Every finding on record at Clark-Lindsey Village

Based on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 11 (R1, R4, R6, R7, R8, R12, R13, R14, R17, R18, R31) of 13 residents reviewed for infection control in the sample list of 26. This failure has the potential to affect all 23 residents in the facility. Findings include:1.) The facility's Employee Illness log documents eight employees were off work due to gastrointestinal (GI) symptoms of vomiting, diarrhea, and/or nausea between 4/16/26 and 4/22/26. The facility's resident infection log with date range January-April 2026 documents nine residents (R1, R4, R6, R7, R12, R13, R14, R17, and R31) had GI symptoms on 4/18/26. The facility's Initiation of Isolation or Precautionary Measures policy dated 7/1/15 documents Universal Precautions are followed for all residents to prevent the spread of microorganisms between residents, staff, and visitors, and all staff are responsible for complying with isolation precautions. This policy documents isolation precautions will be implemented whenever necessary and precautionary measures will be initiated for an infectious or suspected infectious resident. This policy documents contact isolation as one of the precautionary measures implemented to prevent the spread of infectious organisms and the facility follows the Centers for Disease Control and Prevention guidance for isolation and precautionary measures. The facility's Infection Control Policy dated 2/19/19 documents to limit the movement of residents with a highly infectious disease only for medically necessary purposes. This policy documents standard precautions include the use of PPE, hand hygiene and handling equipment or items in the patient environment that are likely contaminated in a manner that prevent the transmission of infectious organisms. The facility's Resident Rooms Daily (cleaning) policy documents to clean all equipment. On 4/21/26 at 9:35 AM the sign to the skilled unit indicates GI illness present and to wash hands with soap and water. On 4/21/26 between 11:27 AM-11:35 AM: V14 (Certified Nursing Assistant/CNA) removed meal tray from R31's room and carried the tray with his bare hands down the hallway and into the dining room. There was contact isolation signage and PPE container on R31's room door. V14 confirmed he carried R31's meal tray out of R31's isolation room with his bare hands to the dining room. V14 stated V14 placed R31's used dishes and utensils into the bin on the cart in the dining room. V14 stated the facility has not been using disposable dishes or utensils, but that is something V14 suggested to management. V20 (CNA) applied gown and gloves to deliver R6's meal tray into R6's room. Contact isolation was posted on R6's room door. V20 gave R6 bites of food and drink. V20 stated R6 had diarrhea twice this morning. V20 did not wear gloves and carried R6's meal tray down the hallway and V20 handled R6's used dishes and utensils with her bare hands putting these items into the bin on the cart in the dining room. V20 confirmed V20 did not wear gloves while handling R6's dishes and should have. On 4/22/2026 from 10:27 AM- 10:52 AM R6's room door contained contact isolation signage and a PPE cart. V21 (Housekeeper) wore the same pair of gloves to clean high touch surfaces in R6's room and bathroom and while handling the soiled mophead. V21 used this same pair of gloves to handle the broom, mop, and toilet brush taken from the housekeeping cart, used these items in R6's room and placed these items back onto the housekeeping cart without disinfecting. V21 removed her PPE upon leaving R6's room but did not perform hand hygiene and then pushed the housekeeping cart down the hallway. V21 reapplied gloves and removed the bagged soiled isolation gowns from R6's room and exited the unit. V21 used the same mop, broom, and toilet brush to clean R8's room, without disinfecting prior. R8's room was not an isolation room. At 10:58 AM V21 stated V21 disinfects high touch surfaces in resident rooms including doorknobs, bathrooms, and tables and gloves are supposed to be changed between each resident room and alcohol-based hand rub (ABHR) used after each room unless dirty, then hands are washed with soap and water. V21 stated the broom and mop handles are disinfected daily. V21 stated there are no specifics for moving from cleaning isolation rooms and non-isolation rooms, V21 just cleans the rooms while the residents are out of their rooms. V21 confirmed V21 did not change gloves while cleaning R6's room and handled the cleaning equipment that was then used to clean R8's room. On 4/22/26 at 10:04 AM R6 was sitting in the dining room with other residents present. R6 is on contact isolation for GI symptoms. On 4/22/2026 at 12:18 PM V19 (CNA) removed R31's meal tray with used dishes/utensils from R31's room and carried the tray with her bare hands down the hallway and into the dining room. R31's door contained contact isolation signage and a PPE cart. On 4/22/2026 at 2:20 PM there was contact isolation signage on R6's room door. V11 (CNA) stated R7 had vomiting and diarrhea starting the morning of 4/17/26 and by that evening R14 had it too. V11 stated isolation was implemented the next day or two when staff were told everyone had it (GI symptoms). V11 and V19 (CNA) applied gowns and gloves to enter R6's room and used a full mechanical lift to transfer R6 onto the toilet. There was a sour smell in R6's room. V11 wore the same pair of gloves and provided perineal cleansing, applied clean brief, and touched handles of the mechanical lift, R6's bed remote controls and R6's bed linens. At 2:40 PM V11 confirmed V11 did not change her gloves after R6's perineal care, cross contaminating items in R6's room. On 4/23/2026 at 8:51 AM R31's room door had contact isolation signage posted. V18 (Registered Nurse/RN) applied gloves and administered R31's eye drops, nasal spray, and oral medications. R31 did not wear a gown and did not change gloves between the different routes of medications. At 10:03 AM V18 confirmed V18 did not wear a gown or change gloves during R31's mediation administration. V18 stated V18 did not think R31 was on isolation since it had been passed on in report that R31 had not had vomiting or diarrhea within the last 24 hours. On 4/23/2026 at 10:23 AM V19 stated R31 had sediment like loose stool yesterday, R31's stools had not yet returned to normal, and R31 remains on contact isolation today. R6's Physician's Order dated 4/18/26 documents Contact precautions per facility guidelines for gastroenteritis (GI inflammation), suspected norovirus (highly contagious GI illness). R6's Nursing Note dated 4/18/2026 at 6:11 PM documents R6 had two episodes of diarrhea. R6's Nursing Note dated 4/21/2026 at 9:49 AM documents R6 had one loose stool during the night. R31's Physician' Order dated 4/18/26 documents Contact precautions per facility guidelines for gastroenteritis, suspected norovirus. R31's Nursing Note dated 4/18/2026 at 6:08 PM documents R31 vomited twice and had three episodes of diarrhea. R31's bowel tracking documents R31 had loose stool on 4/22/26 at 3:47 PM. On 4/23/26 at 2:20 PM V3 (Infection Preventionist) stated on 4/18/26 the facility had nine residents with symptoms of GI illness, including nausea, vomiting, and diarrhea, and contact isolation precautions were implemented until 48 hours of being free of symptoms. V3 stated staff should wear gowns and gloves to enter and when providing cares in these rooms as it is posted on the contact isolation signage on the room doors with step by step instructions. V3 stated washing hands with soap and water is the preferred method of hand hygiene for these rooms. V3 confirmed staff should change gloves when moving from soiled to clean areas to prevent cross contamination. V3 stated V3 leaves it up to the housekeeping supervisor to determine if contact isolation rooms should be cleaned last. V3 stated housekeeping staff should disinfect items after each use, between cleaning contact isolation and non-isolation rooms. V3 stated residents on contact isolation should eat in their rooms and should not be in the dining room. V3 stated the dishes are not disposable and staff should remove the dishes from the isolation rooms and take to the kitchen, but staff should wear gloves to handle the dishes. The Long-Term Care Facility Application for Medicare and Medicaid dated 4/21/26 documents the facility has a census of 23 residents. 2.) On 4/23/2026 at 1:34 PM V17 (Licensed Practical Nurse/LPN) applied a gown and gloves and entered R4's room. V17 used the same pair of gloves to remove R4's right great toe wound dressing, cleanse the wound, and apply betadine and clean dressing. R4's right great toe was necrotic/black with diminished subcutaneous tissue. At 2:00 PM V17 confirmed V17 did not change her gloves until after R4's wound treatment was complete. On 4/23/26 at 2:09 PM V2 (Director of Nursing/DON) stated the nurses should change gloves when moving from soiled to clean areas during wound care. 3) On 04/22/2026 between 12:25 pm - 1:15 pm During constant observation of the resident lunch meal service, V12 (CNA) failed repeatedly to wash her hands or use hand sanitizer, remove soiled gloves between clean and dirty task resulting in cross-contamination. V12 did not don gloves, wash her hands or uses hand hygiene prior to serving R17 and R18 with her bare hands. V12 removed a soiled, empty drinking glass and a dirty plate from R17 and R18's table. V12 walked across the room, and over to a busing tub filled with dirty dishes. V12 rearranged soiled dishes to add the dirty plate and drinking glass she removed from R17 and R18's table. V12 continued with her soiled bare hands. V12 without performing hand hygiene proceeded to the meal service steam table line and got a piece of cake, then served the cake to R18. V12 did not wash her hands or use hand sanitizer. R7 requested ice cream. V12 left the dining room, went to the kitchenette, adjacent to the nursing office, opened the freezer with her soiled hands. V12 retrieved a cup of ice cream from the kitchenette freezer and returned to the resident dining room. V12 removed the lid of the ice cream with the same soiled hands and served the ice cream to R7. V12 then exited the dining room and met with an unidentified family member. The unidentified family member was talking to R14. R14 was seated in a geriatric wheeled chair. V12 stood talking to R14 and the unidentified family members. V12 stood with her soiled hands on her hips while talking. V12 then pushed R14's geriatric wheeled chair into the dining room and parked R14's geriatric wheeled chair at a corner table. V12 adjusted the other dining chairs and adjusted R14's position in the geriatric wheeled chair. V12 CNA did not perform hand washing or use hand sanitizer. V12 went back to the steam table food service line. V12 did not wash her hands or use hand sanitizer. V12 donned gloves, requested food items from dietary staff. Plated food was handed to V12. V12 touched the rim of each plate handed to her. V12 then served R14's meal. V12 went to the beverage area of the food service area and filled R14's lidded drinking glass. V12 continued with the same soiled gloves and sat down at R14's table. V12 fed R14 with the same soiled gloves. V12 also intermittently appeared to text on her phone with the same soiled gloves while she sat feeding R14 his meal and held his straw to drink. V12 finished assisting R14 , removed her soiled gloves and again did not wash her hands or use hand sanitizer. On 4/22/26 at 1:15 pm V12 acknowledged she did not wash her hands, throughout dining services. Acknowledged she handled soiled dishes, meal trays and fed R14, without performing hand hygiene. V12 then stated My bad, I always wash my hands when I provide resident care (did not indicate what type of personal care she was referring to). There is no hand sanitizer in the dining room. We are too busy to wash our hands all the time in the dining room. Usually, Dietary staff serve the residents. V12 then acknowledged there was an operable hand sink, with soap and paper towels present at the beginning of the steam table food service line that she had not used during meal service. On 4/23/26 at 8:20 am V1 (Administrator) stated the expectation for all dietary and nursing staff is to perform hand hygiene throughout resident meal service. V1 confirmed staff failure to prevent cross contamination during meal service is an infection control issue. The facility policy Hand Hygiene dated 02/20/25 documents the following: POLICY STATEMENT The primary objective of hand hygiene is to remove dirt, organic debris, and transient microorganisms as quickly and completely as possible. Hand hygiene continues to be the primary means of preventing the transmission of infection. The same policy documents: PROCEDURE Hand hygiene should occur: When hands are visibly soiled (hand washing with soap and water); Before and after direct Elder contact (for which hand hygiene is indicated by acceptable professional practice); Before and after eating or handling food (hand washing with soap and water); Before and after assisting an Elder with meals; After handling soiled equipment or utensils After removing gloves or aprons; and After completing duty. Consistent use by staff of proper hygienic practices and techniques is critical to preventing the spread of infections. Alcohol based hand rubs (ABHR) cannot be used in place of proper hand washing techniques in a food service setting.

Based on observation, interview, and record review the facility failed to appropriately store and label medications for five (R32, R33, R6, R24, R10) of five residents reviewed for medication storage in the sample list of 26. Findings include: The facility's General Guidelines for Medication Storage dated 2/20/25 documents the following: Medication rooms, carts and supplies must be locked or attended by persons with authorized access and only licensed nurses and consultant pharmacists are allowed access to medications. Internal and external medications should be stored separately. Outdated medications should be immediately removed from stock and disposed of.The facility's General Guidelines for Medication Administration dated 6/17/25 documents to remove outdated or discontinued medications and appropriately discard. 1.) On 4/21/26 at 3:24 PM V10 (Licensed Practical Nurse/LPN) left the medication cart unlocked and unattended near the medication room. V10 walked down the hallway and into a resident room, leaving the cart out of V10's view. V10 returned to the cart at 3:28 PM and confirmed the medication cart was left unlocked/unattended and it should have been locked.On 4/22/2026 at 1:29 PM V10 (LPN) stated all the residents have medications stored in the medication cart.On 4/23/26 at 11:36 AM V17 (LPN) left the medication cart unlocked and unattended near the medication room. V17 entered R1's room and checked R1's blood glucose level leaving the medication cart out of V17's view.On 4/23/26 at 12:16 PM V2 (Director of Nursing/DON) stated medication carts should be locked when left unattended.The Long-Term Care Facility Application for Medicare and Medicaid dated 4/21/26 documents the facility has a census of 23 residents.2.) On 4/21/26 at 3:28 PM the facility's medication cart was reviewed with V10 (LPN). R6's Refresh eye drop bottle was stored in the same compartment as R6's Preservision and Simethicone, oral medications, which was verified with V10. V10 stated oral medications and eye drops should not be stored together. R24's bottle of Preservision/Lutein was dated with an expiration date of March 2026, confirmed with V10.R6's active physician's orders includes orders for Preservision and Simethicone. R24's April 2026 Medication Administration Record documents R24 received Lutein daily.3.) On 4/23/2026 at 11:55 AM the facility's medication room was reviewed with V17 (LPN). The cabinet contained a box of Ipratropium nebulizer solution that was not labeled with a resident's name, confirmed with V17. On the same shelf was a box of Ipratropium/Albuterol 0.5 milligrams(mg)/3 mg per 3 ml vial that was labeled with R33's name. In another cabinet there was a bag of Heparin syringes that were labeled with R32's name and expiration date of February 2026. V17 stated these medications should be destroyed because R33 and R32 are no longer residents at the facility.On 4/23/2026 at 12:16 PM V2 (DON) stated the floor nurses are responsible for destroying medications.R33's census documents R33 discharged on 12/8/25. R32's census documents R32 discharged on 5/5/25.4.) On 4/23/26 at 9:20 AM during V18 (Registered Nurse) administered R10's medications in R10's room. There was a tube of hemorrhoid cream, and a bottle of dry eye relief eye drops on a nightstand next to R10's bed, confirmed with V18. V18 stated V18 did not think the medications belonged to R10 and believed they belonged to R10's family or caregivers. V18 stated medications should not be left in resident rooms.On 4/23/26 at 10:14 AM V7 (LPN/Nurse Manager) stated medications should be stored in the medication cart, R10's family may have brought in the medications, but they have been previously educated to bring all medications to the nurse to store and obtain physician's orders.R10's active physician orders do not include orders for hemorrhoid cream or dry eye relief drops.

