Every finding on record at Elevate Care Des Plaines

Based on interview and record review the facility failed to follow their Abuse and Retaliation Policy Prevention Program and failed to complete a Resident Assessment Post Alleged Physical Abuse. These failures affect one resident (R5) out of 3 residents reviewed for Resident/Patient/Client Abuse.Findings include:The facilities Long Term Care Facility & IID- Serious Injury Incident and Communicable Disease Report for R5 incident date 7/8/2026 Approx 9:05 AM, Reportable Conclusion reads: Although the R5 has since discharged from the facility, appropriate follow up measures were completed prior to discharge, including reassessment of the residents condition and revision of the care plan as indicated. On 8/7/2026 at 9:56AM V1 (Administrator) stated V1 stated an allegation of physical assault did occur on 7/8/2026 involving R5 and a certified nurse's assistant /CNA. V1 stated R5's alleged physical abuse occurred at approximately 9:00AM on 7/8/2026 and R5 discharged home on 7/8/2026 at approximately 4:00PM. V1 stated an abuse assessment should have been in place and updated for R5's post alleged physical abuse for 7/8/2026 but was not. V1 stated moving forward V1 will confirm care plans and abuse assessment will be updated post allegations and will do 1:1 meeting with social services department and V9.On 8/7/2026 at 2:28PM, V2 (Director of nursing/DON) stated she reviewed R5's assessment and did not see Abuse assessments after R5s alleged physical assault and should have been put in place.Abuse and Retaliation Policy Prevention ProgramIV. Establishing a Resident Sensitive EnvironmentResident Assessment : As part of the residents life history on the admission assessment, comprehensive care plan, and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, history of trauma or misappropriation of resident property, who have needs, triggers, and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches that would reduce the chances of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches regularly and update as necessary.Pattern Assessment: At least quarterly, the quality management committee will review concern identification reports, accidents reports, incident reports, missing item reports, and safety committee reports to assess possible patterns or trends suspicious bruising of residents, unexplained accidents, or other unusual occurrences that may constitute abuse, neglect, mistreatment, or misappropriation of resident property. Based on assessment of the reports, the quality management committee will further investigate and/or determine whether a change in facility practices is warranted.VII. Internal InvestigationQuality Management Review: All investigations will be reviewed and assessed for any corrective action while conducting investigations. Assessment for patterns, like cases, changes in protocol will be done immediately if required and reviewed again.

Based on interview and record review, the facility failed to follow their Comprehensive Care Plan policy by not developing a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the residents highest practical physical, mental, and psychosocial well-being. This failure affects 1 resident (R5) out of 3 residents reviewed for Resident/Patient/Client Abuse.Findings include:On 8/7/2026 at 9:56AM V1 (Administrator) stated an allegation of physical assault did occur on 7/8/2026 involving R5 and a certified nurse's assistant /CNA. V1 stated R5's alleged physical abuse occurred at approximately 9:00AM on 7/8/2026 and R5 discharged home on 7/8/2026 at approximately 4:00PM. V1 stated an abuse care plan should have been in place and updated for R5's post alleged physical abuse for 7/8/2026 but was not. V1 stated moving forward for abuse Care plans, V1 will confirm care will be updated post allegations and will do 1:1 meeting with social services department and V9.On 8/7/2026 at 10:15AM, V9 (MDS Care Plan Coordinator) stated R5's abuse care plan was not in place. V9 stated care plans are reviewed and updated quarterly and as needed. V9 stated an abuse care plan should have been in place and updated to reflect R5's post physical abuse allegation dated 7/8/2026 but was not.Facilities Comprehensive Care Plan revised 11-17-17.Purpose: to develop a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the residents highest practical physical, mental, and psychosocial well-being.Guidelines: Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving.

Based on interview and record review, the facility failed to ensure residents remained free from physical and psychosocial harm. This failure caused right ear and abdominal bruises and mental anguish for 1 of 3 residents reviewed (R3) for abuse in a sample of 8.Findings include:R3 is an [AGE] year-old male admitted on [DATE] with cognition intact as per the Minimum Data Set (MDS) dated [DATE].Review of the reportable incidents document that the facility reported a staff member (V4)'s physical abuse allegation of resident (R3) to the state on 7/8/26. The reportables documented that a full body assessment after the alleged abuse revealed R3 had abdominal discoloration, and the right ear showed purple discoloration on the inner antihelix.On 7/21/26 at 10:30 AM, V1 (Abuse Coordinator/Administrator) stated that on 7/8/26, after being notified by V3 (Assistant Director of Nursing/ADON), staff member V4 and resident R3 were separated following an alleged abuse incident. V1 interviewed R3, who reported that V4 became upset after R3 complained about being dressed in another resident's clothing and struck him in the abdomen and on the right side of the head. V1 observed purple discoloration inside R3's right ear, contacted law enforcement, and removed V4 from the facility. Following the incident, R3 requested to return home and was discharged . V1 stated that residents have the right to be free from abuse.On 7/23/26 at 11:45 AM, V15 stated that she was R3's nurse on 7/8/26 when the alleged abuse occurred. After being called to R3's room by V4, R3 reported that V4 had hit him. Although V15 did not witness the incident, she observed bruising on R3's abdomen and reddish-purple discoloration of the right ear. R3 stated the incident occurred after he told V4 that the clothing being used to dress him belonged to another resident. V15 stated that the visible injuries were consistent with something that had occurred that caused the bruising.On 7/22/26 at 10:30 AM, V3 stated that after being called to R3's room by V15 on 7/8/26, R3 alleged that V4 had hurt him. V3 ensured R3's safety, had V4 escorted from the room, notified the administrator, and remained with R3 while an assessment was completed. During the assessment, R3 identified injuries to the right side of his head/ear and abdomen. V3 observed discoloration to the right ear and bruising on the lower abdomen, although the abdominal bruising may have been related to insulin injections and blood thinner use. Following the incident, R3 requested to be discharged home the same day.On 7/21/26 at 2:30 PM, R3 stated over the phone, Every day, someone helps me put clothes on me, as I need help with dressing. On this day, this person (V4) came to my room screaming to get up. He put clothes on me that were not mine. When I addressed my concern, he grabbed my leg and threw me to the side rail and struck me on my abdomen and right side of my head and ear, causing me a bruise on my right ear. I was kind of like, 'Wow.wow.what's happening here. Am I in the Vietnam War?' I am a veteran from the Vietnam War, and I have PTSD, and I feel like it was the Vietnam War. I don't want a man to come to my room, close my door, and treat me like that. I got discharged from that place on the same day because I don't want to go through this anymore.On 7/21/26 at 9:40 AM, R8 (Resident Council President) displayed a photograph on his phone depicting bruising to R3's right ear. R8 stated that R3 is cognitively intact, does not make false allegations, and expressed his belief that R3 had been physically abused.A review of the facility presented the Abuse and Retaliation Policy Prevention Program document: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, retaliation, misappropriation of property, deprivation of goods and services by staff, or mistreatment.

Based on observation, interview, and record review the facility failed to implement fall preventive measures for a resident who is a high fall risk. This deficiency affects one (R121) of six residents in a sample of 35 reviewed for Falls.Findings include:R121 is an [AGE] year-old admitted to facility on 3/4/24 with the following diagnosis in part but not limited to Acute cholecystitis, type 2 diabetes mellitus with diabetic polyneuropathy, other lack of coordination, abnormal posture, history of falling, repeated falls, presence of right artificial hip joint.R121 Restorative observation assessment dated [DATE] indicates: High risk for falls. R121 Risk fall assessment dated [DATE] indicates: Moderate risk for falls.R121 Care Plan dated 11/2024 At risk for Falls related to gait/balance problems. Interventions include Floor mats at bedside.On 7/7/26 at 10:25AM, R121 observed in bed, with floor mats folded against the wall.On 7/7/26 at 10:35AM, V4 (Certified Nurse Aide) said that floor mats should be placed next to bed when resident is in bed. V4 said she is unsure why the floor mats are not next to R121 bed. On 7/7/26 at 1:11PM, V2 (Director of Nursing) said that if a residents fall prevention interventions in care plan indicate floor mats next to bed, then floor mats should be next to bed when residents are in bed. V2 said her expectations are for staff to place floor mat next to bed for residents with fall risk if the interventions are indicated. Facility Policy on Fall Prevention Program revised 11/21/17, Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices utilized as necessary. Quality Assurance Program will monitor the program to assure ongoing effectiveness. Guidelines: The fall prevention program includes the following components. -methods to identify risk factors, -methods to identify residents at risk, -assessment time frames, -use and implementation of professional standards of practice, -immediate change in interventions that were successful, -Care plan incorporates: *Identification of all risk/issue, *Addresses each fall, *Interventions are changed with each fall as appropriate *Preventative measures. Standards: -A fall risk assessment will be performed by a licensed nurse at the time of admission. The assessment tool will incorporate current clinical practice guidelines. -Safety interventions will be implemented for each resident identified at risk. Fall/Safety interventions may include but are not limited to: -Direct care staff will be oriented and trained in the fall prevention program. -Resident will be observed approximately every two hours to ensure the resident is safely positioned in the bed or chair and provide care as assigned in accordance with the plan of care.

Based on interview, observation, and record reviews, the facility failed to provide timely assistance with toileting/incontinent care and personal hygiene for three (R4, R5, R6) of four residents reviewed for ADL care.Findings include:1. R4 is a [AGE] year-old, female, initially admitted in the facility on 10/20/22 with the following diagnoses: Type 2 Diabetes Mellitus without Complications; Encounter for Attention to Tracheostomy; Dependence on Respirator Status; Morbid Obesity with Alveolar Hypoventilation; Chronic Obstructive Pulmonary Disease, Unspecified; Neuromuscular Dysfunction of Bladder, Unspecified; and Lymphedema, Not Elsewhere Classified. MDS (Minimum Data Set) dated 04/25/26 recorded R4's BIMS (brief interview for mental status) score is 15 which means little to no impairment in cognition.On 06/15/26 at 10:50 AM, V9 (Certified Nurse Aide, CNA) was observed providing incontinent care on R4. R4 has indwelling urinary catheter draining to urinary bag. R4 does not wear incontinent brief. R4 uses incontinent pad that was placed under her bottom to absorb bowel leaks. During incontinent care, dried feces were observed on her (R4) lower back. The pillowcase and pillow under her back was also soiled with feces as well as the incontinent pad and bed sheet. R4 was asked regarding issues with incontinent care and call light responses. R4 stated, When I pushed the call light, sometimes I need to wait for long periods of time, especially the night shift. I called this morning, she (V9) came and said she is going to change another resident first. I waited for several hours just to clean me up; right now, I am sitting on my feces. I pushed the call light, and no one came until now. V9 was asked on how often incontinent care is provided on R4. V9 replied, This is the first time she will be cleaned. I checked on her at 7:30 AM. Residents are changed when needed. It had been 3 hours and 20 minutes since R4 was last checked for incontinent care.2. R5 is a [AGE] year old, male, admitted in the facility on 02/24/26 with diagnoses of Parkinson's Disease without Dyskinesia, without Mention of Fluctuations; Unspecified Intracapsular Fracture of Right Femur, Encounter for Closed Fracture with Routine Healing; Presence of Right Artificial Hip Joint; and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. MDS dated [DATE] documented R5's BIMS score of 13 which means little to no impairment in cognition.On 06/15/26 at 11:15 AM, R5 stated I want to get changed. This would be the first for this morning. I need to change; I am wet now. Per V11 (Certified Nurse Assistant, CNA) R5 was checked at 8AM and he (R5) said he was okay. Incontinent care was provided to R5 at 11:25 AM.3. R6 is a [AGE] year-old, female, admitted in the facility on 04/09/26 with diagnoses of Displaced Intertrochanteric Fracture of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing; and Wedge Compression Fracture of T7-T8 Vertebra, Subsequent Encounter for Fracture with Routine Healing. MDS dated [DATE] recorded R6 has BIMS score of 15 which means little to no impairment in cognition.On 06/15/26 at 11:45 AM, R6 stated, It takes a while to answer my call light, sometimes I wait for an hour. I have been trying to get me change now and it's been an hour or more that I have been waiting. I have been wet and needed to get changed. When I used my call light, they came and said they were coming but never came.On 06/16/26 at 1:37 PM, V2 (Director of Nursing) stated, Residents are checked and changed at least every 2 hours.On 06/16/26 at 2:54 PM, V17 (Registered Nurse, RN), V14 (CNA) and V18 CNA were asked on how often incontinent care is provided on residents. V17 stated, I do my rounds and check residents every two hours and if they need to get change, we change them. V14 and V18 both stated that incontinent care on residents is implemented every one to two hours, check and change when needed.Facility's policy titled Incontinence Care, dated 4-20-21 stated in part but not limited to the following:Purpose: To prevent excoriation and skin breakdown, discomfort and maintain dignity.Guidelines: Incontinent resident will be checked periodically in accordance with the assessed incontinent episodes or approximately every two hours and provided perineal and genital care after each episode.

Based on observation, interview, and record review, the facility failed to follow its Respiratory Care Equipment and Supplies policy by failing to change ventilator circuits and filters. This applies to 1 of 3 residents (R1) reviewed for ventilator (Vent)/Tracheostomy (trach) care in a sample of 3.The findings include:R1 is a [AGE] year-old male admitted on [DATE] with cognition intact as per the Minimum Data Set (MDS) dated [DATE].A review of the face sheet documented that R1 was admitted with an admitting diagnosis, including tracheostomy, ventilator dependence, and neuromuscular dysfunction of the bladder.On 3/24/26 at 10:50 AM, R1 was observed in his bed with his spouse, with a Vent/Trach setup and cough assistance. R1 was observed with a dirty-looking ventilator circuit (blue tube from ventilator to tracheostomy) and a filter dated 2/20.On 3/24/26 at 10:50 AM, R1 and his spouse (V4) stated, The facility is not changing the vent circuit every month, which can cause infection. I have a different type of ventilator with cough assistance. Last time my vent circuit was changed on February 20th, as the label indicates, and it has been over a month.On 3/24/26 at 11:35, V5 (Respiratory Therapist) stated, We have his vent circuit and filters to change. I agree that those vent circuits and filters should be changed every 30 days. I was waiting for the first of next month.On 3/24/26 at 1:10 PM, V2 (Director of Nursing/DON) stated that the vent circuit and filter should be changed as per our policy to avoid respiratory infections.A review of the disposable supply change schedule on the facility's Respiratory Care Equipment and Supplies policy document: ventilator circuit and air intake filters need to be cleaned and replaced every 30 days.

Based on interview and record review, the facility experienced a power failure related to an area wide power outage. The facility's backup generator failed to provide back up power for the facility as it is designed to do during a power outage. The facility failed to ensure the safety of all residents dependent on life-sustaining equipment related to inability to provide electricity to life sustaining devices during the power failure. The facility failed to document the generator was in working order by completed weekly testing and monthly testing under load to ensure the backup generators availability in an emergency. These failures resulted in an immediate jeopardy because the failure of the backup generator to properly function at the facility caused every resident dependent of life sustaining devices to be at risk for health and safety. This widespread power failure affected the entire facility including 14 ventilator-dependent residents dependent on life-sustaining equipment putting them at risk for acute respiratory distress and causing them to be sent to the hospital via ambulance.The Immediate Jeopardy began on 09/20/25 at 9:30PM when an area wide electrical power loss caused the facility generator to fail, and the emergency generator power did not activate as designed to backup the main building power source. All areas of the facility and electrical and medical devices requiring electrical power failed to continue to operate which included:-All residents on mechanical ventilators-All residents on tube feeding pumps-All residents utilizing air mattresses-All mechanical lifts-and other departmental functions using electricity.On February 17, 2026, at 2:02PM the facility administrator was notified of Immediate Jeopardy.The facility presented an acceptable removal plan on February 25, 2026, at 12:25PM. The removal of immediacy was validated onsite by the surveyor with interview and record review of steps taken by the facility to implement their Emergency Management Plan. While the immediacy was removed on 2/25/2026, the facility remains out of compliance at a level two due to additional time needed to evaluate the implementation and effectiveness of the plan of correction.Findings include:V1, Administrator on 02/09/26 3:18PM- stated On September 20, 2025, at 9:26 PM, the primary utility power failed. The facility's emergency generator did not engage. V1 said, I came to facility around 9:45PM or before 10PM and the door was already propped open due to V12 (Maintenance Director) opening it. The facility was all dark and I pulled out my emergency prep binder and contacted all the consultants to come in and we pulled out the binder with all the face sheets in case we needed to prepare for evacuation and called the local fire department that we may need to evacuate. I called the hospitals in the area to see if they could accept our patients in event of an evacuation. I confirmed that V12 (Maintenance Director) was working on the generator trying to trouble shoot it and he contacted the generator's contractor, and I gave direction to my team to send emails to families letting them know of the situation. I started with my ventilator patients and the fire chief already came into the building even before I got there. They (electric utility company) came out and they still needed a different team from (electric utility company) to come out because the current team didn't know how to manage the situation. The generator had not kicked in and so I made sure respiratory had attached liquid oxygen and we started this around 11:26 PM and carried the residents through the stairs and staff lit up the stairs flashlights. V1stated the root cause of the generator failure as, The gas tank wires that activated the generator burned out. The generator service company thinks what happened is that the tank that holds the gasoline may had condensation and caused the water and gas to mix and when it transported through the wire, that the mixture burned out the generator. V12 on 2/9/25: Maintenance Director agreed to provide any maintenance logs and testing along with the generator service company visit papers. Review of the facility's maintenance records at the time of the survey found no evidence of monthly load-bank testing or weekly generator inspections for the three months preceding the outage on 09/20/25.V12 on 02/09/26 at 10:14AM: Maintenance Director confirmed that the emergency outlets (Red Plugs) remained without power until a portable generator was sourced and connected at 12:41 AM on the following morning September 21, 2025.The facility's Emergency Operations Plan, Section 4.2, states: If a ventilator battery does not continue operating or power is lost, manual ventilation (Ambu-bagging) must be initiated immediately.V8, RN on 2/9/26 at 4:18 PM: stated he was working a double shift, having started at 7:00 AM and remaining on duty until 11:00 PM (and subsequently until 1:00 AM due to the outage). V8 stated that during this 16-hour period, he did not initiate manual ventilation or conduct specialized respiratory monitoring, stating, 'You had to balance yourself. I didn't do anything to the ventilator patient, it's not my thing.V8 on 02/09/2026 at 4:18 PM with (V1 administrator present), V8 (RN) said I remember that evening. the power went out and it was still light outside and was a couple hours into my shift so maybe 5 or 6 o'clock PM. I stayed there until 1 AM. We put the ventilators into the red outlets, and we watched all the patients' rooms., V8 said he didn't know if ventilators should be plugged into the red outlets but that he switched the plugs from the regular outlets to the red emergency outlets. V8 went on to say that he focused on (R1) because she was on ventilator. V8 stated regarding nursing interventions for R1, I didn't do anything to the ventilator patient, it's not my thing. There is nothing you can do but see if it's warm in the facility since there's no air conditioning since it went out. V8 stated regarding nursing interventions during the emergency situation, Nothing happened except with the power, and I checked to see if (R1) was breathing and if she's in distress. regarding why there was no documentation to show his nursing actions, V8 said, I couldn't document at that time because there was no computer power and when I left it did not come back between 12 and 1 AM. V8 stated regarding other actions taken for any other residents, No I didn't monitor any other residents at that time. We didn't have a lot of staff and so you had to balance yourself. I focused mostly on (R1).V7 on 2/9/2026 at 2:55 PM: confirmed the unit was in total darkness and that manual ventilation was not performed for any of the 14 ventilator dependent residents during the power outage. the nurse on duty at the time of the outage said, The outage started approximately at 9-9:30 (PM). I was there until 2 AM because the paramedics came around 10:30 PM and they asked us if we have a ventilator unit. Meanwhile we attached ventilators to the red emergency outlets. V7 could not verify if there was any power coming from the emergency outlets, V7 said, no all the lights went out, so I called V6 respiratory therapist and told her the light is not coming and everything is dark. We noticed everything is dark on the ventilator and so the RT told me to bring oxygen cylinders. I did 4 or 5 patients, and I put in plugs into emergency outlets to the generator. There was still no power and it was dark. The power came back around 1:15 -1:45 AM before I go home.On 2/11/26: A review of personnel files found that V8 (RN) lacked a documented competency evaluation for ventilator management or emergency respiratory procedures (Ambu-bagging).As of 2/11/26, V8's personnel file lacked a documented competency evaluation for management or emergency respiratory procedures (ambu-bagging)V13 on 2/11/2026 at 1:46 PM identified herself as being one of the nurses working on the eastern side of the ventilator floor and stated regarding where the backup batteries were stored for the ventilators in case of a power failure, V13 stated, I'm sorry, I don't know where they are, nobody told me.V14 on 2/11/2026 at 2:16 PM stated the other nurse on the ventilator floor was asked about the backup batteries for ventilators and stated, I also did not know where to find any backup batteries or where any were stored in case of ventilator battery failure.Facility's undated policy titled, Emergency Operations Plan- Loss of Electrical Power, with a Generator reads in part: Objective: Facility will assure that residents remain safe and comfortable in the unlikely event of a full power outage. Facility is equipped with an emergency generator set which will provide a minimum of 200 hours of emergency power prior to refueling. Procedure: Facility will prepare for a loss of electrical power, with a generator as follows: Upon loss of electrical power, Administrator will determine the likely time of power restoration by contacting Electric Utility Company. Administrator will contact CHUG to begin process of determining bed availability within the immediate area, should evacuation be needed. Nursing Functions: Non-ambulatory residents will remain on their units under close supervision. Nursing staff will ensure that all medical equipment and low air loss beds are energized by utilizing red emergency power plugs throughout the facility. Nursing staff will continually assess residents during this period to assure their physical and emotional wellbeing. Respiratory Functions: Non-ambulatory residents will remain on their units under close supervision by the respiratory therapist. Respiratory staff will ensure that all medical equipment and low air loss beds are energized by utilizing red emergency power plugs throughout the facility. Respiratory staff will continuously assess residents during this period to assure respiratory percentage and levels remain safe.The facility presented an acceptable removal of immediacy plan on February 25, 2026, at 12:25PM, which was validated by the surveyor through interview and record review of steps taken by the facility to implement their Emergency Management Plan. The removal plan included the following:-The facility has an emergency policy and procedure system in place on what to do if the facility's electrical system is affected. The policy was reviewed and revised on 02/17/2026-The emergency policy and procedure affecting the facility's electrical system is reviewed upon hire during orientation and educated on annually.

Based on interview and record review, the facility failed to ensure residents dependent on life-sustaining medical equipment received the specialized respiratory care and continuous clinical monitoring essential to prevent life-threatening complications. during a total facility power loss. These failures affect all residents (R1-R15) who are ventilator dependent.This failure resulted in all ventilator department residents being sent to the hospital to maintain health and safety and placed R1-R15 at risk for Acute Respiratory Distress, Acute Respiratory Failure and Death.The Immediate Jeopardy began on [DATE] at 9:30PM when an area wide electrical power loss caused the facility generator to fail, and the emergency generator power did not activate as designed to backup the main building power source. All areas of the facility and electrical and medical devices requiring electrical power failed to continue to operate. The Facility Emergency Management Plan designed to mitigate these types of emergencies was not effectively activated and implemented and all ventilated residents were evacuated to the hospital. On February 17, 2026, at 2:02PM the facility administrator was notified of Immediate Jeopardy. The facility presented an acceptable removal plan on February 25, 2026, at 12:25PM. While the immediacy was removed on [DATE], the facility remains out of compliance at a level two due to additional time needed to evaluate the implementation and effectiveness of the plan of correction.Findings include:R1's care plan states that she is a [AGE] year-old female with diagnoses including, in part, Chronic Respiratory Failure and COPD.V1, Administrator stated on [DATE] at 9:26PM: The emergency backup generator failed to activate, resulting in a total loss of electrical power to the specialized ventilator unit. The facility remained without electrical power for 3 hours and 15 minutes, until power was restored on [DATE] at 12:41AM.V11 on [DATE] at 1:31PM stated that she documented in the EHR (Electronic Health Record) the final clinical assessment of R1's respiratory status, including ventilator settings and suctioning needs for R1. R1's care plan and POS (Physician's Order Sheets) stated that R1 required full mechanical ventilation via a tracheostomy.R1's EHR for [DATE]-1:31PM-[DATE] 12:05AM showed no clinical monitoring was documented for R1, the medical records contain no documented respiratory assessments, ventilator checks, or evidence of clinical monitoring for R1. V6 (RT) Respiratory Therapist on duty at the start of the power outage, failed to document any respiratory assessments, ventilator checks or clinical monitoring for R1. No documentations of assessments for R1 were able to be presented during the survey, when requested for the duration of the power outage and generator failure.Timeline of events of [DATE]The facility's clinical nursing status during the power failure was characterized by the following:Staffing: One (1) respiratory therapist on-site with documented competency to manage life-sustaining equipment for 14 ventilator-dependent and 6 tracheostomy residents. Nursing: The ventilator unit was staffed with 2 nurses (V7 and V8) and 2 nurse's aides. The Registered Nurse V8 (RN) on duty was working a consecutive double shift exceeding 14 hours per V8 and schedule for [DATE]. V8, RN on [DATE] at 4:18 PM with V1 administrator present said I remember that evening. the power went out and it was still light outside and was a couple hours into my shift, so maybe the power went out around 5 or 6 o'clock. I stayed there until 1 AM. We put the ventilators into the red outlets, and we watched all the patients' rooms. Surveyor asked, should the ventilators be plugged into the red outlets from the beginning?, V8 said he didn't know but that he switched the plugs from the regular outlets to the red emergency outlets. V8 went on to say that he focused on (R1) because she was on ventilator. Regarding nursing interventions for R1, V8 said, I didn't do anything to the ventilator patients, it's not my thing. There is nothing you can do but see if its warm in the facility since there's no air conditioning since it went out. V8 stated what he did as nursing interventions during the emergency outage, V8 said, Nothing happened except the power was all out and dark and I checked to see if she was breathing and if she was in distress. V8 stated regarding how this was conducted and where he documented his nursing actions, V8 said, I couldn't document at that time because there was no computer power and when I left it did not come back on until between 12 and 1 AM. V8 stated regarding any other actions he performed for any other residents he cared for, V8 said, I didn't monitor any other residents at the time. We didn't have a lot of staff and so you had to balance yourself. I focused mostly on R1.V7 on [DATE] at 2:55 PM, stated that, at the time of the outage said, The outage started approximately at 9-9:30PM. I was there until 2 AM because the paramedics came around 10:30 PM and they were questioning us, and we said that we have a ventilator unit. We noticed everything is dark on the ventilator and so the RT told me to bring oxygen cylinders. I did 4 or 5 patients, and I put ventilators [power] plugs into emergency outlets to the generator. The power came back around 1:15 -1:45 AM before I go home.Facility's undated policy/procedure titled Emergency Operations Plan during Loss of Electrical Power, with a Generator reads in part (but not limited to): Should battery on ventilator not continue operating when unplugged from electrical outlet, manual ventilation should be initiated via Ambu-bag located at each resident bedside. Ambu-bag should be connected to oxygen source liquid gas E-tank immediately. Nursing staff will continually assess residents during this period to assure their physical and emotional wellbeing. Respiratory staff will continually assess residents during this period to assure respiratory percentage and levels remain safe. As of [DATE] at 4:18PM V1 and V4 were not able to provide documented evidence that manual ventilation was initiated for R1 or the other ventilator-dependent residents once staff realized the red outlets were non-functional.V1 on [DATE] at 3:00PM stated R1 was removed from the facility on [DATE] and taken to the local hospital via ambulance. The hospital admission records shows R1 was admitted minutes prior to power restoration at the facility, after being in the facility since the power failed without documented evidence of respiratory monitoring or nursing interventionsXXX[DATE] R1's clinical laboratory tests upon admission to hospital from the facility showed elevated lactic acid levels (3.6 mmol/L) normal lab values levels are 0.5-2.2mmol/L. Elevated lactic acid levels in a clinical setting can be a medical marker used to identify tissue hypoxia and metabolic stress sustained during periods of respiratory compromise. Lactic acid is a byproduct of anaerobic metabolism that occurs when cells are deprived of oxygen. (retrieved from American Association of Respiratory care https://www.aarc.org/ 02/26)R1 expired in the hospital on [DATE] due to Chronic Respiratory Failure and Chronic Obstructive Pulmonary Disease as list on the death certificate. The facility presented an acceptable removal plan on February 25, 2026, at 12:25PM which was confirmed onsite by the surveyor by interview and record review. The removal plan included the following:-updated Emergency power outage plan.-updated staffing plan for emergencies-updated command list for Key personnel outlining responsibilities of responsible individuals.-created plan to monitor and track maintenance of life maintaining equipment.-QA tool to monitor and compliance.-facility reviewed and updated staffing plan

