Every finding on record at Eden Village Care Center

Based on observation, interview, and record review the facility failed to report bruises of unknown origin to the State Survey Agency for two (R2, R5) of four residents reviewed for injuries of unknown origin in the sample list of 12.Findings include:1.) R2's Care Plan (undated) documents R2's Diagnoses including Urinary Tract Infection, Malaise, Myalgia, Other Abnormalities of Gait and Mobility, Muscle Weakness, Need for assistance with Personal Care, Adult Failure to Thrive, Ataxia, and Dementia. This Care Plan further documents an admission date of 12/19/2025.R2's Braden Scale dated 12/19/2025 documents R2 has a Braden Score of 14 indicating R2 had moderate risk for developing skin injury.R2's Care Plan dated 12/26/2025 documents a Category: Urinary Incontinence R2 has been incontinent of Bowel and Bladder (B/B) at times. R2 needs assist with incontinence care, toileting. This care plan documents an Approach to provide assistance for toileting. Provide incontinence care after incontinent episodes. Assist with changing incontinence briefs and skin hygiene.R2's Minimum Data Set (MDS) dated [DATE] documents R2 is moderately impaired with decisions regarding tasks of daily life and require cues/supervision.R2's Nurses Notes dated 12/25/2025 documents R2 started to show some signs of new bruising/hematoma on the left posterior forearm.R2's Nurses Notes dated 12/26/2025 documents This RN (Registered Nurse) noted discolored area to entire right forearm and top of hand. Area is red with purple lining to the outside and skin is taught throughout the forearm. Also noted white lines throughout the reddened area. The discoloration is non-blanchable but has minimal swelling to thumb side of forearm. Residents will occasionally complain of pain when arm is moved or being touched. (Physician) notified and new order received. (Two) view X-ray obtained at approximately 11:30AM (R2) tolerated the X-Ray well.On 7/6/2026 at 1:52 p.m., V4 R2's Family stated V4 visited R2 on 12/26/2025 and V4 noticed a huge bruising to R2's right upper arm down to R2's wrist. V4 stated V4 was not notified by any facility staff about the bruise and when the bruise was initially developed or how it was developed. V4 voiced expectations of notification from the facility if any changes in R2's condition as soon as the incident occurred.On 7/8/2026 at 2:35 p.m., V1 Administrator confirmed it was either V1 or V2 Director of Nursing (DON) who does the investigation and reporting for bruises of unknown origin.On 7/8/2026 at 9:00 a.m., V2 Director of Nursing (DON) confirmed awareness of R2's bruises to arm. V2 stated V2 does not remember which side of the arm and the extent of the bruising but V2 admitted remembering a huge size bruising from R2's upper arm but does not remember if it was down to the forearm or all the way down to the wrist. V2 stated if bruising was noted on residents, nurses should do an initial investigation right away to find out where the bruising came from. V2 stated if the origin was unknown, incident report should be completed and need further investigation immediately and report to the (state survey agency) within two hours or 24 hours for no major injuries. V2 stated V2 has been the one conducting investigations and reporting for bruises of unknown origin. V2 confirmed R2's bruising was not investigated and was not reported to (the state survey agency) and it should have been reported.On 7/8/2026 at 3:04 p.m., V1 Administrator stated if the bruising has unknown origin, either V1 or V2 will conduct an investigation immediately and report the incident to (the state survey agency).On 7/9/2026 at 8:34 a.m., V9 Registered Nurse stated V9 called V1 Administrator on 12/26/2025 and notified V1 on 12/26/2025 about R2's bruising to right arm. V9 stated V1 told V9 that V1 will deal with it when V1 comes in the facility. V9 stated V2 DON came in that day and went to R2's room but V9 does not know what happened afterwards. V9 confirmed the bruising was at R2's right arm from the knuckles up to the elbow at that time. V9 stated physician was notified and ordered an Xray and the result was negative. V9 stated the origin of the bruise was unknown and should have been investigated and reported.2.) R5's Care Plan dated 7/1/2026 documents R5's diagnoses including Cerebral Infarction, Cognitive Communication Deficit, and Specified Disorders of Bone Density and Structure. This Care Plan further documents and admission date of 03/13/2026.R5's Care Plan dated 6/19/2026 documents a Category: Activities of Daily Living (ADLs) Functional Status/Rehabilitation Potential with an Approach to provide assist with bed mobility when needed. (Mechanical) lift for transfers. R5 has own tilt-in-space wheelchair for locomotion with staff assist.R5's Care Plan dated 6/19/2026 documents a Category: Medical problem. R5 has been prescribed anticoagulant therapy related to atrial fibrillation. This Care Plan documents an Approach of observe for signs of active bleeding (nosebleeds, bleeding gums, petechiae, purpura, ecchymotic areas, hematoma, blood in urine, blood in stools, hemoptysis, elevated temp, pain in joints, abdominal pain, epistaxis).On 7/7/2026 at 11:00 a.m., V17 Certified Nursing Assistant (CNA) performed incontinence care on R5. During the incontinence care, V17 noticed a purple bruising on R5's left hip. Upon observation, the bruise to R5's left hip was approximately four centimeters by four centimeters (4cm x 4 cm) in size. V17 stated V17 will notify V5 Licensed Practical Nurse (LPN) when V5 comes to do skin assessment on R5. V17 did not ask R5 anything about how the bruise was obtained at this time.On 7/7/2026 at 11:07 a.m., V5 LPN entered the room to perform skin assessment on R5 with assistance of V17 CNA. V17 notified V5 verbally about the bruise to R5's left hip. V5 completed the head-to-toe skin assessment on R5. V5 did not ask R5 anything about how R5 obtained the bruise to left hip at this time.On 7/8/026 at 10:00 a.m., R5's medical records did not contain any documentation about the bruise from 7/7/2026 head-to-toe skin assessment noted on R5's medical records.On 7/8/2026 at 11:09 a.m., V7 R5's family stated the facility called V7 this morning, less than an hour ago about R5's bruising to left hip. V7 confirmed no knowledge of an old bruise to R5's left hip. V7 stated V7 was only told this morning that the bruise has unknown age and unknown cause. V7 confirmed R5's last fall was the end of May of this year and the bruising from that fall should be gone by now.On 7/8/2026 at 11:25 a.m., V2 DON stated V2 could not find any documentation about the bruising to R5's left hip. V2 stated it is considered unknown cause and will start an investigation now. V2 stated it should have been investigated immediately on 7/7/2026 when it was initially identified and reported to the state survey agency according to policy. Facility's Abuse Identification, Prevention and Reporting Policy and Procedure dated 02/25/2026 documents a Purpose of, To provide guidelines for the prevention of resident abuse and actions to be taken in the event any kind of resident abuse is suspected or identified. One of the definitions identified in this policy was Injury of Unknown Origin/Source Abuse. An injury of unknown origin or source that cannot be explained by the resident, and is suspicious because of the extent of the injury, location of the injury (bruising of the inner thigh, buttocks, genitals, chest, face, breast), or a number of injuries at one particular point in time, or numerous incidents of injuries over a time, may be considered resident abuse. This policy further documents that employees are to immediately report to the Administrator for any suspected, observed, or overheard, resident abuse as defined in this policy. The Administrator or his/her designee will provide an initial alleged abuse report to the (state survey agency) within two (2 hours) after the allegation is made if the alleged abuse resulted in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on observation, interview, and record review the facility failed to investigate a bruise of unknown origin for two (R2, R5) of four residents reviewed for injuries of unknown origin in the sample list of 12.Findings include:1.) R2's Care Plan (undated) documents R2's Diagnoses including Urinary Tract Infection, Malaise, Myalgia, Other Abnormalities of Gait and Mobility, Muscle Weakness, Need for assistance with Personal Care, Adult Failure to Thrive, Ataxia, and Dementia. This Care Plan further documents an admission date of [DATE].R2's Braden Scale dated 12/19/2025 documents R2 has a Braden Score of 14 indicating R2 had moderate risk for developing skin injury.R2's Care Plan dated 12/26/2025 documents a Category: Urinary Incontinence R2 has been incontinent of Bowel and Bladder (B/B) at times. R2 needs assist with incontinence care, toileting. This care plan documents an Approach to provide assistance for toileting. Provide incontinence care after incontinent episodes. Assist with changing incontinence briefs, skin hygiene.R2's Minimum Data Set (MDS) dated [DATE] documents R2 is moderately impaired with decisions regarding tasks of daily life and require cues/supervision.R2's Nurses Notes dated 12/25/2025 documents R2 started to show some signs of new bruising/hematoma on the left posterior forearm. R2's Nurses Notes dated 12/26/2025 documents This RN noted discolored area to entire right forearm and top of hand. Area is red with purple lining to the outside and skin is taught throughout the forearm. Also noted white lines throughout the reddened area. The discoloration is non-blanchable but has minimal swelling to thumb side of forearm. (R2) will occasionally complain of pain when arm is moved or being touched. Dr. [NAME] notified and new order received. 2 view X-ray obtained at approximately 11:30AM (R2) tolerated the X-Ray well. On 7/6/2026 at 1:52 p.m., V4 R2's family stated V4 visited R2 on 12/26/2025 and V4 noticed bruising to R2's right upper arm down to R2's wrist. V4 stated V4 was not notified by any facility staff about the bruise and when the bruise was initially developed or how it was developed. V4 voiced expectations of notification from the facility if any changes in R2's condition as soon as the incident occurred.On 7/7/2026 at 12:54 p.m., V14 Registered Nurse (RN) stated if there was a new bruising to a resident, nurses should investigate to determine the origin of the bruise, notify physician and family and then document. V14 stated if the origin was unknown, nurses should fill out an incident report and then verbally report to V2 Director of Nursing (DON) to investigate further. V14 stated V14 was not aware of any investigation conducted into R2's bruises.On 7/7/2026 at 12:58 p.m., V5 Licensed Practical Nurse (LPN) stated V5 was not aware of any investigation for R2's bruises. V5 stated if bruises were identified, nurses should find out how it happened, notify physicians, family and then document. V5 stated if the origin was unknown, nurses complete an incident report and notify V2 DON for further investigation. V5 denies knowledge of investigation about R2's bruises.On 7/8/2026 at 9:00 a.m., V2 Director of Nursing (DON) confirmed awareness of R2's bruises to arm. V2 stated V2 does not remember which side of the arm and the extent of the bruising but V2 admitted remembering a huge size bruising from R2's upper arm but does not remember if it was down to the forearm or all the way down to the wrist. V2 stated if bruising was noted on residents, nurses should do an initial investigation right away to find out where the bruising came from. V2 stated if the origin was unknown, incident report should be completed and need further investigation immediately and report to (state survey agency) within two hours. V2 stated V2 has been conducting investigations and reporting bruises of unknown origin. V2 confirmed R2's bruising was not investigated and was not reported to (the state survey agency).On 7/9/2026 at 8:34 a.m., V9 Registered Nurse stated V9 called V1 Administrator on 12/26/2025 and notified V1 on 12/26/2025 about R2's bruising to right arm. V9 stated V1 told V9 that V1 will deal with it when V1 comes in the facility. V9 stated V2 DON came in that day and went to R2's room but V9 does not know what happened afterwards. V9 confirmed the bruising was located on R2's right arm from R2's knuckles up to the elbow at that time. V9 stated physician was notified and ordered an Xray and the result was negative. V9 stated the origin of the bruise was unknown and should have been investigated and reported.2.) R5's Care Plan dated 7/1/2026 documents R5's diagnoses including Cerebral Infarction, Cognitive Communication Deficit, and Specified Disorders of Bone Density and Structure. This Care Plan further documents and admission date of [DATE].R5's Care Plan dated 6/19/2026 documents a Category: Activities of Daily Living (ADLs) Functional Status/Rehabilitation Potential with an Approach to provide assist with bed mobility when needed. Hoyer lift for transfers. R5 has own tilt-in-space wheelchair (Broda type Med [NAME] chair) for locomotion with staff assist.R5's Care Plan dated 6/19/2026 documents a Category: Medical problem. R5 has been prescribed anticoagulant therapy related to atrial fibrillation. This Care Plan documents an Approach of observe for signs of active bleeding (nosebleeds, bleeding gums, petechiae, purpura, ecchymotic areas, hematoma, blood in urine, blood in stools, hemoptysis, elevated temp, pain in joints, abdominal pain, epistaxis).On 7/7/2026 at 11:00 a.m., V17 Certified Nursing Assistant (CNA) perform incontinence care on R5. During the incontinence care, V17 noticed a purple bruising on R5's left hip. Upon observation, the bruise to R5's left hip was approximately four centimeters by four centimeters (4cm x 4 cm) in size. V17 stated V17 will notify V5 Licensed Practical Nurse (LPN) when V5 comes to do skin assessment on R5. V17 did not ask R5 anything about how the bruise was obtained at this time.On 7/7/2026 at 11:07 a.m., V5 LPN entered the room to perform skin assessment on R5 with assistance of V17 CNA. V17 verbally notified V5 about the bruise to R5's left hip. V5 completed the head-to-toe skin assessment on R5. V5 did not ask R5 anything about how R5 obtained the bruise to left hip at this time.On 7/8/026 at 10:00 a.m., R5's medical records did not contain any documentation about the bruise from 7/7/2026 head to toe skin assessment noted on R5's medical records.On 7/8/2026 at 10:05 a.m., V5 LPN stated V5 did not document anything about the bruise from 7/7/2026 skin assessment because it was an old bruise per V2 DON. V5 confirmed no knowledge when it was initially identified and the origin of the bruise.On 7/8/2026 at 10:08 a.m., V2 Director of Nursing (DON) confirmed V5 LPN had mentioned a bruise on R5's left hip on 7/7/2026. V2 stated it could be a bruise from R5's last fall. V2 went to the desk and reviewed R5's medical record and V2 confirmed R5's last fall was 5/26/2026 but unable to find documentation about the bruising to left hip at this time.On 7/8/2026 at 11:09 a.m., V7 R5's family stated facility called V7 this morning, less than an hour ago about R5's bruising to left hip. V7 confirmed no knowledge of an old bruise to R5's left hip. V7 stated V7 was only told this morning that the bruise has unknown age and unknown cause. V7 confirmed R5's last fall was end of May of this year and the bruising from that fall should be gone by now.On 7/8/2026 at 11:25 a.m., V2 DON stated V2 could not find any documentation about the bruising to R5's left hip. V2 stated it is considered unknown cause and will start an investigation now. V2 stated it should have been investigated immediately on 7/7/2026 when it was initially identified and reported to State Survey Agency.Facility's Abuse Identification, Prevention and Reporting Policy and Procedure dated 02/25/2026 documents a Purpose of, To provide guidelines for the prevention of resident abuse and actions to be taken in the event any kind of resident abuse is suspected or identified. One of the definitions identified in this policy was Injury of Unknown Origin/Source Abuse. An injury of unknown origin or source that cannot be explained by the resident, and is suspicious because of the extent of the injury, location of the injury (bruising of the inner thigh, buttocks, genitals, chest, face, breast), or a number of injuries at one particular point in time, or numerous incidents of injuries over a time, may be considered resident abuse. This policy further documents that employees are to immediately report to the Administrator for any suspected, observed, or overheard, resident abuse as defined in this policy. The Administrator or his/her designee will provide an initial alleged abuse report to the (state survey agency) within two (2 hours) after the allegation is made if the alleged abuse resulted in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on observation, interview, and record review, the facility failed to label food items in the refrigerator with use by dates and dispose of outdated food items in the refrigerator. This failure has the potential to affect all 52 residents residing at the facility. Findings include: On 02/03/24 at 8:06 AM, The initial tour of the kitchen was completed. During inspection of the walk-in refrigerator, it contained the following items: 1. A metal container of Chopped bacon, a metal container of diced tomatoes, a metal container of chopped onions, a metal container of shredded cheese, a metal container of cut up eggs, a metal container of pickle spears, and a metal container of shredded lettuce all of them covered with cling wrap with perpetration (prep) date of 2/2 and no date listed on the use by section. 2. Sliced ham in a meatal container, covered with cling, with a prep date of 1/27 and no date listed on the use by section. 3. Half a ham wrapped in cling wrap with a prep date of 1/24 and a use by date of 1/31. 4. There was a plastic container of tropical fruit covered with cling wrap and there was writing on the top in marker with a prep date of 2/2 and there is no use by date. 5. A plastic container of red and orange Jello covered with plastic wrap and the date of 1/22 written on the plastic wrap and no use by date. 6. There was a pitcher of red and pink juice and two pitchers of tea with the prep date of 2/2 and no use by date. 7. A gallon of milk with about a 1/4 left in the jug with no open date on the jug. On 02/03/25 at 08:15 AM, The walk-in freezer was inspected and contained the following items: 8. A metal pan containing spaghetti sauce was covered with plastic wrap that wasn't secured and the date of 1/13 and no use by date. 9. A metal container of polish sausages covered with cling wrap and dated 1/28 written with a marker, and no use by date. 10. A container of broccoli covered in cling wrap dated 1/30 written with marker and use by date. 11. A container with meat loaf written on the cling wrap dated 1/22 and no use by date. The meat loaf was noted to have freezer burn on it. 12. A container covered with cling wrap with pork roast and the date 1/27 written on it with a marker and no use by date. 13. Plastic container of soup covered with cling wrap; date of 1/28 wrote on it with a marker and no use by date noted. On 02/05/25 at 09:30 AM, V7 Dietary Manager said she has educated her staff on the proper labeling of food. She said she would expect when they open something for them to label it with an open date and an out date so they will know when it's not good anymore. On 02/06/25 at 12:50 PM, V1 Administrator stated she would expect the food to be labeled and dated appropriately. The facility's safe storage of food policy, issue date of 08/08/24, documented Standard: All time/temperature control for safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA (Food and Drug Administration) Food Code.

Based on observation, interview, and record review, the facility failed ensure timely and complete incontinent care was done for 4 of 4 residents (R3, R4, R41, and R52) reviewed for incontinent care in a sample of 30. Findings Include: 1. R3's Face Sheet, current admitted [DATE], documented R3 has diagnoses of but not limited to Urinary tract infection, Unspecified urinary incontinence, Full incontinence of feces, and Severe sepsis with septic shock. R3's Minimum Data Set (MDS), dated [DATE], documented R3 is severely cognitively impaired and is dependent on staff for toileting hygiene, bed mobility, and transfers. R3's Care Plan, last review date of 11/18/2024, documented R3 has been incontinent of bowel and bladder, and she doesn't know when she is wet or soiled. R3 needs assistance from staff for toileting and peri care. R3 has progressing dementia and Multiple Sclerosis (MS). Interventions include but are not limited to report signs of UTI (acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain/difficulty urinating, nausea, emesis, chills, fever, low back/flank pain, malaise, foul odor, concentrated urine, blood in urine) and provide incontinence care after each incontinent episode. Check/change incontinent briefs approximately every 2 hours and as needed. Apply moisture barrier to skin after giving peri care. Monitor for signs of potential skin breakdown. R3's Physician's Orders, dated 12/20/24, documented Certified Nursing Assistant (CNA) may apply moisture barrier after each incontinent episode. Every shift; Days 7:00-3:00, Evenings 3:00-11:00, and Nights 11:00-7:00. On 02/05/25 at 01:41 PM, V29, CNA and V30, CNA transferred R3 back to be via mechanical lift. No hand hygiene was done prior to V29 and V30 applying their gloves. With the same gloves V29 and V30 unfastened R3's incontinent brief. They rolled R3 onto her left side. R3's incontinent brief was wet with urine her buttocks were red and had indentations from where the elastic on the incontinent brief had been. V29 then took a disposable wipe and cleansed R3's gluteal fold and when she was done, she was done with the wipes she threw the wipes onto the floor. She then took another wipe with the same gloves and cleansed R3's right buttocks, placed the wipe in the brief and tucked the brief under R3. V29 and V30 then assisted R3 onto her back with no hand hygiene or glove change done before V29 took another wipe from the pack and cleansed down the right and left crease by the pubic area on R3. V29 then took another disposable wipe and cleansed R3's outer labia. She did not separate the outer labia and cleanse the inner labia. V29 and V30 then assisted R3 onto her right side and V29 cleansed R3 left buttocks. R3 was then placed on her back and her incontinent brief was fastened. V29 and V30 did not clean all areas of incontinence and they did not dry any of the areas. No barrier cream was applied prior to placing R3's clean incontinent brief. V29 and V30 did not do any glove changes or hand hygiene during the incontinent care. On 02/06/25 at 12:27 PM, V2, Director of Nursing (DON) stated she would expect the CNAs to do incontinent care correctly and to follow the policy. She would expect them to wash all areas wet with urine and to change their gloves and use hand gel when going from dirty to clean. V2 stated she expects the CNAs to check and change the residents at least every two hours and changed if the resident is suspected to be soiled. On 02/06/25 at 12:50 PM, V1 Administrator said she would expect the staff to follow the policy and do what is supposed to be done when it comes to incontinent care and all areas of incontinence to be cleaned. She said she would the staff to do hand hygiene appropriately when doing incontinent care. 32874 2. On 2/5/2024 at 1:16PM incontinent care observed. V25, CNA and V26 CNA both sanitized hand prior to donning gloves. R52 on back in bed. V25 removed adult diaper. Diaper saturated with urine and diaper dark yellow in color and strong smell of urine. V25 stated she is a heavy wetter I changed her earlier.V25 then removed gloves sanitized hands and donned new glove. With disposable washcloth cleanses right groin, then new cloth and left groin new cloth the separated labia and cleanse. V25 did not cleanse inner thighs or dry R52. V25 and V26 then turned R52 to left side and V25, removed gloves sanitized hands and cleans buttock and rectal area, removed gloves and sanitized hand and donned gloves applied barrier cream. Placed adult diaper under R52 then tuned to right side and secured diaper. Did not dry R52 or cleanse right buttocks. R52's Care plan dated revised 11/8/2024 documents R52 episodes of incontinence, and needs assistance with incontinence care. R52's care plan documents intervention dated 11/7/2024: Provide incontinence care after incontinent episodes. R52's face sheet dated 10/31/2024 documents in part R52 has a history of Urinary Tract Infection (UTI) and urinary retention R52's Brief Interview Mental Status (BIMS) dated 12/5/2024 documents R52 has severe cognitive impairment. 42108 3. R4's Care Plan, dated 12/31/2024, documents that Problem: I am incontinent of b/b R/T (related to) weakness, disease progression. I need assist with changing inc briefs , hygiene, skin care. Unable to retain new information for bladder re-training s/t dementia dx (diagnosis) and cognitive loss. 2/10/2024 Approach: Provide incontinence care after each incontinent episode. Check/change my incontinence briefs approx (approximately) every 2hrs (hours) and prn (as needed). R4's MDS, dated [DATE], documents that R4 is severely impaired, always incontinent of bowel and bladder and dependent on staff for toileting. On 2/5/2025 at 10:05 AM observed V27, CNA, and V28, CNA, perform incontinent care. R4 was incontinent of urine. V27 and V28 opened the heavily urine soiled incontinent brief and V27 rolled the incontinent brief beneath R4. V27 then took a wipe and cleansed R4's groin and vaginal area, V27 and V28 then assisted R4 onto her right side. V28 then using wipes cleansed R4's entire left buttock and partial right. V27 and V28 then applied the clean incontinent brief. V27 and V28 did not cleanse R4's entire right buttock and inner thighs. 4. R41's Care Plan, dated 1/23/2025, Problem: Senior is incontinent of B/B (bowel/bladder). Needs assist with inc (incontinent) care. Unable to care for herself. She is unaware of when she is wet/soiled. Approach: Provide incontinence care after each incontinent episode. Apply moisture barrier to skin after inc episodes. Assist with changing inc briefs. as needed. R41's Minimum Data Set (MDS), dated [DATE], documents that R41 is severely cognitively impaired, frequently incontinent of urine and bowel and dependent on staff for toileting. On 2/5/2025 at 9:00 AM V27 and V28 provided incontinent care. R41 was heavily incontinent of urine. V27 and V28 assisted R41 into the bed using a mechanical lift. V27 opened the incontinent brief and pushed it beneath R41. V28 then opened right side of the soiled brief, pulled it from between R41's legs. V27 and V28 assisted R41 onto her left side and removed the heavily urine soiled incontinent brief. V28 then removed wipes from package and wiped between R41's buttocks. V28 then applied the clean incontinent brief and placed the cover on top of R41. V28 did not cleanse R41's vaginal area, inner thighs and buttocks. V28 did not apply barrier after incontinent care. The facility's Perineal Care/Catheter Policy & Procedure, dated 2/28/2024, documents Policy: The following procedure should be followed when cleansing the external genitalia and surrounding area. Procedure: 3.) Steps for female residents: a. Position the resident to lie on her back b. use one hand to retract the labia and with the other hand wash front to back. c. Use a separate section of the cleansing cloth for each wipe in a downward motion. d. Cleanse the urethral to the vagina orifice, then wash the labia. e. Cleanse the perineum. f. Place the resident on her side and cleanse the rectal area and buttock from front to back.

