Every finding on record at Evercare of Granite City

Based on interview and record review, the facility failed to care for a dementia resident in a safe manner for 1 of 2 resident (R2) reviewed for abuse in the sample of 10. This failure resulted in R2 sustaining a left humerus fracture. Findings include:Based on interview and record review, the facility failed to care for a dementia resident in a safe manner for 1 of 2 resident (R2) reviewed for abuse in the sample of 10. This failure resulted in R2 sustaining a left humerus fracture. Findings include:R2's admission Record, print date of 12/1/25, documents R2 was admitted on [DATE] with diagnoses of Osteoarthritis and Dementia. R2's Minimum Data Set, dated [DATE], documents R2 is severely cognitively impaired, is dependent on staff for toileting, lower body dressing, chair to bed transfer, is incontinent of bowel and bladder, and has no behaviors. R2's Care Plan, Date Initiated: 05/27/2025, documents, Resident has some memory loss and impaired decision making ability. Dx (diagnosis) dementia. Resident can be resistive to cares, verbally abusive to staff d/t (due to) confusion/dementia. Interventions: dated 5/27/25 revision on 11/4/25. Staff to approach at later time if being combative as able. Inform resident what task you are helping with prior to performing. Staff may need to provide care in pairs if resident is overly stimulated. Refer to psych (psychiatry) as needed. R2's Nursing Note, dated 11/22/2025 2:54 PM, documents, Made aware by CNA (Certified Nurse Aide) staff that he heard a POP while turning and repositioning resident from wheelchair to bed. This nurse assessed resident. Resident noted to be lying in bed on back, holding left arm. resident alert and oriented per usual, verbal, c/o (complaint of) pain to L (left) elbow. No bruising noted to arm; resident stated that the CNA hurt her arm . Limited ROM (range of motion) noted to L arm. Resident noted to have acute pain to L mid-humerus and elbow area. Mild deformity observed to L mid humerus area. Resident rates the pain a 10/10, worsening when area is touched or lifted. Denies numbness or tingling. Distal pulse present, cap (capillary) refill <3 seconds and skin warm. Sensation noted to finger, and able to slowly wiggle fingers, but not able to form a fist at time of incident. Call placed to MD (Medical Doctor) to make aware of incident. New order received to send resident to ER (Emergency Room) for eval/treat (evaluation and treatment). Call placed to 911 for transport. Resident transported to (Regional Hospital). On 11/27/25 at 12:18 PM, V1, Administrator, stated, (R2) did break her arm last Sunday. She was combative with care. I did do an investigation on it and sent in the final report last night. (V4) did not mean to hurt (R2). He has since received training. On 11/27/25 at 1:12 PM, V3, Certified Nurse Aide (CNA), stated, (R2) can become combative. You have to just walk away and left her calm down and then you go back to her. You never make any resident do something they don't want to do. On 11/27/25 at 2:20 PM, V4, CNA, stated, I transferred (R2) to bed using the full mechanical lift by myself. She transferred just fine. I had her on her left side doing peri care. She was being combative. She began to lean over to the edge of the bed. I was trying to get her back into the middle of the bed. She was fighting me. As I was trying to get her back in bed, I heard a pop from her arm. She called out. I ran out of the room and got the nurse. The nurse (V7) examined (R2) and sent her to the hospital. On 12/1/25 at 2:00 PM, V7, Licensed Practical Nurse, stated, (V4) came and got me and told me while he was transferring (R2) he heard her arm pop. When I got into the room, she was in bed. I asked again what happened and (V4) said it happened while he was putting her pants on. I was confusing as to what happened. I assessed her arm, and it was deformed looking. I called 911 and sent her out to the hospital. I have had to tell (V4) before that he is working with older people, and he needs to think about things that he is doing with them like don't push their wheelchair so fast or don't sneak up on them from behind. I don't think he would intentionally hurt anyone. If any resident begins to get combative or refuse care you just leave them be, re-approach them later, or you can see if another staff member can work with them. You never just keep working with them. On 12/2/25 at 2:00 PM, V2, Director of Nurses, stated if a resident is agitated or combative the staff should back away, leave the resident alone, and leave and go get some help. On 12/4/25 at 10:06 AM, V13, Medical Director, stated he expects the residents to be safe. R2's Nursing Note, dated 11/23/2025 11:32 AM, documents, Admitting dx (diagnosis) from (Regional Hospital) is Left distal humerus displaced fx (fractured). R2's Nurses Notes, dated 11/27/2025 09:40 AM, documents, Resident returned from (Regional) Hospital at 7:58 am. R2's Hospital Notes, admission date of 12/22/25, documents, XR (Xray) Elbow Left 3 or more views result date of 11/22/25. Left shoulder / humerus; acute spiral fracture of the left proximal humerus with lateral displacement of approximately one shaft with. No additional fractures noted. The glenohumeral joint remains intact with moderate glenohumeral osteoarthritis. Treatment Plan Note Fracture of left humerus. Assessment & Plan. Ortho (Orthopedics) Trauma consulted. Non-operative management. [NAME] brace. NWB (non-weight bearing) LUE Left Upper Extremity. PT/OT (physical therapy / occupational therapy). The V4, CNA, written statement, undated, documents, While providing care to (R2) on her left side she began falling out of bed. While attempting to get the resident back into a safe position in bed, I heard a loud pop from her left arm, and I heard a loud pop from her left arm, and she called out in pain. I immediately ran to get the nurse. The facility's written interview from V6, CNA, undated, documents, V6 stated she entered the room with V7 LPN. (V4) was crying and saying, I think I broke her arm. V7 assessed R2 and called 911. R2 repeated, He broke my arm. The facility's written interview from V7, dated 11/22/25, documents, V7 stated that V4 pushed R2 to her room in her wheelchair at approx. (approximately) 2:45 PM. V7 stated, Then after a little bit, he came out of the room yelling for me. He was visibly very upset. He looked like he was about to cry. He said, 'I heard a pop when I was repositioning her. I went to the room and assessed (R2). Her upper left arm and elbow looked swollen. It looked like it was deformed. When I went to touch her, she yelled out. (R2) stated, 'he hurt my arm.' I ran down the hall and called 911. The facility's written statement from R1, dated 11/24/25, documents, (V2) interviewed (R1) in her room. At approx. 1:00 PM, I asked (R1) if she was aware of any incident with her roommate on Saturday. (R1) stated, 'yes'. I asked (R1) if she saw anything that had occurred. (R1) stated, 'No the curtain was pulled'. (R1) stated, 'I heard that lady fussing with the man aide (V4)'. She was fussing about her foot. Then I heard her say 'you hurt my arm.' (R1) stated, '(R2) fights and yells with every aide every time she gets care. The Caregiver's Guide to understanding Dementia Behaviors, undated, documents, Agitation refers to a range of behaviors associated with dementia, including irritability, sleeplessness, and verbal or physical aggression. It continues, Most often, agitation is triggered when the person experiences, control being taken from him or her. It continues, Do not try to restrain the person during a period of agitation.

Based on interview and record review the facility failed to implement progressive interventions to reduce falls for 2 out of 9 (R12, R53) residents investigated for accidents in a sample of 34.1. R12's Electronic Medical Record (EMR) undated documents the resident was admitted to the facility on [DATE] and has a medical diagnosis of Parkinson's Disease with Dyskinesia, Dementia, and Alzheimer's Disease. R12's Minimum Data Set (MDS) dated [DATE] documents R12 is moderately cognitively impaired, has an upper and lower extremity on both sides, and needs substantial/maximal assistance with rolling left and right, sitting to lying, lying to sitting on side of bed, and chair/bed to chair transfers. R12's Care Plan Date Initiated 5/23/2025 documents R12 has an increased risk for falls related to impaired mobility, Parkinson's, Cerebrovascular Accident, Hypertension, Alzheimer's, history of falls, Osteoarthritis, incontinence, Bipolar, Anxiety, Major Depressive Disorder with use of psychotropic medication. No new progressive interventions were implemented for R12 after R12's falls on 4/21/2025, 5/17/2025, and 6/25/2025. R12's Fall Risk assessment dated [DATE] documents R12 is at a high risk for falls. R12's Fall Risk assessment dated [DATE] documents R12 is at a high risk for falls. R12's Historical Note dated 10/29/2024 at 6:01 PM documents, Resident had an unwitnessed fall in her room. This nurse was coming to give her medication when resident was found on floor mat by bed. This nurse assessed resident for any pain or head injuries and there was none noted. Once assisted back into chair, resident stated that she did not hit her head upon falling. Resident di state she had some soreness to her left arm and left side. Resident's vital signs were within normal limits. No intervention documented on R12's Care Plan for this fall. R12's Nurses Note (Late Entry) dated 1/25/2025 at 3:00 PM documents, at approx. 3:30pm CNA (Certified Nursing Assistant) waved for this nurse to come to res room. Upon entering room resident was laying on the floor on her right side with left side of her head against dresser. Nurse completed vs (vital signs), ROM (range of motion), pain/skin/injury assessment. neuro assessment. redness and swelling to L (left) side of forehead noted. Hematoma noted to L eye. Res stated, I was trying to get my water. Nurse noted cup of water on res dresser. ROM WNL (withing normal limits). Nurse and CNA assisted res off of floor with gait belt. assisted res up to her bed. Res c/o bilateral pelvic pain by moaning and facial grimacing during assessment. MD (Medical Directory) notified. new order to send to ER (Emergency Room) for evaluation r/t (related to) res possibly hitting head. Res noted to be barefoot. R12's Un-Witnessed Fall Report dated 1/25/2025 at 3:00 PM documents Nursing Description At approx. 3:30pm CNA waved for this nurse to come to res room. Upon entering room resident was laying on the floor on her right side with left side of her head against dresser. Nurse completed vs, ROM, pain/skin/injury assessment. neuro assessment. redness and swelling to L side of forehead noted. Hematoma noted to L eye. Res stated, I was trying to get my water. Nurse noted cup of water on res dresser. ROM WNL. Nurse and CNA assisted res off floor with gait belt. Assisted res up to her bed. Res c/o bilateral pelvic pain by moaning and facial grimacing during assessment. MD notified. New order to send to ER for evaluation r/t res possibly hitting head. Res noted to be barefoot. Resident Description: I was trying to get my water Immediate Action Taken: Resident assessed. Redness and swelling note to L side of forehead, hematoma noted to L eye. no open areas noted. 2A resident to bed with gait belt. Resident then c/o bilateral pelvic pain when assessing BLE AEB moaning and facial grimacing. EMS contacted. Neuro assessment initiated. Pupils equal but sluggish. Ice pack applied to L side of head. EMS arrived approx. 1515 and left enroute to SLU. T-98, R-18, P-67, b/p 118/70 Notes: Care place updated, MD and family notified. Son notified, vs, ROM, neuro check, pain/skin/injury assessment, Res assisted off of floor by nurse and CNA with gait belt, assisted to bed. 911 called. New order to end to ER for eval r/t hitting head. Ice pack applied to L eye. EMS arrived and transported res to ER. Res returned from ER to approx. 22:48 with no new orders. Staff will declutter res. room. staff will ensure res is wearing proper footwear when out of bed, staff will ensure res meals and fluids are within reach. will refer to therapy. Intervention 1/25/2025: staff will declutter resident room, ensure resident is wearing proper footwear when out of bed, staff will ensure resident meals and fluids are within reach, and refer to therapy. No intervention documented on R12's Care Plan for this fall. R12's Progress Note dated 3/3/2025 at 4:40 PM documents, upon hearing the screams for assistance, staff discovered the source of the screams and found the resident in her room on the floor with closet door open. Assessment done in timely manner. No injuries were noted at the time by this writer and 2 additional staff members. No s/s (signs or symptoms) of bleeding, edema or SOB (shortness of breath) thus far. Alert, talkative, and oriented. Neuro checks initiated. Resident xfer safely to w/c (wheelchair) by this writer and staff members. Resident is currently up moving around unit safely, staff readily available to assist, and care plan ongoing. NP (Nurse Practitioner) and DON (Director of Nursing) notified. Per NP, neuro checks and monitor. R12's Witnessed Fall Report dated 3/3/2025 at 4:40 PM documents: Nursing Description At approx. 4:40pm nurse yelling coming from res room. Res roommate was calling for help. She had witnessed this res fall. resident found on the floor in her room in front of her closet door. Assessment done in timely manner, wc noted behind resident. res wearing socks and shoes, room well lit. no clutter. res stated she was looking for food in her closet. Res discussed how she does not like her pureed diet. vs, ROM, pain/skin/injury assessment completed. no c/o pain. no injury noted. res assisted off of floor and up to wc by nurse with gait belt. MD notified and message left for son. Son came to facility to visit notified at that time. Res roommate stated res did not hit her head. Res roommate is alert and oriented. Resident later advised this writer that she was up looking for whole food and did not want the food she gets on her diet order. Immediate Action Taken: MD and res son aware. vs, ROM, pain/skin/injury assessment, neuro check, res xfer safety to w/c by nurse with gait belt. NP notified, will monitor for changes and notify MD as needed. T-97.7, R-20, P-77, b/p 110/70, referred to therapy (PT and ST), med review, anti-roll backs placed on res wc. Notes: Care plan updated, MD and res son aware, vs, ROM WNL, pain/skin/injury assessment, assisted res off of floor by nurse with gait belt up to wc, refer to PT and ST, med review, res had Dysem to wc seat, res has anti tippers to wc, anti-roll backs placed on res wc. Intervention 3/3/2025: medication review, resident to have Dycem to wheelchair seat and anti-roll backs placed on wheelchair. Interventions refer to therapy was used as a previous fall intervention. No intervention documented on R12's Care Plan for this fall. R12's Progress Note dated 3/31/2025 at 9:23 PM documents: This nurse was notified by CNA that resident was on floor. Upon entering room resident was lying on the floor on her right side. Resident was alert and showed no signs of pain or distress. Resident stated that she was walking to other side of room to get her roommates walker. This nurse assessed resident for injuries, no injuries were noted. Resident was lifted to wheelchair by this nurse and CNA. POA (Power of Attorney) and DON were notified. POA and POA requested for resident to be sent to the hospital for further assessment. 911 was called and EMS (Emergency Medical Service) arrived at 8pm. EMT's (Emergency Medical Technician) assessed resident and recommended resident not be transferred to the hospital as all vitals were normal range and there were no physical signs of injury. Resident stated several times that she does not want to go to the hospital. EMT's stated that resident is A/Ox4 (Alert and Oriented) and had the right to refuse the hospital. Resident is being monitored by this nurse with neuro checks started. Resident's son, DON and NP notified of fall. R12's Un-Witnessed Fall Report dated 3/30/2025 at 7:45 PM documents: Nursing Description: This nurse was notified by CNA that resident was on floor. Upon entering room resident was lying on floor on her right side in the middle of the room. Resident was alert and showed no signs of pain or distress. Vs, ROM, neuro check completed, by CNA and nurse with gait belt. assisted to bed. Resident Description Resident stated that she was walking to other side of room to get her roommates walker. Immediate Action Taken: MD and res son called. This nurse assessed resident for injuries, no injuries were noted. vs pain/skin/injury assessment completed, ROM WNL. neuro check. Resident was lifted to wheelchair by this nurse and CNA with gait belt and placed in bed. POA and DON were notified. POA requested for resident to be sent to the hospital for further assessment. 911 was called and EMS arrived at 8 pm. EMT's assessed resident and recommended resident not be transferred to hospital as all vitals were normal range and there were no physical signs of injury. Resident stated several times that she does not want to go to the hospital. EMT's stated that resident is A/Ox4 and had the right to refuse the hospital. Resident is being monitored by this nurse with neuro checks continued. T-98.2, R-16, P-70, B/P 130/66, POA notified. POA agreeable for res to remain at facility. Notes: Care plan updated; SON POA called. MD notified. 911 called. vs, ROM, neuro check, ROM WNL, no injury noted. 911 called per POA request. Ambulance arrived. Res refused transport. Ambulance left. SON notified. SON agreeable to have res remain in facility. Removed roommates walker from room. Res roommate does not utilize walker. Roommate agreeable to removal of walker. Staff will check on re more frequently. Refer to therapy. med review. Will cont. to see psychiatry. Intervention 3/30/2025: remove roommate's walker from room, staff will check on resident more frequently, and continue to see psychiatry. Interventions of refer to therapy and medication review were used as a previous fall intervention. No intervention documented on R12's Care Plan for this fall. R12's Nurses Note dated 4/10/2025 at 2:51 PM documents: CNA informed this nurse that resident was on the floor by heater. Upon entering room resident was sitting on the floor by her wheelchair and in between the heater and her roommates bed. Resident stated she was trying to turn the heat off and slid from her chair. R12's Witnessed Fall Report dated 4/10/2025 at 2:15 PM documents: Nursing Description: At approx. 2:15 pm CNA informed this nurse that resident was on the floor by heater. Upon entering room resident was sitting on the floor by her wheelchair, in between the heater and her roommates bed. Resident stated she was trying to turn the heat off and slide from her chair. vs, ROM, pain/skin/injury assessment completed. Res roommate witnessed fall. Res did not hit her head per roommate. Res assisted off of floor and up to wc by nurse and CNA with gait belt. no c/o pain. no injury noted. Resident Description: Resident stated she was trying to turn the heat of and slid from her chair to the floor. Resident stated she did not hurt anything. Res roommate stated that res did not hit her head. Immediate Action Taken: MD and res son notified. vs, ROM pain/skin/injury Assessment completed, no injuries noted at this time. Resident denies pain or discomfort. VS-165/72 bp, 72 hr., 97.8 temp, 20 resp, 96% o2. Resident placed back in wheelchair via 2 person assist. No new orders from MD. Notes: Care plan updated, MD and res son notified, Will consult with family about option of hospice care. vs, ROM, pain/skin/injury assessment, bed in low position, fall matt, canoe mattress, Dysem in wc seat, anti-roll backs on wc. res assisted off floor by nurse and CNA with gait belt. ss assisted in meeting with both residents to discuss keeping the heater at a temperature they both are agreeable to. Intervention 4/10/2025: consult with family about hospice care option, bed in low position, fall matt, canoe mattress. Interventions Dycem in wheelchair seat and anti-roll backs to wheelchair previously used as fall interventions. No intervention documented on R12's Care Plan for this fall. R12's Nurses Note dated 4/17/2025 at 2:40 PM documents: Staff was called to patient's room around 2:40pm. Patient was found on the floor on left lateral side. No bleeding, skin tears, bruising, extremities deformities, SOB or decline of LOC (loss of consciousness) noted during assessment. Patient denies pain. Currently resting in bed watching TV (television), call light in reach, and care plan ongoing. R12's Un-Witnessed Fall Report dated 4/17/2025 at 2:30 PM documents Nursing Description: Staff was called to patient's room around 2:40pm. Resident was found by staff lying on her left side on the floor between the dresser and the bed. Res was partially on the fall mat. Res stated, I tried to get up, but I failed. Resident was assessed, vs, ROM, neuro check, pain/skin/injury. no new injury noted, and resident was xferred safely from floor to bed by nurse with gait belt. MD and hospice notified. Resident Description: Resident stated I tried to get up, but I failed. Immediate Action Taken: MD and res son notified. Vitas hospice notified. VS B/P 131/78, P 76, R 18, O2 95%, T 97.3. ROM, neuro check, pain/skin/injury assessment. no injury. consult with hospice, med review by hospice, no new orders. Family does not want res sent to hospital. Fall mat in place, bed in low position, canoe mattress on bed. Notes: Care plan updated. MD and vitas hospice notified, son notified, VS B/P 131/78, P 76, R18, O2 95%, T 97.3. ROM, neuro check, pain/skin/injury assessment. no injury. consult with hospice, med review by hospice, no new orders. Family does not want res sent to hospital. fall mat in place, bed in low position, canoe mattress on bed. no new orders. ROM WNL. neuro check WNL. Intervention 4/17/2025: consult with hospice, medication review with hospice. No intervention documented on R12's Care Plan for this fall. R12's Nurses Note dated 4/21/2025 at 3:03 PM documents: Staff was called to patient's room around 3:20pm. Patient was found on the fall matt on right lateral side. Patient denies pain. No bleeding, skin tears, bruising, extremities deformities, SOB or decline of LOC noted during assessment. Xferred safely back to bed by staff. Resident stated nothing going on just was trying to sit up and watch TV on the side of the bed. Educated on using call light for staff assistance. Resident is currently lying down in bed, call light in reach, and care plan ongoing. R12's Un-Witnessed Fall Report dated 4/21/2025 at 3:20 PM documents Nursing Description: Nurse was called to res room by CNA around 3:20pm. Patient was found on the fall matt next to her bed, lying on right lateral side. vs, ROM, neuro check, pain/skin/injury assessment completed. Patient denies pain. No bleeding, skin tears, bruising, extremities deformities, SOB or decline of LOC noted during assessment. VS B/P 114/61, R 18, P 65, T 97.2, Res assisted off floor by CNA with gait belt and into bed. MD and hospice notified. Res son notified. Resident Description: Resident stated she was just sitting up watching TV on side of bed and slid off bed. Res it alert but confused. Patient denies pain. Immediate Action Taken: VS B/P 114/61, R 18, P 65, T 97.2, ROM, neuro check, pain/skin/injury assessment completed. Res assisted off floor by CNA with gait belt and into bed. MD and hospice notified. Res son notified. Res has a canoe mattress in place. Bed was in low position. fall mat next to bed. call light in place. Notes Care plan updated, MD and res son notified, Hospice notified. vs, ROM, pain/skin/injury assessment, neuro check, Res assisted off bed by CNA with gait belt. res had bed in low position, canoe mattress in place, fall mat next to bed. med review, consult with hospice. The interventions noted in this fall intervention were used for previous falls. No new interventions noted. No new interventions noted on R12's Care Plan for this fall. R12's Nurses Note dated 4/27/2025 at 4:56 AM documents: This writer was called to resident's room. Resident was found lying on her left side beside her bed. Resident was under the bedside table, with her left leg resting on the legs of the bedside table. Resident states that she was attempting to pull her bedside table closer and the next thing she knew she was on the floor. Resident denies hitting head. Skin assessed. Reddened area noted to left thigh. No active bleeding observed. No open areas noted. ROM performed. Tolerated well. VS obtained. 110/66 64 18 95% RA (room air). No c/o (complaint of) pain or discomfort voiced. Transferred from floor to bed via 2 persons assist. Tolerated well. Resident was educated to utilize call light to ask for assistance. Resident verbalized understanding and performed a return demonstration. Staff was educated to have personal items within reach for ease of accessibility. R12's Un-Witnessed Fall Report dated 4/27/2025 at 4:30 AM documents: Nursing Description: This writer was called to resident's room. Resident was found lying on her left side beside her bed. Res lying on fall mat. Resident was under the bedside table, with her left leg resting on the legs of the bedside table. Resident Description: Resident states that she was attempting to pull her bedside table loser and the next thing she knew she was on the floor. Immediate Action Taken: MD called. pain/skin/injury assessment. ROM, neuro check, Hospice notified. Reddened area noted to left thigh. No active bleeding observed. No open area noted. ROM performed. Tolerated well. VS obtained. 110/66 64 18 95& RA. No c/o pain or discomfort voiced. Transferred from floor to bed via 2 persons assist with gait belt. Tolerated well. Staff was educated to have personal items within reach for ease of accessibility. This writer spoke with patient care coordinator, RN, a vitas nurse. RN stated a nurse would be out to assess patient later in the day. Resident's son was notified at 4:45 AM. Care plan has been updated. res has bed in low position, fall mat in place, canoe mattress on bed. Notes: Care plan updated, MD notified, vitas hospice notified, res son notified, vs, ROM, neuro check, no c/o pain. 0.2 cm x 0.2cm reddened area to l thigh. no new orders from MD. No new orders from hospice. Hospice visited res that morning. no new orders. Fall mat in place, canoe mattress on bed, bed in low position, staff will ensure res belongings are within reach of res when she is in bed. Broda chair when out of bed. Intervention 4/27/2025: Broda chair when out of bed and resident belongings within reach. No intervention documented on R12's Care Plan for this fall. R12's Nurses Note dated 4/30/2025 at 7:09 AM documents This writer was called to resident's room. Resident was found lying on her left side beside her bed. Resident was under the bedside table, with her left leg resting on the legs of the bedside table. Resident states she doesn't know what happened and that she was probably sleepwalking. Resident denies hitting head. Skin assessed. No areas noted. No active bleeding observed. ROM performed. Tolerated well. VS obtained. 110/66 64 18 96%RA. No c/o pain or discomfort voiced. Transferred from floor to bed via 2 persons assist. Tolerated well. R12's Witnessed Fall report dated 4/30/2025 at 3:17 AM documents Nursing Description: Resident was found by staff lying on her left side on the floor between the dresser and the bed. Lying on fall mat. Resident was assessed, ROM, pain/skin/injury assessment. no injuries noted, and resident was transferred with gait belt and 2 aides from floor to bed. Resident Description: Resident stated she was trying to turn the heat oof and slid from her chair to the floor. Resident stated she did no hurt anything. Res roommate stated that res dd not hit her head. Res heater is on the other side of the room. Immediate Action Taken: Skin/pain/injury assessed. No areas noted. vs, no active bleeding observed. ROM performed. Tolerated well. VS obtained. 110/66 64 18 98.4 96% RA. No c/o pain or discomfort voiced. Transferred from floor to bed via 2 persons assist with gait belt. Tolerated well. Physician notified. Vitas notified. Resident's son was notified at 3:37 AM. Care plan has been updated. no new orders. res has fall mat in place, canoe mattress on bed, bed in low position. Notes: Care plan updated, MD and res son notified, vitas hospice notified. no new orders. vs, ROM, pain/skin/injury assessment. no injury, res roommate witnessed fall. res did not hit her head. Staff educated to check on res frequently and to ensure temperature in room is comfortable for both residents. Intervention 4/30/2025: ensure temperature in room is comfortable for both residents. Intervention staff to check on resident frequently was placed as an intervention for previous fall. No intervention documented on R12's Care Plan for this fall. R12's Nurses Note dated 5/17/2025 at 6:11 AM documents: This writer was called to resident's room. Resident was found lying on her left side beside her bed. Skin assessed. Reddened area noted to left forearm. No active bleeding observed. No open areas noted. ROM performed. Tolerated well. VS obtained. 110/66 64 18 95%RA. No c/o pain or discomfort voiced. Transferred from floor to bed via 2 persons assist. Tolerated well. Resident was educated to utilize call light to ask for assistance. Resident verbalized understanding and performed a return demonstration. R12's Un-Witnessed Fall report dated 5/17/2025 at 5:10 AM documents Nursing Description: This writer was called to resident's room by CNA. Resident was found lying on her left side on fall mat beside her bed. Nurse completed vs, ROM, pain/skin/injury assessment, neuro check. res verbal. No s/s of distress. no c/o pain. small reddened circular area noted to L forearm approx. 0.5 cm x 0.5 cm. MD, resp party son called, vitas hospice notified. res assisted off floor by nurse and CNA with gait belt. assisted to bed. Res unable to explain what happened. Resident Description: Resident unable to give description. Immediate Action Taken: Skin assessed. Reddened area noted to left forearm. Approx. 0.5cm x 0.5cm. No active bleeding observed. No open areas noted. ROM performed. Tolerated well, neuro check. VS obtained. 110/66 64 18 95% RA. No c/o pain or discomfort voiced. Transferred from floor to bed via 2 person assist with gait belt. Tolerated well. Physician notified. Vitas notified. The Resident's son was notified. Care plan has been updated. Consult with hospice re fall safety. Notes: Care plan updated., MD notified, res son notified, Vitas hospice notified. vs, ROM, pain/skin/injury assessment, neuro check. 0.5cm x 0.5cm circular red area to L FA. no open areas. Will observe area for s/s of infection. bed in lowest position, fall mat in place next to bed, canoe mattress on bed, consult with hospice re fall safety. medication review. The interventions noted in this fall intervention were used for previous falls. No new interventions noted. No new interventions noted on R12's Care Plan for this fall. R12's Nurses Note dated 5/28/2025 at 1:31 PM documents resident noted on the floor in bedroom at side of the bed. resident laying on right side. resident stated that she was attempting to get up. alert and oriented x 2, able to make needs known to staff, verbal, no voiced c/o pain at time of incident. full rom noted to all extremities, weakness noted to bilateral lower extremities. no injuries or bruising noted at the time of the incident. VS: 98.0 82 18 132/67 96%-room air. R12's Un-Witnessed Fall report dated 5/28/2025 at 1:30 PM documents Nursing Description: At approx. 1:30 pm CNA found res on floor in her room and called for nurse LPN. LPN found res on the floor in her room. Lying on her left side on her fall mat next to her bed. vs, ROM, pain/skin/injury assessment completed. No injury noted. Neuro check wnl. res assisted off of floor by nurse with gat belt. Placed in bed. Bed in low position. Canoe mattress on bed. MD and hospice notified. Res son notified. Resident Description: Resident unable to give description. Immediate Action Taken: MD, res son notified, Vitas hospice notified. no injury noted. Res will not be sent to ER per hospice and res son. neuro check, ROM WNL, neuro check WNL, vital signs, pain/skin/injury assessment. VS: 98.0 82 18 132/67 96%-o2 sat Res will be placed Broda chair provided by hospice and placed near nurse's station when out of bed. Notes: Care plan updated. MD, res son, Vitas hospice notified. vs, ROM, ROM WNL, neuro check, neuro check WNL, pain/skin/injury assessment, no injury noted. res assisted off floor by nurse with gait belt and placed in bed. Res unable to explain what had happened. Items res uses often were within reach. canoe mattress on bed, bed in low position, fall mat in place next to bed. Consult with hospice re res safety, broad chair provided by hospice. Res will be placed in broad chair when out of bed and placed near nurse's station. Intervention 5/28/2025 documents place in Broda chair when out of bed and near nurses station. Consults with hospice and Broda chair provided by hospice previously used as a fall intervention. R12's Nurses Note dated 6/4/2025 at 6:03 PM documents CNA came to this nurse stating that resident was on the floor. This nurse went to res. room & saw her on the floor. This nurse asked res. did she hit her head & she stated no. This nurse & aides got her back in bed. Res. was assessed with no signs of injury. R12's Un-Witnessed Fall report dated 6/4/2025 at 5:45 AM documents Nursing Description: At approx. 5:45 am CNA came to this nurse stating that resident was on the floor. Nurse entered res room to find res lying on her left side, on floor mat next to her bed. Bed in low position. canoe mattress on bed. Res unable to explain what happened. vs taken, ROM, neuro check, pain/skin/injury assessment completed. no injuries. res assisted off floor by nurse and CNA with gait bed. placed in bed. Resident Description: Resident unable to give description. Immediate Action Taken: MD and res on notified, vs, pain/skin/injury assessment completed. ROM WNL, neuro check WNL. Vitas Hospice Res. Transferred by this nurse & aides & placed back in bed with gait belt. This nurse assessed res. for any signs of injuries a& there were none. V/s taken & are WNL. Consult with hospice re fall safety, fall mat in place, canoe mattress on bed, bed in lowest position. Hospice to complete a medication review. Staff to ensure res is positioned properly in bed before exiting room. T-97, R-16, P-71, b/p 120/19. Notes: MD and res son notified. Vitas hospice notified, vs, ROM, pain/skin/injury assessment completed, ROM WNL, neuro check WNL, no injury noted. hospice consulted re fall safety, fall mat in place next to bed, canoe mattress on bed, bed in lowest position., right side of bed against wall, hospice to perform medication review. Nsg. staff to ensure res is positioned properly in bed prior to leaving room. Intervention dated 6/4/2025 on R12's Care Plan documents make sure resident positioned properly in bed. Intervention medication review by hospice used as previous fall intervention. R12's Nurses Note dated 6/25/2025 at 4:10 PM documents Unwitnessed Fall: This writer was informed that resident was on the floor around 4:12 pm. No witness was presented when resident went from the bed to the floor. Resident was observed to be sitting upright on the floor with precaution fall mat under buttock and lower extremities. Resident told this writer that she attempted to get up and walk. Resident educated on using call light for staff assistance w/ transfers. Full body assessment performed. No deformities to BUE/BLE, bruising, bleeding, wounds or skin tears present at this time. Resident xferred safely from floor to high back chair by staff x3. VS B/P 108/61, P 72, R 18, T 97.1, & O2 97%/ RA. Hospice notified. Per hospice no neuro checks required and monitor resident in house. R12's Un-Witnessed Fall report dated 6/25/2025 at 4:12 PM documents: Nursing Description: Unwitnessed Fall: This writer was informed that resident was on the floor around 4:12 pm. No witness was presented when resident went from the bed to the floor. Resident was observed to be sitting upright on the floor with precaution fall mat under buttock and lower extremities. Resident told this writer that she attempted to get up and walk. Full body assessment performed. No deformities to BUE/BLE, bruising, bleeding, wounds or skin tears present at this time. Resident xferred safely from floor to Broda chair by staff x3 with fait belt. VS B/P 108/61, P 72, T 97.1, & O2 97% RA. Hospice notified. Per hospice no neuro checks required and monitor resident in house. DON notified. Attempted to notify family unsuccessful. left message. Resident Description: I wanted to get up and walk. Immediate Action Taken: MD notified. message left for res son. ROM, no injury noted. VS B/P 108/61, P 72, T 97.1, & O2 97% RA. Resident xferred safely from floor to Broda chair by staff x3 with gait belt. pain/skin/injury assessment. No c/o pain. no new orders from hospice. res will remain in house. res has bed in low position, canoe mattress on bed. Fall mat on floor next to bed. Hospice to complete med review. Notes: Care Plan updated; MD notified. vs, ROM, pain/skin/injury assessment, no injury. res vitas hospice notified. consult with vitas hospice re res safety and anxiety. med review by hospice. Res has canoe mattress on bed, fall mat next to bed, bed in lowest position when res in bed. Res to be placed up in Broda chair PRN and seated near nurses station. The interventions noted in this fall intervention, resident to be placed in Broda chair and seated at nurse's station, and consult with hospice were used for previous falls. No new interventions noted on R12's Care Plan for this fall. R12/'s Nurses Note dated 7/2/2025 at 2:33 PM documents: Res. just had a fall. Res. stated that she didn't fall she slid out of her bed while trying to turn over. Res. states that she didn't hit her head & has no c/o pain or discomfort noted. No bruises or abrasions noted. V/S: 128/72, 18, 97.3 & O2 @97%. DON is aware & hospice is aware of the fall. New bed is being ordered for res. through hospice services. R12's Un-Witnessed Fall report dated 7/2/2025 at 2:35 PM documents: Nursing Description: Hospice social worker came in for visit & noticed res. was on the floor. This nurse went in & saw res. on the floor mat that's next to her bed. Res was lying on her right side. vs taken, ROM, neuro check, pain/skin/injury assessment completed. no injury noted. hospice nurse completed assessment as well. res assisted off the floor by nurse with gait belt. assisted back to bed and positioned comfortably. res has canoe mattress on bed. fall mat next to be

