Every finding on record at Casey Rehab and Nursing

Failures at this level required more than one deficient practice statement.A. Based on observation, interview and record review the facility failed to supervise a resident during a shower for one of three residents (R1) reviewed for falls in the sample of three residents. This failure resulted in R1 falling from the wheelchair during a shower when staff turned away from R1 and R1 suffering from a left pelvic fracture. This past noncompliance occurred from 5/29/26-6/1/26.B. Based on interview and record review the facility failed to supervise a resident during meal time for one of three residents (R2) reviewed for falls on the sample list of three residents. This failure resulted in R2 falling when R2 was left unsupervised in the dining room and suffering a left posterior scalp laceration requiring three staples. This past noncompliance occurred from 6/5/26-6/6/26.Failures at this level required more than one deficient practice statement.A. Based on observation, interview and record review the facility failed to supervise a resident during a shower for one of three residents (R1) reviewed for falls in the sample of three residents. This failure resulted in R1 falling from the wheelchair during a shower when staff turned away from R1 and R1 suffering from a left pelvic fracture. This past noncompliance occurred from 5/29/26-6/1/26. B. Based on interview and record review the facility failed to supervise a resident during meal time for one of three residents (R2) reviewed for falls on the sample list of three residents. This failure resulted in R2 falling when R2 was left unsupervised in the dining room and suffering a left posterior scalp laceration requiring three staples. This past noncompliance occurred from 6/5/26-6/6/26.Findings include: A. R1's Electronic Medical Record (EMR) documents medical diagnoses as Acute Left Pelvic fracture, Osteoarthritis of Knee, Presence of artificial eye, Disorders of bone density and structure, Alzheimer's Disease, History of Lumbosacral Spine and Pelvic fracture, Dementia and Malaise.R1's Fall Risk assessment dated [DATE] documents R1 as a moderate fall risk.R1's Minimum Data Set (MDS) dated [DATE] documents R1 as severely cognitively impaired. This same MDS documents R1 is dependent on staff for total assistance with eating, oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility and transfers.R1's fall care plan intervention dated 4/21/26 documents R1 does not understand mobility limits due to cognitive limitations. This same intervention documents R1 will try to get up from bed/chair unassisted.R1's Nurse Progress Note dated 5/29/26 at 3:41 PM documents R1 slid out of the shower chair with V4 CNA (Certified Nurse Aide) present. This same note documents, (R1) was soapy and slipped out of the chair onto her left side on the floor, bumped forehead and left wrist on the wall. R1's fall investigation dated 5/29/26 documents R1 slid out of a facility shower chair with V4 Certified Nurse Aide (CNA) present. This same report documents R1 was soapy and slipped out of the shower chair. This same report documents the root cause for R1's fall was due to R1was leaning forward and slid out of the shower chair. R1's Final report to the State Agency date 6/4/26 documents R1 sustained a fall in the facility which resulted in R1's left pelvic fracture. On 7/21/26 at 11:00 AM the facility reclining shower chair was being used by staff for another resident. On 7/21/26 at 11:05 AM V4 Certified Nurse Aide (CNA) stated V4 transferred R1 by herself from her wheelchair to a facility shower chair on 5/29/26. V4 stated V4 had R1 very soapy when V4 turned her back to get a washcloth to cover R1's eyes before rinsing the soap off R1. V4 CNA stated that is when R1 leaned forward and fell out of her shower chair. V4 CNA stated R1 landed on her left side on the shower room floor, still in the shower stall. V4 CNA stated R1 leans forward in her wheelchair frequently. V4 CNA stated R1 should have been placed in the facility reclining shower chair but did not realize the facility had a shower chair that reclined. V4 CNA stated she should not have turned her back on R1 knowing that R1 was very soapy and leans forward on her own frequently. V4 CNA stated R1 has Alzheimer's Disease and cannot make safety decisions on her own. On 7/21/26 at 12:30 PM V3 Assistant Director of Nurses (ADON)/Licensed Practical Nurse (LPN)/fall nurse stated V3 was the first nurse to assess R1 after falling on 5/29/26. V3 LPN stated R1 was lying on her left side on the shower room floor still in the shower stall. V3 LPN stated V4 CNA was showering R1 when V4 CNA applied soap, then turned her back on R1 and R1 fell out of her shower chair. On 7/21/26 at 2:45 PM V1 Administrator stated V4 CNA should not have turned her back on R1 when showering R1. V1 Administrator stated the staff are encouraged to use all the tools needed to ensure every resident is safe. V1 stated V4 CNA should have used better judgement when caring for a severely cognitively impaired resident. V1 Administrator stated the staff have been in serviced on resident safety and the facility fall policy. V1 Administrator confirmed the facility caused R1's Left Pelvic fracture by placing R1 at risk for falling when V4 CNA turned around not monitoring R1. Prior to the date of the survey, the facility took the following actions to correct the noncompliance.Effective June 1, 2026, [NAME] Rehab and Nursing implemented the following corrective measures:1. A new fall intervention was implemented on 6/1/26, requiring use of a tilted shower chair during the resident's shower.2. Staff education was completed on 6/1/26, regarding the facility's Fall Reduction Policy and the newly implemented intervention requiring use of the tilted shower chair.3. Audits were initiated on 6/1/26, to monitor compliance with the use of the tilt shower chair.4. The facility incorporated the identified root cause and corrective intervention into its ongoing fall prevention and monitoring processes.5. A quality improvement action plan was initiated on 6/1/26 and the fall will be discussed in the next scheduled QAPI meeting on 7/28/26.B. R2's Electronic Medical Record (EMR) documents medical diagnoses as Acute Left Posterior Scalp Laceration, Vascular Dementia, Atrial Fibrillation, Neurocognitive Disorder, Vitamin B12 Deficiency, Psychotic Disorder with Delusions, Anxiety, Gastro-Esophageal Reflux Disease (GERD), Encephalopathy and Dementia.R2's Fall Risk assessment dated [DATE] documents R2 as a fall risk.R2's Minimum Data Set (MDS) dated [DATE] documents R2 as severely cognitively impaired. R2 as being dependent on staff for oral hygiene, dressing, toileting, bathing, personal hygiene, bed mobility and transfers.R2's Fall Care Plan intervention dated 6/17/25 instructs staff to anticipate R2's needs. A fall intervention dated 11/4/25 for R2 to eat with only supervision. The Care Plan documents a fall intervention dated 12/8/25 for staff to be educated on resident supervision needs while up in wheelchair. An intervention dated 4/4/25 for staff to toilet R2 every hour. R2's Nurse Progress Note dated 6/5/26 at 6:04 PM documents R2 had an unwitnessed fall in the dining room. R1 obtained a laceration to the back of her scalp and was sent to the emergency room.R2's Nurse Progress Note dated 6/8/26 at 8:47 AM documents the facility Interdisciplinary Team (IDT) reviewed R2's fall from 6/5/26. The root cause of R2's fall was determined to be R2 standing out of wheelchair without assistance.R2's Hospital Record dated 6/5/26 documents R2 presented to the emergency room after having an unwitnessed fall at the facility. R2 obtained a one centimeter (cm) laceration to her posterior skull from her fall which required three staples to be placed. R2 was attempting to get up out of her wheelchair unassisted, which caused the fall. R2 was diagnosed with Fall and Closed Head Injury. R2's Computerized Tomography (CT) of her brain/head without contrast result dated 6/5/26 documents R2 had soft tissue swelling on her Left posterior scalp.R2's fall investigation dated 6/5/26 documents R2 was sitting in her wheelchair in the dining room. R2 stood independently from her wheelchair resulting in a fall. R2 obtained three staples to her posterior skull as a result from the fall. R2's Final report to the State Agency dated 6/12/26 documents R2 sustained a fall that resulted in a laceration to the back of her head. This same report documents on 6/5/26 R2 stood from her wheelchair in the dining room, unassisted, lost balance and fell to the floor. Staff were in the day room adjacent to the dining room at the time of the fall. Dietary staff alerted V8 Registered Nurse (RN) of R2's fall. On 7/22/26 at 8:50 AM V10 Unit Aide stated R2 is known to fall a lot. V10 stated she works with the Certified Nurse Aides (CNA) to assist residents. V10 stated R2 should not be left alone due to R2 is a high fall risk.On 7/22/26 at 8:55 AM V11 Certified Nurse Aide (CNA) stated R2 is on fifteen minute checks due to R2 is a high fall risk. V11 CNA stated R2 is supposed to be supervised in the dining room. V11 CNA stated there is supposed to be one CNA in the main dining room at all times during meals. V11 CNA stated R2 may not have fallen if she was monitored more closely. On 7/22/26 at 9:00 AM V9 Licensed Practical Nurse (LPN) stated fall interventions can be found in the resident care plan. V9 stated R2 is considered high risk for falling. V9 LPN stated R2 routinely crawls out of bed, uses her bed remote and generally tries to do things she shouldn't. V9 LPN stated R2 will stand unassisted out of her wheelchair. V9 LPN stated staff should stay in the dining room until all residents are cleared and finished eating their meals. On 7/22/26 at 10:40 AM V8 Registered Nurse (RN) stated on 6/5/26 V13 [NAME] notified V8 RN of R2 falling in the main dining room. V8 RN stated she was positioned in the adjacent living room but did not have visual of R2 in the dining room. V8 RN stated she was the closest staff to R2. V8 RN stated R2 was lying on her side with blood noted to the back of R2's head. V8 RN stated R2's wheelchair seat was in a lower position but not tilted. V8 RN stated R2 had anti-tippers on her wheelchair. V8 RN stated it appeared that R2 had stood up from her wheelchair and fallen. V8 RN stated R2's wheelchair could not have been locked due to R2's anti-tippers would have prevented R2 from pushing her wheelchair back from the table which is where it was found. V8 RN stated the facility was having an event that night which caused a lot of chaos and that is the reason why V8 RN could not position her medication cart in the normal location to be able to visualize all the residents in the dining room. V8 RN stated there were no other staff in the dining room at the time R2 fell. On 7/22/26 at 11:35 AM V13 [NAME] stated she remembers finding R2 on the dining room floor on 6/5/26 vividly. V13 [NAME] stated she had passed through the dining room to the resident community living room to deliver ice cream toppings for an evening social event. V13 [NAME] stated when she passed through the dining room R2 was sitting in her wheelchair with her right wheel locked and her left wheel unlocked and R2 was sitting in her wheelchair up against the dining room table. V13 [NAME] stated V13 returned to the facility kitchen and saw R2 laying on the dining room floor with blood on the back of R2's head. V13 [NAME] stated she yelled for help and V8 Registered Nurse (RN) came into the dining room from the resident community living room to assess R2. V13 [NAME] stated R2 had been sitting in the same spot since before supper was served at 5:00 PM. V13 [NAME] stated R2 may have been sitting there longer but she knows for sure that R2 had been sitting in the same spot from 5:00 PM until R2 fell. V13 [NAME] stated she texted her supervisor (V12) Dietary Manager to inform V12 of R2's fall at 6:31 PM which was immediately after R2 fell. On 7/22/26 at 12:00 PM V2 Director of Nurses (DON) stated staff should supervise all residents during mealtimes. V2 DON stated R2's fall resulting in a left posterior scalp laceration and staples could have been prevented if staff were monitoring R2. V2 DON stated R2 is known for pushing herself back from the dining room table and is known for rocking back and forth in her wheelchair. V2 DON stated R2 was known for standing up unattended prior to R2's fall on 6/5/26. On 7/22/26 at 12:05 PM V1 Administrator stated the facility does not have a policy on monitoring the dining room due to this is a common area. V1 stated residents should be monitored during mealtime.The facility policy titled Fall Reduction Policy revised January 4, 2026 documents the facility will provide an environment that remains as free of accident hazards as possible. The facility will provide supervision and assistive devices to prevent or minimize fall related injuries. Prior to the date of the survey, the facility took the following actions to correct the noncompliance.1. On 6/6/26 a pommel cushion was placed in R2's wheelchair to ensure proper positioning.2. R2's Care Plan was updated on 6/6/2026 to include R2's new pommel cushion for positioning.3. On 6/6/2026 staff were in-serviced on the use/placement of R2's pommel cushion.4. On 6/6/2026 an audit was initiated to ensure R2's pommel cushion was being utilized by staff. This audit is ongoing.5. On 6/8/26 the Quality Assurance team discussed R2's fall on 6/8/26 during the weekday Quality Assurance meeting. The next quarterly Quality Assurance Performance Improvement (QAPI) meeting is scheduled for 7/28/26. V1 Administrator stated both R1 and R2's falls will be discussed in the quarterly QAPI meeting on 7/28/26. These meetings are ongoing.

Based on interview and record review the facility failed to provide necessary supervision of a safe transfer with the mechanical lift and to implement accident prevention interventions for one resident (R1) of four residents reviewed for Accidents in a sample list of four residents. This failure resulted in R1 sustaining a Nondisplaced Oblique Ankle Fracture requiring a visit to the local hospital emergency room. This past compliance occurred from 4/6/26 to 4/12/26.Findings include:Minimum Data Set (MDS) dated [DATE] documents R1 is severely cognitively impaired.R1's Care Plan dated 2/9/26 documents R1's Activities of Daily Living (ADL): Self-care deficit-needs assist to complete quality care and/or poorly motivated to complete ADLs. R1 has Dementia and that interferes with R1's ability to care for self and R1's quality of care. R1 is dependent on staff with all ADL's and meals. R1 transfers using a total body mechanical lift with two staff assist. Staff should explain all procedures prior to starting, advise R1 what is expected of R1 during the transfer, and reassure R1 of safety as needed. R1 is dependent on staff for transfers, ADL's, eating, dressing, and bed mobility. R1's Nursing Progress Note dated 4/5/2026 at 6:00 AM, documents, Night shift nurse notified this nurse that resident had bumped Left great toenail on mechanical lift during transfer, slight bleeding noted. R1's Nursing Progress Note dated 4/6/2026 at 8:44 AM, documents, (R1's) Left ankle swollen and purplish in color, painful to touch. Left knee is a little swollen R1's Nursing Progress Note dated 4/6/2026 at 6:53 PM, documents, (R1) sent to the local ER (emergency room) by ambulance. R1's Nursing Progress Note dated 4/6/2026 at 11:43 PM, documents, (R1) returned to facility via ambulance with soft splint in place to left lower extremity. R1's Xray dated 4/6/26 documents the impression determined an Acute Nondisplaced Oblique Fracture in the Medial Malleolus of R1's left ankle. The Incident Summary dated 4/12/26 documents after review of statements and interviews with reenactment with staff, the injuries observed are consistent with bumping R1's foot/ankle on the mechanical lift bar during transfer. On 6/10/26 at 9:55 AM, V1 Administrator stated nobody knows what happened. V1 Administrator stated staff saw blood on R1's toe and noticed some swelling in R1's foot. V1 Administrator stated the Doctor was notified and had an Xray ordered due to the swelling. V1 Administrator stated they assumed the injury occurred by the total body mechanical lift because the blood on R1's toe and swelling in R1's left foot/ankle matched up as the possible source.On 6/10/26 at 11:26 AM, V3 Assistant Director of Nursing (ADON) stated V3 ADON came in on day shift that day to work the floor and staff told V3 ADON to look at R1's toe. V3 ADON stated after investigating it, it was determined that someone probably had bumped R1's toe on the total body mechanical lift during a transfer, but nobody witnessed it. V3 ADON stated it was later in the day that the swelling was noticed in R1's left foot.On 6/10/26 at 1:08 PM, V8 Licensed Practical Nurse (LPN) stated V11 Certified Nursing Assistant (CNA) told V8 LPN, R1's toe was bleeding when V8 LPN came in that morning. V8 LPN stated it was later when they were giving R1 a bed bath was when they noticed swelling in R1's left foot and knee and reported to V8 LPN. V8 LPN stated V8 LPN assumes it happened when they got R1 up that morning but doesn't know for sure.On 6/23/26 at 11:09 AM, V10 Registered Nurse (RN) stated one of the CNA's told V10 RN there was blood on the bed. V10 RN went and assessed R1. V10 RN stated R1's toe looked like a skinned area and V10 RN cleaned it. V10 RN stated V10 RN thinks it happened on evenings but doesn't know because V10 RN was told five to ten minutes before the end of V10's shift.On 6/23/26 at 11:13 AM, V2 Director of Nursing (DON) stated the incident of bumping R1's left foot on the mechanical lift was the best guess but nobody witnessed it.On 6/24/26 at 8:41 AM, V9 Medical Doctor (MD) stated it is a possibility that the injury occurred by bumping R1's foot on the mechanical lift during transfer.On 6/24/26 at 9:52 AM, V11 Certified Nursing Assistant (CNA) stated V11 CNA didn't witness the incident, but V11 CNA told V8 RN that R1's ankle was swollen and had bruising.Review of using a Mechanical Lift use Policy and Procedure dated 1/15/26 documents the purpose is to help lift residents who are too heavy to lift manually, to promote comfort, and maintain good body alignment while the resident is being moved. The Procedure includes assisting the resident in guiding his/her legs while using the mechanical lift to transfer.Prior to the day of the survey on the day of 6/24/26, the facility took the following actions to correct the noncompliance:On 4/6/26 foam padding was placed on the mechanical lift bar and continued through present day per V1 Administrator.R1's care plan dated 4/7/26 documents to guide R1's feet during use of the total body mechanical lift.All staff were in-serviced on the total body mechanical lift transfer/safety by 4/10/26 according to V2 DON.Comprehensive audits started on 4/7/26 and continued through present day by V1 Administrator.R1 was moved to a new room.The facility presented an acceptable Plan of Correction on 4/10/26. This Plan of Correction was validated by observation, interview, and record review of steps taken by the facility to implement their Plan of Correction.

Based on interview and record review, facility staff (V3 and V5, Certified Nursing Assistants, and V6 Registered Nurse) failed to report allegations of observed and known potential abuse in the required immediate, not more than 24 hour, time frame. This failure has the potential to affect three residents (R2, R3, and R4) out of twelve reviewed for abuse on the sample list of thirteen.Findings include:1. The facility Investigation Report with an initial date of 11/10/25 documents an allegation of V4, Certified Nursing Assistant, hitting R2 with a positioning cushion and stating, I hate you, which was allegedly witnessed by V3, Certified Nursing Assistant. This report documented an investigation detail that the alleged event occurred on 10/27/25. R2 was not interviewable due to severe cognitive impairments. On 1/6/26 at 2:16 PM, V4 stated the alleged incident did not happen. V4 denied having any personal problems with V3. On 1/6/26 at 3:40 PM, V1, Administrator, stated this alleged incident occurred on 10/27/25 according to the staff schedules when V3 and V4 had worked together. V1 confirmed V3 was a new employee at that time and had participated in the new employee training about abuse reporting prior to working any shifts at the facility. On 1/8/26 at 9:55 AM, V3 stated she had witnessed the incident as alleged on 10/27/25 but had not reported the incident until about a week later. V3 stated she was concerned being a new employee and didn't want to experience any backlash from other employees for reporting. V3 denied having any personal problems with V4. On 1/8/26 at 12:49 PM, V2, Director of Nursing, stated V3 did report the allegation to herself in the presence of V13, Business Office Manager, on 11/10/25. V2 confirmed the staffing schedules determined the alleged incident had to have occurred on 10/27/25. V2 stated there had been a previous situation between V3 and V4 when each of the employees felt like the other one was not helping during provisions of resident care and V2 had to implement a verbal intervention about working together as a team. V3's Training Acknowledgement Form dated and signed by V3 on 10/17/25 documents it is the team member responsibility to report immediately to your supervisor any signs of abuse or neglect. This form further documents alleged violations involving mistreatment, neglect or abuse, including injuries of unknown origin, and misappropriation of resident property are to be reported to the facility administrator. This form further documents the employee must report any occurrences of mistreatment observed, heard about, or suspected, no matter what the situation or perpetrator, immediately. 2. The facility Investigation Report with an initial date of 12/1/25 documents an allegation of a resident to resident verbal altercation occurred on 11/29/25 between R3 and R4 wherein R3 threatened to beat R4. On 1/7/26 at 11:25 AM, R3 and R4 stated they get along fine, but confirmed each other that they had arguments in the past because both of them are straight honest and tell it like it is. On 1/6/26 at 3:40 PM, V1, Administrator, stated there had been two staff witnesses to the altercation between R3 and R4, but neither of them had reported the incident to V1. V1 stated the two staff members were V5, Certified Nursing Assistant, and V6, Registered Nurse, a former employee. V1 stated she had learned of the incident because V6 had made a progress note in the electronic medical record system which was dated 11/29/25 (Saturday). V1 stated she learned of the altercation on Monday morning 12/1/25 when she read the reports in the electronic medical record system. V1 confirmed neither of the witnessing employees had called her to report the altercation and she had spoken to V5 during the investigation. On 1/8/26 at 10:25 AM, V5 stated she had witnessed a verbal altercation between R3 and R4 when R3 threatened to beat R4 and had separated the two residents. V5 stated she reported the altercation to the nurse on duty (V6), albeit the facility investigation report documented V5 stated she had not reported it because V6 was present during the altercation. V5 stated she had not reported the altercation to the administrator but did talk to the administrator on 12/2/25 and then stated 12/2/25 was the same date as the altercation. On 1/8/26 at 12:49 PM, V2, Director of Nursing, stated she had been the on-call manager for the weekend of 11/29 and 11/30/25, and neither V5 nor V6 had called her to report the altercation between R3 and R4. V2 stated she had learned of the altercation on Monday morning 12/1/25 at the same time as V1 by reading the reports in the electronic medical record system. V2 stated V6 had signed a statement documenting V6 had received the abuse prevention training about reporting according to facility policy. V6 was not available for an interview. V5's Training Acknowledgement Form dated and signed by V5 on 9/5/25 documents it is the team member responsibility to report immediately to your supervisor any signs of abuse or neglect. This form further documents alleged violations involving mistreatment, neglect or abuse, including injuries of unknown origin, and misappropriation of resident property are to be reported to the facility administrator. This form further documents the employee must report any occurrences of mistreatment observed, heard about, or suspected, no matter what the situation or perpetrator, immediately. The facility abuse prevention policy dated 10/16/23 documents the facility will ensure all associates are properly trained according to the training policies and will ensure all allegations or suspicions of abuse will be reported in the proper timeframe.

