Every finding on record at Citadel at Saint Benedict

Based on observation, interviews and record reviews, the facility failed to follow policy related to use of three-compartment sink; failed to maintain normal range of chemical concentration in the sanitizer buckets; and failed to properly label and date leftover foods in the refrigerator. These deficiencies potentially affect the 86 residents receiving foods in the kitchen. Findings include: Per census report, facility has 88 residents currently residing in the facility. Two residents are currently on NPO (nothing by mouth). On 05/27/25 at 9:55 AM during initial brief tour in the kitchen, the following leftover food items placed in a bowl covered with plastic, unlabeled, were observed stored in the walk-in refrigerator: drained pineapple - dated 05/21; apple sauce - dated 05/24; dried peas - undated; peaches - dated 05/21; cream of mushroom - dated 05/21. There was also a sandwich with lettuce and tomato unlabeled and undated, which was observed inside reach - in cooler. Subsequently, red sanitizer buckets were also checked. V4 (Account Manager Food Services) stated that red buckets are used to wipe counters after food preparation. Normal chemical solution range between 200-400 ppm (parts per million) per sanitizer chart. Facility was using ammonium chloride as chemical sanitizer. V4 used a sanitizer strip and dipped into the sanitizing solution in red bucket number one. The strip read 0-100 ppm per color chart in the strip dispenser. Bucket number two was also tested using a new sanitizer strip, giving a reading of 100 ppm. On 05/27/25 at 11:45 AM during a follow up visit in the kitchen, the three-compartment sink was observed with soiled pots, pans, utensils and kitchen wares stored in the first, second and third sinks. The three-compartment sink was not filled with water. V5 (Dietary Aide) was observed scrubbing and washing pots and pans in the sink. V5 removed food debris from the pots and pans by scrubbing then rinsing and washing it with water directly from the gray hose. Afterwards, the pots and pans were placed inside the dish machine. V5 stated, We don't fill the sanitizer sink with water. We use the gray hose and use the water directly to rinse the pots and pans. Sometimes I use the third sink if I have time. But today, I just came in and I just used the dish machine. It was observed that the gray hose is connected to detergent. The sanitizer hose is not connected to the gray hose. On 05/28/25 at 1:32 PM, V6 (Dietary Manager) was interviewed regarding left over foods. V6 replied, If the food items are not in their original packages, they are left over foods. The left over foods are good for three days. If food items are in their original package, then they are good for 7 days. All food items should be labeled and dated. Left over foods with no dates should be thrown out. V6 was also asked regarding red sanitizer buckets and three compartment sink. V6 stated, Red sanitizer buckets are used to disinfect surface of the work area to prevent cross contamination, kills germs and bacteria. By using the 3- compartment sink, the third sink should be filled with water and sanitizer, and this is where we get the sanitizing solution for the red buckets. Upon testing the water, it should give the correct amount of chemical concentration - we are using quat, should be between 200-400 ppm. Also, the 3-compartment sink should be used all the time to clean and wash pots and pans, to prevent cross contamination. The first sink is filled with soap and water, the second sink is filled with water and the third sink is filled with sanitizer. The 3-compartment sink is what we will be using everyday but right now, it does not hold the water in the second and third sinks. The plugs are loose unable to hold the water for long time. It had been a couple of weeks since it stopped working. The first sink was fixed a week ago. The work order had been requested. Facility presented work order request #2481 dated 03/31/25 showing 3 compartment sink plugs were ordered. There was no work order request to fix the three-compartment sink. There was also no work order receipt that the first sink was fixed a week ago. Facility's policy titled Food Storage, undated, documented in part but not limited to the following: Policy: Sufficient storage facilities will be provided to keep food safe, wholesome, and appetizing. Food will be stores in an area that is clean, dry and free from contaminants. Food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Procedure: 12. Refrigerated food storage: f. All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. Facility's policy titled Food Safety and Sanitation, dated 2014 stated in part but not limited to the following: Refrigerated Storage: All leftovers should be labeled and dated. Leftover food should be used or discarded within 72 hours of preparation. Facility's policy titled Cleaning Instructions: Cloths, Pads, Mop and Buckets, undated, documented in part but not limited to the following: Policy: Cleaning tools will be maintained in clean, fresh, odor-free condition. Procedure: a. Cleaning cloths should be kept in a container of clean sanitizing solution between uses. b. The sanitizing solution will be tested periodically to assure that it maintains the correct concentration. Facility's policy titled Cleaning Instructions: Counter Space, undated, stated in part but not limited to the following: Policy: Counter space will be cleaned and sanitized prior to and following food preparation and meal service, and as needed. Procedure: 2. To sanitize: f. Store cleaning cloths in sanitizing solution between uses. Facility's policy titled Food and Nutrition Services Sanitation and Food Safety dated 2017 stated in part but not limited to the following: A test strip is used to accurately determine the concentration of the sanitizing solution. The strip is dipped into the sanitizing solution and held for the seconds specified on the test kit. Once removed from the sanitizing solution, the strip is compared to the color on the chart. If the color is not within the correct range, adjustment is made until the sanitizing solution is the correct concentration. Facility's policy titled Manual Sanitizing in Three-Compartment Sink dated 2021 documented in part but not limited to the following: Policy: A sink with three-compartments is used for manually washing, rinsing and sanitizing utensils and equipment that can be submerged. It may also be used for tableware. Procedure: Manufacturer's instructions on the wall poster above the three-compartment sink are followed. Food soil is scraped off utensils or equipment into a waste receptacle before being placed in the first sink. Utensils or equipment are washed in the first sink with a pad or brush in a solution of soap, detergent or other cleaning agent. The temperature of the washing solution is no less than 110F or the temperature specified on the cleaning agent manufacturer's label. Utensils or equipment are thoroughly rinsed in water in the second sink. After washing and rinsing utensils and equipment are sanitized in the third sink by immersion in either: Hot water (at least 171F for thirty seconds) or Chemical sanitizing solution used according to manufacturer's instructions. The most common chemical sanitizers are chlorine, iodine and quaternary ammonia. In determining the correct concentration of the sanitizing solution and the length of immersion time, manufacturer's instructions are followed. Testing procedures for Quaternary Sanitizer: 1. Make sure you select the correct test paper for the sanitizer being used. 2. Testing must be done in sanitizer solution that is clean, fresh and at room temperature. 3. Make sure there is no foam on the solution surface before testing. 4. Tear off a 1 1/2 - 2-inch strip of test paper. 5. Hold the test strip in the solution for 10 seconds. 6. Do not move the test paper around, as this will give a false high concentration reading. 7. Remove test strip from solution. 8. Hold test strip up against the color chart on the side of the test strip container. Always refer to the color range on the QT-10 test kit for accurate color matching of strips. 9. The correct reading must be 200-400 ppm. If the solution test does not meet the 200-400 ppm requirements, test again. Take corrective action if the reading remains out of range. 10. Record the solution concentration reading on the appropriate log.

Based on observation, interview and record review, the facility failed to provide appropriate and sufficient supervision for a cognitively impaired resident (R45) with a history of falls, reviewed out of a sample of 39 residents. This failure resulted in R45 falling from her wheelchair and hitting her face against the floor, resulting in an injury of abrasions to her forehead. The facility also failed to properly assess R45 for injury and failed to send her to the hospital for evaluation after the incident. Findings include: R45 is a [AGE] year-old cognitively impaired female resident, with medical diagnosis including but not limited to dementia; cognitive communication deficit; unsteadiness on feet; abnormal posture; pain in left hip; and spinal stenosis, cervical region. R45's high risk for falls care plan, dated 05/06/2025, does not address constant close supervision, based oh her history of falls. R45's Fall Risk Assessment, dated 05/26/2055 indicates no falls in the past three months. Per R45's electronic health record, she had a fall on 04/29/2025. R45's MDS, dated [DATE], Section C, Cognitive Patterns, indicates R45 is severely impaired in cognitive skills for daily decision making. R45's MDS, dated [DATE], Section GG, Functional Abilities, indicates R45 is only capable of providing less than half the effort to stand from a sitting position in a wheelchair. On 05/27/2025 at 12:44 PM, this Surveyor observed R45 sitting in a wheelchair, about ten feet from the nurse's station; with what appeared to be a reddish, moist, bloody abrasion on her forehead, about two inches in diameter. On 05/27/2025 at 1:59 PM, R45 told this Surveyor that she fell and her head still hurt. On 05/29/2025 at 10:36 AM, during interview of V18 (CNA) this Surveyor was informed that on 05/26/2025, at about 7:30 PM, V18 was working in another room, about three rooms from the end of the hall, caring for a resident, and was about to leave the room holding linens and trash, when she heard a loud thud, which sounded like something hitting something else, hard. V18 said she, then, looked outside the room and saw R45 by the nurse's station, lying face down on the ground. V18 said she immediately dropped the linens and trash, looked for V20 (Agency Nurse), saw him with his med cart right, and ran towards R45, with V20 running just behind her. V18 said that once she got to R45, she saw R45's wheelchair by the wall, in front of the nurse's station, and R45 lying face down, about four steps from her wheelchair. V18 said it was standard procedure for staff to be with residents that were fall risks by the nurse's station, but noticed the nurse's station empty. V18 said she believed R45 was the only resident stationed at the nurse's station at that time. V18 said R45's assigned CNA, V14, was at another hall caring for another resident when R45 fell. V18 said that, at the count of three, she and V20 slowly log rolled R45 over in order to assess her. V18 said V20 stayed with R45, while she went to get a facility nurse on the first floor for help. V18 said she, then, spoke to V2 (Director of Nursing) over the phone, then passed V20 the phone, so he could speak to her. V18 said there was blood on R45's forehead, so she got a towel, soaked it in water, placed it on her forehead, then placed an ice pack, and let the nurses handle the matter, while she returned to her residents. V18 said R45 required constant monitoring. On 05/27/2025 at 1:52 PM, during interview of V14 on 05/26/2025 at about 7:30 PM, V14 stated that she was in a room at another hall caring for a resident when R45 fell. V14 said no one was at the nurse's station at that time because everyone was doing things. V14 said V18 told her she heard the fall from down the other hall, and that two nurses assessed R45 after she fell. On 05/29/25 at 1:13 PM, during interview of V20 on 05/26/2025 at about 7:30 PM, V20 stated that he was at the nurse's station charting while observing R45, when he noticed R45 standing up. V20 said he asked R45 to please sit down, but could not get to her in time before she fell because she was too far. V20 said he assessed R45, noticed a little redness on the forehead, iced her forehead, and, per V19 (Medical Director), initiated neuro checks, and continued to monitor her. V20 said R45 fell kind of face down and rolled over, and had a little bit of blood on her forehead, which he cleaned with saline water and a gauze cloth, and placed icing on her forehead. V20 said he told V19 that R45 had hit her head on the floor, she had no loss of consciousness, her vitals were stable, and was bleeding, but was not on blood thinners. On 05/28/2025 at 11:35 AM, during interview V2 said R45's care plan called for close observation and physical and occupational therapy for strengthening and balance, since R45 liked to just get up. V2 said that on 05/26/2025 at about 7:30 PM, R45 was in direct view of one of the staff. V2 said she was told that when R45 fell, V20 was at the nurse's station standing with his cart preparing his medications. V2 said staff called her after R45 fell. V2 said she asked V20 if he was able to visualize R45, and he replied that he was at the nurse's station and that she fell. V2 said she did not ask V20 how he was able to see R45 fall while preparing his meds. V2 said V18 heard R45 fall. On 05/29/2025 at 12:39 PM, V2 said she believed R45's fall may have been caused by either R45 trying to self-transfer or it was behavioral in nature; and if it was behavioral, they would have to create a care plan for it. V2 said if R45 had been sent to the hospital, and an injury, such as a subdural hematoma, a fracture, or a laceration requiring sutures had been discovered, then the facility would have sent an initial report to the State; but since R45 was not sent, they did not notify the State. When this Surveyor asked V2 how she determined R45 had no fracture from the fall without x-rays, V2 said V19 did not order x-rays for R45 after speaking to V20, only neuro checks and monitoring. V2 said she did not know if V20 completed an SBAR. V2 said she did not believe V20's fall risk assessment for R45 was accurate because she was a high fall risk, yet V20 had graded her an 8, when the previous reports were 12 and 13. V2 said the lower the number was on the assessment, the lower the risk was for falls. V2 said the staff knew who the people were that needed closer observations, and were kept nearby. V2 said R45 was within visual proximity of staff, pretty much all the time. When asked by this Surveyor what distance was no longer an effective distance for staff to supervise a fall risk resident, V2 said, I can't be down the hall and say I have a visual and successfully intervene. On 05/28/2025 at 11:35 AM, V3 (Restorative Nurse/Fall Coordinator/LPN) said that, according to a supervisor that told her, on 05/26/2025 at about 7:30 PM, R45 stood up, lost her balance, and fell to the floor, hitting her forehead on the floor at the nurse's station, within view of V20, who was preparing medications at the time. V3 said R45 was a high fall risk according to her assessments. V3 said R45's only injury after her fall was an abrasion to her forehead; so, she was not sent to the emergency room by the doctor. V3 said there were no fall precautions from R45's care plan implemented at the time of her fall, other than being within view of the nurse. V3 said R45 had a previous fall on 04/29/2025. On 05/29/2025 at 11:46 AM, V3 said major injuries could be discovered by either being visible to the facility staff or by the resident being hospitalized and major injuries discovered there. V3 said that V20 told V19 that R45 only had scrapes; so, no x-rays were ordered, just 72-hour neuro checks. When the Surveyor asked V3 what the best procedure to prevent a fall for R45 was, V3 said, I'll get back to you on that. On 05/28/2025 at 1:15 PM, during interview V16 (CNA) stated R45 had dementia and would suddenly stand up from her wheelchair. V16 said R45 was typically calm, but sometimes would think she was at home and needed to do stuff. V16 said she was sitting next to R45 by the nurse's station because that is what V2 and her nurse would tell her she had to always do, and that she was well aware. V16 said even if it was a single resident on a wheelchair stationed by the nurse's station, that resident would have to be supervised by having staff sit alongside them or being near them and keeping an eye out for them. A progress note from 05/26/2025 at 9:54 PM by V20 states, Patient was in wheelchair and stood up and then lost balance and fell, hit forehead on ground, and some minor scrape occurred on middle of forehead. Neuro checks started. MD and DON informed. POA notified.

