Every finding on record at Evercare of Lebanon

Based on observation, interview, and record review, the facility failed to provide adequate pressure relief to prevent new pressure ulcers from developing and prevent declines in existing pressure ulcers in 1 of 1 resident (R8), reviewed for Treatment/Services to Prevent/Heal Pressure Ulcers in the sample of 37. These failures led to R8 developing a new pressure ulcer and a decline in current pressure ulcers.Findings Include: R8's Face Sheet, undated, documents R8 has the following diagnoses, in part: Cerebrovascular Disease, Traumatic Brain Injury, Vascular Dementia, Epilepsy, Hypertension, Hypothyroidism, Hyperlipidemia, Stage 3 Pressure Ulcer to the Sacrum (Coccyx), and Stage 2 Pressure Ulcer to the Left Hip.R8's Minimum Data Set, dated [DATE], documents R8 has severe cognitive impairment, is dependent on staff for all activities of daily living has three stage 2 pressure ulcers that were not present upon admission, and three stage 3 pressure ulcers, one was present upon admission.R8's Care Plan, dated 5/14/25, documents R8 has current skin breakdown with the potential for further breakdown related to decreased mobility, spends most of her time in her bed or chair, and is incontinent of bowel and bladder. R8 has interventions in place to float her heels, and she is dependent on staff to turn/reposition her at least every two hours and more often if needed or requested.R8's Pressure Ulcer Risk Assessment, dated 1/20/26, documents R8 is at high risk for pressure ulcer development. R8's Pressure Ulcer Risk Assessment, dated 4/22/26, documents R8 is at very high risk for pressure ulcer development. R8's Wound Care Note, dated 4/1/26, documents R8 had a newly acquired pressure ulcer to the left hip and a decline in the coccyx and right medial foot wounds. R8's Wound Care Note, dated 4/8/26, documents a decline in the left hip, coccyx and right medial foot wounds. R8's Wound Care Notes, dated 4/15/26 and 4/22/26, document the left hip wound is the same, and a decline in the coccyx and right medial foot wounds. All above notes have comments to offload pressure per facility policy. On 4/29/26 at 2:00 PM, R8 was observed severely emaciated, positioned on her right side. There weren't any pillows or pressure relieving devices between her knees or ankles and her feet were touching the bed and were not floating. Wound care was observed on R8 with V4 (Assistant Director of Nurses (ADON)/Wound Care Nurse), and V12 (Wound Care Physician's Assistant) to all pressure ulcers. R8's sacral wound was approximately 6 cm (centimeters) by 6 cm, covered in wet necrotic tissue (slough), with a foul odor. R8's left hip wound was approximately 5 cm by 5 cm and was covered in dried necrotic tissue. R8's right medial foot wound was approximately 2 cm by 2 cm and was draining clear fluid.On 4/29/26 at 3:17 PM, R8 was observed positioned on her left side, with no pressure relieving devices in place between her knees or ankles, her left foot was touching the bed, and her feet were touching each other. On 4/30/26 at 8:00 AM, R8 was observed in her reclining wheelchair in the dining room.On 4/30/26 at 9:00 AM, R8 was observed in her reclining wheelchair chair in the TV (Television) area.On 4/30/26 at 9:35 AM, 10:00 AM, and 10:27 AM, R8 was observed in her reclining wheelchair in dining room in an activity.On 4/30/26 at 11:16 AM and 11:30 AM, R8 was observed in her reclining wheelchair in the TV area.On 4/30/26 at 11:50 AM, R8 was observed in her reclining wheelchair in the dining room. On 4/30/26 at 10:37 AM, V14 (Certified Nursing Assistant/CNA), stated R8 was just repositioned by her and V15 (Activity Director) about 5 minutes ago. V14 stated she and V15 repositioned R8 in her chair by moving her up in her chair. On 4/30/26 at 10:40 AM, V15 (Activity Director) stated about 15 minutes ago she and V14 repositioned R8 in her chair by moving her up and over in her chair. On 4/30/26 10:55 AM V12 (Wound Care Physician's Assistant) stated ideally R8, would have something between her ankles and knees for pressure relief. V12 stated effective repositioning with R8 would be to get her out of her chair, lay her down/reposition her and get her up again later, not moving her up in the chair. V12 stated R8's deterioration in the right foot and coccyx wounds could have been caused by the lack of effective pressure redistribution. On 4/30/26 at 12:30 PM, V4 (ADON/Wound Care Nurse) stated R8 should be turned and repositioned every two hours. V4 stated when R8 is in bed, she usually has a pillow or something between her knees and ankles. V4 stated when R8 is up in her chair, they reposition her by moving her up in the chair, repositioning her side to side and then lying the back of the wheelchair down. V4 stated she has a special pillow that they usually put between her legs and boots when she is up in the wheelchair, but she forgot to put her boots on this morning. The Wound Management Policy, with a review date of 9/5/25, documents, in part, a resident who has a wound will receive necessary treatment and services to promote healing, prevent infection, and prevent new pressure ulcers from developing. A pressure ulcer is any lesion that is caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers usually occur over bony prominences and are graded or staged to classify the degree of tissue damage observed.The Repositioning Policy, with a review date of 7/1/25, documents, in part, the purpose of the policy is to focus on regularly changing a resident's body position to prevent pressure injuries and provide comfort and well-being. The frequency and specific positioning techniques should be tailored to each resident's individual needs, considering factors such as their mobility, skin condition, medical status, and comfort. The primary goal is to relieve pressure on bony prominences where pressure injuries are most likely to develop. Certain situations, existing pressure injuries, those in specific positions, or those using pressure relieving devices, require specific adjustments to the turning and repositioning plan.

Based on interview and record review the facility failed to ensure sexual abuse allegations were reported for 1 of 4 residents (R3) reviewed for abuse. This failure occurred when R2, who had known sexually inappropriate behaviors, went into R3's room and was observed with his hands in R3's briefs and staff did not report the incident. A reasonable person would likely suffer serious psychosocial harm, such as emotional distress or trauma and fear for safety as a result of sexual abuse. Findings include: Immediate Jeopardy began on 03/24/26 in the A.M., when R2, with known sexually inappropriate behavior, was seen in R3's room with his hand in R2's brief and staff did not report the incident.V1 (Administrator), V12 (Regional Nurse Consultant) and V21 (Regional Director of Operations) were notified of the Immediate Jeopardy on 04/10/26 at 12:57 PM. Abatement plan number one was not accepted. Abatement plan number two was accepted. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 4/14/26, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. R3's Face Sheet, admission date of 03/13/16, documents R3 has diagnoses of but not limited to unspecified dementia, malignant neoplasm of upper-outer quadrant of unspecified female breast, major depressive disorder, recurrent, in partial remission, and hypertension (HTN).R3's Minimum Data Set (MDS), dated [DATE], documents R3 is severely cognitively impaired, and she was dependent on staff for all her activities of daily living (ADLs)R3's Care Plan documents R3 has a terminal prognosis related to (r/t) cerebral atherosclerosis and receives hospice care with an initiated date of 6/20/25. R3's Physician's Orders, dated 01/10/25 at 11:09 AM, documents Hospice to evaluate and treat as indicated.R3's Nurse Practitioners (NP) Progress Note, dated 02/10/26, documents R3 is nonverbal.R3's Progress Notes, dated 03/27/26 at 1:14 PM, documents R3 passed away at the facility at 11:40 AM.R2's Face Sheet, admission date of 08/08/25, documents R2 has diagnoses of but not limited to bipolar disorder, schizoaffective disorder, bipolar type, cerebral infarction, and dysphagia following cerebral infarction. R2's MDS, dated [DATE], documents he is cognitively intact with a Brief Interview of Mental Status (BIMS) of 14 out of 15.R2's Care Plan, with admission date of 08/08/25, has no documentation (problem, goal, or interventions) R2 has sexually inappropriate behaviors.R2's Psychiatry Note, dated 08/18/25, documents he was seen by V26 (Psychiatry Nurse Practitioner/NP) and was seen for follow up for target impulsivity and inappropriate sexual behaviors.R2's Progress Notes, dated 03/30/26, Chief complaint: Per staff patient has recently exhibited hypersexual behavior while in the front of the building, which resulted in his transfer back to the memory care unit. It also documents ongoing behavioral dysregulation with inappropriate sexual behaviors, poor impulse control, and boundary violations evidenced by hypersexual actions inappropriate touching of staff, and need for increased supervision.On 04/02/26 at 11:25 AM, R2 was questioned about the incident regarding R3 and he stated I f****d her in the a**. He said he did touch her inappropriately, that was the first time he had done it, he hadn't done it to anyone else, and that was the reason he was moved to the locked unit.R3's Initial and Final state surveying agency reports were reviewed, and the final report documents the following: Date of Incident: 03/28/26 at 17:30 (5:30 PM).R2 is interviewable and makes informed decisions and alter and oriented times three. He is also capable of communication.R3 is not interviewable, can't make informed decisions, alert and oriented times one and she isn't able to communicate.Detailed Incident Summary documents: R2 is a [AGE] year-old male who resides at the facility. He has a past medical history of bipolar disorders, schizoaffective disorder, anxiety disorder, attention deficit hyperactivity disorder (ADHD), unspecified dementia and depression.R3 is a [AGE] year-old female who resides at the facility. She has a past medical history of unspecified dementia, major depressive disorders and mixed anxiety disorder.Initial Report: Staff reported an alleged resident to resident physical incident. Investigation initiated. Final to follow.Initial Interventions:1. Residents immediately separated2. Residents assessed3. MD & Responsible parties notified4. Increased monitoring5. Investigation initiated6.Final to follow in 5 working days7. Abuse and Neglect In-service startedInvestigation: An allegation was made that R2 allegedly was in R3's room and touched R3 inappropriately after it being reported that he was just in her room. When asked if there were any eyewitnesses, it was reported that they did not know that this was just a rumor they heard.R2 was interviewed and stated that he doesn't know what we were talking about and that he didn't know who R3 was. He knows that he was placed on the secure unit because he was wandering into rooms but that he didn't touch anyone. R2 was on frequent monitoring due to his increased confusion and wandering during the time of this allegation/hearsay rumors. R3 is not interviewable and has since passed away under hospice care. On the date of the allegation R3 was observed several times not under any distress even when R2 was observed in her room. This allegation was alleged after her passing by an anonymous person. Staff were interviewed and stated that they were not aware of any issues with R2 and R3. They were aware of his wandering and that he was placed on the secure unit due to that and his confused behaviors. When asked if R2 uses vulgar and inappropriate language staff did confirm that it is his normal vocabulary. When asked who the abuse coordinator all answered the administrator and they are aware of what should be reported to the administrator.Other residents were interviewed and asked if they have an issue with R2 being inappropriate with them or making lewd gestures. All residents interviewed stated no. They asked if they felt safe in the facility. All reported they do. When asked who they can report abuse or neglect to they reported to the administrator or their nurse.Conclusion: The facility was unable to determine if the allegations that were alleged were true. The rumors that were noted were asked to staff members if they had witnessed any of the allegations. All staff members reported no. When asked if he was in her room there were witnesses that stated he was in her room but not more than 10-15 minutes due to frequent checks on him and on her for different reasons. In an abundance of precautions and due to excessive wandering R2 was placed on the secure unit and due to prior behaviors, he was placed 1:1 for observation.Final Interventions:1) In an abundance of precautions: a facility improvement plan was set in place.2) Staff in-serviced3) Investigation completed4) Resident interviewed5) Staff interviewed6) Initial audit that staff and residents know who to report abuse to.7) Ongoing audits set in place to ensure that allegations of abuse and increased behaviors get reported and interventions implemented timely. On 04/02/26 at 8:55 AM, V7 (Certified Nursing Assistant/CNA) said the incident happened last Tuesday (03/24/26) with R2 and R3 and then R3 passed away a few days later. V7 said she was assisting R3 with her breakfast and she wasn't eating very well so after she was finished, she laid R3 back down in bed and put a new brief on her and made sure it was secured tightly (she said R3 was not able to remove/loosen the brief up herself due to her decline in health). V7 said she then left the room to take care of other residents and about 15 minutes later she was walking by R3's room and looked in. When she looked in, V7 said she seen R2 up against R3's bed rail and so she yelled and told R2 he wasn't supposed to be in that room. She said when R2 started to step away from R3 she noticed his hand was in R2's brief and then he moved his hand away. V7 said she went in and got R2 from the room and she noticed R3's brief was now loose. V7 said V8 (MDS Coordinator) must have heard her yell because she came and got R2 and took him to his room. On 04/02/26 at 10:55 AM, Follow up interview with V7 (CNA). V7 said R3 was positioned on her back after she put her into bed. R2 was standing up close to R3 and when she yelled for him to back away from R3 she saw R2 remove his hand from the front of R3's brief. She said she didn't tell anyone because V8 came and got R2 and took him to his room and then V1 (Administrator) came and got R2 took him to the lobby and told him they were going to move him to a different room, so she thought they all knew. She said it's her fault that it wasn't reported. V7 said no one asked her any questions about the incident between R2 and R3.On 04/02/26 at 12:05 PM, V10 (Business Office Manager/BOM), said R2 had been hanging/lurking around R3's room so they moved R2 to keep him from doing anything.On 04/02/26 at 1:30 PM, V11 (Vice President of Clinical Services) said R2 originally started out on the locked unit but he was having some behaviors with some of the other residents back there. She said he has a vulgar vocabulary and some of the dementia residents couldn't handle it well, so they made the decision to move him off the unit and make him a 1:1 for a while to see how he does. V11 said it was last Tuesday (03/24/26) and R2 was out in the hall and was wandering. She said he pulled his pants down in the middle of the hallway but his shirt was long enough and covered him so you couldn't see anything. V11 said later he wandered across the hall into R3's room and a CNA went back to get R3 up for lunch and found R2 in her room. She said V8 (MDS Coordinator) heard the CNA yell you can't be in here so she went to see what was going on and she then took R2 back to his room and then they notified V1 (Administrator) who in turn called her (V11) and they made the decision to move R2 back to the locked unit and make him a 1:1 so he would be monitored. V11 said nothing was said or reported to them that justified them doing a reportable and turning into the state surveying agency. On 04/07/26 at 11:20 AM, V8 (MDS Coordinator said she was sitting in her office (was the room next door to R3's room) and she heard a CNA who was in R3's room say hey, you're not supposed to be in here. She said she immediately went to the room and when she walked in R2 was sitting in his wheelchair and the CNA was pulling up R3's blanket. V8 said she removed R2 from the room and took him to his room and questioned R2 on what he was doing in that room. She said R2 told her he didn't know. V8 said she immediately went to V1 (Administrator) and reported to her what she saw. V8 said that is when they immediately started making plans to move R2. V8 said she wasn't involved or a part of R2's referral that would have been the old administrator (V16). She said R2 is physically and verbally aggressive, but he hasn't had any inappropriate sexual behavior that she is aware of. On 04/07/26 at 3:30 PM, V24 (CNA) and V25 (CNA) both stated later that same day they seen R2 in R3's room again and had to get him out. They didn't see anything inappropriate going on. They said R2 hadn't been moved back over to the locked unit, but they were in the process of trying to get him moved and they found R2 in R3's room and had to get him out of it.On 04/09/26 at 11:46 AM, V1 (Administrator) said V8 (MDS Coordinator) came into her office (Tues) and told her R2 was in R3's room. She said V8 told her she got him out of the room and took him to his room. V1 said she got up and went down there to check and when she got down there R2 was sitting in his room. Nothing else was reported to her. On 04/09/26 at 11:49 AM, V26 (Psychiatry Nurse Practitioner/NP) said he started seeing R2 when R2 came to this facility. He said R2 had been displaying sexually intermittent sexually inappropriate behaviors. He said he has been doing medication modification since November to keep residents safe. He said to keep resident safe in his opinion there should be medication management, redirection attempts, reinforcement of appropriate behaviors. He said safety is his number one priority and good medication management. On 04/09/26 at 2:47 PM, V6 (CNA) said she wasn't there the day it happened, so she didn't do anything after she heard about R2, there was nothing for her to do. She said it was after the fact, and they had already moved R2 back to the unit. She said if she had been here the of the incident she would have reported it immediately/as soon as possible (ASAP). On 04/10/26 at 11:06 AM, V32 (NP) said when it comes to psychological impact of sexual abuse on a person it depends on a lot of things. She said it is distressing situation for anyone. She said it will differ from person to person also. It can cause emotional damage, anxiety, depression, post-traumatic stress disorder (PTSD), and yes there is always a risk for sexually transmitted disease (STD). On 04/10/26 at 1:10 PM, This surveyor and supervisor went in to inform V1 and other administration (V12 and V21) of the IJ at 12:57 PM. After reading through the IJ information V1 stated they said they did an IDPH reportable investigation and turned it in. This surveyor asked why the investigation wasn't in with the other reported investigations that I had asked for upon entering. V1 said because it hadn't been 5 days, and she hadn't completed the investigation at that time. The facility's Abuse Prevention and Prohibition Program, reviewed date of 12/2/25, documents Purpose: To ensure that the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designated to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and stat requirements. Policy:I. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property.II. The facility is committed to protecting residents from abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors. This policy statement also includes deprivation by any individual, including a caretaker, of goods, services or rights that are necessary for a resident to attain or maintain physical, mental, and psychosocial well-being.III. The Administrator is responsible for coordinating and implementing the facility's abuse prevention policies, procedures, training programs, and systems.It further documents: VI. InvestigationThe facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal acts.The Facility has protocols for investigation of theft/misappropriation of resident property abuse.If the Administrator receives a report of an incident or suspected incident of resident abuse, mistreatment, neglect, injuries of an unknown source or crime, the Administrator or designee, may appoint a member of the facility's management team ( the Investigator) to investigate the alleged incident.If the investigation is delegated, the Administrator provides the Investigator with any supporting documents related to the alleged incident.The facility ensures protection of residents during abuse investigations.The investigator may take some or all of the following steps:Reviews all relevant documentation;Reviews the resident's medical record to determine events preceding the alleged incident;Interviews the person(s) making the incident report;Interviews any witnesses to the alleged incident;Interviews the resident (as medically appropriate);Interviews the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition;Interviews Facility Staff members who have had contact with the resident during the period of the alleged incident;Interviews the resident's roommate, family members, and visitors;Interviews other residents to whom the accused employee provides care or services;Reviews all events leading up to the alleged incident;Exercise caution when handling materials that may be used for evidence of a criminal investigation. The Investigator will ensure the facility does not impede on any criminal investigation (i.e., wash lines or clothing, destroy documentation, and bathing or cleaning the resident before the resident has been examined).Communicates with the Administrator on a daily basis regarding the progress of the investigation; andPrepares an investigation report documenting findings of the investigation.It also documents G. Witness reports must be given in writing and signed and dated.It further documents M. Resident-to-Resident altercations must be reported if the altercation is caused by a willful action that results in physical injury, mental anguish or pain.The presence of a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate non-accidental behavior.Assessing psychosocial outcome of the victim of abuse may be difficult to determine or incongruent with what would be expected. In these situations, the investigatorshould consider how a reasonable person in the resident's circumstances would be impacted by the incident.N. The Administrator will provide initial and follow-up written reports of the results of all abuse investigations and consequent actions to the appropriate agencies as outlined in Section IX below.If the investigation substantiates the allegation, corrective action will be documented as part of the investigation and implemented to prevent recurrence.It also documents VII. Protection D. If the allegation is regarding a resident-resident altercation, the residents will be separated immediately, pending the investigation. Resident-Resident altercations will only be investigated as an incident of abuse if the incident meets the criteria of the definition of abuse.It further documents IX. Reporting/Response A. Facility Staff are Mandatory Reporters.It also documents C. The Facility will report known or suspected instances of physical abuse, including sexual abuse, and criminal acts to the proper authorities by telephone or through a confidential internet reporting tool as required by state and federal regulations.Immediately, but no later than 2 hours after forming the suspicion -if the alleged violation involves abuse or results in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the ombudsman.No later that 24 hours after forming the suspicion- if the alleged violation (e.g., misappropriation of property, neglect) does not involve abuse and does not result in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the Ombudsman.Reporting requirements are based on real (clock) time, not business hours.The administrator will provide the state survey agency, law enforcement and the Ombudsman with a copy of the investigative report within 5 days of the incident. It also documents: Failure to file a report within the required time frames may result in disciplinary action, up to and including termination. X. Special Consideration for Reporting Suspected Incidents of Criminal Sexual AbuseAnyone who suspects that criminal sexual abuse has been committed against a resident must immediately report this information Administrator and to the Director of Nursing Services.The facility will treat allegations as criminal sexual abuse wherein the Facility determines that the resident does not have the decision-making capacity to consent to the sexual act.The Director of Nursing Services or designee will immediately report this information to the Attending Physician.The Administrator then acts to ensure the following steps are taken:The proper authorities and individuals are notified immediately or within 2 hours, including but not limited to law enforcement, the Attending Physician, the resident's representative, the state survey agency, and adult protective services.A Licensed Nurse assesses the resident (alleged victim) for possible injuries.The resident is provided with medical treatment and emotional support necessary to prevent further deterioration of his/her health and wellbeing.The area where the alleged incident occurred is not disturbed or accessed by anyone before law enforcement arrives.The resident's clothing is not changed to avoid disturbing or destroying evidence.The resident is not bathed or, of female, douched, to avoid compromising potential evidence.The resident is transported to the hospital or other destination as instructed by law enforcement.The administrator will follow the reporting requirements outlined in Section IX above. The facility Resident Listing report, dated 04/02/26, documents there are 73 residents residing at the facility. The Immediate Jeopardy that began on 03/24/26. The immediacy was removed on 04/14/26 when the facility took the following actions: All residents that reside in the facility could be affected by deficient practice.A) R3 no longer resides in the facility. B) R2 was placed on the secured unit with 1:1 supervision. No behaviors exhibited since 3/24/26. currently out to the hospital. C)Administrator & Director of Nurses will be in-serviced on the abuse policy & procedure, how to conduct a complete investigation, including interviewing, reporting, and implementation. D) IDT team in-serviced by Administrator on abuse and neglect policy and procedure, reporting timely, and encouraging staff to report abuse & neglect. E) IDT team in-serviced staff on abuse and neglect, reporting timely, and ensuring accurate information was provided when reporting, and reporting of any behaviors. F) Staff will not work until in-serviced on abuse policy, reporting timely, and reporting behaviors to the appropriate staff. G) 24- hour report reviewed for the last 7 days to ensure that no reports of abuse of neglect were not reported timely or needing investigated. H) Facility will interview staff to ensure that no abuse allegations have gone unreported. I) Facility will interview residents to ensure that no abuse allegations have gone unreported. J) Facility will ensure residents who have a history of sexual inappropriate behaviors care plan will be reviewed to ensure interventions are appropriated.1) On-going Audit: The administrator/Designee will review the 24- hour report 5x/wk x 4 weeks to ensure that there were no reports of abuse or neglect. If abuse was noted and not reported 1:1 in-servicing will be completed.2) On-going Audit: The RDO/RNC/Designee will audit any abuse allegation to ensure that investigation was completed, timely and completely per facility policy. If an investigation was not completed 1:1 education will be provided.3) On-going Audit: The Administrator/Designee will review the 24-hour report 5x/wk x 4wks for any behaviors. If a behavior is noted facility will review findings and implement new interventions to ensure resident safety. If behaviors are noted without follow up 1:1 education will be provided. K) Root Cause analysis completed for abuse and neglect.