Based on interview and record review the facility failed to provide adequate pain control for one (R2) of three residents reviewed for pain on the sample list of seven.Findings Include: R2's Physician Order Sheet (POS) dated August 2025 documents R2 was admitted to the facility on [DATE]. R2 is diagnosed with Type II Diabetes Mellitus with Diabetic Polyneuropathy and Muscle Weakness among other medical diagnoses. R2's POS documents a physician order on 7/4/25 for Acetaminophen tablets 650 milligrams by mouth every six hours as needed for mild pain. If more than three doses given in 48 hours- staff are to notify the physician or advanced practice provider. R2's POS documents a physician order on 7/14/25 for Tramadol 50 milligrams by mouth as needed for pain. R2's Medication Administration Record (MAR) dated July 2025 documents R2 received more than three doses of Acetaminophen in 48 hours' time on 7/7/25, 7/8/25, 7/9/25, 7/10/25, 7/11/25, and 7/12/25. There is no documentation that a physician or advanced practice provider were notified of R2's frequent use of the as needed Acetaminophen. The MAR documents R2 rated her pain at an eight or higher for eleven of the fourteen Acetaminophen doses administered from 7/7/25 to 7/12/25. R2's Progress Note dated 7/11/25 at 8:40 PM documents R2 complained of right shoulder pain and V2 Director of Nurses requested a more effective pain medication and was waiting on response from the advance practice nurse. R2's Progress Note dated 7/12/25 at 2:57 AM documents V15 Medical Director was notified of R2's increased pain and request for better pain control. V15 ordered Tramadol 50 milligrams every eight hours as needed for pain. However, V15 could not send the new script to the pharmacy because V15 was not in his office. On 8/13/25 at 3:05 PM V2 Director of Nurses confirmed R2 often complained of pain during her stay in the facility. V2 confirmed R2 was given Acetaminophen more than three times in 48 hours on multiple occasions throughout her stay. V2 confirmed nursing should have notified a physician concerning the continued use of acetaminophen per the order. V2 confirmed on the evening of 7/11/25 R2's pain was unbearable for her, and she requested a stronger pain medication than Acetaminophen. R2 stated she reached out the to the Nurse Practitioner on-call however did not hear back so the nurse on duty overnight (V9 Registered Nurse) reached out to V15 Medical Director (MD) for a different pain medication order. V2 stated V15 ordered Tramadol however could not send the new script to the pharmacy so the nurses could not get the medication out of the medication dispensing machine. V2 confirmed R2 was not able to receive the new Tramadol medication until 7/12/25 at 3:16 PM. V2 stated R2 was tearful and uncomfortable throughout the night. V2 stated staff repositioned her and tried to keep her as comfortable as possible but there was a delay in getting her the pain medication that should not have happened. V2 stated R2's pain did improve some with the administration of the Acetaminophen however she did still require an increase in pain relief (Tramadol) and should not have had to wait 18 hours for the medication to be available. V2 acknowledged a change in procedure is required to make sure medications are available when needed for residents even after hours or on weekends.

Based on observation, interview, and record review, the facility failed to provide appropriate services for a resident with a diagnosis of dementia for one resident (R7) of three residents reviewed for dementia services on a sample list of seven.Findings include: R7's Physician Orders Sheet (POS) dated August 2025, documents R7's diagnosis as: Dementia, mild, with agitation and anxiety disorder.R7's Wandering/Elopement Risk assessment dated [DATE], documents R7 is high risk for elopement.On 8/13/25 at approximately 10:30 AM, a personal alarm was sounding. V7 Certified Nursing Assistant (CNA) ran out the front door towards R7 who was seen walking towards the parking lot. V7 CNA assisted R7 back into the building to the Business Office with V12 Business Office Manager (BOM). On 8/13/25 at approximately 12:10 PM, a personal alarm was sounding. V2 Director of Nursing (DON) ran out the front door towards R7 who was seen walking towards the parking lot. V2 DON assisted R7 back into the building. On 8/13/25 at 12:14 PM, V2 DON stated R7 is very agitated today. V2 stated R7 worries about going to the bank, worried about R7's jeweler, and paying R7's bills. V2 stated R7 is progressively declining. V2 stated staff should be doing 15-minute checks on R7 and making sure R7's needs are being met. V2 stated V12 BOM has not had dementia training and may not know what to do with/for R7. V2 stated dementia training should be completed immediately after starting (working). On 8/13/25 at 12:57 PM, V1 Administrator stated R7 was put on 1:1 with staff after the last time R7 tried to escape. V1 stated just in the last two to three days R7 has been going to the door. V1 stated R7 does have an alarm bracelet on, R7 was given a calendar to show when rent is due, and staff has been letting R7 go out into the courtyard. V1 stated dementia training should be done with onboarding and before starting work at the facility. On 8/13/25 at 1:18 PM, V7 CNA stated V7 took R7 to the business office because R7 always wonders about paying R7's rent. V7 stated R7 does exit seek because R7 is always wants to go to the bank and wondering about rent. On 8/13/25 at 1:45 PM, V2 DON stated R7 was exit seeking a few weeks ago but it has been more frequent this week, so we are moving R7 to the south hall (locked unit). V2 also stated the nurses should be documenting the follow up from R7 getting out of the facility and what interventions were used.R7's Nursing Progress Notes written by V5 LPN, dated 8/8/25 at 1:26 PM, documents exit seeking x 2, continues to think he needs to go to the bank to make arrangements to pay the rent, re-education unsuccessful due to cognition. R7's Nursing Progress Notes written by V5 LPN, dated 8/11/25 at 1:46 PM, documents exit seeking x 3 out the front door, staff had to assist back inside.On 8/13/25 at 1:52 PM, V5 Licensed Practical Nurse (LPN) stated V5 continued to remind R7 his bank account is not here, and someone takes care of R7's business. V5 stated the only other options we have are to follow R7 around or walk with R7 and keep trying to explain this to him to help R7 remember, keep repeating things to him. V5 stated this man (R7) goes out the door about every day and it has been going on for the last week and a half on a daily basis. On 8/13/25 at 2:55 PM, V6 Registered Nurse (RN) stated she does not know where the elopement logbook is and can't say V6 was ever showed that.On 8/13/25 at 3:00 PM, V14 RN, stated V14 is still kind of new so V14 is not sure where the elopement logbook is.The facility's Wandering and Elopement Assessment and Prevention Policy dated Revised 6/4/24, documents all residents shall be assessed for risk of elopement/unsafe wandering, to ensure their safety and prevention from elopement. This same policy documents all departments shall be made aware of the elopement log and the location. This policy also documents the facility uses a multi-faceted approach to prevent elopement including staff education regarding understanding wandering, responsibility to identify, report, and intervene for wandering/elopement risk for residents.

Based on observation, interview, and record review the facility failed to ensure fall interventions were implemented for one (R2) of three residents reviewed for accidents on a sample list of three residents. Findings Include: R2's undated care plan documents R2's medical diagnoses include dementia with agitation, delusional disorders, essential hypertension, spinal stenosis, lumbar region without neurogenic claudication, vitamin B12 deficiency anemia, anxiety disorder, other malaise, urinary tract infection, depression, and psychotic disturbance. R2's undated Care Plan includes fall interventions actively in place as Call Don't Fall sign visible in room, toilet every hour, non-slip strips in front of toilet, scoop mattress, non-slip strips next to bed, non-slip material to recliner and wheelchair seat, 15-minute wellness checks, therapy to screen for services, non-slip strips in front of recliner, Certified Nursing Aide (CNA) to assist to bed at 9:00 pm, and move R2's room closer to nurse station. R2's Visual Bedside Kardex, undated, documents R2 is to have non-skid socks or appropriate footwear at all times, 15-minute safety checks, offer bathroom assistance every hour, maximum assistance with bed mobility and transfers, and all laboratory results to be monitored per physician order. R2's Minimum Data Set (MDS) dated [DATE] documents moderate cognitive impairment with hallucinations, delusions, impaired decision making, sundowning behaviors, non-compliance, and short-term memory loss. The MDS also documents R2 frequently refuses cares and has wandering behaviors. Section GG documents toileting activity requires substantial/maximum assist and R2 has frequent incontinence. R2's individual fall log, undated, documents R2 sustained falls on 3/2/25, 3/20/25, 3/22/25, 3/27/25, 4/6/25, 5/5/25, 5/15/25, 5/18/25, and 5/24/25. R2's Nurse Progress Notes document on 5/5/25 R2 was found on the floor in front of the recliner and R2 stated the recliner threw her out. On 5/6/25 R2's Care Plan, undated, documents the new intervention to add non-slip strips in front of the recliner. R2's May 2025 Progress Notes document on 5/14/25 staff reported R2 had two plus pitting edema to R2's bilateral lower extremities and 11 hours later at 12:30am on 5/15/25, R2 was found in front of the recliner on the floor in R2's room with R2 stating she was trying to go brush her teeth and use toilet. The Progress Notes document the nurse practitioner was notified and the new intervention to have Certified Nursing Assistant (CNA) assist R2 to bed at 9:00pm every night. R2's Nursing Progress Notes dated 5/18/25 document R2 was screaming for help and was found on the floor next to the bedside table in front of the recliner in R2's room with R2 stating she was trying to go use toilet. On 5/20/25 R2's Care Plan, undated, documents the new intervention to move R2 closer to nurse's station. R2's Nurse Practitioner Visit Note dated 5/19/25 documents R2 had a recent unwitnessed fall and documents a diagnosis of hyponatremia and new order for a blood test on 5/22/25. R2's Physician Order Sheet (POS) dated 5/28/25 documents an order for a blood Basic Metabolic Panel (BMP) on 5/22/25. R2's Medication Administration Record for May 2025 documents the order for the BMP was not completed. R2's medical record does not document the CMP was completed or that the physician was notified. R2's medical record does not document hourly toileting. R2's Point of Care (POC)15-minute check log dated 5/15/25 - 5/28/25 does not document ordered safety checks every 15 minutes. On 5/28/25 between 11:00am and 12:00pm continuous observation of R2's room entrance and hallway were completed. At no time was staff observed entering R2's room to complete 15-minute safety checks. On 5/28/25 at 12:35 pm R2 was in the wheelchair in front of the recliner in the room with the bedside table on the left of R2. There was no Call Don't Fall sign in the room. R2's Recliner and wheelchair seat did not have non-slip material in the seat. Non-slip strips were not present on the bathroom floor and the toilet paper holder was broken and hanging off the wall. On 5/28/25 at 12:35 pm R2 stated she currently has no pain but does have episodes of pain stating, of course I have pain from falling all over these floors!' R2 stated she recalls falling in the bathroom a few days ago and confirmed breaking the toilet paper holder. R2 stated she needs to have shoes on all the time, so she doesn't fall. During conversation R2 was rolling the wheelchair back and forth with the brakes in the locked position. R2 demonstrated locking and unlocking the brakes and in both settings. R2 was able to move freely in the wheelchair. On 5/28/25 at 1:40 PM V2 Director of Nurses verified that 15-minute checks were not being accurately documented. V2 stated tomorrow on 5/29/25, R2 will be moved to the dementia unit for better observation of the resident. V2 stated she is unclear why there are no non-slip strips on the bathroom floor as she was sure they were there last Friday 5/23/25. V2 stated she's unsure why R2 doesn't have non-slip material in the wheelchair and recliner. Regarding the BMP blood test for R2, V2 stated the nurse checked off the test on the MAR on 5/21/25 as not obtained and therefore the test was not completed. V2 verified no follow up or provider notification of the missed blood test was completed. V2 agreed that R2's change of condition on 5/14/25 could have contributed to R2's early morning fall on 5/15/25 and that the order given by the nurse practitioner for blood testing was to diagnosis any new medical issues related to the change of condition. The facility policy titled Fall Reduction Prevention dated 10/30/24 documents the purpose is to provide an environment that remains as free of accident hazards as possible and to identify residents who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to prevent or minimize fall related injuries. The policy states all witnessed, unwitnessed and any near falls should be investigated. Resident should be evaluated for change in condition and provider notification should be completed. Current fall prevention interventions should be evaluated, and new interventions should be initiated.

Based on interview and record review the facility failed to timely initiate antibiotic treatment for a urinary tract infection for one of three (R3) residents reviewed for falls in the sample list of three. Findings include: R3's Nursing Note dated 3/31/2025 at 10:55 AM documents R3 continued post fall monitoring with increased weakness and lethargy noted. R3's urostomy was draining dark amber, slightly cloudy urine. V3 Nurse Practitioner was notified, and new orders received. R3's Physician Order dated 3/31/25 documents to obtain urinalysis and culture if indicated. R3's urinalysis and culture with print date 4/5/25 documents leukocyte esterase (white blood cell enzyme) 3+ (normal is negative), white blood cells 10-15 (normal is 0-5), and few bacteria, mucus and white blood cell clumps (all abnormal). These results document greater than 100,000 colony forming units per milliliter (cfu/ml) of mixed bacterial flora with multiple species present and recommends a repeat sample collection if indicated. R3's urinalysis and culture, with print date of 4/9/25, documents leukocytes esterase 4+, white blood cells 20-30, and moderate bacteria and white blood cell clumps. These results document greater than 100,000 cfu/ml of mixed bacterial flora with multiple species present. R3's Progress Note dated 4/10/25, recorded by V3, documents R3 was evaluated due to staff request for increased confusion and urine sent to lab. This note documents an order for Augmentin 500-125 milligrams (mg) by mouth twice daily for seven days for urinary tract infection. R3's Physician Orders dated 4/10/25 and 4/11/25 document to administer Augmentin 500-125 mg by mouth twice daily for seven days. R3's April 2025 Medication Administration Record documents Augmentin was not started until 4/12/25 at 8:00 AM. R3's Nursing Note dated 4/11/2025 at 8:55 PM documents R3's ordered antibiotic was not available in the facility's backup medication system, the pharmacy was notified and verified the medication would be sent to the facility. R3's nursing notes do not document V3 was notified of the delay in starting R3's antibiotic. The facility's Inventory on Hand (backup medication system) documents Augmentin is supplied in 875-125 mg tablets, and not in 500-125 mg tablets. On 5/28/25 at 11:16 AM V2 Director of Nursing stated R3's 4/9/25 urinalysis results were reported to V3 on 4/9/25 through (messaging software), and V3 saw R3 on 4/10/25 and ordered Augmentin. V2 stated the 500 mg dose was not supplied in the facility's backup medication system, so the medication was not started until 4/12/25 when the medication arrived from the pharmacy. V2 stated the facility has a backup pharmacy system, and staff should notify the facility's pharmacy who contacts a backup pharmacy to supply the medication. At 12:34 PM V2 stated physician notification is documented in the nursing notes, including when a medication is not given. On 5/28/25 at 12:09 PM V3 stated V3 rounded in the facility weekly on Thursdays and antibiotics should be implemented by the next morning, or that evening if the facility has the medication in the back up medication system. V3 stated the pharmacy should have delivered R3's Augmentin that night so that it could be started the next morning. V3 stated if the facility would have reported the medication dose was not available. V3 would have given additional orders and asked what dose the facility had on hand. The facility's undated pharmacy guide, titled What to Do If a Medication is Not Available during a Med Pass documents the following: Verify/review pharmacy deliveries. Check the backup medication system for the medication, remove dose, and administer to the resident. If the medication is not available, check to see if there is an alternative medication that can be given with a physician's order. If the medication is not located or unavailable in the backup supply, notify the pharmacy to request delivery from a backup pharmacy and verify the medication will be sent out on the next pharmacy delivery. Notify the provider that the medication was not available to administer as ordered/scheduled and request an order to hold the medication until delivery from pharmacy. These steps will avoid the need to document that medications are not available, will ensure residents receive medications timely, will avoid further potential delay in treatment.