Based on observation, interview and record review, the facility failed to ensure a resident remained free from staff to resident abuse for one of three residents (R1) reviewed for abuse. This failure resulted in R1 sustaining physical injuries and R1 being transported to the emergency department for treatment, ultimately resulting in R1's request discharge against medical advice due to fear and dissatisfaction with the facility. R1 is a [AGE] year-old with diagnoses including heart failure, epilepsy, hypertension, hyperlipidemia and anxiety disorder. On 7/18/25 at 1:50 PM, V1 (Administrator) said she was the abuse prohibition coordinator and was present in the building due to flooding in the basement that evening she was trying to address when V4 nurse had an altercation with the resident R1. V1 indicated she was told by the resident that V4 hurt his wrists and chest during the altercation and that the resident called 911 and police and fire department came to speak with resident. V1 said she personally walked V4 out of the building at around 8:30 PM to investigate the incident and that she had reviewed the facility security closed circuit television (without audio) but did not believe V4 was at fault however suspended the staff member to follow their abuse policy. V1 then offered to show the video surveillance to the surveyor. Facility security video footage (without audio) captured the incident. Although the verbal exchange could not be heard, the footage showed V4 pointing and motioning aggressively to R1 to return to his room. The video also showed physical interaction consistent with the R1's account, including a posture and mannerisms by the nurse (V4) suggestive of an aggressive and confrontational stance. The video footage further supported that the situation escalated instead of being diffused. V4 is seen motioning with his hands for R1 to come towards him whereupon R1 appears to dash down the hall with clenched fists and confronts V4. V4 appears to remain in place instead of walking away from the situation in order to diffuse further escalation. There appears to be a verbal exchange between V4 and R1. V4 again instead of walking away, appears to push R1 away from him and makes contact with the resident's chest and hands. V4 continues to make motions with his hands and points in the direction down the hall in an effort to tell the resident to go back to his room. The whole exchange lasted over 2 minutes whereupon the resident disappears from camera view and V4 returns to nursing station. On 7/19/25 at 3:30 PM, R1 said, a male nurse treated me like some dog. I asked him to go see what's going on with another female resident who kept screaming and screaming and she sounded like she was in a lot of pain, and no one was paying attention to her. I asked this male nurse to go help her and he shouts down the hall to me to quiet down and that it wasn't his patient and to go back to my room. This really upset me because he treated me like I was some mental patient, and this angered me. He kept arguing with me that it wasn't his patient and to stop telling him what to do. He motioned to me to come to him like I was some dog as if he wanted to fight me, so I did that and went over to him, but I didn't hit him or anything, but he was pointing his finger at me and kept motioning to me to get the hell away from him instead of addressing the situation. He pushed me away and that's when I think he hurt my chest, and I must have banged my elbow, but I was so angry that I can't really recall all the details. He's a nurse and should not treat patients this way so I told this when I was in the ER (emergency room.). R1 returned to the facility after treatment but expressed to staff the following day that he no longer felt safe and requested discharge against medical advice. R1 said he was being watched by V3 social worker and other staff and he was treated like an animal and wanted to go somewhere else instead where staff were kind. R1 stated R1 was trying to get another patient some help.On 7/18/25 at 3:30 PM, V3 (Social Service Director) said that he is involved in the orientation of new employees, but that part of his orientation does not include anything related to de-escalation of behaviors but more so a general summary of dementia and emphasis on elopement prevention. On 7/18/25 at 4:10 PM telephone interview, V4 (LPN) said that he did not have any physical contact with the resident and denied raising his voice to the resident. V4 said that R1 placed his chest against his chest and his arms were at his side and he tried to control himself. Surveyor asked what he meant by trying to control himself and asked if R1 made him angry, V4 said that he meant that he wanted to try to make the resident calm was what he meant to say but admits that he was unable to calm the resident down. Surveyor asked where his arms were when this altercation came about, V4 said that his arms were at his side all the time. Surveyor asked if he raised his voice, shout at the resident, or used any type of harsh language, V4 said that he told (R1) that the resident that was screaming was not his and that he had the resident to go back to his room numerous times, but the resident did not listen to him. V4 indicated he had past dementia training but not this current facility. V4 denied de-escalation training on resident behaviors. V4 indicated he was not shown the video. On 7/18/25 at 4:30 PM, V5 LPN said V5 was the other nurse on duty the night of the incident (7/16/25) did not witness the altercation between R1 and V4 as she was busy in another room attending to a different patient however heard a loud argument down the hall. V5 said she heard the resident (R1) screaming at V4 but did not hear V4 saying anything back to the resident. V5 said she heard an argument but only heard R1 shouting. V5 again said, that she heard R1 but said that V4 did not say anything to the resident. V5 stated V5 did not observe what was written in the note, No I was busy in another room. Review of V5's nursing note entry does not align with her statement to the surveyor. On 7/16/25 at 8:30 PM, V5 (LPN) wrote, R1 approached Nurse V4 (LPN) and requested that he check on another resident who was asking for help. Nurse V4 responded promptly and went to assist the other resident. Upon returning, Resident appeared upset and began yelling at Nurse (V4), demanding that he go back and check on the resident again. Resident became increasingly agitated and attempted to physically punch (V4). Nurse V4 raised his hand to block the punch. Nurse V4 then instructed R1 to return to his room and refrain from further aggressive behavior. Shortly after the incident, Resident alleged that Nurse V4 had struck him and requested that the police be contacted. Due to the escalation and the resident's emotional state, the decision was made to send R1 to the emergency room (ER) for further evaluation and safety assessment. Supervisor was notified.Facility abuse policy revised 2022 reads in part, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this guidance is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents.Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention (77 Ill. Adm. Code 300.330). Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individuals' age, ability to comprehend, or disability.

Based on interview and record review, the facility failed to follow physician orders by failing to monitor and apply a resident's negative pressure wound therapy and dressing for a resident with necrotizing fasciitis to the right foot. These failures affect one of three residents reviewed for wound care. This failure resulted in R2 not receiving wound treatment for 5 hours, calling 911, and being transported to local emergency room. Findings include: R2 was admitted to the facility on [DATE] with a diagnosis of necrotizing fasciitis, sepsis, type II diabetes, polyneuropathy and anxiety disorder. R2's brief interview for mental status dated 4/14/25 documents a score of 15/15 which indicates cognitively intact. R2's physician order dated 4/9/25 documents: Right dorsum and plantar foot - Cleanse with Normal Saline Solution (NSS)/wound cleanser, apply negative pressure wound therapy (NPWT) at 125 mmHg (milimeters of mercury) continuous setting every day shift every Tuesday, Thursday, Sunday and as needed. On 4/22/25 at 2:23pm, R2 who was alert and oriented at time of interview said she had a bad wound on her right foot. R2 said on Saturday morning (4/19/2025) she took a shower by herself and disconnected the negative pressure wound therapy . R2 said there was a strong odor coming from her foot and she wrapped her right foot with a towel. R2 said she saw the wound care nurse down the hall after her shower and asked her to come see her but she never came. R2 said she told the social worker and nurse that she needed to see the wound care nurse but they never came. R2 said she waited until around 4 or 5 and said she decided to call 911 because no one was taking care of her foot. On 4/22/25 at 3:53PM, V9 (Certified nursing assistant, CNA) who was assigned to R2 for morning and evening shift was unable to recall if her negative pressure wound therapy was connected during her shifts. V9 said R2 had requested to see the wound care nurse, was unsure of the time but was during the first shift. V9 said the wound care nurse was on the floor and assumed she would see R2 when they did rounds. V9 did not inform anyone of R2's request for the wound care nurse. V9 said she was unsure if R2 was ever seen by wound nurse. On 4/24/25 at 1:34PM, V6 (nurse) who was assigned to R2 day shift 7-3. V6 said R2 wanted to see the wound nurse around 1100am but unsure if she was seen. V6 unable to recall if she called wound care nurse or paged her. On 4/24/25 at 2:21PM, V14 (social service director) said he was manager on duty on 4/19/2025. V14 said around 11:00 AM, he saw R2 yelling out in the hallway about her foot was in pain and her negative pressure wound therapy device had come off. V14 said R2 was observed with a bath towel around her right foot. V14 said he informed the floor nurse of R2's request to see the wound care. On 4/25/25 253PM, V15(front desk) said she saw R2 at the front desk and she was complaining about her foot. R2 reported the wound care nurse saw her in the hallway but did not come to see her to give her treatment. V15 said she paged the wound care and never received a call back. V15 said she paged again and no return call, V15 said she saw wound care nurse on the unit and just assumed she would eventually make it to R2. V15 did not inform anyone of R2's request or do anything further for R2 request. On 4/22/25 at 3:12PM, V7(nurse) who was assigned to R2 on the evening shift 3-11. Around 3:30, R2 reported that she wanted to go to the hospital to get her wound looked at. V7 said R2 negative pressure wound therapy was disconnected and there was a towel around her right foot. On 4/24/24 at 12:38PM, V13(wound care nurse) said she saw R2 in the morning around 8:00AM. R2 said she put a transparent dressing on her foot which was intact and wound drainage container which was about a quarter full. V13 said she did not see R2 after that encounter and did not receive any reports, concerns, or requests about R2. V13 said if she was aware that R2 needed to be seen she would have seen R2 during her shift. V13 said sometimes they will page her, but she does not hear it when she is in a resident room. On 4/25/25 2:48PM, V2 (ADON) said if staff need to contact the wound care nurse on duty, they would call them on their cell phone or call their office. They can leave a message in mailbox or email. V2 said its not standard protocol to page staff if needed. If a resident is requesting for wound care the nurse should call the wound care nurse. If wound care nurse is not available than they would document, and resident would be seen by wound care next day. V2 said if R2 removed her wound vac or dressing she has an as needed order that should have been followed. On 4/25/25 at 1:29PM, V16 (wound nurse practitioner) said negative pressure wound therapy helps to decrease moisture, aide with healing and help blood flow to the area. If a resident is noncompliant with device, it may be needed to change treatments to a daily dressing. If device is removed or turned off it puts the patient at risk for infection or wound to become larger. R2's April's medication administration record and treatment administration record reviewed with no documentation of any treatments provided to R2 on 4/19/25. Records reviewed do not document any monitoring or checks to R2's negative pressure wound therapy R2's progress note dated 4/19/25 at 6:28PM documents: Resident was noted to be non-compliant with prescribed wound care treatment. She independently removed her wound vac device and placed a towel over the open wound. Upon intervention, resident became visibly upset, began crying loudly, and was inconsolable. Nursing staff administered prescribed pain and antianxiety medications for symptom management. Despite being informed that wound care would be continued in-house, resident insisted on being transferred to the hospital for wound treatment. AMA (Against [NAME] l Advice) paperwork was offered; However, the resident refused to sign. Subsequently, the resident contacted 911. Paramedics arrived and transported the resident to the hospital. There were no other documented nursing progress notes on 4/19/25. R2's care plan dated documents: The resident has post surgical wounds post necrotizing fasciitis to the right dorsum foot and right planter foot, diabetic ulcers to the left ankle, blister on the left dorsum foot, and bruise on the right lower abdomen, and has potential for further skin impairment r/t resistance/non-compliance to care, diabetes, and limited mobility. Interventions include: Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short; Educate resident/family/caregivers of causative factors and measures to prevent skin injury; Encourage good nutrition and hydration in order to promote healthier skin; Follow facility protocols for treatment of injury; Keep skin clean and dry. Use lotion on dry skin. Do not apply on (Specify: site of injury); Monitor for side effects of the antibiotics and over-the-counter pain medications: gastric distress, rash, or allergic reactions which could exacerbate skin injury; Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD (medical doctor); Obtain blood work such as CBC (complete blood count) with Diff (differential), Blood Cultures and C&S (culture & sensitivity) of any open wounds as ordered by Physician; Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface; Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. R2's ambulance run report dated 4/19/25 at 4:03PM documents: (ambulance identifier) dispatched to the incident location for a sick person. Upon arrival, crew found R2 Alert and oriented x4 sitting upright in the nursing home lobby awaiting Emergency Medical Service arrival. Patient advises the crew that she has a chronic open wound on her right foot that she needs care for but has not received. Patient and the patient's husband advises the crew that she has been requesting wound care for the past 5 hours and pain management, but has been ignored by the nursing staff and told they would come back. Crew notes large, deep, and weeping open wound that wraps around the entire right foot. Patient has a wound vacuum to use but is not currently in use and is at the patient's side. Just prior to the crews arrival, patient was administered10-325mg of hydrocodone orally by the nursing staff per the patients PRN records. Patient advised that she was fed up with the nursing staff and needed to be transported somewhere that they would actually care for her. Patient advises the crew that she was sepsis and is currently 7 days into her cephalexin treatment. R2's hospital record dated 4/19/25 documents: R2 presents with right foot pain and erythema form nursing home with not getting proper wound care treatment today. Under skin documents chronic wounds over dorsum and plantar aspects of the right foot, pink granulation tissue with exposed tendon. Erythematous skin surrounding the wounds, swelling to the foot as well. Facility grievance dated 4/19/25 documents R2 around 3:47PM, writer was informed that R2 was asking to go to the hospital for swelling and pain. R2 states she ran into the wound care nurse in the morning and requested her to come and visit her. Wound care nurse still had not come to the room. Facility policy revised 05/17 titled Wound care documents to protect the wound from contamination and control bleeding. Under Wound care documentation documents follow physician ordered for wound care.

Based on observation, interview, and record review, the facility failed to follow their policy and procedure for hydration and tube feeding tube care by not ensuring that a resident received the recommended amount of fluids for a resident who is dependent on tube feeding for nutrition. This failure applied to one (R1) of four residents reviewed for hydration and resulted in R1 being hospitalized with diagnoses including dehydration, high blood sodium, and hypotension (low blood pressure). Findings include: R1 is a [AGE] year-old male with a diagnoses history present on admission of Brain Damage due to Oxygen Deprivation, Bacterial Infection, Epilepsy, Congestive Heart Failure, Stage 4 Pressure Ulcers, Acute Kidney Failure, UTI's, Trach Use, and Feeding Tube Use who was admitted to the facility 07/27/2024. On 02/10/2025 at 10:29 AM Observed R1 in his room lying in his bed unable to speak, bed bound, and receiving a enteral nutrition via a tube feeding. R1's current care plan documents he has potential for impaired nutrition related to acute and chronic medical conditions, wound, being tube feeding dependent, and receives nothing by mouth with interventions including; registered dietitian to provide monthly nutrition assessment and evaluate fluid needs and adequacy/appropriateness of current feeding regimen, and report any early signs of fluid overload or dehydration to the physician for further medical evaluation. R1's Monthly Enteral/Skin Note created by V9 (Registered Dietitian) dated 11/01/2024 documents R1 was being readmitted from a hospitalization and was receiving an enteral flush of 30ml of every 4 hours with recommendations to increase his flush back to 200ml every four hours the new flush would provide 2297 ml of fluid. R1's physician order history includes an order effective from 10/31/2024 to 12/02/2024 for flushing his feeding tube with 30ml and of water every four hours. R1's November and December 2024 Medication Administration Records documents he was receiving a flush with 30ml of water every four hours from 10/31/2024 to 12/02/2024. R1's progress note dated 12/2/2024 08:02 Writer spoke with a Registered Nurse at the hospital and was notified that the resident's blood pressure remains severely low, and resident is dehydrated. R1's hospital record dated 12/02/2024 documents he was admitted to the emergency room from the nursing home due to significant hypotension, was evaluated and received a primary diagnosis of dehydration, and of high blood sodium and chloride and acute kidney injury; he was assessed on admission to be profoundly dehydrated with an acute renal insufficiency and high blood sodium and it was noted that he was likely hypotensive related to these diagnoses. 02/13/2024 at 1:12 PM V2 (Director of Nursing) reported that on admission there is a section of the admission assessment that addresses nutrition and the RD (Registered Dietitian), Nurse Practitioner, Physician's Assistant, and Physician are made aware of residents enteral feeding orders received from the hospital and the orders are reconciled on admission. V2 reported the RD then further evaluates the resident's needs, makes recommendations for changes to formula, volume and flushes, and labs are also ordered on admission and readmission. V2 reported labs are ordered and evaluated by the RD, Nurse Practitioner, Physician's Assistant, and Physician and the facility uses pumps for enteral feedings and flushes and these are to be signed off on Medication Administration Records. V2 reported a collaboration of nurses assessments, weights, labs, and RD/Nurse Practitioner/Physician evaluations and recommendations are used. 02/13/2024 at 2:23 PM V2 (Director of Nursing) stated after the RD (Registered Dietitian) makes a recommendation the nurses are to call the physician to see if they agree with the orders and the orders are changed if the physician agrees. V2 stated typically the RDs will put in orders if they change the actual feeding, and the nurses verify the orders so there is a two-step process. V2 stated once the nurse confirms the orders and the orders they are verified in the resident's medical chart under physician orders. V2 stated if a flushing order was needed for R1, and it was not entered it could affect his electrolytes and his hydration. V2 stated if R1 was not receiving enough fluids and the RD recommended an increase in flushes this could possibly cause dehydration because his urine output might decrease. V2 stated fluid intake for R1 is monitored by observing feeding tube flushes and how many cc's (cubic centimeters) of fluid he receives an hour through enteral feeding and his fluid output is monitored by observing whether there is a decrease in how many times he receives incontinence care, whether there is a urine odor, or if incontinence products used may become discolored because of urine concentration. R1's progress notes from 11/01/2024 - 12/02/2024 did not include any communication with his physician regarding V9's (Registered Dietitian) recommendations to increase his fluids as documented in her notes on 11/01/2024. 02/13/2024 at 4:10 PM V2 (Director of Nursing) stated V9 (Registered Dietitian) never submitted an order for R1's recommended fluid increase. V2 stated V9's progress note regarding this recommendation was originally entered into an inactive electronic health record system on 11/04/2024 and the note was never transferred to the electronic health record system that became actively used on 11/01/2024. V2 stated the facility was not aware of or notified of V9's recommendations to increase his fluids until 12/03/2024 when V9 provided this recommendation by email. V2 stated the facility reviewed Medication Administration Records for 24 hours after the transition of the electronic medical record system on 11/01/2024 however there was no order submitted by V9 for R1's fluid increase. V2 stated it was V9's responsibility to ensure the facility received the recommendation or order to increase R1s fluids and she should have communicated this information in real time. V2 stated the concern with V9's failure to ensure the recommendation was communicated or ordered is that R1 was not getting the amount of fluids he needed. V2 stated the physician was never notified of V9's recommendation to increase R1's fluids due to the missing communication from V9. The facility's Tube Feedings/Enteral Nutrition Policy received 02/11/2025 states: Objectives: to maintain the desired fluid status of a resident.

Based on observation, interview, and record review, the facility failed to follow their policy and procedure for housekeeping by not ensuring the rooms and medical equipment of residents who are totally dependent on staff for care and assistance with activities of daily living, were consistently and adequately cleaned and sanitized. This failure applies to four of four residents (R1, R2, R3, R4) reviewed for environment. Findings include: 1. R1 is a [AGE] year-old male with a diagnoses history present on admission of Brain Damage due to Oxygen Deprivation, Bacterial Infection, Epilepsy, Congestive Heart Failure, Stage 4 Pressure Ulcers, Acute Kidney Failure, UTI's, Trach Use, and Feeding Tube Use who was admitted to the facility 07/27/2024. On 02/10/2025 at 10:29 AM Observed multiple dresser drawers near R1's bed open and a mild odor present. On 02/10/2025 at 10:54 AM Observed R1's oxygen machine with visible dust and particles. V5 (Registered Nurse) was present and verbally confirmed the observation and stated the oxygen equipment should be clean. Observed a clean dressing dated 02/10/2025 sitting on R1's dresser near the foot of his bed. Observed R1's respiratory equipment with visible dust in the crevices on the top of the machine. V5 verbally confirmed the observation and wiped away some of the dust to further confirm that the area was unclean. V5 stated there shouldn't be any visible dust on the respiratory equipment. Observed a brown substance spilled over on multiple areas of R1's feeding tube monitor and pole. Observed R1's dresser near the foot of his bed with multiple uncovered and exposed plastic syringes. V5 stated that one of the syringes was for stool collection and the other is for feeding tube flushing and they should both be covered and stored properly. Observed a refrigerator in R1's room with visible dust and particles on the creviced exterior and with visible residue in multiple areas of the exterior. V5 stated the refrigerator exterior surface should be clean and free of visible matter. Observed multiple dresser drawers open. V5 agreed that R1's drawers should be closed and stated it only takes a moment to close them. 2. R2 is a [AGE] year-old female with a diagnoses history of Partial Paralysis following Brain Related Bleeding, Feeding Tube Placement, Protein Calorie Malnutrition, and Dysphagia (Difficulty Swallowing Foods) who was admitted to the facility 01/23/2025. On 02/10/2025 at 11:22 AM Observed R2's oxygen machine with visible dust and particles, a large mat next to the right side of her bed with multiple visible stains and residue, R2's respiratory equipment with visible dust and particles in multiple areas, an uncovered plastic feeding tube suction syringe and a plastic glove sitting directly on top of R2's window seal, multiple yellow spots on R2's window seal and underneath the uncovered plastic feeding tube syringe, R2's feeding tube equipment with a brown substance spilled over onto the monitor and pole, and R2's night stand beside her bed with multiple open drawers with visible dust on the borders of them and visible dust on the top and side exterior of the night stand. R2's current care plan documents she is bed bound, she receives nothing by mouth and her sole source of nutrition and hydration is via enteral feeding related to diagnoses of Dementia, Congestive Heart Failure, Diabetes Mellitus, and Renal Disease or Liver Disease and is dependent with tube feeding. R2's current physician orders include an active order effective 01/23/2025 for Enteral Feeding: Tube Site Care of cleansing with normal saline solution, patting dry, and applying a drain sponge and tape every night shift. 3. R3 is an [AGE] year-old female with a diagnoses history of Alzheimer's Disease, Dementia, Protein Calorie Malnutrition, Aphagia (Inability to Swallow) and Dysphagia (Difficulty Swallowing Foods) who was admitted to the facility 03/16/2023. On 02/10/2025 at 11:14 AM Observed R3's oxygen machine with visible dust and a substance spilled on the floor directly behind it, R3's respiratory equipment with visible dust, a brown substance spilled over on multiple areas of R3's feeding tube monitor and pole, and visible dust and particles on R3's bed frame underneath the head of her bed. V2 (Director of Nursing) was also present and verbally confirmed these observations and stated they would be addressed. 4. R4 is a [AGE] year-old female with a diagnoses history of Stroke, Partial Paralysis, Dysphagia (Difficulty Swallowing), Feeding Tube Use, and Need for Assistance with Personal Care who was admitted to the facility 11/08/2024. On 02/10/2025 at 11:07 AM Observed a refrigerator in R4's room with visible dust and particles on the creviced exterior and with visible residue in multiple areas of the exterior. Observed large padding next to R4's bed with visible stains and residue. V5 (Registered Nurse) was present and verbally confirmed the observations and wiped the padding with a wet towel to confirm the stains could be removed. V5 stated the padding should be clean and free of visible substances. Observed R4's oxygen machine with visible dust and particles. V5 verbally confirmed these observations and stated there should not be any visible dust or other substances present on oxygen equipment. Observed multiple orange spots on R4's window seal and air conditioner. V5 verbally confirmed these observations and stated the spots should not be on R4's window seal. On 02/10/2025 at 11:59 AM V6 (Housekeeping Supervisor) stated nursing is responsible for cleaning the resident's medical equipment because housekeeping staff would be afraid to move the equipment and potentially disconnect something. V6 stated housekeeping staff are responsible for cleaning residents rooms daily which includes blinds, bed frames, padding, nightstands, window seals etc. which ensures these areas stay clean. V6 stated one of the housekeeping staff became ill six weeks ago and she plans on hiring more staff. V6 confirmed there should not be any visible dust, residue, substances, stains, or particles if the residents rooms are cleaned daily. 02/11/2025 1:41 PM V2 (Director of Nursing) and V5 (Registered Nurse) stated the Respiratory Therapists are responsible for replacing and cleaning respiratory care equipment and they have a schedule for this. V2 stated maintaining the cleanliness of resident's respiratory and feeding tube equipment is a collaborative effort which includes respiratory and nursing staff. V2 confirmed aides, nurses, and respiratory staff are all responsible for maintaining the cleanliness of respiratory and feeding tube equipment. When asked by surveyor if staff enter the residents room and observe their respiratory or feeding tube equipment to be unclean should the equipment be left in that condition, V2 stated this should be addressed. The facility's Daily Housekeeping Policy received 02/10/2025 states: Disinfect horizontal surfaces (dressers, nightstands, etc.). Disinfect high touch surfaces (medical equipment).

Based on observations, interviews, and record reviews the facility failed to follow their policy and procedures for feeding tube care by not following physician orders of daily cleansing and dressing of feeding tube site for residents dependent on enteral nutrition. This failure applied to four of four (R1, R2, R3, and R4) residents reviewed for quality of care. Findings include: 1. R1 is a [AGE] year-old male with a diagnoses history present on admission of Brain Damage due to Oxygen Deprivation, Bacterial Infection, Epilepsy, Congestive Heart Failure, Stage 4 Pressure Ulcers, Acute Kidney Failure, UTI's, Trach Use, and Feeding Tube Use who was admitted to the facility 07/27/2024. On 02/10/2025 at 10:29 AM Observed R1 in his room lying in his bed unable to speak and bed bound. Observed V3 (Registered Nurse) uncover R1's feeding tube surgical site to reveal the site to be without a bandage/dressing and with a noticeable scab present. V3 stated feeding tube site dressings should be changed every night shift and R1 does not have a dressing over his site. V3 stated she observed R1's feeding tube surgical site with a dry scab that should be cleaned and have a new dressing applied to it. R1's current care plan documents he receives nothing orally and currently receives nutrition by feeding tube with interventions including change enteral feeding tube dressing per physician's order; he has potential for impaired nutrition related to acute and chronic medical conditions, wound, being tube feeding dependent, and receives nothing by mouth with interventions including change feeding tube dressing per physician's orders, check the feeding tube site regularly for signs/symptoms of infection such as redness, drainage etc.; registered dietitian to provide monthly nutrition assessment and evaluate calorie, protein, and fluid needs and adequacy/appropriateness of current feeding regimen, report any early signs of fluid overload or dehydration to the physician for further medical evaluation. R1's current physician orders include an active order effective 02/01/2025 for Enteral Feeding: Tube Site Care of cleansing with normal saline solution, patting dry, and applying a drain sponge and tape every night shift and as needed for feeding tube surgical opening. R1's February 2025 Treatment Administration Record documents missing information for Enteral Feeding Tube Site Care per physician's orders on 02/05/2025. 2. R2 is a [AGE] year-old female with a diagnoses history of Partial Paralysis following Brain Related Bleeding, Feeding Tube Placement, Protein Calorie Malnutrition, and Dysphagia (Difficulty Swallowing Foods) who was admitted to the facility 01/23/2025. On 02/10/2025 at 10:36 AM Observed V3 (Registered Nurse) uncover R2's feeding tube surgical site to reveal a dressing labeled 02/05/2025, with some visible brown staining, and not completely sealed with tape. V3 stated there was a scab present at R2's feeding tube site and the site is supposed to be clean before a new dressing is applied. V3 stated feeding tube site dressings should be cleaned and changed every night shift and it doesn't look like R2's was. Observed a scab around R2's feeding tube site. 3. R3 is an [AGE] year-old female with a diagnoses history of Alzheimer's Disease, Dementia, Protein Calorie Malnutrition, Aphagia (Inability to Swallow) and Dysphagia (Difficulty Swallowing Foods) who was admitted to the facility 03/16/2023. On 02/10/2025 at 10:49 AM Observed V4 (Licensed Practical Nurse) uncover R3's feeding tube site and reveal R3's site to be without a dressing. V4 stated she observed R3's feeding tube site with a bit of drainage that appears old and there is no dressing present. V4 stated the night shift typically replaces feeding tube site dressings. V4 stated dressings should be present and dated. R3's current care plan documents she is bed bound, she requires a tube feeding related to Dysphagia, receives nothing by mouth and her sole source of nutrition and hydration is by enteral feeding with interventions including requiring total assistance with tube feedings, providing local care to feeding tube site as ordered and monitoring for signs and symptoms of an infection. R3's current physician orders include an active order effective 01/30/2025 for Enteral Feeding: Tube Site Care of cleansing with normal saline solution, patting dry, and applying a drain sponge and tape every night shift and as needed. R3's February 2025 Treatment Administration Record documents missing information for Enteral Feeding Tube Site Care per physician's orders on 02/03/2025. 4. R4 is a [AGE] year-old female with a diagnoses history of Stroke, Partial Paralysis, Dysphagia (Difficulty Swallowing), Feeding Tube Use, and Need for Assistance with Personal Care who was admitted to the facility 11/08/2024. On 02/10/2025 10:44 AM Observed V4 (Licensed Practical Nurse) uncover R4's feeding tube site and reveal the dressing to be without a date. V4 stated there should be a date on R4's feeding tube site dressing. V4 stated when she examines feeding tube site dressings, she looks for a date, cleanness, and for no drainage to be present. V4 stated she observed R4's feeding tube site with a little bit of crust around it and some dry drainage. R4's current care plan documents she is bed bound, requires a feeding tube feeding related to Dysphagia, and she is dependent with tube feeding with interventions including provide local care to feeding tube site as ordered and monitor for signs and symptoms of infection. R4's current physician orders include an active order effective 11/9/2024 for Enteral - Tube Site Care every night shift. On 02/10/2025 at 11:12 AM V2 (Director of Nursing) stated both V3 (Registered Nurse) and V4 (Licensed Practical Nurse) informed her that four residents feeding tube site dressings were not changed, and the sites should be cleaned, changed, and have a dressing applied each night during the 11 PM - 7:30 AM shift. On 02/11/2025 at 1:41 PM V2 (Director of Nursing) and V5 (Registered Nurse) stated missing entries on the TAR (Treatment Administration Record) could indicate that treatment wasn't administered. V2 stated nurses should document on the TAR to confirm that treatment was administered. The facility's Tube Feedings/Enteral Nutrition Policy received 02/11/2025 states: Gastrostomy Tube care is to be done daily and as needed.