Based on observation, interview, and record review the facility failed to have physician orders for Continuous Positive Airway Pressure (CPAP) settings, implement CPAP care/maintenance, and assess vital signs and lung sounds pre/post nebulizer administration for two of two residents (R11, R14) reviewed for respiratory care in the sample list of 26. Findings include: 1.) The facility's General Guidelines for Medication Administration dated 6/17/25 documents to obtain and record any vital signs necessary prior to administering medication and observe for medication actions or reactions and document accordingly. The facility's Nebulizer Administration policy dated 12/1/17 documents to monitor for medication side effects. R14's Hospice assessment dated [DATE] documents:Symptoms: cough, shortness of breath Respiratory Pattern: regular rate Respiratory Effort: increased effort Cough Description: moist, weak Shortness of breath activity level: at restBreath sounds RUF: clear Breath sounds RMF (Right, Middle Field): decreased Breath sounds RLF (Right Lower Field): crackles Breath sounds LUF (Left, Upper Field): clear Breath sounds LLF (Left, Lower Field): decreased Uses supplemental oxygen: no Has nebulizer: noCurrent Symptoms and Severity: Pt (patient) was admitted to (hospital) from 3/16/26-3/23/26. Patient sent from oncology clinic due to increased LE (lower extremity) edema, weakness, and possible confusion. CXR (chest x-ray) noted small pleural effusion. Patient was diuresed with IV (intravenous) Lasix 80 mg (milligrams) BID (twice daily) throughout admission. He received one dose of metolazone 5 mg. Leg edema decreased significantly. Transitioned to torsemide, increased to 40 mg twice daily for discharge back to facility. Pt lost about 40 lbs (pounds) from aggressive diuresis during hospitalization then re-gained about 15 lbs weight gain since return from the hospital, his legs have become swollen again and are weeping. R14's April 2026 Medication Administration Record (MAR) documents Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (milliliter) 1 vial inhale orally four times a day for respiratory distress beginning 4/17/26 until 05/01/2026. There is no documentation in R14's medical record that R14's lungs are assessed or vital signs pre and post nebulizer administrations. On 4/22/2026 at 2:50 PM V10 (Licensed Practical Nurse/LPN) administered R14's Ipratropium-Albuterol nebulizer treatment. V10 did not assess R14's lungs or vital signs prior to administration. On 4/22/26 at 4:15 PM V10 stated R14 receives nebulizer treatments for pneumonia. V10 was asked about any monitoring or assessments for newly ordered nebulizer treatments. V10 stated V10 just makes sure the nebulizer is working but V10 does not do any kind of assessment of lung sounds or vital signs pre/post nebulizer administrations. V10 stated the MAR indicates if vital signs need to be obtained when giving medications. On 4/23/2026 at 12:17 PM V2 (Director of Nursing/DON) stated the nurses should be documenting lung assessments in the nursing notes. V2 stated R14's last documented lung assessment was on 4/7/26, and the nurses should be doing them more frequently. The manufacturer's insert for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML dated February 2025 documents this medication can produce a clinically significant cardiovascular effect in some patients as measured by pulse rate, blood pressure, and/or symptoms. The action of the medication should last up to 5 hours and consult the healthcare provider for increase in dose or frequency, and seek medical consultation if symptoms worsen. 2.) The facility's Use of CPAP or BIPAP (Bilateral Positive Airway Pressure) policy dated 2/7/19 documents to verify the physician's order in the chart, settings are set by a respiratory therapist, and follow cleaning instructions for weekly cleaning of mask, tubing and exhalation port in mild detergent and warm water solution, rinse thoroughly, and air dry. This policy documents to clean the chinstrap and headgear weekly in mild detergent, rinse, and allow to air dry. This policy documents to clean the humidification chamber daily or after each use. On 4/21/2026 at 10:40 AM and on 4/22/26 at 2:50 PM R11's CPAP mask and machine were uncovered on top of R11's nightstand. On 4/21/26 at 12:00 PM R11 stated he uses a CPAP nightly and it does not require routine cleaning/care/maintenance. R11's MDS dated [DATE] documents R11 as cognitively intact. R11's Physician Order dated 5/2/25 document to use CPAP nightly with at home settings. There are no orders for the CPAP settings or care/maintenance of the CPAP. R11's care plan dated 6/6/25 documents R11 uses a CPAP but does not include any interventions for settings, care or maintenance. On 4/22/2026 at 3:25 PM V10 (LPN) stated R11 recently got a new CPAP machine, tubing/mask should be cleaned once per week by the night shift nurse and documented on the Treatment Administration Record. V10 stated there should be physician orders for care/cleaning. V10 stated the CPAP settings are preset by respiratory therapy, nursing does not adjust the settings. V10 stated there should be a bag in R11's room to store the CPAP mask/tubing during the day when not in use. On 4/22/2026 at 3:47 PM V2 (DON) confirmed CPAP settings should be part of the physician's order for CPAP use.

Based on observation, interview, and record review the facility failed to answer the call light timely for a resident that requires assistance with toileting for one of 16 residents (R7) reviewed for dignity on the sample list of 26.Findings include:R7's Minimum Data Set (MDS), dated [DATE], documents R7's Brief Interview for Mental Status score as 11 out of a possible 15, indicating moderate cognitive impairment. The same MDS documents that R7's toileting needs require Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.R7's current Care Plan documents the following: (R7) is at risk for falls related to Parkinson's, history of falls, and hypotension. Be sure the resident's call light is within reach, and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.R7's same Care Plan also documents: (R7) has an ADL (Activities of Daily Living) self-care deficit related to Parkinson's, orthostatic hypotension, and recent hospitalizations. TOILET USE: Dependent.On 4/22/26 at approximately 2:05 p.m., at the end of the resident council group, R7 asked to share personal information regarding toileting assistance. R7 stated that the stand lift used for transfers requires two staff members. R7 stated, I turn on my call light and at times it takes up to 30 minutes for staff to get the (stand lift) to take me to the bathroom. R7 stated she has not been incontinent but has experienced pain while waiting too long to get on the toilet. R7 further stated, Either the CNAs (Certified Nursing Assistants) don't answer the call light for 20 or 30 minutes, or they come and tell me I have to wait because the lift requires two people. They have to find someone to help them. I wait and wait, and sometimes I have to turn my call light back on because I know they have forgotten me. R7 stated this has happened several times, with waits ranging from 15 to 30 minutes. R7 stated the incidents were recent, though she could not recall the exact dates. R7 could not identify specific staff members. R7 then wanted to show this surveyor the stand lift she was referring to. An unidentified CNA pushed R7 down the hallway. R7's wheelchair approached the stand lift parked in the hallway. R7 pointed to the stand lift and stated, This is the one (stand lift) here. Two people (two staff assistance) have to use it to transfer me.On 4/23/26 at 9:30 a.m., V1 (Administrator) provided a call light tracking record of R7's call light activation and response times. V1 reviewed a printed call light record with this surveyor. R7's call light record for the past week clearly documented when R7 turned on the call light and how long it took staff to respond and provide assistance. V1 confirmed the call light activation times were accurate. V1 confirmed the times documented below were excessive. V1 confirmed that waiting for toileting needs to be met is a dignity issue. V1 stated, (R7's) call light should have been answered within the targeted time frame of ten minutes. V1 confirmed that R7's call light was turned on and went unanswered for extended periods on five different occasions. These five delays in call light response times all occurred within a 13-hour and 28-minute time frame. R7's call light was activated as documented below between 4/16/26 at 10:28 p.m. and 4/17/26 at 11:56 a.m., resulting in delays in care:On 4/16/26 at 10:28 p.m., target time 10 minutes, actual time R7's call light was on: 15 minutes and 41 seconds.On 4/17/26 at 6:31 a.m., target time 10 minutes, actual time R7's call light was on: 13 minutes and 38 seconds.On 4/17/26 at 7:57 a.m., target time 10 minutes, actual time R7's call light was on: 21 minutes and 3 seconds.On 4/17/26 at 10:01 a.m., target time 10 minutes, actual time R7's call light was on: 16 minutes and 42 seconds.On 4/17/26 at 11:56 a.m., target time 10 minutes, actual time R7's call light was on: 36 minutes and 53 seconds.The facility policy titled Call Lights, dated 01/30/24, documents the following: POLICY STATEMENTThe purpose of this policy is to establish guidelines relating to the answering of call lights in a timely manner.PROCEDURESCall lights are in each resident room, bathroom, and spa area.Call lights are to be answered as quickly as possible. The goal is to provide person-centered care and meet the residents' needs and expectations as quickly and efficiently as possible.When the nursing staff respond to the call light, the call light panel should then be acknowledged by the staff member, and the call light notification stopped.After answering the call light in the room, staff are to provide the requested service in a timely manner.

Based on observation, interview, and record review the facility failed to assess and care plan for self-administration of medication for one of one resident (R12) reviewed for self-administration of medications in the sample list of 26. Findings include: The facility's Self-Administration of Medications in Skilled Nursing policy dated 11/4/25 documents the interdisciplinary team will assess to determine if the resident is appropriate to self-administer medications. This policy documents the nurse will complete the Assessment for Resident Self-Administration of Medications to aid in determining the resident's ability and the determination will be documented in the resident's medical record and part of the resident's care plan. On 4/21/2026 at 11:00 AM R12 was in bed and there were two blue capsules in a medication cup on R12's overbed table next to R12's bed. R12 stated the nurse brought in four of these pills at breakfast, R12 takes two with each meal, so the remaining two are for lunch time. On 4/21/26 at 1:00 PM V10 (Licensed Practical Nurse) stated the pills at R12's bedside are Creon and R12 has an order to self-administer this medication. R12's Physician Order dated 6/9/25 documents Creon Delayed Release Particles 36000-114000 UNIT give two capsules by mouth with meals for Exocrine Pancreatic Insufficiency, take one with first bite of food and second mid meal. After given these instructions the nurse may leave this medication with R12.R12's active care plan does not document R12 can self-administer medications. There is no assessment for the ability to self-administer medications in R12's medical record. On 4/22/2026 at 9:56 AM V2 (Director of Nursing) stated residents who are approved to self-administer medications should have an assessment, physician order, and care plan to self-administer medications. At 11:32 AM V2 confirmed R12 did not have an assessment or care plan to self-administer medications.

Based on interview and record review the facility failed to provide safe transfers with a mechanical stand lift on two separate occasions, for one of three residents (R18) reviewed for falls on the sample list of 26.Findings include:R18's Minimum Data Set (MDS), dated [DATE], documents R18's Brief Interview for Mental Status score as two out of a possible 15, indicating severe cognitive impairment.The same MDS documents that R18 requires Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.R18's same MDS documents the following fall history at the time of the assessment: two falls with no injury, defined as no evidence of injury noted on physical assessment by the nurse or primary care clinician; no complaints of pain or injury by the resident; and no change in the resident's behavior after the fall. The MDS also documents one fall with Injury (except major) - skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the resident to complain of pain.R18's current Care Plan documents the following: R18 is at risk for falls related to deconditioning, recent hospitalization, and a history of a fall with fracture on admission. The same Care Plan documents: Nurse evaluated for injury: none noted. Coaching completed with the CNA (Certified Nursing Assistant) on using transfer directives. Fall 04/06/2026 (Intervention post fall 4/03/26). R18's same Care Plan also documents: Give clear instructions to (R18) when doing transfers. Staff reminder to review transfer directive on back of bathroom door. LTF (sic) 4/12/2026 (intervention post fall 4/12/26).R18's Transfer Directives, posted on the back of R18's bathroom door and dated 3/10/26, document that R18 is Dependent on the use of a sit-to-stand mechanical lift and requires two staff assist for transfers due to posterior lean once sitting on the edge of the bed.R18's Fall Investigation, dated 4/06/26, documents review of R18's 4/03/26 fall. The investigation documents: Investigation: Resident was assisted to the floor when his legs gave out. The CNA was assisting the resident to use the bathroom. The resident's transfer directives are to use the sit-to-stand mechanical lift with two assists. The CNA thought she could do it with the resident holding the bar and assisting with the gait belt. Per the CNA, the resident had both PT/OT (Physical Therapy/Occupational Therapy) back-to-back that morning.Root cause: Transfer directive not followed.Intervention: Nurse evaluated for injury: none noted. Coaching completed with the CNA on using transfer directives.R18's Fall Investigation, dated 4/14/26, documents review of R18's 4/12/26 fall. The investigation documents: Investigation: The resident was lowered to the floor by CNA when he started to slide down the side of the bed. The CNA assisted the resident to a sitting position at the side of the bed. He had been lying down. He allowed the resident to sit briefly before trying to get him up. The CNA put the gait belt on and told the resident they were going to stand and transfer on the count of three. The resident tried to stand before the count of three and then lost his balance. The transfer directive at the time of the incident was two assists with the sit-to-stand mechanical lift.Root cause: Weakness, not following direction (R18 has a BIMS score of 02 out of 15).Intervention: CNA who was with the resident at the time of the incident was educated on checking the transfer directive prior to assisting the resident. Give clear instructions to (R18) when doing transfers. Message posted in (electronic medical record).On 4/23/26 at 12:15 p.m., V15 (Assistant Director of Nursing/ADON), confirmed that V15 completes the fall investigations in the facility. V15 reviewed R18's Fall Investigation dated 4/03/26.V15 stated, On (R18's) fall 4/03/26, in the bathroom, (V12 CNA), failed to review (R18's) transfer directives posted in (R18's) bathroom. V15 also stated, (R18) required a sit-to-stand mechanical lift for transfers. (V12 CNA) used a gait belt to pivot transfer (R18) to the toilet. I called her immediately and reviewed the importance of following residents' transfer directives posted in the resident room.V15 also reviewed R18's Fall Investigation of 4/12/26. V15 stated, (R18's) fall on 4/12/26 occurred in (R18's) room. (V14 CNA) was in (R18's) room to get (R18) out of bed and dressed. (R18) is a large man. (V14 CNA) should have asked for help. (R18) required assistance of two CNAs for positioning in bed. (V14 CNA) assisted (R18) from a lying position to a seated position. (V14 CNA) had positioned (R18) too close to the edge of the bed. He should have asked for help.The facility policy titled Fall Program, dated 12/07/23, documents the following: POLICY STATEMENTThe purpose of this policy is to establish guidelines relating to fall prevention guidance and interventions for residents in Meadowbrook (unit of the facility) and the [NAME] House (units in the facility) Homes. While falls cannot always be prevented, a comprehensive program will help ensure processes and interventions are in place to minimize the risk and effects of falls as much as possible while maintaining and respecting resident choice and quality of life.

Based on observation, interview and record review the facility failed to administer medications timely and as ordered for two of eight residents (R10, R31) reviewed for medication administration in the sample list of 26. This failure resulted in 5 medication errors out of 27 opportunities resulting in a 18.52% medication error rated. Findings include: 1.) On 4/23/2026 at 8:51 AM V18 (Registered Nurse/RN) entered R31's room and administered R31's medications including Lidocaine 4% topical patch, Gabapentin 250 milligrams/5 milliliters (ml) 2 ml, and Cosopt Ophthalmic Solution 2-0.5 % one drop in left eye. At 8:59 AM these medications were red on V18's computer screen. V18 stated it is because these medications were due at 7:00 AM and the nurses have an hour window before and after the scheduled time to administer medications. V18 was asked why these medications were late and replied V18 has 24 residents to give medications too. R31's April 2026 Medication Administration Record documents Lidocaine is scheduled at 7:00 AM, Gabapentin, and Cosopt are scheduled twice daily at 7:00 AM and 7:00 PM. On 4/23/2026 at 12:16 PM V2 (Director of Nursing) stated medications are to be given within an hour of the scheduled time. 2.) R10's Physician Order dated 9/3/25 documents Polyethylene Glycol mix 8.5 grams in 8 ounces (oz) of water and give by mouth daily. R10's Physician Order dated 10/29/25 documents Guar Gum (fiber) give one packet mixed in 8 oz of water daily.On 4/23/2026 at 9:20 AM V18 (RN) entered R10's room and administered R10's medications including Fiber and Polyethylene Glycol in a cup of thickened apple juice. V18 stated these medications were mixed with 60 ml apple juice. At 9:47 AM the label for R10's Polyethylene Glycol and Fiber directed to mix each medication with 8 ounces of water, confirmed with V18.

Based on observation, interview and record review, the facility failed to ensure resident rights to review the facility State Survey Agency survey results, by failing to provide resident access to State Survey Agency results. This failure affects all 23 residents residing in the facility.Findings include:On 4/22/26 between 1:30 p.m. and 2:10 p.m., during the resident group meeting, R2, R3, R7, and R21 stated they had no knowledge that they could review the state survey results. The same residents stated they had never seen a book or signage directing them to where they could find the state survey results. All four residents verbalized interest in reading about the facility's previous surveys conducted by the State Survey Agency.On 4/22/26 at 2:15 p.m., the main entrance and reception area, along with two additional entrances of the facility, were observed. There was no state survey results book present at any of the entrances. There was no signage directing residents or visitors to where they could find the state survey results.On 4/22/26 at 3:25 p.m., V1 (Administrator) stated the state survey results book had been located in the activity room. V1 stated the book was not in an easily accessible location and acknowledged it needed to be updated with the facility's prior CMS-2567 survey documents.The CMS 671 Long-Term Care Facility Application for Medicare and Medicaid, dated 4/21/26, documents that 23 residents reside in the facility.

