Every finding on record at Evercare of Calhoun

Based on interview and record review, the facility failed to maintain resident safety for 1 of 4 residents (R2) reviewed for resident safety in the sample of 4. This failure resulted in R2 being left unattended, suffering a fall, and sustaining a hematoma to the left side of R2's head and severe pain to left hip. R2 required a transfer to the local hospital and found to have sustained a subcapital femoral neck fracture with at least 2.2 CM (centimeter) superior and 1.5 CM lateral displacement of the fracture. After family and medical considerations, R2 was then transferred to the Regional Hospital Trauma Service for evaluation of surgery where R2 underwent a Left Hip Hemiarthroplasty. Findings include:R2's admission Record, dated 10/15/25, documents R2 was admitted to the facility on [DATE] with diagnosis of Alzheimer's disease, Dementia, Chronic Obstructive Pulmonary Disease (COPD), Hypertension (HTN), Congested Heart Failure (CHF), Anxiety disorder, Major depressive disorder, Convulsions, Lymphedema, Anemia, Trigeminal Neuralgia, and Peripheral Vascular Disease.R2's Care Plan, dated 9/24/25, documents R2 is high risk for falls related to Confusion, Psychoactive drug use, and history of falls. Interventions: Anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, follow facility fall protocol, 10/14/25: Resident has short term memory issues and is not to be left in the restroom unattended for any reason, review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers Interdisciplinary Team (IDT) as to causes. It continues R2 has an Activities of Daily Living (ADL) self-care performance deficit related to Alzheimer's, Confusion, Dementia, Impaired balance, Limited Mobility, Limited Range of Motion (ROM). Interventions: Toilet Use: The resident requires (staff assistance, walker & gait belt) by (1) staff for toileting, Transfer per screen. It continues R2 has had an actual fall with (no injury) Poor Balance, Psychoactive drug use, Unsteady gait. Interventions: Alarms in place for poor safety awareness: TSA (touch sensitive alarm) to bed and wheelchair, bed placed against wall for increased safety, bilateral assist bars to bed, continue interventions on the at-risk plan, keep items frequently used within my reach and keep area free of clutter and safety hazards, anti-roll back device placed to resident's wheelchair, TSA to wheelchair, wireless TSA to bed.R2's Minimum Data Set (MDS), dated [DATE], documents R2 has a severe cognitive impairment and requires partial/moderate assistance for toileting and supervision/touching assistance for transfers. R2's Fall Risk Assessment, dated 9/29/25, documents R2 is a High Fall Risk.R2's Fall Risk Assessment, dated 10/8/25, documents R2 is a High Fall Risk.R2's Nurses Note, dated 10/7/25 at 10:46 PM, documents Resident was using the toilet staff stepped away to get supplies and resident tried standing and fell. Resident assessed and noted to have a hematoma to left side of head about 2 inches above ear and complaining of severe pain to left hip. Swelling noted to front of left hip area. Resident not allowing much ROM to be done. Resident assisted to bed by staff. Neuros WNL (within normal limit) at this time. VS (vital signs) -132/69, 94, 24, 97.8, pulse ox 93%. Daughter notified. Doctor on call notified.R2's Fall Investigation (Final), dated 10/7/25, documents in part On Tuesday, October 7, 2025, around 8:30 PM, (R2) was assisted to the toilet by staff. (R2) was unattended on the toilet when staff heard (R2) fall on the bathroom floor. Resident was assessed and noted to have a hematoma to left side of head about 2 inches above the ear and was complaining of pain to left hip. Swelling was noted to front of left hip area. (R2) was assisted to bed by staff. MD (medical doctor) and POA (power of attorney) notified of incident. Orders from MD received to send (R2) to ER (emergency room) for evaluation and treatment. (R2) was transferred to (local community hospital) where x-rays were taken and revealed a subcaptial femoral neck fracture. (R2) was then transferred on to (regional hospital) for further treatment including surgical repair of fracture. It continues Upon completion of investigation, (R2) was standing up from the toilet and had lost balance and fell on the floor resulting in the fracture and injury to left side of head. At this time, (R2) has not returned to the facility. Upon readmission, facility will follow all orders regarding treatment of fracture and will be reassessed to ensure proper care is received. V2, Director of Nursing (DON's) Investigation of R2's Fall, dated 10/7/25, documents in part Resident was placed on the toilet in room [ROOM NUMBER] due to resident's roommate being on the toilet in their room. Staff left resident to go and get supplies. Resident attempted to stand up unassisted and fell to the floor landing on her left side. Nurse was a couple of rooms up the hall. Nurse (V4, Registered Nurse/RN) stepped out in the hallway and heard a thud. Quickly (V4) and (V3, Certified Nursing Assistant/CNA) went to the bathroom and found the resident on the floor lying on her left side.V3's handwritten statement, dated 10/7/25, documents Resident urgently needed to use the restroom, resident requested privacy as it may take her a while. I stepped around the corner where resident could still be seen, when an alarm started to go off. I told the resident to use bathroom call light when finished as I was stepping out to answer an alarm. Resident confirmed knowing what the bathroom call light was, how to use it, and when to use it when she was finished if I wasn't back yet, answered alarm, talked with (V4, RN) regarding a resident and then heard resident fall in bathroom. All of this occurred in a matter of a few minutes from my recollection of fall incident on the night of 10/7/25. R2's (local hospital) Radiology reports, dated 10/7/25, documents X-Ray Hip 2-3 views left, fall with left hip injury. Findings: Subcapital femoral neck fracture identified. There is at least 2.2 CM (centimeter) superior and 1.5 CM lateral displacement of the fracture.R2's (Local Community Hospital) Discharge summary, dated [DATE], documents R2 was admitted to the floor from the ER for further management evaluation of left hip fracture. Cardiology was consulted due to R2's significant cardiac history and Thoracic Aortic Aneurysm (TAA). After family and medical considerations, R2 was transferred to (Regional Hospital) Trauma Service for evaluation of surgery.R2's (Regional Hospital) Progress Note, dated 10/14/25, documents in part 90 y.o. (year old) female with notable PMHx (past medical history) of dementia (A&O - alert and oriented x1 at baseline), legally blind, CAD (coronary artery disease) with PCI (Percutaneous coronary intervention) in 2013, on Plavix, diastolic HF (heart failure), COPD, mild to moderate aortic stenosis, TAA, Moderate Left ICA (internal carotid artery) stenosis, questionable seizures, who was found down following unwitnessed fall at skilled facility and transferred from OSH (outside hospital) with left femoral neck fracture and UTI (urinary tract infection). Surgery: 10/10/25 Left Hip Hemiarthroplasty.On 10/15/25 at 8:50 AM, V1, Administrator, stated We had a staff member mess up and he left R2 on the toilet for about 11 minutes, which he shouldn't have done, in which time R2 fell off the toilet and fractured her hip.On 10/15/25 at 9:25 AM, V2, Director of Nursing (DON), stated (V3, Certified Nursing Assistant (CNA)), was the one working with (R2) the night she fell. (V3) left (R2) on the toilet and (R2) got up on her own and fell with no one around her. On 10/15/25 at 4:00 PM, V3, CNA, stated It all began when (R2) requested to use the restroom, and her roommate was already in their restroom, so I took her across the hall to use a different one. I assisted (R2) to the toilet and then heard an alarm going off in another room so I asked (R2) if she could use the call light when she is finished, and she said yes. I even asked R2 again, what do you do when you are done and she said she would use the call light, so I felt like she understood so I left her to check on the other alarm. After I checked one alarm, I heard another one going off, so I checked on that one too. Both of those residents were fine, so I stopped to talk to the nurse about those residents when we heard (R2) fall on the floor. When we got there, (R2) was on the floor by the toilet, and it looked like she was trying to walk towards the restroom door and collapsed to the floor. When asked what R2's transfer status was, V3 stated I believe she was a one-person assist with a gait belt. I was never told not to leave her alone until after the fall, now everyone is telling me that she should never be left alone. I was never taught in school when or when not to leave someone by themselves and that I didn't know (R2) well enough to know. On 10/15/25 at 11:48 AM, V5, CNA, stated I worked all the time with (R2) and she was a feisty one, especially when trying to redirect her to call for help. I would always stay with (R2) while in the restroom and she would even get mad at me for staying with her. (R2) always had an alarm on either in her bed or wheelchair.On 10/15/25 at 3:20 PM, V6, CNA, stated (R2) is typically an assist of one with a gait belt. Sometimes she would walk with staff using a gait belt, and sometimes she would complain of her legs hurting and refuse to walk and would have to use her wheelchair. Staff should never leave her on the toilet or anywhere else by herself because she would get up on her own. She always had an alarm on her wheelchair and on the bed and would typically hang out by the nurse's desk talking to everyone. On 10/15/25 at 3:25 PM, V7, RN, stated (R2) was always very quick and the minute you turned your back on her, she was up. You always had to keep your eye on her and know where she is and what she is doing.On 10/15/25 at 3:45 PM, V2, DON, stated I would expect the staff to follow resident fall precautions and interventions to keep them safe. I would expect the staff to monitor any resident who is a High Fall Risk and stay with them while using the restroom to prevent them from getting up on their own and falling.On 10/15/25 at 3:47 PM, V1, Administrator, stated I would expect all staff to keep residents safe at all times and to monitor those residents who are a high fall risk.On 10/16/25 at 9:46 AM, V1 stated That is the only policy we have for fall precautions or Resident safety.The Facility's Interdisciplinary Fall Reduction / Injury Prevention Protocol, dated 1/2025, documents in part Intent: An interdisciplinary approach at reducing falls, preventing injury and increasing safety awareness ultimately resulting in improved quality of care for our residents.

Based on interview and record review, the Facility failed to involve the resident and resident representative in the development of the discharge plan and inform the resident and representative of the final plan in 1 of 3 residents (R2) reviewed for transfer and discharge in the sample of 3. This failure resulted in a disruption in R2's environment, causing reorientation issues and worsening confusion. This past non-compliance occurred from 7/18/25 to 7/21/25.Findings include:R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and diabetes mellitus.R2's Minimum Data Set (MDS) dated [DATE] documented R2 was severely cognitively impaired, ambulated independently, wandered daily, and had both verbal and other behaviors one to three days per week.R2's Care Plan does not address any plan for discharge.R2's 7/6/25 Progress Note by V9, Licensed Practical Nurse (LPN), documents V10 and V7, R2's Family, were looking for a facility for R2 with a locked memory unit but were still trying to decide between two facilities.R2's 7/17/25 Progress Note by V11, LPN, documents R2 will be discharging to another facility on 7/18/25. The note did not document any correspondence with family.R2's Progress Notes do not document V7 or V10 were involved in the development of the final plan or informed of the final plan.On 8/19/25 at 10:39 AM, V7 stated she is R2's Power of Attorney (POA), she did not sign any discharge paperwork for R2, and nobody told her R2 was discharging from the Facility. V4, Social Services Director, previously mentioned to the family that R2 would eventually need a higher level of care, but said there was no rush. V7 had not heard any more about it until on 7/18/25 when V8, R2's Family, got a call from V6, R2's Family, stating he saw R2 at a new Facility. V7 stated, (R2) is not a dog, you can't just dump them off like an animal, like they are trash; that's not fair. V7 stated every time R2 moves to a new facility, her dementia seems to get worse.On 8/19/25 at 8:15 AM, V1, Administrator, stated R2 had worsening dementia. V3, Director of Admissions, and V4 had talked to her family about placing her in a dementia unit. We found a facility with a dementia unit and planned to send R2 there when a bed was ready, but when there finally was a bed ready, nobody sent the family a notification that she was discharged . On 8/19/25 at 8:40 AM, V3 stated she spoke with V8 about R2's worsening dementia and R2 possibly being better off in a dementia unit. V8 stated she would discuss this with V7 and get back to her. V3 notified the accepting facility that R2's family was considering transferring there and would get back to them. V3 later heard R2 would be leaving the Facility on 7/18/25 and assumed someone else had talked to the family, but apparently nobody did. It was all a miscommunication. Apparently V6 was finishing up a stay at the accepting facility when R2 arrived. He saw her and called V7, and that is when it hit the fans.On 8/19/25 at 9:00 AM, V4 stated R2's discharge was a big miscommunication. She and V1 had been talking with R2's family regarding discharge, but R2 was discharged and the family was not made aware she would be transferring that day.On 8/19/25 at 11:18 AM, V1 stated there is no official transfer paperwork. It was just presumed that they had consent and it was ok to transport him in the van.On 8/19/25 at 11:25 AM, V1 stated typically discharges are initiated by the team/family/resident, then referrals are sent out to the facility, the facility is contacted to coordinate a date/time, the physician is contacted for orders, and the family is notified.The Facility's Discharge and Transfer Policy revised 4/2025 documents, Transfer and discharge includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not. The facility will provide sufficient orientation to residents to ensure safe and orderly transfer or discharge from the facility including an opportunity to participate in deciding where to go. If transferred to another health care facility upon order of a physician, a two-copy transfer form is completed. One copy is sent with the resident and the other is filed in the resident's record. Prior to resident being transferred or discharged , the facility must provide a written notice to the resident, and if known, a family member or legal representative of the resident. This must be issued at least 30 days before the resident is transferred or discharged or as soon as practicable for immediate transfers or the resident has not resided in the facility for 30 days. The written discharge/transfer notice must contain the following information: a. The reason for transfer or discharge; b. The effective date of transfer or discharge; c. The location to which the resident is transferred or discharged . Prior to the survey date of 8/19/25, the Facility had taken the following action to correct the non-compliance:On 7/21/25, V1, V2, and V4 were educated by V12 regarding discharge planning to ensure responsible parties were notified of discharges and transfers.On 7/21/25, an Ad Hoc QAPI Meeting including V13, Medical Director, was held to identify issue and discuss the development of a past non-compliance to address.V2 is reviewing discharges and transfers five days a week for 60 days, then three times a week for four weeks, then monthly to ensure compliance.