Based on interview and record review the facility failed to revise care plans with progressive intervention following falls for 2 out of 9 (R12, R53) residents investigated for accidents in a sample of 34.1. R12's Electronic Medical Record (EMR) undated documents the resident was admitted to the facility on [DATE] and has a medical diagnosis of Parkinson's Disease with Dyskinesia, Dementia, and Alzheimer's Disease. R12's Minimum Data Set (MDS) dated [DATE] documents R12 is moderately cognitively impaired, has an upper and lower extremity on both sides, and needs substantial/maximal assistance with rolling left and right, sitting to lying, lying to sitting on side of bed, and chair/bed to chair transfers. R12's Care Plan Date Initiated 5/23/2025 documents R12 has an increased risk for falls related to impaired mobility, Parkinson's, Cerebrovascular Accident, Hypertension, Alzheimer's, history of falls, Osteoarthritis, incontinence, Bipolar, Anxiety, Major Depressive Disorder with use of psychotropic medication. R12's Fall Risk assessment dated [DATE] documents R12 is at a high risk for falls. R12's Fall Risk assessment dated [DATE] documents R12 is at a high risk for falls. The resident had 5 interventions for 15 falls from 10/24/2024 until 9/5/2025. R12's Historical Note dated 10/29/2024 at 6:01 PM documents, Resident had an unwitnessed fall in her room. This nurse was coming to give her medication when resident was found on floor mat by bed. This nurse assessed resident for any pain or head injuries and there was none noted. Once assisted back into chair, resident stated that she did not hit her head upon falling. Resident di state she had some soreness to her left arm and left side. Resident's vital signs were within normal limits. No intervention documented on R12's Care Plan for this fall. R12's Nurses Note (Late Entry) dated 1/25/2025 at 3:00 PM documents, at approx. 3:30pm CNA (Certified Nursing Assistant) waved for this nurse to come to res room. Upon entering room resident was laying on the floor on her right side with left side of her head against dresser. Nurse completed vs (vital signs), ROM (range of motion), pain/skin/injury assessment. neuro assessment. redness and swelling to L (left) side of forehead noted. Hematoma noted to L eye. Res stated, I was trying to get my water. Nurse noted cup of water on res dresser. ROM WNL (withing normal limits). Nurse and CNA assisted res off of floor with gait belt. assisted res up to her bed. Res c/o bilateral pelvic pain by moaning and facial grimacing during assessment. MD (Medical Directory) notified. new order to send to ER (Emergency Room) for evaluation r/t (related to) res possibly hitting head. Res noted to be barefoot. R12's Un-Witnessed Fall Report dated 1/25/2025 at 3:00 PM documents Nursing Description At approx. 3:30pm CNA waved for this nurse to come to res room. Upon entering room resident was laying on the floor on her right side with left side of her head against dresser. Nurse completed vs, ROM, pain/skin/injury assessment. neuro assessment. redness and swelling to L side of forehead noted. Hematoma noted to L eye. Res stated, I was trying to get my water. Nurse noted cup of water on res dresser. ROM WNL. Nurse and CNA assisted res off floor with gait belt. Assisted res up to her bed. Res c/o bilateral pelvic pain by moaning and facial grimacing during assessment. MD notified. New order to send to ER for evaluation r/t res possibly hitting head. Res noted to be barefoot. Resident Description: I was trying to get my water Immediate Action Taken: Resident assessed. Redness and swelling note to L side of forehead, hematoma noted to L eye. no open areas noted. 2A resident to bed with gait belt. Resident then c/o bilateral pelvic pain when assessing BLE AEB moaning and facial grimacing. EMS contacted. Neuro assessment initiated. Pupils equal but sluggish. Ice pack applied to L side of head. EMS arrived approx. 1515 and left enroute to SLU. T-98, R-18, P-67, b/p 118/70 Notes: Care place updated, MD and family notified. Son notified, vs, ROM, neuro check, pain/skin/injury assessment, Res assisted off of floor by nurse and CNA with gait belt, assisted to bed. 911 called. New order to end to ER for eval r/t hitting head. Ice pack applied to L eye. EMS arrived and transported res to ER. Res returned from ER to approx. 22:48 with no new orders. Staff will declutter res. room. staff will ensure res is wearing proper footwear when out of bed, staff will ensure res meals and fluids are within reach. will refer to therapy. No intervention documented on R12's Care Plan for this fall. R12's Progress Note dated 3/3/2025 at 4:40 PM documents, upon hearing the screams for assistance, staff discovered the source of the screams and found the resident in her room on the floor with closet door open. Assessment done in timely manner. No injuries were noted at the time by this writer and 2 additional staff members. No s/s (signs or symptoms) of bleeding, edema or SOB (shortness of breath) thus far. Alert, talkative, and oriented. Neuro checks initiated. Resident xfer safely to w/c (wheelchair) by this writer and staff members. Resident is currently up moving around unit safely, staff readily available to assist, and care plan ongoing. NP (Nurse Practitioner) and DON (Director of Nursing) notified. Per NP, neuro checks and monitor. R12's Witnessed Fall Report dated 3/3/2025 at 4:40 PM documents: Nursing Description At approx. 4:40pm nurse yelling coming from res room. Res roommate was calling for help. She had witnessed this res fall. resident found on the floor in her room in front of her closet door. Assessment done in timely manner, wc noted behind resident. res wearing socks and shoes, room well lit. no clutter. res stated she was looking for food in her closet. Res discussed how she does not like her pureed diet. vs, ROM, pain/skin/injury assessment completed. no c/o pain. no injury noted. res assisted off of floor and up to wc by nurse with gait belt. MD notified and message left for son. Son came to facility to visit notified at that time. Res roommate stated res did not hit her head. Res roommate is alert and oriented. Resident later advised this writer that she was up looking for whole food and did not want the food she gets on her diet order. Immediate Action Taken: MD and res son aware. vs, ROM, pain/skin/injury assessment, neuro check, res xfer safety to w/c by nurse with gait belt. NP notified, will monitor for changes and notify MD as needed. T-97.7, R-20, P-77, b/p 110/70, referred to therapy (PT and ST), med review, anti-roll backs placed on res wc. Notes: Care plan updated, MD and res son aware, vs, ROM WNL, pain/skin/injury assessment, assisted res off of floor by nurse with gait belt up to wc, refer to PT and ST, med review, res had Dysem to wc seat, res has anti tippers to wc, anti-roll backs placed on res wc. No intervention documented on R12's Care Plan for this fall. R12's Progress Note dated 3/31/2025 at 9:23 PM documents: This nurse was notified by CNA that resident was on floor. Upon entering room resident was lying on the floor on her right side. Resident was alert and showed no signs of pain or distress. Resident stated that she was walking to other side of room to get her roommates walker. This nurse assessed resident for injuries, no injuries were noted. Resident was lifted to wheelchair by this nurse and CNA. POA (Power of Attorney) and DON were notified. POA and POA requested for resident to be sent to the hospital for further assessment. 911 was called and EMS (Emergency Medical Service) arrived at 8pm. EMT's (Emergency Medical Technician) assessed resident and recommended resident not be transferred to the hospital as all vitals were normal range and there were no physical signs of injury. Resident stated several times that she does not want to go to the hospital. EMT's stated that resident is A/Ox4 (Alert and Oriented) and had the right to refuse the hospital. Resident is being monitored by this nurse with neuro checks started. Resident's son, DON and NP notified of fall. R12's Un-Witnessed Fall Report dated 3/30/2025 at 7:45 PM documents: Nursing Description: This nurse was notified by CNA that resident was on floor. Upon entering room resident was lying on floor on her right side in the middle of the room. Resident was alert and showed no signs of pain or distress. Vs, ROM, neuro check completed, by CNA and nurse with gait belt. assisted to bed. Resident Description Resident stated that she was walking to other side of room to get her roommates walker. Immediate Action Taken: MD and res son called. This nurse assessed resident for injuries, no injuries were noted. vs pain/skin/injury assessment completed, ROM WNL. neuro check. Resident was lifted to wheelchair by this nurse and CNA with gait belt and placed in bed. POA and DON were notified. POA requested for resident to be sent to the hospital for further assessment. 911 was called and EMS arrived at 8 pm. EMT's assessed resident and recommended resident not be transferred to hospital as all vitals were normal range and there were no physical signs of injury. Resident stated several times that she does not want to go to the hospital. EMT's stated that resident is A/Ox4 and had the right to refuse the hospital. Resident is being monitored by this nurse with neuro checks continued. T-98.2, R-16, P-70, B/P 130/66, POA notified. POA agreeable for res to remain at facility. Notes: Care plan updated; SON POA called. MD notified. 911 called. vs, ROM, neuro check, ROM WNL, no injury noted. 911 called per POA request. Ambulance arrived. Res refused transport. Ambulance left. SON notified. SON agreeable to have res remain in facility. Removed roommates walker from room. Res roommate does not utilize walker. Roommate agreeable to removal of walker. Staff will check on re more frequently. Refer to therapy. med review. Will cont. to see psychiatry. No intervention documented on R12's Care Plan for this fall. R12's Nurses Note dated 4/10/2025 at 2:51 PM documents: CNA informed this nurse that resident was on the floor by heater. Upon entering room resident was sitting on the floor by her wheelchair and in between the heater and her roommates bed. Resident stated she was trying to turn the heat off and slid from her chair. R12's Witnessed Fall Report dated 4/10/2025 at 2:15 PM documents: Nursing Description: At approx. 2:15 pm CNA informed this nurse that resident was on the floor by heater. Upon entering room resident was sitting on the floor by her wheelchair, in between the heater and her roommates bed. Resident stated she was trying to turn the heat off and slide from her chair. vs, ROM, pain/skin/injury assessment completed. Res roommate witnessed fall. Res did not hit her head per roommate. Res assisted off of floor and up to wc by nurse and CNA with gait belt. no c/o pain. no injury noted. Resident Description: Resident stated she was trying to turn the heat of and slid from her chair to the floor. Resident stated she did not hurt anything. Res roommate stated that res did not hit her head. Immediate Action Taken: MD and res son notified. vs, ROM pain/skin/injury Assessment completed, no injuries noted at this time. Resident denies pain or discomfort. VS-165/72 bp, 72 hr., 97.8 temp, 20 resp, 96% o2. Resident placed back in wheelchair via 2 person assist. No new orders from MD. Notes: Care plan updated, MD and res son notified, Will consult with family about option of hospice care. vs, ROM, pain/skin/injury assessment, bed in low position, fall matt, canoe mattress, Dysem in wc seat, anti-roll backs on wc. res assisted off floor by nurse and CNA with gait belt. ss assisted in meeting with both residents to discuss keeping the heater at a temperature they both are agreeable to. No intervention documented on R12's Care Plan for this fall. R12's Nurses Note dated 4/17/2025 at 2:40 PM documents: Staff was called to patient's room around 2:40pm. Patient was found on the floor on left lateral side. No bleeding, skin tears, bruising, extremities deformities, SOB or decline of LOC (loss of consciousness) noted during assessment. Patient denies pain. Currently resting in bed watching TV (television), call light in reach, and care plan ongoing. R12's Un-Witnessed Fall Report dated 4/17/2025 at 2:30 PM documents Nursing Description: Staff was called to patient's room around 2:40pm. Resident was found by staff lying on her left side on the floor between the dresser and the bed. Res was partially on the fall mat. Res stated, I tried to get up, but I failed. Resident was assessed, vs, ROM, neuro check, pain/skin/injury. no new injury noted, and resident was xferred safely from floor to bed by nurse with gait belt. MD and hospice notified. Resident Description: Resident stated I tried to get up, but I failed. Immediate Action Taken: MD and res son notified. Vitas hospice notified. VS B/P 131/78, P 76, R 18, O2 95%, T 97.3. ROM, neuro check, pain/skin/injury assessment. no injury. consult with hospice, med review by hospice, no new orders. Family does not want res sent to hospital. Fall mat in place, bed in low position, canoe mattress on bed. Notes: Care plan updated. MD and vitas hospice notified, son notified, VS B/P 131/78, P 76, R18, O2 95%, T 97.3. ROM, neuro check, pain/skin/injury assessment. no injury. consult with hospice, med review by hospice, no new orders. Family does not want res sent to hospital. fall mat in place, bed in low position, canoe mattress on bed. no new orders. ROM WNL. neuro check WNL. No intervention documented on R12's Care Plan for this fall. R12's Nurses Note dated 4/21/2025 at 3:03 PM documents: Staff was called to patient's room around 3:20pm. Patient was found on the fall matt on right lateral side. Patient denies pain. No bleeding, skin tears, bruising, extremities deformities, SOB or decline of LOC noted during assessment. Xferred safely back to bed by staff. Resident stated nothing going on just was trying to sit up and watch TV on the side of the bed. Educated on using call light for staff assistance. Resident is currently lying down in bed, call light in reach, and care plan ongoing. R12's Un-Witnessed Fall Report dated 4/21/2025 at 3:20 PM documents Nursing Description: Nurse was called to res room by CNA around 3:20pm. Patient was found on the fall matt next to her bed, lying on right lateral side. vs, ROM, neuro check, pain/skin/injury assessment completed. Patient denies pain. No bleeding, skin tears, bruising, extremities deformities, SOB or decline of LOC noted during assessment. VS B/P 114/61, R 18, P 65, T 97.2, Res assisted off floor by CNA with gait belt and into bed. MD and hospice notified. Res son notified. Resident Description: Resident stated she was just sitting up watching TV on side of bed and slid off bed. Res it alert but confused. Patient denies pain. Immediate Action Taken: VS B/P 114/61, R 18, P 65, T 97.2, ROM, neuro check, pain/skin/injury assessment completed. Res assisted off floor by CNA with gait belt and into bed. MD and hospice notified. Res son notified. Res has a canoe mattress in place. Bed was in low position. fall mat next to bed. call light in place. Notes Care plan updated, MD and res son notified, Hospice notified. vs, ROM, pain/skin/injury assessment, neuro check, Res assisted off bed by CNA with gait belt. res had bed in low position, canoe mattress in place, fall mat next to bed. med review, consult with hospice. No intervention documented on R12's Care Plan for this fall. R12's Nurses Note dated 4/27/2025 at 4:56 AM documents: This writer was called to resident's room. Resident was found lying on her left side beside her bed. Resident was under the bedside table, with her left leg resting on the legs of the bedside table. Resident states that she was attempting to pull her bedside table closer and the next thing she knew she was on the floor. Resident denies hitting head. Skin assessed. Reddened area noted to left thigh. No active bleeding observed. No open areas noted. ROM performed. Tolerated well. VS obtained. 110/66 64 18 95% RA (room air). No c/o (complaint of) pain or discomfort voiced. Transferred from floor to bed via 2 persons assist. Tolerated well. Resident was educated to utilize call light to ask for assistance. Resident verbalized understanding and performed a return demonstration. Staff was educated to have personal items within reach for ease of accessibility. R12's Un-Witnessed Fall Report dated 4/27/2025 at 4:30 AM documents: Nursing Description: This writer was called to resident's room. Resident was found lying on her left side beside her bed. Res lying on fall mat. Resident was under the bedside table, with her left leg resting on the legs of the bedside table. Resident Description: Resident states that she was attempting to pull her bedside table loser and the next thing she knew she was on the floor. Immediate Action Taken: MD called. pain/skin/injury assessment. ROM, neuro check, Hospice notified. Reddened area noted to left thigh. No active bleeding observed. No open area noted. ROM performed. Tolerated well. VS obtained. 110/66 64 18 95& RA. No c/o pain or discomfort voiced. Transferred from floor to bed via 2 persons assist with gait belt. Tolerated well. Staff was educated to have personal items within reach for ease of accessibility. This writer spoke with patient care coordinator, RN, a vitas nurse. RN stated a nurse would be out to assess patient later in the day. Resident's son was notified at 4:45 AM. Care plan has been updated. res has bed in low position, fall mat in place, canoe mattress on bed. Notes: Care plan updated, MD notified, vitas hospice notified, res son notified, vs, ROM, neuro check, no c/o pain. 0.2 cm x 0.2cm reddened area to l thigh. no new orders from MD. No new orders from hospice. Hospice visited res that morning. no new orders. Fall mat in place, canoe mattress on bed, bed in low position, staff will ensure res belongings are within reach of res when she is in bed. Broda chair when out of bed. No intervention documented on R12's Care Plan for this fall. R12's Nurses Note dated 4/30/2025 at 7:09 AM documents This writer was called to resident's room. Resident was found lying on her left side beside her bed. Resident was under the bedside table, with her left leg resting on the legs of the bedside table. Resident states she doesn't know what happened and that she was probably sleepwalking. Resident denies hitting head. Skin assessed. No areas noted. No active bleeding observed. ROM performed. Tolerated well. VS obtained. 110/66 64 18 96%RA. No c/o pain or discomfort voiced. Transferred from floor to bed via 2 persons assist. Tolerated well. R12's Witnessed Fall report dated 4/30/2025 at 3:17 AM documents Nursing Description: Resident was found by staff lying on her left side on the floor between the dresser and the bed. Lying on fall mat. Resident was assessed, ROM, pain/skin/injury assessment. no injuries noted, and resident was transferred with gait belt and 2 aides from floor to bed. Resident Description: Resident stated she was trying to turn the heat oof and slid from her chair to the floor. Resident stated she did no hurt anything. Res roommate stated that res dd not hit her head. Res heater is on the other side of the room. Immediate Action Taken: Skin/pain/injury assessed. No areas noted. vs, no active bleeding observed. ROM performed. Tolerated well. VS obtained. 110/66 64 18 98.4 96% RA. No c/o pain or discomfort voiced. Transferred from floor to bed via 2 persons assist with gait belt. Tolerated well. Physician notified. Vitas notified. Resident's son was notified at 3:37 AM. Care plan has been updated. no new orders. res has fall mat in place, canoe mattress on bed, bed in low position. Notes: Care plan updated, MD and res son notified, vitas hospice notified. no new orders. vs, ROM, pain/skin/injury assessment. no injury, res roommate witnessed fall. res did not hit her head. Staff educated to check on res frequently and to ensure temperature in room is comfortable for both residents. No intervention documented on R12's Care Plan for this fall. R12's Nurses Note dated 5/17/2025 at 6:11 AM documents: This writer was called to resident's room. Resident was found lying on her left side beside her bed. Skin assessed. Reddened area noted to left forearm. No active bleeding observed. No open areas noted. ROM performed. Tolerated well. VS obtained. 110/66 64 18 95%RA. No c/o pain or discomfort voiced. Transferred from floor to bed via 2 persons assist. Tolerated well. Resident was educated to utilize call light to ask for assistance. Resident verbalized understanding and performed a return demonstration. R12's Un-Witnessed Fall report dated 5/17/2025 at 5:10 AM documents Nursing Description: This writer was called to resident's room by CNA. Resident was found lying on her left side on fall mat beside her bed. Nurse completed vs, ROM, pain/skin/injury assessment, neuro check. res verbal. No s/s of distress. no c/o pain. small reddened circular area noted to L forearm approx. 0.5 cm x 0.5 cm. MD, resp party son called, vitas hospice notified. res assisted off floor by nurse and CNA with gait belt. assisted to bed. Res unable to explain what happened. Resident Description: Resident unable to give description. Immediate Action Taken: Skin assessed. Reddened area noted to left forearm. Approx. 0.5cm x 0.5cm. No active bleeding observed. No open areas noted. ROM performed. Tolerated well, neuro check. VS obtained. 110/66 64 18 95% RA. No c/o pain or discomfort voiced. Transferred from floor to bed via 2 person assist with gait belt. Tolerated well. Physician notified. Vitas notified. The Resident's son was notified. Care plan has been updated. Consult with hospice re fall safety. Notes: Care plan updated., MD notified, res son notified, Vitas hospice notified. vs, ROM, pain/skin/injury assessment, neuro check. 0.5cm x 0.5cm circular red area to L FA. no open areas. Will observe area for s/s of infection. bed in lowest position, fall mat in place next to bed, canoe mattress on bed, consult with hospice re fall safety. medication review. No intervention documented on R12's Care Plan for this fall. R12's Nurses Note dated 5/28/2025 at 1:31 PM documents resident noted on the floor in bedroom at side of the bed. resident laying on right side. resident stated that she was attempting to get up. alert and oriented x 2, able to make needs known to staff, verbal, no voiced c/o pain at time of incident. full rom noted to all extremities, weakness noted to bilateral lower extremities. no injuries or bruising noted at the time of the incident. VS: 98.0 82 18 132/67 96%-room air. R12's Un-Witnessed Fall report dated 5/28/2025 at 1:30 PM documents Nursing Description: At approx. 1:30 pm CNA found res on floor in her room and called for nurse LPN. LPN found res on the floor in her room. Lying on her left side on her fall mat next to her bed. vs, ROM, pain/skin/injury assessment completed. No injury noted. Neuro check wnl. res assisted off of floor by nurse with gat belt. Placed in bed. Bed in low position. Canoe mattress on bed. MD and hospice notified. Res son notified. Resident Description: Resident unable to give description. Immediate Action Taken: MD, res son notified, Vitas hospice notified. no injury noted. Res will not be sent to ER per hospice and res son. neuro check, ROM WNL, neuro check WNL, vital signs, pain/skin/injury assessment. VS: 98.0 82 18 132/67 96%-o2 sat Res will be placed Broda chair provided by hospice and placed near nurse's station when out of bed. Notes: Care plan updated. MD, res son, Vitas hospice notified. vs, ROM, ROM WNL, neuro check, neuro check WNL, pain/skin/injury assessment, no injury noted. res assisted off floor by nurse with gait belt and placed in bed. Res unable to explain what had happened. Items res uses often were within reach. canoe mattress on bed, bed in low position, fall mat in place next to bed. Consult with hospice re res safety, broad chair provided by hospice. Res will be placed in broad chair when out of bed and placed near nurse's station. Intervention 5/28/2025 documents high back chair provided by Hospice-place in high back chair when out of bed and near nurses station. R12's Nurses Note dated 6/4/2025 at 6:03 PM documents CNA came to this nurse stating that resident was on the floor. This nurse went to res. room & saw her on the floor. This nurse asked res. did she hit her head & she stated no. This nurse & aides got her back in bed. Res. was assessed with no signs of injury. R12's Un-Witnessed Fall report dated 6/4/2025 at 5:45 AM documents Nursing Description: At approx. 5:45 am CNA came to this nurse stating that resident was on the floor. Nurse entered res room to find res lying on her left side, on floor mat next to her bed. Bed in low position. canoe mattress on bed. Res unable to explain what happened. vs taken, ROM, neuro check, pain/skin/injury assessment completed. no injuries. res assisted off floor by nurse and CNA with gait bed. placed in bed. Resident Description: Resident unable to give description. Immediate Action Taken: MD and res on notified, vs, pain/skin/injury assessment completed. ROM WNL, neuro check WNL. Vitas Hospice Res. Transferred by this nurse & aides & placed back in bed with gait belt. This nurse assessed res. for any signs of injuries a& there were none. V/s taken & are WNL. Consult with hospice re fall safety, fall mat in place, canoe mattress on bed, bed in lowest position. Hospice to complete a medication review. Staff to ensure res is positioned properly in bed before exiting room. T-97, R-16, P-71, b/p 120/19. Notes: MD and res son notified. Vitas hospice notified, vs, ROM, pain/skin/injury assessment completed, ROM WNL, neuro check WNL, no injury noted. hospice consulted re fall safety, fall mat in place next to bed, canoe mattress on bed, bed in lowest position., right side of bed against wall, hospice to perform medication review. Nsg. staff to ensure res is positioned properly in bed prior to leaving room. Intervention dated 6/4/2025 on R12's Care Plan documents Med Review-Hospice, make sure resident positioned properly in bed. R12's Nurses Note dated 6/25/2025 at 4:10 PM documents Unwitnessed Fall: This writer was informed that resident was on the floor around 4:12 pm. No witness was presented when resident went from the bed to the floor. Resident was observed to be sitting upright on the floor with precaution fall mat under buttock and lower extremities. Resident told this writer that she attempted to get up and walk. Resident educated on using call light for staff assistance w/ transfers. Full body assessment performed. No deformities to BUE/BLE, bruising, bleeding, wounds or skin tears present at this time. Resident xferred safely from floor to high back chair by staff x3. VS B/P 108/61, P 72, R 18, T 97.1, & O2 97%/ RA. Hospice notified. Per hospice no neuro checks required and monitor resident in house. R12's Un-Witnessed Fall report dated 6/25/2025 at 4:12 PM documents:Nursing Description: Unwitnessed Fall: This writer was informed that resident was on the floor around 4:12 pm. No witness was presented when resident went from the bed to the floor. Resident was observed to be sitting upright on the floor with precaution fall mat under buttock and lower extremities. Resident told this writer that she attempted to get up and walk. Full body assessment performed. No deformities to BUE/BLE, bruising, bleeding, wounds or skin tears present at this time. Resident xferred safely from floor to Broda chair by staff x3 with fait belt. VS B/P 108/61, P 72, T 97.1, & O2 97% RA. Hospice notified. Per hospice no neuro checks required and monitor resident in house. DON notified. Attempted to notify family unsuccessful. left message. Resident Description: I wanted to get up and walk. Immediate Action Taken: MD notified. message left for res son. ROM, no injury noted. VS B/P 108/61, P 72, T 97.1, & O2 97% RA. Resident xferred safely from floor to Broda chair by staff x3 with gait belt. pain/skin/injury assessment. No c/o pain. no new orders from hospice. res will remain in house. res has bed in low position, canoe mattress on bed. Fall mat on floor next to bed. Hospice to complete med review. Notes: Care Plan updated; MD notified. vs, ROM, pain/skin/injury assessment, no injury. res vitas hospice notified. consult with vitas hospice re res safety and anxiety. med review by hospice. Res has canoe mattress on bed, fall mat next to bed, bed in lowest position when res in bed. Res to be placed up in Broda chair PRN and seated near nurses station. Intervention dated 6/25/2025 on R12's Care Plan documents Care plan reviewed with Hospice and Hospice consulted regarding falls, safety, and anxiety. R12/'s Nurses Note dated 7/2/2025 at 2:33 PM documents: Res. just had a fall. Res. stated that she didn't fall she slid out of her bed while trying to turn over. Res. states that she didn't hit her head & has no c/o pain or discomfort noted. No bruises or abrasions noted. V/S: 128/72, 18, 97.3 & O2 @97%. DON is aware & hospice is aware of the fall. New bed is being ordered for res. through hospice services. R12's Un-Witnessed Fall report dated 7/2/2025 at 2:35 PM documents: Nursing Description: Hospice social worker came in for visit & noticed res. was on the floor. This nurse went in & saw res. on the floor mat that's next to her bed. Res was lying on her right side. vs taken, ROM, neuro check, pain/skin/injury assessment completed. no injury noted. hospice nurse completed assessment as well. res assisted off the floor by nurse with gait belt. assisted back to bed and positioned comfortably. res has canoe mattress on bed. fall mat next to bed. bed noted in lowest position. Resident Description: Res. states that she didn't fall she slid out of bed while trying to turn over to her other side. Immediate Action Taken: MD notified. Hospice nurse present. This nurse got res. up from the floor with gait belt. Res. was assessed & no visible injuries noted. V/S were taken & are as follows 128/72, 18, 97.3 & O2 @97%. ROM and neuro check. DON is aware & hospice is aware of the fall. New electric hospital bed with air mattress is being ordered for res. through hospice services. Res currently has canoe mattress fall matts, bed in lowest position. Notes: MD and res son notified. Hospice nurse present. This nurse got res. up from the floor with gait belt. Res. was assessed & no visible injuries noted. V/S were taken & are as follows 128/72, 18, 97.3, O2@97%. ROM and neuro checks. DON is aware & hospice is aware of the fall. New electric hospital bed with air mattress is being ordered for res. through hospice services. fall matts, bed in lowest position. Intervention dated 7/2/2025 on R12's Care Plan documents: Hospice reevaluate and bring different mattress/bed. R12's Nurses Note dated 9/5/2025 at 9:36 AM documents: Resident continues receiving hospice services. No change in condition noted. Resident is A&Ox3 & able to make needs known to staff. Resident needs assist x1 with adls (activities of daily living) and transfers. Resident had a fall this morning while in bed eating breakfast. This nurse assessed resident & she has no visible injuries or bruising noted. This nurse & aide got resident off the floor

Based on interviews and record reviews the facility failed to prevent abuse for 6 out of 8 residents, (R1, R2, R3, R5, R6, R7) reviewed for abuse in a sample of 8. This failure resulted in R2 being hit in the face resulting in a bruised chin, feeling uncomfortable and R5 feeling unsafe in the facility. Findings include: 1. R1's Minimum Data Set (MDS) dated [DATE] documented R1 was cognitively intact, that he has delusions, verbal behavioral symptoms directed towards others occurring daily, rejection of care occurred daily, and wandering occurred daily. R1's MDS continued to document that R1's current behavior status has worsened. R1's Care Plan dated 4/9/25 documented R1 has potential to be physically aggressive related to anger and poor impulse control with interventions placed on 4/9/25 to administer medications as ordered, monitor/document for side effects and effectiveness, analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document, assess and address for contributing sensory deficits, assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain, provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, and encourage seeking out of staff member when agitated. On 4/9/25 R1 was care planned for having the potential to be verbally aggressive related to poor impulse control with interventions placed on 2/3/25 to give the R1 as many choices as possible about care and activities, when the R1 becomes agitated: Intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. R2's face sheet documented he was admitted to the facility on [DATE] with diagnosis of, in part, idiopathic peripheral autonomic neuropathy, major depressive disorder, and atrial fibrillation. R2's MDS dated [DATE] documented he is cognitively intact with no behavioral concerns. R2's Care Plan dated 4/10/25 documented no plan for risk of abuse. R1's face sheet documented he was admitted to the facility on [DATE] with diagnoses of, in part, severe protein calorie malnutrition, schizophrenia and cataract. On 6/23/25 at 10:50 AM, a bruise approximately 3 centimeters in diameter was noted on R2's left lower chin. On 6/23/25 at 11:25 AM, V1, Administrator, and V2, Director of nursing (DON) played a recording of the hallway where the incident on 6/21/25 took place with R2 present. In the video, R2 walked up to the men's restroom door but it was in use, so he walked away, then R1 wheeled up to the restroom and tried to get in. R2 saw R1 at the restroom and walked up to him, bent down with his hands in his pockets, told R1 something and then R1 hit R2's face with a small light colored object grasped in R1's hand approximately the size of his hand, and then again seconds after with a cup of water, the cup making contact with R2's face. The material of the cup could not be identified due to the video quality. After R1 hit R2 twice in the face, V6 (LPN) watched the incident then walked up to the residents and they backed away from each other. On 6/23/25 at 12:30 PM, video footage showed R1 throwing a chair down while R4 was nearby in the room on 6/21/25. The facility's initial report for the abuse investigation dated 6/21/25 documented at approximately 5:00 PM, R1 was in the west unit restroom. When he exited the restroom, he threw a cup with water in it at R2. Residents immediately separated. R1 placed on 1:1. Residents do not reside on the same unit. R2 was noted to have an abrasion to his mouth. MD (medical doctor) notified. ED (executive director) and DON (director of nursing) notified. Residents will remain separated. A full investigation to follow. On 6/23/25 at 10:50 AM, R2 stated he has to use the community men's restroom because he doesn't have one in his room. On Saturday evening, R2 went to use it but someone was in there, so he had to wait. R2 stated he saw R1 try to go in the restroom while the other resident was still in there, so he went up to him and told him not to go in because it was being used and that he had a restroom in his own room if he needed to go. R2 stated R1 then struck him in the face with a metal water bottle and water spilled everywhere. R2 stated he called the local police department and made a report about it. R2 stated he is the resident council president and has gotten many complaints on R1 over the past year. R2 stated the staff assessed him after the incident and offered to send him to the hospital but he said there was no need. R2 stated he has to avoid R1 anywhere he goes in the facility and feels uncomfortable with him here. R2 stated R1 has made verbal threats to him in the past but could not remember details. R2 stated he reported everything to the social worker. On 6/25/25 at 10:36 AM, R2 stated R1 injured his chin, how else would I have this as he pointed to a bruise on his left lower chin. R2 stated R1 threatened him by hitting him in the face. R2 stated, This should be a safe place, I shouldn't have gotten hit. On 6/23/25 at 1:36 PM, R1 stated he has never had any issues with any of the other residents and he gets along with everyone. R1 stated he has never gotten in an argument with anyone here. On 6/23/25 at 2:42 PM, V6 (LPN) stated she was working at the time of the incident with R1 and R2 on 6/21/25. V6 stated she was in the middle of medication pass she thinks and didn't hear anything but turned around and saw R1 hit R2. V6 stated she was on orientation, and it was just her third shift. V6 didn't have the other nurse next to her at the time and was shocked. V6 stated she told R1 not to hit R2 and tried to separate them. V6 stated R1 hit R2 with a Styrofoam cup and the cup broke. V6 stated R1 was put on 1:1 when she first started and was newly off it when the incident occurred. V6 stated at first R1 didn't seem to have a lot of behaviors but she's only worked three days and doesn't know if he was provoked by R2, she couldn't hear anything that was being said. V6 stated it looked like R1 and R2 were waiting for the restroom when it happened. On 6/23/25 at 3:26 PM, V5 (LPN) stated she was in another room when the incident happened with R1 and R2 on 6/21/25. V5 stated R2 told the police that he bent down and told R1 he wasn't supposed to use that restroom. V5 stated there was a red spot on R2's left lower chin he claimed was from R1 hitting him. V5 stated R1 doesn't always start stuff, some residents provoke him, and she doesn't think R1 has the capability of restraining himself in response. 2. R3's face sheet he was admitted to the facility on [DATE] with diagnosis of, in part, spinal stenosis, idiopathic peripheral autonomic neuropathy, and major depressive disorder. R3's MDS dated [DATE] documented he is cognitively intact, with verbal behavioral symptoms occurring 4 to 6 days. R3's Care Plan dated 3/26/25 documented diagnosis of insomnia, MDD (major depressive disorder) with use of psychotropic medication. R3 has a history of becoming verbally abusive to staff and other residents. Becomes irritated easily with interventions to evaluate effectiveness and side effects of psychotropic drugs for possible decrease in dosage/elimination of drug, administer medications as ordered, observe for change in mood/behaviors, refer to psychiatry as needed, observe for changes in cognitive status, notify MD as needed, educate regarding appropriate behavior within the facility, encourage resident to talk about his emotions to avoid any verbal/physical aggression toward others dated 1/11/2025. The facility's abuse investigation involving R1 and R3 dated 2/1/25 documented R3 propelled his wheelchair up to R1 and told him to move out of the way. R1 did not move and R3 began yelling, screaming, and cursing at R1 stating you better f*****g move. R3 screamed and put his face within inches of R1's face. R1 responded by tossing a cup of ice at R3. R3 grabbed R1's arm and raised his hand and made a fist putting it in front of R1's face. The nurse jumped in and separated R1 and R3. R1 was propelling himself to another unit and R3 went after him and stated, I'm going to get you. Staff intervened and redirected R3. The conclusion of the facility's investigation documented on 2/1/25 there was a resident-to-resident altercation between R3 and R1 with no injuries. The residents were separated with no other incidents occurring. Both residents state they feel safe in the facility. On 6/23/25 at 9:55 AM, R3 stated R1 has hit him in the forehead before and he has thrown water and cold coffee at him too. 3. R5's face sheet documented he was admitted to the facility on [DATE] with diagnosis of, in part, hemiplegia and hemiparesis following cerebral infarction, chronic obstructive pulmonary disease, and heart failure. R5's MDS dated [DATE] documented he is severely cognitively impaired and has no behavioral concerns. R5 answers questions appropriately. R5's Care Plan dated 4/18/25 does not document any risk for abuse. The facility's abuse investigation involving R1 and R5 dated 4/28/25 documented at approximately 3:30 AM, R1 was being very disruptive in the common area and hallway on the East Unit. As witnessed by a nurse, R1 was repeatedly going to the fire extinguisher on the wall and opening the door to it. Staff repeatedly attempted to redirect R1 unsuccessfully. R1 began to yell and curse loudly to himself and staff. R1 propelled his wheelchair down the hallway and began to open resident's doors while yell and cursing. Staff attempts at redirection were unsuccessful. R1 went to his room and after a few minutes R1's roommate R5 came out to the nurse's station. R5 stated, I got up out of bed and he threw cold coffee on me and my bed sheets. I think he was mad because I wouldn't talked to him. Nurse separated R1 and R5. The facility's investigation conclusion documented R1 was physically aggressive toward R5 as evidenced by R1 throwing cold coffee on R5. No injury occurred. On 6/24/25 at 12:33 PM, R5 stated R1 used to be his roommate and it was horrible. R5 stated R1 is a ticking time bomb. R5 stated he remembers R1 throwing cold coffee on him while he was sleeping in the middle of the night, and he would take my things all the time and call me offensive names. R5 stated he doesn't trust R1 and thinks R1 is capable of hurting other residents at the facility. R5 stated he didn't feel safe in the same room with R1 ever. R5 stated R1 would creep the halls every night yelling. 4. R6's MDS dated [DATE] documented he is cognitively intact with no behavioral concerns. R6's Care Plan dated 5/12/25 does not document him to be at risk for abuse. R7's face sheet documented she was admitted to the facility on [DATE] and discharged on 5/21/25 with diagnosis of, in part, idiopathic peripheral autonomic neuropathy, type two diabetes mellitus, and generalized anxiety disorder. R7's MDS date 4/28/25 documented she was cognitively intact with no behavioral concerns. R7's Care Plan documented an onset of problem with history of yelling/shouting at other when frustrated with interventions for behavior tracking as needed, refer to psychiatry as needed and group therapy, social services to provide 1:1 with R7 when behaviors are inappropriate last reviewed May 2025. The facility's abuse investigation involving R1, R6 and R7 dated 3/24/25 documented that at approximately 6:00 PM there were two residents (male and female) having a verbal altercation in the dining room. R6 inserted himself into the conversation and stated he was sticking up for the lady. R6 told R1 to quit yelling at the lady. R1 began using racial slurs toward R6. The verbal altercation escalated between R1 and R6 and both were threatening to kick the others a**. Staff immediately separated the two and R6 went to the common area. R1 went to his room and then wheeled himself back up the hall with a butter knife in his hand waving it in the air. This was witnessed by a visitor who told V5 licensed practical nurse (LPN) who followed R1 to the activity room where she saw R1 place the butter knife under the popcorn machine. V5 retrieved the knife. R6 had no other contact with R1. R6 stated, I just heard him (R1) being loud with her, so I said something to him. I told him to get out of here and to quit yelling at her. Then R1 just started yelling at me and calling me a n****r. Then I said I'll kick you're a**. He said the same to me. Then V5 came and took him away. I went to the lobby. I didn't talk to him anymore after that. The interview with R7 documented, I backed into him. I apologized. It was my fault. I wanted to back up and he wouldn't move, so I backed up. He yelled at me, so I called him a mother f****r. The interview with R1 documented, she (R7) backed into me. Then she called me a mother f****r. I called her a b***h. Then R6 came over and we argued. I called him a n***r. We both threatened to kick each other's a****s. I went and got a knife. I wasn't going to do anything with it. It was a butter knife. The facility's investigation conclusion documented there was a verbal altercation between R7 and R1. There was a verbal altercation between R6 and R1. R1 was seen with a butter knife. It is not known what his intentions were. R1 did not attempt to harm anyone with the knife, and it was immediately retrieved. Since that time, they have had no further incidents. R1 and R6 are getting along with no issues. All residents involved stated they are comfortable and safe living in the facility. On 6/25/25 at 9:58 AM, V1 stated she expects all residents to be free from abuse and that the facility is responsible to keep the residents free from abuse. The facility's Abuse policy dated 1/25 documented 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 agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. The policy documented it is the responsibility of all staff to provide a safe environment for the residents. The facility's Resident Rights policy review 1/15 documented facility residents shall have the right to be free from mental and physical abuse.