Based on interview and record review, the facility failed to properly transfer one resident (R1) and ensure that R1 was wearing proper footwear during the transfer. This failure resulted in R1 being hospitalized and sustaining a fracture to the neck. Findings include: R1 is an [AGE] year old female who admitted back to the facility on [DATE] and was discharged to the hospital on 1/10/2025. R1 has multiple diagnoses including but not limited to the following: type II DM, dementia, psychosis, HTN, dysphagia, difficulty in walking, unsteadiness on feet, disorientation, and need for assistance with personal care. V3's (Licensed Practical Nurse) progress note dated 1/5/2025 at 10:00AM states in part but not limited to the following: V4 (Certified Nursing Assistant) was transferring R1 from wheelchair to the shower chair. V4 said R1 began to slide and was lowered to the floor. R1 was wearing slippers at the time of transfer. On 1/15/2025 at 11:15AM, V4 said I was going to give R1 a shower. R1 was previously a resident here and I was familiar with her. However, this was the first time I had given her a shower since she returned. R1 can transfer independently. R1 was sitting in her wheelchair. I placed her walker in front of her, she stood up using the walker, and I attempted to move the wheelchair and replace it with the shower chair. During the transfer, R1 began to slip and slide down to the ground. She was wearing slippers and she seemed weaker than normal. I assisted R1 in sliding down to the ground. V4 said R1 did not need a transfer belt. A transfer belt is used when a resident cannot mobilize themself. R1 can transfer herself and only needs supervision. It is to be noted that per R1's care plan with initiation date of 12/26/2024 states in part: R1 requires substantial/maximal assistance with 1-2 person assistance to move between services. when transferring. Use gait belt with transfers. Per Minimum Data Set (MDS) dated [DATE] states in part but not limited to the following: R1 requires maximum assistance when transferring into the shower and when going from a sitting to standing position. On 1/15/2025 at 1:41PM, V2 (Director of Nursing) stated R1 required a gait belt when transferring and I would have expected V4 to use one during this transfer. R1 was also wearing her favorite red slippers which are not appropriate when transferring. R1 should have had non-skid socks on. Hospital records dated 1/10/2025 state in part but not limited to the following: R1 presenting to the emergency room after a witnessed mechanical fall. It is reported that the fall occurred while R1 was taking a shower. R1 was guided to the ground by nursing staff and V5 (family member) observed bruising today on the back of R1's head. CT impression shows an acute C7 spinous process fracture. On 1/16/2025 at 11:15AM, V7 (Primary Physician) said this type of fracture can occur from any sudden movement or a fall especially in the elderly. Fall Prevention and Management Policy with last review dated of 02/2023 states in part but not limited to the following: The purpose of this policy is to support the prevention of falls by implementation of a preventive program that promotes the safety of residents based on care processes that represent the best ways we currently know of preventing falls. The falls prevention and management program is designed to assist staff in providing individualized, person-centered care.

Based on observation, interview, and record review the facility failed to obtain a urine specimen from a catheter in a timely manner, document indwelling catheter output, ensure catheter care was provided and identify/respond to signs and symptoms of a UTI (Urinary Tract Infection) in a timely manner for 2 of 3 residents (R1, R3) reviewed for indwelling catheters in the sample of 3. These failures resulted in R1 requiring emergency treatment and hospitalization for a severe UTI with sepsis. The findings include: 1. The facility's Grievance Form dated 8/30/24 showed a representative from the Public Guardian's Office expressed concern regarding a phone call received by the emergency department. The ER (emergency room ) informed them that R1 was admitted to the hospital with a sludged catheter. The back page of this form titled, Facility Grievance - Written Decision Form was blank. There were four sections including: Facility information, Grievance/complaint information; Investigation and Results; Was the grievance/complaint confirm (y/n); Resolution. All these sections were blank. R1's Face Sheet 9/29/24 showed diagnoses to include, but no limited to heart failure, chronic kidney disease (Stage 4), history or UTIs, dementia, diabetes, prosthetic heart valve, functional quadriplegia, neuromuscular dysfunction of the bladder, and presence of a chronic indwelling catheter. R1's facility assessment dated [DATE] showed she had severe cognitive impairment; had an indwelling catheter; was dependent on staff assistance for toilet hygiene and shower/bathe; and required substantial/maximal assistance with personal hygiene and bed mobility. R1's Physician Order Sheet dated 8/1/24 to 9/30/24 showed orders for UA (urinalysis), Reflex to Culture dated 8/8/24 and 8/13/24. It does not show an order for the UA ordered on 8/2/24 (per the facility's progress notes). This document showed orders for: Foley catheter care every shift and PRN and Document Foley output every shift. R1's August 2024 MAR (Medication Administration Record) showed Document Foley output every shift, there were no documented urine outputs for 3-11 and 11-7 shifts the entire month. The urine output was not charted 3 times for the day shift and 5 days the facility staff entered medium or large, instead of a volume of urine in milliliters (ml). This document showed R1's Foley Care every shift and PRN was not documented by 3-11 and 11-7 shifts the entire month of August and was not completed on 8/18/24 by the 7-3 shift. This document showed R1's Foley Catheter was changed on 8/11/24. R1's Progress Notes showed on 8/2/24 at 9:44 AM, R1's daughter visited and was concerned that R1 was crying, seemed more confused, and couldn't recognize family members. R1's daughter requested a urinalysis to check for a UTI. The writer notified V10 (R1's Physician) and obtained an order for a lab and a urinalysis. R1's Progress Notes dated 8/8/24 showed lab was called for the urinalysis results and the lab employee reported the urine specimen had not been collected. At 2:19 PM, the urine sample was collected and placed in the first-floor refrigerator for lab pick up. R1's Nurse Practitioner Note dated 8/8/24 showed she was seen for concerns with increased confusion. This document showed the resident slept through the entire visit but did not appear to be in pain or distress. This note showed that the urinalysis and labs ordered were discussed with the nurse. This note showed the indwelling catheter was draining clear yellow urine. R1's Progress Notes dated 8/12/24 showed the nurse called the lab to check on the urinalysis results and multiple bacterial morphotypes were found. The lab recommenced re-collecting a urine specimen. V10 was notified and orders were received to recollect the urine specimen. The nurse was unable to collect the urine sample from the indwelling catheter and reported to the next shift to obtain R1's urine specimen. R1's Progress Note on 8/28/24 by V2 (Director of Nursing/DON) showed R1's daughter called public guardian's office to have R1 sent to the ER. ADON (Assistant Director of Nursing) called R1's doctor (V10) to make him aware of the change in condition and poor appetite. The order to send R1 to the hospital was received. 911 was called. R1's Progress Note by V3 (ADON) was a late entry created on 8/30/24 at 5:45 PM (after R1's Guardian filed a Grievance with the facility). This note showed R1 was able to respond to commands, denied pain. Her family was at the bedside and vital signs were obtained. This note did not address the appearance of R1's urine. (There are no progress notes dated 8/28/24 by the V12 (Licensed Practical Nurse/LPN) that was caring for R1). R1's Progress Note dated 8/29/24 showed R1 was admitted to the hospital for a UTI. R1's UA collected on 8/8/24 showed R1's urine was cloudy yellow, had large leukocytes (white blood cells) and MANY bacteria. This report showed that multiple bacteria morphotypes were present (likely a contaminated specimen) and recommended re-collection of the urine specimen. There was no evidence of a urine specimen obtained by the facility from 8/2/24 to 8/7/24 (the first UA ordered was received 8/2/24 per to R1's progress notes), nor was there a urinalysis report after the 8/11/24 specimen report. R1's UA Report collected 8/13/24 showed R1 had cloudy, yellow urine. This report showed R1's urine contained Large leukocytes, had protein in it, MANY bacteria, had 11-20 HPF (Normal range is 0-5 HPF) Red Blood Cells and had 21-50 HPF (normal range is 0-5 HPF) [NAME] Blood Cells. R1's Lab Report showed on 7/24/24 R1's WBC (White Blood Cell Count) 5.95 and on 8/3/24 R1's WBC increased to 11.82 (Double the last result, indicating a possible infection). R1's Care Plan initiated 12/18/23 showed R1 was at risk for UTI related to history of UTIs. The interventions included, but were not limited to: Monitor for signs/symptoms of sepsis (fever, confusion, lethargy, elevated BP, tachycardia) and report to PCP (Primary Care Physician); Monitor lab work and report abnormalities; Provide peri-care as appropriate to decrease skin contact with moisture; and Report signs of UTI (acute confusion urgency, frequency, bladder spasms, nocturia, burning, pain, difficulty urinating, low back/flank pain, malaise, nausea/vomiting, chills, fever, foul order, concentrated urine, blood in urine) and notify MD as appropriate. R1's Care Plan initiated 10/14/21 showed R1 required a Foley catheter related to neuromuscular dysfunction of the bladder. The interventions included, but were not limited to: Monitor for complications related to catheter use such as catheter obstructions, bladder distension, and pain; Observe drainage (amount, type, color, odor); Provide catheter care daily and as needed; Report UTI (acute R1's emergency room records dated 8/28/24 showed R1 had a temperature of 99.9 degrees Fahrenheit; elevated lactate level (used to diagnose sepsis); elevated kidney function tests (BUN/Creat); elevated WBCs at 26.7 (normal range is 4.2 to 11 K/mcl). (This number is more than double the last WBC obtained at the facility on 8/3/24). This document showed R1 will respond to her name, but continues to say, Yes Lord, and will not answer any other questions. This document showed R1's urine was straw colored with sediment. This document showed that during ED triage, the family reported they called the ambulance because she was less responsive than normal and did not eat as much food as usual today. This document showed at 7:27 PM, the ED nurse spoke with the County Public Guardian regarding R1's condition. R1's Hospital Records dated 8/29/24 showed R1 presented with fatigue and AMS (altered mental status). This record showed R1's family visited her and noted that she was weaker than normal and was not eating/drinking. R1 appears disoriented. R1's CT of her abdomen and pelvis showed bladder wall thickening and perivesicular stranding that may represent acute cystitis (recommend correlation with urinalysis). This document showed R1 was diagnosed with acute toxic metabolic encephalopathy likely due to a CAUTI (Catheter Associated Urinary Tract Infection), sepsis, leukocytosis, and lactic acidosis. R1 was placed on intravenous antibiotics and was hospitalized from 8/28/24 to 9/5/24. On 9/30/24 at 3:04 PM, V18 (County Public Guardian) said R1 had a history of UTIs and had been in and out of the hospital. V18 said the ER nurse reported that R1 had sludge in her urine, and she was concerned with the appearance of the urine. V18 said that gave us concern for how the facility was taking care of R1's catheter. V18 said they had temporary guardianship of R1's financial and healthcare needs and they are responsible for ensuring R1's needs were met at the facility. On 9/29/24 at 12:12 PM, V5 (Registered Nurse/RN) said if a resident is having increased confusion or a change in their mental status, it could be a sign of a UTI or something else going on. V5 said the nurse should complete an assessment and call the doctor for orders. V5 said if a UA is order, it can be obtained for the indwelling catheter right away. The UA results are usually available within 24 hours, but the culture may take 2-3 days. The nurses can look in the chart to see if the labs are completed. V5 said a resident with an indwelling catheter should receive catheter care and urine outputs should be monitored every shift. The purpose of catheter care is to keep the area clean and reduce the risk of infections. V5 said the urine output is records and the nurses should be reviewing to see if there are any trends. V5 said the catheter care and urine output should be charted in the MAR. On 9/29/24 at 12:33 PM, V7 (LPN) said the nurses can collect a UA directly from the Foley catheter and it shouldn't take more than 24 hours to collect the specimen. The surveyor asked V7 if she remembered calling lab for the UA results on 8/8/24 and being told that the UA had not been collected. V7 stated, I don't remember, but if I documented it, then that's what happened. V7 said the nurse should document a volume of urine (in milliliters), not small, medium, large. V7 said we look at the urine output to ensure the catheter is working, the resident isn't having any health issues, and they are hydrated. V7 said the catheter care and urine output should be charted once a shift on the MAR. On 9/29/24 at 1:25 PM, V1 (Administrator) said on 8/30/24 the Grievance Form was completed because the Public Guardian's Supervisor came to the building and reported she was concerned because the ED nurse reported that R1's catheter was sludged. V1 said she assigned the investigation to V2 (DON). V1 said she wasn't sure why the back of the Grievance Form had been blank, and she would have to check with V2 (DON). On 9/29/24 at 1:37 PM, V3 (ADON) said the basic care of an indwelling catheter should include catheter care every shift; measuring the urine output every shift; securing the device; ensure its draining; and changing the catheter as needed. V3 said the resident should have orders for each item and the nurse should sign them off in the MAR as completed. This catheter maintenance is completed to reduce the risk of infections. V3 said an actual amount should be documented for urine output because there is no way to identify what small, medium, and large means. V3 said those should only be used for BMs and incontinence. V3 said the importance of measuring the urine output is to ensure the catheter is patent and monitor the resident's status. V3 said an increased WBC count shows there's possibly an infection. V3 said if a resident is experiencing fever, change in level of consciousness, poor appetite, changes in the color and clarity of the urine, then he would expect the nurse to call the doctor and obtain orders. V3 said the nurse should ensure the orders are completed. V3 said a UA can be obtained quickly from an indwelling catheter and the facility has a specimen refrigerator for storage. V3 said lab usually picks up specimens daily, Monday-Saturday. V3 said he was approached by R1's daughter on 8/28/24 and she said something was wrong with R1. V3 said he did not remember if he looked at R1's catheter, but he obtained vital signs from R1. V3 said 911 was called and R1 left for the ER with 5-10 minutes. On 9/29/24 at 2:30 Pm, V16 (Certified Nursing Assistant/CNA) said she was R1's CNA on 8/28/24. V16 said R1 wasn't acting like herself, she refused to eat breakfast. V16 said she reported it to R1's nurse, but she was an agency nurse and couldn't remember her name. V16 said R1 was screaming like she was in pain and that's not normal. V16 said the only time R1 normally screamed was during care. V16 stated, I told the nurse that too. But I didn't see the nurse go in there. Then her daughter came and asked if I saw her mom crying. I told her that she had cried most of the day. She didn't have much urine in her catheter, but she didn't eat or drink anything. She was definitely different. She is normally able to make her needs known, but she was more confused that day. She looked very tired and wasn't very alert. She was the same way at lunch. That's why I told the nurse again. I tried and tried. Her daughter called 911. On 9/30/24 at 11:11 AM, V12 (LPN) said she no longer worked at the facility, but she was R1's nurse the day she was sent to the hospital (8/28/24). V12 said she talked to R1's Guardian because R1's daughter insisted we sent her to the hospital. V12 said she doesn't remember any of the specifics, just that the daughter thought she was more confused than usual. V12 said she doesn't remember the exact time, just that she had gone on break and when she returned the Guardian called. V12 said the DON and ADON were there too. V12 said she didn't recall the CNA reported R1's poor appetite, crying, and not acting herself. V12 said she remembers giving R1 a pill and she took it fine. V12 said if she knew R1 wasn't eating, had an altered mental status, and was crying then she would have called the doctor. V12 said she didn't recall what R1's urine looked like. On 9/30/24 at 11: 25 AM, V9 (Nurse Practitioner) said the signs and symptoms of a UTI can vary with age. V9 said some possible side effects included: altered mental status, frequency, fever, dysuria, back/flank pain. V9 said if a nurse calls me because the family is concerned about increased confusion and requests a UTI, then I will discuss it with the nurse and usually order an UA. V9 said she expects the facility to collect a UA from a catheter quickly and results are usually available within 48 hours. V9 said the culture will take 2-3 days, but the UA results can be difficult to get/view through the facility's EMR. V9 said R1 is usually up in her chair and can carry on a conversation with her. V9 said R1 doesn't complain much and can tell the staff how she is feeling. V9 said the facility had in-house Providers that would give orders if resident's UA showed UTI and sometimes, she doesn't hear about the UA results until she is in to round on patients. V9 said it's a system that they are trying to improve. V9 said the facility has an in-house Infectious Disease Provider and a consult can be ordered right away. V9 said R1's WBCs doubling could have been a sign of a possible infection, but the providers are careful to not order antibiotics before the culture results. V9 said if she knew the UA had not been collected, R1 was having increased confusion, and the WBCs had doubled, then she may have ordered prophylactic antibiotics. V9 said she was not aware the UA collection was delayed. The surveyor asked V9 what increased confusion, crying, poor appetite, and poor urine output could demonstrate. V9 replied, All her symptoms are signs of UTI, septicemia, and possibly renal failure. I'm sorry to hear this about [R1]. This should have been addressed sooner. On 9/30/24 at 2:05 PM, V2 (DON) said the nurse on the floor is responsible for obtaining a urine specimen. V2 said it shouldn't take long to obtain a urine specimen from an indwelling catheter. V2 said if the resident had other labs ordered, then the nurse should try to collect the urine specimen before lab comes to draw the labs, so they can take it with them. V2 said the nurses are responsible for checking the EMR to ensure an order was entered, the specimen was obtained, the specimen was received by lab, and the results are relayed to the physician. V2 said this is done to catch a possible UTI as soon as possible and start treatment. The surveyor asked V2 what cause sludge in a catheter. V2 said it could be from a buildup of sediment or infection. V2 said catheter care every shift and monitor urine output every shift are part of routine catheter care and she expects it to be done every shift, as ordered. The surveyor asked V2 to review R1's MAR and asked why there were no 3-11 or 11-7 entries. V2 said she did not know. V2 said on 8/28/24 V3 (ADON) exited R1's room and said R1's daughter wanted her sent to the ED and she called the Guardian. V2 said she did not enter R1's room, nor did she assess R1. The surveyor asked V2 why R1's nurse (V12) did not document on R1's status 8/28/24. V2 replied, I don't know. There should be something in the legal documentation to show that something was done. She (V12) was terminated. V2 said she did not see a UA collected between 8/2/24 and 8/8/24. V2 said R1 had a catheter, and the nurse should have been able to collect a urine specimen as soon as possible. V2 said catheter care is done to protect residents from infection and can be completed by the nurse or CNA. The facility's Collecting Urine Specimen from Urinary Catheter Policy dated 2/2023 showed, Objective: To obtain a urine specimen from urinary catheter. Procedure: 1. Verify the order and assemble the supplies . 9. Urine specimens may also be collected by changing the Foley catheter and drainage bag. The facility's Catheter Care Policy dated 7/22 showed, Objective: 1. To cleanse the perineum. 2. To prevent infection and odors . 2. On 9/29/24 at 12:02 PM, R3 was sitting in his wheelchair, in his room, watching TV. R3 had catheter tubing extending from the bottom of his right pant leg. There was a large amount of brown/tan sediment noted in the catheter tubing. R3 said he's had the catheter for a while. R3 said he wasn't having any more problems with it, since they changed it last Friday. R3 said before that it was hurting him, and urine was leaking around the catheter. R3's Face sheet dated 9/29/24 showed diagnoses to include, but not limited to: COPD (chronic obstructive pulmonary disease); ataxia; anemia; bladder neck obstruction; retention of urine; obstructive and reflux uropathy; protein-calorie malnutrition; spinal stenosis; tremor; anxiety; congestive heart failure; and peripheral vascular disease. R3's facility assessment dated [DATE] showed he was cognitively intact; required substantial/maximal assist with personal hygiene; shower/bathe; and bed mobility; was dependent on staff for bed mobility and transfers; and had an indwelling catheter. R3's Physician Order Sheet showed he had orders to: Document urine output every shift and catheter care every shift and PRN (as needed). R3's September 2024 MAR showed 20 missing urine outputs and 31 entries that showed Small, medium, or large (not a volume of urine output). This document showed that R3's catheter care was not documented 8 times. R3's Urinalysis Report collected 9/3/24 showed R3's urine was cloudy, yellow, and contained nitrites, protein, MANY bacteria, RBCs, and >100 WBCs. R3's Care Plan initiated 9/9/24 showed R3 was on antibiotic therapy related positive urine culture for ESBL. R3's ID (Infectious Disease) Follow up Note dated 9/17/24 showed R3 was being seen for ESBL UTI and R3 had mild gross hematuria. On 10/4/24 at 12:23 PM, V2 (DON) said R3 was admitted to the facility with COPD, frequent UTIs, generalized weakness, and had an indwelling catheter.

Based on observations, interviews and records reviews the facility failed to provide a recliner wheelchair to a dependent resident. This failure affected one (R12) resident out of three residents reviewed for resident rights who expressed a desire to get out of bed and interact with the environment. Findings Includes: R12 is [AGE] years old admitted to the facility 09/08/23 with diagnoses including but not limited to multiple sclerosis, Sacral ulcer, Chronic anemia, and protein energy undernutrition. MDS (minimum data set) dated 06/17/2024 reads R12 uses a wheelchair for mobility. On 08/20/24 at 10:30AM during facility rounds R12 observed to be in bed and said, I want to get out of bed, but I don't have a wheelchair. I don't remember when the last time was, I got up. I asked the nursing assistants, but I was told I do not have a chair to get up in. On 08/21/2024 at 10:45 AM Observed V21(Certified Nursing Assistant) getting R12 out of bed to receive a shower. V21 said, I am R12's regular certified nursing assistant. R12 was under Hospice care. After R12 was discontinued from the service, the recliner wheelchair that R12 was using was pick up from the hospice company. I have not gotten R12 up since that time. On 08/21/2024 at 10:45 AM, R12 said, I want to get out of bed. On 08/21/2024 at 11:00AM V16 (Registered Nurse) said, I have not seen R12 getting out of bed. Hospice service used to get R12 out of bed. Hospice services was discontinued on 06/08/24. I am not aware that R12 does not have a recliner wheelchair to use. On 08/21/2024 at 11:15 AM V20 (Assistant Director of Nursing) said, I expect R12 to have a wheelchair. I do not know why R12 has not received a recliner wheelchair after hospice was discontinued. On 08/21/2024 at 2:00PM V2(Director of Nursing) said, I expect all the residents admitted to the facility to obtain a wheelchair during admission or as needed. The facility will provide a wheelchair to all residents that require one. On 08/20/2024 and 08/21/2024 surveyor checked R12's room both days and no wheelchair was available for R12 to use. On 08/21/2024 at 09:57 PM V1 (Administrator) presented Facility Policy titled: Residents' Right for People in the Long-term Care Facility undated, reads: facility must make reasonable arrangements to meet your needs and choices.

