Every finding on record at Elevate Care North Branch

Based on interview and record review, the facility failed to ensure that a resident was free from verbal abuse from staff for one of three residents (R1) reviewed for abuse. Findings include:R1 is the subject of this investigation and is no longer residing in the facility. R1 is a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that are not limited to emphysema, hypertension and bipolar disorder. R1's Minimum Data Set, dated [DATE] indicated that R1 has brief interview for mental status score of 15 which indicated cognitively intact. Review of facility's serious injury incident and communicable disease report dated 06/29/2026 indicated that R1 reported to V12 (Social Worker) that V19 (Former Activity Aide) and R1 had a verbal disagreement where R1 felt threatened by V19. It stated that they allegedly called each other a bitch, and V19 told R1 to get out of her face before he gets dealt with. It stated that V19 was interviewed and admitted to calling R1 a bitch. It stated that V20 was interviewed during investigation and heard both V19 and R1 calling each other bitch. On 07/22/2026 at 1:12PM during interview with V12, V12 stated that she was making rounds and R1 told her that R1 had a disagreement with V19. V12 stated that R1 told her they had an exchange of the b-word when R1 was trying to help the other residents in the smoking area. V12 stated that R1 told her that he felt threatened at the time. On 07/23/2026 at 12:11PM during phone interview, V20 (Activity Aide) stated he was working with V19 on 06/27/2026. V20 stated it was around 6:15PM, and they were assisting residents in the smoking area. V20 stated V19 and R1 were having disagreement and called each other names. On 07/23/2026 at 3:09PM during interview with V2 (Director of Nursing), V2 stated staff is expected to handle a resident in an emotional crisis in a calm and respectful manner. V2 stated staff are expected to make sure all residents are safe, then de-escalate the situation by talking to the resident calmly and politely without raising voice and offering anything that can help the residents calm down. V2 stated if nothing is working, staff are expected to ask for help de-escalating the situation, step back and reach out to administrator if needed. Review of R1's care plan revised 07/22/2026 indicated R1 demonstrates angry and confrontational behavior toward staff with interventions including approaching R1 calmly, respectfully, and in nonthreatening manner, using de-escalation techniques, and offering choices when appropriate and avoiding arguing and confrontation. Review of V19's Job Description as Activity Aide signed on 09/04/2025 indicated qualifications including must have patience, tact, cheerful disposition & enthusiasm, as well as be willing to handle residents based on whatever maturity level at which type they are currently functioning. It indicated physical demands including must be able to relate to and work with ill, disable, elderly, emotionally upset and at times, hostile people within the facility. Review of facility's policy entitled Abuse and Retaliation Policy Prevention Program dated 1-2026 indicated the following: Policy: 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. 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 policy is to ensure 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.

Based on observation, record review, and interview, the facility failed to ensure one (R2) of three residents reviewed for abuse was protected when the facility did not adequately identify, intervene, and protect residents from resident-to-resident abuse. This failure resulted in a resident being exposed to the potential for harm. During the investigation observations were made, interviews were conducted, and records were reviewed. R2 will be known as R2 and is the subject of this Complaint InvestigationR1 will be known as R1 and is the alleged perpetrator. R2 is a [AGE] year-old female who was originally admitted to the facility on [DATE] and continues to reside in the facility. R2 has multiple diagnoses including but not limited to the following: dementia in other diseases classified elsewhere, mild, with agitation, anxiety disorder, unspecified. R2's transfer status is 1- person assist. R2 can ambulate with the assistance of a wheelchair and self-propels. R2's comprehensive assessment section C cognitive status dated 11/10/2025 documents a brief interview for mental status score of 4 out of 15. A score from 0 to 7 indicates the person is considered to have severe cognitive impairment.R2's psychiatric note dated 11/27/25 states R2 is a [AGE] year-old female with a psychiatric history of dementia with hallucinations, anxiety and depression seen for f/u psychiatric evaluation. She was evaluated in her room, seated in her wheelchair, awake, verbal, and cooperative, though communication remained limited by her baseline confusion and preference for Bulgarian. She appeared intermittently anxious and restless but remained able to participate in simple conversation. She continues to show progressive cognitive decline marked by worsening irritability, decreased tolerance for environmental stimulation, and difficulty redirecting during care. No overt hallucinations or delusional thinking were observed, and staff deny clear psychotic behaviors at this time. Despite a recent increase in her evening dose of quetiapine, she continues to have occasional episodes of yelling out and behavioral dis-inhibition, most often triggered by interactions with her roommate or when someone enters her personal space. These episodes remain brief and generally respond to redirection. Sleep and appetite have remained stable, and there have been no recent medical complications reported. R2 social service notes dated 11/4/25 states Well-being check done, R2 is in good spirits, no behavioral symptoms exhibited at this time. No emotional distress exhibited. R2 nursing note dated 11/3/25 states NP updated regarding increase anxiety and agitation, keeps going to other resident's room. Fighting with staff and this writer whenever trying to stop her. Behavior difficult to redirect. NP increased R2's Seroquel and sertraline, orders noted and confirmed. NP gave order for CBC/CMP in am, UA/CS, noted and carried out. R2 nursing notes dated 11/2/25 states R2 is stable during shift, no complaints of pain or discomfort. No changes of LOC. Vital signs are stable. R2 still observe wandering and tend to go to other rooms despite multiple redirections provided. Endorsed accordingly. R2 progress note dated 11/1/25 - Head to toe assessment done- Noted with small open skin on left eyelid, no bleeding, swelling or bruising noted at this time. neuro check initiated, no changes in LOC- R2 is calm, not on any form of distress noted. endorsed accordingly. R1 progress note dated 11/1/25 states Head to toe assessment done, neuro check initiated, wellbeing check and resident is calm. R1 progress note dated 11/1/25 states R1 has had a behavioral episode. Please see the Behavior Observation for details. During the investigation dated 1/7/2026 to 1/8/2026, the surveyor observed the staff providing nursing care to residents while touring the unit. During observations and interviews the surveyor had no identified issues or concerns regarding resident to resident physical abuse, quality of patient care/treatment, improper nursing care, and resident/patient/client rights. Surveyor reviewed grievance/complaint binder for last six months for physical/mental/verbal abuse, quality of care/treatment, patient care, improper nursing care. No issues or concerns were identified.R1 and R2 were reviewed for resident to resident physical abuse with no concerns noted. On 1/7/2026 at 8:45AM surveyor observed nurses performing medication administration, call lights being answered within seconds to minutes. Surveyors noted residents being cleaned up after meals. Surveyor did not notice any resident to resident verbal/mental/physical abuse, neglect or not receiving quality of care/treatment. Surveyor noticed residents up and out of bed. Surveyor did not notice any resident linens to be dirty or soiled, foul odors. Surveyor noticed majority of residents up for meals.On 01/07/2026 at 12:55 surveyor observed R2 in her bed confused, and anxious. R2 was sitting in bed restless and not able to focus. R2 was dressed appropriately for the weather and was wearing shoes. R2 bed was in the lowest position, call light and wheelchair were next to the bed. Surveyor observed R2's face and head with no signs of injuries, bruising, swelling, discoloration. R2 is non-Interviewable due to severe cognition impairment.On 01/07/2026 at 1:10PM surveyor observed R1 in her room sitting in a wheelchair. R1 was watching TV and in good spirits. R1 was confused and forgetful. R1 couldn't remember when or who but said a lady came into her room and she told her to get out but she wouldn't leave. R1 said that's when she started yelling and trying to push the lady out of the room. R1 said she felt guilty and bad about hitting her in the face, but she was just trying to get her out of the room. R1 said it hurts her knowing that she had hit the lady but wanted her out, but she wouldn't listen. R1 said she feels safe and hasn't had any problems with any other residents since then.On 01/07/2026 at 1:30PM V5 (Nurse Supervisor/RN) said V9 (Licensed Practical Nurse/LPN) called her to R1's rooms because they had an argument and R2 had been hit in the face by R1. V5 (Nurse Supervisor/RN) said R2 is AxOx1, has dementia and is confused. V5 (Nurse Supervisor/RN) said R2 had wondered into R1's room and when R1 was yelling for her to get out, R1 had hit R2 in the left eye because R2 wouldn't leave. V5 (Nurse Supervisor/RN) said she did a head-to-toe assessment on R2, and she had some redness under the left eye but no bleeding, bruising or report of pain. V5 (Nurse Supervisor/RN) said R2 didn't need to be sent out to the hospital, but the doctor, administrator, director of nursing, and family were all notified per facility policy. V5 (Nurse Supervisor/RN) said R2 was observed for 3 days, and wellness checks were performed. V5 (Nurse Supervisor/RN) said there have been no other incidents between R1 and R2On 01/07/2026 at 1:40PM V4 (Licensed Practical Nurse/LPN) said she was the nurse's station when she heard a loud noise and voices in R1's room. V4 (LPN) said by the time she got there V9 (Licensed Practical Nurse/LPN) had already separate R1 and R2. V4 (Licensed Practical Nurse/LPN) said she did a full body assessment of R1, and she had no injuries, bruising, scratches or reports of pain. V4 (Licensed Practical Nurse/LPN) said R1 was going to leave the room when R2 was entering and R1 tried to stop R2 but she didn't listen or understand since R2's is confused and English isn't her first language. V4 (Licensed Practical Nurse/LPN) said she did notice a small scratch under R2's eye but no bleeding, bruising, or swelling. V4 (Licensed Practical Nurse/LPN) said there haven't been any altercations before or after this one incident. On 01/07/2026 at 2:00PM V2 (Assistant Social Services Director) said she interviewed both R1 and R2 after the incident took place. V2 (Assistant Social Services Director) said R2 got lost and confused and attempted to enter R1's room. V2 (Assistant Social Services Director) said that's when staff heard a commotion, and they tried to intervene but they found both R1 and R2 in a disagreement and the altercation of R1 hitting R2 in the face had already taken place. V2 (Assistant Social Services Director) said there hasn't been any other altercations between R1 and R2. V2 (Assistant Social Services Director) said during her interview both R1 and R2 expressed they feel safe. R2 progress note dated 1/7/26 states Lorazepam Oral Tablet 0.5 MG Give 1 tablet by mouth every 8 hours as needed for anxiety/agitation for 14 Days. PRN Administration was: Effective Review of the facility policy titled Abuse Prevention and Reporting- Illinois requires the facility to protect residents from all forms of abuse, including resident-to-resident abuse. The facility failed to follow its policy. Definitions: 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 (42 CFR 483.12 Interpretive Guidelines).

Based on interview and record review, the facility failed to follow their Fall Prevention Program policy. The facility failed to prevent fall incident and failed to follow the care plan intervention for fall prevention for residents assessed to be moderate and high risk for fall. This deficient practice affects two residents (R1 and R2) of three residents reviewed for fall incidents.Findings Include: 1. R1 is a [AGE] year-old male resident admitted into the facility on 7/17/2025. R1 is with diagnoses of but not limited to: Chronic Osteomyelitis right ankle and foot, Absence of the Right Foot, Type 2 diabetes, Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Stage 5 chronic Kidney Disease, Congestive Heart Failure, Dependence on Renal Dialysis, Cerebral Vascular disease, Anemia and Abnormal Posture. BIMS (Brief Interview for Mental Status) score of 15 (Cognitively Intact).R1 had multiple fall incidents in the facility, dated 7/30/25 and 8/1/25 both in the dialysis unit.R1 with MORSE Fall Scale Evaluation (Fall Risk Assessment) dated 7/17/25 as Moderate Risk, score of 31; post fall incident MORSE Fall Scale Evaluation score of 65 as High Risk, dated 7/30/25. Fall incident report dated 7/30/25, reads in part: Informed by dialysis nurse, R1 fell on the floor towards the end of dialysis treatment, did not hit his head, no injuries, vital signs within normal limits. Resident description: I told the staff I was having cramps on my legs and I really needed to move. They were unable to assist me right away and I had to get up. I lost my balance and fell on the floor. Fall incident report dated 8/1/25, reads in part: Informed by dialysis nurse R1 fell on the floor, hit his head and busted his lip while trying to get up towards the end of his dialysis treatment. Resident description: I told the staff I was having cramps on my legs and I really needed to move. They were unable to assist me right away and I had to get up. I lost my balance and fell on the floor. Nurse Practitioner made aware with order to send to local hospital due to R1 hitting his head and busted lip. R1 strongly refused and verbalized Absolutely not. I'm fine. I don't want to go through all of that. I feel fine.On 10/10/25 at 10:54AM, V4 (LPN), Nurse of R1 on 7/30/25 and 8/1/25 on the skilled unit, stated dialysis nurse reported R1 fell towards the end of R1's treatment. Per V4, R1 reported R1 could not wait for them to disconnect him. They were all with other patients. R1 could not wait and R1 was inpatient. V4 reported on 8/1/25 that it was reported by the dialysis nurse that R1 was inpatient and wanted to get up right away. R1 fell and hit his head and busted his lip and had a skin tear on the lip. V4 was able to control the bleeding. V4 stated R1 refused to go to hospital and Neuro check initiated and no changes with R1. V4 reported V4 documented the same exact scenario on both falls because it was the same scenario that R1 could not wait and got up. V4 stated the verbatim documentation on both days just happened, and V4 stated V4 did not realize V4 documented it exact verbatim. On 10/10/25 at 12:46PM, V6 (RN) dialysis nurse stated on 7/30/25 fall incident, R1 was cramping and V6 went to R1's chair side to turn off the UF (ultrafiltration) to help ease off the cramping. Blood Pressure was 'okay', alert and oriented. V6 left R1 chair side and programmed the BP (Blood Pressure) check every 15 mins. V6 left the chair side and after few minutes R1 was complaining again with cramping on the legs. As soon as R1 verbalized cramping, R1 stood up and lost his balance and fell on the floor. R1 was in V6's clear view. V6 stated she was at the nurse's station, approximately 10 steps away from R1. Per V6, regarding the fall on 8/1/24, R1 complained of cramping. V6 stated they already knew R1 fell the last time R1 was in dialysis, so we went to R1 as R1 was trying to stand up to make sure R1 wouldn't fall again. R1 was trying to stand up at the time. All three-dialysis staff were surrounding R1. R1 started shouting 'back off' and was motioning of pushing us away. We explained to R1, we just wanted to make sure he is safe because he fell in treatment before. R1 eventually was able to sit down. We gave him his space. V6 turned around and heard a thud noise while walking away and halfway to the nurse's station. There was blood on the bottom lip. We helped him untangled the lines and R1 was able to get back on the chair with stand by assist. On 10/10/25 at 10:19AM V3 (Restorative Nurse/Fall Coordinator) stated when an incident happened, we made sure we did the investigation right away to find the root cause. Post fall huddle. New intervention will be added in the care plan. V3 stated R1 had a fall incident on 7/30/25 at 10 am, fell towards the end of dialysis treatment. V3 stated R1 reported R1 was having cramps in his leg. R1 needed to get up and lost his balance. There was dialysis staff present when the incident happened. Root cause for this fall was non complainant and behavior of R1. Per V3, the fall on 8/1/25 at 10AM, R1 lost his balance and fell on the floor. V3 stated this happened again in the dialysis unit. R1 initially was moderate risk for fall upon admission and became high risk for fall after the fall on 7/30/25. Intervention is to reeducate about safety reminder not to get up by himself.Record reviewed: R1 has a care plan for at risk for falls gait/balance problems secondary to chronic osteomyelitis right ankle and foot, type 2 diabetes, CKD (Chronic Kidney Disease), CHF (Congestive Heart failure), BPH (Benign Prostate Hyperplasia) and Glaucoma, with initial date of 7/17/25 and revision date of 7/27/25. R1's interventions initiated 7/18/25 and revision on 8/4/25, reads: 7/30/25: Reinforce education about safety reminder not getting up by himself. Initiated 7/18/25 and revision on 8/4/25. 2. R2 is a [AGE] year-old female resident. admitted in the facility on 6/11/22 with diagnoses of but not limited to: Type 2 diabetes, Alzheimer, dementia, hyperlipidemia, iron deficiency, hypertension, age-related osteoporosis, osteoarthritis right hip unilateral osteoarthritis right knee, vitamin D deficiency, anorexia nervosa, lack of coordination. BIMS score of 4 (severe cognitive impairment).R2's Fall incident Report dated 9/28/25, reads in part: While writer is giving report to the CNA, noted R2 walking towards to this writer with increased agitation when the writer turned around, observed R2 on the floor in prone position wearing improper footwear. Resident description: I tripped on my slippers.R2 with MORSE Fall Scale Evaluation (Fall Risk Assessment) dated 5/19/25 as high risk, score of 61; Post fall incident MORSE Fall Scale Evaluation score of 31 as Moderate Risk, dated 9/28/25. On 10/10/25 at 11:30AM, V3 (Restorative Nurse/Fall Coordinator) stated R2 fell on 9/28/25, got up and started walking towards the staff and lost her balance. The staff found R2 on the floor when they turned around in prone position. R2 was wearing slippers at the time. The root cause is not wearing the appropriate footwear and R1 should wear appropriate footwear when up from bed. R2 is usually up on the wheelchair. The incident happened in the hallway. R2 can ambulate and walk with supervision. Prone position, neuro check initiated. R2 can get up on her own, requires one staff assist, with walker with followed assist for safety.Record reviewed: R2 has a care plan for potential risks for falls related to/due to osteoarthritis bilateral lower extremities, with Past medical history: Alzheimer's/Dementia, seizures, hypertension, protein-calorie malnutrition, and Iron-deficiency anemia dated 6/14/22.R2 has an intervention of Ensure [NAME] is wearing appropriate footwear/nonskid socks when ambulating or mobilizing in wheelchair since 3/13/24. MORSE Fall Scoring High Risk 45 and higher. Moderate Risk 24-44.Fall prevention program with a revision date of 11/21/2017, reads in part: to ensure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each residence by assessing their risk of fall implementation of appropriate intervention to provide necessary supervision and assistive devices are utilized as necessary. Quality assurance programs will monitor the program to assure ongoing effectiveness.Default prevention program includes the following components: Methods to identify risk factors. Methods to identify resident at risk Assessment time frames. Use and implementation of professional standard of practice. Immediate change in intervention were successful. Notification of decision, family and legal representative. Communication with direct care staff member. Documentation requirements. Care plan incorporates: Identification of all risk and issues, addresses each fall, intervention or change with each fall as appropriate, preventative measure. Safety intervention will be implemented for each resident identified at risk.Accident incident report involving falls will be reviewed by the interdisciplinary team to ensure appropriate care and services were provided and determine possible safety interventions.The director of nursing or designee is responsible for monitoring the fall prevention program, including further staff education programs, purchase of additional equipment, or other appropriate environmental alterations. In addition, director of nursing is responsible for informing the administrator of program analysis.Nursing personnel will be informed of residents who are at risk of falling. The fall risk intervention will be identified on the care plan.Footwear will be monitored to ensure the resident has proper fitting shoes and/or footwear is nonskid.

Based on interviews and record review, the facility failed to ensure that the rights of one (R1) of three residents reviewed for resident rights were respected when staff disregarded the resident's expressed refusal to be transferred via mechanical lift. This failure resulted in R1's actual harm evidenced by pain, loss of dignity, and emotional distress. Findings include:R1 is an [AGE] year-old-male admitted to the facility on [DATE] with diagnosis including but not limited to Unilateral Primary Osteoarthritis, Right Hip; Encounter for Orthopedic Aftercare Following Surgical Amputation; Acute Osteomyelitis, Left Ankle and Foot; Type 2 Diabetes Mellitus; Chronic Obstructive Pulmonary Disease; Hypertensive Chronic Kidney Disease; Dependence on Renal Dialysis; and Atherosclerotic Heart Disease of Native Coronary Artery.According to R1's MDS (Minimum Data Set) assessment dated [DATE] under section C, R1 has BIMS (Brief Interview of Mental Status) score of 15 indicating intact cognition.According to R1's MDS (Minimum Data Set) assessment dated [DATE] under section GG, R1's mobility related to transfer from bed-to-chair and chair-to-bed is assessed as dependent indicating need for 2 helpers with all effort placed on helpers. On 09/16/2025 at 11:56 AM V4 (Certified Nurse Assistant) said, I worked on 09/15/2025 between 3:00 PM and 11:00 PM. I was assigned to care for R1. Me and V5 (CNA) transferred R1 into the bed with mechanical lift when he returned form dialysis. R1 didn't like it, but he cannot move, and his left foot is amputated, so that is the only way to transfer R1. R1 was complaining of right hip pain during the transfer. I don't normally take care of R1, this was maybe the second time I transferred him. After R1 complained of right hip pain, we told V6 (Licensed Practical Nurse). I think V6 (LPN) checked on R1, but I'm not sure because after we put R1 in bed, we left.On 09/16/2025 at 12:12 PM R1 said, Yes, I called in a complaint yesterday. They (CNAs) came in to move me to the dialysis by putting me into a machine that lifts me up. In the process, my right hip, which is very arthritic, was very painful. I knew then, I don't want to do it again. When I returned (from dialysis), I told staff, that I don't want to use the mechanical lift again and they have to figure out another way to transfer me into the bed. Staff insisted there is no other way to move me, and they just proceeded to put me in the mechanical lift. I tried to stop them from doing it, but I couldn't. R1 took a pause, shook his head, then continued, As the machine was lifting me, you could hear click, click, click in my right hip. There is so much bone-on-bone friction in that hip, you can just imagine how much it hurt. Nobody came in to check on me or offer pain medication after that. One of the staff was V5 (CNA), I don't know the other one's name.On 09/16/2025 at 12:35 PM V7 (Physical Therapist) said, R1 just explained to me that he is absolutely against the use of mechanical lift. We used to transfer R1 with slide board; however, R1's physical ability declined upon his recent hospitalization and mechanical lift is the safest mean to transfer him right now.On 09/16/2025 at 12:40 PM V8 (Therapy Director) said, This is the first time I hear that R1 has such an issue with mechanical lift. If R1 really doesn't like a mechanical lift, we can try a slide board. R1 requires new physical ability assessment, due to recent hospitalization, to truly determine what is the safest way to transfer him.On 09/16/2025 at 12:46 PM V2 (Director of Nursing) said, If a resident adamantly refuses something, the staff should accommodate resident's request to the best of their ability, unless the refusal poses risk of any type of injury or compromises safety. If a mechanical lift is resident's recommended mean of transfer based on an assessment, we don't advise staff to look for another way because it poses safety concern. A resident should be given choice and education related to risks and safety concerns during transfer by other means than recommended by the assessment. For example, if a resident returns from dialysis and refuses to be transferred to bed via mechanical lift, we should educate a resident, but we still have to use a mechanical lift because a resident cannot stay in the chair. It is a safety concern for both resident and staff to change means of transfer if they are assessed to be safely transferred only with a mechanical lift.On 09/16/2025 at 2:02 PM V6 (Licensed Practical Nurse) said, I worked on 09/15/2025 between 3:00 PM and 11:00 PM. No one ever told me that R1 was in pan during a transfer. I went into R1's room when he returned form the dialysis, I actually went in there couple of times, and R1 never told me that he had an issue related to a mechanical lift transfer, that he was in pain, nor that he needed a pain medication.On 09/16/2025 at 2:48 PM V5 (CNA) said, I worked yesterday (09/15/2025). I assisted V4 (CNA) with R1's transfer. It was around 4:30 PM - 5:00 PM. R1 returned form the dialysis and needed to be transferred back into bed with mechanical lift, so there had to be two CNAs. R1 got agitated during the transfer. R1 really didn't want to be transferred with a mechanical lift. R1 kept saying No, no, no! As we set up a mechanical lift, R1 was attempting to take straps of the mechanical lift sling loops. V4 (CNA) and I proceeded with the transfer anyways. We continued because R1 was assessed to be transferred with a mechanical lift, so there was no other choice. We have resident rights in-services; I think they are done quarterly but I don't remember last time we had it.On 09/17/2025 at 11:44 AM V9 (Attending Nurse Practitioner) said, R1 was admitted to the facility (07/23/2025) for post left foot amputation skilled therapy. R1 was working with physical therapy and was able to transfer with some help into the wheelchair; however, shortly after, R1 had to be hospitalized due to low hemoglobin and was recently readmitted to the facility (09/12/2025). V9 said R1 is a very difficult resident, who is not compliant with care and recommendations. R1 is non-weight bearing on his left foot and has a right hip arthritis that had been treated with injections to alleviate the pain in the past. Surveyor asked about R1's arthritic right hip and pain that R1 experiences, V9 said, R1's small frame and movement or pressure would cause bone-on-bone frication causing inflammation, which would result in R1's additional pain. Surveyor asked V9 to elaborate on resident rights in relation to resident care, V9 said a resident can make decisions related to their care, even though, R1 might not have deep understanding of simultaneously occurring processes. V9 said, A resident can refuse patient care. Staff should document and educate a resident of the risks of not having care done. Residents are allowed to say No. Honoring resident right is important due to residents' autonomy. Transferring R1 against his wish could have caused his emotional distress.Absent is any documentation prior to 09/17/2025 to show R1's mechanical lift transfer refusal or provided education related to mechanical lift transfers.Absent is any care plan prior to 09/16/2025 to show R1's recommended means of transfer.V4's (CNA) and V5's (CNA) most recent resident right in-service dated 09/16/2025 reviewed. No prior V4's (CNA) and V5's (CNA) resident right in-service available upon request.The facility Resident Rights policy last reviewed on 01/04/2019 reads in part, Purpose: To promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability. Guidelines: Notice of resident rights will be provided upon admission to the facility. These rights include the resident's right to: Exercise his or her rights. Exercising rights means that residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules, as long as those rules do not violate a regulatory requirement. The facility will not hamper, compel, treat differentially, or retaliate against a resident for exercising his/her rights. Facility practices designed to support and encourage resident participation in meeting care planning goals as documented in the resident assessment and care plan are not interference or coercion.

Based on observation, interview, and record review the facility failed to promote and respect resident's dignity during mealtime. This deficiency affects one (R47) of three residents in the sample of 28 reviewed for Resident Rights. Findings include: R47 was admitted on [DATE] with diagnosis listed, in part, but not limited to Hypertensive heart and chronic kidney disease with heart failure ad with stage 5 chronic kidney disease or end stage renal disease, Monoplegia of upper limb following non-traumatic intracerebral hemorrhage affecting right dominant side. Admission MDS/Resident assessment done on 4/11/25 indicated: Section GG Functional abilities. GG0130 Self Care Coded 3 Requires partial moderate assistance in eating. Comprehensive care plan indicated that she has an ADL self-care performance deficit. On 4/15/25 at 12:18PM, R47 is alert, responsive and pleasantly confused. Observed R47 in her room, sitting in wheelchair with pillow place on her lap creating space between lunch tray placed on bedside tray table in front of her. She is eating by herself, with food all over her chest and her lap. She is using spoon and her hands to eat. The pillow is soiled with food. She has her cellphone connected to outlet which is wet/soiled with food. Observed long and dirty fingernails on both hands, with black matter inside the nails. Called V23 LPN (Licensed Practical Nurse), showed and informed observation made. V23 said that sometimes she needs assistance and supervision when eating. V23 said that the CNA (Certified Nurse Assistant) distributed and set up the tray to R47. V23 said that nail care is a CNA responsibility during daily ADLs care. V23 called V26 CNA. V26 said that she is the CNA assigned for R47, but she did not set up the lunch tray for R47. V26 said that lunch tray should be placed closer and accessible to resident. On 4/15/25 at 2:30PM, Informed V2 DON (Director of Nursing) of above observation. R47 soiling her clothes while eating. R47 needs assistance during meals. V2 said, CNA should ensure proper tray set up to resident regarding proper proximity of their tray during meal. V2 said that they don't place food protector to R47 during meals. On 4/16/25 at 12:26 PM, Informed both V1 Administrator and V2 DON that R47 needs partial/moderate assistance in eating as indicated in her MDS/Resident assessment. R47 was observed yesterday eating by herself without assistance, food all over her chest and lap and soiling her clothes from food. Facility's policy on Resident Right's reviewed 1/4/19 indicated: Purpose: To promote the exercise of rights for each resident, including any two face barriers (such as communication problems, hearing problems and cognition) in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability. Facility's policy on Dignity reviewed 4/23/28 indicated: Guidelines: The facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. The facility shall consider the resident's lifestyle and personal choices identified through the assessment processes to obtain a picture of his or her individual needs and preferences. Staff shall carry out activities in a manner which assists the resident to maintain and enhance his/her self-esteem and self-worth. Facility's policy on Feeding and assisting residents to eat indicated: Purpose: To assist the resident to obtain nutrient and hydration. To provide a socializing experience for the resident Procedure: 4. Tuck the napkin under the chin or place on clothing protector. Only necessary to prevent soiling of clothing.

Based on observation, interview, and record review the facility failed to ensure resident call light is within reach. This deficiency affects one (R191) of three residents in the sample for 28 reviewed for accommodation of needs. Findings include: R191 is admitted on [DATE] with diagnosis, in part, but not limited to history of falls, hypertensive heart disease with chronic diastolic congestive heart failure, type 2 diabetes, hyperlipidemia, right femur fracture. A focused care plan for alteration in cardiovascular functioning related to congested heart failure, indicated intervention keep call light within reach dated 4/9/25. On 04/15/25 at 11:13 AM, R191 observed in bed with call light behind bed, R191 said she does not know where her call light is at. On 04/15/25 at 11:23 AM, V29 (Licensed Practical Nurse) made aware of above and said that call light should be within reach and not behind the bed. On 04/17/25 at 02:05 PM, V2 (Director of Nursing) said that all call lights should be within reach of resident, said that call lights are not to be behind the bed. Facility's policy on Call light revisions 2/2/18. Purpose: To respond to residents requests and needs in a timely and courteous manner. Guidelines: 1. All residents that have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility to the resident at the bedside or other reasonable accessible location.