Based on interview and record review, the Facility failed to document notice of transfer requirement for 1 of 3 residents (R2) reviewed for transfer and discharge in the sample of 3. This past non-compliance occurred from 7/18/25 to 7/21/25.Findings include:R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and diabetes mellitus.R2's Minimum Data Set (MDS) dated [DATE] documented R2 was severely cognitively impaired, ambulated independently, wandered daily, and had both verbal and other behaviors one to three days per week.R2's Care Plan does not address any plan for discharge.R2's 7/17/25 Progress Note by V11, LPN, documents R2 will be discharging to another facility on 7/18/25.R2's Progress Notes do not document R2's discharge notice was given or family was contacted regarding R2's discharge.On 8/19/25 at 10:39 AM, V7, R2's Family, stated she is R2's Power of Attorney (POA) and was never notified of R2's discharge by the Facility.On 8/19/25 at 1:55 PM, V1, Administrator, stated he would expect the medical record to contain documentation that notification was made to the resident's representative and a discharge notice was given.The Facility's Discharge and Transfer Policy revised 4/2025 documents, Transfer and discharge includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not. Prior to resident being transferred or discharged , the facility must provide a written notice to the resident, and if known, a family member or legal representative of the resident. This must be issued at least 30 days before the resident is transferred or discharged or as soon as practicable for immediate transfers or the resident has not resided in the facility for 30 days. The written discharge/transfer notice must contain the following information: a. The reason for transfer or discharge; b. The effective date of transfer or discharge; c. The location to which the resident is transferred or discharged .Prior to the survey date of 8/19/25, the Facility had taken the following action to correct the non-compliance:On 7/21/25, V1, V2, and V4 were educated by V12 regarding discharge planning to ensure responsible parties were notified of discharges and transfers.On 7/21/25, an Ad Hoc QAPI Meeting including V13 was held to identify issue and discuss the development of a past non-compliance to address.V2 is reviewing discharges and transfers five days a week for 60 days, then three times a week for four weeks, then monthly to ensure compliance.

Based on observation, interview and record review, the facility failed to implement care plan interventions to prevent falls for 1 of 5 residents (R44) reviewed for falls in the sample of 46. R44 sustained multiple falls while at the facility, including a fall that resulted in a fracture of the left hip. Findings include: R44's Face Sheet, printed 7/19/24, documents she has a diagnosis of Other fracture of lower end of left femur, subsequent encounter for closed fracture with routine healing, Encounter for other orthopedic aftercare, and Fracture of unspecified part of neck of left femur, initial encounter for closed fracture. R44's Minimum Data Set (MDS) dated [DATE] documents R44 is severely cognitively impaired and requires supervision and touch assistance for transfers into chair or bed to chair transfers. R44's undated Care Plan with the goal date of 10/24 documents, Safety Notes: I have a history of falling and am a continued fall risk. I have poor safety awareness. Make sure I have nonskid socks or shoes on before transfers or walking. Keep items that I frequently use within my reach, but keep area free of clutter and safety hazards. Transfer me per (brand name) Transfer Screen. Redirect me and reassure me when I get anxious and wander. I have a high/low bed and bilateral 1/2 rails on my bed, and I have non-skid strips on the left side of my bed because that is the side I get out on. Be sure my bed is in proper position in relation to my non-skid strips. I have a (alarm) to my wheel chair. I have been discontinued from being an elopement risk. If I start to wander, please redirect me or get social services. The goal for this care plan documents, I want to be safe and free of falls. On 7/18/24 at 2:57 PM, R44 was lying in her bed with her wheel chair positioned beside her bed with the brakes unlocked. There were no non-skid strips on the floor on either side of her bed. V16, Certified Nursing Assistant (CNA) came in and pulled R44's blankets back off her feet and R44 had her shoes on in bed. V16 stated (R44) requires assist to transfer safely but will transfer herself at times. V16 stated she had just come down a little while ago to help (R44) lay down in bed and (R44) had already transferred herself into bed without assist. V16 verified there were no non-skid strips on (R44's) floor next to her bed or in her bathroom. R44 woke up and was pleasantly confused. She stated, There is usually someone running around here to help me or I just get up by myself. I do alright. R44's Fall Report dated 10/17/23 documents, Resident was sitting at NS (nurses station) visiting with son. Son left facility and did not tell staff he was leaving and resident stood up, tripped over catheter tubing, and fell , hitting the back of her head. Swelling to back of head. Complaint of head hurting. Sent to (local hospital) for eval. Immediate post-incident action: Bladder training in progress to discontinue foley. Meds reviewed by NP (Nurse Practitioner) 10/17/23. R44's Fall Report dated 10/21/23 documents, Got up from bed unassisted, lost balance and fell . No injury noted. Immediate post-incident action: Ensure gripper socks are on when in bed. R44's Fall Report dated 10/29/23 documents, Unit aide walking by resident's room and saw resident sit herself on the floor between her bed and her wheel chair. Stated she was trying to walk to bathroom and that her legs gave out so she sat down. She did not hit her head. Immediate Post-Incident Action: Non-skid strips place on floor beside bed. R44's Fall Report dated 12/18/23 documents, Resident found sitting on floor next to bed. Wheelchair was facing bed with wheels locked, lights off, floor free of clutter and she had gripper socks in place. Resident stated she was trying to get back in bed when her feet just slid on the floor. Stated she fell like a child would and can't believe that she would do that. Resident denies hitting head, states she fell straight to her bottom in a slow manor. She stated the only thing that hurt is her pride. ROM (Range of Motion) and Neuros WNL (within normal limits) for resident. Immediate post-incident action: make sure bed is in proper position with non-skid strips in correct place in correlation to bed at transfer site. R44's Progress Note dated 12/18/23 at 11:20 PM, which was included in the fall investigation, documents, During examination of the room, noted bed was pushed over so non-skid strips on floor were under wheelchair instead near the area her bed was. Bed was moved back into position so non-skid strips in the proper place. R44's Fall Report dated 1/6/24 documents, Staff heard commotion on hall and upon passing room saw resident propped up on elbow on floor. Nurse alerted. Upon entering room resident was sitting on right hip leaning over on right elbow on floor. Resident states she was trying to transfer from wheel chair to stationary chair to read the newspaper on the side table and missed the chair. Shoes on , room lit. Floor did have spilled water from resident falling over as well as table and paper. AROM (active range of motion) WNL. Skin intact. Denies hitting head. Resident has been more confused today. Immediate post-incident action taken: Additional chairs removed from room and request for UA (urinalysis) sent to MD (Medical Doctor). R44's Fall Report dated 4/8/24 documents, Charge nurse heard resident yelling and upon entering resident's room, observed resident lying on the floor on her back at the foot of her bed, between her bed and the BR (bathroom) door. She came and got writer off East hall to eval resident. Resident stated that she got up to use the bathroom and fell . She is screaming and crying in pain, holding left hip and left groin. LLE (left lower extremity) rotated outward and resident will not let writer perform PROM (passive range of motion) to LLE. Sent to (local hospital) for eval. Immediate post-incident action: will re-evaluate when returns to facility. R44's Progress Note dated 4/9/24 at 4:52 AM documents, Call placed to (local hospital) to check on resident. Nurse (hospital staff) stated that resident was being admitted with left hip fracture and that MD had already been consulted and that resident is to have surgery in am. R44's hospital Radiology Report dated 4/8/24 at 9:41 PM documents, Impression: Mildly displaced transverse fracture through the base of the greater trochanter. Mildly displaced lesser tuberosity avulsion fracture. R44's Morse Fall Scale dated 4/8/24 documents her fall risk score of 90. Per the assessment, a score of 46 or more indicates the resident is at a high risk of falls and high-risk fall prevention interventions should be implemented. R44's (name brand) Screen (for mobility devices) dated 5/24/24 documents R44 requires one person assist for transfers. On 7/19/24 at 10:08 AM V2, Director of Nursing (DON) stated after R44 returned from the hospital, they moved her to a different room because her previous roommate had too much clutter in her room and that was what caused R44 to fall and fracture her hip. She stated the roommate's wheelchair was blocking R44's ability to get into her own w/c and she got off the wrong side of the bed and tried to walk around and fell . She stated the non-skid strips did not have anything to do her fall. V2 stated when R44's room was moved she thinks it was just overlooked that she was supposed to have non-skid strips on the floor to help prevent her from falling. She stated the error has been corrected now. The facility's policy, Accident & Incident Documentation & Investigation Resident Incident revised 7/18, documents, Accidents and/or incidents involving resident care will be investigated and documented on the Resident Incident Report entry form in the (computer) system. An incident is defined as an occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident. Accidents and incidents will be analyzed for trends and patterns to enable the facility to enhance preventative measures to reduce the occurrence of incidents.

Based on interview and record review the facility failed to ensure they had a qualified Infection Preventionist responsible for the facility's Infection Control Program at the facility. This has the potential to affect all 57 residents living in the Facility. Findings include: On 7/16/2024 at 9:00AM, V1, Administrator stated, (V3), Registered Nurse (RN)) was the Infection Control Specialist. On 7/19/2024 at 11:00AM, V3, Registered Nurse, RN, stated I took all the modules, but I did not pass the test. I am not taking it again. Facility job description dated 11/1/2019 states Under the direction of the Director of Nursing Services, the Infection Preventionist serves as a support person within the facility, providing guidance and education; assistance in problem solving related to resident care; monitoring compliance with state and federal regulations and coordinates the Infection Prevention and Control Program as set forth in the Resident Care Policy and Procedure Manual. Essential Duties: Maintains certification in Infection Prevention and Control.