Based on observation, interview, and record review, the facility failed perform proper hand hygiene and glove changes were done during incontinent care and failed to sanitize glucometer between residents during medication pass for 4 of 4 residents (R3, R15, R14, R35) reviewed for infection control in a sample of 30. Findings include: 1. On 02/05/25 at 01:41 PM, V29, Certified Nursing Assistant (CNA) and V30, CNA transferred R3 back to be via mechanical lift with no issues noted. No hand hygiene was done prior to glove placement to put R3 to bed. With the same gloves V29 and V30 unfastened R3's incontinent brief. R3's incontinent brief was wet with urine her buttocks were red and had indentations from where the elastic on the incontinent brief had been. V29 then took a disposable wipe and cleansed R3's gluteal fold and there was a smear of bowel movement (BM) on the wipe. When she was done with the wipes she threw the wipes onto the floor. She then took another wipe with the same gloves and cleansed R3's right buttocks, V29 and V30 then assisted R3 onto her back with no hand hygiene or glove change done before V29 took another wipe from the pack and cleansed R3's pubic area. V29 then took another disposable wipe and cleansed R3's outer labia. She did not separate the outer labia and cleanse the inner labia. V29 and V30 then assisted R3 onto her right side and V29 cleansed R3 left buttocks. R3 was then placed on her back and her incontinent brief was fastened. V29 and V30 did not do any glove changes or hand hygiene during the incontinent care. On 02/05/25 at 01:41 PM, V2, Director of Nursing (DON) said she would expect the CNAs to change their gloves and use hand gel when appropriate. On 02/06/25 at 12:50 PM, V1 Administrator she would expect the staff to follow the policy and do what is supposed to be done when it comes to incontinent care and all areas of incontinence to be cleaned. She said she would the staff to do hand hygiene appropriately when doing incontinent care. 2. On 2/4/2024 at 9:00AM V13, CNA donned gloves ,V13 CNA did not sanitize hands prior to donning gloves prior to entering R15's room Sign on wall pocket attached to R15's door documents, stop contact precautions, everyone must: clean their hands, including before entering and when leaving the room. R15's physician orders dated 2/3/2025 documents contact isolation due to nausea vomiting and diarrhea. 42108 3. On 2/4/2025 at 8:00 AM V8, Registered Nurse, applied a gown, gloves and a N95. V8 then entered R14 room and placed the glucometer on the overbed table without a barrier. V8 then performed a fingerstick and placed the glucometer back on the table without a barrier. V8 then discarded the used strip and placed it in the trash along with the used PPE. V8 then placed the glucometer in his pocket and left the room. V8 then removed the glucometer from his pocket and placed it in the top drawer of the medication cart. V8 did not cleanse the glucometer. On 2/4/2025 at 8:00 AM V8 stated that R14 was on contact isolation for a stomach virus and that R14 was having vomiting and diarrhea. On 2/4/2025 at 8:11 AM The Sign on door of R14's door documents CONTACT PRECAUTIONS EVERYONE MUST: Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. On 2/4/2025 at 11:41 AM V8 applied gloves, removed glucometer from the top of the cart, applied strip. V8 then entered R35's room and performed R35's Fingerstick blood sugar (FSBS) with 317 results. V8 then removed the strip and placed the glucometer on top of the medication cart without a barrier. V8 removed gloves and applied alcohol gel. V8 did not clean or sanitize the glucometer. On 2/4/2025 at 11:47 AM V8 applied gloves, removed uncleaned glucometer from top of cart applied strip and performed R14's Fingerstick blood sugar (FSBS) in the doorway of her room. V8 then removed the strip and placed the glucometer in the top drawer of the cart. V8 removed gloves and applied alcohol gel. V8 did not clean or sanitize the glucometer. On 2/3/25 at 11:33 AM, V9, LPN, stated the facility uses disinfecting wipes with a contact time of 2 minutes for the glucometers. On 2/6/2025 at 12:20 PM V1, Administrator, provided a list of residents who receive fingerstick on 400 Hall R3, R35, R14. On 2/6/2025 at 12:35 PM V2, Director of Nurse, stated that the multi dose vial expiration date is different when opened. V2 stated that the nurse is to place an open date and this date is what they go by for expiration date. V2 stated that the glucometer is to be clean after each use with the wipes. The facility's Infection Control Policy, dated 2/28/24, documents Infection Control - Hand Hygiene Policy: (Facility) recognizes proper hand hygiene to be one of the most important elements of an effective infection control program and one of the best ways to prevent the spread of infection and illness. (facility) will follow the C.D.C. (Center for Disease Control) guidelines regarding hand hygiene. Perform hand hygiene: Before and after providing resident care including bathing, oral care, incontinence care, catheter care and any direct contact with the resident (such as taking a blood pressure/pulse, transferring the resident, etc.). Before and after assisting a resident with toileting. After contact with body fluids or excretions or mucous membranes. After handling soiled or used linens, bedpans, catheters and urinals. It also documents Infection Control Standard Precautions Standard precautions apply to all residents, regardless of their diagnosis or presumed infectious status. It continues f. Resident care equipment should not be used for the care of another resident until it has been cleaned and disinfected.

Based on record review, interview, and observation the facility failed to prevent skin breakdown for 2 of 4 residents, (R1 and R10) reviewed for pressure ulcers in a sample of 30. Findings include: 1. R10 was admitted on [DATE] with diagnosis of, in part, Parkinsonism, Alzeimer's disease, and cerebral atherosclerosis. R10's Care Plan dated 12/11/24, documented she is at risk for altered skin integrity r/t disease processes, incontinence, increased weakness, changes in mobility, fair/poor appetite. It is difficult to get her to off load heels because of her cognitive status, she does not comprehend why it must be done. Difficult to get her to keep heel protectors or pressure reducing boots on as well. 11/5/24; deep tissue injury (DTI) on left heel; provide assist with repositioning as needed; continue to provide assist with incontinence care and with changing incontinence (inc) briefs when needed, keep skin clean and dry. Low air loss (LAL) mattress with bolsters on bed. Float heels when in bed to offset pressure. Apply heel protectors as often as resident will allow. Pressure reducing cushion in reclining chair; weekly skin check to assess for possible alterations in skin integrity; check heels also; help keep R10 clean, dry every shift and prn. R10's Progress Notes dated 11/16/24 documents, while helping CNA toilet resident, nurse noticed 7cm x 8cm pressure ulcer to right buttock with shearing of skin pressure reducing pad applied to reclining chair, no complaints of (c/o) pain or discomfort. R10's record fails to document any additional measure or treatment for Pressure ulcer to right buttock. R10's skin assessment dated [DATE], documented R10 at moderate risk for skin breakdown. R10's skin assessment dated [DATE], documentsed R10 moderate risk for skin breakdown. On 2/5/2024 at 1:10PM, V17, Licensed Practical Nurse (LPN) stated R10 did have an open area on her buttock, but it had been resolved. The Facility Wound summary report dated 8/1/2024 -1/31/2025 fails to document any type of wound or pressure area to 10's buttocks. R10's care plan fails to document pressure sore to right buttock or any type of interventions for right buttock. On 2/6/25 at 9:50 AM, during transfer to the toilet R10's buttock region was red and had darkened discoloration to the coccyx On 2/6/25 at 9:55 AM, V17 stated she looked at R10's buttocks and it definitely had redness, darkened discoloration with hardened areas and that this was new for her. V17 stated R10 did not have any concerns previously with her coccyx. V17 stated she would monitor R10's skin and notify hospice of her findings. 50908 2.R1 was admitted to the facility on [DATE] with diagnosis of, in part, unspecified severe protein-calorie malnutrition, edema and pain. R1's Minimum Data Set (MDS) dated [DATE] documented she is moderately cognitively impaired and is dependent on staff for putting on/taking off footwear, toileting hygiene, bathing self and all transfers. R1's Care Plan dated 11/20/24 documented she is at risk for altered skin integrity due to decreased mobility, incontinence, weakness; on hospice at this time secondary to (s/t) protein/calorie malnutrition diagnosis (dx); has an ulcer on lateral right foot/heel and right foot/bunion area; refer to Medication Administration Record (MAR) for treatment to right outer heel and lateral right foot wounds; monitor for any signs of healing progress; check Right foot wound dressings every shift to assure placement. R1's care plan continued to document R1 having a problem with Activities of Daily Living (ADL)s Functional Status/Rehabilitation Potential, R1's ability to safely perform daily care tasks has changed related to (r/t) changes in condition, weakness. R1 is on hospice at this and needs more help with her care now. Pressure reducing boots discontinued because R1 keeps trying to 'fix' them on her feet causing falls. When R1 is in her wheelchair (w/c) her feet are not resting on any hard surfaces due to the calf rests on leg rests. When R1 is in bed, she is to have gripper socks on with her heels floated. Provide assist with bed mobility as needed; assist with transfer with mechanical lift and using 2 staff assist; W/C used for mobility, she needs some assist with locomotion; assist with dressing tasks; assist with toileting/incontinence care as needed; assist with showers; assist with grooming; bilateral Knee-High compression hose on in morning, off at hour of sleep for edema. R1 had a Braden Scale for Predicting Pressure Sore Risk completed on 8/2/24 scoring her to be a mild risk and again on 11/8/24 scoring her to be a moderate risk. There were no other documented Braden Assessments completed upon discovering pressure ulcers on R1. R1's wound documentation details that she had a coccyx pressure ulcer identified on 9/4/24 and was unstageable with moderate amounts of drainage, the Right top of foot medial right foot (bunion area) wound was identified on 10/18/24 and her Right top of foot lateral wound was identified on 10/24/24; all facility acquired pressure ulcers. R1's wound care orders on 11/3/24, documented the following cleanse open area to right outer foot with wound cleanser then apply wound gel and cover with foam daily and prn; Right lateral foot wound: cleanse with wound cleanser, apply wound gel and absorbent dressing. Change daily and prn. On 2/4/2025 at 10:59 AM, V9, License Practical Nurse (LPN), performed wound care. V9 was observed sitting in wheelchair with feet dangling with compression stockings and socks in place. V9 removed the sock to R1's right foot revealing dried yellow drainage to the wound to the inner right foot next to bunion and outer right side of the foot. V9 attempted to remove the stocking and noted that the stocking was dried to the wound on the inner and outer aspect of the right foot. Upon removal of the stocking, observed open wounds and no dressings in place. During the removal of her stocking, R1 was grimacing and stated it is painful when her bunion is being touched. V9 stated he had no concerns with R1's wounds at this time other than there not being a dressing in place. R1's Progress Notes on 8/8/24 at 2:52 PM documented, New order for bilat Knee-high compression hose for edema, on in (morning) AM, off at (hour of sleep) HS. Tolerated well. Two assist for transfers. As needed (PRN) Norco given this AM for right lower extremity (RLE) pain, helpful. Feeds self with set-up. Continues routine nebulizer. R1's Progress Notes on 9/01/2024 11:42 PM documented, Took meds as ordered, including nebs treatment. Confused, she wandered some this afternoon, trying to go to main dining room (MDR) early and then to leave during supper. She took her meds and went to bed early. Certified Nursing Assistant (CNA) reported that her bottom looked bad, so we checked it out together late this evening. I noted large areas of redness on coccyx and sacrum most of which blanche, although not strongly. There are apparently two very small open areas to coccyx area. Foam dressing applied over area. Hospice should be notified with possible request for sacral foam dressing. Staff reports that she is usually continent during the day but very incontinent overnight. She does try to turn herself while in bed at night but sits on her bottom all day. R1's Progress Notes on 9/04/2024 at 1:43 PM documented, Hospice called to provide low air loss mattress related to (r/t) 1.5-centimeter (cm) by (x) 2 cm unstageable wound to coccyx area. Slough area noted. Wound gel and foam dressing applied to region. Tolerated well. R1's Progress Notes on 9/08/2024 2:29 PM documented, CNA notified writer that resident has red areas to feet. Noted 0.5 cm x 0.2 cm red blanchable area to right bunion region, 1 cm x 0.5 cm red blanchable are to right dorsal foot, also 1cm x 0.6 cm red blanchable region to left inner heel. Patient (Pt) has less edema to (bilateral lower extremity) BLE from diuretic therapy and compression hose. Shoes are not too tight with compression hose and shoes, does occasionally wear fuzzy thick socks with the compression hose. Order for skin prep every (q) shift to bilateral (bilat) feet and heel protector boots in bed. Power of Attorney (POA) updated about status of feet, also pt had removed right hearing aid after lunch for the second time and hearing aid dropped on the floor during transfer from chair to bed during transfer. Hearing aid pieces put in container for pick-up for POA. Coccyx wound dressing changed, nickel size amount of serosang drainage (drng). Continues wound gel and foam dressing. Patient (Pt) is on low air loss mattress now for bed and has wheelchair and recliner seat pads. On 2/6/25 at 12:37 PM, V3, Director of Nursing (DON), stated she expects wound dressings to stay in place especially if it is draining. V3 stated she would find it very hard for a resident to completely remove a dressing from under a compression stocking. V3 stated after a pressure ulcer is found, she expects the nurse to measure and clean it, notify the doctor and get orders, consult the wound nurse and notify the family. V3 stated she does not know why the nurse for R10 documented her having a pressure ulcer to her buttock or why nothing else was documented on it further. V3 stated the facility has daily meetings, including the wound nurse, to discuss a resident's change in skin condition and assess their situations then but we do not document them. The facility's Pressure Ulcer Prevention and Treatment Policy and Procedure documented, It is their objective to provide nursing standards for accurate assessment, prevention, treatment, and implementation of protocols including documentation to help manage residents at any level of risk for skin breakdown. To cleanse, inspect and protect all residents' skin. The policy continued to document any new areas identified will be assessed and documented in the Electronic Medical Record (EMR) by the licensed nurse using observation Skin Integrity Condition, progress note and/or other assessments as appropriate. Physician will be notified of the change in the resident's condition.

Based on interview, observation and record review, the facility failed to ensure the resident's sink water temperature was at a comfortable level for hand or facial washing for 4 of 4 residents (R36, R258, R27, R7) reviewed for safe, clean and comfortable environment in the sample of 25. Findings include: On 3/19/2024 at 9:15 AM, R36 reported there was no hot water in the bathroom since 2021. R36 stated she reported it to staff (unknown) with no results. The water in R36's bathroom sink was observed after running the hot water for 15 minutes, the temperature measured at 40 degrees Fahrenheit. 3/19/24 10:30 AM, R27 Alert and oriented x1, not able to interview. No hot water at the bathroom sink, cold to touch after 15 minutes of running hot water. 3/19/24 11:12 AM, R7 Alert and oriented x1. Not able to interview. No hot water at the bathroom sink, very cold to touch after 15 minutes of running hot water. On 3/20/2024 at 11:30 AM, V11, Director of Facility Services, stated that the water valve is broken, and he called the plumber to replace it and is just waiting on them to come and do it. V11 stated there's no hot water on 600 hall, so they will probably move those residents off the hall. On 3/21/2024 at 8:55 AM, the water temperature recordings were reviewed with no temperature's documented on 3/19/24, 3/20/24 or 3/21/24. On 3/21/2024 at 9:30 AM, V11, Director of Facility Services, stated he hasn't checked the water temperature today. V11 stated he will usually check a couple of times a week. V11 stated he thought it was the water valve yesterday, but the water pump went out. V11 stated they have been having problems for a little while, so hopefully the plumber will get it fixed by this Friday 3/22/2024. On 3/21/2024 at 9:45 AM, V11, Director of Facility Services, was observed going into bathrooms on Hall 600 to check the temperatures of the bathroom sink water. Temperatures were checked at the bathroom sink of R36, recording the water temperature at 68 degrees Fahrenheit after 15 minutes. On 3/21/24 at 10:05 AM, V11, Director of Facility Services, was observed checking the water temperature in R258's bathroom sink, recording the water temperature at 70 degrees Fahrenheit after 15 minutes. On 3/21/24 at 11:55 AM, V4, LPN (Licensed Practical Nurse) reported he knew that maybe sometimes they (maintenance) will work on the water heater for the halls. On 3/21/24 at 12:00 PM, V10, CNA (Certified Nursing Aide) reported when he works hall 600, he will get his water to wash residents on hall 600 from the breakroom. On 3/21/24 at 12:20 PM, V2, Director of Nurses, stated they don't have a policy for water temperatures.

