Every finding on record at Chateau NRSG & Rehab Center

Based on interview and record review, the facility failed to comprehensively assess a resident for post-fall complications, including failing to identify worsening acute pain and failing to obtain timely diagnostics. This failure resulted in a resident receiving delayed care for his left hip fracture.This applies to 1 of 3 residents (R1) reviewed for quality of care in a sample of 5. The findings include:R1's 2/17/26 progress note from 5:30 AM showed R1 .was noted on the floor in front of his wheelchair in an upright sitting position, sustaining a skin tear to the left elbow. When asked what happened, (R1) said that he was reaching for papers on the chair and slid out of the wheelchair. Left elbow cleansed and dressing applied. Wife made aware and also NP [Nurse Practitioner] aware of fall.On 4/23/26 at 10:12 AM, V3 ADON (Assistant Director of Nursing) stated that R1 had a fall on 2/17/26 at 5:30 AM. V3 stated R1 got up from his wheelchair and ambulated with his rolling walker to the bed without assistance. V3 stated R1 got up from his bed, tripped over his leg rest and fell to the floor. R1 was observed to be sitting in front of his wheelchair on the floor. At that time, he had a skin tear to his elbow. V3 stated that V6 (Nurse Practitioner) came and saw R1 and he refused to be assessed by her because of the pain so she ordered a STAT X-ray. V3 stated she remembered R1's daughter calling her and asking about the fall and she told her what happened. V3 stated she had asked her about the X-ray and asked why it took until the next morning to do it. V3 stated she told her they were looking into it. They said there was a delay in the technician arriving at our facility. V3 stated she did not see a note that R1's nurse (V8-RN/Registered Nurse) called the Nurse Practitioner, and she should have documented that. V3 stated it's the Nurse Practitioner's call whether to send him to the hospital or not. R1's 2/17/26 Post-Fall Monitoring form from 8:50 AM showed R1 had pain of 7 out of 10 and as needed pain medication was given. R1's 2/17/26 Medication Administration Note from 9:35 AM showed his as needed administration of 650 mg (milligrams) of Tylenol was ineffective. The note further showed R1 asked physical/occupational therapy assistant to put him back to bed [related to] complaint of left hip pain. Ice pack applied on left hip, as resident requested, NP notified. Resident refused therapy due to complaint of pain. On 4/23/26 at 10:39 AM, V6 (Nurse Practitioner/NP) stated on 2/17/26 a staff member notified her that R1 had a fall early in the morning and she went and saw R1. V6 stated R1 refused to let her do range of motion on him because he had pain in his left hip. V6 stated she told the nurse to put in an order for a STAT X-ray. V6 stated and it is nursing who calls the X-ray company. V6 stated a STAT X-ray means that it should be done within four hours. V6 stated if they don't come within four hours, we request the nurse to call the company. V6 stated the nurse should have called the X-ray company and followed up because she ordered R1's X-ray as STAT. V6 stated if the X-ray company doesn't come within four hours, they need to notify me so we can reassess the situation. V6 stated R1 would need to go to the hospital if he was complaining of excruciating pain or if he was unable to move.On 4/24/26 at 11:37 AM, V8 (RN) stated she worked on 2/17/26 from 6:30 AM to 11 PM and she was R1's nurse. V8 stated R1 had fallen during the night shift at 5:30 AM and at 8:45 AM, he was complaining of pain 7/10 and she gave him Tylenol 650 mg (milligrams). V8 stated after V6 (Nurse Practitioner) saw R1, V6 told her to put in the order for the X-ray. V8 stated she put it in as regular X-ray order. V8 stated after their stand-up meeting, V6 came to her and told her to make it a STAT X-ray order. V8 stated she called the X-ray company and told them it was STAT and they said they would be here as soon as they can. V8 stated if they don't come in within four hours, we have to call the X-ray company and notify the doctor. V8 stated that at 3:55 PM, R1 complained of pain 10/10 and she gave him another Tylenol 650 mg. V8 stated the X-ray company never came that day. V8 stated R1 had his X-ray done on 2/18 and he had a fracture on the hip area.No documentation was present from 2/17 that showed R1's MD was notified of his increased pain and of the X-ray not being completed. On 4/23/26 at 12:00 PM, V4 (R1's wife) stated that R1 had a fall in the facility on 2/17. V4 stated she received a call from someone at 6:38 AM that day (as she was looking at her phone log). She stated she got to the facility at 8:30 AM and R1 was sitting in his wheelchair. V4 stated R1 had an open wound on his elbow which was not dressed, an ice pack on his leg, and a bruise on his forehead. V4 stated R1 was in a lot of pain. V4 stated a Physical Therapist (PT) or Physical Therapy Assistant (PTA) came to the room and asked R1 if he was going to therapy. V4 stated we told her that R1 had a fall during the night shift and he was in a lot of pain. V4 stated she thought the PT or PTA went and told a nurse that R1 needed a pain pill. V4 stated If my husband was in so much pain and he couldn't get up from his wheelchair using his walker and the PTA or the PT had to transfer him using a mechanical lift and X-ray people weren't here yet, then why was (R1) not just transferred to the hospital? V4 stated R1 ended up waiting more than 24 hours and he stayed in bed and experienced a lot of pain. V4 stated the X-ray company did not come until the next day (2/18). V4 stated when they found out it was a fracture, only then did they send him out to the hospital. V4 stated I just don't understand why they couldn't send him to the hospital in the first place instead of him suffering with all that pain. It's ridiculous.On 4/23/26 at 12:45 PM, V2 DON (Director of Nursing) stated R1's X-ray report showed R1's X-ray was not done until 2/18/26 (the following day). V2 stated a STAT X-ray should be done within four hours. V2 stated if they don't come within that time, the nurse is to follow up with the doctor and ask what to do and possibly get new orders whether to go to hospital or order more tests. V2 stated she reviewed the progress notes and there was no documentation on 2/17/26 from V8 (RN) that she contacted the X-ray company. V2 stated V13 (RN) followed up the next day on 2/18/26 with the X-ray company and told them R1's X-ray was not completed yet.R1's 2/17/26 Nurse Practitioner Note (V6) from 1:57 PM showed The patient had a fall on 2/17/26. The staff reported that [R1] was noted on the floor in front of the wheelchair in an upright sitting position, sustaining a skin tear to the left elbow. The examiner assessed the resident. [R1] stated that he was sitting on the edge of the bed and used his walker to reach papers on a chair and fell. [R1] indicates pain in the left hip. [R1] is unable to participate in range of motion. STAT hip X-ray ordered. This note was electronically signed on 2/18/26 at 1:58 PM.R1's 2/17/26 Post-Fall Monitoring form from 9:09 PM showed his pain had gotten worse to a score of 10 out of 10 and as needed pain medication was given. This form also showed R1 experienced Increased difficulty with bed mobility [related to] left hip pain. On 4/24/26 at 2:24 PM, V13 (RN) stated she worked on 2/18/26. V13 stated she noticed that R1's X-ray had not been completed and so she called the X-ray company and told them R1 was supposed to have a STAT X-ray the day before (2/17/26). V13 stated they did not provide her with a reason as to why it was not completed, but the X-ray technician was already in the building seeing another resident, so they came within 20 to 30 minutes to complete R1's X-ray. V13 stated a STAT X-ray should be done within four hours and if the X-ray company hasn't come, she would call the X-ray company and inform the Doctor or NP and let them know what's going on.R1's 2/18/26 left hip Radiology Results Report showed a reported date of 2/18/26 at 9:45 AM with Impression: Acute comminuted left femoral intertrochanteric fracture.R1's 2/18/26 progress note from 3:19 PM showed At 10:30 AM, X-ray result relayed to attending nurse practitioner with new orders received to send (R1) to hospital for evaluation and treatment. 10:50 AM, Ambulance left with (R1) via stretcher en route to hospital. Hospital records showed [R1] admitted to (hospital) for management of left intertrochanteric femur fracture after [Ground Level Fall].patient complaining of pain, was medicated with Oxycodone.he had a left hip open reduction internal fixation of peri trochanteric fracture on 2/20/26 after stress test was completed .Facility's policy titled Physician Orders (8/1/21) shows: III. Execution of Order and Notifications- General: It is the policy of this facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. The safety of residents. is of primary importance. a.) The nurse that takes the physician order will be responsible for executing the order or provide for the safe hand-off to the next nurse. i. Contact.radiology services.as required to execute the medical order. iii. Notify internal staff of changes/updates as appropriate. iv. Notify resident/resident's representative of changes or new orders as appropriate. v. Notify attending or other providers as appropriate.Facility's policy titled Pain- Clinical Protocol dated (8/2008) shows: 3. The physician will perform or order appropriate tests as needed to help clarify aspects of pain (location, cause, etc.). For example, an x-ray may help to identify the cause of joint pain. Resident's physician and resident' s family/responsible party should be notified of significant changes pertaining to resident's pain level.Facility's policy titled Falls- Clinical Protocol (August 2008) shows: Monitoring and Follow-Up- 1. The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have ruled out or resolved. a. Frail elderly individuals are often at a greater risk for serious adverse consequences of falls.

Based on interview and record review, the facility failed to ensure a timely hip X-ray was obtained for a resident after a fall. This applies to 1 of 3 residents (R1) reviewed for diagnostic services in a sample of 5.The findings include:R1's 2/17/26 progress note from 5:30 AM showed .noted on the floor in front of his wheelchair in an upright sitting position, sustaining a skin tear to the left elbow. When asked what happened, (R1) said that he was reaching for papers on the chair and slid out of the wheelchair. Left elbow cleansed and dressing applied. Wife made aware and also NP (Nurse Practitioner) aware of fall .R1's 2/17/26 progress note from 1:57 PM (written by V6-Nurse Practitioner/NP) showed The patient had a fall on 2/17/26. The staff reported that (R1) was noted on the floor in front of the wheelchair in an upright sitting position, sustaining a skin tear to the left elbow. The examiner assessed the resident. (R1) stated that he was sitting on the edge of the bed and used his walker to reach papers on a chair and fell. (R1) indicates pain in the left hip. (R1) is unable to participate in range of motion. STAT hip x-ray ordered .On 4/23/26 at 10:12 AM, V3 (ADON) stated that R1 had a fall on 2/17/26 at 5:30 AM. R1 got up from his wheelchair and ambulated and tripped over his leg rest and fell to the floor. R1 was observed to be sitting in front of his wheelchair on the floor. At that time, he had a skin tear to his elbow. Later V6 (NP) came and saw him and he refused to be assessed because of the pain and she ordered a STAT X-ray. V3 stated I remember R1's daughter calling me and asking me about the fall and she asked me why it took until the next morning to do the X-ray. V3 stated they eventually came on 2/18/26 to do the x-ray. On 4/23/26 at 10:39 AM, V6 (Nurse Practitioner) stated she was notified of R1's early morning fall on 2/17/26 and she went and saw R1. V6 stated R1 refused to let her do range of motion on him because he had pain in his left hip so she told the nurse to put in an order for a STAT X-ray. V6 stated it is nursing who calls the X-ray company. V6 stated a STAT X-ray means that it should be done within four hours. On 4/23/26 at 12:45 PM, V2 DON (Director of Nursing) stated according to the X-ray report, the X-ray was not done until 2/18/26. She said a STAT X-ray should be within 4 hours. On 4/24/26 at 11:37 AM, V8 (RN-Registered Nurse) stated she worked a double shift on 2/17/26 from 6:30 AM to 11 PM and she was R1's assigned nurse. V8 stated R1 had fallen earlier during the night shift at 5:30 AM and at 8:45 AM, he was complaining of pain 7/10 and she gave Tylenol. V8 stated after V6 (NP) saw R1, she told V8 to put in the order for the X-ray and she put it in as regular X-ray order. V8 stated after our stand-up meeting, V6 came to me and told me to make it a STAT order. V8 stated she called the X-ray company and told them it was a STAT X-ray order. R1's 2/18/26 progress note from 8:52 AM (the next day) showed Writer contacted x-ray company regarding estimated time of arrival for X-ray of hip. Per company, a technician has been assigned and will be out this morning to complete X-ray. Exact ETA not available.R1's Physician Orders showed two X-ray orders for his left hip, unilateral with pelvis when performed, 2-3 views one time only on 2/17/26. It does not show it as stat orders. It was ordered by V6 (Nurse Practitioner) and put in by V8 (RN). The first order was put in at 10:47 AM and the second order was put in at 1:05 PM. Both orders show one time only.R1's Radiology Results Report showed results were reported on 2/18/26 at 9:45 AM, and R1 had an acute comminuted left femoral intertrochanteric fracture.Facility's policy titled Physician Orders (8/1/21) shows: III. Execution of Order and Notifications a) The nurse that takes the physician order will be responsible for executing the order or provide for the safe hand-off to the next nurse. i. Contact.radiology services.as required to execute the medical order. iii. Notify internal staff of changes/updates as appropriate. iv. Notify resident/resident's representative of changes or new orders as appropriate. v. Notify attending or other providers as appropriate.

Based on observation, interview and record review the facility failed to ensure a resident had a leg rest while using a wheelchair, this failure resulted in R24 falling out of her wheelchair face forward sustaining a laceration requiring sutures. The facility also failed to ensure a resident was safely repositioned and transferred in a manner to prevent injury. This applies to 3 of 25 residents (R24, R110, R5) reviewed for safety in the sample of 25.The findings include: 1. R24's electronic face sheet accessed on 7/28/25 shows R47 has diagnoses of progressive supranuclear ophthalmoplegia (Steele-[NAME]) R24's facility assessment dated [DATE] shows R24 has no cognitive impairment with BIMS of 14. The same assessment shows R24 has no behaviors of rejection of care. On 7/28/25 at 9AM, R24 was sitting in her wheelchair alert and pleasant. R24 was noted to have stooped posture (hunch over posture) her head and neck were bent forwards. R24 had a dressing noted on the right side of her forehead. On 7/29/25 at 9:04 AM, R24 said she was being pushed in her wheelchair by a CNA to the shower room. R24 said the shower room was away from her room. R24 said as she was being turned around the corner towards the shower room, she fell out of her wheelchair face forward hitting her head on the floor. On 7/29/25 at 9:30 AM V11 said she was R24's Certified Nursing Assistant-(CNA) when R24 fell last 7/18/25. V11 (CNA) said it was close to 8PM, R24 wanted to wheel herself to the shower room. so V11 stayed a few feet away from R24. V11 said she noticed that while R24 was wheeling herself in her wheelchair, R24 was leaning forward. V11 said she did not think any of it. Then R24 was noted to be leaning more towards her side then forward. V11 said she also noticed both of R24's feet were now caught underneath her wheelchair, R24 was unable to hold her feet up while wheeling herself, then R24 fell out of her wheelchair forward. V11 said she then realized R24 did not have her leg rest on. V11 said she should have applied R24's leg rest for safety. V11 said she should have made sure she was nearer R24 so that when she was leaning, I should have just got there sooner to pull her backwards. R24's hospital records dated 7/18/25 documents, diagnosis, head injury, fell out of wheelchair face forward hitting right side of forehead. Laceration repair (to right forehead.) With discharge order to remove sutures in 7-10 days. The Facility Reported Incident (FRI) dated 7/23/25 with date of incident of 7/18/25 show, (res) propelling to shower room, accompanied by CNA when she lost balance and fell forward out of the wheelchair onto the floor. R24 was assessed, noted laceration to her forehead. Pressure dressing was applied and denied pain, 911 called and sent to the local hospital. Returned to facility with 6 sutures to remove within 7-10 days. On 7/29/25 at 1 PM, V10 (Registered Nurse-RN) said R24 leans forward due to her disease, it is like Parkinson but not quite. R24 needs her leg rest when she is in her wheelchair for long distance. R24 was unable to lift her feet up for long periods of time. R24's room was in the middle of the hallway. The shower room was in front of the Nurses station at the end of the hall. On 7/29/25 at 9:45 AM both V12 and V13 (CNAs) said R24 moves very slow. R24 needed to be wheeled for long distances and needs her leg rests for safety. On 7/30/25 at 9AM, V13 (Nurse Practitioner) said R24 has a rare neurological condition that affects her physical function- it affects her movement and balance. This makes R24 high risk for falls. R24's posture is hunch over, (leans forward). R24 moves slow and tires easily. R24 is very alert and knows what is going on, when she relates something, that is really what happened. R24's safety come first. If R24 prefers to use her leg inside the room while in her wheelchair, that was fine. But for R24's safety, which is again the priority, when R24 was outside her room, in her wheelchair going to point A to point B, (room to shower room) R24 should have a leg rest to help her balance and prevent her from falling forward. The facility policy on Falls dated 1/24 shows, Fall Guidelines, to consistently identify and evaluate residents at risk for falls and those who have fallen to treat or refer for treatment appropriately and develop an organization wide ownership for fall prevention. to prevent or reduce injuries related to fall, to enhance residents' dignity and self-worth, to rehabilitate residents to their fullest potential of function. 2. R110's face sheet shows she has diagnoses including weakness, pain to leg and shoulder, abnormal posture, and a history of colon and breast cancer. On 7/28/25 at 10:16 AM, R110 was in bed, on her left mid forearm there was a fading bluish green bruise with several dark purple spots in the middle of it. The bruise wrapped around her inner and outer forearm. Above her bed was a sign indicating that no blood draws or blood pressures should be taken with her left arm. R110 said she got the bruise a week ago Thursday (7/17/25) when an agency CNA (Certified Nursing Assistant) went to turn her to do care and get her out of bed. R110 said instead of the agency CNA assisting her to turn by using her shoulder or back to roll her she grabbed her left arm and pulled on it to turn her. R110 said she had a mastectomy for breast cancer in her left breast and that arm is very sensitive and bruises so there is a sign letting staff know to not use her left arm. R110 said the CNA should not have used her arm at all to turn her. R110 went on to say that while this same agency CNA was then getting her up via a mechanical lift the CNA used a wrong size sling, and she was leaning forward and experienced some pain to her buttocks and kept telling her something is wrong this should not hurt. R110 said the CNA was the only one in the room using the lift to get her up and luckily another CNA ended up coming into the room and helped get her finished up. R110 she was afraid something would happen to her since it was the wrong size sling. R110 said she did tell another staff person the next day about her arm because it was hurting her. R110's Electronic Medical Record (EMR) shows she was seen by V13 (Nurse Practitioner/NP) on 7/18/25. V13 documented in a provider follow up note that R110 had a bruise on her left arm that was caused by a staff person who assisted her with mobility and used her left arm. The investigation for the incident for R110 on 7/18/25 shows photos of her left arm discoloration that was beginning to bruise that had been taken by V15 (Wound Care Nurse). V15 also documented that an aide had gripped her arm during peri care. A witness statement completed on 7/18/25 by V20 (Restorative Aide) shows she entered R110's room and saw R110 being inappropriately positioned in the mechanical lift sling during a transfer. On 7/28/25 at 1:10 PM- V13 (NP) said she was asked to see R110 because she had pain and discoloration (bruising) to her left forearm. V13 said R110 is fully alert and oriented, and what I was told is she was grabbed by a CNA who was heavy handed while assisting her with care. V13 said they would describe the bruise as cuffing, and it would be consistent with someone being grabbed by the arm. V13 said R110 denied that she felt the CNA purposely intended to hurt her, but she should not have used her left arm because R110 does have left sided weakness and swelling from a past mastectomy. On 7/29/25 at 1:47 PM, V17 (Assistant Director of Nursing/ADON) said it was reported to her on 7/18/25 about the incident with the agency CNA and R110. She identified the agency CNA as V19. V17 said V19 was put on a do not return list and was not allowed to work at the facility anymore. V17 said V19 should not have used R110's left arm and she was also made aware from V20 that V19 also used the mechanical lift alone and had R110 in the wrong size sling during the transfer. On 7/29/25 at 1:53 PM, V20 (CNA) said she did walk into R110's room to see if she was ready for her bath and found another CNA transferring her with the mechanical lift alone. V20 said you could see it in R110's face she was uncomfortable, and she was crammed into the sling. V20 said the CNA (V19) should not have transferred R110 alone and she also used a sling that was too small. The facility provided Lifting Machine, using a Portable policy revised August 2008 shows that residents should be properly positioned and comfortable during a mechanical lift transfer. R110's active care plan shows 2 staff should be present during R110's transfer via a mechanical lift. 3. R5's Fall's Report dated 7/16/25 states, CNA on duty called out for help, writer immediately went to room. CNA on duty stated that resident rolled off her air mattress during care, resident noted on the floor to the left side of the bed, lying on her right side. When asked what happened resident stated, I just rolled. On 7/29/25 at 2:10PM, V5 (Registered Nurse) stated, The CNA was (V6). She rolled (R5) over and she was supposed to have 2 people when caring for her. (R5) didn't have any injury, she did not hit her head. We used a mechanical lift to get her off the floor. On 7/29/25 at 2:45PM V6 (Certified Nursing Assistant) stated, I was giving her a bed bath, and I was washing her back and her legs just slipped off the bed. She grabbed onto the halo (side rail) then slid to the floor. We usually have 2 staff to care for her, but the agency girl was pregnant, so I did it by myself. On 7/30/25 at 11:15AM (R5) stated, It was an accident. They usually use 2 people. They have been very careful since the fall. I didn't get hurt- it was just the fear that is caused. R5's Physician's Order Sheet dated July 30, 2025, shows that R5 has diagnoses including Paraplegia, Sacral Pressure Ulcer and Muscle Wasting and Atrophy. R5's Current Care Plan states, Resident has impaired mobility due to paraplegia and The resident is at risk for falls related to decreased mobility, weakness and paraplegia. R5's care plan does not address her need to have 2 staff members to assist with turning and repositioning.

Based on observation, interview and record review the facility failed to ensure medications were properly stored.This applies to 3 of 3 residents (R102, R115, R127) reviewed for medication storage in the sample of 25. The findings include: On 7/30/25 at 9:35 AM, V22's (Licensed Practical Nurse-Agency) medication cart located on 2A. V22 opened the top drawer and removed R102's, R115, and R127's medication cup with pills and tape over the top of the medication cup. V22 said when he went to give his morning medications to these residents, they were receiving care and he did not want to interrupt the care. V22 said he placed the medications back in his medication cart. He said he is new and should have given the medications when they were done receiving care. On 7/30/25 at 11:54 AM, V2 (Director of Nursing) said once medications are dispensed they should not be stored in the medication cart. During med pass nursing should follow the five rights and follow the process of medication administration. There is the potential you could mistakenly give the wrong medications if the medications are pulled and not given at the time dispensed. If a resident is receiving care during medication pass, nursing should wait until the care is complete and give the medications. The facility's Storage of Medications Policy dated 2014 states, Medications and biologicals are stored safely, securely, and properly .all medications dispensed by the pharmacy are stored in the container with the pharmacy label .

Based on observation, interview and record review the facility failed to ensure splints were in place for residents with contractures and failed to ensure an edema glove was applied. This applies to 3 of 8 residents (R79, R89, R83) reviewed for range of motion in the sample of 25.The findings include:1. R79's Physician Order Sheet (POS) dated 7/25 show R79 has diagnoses that include left sided paralysis following a stroke affecting R79's left side. The same POS show an order of left-hand splint, on during daytime up to 5 hours. On 7/28/25 at 9:10 AM during the initial tour, R79 was in bed. R79 used her right hand to lift her left hand and showed it to this surveyor. R79 said she had a stroke and cannot move her left side including her left hand. R79's left hand was tightly closed as a fist. R79 said she used to have a splint to her left hand, but no one had applied her left-hand splint. At 12 PM, and at 2PM, R79 was still in bed, still without a splint to her contracted left hand. On 7/29/25 at 9 AM, R79 was lying in bed leaning to her right side. R79 had her personal things all over the floor. R79 stated I am sorry, I only have one functioning arm. Using her right hand she was trying to position herself in bed. R79's contracted left hand was still without a splint. V9 (Certified Nursing Assistant) was in R79's room and assisted R79's to position in bed, then fixed R79's items that were on the floor to R79's overbed table. At 12PM, R79 still had no splint to her left hand. At 2PM, V9 (CNA) said she did not know about R79 having a splint, If I knew I would have applied it. I thought restorative does it. 2. R89's Physician Order Sheet (POS) dated 7/25 show R89 has diagnoses that include left sided paralysis following a stroke affecting her left side. The same POS show an order of left-hand splint on during daytime up to 5 hours. On 7/28/25 at 9AM during the initial tour, R89 was in bed. R89 said she was lying on her left contracted hand and requested V15 (Wound Nurse) to remove her left hand behind her. R89 said she had a stroke and cannot move her left hand. R89's left hand was contracted with left hand and fingers curled inward like a closed fist. R89 said she used to have splint to her left contracted hand, but no one has applied the splint lately. On 7/29/25 at 12PM, R89 was in bed. R89 had no splint on her left contracted hand. R89's care plan with an initiated date of 5/14/24 under restorative shows, splint -resident will tolerate wearing splint, apply brace/splint as scheduled. On 7/29/25 at 2:10 PM, V8 (Restorative Nurse) said the splint should be applied to help support the contracted hand and prevent further contractures. V8 said she will make sure splints will be applied to R79 and R89 daily to prevent decline of their left-hand contractures. The facility Policy on Splint dated 11/2024 shows, to properly apply splint for support, comfort, or aid in contracture prevention. 3. R83's face sheet shows he is a [AGE] year-old male with diagnoses including paralytic syndrome following cerebral infarction affecting right dominant side, hemiplegia and hemiparesis following cerebral infarction, muscle wasting and atrophy to right shoulder, and multiple sites, and dysphagia. On 7/28/25 at 12:38 PM, R83 was in the dining room feeding himself with his left hand and his right arm dangling in his lap. On 7/29/25 at 9:10 AM, R83 was sitting in his wheelchair with his right arm dangling in his lap. R83 was not able to move his right hand and there was no edema glove in place. On 7/29/25 at 11:58 AM, R83 was in his room sitting in his wheelchair with his right arm positioned in a downward position. V23 (R83's daughter) was in the room, she said his physical therapy was stopped because of his insurance. R83 was walking in physical therapy, and he was receiving exercise to his right upper extremity. V23 said his right arm gets swollen and stiff and she has not seen him with a glove to his right arm. On 7/29/25 at 2:09 PM, V24 (CNA) said R83 is alert, follows commands and directions, he is Spanish speaking and there is language barrier. He transfers with one person assist, he was in physical therapy, and he is supposed to wear a compression glove to his right arm in the morning and off at night. On 7/30/25 at 10:30 AM, V8 (Restorative Nurse) said R83 should be receiving restorative services for dressing and grooming, bed mobility and a glove should be in place to his right side to prevent edema to that extremity. The glove should be placed during the day and off at night. R83's Physician Order Sheets dated July 2025 shows orders including edema glove to be worn during the day and remove at night. R83's current care plan shows his restorative program: edema glove, interventions initiated on 7/28/25 including apply splint/brace per schedule, check for proper placement, and check resident's skin. The facilities Restorative Policy dated 2014 states, To ensure that each resident's individual rehabilitative needs are identified, and appropriate nursing measures are implemented to achieve a maximum level of independence.restorative nursing programs: range of motion, splint or brace device, bed mobility, transferring, walking/ambulation .