Based on interview and record review, the facility failed to ensure the wheelchair locking mechanism was engaged and failed to supervise one high risk for falls resident (R1) in a sample of 3 residents. This failure resulted in R1 falling out of an unlocked wheelchair while sitting in an unsupervised dining room. R1 sustained bruising to the left side of face and a cut above her left eye which, required hospital evaluation and 4 sutures above left eye. Findings include: Facility's reportable to state agency regarding R2 documents in part: Date of Occurrence: 05/31/24, R1 was noted on dining room floor in front of her wheelchair. R1 was laying on her left side and noted with a small cut to above her left eye. Nurse on duty provided first aid. R1 was sent to local hospital for further evaluation. R1 returned from local hospital with four sutures above left eye. Interviews: V10 (Activity Aid) states R1 participated in a group activity. After the activity V10 transported R1 out of the activity room and was instructed by nurse to bring R1 in the dining room. V10 placed R1 by the table in the dining room. V10 could not recall if she locked both sides of the wheelchair. When V10 returned in the dining room with another resident, the incident had already occurred. V12 (Registered Nurse/RN) states he was by the medication cart outside the glass window of the dining room. V12 heard R1 shout and observed that R1 was on floor in dining room. R1 was laying on her left side in front of her wheelchair and partly under the table. V12 noted her right leg was caught in the leg rests of her wheelchair. V12 removed the wheelchair and repositioned R1 on her back. V12 noted the wheelchair was locked on one side. V12 noted R1 had a small cut above her left eyebrow and skin discoloration under the left eye. He provided first aid while staff called 911 and he took the vital signs and within her baseline limits. R1 was alert to her norm with active ROM to all extremities. R1 returned from ED the same evening with negative x-rays and negative head CT. R1 had 4 sutures placed to her left eyebrow area. V11 (Licensed Practical Nurse/LPN) was at the nurses' station receiving a report when she directed the activity aid to assist R1 to the dining room. V11 was next alerted of the incident. V11 responded and noted that V12 was assessing R1. V11 observed R1 was alert to her norm, moving all her extremities. R1's diagnoses includes Dementia with other behavioral disturbances, Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere, Anemia, anxiety disorder, major depressive disorder, essential hypertension, heart failure, glaucoma, osteoarthritis, vertigo of central origin. BIMS score dated 5/08/24 - 3 indicating severe impairment. Nurse's Notes for R1 dated: Nursing Date & Time 05/31/2024 04:54 PM e-Signed by V11 Created Date & Time 05/31/2024 05:32 PM show at 3:20 pm while NOD (Nurse on Duty) was taking report, resident brought to nurses' station by activity directed by NOD to place in dining room by the small table activity said yes. In 1 minute - 2 minutes prior, co-nurse heard (a) sound in dining room, immediately attend noted resident fell of the wheelchair. Then everyone attended noted resident in the floor on her left side has injury on left side of the face. Her wheelchair wasn't lock. 911 called, MD notified. Residents send to Local Hospital ER. At 3:36 pm resident Left the facility alert. Report given to ER nurse. Emergency contact POA notified. Nurse's Note for R1 dated: Nursing Date & Time 05/31/2024 11:34 PM e-Signed by V11 Created Date & Time 06/01/2024 12:04 AM show at 7:30 pm, receive phone call from Local Hospital resident is coming back to the facility. At 8:15 pm resident arrived via (local ambulance service) from the hospital. Resident alert at her baseline. Resident has laceration with 4 absorbable sutures, no need to for call for removal they will dissolve. There is no orbital fracture, no nasal bone fracture, no mandibular fracture, or dislocation with instruction to the remove the gauze in the morning and put warm towel at time. R1's (03/17/2024) Fall Assessment documented in part: score of 15, high risk for falls. R1's care plan (Start Date 08/07/2023) show R1 is at risk for fall related to impaired judgment, confusion, history of falling, muscle weakness, dementia, anxiety, dermatitis, back pain, HTN, GERD, glaucoma, and vertigo. Approach (Start Date 5/31/2024): resident's wheelchair is to be locked at all times. Approach (Start Date 5/14/2024): Falling leaf program. Approach (Start Date 9/24/2023) Observe frequently and place in supervised area when out of bed. Approach (Start Date 9/21/2023): Give resident verbal reminders not to ambulate/transfer without assistance. On 6/21/2024 at 11:51am surveyor observed R1 sitting in wheelchair facing television with wheelchair wheels locked. R1 was dressed, well groomed, and hair combed wearing shoes. R1 was awake and trying to put bib in mouth. R1 had an old dark purplish bruise to left lower side of face. R1 was able to open her eyes. R1 primarily speaks Spanish and CNA (Certified Nursing Assistant) interpreted but was unable to understand R1. R1 was able to nod her head that she was okay. R1 appeared to be sleeping on and off. Both hands of R1 are contracted. R1 did not remember incident of 5/31/2024. On 6/21/2024 at 11:55am V4 (LPN) stated (in part), R1 is okay. We get R1 up before breakfast, if she gets sleepy, we will put her back to bed. After lunch she is usually sleepy, and we put her to bed. Surveyor asked V4 if she was aware of the incident on 5/31/2024 when R1 fell . V4 stated, yes, I was R1's day shift nurse. V4 stated the activity aide brings residents from the activity room and forgot to lock the wheelchair and R1 fell . R1 cannot stand but she moves around a lot, and she needs a lot of supervision. R1 is unable to walk. Surveyor asked what can happen if the wheelchair is not locked and R1 is sitting in the wheelchair. V4 stated, R1 moves around and leans forward and that is how she fell on R1's face, because the wheelchair was not locked. The activity aide put her in the dining room at a table and did not lock the wheelchair wheels. Right after R1 fell , the activity aides were trained on how to avoid falls and make sure to lock wheelchair wheels. Surveyor asked V4 should the dining room be supervised when residents are in the dining room. V4 stated, Yes always have to supervise. V4 stated, I did not see R1 fall, I was giving report at the nurses' station when she fell , and we ran into the dining room. Surveyor asked if anyone was supervising R1 in the dining room. V4 stated, No. On 6/21/2024 at 12:52pm V8 (CNA) stated, I take care of R1 everyday Monday thru Friday, 7am to 3pm. R1 is Spanish speaking. She is total care. I have to do everything; I do everything for her right away. R1 cannot walk, cannot self-propel herself in the wheelchair. I push her in the wheelchair and lock both wheels. R1's hands cannot move chair or take the wheelchair lock off. R1 needs help transferring to the bathroom or anywhere. Surveyor asked V8 if she was working the day R1 fell on [DATE]. V8 stated, yes but I was off when R1 fell . It happened about 3:30pm. I am done at 3:00pm, so I am not sure what happened. Someone told me R1 fell out of the wheelchair and wheels were not locked. On 6/21/2024 at 1:58pm surveyor asked V10 (Activity Aide) what happened on 5/31/2024 when R1 fell . V10 stated, I was done with activity and when I am done, I get the residents to the dining room. I gave R1 to the nurse, and the nurse said to put R1 in the dining room. When I put her in the dining room, I went to take more residents and after a few minutes, R1 fell , and the nurse and the CNA took care of her, but I do not know if it was my fault because I was done with her. Surveyor asked V10 when you put R1 in the dining room, did you lock R1's wheelchair. V10 stated, I do not think I locked both locks on the wheelchair. I remember I locked one. I do not remember if I locked both, but I remember I locked one. I (V10) did not see R1 fall, I do not stay in the dining room. After the incident they asked me questions, I said the truth I put her in the dining room, and she fell . I told them what I told you. I saw how people lock the chair. I have worked here for about 3 months. Surveyor asked V10 who was supervising in the dining room when you left R1. V10 stated, no one I had to go and get other residents. Surveyor asked V10, when you started your job here, did they show you how to use a wheelchair and how to lock the wheelchair, so it does not move. V10 stated, No. When I started it was not for one day, you learn, and you learn. Recently, they showed me, and I must make sure the chair is locked. Recently, they talked about making sure both wheels on the wheelchair are locked. V10 was asked did they show you about the wheelchair and how to lock the wheelchair after R1 fell . V10 stated, Yes. Surveyor asked, V10 are you able to transport residents by yourself. V10 stated, yes, I transport by myself. On 6/21/2024 at 3:10pm V11 stated, I take care of R1 every day that I am here. I remember the incident that occurred on 5/31/2024 when R1 fell . My shift starts at 3:00pm I was at the nursing station getting report. During the report there was an activity aide taking residents to the dining room. The activity ended so R1 was going back to the dining room. When V10 passed by with R1 she was to park her by the wall. I said this resident (R1) can sit in the dining room she has a special table there that is lower than all of the tables due to her size and height because she cannot see with something in front of her because she has tendency to lean forward. V10 replied to me, I know. V10 continued with R1 to the dining room so while I was still taking the rest of the report from the nurse. Within less than 2 minutes my co-nurse was by the medication cart, and I (V11) saw him (V12) run into the dining room, and he noted R1 fell . All of the nurses went to the dining room, and he (V12) noted the resident was placed at the wrong table and the wheelchair was unlocked. I believe both wheels because when she leaned forward and fell . The wheelchair wheeled away from her. R1 is unable to move herself in the wheelchair, she just goes forward. She is Spanish speaking and has table at level that will remind her not to fall. That particular day V10 put her at the wrong table, and nothing was in front of her to help R1 see. R1 noted had blood come out by left eyebrow and bruises on the left cheek. We called 911 right way and did vital signs. I (V11) put pillow under her head and monitored her (R1) vital signs and did not leave her (R1) side until 911 came and put her on the stretcher. Surveyor asked V11 What should have been done with R1 if there was no staff in the dining room yet. V11 stated, R1 has to be with a CNA. I am not sure if there was a CNA in the dining room, I was in report and I do not know if V10 knew if there was a CNA in the dining room. A CNA is supposed to be in there to monitor residents. When R1 was brought into the dining room V10 should have position R1 at the lower table where she sits every day and locked both of her wheelchair wheels. When R1 leaned forward she went on the floor and the wheelchair went back because there was nothing in front of her. Whoever wheels the residents if the resident is going to remain in the wheelchair both wheels should be locked before you turn from the resident. It is a no - no to leave the wheelchair unlocked. There has been recent education regarding falls and fall prevention and included using a wheelchair and making sure wheels are locked. Sometimes no one can understand what R1 is saying. R1 is unable to propel herself or make her needs known. The nurse that first saw R1 said he heard the noise. When R1 returned from the hospital she had sutures on left side by eyebrow, I believe it was 4 sutures that will melt on its own. She has not had any fall since the 5/31/24 fall. The way she is supposed to be position is safe for R1. V10 on that day did not say in front of me that the wheels were locked because she realized that the wheels were not locked. On 6/21/2024 at 3:35pm V12 (RN) stated, I remember the incident when R1 fell I think it was a Friday. When I make my cart for my shift, I heard crying and looked in the window and R1 was on the floor. I heard the cry. I ran there and the CNA came and removed the wheelchair and put straight. The left eyebrow was bleeding. I got a towel and put pressure. R1's nurse came, and the other nurse came, someone took vital signs, and someone called 911. V10 put R1 at the wrong table. She has a small table there and she was moving and sometimes she moves like that, and I think the wheelchair was not locked. R1 always leaning forward and moving so I do not think the wheelchair was locked. I did not check the wheelchair because I was putting pressure on the site. R1's wheelchair should have been locked and R1 should have been put at the small table when placed in the dining room. V10 said, knew the table R1 was supposed to go to but she did not put her at the low table, I am not sure what happened that day. We have had education about falls, fall prevention and how to use a wheelchair. Education included to make sure both wheels are locked on the wheelchair. R1 cannot move herself in the wheelchair but she does move. I do not believe she has fallen since the 5/31/24 fall. Surveyor asked if anyone was in the dining room when R1 fell out the wheelchair. V11 stated, I did not see anyone. On 6/21/2024 at 4:10pm V13 (CNA) stated, I was assigned to her that day, but I came late that day. I was putting diapers and sheets on my cart, so I did not see anything. I saw the nurse running to the dining room. There were nurses and CNAs in the dining room with R1 when I walked in R1 was on the floor. I think she was in a wheelchair. V10 was transporting the residents to the dining room. I do not know what happened, but R1 fell on the floor. I do not know if the wheelchair was locked or unlocked. R1 cannot walk, she can talk but cannot understand what she says. She is only Spanish speaking. R1 is confused and needs total care. R1 is not able to propel herself in the wheelchair. The nurses called 911 and R1 was sent to the hospital. R1 moves a lot in the chair and tries to get up. R1 has a small table for her, and the wheelchair has to have both brakes on. I have had recent education on falls and fall prevention and how to use wheelchair and position and checking to see if resident has to go to the washroom. They have a leaf on the door that indicate they are a fall risk. I do not believe anyone was in the room with her because V10 was talking residents from one room to the dining room. There was only one activity aide person transferring the residents. Someone is supposed to be in the dining room at all times if any resident is in the dining room. On 6/22/2024 at 9:57am V14 (Activity Director) stated, I was not there but I was told V10 was transferring R1 from the activity room on the floor to the dining room. V10 went to the nursing station and the nurse told V10 to put R1 in the dining room. V10 took R1 into the dining room and locked one of the two wheelchair wheels. R1 apparently leaned forward and fell out of the wheelchair. That is pretty much all I know. Surveyor asked, V14 what is the orientation for Activity Aides regarding the use of wheelchairs. V14 stated, Residents that are in wheelchairs should be transferred by the nurse or the CNA. Unfortunately, during the time this incident occurred around 3:00pm the nurses and CNAs are doing shift change so no one was able to assist my staff to bring R1 to where the resident needed to be. Surveyor asked, V14 if activity aides have training on how to use a wheelchair. V14 stated, Yes and no, they understand the leaf on the door or wheelchair means fall risk and they understand their is supposed to be assistance to transfer the resident to and from. I do not know how long nurses and CNAs have not been assisting my staff. They (Activity Aides) recently had education on wheelchairs and the person explained to my staff the importance of locking the wheels on the wheelchairs. Surveyor asked V14 if this was done before or after the incident that occurred on 5/31/2024. V14 stated, Unfortunately, this was done after R1 fell . Prior to that I (V14) do not know when the last time was, they had proper training on that (regarding wheelchairs). V14 further stated, Prior to that incident on 5/31/2024 I (V14) had mentioned to my activity staff that the CNA or nurse should be helping them (activity staff) move residents to and from the activity room to the residents' room or dining room. The staff are usually pretty good at doing that. On 6/22/2024 at 10:25am V14 stated, The main reason the CNA or the nurse always helps with the transfer is supposed to have a staff member watch the residents in the room, we always want to make sure the staff member is watching the resident so incident that happened does not happen. Because it is a distance and if only 1 person is going back and forth who is watching the resident anything can happen in a short amount of time. That is why the CNA or nurse helps transfer back and forth. At that time no one was in the dining room. The nurses were at the nurses' station, but no one was in the dining room and V10 was putting residents at the table per the nurse's request. V14 stated, V10 has only been here for a few months. This is all new to her. I was hired the same time she was, so I did not have anything to do with her (V10) training. On 6/22/2024 at 11:07am surveyor asked V2 (Director of Nursing) regarding incident that occurred on 5/31/2024 with R1. V2 stated, R1 was in an activity and V10 was transferring her (R1) they brought R1 to the nurses' station and V11 directed V10 to take R1 to the dining room. When I interviewed V10 she stated she placed R1 at a table in the dining room. When I (V2) asked if she locked the wheelchair, she said she thought she did. Another aide was also transferring residents into the dining room too. V12 said he (V12) was standing at the med cart near the dining room and heard R1 cry and when he (V12) looked up R1 was on the floor. V12 said he (V12) went in and one of her legs appeared tangled in the footrest of the wheelchair and he (V12) removed the wheelchair, and he thought one side was locked but was not sure if the other side was locked. V12 said R1 had an open wound above left eyebrow and V12 attended to that, and other staff came in they called 911 and got vital signs. R1 was alert to her norm. V12 provided first aid and the ambulance came and took R1 to hospital and he notified the POA and MD. Surveyor asked V2 if there were staff in the dining room at the time of the incident. V2 stated, No one said they were in the dining room. A CNA and V10 were transporting residents to the dining room from activity room. Surveyor asked V2 what the training for use of wheelchairs for activity aides is upon hire. V2 stated, during on-boarding for everybody one of the on boarding processes is discussing fall and look for fall risks and it is everyone's responsibility to prevent falls. (i.e. remove boxes on floor, footrest on wheelchairs, locking wheelchairs) CNAs and nurses get more in-depth training. If wheelchair is not locked, resident can try to stand, and the wheelchair could roll away and when the resident tries to sit down, they could fall. Activity aides are able to transfer residents in their wheelchairs. Surveyor asked V2, how do activity aides know if resident is a fall risk. V2 stated, they are informed by the staff and by the binder we put in place. Also, V14 their supervisor is present during morning meeting, and he brings information to activity staff. Restorative also does training, and we did in-service with all staff regarding falls and how to use locking wheelchairs. On 6/22/2024 at 1:46pm surveyor asked V1(Administrator) regarding the incident that occurred on 5/31/2024 with R1. V1stated, I was here but not on the unit. I heard from nursing she (R1) was going to be sent out to the emergency room . I (V1) asked what happened, and I (V1) was told V12 was the first one on scene, they said V12 did not witness fall. V11 was the nurse for R1, and I (V1) asked her (V11) what happened, and she (V11) told me that activities (V10) transported R1 into the dining room after activities ended. V1 stated, I brought V10 down and talked to her and asked V10 what happened. V10 told me they were doing activities in the corner room and activities was over, so they started to transfer the residents over to the dining room. I asked V10 did you lock the chair because V11 or V12 did assessment and the way the chair was positioned felt chair was not locked. I asked, did you lock the chair, did you lock both locks and V10 said, I believe I did, and I asked her are you sure and V10 stated, I do not know. I do not remember. I remember R1 going out after that then V2 did investigation for the fall. Surveyor asked V1 who can transport residents in wheelchairs. V1 stated, any staff or family member can transport resident throughout the facility. Surveyor asked, are staff given education on how to transport residents in wheelchair. V1 stated, We did after the fall, but I am not sure if it was done before the fall. I know we did education on the wheelchair policy earlier in the year. Surveyor asked when the incident happened on 5/31/2024, what staff member was in the dining room at this time. V1 stated, I did not ask who was in the dining room to be honest, but if residents are in the dining room there should be supervision. Facility's Assessment Tool (7/22 through 6/23) documents in part: Services and care we offer based on our residents' needs: Provide person centered/directed care: identify hazards and risks for residents. Provides training/education and in-servicing to employees upon hiring, during skills validation events, monthly and annually. The facility's Fall Prevention and Management Policy revised on 12/23 shows (in part), The purpose of this policy is to support the prevention of falls by implementation of a preventative program that promotes the safety of residents based on care processes that represent the best ways we currently know of preventing falls. The facility's Wheelchairs policy rev. July 2023 shows (in part) Objective: 1. To provide a safe means of transport for residents. Procedure: 2. Lock wheels.

Based on observation, interview and record review, the facility failed to follow Physician Order for transmission-based precautions for 1 resident (R8) and failed to perform hand hygiene to prevent the spread of infectious microorganisms. Findings include: R8 was admitted on [DATE] with diagnosis that includes diabetes mellitus, systemic lupus erythematosus, Anemia, Acute kidney failure, Urinary tract infection, Pneumonia, unspecified organism, Acute respiratory failure, Unspecified Escherichia coli (E. coli), Listeriosis, unspecified-listeria bacteremia, Neutropenia, unspecified-Neutropenic fever, Bacteremia-listeria bacteremia. R8's Physician Order Sheet start date 5/29/2024 documented, in part Contact Isolation Precautions for Klebsiella, in the urine and MRSA of the nares. R8's Physician Order Sheet start date 5/30/2024 documented, in part Strict contact and droplet isolation precautions related to neutropenic status. All care and services provide by staff in room. R8's care plan dated 5/30/2024 documented in part: Resident is on contact and droplet isolations due to myelodysplastic syndrome and neutropenic status; Goal: Target Date: 6/27/2024 Resident's infection will be resolved/controlled till next review; Approach start date: 5/30/2024 educate visitors on necessary precautions needed for droplet and contact isolation; maintain the resident on droplet and contact isolation precautions in accordance with the Center for Disease Control (CDC) guidelines; place on a private room for strict droplet and contact precautions. Keep door closed at all times. On 5/31/2024 at 1:12pm a droplet sign and a contact precaution isolation sign was observed posted on R8's door. On 5/31/2024 at 1:13pm surveyor was standing in hallway on first floor and observed V5 (CNA) enter residents' room to collect meal tray. Surveyor observed V5 enter room next to R8's room removed tray out of resident's room then proceeded to R8's room. V5 entered R8's room without performing any hand hygiene or donning any PPE (Personal Protective Equipment) and picked up R8's meal tray and exited R8's room and put the used meal tray in cart. After V5 put used meal tray in cart, V5 did not perform hand hygiene and continued to next resident's room and entered a room without performing any hand hygiene. Posted outside of R8's room were two isolation signs. One sign read, droplet precautions and the other sign read, contact precautions, and a plastic bin filled with PPE was at entrance of R8's door. Surveyor asked V5 if she (V5) had education on infection control practice. V5 stated, yes, I have had education and we do not have to put on PPE if we are not going to touch the resident or do care. Surveyor asked V5 if R8 was on isolation and if PPE was required. V5 stated, no I did not touch the resident. Surveyor asked V5 to look at the signs posted at the door of R8. V5 stated, Oh yea, I should have put on PPE because the resident is on droplet and contact. V5 stated, I did not put on any PPE, and I walked out of the room and did not do any hand hygiene. V5 stated, we have enough PPE. On 5/31/2024 at 1:18pm surveyor asked V4 (Registered Nurse /RN) what isolation precautions R8 was on. V4 stated, the resident is on droplet and contact precautions and anyone that enters the room is supposed to wear the PPE that is stated on the signs. Any time anyone enters R8 room, they must put on PPE, so we do not spread infection. The CNA should have put on mask, gown, gloves and perform hand hygiene prior to entering the room and remove all PPE prior to exiting and performed hand hygiene. V4 further stated, the census on the floor was 21 but I sent someone home earlier so now the census is 20. On 5/31/2024 at 2:43pm V3 (Infection Prevention Nurse) if a Droplet and/or Contact sign is on the door staff must wear PPE prior to entering put on (gown, gloves, mask) and when exiting take PPE off and do hand hygiene. Risk if PPE sign is not followed, transfer of micro-organisms can occur. If there is a sign at the door regarding isolation, I expect staff to read sign and follow the sign and wear the appropriate PPE based on what they will be doing with resident. If a resident is on droplet and contact precautions, anyone entering the room must follow the sign on the door regarding PPE. On 6/1/2024 at 11:04am V2 (Director of Nursing) stated, for residents on isolation, I expect staff to follow the sign on the door for whatever PPE is needed. Infection Control Policy dated reviewed June 2020/Revised May 2024 (in part) documented Objective: The facility's written program is for the implementation of systems that provide a safe, sanitary and comfortable environment and helps prevent the development and transmission of communicable diseases and infections. The facility's infection control program includes: 4) The facility maintains protocols and precautions to prevent transmission of infectious agents using the following tiers of precautions: Transmission Based Precautions i. Contact Precautions ii. Droplet Precautions 5) The facility provides personnel protective equipment (PPE) which refer to barriers used alone or in combination to protect mucous membranes, airways, skin, and clothing from contact with infectious agents, PPE used is base upon the nature of the interaction with the resident and/or the likely mode of transmission. 6) Hand Hygiene is utilized to reduce the spread of germs to residents and the risk of the Health Care Provider's colonization of infection by germs acquired from the resident. The facility utilizes hand hygiene via handwashing and alcohol base sanitizers.

Based on interview and record review, the facility failed to supervise a high risk for falls resident (R2) in a sample of 5 residents. This failure resulted in R2 sitting in a wheelchair at the nurse's station, falling asleep and leaning forward and falling out of his wheelchair to the ground face down. R2 sustained small laceration to bridge of nose, required hospital evaluation and required two sutures to the nose. Findings include: Facility's reportable to state agency regarding R2 documents in part: Date of Occurrence (11/20/23), R2 was sitting in a wheelchair at nurse's station and fell asleep, leaned forward, and fell from the wheelchair. R2 was evaluated by the nurse on duty to have active ROM x 4 with c/o (complaint of) pain to head and noted small laceration to the bridge of R2's nose. NOD (Nurse on Duty) provided first aid. R2 was transferred to hospital as a witnessed fall. While at the hospital, received two sutures to the bridge of nose and returned. Interviews: V8 (Certified Nursing Assistant/CNA) states R2 had been up at nurse's station. V8 was in hallway throwing his trash away when he heard R2 fell . R2 was sitting at nurse's station in his wheelchair and fell forward onto the floor face forward. V10 (Licensed Practical Nurse/LPN) went to his side. V9 (CNA) states R2 was trying to get out of bed, so I got him out of bed. I got him up between 5:30 and 6:00 am. I was bringing R2 from room to room with me. I went to help another resident in the dining room, R2 was at nurse's station in his wheelchair. He fell asleep and fell forward out of the wheelchair onto the floor. V10 went to his side to provide care. V17 (CNA) states I was in hallway and heard a noise went to see what it was and seen R2 on floor in front of his wheelchair. I noticed he was bleeding from his nose. V10 went to his side and looked at him. V10 (LPN) states R2 was at nurse's station in his wheelchair when he fell asleep and fell forward from wheelchair to the floor. Noted that he was bleeding from nose. I provided first aid and did neuro checks. I called MD (medical doctor) and received order to send to hospital for further evaluation. 911 was called and care was transferred. Conclusion: R2 was evaluated at hospital and returned with 2 sutures to bridge of his nose. Wound care to be provided until wound is closed. R2 fell asleep while in wheelchair and fell forward to the floor. R2's plan of care was updated, and intervention placed to return to bed when tired. (R2's reportable does not document R2 was seen falling by staff.) R2's diagnoses includes Orthostatic Hypotension, Major Depressive disorder, Coronary artery disease, Atrial fibrillation, COPD, Tremors, Spinal Stenosis and Mild Cogitative Disorder. BIMs score dated 4/3/24 - 00 (indicating severe impairment) On 5/17/24 at 11:32 am, R2 was observed. R2 did not remember the incident of 11/20/23. On 5/17/24 at 11:36 am V7 (Registered Nurse/RN) said R2 is high risk for falls and when he ambulates, he needs to be 1 person assist, he gets up and walks and will fall if he walks by himself. V7 said someone needs to be visually supervising him because sometimes he will want to get up by himself and he will fall. V7 said, she would not leave the resident by himself at a nurse's station without watching him. On 5/17/2024 at 12:33 pm V2 (Director of Nursing) was asked how R2's final report to state agency was documented as a witnessed fall, who witnessed the resident fall? V2 said, she thought it was V9 (CNA). On 5/17/24 at 1:56 pm V9 (CNA) said, on 11/20/23 she was assigned as CNA for R2. V9 said as far as she remembers he was trying to get out of bed, and she did not want to leave him, and she got him dressed and took him with her on her rounds. V9 said she was rounding on her residents and would wheel R2 in a wheelchair with her and she left him outside the door and gave him crackers and cookies. V9 said once she was done rounding, she had to do ADL care (incontinence care) and the nurse (V10) was done with passing medications, and the nurse was at the nurse's station, so she left R2 with V10. V9 said she left and went to the dining room as another resident looked like she will fall and wanted to reposition her. V9 said while she was in the dining room, she heard a loud sound, and she went back to R2, and he was on the floor. V9 said maybe R2 dosed off and the nurse was there as she was sitting by the nurse's station. V9 said, she did not leave R2 alone. She (V9) left him with V10. V9 said R2 has history of falls, and she did not want to leave him alone in bed and she did not want him to fall, sometimes he wakes up at night and he insists on getting up and sometimes he keeps on trying to walk. V9 said when R2 is trying to get out of bed, as much as possible she will ask if he needs anything and will turn on the television and will give him a snack. V9 said that day she was taking R2 with her to prevent a fall. V9 said sometimes he gets confused with time and will say he wants to go home to his wife and is confused that he doesn't belong in the nursing home. V9 said she did not see R2 fall, she just heard a loud sound. On 5/17/2024 at 2:21 pm V10 (RN) said on 11/20/23 she was the night nurse for R2. V10 said it was close to around 5:00 am R2 was trying to get out the bed. The CNA (V9) assisted, and we made rounds and rotated on and off watching R2. R2 was at the edge of the nursing station, it was the end of the shift. V9 went to check on another patient in the dining room. I (V10) was at the nurse's station at the other end and I turned and asked V8 (CNA) a question and then all we heard was boom. As soon as we (V8 and V10) turned around R2 was on the floor, he was face down with a cut on his nose. Day shift was coming in and assisted me (V10). I (V10) did not see R2 fall, I heard R2 and turned around. I (V10) believe V9 saw him fall but she (V9) was in the dining room and could not get to him in time. V9 was in the dining room, and I was at the nurse's station tidying up, you know finishing my charting and things. R2 had been attempting to get up the shift and I (V10) was talking to R2 then I started talking to other staff. We had R2 at the nurse's station so we could keep an eye on him (R2) at the nurses station. On 5/18/24 at 9:19 am V2 (Director of Nursing) said regarding R2 he had history of insomnia and was getting up on his own and sliding off the bed, history of sliding from the bed, when he got up this day the CNA on duty and got him up and was watching him, and then she brought him to the nurse's station, and went to the dining room to attend to another resident, he was in her view with the nurse at the nurses station. V2 was asked how R2 managed to fall asleep and fall if he was watched by staff. V2 said it just happened fast. V2 said both V9 (CNA) and V10 said they saw R2 fall. V2 was asked why the resident fell in that case if he was being watched by the staff. V2 said it happened because they were not close enough to R2 to prevent the fall, they were not able to get to him in time. V2 said the nurse was by him, and she was on the other side of the desk. (R2 was able to fall asleep and lean forward and fall to the ground, staff on duty was not able prevent R2's fall.) Surveyor asked V2 how R2 managed to fall asleep and lean forward and hit the floor. V2 said, it just happened. V2 provided R2's fall history, R2 had 12 falls prior to the incident of 11/20/23. On 5/18/24 at 9:51 am, V11 (Restorative Director) and V2 were present. V2 said R2 came to the facility because he had numerous falls at home and wife was unable to get him off the floor. V11 said when he was at home the wife was providing care alone. V2 said he had multiple falls at home prior to coming here, one of the falls resulted in subdual hematoma. V2 said V17 (R2's wife) had difficult time with getting him up and she started to do activities on the floor like she placed things in front of him, like books, watch television on the floor. V2 said the falls became too much to handle and that's why he came to the facility, he was referral from Veteran Administration. V2 said facility knew he was a fall risk prior to the resident coming here, he has insomnia and post-traumatic stress disorder, is followed by psychologist and neurology. V2 said R2 is showing aggression towards staff and seeks his wife. V2 said R2 has history of anxiety and has had behaviors towards his V17 (R2's wife). V11 had last fall on 4/17/24. V11 said, R2 has a fall care plan with interventions. V11 said after each fall, the facility adds interventions, and some are already discontinued. V11 provided a list of R2's discontinued fall interventions. On 5/18/24 at 11:30 am V2 said the facility does not have policy on monitoring residents, policy on high fall risk residents. V2 said supervision of residents is embedded in everything the facility does and they do not have a written policy on supervision. R2's (Start Date 07/11/2023) care plan documents in part: Resident is at risk for falls related to muscle weakness, impaired cognition, and history of falling and diagnosis of tremors, dementia, anxiety, visual impairment and psychotropic medication, poor safety awareness and spontaneous. Approach (Start Date 7/11/2023): Provide 1 or more staff assistance. If resident has mood/behavior; impaired mobility/weakness, pain, or discomfort; restlessness and or agitation. Approach (Start Date 3/09/2024): Resident is impulsive and due to diagnosis of cognitive impairment resident doesn't remember not to get up without assistance. Staff have exhausted all interventions. Will continue with care plan and monitor resident frequently. R2's (11/3/23) Fall Risk Assessment documents in part: score of 20, high risk for falls. Facility's Assessment Tool (7/22 through 6/23) documents in part: Services and care we offer based on our residents' needs: Provide person centered/directed care: identify hazards and risks for residents. The facility's Fall Prevention and Management Policy revised on 12/23 shows, The purpose of this policy is to support the prevention of falls by implementation of a preventative program that promotes the safety of residents based on care processes that represent the best ways we currently know of preventing falls. 40515 On 5/17/2024 at 3:20pm surveyor asked V8 (CNA) if he remembered the fall incident R2 had in November 2023. V8 stated yes, I worked 11pm-7am shift. I remember but I do not remember the date, but I know he fell on e time. I made a statement. I was in the other room and had trash to empty and linen to dump and as I was walking down the hall, I heard a boom; I was in the hallway. I last saw R2 in the chair because we were watching him. We were all watching him because he is a fall risk guy. He tries to get out of the bed most of the time. The nurse was done passing meds because he was with her then it was almost the end of the shift. I saw him face down on the floor, I tried to get a pillow and ice I don't know but the nurse wanted me to get ice and a pillow. He was at the nursing station because the nurse was with him, we want to keep an eye on him so everyone can see him. I was far from him. I did not see him fall I just heard the boom. On 5/18/2024 at 11:34am surveyor observed residents in 4th floor dining room and without any staff in dining room monitoring residents. Residents sitting in wheelchairs and some in highbacked chairs, groomed and wearing shoes or non-skid socks. On 5/18/2024 at 11:36am surveyor walked to entrance of dining room of 4th floor dining room and spoke to V15 (Activity Aide) and asked what her role was. V15 stated I just finished doing an activity with the residents and sometimes I will pass out coffee and put on bibs. Surveyor observed V15 outside of dining room pouring coffee then passing out to residents. On 5/18/2024 Surveyor continued to observe residents in the dining room without supervision. On 5/18/2024 at 11:38am surveyor observed nurses sitting at the nurse's station. No staff in residents dining room. On 5/18/2024 at 11:42am V16 (LPN) stated all residents on this floor (4th) have dementia/Alzheimer and are confused. We have 2 activity aides; CNAs and we monitor residents. Surveyor asked V16 if residents had to be monitored when in the dining room. V16 stated, yes for safety reasons. On 5/18/2024 at 11:46am surveyor standing in resident dining room observing residents with no supervision. V14 (CNA) entered dining room and took a seat. Surveyor asked V14 if anyone was in the dining room when she walked in. V14 stated, No, when I came in here no one was in here. V14 stated, the nurses can see the residents when they are at the medication cart. Surveyor asked V14 were the nurses standing at the medication cart when you entered the room. V14 stated, No. Surveyor observed both nurses at the nurse's station. V14 further stated, someone has to monitor the residents because they can choke, fall or hurt themselves.