Based on observations, interviews, and record review the facility failed to administer medications per physician's orders for two of five (R24, R61) residents observed during the medication pass in the final sample of 26. There were 29 opportunities with 4 errors resulting in a 13.79% medication error rate. Findings include: R24 is a [AGE] year-old admitted to the facility on [DATE] with diagnosis including but not limited to Heart Failure; Gastro-Esophageal Reflux Disease Without Esophagitis; Hereditary And Idiopathic Neuropathy; Hypertensive Heart Disease With Heart Failure; Personal History Of Covid-19; Presence Of Intraocular Lens; Ocular Hypertension, Right Eye; Nonexudative Age-Related Macular Degeneration, Bilateral; Personal History Of Other Malignant Neoplasm Of Rectum, Rectosigmoid Junction, And Anus; Polyneuropathy; Unspecified Atrial Fibrillation; Anemia In Neoplastic Disease; Essential (Primary) Hypertension; and Major Depressive Disorder. R61 is a [AGE] year-old admitted to the facility on [DATE] with diagnosis including but not limited to Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety; Asthma; Other Lack Of Coordination; Other Reduced Mobility; Protein-Calorie Malnutrition; Acute On Chronic Diastolic (Congestive) Heart Failure; Essential (Primary) Hypertension; Paroxysmal Atrial Fibrillation; Major Depressive Disorder; Hyperlipidemia; Gastro-Esophageal Reflux Disease Without Esophagitis; Retention Of Urine; and Adjustment Insomnia. 1. On 05/27/25 at 11:23 AM Surveyor observed V10 (Licensed Practical Nurse) administering medications to R24. V10 (LPN) administered: 1. Ferrous Sulf (Sulfate) Tab (tablet) (Iron) 325 MG (milligrams) EC (enteric coated) Give 1 tablet by mouth two times a day related to Anemia in Neoplastic Disease due at 9:00 AM and 5:00 PM. 2. Furosemide (Diuretic) 20 MG TABS Give 1 tablet by mouth two times a day related to Heart Failure due at 9:00 AM and 5:00 PM. 2. On 05/27/25 at 11:35 AM Surveyor observed V10 (Licensed Practical Nurse) administering medications to R61. V10 (LPN) administered: Carvedilol (Antihypertensive) Tablet 12.5 MG Give 1 tablet by mouth two times a day for Hypertension due at 9:00 AM and 5:00 PM. Furosemide Tablet 40 MG Give 1 tablet by mouth two times a day for stroke due at 9:00 AM and 5:00 PM On 05/27/25 at 11:45 AM V10 (Licensed Practical Nurse) said, It took me a long time to give medications to one previous resident. Also, R24 likes to take his medications later. I also have to check all residents' vital signs and I have 30 residents in my assignment. There is no documentation in R24's and R61's electronic medical chart to show delayed medication administration or physician notification. On 05/29/25 at 12:32 PM V2 (Director of Nursing) said, It is important to administer medications within scheduled time because medications treat residents' conditions/diseases in a timely fashion. There are parameters and time limits when medications have to administered, especially medications scheduled to be administered multiple times a day. Medications work effectively when they're administered within timely manner. I think, based on the pharmacy policy, the time frame is two hours before and two hours after the schedule time. R24's physical order dated 07/29/2024 reads in part, Ferrous Sulfate Tab 325 MG EC Give 1 tablet by mouth two times a day related to Anemia in Neoplastic Disease. R24's physical order dated 01/17/2025 reads in part, Furosemide 20MG TABS Give 1 tablet by mouth two times a day related to Heart Failure, Unspecified. R61's physical order dated 01/28/2025 reads in part, Carvedilol Tablet 12.5 MG Give 1 tablet by mouth two times a day for Hypertension. R61's physical order dated 01/28/2025 reads in part, Furosemide Tablet 40 MG Give 1 tablet by mouth two times a day for stroke. The facility Administering Medications policy last reviewed 11/2020 reads in part, Medications shall be administered in a safe and timely manner, and as prescriber. Medications must be administered in accordance with the orders, including any required time frame that is indicated specifically in the order by the physician. The pharmacy UnitedRX Policy and Procedure Manual 2024 read sin part, 5.1: DRUG ADMINISTRATION - GENERAL GUIDELINES. Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered precisely as ordered. Unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule for the facility. If a dose of regularly scheduled medication is withheld, refused, or given at other time than the scheduled time, the MAR should reflect documentation as to the reason medication could not be administered.

Based on interview and record review, the facility failed to develop and implement individualized plan of care interventions to reduce the risk of injury from falls. This failure affects two of four residents (R1, R2) reviewed for falls. These failures resulted in R1 being left unsupervised in the dining room and was later observed on the floor with an abrasion to the head. R1 was sent to the hospital and diagnosed with three compression fractures of the thoracic spine. These failures also resulted in R2 rolling out of bed, landing on R2's buttocks on the floor, and was subsequently diagnosed with a left comminuted hip fracture. Findings include: The facility's policy titled accidents and incidents: supervision, investigating and reporting dated 11/2023 denotes in-part the facility provides an environment that is free from accident hazards over which the facility has control. The facility provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes identifying hazard and risk, evaluating and analyzing hazard and risk, implementing intervention to reduce hazard and risk monitoring for effectiveness and modifying interventions when necessary. The facility's policy titled Fall management dated 2013 denotes in-part based on previous evaluation and current data the staff will identify interventions related to the residents' specific risks and cause to try to prevent the resident from falling and try to minimize complications from falling. This policy documents potential fall prevention interventions including, tab alarm for chairs, pad alarm for chairs, wedge cushions, dropping the wheelchair seat, anti-roll back device, anti-tippers for front and or back of wheelchair, pad alarm for the bed, low bed, floor mat beside the residents bed, scoop mattress, half side rails, non-skid socks, bedside commode, urinal at bedside, and frequent toileting. 1. R1's face sheet shows R1 has diagnosis of hemiplegia and hemiparesis following cerebral infraction affecting left non-dominant side, lack of coordination, cognitive communication deficit, other reduced mobility, muscle weakness, wedge compression fracture of first thoracic vertebra, wedge compression fracture of second thoracic vertebra, wedge compression fracture of third thoracic vertebra, adjustment disorders with depressed mood, unspecified dementia, glaucoma, history of falling. R1's Minimum Data Set (MDS) dated [DATE] section C for cognitive patterns shows BIMS (Brief Interview of Mental status) score of 2 (cognitive impairments.) R1's care plan dated 9/27/24 denotes R1 is at risk for falls r/t (related to) confusion and episodes of dizziness. R1 will have no major injuries r/t falls through next review. Interventions: assist resident with ambulation and transfers, utilizing therapy recommendations, determine resident ability to transfer, evaluate fall risk, dycem to chair, invite to participate tin group activities, resident up in chair for meals, encourage not to sit at edge of bed for meals. The facility's final report to the department dated 10/24/24 denotes R1's diagnoses including unspecified injury of head, cerebral infract, hemiplegia and hemiparesis following cerebral infract, abnormalities of gait and mobility, generalized weakness, unspecified dementia with psychotic disturbance, history of falling. the resident stood and attempted to walk after her family left visiting her and she fell . She stated she was going home. The resident was sent to the local emergency department where R1 was evaluated and diagnosed with a closed fracture of the thoracic vertebral body. The resident may have tripped on the leg rest when she got up from the chair. The resident most likely had increased confusion due to a urinary tract infection and seeing her family most likely triggered her to want to go home to join them. On 1/21/24 at 11:41am V1 (CNA-certified Nursing Aide) said he was monitoring the dining room on 10/20/24 after lunch. V1 said his assigned (unidentified) resident needed to go to the rest room and he escorted the resident to the restroom. V1 said he told an unidentified female aide to monitor the dining room, while he assists his resident. V1 said he thinks he yelled that out to someone. V1 said he didn't wait for the aide to come and monitor the dining room before he left the dining room. V1 said he don't know if the aide went to monitor the dining room. V1 said he didn't ask the Nurse to monitor the dining room before he left the residents alone. V1 said he was made aware that R1 had a fall and another staff found R1 on the floor in the dining room. V1 said the purpose of monitoring the dining room is to assist the resident that may need help, get water, to watch the resident that may try to get up, monitor the residents that are at risk for falling and to take care of the resident's needs. On 1/21/25 at 11:30am V4 Licensed Practical Nurse (LPN) said she was summoned to the dining room and she observed R1 laying on the floor on her back, the wheelchair was not far from R1. V4 said she assessed R1's level of consciousness and R1 had an abrasion to R1's head. V4 said she called 911 to escort R4 to the hospital. V4 said V1 did not ask her to monitor the dining room when he left the dining room. V4 said she don't recall R1's family visiting. On 1/21/25 at 11:56am V5 (Director of Nursing) said she completed the fall investigation for R1. V5 said R1 was at risk for falls, R1 had prior history of falls. V5 said the root cause of R1 fall on 10/20/24 was that R1 was confused, wanted to go home, and she stood up from her wheelchair and fell . V5 said there was no staff in the dining room to intervene/assist when R1 stood up from her wheelchair. V5 said the dining room was not being monitored when R1 fell . V5 said R1 had a BIMS score of 2 (cognitive impairments), poor safety awareness, dementia, and history of stroke. R1's fall risk assessment dated [DATE] denotes R1 is alert and oriented x3, and no is checked for predisposing condition. V5 said R1's fall risk assessment is not accurate because it does not capture all of R1's fall risk factors. V5 said the nursing staff needs more training on documentation. 2.R2's face sheet shows R2's diagnoses including fracture of left pubis ramus, aphasia following cerebral infraction, need for assistance with personal care, unspecified dementia and repeated falls. On 1/17/25 at 12:30pm V3, Registered Nurse (RN) said he was doing resident rounds and observed R2 rolling out of bed, V3 said he was able to hold R2 upper body but R2's buttocks landed on the floor. V3 said R2 was squirming/moving about in the bed. V3 said he don't recall a floor mat in place at the time of that fall next to R2's bed. V3 said the bed was lower, but not in the lowest position to the floor. V3 said he could not recall if it was reported to him that R2 had a current pelvic fracture. V3 said R2 denied he was in pain. V3 said he don't know why R2 was moving around in bed. V3 said R2 was not self-transferring when he fell as documented in the incident report and V3 does not know who documented that R2 was self-transferring when R2's fall occurred on 12/27/24. On 1/17/25 at 1:17pm V5 (Director of Nursing) said she completed the investigation for R2's fall on 12/27/24. V5 said R2 is at risk for falls and R2 was admitted for rehabilitation after falling at home. R2 had a pubic ramus fracture upon admission. V5 said she doesn't recall inquiring about R2's previous fall with R2's family. V5 was asked if there were interventions in place to reduce further injury for falls for R2. V5 said R2's interventions were for the bed to be in lowest position, call light in place, call don't fall was to be in place when R2 returned from hospital after the fall. During a follow up interview V5 said putting the bed in the low position was not an effective intervention in reducing further injury for R2. V5 said the root cause for R2's fall was that R2 overestimated his abilities. V5 said she made notations in R2 records of R2 was self-transferring based on V3's description when she interviewed V3. R2's hospital records dated 12/30/24 denotes R2's computed tomography (CT) scan of the pelvis shows a new comminuted displaced fracture of the left hip. R2's baseline plan of care (MDS Kardex Report) with admitted [DATE] denotes in-part short term memory; problem is checked, long term memory; problem is checked. Daily decision making; severely impaired is checked. Falls; major injury is checked, not steady during transitions/walking; moving from seated to standing, walking, turn around, surface to surface transfer are checked. V5 (Director of Nursing) presented the Minimum Data Set (MDS) Kardex report and identified the document as the baseline plan of care for R2. The intervention of bed in lowest position is not documented as an intervention on R2's base line or comprehensive plan of care. R2's radiology service report dated 12/30/24 denotes, a left hip with pelvis 2 views radiology exam was performed with findings of an acute fracture of the greater trochanter, and a questionable nondisplaced fracture of the left superior pubic ramus laterally. Impression: acute left greater trochanter fracture. On 1/22/25 at 11:30am V7 (Consultant) said the Kardex is not the baseline care plan, it is a tool used by the facility. V7 said she will follow-up to determine if a baseline care plan was initiated and developed. V7 said its not accurate that the facility does not use floor mats as a fall intervention. The facility's baseline care plan policy with dated 4/2017 denotes in part a baseline plan of care, to meet the residents' immediate needs shall be developed for each resident with within 48 hours of admission. To assure the resident immediate care needs are met and maintained, a baseline care plan will be initiated within 8 hours and completed within developed within forty-eight hours of the resident's admission. The interdisciplinary team will review the healthcare practitioners' orders and implement a baseline care plan to meet the resident immediate care needs including but limited to, initial goals based on admission orders, physician orders, dietary orders, therapy orders, social services and additional recommendations, if applicable.

Based on interview and record review the facility failed to administer pain medication as ordered by the physician for one of one resident (R2) reviewed for pain management. Findings include: R2's physician order sheet dated 12/27/24 shows orders for acetaminophen (Pain Relief/Antipyretic) tablet 325mg (milligrams) give 2 tablets by mouth every six hours as needed for pain, fever. Norco (Pain Relief) oral tablet 5-325mg, give one tablet by mouth every 8 hours as needed for pain. On 1/17/25 at 12:30pm ,V3, Registered Nurse (RN) said R2 was moving around in bed when R2 had a fall from R2's bed on 12/27/24 around 3:30pm. V3 said he did not recall the nurse reporting to him that R2 was admitted with a pubis ramus fracture. V3 said R2 did not have pain upon assessment. V3 said he did not administer pain medications to R2. R2's pain level summary denotes in-part on 12/27/24 at 8:07am R2's pain level was 5, on 12/27/24 at 3:46pm R2's pain level was 4, on 12/27/24 at 9:35pm R2's pain level was 4, at 9:36pm R2's pain level was 1 and at 9:37pm R2's pain level was 4. R2's medication administration record does not document administration of pain medication for R2 during episodes of pain above.

