Every finding on record at Dobson Plaza

Based on observations, interviews, and record reviews, the facility failed to follow their policy and procedures by not properly labeling and storing food. This failure applies to all 77 residents in the facility who receive meals from the kitchen. Findings include: On [DATE] from 09:43 AM - 10:20 AM during kitchen observations observed an unlabeled partially closed bag of green beans stored in a freezer; Observed freezer number 5 outside thermometer temperature fluctuating from ,d+[DATE] degrees; Observed a large tub of ice-cream in freezer number 5 was soft; Observed 9 unlabeled packs of English muffins, and 9 unlabeled packs of plain bagels stored in the freezer; Observed one pack of raisin bagels with a sell by date of [DATE] stored in the freezer; Observed a large, opened pack of chocolate chip muffins with a use by date of [DATE] stored in the freezer; Observed 3 unlabeled large boxes of muffins stored in the freezer; Observed 2 packs of soft tortillas with a use by date of [DATE] stored in the freezer. Observed a 1.57-pound pack of hamburger buns with a use by date of [DATE] stored in the freezer. Observed five 6lb cans of canned foods stored with undented canned foods in the dry storage area; Observed a separate area for storing dented cans. Observed 2 unlabeled large 20ML bins containing oatmeal stored in the dry storage area. Observed 2 unlabeled 20ML bins containing dry milk powder stored in the dry storage area. Observed refrigerator number 7 with 8 heads of wilted lettuce stored inside. Observed a cart with a cup of coffee, a cup of juice, a bowl of cornflakes, and a partially eaten pastry sitting on the elevator with no staff around. On [DATE] at 10:35 AM V17 (Dietary Manager) stated when items are taken out of their original package the printed used by date is placed on the item before placing in the freezer for storage. V17 stated items should have use by dates to ensure consumption before expiring. V17 stated if the use by date of tortillas is February 2024 they are expired and should be discarded. V17 stated if the package date of hamburger buns is [DATE], they are no longer good to consume. V17 stated dented cans should be placed by the door or sent back right away. V17 stated we wouldn't want the dietary staff to use dented cans because they are not safe. V17 stated freezer temperatures should be below zero. V17 stated if ice cream is soft and the freezer temperatures showing higher than below zero this may mean the freezer isn't cold enough which could cause issues with proper storage and contamination. V17 stated the milk powder and oatmeal were delivered last week but they should have a visible date labeled on them. V17 stated if a food cart with a cup of juice, cup of coffee, bowl of cornflakes, and partially eaten pastry is left on the elevator unattended the residents could consume them and there is a risk of contamination, allergy, or possibly swallowing issues. The facility's Food Return/Rejection Policy received/reviewed [DATE] states: Any item which is past the use by date should be rejected. Storage of dry items including all shelf-stable dried foods includes visible labeling. Any canned item without a label should be rejected. Storage of Fresh Fruits and Vegetables including all fresh produce that is either whole or cut should have no wilting. The facility's Policy for Receiving and Storage of Food Items Policy received/reviewed [DATE] states: Upon delivery, food items are to be kept in their original packaging for storage. Once a food item (without a printed expiration date) is removed from the original box or packaging, the item is then to be labeled with the date of delivery.

Based on observation, interview, and record review, facility staff failed to report an allegation of abuse to the State Survey Agency within 24 hours of being made aware of a potential abuse allegation from a resident. This failure applied to one resident (R70) reviewed for abuse in a total sample of 35. Findings include: R70 is a [AGE] year-old resident admitted to facility on 02/29/2024 with medical diagnoses including but not limited to: legal blindness, muscle weakness, paroxysmal atrial fibrillation- on a blood thinner, polyneuropathy, essential hypertension, prediabetes, and moderate protein-calorie malnutrition. R70 has a Brief interview mental status (BIMS) score of 14/15 dated 06/04/2024 which means cognitively intact. R70 requires partial/moderate assistance for eating, oral hygiene, toileting hygiene, upper body dressing and personal hygiene according to minimum data set (MDS) section GG dated 6/4/2024. R70 requires substantial/maximal assistance for shower/bathe self, lower body dressing and putting on/taking off footwear according to MDS section GG dated 6/4/2024. R70 is on an anticoagulant medication. In physical therapy note written by V11 (physical therapy manager) dated 5/27/24 at 01:51 PM reads He (R70) reported that somebody tried to wrench his arm when he was attempting himself to get to the toilet. On 5/27/2024 at 01:56 PM x-ray was completed on R70 left shoulder, complete 2 views. Report documents slightly swollen and c/o (complaint of) pain. Impression: No acute skeletal injuries of the left shoulder. On 06/10/24 at 10:37 AM R70 was interviewed by surveyor in his room. He was alert and oriented to person and place. R70 stated I believe the guy's name is V12 first name. I woke up very early in morning and was very confused and V12 or whatever his name is got all excited because I was out of my bed and calling mommy or help to get help to go to the bathroom. He wrenched my arm. It didn't hurt that day, but it started hurting. I told V11 the next day and they took pictures. V11 is the head of Physical therapy. It happened in March or April. I don't know when the last time I seen him work. I have been putting heat compresses on it. I am on blood thinners. I think the staff rotate shifts. He speaks with an accent. I think he is Filipino. My biggest problem with him is his attitude like he is the boss and doesn't take your side of the story. You can't reason with V12. R70 left upper arm was noted to be purple and yellow almost full length of upper arm to elbow on front side and stated that it is spreading; it doesn't hurt now. On 06/10/24 at 11:46 AM Another surveyor observed bruise on R70 with this surveyor and resident changed story on when it happened. Large bruise ranging from about 1 inch below shoulder to 1 inch above elbow scattered purplish and yellow in color on anterior aspect of left arm. He now says it happened a week ago Sunday. On 06/11/24 at 10:47 AM Interview with V7 certified nursing assistant (CNA). I am a CNA. I saw the bruise on R70's arm yesterday and told V3 (regional director) about it. R70 is independent and I only help R70. R70 did not tell me how that happened, I just reported seeing it. On 06/11/24 at 10:56 AM Interview with V11 (physical therapy manager). V11 stated my therapist (V29) reported to me limitation of motion and a little swelling to left upper arm on 5/27/2024. I did not directly speak with R70 about it that day. I spoke to him the following day regarding this. R70 told me somebody wrenched my arm. R70 couldn't remember who. He told me it happened on the night shift. V29 told me she told the nurse of the arm limited motion and swelling. If someone tells me something that we suspect abuse, we are to report it right away. I told the floor nurse V12 that R70 said somebody wrenched his arm. It was reported already so I am assuming the nurses have it already. It would be considered abuse if somebody wrenches someone's arm in my book. That is exactly what is documented in my notes. On 06/11/24 at 10:58 AM Interview with V3 (regional director) stated investigation is ongoing. V3 provided us with copies of investigation what has been done so far. I am unaware of R70 stating someone wrenched his arm. He did not tell me that yesterday. I will take it one step further with my investigation. On 06/11/2024 V3 presented unusual occurrence report form dated 6/10/2024 documents V7 (CNA) reported discoloration to resident's R70 left upper arm - when asked resident what happened he stated that he got up at night, I was confused. He said that later his arm hurt, they did xray, they told me That it was old man stuff. On 06/11/24 at 12:17 PM V3 (Regional director) notified by surveyor that R70 accused V12 of wrenching his arm. Also asked for update of investigation once she finishes it. On afternoon of 6/11/2024 surveyor was provided with Facility reported incident report for this incident and was told that V12 was suspended pending ongoing investigation. On 06/11/24 at 03:15 PM Interview with V2 Abuse coordinator. When asked how you go about investigation V2 stated immediately report and look at the details of event. It is not reportable if it is witnessed. Avoid abuse, we work as a team we start an investigation immediately. We train staff on abuse and abuse reporting, Staff report to nurse on the floor and myself or director of nursing (DON). Staff must report immediately. When asked why the x-ray was ordered V2 stated we ordered x-ray because resident reported pain. Nurse called doctor and got the order. Morning nurse called doctor and did x-ray. I am not aware of communication between V11 and V12. When asked if therapy staff should have reported this right away V2 stated yes either to me or his supervisor. This resident uses a lot of interesting language to describe something, like yesterday he said I have old man bones. He describes he got up and was looking for something, he thinks it was his mother and got confused and he thinks it was V12 but not sure that V12 was who caught him. My DON is in Italy, and I am unsure if she started an investigation or not. She can start investigation without me .If R70 didn't use the word wrenched, then she may not have. R70 did not fall. I cannot reach DON. We don't see any communication between DON and staff of another investigation started by DON. When asked if this can be, she stated yes, she could have started an investigation on paper and not on the computer. There is a nurses note. I saw the 27th maybe he said something about his knees buckling and nurse got him back to bed. You know you don't lose your balance neatly. So, it is not necessarily graceful, and it prevented a fall. We investigate like crazy. Yesterday we started an investigation just because of the discoloration. Abuse & Neglect Policies/Procedures in Administrative Manual with a revised date of September 2016 received and reviewed on 6/11/2024 reads: V. Internal Reporting Requirements and Identification of Allegations: All employees are required to report any incident, allegation or suspicion or potential abuse or mistreatment they observe, hear about, or suspect.