Based on observation, interview and record review the facility failed to prevent cross contamination during wound care for one (R24) resident's left plantar heel open diabetic ulcer, failed to monitor R24's left heel diabetic ulcer and failed to follow physician orders for R24's left heel wound treatments for one of two residents (R24) reviewed for skin conditions in a sample list of 27 residents. R24 experienced the worsening of her left heel open wound due to dressing changes not being completed per physician order and not being provided timely incontinence care which led to R24's dressing to be fully saturated with wound drainage and urine which required antibiotics due to a Staphylococcus (Staph) infection. Findings include: R24's medical diagnosis list documents medical diagnoses of Acute Osteomyelitis of the Left Ankle, Diabetes Mellitus Type II with foot ulcer, Morbid Obesity and Polyneuropathy. R24's Minimum Data Set (MDS) dated [DATE] documents R24 as cognitively intact. This same MDS documents R24 requires maximum assistance for toileting and moderate assistance for personal hygiene. R24's Physician Order Sheet (POS) dated January 2025 documents a physician order starting 12/24/24 of left plantar heel: Cleanse with Normal Saline, apply nickel thick Santyl (chemical debriding agent) to wound bed. Cover with absorbent pad and secure with gauze roll daily and as needed if loose or soiled. R24's POS documents a physician order starting 1/3/25 and ending 1/13/25 for Amoxicillin 875 milligrams (mg) Give 875 mg by mouth two times a day related to non-pressure chronic ulcer of Left Heel and midfoot. R24's Skin Integrity care plan initiated 8/24/24 documents (apply) dressing to (R24's) Left Foot. Observe dressing every shift. Change dressing and record observations of site daily. R24's care plan intervention dated 4/3/24 instructs staff to provide incontinence care as needed. This same care plan documents an intervention dated 4/3/24 to monitor, document and report and signs and/or symptoms of infection. R24's Weekly Wound Log dated 12/24/24 documents R24's Left Plantar Heel Diabetic wound with Calcaneus bone exposed as initiating in facility on 7/24/24 as having slough and necrotic tissue with yellow, increased purulent drainage, foul odor and measuring 11.6 centimeters (cm) long by 5.0 cm wide by 0.8 cm deep. R24's Weekly Wound Log dated 12/31/24 documents R24's Left Plantar Heel Diabetic wound with Calcaneus bone exposed as initiating in facility on 7/24/24 as having slough and necrotic tissue with yellow, increased purulent drainage, foul odor and measuring 11.8 centimeters (cm) long by 6.0 cm wide by 0.8 cm deep. R24's Weekly Wound Log dated 1/7/25 documents R24's Left Plantar Heel Diabetic wound with Calcaneus bone exposed as initiating in facility on 7/24/24 as having slough and necrotic tissue with yellow, increased purulent drainage, foul odor and measuring 12.0 centimeters (cm) long by 6.9 cm wide by 1.0 cm deep. This same log documents an antibiotic was started for Methicillin Resistant Staphylococcus Aureus (MRSA) of R24's Left Plantar Heel wound. R24's Treatment Administration Record (TAR) does not document R24's Left Plantar Heel wound dressing change was completed on 1/3, 1/5, 1/6, 1/10, 1/12 and 1/17/25. R24's Nurse Progress Noted dated 1/9/25 at 9:39 AM documents Interdisciplinary Team (IDT) met to discuss R24's behaviors with no refusals of care noted. On 1/14/25 at 10:45 AM R24 was sitting in her wheelchair with her Left foot on a stationary foot pedal. R4's Left foot and ankle were wrapped in gauze that was completely saturated with yellow drainage. R4's gauze dressing was saturated from the upper ankle area to the toes. On 1/14/25 at 11:20 AM V4 Registered Nurse (RN) completed R24's dressing change to her Left Plantar Heel Diabetic Ulcer. V4 RN did not use hand hygiene, nor change gloves after removing R24's saturated, contaminated dressing prior to cleansing R24's entire Left Plantar Heel open wound. R24's prior dressing of a four inch long by four inch wide blue absorbent pad, a white six inch long by four inch wide absorbent pad and an entire roll of gauze were all saturated with yellow drainage. R24 did not have any intact skin on the entire bottom of her Left foot from the pads below the toes to the heel and expanding the entire width of R24's foot. R24's Heel bone was exposed. On 1/15/25 at 9:45 AM R24 was sitting in her wheelchair with her Left foot on a stationary foot pedal. R4's Left foot and ankle were wrapped in gauze that was completely saturated with yellow/pink drainage. R4's gauze dressing was saturated from the upper ankle area to the toes. On 1/14/25 at 10:50 AM R24 stated the staff don't always change her Left Plantar Heel dressing like it is supposed to be done by the Physician order. R24 stated the dressing changes are 'hit and miss'. R24 stated, Look at my (Left) foot. It is soaked. I just got done with an antibiotic for that wound. You would think they (staff) would at least keep it clean. I would do it myself, but I can't reach my foot. On 1/14/25 at 11:40 AM V4 Registered Nurse (RN) stated she should have changed her gloves in between removing R24's old dressing and cleansing R24's Left Plantar Heel open wound. V4 RN stated cross contaminating R24's wound could cause her wound to become re-infected. V4 RN stated R24's dressing was saturated with not only wound drainage but also with urine. V4 stated R24 was incontinent of urine which contaminated her Left Heel wound. V24 RN stated R24's prior dressing had a strong urine odor. V4 RN stated staff should have provided incontinence care for R24 so that the urine did not contaminate R24's dressing and/or open wound. On 1/16/25 at 11:00 AM V2 Director of Nurses (DON) stated licensed nurses are expected to follow the physician orders for R24's dressing changes to her Left Heel. V2 DON stated R24 admitted to the facility in March 2024 with this same wound, it resolved and after two months it reappeared in July 2024. V2 DON stated R24's Left Plantar Heel open wound is categorized as a Diabetic Ulcer and started in July as a small 4.0 cm area on her Left Heel and has worsened to cover her entire bottom of R24's foot. V2 DON stated R24 has been on antibiotics via a Peripherally Inserted Central Catheter (PICC) line for this same wound in the recent past and was just on Amoxicillin 875 mg from 1/3/25-1/13/25 for the same Heel wound. V2 DON stated the staff should be very careful with all resident wounds, but especially with R24's Left Heel open wound to no contaminate it due to this could cause another infection. On 1/17/25 at 2:00 PM V1 Administrator stated the staff failed to monitor R24's Left Heel wound by not providing incontinence care timely to not allow R24's urine to contaminate R24's Left Heel open wound. V1 Administrator stated R24 can be non-compliant, but it is the responsibility of the staff to make sure R24's dressing is kept clean and dry. V1 Administrator stated the facility does not have any documentation that shows the staff were monitoring R24's wound, documenting treatments were completed as per the Physician order or implementing care plan interventions to reduce the risk of R24's wound worsening. The facility policy titled Wound Care revised 11/9/2018 documents staff are to apply gloves, remove dressing to be changed and discard, then remove gloves and discard. Perform hand hygiene, apply new gloves and clean wound bed per order. The facility policy titled Skin Prevention, Assessment and Treatment revised 5/2/2022 documents staff are to provide incontinence care after each incontinent episode, keep skin clean and dry. The goal of wound care of to protect the ulcer from contamination.

Based on observation, interview, and record review the facility failed to maintain their survey results book in a manner accessible to residents. This failure has the potential to affect all 51 residents residing in the facility. Findings include: On 1/15/25 at 9:44 AM, during the resident group meeting, none of the four residents in attendance (R14, R18, R24, and R45) were able to state where the survey results book was located. On 1/16/25 at 1:41 PM, the survey book was located five feet six inches above the floor in a wall caddy directly outside the facility business office. There was no sign in the facility to indicate where the survey results book was kept. On 1/16/25 at 2:52 PM, V1 Administrator, and V14, Regional Representative, confirmed a resident in a wheelchair could not reach the survey results book in it's current location. V14 stated if the caddy on the wall was his, he would rip it off and move it lower. V1 stated she would get the book relocated. The facility Long-Term Care Facility Application for Medicare and Medicaid (1/17/2025) documents 51 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to obtain a Level 2 screening for a resident newly diagnosed with severe mental illness to determine if there was a need for specialized mental health services. This failure effects one resident (R2) out of two residents reviewed for pre-admission screening on the sample list of 27. Findings include: On 1/14/25 at 11:04 AM, R2 was lying in bed in his own room. R2 was speaking in a hyper-manic pattern and was unable to maintain the topic of conversation. R2's Census Detail documents R2 was admitted to the facility 10/12/2006. R2's Interagency Certification of Screening Results dated 8/16/06 documents R2 did not qualify as being developmentally disabled, and there was no reasonable basis to suspect a mental illness. R2's Medical Diagnoses List documents R2 was diagnosed with Delusional Disorder (Severe Mental Illness) on 1/26/21, and Affective Mood Disorder (can be included as severe mental illness) also on 1/26/21. There was no documented screening for Level 2 services for R2 in the medical record after the date of these new diagnoses. On 1/15/25 at 11:35 AM, V1, Administrator, displayed her computer screen for the (pre-admission screening service provider) and stated the only pre-admission screening showing up was on 8/16/06 and there was no Level 2 screen in the system.

Based on interview and record review the facility failed to complete a discharge summary for one (R48) resident out of one resident reviewed for discharge in a sample list of 27 residents. Findings include: The facility policy titled Discharge Summary revised 11/5/2019 documents a discharge summary shall be prepared for each resident discharged from the facility. When the facility anticipates a resident's discharge to a private residence or to another nursing care facility a discharge summary will be developed which will assist the resident to adjust to his or her new living environment. R48's Electronic Medical Record (EMR) documents R48 admitted to facility on 6/30/22 and discharged on [DATE]. R48's Care Plan initiated 2/26/24 documents (R48) wishes to be discharged but has no supportive family/caregivers. (R48) is independent and mostly requires verbal cues for task completion as well as medication management due to intellectual disability related cognitive deficits. R48's Medical Record does not include a discharge summary/recapitulation of stay, Physician order for discharge nor nurse progress note documenting R48's discharge. On 1/15/25 at 1:30 PM V1 Administrator stated the facility does not have any documentation of a discharge summary and/or recapitulation of stay. Physician order for R48's discharge nor any nurse progress notes documenting R48's discharge. V1 Administrator stated R48 requested to move to another Skilled Nursing Facility (SNF), so a referral was sent and R48 moved to that SNF. V1 stated there is no documentation due to this facility was purchased by another corporation on 11/1/24 so all the resident information was given to the old facility corporation.

Based on observation, interview, and record review, the facility failed to maintain safe storage of oxygen cylinders by failing to secure an oxygen tank to prevent being tipped over. This failure effects one resident (R23) out of six reviewed for accidents on the sample list of 27. Findings include: On 1/15/25 at 11:30 AM, there was an E type (3 feet tall, 5 inches diameter, containing between 2,200 and 3,000 pounds per square inch of gas pressure) free standing and not secured in any manner inside the doorway of R23's room. R23 was reclining in bed approximately 10 feet from the oxygen cylinder. On 1/15/25 at 11:35 AM, V1, Administrator, and V2, Director of Nursing, both confirmed oxygen tanks should not be left free standing on the floor without some kind of securement. V1 made an exclamation of, Oh no, why? The facility policy Oxygen Administration and Storage dated 3/8/22 documents E tanks must be secured in a holder. The tank may never be left unsecured at any time. This policy further documents oxygen cylinders must be stored in accordance with the NFPA (National Fire Protection Association) regulations. The current (2024) NFPA regulations to ensure safe handling and operation of oxygen cylinders documents to use racks or chains to secure oxygen cylinders (tanks). On 1/15/25 at 11:45 AM, R23's Nurses Note dated 1/9/25 documents R23 had an episode of low blood oxygen levels on 1/9/25 but had no documented use of any oxygen since that date.

Based on observation, interview and record review the facility failed to properly label medications and failed to monitor expiration dates on medications administered for one (R4) resident out of nine residents reviewed for medication administration in a sample list of 27 residents. Findings include: The facility policy titled Administering Medications revised October 15, 2023 documents medications shall be administered according to Physician's written/verbal orders upon verification of the right medication, dose, route, time and positive verification of the resident's identity when no contraindications are identified, and the medication is labeled according to accepted standards. The facility policy titled Storage, Labeling of Over the Counter Medication, Destruction and Disposal of Medication revised 11/9/2021 documents no discontinued, outdated or deteriorated medications shall be available for use in the facility. Expired medications are to be removed from areas medication carts prior to or at the time of expiration. Medications must be dated upon opening the container, however it may be stored in an individual resident section (of the medication cart) and used for all residents. 1. R4's Physician Order Sheet (POS) dated January 2025 documents a physician order for Zinc Gluconate 50 milligrams (mg), Multivitamin daily, Ibuprofen suspension 100 mg/1 milliliter (ml) give 10 ml, Pantoprazole suspension 4 mg/1 ml give 10 ml per Gastrostomy Tube (G-Tube). On 1/16/25 at 9:30 AM V12 Licensed Practical Nurse (LPN) administered 10 milliliter (ml) of R4's Pantoprazole suspension which had a sticker on the back side of the bottle that read Do Not Use after 1/4/25. V12 LPN administered 10 ml of R4's Ibuprofen suspension. This same bottle of Ibuprofen did not have a medication instruction label. V12 LPN administered Zinc Sulfate 220 mg to R4. V12 administered R4's multivitamin. from a bottle of stock multivitamins with no open date documented on the bottle. On 1/16/25 at 12:30 PM V12 Licensed Practical Nurse (LPN) stated she did not notice the difference between R4's Medication Administration Record (MAR) instructing to administer Zinc Gluconate 50 mg and R4's medication card of Zinc Sulfate 220 mg. V12 LPN stated she should have noticed the difference and questioned R4's Zinc order prior to administering. V12 stated she did not see the sticker on the back of R4's liquid Pantoprazole bottle that ready Do Not Use after 1/4/25. V12 stated R4's Pantoprazole originally comes in a powder form and the pharmacy reconstitutes it to a liquid form. V12 stated because of this the liquid reconstituted form expires much faster. V12 stated she should have seen this and will get the bottle replaced so that no one else makes that error. V12 LPN confirmed there was no label on R4's Ibuprofen suspension. V12 LPN stated she saw that the house stock bottle of Multivitamins did not have an open date. On 1/16/25 at 1:35 PM V2 Director of Nurses (DON) stated all resident medications should have a label. V2 DON stated licensed nurses should not administer expired medications or medications that the expiration date is unknown. V2 DON stated these errors would not be a medication error but definitely would be medication labeling errors. V2 DON stated anytime a house stock bottle of medication is opened, the nurse should write on the bottle what date it was opened so that other nurses will know when to dispose of that bottle. V2 DON stated V12 LPN should have notice the difference in R4's POS order for Zinc Gluconate and the medication card that read Zinc Sulfate. V2 stated this is again another labeling issue due to the facility recently changed pharmacies and the new pharmacy labeled the medication card for R4's Zinc Gluconate as Zinc Sulfate due to a pharmacy exchange. V2 DON stated V12 LPN did not administer the wrong medication but should have questioned the label being different from the POS. On 1/16/25 at 2:45 PM V15 Registered Pharmacist/Pharmacy Manager stated there is no significant clinical difference between Zinc Sulfate 220 mg and Zinc Gluconate 50 mg. V15 stated administering Zinc Sulfate 220 mg instead of Zinc Gluconate 50 mg would not be considered a medication error but should have been questioned by facility staff prior to giving. V15 stated this is a therapeutic pharmacy exchange. V15 stated administering expired Pantoprazole would also not be considered a medication error at that point but should have been noted by the facility staff and a new bottle obtained. V15 stated all medications should have a label including the name and administering instructions. V15 stated any medications that the facility provides should follow the facility medication labeling policy.

Based on interview and record review the facility failed to ensure the resident record was complete for one (R48) resident out of one resident reviewed for closed records in a sample list of 27 residents. Findings include: R48's Electronic Medical Record (EMR) documents R48 was admitted to the facility on [DATE] and discharged on [DATE]. R48's Electronic Medical Record (EMR) does not include Physician Orders, Nurse Progress Notes, Physician Progress Notes, Social Service Progress Notes, R48's weight and vital signs, Activities of Daily Living (ADL) charting and Assessments. On 1/14/25 at 2:00 PM V1 Administrator stated the facility is unable to provide documentation of R48's stay at facility due to a recent change in ownership. V1 stated R48 discharged on [DATE] to another skilled facility per R48's request. V1 Administrator stated whatever information is documented in the EMR is the only information the facility can provide. V1 stated R48's EMR is incomplete, and the facility has no paper documentation of R48's stay. V1 Administrator stated there is no policy for this, but it is known that the facility is expected to have complete medical records of all residents.

Based on observation, interview and record review the facility failed to wear the proper Personal Protective Equipment (PPE) when providing feeding assistance and when administering medications to residents who are COVID-19 positive on Droplet and Contact Isolation Precautions for two of five residents (R38 and R20) reviewed for Infection Control in a sample list of 27 residents. Findings include: The facility policy titled Administering Medication revised 10/15/23 documents adherence to established facility infection control procedures shall be followed during the administration of medications. 1.) R20's Minimum Data Set (MDS) dated [DATE] documents R20 as severely cognitively impaired. This same MDS documents R20 is dependent on staff for assistance with eating. R20's Laboratory Report dated 1/6/25 documents R20 tested positive for COVID-19. R20's Physician Order Sheet (POS) dated January 2025 documents a physician order starting 1/6/25 and ending 1/16/25 for (R20) of COVID Positive--COVID-19 Room. Isolate (R20). Standard, droplet and contact isolation every shift. All services provided in room. R20's Care plan does not include a focus area, goal nor interventions for R20's COVID-19 Contact and Droplet isolation precautions. On 1/14/25 at 12:48 PM V8 Certified Nurse Aide (CNA) did not wear gown nor gloves when assisting R20 to eat her lunch meal at a table by the nurses station. R20 was sitting at a table feeding herself her lunch. V8 CNA walked over to R20 without washing hands, or using hand hygiene, picked up R20's contaminated spoon and assisted R20 to finish eating her lunch. On 1/16/25 at 12:10 PM V8 CNA stated she did not know she was supposed to wear gloves when providing feeding assistance to a COVID-19 positive resident (R20). 2.) R38's Lab Report dated 1/6/25 documents R38 tested positive for COVID-19 on 1/6/25. R38's Physician Order Sheet (POS) dated January 2025 documents a physician order starting 1/6/25 and ending 1/16/25 of COVID Positive--COVID-19 Room. Isolate (R38). Standard, droplet and contact isolation. All services provided in room. On 1/15/25 at 11:51 AM V6 Licensed Practical Nurse (LPN) did not wear an N95 mask, gloves nor gown while she administered R38's scheduled noon medications. Signs for Droplet Precautions and Contact Precautions were posted outside R38's room door. A bin was sitting outside R38's room door with Personal Protective Equipment (PPE) supplies. On 1/15/25 at 11:55 AM V6 LPN stated V6 was aware that R38 is currently on Droplet and Contact Isolation Precautions due to being positive for COVID-19 and should have worn the appropriate PPE. V6 stated V6 could contaminate other residents by not wearing the proper PPE for COVID-19 precautions. On 1/17/25 at 2:00 PM V2 Director of Nurses (DON) stated staff should wear the proper Personal Protective Equipment (PPE) when providing feeding assistance and/or medications to any COVID-19 positive resident. V2 DON stated gloves should be worn to help prevent the spread of COVID-19 and any other organism.