Based on interview and record review, the facility failed to keep a resident (R4) free from abuse in a sample of 5 residents. This failure resulted in R3 punching R4 in the face which caused R4 discoloration to the right eye and bleeding from nose and mouth. This past noncompliance occurred from 12/12/2023 to 12/15/2023. Findings include: Facility's reportable to state agency regarding R3 and R4 documents in part: On 12/12/2023 Nurse on duty, (V5) reported to Administrator R3 allegedly punched R4. Upon assessment, some discoloration was noted to his right eye and bleeding out of his nostrils and mouth. R4 was transferred to the hospital for further medical evaluation. R3 was transferred to the hospital as well for psychiatric evaluation. Police notified. R3's diagnosis includes Chronic obstructive pulmonary disease, unspecified, Anemia in other chronic diseases classified elsewhere, Schizoaffective disorder, depressive type, Amyotrophic lateral sclerosis, Thrombocytopenia, unspecified, Essential (primary) hypertension, Osteoarthritis of knee, unspecified, Hypothyroidism, unspecified, Anxiety disorder, unspecified, Insomnia. R3's care plan documents in part: resident is at risk of abuse due to schizophrenia diagnosis and history of provoking others. R4's diagnosis includes Malignant neoplasm of unspecified part of unspecified bronchus or lung, Dysphagia, unspecified, Benign prostatic hyperplasia with lower urinary tract symptoms, Muscle weakness (generalized), Major depressive disorder, recurrent, unspecified, anxiety disorder, unspecified, Insomnia, unspecified, Essential (primary) hypertension, Unspecified dementia, unspecified severity, with other behavioral disturbance. R4's care plan documents in part: resident is at risk for abuse for diagnosis of dementia and new alleged behavior of saying derogatory and disrespectful comments, problem start date 3/1/23. R4's care plan documents in part: R4 presents with agitation, compulsive behavior, excitability related to diagnosis of anxiety. On 5/17/24 at 10:43 am V4 (Certified Nursing Assistant/CNA) said regarding R3 and R4, the incident happened last year in December. V4 said he recalls the incident, he worked 3 pm to 11 pm shift. V4 said it was around dinner time, he was passing trays to residents who eat in the rooms. V4 said he passed all trays and was assisting other residents and when he was done feeding another resident, he went to R4's room to feed him. V4 said when he walked in, R4 was bleeding from left side, from the nose, and he immediately called the nurse and they both came in. V4 said, R3 admitted that he punched R4. V4 immediately took R3 for safety and he was with him in the nurse's station most of the time until the police came. On 5/17/24 at 12:35 pm V1 (Administrator) said regarding R3 and R4. V1 said it was reported of the incident that around 7 pm by the nurse that R3 punched R4. V1 said she went upstairs and saw R3 being watched by V4. They were by the nurse's station, ambulance came, and police came, both residents went out to the hospital. V1 said she went to R4's room and he had blood on his face and shirt was soiled with food, and paramedics were there, he said he was ok, R4 stopped responding to questions. V1 left and went with police to talk to R3 at the nurse's station and R3 said he hit R4 and was asked how and he demonstrated a closed hand. V1 said when asked why he hit R4, R3 said because R4 was coughing too much and when he asked R4 to stop coughing, R4 coughed again and R3 felt he was doing that on purpose. R3 said R4 responded by calling R3 a filthy [NAME]. V1 asked police on guidance, and because they are both elderly and both had mental diagnosis the police would not pursue criminal charges and R3 was sent to hospital. V1 said facility discharged R3 and R3 did not want to come back to the facility. V1 said R3 never got in an argument with another resident but would get in arguments with staff. R3 was on fluid restriction and if he would ask for water, he would raise his voice and would ask for the water. V1 said she spoke to wife of R4, and she never saw any disagreements, but R3 was never too friendly. V1 said the result of the investigation was that the incident did happen and R3 hit R4 and R3 admitted that he hit R4. R4's (12/12/2023 at 10:16 PM) progress note documents in part: At 5:50 pm writer called to room by CNA for a disruption, walking in the room found resident laying in his bed covered in food, noted skin discoloration, and swelling to right eye and nose bleeding from both nostrils. Roommate resident immediately separated. R4's progress note (12/12/2023 at 11:10 PM) documents in part: hospital called to inquire about patient. Writer informed by NOD (nurse on duty) that patient was admitted to hospital with diagnosis of Trauma of face, head, and mouth. Facility's Abuse Prevention Guidance (rev. 10/22) policy documents in part: this facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property. Prior to the survey date, the facility took the following actions to correct the noncompliance. The deficiency was corrected on 12/15/2023. 1.R3 stated that he did not want to return to the facility and was discharged on [DATE], therefore R3 no longer resides in the facility as of 12/12/2023. 2.Facility followed facility for reporting timeframe and completed through investigation. 3.Facility spoke to R4's wife and R4 confirmed that R3 and R4 had not had any previous disagreements. 4.Facility staff immediately provided 1:1 observation for R3. 5.Following incident, facility conducted abuse in-services for all of facility staff and emphasized prevention and reporting any abuse right away to V1. 6.Facility followed facility policy by having care plans and assessments reviewed. 7.V1 conducted audits on all residents and care plans reviewed and updated as necessary and did risk assessments for residents with PTSD. Audits were done for 4 weeks post incident.

Based on observation, interview, and record review, this facility failed to provide the necessary services, identify a decline, implement interventions, and evaluate the effectiveness of interventions to prevent the decline in range of motion. This affected one of three residents (R1) reviewed for a decline in functional abilities. This failure resulted in R1 developing a contracture of right hand and is unable to extend fingers. Findings include: R1's medical record notes R1 with diagnoses including, but not limited to, tracheostomy, ventilator dependent, left knee contracture, gastrostomy, nontraumatic intracerebral bleed, stroke with hemiplegia affecting right side, cardiac arrest, generalized muscle weakness. On 12/26/23 at 9:18 AM, R1's family member stated that R1's hands are contracted because he is not receiving therapy. R1's family member stated that R1 is supposed to wear a splint on right hand, but she never sees R1 wearing it and now R1's right hand is contracted. On 12/26/23 at 1:30 PM, R1 was observed lying in bed without a right-hand splint. On 12/27/23 at 10:00 AM, R1 was observed lying in bed without a right-hand splint. On 12/27/23 at 1:18pm, V8 (Restorative Aide) was observed on the nursing unit. V8 was observed entering a resident's room at 1:19pm and exiting at 1:35pm. V8 was observed entering another resident's room at 1:35pm and exiting room at 1:55pm. V8 was then observed walking down hallway towards empty resident rooms. V8 was not observed providing PROM (Passive Range of Motion) therapy with R1. V8's documentation in R1's electronic medical record, dated 12/27/23 at 2:30 PM, notes V8 completed 15 minutes of PROM and applied right hand splint for 15 minutes. On 12/27/23 from 2:05pm until 2:46pm, R1 was observed for wound care treatment. R1 was not wearing a right-hand splint. V8 was not observed at any time entering R1's room and providing therapy for R1. R1's functional abilities assessment, dated 10/27/23, notes R1 with impairment in range of motion in both upper extremities (shoulder, elbow, wrist, hand). On 12/28/23 at 8:50am, V7 (Restorative Nurse) stated that she started working at this facility in September 2023. V7 stated that residents that are not receiving skilled therapy will receive restorative therapy. V7 stated that R1 is in restorative's PROM program. V7 reviewed R1's last two restorative assessments, dated 8/25/22 and 11/21/22. V7 stated that neither assessment notes R1 using adaptive equipment for right hand. V7 stated that restorative assessments are completed quarterly for residents. There are no further restorative assessments found in R1's medical record. On 12/28/23 at 9:40am, V9 (Rehabilitation Director) reviewed R1's OT (Occupational Therapy) evaluation dated 4/7/23. V9 stated that the therapist recommended PROM program for R1 and a resting hand splint for prevention of contracture. V9 stated that it notes right wrist with increased tone. V9 stated that this means the therapist was able to work with right hand; this is reason right hand splint was recommended. V9 reviewed R1's OT evaluation dated 9/22/23. V9 stated that it notes R1's right wrist/hand with a lot of resistance, a lot of increased tone and tightness. V9 stated that the right-hand splint would help prevent bad contractures. V9 stated that evaluation also notes slight hand contracture of R1's right hand. V9 informed that R1's right hand splint and PROM program were not reordered after R1 returned from hospital on 12/2/23. V9 stated that the splint and PROM program should have been re-ordered with each re-admission to this facility. V9 stated that R1's right hand splint ordered previously notes for R1 to wear at all times except with bathing or receiving PROM. V9 stated that PROM was ordered daily previously. R1's OT (occupational therapy) evaluation, dated 4/7/23, notes R1 was seen to assess therapy needs, splint assessment, and develop a restorative program. Musculoskeletal assessment noted impairments to both upper extremities. R1's right wrist with no active range of motion, passive range of motion within functional limits but with increased tone. R1 will benefit from a resting hand splint for right hand to decrease risk of contracture. R1 referred to restorative therapy for PROM of all extremities. R1's OT evaluation, dated 9/22/23, notes R1's right wrist with no active range of motion, passive range of motion within functional limits but with spasticity and stiffness noted. R1 with slight contracture noted in right hand. R1 will benefit from continued restorative program for PROM of both upper extremities, positioning in bed as well as additional daily application of a resting hand splint to right hand for prevention of contractures and maintaining current PROM. The therapist trained restorative staff on proper PROM/stretching technique for both upper extremities and completed x 10 repetitions for all joints on all planes. Additionally trained restorative staff on proper application of resting hand splint on right hand. R1's POS (Physician Order Sheet), dated 9/21/23, notes an order for restorative splint/brace to be on at all times to assist in contracture management/maintenance of current ROM (range of motion)/pain management. Special instructions: remove for bathing, ADLs (activities of daily living), and skin checks. This order was not re-ordered upon re-admission to this facility on 10/20/23 or 12/2/23.

Based on observation, interview and record review the facility failed to follow its Accident/Incidents Reporting policy by not completing an incident report, failing to document in the progress notes, failing to assess and monitor for any changes of condition, and failing to notify the physician and family immediately after an incident. The facility also failed to follow its Fall Prevention and Management policy by not implementing fall interventions and failing to update fall care plan after a fall for two (R1, R2) of three residents reviewed for falls. These failures caused a delay in treatment and hospitalization of R1 who sustained a left femoral neck fracture that required surgery. Findings include: 1.) On 12/5/23 at 9:52AM, observed R1 lying in bed. She is awake but confused and restless. Her blanket is by the foot part of her bed. The bed is not on the lowest position. The floor mattresses are folded on the floor. The call light is not within reach. The abductor wedge is at the bedside. Called V9 (Certified Nurse Assistant/CNA) to R1's room and showed V9 the observation. V9 said R1 finished her breakfast in bed before 9:00 AM. V9 said R1 is restless, keeps removing her abductor wedge in between her legs. V9 said that R1's floor mattress should be laid on bilateral sides of the bed and the bed should be on the lowest position. V9 CNA adjusted the bed on the lowest position. On 12/5/23 at 10:00 AM, called V10 (Registered Nurse/RN) and informed of above observation. V10 said that she observed R1 when she made rounds this morning with floor mattresses folded. V10 said that CNAs folded it to provide space and way for the other 2 residents when up in wheelchair for them to get out from the room. V10 said that the floor mattresses should be on both side of R1's bed for safety. On 12/5/23 at 10:30 AM, reviewed R1's medical record with V10. V10 said that R1 is ambulatory with unsteady gait, and she is at high risk for falls. There is no fall incident report and no documentation written in R1's progress notes for 11/2/23. Documentation indicated on 11/3/23 R1 was sent to the hospital due to left hip pain and was admitted with left femur fracture. On 12/5/23 at 12:37 PM, V12 (RN) said that she worked with R1 on 11/2/23 3-11 shift. She said that R1 has unsteady gait and limping when ambulating. She said, around 7:00 PM she went to R1's room and observed R1 bending over to pick up bandage on the floor, by the time she approached R1, she was already down on the floor. She was sitting in the middle of the 2 beds. She left R1 and called for help. When she came back to the room with other staff (V13 CNA, V14 CNA, V15 CNA, and V16 RN) with her, R1 was able to move herself by scooting in a sitting position and reached by the foot part of the bed closer to the door. They transferred her via mechanical lift to the wheelchair. R1 denied any pain. V12 said she assessed R1, and no injury was noted. She did not document the incident in the progress notes and did not complete an incident report. She did not notify R1's PCP (primary care physician) and family about the incident happened because R1 did not complain of any pain and no injuries were noted. She forgot to document the incident in the progress note but she endorsed to the next shift (V21 Agency Licensed Practical Nurse/LPN) what happened. She said, the following day when R1 complained of pain on her left hip, the PCP and family was notified. She said, she should document in the progress note of what happened, complete an incident report, and notified her DON (Director of Nursing) of the incident. On 12/5/23 at 1:03 PM, V13 (CNA) said that she worked on 11/2/23 3-11 shift. V13 said, R1 ambulates with unsteady gait due to her limping. V13 said, she was called by V12 (RN) to help R1. V13 said, she found R1 sitting on the floor by the foot part of the bed close to the door. There were 3 CNAs (V14, V15 and herself) and 2 Nurses (V12 RN and V16) who transferred R1 to wheelchair using gait belt. Four of them assisted R1 to wheelchair while V15 held the wheelchair. R1 was wheeled to the nursing station for monitoring because R1 is confused and trying to get up from wheelchair. On 12/5/23 at 1:24 PM, V14 (CNA) said that he worked on 11/2/23 3-11 shift. He said V13 (CNA) called him to help R1. He observed R1 was lying on the floor by the end of the bed, facing the window. They picked her up and assisted to the wheelchair. V15 (CNA) held the wheelchair and while the rest assisted R1 to the wheelchair. They did not use gait belt because R1 can still stand up. R1 was wheeled to the nursing station for supervision. On 12/5/23 at 1:30 PM, V7 (Restorative Nurse/Fall Coordinator) said that she is responsible for implementing fall interventions and investigation of fall incidents. The floor nurses do the fall assessment upon admission/re-admission, quarterly assessment, annually, significant change of condition and after each fall. She updates the care plan after each fall incident based on root cause analysis/fall investigation. Fall is any change on plane, could be kneeling, lying, anybody position on floor. It could be witnessed or observed. Reaching on the floor or bending over that ended body to land on the floor is considered a fall and should be documented in the progress notes and need to complete an incident report. Any unusual incident happened to the resident should be documented in the progress notes and complete an incident report. The nurse should report the incident to the DON or ADON. Then the nurse will be informed of what immediate intervention should be put in place. Root cause analysis/fall investigation is done by the IDT (Interdisciplinary team) during daily morning meeting. Then the fall care plan will be updated based on the root cause analysis/fall investigation to prevent future falls. R1 is ambulatory but with unsteady gait due to her limping. R1 is at high risk for falls and had multiple fall incidents. On 12/5/23 at 2:22 PM, V15 (CNA) said that she has been working in the facility for 6 weeks. The first time she worked by herself was on 11/2/23 3-11 shift when she took care of R1. She said she was called to R1's room and observed R1 sitting on the floor by the foot of her bed with her both legs extended. She did not know what happened. She held the wheelchair as the 2 nurses and 1 CNA assisted R1 to the wheelchair. R1 was wheeled to the nursing station. V15 said she placed R1 to bed around 9:00 PM by herself. R1 has having hard time pivoting/turning. R1 moaned but when she asked R1 if she is in pain, R1 denied it. V15 reported to V12 (RN) of her observation. V15 said, V12 only endorsed to her that R1 needs 1 person assist and is incontinent. V12 did not inform her that R1 needs supervision, and she is at risk for fall. V15 said that after dinner, R1 was sitting by the nursing station. She does not know who wheeled R1 to her room or if she wheeled herself or walked to her room. On 12/6/23 at 10:13 AM, V21 (Agency LPN) said that she worked on 11/2/23 at 11-7 shift and received endorsement from V12 (RN) that R1 had fall incident and denied any pain. V21 said that she did not know the details of R1's fall. V21 said that she monitored R1, but she can't remember documenting it. V21 endorsed to the next shift and reported to V22 (LPN) that R1 fell on [DATE] 3-11 shift. V21 endorsed to V22 to call R2's PCP (Primary care physician). V21 said that she was still in the facility when R1 was sent out to the hospital for evaluation. V21 said that she does not know why V12 did not complete an incident report for R1 and did not document it in the R1's progress notes of what happened. V21 said that assessment, documentation, and reporting to PCP and family should be done immediately after the incident occurred. On 12/6/23 at 10:20 AM, Review R1's medical records with V7 (Fall Coordinator). R1's fall incident that occurred on 11/2/23 was not documented in progress notes. Fall incident report was not done. R1's PCP and family were not immediately notified after the incident. R1 was not monitored for any changes of condition after the incident. Informed V7 that R1's fall prevention interventions were not implemented. R1 was observed on 12/5/23 that she is not up in chair before breakfast. The bilateral floor mattresses were folded while she was in bed. Her bed was not in the lowest position. On incident of 11/2/23, R1 was not in high traffic area so staff can monitor her. She was observed bending over to pick up something on the floor and by the she approached her she was already sitting down on the floor in her room. R1 was transferred to from wheelchair to bed by V15 (CNA) by herself instead of 2 persons assist. Informed V7 that R1's fall care plan was not updated after she came back from the hospital on 11/8/23 with diagnosis of total left hip arthroplasty due to fracture hip. On 12/6/23 at 11:52AM, V18 (CNA) said that he took care of R1 on 11/2/23 11-7 shift. V18 said that R1 slept during the entire shift, he did not change or repositioned her until 6:30 AM when he was about to provide incontinent care and get her up. R1 complained of pain, and he observed redness on her left hip. V18 kept R1 in bed and reported to the incoming CNA V9. V18 said that he did not report to V21 (Agency LPN) because she was busy, and it was about time for him to leave. V18 said that V21 did not inform him that R1 fell on ,d+[DATE] shift. V18 said, V17 (CNA) told him that R1 fell on ,d+[DATE] shift. V18 said that he is aware that he should report his observation regarding R1's complaint of pain to V21. On 12/6/23 at 12:50 PM, V1 (Administrator) said that V12 (RN) should complete an incident report and document the incident report in R1's progress notes immediately after the incident. The nurse should follow and implement their policy. On 12/6/23 at 1:40 PM, V17 (CNA) said that he worked on 11/2/23 11-7 with V18 (CNA). V17 said that he heard from the 3-11 CNAs that R1 fell and was found sitting on the floor in her room. All of them assisted R1 from floor to her wheelchair. V17 said that he assisted V18 to provide care to R1 because she was complaining of pain on her left hip. R1 was moaning and saying polish language Boli which means pain. They provided incontinence care to R1 at 12:00 AM and 3:00 AM, repositioned at 6:00 AM. They reported R1's complaint of pain to V21 (Agency LPN) each time they provided care. On 12/6/23 at 1:49 PM, V16 (LPN) said that she worked with V12 (RN) on 11/2/23 3-11 shift. V12 called her for help to R1's room. She observed R1 sitting on the floor by the foot part of her bed. All staff (V12 RN, V13 CNA, V14 CNA, V15 CNA, and herself) assisted R1 to her wheelchair. R1 was wheeled to the nursing station. R1 is confused and always attempted to get up and walk. R1 ate in the dining room for dinner. R1 can get up and walk from her wheelchair. V16 said that she is not aware that V12 did not complete an incident report for R1 and did not document in her progress notes of what had happened. V16 said that if she is the nurse assigned for R1 she will complete the fall incident report, document in progress notes what happened including her assessment, notify physician and family member and monitor resident for any changes of condition. On 12/6/23 at 2:15 PM, V2 (Director of Nursing/DON) said that she reviews the fall incident with IDT. Incident report is completed in any unusual occurrence with resident that cause or may potentially cause an injury. Informed V2 of interviews done with all staff who worked with R1 on 11/2/23, 3-11 shift and 11-7 shift. Informed V2 of CNAs reported R1 's complaint of pain on her left hip to the nurses on both 3-11 and 11-7 shift but was not addressed. Reviewed R1's MAR (Medication Administration Record) for 11/2/23 and 11/3/23, no nurses administered with as needed pain medication. V2 presented R1's comprehensive pain assessment done by V12 (RN) as late entry after R1 was admitted to the hospital due to fracture left hip. V2 said that V12 did not complete an incident report nor document it in the progress note because V12 said that R1 intentionally sat down on the floor but if V12 is changing her statement then she should complete an incident report because it's considered as a fall incident. V2 said that she recognized the incident as a fall and did fall in-services on 11/10/23. Informed V2 that after R1 was readmitted on [DATE] from hospital with left total hip arthroplasty due to fracture left hip, R1's fall care plan was not updated and she had multiple fall incidents on 11/10/23, 11/11/23 and 11/19/23. R1 is initially admitted on [DATE] and readmitted on [DATE] with diagnosis listed in part but not limited to Displaced fracture of base of neck of left femur subsequent encounter for closed fracture with routine healing, Presence of left artificial hip joint left total hip arthroplasty, Unilateral primary osteoarthritis left hip, Disorders of bone density and structure Osteopenia, Abnormalities of gait and mobility, Generalized anxiety disorder, Low back pain, Cognitive communication deficit, osteoarthritis, idiopathic scoliosis. Admission fall assessment done on 9/29/23 indicated she is at high risk for fall. Re-admission fall assessment done on 11/9/23 indicated she is at high risk for fall. Care plan indicates that she is at risk for falling related to muscle weakness, history of falls, oblivious to safety, unsteady gait and is not compliant with using assistive device or allowing staff assistance when attempting to ambulate. Interventions: Up in chair before breakfast per resident preference. Bilateral floor mats. Keep resident in high traffic area so staff can monitor. Resident will be monitored often while in bed. 2 persons assist with transfer. Keep the bed in the lowest position with brakes locked. She is at risk for ADL (Activity of Daily living) decline related to muscle weakness and cognitive impairment. Interventions: Locomotion and Walking requires supervision. She is unable to make her needs know due to impaired cognition, poor insight with judgement, poor safety awareness as evident by attempting to ambulate without assistance and irritability when redirected. Interventions: Observed and report changes in resident's condition. Observed for non-verbal signs of distress (e.g., guarding, moaning, restlessness, grimacing, diaphoresis, withdrawal). Turn reposition, communicate, provide peri care, assess for pain, provide liquids/food as needed. MDS (Minimum Data Set) quarterly assessment on 11/1/23 Section GG Functional abilities and goals. Coded: Moderate assistance for Walking; Maximum assistance for transfer. R1's fall incident reports for 2023: 1). 11/19/23 Unwitnessed fall. R1 was found sitting on the floor in her room by CNA. 2). 11/11/23 Unwitnessed fall. R1 was seen sitting on the floor in her room [ROOM NUMBER]). 11/10/23 Unwitnessed fall. R1 was found sitting on the floor mattress in her room. 4) 10/27/23 Unwitnessed fall. R1 was found sitting on the floor in her room. 5) 10/5/23 Unwitnessed fall. R1 was observed scooting from her room into the hallway in a sitting position. 6) 4/14/23 Unwitnessed fall. R1 was noted sitting on the floor by the nurses' station. 7) 4/4/23 Unwitnessed fall. R1 was found lying in prone position having nasal bleeding in the dining room. 8) 3/19/23 Unwitnessed fall. R1 was noticed laying on the floor in the hallway next to the entrance of her room. 9) 1/24/23 Unwitnessed fall. R2 was found on the floor on her right side in the hallway. No fall incident report or any incident report done on 11/2/23 in R1 medical records. R1 initial report of facility reported incident dated 11/3/23 indicated: On 11/3/23 R1 with complaint of left hip pain during initiation of morning care. CNA immediately notified nurse on duty. R1 provided with ordered pain medication and nursing assessment completed. The provider was contacted with order to transfer to hospital for evaluation and treatment. R1 is ambulatory and uses a wheelchair when tired. Based on initial investigation, R1 was observed in her room the previous evening bending over to reach an item on the floor and sat herself down on the floor in the process. R1 has no complaints of pain. Facility received report from the hospital that R1 has fracture of the left femoral neck and mild superior distal displacement of the distal fracture fragment is seen. Summary of the investigation: R1 has history of osteopenia and osteoarthritis, along with the behaviors of resisting care, being aggressive and scooting on the floor. On 11/2/23 around 8:00 PM, R1 was noted by V12 (RN) to be crouched down to pick an item on the floor and that she sat on the floor left hip first. R1 was unable to get herself up from her sitting position on the floor. While V12 looked for assistance R1 was able to scoot herself towards the doorway. Several staff assisted her up from the floor into the wheelchair. R1 was refusing care at this time. Staff brought her out of her room and on several occasions R1 stood up from her wheelchair while at the nurses' station. Later that evening she was assisted in transferring herself to bed. In the early morning of 11/3/23 R1 was noted to be in pain and her left leg was slight shortened. The nurse on duty administered pain medication and notified physician of change of condition and received orders to transfer to hospital. Conclusion: R1's co morbidities such as age, severe degenerative joint disease, osteoarthritis and osteopenia and the action of crouching herself and sitting position on the floor likely contributed to the non-displaced oblique fracture of the left femur. R1's hospital record on 11/3/23 indicated: Chief complaint: patient presents with fall. History of present illness: Patient was noted to have left discomfort today while turning, some abrasions on the left hip. She is ambulatory without assistance at baseline, so unwitnessed fall was suspected. Patient unable to recall events and she is very poor historian. Imaging study showed left femoral neck fracture. Mild superior displacement of the distal fracture fragment. She was given fentanyl for pain. Orthro consulted. Assessment and Plan: Left hip fracture to presumed fall. Ortho consult pending, most likely surgical repair. Pain control. 2.) On 12/6/23 at 9:30 AM, observed R2 sitting in the dining room with V7 (Fall Coordinator). Observed R2 sliding from her wheelchair with wheelchair cushion. V7 said that R2 has fall prevention intervention of anti-slip material placed on her wheelchair seat. V7 called V19 (CNA) for assistance. V7 and V19 assisted R2 to stand and observed no anti-slip material was applied to R2's wheelchair seat. Observed R2's wheelchair cushion slide half of it from the wheelchair seat. V7 said that R2 should have anti-slip material on her wheelchair seat to prevent it from sliding from her wheelchair. V7 and V19 corrected the position of R2's wheelchair cushion. On 12/6/23 at 9:40 AM, V9 (CNA) said that she is the CNA assigned for R2 and got her up in wheelchair. She said, R2 should have anti-slip material to her wheelchair seat, but she cannot find it. On 12/6/23 at 11:25 AM, Review R2's medical records with V7 (Fall Coordinator). Informed V7 that R2's fall care plan was not updated after fall incident on 12/1/23. R2's fall prevention intervention of anti-slip material to her wheelchair seat was not implemented. R2 was observed with V7 on 12/6/23 in the dining room sliding from wheelchair because she did not have anti-slip material in her wheelchair seat. R2 is admitted on [DATE] with diagnosis listed in part but not limited to Dementia with behavioral disturbance, Osteoarthritis, Age related osteoporosis, anxiety disorder. Fall admission assessment on 8/2/23 indicated she is at high risk for fall. Recent fall assessment after fall incident on 12/1/23 indicated that she is at high risk for fall. Care plan indicates that she is at risk for fall related to impaired judgement, confusion, history of falling, muscle weakness, dementia, anxiety, dermatitis, back pain hypertension, gastroesophageal reflux, glaucoma, and vertigo. Intervention: Place anti-slip material in wheelchair. Fall care plan was not updated after she has fall incident on 12/1/23. R2 fall incident reports: 1) 12/1/23 Unwitnessed fall. R2 was found sitting on the floor next to her bed. 2) 11/24/23 Unwitnessed fall. R2 was found sitting on the floor by her bed. 3) 9/27/23 at 9:30 AM Unwitnessed fall. R2 fell in the dining room. 4) 9/27/23 at 1:20 PM Unwitnessed fall. R2 fell in the dining room. 5) 9/24/23 Unwitnessed fall. R2 found lying on her right side. 6) 9/16/23 Unwitnessed fall. R2 was found sitting on the floor next to her bed. 7) 8/29/23 Unwitnessed fall. R2 was found sitting next to her wheelchair. Fall care plan was not updated after she has fall incident on 12/1/23. Facility's policy on Accident and incident report 4/2019 indicates: Objectives: to document all accidents/incidents occurring to residents, visitors, and employees. Procedure: 1. Resident: a. Provide any necessary emergency care. b. Notify the nurse, who then must notify Physician and family. c. Follow up to be continued at minimum for 72 hours which should vital signs, ROM (Range of motion), skin abnormalities, responsiveness general condition changes observed in injury site, etc. d. A complete, thorough, and accurate incident report will be completed as well as a general summary of the event within the resident's progress notes of actual or suspected injuries, family and physician notification and interventions implemented at time of incident. 4. In all cases: a. There must be an exact description of the accident/incident: 1. Location 2. Time and date 3. Level of consciousness 4. Description of injury 5. Description of any emergency care given 6. Vital signs for residents 7. Any persons notified of the incident. Facility's policy on Fall prevention and management 2/2023 indicates: Purpose: to support the prevention of falls by implementation of a preventive program that promotes the safety of residents based on care processes that represent the best way we currently know of preventing falls. The falls prevention and management program are designed to assist staff in providing individualized, person centered. The falls prevention and management program provide a framework and tools to identify and communicate about a resident's risk of fall. Additionally, the program addresses a safe process to follow for supporting a resident who has experienced a fall event. Fall prevention Practices: 1. Universal fall precautions 2. Standardized assessment of fall risk factors 3. Care planning and interventions to address risk factors 4. Post fall response including analysis of procedures and outcomes Universal Fall Precaution: are safe measures that are taken to reduce the chance of falls for all residents, regardless of individual fall risks. Care planning and interventions to address fall risk factors: * The care plan addresses universal fall precautions and individual fall risk factors as applies to the resident. *A fall risk care plan will be implemented as part of the baseline care plan to address universal fall precautions and as part of the comprehensive care plan utilizing information from the fall risk assessment. The care plan will be reviewed and revised at least quarterly and with any fall event the resident might experience.

