistant Director Of Nursing) was already there. R2 was on the floor, vitals were normal, complained of pain and being cold. We put a blanket on R2. We brought R2 back to the bed. I called the doctor, who ordered a STAT x-ray. I gave R2 Tylenol. I believe it was V16 RN who I endorsed it to. I was leaving around 8:00 PM. I still don't understand how it happened. On [DATE] at 2:15 PM V16 RN stated that the x-ray technician came around 12:00 AM. R2 was calm, said the leg hurt. I gave Tylenol. When I got the x-ray results I called the doctor and the doctor ordered R2 be sent out to the hospital. We sent her out around 2:00 AM. The radiology report for R2 dated [DATE] documents; Right knee, Acute distal femur osteoporotic fracture. On [DATE] at 12:45 PM V2 DON (Director of Nursing) stated, Concerning ADL (Activities of Daily Living) assessments, if the resident is in PT (Physical Therapy) they do the ADL assessment, if not in therapy, the nurses do it. They do a judgement call for the assessment. The CNA (Certified Nursing Assistant) involved was from an agency. I assume she was trained on a sit to stand device by the agency. I have spoken with her and she seemed to understand. I have not trained her here and have not seen a demonstration using the sit to stand with her. After this incident with R2 we changed our policy and procedure to a two person assist with the sit to stand. On [DATE] at 11:30 via telephone V10 Agency Representative stated, V6 met her competency requirements for fall prevention, however, V6 was not trained here (Agency) on the sit to stand device. On [DATE] at 12:30 PM via telephone V15 MD (Medical Doctor) Hospitalist stated, R2's death was caused indirectly from the femur fracture. I took care of R2 toward the end, R2 was in hospice and I am the physician on record for R2's death certificate. After R2's surgery for [REDACTED]. We got R2 off the ventilator, but at some point, R2 got a liver injury (shocked liver), R2's electrolytes were hard to control and R2 also suffered a kidney injury. I'm not sure how these conditions occurred. R2 had a very complicated course after the femur repair surgery. R2's Care Plan dated [DATE] documents; ADL Function/Rehab Potential. I require limited care for my bathing, grooming, dressing, mobility and set up for meals. I need extensive assist for transfers. A. I need 2 staff assist with the sit to stand device for transfers. The facility policy titled, Safe Lifting and movement of Residents, dated (MONTH) 2013, documents; In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. 4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. 6. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques.

Based on interview and record review, the facility failed to follow the MDS (Minimum Data Set) for a 2 person assist with transfers using the mechanical lift, and the plan of care interventions of (2) person assist with transfers while utilizing the mechanical lift for one resident (R2) of three residents reviewed for safe transfer.This failure resulted in R2 falling and being evaluated in the local hospital and assessed to have a right femur fracture requiring surgery . Findings Include: R2 was an [AGE] year old with [DIAGNOSES REDACTED]. R2 was hosptalized on [DATE] for a right femur fracture. The facility Incident Report for R2 dated 4/27/18 at 6:10 PM documents CNA (Certified Nursing Assistant, V6) finished giving patient a shower, was transferred from shower chair with sit to stand when patient started slipping and was lowered to the floor. Having complaints of extreme pain of right knee. Staff assisted patient from floor with mechanical lift into bed. Medicated with Tylenol for comfort, vital signs in normal range. Call doc (Medical Doctor) V13, ice to affected area. Final Report to IDPH (Illinois Department of Public Health) RE: R2 On Friday (MONTH) 27, (YEAR) at 6:10 PM agency CNA V6 called for assistance from the shower room. Nurse and another CNA arrived in shower room to find R2 sitting on the floor dressed in a gown with R2's trunk supported by the CNA and R2's feet on the base of the sit to stand (device). During assessment the resident complained of right knee pain. Per agency CNA V6, the resident was being transferred from the shower chair to wheelchair when resident slid to the floor. Nurse notified physician who