Based on observation, interview and record review, the Facility failed to supervise residents, properly tranfer residents, and ensure progressive fall interventions were implemented in 4 of 10 residents (R12, R34, R41, R44) reviewed for accidents and hazards in the sample of 25. Findings include: 1. R12's Face Sheet documents R12 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, Parkinson's disease, type 2 diabetes mellitus, psychotic disorder with hallucinations, post-traumatic stress disorder, difficulty in walking, and history of falling. R12's Minimum Data Set (MDS) dated [DATE] documented R12 was severely cognitively impaired and required substantial assistance with rolling from side to side, sitting to standing, and transfer. R12's Care Plan revised 3/11/24 documents R12 is at risk for falls due to Parkinson's disease, periods of confusion, and history of falls. R12's Fall Risk assessment dated [DATE] documents R12 is at high risk of falls. R12's Progress Note dated 10/30/23 at 1:30 AM documents R12 was found on the floor in his room with buttocks in the air, face on the ground and most of his weight on his left side. The incontinence pad was next to the bed. R12's left eye was puffy and discolored purple/blue, his nose was puffy, his left side and left foot were reddened, and his left knee had small abrasion. R12's Fall Report dated 10/29/23 documents R12 was found lying on the floor in his room by staff. His left eye was puffy, purple, and blue, his left side and left foot were reddened, and his left knee had a small abrasion. R12 complained of pain everywhere at a 10 out of 10 rating. R12's Care Plan revised 3/11/24 documents low bed with floor mats as the intervention for R12's 10/29/23 fall. On 3/20/24 at 1:47 PM, V12, Certified Nursing Assistant (CNA), stated, (R12) is a fall risk, so when he is in bed we lower his bed to the floor and put pads (floor mats) down on each side. On 3/21/24 at 7:32 AM, R12 was resting in bed with a floor mat to his left side. There was no floor mat on his right side, but there was a floor mat propped against the wall. V15, CNA, entered the room and stated R12 normally has two floor mats, but he refused to get out of bed this morning and staff probably forgot to put it back down. 2. R44's Face Sheet documents R44 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, type 2 diabetes mellitus, need for assistance with personal care, muscle weakness, unspecified psychosis, and unspecified abnormalities of gait and mobility. R44's MDS dated [DATE] documented R44 was severely cognitively impaired and used wheelchair, but was independent with rolling from side to side, lying to sitting, and sitting to standing. He required supervision with transfer and walking. R44's Care Plan dated 8/31/23 documents R44 is at risk for falls due to weakness, history of falls, attempts to self-transfer, impulsivity, quick movements, poor memory, and failure to use call light. R44's Fall Risk assessment dated [DATE] documents R44 is at high risk for falls. R44's Progress Note dated 10/26/23 documents R44 was found on his knees in dining room attempting to return to his wheelchair and stated he slid from his wheelchair while propelling himself. There were no injuries. The intervention was placement of a non-skid seat cushion in R44's wheelchair. R44's Fall Report dated 10/26/23 documents R44 had an unwitnessed fall in the dining room while propelling himself in his wheelchair. There were no injuries. A non-skid seat cushion was added to the seat of R44's wheelchair. R44's Care Plan revised 12/5/23 documents non-skid seat cushion as R44's 10/26/23 fall intervention. On 3/20/24 at 9:45 AM, R44 was sleeping in bed in his room. V10, CNA, stated R44 does not have a non-skid seat cushion. V10 lifted R44's wheelchair cushion from the seat of his wheelchair, and there was no non-skid seat cushion on the seat. On 3/20/24 at 1:47 PM, V12, CNA, stated she was unsure whether R44 was supposed to have a non-skid seat cushion in his wheelchair. On 3/20/24 at 3:38 PM, V13, CNA, stated she was unsure whether R44 had a non-skid seat cushion in his wheelchair. On 3/20/24 at 3:43 PM, V14, Licensed Practical Nurse (LPN), stated she was unsure whether R44 has a non-skid seat cushion in his chair. 44953 3. R34's Minimum Data Sheet (MDS) dated [DATE] documents V34 is cognitively intact but requires substantial/maximal assistance with personal hygiene, toilet transfer and tub/shower transfer. R34's Physician Order Summary (POS) undated documents Alzheimer's disease with late onset; Hereditary and idiopathic neuropathy, unspecified; Unsteadiness on feet; Osteoarthritis of knee, unspecified, bilateral; History of falling; Abnormal posture; Muscle weakness (generalized); Dependence on wheelchair; Need for assistance with personal care. R34's Admission Fall assessment dated [DATE] documents R34 is a HIgh Risk for Falls. R34's Fall Investigation dated 3/20/24 documents Resident is A&O X 3 with some forgetfulness and confusion noted at times. She requires assist with all ADLs and usses (sic) wheelchair for mobility. On this date staff went in to assist her in getting up. They changed and provided percare (sic) and assist her in getting dress. The they stood her with gait belt to transfer her to wheelchair they forgot to lock wheelchair brakes and w/c moved. Staff lowered her to the floor to prevent her from falling and injury. Staff was educated and reminded to always ensure that brakes are locked before transferring resident. R34's Care plan dated 4/4/23 documents R34 is at risk for falls due to history of falls at home, increased weakness, glaucoma/macular degeneration, neuropathy. I have reduced mobility at this time. Tends to lean forward slightly, when sitting in wheelchair with head down slightly. Poor standing balance. When standing, she has knees bent slightly making her leg muscles hold her up rather than bearing weight thru her bones. Interventions: I will continue to be assisted with transfers in the most safe and appropriate manner during this review period - Approach: Fall intervention 3/14/24; Staff reminded/re-educated to always make sure the w/c brakes are locked when transferring her. On 3/21/24 at 9:45 AM, R34 stated she did not fall she just slid to the floor. 2 CNAs were holding her up under her (V34) arms and her (V34 ) legs just gave away. (V34 ) did not recall if her wheelchair was locked. On 3/22/24 at 8:48 AM, V2, DON stated in-service training is provided to all staff periodically on the use of any transfer equipment. Therapy provides transfer education to all staff and all staff are encouraged to ask questions if needed. On 3/22/24 at 9:45 AM, V21 CNA stated she and another CNA were involved in the transfer of R34. V21 CNA stated we forgot to lock the wheelchair and yes we did have in-service training on the use of wheelchair. 4. R41's Minimum Data Set (MDS) dated [DATE] documents R41 has severe cognitive impairment, requires partial/moderate assistance with sit to stand, chair to bed transfer and toilet transfer. R41's Physician Order Summary (POS) undated documents pertinent medical diagnosis as history of falling; Unspecified fall, subsequent encounter; Need for assistance with personal care; Weakness R41's Admission Fall Risk assessment dated [DATE] documents he is high risk for falls R41's Fall investigation dated 2/1/24 documents, (R41) was on floor at 1450. He was assisted to bed at PM and inc care/brief was last changed at 1435. He was fully dressed with gripper socks on that time and when found at 1450 he had removed all clothing/socks except shirt. He was apparently trying to toilet self. Laceration to back of head requiring 5 staples in ER. Alert with confusion,forgetfulness. Weak s/tmultiple myeloma. On hospice. Has cognitive deficits. Diabetic with neuropathy. Poor safety awareness. Impulsive. Given a low bed with mats, alarm placed on bathroom door R41's Fall Investigation dated 3/11/24 documents Resident is alert with confusion. diagnosis include multiple myeloma, cognitive communication deficit, muscle weakness, Hypertension, Diabetes Mellitus, and history of falls. He has poor insight to self deficits, poor memory, and poor safety awareness. He requires assist with transfers and uses a reclining wheelchair for mobility. Staff anticipates his needs. On this date he was up in reclining wheelchair in common area, staff were getting people up. When staff member came back to common area resident was on the floor, with the back wheels off the ground. The reclining wheelchair was propped up on leg rest and front wheels. Resident looked like he tried to stand up at the railing and went down to the foot rest, tipping over the chair. Resident states that he was trying to get a drink. A cup holder for his reclining wheelchair was ordered. On 3/21/24 at 1:45 PM, V2, DON stated R41's reclining wheelchair was provided by Hospice without operations manual. On 3/21/24 at 2:30 PM, V23 Restorative CNA stated she arrived at work around 6:00 AM , R41 was not in his reclining wheelchair chair in the hallway leading to common area upon her arrival. At approximately 6:30 AM she (V23) stated the residents were gathered around the coffee carafe for their morning cup of coffee. Upon her (V23)return (R41) was in the reclining wheelchair and parked to the right side of the hall near the hand rail. Upon her return to the area (R41) was found on the floor and his reclining wheelchair was resting on its front wheels and the hind wheels were up in the air near the the left side of the hall. At the time of the fall R41 stated he was trying to get something to drink. (V23) Restorative CNA stated (R41) was known to be restless at times. Cannot recall if other staff were in the area or if all other residents had been returned to their rooms. R41 was unable to be interviewed at this time as his illness had progressed and he (R41) was in the active stage of dying. On 3/21/24 at 2:36 PM, V18, Hospice RN stated her company did order a reclining wheelchair for (R41) from a medical supply company and they would have provided the paperwork upon delivery to the facility. She (V18) had no concerns regarding R41's care. (V18) stated she was notified of his fall but not that it was from the reclining wheelchair. V18 Hospice RN did know R41 to be occasionally restless and occasionally reaching for objects not within his immediate reach. On 3/21/24 at 2:40 PM, V20, Hospice Team Leader provided the operations manual of the reclining wheelchair supplied by the medical supply company. On 3/22/24 at 8:48 AM, V2, DON stated in-service training is provided to all staff periodically on the use of any mechanical equipment. However, there is no specific training for use of the reclining wheelchair. The wheel locks are the same as on other reclining wheelchairs. According to the CNA (V23) there were other residents in the area and a nurse (V26) was at the end of the hall who had the the area within sight. On 3/22/24 at 10:00 AM, efforts to reach V26 unsuccessful. On 3/22/24 at 10: 01 AM, V25, LPN stated in all of her [AGE] years of being a nurse she had never received in-service training on the use of a reclining wheelchair. The Operating Manual for the Centric Tilt Semi- Recliner documents 2.5.3 Location of Chair - Danger of Tipping or Falling Objects. We recommend that when a resident has been moved to their destination, the chair is placed where the resident cannot reach handrails or other objects, fixed or movable. This is to prevent the resident from pulling the chair over or pulling themselves off the seating surface and to prevent the resident from pulling movable objects onto the chair and themselves. We recommend that the chair be used in a supervised area to prevent untrained residents, caregivers, or third parties from unauthorized operation, movement, or unsafe actions such as sitting or leaning on the reclined back, elevated footrest, or the armrests. These actions, if not prevented, put the chair at risk of tipping or damage to the chair. Care Plan dated 3/12/24 documents Resident is at risk for falls due to weakness, decreased functional mobility, DM with neuropathy, history of cerebral infarct, multiple myeloma. Forgetful. Periods of confusion. Poor safety awareness. Decreased reasoning and safe judgement. Impulsive. Poor insight to his own deficits. Has tried to get up unassisted at times. Has tried to toilet self. Staff has found him in bathroom after he covered urine with paper towels. Does not use call light. Does not recall falling. Has worn gripper socks, but has removed them at random. INTERVENTIONS: Fall intervention 3/11/24; Because senior is usually c/o being thirsty therefore he is given a water bottle to keep with him on the reclining wheelchair for ready access to water. - Provide 2 assist with transfers. Reclining wheelchair for mobility with staff assist. Keep floor clean, dry. Keep bed brakes locked. Call light in reach at all times when he is in bed. Remind him to use it. 'Call don't fall' signs in room. Utilize 2 half side rails while in bed for bed mobility and repositioning. Gripper socks on at all times. - Fall intervention 2/19/24; low bed with mats now, alarm placed on bathroom door. - He will wear his glasses as needed. Make sure he is wearing his hearing aid so he can communicate better. Can be up in reclining wheelchair as tolerated. Keep in common areas when up in chair. 42636 On 3/22/24 at 8:45 AM V2, Director of Nurses (DON), stated when a resident falls the nurse will assess the resident, then the nurse and CNAs on the hall have a fall huddle to discuss the cause of the fall and will try something else to prevent future falls. V2 stated the the fall committee meets weekly to discuss the falls, causes, if the interventions are working or if something different needs to be done. V2 stated she will in-service the staff on the new interventions if it is something they are not familiar with. V2 stated the interventions for fall prevention are documented on the care plan, Kardex and on the incident report. The Fall Prevention Policy & Procedure, with a review date of 2/28/24, documents the interdisciplinary team shall review each resident's fall risk prevention plan at a minimum of quarterly and after a fall occurrence, during care conference and modify the plan as needed based upon the resident's functional status during the review process.

Based on interview, observation and record review, the facility failed to ensure an indwelling urinary catheter drainage bag was placed below the level of the bladder to prevent back flow of urine into the bladder and proper drainage of urine in 1 of 1 residents (R2) reviewed for catheters in the sample of 25. Findings include: On 3/21/24 at 9:45 AM, R2 was observed in bed lying on her back with her feet and head slightly elevated with an indwelling urinary catheter in place. The drainage bag was full with urine, backing up in the tubing going into the urethra. The urine drainage leg bag was secured to the top of R2's left knee, not below the level of the bladder causing urine to back flow into the bladder and not allowing for proper drainage. Incontinent/Catheter care was observed with V10, CNA (Certified Nurses Assistant), and V5, CNA. After care was provided, R2 was covered up with her blanket and V10 and V5 left the room, leaving R2's urinary catheter bag in the same position, not below the level of the bladder. R2's Face Sheet, undated, documents R2 has a diagnosis, in part, of Multiple Sclerosis (MS), Need for Assistance with Personal Care, Full Bowel Incontinence, Chronic Obstructive Pyelonephritis, History of Urinary Tract Infections and Neuromuscular Dysfunction of the Bladder. R2's Minimum Data Set (MDS), dated [DATE], documents R2 has severe cognitive impairment, has an indwelling urinary catheter and is incontinent of bowel. R2's Care Plan, dated 5/23/23, documents R2 requires an indwelling urinary catheter due to MS and Neurogenic Bladder with an intervention to provide catheter care every shift and as needed. Keep drainage system closed as much a possible. Keep collection bag below bladder level. Empty bag every shift. Continue to encourage fluids when possible. Remains on enhanced precautions per infection control policy. R2's Physician Order Sheet (POS), documents an order dated 7/8/22, to provide catheter care every shift. R2's POS, documents an order dated 8/4/23, for a urinary catheter due to a diagnosis of Neuromuscular Dysfunction of the Bladder. R2's Progress Note, dated 1/2/24 at 12:07 AM, documents the following: Resident c/o (complaining of) being cold and did not want to get up for her shower or supper, she did agree to a bed bath after supper. CNA (Certified Nurses Assistant) reported that the resident's catheter leaked. Resident's catheter had just been changed three days ago. Noted that staff had left resident's leg bag on while she was in bed all evening, which probably contributed to leaking Foley. Resident cleaned up and a large drainage bag was applied to the catheter. R2's Progress Note, dated, 1/30/24 at 12:50 AM, documents the following: Staff noted that when the leg bag is left on resident in bed, the catheter does not drain properly and instead the leaks. Staff teaching done again. R2's Progress Note, dated 1/30/24 at 2:05 AM, documents the following: CNA informed this writer that the resident's catheter was leaking as the bag was empty and her brief was saturated with urine. New catheter placed using sterile procedure and 16 French catheter. Received good urine return and resident tolerated procedure well. No s/s (signs/symptoms) of distress noted. On 3/22/24 at 8:45 AM V2, DON, stated residents with catheters that are laying down can have their leg bag on for a short time. If they are going to be in bed longer or at night then their leg bag is changed over to the bigger bag. V2 stated their leg bags resist back flow of urine. The Perineal Care/Catheter Care Policy & Procedure, with a review date of 2/28/24, documents for catheter care, at no time should the drainage bag be placed above the bladder; this prevents back flow of urine into the bladder which may cause infection.

Based on observation, interview and record review, the facility failed to provide incontinent care utilizing infection control practices to prevent infection and use appropriate personal protective equipment on a resident that was on enhanced barrier precautions in 1 of 2 residents (R2) reviewed for catheters/urinary tract infections in the sample of 25. Findings include: On 3/21/24 at 9:45 AM, There was a sign on R2's door indicating R2 is on enhanced barrier precautions. R2 was observed in bed lying on her back with her feet and head slightly elevated. An indwelling urinary catheter in place. The urine drainage bag was contained in a leg bag that was secured to the top of R2's left knee, causing urine back flow into the bladder and improper drainage of urine. Incontinent/Catheter care was observed with V10, CNA (Certified Nurses Assistant), and V5, CNA, with the following noted: Neither V10 or V5 had a gown on due to resident being on enhanced barrier precautions. V10 put gloves on with no hand hygiene observed prior to. R2's depend was soiled with urine. V10 used pre-packaged wipes to clean R2's front perineum, then discarded the wipe, V10 then used his dirty hand to grab a clean wipe from the package and wiped R2 again. V10 did this several times without maintaining a clean/dirty field. V10 removed his gloves and donned new gloves without performing hand hygiene. R2 was then turned onto her left side, V10 took a wipe and wiped in a downward motion towards R2's urethra, noting resident had stool in the anal area. V10 then cleaned R2's buttock crease and buttocks without maintaining a clean/dirty field. V10 then changed gloves to apply a clean incontinence brief without performing hand hygiene. R2 was then covered up with her blanket and V10 and V5 left the room, leaving R2's urinary catheter bag in the same position causing back flow of urine into the bladder and improper drainage. R2's Face Sheet, undated, documents R2 has a diagnosis, in part, of Multiple Sclerosis (MS), Need for Assistance with Personal Care, Full Bowel Incontinence, Chronic Obstructive Pyelonephritis, History of Urinary Tract Infections and Neuromuscular Dysfunction of the Bladder. R2's Minimum Data Set (MDS), dated [DATE], documents R2 has severe cognitive impairment, has an indwelling urinary catheter and is incontinent of bowel. R2's Care Plan, dated 5/23/23, documents R2 requires an indwelling urinary catheter due to MS and Neurogenic Bladder with an intervention to provide catheter care every shift and as needed. Keep drainage system closed as much a possible. Keep collection bag below bladder level. Empty bag every shift. Continue to encourage fluids when possible. Remains on enhanced precautions per infection control policy. R2's Physician Order Sheet (POS), documents an order dated 7/8/22, to provide catheter care every shift. R2's POS, documents an order dated 8/4/23, for a urinary catheter due to a diagnosis of Neuromuscular Dysfunction of the Bladder. R2's Progress Note, dated 12/24/23 at 1:04 PM, documents the following: Catheter in place & patent. Draining thick amber urine with foul odor & moderate amount of mucus. Fluids encouraged but she is a poor drinker. Appetite fair. Catheter care given. Resident denies pain or discomfort. R2's Progress Note, dated 1/2/24 at 12:07 AM, documents the following: Resident c/o (complaining of) being cold and did not want to get up for her shower or supper, she did agree to a bed bath after supper. CNA (Certified Nurses Assistant) reported that the resident's catheter leaked. Resident's catheter had just been changed three days ago. Noted that staff had left resident's leg bag on while she was in bed all evening, which probably contributed to leaking Foley. Resident cleaned up and a large drainage bag was applied to the catheter. R2's Progress Note, dated, 1/30/24 at 12:50 AM, documents the following: Staff noted that when the leg bag is left on resident in bed, the catheter does not drain properly and instead leaks. Staff teaching done again. R2's Progress Note, dated 1/30/24 at 2:05 AM, documents the following: CNA informed this writer that the resident's catheter was leaking as the bag was empty and her brief was saturated with urine. New catheter placed using sterile procedure and 16 French catheter. Received good urine return and resident tolerated procedure well. No s/s (signs/symptoms) of distress noted. R2's Urine Culture dated 5/21/23 documents the following bacteria was identified, Klebsiella Pneumoniae ESBL (extended spectrum beta-lactamase), Proteus Miribillis ESBL and Citrobacter Freundii Complex. On 3/22/24 at 8:45 AM V2, DON, stated residents with catheters that are laying down can have their leg bag on for a short time. If they are going to be in bed longer or at night then their leg bag is changed over to the bigger bag. V2 stated their leg bags resist back flow of urine. V2 stated when a resident is on enhanced barrier precautions for an MDRO (multi-drug resistant organism), staff are to wear a gown and gloves when providing incontinent care. V2 stated staff should perform hand hygiene before incontinent care, during and after care. The Perineal Care/Catheter Care Policy & Procedure, with a review date of 2/28/24, documents for catheter care, perform hand hygiene and apply gloves. At no time should the drainage bag be placed above the bladder; this prevents back flow of urine into the bladder which may cause infection. The Infection Control Policy, with a review date of 2/28/24, documents standard precautions apply to all residents, regardless of their diagnosis, shall use appropriate hand hygiene after touching blood, body fluids, excretions, secretions and contaminated items, regardless of whether gloves are worn. Hand hygiene immediately after gloves are removed and between tasks and procedures on the same resident to prevent cross contamination of body sites. Enhanced barrier precautions will be used for residents during high contact resident care activities that provide opportunities for a transfer of multi-drug resistant organisms which include ESBL. Under enhanced barriers staff will wear a clean, disposable, non-sterile gown and gloves when providing high contact resident care areas which include dressing, clothing, showering, transferring, changing linens and providing hygiene.

Based on observation, interview, and record review, the Facility failed to ensure food was stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 59 residents living in the Facility. Findings include: On 1/17/23 at 7:33 AM, the walk in freezer had a small amount of ice on the bottom of the fan. There was a box on a shelf labeled stew vegetables. The plastic bag inside the box was open and not sealed with vegetables exposed to the air. There was no date on the package to denote when it was opened. On 1/17/23 at 7:35 AM, the fan in the walk in refrigerator had a significant amount of dust. There were 3 stainless steel containers of food that were dated, but none were labeled to identify the contents inside. There was one half of a circular shaped cake that was wrapped in plastic wrap and dated, but did not have a label. There was a cart containing approximately 48 individual servings of coleslaw that were not labeled or dated. The entire cart was covered with a plastic sheet, but the individual items inside were not labeled, dated, or wrapped. V7, Dietary Manager, stated, Those will be used for lunch. On 1/17/23 at 7:40 AM, there was dust and dirt behind the ice machine and along the edge of the flooring. The hood above the stove near the dietary office was greasy with black, flaky residue on the metal part of the light. On 1/17/23 at 7:42 AM, there was a fan near the beverage table that was not in use, but covered in dust. V7, Dietary Manager, stated, Maintenance must have put that there. On 1/17/23 at 7:44 AM, the hood above the cook top beside the tray line had grease and dust on the metal part of the lights. V7, Dietary Manager, stated, We are just about due for our 6 month cleaning. We have a specialist that comes in every 6 months to clean the hoods. On 1/17/23 at 7:52 AM, on the shelf below the steam table there were two tubs of cereal that were not labeled or dated. There was also a bag of toasted oats cereal that was sealed up, but not dated. On 1/17/23 at 7:54 AM, there were two 22 quart containers on the counter next to the beverage refrigerator. One container had yellow liquid filled to the 8 quart mark. The other container had red liquid filled to the 8 quart mark. Neither container was labeled or dated. On 1/17/23 at 7:55 AM, the standing beverage refrigerator had 6 trays with individual glasses of yellow liquid that were not labeled or dated. On 1/20/22 at 9:02 AM, V1, Administrator, stated she would expect food service staff to follow the Facility's policy for dating and labeling. The Facility's Safe Storage of Food Policy issued 9/1/21 documents, All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. All packaged and canned food items will be kept clean, dry, and properly sealed. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. The Facility's Resident Census and Conditions of Residents Form (CMS 672) dated 1/17/23 documents there are 59 residents living in the Facility.