Based on observation interview and record review the facility failed to provide nail care and assistance during meal to resident who needs assistance with Activity of daily living (ADL). This deficiency affects one (R47) of three residents in the sample of 28 reviewed for ADL care. Findings include: R47 was admitted on [DATE] with diagnosis listed, in part, but not limited to Hypertensive heart and chronic kidney disease with heart failure ad with stage 5 chronic kidney disease or end stage renal disease, Monoplegia of upper limb following non-traumatic intracerebral hemorrhage affecting right dominant side. Admission MDS/Resident assessment done on 4/11/25 indicated: Section GG Functional abilities. GG0130 Self Care Coded 3 Requires partial moderate assistance in eating. Comprehensive care plan indicated that she has an ADL self-care performance deficit. On 4/15/25 at 12:18PM, R47 is alert, responsive and pleasantly confused. Observed R47 in her room, sitting in wheelchair with pillow place on her lap creating space between lunch tray placed on bedside tray table in front of her. She is eating by herself, with food all over her chest and her lap. She is using spoon and her hands to eat. The pillow is soiled with food. She has her cellphone connected to outlet wet/soiled with food. Observed long and dirty fingernails on both hands, with black matter inside the nails. Called V23 LPN, showed and informed observation made. V23 said that sometimes she needs assistance and supervision when eating. V23 said that the CNA distributed and set up the tray to R47. V23 said that nail care is a CNA responsibility during daily ADLs care. V23 called V26 CNA. V26 said that she is the CNA assigned for R47, but she did not set up the lunch tray for R47. V26 said that lunch tray should be placed closer and accessible to resident. On 4/15/25 at 2:30PM, Informed V2 DON (Director of Nursing) of above observation. V2 said that CNA is responsible to provide nail care to resident during ADLs. CNA should ensure proper tray set up to resident regarding proper proximity of their tray during meal. V2 said that they don't place food protector to R47 during meals. On 4/16/25 at 12:26 PM, Informed both V1 Administrator and V2 DON that R47 needs partial/moderate assistance in eating as indicated in her MDS/Resident assessment. Informed both that R47 was observed yesterday eating lunch in her room without assistance. The food all over her chest, lap and soiling her clothes. Facility's policy on Feeding and assisting residents to eat indicated: Purpose: To assist the resident to obtain nutrient and hydration. To provide a socializing experience for the resident Procedure: 4. Tuck the napkin under the chin or place on clothing protector. Only necessary to prevent soiling of clothing. Facility's policy in Nail care revision date 1/25/28 indicated: 1. Observed condition of resident nails during each time of bathing. Note cleanliness, length uneven edges, hypertrophied nails.

Based on observation, interview, and record review the facility failed to ensure ongoing assessment and monitoring are implemented to identify new skin impairment, worsening of skin disorder and to notify physician for appropriate wound /skin treatment. The facility also failed to update the Skin/wound care plan on a timely manner. This deficiency affects one (R47) of three residents in the sample of 28 reviewed for Quality of Care in Skin/ wound management. Findings include: R47 was admitted on [DATE] with diagnosis listed in part but not limited to Hypertensive heart and chronic kidney disease with heart failure ad with stage 5 chronic kidney disease or end stage renal disease, Monoplegia of upper limb following non-traumatic intracerebral hemorrhage affecting right dominant side. Admission Braden/skin assessment done on 4/6/25 indicated that she is at risk for skin impairment. Physician order sheet indicated: Triamcinolone acetonide external cream 0.1% apply to affected areas topically two times a day for rashes. Moisture barrier after each peri care (CNA may apply, may keep at bedside) every shift for skin. Weekly shower/skin assessment. Acknowledgement of shower and skin assessment completed. If new skin issue: notify physician for order, notify family and complete nursing skin assessment form. Wound care: right anterior arm-cleanse with normal saline, pat dry and cover with dry dressing every MWF and PRN. Comprehensive care plan indicated she has skin impairment related to skin tear, blister and potential skin integrity impairment related to reduced mobility and current diagnosis. Admission skin assessment quick shot dated 4/5/25 indicated: Right anterior arm- rashes; Right hand- fungal; Neck- rashes; Left hand- fungal. R47 is on restorative program for Active ROM (range of motion) to bilateral upper and lower extremities. On 4/15/25 at 12:18PM, R47's room has set up for contact isolation precaution. R47 is alert and pleasantly confused. Observed up in wheelchair with pillow place on her lap creating space between lunch tray placed on bedside tray table in front of her. She is eating by herself, with food all over her chest and lap. She is using spoon and her hands to eat. The pillow is soiled with food. She has her cellphone connected to outlet which is wet/soiled with food. Observed right hand fingers are reddened and swollen compared to left hand fingers. Observed long and dirty bilateral hand nails, with black matter inside the nails. Observed visible rashes on neck, chest, and bilateral hands/forearms. Called V23 LPN (Licensed Practical Nurse), showed and informed observation made. V23 said that sometimes R47 needs assistance/supervision with eating. V23 said that the CNA distributed and set up the tray to R47. V23 said that nail care is a CNA responsibility during ADL (Activity of daily living) care. V23 said that she is not aware of R47's right hand fingers reddened and swollen. V23 assessed bilateral hands. R47 said that she has eczema on her both hands. Observed right dorsal hand fingers irritated, reddened, and swollen. Observed on right hand supination-thickened, dry, hardened yellowish brown discoloration on index, middle and ring finger up to the palm area. Same observation made to the left-hand supination but more prominent on right hand. Skin disorders also observed in between fingers on both hands. V23 said that the wound care nurse is the one applying R47's skin treatment. On 4/15/25 at 12:27PM, Observed open wound on perianal area while V26 CNA was performing incontinence care. V26 said this is her first-time taking care of R47 and was not aware that she has open wound. On 4/15/25 at 12:43PM, Informed V12 DWC- Director Wound Care) of above observation. Reviewed R47's medical record with V12. V12 said R47 was admitted on [DATE] with rashes on neck and right anterior arm, fungal on right and left hand. Surveyor showed to V12 R47's worsening fungal on both hands. Observed right dorsal hand fingers irritated, reddened, and swollen. Observed on right hand supination-thickened, dry, hardened yellowish brown discoloration on index, middle and ring finger up to the palm area. Same observation made to the left-hand supination but more prominent on right hand. Skin disorders also observed in between fingers on both hands. V12 said they do not provide treatment and skin documentation for non-open wound. The floor nurse is the one applying skin treatment of triamcinolone cream to rashes and fungal areas. The floor nurse will also do the weekly documentation in the progress notes response from skin treatment for rashes and fungal. Informed V12 that no weekly documentation was found in the progress notes regarding rashes and fungal identified upon admission on bilateral hands and neck. Informed V12 of open wound observed on perianal area during incontinence care. V12 said he is not aware of this open wound. He was not notified by the floor nurse or CNA. V12 did skin assessment and measurement of R47's open wound on peri anal area. V12 said R47 has MASD (Moisture Associated Skin Disorder) on peri anal area, measures 2.5cm x 4.5cm x 0.1cm with maceration on peri wound. 40% granulation and 60% epithelial. V12 said that he will apply Vit A and D ointment for now until he gets treatment order from the physician. On 4/16/25 at 12:26PM, Informed V1 Administrator and V2 DON of above concerns. Informed both concerns of failure to ensure ongoing assessment and monitoring are implemented to identify new skin impairment, worsening of skin disorder and to notify physician for appropriate wound /skin treatment. On 4/17/25 at 9:30AM, Reviewed with V12 DWC R47 's wound skin assessment report completed by V12 DWC on 4/15/25 indicated: Neck/chest- rashes; Left hand dorsal- rashes; Left hand supination-rashes; Right hand dorsal- rashes; Right hand supination- rashes, scab formation, small bumps. Peri anal- MASD, facility acquired, 2.5cmx4.5cmx 0.1cm, scant blood, superficial, 60% epithelial, 40% red tissues. Informed V12 that he did not document accurately description observed. V12 wrote improvement of skin condition on both hands and neck and chest instead of worsening. Informed V12 that surveyor discussed with him the concerns of worsening of skin disorder for both bilateral hands and neck/chest observed. Informed again V12 of observation made that right dorsal hand fingers irritated, reddened, and swollen. Observed on right hand supination-thickened, dry, hardened yellowish brown discoloration on index, middle and ring finger up to the palm area. Same observation made to the left-hand supination but more prominent on right hand. Skin disorders also observed in between fingers on both hands. V12 said that he has not update R47's wound/skin care plan. He should update it within 24 hours. Facility's facility on Skin condition assessment and monitoring-Pressure and non-pressure revision 6/18/18 indicated: Purpose: To establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure injuries and other non-pressure skin conditions and assuring interventions are implemented. Guidelines: *Pressure and other ulcers will be assessed and measured at least weekly by licensed nurse and documented in resident's clinical record. *Non-pressure skin conditions will be assessed for healing progress and signs of complications or infection weekly. *Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. Changes shall be promptly reported to the charge nurse who will perform the detailed assessment. *Caregivers are responsible for promptly notifying the charge nurse of skin breakdown. *At the earliest sign of a pressure injury or other skin problem, the resident, legal representative and attending physician will be notified. The initial observation of the ulcer or skin breakdown will also be described the nursing progress notes. *The licensed nurse is responsible for notifying the attending physician, Director of Nursing and legal representative for any suspected wound infection. *Physician ordered treatment shall be initiated by the staff on the electronic treatment administration record after each administration. Other nursing measures not involving medications shall be documented in the weekly wound assessment or nurses' notes. Facility's policy on Comprehensive Care Plan revised 11/17/17 indicated: 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 resident's highest practicable physical, mental, and psychosocial well-being. Guidelines: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. * The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that resident is receiving.

Based on observation, interview, and record review the facility failed to ensure appropriate care and service provided to resident on enteral/gastrostomy feeding tube to prevent possible complication. This deficiency affects one (R98) of three residents in the sample of 28 reviewed for Tube Feeding Management. Findings include: R98 was admitted on [DATE] with diagnosis listed in part, but not limited to Pneumonia, Chronic Respiratory failure, Pleural effusion, Anoxic brain damage, Gastrostomy, Tracheostomy. Active physician order sheet indicated: NPO (Nothing by mouth). Enteral feeding order very shift Jevity 1.5 at 55ml/hr. x21 hours or until 1155ml total volume infused. Flush and stop pump when feeding is completed. Head of bed elevated for shortness of breath while lying flat. Oral care every 8 hours and as needed. Comprehensive care plan indicated he has alteration in nutrition status related to Severe protein malnutrition, Anoxic brain damage, Tracheostomy, Gastrostomy and Respiratory failure. Intervention: Elevate head of bed as ordered. On 4/16/25 at 9:29AM, Surveyor and V2 DON (Director of Nursing) went to R98's room. Observed R98 lying flat on bed with GT (gastrostomy tube) connected to enteral feeding pump that is turned off. Observed large oral secretions draining to both side of his mouth to his neck. Observed whitish secretions on both side of the mouth. R98 has tracheostomy tube connected to oxygen. Informed V2 DON of R98's bed position. V2 said that R98'shis bed should be elevated. V2 then took the bed control and elevated the head of the bed. V2 called V32 RN (Registered Nurse). V32 said he forgot to turn on the machine after he administered R98's medication per GT. V32 said he administered R98's medication around 8:30AM. V32 said R98 did not vomit but has a lot of oral secretions. V32 left the room to call V18 Respiratory Therapist. V32 did not assess R98's respiratory status and did not wipe the secretions from R98's mouth. V18 said he made rounds on R98 around 8:00AM. V18 said R98 has a lot of salivary secretions. V18 did oral suctioning. V2 instructed V18 to wipe oral secretions from R98's mouth. On 4/16/25 at 12:36PM, Informed V2 DON of above concern identified that R98 head was not elevated after V35 administered the medication via GT which may cause possible aspiration. R98 has history of Pneumonia. V2 said that it is not necessary to keep the head elevated because the feeding tube is off. Informed V2 that per facility's policy indicates: Elevate head of bed to 30-45 degrees (Semi-fowler's or high fowler's position) and leave in this position at least for 30 minutes after administration of medications. R98's bed was not elevated after V32 administered medication from 8:30AM to 9:29AM. Facility's policy on Gastrostomy Tube-Feeding and care revision 8/3/20 indicated: Purpose: To provide nutrients, fluids, and medications, as per physician orders, to residents requiring feeding through an artificial opening into the stomach. Procedure: 5. Position resident on his/her back with head elevated to minimal 30 degrees and preferable 45 degrees. Facility's policy on Enteral tube Medication Administration effective date 10/25/14 indicated: Policy: The facility assures the safe and effective administration of enteral formulas and medications via enteral tubes. Procedures: Prepare medications for administration. 7. Elevate head of bed to 30-45 degrees (Semi-fowler's or high fowler's position) and leave in this position at least for 30 minutes after administration of medications.

Based on observation, interview, and record review the facility failed to ensure the scheduled medication was compared with the medication label prior to administration affecting 1 of 5 residents (R82) reviewed for medication administration in a total sample of 28. Findings Include: On 4/15/2025 at 11:10 AM, V21 (Registered Nurse/RN) prepared the same medication from a multi dose Insulin vial not belonging to R28. V21 proceeded to administer medication to R82. On 4/15/2025 at 11:11 AM, V21 stated it's okay to give or borrow medication belonging to another resident since R28 needed to go down for Dialysis. On 4/15/2025 at 11:45 AM, V3 (Assistant Director of Nursing) stated when a medication is not available in the med cart, the nurse should use the convenience box to retrieve the needed medication. V3 said they have insulin available in the convenience box. On 4/16/2025 at 8:05 AM, V2 (Director of Nursing) stated nurses should not use medication not belonging to the resident. There should not be borrowing of medication. Instead staff should use the convenience box if medication is not available in the cart. Review of R82's Medical Record read admitted , 3/23/2025, Diagnosis Information include Type 2 Diabetes Mellitus without complications. Order Summary Report read order date 3/23/2025, Insulin Lispro Injection Solution 100 Unit/ML (Insulin Lispro). Inject as per sliding scale. Medication Administration Record indicate on 4/15/2025 R82 received 4 units of Insulin Lispro at 1200. Care Plan Report, 2/10/2025 read Focus: R82 has Diabetes Mellitus. Intervention: Diabetes medication as ordered by doctor. Policy and Procedure Policy Title: Medication Administration, Effective date 10/25/2014 Policy Medications are administered as prescribed in accordance with goo nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the medication management system in the facility. The facility has sufficient staff and medication distribution system to ensure safe administration of medications without unnecessary interruptions. Procedures: A. Preparation 4. Five Rights - Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. 5. Prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR) are compared with the medication label. 11. If a medication with a current, active order cannot be located in the medication cart/drawer . medication removed from the night box/ emergency kit.

Based on observation, interview, and record review the facility failed to adequately monitor resident on antibiotics without adequate indication. This deficiency affects one (R391) of three residents in the sample of 28 reviewed for Unnecessary medication. Findings include: On 4/15/25 at 10:54AM, Observed R391 lying in bed with oxygen via nasal cannula. He is alert and oriented, able to express self and needs to staff. He said that he was admitted 2 weeks ago. He said that he did not have any sign and symptoms of infection. R391 was admitted on [DATE] with diagnosis listed in part, but not limited to Acute and chronic respiratory failure, Chronic obstructive pulmonary disease, Hypertensive heart, and chronic kidney disease with heart failure. Active physician progress notes indicated Azithromycin oral table 500mg give 1 by mouth one time every Monday, Wednesday and Friday for infection dated 4/3/25. No clinical usage indication for specific infection. Comprehensive care plan indicated usage of antibiotic therapy for infection, no indicated of specific infection. No antibiotic/Mc Geer infection monitoring form completed in chart. Hematology test dated 4/4/25 ad 4/9/25 indicated normal WBC (White blood test). Daily body temperature taken since admission indicated no fever, normal body temperature. On 4/16/25 at 9:58AM, V7 Infection Preventionist (IP) said they have antibiotic stewardship program to reduce unnecessary use of antibiotics. They monitor resident on antibiotics using McGeer/Antibiotic monitoring form completed within 48 to 72 hours upon starting on antibiotics. Review R391's medical records with V7 IP. Informed V7 that R391 is on Azithromycin oral antibiotics but no specific indication for specific infection/diagnosis, no specific duration of antibiotics and no infectious disease consults for usage of antibiotics. V7 said he oversees completing McGeer/Antibiotic monitoring form for R391 usage of Azithromycin upon admission. V7 does not know why R391 was on antibiotics. On 4/16/25 at 1:30PM, V7 Infection Preventionist presented completed McGeer/antibiotic monitoring form dated 4/4/25 but no electronic signature and date indicated: #3. Verification of infection status: d. Does not meet criteria for infection. On 4/17/25 at 10:00AM, Informed V2 DON (Director of Nursing) of above concern. On 4/18/25 at 10:47AM, Informed V1 Administrator of above concern. Facility's policy on Antibiotic/Antimicrobial Stewardship Program-Mission Statement and Guidelines effective date 11/28/17 indicated: Mission Statement: This facility is dedicated to implement an Antibiotic/Antimicrobial Stewardship program to reduce the unnecessary use of antibiotics. This program help ensure that our resident get the right antibiotics at the right time for the right duration, and can improve individual patient outcomes, prevent deaths from resistant infections, slow antibiotic resistance, decrease Clostridium Difficile infections and reduce healthcare costs. The facility will strive to incorporate the core elements of antibiotic/antimicrobial stewardship into the daily activities and culture of the facility, creating awareness and work toward long term goals of reducing the unnecessary use of antibiotics. Guidelines: These core elements include the following: 5. Tracking-Monitor at least one process measure of antibiotic use and at least one outcome from antibiotic use 6. Reporting-Provide regular feedback and data on antibiotic use and resistance to prescribing clinicians, nursing staff and other relevant staff to increase awareness. * Medical Director will set standards for antibiotic prescribing practices for all physician providing care in the facility, review antibiotics use data gathered by tracking monitoring and provide feedback and recommendation to ensure that best practices are followed in the medical care or residents in the facility. *The DON will be responsible for providing ongoing education and feedback to staff regarding infection control and appropriate antibiotic prescribing practices through observations, monitoring, and tracking antibiotic use and report findings to the QAA committee. *The Consultant Pharmacist will review the use of antibiotics be performing medication regiment review, reviewing the clinical records and laboratory results, and making recommendations regarding antibiotic use. The Consultant Pharmacist may also provide education and or education materials to nursing staff to assist its increasing awareness and knowledge of appropriate antibiotic use. *The facility will utilize the McGeer's Criteria for determining if the infection meets criteria for treatment with an antibiotic.

Based on observation, interview, and record review the facility failed to ensure outdated/expired medication was removed from resident medication supply affecting 1 of 5 (R20) residents reviewed for medication storage and labeling in a total sample of 28. Findings Include: On 4/15/2025 at 12PM, observed V22 (Licensed Practical Nurse/LPN) medication cart with an opened expired multi dose insulin vial belonging to R20. Insulin vial read Insulin Lispro, open date was not readable and expiration date of 4/11/2025. On 4/15/2025 at 12PM, V22 stated the expired insulin vial should be discarded and re-order from pharmacy. On 4/17/2025 at 1:30PM, V2 (Director of Nursing) stated expired medication should be removed, discarded and re-order from pharmacy. Review of R20's Admission Record read admitted [DATE]. Diagnosis Information include Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy without Gangrene; Order Summary, order date 8/3/2024 read: HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro) Inject subcutaneously before meals for diabetic. Care Plan Report, revision date 8/7/2021 read, Focus: R20 has Diabetes Mellitus. Interventions: Diabetes medication as ordered by doctor. Policy and Procedure: Policy Title: Storage of Medications, Effective date 10/25/2014 Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only by licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: H. Outdated, contaminated, or deteriorated medications .disposed of according to procedures for medication disposal. Expiration Dating A. Expiration dates of dispensed medications shall be determined by pharmacist at the time of dispensing. E. 1 The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. H. All expired medications will be removed from the active supply.

Based on observation, interview and record review, the facility failed to ensure that dining service staff are wearing hair restraints (e.g. hairnet, hat and/or beard restraint) to prevent hair from contacting exposed food. This deficiency has the potential to affect 121 residents who consumes food from the kitchen. Finding includes: On 4/16/2025 at 11:30 AM, during subsequent visit to the kitchen to monitor food temperature, V25 (Dietary Aide) was observed in the kitchen without wearing a hair net. V25 said that he should have cover his hair with a hair net. On 4/16/2025 at 11:32 AM, V8 (Dietary Manager) said that V25 should have a hair net on. On 4/17/2025 at 1:32 PM, V1 (Administrator) said that he expects the dining service staff to wear the hair restraints. Facility Policy: Guideline & Procedure Manual Hair Restraints Guideline: The restraints shall be worn by all Dining Services staff when in food production areas, dishwashing areas, or when serving food. Procedure: 1. Staff shall wear hair restraints in all food production, dishwashing, and serving areas. 2. Hair restraints, hats, and/or beard guards shall be used to prevent hair from contacting exposed food.

Based on observation, interview, and record review the facility failed to use appropriate infection control practices during resident care on contact isolation precaution. The facility also failed to educate visitor on donning appropriate PPE (Personal Protective Equipment) when entering resident on contact isolation. This deficiency affects one (R47) of three residents in the sample of 28 reviewed for infection control. Findings include: On 4/15/25 at 12:18PM, R47's room was set up for contact isolation precaution. R47 is alert and pleasantly confused. Observed up in wheelchair with pillow place on her lap creating space between lunch tray placed on bedside tray table in front of her. She is eating by herself, with food all over her chest and lap. She is using spoon and her hands to eat. The pillow is soiled with food. She has her cellphone connected to outlet which is wet/soiled with food. Observed right hand fingers are reddened and swollen compared to left hand fingers. Observed long and dirty bilateral hand nails, with black matter inside the nails. Observed visible rashes on neck, chest, and bilateral hands/forearms. Called V23 LPN (Licensed Practical Nurse), showed and informed observation made. V23 called V26 CNA (Certified Nurse Assistant). V26 entered the room with proper PPE, then she realized and came out to wear gown and gloves. V23 LPN removed the food particles, on R47's chest, face, and hands. V23 cleaned R47's cellphone placed on her lap, and removed the soiled pillow covered. V23 removed her gown and gloves then performed hand sanitizing outside the door. Surveyor asked V23 why R47 is on contact isolation. V23 said that R47 is on contact isolation for Clostridium Difficile infection. Surveyor asked V23 if she needs to perform hand washing, she said using hand sanitizing is okay. On 4/15/25 at 12:27PM, Observed V26 CNA performed incontinence care with R47. After incontinence care, V26 removed soiled disposable brief and tossed in trash can. No isolation trash bin inside the room. No isolation bag for soiled linens/clothes. V26 rolled the soiled towel (that she used for incontinence care) and placed on bedside stand. She applied clean disposable brief without removing gloves and performing hand hygiene in between. Informed V26 of observation made. V26 said she should remove her gloves after touching soiled brief and linens, performed hand hygiene and wear new gloves before touching clean brief and linen. V26 then removed her gloves and applied a new pair of gloves without hand hygiene. On 4/15/25 at 12:39PM, V27 R47's friend came inside the room without wearing proper PPE (Personal protective equipment). V27 said that she has been visiting R47 twice a week for the past 2 weeks and no one told her that she must wear gown and gloves when entering the R47's room due to isolation. On 4/15/25 at 1:00PM, Called V2 DON (Director of Nursing) and informed of above observation. V2 said staff should perform hand hygiene when coming out resident with C. Diff infection because hand washing with soap and water physically removes the spores from the skin. Hand sanitizers are not effective against C. Diff spores. V2 said R47's visitor should be educated on wearing appropriate PPE and infection control practices for contact isolation when entering R47's room. On 4/15/25 at 2:58PM, Informed V7 Infection Preventionist of above observations and concerns. On 4/16/25 at 12:26PM, Informed both V1 Administrator and V2 DON of above concerns. On 4/17/25 at 9:15AM, V2 DON they for contact isolation set up for C. diff, don't have isolation bag/container for soiled clothes and garbage inside R47 room. They only use the regular trash can for the garbage. They combined R47's soiled clothes and linens to unit soiled hamper. On 4/17/25 at 10:00AM, V7 Infection Preventionist said that resident on contact isolation- for any infections including C. Diff only use the regular trash can inside the room for garbage disposal. The soiled clothes and linens are combined with unit soiled clothes/linens to be sent to laundry. Facility unable to provide policy on contact isolation set up. Facility's policy on Hand hygiene /Handwashing revision 1/10/18 indicated: Definition: Hand hygiene means cleaning your hands by using other hand washing (Washing hands with soap and water), antiseptic hand wash or antiseptic hand rub (i.e. alcohol-based hand sanitizer including foam or gel). Guidelines: When to wash hand with soap and water only (may use alcohol based hand hygiene sanitizer for all other): *After known or suspected exposure to Clostridium Difficile if your facility is experiencing an outbreak or higher endemic rates (alcohol based hand sanitizer should not be used) Examples of when to perform hand hygiene (either alcohol based hand sanitizer or hand washing) *After contact with blood, body fluids or excretions, mucous membranes, non-intact skin or wound dressings. *After gloves removal Facility's policy on Infection Precaution Guidelines revision date 5/15/23 indicated: Guidelines: it is the policy of this facility to, when necessary, prevent the transmission of infections within the facility with isolation precautions. B. Transmission- Based Precautions. Use the CDC Guidelines for Isolation Precautions to determine the infective materials, precaution needed, duration of precautions recommended. 3. Contact Precautions: In addition to standard precaution, use contact precautions for residents known or suspected to be infected with microorganism that can be easily transmitted by direct or indirect contact such as handling environmental surfaces or resident care items. In some instances, residents colonized with these organisms may also require contact precautions, for example, when a draining wound cannot be contained, when a resident exhibits noncompliant behavior with stool or other body fluids or when a resident has very poor personal hygiene, etc. The above includes epidemiologically important organisms (Multidrug-resistant organism) such as Methicillin-resistant Staphylococcus Aureus (MRSA) and Vancomycin-resistant Enterococcus (VRE), other highly transmissible infections such as Clostridium difficile and herpes (simplex or zoster), other transmissible conditions such as impetigo, pediculosis, scabies, and conditions such as rash of unknown origin, conjunctivitis, draining wounds, etc.

Based on observation, interview and record review, the facility failed to follow their incontinence care policy by not checking for incontinence at least every two hours. This affected one of three residents (R1) reviewed for incontinence care. This failure resulted in R1 being soaked in urine for and not checked for incontinence for at least 4 hours. Findings Include: R1's minimal data set section C (cognitive pattern) dated 2/21/25 documents a score of fourteen which indicated cognitively intact. Section GG (functional abilities) document: toilet hygiene dependent helper does all the work. Resident does none of the effort to complete the activity. Section H documents: urinary continence: always incontinent. On 3/1/25 at 11:23am, V4 (CNA) said she started her shift at 7am. V4 said she checked on R1 between 7:00am -8:30am. R1 did not ask to be changed at that time. V4 said R1 asked for some water and a blanket which V4 provided. V4 said this is the first time she was providing incontinence care to R1. R1 had a strong smell of urine. R1 was observed with a saturated adult brief, a redden area on the left inner thigh consistent with R1's sack and penis print, sheet prints on anterior/posterior thighs, wet bed sheet and mattress. V4 and V5 (nurse) both said, R1 had a strong smell of urine. R1's adult brief was saturated with urine. R1's bedsheet and mattress were wet with urine. V5 said the prints on R1's skin are from laying on the bed sheets. V5 said this amount of urine did not occur in two hours. V5 said R1 is a heavy wetter. On 3/1/25 at 11:42am, R1 who was assessed to be alert, orient to person, place and time, said he screamed all night to be changed. R1 said he was changed around 1or 2 am and at 7:15am by the night shift CNA. R1 said, he urinated again and asked to be changed which the night CNA refused and said, I just changed you. R1 was unable to recall the night CNA's name. R1 said he was able to tell what time it was because there is a clock on the wall. R1 had a clock on the wall displaying the correct time that could be seen from R1's head of bed. R1 said, I need to be changed every hour, but staff will tell me I have to wait until every two hours. On 3/1/25 at 2:35pm, R4 (R1's roommate) who was assessed to be alert, orient to person, place and time, said R1 screamed for help all night long. On 3/1/25 at 2:53pm, V6 (DON) said residents should be changed every two hours and as needed to include their request. Incontinence Care Policy dated 11-28-12 documents: 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 interview and record review, the facility failed to ensure the confidentiality of a resident's financial records. This failure applied to one (R1) of three residents reviewed for privacy and confidentiality. Findings include: R1 is a [AGE] year-old male who originally admitted to the facility on [DATE] and continues to reside in the facility. R1 has multiple diagnoses including but not limited to the following: Parkinson's disease, CHF, ESRD, COPD, dementia, delirium, and depression. R1's face sheet shows R1 is his own decision maker, however V7 (Family Member) is R1'S substitute decision maker. On 2/10/2025 at 12:45PM, V3 (Business Office Manager) said, I am responsible to handle the residents financial accounts. I receive and submit payments for them. Resident's financial information is confidential, and I never send e-mails containing any of this information. At 1:05PM, V10 (VP of Accounts Receivable) said we had a situation where V7 (family member) made a payment to the facility, but we did not receive it. V7 sent copies of R1's bank statements to show that the money was withdrawn from the account. At 1:25PM, V1 (Administrator) said we reviewed V3's e-mails and noted that on 1/6/2025 an e-mail was sent to the wrong individual with bank statements belonging to R1. E-mail written by V3 (Business Office Manager) dated 1/6/2025 shows records of R1's bank statements that was sent to an external and inaccurate recipient. R1's Admission Packet and Contract dated and signed by R1 on 1/24/2024 states in part but not limited to the following: No resident shall be deprived of any of the following rights: The right to confidentiality of the resident's financial records. The release of a record shall be by written consent of the resident or the resident's representative.