Based on interview and record review the facility failed to prevent a resident-to-resident altercation for 2 of 5 (R2, R3) residents investigated for abuse. This failure resulted in R3 sustaining a minimal fracture to the left nasal bone. This past non-compliance occurred from 4/30/25 to 5/13/25. Findings include: 1.R2's EMR (Electronic Medical Record) undated documents that the resident was admitted to the facility on [DATE]. R2's EMR dated 1/3/25 documents a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R2's EMR dated 5/6/25 documents a diagnosis of unspecified psychosis not due to a substance or known physiological condition. R2's MDS (Minimum Data Set) dated 4/8/25 documents a BIMS (Brief Interview for Mental Status) score of 15 out of 15. The MDS does not document that the resident had any verbal, physical, or other behaviors. The MDS documents that the resident was independent with roll left and right, sit to lying, and lying to sitting on side of bed. The MDS documents that the resident required supervision or touching assistance for sit to stand, chair/bed to chair transfer, toilet transfer, and tub/shower transfer. R2's Care plan dated 6/5/25 documents Resident exhibits behaviors of being verbally aggressive toward others. No care plan for abuse noted. R2's Nurses Notes dated 4/30/25 at 2:20 AM documents, This writer was informed resident had a physical altercation with his roommate. Resident states that his roommate ran into the back of his wheelchair and then began hitting him on the left side of the back, left arm, and struck him in the face one time, each hit occurring with a closed fist. Resident states he then stood up out of the wheelchair and returned a blow to his roommate one time, to the forehead. Residents separated immediately. Skin assessed. No areas noted. VS obtained. 121/64 69 97.7 97%RA. ROM performed. Tolerated well. Resident c/o pain 10/10 to left arm. PRN (as needed) pain medication administered. DON (Director of Nursing)/Administrator, and physician have been notified. Resident placed on 15-minute checks. Sitting at nursing station at this time. R2's Physical Aggression Initiated dated 4/30/25 documents, At approx. 2:20am this nurse was at the nurses' station when this resident propelled his wc (wheelchair) to the station and reported that he had just had a physical altercation with his roommate. Resident states that his roommate ran into the back of his wheelchair and then began hitting him on the left side of the back, left arm, and struck him in the face one time, each hit occurring with a closed fist. Resident states he then stood up out of the wheelchair and returned a blow to the roommate one time, to the forehead. Both residents immediately kept separate and placed on q (every) 15 min checks. Nurse performed vs (vital signs) as well as a complete head to toe pain/skin/injury assessment. Neuro check, no visible injury noted to this resident. No redness or bruising, no swelling noted. Resident states that his roommate ran into the back of his wheelchair and then began hitting him on the left side of the back, left arm, and struck him in the face one time, each hit occurring with a closed fist. Resident states that he then stood up out of the wheelchair and returned a blow to his roommate one time, to the forehead. Residents separated immediately. Both placed on q 15 min checks. Head to toe pain/skin/injury assessment. No areas noted. VS obtained. 121/64 69 97.7 97% RA (room air). ROM (Range of Motion) performed Tolerated well. Neuro check. Resident c/o pain to left arm. PRN (as needed) pain medication administered. DON (Director of Nursing)/Administrator, and physician have been notified. Res alert and oriented to self and place. Needs reminders to time and situation. No visible injuries noted. c/o (complaint of) pain rated 10. Pain medication given. Effective after 45 min. Res alert and oriented to self and place. Needs reminders to time and situation. Facility received order to send res to (local hospital) geriatric psych unit for evaluation. Res admitted to (local hospital) geriatric psych unit. This resident is alert and oriented x2. He has a hx (history) of disliking his roommates. Has a hx of being verbally abusive toward roommates and threatening to harm roommates. Care plan updated. MD (Medical Director), ED (Executive Director), DON (Director of Nursing), IDPH (Illinois Department of Public Health) notified. Vs, pain/skin/injury assessment completed. ROM WNL (within normal limits). Neuro check, no visible injury noted. Res c/o pain to his left arm. PRN pain medication given. MD gave new order to send to (local hospital) geriatric psych unit for evaluation. Res family notified of new order. Res transported to (local hospital) geri psych unit. Resident admitted . Psychiatric evaluation and med review to be completed at geri psych. Resident moved to different room and to new unit, upon res return, social services will meet 2x wk. for 2 wks. to discuss safety and behaviors, behavior tracking. 2. R3's EMR undated documents that the resident was admitted to the facility on [DATE]. R3's EMR dated 8/2/24 documents a diagnosis of Cerebral Infarction, unspecified. R3's EMR dated 8/3/24 documents a diagnosis of Cognitive Social or Emotional deficit following Cerebral Infarction. R3's EMR dated 8/5/24 documents a diagnosis of Major Depressive Disorder single episode, severe with psychotic features. R3's MDS dated [DATE] documents a BIMS score of 2 out of 15. The MDS does not document any verbal, physical, other behaviors. The MDS documents that the resident has functional limitations on both sides. The MDS documents that the resident requires supervision or touching assistance for roll left and right, sit to lying, and lying to sitting on side of bed. The MDS documents that the resident requires partial/moderate assistance for sit to stand, chair/bed to chair transfer, toilet transfer, and tub/shower transfer. R3's Care plan dated 2/20/25 documents, I have a dx of MDD/anxiety, insomnia, and benefit from the use of psychotropic medications. Resident has h/o resisting cares at time. Can become verbally and physically abusive with staff. Resident has h/o making false statements that other residents or staff are hitting him. No care plan noted for abuse. R3's Nurses Note dated 4/30/25 at 3:17 AM documents, This writer was informed resident had a physical altercation with his roommate. Resident states his roommate hit him. He states he knocked the shit out of me. When asked if he hit his roommate first, resident states he's lying. Residents separated immediately. Skin assessed. Copious amount of bright red blood noted to face, beard, hands. No visible injuries seen. Blood origin determined to be from resident's nose. VS (Vital Signs) obtained. 128/64 68 97.5 97%RA. ROM (Range of Motion) performed. Tolerated well. No c/o (complaint of) pain or discomfort voiced. Family, DON (Director of Nursing), Administrator, and physician have been notified. Resident placed on 15-minute checks. Sitting at nursing in wheelchair until EMS (Emergency Management System) arrived to (sic) transport patient to (local hospital). Transferred from wheelchair to stretcher via 2 persons assist. Tolerated well. Transported to (local hospital) for evaluation and treatment. R3's Nurses Note dated 4/30/25 at 11:55 AM documents, DON spoke with residents' wife via phone. DON explained results of ER (Emergency Room) visit showing fx (fracture) nose. DON explained the results of interviews with both (R3), and the other male involved. Res wife states she will come to the facility to discuss. R3's CAT scan report dated 4/30/25 documents, There is a minimally displaced fracture of the left nasal bone. R3's Facility's Physical Aggression Initiated dated 4/30/25 documents, At approx. 2:20am this resident's roommate informed this nurse that he had a physical altercation with this resident. Nurse immediately ensured these residents were separated. Nurse assessed res vital signs, pain/skin/injury assessment. ROM, neuro check. Res had visible bleeding from his nose. No other injury noted. Nurse attempted to stop nasal bleeding. MD (Medical Director) called. New order to send to ER for evaluation. Resident states his roommate hit him. He states, he knocked the s**t out of me. When asked if he hit his roommate first, resident states. No he's lying. Residents separated immediately. Pain/skin/injury assessment. VS obtained. 121/64 69 97.7 97%RA (room air). ROM, neuro check. Res had visible bleeding from his nose. No other injury noted. Nurse attempted to stop nasal bleeding. MD called. New order to send to ER for evaluation. Both residents involved placed on q (every) 15 min. checks. Ambulance called. Ambulance arrived at approx. 2:35am. Res transported to (local hospital) ER. Res alert and oriented to self only. BIMS of 2. Bright red blood noted from nose. PAINAD 1. Res alert and oriented to self only. BIMS of 2. Res had bright red blood noted from nose. Res sent to ER for evaluation. Res returned at 6:19am with dx (diagnosis) of nasal fx. T (temperature)-98.1, R (respirations)-18, P (pulse)-68, b/p (blood pressure) 140/70. This resident is combative. Combative with care daily. Res does swing his arms in the air daily. Care plan updated, (R3) and roommate immediately separated and placed on q 15 min checks, MD, ED (Executive Director), DON, IDPH (Illinois Department of Public Health) notified. Vs. ROM, neuro check, pain/skin/injury assessment completed. Bleeding noted from nose. 911 called. Res remained at nurses' station with nurse until ems arrived. Res transported to (local hospital) ER for evaluation. Res returned from ER at 6:19am with dx of minimal fx to left nasal bone. Pain medication to be given as ordered. Res wife made aware. Trauma screen completed. Social services to meet with res 2 x wk for 2 wks to discuss behaviors and feelings of safety, refer to psych. Will be given by (V6) psychiatrist; wife agreeable. Med review by (V5) NP and pharmacy, roommate moved to different room on different unit. On 6/5/25 at 12:13 PM, V3, RN (Registered Nurse) stated that he did not witness the incident between (R2) and (R3). He stated he documented everything that he could in his notes. On 6/5/25 at 1:37 PM, V2, DON that (R2) was verbally aggressive with everybody, staff, and residents, but never physically aggressive. Facility's policy Abuse Prevention - Illinois Only dated 1/25 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. Prior to the survey date June 6, 2025, the facility took the following actions to correct the noncompliance. 1. R2 no longer resides in the facility as of 5/17/25. 2. The DON, Staffing Coordinator, Director of Rehab, Dietary Supervisor, and Housekeeping Supervisor in-serviced the staff on Abuse Prevention, Abuse Procedures, and Abuse Reporting. 3. Behavior Tracking audits on residents with behaviors. 4. Interviews and audits for roommate compatibility. 5. Men's group initiated with activities. 6. Trauma Screening on R2 and R3. 7. Care plans updated on residents for all known abuse residents. 8. Abuse was added to the QAPI plan and QAA agenda.

Based on observation, interview, and record review, the facility staff failed to notify the nurse of a resident having a change in condition to ensure timely assessment for 1 of 4 residents (R3) reviewed for quality of care in the sample of 5. This failure resulted in R3 not having timely assessment and subsequently having a Hypoxic/Unresponsive episode, with Cardiopulmonary Resuscitation (CPR) started, and was hospitalized . The Findings Include: R3's Admission Record, dated [DATE], documents R3 was admitted to the facility on [DATE] and was discharged to the hospital on [DATE]. R3's diagnoses includes Chronic Obstructive Pulmonary Disease (COPD), Arteriosclerotic Heart Disease (ASHD), Cardiomyopathy, Myocardial Infarction (MI), Morbid Obesity, Hyperlipidemia, Anemia, Sleep Apnea, Hypertension (HTN), and a Coronary Artery Bypass Graft (CABG). R3's Baseline Care Plan, dated [DATE], documents R3 was alert cognitively, is a fall risk, and the receives special treatment: Oxygen. R3's Minimum Date Set (MDS), dated [DATE], documents R3 was cognitively intact and dependent on staff for toileting, dressing, and transfers, substantial/moderate assistance with showers and partial/moderate assistance for all other Activities of Daily Living (ADLs). R3's Physician Order, dated [DATE], documents, Oxygen: Oxygen at 2 L (liters) per NC (nasal cannula), as needed for SOB (shortness of breath). On [DATE] at 1:46 PM, V4, Licensed Practical Nurse (LPN), stated, I took care of (R3), and she was always on O2 (oxygen). Even though she had an order for PRN (as needed) oxygen, if you tried to lower her dose, or take it off, she would have a hard time breathing and her sats would drop, so I kept her on 3 L/NC. If I would find her with her Oxygen off, she would always look pale and be slightly lethargic and would have to put her Oxygen back on her. On [DATE] at 9:33 AM, R3 stated, That morning ([DATE]) I was assisted up to my wheelchair and then to breakfast. After breakfast, I had to go to therapy and then I asked the CNA (Certified Nursing Assistant/V6) to put me back to bed because I was tired and didn't feel good but wanted to get up later for activities. When (V6) came back and got me up to my wheelchair, I told her I wasn't feeling good and she put the nasal cannula in my nose and pushed me to the nurse's desk and told me to wait there because my oxygen tank was empty, and the nurse had to fill it. When I told her I did not feel anything coming out of my cannula, she told me I told you it was empty and needed to be filled. When I got to the desk, there was no one around and (V6) left. I started to feel funny and the next thing I know, I woke up with people doing CPR on me. Then the ambulance guys came and took me to the hospital. On [DATE] at 2:15 PM during revisit interview, R3 stated, I was assisted to my wheelchair by the CNA, and she put the cannula in my nose and hooked it up to a portable oxygen tank. I told her I was not feeling good. I just didn't feel right and felt tired. I told her that I did not feel any oxygen coming out of the cannula and she told me it was because the oxygen tank is empty. She told me to go to the nurse's desk and sit there until I see a nurse and tell her that I didn't feel good and that I needed oxygen. It seemed to be around 30 minutes without seeing the nurse. The next thing I knew, I woke up with someone doing CPR on me and the EMTs taking me away. I did have my caregiver come visit me that morning, but she did not bring me lunch or give me anything for pain. I was not in any pain and did not receive anything for pain that day. On [DATE] at 1:13 PM, V6, CNA, stated, I had already gotten (R3) up for breakfast and after breakfast, she said she wasn't feeling well and wanted to go back to bed, so we helped her back to bed to rest. She wanted back up before bingo, so later I asked a therapist (V5) for help in getting her up, but the therapist was busy, so I just grabbed someone else, and we got her up to her wheelchair. I put her oxygen on the portable tank and pushed her to the nurse's desk because she wanted to talk to the nurse because she was not feeling well. I couldn't see the nurse so had (R3) sit there while I went and answered another resident's call light. (R3) was awake and talking when I left her at the desk. When asked why she did not tell the nurse that R3 was not feeling well, V6 stated, I hadn't seen the nurse around to let her know, so just went and answered the call light. On [DATE] at 10:08 AM during revisit interview, V6 stated, (R3) was not feeling well and wanted back to bed, so I put her back to bed. Shortly after that, she had two visitors, a male and a female who brought her lunch. When they were visiting, (R3) seemed very happy, perky, smiling, and cheery while she at lunch with them. (R3) was complaining that her head and stomach was hurting that morning. I told the nurse (V7, Licensed Practical Nurse/LPN) that morning that (R3) needed her oxygen tank filled because she went to therapy and used most of it. That is why I parked her at the nurse's desk, so she could tell the nurse she wasn't feeling good and to get more oxygen. I went and answered another resident's call light down the hall from (R3's) room and he is hard to get out what he needs, so I was in there for a while, I'm guessing around 10 minutes but less than 30 minutes. When I came out of his room, that's when they were all over (R3). On [DATE] at 11:53 AM, V6 stated, I did tell the nurse that (R3's) O2 was running empty. It was not in the red yet but was low. I put (R3) on that portable tank to take her to the desk because when I hooked her up, it hissed like it still had air in it. I do regret not looking at the tank to make sure it had oxygen. On [DATE] at 12:30 PM, V5, Director of Therapy Service (DTS), stated, I had a CNA (V3) come ask me for help getting (R3) out of bed and I told her I would be there as soon as I could. When I was on my way, I noticed that (R3) was already up and sitting by the nurse's desk. I said Good Morning (R3) and she did not answer me, which was unusual, so I started talking to her and she was not responding. The Nurse, who was on the floor, must have been with another resident, so I went to the DON's (Director of Nursing) office and got her to come help. On [DATE] at 11:25 AM during revisit interview, V5 stated, (V6, CNA) asked me to help get (R3) out of bed to go to bingo, and when I went to (R3's) room, (V6) told me that (R3) had to get cleaned up first because she was soiled. I left and went back to therapy department and waited for maybe 30 minutes to an hour, and when heading back to help out, that is when I found (R3) at the desk. On [DATE] at 1:24 PM, V7, LPN, stated, I was at lunch and when I came back from lunch, the DON was doing CPR on (R3). I assessed (R3) in the morning when I gave her medications, and she did not have any complaints at that time. When I am at lunch, the other nurse covers for me. I told everyone that day that I was going to lunch. (R3) was always on an oxygen concentrator while in her room and a portable tank when she was up in her wheelchair. On [DATE] at 10:59 AM during revisit interview, V7 stated, I don't remember what time I went to lunch that day. I do know that I let the CNAs know I was going to lunch, and I reported off to the DON. I was probably gone around 30 to 35 minutes. (R3) had no complaints of feeling bad that day. I don't recall seeing any visitors with (R3) that day. The CNA on the floor did not tell me anything about (R3's) oxygen tank needing filled. On [DATE] at 12:20 PM, V2 stated, I was in my office when (V5), came in and got me and said that (R3) needed checked out because she doesn't look good. I immediately went to check on her and she was unresponsive, gray, and was not breathing. I do recall seeing an oxygen tank on her wheelchair but could not tell you how much O2 was in there. (R3) did have a nasal cannula on as well. We then got about four of us and took her to her room and laid her on the floor and could not feel a pulse, so I started CPR. After about three compressions, (R3) began to move and CPR was stopped. We had the Ambu-bag attached to the O2 concentrator and was assisting her breathing. When the EMTs (Emergency Medical Technicians) arrived, (R3) was talking to them before she left the facility. (R3) had an oxygen concentrator in her room and if she felt short of breath, she should have been put on that and the nurse notified instead of taken to the nurse's desk. On [DATE] at 1:55 PM, V2 stated, I would expect the CNAs to get a nurse anytime a resident state they don't feel good and not to leave them alone at the nurse's desk while waiting on the nurse. I would expect anyone putting a resident on O2 to check the tank to make sure there is Oxygen in it. On [DATE] at 11:22 AM during revisit interview, V2, Director of Nursing, DON, stated, EMS (Emergency Medical Service) was called at 2:23 PM, and (V7), was at lunch and returned when the EMS was already here and taking care of (R3). When one nurse goes to lunch, the other nurse covers, or the nurse manager will cover. (V7) did tell me she was going to lunch that day, and she usually takes her lunch after the resident's lunch is over. On [DATE] at 8:30 AM, V10, CNA, stated, If a resident tells me they are not feeling well and wants to see the nurse, I will tell the nurse immediately, and the nurse will go check that resident out and do vital signs. I would not park the resident by the nurse's station to wait for the nurse, I would leave that resident in their room and go get the nurse to go to the resident. On [DATE] at 1:00 PM, V12, Physician, stated, I was not made aware of the incident until last evening ([DATE]) when the facility called me and was asking me about a resident who was sent to the hospital and was found to have Fentanyl in her system. I was not even sure who the resident was. I can tell you that this has happened to other residents at different facilities before with the hospital finding Fentanyl in a resident's urine when they were not on Fentanyl. The facility does not even use Fentanyl. I would expect the CNA to go get a nurse right away anytime a resident states they are not feeling well and needs assistance. On [DATE] at 10:32 AM, V14, Lab Supervisor at (Local Hospital), stated, Our Fentanyl cut off limit is 1 NG (nanogram)/ML (milliliter) and usually once it's positive, it's rare to have a false positive. There are proteins and mouse antibodies that can be found in urine that have been known to give a false positive, however, they usually trigger several false positives and not just one. I remember we had one nursing home resident who tested positive for several things and that was her reason. If the ER (emergency room ) would have called us, we could have double checked it, but we got rid of that urine and no longer have it to do anything with it. I don't see very many false positives with Fentanyl. We do a QC (quality control) every day and it was done on that day as well. On [DATE] at 11:20 AM, V1 stated, We went and talked to (R3), and she has no idea if or how she may have received Fentanyl. The physician ordered for a hair sample from (R3) to be tested for Fentanyl and that was done and sent off and we are waiting for the results. On [DATE] at 11:29 AM, V15, Lab Employee, stated, We did receive about six hairs from (R3) to run a Fentanyl test, but we could not run the test because it takes 120 hairs to get the results. The facility only collected six hairs and put them in a urine cup, and it was not packaged properly. I spoke to the facility and gave them the correct way to collect the sample, and they are supposed to be resending them the correct way. It normally takes between five to seven days, once they receive the sample, to get the results. R3's Nursing Note, dated [DATE] at 8:23 AM, documents, Resident up in wheelchair in the dining room at this time. Resident receives skilled therapy r/t (related to) generalized weakness. VS (vital signs) ,d+[DATE], 69, 99.7, 95% @ (at) 3LNC (liters per nasal cannula). When O2 placed at 2 L (liters), resident's O2 sats drop to 90%. Lung sounds clear to auscultation. Bowel sounds present in all 4 quadrants. Skin warm, dry, and intact. Able to make needs known. Plan of care continues. Monitoring ongoing. R3's Nursing Note, dated [DATE] at 2:49 PM, documents, 2:26 PM (V5) came to DON office asking for help. DON followed (V5) to [NAME] nurse's station to find resident (R3) up in wc (wheelchair). (R3) was nonresponsive to verbal and tactile stimuli, eyes rolled back, skin grey in pallor, no respirations noted, faint pulse noted. 911 called. Crash cart obtained. Res (Resident) pushed to her room, transferred to floor via 4-person lift. CPR initiated. 3 rounds of CPR compressions and ventilation via Ambu bag provided. 4th round of CPR initiated when res became responsive, res squeezed finger of nurse providing compressions. Rising and falling of chest noted. Res verbally responded by moaning. O2 94% on 2L /NC (nasal cannula), P-65. EMTs arrived at this time. Res began verbalizing to EMT's at this time. EMT's exited facility at approximately 2:45 pm transport to (local hospital). R3's Hospital Record/Discharge Summary, dated [DATE], documents in part: Date of Discharge [DATE]. C-Diff (Clostridium Difficile) Positive. She refused to go back to the same nursing home. Patient accepted to (another local facility). Plan: Syncopal episode probably multifactorial in origin, including possibly Fentanyl, she tested positive for Fentanyl in the urine which is not a nursing home medication. She also said that her oxygen tank was empty, and she could have passed because of hypoxia. Acute hypoxic respiratory failure present on admission she was saturating at 81% on room air, blood pressure was 80 she had hypovolemic shock on admission both resolved. Fentanyl in her urine - I spoke with the nursing home and that was not a nursing home medication. Patient was transferred to (current facility) from this facility on [DATE]. She was noted to get some Morphine while she was here, but no Fentanyl was given. Had a Cardiac Cath on [DATE] at (local hospital). R3's Cardiac Cath Hospital Records, page 27, dated [DATE], documents R3 had a Left Heart Catheterization on [DATE] with 2 MG (milligram) of Versed and 75 MCG (microgram) of Fentanyl for the procedure. R3 also had another Cardiac Catheterization from a different hospital on [DATE]. Those hospital records were not available for review. The Facility's Notification of a Change in a Resident's Status, dated ,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. 1. Guideline for notification of physician/responsible party (not all inclusive): a. Significant change in/or unstable vital signs (temperature, BP (blood pressure), Pulse, Respiration). d. Any accident or incident (per Federal and State Regulations). f. Abnormal lab findings. i. Change in level of consciousness.

Based on interview and record review, the facility allowed Certified Nursing Assistants (CNA) to administer Oxygen to residents for 1 of 4 residents (R3) reviewed for administration of Oxygen (O2) in the sample of 5. The Findings Include: R3's Admission Record, dated 3/18/25, documents R3 was admitted to the facility on [DATE] and was discharged to the hospital on 3/7/25. R3's diagnoses includes Chronic Obstructive Pulmonary Disease (COPD), Arteriosclerotic Heart Disease (ASHD), Cardiomyopathy, Myocardial Infarction (MI), Morbid Obesity, Hyperlipidemia, Anemia, Sleep Apnea, Hypertension (HTN), and a Coronary Artery Bypass Graft (CABG). R3's Baseline Care Plan, dated 2/27/25, documents R3 was alert cognitively, is a fall risk, and receives special treatment: Oxygen. R3's Minimum Date Set (MDS), dated [DATE], documents R3 was cognitively intact and dependent on staff for toileting, dressing, and transfers, substantial/moderate assistance with showers and partial/moderate assistance for all other Activities of Daily Living (ADLs). R3's Physician Order, dated 2/27/25, documents, Oxygen: Oxygen at 2 L (liters) per nasal cannula, as needed for SOB (shortness of breath). On 3/18/25 at 9:33 AM, R3 stated, After breakfast, I asked the CNA (Certified Nursing Assistant/V6) to get me up for activities. (V6) got me up to my wheelchair and put the nasal cannula in my nose and pushed me to the nurse's desk and told me to wait there, because my oxygen tank was empty, and the nurse had to fill it. When I told her I did not feel anything coming out of my cannula, she told me, I told you it was empty and needed to be filled. When asked about who usually puts her oxygen on her, R3 stated, Either the CNA or the Nurse will put it on me. They kept me on the oxygen all the time, 24/7. On 3/17/25 at 1:13 PM, V6, CNA, stated, I put (R3) on oxygen on the portable tank and pushed her to the nurse's desk. When asked if she is supposed to put residents on oxygen, V6 stated You would have to ask my supervisor. I have been an aide for a while and have always put the resident on oxygen and have never had a problem. On 3/17/25 at 1:24 PM, V7, LPN, stated, (R3) was on an oxygen concentrator while in her room and a portable tank when she is up in her wheelchair. The CNAs usually tell me when a resident needs another oxygen tank. When asked who is responsible for putting O2 on a resident, V7 stated, The CNAs are not supposed to put the resident on oxygen, they are supposed to come tell us and we put it on. On 3/17/25 at 1:30 PM, V8, CNA, stated, I'm not sure if we are allowed to put the oxygen on residents, you would have to ask my managers. On 3/17/25 at 1:45 PM, V1, Administrator stated, I'm not sure if the CNAs are allowed to put oxygen on residents. I will have to find out for you. On 3/18/25 at 8:05 AM, V9, CNA, stated, When I get a resident out of bed to their wheelchair and they are on oxygen via concentrator, I will place the oxygen on the portable tank to what they were on the concentrator, then I will have the nurse recheck it to make sure it was correct. I am not sure if the CNAs are supposed to be putting oxygen on the residents, but I do it and then have the nurse check it afterwards. On 3/18/25 at 8:30 AM, V10, CNA, stated, When I get a resident out of bed and that resident is on Oxygen via concentrator, I would go tell the nurse the resident needs to be put on a portable tank and the nurse will go and put it on the resident. The CNAs are not supposed to be putting the oxygen on the residents. On 3/18/25 at 8:35 AM, V11, LPN, stated, The nurses are the ones who are responsible for the portable oxygen tanks. If a resident is going from a concentrator to a portable tank, usually it's the CNAs who do it. I am not sure if they are allowed to do so, but they do it, and I will check afterwards to see if they are on the correct amount of oxygen. On 3/17/25 at 2:10 PM, V2, DON, stated, Our CNAs are not allowed to adjust the oxygen on residents, but I believe they are allowed to put them on a portable tank and turn it on to what they are supposed to be on. I see it all the time. The Facility's Oxygen Therapy Policy, dated 8/2014, documents Oxygen is administered to promote adequate oxygenation and provide relief of symptoms of respiratory distress. Responsibility: Nursing Personnel/Respiratory Therapist. Procedure: 1. Oxygen therapy is to be provided under the direction of a written physician's order for O2 therapy is to contain liter flow per minute via mask or cannula/timeframe. On an emergency basis, O2 may be used at 2L/minute until the physician is notified. 2. Explain the procedure to the resident. 3. Assemble the equipment and place appropriate device on resident. 4. Adjust delivery rate as ordered. 5. Check that equipment is functioning properly and assure that mask or cannula is securely and comfortably in place. The Facility's Medication Administration - General Guidelines Policy, dated 8/2016, documents Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Responsibility: All Licensed Nursing Personnel. Procedure: 1. Medications are prepared, administered, and recorded only by licensed nursing, medical, or other personnel authorized by state laws and regulations to administer medications. 2. Medications are administered in accordance with written orders of attending physicians, taking into consideration manufacturer's specifications and professional standards of practice.

Based on observation, interview, and record review the facility failed to ensure food was stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 76 residents living in the facility. Findings include: On 10/15/24 at 8:30 AM, tour of the kitchen was conducted. In the walk-in refrigerator was a roll out cart and on the tray were clear drinks, and pink colored drinks. There were 24 (4 ounce) plastic glasses that had no date and/or label on them. On 10/15/2024 at 8:32 AM, V12, Dietary Manager stated, We just made those drinks today. They should have dated and labeled them. I would expect everything to have a date and label so there is no guessing of when it was made. On 10/15/2024 at 8:33 AM, in the dry storage area is a large, industrial, 72-quart clear container of a whitish brown colored medium grain substance. It is not dated and/or labeled. On 10/15/2024 at 8:34 AM, V12 stated the container contained rice and it should have been dated and labeled. On 10/15/2024 at 8:35 AM, was another 72-quart container, halfway full, containing oblong shaped crumbs. The container was not dated and/or labeled. On 10/15/2024 at 8:36 AM, V12 stated, Those are Panko breadcrumbs. They should have been labeled. On 10/15/2024 at 8:37 AM, There was a clear 72-quart container 1/4 full of what appeared to be some type of dried beans. On 10/15/2024 at 8:38 AM, was a four-quart container of yellowish powder like substance. The container was full. There was no date and/or label. On 10/15/2024 at 8:39 AM, V12 stated the large container was beans and the yellowish substance was cornmeal and they both should have been dated and labeled. On 10/15/2024 at 8:40 AM, the steam table contained scrambled eggs, and boiled eggs. On 10/15/2204 at 8:44 AM, during the breakfast service V11, [NAME] was serving food from the steam table and was wearing kitchen gloves. On 10/15/2024 at 8:47 AM, V11, left the steam table went over to the dirty side of the kitchen, picked up a dirty bowl, sprayed it with an industrial spray hose, cleaned out the bowl took it back to the steam table and continued serving. V11 did not remove her gloves and/or wash her hands and continued serving with the same gloves. On 10/15/2024 at 8:48 AM, V11, was touching the brims of the bowls with her dirty gloved hands and was serving oatmeal. On 10/15/2024 at 8:54 AM, temperatures were taken after the last breakfast tray had been served and were taken with a metal calibrated thermometer and the scrambled eggs were at 117 degrees Fahrenheit (F), and the boiled eggs were at 122.0 degrees F. On 10/15/2024 at 8:57 AM, V12, stated, I would expect all of the food on the steam table to be at least 135 degrees or higher. On 10/18/2024 at 9:54 AM, V15, Dietician stated, I would expect all food to be dated and labeled. All hot food on the steam table should be at least 135 degrees Fahrenheit or higher. If the temperature is lower than 135 degrees, this could be harmful because the temperatures can get in the danger zone and bacteria can grow and thrive at this temperate and could cause foodborne illness to residents. The Monitoring Food Temperatures for Meal Service policy 2016 edition documents, Food temperature will be monitored daily to prevent food borne illness and ensure foods are served at palatable temperatures. Prior to serving a meal. Food temperatures will be taken and documented for cold and hot foods to ensure proper serving temperatures. Any food item not found at the correct holding/serving temperature will not be served but will undergo the appropriate corrective action listed below. If the serving/holding temperate of a hot food is not at least 135 F or higher when checked, they will be reheated to at least 165 F, for a minimum of 15 seconds, only once and discarded or consumed within two hours. The Food Storage (Dry, Refrigerated, and Frozen) Policy 2016 edition documents, Food shall be stored on shelves in a clean, dry area, free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. Label food item held no longer than 24 hours. The label should include the name of the food if not in original packaging, the date by which it should be sold, consumed, or discarded. The CMS 671 Long Term Care Facility Application for Medicare and Medicaid form dated 1016/2024 documents the facility has 76 residents.

Based on interview and record review the facility failed to prevent resident to resident abuse for 2 of 7 residents (R29 and R42) reviewed for abuse in the sample of 31. Findings include: 1. R42's Physician Order Sheet for October 2024 documents, Unspecified dementia, severity with behavior disturbances, unspecified dementia, unspecified severity, with agitation, unspecified psychosis not due to a substance or known physical condition, bipolar disorder, major depression, anxiety disorder, Alzheimer disease, insomnia, essential hypertension, allergic rhinitis, GERD, cognitive communication deficit, and adult failure to thrive. R42's Minimum Data Set, dated dated dated [DATE] documents R42 was cognitively intact for decision making for activities of daily living. R42's Care Plan with problem onset date of 2/9/2024 Diagnosis of bipolar, MDD (major depressive disorder), anxiety, and benefit from the use of psychotropic medication. I exhibit attention seeking behaviors/inappropriate behaviors such as pacing up and down halls, daily verbal outburst of cussing at staff and other residents, racial slurs. Abuse was not addressed in R42's Care Plan. R42's Incident Report documents, On the evening of 2/12/2024 at approximately 8:00 PM, Certified Nursing Assistant CNA, V11 stated, I was working on the East Hall. Resident (R29) ambulated out of her room with her walker. (R29) approached CNA and stated, that lady slapped me when I was in bed and pointed to (R42) just as (R42) was walking past them. (R42) reacted to hearing (R29) and seeing her point at her by hitting her face. CNA (V11) immediately intervened and separated the two residents. (R29) went down the hall to the common area and (R42) went into her room. (V11) called for nurses (V8), Registered Nurse (RN) attended to (R29). (V8) completed a head-to-toe assessment. Assessed (R29) for pain and injury, (R29) noted to have a 0.5 cm in length abrasion to her left cheek. R42's Social Service Note dated 2/13/2024 at 2:55 PM, documents, (V10, Social Service Director) was asked to reach out to (R42's) family and (V9, Adult Protection Service) worker in order to help (R42). Once good phone numbers were obtained, (V10) called (R42's) family member. (R42's) family member answered and (V10) explained that (R42) had attacked not only a staff member but another resident unprovoked. (V10) explained that they were wanting to send (R42) back to the hospital for inpatient psych evaluation and treatment and asked that (R42's) family member come to the facility in order to assist with this. (R42's) family member stated that he would be on his way. (V10) asked (R42's) family member that he bring the guardianship paperwork with him. (R42's) family member stated that the paperwork was not yet completed but that he would bring it. (V10) also reached out to (V9) and explained the situation to her. (V9) agreed to come to the facility in order to assist. (V10), (V2), and (V9) along with (R42's) family member talked with (R42) regarding her actions. (R42) denied hitting anyone or cussing anyone out. (R42) stated that she wasn't listening to anything they had to say and was going back to her room. After talking, (R42's) family member and (V9) determined that it would be best for (R42) to be sent out. (R42) was brought back into the office and explained everything. (R42) then agreed to go to the hospital. (V2) called (Local Hospital). (R42) signed all the paperwork requested by the hospital in order to be admitted . (Hospital) explained that they would send the ambulance once they received the ok from their doctor. When the ambulance arrived (R42) began cussing and fighting with the paramedics and did not want to initially get onto the stretcher. After (R42's) family member talked with her, (R42) was placed on the stretcher with staff assistance and she left the facility. (V9) stated that she feels that (R42) needs more inpatient psychiatric care and treatment at this time and that she will be looking for possibly a locked facility upon discharge from the hospital in the future. 2. R29's POS for October 2024 documents a diagnosis of hyperlipidemia, anxiety disorder, anemia, unspecified psychosis not due to a substance or known physical condition, major depressive disorder, insomnia, and hypertension, and cognitive communication deficit. R29's MDS dated [DATE] documents R29 was severely impaired for cognition of activities of daily living. R29 uses a wheelchair. R29's Care Plan, with a problem onset of 8/12/2021 documents, I have a diagnosis of anxiety, psychotic disorder, and benefit from the use of psychotropic medication. I can become angry and confrontational when I am confused. I have had no history of hitting at staff during these episodes. 2/12/2024 Resident immediate separates. Resident assessed for pain/injury. MD (Medical Doctor) family notified. 15-minute checks for rest of night. (Abuse was not addressed in R29's Care Plan. R29's Incident Report dated 2/12/2024 at 8:00 PM, At approximately 8:00 PM, Resident ambulated out of her room. (R29) spoke with CNA (V11), stating, that lady slapped me in the face when I was in bed, and pointed at another resident (R42). (R42) was walking past and heard (R29) and saw her point at her. (R42) responded by hitting (R29) in the face. (R29) yelled out. CNA (V11) intervened and separated residents. (V11) called for nurse (V8). (V8) performed head to toe assessment for pain/injury/skin. Noted a 0.5-centimeter abrasion to (R29)/ left cheek. No complaints of pain. MD (Medical Director) and family notified. DON notified. Resident placed in new room for her safety. IDPH notified. Area cleansed and left OTA (open to air) per order. R29's Post Incident Action dated 2/12/2024 at 8:00 PM, At approximately 8:00 PM, resident ambulated out of her room. (R29) spoke to CNA (V7), that lady slapped me in the face when I was in bed and pointed at another resident (R42). (R42) was walking past and heard (R29) and saw her point at her. (R42) responded by hitting (R29) in the face. (R29) yelled out. CNA (V11) interviewed and separated residents. Immediate Post Incident Action Care Plan update, resident separated from other resident involved. Resident placed in new room for her safety, medication reviewed, next treatment order, Resident placed on 15-minute checks. On 10/16/2024 at 4:02 PM, V2, Director of Nursing stated, If we can avoid a resident-to-resident altercations at all costs, I would not expect another resident to slap another resident. Hopefully, staff can step in before it escalates to that point. (R42) did wear a lot of rings. The Facility Abuse Policy with a revision date of 11/2/2022 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. Physical Abuse: This includes but is not limited to hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment.

Based on observation, interview, and record review the facility failed to ensure a safe transfer for 1 of 5 residents (R64) reviewed for transfers in the sample of 31. Findings include: R64's Physician Order Sheet (POS) dated October 2024 documents a diagnosis of Down's syndrome, hypothyroidism, major depressive disorder, dysphagia, oral phase, other symptoms and signs with cognitive functions and awareness. R64's Care Plan, with a problem onset date of 11/1/2023, documents, I have a diagnosis of MDD (mental depressive disorder) and benefit from the use of psychotropic medication. I have diagnosis of Down's syndrome, Alzheimer/dementia, I am nonverbal and unable to communicate my needs. R64's Minimum Data Set (MDS) dated [DATE] documents R64 was severely impaired for cognition for activities of daily living. Dependent on staff, helper does all of the effort for most activities. On 10/16/2024 at 4:14 PM, V13, Certified Nursing Assistant (CNA) was pushing a mechanical lift down the hallway. She entered R64's room and closed the door. On 10/16/2024 at 4:20 PM, R64's door was opened and R64 was up in the air in a sling and was being transferred to her wheelchair. R64 was hanging in the air and V13 was by herself. No other staff member was in the room. On 10/16/2024 at 4:21 PM, V13 stated, (R64) was a two person assist and there should always be two people in the room while transferring with a mechanical lift and I have no good reason why I did not have another staff member in the room with me. I have two other aides working on this side of the building now. On 10/16/2024 at 4:33 PM, V2, Director of Nursing stated, I expect there to always be at least two staff present when transferring residents with a mechanical lift and there are no circumstances where a safe transfer can be done with only one staff member. R64's EZ Move Screen Transfer Form documents she is a 2 person assist with lift, patient is unresponsive or non-weight bearing. Patient requires assistance with lateral transfers. The (Brand name) Total Lift Policy dated 8/16/2024 documents, The Invacare 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 the floor (maximum lifting per manufacture guidelines). (Brand name) 450 capacity is less than 450 lbs. (Brand name) 600 weight capacity is less than 600 lbs.