Based on observation, interview and record review, the Facility failed to implement and follow progressive fall interventions and utilize safety devices for 4 of 14 residents (R32, R34, R53, R163) reviewed for falls in the sample of 39. Findings include: 1. R53's January 2023 Physician Order Sheet (POS) documents R53 has diagnoses including unspecified severe protein-calorie malnutrition; unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; unspecified convulsions; restlessness and agitation; spondylosis without myelopathy or radiculopathy, cervical region; and spondylosis without myelopathy or radiculopathy, thoracic region. R53's Minimum Data Set (MDS) dated [DATE] documents R53 is moderately cognitively impaired, requires extensive one person assistance with bed mobility and transfer, and requires total dependence with one person assistance for toileting. R53's Fall Risk assessment dated [DATE] documents R53 is at high risk for falls. The Facility's All Falls for Facility Report dated 1/17/23 documents R53 had falls on 6/29/22, 7/31/22, and 8/1/22. R53's Care Plan with Problem Start Date of 4/1/22 documents, I am at risk for falls due to increased weakness from a recent UTI (Urinary Tract Infection). Care Plan approaches dated 4/1/22 include Call Don't Fall signs in room. R53's Event Report dated 6/29/22 documents resident had unwitnessed fall while attempting to self-transfer. The Evaluation Notes document, Resident trying to get out of bed to urinate however, resident does (have) a Foley cath (catheter) in place. Resident was reminded of Foley and call light use. Staff was educated to keep bed low when (R53) is laying down and mat was placed at bedside. R53's Care Plan documents 6/30/22 Fall Intervention, Low bed with mats on floor at bedside. R53's Event Report dated 7/31/22 documents resident had unwitnessed fall. The Evaluation Notes document, Resident was trying to get up to empty Foley, per resident, 'so my wife didn't have to'. After investigation it was found resident's Foley was full. Intervention was presented to staff to empty Foley at a minimum twice a shift by nursing staff. R53's Care Plan documents 7/31/22 Fall Intervention, Keep Foley (catheter) bag emptied to avoid possible tugging/pulling on catheter from wt (weight) of urine in bag. R53's POS documents, Catheter care every shift. Every Shift; days, evenings, midnights with start date of 4/27/22. R53's Vitals Report does not document R53's catheter bag was emptied on 1/5/23 or 1/11/23. Documentation from 1/1/23 and 1/3/23 through 1/18/23 document R53's catheter bag was emptied only one or two times per day. On 1/18/23 at 8:52 AM, R53 was sleeping in bed in his room. There were no floor mats on either side of R53's bed. Two floor mats were lying against the wall across the room from resident. R53's catheter bag was filled past the 2000 mL (milliliters) mark with amber colored liquid. There was a Call Don't Fall sign on a table several feet away from R53's bed that was out of R53's vision. On 1/18/23 at 10:19 AM, R53's catheter bag was filled to the top of the bag and appeared taut and heavy. V13, Certified Nursing Aid (CNA), stated, It should have been emptied already from the midnight shift, but if it's already that full I'm sure it wasn't emptied. V13 filled up a urinal from the catheter bag, then clamped bag and stated, This was 1000 (mL). V13 then disposed of the urine, filled another urinal, and stated, That was another 1000 (mL). V13 again disposed of the urine and emptied the catheter bag into a third urinal. V13 stated, This is another 300 (mL). Two floor mats remained against the wall, and the Call Don't Fall sign remained face up on the table out of R53's vision. On 1/20/23 at 9:02 AM, V1, Administrator, stated she would expect staff to be following progressive fall interventions and empty catheter bag at least once a shift. 35067 2. On 1/18/2023 at 2:03 PM, R163 was in her wheelchair with no anti roll back's on wheelchair. R163's Face Sheet documents she was admitted to the facility on [DATE] with the diagnoses which include: Repeated falls, hypertension, dementia, bipolar disorder, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (History of), foot drop right foot, polyneuropathy, major depressive disorder, and polyosteoarthritis. R163's Fall Risk Assessment, dated 1/9/23 documents she was a high risk for fall. R163's MDS dated [DATE] documents she has severely impaired cognition and requires limited assistance for transfers, locomotion on unit, and toileting. According to this MDS, R163's balance during transitions and walking is not steady. The facility's document, All Falls for Facility dated 1/17/23 documents R163 had falls on 1/11/2023, 1/14/2023, and 1/16/2023. R163's Care Plan, dated 1/16/2023 documents the focus Falls : I am at risk for falls due to having repeated falls at home, weakness, spinal stenosis with lower back pain (LBP), neuropathy, right foot drop. Mild right lower extremity weakness from old stroke. Forgets safety precautions. Has made self transfer attempts with resulting falls. She has stated that there are other people here that need more help than she does, so she tries to do things on her own. Interventions dated 1/16/2023 include fall intervention encourage resident to eat meals in Main Dining Room (MDR) for safety and supervision, increased staff supervision with intensity based on resident need ankle foot orthosis (AFO) on right foot when out of bed. Intervention added after R163's fall on 1/14/23 is: anti - roll back device applied to resident's wheelchair and resident educated to use call light when needing assistance. R163's Progress Note, dated 01/14/2023 at 07:40 AM, documents therapy reported resident was sitting on floor next to bed. Elder is alert. Denies pain. ROM (range of motion) good to extremities. No injury reported. Up in wheelchair (w/c) dressed per therapy. Reminded to call for help. On 01/18/23 at 10:18 AM, V14, Certified Nurse Assistant (CNA), stated that R163 fell a couple times in this last week. V14 stated, (R163) gets up by herself and is supposed to have help. We tell her to use her call light but sometimes she doesn't. She uses a wheelchair and propel's herself. She's in therapy right now, sometimes she will use her call light and sometimes not. She uses her wheelchair. On 1/18/2023 at 10:18 AM, V15, CNA, stated, (R163) just fell a couple times this week. She uses her call light at times but she sometimes she does not. We make sure her call light is where she can reach it. On 1/18/2023 at 10:20 AM, R163 was observed in therapy using a bicycle. R163 stated she has fallen several times trying to go to the bathroom. She stated she tries to get to the wheelchair from her bed but will fall sometimes. R163 stated she will turn her light on but they don't answer the light in time and and she needs to use the bathroom so she tries to get to the bathroom on her own. On 1/18/2023 at 10:22 AM, V16, Physical Therapist Assistant (PTA), stated, (R163) is getting therapy but she hasn't had any falls that I know of in the facility. They didn't tell me if she fell recently. On 1/19/2023 at 12:55 PM, V21, Restorative Aide stated and confirmed there was no anti roll back device on R163's wheelchair. On 1/19/2023 at 1:02 PM, V20, MDS/Care Plan Coordinator, stated and confirmed there was no anti roll back device on R163's wheelchair and stated she does not know why the anti-rollback is not on R163's w/c because they are included on her care plan. V20 stated a work order for maintenance should have been done to ensure the anti-rollback device was put on R163's w/c. V20 stated V2, Director of Nursing (DON), or V3, Assistant DON, usually do the work orders. On 1/19/2023 at 1:07 PM, V2 stated she thought the work order was turned in to the maintenance department for the anti roll back to be put on R163's wheelchair. On 1/19/2023 at 1:10 PM, V3 stated she or V2 usually put the work order in to maintenance after their morning meetings when they have investigated the falls and discussed them in the morning meeting, She stated sometimes even V20 will put the order in to maintenance. At times, the floor nurse will put in the work orders in to maintenance. V3 stated she is not sure why the anti roll back was not put on R163's wheelchair. On 1/19/2023 at 1:18 PM, V2 stated she is putting in another work order to maintenance for the anti roll back to be put on R163's wheelchair. V2 stated she does not know why they didn't get put on the wheelchair when first ordered. 34964 3. The facility's document , All Falls for Facility dated 1/17/23 documents R32 had falls on 1/17/22, 5/26/22, and 8/4/22. R32's Face Sheet documents her diagnoses to include Cerebral Infarction, Polyosteoarthritis, Other Malaise, Unsteadiness on Feet, Wedge Compression Fracture of Third Lumbar Vertebra, and Generalized Anxiety Disorder. R32's MDS dated [DATE] and 5/5/22 both document R32 is severely impaired cognitively and requires extensive assist of staff for transfers, walking and toileting. R32's Care Plan dated 10/12/22 (revised 1/5/23) documents: Problem: I am at risk for falls with dementia progression. poor safety awareness. Poor insight to my own deficits. History of falls. Has history of suddenly getting up to go to bathroom when she needs to have a BM (bowel movement). Now on hospice s/t (secondary to) condition decline. R32's Care Plan intervention dated 10/12/22 documents: Approach: One assist with all transfers. Make sure she is wearing gripper socks at all times. Make sure she is covered with blankets when in bed. Keep bed in lowest position. Check on her frequently when she is in bed. Up in Broda chair as tolerated. R32's Fall Risk assessment dated [DATE] documented her score as 17, indicating she is at high risk of falls. R32's Fall Event dated 1/17/22 at 5:13 PM documents, Resident is alert with confusion. Her diagnoses include Alzheimer's Disease, Dementia, HTN (hypertension), Depressive Disorder, and Anxiety Disorder. She is ambulates ad lib (as desired), without device. Her gait is slowly declining. Staff walked with her to restroom, staff turned around to get depend out of closet and resident fell on to her knees. Staff was educated on sitting resident safely down on toilet before turning around. Staff should keep a handful of depends in bathroom so resident is not left unattended. R32's Fall Event dated 5/26/22 at 12:03 PM documents, Resident is A&O (alert and oriented) x 0-1 with confusion noted. Her diagnoses include Alzheimer's, Dementia, HTN (hypertension), Cerebral Infarction, Hyperlipidemia, Major Depressive Disorder, GERD (Gastroesophageal Reflux Disease), Unsteadiness on Feet, Low Back Pain, and Generalized Anxiety Disorder. Staff toileted resident and was walking resident to dining room for lunch. Resident was holding onto the handrail and staff let go and stepped away to throw something away and resident tripped over her own feet and landed on buttocks. ROM was WNL (within normal limits) and resident did not hit head. Resident has c/o (complaint of) pain daily so resident was watched closely. Per Kardex resident is to be walking with staff and have a gait belt on. Staff walking with resident at the time was disciplined accordingly. Inservice was done with nursing staff that resident is to have gait belt on during any ambulation and not to be left unattended for any reason until resident is safely sitting or resting in bed. Resident was given her own gait belt, so she has one at all times. 4. The facility's document , All Falls for Facility dated 1/17/23 documents R34 had falls on 5/9/22, 10/2/22, and 11/24/22. R34's Face Sheet documents her diagnoses to include: Difficulty in Walking, Not Classified Elsewhere R34's MDS dated [DATE] documents R34 is severely cognitively impaired and she requires extensive assist from staff for transfers and toileting. R34's Care Plan dated 5/5/22 ( last reviewed 1/5/23) documents, Problem: I am at risk of additional falls due to a history of falling. No safety awareness due to dementia progression. No insight to my deficits. I have Alzheimer's with history of some behaviors. I might try to transfer myself and try to walk unassisted. I do not use the call light. I have wandered around on the secured unit before. I have deliberately sat myself on the floor at times. History of falls. R34's Fall Risk assessment dated [DATE] documents a score of 13. This document states a fall risk score of 10 or higher represents a high risk of falls. R34's Fall Event dated 11/24/22 at 6:07 PM documents, Resident is pleasantly confused with poor safety awareness and no insight to own deficits. Diagnoses include Alzheimer's, Schizoaffective Disorder, MDD (Major Depressive Disorder), and Generalized Anxiety. Resident takes psychotropic medications. At 1720 (5:20 PM) resident fell in restroom with CNA present. Resident was hesitant to ambulate, lost balance, shifted, and fell on to buttocks and hit back of head on bathtub. Small abrasion to back of head with no bleeding. No other injuries noted and ROM WNL. Resident did not get sent to ER (emergency room ) due to neuro checks WNL and no change in condition. Resident did not have a gait belt on while being transferred/assisted with ambulating. Education and in service given to staff that residents need gait belts while transferring and while being assisted with ambulation. R34's Care Plan documented a progressive care plan intervention following her fall on 11/24/22 as: Approach: Fall intervention 11/24/22; Education and in service given to staff that residents need gait belts while transferring and while being assisted with ambulation. On 1/20/23 10:00 AM, V1, Administrator, stated she would expect a gait belt to be used while transferring or walking any resident who is unsteady or needs assist. She stated she would expect staff to ensure a resident is safe before leaving that resident unattended to retrieve an adult diaper or any other needed items. The facility's policy, Gait Belt Policy and Procedure revised 5/21/19 documents, Policy: To protect the safety of residents requiring assist with transfer and to proactively participate in risk management initiative, it is the policy of the (facility) to require the use of gait belts by certified nursing personnel according to the following procedure: It continues, 4) Gait belts will be used during the transfer and/or ambulation of residents requiring assist unless contraindicated by the resident's diagnosis.

Based on interview and record review, the Facility failed to ensure continued assistance with ambulation to prevent resident injury for 1 of 4 residents (R1) reviewed for falls, in the sample of 4. This failure resulted in R1 sustaining a fractured femur from falling while unattended. Findings include: R1's Care Plan dated 5/27/2022 documents, I am at risk for falls due to dementia diagnosis, confusion, forgetfulness, severe impairment. I am up with assist using a walker or I use a wheelchair. I have tried to walk unassisted at times. R1's Minimum Data Set (MDS) dated [DATE] documents R1 required limited assistance for transfers and ambulation. R1's Care Plan dated 11/4/2022 documents, I am at risk for pain and have exhibited signs of pain related to left hip fracture. I am on hospice at this time. The Facility Reported Incident dated 11/2/2022 documents, Final Report on (R1) fall on 10/31/2022 and continues, On 10/31/2022 during shift change, approximately 1505 (3:05 PM) a CNA (Certified Nursing Assistant) was ambulating with (R1) with her w/w (wheeled walker) in the hallway towards her room. There was another resident who is known to be a high risk for falls in her w/c (wheelchair) wander about the hallway going in another room. The CNA saw her and tried to verbally redirect her without success. The CNA told (R1) to wait right here and left her standing by the rail in the hallway while she assisted the other resident out of a room and redirected her back to the common area. When the CNA turned around (R1) was falling backwards to the floor. The nurse was summoned and assessed her. (R1) was assisted up with gait belt and 2 assist to her seated walker. She was then assisted to her bed. She was rubbing her left leg and when asked about pain, she said it hurt. Upon assessment her left leg was noted to be swelling and turned outward. (R1) was sent to the ER (emergency room ) for evaluation and treatment. She was admitted to the hospital with a left femur fracture. (V4) was counseled to complete current ADL (Activities of Daily Living) with resident she was working with before assisting another resident. R1's X-ray Report dated 10/31/2022 documents, Findings: There is a comminuted (breaking of a bone into several small pieces and is the result of high velocity injuries, such as car accidents or falls from a height) intratrochanteric fracture of the proximal left hip with anterior displacement and varus deformity. R1's Care Plan dated 11/10/2022 documents, I have some difficulty comprehending things and understanding others related to my dementia progression. R1's Care Plan was updated on 11/10/2022 and documents, Now non-weight bearing left leg and on hospice. Intervention: Staff educated to stay with senior and complete ADL with that senior before trying to help another. R1's MDS dated [DATE] documents, Significant Change- Extensive assistance of two staff members for transfers. Ambulation- Activity did not occur. On 12/6/2022 at 1:30 PM, V4, Certified Nursing Assistant (CNA) stated, (R1) walked by herself with a walker and supervision. I was taking her from the dining room to the hall. I noticed another resident going into someone elses' room. I asked her (R1) to stay right there and told her I'd be right back. I went to get the other resident and I heard, 'Ahh!' and turned back around and she was already going down. I couldn't catch her. On 12/6/2022 at 2:00 PM, V6, Licensed Practical Nurse (LPN), stated R1 used to walk with a walker prior to her fall but now requires a mechanical lift. V6 stated R1 fractured her left femur (large bone in the upper leg), her family choose not to pursue surgery, and R1 was placed on hospice. On 12/7/2022 at 11:30 AM, V7, LPN, stated, (V4) was taking (R1) to the bathroom. She was walking down the hall with her walker. Another resident, who is very unsteady, starting standing and (V4) didn't want her to fall. (V4) was probably an arms length away but (R1) suddenly went down. (V4) just wasn't close enough to catch her. I assessed her. She said her leg hurt and I noticed it wasn't aligned right. We called 911 and sent her out. She had a femur fracture. Her family didn't want her to have surgery due to her age, so they decided on hospice care. On 12/7/2022 at 2:23 PM V3, Medical Director, stated, (R1) is demented (has impaired cognition). (R1) was told not to move (while the CNA helped another resident). (R1) was already declining but her decline was accelerated by the fall. On 12/8/2022 at 2:33 PM, V2, Director of Nursing (DON), stated, She (R1) shouldn't have been left alone for any amount of time. It's hard to tell if her fall could have been prevented since (R1) walked by herself. (V4) was trying to prevent another resident who is known for falling from falling. The Facility's Fall Prevention Policy and Procedure dated 3/1/2018 documents, Objective-Reduce the risk of resident falls and possibly injury.

Based on observation, interview and record review the facility failed to ensure food was stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 62 residents living in the facility. Findings include: On 11/30/21 at 9:24 AM during the kitchen tour, in the dry storage area, there was a large industrial box of chips sitting directly on the floor. On the shelf there was a package of opened spaghetti. Approximately a pound of spaghetti was still in the box and it was not covered, dated, or labeled and the spaghetti was exposed to the air. Near the doorway of the dry storage area was a large rack that contained 2 buckets with potatoes in them. Inside the container there were 3 potatoes rotten, peeling apart, discolored and they were surrounded by gnats. On 11/30/2021 at 9:28 AM, V5, Dietary Manager stated the potatoes on the shelf were for use and she would throw out the rotten potatoes. On 11/30/2021 at 9:38 AM inside the refrigerator, there was a movable tray and on the tray were shelves and there was a large industrial pan of a soup substance with no date or label on it. On another shelf was a large industrial pan of cut up tomatoes and cucumbers with no date or label on it. In the corner of the refrigerator was a crate with a dried substance on it the size of a softball, it was crusty looking in appearance. On the shelf there was a metal container of ham slices without any date or label. There were 4 containers of 5-pound packages of coffee with ice crystals stuck to the sides of it. There was a large industrial pan of roast beef with the date of 11/26/2021. There was no date to use by. On 11/30/2021 at 9:43 AM, in the freezer there was a large condensation of ice buildup on the ceiling and on the 2 fans. The fans were covered in dust, with dirt and solid think blocks of ice. The condensation was dripping onto 2 large industrial bags of onion rings and 1 large industrial bag of French fries. In the middle there was a solid ice block of ice and a large industrial box of lima beans, and a 36-pound box of chopped spinach with ice on top of the boxes. On 11/30/2021 at 9:47 AM, in the kitchen were 3 large industrial tubs, one was documented as having flour, one was documented as containing sugar, but the 3rd tub was not dated or labeled. On 11/30/2021 at 10:01 AM, V5 stated I expect all food to be labeled and dated. That tub not labeled has rice in it. The Food Safety Product Labeling and Dating Guidelines with a revision dated of 9/1/2021 document, Food that is required to be dated and marked must be discarded if it is in a container that does not bear a date or day. The Facility's Resident Census and Conditions of Residents form, CMS 672, dated 11/14/2021, documented the facility had a census of 62 residents.

Based on observation, interview and record review the Facility failed to follow Dietician Recommendations and follow the menu for 4 of 25 residents (R3, R44, R52 and R58) reviewed for diabetic diets/menus in the sample of 37. Findings include: On 11/30/2021 at 12:00 PM, during the lunch service the following food was being served; chicken and dumplings, peas, and a roll was being served to the following residents R3, R4, R52 and R58. R3's Physician Order Sheets (POS) dated November 2021 with a start date of 4/29/2021 document R3 has diagnoses of Type 2 diabetes with diabetic [CONDITION(S)] unspecified (4/29/2021). The POS also document R3 is taking [MEDICATION(S)] NPH U-100 insulin 28 units once a day. [MEDICATION(S)] sliding scale, blood sugar less than 60 milligrams per deciliter call the physician, blood 151-200 give 5 units, blood sugar 201-250 give 10 units and blood sugar 251-300 give 15 units, 301-350 give 20 units, blood sugar 351-400 give 25 units, if blood sugar greater than 400 give 30 units, if blood sugar is greater than 400 call the MD (Medical Doctor). Check blood sugar 3 times a day 8:30 AM, 12:30 PM and 5:00 PM. R3's POS also documents a diet of Controlled Carbohydrate Diet (CCD). R44's POS dated November 2021 with a start date 1/5/2021, documented R44's diagnoses of type 2 diabetes without complications. R44's POS documents R44 receives [MEDICATION(S)] 2 mg once a day form type diabetes without complications, [MEDICATION(S)] 500 mg once a day, sliding scale of NovoLog flex pen, if blood sugar is less than 50 mg call the MD (medical doctor) 151-200 give 3 units, 201-250 give 6 units, 251-300 give 9 units, 301-350 give 12 units, 351-400 give 15 units, greater than 400 units give 20 units and call the MD. Check before meals and at bedtime. R44's POS also documents a diet of Controlled Carbohydrate Diet (CCD). R52's POS dated November 2021 with a start dated of 4/19/2021 documents a diagnosis of Type 2 diabetes mellitus with other specified complication. R52's POS also documents she is to take 500 milligrams (MG) of [MEDICATION(S)], [MEDICATION(S)] U insulin solution 100 unit/milliliters 15 units give subcutaneous. R52's POS also documents a diet of Regular with yogurt at breakfast and lunch. R58s POS dated November 2021 with a start date of 11/9/2021 documents a diagnosis of type 2 diabetes with other skin ulcer. R58's POS document she is taking 500 mg of [MEDICATION(S)] twice a day for type 2 diabetes with diabetic [CONDITION(S)] unspecified. R59s' diet was CCD for type 2 diabetes with diabetic [CONDITION(S)]. The facility provided a list of residents that were on diabetic diets and the following residents were documented; R3, R44, R52 and R58. The Lunch Menu dated 11/30/2021 documents chicken breast stew with dumplings, ice cream, milk, skim, side salad, garden, cherry tomatoes, soup, cream of mushroom, squash yellow and zucchini roasted with balsamic julienne that was crossed out and replaced with peas. There was no roll documented for the lunch menu on 11/30/2021. On 12/2/21 at 11:18 AM, V18, Dietitian stated I would expect all staff to follow the menu. If staff needs to make changes, I do not expect them to notify me. I was not notified that peas was substituted for the zucchini. I would not expect peas to be substituted for zucchini because of the starch. (V5) is a certified dietary manager and has the knowledge to make changes. She does not notify me, but she calls me with her questions, as needed. The dumplings, peas and roll were not appropriate for residents with diabetes, and it does have the potential to raise their blood sugar. Resident Council Meeting Minutes dated June 23, 2021 document, Many times (2 out of 5 meals per the residents) state that the meal served is different than what is on the menu. A few residents said if they get what is on the menu it is a surprise. The Diet Order Policy and Procedure with a revision dated of 2/5/2020 document, To ensure all residents receive a well-balanced nutritional meal that coincides with physician orders. All resident meals shall be prepared and served following the specific written diet order of the attending physician. The diet will be reviewed quarterly and as needed by the registered dietician.

A. Based on observation, interview and record review the Facility failed to ensure all staff were following Center for Disease Control and Prevention (CDC) guidelines for wearing the proper Personal Protective Equipment (PPE), for the prevention of COVID-19. This has the potential to affect all 62 residents living in the Facility. Finding include: 1. On 11/30/2021 at 11:30 AM to 12:30 PM, V7, Dietary Aide was serving the lunch menu to all residents from the kitchen to the dining room and was not wearing a mask to cover his nose. The mask was pulled down. V7 served the entire lunch menu without covering his nose. On 11/30/2021 at 12:30 PM, V5, Dietary Manger stated, I expect staff to have their mouth and noses covered with their mask while they are serving residents food. On 11/30/2021 at 11/30/21 12:32 PM while feeding residents V6, Certified Nursing Assistant was in the dining room assisting with feeding residents and had a mask on, but it was not covering her nose. On 12/3/2021 at 2:09 PM, V4, Infection Control Specialist (ICP) stated, I would expect all staff when working the floor to follow CDC guidelines and have their mouth and nose covered. The Facility's Infection Control Policy with a revision date of 12/24/2019 document, To ensure the prevention of the transmission of infectious or communicable diseases with the (Facility) services will be provided in a manner which conforms to CDC guidelines. The Center of Disease Control and Prevention Policy provided by the V4, updated on 3/17/21 and 4/1/2021 document, Wear a mask that covers your nose and mouth to help protect yourself and others. Wear a mask over your nose and mouth to help prevent getting and spreading COVID-19. The Facility's Resident Census and Conditions of Residents form, CMS 672, dated 11/14/2021 documented the facility had a census of 62 residents. B. Based on interview and record review the facility failed to adequately develop an ongoing infection control program that adequately collects data to calculate and analyze infection rates and failed to operationalize infection control policies to adequately define infection control practice in the facility. This has the potential to affect all 62 residents living in the facility. Findings Include: 1.R39's Progress Notes dated 10/28/2021 at 6:57 AM, documents (R39) started on [MEDICATION(S)] on 10/26/2021. R39's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This Urinary Tract Infection ([CONDITION(S)]) for R39 was not documented on the log. On 12/2/2021 at 10:00 AM a Culture and Sensitivity Report for R39 for a [CONDITION(S)] on 10/26/2021 was requested. R39's electronic medical records does not document a Culture and Sensitivity was completed for R39 for causative organism for R39's [CONDITION(S)] on 10/26/2021. The facility's Infection Control Log for 10/2021 and 11/2021 did not document R39 as having a [CONDITION(S)]. 2. The Facility's Infection Control log documents R111 had a [CONDITION(S)] beginning on 6/14/21. The Log does not document the causative organism of R111's [CONDITION(S)]. The Infection Control Log documented, On hospice treating symptoms of [CONDITION(S)]. On 12/2/2021 at 10:00 AM a Culture and Sensitivity Report for R111 for a [CONDITION(S)] on 6/14/2021 was requested. R111's electronic medical records do not document a Culture and Sensitivity was completed for R111 for 6/14/2021 for a [CONDITION(S)]. 3. The Facility's Infection Control Log documents R59 had a [CONDITION(S)] beginning on 8/31/2021. The Log did not document a causative organism for R59's [CONDITION(S)]. The Infection Control Log documented, red blood cells and white blood cells. On 12/2/2021 at 10:00 AM a Culture and Sensitivity Report for R59 for a [CONDITION(S)] on 8/31/2021 was requested. R59's electronic medical records do not document a Culture and Sensitivity was completed for R50 for 8/31/2021 for a [CONDITION(S)]. 4. The Facility's Infection Control Log documented R27 had a [CONDITION(S)] beginning on 2/15/2021. The Log did not document a causative organism for R27's [CONDITION(S)]. On 12/2/2021 at 10:00 AM a Culture and Sensitivity Report for R27 for a [CONDITION(S)] on 2/15/2021 was requested. R27's electronic medical records do not document a Culture and Sensitivity was completed for R27 for 2/15/2021 for a [CONDITION(S)]. On 12/3/2021 at 2:25 PM, V4, Infection Control Preventions stated, I am new to this position and some of those holes were from the previous staff member doing this job. I know I have a lot to do to keep up with everything happening in the building. The Facility's Infection Control Policy with a revision date of 12/24/2019 document, To ensure the prevention of the transmission of infectious or communicable diseases with the (Facility) services will be provided in a manner which conforms to CDC guidelines. C. Based on observation, interview and record review the Facility failed to perform hand hygiene during a dressing change for 1 of 5 residents (R58) reviewed for infection control in the sample of 37. Finding includes: On 11/30/2021 at 11:30 AM R58 was in his wheelchair being taken to therapy. V16, Licensed Practical Nurse (LPN) was standing at medication cart. When R58 came up to the medication cart he had no wrappings on legs. V16 applied bandage to R58's right leg, without donning or wearing any gloves during the dressing change. R58's Face Sheet documents he was admitted to the facility on [DATE]. R58's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Bandage instructions as follows, Cleanse open areas to left calf and shin with wound cleanser then apply silver alginate and cover with foam daily and as needed. R58's Care Plan updated 11/1/2021 documents R58 at high risk for infection. R58's Minimum Data Set (MDS) updated 11/5/2021 document R58 was cognitively alert for decision of daily living. On 12/2/2021 at 1:37 PM, V2, Director of Nursing (DON) stated, I expect staff to wear gloves and wash their hands during dressing changes. On 12/3/2021 at 8:30 AM R58 stated The nurses usually wear gloves when changing my dressings, but not always. The Infection Control Policy, undated, states Employees will use hand hygiene before and after any activity involving themselves or the resident. Proper hand hygiene techniques shall be followed. Plastic gloves will be worn whenever coming into contact with body fluids: especially blood fluids. Wear gloves when touching blood, body fluids, secretions, excretions, and contaminated items. Put on clean gloves before touching mucous membranes and non-intact skin.