Based on interview and record review, the facility failed to ensure 2 of 3 (R2, R4) residents reviewed for viral infections in the sample of 3 were administered the correct dose of antiviral medications. This failure resulted in R2 being hospitalized for 21 days and R4 having significant side effects. The findings include: 1. On 10/11/24 at 12:10 PM, V6, Nurse Practitioner (NP), said R2 was diagnosed with shingles and was put on Valtrex (an antiviral), 1 gram (1000 milligrams) three times a day for seven days, which is a standard dose for shingles. V6 said R2 dose should have been adjusted because he is a dialysis patient. R2's dose should have been 500 milligrams (mg) three times a day for seven days. V6 said she does not know why it was not adjusted; it just did not get adjusted. V6 said signs and symptoms of a Valtrex overdose would include confusion and delirium. V6 said R2 was sent to the hospital for low blood glucose but admits that part of it could have been that he had extra Valtrex in his system. V6 said patients with renal (kidney) problems should be given doses of antiviral medications (like Valtrex) based on their creatinine clearance (labs indicating kidney function). On 10/11/24 at 2:25 PM, V2, Director of Nursing, said R2 was admitted to the hospital (on 9/14/24) with altered mental status. V2 said R2 had been receiving Valtrex. V2 said it is his understanding that the NP put in an order for regular dosing versus renal dosing, and R2 was dependent on renal dialysis. V2 said the Valtrex dosing contributed to R2's hospitalization as there are precautions for Valtrex affecting renally impaired patients. V2 said signs and symptoms of Valtrex overdose include hallucinations and decreased mentation. V2 said R2's Valtrex dosage was larger than R2 could tolerate. R2's Admission Record dated 9/24/24 shows R2's diagnoses include, but are not limited to, hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic disease, or end stage renal disease, congestive heart failure, end stage renal disease, and dependence on renal dialysis. R2's Order Summary Report dated 10/11/24 shows and order dated 9/9/24 for Valacyclovir (Valtrex) one gram by mouth every eight hours for cold sores, shingles, or genital herpes for seven days. R2's Medication Administration Record (MAR) for 9/1/24 to 9/30/24 shows R2 began receiving the prescribed Valtrex at 2:00 PM on 9/9/24 and received 12 doses from 9/9/24 to 9/14/24. R2's Progress Notes dated 9/14/24 at 11:57 AM show R2 was lethargic and slow to respond. R2 was sent via ambulance to the hospital. R2's Progress Notes dated 9/14/24 at 9:55 PM show R2 was admitted to the hospital with a diagnosis of altered mental status. R2's History and Physical (H&P) date of service 9/15/24 at 5:28 PM, shows R2 presented to the hospital with altered mental status with minimal responsiveness, herpes simplex infection of the chest wall, and end stage renal disease requiring hemodialysis. R2 had been receiving antivirals orally but he was getting 1 gram instead of the 500 mg for renal dose adjustment. Under the Assessment/Plan of the H&P the physician documented the following: Altered mental status most probably metabolic multifactorial secondary to the high dose of acyclovir and missing his scheduled dialysis on 9/14. R2's hospital Progress Note, date of service 10/3/24 at 5:40 PM, shows . toxic encephalopathy related to acyclovir toxicity present on admission . R2's After Visit Summary dated 10/5/24 show R2 was hospitalized from 9/14/24 to 10/5/24 with a diagnosis of altered mental status. 2. On 10/11/24 at 11:38 AM, R4 said he had shingles and was treated with Valtrex. R4 said he remembers getting dizzy when he was taking the Valtrex and felt much better once it was discontinued. R4's Admission Record dated 10/11/24 shows his diagnoses include, but are not limited to, hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic disease, or end stage renal disease, congestive heart failure, end stage renal disease, and dependence on renal dialysis. R4's Order Summary Report dated 10/11/24 shows R4 was prescribed valacyclovir (Valtrex) one gram by mouth three times a day for seven days on 9/18/24. R4's Progress Notes from 9/24/24 at 11:52 AM show multiple staff report R4 is having bouts of confusion and hallucinations which have increased since he began taking Valtrex. R4's Progress Notes from 9/24/24 at 12:07 PM show R4 was observed with confusion. R4's MAR for 9/1/24 to 9/30/24 shows R4 received Valtrex one gram beginning on 9/18/24 at 2:00 PM and continued to receive an additional five doses before the medication dosage was reduced to 500 mg once a day. On 10/11/24 at 2:25 PM, V2, Director of Nursing, said the Valtrex dosing was improper. V2 said R4 was not originally given a renal dose of his Valtrex. V2 said R4 developed hallucinations after receiving Valtrex, so it was discontinued. V2 said it is the providers responsibility to order the proper dosage of medications. The facility's Administration Procedures for all Medications Policy (effective 10/25/2014) shows it is their policy to administer medications in a safe and effective manner.

Based on observation, interview and record review, the facility failed to follow their fall prevention program by failing to ensure the safe transfer/handling of a resident during care, failed to follow their plan of care to prevent further falls, and failed to keep the resident's immediate surroundings free of accidental hazards. This failure affects 1 (R1) of 4 residents reviewed for falls and resulted in R1 being emergently transferred to the hospital and admitted with acute pain and right knee fracture. Findings include: R1 is a [AGE] year old with diagnoses including but not limited to fracture of medial condyle of right tibia, fracture of seventh cervical vertebra, hypertensive heart disease, congestive heart failure, chronic obstructive pulmonary disease, spinal stenosis and repeat falls. Facility records showed post-fall assessments indicating R1's numerous falls on 7/9/23, 8/14/23, 10/21/23, 12/21/23, 3/4/24, 6/28/24, and with the most recent 7/6/24 which led to the emergency room transfer on 7/8/24 where R1 was diagnosed and treated for a knee fracture. On 8/3/24 at approximately 10:10 AM, surveyor entered R1's room which appeared dark and with no lighting turned on. R1 was lying awake in the first bed and a call light cord appeared above R1's bed away from her reach. There was one fall mat on the right side of the bed, however on the left side of the bed was a folded up fall mat was away from the bed itself. A bedside table was placed atop the right fall mat and had no personal items, water, or phone and did not appear to have any purpose. R1 was awake and able to answer surveyor's line of questioning. R1 knew her name, where she was living, and indicated it was 2024 and added, Why do people keep asking me? Surveyor asked what had happened to her right leg as she was wearing a leg brace. R1 said she had fallen after an altercation with some staff member. Surveyor asked what kind of altercation and if she knew who the staff person was, R1 said it was just a disagreement and the staff person was just careless and did not pay attention when she was transferring onto the wheelchair. Surveyor asked if this staff person said anything inappropriate to her, R1 stated, No, but I know she's Mexican with blonde hair. Surveyor asked R1 how she was feeling today and if the nurse had seen her this morning. R1 said she was feeling lousy and said she saw the nurse earlier when she got her medications. R1 also said she was not sure if her pain on her knee started after a chair transfer or if it happened while she was showering. R1 indicated when she was hospitalized , she forgot the timeline of events and everything became a blur when she was in the hospital. Surveyor asked about the shower and who assisted her to shower, R1 indicated it was a male staff person. Both occurrences were later affirmed by V3 (assistant director of nursing). R1's care plan dated 6/5/23 reads in part, (R1) at risk for falls. Gait/balance problems, pain secondary to cervical spinal stenosis with myelopathy and lumbar spinal stenosis status post cervical compression and fusion followed by lumbar compression and fusion, chronic left hemiplegia. Goal: R1 will not sustain serious injury through the review date. Interventions: Provide visual prompts call don't' fall in resident room. Apply bilateral floor mats when resident is in bed. Bed in lowest position. Falling leaf sign in place. Keep items, water, etc. in reach. Remind resident to call for assistance when ambulating. On 8/2/24 at 11:15 AM, V2 stated, She (R1) is confused and has psych affective disorder and a history of fabricating stories, history of verbal aggression towards staff. She fabricates like answering call lights. She is interviewable and she is here for fracture before, and she had neck fracture from upon admission She said she was going to go to the bathroom but then she was attempting to try to get out of bed and kicked the stand for the bedside table and bumped with her knee. She did not use the call light and she went back to bed. Surveyor asked if the resident is confused how V2 expected for the resident to use a call light to get assistance. V2 had no response. Surveyor asked if it was possible a bump into a side table could sustain an injury such as a knee fracture. V2 indicated that was what was reported to him. On 8/2/24 at approximately 12:30 PM, V3 (ADON) called V5 (night nurse) to speak to the surveyor. V3 remained in the room to witness the conversation. V5 stated, R1 was sleeping throughout the night without complaint and then early in the morning she was asking for ice pack while I was passing my morning medications. I assessed her knee and there was no swelling in sight, and she asked for stronger pain medications. I gave her the ice pack and put it on her knee. I asked do you need pain medication. That was all she told me and there was no swelling or any injury I saw. I did not even know she fell , and she did not get up at all during my shift because normally everyone is sleeping so she did not fall during my shift. I assessed her knee because I am feeling something on her knee, but I did not write any of this down, but I should have. That is a mistake on my part. V5 stated, She (R1) said my knee is pain and sometimes she has an attitude, but she did not say to look at her knee. When she asked for the ice pack, she said she was feeling pain on her knee, so I asked her what's really going on with her knee. She just said to give me ice pack for swelling. She did not allow me to look at her knee. She just said she has pain. Surveyor asked if V5 did any assessment or palpating (examine by touch) of her knee. V5 said, Yes I palpated her knee but like I said I didn't write this down. Surveyor reminded V5 earlier she indicated the resident didn't allow her to touch her knee but now she's claiming she palpated her knee. V5 said, I did assess her (R1) knee and all she tell (sic) me about the knee. She told me all I need is an ice pack, that is the reason. Surveyor asked if she knew how R1 got injured. V5 stated, I don't know what happened with the knee. She did not explain to me what happened, but I should have asked her, so I did not get part of the story. I didn't know what happened to her that night. I don't know anything. I was the only nurse night and there is no manager on duty, and I did not endorse this incident to the next shift. After this interview, surveyor asked V3 (ADON) whether V5 night shift nurse assessed R1's knee or just gave her the ice pack without looking at the knee, V3 said, I don't think she looked at the knee at all. Surveyor asked when the facility discovered R1's knee injury, V3 stated, It was the following shift on Monday 7/8/24 after V5 gave the ice pack to the resident. The nurse V8 (RN) assessed R1's knee because she complained of pain and didn't want to get up for therapy so that was when V8 assessed the resident and called the doctor for a stat x-ray. We tried to trace back how she may have gotten the injury. She was showered the day before on 7/7/24 by V7 (CNA) but there was no report of any fall. Then the DON (V2) investigated it and determined she may have hit her knee on the bedside table. Surveyor asked if the facility determined whether the resident sustained the fracture during transfer, during showering, or hitting of the bedside table. V3 indicated, their investigation was inconclusive. Review of R1's MDS (minimum data set) dated 4/29/24 prior to the incident showed R1 requiring substantial assistance with showering, and tub/shower transfers however was only provided this task by only one staff member V7. V7 (CNA) could not be reached for interviews after several attempts to call from surveyor and from administration. On 8/2/24 at approximately 1:00 PM, surveyor returned to R1's room. Outside the room were 3 names of residents residing in the room, one of which was R1 who was in bed 1. There were no indications or symbols denoting R1 was on any falling leaf program to designate the resident as being at risk for falls. As surveyor entered, the room remained darkened and with the resident in the same position and with one floor mat on the right and a folded up fall mat to the left and away from the bed. The call light remained above R1's head and away from her reach and there were no signs for the resident to prompt resident to call don't fall as indicated in the resident's plan of care. V3 (assistant director of nursing) was shown what surveyor had observed. V3 indicated the folded up mat should have been unfolded and extended across the floor to protect the resident from falling. V3 indicated she did not know where the signs to prompt R1 to call before she fell and acknowledged the call light was not within reach of the resident. V3 proceeded to move the bedside table atop the right floor mat which could have been an accidental hazard and had no purpose beside the resident as it had no other items on it the resident could have used. Surveyor asked V3 if she could ask R1 about her knee and to see if we could examine the injury. With R1's permission, V3 removed the right leg brace and showed the surveyor the fractured knee. V3 said there was some swelling remaining and slight bruising in the center of the knee area. Surveyor and V3 asked the resident if she was in any pain. R1 stated, I'm in pain when I'm moved. R1 went on to describe how she fell and said it may have occurred when V9 (CNA) transferred her to her wheelchair or when she was showered by V7 (CNA) but could not recall anymore. Surveyor asked when she started feeling the pain on her knee. R1 stated it was when she asked the night shift nurse for ice to put on her knee when she noticed there may have been a problem with her knee. Surveyor asked if V5 (night nurse) gave her the ice and if the nurse looked at her knee to assess her pain. R1 stated, No, she never looked at my knee. She just gave me the ice and left. Surveyor asked if V5 inquired why R1 needed the ice pack. R1 stated, No. She seemed very busy, and I saw her only once at the end of her shift. V6 (CNA) statement taken by V2 (DON) pertaining to R1's fall incident of 7/7/24 reads in part, Around 4:30 AM when I was changing R1 diaper she asked for an ice pack for her knees. She said she bumped her leg on the side table when she was going to get up to go to the bathroom. I gave her the ice pack from nurse (V5) and nurse looked at her right knee, but it wasn't swollen or anything. She (R1) said she just went on her briefs because she no longer wanted to get up after that just happened. She went back to sleep, and she did not wake up again for the rest of my shift. V6 (CNA) could not be reached for interviews after several attempts to call from surveyor and from administration. On 8/2/24 at approximately 2:15 PM, V8 stated to surveyor, The resident (R1) told me she doesn't want to get up because she was supposed to be getting physical therapy and so didn't want to get up and said her legs hurt. I checked and noticed her right knee was swelling. I gave her Tramadol (for pain) and she requested an ice pack. This was probably Monday around 9:30 in the morning and I called the NP right away to get an order for X-ray and the results were positive for a fracture, so we sent her out to the emergency room , and she was admitted for a knee fracture but no surgery just immobilizer. Hospital records authored by V10 (hospitalist doctor) reads in part, R1 is a [AGE] year old who presented to the emergency room with chief complaint of fall. Patient is alert and oriented to person, place, and year. Patient says she had a quarrel with a staff member, and they moved the wheelchair causing patient to fall at nursing home. Patient is not sure which day the fall happened. Per ER note, patient fell in the shower. She complaint of neck pain which says is worse, also complaints of low back pain and abdominal pain. CT knee without contrast result date 7/8/24 clinical indication: Right knee fracture. There is a moderate lipohemarthrosis decompressing into a 2 cm Baker's cyst. There is mildly scattered superficial subcutaneous edema. Impression: 1. Acute intra-articular medial tibial plateau fracture. Fall prevention policy and procedures dated 11/21/2017 reads in part, 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 are utilized as necessary. Fall/safety interventions may include: The resident's personal possessions will be maintained within reach when possible. These items include tissues, water, drinking glass and phone. Assistive devices such as walkers and canes will be placed within reach of those residents who have physician's orders to ambulate independently. The resident's environment will be kept clear of clutter which would affect ambulation and remove hazards. Lighting will be appropriate for the time of day and in accordance with the resident's desire and the plan of care. Call lights are answered promptly. Residents who require staff assistance will not be left alone after being assisted to bathe, shower, or toilet. Transfer conveyances shall be used to transfer residents in accordance with the plan of care.