Based on observation, interview, and record review the facility failed to provide supervision of a severely cognitively impaired resident, with a history of elopement, to prevent the resident from leaving the facility unnoticed and unattended. Due to R1's frontal lobe dementia, V20 physician stated (R1) could have been hit by a car, fallen and obtained a fracture, or been injured in a multitude of ways. This failure affects one (R1) of three residents reviewed for supervision. The immediate jeopardy began on 7/28/24 when R1 was allowed to leave the alarmed Dementia unit unsupervised resulting in R1 eloping 0.9 miles away from the facility. V1 Administrator was notified of the Immediate Jeopardy on 8/8/24 at 9:26 AM. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 8/8/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training through ongoing Quality Assurance Performance Improvement (QAPI) review. Findings include: R1 was admitted to facility on 3/14/24. R1's Electronic Medical Record (EMR) documents medical diagnoses as Dementia, Major Depressive Disorder, Altered Mental Status, Cognitive Decline, Colostomy Status and history of Cerebral Vascular Accident (CVA) and Chronic Ulcerative Enterocolitis. R1's admission Minimum Data Set (MDS) dated [DATE] documents R1 as severely cognitively impaired. This same MDS documents R1 as independent in transferring and ambulating. R1's Elopement Evaluation dated 3/21/24 documents R1 as high risk for elopement. R1's Social Service Progress Note dated 3/21/24 documents (R1) has a behavior of exit seeking but is able to be redirected. R1's Medical Record does not include any further social service progress notes. R1's Care Plan dated 3/25/24 documents R1 has wandering behavior and may demonstrate a risk for leaving unattended/elopement due to Altered Mental Status. R1's Care Plan documents an intervention dated 3/25/24 for R1 to have every 15 minute checks. R1's Care plan was first updated on 7/29/24 to include an intervention for staff to monitor R1 at all times when off the Dementia unit. R1's Physician Order Sheet (POS) dated August 2024 documents a physician order dated 7/29/24 of (R1) not to leave facility unless with staff or Power of Attorney (POA) for appointments per POA, (V17). This same POS documents a physician order to start Aspirin 81 milligrams (mg) daily. R1's Nurse Progress Notes document on: 3/23/24 at 9:45 PM (R1) exited the facility via the service door. (R1) was harder to redirect than the other four times. Semi combative. (R1) was assisted by staff to her room. 5/21/24 at 7:00 PM (R1) exit seeking. (R1) went out the front door and over by the trees on our property. Redirected back inside. 5/27/24 at 8:00 PM (R1) exited the building two times with more attempts. 6/1/24 at 6:50 PM (R1) exited out the Northwest service door. Easily re-directed back into the building. 6/16/24 at 'evenings' (R1) in and out of the South (Dementia) unit. (R1) did exit the building one time. 6/18/24 at 5:00 AM (R1) adamant to exit the south hall door. (R1) did get out the front door, exiting the building. (R1) is very swift. Escorted back inside with some difficulty. The facility Investigative Report of Missing Resident dated 7/29/24 documents R1 alert and oriented times one, ambulates independently and eloped from the facility on 7/28/24. This same report documents Family of (R1) called facility to notify (facility) of location (of R1). This same report documents R1 was found at V17 (R1's daughter) house. R1 left the facility unnoticed and unsupervised, at night, after dark in extreme heat and high humidity. R1 walked to a family member's house approximately 11 blocks (0.9) miles from the facility, crossing multiple streets, near a highway/culverts/guardrails/deep ditches. The public website titled www.timeanddate.com documents the high temperature for 7/28/24 was 85 degrees with 88% humidity. On 8/6/24 at 2:00 PM V15 Certified Nurse Aide (CNA) stated, I pushed the code into the door alarm on the Dementia Unit so that (R1) could go out into the main nursing home and sit on the couch. We (staff) do that all the time. I didn't know (R1) was supposed to be supervised when she was off the unit. (V16) CNA and I decided at around 7:30 PM that V16 CNA could go on lunch since it was so quiet on the hall. Right after (V16) left for break, residents started getting up and it became very busy. I didn't check on (R1) or let any other staff know she was sitting alone out there. I guess I should have. V15 stated when R1 returned to the Dementia unit, she continued to pace up and down the hallway. On 8/2/24 at 2:45 PM V10 Licensed Practical Nurse (LPN) stated R1 eloped from facility the evening of 7/28/24. V10 LPN stated R1 was sitting on a couch in the resident lounge area of the main nursing home about 7:30 PM prior to her eloping. V10 stated R1 resides on the alarmed Dementia unit and does occasionally wander through the main nursing home area unsupervised. V10 LPN stated V16 Certified Nurse Aide (CNA) had left the Dementia Unit at 7:30 PM and saw R1 sitting on the couch as she walked by to go to a break. V10 LPN stated it was reported to V10 that no other staff were present with R1 and that V16 did not stay with R1 nor report to anyone that R1 was not being monitored. V10 LPN stated R1 has a long history of 'escaping' the facility. V10 LPN stated R1 has been known to watch staff punch in the alarm codes, wait for the area to clear and then let herself out of the alarmed doors without the alarms sounding. V10 LPN stated the door alarms had not sounded that evening prior to R1 being reported as missing. V10 LPN stated, (R1) has eloped from the facility multiple times before 7/28/24 due to the lack of supervision and (R1) being very sneaky. V10 LPN stated, V16 CNA reported to V10 LPN at 8:30 PM that R1 could not be located. V10 LPN stated, I took off on foot looking around the outside of the building. It was so hot that night. It was dark out by the time we (facility) realized (R1) had eloped. There were dozens of people searching for (R1) including the police, emergency medical services (EMS), off duty facility staff, community neighbors and the facility staff. We (staff and volunteers) searched all over for her. I came across a couple walking their dog and they helped look for (R1) also. I walked about five blocks and then had to come back to the facility because it was miserably hot outside. My clothes were drenched. I don't know how (R1) ever made it as far as she did without passing out. (R1) had just gotten back from the hospital earlier that day for a Small Bowel Obstruction. (R1) was found by her family through (V17's) (R1's) family member's home camera system. (V17) notified the facility of (R1's) whereabouts and then we went to go pick her up. (V17) told us to hurry up and go get her because she was with (V18) (R1's) family member and (V18) did not know how to deal with (R1). (V17) stated 'you never know what (V18) will do'. I called (V2) Director of Nurses (DON) at 9:09 PM after (V17) reported (R1's) whereabouts and then (V2) and I went to get (R1). When (V2) Director of Nurses (DON) and I got to (V17's) house, (R1) looked hot and tired. (R1) looked exhausted. (R1's) face was red and somehow her colostomy bag had come off and she was just a mess with BM (bowel movement) all over her. On 8/6/24 at 9:30 AM V2 Director of Nurses (DON) stated R1 admitted to facility on 3/14/24. V2 DON stated R1 has exited the facility and left the property 'multiple times' prior to 7/28/24. V2 DON stated R1 was supposed to be on 15 minute checks since admission. V2 DON stated, I got the call from (V10) Licensed Practical Nurse (LPN) at 8:30 PM stating (R1) could not be located. We (facility) started a search throughout the building and could not find (R1). There were a lot of people out on the streets looking for (R1). (R1's) family (V17) was the one who called the facility and let us know where (R1) was. I believe (R1) was back inside the facility at 9:30 PM. Otherwise, we would still be looking for (R1). (R1) had left the building so many times before that night, I think she knew right where to go. V2 DON stated no resident should be allowed off the Dementia Unit without staff monitoring them. V2 DON stated, The reason why people have to stay back on the Dementia Unit is because they don't know any better. We (facility) are supposed to keep them safe. (R1) is a tough one because she is alert, ambulatory and determined to leave. (R1) gets physically aggressive when staff try to re-direct her but that is our (facility) problem to solve. We have to do better or (R1) is really going to get hurt. V2 DON stated R1's care plan had not been updated since her admission. V2 DON stated, We (facility) have talked about (R1's) exit seeking and previous elopements in morning meeting but that was never brought back to the staff. The staff rely on the care plan to be able to know what interventions to use. If the care plan is not updated, then the staff have to rely on word of mouth and that is not always accurate. On 8/6/24 at 10:20 AM V1 Administrator stated, (R1) has Frontal Lobe Dementia and really does not belong in our facility. (R1) is too much risk due to her being so mobile, having very poor safety awareness, Dementia and being sharp enough to be able to obtain the codes to the security doors on the Dementia unit. The night (7/28/24) (R1) eloped from the facility, R1 was sitting on the couch unattended by staff out in the main area of the nursing facility. We (facility) aren't even sure which door (R1) exited from. (R1) is quick. The staff had previously been in serviced on the need to always have two staff members on the Dementia unit at all times. That night there was one nurse (V10) Licensed Practical Nurse (LPN) and two (V15, V16) Certified Nurse Aides (CNA) on that unit. (V10) was on another hall and the two CNA's (V15, V16) were supposed to stay on the Dementia Unit. Apparently, V16 CNA left the hall to take a break which left V15 CNA on the hall by herself. That is when (R1) eloped. (R1) was supposed to be checked on every 15 minutes and wasn't. (R1) has been on 15 minute checks since she admitted . There is no reason my staff shouldn't have done those. (R1) gets confused every time she leaves the facility. (R1) had just came back from the hospital that day due to having a Small Bowel Obstruction. That paired with the fact that (V17) was on vacation, I think (R1) was even more adamant on leaving the facility. On 8/6/24 at 1:50 PM V20 Medical Director stated, There was failure from the facility to maintain the safety of (R1). The facility policies and Centers for Medicaid and Medicare Services (CMS) regulations were not followed. V20 stated, In a general statement, anything could have happened to (R1). (R1) could have been hit by a car, fallen and maybe obtained a fracture, or been injured in a multitude of ways. If there was adequate staff the night in question, the facility did not supervise (R1) as she needed to be and therefore (R1) eloped without the knowledge of the staff. On 8/7/24 at 1:40 PM V23 Nurse Practitioner stated, (R1) has a very specific type of Dementia with Frontal Lobe involvement. I have met with (R1) several times and can say that (R1) should not be allowed outside of the Dementia unit unsupervised. (R1's) Dementia would prevent her from being able to make safe decisions. (R1) should not be walking unsupervised off the facility property. (R1) has a higher risk than others due to her Dementia and impulsivity. V23 NP stated R1 is not able to make sound, safe decisions without the assistance of staff. V23 stated R1 could have been injured from falling, hit by a car, or tripped due to her shuffling fast pace. V23 NP stated R1 could have had heat related symptoms like a heat stroke due to her being unable to recognize those symptoms due to her Dementia. On 8/7/24 at 3:10 PM V24 Director of Psychiatry program for facility stated V24 is familiar with R1. V24 stated R1 should never be allowed to be unsupervised when out of the alarmed Dementia Unit. V24 stated, There are not only environmental factors that (R1) may be injured from while walking outside of the Dementia Unit but (R1) has what you call 'excitable agitation.' (R1) has increased agitation with verbal and physical aggressive behaviors when anyone attempts to redirect (R1). If (R1) were out in the community by herself and came across another person who attempted to redirect (R1) that would most likely agitate (R1) and the other person may respond negatively to that interaction possible creating harm for (R1) from a physical altercation. (R1) has impulsivity along with very poor judgement and decision making efforts. (R1) thinks like a small child with no impulse control. (R1) would have significant risk of harm due to her aggressive behaviors related to her Dementia. On 8/2/24 at 1:10 PM V9 (R1) Power of Attorney (POA) stated R1 left the faciity on [DATE] without any staff aware of her elopement. V9 POA stated, My other sister (V17) lives about a mile from the facility. (V17) normally visits regularly and takes (R1) back to her house. (V17) has cameras at her house and that is how we found (R1). (V17) saw (R1) on the front porch of (V17's) house. (V17) then called (V18) (R1's) family member to go over to (V17's) house and I called (V10) Licensed Practical Nurse (LPN) to let the facility know where (R1) was. I don't believe (R1) was badly hurt at all. (R1) has escaped that facility lots of times but this is the furthest she has gone. I don't know what we are going to do with (R1). The staff know (R1) leaves all the time and can't seem to stop her. Maybe they (staff) need more training or something. They (staff) are trying but I want (R1) to be safe too. On 8/2/24 at 10:25 AM V7 Maintenance Director stated the alarms are not checked on the weekends so there is no way to know if the alarms were working on the weekend R1 eloped from facility. On 8/2/24 at 2:06 PM V14 Certified Nurse Aide (CNA) stated, (R1) tried to leave the unit all the time. (R1) sits out in the main resident lounge area off the Dementia unit. The staff out there are supposed to keep an eye on her. I don't know how much good that does since (R1) knows the codes to the doors. On 8/2/24 at 10:17 AM R1 was walking up and down the hallway on the Dementia unit. R1's room is located at the end of the hall directly next to the exit door. R1 walked up to exit door on the Dementia unit and attempted to push the door open. On 8/6/24 at 11:30 AM R1 was pacing the hall of the Dementia Unit. R1 pushed another resident in a wheelchair out of her way to get to the exit door. R1 opened the exit door slightly as staff redirected R1 away from the door. On 8/7/24 at 2:25 PM R1 pushed a heavy wooden chair out of her way in the hallway to walk up to the exit door on the Dementia Unit. R1 attempted to open the door as staff redirected R1. The Immediate Jeopardy that began on 7/28/24 and was removed on 8/8/24 when the facility took the following actions to remove the immediacy. 1. R1's Care Plan was reviewed by the Interdisciplinary Team (IDT) on 8/8/24. On 8/9/24 V8 Resident Care Coordinator (RCC)/Licensed Practical Nurse (LPN) stated the IDT team reviewed and updated R1's care plan and added new interventions to aide in preventing R1 from eloping from the facility again. V8 stated she had a direct role in updating R1's Care Plan. 2. V1 Administrator stated all staff present in facility were in serviced on R1's updated elopement preventions on 8/8/24. 3. The Facility Elopement Policy, Missing Resident and Door Alarm Policy were reviewed by V26 Director of Clinical Operations. V26 stated on 8/12/24 that the facility policies were reviewed on 8/8/24 and were in compliance with state and federal regulations. 4. All staff will have access to and review a communication binder at the beginning of their shift for any safety intervention updates. V8 RCC/LPN stated on 8/9/24 the communication binder was implemented on 8/8/24 and is a new intervention to inform staff of any changes with residents at risk for elopement. V8 RCC/LPN stated V8 will take the communication binder to all Quality Assurance meetings Monday through Friday for the IDT team to review and update. V8 RCC/LPN stated the communication binder will be updated on the weekends through the on call nurse if necessary. 5. V1 Administrator initiated an in-service with all staff in the facility on 8/8/24. Elopement Policy, Missing Resident Policy, Door Alarm Policy, Communication Binder, Dementia Care Policy were included in this in-service. V1 stated the staff present were instructed that safety interventions to prevent elopement must be followed. V1 Administrator stated on 8/9/24 that any staff not present for the in servicing on 8/8/24 will be in-serviced prior to the beginning of their next scheduled shift. V2 DON stated the new hire staff will be trained during orientation through the new employee packet. Any other PRN (as needed) staff, agency staff or staff that have not worked yet will be in serviced. V2 DON will train nurses and V21 will train new hire CNA's. V2 DON stated the department manager will complete the training for any new hire staff for their own departments. 6. V8 RCC/LPN stated V8 initiated chart reviews and updating care plans on 8/8/24 and V8 completed all chart reviews and updated care plans for all residents at risk for elopement on 8/9/24. 7. All exit doors and devices were assessed on 8/8/24 by V7 Maintenance Director. V7 Maintenance Director stated on 8/8/24 that all exit doors and any existing alarms were checked, and all were functioning properly. V7 stated V7 will continue to check all the exit doors and alarms through the week and the on call nurse will check them on the weekends. 8. The elopement binder was reviewed and updated on 8/8/24. V12 Social Service Director (SSD) stated V12 will update the elopement binder with each new admission. V12 stated V12 takes the resident's picture and fill out the elopement resident details form. V12 stated she reviewed the elopement binder on 8/8/24 and found no issues. 9. The IDT team will ensure current safety interventions are being followed for their assigned residents. V1 Administrator stated these audits will occur three times per week for four weeks. V1 stated the IDT team was instructed to report any concerns to V1 Administrator and/or V2 Director of Nurses (DON) for corrective action if necessary. 10. V1 Administrator will perform a drill to determine the effectiveness of staff training on the Elopement Policy, Missing Person Policy and Door Alarm Policy, on random days and different shifts four times in one month. Any concerns identified following the drills will be immediately addressed through additional education by V1 Administrator. V1 stated the facility will have drills starting next week. 11. V7 Maintenance Director stated V7 will continue to check all the exit doors and alarms through the week. 12. The on call nurse will check the exit doors, alarms and devices on the weekends. V7 Maintenance Director stated any problems with the exit doors, alarms or devices will be reported to V1 Administrator. V4 Dietary Manager confirmed that all the exit doors and alarms were functioning properly on 8/10/24 and 8/11/24 during weekend rounds. V8 RCC/LPN confirmed that resident exit alert devices were functioning properly on 8/10/24 and 8/11/24 during resident device checks done by nursing staff and V8. 13. The communication binder will be reviewed twice weekly by V1 Administrator and/or V2 Director of Nurses. V1 Administrator stated this audit has been initiated and will be ongoing for the remainder of the month. V1 Administrator stated V1 reviewed the binder on 8/8/24 prior to putting the binders on the nurses stations. 14. Residents at risk for elopement will be reviewed weekly during Quality Assurance (QA) meetings. V1 Administrator stated the facility began on 8/8/24 to review all residents at risk for elopement and finished the initial review on 8/9/24. V1 stated the elopement binder was reviewed on 8/9/24 and will be updated with any change of status for existing residents and updated with any new information for new residents. 15. All action plans will be reviewed weekly for four weeks by the Quality Assurance Team. V1 stated if there are any concerns or noncompliance, the QA team led by V1 Administrator will resolve any issues immediately. The facility presented an abatement plan to remove the immediacy on 8/8/24. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility two separate times on 8/8/24 for revisions. The facility presented revised abatement plans on 8/8/24 and the survey team accepted the abatement plan on 8/8/24.

Based on interview and record review the facility failed to provide in servicing to staff members on the facility Quality Assurance Performance Improvement (QAPI) program. This failure has the potential to affect all 44 residents residing in facility. Findings include: The facility Daily Midnight Census dated 8/2/24 documents 44 residents residing in the facility. The undated facility Quality Assurance Performance Improvement (QAPI) Solution Revolution Policy documents QAPI includes all employees, all departments and all services provided. The facility educates staff on intervention and anticipation of resident's needs. A facility wide training will be conducted to inform everyone in the facility about the QAPI plan. These trainings will be conducted often and in multiple ways through regular all-staff meetings, department staff in-services, change of shifts report time. Dialogue, examples, exercise, etc. On 8/7/24 at 10:00 AM V22 Registered Nurse (RN) stated V22 has not received any training on the Quality Assurance Performance Improvement (QAPI) process. V22 RN stated, I think that is something the managers do but I really don't know. I haven't had any kind of training on that. On 8/7/24 at 1:40 PM V25 Certified Nurse Aide (CNA) stated V25 has not received any training on QAPI. V25 CNA stated, I have never heard of that. On 8/9/24 at 1:45 PM V19 Certified Nurse Aide (CNA) stated V19 has not received any QAPI program training. On 8/9/24 at 9:26 AM V1 Administrator stated the facility management team including the Medical Director has QAPI meetings at least quarterly. V1 stated the information brought back to the staff is by word of mouth. V1 stated, Apparently we (facility) are not educating the staff on new interventions for residents or any updates to policies or processes. If our staff do not know what those updates are, they will never be implemented.

Based on interview and record review the facility failed to provide twelve hours of mandatory training for Certified Nurse Aides (CNA) yearly. This failure has the potential to affect all 44 residents residing in facility. Findings include: The facility Daily Midnight Census dated 8/2/24 documents 44 residents residing in facility. The facility Inservice Attendance sheets dated August 2023 through August 2024 do not document V27, V28, V29, V30 and V31 Certified Nurse Aide (CNA) have completed twelve hours of mandatory training. The facility provided documentation of employee hire dates and in-services documents the following: V27 Certified Nurse Aide (CNA) was hired on 5/25/2022 and has completed six hours of in-services in the past twelve months. V28 CNA was hired on 10/25/22 and has completed six hours of in-services in the past twelve months. V29 CNA was hired on 9/12/22 and has completed four hours of in-services in the past twelve months. V30 CNA was hired on 9/7/1994 and has completed eight hours of in-services in the past twelve months. V31 CNA was hired on 9/1/22 and has completed five hours of in-services in the past twelve months. On 8/13/24 at 3:00 PM V21 Lead Certified Nurse Aide (CNA) stated all CNA staff should have twelve hours of training every year. V21 stated the trainings are provided by the facility and anyone not present should be receiving the education. V21 stated V21 cannot provide documentation of in-services for V27, V28, V29, V30 and V31.