Based on observation, interview, and record review the facility failed to ensure a resident was free from abuse for 1 of 3 residents (R3) reviewed for abuse in the sample of 6. Findings include: R3's Facesheet dated 1/4/24 showed she had diagnoses to include, but not limited to: metabolic encephalopathy; lack of coordination; abnormalities of gait and mobility; repeated falls; spinal stenosis; unspecified adrenocorticoid insufficiency; congestive heart failure; chronic kidney disease (stage 3A), major depressive disorder; anxiety; and a history of falling. R3's facility assessment dated [DATE] showed she was cognitively intact. R3's Skilled Nursing Evaluation dated 12/15/24 showed she was alert and oriented to person, place, and time; communicated verbally; speech was clear; and was able to understand and be understood. R3's Care Plan initiated 10/21/24 showed, R3 is at risk of possible abuse/neglect related a history of abuse. The interventions included, but were not limited to: Provide me with physical/emotional safety by developing a trusting therapeutic relationship with me. On 1/4/24 at 12:51 PM, R3 was sitting up on the edge of her bed. R3 said she fell (12/18/24) when she tried to take herself to the bathroom. R3 said she wasn't sure exactly how she fell but remembered being on the floor and trying to scoot towards the bed to reach her call light. R3 said she couldn't stand herself up, nor could she reach the call light, so she yelled for help. R3 said V17 (CNA - Certified Nursing Assistant) responded. R3 said V17 came in and said, Oh my, I'm going to need some help to get you up. R3 said V17 left and returned with V18 (RN - Registered Nurse). R3 said as soon as V18 (RN) walked into the room he was questioning her, in a loud, accusing tone. R3 said V18 wouldn't let up and he said, It's my fault, I should have used the call light. R3 said V18 continued to stand over her and scold her like a child. R3 said she was still on the floor. R3 stated, It was so embarrassing, and [V17 -CNA] witnessed the entire thing. [V17] was even getting mad at [V18] and told him not to talk to me like that. R3 said she was on the floor 8-10 minutes with V18 (RN) standing over her and aggressively questioning her and stating, This shouldn't have happened. R3 said she finally snapped and said, Listen A******! I'm already on the floor. I didn't use the call light and fell and I couldn't get myself up. R3 said she told V18 that she wanted to get off the floor. R3 said that stopped the loud questioning, but she was in tears and upset because it went on for a while. R3 said V17 (CNA) and V18 (RN) were having a disagreement in front of her while V18 (RN) was assessing her. R3 said V17 and V18 assisted her into the wheelchair, then another nurse came in, but she didn't know her name. R3 said she was very nice and had both V17 (CNA) and V18 (RN) leave the room and she helped her calm down. R3 said V1 (Administrator) talked to her on 12/19/24 and she told V1 what she told the surveyor. R3 said V1 told her that he was going to make sure that V18 (RN) didn't have any further contact with me. The facility's Final Reportable to IDPH dated 12/23/24 showed, R3 reported that V18 (RN) spoke inappropriately to her last night. R3 reported that V18 spoke to her in an aggressive manner when responding to her call for assistance after she fell when attempting to go to the bathroom on her own. This report showed V18 reported questioning why R3 tried to get up on her own. R3 became upset with the line of questioning and stated that he should not blame her for the fall. V19 (RN) said she went into R3's room to assist V18 and noticed R3 was upset. V19 asked V18 to leave the room and helped calm R3. This report showed, [R3] stated that [V19-RN] helped calm her down but felt that [V18] was questioning her in an aggressive tone regarding why she (was) attempting to toilet herself. On 1/4/24 at 2:17 PM, V18 (RN) said R3 had a fall on his shift (12/18/24). V18 said he has an accent and some people think that he talks loud. V18 said R3 was found on the floor by the CNA (V17). V18 said V17 alerted him and told him to call female nurse to assist me. V18 said he called V19 (RN) for assistance, then headed to R3's room. V18 said V17 was already in R3's room. V18 said he was surprised to see R3 on the floor like that and he may have seemed loud because he was surprised. V18 said he was just asking R3 questions to determine the cause of the fall. V18 said V17 (CNA) and V19 (RN) were in the room with him and R3. On 1/4/24 at 2:42 PM, V17 (CNA) said she was R3's assigned CNA on 12/18/24. V17 said she was in the hall charting and heard a noise. V17 said she stood to investigate the noise and heard someone yelling, Help! V17 said R3's door was closed, she opened it, and found R3 on the floor near her bed. V17 said R3 was in the seated position, on her butt, with her legs crossed in front of her. V17 said she told R3 that she needed to get help. V17 said she alerted V18 to R3's fall and told V18 to call a female nurse (V19) to help. V17 said R3 prefers females to provide hands on care. V17 said she returned to R3's room and V17 followed her. V17 said V18 stood over R3 and asked, How does it feel to be down there? Are you proud of yourself? V17 said she didn't like the way V18 was talking to R3 and stated, Why are you talking to her like that? V17 said V18 continued to loudly, aggressively question R3 while he stood over her (R3 was still on the floor). V17 said she told V18 (RN) to stop talking like that to R3 and he told her to Stay in her place. V17 said at that point R3 got really upset and yelled, I'm already down here Mother F***er, what do you want me to do? V17 said she told V18, She (R3) doesn't deserve that and again he told me to stay in my lane. V17 stated, I'm not going to watch him talk to a resident like that. That's abuse. He (V18) was standing over [R3] yelling. He was scolding her like a child. He just kept, repeatedly questioning her while she was on the floor. Then she snapped on him and he started to move. V17 said they assisted R3 up to the wheelchair before V19 arrived, but their disagreement continued. V17 said she was arguing with V18 (RN) and threatened to call the state. V17 said V19 (RN) arrived at that time and pulled me out of the room. V17 said V19 (RN) told her that she shouldn't be arguing with V18 (RN) in front of the residents and making threats to call the state. V17 said V19 (RN) wasn't there to hear how V18 spoke to R3. On 1/6/24 at 1:11 PM, V19 (RN) said she was working a different unit on 12/18/24 and V18 (RN) called her for assistance because R3 fell . V19 said when she got to R3's room, R3 was already up in the wheelchair but V17 (CNA) and V18 were arguing. V19 said she heard V17 threaten to call the state and she asked V17 (CNA) to leave the room. V19 said she told V17 that it's inappropriate to argue with another staff member in front of the resident and to make such comments. V19 said she went in to assist V18 (RN) and noticed R3 was upset and anxious. V19 said R3 prefers female staff to provide care to her and she had assisted with her care before. V19 said she asked V18 (RN) to leave the room and tried to calm R3. V19 said R3 said it was her fault that she fell and that she just wants to go home. V19 said she didn't witness V18 aggressively questioning R3, but she wasn't able to come down to assist right away. V19 said R3 is alert and oriented and able to recall events. The surveyor asked V19 if a staff member should stand over a resident, on the floor, and ask, How does it feel to be down there? Are you proud of yourself? V19 replied, No, that should never be said to a resident. That's totally inappropriate. V19 said standing over someone, making those remarks, and aggressively questioning them could be considered verbal or mental abuse. V19 said she wasn't aware that V18 (RN) was scolding R3. On 1/6/24 at 1:27 PM, V2 (DON - Director of Nursing) said a resident shouldn't feel like they were being scolded like a child. The surveyor asked if V18 should stand over R3 and say, How does it feel to be down there? Are you proud of yourself? V2 replied, Absolutely not, that's inappropriate. Verbal abuse is the tone used and Mental Abuse is how you make the resident feel. V2 said if R3 felt embarrassed or humiliated, then it would be considered abuse. On 1/6/24 at 1:40 PM, V1 (Administrator) said on 12/19/24, V17 (CNA) reported that V18 (RN) yelled at R3 and spoke to her inappropriately. V1 stated, I'm not sure that she (V17) used the words verbal abuse. V1 said he interviewed R3. V1 said R3 reported that V18's tone was accusatory and she didn't appreciate his tone and questions. V1 said R3 didn't use the word scolded to him, but he could see how she would feel that way. The surveyor asked if V18 (RN) should have stood over resident and asked, How does it feel to be down there? Are you proud of yourself? V1 replied, No that could be abusive. V1 said that would be embarrassing. V1 said R3 never used the word abuse. The surveyor asked if the resident needs to identify it as abuse, for it to be abuse. V1 replied, No, that's probably my bad there. The facility's Abuse Prevention Program dated 10/2022 showed, Policy: This [facility] affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrence of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents . Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families within their hearing distance, regardless of an individuals' age, ability to comprehend, or disability . Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation .

