Every finding on record at Elevate Care Riverwoods

Based on observation, interview, and record review the facility failed to provide adequate supervision, for a dementia resident on a locked unit with known exit seeking behaviors, to prevent a resident from leaving the facility unsupervised for 1 of 3 residents reviewed for supervision in the sample of 3.The findings include:R1's Minimum Data Set, dated [DATE] shows, R1 has a diagnosis of dementia and severe cognitive impairment.R1's elopement report dated 07/26/2026 shows, R1 left the facility and walked a half mile to a gas station. R1 was brought back to the facility by the police. No injury. On 8/10/2026 R1's room was located on a unit that required a code to unlock the double fire-doors to exit the unit. The dining area was separated from the unit by a solid double fire-door held open by magnetic releases. In each corner of the dining area there were two square windows that came from the ground to waist high where a lever freely moved to unlock the window and allow it to be opened. The window screen on one of the windows was dislodged and resting on the ground on the outside. The outside patio area had a rod iron fence and an open locking gate. The gate led to the facility parking lot's exit to a public roadway. There were no sidewalks on the roadway in front of the facility leading to the gas station.On 8/10/2026 at 11:26AM, V8 CNA-Certified Nursing Assistant said, I heard there was an attempted elopement a couple of weeks ago. The resident attempted to go out the window. I do not know who the resident was.On 08/10/2026 at 11:37AM, V7 Memory Care Director said, R1 is an elopement risk due to his behaviors.On 08/11/2026 at 12:30PM, V2 DON-Director of Nursing said, R1 eloped, he got out of the facility. He went out a window on the locked unit and went down the street. The police brought him back. This happened July 27, 2026. On 08/10/2026 at 1:18PM, R1 was dressed, relaxing in bed, watching college football. R1 said, I do not remember leaving the facility. I remember the police bringing me back. How I got to the gas station? I can't remember.On 08/10/2026 at 2:00PM, V6 (R1's Family) said, we did not know R1 got that far. We thought he was found at the facility crawling through the window.On 08/10/2026 at 2:26PM, V5 NP-Nurse Practitioner said, I was notified R1 eloped out of the facility. No injury, R1 had never done anything like this. R1 would voice a desire to leave but never tried.On 08/10/2026 at 3:11PM, V3 RN-Registered Nurse said, I just finished assisting with the evening meal. I saw R1 in the dining room at 6:00PM. I completed the medication pass then assessed a new admission. I realized R1 was missing at 6:30PM. We looked for R1. R1 was found at 6:50PM. R1 was returned to the unit at 7:10PM. I performed a full body assessment. R1 had no injuries. I asked R1 what happened? R1 could not understand why he left or how he left the facility.R1's Care Plan on 08/10/2026 shows, Behavioral Symptoms, exit seeking. The facility did not update the interventions for R1's 07/27/2026 elopement.

Based on interview and record review the facility failed to do a thorough assessment and send a resident to the hospital in a timely manner after a fall. This failure resulted in R1 remaining in the facility for 8 hours after a fall that resulted in a left femoral and elbow fracture. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 9. The findings include:R1's post fall observation form dated 7/23/26 shows, R1 had a fall in her room that was witnessed by V5 Certified Nursing Assistant (CNA). I knees buckled down and lost my balance. CNA help to ease down to the floor [SIC-statement is correct]. The form shows, R1 is alert and oriented to person, place, and time. She complained of pain to her left knee that was painful with range of motion. The doctor was notified at the time and ordered an x-ray for knees.On 8/1/26 at 12:17 PM, R1 stated, she was getting up to start her day around 9:30 AM. She has a left below the knee amputation and wears a prosthetic to her left leg. She usually stands up and pivots into her wheelchair from the bed. This particular day, she was feeling dizzy and waited a few minutes before she was ready to stand up. Once she felt ready, she stood up but still didn't feel right. V5 CNA was with her and she told her she thought she was going to fall. She ended up falling to the ground. She heard a pop and knew she broke her leg. She stated, she was screaming, thinking she broke her leg, it was so painful. They used the mechanical lift to get her back in the bed. When they were trying to get her in the lift, they had to bend her leg back and she screamed it hurt so bad. Once they got her in the bed the pain was a little better but still there. She couldn't remember if they gave her a pain pill or not but was sure she asked for one. They kept telling her that x-ray was going to come but never did come. When her sister (V8) came she was furious and finally they sent her to the emergency room. On 8/1/26 at 9:51 AM, V8 R1's sister stated, V6 Registered Nurse (RN) called and left her a message saying her sister was feeling dizzy and had fallen. She called her right back and V6 RN told her R1 was ok and they were ordering x-rays. She tried calling her sister sometime later and couldn't get ahold of her so she called V6 RN again. V6 RN told her that she was still in pain and they were waiting for the x-ray tech to come still. She left work early and when she got to the facility her sister was still in pain. She knew something wasn't right and was upset because she didn't understand why they let her lay there in pain and didn't send her to the hospital. How dare you let someone lay there for 8 hours in extreme pain. They sent her to the emergency room then. Her sister (R1) broke her left femur and elbow. She had surgery a week prior to place a rod in her left leg. They are hoping she doesn't have to have surgery on her elbow/left arm. On 8/1/26 at 12:44 PM, R9 stated, she was R1's room mate. She couldn't see what happened but could hear everything. R1 had fallen on her stump and was in pain. She was less vocal once she got into bed but she was still in pain. She thought she should have been sent to the hospital right afterwards based on her screaming in pain. She was still screaming in pain when the ambulance came. On 8/1/26 at 1:51 PM, V5 CNA stated, she was transferring R1 from her bed to her wheelchair. She had transferred her before so she knew the routine. This time, R1 said she was dizzy so they waited a few minutes and then R1 said she was ok to transfer. She stood up and took a few steps forward and then said she was going to fall. V5 CNA stated, she tried to get her to go back to the bed but she couldn't so she tried to ease her to the floor. She fell on her knees. She was in pain and she didn't know why they didn't send her out to the hospital. They gave her medication but that still didn't help and she kept complaining of pain throughout the day. On 8/1/26 at 12:52 PM, V6 RN stated, V5 CNA was yelling for help and when they went into R1's room, R1 was on the floor. She asked how R1 fell and R1 told her, her knees buckled and V5 CNA couldn't hold her up. R1 complained of her leg hurting but V6 RN stated, she thought everything was ok. She contacted the doctor and he told her to get an x-ray. She gave her a pain pill right after the fall and helped get her back into bed. When she saw her again she said R1 was better but still in pain. She endorsed to the next nurse what happened and when she came back the next day she found out R1 had been sent to the hospital and had fractures. V6 RN showed, this surveyor the communication that was sent to V7 R1's primary care physician (PCP) via a text message. The text message written at 11:24 AM (approximately 1 hour and 20 minutes after R1's fall) showed, V6 RN texting: R1 had a fall and was complaining of pain, could they get an x-ray? V7 R1's PCP responds: yes please. That is the only communication with R1's PCP via text message and nothing else is documented in R1's electronic medical record. On 8/1/26 at 3:38 PM, V9 Licensed Practical Nurse (LPN) stated, he received report saying she had fallen earlier that day. When he saw her she said she was ok but then he heard her groan and asked her what was wrong. She said she was having pain in her left knee. That was the only thing off. He gave her some more Norco (pain medication) and that didn't help so he sent her out for constant pain. Her family was there and also concerned. He called and got orders (from a different doctor than V7 R1's PCP). On 8/1/26 at 1:31 PM, V7 R1's PCP stated, he had communication with the nurse saying R1 had a fall and they wanted an x-ray. He said yes and that was the only communication he had with the facility on 7/23/26. If he had known she was complaining of extreme pain or more pain than usual he would of said to send her out via 911. R1's progress notes dated 7/23/26 shows, resident with recent witnessed fall earlier this morning. During the shift, resident complained of pain to the left knee, assessment completed, and new orders received from the NP (nurse practitioner) to transfer resident to the emergency department for further evaluation. R1's medication administration record for the month of July shows, V6 RN gave her a Norco (pain medication) at 10:00 AM after R1's fall. R1's SBAR summary dated 7/23/26 shows, R1's change in condition was falls pain (uncontrolled). The facility provided hospital CT (cat scan) imaging of her left knee dated 7/23/26 shows, R1 had a comminuted impacted slightly angulated fracture distal femoral metadiaphysis. Her left femur x-ray shows the same results. The facility provided hospital x-ray for left elbow dated 7/23/26 shows, R1 had a displaced fracture of the coronoid process of the ulna with large elbow joint effusion and a subtle linear lucency extending vertically through the medical humeral condyle suspicious for additional subtle nondisplaced fracture. The facility's serious injury incident and communicable disease report dated 7/23/26 shows, R1 had a fall on 7/23/26 at 9:30 AM and wasn't sent to the emergency room until 6:30 PM later that day. Resident is a [AGE] year-old female with medical history of but not limited to absence of left leg below the knee, anemia, ESRD (end stage renal disease) with dialysis dependence, PVD (peripheral vascular disease), vitamin D deficiency, peripheral autonomic neuropathy and depression. Resident sustained a fall, assessment was immediately performed, pain assessment completed with complaints of pain on the left knee, pain medication administered with relief. NP notified with orders for x-ray to bilateral knee and transfer to local ER for further evaluation. X-ray completed in ER with findings of nondisplaced fracture of the coronoid process of the ulna, subtle linear lucency extending vertical through the medical humeral condyle, and comminuted impacted fracture distal left femoral metaphysis with slight lateral angulation and dorsal offset. Resident was admitted to the hospital with diagnosis of unspecified fall encounter. R1's Minimum Data Set, dated [DATE] shows, she is cognitively intact. R9's Minimum Data Set, dated [DATE] shows, she is cognitively intact. The facility's physician- family notification-change in condition policy dated 7/8/24 shows, Purpose: To ensure that medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, efficient, and effective manner. The facility's assessment of resident policy dated 4/18/22 shows, Purpose: To gather comprehensive information as a basis for identifying resident problems/needs and developing or revising an individual plan of care.

Based on observation, interview and record review the facility failed to ensure residents were transferred in a safe manner and as directed by a physician for 2 of 4 residents (R1, R2) reviewed for resident safety and supervision in the sample of 4. The findings include:1.R1's admission care plan showed R1 was admitted to the facility on [DATE] for rehabilitation and aftercare after having all five toes amputated on his right foot due to his diagnoses of peripheral vascular disease, lower leg cellulitis, and diabetes. R1 was discharged from the facility on 6/17/26. R1's hospital admission report dated 6/4/26 showed R1 was non-weight bearing on his right foot due to the surgical wound on the foot from his toe amputations. R1's skin/wound note dated 6/5/26 showed R1's right foot surgical wound was closed with sutures intact to the wound. No bleeding was noted from the surgical wound.On 6/24/26 at 10:35 AM, a telephone interview was conducted with both V7 (Wife of R1) and V8 (Daughter of R1). V7 and V8 each stated, on 6/8/26, they witnessed R1 place his right foot on the floor and bear weight on his right foot, as facility staff transferred R1 into bed. V8 stated, shortly after R1 was transferred on 6/8/26, she noticed some bleeding on the gauze dressing surrounding R1's right foot surgical wound. V8 stated, I kept telling them (nursing staff) that (R1) was not supposed to bear weight on that foot at all but they kept moving (transferring) him. R1's skin/wound notes and nurses notes dated 6/8/26 showed V9 Wound Nurse observed a small amount of bright red bleeding from the surgical incision on R1's right foot. V7 (Wife of R1) and R1's nurse practitioner were notified of the bleeding. No new physician orders were noted.On 6/24/26 at 11:43 AM, V9 Wound Nurse stated R1 was admitted to the facility with an order for R1 to not bear any weight on his right foot. V9 stated, on 6/8/26, she observed a small amount of bleeding from R1's right foot surgical wound as she was changing the dressing to the foot. V9 stated V7 (Wife of R1) was present during R1's dressing change. V9 stated V7 stated the bleeding to the wound was caused by R1 bearing weight on his right foot earlier in the day during a transfer. V9 stated, I can't say what caused the bleeding. I wasn't there when he was transferred. It was a very small amount of bleeding. I did not see any open areas to the incision at that time. On 6/24/26 at 2:04 PM, V13 Certified Nursing Assistant (CNA) stated she and V12 CNA transferred R1 into bed on 6/8/26. V13 stated she knew R1 was not to bear weight on his right foot. V13 stated, (R1) kept putting his (right) foot down on the floor when we were trying to transfer him. We just continued to transfer him so we could get him into bed. On 6/24/26 at 12:35 PM, V3 Assistant Director of Nursing (ADON) stated, on 6/8/26, R1 was not supposed to bear weight on his right foot. V3 stated, If he was bearing weight on that foot during a transfer, the staff should have stopped the transfer and notified the nurse.2. R2's current care plan showed R2 was at risk for falls due to her diagnoses of weakness, dementia, and glaucoma. The plan showed R2 had sustained previous falls in the facility. R2 was cognitively impaired and exhibited impulsive behaviors due to her diagnosis of dementia. R2's restorative assessment dated [DATE] showed R2 required the assistance of one staff member, with the use of a gait belt, for all transfers. On 6/24/26 at 8:36 AM, V4 CNA placed a gait belt around R2's waist as R2 sat on the side of the bed. V4 transferred R2 into a wheelchair by lifting R2 up by placing her hands under R2's armpits. V4 did not use the gait belt to transfer R2. V4 wheeled R2 into the bathroom via wheelchair. V4 transferred R2 onto the toilet by holding onto the sides of R2's incontinence brief. V4 did not use the gait belt to transfer R2. At 8:41 AM, V4 CNA exited R2's room, leaving R2 alone and unsupervised on the toilet. On 6/24/26 at 12:45 PM, V10 Restorative Director stated staff are to hold onto the gait belt when transferring residents, not the arms or waist of the resident. V10 stated if a resident starts to fall during a transfer and staff are holding onto the resident, not the gait belt, this can cause injuries to the resident. V10 stated R2 is at risk for falls. V10 stated R2 should not be left alone while being toileted due to her history of impulsive behaviors and being at risk of falling if she tried to get up on her own. The facility's Manual Gait Belt and Mechanical Lifts policy dated 1/19/18 showed, Use of gait belt for all physical assist transfers is mandatory.

Based on observation, interview and record review the facility failed to ensure a resident's urinary catheter was kept off the floor and below the level of the resident's bladder for 3 of 3 residents (R1, R3, R4) reviewed for urinary catheters in the sample of 4.The findings include:1.R1's care plan dated 6/5/26 showed R1 was admitted to the facility on [DATE] with a urinary catheter in place due to his diagnosis of urinary retention. The plan showed R1 was discharged from the facility on 6/17/26. On 6/24/26 at 10:35 AM, a telephone interview was conducted with both V7 (Wife of R1) and V8 (Daughter of R1). V7 and V8 each stated R1's urinary catheter bag was on the floor while he was being transferred into bed by facility staff on 6/8/26. V7 and V8 each stated R1 was standing on the urinary bag as he was being transferred. On 6/24/25 at 1:11 PM V12 Certified Nursing Assistant (CNA) stated he and V13 CNA transferred R1 into bed on 6/8/26. V12 stated, I knew (R1) had a catheter, but I was standing behind (R1) when he was transferred so I don't know where his catheter bag was. On 6/24/26 at 2:04 PM, V13 stated she assisted V12 CNA with transferring R1 on 6/8/26. V13 stated, I honestly could not tell you where (R1's) catheter bag was when we transferred him. On 6/24/26 at 11:47 AM, V3 Assistant Director of Nursing (ADON) stated a resident's urinary catheter bags must be kept off the floor to prevent infection and cross-contamination. 2.R3's current care plan showed R3 had a urinary catheter in place due to his diagnoses of urinary retention and hydronephrosis. The plan showed R3 was diagnosed with a urinary tract infection (UTI) on 6/19/26. R3 was receiving IV (intravenous) antibiotics once a day, from 6/9-6/26/26, for treatment of his UTI. The plan showed, Position catheter bag and tubing below the level of the bladder.On 6/24/26 at 8:45 AM, R3 was lying in bed. His right knee bent at a 45-degree angle as his legs rested on the bed. An IV port was noted to his right arm. No urinary catheter bag hung off R3's bed. When R3 was asked if he had urinary catheter, R3 pulled up his right pant leg, pointed to his right thigh, and stated, It's right here. R3's urinary catheter bag was secured in place to his right thigh area. A backflow of urine, towards R3's penis, was noted in the catheter bag and tubing. When R3 was asked how long he'd had a leg bag in place versus a standard urinary catheter drainage bag, R3 stated, About a week. On 6/24/26 at 9:55 AM, R3 remained in bed with his urinary catheter bag attached to his right thigh. On 6/24/26 at 1:20 PM, V3 ADON stated a resident should only have a urinary catheter leg bag on when the resident is up and ambulating during the day. V3 stated, Residents that are in bed or are bed-bound should not have (urinary catheter) leg bags because urine cannot drain (out of the resident) into the bag. The bag needs to be positioned below the level of the resident's bladder to allow urine to drain. 3.R4's current care plan showed R4 had a urinary catheter in place due to his diagnosis of obstructive and reflux uropathy. On 6/24/26, this surveyor conducted a continuous observation of R4 from 9:29 AM-10:02 AM. At 9:29 AM, V5 CNA entered R4's room to provide cares to R4. R4's urinary catheter bag hung off the right side of R4's bed. The bag was secured to the bed frame. At 9:33 AM, V5 CNA lifted R4's catheter bag off R4's bed frame and laid the bag on R4's mattress, next to R4's leg. Upon placing the bag on the mattress, a back flow of urine was noted in R4's catheter tubing. R4's catheter bag remained on the bed until 9:53 AM. At 9:53 AM, the bag slowly fell off the right side of the bed. From 9:53 AM-10:00 AM, R4 remained in bed. R4's catheter bag hung loosely (not secured to the bed) during this time. At 10:00 AM, V5 CNA placed R4's catheter bag on R4's lap. V5 and V6 CNA transferred R4 from his bed to a chair via a mechanical lift. At 10:02 AM, V5 CNA lifted R4's catheter bag off R4's lap and hung it off R4's chair. On 6/24/26 at 11:47 AM, V3 ADON stated a resident's urinary catheter bag should never be laid on the bed of the resident or in the resident's lap as this positioning would not allow urine to drain into the bag. V3 stated urinary catheter bags are to be kept below the level of a resident's bladder to allow urinary drainage and prevent infection. The facility's Urinary Catheter Care policy dated 2/14/19 showed, Indwelling catheters may be secured to prevent trauma and tension. Catheters shall be positioned to maintain a downhill flow of urine to prevent back flow of urine into the bladder or tubing, during transfer, ambulation, and body positioning. Urinary drainage bags and tubing shall be positioned to prevent either from touching the floor directly.