Based on observation, interview, and record review, the facility failed to initiate an investigation in a timely manner for an allegation of abuse for one of one resident (R70) reviewed for abuse in a total sample of 35. Findings include: R70 is a [AGE] year-old resident admitted to facility on 02/29/2024 with medical diagnoses including but not limited to: legal blindness, muscle weakness, paroxysmal atrial fibrillation- on a blood thinner, polyneuropathy, essential hypertension, prediabetes, and moderate protein-calorie malnutrition. R70 has a Brief interview mental status (BIMS) score of 14/15 dated 06/04/2024 which means cognitively intact. R70 requires partial/moderate assistance for eating, oral hygiene, toileting hygiene, upper body dressing and personal hygiene according to MDS section GG dated 6/4/2024. R70 requires substantial/maximal assistance for shower/bathe self, lower body dressing and putting on/taking off footwear according to MDS section GG dated 6/4/2024. R70 is on an anticoagulant medication. In physical therapy note written by V11 (physical therapy manager) dated 5/27/24 at 01:51 PM reads He (R70) reported that somebody tried to wrench his arm when he was attempting himself to get to the toilet. On 5/27/2024 at 01:56 PM x-ray was completed on R70 left shoulder, complete 2 views. Report documents slightly swollen and c/o (complaint of) pain. Impression: No acute skeletal injuries of the left shoulder. On 06/10/24 at 10:37 AM R70 was interviewed by surveyor in his room. He was alert and oriented to person and place. R70 stated I believe the guy's name is V12 first name. I woke up very early in morning and was very confused and V12 or whatever his name is got all excited because I was out of my bed and calling mommy or help to get help to go to the bathroom. He wrenched my arm. It didn't hurt that day, but it started hurting. I told V11 the next day and they took pictures. V11 is the head of Physical therapy. It happened in March or April. I don't know when the last time I seen him work. I have been putting heat compresses on it. I am on blood thinners. I think the staff rotate shifts. He speaks with an accent. I think he is Filipino. My biggest problem with him is his attitude like he is the boss and doesn't take your side of the story. You can't reason with V12. R70 left upper arm purple and yellow almost full length of upper arm to elbow on front side. States it is spreading. It doesn't hurt now. On 06/10/24 at 11:46 AM Another surveyor observed bruise with this surveyor and resident changed story on when it happened. Large bruise ranging from about 1 inch below shoulder to 1 inch above elbow scattered purplish and yellow in color on anterior aspect of left arm. He now says it happened a week ago Sunday. On 06/11/24 at 10:56 AM Interview with V11 (physical therapy manager). V11 stated my therapist (V29) reported to me limitation of motion and a little swelling to left upper arm on 5/27/2024. I did not directly speak with R70 about it that day. I spoke to him the following day regarding this. R70 told me somebody wrenched my arm. R70 couldn't remember who. He told me it happened on the night shift. V29 told me she told the nurse of the arm limited motion and swelling. If someone tells me something that we suspect abuse, we are to report it right away. I told the floor nurse V12 that R70 said somebody wrenched his arm. It was reported already so I am assuming the nurses have it already. It would be considered abuse if somebody wrenches someone's arm in my book. That is exactly what is documented in my notes. On 06/11/24 at 10:58 AM Interview with V3 (regional director) stated investigation is ongoing. V3 provided us with copies of investigation what has been done so far. I am unaware of R70 stating someone wrenched his arm. He did not tell me that yesterday. I will take it one step further with my investigation. On 06/11/2024 V3 presented unusual occurrence report form dated 6/10/2024 documents V7 (CNA) reported discoloration to resident's R70 left upper arm - when asked resident what happened he stated that he got up at night, I was confused. He said that later his arm hurt, they did xray, they told me That it was old man stuff. On 06/11/24 at 12:17 PM V3 (Regional director) notified by surveyor that R70 accused V12 of wrenching his arm. Also asked for update of investigation once she finishes it. On afternoon of 6/11/2024 surveyor was provided with Facility reported incident report for this incident and was told that V12 was suspended pending ongoing investigation. On 06/11/24 at 03:15 PM Interview with V2 Abuse coordinator. When asked how you go about investigation V2 stated immediately report and look at the details of event. It is not reportable if it is witnessed. Avoid abuse, we work as a team we start an investigation immediately. We train staff on abuse and abuse reporting, Staff report to nurse on the floor and myself or director of nursing (DON). Staff must report immediately. When asked why the x-ray was ordered V2 stated we ordered x-ray because resident reported pain. Nurse called doctor and got the order. Morning nurse called doctor and did x-ray. I am not aware of communication between V11 and V12. When asked if therapy staff should have reported this right away V2 stated yes either to me or his supervisor. This resident uses a lot of interesting language to describe something, like yesterday he said I have old man bones. He describes he got up and was looking for something, he thinks it was his mother and got confused and he thinks it was V12 but not sure that V12 was who caught him. My DON is in Italy, and I am unsure if she started an investigation or not. She can start investigation without me . If R70 didn't use the word wrenched, then she may not have. R70 did not fall. I cannot reach DON. We don't see any communication between DON and staff of another investigation started by DON. When asked if this can be, she stated yes, she could have started an investigation on paper and not on the computer. There is a nurses note. I saw the 27th maybe he said something about his knees buckling and nurse got him back to bed. You know you don't lose your balance neatly. So, it is not necessarily graceful, and it prevented a fall. We investigate like crazy. Yesterday we started an investigation just because of the discoloration. Abuse & Neglect Policies/Procedures in Administrative Manual with a revised date of September 2016 received and reviewed on 6/11/2024 reads: V. Internal Reporting Requirements and Identification of Allegations: All employees are required to report any incident, allegation or suspicion or potential abuse or mistreatment they observe, hear about, or suspect. VII. Internal Investigation of Allegations and Response: Incident or allegation involving abuse or mistreatment will result in an investigation.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for abuse for one (R70) of one resident reviewed for abuse in a total sample of 35. Findings include: R70 is a [AGE] year-old resident admitted to facility on 02/29/2024 with medical diagnoses including but not limited to: legal blindness, muscle weakness, paroxysmal atrial fibrillation - on a blood thinner, polyneuropathy, essential hypertension, prediabetes, and moderate protein-calorie malnutrition. R70 has a Brief interview mental status (BIMS) score of 14/15 dated 06/04/2024 which means cognitively intact. R70 requires partial/moderate assistance for eating, oral hygiene, toileting hygiene, upper body dressing and personal hygiene according to minimum data set (MDS) section GG dated 6/4/2024. R70 requires substantial/maximal assistance for shower/bathe self, lower body dressing and putting on/taking off footwear according to MDS section GG dated 6/4/2024. R70 is on an anticoagulant medication. In physical therapy note written by V11 (physical therapy manager) dated 5/27/24 at 01:51 PM reads He (R70) reported that somebody tried to wrench his arm when he was attempting himself to get to the toilet. On 06/12/24 at 02:37 PM During Interview with V3 and V21 RN. V3 Regional Director stated we do not do abuse risk assessments on residents when they are admitted . Residents have a care plan for behavior or history of abuse or behavior of a resident. We do not do a separate abuse risk assessment; it may be brought up in social history but not as a separate assessment. I will continue to look in the charts, but we do not do an abuse risk assessment on residents when they are admitted . On 06/13/2024 at 09:28 AM V13 (Clerical supervisor and schedule coordinator) stated Per V3, we checked the medical records and do not have abuse care plans or risk assessments at this time for R70. On 06/13/24 at 11:00 AM, during phone interview with V4 (social service consultant), V4 said, I am an outside consultant with them; I have worked at the facility for about seven weeks now. I was hired to do MDS's and updating their care plans. I do not have anything to do with assessments when residents are admitted . I am not aware if there are any abuse risk assessments done on admission. I do not do any of the assessments. I do part of their care plans. When considering an abuse care plan, I ask residents if they have any history of drug abuse, suicidal issues, physical emotional or verbal abuse in the past. I would consider a dementia patient at risk for abuse. I would also consider a blind resident at risk for abuse. Both of those incidents would constitute an abuse care plan if they had definitive cognitive loss. But if resident is blind yes, an abuse care plan should be put in there. I also agree all dementia residents should have an abuse care plan as these residents are at risk for abuse. I just did R70's MDS, so the care plan is the next thing I am working on. I am unaware of any abuse care plan or abuse risk assessments for V70 as I am very part time and I have to go in and review it. Abuse & Neglect Policies/Procedures in Administrative Manual with a revised date of September 2016 received and reviewed on 6/11/2024 reads: Resident Assessment: As part of the resident social history assessment, and the MDS assessments, staff will identify residents with increased vulnerability for abuse, mistreatment or who have needs behaviors that might lead to conflict (i.e., combative behavior, verbal outbursts.) Through the care planning process, staff will identify any problems, goals and approaches, which would reduce the chances of abuse, mistreatment. Staff will continue to monitor the goals and approaches on a regular basis. Comprehensive care plan policy with a revised date of 11/17 reads: Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident 7 days after the completion of the comprehensive assessment. 2. The comprehensive care plan is based on a thorough assessment that includes but is not limited to the MDS. 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas. b. Incorporate risk factors associated with identified problems.

Based on observation, interview and record review, the facility failed to follow their controlled substance policy. The facility failed to store and maintain controlled substance in a locked refrigerator. This failure effects one of two medication rooms reviewed for medication storage. The facility also failed to do accurate count of controlled drugs by failing to document in shift change accountability record for controlled substances form, and controlled drug receipt record form. This failure effects two of two medication carts reviewed for medication storage. This deficient practice affects 5 residents reviewed for medication storage in a total sample of 21 residents. Findings include: On 8/1/23 at 10:37 AM, first floor medication storage observation conducted with V14 (RN). Medication cart and binder for shift change accountability record for controlled drugs reviewed. Noted shift change accountability record for controlled substances in July 2023: 21st 3rd shift OFF, 25th 1st shift OFF, and 31st 3rd shift OFF are all empty and no initials. August 1st, 2023, shift OFF is also noted with no nurse initial. In addition, controlled drug receipt/record/disposition form reviewed and noted 2 forms for R47 and R2 were in the binder, however the form was incomplete. The signature of the nurse receiving medication, number of doses and date portion are empty and not filled in. R47's-controlled medication has a date received on 7/26/23 with 30 pills, and R2's-controlled medication has a date received on 6/17/23. On 8/1/23 at 10:45 AM, V3 (Director of Nursing/DON) stated that shift to shift count should be done by both incoming and off going nurses and both nurses must initial and document in the form. Our nursing practice if for the receiving nurse to fill in the portion number of doses and date, and nurse's signature when the controlled medication was received by the nurse on duty. On 8/1/23 at 11:00 AM, first floor medication room observation conducted with V14 (Registered Nurse/RN). Medication room needs to be unlocked by V14. Inside this first-floor medication room, observe a refrigerator, unlocked and with 2 controlled substances for R20's liquid hydromorphone and R69's liquid lorazepam. On 8/1/23 at 11:05 AM, V3 (DON) checked the first-floor medication room refrigerator, inserted the key, and locked it. Unable to pull the refrigerator open. V3 then talked to V14 stating that in order for refrigerator to be locked, V14 need to turn the key all the way. V14 answered saying that V14 checked the refrigerator in the morning, and it is locked. Also stating that surveyor pulled it hard and so the refrigerator opened. Confirmed with V3 that refrigerator should not open if it is locked. On 8/1/23 at 11:30 AM, second floor medication storage observation conducted with V7 (Registered Nurse/RN). Medication cart and binder for shift change accountability record for controlled drugs reviewed. Noted R53 has a controlled medication initiated on 7/10/23 with 30 pills, and on 7/31/23 with 8 pills left. Medication Bingo card reviewed and there are 9 pills left in the card. V7 stated she does not know why there is an extra pill left when it supposed to be 8. V7 stated that she worked 2 days in a row, and she knows she gave the medication to R53. V7 also stated that she did the controlled medication count with the off going shift nurse this morning, also stated she might have overlooked the pills and the form. On 8/3/23 at 1:00 PM, V3 (DON) stated that she spoke to V7 (RN) and V7 (RN) cannot explained why there is an extra pill for R53's Alprazolam 0.25mg. V7 reported to V3 that she gave the medication and counted the medication with another nurse every time she worked the floor.V3 also state she does not also have an explanation why there is an extra pill if this was given daily to R53. Controlled Substances policy (not date) reads in part: Medication included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations. All controlled substances are stored and maintained in a locked cabinet compartment. If refrigeration is required, the refrigerator or container kept in the refrigerator is locked. Policy for Controlled Substances dated August 2017, reads in part: In addition, a PROOF OF USAGE SHEET shall be used to record their administration. This form shall become part of the resident's permanent record. The shift change accountability record for controlled substances must also be completed by the nurses for each shift change. All Class II controlled substances will be locked in the narcotic box.