Based on interviews and record review, the facility failed to contact and notify a resident's primary care physician regarding the onset of a residents change of condition and failed to send a resident out via 911 when all interventions failed to correct an elevated heart rate. This failure resulted in a delay of [R1] being sent to the hospital for a higher level of care more than 15 hours after the onset of the high heart rate and subsequent death. This was identified as an immediate jeopardy. V17 (Director of Nursing) was notified in the administrator's absence of the immediate jeopardy on [DATE] and presented with an immediate jeopardy template. The facility presented an acceptable removal plan to department on [DATE] after items were revised. The Immediate Jeopardy began on [DATE] and was removed [DATE]. The non-compliance remains at a level- 2 since the failure has the potential to affect all residents at this level and the facility needs time to evaluate the effectiveness of the interventions. Findings include: [R1] is a [AGE] year old male admitted to the facility on [DATE] with diagnosis including but not limited to Acute and Chronic Respiratory Failure with Hypoxia; Tracheostomy; Spastic Quadriplegic Cerebral Palsy; Seizures; Encounter for Attention to Gastrostomy; Myoneural Disorder; and Unspecified Intellectual Disabilities. [R1]'s life saving measures status as of [DATE] listed as: Full Code. [R1]'s care plan dated [DATE] reads in part, [R1] has a Tracheostomy s/p acute and chronic respiratory failure with hypoxia. Interventions: Monitor for signs/symptoms of respiratory distress (restlessness, agitation, confusion, increased heart rate (Tachycardia), air hunger, and/or bradycardia; Monitor level of consciousness, mental status, and lethargy PRN; Monitor respiratory rate, depth, and quality (work of breathing), Check and document every shift/as ordered. Resident has potential for alteration in respiratory functioning related to acute and chronic respiratory failure with hypoxia s/p tracheostomy. Interventions: Assess respiratory status, observe for shortness of breath, monitor lung sounds. Call physician for any changes in condition and as needed; Call physician for any changes in condition. [R1]'s progress note written by V12 (RN) dated [DATE] 6:45 AM reads in part, Nurse Name: (V12). Patient Name: ([R1]). Primary Chief Complaint: Medication request per patient. Vitals (not required): T: 98.3 ( F). HR: 151 (bpm). BP Sys: 144 (mm/Hg) /Dia: 81 (mm/Hg). RR: 22 (rpm). SpO2: 96 (%). Summary: 32 yo M with hx of afib with HR up 100s. requesting metoprolol po now. ok to give metoprolol 50mg now. Orders: metoprolol 50mg po x1. Disposition: Stay at Facility. Statement of Medical Necessity: Yes. Consent for telemedicine/virtual visit obtained from patient/POA: Yes. [R1]'s progress note written by V18 (RN) dated [DATE] 11:23 AM reads in part, Received [R1] eyes wide open, HR of 148, not in any visible distress, BP:,d+[DATE], O2 @97%, RR 22. One time order for metoprolol 50mg per (V13) given. Post metoprolol HR at 120. Will continue to monitor. [R1]'s progress note written by V8 (RN) dated [DATE] 1:38 PM reads in part, Per (V7) with order from (V15) for chest x-ray. Order placed. [R1]'s progress note written by V17 (RT Director) dated [DATE] 3:23 PM reads in part, (At) 1515 ([R1]) abnormal VS in respiratory distress, HR 160 RR >35bpm (44) sat ,d+[DATE]% on TC 40%. Pt w/ small yellow thick secretions. AW patent, fio2 increased to 50%. WBC was 22.71 today, (V16 PCP) notified. (V15 Pulmonary Nurse Practitioner) notified, x-ray ordered. Pending results. ([R1]) will be placed on vent full support to prevent respiratory failure w/ settings AC 16 300 +5 40% per (V15). Will notify POA. [R1]'s progress note written by V15 (Pulmonary Nurse Practitioner) dated [DATE] 3:30 PM reads in part, Notified by (respiratory therapy) that ([R1]) for consult to be seen by our service on ,d+[DATE] 08:48am. Notified that ([R1]) on continuous (tracheostomy collar) at 40% and had a 7 TTS trach in place. Then was notified by (respiratory therapy) at (3:20 PM) that ([R1]) had developed increased work of breathing, tachypnea with counted RR 52, HR 150s and sats in low 90s. ([R1]) was given (heart rate lowering medication), cardiology consulted, and ([R1]) had WBC 22 (22,000). ([R1]) placed on mechanical ventilation. [R1]'s vital sign [DATE] timeline: 00:46 AM - HR 105 beats per minute, RR 20 breaths per minute - no interventions 3:20 AM - HR 151 beats per minute, BP ,d+[DATE], RR 20 breaths per minute - tele health medicine notified by V12 (RN), one time dose of heart rate lowering medication ordered and administered. 9:11 AM - HR 148 beats per minute, BP ,d+[DATE] - V8 (RN) confirms with V13 (Admitting NP) that scheduled dose of heart rate lowering medication can be given at 9:00 AM in addition to previous dose. 10:36 AM - RR 20 breaths per minute - no interventions 11:07 AM - HR 120 beats per minute - no interventions 11:23 AM - HR 148 beats per minute, RR 22 breaths per minute -- no interventions 1:34 PM - V15 (Pulmonary NP) notified, STAT chest x-ray ordered (completed but not resulted until [DATE] 9:50 AM) and antibiotic ordered (never given). 3:15 PM - HR 160 beats per minute, RR 44 breaths per minute - [R1] placed on the ventilator. 3:23 PM - WBC was 22.71- V16 (PCP) notified, no new orders. 3:29 PM - BP ,d+[DATE] - no interventions 3:34 PM - V14 (Cardiac NP) notified, orders given at 3:44 PM 3:40 PM - HR 153 beats per minute 3:44 PM - STAT EKG ordered (never completed), heart rate lowering medication ordered (given) 3:51 PM - RR 31 breaths per minute - no interventions 4:45 PM - HR 130 beats per minute - no interventions 4:50 PM - RR 23 breaths per minute - no interventions 4:57 PM - HR 130 beats per minute, BP ,d+[DATE], RR 28 breaths per minute - no interventions 5:44 PM - HR 147 beats per minute - no interventions 5:59 PM - HR ,d+[DATE] beats per minute - V16 (PCP) notified; orders received to send [R1] to the hospital. 7:20 PM - HR 153 beats per minute, RR 33 breaths per minute, increased WOB - paramedics arrived. [R1]'s vital sign timeline shows delay in excess of 15 hours of recognizing and notifying primary care physician of resident's change in condition and need for higher level of care. No hospital transfer order found in [R1]'s electronic medical chart. The following orders were found in [R1]'s medical record. -[R1]'s Tracheostomy physician order dated [DATE], reads in part, High Humidity Tracheostomy Collar: FIO2 40% every day and night shift. -[R1]'s Ventilator physician order dated [DATE] at 3:30 PM reads in part, Mode: AC rate:16, Fio2: 40%, Peep: +5, Tidal Volume: 300. -[R1]'s medication physician order dated [DATE], reads in part, Metoprolol Tartrate Oral Tablet 50 MG, give 50 mg via G-Tube, give 1 tablet via G-Tube every 12 hours for HTN, Hold of SBP <110 or DBP <60. -[R1]'s medication physician order dated [DATE] at 9:31 AM, reads in part, Metoprolol Tartrate Oral Tablet 50 MG, Give 50 mg via G-Tube one time only for HTN for 1 Day. [R1]'s medication physician order dated [DATE] at 3:41 PM, reads in part, Cefepime HCl Solution Reconstituted 2 GM, use 2 grams intravenously every 12 hours for leukocytosis, suspected [NAME] for 7 days. -[R1]'s medication physician order dated [DATE] at 3:51 PM, reads in part, Diltiazem HCl Oral Tablet 30 MG (Diltiazem HCl), give 1 tablet by mouth every 6 hours for tachycardia, hold of SBP <100 and HR <70. Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083%, 3 ml inhale orally via nebulizer every 4 hours as need for shortness of breath and wheezing. -[R1]'s Respiratory Medication Administration Record dated [DATE] reads in part, Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 3ml inhale orally via nebulizer every 4 hours as needed for Shortness of Breath/Wheezing; not documented, blank space. [R1]'s Medication Administration Record dated [DATE] reads in part, Cefepime HCL Solution Reconstituted 2 GM; Use 2 gram intravenously every 12 hours for leukocytosis, suspected [NAME] for 7 days; documented as 6 = resident hospitalized , medication not given. Metoprolol Tartrate Oral Tablet 50 MG; Give 1 tablet via G-Tube every 12 hours for HTN Hold of SBP <110 or DBP <60; documented as given at 9:00 AM. Diltiazem HCL oral tablet 30 MG; Give 1 tablet by mouth every 6 hours for tachycardia Hold for SBP<100 and HR<70; documented as 6 = resident hospitalized ; medication not given. Metoprolol Tartrate Oral Tablet 50 MG; Give 50 mg via G-Tube one time only for HTN; documented as given at 9:46 AM. [R1]'s lab order dated [DATE] at 10:32 PM reads in part, Priority: Routine. CBC with Diff, Comprehensive Metabolic Panel, Lipid Panel w/reflex to direct LDL, Thyroid Stimuli Hormone, Hemoglobin A1C. Ordering physician: (V24 Admitting Physician). [R1]'s routine blood work ordered on [DATE] at 10:32 PM, collected [DATE] at 5:35 AM, results posted on [DATE] at 10:23 PM. WBC (White Blood Cells) 22.71 H (reference range 3XXX,d+[DATE].8). [R1]'s x-ray order dated [DATE] at 1:34 PM reads in part, Priority: STAT. Chest, 2 views. Ordering physician: (V15 Pulmonary Nurse Practitioner). [R1]'s STAT chest x-ray radiology report dated [DATE] reads in part, There is some patchy density at the right base suspicious for infiltrate. The left lung is overall clear. [R1]'s EKG order dated [DATE] at 3:44 PM reads in part, Priority: STAT. EKG. Routine, w/at least 12 leads, w/interpretation, and report. Ordering physician: (V16 Primary Care Physician). [R1]'s STAT EKG radiology report dated [DATE] reads in part, Canceled Study. [R1]'s vital sign timeline shows delay in excess of 15 hours of recognizing and notifying primary care physician of resident's change in condition and need for higher level of care. The local fire department ambulance's patient field care report contained the following information for services given to [R1] on [DATE]. [R1]'s ambulance run sheet dated [DATE] 7:26 PM reads, (Paramedic) dispatched to the above address for an unresponsive person. UOA (upon arrival), (Paramedic) found the ([R1]) lying supine in bed, staring to the right (V19) at his side, on a vent. ([R1]) is alert to his norm per RN (V10), but (V19) said that ([R1]) usually blinks and she hasn't seen him blink during the time she was there with him. The RN (V10) said that ([R1]) was tachycardic and gave him (heart rate lowering medication). (Paramedic) asked how much and when, the RN (V10) scratched his head and then walked away. ([R1]) is [AGE] year but has a body size of a [AGE] year old. ([R1]) is on O2 via trach, has a (urinary catheter) and G-tube. The RN (V10) handed (paramedic) a piece of paper with '(heart rate lowering medication)' written on it. (Paramedic) asked the RN (V10) what time he gave the medication. The RN (V10) said that he couldn't give more due to his B/P (blood pressure). Afterwards, (paramedic) asked what was the ([R1]'s) initial HR (heart rate) and B/P (blood pressure). The RN (V10) had a PCT (patient care technician) empty (urinary catheter) bag and then left the room. ([R1]'s) arms and legs were cool to the touch, but the ([R1]'s) core and head were warm to the touch. ([R1]) was moved to the cot via sheet. (Paramedic) bagged the ([R1]) via trach with a BVM (bag-valve-mask). No resistance felt when bagging. ([R1]'s) pulse and ETCO2 (end tidal [NAME] dioxide) were dropping. (Paramedic) noticed the ([R1]'s) HR (heart rate) dropped from 60's to 38 (beats per minute). (Paramedic) checked a manual HR (heart rate) and unable to feel a carotid or radial (pulse). At that time, (paramedic) noticed the rhythm was asystole. CPR (cardio-pulmonary resuscitation) initiated. (Paramedic) called (destination emergency department) back with update of a cardiac arrest. [R1]'s Death Certificate dated [DATE] reads in part, Cause of Death: A. Bilateral Pulmonary Embolism Non-Traumatic; B. Bilateral Hemorrhagic Pulmonary Consolidation; C. Thrombosis Left Iliac Vein. On [DATE] at 12:39 PM V7 (Respiratory Therapy Director) stated: [R1] was admitted to the facility on [DATE]. [R1]'s initial oxygenation orders were for tracheostomy collar 40% fio2 (5 liters per minute, fraction of inspired oxygen). [R1] was stable on those settings on [DATE] and [DATE]. Around 9:00 AM on [DATE] I was notified by V9 (Respiratory Therapist) that [R1] developed tachycardia (elevated heart rate) but had clear airway and appropriate oxygen saturation level. [R1]'s respiratory rate was into mid 20 breaths per minute, but it was not critical. I assessed [R1] at that time, and, following my assessment, I notified nurse on duty (V8 - Registered Nurse) and V15 (Pulmonary Nurse Practitioner). We are required to notify nurse on duty and pulmonary physician if we notice any resident change in condition. I was concerned with [R1]'s tachycardia. There were no new orders from respiratory side at that time, just to closely monitor. Around 3.15 PM, [R1] was in distress. [R1]'s heart rate was in 150's bpm (beats per minute), respiratory rate was over 35 breaths per minute, rapid and shallow, and oxygen saturation was ,d+[DATE]% on tracheostomy collar. I immediately notified V15 (Pulmonary NP) and I received orders to place [R1] on ventilator to prevent respiratory failure. Right when, I placed [R1] on the ventilator. I notified V19 ([R1]'s family member) via phone, explained reasons behind putting [R1] on ventilator, and I also assured her that I will make sure [R1] has a private room. Based on V19's input, [R1] was sensitive to surrounding stimuli, including roommate's noise and such, so ` him in the private room. If our interventions would not work, we would call 911 at that time; however, respiratory therapy interventions were effective, [R1]'s oxygenation improved, respiratory rate decreased, and heart rate remained elevated, but it would not be an indication to be concerned from respiratory side; therefore, I didn't feel that it was appropriate to call 911 at that time. We also received stat orders for chest x-ray. Before I left, I gave [R1] PRN (as needed) breathing treatment, and [R1] appeared stable. On [DATE] at 1:22 PM V8 (Registered Nurse) stated: I worked [DATE] from 7:00 AM to 3:00 PM. I was assigned to care for [R1] that day. When I arrived at work, around 6.30 AM, I received a report from overnight nurse (V12 - Registered Nurse), that [R1]'s heart rate was in 150's bpm (beats per minute) and he was given medication to lower his heart rate around 4:50 AM. During my morning assessment, [R1]'s heart rate was about 148 bpm, but he didn't appear in any distress, [R1]'s respiratory rate was ,d+[DATE] breaths per minute and his blood pressure was also within normal range. Normal heart rate range is ,d+[DATE] bpm and respiratory rate ,d+[DATE] breaths per minute but [R1] didn't seem to be in distress. V13 (Admitting Nurse Practitioner) was on-site, so I told her about events from last night and this morning regarding [R1], and V13 (Admitting NP) said to give him another dose of medication to lower his heart rate, which was scheduled at 9:00 AM regardless. I went back around 10:00 AM to check on [R1], his heart rate was at 120 bpm at the time, V13 (Admitting NP) recommended further monitoring but didn't place additional orders. [R1]'s heart rate remained in the 120 (bpm) range. I checked [R1]'s vital signs twice more before the end of my shift (at 3:00 PM) and there was nothing concerning. If a resident has a change of condition, we are supposed to notify primary doctor or nurse practitioner and assess the resident. I don't believe there was nothing else I could have or should have done, because only [R1]'s heart rate remained in 120s (bpm), even though his heart rate was outside of normal range, I don't think there was anything else that should have been done. Heart rate could be elevated due to anxiety, infection, heat, respiratory issue, it could be several things. On [DATE] at 2:21 PM V9 (Respiratory Therapist) stated: I worked on [DATE] from 7:00 AM to 7:00 PM. I don't remember getting concerning report about [R1] from off going respiratory therapist. During my initial rounds, around 7.45a-8.15a, I noticed [R1] was tachycardic, his heart rate was over 150 (bpm). I informed V8 (RN - nurse on duty). From respiratory standpoint, [R1]'s oxygen saturation and respiratory rate were within normal range. V8 said that she would notify [R1]'s primary care doctor. After that, between 10a-12p, I did routine check on [R1]. [R1] was stable respiratory-wise, oxygen saturation and respiratory rate were within normal range, his heart rate was improved but remained over 120 bpm which is not withing normal range. I followed up with V8 and she confirmed that she was aware. I did next routine check between 2:00 PM - 2:30 PM. I have noticed that [R1]'s respiratory rate was over 30 breaths per minute, in addition, I noticed increased labor of breathing and use of accessory muscle. [R1]'s oxygen saturation was in high 80s (%) which is below normal range. [R1]'s was breathing was harder and faster than it should be, his respiratory status was jeopardized and required intervention. Before notifying anyone, I initiated interventions such as [R1]'s breath sounds and airway patency assessment, I suctioned [R1]'s tracheostomy, and I placed continuous pulse oximeter for monitoring. I did not notice any improvement in [R1]'s condition. At that point, I notified V7 (RT Director) to get a second opinion. I told him what intervention I had done. V7 notified V15 (Pulmonary NP) and we were given orders to place [R1] on a ventilator. After connecting [R1] to a ventilator, his oxygen saturation and respiratory rate improved to a normal range after; however, [R1]'s heart rate remained elevated between ,d+[DATE] bpm. We continuously monitored [R1] pulse oximetry and ventilator alarms. [R1]'s ventilator alarm was signaling high PEEP (positive end-expiratory pressure), which means that there might be some sort of obstruction in his airway. Peep alarm can be triggered by anxiety as well. Generally speaking, [R1] was fighting the ventilator. I notified V10 (LPN - afternoon nurse on duty). V10 (LPN) checked on [R1] and said he will give him some medication. I continued monitoring until around 4:00 PM - 5:00 PM, but I exhausted all respiratory interventions, yet [R1] remained triggering high PEEP alarm. At that point, V10 (LPN) contacted V16 ([R1]'s primary care physician) and received orders to send [R1] to the hospital, but it wasn't via 911. V10 (LPN) requested transport ambulance. V19 ([R1]'s family member) came in around 6.30 PM, after being notified of [R1]'s change of condition and placing him on the ventilator. V19 requested V10 to call 911. Paramedics arrived around 7.20 PM. Before that, around 7:00 PM, I completed a hand of report to the night shift respiratory therapist, I pointed out the need for [R1]'s continuous monitoring, elevated heart rate, and alarming vent, and I went home. On [DATE] at 3:15 PM V10 (Licensed Practical Nurse) stated: I started my shift around 3:00 PM on [DATE]. I noticed respiratory therapist placing [R1] on the ventilator. V8 (RN) said that [R1]'s heart rate was high during her shift, but they were able to control it. I assessed [R1] upon the beginning of my shift, and I noticed that his heart rate was elevated to about 145 -150 bpm. I notified the V17 (Director of Nursing). V17 (DON) V14 (Cardiac Nurse Practitioner), V14 (Cardiac NP) gave an order for medication to lower [R1]'s heart rate. I gave it to [R1], his heart rate didn't really improve, but his blood pressure decreased, I don't remember the exact numbers and I didn't document it, so I called V16 (Primary Care Physician). V16 (PCP) questioned me why wasn't [R1] sent out to the hospital throughout the day, and then, after further medical record review, V16 proceeded to give me an order to send [R1] to the hospital via transport ambulance. I questioned V16's decision and suggested that we should call 911; however, V16 said that if V14 (Cardiac NP) and V15 (Pulmonary NP) assessed [R1] earlier and didn't feel there was a critical need to send [R1] via 911, I should schedule transport ambulance to send him to the hospital. I scheduled transport ambulance for 9:00 PM. When V19 ([R1]'s family member) arrived in the facility, she looked at [R1] and insisted on calling 911. I then called 911. Paramedics arrived around 7:20 PM, they assessed [R1]'s vital signs, placed him on their stretcher, and transported him out of the facility. On [DATE] at 9:45 AM V13 (Admitting Nurse Practitioner) stated: I did not physically see [R1] on [DATE]; however, I admitted him on [DATE], and I was most familiar with [R1] when nurses called to notify about [R1]'s elevated heart rate. I'm in the facility on daily basis and it is easiest to reach me out of most medical staff. I confirmed that it is ok to give [R1] scheduled dose of medication to lower [R1]'s heart rate at 9:00 AM after receiving previous dose of the same medication earlier that morning. I was also waiting for routine blood test to come back that I ordered upon [R1]'s admission (on [DATE]). I also asked if [R1] is being followed by a cardiologist. Considering [R1] was treated for pneumonia prior to coming to the facility and being new to tracheotomy, I wasn't overly concerned with his tachycardia. I would become more concerned if [R1] developed additional symptoms, the rule of thumb is that, at least three elements of vital signs are abnormal, it might be an infection or sepsis, and it is appropriate then to send a resident out to the hospital. Knowing that his white blood cells level was elevated (to 22,000) in additional to tachycardia, I would definitely send him out to the hospital; however, I was gone (around 11:30 AM) by the time those blood work results came back. On [DATE] at 10:12 AM V14 (Cardiac Nurse Practitioner) stated: I was consulted to see [R1]; however, I did not see him that day ([DATE]). In the afternoon of [DATE], I was told that [R1] had a fast heart rate and was going to be placed back on the ventilator. Nurses asked me if I could see [R1] next time I'll be in the facility (Tuesday [DATE]). Fast heart rate can be associated with respiratory distress or failure, but I did not know his medical history. I always investigate resident's chart before I give orders; therefore, based on [R1]'s chart review, EKG (electrocardiogram) and heart rate lowering medication were two most appropriate orders. I was not aware that [R1]'s white blood cells level was elevated at that time. I don't know if my orders were carried out by the nurses. I did not receive any results of EKG. I don't know what happened after that. Typically, I don't send residents to the hospital, but if I feel the need, I will let the nurse know. For [R1], I didn't feel the need to send him out to the hospital. When I was told he was going back on the ventilator, it seemed like an appropriate intervention. I treat residents' fast heart rate fairly appropriate who reside in long term care facilities, I get often consulted for that. I did not know [R1] expired later that day, this is the first time I hear about it. On [DATE] at 10:59 AM V15 (Pulmonary Nurse Practitioner) stated: On [DATE] at 8:48 AM, I was notified that there was a new resident that I was consulted for. Even though, [R1] was admitted on the evening of [DATE]. I've never seen [R1] face to face, it is pretty typical though. V7 (RT Director) told me that [R1] was admitted with tracheostomy collar, verified orders for the tracheostomy with me, and that was it. Nothing unusual at that point. Later that day, at 3:20 PM, I was notified that [R1] had increased respiratory rate, to over 40 breaths per minute. V7 (RT Director) actually said that [R1]'s respiratory rate was 52 breaths per minute at that time, heart rate was in 150's bpm (beats per minute), his oxygen saturation level in the low 90%, and he was breathing shallow, all of which would tell me, [R1] was in acute respiratory distress. V7 (RT Director) asked for an order to put [R1] on the ventilator and for ventilator settings. Given [R1]'s condition, placing him on the ventilator was an appropriate intervention. V7 (RT Director) also had told me that his white blood cell level was elevated (to 22,000). Based on that, I pre-ordered sputum culture and antibiotic due to suspected respiratory infection. Later on [DATE], I checked [R1]'s electronic medical chart, and found out that he was transferred to the hospital. I could have sent [R1] to the hospital, but he was getting placed back on the ventilator, so I didn't think it was necessary. We usually try to stabilize residents in the facility; I feel that the facility is able to handle respiratory events, have qualified staff and appropriate equipment to do so. On [DATE] at 11:23 AM V16 (Primary Care Physician) stated: If you see someone in distress, you should call 911, not point fingers at other people. The problem is that there are too many agency nurses in the facility. Agency nurses don't care as much. Nurses should call 911 regardless of doctor's and family's opinion if a resident needs critical care. I rely on facility's nursing staff and what I'm told, they are my eyes and ears. Sometimes transporting via regular ambulance makes sense, but [R1]'s heart rate and respiratory rate showed that 911 should have been called. I never insisted on ordering transport ambulance for [R1]. At the very least, staff should have called 911 after second dose of heart rate lowering medication administered at 9:00 AM. It shows that didn't consistently bring [R1]'s heart rate down, so 911 should have been called at the latest around 11:00 AM - 12:00 PM. On [DATE] at 11:45 AM V12 (Registered Nurse) stated: On [DATE] around 3:00 AM, I was notified by respiratory therapist, that [R1]'s heart rate was in 150's (bpm), so, based on that, I reached out to tele health service, and I received an order for heart rate lowering medication. I gave it to [R1] as soon as I receive an order, not sure the exact time. I rechecked his heart rate 30 minutes after I gave medication, and it was around 120s (bpm). After that, around 6:00 AM, I gave [R1] his scheduled medications, and I rechecked his heart rate again, it was 98 (bpm) at that time. Considering [R1]'s heart rate was within normal range, and I endorsed it to the morning shift nurse (V8) and went home. On [DATE] at 11:59 AM V17 (Director of Nursing) stated: I was here (in the facility) on [DATE]. When I looked at [R1] around 3:30 PM, [R1] was already placed on the ventilator. I assessed him, he didn't have any abnormal breath sounds or heart sounds, did not appear to be in respiratory distress; however, [R1]'s heart rate was in high 130s to low 140s (bpm). I spoke to V14 (Cardiac NP), she prescribed heart rate lowering medication and STAT EKG. [R1] was sent out to the hospital before EKG was completed. V10 (LPN) updated V16 (PCP) about [R1]'s condition, and that's when V16 ordered [R1] to go to the hospital. I'm not sure about the exact order of events after that because I left for the day around 4:30 PM. Emergency is considered when there is a sudden change in resident's condition or if any type of injury occurs that can't be managed in the facility. If a resident with tracheostomy can benefit from the ventilator, they will be placed on it. [R1]'s elevated heart rate and white blood cell level, and later respiratory distress, didn't prompt us to call 911 because [R1] was managed by pulmonary, cardiac, and primary care providers. If there is an emergency beyond the capacity of the facility, 911 should be called. [R1]'s condition was managed appropriately until the time 911 was called, so around 7:20PM. I'm not sure if V10 (LPN) called 911 in addition V19 or it was V19 who called, considering V10 already scheduled transport ambulance at that time. I'm not sure if V10 would have called 911 without V19's persistence. Nurses can call 911 against physician's advice, it is within their scope of practice. Especially being physician's eyes and ears, nurses have better picture of the situation. I believe all staff interventions were appropriate for [R1] on [DATE]. I feel that nurses were pro-active enough in providing timely care. We did not discuss [R1]'s incident in QAPI meeting nor had any in-service for staff. On [DATE] at 4:10 PM In follow up interview, V17 (DON) stated: I believe V15 (Pulmonary NP) was on [R1]'s case and [R1]'s primary driver was his respiratory status; therefore, V16 was not notified until 5:59 PM. At the time of [R1]'s distress, around 3:30 PM, when his heart rate was in 160's (bpm), respiratory rate in 40s (breaths per minute), and white blood cell level results were known, V15 (Pulmonary NP) already placed an order for a ventilator. V16 (PCP) was not notified at 5:59 PM when all respiratory and cardiac interventions were exhausted. In regard to ordered laboratory and diagnostic tests, [R1]'s EKG was not completed on [DATE] because he was transported to the hospital. [R1]'s chest x-ray didn't result until the morning of [DATE], and blood work started posting in the portal in the early afternoon of [DATE]. CBC (Complete Blood Count) is prioritized, so it was most likely posted as a partial result and that's how nurses were aware of [R1]'s elevated white blood cell level before 10:23 PM when the rest of [R1]'s blood work results were available. [R1] was a hard stick, his blood sample was not collected until the morning of [DATE], even though the order was placed on [DATE]. Our laboratory doesn't notify us of any abnormal lab results, so it is up to the nurses to follow up on that. On [DATE] at 1:05 PM In follow up interview, V8 (Registered Nurse) stated: I didn't notify V16 (PCP) of [R1]'s change of condition on [DATE] because I wasn't aware of change of primary physician for him. [R1] was assigned to another primary physician when he was initially admitted on [DATE] and then it changed. Besides, V13 (Admitting NP) was on site and was aware of [R1]'s elevated heart rate from previous night, so I just asked her. Later that day ([DATE]), I called around 11:00 AM and spoke to V16. I told him about [R1]'s elevated heart rate, confirmed that he wasn't in any distress, and verified that [R1] had his blood drawn in the morning and results are still pending. V16 told me to monitor [R1] and notify him of blood work results. I checked for [R1]'s blood work results around 1:15 PM, and they were not posted at that time. I didn't talk to V16 again before the end of my shift. Another test for [R1] that was ordered during my shift, was STAT chest x-ray, but I don't remember it being done. In case resident's change of condition, nurse should notify their primary physician. Resident's profile lists their primary care physician, I didn't recheck [R1]'s assigned primary care physician on the morning of [DATE], I assumed it was the same as upon admission. On [DATE] at 1:46 PM V18 (Administrator) stated: I was notified of [R1]'s hospital admission and later succumbing to his change in condition in the evening of [DATE]. I was out of town at that time. I asked if V17 (DON) and V7 (RT Director) were looking into it, meaning if they are looking at reasons why [R1] was sent out and what was the reason for his change in condition. I didn't follow up after that. I didn't notify medical director. I'm not aware of any additional education provided to staff following the incident. On [DATE] at 2:52 PM In follow up interview, V10 (LPN) stated: If resident displays change in condition, nurses should notify V17 (DON) and resident's primary care physician. Right upon the beginning of my shift (around 3:00 PM), I notified V17 (DON) of [R1]'s elevated heart rate. I don't know why I didn't notify V16 (PCP) along with V17 (DON), don't have answer to that. I notified V16 (PCP) one time during my shift. I don't remember exactly the time, but I documented at 5:59 PM. It had to be before 5:00 PM though because we cannot notify V16 (PCP) after 5:00 PM, we need to [TRUNCATED]

Based on interviews and record review, the facility failed to notify and inform a resident's primary care physician (PCP) of the onset of a resident's elevated heart rate, interventions of a nurse practitioner and respiratory therapist not directly under the PCP, and continued changes of condition, including but not limited to abnormal labs for a resident within a timely manner. This applies to 1 resident ([R1]) in the sample. Findings include: According to the Facesheet, [R1] was a [AGE] year old male admitted to the facility on [DATE] with diagnosis including but not limited to Acute and Chronic Respiratory Failure with Hypoxia; Tracheostomy; Spastic Quadriplegic Cerebral Palsy; Seizures; Encounter for Attention to Gastrostomy; Myoneural Disorder; and Unspecified Intellectual Disabilities. [R1]'s care plan dated 06/13/2024 reads in part, [R1] has a Tracheostomy s/p acute and chronic respiratory failure with hypoxia. Interventions: Monitor for signs/symptoms of respiratory distress (restlessness, agitation, confusion, increased heart rate (Tachycardia), air hunger, and/or bradycardia; Monitor level of consciousness, mental status, and lethargy PRN; Monitor respiratory rate, depth, and quality (work of breathing), Check and document every shift/as ordered. Resident has potential for alteration in respiratory functioning related to acute and chronic respiratory failure with hypoxia s/p tracheostomy. Interventions: Assess respiratory status, observe for shortness of breath, monitor lung sounds. Call physician for any changes in condition and as needed; Call physician for any changes in condition. [R1]'s vital sign as documented for 06/14/2024 timeline: 00:46 (12:46 AM) - HR 105 beats per minute 3:20 AM - HR 151 beats per minute 9:11 AM - HR 148 beats per minute 11:07 AM - HR 120 beats per minute 11:23 AM - HR 148 beats per minute 3:15 PM - HR 160 beats per minute, RR 44 breaths per minute - [R1] placed on the ventilator. 3:23 PM - WBC was 22.71- V16 (PCP) notified, no new orders. 3:40 PM - HR 153 beats per minute 4:45 PM - HR 130 beats per minute - no interventions 4:57 PM - HR 130 beats per minute 5:44 PM - HR 147 beats per minute 5:59 PM - HR 145-150 beats per minute - V16 (PCP) notified; orders received to send [R1] to the hospital. 7:20 PM - HR 153 beats per minute [R1]'s record indicated facility staff did not contact V16 for 14 hours (12:46AM-3:23PM) past the onset of [R1]'s elevated heart rate. [R1]'s progress note written by V17 (Respiratory Therapist/ RT Director) dated 06/14/2024 3:23 PM reads in part, (At) 1515 ([R1]) abnormal (vital signs) in respiratory distress, HR 160 RR >35bpm (44) sat 91-93% on TC 40%. ([R1]) w/ small yellow thick secretions. (Airway) patent, fio2 increased to 50%. WBC was 22.71 today, (V16 PCP) notified. (V15 Pulmonary NP) notified, x-ray ordered. Pending results. ([R1]) will be placed on vent full support to prevent respiratory failure w/ settings AC 16 300 +5 40% per (V15). Will notify POA. [R1]'s progress note written by V15 (Pulmonary Nurse Practitioner) dated 06/14/2024 3:30 PM reads in part, Notified by (respiratory therapy) that ([R1]) for consult to be seen by our service on 7/14 08:48am. Notified that ([R1]) on continuous (tracheostomy collar) at 40% and had a 7 TTS trach in place. Then was notified by (respiratory therapy) at (3:20 PM) that ([R1]) had developed increased work of breathing, tachypnea with counted RR 52, HR 150s and sats in low 90s. ([R1]) was given (heart rate lowering medication), cardiology consulted, and ([R1]) had WBC 22 (22,000). ([R1]) placed on mechanical ventilation. Reviewed (electronic medical record) and gave order for sputum (culture) and empiric (antibiotic). (Chest x-ray) on 6/14: There is patchy right hilar and basilar density suspicious for pneumonia. [R1]'s lab order dated 06/12/2024 at 10:32 PM reads in part, Priority: Routine. CBC with Diff, Comprehensive Metabolic Panel, Lipid Panel w/reflex to direct LDL, Thyroid Stimuli Hormone, Hemoglobin A1C. Ordering physician: (V24 Admitting Physician). [R1]'s routine blood work collected 06/14/2024 at 5:35 AM, results posted on 06/14/2024 at 10:23 PM. WBC (White Blood Cells) 22.71 H (high) (reference range 3.4-10.8). On 06/27/2024 at 12:39 PM V7 (Respiratory Therapy Director) stated in part: [R1] was admitted to the facility on [DATE]. [R1]'s initial oxygenation orders were for tracheostomy collar 40% fio2 (5 liters per minute, fraction of inspired oxygen). [R1] was stable on those settings on 06/12/2024 and 06/13/2024. Around 9:00 AM on 06/14/2024 V7 was notified by V9 (Respiratory Therapist) that [R1] developed tachycardia (elevated heart rate) but had clear airway and appropriate oxygen saturation level. [R1]'s respiratory rate was into mid 20 breaths per minute, but it was not critical. V7 stated, I assessed [R1] at that time, and, following my assessment, I notified nurse on duty (V8 - Registered Nurse) and V15 (Pulmonary Nurse Practitioner). We are required to notify nurse on duty and pulmonary physician if we notice any resident change in condition. I was concerned with [R1's] tachycardia. There were no new orders from respiratory side at that time, just to closely monitor. Around 3.15 PM, [R1] was in distress. [R1's] heart rate was in 150's bpm (beats per minute), respiratory rate was over 35 breaths per minute, rapid and shallow, and oxygen saturation was 88-89% on tracheostomy collar. I immediately notified V15 (Pulmonary NP) and I received orders to place [[R1]] on ventilator to prevent respiratory failure. Right when, I placed [R1] on the ventilator. I notified V19 [R1]'s family member) via phone, explained reasons behind putting [R1] on ventilator, and I also assured her that I will make sure [R1] has a private room. On 07/01/2024 at 9:45 AM V13 (Admitting Nurse Practitioner) stated: I did not physically see [R1] on 06/14/2024; however, I admitted him on 06/13/2024, and I was most familiar with [R1] when nurses called to notify about [R1]'s elevated heart rate. I'm in the facility on daily basis and it is easiest to reach me out of most medical staff. I confirmed that it is ok to give [R1] scheduled dose of medication to lower [R1]'s heart rate at 9:00 AM after receiving previous dose of the same medication earlier that morning. I was also waiting for routine blood test to come back that I ordered upon [R1]'s admission (on 06/12/2024). I also asked if [R1] is being followed by a cardiologist. Considering [R1] was treated for pneumonia prior to coming to the facility and being new to tracheotomy, I wasn't overly concerned with his tachycardia. I would become more concerned if [R1] developed additional symptoms, the rule of thumb is that, at least three elements of vital signs are abnormal, it might be an infection or sepsis, and it is appropriate then to send a resident out to the hospital. Knowing that his white blood cells level was elevated (to 22,000) in additional to tachycardia, I would definitely send him out to the hospital; however, I was gone (around 11:30 AM) by the time those blood work results came back. On 7/1/2024 at 4:10 PM V17 (Director of Nursing) stated in part: I believe V15 (Pulmonary Nurse Practitioner) was on [R1]'s case and [R1]'s primary driver was his respiratory status; therefore, V16 (Primary Care Physician/PCP) was not notified until 5:59 PM. At the time of [R1]'s distress, around 3:30 PM, when his heart rate was in 160's (beats per minute), respiratory rate in 40s (breaths per minute), and white blood cell level results were known to be elevated, V15 (Pulmonary NP) already placed an order for a ventilator. V16 (PCP) was notified at 5:59 PM when all respiratory and cardiac interventions were exhausted. [R1]'s chest x-ray didn't result until the morning of 06/15/2025, and blood work started posting in the laboratory portal in the early afternoon of 06/14/2024. CBC (Complete Blood Count) is prioritized, so it was most likely posted as a partial result first and that's how nurses were aware of [R1]'s elevated white blood cell level before 10:23 PM when the rest of [R1]'s blood work results were available. [R1] was a hard stick, his blood sample was not collected until the morning of 06/14/2024, even though the order was placed on 06/12/2024. Our laboratory doesn't notify us of any abnormal lab results, so it is up to the nurses to follow up on them. On 7/2/2024 at 1:05 PM V8 (Registered Nurse) stated: I didn't notify V16 (PCP) of [R1]'s change of condition on the morning of 06/14/2024 because I wasn't aware of change of primary physician for [R1]. [R1] was assigned to another primary physician when he was initially admitted on [DATE] and then it was changed. Besides, V13 (Admitting Nurse Practitioner) was on site and was aware of [R1]'s elevated heart rate from previous night, so I just asked her for orders. Later that day (06/14/2024), I called around 11:00 AM and spoke to V16 (PCP). I told him about [R1]'s elevated heart rate, confirmed that he wasn't in any distress, and verified that [R1] had his blood drawn in the morning and results are still pending. V16 told me to monitor [R1] and notify him of blood work results. I checked for [R1]'s blood work results around 1:15 PM, and they were not posted at that time. I didn't talk to V16 (PCP) again before the end of my shift. Another test for [R1] that was ordered during my shift, was STAT chest x-ray, but I don't remember it being done. On 07/01/2024 at 10:59 AM V15 (Pulmonary Nurse Practitioner) stated: On 06/14/2024 at 8:48 AM, I was notified that there was a new resident that I was consulted for. Even though, [R1] was admitted on the evening of 06/12/2024. I've never seen [R1] face to face, it is pretty typical though. V7 (RT Director) told me that [R1] was admitted with tracheostomy collar, verified orders for the tracheostomy with me, and that was it. Nothing unusual at that point. Later that day, at 3:20 PM, I was notified that [R1] had increased respiratory rate, to over 40 breaths per minute. V7 (RT Director) actually said that [R1]'s respiratory rate was 52 breaths per minute at that time, heart rate was in 150's bpm (beats per minute), his oxygen saturation level in the low 90%, and he was breathing shallow, all of which would tell me, [R1] was in acute respiratory distress. V7 (RT Director) asked for an order to put [R1] on the ventilator and for ventilator settings. Given [R1]'s condition, placing him on the ventilator was an appropriate intervention. V7 (RT Director) also had told me that his white blood cell level was elevated (to 22,000). Based on that, I pre-ordered sputum culture and antibiotic due to suspected respiratory infection. Later, on 06/14/2024, I checked [R1]'s electronic medical chart and found out that he was transferred to the hospital. I could have sent [R1] to the hospital, but he was getting placed back on the ventilator, so I didn't think it was necessary. On 7/2/2024 at 4:06 PM V16 (Primary Care Physician) stated: Facility contacted me about [R1]'s condition at least a couple of times on 06/14/2024, but I don't remember nurses reporting that [R1] had elevated white blood cell level. The last time I remember I was called about [R1] was when the nurse, I don't remember their name, was trying to verify what ambulance service to use to transfer [R1] to the hospital. I think nurses should know what is appropriate for a resident at the time of change in condition, they are physically with the resident. I believe that if [R1] was provided higher level of care sooner, it is possible he would be alive today. Change in [R1]'s primary care physician dated 06/13/2024 at 9:38 AM reads in part, Team, please switch [R1) to (V16 - PCP). The facility Physician Notification of Laboratory/Radiology/Diagnostic Results dated 3/14/18 reads in part, Purpose: To assure physician ordered diagnostic test are performed, and to assure test results are reported to the physician so that prompt, appropriate action may be taken if indicated for the resident's care. Guidelines: A licensed nurse is responsible for assuring the laboratory is notified of physician's orders for testing. STAT or Same Day orders will be called to the laboratory service by the nurse who transcribes the order. A nurse is responsible for monitoring the receipt of test results. Guidelines for Reporting Abnormal Results: All critical laboratory values - also called Alert or Panic values; x-ray or other diagnostic tests reveal suspected findings which may require immediate intervention. In the event a physician does not respond promptly to attempts to convey critical laboratory results, the alternate physician or Medical Director will be notified. Promptly may be defined based on the clinical condition of the resident and the judgement of the nurse in each individual situation. Unless other parameters are ordered by physician: WBC (White Blood Cells) > 12,000. The licensed nurse is responsible for documenting the notification of results in the clinical record.