Based on interview and record review, the facility failed to provide appropriate fall interventions and keep equipment out of the hallways for one of three residents (R1) reviewed for falls on the sample list of 12 residents. Failing to ensure R1 was wearing appropriate footwear resulted in R1 falling and sustaining a laceration that required sutures. Findings include: R1's undated Cumulative Diagnosis Log documents R1's diagnoses as: Agitation due to Dementia, Major Neuro Cognitive Disorder, and Alzheimer's Disease probable with Behavioral Disturbances. R1's Nursing Admission Assessment documents R1 admitted to the facility on [DATE]. R1's Fall Risk assessment dated [DATE], documents R1 as a high fall risk. R1's Minimum Data Set, dated dated dated (MDS) dated [DATE], documents R1 has disorganized thinking and an altered level of consciousness. This same MDS documents R1 has had falls prior to admission to the facility. R1's Psychosocial assessment dated [DATE], documents R1 is easily distracted, is forgetful, has short and long term memory problems, wanders and paces, agitated, and has severe impairment with decision making and problem solving. R1's AIM (Assess, Intercommunicate, Manage) for Wellness report dated 4/28/24 at 10:30 AM, documents a crash was heard and down the hallway and R1 was lying next to a mechanical lift, R1 was on R1's right side, R1 sustained an abrasion to R1's right elbow. R1's Nursing Progress Note dated 4/28/24 at 12:30 PM, documents R1 has been up walking the halls. R1's AIM for Wellness report dated 4/28/24 at 4:00 PM, documents a witnessed fall. R1's Nursing Notes dates 4/28/24 at 6:20 PM, documents an order for blood draws and a urinalysis for repeated falls. R1's AIM for Wellness report dated 4/29/24 at 10:20 AM, documents R1 fell in the hall while ambulating independently, was not witnessed, assessed and found bleeding from a head injury and a small laceration on outer left eyebrow. This same report documents R1 was transported to the hospital. R1's Emergency Documentation notes dated 4/29/24, document a two centimeter linear laceration above the left eyebrow which was repaired with three sutures in the emergency room . R1's also had a diagnosis of a fall as a reason for this same visit. R1's Care Plan dated 5/1/24, documents the intervention for one fall on 4/28/24, to educate staff to keep hall clear and free of clutter; for the second fall on 4/28/24, to obtain a CMP (complete metabolic panel), CBC, (complete blood count) and a urinalysis (UA); for the fall on 4/29/24 to ensure appropriate footwear; and for a fall on 5/1/24, medication review requested. On 5/14/24 at 3:45 PM, V6 Licensed Practical Nurse (LPN) stated R1 wanders around the building. V6 stated R1 walks around a lot and wears gripper socks mostly during the evening and V6 does not know what other shoes R1 has. V6 stated that on 4/28/24, R1 was doing normal wondering and R1 was by the back door by the weight scale and one foot hanging off but R1 was trying to sit on the ground and lost her balance and fell on her bottom and was leaning over to R1's left elbow holding her up. On 5/14/24 at 1:22 PM, V3 Certified Nursing Assistant (CNA) stated R1 was walking like R1 normally does and she sometimes looks down when walking and we cue her to look up. V3 stated V3 passed R1 and was helping another resident and does not know if R1 had shoes on or what shoes they were. V3 stated R1 has slip on shoes and some slide sandals that are plastic and not safe to wear and there is no back on her shoes. On 5/14/24 1:40 PM, V1 Administrator stated R1 had a pair of sandals with a big wide band across the top and no straps in the back and a pair of slip on tennis shoes. On 5/14/24 at 3:15 PM, V5 Licensed Practical Nurse stated R1 has a pair of slip on tennis shoes with no laces and no back and a slipper sock thing with no back on it and it has a plastic sole. V5 stated R1 would be so tired from walking but would keep going that's when V5 thought R1's shoes might not be good. V5 stated she does not remember what if anything was on R1's feet when she fell that time. On 5/14/24 at 2:46 PM, V2 Director of Nursing (DON) stated R1 has a pair of tennis shoes which are slip-ons with no back and also wears a pair of yellow slippers with no back. V2 stated R1's husband was called after R1's fall from 4/29/24 so he could bring in another pair of shoes. V2 stated this was an intervention after that fall. V2 stated this should have been an earlier intervention because R1's shoes were not really safe. V2 stated R1 ran into a mechanical lift that was in the hallway on 4/28/24 which was not supposed to be there because it is a hazard. V2 stated the urine should have been obtained as soon as possible after the order was given since the order was given after the second fall on 4/28/24. V2 confirmed the order for a UA was given on 4/28/24 and was not obtained until 5/2/24. The facility's Fall Prevention Policy dated Revised 11/10/18, documents this policy is to provide for resident safety and to minimize injuries related to falls.

Based on interview and record review, the facility failed to protect the resident's right to be free of physical abuse by another resident for three of three residents (R1, R7, R8) reviewed for physical abuse on the sample list of 12. Findings include: The facility's Incident Report Form - Illinois Department of Public Health (IDPH) Notification dated 2/23/24, documents R8 was in the dining room when R8 reached out and made contact with R7's forehead. R7 and R8 were separated and assessed. R8's undated Face Sheet documents R8's diagnoses as: Unspecified Dementia, Unspecified Severity, with Psychotic Disturbance, Depression Unspecified, and Unspecified symptoms and signs involving Cognitive Functions and Awareness. R8's Minimum Data Set (MDS) dated [DATE], documents R8 is not cognitively intact. R8's Care Plan dated 2/27/24, documents R8 is known/has a history of displaying inappropriate behavior and has a history of hitting staff. R8's untitled document dated 1/4/24, documents R8 having behaviors which include physical aggression-push, grab, physical abusive-hit, scratch, and does not respect personal space. The facility's IDPH Notification Form dated 5/6/24, documents R1 made contact with R7's face. R1 and R7 immediately separated and assessed. R1's undated Face Sheet documents R1's diagnoses as: Mild Neurocognitive Disorder due to known Physiological condition with behaviors and Unspecified Dementia, Unspecified severity with Agitation. R1's MDS dated [DATE], documents R1 is not cognitively intact. R1's Psychosocial assessment dated [DATE], documents R1 enters bedrooms uninvited, rummages in other's space, and is socially inappropriate. R1's Care Plan dated 4/25/24, documents R1 is/has the potential to be physically aggressive, pinches, bites, and kicks. On 5/23/24 at 1:05 PM, R8 stated she never hit anyone on the forehead or any where else. R8 stated R8 does not think she knows R7 and she doesn't remember hitting anyone. R8 stated R8 might have bumped into someone accidentally but has never hit anyone her whole life. On 5/23/24 at 1:15 PM, R1 was asked about the incident with R7. R1 is not able to stop walking, look at someone's face, understand or communicate. On 5/24/24 at 10:00 AM, R7 stated R1 kept coming in R7's room and R7 asked R1 to please leave and R1 just looked at R7. R7 stated R7 told R1 that R1 is not supposed to be in R7's room. R7 stated R1 kept banging on R7's closet door and R7 had a big shirt on and R1 hit the shirt and R7's face. On 5/24/24 at 10:10 AM, R7 stated R7 went to sit at her (R7) table in the dining room and R8 sat down and R8 asked if R7 wanted a cup of coffee and R7 stated it's right over there and R7 pointed to where the coffee was. R7 stated R8 got up and flicked the side of my (R7) head and moved to a different table. On 5/14/24 at 3:32 PM, V6 Licensed Practical Nurse (LPN) stated R1 can have aggressive behaviors at times. On 5/24/24 at 11:00 AM, V18 LPN stated R1 sometimes has physically aggressive behaviors. On 5/23/24 at 12:15 PM, V1 Administrator confirmed R1 made contact with R7's face and confirmed R8 made contact with R7's forehead. The facility's Abuse Prevention Program Policy dated Revised 11/28/2016, documents this facility is committed to protecting our residents from abuse by anyone including other residents. This policy also documents this facility desires to prevent abuse by establishing a resident sensitive and resident secure environment. This policy also documents as part of the resident social history assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of mistreatment, neglect, and abuse of these residents.

Based on record review and interview the facility failed to ensure R1's personal property (tablet computer) was not taken by an employee without R1's permission. Following this incident, R1 had no use of the stolen tablet computer which was later recovered by law enforcement at the employee's residence. Findings include: R1's undated Face Sheet documents medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score of 6 out of 15 possible points indicating severe cognitive impairment. This same MDS documents R1 as requiring extensive assistance of one person for bed mobility and total assistance of two people for transfers. R1's Care Plan dated 7/15/20 documents a focus area of (R1) is hard of hearing and does not wear hearing aids. R1's Initial Incident Report to Illinois Department of Public Health (IDPH) dated 7/6/22 documents (R1)'s (tablet computer) is unable to be located in (R1) room. R1's Final Incident Report to Illinois Department of Public Health (IDPH) dated 7/14/22 documents Investigation Conclusion: (R1)'s (tablet computer) was discovered to be within the possession of an employee, (V3) Certified Nurse Aide (CNA). The local authorities were immediately notified of discovery and subsequently (V3) was terminated from employment. Authorities were able to locate (V3) and remanded (V3) into custody. The (tablet computer) was returned to (R1)'s family without further incident. On 8/5/22 at 11:00 AM V1 Administrator stated R1's family was moving R1's belongings from a room in the back of the building to another room in the front hall to have more privacy and room due to R1 had just began hospice program. V1 stated R1's family reported the (tablet computer) missing during the room to room move. V1 stated (R1)'s granddaughter (V8) got online and tried to track down the missing (tablet computer). (V8) searched for pictures online and somehow found (R1) family pictures and there were also pictures of a female (R1)'s family did not recognize. This person turned out to be (V3) Certified Nurse Aide. (V3) worked night shift at this facility and worked the same hall that (R1) resided. (V3) had ample access to (R1)'s (tablet computer). It would have been easy for (V3) to walk into (R1)'s room at night when (R1) was sleeping and steal (R1)'s (tablet computer). (V8) was able to 'ping' the (tablet computer) to find a location. (R1)'s family let the facility know the location which was in a different county. We (facility) called our local police to update them of this new information and at the same time (R1)'s family called the police from the county where the missing (tablet computer) had been located. (V3) was arrested in the other county, the (tablet computer) was recovered from (V3) home and returned to (R1)'s family. (V3) was terminated due to this incident. We (facility) do not want a thief working here.

Identified failures required more than one deficient practice statement. A.) Based on interview and record review the facility failed to prevent the potential spread of COVID-19 (human coronavirus infection) by failing to follow their policy to restrict staff with symptoms of COVID-19 from working in the facility. The facility also failed to follow Centers for Disease Control and Prevention (CDC) guidance to confirm negative rapid ([MEDICATION NAME]) COVID-19 test results for an employee with a symptom of COVID-19, by using a molecular (Reverse Transcription Polymerase Chain Reaction/RT-PCR) COVID-19 test. These failures resulted in staff with COVID-19 symptoms working in the facility which has the potential to affect all 50 residents residing in the facility. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 1/20/21, the facility remains out of compliance at severity level 2. The facility is in the process of re-educating and training staff on the screening process for COVID 19 and not working while symptomatic or sick. Findings include: a.) The CDC Guidance for Symptoms of Coronavirus dated 12/22/20 states People with these symptoms may have COVID-19: Fever or chills, Cough, Shortness of breath or difficulty breathing, Fatigue, Muscle or body aches, Headache, New loss of taste or smell, Sore throat, Congestion or runny nose, Nausea or vomiting, Diarrhea. The facility COVID-19 Control Measures Policy revised 10/1/20 states Educate all employees if having symptoms of a respiratory infection, fever, sore throat, nausea, vomiting, diarrhea, extreme fatigue, muscle pain, loss of taste and/or smell not to report to work and to contact their regular provider and Screen all employees prior to the beginning of the shift and every four hours. If any are identified as being ill, ask them to return home and contact their primary physician. The CDC Interim Guidance for [MEDICATION NAME] Testing for [DIAGNOSES REDACTED]-CoV2 (human coronavirus) revised 12/5/20 states [MEDICATION NAME] tests for [DIAGNOSES REDACTED]-CoV-2 are generally less sensitive than real-time reverse transcription polymerase chain (RT-PCR) and other nucleic acid amplification tests (NAATs) for detecting the presence of [MEDICAL CONDITION] nucleic acid and A negative [MEDICATION NAME] test result for a symptomatic person should be confirmed with an FDA (Food and Drug Administration)-authorized NAAT. On 1/11/21 at 10:00 am V1 Administrator stated all of the residents in the facility except one have tested positive for COVID-19. V1 stated a staff member most likely brought [MEDICAL CONDITION] into the facility. On 1/11/21 at 10:20 am V4 Laundry Aide and Housekeeper stated V4 had symptoms of a runny nose, nasal drainage and a cough three days before V4 tested for COVID-19 on 12/28/20. V4 stated V4 thought V4's symptoms were from seasonal allergies [REDACTED]. V4 stated V4 worked at the facility on 12/25/20, 12/26/20, 12/27/20 and 12/28/20. V4 stated V4 worked as a housekeeper on 12/25/20 and V4's duties included cleaning resident rooms, bathrooms and shower rooms. V4 stated on 12/26/20 and 12/27/20 V4 worked as a laundry aide and V4's duties were to collect dirty laundry from the shower rooms and put clean laundry away in resident closets and drawers. V4 stated, on 12/28/20 V4 helped with resident room moves and cleaning resident rooms due to several residents testing positive for COVID-19 on 12/28/20. V4 stated V4 was all over the building on 12/28/20. V4 Stated about an hour and 15 minutes before the end of V4's shift on 12/28/20, V4 tested positive for COVID-19 by a rapid COVID-19 test. On 1/14/21 at 1:45 PM V4 stated V4 delivered laundry to all residents over the weekend (12/26/20 and 12/27/20). V4 stated most residents were in their rooms and a few were in the hall. On 1/12/21 at 7:50 am V4 stated V4 self screened on 12/25, 12/26, 12/27 and 12/28. V4 stated V4 checked V4's own temperature and filled out a questionnaire about symptoms. V4 stated V4 should have documented V4's symptoms on the screening form (but failed to do so). On 1/11/21 at 11:00 am V3 Housekeeping Supervisor stated V3 had a dry cough that started on 12/27/20. On 1/12/21 at 7:00 am V3 stated on 12/28/20 V3 was tested with a rapid ([MEDICATION NAME]) COVID-19 test by V6 Regional Director of Operations and the test result was negative for COVID-19. V3 stated V3 told V6 that V3 had a cough but V6 did not instruct V3 to stay home from work. V3 stated V3 went back to the facility around 10:30 am on 12/28/20 and helped with resident room moves, deep cleaning resident rooms, and cleaning hand rails and door knobs due to the COVID-19 outbreak. V3 stated as the day went on V3 felt worse and around 4:00 PM to 5:00 PM a second rapid COVID-19 test was done with a positive result. V3 stated V3 screened V3's self before starting work on 12/28/20. V3 stated V3 thought V3 indicated on the screening form that V3 had a cough. On 1/14/21 at 7:15 am V3 stated V6 completed both of V3's rapid [MEDICATION NAME] COVID-19 tests on 12/28/20. V3 stated after V3 tested positive for COVID-19 V3 was told to finish what V3 was doing and then go home. V3 stated V3 finished delivering laundry to residents and then went home. V3 stated V3 noticed V4 was sneezing and had a runny nose on 12/28/20 around 10:30 am. V3 stated V3 told V4 to get tested for COVID-19 as soon as V4 could. V3 stated V4 was feeling well enough to work. V3 stated V4 was not sent home because they were focusing on moving residents to the COVID-19 Unit. The undated Staff Positive Test Spreadsheet documents V3 and V4 tested positive for COVID-19 on 12/28/20. V4's COVID Screening Questionnaire dated 12/25/20 through 12/28/20 does not document V4 has any signs or symptoms of COVID-19. V3's COVID Screening Questionnaire dated 12/28/20 does not document V3 has a cough or any symptoms of COVID-19. V4's Time Clock Entry sheet dated 12/1/20 through 1/14/21 documents V4 worked at the facility on 12/25/20 from 6:56 AM until 2:56 PM; 12/26/20 from 7:03 AM until 3:02 PM; 12/27/20 from 6:53 AM until 2:55 PM; and 12/28/20 from 6:50 AM until 1:30 PM. V3's Time Clock Entry sheet dated 12/1/20 through 1/14/21 documents V3 worked at the facility from 10:04 AM until 7:24 PM on 12/28/20. On 1/12/21 at 2:00 PM V2 Interim Director of Nurses and Infection Preventionist stated on 12/27/20 staff notified V2 that R1 was sent to the hospital for acute care needs and tested positive for COVID-19 at the hospital. V2 stated on 12/28/20 all staff and residents were tested for COVID-19. V2 stated approximately 20 residents tested positive for COVID-19 on 12/28/20. V2 stated staff screen themselves for symptoms of COVID-19 at the beginning of their shift. V2 stated if staff have symptoms they should report them before they enter the building. V2 stated even if an [MEDICATION NAME] test is negative staff can not work with symptoms. On 1/12/21 V15 Director of Nurses Local Public Health Department stated staff should not be working at the facility if they have symptoms of COVID-19. V15 stated the county positivity rate has been high and has been over ten percent for the last two months. The undated Positive Results Spreadsheet documents 49 residents residing at the facility tested positive for COVID-19 from 12/28/20 to 1/8/21. The Daily Roster dated 12/27/20 documents 50 residents resided in the facility on that date. An Immediate Jeopardy situation was identified on 1/14/21. The Immediate Jeopardy was determined to have begun on 12/25/20 when V4 Laundry Aide/Housekeeper came into work at 6:56 AM sick with symptoms (runny nose, nasal drainage and cough) of a highly contagious disease (COVID-19) and worked as a housekeeper and laundry aide throughout the building potentially exposing all residents to COVID-19. V1 Administrator was notified of the Immediate Jeopardy on 1/14/21 at 2:22 PM. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the immediate jeopardy: 1. A screening audit was completed of staff working in the facility on 1/19/21 to ensure that no staff with signs and symptoms of COVID-19 were working in the facility. Completed by Administrator and Business Office Manager. 2. Staff responsible for oversight of staff screenings were interviewed and confirmed that they were educated regarding review of the screening tool and process for the nurse to completed staff screenings before entrance into the building. Completed by Administrator and Director of Nursing. 3. The Nursing staff was educated on the accurate completion of the screening tool, that all staff are to be screened by a nurse prior to coming into the building and the severity of allowing staff with symptoms of COVID-19 to work in the building. Completed by Administrator and Director of Nursing. 4. All staff were educated not to come to work with symptoms of COVID-19, on accurate reporting of symptoms, and that they must be screened by a nurse before working in the building. Completed by Administrator and Director of Nursing. 5. All staff were educated that any concerns identified on the screening tool should be immediately reported to a supervisor or the Administrator. Completed by Administrator and Director of Nursing. 6. V1 Administrator confirmed V1 reviewed the plan of correction with V17 Medical Director on 1/20/21. B.)Based on interview and record review the facility failed to prevent the potential spread of COVID-19 by failing to ensure symptomatic COVID-19 positive staff were not working in the facility. This failure has the potential to affect all 50 residents residing in the facility. Findings include: b.) The Centers for Disease Control and Prevention's Criteria for Return to Work for Healthcare Personnel with [DIAGNOSES REDACTED]-CoV-2 Infection dated 8/10/20 states Symptom-based strategy for determining when HCP (Healthcare Personnel) can return to work. HCP with mild to moderate illness who are not severely immunocompromised: At least ten days have passed since symptoms first appeared and at least 24 hours have passed since last fever without the use of fever-reducing medications and symptoms (e.g. cough, shortness of breath) have improved. The facility Staffing for COVID-19 policy revised 5/17/20 states Suspected or diagnosed COVID-19 in LTCF (Long Term Care Facility) of any employee that is symptomatic will not be allowed to work until meets criteria and consult with the local health department on when an employee can return to work. The facility COVID-19 Control Measures policy revised 10/1/20 states Maintain Employee infection control log. Review daily to identify any patterns of trends of employees exhibiting signs/symptoms of COVID-19. The undated Positive Results Spread Sheet documents V5 Licensed Practical Nurse and V3 Housekeeping Supervisor tested positive for COVID-19 on 12/28/20. The Spread sheet documents 40 staff members tested positive for COVID-19 between 12/28/20 and 1/9/21. On 1/12/20 at 2:49 PM V1 Administrator provided Employee Infection Control Logs. The Logs document employee symptoms, date of onset of infection and dates absent from work. The last entry on the December 2020 Employee Infection Control Log is dated 12/21/20 and thus was incomplete. No Employee Infection Control Log was available for review or provided for January 2021. The Electronic Mail dated 12/28/20 from V6 Corporate Nurse to V16 Local Public Health Department Staff and carbon copied to V1 Administrator and V2 Interim Director of Nurses states Thank you for allowing us to bring back our asymptomatic staff to work on the Covid Unit, that will ensure we are able to provide the best care possible. On 1/12/20 at 10:30 am V5 stated V5 had chills, a headache, muscle aches and diarrhea that started on 12/27/20. V5 stated V5 tested positive for COVID-19 on 12/28/20. V5 stated on 1/3/21 V2 (Interim Director of Nurses) called V5 and asked V5 to come back to work. V5 stated V2 knew V5 was still having symptoms of COVID-19. V5 stated V5 worked on the COVID-19 Unit on 1/4/21, 1/5/21, and 1/6/21. V5 stated V5 was having symptoms of cough and fatigue. V5 stated on 1/7/21 V5 was unable to work due to fatigue and V5 has not been back to work since that time. V5's Time Clock Entry sheet dated 12/1/20 through 1/14/21 documents V5 worked at the facility 1/4/21, 1/5/21, and 1/6/21. On 1/11/21 at 11:00 am V3 Housekeeping Supervisor stated V3 tested positive for COVID-19 on 12/28/20. V3 stated V3 had symptoms of cough, congestion, chest pain and nausea. V3 stated V3 was told that when V3's symptoms improved V3 could come back to work. V3 stated V3 worked at the facility as a housekeeper on the COVID-19 Unit on 1/2/21, 1/3/21 and 1/4/21 while V3 still had a cough. On 1/12/21 at 7:00 am V3 stated on 1/2/21, 1/3/21 and 1/4/21 V3 worked as a housekeeper on the COVID-19 cleaning resident rooms, and sanitizing hand rails, door knobs and high touch areas. V3's Time Clock Entry sheet dated 12/1/20 through 1/14/21 documents V3 worked at the facility 1/2/21, 1/3/21, and 1/4/21. On 1/14/21 at 1:15 PM V1 Administrator confirmed V3 and V5's 12/1/20 through 1/14/21 time sheets. On 1/12/21 at 8:50 am V15 Director of Nurses Local Public Health Department, stated V15 was concerned that symptomatic COVID-19 positive staff were working at the facility. V15 stated facility staff called the Local Health Department on 12/28/20 with questions and V16 told them that symptomatic COVID-19 positive staff can not work at the facility even on the COVID-19 Unit. V15 stated V6 (Regional Director of Operations) sent an electronic mail to V16 (Local Public Health Department staff) on 12/28/20 confirming V6 understood that only asymptomatic COVID-19 positive staff could work on the COVID-19 Unit. On 1/14/21 at 9:08 AM V6 Regional Director of Operations stated at the beginning of the outbreak on 12/28/20 V6 spoke with V16 Local Public Health Department Staff and V6 thought symptomatic COVID-19 positive staff could work on the COVID-19 Unit. V6 stated later V6 understood that no symptomatic COVID-19 positive staff could work at the facility. 1/14/21 at 1:15 PM V1 Administrator confirmed symptomatic COVID-19 staff were allowed to work at the facility on the COVID-19 Unit. V1 stated V1 was absent from the facility from 12/10/20 through 12/30/20. V1 stated if V1 had been at the facility V1 would have called staff to check on their symptoms. V1 stated V1 does not have a log or tracking of employee symptoms. V1 stated V2 is responsible for all infection control. On 1/14/21 at 8:10 am V2 stated V2 uses infection control logs to monitor and track employee infections and symptoms. V2 stated prior to 1/4/21, when V2 tested positive for COVID -19, V2 was responsible for keeping up the employee infection control logs. V2 stated after 12/28/20 V2 had to work as a floor nurse so V2 could not update the logs. V2 stated V2 assumed V1 was monitoring staff symptoms and return to work status. The undated Positive Results Spreadsheet documents 49 residents residing at the facility tested positive for COVID 19 from 12/28/20 to 1/8/21. The Daily Roster dated 12/27/20 documents 50 residents resided in the facility on that date.