Based on observation, interview, and record review the facility failed to provide dignity during meal time by standing over a resident while feeding. This failure affected 1 resident (R1) reviewed for dignity in a total sample of 21. Findings include: On 8-1-23 at 12:58 PM, R1 was seated at the table in the main dining room. R1 was being fed dessert by V21 (Activity Aide) who was standing at R1's left side. Noted that there was no chair available for V21. On 8-1-23 at 12:07 PM, V21 (Activity Aide) said he would have sat down if there was a chair and V21 thought standing while feeding a resident is optional. On 8-1-23 at 12:10 PM, V3 (DON) said V21 is a CNA and any staff assisting with feeding should be seated. On 8-3-23 at 12:22 PM, V3 said staff should be sitting while feeding assistance for dignity and comfort of the staff and resident. Feeding Policy (no date) was reviewed. Residents' Rights Booklet (no date) documents: Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life.

Based on observation and interview, the facility failed to ensure that 2 residents were free from physical restraints. This failure affected 2 residents (R51 and R57) reviewed for restraints in a total sample of 21. Findings include: On 8-1-23 and 8-2-23, observed R51 and R57 seated in an armed chair (unable to get up from the side of the chair) with their seatbacks against the wall (without space to move backwards) and the table directly in front of the resident (without space to move forward) with other residents seated around the table. The table was noted extending over the resident's lap without the possibility of the resident standing up unless the table was moved forward as witnessed by V5 (Certified Nursing Assistant/CNA), V3 (Director of Nursing/DON), and V22 (Regional Director). On 8-2-23 at 12:11 PM, V6 (Registered Nurse/RN) said a physical restraint prevents a resident from moving freely and physical restraints are not used at the facility. On 8-2-23 at 12:13 PM, V5 (CNA) said physical restraints do not allow a resident to have free movement from the bed or chair. V5 said restraints are allowed with a MD order. On 8-2-23 at 12:15 PM, V3 (DON) said a physical restraint is a barrier that prevents a person from freely moving. V3 said the facility is restraint free unless ordered by MD. V3 said she will adjust the chairs and tables to allow more space for the residents to move their seat backwards from the table. On 8-3-23 at 9:00 AM, R51 and R57 were observed seated at the table with more space from the wall and the seatback of the chair which would allow R51 and R57 more space to move the chair backwards to get up from their chair. Residents' Rights Booklet documents: You have a right to be free from physical or chemical restraints.

Based on observation, interview and record review, the facility failed to correctly use pressure relieving mattress for residents at risk for skin alteration for three of four residents (R11, R28, R69) reviewed for pressure ulcers in a sample of 21. Findings include: On 08/01/2023 at 10:45AM, during observation, R69 was observed lying on low-air-loss mattress with flat sheet, pad and folded flat sheet between her and the mattress. At 10:47AM, R11 was also observed lying on low air loss mattress with flat sheet, pad and folded flat sheet between her and the mattress. At 10:53AM, R28 was also observed lying on low-air-loss mattress with flat sheet, pad and folded flat sheet between her and the mattress. At 11:10AM, during observation with V3 (Director of Nursing/DON), R69, R11 and R28 were again observed under the same circumstances. On 08/01/2023 at 11:10AM, V3 said that there should only be one flat sheet between the resident and the mattress if they are on a low air loss mattress because if there are multiple layers of linen between the resident and the mattress, the benefit of the low-air-loss mattress cannot be maximized. R69's Order Summary Report dated 08/03/2023 indicated admitted [DATE], and diagnoses including unsteadiness on feet, other lack of coordination, and other abnormalities of gait and mobility. R69's Braden Scale for Predicting Pressure Sore Risk (pressure ulcer risk assessment) dated 7/27/2023 indicated score of 16 which is categorized as at risk. R69's care plan revised on 3/15/2023 indicated R69 is at risk for alteration in skin integrity and interventions include R69 needs pressure relieving/reducing mattress to protect skin while in bed. Minimum Data Set (MDS) dated [DATE] indicated R69 is totally dependent with locomotion on and off unit and uses wheelchair as mobility device. R11's Order Summary Report dated 08/03/2023 indicated admitted [DATE], and diagnoses including unsteadiness on feet, other lack of coordination, and restless leg syndrome. R11's pressure ulcer risk assessment dated [DATE] indicated score of 17 which is categorized as at risk. R11's care plan revised on 7/12/2023 indicated R11 is at risk for skin breakdown and interventions include pressure relieving mattress when in bed. MDS dated [DATE] indicated R11 is totally dependent with locomotion off unit, needs extensive assistance with locomotion on unit, and uses wheelchair as mobility device. R28's Order Summary Report dated 08/03/2023 indicated admitted [DATE], and diagnoses including unsteadiness on feet, other lack of coordination, other abnormalities of gait and mobility, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R28's pressure ulcer risk assessment dated [DATE] indicated score of 14 which is categorized as at risk. R28's care plan revised on 10/27/2022 indicated R28 is at risk for skin breakdown and interventions include pressure relieving mattress when in bed. MDS dated [DATE] indicated R28 is totally dependent with locomotion on and off unit and uses wheelchair as mobility device. Facility Documents: Title: Braden Scale for Predicting Pressure Sore Copyrighted 2001 At Risk (score of 15-18) - Pressure-reduction support surface if bed- or chair-bound Title: Manufacturer's Manual Copyright 2014 Intended Use: This product intends to help reduce the incidence of pressure ulcers while optimizing patient comfort.

Based on observation, interview and record review, the facility failed to follow its standard precaution policy for one resident (R59) of twelve residents, observed for infection control practices during dining observation in a sample of 21 residents. Finding include: On 8/2/23 at 12:00pm, during dining observation, V9 (Activity Aid) was observed picking R59's fruit cup from the floor. V9 failed to perform hand hygiene after picking up R59's fruit cup from the floor. V9 proceeded to open the fridge to look for an extra fruit cup, V9 then received a new fruit cup from V8 (Food Service Supervisor) without washing her hands or applying hand sanitizer. On 8/2/23 at 12:00pm, V9 stated, I should've washed my hands or used hand sanitizer after picking the cup from the floor. On 8/2/23 at 12:05pm, V8 (Food Service) stated that staff should clean their hands after picking an object from the floor. Facility policy titled Standard Precautions revised 2/2014 reads: Policy Statement; standard precaution will be used in the care of all residents regardless of their diagnosis, or suspected confirmed infection status . Standard precautions include the following practice: 1. Hand hygiene a. Hand hygiene refers to handwashing with soap (anti-microbial or non-antimicrobial) or using alcohol-based hand rub (gels, foams, rinses) that do not require access to water. b. Hands shall be washed with soap and water whenever visibly soiled with dirt, blood, or body fluids, or after direct or indirect contact with such and before eating and after using the restroom.

Based on observation, interview and record review, the facility failed to post complete nurse staffing data in a prominent place readily accessible to residents and visitors. This failure can affect all 81 residents currently residing in the facility. Findings include: On 08/01/2023 between 9:10AM - 12:10PM during observation, no nurse staffing information was observed at the front desk and on all three units. At 12:10PM, during observation with V1 (Administrator), no nurse staffing information was observed by the front desk and on the first-floor unit. On 08/01/2023 at 12:10PM, V1 said that the daily nursing assignment sheet serves as their staffing posting and is not aware of any other document the facility uses that specifically indicates the number of licensed and unlicensed nursing staff and the actual hours they worked. On 08/03/2023 at 11:50AM, V22 (Regional Director) said that V15 (Scheduler/Front Desk Supervisor) does the nurse staffing information and posts it but she does not know where. At 12:00PM, V22 presented a document for 8/3/2023 and said that it is the nurse staffing information, and it is kept under the pile of papers of the daily nursing assignment clipboard. On 08/03/2023 at 2:05PM, the daily assignment clipboard was observed with V15 noted with multiple sheets of daily nursing assignment sheets from previous days and said that he puts the nurse staffing information underneath those pile of papers. Daily Nursing Assignment Sheet does not indicate the current resident census, actual hours worked by the nursing staff, and specific categories of the nursing staff. Untitled document does not indicate facility name.