Based on interview and record review the facility failed to provide pain management after a fall for a dementia resident observed by the resident's family to have facial grimacing and acting out of character and complaining to staff of left hip pain during dressing. This affected one of three residents (R1) reviewed for pain management. This failure resulted in the staff being notified that R1 was in pain by a family member post fall and R1 not receiving any pain medication. R1 was transferred to the local hospital where R1 was diagnosed and treated with a displaced left femur fracture. Findings include: On 9.6.23 at 11:26am V2 (CNA) said she was assigned to work with R1 on 8/12/23 7-3:00pm shift. V2 said she assisted R1 with breakfast that morning, R1 was in the bed. V2 said she was in the room caring for another resident when the housekeeper informed her that R1 fell . V2 said when she arrived to R1's room and R1's roommate was trying to assist R1 up from the floor. V2 said she intervened, V2 said R1 was laying on the floor on his back, his head was near the roommate's bed. V2 said she went and got the nurse, the nurse arrived, R1 denied pain, the nurse assessed R1. V2 said R1 was picked up, placed back in the bed manually using a gait belt. V2 said about 15 minutes later when she was going to get R1 dressed, R1 complained of pain to the left hip. V2 said she informed V3 (Nurse) of R1's complaint of pain. V2 said she don't know if V3 gave R1 anything for pain. V2 said during her shift she informed V3 about 3 times of R1's complaints of pain. V2 said one time she informed V3, V3 said that he has to follow the doctors' orders, and the doctor an X-ray. V2 said she worked a double (3pm-11pm shift). V2 said R1 had complaints of pain during the evening shift also. V2 said she think she informed the evening nurse about 3-4 times of R1's complaint of pain. V2 said R1's daughter did visit R1 on 8.12.23. On 9.6.23 at 10:50am V1 (R1's family) said she was informed that R1 had a fall. She visited R1 around 6:00pm on 8.12.23 and notice R1 was in pain. R1 was acting out. R1 was not being himself and R1's eyes were rolling up. V1 said she told the nurse that R1 was in pain. V1 then said she don't know if it was the nurse or CNA that she informed of R1 pain. V1 said she don't remember if R1 got something for pain. On 9.6.23 at 1:07pm V3 (Nurse) said he was assigned to R1 on 8.12.23. V3 said it was around 10:30am when V2 informed him that R1 had fallen. V3 (Nurse) said 15-20 minutes after picking R1 up after the fall V2 informed him that R1 was experiencing pain. V3 said when he assessed R1 for pain, R1 denied pain. V3 said he did not give R1 anything for pain. V3 said R1 has dementia. V3 was asked would it be reasonable to believe due to R1's dementia he may not be able to verbalize his pain during your assessment. V3 said that makes since. Review of R1's medication administration record dated 8.12.23, there is no documentation denoting that R1 received pain medication for the complaint of pain in the hip on 8.12.23. On 9.7.23 at 9:44am V11 (Director of Nursing) said she V3 should have given R1 something for pain. R1's pain assessment dated 8.12.23 at 12:23pm denotes in-part, indicators of pain- vocal complaints of pain (that hurts, ouch, stop). Received scheduled pain medication regimen NO is checked. R1's physician order sheet with start date of 4.13.23 shows orders for acetaminophen tablet 500 mg (milligrams) one tablet orally every 8 hours PRN (as needed). Naproxen tablet 500 mg (milligrams) one tablet oral twice a day PRN (as needed). R1's nurse's note dated 8.13.23 1:31pm states Writer spoke with (Nurse Practitioner) about resident. Writer received orders to send patient out to (local hospital emergency room ) for follow-up. Orders received and carried out. R1's emergency room record dated 8.13.23 denotes in part emergency room by ambulance from skilled nursing facility. Patient had a fall yesterday evening was really scheduled for an inhouse X-ray and assessment by physician there but apparently this never happened. Today the patient is less responsive than baseline and has acute pain over the left hip patient only able to respond to his name otherwise nonverbal during assessment. This is a [AGE] year-old male with past medical history of vascular dementia Lewy body dementia, Parkinson's disease, chronic bronchitis presenting to ED (emergency department) for hip pain phone and concerns for sepsis. Patient presenting on stretcher with left leg folded and crossed under self, painful to straighten patient shouting and grimacing when placed in anatomic position was shortened and externally rotated severe tenderness on the lateral compression of hip. ED diagnosis sepsis and close displaced intertrochanteric fracture on left femur. R1's plan of care for pain denotes alteration on comfort secondary to pain related to osteoarthritis and intervertebral disc disorders thoracolumbar region. Goal R1 will express relief/decrease discomfort as evidence by verbalization of decrease or absence of pain, relaxed facial expression and body position. Interventions are to administrator medication as per order and observe for result. Facility policy titled Pain dated 11/22 denotes in-part it is the policy of this facility to school (sic) all residents for pain identify those who are experiencing pain and assess and develop effective individualized pain management care plan.

Based on interview and record review the facility failed to follow the fall prevention policy to develop, implement, reevaluate the effectiveness of interventions to prevent or reduce the risk of falling for a resident with dementia, poor safety awareness, and high risk for falls. This failure affected one of three residents (R1) reviewed for fall prevention intervention. These failures resulted in R1 being involved in a fall incident causing pain to the left hip area. R1 was sent to the local hospital and evaluated and treated for a displaced left femur fracture. Findings include: R1's face sheet shows diagnosis of Parkinson's disease, Alzheimer's with late onset, tremors, abnormalities of gait and mobility, dementia. MDS dated 7.21.23 section C denotes BIMS score of 7(cognitively impaired). Section G for bed mobility denotes R1 is extensive assist with one-person physical assist, transfer denotes R1 is extensive assist with one-person physical assist. Balance during transition and walking for surface-to-surface shows 2- not steady only able to stabilize with staff assistance. Facility final investigation to the department dated 8.14.23 denotes in-part date of occurrence 8.12.23, R1 is the resident, occurrence description: R1 was found on the floor next to his bed. Bed was in lowest position R1 was unable to state what happened. R1 complaint of discomfort to the left leg on exam. Nurse on duty called medical doctor and receive orders for X-rays. While waiting for X-rays it was noted to have swelling to the left hand and fingers. Nurse on duty call medical doctor for further orders, at this time receive orders to send to Emergency department for further evaluation. Nursing on duty for follow up and was informed by hospital that R1 was being admitted with sepsis. On 8.13.2023 at approximately 9:00 PM nurse on duty also have follow up with V1 who informed nurse on duty that R1 had a hip fracture. On 8.14.2023 the nurse at the hospital who stated R1 was admitted with left intertrochanteric fracture was also admitted with sepsis full investigation to follow. Final report denotes in-part, R1 is a [AGE] year-old long term care resident. R1 have (sic) a history of Alzheimer's, Parkinson's osteoarthritis, anxiety depressive disorder and lumbar fracture R1 has a BIMS of 7 and is extensive assist for activity living. R1 has behavioral of whistling, shanking half rails when in his room. R1 also has a behavior getting up out of bed without assistance. Interview with V2 (Certified Nurse Assistant/CNA) on 8.12.23 I was assigned to R1, I made rounds on him around 730am. V2 states she set him (R1) up for breakfast around 8:30 am, and he ate 75%. V2 states at 10:00am R1 was observed on his back at the head of other bed in room. V2 states he (R1) awake and alert to his norm. V2 states that she then went and informed NOD (Nurse on duty) that R1 fell . They went back to his room were NOD assessed him (R1) and took vital signs. V1 states he denied pain at this time. V2 stated that about 15-20 minutes later he (R1) c/o (complained of) left leg pain. Interview with V3 on 8.12.2023 I (V3) was assigned to R1 around 10:00 AM V2 on duty informed me that R1 was on the floor in the room. When I arrived to the room R1 was on the floor next to other bed and almost sitting position. R1 was alert to his norm. Assessed him and at this time he complained of no pain or discomfort. Neuro checks done at this time and were WNL (within normal limits). R1 was assisted up and back to bed no injuries noted at this time. V3 states about 15 minutes later aide on duty inform him of pain to left hip. On assessment I noted no deformities to area MD (medical doctor) called and nurse on duty spoke with V8 (Nurse Practitioner). V8 gave orders for X-rays and labs at this time X-ray and lab notified of orders. Interview with V9 (CNA) on duty 8.12.23 was assigned to R1 from 11pm to 7:00am, states that R1 was alert to his norm during the night. That he whistled for assistance during the night, states that R1 got up during the night and was easily directed back to his bed. Interview with V10 (nurse) on 8.12.23 I was nurse assigned to R1 from 11pm to 7:00 am. I received R1 asleep during my initial rounds. V10 states that R1 was alert to his norm. R1 had gotten out of bed 2-3 times during the night and was easily directed back to bed. Conclusion denotes in-part investigation included record review and interviews. The investigation reveals that R1 frequently gets up on his own and ambulates a few steps with an unsteady gait. On August 12, 2023, R1 experienced a fall while self-ambulating in the room. He was unable to express to staff what happened to cause the fall. On 9.6.23 at 11:26am V2 (CNA) said she was assigned to work with R1 on 8/12/23 7-3:00pm shift. V2 said she assisted R1 with breakfast that morning. R1 was in the bed. V2 said she was in the room caring for another resident when the housekeeper informed her that R1 fell . V2 said when she arrived to R1's room, R1's roommate was trying to assist R1 up from the floor. V2 said she intervened. V2 said R1 was laying on the floor on his back, his head was near the roommate's bed. V2 said she went and got the nurse. The nurse arrived. R1 denied pain. The nurse assessed R1. V2 said R1 was picked up, placed back in the bed manually using a gait belt. V2 said about 15 minutes later when she was going to get R1 dressed, R1 complained of pain to the left hip. V2 said she informed V3 (Nurse) of R1 complaint of pain. V2 said she don't know if V3 gave R1 anything for pain. V2 said during her shift she informed V3 about 3 times of R1's complaints of pain. V2 said one time she informed V3, V3 said that he has to follow the doctors' orders, and the doctor an X-ray. V2 said she worked a double (3pm-11pm shift). V2 said R1 had complaints of pain during the evening shift also. V2 said she think she informed the evening nurse about 3-4 times of R1 complaint of pain. V2 said R1's daughter did visit R1 on 8.12.23. V2 said R1 did not say how he fell . R1 did not say what he was doing when he fell . V2 said R1 has dementia. V2 said R1 bed was in a low position. R1 did not have on any shoes. R1 did not have on any skid free socks. V2 said she don't recall were R1's call light was at. V2 said R1 was a fall risk. V2 said R1's gait was not steady. V2 said R1 could transfer from bed to chair with assistant from staff. On 9.6.23 at 1:07pm V3 (Nurse) said he was assigned to R1 on 8.12.23. V3 said it was around 10:30am when V2 informed him that R1 had fallen. V3 said when he came in the room to assess R1, R1 was on the floor, kind of near the roommate's bed in sitting position almost. V3 said when he asked R1 how he fell , R1 just shrugged his shoulders, R1 did not say anything. V3 said he figured R1 was going to look at the roommate's shoes. V3 said because R1 was near the roommate's bed he figured R1 was going to look at the roommate's shoes. V3 said R1 did not tell him that he was going to look at the roommates' shoes. V3 said he was not aware that R1 was a fall risk. V3 said he found out on the day of the fall that R1 was a fall risk. V3 said he does not know what fall precautions R1 had in place. V3 said the social worker knows what fall precautions R1 has in place. V3 said the social worker puts the fall precautions in place. V3 said when he was completing the fall assessment for R1, that when he noticed R1 had a fall before and that R1 was a fall risk. On 9.7.23 at 12:32pm V9 (CNA) said he did not tell the facility that R1 got up during the night shift. V9 said R1 shakes the bed rails and whistle when he wants a brief change. V9 said he did speak to the DON (Director of Nursing) or administrator regarding this, but he did not say R1 got up that night on 8.12.23. On 9.7.23 at 12:59pm V10 (Nurse) said he did not tell the facility that R1 got up during the night shift. V10 said he heard R1 whistle that night on two occasions. V10 said when R1 whistles he wants a brief change. V10 said maybe V9 told him that R1 got up, V10 then said it was weeks ago, he doesn't remember. V10 said the previous nurse did report to him that R1 had a fall that morning, and the doctor ordered an X-ray. On 9.7.23 V6 (Care plan/ Minimum Data Set Coordinator) said she updates the care plan for medical diagnosis and post fall interventions. V6 said she developed R1's fall risk care plan. V6 said R1 is at risk for fall due to muscle weakness, unsteady gait, Parkinson's, tremors, anxiety, and history of falls. V6 said the team discuss the fall and develop fall interventions together. V6 said the fall interventions would be based on the root cause of the fall. V6 said she do not determine the root cause of the fall. R1 fall investigation conclusion reviewed with V6. V6 said the conclusion is that R1 frequently gets up on his own and ambulates a few steps with an unsteady gait. V6 said R1 getting up with an unsteady gait, with his diagnosis of dementia makes him at risk for falls. V6 said she don't know if the staff reported to her that R1 gets up frequently. V6 said she should have been made aware of R1 getting up frequently. V6 said she can't say what fall interventions would have been put in place because this is discussed with a team. V6 said an immediate intervention post R1 fall on 8.12.23 was to complete an Xray. R1 fall interventions reviewed with V6 which denotes placing R1 near to the nurse station when out of bed for supervision. V6 said this is so that staff can monitoring R1 because R1 will tray and self-transfer when sitting in his room at the bed side. Instruct resident in the proper use of any appliance or devices to aide in balance. V6 said R1 used a wheelchair, and staff is to ensure R1 is not leaning when sitting in the wheelchair. Instruct the resident to ask for assistance prior to attempting to transfer or walk. V6 said R1 should ask for assistance before trying to transfer or walk. V6 was asked if R1 had dementia and would he remember to ask for assistance. V6 was asked if R1 asked for assistance before getting up from bed on 8.12.23. V6 said she miss wrote that intervention, it should have read that staff should remind R1 to ask for assistance before trying to transfer or walk. V6 was asked if R1 would be able to remember to ask for assistance before getting up to transfer or walk. V6 then said maybe the facility could have put a sign up to tell R1 to use the call light before transferring or walking. V6 was asked if R1 would remember to read the sign before transferring or trying to get up. V6 was asked if the interventions be effective if R1 has dementia and may not be able to remember to ask for help before trying to transfer or walk. V6 said the interventions might not be effective. R1 fall risk assessment reviewed with V6 dated 6.28.23, denotes fall score of 2 (low risk). V6 said the fall risk assessment is not correct, it does not capture all the risk factors for R1. If the assessment was completed correctly the score would be 10 thereby placing R1 a risk for falls. V6 said balance problem while standing should have been checked (score1), confined to chair totally unable to ambulate without assist (score 3), and contributing factors (score 2) medications taken (score 2). R1's emergency room record dated 8.13.23 denotes in part emergency room by ambulance from skilled nursing facility. Patient had a fall yesterday evening was really scheduled for an inhouse X-ray and assessment by physician there but apparently this never happened. Today the patient is less responsive than baseline and has acute pain over the left hip patient only able to respond to his name otherwise nonverbal during assessment. This is a [AGE] year-old male with past medical history of vascular dementia Lewy body dementia, Parkinson's disease, chronic bronchitis presenting to ED (emergency department) for hip pain phone and concerns for sepsis. Patient presenting on stretcher with left leg folded and crossed under self, painful to straighten patient shouting and grimacing when placed in anatomic position was shortened and externally rotated severe tenderness on the lateral compression of hip. ED diagnosis sepsis close displaced intertrochanteric fracture on left femur. R1 care plan for fall with problem start date 4/20/2023 denotes in-part one is a risk for falls related to muscle weakness unsteady gait diagnosis of Parkinson's tremors anxiety and history of falling. Goal-R1 will remain free from major fall related injury. X-ray per order. Place resident near the nurse's station when out of bed for supervision and monitoring and guidance. Instruct resident in the proper use of any appliances or devices to aid in balance. Instruct resident to ask for assistance prior to attempting to transfer or walk. Keep it in lowest position with brakes locked. Keep call light in reach at all times. Keep personal items and frequently used items within reach. Observed frequently and place in supervised area when out of bed. Occupy resident with meaningful distractions. Orientate resident when there have been new furniture placement or other changes in environment. Provide one or more staff assist if resident has mood/ behavior, impaired mobility/ weakness pain or discomfort, restlessness and or agitation, provide well maintained footwear. Facility policy titled Falls prevention and management dated 3/2022 denotes in part the purpose of this policy is to support the prevention of falls by implementation of a preventive program that promotes the safety of residents based on care processes that represent the best ways we can currently know of preventing falls. The falls prevention and management program is designed to assist staff in providing individualized person centered care. The falls prevention and management program provide a framework and tools to identify and communicate about a resident risk of falls. Additionally, the program addresses a safe process to follow supporting a resident who has experienced a fall event. Universal fall precautions- universal fall precautions are safety measures that are taken to reduce the chance of falls fall residents regardless of individual fall risk. Care planning and interventions to address fall risk factors- development of fall risk care plan is based on results of falls of assessment as well as investigation of all circumstances and related resident outcomes. The care plan addresses universal fall for cautions and universal fall risk as applies to the resident. A fall care plan will be implemented as part of the baseline care plan to address universal phone caution and it's part of the comprehensive care plan utilizing information from the fall risk assessment the care plan will be reviewed and revised at least quarterly and will any fall event the resident might experience. Post fall response-past history of a fall is the single best predictor of future falls. In fact, there's 30-40% of those residents who fall will so do it again. Thus, it is critical for staff to respond quickly and effectively after a fall. A post fall response includes immediate actions to ensure the safety of the resident assessment clinical review investigation and observations of the dictation of immediate action to prevent further falls notification of appropriate parties.

Based on observation, interview and record review, the facility failed to follow their abuse policy by failing to prevent an incident of staff to resident physical abuse. This affected 1 of 3 residents (R3) reviewed for abuse. This failure resulted in R3 being aggressively pushed in back into her wheelchair. R3 was subsequently sent to the local hospital and was assessed to have sustained a strained neck muscle. Findings Include: R3 was admitted to the facility on [DATE] with a diagnosis of unspecified dementia, with other behavioral disturbances, generalized anxiety disorder, scoliosis, fusion of spine, spinal stenosis, osteoporosis without current pathological fracture and history of falling. R3's Minimum Data Set, dated dated dated [DATE] documents a brief interview for mental status score 03/15 which indicates severely impaired cognition. R3's care plan dated 8/16/22 document R3 has a diagnosis of dementia with behavioral disturbances. Interventions: allow adequate time for resident to respond; maintain a calm environment and approach to the resident; provide reassurance as needed to help the resident safe and secure. R3's screening for abuse dated 2/21/23 documents under risk measure for the likelihood of previous/recent mistreatment and potential future problems/symptoms related to mistreatment: a score of 1 which indicate low On 2/21/23 at 3:01pm, V18 (Certified Nurse Assistance/CNA) said, R3 was sitting behind the nursing station. R3 kept trying to stand up. V19 (Nurse) grabbed R3's wheelchair and slam it forcibly hard against the wall. On 2/22/23 at 5:19pm, V25 (R3's POA) said, I watch the video with R3 and V19. V19 was seen pushing R3 down forcibly in the wheelchair by her shoulder after R3 attempted to stand-up form the wheelchair. V19 look so angry on the video. I requested for R3 to go to hospital on 2/18/22. R3 was frightened. R3 looked out of sorts and upset. I was upset about the incident. Local police department report dated 2/17/23 at 16:47 documents under nature of complaint: battery. Under narrative: The following is a general summary of my recollection of events and all conversations are not verbatim. In summary dispatched to facility for a complaint of elder abuse. V18 (CNA) contacted via phone and reported that V19 (Nurse) became increasing irritated with R3 and at one point pushed R3's wheelchair causing R3 to crash into the wall. Video footage was reviewed on 2/18/23 with observations of R3 attempting to stand up multiple times. The third time R3 attempted to stand up, V19 (Nurse) can be seen entering the room visibly upset. V19 aggressively shoves R3 into the wheelchair using his right hand. V19 (Nurse) then wheels R3 into the hallway where V19 can be observed yelling in R3's face while pointing in her face with his finger. V19 makes a second lunging motion towards her, however due to the lack of camera angles, its undetermined if the lunge was an additional shove. R3's hospital record dated 2/18/23 documents: R3's family was notified yesterday that patient (R3) was forcibly pushed down by staff member at the nursing home on Thursday. He reports R3 had been complaining of neck pain which prompted visit today. Currently R3 denies any neck pain. Although R3 was denying pain initially, later did complain of some low back pain. Was offered Tylenol but declined. Hospital diagnosis: strain of neck muscle. Under neck sprain or strain documents: A sudden force that causes turning or bending at the neck can cause sprain or strain. Facility abuse final report dated 2/23/23 documents under investigation documents: On Saturday police officer returned to view footage. Officers watched the alleged interaction where the restraint was being applied by the nurse. The officer asked to see additional footage from earlier during the day before restraint was applied. At that time, V1 saw on the tape that V19 (Nurse) appeared to use force to her (R3) right shoulder to get R3 to sit back on her wheelchair after she (R3) was repeatedly trying to stand. The investigation also revealed that V19 did not follow the restraint policy and applied a plastic bag. During the course of the investigation, it was also discovered that V19 used force to encourage R3, who was a fall risk to remain in her wheelchair. While the facility believes that V19 actions were intended to protect the resident (R3) from a fall, the application of force violates facility policy and standards. V19 will be terminated. Abuse policy revised 10/2022 documents: The facility affirms the right of our residents to be free from abuse. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental mean. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. Physical Abuse is the infliction of injury on a resident that occurs other than by accident means and that requires medical attention. Physical abuse includes hitting. Slapping, pinching, kicking, and controlling behavior through corporal punishment.