Based on interview and record review the facility failed to implement procedures to ensure antibiotics prescribed are appropriate to treat infections for 3 of 7 residents (R27, R39 and R59) reviewed for antibiotic stewardship in the sample of 37. Findings include: 1.The Facility's Infection Control Log documented on 9/30/21, R39 had a [CONDITION(S)]. There was no causative organism listed for R39's [CONDITION(S)]. R39's Progress Notes dated 10/28/2021 at 6:57 AM, (R39) started on [MEDICATION(S)] on 10/26/2021. R39's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Facility's Infection Control Log for October 2021 and November 2021 had no documentation regarding R39's [CONDITION(S)]. R39's Care Plan dated 11/2/2021 documents, I have a urinary tract infection, I am on an antibiotic for it. Give [MEDICATION(S)] as ordered until 12/13/2021 per urologist orders. Monitor my conditions. Encourage fluids, Good peri care every shift and PRN (as needed). R39's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R39's November 2021 POS documented 11/18/2021- 12/13/2021 [MEDICATION(S)]. R39's Progress Notes dated 11/11/2021 at 4:18 PM, On long term [MEDICATION(S)] for urinary tract infection, history of incontinence of urine. R39's Progress Notes dated 11/8/2021, at 3:59 PM, document, Continues long term [MEDICATION(S)] for urinary tract infection history. R39's Progress Notes dated 11/6/2021 at 8:08 AM, Continues long term use of antibiotic for urinary tract infection. R39's Progress Notes dated 11/5/2021 at 7:30 AM, Continues long term antibiotic for urinary tract infection. On 12/2/2021 at 10:00 AM, the surveyor requested a Culture and Sensitivity Report regarding R39's [CONDITION(S)], which was identified on 10/26/2021. There was no documentation in R39's medical record that a Culture and Sensitivity was obtained to determine if the prescribed antibiotic was effective in treating R39's [CONDITION(S)]. 2. The Facility's Infection Control Log documented R59 had a [CONDITION(S)] on 8/31/21. The Log did not document the causative organism of R59's [CONDITION(S)]. The Infection Control Log documented, red blood cells and white blood cells. R59's POS dated August 2021 documents, Ceflexin [sic] start date 9/1/2021 250 mg every 12 hours for 5 days, 10 doses for [CONDITION(S)]. R59's September 2021 POS document [MEDICATION(S)] 250 mg x 5 days, Urinary tract infection. R59's Progress Notes dated 9/1/2021 at 9:30 PM, First dose of [MEDICATION(S)] 250 mg given this evening. R59's Progress Notes dated 9/5/ at 9:46 PM, ABT (antibiotic) continues. R59's Progress Notes dated 9/4/2021 at 2:49 PM, Resident continues ABT ([MEDICATION(S)]) continues for [CONDITION(S)]. R59's Progress Notes dated 9/3/2021 at 3:24 PM, documents R59 was on antibiotic for [CONDITION(S)]. R59's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/2/2021 at 10:00 AM, the surveyor requested if a Culture and Sensitivity was obtained for R59's [CONDITION(S)] which identified on 8/31/21. The Facility had no documentation a Culture and Sensitivity was completed to determine if the antibiotic prescribed for R59's [CONDITION(S)] was effective. 3. The Facility's Infection Control Log, documented R27 had a [CONDITION(S)] on 2/15/21. The Log did not document a causative organism of R27's [CONDITION(S)]. R27's Nurse's Notes dated 2/14/2021 at 7:35 PM, Resident noted to have urinary tract infection and new order received and noted for [MEDICATION(S)] 500 mg every 12 hours for 10 days. R27's POS dated February 2021 documents 2/15/2021 to 2/24/2021 [MEDICATION(S)] 500 mg, x 10 days for [CONDITION(S)], every 12 hours. R27's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R27 received all of the medication. On 12/2/2021 at 10:00 AM, the surveyor requested a Culture and Sensitivity for R27's [CONDITION(S)] which was identified on 2/14/21. There was no documentation in R27's medical record that a Culture and Sensitivity was completed to determine if the antibiotic prescribed was effective in treating R27's [CONDITION(S)]. On 12/2/2021 at 10:03 AM, V4 Infection Control Preventionist stated there was no Culture and Sensitivity Report completed for R111 because hospice does not require it or do them. V4 stated I do not have any Culture and Sensitivity Reports for (R27), (R39), (R59) or (R111). On 12/2/2021 at 2:35 PM V4 was asked why the pathogens were not identified on the infection control monitoring form. V4 stated The hospital did not send any culture and sensitivity reports. I look through the hospital reports sent with the residents once they have returned. When asked how V4 would know what organism/pathogen was identified to ensure appropriate treatment was being provided and to ensure no isolation is warranted, V4 stated I don't know, the hospital calls and gives report before the residents return and they notify us then if any precautions are required. The antibiotic Stewardship Program with a revision date of 09/2018 document, (Facility) is committed to protect patients and reduce the threat of antibiotic resistance. (Facility) center mission statement for antibiotic use, 'to provide the best Antimicrobial therapy to elders that results in the best outcome with the least amount of adverse effects.' We are committed to Antibiotic Stewardship which refers to an asset of commitment and actions designed to optimize the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . (Facility) will incorporate all seven core elements which are necessary for implementing a successful antibiotic stewardship program.

Based on interview and record review, the Facility failed to prevent the diversion of resident's medication by an employee for 1 of 5 residents (R2) reviewed for misappropriation of property in the sample of 5. Finding includes: The Facility's Investigation Report dated 7/14/21 documents, Executive Director and D.O.N. (Director of Nursing) interviewed employee (V5, Licensed Practical Nurse) on Wednesday July 14th, 2021. Executive Director explained to (V5) that an Internal Security Investigator with the Illinois State Police (ISP) was looking at narcotic sheets in the facility. Explained to (V5) that some of her signatures looked suspicious. Explained to (V5) that a resident agreed to have his urine tested to see if opiates were in his urine as she signed out that she gave him the medication the night before. Explained to (V5) that the resident's urine toxicology report came back and did not have any opiates in his urine and that it should have if resident received his medication as charted by her. Executive Director asked (V5) how that could be possible if she administrated the medication as she charted it. (V5) became very quiet and lowered her head. (V5) looked at DON and then the Executive Director and did not answer the question. DON and Executive Director explained to (V5) that it is best to be honest. (V5) was still crying and shook her head 'yes'. (V5) stated that she did take some of his medications. (V5) was asked what medications she was referencing. (V5) stated 'Oxycodone'. (V5) stated she did not take all the ones that she signed out. The Facility's Untitled document, dated 7/14/21, documents, To whom it may concern, I, (V5) am writing this statement to inform of my decision of taking narcotic medication from my job at (Facility) of (Town) and using it for my personal use. I'm truly sorry for my decision and apologize for doing so. I am requesting help to stop relying on narcotics so I can continue my [MEDICATION(S)] of taking care of people. Respectfully, (V5). On 7/21/21 at 1:00 PM, V1, Administrator, stated that an Investigator came to the facility to complete a random narcotic audit and became suspicious of V5 signing out pain medication frequently. V1 stated that R2 consented to having a urine specimen obtained. V1 stated that the urine results came back without the opiate detected, meaning he had not taken it within the 24 hours of the specimen being obtained. V1 stated that they could only prove that one of R2's pills was diverted. V1 stated she is referring to the dose documented on R2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . V1 stated that R2's urine was obtained on 5/4/21. V1 stated that there was a long delay getting the results from the State Laboratory. V1 stated that when she received the results, V5 was questioned about the medication and admitted to taking it. The Facility's Abuse Identification, Prevention and Reporting Policy and Procedure dated 12/4/2020, documents, PURPOSE: To outline guidelines for the prevention of resident abuse and measures to be taken in the event any kind of resident abuse is suspected or identified. POLICY: All residents have the right to be free from abuse and corporal punishment by anyone, including, but not limited to facility staff, other residents, consultants, volunteers, staff of other agencies, family members, friends or other individuals. The Policy and Procedure documents Misappropriation of Resident Property- Misuse or loss of resident personal items other than through action of the resident, theft of money or other valuables, carelessness in handling, breakable items, eating resident's candy or other food items without the resident's invitation, showing disrespect for resident's clothing or other possessions.

Based on observation, interview, and record review, the facility failed to perform proper hand hygiene on a COVID-19 positive unit to prevent the spread of COVID-19 infection for 1 of 12 residents ( R2) reviewed for infection control in the sample of 12. Findings include: Throughout this survey, R2 resided on the COVID-19 unit. R2's Care Plan, dated 5/17/2020, documents, I have tested positive for COVID 19. Monitor me for signs and symptoms of COVID 19. Document and promptly report signs and symptoms: fever, cough, sneezing, sore throat, respiratory issues. Educate senior, family, visitors of COVID 19 signs, symptoms and precautions. Isolation precautions per facility/Illinois Department of Public Health protocols. On 5/26/2020 at 11:10 AM, V5, Certified Nursing Assistant (CNA), exited R2's room after performing care. V5 removed her gown in the hallway. V5 removed the lid to the biohazard barrel, placed the gown inside the biohazard barrel and placed the lid back on the biohazard barrel with ungloved hands. V5 walked past the alcohol-based hand rub sanitizer dispenser, touched the door bar opening the door and left the unit without performing hand hygiene. On 5/26/2020 at 11:28 AM, V2, Director of Nursing, stated, Absolutely, I would expect the staff to perform hand hygiene prior to leaving the unit. On 5/26/2020 at 11:36 AM, V7, CNA, stated, When entering the unit, you spray down, dress in gown gloves and eyewear. Go inside, wash your hands in room [ROOM NUMBER] and apply gloves. When leaving the hall, you remove the gown. Put it (gown) in the biohazard barrel then go to room [ROOM NUMBER] and wash your hands. You can also use the alcohol-based hand rub sanitizer dispenser before going off the hall. You are to clean your hands before leaving the hall. The Facility's COVID 19 Policy and Procedures, dated 3/12/2020 and updated 5/2020, documents, Infection Control: Follow hand hygiene protocol. It also documents, Objective: Contact Precautions will be used for residents known or suspected to be infected with epidemiologically important microorganisms that can be transmitted by direct contact with the resident or indirect contact with contaminated environmental surfaces or resident-care items.

Based on interview, observation, and record review, the facility failed to wash hands before donning gloves, after removing gloves, when gloves are soiled, and when using serving utensils during the noon meal. This has the potential to affect 82 resident living in the facility. Findings include: On 1/28/2020 at 11:45 AM, V24, Cook, started to serve the noon meal from the steam table. V24 grabbed a hamburger bun with her gloved hand and served the ziti on top of a bun then patted the burger top down with her hand. V24 then rubbed her cheek with her gloved hand. With the same gloves, V24 served 3 meals by grabbing the garlic bread with her gloved hand and placing it on the plate. V24 then left the steam table and got tongs to use for the garlic bread. V24 then resumed serving the meal. V24 then removed her gloves and did not perform hand hygiene. At 12:05 PM, V24 rubbed her eye with her gloved hand and resumed serving the meal. V24 removed her gloves and did not perform hand hygiene. V24 donned new gloves, rubbed her cheek and began serving the meal. On 1/30/2020 at 9:00 AM, V23, Dietary Manager, stated, The staff should be washing their hands before putting on gloves and upon removal. The staff should be changing gloves when soiled. The staff should not be using gloved hands to grab the bread. The facility policy and procedure Hand Hygiene, undated, documents, Times to perform hand hygiene: Before and after preparing food. Before and after eating or handling food. Before putting on gloves and after removing gloves. The Resident Census and Conditions of Residents, CMS 672, dated 1/27/2020, documents that the facility has 82 residents living in the facility.

Based on observation, interview and record review, the facility failed to ensure residents to be free from accidents, injuries and to prevent falls with injuries, for 2 of 2 residents, (R2 and R3) reviewed for falls in the sample of 6. This failure resulted in R2 falling forward from wheelchair without being assessed for wheelchair foot pedals, sustaining a laceration to the forehead requiring emergency room , (ER), care and 20 stitches. R3 sustaining a rib fracture from a fall. Findings include: 1.R2's Fall Report, dated 12/17/19 at 11:10 AM, documents, R2 located in the hallway, sitting in wheelchair. The report further documented, R2 has poor short-term memory loss, poor safety awareness, and requires extensive assistance for all ADL's (Activity of Daily Living), uses a wheelchair for mobility. The Progress Note, dated 12/17/19 at 11:15 AM, documented by V4, LPN, (Licensed Practical Nurse), documented, R2 stated, she wanted to have a bowel movement, after repeatedly yelling Help to nursing passerby. At 11:10 AM, (V4) was pushing (R2) to room, (R2) put feet down and fell forward out of her wheelchair to the floor, (R2) has visual impairment and did not put arms or hands to block fall. R2 sustained a laceration to right side of forehead and was sent out per EMS, (Emergency Medical Service), to ER and received 20 stitches. The Fall Report Evaluation Notes, documented, R2's [DIAGNOSES REDACTED]. R2's emergency room Report, dated 12/17/19 at 12:04 PM, documented, R2 with a large laceration to forehead as a result of R2 falling out of her wheelchair while being pushed down hallway. The Physicians exam documented a 7 cm, (centimeters) laceration to forehead resulting in 3 stitches to the subcutaneous layer, (tissue beneath the skin), and 17 stitches at the skin level, a total of 20 stitches. R2's Minimum Data Set (MDS), dated [DATE], documented severely impaired cognition, short term memory problems, requires extensive assistance from staff with all ADL's, including transfers. R2's balance during transitions and walking documented, not steady, requires staff assistance, including Surface-to-Surface transfer with wheelchair and impairment on one side of lower extremity that places resident at risk of injury. R2's Care Plan, dated 11/22/19, documents R2 at risk for falling related to history of falls with an old right ankle fracture, weight bearing as tolerated to right ankle, although R2 does not tolerate weight bearing well. Also, requires Passive Range of Motion to all extremities 5-7 day per week to maintain her Range of Motion. Also, documents R2's fall incident of 12/17/19, that R2's had no attempts to protect self during fall. R2's Fall Risk Assessment, dated 11/22/19, documented, intermittent confusion, poor recall, judgment, safety awareness, legally blind requires use of wheelchair device, impaired hearing and vision representing a score of 19, indicating high risk for falls. On 01/08/20 at 1:12 PM, R2 had two wheelchair foot pedals lying on the floor of R2's closet. On 01/08/20 at 2:25 PM, V4 stated, if R2 would have had the foot pedals on her wheelchair, she would have never fallen from her wheelchair during transfer. On 01/08/20 at 2:10 PM, V3, CNA, (Certified Nurse Assistant), stated, R2 could sometimes move feet while in wheelchair. Usually transported by staff and unsure if R2 had wheelchair foot pedals. On 01/08/20 at 3:00 PM, V5, CNA stated, R2 could not propel self, and always needed pushed in her wheelchair by staff. On 01/08/20 at 3:20 PM, V6, CNA stated, R2 could not propel self when in her wheelchair. Required staff to transfer her and V6 did not recall R2 using foot pedals. On 01/13/20 at 2:00 PM, V8, Physical Therapy, (PT), stated, with R2's assessment, she would have benefited with the use of wheelchair pedals regarding her contributing medical conditions; right side lower leg immobility, severely cognitively impaired, impaired hearing loss and unable to propel self in wheelchair. On 01/13/20 at 3:45 PM, V2, Director of Nursing, (DON), stated, if foot pedals placed on R2's wheelchair or not. R2's foot still could have slipped down, and R2 still could have fallen. On 01/13/20 at 4:05 PM, V9, Physician stated, he would have expected, R2 to be assessed for foot pedals, this could have helped and possible prevent R2 from falling forward from the wheelchair. 2. R3's Fall Scene Investigation Report, dated 11/09/20 (error, year to be 2019), at 5:50 PM, documented, unwitnessed fall found on the floor in resident's room, attempting to self-transfer and was alone an unattended. Investigation Report continues to document, contributing factors; alert with confusion, forgetful, foot ware used at time of fall, checked as bare feet, bed alarm used at the time of fall, checked as No. R3's Fall Event Report, dated 11/09/19 at 5:50 PM, documented non-ambulatory, found on floor at bedside. Complaints of pain in rib area, and X-ray was obtained. R3's Radiology report, dated 11/09/19 at 9:46 PM, documented R3 sustained an anterior (front) lateral (side) right sixth rib fracture. R3's Fall Risk Assessment, dated 08/19/19, documented, intermittent confusion, poor recall, judgment, safety awareness, balance problems while standing, decreased muscular coordination, requires use of wheelchair, impaired mobility, history of falls evaluated as a score of 17, indicating high risk for falls. R3's MDS, dated [DATE], documents R3, was severely impaired memory cognition and assistance of one staff with all ADL's. The use of a wheelchair for mobility and not steady with balance during transitions and walking, requiring staff assistance. R3's Care Plan, date range of 08/19/19 through 01/09/2020, documented, multiple falls, related to dementia progression with decreased safety awareness that occurred on; 08/30/17, 07/04/18, 08/19/18, 09/20/18, 02/03/19, 02/14/19, 05/11/19, 06/14/19 and 11/19/19, all in relation to self-transfer from wheelchair. R3's Physician order [REDACTED]. On 01/13/20 at 3:55 PM, V2, DON, could not comment how to ensure R3's safety from falls. However, V2 did state that the CNA's electronic charting is located by R3's room and staff could, visual check on R3 more often, but that's if the CNA's are charting. Also, V2 stated, evening meals are served at 6:00 PM and staff probably were getting residents ready to send to dining room. On 01/13/20 at 4:05 PM, V9, Physician stated, if R3 was provided extra supervision, this could lessen R3's fall occurrence and lessen the chance of injury. The Facility's Policy and Procedure, entitled, Fall Prevention Program, dated 03/01/18, documents, incorporate fall risk prevention interventions within the resident's Plan of Care, reduce the risk of resident falls and possible injury and to include; The Restorative Nurse, MDS Coordinators, or the Nurse Facilitator shall reassess each resident quarterly and who demonstrates deterioration in health.