Based on interview and record review the facility failed to ensure 2 of 4 residents (R3 and R5) were protected from resident-to-resident abuse. This failure resulted in R3, who was nonverbal under end-of-life care, being the victim of sexual abuse by another resident (R2) with known inappropriate sexual behaviors. A reasonable person would likely suffer serious psychosocial harm, such as emotional distress or trauma and fear for safety as a result of sexual abuse. Findings Include:1. R3's Face Sheet, admission date of 03/13/16, documents R3 has diagnoses of but not limited to unspecified dementia, malignant neoplasm of upper-outer quadrant of unspecified female breast, major depressive disorder, recurrent, in partial remission, and hypertension (HTN). R3's Minimum Data Set (MDS), dated [DATE], documents R3 is severely cognitively impaired, and she was dependent on staff for all her activities of daily living (ADLs) R3's Care Plan documents R3 has a terminal prognosis related to (r/t) cerebral atherosclerosis and receives hospice care with an initiated date of 6/20/25. R3's Physician's Orders, dated 01/10/25 at 11:09 AM, documents Hospice to evaluate and treat as indicated. R3's Nurse Practitioners (NP) Progress Note, dated 02/10/26, documents R3 is nonverbal. R3's Progress Notes, dated 03/27/26 at 1:14 PM, documents R3 passed away at the facility at 11:40 AM. R2's Pre-admission Progress Notes, dated 07/16/25 at 12:54 PM, documents R2 was going back to his room after a smoke break and was heard by a nurse if he could play with a resident's breast. Social Service confronted him, and he denied it. When Social Service told him a nurse heard him, he had nothing to say. Social Service reminded him that it is highly inappropriate. R2's Pre-admission Progress Notes, dated 07/16/25 at 10:50 AM, documents Resident exhibiting impulsive behaviors wanting to touch other residents inappropriately. Nurse Practitioner (NP) notified and new orders were given to transfer R2 to a local hospital for evaluation and treatment. R2's Face Sheet, admission date of 08/08/25, documents R2 has diagnoses of but not limited to bipolar disorder, schizoaffective disorder, bipolar type, cerebral infarction, and dysphagia following cerebral infarction. R2's MDS, dated [DATE], documents he is cognitively intact with a Brief Interview of Mental Status (BIMS) of 14 out of 15. R2's Care Plan, admission date of 08/08/25, has no documentation (problem, goal, or interventions) R2 has sexually inappropriate behaviors. It does document R2 has potential to be physically aggressive related to (r/t) physical aggression to peer on 02/04/26. Interventions include but are not limited to send out to the hospital for evaluation and room move to (XXX) hallway from the dementia unit. R2's Psychiatry Note, dated 08/18/25, documents the chief complaint: Review of patient's behaviors, and symptoms related to his mental health. History of present Illness: R2 is a male patient with a history of Schizoaffective bipolar type, Generalized Anxiety Disorder (GAD), attention deficit hyperactivity disorder (ADHD), psychoactive substance abuse, tobacco use and insomnia. At the last visit, Divalproex was initiated to target impulsivity and inappropriate sexual behaviors. R2's Progress Notes, dated 03/30/26, Chief complaint: Per staff patient has recently exhibited hypersexual behavior while in the front of the building, which resulted in his transfer back to the memory care unit. It also documents ongoing behavioral dysregulation with inappropriate sexual behaviors, poor impulse control, and boundary violations evidenced by hypersexual actions inappropriate touching of staff, and need for increased supervision. R2's and R3's Final report to the state surveying agency, incident date of 03/28/26 at 5:30 PM, documents: Investigation: An allegation was made that R2 allegedly was in R3's room and touched R3 inappropriately after it being reported that he was just in her room. When asked if there were any eyewitnesses, it was reported that they did not know that this was just a rumor they heard. R2 was interviewed and stated that he doesn't know what we were talking about and that he didn't know who R3 was. He knows that he was placed on the secure unit because he was wandering into rooms but that he didn't touch anyone. R2 was on frequent monitoring due to his increased confusion and wandering during the time of this allegation/hearsay rumors. R3 is not interviewable and has since passed away under hospice care. On the date of the allegation R3 was observed several times not under any distress even when R2 was observed in her room. This allegation was alleged after her passing by an anonymous person. Staff were interviewed and stated that they were not aware of any issues with R2 and R3. They were aware of his wandering and that he was placed on the secure unit due to that and his confused behaviors. When asked if R2 uses vulgar and inappropriate language staff did confirm that it is his normal vocabulary. When asked who the abuse coordinator all answered the administrator and they are aware of what should be reported to the administrator. Other residents were interviewed and asked if they have an issue with R2 being inappropriate with them or making lewd gestures. All residents interviewed stated no. They asked if they felt safe in the facility. All reported they do. When asked who they can report abuse or neglect to they reported to the administrator or their nurse. Conclusion: The facility was unable to determine if the allegations that were alleged were true. The rumors that were noted were asked to staff members if they had witnessed any of the allegations. All staff members reported no. When asked if he was in her room there were witnesses that stated he was in her room but not more than 10-15 minutes due to frequent checks on him and on her for different reasons. In an abundance of precautions and due to excessive wandering R2 was placed on the secure unit and due to prior behaviors, he was placed 1:1 for observation. Final Interventions: 1) In an abundance of precautions: a facility improvement plan was set in place.2) Staff in-serviced3) Investigation completed4) Resident interviewed5) Staff interviewed6) Initial audit that staff and residents know who to report abuse to.7) Ongoing audits set in place to ensure that allegations of abuse and increased behaviors get reported and interventions implemented timely. On 04/02/26 at 8:55 AM, V7 (Certified Nursing Assistant/CNA) said the incident happened last Tuesday (03/24/26) with R2 and R3 and then R3 passed away a few days later. V7 said she was assisting R3 with her breakfast and she wasn't eating very well so after she was finished, she laid R3 back down in bed and put a new brief on her and made sure it was secured tightly (she said R3 was not able to remove/loosen the brief up herself due to her decline in health). V7 said she then left the room to take care of other residents and about 15 minutes later she was walking by R3's room and looked in. When she looked in, V7 said she seen R2 up against R3's bed rail and so she yelled and told R2 he wasn't supposed to be in that room. She said when R2 started to step away from R3 she noticed his hand was in R2's brief and then he moved his hand away. V7 said she went in and got R2 from the room and she noticed R3's brief was now loose. V7 said V8 (MDS Coordinator) must have heard her yell because she came and got R2 and took him to his room. On 04/02/26 at 10:55 AM, Follow up interview with V7 (CNA). V7 said R3 was positioned on her back after she put her into bed. R2 was standing up close to R3 and when she yelled for him to back away from R3 she saw R2 remove his hand from the front of R3's brief. She said she didn't tell anyone because V8 came and got R2 and took him to his room and then V1 (Administrator) came and got R2 took him to the lobby and told him they were going to move him to a different room, so she thought they all knew. She said it's her fault that it wasn't reported. V7 said no one asked her any questions about the incident between R2 and R3. On 04/02/26 at 11:25 AM, R2 was questioned about the incident regarding R3 and he stated I f****d her in the a**. He said he did touch her inappropriately, that was the first time he had done it, he hasn't done it to anyone else, and that was the reason he was moved to the locked unit.On 04/09/26 at 11:49 AM, V26 (Psychiatry Nurse Practitioner/NP) said he started seeing R2 when R2 came to this facility. He said R2 had been displaying sexually intermittent sexually inappropriate behaviors. He said he has been doing medication modification since November to keep residents safe. He said to keep resident safe in his opinion there should be medication management, redirection attempts, reinforcement of appropriate behaviors. He said safety is his number one priority and good medication management. On 04/10/26 at 11:06 AM, V32 (NP) said when it comes to psychological impact of sexual abuse on a person it depends on a lot of things. She said it is distressing situation for anyone. She said it will differ from person to person also. It can cause emotional damage, anxiety, depression, post-traumatic stress disorder (PTSD), and yes there is always a risk for sexually transmitted disease (STD). 2. R5's Face Sheet, admission date of 08/25/25, documents R5 has diagnoses of but not limited to dementia, major depressive disorder, and schizophrenia. R5's MDS, dated [DATE], R5 is severely cognitively impaired, and he is dependent on staff for most of his ADLs. R5's Care Plan, with admission date of 08/25/25, documents safety concerns recipient of physical aggression by peer with bruise to right (R) face/eye. R2's and R5's state surveying agency Investigation documents the following: Initial Investigation: Incident date of 02/04/26 at 7:00 PMIncident Category: Resident to Resident Altercation. Resident #1 Involved in Incident/Reportable Event: R2 is a male, interviewable, informed decisions, alert and oriented times two. Resident #2 Involved in Incident/Reportable Event: R5 is a male, he is not interviewable, can't make informed decisions, alert and oriented times 1. Police were notified.Detailed Incident Summary:R2 BIMS of 14, is a [AGE] year-old male who resides on our secured male unit here at Evercare of Lebanon. He has a past medical history of Cerebral infraction, dysphasia, COPD, Bipolar disorder, schizoaffective disorder, anxiety disorder, ADHD, unspecified dementia, and depression. R5 BIMS 99 is a [AGE] year-old male who resides on our secured male unit here at Evercare of Lebanon. He has a past medical history of obstructive and reflex uropathy, major depressive disorder, schizophrenia and generalized anxiety disorder. Initial Report:Staff reported an alleged Resident to Resident physical altercationInitial Interventions:1. Residents immediately separated2. Residents assessed.3. MD (Medical Doctor) & Responsible parties notified4. Increased monitoring initiated on both residents5. Investigation initiated6. Final to follow in 5 working days. Final Report:A comprehensive investigation including resident/staff interviews and review of both residents' medical records was conducted. Facility staff were interviewed and voiced that R5 was visualized coming out of R2's room. R5, BIMS of 99 was interviewed and could not express to staff any events that just occurred. R2 BIMS of 14 was interviewed and voiced that R5 wandered into his room when he was sleeping and was going through his belongings. R5 expressed feeling startled by R5. When asked if residents feel safe in the facility, R5 stated yup, yup. When asked if R2 feels safe in the facility, he stated yes. Facility staff were interviewed and expressed no concerns related to abuse. Other residents were interviewed and expressed no concerns related to abuse. Based on the results of the investigation, the facility has found no evidence to support abuse. The IDT determined the alleged interaction was related to wandering behavior and cognitive impairments. Final Interventions:1. Increased monitoring for both residents2. R5 sent to hospital for evaluation3. R2 sent to (name of facility) for psych evaluation and returned 2/94. R5 returned same day 2/4 on 15min checks for 72 hours5. R2 room move with resident/family approval and 15min checks for 72 hours6. Psych consultation requested for R27. Assessments completed on both residents: BIMS, Trauma Informed Care, Skin Checks, Pain and vials8. Abuse Policy In-Service completed On 04/02/26 at 8:50 AM, R2 said he did have a fight with someone back here (the unit). He said someone was lying in his bed. When asked what happened he stated, I fought him. R2 was asked if he was hurt during the altercation and he stated, no and when asked if the other resident was hurt R2 said yeah, he was. The facility's Abuse Prevention and Prohibition Program, reviewed date of 12/2/25, documents Purpose: To ensure that the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designated to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. Policy:I. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property.II. The facility is committed to protecting residents from abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors. This policy statement also includes deprivation by any individual, including a caretaker, of goods, services or rights that are necessary for a resident to attain or maintain physical, mental, and psychosocial well-being.III. The Administrator is responsible for coordinating and implementing the facility's abuse prevention policies, procedures, training programs, and systems.It further documents: M. Resident-to-Resident altercations must be reported if the altercation is caused by a willful action that results in physical injury, mental anguish or pain.The presence of a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate non-accidental behavior.Assessing psychosocial outcome of the victim of abuse may be difficult to determine or incongruent with what would be expected. In these situations, the investigatoriii. should consider how a reasonable person in the resident's circumstances would be impacted by the incident.N. The Administrator will provide initial and follow-up written reports of the results of all abuse investigations and consequent actions to the appropriate agencies as outlined in Section IX below.i. If the investigation substantiates the allegation, corrective action will be documented as part of the investigation and implemented to prevent recurrence. It also documents VII. Protection D. If the allegation is regarding a resident-resident altercation, the residents will be separated immediately, pending the investigation. Resident-Resident altercations will only be investigated as an incident of abuse if the incident meets the criteria of the definition of abuse.It further documents IX. Reporting/Response A. Facility Staff are Mandatory Reporters. The facility Resident Listing report, dated 04/02/26, documents there are 73 residents residing at the facility.

Based on interview and record review the Facility failed to ensure misappropriation of medication did not occur for 2 of 3 residents (R6 and R7) reviewed for missing medication in the sample of 8. This past non-compliance occurred from 10/8/2025 to 10/29/2025. Findings include: On 11/19/2025 at 2:52 PM, V1 (Administrator) stated, on 10/18/2025 during the day shift the DON was notified by staff nurse that she tried to reorder (R6 and R7's) medication and the pharmacy had told them they had already sent them a supply of 2 cards (sixty doses). (R6 and R7) were both missing medications. There was only one card on file and there should have been two for each of them. Staff were interviewed and all stated they were doing narcotics counts but the sheet showing there were 60 pills vs thirty was not present either, so everyone's count was off, and we did not know until we got ready to reorder the medication. We were not able to locate the medication, and we did replace but the medication was missing. On 11/19/2025 at 3:02 PM, V2 (Director of Nursing/DON) stated, I got a call on 10/18/2025 by the nurse that when she went to refill (R6 and R7's) alprazolam they learned that the pharmacy had sent 60 pills not 30 pills, so we started an investigation to look into the missing meds. On 11/21/2025 at 10:47 AM, V17 (Licensed Practical Nurse/LPN) stated I was not working the back hall I was working the front hall so when the medication was delivered from the pharmacist, I was the one who signed for it. I got a call from the DON, and she asked me if I had counted the medication when I received it and I told her yes. I also remember there were two cards rubber banded together, and I did sign for the medication and took it back to the Agency nurse (V18 LPN) on the dementia unit. I was not asked to drug test, after they found out some drugs were missing, and they said (V18) was fired because they suspected she was the one taking the drugs. On 11/21/2025 at 11:30 AM, V8 (LPN) stated, I remember (R7) was running low on his medication and I called the pharmacy to reorder. The pharmacy told me that they sent out two cards (60 pills) so he should have 30 more pills, and it was too early. I went and found (V2) she was working the floor to let her know there were issues with missing medication for R7. I guess they did a count and (R6) was missing her medication too. I am not sure if they were able to find out who took the meds. I don't know if anyone was fired. I was not drug tested. 1). On 11/20/2025 at 1:44 AM, R6 was on the locked dementia unit on the female side. R6 was confused and not able to answer questions regarding if she had ever missed any medications. R6's Physician Order Sheet for November 2025 document a diagnosis of: POTS (Postural Orthostatic Tachycardia Syndrome), schizoaffective disorder, HTN (hypertension), hypothyroidism, Afib (atrial fibrillation), anxiety, anemia insomnia, HLD (Hyperlipidemia), GERD (Gastroesophageal reflux disease), polyarthritis, dementia, schizophrenia, cognitive communication deficit, vitamin D deficiency, depression, and allergic rhinitis. R6's Minimum Data Set (MDS) dated [DATE] documents severe cognitive impairment for decision making of activities of daily living.R6's Care Plan documents she makes false accusations of mistreatment by staff/peers. 6/2/25 R6's with new onset of behaviors of sitting on floor and flailing arms, taking a blanket and laying on floor in hallway, delusions that cops are coming to take her away, she has behaviors of laying on floor and wallering. R6's Initial Report dated 10/29/2025 at 6:55 PM, Staff reported alleged misappropriation of property. MD (Medical Doctor), POA (Power of Attorney) and local police notified. Investigation initiated. Final report to follow. (R6) Resident #1 and (R7) Resident #2 neither were documented as identified offender.R6's Pharmacy Packing slip dated 10/8/2025 documents (R6) received 0.5 mg tablet alprazolam 30 cards x2, V17, Licensed Practical Nurse (LPN) signed for those meds on 10/8/2025. R6's Progress Notes does not address her missing any of her alprazolam medication. R6's Controlled Drug Receipt for October 2025 documents, alprazolam tablet 0.5 MG (milligrams) take 1 tablet twice daily. 2.) R7's POS for November 2025 documents R7 with a diagnosis of Parkinson's disease, asthma, hypotension, dementia with agitation, bipolar disorder, anxiety, insomnia and dysphagia. R7's MDS dated [DATE] document R7 was severely impaired for cognition for activities of daily living. On 11/20/2025 at 1:24 PM, R7 was on the locked dementia unit on the men's side of the building. R7 was wandering and unable to answer any questions related to if he had ever missed any of his medications. R7's Initial Report dated 10/29/2025 document, Staff reported alleged misappropriation of property. On 10/29/2025 the DON was notified by staff nurse that she was unable to re-order medications on two residents. Further review by Admin/DON revealed a discrepancy in the number of cards the facility should have on hand. All appropriate notifications were made and investigation initiated. Facility leadership noted one card of 30 alprazolam for (R6) and one card of 30 alprazolam for (R7) to not be accounted for. Both medications were replaced at the expense of the facility. All narcotics were reconciled with no further concerns noted. The Facility undated Abuse Policy documents, To ensure that facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The facility has zero- tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment. Or misappropriation of resident property. This past non-compliance occurred from 10/8/2025 to 10/29/2025: Prior to the survey date of 11/21/2025, the facility had taken the following actions to correct the noncompliance. All staff and residents were interviewed. All staff was in-serviced on medication, destruction and controlled substance disposal, narcotic count verification, log for cards of narcotic medication and abuse. All residents were assessed for behaviors. Daily audit of narcotics was started by the DON. Social Service Director is doing daily audits for psychosocial on residents.