Based on observation, interview and record review, the facility failed to protect a residents' right to be free from verbal, physical and mental abuse by an employee. This failure affected one (R1) of four residents in the sample reviewed for abuse. This failure resulted in R1 feeling unhappy, fearful, and not wanting to have her daughter leave her alone at the facility. Findings include: R1's diagnosis includes: Anemia, unspecified, Hypothyroidism, unspecified, Type 2 diabetes mellitus without complications Hyperlipidemia, unspecified, Essential (primary) hypertension Athscl heart disease of native coronary artery w/o Cardiomyopathy, unspecified Acute respiratory failure with hypoxia, Gastritis osteoarthritis, unspecified site Muscle weakness (generalized). R1's MDS dated [DATE] BIMS - 15 (indicating cognitively intact) Facility's reportable to state agency regarding R1 documents in part: The resident was admitted on [DATE]th, 2024 with the above diagnoses. The writer and administrator was notified by the nursing staff that the resident complained of inappropriate behavior from her night CNA staff, V12 (CNA). She (R1) claims the CNA (V12) grabbed her arm and aggressively lifted her, pulled the oxygen tubing out of her nose, and threw her in the shower. It was also claimed this CNA (V12) tried to make the resident (R1) stand when she was unable. The shower happened approximately at 6:40AM. A body check was performed with extensive new bruising found to the upper right forearm and underneath her right breast. The CNA was suspended pending investigation and police were called. Investigation started immediately. Police arrived and were informed of the suspicions regarding physical harm to the resident. Information was provided to the officer as requested which included pictures. Police investigation was conducted which included an interview between the officer and resident, in the presence of the executive director and director of nursing. The resident's statements were similar to those made upon initial interview with the administrator. Resident said she was rough and she grabbed my arm. She threw my oxygen on the ground. She barely showered me. A large area of bruising to the right upper arm was confirmed with pictures and measurements. The POA and daughter (V17) voiced my mom was scared and upset. And her arm is all bruised and she didn't have that before. New bruising was also found underneath the right breast. Upon review, it was determined a lift was not performed properly, as indicated by the resident. The resident said she kept pulling at me and it hurt. I (R1) asked her (V12) to stop and she wouldn't. Pictures were taken of all the new bruising, measured and confirmed to be new by the POA, clinical staff, and resident. When interviewed, the CNA (V12) denied all allegations and claimed the resident (R1): was screaming all night. She (V12) gave no indication that she was aware of harm caused to the resident and was unresponsive to questions asked regarding the matter. A trauma assessment was completed on R1 who expressed some negative emotional effects as a result of the incident. Conclusion and result: The CNA, V12 was immediately terminated from her position within the facility based on substantial evidence of harm to the resident. She was not allowed or present within the building following the allegations to keep all residents free of harm. The resident and family chose to press charges and police investigation began. Care plan was updated to reflect new injuries and emotional harm to the resident. R1's care plan dated 5/29/2024 documents in part: Problem/Need: Problem Onset: 05/29/2024 Mental distress, Goal & Target Date Show at least one physical sign that stress is being alleviated by 8/1/24, Approaches * Social Services to evaluate and visit* Observe for change in mental status. Document and report any decline to physician * Monitor resident behavior * Approach resident warmly and positively * Encourage verbalization. Listen in non-judgmental manner. * Encourage loved one(s) to visit/telephone * Acknowledge resident's moods in one-to-one interactions. On 6/28/2024 at 2:10pm Surveyor asked V7 (LPN) if she remembered incident involving R1 on 5/29/2024. V7 stated, yes, the best I can remember. I took care of R1 that morning (5/29/2024, 7a-3p). I finished the morning report and the CNA (V5) that works on the side R1 was on came to me and said R1 was not happy with the night CNA (V12) who worked with her. R1 said, V12 was rough. I (V7) went and checked on R1 and she was up in the wheelchair and R1 told me she (R1) did not want to talk about it but she was not happy with the night CNA. I (V7) called V1. I asked resident if she was in pain and she said no, I just don't like the CNA (V12) that took care of me the night (11p-7a) of 5/28/2024 into 5/29/2024. R1 said she was forced to take a shower. R1 seemed agitated and did not want to talk about it so I called V1. She said she was okay with the CNA (V5) that was working with her right then on the day shift (7a-3p). An Assessment was completed by the wound care nurse (V9) who went to check her and did a head-to-toe assessment on resident. Surveyor asked V7 if see saw her bruises. V7 stated, no V9 did her skin assessment on admission and V9 compared if there were changes with her skin. V7 stated, I do not remember seeing any bruises on her before this incident. V1 then came and talked to R1 and they interviewed the CNA (V5) and they called the police. Surveyor asked V7 if V12 has worked since this incident. V7 stated, I only heard that V12 could not come back and I have not seen V12 anymore. On 6/28/2024 at 2:22pm surveyor asked V10 if she remembered the incident that occurred with R1 on 5/29/2024. V10 (CNA) stated, I (V10) did not take care of R1, but I heard what happened to her and I (V10) went to speak to her. R1 spoke Spanish and I would give R1, her tray and coffee in the morning. So that day May 29, 2024, I (V10) came in and heard that something had happened to a resident. I was passing trays and I noticed while passing R1 her tray she was scared. I asked her if she wanted coffee, and I heard something had happened but I did not know who it was. The nurse notified the Director of Nursing (V2) and police and V1 (Administrator), V2 and V7 was talking to R1. R10 stated, R1 told me the CNA (V12) that took care of her that night the forced R1 to take a shower at 3:00am in the morning. R1 stated, she was scared and terrified that she was being forced to take a shower and V12 scared her. R1 did not want to speak that much until her daughter came. R1 looked like she was really terrified. I told R1 to relax and drink her coffee and soon the police department came, and I think the daughter was here by then. R1 looked very serious and terrified looking eyes wide open, she looked tired, but she did not want to go to sleep. I only heard the name (V12), but I did not know her. I had heard she was rough with resident after this happened. R1 told me she was trying to pull stuff from her and yanking stuff away from her, but I do not know if she hit her or not, only pulling stuff away from her. R1 was just really nervous. Before this happened, she would talk to me and smile but after this she was a little terrified and did not want to speak. I have not heard anything before or after this incident about abuse, if I do, I will report right away, I do not tolerate that. On 6/28/2024 at 2:37p V9 (LPN Wound Care Certified) stated, I am familiar with R1 and what happened on 5/29/2024. What happened was the night V12 got her up about 3:00 or 4:00am to take her into the shower room to shower resident. V7 was the morning nurse and mentioned it to me (V9). R1 had a little wound on her buttock, and I was going to do wound care on her buttocks. V7 told me what happened. V9 stated, I (V9) went to the room R1 was sitting in her wheelchair facing the door and R1 told me she was scared, and she did not want the door closed, so we called her daughter and sat with her. R1 was scared. The daughter came a little later. When the daughter came R1 agreed to be put into bed so I could see if anything was there. So R1 got calmer when her daughter came, and we put her in bed, and I did her wound care and during that time we noted redness like a carpet burn that started to turn darker under right breast and arm on the right side. R1 had to be lifted up with the machine, but that is when we noticed that R1 was saying she was pulling something so not sure if the sling was pulled against that area. V9 stated, When she was admitted R1 did not have those marks. I did the body check when she came in and it was different from a fungal rash or something it looked like it was fresh and just happened. R1 stayed in the chair after this incident, the CNA left her in the wheelchair, and we moved her back to bed. When I got on the floor, I was surprised to see R1 up that early because she usually did not get up until 10am and she had therapy, so it was odd for her to be up that early. We notified the daughter, V1 and police took picture of area. From this the police made report. They called the night CNA (V12) I think V1 or V2 and were following up with her. Prior to this incident, I do not recall anything about this CNA (V12). She was just hired, and she trained for a little bit and she worked alone for one or 2 days then the incident happened. I do not know if anyone else complained. R5 was her roommate at that time. R5 can be confused at times but she can talk. R1's first skin assessment wound on buttocks, bilateral swelling lower leg, and redness in peri area, abdominal fold, inguinal area so we were putting anti-fungal powder on that, but nothing else that I saw. I have not seen V12 anymore since incident. On 6/28/2024 at 3:05pm survey asked V5 (Agency CNA) if she remembered the incident involving R1 on 5/29/202. V5 stated, yes, I remember R1 she was such a sweet lady. I took care of her that morning R1 was not herself. I remember when she first came to facility she was in pain and had staples in her stomach, but she was getting better. That morning on 5/29/2024 I (V5) came in and checked on her (R1) and she was sitting in her room up in a wheelchair, her hair was wet, and she was leaning in the wheelchair, and she looked very upset. I (V5) asked R1 what was wrong with her. R1 told me that the lady (V12) made her (R1) get up in the middle of the night and made me (R1) take a shower. R1 stated, she was rough with me like man handled R1. R1 was asking for her daughter and said she does not want to be here. I (V5) let the nurse (V7) know right away. V7 came right away and checked on her. The night CNA (V12) was a new African lady that took care of her (R1) that night. The day it happened R1 was so upset that they called the called the police. I (V5) saw the night CNA (V12) on her way out the door that morning, but I did not get to interact with her. R1 was scared, R1 was shook up. Surveyor asked V5 if she received report from V12 (CNA) V5 stated, V12 did not give me report, they get out of here sometimes before we get here. I remember this incident very well. The nurse that night was V11 (LPN Agency) and I think I recall telling V11 about R1 too. I think when V12 gave R1 the shower V12 was just doing what she had to do. R1 kept saying I only want my daughter, I want my daughter, she kept saying that and she was not like that before. I had not heard of this CNA (V12) being rough with other residents. I am not sure if she had a roommate. If it was it was R5 she is confused. On 6/28/2024 at 3:30pm Surveyor asked V11 (LPN Agency) if she took care of R1 on 5/28/2029 into 5/29/2024 11p-7a shift. V11 stated (in part), I remember her from 2west. I (V11) remember the incident that happened. I do not know exactly what happened, but they (V1 and V2) called me in the afternoon and when I woke up, I called them back. They (V1 ad V2) said R1 had some bruises on her arm, I do not remember what arm. That night, I (V11) helped CNA (V12) change R1 because R1 was screaming that she wanted to talk to her daughter. I told V12, it is 5am we should just change her. I did not notice V12 was rough with any resident. When I (V11) was in the room with the resident, she was normal. Surveyor asked V11 how was R1's behavior the following night. V11 stated, Quiet and was not screaming. I saw the bruises on her arm, I did not check her whole body but when I saw her that night of 5/29/2024 I saw the bruises on her arm that was not there when I helped to change her the night before. I saw her body before because she was naked the night I (V11) helped V12. R1 did not say anything to me about what happened that night. I have not seen V12 since that day. I (V11) was not aware of anything that happened to R1 that night. I (V11) went into R1's room because I heard her (R1) screaming and that is why I (V11) went into the room. When I went into R1's room V12 was not in there, she (R1) was sitting by the door, and I called her (V12) into the room, and I said since she was wet let's change her (R1) because sometime that can make them upset and have behaviors. R1 had a roommate, R5 and she can answer questions. On 6/29/2024 at 10:39am, Surveyor asked V2 regarding incident of 5/31/2024 involving R1. V2 stated, in the morning R1 told morning CNA (V5) that the night CNA (V12) was rough. V5 told V7 and V7 checked R1 and contacted V1 immediately. I interviewed R1 and her story was consistent with the story R1 told me and what R1 told V1. We called the police, and that CNA (V12) was removed from working and then terminated due to findings. R1 stated, the CNA (V12) was rough with her (R1) using the sit to stand and she was sliding back and forth. From my understanding, V13 offered to help her, and the CNA (V12) refused the help. R1 stated, V12 was rough with her (R1), she was swinging me back and forth in the chair. R1's body assessment had bruising on right upper arm and within the crease below R1's breast. I (V2) got into the sling, and I think it is possible the sling was upside down and when it is like that it is not as padded. R1 was then showered and brought back to the room. When I spoke with R1 she seemed frustrated and kind of sad, but very frustrated about the situation. We told her we would investigate and V12 would not be back with her. R1 was pleasant with me, but I did not do any direct care with her. R1 was pretty alert. I do not believe night shift nurse (V11) knew about this situation. Surveyor asked V2 when you spoke to V12 what did she say happened. V12 denied everything but admitted doing a transfer with only one person. V12 denied knowing about any injury or anything. V12 was immediately suspended. R1 was very alert and R1's statement matched the injury, so we terminated V12, she is not to our standard, you do not treat people like that. Prior to this incident, I did hear a comment that it seemed like V12 did not want to be here, but there was nothing tangible to go on. I had no complaints about the care she gave prior to this moment. No one said there were any concerns during her orientation. V12 was asked how bruises got on the resident (R1), V12 stated, she did not know. Surveyor asked V2 how the sit-to-stand is supposed to be used. V2 stated, The sit-to-stand we educate 2 people to use the sit to stand, any mechanical lift I want 2 people that is the safest way. I preach all the time that any mechanical lift you have to have 2 people. R1's daughter was notified and came to visit R1 that day. We kept daughter up to date. R1 ended up going to the hospital, I am almost positive due to kidney issues and R1 did not return. After this incident, we asked residents if they had any safety concerns. R5 can be confused but did not say anything. It was after 7am when R1 reported, and V12 was done with her shift, and V12 was told not to come in until investigation was completed and we gathered the findings. Based on findings, V12 was terminated due to improper technique, and she was rough with the patient and the patient has the bruising to show, so we just terminated. On 6/29/2024 at 11:58am Surveyor asked V13 (CNA) about the incident that occurred 0n 5/29/2024 with R1. V13 stated (in part), I was going in R1's room because I heard R1 screaming. R1 never screams, so I went to see what was wrong. When I walked in R1's arm was inside the sling not outside of the sling. The arm is supposed to be over the sling. V12 had not pulled R1 up yet, I (V13) just fixed it (referring to the sling). V12 was using sit to stand without help. I saw V12 take R1 to the shower. V13 was busy and V13 called me again in the shower room. When I got to the shower room R1 was already in the shower chair. V12 transferred R1 to the shower chair with the easy stand by herself. When R1 was sitting on the shower chair R1 looked like she was going to slide. V12 called me to help push R1 up in the chair. I (V13) said, No, no we cannot push R1 up because we might hurt her. Then V12 said, ok and I (V13) left. When I went back again, R1 was already in the wheelchair. I believe she used the sit to stand, V12 walked out and R1 was in the wheelchair. R1 did not say anything to me, but she looked like she (R1) was not happy. V12 did not say anything. I worked with V12, and I (V13) do not know if there were any complaints, but I let her do the residents, she was a little rough. The way she changed residents and get up when the resident sitting on the chair, she was a little rough, her attitude was okay with me. I tried to tell her what to do and she said OKAY, okay. I (V13) was scared to tell V12, I did not tell anyone because that was my first time working with her. On 6/29/2024 at 1:21pm surveyor called V12 (CNA) regarding incident that occurred on 5/29/2024 with R1. V12 stated (in part), I do not remember R1's name. but I (V12) remember giving R1 a shower not sure of the day. There was no incident, but they (V1) called me and said she (R1) had a bruise on her arm. I (V12) said, I (V12) do not know anything about a bruise because I (V12) did not see any bruise when I (V12) gave her a shower. V12 further stated, before I (V12) moved her (R1) I was asking questions, because there was no clear instructions on how to move residents. V13 (CNA) told me she (R1) could move. I (V12) asked her (R1) to stand up and get in wheelchair. I (V12) got V13 and told V13 she (R1) could not stand up. I got the sit to stand lift, put strap under her and fixed it while R1 stands holding onto device. V13 helped me (V12) take her (R1) to the bathroom to give her (R1) a shower. R1 had a white plaster on her stomach above her navel and I asked V13 if R1 could get a shower. V13 went to ask nurse (V11) if okay to give shower and V11 said yes. I (V12) gave her (R1) a shower. I (V12) do not remember hurting her and neither did I see any mark on R1. V1 called me and told me R1 had a scar on her arm. I (V12) had assistance by V13. At the facility there is not clear instructions, I (V12) have to always run to V13 to ask. Surveyor asked V12, at any time while you cared for R1 did you pull the R1's arm or handled R1 in a rough manner. V12 stated, I did initially pull her arm when I was told she could stand, but when I saw she could not stand I left and got the lift. I (V12) then gave R1 a shower and took R1 and put R1 back in the room I (V12) got R1 dressed and took her (R1) to the room. In the parking lot V13 told me she was a mechanical lift. If residents are not transferred right, the resident can get a bruise. V1 called me and said R1 has a bruise on her arm and said I (V12) was being investigated for abuse and suspended pending investigation. V2 called and said proper care was not given to R1 and I (V12) was going to be separated from the company. I was not told anything else except proper care was not given to the resident. Surveyor asked V12, did you abuse or handle R1 in a rough manner. V12 stated, No. Surveyor asked how R1 got bruises on her arm, V12 stated, I do not know R1 did not have any bruises on her. On 6/29/2024 at 1:57pm V1 stated, I was notified by V7 that R1 had an issue with the CNA, and we determined it was V12. V12 had already left her shift. I spoke with R1 and the daughter. I spoke with the daughter first and she said her mom had significant bruising on her right upper arm. It was definitely new bruising and none of the nurses or daughter had seen this before. Daughter said V12 was rough with her mom (R1) and attempted to lift R1 out of bed alone and R1 was voicing for V12 to stop and pulled oxygen tubing out of R1's nose and gave her a shower, barely putting her under the water according to R1. When I interviewed R1 she told me the same story, what R1 told her daughter is what R1 told me. I (V1) had V9 look her over to assess R1 and she (R1) had bruising under her right breast to her sternum which would explain improper lifting. R1 expressed she was very scared and did not want CNA (V12) to come back into R1's room. R1 seemed very emotionally affected by it. After speaking with them (V17 and R1) I called the police. I then called V12 after police left and I asked V12 very specific questions about R1. V12 stated, she (R1) was a resident she was working with. V12 did know who she (R1) was and I (V1) asked how morning went. V12 stated, it went as it should. I (V1) asked specific question did you give R1 a shower and if she (V12) gave proper care. V12 said, yes. I informed her I (V1) heard differently and V12 denied those claims. I then asked V12 how she lifted R1 to get R1out of bed. V12 said she used an easy stand. I asked if she had assistance because R1 was a 2 person assist. From speaking with staff and V17 and R1, I heard she did not have assistance. I asked V12 if R1 expressed she did not want to get out of bed and did not want a shower. V12 said R1 was difficult. I then asked about the oxygen tubing and forcibly pulling it form R1's nose. R1 said nothing. V12 then got upset with the questions and said R1 was difficult and was screaming all night long. I (V1) asked V12 if she was frustrated with R1, and V12 said no and then said R1 is not easy to work with. I ((V1) stated, other staff have said R1 was lovely and pleasant. R1 has BIMS 15/15 and is very aware what is happening around her. I also asked V12 if she was aware of bruising and V12 said no. When I (V12) left R1 she was fine. I told V12 about the allegations and she is suspended pending investigation. V12 said okay and hung up. We notified V12 at the end of the investigation she was terminated. V12 did not seem to care. V12 did not ask why or asked the status of what we found out. Surveyor asked V1 Why V12 was terminated. V1 stated, I found harm to the resident, and lack of empathy and care for the people she is working with. The bruising was significant. V12 was a new hire might have been her third shift. During V12's orientation, V12 was paired with another CNA and there no concerns that I heard at least. I spoke to V11 the night nurse, but the incident was reported to V7. V13 did mention that V12 was hard to work with that morning (5/29/2024) and did not want to receive help. The night nurse V11 stated, she did not see any bruises on R1. On 6/30/2024 at 4:37pm surveyor called V17 (daughter of R1) regarding incident of 5/29/2024. V17 stated, my mom (R1) passed away. V1 and V2 spoke to me about what happened to my mom when I got to the facility. My Mom (R1) was alert and was able to tell me what happened. I am not sure how forceable she (V12) treated her. I know R1 had a bruise on her arm and underneath her breast that R1 did not have. I am not sure why V12 was forcing R1 to get up from the wheelchair. R1 told me that V12 said to the other CNA that came to check on R1 because she was screaming I (V12) can handle this and closed the door and put R1 in the wheelchair and put R1 underneath the shower. V12 also took R1's oxygen off of R1 and ripped the blanket off the bed. V12 was brutal to my mother (R1). My mom (R1) was such a nice lady. Not sure why V12 did that to my mom (R1). R1 was weak and could not stand but the CNA (V12) made her get in the shower. R1 was trying to tell her she was in pain because she had bedsores but the lady (V12) yanked the blanket from underneath R1 and took the Oxygen off and threw it on the floor. She (V12) put R1 in the wheelchair and forced her to get up yelling at her. When I (V17) got there (facility) R1 had a bruise on her right arm and underneath her right breast area on the same area on the right side. I took a picture of the bruise on her arm, but I (V17) did not get a change to take picture of that bruise underneath R1's breast. The bruise was freshly made, it was red. V12 was trying to make her stand up and she was in pain down in her bottom. I am not sure why anyone would do that to R1. Wound care notes documented date 5/28/24 8AM reads: Resident was up in w/c (wheelchair) facing the open door. Per resident the noc (night) CNA was rude and rough with resident when she took her in the early am for a shower. Noted to have a red mark to her R (right) lateral upper arm as well as under her right breast. Resident was upset and stated she wasn't going to do anything until her dtr (daughter) came. Spoke to resident and informed her will wait for her daughter and assess her skin as well as dress her wound to the sacrum. V9 LPN Per V1 this note was misdated and was documented on 5/29/24 at 8AM when V1 asked wound care nurse to complete a skin assessment on R1 due to allegation of abuse by V12. 5/29/24 visual body map skin for R1 documented by V9 existing sacral sore from admission, red bruising to outer R (right) upper arm, red bruising under R Breast 5/29/24 7-3 in part documents res alert/ verbalizes needs well to staff. Assessed by wound nurse red bruising, R under the breast red bruising to upper R outer arm. Physician Progress note May 29, 2024 10:20 AM document in part: Chief Complaint: Bruises History of Present Illness: female was seen patient was seen on the request of her nurse who reported that patient reported that this morning at 3AM her CNA gave her a shower which she did not want to have. She stated that the CNA took off her oxygen and took of the abdominal binder in an abrupt manner and grabbed her right arm which made her to sustain bruises on her right arm and under her right breast. She stated that she was unhappy that she was handled in that manner because that made her very uncomfortable. She stated that this staff member is always nice to her but she did not know what happened today. The facility notified the police and patient's family about this incident. I notified Dr. who is the physician at this facility. She denied any pain. Physical exam General: awake, alert, elderly, not in respiratory distress, up in bed. Skin - new rt arm bruise and an old bruise with small excoriation under rt breast. Psychiatric - oriented x3, Diagnosis, Assessment and Plan Bruise Right arm and under right breast bruises, keep areas dry and open to air. Hypoxia give oxygen at 2 L via Nasal cannula. Nursing note 5/29/24 3-11 in part document res on bed alert & oriented with O2 (oxygen) 2L (liters)/min (minute) Spo2 (Oxygen Saturation) 97-98% bruise on the Rt (right) upper no s/s (signs/symptoms) of infection and no complained of pain. Nursing note 5/30/24 11-7 in part documents resident in bed, alert oriented x 2-3 w/ (with) periods of confusion, O2 2L via N/C (nasal cannula) - 93%. Still w/ bruises to right outer arm & right under breast. No swelling noted, skin intact. Facility Abuse Prevention Policy (last revised 06/2020) documents in part: Policy Statement Our residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Job Title: Nursing Asst Cert-LTC dated 11/17/2022 documents in part: Job Summary: Assists with basic patient care activities. Responsibilities: Assists patients with tending to personal care, activities of daily living and transfers/transport. Complexity of Work: Within scope of job, ability to work with minimal supervision. Must be able to work in a stressful environment.