Based on observation, interview and record review the facility failed to ensure the prescribed treatment order was in place for a resident with a stage 4 pressure ulcer.This applies to 1 of 6 (R14) residents reviewed for pressure ulcers in the sample of 25. The findings include: R14's Wound Progress Note dated 7/28/25 shows she has a stage 4 coccyx pressure ulcer measuring 3.3 cm (centimeter) length x 0.6 cm width x 0.6 cm depth with moderate amount of serosanguineous drainage. The coccyx treatment includes to cleanse wound with cleanser protect peri wound with skin prep apply alginate with silver to wound bed-loosely pack wound cover with dry dressing and change daily. On 7/30/25 at 9:05 AM, R14 was observed in her room lying in bed. V15 (Wound Nurse) provided wound care to R14. V15 removed R14's foam dressing to her coccyx. An oval size opening to her coccyx with depth was present to the wound. V15 cleansed the wound and applied alginate silver and foam dressing but did not pack the wound.On 7/30/25 at 10:00 AM, V15 said the wound physician comes weekly, we follow the physician orders for the treatment. R14 has been on the same treatment for a while, she does not get packing to her wound and confirmed R14's wound has depth to the wound. V15 said the order does say to loosely fill the wound, but she did not know that.The facility's Pressure Ulcer and Wound Prevention/Management Program Policy updated 2006 states, It is the policy of this facility to ensure residents who has been admitted with pressure ulcers or develop pressure ulcers in house receives necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing, when possible.

Based on observation, interview and record review the facility failed to ensure a resident received 1:1 feeding assistance. This applies to 1 of 25 residents (R22) reviewed for Activities of Daily Living in the sample of the 25. The findings include: On 7/28/25 at 9:46 AM, R22 was asleep in bed. His breakfast tray was sitting on an overbed table in front of him and still had cereal that was in a bowl covered with a lid, a hashbrown with a bite out of it and a sausage patty that was cut up. R22's meal ticket was still on his tray and showed that R22 required 1:1 feeding assistance. There were no staff present in R22's room. On 7/28/25 at 1:16 PM, R22 was in bed and was eating his lunch with some difficulty getting his potatoes onto his spoon. On his meal tray was a sandwich still wrapped in plastic wrap. There were no staff present in R22's room.On 7/29/25 at 8:40 AM, R22 was again observed to have his breakfast tray on his overbed table with no staff present. He was drowsy and would fall asleep and wake up and look at the tray. On 7/29/25 at 8:44 AM, V12 (Certified Nursing Assistant/CNA) said R22 feeds himself, all they have to do is drop the tray off in his room. V12 said there is no master list on the unit for who needs 1:1 feeding assistance they rely on the nurses to let them know. V12 said the nurses have that information on their report sheet and in the computer. On 7/30/25 at 9:45 AM, V16 (Registered Nurse/RN) said nurses check orders and let dietary know who requires 1:1 feeding assistance. When V16 was asked to check if R22 required feeding assistance she pulled up his Electronic Medical Record (EMR) and said R22 has vascular dementia and has an order for 1:1 feeding assistance. V16 said when she is giving him supplements or liquids she stays in the room with him because he does need encouragement to eat and drink. R22's active Physician Order Summary dated 6/25/25 shows an order for R22 to be 1:1 feeding assistance required during meals.R22's current Self-Care deficit care plan initiated 6/27/25 shows R22 is unable to self- feed and is dependent on care giver for assistance with feeding. An intervention listed on the care plan states, Provide 1:1 feeding assist in a calm, unhurried manner.

Based on interview and record review the facility failed to ensure gradual dose reductions were implemented for residents on Psychotropic medications.This applies to 2 of 5 residents (R3 & R4) residents reviewed for Psychotropic medications in the sample of 25.The findings include: 1. R3's Physician Order Sheets dated July 2025 shows orders including Olanzapine 10 mg (milligrams) give one tablet by mouth in the evening for behaviors and Olanzapine 5 mg tablet one time daily for behavior. V25 (Psych Nurse Practitioner's) progress note dated July 9, 2025 (signed 7/14/25) shows R3 has diagnoses including bipolar, agitation due to dementia and anxiety. The progress note shows R3 has been cooperative with staff and has mild anxiety. The orders include to reduce Olanzapine to 7.5 mg at bedtime per GDR (Gradual Dose Reduction). On 7/30/25 at 12:44 PM, V26 (RN) said psych comes in weekly and informs her and the nurse on duty of any changes to the residents' medications. The progress notes get sent for her to review. V26 said R3's psychotropic medication was supposed to be reduced, and they did not make the changes because he was sent out to the hospital. She received the order on 7/14/25 to decrease his Olanzapine to 7.5 at hs (hours sleep). R3 returned back to the facility on 7/22/25 and confirmed his dose has not been decreased. 2. R4's face sheet shows he has diagnoses including Generalized Anxiety Disorder, Unspecified Psychosis, and Unspecified Dementia Severe with Agitation. A Nursing Home Note / GDR (Gradual Dose Reduction) signed by V25 (Psychiatric Nurse Practitioner) shows she assessed R4 on 7/9/25 and indicated the plan for R4's Seroquel (Anti-psychotic) was to reduce it from 50 mg. down to 25 mg. three times a day. R4's Medication Administration Summary (MAR) for 7/1/25-7/31/25 and his active Physician Order Summary both show that R4's Seroquel was not decreased, and he continued to receive 50 mg. three times a day through 7/30/25. On 7/30/25 at 12:48 PM, V26 Psychotropic Nurse said the process for GDR's is that when the psychiatric team sees the residents, they make the recommendations either to her or the nurse on duty to change the psychotropic medications. The family is then called right away, and the orders should be implemented. V26 said she always follows up to make sure it is done but in R4's case she believes his POA (Power of Attorney) was in Florida and R4 was having some behaviors. V26 said there is nothing documented in R4's Electronic Medical Record about attempting to contact the family to inform them of the GDR recommendation. The facility provided Behavior and Psychotropic Medication Management Guideline policy last revised on 9/24 shows that the facility should implement recommendations from the provider as warranted, and Gradual Dose Reductions should be done every 6 months per regulatory guidelines.

Based on observation, interview, and record review, the facility failed to prevent a resident from falling off the bed during care resulting in R1 sustaining a femur fracture. This applies to 1 of 3 residents (R1) reviewed for falls in a sample of 3. The findings include: On March 11, 2025, at 10:39 AM, V3 (CNA/Certified Nurse Assistant) said on February 24, 2025, she had gone to R1's room to change R1's incontinence brief. V3 said R1 was a one-assist from staff and could help her with some things. V3 said when she walked into R1's room to the left side of the bed, she observed R1's body was closer to the right side of the bed, versus being centered. V3 said she flattened R1's bed out and picked up her draw sheet from underneath her left side and told her to turn towards the right, and as V3 turned R1 away from her, R1's legs started falling off the bed out of the right side. V3 said she tried to catch them, but it was too late, and R1 had fallen out of the bed onto the ground. V3 said she ran and notified the nurse. V3 said R1 was on an air mattress, which should have had bolsters on them to prevent the fall. R1's face sheet showed she was admitted to the facility with diagnoses including lack of coordination, lymphedema, morbid obesity, muscle wasting and atrophy in the right and left shoulder, dysarthria and anarthria, pain in right and left knees, dysphagia, major depressive disorder, rheumatoid arthritis, anxiety disorder, abnormalities of gait and mobility, altered mental status, and abnormal posture. R1's MDS (Minimum Data Set) dated February 24, 2025, showed R1 had severe cognitive impairment and showed R1 required moderate assistance to roll to the left and right. On March 11, 2025, at 11:59 AM, V5 (RN/Registered Nurse) said she was called to the room by V3 and when she entered the room, saw R1 was holding onto the bed rails and her knees were on the floor on the side next to the window. V5 said she assisted in lowering R1 to the floor and onto her back, when R1 complained about having pain. V5 said she called 911. V5 said if she had to reposition a resident to provide bed mobility and incontinence care, she would pull the resident closer to her before turning the resident away from her. V5 said she would pull her closer because at times, putting the resident in the center of the bed still may not give enough space for the resident's body to remain on the bed when they are turned away from the staff. On March 11, 2025, at 12:09 PM, V6 (RN) said she was called by V3 (CNA) and when she went to R1's room, saw her kneeling next to the bed with her hands on the halo side rail. V6 said the staff need to help R1 by giving her a push on the buttocks to turn her. V6 said she would have to put one of R1's legs over the other leg for R1, because R1 was only occasionally able to lift her legs, and when she did, it was only a little bit. V6 said R1 had better upper body strength than lower and was unable to walk. V6 said R1 had always been in a wide mattress as R1 was heavier set. V6 said if she provided care for R1, she would pull R1 towards her so there was more space on the other side when she was turned away from her. On March 12, 2025, at 11:15 AM, V17 (NP/Nurse Practitioner) said R1's right femur fracture was a result of her fall. V17 said it was her expectation if one staff was providing R1 with incontinence care, she would roll the resident towards her, not away from her, to prevent the resident from falling out of the bed. V17 said the staff should roll the residents towards them because in the case something occurred, there would be a place for them to roll them back safely, and the staff's placement would create a boundary to aide in them not falling out of the bed. V17 said due to R1's weight and deconditioned muscles, if her legs were close to the edge of the bed, she would not be able to prevent herself from falling off the edge of the bed. On March 12, 2025, at 9:22 AM, V18 (PTA/Physical Therapy Aide) said when the CNA provided incontinence care, the resident should be turned towards the side they are on, not away from them. V18 said this was done because of safety, and turning the resident away could cause a fall. On March 12, 2025, at 9:24 AM, V19 (Director of Rehab) said the resident should be pulled closer to the staff, and then turned away. V19 said the resident should always be in the middle of the bed to turn to the left or the right side. V19 said the staff should also press the button on the air mattress that would make the mattress firm, and not doing so could cause the resident to fall. On March 12, 2025, at 9:32 AM, V20 (Director of Restorative) said R1 was an extensive one-assist prior to her fall, which meant the staff completed majority of the task performed. V20 said R1 would be able to help but would get tired and needed a boost to get her arms to reach the side rail, and a boost given around the hip/glute area to move her leg over. V20 said R1 needed help with the initial turning motion. V20 said she was not notified by any of the CNAs that R1 had any issues with bed mobility. On March 11, 2025, at 1:40 PM, V8 (CNA) said she had previously cared for R1 prior to her fall, and R1 required two staff for bed mobility. V8 said there were days R1 was unable to assist in turning, and once she observed that, she always brought another staff member to assist in providing care for R1. V8 said she wanted to make sure R1 was covered on both sides and would pull R1 towards her before turning her towards the opposite side. V8 said R1 could fall if she was not positioned in either the center of the bed or closer to the staff member. On March 11, 2025, at 2 PM, V11 (CNA) said she had cared for R1 prior to R1's fall and she always had two staff in the room to take care of her. V11 said R1 was on an air mattress and used a mechanical lift for transfers, so they would have two staff. V11 said because R1 was also heavier and on the air mattress, two people was a safety measure. V11 said prior to the fall, R1 was not able to lift her legs to turn during bed mobility. V11 said R1 needed to be pushed towards the halo side rail to grab hold of it. V11 said she would never change R1 by herself and would always pull R1 towards her prior to turning her. V11 said R1 was heavy and did not have balance. On March 11, 2025, at 3:30 PM, V12 (CNA) said she floated all over the facility and had cared for R1 prior to her fall. V12 said R1 was able to turn but she needed help to lift her legs. V12 said R1 had upper body strength but would need her leg lifted to turn her. V12 said if the staff were providing bed mobility, R1 should be centered in the bed before she was turned away from the staff. V12 said R1 would need enough moving room before turning as she was heavier, and it could lead to her falling out of bed. On March 11, 2025, at 3:50 PM, V16 (CNA) said she had taken care of R1 prior to her fall and R1 only needed one person assisting with bed mobility prior to her fall. V16 said R1 needed help crossing her legs, then a boost on her back to get her over so that R1 could grab the side rail. V16 said she would pull R1 closer to her or in the middle prior to turning her because R1 could slide due to the air mattress. V16 said the air mattress would cause R1 to slide more to the side she was lying on. On March 12, 2025, at 3:21 PM, V2 (DON/Director of Nursing) said the residents receiving incontinence care and bed mobility should be placed in the middle of the bed. V2 said the facility did not have a policy regarding which way the resident should be turned. V2 said if the resident was not placed in the center of the bed, rolled away from the staff, and there was no other staff on the other side, it could cause the resident to roll out onto the other side. R1's progress notes showed the following: On February 24, 2025, at 8:10 PM, V5 (RN) wrote, Writer was down the hall passing medication when writer was called to resident room, writer enter resident room noted resident holding on to bed rail with both hands while bilateral knees touching the floor next to the bed by the window. Writer lower resident to the floor on to her stomach, then staff help writer to reposition resident on to her back, resident complained of pain writer administer PRN [As Needed] tramadol 50 mg [Milligrams] PER MD [Medical Doctor] orders. vs [Vital Signs] taken, 911 was called. 153/78, 80, 97.8 20, 93% N/C [Nasal Cannula]. NP [Nurse Practitioner-name] made aware/ ADON [Assistant Director of Nursing]. Resident POA [Power of Attorney- name] made aware of resident fall/Transfer to [Hospital] ER (emergency room ). On February 24, 2025, at 8:34 PM, V5 wrote, 911 in facility, 911 and staff used [Mechanical] Lift to get resident off and placed on stretcher to be transferred to [Hospital] ER for Eval. On February 25, 2025, at 4:13 AM, the documentation showed, @4A.M Writer called [Hospital] ER and spoke with ER nurse regarding resident's status and received report that resident was transferred to [Hospital]. Writer spoke with nurse at [Hospital] and received report that resident is admitted with diagnosis of right femur fracture . On February 27, 2025, at 11:09 AM, V17 (NP) wrote, [History of Present Illness]: .The patient was sent to [Hospital] on 2/24/2025 due to a fall. The patient had the following imaging at the hospital: CT [Computed Tomography] Femur Right WO IV [Without Intravenous] Contrast (2/24/25) Impression: Acute distal right femoral metaphyseal fracture. R1's EMR (Electronic Medical Record) showed the following documentation by the CNAs caring for R1 regarding R1's ability to Roll Left and Right: On February 11, 2025, at 2:07 AM, R1 required moderate assistance. At 1:31 PM, R1 was dependent on staff for bed mobility, and at 4:23 PM, R1 required maximal assistance for bed mobility. On February 12, 2025, at 1:55 PM and 6:07 PM, R1 required maximal assistance for bed mobility. At 11:37 PM, R1 was dependent on staff for bed mobility. On February 13, 2025, at 9:59 PM, R1 was dependent on staff for bed mobility. On February 14, 2025, at 12:04 AM, 1:59 PM, and 9:34 PM, R1 was dependent on staff for bed mobility. On February 15, 2025, at 2:50 AM, 1:59 PM, and 9:30 PM, R1 was dependent on staff for bed mobility. On February 16, 2025, at 4:35 AM, 1:59 PM, and 7:44 PM, R1 was dependent on staff for bed mobility. On February 17, 2025, at 4:32 AM, 1:59 PM, and 11:05 PM, R1 was dependent on staff for bed mobility. On February 19, 2025, at 1:59 PM, R1 was dependent on staff for bed mobility. On February 20, 2025, at 9:22 AM and 9:59 PM, R1 was dependent on staff for bed mobility. On February 21, 2025, at 1:59 PM, R1 was dependent on staff for bed mobility. At 5:37 PM, R1 required moderate assistance from staff for bed mobility. On February 22, 2025, at 4:20 PM, R1 was dependent on staff for bed mobility. At 8:52 PM, R1 required maximal assistance from staff for bed mobility. On February 23, 2025, at 12:58 AM and 9:16 AM, R1 was dependent on staff for bed mobility. At 6:44 PM, R1 required maximal assistance from staff for bed mobility. On February 24, 2025, at 1:07 AM, R1 was dependent on staff for bed mobility. At 1:59 PM, R1 required maximal assistance from staff for bed mobility. The facility's Positioning policy reviewed on October 2021 showed to promote resident comfort, safety, and dignity. To prevent complications of improper positioning such as skin breakdown, contracture development and decreased circulation. The facility was unable to provide a policy regarding bed mobility.

Based on interview and record review the facility failed to ensure fall interventions were in place for a resident who is at high risk for falls for 1 of 4 residents (R1) reviewed for safety in the sample of 6. This failure resulted in R1 falling out of bed and sustaining a laceration to her forehead requiring stitches. The findings include: R1's Minimum Data Set assessment dated [DATE] shows that her cognition is impaired and R1 has had one fall with no injury and two or more falls with injury since her prior assessment. On 1/21/25 at 11:11 AM, V3, Certified Nursing Assistant (CNA) said that on 1/3/25 he went into R1's room to get her up for the morning. V3 said that he removed her fall mat from the floor and removed her bed bolsters from the bed in order to provide incontinence care. V3 said that after incontinence care was provided, he lowered the bed and went to get the mechanical lift sling. V3 said that when he turned back around, he saw R1 with her upper body out of the bed and her head on the floor. V3 said that he repositioned her back into bed, put the floor mat back down and re-applied the bolster and then went and got the nurse. V3's typed and signed statement dated 1/3/25 shows, In order to provide incontinence care and personal hygiene I needed to move the thick floor mat out of the way. After performing care, I lowered the bed back down to the lowest position and prepared the resident for transfer. I went to retrieve the hoyer (mechanical lift) pad for the resident and during this time I noticed the resident began to roll off the bed. I attempted to guide the resident back to bed, but she ended up hitting her head on the floor On 1/21/25 at 12:24 PM, V4 (CNA) said that R1 was at high risk for falls and would be very active at times. V4 said that R1 had a fall mat and bolster on her bed to prevent her from falling out of bed and hurting herself. V4 said that the fall mat and bolster should be in place at all times when R1 is in bed. V4 said that staff should always be prepared with the supplies that are needed to provide care to R1 before they start the care. V4 said that if she did have to get something that she had forgot, she would place the fall mat and bolster back in place before leaving the resident's bedside. On 1/21/25 at 1:02 PM, V13 (Restorative Licensed Practical Nurse) said that R1 wiggled around' in bed a lot so they had an intervention of bolster placement on her bed to help her maintain proper body alignment while in bed. V13 said that R1 has had falls in the past out of bed so the fall mats were implemented to provide extra protection if she did fall out of bed to reduce injuries. V13 said that she did educate V3 that all supplies should be obtained before starting resident care and if he has to step away from the resident, fall prevention interventions (fall mat and bolster) should be re-applied. R1's Progress Notes dated 1/3/25 at 7:30 AM shows, Writer called to resident's room by CNA (Certified Nursing Assistant). CNA states that resident rolled out of bed during transfer to chair. Laceration noted to resident's forehead R1's Hospital Notes from 1/3/25 shows, This is a [AGE] year-old female with a past medical history of dementia, nonverbal, hospice patient, who presents to the emergency department with chief complaint of head injury and fall. Patient reportedly had rolled out of bed around 0730 hours this morning, this was witnessed by nursing home staff. Patient hit her forehead on the ground She did sustain a laceration to her forehead She has had a proximally 3 centimeter largely linear, slightly irregularly shaped laceration to her left upper forehead/frontal scalp 3-4 centimeter frontal scalp contusion on the left repaired with 3 simple interrupted sutures. R1's Fall Care Plan initiated 2/14/24 shows, Resident has a history of falls R/T (Related To) weakness, endurance, CVA, dementia and hx (history) of falls Interventions: Provide re-education to staff on safety device/appliance; Bed bolsters. Re-enforce bed bolsters R1 Bed Bolster Care Plan initiated on 4/3/24 shows, Resident has poor safety awareness r/t dementia, and other co-morbidities and requires bed bolsters to be applied Use bed bolsters to prevent senior from rolling off the bed. Using fall prevention tools such as bolsters and roll guards to reduce the chances of falling out of bed. R1's Care Plan does not mention the use of fall mats. The facility's Falls and Fall Risk, Monitoring Policy revised 8/2008 shows, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .The staff, with the input of the attending physician, will identify appropriate interventions to reduce the risk of falls .Staff will identify and implement relevant interventions to try to minimize serious consequences of falling.

Based on interviews and record reviews, the facility failed to follow its abuse prevention policy by not protecting a resident from verbal abuse from staff. This applies to 1 of 3 residents (R1) reviewed for verbal Abuse in a sample of 3. The Findings include: R1 is a [AGE] year-old female admitted on [DATE] with an admitting diagnosis including vascular dementia. A review of the Minimum Data Set (MDS) dated [DATE] documents that R1 has severe cognitive impairment. On 12/10/24 at 10:10 AM, V5 (Registered Nurse / RN) stated, When I came back from vacation on 12/4/24, I heard from V6 (RN) and V7 (Licensed Practical Nurse / LPN) about the verbal abuse from V4 to R1. R1 is very confused, and I heard V4 called R1 something with the 'f_ _ k' word. On 12/10/24 at 10:13 AM, R1 stated in the presence of V5 (Registered Nurse / RN), It's been a while since someone called me with the 'F' word. But I don't know who or when. On 12/10/24 at 10:15 AM, V7 stated, On 11/20/24 during lunchtime, I was sitting in the nurse's station and could see R1 in the dining room. V4 took R1's tray away, and R1 raised her hand and hit the tray, causing the coffee cup to fall off the tray along with other food items. V4 put the tray on the table, got in the face of R1, and told her loudly, 'If you do this again, I will f_ _k you up.' V4 literally got down and said it on R1's face. I was not her nurse; V6 was the nurse. V6 was next to me with her medication cart. On 11/20/24, V6 notified V3 (Assistant Director of Nuring) about the verbal Abuse, and V2 (Director of Nursing) came to me and asked me what happened. I explained to her that V4 was verbally abusive to R1. On 12/10/24 at 11:00 AM, V6 (Registered Nurse/RN) stated, The CNA (V4) said something to R1 with the 'F' word. V4 said to R1, 'If you put your hand on me, I am going to f_ _ k you up.' I did report to ADON (V3) in detail via text. I texted her on 11/20/24 at 12:40 PM and still have the text on my phone. V9 the Psych Nurse Practitioner (NP) was there and also heard the verbal abuse that happened on 11/20/24 at 12:40 PM. On 12/10/24 at 12:10 PM, V9 (Psych NP) stated that he heard the CNA (V4) saying something loud to R1. V9 added that he was focusing on his work with his computer, and he neither saw the incident nor heard exactly the wording V4 was saying. On 12/10/24 at 10:30 AM, V10 (Unit Clerk/CNA) stated that on 11/20/24, she heard someone in the dining room call the 'F' word. V10 added that she could hear from her office, and the nurse told her that staff member V4 (CNA) was the one calling the 'F' word to R1. On 12/10/24 at 11:15 AM, V2 (Director of Nursing / DON) stated, I can't remember the date of the incident between V4 and R1. V4 was holding a tray in the dining room; R1 hit the tray, and the food fell on the floor. V4 said an explicit word, 'F word' out loud. I pulled V4 from the unit and sent her home immediately as she was disruptive to our unit. It was not explained to me as verbal Abuse and, hence, was not reported to the abuse coordinator on the same day. On 12/10/24 at 2:15 PM, V1 (Administrator/Abuse Coordinator) stated, A resident has the right to be free from verbal Abuse. On 11/20/24, ADON got a text message from V6 saying that V4(CNA) was cursing on the unit; the DON (V2) went to the unit and asked the CNA and interviewed persons who witnessed the incident. V2 determined that the CNA was not exhibiting good customer service and decided to send her home. V2 determined it was not an abuse. They told me V4 was cursing on the unit, and it was not reported to me that V4 was calling the 'F' word to R1 on 11/20/24. A review of the facility presented Abuse Prevention Policy (undated) document: This facility affirms the right of our residents to be free from Abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment .Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individual's age, ability to comprehend, or disability.