Based on record review, interview and observation, the facility failed to identify and implement appropriate fall interventions for a cognitively impaired resident (R25) and failed to supervise a cognitively impaired resident (R50), both with known histories of multiple falls. R25 and R50 are two of four residents reviewed for falls in the sample list of 17. R50 was admitted to a hospital with acute trauma, scalp laceration and a skull fracture after falling on 10/12/19 at the facility. Findings include: 1. R50's Minimum Data Sheet ((MDS) dated [DATE] includes the following Diagnoses: [REDACTED]. This same MDS documents R50 as being severely cognitively impaired, supervision required when ambulating, is to be supervised when up ambulating and has had multiple falls. A facility report titled Fall Risk assessment dated [DATE] documents R50 as being high risk for falls. The facility Fall log dated 1/2019 through 1/2020 documents R50 with the following falls: 2/21/19, 6/15/19, 7/26/19, 8/9/19, 9/9/19, 10/7/19 and 10/12/19. R50's Plan of Care documents that R50 has an identified problem area of Wandering behaviors and to provide supervision and to accompany resident to go where desired. This same Plan of Care identifies R50 with a problem area of falls due to R50 not understanding mobility limits due to cognitive impairment. Interventions of a safety helmet implemented on 7/1/16, keep resident within visuals while ambulating was implemented on 9/21/18. The Plan of Care also documents that R50 was sent to the emergency roiagnom on [DATE] due to a fall and to continue previous safety interventions. This same intervention of continue previous safety interventions are documented in the Plan of Care for falls dated 8/9/19 and 8/18/10. A facility report titled Final Report dated 10/18/19 includes the following documentation on R50: On (MONTH) 12, 2019 at (9:10pm) (R50) was found lying on the floor in the hallway, (R50) assessed and sent to the Hospital for (Evaluation) and (treatment). (R50 had been walking up and down the hallway as (R50) usually does. Staff stated they went to take a resident to the bathroom and passed (R50) in the hallway walking. Staff heard male resident yelling for help, immediately went to see and observed (R50) lying on the floor with no objects around. Nurse was immediately notified and (R50) assessed, (R50) was sent to the Hospital for (evaluation and treatment). Staff Interviews: (V13, Certified Nursing Assistant) works 10-6-I didn't witness the fall. (R50) was up walking when I passed (R50) in the hallway to take another resident to the restroom. I was in the bathroom with another resident when I heard yelling for help from a male resident. I came out and seen a resident on the floor. I called for help from the nurse immediately. I got vitals and (R50) went out to the hospital. V14, Certified Nursing Assistant works 2-10pm-stated I was in the shower room providing ADL (activities of daily living) care to another resident, didn't witness the incident. No other staff member witnesses (sic) this incident. V13, Certified Nursing Assistant documents in a written statement (undated) that V13 did not witness the fall due to toileting another resident and was aware R50 was in the hallway ambulating. This statement is signed by V13. There is no signed statement from V14. Neither Certified Nursing Assistant were available for interview. Hospital records dated 10/13/19 at 1:06 am document the following on R50: (R50 is a [AGE] year old female that presents as a transfer after a fall. The patient has a history of dementia and non-verbal at baseline. History obtained from (R50's) son. (R50) reportedly stood up to ambulate without assistance at her (facility) and fell . She has had recurrent falls for which she wears a helmet. Electronically signed by V16, Hospital Admitting Physician CT (Computed [NAME]ography) Brain (10/13/19): Indication : Acute Trauma; Impression: 1. Small hemorrhagic contusions along the floor and anterior aspect of the right frontal lobe. 2. Left occipital skull fracture which is minimally displaced 3. Cerebral and cerebellar atrophy 4. Small vessel ischemic/[MEDICAL CONDITION] changes 5. Posterior scalp hematoma.; Active Hospital Problem: Diagnoses; Principal Problem Fall; Scalp Laceration, posterior; Occipital fracture; Brain contusion with no loss of consciousness; Trauma - Plan: Admit to surgical floor CT Brain without contrast (10/14/19) Findings: There is redemonstration of trace scattered subarachnoid hemorrhage, which is most pronounced in the right inferior frontal region. This is slightly less conspicuous from prior CT. Trace intraventricular hemorrhage within the occipital horns is more pronounced, which may be related to redistribution. There is redemonstration of bilateral subdural collections, which are increased in size from the prior exam. For reference, the left convexity subdural collection measures 1.5 cm (centimeters in thickness in the right convexity subdural collection measures up to 0.9 cm in thickness (series 2 image 19. On prior CT these collections measured 1.0 and 0.7 cm respectively. The subdural collections are predominately hypodense; although, there is hyperdensity posteriorly on the right (series 2 image 17). There is redemonstration of a non-displaced left occipital calvarial fracture. The middle ear cavities and mastoid air cells reveal no significant opacity. Impression: 1. Increased size of subdural collections along the bilateral cerebral convexities, left greater than right. 2. Slight improvement of trace subarachnoid hemorrhage and increased prominence of trace intraventricular hemorrhage. 3. Non-displaced left occipital calvarial fracture Electronically signed by V15, Radiologist On 2/5/20 at 1:55 pm, V2 Director of Nursing defined and stated supervision of a resident meant that the resident is within visuals of staff at all times. V2 confirmed that R50 was in the hallway ambulating without supervision, fell and was sent to the hospital on [DATE]. V2 stated R50 had a soft helmet on, but could not say whether the helmet had been removed prior to the fall. 2. R25's physician's orders [REDACTED]. The Minimum Data Sheet ((MDS) dated [DATE] documents R25 as being severely cognitively impaired. The MDS also documents R25 requires one person physical assist for transfers, walking in the room, walking in the corridor and requires two person physical assist for toileting. The facility form titled Fall Risk assessment dated [DATE] for R25 documents Fall Risk scores for 8/7/19, 9/20/19 and 11/29/19 at high risk. The form documents R25 to have Occasional Confusion, and Loss of Balance with standing and walking. R25's Care Plan dated 11/22/2019 documents R25 is to have one assist and gait belt for all ambulation. Use additional assist as needed. Personal alarm on while in bed and while up in chair. Check position with cares and functions each shift. R25 is known to unplug and shut off alarm. On 11/8/19 this same Care Plan documents R25 is frequently non-compliant with waiting for staff assistance with ambulation. A facility report titled Final Report dated 1/10/20 documents R25 falling on 1/4/2020 and being admitted to the hospital with [REDACTED]. The report documents R25 was yelling and the CNA (Certified Nursing Assistant) hearing her yell went into the room and found both R25 and her room mate on the floor. The facility report titled AIM for Wellness dated 1/4/20 documents under Nursing Notes R25 complaining of right hip pain, unable to move (R25's) right leg. Shortening noted. Orders received from Nurse Practitioner (V12) to send (R25) to emergency room for evaluation and treatment. Hospital records titled Emergency Department Note Physician Final Report dated 1/4/2020 documents the following for R25: Chief Complaint - (R25) in ED ( Emergency Department) following fall. (R25) has shortening of the right leg. This patient (R25) is an (sic) [AGE] year old female presented to the emergency department by EMS (Emergency Medical Service) from (facility) for an evaluation from a fall. From what can be gathered, (R25) was found on the floor and nursing staff observed shortened right lower extremity. (R25) is complaining of right hip pain and there is obvious shortening of the right lower extremity. X-Ray of the right hip: Impression: Right Intertrochanteric Femur Fracture. On 2/5/20 at 2:05 pm, V2 Director of Nursing confirmed that on 1/4/20, R25 had gotten up from the recliner in the room to help R25's roommate. V2, also confirmed R25's Plan of Care for fall interventions prior to 1/4/20 included pressure alarms while in recliner and bed, with frequent checks. V2 stated R25 has previously had therapy and was instructed to use the call light and wait for assistance. V2 confirmed there were no alarms being used for R25 the night she fell [DATE]. The facility policy titled Fall Prevention dated 11/10/18 documents the following: 1. Conduct fall assessments on the day of admission, quarterly, and with a change in condition. 2. All staff must observe residents for safety. If a residents (sic) with a high risk code are observed up or getting up, help must be summoned or assistance must be provided to the resident. 5. Immediately after any resident fall the unit nurse will assess the resident and provide any care or treatment needed for resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. 7. Report all falls during the morning Quality Assurance meetings Monday through Friday. All falls will be discussed in morning Quality Assurance meeting and any new interventions will be written on the Care Plan. Fall Prevention Interventions: Keep in visual when out of bed. Instructions for resident not cognitively impaired to use call light and wait for assistance.

Based on observation, interview and record review the facility failed to provide a safe environment and supervision to prevent an accident for one of three residents (R1) reviewed for accidents. These failures resulted in R1 falling from the van and sustaining two rib fractures. Findings include: The Physician order [REDACTED]. The Minimum (MDS) data set [DATE] documents R1 is severely cognitively impaired and requires supervision and set up assistance with transfers and locomotion. The Care Plan updated 7/31/19 documents R1 has poor safety awareness and ignores safety standards. The Final Report dated 8/28/19 documents Summary: On (MONTH) 21, 2019 (R1) received a fall that resulted in anterior lateral 9th and 10th rib fractures. The Final Report documents V3 Activity Director, CNA (Certified Nurses Aide) stated We had taken five residents on an outing. When we got back we were unloading residents from the van. Everyone that went was using the lift. I had just lowered the lift to unload a resident (R2) and had assisted (R2) through the facility door when I returned. I had not raised the lift yet as I had to get the previous resident (R2) out of the way. I heard (V4 CNA) yelling No No No and got to the back of the van in time to see (R1) fall from the van in (R1's) wheelchair. (R1) landed on (R1's) shoulders. The Final Report documents V4 stated We were unloading residents from out of the van from our outing. I put (R1) in (R1's) wheel chair and (R1) began to move (R1's self) towards the lift. I realized the lift wasn't up and (R1's) wheelchair began to tip backwards. I tried to hold onto (R1) but could not. (R1) fell backwards in (R1's) wheelchair onto the lift. The Final Report documents R1 stated the girl (V4) had just put me in my wheelchair and I started moving back to go on the lift but the lift was not up and I fell back. The Radiology Report dated 8/21/19 documents R1's left ninth and tenth ribs are fractured. On 9/5/19 at 12:30 PM the rear wheelchair loading van was observed with V6 Transporter. The measurement of the distance from the floor of the van to the ground was 28 inches. On 9/4/19 at 12:10 PM, R1 was in R1's wheel chair moving the wheel chair back and forth with R1's foot. On 9/4/19 at 1:05 PM R1 was seated the R1's wheel chair and R1 was propelling R1's self in the hallway. On 9/4/19 at 10:40 AM, V4 stated (on 8/21//19) V4 and V3 were on a pontoon boat outing with residents. V4 stated when they returned to the facility in the van, V3 and V4 were unloading residents from the van using the wheelchair lift. V4 stated V4 transferred R1 from the van seat to R1's wheelchair and V4 locked the wheels of R1's wheelchair. V4 stated R1's wheelchair was about two feet from the edge of the van floor. V4 stated V4 turned V4's back to grab something and when V4 turned back to R1, R1 was moving R1's feet to go backwards onto the ramp but the ramp was not raised and R1 fell . V4 stated R1 must have unlocked the wheel chair brakes. V4 stated they were having the same problem with R1 on the pontoon boat. V4 stated R1 kept unlocking the wheelchair wheels and moving the wheel chair back and forth on the boat. V4 stated they kept relocking the wheels and asking R1 to stop unlocking them but R1 kept unlocking the wheelchair wheels. On 9/4/19 at 11:00 am V3 stated V3 had taken another resident (R2) off the van with the wheelchair lift and left the lift in the down position while V3 propelled R2 to the facility. V3 stated V3 was at the facility door when V3 heard V4 yelling. V3 stated V3 came around the side of the van and saw R1 falling out of the van in R1's wheelchair. V3 stated R1 fell on R1's shoulder area. V3 stated V3 would normally raise the lift before stepping away from the van. On 9/4/19 at 11:35 am V1 Administrator stated it is safer to always have the lift in the raised position on the van. V1 stated the policy now is to always raise the lift before walking away even if no residents are left on the van. On 9/4/19 at 2:40 PM V5 Physician stated staff should not leave anyone where they can fall. V5 stated someone should have been with R1 so R1 could not move while R1 was in the wheelchair on the van. V5 stated V5 could see how R1 might try to push things along so R1 could get off the van. V5 confirmed R1 fractured two ribs when R1 fell out of the van.

Based on observation, interview and record review the facility failed to immediately report three (3) acquired Stage II Pressure Ulcers to the Nurse, failed to follow the policy for initial treatment, the staff failed to assure the pressure relieving cushion was properly placed in R3's chair, failed to follow the Care Plan for repositioning at least every two hours, failed to follow Physician order [REDACTED]. These collective failures led to the development of new stage II pressure ulcers, unknown by the facility, and worsening of existing pressure ulcers for R3 and R4. Findings include: 1. The physician's orders [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] indicates that R3 requires extensive assistance with bed mobility, transfers, Activities of Daily Living, and toileting. The Skin assessment dated [DATE] indicates R3 is at moderate risk for skin breakdown. The Quality Care Reporting Form dated 8/10/13 documented an unstageable skin tear and described the location as "coccyx-red area with minimal drainage, 4.0 centimeters (cm) x 3.0 cm x 0.1 cm". The Weekly Wound Tracking Report dated 8/10/13 documented a facility-acquired Stage II pressure ulcer on R3's coccyx measuring 1.2 cm x 2.2 cm x 0.1 cm. Another Weekly Wound Tracking Report dated 11/20/13 documented a facility-acquired, unstageable excoriation on left posterior scrotal sac measuring .05 cm x 0.6 cm x 0.1 cm. The Physician Communication and Progress Note dated 8/10/13 documented "coccyx-red area 4.0 cm x 3.0 cm x 0.1 cm, resident (R3) and adds "spends more time in recliner. Needs reminded to lay down after meals and at HS (hours of sleep)." On 12/2/13 at 8:10 am E6 and E22 CNAs (Certified Nursing Assistants) provided incontinence care for R3 and stated that R3 had three open areas on this coccyx that were not there the last time R3 was checked. E6 stated that the areas on R3's coccyx were "open and bleeding." On 12/2/13 at 10:00 am R3 was seated in a recliner chair. Consistent observations (every 15 minutes) of R3 reflect that R3 remained seated in the same recliner chair in the same relative position from 10:00 am to 12:00 pm without being repositioned. At 12:00 noon R3 received his lunch tray while seated in the same chair and remained seated in the same relative seated position in this this chair until 2:00 pm, for a total of four hours. On 12/4/13 at 3:05 pm E7 (MDS/Care Plan Coordinator) stated that staff are to reposition or walk R3 every two hours. On 12/3/13 at 11:50 am E2 (Director of Nursing) stated that she was only aware of the excoriation area on R3's scrotum which is healing and not aware of any open areas on R3's coccyx. E2 stated that CNA's are supposed to report open areas to the nurse immediately. The nurse will complete the assessment and measurements and contact the doctor, family and dietary. According to E2 this was not done. E2 stated that R3 should be repositioned a minimum of every two hours. E2 stated, "(R3) has a gel pad in his soft chair." On 12/3/13 at 2:35 pm E21 (Nursing Assistant) lifted the incontinence pad off the chair cushion and stated "the gray side is up. This is how I put the cushion in the chair." On 12/3/13 at 2:40 pm E2 referenced the cushion in R3's chair and stated that the cushion was placed in R3's chair upside down and that the gray section is to be on the bottom. On 12/5/13 at 9:45 am E1 (Administrator) stated that E2 is educating the staff since 12/2/13 to place the cushion in resident's chairs with the gray section on the bottom. On 12/2/13 at 12:05 pm E10 (Licensed Practical Nurse, LPN) stated she was not informed of R3's newly discovered pressure ulcers found by E6 and E22 that morning. E10 stated, "CNA's did not report to me about bleeding areas on the resident's (R3) buttocks today." On 12/3/13 at 2:00 pm E6 and E20 removed R3's saturated brief to allow E10 to examine the open areas on R3's coccyx. E10 measured three areas on R3's coccyx and stated the pressure ulcers are Stage II. E10 stated that two areas on the right coccyx measure 0.5 centimeters (cm) x 0.3 cm and 0.9 cm x 0.5 cm, and the area on the left coccyx measures 0.5 cm x 0.2 cm. E10 confirmed the pressure ulcers were acquired in the facility. E10 applied barrier cream to the open areas and then left the room to allow E6 and E20 to complete incontinence care. On 12/3/13 at 2:10 pm E6 replaced R3's saturated incontinence brief with a dry brief without providing proper hygiene (cleansing). On 12/3/13 at 2:30 pm E6 stated, "I forgot to wash him (R3)." E6 referenced the policy for incontinence care and stated, "We will clean them (residents) up with soap and water. Yes. He (R3) should have been cleaned with soap and water. I totally forgot to clean him (R3). (R3) didn't get washed up." R3's Restorative Nursing Scheduled Toileting Program dated 3/15/13 documented "Peri (Perineal) care after each incontinent episode." An undated Perineal (Peri) Care Policy for Male Without Catheter provided on 12/4/13 by E2 includes the following procedure to, "....Wet washcloth and apply cleansing agent chosen. Wash pubic area, including upper inner aspect of both thigh as well as the penis and scrotum...Rinse area in same sequence, if applicable..." On 12/9/13 at 12:30 pm E2 referenced E10's assessment and initial treatment of [REDACTED]. R3's open areas should have been cleansed with Normal Saline and Hydrogel or Collagen applied. This protocol should have been implemented until a doctor's order was received to change it." 2. physician's orders [REDACTED]. The Wound Tracking Report dated 11/18/13 documents a newly acquired Pressure Ulcer on R4's left heel measuring 1.0 cm x 0.5 cm x 0.2 cm (depth). The Newly Acquired Skin Condition Report dated 11/19/13 identifies a Stage II Pressure Ulcer on R4's left heel. The Minimum Data Set ((MDS) dated [DATE] indicates that R4 requires extensive assistance with bed mobility, transfers, Activities of Daily Living, hygiene, bathing, and toileting. The Skin assessment dated [DATE] indicates R4 is at moderate risk for skin breakdown. On 12/9/13 at 11:00 am E7 (Licensed Practical Nurse, LPN) referenced a pressure ulcer on R4's left heel, which was first diagnosed on [DATE]. E7 stated that R4's left heel pressure ulcer has "recurred" on 5/24/13, 9/12/13, and 11/18/13. E7 stated that R4 was seen at wound clinic on 11/19/13 and 12/6/13. E7 stated, "Yes, (R4) still has the left heel pressure ulcer." On 12/2/13 at 12:55 pm E3 (LPN) stated, "I came to measure the ulcer on (R4's) left foot." E3 removed R4's protective boot and stocking and stated that there was no pressure ulcer dressing to remove. E3 stated the measurements of the area were 2.0 cm x 2.0 cm. On 12/5/13 at 9:20 am E8 Registered Nurse (RN) stated there is no dressing on R4's left heel pressure ulcer. E8 stated, "A dressing should be on to cover the area." E8 cleansed R4's left heel with Normal Saline, applied antibiotic ointment and a gauze sponge then wrapped dressing with Kling (gauze). E4 stated, "I did not apply a [MEDICATION NAME] pad. I used a gauze pad." Physician Protocol Orders dated 11/19/13 state "treatment for [REDACTED]. The Physician order [REDACTED]. On 12/5/13 at 9:30 am and 12/9/13 at 11:30 am E2 stated that R4's dressing changes on the left heel are documented on the Treatment Administration Record. E2 stated that there is no documentation for R4's dressing being changed on November 27, December 2, 3, or 4, 2013. E2 also stated "The [MEDICATION NAME] pad is non-adhering to the wound area. The order calls for [MEDICATION NAME] to be used." Treatment Records dated November 2013 and December 2013 document that R4's pressure ulcer dressing was not changed on 11/27/13, 12/2/13, 12/3/13, and 12/4/13.