Deficiency requires two deficient practice statements. 1. Based on interview and record review, the facility failed to have effective, resident-centered, fall interventions in place to prevent a fall and failed to adequately supervise a resident at risk for falls. This failure applied to one of one (R6) resident reviewed for falls with injury and resulted in R6 sustaining a fall, then being subsequently transferred to local hospital with diagnosis of right femur fracture and had to undergo surgery for repair. 2. Based on interview and record review the facility failed to ensure that one resident (R2) was properly assisted during repositioning in bed. This failure resulted in R2 sustaining bruises to both right and left upper arms and right hip requiring emergent transfer to a local hospital and being diagnosed with right femoral fracture. Findings include: 1. R6 is a [AGE] year-old female, originally admitted to the facility on [DATE]. R6 has medical diagnoses that include displaced Intertrochanteric fracture of right femur, repeated falls, orthostatic hypotension, unspecified dementia, Parkinson's disease, difficulty in walking, other lack of coordination, abnormal posture, and muscle weakness. Most recent fall risk assessment completed 3/3/23; is at risk for falls. Review of R6's comprehensive care plan includes the following focus areas: R6 has a deficit in ADL performance r/t dx of dementia with behavioral disturbances .Symptoms include cognitive impairment, short attention span, generalized weakness, poor ability to follow directions and occasionally resisting caregiver assistance. Recently readmitted from hospital s/p ORIF (Open Reduction and Internal Fixation). On PT/OT therapy. Now requires total assist with all ADLs other than extensive assist with bed mobility and personal hygiene and supervision with eating. Walk in room and corridor did not occur. Date Initiated: 04/13/2023 Revision on: 4/25/2023 R6 is confused and disoriented and has been noted with occasional restlessness and anxiety by staff. She often sits in front of the nursing station so that staff can keep their eyes on her. Since her recent fall, she is unable to get up by herself . Date Initiated: 04/13/2023 Revision on: 04/24/2023 R6 exhibits cognitive impairment secondary to dx of dementia current cognitive with behavioral disturbances. Consequently, she has problems with decision-making, insight, logic, calculation, reasoning, planning and judgment. Strengths and abilities include recognizing family members and being able to verbalize, see and hear. She had been seen every 2 weeks by in-house psychologist, but he discharged her on 3/24. He noted that she was unable to respond to simple questions and just nodded her head at times. Date Initiated: 04/13/2023 Revision on: 04/25/2023 Facility submitted final incident report dated 3/30/23, which reads: On 3/27/23, at approx. 7AM, this resident (R6) who has Parkinson's and ambulates with a walker, impulsively stood, and started to ambulate without her walker, causing her to lose her balance. Bump to R side forehead. X-ray of R hip results received, 4:18PM, identifying R femur FX with varus angulation. Nurse Progress Note written on 3/27/23 at 7:50 by V14 (Registered Nurse/RN) reads: resident fell in floor, she ambulated without walker and assist, per resident she want to go to washroom, resident have bump in the right side of the head, applied ice pack in the bump are and took VS, bp 149/70 pr 68 rr 19 O2 sat 91 called NP (Nurse Practitioner) with order neuro check for 72 hours called daughter (name) to made aware re: incident [sic] Hospital record for admission on 3/27/23 includes: HPI: .(R6) presented after unwitnessed fall at SNIF. In ED was found she has right hip fracture with plan for ORIF this afternoon. Hx taken partially from patient but mostly from daughter as pt (patient) has baseline cognitive issues. Pt states she tried to get up and likely go to bathroom but she fell although she does not remember how she fell and was fall associated with any pre-syncopal sx like LH, dizziness, CHEST PAIN etc.; Daughter states that mom has hx of orthostatic hypotension and takes meds for it and is supposed to get slowly with help from sitting to standing positions; per daughter, she was told by SNIF that she had unwitnessed fall- likely tried to get up from chair and staff heard the fall- unclear how long was on floor; also she possible bumped her head-head CT and neck CT were done and negative; Per daughter she has frequent UTIs and she just recently finished course of Bactrim 3/17-3/24. Pt has hx of TAVR, but per daughter no recent complaints of SOB, DOE, SP, dizziness, syncope although she has been having frequent falls, attributed to orthostatic hypotension. No recent reported abdominal pain, n/v/diarrhea; no reported black or tarry or bloody stools or other bleeding; She is only taking aspirin 81 mg and no other blood thinners; Pt currently only complaining of R leg pain with any movement 'Denies fevers, chills, HA, LH, dizziness, CP, SOB, palpitations, cough, abdominal pain/n/v/diarrhea, urinary sx .[sic] Review of systems documents .Neuro: A/O x3, moving extremities spontaneously except protective of R leg movement due to pain . XRAY FEMUR MIN 2 VIEWS RT Result Date: 3/27/2023 IMPRESSION: Acute intertrochanteric fracture through the proximal right femur, as above. The remainder of the right femur and bony pelvis are intact. XRAY PELVIS Result Date: 3/27/2023 IMPRESSION: Acute intertrochanteric fracture through the proximal right femur, as above. The remainder of the right femur and bony pelvis are intact . 4/29/23 at 6:17 AM, V14 (RN) stated that she was passing meds on the other side of the hall when R6 fell , and they heard the chair alarm but couldn't get to her on time. I assessed her and she said her pain was 100%. I gave her Tylenol and an ice pack for her head. Didn't send her out to the hospital right away because the NP wanted to wait for the x-ray. 4/30/22 at 12:22 PM, V14 (RN) stated that she called the NP after R6 fell and also called the portable x-ray company because the x-ray was ordered STAT; all before she left that morning, so she ended up staying until about 8:30 AM. V14 added that the NP was worried about a fracture, that's why she ordered the x-ray and (NP) said don't move (R6). V14 was asked if she endorsed to oncoming nurse that the resident should not be moved, and she stated that she told the oncoming nurse about the fall and told her that R6 could use an ice pack. 4/29/23 at 11:50 AM, V17 (RN) stated that she has worked at the facility for more than two years. On 3/27/23, when she came in at the start of shift, the previous nurse told her that R6 had fallen because she had gotten up from sitting on the chair. V17 proceeded to state, I remember (previous nurse) said that R6 fell and got a bump. I asked (nurse) if she called the family and NP. I think she said that she called. I know that I called the NP and asked if we should send her out. She said we should monitor her . 4/28/23 at 12:58 PM, interview with V4 (Certified Nursing Assistant/CNA) stated that she has worked at the facility for [AGE] years and usually works on the first floor. When asked about R6, V4 stated that R6 requires extensive assistance with everything. She was able to walk with her walker independently but not in the hall. R6 needs a lot of reminders, and she can be impulsive when in her wheelchair. She can use her call light, but she's not really alert. She is more confused in the afternoons. I was not here when she fell . Observed R6's room on 4/29/23 at 7am with V12 (Registered Nurse/RN) who confirmed that R6's bed alarm was not connected and on her bed. V12 pulled the bed alarm out from R6's dresser and it was disconnected; V12 stated that staff put it away when they get her out of bed in the morning. V19 (Nurse Practitioner/NP) was interviewed on 4/29/23 at 10:28 AM regarding R6's fall on 3/27/23 and stated, I got a call early in the morning and they said that it looked like she had bumped her head a little bit. I told them to monitor. Then, they called (shortly after) and said she was complaining about pain. I ordered an x-ray. I think she already had some Tylenol, and then I ordered a Norco as well. They are pretty good about calling as soon as they found out. It was a STAT Xray. Within four hours. Sometimes (x-ray company) comes the next day. They do notify if it's over four hours. In that case, we would send them to the ER without the x-ray, but this was not the case. Depends on how fast the ambulance service is. If it's more than a couple hours, I would say 911. I wasn't there so I don't know. I think she has Tylenol on order, just in case. If she is verbally saying she is in pain or having a hard time with repositioning, then I rely on the nurses to let me know. If she was at rest and not confirming pain (it's possible). When we knew she had the fracture then I ordered the Norco. Facility policy was provided (dated 6/2014), titled, Policy Regarding Unusual Occurrences, reads: OVERVIEW: This facility is committed to maximizing each resident's physical, mental and psychological wellbeing. While preventing all unusual occurrences is not possible, it is this facility's policy to act in a practical manner to identify and assess those residents at risk for incidents and accidents, plan for preventive strategies, and facilitate as safe an environment as possible. All resident unusual occurrences shall be assessed, and the resident's existing plan of care shall be evaluated and modified as needed. The facility's Quality Assurance Committee and/or Safety committee shall review the information collected from all resident unusual occurrences for possible changes in facility practices and procedure. Policy: FALLS 1. Fall Prevention Activities for ALL Residents Upon Admission: o During the admission assessment process, ALL residents shall be assessed for the potential for falls, using the Falls Risk Assessment portion of the Safety Assessment Tool. Fall assessments shall include, at a minimum, a history of previous falls, contributing factors, gait and balance activities, medications, need for supervision and/or assistive devices. o For residents who have been identified at risk for falls, the interdisciplinary plan of care shall include initial interventions including supervision and/or assistive devices as necessary. o The effectiveness of each resident's care plan as it relates to falls prevention shall be evaluated and modified at least quarterly. o Falls Risk Assessments shall be completed at least quarterly and updated if necessary. 2. Facility Response to All Resident Falls o For each resident fall, an Unusual Occurrence Report Form shall be completed. If necessary, a new Fall Risk Assessment shall be completed, and the resident's plan of care shall be updated if additional care interventions are indicated. o Each resident fall shall be documented in the resident's clinical record. Documentation shall include time and location of fall (if known), any other facts necessary to describe the fall, any injuries, any care provided, any other descriptive information needed to describe the fall, neurological checks for possible head injuries and all outcomes related to the fall. o As part of the investigative process, interviews may be conducted. o If resident is cognitively intact, have them fill out the Resident Interview Regarding the Fall. o A copy of the Unusual Occurrence Report Form shall be sent to the facility's Administrator, DON/Designee, and Risk Management Coordinator. o The resident's responsible party and attending physician shall be notified of the fall, the cause and circumstance, and any outcomes related the fall. o If a resident fall results in a serious injury, as defined by IDPH licensure regulations, the facility shall contact by phone or fax, the State Department of Public Health within 24 hours to notify official of the incident. (Reference the Unusual Occurrence Report Form) and any related outcomes. 3. Quality Improvement Measures for Resident Falls o The Risk Management Coordinator/DON shall be deemed responsible for the collection of all Unusual Occurrence Report Forms and any other pertinent data. This person will fill out the Internal Quality Assurance Analysis Unusual Occurrence Report. Additionally, this individual shall be responsible for the on-going study of resident falls and related outcome measurements. o Data collected on the resident falls shall be provided to the Administrator, the Safety Committee, and the facility's Quality Improvement Committee. o The facility's Quality Improvement Committee shall be responsible for analyzing the data collected on resident falls and for making recommendations regarding possible changes in the facility's environments or practices. o Based on recommendations from the Quality Improvement Committee, facility-specific staff training shall be provided for all appropriate staff. Unusual occurrences other than falls . 2. R2 is a [AGE] year-old female originally admitted on [DATE] with most recent readmission on 4-5-2023 with medical diagnosis that include and are not limited to: repeated falls, unspecified dementia, major depressive disorder, and joint replacement surgery. Per Minimum Data Set (MDS) dated : 3-16-2023 Functional status reads: R2 needs extensive assistance: staff provide weight-bearing support of two persons physical assistance for transfers. 4-28-2023 at 4:30pm, V6 (Registered Nurse/RN) said on 3-31-2023 at about 4:00am V6 heard a noise from R2's room. I do not know where the noise came from or where it was coming from. I went to the room to see what was going on, I saw that R2 was in bed in the middle of the bed, but her legs were over the footboard and telling me: I am going to get ready because I need to go to school, and I need to see my parents. I called for help and V7 (Certified Nurse Assistant/CNA) came to the room and assisted me to pulled R2 in the bed. I was in one side and V7 was in the other side of the bed, we put our hands under the armpit and pulled her in bed. At about 6:00am when V4, morning CNA, came into R2's room, R2 complained of pain to the right hip. I asked R2 what had happened and R2 told me I was in the floor, and two ladies came and helped me to get in bed. When I assessed R2, I noticed R2 had some bruised areas: right hip and under the armpits in both upper extremities, right and left, I think we (V6, V7) caused the bruises when we pulled her up in bed. 4-28-2023 at 12:10pm, V4 (CNA) said that on 3-31-2023 at 6:00am, I started my rounds and R2 was complaining of pain to the right leg. R2 said that morning that two people lifted her up from the floor after she had a fall. I told the nurse (V6) that was working, and she went to the room to check R2. She had some bruises to the right hip and under the arms. I cleaned R2 and keep her in the bed. 4-29-2023 at 5:50am, V7 (CNA) said, on 3-31-2023 I was called by V6 (RN) to come to the room immediately because she needed help. I came into R2's room and I saw that R2 was at the bottom of the bed in the mid-section with her legs over the footboard trying to get out of the bed. V6 told me I am going in this side, I went to the other side, and we grabbed R2 from under the arms to pulled her in bed. At 6:00am the morning CNA (V4) came and reported to the nurse that the patient had multiple bruises to both under arms and on the right hip area. I did not see any bruises before. I know we are supposed to be using the draw sheet to pull the patients in bed to avoid causing any injuries. 4-28-2023 at 12:10pm, V4 (CNA) said, when I repositioned R2 we used the draw sheet to make sure we repositioned the patient and before we do it, we make sure to ask the patient to put her arms in the chest like giving herself a hug. 4-29-2023 at 8:56am, V2 (Director of Nursing/DON) said when a patient is repositioned in bed, we need to make sure to use the draw sheet to pull the patient up in bed and repositioned, we are not to pull the patient by holding them from under the armpits. 4-29-2023 at 1:00pm, V16 (Regional Director) said, my expectation is that when a complete care resident is repositioned the staff need to use the draw sheet for repositioning and pulled up in bed. R2's record review reads on 4-1-2023 at 11:27am, R2's right hip observed to be slightly swollen, new order received to transfer R2 to the hospital for evaluation. At 12:59pm, R2 left the facility via local ambulance to the local emergency room . Local hospital report dated: 4-1-2023 at 14:16 (2:16pm) reads; XR femur right 2+ views, impression: Mildly displaced right femoral subcapital fracture with foreshortening and coxa [NAME] angulation. V2 (Director of Nursing/DON) presented undated policy title: transfer and mobility policy. 41692