Based on interviews and record reviews, the facility failed to follow its abuse prevention policy by not reporting a verbal abuse allegation to state agency. This applies to 1 of 3 residents (R1) reviewed for abuse reporting in a sample of 3. The Findings include: R1 is a [AGE] year-old female admitted on [DATE] with an admitting diagnosis including vascular dementia. A review of the Minimum Data Set (MDS) dated [DATE] documents that R1 has severe cognitive impairment. On 12/10/24 at 10:10 AM, V5 (Registered Nurse / RN) stated, When I came back from vacation on 12/4/24, I heard from V6 (RN) and V7 (Licensed Practical Nurse / LPN) about the verbal Abuse from V4 to R1. R1 is very confused, and I heard V4 called R1 something with the 'f_ _ k' word. On 12/10/24 at 10:15 AM, V7 stated, On 11/20/24 during lunchtime, I was sitting in the nurse's station and could see R1 in the dining room. V4 took R1's tray away, and R1 raised her hand and hit the tray, causing the coffee cup to fall off the tray along with other food items. V4 put the tray on the table, got in the face of R1, and told her loudly, 'If you do this again, I will f_ _k you up.' V4 literally got down and said it on R1's face. I was not her nurse; V6 was the nurse. V6 was next to me with her medication cart. On 11/20/24, V6 notified V3 (Assistant Director of Nursing) about the verbal abuse, and V2 (Director of Nursing) came to me and asked me what happened. I explained to her that V4 was verbally abusive to R1. On 12/10/24 at 11:00 AM, V6 (Registered Nurse/RN) stated, The CNA (V4) called R1 something with the 'F' word. V4 said to R1, 'If you put your hand on me, I am going to f_ _ k you up.' I did report to ADON (V3) in detail via text. I texted her on 11/20/24 at 12:40 PM and still have the text on my phone. I believe V2 talked to V7 after I reported the abuse to V3. V2 didn't ask anything to me. V4 was sent home before her shift ended, but she came back the next day. On 12/10/24 at 11:35 AM, V3 stated that she was told/texted that V6 thinks V4 was loud to R1, and V6 never mentioned to V3 that V4 called R1 with an 'F' word. V3 continued that she reported the incident to V2, and V2 sent V4 home before V4's shift ended as V4 was disruptive to the unit residents. On 12/10/24 at 11:15 AM, V2 (Director of Nursing / DON) stated, I can't remember the date of the incident between V4 and R1. V4 was holding a tray in the dining room; R1 hit the tray, and the food fell on the floor. V4 said an explicit word, 'F' word' out load. I pulled V4 from the unit and sent her home immediately as she was disruptive to our unit. It was not explained to me as verbal abuse and, hence, was not reported to the abuse coordinator on the same day. A couple of days later, V1 (Administrator) asked me about the incident, as he had heard from others, and I explained it to him. On 12/10/24 at 2:15 PM, V1 (Administrator/Abuse Coordinator) stated, On 11/20/24, ADON got a text message from V6 saying that V4(CNA) was cursing on the unit; the DON (V2) went to the unit and asked the CNA and interviewed persons who witnessed the incident. V2 determined that the CNA was not exhibiting good customer service and decided to send her home. V2 determined it was not an abuse. V1 stated that the staff told him that V4 was cursing on the unit. According to V1 staff did not report that V4 was calling R1 the F word. V1 stated the incident of 11/20/24 was not reported. V1 also stated that all abuse allegations should be reported within 24 hours to the state agency. On 12/10/24 at 10:13 AM, R1 stated in the presence of V5 (Registered Nurse / RN), It's been a while since someone called me with the 'F' word. But I don't know who or when. A review of the last six months reportable indicates that the abuse allegation from V4 to R1 that happened on 11/20/24 was not reported to the state agency. A review of the facility presented Abuse Prevention Policy (undated) document: Employees, without fear of retaliation, may also independently report to state survey agency any allegation of abuse, neglect, exploitation, mistreatment or misappropriation of resident property, and to local law enforcement or state agency if they have suspicion that a crime was committed.

Based on interview and record review, the facility failed to ensure that a personal mail with a gift check was given to the resident whom it was addressed to, and not deposited to the transferring account intended for payment of the resident's room and board. This applies to 1 of 3 residents (R1) reviewed for personal funds in the sample of 3. The findings include: Face sheet and Minimum Data Set (MDS) dated [DATE], shows that R1 is [AGE] years-old who is alert and oriented. R1 was independent to some of her activities of daily living (ADL) care and needs supervision to some. R1 was admitted to the facility on [DATE]. On September 23, 2024, at 10:17 AM, R1 said that she has been living in this facility for almost 2 years. R1 receives her husband's pension from the police department, and she has social security benefits as well. These checks go straight to the facility for payment of her room, board, and treatment. In addition, R1 usually receives a check every Christmas from the Policemen's Annuity and Benefit Fund of Chicago (PABF) for the widows and widowers of the fallen police officers. However, on December 2023, R1 did not receive a check from PABF. R1 followed up from the PABF organization and spoke to an employee from the department who manages those checks. It was a multiple back and forth follow up to the department and to the facility, until such time her contact person informed her that it was already mailed to her and cashed in. In February 2024, V2 (Former Business Office Manager) informed R1 that she found R1's check. The letter was opened, and the check deposited somewhere. V2 wrote R1 a check worth $500 to replace the missing check. R1 was informed that there was an employee in the facility who sort through residents' mails. On September 23, 2024, at 11:55 AM, V2 (Former Business Office Manager) stated that there was a check that came in for R1 (from the Policemen's Annuity and Benefit Fund of Chicago). The facility deposited it in R1's trust fund account. R1 mentioned to V2 that she (R1) was supposed to receive a check every year from that organization and has not received it yet. V2 looked and found it in R1's trust fund account. V2 also said that they can open a resident's mail depending upon the contract the resident signed with the facility. There is a special form where the residents signed giving the facility the permission to open any mail that involves a check. That check (PABF) was deposited on January 19, 2024. V2 was not sure the time that the check was released to R1. There is usually a one-week turnaround from the bank before the check is posted to the resident's account until it appears for availability of withdrawal. That particular issue was brought to V2 only one time. On September 23, 2024, at 12:26 PM, V6 (R1's Daughter/POA medical) stated that the PABF check was deposited in the facility's account, it was released to R1 in late February. The facility is taking all R1's checks and depositing it in the facility's account for her room and board, but the facility is only entitled to R1's social security check and pension check and not her other checks. The facility wrote the $500 check on February 2, 2024. R1 forwarded it to V6 on the first week of March. On September 23, 2024, at 1:03 PM, V4 (Admission Director) stated that all personal mail gets delivered to the residents, business mail goes to the business office to sort it out, to ensure that it is not a social security or pension or something from Medicaid that needs to be addressed. Some residents need help with sorting out their mail. They sign a paper that gives consent to the facility as to which mail the facility can open. On September 23, 2024, at 11:18 AM, V3 (Current Business Office Manager) said that she (V3) manages the residents' accounts such as Medicaid applications, redeterminations, and collections. When a resident needs cash they fill out a withdrawal slip with the receptionist, and they get the cash from V1 (Administrator). The facility then withdraws whatever the resident cashed in from their RFMS (Resident Fund Management Service) account. The resident's checks pertaining to room and board, are given to the business office. These checks were either from their pension, social security, or from the resident's family. The RFMS is the residents' bank account in the facility. This RFMS has two types of accounts, a transferring, and a non-transferring account. The non-transferring account is for the resident which can be withdrawn by the resident whenever they need cash to spend. The transferring account on the other hand is an account that goes towards the resident's care cost (room, board, treatment payment). At 1:14 PM, V3 also stated that R1's $500 PABF check was deposited to the transferring account which means that it could go to her care cost. Facility presented the copy of the letter and $500.00 check from the Retirement Board of the Policemen's Annuity and Benefit Fund of Chicago. The letter read: Dear Annuitant, The Retirement Board of the Policemen's Annuity and Benefit Fund of Chicago (PABF) would like to provide some assistance to you during the holiday season. We are providing you with $500 gift check that is non-taxable to you. The Board wishes you and your family a Peaceful Holiday Season, and a healthy and Happy New Year. Sincerely, Retirement Board of the Policemen's Annuity and Benefit Fund of Chicago. The Policemen's Annuity and Benefit Fund of Chicago check was dated January 8, 2024, addressed to R1. However, it also showed in another document that V2 deposited this check to the bank (through Direct Deposit Management Service/DDMS) on January 11, 2024, instead of releasing it to R1. The $500 was only issued to R1 after R1's inquiries. R1's admission contract with the facility regarding R1's mail shows that R1 signed permission for facility to direct all her business mail to the business office and all personal mail directed to R1. In addition, R1 signed authorization for facility to have her social security check directly deposited to her transferrable account in the facility, while her pension check which is directly deposited to her personal account in a private bank was being withdrawn by the facility via debit card. Both checks are for all her care cost. However, the same signed contract does not include R1's personal checks or other financial resources.

Based on observation, interview and record review, the facility failed to store, prepare, and serve food in a sanitary manner. This has the potential to affect all 116 residents that receive food prepared in the facility kitchen. The findings include: Facility provided information that the census on August 5, 2024, was 117 residents with one resident on NPO (nothing by mouth) status. On August 5, 2024, at 9:17 AM, during initial tour of the kitchen the following observations were made: At the 3-compartment sink, used for wash, rinse and sanitizing dishes, dirty dishes were seen in the sanitizing sink. V6 (Dietary Aide) was seen washing the dishes in the middle sink, which should be used for rinsing dishes. V6 stated that she is going to fill the sanitizing sink with sanitizer. V6 then removed the dirty pans from the sanitizing sink and filled it with water mixed with sanitizer. It was noted that the sanitizing well still had food debris from the dirty pans and also had dirty rags in it. When notified that the sanitizer was contaminated, V6 cleaned and refilled the sanitizing sink with water mixed with sanitizer. When asked if she uses test strips to check the strength of the sanitizer, V6 was not sure of which test strips to use. V6 then used test strips for chlorine sanitizer which tested and remained white color. V6 stated that it should have tested 200 (ppm/parts per million) and pointed to the darkest color scale on the test strip container. V7 (Dietary Aide), who was washing dishes in the high temperature dish machine volunteered to test the sanitizer with the same test strip she uses for the high temperature dish machine. On prompting by State Agency personnel, V6 used the test strip for QUATS (quaternary ammonium compounds) sanitizer that was placed directly in front of the 3-compartment sink with directions for use of the same. The same test strip was unopened and after eventually breaking the seal with some difficulty with her long artificial nails, V6 was able to test the sanitizer but was not sure of what range it should test to and remarked I am guessing that it should test 200. Both V6 and V7 were noted to have long artificial nails and when questioned about it, V6 and V7 stated that they are used to working with the same. V7 was working at the high temperature dish machine. The dish machine wash area had grayish fuzzy patches on the conveyor belt and wall area. The plastic curtains at entrance (dirty side) and exit (clean side) of the dish machine were also noted to have excessive food debris and grayish patches on. A free-standing cart near the dish machine held washed bowls, most of which were not stored inverted. Multiple bowls had food debris and spills still in them. V6 stated that these dishes are used to serve dessert and that they were washed and stored by the dietary staff that worked the night before. V9 (Cook) was seen in the kitchen preparing the lunch meal and was noted to also have long artificial nails. V6, V7 and V9 were noted to wear gloves and remove them in between tasks during meal preparation and service. The walk-in Cooler had several bowls of pudding stored on a free-standing cart open to air. The walk-in Freezer had extensive ice built up under the shelving at the back of the freezer with other miscellaneous debris. There were multiple cardboard boxes containing food products stacked on the floor which appeared dirty and strewed with debris. On the back shelving, there were several cardboard boxes containing frozen meat products of chicken cordon blue, pork crumble, beef, pork and other meat products that were not in cardboard boxes and were completely covered with ice that seemed to have formed from drippings from condensation from above. Multiple unidentifiable boxes of food products including dough rolls were open to air and appeared freezer burnt. V1 (Administrator) who had come to the area stated that V4 (Dietary Director) was on vacation. V1 stated that he is aware of the ice build-up and a company from outside is scheduled to fix the leak that is causing the ice build-up. V1 was notified that the frozen meats and other items with extensive ice build-up will not be at a quality to serve the residents. On August 6, 2024, at 10:30 AM, during pureed meal preparation of vegetable soup, V4 stirred the soup mixture in the blender with a spatula, and then placed the spatula in a sink that had running water and food debris and used utensils. In between pureeing, V4 used the same spatula from the sink to stir the vegetable soup mixture to check the consistency of the soup. V4 was notified that the pureed product was contaminated and was not safe to serve. V4 also had a beard with a beard cover that was under his chin. During further observations on the same day, V5 (Cook) and V10 (Dietary Aide) were also seen in the facility kitchen assisting with food stocking in cooler and freezers and were noted to have long dreadlocks that were partially tucked into a hair net and/or chef cap. V5 was also seen at tray line for lunch service with his dreadlocks partially covered in the hairnet. V4 was notified of the observations. On August 6, 2024, at 4:00 PM, V21 (R61's Power of Attorney) stated Once they were served a thin patty on a dry bun with some mayo on the side. They said it was chicken. The patty was so hard, and one of the ladies hit it on the table and it broke in two. The meat was hard, and freezer burned. None of the residents were able to eat it. On August 7, 2024 at 9:39 AM, V4 stated that the items in the freezer were used to prepare meals. V4 stated that he was aware of the freezer condition prior to going on vacation. V4 added that he threw away the food items that were earlier identified during initial tour covered in ice and freezer burnt. Service Order for Freezer dated July 26, 2024, included the following: Multiple issues appear to be causing ice buildup. There is an active condensate leak above the walk-in freezer coming from poorly insulated suction line drip water onto freezer ceiling then leaking into freezer. The suction line inside of freezer is bad. Water can be seen leaking of drain line when defrost comes on Drain line is partially broken or cracked and hidden under insulation heat tape needs to be replaced. Sections of curtains are missing. Suction lines on both outside unit needs to insulate. Suction line inside of the walk-in cooler also needs new insulation and evaporation coil needs to be cleaned. Outside electrical disconnect for freezer condensing unit is bad electrician work. Facility Policy titled Food Storage (revised June 2023) included as follows: Policy: It is the policy of [Facility] that all food products will be stored under proper conditions of sanitation, temperature, light, moisture, ventilation, and security. Process: 1. Food storage area shall be clean at all times . 13. No meat or vegetable is refrozen . 17. All stored food will be at least 18 inches from the ceiling or pipes, and at least 6 inches off the floor. 18. All exposed foods shall be tightly covered. Facility Policy titled Dishwashing and Sanitation (revised June 2023) included as follows: Policy: It is the Policy of [Facility] to store, prepare, distribute and serve food under sanitary conditions. Purpose: To properly wash and sanitize is necessary to prevent food-borne diseases. Dishware, pots pans or utensils should be thoroughly cleaned and sanitized before use in food preparation or food serving to prevent the spread of food-borne diseases. Process: 2. Culinary Host will be trained in the proper use of the dish machine and three- compartment sink. 4. Food Service personnel will follow cleaning schedules and procedures in all areas for which they are responsible. Mechanical Dishwashing: 3. Dishwashing interior, exterior, jets, filters and rinse areas should be kept clean and free from food build-up. Manual Dishwashing: 1. Pot washing areas and sinks should be cleaned prior to use and have three compartment sinks for washing, rinsing and sanitizing. 3. Items should be pre-soaked (if necessary) and then scraped free of food debris before placing in the wash sink. 5. Items should be washed thoroughly in clean water with detergent solution. Dirty water should be changed frequently. 6. Items should be rinsed thoroughly in clean water to remove any remaining food particles or detergent. 7. If chemical sanitation is used, sanitize for 60 seconds. Solution should be mixed twice the recommended amount of solution to keep the strength because rinse water is carried over to the sanitizing sink. 8. Items should be allowed to air dry. Pots and pans should be inverted to speed drying process and allow excess water to drain away . Facility undated Policy titled Personnel and Sanitation (Policy #121-1) included as follows: 8) An employee who handles exposed food and food-contact surfaces: a) Keeps fingernails clean and neatly trimmed. b) Unless wearing gloves that are in good repair, does not wear fingernail polish or artificial fingernails: e) Uses hairnets, caps, or other effective hair restraints in order to keep hair from contacting food and food -contact surfaces.

Based on interview and record review, the facility failed to ensure that the dietary staff followed the approved recipe for chef salad. This applies to 8 of 8 (R25, R26, R27, R6, R84, R91, R101, R113) residents reviewed for dining in the sample of 25. The findings include: Facility Spring/Summer 2024 (Week 4) Menu on Thursday [August 1, 2024] showed Chef's salad, seasonal fruit, baked fresh roll, cinnamon apple sauce, margarine. On August 5, 2024, at 3:23 PM, R6 stated The whole place got a bowl container of some kind of lettuce with no meat or cheese. There was no bread roll served with it. I ate in the dining room, and everybody was startled. I did not ask for anything else as it was night-time, and the people (from kitchen) had cleaned up and left. On August 5, 2024, at 3:22 PM, R26 stated Last week some time at dinner I got a bowl of lettuce with ranch dressing and no meat. I ate in my room and did not say anything. On August 5, 2024, at 3:18 PM, R91 stated Sometime for dinner last week we got a bowl of shredded lettuce with no meat. I thought 'What is this?' I felt like a rabbit. It was weird. But I don't complain. On August 5, 2024, at 3:20 PM, R84 stated We only got a Styrofoam container of lettuce with couple tomatoes. We all talked about it and R101 was very upset as she was very hungry. It has happened a few months ago once too when we got no meat. On August 5, 2024, at 3:31 PM, R101 stated Last Thursday or Friday night we got a small Styrofoam container with some lettuce and a dressing on the side. They said it was a chef salad platter but there was no meat or cheese or croutons on it. Even the CNAs (Certified Nursing Assistant) said 'We can't feed this to these people.' We complained about it. On August 5, 2024, at 3:26 PM, R113 stated We got just lettuce for dinner last week and most of us went to bed hungry. We all raided our snack cabinets. One of the resident's son's thought we will all starve to death and went and bought 5 pizzas. R27's daughter (V8) stated that it is the last straw, and she took pictures of it and was going to go to the newspapers, but we thought she should take it to V1 (Administrator) first. Everybody told V1 about it including the residents. He said he will look into it. On August 5, 2024, at 3:36 PM, V8 (R27's Power of Attorney) was visiting R27 in her room and stated that R27 is hard of hearing. V8 stated that she visits every day at dinner time and saw that R27 had received just a side order of lettuce and cucumber along with a hard cheese sandwich. V8 added that the cheese sandwich is just an addition to the meal that R27 is supposed to get with every lunch and dinner as written on her meal ticket. V8 stated that she took a picture of the meal with her cell phone. V8 had a picture on her cell phone that showed a Styrofoam container of lettuce with salad dressing on top, 3 small pieces of tomato in one of the compartments, served with a grilled cheese sandwich and a small bowl of a soupy mixture. The salad did not show cheese, or visible meat. Grievance report filed by V8 dated August 1, 2024, included that R27 verbalized displeasure with dinner served on that day. On August 5, 2024, at 4:20 PM, R25 stated that the facility provides small portions of food. R25 stated I think it was last Thursday (August 1, 2024) that everyone got just shredded lettuce and a cup of dressing on the side, and everyone went to bed hungry. I told V1 what we got. R25 stated that she filed a grievance report the next day. Grievance report dated August 2, 2024, included that R25 was displeased about the dinner served on August 1, 2024, dinner. On August 5, 2024, at 4:04 PM, V1 stated that there was a meal last week either on August 1, 2024, or August 2, 2024, that the residents did not like. V1 stated that it was chef salad that the residents were displeased about, and the facility notified the Dietitian to change the menu item. V1 stated that he spoke to V5 (evening Cook) who stated that he was preparing the meal according to the menus. On August 6, 2024, at 9:07 AM, V4 (Dietary Director) stated he was informed that the residents were not a fan of the chef salad. V4 stated It's a preference thing. I am looking into changing this menu item and a few other items that the residents don't care for. The chef salad should have had the turkey as that's the protein. On August 6, 2024, at 9:08 AM, V5 (Cook) stated that he followed the recipe for chef salad and added lettuce, turkey breast, cheese, and tomatoes. V5 added that he prepared a few with no tomatoes, no cheese respectively for those that are not able to have those items. V5 stated that the chef salad was served in a to go disposable container. On August 6, 2024, at 4:48 PM, V11 (Certified Nursing Assistant) stated that she recalls that the residents received a salad with less chicken in it. V11 did not recall seeing any egg or cheese in the salad. V11 stated that there was more salad than chicken and that the residents were not happy with the salad. V11 stated that even if one orders a salad meal from a restaurant there are certain expectations of how much meat you would expect to be put on the salad. Recipe for entree Chef Salad (Recipe #130) included the following ingredients and method of preparation: 1. Dice turkey and ham into 1/4 cubes. 2. Tear lettuce into bite-size pieces. 3. Shred carrots and add to lettuce. Toss lightly. 4. Portion lettuce and carrot mixture into individual salad bowls: 4 1/2 oz/ounce (1 1/2 cup) per bowl. 5. Arrange 1-1/2 oz each of turkey, ham, and 1 oz of cheese on top of lettuce. 6. Slice green peppers into 10 rings. Place one green pepper ring on each salad. 7. Cut tomatoes into 8 wedges and place 2 tomato wedges on each salad. 8. Serve each salad with 2 tbsp (tablespoon) salad dressing. Facility diet order listing showed that R25, R26, R27, R6, R84, R91, R101, R113 were on Regular consistency diets. R27's diet order included Send soft grilled cheese sandwich with lunch and dinner tray.

Based on observation, interview, and record review, the facility failed to follow standard infection control practices with regards to hand hygiene and gloving during provisions of incontinence care. This applies to 5 of 25 (R20, R62, R64, R80, R85) residents reviewed for infection control in the sample of 25. The findings include: 1. On August 6, 2024, at 11:25 AM, V24 and V26 (Both Certified Nursing Assistants/CNAs) rendered peri-care to R80. V24 cleaned R80's perineum from front to back, then she placed a clean incontinence brief underneath R80 while wearing same gloves. V24 then, changed her gloves without performing hand hygiene and continued to reposition R80. V24 then handled the indwelling urinary catheter bag and straightened clean bed linens without performing hand hygiene in between tasks. 2. On August 6, 2024, at 1:39 PM, V25 (CNA) assisted R62 to the toilet where R62 voided and had a bowel movement. After R62 used the toilet, she wiped her frontal perineum, then V25 assisted R62 to stand up and cleaned R62's back perineum. V25 wiped R62's rectum multiple times, pulled R62's incontinence brief and pants back in place and assisted R62 to transfer back to the wheelchair while wearing the same soiled gloves. 3. On August 6, 2024, at 1:54 PM, V24 and V25 (CNAs) rendered incontinence care to R64 who had a large bowel movement. V25 cleaned R64's perineum from front to back, changed the incontinence brief, changed bed linen, applied barrier cream to R64, handled indwelling urinary catheter bag, while wearing the same gloves. 4. On August 7, 2024, at 9:11 AM, V20 (Nurse) administered medications to R85 via gastrostomy tube (g-tube). Prior to administration of medications, V20 donned a pair of gloves, gown, and mask. When V20 entered R85's bedroom, she touched and folded the bedside floor mattress, drew the privacy curtain around R85, filled the plastic container with water to flush the g-tube, check placement of g-tube, and administered medications via g-tube while wearing the same gloves. On August 7, 2024, at 2:32 PM, V2 (Director of Nursing/DON) stated that when staff provides care to the resident, the staff should perform hand hygiene before donning gloves and after contact with residents. They should change gloves and perform hand hygiene in between tasks, they should also change gloves and do hand hygiene when touching different surfaces and equipment. This is to prevent infection and/or spread of infection. 16746 5. On August 6, 2024, at 12:45 PM, with the assistance of V27 (CNA/Certified Nursing Assistant), V15 (CNA) provided bowel and bladder incontinence care R20. With her gloved hands V15 used disposable wet wipes to clean R20's buttocks and perineal area. R20 had wet stool. After cleaning R20, V15 removed her soiled gloves and put on a new pair of gloves without performing hand hygiene (either hand washing or use of alcohol/hand sanitizer), then proceeded to wipe R20's buttocks with a wet washcloth. V15 then again, removed her used gloves, put on a new pair of gloves without hand hygiene (hand washing or use of sanitizer/alcohol), and proceeded to put on R20's clean socks, pants and disposable brief. On August 7, 2024, at 12:31 PM, V2 (Director of Nursing) stated that the staff should wash their hands or sanitize after removing the used or soiled gloves after provision of incontinence care to prevent cross contamination and to ensure infection control is maintained. The facility's handwashing/hand hygiene policy dated March 2020 showed, It is the policy of the facility to assure staff practice recognized handwashing/hand hygiene procedures as a primary means to prevent the spread of infection among residents, personnel, and visitors. Alcohol based hand rubs (ABHR) can be used for hand hygiene when hands are not visibly soiled or contaminated with blood or bodily fluids. The same policy under specifications showed in-part, 4. When hands are not visibly soiled, employees may use an alcohol-based hand rub (foam, gel, liquid) containing at least 60% alcohol in all of the following situations: .g. before moving from a contaminated body site to a clean body site during resident care; h. before and after putting on and upon removal of PPE (personal protective equipment), including gloves; . k. after contact with objects such as medical devices or equipment in the immediate vicinity of a resident that may be potentially contaminated; . m. after removing gloves.