Based on observation, interview and record review the Facility was unable to account for narcotic medication (alprazolam) for 2 of 3 residents (R6 and R7) reviewed for missing narcotic medication in the sample of 8. This past non-compliance occurred from 10/8/2025 to 10/29/2025. Findings include: 1.) On 11/20/2025 at 1:44 AM, R6 was on the locked dementia unit on the female side. R6 was confused and not able to answer questions regarding if she had ever missed any medications. R6's Physician Order Sheet for November 2025 document a diagnosis of: POTS (Postural Orthostatic Tachycardia Syndrome), schizoaffective disorder, HTN (hypertension), hypothyroidism, Afib (atrial fibrillation), anxiety, anemia insomnia, HLD (Hyperlipidemia), GERD (Gastroesophageal reflux disease), polyarthritis, dementia, schizophrenia, cognitive communication deficit, vitamin D deficiency, depression, and allergic rhinitis. R6's Minimum Data Set (MDS) dated [DATE] documents severe cognitive impairment for decision making of activities of daily living.R6's Care Plan documents she makes false accusations of mistreatment by staff/peers. 6/2/25 R6 with new onset of behaviors of sitting on floor and flailing arms, taking a blanket and laying on floor in hallway, delusions that cops are coming to take her away, she has behaviors of laying on floor and wallering. R6's Initial Report dated 10/29/2025 at 6:55 PM, Staff reported alleged misappropriation of property. MD (Medical Doctor), POA (Power of Attorney) and local police notified. Investigation initiated. Final report to follow. (R6) Resident #1 and (R7) Resident #2 neither were documented as identified offender.R6's Pharmacy Packing slip dated 10/8/2025 documents (R6) received 0.5 mg tablet alprazolam 30 cards x2, V17 (Licensed Practical Nurse/LPN) signed for those meds on 10/8/2025. R6's Progress Notes does not address her missing any of her alprazolam medication. R6's Controlled Drug Receipt for October 2025 documents, alprazolam tablet 0.5 MG (milligrams) take 1 tablet twice daily. 2). R7's POS for November 2025 documents R7 with a diagnosis of Parkinson's disease, asthma, hypotension, dementia with agitation, bipolar disorder, anxiety, insomnia and dysphagia. R7's MDS dated [DATE] document R7 was severely impaired for cognition for activities of daily living. On 11/20/2025 at 1:24 PM, R7 was on the locked dementia unit on the men's side of the building. R7 was wandering and unable to answer any questions related to if he had ever missed any of his medications. R7's Initial Report dated 10/29/2025 document, Staff reported alleged misappropriation of property. On 10/29/2025 the DON was notified by staff nurse that she was unable to re-order medications on two residents. Further review by Admin/DON revealed a discrepancy in the number of cards the facility should have on hand. All appropriate notifications were made and investigation initiated. Facility leadership noted one card of 30 alprazolam for (R6) and one card of 30 alprazolam for (R7) to not be accounted for. Both medications were replaced at the expense of the facility. All narcotics were reconciled with no further concerns noted. On 11/19/2025 at 2:52 PM, V1 (Administrator) stated, on 10/18/2025 during the day shift the DON was notified by staff nurse that she tried to reorder (R6 and R7's) medication and the pharmacy had told them they had already sent them a supply of 2 cards (sixty doses). (R6 and R7) were both missing medications. There was only one card on file and there should have been two for each of them. Staff were interviewed and all stated they were doing narcotics counts but the sheet showing there were 60 pills vs thirty was not present either, so everyone's count was off, and we did not know until we got ready to reorder the medication. On 11/19/2025 at 3:02 PM, V2 (Director of Nursing) stated, I got a call on 10/18/2025 by the nurse that when she went to refill (R6 and R7's) alprazolam they learned that the pharmacy had sent 60 pills not 30 pills, so we started an investigation to look into the missing meds. On 11/21/2025 at 10:47 AM, V17 (Licensed Practical Nurse) stated I was not working the back hall I was working the front hall so when the medication was delivered from the pharmacist, I was the one who signed for it. I got a call from the DON, and she asked me if I had counted the medication when I received it and I told her yes. I also remember there were two cards rubber banded together, and I did sign for the medication and took it back to the Agency nurse (V18 LPN) on the dementia unit. I was not asked to drug test, after they found out some drugs were missing, and they said (V18) was fired because they suspected she was the one taking the drugs. On 11/21/2025 at 11:30 AM, V8 (LPN) stated, I remember (R7) was running low on his medication and I called the pharmacy to reorder. The pharmacy told me that they sent out two cards (60 pills) so he should have 30 more pills, and it was too early. I went and found (V2) she was working the floor to let her know there were issues with missing medication for R7. I guess they did a count and (R6) was missing her medication too. I am not sure if they were able to find out who took the meds. I don't know if anyone was fired. I was not drug tested. The Facility Narcotic Counting Policy with a revision date of 11/1/2025 documents, Always participate in the counting of the controlled substances at the beginning and ending of your shift. Never say, go ahead without me and I'll sign later. Never leave it to someone else's discretion when you are the one on duty. If you do not observe the medications that you sign as being present, you may be implicated if the medications are later missing. General Procedure for Counting Controlled Substance. Follow your facilities specific guidelines and use their specific log sheet. Obtain sign-out records/logs and keys to the controlled storage compartment. Have partner to assist in the count. Wash hands or use antiseptic foam/gel. Unlock the medication cart. Select container and read the label. State the medication's name and strength. Count the remaining doses. Observe the number of spaced for medication to ensure no medications have been punched out of sequence thus altering the count. If medications are on a card, observe the integrity of the card to make certain it has not been tampered with. Observe the appearance of the pills to identify if they are correct and ensure there has been no tampering or substitution of medications. Determine amount of liquid medication, if appropriate. Verbally state medication count to person with sign-out record. Listen while partner verifies the count. Return container to its proper location. Repeat steps 6 - 14 for each controlled substance. Sign name, time and date of completed count. Lock medication area. Return sign-out log to proper location. Return keys to appropriate person. Procedure for Responding to Errors in a Controlled Substance Count: Obtain sign-out logs and keys to the controlled substance storage compartment. Have partner to assist with the count. Wash hands or use antiseptic foam/gel. Unlock the medication cart. This past non-compliance occurred from 10/8/2025 to 10/29/2025: Prior to the survey date of 11/21/2025, the facility had taken the following actions to correct the noncompliance. All staff and residents were interviewed. All staff was in-serviced on medication, destruction and controlled substance disposal, narcotic count verification, log for cards of narcotic medication and abuse. All residents were assessed for behaviors. Daily audit of narcotics was started by the DON. Social Service Director is doing daily audits for psychosocial on residents.

Based on observation, interview and record review the Facility failed to ensure residents did not exit through an exit door and were being supervised to prevent any potential elopements for 1 of 3 residents (R2) reviewed for elopement in the sample of 6. This failure resulted in R2 pushing the exit alarm and exiting the facility around 7:45 PM with no staff intervention on 9/25/2025 from a secured memory unit and leaving the facility when it was pitch dark and he was later found at 10:00 PM (two hours and 15 minutes later) and returned to the facility. This past compliance occurred from 9/25/2025 to 9/26/2025. Findings include: The Immediate Jeopardy began on 9/25/2025 when R2 eloped from the facility and there was no staff available to redirect R2. R2 was found at 10:00 PM (two hours and 15 minutes later) and returned to the facility. The area R2 was found is straight from the facility to the residential area but there was no straight access unless one went through steep hills, terrain with lots of sticks, bushes, overgrowth, and steep terrain. V1 (Administrator) and V42 (VP of Clinical Operations) were notified of the Immediate Jeopardy on 10/10/25 at 3:22 PM. The surveyor confirmed by observation, interview, and record review that the immediacy was removed, and the deficient practice was corrected on 9/26/25. On 10/7/2025 at 11:03 AM, upon entering the dementia units there are two locked memory care units, one for males (300 hall) and one for females (200 hall). All doors to enter and exit on both sides of the units are locked and a code is needed. If the code is not entered correctly the alarm sounded for both doors. R2's room is on the male side of the locked memory unit. The door to the outside on the male memory unit is not egressed and sounded immediately when the door was opened. On 10/7/2025 at 12:20 PM, R2's photo was in the elopement book at the nurse's station on both the female and male dementia units identifying R2 as an elopement risk. R2's Physician Order Sheet (POS) for October 2025 documents a diagnosis of Paranoid schizophrenia, drug induced subacute dyskinesia; insomnia; hypertension. R2's POS also document he is taking an antipsychotic medication (Haldol PRN as needed). R2's Minimum, Data Set (MDS) dated [DATE] document R2 has difficulty focusing attention, for example, being easily distracted or having difficulty keeping track of what was being said and has disorganized thinking. R2 has delusions, R2 wanders and R2 receives antipsychotic medications on a routine basis PRN (as needed). R2 ambulates independently and has no impairments. R2's Care Plan with a date of 8/8/2025 document R2 has a history of leaving the facility and hiding in facility dumpsters to watch staff look for him which he found humorous. R2 has a history of leaving facility and walking to the courthouse. R2 has a history of watching staff and when staff are busy with peers (R2) will exit and attempt to get to his nonexistent trailer. R2's Elopement assessment dated [DATE] document R2 was at risk for elopement. On 10/7/2025 at 11:33 AM, V1 (Administrator) stated, We have only had one resident elope since we got our IJ (Immediate Jeopardy). (R2) eloped on 9/25/2025. He was on (Dementia Unit) and went out the door on the evening shift, it was dark, and he walks really fast. Staff responded quickly but because it was dark, and he got away. He was gone for over two hours before we found him. He left and went out the door down the hill across that creek but there is no water, just rocks, and through the wooded area. Staff found him and we alerted the police and there were helicopters, canine units, everyone was looking for him. Once staff found him, they asked him if he wanted a soda, and he said yes and he willingly got into the car, and they brought him back with no issues. He was dressed appropriately and was even carrying a water bottle with him. He said he was doing maintenance work, and he was on a mission. On 10/8/2025 at 10:33 AM, R2 stated he did leave the facility and just went out the back door as nobody was around. I wanted to go catch a bus for personal business that I need to address. It's personal. I just walked out the door and across the field to the bus stop. On 10/8/2025 at 11:44 AM, verified the location where it was documented that R2 was found. It is a three-minute drive and a 24-minute walk. The area is straight from the facility to the residential area but there was no straight access unless one went through steep hills, terrain with lots of sticks, bushes, overgrowth and steep terrain. There are no bus stops in the area. On 10/8/2025 at 5:30 PM, V11 (Local Chief Firefighter) stated, We got a call saying the (Facility) had a missing resident that was on the dementia unit who was missing and confused and had gotten out of the nursing home. This was at night. The (Facility) had sent out a search group but was unsuccessful and was unable to locate (R2). We secured two canine units from neighboring police stations. We were flying [NAME], and we obtained a helicopter with infra-red technology and with the helicopter we were able to find him and once we found him everyone went to that location. I was with the canine units, and it let me tell you it was hectic, and I am not sure who got to him after we identified him because I was running around. It was the helicopter that found (R2) and he was brought back to the facility. I cannot tell you who brought him back to the facility, only that it was the helicopter that alerted us to where to find him. On 10/9/2025 at 11:30 AM, Application for Sunrise/Sunset for (Facility town) document twilight ended at 7:17 PM and it would have been dark outside at 7:45 PM. R2's Progress Notes dated 9/25/2025 at 10:00 PM, Nurse (V19 Licensed Practical Nurse/LPN) and V20 (Certified Nursing Assistant/CNA) both heard door alarm sound. (V19) ran for the door while delegating (V20 CNA) to immediately announce a Code Pink and initiate head count. Nurse began perimeter search with (V21 CNA) and V22 CNA) while simultaneously notifying the administrator and DON. Code pink announced over intercom. Nurse noted current time as 7:45 PM. All residents on 300 hall accounted for besides resident (R2). Head count initiated on 100 hall and 200 hall and all residents accounted for. Administration arrived at facility. POA (Power of Attorney) and NP (Nurse Practitioner) notified while all areas of facility, grounds, and neighboring streets systemically searched. Administration then notified local authorities at 8:05 PM. Elopement information Form copied and shared with authorities. Staff located resident at 9:57 PM approximately two blocks from the facility near the cemetery. Resident willingly got into staff's vehicle and was smiling. Resident stated he was just taking a walk to (surrounding town) as he has a trailer there. NP (Nurse Practitioner) at facility upon return and evaluated resident. Resident denied pain. Skin clear without injury. R2's Initial Report date of incident 9/25/2925 at 7:45 PM, (R2) is a [AGE] year-old male that resides at (Facility) on our male secured unit. (R2) has the diagnosis of but not limited to paranoid schizophrenia, drug induced sub-acute dyskinesia, insomnia, GERD and HTN. Alleged elopement from secured unit without injury. Final report to follow. R2's Final Report date of incident 9/25/2925 at 7:45 PM, documents, Investigation: On 9/25/2025 at approximately 7:45 PM, staff responded to the 300-door alarm. Responding LPN (Licensed Practical Nurse) delegated to a responding CNA to announce a 'Code Pink' and initiate a head count on her way to the door per our facility elopement procedure. The LPN then exited the exterior door with two additional staff and started searching the perimeter of the facility. The LPN notified the Administrator and DON (Director of Nursing) during the perimeter search. The CNA doing the head count could not account for (R2) and updated the LPN with this information. The administrator arrived at the facility approximately 7:55 PM. The administrator then delegated multiple staff to systemically search all areas of the building, grounds, and neighborhood streets and proceeded to call (R2's) POA (power of attorney). Local authorities were notified by the administrator at 8:05 PM, after staff not being able to find (R2) after a thorough systemic search, an elopement Information form on (R2) was provided to the authorities. Facility staff located (R2) at 9:57 PM at (address) which is approximately 0.19 miles away and a 4-minute walk from the exterior door of the facility. Upon staff finding him, (R2) stated to staff, 'Look it is (V21 CNA and V37 CNA).' (R2) was noted to be carrying a water bottle and drinking from it. The staff then asked (R2) if he wanted a (soda), to which he responded he did, and got into the staff member's vehicle. (R2) was dressed appropriately for the weather and was wearing proper footwear. Upon returning to the facility (R2) was smiling and stated upon interview 'I was taking a walk (nearby town), and I have a trailer there.' The provider for the facility was present at (R2's) return and did an examination which revealed no injuries or skin injuries. The Administrator then notified the POA with an update. Conclusion: The root cause of (R2's) exiting the facility is due to his impulsivity related to paranoid schizophrenia. Staff followed policy and procedure and located (R2). R2's Police Report documents, On 9/25/2025 at approximately 8:11 PM, I along with V8 (Local Police Officer) was dispatched to (Facility), reference an older male dementia unit walking out of the facility. I arrived in the area after (V8 Local Police Officer) and began checking the area for the patient identified as (R2). (R2) was last seen wearing a peach colored long sleeved polo shirt, grey sweatpants and brown dress shoes. (V1 Administrator) told me he had left through the door at southwest corner of the building at around 7:45 PM and his direction of travel was unknown. I saw that several other individuals, consisting mostly of employees, were already searching for (R2) before (V8) and I (V7) arrived. It should be noted that (R2) had already been gone for nearly 30 minutes. I contacted (V9, Sergeant Police Officer) and advised of the situation. (V9) contacted (nearby Police) and requested a drone and contacted (Local Fire Department) for their response to help with the search. I spoke with (V10 Chief of Police) who also responded. (V11 Fire Chief) and numerous fire department personnel arrived. (V10) set up a command post at the location and had contacted other agencies for their assistance. His contacts also resulted in a helicopter from (nearby municipal) being deployed with thermal imaging. I spoke further with (V1) and other nursing home staff and learned (R2) was a dementia patient also afflicted with schizophrenia. (V1) has a history of leaving other nursing home facilities with the most recent having occurred when he was at the (Sister Facility) three months ago before he was transferred to (current facility). Prior to that he was a patient at (another facility). (V5 Officer from nearby Police) arrived with his canine partner and attempted to track beginning from the door through which (R2) exited. (Another nearby Police) arrived and deployed his department drone. (Nearby Police V16) arrived with his canine partner and attempted a track beginning from the door through which (R2) exited. (Another local nearby Police V17) also arrived with his canine partner. At approximately 10:00 PM, all units at the scene were informed (R2) had been located by a nursing home employee at the cemetery approximately two blocks south of the nursing home. (R2) was not injured or anything, and he told me he was trying to get to his trailer (nearby city). The LEADS entry was canceled. A photo of (R2) has been attached to this report which has been submitted for information purposes. On 10/9/2025 at 8:35 AM, V17 (Officer from nearby Police) stated, I got a call from (Local Police) and they requested assistance for a missing person from the nursing home. I responded and brought my canine (German [NAME]) to assist. They told me when I got there that the resident had been missing for over 2 hours. My dog followed the trail out the back side of the building and through the brush, it was very hilly, and we came up on a residential house. The owner approached me and told me he saw someone on his ring camera wandering around on his camera. The person had come up to the back of the house and then moved to the front of the house. Then after some time someone came and picked him up in a vehicle. I then got a call that the resident was found. I did not talk with the resident and or see him. There was also a helicopter searching for him as well. I only know about the canine and my dog was picking up his scent and that area at dark was uneven terrain. On 10/9/2025 at 10:31 AM, V42 (Officer with the nearby Air Unit) stated, We did respond to a call at (Facility) on 9/25/2025 we arrived at the scene at (Facility) at 8:45 PM with our helicopter. We were flying over the area with infra-red and were eventually able to locate a hot spot and locate the missing person. I know the canine units were also out looking for the missing person as well. We communicated via the radio and alerted the police force but there was also other ground officers involved. We found the missing person close to the cemetery in a residential area. I am unsure of you who picked up the missing person. We left the (Facility) at 10:16 PM. R2's Elopement Investigation Report dated 9/25/2025 at 7:45 PM documents, (V19 Licensed Practical Nurse) was outside 300 interior exit doors heard 300 exit door alarm go off. I ran to the exit door and told (V20 Certified Nursing Assistant) to announce code pink and begin a head count. Delegated (V21 CNA) to call (V1 Administrator) and V2 (Director of Nursing/DON) while we searched grounds around facility. On 10/7/2025 at 5:20 PM, V19 stated, I was working the night (R2) got out of the facility. I was on the women's unit and earlier that day the exit door on the woman's side (200 hall) was sticking which would cause the alarm to go off. That evening, I went to shut off the alarm and realized the alarm was still going on and that is when I realized it was coming from the men's (300 hall). I ran down to the other hall. You have to enter a code to go from the women's side to the male side and vice versa. I was not working the hall (V23 LPN) had a split hall that night and she was passing out medications on the 100 hall. At that time, I did not realize there was only one CNA working. I guess the other CNA was on break so there was only 1 CNA on that hall that night (R2) eloped. R2's Elopement investigation Report dated 9/25/2025 at 7:45 PM documents, (V20 CNA) was in resident room and heard exit door alarm. (V19) told me to announce code pink and start head count. (V19) and I and (V22, CNA) went straight outside to search. (V1) came in a few minutes later. On 10/8/2025 at 11:00 AM, V20 (CNA) stated, I was working a split which is the 100 hall and the 300 men's hall. My nurse was passing out medications and the other CNA was out on lunch break. I was the only one working on that hall (men's hall) when (R2) exited the building. I was in another room with another resident getting them ready for bed. I have hearing issues, and I heard an alarm, but we had been having issues with the door from the women's side to the male's side and the door was sticking and when I heard the alarm, I thought it was just that door alarming not realizing it was the back door. Then I found out later when they did a head count that (R2) was missing. No, I did not stop when I heard the alarm and check. R2's Elopement investigation Report dated 9/25/2025 at 7:45 PM documents, V21 (CNA) was at 200 hall nurse's station when heard exit door alarm. Went to exit door and outside with (V19) and (V22 CNA) to search. Called (V1) and (V2). Both showed up within ten minutes. Continued to search until I found (R2) at 9:57 PM at mailbox on (residential street). R2's Elopement investigation Report dated 9/25/2025 at 7:45 PM documents, V22 (CNA) was at nurse's station when 300 hall door alarm sounded, went straight outside and started searching perimeter. On 10/7/2025 at 3:05 PM, V22 (CNA) stated, I was working the women's side of the 200 hall and heard the alarm. I ran out the door, it was pitch dark so I could not see anything but then (V19) came and got me and told me the alarm was not on the female side, but it was for the 200 hall men's side. I guess the alarm sounds on both sides. (V20) and I went over to the men's side and started looking for (R2) because they said he had gotten out. It was dark and everybody was looking but we could not find him, but they were able to find him a few hours later. R2's Elopement investigation Report dated 9/25/2025 at 7:45 PM documents, V23 (LPN), I was on the 100 hall when code pink was announced. The last time I saw (R2) was about 6:30 heading to his room after dinner. On 10/8/2025 at 5:22 AM, V23 (LPN) stated she was working the night (R2) eloped from the facility, she was working the 100-hall split and men's memory care unit, when she was notified that (R2) was gone. This was over a week ago and couldn't recall the exact date or time, but it could have been after supper. We did a head count and (R2) was missing. (R2) had not made any attempts or had eloped from this facility but has eloped at other facilities prior to coming here. (R2) is alert and able to carry on a conversation, but after talking to him for a couple of minutes, he is confused and will make weird noises. On 10/8/2025 5:29 AM V31 (CNA) stated she was not here when (R2) eloped. She has known (R2) for about 20 years, and he has been in several surrounding facilities, he tried to elope all the time, and did elope several times. V31 stated after talking with (R2) you realize that he is confused. R2's Elopement investigation Report dated 9/25/2025 at 7:45 PM documents Root cause: Impulsivity related paranoid schizophrenia. On 10/8/2025 at 9:24 AM, V40 (CNA) stated I was working when (R2) got out. I was on the dementia care male side hall. At the time (R2) left the building I was on break. I worked a double shift that day. I was on my lunch break when it happened. When I came back from my break (R2) had already eloped from the building. The police were not there yet, and the nurse (V23 LPN) had me leave the facility and start looking for (R2). I started out walking on foot to see if I could find him. It was so dark I could not see a thing, so I then just got in my car and started driving around looking for him. I just started recently working there and was not familiar with (R2). I know somebody eventually found him and brought him back and the police were involved. On 10/8/2025 at 11:00 AM, V37 (CNA) stated, I was not working that day, but I got a call from (V22 CNA) and she told me (R2) was missing and asked me to come in my truck and start driving down the streets to look for him. I live close. I came to the facility I got (V21), and I started driving to see if I could find him. We found him in a residential area standing there next to a mailbox. I got out of the truck, and he saw me, and I said 'Hey, (R2) you want a soda' and he said yes, and he walked over to the truck, got in, I called (V1) to let her know we found (R2) and he was not hurt. I have no idea how he got where we found him. It was at night and dark, but he seemed fine and was smiling so I brought him back to the facility. On 10/8/2025 at 2:03 PM, V41 (Nurse Practitioner) stated, Residents on the locked memory care unit are typically there because they have dementia, cognitive impairment, and or history of elopement. Most of these residents are confused. (R2) was on the memory unit. I feel (R2) was unique and he was alert and orientated x 3. (R2) does not understand that the reason he is in the facility is for his own protection. I do not think (R2) got very far after he eloped from the facility. I know he said he walked through some weeds and trees, and he wanted to take a shower when he came back. I believe anyone can get potentially get hurt if they are walking through weeds, trees and shrubs. When (R2) was brought back I half expected him not to be able to tell me the date and time, but he was able to. (R2) was even carrying a water bottle. When the police asked him where he wanted to go, he provided a real address. I know he said he thought he was at a bus stop, but I do not believe (town of facility) even has a bus stop. The Facility Missing Elopement Policy Guidelines policy with a revision date of 6/16/2025 documents, The facility strives to promote residents' safety and protect the rights and dignity of the residents. The facility maintains a process to assess all residents for risk for elopement, implement risk reduction strategies for those identified as an elopement risk, and institute measure for resident identification at the time of admission Elopement is the ability of a cognitively impaired resident who is not capable of protecting himself or herself from harm, to successfully leave the facility unsupervised and unnoticed who may enter into harm's way. Wandering refers to a cognitively impaired resident's ability to move about insive (inside?) the facility aimlessly, but often without clear purpose and without regard to one's personal safety. The Immediate Jeopardy and deficiency practice that began on 9/25/2025 was corrected/removed on 9/26/2025 after the facility took the following actions to correct the noncompliance prior to the start of current survey: Facility failed to ensure residents were supervised to prevent elopement. Actions Taken: R2 was moved to a room closer to the nurse's station, placed on 1:1 with re-evaluation after 72 hours, elopement risk re-evaluated, and psych medication review requested. Administrator and Director of Nursing were in-serviced by the VP of Clinical Services. Administrator in-serviced the IDT (Intradisciplinary Team). Current staff were in-serviced on elopement policy and procedure. All residents that reside in the facility will have an elopement risk assessment completed. Elopement Binder was updated based on those risk assessments. Review of policy and procedure were completed to reflect current practice. All staff have been in-serviced on elopement, and procedures on steps to take if a resident is at risk. All facility staff will were in-serviced by 9/26/25 for elopement and staffing. A QA tool was implemented along with Daily audits of the 24-hour report for wandering/elopement risks. Daily audit for elopement risk assessments completed within 72 hours of admission. Audits to continue daily for 4 weeks to ensure that elopement risk is documented. Root Cause Analysis completed for elopement: Deficiency: Failed to prevent elopement. Initiated 9/25/25, Completed on 9/26/2025.