Based on interview and record review the facility failed to protect one (R7) resident's right to be free from abuse and neglect by staff members (V10, V11) out of five residents reviewed for abuse and neglect in a sample list of eight residents. R7 was not provided basic cares such as repositioning and incontinence care timely. R7 was made to cry, scream and yell out in pain as staff refused to assist and reposition R7 during incontinent cares. Findings include:R7's Electronic Medical Record documents medical diagnoses as Gastrointestinal Hemorrhage, Protein-Calorie Malnutrition, Alzheimer's Disease, Dementia, Anxiety, Difficulty in Walking, Need for Assistance with Personal Cares, Cognitive Communication Deficit, Crohn's Disease, Cervical Disc Degeneration, Diverticulitis of Large Intestine, Diabetes Mellitus Type II, Dysphagia, Unsteady on Feet and Repeated Falls.R7's Minimum Data Set (MDS) dated [DATE] documents R7 as moderately cognitively impaired. This same MDS documents R7 requires maximum assistance from staff for personal hygiene and is completely dependent on staff for assistance with eating, oral hygiene, toileting, showering, dressing, bed mobility and transfers. R7's Care Plan interventions dated 7/15/25 instructs the staff to anticipate and meet R7's needs and encourage frequent position changes as condition allows.On 10/14/25 at 10:10 AM, V16 (R7's Power of Attorney/POA) stated the facility is 'short-staffed'. V16 stated R7 has to wait 30-60 minutes sometimes for staff to answer the call light. V16 stated R7 has cameras placed in her room that record 24 hours per day. V16 stated the personal cameras are reviewed daily and 'many times' sees that staff do not enter R7's room for multiple hours at a time. V16 stated R7 is incontinent of urine and bowel and needs to be 'at least changed' (provided incontinence care) every two hours. V16 stated on 9/7/25 V10 and V11 Certified Nursing Assistants/CNAs) assisted R7 to R7's bathroom toilet. V16 stated R7 was being transported from her bed to the toilet using a total body mechanical lift using a toilet sling. V16 stated during the transport back from the toilet to the bed, R7 continued to have a bowel movement. V16 stated R7 was not positioned correctly in the sling and was 'screaming in pain'. V16 stated R7's entire buttocks and hips were showing below the sling and both of R7's arms were forced above her head due to R7 was sliding out of her sling. V16 stated R7 was about a foot away from the toilet. V16 stated she yelled at the staff (V10, V11) to assist R7 back on the toilet to readjust R7's sling, reduce R7's pain and allow R7 to finish having her bowel movement. V16 stated V11 (CNA) yelled at V16 to 'get away from us', 'you need to go sit down' and 'we (V10, V11) are not moving (R7) anywhere, we know what we are doing, now go sit down'. V16 stated V11 (CNA) then pushed a small garbage can under R7. V16 stated R7 was forced to have a bowel movement in a garbage can as she was screaming in pain due to poor positioning. V16 stated R7 would think this would be 'absolutely horrid' and be 'humiliating' to have to have a bowel movement in a garbage can. V16 stated R7 would never have a bowel movement in a garbage can and would be 'mortified' at this entire incident. V16 stated R7 was 'hysterical' and 'afraid' during this transfer back to her bed due to R7 was afraid she was going to fall and was in so much pain. V16 stated V10 and V11 CNAs left R7 on her bed without finishing incontinence care or positioning R7 safely in bed. V16 stated They (V10, V11) just left (R7) there with p*** (expletive) on her. They (V10, V11) walked out of the room and did not come back. V16 stated the facility 'neglected' R7 by not providing perineal and/or incontinence care, not repositioning R7 for extended periods of time and refused to provide pain relief by not transferring R7 as V16 requested the staff to move R7 to a more comfortable position. V16 stated the staff are 'belligerent and confrontational' when V16 asked for assistance. V16 stated V15, V17 (R7's private caregivers) and V16 provide direct cares, repositioning, feeding assistance and administer medications to R7 due to the staff are 'neglectful' by not entering R7's room and force R7's family and caregivers to provide all of the services themselves. V16 stated We (V15, V16, V17) have to do everything for (R7). We (V15, V16, V17) provide all the cares, we administer all of her medications, we reposition (R7), we feed (R7), we provide oral care, nail care, skin care, etc. for (R7). We have to do everything because the staff neglect (R7) on a daily basis. We turn on the call light and no one comes for hours. We have cameras in (R7's) room that shows NO staff enter for six or eight hours or more. Anything (R7) needs, we (V15, V16, V17) have to go get and bring to (R7's) room. We even have to go get her medications because the nurses won't bring them. V16 stated the facility provided packets and a gallon jug of thickener and a device for V15, V16 and V17 to crush R7's medications. V16 stated the facility allows the staff to neglect R7 by knowing that the staff are not providing R7's cares. V16 stated V16 has had multiple conversations and ongoing electronic mail (E-mail) with V2 (Interim Director of Nursing/DON). V16 stated V16 asked V2 to not have V10 and V11 (CNAs) in R7's room and/or providing any cares for R7 after the 9/7/25 incident. V16 stated both V10 and V11 have provided cares since that date (9/7) and when V2 was informed, V2 responded with '(V10, V11) are not (R7's) primary CNAs so that is okay'. V16 stated she asked if there was someone else to speak to about ongoing care concerns and the staff 'neglecting' R7 and was told by V2 that no one else would be able to do anything. On 10/14/25 at 1:20 PM, V1 (Administrator in Training/AIT) stated she was made aware of R7's family concerns on 9/7/25. V1 stated V2 (Interim DON) informed V1 that V2 is 'taking care of that situation' and nothing else needed to be discussed and/or elevated to a grievance report. V1 stated all allegations of any type of abuse should be reported and investigated. V1 stated R7's allegation was an isolated incident and has not had any other concerns brought forward by other residents or resident representatives. V1 stated the facility did not follow their abuse policy. On 10/14/25 at 2:20 PM, V2 (Interim DON) stated V2 has worked 'closely' with V16 (R7's POA). V2 stated V16 has had multiple concerns about the lack of care for R7. V2 stated all residents should be visualized every two hours. V2 stated R7 should be repositioned and offered incontinence/perineal care at least every two hours. V2 stated V16 (R7's POA) is very involved in R7's care but the facility should be providing the cares, medications, assistance with transfers, etcetera. V2 stated V10 and V11 (CNAs) came to V2 a week after V16 (R7's POA) sent V2 DON an electronic mail (E-mail) on 9/7/25 reporting V16's concerns and asking for V10 and V11 to not care for R7. V2 stated she had already responded to V16 on 9/8/25 but had not spoken with V10 nor V11. V2 stated V10 and V11 came to her stating there was an incident on 9/7 involving R7. V2 stated V10 and V11 stated they knew V16 (R7's POA) would 'tattle' on V10 and V11 and they (V10, V11) were reporting themselves. V2 stated she informed V10 and V11 at that time that neither V10 nor V11 should be R7's primary caregiver but could enter R7's room to provide cares. On 10/14/25 at 3:15 PM, V9 and V11 (Certified Nurse Assistants/CNAs) transferred R7 from her recliner to the toilet and back to R7's recliner using a total body mechanical lift with a toilet sling. On 10/14/25 at 3:50 PM, V11 (CNA) stated V10 and V11 (CNAs) transferred R7 on 9/7/25 from R7's bed to the toilet and back to R7's bed again. V11 stated during the transfer R7 was 'screaming, yelling out and carrying on'. V11 stated she did not think anything of this due to R7 'screams every time we transfer her'. V11 stated R7 was finished using the restroom so V10 and V11 began transferring R7 back to her bed. V11 stated R7 began to slide down in the sling. V11 stated R7 continued having more bowel movement during the transfer. V11 stated (R7) was s******* (expletive) all over the floor. Some almost got on my shoe! (V16) was screaming at us (V10, V11) to lay (R7) down in bed so she could be more comfortable and finish getting cleaned up in bed. I told (V16) she needed to get out of my face and go sit down. I can't do my job if (V16) is yelling at me. I pushed a trash can under (R7) and let (R7) finish p****** (bowel movement/expletive) into the trash can so it didn't get on my shoe. Once (R7) was done p****** (expletive), we (V10, V11) transferred (R7) back to her bed and left the room. (R7) kept crying and screaming. (V16) kept yelling at us (V10, V11). We had enough of it. I guess (V16) finished getting (R7) cleaned up because we (V10, V11) were done with (V16). On 10/14/25 at 4:00 PM, V16 (R7's POA) provided camera footage showing on 10/14/25 at 6:01 AM an unknown (CNA) provided perineal care for R7, at 8:00 AM Speech Therapy provided Speech therapy with R7 while R7 was laying in her bed, and there were no other recordings of any staff entering R7's room until 3:10 PM when V9 (CNA) answered R7's call light. Through direct observations, R7 was in her room and staff did not enter R7's room from 10:30 AM-3:10 PM. The facility policy dated February 20, 2025, titled Abuse Prevention and Prohibition documents all residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of resident property and exploitation, including abuse facilitated or enabled through the use of technology, photographing and recording of residents. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness, or in the deterioration of a resident's physical or mental condition. The facility staff should identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur.

Based on observation, interview and record review the facility failed to provide Licensed Nurses to administer medications on multiple occasions for one (R7) resident out of five residents reviewed for Improper Nursing Care in a sample list of eight residents.Findings include:R7's Minimum Data Set (MDS) dated [DATE] documents R7 as moderately cognitively impaired. This same MDS documents R7 requires maximum assistance from staff for personal hygiene and is completely dependent on staff for assistance with eating, oral hygiene, toileting, showering, dressing, bed mobility and transfers. R7's Physician Order Sheet (POS) dated October 2025 documents physician orders to administer:-Cephalexin 250 milligrams (mg)/5 milliliters (ml) starting 9/26/25 with no end date, give daily for recurrent Urinary Tract Infections (UTI). Prophylaxis for one year.-Cholecalciferol 25 micrograms (mcg). Give two tablets daily.-Lactobacillus Rhamnoses give one capsule daily.-Fluconazole 150 mg tablet daily for Vaginal Candidiasis every three days.-Fluoxetine 10 mg tablet daily-Benefiber packet daily-Lisinopril 40 mg tablet twice daily-Pantoprazole 4 mg/ml suspension give 10 ml daily-Polyethylene Glycol (Miralax) powder 8.5 Grams daily-Prednisone 5 mg tablet daily-Prozac 20 mg tablet daily-Zyrtec 10 mg tablet daily-Acetaminophen 1000 mg tablets twice daily-Carvedilol 12.5 mg tablet twice daily-Diclofenac Sodium 1% external gel. Apply to Left Ankle twice daily.-Lidocaine 5% External patch. Apply to neck in the morning, remove at night.-Memantine 5 mg tablet twice daily-Miconazole Nitrate powder 2%. Apply to vaginal area twice daily.-Potassium Chloride 20 milli equivalents (mEq)/15 ml liquid. Give 15 ml twice daily.On 10/14/25 at 11:10 AM, V15 (R7's private caregiver) left R7's room and returned at 11:20 AM with a medicine cup of a small amount of off-white colored liquid. V15 added 15 milliliters (ml) of liquid thickener that was on R7's bedside dresser, placed the mixture in a syringe and administered R7's Pantoprazole by placing the syringe in R7's Left Buccal area and pushing the syringe so that the medicine was forced into R7's mouth. R7 coughed two times as a small amount of the mixture leaked out of the Left side of R7's mouth. V15 used a tissue to wipe away the medication. R7 had two adaptive cups with lids sitting on her bedside table. There were no medication labels on either cup. V15 stated one of the cups has R7's Miralax and the other cup has R7's Benefiber. V15 stated the nurses tell V15 and the caregivers (V10 and V11) that they do not have time to wait for R7 to take her medications, so they give them to V15 and/or private unlicensed caregivers. V15 stated V15 and private caregivers 'have to do it this way or (R7) would not get her medications'. On 10/14/25 at 11:20 AM, V15 (R7's private caregiver) stated she is not a Licensed Nurse, does not work for the facility and has had no official training on how to administer medication, how much thickener to use, what the medication side effects are and what medication interactions may be. V15 stated V12 (Registered Nurse/RN) gave her R7's Pantoprazole at the nurse's station. V15 stated this is a daily occurrence because V15 has been told by 'many' nurses that they (staff) do not have the time to stand and wait on R7 to take her medications due to R7 is a 'slow swallower'.On 10/14/25 at 12:00 PM, V12 (RN) stated V12 provides medications to V16 (R7's POA) and/or V15 and V17 (R7's private caregivers) so that they (V15, V16, V17) can administer R7's medications. V12 RN stated she gave V15 all R7's medications for 10/14/25 for R7's morning scheduled medications including Benefiber and Miralax as well as R7's scheduled noon medication of Pantoprazole. V12 stated she prepares the medications and the 'family/caregivers' administer the medications. V12 stated she does not observe R7's POA and/or private caregivers administer R7's medications. V12 stated she was instructed to provide R7's medications to V16 (R7's POA) and/or caregivers by other nurses. V12 stated This is how we (staff) all do it. Our administration approves of this, so I guess it is ok. V12 stated she is not aware if V15, V16 and/or V17 has any medical knowledge regarding medication administration. On 10/14/25 at 2:25 PM, V2 (Interim Director of Nurses/DON) stated V2 gave approval for V16 (R7's POA) to administer R7's medications without a nurse being present. V2 confirmed V16 and/or V15, V17 (R7) private caregivers are not licensed nurses and are not employed by the facility. On 10/14/25 at 2:50 PM, R7's Benefiber and Miralax were still in the cups sitting on R7's bedside table. The gallon jug of thickener, packets of thickener and pill crusher were still sitting on R7's bedside dresser. V17 (R7's private caregiver) stated R7's Benefiber was 'stone thick' because it had been sitting too long. V17 stated she administers R7's medications daily and has done so for 'months'. V17 stated the facility management gave R7's private caregivers and V16 (Power of Attorney/POA) approval to administer R7's medications. V17 stated she is not a licensed nurse and has never had any formal training on medication administration. V16 (R7's) Power of Attorney (POA) stated V20 (Health Services Administration Coordinator) ordered R7's thickener and pill crusher to keep in R7's room due to V16 and R7's private caregivers were 'bothering' the nurses too much by asking for R7's pills to be crushed and drinks to be thickened. On 10/14/25 at 4:05 PM, V16 (R7's POA) stated V2 emailed V16 on 7/22/25 stating V16 could administer R7's medications without the nurse being present. On 10/15/25 at 9:30 AM, V15 (R7's private caregiver) was assisting R7 to eat R7's breakfast in R7's room. V15 was feeding R7 an orange creamy substance. V15 stated this was R7's Potassium liquid mixed with vanilla ice cream and thickener. V15 stated now the nurses have to mix all of R7's medications. V15 stated R7's adaptive cups contained R7's Miralax and Benefiber. V15 stated We (R7, V15) are working on getting all (R7's) medications down. The staff say they don't have time to stay with (R7). On 10/15/25 at 10:05 AM, V6 (Licensed Practical Nurse/LPN) stated she gave R7's medications to R7 this morning except for R7's Miralax, Benefiber and Potassium. V6 stated she did not have time to wait for R7 to take the Miralax, Benefiber and Potassium due to R7 'takes forever to swallow'. V6 stated I would still be in there (R7's room) if I had to do that. I don't have time for that.On 10/15/25 at 4:45 PM, V2 (Interim DON) stated licensed nurses should be administering all medications. V2 stated she did give approval for V16 (R7's POA) to administer R7's medications to make it 'easier' on the nursing staff. V2 stated the facility will have to review their medication administration policy and educate staff on medication administration. The facility policy dated June 17, 2025, titled General Guidelines for Medication Administration documents the licensed nurse is to identify the resident prior to administering medications. Administer medication and remain with the resident until medication is swallowed. Do not leave a medication in a resident's room without orders to do so. Medications will be administered by legally authorized and trained persons in accordance with applicable State, Local and Federal laws and consistent with accepted standards of practice.