Based on observation, interview and record review, the facility failed to provide adequate supervision and monitoring of residents at risk for falls and with a history of falls for 3 (R1, R3, R4) of 3 residents reviewed for accident hazards in the sample; failed to follow the plan of care to prevent injuries and future falls; and failed to train staff (including agency staff) on fall risk interventions. These failures resulted in all 3 residents requiring emergent transfers to the hospital emergency department. R1 sustained a left shoulder fracture; R3 sustained a non-displaced sacral fracture with required hospitalization ; and R4 sustained a left tibia/fibula (ankle) fracture with required hospitalization and surgical intervention. Findings include: On 3/1/24 at 1:22 PM, V2 (director of nursing) presented surveyor with their fall incidents log in the past 90 days which showed a total of 45 falls. V2 indicated V15 (Restorative LPN/Falls Nurse) was the facility's designated fall nurse in charge of (implementing, monitoring and assessment) the fall prevention program. On 3/1/24 at 2:21 PM interview with V15 (restorative nurse) disputes V2's statement he was the Fall Nurse. V15 stated, I am the Restorative nurse here, not the Fall nurse. My title is Restorative nurse, and I am not in charge of falls; Is what they told you? I'm just part of the team. Surveyor asked to clarify his role. V15 stated, When I come in here, I check if there are any falls and report from nurses. I go to the nursing stations to get initial information about any fall, and we bring it up in the morning huddles. I do continuous in-service fall training and we do it every orientation for new employees. Surveyor asked when V15 conducted last fall risk training. V15 stated, I can't recall when the last time it was done but we have monthly town hall meetings about general nursing stuff. Surveyor asked V15 to provide any documentation showing when in-service training was last conducted by him. V15 indicated he would check but never came back to provide surveyor with said training materials. 1. R1 is an [AGE] year old with diagnosis listed in part with chronic kidney disease with heart failure, atrial fibrillation, congestive heart disease and mild cognitive impairment. Care plan dated 11/22/23 reads in part, (R1) has potential risk for falls. Gait/balance problems, Incontinence, Psychoactive drug use, Vision/hearing problems related to glaucoma, CHF, Hypertension, Atrial fibrillation. Goal: R1 will not sustain serious injury through the review date. Interventions: Keep furniture in locked position; Keep needed items, water, etc. in reach; Maintain a clear pathway, free of obstacles; Evaluated for adaptive equipment and supplies. Re-evaluate as needed for continued appropriateness and to ensure least restrictive device or restraint. R1 educated on using his walker or wheelchair per therapy recommendations; Encourage to participate in activities promote exercise, physical activity for strengthening and improved mobility; Be sure call light is within reach and encourage resident to use it for assistance as needed; Ensure resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. Fall assessments dated 11/29/22, 12/6/22, 2/28/23, and 12/24/23 all showed R1 to be at High Risk for Falling. Fall assessments dated 11/21/22 and 12/24/23 showed R1's history of fall incidents. On 3/1/24 at 10:35 AM, surveyor entered the locked dementia unit behind two double doors. R1 was in his room seated in his wheelchair, appearing very disoriented and unable to follow any line of questioning. R1 was fully dressed but had socks that appeared to have no grip on the floor as R1 was sliding his feet as he appeared stuck in between the bathroom and closet doors trying to maneuver himself out of the room. Surveyor exited the room in search of an aide or nurse and asked V4 who identified herself as the social worker and unit manager. Surveyor asked V4 where the nurses or aides were. V4 stated, It should be V8 (agency LPN) on that side taking care of R1, but I don't know where she is. Surveyor approached V7 (LPN) who indicated there were two nurses on the unit with 50 residents and 4 CNA's. V7 stated, I don't know where V8 is, but I don't take care of that side. I think V8 is probably in one of the resident rooms. On 3/1/24 at 11:45 AM, surveyor asked the V8 agency nurse about the unit, V8 stated, I know this is the dementia unit, but I don't know if I can tell you anything else because I am agency here. Surveyor asked if she was informed of any residents at risk of falls, V8 stated, No. I wasn't told anything. Surveyor asked if V8 received any endorsement from the nurse when she came in. V8 stated, No I wasn't told anything, like I said. Surveyor asked if V8 received any orientation about the residents specific to the unit. V8 stated, No. I just pick up the shift and I work it. I don't know where they put me, I just go where I'm told. The facility's internal investigation, along with the surveyor's investigation of R1's fall showed the following: On 12/24/2023 00:42 (12:42 AM) V5 (LPN) wrote in part: Nurses Note. 11:10 PM, CNA doing rounds found the patient (R1) on the floor by the side of the bed. Patient found lying on the left side of the body with the right leg straight and left leg slightly flexed. V5's signed statement on 12/26/23 obtained by V2 (director of nursing), reads in part, I (V5) came to my schedule shift 12/23/23. Once I got into the unit, (V17) agency nurse was rushing to go home. Both of us did the medication count and she handed keys and left. CNA then came to me and mentioned the patient was observed sitting on the floor. I immediately came to the room and observed patient sitting on the floor. Patient stated, I don't remember how I fell down. Doctor on call notified and ordered pain medication and x-ray, neurological checks taken and recorded. On 3/1/24 at 3:10 PM, Surveyor interviewed V5 who stated, (R1) was more of a newer patient for me because I was rotating in the facility, and I think it could have been the first time I was taking care of him. Surveyor asked if V5 was informed of R1's fall risk or plan of care to prevent R1 from falling. V5 stated, No, like I said I was pretty new to the unit (referring to the dementia unit). Surveyor asked if V5 received any endorsement from the outgoing agency nurse (V17). V5 stated, No. As I mentioned in my statement to the DON, agency nurse was in a rush to get out of there and she quickly did the medication count and just handed over the keys and left. I'd say about 30 minutes into my shift, my CNA called me to the room and said she found the resident on the floor beside his bed. I called the doctor, and he ordered x-rays and neuro checks. Surveyor clarified whether the facility staff informed her of R1's fall risk. V5 stated, I only found out afterwards when he fell but I didn't know. I was not told at all he was a fall risk. I only found out as soon as the other nurse came from the other unit told me. Surveyor asked V2 (DON) the identity of the agency nurse. V2 indicated it was V17 (Agency LPN). V2 stated, We no longer use V17 ever since incident. Surveyor requested contact information for V17 but was not provided any during the survey. On 1/2/2024 at 09:32 AM V16 (Nurse Practitioner) wrote in part, Progress Notes. Chief Complaint/Reason for this Visit: Debility, COVID 19 infection, recent fall with acute fracture of clavicle and left acromion, lab review. HPI (History of Present Illness) Relating to this Visit: Informed by staff today patient with recent diagnosis of COVID infection and recent fall with acute fracture of clavicle and left acromion. Patient was evaluated in the ED on 12/25/23. Hospital records dated 12/24/2023 authored by V18 (hospital ED physician) showed in part, HPI (History and Present Illness): Patient is an [AGE] year old male who presents to the ED with fall 2 days ago. Patient is a nursing home resident, was reporting shoulder pain and had an x-ray today which reportedly showed a left shoulder fracture. Patient currently reporting left shoulder and left hip pain. Indication: [AGE] year old male fall, trauma. Findings: Left clavicle: There is an acute mildly displaced and mildly angulated oblique fracture through the mid shaft of the left clavicle. There is mild posterior apex angulation and slight overriding of the major fracture fragments. Patient was placed in a sling his upper extremities are neurovascularly intact given a Norco for pain. 2. R3 is an [AGE] year old with diagnoses including history of falling, Parkinson's Disease, Osteoarthritis, and Dementia. R3's fall risk assessments dated 12/8/23, 1/2/24, 1/24/24, and 2/24/24 all showed the resident to be at High Risk for Falling. Facility fall incident report dated 2/21/2024 authored by V2 (director of nursing) reads in part, [AGE] year old female with diagnoses including history of falling, Parkinson's Disease, and Dementia. Her BIMS is at 04 (severe cognitive impairment). She requires partial assistance with transfers. CNA on duty stated resident was being assisted with transfer from the wheelchair to the bed to provide peri care. During transfer resident became agitated and attempted to push herself away from CNA. Resident's shin came into contact with bed frame. Resident sent out to hospital for evaluation and treatment. Resident admitted for left tibia/fibula fracture and returned to facility post ORIF (Open Reduction Internal Fixation) surgery on 2/24/24, weight bearing as tolerated with boot to left lower extremity. On 3/1/24 at 11:45 AM, R3 was seated in a high back wheelchair in the dining room dressed in hospital gown and black colored left leg brace. In one corner of the dining room sat V9 (agency CNA) with her focus directed at her laptop computer. V9 was asked her responsibility. V9 indicated she was there to monitor the residents. Surveyor asked how V9 was able to do this while focused on her computer. V9 did not respond and got up and walked away from surveyor. Surveyor approached R3 who appeared confused and was speaking nonsensical words spoken in Spanish and could not follow any line of questioning from the surveyor. V19 (activity aide) was asked her responsibility. V19 stated, I'm doing activities for the residents and we're doing trivia now. Surveyor asked who the residents were currently in the dining area were considered fall risk residents, V19 stated, I don't know. On 3/2/24 at 10:40 AM, surveyor entered the locked dementia unit and approached V13 (Agency LPN) and asked about the unit. V13 stated, I'm an agency nurse and it's my first time here. Surveyor asked if V13 knew the type of unit she was in. V13 stated, No. No one told me anything. Surveyor asked if V13 received any endorsement during shift change, V13 stated, No. The nurse was already gone when I got here. Surveyor clarified if V13 received any sort of orientation or training for the unit and/or whether V13 was informed of any residents at risk for falling and specifically for R1 and R3 who were assigned to her., V13 stated, Sorry, I wasn't told anything. I got here and was told to go here and that's it. On 3/2/24 at 11:15 AM, V1 (administrator) was informed about the information V13 had given. V1 indicated and affirmed it was an oversight and the facility was working to fix the nursing supervisory issues. On 3/1/24 at 1:30 PM, V2 (Director of nursing) was asked to provide investigation pertaining to 2/21/24 incident in order to identify staff involved. V2 indicated to surveyor there was no information found with no explanation. Hospital record dated 2/21/24 reads in part, This patient is an [AGE] year old female with a past history significant for Depression, hypertension, Parkinson's, Senile Dementia. Presents to hospital ED from nursing home after falling from bed with left Tibial Fracture and complains of Pain in left lower leg. Previous admission was for a right hip fracture a couple weeks prior to this admission. Further evaluation and work up as follows: Status post Fall, left leg pain, Left distal Fibula Fracture, Anemia, Chronic stable right hip fracture. 2/21/24 planned for ORIF of left [NAME] with Intramedullary Nailing of Left Distal Tibia Fracture. 3. R4 is an [AGE] year old cognitively impaired resident with diagnoses including Alzheimer's Disease, Dementia, and hypertensive kidney disease. R4's fall assessments dated 3/11/23, 9/7/23, 1/22/24 and 1/27/24 all assessed R4 as High Risk for Falling. R4's history of falls showed the resident falling on 3/11/23, 9/7/23 and 1/22/24. Care Plan dated 12/13/23 reads in part, (R4) is at risk for falls related to impaired cognition with poor safety awareness, risk factors: Alzheimer's Disease, Dementia, History of falls, Anemia, polypharmacy with psychoactive medications and its potential side effects and recent fall. Goal: Resident will resume usual activities and will lessen fall incident occurrences and or impact of injury if fall occurred. Interventions: Falling Leaf program for increased awareness of fall risk and augmented fall prevention approaches; Keep furniture in locked position; Keep needed items, water, etc. in reach; Maintain a clear pathway, free of obstacles; Place call light within resident's easy reach and use for assistance; Room close to nurses' station; Remind resident to use the call light to call for assistance for transfers and ambulation; Encourage to participate in activities promote exercise, physical activity for strengthening and improved mobility; Ensure resident is wearing appropriate footwear when ambulating. Facility incident report dated 1/12/24 submitted by V2 (director of nursing) reads in part, (R4) was observed laying on the floor next to her bed with feet closest to bed and head closest to door. Noted to have pain on right knee and limited mobility on right lower extremity. She (R4) is unable to say what happened. Received order to transfer to ED for further evaluation. Possible fracture on right sacral Aral noted per CT (Cat Scan). Hospital record dated 1/22/24 showed in part, Hospital course: (R4) is an [AGE] year old female admitted [DATE] for Urinary tract infection, Fall, Back pain unspecified back location. Status post Unwitnessed Fall Possible Sacral Alar Fracture. 1/23/2024 Orthopedics consult about possible Alar Sacral Fracture and state no restrictions, is healing and non-displaced. (Non-displaced fractures are still broken bones, but the bone pieces weren't moved far enough during the break to be out of alignment, but still considered a fracture.) Observations conducted on 3/1/24 at 10:37 AM showed R4 remaining in bed behind a closed door with no direct line of sight from staff. At 10:45 AM, Surveyor asked V7 (LPN) if R4 was one of her residents. V7 stated, Yes. This side is my unit (pointing down one hall) and I'd say we have about 50 residents and all of them have dementia because this is the dementia unit. Surveyor asked who the residents were at risk for falls. V7 stated, Most of them here are, maybe all of them. Surveyor asked if she was provided any in-service training related to fall prevention. V7 stated, I have but I don't remember when. On 3/2/24 at 10:45 AM, R4 remained behind a closed door of her room. When surveyor entered, there was a care giver was inside the room with R4. R4 was in the bathroom standing upright and was bending to squat over the toilet. R4 was fully naked and per V14, she assisted R4 to the bathroom so R4 could use the toilet. R4 was observed barefoot and naked with no foot wear or slip resistant socks worn. The resident appeared unsteady as she squatted down and was taking toilet paper to clean herself while V14 was at the door watching and not assisting R4. Surveyor asked V14 if she worked at the facility. V14 stated, I'm her care giver but I'm a CNA. Surveyor asked why she did not ask for facility staff to assist resident to the bathroom. V14 stated, I can't find anyone. Surveyor asked if V14 used the call light for staff to assist the resident to the bathroom. V14 stated, No. Surveyor asked if V14 knew if resident was at risk for falls and/or what those precautions were. V14 stated, I don't know, please ask (V4) Surveyor clarified whether the facility provided her training on fall prevention. V14 stated again, I don't know, ask (V4). Hospital record dated 2/21/24 reads in part, This patient is an [AGE] year old female with a past history significant for Depression, hypertension, Parkinson's, Senile Dementia. Presents to hospital ED from nursing home after falling from bed with left Tibial Fracture and complains of Pain in left lower leg. Previous admission was for a right hip fracture a couple weeks prior to this admission. Further evaluation and work up as follows: Status post Fall, left leg pain, Left distal Fibula Fracture, Anemia, Chronic stable right hip fracture. 2/21/24 planned for ORIF of left [NAME] with Intramedullary Nailing of Left Distal Tibia Fracture. Policy dated 11/21/17 titled Fall Prevention Program reads in part, 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 are utilized as necessary. The 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 were successful; Notification of physician, family representative; Communication with direct care staff members. Fall/safety interventions may include but are not limited to: Direct care staff will be oriented an d trained in the Fall Prevention Program; The nurse call device will be placed within the resident's reach at all times; The resident's personal possessions will be maintained within reach when possible; The resident's environment will be kept clear of clutter which would affect ambulation and remove hazards; Residents will be observed approximately every two hours to ensure the resident is safely positioned in the bed or char and provide care as assigned in accordance with the plan of care; Call lights are answered promptly; Residents who require staff assistance will not be left alone after being assisted to bathe, shower, or toilet; Nursing personnel will be informed of residents who are at risk of falling; Foot wear will be monitored to ensure the resident has proper fitting shoes and/or footwear is non-skid.

Based on interview and record review, the facility failed to ensure 2 persons physical assist for bed mobility was utilized while providing incontinence care to prevent an avoidable incident. This affected one of three residents (R2) reviewed for avoidable accidents during care. This failure resulted in R2 sustaining four skins tears to the left arm. Findings Include: R2 is a [AGE] year-old with the following diagnosis: type 2 diabetes, end stage renal disease with dialysis, dementia, and peripheral vascular disease. R2 was admitted to the facility on [DATE]. A Skin note dated 8/22/23 documents a new skin alteration was found on R2. The Skin Assessment at 8/22/23 documents there's a new skin condition noted. The left forearm was noted with new skin tears. There's no documentation of how many skin tears. R2 reported being changed when the skin tears occurred. All wound assessment details reports were reviewed. Skin tears were noted on 8/22/23 to the left dorsal wrist, left, medial forearm, left, distal forearm, left, proximal forearm, and left upper arm. These are all documented as skin tears that were facility acquired. The Final Incident Report dated 8/28/23 documents, R2 reported to the administrator the overnight CNA (V11) caused skin tears to the left arm while changing R2. The police were notified. R2 admitted V11 came into the room throughout the night to ask to change R2, but R2 kept yelling at V11 to leave. At around 6 AM, R2 allowed V11 to change R2. While changing R2, V11 rolled R2 over with R2's left arm to change R2. R2 did not think V11 was trying to hurt R2. R2 stated that V11 had to reposition R2 several times to be cleaned up. R2 did not notice the skin tears until R2's family member brought it to R2's attention. When V11 was interviewed, V11 reported changing R2 at 6 AM. V11 reported R2 was upset with V11 for turning on the lights while providing care. V11 reported that V11 assisted in turning R2 with the left arm to roll R2 over to be changed. V11 stated R2 needed to be reposition several times for proper peri care to be provided. V11 denied seeing any skin tears and did not report any issues in the nurse report because there were no concerns after providing care. Upon investigation, no other residents complained about V11. R2 has skin that is thin and fragile. While being cleaned, V11 was repositioning R2 with the left arm, which may have caused the skin tears. R2 stated that V11 was not trying to hurt R2 and there was no intent for harm. The Police Report dated 8/22/23 documents the police were called to the facility for possible abuse to R2. R2 stated V11 cleaned R2 this morning around 6:00AM. R2 reported not being able to move in the bed without assistance so V11 helped R2 roll onto R2's side. R2 endorsed once on R2's side, V11 began cleaning R2 but was aggressive so R2 would scream out. R2 stated any time R2 would scream out then V11 would squeeze R2's arm causing the skin tears. V11 is currently suspended from the facility pending investigation. On 9/19/23 at 1:50PM, R2 was visited in the dialysis room and allowed the surveyor to come speak with R2. R2 had a Geri sleeve covering the left hand with the fingers exposed the went all the way up to about one inch above R2's elbow. The sleeve was removed by the dialysis nurse. Two areas that were the size of a dime were closed but had a lighter, pink discoloration than the rest of the skin. R2 pointed to the two areas and stated that was where the skin tears were before they healed. When asked how R2 got the skin tears, R2 stated, Someone tried to beat me up. The surveyor asked R2 other questions related to the incident but R2 would not respond. On 9/19/23 at 3:08PM, V7 (Restorative Nurse) stated R2 is totally dependent and is not able to do any ADL care independently. V7 endorsed R2 can partially help when turning from side to side. V7 stated, (R2) only needs one person performing incontinence care because bed mobility is about moving in the bed yourself, not about when you're being turned during incontinence care. That is not considered bed mobility. V7 stated both nurses and CNA's have access to the charting system to see how each resident should be cared for. V7 stated agency staff also has access to the computers. V7 stated, Each situation is different and it depends on the CNA but if they need to get someone else because they don't feel comfortable doing incontinence care alone then they need to ask someone for help. V7 stated the facility does these assessments so each staff member knows how to care for each resident, and the residents are being given the best care that can be provided. On 9/19/23 at 3:21PM, V8 (Wound Care Coordinator) stated R2 had skin tears to the left arm, left wrist, dorsal, left, forearm, proximal, left forearm medial, and left upper arm with some general bruising noted to all the skin care sites. V8 reported all the skin tears were found on August 22. V8 endorsed being told by R2's family and R2 that the CNA caused them during the night shift when R2 was being changed. V8 stated R2 is at risk for having skin tears easily because she is on blood thinners and has had a history of skin tears in the past. V8 endorsed doing wound care on R2 and R2 is a maximum assist when turning in bed. V8 stated V8 performs the wound care with another wound tech so there's always two people turning R2. V8 denied R2 being able to hold onto the side rail when turned. On 9/19/23 at 3:43PM, V9 (CNA) stated R2 can help staff very little when they are providing care. V9 endorsed R2 can only put R2's hand over the side rail to hang on. V9 reported R2 is a two person assist with the transfer but when staff is turning R2 and changing R2, two people are not required. V9 stated R2 can hang onto the side rail so you don't have to use two staff. V9 endorsed when staff changes a resident, they must turn the resident side to side to make sure they're completely clean. V9 stated, I normally turn the resident to the side and clean them while I hold them with my other hand. On 9/19/23 at 4:06PM, V10 (Nurse) stated staff normally just turn R2 with one person since R2 can hold onto the rail. V10 endorsed the only time staff uses two people is when we transfer R2 out of bed. V10 reported staff goes by what each resident can do with how much assistance is provided. V10 stated, If they can help us turn then we only use 1 person to change them. On 9/20/23 at 9:38AM, V11 stated R2 had a bowel movement so V11 was cleaning R2 and turned R2 on the side facing the window. R2 endorsed being alone when cleaning R2. V11 stated, I turned R2 and held R2 with one arm and cleaned R2 with the other arm. V11 reported not having access to the computer and V11 did not know how many people R2 needed to turn. On 9/27/23 at 1:44PM, V1 (Administrator) stated when R2 and V11 were interviewed, they both agreed there was no ill intent to harm but maybe the skin tear occurred during repositioning. V1 reported the facility provided education to V11 that R2 had sensitive skin so repositioning needed to be done carefully. V1 endorsed V11 was the only one changing R2 that night. V11 stated all agency staff are given access to the computer system usually on their first day. V11 stated if agency staff doesn't have access, then they should be asking other staff on how residents should be cared for. The Restorative Observation dated 7/18/23 documents R2 turns self from side to side in bed with a two-person physical assist. R2 turns from left to right and turns from right to left with a two-person physical assist. R2 needs a two-person physical assist to be able to center self in the bed. R2 is an extensive assist with bed mobility. Program progress documents R2 needs a two person staff assist. R2 is always incontinent of bowel and bladder. R2 has no independent movement and needs motivation. The Minimum Data Set (MDS) Section G dated 7/19/23 documents R2 needs an extensive two-person physical assist with bed mobility. Bed mobility is defined as how a resident moves to, and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture. The Care Plan dated 1/8/21 documents R2 requires staff assist with bed mobility function related to but not limited to diagnosis of diabetic neuropathy, end stage renal disease, and generalized muscle weakness. R2 would benefit from a bed mobility, restorative nursing program for bed mobility positioning. This care plan also documents R2 has an actual ADL self-care deficit related to weakness, impaired mobility, and decrease physical function. There are interventions for both care plans that staff should assist with bed mobility, turning and positioning as necessary. There is no specific documentation on how many staff are required to assist R2 bed mobility on the care plan. The Care Plan revised on 8/28/23 documents R2 has active wounds and has potential for skin impairment related to history of wounds, reduced mobility, age, thin/ fragile skin, bowel and bladder, incontinence, and diagnoses. On 8/22/23, four skin tears were noted to the left arm.

There are 3 Deficient Practice Statements: I. Based on interview and record review the facility failed to implement effective fall interventions to include monitoring/supervision, and safe outpatient transport. This affected three of three residents (R1, R17, and R18) reviewed for fall prevention. This failure resulted in R1 getting out of bed at approximately 3:30am falling to the floor sustaining a right femoral neck fracture. II. Based on interview, observation and record review, the facility failed to follow their employee hand book policy and not sleep while on duty. The facility also failed to ensure the facility was safe by not ensuring entrance doors were locked. This failure has the potential to affect all 27 residents on 1A unit and 10 residents on ,d+[DATE] unit. On 8.4.23 at 4:00am the facility was observed to be unsecured, and 3 facility staff was found to be sleeping on duty. III. Based on interview and record review, the facility failed to follow their rounding facility practice and conduct resident checks at least every 2 hours. This affected one of three residents (R16) reviewed for 2 hourly checks. This failure resulted in R16 being found over three hours lifeless, unresponsive with rigor mortis, cold to the touch, mottled skin, and pooling of blood to the back side. Findings include: I. R1 R1 admitted to the facility on [DATE] with a diagnosis of type II diabetes, kidney disease, encephalopathy, and history of falling. R1's fall risk dated [DATE] documents: R1 is at high risk for falling. Under gait: impaired gait (difficulty rising from the chair, uses chair arms to get up, bounces to rise, keeps head down when walking, watched the ground, grasps furniture, person or aid when ambulating, cannot walk unassisted). Under mental status: overestimates or forgets limits. R1's fall care plan dated [DATE] documents: R1 is at high risk for falls due to impaired balance, gait and mobility, needs assistance with surface-to-surface transfer related to weakness and impaired cognition with confusion secondary to dementia, diabetes, unsteadiness on feet, lack of coordination and history of falling and recent fall on [DATE]. Interventions in place prior to fall on [DATE]: Keep furniture in locked position. Date Initiated: [DATE]; Maintain a clear pathway, free of obstacles. Avoid repositioning furniture. Date Initiated: [DATE]; Keep needed items, water, etc. in reach. Date Initiated: [DATE]; Encourage to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Date Initiated: [DATE]; Be sure call light is within reach and encourage resident to use it for assistance as needed Date Initiated: [DATE] Revision on: [DATE]; Ensure that resident is wearing appropriate footwear (nonskid socks/rubber soled shoes) when ambulating or mobilizing in wheelchair. Date Initiated: [DATE] On [DATE] at 3:29PM, V19 (Nurse) said R1 was fall risk and would try to get up form bed. V19 would be looking for coffee at times. At time of fall, R1 observed coming out of room by V83 (CNA). V83 attempted to get to R1, but he fell on his right side by door of his room. On [DATE] 946AM, V83 (CNA) said R1 was a fall risk and would try to get up and walk from his wheelchair. On [DATE] 10:30Am, V5 (social service) said R1 had behavior of being restless and attempting to get up unassisted. Interventions in place were to move closer to nursing station, frequent rounding at least every 2 hours and R1 needed to be supervised. On [DATE] at 12:44am, V41 (CNA) said R1 had behaviors of trying to get up unassisted and tries to get coffee. R1 hospital record dated [DATE] documents: x-ray of right hip: transverse, displaced and overlapped subcapital fracture of the right femoral neck. R17 R17 admitted to the facility on [DATE] with a diagnosis of major depressive disorder, cyst of pancreas, cauda equina syndrome, hyperlipidemia, vascular disease, and hypertension. R17 progress notes dated [DATE] documents R17 informed writer that she fell on her right side with wheelchair yesterday on her way to V88 (MD) appointment. R17 said she informed the doctor and x-rays were done aside from scheduled back x-rays and no injury noted. Body assessment done, no bruise, no swelling. On [DATE] at 2:05PM, R17 who was alert and oriented x 3 said on [DATE] she was going to doctor appointment and she fell in the facility van while she was in her wheelchair. R17 said the driver did not strap her wheelchair in correctly and when the facility van turned right the wheelchair tipped over causing the resident to fall while in the wheelchair to her right side. On [DATE] at 1:36PM, V90 (transportation company) said R17 did sustain a fall on the transportation trip on [DATE]. V90 was unable to provide any further information. On [DATE] at 11:20AM, V1(Administrator) said transportation called to inform the facility of the incident but unsure of the date or who spoke to the company. V1 said they have no control over the transportation company and if a resident is a fall risk, they will provide an escort. R18 R18 was admitted to the facility on [DATE] with a diagnosis of encephalopathy, traumatic subdural hemorrhage without loss of conscious, aphasia, repeated falls, hemiplegia, and hemiparesis affecting right side, epilepsy, acute respiratory failure with hypoxia, pulmonary nodule, heart failure, hyperlipidemia, atherosclerotic heart disease and dementia. R18 fall report dated [DATE] documents resident was observed sitting on the floor beside wheelchair. Under location: dining room. No injuries observed. On [DATE] at 12:58PM, V47(CNA) said she was assigned to monitor dining room on [DATE]. V47 said she was talking to another resident in the room when she heard a resident screaming. V47 said she turned around and observed R18 on the floor by his wheelchair. On [DATE] at 11:59AM, V2 (DON) said staff are to be always monitoring the dining room when there are residents in the room. Staff should be able to see all residents to ensure they are supervised and overseeing their safety. -- II. On [DATE] at 4:00AM, while walking to enter the facility, V57 (CNA) was observed through outside glass door sleeping in the hallway on unit ,d+[DATE] wing in a patient dialysis chair. On [DATE] at 4:02am, V55 (CNA) and V54 (CNA) was observed laying on a resident's Geri-chairs, with the light cut off in the dark with eyes closed consistent with sleeping. V58 (RT) said, those are the CNA 's for this unit, one is from agency. V58 did not reply when asked how long V55 and V54 were in the back, sleeping/resting in the Geri-chairs. On [DATE] at 4:13am, V55 (CNA) remained in the Geri-chair in a reclined position in the dark. On [DATE] at 4:15am, V54 (agency CNA) remained in the Geri-chair in a reclined position in the dark, eyes closed consistent with sleeping. Surveyor walked past V54 who did not move or shift. At 4:30am, V54 awoke said and I'm on break. On [DATE] at 2:12PM, V2 (DON) said staff should not be sleeping because they are on the job and cannot monitor residents. Staff should be monitoring for safety, and you cannot do that if you are sleeping. On [DATE] at 12:10PM, V1 (Administrator) said certified nursing aides are expected to be rounding on patients at least every two hours, answering call lights and completing any assigned tasks. For residents on the vent unit, staff should be rounding more frequently but at a minimum every two hours. Staff should not be taking breaks in residents areas and should not be sleeping on units. V1 said she reviewed the video footage on that morning and observed V55 (CNA) in chair for almost two hours, V54(CNA) for almost an hour and V57 (CNA) was in chair for fifteen to twenty minutes before surveyors arrived in the building. Those staff were all terminated or placed on do not return list. Certified nursing job description undated documents: the certified nursing assistant (CNA) is responsible for providing resident care and support in all activities of daily living and ensures health, welfare, and safety of all residents. Midnight census dated [DATE] documents 27 residents on unit 1-A. CNA assignment sheet dated [DATE] 11am- 7 shift documents V57 (CNA) was assigned to midnight census dated [DATE] documents - 10 residents. On 8.4.23, at 4:00 am, three surveyor staff entered the facility through the main door. The main door was an automatic double sliding doors that were observed open. The second door which was an automatic sliding door was observed open as well. There were no staff present at the front desk. Surveyor were able to walk right into the facility and enter the ,d+[DATE] unit. On [DATE] at 2:40PM, V101 (consultant) said there is a nursing station desk at the second door and staff are usually at the desk to see anyone coming in or leaving. If staff are rounding or providing patient care they should still be able to see anyone coming or leaving the building. On [DATE] at 11:57AM, V101 (consultant) said the facility entrance doors would preferrable be closed during off hours to ensure nothing comes in that is not supposed too. On [DATE] at 2:20PM, V2 (DON) said they do not have anything in place for someone monitoring nursing station/ desk on overnights. Facility census dated [DATE] documents: 140 residents 41156 III. Nursing note documented on [DATE] at 6:23AM, reads in part: R16 was found unresponsive and with no pulse or respiration by the nurse at approximately 6:15AM. Code blue called. 911 called. R16 was still warm to the touch. CNA stated she last saw resident at around 4 am, and R16 was able to open his eyes. On [DATE] at 12:00 PM V16 (RN) stated V16 was assigned R16 on [DATE] night shift. V16 stated the last time he saw R16 was at around 2 am and CNA last saw R16 around 4 am. At approximate 6 in the morning, V16 noted R16 was unresponsive with no pulse and not breathing. V16 called code blue and other staff came into the unit. CPR was initiated by other nurses while V16 called 911. Paramedics then arrived and took over the care. Paramedics called the time of death at approximately 6:30 in the morning. V16 stated V19 (RN) responded to the code blue, and one agency nurse, but cannot recall the name. V16 stated he worked double that night, ,d+[DATE] and ,d+[DATE] shift. V16 stated, during the evening shift, R16's family was at bedside and R16 was not in distress. During the last round V16 saw R16 breathing, asleep with the rise and fall of chest. On [DATE] at 11:30 AM, V18 (CNA) stated she does not recall R16 and that V18 is an agency staff and works in different facility. Denied remembering R16 or any situation in the facility that a 911 was called and a resident expired. Reviewed Point of Care documentation where CNA documents the care given to a resident. Dated [DATE], all shifts with no documentation and no initials to show a care was provided. Fire Department report dated [DATE], reads in part: dispatched 6:22:48. Dispatched for cardiac arrest. Crew found staff performing CPR (Cardiopulmonary Resuscitation). Crew asked staff when was the last time R16 was seen alive. Staff said they did not know that they are from different wing and was asked to help. Crew assessed R16 and found to be cold to the touch, rigor, mottled skin, and pooling of blood to the back side. Cardiac monitor was placed and the rhythm noted was Asystole. Time of death 6:34AM. Bilateral eyes, nonreactive, fixed. On [DATE] at 10:00 AM, V39 (Cook County Medical Examiner Investigator Badge number 73) stated that rigor mortis obvious by 2 hours after death on limbs, and after 6 to 8 hours rigor mortis will start to go away. Blood pooling becomes more obvious 3 to 4 hours after death. It is okay to say that a body with obvious blood pooling in the back side had expired ,d+[DATE] hours when found with obvious sign of death, such as blood pooling. On [DATE] at 12:00 PM, V1 (Administrator) the facility does not have a specific rounding/monitoring and supervision policy. Facility practice is to check on residents at least every 2 hours, or often as needed. On[DATE] at 3:00 PM, V9 (Director of Nursing) stated that nursing staff are expected to check on the residents at least every 2 hours, change and provide care as needed. Check for safety and for any changes in condition and report to the attending doctor.