Based on interview and record the facility failed to complete a thorough investigation of injury of unknown origin, this failure affected one resident (R2), reviewed for investigation of unknown origin. Findings include: R2 is a [AGE] year-old female originally admitted on [DATE] with most recent readmission on 4-5-2023 with medical diagnosis that include and are not limited to: repeated falls, unspecified dementia, major depressive disorder, and joint replacement surgery. On 4-28-2023 at 10:00am, V2 (Director of Nursing/DON) presented reports sent to IDPH- on 4-1-2023 initial report and 4-4-2023. final report with interviews for three different staff members that worked with R2 on the day of the incident: V6 (Registered Nurse/RN) and V5 and V8 (Certified Nurse Assistants/CNAs). On 4-29-2023 7:45am, V2 (DON) said R2's incident happened on 3-31-2023 during 11-7, the nurse was V6, and we had 2 CNAs, V5 and V8. On 4-28-2023 at 3:25pm, V8 (CNA) said, I started working the last week of March 2023, I was in orientation, but they have not given me any more days, I am waiting for them to call me. R2 was my patient but she was ok, my last worked shift was on 3-30-23 during 11-7 and R2 was fine, no concerns, I was orientating with V5 (CNA) on that day, 2nd day. I never work on 3-31-2023 during 11-7 shift. On 4-28-2023 at 3:50pm V5 (CNA) said on Friday 3-31-2023, I was working 11-7 on the first floor with V7 (CNA), she had R2's. V6 (RN) completed a body assessment and R2 had a bruised to the right hip. V8 (CNA) never worked with me on that night- The one that took care of R2 was V7 (CNA). On 4-28-2023 at 4:30pm, V6 (RN) said on 3-31-2023 V6 was working 11-7 on the first floor. V6 had 2 CNAs (V5 and V7) that worked with V6 in the floor. V8 (CNA) was not working on the floor on that night. On 4-29-2023 at 5:50am, V7 (CNA) said I only work on Friday's 11-7. On 3-31-2023, I was working in the floor with V5 (CNA) and V6 (RN). At about 1:00am, I was called by V6 to come to the room immediately because she needed help. I came into R2's room, and I saw that R2 was at the bottom of the bed with her legs over the footboard, trying to get out of the bed. On 4-29-2023 at 8:30am reviewed the nursing schedule for 3-31-2023 and punch in and out/attendance record with V2 (Director of Nursing/DON). V2 said we do not have any statement from V7 (CNA), and V8 is no longer here, she resigned as of 3-31-2023 at 10:00am. She worked only 2 days here at the facility. At 8:56am, V2 said V1 (Assistant Administrator) or myself (V2- DON) are responsible to complete any investigation for any injury of an unknown origin, fall and or abuse. We talk to all the staff members that worked on the day of the incident to make sure we interview them to be able to determine what had happened. I do not have any statement from V7 (CNA) since she worked with V5 on Friday, 3-31-2023. At 1:00pm V16 (Regional Director) said my expectation is when we are completing any kind of investigation, we need to make sure to interview all the staff members that worked on the shift in question to make sure we can determine what had taken place. We need to do a complete investigation, Abuse policy dated: 9-2016 reads: investigation procedure regardless of the specific nature of the allegation: an interview with staff member having contact with the resident and accused individual during the period of the alleged incident, an interview with staff members having contact with the resident.

Based on interview and record review, the facility failed to follow standards of professional practice after a resident experienced a fall by not immobilizing the suspected area of injury and allowing the resident to continue weight bearing activity. This failure applied to one of one (R6) resident reviewed for standards of practice. Findings include: R6 is a [AGE] year-old female, originally admitted to the facility on [DATE]. R6 has medical diagnoses that include displaced Intertrochanteric fracture of right femur, repeated falls, orthostatic hypotension, unspecified dementia, Parkinson's disease, difficulty in walking, other lack of coordination, abnormal posture, and muscle weakness. Most recent fall risk assessment completed [DATE]; is at risk for falls. Review of R6's comprehensive care plan includes the following focus areas: (R6) has a deficit in ADL performance r/t dx of dementia with behavioral disturbances .Symptoms include cognitive impairment, short attention span, generalized weakness, poor ability to follow directions and occasionally resisting caregiver assistance. Recently readmitted from hospital s/p ORIF. On PT/OT therapy. Now requires total assist with all ADL's other than extensive assist with bed mobility and personal hygiene and supervision with eating. Walk in room and corridor did not occur. Date Initiated: [DATE] Revision on: [DATE] Facility submitted final incident report dated [DATE], which reads: On [DATE], at approx. 7AM, this resident (R6) who has Parkinson's and ambulates with a walker, impulsively stood and started to ambulate without her walker, causing her to lose her balance. Bump to R side forehead. X-ray of R hip results received, 4:18PM, identifying R femur FX with varus angulation. Nurse Progress Notes include the following: [DATE] at 7:50 written by V14 (Registered Nurse/RN) reads: resident fell in floor, she ambulated without walker and assist, per resident she wants to go to washroom, resident has bump in the right side of the head, applied ice pack in the bump are and took VS bp ,d+[DATE] pr 68 rr 19 O2 sat 91 called NP (Nurse Practitioner) with order for neuro check for 72 hours called daughter (name) to made aware re: incident [sic] [DATE] 12:36 written by V17 (Registered Nurse/RN) reads: Resident remains alert and responsive, oriented x,d+[DATE]; not in any acute distress, no shortness of breath noted post fall incident, no change in mental status pain level same from right thigh, able to move all extremities with baseline limitations, still awaiting x-ray to right pelvic and femur as ordered, had both breath fast and lunch with fair appetite; neurological assessment in progress with no changes noted, was assisted as needed .[sic] [DATE] 15:39 written by V18 (Registered Nurse/RN) reads: Received sitting in chair in front of nurses' station. Now complain of pain upon standing. Stat portable x-ray, here to do the x-ray and noted resident c/o pain. PRN Tylenol given Daughter at bedside. Waiting for x-ray result. [sic] [DATE] 16:15 written by V18 (RN) reads: X-ray result available showing acute right intertrochanteric fracture. NP made aware with orders to send resident to (local hospital) ER for evaluation and treatment and ok to give Norco ,d+[DATE] 1 tab for pain now .[sic] [DATE] 19:02 written by V18 (RN) reads: Picked up by (ambulance) in stable condition to (local hospital). Endorsed. [sic] Hospital record for admission on [DATE] includes: HPI: .(R6) presented after unwitnessed fall at SNIF. In ED was found she has right hip fracture with plan for ORIF this afternoon. Hx taken partially from patient but mostly from daughter as pt (patient) has baseline cognitive issues. Pt states she tried to get up and likely go to bathroom but she fell although she does not remember how she fell and was fall associated with any presyncopal sx like LH, dizziness, CHEST PAIN etc.; Daughter states that mom has hx of orthostatic hypotension and takes meds for it and is supposed to get slowly with help from sitting to standing positions; per daughter, she was told by SNIF that she had unwitnessed fall- likely tried to get up from chair and staff heard the fall- unclear how long was om floor; also she possible bumped her head-head CT and neck CT were done and negative; Per daughter she has frequent UTIs and she just recently finished course of Bactrim ,d+[DATE]-,d+[DATE]. Pt has hx of TAVR, but per daughter no recent complaints of SOB, DOE, SP, dizziness, syncope although she has been having frequent falls, attributed to orthostatic hypotension. No recent reported abdominal pain, n/v/diarrhea; no reported black or tarry or bloody stools or other bleeding; She is only taking aspirin 81 mg and no other blood thinners; Pt currently only complaining of R leg pain with any movement 'Denies fevers, chills, HA, LH, dizziness, CP, SOB, palpitations, cough, abdominal pain/n/v/diarrhea, urinary sx .[sic] Review of systems documents .Neuro: A/O x3, moving extremities spontaneously except protective of R leg movement due to pain . XRAY FEMUR MIN 2 VIEWS RT Result Date: [DATE] IMPRESSION: Acute intertrochanteric fracture through the proximal right femur, as above. The remainder of the right femur and bony pelvis are intact. XRAY PELVIS Result Date: [DATE] IMPRESSION: Acute intertrochanteric fracture through the proximal right femur, as above. The remainder of the right femur and bony pelvis are intact . [DATE] at 6:17 AM, V14 (RN) stated that she was passing meds on the other side of the hall when R6 fell , and they heard the chair alarm but couldn't get to her on time. I assessed her and she said her pain was 100%. I gave her Tylenol and an ice pack for her head. Didn't send her out to the hospital right away because the NP wanted to wait for the x-ray. [DATE] at 12:22 PM, V14 (RN) stated that she called the NP after R6 fell and also called the portable x-ray company because the x-ray was ordered STAT; all before she left that morning, so she ended up staying until about 8:30 AM. V14 added that the NP was worried about a fracture, that's why she ordered the x-ray and (NP) said don't move (R6). V14 was asked if she endorsed to oncoming nurse that the resident should not be moved, and she stated that she told the oncoming nurse about the fall and told her that R6 could use an ice pack. [DATE] at 11:50 AM, V17 (RN) stated that she has worked at the facility for more than two years. On [DATE], when she came in at the start of shift, the previous nurse told her that R6 had fallen because she had gotten up from sitting on the chair. V17 proceeded to state, I remember (previous nurse) said that R6 fell and got a bump. I asked (nurse) if she called the family and NP. I think she said that she called. I know that I called the NP and asked if we should send her out. She said we should monitor her. I asked NP if she wanted to do an x-ray, and she said that she ordered one already. The resident wasn't complaining of any pain throughout the shift. I assessed her because we took her to the bathroom. The aid took her to the bathroom, I wasn't the one who took her to the bathroom. I did not notice anything abnormal when I assessed her. V17 confirmed that there is a facility policy that should be followed post fall and that she followed the protocol in assessing the resident. [DATE] at 5:44 PM, V20 (CNA) was asked if she worked with R6 during the day shift on [DATE] (after the fall). V20 stated that she recalled taking the resident to the bathroom. V20 said, I asked her to stand up and noticed that she can't stand up like usual. V20 was asked if she reported this to the nurse or get any special instructions to follow. V20 responded, I just didn't want her to stand up long because I knew that she had fallen earlier. I had to do everything fast, fast with her. I know the nurses were monitoring everything about her. I worked ,d+[DATE]pm that day. I know that I took her to the bathroom in the morning and after lunch. Before she fell , she only needed one person assist, and now sometimes therapy can stand her up if it's something that won't take too long. [DATE] at 1:35PM V1 (Assistant Administrator) said I was here and spoke to R6 on that day, her daughter was here until they took her to the hospital. R6 didn't start complaining of pain until the afternoon. V19 (Nurse Practitioner) was interviewed on [DATE] at 10:28 AM regarding R6's fall on [DATE] and stated, I got a call early in the morning and they said that it looked like she had bumped her head a little bit. I told them to monitor. Then, they called (shortly after) and said she was complaining about pain. I ordered an x-ray. I think she already had some Tylenol, and then I ordered a Norco as well. They are pretty good about calling as soon as they found out. It was a STAT x-ray. Within four hours. Sometimes (x-ray company) comes the next day. They do notify if it's over four hours. In that case, we would send them to the ER without the x-ray, but this was not the case. Depends on how fast the ambulance service is. If it's more than a couple hours, I would say 911. I wasn't there, so I don't know. I think she has Tylenol on order, just in case. If she is verbally saying she is in pain or having a hard time with repositioning, then I rely on the nurses to let me know. If she was at rest and not confirming pain (it's possible). When we knew she had the fracture, then I ordered the Norco. On [DATE] at 3:47 PM V19 (NP) said that it's protocol to immobilize the area of concern when x-ray is pending and to notify her of any changes. V19 affirmed that staff shouldn't be moving the extremities when an x-ray is pending to rule out an injury. That's standard. V19 added that facility staff didn't tell her that they were standing R6 up and getting her up to go to the bathroom while the x-ray was pending. Facility was asked to provide any policies and protocols related to caring for residents after a fall and provided policy dated ,d+[DATE], titled, Policy Regarding Unusual Occurrences. Policy does not address preventative care after a fall as related to immobilization of suspected area of injury. Review of recommendations dated [DATE] from the Mayo Clinic (medical center) in the event of a Fracture (broken bones): First aid includes: A fracture is a broken bone. It requires medical attention. If the broken bone is the result of major trauma or injury, call 911 or your local emergency number. Also call for emergency help if: The person is unresponsive, isn't breathing or isn't moving. Begin CPR if there's no breathing or heartbeat. There is heavy bleeding. Even gentle pressure or movement causes pain. The limb or joint appears deformed. The bone has pierced the skin. The extremity of the injured arm or leg, such as a toe or finger, is numb or bluish at the tip. You suspect a bone is broken in the neck, head or back. Don't move the person except if necessary to avoid further injury. Take these actions immediately while waiting for medical help: Stop any bleeding. Apply pressure to the wound with a sterile bandage, a clean cloth, or a clean piece of clothing. Immobilize the injured area. Don't try to realign the bone or push a bone that's sticking out back in. If you've been trained in how to splint and professional help isn't readily available, apply a splint to the area above and below the fracture sites. Padding the splints can help reduce discomfort. Apply ice packs to limit swelling and help relieve pain. Don't apply ice directly to the skin. Wrap the ice in a towel, piece of cloth or some other material .