Based on observation, interview and record review, the facility failed to provide dependent residents with timely assessments, treatments, turning and repositioning and monitoring skin conditions for any newly developed pressure ulcers for 2 of 5 residents (R1, R4) reviewed for pressure ulcers in the sample of 10. This failure resulted in R1 developing three new unstageable and one stage II pressure ulcers that had not been identified by the facility; and R4 developing three, stage II and one unstageable pressure ulcers that had not been identified by the facility. Findings include: 1. On 05/03/19 at 9:55 AM to 12:10 PM in 15 to 20-minute intervals, R4 was observed sitting up in a wheelchair in her room sleeping. At 12:10 PM, V17, Certified Nurse's Assistant (CNA) was observed to go into R4's room and take her to the dining room. V17 stated R4 had been up in wheelchair since before breakfast, approximately 8:00 AM. On 05/07/19, R4 assessed by the Specialized Wound Management (SWM) nurse with no new orders. On 05/09/19 at 11:55 AM, V10, Licensed Practical Nurse (LPN) was observed during pressure ulcer treatments for R4. R4 had just been transferred from the wheelchair to bed via mechanical lift. The pressure ulcer to the left heel (previously unstageable) was observed to be healed. He then cleansed the left heel with wound cleanser and applied skin prep to the entire heel without a dressing. When asked to view the right heel, V10 stated, there's nothing there. R4's right heel was observed and a small (pea sized), circular brown area was identified. V10 stated, he had not known or seen this area before. V10 stated, the area would be considered unstageable since it was brown and covered. No treatment was done for the right heel. When R4 was turned to the left side for skin check, she stated oh, please be careful, that hurts so bad. V10 asked her what hurt, and she stated, my butt. R4 was observed to have a urinary catheter in place draining clear yellow urine. R4's buttocks were observed, and three 2 x 2 cm open areas were identified. V10 stated he was not aware of these open areas and that the SWM nurse saw her on Tuesday (05/07/19). R4's incontinent brief was saturated with bloody yellow drainage. The open areas were surrounded by a large area of excoriation. V10 cleansed with wound cleanser and 4 x 4 gauze to dry, then applied [MEDICATION NAME] cream (barrier cream) to the entire area. During this time, R4 was wincing and stated, that it really hurt. V10 then rolled R4 to her back with the soiled incontinent brief and no dressing. V10 stated, R4 had been up in the wheelchair since before breakfast, approximately 8:00 AM. R4 stated, she had not been toileted or repositioned since before breakfast and that her bottom really hurts. The physician's orders [REDACTED]. On 04/26/19, a POS documented R4's pressure ulcer treatments as skin prep to bilateral heels twice daily. Waffle boots, bilateral feet and float heels in bed. The Minimum Data Sheet (MDS), dated [DATE], documented R4 had a score of 12 Brief Interview for Mental Status (MDS) and required total assist of two staff for transfers and toileting; and extensive assist of two for bed mobility, dressing and hygiene. It documented R4 has a urinary catheter but, was always incontinent of bowel. The care plan, dated 05/07/19, documented R4 had a urinary catheter for constant incontinence caused open areas to the bottom. On 04/26/19, a nurse's admission note documented R4 had a non-blanchable Deep Tissue Injury (DTI) to the left heel. On 04/27/19, an admission body observation note documented R4 had only one pressure ulcer to the left heel. On 05/01/19, an Eden Pressure Ulcer Risk Assessment documented R4 was at high risk for developing pressure ulcers with a score of 33. On 05/07/19, a SWM nurse note documented R4 had bilateral buttock excoriation complicated by incontinence. There was no documentation R4 had open areas to her bottom. On 05/09/19, a nurse's note documented R4 was seen by the Physician with no new orders. There were no nurse's notes documenting any treatment rendered for the open areas on her buttocks. On 04/30/19, the Weekly Pressure Ulcer Report documented, R4 had three open areas on her bilateral buttocks, two on the right buttock measuring 0.5 x 0.5 cm each and one on the left buttock measuring 1.3 cm x 0.5 cm. There were no descriptions, status or treatment documented. As of 05/10/19 2:00 PM, there were no new orders on the POS. On 05/10/18 at 12:00 PM, V2, Director of Nursing (DON) was informed of R4's open areas and stated the barrier cream used was for open areas as well as excoriated areas. 2. The POS for R1 documents diagnosis, as Pressure Ulcer of Right Hip, History of Pressure Ulcer of Sacral Region, Urinary Tract Infection [MEDICAL CONDITION], Contracture of Extremities, [MEDICAL CONDITIONS] Resistant Staphylococcus (MRSA), Indwelling Urinary Catheter, and Gastrostomy Tube. The MDS, dated [DATE] documents R1 was unable to complete the BIMS test and is moderately impaired with cognition. The MDS documents, R1 requires extensive assistance with personal hygiene and bed mobility and at risk for skin breakdown. On 5/03/2019 at 10:45 AM, R1 was in bed on the left side. A contact isolation sign was posted on the door. R1 had an indwelling urinary catheter and a mechanical feeding pump attached to a gastrostomy tube. At that time, V26, CNA reported R1 [MEDICAL CONDITION] in his urine. There was a dressing to the right shin and the right hip. R1's lower extremities were contracted into a fetal position. A pillow was between his legs. R1's feet were resting directly on the mattress. R1 had oxygen being delivered via a nasal cannula, with padding around tubing near ears. R1 was alert and could make his needs known. On 5/03/2019 at 11:20 AM, V26 and V27, CNA's weighed R1 using a mechanical lift. R1's weight was 159 pounds, after R1's weight was obtained, he was positioned on his right side. On 5/03/2019, R1 remained positioned on his right side at 12:00 PM, 12:30 PM, 1:30 PM, 2:00 PM, 2:45 PM, 3:30 PM, 4:05 PM, 4:15 PM and 4:30 PM. His feet remained directly on the mattress each time. R1's Admission Body Assessment, dated 4/22/2019, documents he was readmitted from the hospital with open area to the right shin measuring 0.5 cm X 0.5 cm. The Assessment documented R1's weight as 144.5 pounds on readmission. A Progress Note dated 4/30/2019 from a Special Wound Consultant, V29, Nurse Practitioner (NP) documents, R1 was being seen for pressure ulcers of bilateral ears and right hip, left ear onset 4/08/2019-healed. Right hip pressure injury onset date of 4/22/2019, measures 0.5 X 0.5 X 0.2 cm. R1's Progress Notes, dated 5/08/2019 at 9:50 AM, documents, has 2 new blisters to right upper inner thigh, 1. 1/4 cm X 1 cm, 2. 0.8 X 1.3 cm, both blisters intact and fluid filled, sheared place noted on right lower abdomen where noted that resident leans due to contractures and across from blisters on thigh area 1.0 X 1.2 X 1.0 cm, also, sheared area noted to left inner knee 0.8 X 0.5 cm X 0.1. Nurse notified of new areas and orders received. On 5/09/2019 at 10:00 AM, R1 was on his right side. A pillow was partially between R1's knees. His feet were directly on the mattress. There was a dressing to the right medial leg dated 5/08/2019. At that time, V14, LPN applied a skin preparation wipe to R1's right inner thigh, where a dark scabbed, unstageable area remained. V14 reported R1 is turned and repositioned every 2 hours. On 5/09/2019 at 10:35 AM, V14 was asked why R1 had no pressure relief for his feet, V14 replied, I don't know. That's a good point. R1's legs were contracted inward as well as upward. On 5/09/2019 at 11:05 AM, V22, CNA reported they were going to get R1 up into a wheelchair because the facility was getting him a new mattress. V22 applied foam heel protectors t R1's feet at that time. V22 also reported R1 is turned from side to side every 2 hours. As V22 began to apply the heel protectors, a small blister was seen to the outside of the fifth toe of the right foot where it rested on the mattress. There was also a Stage II open area between toes 4 and 5 of right foot where these toes overlapped because of resting on the mattress as well. On 5/09/2019 at 8:55 AM, 9:45 AM and 10:00 AM, R1 remained on his right side with his feet directly on the mattress, with no pressure relieving interventions in place. The Progress Note written by V14, dated 5/09/2019, at 11:44 AM, documents, in part, During care it was noted that resident has 0.5 X 1.0 cm blister to outer aspect of (Right) little toe. Blister closed. There was no documentation related to the open area between the toes 4 and 5 to the right foot. There was no PO to address this area as well. On 5/09/2019 at 1:55 PM, V14 reported she put antibiotic ointment and a dressing to R1's open area between his fourth and fifth toe to the right foot. V14 then removed the heel protector to reveal the dressing to that area. V14 reported the area between the toes is a Stage II pressure ulcer. V14 reported R1 would be receiving a low air loss mattress that day to assist with pressure relief. R1's Care Plan, dated as revised 4/30/2019, documents, in part, I am at risk for skin breakdown. I am quadriplegic from old MVA (motor vehicle accident). Contracture of legs and arms. Evidence of old healed areas on hips, sacrum. Approaches include: Assess any potential pressure ulcers for location, stage, size. Keep bony prominences from direct contact with one another with pillows, folded towels, et cetera. Assist with repositioning every 2 hours and PRN (as needed). Keep pillow or folded towel between contracted knees/legs to reduce pressure. The facility's policy and procedure undated and entitled, Pressure Ulcer Prevention and Treatment Protocol documents, in part, Objective to provide nursing standards for accurate assessment, prevention, treatment and implementation of protocols, including documentation to help manage residents at any level of risk for skin breakdown. To cleanse, inspect, and protect all residents' skin. Skin checks are completed by CNAs during daily care and on shower days. Any areas of concern will be reported to the nurses. On shower days the status of the resident's skin will be reported to the nurse via the shower sheet. Moderate and high-risk Protocol: Mattress with pressure reducing/relieving properties (e.g. ((for example)) pressure redistribution mattress) may be placed on resident's bed. Turning/positioning will be provided as necessary.

Based on observation, record review and interview the facility failed to implement safety measures and or progressive fall interventions for 3 of 5 residents (R36, R9, and R29) reviewed for fall in the sample of 36. This failure resulted in R36 falling and being sent to the hospital for head trauma and a wound to the left side of her forehead requiring steri strips. Findings Include: R36's Electronic Health Record (EHR) [DIAGNOSES REDACTED]. R36's Care Plan dated 03/18/19 documents R36 is unable to communicate and follow basic instructions. R36's Care Plan also documents I am a potential risk for falls related to my decline from Dementia. R36's Care Plan documents R36 had a fall on 09/03/18 due to (R36) sitting down in the hallway, and R36 was unable to tell staff why she sat down in the hallway. R36's intervention for this fall was to slow down when walking, and hold her head up. R36's Care Plan documented on 10/16/18 R36 had a fall while being assisted back to her room after supper. R36 hit her head, and was sent to a hospital. R36's intervention for this fall is to walk with (R36) holding on to her gait belt as she uses a wheeled walker, and do not let go of R36. R36's Care Plan dated 03/18/19 documents as of 3/19/19 R36 is no longer able to walk due to her dementia progression. R36's Minimum Data Set ((MDS) dated [DATE] documents R36 was a 2/2 for walking, which represents limited assistance of one staff. R36's MDS dated [DATE] also documents R36 balance for walking was a 1, which represents not steady but able to stabilize without staff assistance. R36's MDS dated [DATE] documents R36 is an 8/8 for walking, which represents the activity did not occur. R36's balance for walking is an eight, which represents the activity did not occur. R36's Event Report/Safety Events form dated 09/03/18 documents an unnamed Certified Nursing Assistant (CNA) observed R36 to sit on the floor. R36 was unable to say why she sat on the floor. R36's Intervention is remind R36 to slow down, when walking. R36's Event Report/Safety Events form dated 10/16/18 documents V15 CNA was ambulating R36 back to her room to get ready for bed. V15 let go of the resident. R36 lost her balance and fell forward hitting the left side of her forehead on the floor. A large bump showed up on R36's head right away. R36 had two open slits to the center of the swollen area with moderate bleeding. Steri strips and ice were applied to her forehead. R36 was sent to the hospital for a CAT (computerized axial tomography) scan of her head. R36's EHR Progress Noted dated 10/17/18 documents CAT scan results are extensive [MEDICAL CONDITION] changes and a small focal hemorrhage in left occipital lobe. R36's EHR Progress Note dated 10/22/18 R36 returned from the local hospital with an Intraparenchy hematoma of the brain due to trauma, and steri strips to the left forehead. On 03/21/19 at 11:45 AM V19 CNA and V20 CNA entered the residents room, and told the resident time to get up for lunch. V20 stated (R36) was weak so she needed two people to get her up. V19 placed a gait belt around her waist and V19 and V20 sat R36 on the side of the bed, and then lifted her up into her wheelchair. R36 did not pivot, but R36 was very rigid during her transfer. On 03/22/19 at 8:40 AM V2 Director of Nursing stated I expect they stay with the Elder, if they are care planned for assistance. On 03/22/19 at 9:13 AM V18 Nurse Practitioner stated If she needs assistance I would expect the CNA to stay with the patient. On 03/22/19 at 12:42 PM V15 stated We were walking with her (R36) walker to bed, and I stopped at the linen to get her a pad for her bed and a gown. She (R36) fell . 2. On 03/19/19 09:52 AM, R9 was observed sitting up in a high back wheelchair in dining area. R9 was observed wearing a helmet, dressed with shoes on and tapping right foot lightly on floor in a nervous motion. At 10:08 AM, R9 was observed taken by wheelchair to the activity of roll the ball. At 10:44 AM, R9 was given a puzzle type flexible toy for self activity. At 11:03 AM, R9 was observed ambulating with V16, CNA down the hall to the bathroom with a semi-steady gait. R9 was toileted and assisted back to the wheelchair in the hall and taken to dining room for lunch. The POS, dated 03/01/19, documented R9 had the following diagnoses, in part as, cerebral ischemia, palliative care, [MEDICAL CONDITIONS], Dementia with behavioral disturbances, anxiety and [MEDICAL CONDITION]. It documented on 06/20/18, may use soft helmet for protection when up. The MDS, dated [DATE], documented R9 had a BIMS score of zero and required extensive assistance of at least one staff for ambulation, transfers, toileting and bathing. It documented R9 was on no restorative programs or any type of therapy. The Event Reports for R9 were reviewed. It documented R9 had fallen at least 50 times from 05/31/18 to 02/17/19. The injuries sustained with these falls ranged from bruising, skin tears and lacerations. On 08/17/18 at 1:17 PM, R9 fell to the floor while attempting to sit in a chair. The intervention was to help her sit down in chair. On 08/17/18 at 2:40 PM, R9 fell to the floor sustaining a laceration to the left elbow. The intervention was to place a stop sign on the door. On 10/23/18 at 7:47 PM, R9 fell sustaining a skin tear to the left elbow. The intervention was to redirect away from furniture and to move furniture to allow more space. On 01/01/19 at 11:41 AM, R9 fell in the hallway sustaining a laceration to her face. The intervention was to continue to monitor safety utilizing approaches. On 01/14/19 at 12:30 PM, R9 fell in hallway and re-opened skin tear on nose from prior fall. The intervention was to pad the helmet and use hip protectors. On 01/25/19 at 1:15 PM, R9 fell in the hallway sustaining a cut to the inside of her lip. The intervention was to continue the approaches to keep safe. On 02/17/19 at 9:00 AM, R9 fell in the hallway. There was no intervention listed. The interventions listed for these falls were repetitive and not effective to keep R9 safe from falling. The care plan, dated 12/04/18, documented R9 had a history of [REDACTED]. It also documented R9 was confused, disoriented, wanders and paces. It documented R9 was unaware of her problems or safety risks. On 03/19/19, the care plan documented under falls I am no longer able to ambulate around the unit. I now have a high back wheelchair with anti tippers on the back to prevent me from tipping my chair backwards. I need assist of one for locomotion. On 03/21/19 at 8:55 AM, V16 stated it's hard to watch all of these residents when sometimes there's only two CNA's on the unit. She stated R9 falls a lot when we're helping other residents. At 9:00 AM, V17, CNA stated R9 was always moving and staff can't watch her all the time. 3. R29's MDS dated , 1/12/19, documents R29's Cognitive Skills for daily Decision Making score of 3 indicating R29 is severely impaired for daily decision making. R29's MDS further documents that R29 is not steady in moving from seated to standing position, moving on and off toilet and surface-to-surface transfer. R29's MDS further documents R29 uses a wheelchair for locomotion on the unit. R29's MDS dated , 10/12/18, documents R29's BIMs Score of 3 indicating R29 has severely impaired cognition. R29's MDS further documents R29 requires limited assistance with the support of 1 staff for transfers, requires limited assistance for locomotion on unit with support of once staff, and R29 uses a wheelchair for locomotion on the unit, and is not steady moving from seated to standing position and surface to surface transfer. R29's Event Reports (Falls) reviewed for the year, (March (YEAR)-March 2019) documents R29 has had 51 falls. R29's Event Report, dated 2/5/19, at 9:30 AM documents in part, Called to residents room @ this time. Resident was resisting care during transfer with CNA. Resident fell and hit head on metal bed frame. Small laceration noted to (R) eyebrow with moderate amount of bleeding noted. Slight swelling noted. Pupils unequal. Call placed to 911 and resident sent to the emergency room alert and responsive. Resident returned at 1:48 PM with 3 sutures to (R) eyebrow. R29's Care Plan, dated 1/12/19, documents Falls: (R29) has a history of repeated falls. Poor safety awareness, unsteady on feed, impulsive. Dementia diagnosis. (R29) will try to get up from wheel chair at anytime, (R29) does not lock my brakes. (R29) has been belligerent and difficult to redirect at times, (R29) does not like anyone telling me what to do. (R29) tries to get up and walk, but sometimes legs buckle. (R29) does not understand that I need to have help when walking. Continued falls expected due to late stage dementia progression, [MEDICAL CONDITION], increasingly poor safety awareness. Use sit to stand device as needed for transfers. R29's intervention for the fall 2/5/19 at 9:30 AM documents in part, (R29) became agitated very quickly during care and transfer. (R29) fell , struck his head on bedframe. Laceration above right eye. Root cause; agitation, resistiveness. Intervention: continue all interventions to keep (R29) safe as possible. 2 staff when giving direct care. On 3/21/19 at 10:40 AM, V12 Certified Nurse Assistant (CNA), transferred R29 from his wheel chair into bed using the sit to stand machine with a gait belt around R29s waist. R29 able to hold onto hand grasps and tolerated the transfer without difficulty. On 3/21/19 at 11:00 AM, V12 stated I usually always transfer R29 by myself because there are only two-or three CNA's on the unit and it is hard to keep up on the other residents and keep them all safe. R29's Event Report, (Fall) dated 1/3/19 at 5:30 AM documents in part, (R29) sitting in floor in front of wheel chair next to counter, hand on counter and other hand in wheel chair. No injury noted. R29's Care plan, dated 1/12/19, documents, 1/3/19 0530 tried to stand up from his wheel chair and sat on floor. Root: poor safety, impulsive. Intervention: Continue to use previous interventions and keep him as safe as possible. R29's Event Reports on 12/25/18 document 3 falls. 1) 9:30 AM, noted sitting on floor beside bed, mattress half off bed, incontinent of urine on bed and floor. No injury 2) 2:45 PM Resident in wheel chair in activity area and stood up, fell to floor, breaking wheelchair armrests off wheelchair and cut right 4th finger. First aid provided. 3) 4:00 PM Resident observed by another nurse sitting in wheel chair and kneeled down on one knee then sat in the floor no injury. R29's Care Plan, dated 1/12/19, documents in part, 12/25/19 Fall at 9:30, 2:45 PM and 4:00 PM, Interventions: Continue to use current interventions, keep as safe as possible. R29's Event Report (Fall), dated 12/26/19, at 3:47 PM documents in part: At 2:30 PM observed by visitors sliding to floor from wheel chair in hall one. No injury. R29's Care Plan, dated 1/12/19. documents, 12/26/19 2:30 PM, Stood up from wheel chair and slid to floor in hallway. Root; impulsivity, poor safety. Intervention: Continue to use current interventions; keep as safe as possible. On 3/21/19 at 2:45 PM, V2 Director of Nurses (DON) when asked if progressive interventions were implemented with the falls on 1/3/19,12/25/19 and 12/26/19, V2 stated We have tried as many things as we possibly can with R29, on those situations the fall committee reviewed and agreed to continue the current interventions. V2 stated Yes, staff should have used two staff members while providing the transfer on R29 on 3/21/19 as documented in the care plan. The Facility's policy on Falls titled Fall Procedure undated documents in part: 2. Defining Details of Falls. a. After an observed or probable fall, the staff will clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred. b. For each individual, staff will distinguish falls in the following categories: 2. Falling while attempting to stand up from a sitting or lying down position and 3. Falling while already standing and trying to ambulate. 3. Identifying Causes of Fall or Fall risk: c. The staff will continue to collect and evaluate information until they either identify the cause of the falling or determine that the cause cannot be found. 5. Identifying Complications of a fall: a. Staff, with the attending physicians input, will define the complications of a fall such as bruising, fracture, or increased fear of walking. b. Additionally, the staff and physician will identify significant potential complications of falling for each resident at risk for falling; (e.g. fracture in someone with [MEDICAL CONDITION] or bleeding in someone receiving anticoagulation. Documentation: When a resident falls, the following information should be recorded in the resident's record: 3. Interventions, first aid, or treatment administered. 6. Appropriate intervention taken to prevent future falls. Strategies for reducing the risk of falls: * Footwear properly fitted * Non-skid slippers. Staff education: All staff and volunteers receive orientation in fall prevention efforts and strategies.

Based on observation, interview and record review, the facility failed to timely identify, assess, and treat pressure ulcers for 1 of 3 residents (R3) reviewed for pressure ulcers in the sample of 13. This failure resulted in R3 acquiring unstageable pressure ulcer on his right heel and a Stage 3 pressure ulcer on his left heel. Findings include: On 1/31/19 at 2:55 PM, V14, Registered Nurse (RN), removed the dressings from R3's left and right heels. R3 had healing pressure ulcers on both heels. R3's Minimum Data Set ((MDS) dated [DATE] documents R3 is cognitively intact and needs extensive assistance from two staff person with bed mobility, toileting, and transfers. That MDS further documents R3 is without any skin conditions or pressure ulcers; however; it documents R3 is at risk for developing pressure ulcers. R3's Care Plan, dated 11/11/18, documents R3 was at risk for pressure ulcers. The Care Plan documented Assist me with turning and repositioning every 2 hrs (hours) and prn (as needed. Use moisture barrier to protect my skin every shift. Float heels with pillows when in bed or use heel protectors. R3's Nurse's Note dated 11/27/18 at 5:31 PM documents, During shower this late AM, 6 centimeter (cm) by 4 cm wound noted to left heel, 2 different open areas inside wound, draining serous. This Nurse's Note documented that his heels were to be floated in bed. R3's Physician order [REDACTED]. Skin prep per wound. [MEDICATION NAME] to wound bed. Cover with a 4 by 4 gauze. Change daily. Wound Management to be consulted and treat wounds as indicated. R3's Treatment Flow Sheet, dated (MONTH) (YEAR), documented Daily Skin Assessment: High Risk for Breakdown. The Flow Sheet did not document a skin assessment was completed on 11/4, 11/5, 11/7, 11/17, 11/18-11/21 and 11/27-11/30/18. A handwritten order, dated 11/27/18, documented Float heels in bed. R3's Treatment Record, dated (MONTH) (YEAR), documented Float heels in bed. There were eight days during the 3-11 shift, staff did not document R3's heels were floated. R3's Treatment Record, dated (MONTH) 2019, documented Float bilateral heels in bed BID (twice daily). The Treatment Record did not document staff floated R3's heels during the 3-11 shift on 1/1 through 1/8/19. R3's Nurse's Note dated 1/08/19 at 3:47 PM documents, in part, also noted to have UTS (Unstageable) wound to right heel. Wound nurse treating accordingly. R3's Nurse's Note, dated 1/10/19 documented Open area to right heel, cleansed with wound cleanser. Santyl and dry dressing order received. R3's Wound Management Notes, visit date 1/15/19 documents R3 had a Stage 3 pressure ulcer to his left heel measuring 1.5 cm by 1.5 cm by 0.3 cm with 10% necrotic tissues. The Note documented V31, Nurse Practitioner completed the initial would assessment plan regarding R3's right heel pressure ulcer. The Note documented an unstageable pressure ulcer to R3's right heel measuring 2 centimeters (cm) by 2 cm with undetermined depth. The Note documented the pressure ulcer had 70% necrotic tissue. The Note documented the onset of the pressure ulcer to have begun on 1/10/19, although the pressure ulcer was documented as being discovered on 1/8/19. R3's Treatment Flowsheet, dated (MONTH) 2019, documented Right heel wound: cleanse with NS (Normal Saline), skin prep peri wound. Apply Santyl to wound bed, cover with dry dressing. Change daily and prn (As needed). There was no documented as R3's treatment was completed for this pressure ulcer on 1/24 and 1/25/19. R3's Weekly Wound Measurements dated 1/31/19 documents measurements of R3's left heel beginning on 12/4/18 until present. And R3's right heel beginning on 1/15/19 until present. There was no documentation including description and size of the pressure ulcer on 1/10/19 when it was found. On 2/1/19 at 10:10 AM V2 Director of Nurses (DON) stated that she would expect CNA and nurses to assess skin when coming in contact with a resident, in the shower, during incontinent care. Any direct care activities. On 2/7/19 at 11:35 AM V19, Certified Nurse Assistant (CNA) stated that is the hall she normally works and that she was not aware of R3's pressure ulcers on his heel. On 2/7/19 at 2:35 PM, V31, Nurse Practitioner (NP), stated that (R3's) heels were probably avoidable with off-loading. The facility policy and procedure Pressure Ulcer Prevention and Treatment Protocol revised 11/17/17, documented for residents at high risk for pressure ulcers b) Daily skin checks are completed by the nurse, as well as skin checks by CNAs during care and on bath days. Changes are addressed at that time. The Policy and Procedure documented e) Resident's bony prominences will be protected. Skin contact surfaces may be padded.