Based on observation, interview and record review, the facility failed to assess, monitor, prevent urinary tract infections and secure indwelling catheters. This affected four of four (R6, R7, R27, R39) residents reviewed for indwelling catheter and catheter care. This failure resulted in R6 sustaining labia wound consistent with the width of the indwelling catheter, R7 being diagnosis with sepsis due to polymicrobial infection, R27 having a partially obstructed urine output with feces caked on the catheter and R39 who had a history of urinary retention complaining of abdominal pain which result in a urinary tract infection. Findings includes: (R6) R6 had the diagnosis of Neuromuscular Dysfunction of Bladder. Minimal data set dated [DATE] section H documents: indwelling catheter On 7/28/23 at 9:37am, V38 (medical doctor) said, R6 did not received Foley catheter care using any aseptic techniques. R6's Foley insertion site was not cleaned properly. The facility was not practicing infection control protocols. There is no way that many bacteria are jumping into a Foley without facility staff spreading contaminates. Emergency Department (ED) note dated 4/8/23 documents: Foley catheter is out and is draining white pus material. ED diagnosis documents: Urinary tract infection associated with indwelling urethral catheter. R6's old catheter from nursing home was not stabilized with a stat lock or tape to the leg and only was being held by R6's diaper. While changing out the Foley a wound was found to the labia with the same width of the Foley catheter. Urine Culture collected date 4/8/23 at 2014 (8:14 pm) documents: Three or more organisms present (polymicrobial sepsis): gram positive cocci in chains, staphylococcus and yeast, etiology was unclear. R6 was admitted with UTI possible urosepsis. (R7) R7 had the diagnosis of Neuromuscular Dysfunction of Bladder. Minimal data set dated [DATE] section H documents: indwelling catheter On 8/4/23 at 9:19am, V59 (nurse practitioner) said, R7's Foley infection was related to poor care. Hospital paperwork dated 4/14/23 documents: R7 was admitted to the floor at this time. Urine culture positive for proteus mirabilis and Providencia stuartii. UA dated 4/14 with moderate leukocytes and many bacteria. Nursing admission report undated documents: Sepsis secondary to UTI. (R27) R27 was diagnosis with Anoxic Brain Damage, Acute Respiratory Failure with Hypoxia, encounter for attention to Tracheostomy, dependence on respirator (ventilator), End Stage Renal Disease Dependence on Renal Dialysis and Pressure Ulcer of Sacral (Stage 4). Minimal data set section H (bladder and bowel) dated 6/7/23 documents: Indwelling catheter On 7/28/23 at 9:37am, V38 (medical doctor) said, R27's Foley catheter was infected. The cultures showed multiple drug resistance organisms. R27's catheter was not changed appropriated if at all. The insertion site was not cleaned properly. The facility was not practicing infection control. There is no way that many bacteria are jumping into a Foley. On 7/28/23 at 3:11pm, V43 (wound tech/CNA) said, R27 had a Foley. V43 said when R27 had a bowel movement, the fecal matter would come up in between R27's legs and cover the Foley. After a bowel movement, R27's Foley tube would need to be clean from the insertion site down. V43 said V43 did not provide any care for R27. R27 was discharged to the hospital. On 7/28/23 at 3:52pm, V45 (restorative aide) said, V45 provided ADL care for R27 with V43. On 8/4/23 at 9:44am, V4 (wound nurse) said V4 didn't see any Foley orders for R27. R27's physician order sheet dated 7/1/23 - 7/31/23- did not document any Foley order. Hospital paperwork dated 7/21/23 documents: Foley looks like it was sliding in and out with caked on stool, kinked and foul-smelling. R27's Foley and penis was caked with stool. Foley was knotted through the stat lock partially obstruction output. (R39) R39's minimal data set dated [DATE] section H documents: indwelling catheter On 8/10/23 at 2:00pm, R39 was observed to have the tubing from indwelling catheter through the stabilization device attached to R39's left upper anterior thigh. This tubing was draped over R39's left lateral thigh, under left thigh, under R39's left hand, and then draped over the bed. R39's indwelling catheter was not visible. On 8/10/23 at 2:00pm, V30 RN (registered nurse) stated R39's indwelling catheter tubing looked okay. When questioned if the indwelling catheter or the tubing should be inserted through the stabilization device on R39's left thigh, V30 appeared puzzled and did not respond. When asked to see R39's indwelling catheter, V30 again appeared puzzled and did not respond. This surveyor asked V30 to remove the fastener on R39's incontinence brief and pull back brief so catheter could be visualized. R39's catheter was under penis, went down the right side of scrotum, under scrotum, and ended at left groin. When questioned if R39's catheter looked okay, V30 responded yes. This surveyor asked V30 to reposition R39's indwelling catheter so skin under catheter could be assessed. R39's skin was reddened from the catheter. Progress noted dated 8/6/23 documents: R39 was sent out for lower abdominal pain, ended up having urinary retention. R39's urine culture results, dated 8/10/23 documents: urine with more than 100,000 colonies/ml candida albicans: candida infection. Progress noted dated 8/13/23 documents: R39 complains of abdomen pain. Visibly upset, anxious and concerned that there is something wrong. Progress noted dated 8/14/23 documents: R39 was transported to the hospital. Policy, revised 9/1/2016, notes catheter stabilization shall be used to preserve the integrity and position of the catheter.

Based on interview and record review, the facility failed to monitor and implement an effective to plan to prevent an unplanned significant weight loss for residents receiving enteral feedings. This affected two of three residents (R6, R46) reviewed for significant weight loss. This failure resulted in R6 having a 15.8% weight loss in one month (2/2/23 - 3/7/23) and R46 having a 12.9% weight loss in two months. Findings Include: (R6) R6 had the diagnosis of dysphagia and encounter for gastrostomy tube. On 7/26/23 at 11:08am, V44 (dietitian) said, on March 30th R6 had a weight loss. V44 was going to increased R6 feeding but R6 was sent to the hospital. On 7/26/23 at 11:26am, V29 (nurse) said, V29 pushed air into R6's g-tube to check for placement and R6 grimaced with pain and R6 had a bulge and redness at the g-tube site. R6's progress note dated 4/4/23 documents: Writer (V29) noticed bulging on g-tube site. Auscultated and no sound detected. Noted grimacing when flushed with air. R6 was discharged to the hospital. R6 returned. emergency room doctor checked and it was only the balloon. On 7/27/23 at 12:38pm, V30 (nurse) said, R6 had a problem with her g-tube being flush and grimaced with pain a few days prior to my assessment. I flushed R6's g-tube and noticed a bulged at the g-tube site. R6 was sent to the hospital on 4/8/23 for a dislodged PEG tube. Progress note dated 4/6/23 documents: (V30) observed resident (R6) grimacing upon air flushing and observed bulging. Feeding stopped. On 8/16/23 at 4:15pm, V44 said, V44 was looking through the R6's chart. V44 said, R6's weight for February was the same weight recorded in the hospital so V44 cannot vouch for that weight being accurate. V44 said V44 requested a re-weight that was not done for February. R6 had the monthly weight recorded in March. V44 said, the goal was to get R6 to gain weight. On 7/28/23 at 9:37am, V38 (medical doctor) said, R6 had malabsorption related to stopped feeding. On 8/15/23 at 1:54PM, V2 (DON) said, if a resident was receiving gastronomy tube feeding, they should not lose weight. Dietitian note dated 3/30/23 documents: R6 has a significant weight loss. 2/13 (readmit weight per hospital)-136.6#, 2/2-152.1#, 1/19 (adm)-150.6#. Weight loss of -6.3% x 2 weeks, -15.8% x 1 mo. R6's weight report document: dated 4/4/23 - 124.3 pounds, 3/7/23- 128.0 pounds, 2/13/23 -136.6 pounds 2/2/23 - 152.1 pounds. Physician order sheet dated 2/16/23 documents: Glucerna 1.5 Cal @ 50 mL/h VIA PUMP ASSIST x 21 h or until 1050 mL given. May hold TF 1 h q shift for wound care, other ADLs. Hospital paper dated 4/8/23 documents: R6 presented to the ED with the chief complaint of g-tube dysfunction. Tube has not been functioning for the past four (4) days per emergency medical service (EMS) report. Nursing home stated they were unable to flush anything through or give tube feeding, so they have been infusing an unknown amount of dextrose through an IV they placed. Percutaneous gastrostomy (PEG) tube not appearing to be in correct place/mal positioned. ED diagnosis documents: Gastrostomy tube dysfunction: Dysphagia: severe protein calorie malnutrition with PEG tube. R6's weight was 119 pounds and 0.8 ounces R46 R46 was admitted to the facility on [DATE] with a diagnosis of anoxic brain damage, moderate protein-calorie malnutrition, dysphagia, and encounter for gastrostomy, pressure ulcer stage four, anemia, and persistent vegetative state. On 8/4/23 at 5:50am, V2 assessed R46 for incontinence. R46 was lying on right side and was turned onto her back. R46's gown was wet. V2 lifted R29's gown and observed a face towel wrapped around R46's gastrostomy tube. V2 stated, V2 was informed that this is a chronic problem for R46 because stoma is large. V2 said the towel should not be wrapped around R46's tubing, there should be a gauze dressing/drain sponge at the insertion site. V2 said, R46's stoma is draining a lot. R46's stoma was observed to be oozing brown liquid consistent with the brown enteral feeding being pumped through R46's g-tube site. R46 was oozing from the proximal stoma with every inspired breath. V2 said, R46's feeding should not be oozing out. V2 said the nurse is expected to notify the physician and not just wrap a towel around it. V2 said, if R46's feeding is oozing out it can't be determined how much feeding R46 is actually receiving. On 8/15/23 at 1:07pm, V44 (dietician) said, V44 was not notified of any additional weight loss for R46 for the month of August by the facility. V44 said, V44 found out about R46's current weight loss through a chart review last week. V44 said, V44 has not made any changes yet to R46's tube feeding due to the facility not having their monthly Nutritional at risk meeting because Illinois Department of Public Health (IDPH) was in the building. V44 said, it was on V44's to-do list. V44 confirmed, R46 sustained a 6.9% weight loss in one month which was significant. R46 had a 12.9% weight loss in three months after review of current August weight. V44 said, V44 increased R46's feedings on 7/30/23 due to weight loss and requested a reweigh of the resident to ensure weight loss. V44 said, V44 never received the re-weigh information and does not see the information in medical record. V44 said, V44 would not expect R46 to lose weight nor was R46 on a weight loss program but there can be other factors contributing to weight loss like malabsorption, diuretic use or wounds. On 8/15/23 at 1:54pm, V2 said, V2 was just made aware of R46's weight loss. V2 said if a resident was receiving gastronomy tube feeding, they should not lose weight. A resident may have weight loss which can vary based on resident's co-morbidities. V2 said, V2 did not see any follow-up for the progress notes 6/4/23 and V2 would expect someone to follow-up with R46's gastronomy tube site leaking because that is not expected. R46's weight loss could be associated with the gastronomy site leaking due to resident not receiving feeding. We do monthly weights to evaluate any trends and put in new interventions. V2 said R46 doesn't not have a reweighs. R46's weight summary documents on 8/9/23 weight 122.4 pounds 7.5 percent change comparison to weight 6/6/23 140.6, 12.9 percent 18.9 pounds; 5.0 percent change over 30 days comparison weight 7/10/23 131 pounds 6.9 percent nine pounds. 7/10/23 weight 130.6 pounds 5 percent change over thirty days comparison weight 6/6/23 141 pounds which 7.1 percent loss of ten pounds; 6/6/23 weight 140.6; 5/4/23 132 pounds; 4/4/23 133.8 pounds; 3/11/23 132.4 pounds; 3/6/23 135.2 pounds. R46's progress note dated 6/4/23 documents: Patient has an increased work of breathing (WOB). Upon assessing patient, patient has leakage around the gastrostomy tube site. Nurse notified. R46's dietary note dated 7/30/23 documents: current tube feeding orders: 1.5 Cal at 45 milliliters/hour x 18 hour via pump assist or until 1080 mL given. Weight 130.6pounds (7/10), BMI 29.3 (overweight, Body mass index BMI not accurate for heights under 60). Weight history: 6/6-140.6 pounds, 5/4-132 pounds, 4/4-133.8pounds, 3/6 (admission)-135.2pounds. Weight changes of -7.1% x 1 month, -2.4% x 3 months. Previously triggered for significant weight gain (in June). Increase feeding rate related to weight loss. Enteral feeding 1.5 Cal at 55 milliliters/hour x 21 hour via pump assist. Weight Monitoring Policy undated documents: To ensure the client maintains acceptable parameters of nutritional status unless their clinical condition demonstrates that this is not possible.

Based on observation, interview and record review, the facility failed to follow their gastrostomy tube (g-tube) policy by not monitoring, assessing or inspecting the stoma site for placement, signs of infections, and gastric leaking. This affected three of three residents (R6, R46, R10) reviewed for G-tube policy and procedures. This failure resulted in (R6) being hospitalized with an infected g-tube site which required surgical interventional; R46's g-tube feeding leaking out at the insertion site with each inspiration; and R10 having leaking g-tube site with no dressing. Findings Include: R6 On 7/26/23 at 11:26AM, V29 (nurse) said, V29 checked R6's g-tube for residual without any issues then I pushed air into R6's g-tube to check for placement. R6 grimaced with pain. V29 said, V29 saw a bulge/bubble and redness at R6's g-tube stoma. R6 was sent to the hospital and returned. The hospital did not do anything for R6 g-tube. Progress note dated 4/4/23 documents: Writer (V29) noticed bulging on g-tube site. Auscultated and no sound detected. Noted grimacing when flushed with air. R6 was discharged to the hospital. R6 returned. emergency room doctor checked and it was only the balloon. On 7/27/23 at 12:38pm, V30 (nurse) said, V30 flushed R6's g-tube and noticed a bulged at the g-tube site. V30 got an ordered for a stat abdominal x-ray that was not done when ordered. R6 was sent to the hospital on 4/8/23 for a dislodged PEG tube. Progress note dated 4/6/23 documents: (V30) observed resident (R6) grimacing upon air flushing and observed bulging. Feeding stopped. STAT KUB. Radiology report dated 4/7/23 documents: Percutaneous gastrostomy tube overlies the left upper abdominal quadrant, for intraluminal confirmation, consider repeat imaging with pre and post air administration. Radiology report dated 4/8/23 documents: Tip of gastrostomy tube is not adequately within the stomach after air insufflation. On 7/28/23 at 9:37am, V38 (medical doctor) said, R6 was hospitalized with an abscess in the abdominal wall due to poor g-tube care and insufficient/poor dressing changes, if any. R6's g-tube infection was associated with extremely poor gastrostomy care and infection control practices. Infection spread to the abdominal wall. Microorganism deposited air, air leaked into R6's abdominal wall resulting in a very serious but preventable infection that required surgical debridement and drain in place. R6 had a multiple drug resistance polymicrobial infection. This massive infection made it hard to remove R6's old g-tube. R6's blood stream was infected as result of the g-tube infection. R6's blood culture contained yeast. Yeast does not naturally grow in the blood. R6's g-tube was not clean properly. R6 had to be given total parenteral nutrition intravenously. On 8/4/23 at 8:08am, V2 (DON) said, Y/N -on the medication administration record (MAR) is asking, (Y) means yes it was done or (N) means no it was not completed, it is my expectation to document every task complete, if its blank, that task was not completed or didn't happen. Medical Administration records dated 3/1/23 - 3/31/23 document: G-tube care and dressing change every night shift Y/N. On 3/2/23, 3/3/23, 3/5/23, 3/6/23, 3/15/23 and 3/20/23 documents: (N/no) and 3/9/23, 3/14/23, 3/16/23, 3/19/23, 3/23/23 and 3/27/23 was blank/no documentation. Medical Administration record dated 4/1/23 - 4/8/23 document: G-tube care and dressing change every night shift Y/N. 4/2/23 and 4/6/23 was blank/no documentation. Hospital paperwork dated 4/8/23 documents: R6 present to the emergency department (ED) with the chief complaint of gastrostomy tube dysfunction. Tube has not been functioning for the past four (4) days per emergency medical service (EMS) report. Nursing home stated, they were unable to flush anything through or give tube feeding, so they have been infusing an unknown amount of dextrose through an intravenous (IV) they placed. G-tube with drainage around the insertion site. Percutaneous gastrostomy (PEG) tube not appearing to be in correct place/malposition. Abdominal x-ray report with G-tube in indeterminate location. R6 presented from the nursing home for G-tube malfunction, buried bumper/entrapped bumper with feeding leaking to G-tube site track. It is not clear how long this buried bumper syndrome has been ineffective. Minimal tenderness noted at the PEG site. Abdominal exam reveals soft, with 2 milliliter mm x 2 mm opening over previous G-tube site 20mL of foul smelling purulent drainage with white specks suspected to be particulate of feed present. Purulence expressed from former G-tube site, recommend ostomy bag to be place over opening. R6 was admitted with fever and leukocytosis. Not a simple G-tube replacement. Sever dissecting soft tissue infection deep to the edge abdominal wall extending from the level of the catheter balloon into the lower pelvis and beneath the fascia. JP drain remain in place at prior PEG tube location with purulent output. Decreasing but persistent air-fluid collection along the left ventral abdomen and in the lower abdomen/pelvis with coiled surgical drain with tip terminating in the left upper quadrant cranial to the dominant component of air fluid in the left central abdomen. Active infection and drainage of pus/feeding tube. Localized infection due to poor gastrostomy site care at nursing home. Gastrostomy Tube-Feeding and care dated 8/3/20 documents: Stoma site care: inspect the surrounding skin for redness, tenderness, swelling, irritation, purulent draining, or gastric leakage. R46 On 8/4/23 at 5:50am, V2 assessed R46 for incontinence. R46 was lying on right side and was turned onto her back. R46's gown was wet. V2 lifted R29's gown and observed a face towel wrapped around R46's gastrostomy tube. V2 stated, V2 was informed that this is a chronic problem for R46 because stoma is large. V2 said the towel should not be wrapped around R46's tubing, there should be a gauze dressing/drain sponge at the insertion site. V2 said, R46's stoma is draining a lot. R46's stoma was observed to be oozing brown liquid consistent with the brown enteral feeding being pumped through R46's g-tube site. R46 was oozing from the proximal stoma with every inspired breath. V2 said, R46's feeding should not be oozing out. V2 said the nurse is expected to notify the physician and not just wrap a towel around it. V2 said, if R46's feeding is oozing out it can't be determined how much feeding R46 is actually receiving. On 8/11/23 at 2:16pm, V2 (DON) said, V2 asked V56 (nurse) to check R46's g-tube site. V56 applied a drain sponge and the drainage stop. V2 said, V56 called the doctor but V56 did not document it. If it's not documented is not done. On 8/11/23 at 2:22pm, V56 (nurse) said, V2 texted me to check R46 due to her g-tube draining. When V56 assessed R46, R46 was on her back, head up and G-tube site was not draining. I applied a drain sponge and told the day shift nurse to call the doctor. I did not call the doctor. I would not call the doctor if I did not observe any drainage. On 8/15/23 at 2:46pm, V96 (diagnostic imaging personnel) said, the R46 g-tube placement cannot be confirmed which is why a non-ionic contrast was suggested. Air inflation in a negative pressure ionic contrast. Respiratory note dated 6/4/23 documents: patient (R46) has an increased work of breathing (WOB). R46 has leakage around the g-tube site. Progress note 8/11/23 documents: Reported by CNA residents (R46) g-tube ostomy is leaking. Writer immediately attended and assessed. Resident noted with scant drainage on g-tube site, non-distended, bowel sounds are present in all quadrants. Ordered STAT KUB. Abdominal 1 view dated 8/12/23 documents: Gastrostomy tube seen in place with tip in left mid abdomen, its position cannot be commented, wound recommend non-ionic contrast injected via gastrostomy for tip confirmation. Gastrostomy Tube-Feeding and care dated 8/3/20 documents: Stoma site care: inspect the surrounding skin for redness, tenderness, swelling, irritation, purulent draining, or gastric leakage. R10 On 7/27/23 at 9:40am, R10 was observed lying in bed. R10's gown was observed to have a 3 inches x 5 inches area of dried dark red drainage over R10's upper abdominal area. On 7/27/23 at 10:55am, V33 CNA (certified nurse aide) was observed providing incontinence care for R10. When V33 removed R10's gown, drainage on gown was directly over R10's gastrostomy site. R10 did not have a dressing at gastrostomy tube insertion site. On 7/27/23 at 12:10pm, V31 LPN (licensed practical nurse) stated the night shift nurse is responsible for changing the gastrostomy tube insertion site dressing. V31 stated he is unsure if R10 currently has a dressing at gastrostomy tube insertion site. V31 stated all gastrostomy tubes should have a dressing unless physician orders no dressing. On 7/27/23 at 12:30pm, V30 RN (registered nurse) stated all gastrostomy tubes should have a dressing covering insertion site. V30 stated the nurse on night shift is responsible for changing this dressing. V30 stated if a dressing is not present, V30 will place dressing after cleaning site with normal saline.

Based on interview and record review, the facility failed to follow their pain policy by not developing an effective pain management plan for one resident with persistent pain and break through pain after 1 to 2 hours. This affected one of three residents (R17) reviewed for pain management. This failure resulted in R17 experiencing episodes of pain crying to staff, expressing being unhappy with current pain management plan and requesting to go the hospital. R17 required spinal surgery for hardware and pain management. Findings include: R17 admitted to the facility on [DATE] with a diagnosis of major depressive disorder, cyst of pancreas, cauda equina syndrome, hyperlipidemia, vascular disease, fusion of spine, wedge compression fractures t7- t10 vertebra and hypertension. R17's brief interview for mental status score dated 4/6/23 documents a score of 15/15 which indicates cognitively intact. R17's Minimum Data Set, dated dated dated [DATE] under section J pain management documents: have you had pain or hurting in last 5 days with a score of 'yes'. On 8/4/23 at 9 :10 AM, R17, who was alert and oriented at time of interview R17, said she was taking pain medication two to three times a day with no relief. R17 said she told everyone about her pain with no changes. R17 said pain medication would relieve her pain for an hour to two hours but then return. R17 said she would get Tylenol in-between for pain but was not helpful. R17's progress note dated 4/15/23 documents: Resident complained of pain despite having Morphine 15 mg q 12 hours. Notified V84 (MD) with order Acetaminophen 325 mg give 2 tabs every 4 hours. Noted and carried out. R17's progress note dated 4/18/23 documents: R17 informed writer that she is still having unresolved pain from her mid back throughout the day even with scheduled morphine medication. Writer called V88 (neurosurgeon) office and spoke to staff who will give the message to the nurse. A nurse will callback. R17 encounter note dated 5/16/23 reviewed: patient reports she has had excruciating pain over the past month without an inciting event. Pain is located between her scapula at the top of her construct. No weakness. During encounter patient became tearful and stated if she had to live with the pain any longer, she would kill herself. Orders placed CT of spine, Xray scoliosis and referral to pain clinic. Pain documents as 10/10 worst pain ever. R17 palliative progress note dated 5/18/23 documents: R17 reports pain 8/10 pulling, stabbing in the back radiating up to bilateral scapulae and around towards the chest with sharp poking pain, pain worse since revision surgery in 11/2022. R17 admits she feels the screws in her back and reports fair relief from her current treatment. R17 palliative progress notes 6/6/23 documents: R17 reports pain in back radiated to chest, moderate to severe, worse with movement. Patient reports pain with deep breathing, sneezing and cough- reports increase in symptoms in the past week. R17's progress note dated 6/25/23: patient seen in follow up for back pain. Not happy with current pain management. Discussed with daughter in detail neuro surgery referral ordered. R17's progress note dated 6/27/23 documents: Daughter and resident requesting to send resident out to the emergency room to be evaluated for her back pain. R17 reported pain is eight out of ten. R17 hospital records dated 6/28/23 documents under history: R17 with pertinent thoracic and lumbar fusion as well as recent traumatic burst fracture of lumbar region with compression fracture T7 through T10 presents now for evaluation of severe back pain. Patient reports the pain has become progressively worse in the last couple of weeks now not responding to medications in her current skilled nursing facility. She (R17) reports back in May that in the process of returning for a follow-up visit she was inappropriately strapped in to wheelchair on what a tipping over resulting in an acute injury. Patient reports that the pain is most severe in the mid part of her upper back right between her shoulder blades and she is reporting shooting pain down her right arm and wrapping around the right side of her chest. The right side of her chest discomfort is worse with deep inspiration. Nursing home records reviewed but no discrete indication for the transfer was contained. She did however have prior plain films done at the nursing facility which revealed what they described as burst compression fractures in both the thoracic and lumbar regions. Recent imaging reflects: Impression 1. Noncontract cervical and thoracic spine CT examinations shows new findings at the cranial termination of multilevel posterior instrumentation/fusion of the thoracic segments as detailed. 2. Findings are consistent with fusion failure and possibly discitis/osteomyelitis at T3/T4 level. 3. The cervical segments show multilevel deformities of disc related spondylosis in the upper and mid cervical segments as noted. Under chief complaint and reason for admission documents T5 vertebra fracture and hardware failure. Hospital note dated 6/28/23 documents: The patient is a [AGE] year-old female, known to the Neurosurgery Service. The patient has had a previous T10 to pelvis, which required extension of hardware all the way up to the level of T5, which she had proximal junctional kyphosis. At that time, the surgery was done and it went very well. This was done back in September of 2022. She recovered very nicely. However, over a period, she developed increased stress along the level of T4, the un-instrumented level resulting in proximal junctional kyphosis to the point at which the vertebral body collapsed. Once the vertebral body collapsed, she developed some significant amount of back pain and numbness and tingling in the thoracic dermatomal distribution. She came in for evaluation and a scoliosis film was performed and it was evident that she had a positive sagittal balance, which required correction of the kyphotic deformity. She was a surgical candidate and was taken to the OR for correction. On 8/10/23 at 10:10AM, V49 (Nurse) said R17 would complain of back pain most days she took of her. R17 would usually rate her pain 8/10. R17 had scheduled pain medication twice a day and she would usually ask for additional mediation in the afternoon. R17 had a Tylenol as needed order. V49 said she did not think Tylenol was working anymore for R17, but she was being seen by palliative and neurosurgeon. V49 does not recall contacting V88 (neurosurgeon) about pain except once because R17 was requesting an appointment sooner because of her pain but was unable to get a sooner appointment. On 8/10/23 at 11:20AM, V9 (ADON) said R17 was always in pain and was referred to palliative on 5/18/23. R17 was having more pain after the fall on 5/16/23. Nurses are expected to call the doctors when there is a change and if pain worsens, then resident should be sent out to the hospital. On 8/9/23 at 10:07AM, V93 (palliative nurse) said she was referred to see R17 in May for more psychosocial support. V93 said R17's pain was being managed by pain clinic at hospital and they would the primary source for prescribing or changing pain medication. On 8/9/23 at 11:26am V84 (MD) said R17 was having pain from surgery in her back. R17 pain was being treated with morphine, Norco and Lidoderm patch. CT scans performed on 6/16/23 were ordered by V88 (neurosurgeon) and not aware of results or findings. Xray was done on 6/25/23 and referred to V88. R17 was receiving a high dose of controlled pain medications and did not feel comfortable with patient being on additional medications due to her small size. Patient was being followed by palliative and rehab for pain management On 8/10/23 at 3:03PM, V91 (pharmacy) said 15 mg is the lowest dose of morphine and is not weight based. Recommended to start with lowest dose for short period of time and monitor for effectiveness. V91 said, 15 mg can be given every 8 hours but would be based on doctor preference and patent tolerance. On 8/10/23 at 2:52PM, V92 (CNA) said R17 was in pain all the time. She was crying form the pain and would ask me to get the nurse for pain pills. On 8/1/23 at 12:55, V25 (therapy) said R17 was referred to therapy on 5/26/23 but refused evaluation due to pain. Pain management program revised 1/29/18 documents: to establish a program which can effectively manage pain in order to remove adverse physiologic and physiological effects of unrevealed pain and to develop an optimal pain management plan to enhance healing and promote wellness.