Based on observation, interview, and record review, the facility failed to assist residents identified as needing assistance with personal hygiene. This applies to 4 of 5 residents (R20, R85, R100 and R108) reviewed for ADLs (activities of daily living) in the sample of 25. The findings include: 1. R108 had multiple diagnoses including, dementia with other behavioral disturbance and weakness, based on the face sheet. R108's quarterly MDS (minimum data set) dated July 23, 2024, showed that the resident was severely impaired with cognitive skills for daily decision making. The same MDS showed that R108 was totally dependent on the staff with her ADLs including upper body dressing and personal hygiene. On August 5, 2024, at 11:36 AM, R108 was sitting in her reclining wheelchair inside the unit dining/activity room. R108 was alert but confused. R108's fingernails were short with black substances underneath. R108 was observed sticking her fingers inside her mouth. V14 (CNA/Certified Nursing Assistant) was present during the observation and confirmed that R108's fingernails had black substances underneath. On August 6, 2024, at 10:51 AM, R108 was sitting in her specialized wheelchair inside the unit dining/activity room. R108 was alert and confused. R108's gray sweater had food debris on the chest area. V15 (CNA) was present during the observation and confirmed that there were food debris from breakfast on R108's sweater. R108's active care plan initiated on June 10, 2024, showed that the resident's ability to perform ADLs was impaired related to cognitive loss. The same care plan indicated that R108 needed maximum/total assistance with all her ADLs. 2. R20 had multiple diagnoses including hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, type 2 diabetes mellitus, cognitive communication deficit and generalized muscle weakness, based on the face sheet. R20's significant change in status MDS dated [DATE], showed that the resident was severely impaired with cognition. The same MDS showed that R20 required maximum assistance from the staff with personal hygiene and lower body dressing, and moderated assistance from the staff with upper body dressing. On August 5, 2024, at 12:13 PM, R20 was sitting in her reclining wheelchair inside the unit dining/activity room. R20 was alert, verbally responsive but confused. R20's fingernails were long, jagged with black substances underneath. V16 (Registered Nurse) was present during the observation and confirmed that R20's fingernails need trimming and cleaning because they were long, jagged and with black substances. On August 6, 2024, at 10:54 AM, R20 was sitting in her reclining wheelchair chair inside the unit dining/activity room. R20's pants and long sleeve shirt had scattered food debris and her fingernails were long and jagged. V15 (CNA) was present during the observation and confirmed that R20 had food debris on her pants and shirt. V15 also confirmed that R20's fingernails were long and jagged. R20's active care plan initiated on June 10, 2024, showed that the resident had limitation in ADL functional status. The same care plan showed that R20 required extensive assistance for grooming and dressing. 3. R100 had multiple diagnoses including cerebrovascular disease, dementia and history of transient ischemic attack and cerebral infarction without residual deficits, based on the face sheet. R100's quarterly MDS dated [DATE], showed that the resident was severely impaired with cognition and required total assistance from the staff with personal hygiene. On August 5, 2024, at 11:47 AM, R100 was sitting in her reclining wheelchair inside the unit dining/activity room. R100 was alert and confused. R100 had accumulation of long facial hair above and directly below her lips, and on her chin. V12 (Registered Nurse) who was present during the observation confirmed that R100 had accumulation of long facial hair and that the resident needs assistance with shaving. On August 6, 2024, at 11:20 AM, R100 was sitting in her reclining wheelchair inside the unit dining/activity room. R100 was alert and confused. R100's fingernails were long with black substances underneath. V13 (Registered Nurse) was present during the observation and confirmed that R100's fingernails were long and needed to be cleaned due to black substances underneath. R100's active care plan initiated on February 14, 2024, showed that the resident's ability to perform ADLs was impaired related to cognitive loss. 4. R85 had multiple diagnoses including Parkinson's disease without dyskinesia, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, weakness and vascular dementia with other behavioral disturbance, based on the face sheet. R85's quarterly MDS dated [DATE], showed that the resident was moderately impaired with cognition. The same MDS showed that R85 required maximum assistance from the staff with personal hygiene. On August 5, 2025, at 10:59 AM, R85 was in bed, alert and verbally responsive. R85 had accumulation of long facial hair and his fingernails were short, jagged with black substances underneath. R85 stated that he wanted the staff to shave him, and to file and clean his fingernails. V12 (Registered Nurse) was present during the observation and confirmed that R85 needed shaving and his fingernails needed to be filed and cleaned. R85's active care plan initiated on May 10, 2024, showed that the resident had limited ability to groom self, related to decrease mobility and endurance due to hemiplegia of the right dominant side. The same care plan showed an intervention to include, Provide assistance for grooming at level resident requires. On August 7, 2024, at 12:25 PM, V2 (Director of Nursing) stated that it is expected and is part of the facility's nursing care/service to ensure that residents who are needing assistance with ADLs including removing/shaving unwanted facial hair, fingernails trimming and cleaning and dressing should be assisted by the staff to maintain resident's dignity, comfort and hygiene/grooming.

Based on observation, interview, and record review, the facility failed to ensure that the indwelling urinary catheter was not positioned above the resident's bladder and failed to clean the catheter tube during incontinence care. This applies to 2 of 4 (R64 and R80) residents reviewed for peri-care and catheter care in the sample of 25. The findings include: 1. R80's face sheet shows that R80 has multiple medical diagnoses which includes Benign Prostatic Hyperplasia (BPH) with lower urinary tract symptoms. On August 6, 2024, at 11:25 AM, R80 was resting in bed, he had an indwelling urinary catheter with the urinary bag hanging on the left side of the bed. V24 and V26 (Both Certified Nursing Assistants/CNA) rendered peri-care to R80. V24 cleaned R80's perineum from front to back. V24 cleaned the tip of R80's penis, however, she but did not clean the catheter tube. When V24 and V26 repositioned R80 on his right side, V24 lifted and handed the urinary bag to V26 to place it on the right side of the bed. The urinary bag was lifted high above the bladder which made the urine inside the urinary tube flow back towards R80's bladder. V24 also emptied the urinary bag by lifting the bag high above the bladder while emptying into to the urinal, it was observed that the urine in the tube continued to flow back towards the bladder. 2. R64's face sheet shows that R64 has multiple medical diagnoses which include Benign Prostatic Hyperplasia (BPH) with lower urinary tract symptoms and urinary tract infection (UTI). On August 6, 2024, at 1:54 PM, R64 was resting in bed, he was awake, and was observed with a suprapubic urinary catheter. V24 and V25 (Both CNA) rendered incontinence to R64 who had a bowel movement. V25 cleaned R64's perineum from front to back. As V24 and V25 repositioned R64 on his right side, V24 handed the catheter bag to V25 to place the urinary bag on the right side of the bed. V24 lifted the urinary bag high above R64's bladder which made the urine inside the catheter tubing flow backwards towards R64's bladder. In addition, V25 did not clean the urinary catheter during the provision of care. On August 7, 2024, at 2:46 PM, V2 (Director of Nursing/DON) stated that when doing perineal care for a resident who has an indwelling urinary catheter, the staff must clean the catheter tube that is near the insertion site. When repositioning and transferring a urinary bag, the staff should not lift the urinary bag above the bladder, this is to prevent the urine from flowing backwards into the bladder and to prevent potential UTI. The Facility's Policy and Procedure for Urinary Catheter Care with revised date of September 2005 shows: Purpose: The purpose of this procedure is to prevent infection of the resident's urinary tract . General Guidelines: 4. The urinary bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder . Steps in the Procedure: 15. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward.

Based on observation, interview, and record review, the facility failed to check the placement of the gastrostomy tube (g-tube) prior to administration of medication. This applies to 1 of 2 residents (R80) reviewed for gastrostomy tube in the sample of 25. The findings include: On August 7, 2024, at 9:47 AM, V29 (Nurse) administered Hydrocodone-Acetaminophen 5-325 milligram tablet to R80 via g-tube. V29 flushed R80's g-tube with 60 milliliters (ml) of water and then administered Hydrocodone-Acetaminophen. Then V29 flushed the g-tube again with 60 ml of water. V29 did not check the placement of the g-tube prior to administering the medication. V29 stated that she forgot to do it. On August 7, 2024, at 10:51 AM, V28 (Assistant Director of Nursing/ADON) stated that when giving g-tube medication, the staff should check for the placement of the g-tube either by aspiration of residual or auscultation with stethoscope. This is to make sure that the medication is going into the right place. One of R80's g-tube care plan interventions dated July 15, 2024, shows Check placement and patency of feeding tube before each feeding or medication administration. R80's Medication Administration Record (MAR) dated August 2024 shows: Check for placement prior to medication, flush, or feeding administration. Aspirate residual feeding if more than 100 ml, hold feeding for 1 hour and recheck if still greater than 100 ml. Notify physician if no aspirate is obtained, check for placement using auscultation. If unable to aspirate or verify placement, hold administration of medication, flush or feeding and notify MD as needed.

Based on observation, interview and record review, the facility failed to recognize, evaluate and manage a resident's pain during care. This applies to 1 of 1 resident (R24) reviewed for pain management in the sample of 25. The findings include: R24 had multiple diagnoses including, senile degeneration of the brain and dementia without behavioral disturbance, based on the face sheet. R24's quarterly MDS (minimum data set) dated May 9, 2024, showed that the resident was severely impaired with cognition and required total assistance from the staff with her ADLs (activities of daily living). On August 5, 2024, at 10:31 AM, R24's door was closed, and the resident could be heard from outside of the door, moaning. Upon entering R24's room, the resident was in bed and was moaning. R24 was confused and could not verbalize pain when asked. V15 (CNA/Certified Nursing Assistant) and V17 (CNA) stated that they just finished providing morning care to R24. According to V15, R24 would be moaning during provision of care. V15 was not aware if R24 had received any pain medication prior to them providing morning care. V15 was observed applying the bilateral hand splints to R24. V15 was asked to inform the nurse about R24's continued moaning but V15 continued to apply the hand splints, even though the resident had increased moaning and appeared to be in pain when her hand was touched to apply the hand splints. Immediately after the bilateral hand splints were applied to R24, V16 (Registered Nurse) came in the room. V16 assessed R24, then stated that the resident is hospice care. According to V16, R24 appeared in pain, and she will administer pain medication. R24's active order summary report showed that the resident was admitted to hospice care on May 8, 2024. The order report showed multiple orders for pain medications dated January 31, 2024, for Acetaminophen 650 mg, insert one suppository rectally every four hours as needed and Acetaminophen 325 mg chewable, give two tablets orally every four hours as needed. The same order report showed an order dated May 8, 2024, to administer Morphine Sulfate (concentrate) oral solution 100 mg/5 ml, give 0.25 ml by mouth every two hours as needed for pain. R24's MAR (Medication Administration record) for the month of August 2024 showed that on August 5, 2024, at 11:03 AM, V16 (Registered Nurse) administered Morphine Sulfate 100 mg/5 ml, 0.25 ml by mouth due to pain. The MAR showed that on August 5, 2024, at 11:03 AM, R24's pain level was documented as 10. The same MAR showed that the Morphine Sulfate was effective. Further review of the same MAR showed no evidence that R24 had received any other pain medication on August 5, 2024, prior to the administration of the Morphine Sulfate at 11:03 AM, R24's active care plan initiated on June 13, 2024, showed that the resident was at risk for pain. The same care plan showed multiple interventions including, monitor and record any non-verbal signs of pain ([example] crying, guarding, moaning, restlessness, grimacing, diaphoresis, withdrawal, etc. (etcetera), monitor and record any complaints of pain: location, frequency, effect on function, intensity, alleviating factors, aggravating factors, and administer medications. Monitor and record effectiveness. Report adverse side effects. On August 7, 2024, at 1:35 PM, V2 (Director of Nursing) stated that when R24 was moaning and was visibly in pain when her bilateral hand splints were being applied, the CNA should stop the application and inform the nurse, to ensure that the resident was assessed for pain and appropriate pain medication was administered before continuing with the care/application. V2 stated that R24 is hospice care and the main goal for this resident is pain management and comfort. On August 7, 2024, at 2:26 PM, V22 (Nurse Practitioner) stated that it is appropriate for the staff to stop applying the hand splints if the resident was moaning during the application, have the nurse assess the resident and if after the assessment the resident was identified with pain, the appropriate pain medication should be administered. After the administration of the pain medication, the staff should wait to assess the effectiveness of the pain medication and if it was effective, the procedure or the application of the splints may proceed. The facility's policy regarding pain management program dated July 2019 showed in-part, It is the policy of the facility to facilitate resident safety, independence, promote resident comfort, preserve and enhance resident dignity and facilitate life involvement. The purpose of this policy is to accomplish the goals through pain management program. The same policy under definition showed, The facility will utilize a consistent pain assessment. The resident's descriptive words regarding the quality, duration, and location of pain will be used to evaluate the pain and to identify changes in pain. When the resident is unable to describe pain, physical signs such as grimacing, body posturing/protecting, vital sign changes and changes in behavior and mood will be used to determine the presence of pain.

Based on observation, interview, and record review, the facility failed to follow physical therapy's recommendations for safe transfer of the resident. The facility also failed to safely transfer a resident into a wheelchair. This failure resulted in R2 sustaining a leg fracture following a fall, due to an improper transfer. This failure also resulted in R1 sustaining an ankle fracture after telling facility staff to stop when her leg got caught during a transfer into a wheelchair. This applies to 2 of 3 residents (R1 and R2) reviewed for accidents in the sample of 3. The findings include: 1. R2's EMR (Electronic Medical Record) showed R2 was admitted to the facility on [DATE], with multiple diagnoses including: dementia, history of falling, sacrum fracture, and diabetes. R2's MDS (Minimum Data Set) dated October 5, 2022, showed R2 had moderate cognitive impairment and required extensive assistance of one facility staff member for transfers between surfaces. On January 3, 2023, at 3:47 PM, R2 was lying in bed in her room with an immobilizer on her right leg. R2 said [facility staff member] could not hold me so she let me go and I fell on the floor. I broke my knee. The facility's reportable submitted to IDPH (Illinois Department of Public Health) on December 30, 2022, showed R2 sustained a right tibia (leg) fracture following a stand pivot transfer. On January 3, 2023, at 1:55 PM, V7 (Agency CNA/Certified Nursing Assistant) said, On December 26, 2022, I did not have my gait belt. I was transferring [R2] from the toilet to her wheelchair, and when I stood her up, I tried to get her back on the toilet, but she was resisting. Since she did not want to go back to the toilet, I was going to transfer her into the wheelchair, but she dropped. I called for help, but no one came so I lowered [R2] to the floor. There was not enough space in the bathroom, so her legs crisscrossed underneath her. I should have used a gait belt. On January 4, 2023, at 11:39 AM, V13 (Therapy Director) said, A resident's transfer status is on a care card located on or in the resident's closet. The care card tells facility staff how a resident is to be transferred. [R2] was discharged from therapy on December 13, 2022, and at that time she was a one person assist for transfers with a gait belt. Facility staff should always use a gait belt on any transfer. On January 4, 2022, at 12:01 PM, V14 (Physician) said, Facility staff should be using a gait belt when transferring [R2]. The improper transfer led to [R2]'s fracture. The CNA sat the resident on the floor, and it caused the fracture. The CNA should have used a gait belt. On January 3, 2023, at 3:06 PM, V1 (Administrator) said, [V7] should have used a gait belt when transferring [R2]. On January 3, 2023, at 3:20 PM, V1 said, The 'Safe Patient Lifting Policy' is how staff are educated on how to transfer a resident. R2's care card prior to R2's fracture showed R2's transfer status was Transfer, use gait belt, one person, and extensive assist. R2's care card after R2's fracture showed, Right knee immobilizer. Transfer using mechanical lift. Total Assist. A progress note dated December 26, 2022, at 12:31 PM, by V9 (LPN/Licensed Practical Nurse) showed, This writer was informed by resident's CNA that when she was in the bathroom trying to transfer resident from commode to chair, resident was still having a bowel movement and she informed resident so that she could transfer her back to the commode. Resident refused to sit back on commode and wanted to sit on her wheelchair. As CNA is trying to assist resident back to the commode resident is not listening to commands of CNA, so to keep resident safe, CNA lower resident to the floor. As resident is being lowered to the floor resident hit her knee on the floor. Resident did complain of pain to the right knee. This writer contacted [V14] however her NP (Nurse Practitioner) answered. This writer informed NP of fall and complain of knee pain. This writer also contacted resident's daughter to inform her of incident. Resident was helped off the floor by staff and safely back to wheelchair. A progress note dated December 27, 2022, at 2:01 AM, by V10 (LPN) showed, .Resident admitted to [local] hospital for right tibia fracture. The facility's undated document titled, SAFE PATIENT LIFTING POLICY For all employees in nursing department, showed, Purpose: The Safe Patient Lifting Policy exists to ensure a safe working environment for resident handlers. The policy is to be reviewed and signed by all staff that perform or may perform resident handling. The safety committee will review this policy annually with changes made accordingly. Process and Procedures: .Gait belt usage is mandatory for all resident handling with the exception of bed mobility and medical contraindications. The gait belt will be considered a part of the certified nursing assistant's uniform . 2. R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including: Parkinson's disease, cognitive communication deficit, lumbar radiculopathy, and idiopathic peripheral autonomic neuropathy. R1's MDS (Minimum Data Set) dated December 19, 2022, showed R1 was cognitively intact, and was totally dependent on one facility staff member for bathing. The MDS continued to show R1 required extensive assistance of two facility staff members for transferring between surfaces. R1's transfer care plan dated March 5, 2022, showed, In order to improve quality of life and participate in chosen activities, resident will safely transfer utilizing [full body mechanical] lift through next review. The care plan continued to show the following approach dated March 5, 2022, Use appropriate equipment with any mechanical lift device (e.g., straps, slings). Observe for presence of pain/discomfort (such as verbalization, moaning, groaning, guarding and/or flinching) during transfers. Maintain body in functional alignment during transfers. Ensure safe placement of extremities during transfers. Ensure wheelchair is locked and secured prior to transfer. Facility Documentation submitted to IDPH (Illinois Department of Public Health) on December 21, 2022, showed, Facility Incident Report Form . Description of Occurrence: .R1 complained of discomfort to left lower extremity, pain medication given, tolerated well and effective. Doctor notified; order given to obtain x-ray. Order noted and carried out. X-ray received and results of acute fracture to Medial Malleolus (ankle). New order given to send R1 to emergency room for further evaluation . On January 3, 2023, at 11:08 AM, R1 was lying in her bed with a soft cast on her left leg. R1 said, The CNA caught my leg in the cart. I told her to stop, but she kept going. She was getting me back into the wheelchair from the shower chair. My leg cracked. She transferred me by herself. On January 4, 2022, at 3:02 PM, R1 said, The CNA was getting me into the wheelchair from the shower chair, and she was moving the leg rests on the wheelchair. My leg got caught and I told her to stop, but she did not stop. My leg was caught and then my leg cracked. On January 4, 2022, at 11:29 AM, V8 (Agency CNA) said, On December 14, 2022, I gave [R1] a shower. I did a stand to pivot transfer with [R1] by myself from the shower chair to the wheelchair. I did not look at [R1]'s care card prior to transferring her. On January 5, 2022, V15 (Physician) said, [R1]'s leg getting caught in her wheelchair could have cause [R1]'s fracture. [R1] can tell if she is pain and something is not right. The CNA should have stopped, that is common sense. [R1] should have been transferred per the facility policy. On January 4, 2022, at 1:41 PM, V6 (NP/Nurse Practitioner) said the incident on December 14, 2022, is what could have led to R1's fracture because it is the only trauma she has had. V6 continued to say R1 told V6 her leg got caught and then had some pain. V6 said R1 has enough cognition to say stop if something hurts, and if R1 said stop then staff should have stopped. V6 continued to say staff should be following R1's care card for how to transfer R1. On January 4, 2022, at 3:11 PM, V2 (DON/Director of Nursing) said, If a resident tells a staff member to stop during care the staff should stop and assess why the resident is saying stop. On January 4, 2022, at 11:39 AM, V13 (Therapy Director) said, [R1] has always been a [full body mechanical lift] while she has resided in the facility. [R1] should not be a stand to pivot transfer if the resident is identified by the facility as being a [full body mechanical lift] transfer. A progress note dated December 15, 2022, at 2:40 PM, by V6 (NP) showed, .Seen per staff request for two spots of bruises to left leg. Noted today. Patient reports pain to left ankle. She reports 'her leg got caught in the shower chair yesterday' has not asked for pain medications. Pain worse with movement or touch .Pain of left ankle joint: recent trauma, stat x-ray ordered, acetaminophen for pain, discussed with attending physician, discussed with ADON (Assistant Director of Nursing), discussed with bedside nurse. A progress note dated December 16, 2022, at 11:14 AM, by V6 showed, Left ankle x-ray showed acute fracture involving the medial malleolus (ankle). Send to emergency room for evaluation and treat. [V15] notified. R1's care card showed R1 was a full body mechanical lift prior to R1's fracture and after R1's fracture. The facility's undated policy, titled Safe Lifting and Movement of Residents, showed, Policy Statement: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses mechanical lifting devices for the lifting and movement of residents. Policy Interpretation and Implementation: 1. Mechanical lifting devices shall be used for any resident needing a two person assist. Except during emergency situations or unavoidable circumstances, manual lifting is not permitted. 2. Staff responsible for direct resident care will be trained in the use of mechanical lifting devices. The manufacturer of purchased equipment shall provide initial staff training on the use of mechanical lifts, as well as on the routine checks and long-term maintenance of equipment. Subsequent training and retraining of staff on the use of mechanical lifting devices shall be conducted by designated team members . 7. The transferring needs of residents shall be assessed on an ongoing basis. Resident transferring and lifting needs shall be documented in the care plan. Assessment of the resident's transferring needs shall include: a. mobility of the resident (degree of dependency); b. size of the resident; c. weight-bearing ability; d. cognitive status .