Based on interview and record review, the facility failed to ensure residents were free from abuse for 4 of 4 residents (R10, R22, R37, R112) reviewed for abuse in the sample of 45. Findings include: 1. R22's Face Sheet documents R22 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, morbid, obesity and pain. R22's Minimum Data Set (MDS) dated [DATE] documented R22 was severely cognitively impaired and ambulated via wheelchair. R22's Care Plan dated 6/5/24 does not address abuse. R112's Face Sheet documents R112 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia, auditory hallucinations, and homicidal ideations. R112 was discharged from the Facility on 12/7/23. R112's MDS dated [DATE] documents R112 was severely cognitively impaired and ambulated with wheelchair and walker. R112's Care Plan dated 9/27/23 does not address abuse. The Facility's Initial Incident Description sent to the Illinois Department of Public Health (IDPH) on 12/6/23 documents, On Wednesday December 6th, 2023 at 1:30pm, it was reported that (R112) made contact with (R22)'s arm. Residents were immediately separated and (V1) immediately notified. R22's 12/6/23 Resident Incident Report reported by V6, Certified Nursing Assistant (CNA), and prepared by V12, Registered Nurse (RN), documents, This resident sitting in wheelchair in hallway as staff moving belonging from room [ROOM NUMBER] to new room [ROOM NUMBER]. Another resident going down the hallway passed this resident and hit this resident in the right arm/bicep with closed fist. R112's 12/6/23 Resident Incident Report reported by V6, CNA, and prepared by V10, Licensed Practical Nurse (LPN), documents, Staff reported that resident was with a staff member on North hall when she came upon a resident in a wheelchair and she reached out and hit her, they were immediately separated and checked for injuries. On 7/18/24 at 9:20 AM, R2 stated she did not recall the 12/6/23 incident and could not remember if another resident has ever hit her in the facility. On 7/18/24 at 10:16 AM, V6, CNA, stated R112 went by R22 in the hallway and punched her. She stated she separated the residents and reported the incident to her nurse. On 7/18/24 at 9:35 AM, V1, Administrator, stated R112 had a behavior and hit R22. The Facility's Final Incident Description sent to IDPH on 12/13/24 documents, On 12/6/2023 at approximately 1:30 PM, (R112) was walking with a staff member down north hall of the facility when they approached (R22) in the hallway and it was reported that (R112) with a closed fist made contact with (R22)'s right arm/bicep. Upon final investigation it found that (R112) did make contact with (R22)'s right arm. 2. R10's Face Sheet documents R10 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, atrial fibrillation, and chronic kidney disease. R10's 7/18/24 MDS documents R10 was cognitively intact and ambulated via wheelchair and walker. R10's Care Plan dated 7/12/24 does not address abuse. R37's Face Sheet documents R37 was admitted to the facility on [DATE] with diagnoses including unspecified dementia and cerebral infarction. R37's MDS dated [DATE] documented R37 was severely cognitively impaired and ambulated with walker. R37's Undated Care Plan with goal date of 9/6/24 documents R37 was verbally abusive at times, had threatened staff, yelled out, and had hallucinations and delusions. The Facility's Initial Incident Description sent to the State Survey Agency on 1/23/24 documents, On Tuesday January 23, 2024 at 10:45AM, it was reported that (R37) made contact with the back of (R10). Residents were immediately separated and (V1) immediately notified. R10's Resident Incident Report reported by V13, CNA, and prepared by V9, LPN, on 1/23/24 documents, This resident explained that another resident was in his bed. This resident attempting to tell other resident he is in the wrong room, other resident became agitated and began yelling and hit this resident with call light 4 or 5 times across upper back. Writer came to room in response to the call light and did separate residents. On 7/18/24 at 1:20 PM, R10 stated R37 came into his room and thought it was his own. He stated R37 was insistent he was in the right room and did not want to leave, then hit R10 a couple of times with the call light. On 7/18/24 at 9:27 AM, R37 was unable to respond appropriately to questions or provide any information regarding 1/23/24 incident. On 7/18/24 at 9:35 AM, V1, Administrator, stated R37 was in the wrong bed and hit R10 with the call light. On 7/18/24 at 9:54 AM, V13, CNA, stated R37 went into R10's room, believing it was his own, then yelled at R10 about being in his room and hit him with the call light. V13 stated she entered the room after she heard yelling and separated the residents and helped de-escalate R37. The Facility's Hand-Written Statement by V14, LPN, on 1/23/24 documents, Resident (R10) stated to this nurse that he was sitting in his w/c (wheelchair) with his blankets on. Resident (R37) came into his room and told him he was in the wrong room. (R10) replied that he was mistaken and this is his room. Directed him back to his room next door. (R37) then grabbed the call light cord and raised his arm with it to hit him. (R10) pulled his blankets over his head and leaned forward in his chair. (R37) hit him 4-5 times mid back with the chord {sic}. Staff immediately came in and moved him in his wheelchair out of the way. On skin assessment, resident has two small areas of redness to mid back. Not raised. On 7/18/24 at 10:42 AM, V14, LPN, stated she was called down to R10's room where R37 was in R10's bed. She stated she did not see R10 hit R37, but R10 told her R37 hit him and R37 had the call light balled up in his fist. On 7/18/24 at 2:02 PM, V9, RN, stated V13, CNA, called her down to R10's room where R37 thought R10 was an intruder and was hit him with the call light multiple times. She stated R10 was not seriously injured, but had a red mark on his back. The Facility's Final Incident Description submitted to the State Survey Agency on 1/30/24 documents, On 1/23/2024 at 10:45AM, (R37) had put himself in the bed of (R10). (R10) approached (R37) and told him that he is in the wrong room and bed and (R37) became agitated and started yelling and had contacted (R10) via call light cord lightly striking his back. Upon final investigation, (R37) did contact (R10) via call light. (R37) really believed he was in his own bed and simply reacted. On 7/19/24 at 11:25 AM, V1, Administrator, stated he expects the facility to keep residents free from abuse. The Facility's Abuse Prevention Policy revised 10/2022 documents, The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteer and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. Abuse: Will infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse may be resident-to-resident, staff-to-resident, family-to-resident, or visitor-to-resident. Physical Abuse: This includes but is not limited to hitting, slapping, pinching, and kicking.

Based on interview and record review, the facility failed to implement a Quality Assurance Performance Improvement (QAPI) Program which meets at least quarterly with the required members, including the Medical Director. This failure has the potential to affect all 57 residents who reside in the facility. Findings include: On 7/17/24 at 2:41 PM, V1, Administrator, stated the last QAPI Meeting was in March 2024, and the next meeting has not yet been scheduled. He stated V15, Medical Director, does not regularly attend the meetings, so he sends him a recapulation email after each meeting. On 7/19/24 at 11:25 AM, V1, Administrator, stated a QAPI meeting is set for 7/26/24 with V15, Medical Director, and they will continue on a monthly basis moving forward. He stated he expects all facility policies to be followed. The Facility's Quality Improvement Program revised 10/2022 documents, The Quality Improvement Committee will assess and monitor the quality of services provided to the residents in the facility in order to identify potential problems and/or opportunities for improvement. The committee will implement and systemically evaluate programs and processes to identified problems in order to proactively improve health care delivery. The committee will meet monthly at an established time. Committee team members shall consist of DNS (Director of Nursing Services), Medical Director or designee, and three other staff; at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and the Infection Preventionist.

Based on interview and record review the facility failed to investigate and provide treatment for bruises and abrasions to one of three residents (R2) reviewed for resident injury on the sample list of 11. Findings include: R2's Care Plan, not dated, documents, Positioning/Bowel and Bladder/Skin Integrity: Please encourage me to turn and reposition myself when in bed and reposition myself when up in my chair. Assist me if needed. I have a pressure re-distribution mattress on my bed and pressure re-distribution cushion in my wheelchair. Please look at my skin during showers and with any care and report any redness, bruising or open areas to my nurse/MD (Medical Doctor) right away. Please observe my skin weekly and notify MD with any decline or change in condition. R2's Minimum Data Set, undated, documents, that R2 was severely cognitively impaired, required assist from staff for activities of daily living, (ADL), does not document any skin concerns. R2's undated Face Sheet, documents diagnoses including Type 2 diabetes mellitus without complications, Sick sinus syndrome, old myocardial infarction, Atherosclerosis heart disease of native coronary artery without angina pectoris, dementia, R2's Weekly Skin Assessment, dated 11/24/2023, at 3:40PM, documents, No skin issues present. R2's Notes, dated 11/25/23, at 11: 23AM, documents, Nursing: Resident left the facility via family vehicle. will be gone until Monday. Resident's meds (medications) were sent with family. R2's Notes, dated 11/26/23 at 5:34PM, documents, Nursing: Resident returned to facility with family per family vehicle. R2's Notes, dated 11/27/23 at 1:32AM, documents, Nursing: Resident was out with family the last few days and arrived back to the facility this evening. Staff noticed bruising to resident's left foot this pm, on top of foot and toes. Resident was unsure what happened. Will continue to observe. R2's Weekly Skin Assessment, completed date 11/29/2024 at 4:11AM, documents, large dark reddish- purple Purpura to right wrist and Reddish colored bruising to left wrist. R2's Weekly Skin Assessment, completed date 12/06/2023 at 12:55AM, documents, bruise to right wrist-change condition, bruise left wrist resolved, sacrum abrasion still present, left lateral calf purpura still present, left lateral foot bruise still present, right thigh bruise still present, left thigh bruise still present. R2's Weekly Skin Assessment, completed date 12/15/2023 at 1:11AM, documents, bruise to right wrist still present, sacrum abrasion still present- abrasions to the right and left sacrum, left lateral calf purpura still present, left lateral foot bruise still present, right thigh bruise still present, left thigh bruise still present. Scab to the bridge of nose is resolved. R2's Weekly Skin Assessment, completed date 12/20/2023 at 11:33AM, documents, bruise to right wrist still present, sacrum abrasion still present- abrasions to the right and left sacrum, left lateral calf purpura still present, left lateral foot bruise still present, right thigh bruise still present, left thigh bruise still present. On 4/26/24 at 3:15PM V14, R2's family, stated, that he would like to know what happened when R2 fell and broke her pelvis. He stated he has tried to get information from the facility and they tell him he has to wait for a report. V14 stated, that he has some family members who work at the facility and the facility won't give them any information either. V14 stated, that (R2) had a fall back in June and the facility never explained what happened and (R2) had bruises on her face like she fell face first out of the wheelchair. V14 stated, that he did not get informed of any bruises his mother had in November on her legs and thighs. On 5/14/2024 at 11:08AM V2, Director of Nurses, stated, that she believes that the multiple bruises came from an outing with family. V2 stated, that R2 had a wound to her coccyx in the past, but that has healed. When asked about the abrasions to R2's right and left sacrum, V2 responded a shear. V2 stated, that usually they do nothing with it and that the CNA's, (certified nurse's assistant), apply barrier cream. V2 stated, that they don't usually document anything. V2 stated, that this information should be documented in the wound notes and she would get the documentation for me. V2 stated, that outside of the bruising to R2's right foot there is no other documentation of bruising and abrasions. On 4/26/2024 asked for an investigation of the bruises. As of 5/15/2024 the facility was unable to provide any investigation or explanation of these bruises and there were no fall reports around that time for R2. On 5/14/2024 at 1:10PM V8, Registered Nurse, (RN), stated, that when finding or being notified of bruising you go down and assess. V8 stated, that then you try to find out how it happens. V8 stated if you know what happened then good but if not then they fill out an incident report. V8 stated this is the responsibility of the nurse. On 5/14/2024 at 1:13PM V15, Licensed Practical Nurse, (LPN), stated, that she has worked at the facility for years. V15 stated, that she provided care for R2. V15 stated, that R2 was ambulatory. V15 stated, that R2 had poor safety awareness and was forgetful. V15 stated, that R2 had a wound in the past, but was not aware of any prior to discharge. V15 stated, that if there is a skin issue or injury an incident report is completed and they try to find out what happened/cause of the bruise and get treatment. On 5/14/2024 at 1:15PM V16, RN, stated, that she cared for R2, but it has been a while. V16 stated, that she does not remember any particulars as it relates to her. V16 stated the normal practice is when you are notified of a bruise you assess then you try to find out what happened. V16 stated, that you complete an incident report and if you can't find out what happened then V1 and V2 are notified. The report is given to them for further investigation. On 5/15/2024 at 5:33AM V17, LPN, stated, that she cared for R2. V17 stated, that she received in report that R2 had returned from outing with family and some bruising was found. V17 stated, that she did her own skin check and documented her finding. V17 stated, that she was not aware how R2 got the areas. V17 stated, that she did not complete an incident report because that would have been done by the nurse that found the areas. V17 stated she is aware of an area to R2's buttocks and it was an abrasion. V17 stated, that the area would open up and then it would close and open again. V17 stated, that they had tried barrier but that didn't work and she spoke with the previous Wound Nurse and applied a treatment similar to skin prep. V17 stated it worked but the area would reopen. On 5/15/2024 at 3:02PM V1, Administrator, stated, that he would expect his staff to follow the policy as it relates to incidents and injury. The facility's Accident & Incident Documentation & Investigation Resident Incident, dated 7/18, documents, POLICY: Accidents and/or incidents involving resident care will be investigated and documented on the Resident Incident Report entry form in the LTC system. An incident is defined as an occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident. Accidents and incidents will be analyzed for trends or patterns to enable the facility to enhance preventive measures to reduce the occurrence of incidents. It continues PROCEDURE: 1. General Information: a. The Licensed Nurse assigned at the time of the resident care accident/incident is responsible for conducting an investigation of the circumstances surrounding the accident/incident, and for notifying the Supervisor, Director of Nursing, and/or the Executive Director as appropriate. b. The Licensed Nurse at the time of the incident is responsible for initiating / completing the Resident Incident Report, ensuring that all items identified on the form have been completed as applicable to the accident/incident. c. The Licensed Nurse at the time of the incident is responsible for documenting the incident in the resident's medical record, in accordance with the guidelines below and set forth on the Resident Incident Report. d. If incident/accident is related to a visitor, refer to Accident & Incident Documentation & Investigation-Visitor Incident Policy. 2. Notification and Documentation in the Resident's Medical Record: a. The Licensed Nurse shall place the resident on the 24-Hour Report, document the incident, and notify the supervisor and Director of Nursing for follow through as needed. b. The Licensed Nurse may complete a Nurses' Notes, and update the Resident Care Plan as needed c. The Nurse's Notes could contain the following documentation on Date and time of incident: Clear, objective facts of what occurred; The last time the resident was seen by staff prior to the incident; An evaluation of the resident's condition at the time of the accident/incident could include a description of the resident, vital signs, and any other physical characteristics apparent as a result of the accident/incident; Any treatment provided; Any contacts made or attempted with the resident's physician, family, legal representative, or any other health care professional or person involved with the resident's care; The resident's outcome and any information concerning the incident; and on The Nurse's signature, date, and time of the charting. The Executive Director / Director of Nursing will notify the State Department of Health in accordance with reporting guideline's in the event the accident/incident is reportable. The Attorney General may need notification also. (Mississippi only).