Based on observation, interview and record review, the facility failed to follow their policy on physically restraints. This affected 1 of 3 residents (R3) reviewed for restraints. This failure resulted in R3 being physically tied to a wheelchair with plastic garbage bags, restricting R3 right to move freely. Using the reasonable person theory R3 would have been embarrassed and humiliated by be tied to a wheelchair with plastic bags. Findings Include: R3 was admitted to the facility on [DATE] with a diagnosis of unspecified dementia, with other behavioral disturbances, generalized anxiety disorder, scoliosis, fusion of spine, spinal stenosis, osteoporosis without current pathological fracture and history of falling. R3's Minimum Data Set, dated dated dated [DATE] documents a brief interview for mental status score 03/15 which indicates severely impaired cognition. R3's care plan dated 8/16/22 document R3 has a diagnosis of dementia with behavioral disturbances. Interventions: allow adequate time for resident to respond; maintain a calm environment and approach to the resident; provide reassurance as needed to help the resident safe and secure. R3's screening for abuse dated 2/21/23 documents under risk measure for the likelihood of previous/recent mistreatment and potential future problems/symptoms related to mistreatment: a score of 1 which indicate low. On 2/21/23 at 3:01pm, V18 (Certified Nurse Assistant) said, R3 was sitting behind the nursing station. R3 kept trying to stand up. V19 (Nurse) tied two clear plastic garbage bags together, wrapped the bags around R3, underneath R3's breast and tied it to the back of R3's wheelchair. R3 was tied to her wheelchair for fifteen minutes. I took the plastic bags off R3 and place them in the second draw behind the nursing station on the right side. On 2/21/23 at 3:30pm, the surveyor requested, V26 (Nurse) to open the second draw on the right side behind the nursing station, two clear white long plastic bags similar to garbage bags were tied together in a knot. On 2/21/23 at 3:40pm, body assessment completed by V20 (Nurse). R3 was observed with a liner redden area located on the upper back to the right of R3's spine. V20 said, R3 did not have that mark on her back yesterday. On 2/21/23 at 4:08pm, R5 who was assessed to be alert and oriented to person, place, and time, said V19 crossed the lines, R3 had to go to the bathroom. V19 grabbed a bag, tied it around R3 waist and tie R3 to her wheelchair. R3 started yelling, stop, stop it. R3 doesn't and won't remember the incident. On 2/21/23 at 5:30pm, the surveyor observed video recording with V1 (Administrator). V1 identified all staff and resident on the screen. The video recording of V19 and R3 was dated 2/16/23 at 4:43pm. R3 was observed in the dining room sitting at a table. R5 was sitting directly in front of R3. R3 attempted to stand up from her wheelchair multiple times. V18 ran to R3. R3 sat back down. V19 took R3 to another table, placed the back of R3's wheelchair to the wall and slid the table up R3's body. R3 was observed with no room to move between the wall and table. V19 left the dinning, returned with a long white plastic bag in hand. V19 wrapped the bag under R3's breast and tied it to the back of R3's wheelchair. On 2/22/23 at 5:19pm, V25 (R3's POA) said, I watch the video with R3 and V19. V19 tied a garbage bag around R3 and tied it to R3's wheelchair. R3 had attempted to stand-up from the wheelchair prior to being tied. I requested for R3 to go to the hospital on 2/18/23. R3 was frightened. R3 looked out of sorts and upset. I was upset about the incident. V19 demeanor on the video, looked angry. On 2/23/23 at 2:06pm, V29 (Medical Doctor) said, I was not informed R3 was restrained with a plastic bag and tied to the wheelchair. No human should be restrained like that. R3 had Dementia and was recovering from a hospitalization with Sepsis. Restraining R3 was not good to do and would have increased R3's agitation and made R3 upset. R3 could have hurt herself. Initial Report dated 2/17/23 documents: V18 (CNA) alleged V19 (Nurse) improperly used restrain. Local police department report dated 2/17/23 at 16:47 documents under nature of complaint: battery. Under narrative: The following is a general summary of my recollection of events and all conversations are not verbatim. In summary dispatched to facility for a complaint of elder abuse. Upon arrival, V1 (Administrator) related that on 2/16/23 V18 (CNA) came into the office and wanted to file a complaint about improper use of restraints on elderly resident. V19 (Nurse) used a piece of plastic to restrain R3's abdomen when she began attempting to stand up during mealtime. V1 further related that V19 admitted to using a piece of plastic to restrain her (R3) abdomen due to not having immediate access to proper abdomen restraint. Video footage was reviewed on 2/18/23 with observations of R3 attempting to stand up multiple times. The third time R3 attempted to stand up, V19 can be seen entering the room visibly upset. V19 returns R3 to the dining room and returns with two (2) clear plastic garbage bags tied together. V19 proceeds to tie R3 around her chest to the wheelchair with two garbage bags. R3's hospital record dated 2/18/23 documents: Family report, he was notified yesterday that patient was restrained using a plastic bag by staff member at the nursing home on Thursday. Skin assessment dated [DATE] documents: redness which measured 1.2 cm (length) X 1.2cm (width) x no depth. Facility policy regarding physical restraints undated documents: In compliance with state and federal regulations, this facility is committed to limiting and reducing the use of physical restraints. The use of physical restraints shall be limited to situations necessary to maximize the resident's physical, mental and psychosocial well-being and to treat the resident's medical symptoms. It shall be the policy of this facility that physical restraints shall not be applied for the purposes of punitive actions against a resident or for staff convenience. Physical restraint means any manual method or physical or mechanical device, equipment or material that meets all the following criteria: is attached or adjacent to the resident's body; cannot be removed easily by the resident (resident is able to remove the device the same manner it was applied to by the facility staff); restricts resident freedom of movement or normal access to his/her body. Convenience means actions taken by the facility to control resident behavior or maintain a resident, is not in the resident's best interest, with less effort or expense than would otherwise be required by the facility.

Based on interview and record review, the facility failed to monitor and recollect a contaminated urine culture sample for a resident with an indwelling catheter and a history of urinary tract infections. This affected 1 of 3 (R1) residents reviewed for physician orders. This failure resulted in R1 who was observed with purulent urine, abnormal urinalysis, and low urine output, being hospitalized for complicated catheter associated urinary tract infection with sepsis present on admission(POA) and pseudomonal bacteremia secondary to urinary tract infection. Findings include: R1 admitted to the facility on [DATE] with a diagnosis of urinary tract infection, multiple scleroses, sepsis, and neuromuscular dysfunction of the bladder. R1's Minimum Data Set, dated dated dated [DATE] documents a brief interview for mental status score of 13/15 which indicates cognitively intact. R1's laboratory report dated 1/26/23 documents under urine culture: mixed flora more than 100,000 count. Multiple bacterial morphotypes present, possible contamination. Suggest a recollection if clinically indicated. Urinalysis dated 1/25/23 documents under bacteria many and leukocytes large. R1's nurse practitioner progress notes dated 1/24/23 documents: Patient reports having (indwelling catheter) changed over the weekend due to being dislodged. Nursing notes indicate (indwelling catheter) was changed last night due to leaking. (Indwelling catheter) to gravity, urine purulent, yellow in tubing. Do not change (indwelling catheter) for leaking. Ok to flush if possibly clogged. (Indwelling catheter) only to be changed only monthly or if dislodged. Urinary tract infection-purulent output in (indwelling catheter). Checking urinalysis with culture and sensitivity. R1's nurse practitioner progress notes dated 1/26/23 documents: Patient states that she had (indwelling catheter) changed last night due to leaking. Urine specimen was sent to the lab. Under genitourinary documents: positive leaking. Under assessment and plan: leaking (indwelling catheter) monitor urinary output, urinalysis 1/25 positive for large leukocytes and many bacteria; urine culture showed mixed flora- contamination- will recollect; no leukocytosis, no fever; will educate nursing staff to not exchange (indwelling catheter) every time is leaking; may flush (indwelling catheter) if concerned for clogging. R1's February 2023 medication administration record for (indwelling catheter) output every shift document on 2/4/23 700-300pm shift 350ml, 300- 1100pm shift 100 ml,11-7am shift medium. On 2/5/23 700-300pm shift 200ml, 300- 1100pm shift 60 ml,11-7am shift medium. No documentation for 2/6/23 am shift. R1's progress note dated 2/6/23 at 6:52AM documents: This morning states her abdomen has colic and cramps. Abdomen somewhat distended with some tympany noted. States the last bowel movement when given a shower a few days ago. Positioned to the left side of her body and will request assistance to place her on the commode for relief. R1's progress notes dated 2/6/23 at 3:47PM documents: Writer found the patient with altered mental status, tachycardia, and fever. Referred to nurse practitioner with order to send resident to local hospital for evaluation. Picked up at 1:48PM. R1's hospital record dated 2/6/23 documents under discharge diagnosis: complicated catheter associated urinary tract infection with severe sepsis present on admission (POA), acute metabolic encephalopathy, pseudomonal bacteremia secondary to urinary tract infection. R1's hospital record dated 2/6/23 documents: bed side ultrasound utilized, does have a distended bladder with indwelling foley catheter, concern for urinary retention, possibly clogged foley catheter. Under hospital course side ultrasound, patient does have a significant urine in her bladder. On 2/21/23 at 11:28AM, V2(Assistant Director of Nurses/ADON) said nurse practitioners will verbally inform nurse on duty of any new orders and nurse would be responsible for carrying out the order. V2 said she is not sure what happened and possibly a miscommunication for why R1's urine culture was not recollected. V2 said nurses are responsible for documenting amount of urine at the end of the shift. Urine output 200 ml or less she would expect nurses to check the foley, check for abdominal distention and notify doctor of changes. On 2/22/23 at 10:00AM, V13(Physician) said for R1's urine culture with mixed flora, they would not start treatment but would have re-culture the urine to rule out infection. V13 said he would expect the physician's orders to be followed. V13 said he was not sure and would not be able to determine if the facility's failure of not rechecking R1 urine led to her hospitalization for urinary tract infection and sepsis. V13 said urine output less than 150 ml during an 8-hour shift would be abnormal and would expect to be notified. Facility policy titled Physicians orders revised 5/17 documents: the nursing staff member or the one assigned to the resident is responsible to transcribe the order. Transcribing the order includes completing laboratory requests. For facilities on electronic health records. Orders must be promptly entered into the computer. Facility policy titled catheter insertion and maintenance revised 10/22 documents: to maintain constant urinary drainage based on physician order. Maintain a closed urinary system to prevent introduction of bacteria into urinary tract. Measure drainage at the end of each eight hour shift, if ordered, unless more frequent measurement has been ordered.

Based on interview and record review, the facility failed to follow their fall policy and plan of care by not using a mechanical lift for transfers. This affected 1 of 3 (R2) residents reviewed for safe transfers. This failure resulted in R2 sustaining a fall with a large hematoma, swollen left knee and an oblique fracture of the proximal tibia that required hospitalization and surgical interventions. Findings Include: R2 was diagnosis with hemiplegia and hemiparesis following cerebral infraction affecting left non-dominate side and history of falling. Brief interview for mental status dated 1/12/23 documents a score of nine which indicates moderately impaired. Section F (functional status) dated 1/12/23 documents: R2 is total dependent with two plus physical assist with transfers. R2 has impairment on one side to the upper extremity (shoulder, elbow, wrist, hand) and impairment on both sides to the lower extremities (hip, knee, ankle, foot). Care plan dated 1/2/23 documents R2 had inability to transfer self and is at risk for ADL decline related to muscle weakness. R2 requires two staff assist with use of mechanical lift for transfers. On 2/17/23 at 12:01pm, R2 who was assessed to be alert to person, place and time said, I was being assisted from my wheelchair to the bed by V8 (Certified Nurse Assistant/CNA) and V10 (CNA). V8 and V10 were on each side of me, both V8 and V10 were holding me under my arm, no gait belt or mechanical device was used. V8 and V10 lifted me up from my wheelchair, I lost my balance and fell . I fell on the floor, on my buttock with my leg bent under my body. On 2/17/23 at 4:08pm, V8 said V10 help me put R2 in bed. V10 lifted R2 from the wheelchair by placing his arms under R2 arms like a forklift. V10 picked R2 up without using a gate belt or mechanical lift. V10 sat R2 up on the bed, R2's legs did not come with R2's body. I grabbed R2's leg and swung them with R2's body. We did not use the mechanical lift due to R2 not having the sling pad under her buttock while sitting in her wheelchair. It would have been impossible to get a pad under R2 while in the sitting position in her wheelchair. We did not use a gait belt either. Anytime, I need to transfer R2 from the wheelchair, I always get help from a male staff member to assist with lifting R2. I have not had any training on transfers or fall prevention. On 2/21/23 at 1:57pm, V15 (Occupation Therapist) said, R2 can't transfer from the wheelchair to the bed without a mechanic lift. A two person assist without a gait belt due to R2's limited mobility and strength would be unsafe. On 2/21/23 at 12:08pm, V27 (Nurse Practitioner) said, an oblique fracture tibia is caused by a direct landing with the knee in a flex position on a hard surface. R2 is dead weight. R2 can't stop or support herself with any momentum. R2 is not a candidate for a two-person transfer. R2 does not have strength. R2 is alert and orient times three (person, place, and time). New Employee (V8) Orientation Check List no date documents: V8's Initial for fall prevention and no trainer initial was documented. Fall risk assessment dated [DATE] documents: R2 is a high fall. R2's fall incident dated 1/21/22 documents: Type: fall Location: resident room, Activity: Transfer: Cognition prior to and after occurrence: Oriented X3. Injuries: Left lower leg skin discoloration: Notes: CNA informed writer that this resident (R2) leg does not look too good. R2's left lower extremity was noted to have increased edema and discoloration. R2 stated, I slipped off my wheelchair yesterday. Transfer form dated 1/21/23- R2 was transferred to the hospital due to left knee swelling and bruising. Hospital papers dated 1/21/23 documents: R2 presented to the emergency room from the nursing home for evaluation of the left knee hematoma that was painful to touch. R2 said, she had a fall yesterday. R2 had left weakness and flaccid, bilateral leg weakness, left knee with large hematoma, and was swollen. Bruising and erythema (redden) present. Knee X-ray dated documents: oblique fracture of the proximal tibia (The proximal tibia is the upper part of the shinbone that connects to the knee joint) extending from the medical margin superior. Preoperative diagnosis documents: Left displaced medial tibial plateau fracture, left displace tibial tubercle fracture with patellar tendon avulsion (tendon rupture) and left lower extremity hematoma with skin threatening. Procedure performed was an open reduction and internal fixation left tibial plateau, open reduction and internal fixation left tibial tubercle and incision and drainage of deep hematoma left tibia. Fall policy dated 10/2022 documents: It is the policy of the facility to have a fall reduction program that promotes the safe of resident in the facility. The program's intent is to assist clinical staff in determining the needs of each resident through the use of standard assessment, the identification of each resident's individual risks, and the implementation of appropriate interventions, supervision and/or assistive device deemed appropriate. Example of standard fall/safety precautions that may be applicable. #1. Staff will be oriented and trained in the fall reduction program. #12. Transfer conveyance shall be used to transfer resident in accordance with the plan of care.

Based on observation, interview and record review the facility failed to ensure a resident's negative pressure wound therapy machine was continuously on when applied to a pressure wound for 1 of 3 residents (R5) reviewed for pressure wounds in the sample of 9. This failure resulted in R5 developing an infected pressure wound and sent the hospital. The findings include: R5's Face Sheet shows that he was admitted to the facility on [DATE]. R5's hospital After Visit Summary does not show a medication order for antibiotics on admission. R5's Wound Management Detail Report dated 12/22/22 shows that R5 had a stage 4 sacrum ulcer measuring 11 centimeters (cm) x 8 cm x 2 cm that had a heavy amount of serosanguineous drainage (clear/bloody draining that is present in a healthy healing wound) with no odor present. R5 had a negative pressure wound therapy (wound V.A.C) machine attached to the wound. R5's Physicians Order Sheet shows an order dated 12/22/22 for, Site: Sacrum-cleanse area with noncytotoxic wound cleaner, pat dry, apply skin prep, drape, black foam to wound bed, drape, connect the wound vac at 125 mmHg continuous suction. May use Dakins soaked gauze and foam or bordered gauze if wound vac seal is not achievable. R5's Nursing Notes dated 12/26/22 at 10:47 AM shows, Wound care update-Upon assessment of sacral wound I observed there was no seal and the wound vac dressing was completely soaked, wound bed had a foul odor, erythema on peri wound and maceration, NOD (nurse on duty) reported she turned the machine on this am. On 2/10/23 at 9:30 AM, a wound V.A.C machine was observed in a resident room. The machine had a note on it that said, Do not turn this machine off. On 2/10/23 at 12:00 PM, V18 (Licensed Practical Nurse) said that she worked on 12/26/22 the day shift. V18 said that during her morning rounds she went into R5's room and it smelled horrible. V18 said that she checked the wound V.A.C machine and it was off. V18 said that she then turned the wound V.A.C machine on and notified the wound nurse. On 2/10/23 at 11:15 AM, V4 (Wound Registered Nurse) said that wound V.A.Cs are never to be turned off unless the dressing is being changed. V4 said that she has notes on each machine that says to not turn them off. V4 said that wound V.A.Cs can only be left off for about 2 hours before the resident is at risk for infections, drainage accumulation and wound deterioration. At 11:35 AM, V4 said that she came in Monday morning (12/26/22) and the day shift nurse said that they were having issues with the machine beeping and she turned it on when she came in. V4 said that she asked her how long the V.A.C had been turned off and the nurse did not know. V4 said that the nursing staff is directed to call her if the machine is beeping and if she cannot attend to the machine right away, the machine should be removed and a wet to dry dressing should be placed on the wound until she can re-apply the wound V.A.C. R5's Wound Culture Report dated 12/28/22 shows there was heavy growth of Escherichia coli and moderate growth of Enterococcus species present. R5's Nursing Notes on 12/30/22 show, Relayed wound culture lab results to [Nurse Practitioner], with order to send resident out for further evaluation due to worsening infection to sacral wound. On 2/10/23 at 12:15 PM, V19 (emergency room Registered Nurse) said that R5's emergency room Report from 12/30/22 documents that he arrived at the hospital with a 15 cm x 15 cm sacral wound that had purulent draining (white/yellow drainage that is a sign of infection) and a foul odor present. R5's Care Plan dated 12/27/22 shows, [R5] is currently receiving negative pressure wound therapy due to pressure ulcer [R5's] ulcer will not increase in size. Ulcer will not exhibit signs of infection .Confirm the unit is on and set the appropriate negative pressure settings, that the foam is collapsed and NPWT device is maintaining the prescribed therapy and pressure. Address and resolve alarm issues If seal the seal is broken, or alarm is [sic] does not resolve remove and apply moist dressing and notify MD (Medical Doctor). The facility's undated (brand name) Negative Pressure Wound Therapy Quick Reference Card shows, Warning alarms need to be addressed as soon as possible. The therapy is stopped or lessened as long as the cause of the alarm is not corrected. If you are unable to correct the cause of the alarm, contact the physician for instructions. If you are unable to reach the physician, contact an emergency room for assistance .Failure to obtain and follow instructions from the treating physician could result in injury or death.

Based on observation, interview, and record review facility failed to provide emergency diagnostic services and failed to follow up and relay emergency diagnostic services' results to medical practitioner. The facility also failed to administer three out of four seizure medications for two (R3, R4) out of two residents reviewed for quality of care in the sample of 11. These deficiencies resulted in R3's delayed treatment of right hip fracture with subsequent right hip surgery and R4's hospitalization due to multiple seizures. Findings include: 1. R4 admitted to facility 12/02/2022 and has past medical history not limited to: Epilepsy, Metabolic Encephalopathy, Other specified postprocedural s/p craniotomy, Cerebral Ischemia, Other cervical disc degeneration (unspecified cervical region), Presence of cerebrospinal fluid drainage device s/p shunt, and Spinal stenosis (cervical region). Reviewed R4's facility transfer/discharge summary that showed on 12/04/2022, R4 was transferred to the emergency room as a result of having multiple seizures while at facility. No care plan found in R4's electronic medical record. Progress Note dated 12/04/2022 04:32 PM showed facility called hospital for follow up. Nurse stated that resident has been admitted with diagnosis of seizure. Progress Note dated 12/04/2022 04:30 AM showed, Pt began seizing @0345, lasted for 1.5 minutes. After seizure pt (patient) eyes open to stimulus but was not responding as usual. VS BP 129/84 P 134 RR 20 O2 93% BS 150. Pt began seizing again 2 minutes apart for 2.5 minutes. Called primary physician regarding findings and was advised to send pt to local emergency per nurse practitioner order. Pt was sent via fire department @0400. DON (Director of Nurses) notified. Nurse Practitioner aware. Emergency contact notified; SMS VM left with call back number and extension. Gave report to [nurse] in ER. Reviewed R4's active physician orders from 12/02/2022-12/04/2022 (upon discharge) that showed orders for the following anti-seizure medications: clobazam (Schedule IV) 10 mg tablet via gastric tube twice a day 09:00 AM, 04:30 PM; levetiracetam solution 100 mg/mL amt:20mL via gastric tube every 12 hours 09:00 AM, 09:00 PM; phenytoin suspension 125 mg/5 mL amt:10mL via gastric tube twice a day 06:00 AM, 06:00 PM; Vimpat (lacosamide) (Schedule V) 200 mg tablet via gastric tube every 12 hours 09:00 AM, 09:00 PM. Reviewed R4's medication administration record from 12/01/2022-12/20/2022 that showed R4 was not administered 3 of 4 scheduled seizure medications while at the facility as follows: R4 was not administered clobazam (Schedule IV) 10 mg tablet at 04:30 PM on 12/02/2022 and at 09:00 AM and 04:30 PM on 12/03/2022. Total of 3 missed medication administrations. R4 was not administered phenytoin suspension 125 mg/5 mL (10mL) at 04:30 PM on 12/02/2022. Total of 1 missed medication administration. R4 was not administered Vimpat (lacosamide Schedule V) 200 mg tablet at 09:00 PM on 12/02/2022, at 09:00 AM and 09:00 PM on 12/03/2022. Total of 3 missed medication administrations. R4's medication administration record from 12/01/2022-12/20/2022 also showed that R4 was not administered warfarin 6mg (anticoagulant) at 04:00 PM on 12/02/2022. Documented reasons all showed not administered: drug/item not available. On 12/20/2022 at 2:44 PM, V2 (Director of Nursing) said her expectations regarding medication administration is for nurses to administer medications as prescribed within the 1-hour window before and after its scheduled time. V2 then said if a medication is unavailable, nurses should check in the facility's automated medication dispensing system first to see if medication is available for administration, then call the pharmacy to inquire why medication is not available and can do a stat (emergency) order. When asked if a resident's physician should be contacted, V2 said she was unsure of their policy on how many missed doses warrant contacting the physician. V2 also said nurses should document the missed medication and any correspondence with pharmacy and the resident's physician within their medical record. At 2:48 PM, V2 said the facility has several consistent agency staff who are coming in to help fill staffing holes. When asked what the process is when an agency nurse comes into facility, V2 said they receive a brief one-time orientation. Requested facility policy for contract staff, none provided during course of investigation. Requested facility policy for missed medication administration, none provided during course of investigation. Requested list of medications stored within the facility's automated medication dispensing system. None provided during course of investigation. Reviewed facility's medication administration policy last reviewed 05/17 that showed: Objective: To document the administration and ordering of those medications deemed necessary by the physician to improve and/or stabilize specified diagnosis of the resident. Procedure: All Medications must be administered to the resident in the manner and method prescribed by the physician. In the event that a medication cannot be given, the reason must be documented in the Nurses Medication Notes on the MAR or Progress Notes. Documentation of meds given will be done in a consistent manner by the nurse placing their initials in the appropriate space on the MAR. 46066 2. R3 was admitted to the facility on [DATE] with diagnosis including but not limited to bipolar disorder, History of Falls, Scoliosis, Personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits, Age-related osteoporosis without current pathological fracture, Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. According to MDS (Minimum Data Set) dated 09/30/2022 under Section C, R3 has a BIMS (Brief Interview of Mental Status) score of 6 indicating severely impaired cognitive functioning. On 12/19/2022 at 11:23 AM the surveyor observed R3 sitting in the wheelchair in the common area, participating in the activities at this time. On 12/19/2022 at 11:23 AM the surveyor asked R3 about her fall incident on 10/17/2022, R3 stated, Where did it happen? Surveyor clarified that R3 suffered a fall at the facility where she currently resides. R3 stated, Oh yes, I think I fell and hurt my hip but it's all better now. Not sure how it happened. I don't remember what happened after that. Surveyor unable to interview R3 due to R3's severe confusion. Per record review, incident report with occurrence date of 10/17/2022, reads in part, At approximately 5:00 PM on October 17th, 2022, nurse (V10 Licensed Practical Nurse) was notified by Certified Nursing Assistant that R3 had fallen in her room. R3 complained of mild pain to the right hip. Medical doctor notified with order for stat x-ray of right hip and pelvis. At approximately 11:40 AM on October 18th, 2022, x-ray results of right hip and pelvis received and revealed a fracture of the right femoral neck. V14 (Nurse Practitioner) made aware with order to send to hospital's emergency department for further evaluation and treatment. Per record review, progress note dated 10/17/2022 at 9:58 PM written by V10 (Licensed Practical Nurse) reads in part, [V10 (LPN)] was informed by the duty Certified Nursing Assistant that R3 is sitting on the floor near the edge of the bed. [V10] Conducted physical assessment, R3 [displayed] little discomfort to her right hip. Primary doctor was informed and ordered right hip x-ray; order was carried out. Per record review, radiology order dated 10/17/2022 at 9:13 AM reads in part, Order description: Rt Hip, STAT - Immediately. Per record review, outpatient medical diagnostic service company radiologic order dated 10/17/2022, reads in part, Study description: R-hip with Pelvis; reported date and time: 10/18/2022 12:06 AM; Impression right hip: impacted transcervical fracture of the right femoral neck with varus deformity. Per record review, ambulance report dated 10/18/2022 reads in part, Ambulance at scene 10/18/2022 at 1:37 PM. Emergency medical crew assessed vital signs at this time which revealed several emergent findings. Per record review, surveyor noted ambulance arrived approximately 20 hours after R3 suffered fracture to the right hip. Per record review, hospital record dated 10/19/2022 at 7:50 AM, reads in part, R3 presented to emergency department after fall. diagnosed with right hip fracture and urosepsis. Patient has right hip pain. Per record review, operative note dated 10/20/2022 reads in part, R3's pre-op diagnosis: right hip fracture; Procedure: Hemiarthroplasty Right Hip; Findings: Displaced comminuted femoral neck fracture. Per record review, surveyor noted that R3's right femoral fracture went from an impacted fracture to a displaced fracture between 10/17/2022 and 10/20/2022. On 12/19/2022 at 2:23 PM the surveyor interviewed V2 (DON). V2 (DON) stated, Stat order should be carried out within 4-6 hours from the time when it was received. Outpatient diagnostic services company provides all of our x-ray needs, including regular and stat. When a nurse becomes aware that stat x-ray is needed, he or she should put the order into electronic health record system and call the outpatient diagnostic services company to make sure they received the order. Outpatient diagnostic services company should come withing 2 hours from the time when they receive our stat order. On 12/19/2022 at 3:33 PM the surveyor interviewed V10 (Licensed Practical Nurse/LPN). V10 (LPN) was a nurse on duty upon R3's fall. V10 (LPN) stated, R3 suffered a fall on 10/17/2022 around 5:00 PM. Once the fall was reported to me, I performed an assessment and R3 expressed that she has some pain in the right hip area. I called the doctor and suggested that we should do a stat x-ray. I proceeded to put the order into electronic health record system for stat right hip x-ray and called outpatient diagnostic services company to ensure that they received the order. I didn't see them before end of my shift at 11:00 PM. Per record review, progress note dated 10/18/2022 at 12:02 AM written by V10 (LPN) reads in part, R3 was x-ray on her right hip, waiting for results. Discrepancy in V10's (LPN) interview and progress note noted. On 12/20/2022 at 10:00 AM the surveyor interviewed V11 (LPN). V11 stated, I worked night shift from 10/17/2022 to 10/18/2022 from 11:00 PM to 7:00 AM. I don't remember seeing outpatient diagnostic services company come out on my shift. I knew that the resident suffered a fall in the afternoon of 10/17/2022 and was waiting for an x-ray. I called around 4:00 AM on 10/18/2022 to follow up with outpatient diagnostic service company and they said that they will send somebody out; however, I didn't see anyone before the end of my shift at 7:00 AM. I did not chart that I made a follow up call. Per record review, progress note dated 10/18/2022 at 11:40 AM written by V16 (LPN) reads in part, [R3's right lower extremity] shortened and externally rotated. Per V2 (DON), V16 (LPN) did not answer the phone and V2 feels that she should not provide contact number to surveyor without V16's approval. Unable to interview V16 (LPN). On 12/20/2022 at 12:11 PM the surveyor interviewed V14 (Nurse Practitioner). V14 (NP) stated, I found out about R3's fall on 10/18/2022 around 9:30 AM during team's morning meeting. I went up and checked on R3. R3 didn't complain of any major discomfort, only mild pain to her right hip that was treated with in-house pain medication. There were no x-ray results available at that time. I spoke to V16 (Licensed Practical Nurse) around 11:00 AM, and we called outpatient medical services company; we received results over the phone, and they also faxed them to the facility around that time. The surveyor asked if delay in receiving x-ray results of R3's hip could have a negative outcome on her injury. V14 (NP) stated, R3 needed an orthopedic evaluation to determine appropriate treatment. Supposedly, R3 was at a higher risk for blood clot formation due to fracture. On 12/20 2022 at 12:42 AM the surveyor interviewed V2 (DON). V2 stated, I just spoke to outpatient medical services company that performed R'3 x-ray on the night of 10/17/2022- 10/18/2022. They informed me that they faxed results on 10/18/2022 at 1:11 AM to a number that doesn't belong to our facility. Surveyor asked how did V2 (DON) find out about R3's missing hip x-ray results. V2 (DON) stated, On 10/18/2022 at 9:30 AM, during team meeting, we realized that there was no follow up of R3's fall and that's when V14 (NP) and V16 (LPN) called outpatient medical services company to follow up on R3's hip x-ray results. Surveyor clarified what could V11 (LPN) have done to prevent delay in receiving R3's stat x-ray results. V2 (DON) stated, V11 could have reached out to me to notify me that R3's x-ray was done but no results were reported. I could have tried to get R3's results myself. Our nurses are aware of urgency of stat results; however, I can't speak for the agency nurses. No stat order facility policy available upon request per V2 (DON).