Based on interview and record review, the facility failed to respect the resident's rights to receive packages and mail unopened. This failure has the potential to affect all 72 residents residing in the Facility. Findings include: 1. On 8/29/2023 at 1:15 PM, R41 stated, I've had 6 or 8 letters opened and amazon packages opened multiple times. Maybe they thought they were opening (R41's name)'s mail. That's how it was explained to me. The package (that was opened) is what really p**sed me off. It was just coffee and sugar, not like it was heroin. On 8/31 at 11:25 AM, R41 stated, I had a Wal-Mart and Amazon package opened. Best guess is they mixed it up. There is a shipping label on the package and you could see it had been taped back up with clear tape. It really boggles my mind. It looked like someone put some real effort into opening it. The Amazon package looked like it was cut open with a razor. I know I'm not the only one but I don't remember who else had it happen. I just heard about it in passing. 2. On 8/29/2023 at 1:20 PM R37 stated, I have had letters open when I got them a couple times. On 8/30/2023 at 11:54 AM, R37 stated, Sometimes my mail is open. You can tell it has been taped back shut. It happens about twice a month. Sometimes it's from Social Security. I think it should be my business, not this places'. I don't know what they are looking for. The Resident Council Meeting Minutes dated 5/30/2023 documents the Resident Rights Reference and it includes, Right to send and receive mail unopened. The Resident Bills of Rights dated 1/23 documents, Each resident has a right to a dignified existence, self-determination, and communications with and access to persons and services inside and outside the Facility in a manner and in an environment that promotes maintenance or enhancement of (his or her) quality of life, regardless of diagnosis, severity of condition or payment source and to exercise those rights as a citizen of United States without interference, coercion including those rights specified herein. Facility residents shall have the right to: Send and receive mail promptly and unopened. The Resident Census and Conditions of Residents form (CMS-672), dated 08/28/23, documents, there are 72 residents residing at the facility.

Based on observation, interview, and record review, the facility failed to ensure the daily nursing staff posting was current for 2 of 4 days of the survey. This failure has the potential to affect all 72 residents residing in the facility. Findings include: On 08/28/23 at 08:30 AM, an observation was made of the daily nursing staff posting, dated 08/21/23, located inside of the main entrance doors. It documents there were currently 72 residents residing in the facility at the start of the shift. It specified the Registered Nurses, (RNs), and Licensed Practical Nurses, (LPNs), work 12-hours shifts but did not specify the times of the shifts. It did not specify the times or shifts the Certified Nursing Assistant, (CNAs), were to work. On 08/29/23 at 11:04 AM, and observation was made indicating the daily nursing staff posting had not been changed. On 08/29/23 at 11:15 AM, V1, Administrator stated the daily staffing should be updated every day. V1 said she currently doesn't have anyone to update the sheet but she will get it changed. The Resident Census and Conditions of Residents form (CMS-672), dated 08/28/23, documents, there are 72 residents residing at the facility.

Based on observation, interview, and record review, the facility failed to remove expired medications from the medication cart; failed to store Tuberculin (TB) Solution at the proper temperature; failed to discard the TB solution after 30 days as documented on the TB solution box in 1 of 2 medication carts inspected. Medications were left on three different resident's bedsides tables (R6, R15, R54) during med pass. This failure has the potential to affect all 72 residents residing at the facility. Findings included: 1. On 08/28/23 at 09:45 AM, The medication cart on the 200 hallway was inspected. The medication cart contained the following: 1. A bottle of Folic Acid 400mcg with an expiration date of 04/23. 2. A bottle of Vitamin B12 100mcg with an expiration date of 06/23. 3. A bottle of Geri Dryly allergy relief 25mg with an expiration date of 04/23. 4. A bottle of TB solution located in the medication drawer with an open date of 05/03/23. The package documents, store at 35 degrees to 46 degrees Fahrenheit (F), and discard after 30 days. On 08/28/23 at 09:55 AM, V3, Licensed Practical Nurse, (LPN), verified the above medications were expired and the TB solution should have been stored at a temperature of 35 to 46 degrees F and should have been disposed of after 30 days of opening. On 08/31/23 at 10:25 AM, V2, Director of Nursing, (DON), stated she would expect the expired medications to not be on the medication cart. V2 stated the TB solution should not be on the medication cart, it should be kept in the refrigerator unless it is expired and then disposed of appropriately. V2 stated the TB solution is used for everyone in the facility. 40650 2. On 08/30/2023 at 9:35 AM, V7, Certified Nurse Assistant, (CNA), donned gloves, pulled privacy curtain with her right hand that was gloved, and retrieved Neosporin (antibiotic ointment) out of R15's nightstand drawer. V7, CNA then applied Neosporin ointment just below R15's dressing to his coccyx. V7 placed the opened tube on R15's bed with the lid off. V7, CNA, stated R15's wife wants it on him and it helps with keeping the pressure off it. V7 then, with gloved hands, replaced the cap to the Neosporin ointment and placed it back in R15's nightstand drawer. R15's Physician orders, dated 3/29/2023 documented, [NAME] zinc cream to buttock and peri area daily as needed. There was not an order for the Neosporin ointment for the resident. R15's Care plan, dated 07/2023, documented, Provide me skin care after any incontinent episode. On 08/31/2023 at 9:10 AM, V4, CNA, stated she would not put medication on a resident because she is not a nurse. On 08/31/2023 at 9:15 AM, V17, CNA she would not put medication on a resident because she is not a nurse. On 08/30/2023 at 3:45 PM, V2, Director of Nurses stated the CNA's are not to put antibiotic ointment on any residents because it is beyond their Scope of Practice. 44967 3. R6's Facesheet, undated, documents R6 was admitted to the facility on [DATE]. R6's Diagnosis include Cerebral Vascular Accident, (CVA), Hemiplegia, Idiopathic Peripheral Autonomic Neuropathy, COPD, Major Depressive Disorder, (MDD), Bipolar Disorder, Convulsions, Schizophrenia, Falls, Traumatic Brain Injury, HTN. R6's Care Plan, dated 8/11/23, documents R6 requires assist with ADLs related to Diagnosis of CVA left side hemiplegia, COPD. Interventions: I transfer independently, provide me assist with any and all Activities of Daily Living, (ADLs), as needed, encourage me to wait for assistance to ambulate. It continues R6 has a diagnosis of MDD, insomnia, bipolar disorder with use of psychotropic medication. Interventions: Administer medications as ordered, evaluate effectiveness and side effects of medications for possible decrease/elimination of psychotropic drugs. It continues R6 requires healthcare monitoring related to Diagnosis of seizure disorder, Interventions: Administer medications as ordered. R6's MDS, dated [DATE], documents, R6 is cognitively intact with a BIMS 13 and is independent on bed mobility, transfers, and toilet use. R6 requires supervision for ambulation and locomotion and assist of one staff member for bathing. R6's MAR, dated August 2023, documents, Atorvastatin 10 MG, (milligram), Q, (every), Day at 8:00 AM, Fenofibrate 160 MG Q Day at 8:00 AM, Meloxicam 15 MG Q Day at 8:00 AM, Gabapentin 800 MG TID, (three times a day), at 8:00 AM, 12:00 PM, and 8:00 PM, Keppra 500 MG BID, (twice a day), at 8:00 AM and 8:00 PM, Fluphenazine 5 MG BID at 8:00 AM and 8:00 PM, and Fluoxetine 20 MG Q Day at 8:00 AM. On 8/28/23 at 10:10 AM, R6 was seen lying in bed with a medicine cup sitting on his bedside table with seven pills in it. On 8/28/23 at 10:11 AM, R6 stated, They put my medicines there on my table and I must have fallen asleep. They leave them there and I take it when I get up. On 8/29/23 at 11:30 AM, V9, Licensed Practical Nurse, (LPN), stated, Medications are never left at the bedside. I stand there and make sure the resident takes the medications before I leave. 4. R54's Facesheet, undated, documents, R54 was admitted to the facility on [DATE]. R54's Medical Diagnosis include Chronic Obstructive Pulmonary Disease, (COPD), Malnutrition, Major Depressive Disorder, Hypertension, (HTN), and Cognitive Communication Deficit. R54's Care Plan, dated 7/26/23, documents, R54 has a diagnosis of COPD and require healthcare monitoring. Interventions: Administer medications, inhalers, nebs as ordered. R54's Minimum Data Set, (MDS), dated [DATE], documents, R54 is cognitively intact with Basic Interview for Mental Status (BIMS) of 15. R54 requires extensive assistance from one staff member for toileting and bathing. R54 requires limited assistance from one staff member for ambulation/locomotion. R54 is independent for bed mobility, transfers, and dressing. R54 is always continent of bowel and bladder. R54's Medication Administration Record, (MAR), dated August 2023, documents, Flonase one spray each nostril every Day at 8:00 AM. On 8/28/23 at 10:25 AM, R54 stated, The nurse has dropped my meds off at my table and did not wake me up. I woke up and my cup of meds were here. I woke up once and knocked the cup of meds off, and luckily, I found all of them on the floor. Flonase spray was seen sitting on R54's bedside table. On 8/29/23 at 8:30 AM, R54 stated, They took my Flonase that I always keep on my table to use. On 8/31/23 at 10:26 AM, V2, Director of Nursing, (DON), stated, I would expect the nurses to stay by the resident during medication pass to ensure that the resident takes all medications given. The nurses should not be leaving any medications at the bedside. The Facility's Medication Administration Policy, dated 8/2016, documents, Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. 5. All current medications and dosage schedules are listed on the resident's medication administration record eMAR, (electronic medication administration record), /eTAR, (electronic treatment administration record), and administered timely according to facility policy. 15. For residents in the facility not in their rooms or otherwise unavailable to receive medication on the pass, the MAR/TAR is flagged. When a resident is unavailable, the medication will be administered as near to the scheduled time as able. for the eMAR, the nurse reviews my unsigned records. The Facility's Medication Storage Policy, dated 11/2010, documents, Medication supply must be accessible only to Licensed Nursing Personnel, or staff members lawfully authorized to administer medications. All drugs, treatments, and biologicals must be stored securely and following the manufacturer's labeled recommendations, or per facility policy. 6. Medications will be stored on the medication cart, or in other designated area for extra supply of medications, except for those requiring refrigeration.

Based on interview and record review the facility failed to ensure that all required Professional Department Heads were present at their Quality Assurance meetings at least quarterly. This failure has the potential to affect all 72 residents residing in the facility. Findings include: On 8/31/2023 the Facility's Monthly Facility Quality Assurance, (QA), and Meeting Minutes from January 2023 through August 2023 were reviewed. There was only one month, (June), that had been signed by V14, Medical Director, (MD). V11 Infection Preventionist, (IP), was not listed or included on any of the forms. On 8/31/2023 at 9:30 AM, V22 stated, she oversees the Quality Assurance Program and they meet monthly. V22 stated, I will go through them with you, (the Monthly Facility Quality Assurance and A Minutes). Is (V11, Infection Preventionist) supposed to be on this form? There is infection control stuff on here but the DNS, (Director of Nursing Services, V2), puts it into the minutes. You're right. There is only one (month signed by V14). The Monthly Facility QA and A form is dated 7/30/2022, but V22 stated, it was 7/30/2023 and corrected it on the form. The Facility's Quality Improvement Program dated 10/22 (October 2022) documents, The Quality Improvement Committee will assess and monitor the quality of services provided to the residents in the facility in order to identity 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. On 8/31/2023 at 11:33 AM, V1, Administrator, stated she would expect anyone in attendance at the QA meeting to sign the form, to document that they were present. The Resident Census and Conditions of Residents form (CMS-672), dated 08/28/23, documents, there are 72 residents residing at the facility.

Based on observation, interview and record review, the facility failed to provide assistance with grooming and hygiene to dependent residents for 5 of 8 residents (R7, R21, R24, R51, R57) observed for Activities of Daily Living, (ADL), in the sample of 32. Findings include: 1. R7's Face sheet, undated, documents, R7 was admitted to the facility on [DATE]. R7's Medical Diagnosis, Chronic Obstructive Pulmonary Disease, (COPD), Alzheimer's Disease, Dementia, Arteriosclerotic heart disease, (ASHD), Major Depressive Disorder, Anemia, Hypertension, (HTN), Alcohol Dependence, and Cognitive Communication Deficit. R7's Care Plan, dated 7/26/23, documents, R7 is at risk for skin issues related to, impaired mobility, Alzheimer's/Dementia, Incontinence. R7 has frequent rashes to my groin, due to my hygiene practices. Encourage me to take my showers and to have proper hygiene, provide me preventative treatment to my groin as ordered. It continues R7 requires assist with some ADL related to, impaired mobility, Diagnosis Alzheimer's/Dementia, COPD. Interventions: Provide me with an and all ADLs as needed, provide me with set up assist and encouragement for those ADL tasks that I am able to perform independently. R7's Minimum Data Set, (MDS), dated [DATE], documents, R7 is cognitively intact with Brief Interview for Mental Status, (BIMS) of 13. R7 requires physical help of one staff member for bathing and set up and supervision of one staff member for personal hygiene and toilet use. On 8/28/23 at 9:40 AM, R7 was seen sitting in his wheelchair with a strong odor of urine and body odor that was smelled from outside his door. R7 appears dirty, clothes are soiled with a t-shirt which was yellow and stained in color, and soiled pants. R7 stated he uses the restroom himself and showers maybe once a week. R7 said he changes his clothes himself. On 8/28/23 at 10:24 AM, V4, Certified Nursing Assistant, (CNA), stated, I know that (R7) gets his showers, I make sure of it. I worked Saturday and he got one then. I can't help it if the other shifts don't change his clothes. On 8/29/23 at 8:38 AM, R7 wheeling himself around in wheelchair with a strong body/urine odor and the same clothes that he had on yesterday. R7's sweatpants appear soiled and urine stains from his groin to his knees. On 8/29/23 at 11:58 PM, V9, Licensed Practical Nurse, (LPN), saw R7 on his way to the dining room for lunch and noticed he was saturated in urine, had very soiled clothing on, and had a strong odor coming from him. V9 took R7 to his room and alerted V6, CNA, who assisted R7 to get cleaned up. V6 put R7 in the restroom, gave R7 wet washcloths sprayed with peri-cleaner, with which R7 wiped himself. V6 gave R7 a clean pair of pants and a clean shirt, and R7 put them on. R7 stated he has not changed clothes yet today. The Facility's Shower schedule documents, R7's showers are scheduled on Wednesdays and Saturdays on Days. The Facility's Shower sheets were reviewed for the past two weeks with R7 having a shower sheet completed on 8/16/23 (Wednesday), 8/19/23 (Saturday), 8/23/23 (Wednesday), and the one undated which is a blank page - in the 8/26/23 section of book. The 8/19/23 sheet documents, Will only do on Weds. The 8/23/23 sheet documents, shower given with clothing clean and dry, hair washed and combed, nails cleaned and trimmed, dentures cleaned and in place. 2. R51's Face sheet, undated, documents R51 was admitted to the facility on [DATE]. R51's Medical Diagnosis include Osteoarthritis, Idiopathic Peripheral Autonomic Neuropathy, Hyperlipidemia, Dementia, Type 2 DM, Major Depressive Disorder, Anemia, HTN, Cognitive Communication Deficit, GERD, Malignant Neoplasm of Tongue. R51's Care Plan, dated 7/24/23, documents, R51 requires assist with ADLs r/t impaired mobility, OA, Impaired Cognition/safety awareness d/t Dx Dementia. Interventions: Provide assist with any and all ADLs as needed, provide set up assist/encouragement for those tasks that I am able to perform independently. R51's MDS, dated [DATE], documents, R51 has a severe cognitive impairment with a BIMS of 3. R51 requires physical assistance from one staff member for bathing, supervision with set up help for personal hygiene and toilet use and is independent on dressing. R51 is occasionally incontinent of urine and always continent of bowel. On 8/28/23 at 11:12 AM, R51 wheeling himself around the facility in his wheelchair, appears with greasy hair, strong odor of urine. R51 stated he's wet now and he is incontinent in his brief. R51 stated he can use restroom himself but is incontinent at times. On 8/29/23 at 8:48 AM, R51 was seen in the dining room in wheelchair, appears to have greasy hair, same clothes as yesterday, rolling around facility. R51 stated he didn't get a shower yesterday and doesn't remember the last one he got. R51 stated he is wearing the same clothes as yesterday because they seem clean to him. On 8/29/23 at 1:38 PM, V7, CNA, stated, I gave (R51) a shower on Saturday (8/26/23). I start with his hair and go to his face and work my way down. I was supposed to complete the shower sheet, but I did not that day. (R51) has thin hair and I think his scalp is oily and that is why he looks greasy. The Facility's Shower schedule documents, R51's showers are scheduled on Wednesdays and Saturdays Evenings. The Facility's Shower sheets were reviewed for the past 2 weeks with R51 having two shower sheets, one on 8/16/23 documenting, a shower with hair washed, nails cleaned, and clean clothing on. The other shower sheet was on 8/26/23 and only has the word shower written on it with nothing else documented. On 8/31/23 at 10:27 AM, V2, Director of Nursing, (DON), stated, I would expect the staff to provide the residents a bath as scheduled and a clean change of clothes daily. 40701 3. R24's Face Sheet dated 8/30/2023 documents, R24 has had a stroke. R24's MDS dated [DATE] documents, R24 is cognitively intact and requires extensive assistance with personal hygiene needs. R24's Care Plan dated 11/10/2022 documents, R24 requires assist with ADL related to impaired mobility. Provide assist with any and all ADLs as needed. On 8/29/2023 at 1:21 PM, R24 stated, I don't have anyone to do it (nails). I don't have strength in my left hand and I'm left-handed. R24 looked at her nails and stated, They need fixed. I used to always keep them nice and painted. They need trimmed quite a bit. R24's nails were observed to be long, some being one centimeter past the fingertip, jagged, uneven and with faded nail polish. On 8/29/2023 at 3:15 PM, V18, Certified Nursing Assistant stated, R24's shower days are Wednesday and Saturday evenings. On 8/31/2023 at 10:30 AM, V2 Director of Nursing, (DON), stated, nails care should be done on shower days. 4. R57's Face Sheet documents, R57 has a diagnosis of osteoarthritis and neuropathy. R57's MDS dated [DATE] documents, R57 is cognitively intact and requires extensive assistance with personal hygiene needs. R57's Care Plan dated 8/9/2022 documents, R57 requires assist with Activities of Daily Living related to neuropathy, osteoarthritis, and impaired cognition/safety awareness. Provide assist with any and all ADLs as needed. On 8/28/2023 at 2:03 PM R57's nails to bilateral hands were long, a half of a centimeter past his fingertips and had a dark substance underneath. R57 had concerns with how long his nails were. R57 stated, he has scratches on his back, because he has neuropathy and cannot feel when he is scratches himself. R57 stated, I've asked them to clip them, but I guess they forget. On 8/30/2023 at 10:00 AM, R57's nails remained long and unkempt. R57 stated, They still need cut. On 8/31/23 at 10:27 AM V2, Director of Nursing, (DON), stated, I saw (R57's) nails yesterday, I had the CNA clean them up. On 8/31/2023 at 11:16 AM, R57 stated, he felt much better about his nails after they were clipped. R57's nails were observed to be shorter and clean. 44556 5. R21's Face sheet, print date of 08/31/23, documents R21 has diagnoses of but not limited to hyperlipidemia, old myocardial infarction, hypertension, obstructive and reflux uropathy. R21's Minimum Data Set (MDS), dated [DATE], documents R21 is severely cognitively impaired and requires extensive assistance, one-person physical assist with bed mobility, transfer, dressing, toilet use, personal hygiene, and physical help in part of bathing, one-person physical assist. He has an indwelling catheter and is always incontinent of bowel. R21's Care Plan, admitted [DATE], documents I (R21) request assist with my ADLs related to (r/t) impaired mobility, impaired cognition, diagnosis (dx) dementia, and Congestive Heart Failure (CHF). I will choose not to shave. Provide me assist with any and all ADLs as needed. Provide me set up assist and encouragement for those tasks that I am able to perform independently. On 08/28/23 at 10:46 AM, R21 was observed lying in his bed with his head elevated. His hair was disheveled/unkept, his beard was long, his fingernails were long, and his toenails were observed to be long, thick, brown in color, and curled under. His feet were dry and scaly with skin flaking off them. R21's shower sheets for the month of August 2023 were reviewed and document the following: 08/10/23- no shower sheet was found in the shower book. 08/14/23- documents he refused a shower. 08/17/23- no shower sheet was found in the shower book. 08/21/23- documents he was in the hospital. 08/24/23- documents he refused. 08/28/23- no shower sheet was found in the shower book. 08/31/23 10:30 AM V2, Director of Nursing (DON) stated she would expect the showers to be given per the shower schedule if the resident will let them give it. She said she would expect the fingernail and toenail care to be done at the same time as the showers and as requested by the resident. The facility policy Bath/Shower-Dependent, undated, documents Policy: A bath (shower/tub) for cleanliness and comfort is scheduled at least weekly for each resident. Responsibility: Nursing Assistants or Licensed Nurses monitored by Charge Nurse. It further documents Equipment: 3. Soap/shampoo 4. Shower/tub chair 5. Gloves It also documents Procedure: 4. Apply gloves. 5. Assist resident to shower/tub chair, if appropriate. It further documents 11. Wash face with warm washcloth. 12. Shampoo hair unless done by beautician. 13. Bathe, rinse, and dry upper body with special attention under breast. 14. Bathe, rinse, and dry lower body with special attention to groin, skin folds and between toes. The facility policy A.M. Care, undated, documents Policy: A.M. Care will be given to residents daily. Responsibility: All Nursing Assistants. Equipment: 1. Wash basin (for bed resident) 2. Washcloth and towel 3. Soap 4. Comb and brush 5. Toothbrush, toothpaste, drinking glass and emesis basin 6. Shower chair or wheelchair 7. Razor, shaving cream Procedure: 4. Provide oral hygiene. 5. Resident to wash, rinse, and dry face and hands if able. 6. Wash, rinse, and dry underarms (also under female breast). Wash perineal and rectal areas. 8. Apply deodorant as needed. 9. Dress or assist resident to dress include shoes, stockings, and undergarment. 10. Provide nail care as needed. 11. Provide/ assist with shaving (male and female) as needed. 12. Position resident for comfort. Place call light within easy reach.

Based on observation, interview and record review, the facility failed to provide timely and complete incontinent care for 4 of 5 (R7, R15, R59, R65) residents, reviewed for incontinent care in a sample of 32. Findings includes: 1. On 08/30/2023 from 10:00 AM until 1:20 PM, using 15-minute intervals, R59 was up to her wheel chair in an activity and then was taken out to the dining room for lunch. At 1:10 pm R59 head was lowered towards the dining room table. A staff member was sitting next to R59 assisting another resident with eating. At 1:15 PM, R59 was taken out of the dining room, by a staff member and placed at the nurse's station. At 1:20 PM V14, Certified Nurse Assistant, (CNA), took R59 into her room and R59 stated she was tired. V14 stated she was not able to check R59 because she was busy taking care of and getting other residents up for therapy. V14, CNA unfastened R59's urine-soaked adult incontinent brief and with the same gloved hands, took several disposable wipes and cleansed R59 abdominal fold and labia. V14, then took another hand full of disposable wipes and in a circular motion cleansed R59 right buttock, vaginal and rectal area with the same wipes and not folding them over or getting a new disposable wipe. R59's Face sheet, dated 08/31/2023, documented, diagnoses of cognitive communication deficit and a history of falling. R59's Physician orders, dated 08/2023, documents, an order for Barrier cream to buttock daily, (as needed). R59's Minimum Data Set, (MDS), dated [DATE], documented R59's cognition was severely impaired. R59 requires extensive assistance of 2 staff members for transferring to and from wheelchair to bed, toileting and personal hygiene. R59's MDS, documents R59 is always incontinent of bowel and bladder. R59's Care Plan, dated 12/30/2022, documented, Assist me with repositioning as needed. Provide me skin care after any incontinent episode. Provide me assist with any and all, (activity of daily living), as needed. 2. On 08/30/2023 at 9:35 AM, V6, CNA, took a disposable cleansing wipe and cleansed R15's right hip from back to front twice without using a clean wipe or turning the wipe over. R15's Care plan, dated 07/2023, documented, Provide me skin care after any incontinent episode. R15's Face sheet, dated 08/31/2023, documented, diagnoses of Overactive bladder, history of falling, and chronic kidney disease, stage 3 unspecified. R15's MDS, dated [DATE], documented R15's cognition was severely impaired, requires extensive assist of 2 staff members for toileting and extensive assist of 1 staff member for personal hygiene. On 08/31/2023 at 09:10 AM, V4, CNA stated residents are checked for incontinence, turned and reposition every 2 hours or sooner and that residents are cleansed from front to back when doing incontinent care. On 08/31/2023 at 09:20 AM, V17, CNA stated residents are checked for incontinence, turned and repositioned every 2 hours. V17, also stated, that residents are cleansed from front to back when doing incontinent care. 44967 3. R7's Facesheet, undated, documents, R7 was admitted to the facility on [DATE]. R7's Medical Diagnosis, COPD, Alzheimer's Disease, Dementia, ASHD, Major Depressive Disorder, Anemia, HTN, Alcohol Dependence, HTN, Cognitive Communication Deficit. R7's Care Plan, dated 7/26/23, documents, R7 is at risk for skin issues r/t impaired mobility, Alzheimer's/Dementia, Incontinence. R7 has frequent rashes to my groin d/t my hygiene practices. I will refuse to allow staff to assist me. Encourage me to take my showers and to have proper hygiene, provide me preventative treatment to my groin as ordered. R7 requires assist with some ADLs r/t impaired mobility, Dx Alzheimer's/Dementia, COPD. I will often refuse to allow staff to assist me with grooming and hygiene. I frequently refuse to shower. Interventions: Provide me with any and all ADLs as needed, provide me with set up assist and encouragement for those ADL tasks that I am able to perform independently. R7's MDS, dated [DATE], documents, R7 is cognitively intact with BIMS of 13. R7 requires physical help of one staff member for bathing and set up and supervision of one staff member for personal hygiene and toilet use. On 8/28/23 at 9:40 AM, R7 was seen sitting in his wheelchair with a strong odor of urine and body odor that was smelled from outside his door. R7 appears dirty, clothes are soiled with a white t-shirt which was yellow in color and soiled pants. R7 stated he uses the restroom himself, and showers maybe once a week, and he changes his clothes himself. On 8/29/23 at 8:38 AM, R7 was seen wheeling himself around in his wheelchair, with a strong smell of urine odor, with the same clothes that he had on yesterday, grey sweatpants appear very soiled with urine stains from the groin to the knees. On 8/29/23 at 9:25 AM, R7 sitting in his wheelchair in his room, with the front of his sweatpants wet and soaked with urine, a strong urine odor noticed upon entrance to room. On 8/29/23 at 10:30 AM, R7 continues to sit in his wheelchair with same soiled sweatpants and strong odor of urine. On 8/29/23 at 11:20 AM, R7 sitting in his wheelchair, now pants are soaked from crotch to knees. Strong odor of urine. On 8/29/23 at 11:58 PM, V9, Licensed Practical Nurse, (LPN), saw R7 on his way to the dining room for lunch and noticed he was saturated in urine. V9 took R7 to his room and alerted V6, CNA, who assisted R7 to get cleaned up. V6 put R7 in the restroom, gave him wet washcloths sprayed with peri cleaner. R7 wiped himself up. V6 gave clean pair of pants and he put them on, gave R7 deodorant to use and a clean shirt. R7 stated he has not changed clothes yet today. 4. R65's Facesheet, undated, documents, R65 was admitted to the facility on [DATE]. R65's Medical Diagnosis include Dementia, Type 2 Diabetes Mellitus, (DM), Major Depressive Disorder, Hyperlipidemia, Cerebral Infarction, Hypertension, (HTN), and Benign Prostatic Hyperplasia. R65's Care Plan, dated 7/26/23, documents, R65 is at increased risk for skin issues related to impaired mobility, impaired cognition/communication, Dementia, and Incontinence. Interventions: Provide with skin care after each incontinent episode. R65's MDS, dated [DATE], documents, R65 has a severe cognitive impairment with a Basic Interview for Mental Status, (BIMS), of 3. R65 requires extensive assistance from one staff member for all ADLs. R65 is always incontinent of bowel and bladder. On 8/29/23 at 10:18 AM, R65 was seen lying in bed. When V4, CNA, and V6, CNA, entered to provide incontinent care all supplies were already sitting on the bedside table. Both CNAs washed hands in restroom sink and donned gloves. V4 used wet disposable wipes to wipe R65's penis, scrotum, and groins. V4 doffed her gloves, wiped her face with her hands and then washed her hands in the restroom sink. V4 donned clean gloves and wiped R65's buttocks and anal area from back to front, (crease of buttocks to scrotum). V4 did not change her gloves and continued to tuck the soiled incontinent brief under R65, then a clean incontinence brief was tucked under R65. R65 was rolled onto the new brief and the brief was secured. During the incontinent care, V6's cell phone rang and V6 pulled it out of her pocket with her gloves on and stopped the ring and placed it back in her pocket, then continued to assist in the incontinent care. On 8/31/23 at 10:24 AM, V2, Director of Nursing, (DON), stated, I would expect the staff to provide timely and complete incontinent care to all residents. The Facility's Incontinent Care Policy, dated 7/2012, documents, To provide routine, preventive skin, perineal care to residents after an incontinent episode. 6. Provide Privacy. 7. Put on gloves before removing wet and/or soiled items. 9. Avoid unnecessary exposure of the resident during the procedure. 11. When washing perineal area, wash the entire area moving from front to back. For male residents retract the foreskin while using a clean area of the washcloth for each stroke. 12. Rinse the perineal area and other skin surfaces washed with warm water and a washcloth from front to back. 14. Dry the perineal area front to back and all skin surfaces washed. 16. Remove gloves and discard. Wash hands.

Based on observation, interview and record review, the facility failed to perform appropriate hand hygiene and glove changes for 4 of 6 (R15, R34, R59, R65) residents observed for infection control, in a sample of 32. Findings include: 1. On 08/30/2023 at 1:20 PM V14, Certified Nurse Assistant, (CNA), took R59 into her room, donned gloves without benefit of hand hygiene. V12, Licensed Practical Nurse, (LPN), entered R59's room, donned gloves without benefit of hand hygiene. V14 was able to unfasten R59's urine-soaked adult incontinent brief, and with the same gloved hands, took several disposable wipes and cleansed R59 abdominal fold and labia. V12, LPN and V14, CNA, with the same gloved hands laid R59 to her left side. V14 took another hand full of disposable wipes and in a circular motion cleansed R59 right buttock, vaginal and rectal area with the same wipes and without benefit of hand hygiene or glove change. V14 then removed the urine-soaked adult incontinent brief and threw it on to the floor and placed a clean adult incontinent brief on the resident. 2. On 08/29/2023 at 9:35 AM, V6 and V7, both CNAs, performed hand hygiene, donned and gloves. V6, then took a folded-up piece of paper out of her shirt pocket and placed it on the nightstand. V6 then took the trash bag, and after V7 CNA pulled R15's covers back, V6 placed the trash bag on the bed, unfastened R15's adult incontinent brief, exposing R15's penis, groin, abdominal fold. V6, then took a wipe that was already on the overbed table and cleansed front to back R15's abdominal folds, bilateral groins, with a different wipe each time. V6 then doffed her gloves, performed hand hygiene, doffed her right glove then with her gloved hand pulled the privacy curtain so she could get back by R15's bed. R15 was then placed on his right side. V6 and V7 performed incontinent care, both doffed gloves and performed hand hygiene. V6 then donned her glove to her right hand and again pulled the privacy curtain with her gloved hand. V6 and V7 performed more incontinent care on R15. V7, then doffed her gloves, performed hand hygiene and donned gloves. With gloved hands V7 pulled R15's privacy curtain with her right hand that was gloved, retrieved Neosporin, (antibiotic ointment) out of R15's nightstand drawer and placed it on R15's bed. V7 then performed hand hygiene with alcohol-based hand rub (ABHR), and donned gloves. V7, CNA then applied Neosporin ointment just below R15's dressing to his coccyx. V7 placed the opened tube on R15s bed with the lid off. V7, then with the same gloved hands, replaced the cap to the Neosporin ointment and placed it back in R15's nightstand drawer. On 08/31/2023 at 09:10 AM, V4, CNA stated she washes her hands and changes gloves about 2 to 3 times during incontinent care and also if she touches a curtain with gloved hands, she would change gloves and wash her hands before she performs care on the resident. 08/31/2023 at 09:20 AM, V17, CNA stated she would wash her hands after incontinent care to the peri area was done as long as she did not cross contaminate. V17 stated she would change gloves and wash her hands if she touched an inanimate object, like a privacy curtain with a pair of gloves on before she provides incontinent care. 3. On 08/30/2023 at 10:30 AM V13, LPN performed hand hygiene and put gloves on. V13 then sprayed wound cleanser from a bottle that was used for multiple residents, on to 4x4 gauze pad and cleansed R34's pressure area. V13 then removed her gloves and performed hand hygiene and donned new gloves. V13 opened the calcium alginate with silver with her gloved hands and placed it in R34's wound bed. V13 then retrieved the bordered dressing out of an open package and placed it on top of the wound all without benefit of hand hygiene and glove changes. V13 doffed gloves, performed hand hygiene, donned gloves. V13, LPN then touched the left side of her nose and with donned gloves, opened the calcium alginate package and applied the dressing to R34 wound. On 08/31/2023 at 09:15 AM, V16, Registered Nurse, (RN), Wound Nurse stated she would leave the dressings in the sterile packaging and when she was ready to use them, she would open them, performed hand hygiene and put on new gloves. 44967 4. R65's Facesheet, undated, documents, R65 was admitted to the facility on [DATE]. R65's Medical Diagnosis include Dementia, Type 2 Diabetes Mellitus, (DM), Major Depressive Disorder, (MDD), Hyperlipidemia, Cerebral Infarction, Hypertension, (HTN), and Benign Prostatic Hyperplasia. R65's Care Plan, dated 7/26/23, documentsR65 is at increased risk for skin issues related to, impaired mobility, impaired cognition/communication, Dementia, and Incontinence. Interventions: Provide with skin care after each incontinent episode. R65's MDS, dated [DATE], documents R65 has a severe cognitive impairment with a Basic Interview for Mental Status, (BIMS), of 3. R65 requires extensive assistance from one staff member for all ADLs. R65 is always incontinent of bowel and bladder. On 8/29/23 at 10:18 AM, R65 was seen lying in bed. When V4 and V6, both CNAs, entered to provide incontinent care all supplies were already sitting on the bedside table. Both CNAs washed hands in restroom sink, both donned gloves. V4 used wet disposable wipes to wipe R65's penis, scrotum, and groins. V4 doffed her gloves, then wiped her face with her hands, and then washed her hands in the restroom sink. V4 donned clean gloves and wiped R65's buttocks and anal area from back to front, (crease of buttocks to scrotum). V4 did not change her gloves and continued to tuck the soiled incontinent brief under R65. Then a clean incontinence brief was tucked under R65 and he was rolled onto the new brief and the brief was secured. During the incontinent care, V6's cell phone rang and V6 pulled it out of her pocket with her gloves on and stopped the ring and placed it back in her pocket, then continued to assist in the incontinent care. On 8/31/23 at 10:25 AM, V2, Director of Nursing, (DON), stated, I would expect all staff to change their gloves when soiled, and to perform hand hygiene before care, during glove change, and after care. The Facility's Standard Precautions Policy, dated 9/2019, 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. 2. Wash hands when visibly soiled, after contact with blood, body fluids, secretions, excretions, patient's intact skin or wound dressings and contaminated items immediately after removing gloves and between patient contacts. Wear gloves when touching blood, body fluids, secretions, excretions, contaminated items with mucus membranes and non-intact skin. If hands move from a contaminated site to clean body site during care, wash hands using a non-antimicrobial soap and water, antimicrobial soap and water or alcohol-based hand rub. Wash hands before direct contact with patients. 5. Handle soiled patient care equipment in a manner that prevents transfer of microorganisms to others and to the environment; wear gloves if visibly contaminated; perform hand hygiene. 6. Environmental control - follow procedures for routine care, cleaning and disinfection of environmental surfaces, especially frequently touched surfaces in patient care areas.

Based on interviews and observations, the facility failed to provide a call light that was within reach of the resident for 3 of 18 residents (R5, R7, R48) reviewed for call lights in the sample of 32. Findings include: 1. R48's diagnoses include Alzheimer's Disease, Dementia, Major Depressive Disorder, Hyperlipidemia, Hypertension, (HTN), Gastroesophageal Reflux Disease, (GERD), Cognitive Communication Deficit. R48's Care Plan, dated 8/21/23, documents R48 is at increased risk for falls, related to left hip fracture status post fall, HTN, MDD, (Major Depressive Disorder) /Insomnia with use of Psychotropic medication, Alzheimer's/Dementia. Interventions: Place call light and frequently used items within safe reach. R48's Minimum Data Set, (MDS), dated [DATE], documents R48 is cognitively intact with a Basic Interview for Mental Status (BIMS) of 14. R48 requires supervision with set up assist for bathing. R48 is independent for all other Activities of Daily Living, (ADLs). R48 is always continent of both bowel and bladder. On 8/28/23 at 10:37 AM, R48's call light was seen lying on the floor between the bed and the wall and was not visible or available for R48 to use. On 8/28/23 at 10:38 AM, R48 stated, The call light is always down there. On 8/29/23 at 8:28 AM, R48's call light remains on the floor between the wall and his bed, and is not visible, or available for R48 to use. On 8/30/23 at 8:51 AM, R48 was asleep in his bed with his call light still on the floor between his bed and the wall and is not visible or available to R48 if needed. 2. R7's Face sheet, undated, documents R7 was admitted to the facility on [DATE]. R7's Medical Diagnosis, Chronic Obstructive Pulmonary Disease, (COPD), Alzheimer's Disease, Dementia, Arteriosclerotic heart disease, (ASHD), Major Depressive Disorder, Anemia, HTN, Alcohol Dependence, AND Cognitive Communication Deficit. R7's Care Plan, dated 7/26/23, documents R7 is at risk for skin issues related to impaired mobility, Alzheimer's/Dementia, Incontinence. R7 has frequent rashes to my groin due to hygiene practices. Encourage to take showers and to have proper hygiene, provide preventative treatment to groin as ordered. It continues R7 requires assist with some ADLs related to impaired mobility, Diagnosis of Alzheimer's/Dementia, COPD. Interventions: Provide R7 with any and all ADLs as needed, provide R7 with set up assist and encouragement for those ADL tasks that he is able to perform independently. R7's MDS, dated [DATE], documents R7 is cognitively intact with BIMS of 13. R7 requires physical help of one staff member for bathing and set up and supervision of one staff member for personal hygiene and toilet use. On 8/28/23 at 9:40 AM, R7's call light was seen lying behind R7's nightstand and was not visible and unreachable for R7 to use. On 8/29/23 at 8:38 AM, R7's call light remains behind his nightstand and not visible or available for R7 to use. On 8/30/23 at 8:49 AM, R7's call light was seen in the same place, lying on the floor behind his nightstand and not visible or available to R7 to use. 3. R51's Face sheet, undated, documents R51 was admitted to the facility on [DATE]. R51's Medical Diagnosis include Osteoarthritis (OA), Idiopathic Peripheral Autonomic Neuropathy, Hyperlipidemia, Dementia, Type 2 Diabetes Mellitus (DM), Major Depressive Disorder, Anemia, HTN, Cognitive Communication Deficit, GERD, and Malignant Neoplasm of Tongue. R51's Care Plan, dated 7/24/23, documents R51 requires assist with ADLs related to impaired mobility, OA, Impaired Cognition/safety awareness due to Diagnosis of Dementia. Interventions: Provide assist with any and all ADLs as needed, provide set up assist/encouragement for those tasks that R51 is able to perform independently. R51's MDS, dated [DATE], documents R51 has a severe cognitive impairment with a BIMS of 3. R51 requires physical assistance from one staff member for bathing, supervision with set up help for personal hygiene and toilet use and is independent on dressing. R51 is occasionally incontinent of urine and always continent of bowel. On 8/28/23 at 11:12 AM, R51 call light was seen behind his nightstand and not visible and unavailable to R51. On 8/28/23 at 11:13 Am, R51 stated, I don't even know if I have a call light. On 8/29/23 at 8:48 AM, R51's call light remains on the floor and behind his nightstand, and is not visible, or available to R51 to use. On 8/30/23 at 8:47 AM, R51's call light remains lying on the floor behind R7's nightstand and is not visible or available to R51. On 8/31/23 at 10:15 AM, V1, Administrator, stated, We don't have a policy for call lights. I do expect the resident's call light to be always available to the resident and to be answered quickly once turned on. This upsets me because it is important to me. On 8/31/23 at 10:23 AM, V2, Director of Nursing, (DON), stated, I would expect all staff to make sure all residents have their call light within reach and to answer it as soon as possible.