ordered STAT (immediate) x-ray of right knee. Right knee Xray which indicated an acute distal femur osteoporitic fracture with lateral displacement. Results related (relayed) to physician who ordered R2 be sent out to the hospital. R2's POA (Power of Attorney) notified. While at hospital R2 underwent ORIF (open reduction internal fixation surgery) for femur fracture. On 7/5/18 at 1:30 PM, via telephone Agency CNA V6 stated, I was working with R2, I gave R2 a shower. I applied sling under arms. R2 had a bowel movement in the shower, I wanted to clean R2 up before he/she sat down. R2 was on the sit to stand and I was wiping R2. R2 slowly slid out of the sling under her/his arms. I called for help, I put my body against R2 to support R2. When help came, R2 was already on the floor. I knew R2 can't stand to long, I believe it was under two minutes R2 was in the sling. I was alone during the transfer. R2 didn't say anything until R2 was on the floor, then complained of right leg pain. I did the same thing (transfer) with R2 the prior week with no problems. The nurse assessed R2 while on the floor. It happened around 6:00 PM. On 7/6/18 at 1:10 PM, V14 RN (Registered Nurse) stated, Someone called for help, the ADON (Assistant Director Of Nursing) was already there. R2 was on the floor, vitals were normal, R2 complained of pain and being cold. We put a blanket on R2. We brought R2 back to the bed. I called the doctor, who ordered a STAT x-ray. I gave R2 Tylenol. I believe it was V16 RN who I endorsed it to. I was leaving around 8:00 PM. I still don't understand how it happened. On 7/6/18 at 2:15 PM, V16 RN stated that the x-ray technician came around 12:00 AM. R2 was calm, said the leg hurt. I gave Tylenol. When I got the x-ray results I called the doctor (V13) and the doctor ordered R2 be sent out to the hospital. The radiology report for R2 dated 4/28/18 documents; Right knee, Acute distal femur osteoporotic fracture. On 7/3/18 at 12:45 PM, V2 DON (Director of Nursing) stated, Concerning ADL (Activities of Daily Living) assessments, if the resident is in PT (Physical Therapy) they do the ADL assessment, if not in therapy, the nurses do it. They do a judgement call for the assessment. The CNA (Certified Nursing Assistant) involved was from an agency. I assumed she was trained on a sit to stand device by the agency. I have spoken with her and she seemed to understand. I have not trained her here and have not seen a demonstration using the sit to stand with her. After this incident with R2 we changed our policy and procedure to a two person assist with the sit to stand. On 7/5/18 at 11:30 via telephone V10 Agency Representative stated, V6 met her competency requirements for fall prevention. V6 was not trained here (Agency) on the sit to stand device, only a mechanical lift. On 7/6/18 at 9:20 AM V9 PTA Physical Therapy Assistant stated that for the sit to stand, we would use the Standing Static Goal Status. For R2 the progress summary states R2 could stand one minute. This is R2's last therapy treatment, R2 met most of her/his goals and was discharged (from PT) on 3/15/18. The PT Therapist Progress and Discharge Summary dated 3/15/18 for R2 documents; End of Goal Status as of 3/15/18 Goal Met on 3/16/18 able to maintain balance with handheld support and constant contact guard assist for less than 1 minute. On 7/6/18 at 12:30 PM via telephone V15 MD (Medical Doctor) Hospitalist stated, R2's death was caused indirectly from the femur fracture. I took care of R2 toward the end, R2 was in hospice and I am the physician on record for R2's death certificate. After R2's surgery for [REDACTED]. We got R2 off the ventilator, but at some point, R2 got a liver injury (shocked liver), R2's electrolytes were hard to control and R2 also suffered a kidney injury. I'm not sure how these conditions occurred. R2 had a very complicated course after the femur repair surgery. R2's Care Plan dated 2/19/18 documents; ADL Function/Rehab Potential. I require limited care for my bathing, grooming, dressing, mobility and set up for meals. I need extensive assist for transfers. A. I need 2 staff assist with the sit to stand device for transfers. The MDS dated [DATE] Section G documents Transfers; total dependence full staff performance every time during entire 7 day period. Two plus persons physical assist.