Based on interview and record review, the facility failed to notify a resident's family/emergency contact of a change in condition and transfer to the hospital for 1 of 3 residents (R2) reviewed for notification of changes in the sample of 5. Findings include: R2's Face Sheet documents he was admitted to the facility on [DATE] with the diagnoses to include adjustment disorder with Mixed Anxiety and Depressed Mood, Hyperlipidemia, Gastro-esophageal Reflux Disease Without Esophagitis, Peripheral Vascular Disease, Nicotine Dependence, Hypothyroidism, Pain and Pneumonia. R2's Face Sheet documents V10 is R2's Responsible Party. R2's Progress Note dated 12/13/23 at 3:25 AM document, 12/12/23 at 7:20 PM EMTs (Emergency Medical Technicians) arrived at the facility after resident called 911 from his cell phone to say he was having chest pain. This nurse accompanied the emergency response team to the resident's room. He told them he called from his cell phone after having chest pain for 2 days. Resident did not report chest pain to the nursing staff anytime throughout the day. Resident answers questions appropriately and per his request was taken to (local hospital) for further evaluation. (Local hospital) called the facility at 10:20 PM to inform the facility that they would be discharging the resident back to the facility. Dx (diagnosis): Noncardiac Chest pain with a recommendation to follow up with his healthcare provider on 12/13/23 for further eval and treatment if needed. Resident arrived back at the facility at 11:27 PM. He denied pain/discomfort. He is resting comfortably with his call light within reach. Will continue to monitor throughout shift. On 12/29/23 at 12:33 PM, (V10) R2's Emergency Contact, stated, Nobody called and let me know when (R2) had to call 911 himself to go to the hospital for chest pains. That was a few weeks before I came to take him home for Christmas. On 1/3/24 at 8:14 AM during phone interview, V1, Administrator stated he cannot find any documentation that R2's emergency contact, V10, was contacted when he went to the hospital on 12/13/23. He stated he would expect resident's family, responsible party and/or emergency contact to be notified when they are sent to the hospital. The facility's policy, Notification of a Change in Condition in Resident's Status, revised 11/17 documents, Policy: The attending physician/physician extender (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist) and the resident representative will be notified of a change in a resident ' s condition, per standards of practice and Federal and /or State regulations. Procedure: 1. Guideline for notification of physician / responsible party (not all inclusive): j. Abnormal complaints of pain, ineffective relief of pain from current regimen. 2. Document in the Interdisciplinary Team (IDT) notes: a. Resident change in condition b. Physician/physician extender notification c. Notification of responsible party.

Based on interview, observation and record review, the facility failed to provide pain relief for 1 of 16 residents (R51) reviewed for pain in the sample of 36. This failure caused R51 to holler out and moan in pain and show physical signs of pain from 10:48 AM until 3:10 PM on 5/30/23. Findings include: R51's Face Sheet, print date of 5/31/23, documents that R51 was admitted on [DATE] and has diagnoses of Dementia, Type 2 Diabetes and Urgency of urination. R51's Minimum Data Set, dated dated [DATE], documents that R51 is severely cognitively impaired. R51's Nursing Note, dated 5/30/23 at 2:41 AM, documents, Resident returned to facility about 2:25 AM per (local hospital) ambulance by 2 EMT's (Emergency Medical Technicians). Resident has a left pubic fx (fracture). New orders for Hydrocodone 5/325 1 or 2 tabs (tablets) PO (by mouth) Q (every) 6 hours PRN (as needed), Zofran 4 mg (milligrams) PO Q 6 hours PRN, No weight bearing and to make an appointment with (V18 Orthopedic Doctor) on 5/30/23 for follow up noted. R51's Nursing Note, dated 5/30/23 at 6:27 PM, documents, Resident very restless this am Tylenol given for discomfort with no relief noted. Called pharmacy and asked them when the e-run (emergency run) for the Norco (Hydrocodone) would get here spoke with (V19, Pharmacy Technician) and he said he did not know it needed to be sent out but he would take care of it this was at 830am and 1130 resident still having lots of pain called pharmacy and spoke with (V20, Pharmacy Technician) and he said he had just gotten a hard copy from (V21, Nurse Practitioner) told him that was for addition meds (medications) the initial order was for 15 pills and 1 -2 pills every 6 hours he researched and found the order and said it has not been sent earlier but was on its way now. Contacted (V21) and receive order for 1 time stat dose of tramadol 50 mg po 2 tabs. Medication given with some relief. At 4pm received Norco from pharmacy and meds given to resident. R51's Nursing Note, dated 5/31/23 at 1:11 AM, documents, Resident noted to be in extreme pain at times. PRN given this shift and was effective. R51's Hospital Emergency Department Disposition, arrival date of 5/29/23, documents, Instructions: No weight bearing. Prescription Medications: Hydrocodone / APAP 5 mg / 325 mg: take 1 to 2 orally every 6 hours as needed for acute pain. Dispense fifteen (15). No refills. R51's Pelvis X-ray, dated 5/29/23 at 11:20 PM, documents, Impression: Left pubic fracture. R51's Medication Administration Record, dated 5/30/23, documents that R51 got her first dose of Hydrocodone /APAP at 4:00 PM and a dose of Tramadol 100 mg at 2:00 PM. On 5/30/23 at 10:48 AM, R51 was sitting up at the nurses station in a recliner geriatric chair. R51 was observed to be fidgeting in the seat throwing her left leg across the arm of the chair, holding her left buttock, moaning and having facial grimaces. On 05/30/23 from 1200 PM to 12:50 PM, R51 stated several times the she was in pain and was uncomfortable. Throughout meal service, R51 was sitting up in a high back reclining geriatric chair with her left leg hanging off of the chair, when staff attempted to reposition R51, she groaned out in pain, expressed facial grimacing and did not want the pillow underneath her which is what they were trying to do for comfort. On 05/30/23 at 1:20 PM, V23, Certified Nurse Aide (CNA), and V8, CNA, transferred R51 from her geriatric reclining chair to her bed using a full mechanical lift. During the transfer R51 hollered out in pain. Once in bed, V23 and V8 attempted to roll R51 to the side to remove the full mechanical lift sling and provide incontinent care. R51 hollered out in pain and refused to move. R51 continually attempted to hold her left buttock. V23 and V8 both questioned what they should do. V8 left the room to get help. V8 came back with V3, Registered Nurse (RN) / Staff Development Coordinator. V23 and V8 attempted to roll R51 again. R51 hollered out in pain and continually attempted to hold her left buttock. V3 left the room and went and got V5, ( Fill in Administrator/RN). Another attempt to roll R51 was made. R51 hollered out in pain, attempted to hold her left buttocks and grimace in pain. V5 stated to V23 and V8 to just leave R51 the way she is and she was going to go talk to (V7 RN) about R51. On 05/30/23 at 3:10 PM, R51 was lying in bed with her eyes closed, left leg bent and an ice pack on her left buttock. On 5/30/23 at 9:20 AM, V7, Registered Nurse (RN), stated, (R51) fell last night and fractured her pelvis. The hospital sent her back with an order of Vicodin for pain. I am waiting for the pharmacy to deliver it. She has been given some Tylenol for pain. She is Non-weight bearing and she has a follow up appointment with the orthopedic doctor (V18) in a week. There is nothing they can do for a pelvic fracture so it is just pain control and non weight bearing until she sees (V18). On 5/30/23 at 10:50 AM, V22, Certified Occupational Therapy Assistance (COTA), stated, (R51) was transferred to the geriatric reclining chair using the full mechanical lift. V22 was questioned how V22 handled the transfer, V22 stated, 'It was very painful for her. She is having a lot of pain. On 5/30/23 at 2:02 PM, V7 stated, Pharmacy has still not delivered the Vicodin for (R51). I have been trying to get it for her. They tell me it is on the way. I just spoke to (V21) and she sent a prescription for Tramadol to the pharmacy. Our emergency pharmacy kit does not have Vicodin in it. That is why the order for Tramadol. Once pharmacy gets that I can access the emergency pharmacy kit and get the Tramadol out of it to give to her. On 6/1/23 at 12:50 PM, V2, Director of Nurses, stated, When a resident comes from the hospital with a prescription for narcotics, the hard copy of the prescription has to go to the pharmacy. When she came back it was in the middle of the night and we did not have staff to drive it to [NAME] to get it filled. The pharmacy came in the morning and picked up the prescription and took it to the pharmacy in St. Louis Missouri which even took longer. I don't know why (V7) didn't try to get her Tramadol earlier and why she waited. I agree the order to get her Tramadol should have been done earlier so she could have some pain relief while waiting on the Vicodin. (V21) sent the script for Tramadol over to the pharmacy electronically. That is how the pharmacy is getting that prescription so it can be processed. I know in the future if the emergency room is going to send a resident back with a narcotic the hospital doctor needs to electronically send the prescription directly to the pharmacy and not send a hard copy for narcotics that way there will not be a long delay in getting narcotics. On 6/1/23 at 1:54 PM, V5 stated, I was mortified when I saw her. I can't believe the hospital sent her back and did not admit her. I even called the hospital on Wednesday to make sure she was supposed to be out of bed and they said they wanted her up and not bed rest. If they sent her back they should have pre-medicating her for pain. V5 was questioned as to what her opinion of the delay of Vicodin was, V5 stated, Well she was getting Tylenol and she got a Tramadol while we were waiting on the Vicodin. The policy Pain Evaluation / Management, dated 1/15, documents, 4. If no relief or if the resident finds pain above acceptable levels notify the physician. 5. Notify the physician if resident's response to their medication or treatment is not satisfactory to develop further interventions for relief of pain.

Based on interview, observation, and record review, the facility failed to obtain pain medication in a timely manner and have a system in place to obtain pain medication for a resident in a timely manner for 1 of 16 residents (R51) reviewed for pharmacy services in the sample of 36. This failure caused R51 to holler out and moan in pain and show physical signs of pain from 10:48 AM until 3:10 PM on 5/30/23. Findings include: R51's Face Sheet, print date of 5/31/23, documents that R51 was admitted on [DATE] and has diagnoses of Dementia, Type 2 Diabetes and Urgency of urination. R51's Minimum Data Set (MDS), dated [DATE], documents that R51 is severely cognitively impaired. R51's Nursing Note, dated 5/30/23 at 2:41 AM, documents, Resident returned to facility about 2:25 AM per (local hospital) ambulance by 2 EMT's (Emergency Medical Technicians). Resident has a left pubic fx (fracture). New orders for Hydrocodone 5/325 1 or 2 tabs (tablets) PO (by mouth) Q (every) 6 hours PRN (as needed), Zofran 4 mg (milligrams) PO Q 6 hours PRN, No weight bearing and to make an appointment with (V18, Orthopedic Doctor) on 5/30/23 for follow up noted. R51's Nursing Note, dated 5/30/23 at 6:27 PM, documents, Resident very restless this am Tylenol given for discomfort with no relief noted. Called pharmacy and asked them when the e-run (emergency run) for the Norco (Hydrocodone) would get here spoke with (V19, Pharmacy Technician) and he said he did not know it needed to be sent out but he would take care of it this was at 830am and 1130 resident still having lots of pain called pharmacy and spoke with (V20, Pharmacy Technician) and he said he had just gotten a hard copy from (V21, Nurse Practitioner) told him that was for addition meds (medications) the initial order was for 15 pills and 1 -2 pills every 6 hours he researched and found the order and said it has not been sent earlier but was on its way now. Contacted (V21) and receive order for 1 time stat (now) dose of tramadol 50 mg po 2 tabs. Medication given with some relief. At 4pm received Norco from pharmacy and meds given to resident. R51's Hospital Emergency Department Disposition, arrival date of 5/29/23, documents, Instructions: No weight bearing. Prescription Medications: Hydrocodone / APAP 5 mg / 325 mg: take 1 to 2 orally every 6 hours as needed for acute pain. Dispense fifteen (15). No refills. R51's Medication Administration Record, dated 5/30/23, documents that R51 got her first dose of Hydrocodone /APAP at 4:00 PM and a dose of Tramadol 100 mg at 2:00 PM. The policy Ordering and Receiving Medications form Pharmacy, dated 8/16, documents, Medications are ordered and received from the pharmacy in a timely manner. The policy Controlled Medications Administration, dated 8/16/23, documents, 3. Schedule !! controlled medications are delivered to the facility on ly if original written or faxed (if allowed by state law) prescription has been received by the pharmacy. Schedule III, IV and V controlled medications are delivered to the facility on ly if a written or verbal prescription with all legal requirements has been received by the pharmacy. Only the prescriber or their agent can provide the pharmacy with a legal prescription for controlled substances. On 5/30/23 at 10:48 AM, R51 was sitting up at the nurses station in a recliner geriatric chair. R51 was observed to be fidgeting in the seat throwing her left leg across the arm of the chair, holding her left buttock, moaning and having facial grimaces. On 05/30/23 from 1200 PM to 12:50 PM, R51 stated several times the she was in pain and was uncomfortable. Throughout meal service, R51 was sitting up in a high back reclining geriatric chair with her left leg hanging off of the chair, when staff attempted to reposition R51, she groaned out in pain, expressed facial grimacing and did not want the pillow underneath her which is what they were trying to do for comfort. On 05/30/23 at 1:20 PM, V23 Certified Nurse Aide (CNA), and V8, CNA, transferred R51 from her geriatric reclining chair to her bed using a full mechanical lift. During the transfer, R51 hollered out in pain. Once in bed V23 and V8 attempted to roll R51 to the side to remove the full mechanical lift sling and provide incontinent care. R51 holler out in pain and refused to move. R51 continually attempted to hold her left buttock. V23 and V8 both questioned what they should do. V8 left the room to get help. V8 came back with V3, Registered Nurse (RN) / Staff Development Coordinator. V23 and V8 attempted to roll R51 again. R51 hollered out in pain and continually attempted to hold her left buttock. V3 left the room and went and got V5, Fill in Administrator / RN to come and assess. Another attempt to roll R51 was made. R51 hollered out in pain, attempted to hold her left buttocks and grimace in pain. V5 stated to V23 and V8 to just leave R51 the way she is and that she was going to go talk to (V7, RN) about R51. On 05/30/23 at 3:10 PM, R51 was lying in bed with her eyes closed, left leg bent and an ice pack on her left buttock. On 5/30/23 at 9:20 AM, V7, Registered Nurse (RN), stated, (R51) fell last night and fractured her pelvis. The hospital sent her back with an order of Vicodin for pain. I am waiting for the pharmacy to deliver it. She has been given some Tylenol for pain. She is non-weight bearing and she has a follow up appointment with the orthopedic doctor (V18) in a week. There is nothing they can do for a pelvic fracture so it is just pain control and non weight bearing until she sees (V18). On 5/30/23 at 10:50 AM, V22, Certified Occupational Therapy Assistance (COTA), stated, (R51) was transferred to the geriatric reclining chair using the full mechanical lift. V22 was questioned how V22 handled the transfer, V22 stated, 'It was very painful for her. She is having a lot of pain. On 5/30/23 at 2:02 PM, V7 stated, Pharmacy has still not delivered the Vicodin for (R51). I have been trying to get it for her. They tell me it is on the way. I just spoke to (V21) and she sent a prescription for Tramadol to the pharmacy. Our emergency pharmacy kit does not have Vicodin in it. That is why the order for Tramadol. Once pharmacy gets that I can access the emergency pharmacy kit and get the Tramadol out of it to give to her. On 6/1/23 at 12:50 PM, V2, Director of Nurses, stated, When a resident comes from the hospital with a prescription for narcotics, the hard copy of the prescription has to go to the pharmacy. When she came back, it was in the middle of the night and we did not have staff to drive it to [NAME] to get it filled. The pharmacy came in the morning and picked up the prescription and took it to the pharmacy in St. Louis Missouri which even took longer. I don't know why (V7) didn't try to get her Tramadol earlier and why she waited. I agree the order to get her Tramadol should have been done earlier so she could have some pain relief while waiting on the Vicodin. (V21) sent the script for Tramadol over to the pharmacy electronically. That is how the pharmacy is getting that prescription so it can be processed. I know in the future if the emergency room is going to send a resident back with a narcotic the hospital doctor needs to electronically send the prescription directly to the pharmacy and not send a hard copy for narcotics that way there will not be a long delay in getting narcotics. On 6/1/23 at 1:54 PM, V5 stated, I was mortified when I saw her. I can't believe the hospital sent her back and did not admit her. I even called the hospital on Wednesday to make sure she was supposed to be out of bed and they said they wanted her up and not bed rest. If they sent her back, they should have pre-medicating her for pain. V5 was questioned as to what her opinion of the delay of Vicodin was, V5 stated, Well, she was getting Tylenol and she got a Tramadol while we were waiting on the Vicodin.