Based on interview and record review the facility failed to timely identify and treat [MEDICAL CONDITION] for 2 of 2 residents (R2, R3) reviewed for quality of care for wounds in the sample of 6. This failure resulted in R2 and R3 being hospitalized for [REDACTED]. Findings include: 1.R2's Electronic Medical Record (EMR) documents in part, R2 was admitted to the facility on [DATE] with partial [DIAGNOSES REDACTED]. R2's physician's orders [REDACTED]. R2's Minimum Data Set ((MDS) dated [DATE] documents R2 Brief Interview for Mental Status is 14 cognitively intact. R2's Care Plan dated 12/18/18 documents a goal that R2's skin will remain intact during the next 90 days. The intervention for this goal documents Conduct a systematic skin inspection daily. R2's Shower Record/Skin Audits, dated 12/1, 12/6, 12/9, 12/12, 12/19 and 12/22/18 documented reddened areas to her buttocks region. On the back of R2's (MONTH) (YEAR) Treatment Flow sheet, documentation dated 12/21/18 noted there were 0 (no) reddened or opened areas noted at this time. R2's Shower Record/Skin Audit, dated 12/26/18 did not identify any issues with R2's skin condition. R2's Progress Note, dated 12/26/18, documents, Elder remains on Therapy as ordered. Elder up per w/c (wheelchair) to main DR (Dining Room) this AM, appetite good, elder fed self. No c/o pain or sob (shortness of breath) noted, resp. (respirations) even and unlab (unlabored). No cough or congestion noted. No c/o (complaints) noted per elder. Family, daughter reported noting rash like area to RLE (Right Lower Extremity), thigh, elder stated itches at times, and stated she thought it was just dry skin, on MD (medical doctor) list for doctor to see today. R2's Progress Note, dated 12/26/18, at 5:17 PM, documented R2 was seen by V10, R2's Physician, with no new orders received. V10's Progress Note, dated 12/26/18, did not document that he assessed R2's rash. On the back of R2's (MONTH) (YEAR) Treatment Flow sheet, documentation dated 12/28/18 documented no redness or open areas noted. R2's Shower Record/Skin Audit, dated 12/30/18 documented reddened areas rash and bruise noted to R2's right lower extremity. There was no documentation in R2's Progress Notes on 12/30/18 regarding reddened areas, rash and bruise found during R2's shower and if the facility assessed these areas. There is no documentation in R2's Progress notes from 12/26 through 1/3/19 regarding a rash to R2's right lower extremity. R2's Progress Note dated 1/4/19 at 2:30 PM documents, CNA (Certified Nurse's Aide) called this nurse to elder's bathroom. Scattered [MEDICATION NAME] rash on right thigh. C/O itching to area. Also noted reddened, slightly [MEDICAL CONDITION] area on inner and posterior right knee. Skin warm, dry, no open area noted at knee. No c/o pain to knee area. (V10) notified. R2's Treatment Record dated 1/4/19 documents, Red, [MEDICATION NAME] rash on R (right) thigh. Red area on inner R (right) knee, sl (slight) slight [MEDICAL CONDITION]. C/O (Complains of) itching to rash site. Denied pain. No open areas, no drainage from rash or knee. On 1/4/19, there was no documentation in R2's Medical Record V10 provided a response to the facility regarding R2's rash. On 1/17/19 at 9:30 AM, V12 Licensed Practical Nurse (LPN) stated, I saw the rash on (R2's) right thigh on 1/4/19 and called (V10's) office, and I never spoke to (V10) but I spoke with someone, told them about the rash and they told me to fax the information to the office and I did. I never received a call back with any new orders. R2's Progress Notes dated 1/5/19 at 1:53 PM document, At 12:00 PM, elder resting in recliner chair at BS (bedside), alert to self and pleasantly confused. Noted increased weakness and also noted change in mental status today. At Noon, Daughter, POA (Power of Attorney) here and concerned about elders change in condition. Elder assessed per Nurse and noted, BP (blood pressure) 122/62, T (Temperature) 99.1 AX (axillary), P (pulse) 64, R (respirations) 16, O2 sats (oxygen saturation) 96% on RM (room) air. Elder denied pain or sob (shortness of breath) to nurse at first but then voiced c/o complaints pain to RLE (right lower extremity), skin pink and w/d (warm and dry) to touch. Slight non[MEDICAL CONDITION] noted to RLE/ankle area. No redness or tenderness noted to touch. POA/daughter here and requested elder be sent to ER (emergency room ). Elder alert and verbally responsive with staff and family, but noted increased confusion. Called (V10's) exchange at 12:20 PM, and spoke with MD at 12:30 PM, and gave update. (Ambulance) here at 1:10 PM and transported elder per stretcher to (local hospital), called (nurse at ER) there, and gave report. ADON (Assistant Director of Nurses) called and updated. R2's emergency room Visit Report dated 1/5/19, V3 emergency room Medical Doctor documents General Context: Patient brought to the emergency room for low blood pressure and [MEDICAL CONDITION] right leg, fever. The ER Visit Report documented HPI (History of Present Illness): Patient presents to the ER with swelling to right leg with obvious [MEDICAL CONDITION], fever, mild confusion. Emergency department (ED) Progress Note: 1/5/19 5:03 PM, Patient to be admitted to the medical floor, patient is a DO NOT RESUSCITATE, [DIAGNOSES REDACTED]. R2's Hospital Consultation from V4, Medical Doctor, dated 1/6/19 documents REASON FOR CONSULTATION: Right lower extremity [MEDICAL CONDITION]. HISTORY OF PRESENT ILLNESS: This is a [AGE] year old female well known to me with previous history of polymicrobial bacteremia secondary to [MEDICATION NAME]. Currently has been doing well. Patient was at the nursing home and subsequently had developed right lower extremity pain and redness. Patient is also running a low grade fever and has bed slightly lethargic on the day of admission. Patient was sent to the emergency room for further evaluation. The Consultation Report documented EXTREMITIES: Right shin there are areas of [DIAGNOSES REDACTED] with fluid- filled small blisters that ruptured with serosanguineous bloody fluid draining from it. ASSESSMENT AND PLAN: 1.[MEDICAL CONDITION] with [MEDICAL CONDITION], change in mental status associated with right lower extremity [MEDICAL CONDITION], currently on [MEDICATION NAME] and [MEDICATION NAME], which is adequate. I would continue current mode of therapy. Follow up on blood culture, repeat complete blood count (CBC) and basic metabolic panel (BMP) in am. Blood pressure is stable on bolus of intravenous fluid (IV) fluid. 2. Change in mental status, most likely secondary to [MEDICAL CONDITIONS]. R2's Hospitalist V11's History and Physical documented [AGE] year old female with past medical history of [REDACTED]. History was taken from the patient and her daughter at bedside. As per the daughter patient usually calls her once a day, however she did not receive a phone call from her mom today. When the daughter went to see her mom, she found that her mom has right lower extremity pain and swelling. She was also having low grade fevers for one day. At baseline, the patient is able to walk and is able to hold a conversation. She was at her baseline until up to 3 days back. Patient appeared sleepy. She was easily arousable and answered some of the questions. She stated that her major complaint is right lower extremity pain. The report documented The source of infection is most likely right lower extremity [MEDICAL CONDITION], start IV [MEDICATION NAME] and [MEDICATION NAME]. repeat [MEDICATION NAME]. On 1/14/18 at 10:42 AM, V16, R2's daughter, stated, On 1/5/19, I tried calling my mom at the nursing home and she didn't answer her phone, so I came to the home to visit her, she was wrapped up in a blanket in her chair, I was repositioning her blanket and noticed her red swollen leg, I told the nurse she needed to go to the ER. The facility would have had to see her swollen leg. She has an infection in her leg, fungus in her groin. She still has the infection in her right leg that they (hospital) are treating with IV antibiotics. Her BP was very low in the ER, I think 75/40 due to the infection. Her leg was red, swollen and blistered. Also, on the bottom of the same leg she has a sore. On 1/17/19 at 11:00 AM, V10 stated, I remember on 1/4/19 someone notified me of the rash on (R2's) right thigh, I told someone if they were concerned they should send her to the ER. I don't remember who I talked too. Then they called me on the 5th and said they were sending her to the ER. When I saw (R2) on (MONTH) 26th I did see the rash, kind of looked like it might have come from a bad scratch. I don't know why I did not put it in my notes when I saw her that day. R2's (MONTH) 2019 Physician order [REDACTED]. 2. R3's Face Sheet, documented R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R3's Care Plan dated 11/16/18 documents Open, weeping areas on lower left leg r/t (related to) [MEDICAL CONDITION] in left leg. The approach, dated 11/16/18 documented Skin inspection and assessment every day. The approach, dated 11/20/18 documented check condition of my skin on legs, underneath right leg splint, every shift. Monitor for redness, rubbing or potential pressure areas. Notify MD of problems. R3's Shower Record/Skin Audit, dated 12/31/18, documented leg brace on right. There were no other skin issues identified on this Audit. R3's Progress Note dated, 1/3/19, at 4:33 PM document, PT (patient) c/o left leg pain to daughter on the phone, Not writer on day shift at either med pass times. Noted red, warm, swollen region to lower posterior thigh, calf is very tender, ankle tender, pt yelled at palpation of posterior tibial (tib) pulse check, pedal pulse +1 . left toes cool, pt has impaired circulation, did have cap refill. Vital signs (VS) 99.3, 61, 18, 115/53. R3's doctor's office informed. Director of Nurses (DON) called to view left lower extremity (LLE) as well. Ambulance paged at 4:00 PM. Ambulance here and pt left at 4:30 PM. POA informed of transfer and status. ER called per staff nurse. R3's ER History of Present Illness, dated 1/4/19 documents in part, Chief Complaint: Tonight is sent from the nursing home secondary to left leg redness and fever. History of Present Illness: This is an [AGE] year old demented Caucasian female with known past medical history of [REDACTED]. The patient had a temperature of 100.2 degrees in the ER yesterday and the patient was found to have a significantly elevated white cell count in the ER of 40.9 with 26 bands, as well as acute [MEDICAL CONDITION] with a creatinine of 2. Peripheral vascular ultrasound did not demonstrate any acute [MEDICAL CONDITIONS]. The patient was admitted to the hospital for her left lower extremity [MEDICAL CONDITION]. Assessment and Plan: 1. Left lower extremity [MEDICAL CONDITION]. The patient has been admitted to med-surge. Continue antibiotic therapy. Blood cultures are pending. Monitor area of [MEDICAL CONDITION]. Monitor vital signs closely and urine output. Continue IV hydration overnight. 2.[MEDICAL CONDITION], rule out [MEDICAL CONDITION] with fever, significant leukocytosis, tachypnea, acute [MEDICAL CONDITION]. The source [MEDICAL CONDITION] appears to be [MEDICAL CONDITION]. We will continue antibiotic therapy. 3. Leukocytosis, secondary to [MEDICAL CONDITION]. 13. [MEDICAL CONDITION] with renally closed [MEDICATION NAME] and full code status. I suspect the patient will likely need at least 2 nights of inpatient medical therapy for acute [MEDICAL CONDITIONS] and comorbid conditions listed above. R3's POS dated (MONTH) 2019 documents in part, Daily Skin Assessment: High Risk for Breakdown. Once a Day 7-3 shift. R3's Treatment Flow Sheet, dated 1/1/19-1/31/19, documents Daily Skin Assessment: High Risk for Breakdown. Once a Day. There was no skin assessment documented as being completed on 1/1/19, 1/2/19 or 1/3/19. On 1/15/18 at 10:40 AM, V14 R3's daughter stated, I was talking to my mom on the phone on 1/3/19 and she told me her left leg hurt. I called the nurse and told him to go in and look at her left leg and found it was red, warm and swollen, that's when they sent her to the ER. On 1/17/18 at 9:15 AM, when asked if the nurses should have seen the [MEDICAL CONDITION] on (R2) and (R3) during the daily skin assessments, instead of R2's and R3's daughters alerting the nurses to this, V5 Assistant Director of Nurses stated, They have all of their shift to do the skin assessment, regardless of who found the [MEDICAL CONDITION] the outcome would have been the same. The facility's Policy and Procedure for Skin Assessments, revised 3/6/2018, documents In order to document issues related to skin integrity or other injuries, it is the Policy of the (Facility) that a Shower Record/Skin Audit will be completed as outlined below. The Procedure documented 1) The charge nurse will pass out Shower Record/Skin Audit forms to certified nursing personnel along with the daily assignment sheet. 3) After completion of the Resident shower, certified nursing personnel will complete the Shower Record/Skin Audit form to include but not be limited to the following information: a) Reddened areas b) Opened areas c) Skin tears d) Bruising e) rashes f) Podiatry consult needed g) Date shower or bath given h) Resident refusal for bathing if applicable i) other information as necessary. 4) After completion of the Shower Record/Skin Audit form certified nursing personnel will submit such to the charge nurse for review. 5) Nursing Personnel will document on the Shower Record/Skin Audit form any additional information that may be needed as well as any actions taken (treatment, incident report, etc.) 6)After review, nursing will submit the Shower Record/Skin Audit form to the Director of Nursing for additional review. 7) Shower Record/Skin Audit sheets will be maintained by the facility for one year to assure availability for additional review if necessary.

Based on interview and record review, the facility failed to assess, identify causative factors contributing to falls; implement, monitor and modify current interventions to prevent falls for 2 of 4 residents (R1, R3) reviewed for falls and injuries in the sample of 8. This resulted in R1 and R3 being sent to the hospital for evaluation and treatment of [REDACTED]. R1 sustained a head laceration with 7 staples and R3 sustained multiple contusions including a large left periorbital swelling and bruising, contusions to the left shoulder and right knee and a laceration to the right middle finger with 5 sutures. Findings include: 1. R3's Physician order [REDACTED]. R3's Minimum Data Set (MDS), dated [DATE] and 11/16/16, documents R3 is severely cognitively impaired and requires extensive assistance of one staff person for transfers, ambulation and dressing and is totally dependent on staff for toileting. The MDS, dated [DATE], documents R3 requires extensive assist of one staff person for walking between locations in his/her room and walking in corridor on unit. The MDS, dated [DATE], documents R3 requires limited assist of one staff person for walking in room and in corridor on unit. Both MDS document R3 was not steady and only able to stabilize with staff assistance when moving from the seated to standing position, turning around, moving on and off toilet and surface-to-surface transfers. R3's Fall Risk Evaluation, dated 11/16/16, documents R3 has a total score of 17 (score of 10 or higher represents a high risk for falls). R3's Safety Event Report, dated 4/29/16, documents at 9:13 PM, R3 was apparently walking to bathroom with staff and slipped on wet floor and sat down on the floor. R3's Care Plan entry, dated 4/29/16, documents, Staff reminded to always put shoes on R3 prior to walking her or keep gripper socks on her at night. Surgical shoe on left foot due to fracture of small toe. R3's Safety Event Report, dated 5/27/16, documents at 2:56 PM, R3 fell in common area after she tried to stand up unassisted from recliner. R3's Care Plan entry, dated 5/27/16, documents, Frequent visual checks and assist with transfers as usual. R3's Safety Event Report, dated 10/16/16, documents at 2:05 PM, R3 was walking with staff, tripped over her own feet and fell and hit right side of her head. R3's Care Plan entry, dated 10/16/16, documents, Frequent checks. Staff to continue current plan of care. Staff reminded to get assist from another staff member to help with walking. On 12/12/16 at 1:05 PM, E3, Assistant Director of Nursing (ADON), stated that at the time of the fall R3 only needed standby assist so E15, Certified Nursing Aide (CNA), did not use a gait belt when she ambulated E3. R3's Safety Event Report, dated 11/20/16 documents at 2:30 AM, R3 was found on the floor at the end of the bed next to wall and a red area noted to left cheek. Care Plan Note for 11/20/16 documents, Frequent visual checks. R3's Safety Event Report, dated 11/20/16, documents at 3:40 AM, R3 was found in her room lying on the floor next to her bed. R3 had a large amount of facial swelling and bruising to her right knee and a skin tear to the back of her right 3rd finger. Left eye swollen. R3 was sent to the ER. R3's Story Of My Fall Form, dated 11/20/16 at 3:40 AM, documents, (Question) When was the last time the staff assisted you in any way? (Answer) 2:30 AM Resident fell at 2:30 AM. (Question) What did they do for you? (Answer) Bed Check - hourly checks. This form was signed by E16, CNA. R3's Nurse's Notes, dated 10/20/16 at 3:40 AM, document, Went to (room #) to check on Elder lying on the floor next to bed on left side @ 3:40. Noted elder lying between bed and night stand. elder has significant large amount of facial swelling: left eye bruised swollen shut. 3rd right finger bleeding skin tear noted to back of 3rd finger on right hand. Cleansed finger, applied TAO (Triple antibiotic ointment) and band aid to it. Noted bruising right knee measures 4 x 3 centimeters reddish bruising to right knee. ROM (range of motion) to right knee. Ice applied to left eye and face. Initial neurochecks @ 0345. Neurochecks WNL (within normal limits). No changes is responsive with normal usual responses from elder. Unable to check left eye due to swelling. Called MD (Medical Doctor). The Nurse's Notes document R3 was transferred to ER, family, Department, and ADON (Assistant Director of Nursing) notified of fall and injury. On 12/14/16 at 2:48 PM, E4, Licensed Practical Nurse (LPN) stated R3 was on hourly bed checks after the first fall the night of 11/20/16. On 12/14/16 at 2:55 PM, E17, CNA, stated R3 was on hourly bed checks after her earlier fall at 2:30 AM that night. On 12/14/16 at 9:20 AM, E2, Director of Nursing (DON), stated R3 did not fall often and on the night she fell twice she actually had UTI (Urinary Tract Infection). 2. R1's POS, dated 12/2016, documents multiple [DIAGNOSES REDACTED]. R1's MDS, dated [DATE] and 11/18/16, document R1 is severely impaired cognitively and requires extensive assistance of one staff person for transfers and dressing and totally dependent on staff for toilet use. Both MDS document R1 was not steady and only able to stabilize with staff assistance when moving from the seated to standing position, turning around, moving on and off toilet and surface-to-surface transfers. R1's Fall Risk Evaluation, dated 11/17/16, documents R1 has a total score of 18 (score of 10 or higher represents a high risk for falls). R1's Safety Event Report, dated 3/9/16, documents at 9:45 PM, R1 slid out of his wheelchair reaching for something in the trash can. The Care Plan with entry date 3/9/16 documents, Continue current plan of Care. R1's Safety Event Report, dated 6/20/16, documents at 7:30 PM, R1 fell while trying to transfer self onto toilet, hit head, sent to ER for evaluation of head laceration. R1's Story of my Fall Sheet, dated 6/20/16, documents the last time R1 was toileted was at 3:15 PM. R1's Nurses' Notes, dated 6/20/16 at 11:30 PM, documents, (Recorded as Late Entry on 6/21/16 at 00:47), Elder got up out of wheel chair on Hall 100 and tried to take self to restroom. Elder fell and hit head on the floor. Elder sustained an 8 centimeter laceration to the left occipital area of the head. R1's Care Plan entry, dated 6/20/16, documents, Ice for pain, monitor for infection, neurochecks per facility protocol. R1's Care Plan was not revised at this time with progressive interventions to prevent her from future falls. R1's Safety Event Report, dated 10/3/16, documents at 4:53 AM, R1 was found on the floor in doorway to Room 107 (R1 lives in another room on that hall), incontinent of bowel at the time. R1 was confused. BM (bowel movement) was found on his bed in his room also. R1's Care Plan entry, dated 10/3/16, documents, Continue current plan of care. The Care Plan was not updated with any new/progressive interventions to prevent future falls. R1's Safety Event Report, dated 10/11/16, documents at 10:00 PM, R1 was found in the shower room, slid from wheel chair onto floor. R1's Story Of My Fall Form, dated 10/11/16, documents,(Question) What fall interventions were in place? (Answer) Chair Alarm. (Question) Were the fall interventions in place applied properly and functioning properly? (Answer) No. Chair alarm had a low battery on it. R1's Care Plan entry, dated 10/11/16, documents, Frequent checks to monitor his location and safety. The Care Plan was not updated with any new/progressive interventions to prevent future falls. R1's Safety Event Report, dated 11/30/16, documents at 7:45 AM, R1 fell in his room after getting out of bed and attempting to walk. No shoes on, slipped on the floor. R1's Care Plan entry, dated 11/30/16, documents, Frequent checks. Staff to get him up when he is awake. He is awake anywhere from 5 AM on. This varies day to day. On 12/12/16 at 1:55 PM, when asked, what Frequent checks mean? E3 stated it means 15 minute checks for 24 hours done after every fall. On 12/14/16 at 11:30 AM, E2 stated there is not enough information on the fall investigation form provided by staff. E2 stated when the forms are submitted, she would not go back and add any new information surrounding the fall because that would be altering the document. The Facility Policy on Assessing Falls and Their Causes, dated 2001, documents, When a resident falls, the following information should be recorded in the resident's medical record: and lists in part, 6. Appropriate interventions taken to prevent future falls.