Based on observation, interview, and record , the facility failed to properly use a gait belt and supervise a resident while assisting with ambulation to prevent a fall for one of four residents (R4) reviewed for falls, in a sample of four. This failure resulted in R4 sustaining an acute non-displaced intertrochanteric fracture. Findings Include: Facility's incident report dated 11/4/14 at 11:00am documented, R4 was in the therapy gym. R4 was exiting the private treatment room with her walker with a gait belt on and the therapist(E9), providing stand by assistance (SBA). R4 fell backward while ambulating. The record further indicate R4 fell on to her left hip, and hit her head on the door. R4 reported pain of 10/10 pain scale while standing, and 3/10 while sitting in the wheelchair per this incident report. The therapist was not in contact with the gait belt when R4 was ambulating. At 11:05am on 11/12/14 E7 (Licensed Physical Therapist) states, "The physical therapist, and assistants should use a gait belt with all transfers, and ambulation. Their hands should be on the gait belt at all times when the resident is standing. When a therapist is holding the gait belt their hand should be around the belt and closed firmly." At 9:14am on 11/12/14 E9 (Physical Therapy Assistant)states,"I (E9) was walking out of the private treatment room with R4, she (R4) was using her rollator walker, and she had a gait belt on. I (E9) was giving R4 stand by assistance, meaning I was standing close by her (R4). R4 turned to say hello to E6, and she loss her balance falling backwards. She (R4) tried to grab the walker. I(E9) was along side of her, it was a chair in her path that I tried to push it out of the way prior to the fall with one hand. My left hand was back toward R4 near the gait belt. When she went backwards we (E6 and E9) tried to reach for her (R4) and I (E9) was only able to grab enough of the belt to keep R4 from hitting her head on the floor because she had hit her leg pretty hard on the floor. I (E9) feel like maybe we could have used the regular walker with two wheels, it may have slowed her down." Facility incident reports, and care plan indicate that R4 had a fall on 10/23/14 and sustained an open area to the occipital region of her head with bleeding. R4's MDS(Minimum Data Set) functional status indicate that R4 required limited assistance of one staff with transfers, and ambulation's. Fall assessment for R4 dated 9/10, 10/23, and 11/4/14 indicate R4 has transfer difficulties, unsteady gait, and uses an assistive device (wheelchair). At 9:45am on 11/12/14 Z2(Nurse Practitioner) states, "R4 was here because of a fall she had earlier this year in her apartment. She had a pubic bone fracture and a pelvic hematoma. She was here to get rehabilitation and get stronger. I believe her baseline was walking with a walker in her apartment. I required that R4 had assistance with ambulation. I can't recall anything acute going on with R4. She was making good progress. I can't comment on therapy because I wasn't there. The facility should have their protocols in place to maintain patient safety." On 11/13/14 at 12:00pm Z1(Attending Physician) states, I saw R4 in the morning on the day of the fall. She was doing good in therapy and was due to go home soon. I heard about the fall from my NP(Nurse Practitioner), that her X-ray was positive for a fracture. I sent her out to the hospital after I got the results. She had no neurological concerns or health conditions that contributed to the fall. She had two falls in the past and that's why she was in therapy to work on preventive measures for falls. She should have had assistance with ambulation because of the prior falls. Her injury at this time is a result of the trauma from falling." Facility policy dated 10/7/2011 indicate a gait belt is mandatory for all residents handling with the exception of bed mobility and medical contraindications. R4 didn't have any documented contraindications of gait belts being used. E9 verbalized that she had tried to grab R4's gait belt indicating she didn't maintain hand contact with R4's gait belt.