Based on observation, interview, and record review, the facility failed to properly store medication, and label Tubersol. This has the potential to affect all 57 residents living in the facility. Findings include: On 5/30/23 at 9:00 AM, The facility's Medication Storage Room was inspected. The refrigerator located in the medication room contained the following: 1. 3 open multidose vial of Tubersol (TB) without an open date. The Tuberculin Purified Protein Derivative (Mantoux) Tubersol package insert, dated April 2016, documents A vial of TUBERSOL which has been entered and in use for 30 days should be discarded. 2. R33's bottle of liquid Lorazepam Concentrate. 3. R6's bottle of liquid Lorazepam Concentrate. 4. R31's bottle of liquid Lorazepam Concentrate. On 5/30/2023 at 9:05 AM V8, RN, stated that the multidose vial of Tubersol was open and in use. V8 stated that the Tubersol should have an open date on it. V8 stated that the refrigerator should be locked. V8 stated that she unlocked the refrigerator and did not lock it back. On 5/23/2023 at 2:30PM, V2, Director of Nursing, stated that multi dose vials of Tubersol have a different expiration date from what's on the bottle once open and should be thrown away after this date. V2 stated that she believes it is 28 or 30 days. V2 stated that the TB vials are to be labeled with an open date when put in use. V2 stated that labeling the medication with a date open date lets the nurses know when the expiration date is. V2 state the Tubersol can be used on everyone as long as they have no allergies. The Resident Census and Condition of Residents form (CMS 672), dated 5/30/2023, documents that the facility has 57residents living in the facility. The facility's Medication Storage Policy, dated 11/10, documents Policy: All drugs, treatments, and biologicals must be stored securely and following the manufacturer's labeled recommendations, or per facility policy.

Based on observation, interview, and record review the facility failed to utilize safe transfer techniques to prevent accidents for 4 of 5 residents (R1, R28, R30, R53) reviewed for accidents/supervision in the sample of 36. Findings include: 1. R1's Care Plan, dated 7/26/21, documents I am a total lift for transfers with two staff assist. R1's Minimum Data Set (MDS), dated [DATE], documents that R1 is totally dependent of 2 staff members for transfers. On 5/30/23 at 9:15 AM V11, Restorative Nurse, and V9, Restorative Aide, transferred R1 from her wheelchair to the bed using a full body mechanical lift. V11 operating the controls and V9 stood behind the wheelchair. V9 then moved the machine back and R1 started to sway in the sling. With V9 operating the controls V9 transported R1 from the wheelchair to the bed swinging without staff contact. 2. R28's Care Plan, dated February 3, 2017, documents Since having my stroke, I have left sided hemiplegia. I am not safe to get up on my own. I am a two person assist using the total lift with a TL2 purple edge sling. R28's MDS, dated [DATE], documents that R28 is totally dependent on 2 staff for transfers. On 5/31/23 at 130pm V12, Certified Nurse Aide/CNA, and V15, Nursing assistant (NA), assisted R28 to her bed from her wheelchair using a full body mechanical lift. V12 applied R28's sling straps to the lift. With V12 operating the controls V15 stood behind the wheelchair. V12 then moved the machine back transported R30 from the wheelchair at the far end of the room to the bed allowing R28 to swing freely in the sling without staff contact. 3. R30's Care Plan, Dated November 10, 2016, documents I am a two assist with total lift to transfer. R30's MDS, dated [DATE], documents that R30 is totally dependent on 2 staff for transfers. 05/30/23 at 2:18 PM V6, CNA, and V13, CNA, assisted R30 into the bed using a full body mechanical lift. V6 and V13 applied R30's sling straps to the lift. With V13 operating the controls V6 stood behind the wheelchair. V13 then moved the machine back and R30 started to swing in the lift. With V13 operating the controls transported R30 from the wheelchair at the far end of the room to the bed swinging without staff contact. 4. R53's Care Plan, dated August 28, 2022, documents I am a fall risk, and have a history of falls at home. I am a one person transfer with gait belt using a walker when I walk. R53's MDS, dated [DATE], documents that R53 requires extensive assist of 1 person for transfers. On 5/31/2023 at 11:31 AM R53's chair alarm was sounding. R53 transferred self to the toilet. V12 assisted R53 with toileting. V12 then grabbed R53 under her right arm and assisted R53 into the standing position. R53 noted to sway when standing and holding onto the bar. V12 then assisted R53 into the wheelchair. V12 did not apply a gait belt to R53 for the transfer. V12's gait belt was around her waist. On 6/1/2023 at 1:40 PM V2, Director of Nursing, stated that she expects the staff to apply a gait belt when assisting with a manual transfer. V2 stated that V12 should have applied the gait belt when transferring R53 from the toilet. V2 stated that when the staff are transferring a resident in a total mechanical lift both staff are to participate in the transfer. V2 stated that a staff standing behind a wheelchair or on the other side of the bed is not participating in the transfer. V2 stated that the resident should not be left unattended and left to swing in the lift. The facility's Transfer Belt/Gait Belts policy, dated 4/14, documents the policy is to promote safety in transferring residents, a gait belt is utilized when deemed appropriate. It also documents, A gait belt is used if indicated on care plan. The (Full Body Lift) Total Lift policy documents that the (Full Body Lift) total lift is to be used for total lifts and/or to obtain a resident's weight from bed to chair, chair to bed, or from floor.

Based on observation, interview, and record review, the facility failed to provide complete incontinent and perineal care for 6 of 6 residents (R1, R9, R18, R30, R35 and R53) reviewed for incontinent and perineal care in the sample of 36. Findings include: 1. 05/31/23 10:35 AM R9 was on the bedpan. V9, Certified Nurse Assistant, CNA, removed the bed pan from underneath of R9. V9 rolled R9 back over on to her back. V9 then cleansed R9's abdominal fold, left inner groin and down the center of R9's labia. She did not cleanse R9's right groin. V9 then assisted R9 to roll on to her right side and V9 then cleansed R9's left hip, buttock, and peri rectal area. V9 did not cleanse R9's right hip or buttock. R9's Minimum Data Set (MDS), dated [DATE], documented that her cognition was severely impaired, she was totally dependent upon 2 staff members for toileting and that she was always incontinent of bowel and bladder. 42108 2. R1's Care Plan, dated 7/26/21, documents I am incontinent of both bowel and bladder. I do wear incontinent protective undergarments. R1's MDS, dated [DATE], documents that R1 is always incontinent of bowel and bladder and totally dependent on 2 staff for toileting. R1's Bladder Continence Evaluation, dated 5/15/23, documents that R1 is incontinent of bladder and dependent on staff for toileting. On 05/30/23 at 2:00 PM V13, CNA, and V6, CNA, assisted R1 with incontinent care. R1 was incontinent and heavily soiled of urine. R1's lift pad and pants were soiled with urine. V6 and V13 assisted R1 into the bed using the mechanical lift. V6 and V13 removed R1's pants, opened the incontinent brief and rolled it between R1's legs. V6 using a premoistened washcloth wiped down the middle of R1's peri area. V6 and V13 assisted R1 onto her right side. V6 then using a premoistened wipe and wiped R1's rectal area. V6 and V13 then applied R1's incontinent brief. V6 and V13 did not clean R1'sinner labia, vaginal, peri, groin area, inner thighs, and buttocks. 3. R30's Care Plan, dated 11/10/2016, documents I am incontinent of urine/bowel and need assistance with peri-care after each incontinent episode. I do wear protective undergarments. I am also at risk for urinary tract infections due to my incontinence so monitor me for signs and symptoms of infection. R30's MDS, dated [DATE], documents that R30 is always incontinent of bowel and bladder and totally dependent on 2 staff for toileting. R30's Bladder Continence Evaluation, dated 5/15/2023, documents that R30 is moderately impaired cognitively. It documents that R30 is incontinent and dependent on staff for care. On 05/30/23 at 2:18 PM V13 and V6 assisted R30 with incontinent care. R30 was incontinent of urine. V6 and V13 assisted R30 into the bed using the mechanical lift. V6 and V13 removed R30's pants, opened the incontinent brief and rolled it between R30's legs. V6 using a premoistened washcloth wiped down the middle of R30's peri area. V6 and V13 assisted R30 onto her right side. V6 then using a premoistened wipe wiped R30's rectal area. V6 then using a premoistened wipe wiped R30's rectal area again. V6 and V13 then applied R30's incontinent brief. V6 and V13 did not clean R30's inner labia vaginal, peri, groin area, inner thighs, and buttocks. 4. R53's Care Plan, dated August 28, 2022, documents I am occasionally incontinent of bowel and bladder. R53's MDS, dated [DATE], documents that R53 is frequently incontinent of urine, occasionally incontinent of bowel and requires extensive assist of 1 person for toileting. On 5/31/2023 at 11:31 AM, V12, CNA assisted R53 with toileting. R53 transferred self to toilet. R53 was incontinent of urine. V12 removed R53's heavily soiled incontinent brief and applied a new one. R53 then voided on toilet. R53 with 2 squares of toilet paper wiped her vaginal area. V12 then took toilet paper and wiped R53's anal area. 5. On 06/01/23 at 1:25 PM, V17, CNA, and V15, CNA, entered R18's room to provide incontinent care. V15 and V17 washed hands with soap and water and donned gloves. R18 was wet as verified by V17 and V15. V17 cleansed R18 front peri area during cleansing of labia visible stool on the cleansing wipe. V17 did not obtain any additional wipes to cleanse R18. R18 then turned to left side facing wall. R18 was incontinent of loose stool which had leaked out of adult brief and leaked on the bed. V17 rolled soiled linens under R18 and cleansed R18. V17 did cleanse R18's thighs and buttock and when cleaning rectal area. R18 had visible stool on cleansing wipe. V17 did not cleanse rectal area after cleaning wipe visible with feces. R18 was never dried during incontinent care. R18's MDS, dated [DATE], documents R18 is totally dependent and requires two plus physical assistance for toileting. R18's MDS documents that R18 is always incontinent. 6. On 05/30/23 1:25PM, R35 was being pushed down hall towards her room by V6, CNA. V6 transferred R35 to toilet from wheelchair with gait belt. While R35 stand holding bar, V6 removed R35's pants. R35's adult diaper was urine soaked. While R35 was sitting on the toilet, V6 placed clean adult diaper around ankles and pulled up above thighs where wet clothing has been. then placed clean pants on and up to R35's thighs. After toileting R35, V6 assisted R35 to stand while R35 was holding bar. V6 took cleansing wipe and stood behind R35 and swiped from the front to the back and then pulled up R35's adult diaper and pants. R35's MDS dated [DATE] documents R35 requires extensive assistance of one person for toileting. R35's Care Plan, dated 3/12/ 2018, documents R35 has a history of urinary tract infection and urinary retention. On 6/1/2023 at 1:40 PM V2, Director of Nursing, stated that she expects the CNAs to clean all areas of incontinence. V2 stated that she would expect the CNA to perform incontinent care. The facility policy Incontinent Care dated reviewed 1/15 documents #10 wash the resident's entire perineal area, and all areas affected by incontinent with wash cloth, soap, warm water, peri-wash, or wipes. #11 When washing perineal area, wash the entire area moving from the front to back. #12 Rinse the perineal area and other skin surfaces washed with warm water and a washcloth from front to back. The Policy documents #14 Dry the perineal area front to back of all skin surface washed. #16 remove gloves and discard. Wash hands.