Based on observation, interview, and record review the facility failed to identify areas of pressure before becoming unstageable and failed to change the dressings as ordered by the Physician. This applies to three of eight residents (R49, R38, R81) in the sample of 24 reviewed for pressure. This failure resulted in two residents (R49) and (R38) developing unstageable pressure injuries. The findings include: 1. The facility face sheet for R49 shows diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessment dated [DATE] shows her to have severe cognitive impairment and requires extensive assistance with bed mobility. The wound management detail report for R49 shows a pressure ulcer to the right heel was first identified on 6/28/2022. At that time the wound measured 4 by 3 centimeters with necrotic tissue present. The wound was not staged until 7/14/2022 and was staged as unstageable with slough and eschar. The care plan for R49 dated 6/27/2022 shows interventions to prevent heel pressure ulcers such as heel boots, using positioning devices and pressure reducing redistribution surfaces were put into place after the development of the pressure ulcer. On 9/22/22 at 12:10 PM, V2 Director of Nursing (DON) said, an area of pressure should be found prior to becoming unstageable and having necrotic tissue. On 9/22/22 at 12:20 PM, V4 Agency Wound nurse said an area of pressure should be found prior to becoming a stage 2 or unstageable. 2. The facility face sheet for R38 shows diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessment dated [DATE] for R38 shows her to have severe cognitive impairment and requires extensive assistance of two staff for bed mobility. The wound management detail report for R38 shows on 1/24/2022 a 3.5 by 3 centimeter area with necrotic tissue and drainage was found on her left heel. The wound was staged as unstageable on 2/3/2022. On 9/22/22 at 12:10 PM, V2 Director of Nursing (DON) said, an area of pressure should be found prior to becoming unstageable and having necrotic tissue. On 9/22/22 at 12:20 PM, V4 Agency Wound nurse said an area of pressure should be found prior to becoming a stage 2 or unstageable. The care plan for R38 dated 1/27/2022 shows interventions to prevent heel pressure ulcers were put into place after the development of the pressure ulcers. 3. R81's Resident Face Sheet, provided by the facility on 9/22/22, showed she was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Pat peri wound dry. Apply (wound gel) to wound bed. Apply barrier ointment to wound edges to prevent maceration. Cover with foam dressing daily and as needed if soiled or loosened. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Pat peri-wound dry. Apply (wound gel) to wound bed. Apply barrier ointment to wound edges to prevent maceration. Cover with foam dressing daily and as needed if soiled or loosened. the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Pat peri-wound dry. Apply (wound gel) to wound bed. Apply barrier ointment to wound edges to prevent maceration. Cover foam dressing daily and as needed if soiled or loosened. On 9/21/22 at 10:00 AM, V4 (Agency Wound Nurse) went into R81's room to perform the dressing changes for R81's multiple areas of pressure. V4 removed the old dressing from the left posterior upper thigh and performed wound care. The dressing was dated 9/19/22. V4 removed a large undated dressing from R81's right gluteal area and performed wound care. V4 then removed a dressing on R81's right posterior upper thigh and performed wound care. That dressing was also dated 9/19/22. V4 said she thinks R81's order is to change the dressings daily and as needed. V4 verified that the dressings for the left and right posterior upper thighs were both dated 9/19/22 and the larger middle dressing was undated. R81's Treatments Flow Sheet for 9/1/22-9/30/22, showed the dressing changes to R81's left posterior upper thigh, right gluteal area and right posterior upper thigh are to be done daily and as needed if soiled or loosened. R81's pressure ulcer care plan showed she had multiple stage 3 pressure injuries. the care plan showed interventions in place were to assess and record the condition of the skin, assess the pressure ulcer for location, stage, size. presence or absence of granulation tissue and epithelization (healthy new skin growth), keep clean and dry as possible. Minimize skin exposure to moisture, keep linens as clean and dry as possible, provide incontinence care after each episode, and perform treatment per TAR (Treatment Administration Record). R81's Wound Management Detail Report, provided by the facility on 9/22/22, showed R81 had stage 3 pressure injuries to her right and left thighs and to her gluteal fold. These pressure injuries were present on admission. On 9/22/22 at 1:23 PM, V2 (Director of Nursing) said if the dressing was dated 9/19/22, and the order was to change the dressing every day, then it should have been changed on 9/20/22. V2 said if the dressing is dated 9/19/22 and the order is to change the dressing every other day, then it should have been changed on 9/21/22. V2 said she would expect the nurses to follow the doctor's orders for wound treatments. V2 said it is important to promote wound healing and for continued assessments of the wounds. The facility's policy and procedure titled Pressure Ulcer and Wound Prevention/Management Program, last updated 12/5/06, showed It is the policy of this facility to .Ensure a resident who has been admitted with pressure ulcers or develops pressure ulcers in-house, receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing, when possible. To prevent and manage wound care through a group of health care professionals.

Based on observation, interview, and record review, the facility failed to follow care plan interventions to prevent a resident from falling from a wheelchair, while being propelled by facility staff from one area of the facility to another area. This failure resulted in R1 experiencing a fall from her wheelchair and sustaining a scalp laceration requiring closure with sutures, subgaleal hematoma, and acute fracture of cervical and [MEDICATION(S)] spine vertebrae. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 3. The findings include: On August 24, 2021 at 12:09 PM, R1 was sitting in a reclined wheelchair in her room. R1 was wearing a hard plastic cervical collar. R1's bilateral feet were strapped to leg rests on the wheelchair, and R1 was wearing a seatbelt. R1's left arm was contracted at the elbow and wrist and her arm was held tightly to her chest. R1 was using her right arm and hand to frequently reach up to her cervical collar, attempting to remove the collar. A personal caregiver was sitting at R1's right side and frequently reached for R1's right hand to keep R1 from removing her cervical collar. R1 was not able to be interviewed due to her cognitive status. The EMR (Electronic Medical Record) shows R1 was admitted to the facility in December 2019. R1 was recently hospitalized on [DATE] following a fall and returned to the facility on [DATE]. R1 has multiple diagnoses including, [CONDITION(S)], repeated falls, right humerus fracture, stable burst fracture of the first cervical vertebra, fracture of the fourth [MEDICATION(S)] vertebra, unsteadiness on feet, major depressive disorder, dysphagia, difficulty walking, displaced spiral fracture of the shaft of the right humerus, dementia, hearing loss, heart disease, age-related [CONDITION(S)], and abnormal posture. R1's MDS (Minimum Data Set) dated July 5, 2021 shows R1 has severe cognitive impairment, is totally dependent on facility staff for transfers between surfaces and bathing, requires extensive assistance with bed mobility, dressing, and toilet use, limited assistance by one facility staff member with locomotion on and off the unit, and requires supervision with eating. R1 is always incontinent of bowel and bladder. On June 13, 2021 at 7:45 PM, V9 (RN-Registered Nurse) documented: [R1] was sitting in wheelchair, being pushed to her room by [V3] (Activity Aide). The resident had her legs raised while being taken to her room and suddenly lowered her feet to the floor, leaned forward and she fell out of her wheelchair. The resident was assisted from the floor with the use of a [mechanical lift] and she was assisted to bed. A head-to-toe assessment was done at that time. There were no new open areas, bruises, lacerations noted on the resident. The resident was able to move all extremities as before the fall. The resident was unable to move the left upper extremity before the fall due to paralysis. The resident denies pain, or discomfort at this time The facility's Fall Root Cause Analysis Form dated June 14, 2021 shows: Root cause determination: While being pushed by staff, resident put her foot down and came out of w/c (wheelchair). Based on the above assessment and direct observation at the location of the fall, the FMT (Fall Management Team) determines the following new interventions and recommendations need to be implemented: Re-education to staff. Will allow resident to propel own w/c or apply leg rest when propelling w/c for resident. On June 14, 2021 at 1:03 PM, V4 (Restorative Nurse) documented, [R1] incident reviewed at fall committee meeting. Staff agreed to have a meeting with [V5] (POA-Power of Attorney/Daughter) and daughter-in-law. Team discussed incident from 6/13/21. Family is going to supply leg rest for wheelchair and restorative team placed a leg rest holder bag on the back of wheelchair for leg rests to be kept when resident is propelling self. Staff will apply leg rest to wheelchair when staff is propelling her. Therapy team is going to continue to work with transfers. R1's fall care plan, initiated December 23, 2019 shows multiple approaches/interventions, including the following approach initiated on June 14, 2021: Leg rests to be applied to wheelchair before staff propels wheelchair for resident. Replace leg rests in bag in back of wheelchair when resident is propelling self. The facility provided Educational Inservice Sign In Forms for this investigation. On May 22, 2019, multiple facility staff members, including V3 (Activity Aide) were educated and signed the employee attendance for the in-service on the following: Goals: Residents without leg rests cannot be transported. On June 15, 2021, multiple facility staff members, including V3 were educated and signed the employee attendance for the in-service on the following: Goals: [R1] now has a bag on the back of wheelchair to hold her leg rest. When she is being transported by staff, she needs leg rest put on and then taken off when she is going to propel by herself. On August 17, 2021 at 9:05 AM, V10 (LPN-Licensed Practical Nurse) documented: This writer was informed by the activity aide on shift that [R1] had fell forward out of her w/c while in dining area and hit her head. Upon arrival to resident's location, resident was observed on floor on her back. Resident alert/awake with scant amount of blood on floor area right side of her head. [R1] was noted with laceration to the frontal lobe. Direct pressure/ice pack applied to area. Full set of vitals obtained all within resident's normal range. Family notified/aware, MD notified, notified/aware gave orders to send resident out for evaluation. Stretcher accompanied by EMT x 2 with f/u with hospital later for update. The facility's fall root cause analysis form dated August 18, 2021 shows R1 placed her foot down while being moved in activity. R1's hospital records show CT (Computed Tomography) Scan Spine Cervical results dated August 17, 2021: Impression: Acute fracture of the right anterior and posterior arches of C1 (Cervical vertebrae number 1) with mild displacement. Interval worsening of anterior wedging at T4 ([MEDICATION(S)] vertebrae number 4) compared to 6/1/2021. Consistent with acute on chronic compression fracture. Otherwise unchanged examination compared to 6/1/2021. CT head/brain dated August 17, 2021: Gas and fluid-filled frontal subgaleal hematoma. No calvarial fracture. No acute intracranial abnormality. Laceration: 1.5 cm laceration to central superior scalp requiring three sutures to close. On August 24, 2021 at 11:16 AM, V1 (Administrator) and V2 (DON-Director of Nursing) said, [R1] was in the hallway after breakfast and going to an activity. The resident was propelling herself to the dining room and [V3] (Activity Aide) decided to assist her and was trying to push her. [R1] kicks her feet out all the time and so we don't keep the leg rests on the wheelchair. We use the footrests for long distances. This is something we worked out with the family. The distance wasn't far, maybe less than ten feet. We worked with the family prior to her return to the facility. The family has provided a one-to-one sitter for [R1] to prevent [R1] from removing her cervical collar because the hospital reported she was pulling her cervical collar off and the hospital had to restrain her. She has [CONDITION(S)] and she has a contracted left arm and the other arm hangs down and [R1] didn't have the ability to put her hands down to break her fall. On August 24, 2021 at 12:34 PM, V4 (Restorative Nurse) said, [R1's] family has been very involved in her care. She propels herself and sometimes she scoots herself down in the seat and puts her right leg up in the air and brings it down to get a heel/toe motion to get going. What that has caused is her falling forward out of the chair doing this motion. It was during a transport by facility staff that she put her foot down and she came forward out of the chair. This happened twice in the last few months. We do train the staff to use the leg rests when moving the residents. I think [V3] was just rearranging [R1] in the dining room and I don't know if she thought about putting the leg rests on. We have a policy that people should not be pushed in a wheelchair without the leg rests if you are pushing a resident . I believe it was her thought that she wasn't going far so she didn't know if she should use the leg rests. We did an in-service with all staff back in June 2021 after [R1] fell from the wheelchair while being pushed by the staff. A care plan intervention was put in place on June 14, 2021 to use leg rests when pushing [R1] in the wheelchair, and we had the leg rests and the bag on the back of [R1's] wheelchair. There were notes posted by us and the family to alert staff. There is a care card is in [R1's] room and it was definitely on her care card before the fall on August 17 to use the leg rests when pushing her in the wheelchair. The bag with the leg rests was actually right there on [R1's] wheelchair when she fell on [DATE]. On August 24, 2021 at 1:39 PM, V3 (Activity Aide) said, I've worked here a long time. The most recent fall was the first one I've experienced with [R1]. I was starting activities around 9:00 or 9:15 AM. I saw [R1] in the hallway and wandering in her wheelchair, propelling herself which is typical for her. I went over to her and I started pushing her into the dining room from the hallway. I pushed her wheelchair about 20 feet. Suddenly, she put her foot down and she started falling forward and I just couldn't stop it. She hit her head on the floor. She couldn't put her hands out to stop her fall because she always holds her left hand up against her chest and can't move that right hand very well. I don't remember being told she needed leg rests on before pushing her. I know there are care cards in the room, but I don't go in the resident rooms, so I never saw the care card with care instructions for [R1]. I would never see the resident care cards. She usually doesn't have her leg rests on because she wanders in the hall. I wasn't thinking about it. [R1] was sitting on a [mechanical lift] sling in her wheelchair. The sling was hanging over the back of the wheelchair and the leg rests were hidden behind the sling. As an activity aide I cannot see the care plan interventions in the computer. We don't get any report from the nurses on the care of the residents. On August 24, 2021 at 4:19 PM, V5 (POA/Family Member), V6 (Family Member), and V7 (Family Member) said, [R1] has had many, many falls at the facility. She had a fall in June 2021 from her wheelchair. A facility staff member was pushing her in her wheelchair without leg or footrests in place and [R1] put her foot down abruptly and she fell forward out of the wheelchair and hit her head. We have had multiple meetings with the facility regarding [R1's] many falls, and it was decided that leg rests would be put on [R1's] wheelchair anytime facility staff were propelling her wheelchair or moving her. We wanted our mom to be able to still have some independence and she loves to self-propel her wheelchair with her legs and feet, so we did not want to take that away from her. The goal was to maintain her independence and keep her safe at the same time. We cooperated fully with the facility to prevent another accident from happening again. We purchased new leg rests for her wheelchair with a bag that was to be hung from the back of her wheelchair, making the leg rests readily available for all staff. We were told all facility staff were given training to ensure leg rests would always be put in place anytime they were moving [R1]. There was never a stipulation during our meetings about the distance she was being pushed before the leg rests would be applied to the wheelchair. The facility ensured us if anyone was pushing the wheelchair, the leg rests would be used. There was even a sign in her room visible to anyone who walked into her room that said to make sure leg rests were used when pushing our mom in her wheelchair. It was understood that if they were pushing her, the leg rests would be put in place. Our understanding was they knew there was a risk and if they pushed her wheelchair without the leg rests, in doing so, it could result in an injury. When they called us on August 17, 2021 and told us she fell and needed to go to the hospital, we asked for two days for details of what happened. We were finally told she was being pushed by a facility staff member without the leg rests on her wheelchair and she fell forward out of the wheelchair. She required a hospital visit, sutures to her head, has two fractures in her vertebrae, and now needs to wear a cervical collar until the fracture is healed because she wasn't a good candidate for surgery. We had to hire a one-to-one care giver to sit with her to ensure she does not remove the cervical collar since she has dementia and doesn't understand instructions to keep the collar on. It is very sad and disheartening for us as a family to see her go through this. On August 25, 2021 at 2:42 PM, V12 (Therapy Director) said, If any facility staff member is to push a resident from one location to another, therapists want to see the wheelchair with the leg rests on. I would tell you to put the leg rests on the wheelchair no matter how far a resident is being pushed in the wheelchair, from anywhere at anytime. It's a safety issue. On August 25, 2021 at 3:02 PM, V1 (Administrator), V2 (DON), and V4 (Restorative Nurse) said during meetings with R1's family, the facility assured the family leg rests would be used whenever facility staff propels R1 in the wheelchair. V1 said at no time did the facility tell R1's family the leg rests would be used for propelling R1 for long distances only. On August 24, 2021 at 2:41 PM, V8 (Medical Director/R1's Physician) said, I would absolutely expect the facility to follow their care plan interventions. No nursing home resident should fall and break their bones. The head laceration, head hematoma and the cervical and spinal fractures were most definitely caused by the fall and the facility's failure to apply leg rests to the wheelchair before pushing her in the wheelchair.

Based on interview and record review the facility failed to supervise a resident who was at high risk for falls in the dining room. The facility also failed to identify and implement specific interventions to prevent further falls and injuries. This resulted in R1 sustaining an right orbital floor fracture (traumatic injury to eye socket) and lacerations to the lip requiring suturing and R3 sustaining a head injury requiring 7 staples for closure. This applies to 2 of 3 residents (R1 and R3) reviewed for falls in the sample of 3. The findings include: 1). R1's face sheet showed R1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Upon admission, R1's Minimum Data Set ((MDS) dated [DATE], showed R1 had a BIMS (Brief Interview for Mental Status) score of 3 which indicated R1's cognition was severely impaired. R1's BIMS score on 7/18/18 was a 7, which indicates R1's cognition continued to be assessed as being severely impaired. In addition, R1's 7/18/18 MDS showed R1 required oversight, encouragement or cueing during walking and locomotion. R1 received a BIMS score of 4 on 10/9/18 during a significant change assessment, which indicated R1's cognition continued to be severely impaired. During that assessment, R1 was determined to need extensive assistance with locomotion on the unit. R1's Fall Events showed R1 sustained falls on 4/7/18, 9/25/18 and 10/10/18. The fall assessment on 9/25/18 showed R1 was noted with fall in 1B dining room after dinner. R1 sustained injury/laceration ¾ inches to lower right lip, also 5 cm hematoma noted above the right eye, R1 was unresponsive X (times) (for) 1 minute, moderate bleeding from head and lip. 911 EMS (Emergency Medical System) was called, ice compresses applied .R1 was transported .to ER (emergency room ) . R1's 9/25/18, emergency room Record Final Report showed R1 sustained a 2.5 cm (centimeter) laceration on the upper lip crossing right side of vermillion border (a sharp line beteen the upper lip and normal skin) requiring 9 sutures to close; ecchymosis (bruise) to right upper and lower eyelid and a large hematoma on dorsum (back) of right hand. R1 sustained a fall, laceration, contusion, sprain, strain, head injury, dizziness, in addition to an orbital floor fracture . R1's Consultation Final Report completed on 9/27/18 showed steri strips were placed on R1's right brow line laceration and sutures placed to a laceration on the corner of R1's right lip and found to have a right maxillary sinus (nose) fracture. The Consultation Report continued to show during the examination, R1 was drowsy, had significant bruises on the right side of her face, arousable, but difficult to speak due to lip laceration. On 12/20/18 at 11:10 AM, V4 (Nurse) denied being the dining room when R1 fell . V4 reported being at the nursing station while R1 was in the dining room. V4 stated he had direct eye sight to where R1 was seated. V4 stated he saw R1 rise, take a couple of steps and fall before he could reach her. V4 added there was an unnamed CNA (Certified Nursing Assistant) assigned to the dining room, who had left the dining room unattended. On 12/20/18 at 11:23 AM, V2 (Director of Nursing, DON) stated when residents are fall risks, they should not be alone or unsupervised in the dining room. V2 stated V4 was actually in the dining room when R1 fell face forward, which was contradicted by V4. On 12/20/18 at 1:15 PM, V6 (CNA) stated residents who are high fall risks should never be left alone in the dining room. On 12/20/18 at 2:17 PM, V7 (CNA) stated residents who are high fall risks should never be left alone in the dining room. On 12/20/18 at 2:08 PM, V8 (physician) for R1 stated R1 did not have the concept of danger for herself and V8 was not aware that there wasn't staff in the dining room when R1 fell . V8 added they should have had someone with R1, staff knew R1 was a high fall risk. R1's Fall Risk Assessments completed on 2/25/18; 4/7/18 and 10/10/18 all showed scores that indicated R1 was determined to be at high risk. R1's progress note after fall on 10/10/18 at 9:47 AM showed R1's right knee is reddened . R1's care plan on 2/26/18, showed Falls as a problem and noted R1 was at risk for falls. After R1's fall on 4/7/18, the new approach/intervention documented on 4/9/18 was provide low stimulating environment at night to promote sleep. After R1's fall on 9/25/18, the new approach/intervention documented on 10/2/18 was bilateral floor mats and bed bolsters to prevent injury. After R1's fall on 10/10/18, the new approach/intervention documented on 10/10/18 was transfer to chair after dressing. 2). R3's face sheet showed R3 was admitted on [DATE] with [DIAGNOSES REDACTED]. Upon admission, R3's admission Minimum Data Set ((MDS) dated [DATE], showed R3 as rarely or never understood and without a BIMS (Brief Interview for Mental Status) score in addition to R3 requiring extensive assistance with bed mobility and transfer with the 2 persons' physical assistance. R3 received a BIMS score of 10 on the quarterly assessment completed on 12/07/18 which indicates R3 cognition was moderately impaired in addition to R3 requiring extensive assistance with bed mobility and transfer with the 2 persons' physical assistance. Progress notes showed on 10/31/18 at 1:40 PM, R3 was found on the floor bleeding from the head. R3 was transported to the ER (emergency room ). R3's POS dated 11/1/18 showed a physician's orders [REDACTED]. Monitor . On 12/18/18 at 10:20 AM, R3 was observed in bed at the end of the hallway requesting help and asking for water. Writer could not locate a call light and stepped into hallway to ask for staff assistance. V9 (CNA) and V10 CNA responded and stated R3 does not have a call light, but has a bell to ring instead. V9 and V10 located the bell underneath R3's bed after about 10 minutes. R3's remote control was located by V2 on the over bed table and not within the reach of R3. There was no basket at R3's bedside to place the remote control. R3's Safety Events - Fall Events showed the following: 9/1/18 at 12:00 PM - Fall observed sliding over the bed bolsters down the left side of the bed hitting the head first to the floor mat . 9/8/18 at 4:00 AM - Fall - staff heard a noise .resident observed on the floor .R3 responded I flipped and fell down on the floor .skin tear below left knee 9/27/18 at 7:45 AM - Observed sitting on floor mat. R3 with very poor safety awareness and high fall risk . Resident stated she slid off her bed, trying to get her diaper. 10/16/18 at 10:18 PM - Fall at bedside - got out of bed trying to get to her wheelchair 10/19/18 at 6:02 PM - Fall - found scooting on floor 10/19/18 at 6:15 PM - Fall in room - sitting on floor mat 10/20/18 at 6:52 AM - Fall - got out of bed, crawling on floor 10/23/18 at 8:30 PM - Fall - .observed sitting on the floor next to her bed .was trying to pick up pillow off the floor and fell . Noted a small skin tear 2 cm X 2 cm with a small amount of bleeding . 10/24/18 at 9:24 PM - Fall - resident was observed sitting on the floor in her room near the door .said she was trying to get her TV (television) remote 10/27/18 at 8:00 AM - patient observed on floor halfway into the hallway .foley disconnected from bag but catheter still in patient . 10/31/18 at 1:40 PM - Observed sitting at foot of bed Bleeding from back of head, noted laceration to left side of posterior scalp. 10/31/18 progress note at 1:41 PM showed .resident on floor, serosanguineous blood noted on floor .going out to hospital for evaluation and scalp bleeding . 11/1/18 at 5:50 AM - Resident observed on the floor in the hallway 11/4/18 at 7:15 AM - Fall - Resident got out of her bed 11/6/18 at 1:25 AM On floor in hallway .fell from bed, scooted into hallway. After R3's fall on 11/6/18, the progress note showed R3's son stated you know this happens like every day and I get a call like every day of my life, are there any precautions that you guys are taking to make sure she doesn't fall. R3's care plan on 9/2/18, showed Falls as a problem and noted R3 was at risk for falls. The following new approach/intervention showed as follows: 9/1/18 event - approach/intervention dated 9/2/18 was Medication to assist with involuntary movements; bilateral floor mats, bed will remain locked at all times, bed in lowest position and bed bolsters in place. 9/8/18 event - approach/intervention dated 9/10/18 was Medication review for anxiety. This intervention did not occur. 9/27/18 event - approach/intervention dated 9/27/18 was do not leave R1 unattended on the bedpan 10/12/18 event - approach/intervention dated 10/12/18 was Bell within reach. On 12/18/18 at 10:20 AM, R3's bell to call for help was not with the resident. V9 and V10 located the bell underneath R3's bed after about 10 minutes 10/16/18 event - approach/intervention dated 10/16/18 was Provide adequate pillows for comfort 10/19/18 at 6:02 PM event - no new approach/intervention 10/19/18 at 6:15 PM 2nd event - no new approach/intervention 10/20/18 event - approach/intervention dated 10/22/18 was Toileting Program and Monitor Behaviors for Trends and Patterns 10/23/18 event - approach/intervention dated 10/23/18 was MD (medical doctor) to review for anti-anxiety meds Same intervention as after 9/8/18 event. This intervention did not occur. 10/24/18 event - approach/intervention dated 10/24/18 was R3 was trying to get R3's remote off the floor. We will attempt a basket on the side of the bed to place the remote On 12/18/18 at 10:20 AM there was no basket on the side of the bed. The remote control for the TV was on the overbed table next to the wall. R3 was unable to reach it. 10/27/18 event - approach/intervention dated 10/28/18 was R3 will have a room change to .unit 10/31/18 event - approach/intervention dated 10/31/18 was Offer helmet to protect head from injury 11/1/18 event - approach/intervention dated 11/1/18 was Reoriented to room and TV, TV on at all times 11/4/18 event - approach/intervention dated 11/4/18 was Staff to monitor pillows are in place, remote and bell are within reach Same interventions as after 10/16/18 and 10/12/18 and 10/24/18 events. Additional approach/intervention included Offer to toilet around 7:00 AM Similar intervention after 10/20/18 event 11/6/18 event - approach/intervention dated 11/6/18 was provide toileting assistance after meals Similar intervention after 10/20/18 event. R3's initial care plan dated 9/1/18 showed R3 was at risk for injury of which approach/interventions included to keep the call light in reach at all times and to keep personal items and frequently used items within reach. On 12/18/18 at 2:11 PM, V2 (Director of Nursing) stated that the interventions documented on 9/2/18 on R3's care plan were already in place and initiated on 9/1/18 interim care plan. On 12/19/18 at 12:09 PM, V5 (restorative nurse) was asked if V5 was aware that R3 had sustained 8 additional falls after implementing the toileting program and if V5 felt the toileting program was effective. V5 replied not really, I think everyone was trying to adjust to her and find the best solution. On 12/19/18 at 3:34 PM, V2 stated the care plan for R1 was not updated after R1's fall on 9/25/18. On 12/20/18 at 10:05 AM, V3 (physician) of R3 stated, V3 was aware of multiple falls including requiring staples for a head wound. V3 stated V3 witnessed R3 wanting the bell which was not close or within reach of R3. V3 acknowledged due to R3's condition, R3 is unable to hold on to the bell and R3's involuntary movements may cause R3 to drop or throw the bell. V3 acknowledged that R3's room is near the end of the hall and should be closer to the nursing station. V3 added I am always worried that I am going to get another call that she has busted her head. V3 shared the staff should have more interaction with R3 and provide activities that are engaging for R3, so R3 doesn't frustrated and try to do things on R3's own. Facility provided a policy titled Fall - Clinical Protocol revised (MONTH) 2008 showed The staff will document risk factors for falling in the resident's record .The staff will document falls that occur while the individual is in the facility . staff will attempt to define possible causes within 24 hours of the fall .the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling .If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions based on assessment of the nature or category of falling, until falling reduces or stops .The staff and physician will monitor and document the individual's response to intervention intended to reduce falling or the consequence of falling .if the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions. Facility provided policy titled Care Plans (Comprehensive) updated (MONTH) (YEAR) showed the policy statement as An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's .needs is developed for each resident. Facility provided a policy titled Quarterly Review of Care Plans revised (MONTH) 2006 showed 1. The care planning/interdisciplinary team is responsible for maintaining care plans on a current status. 2. The care planning/ interdisciplinary team is responsible for the periodic review and the updating of care plans: a) when there has been a significant change in the resident's condition b) when the desired outcome is not met .