Based on interview, record review and observation the facility failed to supervise R2 and R3, resulting in R2 sustaining a fractured wrist when he tipped over in his wheel chair. R3 sustained a fall from the toilet with minor injuries. The facility failed to properly transfer R4, a non-weight bearing resident to the toilet, resulting in the gait belt slipping up under the breasts and staff pulling up on resident's arms. R2, R3, and R4 are three of five residents reviewed for falls inthe sample of 14. Findings Include: 1. R2's Minimum (MDS) data set [DATE] documents he is moderately cognitively impaired and requires extensive to total assist with bed mobility, transfers, wheelchair locomotion and activities of daily living. The Physical Restraint assessment dated [DATE] documents a soft cushion restraint was implemented for R2 on that date due to a history of multiple falls, forward leaning upper body, cognitive impairment and unawareness of safety needs. The fall investigation dated 10/15/13 documents R2 was found in his room, in his wheelchair with his wheelchair tipped over on its left side with a soft cushion restraint in place with his left arm behind him on that date. The same investigation report documents that R2's roommate, R24, reported that R2 stood up from his wheelchair and the wheelchair tipped over sideways. Nurses Notes dated 10/15/13 10:30 AM document that at that time R2's left arm was pinned under his body. Nurses Notes dated 10/15/13 document R2 was sent to the local hospital emergency room at that time. The X-Ray report dated 10/15/13 documents R2 was diagnosed with [REDACTED]. The Fall Analysis Log dated January 2013 through October 2013 documents R2 experienced 16 falls prior to the 10/15/13 fall including a fall on 6/5/13 when R2 flipped over backwards while he was seated in his wheelchair. On 12/4/13 at 2:20 PM E2 Director of Nurses confirmed that R2 was in his room seated in his wheelchair with a soft cushion restraint in place across his lap unsupervised when he fell on [DATE]. At that time E2 stated that R2 should not be left in his wheelchair unsupervised and that during her investigation she was unable to determine why R2 was left unsupervised in his in his wheelchair on 10/15/13. On 12/4/13 at 1:35 pm E19 Certified Nurses Aide (CNA) stated R2 frequently leaned over his soft cushion restraint while he was seated in his wheelchair and frequently tried to stand up while he was seated in his wheel chair with the soft cushion restraint in place before he fell {on 10/15/13}. At that time E19 further stated that when she began working at the facility in August she was instructed not to leave R2 unsupervised while he was seated in his wheelchair. On 12/4/13 at 1:40 PM E23 CNA stated that {prior to the 10/15/13 fall} R2 was not be left unsupervised in his wheelchair with the soft cushion restraint in place because he had a tendency to try to stand up. 2. physician's orders [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] indicates that R4 weighs 182 pounds at 64 inches in height and requires extensive assistance with bed mobility, transfers, Activities of Daily Living, hygiene, bathing, and toileting. The MDS also documented that R4 is frequently incontinent and does not walk. The Fall assessment dated [DATE] indicates R4 is at high risk for falls. On 12/3/13 at 11:20 am E6, E17, and E22 (CNAs) entered R4's room to assist R4 to the bathroom. E6 applied a gait belt to R4 while seated in the wheelchair. E6 and E17 struggled to raise R4 from the wheelchair. E6 and E17 with one hand on the gait belt and another under the R4's arms, transferred R4 to the high rise toilet seat. During this transfer R4 was not bearing any weight. The gait belt rose from R4's waist area to under R4's breasts. R4's elbows and arms were stretched upward. R4's knees were buckled and only the toe area of the boot protectors contacted the floor. E17 stated, "(R4) did not stand up at all. We lifted her." E17 stated that R4 was not bearing any weight and was extremely heavy. E17 stated, "I think (R4) weights about 275 pounds." On 12/5/13 at 8:50 am E5 (CNA) stated, "On Monday 12/2/13 we had to use the bed pan because she (R4) was not weight bearing. If I go to raise her (R4) to a standing position and she (R4) is unable to help, then we get the (mechanical lift). If resident (R4) is unable to bear weight, I would not attempt to put her (R4) on the toilet." On 12/3/13 at 11:35 am E7 LPN (Licensed Practical Nurse and Care Plan Coordinator) stated, "I did not know this resident (R4) was a three-person transfer to use the toilet. My understanding was that she (R4) was not bearing weight..." E7 stated that it was determined that if R4 could not bear weight staff were to use a mechanical lift for transfers. On 12/3/13 at 11:50 am E1 (Administrator) stated that if the R4 cannot bear then a mechanical lift should be used in transferring R4 to the bed and use a bed pan. E1 added, "And if a (mechanical lift) is being used then they (CNAs) should not transfer (R4) to a high rise toilet." 3. The physician's orders [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] indicates that R3 has severe cognitive impairment and requires extensive assistance with bed mobility, transfers, Activities of Daily Living, and toileting. The Physical Therapy Recertification Report dated 10/23/13 documented R3 is a fall risk with poor posture, tight neck muscles affecting posture, decreased standing balance, and unsteady gait. The Fall Log Report documented R3's falls on 4/23/13, 5/19/13, 6/13/13, 8/13/13, 10/8/13 and 10/16/13. Nurses Notes dated 8/13/13 at 6:20 am document that R3 was found on floor in the bathroom doorway lying on his (R3) right side with right side of head and right shoulder on door frame. There was a "small abrasion on (R3's) right shoulder with red area and also a red area on(R3's) right side of head." R3 was transferred by ambulance to the hospital and admitted for observation. On 12/4/13 at 3:35 pm E2 (Director of Nursing) reference R3's Fall Investigation Report dated 8/13/13 and stated that the CNA (no longer at the facility) had taken (R3) to the bathroom and clipped the call light to R3's shirt, within reach, and then went to see about another resident. E1 stated, "When the CNA returned (R3) was on the floor." E1 stated that R3 was unsupervised during the time the CNA left to attend to another resident. E1 stated that R3 was capable of using the call light at the time of this fall but R3 was not consistent in using it. On 12/5/13 at 10:25 am E7 Care Plan Coordinator referenced R3's fall on 8/13/13 and stated that R3 is cognitively impaired and should not have been left alone in the bathroom. E7 stated that the MDS dated [DATE] indicated that R3 required one assistant for toilet use. On 12/2/13 at 3:25 pm E7 referenced R3's fall on 8/13/13 and stated that she updated R3's Care Plan to "remind (R3) to use call light for toileting." E7 added that R3 is inconsistent with using the call light and sometimes he doesn't use it. On 12/3/13 at 8:05 am and 8:35 am E6 CNA stated that R3 sleeps most of the time. E6 stated that when R3 was first admitted to the facility (R3) was more alert and able to pull the light cord. E6 stated that R3 has not been able to use the call light for the past 7-8 months. On 12/5/13 at 10:45 am E1 referenced R3's unsupervised fall in the bathroom on 8/13/13 and stated there is no specific policy for supervising a resident during toileting.

Based on interview, record review and observation the facility failed to provide justification for the use of duplicative antipsychotic medication therapy and failed to attempt gradual dose reductions for antipsychotic medications for two of four residents (R2 and R3) reviewed for psychoactive medications in the sample of 14. These failures resulted in somnolence for R2 and R3 in addition to functional declines with ambulation, transfers and all activities of daily living for R2. Findings Include: 1.) The Behavioral Center Discharge Summary dated 5/24/13 documents R2 was admitted to the Behavioral Center on 5/11/13 with a chief complaint of increased verbal and physical aggression and that R2 has [DIAGNOSES REDACTED]. The same Discharge Summary documents R2 returned to the facility on [DATE] with orders for the following medications [MEDICATION NAME] (antipsychotic) 5 milligrams (mg) in the morning and 10 mg in the evening, [MEDICATION NAME] (antipsychotic) 10 mg twice daily and [MEDICATION NAME] (antidepressant) 150 mg twice daily. The Minimum Data Set discharge assessment dated [DATE] documents R2 required only limited assistance with transfers, ambulation and activities of daily living when he was transferred to the Behavioral Center on 5/11/13. The Minimum (MDS) data set [DATE], eight days after readmission to the facility from the Behavioral Center, documents that R2 required extensive assist with transfers, ambulation and all activities of daily living except eating. On 12/9/13 at 2:00 PM the functional decline documented on R2's 5/10/13 and 5/31/13 Minimum Data Sets was reviewed with E7 Minimum Data Set Coordinator at that time she stated she believed R2's decline was caused by his {antipsychotic} medication. Nurses Notes dated 7/22/13 document Z4 family member requested a medication review for R2 due to weight loss and multiple falls. Nurses Notes dated 7/25/13 document a new order to decrease R2's [MEDICATION NAME] to 100 mg twice daily with no changes in R2's antipsychotic medication. The Physical Restraint assessment dated [DATE] documents R2 was restrained on that date with a soft cushion lap restraint due to a history of multiple falls, unsteady balance when standing and ambulating, and upper body forward leaning. Nurses Notes dated 8/11/13 document Z4 family member requested a further reduction in R2's sedating medication on that date stating "It seems like he sleeps all the time." Nurses Notes dated 8/13/13 document the following order from R2's Physician Z2, "continue {medications} at present dose unless the family insists on a decrease." The September, October, November and December 2013 Behavior Monitoring Records Document R2 has target behaviors of yelling and cussing, kicking and hitting, rolling around on the floor, resistant to care, urinating in inappropriate places, becoming agitated when he sees himself in the mirror, exit attempts and wandering. The September 2013 Behavioral Monitoring Record documents R2 had six episodes of rolling around on the floor, one episode of resisting care and one episode of cursing and attempting to hit a Certified Nurses Aide (CNA) during the month of September. The October 2013 Behavior Monitoring Record documents R2 had three episodes of unplugging the bed (10/13/13 and 10/23/13), two episodes of rolling on the floor (10/27/13 and 10/28/13), and one episode of being resistive care (10/27/13). The November and December 2013 Behavior Monitoring Records through 12-9-13 document that R2 exhibited no behaviors. The Minimum (MDS) data set [DATE] documents that R2 exhibits no behaviors and no wandering and that R2 has declined to requiring total assistance with transfers, hygiene and bathing and that R2 is unable to ambulate. On 12/3/13 at 10:50 AM E10 Licensed Practical Nurse stated that R2's behaviors can be easily redirected. On 12/2/13 at 3:55 PM E9 CNA stated R2's behavior is not aggressive. On 12/2/13 at 12:25 PM R2 was sitting in his wheel chair with his trunk flexed leaning forward and appeared lethargic. On that same day at 12:45 PM R2 was slumped over in his wheelchair leaning on his soft cushion restraint and the right side of his wheel chair sleeping. At 1:05 PM on that same day R2 required total assistance of E11 CNA and E12 CNA to transfer from his wheelchair to his bed. R2 then slept as E11 and E12 assisted him with incontinence care. On that same day R2 was sleeping at 3:30 PM and 3:50 PM. On 12/3/13 at 7:25 AM R2 was seated at the assist dining table with his trunk flexed forward leaning to his left side and over his soft cushion restraint. At 7:30 AM E16 CNA sat down at the table with R2, removed the soft cushion restraint and asked R2 if he could sit up. R2 did not sit up and his trunk remained in a flexed position as E16 fed him his breakfast. At that time E16 stated that {R2} is leaning over because he is tired. On that same day at 8:00 AM E16 and E17 CNA transferred R2 from his wheel chair to his bed. At that same time E16 stated sometimes R2 sleeps through his meals. At 12:05 PM on that day E17 stated R2 has been in his bed since he finished breakfast (at 8:00 AM) and that R2 was sleeping when she came in to reposition him. E17 further stated at that time that R2 looked sleepy. On 12/4/13 at 7:50 AM R2 was seated in his wheelchair at the assist dining table with his trunk flexed forward. On 12/3/13 at 12:25 PM E2 Director of Nurses stated that R2's forward leaning increased after he returned to the facility from the behavioral center (on 5/24/13). E2 explained that the antipsychotic medication may have contributed to R2's increased forward leaning. On 12/3/13 at 2:25 PM Z6 Pharmacist confirmed that R2's forward lean is a possible side effect of antipsychotic medication therapy. The physician's orders [REDACTED]. On 12/3/13 at 11:00 am E2 Director of Nurses was unable to provide justification from Z2, R2's Physician, for the continued use of the duplicative antipsychotic therapy and agreed that based on R2's current assessment his antipsychotic therapy is not appropriate. The Nursing Lexi-Drug Guide 2013 lists drowsiness as an adverse reaction to [MEDICATION NAME] and somnolence as an adverse reaction to [MEDICATION NAME]. The Chemical Restraint Policy dated 3/15/11 states that An unnecessary drug is any drug used in excessive dose, including duplicative therapy. 2. The physician's orders [REDACTED]. The POS documented that R3 receives the following antipsychotic medications: [MEDICATION NAME] ([MEDICATION NAME]) 1 milligram (mg) take 1.5mg tablets by mouth twice a day, [MEDICATION NAME] 5 mg take one tablet under the tongue at bedtime, and [MEDICATION NAME] ([MEDICATION NAME]) injection 10 mg, inject 5 mg every 8 hours as needed. The Minimum Data Set ((MDS) dated [DATE] indicates that R3 has severe cognitive impairment and requires extensive assistance with bed mobility, transfers, Activities of Daily Living, and toileting. The Physical Therapy Recertification Report dated 10/23/13 documented R3 is a fall risk with poor posture, tight neck muscles affecting posture, decreased standing balance, and unsteady gait. The Care Plan start date of 1/2/13 and updated 11/25/13 documents that R3 requires use of [MEDICAL CONDITION] Medication to manage mood and/or behavior issues, "He (R3) becomes restless, paces and wanders. He has made exit attempts and is redirected back inside. He has threatened staff that he will hit them at time when being redirected." R3's Care Plan included "Attempt/Initiate Gradual Dose Reduction as recommended by RPH (Pharmacist) and as ordered by MD (Medical Doctor). R3's Care Plan documented a written note on 2/18/13 "Out to... Behavioral Unit." The [MEDICAL CONDITION] Medication assessment dated [DATE] lists the following antipsychotic medications: [MEDICATION NAME] 5mg sublingual (under the tongue) every 8 hours as needed and [MEDICATION NAME] 5mg Intramuscularly (IM) injection every 8 hours as needed with start date of 8/15/13 and [MEDICATION NAME] 1.5 mg twice a day with start date of 8/15/13. The response "N (no)" is marked in the section asking if there "Has been an attempt to taper current medication." Comments written by E7 (LPN) indicated that R3 was having no behaviors at the time of this assessment. On 12/5/13 at 10:25 am E7 LPN (Licensed Practical Nurse, Care Plan Coordinator) stated that R3's behaviors have decreased since August 2013. E7 referenced R3's multiple antipsychotic medications and stated that she (E7) completes the [MEDICAL CONDITION] Medication Assessments for R3 and that there have been no Gradual Dose Reduction attempts since R3 returned from the Behavioral Center on February 26, 2013 and since R3 was admitted to the facility on [DATE]. The Pharmacy Recommendation dated 6/28/13 documents "(R3) is currently receiving [MEDICATION NAME] 1.5 mg twice daily and [MEDICATION NAME] 5 mg at bedtime. Black Box Warning: Increase mortality in elderly patients with dementia-related [MEDICAL CONDITION]: Elderly patients with dementia-related [MEDICAL CONDITION] treated with atypical antipsychotic medications are at an increased risk of death...Please review current therapy and consider if a change can be make from this current medication or possible dosage reduction. If change is not warranted, please document below the risk versus benefit of continued use of [MEDICATION NAME] and [MEDICATION NAME] in this patient. Thank you." On 7/18/13 R3's Physician checked "Disagree" and wrote "Pt (patient) controlled." There was no documented clinical rationale for why an attempted dose reduction would be likely to impair the resident's function or increase distressed behavior. On 12/9/13 at 2:50 pm Z5 (R3's Physician) stated, "I am afraid to reduce the dosage of his (R3) medication due to his previous behaviors. We just continue the medications (antipsychotics) as prescribed by the Behavioral Center. I never bother to change the medications." Z5 stated that R3's antipsychotic medications were prescribed by a psychiatrist and it is the responsibility of the psychiatrist to change R3's antipsychotic medications. Z5 stated, "I don't do anything to reduce the dose." On 12/9/13 at 3:05 pm Z6 (Pharmacist) stated that he (Z6) sent a Gradual Dose Reduction recommendation to Z5 on 7/18/13 and Z5 indicated the patient (R3) was controlled. Z6 stated that medication recommendations are sent to Z5 and not to the Behavioral Center. On 12/9/13 at 3:45 pm E1 (Administrator) stated that when a resident is discharged from the Behavioral Center back to this Facility it is the Primary Care Physician's responsibility to address the antipsychotic medication Gradual Dose Reduction. Behavioral Monitoring Records for July, August, September, October, November, and through December 5, 2013 do not document any aggressive or combative behaviors toward self (R3) or others. The following behaviors were documented in July through September 2013: July 4, "Res (R3) put hands on floor and walks on all fours", August 1, 2, and 25, "Wandering", September 6, 7 10, and 14, "Wandering", September 10, "Wandering and resisting care." There were no behaviors documented in October, November, or December 2013. The MDS dated [DATE] and 6/5/13 documented that R3's need for staff assistance for transfers, ambulation, Activities of Daily Living, hygiene and toileting increased from one staff assistance on 6/5/13 to two staff assistance needed on 11/18/13. On 12/2/13 at 12:50 pm, 2:20 pm, 3:30 pm and 4:40 pm and on 12/3/13 at 8:30 am, 10:00 am-12 pm, and 2:00 pm R3 was sleeping in his (R3) recliner chair with his eyes closed and head nodded forward. On 12/3/13 at 8:05 am and 8:35 am E6 CNA stated, "He (R3) sleeps most of the time." E6 stated that when R3 was first admitted to the facility was able to pull the light cord. E6 stated that R3 is not able to use the call light for the past 7-8 months, about May or June 2013. The Dietary Services Communication Report dated 11/6/13 documents that in November 2013 R3 weighed 189 pounds. The report stated that R3 had significant weight losses for past three (8.3%) and six months (12.5%). The Chemical Restraint Policy dated 3/15/11 states, "Resident who use antipsychotic drugs shall receive gradual dose reductions and behavior interventions, unless clinically contraindicated, in an effort to discontinue the drugs."