Based on observation, interview, and record review, the facility failed to have an adequate number of staff available to care for the residents when reviewed for staffing. This failure has the potential to affect all 76 residents residing in the building. Findings Include:The facility's Final Report to the state surveying agency, dated 10/3/25, documents R2 eloped from the facility on 9/25/25 at 7:45 PM from the male locked memory care unit, on which he resided. On 10/7/25 at 5:05 AM, there were two CNAs (Certified Nursing Assistant), one on the male locked memory care unit, one on the female locked memory care unit, and one nurse that was working both the male and female locked memory care units. V28 (Licensed Practical Nurse/LPN), was observed in the beauty shop with the lights off, leaned back in a chair, sleeping. V28 was working on the 100 hallway with two CNAs.On 10/7/2025 at 5:20 PM, V19 (LPN) stated, I was working the night (R2) got out of the facility. I was on the women's unit and earlier that day the exit door on the woman's side (200 hall) was sticking which would cause the alarm to go off. That evening, I went to shut off the alarm and realized the alarm was still going on and that is when I realized it was coming from the men's (300 hall). I ran down to the other hall. You have to enter a code to go from the women's side to the male side and vice versa. I was not working the hall (V23 LPN) had a split hall that night and she was passing out medications on the 100 hall. At that time, I did not realize there was only one CNA working. I guess the other CNA was on break so there was only 1 CNA on that hall that night (R2) eloped.On 10/8/25 at 5:22 AM, V23 (LPN) stated she was working the night R2 eloped from the facility, she was working the 100-hall split (1/2 of the 100 hallway and the male memory care unit), when she was notified that R2 was gone. V23 stated this was over a week ago and couldn't recall the exact date or time but it could have been after supper. V23 stated they did a head count and R2 was missing. On 10/8/25 at 5:39 AM, V28 (LPN) stated he has worked the midnight shift for over 20 years and had never had trouble with it until he was in a car accident recently. V28 stated sometimes he just needs to sit back, relax, and waits for his name to be called when he is needed. On 10/8/25 at 6:37 AM, V1 (Administrator) stated she has not had any recent concerns brought to her attention regarding staff sleeping on the job. V1 stated she will often come into the facility between 2:00 AM and 5:00 AM, to talk with the night shift staff and hasn't observed anyone sleeping. On 10/8/2025 at 11:00 AM, V20 (CNA) stated, I was working a split 100 hall and men's hall. My nurse was passing out medications, and the other CNA was out on lunch break. I was the only one working on that hall when (R2) exited the building. I was in another room with another resident getting them ready for bed. I have hearing issues, and I heard an alarm, but we had been having issues with the door from the women's side to the male's side and the door was sticking and when I heard the alarm, I thought it was just that door not realizing it was the back door. Then I found out later when they did a head count that (R2) was missing. No, I did not stop when I heard the alarm and check.The Staffing Policy, undated, documents it is the policy of the facility to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident. Nurse staffing shall be based upon resident evaluation by the Administrator and Director of Nursing as specified by the (state surveying agency). The Resident Census, dated 10/7/25, documents there are 76 residents residing in the facility.

Based on observation, interview and record review the facility failed to ensure residents did not exit through an exit door and were being supervised to prevent any potential elopements for 1 of 6 residents reviewed for elopement in the sample of 15. This failure resulted in R2 pushing the exit alarm and exiting the facility around 3AM on 6/19/2025 from a secured memory unit into pitch darkness and was found wandering around by a civilian driving in his car two subdivisions over (one block east and one block north) from the facility. This past non-compliance occurred on 6/19/2025.Findings include: The Immediate Jeopardy began on 6/19/2025 when R2 eloped from the facility at around 3AM in the morning in the pitch darkness and R2 was found on the side of the road by a civilian. The civilian was driving their car and contacted the police department because R2 was confused and wandering around in the street. V1 (Administrator) was notified of the Immediate Jeopardy on 7/3/25 at 2:30PM. The surveyor confirmed by observation, interview, and record review, that the immediacy was removed, and the deficient practice was corrected, on 6/19/24. R2's Physician Order Sheet (POS) for June 2025 document a diagnosis of Encephalopathy, HTN (Hypertension), neurocognitive disorder with Lewy bodies, and cerebral atherosclerosis (Dementia). R2's Minimum Data Set (MDS) dated [DATE] document R2 was severely impaired, and she requires specialized unit Alzheimer/dementia. R2's Care Plan does not address elopement behaviors before 6/19/2025. R2'S Care Plan documents (R2) has an ADL (activities of daily living) self-care deficit related to decreased physical functioning and severe cognitive impairment. Date initiated 2/10/2025. (R2) is High risk for falls related impulsive unaware of safety needs, poor judgment, decreased physical function, medication that can predispose to falls. R2's Elopement Evaluation dated 1/24/2025 documents, Risk for wandering/Elopement Identified. R2's Progress Notes dated 5/3/2025 at 1:10 PM, Late Entry: Elopement Evaluation: History of elopement while at home: No. Wandering behavior a pattern or goal-directed: No. Wanders aimlessly or non-goal-directed: Yes. Wandering behavior likely to affect the safety or well-being of self/others: No. Wandering behavior likely to affect the privacy of others: No. Recently admitted or re-admitted (within past 30 days) and has not accepted the situation: No. Elopement Score: 2.0. R2's Progress Notes dated 6/19/2025 at 4:06 PM, Note Text: Writer notified (R2) (eloped from the) facility around 3:45 am. Stated that Alarm sounded, staff check door and surrounding did not see anyone. Did a head count and realized that (R2) was not available. Staff notified Admin and 100 Nurse of situation. Staff got in vehicle and located (R2). (Son) was contacted and made aware of elopement. (R2) is doing fine, stated that she was just trying to go home. One to One has been put in place. Room move further away from exit door and 15 min. checks started. Care plan updated and education to be given to staff by DON (Director of Nursing). R2's Initial Report to the state surveying agency for incident date 6/19/2025 documents, at 3:35 AM, (R2) is an [AGE] year-old female that residents at (Facility). (R2) has the diagnosis of but not limited to encephalopathy, HTN, neurocognitive disorder with Lewy bodies and cerebral atherosclerosis. Alleged elopement from secured memory unit without injury. Final report to follow. R2's Final Report documents, On 6/19/2025 at 3:35 AM staff responded to the 300 North door alarm. CNA on the unit went to the door, did a visual parameter check from the doorway, no findings. Staff then followed out elopement procedure and proceeded with a head count, simultaneously (V6 Licensed Practical Nurse/LPN) was outside checking the perimeter of the facility. Staff contacted (V6) that (R2) was not accounted for. (V1) and DON (Director of Nursing) were notified. (V6) after completion of parameter check got into her vehicle to widen the search. At approximately 3:42AM, (V6) on the street parallel to the facility (R2) was noted to be sitting in a front yard with a local resident. (R2) was out of the facility for approximately 7 minutes. She stated Honey, I am so sorry, I just wanted to go home. (R2) was dressed appropriately for the weather, she was wearing proper foot ware. Police did come out to the facility at approximately 4 AM to ensure that resident was well, since local resident had called them. No concerns were noted by the police. Conclusion: the root cause of (R2) exiting the Facility is due to her confusion related neurocognitive disorder with Lewy bodes, Staff followed procedures and located (R2) in a timely manner. On 6/30/2025 at 1:08 PM, V6 (LPN) stated, I was working the night (R2) got out of the facility. It happened around 3 AM in the morning because it was still dark outside. (R2's) room is on the locked women's dementia unit. (R2's) room was down the hall close to the exit door. When (R2) exited through the exit door, I did not see her leave, but the alarm went off. We looked outside the door but could not see anything because it was pitch black. (R2) went out the door and me and (V4), Certified Nursing Assistant (CNA), ran out the door looking for her. We did a sweep, but it was so dark outside, and we could not find her. After looking for her, I got in my car, and I finally found her in the second subdivision in someone's yard. There was a man with her at that time. I am not sure how long she was gone for. When I found her, we did an assessment after I brought her back here and she did have bruises on her legs but seemed to be okay. I am not sure what she was wearing at that time, but I think it was appropriate. I did a skin assessment on her and she did have bruising on both of her shins, and I believe her forearm. A Statement provided by V6 dated 6/19/2025 documents, I was on the 200 hall nurses' station and heard 200 North door alarm sound. I headed towards the door and another staff member was already there looking outside. (V1) and other nurse alerted, and I went outside and got in my vehicle and started searching. Came upon bystander assisting resident. He stated she was sitting the grass in a front yard. Resident got right into my vehicle. On 6/30/2025 at 4:50 PM, V10 (Local Police) stated, We got a call after 3:10 AM from a male citizen who said they were driving in the early hours of the morning and found a confused woman wandering in the road. The woman was one block east, and one block north of the (Facility). We found out that the confused woman was a resident at the nursing home and all the staff had lost sight of her. (R2) had eloped from the (Facility). We did not get a call from the (Facility) but from a male citizen because they were concerned for her safety. I did not do a report and staff arrived and took (R2) back to the (Facility) and I went later and checked on her at the facility. On 7/1/2025 at 1:03 PM, V4 (CNA) stated she had only been working in the facility for about two months. I remember that night (R2) got out because I was working the floor. I was giving care to another resident that night and was in the resident's room when I heard the door alarm go off and I went running. The nurse (V6) and I were both looking but we did not see anything, but it was dark outside. I almost fell in a hole, there is a door drop pad and I almost fell. V6 went one way, and I went the other and we could not find her so we both got in our cars and went opposite directions looking for (R2). I did not find (R2) but (V6) did find her and brought her back to the facility. I think she was gone for about a half an hour. (R2) said she wanted to go home. The Police came by later and was checking on her. I am not sure what she was wearing. A Statement Provided by V4 (CNA) dated 6/19/2025, documents, I was on the 100-hall nurse station when I was notified by another staff member that there was possible elopement. I went to the 200-hall while staff was outside searching. Searched hall and completed head count. On 7/2/2025 at 1:14 PM, V17 (CNA) stated she was working the 100-hall, and a staff member came up to her to tell her a resident went out the door. I went to the back hall, and we did a head count. It was around 3 AM in the morning. Things got hectic. They were able to find the resident and return them back to the facility. I am not sure how long they were actually gone. A statement provided by V17 dated 6/19/2025 documents, I was on the 100-hall nurse station when I was notified by another staff member that there was possible elopement. I went to the 200-hall while staff was outside searching. Searched hall and completed head count. On 7/2/2025 at 1:23 PM, V19 (LPN) stated, I was the nurse working the 100-hall. A staff member came up to me and told me that someone had gotten out. I made sure someone was watching my hall as I went to the dementia locked unit and did a head count. (R2) was missing. The nurse on that hall (V6) and a CNA were looking for her outside. Things got hectic and I am not sure how long they were gone and/or when (R2) returned but I know (R2) was brought back to the facility. I am not sure what she was wearing but I believe it was appropriate. A statement provided by V19 dated 6/19/2025 documents, I was the 100-hall when staff notified me of possible elopement on 200-hall. I went to the 200-hall and searched all the rooms for possible missing resident and then back to the 100-hall and completed head count. On 7/2/2025 at 1:26 PM, V18 (CNA), stated, I was working the night (R2) got out of the facility. I was working the 100-hall. All I know is a CNA came from the locked dementia unit and asked us if we had seen anyone leave the building. I told her no, and I hadn't seen anyone. I went down to the dementia unit, and we did a head count on both sides male and female sides. I then walked out of the back, and I went one way, and the other CNA went the other way and we walked the entire perimeter of the building. I almost fell because it was pitch black and bumpy and I was so worried (R2) could have fallen too and maybe she was near me, but I could not see her. I did two walk arounds. Then I went back into the facility and got my cell phone because I wanted a light. I walked the perimeter again but could not find her. I then went back to my hall (100 hall). Later (V6) returned and she had found (R2). I would say (R2) was gone maybe 20-30 minutes give or take. A Statement provided by V18 (CNA) documents, I was on the 100-hall when I was notified of possible elopement. I immediately went outside and checked building perimeter then came inside and completed head count on Looking glass. On 7/2/2025 at 9:02 AM, R2 stated she had never tried to leave the facility. R2's skin assessment dated [DATE] document she had new issues of bruising on her front left knee, left shin, right shin and right inner forearm. On 7/2/2025 at 10:02 AM, upon exiting the emergency door there is a drop off from the cement slab to the ground of about three inches. There are large amounts of vegetation, in front including bushes, weeds and fences separating the facility from a subdivision. There are several breaks in the fence to the subdivision after each house, but the vegetation is thick. Upon finding an opening and crossing over one would be in a residential yard. This street is lined with houses and crossing the street is another line of houses, and behind these houses are steep inclines and more vegetation. R2 was found in the second subdivision. The Facility Missing Elopement Policy Guidelines policy with a revision date of 6/19/2025 documents, The facility strives to promote residents' safety and protect the rights and dignity of the residents. The facility maintains a process to assess all residents for risk for elopement, implement risk reduction strategies for those identified as an elopement risk, and institute measure for resident identification at the time of admission Elopement is the ability of a cognitively impaired resident who is not capable of protecting himself or herself from harm, to successfully leave the facility unsupervised and unnoticed who may enter into harm's way. * Wandering refers to a cognitively impaired resident's ability to move about insive (sic) the facility aimlessly, but often without clear purpose and without regard to one's personal safety. The Immediate Jeopardy that began on 6/19/2025 was corrected/removed on 6/19/25 after the facility took the following actions to correct the noncompliance prior to the start of current survey:R2's room was moved closer to the nurse's station. R2 was placed on 1:1 for 72 hours. R2's elopement risk was re-evaluated. R2 was placed on enhanced monitoring.All staff were in-serviced on elopement policies and procedures and verified on 6/19/2025.Daily audits were being conducted and reviewed by V1 and V2. The first daily audit was dated 6/19/25.Elopement evaluations were completed on all residents.Completion date 6/19/25

Based on observation, interview and record review the facility failed to provide the required Registered Nurse (RN) coverage services for eight consecutive hours a day for seven days a week. This has the potential to affect all 75 residents living in the facility.Findings include: On 7/8/2019 at 10:33 AM, V1 (Administrator) stated, No, we do not have a RN working every day for 8 consecutive hours except for (V2) who is the Director of Nursing (DON). We have a Census of 78 residents. The DON is the only RN we have working in the building. We are in the process of recruiting. The only RN we had working was the DON. On 7/8/2025 at 10:39 AM, V2 stated, I am the only RN working in the building. I know I only count as half, but we do not have any other RN that worked on the days you requested. The Facility's Nursing Schedule dated 6/25/2025 -7/28/2025 documents there was no RN working in the facility except for the RN House Supervisor/DON. During this survey from 6/30/2025 to 7/3/2025 no RN was observed working in the Facility. V2 was not present in the building during the survey. The Facility undated Facility Assessment documents the Facility will employee Registered Nurses and Director of Nursing. The CMS 671 Form Long Term Care Facility Application form dated 7/8/2025 documented the facility had a census of 75 residents.

Based on interviews and record reviews the facility failed to provide Register Nurse (RN) coverage for at least eight consecutive hours a day, seven days a week. This has the potential to affect all 54 residents residing in the facility reviewed for RN coverage in a sample of 39. Findings include: The facility's Nursing Master Schedule documented the following dates did not have an RN working: 11/10/24, 11/23/24, 11/24/24, 11/30/24, 12/1/24, 12/7/24, 12/8/24, 12/14/24 and 12/15/24. On 12/17/24 at 11:38 AM, V14 (Certified Nursing Assistant), stated during the weekends the facility will frequently not have an RN on duty. On 12/17/24 at 10:54 AM, V1 (Administrator) stated she is aware the facility is short on RN coverage over the weekends. V1 stated there are job postings for RNs on three different websites and one RN is having health concerns so has she not been able to pick up shifts lately. The facility's Nurse Staffing Policy, undated, documented it is the policy of the facility to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident.

Based on observation, interview, and record review, the facility failed to operationalize the facility's Legionella Policy and Procedure and perform hand hygiene to prevent the spread of infections (R5). This has the potential to affect all 54 residents. Findings include: 1. On 12/17/24 at 9:20 AM, V17 (Maintenance Director) stated that he runs the water and flushes toilets monthly in the empty rooms. V17 stated he also checks the temperatures of the hot water in each room and flushes the boilers monthly. A log was provided with documented these checks occurring monthly. V17 stated that the city performs the water sampling. On 12/17/24 at 3:15 PM the Legionella Policy and Procedure was reviewed with V17. The policy documented to run water through taps and showers no longer in use or used infrequently for a minimum of one minute weekly. In addition, to check hot and cold-water temperatures after water has been running for one minute randomly weekly. V17 stated that he only runs the taps and showers in infrequently used rooms monthly and checks water temperatures in all rooms monthly. V17 provided a logbook which documented each room checked monthly. The policy and procedure direct maintenance director to take shower heads apart every three months to clean and disinfect. V17 stated that he has never taken the shower heads apart. On 12/18/2024 at 8:05 AM, V17 stated that he does not have a water flow diagram in the facility. When asked what areas of the facility have been identified to have opportunistic waterborne pathogen growth, he stated that he knows the places where there may be stagnant water such as the unused rooms. On 12/18/24 at 1:05 PM, V17 stated that he has not been trained on legionella policies and procedures. On 12/18/2024 at 11:00 AM, V1 (Administrator) stated that there has been no training of any facility staff on legionella procedures or policies. Legionella Policy and Procedure dated 8/10/18, documented the two main reasons to monitor water temperatures and conditions is to prevent the risk of scalding and Legionnaires Disease. All premises where there are hot and cold-water outlets and air conditioning systems including portable humidifiers. This policy applies to all staff, residents, volunteers, and members of the community. Legionella Bacteria thrive and multiply in hot or cold-water systems and storage tanks and then spread through spray from showers and taps. The following measures may be initiated to minimize and control the risk by having the water system inspected maintained and cleaned annually, ensure water cannot stagnate anywhere in the system by removing redundant pipe work as needed, run through taps and showers no longer in use or infrequently used for a minimum of one minute once a week, check hot and cold water temperature after water has been running for 1 minute, take shower heads apart every 3 months to clean and disinfect quarterly, and annual servicing of boiler and thermostatic mixing valves annually. Legionella Risk assessment dated [DATE] updated with the question answered yes that this is a healthcare facility with residents who have chronic and acute medical problems or weakened immune systems. 44967 2. R5's Admission Record, dated 12/17/24, documents R5 was admitted to the facility on [DATE] with diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Atrial Fibrillation, Hypertension, Arthritis, Major Depressive disorder, Generalized Anxiety disorder, Bipolar Disorder, Right and Left above knee amputations (AKA), and Dependence on supplemental oxygen. R5's Care Plan, updated 8/27/24, documents R5 is rarely able to perform Activities of Daily Living (ADLs) without weight bearing/hands on assist of 1-2 caregivers related to Amputation Bilateral AKA. Toilet Use: R5 requires partial to max assist by one staff for toileting, utilizes urinal and bed pan for toileting, not a candidate for toilet use due to sitting balance. R5's Minimum Data Set (MDS), dated [DATE], documents R5 has a Moderate Cognitive Impairment and is Dependent on staff for toileting, R5 is frequently incontinent of urine and occasionally incontinent of bowel. On 12/16/24 at 12:05 PM, V9 (Certified Nursing Assistant/CNA), was seen performing incontinent care on R5 prior to getting him up for lunch. V9 came into room with gloves on and a clean brief in her hands. V9 started the water running in the sink, then left the room and returned to the room with one towel. V9 wet approximately a quarter of the towel in the sink and walked over to R5 and performed incontinent care on him. After incontinent care, V9 then used the same soiled gloves to put R5's shorts on him. There were no glove changes done during this care and no hand hygiene seen done before, during glove changes, or after care and before leaving the room. On 12/18/24 at 11:00 AM, V9 stated I always do hand hygiene when I start in the morning and then after I do something with the residents. On 12/18/24 at 12:10 PM, V1 (Administrator) stated I would expect the staff to perform timely and complete incontinent care, including proper equipment needed, proper hand hygiene and glove changes before care, during glove changes, and after care. All staff should be doing hand hygiene before and after resident contact and before leaving the resident's room. The Facility's Hand Hygiene Policy, dated 12/2018, documents in part: All staff will wash hands, as washing hands as promptly and thoroughly as possible after resident contact and after contact with blood, body fluids, secretions, excretions, and equipment or articles contaminated by them is an important component of the infection control and isolation precautions. The Facility's Perineal Cleansing Policy, dated 9/21/10, documents in part: To eliminate odor; to prevent irritation or infection and to enhance resident's self-esteem. Equipment: 1. Washcloth and towel. 2. Soap, other cleansing agent or (brand name cleansing agent). 3. Gloves. 4. Wash basin. 5. Plastic bag. Male without catheter: 4. Wet washcloth and apply cleansing agent chosen. 5. Wash pubic area, including upper inner aspect of both thighs as well as the penis and scrotum. b. Wash area under scrotum. 6. Rinse area in same sequence, if applicable. 7. Place soiled items in plastic bag. 8. Dry carefully and proceed with cleansing of the anal area. 10. Rinse cloth and proceed with the cleansing of the anal area. 11. Washing should alternate side to side, ending with the center anal area. 12. Rinse cloth and entire area in the same sequence, if applicable. 13. Place soiled items in plastic bag. 14. Dry area thoroughly. 15. Remove gloves and wash hands with soap and water, cleansing gel, or (brand name cleansing agent). 16. Apply clean incontinent product, clothes, or position resident comfortably. 17. Wash hands with soap and water, cleansing gel or (brand name cleansing agent). Note: The basic infection control concept for peri-care is to wash from the cleanest to the dirtiest area and remember to change or remove gloves and wash hands when going from working with contaminated items to clean items. The Facility's Centers for Medicare and Medicaid Services Form 671 dated 12/16/2024 documents there are 54 residents residing at the Facility.