Based on interview and record review the facility failed to maintain accurate medical records for one (R7) resident out of five residents reviewed for Improper Nursing Care in a sample list of eight residents.Findings include: R7's Minimum Data Set (MDS) dated [DATE] documents R7 as moderately cognitively impaired. This same MDS documents R7 requires maximum assistance from staff for personal hygiene and is completely dependent on staff for assistance with eating, oral hygiene, toileting, showering, dressing, bed mobility and transfers. R7's Physician Order Sheet (POS) dated October 2025 documents physician orders to administer:-Cephalexin 250 milligrams (mg)/5 milliliters (ml) starting 9/26/25 with no end date, give daily for recurrent Urinary Tract Infections (UTI). Prophylaxis for one year.-Cholecalciferol 25 micrograms (mcg). Give two tablets daily.-Lactobacillus Rhamnoses give one capsule daily.-Fluconazole 150 mg tablet daily for Vaginal Candidiasis every three days.-Fluoxetine 10 mg tablet daily-Benefiber packet daily-Lisinopril 40 mg tablet twice daily-Pantoprazole 4 mg/ml suspension give 10 ml daily-Polyethylene Glycol (Miralax) powder 8.5 Grams daily-Prednisone 5 mg tablet daily-Prozac 20 mg tablet daily-Zyrtec 10 mg tablet daily-Acetaminophen 1000 mg tablets twice daily-Carvedilol 12.5 mg tablet twice daily-Diclofenac Sodium 1% external gel. Apply to Left Ankle twice daily.-Lidocaine 5% External patch. Apply to neck in the morning, remove at night.-Memantine 5 mg tablet twice daily-Miconazole Nitrate powder 2%. Apply to vaginal area twice daily.-Potassium Chloride 20 milli equivalents (mEq)/15 ml liquid. Give 15 ml twice daily.R7's Medication Administration Record (MAR) dated October 2025 documents V12 (Registered Nurse/RN) and V6 (Licensed Practical Nurse/LPN) administered R7's scheduled daily, and twice daily medications as ordered by the physician. On 10/14/25 at 12:00 PM, V12 (RN) stated V12 signs out medications for R7 that she does not administer. V12 stated she gives R7's medications to V16 (R7's Power of Attorney/POA) and/or R7's private caregivers to administer R7's medications. V12 stated she cannot confirm that R7 receives her medications prior to V12 signing out on R7's MAR as being given. On 10/15/25 at 10:05 AM, V6 (LPN) stated she gives all R7's medications to R7's private caregivers and/or V16 (R7's POA). V6 stated she signs out R7's MAR that R7's medications are being given because she 'trusts the family to give the meds so I don't have to waste my time doing it'. On 10/15/25 at 4:15 PM, V2 (Interim Director of Nurses/DON) stated the staff should document all the work they do. V2 stated nurses should ensure the resident is receiving the prescribed medications prior to signing off that the medication has been administered. The facility policy dated June 17, 2025, titled General Guidelines for Medication Administration documents the facility nurse should return to the medication cart and document medication administration with documentation in the Medication Administration Record (MAR) immediately after administering medication to each resident. Medications will be administered by legally authorized and trained persons in accordance with applicable State, Local and Federal laws and consistent with accepted standards of practice.

Based on interview and record review the facility failed to report an allegation of neglect for one (R7) resident out of five residents reviewed for Abuse in a sample list of eight residents. Findings include:R7's Minimum Data Set (MDS) dated [DATE] documents R7 as moderately cognitively impaired. This same MDS documents R7 requires maximum assistance from staff for personal hygiene and is completely dependent on staff for assistance with eating, oral hygiene, toileting, showering, dressing, bed mobility and transfers. The facility is unable to provide documentation of R7's allegation of abuse/neglect on 9/7/25 as being reported to the State Surveying Agency. On 10/14/25 at 10:10 AM, V16 (R7's Power of Attorney/POA) stated the facility is 'short-staffed'. V16 stated R7 has to wait 30-60 minutes sometimes for staff to answer the call light. V16 stated R7 has cameras placed in her room that record 24 hours per day. V16 stated the personal cameras are reviewed daily and 'many times' sees that staff do not enter R7's room for multiple hours at a time. V16 stated R7 is incontinent of urine and bowel and needs to be 'at least changed' (provided incontinence care) every two hours. V16 stated on 9/7/25 V10 and V11 Certified Nursing Assistants/CNAs) assisted R7 to R7's bathroom toilet. V16 stated R7 was being transported from her bed to the toilet using a total body mechanical lift using a toilet sling. V16 stated during the transport back from the toilet to the bed, R7 continued to have a bowel movement. V16 stated R7 was not positioned correctly in the sling and was 'screaming in pain'. V16 stated R7's entire buttocks and hips were showing below the sling and both of R7's arms were forced above her head due to R7 was sliding out of her sling. V16 stated R7 was about a foot away from the toilet. V16 stated she yelled at the staff (V10, V11) to assist R7 back on the toilet to readjust R7's sling, reduce R7's pain and allow R7 to finish having her bowel movement. V16 stated V11 (CNA) yelled at V16 to 'get away from us', 'you need to go sit down' and 'we (V10, V11) are not moving (R7) anywhere, we know what we are doing, now go sit down'. V16 stated V11 (CNA) then pushed a small garbage can under R7. V16 stated R7 was forced to have a bowel movement in a garbage can as she was screaming in pain due to poor positioning. V16 stated R7 would think this would be 'absolutely horrid' and be 'humiliating' to have to have a bowel movement in a garbage can. V16 stated R7 would never have a bowel movement in a garbage can and would be 'mortified' at this entire incident. V16 stated R7 was 'hysterical' and 'afraid' during this transfer back to her bed due to R7 was afraid she was going to fall and was in so much pain. V16 stated V10 and V11 CNAs left R7 on her bed without finishing incontinence care or positioning R7 safely in bed. V16 stated They (V10, V11) just left (R7) there with p*** (expletive) on her. They (V10, V11) walked out of the room and did not come back. V16 stated the facility 'neglected' R7 by not providing perineal and/or incontinence care, not repositioning R7 for extended periods of time and refused to provide pain relief by not transferring R7 as V16 requested the staff to move R7 to a more comfortable position. V16 stated the staff are 'belligerent and confrontational' when V16 asked for assistance. V16 stated V15, V17 (R7's private caregivers) and V16 provide direct cares, repositioning, feeding assistance and administer medications to R7 due to the staff are 'neglectful' by not entering R7's room and force R7's family and caregivers to provide all of the services themselves. V16 stated We (V15, V16, V17) have to do everything for (R7). We (V15, V16, V17) provide all the cares, we administer all of her medications, we reposition (R7), we feed (R7), we provide oral care, nail care, skin care, etc. for (R7). We have to do everything because the staff neglect (R7) on a daily basis. We turn on the call light and no one comes for hours. We have cameras in (R7's) room that shows NO staff enter for six or eight hours or more. Anything (R7) needs, we (V15, V16, V17) have to go get and bring to (R7's) room. We even have to go get her medications because the nurses won't bring them. V16 stated the facility provided packets and a gallon jug of thickener and a device for V15, V16 and V17 to crush R7's medications. V16 stated the facility allows the staff to neglect R7 by knowing that the staff are not providing R7's cares. V16 stated V16 has had multiple conversations and ongoing electronic mail (E-mail) with V2 (Interim Director of Nursing/DON). V16 stated V16 asked V2 to not have V10 and V11 (CNAs) in R7's room and/or providing any cares for R7 after the 9/7/25 incident. V16 stated both V10 and V11 have provided cares since that date (9/7) and when V2 was informed, V2 responded with '(V10, V11) are not (R7's) primary CNAs so that is okay'. V16 stated she asked if there was someone else to speak to about ongoing care concerns and the staff 'neglecting' R7 and was told by V2 that no one else would be able to do anything. On 10/14/25 at 1:20 PM, V1 (Administrator in Training/AIT) stated she was made aware of R7's family concerns on 9/7/25. V1 stated V2 (Interim Director of Nursing/DON) informed V1 that V2 is 'taking care of that situation' and nothing else needed to be discussed and/or elevated to a grievance report. V1 stated the allegation of neglect was not reported to the State Surveying Agency. V1 stated all allegations of any type of abuse should be reported and investigated. V1 stated R7's allegation was an isolated incident and has not had any other concerns brought forward by other residents or resident representatives. V1 stated the facility did not follow their abuse policy. On 10/14/25 at 2:40 PM, V2 (Interim DON) stated V16 (R7's Power of Attorney/POA) e-mailed V2 on 9/7/25 reporting V16's concerns and asking for V10 and V11 to not care for R7. V2 stated V10 and V11 (Certified Nursing Assistants/CNA) came to V2 a week after V16 sent V2 an electronic mail (E-mail) on 9/7/25. V2 stated V10 and V11 came to her stating there was an incident on 9/7 involving R7. V2 stated V10 and V11 stated they knew V16 would 'tattle' on V10 and V11 and they (V10, V11) were reporting themselves. V2 stated V1 (AIT) is still learning the role of Abuse Coordinator so if an allegation would need to be reported to the State Surveying Agency, V2 would be the person to do that. V2 stated she did not report this allegation to the State Surveying Agency.The facility policy dated February 20, 2025 titled Abuse Prevention and Prohibition documents the Administrator or Administrator's designee will report immediately but no later than two hours after the allegation is made to the State Agency if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on observation, interview and record review the facility failed to ensure residents rights were honored for one (R1) resident out of five residents reviewed for Resident Rights in a sample list of eight residents.Findings include: R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. This same MDS documents R1 as requiring set up assistance with eating, oral hygiene, is dependent on staff for assistance with dressing and requires moderate assistance for bed mobility and transfers.R1's Care Plan initiated does not include a focus area, goal nor interventions for R1's resident's right to make her own choices. On 10/15/25 at 9:47 AM, R1 was laying in her bed with her breakfast tray of food sitting on her bedside table. R1 stated she just finished her breakfast. R1 stated she prefers to get up out of bed 'much earlier around 7:00 AM' to eat her breakfast in the dining room. R1 stated she enjoys talking with the other residents. R1 stated she was told by the facility staff that the facility was 'short staffed' today and did not have enough staff to get her up earlier. R1 stated The girls (staff) work hard and I understand that they are trying but I would like to get up to the dining room table for all of my meals. I don't mind this once in a while, but it has recently become the norm to have me eat breakfast in bed because of low staffing.On 10/15/25 at 10:00 AM, V19 (Certified Nursing Assistant/CNA) stated the facility did not have enough staff this morning (10/15/25) to get all the residents out of bed and out to the dining room for breakfast. V19 stated there are multiple residents who would normally go to the dining room but just can't due to lack of staff. V19 stated there are plenty of 'bodies' but those extra staff do not provide cares for staff. V19 stated the residents should be able to go to the dining room if they choose to. On 10/15/25 at 11:30 AM, V2 (Interim Director of Nurses/DON) stated the facility does provide more than the regulatory requirement of staff to provide cares for the residents. V2 stated the residents should be provided the cares as requested and/or needed without question. V2 stated she was aware of staffing concerns on R2's hall this morning (10/15), but the ancillary licensed staff (V20 Health Services Administrative Coordinator/CNA) was on the hall. V2 stated she will in-service (V20) ancillary staff to ensure resident care takes priority. V2 stated R1 should have been assisted up to the dining room for breakfast if that is what R2 prefers. The State Agency pamphlet dated April 2024 documents the facility must make reasonable arrangements to meet your needs and choices.

Based on interview and record review the facility failed to investigate an allegation of neglect for one (R7) resident out of five residents reviewed for Abuse in a sample list of eight residents. Findings include: R7's Minimum Data Set (MDS) dated [DATE] documents R7 as moderately cognitively impaired. This same MDS documents R7 requires maximum assistance from staff for personal hygiene and is completely dependent on staff for assistance with eating, oral hygiene, toileting, showering, dressing, bed mobility and transfers. The facility is unable to provide documentation of R7's allegation of Abuse/neglect on 9/7/25 as investigated by the facility. On 10/14/25 at 10:10 AM, V16 (R7's Power of Attorney/POA) stated the facility is 'short-staffed'. V16 stated R7 has to wait 30-60 minutes sometimes for staff to answer the call light. V16 stated R7 has cameras placed in her room that record 24 hours per day. V16 stated the personal cameras are reviewed daily and 'many times' sees that staff do not enter R7's room for multiple hours at a time. V16 stated R7 is incontinent of urine and bowel and needs to be 'at least changed' (provided incontinence care) every two hours. V16 stated on 9/7/25 V10 and V11 Certified Nursing Assistants/CNAs) assisted R7 to R7's bathroom toilet. V16 stated R7 was being transported from her bed to the toilet using a total body mechanical lift using a toilet sling. V16 stated during the transport back from the toilet to the bed, R7 continued to have a bowel movement. V16 stated R7 was not positioned correctly in the sling and was 'screaming in pain'. V16 stated R7's entire buttocks and hips were showing below the sling and both of R7's arms were forced above her head due to R7 was sliding out of her sling. V16 stated R7 was about a foot away from the toilet. V16 stated she yelled at the staff (V10, V11) to assist R7 back on the toilet to readjust R7's sling, reduce R7's pain and allow R7 to finish having her bowel movement. V16 stated V11 (CNA) yelled at V16 to 'get away from us', 'you need to go sit down' and 'we (V10, V11) are not moving (R7) anywhere, we know what we are doing, now go sit down'. V16 stated V11 (CNA) then pushed a small garbage can under R7. V16 stated R7 was forced to have a bowel movement in a garbage can as she was screaming in pain due to poor positioning. V16 stated R7 would think this would be 'absolutely horrid' and be 'humiliating' to have to have a bowel movement in a garbage can. V16 stated R7 would never have a bowel movement in a garbage can and would be 'mortified' at this entire incident. V16 stated R7 was 'hysterical' and 'afraid' during this transfer back to her bed due to R7 was afraid she was going to fall and was in so much pain. V16 stated V10 and V11 CNAs left R7 on her bed without finishing incontinence care or positioning R7 safely in bed. V16 stated They (V10, V11) just left (R7) there with p*** (expletive) on her. They (V10, V11) walked out of the room and did not come back. V16 stated the facility 'neglected' R7 by not providing perineal and/or incontinence care, not repositioning R7 for extended periods of time and refused to provide pain relief by not transferring R7 as V16 requested the staff to move R7 to a more comfortable position. V16 stated the staff are 'belligerent and confrontational' when V16 asked for assistance. V16 stated V15, V17 (R7's private caregivers) and V16 provide direct cares, repositioning, feeding assistance and administer medications to R7 due to the staff are 'neglectful' by not entering R7's room and force R7's family and caregivers to provide all of the services themselves. V16 stated We (V15, V16, V17) have to do everything for (R7). We (V15, V16, V17) provide all the cares, we administer all of her medications, we reposition (R7), we feed (R7), we provide oral care, nail care, skin care, etc. for (R7). We have to do everything because the staff neglect (R7) on a daily basis. We turn on the call light and no one comes for hours. We have cameras in (R7's) room that shows NO staff enter for six or eight hours or more. Anything (R7) needs, we (V15, V16, V17) have to go get and bring to (R7's) room. We even have to go get her medications because the nurses won't bring them. V16 stated the facility provided packets and a gallon jug of thickener and a device for V15, V16 and V17 to crush R7's medications. V16 stated the facility allows the staff to neglect R7 by knowing that the staff are not providing R7's cares. V16 stated V16 has had multiple conversations and ongoing electronic mail (E-mail) with V2 (Interim Director of Nursing/DON). V16 stated V16 asked V2 to not have V10 and V11 (CNAs) in R7's room and/or providing any cares for R7 after the 9/7/25 incident. V16 stated both V10 and V11 have provided cares since that date (9/7) and when V2 was informed, V2 responded with '(V10, V11) are not (R7's) primary CNAs so that is okay'. V16 stated she asked if there was someone else to speak to about ongoing care concerns and the staff 'neglecting' R7 and was told by V2 that no one else would be able to do anything. On 10/14/25 at 10:20 AM, V16 (R7's Power of Attorney/POA) stated she emailed V2 (Interim Director of Nursing/DON) on 9/7/25 following a 'terrible incident' between V10 and V11 (Certified Nursing Assistants/CNAs) and R7. V16 stated V2 responded in email to V16 on 9/8/25. V16 stated no one ever came around and interviewed V16 nor V15, V17 (R7's private caregivers) to obtain a witness statement. On 10/14/25 at 3:50 PM, V11 (CNA) stated V10 and V11 reported to V2 (Interim DON) a week after 'something happened' on 9/7/25. V11 stated V10 and V11 went to V2 due to 'we (V10, V11) knew that V16 would 'tattle' on us so, we just talked to V2 ourselves. V11 stated no one had discussed the situation on 9/7 with her prior to that and no one had told her to not be R7's primary caretaker. On 10/14/25 at 1:20 PM, V1 (Administrator in Training/AIT) stated she was made aware of R7's family concerns on 9/7/25. V1 stated V2 (Interim DON) informed V1 that V2 is 'taking care of that situation' and nothing else needed to be discussed and/or elevated to a grievance report. V1 stated the allegation of neglect was not reported to the State Agency. V1 stated all allegations of any type of abuse should be reported and investigated. V1 stated R7's allegation was an isolated incident and has not had any other concerns brought forward by other residents or resident representatives. V1 stated the facility did not follow their abuse policy.On 10/14/25 at 2:40 PM, V2 (Interim DON) stated V16 (R7's POA) e-mailed V2 on 9/7/25 reporting V16's concerns and asking for V10 and V11 to not care for R7. V2 stated V10 and V11 (CNAs) came to V2 a week after V16 sent V2 an electronic mail (E-mail) on 9/7/25. V2 stated V10 and V11 came to her stating there was an incident on 9/7 involving R7. V2 stated V10 and V11 stated they knew V16 would 'tattle' on V10 and V11 and they (V10 and V11) were reporting themselves. V2 stated V1 is still learning the role of Abuse Coordinator so if an allegation would need to be reported to the State Agency, V2 would be the person to do that. V2 DON stated she did not report this allegation to the State Agency.The facility policy dated February 20, 2025, titled Abuse Prevention and Prohibition documents when an incident or suspected incident is reported, an investigation will be done immediately. The Administrator will be informed immediately of any suspected incident and/or an injury of unknown origin. The Administrator will appoint someone to initiate and lead an investigation.