Based on observation, interview and record review, the facility failed to provide privacy for 1 of 6 residents (R15) reviewed for incontinent care in a sample of 32. Findings include: On 08/29/2023 at 9:35 AM, V6, Certified Nurse Assistant, (CNA), and V7, CNA unfastened R15's adult incontinent brief, exposing R15's penis, groin, abdominal fold. After incontinent care, V6 doffed her gloves, V6 then performed hand hygiene in R15's bathroom and donned gloves, leaving R15's penis and groin expose. V6 and V7 both CNAs, performed incontinent care to R15's peri rectal and buttock area and when it was complete V6 and V7, both doffed their gloves and performed hand hygiene in the bathroom. R15's private areas were left exposed. Care plan dated 07/2023 documented, provide me skin care after any incontinent episode. On 08/31/2023 at 9:10 AM V4, CNA stated she would provide privacy during incontinent care by covering up the resident up. On 08/31/2023 at 9:15 AM, V17, CNA stated she would provide privacy during incontinent care by covering up the resident up. On 08/30/2023 at 3:45 PM, V2, Director of Nurses, stated she would expect the CNAs to keep residents covered while performing incontinent care. The Facility's policy, Incontinent Care, dated 07/2012, documented, 6. Provide privacy. 9. Avoid unnecessary exposure of the resident during the procedure.

Based on interview and record review, the facility failed to follow up with hospital orders and clarify the need for an antibiotic for 1 of 4 (R33) residents reviewed for unnecessary mediations in the sample of 32. Findings include: The Facility's Infection Control Log dated 8/1/2023-8/25/2023 documents, R33 had a urinary infection, no culture was performed and R33 was prescribed an antibiotic. R33's Progress Notes 8/1/2023 documents, R33's suprapubic catheter became clogged and R33 was sent to the local hospital. R33's Urinalysis dated it was collected 7/31/2023. It further documents R33's urine had >100,000 mixed urogenital flora (common bacteria). R33's Patient Visit Information documents, R33 was prescribed an antibiotic every 12 hours for 3 days for an acute UTI. R33's Medication Administration Record (MAR) dated August 2023 documents, R33 received this antibiotic. On 8/31/2023 at 1:00 PM, V23, Regional Nurse stated, It was normal flora so they wouldn't have prescribed an antibiotic. On 8/31/2023 at 1:10 AM, V2, Director of Nursing (DON) stated, We had already did a urine on her, went out to the hospital before we had the sensitivity. 08/31/23 10:30 AM V2, Director of Nurses stated for the infection control log, they refer to the lab results and don't order antibiotics unless the Medical Director orders the antibiotics for a resident. VS stated they will not give antibiotics until the culture and sensitivity are back from the lab and that the infection control nurse keeps record of all of it and calling the hospital for laboratory result and cultures. V2 stated they use the SBAR (Situation Background Assessment and Recommendation) tool for their criteria for infection control. The Facility's Antibiotic Stewardship Program dated 10/22 (October 2022) documents Actions to Improve Use -the Medical Director is the review the antibiotic Use Report and Physician's Practices Report quarterly and ensure that Physicians are following best practice. It further documents Pharmacy consultant is to review microbiology culture results and provide feedback on antibiotic selection to determine if the right drug was used to treat the infection. If continues to document microbiology culture data will be used to assess and guide future antibiotic selection.

Based on observation, interview and record review the facility failed to prevent pressure ulcers for 1 of 4 residents (R62) reviewed for pressure ulcers in a sample of 36. This failure resulted in R62 sustaining an pressure ulcer on his left BKA. Findings include: R62's Care Plan dated 4/1/2021 documents problem: at increased risk for skin issues related to impaired mobility diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Goal: no break in skin integrity through next review 12/2022. Approaches: observe skin daily with cares, perform weekly skin assessments, notify physician of any abnormal findings. Pressure relieving mattress on bed and cushion in w/c as tolerated. Staff to assist with repositioning, perform a skin risk assessment quarterly and PRN, treatment as ordered. 5/2/2022 staff handwritten note treatment as ordered, prosthetic ortho looking at leg 5/9/2022. 6/20/2022 staff handwritten stage 3 pressure to left BK and left distal BKA admitted with from hospital. 6/20/2022 treatment as ordered; wound specialist ordered. 8/27/2022 handwritten left BKA Pressure wound stage 3. R62's Undated Face Sheet documents he was initially admitted to the facility on [DATE]. R62's Evaluation of Pressure Ulcer Risk, dated 4/8/2022 documents bed mobility problem: no. Bedfast: no. Bowel incontinence: no. Peripheral Vascular Disease (PVD): no. Previous ulcer: no. Skin desensitized to pain or pressure: no. Daily trunk restraint: no. It was determined R62 was not at risk of pressure ulcers. R62's Nursing Notes dated 5/2/2022 at 3:20 AM V6, Wound Nurse documented observed resident this shift, noted open area to left BKA related to ill-fitting prosthetic. Treatment applied as ordered. Prosthetic company coming 5/9/2022 to re-fill few new prosthetics. Physician and responsible representative aware of current situation. No assessment of the pressure ulcer was documented. R62's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .) 5/31/2022 wound specialist consult and treat. R62's Medical Record dated 5/2022 no documentation the prosthetic company assessed his left leg prosthetic. R62's quarterly Minimum Data Set, (MDS), dated [DATE] documents he is alert, and needs is independent for bed mobility, transfers, locomotion on and off unit, eating and toilet use. Supervision with setup only for dressing and personal hygiene. Determination of pressure ulcer risk: resident has a pressure ulcer, formal assessment instrument tool and clinical assessment, resident at risk for developing pressure ulcers, 1 stage 2 pressure ulcer. Skin and ulcer treatments included pressure reducing device for chair and bed and pressure ulcer care. Mobility device: wheelchair. R62's Initial Wound Specialist Nurse Practitioner Note, dated 6/7/2022 HPI (history of present illness): initial consult of this [AGE] year-old male, who was noted on 5/2/2022 to have a pressure ulcer secondary to his prosthesis. Currently treating with [MEDICATION(S)]. He was noted today to have a new distal lateral area of his left BKA as well, awaiting orders. Patient has history of left BKA, DM and [CONDITION(S)]. Initial assessment of left BKA noted on 5/2/2022 stage 3 pressure ulcer with 100% granulation which measured 2.9 cm x 2.5 cm x 0.3 cm. Left BKA lateral distal noted 6/7/2022 stage 3 pressure ulcer with 100% granulation which measured 0.7 cm x 0.9 cm x 0.3 cm. R62's 6/2022 POS, dated 6/7/2022 documents discontinue current treatment to left BKA. Cleanse left BKA with wound cleanser apply skin prep to peri wound area apply alginate cover with foam dressing every day and PRN. R62's POS dated 6/10/2022 documents send resident to hospital for evaluation. R62's POS, dated 6/16/2022 documents a physician's telephone order for new BKA prosthesis. R62's Evaluation of Pressure Ulcer Risk, dated 6/20/2022 documents bed mobility problem: no. Bedfast: no. Bowel incontinence: no. PVD: no. Previous ulcer: yes. Skin desensitized to pain or pressure: no. Daily trunk restraint: no. Staff circled diabetes on the form. It was determined R62 was at risk of pressure ulcers. R62's Medical Record documents no readmission skin assessment dated [DATE]. R62's POS, dated 6/21/2022 documents a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R62's Wound Nurse Practitioner dated 6/21/2022 documents unstageable pressure ulcer on left BKA measured 3 cm x 2.5 cm x UTD (unable to determine.) Wound bed 10% granulation and 90% necrotic. Peri-wound area scarring dry and flakey. Moderate yellow drainage. R62's 7/2022 POS documents cleanse left BKA with wound cleanser, apply [MEDICATION(S)], cover with dressing every day and PRN. R62's Wound Specialist Nurse Practitioner Note, dated 8/9/2022 HPI: [AGE] year-old male with a pressure ulcer of his left BKA secondary to his prosthesis. Currently treating with [MEDICATION(S)] and calcium alginate. He also has history of diabetes and [CONDITION(S)]. Assessment of Left BKA pressure ulcer stage 3 with 100% granulation which measured 2 cm x 1.5 cm x 0.3 cm. Peri wound scarring dry, flakey with moderate yellow exudate. R62's POS dated 8/2022 documents a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .) R62's Evaluation of Pressure Ulcer Risk, dated 8/27/2022 documents bed mobility problem: no. Bedfast: no. Bowel incontinence: no. PVD: yes. Previous ulcer: no. Skin desensitized to pain or pressure: no. Daily trunk restraint: no. Staff circled diabetes on the form. It was determined R62 was at risk of pressure ulcers. R62's POS dated 9/2022 documents a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Weekly skin checks. R62's quarterly MDS, dated [DATE] documents he is alert, and needs extensive assistance of setup only for bed mobility, locomotion on and off unit, dressing, eating, and personal hygiene and extensive assistance with two-person physical assist for transfers and toilet use. Mobility device was a wheelchair and limb prosthesis. Determination of pressure ulcer risk: resident has a pressure ulcer, formal assessment instrument tool and clinical assessment, resident at risk for developing pressure ulcers, 1 stage 3 pressure ulcer. Skin and ulcer treatments included pressure reducing device for chair and bed and pressure ulcer care. On 10/4/2022 at 9:30 AM R62 was sitting in his wheelchair in his room with a left leg prosthetic on. On 10/5/2022 at 9:00 AM, R62 was sitting in his wheelchair in his room with a left leg prosthetic on. Observation on 10/6/2022 at 8:15 am V6, Wound Nurse provided wound care to R62's left BKA. V6 washed her hands and donned gloves she removed a dressing dated 10/5/2022 removed gloves, washed hands and donned gloves and cleansed the pressure ulcer with dermal wound cleanser. V6 applied Prizma and cover the pressure ulcer with a dry dressing. The pressure ulcer wound bed was 80% granulation tissue and 20% red. It measured 0.7 cm x 0.4 cm. The peri wound area (area surrounding pressure ulcer) was dry and there was a small amount of serosanguineous drainage. On 10/6/2022 at 8:20 AM V6, Wound Nurse stated R62 in May 2022 staff notified her he had skin breakdown on his left BKA. She assessed it and documented a stage 3 pressure ulcer on this left BKA. R62 is alert and told her it was caused by his leg prosthetic rubbing against his skin. He was transferred to the hospital a few months ago and when he was readmitted the left BKA pressure ulcer was a lot bigger, so she documented it as a non-facility acquired pressure ulcer. On 10/6/2022 at 2:00 PM V16, Director of Therapy stated R62 was admitted to the facility years ago and he brought his left leg prosthetic with him upon admission. When residents are admitted to the facility with a prosthesis therapy staff evaluate to ensure it fits them properly. The prosthetic evaluation wouldn't be in therapy notes because they document it on a template, and it is not printable. On 10/6/2022 at 1:00 PM V2, DON stated the pressure ulcer on R62's left BKA was assessed in May 2022 and the wound nurse practitioner assessed it weekly. R62 told V2 his left leg prosthetic was rubbing against his skin and caused it to open, it was a facility acquired pressure ulcer. She expected staff to assess and document resident's skin under a prosthesis every day and to document the assessment on the weekly skin assessment. R62's Weekly Skin Assessment, dated 4/2022 through 10/2022 no assessment of R62's skin under the prosthesis. On 10/6/2022 at 1:17 PM, V29 Wound Nurse Practitioner stated she initially assessed the pressure ulcer on R62's left BKA on 6/7/2022. Staff informed her the pressure ulcer was caused from an ill-fitting prosthesis on his left leg. V29 stated this was an avoidable pressure ulcer because staff should have been checking the prosthesis to ensure it fit R62's left BKA properly and assessing his skin under the prothesis as well. On 10/6/2022 at 2:00 PM R62 was sitting in his room with his left prosthetic on. R62 stated they amputated his left leg about 5 years ago and his right leg 8/2022. He has a lot of health issues including diabetes, PVD and he's on [CONDITION(S)]. He got a wound on his left BKA because his leg prosthetic rubbed against his skin. The prosthetic company came to the facility a while ago and replaced a part on his prosthesis he didn't know when the prosthetic company came out. On 10/7/2022 at 7:30 AM V1, Administrator stated R62 wasn't compliant with wearing his left leg prosthetic. On 10/7/2022 at 8:00 AM, R62 was sitting in his wheelchair outside the dining room with his leg prosthesis. On 10/7/2022 at 9:43 AM, V28 Vascular Physician stated R62 had a left BKA years ago due to DM, [CONDITION(S)] and severe PVD. If a pressure ulcer developed from an ill-fitting prosthesis is an avoidable pressure ulcer. He expected the facility staff to follow their pressure ulcer and skin policies and assess the skin under the prosthesis per facility protocols. R62's Physician's Telephone Order dated 10/7/2022 documents a new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Pressure Ulcer/Injury & Skin Conditions Guide for Wound Evaluations Document Policy, dated 11/2017 policy: it is the practice of this facility to ensure residents with pressure ulcers receive necessary evaluation and treatment to promote healing, prevent infection and prevent new ulcers from developing. The assessment documentation includes length, width and depth measurements, tunneling/undermining, exudate (drainage), wound bed, peri-wound and pain, wound status: healing, no change, physician/family notifications, order changes and nutrition/hydration status. Upon identification of a pressure ulcer regardless, if developed in house or upon admission, the area is to be documented on the Wound Evaluation form or in electronic format. Contact physician, interdisciplinary team, family members, and significant others as indicated. Initiate appropriate treatment per treatment protocol and physician order. Evaluate further interventions that may be indicated to promote healing and prevent infection. Documentation of wound status will occur at least once a week. this weekly evaluation will be documented electronically or on the Wound Evaluation Form/Skin Condition Form as appropriate. The physician is to be notified if there is no improvement in area, signs and symptoms of infection or signs of deterioration. The Unit Manager/Charge Nurse are responsible to ensure pressure ulcer treatment plan is addressed on the resident's plan of care. The Guide for Wound Evaluation and Documentation (above) can be utilized as a reference tool for licensed nurses when completing this documentation. This guide can be kept in the front with the treatment sheet for the month if completed manually. This is placed in the medical record. The Director or Nursing and/or designated licensed nurses will make pressure ulcer rounds on a weekly basis. Documentation of the area will be address. Resident progress or lack of progress will be evaluated. Directives may be given for further interventions and changes in plan of care. The resident's current care plan will also be reviewed. When a pressure ulcer heals, a preventative plan of care should have initiated.

Based on observation, interviews, and record review the facility failed to provide restorative or licensed therapy to prevent the decline in Range of Motion, (ROM), for 1 of 3 residents, (R4) reviewed for restorative programs in the sample of 36. This failure resulted in (R4's) physical decline not able to use his left arm, limited ROM in his right arm. Findings include: R4's Minimum Data Set, (MDS), dated [DATE], documents R4 is intact cognitive response for cognitive skills for decision making, requires extensive assistance with two person physical assist for bed mobility, requires extensive assistance with two person physical assist for transfers, requires extensive assistance with one person assist for dressing, requires extensive assistance extensive assistance with one person physical assist for eating, requires extensive assistance with one person physical assist for personal hygiene, special treatments, procedures, and Programs zero (0) documentation for physical therapy, speech therapy, occupational therapy, or restorative nursing programs. R4's Care Plan dated 06/21/2022, documents R4 is a short-term care resident to return home with family and home health services. Interventions dated 06/21/2022 encourage me to participate in all recommended therapies. Require assist with Activities of Daily Living (ADL's) r/t impaired mobility impaired cognition will often refuse care, meds, and therapy. Transfers with 2 assist and Hoyer Lift - bedrest at this time per residents/family request, provide assist with any and all ADLs as needed. Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On, 10/04/2022 at 11:58 AM, V18 R4's mother said, R4 tries to feed himself with finger foods. I bring in chicken tenders most of the time. Break the chicken tenders apart then hand him the chicken he will put it in his mouth using his right arm. V18 said she brings food in for him to eat because they serve him food he doesn't like and won't eat, and he likes the chicken tenders. He needs finger foods so he can use that right arm to feed himself. At times I will feed him, or the staff will feed him the foods that are not finger foods. V18 said he lost the ability to feed himself or do anything because he hasn't had any kind of exercises or therapy on him for a while now. V18 said R4 had a [CONDITION(S)] and stroke, and he needs therapy and exercises. I've told them he needs to be exercised but was told by staff that management said he couldn't have therapy. V18 said at times R4 can push the TV remote button, and call light at times with his good hand. V18 said R4 has not walked since February 2022. She said his legs and arms are sore most of the time and know it's because he does not get exercised. V18 said they don't get him up in a chair, or ever give him a shower. Would like to see him get up for just a bit, I know he has sores on his bottom but would like him up for a little bit and have a shower, exercises, and some kind of therapy to help him. 10/04/2022 at 1:30 PM V7 Licensed Practical Nurse/Restorative Nurse (LPN/RN) said, R4 is not on any Restorative Programs, not sure why he isn't. 10/04/ 2022 at 1:42 PM V2 Director of Nursing (DON) said, R4 was in Hospice and family revoked him being on Hospice, not interested in Hospice - family not on board. V2 said R4 came off Hospice 8/19/2022. Not sure why R4 wasn't placed on restorative program and screened for therapy. On, 10/05/2022 at 1:50PM, V20 R4's dad stated, don't want Hospice again they told us he wasn't eating and needed Hospice. The facility finally put him on a pill to help with his appetite. His appetite is better since on the pill. V20 said he told V6 Licensed Practical Nurse/Wound Care Nurse (LPN/WCN) they wanted him to get up to a chair, shower, and evening sit on side of the bed to soak his feet. V20 said, the WCN said they can't get him up in a chair because my boss said he couldn't get up. V20 said he is losing his ability to do anything by not getting therapy. On, 10/05/2022 at 2:03PM, R4 stated, I haven't got up for a shower, no exercises, only a bed bath. I would like to have a shower and have some exercises. On, 10/05/2022 at 2:57PM, V23 Certified Nurse Aide (CNA) assisted V6 LPN/WCN with providing treatment to R4's wounds. R4 used his right hand and grabbed the handrail to help roll to his right side for treatment to be provided. On, 10/06/2022 at 10:35AM, V15 Occupational Therapists (OT) stated, I evaluated R4 yesterday and we are picking him up for OT for self-feeding, grooming, hygiene, fine motor coordination, and positioning five times per week for eight weeks. On, 10/06/2022 at 10:45AM, V16 Occupational Therapists (OT) Director of Therapy Services said, anytime a resident comes off skilled therapy an email is sent to V7 Restorative Nurse and V1 Administrator cc'd for recommendations. R4 was discharged off skilled therapy because he went on Hospice. V16 said, when he was discharged from Hospice not sure what happened to why he wasn't screened after his Hospice discharge. On, 10/06/2022 at 12:25PM, V18 R4's mom at bedside visiting with R4. R4's head of bed elevated, and R4 has his right arm behind his head watching TV and talking to his mom. On, 10/06/2022 at 12:46AM, V16 (OT) stated we have no documentation that R4 was screened again after his discharge from Hospice. On, 10/07/2022 at 10:02AM, V24 Certified Occupational Therapy Assistant (COTA) stated it is possible if a resident comes off skilled therapy could decline if not recommended for Restorative Programs. On, 10/07/2022 at 10:06AM, V15 Occupational Therapists (OT) said, a Functional Maintenance Program (FMP) recommends the Restorative Program so any resident being discharged off skilled therapy and staying here in the facility is recommended a restorative program to help maintain, or decline. R4's Departmental Notes, dated 8/24/2022 at 4:00PM, documents, (R4) has chosen to discharge from hospice services as of 09/19/2022. R4's Departmental Notes, dated 8/26/2022 at 2:51PM, document, Interdisciplinary Department Team (IDT) meeting held (R4's) chart reviewed, wound care discussed, no new orders, no recommendations received, (R4) has been taken off hospice care, wound care specialists, registered dietician, director of nursing, responsible representative, medical director, aware of status. R4's Physical Therapy PT Discharge Summary dated 6/22/2022 - 6/29/2022, documents, discharge recommendations you are discharged from physical therapy on 6/29/2022 due to no longer requiring the skills of a therapist. You are discharge to this skilled nursing facility with hospice. You will require full time nursing care. You did not achieve your personal goal for wanting to get up in a wheelchair. Restorative program established/trained equals not indicated at this time. Functional maintenance program established/trained equals not at this time. Prognosis to maintain Current Level of Function (CLOF) equals N/A, Factors Impacting Prognosis Equal Risk for change in medical condition. R4's Occupation Therapy Treatment Encounter Notes dated 10/07/2022, documents, precautions/contraindications fall risk, foley catheter and rectal tube. Patient provided with Estim PENS UE triphasic to right forearm to facilitate wrist Range of Motion (ROM)/strength needed for self-feeding and hygiene/grooming. Patient provided with Active Range of Motion (AROM) to left upper extremity (LUE) and educated on SROM to increase ROM and strength to facilitate bilateral upper extremity (BUE) movement with washing face. Patient completed self-feeding with finger foods eating two sandwiches with SBA. Patient completed hygiene/grooming washing face with SBA Subject: Nursing Rehabilitation/ Restorative Care Policy dated 10/09 Rehabilitative or restorative care refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as is possible. Focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. A restorative program should be started when a resident is admitted with restorative needs, but not a candidate for therapy, or when the need arises during a stay.

Based on observation, interview and record review the facility failed to document, assess, monitor and implement safety measures for 1 of 10 residents (R32) reviewed for falls in the sample of 36. This failure resulted R32 falling from his wheelchair and sustaining a focal hemorrhagic confusion of cerebrum (brain bleed) and being hospitalized and admitted to the trauma intensive care unit. Findings include: The Incident Log provided by the facility documents R32 had a fall on 1/5/2022 at 6:45 PM and suffered an injury. The log also documents R32 fell in resident room on 6/30/2022 at 5:30 PM, R32 was found on floor. The Fall log does not document any other falls for R32. R32's Physician Order Sheet (POS) dated October 2022 documents a diagnosis of [CONDITION(S)] following cerebral infarction affecting right dominant side, [CONDITION(S)], other symptoms and signs with cognitive functions following non-traumatic [CONDITION(S)]. R32 also has an order for 50 milligrams (mg) of [MEDICATION(S)] by mouth daily. R32's Diagnosis History document a diagnosis of [CONDITION(S)] following non-traumatic intracerebral hemorrhage dated 7/22/2022 and [CONDITION(S)] following non-traumatic intracerebral hemorrhage dated 6/17/2022 and history of falling. R32's Fall assessment dated [DATE] document R32 was a high risk for falls. On 10/11/2022 at 9:49 AM, V30, Licensed Practical Nurse, (LPN), stated, (R32) would have behaviors of screaming and yelling, but he was easily redirected. I did not have any issues with him personally. I know he was involved in one resident to resident altercation, and he got into it with another resident. Again, I did not have any issues with redirecting him. On 10/11/2022 at 10:03 AM, V31, Certified Nursing Assistant (CNA) stated, (R32) has a history of screaming and yelling. It was usually started with another a resident. I did not have any issues with any issues with redirecting him. (R32) had a stroke a few months ago and he yells a lot now. On 10/11/2022 at 10:15 AM, V7 stated, At times (R32) will yell out and if he is upset, he will cuss loudly. As long as he has his cigarettes, he is usually happy. I do not have any issues with redirecting him. (R32) had a stroke back in July and has issues with communicating things from his brain to his mouth. He yells out a lot. R32's Care Plan dated 10/2022 documents R32 requires assist with all activities of daily living related to impaired mobility, weakness, diagnosis [CONDITION(S)] with right side [CONDITION(S)]. R32's Care Plan also documents he is at increased risk for falls related to impaired mobility/weakness, diagnosis of right-side [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], depression with the use of [CONDITION(S)] medication. R32's Progress Notes showed nothing documented in his medical records regarding his fall on 10/3/2022. R32's Progress Notes handwritten dated 10/4/2022 at 5:00 AM, written by V17, Licensed Practical Nurse shows, Resident presented to this nurse by facility staff after having a behavior causing him to topple his wheelchair backward and hit the ground around 7:20 PM on 10/3/2022 in the hallway. This fall was witnessed and reported to this nurse as intentional. This nurse called (V2, Director of Nursing) at 7:33 PM to make her aware. Spoke with Nurse Practitioner (V25) at 7:35 PM and received orders to send the resident out for evaluation related to large knot that had formed on the back of his neck, continued behaviors and blown pupils slow to react. Emergency Medical Services was called to make a transfer of the resident from facility to (Hospital) around 7:40 PM. Report called into Emergency Department at this time. Emergency Medical Services (EMS) arrived and resident extremely confused and combative while responding inappropriately. EMS informed this nurse they would be taking the resident to a different hospital instead for better plan of care. This resident has no contacts listed. R32's Resident Incident Report dated 10/3/2022 at 7:20 PM, Resident was noted to be yelling and rocking his wheelchair and tipped it backwards in the hallway. Nurse assessed resident. Range of Motion performed. Resident placed back in his wheelchair. DON and NP notified of fall. NP gave order to send to ER for evaluation. Knot/hematoma to back of head 2 x 2 centimeters. Additional Follow ups: Sent to emergency room for evaluation. admitted to hospital with altered mental status, subarachnoid hemorrhage stroke, will place anti roll backs on resident wheelchair upon his return. The Incident Report was not reported to the state until 10/6/2022. R32's Initial Report dated 10/6/2022 documents, (R32) fell at approximately 7:15 PM on 10/3/2022, (R34) was transferred to emergency room for a bump of his head. He was admitted to hospital with altered mental status and a subarachnoid hemorrhage per the Nurse on 10/5/2022 at approximately 5:30 PM. Final to follow. This report was not sent to the state until 10/6/2022. R32's Incident/Accident Report dated 10/3/2022 at 7:20 PM, documents, resident started yelling and attempted to tip wheelchair. Large hematoma to back of head. Resident sent to emergency room . On 10/7/2022 at 1:45 PM, V26, Registered Nurse (RN) stated, If a resident has a fall there is a neurological evaluation form in the drawer at the nurse's station that we are supposed to fill out and then place in the resident's chart. On 10/17/2022 at 2:22 PM, R32's chart was reviewed and does not have any Neurological Evaluation Flow Sheet present in his chart or Incident Report. No neuro checks were present in the R32's medical records. R32's Hospital Records dated 10/3/2022 at 808 PM, (R35) us a [AGE] year-old male with past medical history significant for hypertension, [CONDITION(S)], type 2 diabetes mellitus, right branch vein occlusion, and chronic left cerebellar stroke who present with AMS (altered mental status) and vomiting of S/P (Status post) fall from wheelchair. The fall occurred at an unknown time. There was unknown LOC (loss of consciousness). They did not arrive on a backboard and continued to remove the c-collar. The patient is altered and unable to provide a history due to mental status. On arrival, patient was reported to be alert and orientated x 2 but not on exam now, patient is non-verbal and lethargic. R32's Hospital Records dated 10/4/2022 document, admitted to the Intensive Care Unit (ICU) overnight. Worsening head bleed on CT (Computed tomography), follow up ordered. Platelet dysfunction addressed. R32's Assessment documents focal hemorrhagic confusion of cerebrum. On 10/11/2022 at 10:33 AM, V1, Administrator stated, I did not view the incident on the camera because it happened in the lounge area right in front of the area where residents go outside to smoke. The camera did not catch the fall. On 10/11/2022 at 10:41 AM, V17, LPN, Agency nurse stated, I did not witness (R34's) fall. I do not what his behavior were occurring at the time because I was not there. I was told (R32) threw himself from his wheelchair and the CNA put him back into his wheelchair and brought him to me. The CNA had got him up and he was in his wheelchair when I saw him. I am agency so I cannot tell you who the CNA was. I had to run around trying to find his chart, and the physician's information. (R34's) pupils were blown and his pupils were large. I was scared he had a brain bleed. I did not document any neuro checks on him, but he was with me the whole time. On 10/11/2022 at 12:46 PM, V33, Medical Director stated, Any resident with a fall I would expect staff to follow protocol and assess the residents, do neuro checks on the residents and send the resident out to the hospital. If a resident was yelling out, I would expect staff to try and find out why they were yelling and what was going on with them. On 10/11/2022 at 11:42 AM V32, R32's hospital nurse stated (R32's) CAT scan (CT) documents, R32 has an acute subdural hemorrhage, an acute subarachnoid hemorrhage, and an acute intraventricular hemorrhage. V32 stated these are all documented as acute, so the head injuries were caused from R32 falling and hitting his head. The Interdisciplinary Fall Reduction/ Injury Prevention Protocol with a revision dated of 7/12 documents, An interdisciplinary approach at reducing falls, preventing injury and increasing safety awareness ultimately resulting in improved quality of care for our residents. Witnessed statements are to be obtained as soon as possible post fall, by all staff members working on that unit.