Based on interview and record review, the facility failed to safely transfer a resident (R1) using a mechanical lift and failed to follow the facility procedure for use of a mechanical lift for one (R1) of four residents. The facility failure to follow the mechanical lift transfer safety guidelines resulted in injury to R1 who sustained bruises during a one-person staff transfer. Findings include: R1's diagnosis includes: Anemia, unspecified, Hypothyroidism, unspecified, Type 2 diabetes mellitus without complications Hyperlipidemia, unspecified, Essential (primary) hypertension Athscl heart disease of native coronary artery w/o Cardiomyopathy, unspecified Acute respiratory failure with hypoxia, Gastritis osteoarthritis, unspecified site Muscle weakness (generalized). Facility's reportable to state agency regarding R1 documents in part: The resident was admitted on [DATE]th, 2024, with the above diagnoses. The writer and administrator was notified by the nursing staff that the resident complained of inappropriate behavior from her night CNA staff, V12 (CNA). She (R1) claims the CNA (V12) grabbed her arm and aggressively lifted her, pulled the oxygen tubing out of her nose, and threw her in the shower. It was also claimed this CNA (V12) tried to make the resident (R1) stand when she was unable. The shower happened approximately at 6:40AM. A body check was performed with extensive new bruising found to the upper right forearm and underneath her right breast. MDS dated [DATE] BIMS - 15 (indicating cognitively intact) R1's care plan (in part) documents Problem Onset: 05/29/2024 Self-care deficit requires assistance of 1-2 staff for ADL (activities of daily living) tasks Goals and Target Dates Will increase independence with ADL's 8/29/24 Approaches Baths/showers with hair/nail care * Partial baths on non-shower days. Set-up bathing supplies for partial baths daily. * Assist of 2 persons for all transfers using (mechanical) lift. Assist for mobility around the facility via w/c (wheelchair). R1's care plan documents Problem Onset: 05/29/2024 R1 has a red bruising noted R under the breast and R outer upper arm. Goals and Target Dates bruises will be resolved thu the next review. 8/29/24 Approaches Keep area clean and Dry * Evaluate and assess for the source of bruising. * R1 needs a daily observation of skin with routine care R1 needs a full skin evaluation weekly with bath/shower. On 6/28/2024 at 3:30pm Surveyor asked V11 (LPN Agency) if she took care of R1 on 5/28/2029 into 5/29/2024 11p-7a shift. V11 stated about 6am she (V12) called for another CNA (V13) to help transfer R1 to a wheelchair and then bathroom. I (V11) learned the CNA (V12) used the sit to stand lift to transfer R1 without calling for extra help. I asked V13 if when V12 used the sit to stand she called her (V13) to help. V13 stated, she did not call her to help transfer R1 so whatever happened with the bruises it happened in the bathroom because R1 did not have any bruises when I (V11) was in the room, we turned her and everything and I did not see any bruises on her body. After the bathroom, I (V11) did not check R1 again because I was busy running, R1 did not tell me anything about bruises or anything that happened. I found out about the bruises when they called me. On 6/29/2024 at 10:39am, Surveyor asked V2 (Director of Nursing) regarding incident of 5/31/2024 involving R1. R1 stated (in part), the CNA (V12) was rough with her (R1) using the sit to stand and she was sliding back and forth. From my understanding, V13 offered to help her and the CNA (V12) refused the help. R1 stated, V12 was rough with her (R1), she was swinging me back and forth in the chair. R1's body assessment had bruising on right upper arm and within the crease below R1's breast. V2 stated, V12 denied everything but admitted doing a transfer with only one person. Surveyor asked V2 how is the sit to stand supposed to be used. V2 stated, The sit to stand (lift), we educate 2 people to use the sit to stand, any mechanical lift I want 2 people that is the safest way. I preach all the time that any mechanical lift you have to have 2 people. Based on findings, V12 was terminated due to improper technique and she was rough with the patient and the patient has the bruising to show, so we just terminated. On 6/29/2024 at 11:58am Surveyor asked V13 (CNA) about the incident that occurred 0n 5/29/2024 with R1. V13 stated, I was going in R1's room because I heard R1 screaming. R1 never screams, so I went to see what was wrong. When I walked in R1's arm was inside the sling not outside of the sling. The arm is supposed to be over the sling. V12 had not pulled R1 up yet, I (V13) just fixed it (sling). V12 was using sit to stand without help. I saw V12 take R1 to the shower. V13 was busy and V13 called me again in the shower room. When I got to the shower room R1 was already in the shower chair. V12 transferred R1 to the shower chair with the easy stand by herself. When R1 was sitting on the shower chair R1 looked like she was going to slide. V12 called me to help push R1 up in the chair. I (V13) said, No, no we cannot push R1 up because we might hurt her. Then V12 said, ok and I (V13) left. When I went back again, R1 was already in the wheelchair. I believe she used the sit to stand, V12 walked out and R1 was in the wheelchair. On 6/29/2024 at 1:21pm surveyor called V12 (CNA) regarding incident that occurred on 5/29/2024 with R1. V12 stated, I do not remember R1's name. but I (V12) remember giving R1 a shower not sure of the day. There was no incident, but they (V1) called me and said she (R1) had a bruise on her arm. I (V12) said, I (V12) do not know anything about a bruise because I (V12) did not see any bruise when I (V12) gave her a shower. V12 further stated, before I (V12) moved her (R1) I was asking questions, because there was no clear instructions on how to move residents. V13 (CNA) told me she (R1) could move. I (V12) asked her (R1) to stand up and get in wheelchair. I (V12) got V13 and told V13 she (R1) could not stand up. I got the sit to stand lift, put strap under her and fixed it while R1 stands holding onto device. V12 stated, I did initially pull her arm when I was told she could stand, but when I saw she could not stand I Ieft and got the lift. That was on her left side or so, I do not remember what side. When I (V12) was leaving V13 told me R1 is a mechanical lift transfer but nothing was there to tell me. I (V12) always had to ask how to transfer each of the residents. I (V12) do not think V13 was familiar with R1. I (V12) then gave R1 a shower and took R1 and put R1 back in the room I (V12) got R1 dressed and took her (R1) to the room. In the parking lot V13 told me she was a mechanical lift. If residents are not transferred right, the resident can get a bruise. V2 called and said proper care was not given to R1 and I (V12) was going to be separated from the company. I was not told anything else except proper care was not given to the resident. Surveyor asked V12 did you use mechanical lift without another staff person. V12 stated, Yes, there was no one to help me and R1 could not stand. On 6/29/2024 at 1:57pm V1 (Administrator) stated (in part), I was notified by V7 that R1 had an issue with the CNA and we determined it was V12. V12 had already left her shift. I spoke with R1 and the daughter. I spoke with the daughter first and she said her mom had significant bruising on her right upper arm. It was definitely new bruising and none of the nurses or daughter had seen this before. Daughter said V12 was rough with her mom (R1) and attempted to lift R1 out of bed alone and R1 was voicing for V12 to stop and pulled oxygen tubing out of R1's nose and gave her a shower, barely putting her under the water according to R1. When I interviewed R1 she told me the same story, what R1 told her daughter is what R1 told me. I (V1) had V9 look her over to assess R1 and she (R1) had bruising under her right breast to her sternum which would explain improper lifting. I (V1) asked specific question did you give R1 a shower and if she (V12) gave proper care. I then asked V12 how she lifted R1 to get R1out of bed. V12 said she used an easy stand. I asked if she had assistance because R1 was a 2 person assist. From speaking with staff and V17 and R1, I heard she did not have assistance. Told V12 about the allegations and she is suspended pending investigation. V12 said, okay and hung up. We notified V12 at the end of the investigation she was terminated. V12 did not seem to care. V12 did not ask why or asked the status of what we found out. Surveyor asked V1 Why V12 was terminated. V1 stated, I found harm to the resident, and lack of empathy and care for the people she is working with. The bruising was significant. Review of Medical Records, Surveyor did not see any documentation in the medical record regarding how R1 was transferred by V12 on 5/29/2024, nor did facility provide documentation. Facility Procedure: Lifting Machine, using a Portable last approved 04/2024 documents in part: Purpose The purpose of this procedure is to help lift residents using a manual lifting device. Preparation A. Review the resident's care plan to assess for any special needs of the resident. General Guidelines Two (2) nursing associates are required to perform this procedure. Procedure For Sit-to-stand: B. Position sit-to-stand lift sling under resident's axilla and secure safety belt around waist. I. crank the resident up with the lift. Your helper *guides the resident by holding the sling. Documentation The following information should be recorded in the resident's medical record: B. Amount of assistance that was given and the number of people who assisted. Facility's Assessment Tool (FY24) documents in part: Services and care we offer based on our residents' needs: Provide person centered/directed care: identify hazards and risks for residents. Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies, Staff training/education and competencies are necessary to provide the level and types of support and care needed for our resident population, Topics Activities of daily living - using mechanic lifts. Job Title: Nursing Asst Cert-LTC dated 11/17/2022 documents in part: Job Summary: Assists with basic patient care activities. Responsibilities: Assists patients with tending to personal care, activities of daily living and transfers/transport. Complexity of Work: Within scope of job, ability to work with minimal supervision. Must be able to work in a stressful environment.