Based on observation, interview, and record review the facility failed to ensure fall precaution interventions were implemented for two residents and failed to ensure resident safety while providing care resulting in a resident falling out of bed sustaining a hip fracture. This failure resulted in a hip fracture requiring hip surgery and hospitalization with blood transfusions. This applies to 3 of 5 residents ( R1, R2, and R3) reviewed for falls in the sample. The findings include: 1. According to the Admission Face Sheet R1 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) dated [DATE] shows R1's cognition was severely impaired with a Brief Interview for Mental Status (BIMS) scoring four out of ten points and weighed 251 pounds. The MDS shows R1 needed extensive assistance of two staff members for bed mobility and toilet use. The MDS shows R1 was totally dependent on two staff members for transfers. A Fall Risk assessment dated [DATE] shows R1 was a high fall risk. The care plan showed R1 was at a risk for falls due to a history of cerebral vascular accident causing impaired weakness and muscle strength on the left side. The fall care plan had interventions encourage resident to use environmental devices such as hand grips, hand rails, etc. Bilateral halos to bed to aide in reposition and promoting bed mobility. Keep bed in lowest position with brakes locked. The care plan also showed R1 had limited ability to move independently in the bed due to left [DIAGNOSES REDACTED] and other comorbidities. An intervention included to provide adaptive equipment as needed to assist with bed mobility. The care plans did not address whether R1 needed extensive assistance or the amount of staff members required during care. According to the Ambulance Run Report dated October 17, 2017 at 5:41AM, the arrival crew found R1 lying on the ground wailing in agony. R1 was complaining of left hip pain rating it 10 out of 10. R1 had laceration to the back of the head, swelling and tenderness to the left hip and the left leg was shorter than the right leg. The hospital emergency room report dated October 17, 2017 showed R1 had a hematoma to the right eyebrow, a three centimeter laceration to the right posterior auricle with mild to moderate swelling and ecchymosis to the anterior auricle, and left leg shortened, rotated internally with left hip and thigh tenderness. A Computerized Tomography report dated October 17, 2017 showed R1 had soft tissue swelling around the right frontal bone and right orbit. An X-ray dated October 17, 2017 showed R1 had an acute displaced fracture of the proximal left femur, probably an intertrochanteric type. An orthopedic consultation report from Z6, Medical Doctor (MD) Orthopedic Surgeon, dated October 18, 2017 showed R1 suffered a fall at the facility when they dropped me injuring her left hip. Additionally, she had a scalp laceration as a complication of the fall .(R1) is in an extremely bad mood. She complains of pain and is frustrated in her situation. The impression shows a left hip intertrochanteric fracture with a recommendation for surgical intervention for pain control and to facilitate care. Risks and benefits of surgery including but not limited to infection and bleeding. On October 25, 2017 at 10:10AM, Z7, Registered Nurse (RN) hospital, said R1 was confused and uncooperative most of the time. Z7 said R1 had received two units of blood for the second time since surgery due to R1's hemoglobin level dropping. R1 was lying in bed in the hospital with bruising noted around the entire right periorbital area. R1 said she wasn't doing so well since they dropped her at the nursing home. On October 23, 2017 at 3:55PM E5, LPN, stated R1 was alert, verbal, and oriented to person and sometimes to place. R1 was able to express and localize pain. E5 said R1 preferred to stay in bed and did not want to get out of bed very often. E5 said R1 had an active pressure wound which required the use of the alternating pressure air mattress, plus R1 was larger requiring a bariatric bed. R1's bariatric bed had a trapeze positioning device above the head of the bed. On both the left and right side near the head of the bed were small round side handrails approximately 12 inches wide. E5 said a resident care card was placed inside the door of the resident's wardrobe closet for the nursing assistants to reference what type of care the resident needed. R1's resident care card was starred showing R1 needed cares in pairs. R1 was a total assist of two staff members for transfers with a total body mechanical lift and with bed mobility. The care card also showed R1 needed total assistance for toileting and transfers with a flaccid left side. On October 25, 2017 at 4:15PM E9, Certified Nursing Assistant (CNA), stated she had taken care of R1 on October 17, 2017 when R1 slid out of bed. E9 said she had worked at the facility for 14 months but usually worked another unit. At the beginning of the shift, E9 received a walk through with the nurse who gives instructions about the residents. E9 said the nurse had mentioned to watch R1's roommate because she would get out of bed, but there was no mention of the care R1 had required. E9 said she had taken care of R1 without assistance of any other staff, without any problems, several months earlier when R1 was on another unit. E9 said she had done R1's incontinence care by herself a couple of times during the shift. Between 5:00 and 5:30AM E9 was standing on the right side of R1's bed with R1 positioned on her left side and was almost done providing R1's incontinence care by herself when R1 started wiggling in bed. E9 said she held onto R1's gown as R1 fell out of left side of the bed onto the floor. E9 said the air mattresses are slippery so R1 fell out of bed and the bed sheet went with. E9 ran out of the room to get a nurse. When asked how the CNAs received information about resident care, E9 said the residents had a care card on the inside of the door of their wardrobe closet. E9 said R1 did not have side rails on the bed because the facility had been side rail free. On October 24, 2017 at 11:30AM E8, Licensed Practical Nurse (LPN), said it was the first time she had worked with E9 (CNA) on October 17, 2017 night shift. E8 said she told E9 to check the resident care cards to see what type of care they needed. E8 said sometime before 6:00AM E9 came running to the nurse's station saying R1 had fallen out of bed. E8 said R1 was a two person assist for incontinence care but E9 told (E8) she had been doing incontinence care by herself. Upon arriving in the room, E8 saw R1 lying next to the left side of the bed on the floor trying to hold onto the dresser. R1 was on the floor with her bedsheets. E8 said R1 had blood coming from the right side of head but couldn't tell where it was coming from. R1 was screaming in pain Pain! Left side. Left leg. E8 said she assessed R1 but R1 refused to do range of motion with her legs. E8 called 911 to take R1 to the hospital emergency room . E8 said R1 was not difficult to change when two people are assisting her and R1 can try to help with the over the bed trapeze bar. On October 24, 2017 at 4:08PM E10, CNA, said on October 17, 2017 R1 was lying on the floor next to the left side of the bed and crying that her leg was hurting. E10 thought it took 4 people including the paramedics to get her off the floor. E10 said he had never seen R1 try to get out of bed by herself and had not seen her use the over the bed trapeze bar to assist with mobility. E10 said R1 needed two staff members to assist her with care. The bariatric alternating pressure mattress user's instruction manual shows the mattress is 78.7 inches in length and includes It is recommended to use this mattress system with a bedframe with adequate side rails to prevent falling. The user's manual shows the mattress is 78.7 inches in length. A quarter side rail would be 19.6 inches in length. This is significantly more than the approximately 12 inch round side handrails in place on R1's bed. On October 26, 2017 at 8:20AM when asked what adequate side rails were, Z5, Drive Devilbiss Healthcare Technical Support, said quarter, half, full, and mid side rails could all be used but a minimum of a quarter side rail was recommended for use with the mattress to help prevent a resident from falling out of bed. Z5 said the side rail should also be high enough to clear the mattress plus the resident when lying in the bed. 2. According to the Admission Face Sheet, R3 had [DIAGNOSES REDACTED]. The MDS dated [DATE] showed R3 was cognitively intact with a BIMS of 14 out of 15 points. The MDS shows R3 needed extensive assistance of one staff member for bed mobility, transfers and toilet use. Fall Risk Assessments dated October 23, 2017 and October 3, 2017 show R3 was a high fall risk. The Fall Risk assessment dated [DATE] showed R3 had three or more falls in the last three months including falls on October 21 and October 22, 2017. The care plan shows R3 was at risk for falls due to impaired mobility and lack of endurance. Interventions included to place R3 in high back wheelchair in a supervised area when having signs of increased agitation, keep bed in lowest position, to allow legs to touch the floor, provide proper, well maintained footwear, non-skid socks or slippers, left side floor mat, and bed up against the wall per family request. The care plan shows R3 had limited ability to move independently in bed due to decreased mobility and weakness related to abdominal cancer. The care plan did not address R3's mobility or transfer. The Electronic Health Record (EHR) showed R3 had the following falls: September 18, 2017 a fall between the bed and the wall; September 18, 2017 a fall next to the bed; September 27, 2017 a fall, R3 slid off the left side of the bed; September 30, 2017 a fall near the foot of the bed; October 2, 2017 a fall at the bedside; October 21, 2017 a fall next to the bed; and October 22, 2017 R3 slid out of the highback wheelchair. On October 23, 2017 at 11:42AM R3 was awake, reclined in the highback wheelchair near the nurse's station. E6, LPN Restorative Nurse, stated R3 was alert and oriented to person with confusion. R3 said she needs to be watched for fall precautions. On October 23, 2017 at 1:12PM R3 was sitting in the highback wheelchair and kept leaning forward. Z4, R3's family member, placed her hand on R3's left shoulder to hold (R3) back and said Hey, don't do that, you'll fall. Z4 said R3 has had multiple falls while in the facility and would like to know what the facility was going to do about it. Z4 said R3's bed was not always in the lowest position and they gave R3 a scoop mattress but didn't feel it would keep R3 from falling out of bed. Z4 said she has often come into the room and the floor mat was not on the floor in the room. Z4 said when R3 was admitted in July 2017 R3 was able to get up to use the bedside commode but was no longer able to stand up. On October 23, 2017 at 1:32PM E14, RN-Wound Care Nurse, and E6 (LPN Restorative Nurse), transferred R3 from the highback wheelchair to the bed using a total body mechanical lift for incontinence care. After incontinence care, E14 and E6 positioned R3 supine in bed with the head of the bed elevated 30 degrees. Both E14 and E6 left the room without lowering the bed to the low position or placing the fall mat on the floor. The fall mat was leaning against the wall near the window. On October 23, 2017 at 3:15PM R3 was awake, lying in bed in a mid to high position with top of mattress approximately 30 inches from the floor. No floor mat was on the floor. E15, RN, stated R3's bed should be in the low position and a floor mat should be on the floor. The care card shows R3 should use a non-skid mat on the wheelchair seat which E6 (LPN) had written in earlier after care. R3's resident care card provided by the facility includes cares in pairs, left side floor mat, total body mechanical lift with two staff members, non-skid mat to wheelchair seat, bed bolsters, and bedside commode. On October 24, 2017 at 10:30AM R3 was reclined in a highback wheelchair with regular white crew socks on. On October 24, 2017 at 3:15PM R3 was awake in bed kicking her socks off her feet. R3's bed was not in the lowest position. 3. According to the Admission Face Sheet R2 had [DIAGNOSES REDACTED]. The MDS dated [DATE] shows R2's cognition was severely impaired with a three out of fifteen points on the BIMS. The MDS shows R3 needed extensive assistance for bed mobility, toilet use, and transfers with two staff members. Fall Risk Assessments dated July 26, 2017 and October 19, 2017 show R2 was a high fall risk. The EHR showed R2 had a fall on October 17, 2017. A care plan shows R2 was at risk for falling related to a [DIAGNOSES REDACTED]. Interventions included non-skid socks or shoes on while up in wheelchair or in bed, fall mat to the right side of the bed, low bed keep in lowest position. On October 23, 2017 at 11:15AM R2 was asleep lying in bed with her upper body leaning to the left side near the edge of the bed. On October 23, 2017 at 2:52PM R2 was awake in low bed with the head of the bed slightly elevated and was lying diagonal across the bed with her head to the left side of the bed and her feet at the right corner. R2 was lifting her legs onto the wheelchair which was positioned next to her bed. The waistband of R2's pants were pulled around her mid thighs and R2 had regular white crew socks on. E13, CNA, said when she came on shift at 2:30PM she noticed R2's pants were around her thighs but did not adjust them. E13 said the previous shift must have left them that way after providing incontinence care after lunch. E13 said R2's behavior frequently will be lifting her legs together in unison almost coming to a sitting position and will continue rocking like that causing her to scoot down in bed. E13 did not think R2 had any falls but said we keep an eye on her because of the rocking motion and scooting down in bed. After providing incontinence care E13 left R2's bed in a mid high position with the top of the mattress approximately 30 inches from the floor and placed the wheelchair on the floor mat against the bed. E13 stated R2 was a fall risk and thought the bed should be in the lowest position, but was told by management the bed should not be in the lowest position but left higher so the resident could get out of bed. On October 24, 2017 at 10:50AM R2 was awake lying in bed lifting her legs up and down in unison. R2's pants waistband was around her mid thighs and she had regular white crew socks on. At 11:05AM E16, RN MDS Coordinator, did not know why R2's pant waistband was left around her thighs. E16 pulled R2's pants up and repositioned R2 in bed. E16 left the room but did not return the bed to the lowest position after providing care. On October 23, 2017 at 4:00PM E2, Director of Nursing (DON), said any fall precaution interventions are resident specific and would be reflected in the resident care plan and on the resident care cards.

Based on interview and record review facility failed to notify a residents physician in a timely manner of continued severe pain after a fall incident and failed to develop, implement, and monitor targeted behaviors for which [MEDICAL CONDITION] medications are being used. This failure resulted in a five day delay for medical evaluation and treatment. Seven days after the fall incident the resident was sent to the hospital for evaluation of pain and diagnosed with [REDACTED]. This applies to 1 of 9 residents (R12) reviewed for pain in the sample of 24 and 2 of 7 residents (R7 and R8) reviewed for [MEDICAL CONDITION] medications The Findings include; 1) R12 admitted to facility February 17, 2017 with [DIAGNOSES REDACTED]. On July 11, 2017 at 2:30PM, R12 observed in a bariatric bed with a low air loss mattress. R12 was unable to move lower extremities upon request. R12 had oxygen at three litters per nasal cannula, rarely spoke when questioned. R12 did say her pain is not being managed with medications provided. R12's right arm was in a sling and daughter at bedside. July 11, 2017 at 2:30PM, R12's daughter (Z5), stated R12 has had a couple fall incidents since admission to facility. The facility told me she fell in June trying to get out of bed by herself. R12 usually requires a two person mechanical lift for transfers and has not been able to walk for a very long time. R12's incident / accident event reports include: - June 15, 2017 at 5:30PM, R12 found on the floor next to her bed with complaints of severe right shoulder pain. This incident report documents R12 was confused as was prior to the incident. The report also states R12 told staff she stood up to answer the phone and slid to the floor. After the fall on June 15, 2017 R12 had a portable right shoulder X-Ray completed at facility, which did not reveal any fracture. Progress notes after the June 15, 2017 fall included: June 16, 2017 at 1:27PM, R12 complained of right shoulder pain and refused to get up and out of bed. June 16, 2017 at 10:11PM, R12 complained of right shoulder pain. June 17, 2017 at 5:42PM, resident in bed, awake most of night, complaints of right shoulder pain. June 18, 2017 at 11:09AM, Resident with complaints of right shoulder pain, pain medication given. Right arm swollen and elevated on a pillow. No assessment documented in progress notes by nursing on June 19, 2017. June 20, 2017 at 11:43AM Z8 (nurse practioner), documents right shoulder follow-up. Patient reports pain to right shoulder. Patient unable to describe or quantify pain. Per nursing R12's daughter requested to have the right shoulder pain addressed. Right shoulder range of motion limited, right upper extremity [MEDICAL CONDITION] present. June 20, 2017 at 12:52PM, R12's daughter (Z5), is reporting that the resident has increasing pain in right upper extremity. R12 cries out when touched or range of motion applied. Z8 called and notified. June 21, 2017 at 11:46AM, resident shouting and yelling with pain of right upper extremity. Resident reports the pain is terrible. Z8 called and notified. Z8 ordered an X-ray of right upper extremity. June 22, 2017 at 8:00AM, Resident complaint of pain to right shoulder and right arm, scheduled Tylenol administered as ordered. Resident scheduled for an X-Ray waiting for technician to come to facility. Seen by Z7 (attending physician) and Z8 with orders to start resident on [MEDICATION NAME] 50mg twice a day and [MEDICATION NAME] dose pack. June 22, 2017 at 10:45AM, X-Ray completed, pending results. June 22, 2017 at 3:50PM, X-Ray results relayed to Z8 and orders received to send R12 to the emergency room for further evaluation. June 22, 2017 at 5:00PM R12 transferred to hospital for evaluation of right shoulder pain. There is no documentation that the physician or nurse practioner were called and notified of R12's severe right shoulder pain between June 15, 2017 fall and June 20, 2017. R12's June 22, 2017 hospital emergency report documents presence of a post traumatic, acute right humeral neck fracture without displacement. R12's February 24 and April 14, 2017 minimum data set assessment (MDS), include R12 requires extensive assist of 2 with bed mobility, transfers and bathing. The MDS also documents requires extensive assist with ambulation, dressing, eating, hygiene and toileting. R12 scored incontinent of both bowel and bladder. R12's MDS scored the resident with cognitive impairments with a BIMS score (brief interview of mental status) at a 5 out of possible 15. July 21, 2017 at 9:55AM, during a telephone interview, Z8 (nurse practioner), stated I have cared for R12 since she was admitted to facility. R12 is alert and oriented to person and sometimes time. R12 is totally dependent on staff for all areas of activities of daily living and requires a mechanical sling lift for transfers. When I was told R12 slid out of bed on June 15, 2017 while trying to answer a phone, I was pretty sure it was due to positioning to close to the edge of the bed. R12 would not ever attempt to get out of bed independently. Z8 stated I was not notified that R12 was complaining of severe pain in the right shoulder after her June 15, 2017 fall until June 20, 2017. If I was aware I would have ordered stronger pain medication and another X-Ray. I am usually off on weekends but I still take calls for my patients, so there is no reason not to notify me of the severe pain until June 20, 2017 when the residents daughter requested further evaluation of the pain. On July 11, 2017 at 10:02 AM, R8 was in the hallway sitting in her wheelchair sleeping; at 2:11 PM R8 was at the facility sunroom (2nd floor) sitting in her wheelchair sleeping during activities. On July 12, 2017 at 8:45 AM, R 8 was in the hallway sitting in her wheelchair sleeping. E 8 (Activity Aide) stated R 8, Always sleeping, no behavior problem, if you wake her up. She will open her eyes then goes back to sleep. No, I never saw her with any kind of behavior. Most of the time she's sleeping. At 11:01 AM, E29 (Nurse) stated, she does not have any behavior. She's sleeping most of the time. R 8's Medication Administration Record [REDACTED]. R 8's electronic clinical record showed R 8 has a diagnoses to include Dementia. On July 12, 2017 at 1:30 PM, E 2 (Director of Nursing) said, there was no identified targeted behavior identified for R 8 and there was no behavior monitoring done. Findings include: Dementia Care/Behavior Management Physicians Order Sheet (POS) dated 7/1/17 to 7/31/17 indicates R7 is [AGE] year old, was admitted to the facility 11/25/16 and has current diagnoses that include Unspecified Dementia with Behavioral Disturbance (Primary), Obesity, Unspecified Cervical Vertebral fracture, Pseudobulbar Affect, Conduct Disorder - Aggression, History of Falls. Significant Change MDS (Minimum Data Set) dated 6/13/17 indicates R7 scores 7/15 on BIMS (Brief Interview for Mental Status) and is severely cognitively impaired. POS indicates R7 was admitted to Palliative Care on 4/18/17 and then admitted to Hospice Care on 6/6/17 with [DIAGNOSES REDACTED]. Hospital Discharge records dated 2/20/17 at 3:44am indicate the following medications were ordered at discharge: [MEDICATION NAME] (antipsychotic) 200mg (milligrams) at bedtime and 50mg three times per day. [MEDICATION NAME] (antipsychotic) 4mg twice daily. POS indicates R7 receives [MEDICATION NAME] 200mg at bedtime and 50mg three times per day with diagnoses of Other Conduct Disorders - Aggression. POS indicates both doses of [MEDICATION NAME] were ordered on readmission from the hospital on [DATE] and have continued unchanged. POS also indicates R7 also receives [MEDICATION NAME] 4mg at bedtime and 2mg twice daily. No diagnoses is documented for [MEDICATION NAME]. Nurses Notes dated 2/25/17 at 11:21pm indicates that R7 was in no apparent distress, had refused to go to bed and was sleeping in her wheelchair. Note indicates R7 required frequent redirecting as R7 wanders. Note indicates R7's [MEDICATION NAME] was changed to 2mg (milligrams) twice daily and 4mg at bedtime. This change did not reduce the total daily dosage of [MEDICATION NAME] which continued at 8mg. On 7/20/17 at 10:05am E2, DON (Director of Nursing) stated that several of R7's medications were changed on 3/6/17. E2 stated that only the administration times of the medications ordered on [DATE] were changed to better accomodate R7's schedule and compliance with taking medications. E2 stated that R7's dosage of [MEDICATION NAME] did not change on that date. Psychiatric Progress Notes dated 1/11/17 through 6/8/17 indicate Nurse and Staff Reported Patient stable, behaviorally manageable, no acute anxiety, affective or psychotic symptoms except for 2/25/17 note which indicates R7 was hospitalized for [REDACTED]. Nurses Note dated 2/20/17 at 6:51pm indicate R7's family was notified of current medications including Psychiatric medications ordered for treatment of [REDACTED]. Nurses Note dated 2/20/17 at 10:27pm indicates R7 exhibited no significant agitation, restlessness or confusion. Nurses Note dated 2/22/17 at 6:03am indicates R7 was awake all night, refused to go to bed, wandering the unit, not easily redirected. Nurses Note dated 2/23/17 at 8:17pm indicates R7 refused to eat, refused to use toilet, restless, pacing by nurses station, requesting to wash dishes, clean cabinets and kitchen, loud, arguementative, removed alarm band and exit seeking. Nurses Notes dated 2/24/17 at 9:18pm indicates R7 yelling at staff to leave her alone. Nurses Notes dated 2/27/17 at 4:12pm indicates R7 refused skin assessment, refused vital signs, wandering in hallways and knocking on doors, going into other resident rooms, argumentative and verbally aggressive with redirection. Nurses Notes dated 2/27/17 at 11:29pm indicates R7 up in wheelchair and refuses to be repositioned, observed removing trash can lid by nurses station and stating I have to clean up. Nurses Notes dated 2/28/17 at 6:34pm indicates R7 refusing to be checked or changed, declined to eat supper and stating I don't want to eat, I just want to go home. Social Service Note dated 3/20/17 at 3:14pm indicates R7 is an independant person and does not like to be directed by staff. Note indicates R7 can become agitated and harder to redirect if she thinks she is being told what to do. Note indicates R7 likes to move around the unit and look into other resident rooms, going into the sun room and offices. Note indicates R7 likes to clean her room and dining room, refuses her medications and showers at times. Note indicates R7 occassionaly uses inappropriate language toward staff. Nurses Notes reviewed from 7/1/17 to 7/14/17 indicate intermittent behaviors of confusion, restlessness and occasional refusal of care. On 7/13/17 at Z3, Psychiatrist stated that R7 was very restless and was sent to a behavioral hospital and came back with these ([MEDICATION NAME]) medications. Z3 stated that ([MEDICATION NAME] and [MEDICATION NAME]) are an unusual combination for this resident based on her age. Z3 stated that R7 was impulsive, attention seeking and has a strong personality and on these medications R7 is manageable. On 7/13/17 at 9:00am E2, DON stated that there is no formal behavior monitoring and that Staff just document behaviors as they occur in the progress notes. On 7/20/17 at 10:15am E2, DON stated that the facility is working with the psychiatrist to make him aware that residents can scream or act out as much as they want and if they are not a danger to themselves or others, ([MEDICAL CONDITION]) medications need to be justified. Notes reviewed between 2/2017 and 7/2017 indicated R7 was not a danger to self or danger to others. Care Plan dated 11/26/16 indicates R7 receives [MEDICAL CONDITION] medication and has a [DIAGNOSES REDACTED]. Care Plan reviewed was not specific to antipsychotic medications precribed and administered to R7 and did not include target behaviors. Care Plan interventions were not adjusted as needed. Care Plan dated 11/30/16 indicates R7 has verbal behavioral symptoms directed towards others, screaming and cursing. Goal indicates resident screams at staff when approached for care. Approaches were last updated 2/11/17. Care Plan dated 1/19/17 indicates R7 with a history of hallucinating. Goal is for R7 not to harm herself or others. This goal is not appropriate to the problem of hallucinations. No documentation was found or presented to indicate R7 was a harm to self or others or what type of hallucinations R7 experienced. No documentation was found to show attempts to prevent potentially distressing behaviors or implementation of assessment of approaches to address R7's behaviors as a form of communication. Facility policy on Behavior Management was requested on 7/20/17. No policy was presented. 5. R6's General Order dated June 29, 2016 documents R6 admitted on that date with an order to complete implanted cardiac defibrillator device (implanted August 27, 2010) checks. On July 12, 2017 at 11:55am, Z8 (Nurse Practitioner) stated R6's implanted defibrillator device is to be checked every three months. R10's Resident Face Sheet dated July 13, 2017 documents R10 admitted on that date with a cardiac pacemaker. R10's Care Plan for a pacemaker dated March 11, 2017 documents R10 with an intervention to have pacemaker checks every three months (13 weeks). On July 13, 2017 at 3:25pm, E43 (Nurse Consultant) confirmed pacemaker and implanted cardiac defibrillator devices should be checked every three months. E43 stated there is no evidence R10 and R18's devices were checked every three months.