Based on interview and record review the facility failed to document, follow up and resolve grievances for one (R7) resident out of five residents reviewed for grievances in a sample list of eight residents. Findings include: R7's Minimum Data Set (MDS) dated [DATE] documents R7 as moderately cognitively impaired. This same MDS documents R7 requires maximum assistance from staff for personal hygiene and is completely dependent on staff for assistance with eating, oral hygiene, toileting, showering, dressing, bed mobility and transfers. On 10/14/25 at 8:30 AM, during the entrance conference, V2 (Interim Director of Nurses/DON) stated the facility has not had any family concerns and/or grievances for the past three months. V2 stated there is no grievance log or grievance reports. On 10/14/25 at 10:20 AM, V16 (R7's Power of Attorney/POA) stated on 9/7/25, V10 and V11 (Certified Nurse Assistants/CNAs) assisted R7 to R7's bathroom toilet. V16 stated R7 was being transported from her bed to the toilet using a total body mechanical lift using a toilet sling. V16 stated during the transport back from the toilet to the bed, R7 continued to have a bowel movement. V16 stated R7 was not positioned correctly in the sling and was 'screaming in pain'. V16 stated R7 was about a foot away from the toilet. V16 stated V11 (CNA) then pushed a small garbage can under R7. V16 stated R7 was forced to have a bowel movement in a garbage can as she was screaming in pain due to poor positioning. V16 stated V16 has had multiple conversations and ongoing electronic mail (E-mail) with V2 (Interim DON). V16 stated V16 asked V2 to not have V10 and V11 CNAs in R7's room and/or providing any cares for R7 after the 9/7/25 incident. V16 stated both V10 and V11 have provided cares since that date (9/7) and when V2 was informed, V2 responded with '(V10, V11) are not (R7's) primary CNAs so that is okay'. V16 stated she asked if there was someone else to speak to about ongoing care concerns and the staff 'neglecting' R7 and was told by V2 that no one else would be able to do anything. On 10/14/25 at 1:20 PM, V1 (Administrator in Training/AIT) stated she was made aware of R7's family concerns on 9/7/25. V1 stated V2 (Interim DON) informed V1 that V2 is 'taking care of that situation' and nothing else needed to be discussed and/or elevated to a grievance report. On 10/14/25 at 2:20 PM, V2 (Interim DON) stated V2 has worked 'closely' with V16 (R7's POA). V2 stated V16 has had multiple concerns about the lack of care for R7. V2 stated V16's concerns were never reported to V21 (Grievance Officer) due to V2 did not think V16's concerns needed to 'rise to the level of a grievance'. On 10/15/25 at 12:05 PM, V21 (Grievance Officer) stated grievances can be brought forward from residents, resident representatives, staff, visitors or anyone who has a grievance. V21 stated she has not received nor been made aware of V16 (R7's POA) concerns. V21 stated V16's concerns would 'rise to the level of a grievance' and should have been brought forward.The facility policy dated October 19, 2022, titled Grievance Policy documents It is the policy of this facility that each resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their facility stay. Voicing grievances is not limited to a formal, written grievance process but may include a resident's verbalized complaint to facility staff.

Based on observation, interview, and record review the facility failed to ensure adequate supervision was provided during toileting for 1 (R1) of 3 residents reviewed for falls on the sample list of 4. This failure resulted in R1 sustaining multiple acute fractures involving the left humerus.Findings include:R1's diagnosis in part is documented as history of falling, retention of urine, anxiety disorder, difficulty in walking, cognitive communication deficit, acute on chronic systolic (congestive) heart failure, permanent atrial fibrillation, chronic respiratory failure with hypoxia, and pulmonary hypertension.R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score of eight indicating the R1 has moderate cognitive impairment.R1's MDS admission assessment dated [DATE] documents that R1 is dependent on staff for toileting hygiene tasks. This MDS also documents that R1 requires Substantial/maximal assistance from staff when going from a sitting to standing position.R1's Care Plan initiated on 07/08/2025 documents that R1 is at risk for falls related to deconditioning. This Care Plan documents that staff are to follow facility fall prevention guidelines. This Care Plan documents an intervention for certified nurse assistants to maintain proactive contact with residents to anticipate needs.R1's Fall Risk Evaluation dated 07/08/2025 documents that R1's assessment score was 17.0. A score of ten or higher indicates that R1 is at high risk for falls.R1's Incident report dated 7/15/2025 at 2:30 AM documents that V8 (Certified Nurse Assistant/CNA) reported that the resident fell on her bathroom floor. This report documents that R1 stated that she voided and was going to get a wipe and stand on her own and fell on her left arm. This report documents that the CNA stated that he was just in her room to fix her bed while she was in the bathroom. This incident report documents that R1's left arm was bent with obvious signs of deformity and bruising and that R1 could not move it and stated it was painful. Radiology results dated 7/15/2025 document that R1 sustained Findings: Acute comminuted displaced fracture involving the left humeral head/neck with soft tissue swelling. Acute comminuted displaced angulated fracture involving the proximal third shaft of the left humerus with soft tissue swelling. Impression: Multiple acute fractures involving the left humerus. On 7/26/25 at 11:46, R1 is lying flat on her back in bed and a brace is on her left arm. R1 stated she had a fall, broke her arm and it is painful. On 7/26/25 at 2:28 PM, V7 (CNA) stated that when a resident has a known fall risk they should never be left unattended when they are sitting on the toilet. On 7/26/25 at 3:08 PM, V8 (CNA) stated that he knew R1 was a fall risk and should not have left R1 alone on the toilet.On 7/26/25 at 4:04 PM, V5 (Registered Nurse/RN) stated that she would expect that all CNAs should not leave a resident unattended on the toilet if they were a fall risk. On 7/26/25 at 4:14 PM, V4 (Licensed Practical Nurse) stated that it was well known, and it is documented that R1 is at risk for falls and that R1 should not have been left unattended on the toilet. On 7/27/25 at 9:32 AM, V12 (Director of Nursing) (former-at time of incident) stated that R1's outcome would have been different if V8 (CNA) would have stayed at R1's side while she was on the toilet to prevent R1 from falling.

Based on observation, interview, and record review the facility failed to follow physician admission orders to assess and monitor a surgical site, failed to provide a physician ordered shampoo to use over a surgical site, failed to initiate Enhanced Barrier Precautions (EBP), and failed to update the care plan. These failures resulted in a surgical infection which required additional appointments, antibiotics, a second hospitalization , and surgery for one (R1) resident out of three residents reviewed for Quality Care/Treatment in a sample list of three residents. Findings include: R1's undated Face Sheet documents R1 admitted to the facility on [DATE] with medical diagnoses as Cerebral Infarction, Nontraumatic Intracerebral Hemorrhage, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left non-dominant side, Dysphagia, Lack of Coordination, and Difficulty in Walking. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is dependent on staff for toileting, dressing, bed mobility, and maximum assistance for bathing. R1's Hospital Summary and Discharge Record dated 3/24/25 documents R1's medical diagnoses as Left Hemiplegia, Midline shift of brain, Oropharyngeal Dysphagia, PEG (Percutaneous Endoscopic Gastrostomy) status, Status post Craniectomy, Left Homonymous Hemianopsia, Neurologic neglect, and Intercranial bleed. This same record documents physician orders for staff to complete daily skin checks, bathe R1 with a disinfectant/antiseptic soap, R1 is to wear a cranium helmet when out of bed, and R1 should be on Craniectomy precautions. R1's Admission assessment dated [DATE] documents R1 as cognitively intact. This same assessment does not document R1's surgical site on her scalp, use of helmet, or isolation precautions to be used for R1's surgical site. R1's Skin Evaluation dated 3/27/25 documents R1 had no skin issues. R1's Nurse Progress Note dated 4/28/25 at 8:03 PM documents R1 returned from V7 (Neurologist) appointment. An infection on R1's Hemicraniectomy wound. R1 was started on an antibiotic for the infection and referred to V29 (Infectious Disease Physician) and to the wound clinic. A dressing was applied to R1's scalp at the follow up appointment which was rewrapped upon return from facility. R1's Neurology Progress Note dated 4/28/25 documents V7 (Neurologist) saw R1 for a post operative visit. V7 found two areas of dry material that once uncovered shows purulent material for R1's two areas on her Cranial surgical site that were not healed. Wound cultures were obtained and sent out for evaluation. R1's infection did not spread and has no fluid collection. R1 will be referred to an Infectious Disease Physician and a wound clinic. R1's Neurology Progress Note dated 5/12/25 documents R1 recently developed two spots of infection on the upper and anterior portion of the Cranial flap that are not improving. V7 (Neurologist) recommends re-exploration of the area of the Craniectomy with scalp excision and debridement. R1's Procedure Note dated 5/15/25 documents R1 underwent a Right re-exploration of Right Frontal/Parietal Craniectomy for scalp excision with debridement. R1 was placed under general anesthesia with an endotracheal tube placed. R1's head was shaved. R1's scalp was dissected, lifted over the infected area and then the piece of scalp was sharply removed for the approximate length of six centimeters (cm) by two cm wide. R1's Physician Order Sheet (POS) dated May 2025 documents a physician order starting: --4/28/25-5/12/25 for Sulfamethoxazole-Trimethoprim (Bactrim) 800-160 milligrams (mg) twice daily for fourteen days for (surgical site) wound infection. This order was discontinued 5/2/25 per (V29) Infectious Disease doctor recommendation. --5/2/25-5/12/25 for Cephalexin (Keflex) 500 mg four times daily for ten days. --5/2/25 with no ending date for Enhanced Barrier Precautions (EBP) per facility guidelines. R1's POS does not include an EBP order prior to 5/2/25. --5/3/25 to cleanse R1's scalp incisional wounds/scabs if there is any drainage with wound cleanser, pat dry, apply absorbent gauze, wrap with gauze, and secure with tape over gauze as needed. --5/6/26 with no end date for R1 to wear a helmet to be worn at all times, including while sleeping, except for personal hygiene. There were no physician orders in R1's POS prior to 5/6/25 for R1 to wear a helmet. R1's Medication Administration Record (MAR) dated March, April and May 2025 do not include physician orders to check R1's skin daily, ensure R1 was wearing her helmet when out of bed or provide antiseptic/disinfectant shampoo to R1's surgical site during showers. R1's Treatment Administration Record (TAR) dated March, April, and May 2025 do not include physician orders to check R1's skin daily, ensure R1 was wearing her helmet when out of bed, or provide antiseptic/disinfectant shampoo to R1's surgical site during showers. On 5/14/25 at 9:40 AM V3 (R1's family member) stated R1 admitted to the facility on [DATE] after having a Cerebral Vascular Accident (CVA) followed by a Right sided Craniectomy in February 2025. V3 stated R1 was admitted to a hospital and then went to an acute Rehabilitation facility prior to admitting to this facility. V3 stated R1 has not been receiving the care that V7 (Neurosurgeon) ordered for R1. V3 stated R1 admitted to the facility with an open wound on her head and was supposed to wear a helmet at all times. V3 stated R1's incision had two separate areas that were not completely healed upon admission to the facility. V3 stated the facility has not monitored R1's incision site since admission and now R1 has an infection that will require surgery to remove the infection. V3 stated the facility is at fault for R1 obtaining an infection and R1 having to stay in the hospital again and losing 'precious' time in therapy. V3 stated R1 will have to start from scratch again if she makes it out of surgery. On 5/14/25 at 11:25 AM V8 (R1's husband) stated R1 was living at home with V8 when she had a CVA. V8 stated R1 had to have almost half of her skull removed due to the pressure from a bleed inside her head. V8 stated they (R1, V8) have had a long road due to her Craniectomy, hospitalization s, therapies, and ongoing struggles with trying to keep up with everything. V8 stated R1 entered this facility with the intention to get therapy and then go back home. V8 stated because the staff didn't look at R1's incision site and didn't clean it or report any changes, R1 got an infection and now must have another surgery on 5/15/25. V8 stated V7 (Neurosurgeon) is going to remove the infection by removing approximately one to two inches wide and four to six inches long of her scalp and then sew the remaining sides back together again. V8 stated R1 was progressing in her therapy and now will have to start all over. V8 stated I just hope she (R1) makes it out of surgery. There is a risk of her not making it through this surgery and I just can't stand the thought of any life without her. (R1) should not have to be going through this at all. This wasn't in the plan. On 5/14/25 at 11:35 AM R1's room did not have any signage designating R1 was on Enhanced Barrier Precautions (EBP), no Personal Protective Equipment (PPE) available and no designated bins in her room for PPE disposal. V9 (LPN) removed R1's helmet to show two dime sized dark scabbed areas with unattached edges and yellow drainage around both areas. V9 did not wear a gown when removing bandage on R1's Scalp surgical site. V9 stated during the observation that the drainage had been present 'for a couple of days'. V9 confirmed there was no dressing covering R1's two open draining areas from her surgical incision. On 5/14/25 at 1:45 PM V14 (LPN) did not wear a gown when obtaining a blood sample from R1. V14 LPN stated she did not know R1 was on any type of precautions. On 5/14/25 at 1:50 PM V11 and V12 (Certified Nursing Assistants/CNAs) transferred R1 from her high back padded wheelchair to her bed and then back from her bed to her wheelchair using a total body mechanical lift. V11 and V12 did not wear gloves or gowns when transferring R1. R1's helmet has several long oval shaped openings in the top which shows R1's scalp. Both V11 and V12 CNAs adjusted R1's helmet from the top end with bare hands during the transfers without wearing Personal Protective Equipment (PPE). On 5/14/25 at various times during first and second shifts R1 did not have a sign posted outside her room indicating R1 was on Enhanced Barrier Precautions (EBP). R1 did not have any supply of Personal Protective Equipment (PPE) outside her door or easily accessible. On 5/15/25 at 9:00 AM V5 (CNA/Shower Aide) stated she has given R1 showers multiple times. V5 stated she does not know of any kind of antiseptic/disinfectant soap to use on R1. V5 stated she has only used the facility soap to wash R1's hair. V5 stated R1's incision site has been red for a long time and that she did not need to report this 'because the nurses already know'. On 5/15/25 at 3:45 PM V28 (Advanced Nurse Practitioner) stated she would expect that the facility follows the physician and discharge summary/orders for R1. V28 stated R1 obtained the infection Methicillin Susceptible Staphylococcus Aureus (MSSA) under the care of the facility and R1's infection was not sourced internally. V28 stated R1's infection was 'an external infection' which could have been caused by the staff not properly caring for R1's surgical incision. V28 stated the staff should have been assessing R1's surgical incision site daily, R1 should have been wearing her helmet when out of bed, and any changes such as redness to the surgical site or a change in R1's neurological status should have been reported to V7 (Neurologist) immediately. V28 stated R1 required surgery to debride the surgical site due to the infection. V28 stated R1 would not have to have a second surgery if the facility followed V7's physician orders upon admission. V28 stated R1 would require a hospital stay in the Intensive Care Unit (ICU) following her second surgery and that this would be a setback for R1 reaching her therapy goals and eventual return to her home. On 5/16/25 at 9:50 AM V1 (Administrator) stated R1 admitted to the facility with physician orders to assess her surgical site on her Superior scalp daily, R1's helmet was to be on when out of bed and antiseptic/disinfectant was to be provided for cleansing R1's surgical site during showers. V1 stated the facility did not put those orders in place and did not clarify any orders with V7 (Neurologist). V1 stated R1 should have been placed on Enhanced Barrier Precautions (EBP) upon admission. V1 stated R1 should have had her surgical site assessed upon admission and monitored at least weekly thereafter. V1 stated R1's helmet should have been on when R1 was out of bed only. V1 stated the facility cannot provide documentation of any of these things being done for R1 because the staff did not follow the discharge summary/instructions. V1 stated if the staff had been assessing R1's wound she might not have had an infection. V1 stated R1's second surgery on 5/15/25 was not a part of her rehabilitation plan. V1 stated R1 had to have this second surgery due to an MSSA infection that 'was most likely caused by us (facility)'. V1 stated V1 and V2 (DON) will be doing a lot of training to help the staff understand a higher level of care and to help educate the staff to let them know that reporting questions and/or changes in a resident's care is very important. On 5/16/25 at 11:00 AM V2 (DON) stated R1 had a massive Cerebral Vascular Accident (CVA) followed by a Craniectomy in February 2025 prior to her admission to the facility. V2 stated R1 admitted to the facility on [DATE] with two areas on her surgical scalp incision that were not completely healed. V2 stated there is no documentation of R1 admitting with a surgical site, no documentation of R1's surgical site being assessed or monitored and no documentation of R1's helmet that she was supposed to be wearing when out of bed. V2 stated the facility should have entered in the physician discharge summary/instructions. V2 stated R1 was supposed to have an initial assessment and then daily skin assessments of her surgical site from her Craniectomy but the facility did not initiate those orders and therefore the staff did not know to check R1's surgical site daily. V2 stated the facility does not have a wound program for skin tears, surgical sites, abrasions, bruises, etc. V2 stated We (facility) have a skin program for pressure ulcers but not for any other type of wound. I am fixing that problem today. We (facility) could have done a much better job at managing (R1's) surgical wound. R1 should have been placed on Enhanced Barrier Precautions (EBP) from her admission, we should have called to clarify her orders when she admitted and not waited until she had been a resident here for over a month. Unfortunately (R1) did obtain her infection to her surgical site under our care from not implementing isolation precautions and not following physician orders for the care of her surgical site. V2 stated the facility provides a standard shampoo and body wash but did not provide R1's antiseptic/disinfectant shampoo for her showers. V2 stated R1's care plan did include 'helmet for protection' but that should have been clarified as to when R1's helmet should have been on and off. V2 stated she understood why the staff were confused about the placement of R1's helmet because the intervention was unclear. V2 stated the combination of the staff not assessing R1's surgical site, not using the correct shampoo that was ordered by V7 (Neurologist) and not following up timely after her admission most likely caused her infection which led to her second surgical procedure. The facility policy titled Skin Impairment Prevention and Wound Management effective December 12, 2024, documents the facility will provide an aggressive skin care program using current standards of clinical practice. The presence of wounds will be indicated on the admission nursing assessment. Wound status will be monitored as ordered by the Physician. A complete wound assessment will be done weekly by a licensed nurse for all wounds, ulcers, and impairments in the skin integrity. Staff will document the wound using the weekly observation assessment.