Based on interview and record review the facility failed to monitor and assess for signs of urinary catheter obstruction and monitor urine output for one (R21) of one resident reviewed for urinary tract infections on the sample list of 37. This failure resulted in R21's emergent hospitalization and diagnosis of severe sepsis and acute kidney injury. Findings include: R21 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Metabolic Encephalopathy; Alzheimer's Disease; Age related Osteoporosis; Anemia; and Peripheral Vascular Disease. R21's physician order dated 02/01/2024 reads in part, (Urinary) catheter care every shift; Change (Urinary) catheter as needed. R21's care plan reads in part, Problem onset: (R21) has (urinary) catheter to assist in unstageable sacral pressure ulcer. Approaches: Ongoing assessment of color, clarity and character of (R21's) urine; Ongoing assessment of (R21's) for symptoms of urinary [NAME] infection; Change (R21's) catheter tubing/bag per protocol and as needed. On 05/15/24 at 11:04 AM V16 (Licensed Practical Nurse) stated in summary: Urinary catheter care is split between nurses and Certified Nursing Assistants (CNAs). Nurses flush urinary catheter if there is an order. CNAs do catheter perineal care and empty urinary catheter bags and report to the nurse if there are any changes in urine appearance. If a CNA reports to the nurse that there is a sediment or change in urine appearance or output volume, the nurse will call the doctor and obtain flush order unless there is existing order. Nurses are obligated to assess the catheter every shift. I might have worked with R21 on days prior to her hospitalization but I did not notice any changes in the urine output or appearance. We don't document catheter assessments if there are no concerns, we are not obligated to document on routine catheter assessment. On 05/15/24 at 11:17 AM V3 (Quality Director/Infection Preventionist) stated in summary: Urinary catheter care is divided between nurses and CNAs. Nurses insert urinary catheter, flush it, and obtain specimen samples. CNAs do perineal care along with catheter care and change the bag if needed. Nurses and CNAs are required to assess urinary catheters every shift (three shifts a day). Urinary catheter assessment is done to prevent infections and to monitor for symptoms of dehydration. Nurse's urinary catheter assessment should consist of urine appearance, signs of occlusion, determination whether catheter is intact and patent, scheduled bag or catheter change, and flushing. CNAs would change urinary bag if catheter went from full bag to a leg bag and opposite, and they are also required to clean the catheter tube. On 04/22/2024, Agency nurse was on duty, and she called me to further assess R21. R21's blood pressure was dropping, and she was unresponsive. I went and called the doctor and said that we will be sending R21 to the hospital. On 05/15/24 at 11:54 AM V17 (Certified Nursing Assistant) stated in summary: Certified Nursing Assistants have to make sure urinary bags are emptied by the end of the shift. I was told to report if I see any blood in the urine, resident experiences pain from the catheter, or if something looks different in general. Facility's expectation for catheter monitoring is every time I provide perineal care. Catheter perineal care should be done at the beginning of each shift, especially, to make sure bag is empty. If a urinary catheter is obstructed the urine will not drain to the bag and that should be reported to the nurse. We are required to document that urinary catheter is present but not that the bag was emptied, or care was provided. On 05/15/24 at 12:32 PM V18 (Certified Nursing Assistant) stated in summary: I took care on R21 on the morning of 04/22/024. I noticed that R21 was out of it, and she didn't look good, so I notified the nurse (V16) on duty. I performed R21 perineal care before earlier that morning, I didn't notice anything different with her catheter, there was no urine or sediment in the tubing and urinary bag was empty. On 05/15/24 at 02:21 PM V16 (LPN) stated in summary: I work on both days before R21 was hospitalized and there was nothing wrong with R21's catheter on 04/20/2024 and 04/21/2024, at least I didn't document anything in the progress note, which means there was nothing unusual. CNAs didn't notify me of anything unusual either. We are not required to document urinary catheter output. If there is no urine output, CNAs usually notify the nurse. Urinary catheter care consists of checking that catheter is intact, and there are no problems with it. Urinary catheter assessment is done quarterly. Nurses and CNAs are both responsible for catheter assessment. There is no daily urinary catheter assessment documentation required by the facility. On 05/15/24 at 03:47 PM V2 (Director of Nursing) stated in summary: Urinary output is not required to be documented; it is something we need to implement. Urinary catheter care is documented in the Treatment Administration Record, and it shows that nurses ensuring that urinary catheter care has been done properly by CNAs. Surveyor pointed out that R21's Treatment Administration Record shows that urinary catheter care was done on two shifts after R21 was transferred to the hospital on 04/22/2024, V2 (DON) stated, I doubt nurses went to the hospital to check on R22's urinary catheter, nurses should be documenting what they truly done. On 05/16/24 at 11:26 AM V27 (Medical Director) stated in summary: Urinary catheter calcification is a buildup of calcium and plaque that occurs in the bladder and can transfer into catheter tubing and urinary bag. I don't know how long it takes for calcification to build up to the point of obstruction. Obstructive uropathy is an obstruction of urine drainage that can cause urinary retention. Obstruction causes urine to be stagnant in the bladder and that's what causes infection, but the time frame to develop infection depends on the resident. Urinary catheter should be flushed at least once a shift, I imagine it is included in the urinary catheter care. It is important to document residents' urinary output to monitor whether urinary catheter is obstructed. Urine output should be documented once a shift. Progress note dated 04/22/2024 at 12:37 PM written by V3 (Quality Director/Infection Preventionist) reads in part, Today, approximately at 11:30 (AM), (R21's) bp (blood pressure) was 87/56 with spo2 (oxygen saturation) at 97%. Intact (urinary) catheter draining dark colored urine. Hospital record dated 04/22/2024 4:42 PM reads in part, HPI (History of present illness): (R21) from nursing home after being found to be unresponsive today, with tachycardia and hypotension. Per (family member) at bedside, states that (R21) was eating appropriately and acting her normal self approximately 1 week ago and is nervous (R21) has developed yet another infection that has led to today symptom. Diagnosis: Severe Sepsis, Dehydration, AKI (Acute Kidney Injury). Assessment: It is clear (urinary) catheter has not been replaced for multiple days and had calcified to the point of obstruction. Obstructive uropathy with subsequent UTI (urinary [NAME] infection) found on physical exam and laboratory findings. R21's (Urinary) catheter care record for February, March and April (1st to 21st) 2024 show that urinary catheter care was done inconsistently. R21's (Urinary) catheter care record for April 22, 2024, shows that urinary care was documented after R21's hospital transfer. Urinary catheter care record appears inaccurate and not well documented . R21's Change (urinary) catheter as needed record shows that R21's urinary catheter was never documented as changed between 02/01/2024 and 04/22/2024. There is no record of R21's urinary catheter output documented between 02/01/2024 and 04/22/2024. There is no record of R21's assessment, change in condition, or vital signs documented in days preceding to 04/22/2024. Last know vital signs set checked on 02/16/2024. The facility policy Procedure: Urinary Catheter Care dated 01/2024 reads in part, Observe the resident's urine level for noticeable increases or decreases. If the level stays the same, or increases rapidly, report it to the physician or supervisor. It is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. Observe for other signs and symptoms of urinary [NAME] infection or urinary retention. Report findings to the physician or supervisor immediately. If the catheter material is contributing to obstruction, notify the physician and change the catheter if instructed to do so.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent (%). A medication pass observation on 05/13/2024 revealed 26 medication administration errors out of 31 opportunities, resulting in an 83.87% medication error rate. Findings include: Medication pass observation conducted on 05/13/2024 with V5 and V13 (Agency Registered Nurses) to 3 residents (R6, R7, R33) with the following observations: R7: On 05/13/24 11:28 AM, entered R7's room and observed a small clear plastic medication cup on top of the bedside table that was near the foot of bed which contained nine pills within. When asked whose medications were on the table, R7 stated those are my morning meds. She added that the nurse brought them earlier this morning, but she does not recall her name of nurse or the exact time the pills were left but knows it was before breakfast. R7 then said she knows the nurses are not supposed to leave her medications and she would prefer if the nurse stayed, but they are busy and trust her (R7) enough to take them by herself. When asked what the medications were called, resident stated they were the same ones I take every morning, but I haven't taken them yet. On 05/13/24 at 11:52 AM, observed V5 (Agency Registered Nurse) enter R7's room to administer her noon meds when surveyor observed V5 pick up a plastic med cup which contained the nine pills previously observed on R7's bedside table by surveyor. Observed V5 (Agency Registered Nurse) give R7 the two noon meds then proceeded to administer the medications from within the plastic cup that she picked up from the bedside table. On 05/13/24 at 11:56 AM, V5 (Agency Registered Nurse) said the medications she administered within the med cup were R7's 9:00 AM medications. V5 then said that she did not want to stand over R7 while she took all her pills, so she left them at the bedside. She also said that she knows she should have stayed with the resident to observe her take the medications. V5 then said the pills within the med cup administered to R7 were: losartan potassium (antihypertensive) 100mg (milligrams) one tab (tablet), metoprolol succinate (antihypertensive) ER (extended release) 50mg (3 tablets to equal 150mg), vitamin b-12 500 microgram (mcg) one tablet, amlodipine besylate (antihypertensive) 2.5 mg one tab, eliquis (blood thinner) 2.5mg one tab, ferate (iron) 27mg one tab, furosemide (diuretic) 40mg one tab. V5 then said there is a one hour window prior to and after scheduled med administration time so R7's 9:00 AM medications were administered late. V5 added that she took R7's blood pressure this morning because it should be checked prior to administration. Reconciliation of R7's active physician orders with medication administration log showed all the prescribed medications as indicated above by V5 that are scheduled for 9:00 AM with special instructions for the following medications: losartan potassium 100mg one tab hold if systolic blood pressure is less than 100, metoprolol succinate ER 50mg (3 tablets to equal 150mg) hold if systolic blood pressure is less than 110 0r pulse less than 60, and amlodipine besylate 2.5 mg one tab hold if systolic blood pressure is less than 110. Per R7's Medication Administration Record (MAR), her 9:00 AM medications were documented as being administered by V5 (Agency Registered Nurse) with her initials/signature. Surveyor did not observe V5 obtaining of R7's blood pressure prior to administering the blood pressure medications. On 05/13/24 at 12:09 PM, V5 (Agency Registered Nurse) stated that she has been a nurse for a year and knows that she should not leave medications at the bedside and should stay with resident to ensure they were taken. She added that R7 and R34 don't like for the nurse to stand over them while they take their medications, so to not cause any problems with these residents, she left their medications at the bedside. R6: On 05/13/24 at 12:15 PM, V13 (Agency Registered Nurse) said she just came in at 11:15 AM this morning because she is covering for a nurse who did not show up. She added that there is a one hour window before/after scheduled med times so all the medications she will be administering will all be late. She then said that she comes to the facility 1-2 times a week. V13 then said she never leaves meds at the bedside to ensure the right resident is receiving the right medications and added that a confused resident could wander into a room and take the medications if left at the bedside. At 12:41 PM, V13 (Agency Registered Nurse) administered the following medications to R6: fenofibrate (antilipemic) 48mg one tablet, acetaminophen (pain medication) 325mg (2 tabs), ferrous gluconate (iron) 324mg one tablet, bumetanide (diuretic) 0.5mg one tablet. She added that the rest of the medications listed on R6's MAR were for the evening medication pass. R6's active physician orders were reconciled with R6's medication administration log and noted the above mentioned medications as indicated by V13 with the following prescribed (9:00 AM) medications that were not observed as administered by V13 on 05/13/2024 but were initialed as being administered: levetiracetam (anticonvulsant) 250mg one tablet, eliquis (blood thinner) 2.5mg one tablet, potassium chloride (potassium supplement) ER 10 milliequivalent (meq), meclizine (antivertigo) 25mg one tablet. R33: On 05/13/24 at 12:49 PM, observed R33 sitting on side of bed with lunch tray set on bedside table. R33 said she was finished eating her lunch, after she ate all she wanted to eat. V13 (Agency Registered Nurse) then obtained R33's vital statistics and blood sugar then administered the following medications to her at 12:58 PM: insulin aspart (novolog) 2 units per sliding scale (scheduled for 11:00 AM), sertraline (antidepressant) hcl (hydrochloride) 50mg one tablet, aspirin (nonsteroidal antiinflammatory) ec (enteric coated) 81mg one tablet, clopidogrel (antiplatelet) 75mg one tablet, multivitamin (vitamin supplement) one tablet, ferrous sulfate (iron) 325mg one tablet, sodium bicarbonate (alkalinizing agent) 650mg one tablet, one oyster shell 500-vitamin d3 (supplement) 200mg tablet, vitamin c (viatmin supplement) 250mg one tablet. R33's active physician orders and medication administration log for R33 were reviewed and noted the following medications were not observed as administered per physician orders by V13: insulin aspart 100 unit/ml give 7 units subcutaneously before meals at 12:00 PM, gabapentin (anticonvulsant) 100 mg at 8:00 AM. Both medications were initialed as being administered by V13 (Agency Registered Nurse). On 05/13/24 at 02:11 PM, V2 (Director of Nursing) said today there are two agency nurses working on the second floor due to their regular nurses not being on duty today. She then said the med pass is slow today due to the system being down and an agency nurse did not show up so V3 (Quality Director) relieved the night nurse around 8:15-8:30 AM. V2 then said her expectations with the medication administration is to follow the five rights and to stay with the resident to ensure the resident is taking their medications. V2 (DON) said nurses are not to leave medications at the bed side to ensure that a confused resident doesn't wander in the room and take another resident's meds. V2 also said the medication administration window is one hour prior to and after the scheduled time so if given after that hour window, then the medication is considered late and nurses must notify the physician and document the late administration. On 05/14/24 at 02:20 PM, V17 (Nurse Practitioner) said her expectations for facility staff is to follow the five rights for each resident, observe medication administration and to check blood pressure (bp) with all bp meds. V17 then said when a medication is administered late, especially when prescribed more than once daily, the nurse should call the physician so adjustments can be made to the later administration times. On 05/15/2024 at 1:02 PM, V2 (Director of Nursing) said nurses are to administer fast-acting insulins (insulin aspart) 10-15 minutes prior to a resident eating their meal. Medication Administration policy last revised 12/2021 indicated that medications shall be administered in a safe and timely manner; shall be administered in accordance with the orders; resident may self-administer medications only if determined to do so by physician. R6, R7, R33 nor R34 have an active physician order to self-administer medications. No medication administration/physician progress notes were provided by facility for review.

Based on observation, interview, and record review, the facility failed to ensure that medical staff were properly trained to administer prescribed medications according to physician's orders and residents were free from significant medication errors. Three (R6, R7, R34) residents in the sampled medication pass of four residents (R6, R7, R33 and R34) experienced medication administration errors by the medication nurse. Findings include: R34: On 05/13/24 at 10:45 AM, observed R34 sitting in her wheelchair next to the bed with a bedside tray table in front of her. Also observed a clear, plastic medicine cup in front of resident on the bedside table that contained six pills within the cup. R34 said that her nurse had just left them a few minutes ago but she could not recall the nurse's name. She also said that she had already taken a few pills and needs to take the rest of her morning medications. When asked what these morning medications were, R34 said one is for my stomach, two are water pills, and I believe the one green pill is my iron pill. R34 could not remember what the two pink pills and one white pill were taken for but knows that she takes them every day. R34 added that if the nurse has the time, then she will stay with her to watch her take the medications. R34 then proceeded to self-administer the remaining six pills within the plastic med cup. Reconciliation of R34's active physician orders and medication administration record (MAR) for May 2024 showed the following medications as prescribed and scheduled per MAR at 9:00 AM: allopurinol (uric acid reducer) 300 milligram (mg) one tab by mouth daily, vitamin d3 (vitamin supplement) 25 microgram (mcg) one tab by mouth daily, aspirin (nonsteroidal antiinflammatory) enteric coated (ec) 81mg one tab by mouth daily, potassium citrate (urinary alkilinizer) extended release (er) 10 milliequivalent (meq) one tab by mouth daily, metolazone (diuretic) 5mg one tab by mouth daily, (certavite) senior multivitamin one tab by mouth daily, polyethylene glycol (stool softener) 3350 powder give 17 grams (g) with 6 ounce of water daily, metoprolol tartrate (antihypertensive) 50mg one tab by mouth every 12 hours (9a, 9p and hold if systolic blood pressure is below 110 or heart rate below 60), ferrous gluconate (iron supplement) 324mg one tab by mouth twice daily, magnesium oxide (supplement) 400mg one tab by mouth twice daily, metformin (antidiabetic) hcl (hydrochloride) 1000mg one tablet by mouth twice daily. Per R34's MAR, her 9:00 AM medications were documented as being administered by V5 (Agency Registered Nurse) with her initials/signature. Surveyor did not observe this documented administration by V5 or the obtaining of R34's blood pressure prior to taking the blood pressure medication. R7: On 05/13/24 at 11:48 AM, V5 (Agency Registered Nurse) said R7 has two medications scheduled for noon then began prepping those medications. At 11:52 AM, V5 entered R7's room to administer her noon meds when surveyor observed V5 pick up the plastic med cup that contained the nine pills that were previously observed on R7's bedside table by surveyor. V5 gave R7 the two noon meds then proceeded to administer the medications from within the plastic cup that she picked up from the bedside table. On 05/13/24 at 11:56 AM, V5 (Agency Registered Nurse) said the medications she administered within the med cup were R7's 9:00 AM medications, then said she did not want to stand over R7 while she took her pills, so she left them at the bedside. V5 also said she knows that she should stay with the residents to administer their medications and observe the residents take their meds. V5 then said the pills within the med cup administered to R7 were: losartan potassium (antihypertensive) 100mg one tab, metoprolol succinate (antihypertensive) ER (extended release) 50mg (3 tablets to equal 150mg), vitamin b-12 (supplement) 500 microgram (mcg) one tablet, amlodipine besylate (antihypertensive) 2.5 mg one tab, eliquis (blood thinner) 2.5mg one tab, ferate (iron supplement) 27mg one tab, furosemide (diuretic) 40mg one tab. V5 then said there is a one hour window prior to and after scheduled med administration time so R7's 9:00 AM medications were administered late. V5 added that she took R7's blood pressure earlier this morning. Reconciliation of R7's active physician orders and medication administration record (MAR) for May 2024 showed the following prescribed medications scheduled per MAR at 9:00 AM and documented as being administered by V5 (Agency Registered Nurse): losartan potassium (antihypertensive) 100mg one tab, metoprolol succinate antihypertensive) ER 50mg (3 tablets to equal 150mg), vitamin b-12 (supplement) 500 microgram (mcg) one tablet, amlodipine besylate (antihypertensive) 2.5 mg one tab, eliquis (blood thinner) 2.5mg one tab, ferate (iron supplement) 27mg one tab, furosemide (diuretic) 40mg one tab. On 05/13/24 at 12:09 PM, V5 (Agency Registered Nurse) stated that she has been a nurse for a year and knows that she should not leave medications at the bedside and should stay with resident to ensure they are taken. She added that R7 and R34 dislike for the nurse to stand over them while they take their medications, so to not cause any problems with these residents, she left their medications at the bedside. She added that moving forward, she will not leave any more medications at the bedside. R6: On 05/13/24 at 12:15 PM, V13 (Agency Registered Nurse) said she just came in at 11:15 AM this morning because she is covering for a nurse who did not show up. She added that there is a one hour window before/after scheduled med times so all the medications she will be administering will all be late. At 12:41 PM, observed V13 (Agency Registered Nurse) administer the following medications to R6: fenofibrate 48mg one tablet, acetaminophen 325mg (2 tabs), ferrous gluconate 324mg one tablet, bumetanide 0.5mg one tablet She added that the rest of the medications listed on R6's MAR were for the evening med pass. Reconciled R6's active physician orders with medication administration log and noted the medications as indicated by V13 with the following prescribed (9:00 AM) medications that were not observed as administered by V13 on 05/13/2024 but were initialed as being administered: levetiracetam (anticonvulsant) 250mg one tablet, eliquis (blood thinner) 2.5mg one tablet, potassium chloride (supplement) ER 10 milliequivalent (meq), meclizine (antivertigo) 25mg one tablet. On 05/13/24 at 02:11 PM, V2 (Director of Nursing) said today there is two agency nurses working on the second floor due to their regular nurses not being on duty today. She then said the med pass is slow today due to the system being down and an agency nurse did not show up so V3 (Quality Director) relieved the night nurse around 8:15-8:30 AM. V2 then said her expectations with the medication administration is to follow the five rights and to stay with the resident to ensure the resident is taking their medications. V2 (DON) said nurses are not to leave medications at the bed side to ensure that a confused resident doesn't wander in the room and take another resident's meds. V2 also said the medication administration window is one hour prior to and after the scheduled time so if given after that hour window, then the medication is considered late and nurses must notify the physician and document the late administration. On 05/14/24 at 02:20 PM, V17 (Nurse Practitioner) said her expectations for facility staff is to follow the five rights for each resident, observe medication administration and to check blood pressure (bp) with all bp meds. V17 then said when a medication is administered late, especially when prescribed more than once daily, the nurse should call the physician so adjustments can be made to the later administration times. On 05/15/2024 at 1:02 PM, V2 (Director of Nursing) said nurses are to administer fast-acting insulins (insulin aspart) 10-15 minutes prior to a resident eating their meal. Medication Administration policy last revised 12/2021 indicated that medications shall be administered in a safe and timely manner; shall be administered in accordance with the orders; resident may self-administer medications only if determined to do so by physician.