Based on observation, interview and record review the Facility failed to document falls, assess and monitor and implement safety measures for 3 of 10 residents (R26, R28, R165) reviewed for falls/incidents in the sample of 40. This failure resulted in R165's fall sustaining a fracture to left humerus, left shoulder humerus fracture and compression fractures of T1, T3 and T4. Findings include: 1. On 11/2/2021 at 9:35 AM, when entering R165's room he was lying on his bed. The sheet around R165's head was stained in a brown ring the size of a football circling his head. The Peripherally inserted central catheter (PICC) line machine was beeping and V2, Director of Nursing (DON), entered the room and shut off the machine and left the room. On 11/2/2021 at 9:39 AM, V2 stated, I am not sure what is happening with (R165) or what is going on with the brown staining around his head. I will have a look. He has sutures to that area it looks like the area is wet, I will go and get the Wound Nurse. On 11/4/2021 at 2:21 PM, V7, Wound Nurse stated, (R165) was admitted with a cranioplasty and multiple sutures to his head. (R165) had about 35 sutures in his head when he came here from the hospital. This area here is wet and stated there was drainage coming from an area on R165's head sutures. I will contact the doctor. The Incident Log provided by the Facility on 11/2/2021 document R165 had a fall on 9/24/2021 at 6:40 PM, 9/29/2021 at 10:30 AM, and 9/29/2021 at 10:31 AM. R165's Face sheet documents he was admitted to the facility on [DATE]. R165's Nurses Notes dated 9/27/2021 at 9:35 PM, document, New admit charting day 3. Resident is high risk for falls. Resident incontinent of bowel and bladder with good peri care given with each incontinent episode. Resident is assist of 2 with use of gait belt for transfers. Resident is assist for 2 for Activities of Daily Living related to resident becoming combative with personal care. Resident has no injuries noted related to incident. Resident has canoe mattress and safety floor mat on left side of bed. No complaints of pain or discomfort voiced. Call light in easy reach. R165's Physician Order Sheet for September 2021 documents a diagnosis of [CONDITION(S)] following cerebral infarction affecting left non-dominant side. [MEDICATION(S)] (apixabin-a blood thinner) 5mg (milligrams), take 1 tablet by mouth 2 times a day. [MEDICATION(S)] (a blood thinner) 5000 unit/milliliter inject 1 milliliter subcutaneously every 12 hours. R165's Interim Care Plan dated 9/24/2021 documents, Cognition confuse, alert and orientated times one. Bowel and Bladder, risk for incontinence, [CONDITION(S)], incontinent of bowel and bladder, History of Falls, high low bed related to craniotomy. R165's Nurses' Notes dated 9/24/2021 at 6:00 PM, documents, Resident transferred to room. Resident oriented to new facility and staff, Resident is confused, does not understand where he is or that the people in the room are nursing staff. Resident talking to right side of bed not to a person. Residents' states, 'he needs to go to work with [NAME],' Resident is somewhat aggressive with nurses and while trying to reposition him in bed. Attempts made to de-escalate resident with some success. Resident has slight left side facial droop, left arm is flaccid, left leg very weak, right arm leg strong and able to grip with right hand, right leg strong, lung sounds clean, respirations even and unlabored, bowels sound positive, abdomen soft and non-distended, condom catheter patent and draining dark yellow urine, incision to right side of resident head well approximated, moisture or staples open to air. Resident denies pain, call light given to patient, use of call light education done with patient, will continue to monitor. R165's Nurses Notes dated 9/24/2021, documents, At approximately 6:40 PM, resident's call light was (on), Certified Nursing Assistant went to answer the light when he came down to the nurse's station to get nurse because resident was sitting on the floor on his buttocks, legs folded 'Indian style'. When asked what happened resident stated, 'I went to stand up fell straight to the floor.' Resident roommate alert and orientated x 3-4 (person, place, time and situation) stated he turned the call light on when he fell on the floor. He did not hit his head. Range of Motion (ROM) pain and body assessment completed. No injury noted at this time. Resident very agitated, PRN (as needed) order for 2.5 mg of [MEDICATION(S)] by mouth, Resident's medication not in the facility yet. This nurse checked Emergency kit to find (IM) intramuscular. Contacted Nurse Practitioner and informed her of fall, gave 1 time order for 2.5 milligrams of [MEDICATION(S)] ([MEDICATION(S)]) Intramuscularly (IM). Resident brought up to nurse's station related to keep trying to get up. Resident verbal/physical combative with staff, Will continue to monitor. R165's Resident Incident Report dated 9/24/2021 at 6:40 PM, documents, Resident attempted to out without assistance and fell to the floor. Resident was very agitated at time of occurrence. No injury. R165's Incident Follow Up dated 9/24/2021 at 6:40 PM, documents, Resident attempted to out without assistance and fell to the floor. Resident was very agitated at time of occurrence. Incident Recorded in Progress Notes 9/24/2021. Addressed in Care Plan. R165's Nurses Notes dated 9/29/2021 at 12:57 PM, documents, Resident noted on the floor in resident bathroom, appeared that resident was transferring from chair to toilet unassisted, when asked what happen resident stated, 'I have to poop' resident noted skin tears to both right and left elbows, area cleaned with wc (wet cloth), pat dry, [MEDICATION(S)] and covered with dry dressing, resident alert and oriented, able to make needs known to staff, verbal complaint about pain to left shoulder area placed to Medical Doctor to report incident and make aware of pain to left shoulder. R165's Nurses Notes dated 9/29/2021 at 7:38 PM, documents, Call placed to ambulance for transport at around 7 PM and they arrived at 7:37 PM, Resident assisted by 2 assist and ambulance. Report called to emergency room but got no answer. Will try again. On 11/3/2021 at 9:30 AM, R165's Incident Reports for falls was requested for 9/24/2021 at 6:40 PM, 9/29/2021 at 10:30 AM, and 9/29/2021 at 10:31 AM. No Resident Incident Report was provided by the Facility for the two falls on 9/29/2021. R165's Nurses Notes dated 9/29/2021 at 7:04 PM, documents, Call placed to (V23) Physician, related to x-ray result to left shoulder that shows fracture to left humerus. Received new order to send to emergency room . On 11/3/2021 at 9:01 AM, all nurses notes and Fall reports were requested from 9/24/2021 t0 9/29/2021 for R165. All the nurses' notes were reviewed for R165 and there was no documentation regarding R165 having 2 falls on 9/29/2021. There was no Fall Report provided documenting what fall interventions were put into place for R165 for his first fall on 9/29/2021 or the second fall. There were no nurses' notes documenting R165 was being monitored or any interdisciplinary approaches the facility was doing for R166 for his fall on 9/29/2021. On 11/5/2021 at 3:00 PM, V1, Administrator, stated We have given you everything for (R165's) falls. An undated report prepared by V2, Director of Nursing, stated, On 9/29/2021 at approximately 11:00 am, (R165) had a fall and complained of left shoulder pain. Medical Doctor notified with new order for x-ray to left shoulder. RR (resident representative) notified. X-ray results show fracture to the left humerus. Medical Doctor notified with orders to send to the emergency room (ER) for evaluation and treatment. Resident R (representative) notified. Director of Nursing notified and started investigation. The following was reviewed. Face sheets and diagnosis, Care Plans, Nurses' Notes, Physician Orders, Labs, Assessments, Medical Doctor and Resident Representative notified, Hospital Report and EZ move reviewed. In conclusion through interviews and chart review, (R165) had 2 falls on 9/29/2021. The first fall occurring at 10:30 in his room. The second fall occurring at 11:00AM in his resident bathroom. On 9/24/2021 (R165) was identified upon admission as a fall risk. (R165) was placed in a low bed with a canoe mattress, fall mat placed on floor next to bed upon admission. On 9/29/2021 around 10:30 AM, (R165) attempted to get out of bed without assist to go to the bathroom. (R165) was found on his left side on the floor on left flaccid arm. (R165) was checked and changed due to incontinent of urine around 9:30 AM, prior to the first fall. At approximately 11:00 AM, (R165) was found on the floor in his bathroom. (R165) attempted to put himself back on the toilet around 10:40 AM and fell and then complained about left shoulder pain. Staff had just placed (R165) on the toilet around 10:40 AM so that he could have a bowel movement and was assisted back to his wheelchair. Medical Doctor was notified. New orders received for an x-ray that was positive for a fracture to the left shoulder. Orders received to send to emergency room . Resident Representative and Stage was notified. (R165) was admitted to the (local hospital) and remains at the hospital at this time. (R165) is impulsive and did not call or wait for assistance and has [CONDITION(S)] which could be a contributing factor that caused the fracture to the left shoulder. (R165) recently had a craniotomy prior to admission to the facility. On 11/4/2021 at 3:30 PM, the facility only provided the Incident Report for falls for R165 for 9/24/2021 at 6:40 PM. No Resident Incident Report requested was provided for the 2 falls on 9/29/2021. R165's Nurses' Notes do not document a fall on 9/29/2021 at 10:30 AM and/or 11:00 AM. R165's nurses' notes do not document anything regarding R165 falling in his room. R165's nurses' notes do not document R165 was toileted before his fall in the bathroom. R165's medical records do not document on 9/29/2021 multiple falls for R165. R165's medical records do not document R165 was being monitored, assessed or any neuro checks were being provided. R165's Care Plan with a Problem Onset 10/18/2021, documents (R165) I am increased risk for falls related to my impaired mobility [CONDITION(S)] diagnosis, [CONDITION(S)] ([CONDITION(S)]), impaired cognition, communication impulsive behaviors/impaired safety awareness, decompressive cranioplasty related to [CONDITION(S)], incontinence, Diagnosis of [CONDITION(S)], Afib, High Blood pressure, use of [CONDITION(S)] medication, history T3, T4 fractures and fracture of left humerus status post fall. On 11/4/2021 at 2:21 PM, V2, Director of Nursing (DON,) stated, He (R165) was admitted with cranioplasty and multiple sutures. (R165) had 3 falls while he was here in the Facility. He was being assessed after his second fall on 9/29/2021 and was complaining of pain, we got x-rays and he had a fracture and was sent out to the local hospital. From the local hospital he was sent out to another hospital and then another hospital. His cranioplasty had to be redone. (R165) did have some compression fractures but I am not sure he got them while he was at our facility. The hospital had to send him out again because they had to redo his cranioplasty because he had some [CONDITION(S)], and they could see some hardware. I would expect this to be charted in his nurse's notes. R165's Hospital Records dated 9/29/2021 document, Traumatic subdural hemorrhage with loss of consciousness of unspecified duration sequela-traumatic acute subdural hematoma initial encounter. Patient coming from (Facility) and rehab patient had an unwitnessed fall today at approximately 12:00 PM, Patient has complaint of left shoulder pain. (Facility) did outpatient x-ray that shows an acute fracture of the surgical neck humerus with mild displacement. Mechanism of injury: Fall. Patient fell from his wheelchair at approximately 12:30 PM. Patient was complaining of left arm pain so the nursing did x-ray and found he had a humerus fracture. Nursing home sent patient over at approximately 8 PM, upon arrival patient is alert and oriented times one. R165's Hospital 2 notes documents (R165) is a [AGE] year-old with past medical history of [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], and RMCA stroke and a documented past psychiatric history, major depressive disorder who was admitted on [DATE] for Level 2 Trauma after falling in a nursing home with resulting left humerus fracture and compressed fracture of T1, T3 and T4. R165's Hospital Records dated 10/7/2021 document, (R165) is a [AGE] year-old male, was brought to (hospital) by EMS (emergency medical systems) on 9/29/2021 following a fall at skilled nursing facility. Workup showed subdural fluid collection consistent with post-operative changes and age indeterminate T3 and T4 compression fracture. R165's Hospital Records from his second hospital dated 9/30/2021 document, (R165) is a [AGE] year-old male who presents as a level 2 trauma transferred from (former hospital) fall at 1:00 PM. He lives in a nursing home and fell while transferring from wheelchair to commode. There was unknown Level OC (of consciousness). They arrived on a backboard and without a c-collar in place. Workup at (hospital) revealed left humerus fracture and a right shoulder displaced humerus (SDH). Patient is on [MEDICATION(S)] and did not receive [MEDICATION(S)] before transport. Injuries: SDH, right humerus fracture and age indeterminate T3 and T4 compression fractures. Patient was admitted to the Intensive Care Unit (ICU). The Interdisciplinary Fall Reduction/Injury Prevention Protocol Policy dated 7/2021 documents, An interdisciplinary approach at reducing falls, preventing injury and increasing safety awareness ultimately resulting in improved quality of care for our residents. Assess the resident for adverse reactions/side effects/ vital signs, left and right arm blood pressure and, when applicable, a neurological check. Monitor the resident's condition until stable or according to physician's orders. A detailed account of the incident must be recorded in the medical record. Such documentation should include but is not limited to: time and date of incident, the name and strength of medication, condition of the residents, treatment administered, time the physician was notified and his/her instructions, time, time the resident and or legal representative was notified. On 11/10/2021 V23, Physician stated I expect all residents to be monitored and assessed after falls, vital signs taken, and any neurological checks if there is a suspected head injury. This should be documented in the resident's file. (R165) had a history of falls and was at high risk I would expect him to be watched and monitored. 2. On 11/2/21 at 1:04PM, R28 was observed with 5 burn holes on his lap blanket. R28 stated they are from cigarette ashes dropping on it. On 11/4/21 at 9:12AM, R28 was observed with a burn hole in the upper left side of his pants. R28 states it is from his cigarette ashes dropping on it. R28's Face Sheet, undated, documents a diagnosis of Dementia. R28's MDS, dated [DATE], documents R28 is cognitively intact. R28's Care Plan, dated 9/9/16, documents R28 is a smoker with the following interventions: staff to remind me of designated areas for smoking, provide education to my family and friends regarding smoking policy, perform a smoking risk assessment quarterly, supervised smoking and cigarette and lighter is to be kept at the nurse's station. R28's Smoking Safety Evaluation, dated 8/9/21, documents R28 is able to manage ashes, has no history of smoking related incidents, smokes safely with minimal supervision and is to be supervised smoking by staff. On 11/4/21 at 9AM, V1, Administrator, states R28 will not wear a smoker's apron and the burn holes in his blanket are from a long time ago. The Smoking policy, dated 6/2021, documents all resident's will be subject to modified smoking limitations. Limitations may include, but are not limited to: facility storage of tobacco products and/or fire materials, designated smoking times, assistance with lighting tobacco products, assistance to hold cigarette, supervised smoking by staff and/or other protective/safety measures as determined appropriate by the individualized plan of care based on the smoking evaluation. 3. R26's quarterly MDS, dated [DATE], documents R26 as severely cognitively impaired, requires supervision for bed mobility and eating; Extensive assistance of one person for walk in room, walk in corridor, locomotion on unit, locomotion off unit, personal hygiene, bathing, toileting, dressing, transfers. R26's balance during transitions and walking: Steady at times when moving from seated to standing position, surface to surface transfer and moving on and off toilet; walking and turning around: not steady, only able to stabilize with staff assistance. Mobility devices: walker and wheelchair. R26 has had no falls since admission. R26's Morse fall scale, dated 7/29/21, documents the resident was high risk for falls and to implement high risk fall prevention interventions. R26's Care plan undated documents, Problem: I am at increased risk for falls related to my impaired mobility, impaired cognition/safety awareness. -Goal: My falls/injuries will be minimized through management of my risk factors through next review. -Target date: 11/2021. -Approaches: perform a fall risk assessment on me quarterly and PRN (as needed), provide me a safe environment, place my call light and frequently used items within safe reach, give me verbal reminders not to ambulate or transfer without assistance, I transfer with 1 assist and gait belt, keep my bed in lowest position, refer me to therapy/restorative nursing as needed, encourage me to change positions slowly to avoid dizziness, I have a canoe mattress on my bed. 10/16/21 encourage use of gripper socks. R26's nurse's note dated, 10/17/21 at 3:30 AM, documents, resident found sitting on her bathroom floor by CNA. Res states she was attempting to sit in wheelchair after using the bathroom and slid down to the floor. No apparent injuries. Resident denies pain. She was transferred from the floor by 2 staff and assisted to bed. Res (Resident) educated on the use of her call light and encouraged to wait for assistance before transferring self. R26's incident/accident report, dated 10/17/21, documents res was found on her bathroom floor sitting on her bottom. No apparent injury noted. Resident's states she was attempting to sit in wheelchair and missed chair. Steps taken to prevent recurrence: educate resident to wait for assistance. No injuries sustained. The incident witness statement was blank. R26's Morse fall scale, dated 10/17/21, documents the resident was high risk for falls and to implement high risk fall prevention interventions. R26's medical record showed no new approaches added to her medical record or care plan after she fell on [DATE]. On 11/5/21 at 3:50 PM, V2, Director of Nurse's (DON) stated when a resident fall she expects staff to update the resident's care plan the same day with an intervention that is not already listed on the care plan and for staff to follow the facility's fall policy. The facility's policy, Interdisciplinary Fall Reduction/Injury Protocol dated 7/2012 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: Nursing to complete a fall risk evaluation upon admission, re-admission, quarterly and with significant change. If the total score places the resident at risk, determine appropriate interventions. Once selected, implement the intervention and then add to the resident's plan of care and pocket care guide (PCG). All new admissions/readmissions will be monitored for approximately 72 hours of their stay.

Based on interview and record review the facility failed to administer medication as ordered to 1 of 3 residents (R2) reviewed for medications in the sample of 3. This failure resulted in R2 becoming unresponsive requiring ambulance transfer to the emergency room and a 4-day hospitalization . Findings include: R2's Minimum Data Set, (MDS), dated [DATE] documents R2 is cognitively intact. It also documents that R2 is a [AGE] year-old male with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/16/2021 at 9:19 AM, V1, Administrator, stated, I know why you are here. It is because the doctor wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/16/2021 at 9:30 AM, when 3 months of medication error reports were requested, V1 stated, There have been no medication errors over the last 3 months. On 6/16/2021 at 10:20 AM, R2 stated that he had his tooth pulled by the dentist. R2 stated he was put on medication, but he didn't have any problems when the tooth was pulled. R2 stated when he asked the nurse why he was taking the medication, the nurse didn't give him an explanation and said he had to take it because the doctor ordered it. R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] 800 mg 1 po q (every) 8 hours PRN (as needed). R2's Physician's Telephone Order, dated 6/7/2021 at 4:22 PM, documents the order, [MEDICATION(S)] 50 mg q 4 hours x5 days PRN. R2's POS, dated 6/7/2021, which was transcribed from the Telephone order, documents D/C (discontinue) PCN as allergy. [MEDICATION(S)] 50 mg po q 4 hours x5 days. R2's Departmental Notes, dated 6/5/2021 at 11:11 AM by V11, LPN, documents, Resident received orders per [NAME] dentist (dentist name) for this resident on 6/4/2021. No. (new order) [MEDICATION(S)] 500 mg 1 po TID x7 days, [MEDICATION(S)] 800 mg 1 tab po q8h prn. Resident is responsible for self and this nurse faxed over script to (name) pharmacy. R2's Departmental Notes, dated 6/5/2021 at 6:04 PM by V11, LPN, documents, Resident continues location monitoring and is compliant with signing in and out and where about verified by per this nurse. Resident has started on ABTX (antibiotic treatment) r/t (related to) tooth extraction and not ASE (adverse side effects) noted to ABTX this shift. resident remains afebrile and no c/o (complaint of) pain or discomfort voiced at this time. R2's Departmental Notes, dated 6/6/2021 at 11:46 AM by V11, LPN, documents, Resident continues ABTX r/t multiple tooth extractions and no ASE noted to ABTx and no swelling noted to face at this time. Resident has good appetite noted. afebrile. No c/o pain or discomfort currently. Resident also continues on location monitoring and is compliant and where about verified per this nurse throughout this shift. R2's Departmental Notes, dated 6/7/2021 at 2:58 PM by V9, LPN, documents, Resident currently on [MEDICATION(S)] related to teeth, resident has allergy to PCN (Penicillin), no adverse side effects noted at this time. MD (medical doctor) and resident made aware of current status. R2's Departmental Notes, dated 6/7/2021 at 4:25 PM by V9, LPN, documents, Received orders to D/C (discontinue) PCN allergy, and [MEDICATION(S)] 50 mg 1 po q 4 hours x 5 days PRN as needed for itching, MD and RR (resident representative) aware of current status. R2's Departmental Notes, dated on 6/8/2021 at 10:37 PM by V13, Registered Nurse (RN), documents, Remains on ABT (antibiotic) following tooth extraction. [MEDICATION(S)] given as ordered with no adverse reaction noted. denies c/o pain. denies c/o discomfort with chewing. up and about independently. sitting in activity room at this time watching TV. R2's Departmental Notes, dated on 6/9/2021 at 12:11 PM by V2, LPN, documents Remains on abt related to tooth extraction no voiced c/o pain or discomfort. on location monitoring complaint with signing in/out. R2's Departmental Notes, dated 6/10/2021 at 1:03 PM by V11, LPN, documents, Management of this facility made this nurse aware that resident was not acting right this present day at 12:30 PM. Resident was sitting in activity room and c/o headache. Resident was not able to grasp hands of this nurse and bilateral upper extremities displayed involuntary movement and resident was able to speak at times but needed to allow time for resident to answer questions. Resident has moments of blank stare and not able to respond to this nurse. B/P 97/84 P75 -16-97.7. At 12:35 PM this present day, Dr. notified, and this nurse received new order to send resident to ER (emergency room ) for eval and tx (treatment). This nurse called (local), ambulance and requested lights and sirens this present day. This nurse called and gave report to (local) ER nurse of this resident. 12:42 this day this nurse called daughter and made aware of resident status at this time. (Local) EMS (Emergency Medical Services) x 2 attendants here in this facility this present day at 12:50 PM to transport resident to ER for Eval (evaluation) and Tx. R2's POS dated 6/10/2021 documents Send to (local emergency room ) for evaluation. R2's Departmental Notes, dated 6/10/2021 at 5:23 PM by V11, LPN, documents, This nurse called local hospital to receive update and report that resident was being transferred to another hospital for altered mental status. R2's discharge instructions from hospital document altered mental status from 6/10/2021-6/14/2021 and in bold handwritten writing Do not give [MEDICATION(S)]! on page 6 of 6 instructions document, You were hospitalized due to confusion and abnormal movements called [CONDITION(S)] due to over sedation from your home medication. Please DISCONTINUE [MEDICATION(S)]. Please use [MEDICATION(S)] sparingly and only as needed (Not scheduled). R2's assessment plan from hospital documents, The patient's mental status has notably improved. Likely etiology is toxic/metabolic in the setting of polypharmacy (Scheduled low-potency opioids and baclofen) + high amounts of [MEDICATION(S)] administration (receiving 300 mg PO every day for 3 days). Overall, we are reassured by his improvements. Will discuss continuing AED (antiepileptic drugs) therapy moving forward. Altered mental status likely toxic/metabolic in the setting of polypharmacy, (opioids, muscle relaxants, high [MEDICATION(S)] administration.) R2's POS, dated 6/14/2021, documents 1.) D/C [MEDICATION(S)] 2.) Place [MEDICATION(S)] on Allergy List. R2's June 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/16/2021 at 11:49 AM, V3, Pharmacist, stated that if a physician ordered a medication and the nurse transcribed it as a scheduled medication, this is a medication error and it is a significant medication error with [MEDICATION(S)] being ordered as a PRN and given as a scheduled medication. On 6/16/2021 at 3:30 PM, V1, Administrator, asked, Would you like a copy of the medication error form that we completed on R2? We do not keep medication error forms in the physical chart I keep them in a folder. The facility Medication Error Form dated 6/10/2021 documents in part, (R2) given [MEDICATION(S)] 50 mg q 4 hours routine + order was 50 mg PRN for 5 days. Outcome to resident sent to ER for eval. On 6/16/2021 at 4:12 PM, V8, Nurse Practitioner, stated, It is a medication error if a nurse gives a PRN medication as a scheduled medication. I told the facility to make out a medication error form for this mistake. Yes, I consider it a significant medication error when a resident has to go to the hospital over a PRN medication being given as a scheduled medication. On 6/17/2021 at 8:53 AM, V1, Administrator, stated that R2 was in the hospital from 6/10/2021 until 6/14/2021 she did not have any other assessments that were done on (R2) prior to hospitalization , from the nurses other than what was in the chart that she did not have any paper documentation. On 6/17/2021 at 10:30 AM, V10, daughter of R2, stated that she usually has contact with her dad frequently and she didn't know anything about the medication he was on after the dental visit until they notified her of the incident prior to being taken to the hospital. V10 stated that her father asked the nurses what the medication was for and they just told him he had to take it because the doctor ordered it. The facility's Medication Administration General Guidelines policy and procedure, dated 8/2016, documents, 13. When PRN medications are administered, the following documentation is provided: a. Date and time of administration, dose, route of administration (if other than oral), and if applicable, the injection site. b. Complaints or symptoms for which the medication was given. c. Results observed from giving the dose and the time results were noted. d. Resident pain evaluation per facility policy, if applicable. e. Signature or initials of person recording administration and signature or pintails of person recording effects if different person administering.

Based on interview and record review the facility failed to answer call lights to provide timely dignified care for 4 of 5 residents (R2, R3, R5, R7) reviewed for call lights in a sample of 13. This failure resulted in R2 having feelings of embarrassment and she doesn't matter, R3 having feelings of embarrassment and being like a child and R5 crying when talking about her experience with not receiving timely care. Findings include: 1. R3's Care Plan, not dated, documents in part, I require assist with my ADL's (Activities of Daily Living) r/t (related to) my impaired mobility. Dx (diagnosis) CVA (stroke), s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] R3's Minimum Data Set (MDS), dated [DATE], documents R3 is cognitively intact, frequently incontinent of urine and requires extensive assist of 1 for all ADL's except eating. On 3/22/2021 at 10:27 AM R3 stated that there is not enough staff and only have one CNA (Certified Nursing Assistant) on evenings. R3 stated that it takes a long time to answer the call light if they answer it at all, especially on evenings. On 3/23/2021 at 10:30 AM R3 stated that she has had accidents (incontinent episodes) waiting on staff to answer her call light. R3 stated that she feels embarrassed and it makes her feel like a child. 2. R2's Care Plan, not dated, documents in part, I require assist with my ADL's r/t my impaired mobility. Dx [CONDITION(S)] (Chronic Obstructive Pulmonary Disease), CHF (Congestive Heart Failure), OA (Osteoarthritis). I have some hearing loss. I have a L (left) prosthetic eye. On 3/23/2021 at 10:19 AM R2 stated that she has sat in stool for about 3 hours waiting on staff to clean her up. R2 stated that she is incontinent of bowel and bladder and needs help with cleaning. R2 stated that she needs two people to help turn her over and because they only have one CNA it takes even longer to receive care. R2 also stated that she has waited for 40 minutes, fell asleep waking up 1 hour later and no one has answered her light or changed her. R2 stated that she feels embarrassed and like she doesn't matter. R2 stated she waits as long as she can before calling for help, because she doesn't want to inconvenience the staff. 3. R7's Care Plan, not dated, documents in part, I require assist with my ADL's r/t my impaired mobility - dx CVA (stroke) with [CONDITION(S)]. R7's MDS, dated [DATE], documents R7 is cognitively intact, always incontinent of bowel and bladder and requires extensive assist from staff for ADL's. On 3/24/2021 at 10:00 AM R7 stated that call lights can take over an hour to be answered. On 3/22/2021 at 3:20 PM V20 (CNA) stated that she and V19 (CNA) were the only CNAs in the building on 3/13/2021 and 3/14/2021 for the evening shift. V20 stated that this has happened before, as recent as the Monday prior. V20 stated that with one CNA on the hall she is not able to give the residents the proper care they deserve. V20 also stated that the residents had to wait for long periods of time to get care. V20 stated it took over an hour to answer some residents' call lights and longer than that to get care. V20 stated that if she is in a room with a resident and someone else's light is on it may take a long time before that resident gets care. With one staff she can't be everywhere. V20 stated, There were two nurses here, but they were busy passing pills and stuff. They (Nurses) couldn't and didn't help us. V20 stated that they kept calling the staff coordinator to get help, but she didn't answer the phone. V20 stated, Sometimes you have to leave the hall unattended to go help on the other side of the building. V20 stated that the residents that needed two people to assist had a very long wait. V20 stated that she couldn't do them by herself. V20 stated she needed help and there was none. On 3/22/2021 at 3:50 PM V19 (CNA) stated that she and V20 were the only CNAs in the building. V19 stated that she felt that the residents were not getting quality care. V19 stated that it is impossible when she is the only aide working the hall. V19 stated call lights were not answered timely and some people waited up to three to four hours to be checked and changed. V19 stated if someone fell , she wouldn't know because she is in another person's room or at the other end of the hall at the other end of the building. V19 stated showers were not completed. V19 stated she is not aware if anyone made any calls. V19 stated there is no need to complain, there is no one to come in. V19 stated they don't have the staff. On 3/23/2021 at 10:50 AM V2 (Director of Nursing) stated they have contracts with two staffing agencies. V2 stated if someone calls off, they reach out to them. V2 stated, If they can't get anyone then the nurse managers come in and help. V2 stated that she would have to check into why this didn't happen. On 3/23/2021 at 2:20 PM V22 (Regional Clinical Nurse) stated that she would expect the staff to answer the call light before one hour and provide care before three to four hours. On 3/23/2021 at 2:30 PM V1 (Administrator) stated that the facility did not have a call light policy. The Facility's Resident Council Record, dated 2/16/2021, documents in part, Issues, Recommendations, Comments: Not enough CNAs. It also documents Call light, they take too long. 4. R5's Care Plan, not dated, documents in part, I require assist with my ADL's r/t my impaired mobility. Dx [CONDITION(S)], OA, scoliosis, [CONDITION(S)]. R5's MDS, dated [DATE], documents R5 is cognitively intact and requires extensive assist with ADLs. On 3/22/2021 at 10:50 AM R5 stated that there isn't enough staff. R5 stated call lights on evenings can take anywhere from 30 minutes to 90 minutes to be answered. R5 stated that one Sunday she was in BM (bowel movement) for 2 hours and 45 minutes. R5 stated she was incontinent of BM twice during that time. R5 also stated another time she was in pee (urine) for 2 hours. During this interview, R5 was shaking and tearful when discussing this subject.

Based on observation, interview and record review, the facility failed to provide supervision and assistive devices for 4 of 7 residents (R38, R42, R74, R78) reviewed for falls in the sample of 41. This failure resulted in R38 falling multiple times sustaining a fractured humerus and [MEDICAL CONDITION]. Findings include: 1. On 09/17/19 12:32 PM, R38 was observed sitting up in a wheelchair with a wedged cushion between her legs at the assisted dining room table. At 2:52 PM, V5 (Certified Nursing Assistant/CNA) stated R38 does not ambulate anymore after she fell and broke her hip. The physician's orders [REDACTED]. The POS documented R38 required a full mechanical lift, a wedged cushion when up with activities, anti-tippers to wheelchair and canoe mattress. The Minimum Data Set (MDS), dated [DATE], documented R38 was severely cognitively impaired and required extensive assist of one to two staff for mobility, transfers, toileting and bathing. The Care Plan, dated 08/11/19, documented approaches, in part as, provide a safe environment, observe frequently to anticipate and meet needs and give verbal reminders not to ambulate or transfer without assistance. On 03/06/19, the Falls: Morse Scale documented R38 was at risk for falls. On 08/11/19, the Falls: Morse Scale scored R38 with a 75, high risk for falls. On 03/17/19, a Resident Incident Report (RIR) documented R38 was found on the floor at the nurse's station, having stood up from wheelchair in an attempt to self-ambulate. There were no injuries reported. It documented the interventions as continue Occupational Therapy, chair alarm and Physical Therapy to evaluate for wheelchair positioning. On 03/25/19, a RIR documented R38 was found on the floor next to her bed. There were no injuries reported. It documented the intervention was to offer toileting before and after meals and encourage R38 to stay in high traffic areas. On 03/27/19, a RIR documented R38 was found on the floor at the nurse's station. It documented R38 complained of left hip pain. The intervention was for staff to keep resident at their side until ready to go to bed. On 04/02/19, a RIR documented R38 was found on the floor in a pool of urine by her bed. R38 complained of left buttocks and leg pain. X-rays were negative for fractures. It documented the intervention was R38 continues to be toileted frequently. No new interventions were put into place. On 04/10/19, a RIR documented R38 was found on the floor at the nurse's station on her right side. It documented the chair alarm was sounding. R38 complained of right upper extremity pain. X-ray revealed a right humerus fracture. The intervention was for therapy evaluation for positioning, anti-lock brakes and safety release belt when available. There were no observations of R38 having a self-release belt during this survey but on 09/17/19 at 2:45 PM, R38 was observed sitting in the wheelchair across from the nurse's station, the desk was between staff and R38. On 08/06/19, a RIR documented R38 was witnessed by staff to stand up from her wheelchair and fall onto her buttocks to the floor and rolled to the left side into a fetal position, yelling out and grimacing when assessing right leg. X-ray revealed R38 fractured right femoral neck of right hip. R38 was hospitalized and returned to facility on 08/11/19. The interventions were staff educated on fall precautions, staff to monitor when in activities and anti-tippers to the wheelchair. The Interdisciplinary Fall Reduction/Injury Prevention Protocol was reviewed. It documented under Intent: An interdisciplinary approach at reducing falls, preventing injury and increasing safety awareness ultimately resulting in improved quality of care for our residents. Recommendations: Nursing to complete a fall risk evaluation upon admission, re-admission, quarterly and with significant change. If the total score places the resident at risk, determine appropriate interventions. 2. On 9-17-2019 1:15 PM, R78 reported that the facility took off her side rail, without explanation as to why and R78 rolled out of bed because her side rail had been removed. R78 had an air mattress laying on top of the therapeutic raised perimeter mattress. On 09/18/2019 at 2:50 PM, V28 (Quality Technician) stated that it is definitely not recommended to place any other overlay mattress on top of the therapeutic perimeter mattress. This takes away from the therapy for the patient. The Manufacturer guidelines document in part, the therapeutic raised perimeter mattress with wings as supportive, raised perimeter (8 high) cradles the resident, helping prevent injury by discouraging independent exits from bed and gently urging users away from danger positions near the edge of the mattress. R78's Quarterly Minimum Data Set ((MDS) dated [DATE] documents intact cognition. The MDS also documents in part, a functional status for Bed Mobility as requiring extensive assistance with one-person physical assist. [DIAGNOSES REDACTED]. R78's Morse Fall Scale dated 8/23/2019 documents, no fall risk. R78's Side Rail Evaluation Form dated 5/14/2019 and 8/23/2019, document NA to all questions with no additional comments. R78's Care Plan revised date 8/31/2019, documents in part, I am at risk for falls r/t (related to) my impaired mobility/weakness, right BKA ([MEDICAL CONDITION]), mid foot amputation. Care plan approach documents, I have a canoe mattress on my bed. Edit made on care plan dated 8/31/19 to add Fall with no injury. On 8/31/19 at 5:57 AM Nursing was walking down hallway and heard resident scream for help, walked into residents' room and resident was laying on her back with her head against her nightstand with her stump and wound vac on her bed. Her back and neck were flat on the floor, resident stated that she hurt her neck and back. R78 Resident Fall Investigation dated 8/31/2019, documents the Post-Incident Action: Therapy to follow-up with resident r/t safety awareness. On 09/18/2019 to 1:25 PM in an interview with V25 (Physical Therapist) and V26 (Occupational Therapist/OT), neither recalled nor was able to find documentation regarding the care plans recommendations for nursing to follow up for safety awareness tips regarding R78's fall on 8/31/2019. V26 stated resident falls are reviewed in monthly department meetings. V26 stated there is no consult from therapy regarding the use of side rails but side rails may benefit residents who need them for mobility. 3. On 9/18/19 at 1:44 PM R42 stated all his toes on his right foot and part of his foot were amputated. R42 also has stasis ulcers on left leg which are very painful. R42 stated it is difficult to transfer from bed to wheel chair (w/c) or from w/c to bed because of the pain in his feet and the loss of gait and balance. R42 stated using the side rail that had been removed from his bed helped a lot as that kept some of the weight off his legs and foot. The side rails also helped R42 with balance. R42 felt the side rail would have helped prevent him from some of the falls he has had. R42 could have grabbed it to keep from falling out of bed or just from falling forward out of w/c, when he was sitting by the bed. R42 stated, One day staff just came in and took the side rails off; no one told me why they were removing them. Per the Facility's Incident and Accident Log, R42 had falls on 1/31/19, 2/12/19, 2/26/19, 3/10/19, 3/19/19, 7/3/19, 9/12/19 and 9/16/19. R42's recent fall on 9/12/19 documents, Resident stated he was reaching for his w/c and rolled out of bed. R42's MDS dated [DATE] documents his BIMs score of 15, indicating he is alert and oriented. The same MDS also documents R42 requires extensive assist of one staff for transfers and locomotion in the facility, although he propels himself in a w/c throughout the facility and outside to the smoke area. The MDS documents that R42 has a balance problem and was only able to steady self with staff assistance when moving from a seated to a standing position, moving on and off toilet, and when transferring surface to surface, including from bed to w/c or w/c to bed. R42's Side Rail assessment dated [DATE] documents R42 uses a right horseshoe rail but does not include any explanation of risks, benefits or recommendations on how to use it. R42's next Side Rail assessment dated [DATE] does not document any type of enabler or side rail, but documents Y for yes to the question, Does the resident have voluntary movement? All the other assessment questions on this form are marked N/A (Not Applicable). R42's undated Care Plan documents the problem, I require assist with my ADL's (activities of daily living) r/t (related to) impaired mobility/weakness, Dx ([DIAGNOSES REDACTED]. There is no date documenting when the enabler bars were discontinued. On 9/20/19 at 1:05 PM V10 (Care Plan Coordinator) stated she did not know when or why the right-side enabler was removed from R42's bed. V10 stated she removed it from R42's care plan when V1 (Administrator) and V2 (Director of Nursing/DON) told her the enabler had been removed. V10 stated she did not know if R42 needed the enabler or not and was not aware of the reason why the enabler was discontinued. V10 stated there was not a Care Plan Note discussing reason the enabler was discontinued. On 9/20/19 at 1:08 PM V2 stated the date on the siderail assessment would have been the date the enabler would have been discontinued. The assessment would be the reason the enabler was discontinued. V2 did not give an explanation why the enabler was discontinued even though R42 stated it helped him. 4. On 9/17/19 at 9:22 AM R74 was sitting on toilet. Her door was open and there was no clear view of the resident from the hall. R74 stood up from the toilet and turned around and let herself drop into the seat of her w/c, which was causing the w/c to roll back into the wall. About a minute later, V14 (Certified Nursing Assistant/CNA) walked into the room as R74 was wheeling herself back to her bed and stated, Oh, you got yourself off the toilet, did you? and then assisted R74 to transfer back to bed. V14 stated, She (R74) should have waited for me to come back and help her off the toilet. The Facility's Incident Log dated 2/20/19 to 9/17/19 documents R74 had five falls during that time on 2/17/19, 3/27/19, 4/2/19, 4/14/19, and 6/9/19. A review of R74's Resident Incident Reports and staff interviews document the following: on 2/17/19 at 10:20 AM R74 was found on the floor in her room; on 3/27/19 R74 was found lying on the floor near her bathroom; on 4/2/19 R74 was left sitting on bed while CNA left the room to get more towels to clean urine off the bathroom floor and she fell ; on 4/14/19 CNA left resident sitting on bed while she went to get her wheel chair from out in the hall and resident fell and sustained two lacerations to her forehead that required an emergency room visit for two staples to close the laceration on her right forehead; and on 6/9/19, R74 transferred herself from the toilet to her w/c, which was not locked and it rolled backwards and R74 fell to the floor. R74's MDS dated [DATE] documents R74 is severely cognitively impaired and requires extensive assist of one staff for ambulation and transfers and documents R74's is not steady when moving from a seated to standing position, including moving on and off the toilet, and can only stabilize with human assistance. R74's undated Care Plan with a review date of (MONTH) 2019 documents, I am at risk of falls r/t (related to) my impaired mobility d/t (due to) h/o (history of) right [MEDICAL CONDITION], h/o falls, dx ([DIAGNOSES REDACTED]. The interventions include transfer with assist of one, provide me with a safe environment, and observe me frequently to anticipate and meet my needs. On 9/18/19 at 3:55 PM V1 stated R74 should not have been left alone when she was on the toilet. The Facility provided the document, Clinical Guidance for the Assessment and Implementation of Bed Rails in Hospitals, Long Term Care Facilities, and Home Care Settings date (MONTH) 2003 as their policy for side rails and mobility. This policy documents, Bed rails are adjustable metal or rigid plastic bars that attach to the bed and are available in a variety of shapes and sizes from full to half, one-quarter, and one eighth in lengths. Bed rails can facilitate turning and repositioning within the bed or transferring in and out of a bed.

Based on interview and record review the facility failed to promote resident's dignity by not answering call lights timely for 3 of 8 residents (R6, R7, R11) reviewed for dignity in the sample of 20 residents. This failure resulted in R6, R7 and R11 having frequent episodes of urinary incontinent, this causing them to have feeling of embarrassment and degradation. Findings include: 1. On 05/07/19 at 11:00AM, R6 stated, This morning staff woke me up and then, I had to wait an hour with call light on before going to the bathroom. R6 stated she urinated on herself and this embarrassed me to death. R6's Minimum Data Set ((MDS) dated [DATE] documents cognition intact and always continent of urine. Functional Status documents, toileting with extensive assist of two people. 2. On 05/07/19 at 11:05AM, R7 stated it takes forever to get her call light answered. R7 stated she has had frequent accidents (incontinent of urine) due to her call light not being answered. R7 stated she feels bad sitting in her own pee, this is degrading to me. R7's MDS dated [DATE] documents cognition intact and occasionally incontinent. Functional Status of extensive assist to toilet per one person. 3. On 05/08/19 at 9:12AM, R11 stated it takes over an hour plus to get call light answered. She has had accidents (wet the bed) and feels embarrassed having staff change her. R11's MDS dated [DATE] documents cognition intact and transfer with one assist and toilet use with supervision of one person. On 05/09/19, at 8:57AM, V2 (Director of Nursing/DON) stated there was no policy for answering call lights or toileting but standard of care is to toilet every 2 hours or as needed. Grievance/Missing Property Monthly Tracking Log dated (MONTH) 2019 documents that on 04/08/19 R20's sister filed a grievance documenting CNA (Certified Nurse Aide) refusing to toilet R20 and telling him to go in his brief.

Based on interview and record review the facility failed to implement safe transfers for 1 of 3 residents (R9) reviewed for falls in the sample of 13. This failure resulted in R9 being sent to the emergency room and admitted to the hospital with [REDACTED]. Findings include: On 4/01/19 at 1:50 PM V2 (Director of Nursing/DON) stated that R9 reported to V2 that V12 (Certified Nursing Assistant/CNA) had picked R9 up using her muscles, and tripped falling into nightstand. V2 stated that when questioned about the incident, V12 did state that she picked R9 up. V2 stated that R9 is to be transferred with a mechanical lift. R9's Care Plan dated 9/18/13 documents that R9 is at risk for falls. R9's Care Plan Documents that R9 is to be transferred with assist, times 2 and the use of a mechanical lift. R9's Minimum Data Set (MDS) date 1/02/19 documents that R9 requires extensive assistance and two plus person physical assistance for transfers. R9's X-ray report dated 3/27/19 documents fixated [MEDICAL CONDITION], Anatomic alignment, Hardware intact, and Osteopenia with [MEDICAL CONDITION] change. R9's X-ray report dated 3/31/19 documents fixated intertrochanteric fracture with moderate healing. R9's X-ray report dated 4/04/19 of AP and lateral views of the right knee documents mildly displaced oblique [MEDICAL CONDITION] femur metaphysis at the distal margin of the right femoral, antegrade intramedullary nail. R9's x-ray report dated 4/01/19 documents a distal femoral fracture at the distal margin of the intramedullary nail. R9's Physician order [REDACTED]. On 4/04/19 at 2:00PM V2 stated that she would expect staff to use mechanical lift if indicated for a resident. On 4/08/19 at 1:28PM V15 (R9's Physician) stated that an improper transfer could have contributed to R9 receiving a fractured femur. The Facility Policy Invacare Total Lift dated 8/16 documents the total lift is to be used for total lifts.