Based on observation, interview, and record review the facility failed to provide fall supervision for two residents that sustained unwitnessed falls and required emergent transfer to local hospital resulting in fractures. This failure affected two of 18 residents (R7 and R51) reviewed for falls and resulted in R7 obtaining a left wrist fracture and in R51 obtaining a fracture of the right leg. Findings include: R7 is an [AGE] year old male admitted to the facility 07/04/2020 with diagnoses that include, Dementia, Alzheimer's and history of falls. R7 is severely cognitively impaired with a BIMS score of 00 and requires dependent two-person physical assistance with transfers and extensive two-person physical assistance with ambulation. On 1/17/22, R7 sustained a fall while in the day room with no injury. Fall incident report form indicates that at 2pm, R7's chair alarm was heard going off by staff. Resident was seen getting up from the chair, however there was no staff close enough to assist R7 with the fall. On 3/6/22 R7 had a fall that resulted in closed fracture of the left radius. According to the incident report, R7 was in bed and activated the bed alarm by getting out of bed. Staff saw resident on the floor and sent to the hospital for evaluation. On 07/21/22 at 10:55 AM, R7 was observed in the day room, alert and confused, standing next to a wheelchair which had a chair alarm activated. R7 exhibited an unsteady gait with tremors. R7 required the assistance of two aids to be assisted to a dining room chair. 07/21/22 10:58 AM, V16 (Restorative CNA) said, R7 requires constant supervision because he is high fall risk. He has had some falls before where he was hurt. I was assigned to watch over the day room, but I was at the nurse's station washing my hands and when I heard the chair alarm go off. I rushed over to him. He had already gotten up and was standing on the side of the wheelchair holding onto the table. He could have easily fallen if we didn't get to him in time. R7 care plan and fall policy reviewed. Fall assessment dated [DATE] had an assessment number of 50. Assessment sheet revised 10/2016 states Implement Fall precautions for a total score of 15 or greater. Quarterly effectiveness of fall care plan interventions reviewed for fall incidents occurring 1/17/22 and 3/5/22 with no new interventions. R51's face sheet documents she is an [AGE] year-old female with a diagnoses history of Dementia, [CONDITION(S)], Age Related [CONDITION(S)], Difficulty walking, and Repeated Falls who was originally admitted to the facility 05/17/2022. R51's fall assessment dated [DATE] documents a score of 55; implement fall precautions for a total score of 15 or greater. R51's Minimum Data Set, dated dated dated [DATE] documents she has a Basic Interview for Memory Score of 8, requires one person assistance for transfers, and requires extensive one person assistance with toileting. R51's current urinary incontinence care plan initiated 05/26/2022 documents she is frequently incontinent of bowel and bladder with interventions including assist to toilet at regular intervals, such as every two hours and as needed ; R51's current fall care plan initiated 05/26/2022 documents she has a potential for falls related to diagnoses of dementia, [CONDITION(S)], and [CONDITION(S)] joint disease with interventions including give R51 verbal reminders to ask for assistance with ambulation and transfers as needed, provide toileting assistance as needed. R51's current physician order sheet documents fall precautions. Incident Investigation Report dated 07/20/2022 documents R51 who ambulates with rolling walker, stood from toilet, lost her balance, kneeling in front of her walker, x-ray results arrived this morning indicating an acute fracture; ambulatory resident R51 used her rolling walker to self toilet, pulled the call light and was observed by staff kneeling on the floor of the toilet with her walker in front of her, when asked what happened she stated she lost balance when she stood and kneeled to the floor. 07/21/2022 9:10 AM, V26 (Physician) stated R51 couldn't explain what happened during her fall. V26 stated R51 has a poor memory. V26 stated R51 was treated for a fracture after her fall and was observed by him in the emergency room . V26 stated R51 was seen by the nurse practitioner yesterday and reported she fell while in the bathroom. 07/19/22 at 2:10pm, when asked R51 what happened, she stated she stood up, lost balance and fell on the floor. 07/21/2022 at 10:59 AM, V16 (Certified Nursing Assistant/CNA) stated incontinence care is documented once per shift. 07/21/2022 at 11:00 AM, V5 (Registered Nurse/RN) stated she was the responding nurse for the fall incident. V5 said around 1:30pm on 07/19/22, I remember seeing her in the day room as I was passing medication. Believes R51 got up unwitnessed and walked to the bathroom sometime after seeing her at 1:30pm. Stated she believed R51 to have fallen by herself in the bathroom and pulled the call light post fall. V5 said she responded to the call light in the bathroom and saw her already lying on the floor at around. V5 stated R51 is able to toilet herself and her walker was in front of her when she fell . V5 said there was an activity aide in the day room that was responsible for monitoring the residents at this time. V5 verbalized that it is her expectation that the activity aide would let her know if the residents need anything, such as going to the bathroom. If the activity aide needs to leave the area, they should be letting her know; I am unsure of where the activity aide was at the time of the fall. V5 (RN) states R51 needs supervision to go to the bathroom. V5 said I expect my aides to supervise and assist her when going to the bathroom. Most residents that use walkers do not have good balance in the first place. At 11:15 AM, V16 (CNA) stated that she was the Activity Aide at the time of the fall incident. V16 said that R51 walks with a walker and independently walks around the facility unsupervised all the time. V16 witnessed R51 stand up, leave the dayroom with her walker, and head towards her room prior to the fall. At 11:30 AM, V8 (Director of Nursing/DON) said R51 has fall precautions in place, meaning that she is at a high risk for falls. V8 stated that R51 has a diagnosis of dementia and will ambulate back and forth to her room during the day with walker. V8 said her expectation for residents that are at a fall risk would be to oversee or supervise when the resident is ambulating and assist when in need of help. The day room should not be left unattended, there are residents that are high risk for falls located in the day room. R51's progress note dated 07/20/2022 documents she fell in bathroom to her knees yesterday. R51's physician progress note dated 07/21/2022 documents she fell to her knee when getting off the toilet, x-rays showed a fracture of the right leg, she was sent to the emergency room and posterior mold was applied. R51's July 2022 bowel and bladder record does not document incontinence care from 07/01/22 - 07/19/22. The facility's fall policy received 07/21/2022 states: Fall Prevention Activities for ALL Residents Upon Admission - For residents who have been identified at risk for falls, the interdisciplinary plan of care shall include initial interventions, including supervision, and or assistive devices.

Based on observation and interview, the facility failed to follow their kitchen sanitation practices by not wearing hair coverings properly while preparing food and while in the food preparation area and failed to practice proper hand hygiene while in the kitchen. This failure has the potential to affect all 82 residents currently in the facility. Findings include: 07/19/22 at 09:07 AM, observed V25 (Cook) hair exposed from hairnet on sides and back of head while preparing purees. 07/19/22 at 10:48 AM, observed V25's hair exposed from underneath her hair net while preparing meal trays; observed V7 (Dietitian) hair exposed from hairnet on the sides of her head while assisting with meal prep. 07/19/22 at 11:25 AM, observed V10 (Administrator) in the kitchen prep area with hair exposed from underneath her hairnet on both sides of her head. Observed V10 touched her face mask multiple times without performing hand hygiene and laid her hands down on the food prep table. 07/20/22at 2:25PM, V7 (Dietitian) stated that the pitcher sitting in the pitcher that was sitting in the 10ppm sanitizer solution in the three-compartment sink on 07/18/2022 is the pitcher used to refill the sanitizer bucket. V7 stated the almond milk that was open and labeled in the refrigerator had been opened by staff that morning and was required to be labeled as opened by the end of the shift. V7 stated the maintenance staff stated the freezer with the ice buildup needs a new part but is still maintaining temperatures properly. V7 stated hairnets should completely cover hair while working in the kitchen to prevent contamination. V7 confirmed if staff touch their face mask without performing hand hygiene then touch a food preparation surface this could cause contamination.