Based on observation, interview and record review the facility failed to follow their Fall Management Policy and failed to supervise and monitor one resident (R7) displaying unsafe behaviors of eight residents reviewed for falls of 24 sampled residents. This failure resulted in R7 sustaining neck fractures from a fall in the bathroom while unsupervised. This failure resulted in R12 sustaining a fractured humerus. This applies to 4 of 9 residents (R3, R5, R7, R12) reviewed for fall risk in the sample of 24. 1) Physicians Order Sheet (POS) dated 7/1/17 to 7/31/17 indicates R7 is [AGE] years old and was admitted to the facility 11/25/16 and has current [DIAGNOSES REDACTED]. Significant Change MDS (Minimum Data Set) dated 6/13/17 indicates R7 scores 7/15 on BIMS (Brief Interview for Mental Status) and is severely cognitively impaired. On 7/11/17 at 2:20pm R7 was in bed and was noted to be scooting along the length of the bed in an effort to get out of bed. On 7/12/17 at 9:45am R7 was observed in bed sleeping. No floor mats were in place next to R7's bed. On 7/12/17 at 1:55pm R7 was observed in bed sleeping with no floor mats on the floor the next to R7's bed. A grey floor mat was noted to be leaning against the wall to the right of R7's bed and a rolled up black mat was near the window by R7's bed. On 7/12/17 at 2:10pm E30, CNA (Certified Nursing Assistant) stated that she was R7's assigned CNA for the day and is aware of R7's Care Cards that indicate what type of basic care should be given to R7. E30 stated that she did not notice that R7 should have floor mats when R7 is in bed. At that time E15, LPN (Licensed Practical Nurse) stated that Hospice staff were with R7 and left R7's room without placing the floor mats on the floor. E15 acknowledged that R7's assigned staff (nurse and CNA) are responsible to ensure the mats are on the floor when R7 is in bed. Care Card found inside R7's closet on 7/12/17 indicate R7 requires Floor mat - both sides. Falls Care Plan dated 11/25/16 indicates R7 at risk for falling due to history of multiple falls, impaired cognition and balance. Approach dated 3/23/17 indicates bilateral mats to bedside. Nurses Notes and Fall Root Cause Analysis Forms indicate R7 had seven documented falls prior to 2/20/17. On 12/12/16 fell in bathroom while attempting self grooming. On 12/25/16 fell while reaching for something in her drawer. On 12/28/16 fell due to wheelchair unlocked. On 12/28/16 fell while trying to get something out of bathroom drawer. On 1/3/17 stood up to close to drapes and slipped to floor. On 1/8/17 at 2:20am fell while transferring from bed to wheelchair while trying to go to the bathroom. On 1/8/17 at 2:02pm stood up to pour water, lost balance with only socks on feet and fell . \ Nurse Note dated 2/10/17 1:41am indicates R7 busy wandering hallways, several attempts to get out of her wheelchair, using foul language, refused care sitting in wheelchair at this time. Nurse Note dated 2/10/17 at 2:15am indicates R7 was found on the bathroom floor under the sink. Note indicates R7 sustained a laceration to back of her head. Note indicates R7 was transferred to the hospital for evaluation at 2:40am . Nurses Note dated 2/20/17 at 1:30pm indicates R7 returned from the hospital with a cervical collar, posterior cervical spine fusion due to C6, C7 and T1 vetebral body fractures. Safety Events - Fall Event dated 2/22/17 at 9:30pm indicates R7 was found on her back on the floor of her room. Progress Notes dated 2/22/17 at 10:00pm indicate R7 fell in her room out of her wheelchair onto the floor and was found lying on her back. Root Cause Analysis Form dated 2/22/17 indicates R7 was agitated from not sleeping. Recommendation/Interventions: Medication review to address insomnia. Safety Event - Fall Event dated 2/23/17 at 4:50pm indicates R7 was observed sitting on her buttocks in the hallway. Progress Note dated 2/23/17 at 4:50pm indicates R7 was observed sitting on her buttocks on the floor in front of her wheelchair in the hallway near the nurses station. Root Cause Analysis Form dated 2/23/17 indicates R7 was agitated due to pain. Recommendations/Interventions: Physician to schedule pain medications. Safety Event - Fall Event dated 3/22/17 at 8:28pm indicates R7 fell from bed onto floor and was found sitting with her back against bed. Progress Note dated 3/22/17 at 8:25pm indicates R7 stated that she slid off the bed onto the floor. Root Cause Analysis Form dated 3/22/17 indicates R7 stated slid off bed. Recommendations/Interventions: Floor mats to bedside. Safety Event - Fall Event dated 3/27/17 at 3:45am indicates R7 slid from wheelchair in hallway. Progress Notes dated 3/27/17 at 6:17am indicates R7 was sitting in her wheelchair in front of the nurses station. Staff noticed resident was sitting on the edge of the chair. Note indicates R7 refused redirection to sit back in chair and the a few seconds later staff was at end of hallway and noted R7 had slid from wheelchair and was sitting on floor in front of her wheelchair. Safety Events - Fall Event dated 6/8/17 at 11:45pm indicates R7 fell forward from the wheelchair in the hallway at that time and was witnessed. Event indicates care plan was reviewed on 6/9/17. Progress Note dated 6/8/17 at 11:45pm indicates R7 was behind the nursing station, staff was in front of the nursing station when R7 suddenly landed on the floor with the high back wheelchair tipped over. Note indicates R7 sustained a bump on right forehead. Fall Root Cause Analysis Form dated 6/8/17 at 11:45pm indicates R7 was attempting to stand up. Recommendations/Interventions: (R7) will use a regular wheelchair without leg rests and not with a high back. Safety Event - Fall Event dated 6/15/17 at 8:05pm indicates R7 fell forward from her wheelchair to the floor while out in the hallway. Event indicates R7 was witnessed trying to move her wheelchair, leaning forward and then falling forward onto the floor. Progress Note dated 6/15/17 at 8:05pm indicates R7 fell to the right side on her hand. Note indicates R7 sustained small dry abrasion on left knee. Fall Root Cause Analysis Form dated 6/15/17 at 8:05pm indicates (R7) wanted to go to the room with roomate. Recommendations/Interventions: Drop rear axle of wheelchair seat. Safety Event - Fall Event dated 6/18/17 at 8:00pm indicates R7 fell from wheelchair near nursing station. Event indicates R7 was leaning forward from wheelchair and that the fall was witnessed. Progress notes dated 6/18/17 at 8am indicates At 8pm (R7) sitting at nurses station in wheelchair, leaned forward in wheelchair and fell forward on left lateral side. Fall Root Cause Analysis Form dated 6/18/17 at 8pm indicates R7 fell asleep in chair. Recommendations/Interventions: Place R7 on sleeping schedule and place into bed at 7:30pm. Safety Event - Fall Event Form dated 6/20/17 at 10:35am indicates R7 fell from wheelchair in hallway. Event indicates fall was unwitnessed and that just prior to fall R7 was observed leaning forward to pick things off the floor. Progress Note dated 6/20/17 at 10:45am indicates R7 was found laying on the hallway floor by another nurse. Note indicates that a few minutes prior to the fall, staff witnessed R7 reaching for something on the floor, was repositioned and asked to sit back in her chair. Note indicates R7 injured right side of forehead. Fall Root Cause Analysis Form dated 6/20/17 at 10:23am indicates R7 was reaching for something on the ground. Recommendation/Interventions: Care plan with family who agreed to have resident placed into reclining chair during restless and lethargic periods and a rummage box provided to assist with activity needs. Safety Event - Fall Event Form dated 6/23/17 at 8:00pm indicates R7 fell while trying to get up from her wheelchair and attempting to walk. Event indicates R7 received a reddened bump to right side of forehead. Progress Note dated 6/23/17 at 9:30pm indicates that staff found R7 on the floor by the nurses station. Fall Root Cause Analysis Form dated 6/23/17 at 8pm indicates R7 had agitation due to pain. Recommendations/Interventions: Hospice to evaluate medication regimen, attempt to place R7 in bed every 2 hours. All Root Cause Analysis Forms identifying pain as the cause of R7's falls was not indicated on the corresponding Safety Event Form Assessment of Resident Pain. All assessments indicated No pain. On 7/21/17 at 9:45am Z8, NP (Nurse Practitioner) stated that she is not an official part of the fall management team however does make suggestions related to residents falls. Z8 stated that R7 is very non-compliant with care and redirection. Z8 stated that R7 will at times attempt to go to the bathroom by herself and refuses to let staff help. Z8 stated that she has witnessed R7 attempting to go to the bathroom by herself and at those times she (Z8) has stayed with R7 until another staff could stay with R7 as she would be unsafe to be alone in the bathroom (due to impulsive behavior and poor safety awareness). Z8 stated that the only way to keep R7 safe at those times is to stay with her, definitely requiring close supervision or 1:1. Z8 stated that only having staff stay with (R7) 1:1 would have prevented R7 from falling when she fractured her neck. Z8 stated that R7 could be really mean to staff but they still needed to stay with (R7) for safety. On 7/21/17 at 10:20am E2, DON (Director of Nursing) stated that a Restorative Nurse (who no longer is employed at the facility) was gathering information on falls and bringing it to the team for analysis. E2 stated that a new Restorative Nurse started three months ago. E2 stated that it was identified that the previous Restorative nurse was not accurately identifying the root cause of falls, updating care plans or obtaining accurate information gathered for falls and It was not long after that she (Restorative Nurse) resigned. E2 stated that there is a mismatch of the root cause of the falls and the actual documentation and interviews of staff. E2 stated that the Restorative Nurse was also responsible for the falls care plans. E2 stated that if any resident is exhibiting unsafe behaviors, staff should stay with the resident. E2 agreed that R7 was at risk for falling when sitting on the edge of her wheelchair , bending forward in her wheelchair and when agitated and restless. E2 stated I don't know why staff didn't stay with (R7). Notes indicate neck fractures on 2/20/17 as a result of a fall were preceeded by restless and agitated behaviors with multiple attempts by R7 to get out of her wheelchair. Staff did not monitor or supervise R7 while displaying unsafe and high risk behaviors which resulted in R7 sustaining cervical neck fractures. Care plans presented by the facility do not address the need for staff to stay with R7 when exhibiting unsafe behaviors and did not update R7's frequent behaviors of bending forward from her wheelchair as R7 continued to fall forward after the rear axle of the wheelchair was modified. No other interventions were found to address R7's falling forward out of her wheelchair. Facility Policy/Falls Clinical Protocol dated/revised 2008 indicates: Based on preceeding assessment, staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. The staff will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. If individual continues to fall, the staff and physician will re-evaluate the situation and consider other reasons for the residents falling (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions. 2) R12 admitted to facility February 17, 2017 with [DIAGNOSES REDACTED]. On July 11, 2017 at 2:30PM, R12 observed in a bariatric bed with a low air loss mattress. R12 was unable to move lower extremities upon request. R12 had oxygen at three litters per nasal cannula infusing, rarely spoke when questioned. R12 did say her pain is not being managed with medications provided. R12's right arm was in a sling and daughter at bedside. July 11, 2017 at 2:30PM, R12's daughter (Z5), stated R12 has had a couple fall incidents since admission to facility. The facility told me she fell in June trying to get out of bed by herself. R12 usually requires a two person mechanical lift for transfers and has not been able to walk for a very long time. R12's February 22, 2017 and June 16, 2017 fall risk assessments document at risk for falls. R12's incident / accident event reports include: - February 22, 2017 (5 days after admission to facility), at 2:30PM, R12 had a fall incident while being transferred by staff using mechanical sling lift. - March 08, 2017, 3:09PM, while being transferred from wheel chair to standing position in a sit to stand lift, R12 sustained two skin tears to the right forearm from the un-capped metal edge of the sit to stand lift hand rail. - April 03, 2017 at 1:35PM, R12 sustained two skin tears with open flap to left posterior hand requiring steri-strips to close wound. Incident report documents the injury occurred during a staff assisted transfer. - June 15, 2017 at 5:30PM, R12 found on the floor next to her bed with complaints of severe right shoulder pain. This incident report documents R12 was confused as was prior to the incident. The report also states R12 told staff she stood up to answer the phone and slid to the floor. R12's June 22, 2017 hospital emergency report documents presence of a post traumatic, acute right humeral neck fracture without displacement. R12's February 24 and April 14, 2017 minimum data set assessment (MDS), include R12 requires extensive assist from 2 staff with bed mobility, transfers and bathing. The MDS also documents requires extensive assist with ambulation, dressing, eating, hygiene and toileting. R12 scored always incontinent of both bowel and bladder. R12's MDS scored the resident with cognitive impairments with a BIMS score (brief interview of mental status) at a 5 out of possible 15. R12's weights ranged between 299.8 to 316.8 pounds. R12's Z6 (physiatrist) April 27, 2017 progress note, Z8 (nurse practioner) April 25, April 28, May 02 and June 20, 2017 progress notes and June 22, 2017 emergency room progress notes describe R12 as cognitively impaired. R12's physical therapy progress notes include: - April 19, 2017 = requires maximum assist with bed mobility. - April 24 and April 26, 2017 = R12 does not initiate movements by self even with external encouragement. Yells when staff attempt to assist her with movement. R12's occupational therapy progress notes include: - April 02, 09, 16, 13 and 26, 2017 = requires maximum assist of two staff rolling side to side in bed, using small circular hand grip device at head of bed, Halos. Decreased bilateral upper extremity range of motion and has right upper extremity strength impairment and pain. R12's April 20, 2017 restorative referral include requires mechanical sling lift for transfers and requires maximum assist to roll from side to side in bed with use of small circular hand grip device at head of bed Halos. During July 14, 2017 , 2:05PM interview E27 (R12's occupational therapist), stated R12 would never attempt to get out of bed or initiate independent bed mobility without staff assistance and requires mechanical sling lift transfers with two person assist. During this interview E27 took surveyor into the therapy room to show the sit to stand lift used on R12 when the resident sustained [REDACTED]. During July 14, 2017, 10:30AM interview, E26 (R12's nurse aide), stated R12 requires two assist with bed mobility and transfers using a mechanical sling lift. R12 would not attempt to get out of bed without staff assistance. R12 is unable to independently move around in bed and frequently refuses to get out of bed. July 14, 2017 at 10:35AM, E25 (nurse), stated R12 is sometimes observed with her legs dangling off the edge of her bed. During July 14, 2017, 10:49AM interview, E9 (restorative nurse), stated R12 requires extensive assistance of two staff with bed mobility and transfers. E9 stated (R12) would absolutely not attempt to get out of bed on her own. E9 said staff need to carefully place R12 in the center of the bed during mechanical lift transfers, not near the edge of bed. R12's June 15, 2017 fall from bed was directly caused from being positioned to close to the edge of the mattress, poorly positioned, not in the center of mattress by staff. E9 stated she re-educated staff on proper positioning R12 in bed for safety. Staff also told to use pillows for positioning on R12. E9's description of the root cause of this fall is not documented on the incident report or fall analysis report. July 14, 2017 at 10:55AM, R12 observed being provided care by E26 and E4 (restorative aide). E26 and E4 were attempting to pull R12 up toward head of bed without locking bed wheels. During this repositioning R12's bed continued to move around and back and forth. After E4 and E26 repositioned R12 further up in bed they left R12 alone in room. R12 was positioned toward the right side of mattress within two - three inches from the edge of mattress and no pillows were being utilized to aide in positioning R12. During July 14, 2017 telephone interview, around lunch time, E28 (nurse aide), stated R12's left posterior hand skin tear occurred while E28 was turning the resident in bed, R12 attempted to grab hold of the bedside Halos but the bed control device was wrapped around the Halos and cut open her hand. July 21, 2017 at 9:55AM, during a telephone interview, Z8 (nurse practioner), stated I have cared for R12 since she was admitted to facility. R12 is alert and oriented to person and sometimes time. R12 is totally dependent on staff for all areas of activities of daily living and requires a mechanical sling lift for transfers. When I was told R12 slid out of bed on June 15, 2017 while trying to answer a phone, I was pretty sure it was due to positioning to close to the edge of the bed. R12 would not ever attempt to get out of bed independently. Z8 stated I was not notified that R12 was complaining of severe pain in the right shoulder after her June 15, 2017 fall until June 20, 2017. If I was aware I would have ordered stronger pain medication and another X-Ray. I am usually off on weekends but I still take calls for my patients, so there is no reason not to notify me of the severe pain until June 20, 2017 when the residents daughter requested further evaluation of the pain. R12's current care plan does not include any individual interventions to prevent incidents and accidents with or without injury. Facilities fall protocol dated revised August 2008, include the need to thoroughly evaluate possible causes of falls and accidents and develop individual interventions and then evaluate if interventions are working. This was not done with any of R12's 4 fall and/or injury reports. 3) On July 11, 2017 at 1:32PM a aerosol spray can of air freshener observed on top of R5's bedside stand. R5 independently self propels herself in and out of her room, to and from activity programs leaving her room open, unsupervised and accessible to cognitively impaired resident R5's room is located on the first floor where facility identified 23 independently ambulatory residents. Of the 23 independently ambulatory residents 4 were documented with cognitive impairments (R28, R29, R32 and R35). 4) On July 11, 2017 at 1:48pm, E18 and E20 (Nursing Assistants) transferred R3 via a mechanical lift. E18 operated the controls on the lift and E20 stood behind a wheelchair that was pushed up to and on the same side of the bed as E18 as R3 was lifted into the air. Neither E18 nor E20 were near R3 to guide and supervise R3 while being lifted nor close enough to intervene if R3 required assistance during the transfer. On July 12, 2017 at 10:23am R3 was in bed with the bed in the high position. R3 stated E18 left the room to get assistance to transfer R3 to the wheelchair. At 10:34am E18 entered R3's room with E19 (Nursing Assistant). E18 and E19 transferred R3 via a mechanical lift. E18 operated the controls on the lift and E19 stood behind a wheelchair that was pushed up to and on the same side of the bed as E18 as R3 was lifted into the air. Neither E18 nor E19 were near R3 to guide and supervise R3 while being lifted nor close enough to intervene if R3 required assistance during the transfer. On July 12, 2017 at 10:44am, E19 stated one person is supposed to be located next to the resident to spot the resident during the mechanical lift transfer. E20 stated the bed is supposed to be in low position when a resident is in bed unsupervised. R3's Fall Risk assessment dated [DATE] documents R3 at a high risk of falls. R3's Brief Interview of Mental Status documents R3 as cognitively intact.

Based on record review and interview the facility failed to ensure that a resident identified as high risk for fall was provided a device to support and prevent the resident (R2) from rolling out of bed during incontinence care. This failure resulted in R2 sustaining a fracture on the left hip/femur. The findings include: R2's admission record sheet showed that the resident has multiple [DIAGNOSES REDACTED]. R2's weight records indicated that the resident weighed 198 pounds on 12/10/13. R2's quarterly MDS (Minimum Data Set) dated 9/23/13 showed that the resident has a BIMS (Brief Interview for Mental Status) score of 11, indicating that the resident has orientation problem. The same MDS showed that R2 required extensive assistance x 2 or more person physical assist for transfers, bed mobility, hygiene and toilet use. R2's care plan dated 7/3/13, indicated that the resident has limitation with bed mobility related to impaired mobility and weakness. An approach dated 6/5/13 shows that the staff will assist in repositioning. R2's care plan to address risk for skin breakdown dated 6/9/13, indicated an approach to provide incontinence care after each incontinent episode. R2's care plans did not reflect how much assistance and how many staff is needed to provide bed mobility and incontinence care to the resident R2's point of care history from 6/1/13 through 12/11/13 showed that the resident required extensive assistance to total dependence with toilet use with varying staff support from 1 person to two or more persons physical assist. R2's Fall Risk Observation dated 7/3/13 scored the resident "15" and another Fall Risk Observation dated 9/24/13 scored the resident "20", indicating for both assessments that R2 is a High risk for falls. R2's Event Report dated 12/11/2013 (9:30 PM) showed that the resident fell /rolled out of bed while being assisted by a CNA (Certified Nursing Assistant) with peri-anal care after having a bowel movement. The same report documented, "Resident noted lying on the floor on her back. C/O (complaint of) pain on her right foot; noted with bleeding open area underneath her right 4th toe, and a forming hematoma on dorsal aspect of right foot. Resident was moving her right ankle. Has chronic limited ROM (range of motion) and deformities of both BLE (bilateral lower extremities) esp on knees from previous injury/surgery." R2's progress notes dated 12/11/13 (10:00 PM) showed that the resident was complaining of pain all over and pain/soreness on her left groin area. R2 was also asking to be sent out to the hospital. R2's physician was notified and gave the order to send the resident to the hospital for further evaluation. In an interview held inside the admission office on 1/15/14 at 3:00 PM, E4 (CNA) stated that on 12/11/13 she was staff assigned to take care of R2 from 2:30 PM through 10:30 PM. Per E4, R2 is not able to turn and reposition by herself without staff assistance, but is able to grab on to the halo on the head part of the bed to maintain the position after being turned. According to E4, on 12/11/13 at approximately 9:30 PM, she positioned R2 on her right side (away from her (E4)) to clean the resident because R2 had an incontinent bowel movement. R2 was observed holding on to the halo that was on the head part of the bed (right side). Per E4 she had her gloved left hand on R2's buttocks area (to separate), while her right gloved hand was wiping the stool from R2's anal area. Per E4, towards the end of the incontinence care, she noticed that her left hand glove was soiled with stool, so she lifted her left hand from R2's buttock area and R2 started to roll out of bed. E4 stated that it happened so fast and she was not able to stop the fall. In another interview held inside the admission office on 1/15/14 at 2:45 PM, E4 stated that on 12/11/13 when she positioned R2 on her right side on the bed to provide incontinent care, R2 was not on the edge of the bed. Per E4, since R2 was a heavy set lady her left leg was over her right leg, but the left leg was not touching the bed. Per E4, it happened so fast that her bottom half went down first and she does not know when R2 let go of holding the right side halo. E4 stated that she did not provide any other device such as pillows on the edge of the bed to support and potentially prevent R2 from rolling out of bed. R2's final Facility Incident Report Form reported to the State Agency on 12/13/13, documented that the resident was diagnosed at the hospital with Fractured left hip/femur. In an interview held on 2/3/14 at 1:44 PM, Z2 (Physician) stated that, " a bedrail could have prevented the fall," especially since only one staff was providing care and due to resident being over weight. Z2 also stated that the CNA could have asked for help from other staff to care for the resident.