Based on interview and record review the facility failed to follow their Grievance policy by not following up on a resident (R1) complaint timely for one out of three residents reviewed for grievances in a sample list of three residents. Findings include: The facility policy titled Grievance Policy dated 10/19/22 documents each resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear or discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their facility stay. The facility will ensure prompt resolution to grievances, keeping the resident and the resident representative informed throughout the investigation and resolution process. The Grievance Officer will be responsible for tracking grievances through their conclusion, lead necessary investigations, communicate with residents through the process to resolution. The Grievance Officer works with facility staff utilizing root cause analysis processes for resolution of the grievance or concern. The Grievance Officer will initiate the appropriate notification and investigation processes per individual circumstance and facility policies. The investigation will consist of at least the following: a review of the completed complaint report, interview with the person reporting the incident, interview with any witnesses to the incident, review of the resident medical record, interviews with staff having contact with the resident during the relevant periods of the alleged incident, interviews with the resident's family members and a root-cause analysis of the circumstances surrounding the incident. R1's undated Face Sheet documents R1 admitted to the facility on [DATE] with medical diagnoses as Cerebral Infarction, Nontraumatic Intracerebral Hemorrhage, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left non-dominant side, Dysphagia, Lack of Coordination and Difficulty in Walking. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is dependent on staff for toileting, dressing, bed mobility and maximum assistance for bathing. R1's Nurse Progress Note back dated 4/2/25 at 3:24 PM documents V8 (R1's spouse) reported to V9 (Licensed Practical Nurse/LPN) that someone bumped R1's head during her transfer this morning for a shower. This same note was dated as entered on 5/2/25. R1's Electronic Medical Record (EMR) does not include any alleged accident nor any investigation. The facility grievance log dated 5/2/25 documents R1stated she bumped her head during a transfer with a total body mechanical lift. On 5/14/25 at 11:20 AM R1 stated she doesn't remember exactly when her head was bumped on 4/2/25 but knows it was before actually taking a shower. R1 stated the staff pushed her in the shower chair around the corner of the bathroom too fast. R1 stated she felt like a knife was slicing through her head. R1 stated that hurt something awful. R1 stated she didn't know if the skin was broken or not on the top of her scalp where her incision was but it sure hurt like it did. R1 stated she didn't say anything to the staff at that time because she didn't want them to lie about it. R1 stated she told her husband so he could let the nurse (V9) LPN know. On 5/15/25 at 10:25 AM V19 (Director of Residential Services/Grievance Officer) stated R1 told V8 (R1's) husband on 4/2/25 that the staff bumped R1's head during a shower earlier that morning. V19 stated V8 reported this to V9 (LPN), who then reported this to V2 (DON) on 4/2/25. V19 stated V9 and V2 both looked at R1's head to find no injuries on 4/2/25. V19 stated there was nothing else done about this incident until 5/2/25. V19 stated R1's assessment of her head documented in her clinical record was actually entered on 5/2/25, not 4/2/25 as the grievance log documents. V19 stated the facility did not follow their Grievance policy by not immediately investigating this incident. On 5/15/25 at 11:25 AM V8 (R1's) husband stated R1 told him that the staff bumped her head that morning (4/2/25) and he let the nurse (V9) LPN know. V8 stated V9 (LPN) and V2 (Director of Nursing/DON) both looked at R1's head and there was no injury. V8 stated no one ever asked how R1's head was bumped or talked to R1 or the staff to try to prevent that from happening again.

Based on interview and record review the facility failed to timely investigate an accident and update the resident care plan for one (R1) resident out of three residents reviewed for Accidents in a sample list of three residents. Findings include: R1's undated Face Sheet documents R1 admitted to the facility on [DATE] with medical diagnoses as Cerebral Infarction, Nontraumatic Intracerebral Hemorrhage, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left non-dominant side, Dysphagia, Lack of Coordination, and Difficulty in Walking. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is dependent on staff for toileting, dressing, bed mobility and maximum assistance for bathing. R1's Nurse Progress Note back dated 4/2/25 at 3:24 PM documents V8 (R1's husband) reported to V9 (Licensed Practical Nurse/LPN) that someone bumped R1's head during her transfer this morning for a shower. This same note was dated as entered on 5/2/25. R1's Electronic Medical Record (EMR) does not include any investigation or updated care plan intervention for R1's reporting of the staff hitting her head during a shower on 4/2/25. On 5/14/25 at 11:20 AM R1 stated she was assisted up into her shower chair the morning of 4/2/25 by two Certified Nursing Assistants/CNAs (V5, V12). R1 stated after she was up, V12 left the room and V5 gave her a shower in the shower in her room. R1 stated she doesn't remember exactly when her head was bumped but knows it was after V12 left and before actually taking a shower. R1 stated the staff pushed her in the shower chair around the corner of the bathroom too fast. R1 stated she felt like a knife was slicing through her head. R1 stated that hurt something awful. R1 stated she didn't know if the skin was broken or not on the top of her scalp where her incision was but it sure hurt like it did. R1 stated no one ever asked her anything about that incident. On 5/14/25 at 11:25 AM V8 (R1's husband) stated V8 reported to V9 (Licensed Practical Nurse/LPN) on 4/2/25 that the staff had bumped R1's head in the shower. V8 stated no one ever asked him anything about the incident. On 5/15/25 at 9:05 AM V5 (CNA) stated R1 is cognitively intact and did not say anything to V5 about getting her head bumped. V5 stated no one ever asked her how it might have happened or who was in the shower assisting V5 with R1 until yesterday (5/14/25). On 5/15/25 at 9:10 AM V17 (CNA) stated R1 was not his client on 4/2/25 and did not help with her shower that morning. V17 stated no one asked V17 if he knew anything about R1's head being bumped on 4/2/25. V17 stated V17 heard about this incident on 5/14/25. On 5/15/25 at 9:15 AM V18 (CNA) stated he did not help transfer R1 to/from the shower on 4/2/25. V18 stated no one asked V18 if he knew anything about R1's head being bumped on 4/2/25. V18 stated V18 heard about this incident on 5/14/25. On 5/15/25 at 3:20 PM V2 (Director of Nurses/DON) stated R1's report of the staff bumping her head while in the shower on 4/2/25 was not investigated until 5/2/25. V2 stated V8 (R1's husband) did report this incident to V9 (LPN) that morning. V2 stated both V9 and V2 did look at R1's head but since there was no injury, there was no investigation as to the validity of R1's complaint. V2 stated the facility should have investigated to see if R1's head was bumped, how it may have been bumped and who all was involved with R1's shower that morning so that the facility could put measures in place to ensure R1's head was not bumped again the same way. The facility policy titled Incident and Accident Reporting dated July 18, 2013, documents an incident report in the resident's Electronic Medical Records (EMR) will be completed by the nurse as soon as possible after the incident/accident occurs. The nurse will start the incident investigation within 24 hours of the event or as soon as possible. After the incident investigation is complete, the Director of Nurses (DON) and other staff members as appropriate will review for further action/interventions that need to occur. Any interventions/actions will be documented on the investigative report. That information is then shared with the appropriate staff members and placed on the care plan.

Based on observation, interview, and record review the facility failed to ensure proper wheelchair positioning to prevent a fall, failed to provide safe equipment, and failed to use a mechanical lift for transfers for one (R269) of 16 residents reviewed for accidents on the sample list of 21. These failures resulted in R269 requiring emergency room treatment after falling from a wheelchair and hitting R269's head on the floor. R269 sustained a head injury and a hematoma to the left forehead. These failures also resulted in R269 sustaining skin tears to the left and right forearm. Findings include: On 2/3/25 at 11:12 PM, R269 was sitting in a reclining wheelchair by the nurse's station. R269 had a yellowish - blue bruised raised area above the left eye. This bruising extended down the left side of R269's face to underneath of R269's chin. R269 had skin protective sleeves on the left and right arm. Black and yellowish bruising was seen underneath these sleeves. R269's Incident Report dated 1/29/25 documents that R269 was found on the floor in front of her reclining chair. A hematoma was noticed to the left temporal area and skin tear to the left knee. This incident report documents that R269 was watching television prior to the fall. This report documents R269 was sent to the emergency room for an evaluation. R269's emergency room visit notes dated 1/29/25 documents R269 was seen in the emergency room for a head injury due to a fall at the facility. These notes document R269 sustained a hematoma to the left forehead as a result of the fall. On 2/05/25 at 1:38 PM, V18 (Certified Nursing Assistant/CNA) stated just prior to R269's 1/29/25 fall, R269 was seen sitting comfortably watching television in a slight reclining position in the reclining wheelchair. V18 stated that the reclining wheelchair was not all the way reclined. On 2/04/25 at 1:56 PM, V2 (Director of Nursing) stated V2 investigated the cause of the fall occurring on 1/29/25. V2 stated she interviewed the CNAs (V18 and V45) who were caring for R269 at the time of the fall. V2 stated these interviews concluded that R269's reclining wheelchair was not reclined at the time of the fall. V2 stated it should have been reclined because R269 has poor core strength and R269 has been getting therapy for this. V2 stated she determined that R269 fell forward out of the chair due to poor core strength and the chair not being reclined. On 2/4/25 at 8:47 AM, V11 (Advanced Practice Nurse) was conducting an assessment on R269. V11 stated R269's injuries are consistent with the fall however he cannot see R269 being able to move self out of the reclining wheelchair if the chair was reclined. On 2/04/25 at 12:25 PM, V16 (Physical Therapist) stated that R269 has poor core balance, and that therapy has been working on strengthening. V16 stated that R269's reclining wheelchair should be fully reclined to prevent R269 from falling forward out of the chair. R269's incident report dated 1/27/25 at 11:00 AM documents, R269 was found to have a skin tear measuring 15.3 centimeters to the left arm and a three-centimeter skin tear to the right arm. This incident report documents that the staff have observed R269 putting both arms through the openings underneath the wheelchair armrests. This report documents that the metal bolts underneath the arm rests had rough edges which could have possibly caused the skin tears. On 2/5/25 at 10:15 AM, V45 (CNA) stated that she assisted R269 to the bathroom on 1/27/25 and noticed dry blood on R269 right and left arms. V43 stated that R269 has a daily habit of putting her arms between under the armrests. V43 stated she didn't tell anyone about R269 repeated daily stuffing arms through the wheelchair armrest and the seat of the chair. V43 stated that she always wears short sleeve shirts and tended to slide down in the wheelchair. V43 stated that upon inspection the bolts under the armrest were sharp and consistent with the skin tears. On 2/04/25 01:56 PM, V17 (Assistant Director of Nursing) and V2 (Director of Nursing) stated that R269's wheelchair had sharp bolts underneath the arm rest on both the right and left side of the wheelchair. V2 stated V2 was working when R269 was found to have the skin tears. V2 stated it was determined that the skin tears were caused from the bolts on the wheelchair. On 2/5/25 at 12:58 PM, V9 (Maintenance Director) stated the facility does not have a process for ensuring that wheelchairs are safe prior to use. On 2/04/25 at 12:25 PM, V16 (Physical Therapist) stated that R269 was a sit to stand lift but then had a stroke, R269 returned to the facility on [DATE]. V16 stated R269 was made a full mechanical lift on 1/30/25. V16 stated R269's transfer status is written on a transfer directive sheet and taped to the back of the bathroom door. R269's Transfer Directive dated 1/30/25 documents R269 is a full mechanical lift for transfers. On 2/04/25 at 10:35 AM, V14 and V15 (Certified Nursing Assistants) transferred R269 with the sit to stand lift. On 2/04/25 at 11:07 AM, V14 and V15 transferred R269 with the sit to stand lift. On 2/04/25 at 1:56 PM, V2 (Director of Nursing) stated V14 and V15 should have transferred R269 with the full mechanical lift.