Based in interview and record review, the facility failed to follow the abuse policy by not notifying the abuse coordinator with allegation of employee-to-resident abuse. This failure affected one (R1) of three reviewed for reporting abuse. Findings include: On 1-30-24 at 12:45 PM, V1 said when there is an allegation of abuse, the staff is expected to report the allegation of abuse to the abuse coordinator immediately. V1 said R1's nurse did not report the allegation of employee-to-resident abuse to her. V1 said she will send a state reportable, suspend staff pending investigation, begin investigation, and in-service staff on reporting abuse allegation. On 1-30-24 at 12:10 PM, V2 (Director of Nursing) said all staff are expected to notify Administrator and Director of Nursing immediately about any allegation of employee-to-resident abuse. V2 said the facility can begin the process of the abuse investigation. V2 said she was not made aware of the employee-to-resident allegation of abuse until told by surveyor. On 1-30-24 at 12:03 PM, V5 (Registered Nurse) said R1 is alert, confused, and able make simple needs known. V5 said R1 said 2 Certified Nurse Aides pushed R1 into bed however V5 was present and informed R1 no staff pushed her in bed. V5 said R1 did not complain of pain at that time and later complained of chest of pain. V5 said R1 was complaining of chest pain and she sent out to hospital. V5 said she does not recall telling V2 (Director of Nursing) or V1 (Administrator) about the employee-to-resident abuse allegation. Abuse Reportables were reviewed and did not document any concerns of R1's employee-to-resident abuse prior to this investigation. Abuse Policy documents: Reporting: Alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported to the Administrator or designee and to the following other officials or agencies.

Based on interview and record review the facility failed to follow their safe lifting and moving of patient's policy and use appropriate techniques when turning and repositioning a resident to prevent an avoidable accident for 1 of 3 residents (R1). This failure resulted in R1 sliding out of bed during care sustaining a rug burn to the left knee. Findings include: R1 face sheet shows R1 has diagnosis of hemiplegia following cerebral infraction affecting left non dominate side, and neuromuscular dysfunction of bladder. R1 MDS dated [DATE] denotes in-part that R1 requires extensive assist with 2 plus person physical assist with bed mobility. R1 physical therapy plan of care initial assessments denote R1 has contractures, decrease in strength, reduced balance, and increased need for assistance from others. On 4/28/23 at 9:28am V1 (R1 Family) said his brother who is the power of attorney informed him that the facility told him that R1 scraped her knee on something, V1 said his brother did not give him any details. V1 said when he visited with R1, R1 he observed R1 with a bandage on her left knee, V1 said he did not see a bruise. V1 said he did not ask anyone at the facility about what happened to R1's knee, V1 said he did not look under the bandage. V1 said he just want to make sure that R1 is okay at the facility. Facility incident report dated 4/23/23 denotes in-part CNA (certified nursing assistant) call for help, found resident on the floor on her back in lying position. According to CNA, while she was changing resident, resident was rolling off the bed CNA caught her and gently placed her on the floor. Resident with skin tear on left knee. No change on ROM (range of motion) of extremities. R1 progress notes dated 4/23/25 denotes family and physician notified of incident. Review of R1 progress notes and incident report there is no documentation of large bruise to R1 left knee. On 4/28/23 at 10:30am R1 observed resting in bed, awake, alert, response to communications with nodding her head yes, and no. R1 bed noted with a right-side rail in place. R1 able to follow directives. R1 observed resting on air mattress, R1 able to follow redirections, R1 nodded her head up and down when asked if surveyor could look at her skin, R1 pointed to the nurse and the nurse asked R1 was it okay and R1 nodded her head in the up and down motion. R1 left knee was noted with a border gauze, and xeroform treatment under the border gauze, R1 has an oval shape pinkish area to the left knee, there is no bleeding noted, no drainage noted, no odor noted. R1 was asked if she fall, R1 nodded her head in the up and down motion. Surveyor pointed to the floor and asked R1 if she fell on the floor, R1 again nodded her head in the up and down motion. The nurse placed the dressing back on R1's knee. R1 was thanked for her time and observation. On 4/28/23 at 10:42am V2 (Nurse) said she was the nurse on duty when R1 was assisted to the floor by the CNA. V2 said V3 (CNA- certified nursing aide) informed her that she was changing R1 (providing incontinent care), and she turned R1, and R1 began to slide out of the bed, and so she assisted R1 to the floor. V2 said when she went to the room to assess R1 she noticed R1 with a skin tear to the left knee. V2 said she don't know what R1 hit her knee on to cause the skin tear. V2 said after assessing R1, R1 was lifted with a bed sheet and placed back in the bed. V2 said the physician and family was notified and orders were given. On 4/28/23 at 11:07am V3 (CNA-certified nursing assistant) said she was an agency CNA staff, and she was responsible for R1 care on 4/23/23 (morning shift). V3 said she had provided incontinence care to R1, and she was changing the sheet on the bed when R1 began to slide out the bed. V3 said she assisted R1 to the floor. V3 said R1 was in the middle of the bed when she turned R1 to the left (away from the wall and bed rail) to change the sheet. V3 said she was standing on the left side of the bed also. V3 said R1 has a new mattress, and it has bumps in it (air mattress) and that's why R1 was sliding. V3 said R1 began to slide, and her instincts was to catch R1 and bring R1 to the floor. V3 said the best thing was to gently bring R1 to the floor. V3 said she saw the abrasion to R1 left knee and she really believe it came from the carpet when she lowered R1 to the floor, but she can't be 100% certain. V3 said she was the only person assisting R1 at that time with incontinent care and bed mobility. V3 said she got report that R1 needed extensive assist, but no one informed her of how many physical assist that R1 needed. On 5/1/23 at 11:35am V4 (restorative nurse) said when turning R1 the staff should inform the resident that care is going to be provided inform R1 that she will be asked to assist with the turn by holding the assistive devices if she can. V4 said because R1 legs are contracted, R1 legs should be adjusted for comfort and to allow for the turning. R1 should be cued to assist as appropriate, ensure that R1 is in the middle of the bed initially, then pull R1 body to the opposite side of the turn, use the bed pad to assist with the turn (hold the bed pad near bottom and near back of patient), lift and push simultaneously to turn R1 onto the side. V4 said R1 has assistive devices used for bed mobility. V4 said R1 require extensive assist with 1-to-2-person physical assist with bed mobility. V4 said the staff has been in-serviced. On 5/1/23 at 3:25pm V7 (therapist) said R1 needs 2-person physical assist with bed mobility for turning and repositioning this is for safety, and this is because of the incident. V7 said the goal is for R1 to have one person assist with bed mobility. V7 said part of what therapy does is care giver education and so today he demonstrated to the facility on how to turn and reposition R1 with one-person physical assist. On 5/1/23 at 11:30am V5 (Administrator) said V3 has not being back to the facility to be in-serviced on facility practices, however all other CNA has been in-serviced. V5 said the facility has identified the root cause analysis was the position of R1 when R1 was being turned, V5 said R1 care plan has been updated, the air mattress is in place as a preventive measure for skin integrity. V5 said R1 family did receive an update on the incident. R1 MDS dated [DATE] denotes in-part that R1 requires extensive assist with 2 plus person physical assist with bed mobility. Facility CNA competency assessment, make occupied bed denotes in-part identify patient (safety) greet patient, explain procedures; provide privacy (residents rights), place bed in appropriate position, position resident on one side of the bed, utilize assist device if applicable, tuck dirty linen on first side, reposition resident to other side, remove soiled linen and complete tucking in bottom linen and dispose soiled linen, reposition resident to comfortable position. Facility policy titled safe lifting and moving of patients, with last approve date of 01/2022 denotes in-part in order to protect the safety and well being of associates and residents, and to promote quality care, this community uses appropriate techniques and devices to lift and move residents.

Based on interviews, and record reviews the facility failed to follow their bed hold policy. Facility failed to provide bed hold policy in which a written notice which specifies the duration of the bed hold at the time of transfer in the hospital. This practice failure affect one resident (R1) of three resident reviewed for transfer: bed hold policy. Findings include: R1 with initial admission in the facility on 1/2/23, last date of re-hospitalization was 2/25/23. On 3/3/23 at 11:30am, V4 (Admission Director) stated We give the bed hold policy on admission packet upon admission in the facility. On 3/8/23 at 11am V1(Administrator) stated We give the Bed hold policy on admission and every readmission, R1 was just readmitted on [DATE], and went out couple of days after. So it was given prior to her transfer. Son signed the readmission packet with bed hold policy in it on 2/23/23. Facility unable to provide signed bed hold policy dated 2/25/23, the day that R1 was transferred in the hospital. Bed-Hold and Returns policy with the last revised date on 12/2017 and last approved date on 12/2021 reads in part: At the time of transfer for hospitalization or therapeutic leaves, nursing facility must provide to the residents or resident representatives written notice which specifies the duration for the bed hold. Prior to transfer, written information will be given to the residents and the resident representative that explain in detail: the duration of the bed hold, the reserved bed payment policy as indicated by the state plan; and the details of the transfer (per Notice of Transfer).

Based on observation, interview, and record review, the failed to follow its policy to assess, identify, treat, and monitor resident who is at risk for developing pressure ulcer resulting in Deep Tissue Injury (DTI) . This deficiency affects two (R4, R55) of three residents in a sample of 18 reviewed for pressure ulcer/wound care management. Findings include: On 3/3/21 at 10:06am V14 Wound Care Coordinator (WCC) stated that R55 has left buttocks moisture associated skin disorder (MASD), she classified it as skin irritation/excoriation in wound report. Treatment ordered was Mupirocin 2% ointment and Calcium Silver Alginate. V14 turned R55 to his left side to provide wound care on sacral area. V14 stated right buttocks has skin dry, peeling skin, no redness, and skin intact. V14 stated it is getting better. Left buttocks has redness around periwound of the dry scab. Observed V14 apply wound treatment to both right, and left buttocks. She stated that mupirocin is for the redness/inflammation and calcium silver alginate is anti-bacterial. She stated she applied to both because right, and left buttocks because of treatment ordered. Review with her that wound report only identified left buttocks. She stated that she just following physician ordered. On 3/3/21 at 3:43pm V15 Pharmacist stated that if Mupirocin 2% and Calcium Silver Alginate was applied to right buttocks which has dry, and peeling skin, no redness, skin intact, more dryness to the skin. R55's March 2021 physician order [REDACTED]. R55's Care plan indicated: R55 has excoriation in left buttocks. He is at risk for skin breakdown due to limited mobility, and incontinent of bladder. R55's wound care report completed by V14 WCC indicated: 2/24/21 Wound type: Irritation /excoriation; Wound location: Left buttocks; Measurements: 3 x 2.6 x 0cm, No drainage, Red or darker pink, moderate irritation. Date wound identified: 10/12/20. 1/8/21 Wound type: Irritation/excoriation; Wound location: Left buttocks; Measurements: 1.5 x 1.5 x 0 cm, No drainage, Red or darker pink, moderate irritation. R55's wound report from Jan to February 2021 wound report only identified Left buttocks. On 3/3/21 at 10:34am. V14 WCC stated that R4 has MASD on his left buttocks, but she classified it as irritation/excoriation on wound report. His treatment is Calcium Silver Alginate. She turned R4 to his left side and removed wound foam dressing covering right and left buttocks dated 3/1/21. Review with her wound report dated 3/1/21 indicated R4 has identified Left buttocks. She stated that he has DTI on R buttocks and this is new. She stated that she did the dressing on 3/1/21 and she did not notice the wound impairment on right buttocks. She measured Right buttocks wound after cleansing with NSS, measuring 2.5x 4.2 cm. She described it as purplish discoloration with maceration, skin intact, soft and mushy. She stated that she will refer it to the wound doctor. She measured Left buttocks , 1.5 x1.5 cm, dried scab. She stated the left buttocks improved from last measurement she did on 3/1/21, 3x4cm. She applied calcium silver alginate to left buttocks as ordered and applied foam dressing which covered the right and left buttocks. R4's March 2021 Physician order [REDACTED]. R4's care plan indicated excoriation on left buttocks. R4's wound report completed by V14 WCC indicated: 2/18/21 Wound type: irritation/excoriation; Wound Location: Left buttocks/both buttocks; Date identified 7/31/20; Measurement: 3.5 x 6 x 0.10cm ; No drainage, red or darker pink , moderate irritation 2/24/21 Wound type: irritation/excoriation; Wound Location: Left buttocks; Date identified 7/31/20; Measurement: 3.5 x 6 x 0.10cm ; No drainage, red or darker pink , moderate irritation 3/1/21 Wound type: irritation/excoriation; Wound Location: Left buttocks; Date identified 7/31/20; Measurement: 3x 4 x 0cm ; No drainage, light pink, mild irritation On 3/3/21 at 11:00am V5 CNA stated that R4 usually gets up early in the morning at 6am and goes to bed after dinner. He has urinary catheter. He calls for help when he wants to use the bathroom for his bowel movement. On 3/3/21 at 11:57am R4 stated that he wanted to get up early in the morning. R4 is up in his wheelchair for 12 hours, and 12 hours in bed. R4 is alert, and oriented, times three, and able to verbalize needs to staff. On 3/4/21 at 9:54am V14 WCC stated that she was on medical leave form [DATE] and resumed working on [DATE]. She stated that R4 and R55 has both right and left skin irritation/excoriation from MASD but she only documented in wound report Left buttocks. She stated that if the wound is resolved or new wound is identified, physician should be notified to re-evaluate wound treatment and update care plan. She added that there are no continuity and consistency of documentation because if the census is low, nurse on the floor are doing the weekly wound measurement and documentation too. Facility's policy on Skin identification, Evaluation and Monitoring indicated: Procedure: Weekly: B. Document in medical record the findings of general skin check. 1. If wound is present and previously identified: a. Document integumentary findings. i. Appearance of the wound, including measurements ii. Treatment applied/initiated per healthcare provider order in the medical record. 2. If new wound is identified: a. initiate protective dressing b. Notify health care provider of findings and for further treatment orders. 4 Document evaluation in the medical record. C. Update plan of care with each intervention.