Based on observation, interview and record review, the facility failed to perform hand hygiene and glove changes appropriately during care, and cleaning soiled bed mattress and wheelchair seat pad for 6 of 6 residents(R9, R18, R33, R35, R48, R50) reviewed for infection control in the sample of 36. Findings include: 1. 05/31/23 10:35 AM, R9 was on the bedpan, V8, Certified Nurse Assistant (CNA) and V9, CNA, came into the room, both performed hand hygiene, both donned gloves. V8, with gloved hands, touched her hair, tucking her hair behind her right ear and the placed hand in shirt pocket, proceeded to the right side of R9's bed to assist with taking her off of the bed pan. V9 proceeded to uncover R9, open the disposable cleansing wipes with same gloved hands, removed the bedpan from underneath R9 and started to cleanse R9's abdominal fold, left inner groin and down the center of R9's labia with the same pair of gloves. V9, with the same soiled gloves, assisted R9 to roll on to her right side and V9 then cleansed R9's left hip, buttock and peri rectal area. 2. On 05/31/2023 at 10:20 AM, V8 took R48 into her room. V8 placed a gait belt on R48 and transferred her into her bed without the benefit of hand hygiene nor did she don gloves. 3. 05/31/2023 at 11:00 AM, V10, Registered Nurse (RN)/ Wound Nurse, performed hand hygiene, donned gloves, took a medicine cup of dakin's solution, packages of 4x4 gauze, a package of Melgisorb AG, cotton tip applicators, mepilex foam dressing, gloves and a barrier for the bed. V10 set all the wound dressing supplies on R50's overbed table, pulled R50's privacy curtain and then closed R50's door with her gloved hands. V10 went to R50's bedside, touched R50's right arm with the same gloved hands, explained what she was about to do. V10 pulled the blankets down to expose R50's buttocks and hips placed barrier down on the bed, unfastened R50's incontinent brief, that was wet, and removed the saturated wound dressing from R50's sacral coccyx area. V10 then doffed gloves, performed hand hygiene and donned a clean pair of gloves. V10, with her clean gloves opened the 4x4 gauze packages, placed gauze in medicine cup of dakin's solution, took 1 piece of dakins solution soaked gauze, wrapped it around a cotton tip applicator and cleansed the 9 o'clock tunnel, then took a 2nd gauze soaked with dakin's solution and used it to clean the wound bed. She then took the 3rd dakins soaked gauze and cleansed around the outside of of the wound all with the same gloved hands. V10 then doffed her gloves, performed hand hygiene with Alcohol Based Hand Rub, donned gloves, opened the Melgisorb AG package and took out the dressing, wrapped it around the cotton tipped applicator and placed it in the wound tunnel spreading it down into the wound bed. V10 took the foam dressing placed a 4x4 gauze pad on top of it and placed it over the wound. She then removed the barrier and reattached the soiled adult incontinence brief. 4. On 5/30/23 at 12:05 PM, V10, RN, entered R33's room to do the treatment on R33's legs. R33 right lower leg has multiple scattered scratches and scabs. R33's left leg has 2 scabbed venous ulcer areas with the approximate size of dimes. The areas around the wounds were red. The areas were cleansed and Bacitracin was applied, abdominal pad (ABD) and then gauze. During the dressing changes, V10 changed her gloves 3 times without hand hygiene in between. 5. On 06/01/23 at 1:25 PM during incontinent care, V17, CNA, rolled soiled linens under R18 and cleansed R18. R18's mattress was visibly wet from loose stool. V15 took soiled linens that were removed out from under R18 and swiped across the wet area on mattress. Then both CNAs placed adult diaper on R18. While R18 on mattress, V15 used cleansing wipes and cleansed the area on mattress that R18 has already been placed in. 6. On 05/30/23 01:25PM during incontinent care while R35 sitting on the stoo,l V6, CNA, removed wet pants and diaper which was soaked. V6 placed clean adult diaper around ankles and pulled up above thighs where wet clothing had been. V6 placed clean pants on and up to thighs. The pad in wheelchair wasvisible wet with urine. V6 did not clean pad in wheelchair prior to sitting R35 back in the chair. On 06/01/2023 at 12:55 PM, V2, Director of Nurses, stated that she would expect to staff to perform hand hygiene and change gloves during incontinent care and wound care. The facility policy Standard Precautions dated history 9/19 documents standard precautions will be utilized to provide a primary strategy for the prevention of healthcare-associated infectious (HAI) agents among patients and healthcare personnel. The policy documents standard precautions applies to blood; all body fluids, secretions, exertions except sweat, non-intact skin; mucous membranes. The policy documents #4 during delivery of healthcare, avoid unnecessary touching of surfaces in close contact proximity to the patient to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands t surface. #2 Wash hands when visibly soiled, after contact with blood, body fluids, secretions, excretions, patients intact skin or wound dressings and contaminated items immediately after removing gloves and between patient contacts. #6 environmental control- follow procedures for routine care, cleaning and disinfection of environmental surfaces, especially frequently touches surfaces in patient care areas.

Based on observation, interview and record review, the facility failed to feed residents in a manner which promotes resident's dignity for 1 of 4 residents (R51) reviewed for dignity in a sample of 36. Findings include: On 05/30/2023 during the lunch observation between 12:20 PM to 12:50 PM V3, Registered Nurse Staff Development Coordinator, set up R51's meal tray and stood up and fed R51 the entire meal. On 06/01/2023 at 12:55 PM, V2, Director of Nurses stated that she would expect the staff to be sitting down when feeding a resident. 06/05/2023 at 9:24 AM V2 stated that the facility does not have a policy for staff to be sitting down to feed a resident. R51's Minimum Data Set, dated dated [DATE], documented that R51 cognition was severely impaired and that she required supervision with physical assistance of 1 staff member.

Based on observation, interview, and record review, the facility failed to ensure nutrition was provided as ordered and per standards of practice for 1 of 2 residents (R10) reviewed for tube feeding management in the sample of 36. Findings include: R10's Physician's Order (PO), dated 12/02/19, documents Jevity 1.5 @ (at) 55 ml (milliliters)/hr. (hour) x 24 hours via g tube (gastrostomy tube). R10's Care Plan, dated December 3, 2019, documents I am NPO (Nothing by mouth). I have a diagnosis of Dysphagia. I have a PEG (Percutaneous Endoscopic Gastrostomy)- tube and receive Jevity per MD (medical doctor) orders. I receive Jevity 1.5 at 55ml/hr./24 hours. I have water flushes per tube per MD order. I am to receive medication per tube, all those compatible can be given at once with a 30 ml bolus of water at appropriate times. It also documents that it can be disconnected for no more than one hour a day during ADLs (Activities of Daily Living), therapy, or activities. On 5/30/23 at 9:30 AM R10 was up in wheelchair, out of room. The tube feeding container was not attached to the gastric tubing. On 5/30/23 at 12:40 PM V14, Licensed Practical Nurse, crushed R10's Baclofen 10mg tablet and placed in a cup. V14 then poured and unmeasured amount of water into the cup and entered R10's room. R10 was lying in bed. R10's gastric tubing not connected to feeding container. V14 grabbed a hold of the gastric tubing, opened the spout, and poured the mixture in the cup into the gastric tubing. The liquid stopped flowing. V14 then milked the tubing freeing sections of feeding caught in the tubing. V14 then allowed the liquid to free flow into tubing. V14 then connected the gastric tubing to the bottle of feeding and turned it on. The Jevity feeding bottle was not labeled with the resident's name, formula ordered and date. On 6/1/2023 at 12:45 PM V2, Director of Nursing, stated that she expects the feeding bottles to be filled in prior to administration of feeding. V2 stated that she would expect the staff to flush the g tube before and after administration of medication. V2 stated that the facility only checks placement every eight hours but that she would expect the nurses to follow the policy. V2 stated that R10 has an order to be off the feeding for an hour and that is what she expects. The facility's Tube Feeding policy, dated 7/2018 documents Procedure: 5c. Flush prior to administering medication, in between and after all medication with approximately 15cc of water. 7. Label the feeding bag with the resident's name, formula ordered and date. The facility's Enteral Tube Medication Administration Procedures, dated 2/18/2023, documents Procedure 2. Prepare medications for administration. 4. Wash hands and apply gloves. 5. Verify tube feeding placement per tube feeding policy. 6. Stop enteral feeding and flush tube with at approximately 15 ml of water prior to administration of water each dose unless fluid restriction.