Based on interview and record review the facility failed to ensure laboratory tests were completed as ordered. This applies to 1 of 3 residents (R1) reviewed for laboratory services in the sample of 3. The findings include: On 5/4/26 R1's EMR (Electronic Medical Record) showed two Urine Culture results. The first one dated 4/15/26 that states, Invalid and No urine specimen received. Test cancelled. Please recollect if clinically indicated. The second one dated 4/20/26 also states, Invalid.On 5/2/26 at 12:35PM V7 (Nurse Practitioner) stated, For like a week she had a decreased appetite. When I talked to her daughter, she said this usually happens when she has a UTI. We did labs and she was hypernatremic and her blood sugars were low. I ordered a UA/C&S twice, but it came back as Invalid. She was slowly getting worse and then I saw her early the next morning and she had a right sided facial droop and was pocketing her food. Her sodium was coming down but she was not eating full meals. She had no elevated white count on the CBC. Her INR was all over the place, but I assumed that was all based on dietary intake not on the dosing because she was on the same dose she had been on for quite some time. She had no fever, no hypotension. Her daughter said she usually had a mental status change with a UTI but that was hard to see with her. She was still alert, still tracking when you spoke to her. I called the daughter and told her she really had two options. I could send her to the hospital, or I could call in hospice. I said it could be a stroke, but I would see her and she would respond, she opened her eyes, she had the facial droop, but she was still chewing on that side also. her daughter wanted to send her to the hospital, and I respected the daughter's wishes. The D5W brought her sodium down but she was still not acting right. It could have been dehydration or stroke.I talked to the NP (Nurse Practitioner) caring for her at the hospital. She has a UTI (Urinary Tract Infection). She had a CT and she was negative for a stroke. She has just some Chronic Ischemic changes. They put a NG (Nasogastric) tube in her when she got here and I think they are planning to put in a GT (Gastrostomy Tube) tomorrow. They were trying to stabilize her INR first. I ordered the UA/C&S twice at the facility and I don't know why the results were not coming back. I did not want to wait another 3 days for another lab result to see if she had a UTI. I also did not want to just order an Antibiotic without know if there was truly an infection and if the antibiotic would be effective. That is what is wrong with the healthcare system. She was eating, just not as much. We were giving her glycemic control. I evaluated her for 7 days. She had no acute vital sign changes; no acute lab changes. I was worried when she started pocketing food and I think it was a very appropriate time to send her out.On 5/4/26 at 2:50PM V3 (Director of Nursing) stated, V4 (LPN) got the order for the straight catheter (for R1) but he couldn't get any urine. So, he contacted (V7) and that is when they started the IV fluids. (V4) put it on the Nursing Contact Form in the (EMR) and it never went anywhere from there. Then on the 18th they were finally able to get some urine, and I am not sure why that one came back as invalid. We were monitoring her closely the whole time.On 5/4/26 V3 then provided another lab report dated 4/20/26 that states, Specimen rejected. No name on Specimen Cup.

Based on interview and record review, the facility failed to ensure 1 of 27 residents (R76) in the sample of 27 was evaluated by a dentist. This failure resulted in R76 developing a tooth infection and requiring antibiotic treatment.The findings include:On 8/4/25 at 10:04 AM, R76 said he has been waiting months to see the dentist. R76 said he has been telling the facility at his care plan meetings that he wants to see the dentist. R76 said he has been using Orajel (an over-the-counter numbing agent) for tooth pain and proceeded to take a tube of Orajel from a bag attached to his left side rail. R76 said he is now taking an antibiotic for his mouth infection and said his mouth is all swollen. R76's Physician's Orders (printed 8/5/25) show an order written on 5/8/25 at 11:13 AM which shows the following: Patient to be seen by a dentist per family request. Patient complains of sharpness on inside upper tooth, patient felt small piece of tooth break off. R76's Order Summary Report dated 8/5/25 show an order dated 7/30/25 for Clindamycin (antibiotic) three capsules every eight hours for Tooth Infection for seven days. On 8/5/25 at 1:52 PM, V2, Director of Nursing (DON), said a dentist comes into the facility to see residents once a month, and a hygienist comes once a month too. V2 said residents can get on the dental list by letting the nurse know they'd like to see the dentist, then the nurse notifies Social Services (SS). SS puts the patient on the dentist list to be seen. V2 said residents are generally seen the very next month, and the dentist will come sooner if there is an immediate need also. V2 said any of the residents can see the dentist. R76's Nurses Notes dated 5/8/25 at 11:17 AM show R76's family were visiting and requested R76 be seen by a dentist. Family reported that R76 complained of sharpness on his inside upper tooth after feeling a small piece of his tooth break off. An order for a referral to the dentist was placed and R76 was added to the inhouse dentist list. R76's Nurses Notes dated 7/30/25 at 10:27 AM show R76 is complaining of tooth discomfort and has swelling of the right cheek. R76's family would like R76 to be seen by the in-house dentist and was then added to the list. R76's Nurses Notes dated 7/30/25 at 10:55 AM show V16, R76's Nurse Practitioner (NP), ordered an antibiotic for R76 for his tooth. On 8/6/25 at 1:26 PM, V15, R76's doctor, said it's possible for a chipped tooth to turn into an infected tooth, but R76 should have had a dentist evaluate him. On 8/6/25 at 1:30 PM, V16 said she saw R76 yesterday (8/5/25) because they consulted her earlier in the week because they thought R76 had a tooth infection because he had swelling in the mouth and gums. V16 said she started R76 on antibiotics on 7/30/25, the day she was notified about R76's oral swelling. V16 said she also ordered to get him to a dentist ASAP. V16 said she was not aware of any prior oral concerns, pain, or a chipped tooth. V16 said having (oral) pain and a chipped tooth for a couple of months could have contributed to the development of a tooth infection. V16 said no oral problems regarding R76 were reported earlier; she was not aware of any prior oral/teeth complaints or concerns. The facility was unable to provide any documentation that R76 was seen by a dentist from 5/8/25 to 8/4/25. The facility's Policy on On-Site Health Care Services (undated) shows it is the facility's policy to assist residents in arranging health services on site as needed per resident request. On-Site services available include dental care.

Based on interview and record review the facility failed to ensure a resident was free of mental and verbal abuse for 1 of 27 residents (R56) reviewed for abuse in the sample of 27. The findings include:The facility's initial Serious Injury Incident report dated 8/4/25 showed, On 8/4/25, Administrator was made aware of an allegation of verbal/mental abuse. (R56) alleges that (V4 Certified Nursing Assistant/CNA) slammed her door and told her I'll show you what being mean looks like. MD (Medical Director) and Ombudsman notified. Final report to follow.R56's resident assessment dated [DATE] showed R56 was cognitively intact. On 8/4/25 at 9:50 AM, R56 stated that sometime over past couple of weeks she reported to a supervisor that she no longer wanted V4 CNA to take care of her because V4 CNA was mean to her. R56 stated V4 CNA would put me to bed late. She wouldn't answer my call light so I could get changed. R56 was unable to remember the supervisor's name that she spoke to about V4 CNA. R56 stated, Then this weekend, (V4 CNA) came into my room. She asked me why I reported she was mean. I told her to leave. She said I will show you how mean I am. She walked out and slammed my door. R56 stated, I don't like it when people speak to me like that. I have to live here the rest of my life. I don't want her to take care of me again. On 8/5/25 at 10:10 AM, R56 stated she reported this past weekend's incident, between her and V4 CNA, to V6 CNA on Saturday (8/2/25) or Sunday (8/3/25). On 8/5/25 at 10:30 AM, V6 CNA stated, on Sunday (8/3/25), R56 reported to V6 that V4 CNA had confronted R56 about reporting her for being mean. V6 CNA stated R56 reported V4 CNA had come into R56's room, said I will show you how mean I am, and then slammed her door. R4 CNA's timecard showed R4 worked in the facility on 7/31/25, 8/1/25, and 8/2/25.On 8/5/25 at 11:25 AM, V4 CNA stated last Thursday (7/31/25), she was told by V8 Facility Scheduler that she was no longer allowed to take care of R56 and was not allowed in her room because R56 reported that V4 CNA had been mean to her. V4 stated she went to R56's room to speak to R56 about reporting her, despite being told not to by V8 Facility Scheduler. V4 was unable to say exactly which day this happened, stating It was one of the evenings I worked on 7/31/25-8/2/25. V4 stated, I wanted to talk to her because she had said I was mean and I wasn't. I didn't want her to say or think I was mean. V4 denied slamming R56's door or making any threatening statements to R56 at that time. V4 CNA stated on Friday (8/1/25) or Saturday (8/2/25) R56's call light was on. V4 CNA stated she answered R56's call light. V4 stated, I went to her doorway to let her (R56) know that her CNA was busy. I asked her if she wanted me to come in and help her. (R56) said no and asked me to shut her door. I don't think I slammed her door, but I could have accidently shut it hard. V4 CNA denied making any threatening statements to R56 at that time. The facility's Abuse Prevention and Reporting policy dated 10/24/22 showed, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. Mental abuse is the use of verbal or nonverbal conduct which causes or has to potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. Examples of mental and verbal abuse include but are not limited to: Harassing a resident. Yelling or hovering over a resident, with the intent to intimidate. Threatening residents.

Based on interview and record review the facility failed to ensure a stop date was included in the order for as needed psychotropic medications for 2 of 5 residents (R16, R51) reviewed for unnecessary medications in the sample of 27. The findings include: R16's Physician's Order Sheet dated 8/6/25 shows an order for Lorazepam (Antianxiety) 0.5 ML (1mg) every 24 hours as needed for anxiety and an order for Lorazepam 0.5ml (1mg) every 4 hours as needed for anxiety, both started on 3/12/25.R51's Physician's Order Sheet dated 8/6/25 shows an order for Lorazepam 0.5mg every 4 hours as needed for anxiety started on 6/25/25.On 8/6/25 at 11:45AM V3 (RN, Assistant Director of Nursing) stated, Both (R16 and R51) are with hospice and sometimes they give a 14 day stop date and sometimes they don't. I try to audit the charts and catch them or the nursing staff can find it and change it. The facility policy entitled Psychotropic Medication- Gradual Dose Reduction 2/1/18 states, PRN (As needed) hypnotic, antianxiety or antidepressant medications shall not be used beyond 14 days unless the prescribing practitioner indicates the clinical rationale foe extended use and the expected duration for PRN use of the medication.

Based on interview and record review the facility failed to ensure an allegation of abuse was immediately reported to administration for 1 of 27 residents (R56) reviewed for abuse in the sample of 27. The findings include:On 8/4/25 at 9:50 AM, R56 stated, This weekend, (V4 Certified Nursing Assistant/CNA) came into my room. She asked me why I reported she was mean. I told her to leave. She said I will show you how mean I am. She walked out and slammed my door. R56 stated, I don't like it when people speak to me like that. I have to live here the rest of my life. I don't want her to take care of me again. R56 was unable to verify if the incident with V4 CNA transpired on Friday (8/1/25) or Saturday (8/2/25). R56 stated she reported the incident with V4 CNA to V6 CNA on either Saturday (8/2/25) or Sunday (8/3/25). On 8/5/25 at 10:30 AM, V6 CNA stated, on Sunday (8/3/25), R56 reported to V6 that V4 CNA had confronted R56 about reporting her for being mean. V6 CNA stated R56 reported V4 CNA had come into R56's room, said I will show you how mean I am, and then slammed her door. V6 stated she reported the allegations to the weekend manager, V7 Infection Preventionist (IP), on 8/3/25. The facility's initial Serious Injury Incident report dated 8/4/25, at 2:53 PM, showed the facility's initial abuse investigation involving R56 and V4 CNA was not started until 24 hours after the allegation of abuse had been made. The report showed, On 8/4/25, Administrator was made aware of an allegation of verbal/mental abuse. (R56) alleges that (V4 Certified Nursing Assistant/CNA) slammed her door and told her I'll show you what being mean looks like. MD (Medical Director) and Ombudsman notified. Final report to follow.On 8/5/25 at 10:34 AM, V7 IP stated, on 8/3/25, V6 CNA reported to her that R56 reported V4 had been mean to her and R56 did not want V4 taking care of her anymore. V7 IP stated, (V6 CNA) did not tell me that allegedly (V4) had slammed (R56's) door and made the statement she would show her how mean she was. (V6 CNA) should have told me about that because that could be considered abuse. I would have reported that right away to (V1 Administrator) on that Sunday (8/3/25).On 8/5/25 at 10:50 AM, V1 Administrator stated an abuse investigation related to the incident between R56 and V4 CNA, was not initiated until 8/4/25 because V1 had not been informed of the allegations that V4 CNA slammed R56's door and then made the statement that V4 will show her how mean she is. V1 stated, I did speak with (V7 IP) over the weekend but she did not tell me about the incident because it sounds like (V6 CNA) didn't tell her. V1 Administrator stated V6 CNA should have called her directly on Sunday, 8/3/25, to report the incident and allegations involving R56 and V4 CNA because the allegations made by R56 could be considered verbal or mental abuse. V1 stated she has told her staff repeatedly that any allegations of abuse are to be reported to me, immediately. The facility's Abuse Prevention and Reporting policy dated 10/24/22 showed, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment of residents. This will be done by:. Implementing systems to promptly and aggressively investigate all reports and allegations of abuse. Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, or to an immediate supervisor who must then immediately report it to the administrator.

Based on interview and record review the facility failed to assist a resident to obtain medical appointments in a timely manner for 1 of 27 residents (R92) reviewed for quality of care in the sample of 27.The findings include: R92's face sheet shows he has diagnoses including: History of malignant neoplasm of the nasal cavities, ear and sinuses, and age related cataracts. On 8/5/25 at 9:23 AM, R92 said he is having a hard time getting his follow up appointments scheduled for his hip and for eye cataracts. R92 said its been several months and when he asks staff about getting the appointments they tell him, were working on it. On 8/5/25 at 1:53 PM, V2 (Director of Nursing) said the current process to schedule appointments is the nurses fill out a form or she V1 (Administrator) and V3 (Assistant Director of Nursing) audit the physician orders to find an order for an appointment. V2 found that a dermatology appointment is scheduled for R92 for December 2025 but there was no oncology appointment or appointment scheduled for cataract follow up. V2 verified with the surveyor that there are orders in R92's Electronic Medical Record (EMR) to see an Opthamologist at a local hospital for cataract follow up which was entered on 6/9/25 and for R92 to see an Oncologist for follow up for a suspicious bone lesion on his hip entered on 7/15/25. R92's Practitioner Progress notes completed by V11 (Nurse Practitioner) show on 5/13/25 V11 documented that R92 will need an oncology consultation for additional work up for a suspicious bone lesion on his right hip. R92 continues to document this in her progress notes on 5/20/25, 5/27/25, 6/3/25, 6/10/25, 6/17/25, 6/24/25, 7/1/25, 7/8/25, 7/15/25 and 7/22/25. V11's 6/10/25 progress note for R92 shows that R92 had an eye appointment on 6/9/25 and needs an appointment made for left eye cataracts at a local hospital or alternative provider. R92's EMR do not show any appointment was made for R92 to see the oncologist or for the cataract follow up. On 8/6/2025 at 10:10 AM, V1 (Administrator) said the had to let the staff person who had been scheduling medical appointments go and as a result V1, V2 and V3 are all catching things up and auditing the charts to check and schedule any missed appointments. On 8/6/25 at 10:38 AM, V11 said R92 has had a history of cancer and on a follow up CT scan they found a spot on R92's hip that is suspicious for metastasis and requires further workup by an Oncologist. R92 said she kept telling the former scheduler (V12) that he needed this appointment scheduled and V12 would just respond I am working on it. but the appointment was not getting scheduled. V11 said she was also communicating with the nurses about it and finally put in an order for it on 7/15/25. V11 said she after she alerted management that the appointment had not been scheduled she was contacted back that a biopsy maybe needed prior to the oncology appointment. V11 said she was also aware that R92 needed to have follow up for cataracts and she put that order in when she saw the consultation report on 6/9/25. V11 said R92 also told her has been waiting for appointments to get scheduled and was upset about it.

Based on observation, interview and record review the facility failed to implement low air loss mattresses at the correct settings for residents with pressure injuries. The facility failed to ensure a pressure prevention wheelchair cushion was in good and working order. These failures apply to 3 of 8 residents (R9, R126, R82) reviewed for pressure injuries in the sample of 27. The findings include: 1.R9's August 2025 wound assessments showed R9 had pressure injuries to his right heel, right lower leg, sacrum and mid-back area. The assessments showed all of R9's wounds were identified on 8/1/25, upon his readmission to the facility. R9's physician order dated 8/1/25 showed, Low Air Loss Mattress in use. Check for proper functioning and settings every shift. R9's weight record dated 7/8/25 showed R9 weighed 151.8 pounds (lbs). On 8/4/25 at 10:03 AM, R9 was in bed on a low air loss mattress. R9's low air loss mattress was inflated however the mattress settings showed the mattress was programmed for a resident weighing 250 lbs, not 151 lbs. On 8/4/25 at 12:45 PM, R9's low air loss mattress was still programmed for a resident weighing 250 lbs. 2. R126's August 2025 wound assessments showed R126 had pressure injuries to his left ischial tuberosity and sacrum. R126's physician order dated 7/4/25 showed, Low Air Loss Mattress in use. Check for proper functioning and settings every shift. R126's weight record dated 7/31/25 showed R126 weighed 148 lbs. On 8/4/25 at 12:43 PM, R126 was asleep in bed on a low air loss mattress. R126's mattress was inflated however the mattress settings showed the mattress was programmed for a resident weighing 320 lbs, not 148 lbs. On 8/5/25 at 8:12 AM, V9 Wound Nurse stated all residents in the facility are on low air loss mattresses. V9 stated, Those mattresses are weight based. The need to be set at an accurate weight of the resident to make sure the mattress is comfortable and so it fits the resident to make sure it's offloading areas of pressure on a resident's body. If the mattress is not set at the correct weight, it won't help prevent or heal pressure injuries. The facility's low air loss mattress operation manual (undated) showed the facility's low air loss mattress is designed for bed sore and wound care therapy treatment and prevention. The manual showed low air loss mattresses treat pressure injuries by continuously redistributing pressure across the body and reducing areas of pressure to wounds and bony prominences on the body. The manual showed staff were to turn the pressure adjust knob to the mattress to set a comfortable pressure level by using the weight scale as a guide. 3. On 8/4/24 at 10:30 AM R82 was sitting in his wheelchair in the dining room. R82's seat cushion appeared bottomed out and sunken in the middle and R82 was sitting directly on his sacral area. On 8/5/25 at 9:45AM R82 was in bed for wound care. R82 is very thin and R82's coccyx appeared boney and somewhat reddened. Zinc Ointment was applied for skin protection as ordered On 8/6/2025 at 9:23 AM R82 was attempting to stand and reposition himself several times in the wheelchair. R82's wheelchair cushion remains sunken in the middle and raised on the sides. ( U shaped) R82's Wound assessment dated [DATE] shows that R82 is High Risk for Pressure Ulcers as of 8/3/25 and currently has Moisture Associated Skin Damage (MASD) to his bilateral buttocks. On 8/6/2025 at 11:23 AM V14 (RN Wound Care) stated, The cushion does look a little sunk in in the middle- I will see if we have another harder one in the office and try to switch it out. The facility policy Pressure Ulcer Prevention dated 1/15/18 states, Use pressure reducing pads in chairs (all types) to protect boney prominences for residents identified as Moderate/High/Severe risk.