Based on interview, observations and record review, the facility failed to provide safe transfers, adequate supervision and an effective falls prevention plan for 5 of 5 residents (R1, R2, R7, R8, R9) reviewed for falls and falls prevention in a sample of 14. These failures resulted in R1 falling numerous times sustaining multiple facial fractures from her last fall. Findings include: 1. R1's Minimum Data Set (MDS) documents R1 as a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS documents R1 to have short/long term memory deficits with moderate impaired cognition. The Falls Scale dated 7/6/18 documents R1 to have a total score of 65 with 46+ being high risk with the action for staff to implement high-risk fall prevention interventions. R1's Resident Incident Report dated 7/11/18 at 5:11 PM, documents It was reported to the nurse by 3 nurses sitting at West hall nurses station that CNA (Certified Nurse Aide) ran over resident's foot while pushing another resident's wheelchair to dining room. The report documented R1's great toe right foot toenail is loose and bleeding. The immediate action was to assess the injury and educate CNA on importance of safety while pushing wheelchair. An X-ray of R1's right foot was done and reported as negative for fractures. R1's Resident Incident Report documents on 7/30/18 at 5:31 AM, R1 was found on the floor in the activity room laying on her right side. The report documents that R1 had gripper socks on at the time. The immediate post-incident action added was to encourage resident to stay in traffic areas even though R1 has moderate cognitive impairment. The report documents R1 continues to ambulate about facility independently. R1's Resident Incident Report dated 8/7/18 documents at 9:21 AM, R1 rolled off couch onto the floor. No injury was noted. The report documents R1 continues to ambulate about facility independently. Intervention added was to encourage R1 to go to her room to rest when she is tired. There is no evidence they took R1's cognitive impairment and poor safety awareness into account when contemplating this added intervention. R1's Resident Incident Report documents on 9/2/18 at 5:55 PM, R1 was found on the floor in the hallway. The report documents the fall was unwitnessed with no injuries noted. The Report documents when they stood her up, she fainted and was then lowered to the floor by the nurse. The report documents R1 regained consciousness within 10 seconds and was take to her room in a wheelchair. The Immediate action documented as taken was to do neuro (neurological) checks and the follow up documents R1 continues to ambulate throughout the facility. R1's Resident Incident Report documents on 9/7/18 at 5:46 PM, R1 was in the dining room at supper time walking around tables and tripped on another resident's wheelchair. The report documents R1 fell backwards hitting her head on the edge of the fireplace sustaining a hematoma to the back of her head. Immediate actions taken were to do 15 minute checks and neuro checks. The report documents R1 continues to ambulate independently without any added supervision or increased monitoring. The Departmental Note dated 10/4/18 entered at 2:17 PM by V11 (Licensed Practical Nurse/LPN) documents Nurse stated that my resident was on the floor in hallway, went down to nurse who was with resident assessing her, bruising and blood noted from nose. The Note documented a call was placed to physician and family with the ambulance arriving to transport R1 to the emergency department. The Departmental Note entered by V2 (Director of Nurses/DON) dated 10/4/18 at 5:23 PM documents the facility called the hospital to check the status of R1 and was told that she had multiple facial fractures. The note continues to document that R1's daughter stated to this nurse that she did not want resident to be confined to wc (wheelchair) and did state to this nurse that she knows that her Mom is mobile and that falls are going to occur. This nurse assured family that resident would be on 15 minute checks when she returns from ER (emergency room ) and that staff was going to attempt to keep resident on the east side of the building for closer monitoring. Hospital Records X-ray dated 10/4/18 documents under Findings: Comminuted [MEDICAL CONDITION] wall of the right maxillary sinus communicating with the nasal vault. There is a nondisplaced [MEDICAL CONDITION] wall of the right maxillary sinus with air within the immediate right para maxilla soft tissues. There is a nondisplaced [MEDICAL CONDITION] aspect of the right and left maxillary sinus. There is a nondisplaced nasal septal fracture. Comminuted nasal plate fractures noted, right greater than left. The zygomatic arches are intact. The pterygoid processes are intact. Severe tighward nasal septal deviation of the septum is noted. Evidence of an outdistanced [MEDICAL CONDITION] medial left maxillary sinus wall. A comparison between the MDS dated [DATE] which documents R1 to be independent in all aspects of mobility and ambulation and the quarterly completed on 10/4/18 documents a decline in balance and ambulation. The MDS dated [DATE] (quarterly) documents R1 to have long/short term memory deficits with moderate cognitive impairment. The MDS also documents R1 to require extensive assist of one staff for transfers and set up/supervision for walking in her room/corridor and for locomotion on/off unit. The MDS section entitled Balance during transitions and Walking documents that R1 was steady at all times for moving from seated to standing position, moving on/off toilet and surface to surface but was not steady, but able to stabilize without staff assistance for walking and turning around. There is no evidence the facility took this information and revised R1's fall prevention plan to include increased supervision/assistance, monitoring R1 during periods of continual ambulation for fatigue/weakness and R1's poor safety awareness. The Care Plan dated 7/2018 documents Problem/Need of being at risk for fall r/t (related to) impaired mobility, dx (diagnoses) dementia/Alzheimer's, [MEDICAL CONDITION], incontinence, use of antipsychotic medications. Written in documents Frequent falls r/t (related to) [MEDICAL CONDITION] episodes. R1 had multiple falls identified on the care plan as occurring 7/30/18, 8/7/18, 9/2/18 and 10/4/18 with the immediate interventions added in according to the date of the fall. The goal is to have falls/injuries minimized through management of risk factors through next review (MONTH) (YEAR). Interventions include: Perform a fall risk assessment quarterly and PRN (as needed), provide a safe environment, place my call light and frequently used items within safe reach, and encourage me to participate in activities safely. The care plan failed to reflect R1's overall decline in mobility over the past quarter including her need for a wheelchair at times. The care plan failed to include her need for supervision or continual monitoring for [MEDICAL CONDITION] and/or weakness or her continual wandering about. The interventions used at the time of the falls were ineffective in preventing her from falling and sustaining life threatening injuries. The preventative plan also fails to reflect any interventions toward educating the family who requested that she be ambulating independently. A Fall Risk Assessment completed 10/4/18 following the fall with facial fractures assesses R1 at a lesser risk with a score of 55 with no explanation as to how that would be since she'd had at least 4 falls since that time. On 10/10/18 at 1:30 PM, R1 was in bed. R1 had extensive dark blue/purple bruising about her face from the eyes down which extended down her neck into the clavicle area and sternum of her chest. R1 did not respond when spoken to but just looked about the room when spoken to. On 10/17/18 at 3:01 PM, V11 (LPN) stated the facility reviewed the camera feed of R1's fall on 10/4/18 and determined she turned and tripped over her own feet falling to the floor. There were no staff in attendance. V11 stated R1 continually wandered about the facility and had periods of [MEDICAL CONDITION] as well but that she was not aware of any spells recently. V11 stated there were times when they would use a wheelchair for R1 but she often refused. V11 stated CNAs would assist but she was never categorized as a stand by assist until she returned following her fall on 10/4/18. On 10/17/18 at 10:35 AM, V2 (Director of Nurses/DON) stated she had no explanation as to why R1 would have been assessed at a lesser fall risk in (MONTH) than in July. On 10/18/18 at 12:55 PM, V18 (Nurse Practitioner) for V17 (Physician) stated she recalled R1 and stated she walked and walked. V18 stated R1 had poor safety awareness. V18 stated she was told R1 tripped over her own feet when she fell on her face this last time. V18 stated R1's family did not want her confined to a wheelchair but staff would occasionally get her to lay down on the sofa by the nurse's station. V18 stated she would expect the facility to identify decline in mobility such as was identified in the MDS and put forth effective interventions to ensure safety and would consider increased supervision and monitoring for weakness a part of that. The facility's policy/procedure entitled Interdisciplinary Fall Reductions/Injury Prevention Protocol dated 7/2012 document the intent as An Interdisciplinary approach at reducing falls, preventing injury and increasing safety awareness ultimately resulting in improved quality of care for our residents. Under Recommendations, it documents Nursing to complete a fall risk evaluation upon admission, re-admission, quarterly and with significant change. The policy documents safety devices being checked for placement, staff to wear/use gait belts at all times but fails to reflect any interventions of supervision and/or increased monitoring. 2. The MDS dated [DATE] documents R2 as a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS documents R2 to be cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15. The MDS also documents R2 required extensive assist of two staff for transfers. The Care Plan dated (MONTH) (YEAR) documents R2 was at risk for falls related to impaired mobility due to [MEDICAL CONDITIONS] with left side [MEDICAL CONDITION], hypertension, use of diuretics, [MEDICAL CONDITION], impaired vision, use of antipsychotic medication for sleep and dementia with recent left above knee amputation. The goal is to have injuries minimized through management of risk factors though the next review. Interventions include, in part, transfer with 2 assist and full body mechanical lift. A Resident Incident Report documents on 10/8/18 at 9:20 AM, was in resident room and resident stated that on Saturday 10/6/18, CNA was in residents room transferring resident when she left go of residents chair and resident fell back. No injuries were documented. Departmental Notes dated 10/9/18 at 2:07 PM document Resident self reported fall that occurred on 10/6/2018. Resident stated that around 1:30 PM staff was attempting to get him from the bed to the w/c (wheelchair). Staff was successful and did get resident into w/c and unhooked from the (full body mechanical) lift. w/c was reclined and tilted back to the floor. Resident stated that he did not get injured and he did not hit his head. On 10/10/18 at 1:00 PM, R2 was sitting in his wheelchair in his room. R2 recalled the fall well and stated the CNA (didn't know the name) was on her cell phone by herself when the back of his w/c fell backward causing him to slide out the back of the chair when she lowered him into it. R2 stated the CNA went and got another CNA and with her help, used the mechanical lift to get him off the floor. R2 stated no nurse came down before he was lifted off the floor and he didn't say anything to anyone until that Sunday morning. R2 stated the staff are supposed to always use two staff during a full body lift. R2 denied injuries. On 10/10/18 at 2:00 PM, V2 (DON) stated the CNA who transferred R2 without assistance was V13 and is no longer employed by the facility as they have a policy that requires two to use a full body mechanical lift to transfer. V2 stated it is the policy of the facility to have at least 2 staff to transfer with a full body mechanical lift. V2 stated V13 did not report the fall to the nurse and they did not know about it until R2 self reported the incident two days later. The policy/procedure entitled Total Lift dated 8/2016 documents The Total lift is to be used for total lifts and/or to obtain a resident's weight from bed to chair, or from the floor. 3. The MDS dated [DATE] documents R7 as having no cognitive impairment with a BIMS score of 15. The MDS documents R7 to require extensive assist of 2 staff for transfers. The Care plan dated October, (YEAR) documented R7 to be at risk for falls due to impaired mobility in part. Interventions include transfers with the assist of three staff and a full body mechanical lift. On 10/10/18 at 1:30 PM, R7 confirmed she is transferred with a full body mechanical lift. R7 stated ,They are supposed to use three staff but sometimes use only two. When asked if she is ever transferred by just one CNA, R7 responded, Yes, but not very often. 4. The MDS dated [DATE] documents R8 to be cognitively intact with a BIMS score of 15. The MDS documents R8 requires extensive assist of two staff for transfers. The care plan dated 8/2018 documents R8 to be at risk of falls due to impaired mobility with an intervention documented as I transfer with a (full body mechanical lift) and 2 assist. On 10/10/18 at 1:25 PM, R8 stated he is transferred using the full body mechanical lift. R8 stated he has been transferred by one staff with the lift and at times, lifted by a CNA to transfer too. R8 stated he has never fallen during a transfer and added that the CNA who lifts him is strong. 5. The MDS dated [DATE] identifies R9 as an [AGE] year old female admitted to the facility on [DATE]. The MDS documents R9 to have short/long term memory deficits with severe cognitive impairment. The MDS documents R9 requires extensive assist of two staff for transfers. The Baseline Care Plan (undated) documents under safety, that R9 is to be transferred with 2 assist and gait belt. A Resident Incident Report documents on 10/12/18 at 2:31pm, the nurse was called into residents room from Hospice nurse and resident was noted in sitting position on floor. V15 (Hospice staff) stated that she took resident into room to toilet alone. Resident scooted buttocks to the end of the chair and began to fall to the floor. Nurse was able to intervene and lower resident to the floor. No injuries were noted at the time except bruising and redness to left eye reported on 10/13/18. The report does not document whether R9 had on a gait belt during the transfer or not. Departmental Notes dated 10/12/18 at 4:58 PM entered by V16 documented R9 was taken to bathroom by Hospice nurse. The hospice nurse reported that while she was transferring (R9) to the toilet she lost control of the transfer and gently lowered (R9) to the floor while holding the gait belt. (R9's) buttocks made soft contact with the floor. (R9's) head and other body parts did not make contact with the floor, wall or toilet. (R9) was able to stand and transfer to toilet and chair afterwards. No injuries were found to her buttocks or other body parts. (R9) did not lose consciousness or become suddenly weak or dizzy. On 10/16/18 at 12:45 PM, R9 was in the dining room being assisted with her meal. R9 was sitting in a reclining chair. R9 had a blackened eye on the left which extended down into her cheek area. On 10/16/18 at 3:23 PM, V2 (DON) stated she has yet to get a report from Hospice on the incident and doesn't understand how R9 received a black eye when R9 was supposedly lower to the floor. V2 stated V15 stated she had a gait belt on but no one recalls seeing it at the time of the fall. V2 also stated the Hospice notes fail to reflect the fall/improper transfer and she has been unable to reach anyone at Hospice in regards to this incident. V2 stated R9 is a 2 staff pivot transfer with a gait belt and she would expect Hospice to do a safe transfer as identified by R9's care plan. On 10/18/18 at 12:55 PM, V18 stated she understands the facility assesses each resident for safe transfers and would expect staff to follow recommendations for full body mechanical lifts and/or pivot transfers. The policy/procedure entitled Transfer Screen dated 8/2011 documents the policy as: To determine a safe and appropriate method of transferring a resident, nursing staff will perform a transfer screen on each resident. The policy continues to document Nursing is to enter the appropriate transfer on the resident's care plan and pocket care guide.

Based on interview, observations and record review, the facility failed to provide appropriate consistent catheter care including insertion for 3 of 3 residents (R6, R10, R12) reviewed for urinary catheter services in a sample of 12. This failure resulted in hospitalization for R6 after a catheter was inserted improperly with the bulb inflated in the urethra. Findings include: 1. The Admission Record documents R6 was admitted to the facility on [DATE]. The Interdisciplinary Progress Note dated [DATE] documents R6 had a free flowing urinary catheter and is continent of bowel. R6's physician's orders [REDACTED]. R6's Instant Care Plan dated [DATE] documents R6 had a urinary catheter and staff were to do catheter care every shift and record output every shift. The Medication Administration Record [REDACTED]. There was no documentation the staff changed R6's catheter or initialed this as being done in (MONTH) (YEAR). The (MONTH) (YEAR) MAR indicated [REDACTED]. A Departmental Note dated [DATE] at 1:47 PM entered by V8 (Licensed Practical Nurse/LPN) documents R6 was seen by V18 (Nurse Practitioner) for V17 (Physician) and received the following orders for a urinalysis (UA) with C&S (culture and sensitivity) if indicated. Urine collection via catheter bag and stored in refrigerator. Resident urine clear yellow in color, foul odor noted. No noted hematuria. R6's Urinalysis results, dated [DATE], document R6 to have a urinary tract infection [MEDICAL CONDITION] of > (greater than) 100,000 colony forming unit/milliliter (CFU/ML ) of Escherichia coli (E. coli) which required an antibiotic of [MEDICATION NAME] 875 milligrams (mg) twice daily. The Departmental Notes dated [DATE] at 5:06 PM document new order from (V17) for UA C&S if ind (indicated). POA (power of attorney) aware. There is no information present in the departmental notes from [DATE] through to [DATE] that would explain why R6 had a UA done. The UA results dated [DATE] document R6 to have a UTI culturing > 100,000cfu/ml. The Departmental Notes dated [DATE] at 5:27 AM documents ua (urinalysis) results received, awaiting C&S (culture and sensitivity). (V18 Nurse Practitioner) aware, no (no new orders) received, resp (responsible) party aware. At 9:29 AM, V2 (Registered Nurse/RN) documents CNA (Certified Nurse Aide) approached this nurse this am stating that the resident had blood in catheter bag. Resident was assessed abd (abdomen) soft nontender, bowel sounds present x (times) 4 quads. The note continues that R6 seemed weak, stating he would like to stay in bed. The Note continued that V17 was notified and an antibiotic [MEDICATION NAME] 1 gram was given. There was no further documentation regarding R6's urine until [DATE] at 5:16 AM. Departmental notes dated [DATE] at 5:16 AM, documents late entry for [DATE], lab results back. V18 notified of labs, new orders received to send resident to hospital for evaluation and treatment. The note continues to document freely draining per gravity but again, fails to document the characteristics of the urine. The next entry is documented in the Departmental Notes is dated [DATE] at 5:55am and is a late entry for [DATE] at 5:45pm which documents the ambulance is here to transfer resident to hospital. Hospital Transfer Form dated [DATE] for offsite extended care documents discharge orders to include: 1. Rocephen 1gm IM (intramuscular) daily times 4 days 2. BMP (Basic Metabolic Panel) Monday - Call physician with results 3. Last (catheter) place by NH (nursing home) had balloon blown up in urethra - please have RN (Registered Nurse) confirm placement next time in part. The care plan dated (MONTH) (YEAR) identifies R6 to have a catheter and an increased risk of infection and other complications with interventions to change catheter per orders, observe for s/s (signs/symptoms) of infection; color, amount, consistency, odor, abdominal fullness, pain, keep drainage bag lower than level of bladder, maintain closed system, monitor output, observe for positioning of tubing, leg strap, catheter care every shift and PRN (as needed) and follow-up with urologist PRN. There is no intervention listed to ensure correct pericare given or that R6 had a UTI culturing E. coli, which is an intestinal bacteria. The care plan also failed to ensure correct collection of a urine specimen. R6 continued to have UTI's as follows: [DATE] - >100,000cfu/ml [MEDICATION NAME] Cloacae, [DATE] and [DATE] > 100,000cfu/ml E. coli. The care plan reviewed quarterly fails to reflect any added interventions in light of R6's multiple UTI's. Departmental Notes reviewed from [DATE] through [DATE] document R6 to be on a routine Antibiotic for chronic UTI's with the catheter draining but includes no characteristics of his urine and no abnormal behavior including lethargy as occurring. The MAR for (MONTH) (YEAR) documents R6 to receive [MEDICATION NAME] 100 mg daily for frequent UTI's with catheter care and output recorded twice daily. The MAR indicated [REDACTED]. The departmental notes from [DATE] through [DATE] fail to reflect a catheter change. On [DATE] at 9:53 PM, the departmental notes entered by V2 (DON/RN) document Resident con't (continues) on LT (long term) abt (antibiotic) therapy for chronic UTI, resident took all medications without difficulty. Resident con't to have catheter in place and draining well. and resident has an output recorded as 275ml at 9:45 PM. Resident was noted to have scant bleeding from cath insertion site. On [DATE] at 4:09 PM Departmental Notes entered by V11 (LPN) document Was passing by resident at dining room table this am at 8am noted that residents hands were shaking, looked at resident and his color was off kind of gray, did not respond to my voice, could not follow commands, got stethoscope, heard audible wheezing, shaky color change, could not get a reading on by pulse ox (Oximetry), immediately took resident to room had staff lay him down could not get a reading on BP (blood pressure), 99.2 was his temp (temperature) and 108 was his pulse. Resident was having difficult time breathing. Looked at resident, Resident catheter and noted blood and urine mixed to together in bag as well as tube, got O2 (oxygen) applied it with pulse ox on finger @ (at) 2 L (liter) no oxygen level noted, turned up to 3 L noted level was 79% took to 3.5 L and stayed at 79%. asked another nurse to stay with resident; call placed to V17, Physician, at 7:56am, call placed to ambulance at 8:02, call placed to family member. Hospital Records dated [DATE] document R6 to have a UTI caused by baterium E. coli. The History and Physical (H&P) dated [DATE] documents He presented to hospital with lethargy, He was sent from a nursing home. According to family members, he was just sleeping all day, not communicating with staff as he usually does. Upon physical Exam, the H&P documents Temperature was 103.1, pulse 101 with blood pressure in the emergency room as ,[DATE]. Under Assessment, the H&P documents 1. [MEDICAL CONDITION], most likely coming from Urinary tract infection in a patient with underlying dementia, in part. The Departmental notes document R6 being readmitted to the facility on [DATE] and expired on [DATE]. On [DATE] at 9:40 AM, V20 (R6's family member) stated R6 continually had UTI's and would exhibit certain behaviors and symptoms which the facility had difficulty picking up on. V20 stated R6 would get really sick before staff noticed and would end up in the hospital. V20 stated when R6 was hospitalized in (MONTH) (YEAR), the physician at the hospital told them about the catheter being inserted wrong with the balloon blown up in the urethra. V20 stated often times, family would note his urine being cloudy, etc before staff and would have to tell them to get a UA. V20 questioned the E. coli and stated often R6 would sit for periods of time in bowel movement. The policy entitled Catheter Insertion dated ,[DATE] documents the policy as: A catheter is utilized to establish/maintain drainage from the bladder and to ensure routine urinary elimination. Under procedure, it documents * NOTE: Male catheterization: Continue inserting catheter ,[DATE] inches after urine flow starts. Inflate balloon. Pull back gently on catheter until resistance is met, indicating proper placement. On [DATE] at 11:38 PM, V1 (Administrator/Nurse) stated she has no policy/procedure on proper method of collecting a urine specimen from a resident with a catheter but probably wouldn't collect it from the drainage bag. Mosby's Manual of Diagnostic and Laboratory Tests, Third Edition, dated 2006, by Pagana and Pagana, Chapter 11 Urine Studies, page 957, documents In patients with an indwelling urinary catheter in place, a specimen is obtained by attaching a small-gauge needle syringe and aseptically inserting the needle into the catheter at a point distal to the sleeve leading to the balloon. The manual documents The urine that accumulates in a plastic reservoir bag should never be used for a urine test. 2. The Minimum Data Set ((MDS) dated [DATE] documents R10 as a [AGE] year old male readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS documents R10 to be cognitively intact with a Brief Interview of Mental Status score of 15. The MDS documents R10 to have urinary catheter and be occasionally incontinent of bowel movement. The care plan dated (MONTH) (YEAR) documents R6's to have [MEDICAL CONDITION] and an indwelling catheter. The interventions include: refer to urology PRN, obtain my output every shift, perform catheter care every shift and PRN, ensure proper positioning of my catheter tubing, drainage bag, encourage to use a leg strap, utilize privacy bag for my dignity, observe me for s/s of UTI, encourage oral intake, and change catheter monthly. On [DATE] at 1200 PM, R10 stated he never gets catheter care but they do change it every month. R10 was sitting in his room in his wheelchair with the catheter tubing going down his pant leg. The tubing was resting on the floor. Urine in the tubing was cloudy, yellow with moderate sediment. R10 stated he is a mechanical lift sit to stand transfer. R10 denied having catheter care. On [DATE] at 3:30 PM, R10 was laying on his back in bed. V21 (CNA) explained to R10 that she was going to do catheter care. R10 had on a paper brief which appeared wrinkled, damp. When R21 pulled the brief off, R10 was noted to have dried bowel movement (BM) on his scrotum. R10 had no leg strap on securing his catheter. V21 provided care then rolled R10 to his left side. R10 had dried BM on bilateral inner buttocks but had no BM at his rectum. R10 stated he last had a BM earlier that morning on the toilet and had the brief on since that time. 3. R12's MDS, dated [DATE], documents R12 had a BIMS score of 15 indicating that R12 has intact cognition. R12's Physician order [REDACTED]. R12's POS sheets for (MONTH) (YEAR) through (MONTH) (YEAR) document in part, Change cath (catheter) monthly on the 15th and as needed. Catheter care every shift 7AM-7PM and 7PM-7AM. R12's POS dated [DATE] documents Catheter change monthly at urologist doctor's office per RP (responsible party) request. R12's POS dated [DATE] documents [MEDICATION NAME] 100 mg twice a day for Urinary Tract Infection. R12's Urine culture dated [DATE] documents greater than 100,000 Escherichia coli (E-Coli). R12's progress note dated [DATE] documents in part, F/C (Foley cath) changed using sterile technique. R12's Progress Note dated [DATE] at 4:42 PM documents Made aware by PT (Physical Therapy) that resident has blood draining from catheter, Foley tube assessed and blood clot noted in tubing, call made to Physician and office refer to Urologist, call made to daughter V19 to make aware and daughter stated 'the cath needs to be changed' made aware that there were no 16 F cath in the building, call made to Nurse Practioner to increase cath size to 18 F, daughter okay with new order, cath to be changed by staff nurses. R12's progress note dated [DATE] at 5:22PM documents 16 F coude cath inserted, scant amount of blood noted in return, straw colored urine noted. Resident denies pain or discomfort before, during and post insertion of cath, will continue to monitor for changes of condition. R12's Care Plan undated documents in part, Problem Onset: I have a [DIAGNOSES REDACTED]. I have a catheter. I am at risk for UTI's (Urinary Tract Infections) related to my Foley catheter. (16 French Coude). Goal/target date: I will have no complications associated with my catheter use thru next review Oct/2018. Approaches: Change my catheter per orders, Offer me acid ash drinks (for example cranberry juice), Ensure proper positioning of my catheter tubing and drainage bag, Utilize leg strap, Provide me a privacy bag for dignity. Record my output every shift. Provide me with Foley catheter care every shift and as needed. Observe me for signs and symptoms of UTI. On [DATE] at 2:30 PM, V19 (R12's Power of Attorney) stated that the facility does not complete catheter care twice a day and further stated that the facility is supposed to change the catheter monthly on the 15th, however there have been times that R12 has gone over 6 weeks without getting his catheter changed. V19 has now set up appointments with the Urologist monthly to ensure R12's catheter gets changed timely. V19 stated that R12 has a history of urinary tract infections and was diagnosed with [REDACTED]. R12 had a catheter inserted at that time. V19 stated that during an Urologist visit on [DATE], when R12's incontinent brief was removed there was a foul odor and purulent drainage coming from the tip of R12's penis. V19 stated R12 was placed on antibiotics at that time for a urinary tract infection. R12's POS dated [DATE] documents Bactrim SS every day for 10 days for UTI. On [DATE] at 2:30 PM, R12 was laying in bed with catheter bag attached to the right side of the bedrail draining clear amber urine. R12 stated that the facility staff do not complete catheter care twice a day. On [DATE] at 9:30 AM, R12 was sitting up in his recliner. R12's catheter bag was laying on the floor with clear amber urine present. During interview with V2 (DON) on [DATE] at 11:05 AM, V2 stated Yes, I would expect the nurses to follow Physician orders [REDACTED]. V2 further stated, The catheter bags should not be laying on the floor.

Based on interview and record review, the facility failed to ensure that oxygen therapy and saturation monitoring was provided as ordered for 1 of 3 residents (R3) reviewed for oxygen therapy in a sample of 14. This failure resulted in R3 becoming hypoxic/unresponsive and requiring hospitalization . Findings include: 1. The Admission Record documents R3 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Hospital Record also documents that R3 was verbal with an electronic device and had a [MEDICAL CONDITION] (trach) collar on. R3's Hospital Discharge Orders and Summary, dated [DATE], document medications to be given but did not document any orders for oxygen (O2) and/or SpO2 (Peripheral capillary oxygen saturation) to be done. The facility's Interim Care Plan dated [DATE] did not document R3 had [MEDICAL CONDITION] and did not identify any use of oxygen or the needs/orders for SpO2 being done. The Medication Administration Record [REDACTED]. The Interdisciplinary Progress Notes dated [DATE] (no time) documents Resident was admitted via ambulance from hospital around 4:30 pm. Resident is AOx3 (alert oriented time three) and can make all needs known. Resident has a fresh stoma but can speak using a voice box. Resident is full code. The admission Note includes no information as to R3's [MEDICAL CONDITION] collar and whether she had the need for oxygen and/or SpO2. The Progress Notes entered on [DATE] at 6:06 PM by V8 (Licensed Practical Nurse/LPN) document at approximately 11am, R3's respirations were even non labored. No sob (shortness of breath) noted. cap (capillary) refill less than 3 seconds and at approximately 12:50 PM grandson alerted staff to come to room. Vital signs: bp (blood pressure) ,[DATE], pulse 134, respirations 22 non labored, spO2 81% O2 applied at 2L (Liter)-5L for comfort. SpO2 increased to 88% - unable to maintain SpO2 at a good level. Resident responded to tactile stimulation and when writer calls residents name loudly resident opened her eyes for a very brief period. Code status verified as Full Code. EMS (Emergency Medical Services) dispatched. Resident sent to hospital for further evaluation. Respective Party notified. Hospital Records dated [DATE] document under History of Present Illness Pt (patient) is a 79 y/o (year old) CF (Caucasian female) who presents to the ED (emergency department) with C/O (complaints of) unresponsive. Per pts grandson at bedside, she was also off of O2 for unknown time span and When he saw her this afternoon, he states that she was only responding to pain. However, she is normally a & o x 3. Per pt's grandson, her pulse ox (oximetry) was in the 70's and A Fib at 120. While en route to ED, the pt's pulse ox was 99 while on O2. Under the Assessment and Plan, it documents: Altered Mental status could be due to the [MEDICAL CONDITION]. It was reported that the patient has been off [MEDICAL CONDITION] for almost 24 hours. Arterial blood gases were drawn, and she is hypoxic with her O2 of 62. The Hospital Records discharge date d [DATE] document physician's orders [REDACTED]. The Progress notes on readmitted d [DATE] document resident arrived at 5pm via ambulance with 2 EMT's present. The notes document continues on [MEDICAL CONDITION] setting in place. The Progress note reflect random entries regarding R3's oxygen [MEDICAL CONDITION] as such: [DATE] at 3:34pm O2 @ (at) 3 L per O2 collar covering [MEDICAL CONDITION] site, [DATE] at 5:36am on humidified air, sats 98%, [DATE] 2:14pm O2 at 3L per O2 collar covering [MEDICAL CONDITION] site with an O2 sat of 97% on room air, [DATE] at 2:53am, O2 @ 2L per O2 collar covering [MEDICAL CONDITION] site. [DATE] at 11:14pm, O2 at 2L per O2 collar, and on [DATE] at 2:44am, the same as is on [DATE] at 3:27am. Neither the Treatment Administration Record nor the MAR indicated [REDACTED]. A Weekly Respiratory assessment dated [DATE] signed by V10 (Respiratory Therapist) documents (R3's) respiratory rate as 18, unlabored, diminished breath sounds, with the SpO2% as 77% then up to ,[DATE]%. Under Comments and Recommendations, V10 documents Resident was sitting up in chair w/no (with no) and SpO2 up to ,[DATE]%. noted distress, SpO2 (low) but fixed humidity + (and) O2 and SpO2 went up to ,[DATE]%. Talked with nursing for orders and to talk with home health care company to get size of Larry tube. Will re-evaluate as needed. The next progress note dated [DATE] at 6:42 AM documents CNA (certified nurse aide) came to this writer and stated 'resident with [MEDICAL CONDITION] not breathing.' Went to resident room and on the way there had the CNA call 911. Upon entering residents room resident was unresponsive. Resident full code therefore CPR (cardiopulmonary resuscitation) was initiated by this nurse. The note documents EMS arriving and transporting R3 to the hospital. Hospital Records dated [DATE] dated [DATE] document the [DIAGNOSES REDACTED]. MAR's from [DATE] on R3's readmission following her hypoxic episode [MEDICAL CONDITION] to keep ox sats > 90% but fail to reflect any initials as being done from [DATE] through [DATE]. The MAR for (MONTH) (YEAR) reflects only initials for O2 sats being done on each shift [DATE] but fails to reflect the level itself. On [DATE] at 12:55 PM, V2 (Director of Nurses) stated she was unable to locate any documentation that SpO2's were done and documented but did see a random one in the progress notes. On [DATE] at 1:35pm, V2 stated R3 did not have [MEDICAL CONDITION] tube but only had a stoma. V2 stated R3 had a cover for it which she refused to wear. V2 stated the nurses should have been documenting R3's use of oxygen in light of the SpO2 levels but couldn't find where they had consistently documented it. On [DATE] at 12:45 PM, V1 (Administrator/Nurse) stated that R3's order did not include any specifics on how to maintain SpO2 sats but just keep it above 90%. V1 was unable to state how staff were to do that without checking the oxygen levels or SpO2's regularly to determine what exactly the levels were. In addition, V1 confirmed there were no orders for Oxygen administration but that the nurses did document administering it to R3 on several occasions. The policy/procedure entitled Oxygen Therapy dated ,[DATE] fails to document any information in regards to obtaining SpO2s or how to maintain levels of Oxygen above 90%. On [DATE] at 12:55 PM, V18 (Nurse Practitioner) for V17 (Physician) stated they don't usually give specifics but to keep O2 sats above ,[DATE]% and would expect them to have protocols to follow such as every shift. V18 stated she would also expect them to do it and document monitoring the resident for signs/symptoms of [MEDICAL CONDITION] in a consistent manner.

These failures resulted in two deficient practice statements. A. Based on observation, interview and record review, the facility failed to provide supervision to prevent resident to resident altercations and implement interventions after incident occurred for 1 of 1 resident (R9) in the sample of 17 and 1 resident (R24) in the supplemental sample. This failure resulted in R24 inappropriately touching R9 causing her to be fearful during the hour long incident and experiencing nightmares related to the incident. B. Based on record review, observation and interview, the facility failed to supervise and implement fall interventions for one of seven residents (R14) reviewed for falls in the sample of 17. This failure resulted in R14 falling and sustaining a fracture of the left femoral neck and a left distal radial metaphyseal fracture. Findings include: A. R24's Physician order [REDACTED]. R24's Minimum Data Set (MDS), dated [DATE], documents behavior not exhibited for other behavioral symptoms directed toward others. R24's MDS also documents no conditions that are related to ID/DD (intellectual disability/developmental disability) status. R24's Social History/Psychosocial Assessment, dated 9/7/17, documents, in part, prior psychiatric treatment/concerns: developmentally disabled. Mental Health Diagnosis/History: anxiety. Behaviors (Y/N): N Physical Aggression. R24's OBRA-1 Initial Screen Identification of Individuals for Whom There is a Reasonable Basis to Suspect a Developmental Disability or a Mental Illness, dated 9/6/17, documents in part intellectual disability; other indicators of mental illness. R24's Instant Care Plan, dated 9/7/17, documents, in part, inappropriate touching another resident. The intervention documented is 15 minute location monitoring, behavior tracking. R24's Behavior/Intervention Monthly Flow Record, dated 10/2017, documents tracking behaviors of pushing wheel chair into others, disruptive, s/s (signs and symptoms) of aggression. There is no documentation of behavior tracking of R24 touching others inappropriately. On 10/10/17 at 1:10 PM, E18, Physical Therapy Aide (PTA), informed another surveyor to be careful of R24 due to his inappropriate touching, because R24 was attempting to touch the surveyor's arm. E18 stated R24 has the behavior of grabbing a person's arm and touching further up the arm until R24 was told to stop. R24 was propelling self about the hall without supervision. On 10/12/17 at 10:00 AM, while interviewing E19, Licensed Practical Nurse (LPN) at the Nurse's station, R24 propelled himself to the Nurses Station and grabbed the surveyor's left arm multiple times. R24 continued to massage surveyor's left arm, moving upward until the surveyor intervened. R24 had no staff around, except E19 who was being interviewed. E19 did not intervene or redirect R24. R24 laughed inappropriately as he was massaging the surveyor's left arm. On 10/12/17 at 1:10 PM, R24 was propelling himself in the hall towards the Nurses Station without supervision. R24's Behavior/Intervention Monthly Flow Record, dated 10/2017, documents tracking behaviors of pushing wheel chair into others, disruptive, s/s of aggression. R9's Abuse Investigation Statement, dated 10/05/17, documents, in part, R24 came into R9's room and inappropriately touched her. R9's Abuse Statement documented Resident (R9) stated she was doing crossword puzzles around 6:30 PM when (R24) came into her room and continued to get closer to her. R9's statement documents Resident (R24) said he wanted to watch TV, and resident (R9) replied there was nothing to watch at the time. Resident (R9) stated soon after, (R24) placed his hand on her stomach and began rubbing and would not stop. Resident (R9) then shouted, 'No!' (R24) stopped, and 'I screamed or something.' The Statement documented Resident (R9) stated a while later, 'a nurse or something' came in and asked (R24), 'What are you doing?' and took (R24) to his room. ED (Executive Director, E1) asked resident (R9) if she had called for help. The Statement documents Resident (R9) replied that she did not, because she was afraid of what (R24) would have done to her. Resident (R9) stated she has had traumatic experiences in her life, one almost near death experience where she was beaten. SSD (Social Service Director, SDD, E14) asked resident (R9) if the door was open. Resident (R9) and R9 replied that it is always open because she was claustrophobic. ED (E1) asked resident (R9) if she felt like (R24) abused her. Resident (R9) replied, No kidding! He told me to shh! The Statement documented ED (E1) asked resident (R9) how long (R24) was in her room. Resident (R9) replied, at least an hour or more. The Facility Investigative Report, dated 10/6/17, documents, On 10/6/17 at approximately 8:50 am (R9) reported to staff last night, (R24) came into her room and touched her abdomen. (R9) stated she thought (R24) was going to touch her private areas, so she distracted (R24) by turning on the computer and showing religious information. The Investigative Report documented Upon completion of the investigation the facility substantiated the altercation did occur. On 10/13/17 at 11:13 AM, R9 stated when R24 came in her room and touched her, I was floored! I thought 'What the heck?' I was scared. I was so upset, I was really scared. I thought, 'What do I do?' On 10/13/2017 at 4:00 PM, Z7, Clinical Operations Nurse, reported R24 was placed on 1:1 observation on 10/12/2017 after the Daily Status Meeting at 4:00 PM, when it was brought to their attention that R24 propels himself around the facility without supervision. This was six days after this incident occurred. E1 was present and was in agreement with Z7. On 10/17/17 at 11:25 AM, Z7 stated, (E1) can administratively put someone on 1:1 anytime he wants. We don't document anything when someone is put 1:1. Z7 also reported the facility does not have a policy for 1:1 monitoring. Z7 also stated, You know, I talked to her just to find out everything that happened. And she's fine. Z7 reported R9 doesn't have any issues with the incident. On 10/17/17 at 11:20 AM, R9 stated in part, When (R24) came in my room and touched my abdomen, I was scared at first. My mind went blank. I was flabbergasted, and I couldn't think. I was afraid to tell him to get out. I don't know what he is capable of. I turned on my computer to get his mind on something else. But he (R24) just continued rubbing, and he tried to touch my private area. He hasn't touched me since then, but now there's people with him now. I've started having nightmares. I've had 3 nightmares since this. R9's MDS, dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 15, indicating R9 is cognitively intact. R9's Care Plan, dated 9/25/17, documents a [DIAGNOSES REDACTED]. R9's Social History/Psychosocial Assessment, dated 10/9/17, documents provoking factors for mood/behavior as being touched in an unwanted manner. R24's Resident Location Monitoring form, dated 10/7/17 at 6:00 PM, through 10/10/17 at 1:00 PM fails to document that observations were completed on 10/9/17 from 12:00 AM till 6:00 AM, and from 2:00 PM till 6:00 PM. On 10/10/17, the form fails to document observations were completed from 2:00 PM till 6:00 PM. On 10/17/17 at 10:37 AM, E14, Social Services Designee (SSD), stated the SSD is educating R24 on inappropriate touching by 1:1 visits 3 times per week and educating on personal space. E14 also stated, He answers using yes and no and sign language, but I don't know sign language. On 10/17/17 at 1:40 PM, Z6, Physician, reported he is aware of the incident that occurred on 10/5/17 with R9 and R24. Z6 stated, I think they (the facility) need to do good screening and assessing, and if you want to admit that type of person, you need to be prepared to provide the care he needs. I think he (R24) needs 24 hour 1:1. On 10/17/17 at 2:08 PM, E21, Care Plan/MDS Coordinator stated, Here's the new MDS for (R24), I had him marked wrong. That's my fault, but I fixed it. The facility's undated Abuse Policy documents, Policy: 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. The policy continues, Section C) Sexual Abuse: This includes, but is not limited to sexual harassment, sexual coercion or sexual assault or non-consensual sexual contact of any type with a resident. The Policy continued, Protection: #3. It is the responsibility of all staff to provide a safe environment for the residents. Resident care and treatments shall be monitored by all staff, on an ongoing basis, so that residents are free from abuse, neglect, or mistreatment. Care will be monitored so that the resident's care plan is followed. B. R14's Physician order [REDACTED]. R14's MDS, dated [DATE], documents R2's balance is not stable, only able to stabilize with staff assistance for moving from seated to standing position, walking, turning around, moving on and off the toilet, and surface to surface transfers. R14's MDS documents a (BIMS) score of 4, which represents severely impaired with cognition. R14's Care Plan, dated 03/06/16, documents R14 is at risk for falls related to weakness, mobility impairment, and the use of psychotropic medication. The Care Plan documents on 01/3/17, R14 had a fall without injuries with interventions of neurological checks, check for proper footwear. The Care Plan also documents another fall on 01/04/17 without injury. Her interventions are bed and wheelchair alarms, and a rubber, non-slip pad in her wheelchair. R14's Care Plan also documents a fall on 05/05/17 with injuries. The interventions are bilateral floor mats and tab alarm to her wheel chair. R14's Care Plan, dated 05/23/17, documents R14 needs the assistance of one staff for transfers. R14's Resident Incident Report, dated 05/05/17 at 9:55 AM, documents R14 was found on the floor yelling in pain. R14 stated she was trying to get into her wheelchair, and it rolled back because she forgot to lock her brakes. R14 stated she turned off her alarm, because it was too loud. An untitled letter regarding R14, dated 05/09/17, written by Z4, former Director of Nursing (DON), documents on 05/05/17 at 9:55 AM, R14 was found lying on her side left side on the floor in her room next to her bed. It also documents R14 was sent out to the local hospital and diagnosed with [REDACTED]. R14's X-ray Report, dated 05/05/17, documents a fracture of the left femoral neck and a left distal radial metaphyseal fracture with comminution. The facility Departmental Notes, dated 05/15/17, documents R4 arrived back to the facility via local ambulance. R14 had a brace to her left arm, with noted bruising to her fingers. R14 had staples and a dressing intact to her left hip. R14's pedal pulses were present. R14 had pain rated as 9 out of ten, and Tylenol was given. On 10/12/17 at 8:30 AM, R14 wheeled herself into the bathroom and toileted herself. R14 then wheeled herself to the bed and transferred herself into bed. R14's bed alarm then sounded. R14 stood up, hanging onto her wheel chair, and moved her bed alarm down to her feet. The bed alarm wasn't sounding. E19, Licensed Practical Nurse (LPN), who was in the room and witnessed the transfer, told R14, No, you have to sit on it. E19 moved the bed up to where R14 could sit on it. R14 then got herself into the bed, sitting on the pressure pad alarm. E2, DON, on 10/13/17 at 9:00 AM, stated, We are trying to beef up our rounds for Nurses and Certified Nursing Assistants.