Based on observation, interview, and record review , the facility failed to follow their policy on dating opened food Items in refrigerator, cooler, and dry food storage area for 56 of 59 residents eating from the kitchen. Findings Include: 3/2/2021 At 10:50 am during observation in the refrigerator cooler area 6 containers of thickened lemon water, and 4 containers of thickened water open no date. In the dry food storage area a large bottle of hot sauce, food coloring, chocolate pieces in a bag, a container of chocolate sprinkles, a container of rainbow sprinkles, a bag of Oreo cookie pieces , a plastic bag of planta powder mix, and a bag of corn meal, all open, no date. 3/2/2021 At 11:30 V9 (Dietary Services) said, all food that is open should be dated no exceptions. 3/4/2021 At 10:55am A record review of the facility policy titled : Food and Supply Storage (Date Revised 1/20) Procedures: . The words sell-by, best-by, enjoy-by, or use-by, should precede the date. . Cover, label, and date all unused portions and open packages.

Based on observation, interview, and record review, the facility failed to follow medication storage policy. Facility failed to discard Insulin vials, eye drop, [MEDICATION NAME] purified ([MEDICATION NAME]) vial, and oral supplement from the medication carts and medication rooms. This deficiency was observed in two medication carts and two medication room reviewed for medication storage. Findings include: On 03/02/21 10:52 AM Medication room and labeling observation was conducted on 2 West medication room with V2 (Director of Nursing) observed R27's Humalog insulin vial inside the refrigerator with documented discard date of 2-28-2021. V2 said, the vial should have been removed and discard on 2-28-2021, it should not be in the med room. On 03/02/21 11:24 AM Medication Cart and labeling observation done on 2 west medication cart with V3 (Licensed Practical Nurse), observed R25's [MEDICATION NAME] acetate 1% with documented discard date 2-12-2021 and R24's Lantanoprost 125mcg/2.5ml discard date 3-1-2021 both inside of the medication cart. V3 said, we are supposed to remove and replaced any medications that are dated to be discard, I do not know why the two vials were in the cart. On 03/02/21 11:37 AM Medication room observation done on 2 East Medication Room with V4 (Licensed Practical Nurse), observed an 887ml bottle of UTI pro stat liquid supplement with expiration date of 4-16-2020 and one [MEDICATION NAME] purified /Mantoux with discard date 2-17-2021 V4 said, We are not supposed to have any expired medications in the med room and the [MEDICATION NAME] should had been discard on 2-17-2021, I do not know why it was not discarded. On 03/03/21 01:13 PM V2 (Director of Nursing) said, my expectation is that the medications that are expired according to manufacture date and or by the date the nurse documents on it when the medication is opened Discard date by: need to be taken out of the medication cart or the medication room, is not acceptable to have any medications that are past due or expired, they need to be removed and disposed. V2 Presented: Labeling of Medication Containers dated: 12/2016 with last revision 12/2019 reads: medications maintained in the community shall properly labeled and with expiration date.

Based on observation, interview, and record review, the facility failed to follow their infection control protocol by not performing hand hygiene when performing incontinence care to five residents (R19, R34, R39, R42 and R63) reviewed for incontinence care. Findings include: On 03/02/21 10:37 AM V6 (Certified Nursing Assistant) provided incontinence care to R42. R42 is an [AGE] year old female originally admitted on [DATE] with medical [DIAGNOSES REDACTED]. V6 said R42 is total care patient, needs complete care, I will apply a barrier cream because R42 is incontinent. V6 was observed putting on gloves without performing hand hygiene, provided incontinence care, removed the incontinent brief that was saturated with urine a large soft bowel movement. V6 cleaned the perianal area, applied incontinence cream, put on a new incontinence brief, put clean linen in the bed and a new cover using the same pair of gloves. 03/03/21 11:12 AM V6 said, I know I did wrong, when I change R42 I need to washed my hands and change the gloves after I cleaned the feces because everything I did touch after was contaminated, I know I did wrong, my mistake. On 03/03/21 09:08 AM V5 (Certified Nursing Assistant) provided incontinence care to (R34). R34 is an [AGE] year old female, originally admitted on [DATE] with most recent readmission on 9-10-2020 with medical [DIAGNOSES REDACTED]. V5 (Certified Nursing Assistant) was observed performing morning care including incontinence care to (R34), V5 did not perform hand hygiene/ hand washing before applying the gloves. V5 washed R34's upper part of the body and the perineal area, removed the incontinent brief that was saturated with urine, with the same pair of gloves V5 open R34's night stand and pulled an incontinent cream, applied it to R34's perianal area and put in a new incontinent brief, then proceeded to dressed R34. 03/03/21 09:30 AM V5 said, I was supposed to washed my hands before putting the gloves on, after I clean R34's perineal area and at the end when I finished providing care, but I did not washed my hands. On 03/03/21 09:40AM V6 (certified Nursing Assistant) provided incontinence care to (R39). R39 is a [AGE] year old male originally admitted on [DATE] with most recent readmission 1-4-2021 with medical [DIAGNOSES REDACTED]. V6 observed applying a pair of gloves without performing hand hygiene. V6 performed incontinence care and applied a new incontinence brief without removing the same pair of gloves. V6 said, I was just doing it fast to have the patient ready for the wound care nurse, I know I need to wash my hands before applying the gloves and after cleaning the patient. On 03/03/21 10:01 AM Incontinence care and mechanical transfer observation done with V6 and V7 (Certified Nursing Assistants) with R19. R19 is a [AGE] year old male originally admitted on [DATE] with most recent readmission on 12-23-2020 with medical [DIAGNOSES REDACTED]. V6 and V7 (Certified Nursing Assistants) V6 said, I am going to do the care, V7 will be here to help me turn, repositioned and transfer R19 because R19 is unable to assist with the care. V6 and V7 put on gloves, no hand hygiene/hand washing observed prior putting the gloves. V6 continued to provide morning care including incontinence care. V6 removed a saturated brief of urine, and smear of feces in incontinence brief, V7 cleaned the perianal area with the same pair of gloves, applied incontinence barrier cream , and a clean incontinence brief. V6 removed gloves and applied a new pair without any hand hygiene. V6 said I am supposed to do hand hygiene with the hand sanitizer or to wash my hands before starting cleaning R19, after going form dirty to clean and at the end of providing care. On 03/03/21 10:40 AM Incontinence care done by V8 (Certified Nursing Assistant) to R63. R63 is an [AGE] year old female originally admitted on [DATE] with most recent readmission on 9-4-2020 with medical [DIAGNOSES REDACTED]. V8 (Certified Nursing Assistant) said R63 is a total care and incontinent of bowel and bladder. V8 put on gloves, no hand hygiene hand washing was done prior the glove application, V8 continue to provide incontinent care, removed a saturated brief with urine, and smear of feces, cleaned the perianal area then went to the entry door of the room to look for another pair of gloves and said, I do not have any gloves, asked another coworker to bring a box of gloves. V8 applied a new pair of gloves without any hand hygiene/ hand washing. V8 said, I am supposed to do hand hygiene, I probably forgot to do it because I was worried I did not have any more gloves, I am sorry. 03/03/21 1:15 PM V2 (Director of Nursing) said, my expectation is that the nursing staff needs to wash their hands and put a new pair of gloves, before starting providing patient care, after cleaning anybody fluid including urine, feces going from dirty to clean and at the end of care, no staff should be using the same pair of gloves after doing incontinence care and applying new incontinent briefs or putting new bed linen, that will be cross contamination. V2 presented: Hand Hygiene dated: 5-2018, last revised 4-2020 reads: This community considers hand hygiene the primary means to prevent the spread of infections, before moving from a contaminated body site to a clean site during resident care and after removing the gloves

Based on observation, interview, and record review, the facility failed to follow their policy for self-administration of medication for one resident (R115) of six residents reviewed for medications in the sample of eighteen. Findings include: 3/2/21 11:20 AM One [MEDICATION NAME] inhaler 90 mcg per activation noted on R115's bedside table next to the resident. R115 said, I have asthma. I keep it in case I need it. 3/2/21 11:30 AM V17 (RN-Registered Nurse) said, it shouldn't be at the bedside. She may have brought it from the hospital. The NP (Nurse Practitioner) is here. I'll ask her to write an order. 3/2/21 12:00 PM V17 presented an order, okay to keep [MEDICATION NAME] inhaler at the bedside written by V20 (Nurse Practitioner). 3/3/21 2:00 PM V2 (Director of Nursing) said that there was not a Self-Medication Administration Assessment done on R115. A Policy titled, Self-Administration of Medications reads, 1. As part of their overall evaluation, the nursing associates will assess each resident's mental and physical abilities, to determine whether self-administering medications is clinically appropriate for the resident. 2. The nurse will complete the self-administration of medication assessment. 3. If the nurse and physician determines that a resident can safely self-administer medications, an order will be obtained for self-administration of medications.

Based on observation, interview, and record review, the facility failed for follow physician order [REDACTED]. This deficiency affects one (R4) of two residents reviewed for following physician order [REDACTED].>Findings include: On 3/3/21 at 11:57am R4 stated that she has been in the facility for almost 2 years, but no one check her pacemaker. He cannot remember when got the pacemaker. He does not feel dizzy nor having palpitation of chest pain. R4's March 2021 Physician order [REDACTED]. R4's Care plan indicated: Potential for pacemaker failure or malfunction (date initiated 10/20/19). Intervention listed in part: Pacemaker checks as ordered and as recommended by manufacturer. Record pacemaker setting and target heart rate. Monitor for signs and symptoms of failure: dizziness, palpitation, [MEDICAL CONDITION], irregular pulse, shortness of breath or altered level of consciousness and contact physician. No monitoring documentation for monitoring for sign and symptoms of pacemaker failure/malfunction. R4's [DIAGNOSES REDACTED]. On 3/3/21 at 2:10pm V2 Director of Nursing (DON) stated that they have not done pacemaker check with R4, but she will call the company and have it done today. Pacemaker usually done annual or as needed as indicated by physician. Review facility's policy on Care of a resident with Pacemaker indicated: C. Pacemakers are electronic devices that artificially stimulates the heart muscle with electrical impulses when the heart rhythm is too slow ([MEDICAL CONDITION]). Complications: A. If a pulse generator or battery fails or if the leas become displaced the pacemaker may not work properly, leading to bradyarrhymias. Monitoring: A. Monitor the resident for pacemaker failure by monitoring signs and symptoms of bradyarrhymias. C. The pacemaker battery will be monitored remotely through telephone or an internet connection. The resident's cardiologist will provide instruction on how and when to do this.

Based on interview and record review the facility failed to have two staff members transfer a resident into the bed and ensure a nursing staff (Z3) is trained regarding techniques for transferring a resident. This applies to one of three residents (R2) reviewed for injuries, in a sample of 6. As a result, R2 sustained a fractured humerus (arm bone). Findings Include: On 10/8/15 at 1:00 pm R2 stated that her shoulder was hurt when someone was putting her back to bed. R2 stated the Certified Nursing Assistant (CNA) picked her up under her arms. R2's progress note dated 8/22/15 indicated R2 stated the pain started after being lifted from the chair to the bed. R2's minimum date set assessment ((MDS) dated [DATE] includes [DIAGNOSES REDACTED]. R2's incident report dated 8/21/15 indicates R2 complained of right shoulder pain when lifting arm. R2's incident report indicates that R2 had swelling of the whole right arm. R2's final investigation report dated 8/28/15 that R2's CNA transferred R2 from the chair to the bed without assistance from other staff and without the use of a mechanical lift. The report also indicates that all staff interview denied assisting Z3 (Agency CNA) getting R2 into bed. R2's radiology report dated 8/22/15 indicates that R1 had a recent fracture involving the humeral neck with medial displacement. On 10/14/15 at 3:49 pm E10, Registered Nurse (RN) stated Z3, Agency CNA caring for R2 was from an agency. E10 stated early in the evening Z3 informed her R2 had not been placed in the bed because R2 requires two person transfer assistance. E10 stated Z3 was informed to ask for help when placing R2 in the bed. E10 stated later in the shift Z3 reported R2 was placed in bed and was complaining of right shoulder pain. E10 stated Z3 was aware that R2 required two person transfer assistance. R2's MDS dated [DATE] indicates R2 is total dependence requiring two or more person physical assistance. R2's MDS indicates R2's range of motion is impaired on both sides for upper and lower extremities. R2's falls care plan updated 8/20/15 includes an intervention for mechanical lift for transfer with two staff assist. R2's activities of daily living care plan updated 8/20/15 include an intervention for assist of two people for all transfers with use of mechanical lift. On 10/14/15 at 4:01pm E12, Restorative Nurse stated it is never okay to transfer a resident by lifting under the arms. E12 stated that R2 requires a mechanical lift for transfers. E12 stated staff must be gentle and careful when handling residents with fragile and brittle bones. On 10/14/15 at 6:00 pm E2, Director of Nursing stated Z3 is an agency CNA and the agency is responsible for training their staff. E2 stated that the agency makes sure the requirements of the facility are met before sending a CNA. E2 stated the agency sends CNA's that are experts in the field. The facility's safe patient/resident handling and movement dated 1/7/13 indicates the facility requires that any employee whose duties includes, or may include, lifting, transferring and reposition patients/residents be properly trained in use of patients/residents handling and movement. The policy also indicates that staff should utilize the proper techniques, lifting devices, etc. to match the identified task and the employees should avoid manual lifting unless identified as a qualifying manual lift.