Based on observation, interview, and record review, the facility failed to ensure that residents were receiving showers twice a week per facility protocol and failed to provide documentation that bath were given as scheduled. This failure applied to seven of seven residents (R14, R37, R42, R43, R49, R72, R79) reviewed for ADL's Activities of Daily Living. Findings include: On 07/19/22 at 9:30 AM, V28 (Ombudsman) said, One of the things the facility can improve on is showering and grooming of residents' nails. At 11:52 AM, R14's family member (V19) said: I would like for R14 to have lotion applied after bathing, I supply the lotion. They need to clean between her toes when bathed too. R14 is unable to provide an interview due to having a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 07/20/22, V22 (Certified Nurse Assistant/CNA) said, R14's bath schedule is due for a shower tomorrow, Thursday. Observed, a posted shower schedule on the wall behind the nurse station, it reads: R14's showers are on Sunday 3PM-11PM shift and Thursday 7AM-3PM shift. Observed, at the nurse station a binder labeled: daily skin assessment, dated: June 22 the form is not completed. There is no daily skin assessment form started for any days in July 2022. The July 2022 bath/showers flow sheet to be completed by CNA's observed to be without any documentation. 7/20/22 at 10:32 AM, V6 (Registered Nurse/RN) said, I do not have R14's bath/shower sheet and daily skin assessment forms, you have to ask V8 (Director of Nursing/DON). The CNAs are responsible to fill out the forms and tell me what they find out. The CNA would call me if it's okay, I don't fill out anything. I'm not always available, so I rely on them. I document if they tell me they find something, I will do a skin assessment. I do not have any assigned skin assessment in my shift; it's only by exception. The CNA gives the shower, they don't necessarily call me to check the patient. At 10:48 AM, V8 (DON) said, the CNAs are responsible for filling out the bath/shower record and doing the showers. I don't see any signatures from the CNAs for bath and showers. The nurse makes sure the baths and showers are given; they just may have failed to document. The nurse makes sure the showers are done before the end of the shift. The documentation doesn't mean the shower was done. At 10:54 AM, observed R79's CNA flow record for bath/showers with no documentation for July 2022. There is no daily skin assessment form for July 2022. V8 (DON) said R79 is new to us, she just came two weeks ago. I don't see it, the daily skin form or flow sheet. R79 got here on 6/22, seems I will have to in-service. It's the same CNA not filling out the forms. At 11:01 AM, observed R42's CNA bath/shower flow record and daily skin assessment with no documentation. V8 (DON) said I think it's the same CNA, I will in-service her. No, it's not filled out, both forms. The nurse is the supervisor for the floor, and I supervise the nursing department. The nurse has to check the daily activities for the CNA's. At 11:04 AM, R49 does not have a bath/shower flow record for 7/2022. There is no documentation on the daily skin assessment sheet dated 6/22. There is no daily skin assessment for July 2022. V8 (DON) said, He was in and out of the hospital this month. He doesn't have the forms. He came back on July 3rd. I don't know why he doesn't have the bath sheet; they should have documented on the skin assessment. The person who fills out the bed/shower sheets is no longer with us. On 07/21/22 at 02:04 PM, V11 (Regional Director) said, Our CNAs know to give the residents a shower or bed bath two times a week. The nurse makes sure the aide does the shower; she doesn't document it. The nurse is in charge of making sure the aides do them, we don't have a policy for the nurse to document the showers. Facility presented: undated policy- Patient Care Policy indicates: All patients must be washed daily and given a 2x (times) weekly bath or sponge bath if refused. R43 is an [AGE] year old female admitted into the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 07/21/22 11:43 AM, R43 said, I'm supposed to get my shower twice a week but they told me that my regular CNA was not here so I have to wait for them to come back to get my showers. I only had one shower this month. I was supposed to have a shower yesterday and it was not done because my regular CNA was not here. Record review of R43'sCNA flow sheet noted R43 only had one shower which was on July 10th. There are no more showers noted. 07/21/22 12:21 PM Record review of R37's CNA flow sheet noted R37 has not had a shower for the month of July. 07/21/22 12:16 PM Record review of R72's CNA flow sheet noted R72 have not had a shower the month of July. On 07/20/2022 at 11:35am, V8 (DON) said the residents are showered twice a week. We have a schedule, the shower schedule is on the daily assignment sheets for them to see. They should chart on the flow sheet . The nurse on the floor should check to make sure it's completed. The CNA (certified nursing assistant) should check and if they see anything on their skin they should report it to the nurse and document on the flow sheet. On 07/20/2022 at 11:44am, interview with V16 (CNA) said: We shower them twice a week if they refuse we will leave them alone and check back later if they still refuse we have to tell the nurse and they will talk to them. No, we don't document the nurse will document, if we give the shower we will put an S in the shower book flow sheet.

Based on observation, interview, and record review, the facility failed to properly clean medication carts and dispose of multiple loose medications in the medication cart, failed to properly label a controlled substance medication bottle in the medication room refrigerator and failed to correctly store resident medication. This failure applied to one of one (R238) resident reviewed during medication storage task. Findings include: On 07/18/2022 at 12:45pm first floor cart checked with V2 (Licensed Practical Nurse/LPN) on the cart surveyor noted a daily medication [MEDICATION(S)] with medications in the compartments. The [MEDICATION(S)] did not have a resident name room number or type of medications label. V2 (LPN) said, The medication is for R238, she came in yesterday and the family wants us to use the rest of these medications first. The family did the medication at home and they want us to use this. Surveyor noted 3 nights of unknown medications and two days of unknown medications. In the daily [MEDICATION(S)] for Tuesday, there are 6 unknown medications, Wednesday has 7 unknown medications. The night medications as follows: Sunday night has 7 unknown medications, Monday has 8 unknown medications, and Tuesday has 7 unknown medications. On 07/18/2022 at 1:38pm, second floor cart checked with V3 (Registered Nurse/RN) surveyor noted 12 loose unidentified medications (Capsules and tablets) on the cart. Second floor medication room checked bottle of 17mls of [MEDICATION(S)] oral concentration with no name or room number noted on the bottle there is no narcotic sheet attached or noted in the Control substance sheet. V3 (RN) said, I'm not sure who the medication belongs to, I will try to find out. No, it should not be in here like this. 07/21/22 12:58 PM, interview with V8 (Director of Nursing/DON) said, Nurses should not be giving any medications that are not identifiable. The nurses are not supposed to be taking medications from any container that they did not prepare themselves. So, this particular patient came from home; they kept it in a locked cart to make sure that the resident had medications. The resident was admitted Sunday and the medications were picked up on Monday and removed from the cart. On 07/19/2022 Record review of a document titled Storage of Medications under policy statement states the facility shall store all drugs and biologicals in a safe, secure and orderly manner. Under Policy Interpretation and Implementation number one states: 1. Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medication between containers 3. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing.

Based on observation, interview, and record review, the facility failed to properly prevent and/or contain the spread of COVID-19 as evidenced by not ensuring that residents and staff consistently and correctly wear face masks as required; failed to keep a COVID-19 positive resident on isolation precautions per protocol; failed to perform hand hygiene while in the dining room assisting residents with their meals; failed to prevent cross contamination of clean and dirty linens; and failed to doff PPE after exiting an isolation room. These failures affected three of 18 (R49, R58, and R84) residents reviewed for infection control and have the potential to affect all 30 residents currently residing on the 3rd floor of the facility. Findings include: On 07/18/22 at 11:54 AM, R49's room observed with a PPE (Personal Protective Equipment) bin set up at the door with Contact/Droplet isolation signs posted at room entrance. The door is open to the hallway. Currently there are no other positive cases of Covid-19 on the unit. At 11:55 AM, V17 (Certified Nurse Assistant/CNA) observed applying PPE at the entrance of R49's room, she did not perform hand hygiene prior to donning a gown and gloves. V17 (CNA) was inquired of steps to don (apply) PPE. V17 stated, I should wash my hands or use hand sanitizer. At 12:37 PM, R49 observed sitting in his wheelchair with the room door open to the hallway. R49 is not wearing a face mask and is currently positive for Covid-19. V6 (Registered Nurse/RN) was inquired of R49. V6 (RN) stated, I think he had a positive result on Saturday for Covid. I'm unable to close his door because he has a tendency to get up and fall. He took his mask off; he was wearing one. Source control is not provided to prevent the spread of Covid-19 on the unit. There is no face mask on R49's lap or face. There is no face mask on his over bed table sitting in front of him at the door. At 12:41 PM, record review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident to wait for assistance before exiting. On 07/19/22 at 12:48 PM, interview with V11 (Regional Director/ Infection Preventionist) regarding infection control and signage of active Covid-19 in the facility. V11 was inquired of Covid-19 signage upon entrance to the facility on [DATE]. V11 stated, We send out letters to the families, I didn't know there weren't any signs. We have a letter at the front on the window of the office. On 07/21/22 at 02:04 PM, V11 (Regional Director) provided the in-service training records for V17 (CNA) regarding Covid-19 infection prevention in the health care setting, Infection Control Covid-19 and Donning and Doffing PPE video in-service. 07/21/22 02:09 PM, V11 inquired of the steps to put on PPE Personal Protective Equipment. V11 stated, On the CDC forms, it says to perform hand hygiene between steps. We also do hand washing or use hand sanitizer before putting it on. We have hand sanitizer near the rooms. We use the updated CDC (Centers for Disease Control) guidance for staff to use full PPE when taking care of residents that are Covid positive. Facility provided their Policy and Procedure: Covid-19 states in part: Purpose: To reduce the risk of transmission of the Corona Virus Disease (Covid-19) in this healthcare setting. Policy: The facility will conduct education, surveillance and infection control and prevention strategies to reduce the risk of transmission of Covid-19. The facility will follow and implement recommendations and guidelines in accordance with the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), the Illinois Department of Public Health (IDPH) and the local health department. Elements of Corona/Covid-19 Virus Plan: Facility will monitor for spread of respiratory/Covid-19 virus type symptoms in the facility and use these results to implement preventative precautions. Staff education: Signs are posted from the CDC about the Corona Virus/Covid-19 Virus. Staff will be in-serviced regularly regarding infection control procedures such as, but is not limited to: Hand hygiene, Gown and glove use, Accu-check policy and procedures, Donning/Doffing PPE, Social Distancing, Isolation Procedures for Droplet and Contact, cleaning and disinfecting and specimen collection procedures. Staff will use Universal/Contact and Droplet Precautions with symptomatic residents and will be placed in isolation. The Illinois Department of Public Health Covid-19 Updated March 22, 2022 Interim Guidance for Nursing Homes and other Licensed Long-Term Care Facilities states in part: The core principals of Covid-19 infection prevention: Source Control (masks, face coverings and other respiratory protection) Hand hygiene (use of alcohol-based hand rub is preferred) Physical distancing Appropriate use of personal protective equipment (PPE) Instructional signage throughout the facility and communication Hand Hygiene: the facility must train and validate competencies of all staff on hand hygiene. Source control: It is safest for residents and visitors to wear source control and physically distance, particularly if either are at risk for severe disease or are not up to date with Covid-19 vaccinations. Universal PPE (Personal Protective Equipment) for HCP Healthcare Personnel If a resident is suspected or confirmed to have Covid-19 or is not up to date with Covid-19 vaccinations, and the resident is identified to be a close contact, HCP must wear an N95 respirator, eye protection, gown and gloves. Management of Residents- Updated Residents with Confirmed Covid-19: Single room, door closed (if safe to do so). Isolate using transmission- based precautions Staff wear full PPE (N95 respirator, gown, gloves, eye protection). On 07/18/22 at 11:04 AM, observed R84 in hall not wearing mask over mouth and nose and not redirected by V10 (Administrator) to readjust her mask over her nose and mouth. On 07/18/22 at 11:18AM, observed R58 came out of her isolation room without a mask and asked about lunch. On 07/18/22 at 11:27 AM, observed V20 (Certified Nursing Assistant/CNA) set up R6's tray and adjust her in bed with gloved hands, then doff gloves and grab a clean towel from the clean linen cart while carrying removed gloves without performing hand hygiene. On 07/18/22 at 11:42 AM, observed V21 (Activities) remove R3's mask and place on table without performing hand hygiene then continue to assist other residents to in the dining area. V21 stated, (R3) needs more assistance and so she removed her mask. Observed R3 multiple times with some slight sounds of congestion. On 07/19/22 at 07:58AM, observed V18 (Receptionist) in the first floor hallway with no mask on. On 07/19/22 at 08:18AM, V18 (Receptionist) stated he was not wearing his mask earlier because he was hot. On 07/19/22 at 08:42 AM, V23 (Certified Nursing Assistant/CNA) dropped multiple clean clothing protectors on the floor and placed them on the clean linen cart. On 07/19/22 at 08:45 AM, observed V24 (Certified Nursing Assistant/CNA) enter an isolation room, donned gown and exited the isolation room wearing the gown, and walked through hall with multiple residents and staff present, then returned to the isolation room and doffed gown. On 07/20/22 at 1:35 PM, V8 (Director of Nursing) stated if a gown is donned and worn in an isolation room it should be removed before leaving the room to prevent contamination. V8 stated that placing clothing protectors that fell on the floor back on the clean linen cart could cause contamination. V8 stated that R58 is difficult to redirect to stay in her room while on isolation and forgets why she is on isolation. V1 stated R58 usually comes out of her room and sits right outside the administration office. 07/21/22 11:57 AM, V8 (DON) stated, staff should remind residents to wear their mask if observed not doing so and staff must wear masks. V8 stated there is a risk for transmission if staff don't instruct residents to wear masks or if staff are not wearing masks. V8 confirmed that R58 was positive for COVID on 07/18/2022.