Based on interview and record review, the facility failed to follow proper techniques for mechanical lifts and pivot transfers according to their policy for 2 of 7 residents (R1 and R2) in a sample of 7. This failure resulted in R1 sustaining a fractured femur 5/14/16 and R2 who sustained a fractured hip 5/12/16 during improper transfers. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] documents R1 to require extensive assist of one staff for transfers and to have long/short term memory loss. R1's Care Plan, dated April 2016, documents R1 requires transfers with one assist and a gait belt. The Facility's Injury of Unknown Origin Investigation report documents, on 5/14/16, at approximately 4:15 PM, R1 was sitting at the nurses station and complained of right leg pain and was rubbing his right upper leg. The report documents that upon assessment, R1's right upper leg was swollen with no bruising or redness noted. The report documents the physician was notified with an order for [REDACTED]. R1's X-ray report, dated 5/14/16, documents a Spiral fracture of the distal right femoral shaft with shortening, displacement and apex anterior angulation. R1's Nurse's Notes documented R1 was transferred to the hospital emergency room (ER) for evaluation and treatment. The website OrthoInfo, Femoral Shaft Fractures (Broken Thighbone,www.orthoinfo.aaos (American Academy of Orthopedic Surgeons).org documents a spiral fracture as Fracture line encircles the shaft like the stripes on a candy cane. A twisting force to the thigh causes this type of fracture. The facility's investigation documents R1 was last transferred by E3, Certified Nurse Aide (CNA) the afternoon of 5/14/16. A written statement from E3, dated 5/14/16, documents he told R1 he was going to get him up on the side of the bed and grabbed (R1's) feet as he grabbed ahold the bed rail on the left and turned his body to sit up on the side of the bed as I turned his feet toward the floor. E3 documented R1 repeatedly cursed as was normal and then wrote So I told him we were going to stand up and I wanted him to put his hands on wall like we always do. So I grabbed his hand with my other hand on the back of his pants to help give him a boost if needed but when counting to three trying to get him to stand his legs wouldn't lock out so I sat him back down. I said to him 'what's wrong with you still tired or something' and he just said (curse words) again. E3 continued to write So I told him we gonna try this again on the count of 3 but this time he couldn't stand neither so I let him sit on the side of the bed again. E3 documented he asked R1 again if something was wrong and R1 did not reply. E3 documented I figured he just had along day and was tired so I told him I'm gonna help you transfer to your wheelchair so I put my hands on his left and right hip counted to three and transferred him from the bed to his wheelchair. E3 documented R1 propelled himself down the hall with no complaints. There was nothing in the investigation documenting that E3 used a gait belt with R1 for the transfer or asked for additional assist since R1 seemed to require more than one assist at that time. A written note by E6, Registered Nurse (RN), dated 5/14/16, documents At around 4:15pm writer was in the hall preparing meds when she heard a loud noise behind her sounding like it came from room 219 (R1's room) and she immediately went into the room. E6 documented R1 was on the edge of the bed and when writer asked CNA what happened, E3 told E6 that R1 wouldn't stand. E6 documented E3 attempted to get R1 up again and two minutes later brought resident out of the room in his wheelchair. There is no evidence E6 attempted to assist E3 in transferring R1 or advised him to get additional assistance since he seemed to require it at that time. On 6/14/16 at 12:55 pm, E3 stated that he was very familiar with R1 at the time of his fracture and that he had transferred him multiple times without any problems prior to that. E3 described the event as he had written it in his statement. E3 was asked if he used a gait belt during the transfer with R1 and stated No, (R1) had no gait belt on, should have had one on him but I didn't. E3 stated R1 did not appear in any pain during the transfer. A statement dated 5/14/16 written by E14, CNA documents she care for R1 during the day shift on 5/14/16 and had no difficulties or complaints during transferring him to and from bed throughout the day. On 6/15/16 at 9:20 am, E14 stated R1 had no problems that day and she last transferred him to between 2:00pm and 2:15pm the afternoon of 5/14/16 with no difficulties. E14 stated she checked on R1 at 2:30 pm and he was asleep. On 6/14/16 at 2:00 pm, E1, Administrator, stated the facility policy would be to use gait belts on all pivot transfers and that E3 had been inserviced on gait belt transfers regularly with one done just prior to the incident occurring. E1 provided Transfer training sheets including gait belt use that documents E3 was last trained on 3/23/16. Disciplinary Notes dated 5/17/16 for E3 document On 5/14/16 Employee failed to follow safety rules by failing to use a gait belt when transferring a resident. On 6/15/16 at 9:00 am, E1 stated she interviewed E14, the CNA that transferred R1 to bed on 5/14/16 and that E14 stated she had no difficulty transferring R1 to bed and R1 had no complaints. The facility's policy entitled Transfer belts/gait belts dated 4/14 documents it is the policy of the facility to promote safety in transferring residents, a gait is utilized when deemed appropriate. Under procedure, it documents 1. A gait belt is used if indicated on care plan. and 3. The resident is transferred by grasping the secured gait belt to provide stability and balance during movement. 2. R2's MDS dated [DATE] documents he requires total assist of two staff for all transfers. R2's Care Plan, dated April 2016 documents R2 is at risk for falls due to impaired mobility and Multiple Sclerosis in part. The Interventions document R2 is to be transfer per mechanical lift and assist of two staff. The Facility's Incident Report documents on 5/12/16 at 3:45 pm, R2 had a fall with a fractured hip. The Departmental Notes, dated 5/12/16 at 5:30 pm written by E7, RN document Resident on floor in room. CNA stated resident slipped out of (mechanical lift) pad during transfer. Injuries described in this note documents laceration noted to forehead abrasion to left elbow and left knee, resident is complaining of left hip pain. The note documents the physician was called and an order for [REDACTED]. The next entry into the Departmental Notes is at 8:00 pm and documents Results of L (left) hip x-ray shows nondisplaced L hip fx (fracture) results called to the MD (Medical Doctor). E4's, CNA, written statement documents that on 5/12/16, there were two aides on the hall and it was about supper time. E4 documented R2 was a 2 man mechanical lift. E4 documented the other CNA was on break and she preceded to get him up myself. When I got him in air and was almost to his chair he then started to slide out sling hitting the floor. On 6/14/16 at 1:25 pm, E1 stated in investigating the incident, it was determined E4 did not hook the mechanical lift sling correctly causing R2 to slide out of the sling when lifted. E1 also stated E4 was alone doing the lift and should have had another staff member to assist. E1 provided training records for E4 on mechanical lifts done on 3/23/16 and 5/4/16. Disciplinary notes dated 5/16/16 document that Employee failed to follow pocket guide when using a (mechanical lift) while transferring a resident, which resulted in negative outcome. The facility's policy for Mechanical lifts dated 10/09 documents staff are to ensure four spring clips are in position before attempting to lift.

Based on observation, interview and record review, the facility failed to ensure 2 of 8 residents (R7 and R9) in the sample of 15 reviewed for falls were transferred safely. This failure resulted in R7 obtaining a fracture of the clavicle. Findings include: 1. R7's Care Plan of 2/13/12 documents R7 has potential for falls and decreased ability to perform ADL's (Activities of Daily Living) related to [DIAGNOSES REDACTED]. The Care Plan notes of 6/3/13 and 7/8/13 document to transfer via mechanical sling lift with 2 assistance. R7 was observed through out the survey to have her left arm in a sling. R7 stated her clavicle was fractured during a transfer. The Nurses Note of 7/27/13 documents R7 just finished shower. Aide taking her to room. While in room, sitting at nurse station heard some screaming/yelling. Went to investigate resident sitting on side of bed making faces like grimacing and stating her left shoulder is hurting. Note documents Z1, R7's Physician, ordered an X-ray. The X-ray report of 7/27/13 was negative for fracture. The Nurses Note of 7/31/13 documents Z1 assessed R7 and ordered an x ray of the left Clavicle. The X-ray report of 7/31/13 documents a fracture of mid shaft of clavicle with inferior displacement and overriding of distal fracture fragment appears sub acute. The Facility "Falls Witness Statement" of 7/27/13 signed by E10, Certified Nurses Aide, CNA, documents, "We use a gait belt to transfer her to bed." "Falls Witness Statement" of 7/27/13 documents, "Ready to put to bed...Transferring with gait belt from chair to bed two people." The Facility investigation report documented E10 and E11 were given "Category one violation" stating "On 7/27/13 employee failed to follow accurate and available care guide information and transferred a resident by improper method resulting in significant injury to resident." 2. On 9/11/13, at 9:40 a.m., E6 and E7 CNA's were preparing to transfer R9 with the mechanical lift from bed to wheelchair. R9 was observed to attached two of the four clips onto the bar of the lift. E6 and E7 did not observe, assist, or check placement of the two clips that R9 attached to lift bar before transferring R9. R9 was further observed to independently operate the remote as she was transfered. E7 was observed to have R9's wheelchair tipped on the back two wheels with the front two wheels suspended in free air. R9 lowered herself to the wheelchair by operating the remote. E7 continued to have the wheelchair tipped back on the back two wheels until R9 was positioned in the wheelchair. Interview with E6 on 9/12/13 at 12:25 p.m., and E6 stated that R9 is not transferred with the mechanical lift. R9's Care Plan dated 7/20/12 documents that transfers are to be done with the assist of 2 and a mechanical lift. The Minimum Data Set, MDS, dated [DATE] documents R9 is totally dependent on two or more staff for transfer and weighs in excess of 300 pounds.

Based on record review and interview, the facility failed to provide timely laboratory services, treatment, and sufficient fluids for 2 of 3 residents (R2, R3) reviewed for urinary tract infection in a sample of 3. This failure resulted in R2 and R3 becoming dehydrated and required hospitalization for treatment. R3 expired on [DATE]. The findings include: 1. R2 was admitted to the facility on [DATE] with diagnoses, in part, of Alzheimer's, Diabetes Mellitus, Pressure Sore on the heel, and [MEDICAL CONDITION]. R2 had a history of [REDACTED]. The Care Plan dated [DATE] identified R2 with recurrent urinary tract infections with the approach to "Monitor for adverse effects", "Report to physician/nurse practitioner" and "Encourage Fluids". The Care Plan also identified R2 at risk for dehydration with the goal to be well hydrated. The approaches include, in part, "Observe and document food and fluid intake" and "Encourage consumption of food". R2 was assessed on the "Assessment of Dehydration Risk" on [DATE] as low risk. On [DATE] at 10:00 PM, nurses notes documented the physician was contacted and orders for a urinalysis and culture and sensitivity was obtained. The nurses note documents R2 was "being sluggish this evening and c/o (complained of) UTI (urinary tract infection) possible". The lab report for the urinalysis documented the urine was "Collected" on [DATE] at 7:00 PM and "Received" on [DATE] at 4:28 AM. The laboratory (lab) report documented the urinalysis was "Reported" on [DATE] at 10:34 AM to the facility. The lab report documented "TNTC" (too numerous to count) for white blood cells and a culture was indicated. The culture lab report documented the culture was "Received" on [DATE] 1:48 PM and "Reported" to the facility on [DATE] at 10:22 AM. The culture lab report documented greater than "100,000 CFU/ML (colonies forming units/milliliter)" of Proteus mirabilis. The lab report documented the physician was not contacted with the results until [DATE] at 12:10 AM and [MEDICATION NAME] 500 milligrams three times per day for 10 days was ordered. The nurses notes dated [DATE] at 3:51 AM also documented the physician was notified and [MEDICATION NAME] 500 milligrams three times per day for 10 days was ordered. According to the June and July, 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The urinalysis was ordered on [DATE] at 10:00 PM with the first dose of antibiotic not given until [DATE] at 8:00 AM. E2, Director of Nursing (DON), stated in an interview on [DATE] at 9:25 AM that the lab takes two days from when the urinalysis results are obtained to do the culture. E2 stated they had problems getting a sample from R2 and when they did the lab did not pick the sample up until the next day. E2 stated the lab will not do stat urinalysis so they have to wait until the sample is picked up. E2 stated the antibiotic was given early in the morning on [DATE]. The MAR indicated [REDACTED]. The "Quarterly Nutritional Re-Evaluation" dated [DATE] documented R2's weight was 132.6 pounds with fluid needs at 1800 milliliters per day. According to the nurses notes dated [DATE], R2 weighed 139 pounds. The "Nutritional Assessment" dated [DATE] documented normal fluid needs at 30 cubic centimeters (cc) per kilogram (kg) of body weight and increases the fluid needs to 35 cc per kg for urinary tract infection or dehydration. According to the Nurses Notes dated [DATE] at 2:34 PM, E8, Registered Dietitian, assessed R2 for normal fluid needs of 1860 cc's per day based on a weight of 135.6 pounds. The note did not address that R2's fluid needs would increase due to the urinalysis reported to the facility on [DATE] at 10:34 AM. Based on the "Nutritional Assessment" calculations and R2's weight of 135.6 pounds, R2's fluid needs would be 1849 cc's (weight in kg x 30 cc's) for normal needs and increase to 2157 cc's (weight in kg x 35 cc's) with a urinary tract infection. The "Meal Report" documented the following fluid amounts at meals for R2: [DATE]-2040 cc's, [DATE]- 1800 cc's, [DATE]-1080 cc's, [DATE]- 960 cc' s', [DATE]-1560 cc's, [DATE]-incomplete, [DATE]-incomplete, [DATE]-1540, and [DATE]-incomplete. The average amount of fluid taken in by R2 in June on the "Meal Report" was 1530 cc's per day as calculated by the facility. R2 had a lab report on [DATE] with the blood urea nitrogen (BUN) at 33 (,[DATE]) and creatinine of 1.2 (0XXX,[DATE].25). The facility provided fluid intake amounts on [DATE] that included the "Meal Report", medication pass fluids and Prostat supplement for R2 as follows: [DATE]-2490 cc's; [DATE]-2250 cc's; [DATE]-1530 cc's; [DATE]-1830 cc's; [DATE]-2010 cc's; [DATE]-breakfast and lunch fluids not charted; [DATE]-breakfast and lunch fluids not charted; [DATE]-1990 cc's; [DATE]-admitted to hospital at 2:52 PM-1020 cc's prior to admission. According to the lab report routine ordered labs were done on [DATE]. On [DATE] at 12:32 PM, the lab reported that the BUN (Blood Urea Nitrogen) was 114 (,[DATE]) and the creatinine was 2.9 (0XXX,[DATE].1). Sodium and potassium levels were within normal limits. According to the lab report, the BUN and creatinine were at "critical high" levels. According to the nurses notes dated [DATE] at 2:52 PM, the Physician, Z1, was notified and R2 was sent to the hospital due to "critical high labs". According to the History and Physical dated [DATE], R2 was admitted to the hospital on [DATE] with "Reason for Admission" as "Dehydration and acute urinary tract infection". The History and Physical documented the family "reports her mother has been lethargic and is normally alert. Fatigued, easily exhausted and not participating in minimal activities of daily living". The "Assessment" documented dehydration, acute [MEDICAL CONDITION] on [MEDICAL CONDITION], stage 4, metabolic [MEDICAL CONDITION], acute urinary tract infection, Diabetes type 2, sacral decubitus ulcer and hypertension. R2 was discharged from the hospital on [DATE] with final [DIAGNOSES REDACTED]. R2's blood urea nitrogen on discharge was 36 (,[DATE]) with a creatinine of 1.11 (0XXX,[DATE].1). Z1, Physician and Medical Director, stated in an interview on [DATE] at 1:20 PM that R2 was hospitalized with acute dehydration due to low intake. Z1 was provided the fluid intake amounts from the "Meal Intake" sheet which only listed meal fluid amounts. Z1 stated there was a correlation between the low fluid intake, urinary tract infection and impaction. Z1 stated the impaction goes hand in hand with low fluids and then the urinary tract infection makes it even more difficult. Z1 stated the kidneys were impaired due to low fluid intake and then the infection would increase the difficulty. Z1 stated if R2's BUN and creatinine went back to normal baseline after hospitalization then she was dehydrated. Z1 stated it is hard to see "day to day" and the only thing that would have helped if someone was paying attention to the numbers. Z1 stated someone has to monitor the intake daily. 2. R3 was admitted to the facility on [DATE] with diagnoses, in part, of [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], and [MEDICAL CONDITION] stage 3 with creatinine between 1.2 and 1.7, according to the history and physical dated [DATE]. A lab report dated [DATE] documented R3's Blood Urea Nitrogen (BUN) at 42 (,[DATE]) and creatinine 1.7 (0XXX,[DATE].1). The history and physical noted R3 had a "mild urinary tract infection" and [MEDICATION NAME] was ordered on discharge to the facility. There was no culture and sensitivity documented. The initial nurses notes from the facility documented R3 required assist of ,[DATE] staff and was alert and oriented times 3 and "Pleasant and cooperative, able to make needs known". A regular diet was ordered. On [DATE] at 2:07 AM, R3 complained of nausea, vomiting and constipation. At 7:40 AM the nurses note documented R3 was nauseated and [MEDICATION NAME] 25 milligrams three times per day was ordered. The nurses notes documented R3 "consumed 120 cc's all shift". R3 was "alert and oriented x 3". The nurses notes dated [DATE] at 4:39 AM documented "Resident consumed 100 cc all shift". On [DATE] at 6:30 AM the nurses notes documented R3 started "yelling she can't breathe". The family called and stated R3 was more confused. On [DATE] at 9:00 AM, a lab report documented R3's BUN at 96 and creatinine at 6.3. Both were documented as "CH" (critical high). On [DATE] at 11:23 AM, Z2, Nurse Practitioner, saw R3 and ordered to hold [MEDICATION NAME], give [MEDICATION NAME] 30 grams, recheck the labs and do a urinalysis with a culture and sensitivity as indicated on [DATE]. Z2 documented as "Assessment/Plan" that "(elevated WBC (white blood count) CXR (chest Xray) UA (urinalysis) [MEDICAL CONDITION]-diuretic use hold [MEDICATION NAME] [MEDICAL CONDITION]-1 dose [MEDICATION NAME] Hold K (Potassium)". In an interview on [DATE] at 9:00 AM, Z2 stated she was not aware of R3's low fluid intake. Z2 stated she does not have access to the fluid intake on the computer and staff have to inform her. Z2 stated she had thought R3 was in [MEDICAL CONDITION] with [MEDICATION NAME] use. Z2 stated R3 had a high white blood count and she had ordered a urinalysis for [DATE]. Z2 stated R3 could stand when first admitted , according to Physical Therapy, but then declined. Z2 stated R3's fluid needs would have been ,[DATE] cc's per day based on her weight of 320 pounds. E2, Director of Nursing (DON), documented R3 received the following fluids from the "Meal Intake" sheet and medication pass: [DATE]-1200 cc's, [DATE]-1200 cc's, [DATE] 1200 cc's, [DATE]-1060 cc's, [DATE]-840 cc's. E2 stated on [DATE] at 11:50 AM that the urinalysis was not obtained. E2 confirmed the urinalysis was ordered on [DATE] and R3 went to the hospital on [DATE]. On [DATE] at 6:43 AM, the nurses notes documented R3 was "yelling now "Help Me" "Help Me" "I can't breathe". At 12:02 PM, E2 documented that she approached R3 and her family and told them the physician had been contacted regarding her anxiety and lab results. E2 documented Z1 was going to be in the facility to examine R3. At 1:25 PM the nurses notes documented Z1 was in the facility with orders to send R3 to the hospital. The History and Physical dated [DATE] documented R3 was admitted to the hospital with [REDACTED]. R3 was "confused, just moaning out loud". The history and physical documented the BUN at 126 and a creatinine of 6.8. The urine was noted as "Turbid, packed full of white cells and many bacteria". R3's white blood count was 19.3 (4XXX,[DATE].0). The "Assessment" documented 1. [MEDICAL CONDITION]. This is metabolic. Etiology uncertain at this time, but there are multiple factors. The patient is significantly dehydrated. 2. Acute [MEDICAL CONDITION]. I suspect related to volume depletion. 3. Cardiac Arrhythmia, secondary to underlying metabolic problem. 4. Hypertension. The discharge summary dated [DATE] documented the final [DIAGNOSES REDACTED]. The Urine culture dated [DATE] documented R3 culture was greater than 100,00 of Proteus mirabilis which was resistant to [MEDICATION NAME]. R3 had received [MEDICATION NAME] on her admission to the facility on [DATE] for a urinary tract infection.

Based on record review and interview the Facility failed to assess and monitor for hydration needs for 2 of 3 residents (R2, R3) reviewed with increased hydration needs due to urinary tract infections in a sample of 3. This failure resulted in R2 and R3 becoming dehydrated and required hospitalization . R3 expired on [DATE]. The findings include: 1. R2 was admitted to the facility on [DATE] with diagnoses, in part, of Alzheimer's, Diabetes Mellitus, Pressure Sore on the heel, and [MEDICAL CONDITION]. R2 had a history of [REDACTED]. The Care Plan dated [DATE] identified R2 with recurrent urinary tract infections with the approach to "Monitor for adverse effects", "Report to physician/nurse practitioner" and "Encourage Fluids". The Care Plan also identified R2 at risk for dehydration with the goal to be well hydrated. The approaches include, in part, "Observe and document food and fluid intake" and "Encourage consumption of food". The Care Plan also identified R2 has a problem with a [DIAGNOSES REDACTED]. Describe amount, color, and consistency. Assist to toilet as needed. Meds as ordered. DSS every day per PO (passing orally). Fiber therapy cap (capsule) PO every day. Suppository (every other day) and be placed on toilet ,[DATE] hour after given". There are no approaches for constipation regarding fluid intake. R2 was assessed on the "Assessment of Dehydration Risk" on [DATE] as low risk. On [DATE] at 10:00 PM, the nurses notes documented the physician was contacted and orders for a urinalysis and culture and sensitivity was obtained. The nurses note documents R2 was "being sluggish this evening and c/o (complained of) UTI (urinary tract infection) possible". The laboratory (lab) report for the urinalysis documented the urine was "Collected" on [DATE] at at 7:00 PM and "Received" on [DATE] at 4:28 AM. The lab report documented the urinalysis was "Reported" on [DATE] at 10:34 AM to the facility. The lab report documented "TNTC" (too numerous to count) for white blood cells and a culture was indicated. The culture lab report documented the culture was "Received" on [DATE] 1:48 PM and "Reported" to the facility on [DATE] at 10:22 AM. The culture lab report documented greater than "100,000 CFU/ML (colonies forming units/milliliter)" of Proteus mirabilis. The lab report documented the physician was not contacted with the results until [DATE] at 12:10 AM and [MEDICATION NAME] 500 milligrams three times per day for 10 days was ordered. The nurses notes dated [DATE] at 3:51 AM also documented the physician was notified and [MEDICATION NAME] 500 milligrams three times per day for 10 days was ordered. The "Quarterly Nutritional Re-Evaluation" dated [DATE] documented R2's weight was 132.6 pounds with fluid needs at 1800 milliliters per day. According to the nurses notes dated [DATE], R2 weighed 139 pounds. The "Nutritional Assessment" dated [DATE] documented normal fluid needs at 30 cubic centimeters (cc) per kilogram (kg) of body weight and increases the fluid needs to 35 cc per kg for urinary tract infection or dehydration. According to the Nurses Notes dated [DATE] at 2:34 PM, E8, Registered Dietitian, assessed R2 for normal fluid needs of 1860 cc's per day based on a weight of 135.6 pounds. The note did not address that R2's fluid needs would increase due to the urinalysis reported to the facility on [DATE] at 10:34 AM. Based on the "Nutritional Assessment" calculations and R2's weight of 135.6 pounds, R2's fluid needs would be 1849 cc's (weight in kg x 30 cc's) for normal needs and increase to 2157 cc's (weight in kg x 35 cc's) with a urinary tract infection. The "Meal Report" documented the following fluid amounts for R2: [DATE]-2040 cc's, [DATE]- 1800 cc's, [DATE]-1080 cc's, [DATE]- 960 cc' s', [DATE]-1560 cc's, [DATE]-incomplete, [DATE]-incomplete, [DATE]-1540, and [DATE]-incomplete. The average amount of fluid taken in by R2 in June on the "Meal Report" was 1530 cc's per day as calculated by the facility. R2 had a lab report on [DATE] with the blood urea nitrogen (BUN) at 33 (,[DATE]) and creatinine of 1.2 (0XXX,[DATE].25). E2 stated in an interview on [DATE] at 2:50 PM that the "Meal Report" will issue an "Alert" to nursing staff if the fluid amount is too low. E2 stated the computer system should trigger an alert if the fluid intake falls below the amount needed for hydration. E2 stated the nursing staff was responsible to review the fluid amounts when the alert is issued. E2 stated the meal report only lists the meal intake and does not have the medication pass or any fluids R2 would have consumed other than the meal. E2 stated in an interview on [DATE] at 9:25 AM that she was not sure how or who uses the information with the fluid amounts. E2 stated there may be a systems problem. E2 stated R2 also received fluids at activities, 360 cc's with med pass, from the pitcher in her room, and a 240 cc supplement twice a day. R2 has a physician order [REDACTED]. There is no documentation of R2's fluid intake other than the "Meal Report" and the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. . The facility provided fluid intake amounts on [DATE] that included the "Meal Intake", medication pass fluids and Prostat supplement for R2 as follows: [DATE]-2490 cc's; [DATE]-2250 cc's; [DATE]-1530 cc's; [DATE]-1830 cc's; [DATE]-2010 cc's; [DATE]-breakfast and lunch fluids not charted; [DATE]-breakfast and lunch fluids not charted; [DATE]-1990 cc's; [DATE]-admitted to hospital at 2:52 PM-1020 cc's prior to admission. E1, Administrator, stated on [DATE] at 9:45 AM that the computer system for the "Meal Alert" only issues an alert if the staff forget to chart the fluids in the computer system. E1 stated the computer system does not alert staff if the fluid amount is under the residents needs. E5, Licensed Practical Nurse (LPN), stated in an interview on [DATE] at 2:15 PM that the DON or ADON (Assistant Director of Nursing) would review the fluid intake. E5 stated R2 would always drink fluids for her but she had not been acting like herself. E5 stated R2 was not taking in as much fluids. E5 stated the aides put the amount of fluids taken in and then if it is low a "care alert" comes up and the DON, ADON or Unit Manager review it. E5 stated if it was low they would try different interventions such as supplements or encouraging fluids. E5 stated R2 was more quiet and there was a change a few days before she went out to the hospital. Z2, Nurse Practitioner, progress note dated [DATE] documented "Seeing pt. (patient) for F/U (follow up) abd. (abdomen) distended. Hypoactive bowels sounds. No c/o (complaint of) pain (at) present". Z2 documented under "Assessment/Plan" "constipation-await KUB results has orders for [MEDICATION NAME] and [MEDICATION NAME]". There was no documentation on the progress note regarding fluid intake E4, LPN, stated in an interview on [DATE] at 1:15 PM that she assisted E5 in giving R2 an enema on [DATE]. E4 stated R2 did have good results but the stool was hard. E4 stated R2 was not herself and seemed uncomfortable. According to the lab report routine ordered labs were done on [DATE]. On [DATE] at 12:32 PM, the lab reported that the BUN (Blood Urea Nitrogen) was 114 (,[DATE]) and the creatinine was 2.9 (0XXX,[DATE].1). Sodium and potassium levels were within normal limits. According to the lab report, the BUN and creatinine were at "critical high" levels. According to the nurses notes dated [DATE] at 2:52 PM, the Physician, Z1, was notified and R2 was sent to the hospital due to "critical high labs". According to the History and Physical dated [DATE], R2 was admitted to the hospital on [DATE] with "Reason for Admission" as "Dehydration and acute urinary tract infection". R2 was also found to have a fecal impaction on admission to the hospital. The History and Physical documented the family "reports her mother has been lethargic and is normally alert. Fatigued, easily exhausted and not participating in minimal activities of daily living". The "Assessment" documented dehydration, acute [MEDICAL CONDITION] on [MEDICAL CONDITION], stage 4, metabolic [MEDICAL CONDITION], acute urinary tract infection, Diabetes type 2, sacral decubitus ulcer and hypertension. R2 was discharged from the hospital on [DATE] with final [DIAGNOSES REDACTED]. R2's blood urea nitrogen on discharge was 36 (,[DATE]) with a creatinine of 1.11 (0XXX,[DATE].1). Z1, Physician and Medical Director, stated in an interview on [DATE] at 1:20 PM that R2 was hospitalized with acute dehydration due to low intake. Z1 was provided the fluid intake amounts from the "Meal Intake" sheet which only listed meal fluid amounts. Z1 stated there was a correlation between the low fluid intake, urinary tract infection and impaction. Z1 stated the impaction goes hand in hand with low fluids and then the urinary tract infection makes it even more difficult. Z1 stated the kidneys were impaired due to low fluid intake and then the infection would increase the difficulty. Z1 stated if R2's BUN and creatinine went back to normal baseline after hospitalization then she was dehydrated. Z1 stated it is hard to see "day to day" and the only thing that would have helped if someone was paying attention to the numbers. Z1 stated someone has to monitor the intake daily. 2. R3 was admitted to the facility on [DATE] with diagnoses, in part, of [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], and [MEDICAL CONDITION] stage 3 with creatinine between 1.2 and 1.7, according to the history and physical dated [DATE]. A lab report dated [DATE] documented R3's Blood Urea Nitrogen (BUN) at 42 (,[DATE]) and creatinine 1.7 (0XXX,[DATE].1). R3 had been hospitalized due to a nose bleed prior to being admitted to the facility. The history and physical noted R3 had a "mild urinary tract infection" and [MEDICATION NAME] was ordered on discharge to the facility. There was no culture and sensitivity documented. The initial nurses notes from the facility documented R3 required assist of ,[DATE] staff and was alert and oriented times 3 and "Pleasant and cooperative, able to make needs known". A regular diet was ordered. On [DATE] at 2:07 AM, R3 complained of nausea, vomiting and constipation. At 7:40 AM the nurses note documented R3 was nauseated and [MEDICATION NAME] 25 milligrams three times per day was ordered. The nurses notes documented R3 "consumed 120 cc's (cubic centimeters) all shift". R3 was "alert and oriented x 3". The nurses notes dated [DATE] at 4:39 AM documented "Resident consumed 100 cc all shift". On [DATE] at 6:30 AM the nurses notes documented R3 started "yelling she can't breathe". The family called and stated R3 was more confused. On [DATE] at 9:00 AM, a lab report documented R3's BUN at 96 and creatinine at 6.3. Both were documented as "CH" (critical high). On [DATE] at 11:23 AM, Z2, Nurse Practitioner, saw R3 and ordered to hold [MEDICATION NAME], give [MEDICATION NAME] 30 grams, recheck the labs and do a urinalysis with a culture and sensitivity as indicated on [DATE]. Z2 documented as "Assessment/Plan" that "(elevated WBC (white blood count) CXR (chest Xray) UA (urinalysis) [MEDICAL CONDITION]-diuretic use hold [MEDICATION NAME] [MEDICAL CONDITION]-1 dose [MEDICATION NAME] Hold K (Potassium)". In an interview on [DATE] at 9:00 AM, Z2 stated she was not aware of R3's low fluid intake. Z2 stated she does not have access to the fluid intake on the computer and staff have to inform her. Z2 stated she had thought R3 was in [MEDICAL CONDITION] with [MEDICATION NAME] use. Z2 stated R3 had a high white blood count and she had ordered a urinalysis for [DATE]. Z2 stated R3 could stand when first admitted , according to Physical Therapy, but then declined. Z2 stated R3's fluid needs would have been ,[DATE] cc's per day based on her weight of 320 pounds. E2, Director of Nursing (DON), documented R3 received the following fluids from the "Meal Intake" sheet and medication pass: [DATE]-1200 cc's, [DATE]-1200 cc's, [DATE] 1200 cc's, [DATE]-1060 cc's, [DATE]-840 cc's. E2 stated on [DATE] at 11:50 AM that the urinalysis was not obtained. E2 confirmed the urinalysis was ordered on [DATE] and R3 went to the hospital on [DATE]. On [DATE] at 6:43 AM, the nurses notes documented R3 was "yelling now "Help Me" "Help Me" "I can't breathe". At 12:02 PM, E2 documented that she approached R3 and her family and told them the physician had been contacted regarding her anxiety and lab results. E2 documented Z1 was going to be in the facility to examine R3. At 1:25 PM the nurses notes documented Z1 was in the facility with orders to send R3 to the hospital. The History and Physical dated [DATE] documented R3 was admitted to the hospital with [REDACTED]. R3 was "confused, just moaning out loud". The history and physical documented the BUN at 126 and a creatinine of 6.8. The urine was noted as "Turbid, packed full of white cells and many bacteria". R3's white blood count was 19.3 (4XXX,[DATE].0). The "Assessment" documented 1. [MEDICAL CONDITION]. This is metabolic. Etiology uncertain at this time, but there are multiple factors. The patient is significantly dehydrated. 2. Acute [MEDICAL CONDITION]. I suspect related to volume depletion. 3. Cardiac Arrhythmia, secondary to underlying metabolic problem. 4. Hypertension. The discharge summary dated [DATE] documented the final [DIAGNOSES REDACTED]. The Urine culture dated [DATE] documented R3 culture was greater than 100,00 of Proteus mirabilis which was resistant to [MEDICATION NAME]. R3 had [MEDICATION NAME] her admission to the facility on [DATE] for a urinary tract infection. The "Nephrology Consultation" dated [DATE] documented R3 had a urinary tract infection and "is quite delirious". The consult noted "trace [MEDICAL CONDITION]" and the "Oropharynx very dry". The "Assessment" documented: "1. Acute [MEDICAL CONDITION] of unclear etiology. I do understand this patient has a history of [MEDICAL CONDITION]. I would presume the etiology of her acute [MEDICAL CONDITION] to be volume depletion in the setting of [MEDICAL CONDITION] with anorexia on [MEDICATION NAME]. 2. Urinary tract infection, currently on [MEDICATION NAME]. Consider another antibiotic [MEDICATION NAME] prescribed on [DATE]. 3. [MEDICAL CONDITION] with presumed anorexia. 4. Mild [MEDICAL CONDITION] on both beta-blocker and non-dihydropyridine calcium channel blockers. 5. [MEDICAL CONDITION] of unclear etiology. May be related to poor motivation of breathing with [MEDICAL CONDITION] or may be related to decompensated [MEDICAL CONDITION] or might be her baseline with [MEDICAL CONDITION]. 6. [MEDICAL CONDITION] of unclear type and severity. 7. [MEDICAL CONDITION] on [MEDICATION NAME]. 8. Coagulapathy related to [MEDICATION NAME] and likely anorexia with lesser Vitamin K intake." According to the "Palliative Care Note" dated [DATE], R3 was transferred to hospice services. The "Medical Certificate of Death", dated [DATE], documented "Cause of Death" as "Metabolic Acidosis" and "Acute [MEDICAL CONDITION]". .