Based on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) for 1 of 27 residents (R153) reviewed for infection control in the sample of 27.The findings include:On 8/4/25 at 9:42 AM, R153 said he has wounds on his legs and feet. R153's room had no EBP signs on or near the entrance to his room and no Personal Protective Equipment (PPE) was located outside of his room. On 8/6/25 at 9:21 AM, V14, Wound Care Nurse, said R153 has an unstageable pressure ulcer on his right posterior ankle. V14 said R153 is getting daily wound treatment to the site. On 8/6/25 at 10:20 AM, V7, Infection Preventionist, said residents with open wounds need to be on EBP. The facility's Enhanced Barrier Precautions (EBP) Policy (effective 1/15/24) shows the purpose is to minimize the risk of acquiring, transmitting, or complications resulting from multi-drug resistant organism (MDRO) colonization among residents in this setting.

Based on observation, interview and record review the facility failed to ensure a resident was provided incontinence care in a safe manner for 1 of 3 residents (R1) reviewed for safety in the sample of 3. This failure resulted in R1 falling from the bed during care and sustaining bilateral toe fractures. The findings include: R1's Face Sheet shows that he admitted to the facility on [DATE] and has diagnoses of: morbid obesity, rheumatoid arthritis and history of falling. R1's Nursing Notes dated 4/21/25 at 2:20 PM shows that R1 is alert and oriented x 4, 2 assist with sit to stand and would be coming to facility after 2 PM. R1's Nursing Note dated 4/21/25 at 8:48 PM shows, Around 4:00 PM CNA (Certified Nursing Assistant) called this nurse and stated that the resident is on the floor .observed resident on the floor, laying a supine position, next to bed . On 4/30/25 at 9:22 AM, R1 was laying in bed. R1 had a bariatric bed. R1 had a splint to his right great toe. R1 had joint deformities to the fingers on his left hand. On 4/30/25 at 9:22 AM, R1 said that he had a fall out of bed and fractures his toes on both of his feet. R1 said that the aide came in to get him cleaned up and turned him to his right side. R1 said that once he turned, he was really close to the edge of the bed. R1 said that he was holding onto the side rail with his left hand. R1 said that due to his rheumatoid arthritis, he could no longer hold onto the railing so he let go and fell out of the bed. R1 said that he told the aide I am not going to be able to hang on much longer. R1 said that his top half fell off the bed first and he hit his head on the night stand and then his lower half fell and he hit his feet hard on the floor. R1 said that he was sent to the hospital and they told him that he had a fracture of his big toe on the right foot and two fractures on his left foot. R1 said that he returned to the facility and was unable to get out of bed until his orthopedic appointment that was 4/29/25. On 4/30/25 at 10:56 AM, V3, Certified Nursing Assistant (CNA) said that R1 had just admitted to the facility and the nurse practitioner told her that he needed to be changed so she went in to change him. V3 said that the nurse told her that he was a one assist so she was the only person in the room to provide the care. V3 said that R1 was in the center of the bed at the start of the care. R1 was turned to his right side by instructing him to grab the side rail with his left hand and she helped him turn his body to the side. V3 said that she was positioned on his left side of his bed. V3 said that when he turned, he was really close to the side of the bed due to him being so big. V3 said that at that time he had a standard size bed. V3 said that she could not move him closer to the center of the bed because of his size. V3 said that she started providing incontinence care and about 10 minutes into the care, he said that his hands were getting weak but before she could tell him to put his hand down, he fell off the bed. V3 said that his upper half flipped over the side rail and then his lower half went off the bed and he landed on the floor. V3 said that the incident happened around 3:45 PM on 4/21/25. On 4/30/25 at 10:12 AM, V6 (CNA) said that a resident should always be in the middle of the bed when providing care so they do not get too close to the edge of the bed and fall off. At 9:36 AM, V7 (CNA) said that residents should not be close to the edge of the bed when providing cares so they do not fall out of the bed. On 4/30/25 at 2:08 PM, V5 (Restorative Registered Nurse) said that during incontinence care, the resident should always be in the center of the bed. V5 said that the staff do not want them close to the edge of the bed to prevent them from falling. V5 said that if the resident is too close to the side of the bed once they are turned, the staff should use the pad or sheet that is under them to pull them closer to the middle of the bed before providing the cares. V5 said that staff should re-position them in bed prior to turning them so that when they are turned, they are still in the middle of the bed. On 4/30/25 at 1:24 PM, V4 (Therapy Director) said that R1 had not been seen by therapy yet prior to his fall due to him just arriving at the facility. V4 said that R1 was seen by Occupational Therapy on 4/23/25 and needed moderate assist of two staff to sit at the side of the bed. V4 said that Physical Therapy had to be postponed until after his orthopedic appointment on 4/29/25 due to him being non-weight bearing. V4 said that R1 should have had another person on the other side of the bed for safety especially since he was a new patient and they didn't know him too well and because of his size. V4 said that if the staff couldn't pull him back to the middle of the bed, they should have know to get a second person as well. R1's emergency room Note dated 4/21/25 shows, Your diagnosis: Right 1st phalanx fracture, left 5th metatarsal fx (fracture) R1's Nursing Notes dated 4/22/25 at 12:05 AM shows, returned from [Local ER] via ambulance stretcher .three person lift to bed. Post right 1st toe 2nd phalanx FX (fracture), left 5th metatarsal FX .noted with CAM boots on each foot. Per hospital, NWB (non-weight bearing) to feet until seen ortho in 1 week R1's Orthopedic Office Visit Notes dated 4/29/25 shows, Patient presents the office today for evaluation of his right foot pain. Patient fell out of bed about 9 days ago. He struck his foot and suffered pain and swelling. Presented the emergency department where x-rays were taken revealing pt sustained a fracture of the right great toe, proximal phalanx and left small, fifth toe proximal phalanx and base of left fifth metatarsal. The facility's Fall Prevention Program Policy revised on 11/21/17 shows, The fall prevention program includes the following components: Use and implementation of professional standards of practice.

Based on observation, interview, and record review the facility failed to identify pressure ulcers prior to becoming advanced stages for 2 residents (R47, R97). This failure resulted in R97 developing a stage 3 pressure ulcer. The facility failed to have preventative measures in place for a resident (R8) with a stage 4 pressure ulcer, failed to implement wound treatment for 2 residents (R26, R47), failed to provide pressure ulcer prevention measures for a resident (R35), failed to accurately assess a wound for 1 resident (R97), failed to assess a reopened, advanced stage pressure ulcer for 1 resident (R26). These failures apply to 5 of 9 residents reviewed for pressure ulcers in the sample of 30. The findings include: 1. R97's electronic face sheet printed on 7/25/24 showed R97 has diagnoses including but not limited to hypertensive chronic kidney disease, end stage renal disease, dependence on renal dialysis, type 2 diabetes, morbid obesity, peripheral vascular disease, and pressure ulcer of left buttock stage 3. R97's facility assessment dated [DATE] showed R97 has no pressure ulcer injuries. R97's skin risk assessment dated [DATE] showed R97 is at risk for skin breakdown. R97's Wound Assessment Details Report dated 7/16/24 showed, Trauma/Abrasion, facility acquired, left buttocks, 1x1x0cm (centimeters). R97's Wound Assessment Details Report dated 7/19/24 showed, Pressure Ulceration Stage 3, facility acquired, left buttocks, 1x2.3x0.2cm, light serosanguinous (thin, yellow/pink) drainage. On 7/25/24 at 1:18PM, V4 (Wound care nurse) stated, (R97's) pressure ulcer is new for her, it is not a reopened pressure ulcer. I wasn't the one who assessed her wound. The person who assessed it is no longer here. I don't think she really knew how to assess wounds very well. (R97) should have never developed a stage 3 pressure ulcer. She is very compliant with offloading and repositioning and gets her showers regularly so this definitely should have been identified prior to a stage 3. I know that she was having some loose stools for a bit but I can't even say that is an excuse for her developing the ulcer. Hers should have been identified prior to a stage 3 for sure. It was initially assessed as an abrasion which was incorrect. Once the wound physician saw (R97) it was correctly assessed and proper treatment was initiated. There is no way this was ever an abrasion. It is clearly on an area where there is pressure so it should have been assessed as that 'from the get go.' Skin assessments should be done during perineal care, dressing, bathing, etc. Anytime they are able to observe skin they should be checking it. Shower days are best days because they have a whole view of the resident's body. It is important to identify wounds early for the best chance to heal a wound. New wounds need to have treatment initiated immediately to prevent worsening or infection or delay. The facility's policy titled, Pressure Injury and Skin Condition assessment dated [DATE] showed, Purpose: To establish guidelines for assessing, monitoring, and documenting the present of skin breakdown, pressure injuries and other ulcers and assuring interventions are implemented .3. A wound assessment will be initiated and documented in the resident chart when pressure and/or other ulcers are identified by licensed nurse .11. A wound assessment for each identified open area will be completed and will include .c. stage of pressure ulcer . 2. R26's electronic face sheet printed on 7/25/24 showed R26 has diagnoses including but not limited to chronic embolism and thrombosis of left femoral vein, peripheral vascular disease, alcoholic cirrhosis of liver, morbid obesity, and dementia without behaviors. R26's facility assessment dated [DATE] showed R26 has 1 stage 3 pressure injury. R26's physician's orders from (local wound center) dated 5/14/24 showed, Pressure injury posterior thigh and right buttock Stage 3 cleanse with normal saline, apply skin prep and Enluxtra, cover with mepilex border foam daily. R26's May 2024 physician's orders showed, 5/21/24 Wound care: right buttock-cleanse with normal saline, pat dry, apply Enluxtra/skin pep to peri-wound, cover with mepilex bordered foam dressing. (7 days after R26's wound physician ordered the treatment) R26's wound assessment dated [DATE] showed, Pressure ulceration stage 3, right buttock, facility acquired, 0.5x0.5cm with scant, serous (clear/yellow) drainage. (This assessment was completed 6 days after R26's wound reopened). On 7/25/24 at 1:18PM, V4 (wound care nurse) stated, (R26) has 2 pressure wounds- 1 is on his posterior right thigh and 1 on his right buttock. He doesn't follow recommendations, and these are both ongoing pressure wounds. His right buttock has healed and reopened. Staging for a reopened wound has to be staged as it was before. His was a stage 3 and reopened so we had to stage it as a stage 3. The nurse that received the orders and assessment from the wound center should have notified the wound team right away when his buttocks was determine to have reopened so that we could do an assessment and implement orders. 38488 3. R47's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include hypertensive chronic kidney disease, dementia with behavioral disturbance, generalized osteoarthritis, osteoporosis, hyperlipidemia, and peripheral vascular disease. R47's facility assessment dated [DATE] showed she has severe cognitive impairment and is dependent on staff for all cares. R47's care plan initiated 12/31/24 showed, [R47] has pressure injury to sacrum, is at risk for delayed wound healing, and is at risk for further alteration in skin integrity related to: Dementia, Chronic Kidney Disease, Hypertensive Chronic Kidney Disease, bradycardia, generalized osteoarthritis, osteoporosis . contractures, fragile skin, immobility, incontinence of bowel, and incontinence of urine . Interventions . Treatments as ordered by provider . R47's initial wound assessment dated [DATE] showed a facility acquired stage 3 pressure ulcer to R47's sacrum measuring 1.5 cm x 1.0 cm x 0.1 cm. R47's December 2023 eTAR (electronic Treatment Administration Record) showed an order started 12/31/23 showed Wound Treatment to Sacrum; cleanse area with normal saline pat dry and apply medihoney and cover with foam dressing every 24 hours as needed. This order was not documented as completed on 12/31/23 on the December 2023 eTAR. R47's January 2024 eTAR showed a new order dated 1/5/24 for Wound Treatment to Sacrum; cleanse area with normal saline, pat dry and apply medihoney and cover with foam dressing every day shift for wound care. There was no evidence of dressing changes being completed for R47's sacral wound from 1/1/24 through 1/4/24. On 7/25/24 at 11:12 AM, V2 DON (Director of Nursing) said to identify new skin issues the staff should be doing skin assessments with all cares such as incontinence care, showers, and activities of daily living. On 7/25/24 at 2:10 PM, V4 RN (Registered Nurse) said it is important to identify wounds quickly and get interventions and treatments added immediately so the wound does not get worse. 20042 4. On 7/24/24 at 7:58 AM, R8 was sitting up in bed, with the head of her bed at 90 degrees. R8 had an over the bed tray table in front of her. At 8:50 AM and 11:54 AM, R8 was sitting up in bed with her head of the bed at 90 degrees. There weren't any positioning devices in place. At 11:54 AM, R8 was asked if anyone had turned her or repositioned her in bed today and she replied, No. At 12:56 PM, R8 will in the same position she was in at 7:58 AM, 8:50 AM, and 11:54 AM. R8's alert and oriented roommate (R27) stated no one had been in to reposition R8 all morning. On 7/24/24 at 2:11 PM, V4 RN (Registered Nurse/Wound Care Director) stated R8 has a pressure ulcer to her sacrum and should be repositioned every two hours. The Wound Assessment Details Report dated 7/19/24 for R8 showed she has a stage 4 pressure ulcer to the sacrum that is 1 cm x 4 cm x 1.50 cm (L x W x D). R8's Care Plan dated 5/29/24 showed, R8 has a pressure injury to her sacrum Foam wedges for proper offloading. Turn and position the resident per physician's orders. The MDS (Minimum Data Set) dated 5/29/24 for R8 showed moderate cognitive impairment; substantial/maximal assistance needed for rolling left and right; dependence for transfers. The facility's Pressure Ulcer Prevention (1/15/18) showed, turn dependent resident approximately every two hours or as needed and position resident with pillow or pads protecting bony prominences as indicated. 5. On 7/24/24 at 8:48 AM, R35 was dressed and sitting in her wheelchair in her room with a tray table in front of her. R35 had a thin pressure relief cushion in place to her wheelchair. The cushion did not come to the front edge of wheelchair seat; the cushion was approximately 1 inch back from the edge. On 7/24/24 at 12:00 PM, R35 was sitting in her wheelchair at the dining room table for lunch. R35 had a thin pressure relief cushion in place to her wheelchair. The cushion did not come to the front edge of wheelchair seat; the cushion was approximately 1 inch back from the edge. V20 (R35's daughter) was feeding R35 and stated, she has not been notified of any pressure ulcers. After lunch they will lay her down due to her pressure ulcers in the past. R35 usually gets pressure to her buttocks. V20 stated she would appreciate it if they would call her and let her know when R35 has a pressure ulcer. On 7/24/24 at 1:20 PM, V9 LPN (Licensed Practical Nurse/Wound Nurse) changed the dressing to R35's left buttock wound. There was scarring to R35's left buttock and a small, slit like opening to her left buttock. V9 stated the pressure ulcer was either a stage one or stage two and is open. V9 stated she would need to look in the computer for the stage of the pressure ulcer. V9 was shown the pressure relief cushion in R35's chair that was flattened, worn in appearance, and positioned approximately 1 inch back from the edge of the wheelchair. V9 measured the cushion and stated it was 4 cm thick. R35 stated the wheelchair cushion should come out to the edge of the chair and should be thicker. On 7/24/24 at 1:59 PM, V4 RN (Registered Nurse/Wound Care Director) stated for pressure relief cushions in wheelchairs the staff should be looking for signs of wear and replace the cushion. The cushion should fit the chair. The Wound Care Physician Note dated 7/18/24 for R35 showed, follow up left buttock wound - re-opened; stage 3 pressure; 0.5 cm x 1.2 cm x 0 cm; 100 % non granulating tissue with defined margins. Date reported - 7/18/24. Preventative measures in place - low air loss mattress, heel offloading being done, turning schedule present, wheelchair cushion. Assessment and Plan: Pressure ulcer of left buttock, stage 3. Clean with normal saline, apply medicated petroleum dressing and dry dressing. Plan of care: Upright incline limit to 30-45 degrees for prolonged period of time, when there is a risk for ischial pressure, unless patient can reposition. Wheelchair cushion or custom molding when sitting and re positioning as needed. Please limit wheelchair for maximum of 2 hours at a time. The Nurse Pressure Injury assessment dated [DATE] showed a left posterior stage 3 pressure ulcer that was first identified on 7/16/24 when bathing/showering. The Face Sheet dated 7/25/24 for R35 showed diagnoses including Parkinson's disease, hypertension, diabetes mellitus, hyperlipidemia, osteoarthritis, and hypothyroidism. The MDS (Minimum Data Set) dated 5/28/24 for R35 showed moderate cognitive impairment; dependence for transfers; and substantial/maximal assistance for rolling left and right.