Based on record review, observation and interview the facility failed to implement fall intervention of assistive devices for R1 and R2. The facility also failed to adequately supervise (R1 and R2) cognitively impaired residents with known history of falls and repeated falls, resulting in R1 and R2 sustaining falls with injuries. R1's unwitnessed fall resulted in R1 sustaining multiple fractures requiring hospitalization . R2's unwitnessed fall resulted in R2 sustaining a laceration above the right eye requiring emergency medical services of sutures and hospital admission for observation. These failures affected two (R1 and R2) of three residents reviewed for falls on the sample list of three. Findings include: 1.) R1's Morse Fall Scale Risk assessment dated [DATE] documents R1's admitted as the same 10/26/22. R1 fall risk assessment score as 75 indicates R1 score equals high risk for falling, has a history of falls and uses crutches, cane or a walker. R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview of Mental Status score of 14 out of a possible 15 indicating no cognitive impairment (on admission, prior to urinary tract infection, later identified confusion). The same MDS documents R1 requires extensive assistance of one person for transfers, toileting, bed mobility, uses a wheelchair and walker for mobility, is not able to stabilize balance without staff assistance during walking, surface to surface transfers, or seated to standing positioning. The same MDS documents R1 has impairment of one lower extremity. The same MDS documents R1 had a fall with fracture prior to admission to the facility 10/26/22. The facility fall log Incident by Incident documents R1 fell five times since admission to the facility 10/26/22. R1's Care Plan dated 10/26/22 and revised 11/2/22, 11/8/22 and 12/02/22 documents the following: Acute Pain, Date Initiated: 11/08/2022 Resident Will Be Free of Pain /Discomfort. Date Initiated: 11/08/2022 Administer ice packs as ordered. Administer pain medications per order, if non-medication interventions are Encourage non-medication suggestion for pain relief. (R1) is risk for falls r/t recent falls with injury, multiple hospitalization s & comorbidities, deconditioned, impaired balance. Date Initiated: 11/08/2022 frequent checks, non-skid footwear at all times, place walker within reach of resident when leaving. Fall 11/02/2022 R1's first Unwitnessed Fall Incident Description and investigation note signed by V3, Licensed Practical Nurse (LPN), dated 11/2/22 at 1:56 pm, documents the following: Resident (R1) was noted by staff to be sitting upright on the floor with her back leaned against the wall with AC (air conditioner) unit. The room was in order, nothing, tipped over or out of place. wheelchair was three feet from resident towards the bathroom. At the time of the incident resident was continent, in a nightgown, with bare feet, call light was within reach when in bed but not activated. On nurse assessment no obvious injuries, (vital signs) and neuros (neurological assessment) WNL (within normal limits). Resident complained of pain rated 3/10 (three out of a possible 10, 10 being the worst pain level) to the left hip where she had recently (10/20/22) had hip surgery. Provider (unidentified) notified and an order (for) X-ray of (R1's) leg and hip. Resident diagnosed with UTI (Urinary Tract Infection) late 11/1/22, provider waiting to start antibiotic treatment until culture and sensitivity results. Resident last visualized by staff 1 (one hour) before falling asleep in bed. Staff reported overnight resident was more confused than baseline. When resident asked about fall (R1) reported (R1) was trying to go to the bathroom and thought her walker was nearby, she couldn't stand the pain anymore and fell down. [NAME] was on the opposite side of the room. Root cause: UTI, bare feet, poor lighting, no light (call light) activated, walker out of reach. Intervention - frequent checks, non-skid footwear at all times, place walker within reach of resident when leaving (room). On 12/7/22 at 3:56 pm V3 (Licensed Practical Nurse/LPN) confirmed her documentation of the above fall and stated the fall occurred around 7:15 am day shift 11/2/22 and was documented late as 11/2/22 at 1:56 pm. V3 confirmed the events as documented above, up without assistance, last visualized one hour prior, confusion, walker out of resident reach, and bare feet. On 12/9/22 at 7:40 am R1 was lying in a low bed, floor mat in place and call light cord attached to R1's blanket. R1 was holding the call light activator button handle and stated I don't know how to get this slot machine to work. Is it a quarter to play? R1 stated she could use some help. R1's wheelchair was positioned eight feet away from the right side of R1's bed. R1's walker was positioned ten feet away from the foot of R1's bed. R1's walker was folded and leaning behind R1's recliner. R1 feet were bare. On 12/9/22 at 7:45 am V12 (Registered Nurse/RN) entered R1's room and confirmed R1's wheelchair and walker placement, bare feet and confusion with the call light. V12 verified the interventions on the care plan and stated the night shift may have thought the fall interventions were supposed to be implemented on days and should be implemented on days and night shifts. R1's second Unwitnessed Fall Incident Description and investigation note signed by V10 (RN) dated 11/02/22 at 3:28 pm, is the second fall of this day and documents the following: Nursing Description: ST (V13 Speech Therapist) came and found this nurse (V10 RN) to report pt (patient-R1) was on the floor. This nurse (V10 RN) went to assess resident (R1). She (R1) was face down on the floor between window and bed. Complaining of pain in R (right) shoulder. Pt (R1) was last seen 2 (two) minutes prior in wheelchair. This nurse (V10 RN) stepped out to get antibiotic to treat UTI. Before this nurse left (V10 RN), she (V10 RN) reminded pt (R1) to not get out of her (R1's) chair on her (R1's) own and to use the call light. Pt was wearing non-skid socks and was not incontinent. Immediate Action Taken: Description: Assessed resident. She (R1) is yelling and complaining of severe R (right) shoulder pain. Rolled resident onto her back to be able to put (mechanical lift) sling under her and got her up with 2 (two) assist and (mechanical lift). Put pt (R1) in bed. Notified Nurse Practitioner (V11 NP). Who gave orders to send (R1) to (the) hospital. Notified (V8 Family Member). Resident Taken to Hospital: Yes. The same report documents the following: Notes: Pt (R1) is normally fully alert and oriented. UTI was found this am (morning before first fall 11/2/22, noted above). Since then, pt has only been alert and oriented to self and has become confused and agitated. On 12/7/22 at 3:20 pm V10 (RN) stated On 11/2/22 in the afternoon, I had just left (R1) in her wheelchair and reminded her (R1) not to get up. I was going to get medicine for her UTI (Urinary Tract Infection). (R1) was really confused and had fallen just before I came in that same morning (11/2/22). I think I came that day at 7:30 am. (V2 Director of Nursing) and (V14 Social Service Director) had also been going into talk resident (R1) into having an X-ray from (R1's) fall that morning. That fall happened just before my shift. (R1) was very confused, had just been diagnosed with a UTI. We called (V11) Nurse Practitioner and got an order (physician/provider) for Rocephin (Intramuscularly antibiotic). When I (V10 RN) left her room, I was only gone a couple minutes to draw up (fill a needled syringe) the Rocephin. I (V10 RN) asked her (R1) not to get up. I (V10 RN) told her I would be right back. Since, I (V10 RN) knew she (R1) had had the increase confusion, I (V10 RN) probably should not have left her (R1) alone. I just thought once she (R1) had the antibiotic (Rocephin), she may be less confused and willing to get the X-ray. R1's (Private Hospital) Surgical Discharge Summary dated 11/5/22 documents R1 was admitted to the hospital post-unwitnessed fall at this skilled nursing facility on 11/02/22. (Private Hospital) Surgical Discharge Summary documents R1's hospital admission diagnoses list included: Trauma Fall Encounter, Closed Fracture of Proximal End of Right Humerus Unspecified Fracture Morphology Initial Encounter, Closed Interochanteric Fracture Left Hip, Initial Encounter, Pubic Ramus Fracture, and Acute Cystitis Without Hematuria. R1's same (Private Hospital) Surgical Discharge Summary documents R1 had surgical repair of left hip two weeks prior to this hospital admission. This hospitalization [DATE] Patient (R1) was found to have a proximal Humerus fracture and new interval increase displacement of lesser trochanter fragment, both injuries did not require surgical intervention. The same report documents Patient (R1) initially had reasonable pain during the initial stages of her admission. Her (R1) pain was eventually controlled with PO (by mouth) medications. During her stay she was treated for suspected UTI (Urinary Tract Infection) with IV (Intravenous) Ceftriaxone (antibiotic) and eventually switched to Bactrim (unidentified route). The same report documents R1 was discharged from the hospital back to this same skilled nursing facility on 11/05/22. On 12/07/22 at 1:21 pm V11 (Nurse Practitioner/NP) confirmed R1's fractures were caused by R1's fall 11/2/22. V11 stated V11 had evaluated R1 after the first fall 11/2/22 and R1 was complaining left leg pain. V11 stated V11 evaluated R1 after her first fall 11/2/22 (R1) did not complain of arm pain at that time V11, stated it is hard to know if (R1's) arm fractures were from the first fall on 11/2/22 or the second fall that day. Her fractures were confirmed when she was sent out to the hospital post the second fall. I ordered an x-ray of (R1's) hips when I evaluated (R1) after the first fall. (R1) did have a complaint of leg pain. (R1) did not complain of arm pain, to my knowledge until after the second fall. It was likely the second fall caused the arm fracture, but it is hard to really tell. V11, NP also stated We knew (R1) had a UTI. (R1) had some delirium. I am always concerned with possibility of c-diff and hold off prescribing antibiotics until we have the culture back. I don't think R1 should have been educated to stay in (R1's) wheelchair. Someone needed to keep a close eye on (R1). (R1) was very confused when I saw (R1) that morning. V11 also stated the care planned interventions should be consistently implemented. R1's care plan interventions for non-skid socks, and to keep (R1's) walker and wheelchair within reach staff are aware of what they should be doing this. R1's third Unwitnessed Fall Incident Description and investigation note signed by V5 (RN) dated 11/20/22 at 8:15 am, documents R1 was found on the floor, incontinent and with bare feet, on floor mat next to R1's bed. V5 also documents R1 had not been visualized since between 7:00 am and 7:15 am by V5. V5 also documents on the same fall report, V5 did not know the last time an unidentified Certified Nursing observed R1. V5 also documents the following: Night shift (unidentified staff member) gave report to day shift (V5 ) that res (R1, resident) had been dangling (R1's) feet out of bed several times throughout the night and needed to be put back to bed. The same investigation note documents the root cause of this fall as: weakness, incontinence and confusion. Intervention: Video monitoring during night, frequent checks, leave door open for increased supervision. On 12/7/22 at 12:10 pm V5 stated I worked on 11/20/22 and responded to a CNA (unidentified) who found (R1) on the floor mat next to her bed. (R1's) call light was not turned on but was within (R1's) reach while in bed. The call light was clipped to (R1's) bedsheet. I had seen (R1) about 45 minutes before (R1) fell . (R1) was asleep. (R1) told me when I evaluated her on the floor, (R1) had to go to the bathroom and got up by (R1's) self. (R1) did not have non-skid sock on, I documented that in my note. I was told in report that (R1) had been dangling (R1's) feet off the bed overnight shift and staff had to assist (R1) in putting (R1's) feet back in bed. I guess (R1) was kind of restless for them (night shift). (R1) was asleep when I saw (R1) about 7:15 am. I documented that as well. (R1's) room has been changed to here (points to the room closest to the nurse's station), closer to the nurses station. (R1) is so sweet and said (R1) doesn't like to bother staff. I reminded (R1) that is what we are here for, to help (R1) and the other residents. Video monitor placed in (R1's) room to keep (R1) safe after that fall as well as the closer room. (R1) had no injury and I called (V9, Physician) and (R1's family member) to report. R1's fourth Unwitnessed Fall Incident Description and investigation note signed by V12 (RN) dated 11/21/22 at 7:30 am, documents R1's family member (V8) found R1 on the floor. R1 had been having an increase in confusion and was unable to communicate what R1 was trying to do. No injury identified except complaint of ongoing pain of right arm and left leg. Root cause: UTI, incontinence, weakness, and confusion. Intervention identified for signage to be placed in R1's room to put on call light for help and wait before getting up. On 12/9/22 at 7:45 am V12 (RN) confirmed R1's fall as written 11/21/22 and stated V12 was new and working with another nurse (unidentified) that day. V12 also stated V12 believed V12 documented the fall details correctly as they occurred. R1's fifth Unwitnessed Fall Incident Description and investigation note signed by V3 (LPN) dated 11/26/22 at 9:30 am documents R1 was found on the right side of R1's bed, had no clothes on, was covered in feces from torso to bilateral legs and arms. The same Incident Description investigation note documents the last time R1 was visualized was at 7:30 am (two hours prior to fall) and was sleeping at that time. The same report documents the (unidentified CNA) had been told in report from night shift R1 was last changed at 5:00 am. The same report documents neither wheelchair or roller walker were nearby. The same report documents Resident description as follows: Resident (R1) said (R1) was going to crawl to the bathroom. When asked why (R1) didn't use (R1's) call light, the resident (R1) said '(R1) didn't think anyone was here.' Resident (R1) denies any new pain. On 12/7/22 at 3:56 pm V3 (LPN) confirmed R1's fall 11/26/22 fall is accurately documented. V3 stated R1 was not changed after 5:00 am, was sleeping, and neither R1's wheelchair or walker were nearby R1. 2.) R2's Morse Fall Scale Risk assessment dated [DATE] documents R2's fall risk assessment score as 90 equals high risk for falling, has a history of falls and uses crutches, cane, or a walker. R2's Minimum Data Set (MDS) dated ,d+[DATE] documents R2 was admitted to the facility on [DATE]. The same MDS documents R2 has severe cognitive impairment, ambulates with limited staff assistance of one person and requires extensive assistance of one staff with transfers, bed mobility and toileting needs, is unsteady with all transitions and only able to stabilize with staff assistance. The same MDS documents R2 had one fall prior to admission (10/16/22), uses a walker and a wheelchair for mobility. R2's Unwitnessed Fall Incident Description and investigation note signed by V5 (RN) dated 10/23/22 at 11:01 am, documents the following: Res (R2) was fof (found on floor) at the nurse's station, lying on (R2's) back in between the desk and the sitting chairs. Res (R2) was found at 11:01 am. Res (R2) was last seen sitting in the chair with the walker beside (R2) at 10:58 am. Res (R2) had been fed breakfast, toileted and taken outside in (R2's) wheelchair for a stroll. (R2) was then placed at the nurse's station in the chair. Resident (R2) was unable to tell staff what had happened or what lead to the fall due to res (R2's) hx (history) of Dementia and non-sensical communication pattern. Resident description: Res (R2's) shoes were on and (R2) was continent at the time of the fall. [NAME] was off to the side near (R2's) head. Res (R2) was conscious when found and alert to baseline orientation. Immediate Action Taken: Laceration noted to right forehead above the eyebrow. Wound cleansed with NS (normal saline), skin, scalp and hair also cleaned. Wet to dry dressing placed over wound. (Unidentified family member) and on call Nurse Practitioner (V11, NP) notified. Vitals taken Neuros (neurological assessment) checked. Res (R2) should be monitored with a baby monitor or 1:1 (one on one) assistance at all times. Resident taken to the hospital? Yes. The same report Unwitnessed Fall Incident Description and investigation note documents: Camera footage (at the nurse station) was reviewed and showed R2 got up from a chair less than a minute after staff went to answer a call light. Resident (R2) walked to the call light box located near the nursing station, without (R2's) walker and pushing buttons on the call light box. Resident (R2's) gait appeared unsteady during the entire event. Root Cause: Weakness, unsteady gait, ambulating without walker. Intervention- transported to ER (emergency room ), continue to work with PT/OT/ST (Physical Therapy/Occupational Therapy/ Speech Therapy). Place signage on walker reminding resident not to get up without assistance, educate staff to place walker directly in front of resident if leaving (R2) unattended. R2's Hospital Discharge Summary dated 10/27/22 documents R2 was admitted to the hospital, from the emergency department 10/23/22 post fall in the facility. Discharge diagnoses included: AMS (Altered Mental Status) possibly in setting of underlying (D) dementia, Fall suspected mechanical, per chart review, Physical deconditioning - PT/OT (Physical Therapy/Occupational Therapy) recommending ECF (Extended Care Facility), Failure to Thrive, Decreased Oral intake. The same report documents an extensive work-up was completed while R2 was hospitalized , and five sutures were placed in R2's forehead that are to be removed from forehead laceration in one week. The same Hospital Discharge summary documents: Fall precautions recommended. R2's additional fall Unwitnessed Fall Incident Description and investigation note signed by V18 (RN) dated 12/01/22 documents the following: CNA (unidentified) watching camera (in R2's room), looked away (stopped observation) to chart and when looked back, (R2) was out of view of camera. When CNA (unidentified) went to check on resident (R2), (R2) was on (the) floor mat. This RN (V18) alerted, went to room. Resident (R2) found next to be prone no visible wounds. This RN and 2 (two) CNA's (unidentified) moved resident (R2) back to bed and this RN did a full assessment with no adverse findings. Resident (R2) brought out to sit by the nurse's station for closer observation. Root cause: Poor safety awareness r/t (related to) resident's (R2) baseline mentation. Fall intervention: To have res (R2) in the common area for supervision when not sleeping. On 12/09/22 at 1:45 pm V2 (Director of Nursing/DON) confirmed R1, and R2 are at high risk for fall. V2 confirmed V2 does all the fall investigations and determines root cause and targeted interventions to prevent further falls. V2 DON reviewed fall investigations and stated R1 and R2 were confused at the time of their falls and should have had closer supervision by staff. The facility policy Fall Risk Assessment and Protocol dated 4/21/22 documents the following: Policy Statement, The purpose of this policy is to outline methods of assessment of risk, interventions, to attempt to prevent falls and provide guidance on actions should a fall occur. Fall definition: a fall is defined as failure to maintain an appropriate lying, sitting, or standing position, resulting in an individual's abrupt, undesired relocation to a lower level. The same policy documents: PROCEDURES A. Assessment 1. Residents will be assessed upon admission, quarterly, prn, or upon a change in condition that affects their fall risk. 2. Those residents whom have been identified as being at risk for falls will have this noted within their care plan. B. Interventions 1. Call light within reach 2. Bed in low position 3. Nonslip footwear when ambulating Individualized additional interventions will be determined and implemented for the individual resident based upon decisions by the interdisciplinary team. C. Documentation 1. Individualized interventions will be documented in the resident care plan 2. An evaluation of the effectiveness of the identified interventions will be done quarterly at a minimum. Interventions will be reviewed and updated as necessary based upon the guidance of the team. D. Fall Occurrence 1. Residents shall be assessed immediately after a fall by the nurse 2. The residents MD/APN and family will be notified of the fall, as well as informed if there is an injury 3. Resident will be assessed each shift X 72 hours and this assessment will be documented in the medical record 4. If the resident is injured, refer to the Incident and Accident Reporting Policy. The facility policy Incident and Accident Reporting Policy dated 07/18/13 documents the following: Policy Statement, Accidents or incidents occurring in (facility name) Health Center or involving (facility name) Residents shall be investigated and reported to the Director of Nursing or his/her designee. Numerous and varied accident hazards exist in our everyday life. Not all accidents are avoidable. The condition of some or our residents increases their vulnerability to hazards in the resident environment and can result in life threatening injuries. We are responsible to provide care to our residents in a manner that helps promote quality of life. This includes respecting residents' right to privacy, dignity and self-determination, and their right to make choices about significant aspects of their life in the facility. For a variety of reasons, residents are exposed to some potential for harm. Although hazards should not be ignored, there are varying degrees of potential for harm. It is reasonable to accept some risks as a trade-off for the potential benefits, such as maintaining dignity, self-determination, and control over one's daily life. Staff are encouraged and expected to report incidents/accidents immediately. DEFINITIONS, Accident: Refers to any unexpected or unintentional incident, which may result in injury or illness to a resident. Assistance Device/Assistive Device: Refers to any item (i.e. handrails, transfer lifts, canes, etc.) that are used by, or in the care of a resident to promote, supplement, or enhance the resident's function and/or safety. Fall: Refers to unintentionally coming to rest on the ground, floor, or other lower level but not as a result of an overwhelming external force. An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Hazards: Refers to elements of the resident environment that have the potential to cause injury or illness. Resident Environment: Includes the physical surroundings to which the resident has access. Risk: Refers to any external factor or characteristic of an individual resident that influences the likelihood of an accident. Supervision: Refers to an intervention and means of mitigating the risk of an accident.