Based on observation, interview and record review, the facility failed to assess, identify causative factors contributing to falls, implement individualized interventions, and modify interventions when falls continued for 3 of 16 residents (R1, R2 and R4) who were reviewed for falls, in the sample of 20. This failure resulted in R4 falling and sustaining a fracture of the thoracic vertebra. Findings include: 1. Review of Incident Report Detail for R4 documents falls on 6/3/13, 6/10/13, 7/25/13, 8/7/13 10/10/13 and 11/24/13. Incidents were documented on R4's care plan of 4/5/13 with no new interventions implemented except for incident 10/10/13 when facility implemented an alarm on bed and wheel chair. Incident Log documented R4 fell on [DATE]. Investigation Summary of 11/27/13 documents E8, Certified Nurse Aide (CNA) lifted R4's legs on his bed to elevate his legs and the wheelchair tipped backwards. Report documents R4 struck his head on the dresser. R4's November 2013 Physician order [REDACTED]. Hospital Physician Discharge Summary of 11/26/13 documents a [DIAGNOSES REDACTED]. Review of untitled document dated 11/27/13 done by E3 Assisted Director of Nursing (ADON) interview with E8 states she often puts R4's feet up on his bed per his request. E9 Liscenced Practical Nurse (LPN) stated R4 requests his legs put up on bed when sitting in wheelchair. E3 ADON discussed and explained to them that if R4 request to put feet up on the bed that facility should provide a foot stool. This information is not documented on R4 care plan. An undated Fall Prevention Approaches check list form documents, "12/23/12 Patient protector, 12/14/13 Dycem and 10/10/13 Smart pad w/c (wheelchair) and bed". Facility POLICY: FALL PREVENTION PROGRAM with reversion dated 5/8/01 documents OBJECTIVES: 2. Incorporate fall risk prevention interventions within the resident's plan of care. 3. Reduce the risk of resident falls and possible injury. PROCEDURE: 6. Any resident experiencing a pattern to fall incidents or an injury as a result of a fall shall have a Post Fall Assessment completed by a member of the safety committee. On 12/12/13 at 12:45PM, E3 stated there is no assessment of causal factors for falls or individualized approaches. E3 stated interventions should be on R4's Care Plan. 2. The POS, dated 12/01/13, documented R2 as having the following diagnoses, in part as, Dementia and Psychosis. The Minimum Data Set (MDS), dated [DATE], documented R2 is moderately cognitively impaired displaying disorganized thinking requiring extensive assist of at least 2 staff for bed mobility, transfers, dressing, toilet use, hygiene and bathing. It also documented R2 has a supra-pubic catheter for the bladder and is frequently incontinent of bowel. The Fall Risk Assessment, dated 08/30/13, documented R2 as being at risk for falls with a score of 27. The Care Plan, dated 12/05/13, documented R2 as being at risk for falls "due to cognitive loss, poor safety awareness and weakness secondary to disease processes and taking antidepressant and antipsychotic daily." It also documented R2 is unable to use the call light effectively and unable to voice needs. It also documented approaches, in part as, "anticipate needs, assess and evaluate cause of falls, smart pad in wheelchair and bed at all times, mat on floor at bedside, monitor for any signs or symptoms of acute problems or situations that could contribute to falls." On 05/28/13 at 7:20 PM, an incident report documented R2 was found by staff sitting on the floor next to his bed with his shirt off and trying to remove his pants. No documentation of the chair alarm sounding. The measures to prevent falls documented to do hourly checks and put R2 to bed earlier. This was not incorporated into the care plan. On 06/22/13 at 6:15 PM, an incident report documented R2 slid from wheelchair attempting to transfer himself to a dining room chair. It documented the chair alarm was sounding and staff present. The measures to prevent falls documented monitor closely, when restless offer walking or toileting. This was not incorporated into the care plan. On 07/07/13 at 1:40 AM, an incident report documented R2 was found sitting on the floor next to his bed. It documented the bed alarm was sounding. The measures to prevent fall documented "continue current care plan." This was not incorporated into the care plan. On 07/23/13 at 10:30 PM, an incident report documented R2 was found on the floor on the mat next to his bed. It documented the bed alarm was sounding. The measures to prevent falls documented frequent visual checks. On 08/27/13 at 10:40 PM, an incident report documented R2 was found on the floor in the doorway of his room. It documented the bed alarm was sounding. The measures to prevent falls documented place on hourly visual checks. On 09/09/13 at 7:00 AM, an incident report documented R2 was found lying on the floor with socks on. It documented that the alarm was not sounding and not on the bed. The measures to prevent falls documented staff educated regarding use of alarms. In all of these falls, there was no documentation of the causative factors or assessments and interventions put into place after each incident. On 12/10/13 at 12:45 PM, R2 was observed in the TV area of the 100 and 200 unit. R2 was attempting to propel himself out into the hall and staff brought him back to the TV area and tilted his chair back so that his feet were approximately 4 inches off the floor. R2 was then observed trying to push his bottom forward to touch the floor with his feet. Then E4, CNA took R2 to his room. At 1:05 PM, E4 was observed to tilt R2's wheelchair back due to him trying push his bottom forward out of the chair. Even after tilting the chair back, R2 continued to push his bottom forward to the edge of the chair. E4 stated that they (staff) has to tilt his chair back when he's restless sometimes or he'll fall out of his chair. E4 used a sit to stand mechanical lift to transfer R2 to the toilet. At 1:25 PM, E4 stepped out of the bathroom, leaving R2 sitting on the toilet alone for approximately 3 minutes. On 12/12/13 at 12:45 PM, E3, DON (Director of Nursing) stated that staff are not assessing for alarm effectiveness when a resident falls. She stated that staff are putting alarms on those residents after they fall the first time without assessing the causative factors first. She stated that staff are applying alarms to notify staff when a resident is moving around. She also stated that falls are still occurring despite the alarms. 3. R1's Minimum Data Set, dated dated [DATE], documented severe cognitive impairment and total dependence of one to two person's physical assistance with mobility and transfer. R1's Care Plan, start date 7-10-13, documented, in part, that R1 was at risk for falling related to poor safety awareness and history of falls. R1's Incident Report Detail, dated 9-12-13, documented R1 was observed lying on the floor in her room. R1 was not documented as incurring an injury; however, the Incident Report documented "staff educated re safety with geri chairs." R1's Care Plan, entry date 9-12-13, documented "Staff re-educated to be sure chair is reclined and that she is not in room alone." R1's Event Report, dated 11-4-13, documented R1 slid out of her chair onto her right side. It was also noted that R1 was crying in pain/fear resulting in a reduction of range of motion in her right shoulder. R1's Event Report also documented, "staff notified to make sure tilt-recliner chair is in tilt position. not full erect, with Dysom pad." R1's Care Plan, dated 11-4-13, documented "fell 8:15a.m. in studio from w/c (wheel chair)". R1's Care Plan, dated 9-12-13 and 11-4-13, and chart documented that both R1's falls occurred as a result of improper chair placement. R1's chart did not document fall assessments nor causative factors of R1's falls in relationship potential interventions to prevent further falls from her chair.

Based on record review and interview, the facility failed to administer the correct medications to the correct resident as ordered by the physician, resulting in a significant medication error for one of five residents (R3) monitored for medication errors in the sample of five. This failure resulted in R5's blood pressure dropping rapidly and being sent to the hospital for emergency treatment. Findings include: On [DATE], at 10:00 AM, the Incident Summary Report for medication errors dated [DATE] to [DATE] were reviewed. The Incident Report Detail for R3, dated [DATE], documents, in part, "Most recent caregiver-(E3, LPN) (Licensed Practical Nurse), She (R3) received the wrong medications. She got the medications that belonged to another resident. Additional Information; [MEDICATION NAME] 50 mg (milligrams), [MEDICATION NAME] 50 mg, [MEDICATION NAME] 145 mg, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 50 mg. No ill effects noted." The measures to prevent reoccurrence documented are "More carefully identify residents using assistance of more experienced staff." On [DATE], at 3:48 PM, R3 was interviewed related to the medication error of [DATE]. "The first medication error, they gave me pills. I said I was sick to my stomach. I threw up and threw up. I don't remember who gave it to me. I was kind of dazed. My son and husband came to the hospital and were praying. My husband talked to the doctor and nurse in the ER (emergency room ). He got mad. My blood sugar must have gone out of whack. I didn't remember. The hospital told me they gave me the wrong medication." On [DATE], at 3:30 PM, E3, LPN was interviewed related to the medication error of [DATE] for R3. E3 reported she was orienting a new nurse, E6, Registered Nurse (RN). E3 reported R3 had already received her morning medication, including insulin. E3 reported she prepared medication for R5, including an insulin injection and asked E6 if she felt comfortable giving the medication to R5 and E6 agreed. E3 stated, "I told (E6) (R5's) (glucometer blood sugar level) and how much insulin to give her per sliding scale. She (E6) took everything and came back and told me about (R3). She kept calling her (R3) ""the new lady"", and didn't know her name. I called Z1, Physician, got R3 out of bed and gave her some food. I took her vital signs every 15 minutes. Her blood pressure started to drop. She had no loss of consciousness. R3 got nauseous and puked a little bit. I call 911 (emergency number) and had her sent out." E3 reported she was sent by ambulance to the local hospital. E3 stated, "She (R3) had received extra insulin and a bunch of meds (medication)." During the interview E3 was asked how to identify a resident for a medication pass. E3 replied, "By their name on the door and ask another staff. Their picture is on the MAR (Medication Administration Record), TAR (Treatment Administration Record) and a picture in their chart. Their picture is taken on admission." On [DATE], at 2:16 PM, E6, RN was interviewed. E6 reported she had been orientating with E3 on [DATE]. E6 reported she became employed at the facility on [DATE]. E6 stated, "She (E3) had popped out some pills and drawn up insulin and said take it down to the new lady, (R3). She (R3) had been moved from room [ROOM NUMBER] to 507 that AM. I walked in and said to (R3), ""Here's your meds."" I guess in retrospect I should have asked her name. I assessed her right arm. I took the insulin and pills to R3 about 8:30 AM. I went back and told E3 about assessing R3's right arm and then she (E3) knew I gave her (R5's). I was afraid her (R3) blood sugar would drop and she was given extra (liquid food supplement) and encouraged to eat a breakfast tray. I rechecked her blood sugar. It had gone up over 400 (normal fasting=70 to 110 mg per deciliter). We checked her blood pressure every 15 minutes. The doctor was called and said send her to the hospital. Her blood pressure began to drop, ,[DATE] something. She was still in her wheelchair and alert. She went to the hospital around 9:30 AM and was back at 1:00 PM. The resident's don't wear arm bands. The only way to identify is their name on the door, a picture on the MAR indicated [REDACTED]. Also, after she ate breakfast she said she was going to be sick and vomited. I now double and triple check medications. E3 documented the nurses notes at that time." On [DATE], at 10:15 AM, E2, Director of Nursing (DON) was interviewed about the medication errors for R3. E2 reported the medication error occurred while E3 was orientating a new nurse, E6. E2 stated, "There were two different stories. E6 said E3 told her to give the meds to the new lady, R3. E3 said she told her to give them to (R5). E6 gave R3 R5's medication during morning med pass, insulin and pills. Her blood pressure was running high. R3 is also diabetic, but not on insulin The insulin didn't hurt her. Her blood pressure started going down. She did have an emesis and was sent to the ER and sent back in 2 or 3 hours. E6 realized what happened and was devastated. Both (E3 and E6) are experienced nurses. They should have gone back and looked and they didn't." In an interview on [DATE], at 2:43 PM, E2 reported, "I am well aware of a medication error problem." E2 reported the errors in the facility for 2013 have been related to improperly identifying the correct resident and failing to follow the facility's medication administration policy and procedures. On [DATE], at 11:50 AM Z1, Physician was interviewed related to the medication error for R3 on [DATE]. Z1 reported he was aware of the medication error and considered this to be a significant medication error. Z1 stated, "They gave the wrong medication. The patient could have died . The patient could have been allergic and or had a severe reaction to too much blood pressure medication and too much insulin. Thank God she threw up." Z1 reported he is aware of a medication error problem at the facility. On [DATE] R3's MAR for ,[DATE] was reviewed. The MAR for ,[DATE] documents E3 administered the following medication to R3 for her scheduled 8:30 AM medication pass; [MEDICATION NAME] 50 mg, [MEDICATION NAME] 20 mg, the blood pressure medications of [MEDICATION NAME] 25 mg, and [MEDICATION NAME] 2.5 mg, and Aspirin 325 mg. The MAR indicated [REDACTED]. The Incident Report Detail for R3, dated [DATE], at 8:30 AM, was documented by E4, Assistant Director of Nursing (ADON). The Report documents on [DATE], at 8:30 AM, "(R3) received the wrong medications. She got the medications that belonged to another resident. Additional info (information)-[MEDICATION NAME] 50 mg, [MEDICATION NAME] 50 mg, [MEDICATION NAME] 145 mg, [MEDICATION NAME] 100 mg, and [MEDICATION NAME] 50 mg (an antihypertensive medication). Measures to prevent/ When training new nurses, the training nurse should say the resident's name and room number, and she should go with the orientating nurse. Send to ER for decreased BP (blood pressure)." The physician's orders [REDACTED]." E3's Nurses Note for R3, dated [DATE] at 5:08 PM, documented, in part, "IR (incident report) med error. Resident was given another resident meds and insulin, communication error between nurses. (Z1) paged and called cell phone, exchange and both Friday offices, did not receive call back for one hour. Resident got up in wheelchair and taken to dining room so we could observe her, early breakfast tray gotten and 120 cc (cubic centimeters) of (liquid food supplement). Nurse got vs (vital signs) every 15 minutes for first hour and (glucometer) checks. At 8:25 AM (BP) ,[DATE], (pulse) 70, (respirations) 24, (temperature) 97.2, (glucometer) check-319, at 8:40 AM, BP-,[DATE], 94-(pulse), (respirations)-24, (glucometer) check 424, at 9:00 AM, BP-,[DATE], 88, 16, resident also complains of nausea and moderate amount of emesis, undigested food, At this time 911 called and here within minutes. (Z1) notified. Family and POA (Power of Attorney) and son notified resident sent to hospital for further observation. Resident returned at 1:00 PM, some confusion noted and not recalling earlier events." The physician's orders [REDACTED]." The ER physician documentation addendum notes, dated [DATE], at 18:46 (6:46 PM) documents, in part, "Patient (R3) felt better after throwing up. Patient's glucose was 400. Patient received excess of 40 units long acting insulin. IMPRESSION: Accidental excess of insulin and medication. Pt (patient) present to ED (emergency department) with nausea and vomiting. Pt states symptoms began this morning after being given too much insulin. Pt was given wrong medications this AM, instead of pt's medications, pt was given: [MEDICATION NAME] 50 mg, [MEDICATION NAME] 50 mg, [MEDICATION NAME] 10 mg, [MEDICATION NAME] 5 mg, [MEDICATION NAME] XL 150 mg, [MEDICATION NAME] 5 mg, [MEDICATION NAME] 20 mg, [MEDICATION NAME] 20 mg, Iron 150 mg, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 40 mg, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 50 mg, [MEDICATION NAME] (insulin) N 50 units, [MEDICATION NAME] (insulin) 8 units. On [DATE], the clinical record for R5 was reviewed. The POS and MAR for R5 in ,[DATE] documents R5 is to receive during morning medication pass the following medication; [MEDICATION NAME] 50 mg, [MEDICATION NAME] 50 mg, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 50 mg, [MEDICATION NAME] ([MEDICATION NAME]) 20 mg, Iron Complex 150 mg, [MEDICATION NAME] ([MEDICATION NAME]) 40 mg, [MEDICATION NAME] ([MEDICATION NAME]) 100 mg, [MEDICATION NAME] ([MEDICATION NAME]) 10 mg, Aspirin 325 mg, [MEDICATION NAME] 10 mg, [MEDICATION NAME] XL 150 mg, [MEDICATION NAME] 5 mg, [MEDICATION NAME] 20 mg, [MEDICATION NAME] N 50 units, and [MEDICATION NAME] 8 units. The facility's policy and procedure entitled, ' General Medication Administration Procedures' documents, in part, "Medications are to be poured, administered and charted by the same licensed person in that order. Open the unit dose package only when you are administering medication directly to the resident. Removing the medication from its unit dose packaging in advance lessens the ability to positively identify the medication and increased the chance of drug administration errors. Before administering the dose, the nurse must make certain to correctly identify the resident to whom the medication is being administered. After the resident has been identified, administer the medication, watch the patient consume the medication until gone and immediately chart doses administered on the medication administration record."

Based on record review and interview, the facility failed to assess, identify causative factors contributing to falls, implement interventions based on fall history, and monitor and modify those interventions when injuries continued for 1 of 8 residents (R17) in the sample of 19. This failure resulted in R17 fracturing her left wrist and receiving concussion/contusion to her left eyebrow eyesocket area after removing her alarm(s) and falling. Findings include: R17's Minimum Data Set (MDS), dated [DATE], documented diagnosis, in part, of Alzheimer's Disease and impaired balance with moving from seated to standing position, walking, moving on and off toilet and surface to surface transfer. R17's Care Plan, initial date of 9-24-10, documented R17 was at risk for falls related to having a history of falls, poor safety awareness, stooped posture and unsteady gait. It was also documented R17 would try to get up out of bed or chair and walk unassisted. R17's Incident Report, dated 9-17-11 at 7:05a.m. and signed by E7, Licensed Practical Nurse (LPN), documented "Fall reported...observed at bedside, in sitting position. Stated, 'I was trying to get in my chair.' A reddened raised area noted to forehead, stating 'I hit my head on the floor.' A& O (alert and oriented) to self only. Likes to be independent. Bed alarm did not activate. Stated, 'I turned it off because I hate its loud noise.' he uses w/c (wheelchair) for mobility, but will attempt to amb (ambulate) about room indep (independently), requires assists transfers, poor safety awareness, poor short term memory." E7 stated, on 3-30-12 at 11:00a.m., "Yes, R17 took off her alarm..she felt she was being trapped...yes..alarm sound irritated her..never liked that alarm." R17's Incident Report, dated 9-18-11 at 6:20a.m., documented "Observed resident lying on back on floor. Red area noted to back of head. Had removed alarms from bed and pt (patient) prot (protector) (alarm)." R17's Incident Report, dated 9-28-11 at 8:50a.m., documented "Pt noted to be laying on her right side parallel to bed with head directed towards HOB (head of bed). Large hematoma to right side of forehead with skin tear in center, left wrist noted to be disfigured bruise to right knee. Smart pad was in place and she turns off the alarm." R17's Nursing Notes, dated 9-28-11, documented R17 was sent to a local emergency room for evaluation and returned to the facility with a cast on her left arm for a fractured left wrist and R17's Incident Report, dated 10-4-11 at 5:57a.m., documented "Found on floor in front of bedside chair. Pt protector not sounding, removed by eldr (elder) previous to fall. No injured noted." On 3-29-11 at 11:30a.m., E3, Assistant Director of Nursing (ADON), provided a list of R17's Fall Prevention Approaches which documented "Verbal cueing and reminders (not dated), frequent visual checks (not dated), ambulation (not dated), proper shoes/non-skid socks (dated 10-26-10), patient protector (not dated) , keep in high traffic areas (dated 10-1-10), smart pad bed (dated 12-4-10)." E3 stated, on 3-29-11 at 11:30a.m., that the patient protector and smart pad bed were alarms. During review of R17's Incident Reports, with E3 stated, on 3-29-11 at 11:30a.m., that she did not know why R17's repeated removal and verbalized irration with her alarms had not been addressed. During review of R17's fall history with E1, Administrator, on 3-30-11 at 11:00a.m., E1 stated R17's irritation with the alarm and removal should be addressed. The facility did not provide documentation that R17's alarms had been identified as factors contributing to her repeated falls or that the facility assessed, monitored and/or modified R17's fall interventions to prevent repetitive falls. .

Based on record review and interview, the facility failed to adequately supervise and ensure foot rests were in place on the wheelchair, for 1 (R1) of 3 residents in the sample identified as being at risk for falling. This failure resulted in R1 falling forward out of his wheelchair sustaining skin tears to his hands and arms; and a laceration to his forehead, which required thirteen sutures. Findings include: 1. R1 resides on the dementia unit of the facility. R1's most recent Minimum Data Set (MDS), dated [DATE], shows that he is severely cognitively impaired; does not ambulate independently; is dependent on staff for all activities of daily living; is not able to stand without physical support; and requires partial physical support to sit. R1's plan of care, dated 12/20/09 until present, shows a "Problem" of "I am at risk for falls related to use of antipsychotic medication daily. I have also had a decline in cognitive status related to dementia progression. History of falls. Poor safety awareness. Decreased ability to protect self during a fall." Included in the "Approaches" for this "Problem" is "make sure foot rests are on wheelchair and feet are on them when transporting him." The "Incident Report Detail", dated 5/16/10, 11:00 AM, states "Called to Hall 100 by Certified Nurses Aide (CNA), elder lying on his stomach face down on the floor. Laceration and abrasion noted to left forehead, bridge of nose and under nose. Elder apparently reached forward to pick something up off the floor while CNA was pushing his wheelchair. CNA did not have time to stop wheelchair before he fell . Dementia with no safety awareness." Listed on the form is "Measure to Prevent: Apply wheelchair footrests to wheelchair to help elder sit back further when in chair." The "Incident Report Detail", dated 11/30/10, 2:40 PM, states "CNA was pushing wheelchair back to dining room from bathroom, he reached forward and fell out of his wheelchair hitting his (face) on the floor. He obtained a laceration to his forehead and skin tears to his hands and arms. He was sent to the emergency room for evaluation and treatment. (R1) has dementia, confusion and no safety awareness. Behavior of reaching forward to pick up things that only he sees. Had patient protector on wheelchair and is supposed to use foot rests when in wheelchair. Foot rests help him to maintain correct position in wheelchair. His foot rests were not in place." Staff interviews are included in the 11/30/10 investigation. E4, CNA, wrote: "11/30/10, (E3), CNA, was pushing R1 in the wheelchair without his foot pedals. R1 reached forward as if he was going to pick something up off the floor. He then fell right on his face." E3's statement is as follows: "On the evening of 11/30/10, at 2:40 PM, I (E3), was returning to the dining room with (R1). As we came to his table, I stopped to move the chair that was there. As I turned back around, (R1) was leaning forward reaching toward the ground. As he was leaning, I attempted to catch him but, he then continued resulting in a fall." In an interview with E1, on 12/7/10, at 1:20 PM, it was stated that the facility did put corrective actions in place after R1's fall on 5/16/10. E1 stated that R1 is to have foot pedals on his wheelchair at all times and there were not any foot pedals on his wheelchair on 11/30/10 when he fell . Hospital emergency room notes, dated 11/30/10, 6:00 PM, show that R1 had a "contusion to the right forehead with mild amount of swelling. There is a 4 centimeter linear laceration running vertically on the right side of the forehead, with active venous oozing. Laceration/Wound Repair - Number of Sutures/Staples: 12. Primary Diagnosis: [REDACTED]." R1's facility nurses notes, dated 11/30/10, 9:56 PM, states "Elder returned from emergency room at 7:20 PM. Has a laceration to right forehead with 13 sutures in place. Had received report via phone from emergency room nurse that CT scan was performed and negative. Sutures to be removed in 5 days. Has steri-strips to top left hand skin tear, 3rd finger right hand, skin tear and right elbow skin tear. Elbow has dressing in place. Head wound has dressing and wrap in place that wrap keeps coming off. Inner aspect of right eye also black."