Based on interview and record review, the facility failed to ensure the contracted radiology contractor conducted a stat x-ray instead of a routine/standard x-ray. This affected one of three residents (R1) reviewed for radiology testing per order. This failure resulted in R1 having to wait 7 hours for an x-ray and treatment of a which revealed right femoral neck fracture. Finding include: R1 admitted to the facility on [DATE] with a diagnosis of type II diabetes, kidney disease, encephalopathy, and history of falling. R1's progress note dated 4/20/23 at 7:30AM documents: Endorsed by night nurse that (R1) resident was seen by CNA from the nursing station walking out of his room, (R1's) knees buckled and CNA ran to steady R1 but was not able to hold him on time and R1 fell on his right side. Head to assessment done and noted facial grimacing upon movement on right leg. Resident (R1) verbalized pain on his right knee. No swelling/redness/bruising noted. No shortening of the extremity. Doctor aware and received order STAT x-ray of right knee/right hip. R1's physician order sheet dated 4/20/23 at 8:00AM, x-ray of right hip and right knee stat. On 7/26/23 at 1:51PM, V26 (x-ray representative) said R1's x-ray was called in as a stat x-ray on 4/20/23 at 8:03AM, informed nurse that it would not be able to do it stat. Technician arrived at 2:02PM, results faxed to the facility 2:12PM. Facility was called at 3:20PM to report results. On 8/9/23 at 11:59AM, V2 (DON) said stat x-ray should be performed within 4 hours. If they are unable to provide service within time frame then the doctor should be notified and possibly send resident to emergency room . R1's medical record did not document any documentation to the doctor after x-ray order to inform of delay in x-ray. R1's right hip x-ray dated 4/20/23 documents: There is a contour deformity of the right femoral neck, with questionable lateral lucency. Findings suspicious for femoral neck fracture. Recommended CT for further evaluation. R1 progress note dated 4/20/23 at 2:56PM documents: ambulance called and gave an estimated time of arrival of one hour to one and one half hours. R1 progress note dated 4/20/23 at 4:11PM documents: resident transported to local hospital.

Based on interview and record review, the facility failed to apply foot rests to a wheelchair for 1 of 3 residents (R2) reviewed for falls. This failure resulted in R2 falling forward, hitting her head, requiring emergent transfer to local hospital and was found to have small acute subdural hematoma. Findings include: On 10-3-18 at 12:30PM, V2 (Director of Nursing/DON) stated R2's initial and subsequent fall assessments note R2 is a high fall risk. V2 stated that foot rests prevent injury to lower extremity and support lower extremity. On 10-5-18 at 11:50 AM, V3 (Nursing Supervisor) stated on 7-25-18, R2 requested to have a pillow on her back which could have made her lean forward in the wheelchair. R2 put her feet down causing her to fall out of the chair. Foot rests could prevent feet from touching the ground. If staff is pushing a resident in a wheelchair, they should use foot rests for safety to prevent feet from touching the ground. On 10-3-18 at 1:25 PM, V7 (Certified Nurse Aide/ CNA) stated he assisted R2 to her wheelchair for her breakfast meal around 8:00 AM, V7 was pushing R2 in her wheelchair to the dining room without the foot rests. He stated R2 was able to lift her legs up but suddenly leaned forward, put her feet down, and fell forward. V7 admitted that he did not apply foot rests to the wheelchair. V7 also stated R2 is a fall risk from her bed and has floor mattress. On 10-3-18 at 1:44 PM, V8 (Registered Nurse/ RN) stated she did not witness R2' s fall. V7 reported the fall to V8. V8 arrived and R2 was on the floor with V7 present. There was a laceration to R2' s head. V8 came less than 30 seconds after the fall. R2 was alert, talking, and able to move her extremities without pain. V8 treated R2' s laceration and applied gauze. R2 told V8 that she fell from the wheelchair. Nurse treated the laceration, notified the Nurse Practitioner, and sent to local Emergency Department (as ordered). V8 stated that she applies resident foot rests when pushing a resident in their wheelchair. On 10-5-18 at 10:24 AM, V9 (Minimum Data Set/MDS Coordinator) stated G0400 on MDS dated [DATE] notes R2 is having limited range of motion/ limitations to both lower extremities. On 10-3-18 at 2:29 PM, V10 (Physical Therapist) stated foot rests are for safety. If a resident is self-propelling, they do not need foot rests. If V10 is pushing a resident in their wheelchair, V10 would use the foot rests. Therapists always use foot rests when transferring R2 or any resident to the therapy area. R2 is a high fall risk due to shuffling gait and anxiousness. On 10-3-18 at 2:08 PM, V12 (Restorative Nurse) stated R2 is able to self-propel her wheelchair via pedaling and using her arms. If R2 is self-propelling, she would not need her leg rests. If she is being pushed in her wheelchair, R2 should have foot rests on her wheelchair. No one can predict when their feet will come down. R2 has limitations to both lower extremities. R2 has a history of falls. This indicates lower extremity weakness. R2' s Fall incidents (6-18-18 and 7-28-18), nursing notes, SBAR forms, physical therapy notes, and Fall care plans (updated) were reviewed. Fall Prevention Program revision date 4-16-13 was reviewed. Initial and subsequent fall assessments (12-26-15 and 6-1-18) note R2 is a high fall risk. R2' s Hospital Medical Record dated 7-25-18 at 1:50 PM documents R2 has a history of injury. Hospital record documents R2 stated she was being pushed in her wheelchair when her foot was caught and she fell forward hitting the front of her head on the wall corner. Hospital Medical Record dated 7-25-18 at 2:23 PM documents Impression: small acute subdural hematoma adjacent to lateral convexity surface of the left cerebral hemisphere . R2's MDS dated [DATE] notes question C0500 BIMS score 9:15. Question G0110 B1 notes R2's self-transfer status as requiring extensive assistance. G0300 notes R2's balance is not steady and requires assistance. G0400 notes R2's lower extremities have impairment on both sides. R2's Physical Therapy and Plan of Treatment dated 6-1-18 to 6-30-18 notes R2 with [DIAGNOSES REDACTED]. Evaluation notes R2 has decreased postural alignment and reduced functional activity tolerance indicating the need for PT to facilitate with all functional mobility, increase functional activity tolerance and increase lower extremity range of motion and strength. Precautions: Fall risk. R2's Face Sheet notes [DIAGNOSES REDACTED]. In Service Record dated 7-25-18 and 9-4-18 notes Outline: Staff to make sure leg rests are on when patient/ resident is unable to propel self with their legs and while patient/ resident is being push while on wheelchair. Manual Wheelchair Policy dated 2006 documents leg rests are add-on extensions that support the lower extremities.

Based on interviews and record reviews, the facility failed to conduct an accurate abuse/neglect risk assessment for R1 plan and implement interventions to address R1's increased risk for abusive and aggressive behaviors; failed to conduct an accurate abuse/neglect risk assessments for R2 to identify R2's risk for increased vulnerability/potential for abuse and develop and implement care plan interventions to prevent R2 from abuse. These failures affected two of five residents (R1 and R2) reviewed for abuse in a sample of 10 residents. As a result of the failure R2 was pushed by R1 out of the wheelchair onto the floor and R2 sustained two fractures within the spine. Findings include: On (MONTH) 1, (YEAR), an initial report of potential abuse was sent to IDPH had the following information: (V5) nurse on duty informed the manager on duty (V4) that (R2) was pushed out of wheelchair by (R1). (V1, administrator) was notified. A body check was performed by (V5) and V2 (Director of Nursing). V20 (Physician) was notified and they ordered an x-ray. Investigation: (V5) reported to (V4) that around 8:20 am on (MONTH) 1, (YEAR), (R1) went into the room of (R2) and pushed (R2) out of wheelchair. Staff said they heard (R2) telling (R1) to get out of their room and by the time they got to the room, (R2) was on the floor. The resident that pushed (R2) out of wheelchair then went back to (R1's) room and laid in bed. V5 notified both MD's (V20) and (V21) and both families. Staff was made aware to give (R1) 1:1 care. (V20) ordered an x-ray of lower back finding that (R2) cracked two vertebrae and (V21) ordered that (R1) be sent to the emergency room for a psychiatric evaluation and later to be admitted to a (local hospital). Conclusion: The Resident to resident incident is determined to be founded. V1 (Administrator) was interviewed on 9/13/18 at 4:17 pm. V1 stated that R1 was sent out to hospital per involuntary petition transfer for behavior. V1 stated that R1 went into (R2's) room and pushed R2 out of the wheelchair causing a fracture on R2. V1 confirmed that R1 caused physical harm to R2 so resident to resident incident is determined to be founded. V1 stated that there was nothing that could have been differently done because the facility has implemented appropriate interventions for R1. V5 (Nurse) was interviewed on 9/14/18 at 9:16 am. V5 stated that R1 speaks Polish and wanders in other people's room. V5 stated that on the day of the incident (9/1/18), R2 was on the way back to the room from dining room; R1 was already in R2's room and R2 starts yelling, Get out of my room! V5 stated that the medication cart was parked near the entrance of the dining area. V5 stated that V5 saw V6 (CNA) yelling and running towards R2's room and by the time V5 got to R2's room, R2 was already sitting on the floor. V5 stated that V5 assessed R2. V5 stated that R2 complained that R2 was sore but range of motion was ok. V5 stated that R2 stood up and sat on chair and still continued to do what R2 usually does. V5 stated that R1 was placed on 1:1. V5 stated that V16 was informed of the incident and that at that point V5 stated that V5 was still trying to get hold of the doctor (V21). V5 stated that R1 was sent to a (local hospital). V5 confirmed that R2 sustained injury/fracture - T12 and L1 compression. V6 (Certified Nursing Assistant/CNA) was interviewed on 9/14/18 at 10:30 am. V6 stated that at the time of the incident, V6 was assisting another resident in another room and V6 heard yelling Get out of my room! V6 stated that V6 ran to that room and saw R2 on the floor and saw R1's hands up by chest like (R1) pushed someone V6 stated that R2 was trying to get up and told R2 to stay on the floor. V6 stated that I told (R1) about what (R1) did but (R1) started screaming and tried to push me too and I told (R1) to stop and then came (V11 - CNA), who working that day and (R1) brought back to room. V6 stated that R2 complained of back pain 1 hour after. V11 (CNA) was interviewed on 9/17/18 at 2:05 pm. V11 stated that R1 is very confused and speaks only polish. V11 stated that R1 needs assistance with dressing, bathing but ambulates well. V11 stated that R1 is very nervous, very crabby and talks loudly. V11 stated that R1 goes in other resident's rooms and at times, even lays down on other resident's beds. V11 stated that at the time of the incident, R1 was difficult and very nervous this day. V11 stated that V11 heard R2 loudly and went to (R2)'s room and saw R2 on the floor. V11 stated, R1 had a navy blue blanket over (R1's) arms I asked (R1) and (R1) said in polish 'I'm sorry but (R2) is not good to man' and I brought (R1) to room. V11 stated that R1 always goes in other residents' rooms and stated, Maybe in this room (referring to R2's room) because R2 is also noisy. V8 (Dementia Coordinator/Social Services) was interviewed on 9/17/18 at 3:18 pm . V8 stated that R1 was initially admitted to the first floor and then transferred to the dementia locked unit because of R1's wandering behavior - for safety, because the dementia unit is a secured unit. V8 stated that R1 was going into other residents' rooms and attempts to go into nurses' station. V8 stated that R1 is confused and got more confused as time went by. V8 stated that R1 wandered around the unit, entered other residents' rooms, rummaged through other residents' belongings, use other residents' clothes and would urinate in inappropriate places. V8 stated that R1 also only speaks Polish and would speak loudly and wander around. V8 stated that psychiatrist referral was initiated on 7/10/18 but due to R1's insurance issues, psychiatrist only saw R1 on 8/29/18 and recommended use of psychiatric medications. V8 stated that V8 does the updates to the plan of care and identifies interventions for behavior issues. V8 stated that when R1 was transferred to the dementia unit 4/25/18, interventions identified included frequent checks, group activities, wander guard and transferring to the secured unit. V8 that V8 would monitor the effectiveness of these interventions by asking staff for input. V8 confirmed that these interventions were not documented on R1's care plans and no goals were identified for these specific interventions. V8 stated that on 6/1/18 during a significant change assessment, care plans were updated to include wandering behaviors and also abuse/neglect potential risk assessment was conducted for R1. V8 confirmed that there were no goals and interventions identified addressing R1's assessment for abuse/neglect potential risk during the entire facility stay. V8 stated that on 9/1/18, R1 went to R2's room and pushed R2 out of the wheelchair. V8 also stated that this is the first time R1 had an altercation with fell ow resident. V8 stated that staff could have redirected R1 to go to the dining room but at that time, which was around breakfast time, the CNAs are usually getting residents up, the activity staff are assisting other residents in the dining room for breakfast and there is only 1 nurse - who would be usually passing medications at that time. V8 was interviewed again on 9/19/18 at 5:00 pm and confirmed that R2 had a significant change in condition assessment. V8 confirmed that R2's risk assessment for abuse/neglect potential was done on 11/2017 and was not reviewed to reflect current behavior status during significant change of condition assessment and that there were no goals and interventions developed and implemented addressing R2's vulnerability for abuse/neglect. V8 confirmed that the abuse/neglect risk assessment is conducted to determine a residents' potential for being abused. R2 was interviewed on 9/18/18 at 5:15 pm in R2's room. R2 stated that there was one incident when, this one man (I don't know the name) went into my room and yelled to get out of my room; He went to me and knocked me off and I fell on the floor. R2 stated that staff came and got (R1) out and then (R1) was gone that evening. R2 stated well, Maybe it is the way I called (him) off but this is not the first time (he) went in my room. I feel safe here . I've seen a doctor for my back. V22 (Licensed Practical Nurse) was interviewed on 9/19/18 at 3:30 pm. V22 stated that R1 enters into other resident's rooms. V22 stated that there was an incident on 8/15/18 between R1 and R10 - they were yelling and screaming at each other. V22 stated that V22 saw R1 make a fist, which V22 thought was a gesture, and tried to separate R1 and R10 but couldn't; and stated that it was a good thing that V15 (R1's family) came in and calm R1 down. V22 stated that it was very difficult to redirect R1 and there were even (unnamed) family members in the unit that were concerned about R1 going in and out of other residents' rooms. V1 and V8 were asked regarding the incident between R1 and R10 on 8/15/18, and both were not aware of this incident and no investigation was conducted. According to R1's face sheet, R1 is diagnosed with [REDACTED]. R1's progress notes were reviewed and document the following behaviors on the following dates: 4/12/18 at 12:18AM- multiple episodes of getting up and attempts of pulling out inner and outer cannula of [MEDICAL CONDITION] (trach) 4/12/18 at 5:53PM - taking off cervical collar 4/13/18 at 3:38AM - with episodes of trying to get out bed 4/13/18 at 9:32AM - pulled out [MEDICAL CONDITION] out, tried to insert [MEDICAL CONDITION] resident noted to be agitated refusing and pushing staff away 4/14/18 at 8:06PM - dressing [MEDICAL CONDITION], but had multiple episodes of taking it off throughout the day, redirected a needed but (R1) repeatedly exhibits said behavior 4/15/18 at 7:35PM - multiple episodes of taking off dressing [MEDICAL CONDITION] and (left) leg immobilizer, redirected and reoriented as needed, somewhat effective. (R1) temporarily stops behavior but restarts after some time. 4/21/18 at 10:54AM - (R1) rummaging at things 4/22/18 at 8:20AM- noted with episode of getting out of bed, despite redirected several times 4/22/18 at 4:09PM - noted at times getting up without purpose 4/25/18 at 2:03AM- getting up several times without calling for help 4/25/18 at 4:38PM - (R1) at times getting up without purpose and wander around going to other patients room 4/26/18 at 3:02PM - wandering at times 4/27/18 at 2:58PM - wandering at times 4/28/18 at 2:33PM - wandering at times, refusing to use urinal 4/30/18 at 8:12AM - assisted to the washroom for toileting needs but refused to go inside washroom with staff, (R1) was urinating in his diaper, (incontinent brief) changed x 3, Bed soaked with urine, Refused to use urinal 4/30/18 at 2:32PM - wandering at times 4/30/18 at 9:43PM - noted wandering, tried to open doors 5/01/18 at 2:38PM - wandering at times 5/21/18 at 2:51PM - wandering at times 5/23/18 at 2:39PM - wandering at times 5/25/18 at 3:21PM - wandering at times 5/25/18 at 2:26PM - wandering at times 5/26/18 at 8:15PM - wandering and tends to go to other resident's room 5/29/18 at 2:20PM- wandering at times 5/30/18 at 7:26AM - wandering around the unit at times 5/31/18 at 7:59AM - G (gastrostomy) tube site was not changed due to resident was pushing nurse hands 6/14/18 at 4:57AM - (R1) was opening all the closet and kept on putting the clothes of other residents specially the boxer shorts and underpants. Staff intervene to what (R1) was doing but (R1) was trying to hit the staff 7/3/18 at 1:45PM - increase in confusion during the night, wandering into other resident's room attempting to wake them up and also had shown exit seeking behavior, symptoms not altered easily 7/18/18 at 9:15PM - noted wandering, tends to go room by room and opened the exit door multiple times, difficult to redirect, (R1) screamed toward to the staff, saying K***a K***a per Polish staff (R1) is swearing and saying bad words 8/15/18 at 11:21PM - tends to go to other room and used the bathroom, re-directed to go to his own bathroom but noted screaming towards staff, noted screaming towards other resident and noted making a fist, separated to other resident but to no avail and no changes, but (V15 - R1's family) came and get calmer 8/17/18 at 8:49PM - Resident wanders at times entering different resident's room, raised voice towards the staff when tried to re-direct 8/18/18 at 2:56PM - wandering, verbally aggressive with staff and other residents, difficult to redirect 8/18/18 at 11:49AM - (R1) wanders at times entering different resident's room and facing around the hallway 8/18/18 at 8:27PM - still up at this time, wandering around 8/20/18 at 8:24AM - (R1) kept on walking on the hallway and goes to other resident room 8/20/18 at 2:37PM - wandering, verbally aggressive with staff and other residents 8/20/18 at 7:45PM - wandering, tends to go room by room, re-directed to his room, but screamed towards the staff and gets agitated 8/21/18 11:20PM - seen (R1) entering other residents room without their permission. Other resident and family verbalized their concern regarding the matter .; when redirected, (R1) gets agitated and starts screaming to staff; Still up at this time and refuses to go to bed, constantly going to nurses station and opening the doors without permission; Wandering in the hallways and attempted to escape the door leading to other units. 8/21/18 at 8:06AM- continued to wander in unit 8/21/18 at 9:01PM- tried to open the door to check the resident, but noted entrance door was blocked with bathroom door, when this writer opened the door, (R1) started raising voice, screaming and pointing fingers; noted wearing roommate's clothes, noted swapping clothes of roommates, urinating on floor in room, difficult to redirect, because (R1) gets agitated and aggressive 8/23/18 at 8:13AM- (R1) goes to another room that has a vacant bed and (R1) will sleep there, (R1) gets upset if you tell (R1) that (R1) can't do it 8/23/18 at 3:12PM - wandering, tends to go room by room, redirected to room but screamed towards the staff and gets agitated 8/23/18 at 8:57PM - noted entering other resident's room, and other residents get aggravated because of (R1) opening the closets, redirected multiple times, but no avail, (R1) gets aggressive and screamed towards the staff 8/24/18 at 1:57PM- (R1) wandering at times, verbally aggressive with staff and other residents, difficult to re-direct 8/24/18 at 10:12PM - around 7:00 PM -7:30 PM, heard exit door alarming, writer and staff run fast to the exit door right away, found (R1) on the 2nd step of the stairs going down, calmly redirected (R1) to go back to the unit, (R1) followed but screaming and swearing in dialect towards the staff 8/25/18 at 6:23PM - wanders within the hallway, able to be redirected 8/26/18 at 5:49PM - with episode of going to another residents' room ., walks around the unit 8/26/18 at 3:17PM - (R1) wandering at times, verbally aggressive with staff and other residents, difficult 8/26/18 at 7:53 PM - wandering, tends to go room by room, redirected with fair outcome 8/27/18 at 7:37PM - wandering, tends to go room by room, using other resident bathroom, redirected (R1) to room but (R1) screamed towards staff 8/28/18 at 4:08 AM - wandering around unit 8/28/18 at 2:27 PM - wandering, tends to go room by room 8/28/18 at 7:53 PM - wandered 8/28/18 at 11:20PM - (R1) still up at this time, repeatedly saying that (R1) is going to take the bus, when diverted attention and redirected, started screaming in (R1's) language to all staff 8/29/18 at 6:25AM - unable to be redirected to stay in room, wanders in unit 8/30/18 at 2:49PM - (R1) wandering at times, verbally aggressive with staff and other residents, difficult to redirect 8/30/18 at 7:02PM - late entry for 8/29/18 - while this writer offered (R1) a snack, (R1) suddenly grabbed this writer's hand very tight, screaming and speaking in polish, this writer calmly told (R1) to remove hand from wrist, then (R1) removed it and walked away and came back saying sorry, sorry 8/30/18 at 7:35PM - walking around the unit with supervision of staff, entering into other resident's room, multiple times, redirected with no avail, (R1) screamed to the staff when redirecting 9/1/18 at 3:20PM - 8:20AM, (R1) wandered into female patient room (R2), when verbally reprimanded by female resident (R2), (R1) began yelling at her loudly and pushed (R2) onto the floor R1's latest care plans, pages 1-23, were reviewed. R1's care plans document: Problem start date: 6/1/2018 (R1) experiences wandering (moves with no rational purpose, seemingly obvious to needs or safety) and is an elopement risk Goal: (R1) will wander safely within specified boundaries Approach: Assess (R1) for placement in a specially designed therapeutic unit Encourage and invite to attend daily activities for cognitive stimulation and socialization Equip with a device that alarms when wanders. Check for proper functioning of device. Frequent visual checks for (R1's) whereabouts at all times Maintain a calm environment and approach to (R1) Remove (R1) from other resident's rooms and unsafe situations. When (R1) begins to wander, provide comfort measures for basic needs. Problem start date: 3/27/18 (R1) has signs and symptoms of mood and behavioral symptoms by episodes of anxiety, restlessness, has inappropriate behavior of urinating anywhere such as the floor and hanging clothes in any places. (R1) does rummage into other residents' belonging s and will wear other residents' clothes, (R1) does get agitated and can refuse care. (R1) gets verbally abusive and exhibits physical aggression. (R1) wanders and paces around the unit, entering other residents' rooms and (R1) is at risk for elopement related to severe confusion. Long term goal: (R1) will exhibit less episodes of having negative behavior by next review. (R1) will wander safely within the boundaries of the unit. Approaches 9/3/18 - Provide 1:1 close monitoring due to aggressive behavior as evidenced by (R1) pushed a resident on the floor on 9/1/18 causing the resident to fall 8/31/18 - Psychiatry consult on 8/29/18 6/1/18 - Check for any triggers of behavior such as the need to be toileted, hunger, thirst or pain. Provide interventions for such triggers 6/1/18 - Encourage and invite (R1) to join activity programs as a diversion for negative mood and behavior problems 6/1/18 - Encourage frequent family visits and interactions. Call family to assist in calming down during episodes of agitation 6/1/18 - Encourage to verbalize feelings, concerns, fears etcetera. Clarify misconceptions. 6/1/18 - Equip with wander guard 6/1/18 - Frequent checks for (R1's) whereabouts 6/1/18 - Identify relationships that (R1) could draw on. 6/1/18 - If non pharmacological interventions fail then administer medications as ordered. Monitor and record effectiveness. 6/1/18 - Observe for signs and symptoms of depression 6/1/18 - Provide consistent caregivers as possible, preferably a polish speaking staff if available 3/27/18 - Obtain a psychiatric consult/psychosocial therapy. 3/27/18 - Work with (R1) to identify effective coping mechanisms. R1's Psychosocial well-being - abuse/neglect risk (assessment) was generated on 3/27/18 at 4:29 pm by V10 (Business office staff/former Social Services staff). There were no entries documented. R1's Psychosocial well- being - abuse/neglect risk (assessment)was generated on 5/30/18 at 12:53 pm by V8 (Dementia Coordinator) and documented the following: Observation Details. Answer each of the question Yes =1 point, No = 0 points. Calculate points and record total. Score of 4 or more requires care planning. Does resident exhibit anxiety, fear or anger? Yes Does resident exhibit confusion, disorientation or forgetfulness? Yes Does resident have communication barriers? Yes Does resident wander, hoard or enter other residents' rooms? Yes Does resident have chemical or substance abuse currently or in the past? No But according to Minimum Data Set Assessment (MDS) with an assessment reference date (ARD) of 3/17/18, under section I7900: [MEDICAL CONDITION] with intoxication [MEDICAL CONDITION]; And Per Face sheet Diagnosis: [REDACTED]. Does resident exhibit depression or low self-esteem? But according to MDS with an ARD of 3/17/18, under section D0500 B. Feeling or appearing down, depressed or hopeless, Symptom present - 1 (Yes), Symptom Frequency - 2 (7-11 days); And according to the face sheet, diagnosed with [REDACTED].>Total score of 4 V8 was interviewed on 9/17/18 at 2:30 pm. V8 stated that the abuse/neglect risk assessment is completed upon admission and when there is a significant change. V8 confirmed after reviewing R1's current care plan that R1's care plans did not document any measurable goals and individualized interventions addressing abuse/neglect risk for R1. Next, according to R2's face sheet, R2 is diagnosed with [REDACTED]. R2's progress notes documented on 9/1/18: 8:20 am, (R2) pushed onto floor by (R1), witnessed fall. (R1) complained of pain 7/10. Took [MEDICATION NAME]. R2's patient X-ray report on 9/1/2018: Procedure: X-ray, Spine, Lumbo-sacral 2 or 3 views Examination: Lumbar spine vies History: Trauma Technique: 3 views of the lumbar spine were obtained Comparison: None Findings: There is levoscoliosis. Marked compression of T12 and L1 is noted. There is no evidence of dislocation Impression: T12 and L1 compression/ recommend MRI (Magnetic Resonance Imaging). [MEDICAL CONDITION] changes. R2's 11/12/2017 abuse/neglect risk assessment documents: Observation details: Does resident exhibit anxiety, fear or anger? Yes Does resident exhibit confusion, disorientation or forgetfulness? Yes Does resident wander, hoard, or enter other residents' rooms? No answer Does resident have a [DIAGNOSES REDACTED]. Calculate and Record total. Score of 4 or more requires care planning. Does resident have chemical substance abuse currently or in the past? (Answer) No But according to resident face sheet: diagnosed with [REDACTED]. Does resident have a psychiatric history currently or in the past? (Answer) No But according to resident face sheet: diagnosed with [REDACTED]. Does resident wander, hoard or enter other resident's rooms? (Answer) No But observed on 9/18/18 at 5:15 pm, keeping used plastic cups in room; stated keeping them to use them later on. V8 confirmed that (R2) tends to hoard stuff such as food. V8 was interviewed on 9/19/18 at 5:30 pm. V8 stated that the abuse/neglect risk assessment is completed upon admission and when there is a significant change. V8 confirmed that there was no abuse/neglect risk assessment completed for R2 during a significant change assessment on 5/4/18. V8 confirmed after reviewing R2's current care plan that R2's care plans did not document any measurable goals and individualized interventions addressing abuse/neglect risk for R2. The facility's 2/2017 revision Abuse Prevention Program policy document -under IV. Establishing a Resident Sensitive Environment: The facility desires to prevent abuse, neglect, exploitation, mistreatment and misappropriation of resident property by establishing a resident sensitive secure environment. This will be accomplished by a comprehensive quality management approach involving the following: -Resident Assessment: As part of the resident social history evaluation and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect exploitation, mistreatment or misappropriation of resident property who have needs and behaviors that might lead to conflict. Through care planning process, staff will identify any problems, goals and approaches, which 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 on a regular basis. -under VI. Protection of Residents Residents who allegedly abused another resident shall be immediately evaluated to determine most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees.

Based on interviews and record review the facility failed to follow safe transfer techniques when using a mechanical lift during transfer. This failure resulted in R17 sustaining a fracture of the tibia and fibula. This failure applies to one of two residents reviewed for falls from a total sample of twenty two . Findings include: R17's medical record documents the following Diagnosis: [REDACTED]. On 2/6/15 at 1:00pm, a review of the Minimum Data Set (MDS) noted " Assessment Reference Dates (ARD) of 1/19/15 documents (R17) with no behaviors, bed mobility, transfer, toileting and all scored as 3/3 = Two person physical assist. Walking in room or around the unit is scored as 8/8 = activity never occurred. R17 is a resident that requires a two person assist with mechanical lift. " On 2/6/15 at 10:00am, the Care Plan noted " (R17) is at risk for falls related [DIAGNOSES REDACTED] and seizure disorder, poor mobility skills, weakness, intake of psychotropic medications, anticoagulants, hypoglycemic and narcotic medications, with [DIAGNOSES REDACTED]. Care plan also indicates R17 requires special transfer with use of a mechanical lift. A review of the facility incident report (undated), filled out on 1/27/15 indicates that R17 (resident) was noted by E8, CNA, with bruising and swelling to left anterior shin. R17 reported pain to her left shin with movement. R17 was unable to recall events that caused the pain according to the incident report. On 1/26/15 at 3:11pm, the facilities actions upon discovery of the swelling and bruising administered PRN (as needed) pain medication and ice pack applied. R17 had X-rays done of left tibia and fibula which revealed a " spiral fracture of the distal shaft of the tibia and an oblique fracture of the proximal fibula with no significant displacement. Some demineralization and degenerative arthritic changes are also noted. " On 1/27/15 at 11:45am, an investigation was conducted by E2 (Director of Nursing). E2 interviewed staff E11, (CNA), and E12, (CNA), who worked the day prior to the incident. E11, (CNA), and E12, (CNA), reported " that R17 was transferred back from her wheel chair to bed with 2 persons assists. Staff does not recall the resident crying out or hitting any object with her leg. " E2 states in the incident report " at this point the only plausible cause of the injury is transfer technique. " On 2/5/15 at 11:20 am, E8, (Certified Nursing Assistant/CNA) states " 1/26/15 while assessing R17 ' s skin, noticed bruising on left lower leg, she then notified E10. " E8 also states " she transferred E17 alone on 1/25/15 using a mechanical lift and she should not have transferred her using mechanical lift alone. " On 2/5/15 at 11:50am (E6), LPN stated on 1/26/15 she was notified of bruising on E17 ' s left lower leg. E6 called the doctor for x-ray orders. E6 also states that R17 is bedridden and a mechanical lift should always have 2 people when using it. On 2/5/15 at 4:20pm Z1,(physician) returned call and stated that a spiral fracture can occur by twisting or by putting the leg in something. On 2/6/15 at 10:30am, E2 states that MDS shows 2 person assistance is required for transfers, there should be 2 person assisting when using the mechanical lift. Record Review: On 2/5/15 at 11:00am, received report from E2, Investigation Report, Plan of Action: Number 1 states " Re-competency all nursing and activity staff on Lift Transfers On 2/5/15 at 11:00am, received Illinois Department of Public Health Incident Report. Page 3, column 3 states ... " .at this point, the only plausible cause to the injury is transferring technique. " On 2/5/15 at 11:00am, Care Plan received from E2 stating E17 risk for falling. On 2/5/15 at 11:00am, MDS received from E2. Section G shows that resident is a two person physical assist. On 2/5/15 at 11:00am, received SAFE PATIENT LIFTING POLICY For all employees in nursing department. Process and Procedures, 5th item listed states: Resident transfer status will be properly communicated with care plan card in room, coding system or at the Kiosk. On 2/6/15 at 10:00am, received Care Plan from E2. Page 48, states " Resident requires special transfer with use of hoyer lift R/T generalized weakness. On 2/6/15 at 10:00am INCIDENTS & ACCIDENTS report received from E2. Policy number 1 states " All staff will be trained upon hire on proper usage of facility equipment, including but not limited to accu-check machines, tube feeding, lifts, etc.