Based on observation, interview, and record review the facility failed to maintain the wheel lock on a wheelchair in safe working order for one resident (R1) in a sample of three residents reviewed for falls. This failure resulted in R1 falling and sustaining a fracture to R1's fibula and tibia. Findings Include: R1's physician's orders [REDACTED]. R1's X-ray report from a local hospital dated 7/2/17 at 9:58AM documents Fracture of the proximal right fibula is minimally displaced. Minimally displaced fracture of the tibial metadiaphysis at level of prosthetic stem. Right knee hemarthrosis. R1's history and physical 7/12/17 by Z2, Clinical Nurse Specialist (CNS) documents patient admitted in early May for rehabilitation after Urinary Tract Infection [DIAGNOSES REDACTED]. She fell on [DATE] and sustained a fracture of (R1's) Tibia/Fibula. A web based maintenance request # dated 7/1/17 at 1:52PM by E8, Licensed Practical Nurse (LPN) documents Description: Lock on resident wheelchair broken. Details: (R1's room number) a lock on wheelchair broken. R1's progress notes on 7/2/17 at 6:35AM E4, Registered Nurse (RN) documents, (R1) sat at the edge of the seat. The wheelchair moved slightly and E7, (Certified Nurse's Aide) (CNA) lowered (R1) to the floor onto (R1's) buttocks and right knee. After R1 was sitting on the floor,(R1) laid back onto her back with (R1's) left leg extended in front of her and (R1's) right leg bent a the knee. E4 also documented Upon examination of the wheelchair, the left wheel does not completely lock when the brake is locked. R1's Minimum Data Set ((MDS) dated [DATE] documents R1 as cognitively intact. On 7/24/17 at 12:10PM R1 was being transferred from a wheelchair to the toilet via a sling type (full body) mechanical lift. R1 stated This lift scares me a little and it kind of aggravates my broken leg. Before I fell and broke my leg, I could stand with the gait belt. R1 was wearing a leg immobilizer from R1's mid-thigh to R1's ankle on the right leg. On 7/24/17 at 11:35AM R4 confirmed that prior to R1's 7/2/17 fall R4 had been R1's roommate. R4 stated I heard (Z1) tell CNA and the nurse both the night before (R1) fell , the next morning that (R1's) wheel chair was broken and the brake wouldn't hold. R4's Brief Inventory of Mental Status (BIMS) dated 7/13/17 documents that R4 is cognitively intact. On 7/24/17 at 12:11PM E5, Certified Nurse's Aide (CNA) stated when I came in that day before (R1) fell I reported to my charge nurse E8, (Licensed Practical Nurse) that one of the locks was not working on (R1's) wheel chair and the nurse (E8) put in a work order. E5 confirms that prior to the 7/2/17 fall R1 was able to transfer with a gait belt and one staff. On 7/24/17 at 12:11PM E6, Certified Nurse's Aide (CNA) stated I was aware that the wheel chair (R1) was using had a malfunctioning brake 7/1/17, the day prior to (R1's) fall. E6 confirms that prior to the 7/2/17 fall R1 was able to transfer with a gait belt and one staff. On 7/24/17 at 1:00PM E3, Registered Nurse (RN) stated When I got to the unit 7/2/17 at 7:00AM, I was told in report that (R1) had fallen and her right leg was bent under (R1). R1 was complaining of more pain and we immediately sent (R1) to the hospital. We heard later from the hospital that R1's fibula and tibia were broken. On 7/24/17 at 4:06pm Z2, Clinical Nurse Specialist (CNS) stated, I do believe that when (R1) fell at (the facility) on 7/2/17 early morning, (R1) sustained a fibular/tibial fracture as a result of that fall. The facility's policy titled Safeguarding Adaptive Equipment dated 3/3/15 states adaptive equipment may include, but is not limited to glasses, hearing aides, dentures, dining utensils, and ambulation/mobility equipment. This policy further states: If a resident's adaptive equipment is in need of repair, then staff make arrangements for a replacement (if able, such as walker, wheel chair) and/or send in the item to be repaired after notifying resident and/or responsible party.

Based on record review and interview, the facility failed to provide safe transfer technique and assistive device for 1 of 4 residents sampled for falls (R8), out of a sample of 8, by failing to utilize a sit-to-stand lift as directed. This failure resulted in an ankle fracture for R8. Findings include: According to admission records and the physician's orders [REDACTED]. Hospital records show that R8 had a Right Hip Fracture following a fall on 8/2/11. The [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed R8 with no memory problems and minimal cognitive impairment. The MDS also stated that R8 did not ambulate and required extensive assistance for transfers and toileting. Interdisciplinary Notes dated 9/18/11 for 9/17/11 states the following: "CNA (Certified Nurse Aide) reported to nurse in the afternoon of 9/16/11 that resident's right ankle got twisted while she was being transferred from toilet to WC (wheelchair). Nurse assessed right ankle for any possible problems such as dislocation or fx (fracture), but found no signs of any problem; resident denied pain and discomfort when ROM (range of motion) was done on rt (right) ankle. However, daughter notified this evening that res.(resident) rt ankle was swollen. Nurse found ankle to be swollen, warmer than the left leg and res. c/o (complained of) discomfort when moved. . . . .send res. to ED (emergency department) for evaluation and treatment. . . ." R8 returned to the facility the same day (9/17/11) with a splint for a Trimalleolar Fracture of the right ankle. The Initial Notification report to IDPH (Illinois Department of Public Health) stated that R8 was "lowered to floor" and sent to the hospital for treatment. The Resident Incident Report dated 9/17/11, stated that E7 (CNA) took R8 to the bathroom by wheelchair, and transferred from the wheelchair to the toilet. E7 stated that R8's "ankle got twisted while she (R8) was being helped from toilet to WC. Nurse assessed right ankle for any possible signs of dislocation or FX, but did not find any. . . ." The Incident Report Follow-Up dated 9/19/11 stated that R8 was to be transferred with a type of lifting device. The report continues that on Friday, September 16, 2011, E7 assisted R8 from the wheelchair onto the toilet. When R8 finished and stood for E7 to clean her and pull up her pants, R8 "started to get weak and go down on the floor. {E7} let her (R8) down slowly onto the floor. {E7} reported that her (R8) body was twisted to the left (she has right sided weakness from previous CVA). {E7} noticed that her right ankle was twisted and facing out when she was on the floor. . . ." R8 denied any pain or discomfort at this time. E7 got R8 up and placed her in the wheelchair by herself at this time, prior to having R8 examined by the nurse. E8 (nurse) assessed R8 when E7 informed him of the incident. E8 also found the range of motion in the ankle was within normal limits, and R8 did not complain of pain. (E8 did not document this assessment at the time - not until the 9/18/11 late entry.) R8 was again assessed on 9/17/11 at 3:51am with no changes and no complaints of pain. On 9/17/11 at 5:30pm was when R8's daughter told the nurse that R8's right ankle was swollen. The physician was notified and R8 was sent to the hospital. Hospital X-ray report of 9/17/11 confirms the [DIAGNOSES REDACTED]. The careplan reviewed on 8/10/11 states that R8 had right-sided weakness from the CVA and was weight-bearing as tolerated on the right, from the hip fracture of 8/2/11. The careplan also states that for transfers, staff was to use the "{sit-to-stand assistive device}at present. . . .Be sure that my right leg is properly positioned on the platform of the {lift}. Be sure and cue me to stand up straight when I am on the lift. . . ." The Transfer Directive completed by Physical Therapy on 8/11/11 also stated that this type of lift referred to as the "Red lift" was to be used for R8, and also gave instructions for proper positioning as noted in the careplan. On 3/7/12 at 11:50am, E2 (Director of Quality Assurance) confirmed that E7 transferred R8 improperly, that E7 should have used the lift device and did not. E2 stated that E7 had asked R8 if R8 used the lift and R8 stated she did not.

Based on observation, interview and record review the facility failed to apply any pressure relieving devices to R2's pressure ulcer located on the left heel. The facility also failed to notify the Registered Dietician of this pressure ulcer and a 16.5 pound weight loss for R2. R2 acquired the deep tissue injury in the facility. R2 was one of two residents sampled (R2,R3) for pressure ulcers in a total sample of 7. Findings include: The physician's orders [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] states that R2 requires extensive assistance for all activities of daily living to include bed mobility, transfers and toileting. The MDS continues to identify that R2 has impairment of both upper and lower extremities on one side of her body and is unable to move that part of the body. The same MDS identifies that R2 has an unstageable pressure ulcer with suspected deep tissue injury. The facility's skin assessment titled "Braden Skin Assessment" dated 1/13/11 identifies R2 as high risk for pressure ulcers. R2's nutritional assessment dated [DATE] states that ".....(R2) current eating pattern ......puts (R2) at high risk for [MEDICAL CONDITION] and [DIAGNOSES REDACTED].......Weigh weekly and monitor...". The facility's documentation titled "Skin Assessment Form" documented on 1/29/11 states that R2 acquired a skin condition on 1/29/11 and is receiving a treatment to this area twice a day till healed. The skin assessment gives the description of the area to be 3 cm (centimeter) by 0.5 cm red area on left outer heel. The skin assessment form states the cause of the area is "Pressure". R2's nurses note dated 1/29/11 states "(R2) has a 3cm by 0.5cm red area on left outer heel; treatment of [REDACTED]."Nurses Notes dated 2/2/11 states "Area is a suspect (sic) deep tissue injury. Persistent dark red and boggy feel to area." The admission nursing notes of 1/26/2011 shows R2 did not have any skin issues upon admission. On 2/8/11 at 1:10 PM R2 was sitting in the wheelchair with no- skid booties on both feet and both feet were resting directly on the wheelchair pedals. R2 was transferred to her bed from the wheelchair by use of a mechanical lift at 2:10 PM by E9 and E14 CNA's (Certified Nurse Assistants), and was positioned on the left side with a pillow to the back area. R2's heels were sitting directly on the bed . On the same day at 4:30 PM R2 was lying in the bed directly on her back with her heels resting directly on the bed. R2 at 10:10 AM on 2/9/11 was sitting up in bed with her heels resting directly on the bed. R2 lifted her left heel up off the bed and a beefy reddened area with flaky skin and soft mushy center was present on the outer heel. At 10:50AM on 2/9/11 E20, RN (Registered Nurse) performed the treatment for [REDACTED]. Upon completion of the treatment E20, RN replaced the non-skid socks over the heels and placed the heels back onto the mattress of the bed. R2's Weight Trend Graph dated 2/10/11 shows that R2 was weighed upon admission to the facility on [DATE] at 122 pounds. The second admission to the facility on [DATE] records the weight to be 126.50 pounds. The weight of R2 which was done on 2/1/11 records 110 pounds and weight on 2/8/11 shows to be 110 pounds. Total weight loss of 16.5 pounds was not reported to E17, Registered Dietician. On 2/9/11 at 10:20 AM E17, Registered Dietician stated that "No, I did not know about (R2)'s pressure ulcer . I found about it last night in our meeting with the Administrator.....No, I was also not told of the weight loss issue with (R2)......" Care Plan dated 1/27/11 for R2 does not address the pressure ulcer or the use of preventive devices to float (off loading) the heels to prevent further pressure on the heels, and the care plan does not address the issue of weight loss for R2. The facility's policy titled "Skin Impairment Prevention and Wound Management" dated 8/1/08 under the area "#4 Managing Tissue Load" states " It is the policy of this facility to manage tissue load and improve tissue tolerance to pressure, friction and shearing forces. This will be accomplished through the use of appropriate positioning practices, positioning devices, and support surfaces." E3, RN Clinical Coordinator confirmed on 2/9/11 at 2:55 PM the care plan for R2 does not address the issues of the pressure ulcer on the left outer heel, preventative measures to float or off load the heels or the decrease in weight that R2 has experienced.