Based on observation, interview, and record review, the facility failed to maintain safeguards and systems in place to control, account for, and correctly reconcile controlled medications in order to prevent loss, diversion, or accidental exposure. These failures affected one of one resident (R59) reviewed during medication administration. Findings include: On [DATE] at 1:19pm, Narcotic count completed on the first floor with V2 (Licensed Practical Nurse/LPN) surveyor noted R59 Controlled Drug Receipt/ Record /Disposition form for her [MEDICATION(S)] IR 15mg tablets. According to the form there should be 22 tablets left on the bingo card, on the actual card there is 21 tablets left. During interview, V2 (LPN) said, I don't know what happened to it. No, I didn't count with the nurse this morning she was already gone when I got here. We are supposed to count with another nurse at the beginning and at the end of our shift. No, we should not count by our self. On [DATE] at 1:38pm, Second floor medication room checked. Surveyor noted a bottle with 17mls of [MEDICATION(S)] oral concentration with no name or room number noted on the bottle, there is no narcotic sheet attached or noted in the Control substance book. V3 (Registered Nurse/RN) said I don't know who this belongs to, I can try to find out. No, it should not be in here like this. On [DATE] at 9:46am, V8 (Director of Nursing/DON) said, They forgot to take the sheet out of the book when pharmacy came to do the audit; the medication was expired and they took the medication. The nurses are supposed to do the Narcotic count at the beginning and the end of their shift. No, she should wait until another nurse comes, it has to be two nurses to count. When wasting medication there should be two nurses to witness the wasting. The Controlled Drug Receipt/ Record/Disposition is use to prevent loss or misuse and accountability. If there is a discrepancy, they are supposed to call the supervisor, then we will do a search and report it to administration and they will start an investigation. If the medication is in the refrigerator, it should be labeled properly with the name of the person, drug and doses, and it has to be labels that are printed by pharmacy. If the label is missing, it should not be stored in the refrigerator; the nurse should give it to the supervisor so it can be disposed of properly. On [DATE] Document submitted by the facility Title Preparation and General Guidelines Controlled substances. With the revision date of [DATE]. Under Policy states: Medication included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations. Under procedures Letter E states. Accurate accountability of the inventory of all controlled drugs is maintained at all times. When a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR) 1) Date and time of administration (MAR, Accountability Record). 2) Amount administered (Accountability Record) 3) Remaining quantity (Accountability Record) 4) Initials of the nurse administering the dose, completed after the medication is actually administered (MAR, Accountability Record) On [DATE] Record review of a document titled Storage of Medications under policy statement states the facility shall store all drugs and biologicals in a safe, secure and orderly manner. Under Policy Interpretation and Implementation number one states: 1. Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medication between containers 3. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing.

Based on interview and record review, the facility failed to follow the Abuse & Neglect Policies/Procedures by Certified Nurse Aide (CNA) not notifying supervisor and administrator of allegation of physical abuse, facility failure to investigate allegation of physical abuse, and facility failure to report allegation of physical abuse to state agency. This failure affected 1 resident (R1) of 3 reviewed for abuse. Findings include: On 7-13-22 at 10:00 AM, R1 initially denied concerns of employee physical abuse however, R1 said on 7-4-22, V7 (3rd shift Certified Nursing Assistant/CNA) jumped over the bedrails and jumped on top of R1. V7's entire body made contact on top of R1's body. R1 said she had leg pain and bruising as a result of this abuse. R1 said V7 was upset at R1 and R1 does not know why. R1 said she reported allegation of abuse to V3. On 7-13-22, 10:36 AM, V3 (Certified Nursing Assistant/CNA) said she did not work on 7-1-22. R1 said one night CNA (no name mentioned), then later identified V7. R1 told nurse on duty (V6) and V6 (Registered Nurse/RN) went into R1's room. R1 reported that V7 (CNA) jumped over the bed rail and jumped on R1's body on 7-4-22. V3 said this was reported to V6 (RN) and V6 went to see R1. V3 is not aware of any allegations. On 7-13-22 at 11:13 AM, V4 (Assistant Administrator) said local police came to see R1 re: concerned party made concerns of facility giving R1 medications to cause dementia. No mention of R1's physical abuse to V4 or police at that time. No injuries or signs of abuse found on R1. No report of abuse from R1 or staff. V4 was not aware of abuse allegation, no abuse investigation was started, and no state report filed. On 7-13-22 at 11:55 AM, V2 (Director of Nursing/DON) said no concerns of physical abuse from R1 or concerned party on 7-1-22 and 7-4-22. No staff or resident reported abusing R1. R1's concerned party called local police in regard to allegation of facility was over medicating R1 to appear she has dementia. No concerns of physical abuse reported by R1 or police. R1 did not show any signs of abuse. V2 did not receive allegation of abuse thus this was not reported to state agency. Facility provides abuse in-services frequently. If staff receives abuse allegation, they are to report to supervisor immediately and ensure resident safety. The facility will conduct investigation and V7 (CNA) will be suspended pending investigation. On 7-13-22 at 11:41 AM, V6 (RN) said V6 did not receive concerns of physical abuse from R1 or V3. V6 does not work directly with V7. V6 did not receive concerns of physical abuse from V3 (CNA). V3 reported R1 was confused and not eating. R1 is very paranoid and delusional as noted by MD thinking food is poisoned. V6 (RN) said she was unaware of employee to resident abuse allegation. R1's Medical records and Abuse Log was reviewed. There are no concerns of employee physical abuse from R1 noted. There was no documentation of R1's physical abuse allegation investigation, no documentation of reporting to state agency, and no documentation MDS (ARD 7-6-22) documents: BIMS Summary Score: 11. Potential Indicators of [CONDITION(S)]: B. Delusions. Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Abuse Policy (revised 9-2016) documents: Policy: Implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively and making the necessary changes to prevent future occurrences. Supervisors shall immediately inform the administrator or designee of all reports of suspicion of potential abuse, neglect, exploitation, mistreatment or mistreatment or misappropriation of residents' property. Initial reporting of Allegations: When an allegation of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property has occurred, the resident representative and Department of Public Health regional office shall be informed .

Based on interview and record review the facility failed to safely transfer one resident (R1) using a two person assist as directed by the facility care plan guide for Certified nursing assistants. This deficient practice caused R1 to fracture the right femur and required surgical intervention. This applies to one resident (R1) out of three (R1, R2, R3) reviewed for falls and neglect. The findings include: R1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The MDS (Minimum (MDS) data set [DATE]), showed that R1 needed two assistants for transfer from bed to chair. The document also showed that R1 had impairment to both lower extremities. The MDS dated [DATE] and 7/10/14 showed the same information for transfers and the need for two staff to provide weight bearing support. A nursing note written by E4 (Registered Nurse) showed that on 8/14/14 at 6:50am E4 was called to R1s room. The note showed that E5 (Certified Nursing Assistant) was transferring R1 from bed to wheelchair when R1 " lost balance " and started to fall. E4 documented that R1 did not complain of pain and had no visible injury. On 8/17/14 at 6:50 am E4 stated, " R1 was to be transferred with two assistants. I scolded E5 for not asking for help. R1 did not appear in pain so I helped E5 put R1 in the wheelchair using a sling lift and we took her to breakfast " On 8/15/14 at 2:45pm, E6 (Certified Nursing Assistant) said that while caring for R1 there were no signs of pain. E6 reported that she was assigned to R1 since 7:00am that morning and did not get R1 out of the chair until 12:00pm. That is when E6 noticed swelling to the right leg. E6 then notified E7 (registered Nurse) of the swelling of the leg. On 8/15/15 at 3:15pm, E7 stated, " When I touched R1's leg, R1 said Oww. R1 had no falls during my shift. R1 is incontinent and requires two people to transfer from bed to chair. R1 was not able to tell us if she needs to go to the bathroom " . E7 then called the physician. E7 sent R1 to the community hospital at 2:15 pm (per nursing note dated 8/14/14). E5, CNA (Certified Nursing Assistant) was unavailable for interview during the survey. E2, (Assistant Administrator) reported on 8/18/14 at 12:30pm, via telephone that E5 CNA was not returning to the facility at this time and may require further in servicing/education if returning to the facility. On 8/18/14 at 2:00pm, Z2 (registered Nurse) from the community hospital stated, " The degree of the injury did not match the history obtained from the nursing home. R1's right was extremely swollen and deformed. Both of R1's legs were contracted so I don't know how she could stand up to get in a chair. R1 had a severe fracture that completely separated the femur " . An x-ray taken at the community hospital showed that R1 had an oblique fracture of the right distal femur. The hospital records dated 8/14/14 from the emergency department showed that after assessing the nursing home paperwork and the injury to R1's leg, the emergency room doctor was notified and social services were called. The elder abuse hotline was called. Hospital records dated 8/18/14 showed that R1 underwent an open reduction internal fixation surgical procedure to treat the fracture to the right leg.