Based on observation, interview, and record review the facility failed to ensure hairnets were worn correctly, failed to ensure staff were knowledgeable in the use of the dishwasher, and failed to ensure expired foods were destroyed. This applies to all residents residing in the facility. The findings include: The CMS 671 form dated [DATE] showed 153 residents residing in the facility. 1. On [DATE] at 10:35 AM, V13 (DA-Dietary Aide) was seated in the kitchen office wearing her hairnet only covering the bun on top of her head. At 11:41 AM, V13 was standing at the food service tray line and her hairnet was only on her top bun. At 1:01 PM, V13 tested the dishwasher sanitation level. The hairnet was only covering half of her head. On [DATE] at 1:35 PM, V13 was seated in the kitchen office and her hairnet was only covering her top bun. On [DATE] at 1:15 PM, V12 (Food Service Director/Registered Dietician) stated hairnets are require by everyone in the kitchen. They are important to prevent cross contamination. Hairnets keep hair out of resident food. Staff need to be sure their hair is fully covered to keep food safe. The facility's undated Hair Restraints policy states: 1. Staff shall wear hair restraints in all food production, dishwashing, and serving areas. 2. On [DATE] at 10:39 AM, V14 (DA-Dietary Aide) was operating the dishwasher and running coffee cups through it. V14 was asked how he knows if the dishwasher is sanitizing the dishes correctly. V14 pointed to a temperature dial at the front of the machine. V15 (DA) was called over and translated for V14. Both dietary aides explained the temperature dial is watched during use to be sure it reaches 100 degrees. A test tray was run and V14 pointed to the dial and showed it was at 100 degrees. The dietary aides said the temperature is recorded in the logbook to show the 100 degrees was reached. The aides said the machine is checked that way before every meal and all kitchen staff are responsible for doing it whenever they are assigned the dishwasher. The facility dishwasher log for [DATE] was reviewed and showed the entire month readings at exactly 100 for everyday and every mealtime. The log had an area at the top that read: Required PPM: (blank). Under the required PPM was: minimum 50 PPM. On [DATE] at 11:06 AM, V12 (Food Service Manager) stated he was unsure how the dishwasher sanitizes the dishes. V12 supplied a typed document that showed the dishwasher has three stages. The third stage rinses the dishes at temperatures between ,d+[DATE] degrees Fahrenheit to sanitize them at the high heat level. On [DATE] at 11:16 AM, V16 (DA) stated the dishwasher is tested using test strips that show the sanitizer solution level. V16 said the test strip changes to a dark purple to show the level. V16 ran a test load and used the strip to test the sanitizer level. The strip did not change color in anyway and read less than 10 ppm (parts per million). V16 did a second test and again the strip read less than 10 ppm. V16 said we will notify the maintenance staff right now to determine what is going wrong. On [DATE] at 11:35 AM, V21 (Maintenance) stated the hose into the sanitizer solution was not reaching down into the solution all the way. It was not sanitizing the dishes correctly. If it can't reach the solution, the dishes are not properly sanitized. It needs to test between 50 and 100 ppm to be sure it is working correctly. V21 clarified the machine was not a high temperature type machine and sanitized items using the chemical disinfectant type process. On [DATE] at 1:01 PM, V12 (Food Service Manager) said the dishwasher testing is done before every use. Staff need to use strips to see if the concentration is correct. It needs to test at 50 ppm or higher to be sure it is working correctly. The log should show the PPM and not the temperature. All kitchen staff need to know how to test it. Food borne illness is a big risk if dishes are not cleaned and sanitized the right way. The facility's undated Dishwashing: Machine Operation policy states:1. All dishwashing machines should be operated according to manufacturer recommendations (all items) should be cleaned and sanitized in either a high-temperature dishwashing machine .or a chemical-sanitizing dishwashing machine that uses a chemical sanitizing solution. 3. On [DATE] at 11:50 AM the walk-in refrigerator had a pan of cooked rice in it and the dating on the pan was not legible. A container of beef flavored base had a use by date of ,d+[DATE] written on it. A second one next to it did not have any date on it. Both containers were 90% used. The same refrigerator had three open, one-gallon containers of salad dressing in it. All three were open and without any type of use by date on them. On [DATE] at 12:05 PM, the dry storage room had several large bins of dry food items. A bin of a thickener had a use by date of by [DATE] and the flour use by date of [DATE]. The oatmeal had a prep date of ,d+[DATE] and the use by date was blank. The sugar had a prep date of [DATE] and the use by date was blank. A bin of uncooked rice had no date on it at all. Bins of barley, lentils, and dry green split peas did not have any dates on them. On [DATE] at 1:07 PM, V12 (Food Service Manager) was shown the expired and undated food items. V12 said dates should be checked by staff on a daily basis. It is important to ensure the quality and high standards. Dates show the food is not spoiled or outdated. All expired foods should be thrown away. There is the potential for resident illness if expired food is used. Everything needs a use by or expiration date on it. The facility's undated Labeling and Dating Food (Date Marking) policy states: All foods stored will be properly labeled according to the following guidelines. Expiration dates on commercially prepared, dry storage food items will be followed. Once a package is opened, it will be re-dated with the date the item was opened and shall be used by the safe food storage guidelines or by the manufacturer's expiration date.

Based on interview and record review, the facility failed to offer snacks for 4 of 4 residents (R68,R98,R109,R130). This applies to 1 of 1 residents reviewed for HS (bedtime) snacks in the sample of 30 and 3 residents outside of the sample. The findings include: On 7/24/24 at 11:00AM, the resident council meeting was held on the main dining area. R68, R98, R109 and R130 were present in the meeting and stated they are not offered bedtime snacks. R130 stated if she goes and finds someone they will give her a snack but they are not routinely offered. All 4 residents stated they would like to be offered a snack before bed as they get hungry between dinner and breakfast. R68, R98, R109, and R130's facility assessments were reviewed and showed all residents have no cognitive impairment and no documentation was present in their chart regarding snacks being offered, refused, or accepted. On 7/24/24 at 12:45PM, V6 (Dietary Manager/Registered Dietician) stated, We provide snacks such as cookies, fresh fruit, sandwiches, and yogurt to all the units and they are to be passed out by the aides on each unit. Residents only get HS snack if they request them. We leave 10 -12 packages of snacks on each unit and when I check the trays there are maybe 1 or 2 packages gone. It's never all gone or even half of the items. On 7/25/24 at 1:00PM, V2 (Director of Nursing) stated, We have snacks available at all nurse's stations. The residents just have to ask for a snack and we will provide one for them. We do not go around and offer a snack nor do we document it. We don't need to monitor every single thing our resident's ingest. If they want a snack, they know where we keep them. The facility's policy titled, Fortified Foods, Supplements, and Snacks dated 2020 showed, d. Snacks: regular food items that are available on the units or can be specified to be served at designated times (such as HS for a diabetic) and generally not required to be ordered by the physician .9. The resident's acceptance and tolerance of fortified foods, med pass, and other supplements/snacks is monitored for resident tolerance and acceptance by the dining services manager and registered dietician. Acceptance observational data may be included in a progress note, care planning summary documentation, or by other members of the interdisciplinary team in designated locations in the medical record such as nursing or therapy notes .

Based on interview and record review, the facility failed to offer and perform care plan conferences for 1 resident (R26) reviewed for care plans in the sample of 30. The findings include: R26's electronic face sheet printed on 7/25/24 showed R26 has diagnoses including but not limited to chronic embolism and thrombosis of left femoral vein, peripheral vascular disease, alcoholic cirrhosis of liver, morbid obesity, and dementia without behavior. R26's facility assessment dated [DATE] showed R26 has no cognitive impairment. On 7/24/24 at 10:23AM, R26 stated, I have only had 1 care plan meeting within the past year and it was mainly about physical therapy. I would like to have regular meetings to discuss my care. Surveyor requested all of R26's care plan conference meeting summaries for the past year and the facility provided 1 document titled, IDT (Interdisciplinary Team) Care Conference Summary dated 11/10/23 and both R26 and his mother attended the conference. On 7/25/24 at 9:48AM, V17 (social services) stated, (R26's) last care plan meeting was 11/10/23. He attends his meetings with his mother. Currently, the only concerns are that he has a lot of extra items in his room. Care plan meetings are held every 3 months for all residents and they are invited as well as their power of attorney/guardian. I usually ask (R26's) mother if she wants one and the last time she said she didn't need one right now. (R26) has a surrogate decision maker who is his mother so she decides everything for him. When the time came to have a meeting I asked them both and they didn't want a meeting from what I remember. I didn't document it anywhere. I kept asking him but I never documented it so I can't show you anywhere that I offered the meeting. We didn't meet as a team to discuss his care either. I'm not sure if that's a problem or not. On 7/25/24 at 1:00PM, V2 (Director of Nursing) stated, We are in communication with (R26) and his mother frequently. I know I have offered a care plan meeting to both of them but I don't see where I documented the conversations. We haven't met as an IDT to discuss his care in a long time. I didn't realize we still needed to meet even when the resident and family declined to meet. The facility's policy titled, Comprehensive Care Plan dated 11-17-17 showed, 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 psychological well-being .The resident and/or resident representative shall be invited to review the plan of care with the interdisciplinary team either in person, via telephone or video conference (if available) at least quarterly .

Based on observation, interview, and record review the facility failed to ensure a resident's heels were offloaded and failed to identify a wound to a resident's heel for 1 of 4 residents (R8) reviewed for wounds in the sample of 30. The findings include: On 7/23/24 at 10:41 AM, R8 was laying on her right side in bed with her left heel laying on her bed and her right heel laying on a pillow. R8 had offloading boots sitting in the window of her room. V3 CNA (Certified Nursing Assistant) was asked to come inside R8's room. V3 lifted R8's right heel up and there was a dressing in place. V3 lifted R8's left heel up, a black area was present to her heel. R8's skin to her left foot was dry and cracked with large flakes of skin present. V3 stated she was not aware of the area to R8's left heel. V3 stated R8's heels were to be elevated off the mattress when she is in bed. V3 was asked to check with the nurse to see if she was aware of the discoloration to R8's left heel. At 10:51 AM, V3 came back to R8's room and stated the wound nurse was going to check and see if anyone knew about the area to R8's left heel. V4 RN (Registered Nurse/Wound Care Director) came into R8's room and stated they are doing a preventative dressing to R8's right heel that is changed every 3 days. V4 stated she was not aware of any problem to R8's left heel. V4 stated there is dry eschar present to R8's left heel. V4 stated she V8 should have the offloading boots on for prevention. V4 stated staff are to let her or the primary nurse know immediately when there are changes to a resident's skin. The Wound assessment dated [DATE] at 11:20 AM for R8 showed a vascular wound to her left heel; tissue type - necrotic, firm, and adherent; 2 cm (centimeter) x 2 cm x unknown (L x W x D). The Care Plan initiated on 7/23/24 for R8 showed, R8 has an arterial wound to her left heel. Offload bony areas using pillows, foam wedges, and/or offloading devices. Offload heels using heel protecting devices. The Order Summary Report dated 7/24/24 for R8 showed an active order that started on 1/6/24 to offload heels with foam boots/pillows while in bed, every shift for prevention. The Face Sheet dated 7/24/24 for R8 showed diagnoses including stage 4 pressure ulcer of the sacral region, protein-calorie malnutrition, vascular dementia, hypertension, peripheral vascular disease, major depressive disorder, residual schizophrenia, anemia, osteoarthritis, and hyperlipidemia. The Care Plan initiated on 7/25/24 for R8 showed, R8 has a diagnosis of peripheral vascular disease. Keep skin on extremities well lubricated with lotion in order to prevent dry skin and cracking of the skin. Monitor for any signs and/or symptoms of skin problems related to peripheral vascular disease including redness, edema, blistering, itching, burning, bruises, cuts, other skin lesions. Monitor the extremities for, document and notify the physician of any signs and/or symptoms of injury, infection or ulcers. The MDS (Minimum Data Set) dated 5/29/24 for R8 showed moderate cognitive impairment; substantial/maximal assistance needed for rolling left and right; dependence for transfers. The facility's Pressure Injury and Skin Assessment policy (1/17/18), 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 a detailed assessment. Care givers are responsible for promptly notifying the charge nurse of skin breakdown.

Based on observation, interview, and record review the facility failed to check placement prior to starting feeding, failed to flush after tube feeding, and failed to ensure a resident received tube feeding as ordered for 2 of 2 residents (R43 & R125) reviewed for tube feeding in the sample of thirty. The findings include: 1. On 7/24/24 at 8:44 AM, R43 was not in her room; R43 was at dialysis. R43's opened tube feeding bottle was hanging on a pole with the tubing attached to the pump and the pump turned off. On 7/24/24 at 1:05 PM, R43 was back in her room, in her bed and the tube feeding was no longer hanging on the pole. V8 LPN (Licensed Practical Nurse) was out in the hallway at her medication cart. V8 stated, the order for her tube feeding is to turn it off at 12:00 PM. The night nurse gets her ready and off to dialysis. She was over at dialysis at 7 AM and did not have the tube feeding with her. I was questioning it myself; not sure why they don't change either her dialysis time or her tube feeding time around dialysis. It would make more sense to do do dialysis from noon to 4:00 PM. R43's tube feeding starts at 6:00 PM and is to run until 12:00 PM the next day. Tube feeding isn't given during dialysis. I know her tube feeding was not going while she was at dialysis today. The Order Listing Report for R43 dated 7/25/24 showed on 7/10/24 R43 had an order for tube feeding to infuse at 55 ml per hour for 18 hours from 6:00 PM to 12:00 PM. The order was revised on 7/24/24. After the interview with V8 LPN on 7/24/24 at 1:05 PM, the Order Summary for R43 showed a new order was entered at 3:00 PM changing the enteral feeding time to start at 12:00 PM and end at 6:00 AM for the tube feeding that provided a carbohydrate steady feeding with 0.08 gram-1.8 Kcal./ml liquid (55 ml /hr) x 18 hours. On 7/25/24 at 11:15 AM, V2 DON (Director of Nursing) stated she changed R43's orders yesterday so R43 would get the tube feeding around her dialysis schedule. The Dietary Note dated 7/8/24 for R43 showed, R43 had been receiving mixed nutrition orally and enterally but was change to nothing by mouth due to difficulties swallowing. R43's enteral feeding was increased to meet her needs. Tube feeding at 55 ml x 18 hours (990 ml total formula). Will coordinate care with dialysis. The Face Sheet dated 7/25/24 for R43 showed diagnoses including hypertensive chronic kidney disease, end stage renal disease, dependence on renal dialysis, gastrostomy, atherosclerotic heart disease, seizures, hyperlipidemia, functional quadriplegia, polyosteoarthitis, and peripheral vascular disease. The Care Plan dated 5/15/24 for R43 showed she requires enteral feeding Enteral feeding is related to pneumonia and diagnosis of dysphagia. Enteral nutrition per physician's order. The facility's Tube - Feeding and Care policy (8/3/20) showed, Methods of administration: continuous: Prescribed amount of formula volume is given over a specific period of time that is usually less than 24 hours. Licensed nurse will review physician's order for type of formula, concentration, rate of flow, and method of administration. 34891 2. R125's face sheet printed on 7/25/24 showed diagnoses including but not limited to cervical fracture, dysphagia (difficulty swallowing), and encounter for attention to gastrostomy (surgery to insert a tube through the abdominal wall and into the stomach for liquid nutrition). R125's July 2024 order summary report showed orders start dated 7/15/24 for NPO (nothing by mouth) and liquid nutritional formula four times a day at 355 milliliters via the gastrostomy tube. On 7/25/24 at 9:46 AM, V10 (Registered Nurse) administered R125's liquid nutrition via the gastrostomy tube (G-tube). V10 inserted the piston syringe into the end of the G-tube and flushed with 50 milliliters of water. V10 gave the 355 milliliters of liquid nutrition and closed the G-tube. V10 did not check for placement prior to administering the liquid nutrition and did not flush the tube after administration. V10 said he gives R125 his medications and liquid nutrition twice per shift, once in the morning and again at noon. On 7/25/24 at 12:21 PM, V2 (Director of Nurses) stated feeding tubes should be checked for proper placement prior to anything going into it. It is important to ensure it is the right place in the stomach. There is the potential for infection and improper infusion. The flushes are important to ensure the tube has nothing left in it and the full quantity of nutrition or medication is received. The facility's Gastrostomy Tube-Feeding and Care policy last revision dated 8/3/20 states under the bolus feeding section: 1. Check placement and residual .3. Administer the prescribed feeding .4. Flush tube with approximately 30 milliliters of water.

Based on observation, interview and record review, the facility failed to ensure narcotics for discharged residents were removed from the medication cart in 1 of 6 medication carts reviewed for the medication storage task. The findings include: On [DATE] at 10:22 AM, the far-west medication cart was reviewed with V11 (Registered Nurse-RN). In the narcotic box of the medication cart, two medication cards along with their reconciliation sheets were behind a box of tissues. V11 RN said the cards belonged to two residents that have been discharged from the facility. One medication card contained Tramadol (a narcotic used to treat moderate to severe pain) for R307. V11 said she thinks R307 was discharged about a week prior. The other medication card contained Morphine (a narcotic used to treat moderate to severe pain) 30 mg tablets for R308. V11 said R308 was discharged from the facility about a month prior. V11 said the medications for R307 and R308 should not be in the medication cart; they should have been given to V2 (Director of Nursing-DON) when R307 and R308 left the facility. On [DATE] at 12:28 PM, V2 (DON) said when a resident is discharged from the facility, the resident's medications should be discontinued. V2 said the facility's policy is to send the narcotics back to the pharmacy as soon as possible. If the pharmacy will not take the medications back, the pills should be destroyed. V2 said this should happen as soon as possible to eliminate any issues or risks. R307's Admission Record, provided by the facility on [DATE], showed he was admitted to the facility on [DATE] and discharged on [DATE]. R307's Order Summary Report, provided by the facility on [DATE], showed an order for Tramadol 50 mg (milligram) tablets. Give one tablet every six hours as needed for pain. The report showed another order for Tramadol 50 mg tablet. Give half a tablet every six hours as needed for moderate pain. The report also showed an order dated [DATE] for R307 to be discharge to home on [DATE]. R308's Admission Record, provided by the facility on [DATE], showed he was admitted to the facility on [DATE] and discharged on [DATE]. R308's Order Summary Report, provided by the facility on [DATE], showed an order for Morphine Sulfate ER extended release 30 mg tablet. Give one tablet at bedtime for pain/pain management. The report showed an order dated [DATE] to discharge R308 to home on [DATE]. The report also showed an order dated [DATE] to discontinue all current orders upon discharge or 24 hours after hospitalization . The facility's policy and procedure titled Medication Storage, with a revision date of [DATE], showed 15. Facility should ensure that medications and biologics for expired or discharged residents are stored separately, away from use, until destroyed or returned to the provider.