Based on observation, interview and record review, the facility failed to provide adequate supervision to 2 of 6 residents (R2, R11) reviewed for falls in the sample of 11. This failure resulted in R2 having falls on two separate dates, both times requiring her to be sent to the emergency room and receiving 8 sutures to her head and a cervical fracture (C6) after the first fall on 2/17/22 and 12 sutures to her forehead on 6/11/22. Findings include: 1. On 6/15/22 at 5:33 AM R2 was lying in her bed and was noted to have a gauze dressing covering her forehead. V14, Certified Nursing Assistant (CNA), and V15, CNA, were boosting R2 up in bed. V14 stated when R2 is up in her wheelchair (w/c) she is never left alone in her room because she will try to stand up without assist and has had multiple falls. R2's Face Sheet documents her diagnoses to include [CONDITION(S)], Pain, Unspecified Diastolic (Congestive) Heart Failure, Unspecified [CONDITION(S)], Alzheimer's Disease, Type 2 Diabetes Mellitus, Generalized Anxiety, Unspecified Sequelae of Cerebral Infarction, and [CONDITION(S)]. R2's Minimum Data Set (MDS) dated [DATE] documents her Brief Interview for Mental Status score as 9, indicating she is moderately cognitively impaired. The MDS further documents R2 requires extensive assist of 2 persons for bed mobility, transfers, and toileting, and is dependent for locomotion on and off the unit. The assessment documents R2 had no functional limitations to her upper or lower extremities and her balance during surface-to-surface transfers is not steady and she is only able to stabilize with staff assistance. Per this assessment R2 is always incontinent of bowel and bladder. R2's Care Plan dated 8/26/16 with the goal date of 7/12/22 documents, Safety Notes: I would like to keep my alarms in place at this time. I am a fall risk due to my history of falls and diagnoses of Convulsions, s/p (status post) [CONDITION(S)] (Cerebral Vascular Accident) and [CONDITION(S)]. I do have alarms on my bed due to my poor safety awareness. I have tried to stand by myself before. I do have assist bars on my bed to help with bed mobility. Keep items that I frequently use within my reach but keep area free of clutter and safety hazards. Please offer me activities throughout the day. Please put on gripper socks on me while in bed as tolerated. 2/17/22 Please make sure my alarm is working as it has been replaced due to my fall. 6/11/22 Please assist me to a common area while up in (high backed) wheelchair. 6/11/22 Remind staff if I'm standing, attempting to stand up on my own to place me in a common area. 6/12/22 Observe my laceration to my forehead for s/s (signs/symptoms) of infection and pain. Notify MD (Medical Doctor) of my changes in condition-treatment as ordered-remove my 12 sutures in one week as ordered. R2's Care Plan further documents, under Mobility/Transfers: I am an assist of 2 with a total lift for transfers. I have a history of a broken femur and had surgery for this fracture of pelvis. Brand name of chair (high back reclining wheel chair) for comfort. R2's Morse Fall Scale dated 6/11/22 documents her score as 90, indicating she is at high risk for falls. R2's Progress Note dated 2/17/22 at 4:51 PM documents, CNAs called nurse into resident's room-lying on the floor with large pool of blood under her head. Large lacerations on both sides of head and forehead-had been sitting in chair (high back reclining wheelchair). Alarm in place but not sounding. Family, Medical Doctor (MD), ambulance called. Blood noted on corner of bedside table. R2's Progress Note dated 2/18/22 at 10:01 AM documents, Resident remains on follow-up from fall on 2/17/22 with injuries noted to head, staples intact to three lacerations on head, pressure dressing in place, clean, dry, intact. Soft cervical collar in place due to C6 fracture (fx). No s/s of pain or distress noted. Neuro checks WNL (within normal limits). Family here at bedside. R2's Serious Injury Incident Report dated 6/11/22 at 9:10 PM documents, Incident Type: Fall; Type of Injury: Laceration-deep; Incident level: unwitnessed; Please see Nurses Notes, Large laceration to mid forehead with large amount of bleeding. Immediate Post Incident Action: Staff education to assist resident to a common area when trying to transfer or stand per self. Place in a common area when up in high backed chair as tolerated. R2's Progress Note dated 6/12/22 at 4:00 AM documents, Late entry for 6/11/22 at 9:10 PM: Staff member, (V19, Unit Aide) came and got writer from another resident's room, saying that resident was attempting to get up independently. As this writer ran to nurses station, heard a large thud and when rounding the corner, witnessed resident lying on the floor in front of her reclined high backed chair. Resident was lying on her right side and noted a large, deep laceration to mid forehead with a large amount of bleeding. Resident assisted onto her back and pressure dressing and ice applied to forehead. Second nurse called resident's daughter, at 9:13 PM and received consent to send resident to (local hospital). Neuro checks initiated and were WNL for this resident. V/S (vital signs) 170/100, 88, 20, 98.0. AROM (Active Range of Motion) /PROM (Passive Range of Motion) to all 4 extremities without signs or symptoms of pain. Ambulance dispatched and arrived at facility at 9:20 PM. Resident placed in c-collar and transferred to stretcher per 4 assist. Resident enroute to (local hospital) at 9:27 PM with daughters to follow. MD made aware. R2's Radiology Report dated 6/11/22 documents, under Impression: 2. Small midline frontal scalp hematoma with associated laceration. On 6/16/22 at 8:36 AM, V19, Unit Assistant (UA), stated she was called into work on 6/11/22 because they were short on staff. V19 stated after dinner she was told to sit with R2, who was in her reclining wheel chair, in front of the nurses station to keep an eye on her. V19 stated she was not familiar with R2, and stated none of the other staff told her R2 tries to stand up by herself or that she is a fall risk. V19 stated any other time she had seen R2 in her chair, R2 was calm or sleeping. V19 stated the two Certified Nursing Assistants (CNAs) who were working that evening were down the hall in resident rooms, V20, Licensed Practical Nurse (LPN) was down the hall passing medications and V21, LPN was outside on the phone. V19 stated when she first approached R2, she could see R2 was wet and R2 smelled strongly of urine. V19 stated she let V6, CNA, know R2 was wet and V6 told her, Well she's just going to have to wait. V19 stated R2 started pulling at her clothes and trying to stand up in front of her wheelchair (w/c), and V19 would tell her, You need to sit down, and R2 would sit down for a minute, then try to get right back up. V19 stated R2 continued to pull at her pants like she was uncomfortable and hitting at V19 for trying to tell her to sit back down. V19 stated she (V19) started yelling loudly, I need help here. She stated she could see V20 down the hall and V20 pointed at her, but then V20 went into a resident's room. V19 stated nobody came and R2 continued to try to stand up, and was starting to try to hit V19, so she (V19) ran as fast as she could down to tell V20 that she needed help because R2 was trying to stand up, and they both ran back to where R2 had been sitting in her chair, but it was too late because R2 was already laying on the floor and her head was bleeding. V19 stated she has never worked in the health field until about two weeks ago when she was hired by the facility as a unit assistant. She stated her job duties include making beds, taking meal orders, assisting residents in wheelchairs to the dining room at breakfast, lunch and dinner, passing trays and picking up finished trays in the dining room. V19 stated she did not think about that she should push R2 in her w/c when she went to look for help, but just felt like she could hurry and get help and get right back to R2. 2. R11's Face Sheet documents her diagnoses to include [CONDITION(S)] Pectoris, Major Depressive Disorder, Gastro-[CONDITION(S)] Reflux Disease, Age Related [CONDITION(S)], Unspecified Dementia with Behavioral Disturbance, and Generalized Anxiety Disorder. R11's MDS dated [DATE] documents she is severely cognitively impaired and requires extensive assist with transfers and toileting. The MDS documents R11 is not steady when moving from seating to standing position, when walking, when turning around when walking, moving on and off toilet, and during surface-to-surface transfers and she is only able to stabilize her balance with staff assist. The MDS further documents R11 is occasionally incontinent of urine. R11's Care Plan dated 12/10/21 with the goal date of 6/8/22 documents: Safety Notes: 1/1 Please place non-skid footwear per my fall as tolerated. 1/14 Observe alarm for function. 1/16 Send to ER to evaluate. Please leave bathroom door cracked with light on as resident tolerates. I do have a history of falls prior to coming to this facility. Due to my dementia and impaired cognition I am at risk for falls. I do not call for assist with transfers or ambulation. I also take [CONDITION(S)] medication daily increasing my risk for falls. Make sure I have nonskid socks or shoes on before transfers or walking. Keep items that I frequently use with in my reach but keep area freeze of clutter and safety hazards. 3/25/22 Due to my fall, please place me in staff's line of sight if awake as tolerated. 4/26/22 Please toilet me in the AM prior to taking me to assisted dining room for meal. R11's Care Plan further documents, under Mobility: I am independent with bed mobility. I have grab assist bars on my bed. I can reposition myself when sitting up in a chair. I am 1 staff assist and gait belt with transfers and ambulation inside the facility. According to the facility's incident log dated 12/15/21 through 6/15/22, R11 has had falls on: 1/1/22 at 5:30 AM in her room. (Intervention- non-skid foot wear) 1/14/22 at 5:00 AM in her room.(Intervention-observe alarm for function) 1/16/22 at 9:45 PM in her room. (ER visit) (Intervention-leave bathroom light on and door cracked as tolerated by resident) 3/25/22 at 8:45 PM in her bathroom (Intervention-place me in staff's line of sight if awake as tolerated) 4/26/22 at 7:00 AM in her room (Intervention-please toilet me in AM prior to going to DR (dining room) V11's Morse Fall Scale dated 4/26/22 documents a score of 95 which indicates she is a high fall risk. On 6/16/22 at 8:36 AM, V19, Unit Assistant (UA), continued on stating she stayed late again last night (6/15/22) to help out and she was told to sit with R11 after dinner until they (CNAs) came to get them. V19 stated R11 had been done in the dining room for about 35 minutes and was asking to go back to her room. V19 stated R11 wanted to go to her room to go to bed and V19 told her she would have to wait a little bit until the CNAs were ready for her. V19 stated R11 started pulling her pants down and trying to take her clothes off while still in the dining room, so V19 called for help. V19 stated V6, CNA, came up to her and told her (V19), You're going to have to fu***** wait because I can't help you right now. You obviously are not a good fit for a job in health care. and then walked away. V19 stated she knows R11 has a history of falls and she was afraid she would fall if she tried to get up because she had pulled her pants down to her knees. V19 stated she talked to V2, Director of Nursing (DON), this morning about what happened, and V2 told her she was sorry it happened to her. On 6/16/22 at 2:45 PM, V1, Administrator, stated she would expect staff to stay with a resident who was trying to stand, who was not safe to stand, until help came. She stated she would not want that staff to leave the resident if they were not safe. V1 also stated she would expect appropriate staff to meet a resident's needs in a timely manner, especially if that resident was demonstrating unsafe behaviors. She stated she would have expected the CNA to take R11 to her room when she was asking to be taken to her room after dinner and CNAs should have provided incontinent care for R2 on 6/11/22 when V19 let them know R2 was wet. On 6/17/22 at 3:10 PM in a phone interview initiated by V1, Administrator, V1 stated, I have evidence I want to tell you about. I watched the video from the time (R2) fell on [DATE] and it showed on that night that (V19) only left (R2) alone for about 15 seconds to go report to the nurse that (R2) was trying to stand up by herself. (V19) was only away from (R2) for those 15 seconds and (R2) fell forward out of her chair onto the floor, striking her head and getting a laceration on her forehead. Hospitals use sitters who are not certified all the time; it was appropriate for (V19), a unit assistant, to be sitting with (R2). The facility's policy, Interdisciplinary Fall Reduction/Injury Prevention Protocol dated 7/12 documents, Intent: An interdisciplinary approach at reducing falls, preventing injury and increasing safety awareness ultimately resulting in improved quality of care for our residents. Recommendations: Safety devices will be checked for placement and functioning by each shift and signed off as in place and functioning on the Flow/MAR (Medication Administration Record). The type of alarm and when it is to be applied should be clear. For example, pressure alarm on when resident in bed, or tabs alarm when resident up in wheelchair. The facility's Job Description: Nursing Assistant (Non-Certified) effective 11/15/13 documents, Performs non-direct care resident activities and services under the direction of the Supervisor. Skills: Must demonstrate knowledge of safety techniques. Experience: A minimum of three months of similar nursing assistant experience in long term care preferred.

Based on observation, interview, and record review, the facility failed to properly store medication, label insulin and discard expired medications. This has the potential to affect all 62 residents living in the facility. Findings include: On 5/17/2022 at 9:15 AM, the North Apple Blossom Street Hall medication cart was inspected. The medication cart contained the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] 1. R10's [MEDICATION(S)] 100 unit/ml (milliliter) Kwikpen without open date. V9, Licensed Practical Nurse (LPN). Verified that the medication was open and in use. On 5/17/2022 at 9:17 AM, V9 stated that the [MEDICATION(S)] should have an open date. V9 stated that the the medication should not be used without the open date. V9 stated that there is a specific time that the medication can be used and this is why the open date is important so that the medication is not used past the ?? days. V9 stated that she would destroy the medication. On 5/18/2022 at 2:05PM, V3, Assistant Director of Nursing (ADON), stated that the insulin, [MEDICATION(S)] has a specific use time once open. V3 stated that the open date or the end date is important and one of them should be on the bottle to let the nurses know when it was open so that the medication won't be used passed its use by date. V3 stated that the expired medications are to be discarded. V3 stated that the nurse is to check the medication expiration date prior to administering medication. This is the triple check system. The [MEDICATION(S)]'s Manufacturer instructions documents In-use Pen: Store the Pen you are currently using at room temperature [up to 86°F (30°C)] and away from heat and light. Throw away the Pen you are using after 28 days, even if it still has insulin left in it. On 5/17/2022 at 9:20 AM, the facility's medication storage room was inspected. The refrigerator, located in the medication storage room contained the following: 2. 1 box of Shingrid [MEDICATION(S)] Vaccine Recomb adjunct with expiration of 5/7/22 3. Open unlabeled with date opened multi dose vial of Moderna COVID Vaccine. 4. Open unlabeled with date opened multi dose [MEDICATION(S)] (TB) vial The medication room also had the following: 5. 4 bottles of [MEDICATION(S)] 50 mcg (micrograms) with expiration date of 1/2022. On 5/17/2022 at 9:24 AM, V9 stated that the bottles of [MEDICATION(S)] and the vial of TB is used for anyone that has an order and not allergic. V9 stated that if there was an order to give the medication she would have used this medication from the medication room and refrigerator. The facility's Medication Storage, policy, dated 11/10, documents Policy: All drugs, treatments, and biological must be stored securely and following the manufacturer's labeled recommendations, or per facility policy. It also documents, Procedure: 12. The following medications must removed from from stock and disposed of properly on a continuous basis: outdated, contaminated, recalled, deteriorated, unlabeled medications, or those with soiled or broken/cracked containers. The Resident Census and Conditions of Residents, CMS 672, dated 5/16/2022 documents that the facility has 62 residents living in the facility.

Based on interview and record review, the facility failed to provide consecutive 8 hour Registered Nurse (RN) coverage in the facility. This has the potential to affect all 62 residents in the facility. Findings include: There was no consecutive 8-hour RN coverage in 24 hours on 1/2/22, 1/11/22, 1/15/22, 1/20/22, 1/30/22, 2/7/22, 2/8/22, 3/6/22, 4/20/22, 4/22/22, 4/23/22, 4/29/22, 5/3/22, 5/7/22, 5/8/22, 5/12/22, 5/17/22. On 5/18/2022 at 11:30 AM, the Nursing Working staffing schedule from 1/1/2022 through 5/18/2022 was reviewed with V3, Assistant Director of Nurses. V3 stated that the facility has had some staffing concerns. V3 stated that they are actively recruiting and currently using agency staff to fill shifts. V3 stated that she does not handle the RN schedules and that RN coverage would need to be discussed with V2, Director of Nurses. V3 stated that V2 is out on medical leave at this time and is not available. On 5/19/2022 at 10:27 AM, V2, Administrator, stated that the facility does not have a staffing policy. V2 stated that they follow state and federal guidelines for staffing. The Resident Census and Conditions of Residents, CMS 672, dated 5/16/2022 documents that the facility has 62 residents living in the facility.