Based on interviews, observations, and record reviews the facility failed to feed residents in a dignified manner for 4 out of 4 residents (R11, R14, R17, R34) reviewed for dignity in a sample of 39. Findings include: 1.R34 was admitted to the facility on [DATE] with diagnoses of, in part, dementia with behavioral disturbances, major depressive disorder, and chronic post-traumatic stress disorder. R34's Minimum Data Set (MDS) dated [DATE] documented he has severely impaired cognitive skills for daily decision making. R34's MDS further documented he is dependent on staff for eating assistance. R34's Care Plan last revised on 09/4/2024 documented R34 is dependent for Activities of Daily Living (ADLs) with interventions for staff to feed him his meals. On 12/16/2024 at 12:25 PM, V11 (Certified Nursing Assistant/CNA) fed R34 while standing over him. 50628 2. On 12/16/24, at 12:14 PM, R11, R14, and R17 were seated at a table together in the dining room. When questioned regarding needed level of assistance, V14 (CNA) and V15 (CNA) stated they are feeders. This was done within earshot of the R11, R14 and R17. R11's Minimum Data Set (MDS) documented that R11 is severely cognitively impaired and is dependent on staff for eating. R17's MDS documented that R17 is severely cognitively impaired. It documented that she requires partial/moderate assistance with eating. R14's MDS dated [DATE] documented R14 is severely cognitively impaired. It documented that she is dependent for eating. On 12/18/24 at 1:30 PM V19 (CNA) stated that when addressing residents who need assistance with their meals being fed to them, she would address the resident by their name and inform them that she would be feeding their lunch. V19 would then proceed to tell them what is on their plate and ask which food they would like to start with. On 12/18/24 at 3:15 PM V20 (CNA) stated that when addressing residents who need feeding assistance with their meals, she would address the resident by his name as Mr. or Mrs. and then inform them that it is time to eat and then she would tell them what is on the menu for that meal. The facility's Assistance with Meals Policy, with a revision date of 07/2017, documented residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: not standing over residents while assisting them with meals and avoiding use of labels when referring to residents such as feeders.

Based on observation, interview, and record review, the facility failed to implement progressive care plan interventions and ensure interventions were followed to prevent falls for 4 of 6 residents (R5, R10, R30, and R31) reviewed for falls in a sample of 39. Findings include: 1. R10's Face Sheet, admitted [DATE] documented R10 has diagnoses of but not limited to Dementia, malignant neoplasm of prostate, Chronic obstructive pulmonary disease (COPD), and hypertension (HTN). R10's Minimum Data Set (MDS) dated [DATE], documented R10 is moderately cognitively impaired with a brief interview for mental status (BIMS) of eight out of 15 and he requires supervision or touching assistance with transfers and walking. R10's Care Plan, with admitted [DATE], documented R10 has risk factors that require monitoring and intervention to reduce potential for self-injury. High risk for fall per risk assessment. Had a fall in previous six months when residing at home with son. Date initiated: 04/22/24. Interventions include but not limited to keep environment well-lit and clutter free. Observe for unsteady/unsafe transfer or ambulation and provide stand by or balance support as needed. Remind of safety precautions and limitations as necessary. It also documented R10 has had an actual fall with no apparent injury, minor injury, Root cause may be related to (r/t) assistive device not within reach, cognitive impairment- unaware of safety needs. 09/05/24 fall without injury, root cause: cognitive deficits-forgets to utilize walker even with signs to remind him to use the walker on walker in room. 10/03/24 fall without injury, root cause: cognitive deficits-poor judgement & and unaware of safety needs. Interventions include but not limited to new interventions for prevention of this type includes staff to ensure cane or walker is within R10's reach when in bed. emergency room (ER) for eval for change in condition. 09/06/24 15-minute checks. 10/03/2024 Physical Therapy (PT)/Occupational Therapy (OT)/Speech Therapy (ST) to eval & treat as indicated. R10's Assess/Intercommunicate/Manage (A.I.M.) for Wellness form, dated 09/05/24, was reviewed and documented R10 had a fall. R10 was in his room walking without his walker, fell backwards into door sliding to the floor. The nurse did his assessment while on the floor and seen he didn't have any injuries and he did not voice any complaints. R10 was assisted up out of the floor with a gait belt and walked to his bed with his walker. R10's Fall Risk Assessment, dated 09/05/24, documented he was a high risk for falls with a score of 17. R10's Interdisciplinary Team (IDT) progress notes, dated 09/06/24 at 9:00 AM, was reviewed and documented the root cause of R10's fall on 09/05/24 was due to deficits- forgets to use his walker for ambulation and the new intervention was to start R10 on 15-minute checks. R10's A.I.M for Wellness form, dated 10/03/24, documented R10 had an unwitnessed fall in his room. Nurse was notified by staff R10 had fallen. Upon entering the room resident was in a sitting position and had his shoe in his hand and the comforter was under his feet. The nurse completed a skin assessment, and no redness, bruising, or other injury was noted. R10 complained of leg pain range of motion (ROM) was done and it was with in normal limits (WNL). The doctor was notified and said to monitor R10 and if he continues to complain to get an x-ray of his legs. R10's A.I.M for Wellness form, dated 10/15/24 documented R10 had an unwitnessed fall. R10 was lying face down. R10 was assessed while in the floor and was noted to have a skin tear to his left hand/fingers and steri-strips were applied. There were no other visible injuries noted. R10 complained of pain to his lower left abdomen when pressure applied with no rebound tenderness. He was assisted back to his wheelchair with gait belt and two assist. ROM WNL. Alert and able to make needs known. The Nurse Practitioner (NP) was notified, and new orders were given. R10's Fall Risk Assessment, dated 10/15/24, documented he was a high risk for falls with a score of 19. R10's 15-minute checks for the months of September 2024, October 2024, and November 2024, were reviewed and had multiple sections with no documentation R10 was checked every 15 minutes per his care plan intervention. On 12/18/24 at 12:47 PM V1 (Administrator) stated if someone was on 15-minute checks she would expect the 15-minute checks to be completed. V1 was given the October 2024 15-minute checks for R10 and informed they all appeared to be done in the same handwriting. V1 just shook her head. 44967 2. R5's Admission Record, dated 12/17/24, documents R5 was admitted to the facility on [DATE] with diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Atrial Fibrillation, Hypertension, Arthritis, Major Depressive disorder, Generalized Anxiety disorder, Bipolar Disorder, Right and Left above knee amputations (AKA), and Dependence on supplemental oxygen. R5's Care Plan, updated 12/16/24, documents R5 is a High Risk for falls. Interventions: Use Mechanical Lift with two assist and gait belt for all transfers. Use additional assist as needed when R5 is not feeling well, fell ing weak or dizzy device used for transfer Mechanical Lift, Observe for and educate on proper technique and use of device. It continues R5 has had an actual fall with on apparent injury. Root cause may be related to A&O (alert and oriented) R5 chooses self-mobility despite known/understood risks. 8/30/24: fall from bed during self-mobility-mattress slick vinyl. Interventions (9/3/24): For no apparent acute injury, determine and address causative factors of the fall, OT (Occupational Therapy) consult for safety in executing ADL (Activities of Daily Living) tasks, PT (Physical Therapy) consult for strength and mobility, continue interventions on the at-risk plan, new mattress that covering is not slick vinyl, 11/28/24: fall during car transfer per family when returning from LOA (Leave of Absence). Interventions (11/29/24): Educate family on R5's safety with transfers and requesting staff assistance when returning from LOA. R5's Care Plan, continued, documents R5 is alert and oriented and usually makes decisions regarding cares, decision made to self-transfer despite consequences, has physical limitations that may place R5 at risk for falls during transfer. R5 understands risks of self-transfer and believes benefit of independence outweigh risks/consequences of fall. 10/17/24: Fall with self-transfer - Root cause: hypotension. 10/15/24: Fall with self-transfer - not receptive to education on the ill effects of self-transfer. 11/19/24: Fall wheelchair to floor due poor sitting balance, and another fall bed to floor due to self-transfer. Interventions (10/15/24): 15-minute checks, (8/27/24): Assist R5 to clean and place prescribed eyewear when awake, assure R5 that staff is plentiful and available for assist at any time, encourage to verbalize feeling regarding bothering staff. Encourage R5 to use call light and ask for help when feeling weak or lightheaded, fall risk assessment quarterly and as needed with change in condition or fall status, review quarterly and PRN (as needed) R5's ADL, mobility, cognitive, behavior, and overall medical status, Interdisciplinary team (IDT) review of changes and needs with R5 and/or responsible party during care plan. R5's MDS, dated [DATE], documents R5 has a Moderate Cognitive Impairment and is Dependent on staff for toileting, bathing, bed mobility, chair/bed-to-chair transfer, sit to lying and lying to sit on side of bed. R5 is frequently incontinent of urine and occasionally incontinent of bowel. The Facility's Fall Log, for the past six months, documents R5 has had falls on 8/29/24, 10/15/24, 10/17/24, 11/19/24 X 2, 11/28/24, and 12/13/24. R5's Fall Risk Assessment, dated 10/28/24 documents R5 is a high fall risk. R5's AIM (Assessment Intervention Management) for Wellness Assessment, dated 11/19/24, documents R5 had a fall: Resident found on floor lying by wheelchair in room. Resident states he slipped from his chair. Fall Risk Assessment, dated 11/19/24, documents R5 is a High Fall Risk. R5's AIM for Wellness Assessment, dated 11/19/24 (second fall), documents R5 had a fall: Resident found lying on floor on back. Resident fell from bed unwitnessed, no injury noted. Placed on neuro checks and ROM (range of motion) WNL (within normal limit). R5's AIM for Wellness Assessment, dated 11/28/24, documents R5 had a fall: Notified by daughter in front parking lot as they had resident on slide board attempting to get him into wheelchair out of car. They had to lower him to the ground. By the time this nurse got down there they were wheeling him into the building. Assessed resident in room. VS WNL. Appeared somewhat out of sorts. Daughter said that he was high and had been smoking, did not say what he was smoking. Fall Risk Assessment, dated 11/29/24, documents R5 is a High Fall Risk. R5's AIM for Wellness Assessment, dated 12.13/24, documents R5 had a fall: Resident was in his room when attempting to transfer himself to his bed. Wheelchair rolled back and resident fell to floor on his buttock. ROM and Vitals WNL, Resident placed on neuro checks and fall precaution. Fall Risk Assessment, dated 12/13/24, documents R5 is a High Fall Risk. On 12/16/24 at 9:55 AM, R5 was seen lying in bed with bilateral AKAs. R5 stated that he has fallen several times while trying to get himself out of bed to his wheelchair, and usually lands on his butt. There are no fall precautions seen in the room. On 12/16/24 at 12:05 PM, V9 (Certified Nursing Assistant/CNA) was performing incontinence care on R5. After incontinence care, V9 told R5 that he can get himself up now and after three attempts just to sit up in bed, R5 got himself to sit up by using the wobbly side rail while pulling himself upright on the edge of the bed, then R5 scooted himself to the locked wheelchair next to his bed. R5 appeared to have difficulty getting himself up and over to the wheelchair with V9 not helping or standing by the bedside. V9 was picking up around the sink while R5 transferred himself. On 12/16/24 at 1:30 PM, R5 stated Some people will help me get in or out of my wheelchair, and others just walk away and leave me to do it myself. They don't do s*** around here, I have to do it myself. When asked if he refuses staff assistance, R5 stated No I don't refuse, but when they don't offer to help me, I just do it myself. On 12/17/24 at 9:45 AM, V9 (CNA) stated We try to stand by for (R5) but by the time we get there, he has already transferred on his own. We should be standing by him when he transfers to keep him safe. 3. R30's Admission Record, undated, documents R30 was admitted to the facility on [DATE] with diagnosis of Generalized Anxiety Disorder, Major Depressive Disorder, Osteoporosis, Chronic Kidney Disease, Heart Failure, Atrial Fibrillation, and Hypertension. R30's Care Plan, dated 4/16/24, documents R30 has risk factors that require monitoring and intervention to reduce potential for falls. Interventions: Assess cognitive deficits and accommodate forgetfulness regarding safety devices and environmental risks, Encourage and assist placement of proper non-skid footwear, encourage rest periods during ambulation, place chair in hall for rest periods as needed. Encourage to use call light and ask for help when feeling weak or lightheaded. Encourage to wear brief during daytime hours to minimize risk of slipping on wet floor during toileting. Fall risk assessment quarterly and as needed with change in condition or fall status. IDT review of ADL status and fall potential with changes in condition or fall status. Ensure that adaptive devices-walker is within reach and in good repair, Keep call light within reach at all times. Answer promptly and notify R30 that help is coming. Keep environment well-lit and clutter free. Remind of safety precautions and limitations as necessary. Set up bathing supplies as needed and assist PRN to prevent spilling/slipping. It continues (11/7/24): R30 has had an actual fall with serious injury - fracture right foot. Root cause may be related to poor balance, loss of balance, unsteady gait. Interventions: Neuro-checks per facility protocol, OT consult for safety in executing ADL tasks, PT consult for strength and mobility, ST consult for cognitive evaluation. Continue interventions on the at-risk plan, New Intervention: (11/7/24) PT to eval and treat as indicated. It continues (4/16/24): R30 has increased risk for fractures/spontaneous fractures related to osteoporosis. it continues (11/7/24): R30 has a bone fracture related to ground level fall. Intervention: Support injured area with pillows and immobilize part as appropriate. R30's MDS, dated [DATE], documents R30 is cognitively intact and is dependent on staff for bathing and dressing, requires partial/moderate assistance for toileting and dressing, and requires substantial/maximal assistance from staff for all transfers. R30 is frequently incontinent of both bowel and bladder. R30's Nursing Summary Assessment, dated 8/9/24, documents R30 has not had any falls in last 30-days and is a Low Fall Risk. The Facility's Fall Log for the past six months, documents R30 has had one fall on 11/6/24. R30's AIM for Wellness Assessment, dated 11/6/24, documents R30 had a fall: Was notified by staff that resident fell upon entering TV Room. Resident is in sitting position, skin assessment done, has abrasion to side of right foot and unable to bear weight. C/O (complaint of) pain PRN (as needed) was given. Notified Dr., received NO (new order) for STAT X-Ray to right foot, ankle, tibia, and fibula 3 views. Notified DON (Director of Nurses), POA (Power of Attorney), of unwitnessed fall with injury. (x-ray company) called and on the way. R30's Fall Risk Assessment, dated 11/6/24, documents R30 was a Low Fall Risk. R30's Radiology Report, dated 11/6/24, documents R30 has an Acute Comminuted fracture of the distal right fibular shaft and medial malleolus with soft tissue swelling. On 12/16/24 at 9:28 AM, R30 was seen sitting on side of her bed with her right ankle ace wrapped. R30 stated she fell at the facility and fractured her ankle. There were no fall precautions seen in the room. R30's Call Light was seen hanging down the wall and between the wall and her bed and was not in reach of R30. On 12/17/24 at 11:50 AM, R30 was seen in her wheelchair with a large boot covering her left foot and ankle. R30 stated her physician's appointment went well, however, there is still an infection in her ankle. R30's Call Light is still hanging down the wall between her bed and the wall and not in reach. On 12/18/24 at 10:58 AM, R30 was seen asleep in her bed with her wheelchair next to side of her bed, with one wheel was locked and the other unlocked. R30's call light was still hanging down the wall and between her bed and the wall with the button on the floor. On 12/18/24 at 12:14 PM, V1 (Administrator) stated All residents who are on fall precautions should have fall interventions in place and their call lights within reach. The Facility's Fall Evaluation and Prevention Policy, undated, documents in part: To ensure that the resident's environment remains as free of accident hazards as is possible, and that each resident receives adequate supervision and assistance to prevent accidents. The goal is to prevent falls if possible and avoid any injury related to falls. The Care Plan should only specify a few interventions at a time so that the staff can determine what intervention is not successful and needs to be changed. Residents should be evaluated for their fall risk: On admission/re-admission to the home, following any change of status that may affect balance, mobility, or safety, Following a fall, and Quarterly. 4. R31's Admission Record, dated 12/18/24 documents R31 was admitted to the facility on [DATE] with diagnosis of Obesity, Osteoporosis, Anxiety Disorder, Chronic Obstructive Pulmonary Disease, Pulmonary Embolism, Venous Thrombosis/Embolism, and Gout. R31's Care Plan, dated 12/6/24, documents R31's review shows low risk for falls. 9/6/24: High Fall Risk, 12/6/24: Fall Score 13 = High Risk. Interventions: 6/17/24: Be sure call light is within reach and encourage R31 to use it for assistance as needed. R31 needs prompt response to all requests for assistance. Follow facility fall protocol. It continues (6/19/24): R31 has had an actual fall with no apparent injury. Root cause may be related to attempted side to side bed mobility using mattress edge and rolled out of bed. Interventions: Restorative nursing bed mobility program review/initiation, continue interventions on the at-risk plan, New Intervention: half bilateral side rails to enable increased independence/safety with side-to-side bed mobility. It Continues (6/17/24): R31 is dependent for ADLs - unable to assist/assists only minimally. Interventions: Transfer R31 using mechanical device of (full body mechanical) lift and two staff members. Keep hand on R31 to reassure of safety if needed. R31's MDS, dated [DATE], documents R31 is cognitively intact and is dependent on staff for all ADLs. R31 is always incontinent of both bowel and bladder. The Facility's Fall Log for the past six months, documents R31 has only had one fall on 6/19/24. R31's Fall Risk Assessment, dated 6/19/24, documents R31 is not a High Fall Risk. R31's AIM for Wellness Assessment, dated 6/19/24, documents: Was notified by staff that resident was on the floor. Upon entering the room, resident was lying next to the bed. Skin assessment done; no injuries noted. Placed a call to doctor with no new orders received. Notified POA of unwitnessed fall with no injury. On 12/16/24 at 10:00 AM, R31 was seen lying in bed. R31 stated she fell out of bed once, but now she is bedridden and unable to walk, and doesn't get up on her own. On 12/16/24 at 11:50 AM, V9 (Certified Nursing Assistant/CNA), was about to get R31 out of bed and to her wheelchair using a full body mechanical lift device. Upon entrance, V9 already had the device sling under R31 and attached to the device, which was unlocked. V9 stated I have to go get some help. and waited for V10 (CNA) to come in and assist. V10 entered and both lifted R31 off the bed, having R31 hold onto the crossbar on the device, and pulled R31 to her wheelchair with neither CNA holding onto R31. V9 held the unlocked wheelchair and tilted it backwards, while V10 moved R31, swinging in the air, from her bed to her wheelchair, and then R31 was lowered and disconnected from the lift. On 12/18/24 at 11:02 AM, V9 (CNA) stated I have to use two people with the (full body mechanical lift) because I can't do it by myself. On 12/18/24 at 12:14 PM, V1 (Administrator) stated All residents who are on fall precautions should have fall interventions in place. I would expect any staff using the (full body mechanical lift device) to use two people and to hold onto the resident during the entire transfer. The Facility's Mechanical Lift Policy, dated 10/30/08, documents The mechanical lift may be used to lift and move a resident with limited ability during transfer while providing safety and security for residents and nursing personnel. Procedure: 8. Position lift at side of bed. Lock wheels on lift. 10. Have resident cross arms over chest. 11. Instruct the resident that they will be raised off the bed and start to raise the resident using a slow, steady movement. It may be necessary to support the resident's head. 12. Move resident to chair or wheelchair and lower resident. The guidance strap may be used to guide the resident into a proper position while resident is being lowered.