Based on interview and record review the facility failed to ensure a resident was safely transferred, via a mechanical lift, in a manner to prevent resident injury. This failure resulted in R1 fracturing her right clavicle(collarbone) and right lower leg (tibia and fibia), after falling out of a mechanical lift, due to the cloth sling of the mechanical lift becoming unhooked from the lift. This failure applies to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 3. The findings include: The facility's Fall Incident report dated 1/10/24 showed staff (V4 Registered Nurse/RN and V5 Certified Nursing Assistant/CNA) were transferring R1 from her bed to wheelchair, via a mechanical lift, when R1 moved her upper body in the lift sling which caused the sling to unhook from the lift. R1 then fell out of the lift, onto to the floor. 911 was called. R1 was transferred by ambulance to a local hospital. V10 (Family of R1) was in R1's room and witnessed R1's fall. The report showed prior to the transfer, R1 and V10 were speaking loudly back and forth to each other, in their native language, as R1 was initially refusing to get out of bed and was refusing cares offered by staff. The report also showed facility staff had to remind (R1) more than once to keep her arms crossed over her chest and to sit still while attempting to transfer R1. R1's hospital records dated 1/10/24 showed, Patient was being transferred by [mechanical] lift at nursing home and fell . Patient complains of right leg pain and right shoulder pain . The records showed R1 was diagnosed with a right clavicle (collarbone) fracture and a right tibia/fibia (lower leg) fracture as a result of the fall. R1's current care plan showed R1 had a history of behaviors including moderate to extreme anxiety, refusing cares, depression, agitation, impulsive behaviors, verbal behaviors, and physical behaviors. The care plan showed, Utilize de-escalation strategies when a resident has an episode of agitation/anxiety behaviors . allow time alone to promote calmness .Evaluate the potential causal factors contributing to feelings of anxiety. Work with the resident to eliminate causes whenever possible. A care plan focus area for R1, initiated 7/23/23, showed R1 required the use of a [mechanical] lift for transfers related to her diagnoses of anxiety, weakness, and a previous fall resulting in a right femur fracture. The care plan focus area showed R1 had a history of moving during [mechanical] lift transfers. The plan showed, Hook sling loops on metal hooks and pull sling down to ensure security . Prompt resident prior to lifting to ensure readiness . On 1/22/24 at 11:47 AM, R1 was in bed. Purple bruising was noted above R1's right eye and down R1's right lower leg. This surveyor tried to interview R1, twice, but was unsuccessful. Although awake, R1 would only shrug her shoulders and gave no verbal response when questioned. On 1/22/24 at 10:20 AM, V5 CNA stated on 1/10/24, R1 and V10 (Family of R1) were arguing and yelling at each other because (R1) was refusing to get out of bed and go to her appointment. (R1's) face was red. She was mad. V5 stated R1 eventually agreed to get out of bed and go to her appointment but continued to argue with V10. V5 stated, We (V10 and V4 RN) continued to get (R1) ready. We got her up into the lift. She was still arguing with (V10). When (R1) leaned to her left to shake her left hand at (V10), the lift sling dipped down and the sling loop, by her left leg, came away from the lift. (R1) rolled out of the lift onto the floor. I don't know how that happened. V10 stated for resident safety, staff are not to transfer a resident via mechanical lift if the resident is agitated. V10 stated, (R1's) family gets her worked up a lot. Next time, we will ask her family of leave the room so she can calm down. On 1/22/24 at 10:32 AM, V4 RN stated on 1/10/24, V10 (Family of R1) was shouting at R1 and R1 was yelling back at (V10) because (R1) initially did not want to go to her appointment. (R1) was all worked up. We continued to work on getting (R1) up. We got her up off the bed, in the sling. She was still arguing with her family. She kept moving while in the sling. We told her to cross her legs and arms (during the transfer) but she wouldn't listen to us. As (R1) raised her arm at (V10) and was screaming, it caused her weight to shift in the sling. The sling dipped down and came unhooked from the lift. (R1) fell on the ground. It happened so fast . V4 stated, We shouldn't have transferred her when she was all worked up. We should have removed her family and given her time to calm down. On 1/22/24 at 10:50 AM, V10 Family of R1 stated on 1/10/24, R1 was agitated prior to the transfer because, She was not ready for the doctor's appointment when I got there. She was confused and is very hard of hearing. She was not sure what doctor she was going to see . V10 stated, The sling part came away from the lift. (R1) tumbled out of the lift, head first, onto the floor . On 1/22/24 at 11:15 AM, V3 Nurse Practitioner (NP) stated R1 was hard of hearing and had periods of confusion. V3 stated, (R1) has anxiety. She can get agitated and refuse cares. Within the past year, she fell and broke her right femur (upper leg). She was hospitalized where she underwent surgery to repair her femur. While hospitalized , staff dislocated her previously repaired femur fracture, during a transfer. She had to go back to surgery again. By the time she got admitted to the facility, she was so scared of being hurt when transferred or during cares, she was in a full-on panic disorder. She was refusing all cares. I had to put her on medications initially to help treat her panic disorder. If (R1) gets worked up, agitated, refuses cares, or is not cooperative, staff should come up with a plan to mitigate her safety concerns. Hold off on transferring her. Let her express her concerns, then try to reapproach her. If she won't follow staff instructions such as holding still during a transfer, don't transfer her. Give her time and reapproach. If she is having behaviors and has an appointment she must go to, slide her from her bed to a gurney, to make sure she is transferred safely. On 1/22/24 at 8:54 AM, this surveyor and V9 Maintenance Director examined the mechanical lift and cloth sling used to transfer R1 on 1/10/24. No defective areas and/or missing parts were noted on the lift. No weakened areas or holes were noted on the cloth sling. V9 stated there was no way the sling just comes away from the machine if the loops are secured in place and two staff are doing the transfer. V9 stated when residents are being transferred via mechanical lift, the resident should be calm to prevent any resident injury. On 1/22/24 at 9:50 AM, V8 (Representative of the company that manufactures the mechanical lift used to transfer R1) stated, We leave it up to the discretion of the facility but we recommend that a resident is in a calm state when transferring them in a lift. V8 stated if the resident can't be still and calm, then we don't recommend transferring them to ensure they aren't injured while being transferred.

Based on interview and record review the facility failed to complete quarterly and significant change dietary assessments on residents. The facility failed to ensure dietary assessments were completed by the Registered Dietician. The facility failed to identify resident weight loss prior to the weight loss becoming significant. The facility failed to ensure weight loss treatment interventions were initiated in a timely manner, once resident weight loss was identified. These failures resulted in R37, R69, R144, R9, and R79 sustaining a significant weight loss. These failures apply to 5 of 10 (R37, R69, R144, R9, R79) residents reviewed for weight loss in the sample of 31. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 3/27/23, when the facility's Registered Dietician (V6) failed to assess and complete a dietary assessment on R37, upon her admission to the facility. V1 (Administrator) was notified of the Immediate Jeopardy on 8/31/23 at 12:46 PM. This surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 9/1/23 however, noncompliance remains at a Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: 1. R37's Admission Record dated 3/27/23, showed R37 was admitted to the facility with diagnoses of dementia and a left hip wound related to recent hip surgery. An admission dietary profile for R37, dated 4/13/23, showed the profile was completed by V7, a non-certified Dietary Manager. R37's electronic medical records dated 3/27/28-4/25/23 were reviewed and showed no admission dietary assessment was completed by V6 Registered Dietician (RD). R37's Weight Report dated 8/29/23 showed R37 weighed 119.4 pound (lbs) upon admission to the facility. The record showed R37 weighed 118 lbs on 4/4/23 and 89 lbs on 4/25/23 which resulted in a significant weight loss of 24.5 % (29 lbs) in 21 days. R37's dietary note date 4/26/23, showed V6 RD's first visit/assessment of R37. The note showed R37 was not assessed by V6 RD until 28 days after admission and not until after R37 had sustained significant weight loss. A Dietary Note for R37, dated 5/15/23, showed R37 was assessed by V6 RD. The note showed, unintended weight loss . The note showed R37 was started on a diuretic on 4/21/23 but R37 had only been on the medication three days prior to the significant weight loss being discovered. On 8/29/23 at 10:00 AM, V6 RD stated, I am not full time or part time in the facility. I work in the facility on a consulting basis. I don't complete the admission, quarterly (every 3 months), or annual dietary assessments on the residents. The CDM (certified dietary manager) does those assessments. I don't routinely see residents unless they have significant weight loss, pressure wounds, are on dialysis, or require tube feeding. A resident could potentially be in the facility for months to years before I would need to see them. I don't see residents with dementia or with surgical wounds unless they have significant weight loss. Dementia and surgical wounds can put residents at risk for weight loss but those are not reasons or triggers for me to see a resident. The goal is to intervene before weight loss becomes significant. I did not see (R37) until after she had already had significant weight loss. I don't know why her admission dietary assessment was not completed until 4/13/23. I don't know exactly why she had such a significant weight loss. V6 RD stated she was aware V7 was not a certified Dietary Manager. On 8/29/23 at 1:12 PM, V7 Dietary Manager stated he was not certified in dietary management but, he was currently enrolled in school for dietary management. V7 stated he had no certifications in food service management, did not have an associate's degree, and had no past work experience in long term care facilities. V7 stated, I do the admission, quarterly, and annual dietary assessments on residents. The admission assessment should be done within 48 hours of admission. I am not sure why I did (R37's) admission assessment so late. I must have overlooked it. Nursing should be monitoring residents for weight loss. I only look at weights when I am doing a residents' quarterly assessments . V7 stated he did not routinely complete residents' dietary assessments collaboratively with V6 RD, despite him not being a certified dietary manager. V7 stated he had never completed a dietary assessment on a resident prior to him being hired by the facility. On 8/31/23 at 8:23 AM, V13 Nurse Practitioner (NP) stated the expectation is that the Registered Dietician assesses residents upon admission and quarterly to monitor residents for weight loss, weight gain, or any changes in nutritional needs. V13 stated any changes need to be reported to the physician or nurse practitioner immediately. V13 stated, If a Registered Dietician is not assessing residents at least quarterly, changes in a resident's condition could get missed which includes not catching a resident's weight loss. If weight loss is not caught in time, residents could develop malnutrition and/or wounds. On 8/31/23 at 8:23 AM, V1 Administrator stated V6 RD should be completing admission, quarterly, annual, and significant change dietary assessments on all residents. V1 stated she was notified on 8/30/23, that V6 RD was not completing the necessary dietary assessments on all residents. V1 stated, I didn't know, until yesterday, that (V6 RD) was not doing all the assessments. Nursing is responsible for monitoring residents for weight loss. (V6 RD) is responsible for running the weekly weights to see who triggers for significant weight loss or is losing weight. We want to stop the weight loss before it become significant. The Registered Dietician is also responsible for making sure the residents get the proper nutrition, proper diet, and for noticing any changes in weight. V1 stated because V7 (Dietary Manager) was not certified, he was not to be completing any resident dietary assessments, on his own. On 8/30/23 at 10:55 AM, V32 Regional Director of Operations stated, We have some concerns about (V6 RD's) job performance. We are in the process of letting her go. All resident admission, quarterly, annual, and significant change dietary assessments should be completed by the Registered Dietician. V32 stated he was aware V7 Dietary Manager was not certified. 2. R69's Admission Record dated 2/11/22 showed R69 had diagnoses including Parkinson's disease, dementia, dysphagia, and muscle wasting/atrophy. R69's electronic medical records dated 8/1/22-8/27/23 were reviewed. The records showed the last dietary profile/assessment completed on R69 was 2/21/23, done by the previous CDM. No quarterly dietary assessment dated on or around 5/21/23 was noted for R69. R69's Weight Report printed 8/29/23 showed R69 weighed 143.2 lbs in May 2023 and 129.9 lbs in August 2023. This showed R69 sustained a significant weight loss of 9.3% (13.3 lbs) in three months. A Dietician Evaluation for R69, was completed by V6 Registered Dietician on 8/28/23, after R69 had sustained significant weight loss. The note showed, Unintended weight loss . V6 RD started R69 on nutritional supplements/weight loss treatment interventions on 8/28/23. On 8/29/23 at 10:00 AM, V6 RD stated, I didn't see (R69) until yesterday (8/28/23). Her last dietary assessment was completed on 2/21/23. I am not sure why she did not have as assessment done in May 2023. No one called me from the facility to tell me she was losing weight. I ran the facility's weight reports sometime during the middle of July (2023). I knew about (R69's) weight loss in July (2023) but did not put any interventions or supplements in place until yesterday. It was an oversight on my part. It got overlooked. That was my responsibility. On 8/29/23 at 1:01 PM, V13 Nurse Practitioner (NP) stated she was not aware of R69's significant weight loss from May 2023-August 2023. V13 stated, We should have been notified of (R69's) weight loss as soon as it was discovered so we could have implemented interventions. If (V6 RD) was aware of (R69's) weight loss in July (2023), she should have implemented interventions immediately. 3. R144's Admission Record dated 4/5/23 showed R144 was admitted to the facility with diagnoses of a stroke (CVA/cerebral infarction), dementia, aphasia (inability to verbally communicate), and subdural hemorrhage (brain bleed). An admission dietary profile for R144, dated 4/16/23, showed the profile was completed by V7, the non-certified Dietary Manager. R144's electronic medical records dated 4/5/23-7/27/23 were reviewed and showed no admission dietary assessment completed by V6 RD. R144's Weight Report dated 8/31/23 showed R144 weighed 135 lbs in June 2023 and 120 lbs in July 2023. This showed R144 sustained a significant weight loss of 11.1 % (15 lbs) in one month. A Dietician Evaluation for R144, was completed by V6 RD on 7/28/23, after R144 had sustained significant weight loss. The note showed, Unintended weight loss related to decreased PO (oral) intakes as evidenced by chart review . On 8/31/23 at 9:18 AM, V6 RD stated she was unaware R144's oral intake had decreased until after R144 had sustained significant weight loss. V6 stated, I didn't assess her until after she had significant weight loss. I did not see her upon admission because she wasn't on dialysis, tube fed, and didn't have any pressure wounds. 40085 4.) R9's face sheet shows she was admitted to the facility on [DATE] and has diagnoses including: Type 2 diabetes with diabetic neuropathy, depression, anxiety, adjustment disorder with depressed mood, vascular dementia unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. R9's electronic medical record shows she had a dietary assessment completed on 10/27/23 on admission, a quarterly dietary evaluation/assessment was completed on 2/1/23 (both completed by a former dietary manager). The next dietary evaluation was not completed until 8/29/23 after V6 Registered Dieitican (RD) was made aware of R9's significant weight loss by the surveyor. R9's weight and vitals summary shows she weighed 245 lbs. on 6/8/23 and weighed 220.5 lbs. on 7/19/23 a 10% - 24.5 lb weight loss in one month. R9's 8/11/23 weight was 223 lbs. R9's electronic medical records dated 5/1/23-8/29/23 were reviewed. These records showed no documentation R9 was ever assessed by V6 (RD) even after R9 sustained a significant weight loss. 8/29/23 1:07 PM, V7 (non-certified Dietary Manager)- said he is responsible for the quarterly dietary assessments and then gets the RD involved after he sees the resident. He said he was not aware of R9's significant weight loss and that there really is no process in place for notifying him of significant weight loss for residents. V7 said now that he is aware of R9's significant weight loss he will notify V6 and let her know because she would be the person to recommend interventions. On 8/29/23 at 1:41 PM, V6 (RD) said R9's weight loss should have triggered in the computer for a significant weight loss. She said it was towards the end of the month when she got the resident weights for July so she decided to wait to see Augusts weights. She said she can't speak for the programmers, but this is pretty concerning that PCC (electronic medical record/EMR) is not triggering significant weight loss. V6 said she does not believe she has done any assessment on R9, the last quarterly assessment was last done in 2/1/2023. (No quarterly assessment was done in May or August of 2023 no significant weight loss assessment has been done as of today). V6 said the computer should have also triggered for a quarterly assessment and then V7 should completed those, but if the computer does not trigger it then he would not know to do one and quarterly assessments are being missed. On 8/29/23 at 2:01 PM, V1 (Administrator) said V6 (RD) is responsible to be reviewing weights to see who triggers for significant weight loss. 5.) R79's face sheet shows he was admitted to the facility on [DATE] and has diagnoses including: end stage renal disease, type 2 diabetes, congestive heart failure and acquired absence of below the knee amputation. R79 had a dietary evaluation completed on admission on 3/13/23, and again on 3/20/23. R79's 3/20/23 assessment completed by V6 (RD) shows he had a recent unplanned weight loss a current pressure injury. R79 went to the hospital for a medical procedure and a dietary re-assessment was completed on 5/1/23 upon his return. R79's EMR shows There are no additional quarterly or significant change dietary assessments or evaluations done on R79 after 5/1/23. R79's weights and vitals summary showed on 4/1/23 he weighed 366.3 pounds. On 8/6/23 he weighed 324 pounds. A total weight loss of 42.3 pounds (11.55%) in 4 months. On 8/28/23 at 10:53 AM, R79 said he has lot a lot of weight loss, over 85 lbs. and no one from dietary is seeing him that he is aware of. On 8/28/23 at 1:14 PM, V7 (non-certified Dietary Manager) said he is unaware if the facility follows the 3 month weight loss if it is 7.5%, he thinks the facility just follows the 5% and 10% weight loss to determine significant weight loss. V7 said R79 was last seen by him on 4/24/23 and he was not aware of significant weight loss for R79. On 8/8/23 at 1:35 PM, V6 (RD) said she was not aware of significant weight loss for R79 and she last saw him on 5/1/23. V6 said he also should have triggered in the computer for significant weight loss and a quarterly assessment but for some reason did not. The facility's Weight Assessment and Intervention policy dated 2020 showed, The goal is to ensure adequate parameters of nutritional status are maintained by preventing unintentional weight loss . Any weight change of 5% of more since the previous weight assessment shall be re-taken the next day to confirm. If the weight is verified, nursing will notify the appropriate designated individuals such as the physician, Registered Dietician, Dining Services Manager, or other members of the interdisciplinary team within 24 hours. Verbal notification must be writing . The policy defined significant weight loss as a loss of 5% of a resident's weight in one month, 7.5% in three months, or 10% in six months. The facility's Registered Dietician Roles and Responsibilities policy dated 2020 showed, The Registered Dietician will provide routine scheduled consultations to monitor compliance with state and federal regulations and plan nutritional care for residents. The policy showed the Registered Dietician (RD) will assess/monitor the nutritional needs of residents and keep the physician and appropriate staff informed of the nutritional status of residents. The policy showed the RD will provide nutrition documentation for residents according to established schedules and guidelines including assessment and changes in resident nutritional plans . The Immediate Jeopardy that began on 3/27/23 was removed on 9/1/23, when the facility took the following actions to remove the immediacy: 1. R144's dietary orders have been updated to reflect current recommendations including Ensure (7/31/23) and frozen nutritional treats (8/1/23). Weights are currently being monitored-monthly weight increase of 3 lbs in August. R144 will be reassessed by Dietician on 9/1/23. 2. R9's dietary orders have been updated to reflect current recommendations including Glucerna (8/30/23). Weights are currently being monitored-monthly weight increase of 2.5 lbs. Reviewed by Dietician on 8/29/23. Resident will be reassessed by Dietician on 9/1/23. 3. R37's dietary plan has been updated to reflect current recommendations. Weights are currently being monitored-monthly weight increase of 2.3 lbs. Reviewed by dietician on 8/29/23. Resident will be reassessed by Dietician on 9/1/23. 4. R79's dietary orders have been updated to reflect current recommendations including Glucerna (8/30/23). Weights are currently being monitored. Reviewed by the Dietician on 8/30/23. Resident will be reassessed by Dietician on 9/1/23. 5. R69's dietary orders have been updated to reflect current recommendations including frozen nutritional treats (8/29/23) and calorie count for 3 days (8/30/23). Weights are currently being monitored-monthly weight increase of 2.5 lbs. Reviewed by the Dietician on 8/28/23. Resident will be reassessed by Dietician on 9/1/23. 6. Medical Director was notified of Immediate Jeopardy 8/31/23 at 1:32 PM. 7. Facility will audit current residents and all new admissions in the last 30 days to ensure required dietary assessments are completed by a Registered Dietician by 9/7/23. 8. All residents' weights will be obtained by nursing and the restorative team by 9/1/23. 9.The facility Weight Policy was updated to include that losses greater than 5 lbs in one calendar month will be referred to RD and MD will be informed. The DON, ADON, and/or Designee will monitor weights to discover loss prior to it becoming significant. 10. Facility nurses and CNAs will be educated on reporting changes in intake, changes in diet preferences, and changes in condition to the DON, ADON, and/or designee. 11. The facility held an emergency QAPI meeting on 8/31/23 to discuss the policy relating to dietary assessments, quarterlies, and significant changes, along with interventions for residents with significant weight loss. 12. The Nurse Consultant, Director of Nursing, and/or designee will conduct chart audits to review that residents who have had significant weight loss will have interventions implemented starting 8/28/23. 13. The Nurse Consultant, Director of Nursing, and/or designee will audit to ensure that all required admission, readmission, quarterly, annual, and significant change assessments are completed by a Registered Dietician. Future audits will be completed daily for two weeks, then two times per week for four weeks, followed by weekly for 6 weeks. Any findings of noncompliance will be immediately reported to the Attending Physician and Family. 14. Findings of the QA audit shall be used to determine the level of compliance and need for additional training will be completed immediately and shall be submitted to the QAPI Committee for review and follow-up.