Based on interview and record review, the facility failed to provide a resident with assistance during a transfer for a resident assessed to require assistance with repositioning/transferring. This failure applied to one (R1) of three residents reviewed for assistance with transfers. This failure resulted in R1 having a fall, requiring emergent transfer to local hospital, and being diagnosed with a fractured femur. Findings include: R1 was admitted to the facility on [DATE] and has medical diagnoses that include presence of right artificial hip joint, fracture around internal prosthetic right hip joint, (subsequent encounter), [CONDITION(S)] (right hip), chronic pain syndrome, unsteadiness on feet, difficulty in walking, aftercare following joint replacement surgery - right total hip arthroplasty, spinal stenosis, and need for assistance with personal care. 1/8/22 at 12:25pm, R1 was in R1's room in bed. R1 was alert and oriented and had a clear recollection of events related to recent fall. Surveyor was able to determine that R1 was is a reliable historian of events. R1 stated, In October a CNA was helping me go from the walker to the wheelchair, then she left the room, and I was supposed to have someone with me at all times because I came here after hip surgery. I can't remember who the CNA was, and I don't think I've seen her since. But she came in to help me get to the bathroom and when I was done, she helped me get up and I was using the walker to get back into my wheelchair and in the middle of it she just left; she didn't say anything or tell me that she was leaving, so as I was trying to get into the wheelchair my foot hit the back of the wheelchair and I fell . I was out of it after the fall, I was so disoriented and in so much pain. I just remember hearing voices say, Let's move (R1) and I thought oh, no, please don't touch me because I was in excruciating pain. I knew right away that something was broken, and it turned out to be my femur on the same side where I had just had the hip surgery. I did tell the nurse that the CNA left me, and I told them (staff) when they came back to ask me what happened. I don't know why the CNA just left like that in the middle of helping me. When surveyor asked R1 if she knows how to use R1's call light and if R1 ever tries to get up on R1's own. R1 stated, No, I never try to get up on my own. I don't want to fall again. I want to go home. I'm miserable here and it's disappointing that I was getting better and because of the fractured femur, now I have to be here longer. Facility provided final incident report to State agency on 10/16/21 that includes: Occurrence description: On October 11th at approximately 10:45am, CNA (named) had observed the resident (R1) on the floor next to the left side of (R1) bed and immediately called for the resident's nurse (named). Nurse (named) promptly proceeded to the resident's room. Resident was observed lying face towards the bathroom door and bilateral legs extended. Resident is alert, verbally responsive, and oriented x 3. Upon completion of a full body assessment, (R1) was noted with pain, slight swelling, and discoloration of the right leg, along with limited range of motion in the extremity. Nurse (named) administered PRN pain medication to help relieve discomfort. Resident was alert at (R1's) baseline. No changes in level of consciousness. No other physical injuries noted. NP (named) of primary MD (named) was notified and gave orders to send resident (R1) to (local hospital) ED for evaluation and treatment. Paramedics were called and the resident was transported as ordered at approximately 11:45am. Nurse (named) updated emergency contact of resident's status. On October 11th at approximately 6:30pm, the facility was notified by (local hospital) that resident (R1) would be kept for observation overnight. At 10:51am on October 12th, the facility was notified that (R1) was diagnosed with right periprosthetic femur fracture. Administrator, MD, and Clinical team were notified. CNA (named) was returning from a break, upon entering the floor she heard a loud noise and proceeded towards it. CNA (named) entered (R1)'s room and had observed (R1) on the floor near (R1's) bed. CNA (named) immediately notified the resident's nurse. At around 10:45 Nurse (named) was notified by CNA (named) that resident (R1) was observed on the floor on (R1's) left side of the bed. This nurse immediately went to resident's room. Prior to the incident the resident was observed in (R1's) bed watching TV. At the time of the event, resident was observed by Nurse (named) lying face towards the bathroom door and bilateral legs extended. (R1) is alert, verbally responsive and oriented x 3, which is (R1's) baseline. Per Nurse (named) the resident was then turned to (R1's) back using a log roll method with 3 staff assist. Upon assessment, the resident did not show any facial injuries - there was no swelling, bruising, and/or redness noted on (R1's) face. Resident complained of pain in the right knee, Nurse (named) noted that the range of motion to the right leg was limited and noted slightly swollen and discolored. Resident's vital signs were stable. Nurse (named) stated that (R1)'s surroundings remained clutter free, the floor was clean and dry, and the resident was observed with non-skid socks on. (R1's) wheelchair was noted to be in locked position by the right side of the bed. When Nurse (named) asked the resident how the incident occurred, (R1) stated (R1) was transferring self from the bed to (R1's) wheelchair. A head-to-toe assessment was done, PRN [MEDICATION(S)] 325/10 was given at 11:15am. NP from MD (named) was notified by Nurse (named) with orders to send the resident to local hospital. Nurse (named) also notified the resident's emergency contact. 911 was called and (R1) was sent to local hospital 11:45am. CNA (named) at the time of the event was assisting another resident with a call light. This CNA had rounded on the resident approximately 15 minutes prior to the event . Conclusion: After thorough investigation and based on observations by staff, as well as resident statement, the facility determined that the resident had attempted to get up from (R1's) bed without calling for assistance. Resident's prior diagnosis of unilateral primary [CONDITION(S)] of the right hip, spinal stenosis, muscle weakness, difficulty walking, other lack of coordination, and unsteadiness on feet puts R1 at a high risk for a fall. Resident was assessed for injuries and pain was treated timely. Vital signs, neurological checks, and range of motion were completed. Resident was sent to (local hospital) for evaluation and treatment. Upon future return to the facility, (R1) will be monitored for pain, changes in LOC, any signs of infection, and will be evaluated by therapy for rehabilitation. Per Administrator, the previous Director of Nursing was the person who conducted this investigation and there is no other information. Hospital record dated 10/11/21 confirms that R1 obtained a periprosthetic fracture of the right proximal femur as a result of aforementioned fall. R1's MDS (Minimum Data Set) assessment dated [DATE] documents that R1 has a BIMS (Brief Interview of Mental Status) score of 15 (cognitively intact) and is coded as 3/2 (extensive assistance required/one-person physical assist) for transfers. R1's current care plans include: Problem (R1) is limited in physical mobility, requires use of bed rails for bed mobility R/T generalized weakness, right side joint replacement of the hip. (Created: 7/15/21) Approach (includes and not limited to) Provide 1 person assistance for repositioning/transferring. (Created: 7/15/21) Problem (R1) is at risk for falling R/T ROM limitations, General muscle weakness, Right side joint replacement surgery. (Edited: 10/21/21) Approach (includes and not limited to) Check for toileting needs and provide assistance as needed. (Created: 7/15/2021) Care plan also includes the following information dated 10/12/21 (regarding fall): Alert and Oriented: Resident is A&O x 3. Verbally responsive . Incontinent/continent: Incontinent . What type of assistance needed for ADL and Transfer: Limited 1 Person Assist . Use what device to ambulate: WC, is in good working condition, able to lock and unlock WC . Recent Administration of PRN (as needed medication): Resident Requested [MEDICATION(S)] 10-325mg was given after the fall at 11:15am . Resident Statement: I was transferring myself from bed to WC??? . Root cause: Transferring self without assistance, resident did not pull the call light at the time of fall . 1/9/22 at 2:10pm, V6 (RN), who was the nurse on duty at the time of the fall on 10/11/21, stated, I don't usually work on that floor and I had recently started working at the facility, so at that time I wasn't too familiar with (R1). The CNA told me that R1 was on the floor. The resident was in so much pain that R1 couldn't answer my questions but R1 said R1 was trying to transfer self to the wheelchair. I sent R1 out to the hospital immediately after giving R1 pain medication. I asked the CNA who was assigned to work on that side where she was, and she said that (at the time of the fall) she was in another room. (R1) does normally ask for help; R1 is not like that (impulsive) and R1 knows how to use the call light. Progress Note written by V6 (RN) on 10/11/21 at 11:30AM includes: Prior to the incident resident was observed in R1's bed watching TV. At around 10:45am notified by the CNA that resident is observed on the floor. Writer immediately rushed to the resident's room and observed (R1) lying on the floor on (R1's) left side of the bed. Resident was observed lying face towards the bathroom door and bilateral legs extended. Resident is alert, verbally responsive and oriented x 3, which is (R1's) baseline. Resident was then turned to (R1's) back using log roll method with 3 staff assist .Wheelchair was noted to be in locked position by the right side of the bed. When asked resident how did the incident occurred (R1) stated, I was transferring myself from bed to WC. Head to toe assessment was done . 1/9/22 at 2:46pm, V7 (CNA), who was the person who found R1 after the fall stated, I remember that day because our regular nurse was off. It was after my break around 11am and when I got off the elevator, I heard a sound like a walker falling and I knew that R1 is the only person in that area who used a walker. I ran into R1's room and R1 was on the floor by R1's walker. R1 did say that somebody was helping R1, but I don't remember who it was. R1 is very, very, alert and R1 knows how to use R1's call light. R1 always calls for help when R1 needs help. R1 is very alert and R1 tells the nurse everything. Review of staffing sheet for (R1)'s unit on the date of incident 10/11/21, 7am-3pm documents that V6 (RN) was the nurse on duty and there are two CNAs assigned to the unit, V7 (CNA) and V9 (CNA). On 1/8/22, V1 (Administrator) provided surveyor with a copy of V9's (CNA) personnel file; there was no current contact information in the file. Surveyor asked to speak with V9 if at all possible. 1/10/22 at 12:58pm, V1 re-confirmed that V9 was on leave of absence. No contact information for V9 was provided. Facility provided Activities of Daily Living (ADLs) policy with a review date of May 2021 policy reads: Policy: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). To ensure that their activities of daily living (ADLs) does not diminish unless the circumstances of their clinical condition(s) demonstrate that Diminishing. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs. independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care). b. Mobility (transfer and ambulation, including walking). c. Elimination (toileting). d. Dining (meals and snacks. e. Communication (speech, language, and any functional communication systems).

Based on observation, interview, and record review, the facility failed to implement fall interventions by not monitoring a cognitively impaired resident, failed to transfer resident by use of gait belt, failed to follow their policy for a wandering resident, and failed to monitor the functionality of R2's chair alarm. This applies to 1 of 3 residents reviewed for falls. As a result, R2 wandered out of the dining room without staff being aware, and fell in the shower room, resulting in R2 sustaining a [MEDICAL CONDITION]. Findings include: On 11/26/19 at 12:40 PM, observed V3 (certified nursing assistant - CNA) and V4 (CNA) transferring R2 from wheelchair to bed without using gait belt. V3 and V4 stated, We don't need to use gait belt with two person assist. Record review on R2's fall care plan document: Transfer via gait belt with extensive assistance from two staff members, Bed, chair, and clipper alarms provided and to be used daily. On 11/27/19 at 11:30 AM, V2 stated, I'm going to in-service my staff in regards to the use of a gait belt for resident transfer. They should have used gait belt to transfer R2. Review of facility fall log indicates R2 had five falls within a six-month period (5/28/19, 7/2/19, 9/7/19, 9/21/19, and 10/23/19), with injury on the last two falls (9/21/19 and 10/23/19). Review of R2's MDS section C Cognitive Patterns (effective 10/01/19) indicates R2 is cognitively impaired. Review of R2's progress note, dated 9/21/19, documents housekeeping found resident on the floor. Upon assessment R2 was observed with quarter size bump and bruise to left side top of head. Family and the physician were notified, but family refused to send R2 to local hospital for CT (computerized tomography) of head. Record review on reportable indicates on 10/23/19 during breakfast, R2 wheeled her wheelchair from dining room to the shower room without supervision, and experienced a fall which resulted in a left [MEDICAL CONDITION]. Review of hospital record (physician documentation dated on 10/23/19) indicates X-ray of left hip and pelvis noted with intertrochanteric comminuted fracture of left hip. On 11/26/19 at 11:10 AM, V2 (Director of Nursing) and V6 (Fall Care Plan Coordinator) stated, We are updating care plan with new interventions. On 10/23/19 when R2 had fall, the chair alarm wasn't alarming. Everyone is responsible to monitor dementia patient while they move around. She exited the dining room but nobody noticed. On 11/22/19 at 3:00 PM, V5 (CNA) stated, I was in the dining room on 10/23/19 at around 9:30 AM assisting residents with breakfast. I saw R2 eating her breakfast in dining room (DR), but I didn't see her going out from the dining room. She left before breakfast was over. She had an alarm on her wheelchair, but it wasn't going off when R2 had fallen. My friend V7 (CNA) called me and said R2 had fallen. I went with V7 to the shower room and saw R2 on her back. No alarm was going off at that time. I don't know what happened. We had two CNAs in DR assisting residents. Two CNAs were passing trays to resident rooms. On 11/26/19 at 2:30 PM, V7 stated, I was the assigned CNA for R2 on 10/23/19 when she fell . I was passing breakfast trays to those residents who eat in their room. Three CNAs in dining room were supposed to monitor R2. Nobody saw her going out to bathroom. On 11/22/19 at 3:15 PM, V8 (CNA) stated, On 10/23/19 at around 9:30 AM I was assisting with feeding in a resident's room. The other CNA (V7) asked me what happened. R2 had fallen in the shower close to where I was feeding a resident. I didn't hear any sound. I didn't hear any alarm. She used to have chair alarm, but I don't know why it wasn't going off. On 11/26/19 at 1:11 PM, V10 (R2's nurse on 10/23/19) stated, R2's fall on 10/23/19 happened around 9:30 AM. I was passing medication and I heard from V7 that R2 had fallen on the high side shower room. I went there and saw her flat on her back. I saw one leg was short. R2 was holding her left hip and complaining of pain. We called 911 and Paramedics got her up. On 11/26/19 at 1:45 PM, V9 (attending physician) stated, R2 has dementia and is on fall precautions. All fall precaution patients should be monitored while in dining room. I will tell nurses to monitor R2 to prevent fall. Record review on wandering residents care policy, revised on 05/17, documents: Approaches with a wandering resident need to be direct and non-threatening. All efforts are to be made to keep a resident safe in his/her environment. Record review on (undated) fall reduction program document: Assigned nursing personnel are responsible for ensuring that ongoing precautions are put in place and consistently maintained per the individual's plan of care. Alarm may be useful . the use of alarm does not substitute for supervision. The use of alarm requires on-going monitoring to determine functionality.

Based on interview and record review, the facility failed to comprehensively assess, monitor fluid intake and output and update physician timely in order to obtain an immediate medical intervention to prevent dehydration. This resulted in a severe dehydration and acute kidney injury. This applies to one of three residents (R1) reviewed for dehydration. The findings include: The POS (Physician order [REDACTED]. The most recent MDS (Minimum Data Set) dated 12/4/2014 showed that R5 was always incontinent for bladder and bowel elimination. The nurse's notes dated 12/16/2014 showed that Z1 (R1's Attending Physician) was notified because R1 had developed a fever of 100.5 Fahrenheit. Z1 ordered to give Tylenol, call him if temperature reaches 101 and above and to "PUSH FLUIDS." The MAR (Medication Administration Record) dated 12/22/2014 to 12/31/2014 and the nurse's notes dated 12/16/2014 to 12/31/2014 showed that R1 had a fever for 11 out of 16 days. The nurse's notes from 12/24/2014 to 12/31/2014 randomly documents that R1 was noted with increased weakness, poor appetite and lethargy. There was no assessment to determine what was causing the fever and detect any signs of impending dehydration. There was no monitoring of fluid intake and output whether R1 was receiving adequate fluids. There was no documentation in the clinical record to show that Z1 was notified regarding R1's lingering fever, poor appetite, weakness and lethargy. On 12/31/2014 at 8:00 A.M., the nurse's notes documents that "(R1) continue to be weak, lethargic and sleepy and seemed like has trouble keeping her head up straight." Further review of the nurses notes document that at 3:30 P.M. 4:00 P.M., R1's family member visited and E12(Registered Nurse) that R1 was "not talking, confused and mild drooping of the left side of the face." R1 was sent to the hospital after Z1 was notified and was admitted with dehydration and acute kidney injury. On 1/6/2015 at 1:45 P.M., E6 (Registered Nurse) stated that he received order from Z1 to "push fluids to rule out dehydration" on 12/16/2014. E6 also added that though R1 was encouraged for fluids intake, R1 was not monitored for adequate fluid intake. E6 also added that there was no comprehensive assessment to determine what was causing the lingering fever of 2 weeks and if there was any signs of dehydration. E6 further added that Z1 was not notified with regards to R1's lingering fever, weakness, increasing lethargy and poor appetite. On 1/6/2015 at 2:40 P.M., E7(LPN, Licensed Practical Nurse) stated that R1 was noted with increasing weakness, poor appetite, fever and slow to response for almost two weeks prior to R1 being transferred to the hospital on [DATE]. E7 stated that Z1 was notified on 12/31/2014 regarding R1's current medical condition when R1's family visited and was concern. On 1/6/2015 at 2:15 P.M., E8(Certified Nurse Assistant, CNA) stated that R1 was noted with increased weakness, slow to response, poor appetite for the past two weeks prior to R1 being transferred to hospital. E8 also stated that she had informed E6 regarding R1's declined. On 1/6/2015 at 2:34 P.M., E9 (CNA) stated that he noticed R1 to be "sleepier, increasing weakness and poor appetite " for the past few weeks prior to R1 being sent to the hospital. On 1/12/2015 at 11:17 A.M., E5 (Registered Dietician) stated that R1's estimated fluid needs was 2100 - 2450 cc/daily. E5 also added that low or high grade fever would cause dehydration. E5 also stated that fever causes insensible water losses through skin, mouth and perspiration. As E5 added, there should have been monitoring of fluid intake and output, assessment of dehydration by checking mucous membranes, skin turgor, urine color and concentration. E5 further added that due to R1's fever, dehydration could have been prevented if there was an adequate and timely intervention in place. On 1/12/2015 at 11:45 A.M., Z1 stated that he should have been notified when R1 had increased weakness, lethargy, poor appetite and an ongoing fever. Z1 further added that if he would have known, he have ordered immediate intervention to prevent dehydration and acute kidney injury. Z1 also added that dehydration is a preventable condition if immediate timely treatment was in placed. The hospital emergency department record dated 12/31/2014 indicated that R1 was admitted with acute kidney injury with "marked dehydration based on laboratory values of Sodium 160(normal range was 135-145); Potassium 6.0 (normal range was 3.4-5.1); Chloride 123 (normal range was 98-107); BUN was 153(normal range was 10-20) ; [MEDICATION NAME] was 5.36( normal range was 0.50-1.10) which was normal few weeks ago; WBC count elevated to 26,000 and positive for urinary tract infection and pansinusitis." The hospital record dated 1/7/2014 indicated that R1 was placed on palliative care and was discharged to another nursing facility and was placed on hospice care.

Based on interview and record review, the facility failed to inform the physician promptly of significant changes in clinical condition. This had delayed the treatment which resulted to an admission to the hospital with [DIAGNOSES REDACTED]. This applies to one of three residents (R1) reviewed for dehydration. The findings include: The POS (Physician order [REDACTED]. The MAR (Medication Administration Record) dated 12/22/2014 to 12/31/2014 and the nurse's notes dated 12/16/2014 to 12/31/2014 showed that R1 had a fever for 11 out of 16 days. The nurse's notes from 12/24/2014 to 12/31/2014 randomly documents that R1 was noted with increased weakness, poor appetite and lethargy. There was no documentation in the clinical record that Z1 (R1's Attending Physician) was notified regarding R1's lingering fever, poor appetite, weakness and lethargy. On 12/31/2014 at 8:00 A.M., the nurse's notes documents that "(R1) continue to be weak, lethargic and sleepy and seemed like has trouble keeping her head up straight." Further review of the nurses notes document that at 3:30 P.M. 4:00 P.M., R1's family member visited and told E12 (Registered Nurse) that R1 was "not talking, confused and mild drooping of the left side of the face." R1 was sent to the hospital after Z1 was notified and was admitted with dehydration and acute kidney injury. On 1/6/2015 at 1:45 P.M., E6 (Registered Nurse) stated that that Z1 was not notified not until 12/31/2014 regarding R1's lingering fever, weakness, increasing lethargy and poor appetite. On 1/6/2015 at 2:40 P.M., E7(LPN, Licensed Practical Nurse) stated that R1 was noted with increasing weakness, poor appetite, fever and slow to response for almost two weeks prior to R1 being transferred to the hospital on [DATE]. E7 stated that Z1 was notified on 12/31/2014 regarding R1's current medical condition when R1's family visited and was concern. On 1/6/2015 at 2:15 P.M., E8(Certified Nurse Assistant, CNA) stated that R1 was noted with increased weakness, slow to response, poor appetite for the past two weeks prior to R1 being transferred to hospital. E8 also stated that she had informed E6 regarding R1's declined. On 1/6/2015 at 2:34 P.M., E9 (CNA) stated that he noticed R1 to be "sleepier, increasing weakness and poor appetite " for the past few weeks prior to R1 being sent to the hospital. On 1/12/2015 at 11:45 A.M., Z1 stated that he was not notified regarding R1's increased weakness, lethargy, poor appetite and an ongoing fever for the past two weeks prior to hospitalization on [DATE]. Z1 also stated he could have ordered intervention such as blood work, intravenous fluid or sent her out to hospital sooner for an immediate intervention in order to prevent dehydration and acute kidney injury. Z1 also added that dehydration is a preventable condition if immediate timely treatment was in placed. The hospital emergency department record dated 12/31/2014 indicated that R1 was admitted with acute kidney injury with "marked dehydration, urinary tract infection and pansinusitis." The hospital record dated 1/7/2014 indicated that R1 was placed on palliative care and was discharged to another nursing facility and was placed on hospice care. The facility's policy for "Change in a Resident's Condition or Status" dated 12/2013 showed that the nurse will notify the resident's attending physician when "...There is a significant change in the resident's physical, mental...; Deemed necessary or appropriate in the best interest of the resident."

Based on interview and review of documents the facility failed to provide adequate supervision in one of three residents sampled. Facility staff left R1 in the toilet room by herself without adequate supervision . This resulted in R1 receiving a 3 centimeter laceration to her left forehead and a fractured left femur. Findings include: R1 is a [AGE] year old female with a [DIAGNOSES REDACTED]. R1 was first admitted to the facility on [DATE]. R1 was assessed by the facility with poor safety awareness, risk for falls, and was on fall precautions. R1 is alert but confused and very forgetful. R1s latest physician orders [REDACTED]. R1 was also ordered to be on hip dislocation precautions. Review of documents reveal R1 had two falls. The first was on 7/14/14 while in the dining room at lunch R1 stood up from chair and fell . R1 was sent out to the hospital and was diagnosed with [REDACTED]. The 2nd fall was on 8/2/14 at 7:30AM . R1 was brought to her (Room 417) toilet room. E3 (Certified Nurse Aid ) left R1 unattended on the toilet. When E3 returned R1 was found laying on the floor. R1 sustained a laceration to the left side of forehead R1 was sent out to the hospital. R1 was admitted to the hospital and diagnosed with [REDACTED]. E3 ( Certified Nurse Aid) 11:20AM 8/12/14 stated R1 was sitting up in her bed around 7AM on 8/2/14. I took her to the toilet room and sat her down on the toilet. I gave her the nurse call and told her to pull it when she is ready. I stepped out of her room for two to three minutes to get a diaper down the corridor. When I returned R1 was on the floor. The call light was not pulled. I made a mistake. I should not have left her. E4 ( Nurse) 1:07PM 8/12/14 stated at the start of my shift at approximately 7AM , I was notified by other staff that a resident was on the floor. E3 stated to me that R1 wanted to use the toilet . E3 left her for a few minutes. When he came back R1 was on the floor. E4 stated that R1 had a urinary tract infection and was even more confused. R1 should not have been left by herself. Document review of incidents shows on 8/2/14 at 7:30AM , E3 took R1 to her toilet and left her . When E3 returned R1 was on the floor on her left side. There was blood on her face. R1 sustained a deep 3 centimeter laceration on her left forehead and a bump / bruise on the left eyebrow. R1 was assessed by staff and the ambulance was called. Hospital records dated 8/2/14 show R1 sustained lacerations to her forehead and a fracture to the left proximal femoral diathysis. R1 required surgery to repair the fracture.

Based on observation, interview and record review, the facility failed to prevent new and recurring pressure sores from forming by not implementing pressure relieving methods for two residents (R2) and (R21) in a sample of 24. Findings include: 1. On May 23, 2011 from 12:15pm until 2:30pm, R2 was observed in bed laying in the back position, no repositioning of resident was observed during this time. During an interview at 2:00pm, R2 stated that she has sores on her feet, but declined to have surveyor observe them at this time. She also, stated that she does not like getting out of bed and only likes laying on her back. On May 23, 2011, at 2:20pm, E5 (RN) stated that R2 developed the pressure sores on her feet because she wears her shoes twenty four hours a day and refuses to take them off. She also, stated during this interview that R2 only gets out of the bed to take a shower, then she goes right back because she doesn't like being up, "she refuses and starts to scream." On May 24, 2011, at 10:45am, E5 (RN) Registered Nurse exposed R2's pressure sores for observation. There was noted to be one dime sized open sore on the bilateral malleolus and one 1/2 inch ulcer on the left great toe. Record review of wound assessment dated [DATE] measures the pressure sores to be Left inner malleolus 1 x 1cm, Right inner malleolus 1.2 x 1 cm and Left great toe 0.1 x 0.1 cm. Record review of nursing notes dated 5/20/2011, documents that pressure sores were discovered on 5/20/2011 during R2's shower and that the physician has been notified. Also, stated that R2 likes to wear her shoes at all times and the daughter was notified in hopes of convincing her not to wear her shoes 24 hours a day. During observation on May 24, at 10:45 am R2 is noted to be laying on a hard beige mattress and no heel protector devices in place. Record review of physician orders [REDACTED]. On May 24, 2011 at 10:30am, E5 stated that the beige mattress that R2's is laying on is a regular mattress and not pressure reducing. Record review of Braden skin assessment documents that R2 is at moderate risk for developing pressure sores. Record review of treatment record dated 4/25/2011 documents that R2 had a pressure sore on the coccyx, which was healed 5/1/2011. On May 24,2011 from 10:45 am until 12:40pm R2 is noted in bed laying in back position, no repositioning of resident observed during this time. On May 25, 2011, from 10:30 am, until 12:00pm, R2 is observed in bed laying in the back position, no repositioning of resident observed at this time. Record review of the physician orders [REDACTED]. 2. On May 24, 2011 from 10:30 am to 12:00 pm, R21 was observed to be sitting in the reclining chair in the hallway. No repositioning of resident was observed between these times. On May 25, 2011 at 10:30 am, R21 was observed to be sitting in the reclining chair in the hallway, she was observed to be in the same position at 11:30am in the den and still in the same sitting position in the reclining chair in the hallway at 12:30pm. During interview with R21 at 10:30am, she states, "No, they don't reposition me...it would feel good. They don't bring me to the bathroom. I sit in this diaper." When asked by the surveyor regarding what time she goes back to bed/get changed, R21 states "It depends on my back, if it hurts. They don't have change my diaper right after lunch. I don't like to stay in my room. I don't want to go back to bed because I'll get pneumonia." During an interview at 1:30pm E8 (Certified Nursing Assistant) stated, "We don't usually change her until 3 pm because she does not want to." At 2:00pm, E16 (Licensed Practical Nurse) asked R21 if they can put her back to bed to be changed. R21 stated that she did not want to go back to bed at this time but was finally convinced by E16. R21 was brought to room [ROOM NUMBER]. At 2:05pm, R21 was transferred to bed and changed. R21's diaper was soaked with urine and she also had a bowel movement. It was observed that R21 had redness on both cheeks of her buttocks. E5 (Registered Nurse) states, "She has a stage I pressure ulcer and we apply zinc oxide to it." Review of the Braden Scale skin assessment dated [DATE] documents that patient is at moderate risk for pressure ulcer. Review of nurses notes did not show any documentation for the recurrent pressure ulcers. E5 (Registered Nurse) stated that they do not have measurements for R21's pressure ulcer. Review of physician's orders [REDACTED]. Review of the Interdisciplinary Care Plan dated 4/6/11 had no documentation of assessment of recurrent pressure ulcer nor any updated interventions for the pressure ulcer.