Based on observation, interview, and record review, the facility failed to date medications containers that had been opened, and to ensure proper medication storage was maintained during medication administration for 4 of 4 residents (R6, R32, R49, R105) reviewed for medication labeling and storage in the sample of 39. Findings include: 1. On 12/16/24 at 9:48 AM, R49 was seen walking around her room. There was a cup of medications with eight pills in it sitting on the nightstand table. V8 (Licensed Practical Nurse/LPN) had already passed medications on R49's hall. R49's Medication Administration Record (MAR) dated 12/1/24 through 12/31/24, documents the following eight medications were given at 8:00 AM: Allopurinol 100 MG (milligram) Once Daily, Amlodipine 10 MG Once Daily, B Complex/C Folic Acid 1 MG Once Daily, Metoprolol 100 MG Once Daily, Sevelamer Carbonate 800 MG (2 tabs) TID (three times daily), Hydralazine 100 MG TID, and Vitamin D 4000units Once Daily. 2. On 12/16/24 at 10:07 AM, R32 was seen sitting on the side of her bed with Ellipta and Flonase Inhalers seen sitting on her nightstand table. V8 had already passed medications on R32's hall. R32's MAR, dated 12/1/24 through 12/31/24, documents the following medications was given at 8:00 AM: Anoro Ellipta Inhale one puff by mouth Once Daily. Fluticasone 50 MCG (microgram) one spray in each nostril Once Daily PRN (as needed) is listed on the MAR but was not documented as given. On 12/19/24 at 9:10 AM, V8 stated I never leave a cup of medications sitting in the resident room for them to take on their own. I make sure they take them when I give it to them. Inhalers are kept in the med cart. 40701 3. On 12/16/2024 at 10:03 AM, the 100-hall medication cart was inspected with V7 (Licensed Practical Nurse/LPN). At this time, there was a bottle labeled (R6) escitalopram 5 milligrams/milliliters. At this time, V7 confirmed the bottle was opened and there was no date to indicate when the bottle was opened. V7 stated he writes the date on the bottle if he breaks the seal of the bottle. R6's Physician's Orders dated 12/1/2024-12/31/2024 documents, escitalopram 10 ml per G-tube (Gastroenterol tube). 4. On 12/16/2024 at 10:17 AM, R105 was in her room. There were two medication cups on the nightstand. One cup had two colored circular tablets and the other cup had a circular white pill in it. At this time, R105 stated one of the cups contained Tums tablets (2) and the other cup contained one Tylenol tablet. R105 stated she did not bring the medications from home. R105's Physician's Orders undated documents R105 can have two tablets of Tylenol 500 milligrams every 6 hours as needed for pain, as well as one Calcium Carbonate (tums) 500 mg daily at 8 AM. On 12/17/2024 at 11:14 AM, V7 (LPN) stated medications should not be kept at beside and he does not know of any residents who does keep them in their room. V7 stated he watches the residents to ensure they consume all their medications. On 12/17/2024 at 1:51 PM, V1 (Administrator) and V2 (Director of Nursing) stated medications at the bedside are not allowed. V1 added it is a big no. V1 and V2 stated liquid medications kept in bottles should be dated with the date the container was opened. On 12/18/2024 at 2:10 PM, V3 (Assistant Director of Nursing) stated medication bottles should be dated to reflect when the bottle was opened and medications should not be left at the bedside, unless there is a doctor's order, which R105 does not have. The Facility's Procurement and Storage of Medications Policy dated 11/6/2018 documents, All mediation containers shall be labeled with the date opened by the person breaking the container seal. The Facility's Medication Administration Policy dated 11/18/2017 documents, Drugs and biologicals are administered only by physicians and licensed nursing personnel. Definition: Drug administration shall be defined as an act in which a single dose of a prescribed drug or biologicals is given to a resident by an authorized person in accordance with all laws and regulations governing such acts. The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container), verifying it with physician's orders, giving the individual dose to the proper resident and promptly recording the time and dose given. It further documents, Observe the resident consume the medication to ensure resident swallows medication. Never leave prepared medications unattended. No medications should be left at bedside unless specifically ordered by the physicians and then only in limited amount as described by the physician.

Based on observation, interview, and record review the facility failed to provide incontinent care per standards of practice for 3 of 5 residents (R5, R11, R26) reviewed for incontinent care in a sample of 39. Findings include: 1. R11's Face Sheet, original admitted [DATE], documented she has diagnoses of but not limited to of Brain aneurysm, hypertension (HTN), Seizures, Cerebrovascular accident (CVA), Gastroesophageal reflux disease (GERD), Osteoarthritis, and Acute metabolic encephalopathy. R11's Minimum Data Set (MDS), dated [DATE], documented R11 is severely cognitively impaired with a brief interview for mental status (BIMS) of 07 out of 15 and is dependent on staff for her activities of daily living (ADLs). R11's Care Plan, admitted [DATE], documented R11 may be predisposed to develop skin impairment caused by pressure. Related to (R/T) Right hemiplegia, neuropathy, decreased mobility, incontinent bowel, and bladder (B&B). High risk per Braden. Goal: R11 will have intact skin, free of redness, blisters, or discoloration through review date. Interventions: Apply house stock incontinent barrier cream to peri area with every after incontinent episode and as needed. Toilet/change brief when wet and upon rising, at bedtime (HS) and after meals. R11 is at risk for skin impairment R/T incontinent of urine. Goal: Breakdown due to incontinence and brief use through the review date. Interventions: Incontinent: Check every 2 hrs (hours) and as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. Clean peri-area with each incontinence episode. On 12/17/24 at 09:30 AM, V14 (Certified Nursing Assistant/CNA) and V15 (CNA Coordinator) were observed doing incontinent care on R11. R11's wet incontinent brief was removed by V14 and V15. V14 then assisted R11 onto her back and separated R11's legs. V14 took a disposable wipe and cleansed the left crease between R11's thigh and pubic area then disposed of the wipe. She got another disposable wipe and wiped down the right crease between R11's thigh and pubic area then threw the wipe away. V14 then took another disposable wipe, opened the labia, and cleansed the inner area and failed to wash the outer labia. She disposed of the wipe in the trash then took a towel and dried all the areas. R11 was assisted onto her left side and V14 cleansed the right buttock and gluteal cleft. A new brief was placed and R11 was rolled onto her back, the new brief was fastened. CNAs failed to apply barrier cream per R11's care plan. V14 and V15 failed to cleanse R11's left buttock. V14 and V15 also failed to use a washcloth, wash basin, and soap per facility policy. 2. R26's Face Sheet, dated 08/22/2023, documented R26 has diagnoses of but not limited to dementia, chronic kidney disease, diabetes mellitus II, hypertension (HTN), and hepatitis C. R26's MDS, dated [DATE], documented R26 is severely cognitively impaired with a BIMS of 04 out of 15 and requires substantial assistance from staff with all her ADLs and transferring. R26's Care Plan, dated 08/22/2024, documented R26 may be predisposed to develop skin impairment caused by pressure. R/T high risk per Braden scale- Risk factors noted as: decreased mobility and spends all of time in chair or bed, incontinent of B&B, diabetes, unaware of need to change position and unable to do so without staff assist, terminal care r/t heart failure. Intervention include but not limited to Apply house stock incontinent barrier cream to peri area after incontinent episode and as needed. Toilet/change brief when wet and upon rising, at HS and after meals. R26 is at risk for skin impairment r/t incontinent of urine and unable to retrain due to cognitive losses. R26 will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions include but not limited to clean peri-area with each incontinence episode, check every two hours and as needed for incontinence. Wash, rinse, and dry perineum. On 12/17/24 at 10:40 AM, V14 (CNA) and V10 (CNA) assisted R26 onto her back and the old incontinent brief was removed by V14. V14 took a disposable wipe and cleansed the crease on the right and left side between the pubic area and inner thigh of R26. V14 then disposed of the wipe and got a new wipe. She separated the labia and cleansed the inner labia but failed to cleanse the outer labia. V14 took a clean towel and dried all areas. R26 was assisted onto her right side and left buttocks cleansed and dried she was then assisted onto her left side and right buttocks cleaned and dried. V14 and V15 failed to apply lotion or barrier cream per R26's care plan and failed to use a washcloth, soap, and wash basin per facility policy. On 12/18/24 at 12:47 PM, V1 (Administrator) stated if the resident's care plan documented barrier cream was to be applied after each incontinent episode, she would expect them to be using barrier cream on the resident. 44967 3. R5's Admission Record, dated 12/17/24, documents R5 was admitted to the facility on [DATE] with diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Atrial Fibrillation, Hypertension, Arthritis, Major Depressive disorder, Generalized Anxiety disorder, Bipolar Disorder, Right and Left above knee amputations (AKA), and Dependence on supplemental oxygen. R5's Care Plan, updated 8/27/24, documents R5 is rarely able to perform Activities of Daily Living (ADLs) without weight bearing/hands on assist of 1-2 caregivers related to Amputation Bilateral AKA. Interventions: Bed Mobility: R5 requires max assist of one staff to turn and reposition in bed, Side Rails: Bilateral half rails up as per doctor order for increased independence with bed mobility, Toilet Use: R5 requires partial to max assist by one staff for toileting, utilizes urinal and bed pan for toileting, not a candidate for toilet use due to sitting balance. Transfer: Assist to transfer R5 using full body mechanical lift device and two staff members, keep hand on R5 to reassure of safety. R5's Minimum Data Set (MDS), dated [DATE], documents R5 has a Moderate Cognitive Impairment and is Dependent on staff for toileting, bathing, bed mobility, chair/bed-to-chair transfer, sit to lying and lying to sit on side of bed. R5 is frequently incontinent of urine and occasionally incontinent of bowel. On 12/16/24 at 9:55 AM, R5 stated that he just voids in his incontinence brief and will let staff know to get cleaned up. On 12/16/24 at 12:05 PM, V9 (CNA) was seen performing incontinent care on R5 prior to getting him up for lunch. V9 came into room with gloves on and a clean brief in her hands. V9 started the water running in the sink, then left the room and returned to the room with one towel. V9 wet approximately a quarter of the towel in the sink and walked over to R5 and wiped R5's bilateral groins, and abdominal fold with the wet part of towel, then used the dry part of towel to dry the same areas. There was no wiping of R5's penis or scrotum. V9 had R5 roll to his left side by holding onto the bed rail, then used the same wet towel as previously used to wipe R5's buttocks and anal area. The soiled linen and brief were tucked under R5 as he rolled over to his right side for V9 to pull them out, then onto his back. V9 had R5 roll over to his left again while she reached inside his brief and wiped moisture barrier cream on his buttocks and then secured the brief. On 12/18/24 at 11:00 AM, V9 stated I always do hand hygiene when I start in the morning and then after I do something with the residents. On 12/18/24 at 12:10 PM, V1 (Administrator) stated I would expect the staff to perform timely and complete incontinent care, including proper equipment needed, proper hand hygiene and glove changes before care, during glove changes, and after care. All staff should be doing hand hygiene before and after resident contact and before leaving the resident's room. The Facility's Hand Hygiene Policy, dated 12/2018, documents in part: All staff will wash hands, as washing hands as promptly and thoroughly as possible after resident contact and after contact with blood, body fluids, secretions, excretions, and equipment or articles contaminated by them is an important component of the infection control and isolation precautions. The Facility's Perineal Cleansing Policy, dated 9/21/10, documents in part: To eliminate odor; to prevent irritation or infection and to enhance resident's self-esteem. Equipment: 1. Washcloth and towel. 2. Soap, other cleansing agent or (brand name cleaning agent). 3. Gloves. 4. Wash basin. 5. Plastic bag. Male without catheter: 4. Wet washcloth and apply cleansing agent chosen. 5. Wash pubic area, including upper inner aspect of both thighs as well as the penis and scrotum. b. Wash area under scrotum. 6. Rinse area in same sequence, if applicable. 7. Place soiled items in plastic bag. 8. Dry carefully and proceed with cleansing of the anal area. 10. Rinse cloth and proceed with the cleansing of the anal area. 11. Washing should alternate side to side, ending with the center anal area. 12. Rinse cloth and entire area in the same sequence, if applicable. 13. Place soiled items in plastic bag. 14. Dry area thoroughly. 15. Remove gloves and wash hands with soap and water, cleansing gel, or (brand name cleaning agent). 16. Apply clean incontinent product, clothes, or position resident comfortably. 17. Wash hands with soap and water, cleansing gel or (brand name cleaning agent). Note: The basic infection control concept for peri-care is to wash from the cleanest to the dirtiest area and remember to change or remove gloves and wash hands when going from working with contaminated items to clean items.

Based on observation, interview and record review, the facility failed to ensure oxygen tubing was dated as well as provide humidified water per their policy for 3 of 3 residents (R5, R12, R31) reviewed for oxygen administration, in the sample 39. Findings include: 1. On 12/16/2024 at 10:46 AM, R12 was wearing an oxygen cannula connected to a humidifier bottle attached to an oxygen concentrator. There was no date observed on the bottle or the tubing. On 12/17/2024 at 1:05 PM, V7 (Licensed Practical Nurse/LPN) stated oxygen tubing and humidifier bottles are changed on night shift by the nurse and it should be dated. R12's Medication Administration Record (MAR) dated 12/1/2024-12/31/2024 documents R12 has a Physician's Order for oxygen at 2-5 Liters/minute as needed for shortness of breath. R12's Physician's Orders do not include an order to change the oxygen tubing. On 12/17/2024 at 1:50 PM, V1 (Administrator) and V2 (Director of Nursing) stated the oxygen tubing should be dated to ensure it is changed weekly. On 12/18/2024 at 2:10 PM, V3 (Assistant Director of Nursing/ADON) stated oxygen tubing should be dated and changed weekly. As of 12/19/2024 at 10:30 AM, R12's oxygen tubing remained undated and was in use. 44967 2. R5's Admission Record, dated 12/17/24, documents R5 was admitted to the facility on [DATE] with diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Atrial Fibrillation, Hypertension, Arthritis, Major Depressive disorder, Generalized Anxiety disorder, Bipolar Disorder, Right and Left above knee amputations (AKA), Obstructive Sleep Apnea (OSA), and is Dependent on supplemental Oxygen (O2). R5's Care Plan, updated 8/27/24, documents R5 has oxygen therapy related to heart failure, COPD, chronic respiratory failure with hypoxia. Interventions: Give medications as ordered by physician, monitor for signs/symptoms of respiratory distress, Oxygen Settings: O2 at 3 Liters (L)/Nasal Cannula (NC) continuously, position R5 to facilitate ventilation/perfusion matching: Head of Bed (HOB) elevated or extra pillows behind back when in bed due to unable to lay flat. It continues R5 is at risk for complications from COPD, OSA, Chronic Respiratory Failure with Hypoxia. Interventions: Head of bed elevated and/or extra pillows behind his back when in bed due to unable to lay flat or out of bed upright in a chair during episodes of difficulty breathing. R5's Minimum Data Set (MDS), dated [DATE], documents R5 has a Moderate Cognitive Impairment and is Dependent on staff for toileting, bathing, bed mobility, chair/bed-to-chair transfer, sit to lying and lying to sit on side of bed. R5 is frequently incontinent of urine and occasionally incontinent of bowel. R5's Physician Order, dated 11/30/24, documents Change O2 tubing and humidifier weekly on Sunday 10P-6A. R5's Treatment Administration Record (TAR), dated December 2024, documents Change O2 tubing and humidifier weekly on Sunday 10P-6A. On 12/16/24 at 9:55 AM, R5 was seen lying flat in bed on one pillow, and on O2 at 3 L/NC, no humidified bottle seen attached to concentrator. On 12/17/24 at 9:45 AM, R5 seen lying in bed flat with one small pillow under his head. R5 had both nasal cannulas on him, one from his portable oxygen tank on the back of his wheelchair, and the one attached to the concentrator next to his bed with both running at 3 L/NC with no humidified bottle of water attached. On 12/17/24 at 11:45 AM, R5's Oxygen concentrator was running at 3 L/NC to a nasal cannula lying on the bed and not on R5. There was no water bottle (humidified) attached to the concentrator. 3. R31's Admission Record, dated 12/18/24 documents R31 was admitted to the facility on [DATE] with diagnosis of Obesity, Osteoporosis, Anxiety Disorder, Chronic Obstructive Pulmonary Disease (COPD), Pulmonary Embolism, Venous Thrombosis/Embolism, and Gout. R31's Care Plan, dated 12/6/24, documents R31 is at risk for complications from COPD. Interventions: Give aerosol or bronchodilators as ordered, head of bed elevated. R31's MDS, dated [DATE], documents R31 is cognitively intact and is dependent on staff for all Activities of Daily Living (ADLs). R31's Physician Order, dated 3/1/23, documents Oxygen at 2 L (liters)/NC (nasal cannula) to keep sats >90% as needed. R31's Physician Order, dated 3/1/23, documents Change O2 tubing on Sundays 10-6. On 12/16/24 at 10:00 AM, R31 was seen lying in bed on O2 at 3 L/NC with a humidified water bottle not dated and empty while attached to the oxygen concentrator. On 12/17/24 at 11:42 AM, R31's Oxygen concentrator was running at 3 L/NC with cannula lying on the floor and a water bottle attached to the concentrator that was empty and not dated. On 12/18/24 at 11:40 AM, V8 (LPN), stated All of the nurses are responsible for setting up Oxygen for the residents who have orders for it. There should be a humidified water bottle attached to the concentrator and both the water bottle and the nasal cannula get replaced once a week. On 12/18/24 at 12:15 PM, V1 (Administrator) stated The nurses should be putting a new humidified water bottle on each Oxygen concentrator with a date of attachment, along with a clean nasal cannula for the resident once a week. The Facility's Liquid Oxygen Policy, dated 8/2003, documents in part: A method of supplying supplemental oxygen to a resident. A. Liter flow should be checked and documented every shift. Equipment Needed: D. Humidifier. Procedure: Attach humidification. The policy does not address dating of oxygen supplies.

Based observation, interview, and record review, the facility failed to maintain equipment in safe condition regarding lint buildup and failed to follow the Facility Policy. This has the potential to affect all 54 residents in the facility. Findings include: On 12/27/24 at 9:15 AM, V16 (Laundry/ Housekeeping) stated that she has never cleaned the lint traps and doesn't know when they were last cleaned. The two lint traps each measuring 36 inches x 23 inches located at the bottom of each dryer showed an accumulation of a moderate amount of lint. A horizontal red sign on the door handles states Urgent: Lint compartment must be cleaned daily. On 12/17/24 at 9:20 AM, V17 (Maintenance Director) stated that he cleans the lint traps monthly and provided a checklist that showed the monthly cleaning log that documented when the lint traps were cleaned V17 stated that he thinks that it would be better if this was done at the end of each shift. V17 checked with V18 (Regional Maintenance Director) who stated that the lint traps should be changed after every dryer cycle. On 12/17/24 at 1:15 PM V17 stated that lint traps not being cleaned poses a fire hazard. On 12/18/24 at 9:40 AM, V1 (Administrator) stated that her expectation is that the dryer lint trap should be cleaned daily. The Facility Policy titled, Servicing the Dryer/Preventive Maintenance Instructions. (Lint related) documents, Daily- 1) Clean lint screen. Use soft brush if necessary. 2. Check lint screen for tears. Replace if necessary. 3) Clean lint from lint screen compartment. Monthly- 1) Remove lint accumulation from end bells of motor. 2) Remove lint from front control compartment. 3) Remove lint and dirt accumulation from top of the dryer and all around the burners and burner housing. Failure to keep this port leads to build-up of lint creating a fire hazard. Quarterly- 1) Remove lint accumulation from primary airports in burners. Semi-Annually - 1) Remove and clean main burners. 2. Remove all lint accumulation. Remove from panel, lint screen and check for accumulation. Annually Check and remove any lint accumulation from exhaust system. The Facility policy titled Dryer Lint Cleaning Policy and Log, documents, All dryer lint traps must be cleaned by laundry staff every (dryer) cycle. Staff must ensure this gets completed to ensure proper and safe functioning of the dryer. Be aware of the sensors and wiring when cleaning out lint areas so as to not damage the equipment. Dryer lint trap, burner box and all other areas of the dryer must be thoroughly cleaned/vacuumed and inspected monthly by maintenance staff. Track date of each dryer cleaning/inspection under each dryer unit. Include any issues or repairs made in notes. An article written by retired fire chief titled McKnight's Long-Term Care dated 4/2/22 state that the laundry room is an area of your healthcare facility requires vigilance and a strong operational commitment to prevent fires. Policies, procedures, and safety protocols should be developed in accordance with manufacturer's guidelines to help ensure proper operation of laundry equipment. Staff should be continuously trained on these procedures to help reduce the potential for fires. Lint traps should be regularly emptied, and all interior and exterior surfaces should be maintained in a condition that is free of combustible materials like lint. Again, follow the information contained in the equipment's' operating manuals and safety guidelines to help ensure proper operations and a reduced risk of fire. Some nursing homes have developed a log to document the frequency of lint trap cleaning daily. Maintenance and cleaning of other elements of commercial laundry equipment, including the clothes dryers, should be on your facility's preventative maintenance schedule. This type of equipment is typically inspected and comprehensively cleaned at least monthly or more frequently depending on use. The more active the equipment is, the more frequently it should be cleaned. The Long-Term Care Facility Application for Medicare and Medicaid, CMS 672, dated 12/16/2024 documents there are 54 residents residing at the Facility.

Based on interview and record review, the Facility failed to document the discharge in the medical record and communicate necessary information for receiving facility for 1 of 3 residents (R2) reviewed for discharge in the sample of 5. Findings include: R2's Face Sheet documents, R2 was admitted to the facility on [DATE] with diagnoses including hypertension, diabetes, chronic liver disease, anxiety, and chronic depression. R2's Minimum Data Set, (MDS), dated [DATE] documented, R2 was severely cognitively impaired with inattention and disorganized thinking. The MDS documented, R2 had delusions, verbal behavioral symptoms directed toward others, other behavioral symptoms not directed toward others, and was independent with mobility. R2's Care Plan starting [DATE] documents, R2 has behavioral disturbances including stripping clothes in public areas, verbal aggression, and throwing items at staff. R2's Nurse's Note dated, [DATE] at 8:00 PM documents, R2 was sent to the emergency room after exhibiting physically aggressive and sexually inappropriate behaviors. R2's Medical Record does not contain any documentation, after the above incident on [DATE] at 8:00 PM. R2's Medical Record does not contain documentation regarding discharge, basis for discharge, physician documentation, physician contact information, resident representative contact information, advanced directives, care plan or any other important information that would be necessary for R2's care at the receiving facility. On [DATE] at 9:15 AM, V1 (Administrator) stated there is no documentation in R2's Medical Record, because the Facility did not initiate an involuntary discharge. She stated, R2's bed hold expired, and they did not accept her back after that. On [DATE] at 11:50 AM, V7 (Social Services Director), stated, the Facility did not initiate an involuntary discharge for R2, but she was not allowed to return after her bed hold expired. On [DATE] at 1:48 PM, V2 (Director of Nursing), stated R2 did not have an involuntary discharge, but her bed hold expired, and she did not come back. The Facility's Undated Transfer and Discharge Policy and Procedure documents, .documentation, in the residents clinical record shall be required. The residents attending physician must document in the residents clinical record that the facility cannot provide for the residents welfare, or that the resident no longer requires the facilities services.