Based on interview and record review the facility failed to ensure a residents medication was given as prescribed and failed to ensure medication orders were transcribed correctly to avoid a significant medication error. This failure resulted in six of R9's medications being mistakenly discontinued without a physicians order. As a result of this failure R9 developed worsening psychiatric symptoms (paranoia) and was sent to the emergency room for evaluation. This applies to 1 of 7 residents (R9) reviewed for physician orders in the sample of 31. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 8/1/23, when the facility discontinued R1's medications without a physician order. V1 (Administrator) was informed of the Immediate Jeopardy on 8/30/23 at 2:21 PM. This surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 8/31/23 however, noncompliance remains at a level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R9's face sheet shows she was admitted to the facility on [DATE] and has diagnoses including: Type 2 diabetes with diabetic neuropathy, migraine without migrainosus, depression, adjustment disorder with depressed mood, vascular dementia unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. R9's 8/3/23 minimum data set shows she has on going pain and depression. R9's active care plan initiated on 11/30/22 shows R9 has a severe mental illness and has symptoms of delusions, paranoia and poor insight and judgement. R9's care plan also shows she has potential for pain due to migraines and a history of a fracture. R9's physician order summary (p.o.s) show the following medication orders were all discontinued on 8/1/23 : Effexor XR (Venlafaxine HCl ER-extended release) (Anti-depression and anxiety medication) 150 milligrams (MG.) 1 tablet per day start date 10/26/22, bupropion HCL ER (SR) 150 MG. (Anti-depressant) 1 time per day start date 10/26/22, lamotrigine 25 MG. 3 times per day, (anti-seizure medication and also mood stabilizer) start date 10/26/22, Topiramate 25 MG./ Topamax 1 time per day, (medication to treat epilepsy and migraines) start date 10/25/22. Duloxetine (Anti-depressant/anti-anxiety) 60 MG. 1 time per day start date 6/9/23, and Gabapentin 400 MG. (used for neuropathy pain) 1 capsule 3 times a day start date 6/8/23. There are no notes in R9's electronic medical record indicating who discontinued the medications or why. A consultation report completed by V26 (Psychiatric Nurse Practitioner) on 6/30/23, shows he saw R9 and made no medication adjustments. The report identifies R9 is on the following psychotropic medications: Venlafaxine for depression and anxiety, Bupropion and duloxetine for depression, Lamictal and Topamax for mood stabilizers. The consultation report also says a gradual dose reduction of those medications are contraindicated and R9 is not a candidate at that time due to on going symptoms. R9's 8/1/23 9:13 PM, nursing progress note shows R9 had returned from a doctor appointment and the doctor will fax a consultation report to the nurses station. The consultation report from a pain doctor on 8/1/23 at 3:16 PM, shows a prescription to increase R9's Gabapentin order to 600 MG. 3 times a day for neuropathy pain, and to change/ add Cymbalta 30 MG every 12 hours or two times a day. R9's MAR and pos show those ordered were not carried out. A consultation report completed by V26 (Psych NP) on 8/29/23 states the following: Patient was last seen by writer on 6/30/23 and no medication changes were made. Cymbalta, Wellbutrin, Effexor, Lamictal, Topamax and Melatonin were discontinued on 8/1/23 for unknown reason. The report shows that R9 is having depression an increased episodes of inappropriate behaviors, insomnia, anxiety and agitation. R9's Medication Administration Summary (MAR) from 8/1/23 to 8/31/23 show she received 1 dose of Effexor, bupropion, Duloxetine, and Topiramate on 8/1/23 and then it was discontinued and no further doses were received in August. R9 missed 30 doses of each of those medications in the month of August. The MAR also shows R9 received 3 doses of each of Gabapentin and lamotrigine on 8/1/23 (ordered to be given 3 times a day) and then it was discontinued and no further doses were given in August. In total R9 missed 90 doses of each of those medications. R9's Nurse Practitioner Progress Note completed by V27 (Nurse Practitioner/NP) on 8/8/23 at 9:47 AM, shows R9 is having an increase in paranoid symptoms. Nursing progress notes for 8/29-8/30/23 show R9 was increasingly paranoid and was calling 911 to report feeling unsafe and seeing people with a knife hidden being their ear. Police arrived at the facility and R9 made an allegation of an assault occurring. R9 was sent to the emergency room for evaluation. Medication orders were obtained for R9 to be started on a mood stabilizer (Depakote) and a anti psychotic medication (Seroquel) due to her psychotic symptoms. R9 returned from the emergency roiagnom on [DATE]. On 8/30/23 at 9:05 AM, V2 (Director of Nursing) said she was not aware why R9's psychotropic and pain medications were stopped abruptly but she will investigate it. At 9:56 AM, V2 said what happened with R9's medication was R9 had went out for a doctor appointment to the pain clinic on 8/1/23 and then returned to the facility. The nurse on duty ( V22-Nurse Supervisor) mistakingly thought R9 had went to the hospital so she discontinued all of R9's medications. When R9 returned to the facility later that evening V22 tried to add the medications back and missed a few. V2 said V22 should not have discontinued R9's medications and she also did not call the physician to verify any of the pain doctors new orders. On 8/30/23 at 9:33 AM, V26 (Psych NP) said he was called to see R9 on 8/29/23. He said he could not figure out who stopped and why her psychiatric medications were stopped. He verified he was not the one who had given orders to discontinue those medications. V26 said he would say that R9 was having an increase in her paranoia from the last time he saw her until yesterday. At 12:56 PM, V26 said the obvious effect of R9 being off her medications would be an increase in psychiatric symptoms including mood, paranoia, and hallucinations. On 8/30/23 at 10:22 AM, (V22) said she made a huge mistake with R9's medication orders. She said she was told by another nurse that R9 was in the hospital so automatically I discontinued the medication orders and then when R9 returned and I learned she only went to a medical appointment I tried to reinstate her orders and I thought I had gotten everything but I missed a few. No one ever questioned it until now why all of R9's psychotropic medications and some of her pain medications were stopped. V22 said she did not call any physicians to verify any of the orders after R9 returned from the pain appointment. V22 said she should not have discontinued the medications, and it is protocol that after appointments or hospital stays the medication orders are verified with the physician and carried out but she missed the new orders also. On 08/30/23 11:56 AM - V27 (NP) said her office was not called to discontinue R9's psychiatric or pain medications and she believes R9's topamax and lamotrigine medications were being used more for migraines. She said she would be even more concerned if R9 had a active seizure disorder and if the medications were for seizures then missing them would put her at risk for an increase in seizures. V27 said by R9 missing her other medications there could be changes in mood and behaviors and increased pain. V27 said the facility should contact their office if a resident goes out and comes back to verify medication orders. On 8/31/23 at 9:11 AM, R9 said she does not recall making any accusations to anyone. She was paranoid about talking with this surveyor and stated, Maybe I need my family here I don't know what you are up too. R9 said she has diabetic neuropathy and has pain all the time. On 8/31/23 9:08 AM, V31 (Licensed Practical Nurse/LPN) said R9 been asking for increased amounts of PRN (as needed) norco (pain medication) this past week and has an increase in paranoia. He said he was there on 8/29/23 in the evening when R9 called 911 and was later sent to the hospital. R9 was seeing people with pocket knives, and saying she doesn't feel safe in facility. On 8/31/23 9:13 AM- V24 (Certified Nursing Assistant/CNA) said R9 has had increase in paranoia over this past month and has been hallucinating seeing children, cats, and monkeys. The facility provided Transcription of Physician Orders- Procedure effective date 11-3-22 says nurses should review the discharge summaries or records from other facilities and verify with the residents physician of any new or changes in medication orders. All orders should be checked to verify they were entered into the electronic medical record correctly. The Immediate Jeopardy that began on 8/1/23 was removed on 8/31/23 when the facility took the following actions to remove the immediacy: 1. Staff involved and all Nurses on the AM and PM shifts were in-serviced on 8/30/23 about discontinuing physician orders, medication administration policy and transcription of orders. 2. The Nurse Consultant/DON will perform chart audits for all discontinued medication orders for the month of August 2023. 3. The Nurse Consultant will provide in-servicing and training for licensed nurses including agency and prn nurses who are on vacation or medical leave. They will be required to completed the in-servicing before the start of their shift. All nurses will receive the in-servicing by 9/9/23. 4. The Nurse Consultant/ DON will train all newly hired nurses will also receive education regarding the new policy on a second double check system where new orders are verified by two nurses. This will be completed by in house nurses by 8/30/23. Any staff on vacation or on leave will be notified via telephone. On going education for new hires and agency staff will continue prior to the start of their shift for all new hires. 5. The Nurse Consultant and DON will conduct char audits for all charts of all residents who have had appointments or hospital stays in the month of August 2023. These audits will be done by 9/1/23. Future audits will be completed daily for two weeks, then two times per week for four weeks, followed by weekly for six weeks. 6. The medical director and attending physician were notified of the medication error on 8/30/23. 7. An emergency QA meeting was held by the facility on 8/30/23. The audit findings will continue to be reviewed during QA meetings. Findings of the QA audit will be used during QAPI review and will determine compliance level and additional follow up as needed.

Based on interview and record review the facility failed to safely transfer a resident (R69) via wheelchair. This failure resulted in R69 sustaining a fall with injury which included a laceration to her forehead that required sutures. The facility failed to ensure a resident was safely transferred from wheelchair to bed. These failures apply to 2 of 31 residents (R69, R37) reviewed for resident safety/supervision in the sample of 31. The findings include: 1. R69's care plan dated February 2022, showed R69 was cognitively impaired with poor judgement and poor safety awareness related to her diagnosis of dementia. The care plan showed R69 also had a diagnosis of Parkinson's disease which put her at risk for falls due to her impulsive behavior movements while sitting in her wheelchair. The care plan showed staff will continue to monitor how resident is sitting in her wheelchair . R69's Nurses Notes dated August 13, 2023, showed a certified nursing assistant (CNA) was pushing R69 in her wheelchair. The CNA suddenly stopped pushing R69 in her wheelchair which caused R69 to fall forward out of her wheelchair, onto the floor. The note showed R69 sustained a 2.5 cm (centimeter) laceration on her left forehead with bleeding due to the fall. 911 was called. R69 was sent to the hospital, via ambulance, for an evaluation. R69 returned to the facility, from the hospital, on August 13, 2023, after receiving five sutures to repair her forehead laceration. On August 29, 2023, at 11:51 AM, V10 CNA stated, An agency CNA was pushing (R69) down the hall in her wheelchair. I was walking next to them. (R69) was in her wheelchair. I had taken the leg rests off her wheelchair earlier that day. A resident that was walking in front of (R69) stopped suddenly so the CNA, pushing (R69), had to stop. When he stopped, (R69) went forward out of her wheelchair. She hit her head on the floor. She had a cut on her head. She was not scooted back in the seat of her wheelchair before she fell . I kept telling her to scoot back in her wheelchair, but she didn't listen. On August 29, 2023, at 12:29 PM, V12 Restorative Nurse stated, (R69) has dementia and is very confused. She has no safety awareness. She has a high-back, reclining wheelchair because she tends to lean forward in her chair. She has poor trunk control. When she is up in her wheelchair, the leg rests should be on the chair, with her legs on the rests, to help position her back in the seat of the chair. If she is leaning forward in her chair, staff need to direct her to sit back. Staff should make sure she is not leaning forward in her wheelchair when transporting her. If she is not positioned correctly in her chair, she could fall forward out of the chair. On August 29, 2023, at 1:01 PM, V13 Nurse Practitioner stated R69 has a high-back, reclining wheelchair because she has a tendency to lean forward and has slid out of her wheelchair before. V13 stated, (R69) is very confused and has poor safety awareness. If she is scooted forward in her wheelchair or leaning forward in her chair, staff should reposition her towards the back of the wheelchair to make sure she's safe when transporting her. 2. R37's assessment dated [DATE], showed R37 was severely cognitively impaired. The assessment showed R37 required the extensive assistant of 2 staff for transfers. On August 28, 2023, at 12:15 PM, R37 was seated in a wheelchair next to her bed as V3 CNA stood next to her. V3 CNA transferred R37, from her wheelchair to the bed, by holding onto R37's pants with her right hand. No gait belt was used during the transfer. V3 CNA was the only staff in the room. On August 29, 2023, at 12:38 PM, V12 Restorative Nurse stated R37 should be transferred by 1-2 staff, with the use of a gait belt. V12 stated gait belts should be used when transferring all residents. The facility's Manual Gait Belt and Mechanical Lifts policy dated January 19, 2018, showed, Use of gait belt for all physical assist transfers is mandatory.

Based on interview and record review the facility failed to ensure a bed side rail remained secure during incontinence care for 1 of 3 residents (R1) reviewed for safety in the sample of 3. This failure resulted in R1 falling out of bed and sustaining a cervical spine fracture, scalp laceration, and multiple skin tears. The findings include: On 9/14/21 at 9:20 AM, V1 (Administrator) said R1 fell from bed while receiving incontinence care. V1 said the side rail R1 was using for support, Collapsed. V1 believed R1 pressed the emergency release button causing the side rail to unlock and slide to the down position. V1 added the bed rail was working prior to the fall and after the fall. On 9/14/21 at 9:37 AM, V3 (Certified Nursing Assistant) said he was providing incontinence care to R1 on 9/6/21 at 10:15 PM. According to V3, R1 was in bed and turned to his right side. R1 held onto the right bed side rail for support. V3 said when he was placing a clean adult incontinence brief on R1, V3, Heard the side rail that R1 was using for support go to the down position. V3 said R1 then fell out of bed onto the floor. V3 said after the fall, R1 was bleeding and V3 yelled for the nurse to call 911. V3 said the side rail that R1 used for support was in the locked position at the start of incontinence care. V3 thought R1 pushed the emergency release button that was located under the side rail causing the side rail to unlock and go to the down position. On 9/14/21 at 9:59 AM, V4 (Registered Nurse) said he was the nurse taking care of R1 when R1 fell . V4 said as a result of the fall R1 sustained a skin tear to R1's leg, arm, and head. V4 said R1 was sent to the emergency room . R1's Emergency Department Encounter documentation dated 9/6/210 showed R1 presented to the emergency room after having a bed rail give way causing a fall. R1's CT scan results showed an, Acute fracture of the C6 and C7 vertebra. The same documentation showed, R1 had a, Large scalp laceration down to the bone and laceration to the right leg and skin tears to both elbows. R1's progress note dated 9/7/21 showed R1 was admitted to the hospital with a cervical spine fracture. On 9/14/21 at 12:19 PM, V8 (R1's Nurse Practitioner) said she did not believe R1 had [CONDITION(S)] (weakening of the bones). R1's electronic medical record did not include the diagnosis of [CONDITION(S)]. R1's Post Fall Observation form dated 9/6/21 showed, [R1] stated that the right side rail just suddenly [dropped] down on the side of the bed that is why he fell . R1's brief interview for mental status done on 7/2/21 showed R1 was cognitively intact. R1's Minimum Data Set (MDS) dated [DATE] showed for bed mobility R1 required extensive assistance of staff, Resident involved in activity staff [provided] weight bearing support. The same MDS showed R1 was total dependent on staff for incontinence care/toileting.

Based on observation, interview and record review the facility failed to maintain access to hot water at 110 degrees Fahrenheit (F) and below. This applies to 17 of 21 residents (R1-R12, R15, R16, R18, R20, R21) reviewed for accident hazards in the sample of 24 and 59 residents (R26-R85) in the supplemental sample. An Immediate Jeopardy began on July 13, 2015 at 1:10 PM when the water temperature in Room 303 measured 133.5 degrees Fahrenheit. On July 13, 2015 at 3:50 PM, E1 (Administrator) was notified of the immediate jeopardy. The immediacy was removed on July 13, 2015 at 4:30 PM. The facility remains out of compliance, at a level 2, due to the facility's need to monitor water temperatures at various times of the day. The findings include: On July 13, 2015 at 11:15 AM, surveyor's thermometer was verified as accurate to 32 degrees Fahrenheit using an ice bath. On July 13, 2015 between 1:15 PM and 2:20 PM, water temperatures in resident sinks on the 300 and 400 wings of the facility were measured at a range of 113 degrees F to 133.5 degrees F. E4 (Maintenance Supervisor) was present during the water temperature checks on 300 and 400 wings. E4 checked his facility thermometer which was accurate. During the same time frame the shower rooms of the 300 and 400 wing temperatures ranged from 115.3 degrees F to 122.6 degrees F. On the 200 wing Room 224's temperature was 114 degrees F., and room 225's temperature was 122.4 degrees F. On July 13, 2015 at 1:50 PM, E4 stated let me do the baby test . E4 placed his wrist under the running water, pulled back quickly, and stated, That's hot! After checking the water heater, E4 stated, something is wrong. The return is 100 degrees F. The outgoing (hot water) is measuring 112 degrees F. Maybe the thermometer (in the plumbing circuit) is bad. On July 14, 2015 at 10:30 AM, E4 (Maintenance Director) stated during interview that temperatures are taken daily in the morning. Two different rooms are checked on each wing. This rotates the rooms being checked so all the rooms will get checked every month. The Daily Maintenance Checklist reviewed from July 1, 2015 through July 13, 2015, shows temperatures were always taken between 7:45 AM and 8:16 AM. Temperatures during this time frame ranged from 108 degrees F to 112 degrees F. No further testing of temperatures were done for the two rooms where the temperatures were over 110 degrees at other times of day. High water temperature rooms 302, 303, 317, 327, 330, 408, 409, 410, 417, and 420 had no recorded water temperatures from July 1 to July 13, 2015. The Center for Medicare and Medicaid's State Operations Manual, appendix PP, as of August 17, 2007 has a Time and Temperature Relationship to Serious Burns table showing a water temperature of 127 degrees F. with an exposure time of one minute or 133 degrees F. at 15 seconds can cause a third degree burn. The surveyor confirmed the facility took the following steps to remove the immediacy of the situation: · The facility warned residents of the hot water and posted warning signs in affected areas. · The facility exchanged the mixing valves in the areas affected by high water temperatures. · The facility in-serviced staff on the requirements to maintain water temperatures and the procedures if water temperatures exceed 110 degrees F. · Water temperatures are to be taken at different times of day and documented appropriately. On July 13,2015 at 12:27PM, E13(Certified Nursing Assistant) assisted R1 to wash his hands after using the restroom. E13 turned the hot water on and R1 put his hands under the water and began to wash them. Within about 3 seconds R1 quickly pulled his hands back out of the water as the water was too hot. II. Based on observation, interview, and record review, the facility failed to monitor for signs and symptoms of aspiration and choking and failed to supervise a resident with swallowing difficulties during meal time. This applies to 1 of 16 residents (R9) reviewed for safety and supervision in the sample of 24. The findings include: On July 13, 2015 at 12:50 PM, R9 was in her room, in bed, alone, eating her noon meal. R9's tray had pureed food in a divided plate, thickened water and thickened chocolate milk. On July 14, 2015 at 12:25 PM, R9 was alone in her room, sitting up in bed, eating her pureed and thickened liquids meal. R9 said she sits up to eat. R9 had food accumulating in her lower right gum line and cheek. R9's March 17, 2015 Care Plan shows interventions that include: Monitor during mealtime, monitor for signs and symptoms of aspiration or choking. R9's July 2015 Physician order [REDACTED]. R9's March 26, 2015 Precautions for Feeding and Swallowing form states, Patient must be fed, monitor pulmonary status, ask patient to swallow two times after each bite, alternate between food and liquid. On July 15, 2015 at 9:55 AM, E7 (Registered Nurse) said during interview that R9 gets very nervous. R9 and her family prefer that she eat in her room. E7 said R9 doesn't like the crowd in the dining room. On July 15, 2015 at 10:30 AM, E6 (Assistant Director of Nursing) said R9's preference is that she eat in her room and that being up makes her cry. E6 stated, There should be somebody there in the room with her while she eats. At 2:35 PM, E6 said that R9 wants to be more independent so the CNA's (Certified Nursing Assistants) are setting her meals up and R9 asks the CNA's to leave. We still need to monitor (R9) in her room.