Based on observation, record review and interview, the facility failed to provide assistance/supervision to residents at risk for falls. failed to implement effective fall precautions on admission for a resident at high risk for falls and failed to correctly assess residents at high risk for falls. The facility failed to implement specific interventions to prevent falls and failed to analyze circumstances to identify the reasons for resident's falls. The facility also failed to re-evaluate the effectiveness of their interventions in order to prevent further falls. This applies to three ( R 3, R2, R22) of nine residents in the sample of 24 resident reviewed for supervision. As a result of this failure R22 fell and sustained a displaced fracture to her left hip and R2 sustained a nasal fracture. The findings include: (1) Review of R22's admission face sheet showed R22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's incident reports showed R22 had 7 falls from 3/3/13 to 8/7/13. The falls dates included 3/3, 3/6, 3/31, 4/17, 5/16, 8/1 and 8/7/13. The incident report documentation for 8/1/13 at 1:47 p.m. showed R22 was observed on the floor near her bed. At this time R22 complained of pain to her left hip and leg. The incident documentation showed R22 was sent to a nearby hospital where she was admitted and diagnosed with [REDACTED]. Review of a quarterly fall assessment done for R22 dated 6/4/13 scored R22 at a " 4 " (low risk). Further review of this fall assessment showed many of R22's risk factors had not been identified and added to R22's fall score. These factors omitted included " Intermittent Confusion " (on 4/17/13- R4 had been hospitalized for [REDACTED].) Factors omitted also included " Confined to wheel chair. " The Fall CAA (care area assessment) for Falls dated 6/4/13 showed documentation R22 " now uses a wheel chair. " Other omitted factors included the incorrect number of falls identified and R22's Dementia [DIAGNOSES REDACTED]. When all of R22's fall factors were identified; R22's scored a " 15. " The fall assessment denotes a score of 10 or higher represents a high risk for falls. Another fall assessment done for R22 on 8/2/13 showed R22's fall risk scored at an " 8. " The fall assessment again did not correctly identify all of R22's fall risk factors. Review of this fall assessment showed R22 should have scored a " 14 " - high risk. Toward the end of the fall assessment there is a section for referrals. Neither of the fall assessments showed R22 should be referred to the Fall Prevention Program. Review of the facility's Fall Prevention Program policy showed: A score of 10 or more places the resident on a High Risk. In addition to the use of Standard and Moderate Fall Precautions, the following interventions will be implemented for resident identified at High Risk. 1. The resident will be checked approximately every two hours or as according to the care plan, to assure they are in a safe position. 2. In the event safety monitoring is initiated for 15-30 minute periods, a documentation record will be used to validate observations. Review of R22's fall plan of care showed no approaches that R22 had interventions initiated for interventions for high risk fall residents as noted on the facility's Fall Prevention Program. On 8/30/13 at 11:00 a.m. E7 (Restorative Nurse) stated, " R22's fall assessments for 6/4/13 and 8/2/13 were not completed correctly. They should have been scored with all of R22's fall risk factors included and should have scored her at high risk. When residents are scored at high risk for falls the staff are made aware the resident is at high risk for falls and the staff monitors the resident more closely. " At this time E7 also stated R22 should have a wheel chair alarm and R22 is encouraged to ask for assistance/use call light before going to the bathroom. Review of R22's plan of care showed neither of these interventions were addressed on R22's fall care plan. When E7 was asked why R22 was having falls and/or what were the circumstances surrounding her falls; no answer was given. Observation of R22 on 8/30/13 at 9:00 a.m. noted R22 to be up and ambulating per wheel chair in her room. R22 had a wheel chair alarm attached to her wheel chair but the alarm was not attached to R22's clothing making the alarm non-functional if R22 stood up from her wheel chair. At this time R22 stated, " They tell me to use the call light and call for help before I go to the bathroom, but they don't answer the call light so I go to the toilet myself. I fell a little while ago and fractured my left hip. I was trying to put some items away. They don't watch me. " (2) R3 is an [AGE] year old female admitted to the facility on [DATE] at 6:30 pm. R3's [DIAGNOSES REDACTED]. R3 speaks Serbian, but her care plan of 8/12/13 states R3 is able to understand English and is able to make her needs known in English. Her Admission Fall Risk assessment dated [DATE] timed at 7:34 pm is incomplete. It scores R3 with 4 points for intermittent confusion and also with 4 points for being on 3 or more medications which can contribute to falls. The section entitled " Evaluation " is to calculate the number of points in order to determine the resident's fall risk score. There is no number in this section. This assessment makes a referral for R3 for PT and TO (Physical and Occupational therapy). It also indicates to initiate a plan of care. On 8/30/13 at 10:40 am, E1 (Administrator) stated fall risk assessments are to be done on admission and quarterly, as well as upon a change in condition, including after every fall. E1 agreed that R3 ' s initial fall risk assessment was incomplete. Admission nursing note on 5/17/13 timed at 6:30 pm indicates R3 needs maximum assistance of 2 people for ADLs (activities of daily living), and R3 ambulates with a walker. On 5/18/13 at 1:42 pm, nursing note indicates R3 is at high risk for falls, and " all safety precautions to be put in place " . There is no documentation of what specific interventions were applied or put in place, or what time safety precautions were initiated. A nursing note from 5/18/13 at 10:01 pm reflects R3 was observed lying on the floor on her side after getting out of the low bed. A mobility alarm was in place. R3 sustained a wrist injury and was sent to the hospital. A nursing note from 5/19/13 timed at 7:00 am indicates R3 sustained a non-displaced fracture of the distal radius. R3's fall care plan was dated 5/24/13, with the following interventions dated 5/25/13: analyze resident's falls to determine patterns/trends; clip alarm to alert staff of unassisted transfers; keep bed in low position with brakes locked; observe frequently and place in supervised area when out of bed; occupy resident with meaningful distractions, with music or conversation; place resident in fall prevention program; keep resident invisible area when up in wheel chair; provide proper, well-maintained footwear; provide toileting assistance when needed. At 12:25 pm on 8/30/13, E1 stated she had staff looking to see if they could find an initial care plan for falls for R3, as R3's current falls care plan started on 5/24/13. No additional care plan was presented by facility staff for review. E1 also stated she had been unable to locate documentation which shows what specific interventions were put in place for R3 upon admission. A facility incident report dated 6/17/13 at 8:25 pm reflects R3's safety alarm was heard and upon entering room. The safety alarm noted clipped on bottom of privacy curtain. R3 was observed lying on her back on the floor, with no apparent injury. R3 was described as restless and agitated and she was taken to the nurse's station for increased monitoring. R3's 6/18/13 fall care plan intervention is to obtain a urinalysis and culture and report any abnormal findings. There were no additional interventions put in place at this time and the tests ordered would not stop R3 from falling. An incident report dated 8/1/13 timed at 10:22 pm indicates R3 observed self-transferring in the washroom and she fell . This was witnessed by staff, but staff were unable to reach R3 in time to stop her from falling. The report indicates again R3 was able to remove her alarms and has not been compliant with safety precautions. Fall interventions for this 8/1/12 fall include changing to a pad alarm to be in her wheel chair and again, to assist R3 to visible areas when restless. (This intervention was already in place from 5/24/13 care plan, which stated R3 was to be placed in supervised areas when out of bed). R3 sustained 3 falls (6/17/13, 7/22/13 and 8/1/13) after removing her safety alarm, before the type of alarm was changed to a pad type of alarm, after her fall on 8/1/13.) The use of a clip alarm was ineffective as R3 was able to repeatedly remove this type of alarm. Her alarm type was not changed until after 3 falls, when a pad alarm was placed. R3 had an initial fall risk assessment begun on admission on 5/17/13, which was incomplete. Her next fall risk assessment was completed on 8/2/13, after her 8/1/13 fall. This assessment scored R3 at high risk for falls, with a score of 23. There was no fall risk assessment completed after her 6/17/13 and 7/22/13 falls. Facility Fall Prevention Program states that a Fall Risk Assessment will be performed by a nurse at the time of admission, and that this assessment tool will incorporate current clinical practice guidelines. A Fall Risk Assessment will be performed at least quarterly and with each significant change in mental or functional condition, and after any fall incident. It also states that the admitting nurse and assigned CNA (certified nursing assistant) are responsible for initiating safety precautions at the time of admission. On 8/27/13 at 11:30 a.m., R2 was observed seated in a reclining chair outside her room. R2 resides on the memory support unit due to her need for supervision, [DIAGNOSES REDACTED]. R2 has a history of falling from the bed onto the floor as shown in the incident reports on the following days: On 11/21/12 at 6:45 a.m. fell from bed, On 1/11/13, 4:50 a.m. on the floor on left side on top of floor mat, On 1/15/13 at, 12:45 a.m. lying on the floor on top of her bed cover beside her bed on the left side lying position, On 1/17/13 at 3:35 p.m. found on the floor mat, wrapped up in covers, On 2/5/13 in the bumper pad, sitting position on the floor mat at bedside with back against, On 2/4/13, 6:25 a.m. Hit head on the floor, fell from wheelchair in dining room during mealtime, was not witnessed due to staff feeding other residents, On 2/18/13 at 4 a.m., found on the floor, bed alarm off, On 3/25/13 at 6:45 p.m. fell from wheelchair onto floor, On 4/15/13at 7 p.m. next to her bed on the floor, On 4/17/13 at 3:15 p.m. laying on the floor with head toward window on left lateral position on the floor mat,4/29/13 at 3:30 a.m. fell from the bed, hit head on chest, sustained a nasal fracture, On 5/18/13 at 3:15 p.m. sitting on the floor next to right side of bed, incontinent pad with soft stools, appears resistant had been trying to take it off), On 5/25/13 at 2:10 p.m. fell out of bed, found on the floor mat, On 6/28/13 at 10:15 p.m., on the floor next to floor mat, lying on the floor, A summary of R2 ' s incidents show R2, had ten falls from the bed before sustaining a nasal fracture on 4/29/13. The nursing notes (observation) dated 4/29/13 show R2, hit her face on the chest next to her bed and was found on the floor and sustained a nasal fracture. Neither the fall assessment nor nurse notes showed the facility analyzed why R2 was falling. E2 (director of nurses) on 8/28/12 said she was responsible for analysis of the falls in the facility. R2 was unable to present any additional information regarding R2 ' s fall upon request on 8/29/13. The changes and interventions are generalized and not specific for R2's falling. An example of the approaches and interventions the facility developed on 11/16/12 are , " to give verbal reminders, keep call light in reach at all times, re-educated resident on safety prevention measures. R2 ' s Minimum Data Set 11/22/12 shows a score of 7 for the Brief Interview of Mental Status ( BIMS) showing moderate cognition impairment and inability to make decisions. R2 was evaluated for fall risk on 5/14/13 to have a score of 17 and on 8/28/13 a score of 18. The facility ' s fall risk observation assessment calculates any resident above a score of 10 to be at high risk for falls. The fall care plan was reviewed with E2 (director of nurses) on 8/29/13. The care plan and fall assessment did not reflect R2's comprehensive evaluation and the intervention for the prevention of her falling.

Based on observation, record review and interview the facility failed to prevent one resident (R3) from falling and sustaining injuries during a staff assisted transfer from bed to wheel chair. As a result of this failure R3 fell to floor and was hospitalized with a right hip fracture. R3 also sustained lacerations which required sutures to the bilateral knee and right lower leg. This is for one resident (R3) in the sample of four reviewed for falls and transfers. The findings include: Review of R3's admission face sheet showed R3 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility incident/investigation report dated 6/28/12 at 10:50 a.m. for R3 showed R3 sustained a fall while transferring himself with his walker from his bed to his wheel chair while staff was assisting. The report notes R3 complained of pain to his right side. First aid was rendered and R3 was transferred to a nearby hospital with resultant [DIAGNOSES REDACTED]. Nursing note documentation for the same date and time showed R3's right lower leg with a moderate amount of bleeding and with R3 complaining of right lower leg pain. Nursing note documentation dated 7/3/12 showed R3 was readmitted to the facility with [DIAGNOSES REDACTED]. Continued nursing documentation showed R3 had 9 staple sutures to the right hip, 4 staple sutures to the upper outer thigh, 2 separate lacerations with 2 staples in each laceration to the outer side of the right knee, and 11 stitches in the right shin. On 8/8/12 at 3:10 p.m. R3 was observed sitting up in his wheel chair in his room. R3 was noted leaning to the right side and drooling from the right side of his mouth. R3's right arm and hand was constantly shaking with tremors. R3's speech was slow but R3 was alert and verbally responsive. Interview with R3 at this time regarding his fall on 6/28/12 noted R3 to say, "E5 (CNA) was helping me. E5 was cleaning me up for a long time. I can't stand that long. I was getting tired. I usually have 1 person help me with a transfer. They usually put their arm around me and help me walk. I don't use a walker. I was walking to my wheel chair, made a sharp turn to sit down and down I went. I broke my hip. It still hurts." Further review of the 6/28/12 fall incident showed E5 (CNA) was assisting with R3's transfer when R3 fell . Review of facility interview with E5 and interview with E5 on 8/8/12 at 2:25 p.m. noted E5 to say, "R3 needs limited or extensive 1 assist with standing. I grabbed him under his arm and assisted him to stand. I didn't use a gait belt. He doesn't need assistance with walking to his wheel chair. When I stood him up he had a BM (bowel movement). He was standing and holding on to his walker while I was cleaning him. He told me he needed to sit down so I finished cleaning him, pulled up his pants and went to stand behind his wheel chair so he could sit down. He started to walk to his wheel chair and fell . I never hold on or touch R3 when he's ambulating. He walks on his own." Review of R3's annual MDS (minimum data set) showed R3 needed extensive 2+ persons physical assist. This MDS showed R3 had impaired mobility in both lower extremities. It also showed with balance during transfers and walking, R3 was not steady and only able to stabilize with staff assist in moving from seated to standing position, moving on and off toilet, and moving from surface to surface transfers (between bed and chair or wheel chair). Interviews with nursing/restorative staff, review of CAA (care area assessment) information, and review of R3's personal care card showed conflicting information as to whether R3 was a 1 person or 2 person assist with transfers. R3's personal care card was not descriptive in addressing transfers. The care card showed R3 was extensive assist with walker but did not address whether R3 needed 1, 2, or more staff assistance. Interview E4 (LPN - Restorative Nurse) on 8/8/12 at 3:40 p.m. noted E4 to say, "R3 was a 1 person assist with gait belt and contact guard assist, meaning the CNA should apply the gait belt to the resident and hold on to the back of the gait belt when the resident walks." Interviews with E7 (CNA) and E9 (Restorative CNA) on 8/16/12 at 12:55 p.m. and 1:30 p.m. noted both to say, "R3 is a 2 person assist transfer." E8 (CNA) stated, "I worked with R3 before he fell and he was a 2 person sit to stand mechanical lift transfer." During interview with E10 (Restorative CNA) on 8/16/12 at 1:45 p.m. E10 stated, "I believe R3 is a 2 person assist transfer, but according to the care card he is a 1 person assist transfer." E10 admitted with a 1 person assist transfer a gait belt is used and contact guard assist is used when the resident ambulates. As noted above, E5 (CNA) stated R3 was a 1 person assist transfer, but only needed assist with standing, no contact guard assistance with ambulation. Review of CAA (care area assessment) documentation dated 6/13/12 addressing ADL Functional Status showed "R3 requires extensive staff assist with ADL's and utilizes sit to stand for transfers." The CAA addressing Falls notes, "R3 requires use of sit to stand lift for all transfers with 2 staff assist." R3's plan of care addressing falls that was in effect on 6/28/12 (date of R3's fall) was requested from administrative nursing staff. No plan of care was given.

1. Based on observation, interview and record review the facility failed to cool 3 pork roasts in a manner to prevent food borne illness. This failure had the potential to place 133 residents (who receive oral diets) at risk for food borne illness. This failure resulted in an Immediate Jeopardy. Findings include: On 7/11/11, review of the facility's menus show that the lunch entree for 7/12/11 was Tender Caramelized Onion Pork Roast. At 11:45 AM, E35 (Morning Cook) stated that the pork roasts were in the process of being cooked. At 2:00 PM the cooked pork roasts were observed in the facility's freezer, on a cookie sheet, covered with aluminum foil. A paper label taped to the foil documented that the roasts were placed in the freezer at 1:30 PM, at temperature of 135F. At 3:50 PM, the temperature of the roasts was 90F. Temperatures were taken in the presence of E36 (Food Service Supervisor). When asked about her plan to cool the roasts to 41F in 4 hours, E36 said that she would cut the roasts into smaller pieces. In order to continue the monitoring of the pork roast the kitchen was entered at 7:35PM. E16 (diet tech) was present in the kitchen. E 16 was informed that the temperature of the pot roast prepared earlier in the day by E35, was going to be checked. E 16 went to the walk-in cooler and obtained a large pan containing the pot roast. On observation the large pan contained two smaller pans , each with two large pieces of meat that together made one whole roast. The two smaller pans were surrounded by ice. The contents were covered loosely with plastic wrap and carried a label that read: "Date prepared 7/ 11/11" "140 degrees- 1:30PM" "70 degrees- ____" "Date cooled 7/11/11" "70 degrees-______ 41 degrees-______" The only written entry on the label was the initial one (1:30PM). E16 was asked if he was going to take the temperature of the roast and he stated that he was not. He was then asked if there was a cook or someone else who was going to check the temperature. E16 stated that E20 the evening cook was there and she would return soon as she was out delivering snacks. Shortly after, E20 returned to the kitchen and was asked if she was ready to check the temperature on the roasts. E20 responded that she was not going to check the roasts, that they were the "day cooks food and that she did nothing with the day cooks food". E20 also confirmed that no one had left a message saying that the temperature needed to be checked on her shift. This food was to be served for lunch the next day 7/12/11. E20 further added that she " wouldn't check anything this late." The roasts were uncovered and the temperature of two of the four roasts were measured to be 48 degrees and 50 degrees at 7:42 PM. Further interview with E16 showed that he had been present in the kitchen at 11:30AM. E16 stated that he knew that 1:30PM was the time the roasts were put into the freezer. He further stated that:" E35 (the cook) must have cooked it about 10:30AM because when I got here at 11:30AM it was already cooked." E 16 also said the roasts were on a cart, they were taken out during tray line. E16 was asked if he checked the temperature before placing it in the freezer. He responded that he had not. E16 was asked to make a copy of the label on the roasts. When he returned with the copy, E16 stated to E20 that the Administrator had said that they would need :"to toss it (the roasts) since it's not at the right temperature." On 7/12/11 at 10:30 AM, E35 stated that the Pork Roasts were cooked on 7/11/11, He said that he checked the temperature of the roasts and they were 165F and turned off the oven. E35 further stated that he took the pork roasts out of the oven at 10:10 AM, placed them in a flat pan and after wrapping the pan with aluminum foil, set it on the food preparation table. At 11:50AM, he told E40 (Dietary Aid) to put the pan into the walk -in cooler. E35 also stated that he did not communicate the need for checking the temperature of the roasts to E20 (Night Cook). At 10:45 AM E40 said that he placed the pan containing the roasts into the walk-in cooler. He further stated that he did not check the temperature of the roasts. At 10:50 AM E16 said that he placed the pan containing the pork in the freezer at 1:30 PM. He also admitted that he did not take the temperature of the roasts. An Immediate Jeopardy (IJ) was identified on 07/12/11 at 3:00 PM The Immediate Jeopardy was determined to have begun on 07/11/11 at 7:42PM when the facility failed to cool the pork roasts to an internal temperature of 41F within 6 hours after cooking. The facility's Administrator was informed of the Immediate Jeopardy on 7/12/11 at 3:30 PM. Surveyors confirmed through record review and staff interview that the facility took the following actions to remove the immediate jeopardy. 1) The pork roasts were discarded at on 7/11/11 at 8:30 PM. 2) The facility conducted in-services on 7/12/11, about proper cooling of potentially hazardous food citing a completion date of 7/14/11, when all dietary staff was to be in serviced. In addition the facility stated that this educational training will be ongoing until the staff has passed a written competency exam with a 100% pass rate. Documentation presented by the facility indicated that by 1/14/11, all 15 dietary staff members had successfully passed the competency exam. 3) The facility reviewed the rapid cooling and procedural guidelines with the dietary manager and cooks. 4) Dietary Consultant/Designee will review and monitor on a daily basis the food service rapid cooling record to monitor critical control points during the cooling process and documentation of the procedural protocols. The cook will be responsible for documenting on food service cooling record the time and the temperature during the cooling process.... 5) Dietary Consultant/Designee will conduct 1:1 written competency with food service manager dietary aides and cooks to ensure they are knowledgeable about the rapid cooling...within three days of hiring, annually and as needed. 6) Administrator/Designee will conduct random audits beginning on 7/14/11 3-5 x/week to ensure facility policies and procedures in relation to rapid cooling of food is being adhered to at all times... 7) Quality Assurance Committee will review audit tools for the Food Service Rapid Cooling Records at the Monthly QA meting and report findings for review.... On 7/13/11 surveyors interviewed E16, E35, E39, E40 and E41 on 7/14/11. On 7/13/11 at 11:15 AM E35 was unable to tell the surveyor the protocol for the rapid cooling of food. 15 minutes later an additional surveyor also interviewed E35. E35 was unable to state the procedures for rapid cooling of food and additionally stated that he does not document food temperatures. The surveyors presented this information to E1 during the daily status meeting at 5:30 PM on 7/13/11. On 7/14/11 the facility amended its plan of action for removal of the immediate Jeopardy by documenting that E35 will fill the position of dietary aide until such a time that he is able to successfully demonstrate competency in rapid cooling of food..... On 7/15/11 the facility further amended its action plan to state that "E35 will be removed effectively from Chateau Nursing and Rehabilitation Center dietary schedule until he has successfully passed all competency exams (Rapid Cooling Exam, Handling Food Safely, and Food Borne Pathogens). While the Immediate Jeopardy was removed on 7/15/11, the facility remains out of compliance at a severity level 2 as E35 has not completed and passed all competency exams nor has demonstrated competency in the rapid cooling of food. Additionally, the facility will not be serving products that require rapid cooling methods until 7/31/11, 8/3/11 and 8/6/11. 2. Based on observation, and interview, the facility to ensure that the dishwashing machine was sanitizing dishes and tableware, thaw food in a manner that prevents potential cross contamination, air dry dishes and plates after washing and sanitizing, ensure that hand soap and hand sanitizers are not empty, keep food that does not require cooking separate from from soiled utensils/dishes, provide a means to keep foods and nutritional supplements at the appropriate temperature , and clean the floor-wall junctures of the walk-in cooler. Findings include: - On 7/11/11, at 10:15AM, the facility's chemical dishwashing machine was not delivering enough chemical to sanitize tableware and dishes. Surveyor checked the sanitizer level with a chlorine test strip. The strip did not turn from white to blue, indicating that no chlorine was present in the water used to sanitize the dishes. In addition, the surveyor used a test strip to check a wet spot on a plate that just came out of the dish machine and again, there was no color change in the test strip. On the wall of the dish machine room was sanitizer monitor log. There was no documentation about the sanitizer levels for 7/8, 7/9 and 7/10/11. E36 (Food Service Supervisor) stated that the sanitizer levels should be checked at the time the dishwashing is started. E40 (Dishwasher) told the surveyor that he checks for proper operation of the dish machine by visual inspection, and checking the container of chlorine to be sure it is not empty. He further stated that he had changed the chlorine prior to the starting the dishwasher on 7/11/11, but does not check the concentration of chlorine with a test strip. - At 12:50 PM, 2 plastic bags of cubed turkey were thawing in cold standing water in a food preparation sink. E36 acknowledged that this procedure was incorrect, and that this food should be thawed under cold running water. - At 10:45 AM 23 of 27 plates stacked in the spring-loaded plate holder were wet, suggesting that they were not dried prior to stacking. Additionally 1 of these plates had dried food debris. - At 10:00 am, the soap dispenser located by the dish washing area was empty. On 7/12/11, at 10:25AM, the hand sanitizer dispenser located by the entrance to the kitchen was empty. - On 7/12/11 at 6:55PM (after the evening meal was served), a partial used head of leaf lettuce and slices of tomatoes were uncovered and directly in contact on counter along with a used soiled knife, a soiled colander, a dirty bowl and 2 soiled platters.. - An uncovered metal pan of approximately 50 cooked fish nuggets was placed on a soiled food cart by the dirty dish room. There were no means to either cool this food nor to keep it warm. Z5 (Dietary Consultant) asked E20 (cook) what she was going to do with this food. E20 replied "I don't know". Z5 then instructed E20 to discard the food - On 7/14/11 at 11:18 AM, on top of the medication cart #1, a carton of Nutritional Supplement ( high in Calorie and high in Protein) was observed placed inside a clear plastic container without a refrigeration source. The Nutritional supplement was opened dated 7/14/11. According to E28 (nurse) he opened the supplement at 10:00 AM for medication pass and will use the remaining supplement for the next medication pass. The Nutritional supplement label indicated, "Reseal & Refrigerate unused beverage." The storage & handling instructions indicated, "Refrigerate after opening." Using a facility thermometer, the temperature of the supplement was obtained and registered at 66.8 degrees Farenheit. E1 who was present during this observation told E28 to dispose of the nutritional supplement, after the temperature was obtained. - While observing the Walk-In cooler in the kitchen, at 10:30AM the, floor-wall junctures (both accessible and under the shelves) were soiled with dried food debris. - On 7/14/11 at 11:18 AM, on top of the medication cart #1, a carton of Nutritional Supplement ( high in Calorie and high in Protein) was observed placed inside a clear plastic container without a refrigeration source. The Nutritional supplement was opened dated 7/14/11. According to E28 (nurse) he opened the supplement at 10:00 AM for medication pass and will use the remaining supplement for the next medication pass. The Nutritional supplement label indicated, "Reseal & Refrigerate unused beverage." The storage & handling instructions indicated, "Refrigerate after opening." Using a facility thermometer, the temperature of the supplement was obtained and registered at 66.8 degrees Farenheit. E1 (Administrator) who was present during this observation told E28 to dispose of the nutritional supplement, after the temperature was obtained.