Based on record review and interview, the Facility failed to provide effective pain management and timely emergency medical services for 1 of 2 residents (R2), reviewed for falls in the sample of 7. This failure resulted in a delay in treatment for [REDACTED]. Findings include: The Facility nurses notes for R2 document, "6/14/12, 9:50 PM, reported to this nurse by staff that report was needed. R2 was found on the floor of her room at 9:30 PM by a CNA, by the white shelves in her room. R2 had unbuckled her seat belt of the wheelchair and tried to stand up. Abrasion to right temple area in hairline and right wrist. E2, Director of Nursing, was notified at this time. 10:15 PM, Power of Attorney (POA) was notified of the incident. Told us to call him if anything changed. 10:30 PM, R2 resting quietly at this time. Call light in reach. Bed alarm activated. 6/15/12, 9:50 AM, This nurse called and informed physician of R2 complaining of hip pain. Telephone order received to x-ray right hip and monitor for changed and notify physician. 10:15 AM, POA notified of complaints of pain and new order. He stated "let me know what it says". 1:30 AM, x-ray technician arrived. 4:00 PM, family arrived and wanted R2 sent out to the emergency room due to no report yet and she is hurting even after pain medication has been given. Physician notified of this and received order to send R2 to emergency room for evaluation. 4:30 PM, R2 left facility via ambulance. 4:40 PM, x-ray report received. X-ray report sent to physician. 10:45 PM, (late entry) for 3:45 AM, R2 complaining of pain in her right hip and leg. Called E2 and she said to call R2's physician. Called his home once and paged him twice. No response. Had staff leave R2 in bed. Passed on in report that still waiting for Dr's response". E3, LPN, is the nurse who initially assessed R2 after her fall. E3 was interviewed concerning the incident on 7/16/12 at 2:10 PM. E3 said that she was working on the back hall that evening and another LPN, E5, was working on the front hall. E3 said that the two CNA's working on the front hall came to her and told her that R2 had fallen. The two CNA's said that they reported it to E5 but, it was her last night working in the Facility and did not want to be bothered with any paper work. E5 reportedly told the CNA's "It never happened and I'm not filling out a report". E3 said "I went and assessed R2 and did the incident report. I had the girls put her in bed. Her legs were equal and she had no complaints of pain. R2 just wanted to go back to sleep. She was not in any pain. She was not grimacing or showing any other non-verbal signs of pain. I kept trying to call her Dr but, could not get an answer anywhere. I even called the hospital and had them page him. I forgot to document all of the attempts I made to get ahold of him. It was close to shift change". E4 was the nurse who came on the night shift on 6/14-15/12 and relieved both E3 and E5. During an interview with E4 on 6/16/12, at 2:22 PM, it was stated that E3 caught her by the time clock and told her about R2 falling and E5 not filling out an incident report. E4 said that she told E3 to call the DON. E3 did that immediately. E2 told E3 to call the hospital and have the Dr. paged. E3 had the Dr paged however, got no response. E4 said that she continued to check on R2 and R2 slept until about 3:00 AM. E4 said that when the CNA's attempted to turn R2, R2 began screaming out in pain. E4 said that she told the CNA's to leave R2 in bed and attempted to once again call R2's physician. E4 still got no response. E4 said "It did not dawn on me to call the Medical Director or 911. I called E2 again and she said to keep trying to get ahold of him. I still hadn't gotten ahold of him when day shift came on duty". During a telephone interview with Z3, R2's power of attorney, on 7/17/12 at 9:50 AM, it was stated that when he arrived at the Facility on 6/15/12 at 4:00 PM, R2 was moaning in bed and thrashing about. Z3 said that R2's condition was very upsetting - "she was in terrible pain". Z3 said that he demanded R2 be sent to the emergency room immediately. R2 was originally admitted to the Facility from an assisted living facility on 1/14/12, with diagnoses, in part of Dementia, [MEDICAL CONDITION] and fractured right femur. R2's physician order's documents an order dated 12/1/11 for "[MEDICATION NAME] with Aspirin, 5/500, take one tablet by mouth every 4 hours as needed". A review of R2's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 7/19/12, at 2:20 PM, E2 presented documentation that 2 [MEDICATION NAME] tablets were signed out on R2's "Shift Count Narcotics Record". The "Shift Count Narcotics Record" documents that on 6/15/12 at 6:00 AM, R2 had 28 [MEDICATION NAME] tablets. On 6/15/12, at 10:00 PM, R2 had 26 [MEDICATION NAME] tablets remaining. There is no documentation in R2's clinical record that the Facility assessed R2's pain level prior to and after administering [MEDICATION NAME] tablets on 6/15/12. R2's "Pain Assessment", dated 4/11/12, documents that R2 had "No Pain Indicators Present - verbal and/or non-verbal". E7, LPN, was the nurse working with R2 during the day shift on 6/15/12. During an interview with E7 on 7/19/12 at 11:20 AM, it was stated that E7 did give R2 two doses of [MEDICATION NAME] during the day shift. E7 said that it was "really busy that day. I gave R2 a dose before noon and before she went out. I forgot to sign it off. R2's family came to me and said that she was acting like she was hurting bad. When I saw her, R2 was slightly grimacing but, not acting like she was in a lot of pain - she wasn't crying out. The [MEDICATION NAME] did help some - I forgot to chart that also - the grimacing was lessened and her family said that it seemed like it relieved her pain". During an interview with E2 on 7/16/12, at 1:15 PM, it was stated that they are not used to being unable to contact a resident's physician and the nurses did not think about calling 911 to send R2 out to the emergency room or to contact the Medical Director. The Facility policy entitled "Guidelines for Physician Notification of Resident Change in Condition" documents "Falls - hip pain with palpation of inability to walk - immediate notification". The policy does not address what facility staff are to do when unable to contact a resident's physician. E2 confirmed during the interview on 7/16/12 at 1:15 PM that the Facility does not have a policy regarding inability to contact a resident's physician. R2's hospital history and physical documents that she was admitted to the hospital on [DATE] for a displaced right intertrochanteric [MEDICAL CONDITION]. R2 "was cleared for surgery and an open reduction, internal fixation of the right [MEDICAL CONDITION]" was performed. Z1, Medical Director, was interviewed by telephone on 7/30/12 at 11:35 AM. Z1 stated that the Facility "should have tried harder to get in touch with Z2. They (the Facility) has my home phone number. They should call the hospital. They need to try harder and if they can't get in touch with a physician, they should call me. They could have called 911 - I would have expected that". Z2, R2's physician, was interviewed by telephone on 7/30/12 at 1:00 PM. Z2 stated "I was not aware of them (the Facility) trying to call me. The local hospital is my answering service - after 5:30 PM, our phones get answered at the hospital switchboard. The hospital operator then pages or calls me. Plus, my home phone number is in the phone book. I didn't get the message about R2 until 9:47 AM on 6/15/12. There was no great urgency in the message, that's why I ordered a mobile x-ray. They didn't assess her well and relay that information to me. They should have sent her out 911 if they couldn't get ahold of me. It should have been automatic".

Based on record review and interview, the Facility failed to identify individual resident risk; implement effective interventions and monitor those interventions, for 1 of 3 residents (R2) reviewed for falls in the sample of 7. This failure resulted in R2 sustaining an intertrochanteric fracture. Findings include: A review of R2's clinical records document that she was originally admitted to the facility on [DATE], with diagnoses, in part, of Fracture of Femur, Parkinson's Disease and Dementia. R2's Minimum Data Set (MDS), dated [DATE], documents that R2 is cognitively impaired; required the limited physical assistance of one staff member for transfers, walking and activities of daily living; and was not steady while moving from a seated to standing position, walking or surface-to-surface transferring. R2's care plan, with a beginning date of 1/23/12, documents a "Problem" of "FALLS: Resident has risk factors that require monitoring and intervention to reduce potential for self injury. Risk factors include confusion, impaired cognition, unaware of safety, needs extensive assistance of 1 with activities of daily living, impaired balance, requires assist to stand, tremors, history of falls, left hip replacement, weakness, gets up without assist and should not, laxative and psychotropic use". The Care Plan "Goal" for this "Problem" documents "Resident will follow safety suggestions and limitations with supervision and verbal reminders for better control of risk factors". The Care Plan "Approaches" for this "Goal" include "Observe for non-verbal signs of restlessness that may precipitate movement and attempts to stand/walk unattended; self releasing belt applied to wheelchair, to wear when in wheelchair and she is able to release it herself". The plan of care does not address what staff is supposed to do if R2 is showing signs of restlessness. There is no assessment for the use of the self-releasing seat belt in R2's clinical record. R2's "Fall Risk Assessment", dated 4/11/12, documents that R2 was at "High Risk" for falls. During an interview with E6, Licensed Practical Nurse (LPN) and Care Plan/MDS Coordinator, she stated that the Facility applied an alarmed self-releasing seat belt to R2's wheelchair on 1/17/12. E6 confirmed that the Facility failed to assess R2 for the use of the seat belt. E6 stated that "in the beginning" R2 was able to comprehend that the belt served as a reminder to her not to ambulate independently. E6 said that she believes that R2's mental status had been declining prior to her fall on 6/14/12. E6 also confirmed that the Facility failed to care plan for interventions when R2 would become restless or "fidgety". R2 does not have a physicians order for the use of the alarmed self-releasing seat belt. The facility incident investigation reporting forms document that R2 had falls in the Facility on 1/16/12, 1/19/12,2/18/12 and 6/14/2. The investigation for the 1/16/12 fall documents that at 5:00 AM, "R2 was seated in living room watching television. (R2) told staff that the show was over and she was getting up to change the channel and fell ". The corrective action for this fall is "will make sure that she has a remote for her TV No injuries were noted. PT/OT to evaluate and treat". Physical Therapy Discharge Summary, dated 1/16 - 3/3/12, documents that physical therapy was providing strengthening exercises to R2's lower extremities "to increase hip and knee strength". R2 was discharged from physical therapy on 3/3/12 as she had "met her maximum potential". On 1/19/12, at 4:00 PM, the investigation documents that R2 was "transferring from bed to get water". The form states that a bed alarm was present however, it does not state if the bed alarm was sounding. The corrective action for this fall is "resident is confused, has dementia, make sure water and belongings are close to resident's chair or bed so resident can reach them". No injuries were noted. On 2/18/12, at 2:45 PM, the investigation form documents that R2 had been sitting in her recliner and "fell going to the bathroom" at 2:45 PM. R2 sustained a skin tear (no size given) to her left elbow. The corrective action for this fall is "resident up by herself to go to the bathroom, spoke with resident's family and asked if we could move her closer to the nurses station for increased observation". The investigation does not document if the alarmed self releasing seat belt was on the chair or if it was sounding. The Facility "Final Investigation Report" documents that "On June 14, 2012, Certified Nurses Aide (CNA) responded to alarm sounding and noted R2 on the floor by her wheelchair. CNA attempted to put resident to bed around 8:30 PM, R2 refused, as CNA was working she would do a visual check on R2 due to resident being fidgety. The CNA stated that she hear R2's alarm going off. When she entered the room the CNA saw R2 on the floor by her wheelchair with her self releasing belt disengaged. E3, Licensed Practical Nurse (LPN), was notified of the incident and assessed R2, who had no obvious injuries at the time. R2 began showing signs of pain during the early morning of 6/15/12. R2's physician was notified and an x-ray was ordered. At 1:30 PM, mobile x-ray company arrived and x-ray was taken. At 4:30 R2 was sent to the hospital. Final x-ray results arrived at Facility at 4:45 PM showing an intertrochanteric fracture". The investigation for the fall which occurred on 6/14/12 documents that at 9:30 PM, R2 experienced a fall from her wheelchair. R2 sustained an abrasion to her right temple and right wrist, and a right intertochanteric fracture. The investigation documents that R2 was sitting in her wheelchair in her room at the time of the fall. The seat belt was on the wheelchair. The investigation does not state if the seat belt was released and/or sounding. E10, CNA, was interviewed by telephone on 8/1/12 at 10:55 AM. E10 said that she was the CNA assigned to R2 the evening of 6/14/12. E10 said that she had worked with R2 since R2's admission to the facility on [DATE]. R2 said that she was very familiar with R2. E10 said that throughout the evening of 6/14/12, R2 had been crying and was agitated. E10 said that R2 was very agitated during supper, "she kept fidgeting with her seat belt, she would mess with it until she got it open - shaking and squeezing on the buckle. I pushed her back to her room after supper and asked her if she wanted to watch television or sit in her recliner. She was crying the whole time. She said that she just wanted to sit there. "I didn't lock her wheelchair wheels so that she could scoot around if she wanted to. She cried a lot and fidgeted all of the time". E10 said that she left R2 sitting in her wheelchair in her room where she could be visualized whenever E10 walked by the door to R2's room. "I put R2 in her room at about 6:15-6:30. Every time I went by her room I looked in on her. I heard her seat belt alarm going off about the time I was doing bed checks. I went in and found her lying on the floor on the other side of her wheelchair". E10 said that R2 is restless "a lot". E10 said that R2's family liked her to wear dresses and she would pick at the hem of her dress or lean over and fiddle with her wheelchair. E10 said "R2 was always keeping her fingers busy". E10 said that R2 would have moments of lucidity but, was confused most of the time. E10 said that she learned how to work with R2 from experience. E10 said that she found that when R2 got restless, R2 liked sitting in her recliner, eating candy or watching television. E10 said that she never read anything in R2's plan of care what to do when R2 became restless.

A. Based on interview and record review, the facility failed to implement care plan interventions to prevent injury for R9, one out of six residents reviewed for falls, in the sample of 14. R9 sustained a fractured right wrist as a result of a fall from bed. Findings include: R9's Physician order [REDACTED]. R9's Fall Risk assessment dated [DATE] assesses R9's fall risk score as 19, indicating R9 is at high risk for falls (Score of 10 or more indicates high risk). R9's Care Plan dated 02/04/11 indicates R9 has risk factors that require monitoring and intervention to reduce potential for falls. These interventions include use of a " mat on the floor beside bed. " There have been no updates or changes to the Care Plan since it was initiated 02/04/11. On 12/30/11 at 12:15p.m. E3, Care Plan Coordinator, stated she did not recall any changes to R9's Plan of Care. On 12/30/11 at 12:30p.m. E5, Social Service Director, stated that the mat had not been discontinued to her knowledge and that it should have been on the floor next to her bed. The Quality Care Reporting Form and Incident Investigation Report dated 04/29/11 report that on 04/29/11 at 2:45p.m. R9 was found "on floor, adjacent to her bed." There was no floor mat on the floor next to R9's bed. The Investigation Report dated 04/29/11 states the "floor mat had been discontinued." The Radiology Report dated 04/29/11 indicates a "fracture at distal radial medial metaphysis" or a fracture of the right wrist. B. Based on observation, interview, and record review, the facility failed to supervise and provide a safe environment for four of six residents (R3, R4, R10, R13) reviewed for falls/safety/supervision in the sample of 14 residents. R10 was alone in her room with a wet floor and unable to reach her call bell. The facility failed to ensure R10's call bell was within reach at all times. The facility failed to ensure that assistive toilet devices were secured to toilets in R3/R4 and R13's toilet rooms so as to prevent potential falls. The facility failed to ensure that one exterior door was equipped with a functioning alarm to alert staff if a resident leaves the building. Findings include: 1. R10's Physician order [REDACTED]. R10's Fall Risk assessment dated [DATE] indicates a score of 17 (10 points or more equals high risk for falls) which places R10 at high risk for falls. On 12/29/11 at 10:12 a.m., R10 was alone in her room and seated in her recliner against the opposite wall in her room from her bed. R10's call bell was lying on her bed, approximately four feet from the resident. R10 was unable to reach her call bell. The floor of the room was wet after just being mopped. A "Caution Wet Floor" sign was placed in the doorway of R10's room. On 12/29/11 at 10:20a.m., E2, Director of Nursing (DON) witnessed R10 alone in her room, unable to reach her call bell, and the floor wet. E2 confirmed the call bell should be within R10's reach and clipped the call bell on R10's blanket in her recliner. R10's Care Plan dated 01/21/11 indicates R10 is severely cognitively impaired, requires set up help for meals, and has risk factors that require monitoring and intervention to reduce potential for falls, and has a history of falls. The 01/21/11 Care Plan further directs staff to "Keep call light within reach at all times." R10 has the ability to use the call bell as evidenced below: R10's Range of Motion (ROM) assessment dated [DATE] documents R10 as having full range of motion (greater than 80% functional ROM of joint) of bilateral shoulders, elbows, wrists, fingers, thumbs, hips, ankles, and toes. The ROM assessment dated [DATE] documents R10 as having moderate ROM (50-80% functional ROM of joint) of bilateral knees. On 12/29/11 at 1:05p.m., R10 fed herself and drank iced tea with supervision and occasional cueing from staff. On 12/29/11 at 5:10p.m. E3, Licensed Practical Nurse (LPN) and Minimum Data Set (MDS) and Care Plan Coordinator indicated R10 could possibly use the call bell. 2. On 12-27-11 at 12 noon R3 and R4's toilet was equipped with a plastic seat riser with attached armrest/grab bars. At this time the seat riser assembly was not tight fitting to the toilet. The assembly moved about on the rim of the toilet when grasped. R3's 12-7-11 Minimum Data Set reflects that she is dependent upon staff for toilet use. R3's Care Plan dated 12-14-11 reflects that she is at risk for falls with an intervention which states to "...ensure adaptive devices in good repair..." R3's Nurse's Notes reflect that she sustained a fall from the toilet with an injury on 1-16-11. R4's 11-23-11 Minimum Data Set documents that R4 has a history of falls. Her 11-13-11 Fall Risk Assessment reflects that she is at high risk for falls. R4 was observed ambulating to and from her toilet room with her wheeled walker on on 12-27 and 12-28-11. On 12-29-11 at 11:30 a.m. R13's toilet was equipped with a plastic toilet riser with attached armrest grab bars. The assembly was not tight fitting to the toilet rim and could be moved when grasped. 3. R3's Nurses Notes dated 8-17-11 reflect that she fell from her bed and sustained a facial fracture and head laceration. Post fall interventions put into effect and documented on her 12-14-11 Care Plan reflect to keep R3's bed in the low position with wheels locked. On 12-28-11 R3 was in bed asleep. Her bed was not in the low position and the wheels were not locked. This was verified by E3, Licensed Practical Nurse at 9:20 a.m. 4. On 12-28-11 at 11:20 a.m. the Living Room exterior door which opens to the enclosed courtyard was equipped with an audible alarm device that did not function. E15, Maintenance Supervisor stated at this time that the alarm is armed 24 hours a day and is checked twice weekly. E15 stated he did not know the alarm was not working. E15 stated the alarm is in place to alert staff when residents go outdoors. Some areas within the courtyard are not able to be viewed from indoors. The Centers for Medicare and Medicaid Services 672 form completed on 12-27-11 reflect that there are 3 residents who are independent with ambulation. Independent residents were present near this door without staff present on 12-27, 12-28, and 12-29-11 at various times of the day.