Based on observation, interview and record review, the facility failed to provide specific fall intervention, failed to modify care plan interventions after multiple incidents of falls and failed to provide supervision to prevent further falls to a resident who was identified as high risk for fall. This applies to one of three residents (R1) reviewed for falls. This failure resulted in R1 sustaining a large subdura hematoma after a fall on June 21, 2015, when left with out supervision, which led to the resident's documented decline in ADL (activities of daily living) and hospice care placement. The findings include: R1 is a [AGE] year old originally admitted to the facility on Febuary 2, 2014. R1's face sheet showed R1 has [DIAGNOSES REDACTED]. The two most recent MDS (Minimum Data Set) assessments dated February 24, 2015 and May 25, 2015 showed that R1 required supervision with one person physical assist for ambulation and eating. The MDSs also showed R1 scored 14 and 13 in cognition (cognitive intact). However; during the past few months, R1 sustained three falls (3/24/2015, 6/14/2015 and 6/21/2015). The incident reports showed the following R1's falls: - 3/24/2015 at 12:40 A.M. showed (R1) used the urinal and when he stood up, lost balance and fell and hit his head in the cabinet. The report also showed that R1 laceration to the back of his head was noted with minimal bleeding. The report showed R1 was sent out to the hospital and was diagnosed with [REDACTED]. The hospital Computed Tomography) CT scan of the head dated 3/25/15 showed R1 with occipital laceration about 1-3/4 inches and 8 millimeter (mm) subdura hematoma. - 6/14/2015 at 1:15 P.M. showed that (R1) was waiting by the doors to the unit and was asked to back up and while he was backing up his shoes caught in the carpet and he fell to his knees. No injuries were noted with this fall. The post fall huddle dated 6/14/15 identified R1's fall risk assessment as 10 (High Risk). The post huddle fall also added that R1 to have a scheduled times to be taken out of the unit. This was not incorporated in R1's care plan. 6/21/2015 at 11:10 A.M. showed that (R1) was observed on the floor with abrasion to occipital area and scant bleed. The report showed R1 was sent to the hospital. The hospital CT scan report dated 6/21/15 showed 'large acute and subacute subdura hematoma with maximal thickness 1.5cm with diffuse edema and midline shift to the right by 1.1cm The Fall and Accident/Incident Resident Management Review showed that R1's falls were reviewed with plan of care as follows: As the result of the 3/24/2015 fall, R1's care plan was updated as provide R1 with bed alarm for safety; therapy to pick R1 up for skills training; keep needed items within reach; maintain a clear pathway and to be sure R1's call light is within reach and encourage R1 to use it for assistance as needed. There was no further plan of care with specific intervention to prevent possible fall. As the result of the 6/14/2015 fall, the care plan showed to re-educate R1 not to stand by the exit doors as people comes in and out of the unit. R1 scored 8 in fall risk assessment ( high risk). There was no other plan of care or any modification with the current interventions to prevent further fall. There was nothing in the care plan to show that the facility plans to supervise R1 during ambulation. As the result of the 6/21/2015 fall, the plan of care was to provide R1 safety devices such as bed sensor alarm and chair sensor alarm for added safety. It also showed to ensure R1 is wearing appropriate footwear, non skid when ambulating or mobilizing in wheelchair. Facility records did not show how R1 sustained this fall. The nurse (E3) that took R1 for coffee break stated during interview she left R1 in the far east pod with no staff or other resident present. On 6/30/2015 at 12:40 P.M., E2 Director of Nursing (DON) stated R1 likes to go to the front lobby for coffee and ambulate around the unit. E2 provided recent care plan for fall prevention that was reviewed by the facility staff with each falls on 3/24/2015, 6/14/2015, 6/22/2015 and at admission, quarterly. It was indicated in the care plan that R1 was a high risk for falls related to history of multiple falls, and adverse reactions related to meds. On 3/24/2015: Provided with bed alarm for safety.On 6/22/2015: Provided with safety devices such as bed sensor alarm and chair sensor alarm for added safety. The rest of interventions were non-specific and generalized care plan such as clear pathway, keep needed items within reach, monitor medications for possible side effects, call light within reach, educate and remind for safety. There was no specific intervention and mention of supervision or assist to ambulate in the unit to ensure R1's safety of the identified problem of R1 likes to go for a cup of coffee and ambulate around the unit. E2 provided a unit notice to staff members that showed, R1's name, room number and instruction that reads= 'coffee & off the unit schedule (with staff supervision) 7 days a week including weekends'. Morning shift -10:30AM and afternoon shift 3:30 PM and 7:30PM each with staff supervision. The Daily nursing progress note dated June 21, 2015 10:30 A.M., showed R1 approached E3 (Nurse) to escort him to get coffee and stayed in the far east Avalon pod to drink his coffle. The note showed at 11:10 A.M., E3 went back to check on R1 and found him on the floor. The note showed E3 noted abrasion to the back of R1's head. The same progress note (the day of the fall) showed R1 independent with bed mobility, transfer, dressing personal hygiene and toileting and ambulation. The note further showed R1 was sent to the hospital for evaluation. Facility's admission log showed R1 was readmitted to the facility on [DATE]. The daily nursing progress notes dated June 23, 2015 showed R1 with extensive assist in bed mobility, transfer, toileting, dressing and personal hygiene R1 was noted on this chart to use wheelchair for ambulation/mobility. The subsequent daily nursing progress notes dated June 25, 2015 through June 30, 2015 showed R1 with total dependence in all areas of ADL. The nurses note dated June 24, 2015 at 5P.M., showed R1 was fed with 60 percent of dinner while the nurses note of June 25, 2015 3-11 shift showed R1 was fed with 20 percent of meal. On June 30, 2015 at 1:30P.M., E3(Nurse) stated on June 21, 2015, R1 asked her to escort him to get coffee. E3 stated she took R1 for the coffee and then left him in the far east Avalon pod to watch the television. E3 stated there was no staff or other resident present when she left R1 at the far east pod. When asked if E3 asked anyone to supervise R1, E3 stated no but that she has to pass medications to other residents. E3 stated she never designate anyone else to supervise R1 at the pod because she felt R1 should be 'ok'; but unfortunately he was found on the floor upon returning to check on R1. The 'coffee and off unit schedule for R1 dated June 15, 2015 showed R1 coffee and off unit schedule with staff supervision. E3 stated R1 has not being verbally responsive in the past few days. R1's hospital CT scan record showed R1 had a large subdura hematoma. The facility's admission record showed R1 was readmitted to the facility on [DATE]. The daily nursing progress note dated June 26, 2015 showed R1 was noted to be sluggish and put back to bed. The note showed the doctor was notified. The evening note showed R1 with close eyes and non verbal. The daily nursing progress note dated June 27, 2015 showed R1 was evaluated by hospice care. The note also showed R1 was not verbally responsive, closed eyes, would not respond to his name. The note showed R1 was admitted to hospice as he has declined in activities of daily living and non-verbally responsive. R1's physician order [REDACTED]. Give comfort pack as directed. Admit to Vitas hospice today. On June 30, 2015 at 10:30 A.M., tour of the Avalon unit was made with E2. R1 was observed in bed, eyes closed and would not respond to greetings. The far east pod was also observed to be located at the far east end of the unit. The far east pod is not immediately visible to someone passing in the hall way of east unit. The far east pod is also not visible from the nursing station. The failure to revise R1's care plan to reflect R1's need of assistant with supervision and the failure to allow R1 to have un-supervised coffee break on June 21, 2015 resulted to R1's fall, subdura hematoma and his decline in ADL status and hospice placement. On July 1, 2015 at 3:10 P.M., E6 Certified nursing assistant (CNA) stated she cared for R1 'today'. E6 stated R1 was not verbally responsive, did not eat or drink anything and had only one slightly wet diaper. On July 1, 2015 at 2:45pm, Z1 (Doctor) stated that R1 it was indicated through R1's progress notes that R1 is high risk for fall and that R1 should have been closely monitored and should not have been left alone given the fact that R1 is high risk for falls and this was documented in all doctor's progress notes. Z1 added that R1's fall on June 21, 2015 was a contributing factor to his decline in activities of daily living and been placed on hospice care.

Based on observation, interview and record review, the facility failed to implement and revised R4's plan of care based on the assessed risk factors and individualize the needs of R4. Also, the facility failed to turn, reposition and toilet R3; to prevent and promote healing of her facility acquired stage II pressure sore. These failures resulted in worsening of R4's pressure ulcer on her sacrum from a Stage II to an infected Stage IV pressure ulcer. This applies to two (R3 and R 4) of three residents reviewed for pressure ulcer in the sample of 24. Findings include: On 05-08-13 at 11:05 AM, R 4 was observed sitting in her wheelchair in her room. R 4 confirmed she has a pressure ulcer on her sacrum and stated, " It started in the hospital. It was a small one, now it's bigger. I was told (by the staff). I sit in my chair for quite a while. I don't particularly like it (sitting on her wheelchair) oh yeah, I' ll say longer than two to three hours. I know it's not good to sit for a long time. It's not good for healing but no one will put me back to bed. The CNA has so many patients to take care. " On 05-08-13 at 12:00 PM, the Treatment Nurse/E 4 stated " She (R 4) was admitted with a Stage II pressure ulcer on her sacrum, it got worse because of her immobility and her incontinence, now it's a Stage IV. " R4's Physician order [REDACTED]. E4 confirmed R 4 ' s sacral wound is infected. Review of the wound documentation report sheets showed that on 04-10-13 -R 4 has a Stage II pressure ulcer on the sacrum upon admission. On 04-24-13 this wound progressed to a Stage III and decline further to a Stage IV on 04-30-13. R 4 ' s physician order [REDACTED]. 04-30-13 low air mattress On 05-08-13 at 2:25 PM, during the treatment observation with the Treatment Nurse (E 4), E 4 identifies and describe R 4 ' s wound as follows: Sacrum (location) - Stage IV measured at 3.5 cm length X 2.5 cm width X 1.2 cm depth with undermining of 1.0 cm at 10 o'clock, 1.5 cm at 12 o'clock and 1.0 cm at 2 o'clock. R 4 ' s pressure ulcer care plan dated 04-09-13 was not updated and revised based on the progress or specific needs of R 4. R 4 ' s plan of care presented by E 4 on 05-08-13 still reflects the Stage II pressure ulcer, the current infection on the sacral wound was not address anywhere in R 4 ' s care plan that was presented. R 4 ' s care plan reads as follows: Stage II pressure ulcer -sacral. Goal will be healed in 3 months, will be pain free. Provide wound care. Observe/check the site for infection. Instruct the resident (R 4) to notify the nurse whenever there is pain in the wound sits. Document wound, status, healing ... Keep the area clean and dry. Assess and review nutritional/caloric intake ...Reposition every two hours. On 05-08-13 at 2:30 PM, the CNA/E 5 stated " she ' s alert and oriented but she needs assist with all her Activities of Daily Living. We don ' t really have a specific time to reposition her. We reposition all our patients every two hours. " On 05-08-13 at 2:25 PM, E 4 stated, " We don't have a specific time for repositioning patients. We don't evaluate patients for tissue tolerance, we reposition all of our residents every two hours. " -On 5/8/13 from 9:40 am to 12:45 pm during constant observation R3 was in her adult recliner chair, and she was stationed in Special Care Unit for Dementia residents. From 9:40 am to 12:45 am no staff has turned, repositioned or taken R3 to toilet. The only activity that occurred during this time of observation was at 11:30 am E11 (Activity Aide) wheeled R3 in the dining room from one table to another table which is two yards from where R3 was stationed. E11 was not aware if R3 had a pressure sore. R3 was confused, disoriented, cooperative, and presented no management problems. R3 is totally dependent on staff for her activities of daily living including transfer, ambulation, turning, positioning and toileting. On 5/8/13 at 10:25 am E7, the Certified Nurse Aide (CNA) stated he got R3 up in the morning at 6:30 am for breakfast and he will take her back to bed after lunch. E7 stated R3 is continent, she does not ask for any thing, and he does not do any thing when she is in the activity. At 1:45 pm E7 stated he took R3 to bed at 1:30 pm, changed her diaper because she was incontinent of urine. R3's 1/11/13 wound assessment noted she had Deep Tissue Injury (DTI) on 12/17/12 that measured 1.3 cm x 0.1 cm on her sacrum. On 4/30/13 the sore noted to be a Stage II which measured 1.5 cm x 1.5 cm x 0.1 cm. On 5/9/13 at 11:30 am two treatment nurse (E4 and E13) provided treatment for [REDACTED]. The sore measured 3.0 cm x 2.0 cm x 0.2 cm. R3's pressure sore started with a stage I on 12/17/112 and worsened to a stage II on 4/30/13, did not heal and increased in size by 5/9/13. R3's 2/27/12 Braden Scale scored (11) which indicates she is at high risk for acquiring pressure sores. The risk factors identified in the Braden Scale were sensory perception, moisture, activity, mobility, nutrition and friction and shearing. The facility did not further evaluate these risk factors to determine if these risk factors could be modified. R3's 4/27/13 stage II pressure on sacrum interventions included 'reposition every two hours.' This intervention was not implemented on 5/8/13 from 9:40 am to 12:45 pm. The interventions did not include to toilet or incontinence care. On 5/9/13 at 11:30 E4 verified lack of comprehensive evaluation of risk factors the development of pressure sore, and lack of individualized interventions to prevent the development of pressure sore and to promote healing of pressure sore.