Based on interview and record review, the facility failed to assess, monitor, and provide timely treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in R2 not being sent to the hospital for evaluation of nausea and vomiting until 12 hours after onset of symptoms. R2 expired the next day in the hospital with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Finding include: R2's Face Sheet documents he was admitted to the facility on [DATE] and was discharged on [DATE]. His Face Sheet documents his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Progress Note dated [DATE] at 11:33 PM documents, Resident remains on droplet precautions due to observation/assessment of status due to COVID-19 Public Health Emergency with adherence to CDC/CMS Isolation Guidance. Resident had one episode of emesis. No complaint of upset stomach or discomfort. Abdomen soft and non-tender to touch. Bowel sounds (BS) active x 4. Lungs clear and equal bilaterally. Continues on Mucinex with no adverse side effects (ASE) noted. Will continue to monitor. This progress note was signed by V13, Unlicensed Staff. There were no other progress notes documented in R2's medical record until the next morning at 6:57 AM. R2's Progress Note dated [DATE] at 6:57 AM documents, Nurse called to room because resident moaning and not responding per normal for resident. Resident awake and making moaning noises, will not answer staff with words. Resident is hard of hearing but will normally answer staff appropriately. Decreased LOC (Level of Consciousness). Respirations 24 but does have short periods of apnea, sats vary 84% to 94% on room air. O2 (oxygen) applied per nursing measure and head of bed (HOB) elevated. Lungs clear. Blood pressure ,d+[DATE], heart rate 85, BS+4. Reported resident did have an emesis through the night. Family notified of decline and need to transfer to ER (emergency room ). Ambulance notified. Transfer papers completed. No POLST in chart; full code status. The last vital signs documented for R2 in his medical record before he was assessed and sent to the hospital on [DATE] at 6:57 AM were documented on [DATE] at 3:29 PM in his Progress Notes as ,d+[DATE], 97.6, 86, 16 and 96 %. R2's Resident Transfer Form, untimed, dated [DATE] documents, under, Events or change in condition leading up to request for ER evaluation/ reason for ER visit or reason for consult, emesis; decreased sats (oxygen levels) and decreased LOC. The transfer form documents R2's usual cognition was alert and oriented, confused at times. R2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . This medication was not documented as being given during the month of January. R2's Hospital Records dated [DATE] document his clinical impression as: New onset [CONDITION(S)] with uncontrolled rate, aspiration pneumonia and moderate acute renal failure. R2's Death Certificate dated [DATE] documents R2's date of death as [DATE], and lists his cause of death as [CONDITION(S)], [CONDITION(S)] with Rapid Ventricular Response, and COVID Pneumonia with Aspiration Pneumonia. On [DATE] at 6:00 PM V3, Registered Nurse (RN) stated she was the nurse who sent R2 out to the hospital on [DATE] because he was not acting like himself. V3 stated R2 was usually able to make his needs known but, on that morning, he would not answer simple questions. She stated his pulse ox was in the 80's and his blood pressure was low. V3 stated R2 was sent to the local hospital and admitted with Aspiration Pneumonia and [CONDITION(S)]. V3 stated on the report sheet from the night before, it documented R2 had been stating he felt ill but did not have any specific complaints. She stated the nurse giving her report was V13, who reported R2 had vomited the night before, but didn't have any problems through the night. V3 stated when she had last taken care of R2 a couple of days earlier, he was doing good through his illness with COVID-19. On [DATE] at 1:10 PM during phone interview with V13, unlicensed staff, she stated she did take care of R2 on [DATE] and stated R2 had an emesis and stated she does not do very well with vomit, but it appeared to be undigested food. V13 stated R2 was sitting up at the end of his bed and had vomited onto the floor. She stated she listened to his lungs and they were clear, and his bowel sounds were good. V13 stated she had another nurse who was working that night, V25, Licensed Practical Nurse (LPN), also listen to R2's lungs and she said they were clear too. V13 stated she gave him a [MEDICATION(S)] for nausea but stated she does not remember if she charted it or not and stated R2 didn't have any more complaints that night. V13 stated she gave him medications around 6:00 AM and he was his usual self but stated he was moaning and said he didn't feel good but did not have any specific complaints. V13 stated she found out the next night when she came to work that he had been sent out to the hospital. On [DATE] at 2:40 PM V25, LPN, stated she was working the evening/night shift (6:00 PM to 6:30 AM) on [DATE] and heard R2's bed alarm sounding at about 7:30 PM. She stated she remembers the time because she was just passing her 8:00 PM medications. V25 stated R2 was on the COVID unit, and V13 was his nurse, but when nobody responded to his alarm, she (V25) went down to check on him. V25 stated just as she walked into his room, R2 was sitting on the end of his bed and he vomited. V25 stated there were some undigested pills in the vomit so she assumed he had just taken his medication. V25 stated she yelled for V13 to come to R2's room, but as soon as V13 got to R2's doorway, V13 stated I don't do puke and she refused to come in and assess R2 until it was all cleaned up. V25 stated she assessed R2 and his lungs sounded clear, but he was complaining of being nauseated. V25 stated she does not know if V13 gave R2 anything for nausea because after the UA (unit assistant) and the CNA (Certified Nursing Assistant) got the floor and R2 cleaned up, V13 went into R2's room to assess him, and V25 stated she heard R2 tell V13, I don't feel good. I feel nauseous. V25 stated, during the rest of the shift, while they were at the nurses' desk, she heard the CNA and UA report to V13 that R2 had vomited again around 11:30 PM, and early in the morning the UA told V13 that R2's legs didn't look right. V25 stated she does not know if V13 assessed R2 anymore that night, but she did not see her go into his room again. On [DATE] at 3:23 PM V26, UA, stated she was working with V27, CNA, on [DATE] from 9:30 PM to 5:00 AM on the COVID unit. She stated V25 went into R2's room just as he was throwing up. V26 said V25 informed R2's nurse, V13, that she needed her to come to R2's room because he had vomited, but V13 told her that she does not do vomit, and V13 would not enter R2's room until V26 and V27 got R2, and his floor cleaned up. V26 stated V25 did check R2's lungs when V13 would not come in his room. V26 stated R2 did vomit again through the night, and he was not acting like himself. V26 stated when they would walk by his room, R2 would be hanging part way out of his bed and they had to go in and position him safely in his bed several times. V26 stated R2 was mumbling and not making sense. She stated he became delusional and was talking about a washing machine, but she could not understand what he was saying. She stated she and V27 went to V13 several times with concerns about how R2 was acting and let her know when he vomited again, but stated V13 told them, His lungs are clear .there is nothing I can do about it. V26 stated they continued to report R2's condition to V13, but V13 did not go down and assess R2 when he got sick again. V26 stated she did tell V13 that R2's legs turned a funny color the first time they went in to clean him up; skin tone, purple and pink that looked like a spider web pattern, and V13 told her that was probably because he was sitting up on the side of the bed. V26 stated she and V27 reported to the oncoming staff that R2 had vomited twice during the night, and the oncoming CNAs stated they would let their nurse know. V26 stated she did not know what happened after that because she leaves at 5:00 AM. On [DATE] at 3:30 PM V1, Administrator, confirmed she could not find any documentation of assessments for R2 for [DATE] on night shift to assess for his change in condition after he had emesis earlier on the evening shift. She stated she would have expected the staff to reassess him to ensure he did not continue to have emesis and stated he should have had at least two sets of vital signs, including checking his oxygen levels, on the night shift, because he was on the COVID unit. On [DATE] at 1:47 PM during phone interview, V14, Medical Doctor (MD) stated he had checked with the answering service regarding [DATE] and [DATE] and they did not receive any calls from the facility about R2 having a change of condition on the night shift on those dates. V14 stated if R2 had only had one emesis, and this was not out of the ordinary for him, he would not necessarily expect the facility to call and report that in the middle of the night, but if R2 had continued to have another emesis, and this was not normal for him, they should have called and reported it. V14 stated if R2 was continuing to have s/s (signs and symptoms) that were abnormal for him, or if he was requiring more oxygen and more care due to a change in his condition from his normal baseline, he would expect to be notified. V14 stated he could not say without any doubt that R2's outcome would have been different had the facility called and reported his change in condition sooner, but if he had been sent to the ER earlier when he first had changes in his condition, the sooner he would have received a higher level of care, and the better the outcome he would have expected, quite possibly with a better outcome overall. The facility's policy, Notification of a Change In a Resident's Status revised ,d+[DATE], documents, The attending physician/physician extender (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist) and the resident representative will be notified of a change in a resident's condition, per standards of practice and Federal and/or State regulations. Procedure: 1. Guideline for notification of physician/responsible party (not all inclusive): a. Significant change in / or unstable vital signs (Temperature, B/P, Pulse, Respiration); b. Emesis/diarrhea; e. Symptoms of any infectious process; k. unusual behavior.

Based on observation, interview, and record review the facility failed to provide adequate supervision during toileting to prevent falls for 1 of 3 residents (R1) reviewed for falls in the sample of 3. This failure resulted in R1 falling and sustaining a head injury requiring sutures. Finding includes: R1's February 2017 Physician order [REDACTED]. R1's History and Physical, dated 11/23/16, documents in part [DIAGNOSES REDACTED]. R1's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview of Mental Status (BIMS) of 13, indicating cognition intact. R1's MDS dated [DATE] and 12/12/16 documents R1 requires extensive assistance of 2 persons for toileting and Section G, Functional Status. Coding: 2. Not steady, only able to stabilize with staff assistance, with regard to R1 moving on and off toilet. R1's Care Plan, dated 9/23/2016, documents R1 is a fall risk, has a history of multiples falls prior to admissions, poor safety awareness and visually impaired. The Care Plan documents on 10/5/16, R1 rolled off bed and interventions included a low bed, concave mattress, and anti-skid strips beside R1's bed. The Care Plan documents on 10/14/16, R1 fell attempting to get up independently, and 10/25/16 R1 was found beside the bed on the floor, and alarm was not sounding. The facility's Morse Fall Scale dated 11/15/16 documents R1 having a score of 105 (score of 46 or more indicating high risk for falls). R1's Morse Fall Scale dated 12/8/16 documents R1 having a score of 75. On 2/23/17, R1 had a yellow discoloration to the outer orbital of her right eye. An indentation on R1's mid forehead was visible and R1 stated that was where the sutures were recently removed. Facility Incident Report Form, dated 2/4/17 documents in part, R1 sustained a fall with a laceration, was sent to the ER (emergency room ), where R1 received 7 sutures to R1's right mid forehead laceration. The Incident Report Form further documents CNA (Certified Nursing Assistant) overhead a noise coming from resident (R1) restroom upon entering (R1) on the floor lying on (R1's) Lt (left) side in front of the toilet facing the door. R1's Discharge instructions from ER, dated 2/4/17, documents R1 received sutures to the forehead, findings negative for fracture, was prescribed antibiotic medication, and instructed to follow up with R1's primary care physician. On 2/22/17 at 11:01 AM, E3, Assistant Director of Nursing, stated R1 was in the bathroom on 2/4/17 asking for privacy from E5, CNA. R1 called for CNA after losing balance while trying to pull up R1's pants and R1 should not have been left alone. E3 stated R1 continues to need assistance as R1 is legally blind and dependent on staff. On 2/22/17 at 1:00 PM, E5 stated that on 2/4/17 R1 asked for privacy in the bathroom. E5 stated she stepped outside of visual sight of R1, heard R1 yell out, and upon entering the bathroom, found R1 on the floor. E5 further stated, If a cognitive resident doesn't want staff in the bathroom, a staff member can step out of the bathroom, but have to have visual sight on resident all the time. On 2/23/17 at 10:40 AM, E9, CNA, stated E9 works consistently down the hall in which R1 resides. E9 further stated R1 will stand up even when E9 has been in the bathroom with R1 during care, and (R1) needs to have someone there even before the falls. While in the bathroom, have to ask (R1) to grab the bar in the bathroom, even as you're cueing (R1) and you're waiting for (R1) to go to the bathroom, (R1) won't wait, (R1) just stands up. On 2/23/17 at 10:55AM, E10, CNA stated E10 works consistently with R1 and knows R1 is impulsive, and On a good day (R1) will stand up, grab the bar, even with me in there and tell (R1) to hold on, and (R1) automatically just stands up. E10 further stated, R1 is blind, and should not be left on the toilet alone. On 2/23/17 at 11:30AM, E11, Registered Nurse (RN), stated during the incident involving R1 on 2/4/17, R1 was trying to stand up unassisted after toileting, has a pad alarm on R1's wheelchair, is legally blind, and R1's condition may vary. E11 further stated because R1's pad alarm is not used on the toilet, R1 should not be left on the toilet alone and should be in visual sight during toileting. On 2/23/17 at 11:55 AM, E13, Director of Rehabilitation, stated R1 was screened on 2/6/17, which is what is done for all residents in the event of a fall, and R1 requires assistance of 1 with a gait belt with transfers off of the toilet. On 2/22/17 at 10:00AM, R1 stated R1 got up from the toilet, pulled pants down and put R1's left hand on the bar. R1 stated her pants to be around R1's ankle, and so I let loose and I fell . R1 stated, Said she'll (E5) be right back, I was already on the floor when (E5) came back. R1 further stated R1 was bleeding from the forehead. R1 said she has pain for a few days after the fall, and takes medication on a routine basis for pain. On 2/23/17 at 2:20PM, Z1, Physician, stated given R1's current situation and being legally blind, it's a safety risk, and that R1 should be visually checked on. The Facility's In-service, dated 2/15/17, documents in part, If a resident is not independent with transfers on PCG (Patient Care Guide), cannot be left alone on the toilet. R1's Patient Care Guide with a printed date of 2/22/17, documents in part, Toilet 2. Assistance: 2=One Person Physical Assistance. Facility's undated policy documents Accidents and Incidents will be analyzed for trends or patterns to enable the facility to enhance preventive measures to reduce the occurrence of incidents.