Based on interview and record review, the Facility failed to follow discharge requirements for 1 of 3 residents (R2) reviewed for discharge in the sample of 5. Findings include: R2's Face Sheet documents, R2 was admitted to the facility on [DATE] with diagnoses including hypertension, diabetes, chronic liver disease, anxiety, and chronic depression. R2's Minimum Data Set, (MDS), dated [DATE] documented, R2 was severely cognitively impaired with inattention and disorganized thinking. The MDS documented, R2 had delusions, verbal behavioral symptoms directed toward others, other behavioral symptoms not directed toward others, and was independent with mobility. R2's Care Plan starting [DATE] documents, R2 has behavioral disturbances which include stripping clothes in public areas, verbal aggression, and throwing things at staff. R2's Nurse's Note dated [DATE] at 8:00 PM documents, R2 was sent to the emergency room after exhibiting physical aggression and sexually inappropriate behaviors. R2's Medical Record does not contain any documentation after the above incident on [DATE] at 8:00 PM. R2's Medical Record does not document a plan for discharge, basis for discharge, or advanced notification of discharge to R2 and her representative. On [DATE] at 9:15 AM, V1 (Administrator) stated, R2 was not given an involuntary discharge notice, but her bed hold expired while she was in the hospital, and they chose not to readmit her. On [DATE] at 11:50 AM, V7 (Social Services Director), stated, R2 did not return to the Facility after hospitalization , because her bed hold expired. She stated, R2 was not given an involuntary discharge. On [DATE] at 12:30 PM, V2 (Director of Nursing), stated, R2's bed hold expired, and the Facility did not take her back. She was unaware whether R2's responsible party was notified. The Facility's Bed Hold Guarantee Policy revised [DATE] documents, A Medicaid resident, whose hospitalization or therapeutic leave exceeds the 10-day bed-hold period, may return to their previous room if available or immediately upon the first availability of a bed in a semi-private room. If the facility determines that a resident who was transferred with an expectation of returning to the facility cannot return to the facility, the facility must comply with 42 CFR, Sec 483.15 (c). The Facility's Undated Transfer and Discharge Policy and Procedure documents, Except for the case of late payment or nonpayment, the facility shall notify the resident and the residents family member, surrogate or representative of the transfer and the reasons for the transfer as stated in the clinical record. The planned involuntary transfer or discharge shall be discussed with the resident, guardian, residents' representative and/or the person or agency responsible for the resident's placement, maintenance and care in the facility. The discussion shall be carried out by the administrator or his/her designee. The content of the discussion and explanation shall be summarized in writing, including the names of those in attendance. The summary shall be made a part of the residents clinical record. A physicians discharge order shall be obtained in the residents record prior to discharge. Prior to transfer or discharge the Social Services Director shall counsel the resident and summarize the counseling session in the residents record.

Based on interview and record review, the Facility failed to allow a resident to return to the Facility following hospitalization in 1 of 3 residents (R2) reviewed for transfer/discharge in the sample of 5. Findings include: R2's Face Sheet documents, R2 was admitted to the facility on [DATE] with diagnoses including hypertension, diabetes, chronic liver disease, anxiety, and chronic depression. R2's Minimum Data Set, (MDS), dated [DATE] documented, R2 was severely cognitively impaired with inattention and disorganized thinking. The MDS documented, R2 had delusions, verbal behavioral symptoms directed toward others, other behavioral symptoms not directed toward others, and was independent with mobility. R2's Baseline Care Plan dated [DATE] documents, plan to initiate behavior monitoring and psychiatric medication use. R2's Care Plan starting [DATE] documents, R2 has behavioral disturbances which include stripping clothes in public areas, verbal aggression, and throwing things at staff. R2's related diagnoses included chronic schizophrenia, chronic depression, and anxiety. The interventions added were medication review and order for psychiatric consult. R2's Progress Note dated [DATE] by V5 (Nurse Practitioner/NP), documents R2 has a diagnosis of paranoid schizophrenia and was placed at this Facility after going to the hospital, due to having an altercation with a resident at another facility. R2's Progress Note dated [DATE] at 8:45 PM documents, R2 was yelling out nonsensical sentences, then dropped her pants to the floor, grabbed her vagina, and made several statements about her vagina. R2's Nurse's Note dated [DATE] at 4:30 AM documents, R2 was being inappropriate to staff, attempting to pull staff pants down, and making inappropriate gestures. R2's Nurse's Note dated [DATE] at 12:00 AM documents, R2 went to the nurse's station and started singing as loud as she could, then placed both fists in the air and threatened staff member, then went down the hall, removed clothes, and engaged in sexually inappropriate behavior. R2's Nurse's Note dated [DATE] at 10:00 PM documents, R2 attempted to leave through the exit door at the end of the hallway. R2's Nurse's Note dated [DATE] at 5:45 PM documents, R2 was being inappropriate and speaking inappropriately to other residents, then removed her clothing and threw juice at another resident. R2's Nurse's Note dated [DATE] at 8:00 PM documents R2 was in another resident's room threatening to kill her, then went down the hall and slapped another resident on the shoulder. R2 then grabbed a pill crusher and attempted to hit a nurse in the head. Staff were able to obtain the pill crusher, but R2 then hit another staff member in the head with her fist. R2's Psychiatrist was notified and gave orders to send R2 to the emergency room . On [DATE] at 7:55 AM, V4 (Business Office Manager) stated, R2 was sent to the hospital, because she was having a lot of sexual behaviors. She stated other residents were afraid of her, and she tried to hit a nurse. On [DATE] at 9:15 AM, V1 (Administrator) stated, R2's bed hold expired while she was in the hospital, and they chose not to accept her again. She was not involuntarily discharged , but they just did not readmit her after her bed hold expired. She stated, R2 was not appropriate for this setting and had episodes of physical aggression and sexually inappropriate behavior. She stated, they were unaware of R2's behaviors when they accepted her, but they would not have accepted her if they had known about them. On [DATE] at 11:50 AM, V7 (Social Services Director), stated, R2 did not come back to the Facility, because her bed hold expired. On [DATE] at 12:30 PM, V2 (Director of Nursing), stated R2 had a bad behavioral episode and had to be sent to the hospital. She stated the hospital called for R2 to return, and the Facility stated her bed hold had expired. On [DATE] at 1:48 PM, V6 (Licensed Practical Nurse), stated he remembers R2 blurting out inappropriate things to him sometimes when he walked past the dining room, but did not have much interaction with her until the night she was hospitalized . He stated, She was acting very inappropriately and was out of control. It was nuts. The Facility's Bed Census dated [DATE] documents Room XXX was not occupied. On [DATE] at 1:15 PM V1 (Administrator) stated, there was a bed available for R2 (Room XXX), but they did not allow her to return. The Facility's Bed Hold Guarantee Policy revised [DATE] documents, This facility strives to insure {sic} that each Medicaid resident, who is discharged to an acute care setting or takes a therapeutic leave, has a bed reserved for his/her return. Beds shall be held for 10 days for hospitalization and therapeutic leave for Medicaid recipients and indefinitely for Private Pay residents who elect to pay the charges. A Medicaid resident, whose hospitalization or therapeutic leave exceeds the 10-day bed-hold period, may return to their previous room if available or immediately upon the first availability of a bed in a semi-private room. If the facility determines that a resident who was transferred with an expectation of returning to the facility cannot return to the facility, the facility must comply with 42 CFR, Sec 483.15 (c).

Based on observation, interview and record review, the facility failed to prevent resident to resident abuse for 7 of 8 residents (R23, R37, R41, R42, R44, R45, R49) reviewed for abuse in the sample of 38. This failure resulted in harm based upon the reasonable person concept, as R23, R41, R42, R44, R45, and R49 would have experienced psychosocial harm including fear, anger, and humiliation as a result of physical abuse, since a reasonable person would not want to be physically abused in their home. Findings includes: 1. During the survey from 2/20 through 2/27/24, R44 was residing on the memory care unit. R44's Minimum Data Set (MDS) dated [DATE] documents that R44 is severely cognitively impaired. R44's Resident to Resident Investigation entitled Investigation of possible Neglect/Abuse form, dated 3/4/23, documents R44 was convinced that R42 is his wife. The Investigation documented that both reside on the dementia unit. The Investigation documented R44 became agitated at R42 grabbed her wrist and then slapped her. The Untitled Follow up to the initial report documents R44 and R42 reside on our memory care unit. The Follow-up report documented R44 was convinced that R42 was his wife, and he wanted her to leave with him. The report documented R44 grabbed her wrist, and when she refused to go, R44 slapped her in the face. The report documented the nurse assessed R42, and she had no bruising or injuries to face or wrist. The report documented In conclusion the QA (Quality Assurance) team implemented a new intervention that the residents are to remain apart. R42's MDS dated [DATE] documents R42 is moderately cognitively impaired. R42's Behavioral Care Plan dated 1/1/24 documents Resident will have a stable, safe environment with routine scheduling of activities. The Care Plan document to Monitor for signs and symptoms of fatigue or agitation. R44's Incident investigation form dated 4/19/23 documents a resident-to-resident altercation occurred on 4/18/23. The form documented CNA (Certified Nursing Assistant) heard a slap. (R44) states (R42) slapped him, R44 slapped back. Must keep residents apart. Must have staff in the common area. Immediately separated. V23's (CNA) written statement dated 4/18/23 documented I heard (R44) and (R42) arguing. She was calling him names because he bumped into her walker. I went to break them up and before I got in there, I heard a slap and seen (R44) standing over (R42). (R44) stated that she hit him, so he hit her back. The follow up to the initial report, dated 4/19/23 documented In conclusion, the QA team implemented a new intervention that the residents are to remain apart from each other and staff must be present in common areas at all times. 2. R44's follow-up report, dated 5/8/23, regarding the incident on 5/3/23, documents I was reported by the nurse and staff that (R44) wandered into (R45) room. She (R45) then yelled at him (R44) to get out. Staff heard altercation and ran to the room. Upon entrance both residents were hitting each other and yelling. Staff immediately separated them. Upon assessment the nurse noted scratches on both resident's arms. After redirection no further incidents occurred. R44's Nurse's Note, dated 5/3/23 documented Was notified by staff that he heard resident yelling. (R44) wanted resident out of her room. CNA separated residents (and) notified me. Skin assessment done. The Note documented 3 x 1.5 purple bruise L (left) forearm, 1.5 x 1 purple bruise to L forearm, 4.5x3.5 purple bruise L forearm, 2 x .5 purple bruise top left hand, 1.5 x 1 purple bruise to left hand and 2 x 1 purple bruise top of left hand. R45's Nurse's Note, dated 5/3/23, documented Was notified by staff that he heard yelling for (R44) to get out of her room. CNA separated residents and notified the nurse skin assessment done. Resident has 1.x .2 scratch to top of left hand, 1.5 x .5 bruise to left hand (and) 2 x 2 bruise to top of left hand. R45's MDS dated [DATE] documents R45 is severely cognitively impaired. R45 Behavioral Care Plan dated 2/17/24 documents R45 has behavioral disturbances and cognitive deficits. R45's Care Plan Intervention documents Remove resident from situations that are causing anxiety and observe for cues of agitation. 3. R44's Initial Report, dated 7/7/23, regarding incident date 7/6/23 documents There was a resident-to-resident altercation between (R44) and (R41). The report documented Both residents showing aggressive behaviors. (R44) had his hands around (R41) neck, and (R41) scratched (R44). R44's Quality Care Reporting Form, dated 7/6/24, documents scratches to hand, arm, face. R41's A.I.M for Wellness form, dated 7/6/23, documented Was called to TV room when heard screaming. When I got in, I witnessed the other resident hovering over resident with hand on neck. Residents were separated calmed down. The report documented there was redness on R41's neck. R41's MDS dated [DATE] documents R41 is severely impaired for daily decision making. R41's Behavior Care Plan dated 12/2/23 documents residents have behavioral disturbances and cognitive deficits. R41's Goal is resident will have stable, safe environment with routine scheduling of activities to decrease. The Care Plan goal documents Interventions: remove resident from situations that are causing anxiety and observe for cues of agitation. 4. R44's Incident Investigation Form dated 1/28/24 at 3:00 PM documents V25's (CNA) Interview as I was standing in the doorway of the sitting room on the Dementia Unit. (R44) walked by and was heading to the couch to sit by (R23). (R23) then moved the walker next to her in (R44's) way so he couldn't sit down. (R23) stated b**** f*** you. He tried to move the walker out of the way, but she moved it back in front of him. (R44) then threw the walker and placed his left hand on (R23) throat. I immediately stepped in between them and pulled his hand off her throat. He then tried to slap her, while I was pulling him away stated I'm gonna get ya I took (R44) to the dining room to redirect him and immediately notified the nurse. R44's Psychiatry Note dated 1/29/24 documents Chief Complaint: Patient stated I'm fine. Per staff the patient attempted to strangle another resident. He has a documented history of Major Depressive Disorder, General Anxiety Disorder, and Dementia with behaviors. He denies feeling depressed or hopeless. Physicals and verbal aggression. R44's medications are Depakote 500mg (milligrams) QD (every day), Escitalopram 15mg QD Ativan 1 mg at 6:00 PM. R23's MDS dated [DATE] documents R23 is severely cognitively impaired. R23's Behavioral Care Plan dated 2/15/24 documents Resident will have a stable, safe environment with routine scheduling of activities to decrease behaviors. On 2/22/24 at 3:05 PM V23 (CNA), stated, Sometimes he (R44) is sweet and helpful with other resident's other days he is easily agitated. We try to redirect and get him away from other residents. We sometimes get him a new staff and that helps get him away from other residents. He has 15-minute monitoring and also behavior charting. On 2/23/24 at 9:35 AM V14 (CNA) stated, He (R44) has behaviors, but his behaviors are more spread out now. He can be a handful. 45947 5. R49's Face Sheet documents R49 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and dementia. R49's MDS dated [DATE] documented R49 was severely cognitively impaired and required supervision with ambulation. R49's Care Plan starting 7/26/23 documents, Impaired cognition as related to Alzheimer's/Dementia. R49's Care Plan does not address abuse. R37's Face Sheet documents R37 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, unsteadiness on feet, and other lack of coordination. R37's MDS dated [DATE] documented R37 walked with supervision. R37's cognition was not evaluated. R37's Care Plan starting 10/19/22 documents, Resident may display ineffective coping or overt behaviors due to PTSD (Post-Traumatic Stress Disorder) diagnosis. R37's Care Plan does not address abuse. The Facility's Initial Report sent to the state agency on 9/22/23 at 7:10 PM documents R37 and R49 were involved in a resident-to-resident altercation. The Report documented there were no injuries, the residents' physicians and families were notified, and an investigation was initiated. V13's (Activities Director) Witness Statement dated 9/22/23 at 7:30 PM documents, In the doorway of nurses station on (Memory) unit, at 7:00 PM, (R37) was walking down the hallway from his room without his walker, so I walked to his room and got it for him. He was agitated and yelled this is your fault. (R37) then started walking with walker, and aggressively jerking his walker around. (R37) was screaming about his wife. (R49) then walked from the dining room and put his hand on (R37)'s shoulder and said, Hey bud calm down. (R37) yelled I [sic] not going to f******* calm down. (R49) then put both of his hands on (R37)'s chest pushing him down. (R37) landed on his buttocks. On 2/21/24 at 12:23 PM, V13 (Activities Director) stated she witnessed the incident between R49 and R37. V13 stated, Basically, (R37) was agitated and yelling and cussing at me, trying to leave (the locked unit). I was trying to calm him down. We had called his wife and tried other things to calm him down. He was standing by the nursing station when (R49) came up and said, 'Hey, [NAME] .Calm down, Bud. It's not that serious.' (R37) reacted by yelling and screaming and continuing to cuss. (R49) pushed him, trying to be protective of me, I think. I think (R37) was blaming me for his wife not coming down here. (R37)'s butt hit the ground, but he did not hit his head. He didn't express pain but was still irate. I stood in between them blocking them (from each other) until another staff member came to help me separate them. (R49) went to the TV room, and (R37) refused to get up. The Facility's Final Report sent to the state agency on 10/31/23 substantiated the abuse, documenting, Investigation revealed (R49) did push (R37) down onto his buttocks. On 2/23/24 at 10:40 AM, V1 (Administrator) stated she expects the Facility to follow its abuse policy. The Facility's Abuse Prevention Program Policy revised 11/28/2016 documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. This facility is committed to protecting our residents from abuse by anyone including but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individual. Abuse is the willful injection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. An adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof.

Based on interview, and record review, the facility failed to prevent resident to resident sexual abuse for 2 of 3 residents (R2 and R3) reviewed for abuse in a sample of 7. This failure resulted in harm as a reasonable person would not engage in sexual encounters without the decisional capacity to do so. Findings include: 1.) R2's Physician Order Sheet, (POS), dated October 2023 document, a diagnosis of cerebral atherosclerosis, vascular dementia with other behavioral disturbances, hypertension, Alzheimer late onset, major depression, and severe with psychotic symptoms. R2 was also taking Quetiapine fumarate 25 mg once daily in the afternoon and two 50 mg tablets by mouth of Quetiapine at bedtime. Quetiapine is an Antipsychotic medication. R2's baseline Care Plan dated, 8/28/2023 document, R2 is alert to self, for bed mobility she is dependent, with locomotion walks with walker, toileting she is an assist of one and uses pull up briefs. For ambulation, she is independent, she has poor safety awareness, wanders, and uses psych medication. R2's Care Plan with a goal of 2/2/2023, documents R2 has impaired cognition as related to Alzheimer disease/Dementia. R2's Care Plan does not address abuse. R2's Minimum data Set, (MDS) was not available to review, due to the facility's electronic system being hacked. R2's Elopement assessment dated [DATE], document, R3 is at risk for elopement, has poor decision-making skills, inability to identify safety needs and has severe mental illness. The form also documents visual checks every 15 minutes. R2 was admitted to the facility on [DATE] and was admitted on Hospice Care. R2 was admitted to the Dementia Lock down unit. On 10/31/2023 at 2:44 PM, V1 (Administrator) stated, (R2) and (R3) are both on the Dementia Unit, it is a locked unit. They are both severely impaired for decision making. A staff room found (R2) in (R3's) room and she did not have any pants on, (R3) had his genitals in his hand. We put both residents on one on ones and we are monitoring. This is the first time I am aware of any sexual nature between them. They had held hands in the past but that is it. R2's Incident Report with the date of incident of 10/20/2023, at 5:29 PM, documents, Alleged inappropriate physical contact between residents reported. No injuries reported. Investigation initiated. Final report to follow. R2's Nurse's Notes dated, 10/20/2023 at 5:30 PM, On 5 PM, this nurse was alerted by aide that resident was in male resident ('s) room with (adult briefs) off and pants off. Resident lying in male resident('s) bed undressed with fully dressed male resident sitting next to her. Both residents immediate separated. Skin assessment performed also, no signs or symptoms of injury, nor redness, no swelling. Resident alert to self with confusion per usual and unable to state incident. Administrator immediately contacted. Also reported to facility management in which incident was further addressed. Resident is currently on one on ones and monitoring. No signs or symptoms of distress or discomfort observed. Care ongoing. R2's Progress Notes dated, 10/20/2023 at 5:45 PM, Call placed to family to report incident of resident in another resident's room (male resident) with (adult brief) and pants down. Head to toe assessment completed by this writer and another nurse. No trauma noted. Administration is aware. On 11/2/2023, at 11:27 AM, V10 (Family of R2) stated, I was notified on Friday from a Nurse, I think it was (V8 Licensed Practical Nurse/LPN). She told me they had found my mom naked from the waist down with a man, but they could not tell me his name, because of HIPPA. My mom is very confused, when I come to visit her, she thinks I am her mom. She thinks every man she meets is her husband. The Nurse said my mom was beside herself when they found her. When I asked more details and what she meant by 'beside herself' and if she was 'beside herself', because she got caught or because she is upset. The Nurse would only say that she did not feel my mom initiated it. When I called the Administrator the next day, I got an entirely different story. This frustrates me because the Dementia Unit is not that big. This should have never happened. I do not put the blame on the man or my mom, but when you put your mom in a locked Dementia Unit, you don't expect to get a call telling them your mom is 'beside herself' and staff found her naked from the waist down with another man. The Administrator was trying to tell me they were being supervised and were only left alone for 10 minutes, but that cannot be true, because it takes my mom 20 minutes to get her clothes off. I just felt like (V1) was trying to cover herself and the facility and was not taking any responsibility. V1 told me I could take my mom someplace else. There are not a lot of locked Dementia Units in this area. It was very upsetting to me to say the least. I just am not sure if my mom was taken advantage of and feel like things should have been put in place to protect her so nothing like this could happen to her or any other female resident living in the facility. I came to visit my mom the next day and her dementia is so bad she could not tell me anything and had forgotten all about it. Statement by V9 (Certified Nursing Assistant/CNA), dated 10/23/2023 documents, I walked into (R3's) room and (R2) was laying on her back on the bed her pants pulled down. (R3) was standing at the end of the end of the bed fully clothed but, had genitals in his hand. I stated, 'What are you doing here' (R3) replied 'I am not doing anything. I was readjusting myself.' (R2) stated, 'We are just finishing up here.' I immediately notified the Nurse of the situation. On 11/2/2023 at 4:31 PM, V9 (CNA), stated, I was getting everyone up and ready in the dining room. That's when I noticed (R2) and (R3) were not there. (R3's) door was closed and I knocked and when I opened the door (R2) was in his bed without any pants on and (R3) had his genitals in his hands. I asked what is going on here and (R2) stated they hadn't finished yet. This is the first time I have ever seen (R3) do something like this. They normally like to sit together, but I have never seen them hold hands, kiss, or anything like that. (R3) seemed flustered. I immediate went and got the Nurse. 2.) R3's Physician Order Sheet document, he is a [AGE] year-old male. R3's POS also documents, a diagnosis of Early onset dementia with moderate severity. No other diagnosis was documented for R3. R3's Nursing Summary dated, 10/12/2023 document, he has aggression and agitation. He is alert and oriented x 3, with moderate impaired decisions. He is verbally and physically abusive and he is on the dementia care unit. He is independent on his activities of daily living, continent of bladder and bowel and walks independently. R3's Elopement assessment dated , 8/29/2023 document, R3 was low risk for elopement. The form also document the IDT (Intradisciplinary Team) has reviewed the resident's capabilities, needs and preferences and has determined resident is not at risk of leaving home unattended. R3's Nurse's Notes dated, 10/20/2023 at 5:35 PM, At 5 PM this nurse was alerted by aide that resident had female resident in his room with her brief/pants off. When this nurse arrived to his room, he was sitting upright fully dressed with female undressed and lying in his bed. Both resident immediately separated and assessed. Both currently being closely monitored. Incident reported to administrator and management in facility. R3's Nurse's Notes dated 10/20/2023 at 5:45 PM, Called Power of Attorney about resident having a female resident in room with pants down. Both residents found with their pants down by Certified nursing assistants. On 11/2/2023 at 1:48 PM, V11 (Medical Director) stated, I am not familiar with the residents at the facility the NP (Nurse Practitioner) might have more insight, because she sees them more than me. As far as a Locked Dementia Unit it is tricky, because sometimes if you take a resident off the unit, then they become an elopement risk, normally I would expect residents on the Locked Dementia Unit to have been an elopement risk and have a dementia diagnosis. The two biggest groups of sexually transmitted diseases are teenagers and the demented elderly patients. I could understand how a family could be upset when there are sexual relationships going on in the nursing home. The key is there any psychological damage from the encounter? It is not always easy to determine this because of the memory issues. We can't always make a generic judgement. The questions we must ask ourselves is how we prevent this and how do we keep this from occurring. On 11/2/2023 at 2:32 PM, V12 (NP) stated, If a resident is on the locked dementia unit I would not expect them to be able to make appropriate choices and possess reasonable decision-making abilities for life decision. That is usually why they are on the unit because of their inability to make good decisions. On 11/2/2023 at 4:40 PM, V8 (LPN) stated, I was passing medications and the aid (V9) came and got me and told me (R2) was in (R3's) room and they were both undressed and (R3) was on top of (R2). I immediate came to the room and when I entered (R2) was laying in the bed and did not have any pants on. (R2) is very confused and sometimes she can't not verbally tell you what is going on. When I entered the room, I asked what happened and (R2) said we were just finishing and then would not say anything else. I separated them and did an assessment on (R2). After the incident she appeared anxious and upset. I remember seeing them earlier in the room with the couch and (R2), (R3) and (R7) were all sitting together on the couch and (R3) was kissing both on the forehead but (R7) got up and walked away. After (R7) left I think (R3) started fixating on (R2). I never saw them together in a sexual nature before that day. The Abuse Prevention Policy with a revision date of 11/28/2016 documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriations of resident property, and exploitation as defined below. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to required, to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect, or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment.