A. Based on interview and record review the facility failed to ensure two staff members transferred one of one residents sampled, with a mechanical lift transfer, (R1), in a sample of three residents. This failure resulted in (R1) sustaining a left femur fracture, undergoing surgical intervention, prolonged pain, hospitalization , diagnostic procedures and therapy. B. Based on interview and record review the facility failed to instruct and train staff on proper transfer procedures and did not utilize a transfer slide board for one of one residents utilizing a slide board, (R3) in a sample of three. As a result of this failure (R3) sustained a right humerus fracture, suffered extreme pain, prolonged rehabilitative therapy and emotional distress. C. Based on interview and record review the facility failed to develop and implement individualized interventions to prevent recurrent falls for one of three residents sampled with a known history of recurrent falls and injuries, (R2). As a result of this failure R2 has sustained multiple rib and sternal fractures. Findings include: A. The 1-1-2012 through 1-31-2012 Physician order [REDACTED]. Annual MD'S, (Minimum Data Set), of 7-29-2011 and Quarterly MDS of 10-28-2011 Section G: Functional Status, B. Transfer, contain documentation that R1 is "totally dependent on two staff members." The 12-4-2011 Physician Discharge Form contains documentation that R1 was admitted to the hospital on 11-29-2011, after sustaining a fall off of a (mechanical lift), during transfer. R1 sustained a left femur fracture and had closed reduction intervention with percutaneous pinning. R2 has a prior medical history of [REDACTED]. E2, (DON/Director of Nursing) on 1-23-2012 at approximately 2:30pm. stated, "This is (R1's) complete and current Care Plan. This same 7-29-2011 Care Plan, updated 11-29-2011 contains the following documentation: "Focus: (R1) has an (ADL), Activities of Daily Living Self Care Performance Deficit related to [DIAGNOSES REDACTED], initiated 7-29-2011 and 10-28-2011 with Interventions: Transfer: (R1) requires two person total assistance with transfers using (Portable Total Body Lift). Focus: (R1) is at risk for falls characterized by multiple risk factors related to use of psychotropic medications, [DIAGNOSES REDACTED]. Interventions: Transfer: (R1) requires two person total assistance with transfers using (Portable Total Body Lift)." The 7-29-2011 Interventions is crossed out, and standing mechanical lift is handwritten in to replace portable total body lift. E4, (CNA)/Certified Nursing Assistant)'s Witness Statement completed 11-20-2011, for the 11-29-2011 at 10:10am. incident involving R1 is, "Proceeded to get (Standing Mechanical Lift) from hallway, wheelchair was also prepared. (R1) was assisted to sitting position in bed, (Standing Mechanical Lift) was then placed in front of (R1), applied harness to (R1). Proceeded to lift (R1) to standing position, wheelchair was then placed behind (R1). (R1's) left foot slipped off platform. (R1) was holding onto lift with both hands. The harness was also supporting (R1). I went to the doorway and asked for assistance, nurse assistance with transfer. (R1) was not wearing non-skid socks." The 11-29-2011 Accident/Incident Report, completed by E5, (LPN/Licensed Practical Nurse), contains the following documentation: "11-29-2011 at 10:10am. CNA, (Certified Nursing Assistant/E4), called me to (R1's) room. (R1) was observed holding onto (Standing Mechanical Lift), supported with harness, left foot was observed resting on the floor. (R1) eased to wheelchair. (R1) complained of right leg pain.....Physician notified, received x-ray orders for right hip and right pelvis. As needed Dilaudid given at 9:45am." According to Lexi-Comp's Drug Reference Handbooks, 12th Edition Geriatric Dosage Handbook page 750-753, Dilaudid is a controlled narcotic analgesic used to manage moderate to severe pain. Observe patient for oversedation and may cause drowsiness. Notification on 11-30-2011 at 4:54pm. to Illinois Department of Public Health is, "(R1's) foot slid, during transfer. Complained of pain on right upper leg. Physician notified and ordered x-ray. (R1) sent to emergency room for evaluation and admitted with right femur fracture." The 11-30-2011 untitled narrative report is, "On 11-29-2011 (R1's) left foot slid during transfer. (R1) complained of pain to right hip. The resident was sent to hospital and admitted with right femur fracture. Medical record review, resident and staff interviews revealed the following facts: 1. (R1) was assisted to transfer using a (Standing Mechanical Lift) on 11-29-2011 at approximately 10:10am. 2. (R1's) left foot slipped off platform while standing on the lift. Resident held onto lift supported by harness. No fall incident occurred. 3. (R1) observed not wearing non-skid socks. 6. (R1) at approximately 1:00pm. complained of pain again to right hip. Order for x-ray received. 7. (R1) sent to (Name) Hospital and admitted with right femur fracture. A review of the facility's conclusion: "Following an investigation it is reasonable to conclude that (R1) had inappropriate footwear and left foot slipped off platform during transfer, using a (Sitting Mechanical Lift). Causing (R1) to be suspended in the harness at a lower position. Staff intervened right away by lowering (R1) onto wheelchair." On 1-23-2012 at 4:10pm. E2, (DON) stated, "Yes, (E4/CNA) did not follow Policy, by transferring (R1) by himself and not two staff members on 1-29-2011. (E4) was using the (Sitting Mechanical Lift) to transfer (R1). We require two staff members for mechanical transfers. (E4) was disciplined for the improper transfer." E4, (CNA)'s personnel file contains Employee Report of 11-30-2011 containing the following documentation: "Employee Action/Discipline: Suspension until 12-2-2011 for improper transfer of resident. (E4) was inserviced on transfer techniques on 11-30-2011. Will do another competency on 12-5-2011." Additionally, E4's personnel file contains mechanical lift and transfer competency training and completion on 1-10-2008 and 11-16-2009. Validation of Competency Mechanical Lift for E4, (CNA) of 11-30-2011 includes documentation that two staff members are required for transfers with the mechanical lifts. R1 on 1-25-2012 at 2:05pm. stated, "When I was transferred and fell off the standing lift one person was doing the transfer. (E4) was the person doing the lifting, by herself. The lift began to fail, I started to fall off the lift and (E4) noticed. I was falling and (E4) ran out and got (E5/LPN/Licensed Practical Nurse). I was hanging onto the bar. They both tried to shove me into the wheelchair. My waist and hip hit the wheelchair. I was in a lot of pain. I had surgery. I still have significant pain in my hip. I developed a hernia after this. (E4) had lifted me alone, with the mechanical lift, alone 10 or 15 times prior to this. Other people use two staff members." B. The Physician order [REDACTED]. Facility notification, with fax date/time stamp of 11-3-2011 at 8:02pm., to the Illinois Department of Public Health regarding the 10-29-2011 incident contains the following documentation. "Complete Description of Occurrence: During transfer (R3's) right arm slipped on the bed rail. (R3) complained of right shoulder pain. Pain meds provided. Sent out to hospital for evaluation. (R3) alert and orientated." Z4, (Family Member) on 1-23-2012 at 11:29am. provided the following information: R3 had just returned from the hospital, on 10-29-2011, after surgical intervention for a left leg fracture. R3 is obese and required two staff members and a slide board for transfers prior to the surgery. R3 has stage 4 [DIAGNOSES REDACTED] and weakened bones. The facility was aware of R3's known history due to previous admissions at the facility. R3 had a fear of falling due to her declining medical condition. R3 is alert and coherent. E6, (CNA) and another CNA were transferring R3 from the wheelchair to the bed. E6 placed a walker in front of R3. R3 asked for the slide board and did not receive it. R3 was transferred using the slide board prior to the surgery. During the transfer R3 became unsteady and went to grab the side rail on the bed and it was not locked and R3 went down hard on her arm on the rail and fell on the bed. R3 cried out in pain. E11, (Nursing Supervisor) came in and moved her fingers around. A portable x-ray was ordered and the technician could not get a good picture due to the pain R3 was in. That x-ray showed no fracture. From 10-29-2011 through 11-1-2011 R3's pain was severe and continued. Z4 contacted R3's Orthopedic Physician, (Z1). Z1's nurse contacted the facility to say R3 was going to the hospital for evaluation due to her extreme pain. R3 went to the hospital on 11-1-2011 and was diagnosed with [REDACTED]. R3 is right handed. R3's rehabilitation and therapy was prolonged and delayed due to the fracture. R3 could no longer take care of personal hygiene after toileting and could not apply make-up. R3's depression grew worse. R3 required out of facility specialty appointments and suffered extreme pain. On 1-25-2012 at 12:35pm. E2, (DON) stated, "(Z1/Orthopedic Physician) called for the facility to send out (R3) for evaluation on 11-1-2011." E2, (DON) on 1-25-2012 at 9:15am. provided R3's Timeline containing the following documentation: "2-15-2011 (R3) admitted with [DIAGNOSES REDACTED]. 4-6-2011 discharged home after completion of therapy. 8-24-2011 admitted to (Facility) with left distal femur pathologic fracture and open reduction internal fixation on 8-19-2011: imaging results from hospitalization show possible compression fracture of the left tibia. 10-6-2011 Returned from orthopedic appointment: femur stable; questionable impending fracture left tibia. 10-27-2011 Discharge to hospital for planned open reduction internal fixation left tibia for impending pathological fracture. 10-29-2011 readmitted after left tibia open reduction internal fixation. Complaints of right shoulder pain. Pain resolved with ice pack and positioning; able to complete range of motion without pain. 10-30-2011 Complaints of right shoulder pain; physician notified with order for right shoulder x-ray; x-ray completed. 10-31-2011 Result of right shoulder x-ray shows no acute fracture with metastatic disease and moth eaten pattern. Physician notified. 11-1-2011 Continues to complain of right shoulder pain. Physician notified with order to send (R3) to emergency room for evaluation of right shoulder pain. Returned from emergency room with sling. 11-3-2011 Confirmation of [DIAGNOSES REDACTED]. Nursing Note of 10-30-2011 "Time 7-3 is, "(R3) complained of elbow and shoulder pain during range of motion. No redness, no swelling noted, x-ray ordered for shoulder and upper arm." The Nursing Note of 10-30-2011 at 10:00pm. is, "(R3) complains of right humerus pain; x-rays taken and showing degeneration of right humerus, probable due to cancer metastasis." Nursing Note of 10-31-2011 "Time 7-3 (R3) complains of right arm pain." The 10-31-2011 at 10:00pm. Nursing Note is, "(R3) in bed with right arm still sore. Hot compress applied, pain med given for relief." Nursing Note of 11-1-2011 "Time 7-3 (R3) complained of right shoulder pain, 2 tabs given, no effect, given at 1pm., still complaining of pain referred to psych/psychotropic, to see patient." 11-2-1011 Palliative Care Note, "Seeing (R3) for symptom management involving [DIAGNOSES REDACTED]. (R3) was doing well until the recent setback of right humerus fracture. Discouraged." Psychology Progress Note of 11-3-2011 is, "(R3) expressed frustration over events following leg surgery. Which (R3) reports resulted in shoulder fracture. Processed feelings. Redirected to leg surgery that she reported is very successful. Talked about reasonable hope that shoulder will be ok as well. Supportive treatment." 11-9-2011 Palliative Care Note, "Seeing (R3) for pain to arms and complex medical decisions....Disgusted with current situation." Psychology note of 11-14-2011 at 10:00am. "(R3) is increasingly depressed.....feelings of helplessness and hopelessness." The 11-1-2011 at 3:15pm. Nursing Note is, "(Z1/Orthopedic Physician)'s nurse called and said (R3) needs to go to the emergency room for uncontrollable and unmanageable pain to right shoulder. Explained that x-ray shows no fracture, but (Z1) wants her pain managed at the emergency room ." Accident/Incident Report of 10-31-2011 for R3's 10-29-2011 injury includes three interviews with E6, (CNA), E7, (CNA) and E11, (Nursing Supervisor). E6 and E7's signed statements document R3 refused to wear a gait belt and do not mention the slide board for transfer. Nursing Assistant Assignment Sheet of 10-29-2011 does not contain documentation of how R3 should be transferred. E2, (DON) after review of the same Nursing Assistant Assignment Sheet on 12-25-2012 at 11:05am. stated, "I cannot see any documentation about (R3's) transfer. I'll see if we have any documentation regarding an assessment, staff instructions or training for (R3) after she returned from the hospital and surgical procedure on 10-29-2011." No further information could be provided. E6, (CNA) on 1-25-2012 at 2:45pm. stated, "I've worked at the facility for six or seven months as a CNA. I received training in each unit on Policies and Procedures for CNA's. I've worked with (R3) many times. When (R3) came back from the hospital on 10-29-2011 she asked to get into bed. Her husband was there also. I asked for (E7/CNA). Before (R3) went to the hospital she was always very anxious and afraid when we transferred her, so we always transferred (R3) with two people. (R3) was using the sliding board before she went to the hospital. That day (E10) the Wound Nurse was asked how to transfer (R3). (E10) said use the gait belt, didn't specify sliding board. (R3) just came back from the hospital and is very anxious, so be careful. I know (R3) is very heavy and very afraid of transfers. She's very hard to transfer. (E10) said to do a two person with gait belt transfer, use walker as support. (E7) and I told (R3) what we were going to do . Put (R3) in bed with gait belt. (R3) tried to grab walker. She wasn't near the bed. She didn't fall. She then accepted the gait belt. We put the gait belt on her. She tried to grab the bed rail. The bed rail was down. (R3) said oh my god my shoulder. (E10) works full time with wounds, he's a registered nurse. (R3) came back after shift report, so I asked (E10) how to transfer (R3) because (E10) was at the desk. I don't remember who the nurse was that night." After asked about a sliding board, E6 stated, "(E7) offered the sliding board and (R3) refused." The 6 Mobility Transfer and Ambulation Competency is, "1. Assess resident's ability to transfer. 2. Identify need for transfer equipment and additional assistance." On 10-25-2012 at 3:35pm. Z4, (Family Member) stated, "On 10-29-2011, after (R3) returned from the hospital and her surgery, (R3) asked to be put to bed because she was tired. (R3) told (E6/CNA) I would like to be transferred with a slide board. (E6) said have you stood in the hospital? Did they get you up after surgery? (R3) said yes. (E6) said that's what we will do. We will get you up with a gait belt on. (R3) made it perfectly clear, she wanted the slide board. She told (E6) that she normally used the sliding board and preferred that. (R3) is quite large. (R3) has a terrific fear of falling due to her previous fracture and bone condition due to her metastatic cancer, and still does. In February 2011 (R3) had an ischial fracture of her pelvis. She went to the Facility for rehabilitation and went home. Then in August she had a fractured left leg, after a fall and returned to the Facility for rehabilitation. On October 27-2011 she required surgery to her left leg due to healing and alignment. (R3) returned to the facility on [DATE] in the evening around 4 or 5pm. I was there the whole time." R3 on 1-24-2012 at 2:45pm. stated, "Two CNAs, (E6) and one other CNA were transferring me from the wheelchair to the bed, without a slid board, and dropped me onto the side of my bed. I broke my arm. My arm hit the side rail on the bed. I had a lot of pain. First, no pain, then a lot of pain. I asked for the slide board and they said they would transfer me with the gait belt and walker. I went back to the hospital and had an x-ray. I couldn't get in good enough position for the x-ray at the facility due to the pain. The pain was horrible. My rehabilitation was delayed for my leg." On 1-24-2012 at 2:27pm. Z1, (Orthopedic Physician) stated, "(R3) is morbidly obese. She is riddled with stage 4 metastatic [DIAGNOSES REDACTED] throughout her entire body. The fracture was pathologic. (R3) was pivoting on weight after a recent surgical fracture repair. (R3) requires multiple people for transfer. A metastatic pathologic area of any bone is of much greater responsibility of staff during a transfer due to the possibility of fracture. I don't know if the fracture of (R3's) arm was preventable, but if the transfer was incorrect, yes. I wasn't there during the transfer. However, common sense is (R3) would need assessment of her condition at the time of transfer. (R3) would need assistance with morbid obesity, weakened bones, and just getting back from the hospital and recent surgical repair on her leg. (R3) is at greater risk for fracture and was known to the facility to have these medical problems and co-morbidities." E8, (ADON/Assistant Director of Nursing) on 1-24-2012 at 12:55pm. stated, "I helped with the investigation of (R3's) 10-29-2012 incident and injury. I don't know why a sliding board wasn't used. I think we asked the CNAs' about the sliding board and I don't recall the CNAs' response." E9, (Charge Nurse) and E8, (ADON) on 1-24-2012 at approximately 1:10pm. affirmed R3 was transferred using a sliding board during her residence at the facility. Z2, (Physician/Medical Director) on 1-25-2012 at 12:05pm. stated, "I am (R3's) physician. She has metastatic cancer and brittle bone disease. I don't know about the assessment and transfer information after (R3) returned from the hospital on 10-29-2011. I know the staff transferred (R3), basically the same way during her stay at the facility." The 8-31-2011 Admission MDS and 11-24-2011 Quarterly MDS, Section C. Cognitive Patterns document R3 does not have short or long term memory deficits. Section G. Functional Status: B. Transfer document R3 requires extensive two plus staff member assistance. G0300 Balance During Transitions and Walking, A. Moving from seated to standing position, E. Surface to surface transfer "Not steady, only able to stabilize with human assistance." The 10-29-2011 Fall Risk Evaluation completed after R3 returned from the hospital, prior to injury, contains documentation that R3 is, "A. Alert. B. Chair Bound. Gait/Balance, Not able to perform function. High Risk for falls." C. The Physician order [REDACTED]. Additionally, R2 was admitted to the facility on [DATE]. The 10-1-2011 through 1-23-2012 Fall Tracking Log contains documentation regarding R2: 10-4-2011 at 2:00am., fell in bedroom, sent to hospital with resulting fracture. 12-6-2011 at 7:45am., fell in bedroom, sustained a bruise. 12-21-2011 at 1:05pm. fell in dining room, no injury. 12-25-2011 at 8:00am. fell in bedroom, sent to hospital with resulting fracture. On 1-23-2012 at 4:15pm. E2, (DON), was requested to provide a timeline from February 2011 to January 2012 and interventions implemented by the facility for R2's recurrent falls with resulting injuries. E2, (DON), on 1-25-2012 at 9:15am. provided a Timeline and Interventions, implemented by the facility, for R2's recurrent falls with injuries, which follows: "2-14-2011 Care Plan updated; Educated (R2) regarding recommendation to sit while doing her grooming. 3-31-2011 Care Plan updated, started physical therapy for ambulation, gait training, and transfer. 5-30-2011 Seen by Nurse Practitioner; medications reviewed and urinalysis and culture completed, negative. 7-31-2011 Care Plan updated; non-skid shoes recommended by nursing for safety and use of walker. 8-21-2011 Care Plan updated; Re-educated (R2) on use of call light and that hearing aide will be kept in medication cart when not in use. Staff to assist in applying hearing aide. 10-4-2011 Care Plan updated; One to one care giver as determined by resident need. 10-14-2011 Care Plan update; re-educated regarding transfers with assist and Medical Director evaluation; Investigation concludes no fall. 12-6-2011 Care Plan update; Re-educated to call for assistance when going into her closet; labs done. Investigation concludes no fall. 12-25-2011 Care Plan update; re-educated on use of call light; one to one sitter as determined by resident and physical therapy evaluation." E2, (DON) on 1-25-2012 at 9:15am. stated, "These are the Interventions that have been implemented for (R2), and therapy evaluated her. (R2) had a history of [REDACTED]. Here is the time line." R2's Current Care Plan from 3-31-2011 to present Identifies R2 is at risk for falls and contains documentation of interventions of "Re-educate on call light use, free room of clutter, restorative therapy programs, one to one sitter, assist with transfers." On 1-25-2012 at 10:10am., 12:55am., and 3:45pm., any supporting documentation regarding one to one sitter usage, time frames, or implementation of sitters was requested. E2, (DON) on 1-25-2012 at 12:25pm. stated, "We have two CNAs that do 1 to 1 sitting. Both CNAs work here. We do not have supporting documentation regarding the one to one sitter and R2." R2's Fall Risk Assessment of 12-26-2011, 1-2-2012-1-18-2012 document R2 is at "High Risk" for falls. Hospital History and Physical of 3-8-2011 contains documentation that R2 sustained 3rd, 4th, and 5th. rib fractures with a sternal fracture after a fall at the facility. Accident/Incident Report of 10-4-2011 contains documentation that R2 was found on floor with a skin tear to right forearm and one on left middle arm. "Sent to hospital for evaluation and is admitted with [DIAGNOSES REDACTED]. Accident/Incident Report of 11-14-2011 is, "(R2) complains of right rib pain. X-ray order." Hospital Discharge of 11-17-2011 is, "8th rib fracture secondary to fall, old and new rib fracture." Accident/Incident Report of 12-6-2011 at 7:45am. contains documentation that R2 had a bruise of unknown origin to the right forearm. Accident/Incident Report of 12-25-2011 contains documentation that R2 was found on floor. Sent to hospital with a [DIAGNOSES REDACTED]. rib fractures. The 1-2-2012 Hospital Discharge Summary contains documentation that R2 was admitted to the hospital on 12-25-2011 with [DIAGNOSES REDACTED]. rib fractures and sternal fracture. E9, (Charge Nurse) and E8, (ADON) on 1-25-2012 at 12:55pm. affirmed interventions identified above were the only interventions that had been implemented by the facility for R2. Additionally, E8 and E9 affirmed R2 has macular degeneration, only seeing shadows, has hearing aids, has recurrent falls with injury of rib fractures and sternal fracture. On 1-25-2012 at 12:05pm. Z2, (Physician/Medical Director) stated, "I did not know (R2) was having falls since 2008. I do know I asked the facility about a tether alarm for her. I don't follow (R2) directly." Z3, (Physician) on 1-25-2012 at 12:17pm. stated, "I know (R2's) medical history. I don't know what other interventions the facility has implemented for (R2's) falls and weakened bones, disease process