Based on interview and record review, the facility failed to notify the physician promptly of high panic laboratory results as well as change in condition for 1 of 6 resident (R1) in six sampled residents. This delay in treatment process resulted in failure to provide appropriate and timely medical intervention resulting in a rapid deterioration of condition. Findings include: Physician order [REDACTED]. Clinical record documented that R1 had a fall on [DATE] with no apparent injury. 72 hour post incident documentation stated that no injuries were noted. During this time R1 was on [MEDICATION NAME] and [MEDICATION NAME] therapy as shown on the [DATE] Physician order [REDACTED]. R1 was transferred to a local area hospital on [DATE] for swelling and hematoma of the right lower arm and returned to the facility on [DATE]. On [DATE], R1 was again transferred to the hospital for right arm necrosis and returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. Nurses Notes documented as follows: -on [DATE] documented first reported diarrhea; -on [DATE] started on Oxygen at 2 liters per nasal cannula as needed for shortness of breath, and stool specimen collected for ,[MEDICAL CONDITION]. difficil. -on [DATE], it was noted that R1 had poor appetite, and scheduled for Comprehensive Metabolic Profile, Complete Blood Count, Urine Analysis and Culture/sensitivity on [DATE]. -on [DATE], maintained on isolation precaution for ,[MEDICAL CONDITION]. difficil of the stool. Laboratory report for Comprehensive Metabolic Profile documented the following: -Date reported : [DATE]. -Time reported: 05:00 PM. -BUN (Blood Urea Nitrogen) 143.0 High Panic (Normal ,[DATE] milligrams/deciliter) -Sodium 172 High Panic (Normal ,[DATE] milliequivalents/liter) -Chloride 137.8 High Panic (Normal ,[DATE] milliequivalents/liter) Nurses Notes failed to show that the physician was notified at any time of the high panic laboratory results dated [DATE]. Nurses Notes dated [DATE] starting at 12 midnight noted R1 with increasing restlessness, agitation, deteriorating condition, and that family was notified but not the physician. At 7:20 AM, R1 was noted unresponsive, vital signs unappreciated At 7:35 AM Nurses Notes documented that Z1 (Attending Physician/Medical Director) was notified of R1 ' s condition. This was the only time that physician notification was documented from the time the laboratory high panic report was received and up to the time the change in R1 ' s condition was noted. On [DATE] at 9:10 AM, E1 (Administrator) stated that she was on maternity leave for the period from [DATE] until [DATE]. In a phone interview on [DATE] at 5:20 PM, Z1 (Attending Physician/Medical Director) stated that he should have been notified immediately of the critical laboratory results and that they never called him. Z1 said that it was faxed to his office at 10 PM that night ([DATE]) and that (R1) expired the following morning ([DATE]). Z1 stated that those critical values can cause a patient to go into [MEDICAL CONDITION] and that as medical information was available, the family could have been provided with options if they wanted to send (R1) out to the hospital or not. Z1 added that it was a question of the degree of clinical judgement on the part of the staff. On [DATE] at 8:25 AM, E3 (Director of Nursing) stated over the phone that the nurse on duty pages the attending physician for change in condition notification. E3 added that if resident condition deteriorates, it is the nurse's judgement to call 911. Regarding the high panic laboratory results on [DATE], E3 stated that the nurse on the floor missed the report in the fax machine, faxed it to the doctor's office at 10 PM, and never placed a call to the doctor. The facility's Policy and Procedure on Notification of the Physician documents in part that, "Nursing will notify the resident 's physician or nurse practitioner when: b. There is a significant change in the resident ' s physical, mental or emotional status, e. It is deemed necessary or appropriate in the best interest of the resident. " The facility's Policy and Procedure on Change in the Resident 's Condition documents in part that, "Responsibility: RN (Registered Nurse), LPN (Licensed Practical Nurse). 1. Should there be a change in the resident ' s physical, mental or emotional status, the attending physician should be notified. 2. If the attending physician does not respond within 30 minutes, contact the medical director. 4. If at anytime during this process the resident condition deteriorates or it is determined a medical emergency exists, then send the resident to the hospital via 911. 6. Documentation will be present in the resident record."

Based on interview and record review, the facility failed to obtain timely physician's orders for treatment, provide appropriate services and timely care for 1 of 6 residents (R1) in a sample of 6 by failing to promptly report critical laboratory findings to the physician and by failing to notify physician of significant change in condition in a timely manner. This failure to provide appropriate and timely medical interventions resulted in a rapid deterioration of R1's condition. R1 expired the next morning [DATE]. Findings include: According to Physician Order Sheet dated ,[DATE], R1 was an [AGE] year old resident with multiple [DIAGNOSES REDACTED]. Clinical record documented that R1 had a fall on [DATE] with no apparent injury. 72 hour post incident documentation stated that there were no injuries noted. During this time, R1 was on [MEDICATION NAME] and [MEDICATION NAME] therapy as shown on Physician Order Sheets. On [DATE] a bruise on the right lower arm was noted. R1 was transferred to a local area hospital on [DATE] for swelling and hematoma of the right lower arm and returned to the facility on [DATE]. On [DATE], R1 was again transferred to the hospital for right arm necrosis and returned to the facility on [DATE] with [DIAGNOSES REDACTED]. Nurses Notes documented the following: -on [DATE] documented first reported diarrhea; -on [DATE] started on Oxygen at 2 liters per nasal cannula as needed for shortness of breath, stool specimen collected for ,[MEDICAL CONDITION]. difficil. -on [DATE] noted poor appetite and scheduled for Comprehensive Metabolic Profile, Complete Blood Count, Urine Analysis and Culture/Sensitivity for [DATE]. -on [DATE] R1 was maintained on isolation for ,[MEDICAL CONDITION]. difficil of the stool. Laboratory report for Comprehensive Metabolic Profile documented the following: -Date reported : [DATE]. -Time reported: 05:00 PM. -BUN (Blood Urea Nitrogen) 143.0 High Panic (Normal ,[DATE] milligrams/deciliter) -Sodium 172 High Panic (Normal ,[DATE] milliequivalents/liter) -Chloride 137.8 High Panic (Normal ,[DATE] milliequivalents/liter) Nurses Notes failed to show that the physician was notified at any time of the high panic laboratory results dated [DATE]. Nurses Notes dated [DATE] starting at 12 midnight noted R1 with increasing restlessness, agitation, deteriorating condition, and that family was notified but not the physician. At 7:20 AM, R1 was noted unresponsive, vital signs unappreciated At 7:35 AM Nurses Notes documented that Z1 (Attending Physician/Medical Director) was notified of R1 ' s condition. This was the only time that physician notification was documented from the time the laboratory high panic report was received and up to the time the change in R1 ' s condition was noted. On [DATE] at 9:10 AM, E1 (Administrator) stated that she was on maternity leave for the period from [DATE] until [DATE]. In a phone interview on [DATE] at 5:20 PM, Z1 (Attending Physician/Medical Director) stated that he should have been notified immediately of the critical laboratory results and that they never called him. Z1 said that it was faxed to his office at 10 PM that night ([DATE]) and that (R1) expired the following morning ([DATE]). Z1 stated that those critical values can cause a patient to go into [MEDICAL CONDITION] and that as medical information was available, the family could have been provided with options if they wanted to send (R1) out to the hospital or not. Z1 added that it was a question of the degree of clinical judgement on the part of the staff. On [DATE] at 8:25 AM, E3 (Director of Nursing) stated over the phone that the nurse on duty pages the attending physician for change in condition notification. E3 added that if resident condition deteriorates, it is the nurse's judgement to call 911. Regarding the high panic laboratory results on [DATE], E3 stated that the nurse on the floor missed the report in the fax machine, and then faxed it to the doctor's office at 10 PM, and never placed a call to the doctor. Policy and Procedure on Notification of the Physician states, " Nursing will notify the resident ' s physician or nurse practitioner when: b. There is a significant change in the resident ' s physical, mental or emotional status, e. It is deemed necessary or appropriate in the best interest of the resident. " Policy and Procedure on Change in the Resident ' s Condition states, " Responsibility: RN (Registered Nurse), LPN (Licensed Practical Nurse). 1. Should there be a change in the resident ' s physical, mental or emotional status, the attending physician should be notified. 2. If the attending physician does not respond within 30 minutes, contact the medical director. 4. If at anytime during this process the resident condition deteriorates or it is determined a medical emergency exists, then send the resident to the hospital via 911. 6. Documentation will be present in the resident record."

Based on observation, interview and record review, the facility failed to supervise 2 residents ( R3 and R2 ) out of 5 residents reviewed for falls. R3 has a [DIAGNOSES REDACTED]. This failure resulted in an Immediate Jeopardy when on [DATE] at around 12:15 PM, R3 was observed unsupervised in his wheelchair by the stairwell area that leads to the basement. R3 fell down the stairwell (15 steps) and was sent to the hospital via 911. R3 sustained a C7 cervical fracture, 6 x 4 inch laceration to the head, anterior left scalp hematoma, and subarachnoid hemorrhage. R3 expired at the hospital on [DATE], after life support was removed. Findings include : A) R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R3's hospital History and Physical ( H & P ) dated [DATE], indicated that R3 was initially from another facility where he sustained a Non - Displaced Left Intertrochanteric Fracture, after falling from his wheelchair. R3 feel asleep in the wheelchair and fell out of his wheelchair sustaining this injury. At the hospital, no surgery was done because of R3's medical issues and instead, R3's left lower extremity was placed on Non-Weight Bearing Status, to allow healing. This H & P also indicated, that Z2 said that in the last month and a half prior to the hospitalization , that R3's mental status has been declining significantly, that he had significant change in cognition, and had some level of delirium. At the hospital, Z2 functioned as R3's agent, as R3 was not able to engage in meaningful informed consent for himself. R3's progress note dated [DATE] at 8:52 AM indicated that although R3 appears alert and oriented x ,[DATE], R3 has periods of forgetfulness and confusion. R3's [DATE] Progress note at 8:12 AM, also mentioned that R3 has periods of confusion, and needs 2 staff assistance for bed mobility. R3's Minimum data Set ( MDS ) dated [DATE], also coded R3 as moderately impaired ( decisions poor, cues/ supervision required ) in Cognitive Skills for Daily Decision Making. R3's [DATE] Care plan also indicated that R3 has impaired decision making due to cognitive deficits. On [DATE] at 10:20 AM, E8 ( nurse ) said that she took care of R3 when he was at another unit of the facility. E8 thinks R3 has periods of confusion. E8 explained that R3 would yell a lot, but when E8 came to see what R3 needed, R3 would become quiet and would respond that nothing is wrong. Then as soon as she stepped out, E8 said that R3 would start yelling again. Similarly, according to E7 ( nurse ) on [DATE] at 3:02 PM, R3 was demanding, confused at times, and is always shouting in his room when he wants to smoke. E7 said that one time R3 asked her if it was lunch time, when it was only breakfast time. E7 continued that one time, R3 insisted that his wallet with $30 is missing, and insisted that it was just in his pocket. It turned out, Z2 said that his wallet had been left home since R3 was admitted to the facility. On [DATE] at 2:05 PM, E6 (certified nurse aide / CNA ) also said that R3 would scream in bed, would become quiet when E6 was in the room, and would start screaming again afterwards. R3's hospital Physical Therapy Evaluation dated [DATE] indicated that R3 is blind in his left eye and has poor vision on the right eye. R3's [DATE] Nurses Notes entry at 4 AM, also indicated that R3 cannot see in his left eye. R3's care plan dated [DATE] however, erroneously listed R3 only as with decreased vision in the left eye rather than being blind as per hospital record, and did not mention vision impairment on the right eye. R3 has no vision test or assessment while at the facility, to determine the extent of his vision impairment. On [DATE] at 2:25 PM, Z1 ( R3's attending physician )said that she is aware that R3 is blind in the left eye and has blurry vision in the right eye, but does not know the extent of his vision impairment. Z1 said that she did not test R3's vision. R3's Physician order [REDACTED]. This order was revised on the same day, to Bed Rest except on Hemodialysis. Z1 wrote on R3's physician progress notes [REDACTED]. On [DATE], Z1 wrote in R3's physician progress notes [REDACTED]. On [DATE] at 2:05 PM, Z1 said that there was no surgery done on R3's fractured Left Hip, so R3 was placed on bed rest for 6 weeks. Z1 said that she is aware that R3 would scream when he is on bed rest, so the facility had him get out of bed to smoke once a day. E10 ( Social Worker ) said on [DATE] at 1:55 PM, that when R3 came to the facility, he was placed on bed rest, but R3 would howl and complain that he wants to get out of bed and smoke. E10 added that Z2 and R3 made a compromise with the facility, that R3 would be allowed to smoke once a day at 3 PM, even though it is against physician orders. On [DATE] at 2:27 PM, E3 ( nurse ) said that she was R3's nurse on [DATE]. E3 said that R3 came back to the unit after his inhouse dialysis at around 11:30 AM. E3 continued that she came to R3's room after hearing R3 yelling. E3 said that R3 was in the dialysis chair, and said that he wanted to go back to bed. E3 continued that she told R3 she is going to get help, and R3 responded by saying " Hurry up." E3 said that as soon as she got in the hallway, R3 screamed again that he needed help. E3 said that when she came back to his room, R3 was already sitting at the edge of his bed and apparently transferred himself to bed without assistance and despite her instruction not to. E3 continued that she told R3 not to do that again, and as soon as R3 layed his his head down in bed, R3 said he wanted to get out of bed again. E3 said that she saw E6, and E6 together with E5 ( CNA), helped R3 out of bed. E3 said that she saw E5 wheel R3 to the Dining Room afterwards. E3 further said, that R3 did not stay in the Dining Room and propelled himself to E3, and asked E3 if E3 could take R3 outside for a smoke. E3 said she told R3 to wait after lunch time, which is in 30 minutes. E3 said this was the last time she saw R3, which was between 11:55 AM to 12 PM. E3 said that R3 is supposed to be on bed rest for 6 weeks because of his hip fracture, but was up in his wheelchair because R3 was screaming, shouting, and insisting to get out of bed. E3 said that she only took care of R3 once before, and didn't remember him screaming or trying to get out of bed during that time. E3 continued that she is aware that R3 has vision problems in his right eye, but does not know to what extent. E3 also said that R3 is unsafe, as he transferred himself without assistance despite of her ( E3's ) direction to wait for staff. E6 ( CNA )said on [DATE] at 2:05 PM, that R3 is a very demanding guy, and is screaming and yelling all the time. E6 said that R3 never listens to anyone, wants to smoke anytime he wants, and will not stay in one place and would wheel himself in his wheelchair. E6 said that she is aware R3 has a schedule to smoke at 3 PM. E6 said that on [DATE], she was not assigned to R3, and had taken care of R3 only once before. E6 said that when she first took care of R3, R3 screamed and yelled while in bed, but E6 said she did not get him up, until it was close to 3 PM, his smoking schedule. Even though R3 screamed and yelled, E6 said she would check R3 frequently and he did not fall while in bed that day. E6 said she was not aware he is supposed to be on bed rest at all. E6 added that on [DATE], R3 went back to bed from his chair without any assistance. E6 said she stayed with him until E5 (who was assigned to R3 that day ) came in, and helped E6 place R3 in his wheelchair from bed. E6 said that was the last time she saw R3, as she left R3 with E5 after that. Aside from E6, E7 ( R3's regular nurse ) also said that although R3 would always want to get out of bed and smoke, E7 would leave R3 in bed, until it is time for him to smoke at 3 PM. E7 said that R3 would yell, but distraction and his prn medication ( Xanax ) is given to address his yelling. E7 said that R3 never tried to get out of bed, and is immobile in bed. E7 continued that she leaves R3 in bed, because R3 has an order for [REDACTED]. After dialysis, E7 said that R3 is put back in bed. E7 said that there was only 1 time, when R3 was gotten out of bed while E7 was working : that was when R3's family were there to watch R3. E7 added that R3 would demand to smoke at times, but that she would just explain to him why he needs to stay in bed, and R3 stays in bed. E7 said that she is aware R3 could not see from his left eye. On [DATE] at 11 AM, E5 ( CNA ) said that on [DATE], around 11:45 PM, she passed by R3's room, and saw R3 talking to E6. E5 said that R3 verbalized that he does not want to stay in bed, he is in pain, and he wants to smoke. E5 said that E6 and she had no choice, but to put R3 in his wheelchair from his bed. E5 said that she wheeled him to the dining room afterwards, but he refused to stay there, and went to the nurses station instead. E5 said that she next saw R3 in the hallway wheeling towards room 137, when she came out of room 137 to assist another resident in room 139. E5 said that she saw R3 in the hallway and told him to go back to the dining room, but does not know if R3 did. E5 said that that was the last time she saw R3 prior to his accident. E5 said that she does not know R3 is supposed to be on bed rest when E6 and she, got him out of bed to the wheelchair on [DATE]. Finally, E5 said that if she knew R3 is supposed to stay in bed, she would have left him in bed, and would ask the nurse for direction regarding R3's desire to get out of bed. Per E4 ( nurse ) during [DATE] interview at 3:30 PM, she came to work at 11 AM. E4 said also that she is not really familiar with R3, does not know he has an order for [REDACTED]. E4 said that on [DATE], she last saw R3 sitting in his wheelchair by the nurses station. R3's Nurses Note dated [DATE] indicated that at 12:15 PM, R3 was noted supine on the floor at the bottom of the stairs, near the employee stairwell. R3's wheelchair was on top of his upper torso, and he was bleeding from the head. R3 was sent to the hospital via 911. On [DATE] at 1:43 PM, E9 ( second floor nurse ) said that she was walking in the 1st floor hallway on [DATE] at around 12:15 PM, when she saw R3 on the top of the stairwell. E9 continued that she yelled for R3 to hold on, but is not sure if R3 heard her. E9 said that she saw R3's hand on the wheelchair wheels, and that R3 propelled forward down the stairs. E9 said that there were no staff in that area supervising R3 during this time. E9 said that R3 must have moved the unlatched stair guard on the side, otherwise he would not have been able to go down the stairs. On [DATE] at around 12:05 PM, the stairs where R3 fell down was observed with 15 steps. The stairwell was next to the alarmed door exit leading to the outside of the facility, where residents normally smoke under staff supervision. The hallway where R3 was last seen is separated from this stairwell area by a double swing door, which were not alarmed prior to [DATE] per E11 ( falls nurse ). The back of the stairwell area is an alarmed door leading to another hallway. On [DATE] at 2:27 PM, E3 said that this double swing door is usually closed at all times, but they are opened during meal time for the trays from the kitchen, which is also in the stairwell area. Facility's investigation did not explain why R3 was left unsupervised in an area that is hazardous to residents like R3, who has a recent history of falling from his wheelchair, an amputee of the left leg, someone with periods of confusion and was initially care planned as having cognitive deficit, a resident who is blind in the left eye and has impaired vision in the other eye, and someone who has poor safety judgment and poor impulse control, as evidenced by transferring himself from a dialysis chair to bed unassisted despite staff direction not to. R3 also has an order for [REDACTED]. As above, R3 during other times stayed in bed as ordered, without any incident of trying to get out of bed, or without any incident of falls from bed. Instead of redirection, prn medication, or distraction to address R3's yelling, anxiety, demands to get out of bed so he could smoke, E3 allowed R3 to be transferred from bed to chair despite physician order [REDACTED]. R3's hospital CT ( Computer Tomography ) Scan on [DATE] showed a non-displaced fracture of the superior articular facet on the right at C7. Other trauma were also noted on [DATE] : ER's Trauma Flowsheet indicated a 6 x 4 inch laceration; R3's Xray of the pelvis showed a transverse fracture through the lower trochanteric region and an oblique fracture through the intertrochanteric region of the left femur. It cannot be determined if these were the same left hip fractures R3 sustained from a fall from another facility recently, or new ones sustained from the [DATE] fall down the stairs. R3's hospital H & P also indicated that he sustained an anterior left scalp hematoma. Added to this, R3's hospital Consultation report dated [DATE], indicated that the CT scan of the brain also showed a very minimal traumatic subarachnoid hemorrhage, and soft tissue swelling of the left parietal frontal region extracranially. R3's [DATE] repeat CT indicated a new swelling of the left hemisphere, either from ischemia or contusion. R3 was extubated on [DATE] and expired at the hospital. E1 ( Administrator ) and E2 ( Director of Nursing ) were notified of the Immediate Jeopardy on [DATE]. While the Immediacy was removed on [DATE], the facility remains out of compliance at severity level 2, because the facility has yet to inservice the new hires on all shifts, has yet to assess if new interventions and policies are effective on the possible affected residents, and the facility's evaluation of the new plan of care has yet to be conducted. The facility took the following steps to correct the Immediate Jeopardy: 1) Maintenance staff installed alarms on the double swing doors leading to the stairwell area, and on the door at the back of the stairwell area on [DATE]. A latch was also placed on the stairwell guard, and signs were hung to ensure that these double doors, exit door, and stairwell guard are close at all times. This was finished on [DATE], and an oversight to ensure compliance is done on an ongoing basis by the Administrator. 2) Starting [DATE], all wheelchair - bound residents on the 1st floor were assessed for vision problems. This was done by the ADON and was completed on [DATE]. No resident was determined to have problems with blindness. A QI form was developed to screen all new admissions or readmissions for vision impairment starting [DATE]. This will be done by the nurses who will admit the residents, and will be audited on a quarterly basis by the DON. Trends will be discussed during quarterly meetings. 3) Inservices to ensure that the above doors are shut at all times, and inservices to ensure that all residents should not be left unsupervised in the stairwell area, was started by each department head for all their department staff members on [DATE]. This was completed on [DATE]. The Administrator also met with the resident council members on [DATE]to inform the council, that residents would no longer be allowed to stay by the stairwell area when it is not smoking time. 4) An inservice to reinforce that all physician orders [REDACTED]. This was completed on [DATE]. As part of the QA process, the DON will ensure quarterly inservices are done starting [DATE]. 5) A behavior management policy inservice for nurses was done on [DATE] by nursing supervisors to address residents' behavior issues. This was completed on [DATE] for all shifts. It will be a part of QA process as quarterly inservices to be overseen by the DON starting [DATE]. B) R2 has [DIAGNOSES REDACTED]. R2's incident report dated [DATE] indicated that at 4 PM, R2 was found in the hallway laying on the floor next to her wheelchair. R2 said that she was trying to get up from her wheelchair, lost her balance and fell . R2 was sent to the hospital and was diagnosed with [REDACTED]. On [DATE] at 1:30 PM, E11 ( falls nurse ) said that on [DATE], R2 stood up without her walker, and fell for the first time. E11 said that R2 broke her hip from this fall. E11 said that when R2 was readmitted to the facility after this, R2 was placed on alarms, her room was placed closer to the nurses station, and R2 was placed on therapy. R2's [DATE] incident report indicated that at 6 PM, R2 was found on the floor inside room 127's bathroom. R2 said per facility's investigation that she was trying to transfer from the toilet to the wheelchair when she fell . E11 said on [DATE] at 1:30 PM that during her investigation, E12 ( CNA ) assigned to R2 did not turn R2's wheelchair pad alarm on, thus there was no alarm heard when R2 stood up and walked to the bathroom at around 6 PM. E11 said that E12 placed her in the dining room around 4:15 PM. R2's care plan dated [DATE] indicated that aside from the use of mobility alarms, R2 is also supposed to be placed in a supervised area when up and awake, and is supposed to be observed frequently.

Based on observation, interviews and record review, the facility failed to provide an environment free of hazards to 2 of 2 sampled residents (R1 and R2) who were identified as high risk for falls. This failure resulted in the facility failing to: 1. ensure that R2's monitoring device (bed alarm) was in functioning mode at all times. This failure resulted to R2 being found on the floor on 12/10/2009 at 3:00 A.M without staff knowledge; 2. ensure that appropriate mechanical lift transfer device was used when R1 was transferred from bed to wheelchair on 5/24/2010. This failure had precipitated R1 from developing an increased marked swelling with pain of the right leg which resulted to R1's hospitalization for further treatment. The failure resulted in R1 being admitted to the hospital with [REDACTED]. Findings include: 1) R2 is an [AGE] year old with [DIAGNOSES REDACTED]. R2 was assessed as confused and needs extensive assistance with 1 person physical assist for all aspects of ADL's. (activities of daily living). Per record, R2 is a high risk for fall . Care plan dated 11/25/2009, showed that there are interventions to prevent R2 from fall incidents . Some interventions are as follows: bed pad alarm on while in bed; low bed with extra mattress on the floor. Review of incident report showed that R2 fell on [DATE] at 3:00 A.M. Further review of the incident report showed that a nurse heard a noise "help, help" and that R2 was found lying on the floor near bed in her room. This report indicated that R2 was trying to reach for her wheelchair. Review of facility's fall investigation regarding R2's fall incident of 12/10/2009 showed that E4(CNA-certified nurse assistant ) who was assigned to R2 at time of fall had failed to turn on the bed pad alarm monitoring device. Further review of the facility's fall investigation indicated that R2 was already on the floor when R2 was heard asking for help. There was no indication that there was any monitoring device to alert staff for R2's any attempts for unassisted transfer/and or ambulation . 2) R1 is a [AGE] year old with [DIAGNOSES REDACTED]. R1 was originally admitted to the facility on [DATE]. As record indicated, R1 has mild to moderate cognitive impairment. Record also showed that R1 is alert , however forgetful and confused. R1 who has [DIAGNOSES REDACTED]. R1 was also identified as a bed bound resident. Per MDS (minimum data set) dated 3/26/20, R2 was also assessed as having functional limitation in range of motions on both sides of arms, hands, legs and feet. Review of the nurse's notes showed the following : 5/25/2010: at 6:30 A.M., (R1) with complaint of pain on right lower leg , with mild swelling. at 1P.M.-noted swelling on right leg below the knee to the foot, warm to touch , constant pain noted. Faxed to M.D., awaiting for orders. 5/25/2010: at 6 P.M.-swelling on right leg from hip to the foot. , warm to touch. at 10 P.M., called M.D,. with order to send (R1) to hospital emergency room for evaluation. (R1) complained of pain, very swollen , warm to touch. at 11:50 P.M., transported to hospital via ambulance 5/26/2010 at 7:00 A.M. (R1) admitted at the hospital with [DIAGNOSES REDACTED]. Review of the facility's incident and investigation report dated 6/1/2010 showed that on 5/25/2010, R1 was noted with mild swelling of the right lower leg with pain. It was also indicated that the swelling had increased in size and with continued with pain which had subsequently lead to R1's hospitalization on [DATE] for further evaluation. The facility's conclusion for the investigation of this injury indicated that E5, the CNA(certified nurse assistant) assigned to R1 on 5/24/2010 morning shift, had inappropriately transferred R1 from bed to wheelchair and vice versa by failing to use a mechanical lift transfer device. Further review of this facility's investigation showed that E5 was new to the facility and was not aware that R1 needed a mechanical transfer lift device during transfers. E5 when interviewed on 9/1/201 at 2:00 P.M., stated that she did not used the mechanical lift transfer device when she had assisted R1 for transfer from bed to wheelchair and vice versa. E5 added that since she was new to the facility, E5 was not aware that R1 needed the mechanical lift device for transfer. When interviewed on 9/1/2010 at 2:30 P.M., E3(Assistant Director of Nursing) stated that R1 is bed bound and only on special circumstances that R1 get out of bed. E3 also stated that E5 did not used the mechanical lift transfer device when R1 was transferred from bed to wheelchair and vice versa on 5/24/2010, sometime around the mid morning and before lunch. Further stated by E3 that R1 had remained in bed since after being put back to bed before lunch on 5/24/2010, until the time R1 was first noted with right leg swelling with pain on 5/25/201 at 6:30 A.M. all the way to the time R1 was sent out to the hospital on [DATE] at 11:50 P.M. E1 (administrator) stated on 9/1/2010 at around 3:00 P.M. that E5 was given instructions to ensure that appropriate use of safety devices during transfers are implemented. R1 was readmitted back to the facility on [DATE]. R1 was observed on 9/1/2010 at 3:30 P.M., lying in bed with a right leg immobilizer in placed.