Based on interview and record review, the facility failed to provide supervision to prevent falls for 1 of 7 residents (R22) reviewed for falls in the sample of 24. This failure resulted in R22's multiple falls sustaining fractures of left radius and pelvic fractures on 2 separate occasions. Findings include: R22's Face sheet documents admitted [DATE]. R22's Cumulative Diagnosis Log dated 10/1/2015 documents diagnosis of Dementia with Behavioral Disturbances, Unspecified Psychosis, Parkinson's, Fahr's Syndrome, Osteoarthritis, Seizures. R22's Minimum Data Set (MDS) dated [DATE] documents R22 is severely cognitively impaired, requires extensive assist with walking in room, walking in corridor, transfers, and toilet use. R22's MDS also documents balance is not steady, only able to stabilize with staff assistance for walking and all transitions. R22's fall risk assessments dated 7/7/2022 documents R22 has a fall risk score of 17. R22 is at high risk for falls. The facility fall log documents R22 sustained falls on 8/3/2022, 11/4/2022, 12/3/2022, 12/4/2022, 12/20/2022, and 1/7/2023. R22's A.I.M (Assess, Intercommunicate, Manage) for Wellness note, dated 8/3/2022 at 11:15 AM, documents R22 was found in her bathroom on the floor. R22 complained of pain to left elbow. R22's hospital x-ray results, dated 8/3/22, document a non-displaced fracture of the left radius. R22's QA (Quality Assurance) Progress Notes, dated 8/4/22, documents root cause of R22's fall related to poor footwear and cluttered room. R22's fall risk assessments dated 11/4/2022 documents R22 has a fall risk score of 19. R22 is at high risk for falls. R22's MDS dated [DATE] documents R22 is severely cognitively impaired, requires extensive assist with walking in room, walking in corridor, transfers, and toilet use. R22's MDS also documents balance is not steady, only able to stabilize with staff assistance for walking and all transitions. R22's A.I.M for Wellness note, dated 12/3/22, documents a fall with R22 found on her hands and knees. R22 stated she was eating and slid out of bed. No injury noted. R22's A.I.M for Wellness note, dated 12/4/22, documents housekeeper found R22 on floor in bedroom. R22 had no concerns. R22's QA Progress Note, dated 12/5/22, documents QA team review of recent fall 12/3/22 when R22 slid out of bed while eating at the side of the bed. Intervention: in-service staff that R22 is to eat meals in chair. R22's A.I.M for Wellness note, dated 12/20/2022 at 6:30PM, documents the nurse heard R22 fall in room, unwitnessed. R22 was sent to the local hospital for evaluation. R22's hospital records, dated 12/20/22 document diagnosis of posterior pelvic fractures. R22's care plan updated 1/7/2023 documents R22 has risk factors that require monitoring and interventions to reduce potential for self-injury related to fall. Risk factors include Diagnosis of Fahr's Syndrome, Osteoporosis, seizures, adverse side effects to medications, uses of assistive devices, incontinent episodes of bowel and bladder. Interventions include: review quarterly and as needed, insure that adaptive devices-walker/cane/wheel chair within reach and in good repair, encouraged assist placement of proper nonskid footwear, observe for unsteady/unsafe transfer or ambulation and provide stand by or balance support as needed, monitor for signs of fatigue during ambulation, notify MD (Medical Doctor) of any injuries, right half rail up, in-service staff that (R22) is to eat in chair, therapy evaluation, medication review, dining room encouraged for meals. On 1/26/2023 at 9:00AM, V4 (Social Services Director) stated, The reason (R22) fell was usually due to her self-transferring and not using the call light. Now we are checking her more frequently. (R22) is being brought to the dining room for meals and not eating in her room. On 1/26/2023 at 9:10AM, V3 (MDS Coordinator) stated, (R22) seems so much better now that she is going to the dining room. It has really helped her cognition. On 1/26/2023 at 9:30AM, V9 (Certified Nursing Assistant/CNA), stated, (R22) goes to the dining room now for meals. She doesn't take a room tray anymore. She wasn't using the call light to get up. I also try to get her to activities or the television room after she eats. Sometimes she will agree to that and sometimes not. We really watch her close. On 1/26/2023 at 10:20AM, V10 (Nurse Practitioner) stated (R22)'s falls seemed to be around breakfast times. She would get up and lose her balance. The staff has been good to check her frequently and take her to eat in the dining room. The Facility's undated Fall Prevention policy and procedure documents, Policy: To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. (Facility corporate) has established a visual alert system to check those at risk.

Based on interview and record review, the facility failed to safely secure residents in the facility van during transport for 1 of 4 residents (R2) reviewed for accidents in the sample of 4. This failure resulted in R2 falling from her wheelchair during transport, sustaining a deep forehead laceration, fractured nose, and fracture of the neck and spine. Findings include: R2's Face Sheet, undated, documents R2 has diagnoses of Post subarachnoid Hemorrhage and seizure disorder. R2's Minimum Data Set (MDS), dated [DATE], documents R2 is moderately cognitively impaired and requires extensive assistance, one-person physical assist with transfer and locomotion off unit. It also documents mobility devices, wheelchair. R2's Care Plan, dated [DATE], documents R2 has a self-care deficit-needs supervision and/or assist to complete quality care and/or poorly motivated to complete Activities of Daily Living (ADL's) related to Cerebrovascular Accident (CVA), Subdural Hematoma (SDH), Diabetes Mellitus Type II (DM2). Resident requires extensive assist of 1 staff for bed mobility, transfers, toileting, dressing and hygiene. Uses wheelchair as assistive device. R2's initial report was submitted to the Illinois Department of Public Health (IDPH) on [DATE] and documented the incident occurred on [DATE]. The Initial Report documents Alleged motor vehicle incident in company van. Investigation initiated. Final report will be sent. The Initial Report documented R2 received a laceration and fracture. The Incident documented that R2 was hospitalized on [DATE] at 1:00 PM. A final report was submitted to IDPH on [DATE], and documents on [DATE], R2 was in the company van attending an appointment to obtain the COVID booster. The final report documented V4 (Van Driver/Certified Nurse's Aide) was at an intersection when the light turned yellow, and she decided to take caution and stop. The report documented The resident (R2) fell out of chair onto van floor and hit her head. 911 were call to the scene and the resident was transported to the hospital. Upon my investigation, the driver and passenger, V3 (Certified Nurse Assistant/CNA), both stated that the resident was buckled into the van and was seated next to a friend talking. The driver (V4) replicated how and where the resident was positioned and buckled in. In conclusion, the driver (V4) was suspended pending investigation. R2's Progress Notes, dated [DATE] at 1:00 PM, documents Writer received phone call from V4 (CNA) in transportation. (V4) state resident was being transported via Emergency Medical Services (EMS) to emergency room (ER) after sustaining a laceration to forehead after falling forward out of wheelchair during transport. Writer notified Administrator, DON (Director of Nursing) and V7 (Power of Attorney/POA). R2's Investigation report done on [DATE] at approximately 10:00 AM, documents an interview with V4. R2's Investigation documented that V4 stated there were 4 people in the van including her, V3 (CNA), R1, and R2. The Report documented they went to (name of pharmacy) in a local town to get COVID vaccines for both residents (R1 and R2). The Investigation documented V4 stated the light turned yellow, and the driver (V4) applied brakes to stop at the intersection. The Investigation documented that V4 stated she had transferred R2. The Investigation Reported documented The time was approximately 10:50 AM, when the resident (R2) fell from wheelchair to the floor hitting her head and creating a large laceration on her forehead. 911 was called and local police and ambulance showed up. Resident (R2) was transported to a local hospital from the scene. Upon return (V4) recreated the scene of how the resident (R2) was loaded into the van with Administrator (V1) and Maintenance (V8). It was noted that she (V4) did not have the resident (R2) secured in the proper position or equipment. R2's Hospital Emergency Department record from [DATE] at 2:45 PM, documents R2 had a non-contrast head Computerized Tomography (CT), and it documented chronic left extra-axial, extradural fluid collection that is stable from prior and thin strip of hyper density also stable from prior exam consistent with postsurgical changes. The CT also noted a comminuted minimally displaced fracture of the anterior nasal bone as well as left frontal scalp hematoma. CT of the cervical spine shows anterior inferior nondisplaced cervical vertebra (C2- the axis is the second vertebra of the spine) fracture and posterior vertebral body fracture with extension to the bilateral C2 pedicles (the short portion of bone connecting the posterior elements with the vertebral body), minimally displaced left C2 transverse process fracture (a break in one or more of the wing-like bones on the right and left side of each vertebra in the spine.) CT of thoracic spine shows nondisplaced right T1 (the first of twelve vertebrae of the thoracic spinal column) transverse process fracture (type of spinal fracture). Scalp laceration, nasal bone fracture, and bilateral subsegmental PE (Pulmonary Embolism) without shortness of breath clinically. It also documents R2 has a past medical/surgical history of Prior left subdural hemorrhage (Status Post (s/p) left decompressive hemicraniotomy (a brain surgery that removes a portion of the skull) on [DATE] and [DATE], Cranioplasty (a surgical operation on the repairing of cranial defects caused by previous injuries or operations, such as decompressive craniectomy) on [DATE]). On [DATE] at 12:10 PM, V3 stated she was in the van when the incident happened with R2. V3 said she wasn't the staff member who secured R2 into the van on the day of the incident, she secured R1 in the van. R1 was sitting in the seat and had a seatbelt that went across her, R2 had a seatbelt that was across her lap. V3 stated they were leaving a store in a nearby town when the light changed and V4 suddenly stopped. V3 stated R2 went over her seatbelt and out of her chair. V3 stated she never looked or paid attention to R2's seatbelt prior to them leaving the store. On [DATE] at 12:20 PM, R1 said V4 went to make a left-hand turn and when she did R2 flew out of the wheelchair. R1 stated when R2 fell out of her wheelchair she hit her head on the metal hardware on the floor that is used to buckle in another wheelchair. R1 said R2 had a big gash on her forehead and R2's nose was bleeding. On [DATE] at 2:02 PM, V4 stated she was driving back from an appointment, when the stop light turned yellow, she said applied the brakes, the van didn't feel like it was going to stop, so she pushed a little harder to stop, and when she turned around to check on the residents, R2 was on the floor of the van. On [DATE] at 10:11 AM, V1 stated after the incident she (V1) and V8 (the maintenance man) recreated the entire incident of what happened on that day. She said she made V4 take her out to the van and show her (V1) exactly how she (V4) secured R2 in the van. On [DATE] at 11:50 AM, V1 (Administrator) stated V4 told her that R1 wanted R2 to sit right next to her in the van. V1 said that is not possible to do correctly. V1 said there are two stations for the wheelchairs to go. V1 said you can place a wheelchair in station 1 and secure the wheelchair by using the hooks that are located on the track up front and secure the back of the wheelchair by using the hooks that are in the middle of the van and you would use the lap seatbelt that is in the middle of the van. V1 said if you use the second station you would secure the front of the wheelchair by using the second set of hooks on the middle track and you would use the hooks at the back of the van to secure the back of the wheelchair and use the lap seatbelt that is in the back of the van. So V1 had V4 recreate the incident using herself (V1) in place of R2. V1 said V4 positioned her (V1) on the second set of tracks (which is located in between wheelchair station one and wheelchair station two). V4 used the hooks from the first set of tracks to secure the front of the wheelchair, and the hooks from the back set of tracks to secure the back of the wheelchair which made the wheelchair secure. Then V1 said when V4 placed the lap seatbelt on her (V1) she used the seatbelt that was located on the second (or middle) set of tracks and that made the lap seatbelt have too much slack. V1 said with the seatbelt in this position she was able to throw herself out of the wheelchair. V1 stated when she was placed in the van correctly and secured correctly, she was unable to get out of the wheelchair. On [DATE] at 11:00 AM, V1 said she would expect the staff that are transporting to use the proper labeled equipment for the station to secure the resident in the van. On [DATE] at 11:05 AM, V8 (the maintenance man) stated V4 showed V1 and himself how she buckled R2 in her wheelchair the day of the incident. V8 stated the way V4 showed them (V1 and V8), V4 had buckled R2 half in one wheelchair station and half in the other wheelchair station. V8 said the chair was secured but the lap belt would have been down further on her thighs/knees, which wouldn't prevent the body from traveling. V8 said based on what V4 had told him on how she secured R2 in the chair the lap belt was to slack and not secured properly on R2's hip bone. V4's Driver's license documentation was reviewed on [DATE] at 10:45 AM, and documents V4's driver's license expired on [DATE]. On [DATE] at 10:20 AM, V4 stated she did get her driver's license renewed but she was late in doing that. She said the facility doesn't have a copy of her new license. On [DATE] at 10:50 AM, V1 (Administrator) stated she did not know V4's driver's license had expired until in November, the day after the incident with R2. V1 stated V4 came to her and said she needed to bring V1 a copy of her new license. On [DATE] at 2:30 PM, V1 said this incident could have been avoided if R2 had been secured in the van correctly. The Facility Van Usage Policy and Procedure, no date noted, documents Purpose: The purpose of this policy is to establish procedures by which employees formally acknowledge and accept responsibilities of operating a Facility owned van on behalf of [NAME] Health Care. Further, it establishes requirements for enforcement of operating procedures and safe driving practices. Policy: When employees operate a facility owned van, they have inherent responsibilities to care for the vehicle and residents, obey all state and local traffic laws, and abide by established driver operating procedures. This policy is designed to ensure that employees authorized to operate vehicles for the purpose of conducting business and transporting residents for the company will comply with certain conditions. Procedure: To ensure proper van usage: 1 Maintenance measures will be followed: It further documents b. Maintenance checks using the Vehicle Maintenance Check List. 2 Before operating a facility owned van, employees should obtain adequate authorization and comply with the requirements of an authorized employee. a. Possess valid driver's license It further documents e. Complete required van training in-services The policy also documents 3 Employees must practice safe driving procedures and obey the rules of the road when operating a facility owned van. It further documents b. Wear seat belts anytime the vehicle is in motion and require all passengers to wear seatbelts. C. Ensure all residents and wheelchairs are safely secured.

Based on observation, interview and record review the facility failed to implement infection control procedures to prevent the spread of COVID-19 as evidenced by: failing to isolate COVID-19 positive resident from other residents whose COVID-19 status is unknown; failing to identify COVID-19 related symptoms and utilize testing strategies to determine the extent of outbreak; failing to implement required isolation procedures; failing to ensure all staff wear required personal protective equipment; failing to ensure staff conducted required screening and do not work with possible COVID-19 symptoms; and failing to encourage residents to wear source control and socially distance. This failure resulted in an Immediate Jeopardy (IJ) which began on [DATE], when R14 who was COVID-19 positive was placed in a room with R13 whose COVID-19 status was unknown. Of the 17 residents (R1, R2, R5, R6, R8, R9, R11, R12, R13, R14, R16, R17, R18, R19, R20, R21, R22) who tested positive from COVID-19 from [DATE] through [DATE], R13 was hospitalized and R13 expired due to complications from COVID-19. Due to these residents' comorbidities and vulnerabilities, this failure increased their risk for severe illness from COVID-19 and possible death for all 54 residents living in the facility. The Immediate Jeopardy was identified on [DATE]. On [DATE], at 11:10 AM, V1 (Administrator) was notified of the Immediate Jeopardy. The surveyor confirmed by observation, record review and interview that the Immediate Jeopardy was removed on [DATE] but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of in-service training. Findings include: 1.The Facility Surveillance Log Line List documented the following residents tested Positive for COVID-19 on the following dates: R14, R16 and R18 tested positive on [DATE]; R6, R13 and R17 tested positive on [DATE]; R19 and R20 tested positive on [DATE]; R9 tested positive on [DATE]; R8 and R21 tested positive on [DATE]; R5 tested positive on [DATE]; and R1, R2 and R22 tested positive on [DATE]. R11 was not documented but her medical records document she was positive on [DATE] and R12 was positive as well. This is a total of 17 residents tested COVID-19 positive from [DATE] to [DATE]. R13's Hospital Discharge/Death Summary documented R13 was admitted to the hospital on [DATE] and expired on [DATE]. The Summary Documented Patient tested positive for COVID. R13'S State of Illinois Certificate of Death Worksheet, dated [DATE], documents R13's cause of death as Acute Respiratory Failure, [CONDITION(S)], COVID-19 Pneumonia. The Facility Surveillance Log Line List documents on [DATE], V21 (Certified Nursing Assistant/CNA) tested positive for COVID-19. V1 (Administrator) was documented as testing positive on [DATE]. V20 (Social Service) was positive on [DATE]. V22 (Housekeeping/Supervisor) on [DATE]. V11 (CNA)was positive on [DATE]. V27 (CNA) was positive on [DATE]. V24 (Housekeeper Supervisor) was positive on [DATE]. V25 (Licensed Practical Nurse/ LPN) tested positive on [DATE]. V6 (CNA) tested positive on [DATE]. 2. On [DATE] at 10:44 AM, R11 resided in a room that is centrally located on the dementia care unit hallway across from the main dining area. R11 was sharing a room with R10. R11's door was open to the hallway. There was signage on R11's door indicating that R11 was on contact/droplet precautions. On [DATE] at 10:44 AM, R12 resided in a room by self that is centrally located on the dementia care unit hallway across from the main dining area. There was signage on R12's door indicating R12 was on isolation. R12's Lab report with a specimen collected date of [DATE] and reported date of [DATE] documents R12 was positive for COVID-19. R11's Lab report with a specimen collected dated of [DATE] and a reported date of [DATE] documents R11 was positive for COVID-19. R10's medical record was reviewed. There was no documentation in R10's medical record that R10 was positive for COVID-19 although R10 was sharing a room with R11. On [DATE] at 12:32 PM, R11 and R12 were both in the dining room on the dementia unit eating lunch with the rest of the residents. R11 and R12 were seated at their own table but they were not six feet apart from the table of R15. R11 and R12 are currently on contact isolation for COVID-19. R24 was also eating in the dining room being assisted with feeding and R24 was not vaccinated. The weekly COVID-19 Vaccination Cumulative Summary for Residents for Long Term Care Facilities Tracking Worksheet provided by the Facility on [DATE] at 10:03 AM, documents R24 had not received any vaccines. On [DATE] at 12:39 PM, V19 (Licensed Practical Nurse/LPN), stated, (R10 and R11) share a room. (R11) is positive for COVID but (R10) is not positive for COVID. I am not in charge of rooms. I have no idea why (R10) is sharing a room with a COVID positive resident. On [DATE] at 11:02 AM, R11's door was open and R27 walked inside R11's room. R11 was sitting in the wheelchair. R27 entered R11's room and started going through R11's dresser drawers. R27 was touching all contact surfaces, and eventually sat down on R11's bed. R27 was in R11's from 11:02 AM to 11:33 AM. On [DATE] at 11:37 AM, V28 (LPN) stated (R27) should not be in that room. (R11) is on contact isolation but (R27) is not. I am not sure why the door was left open. It should stay closed, so no one comes inside here. I know (R11 and R12) are allowed to eat in the main dining room for this unit, but I am not sure why because (R11 and R12) are both on contact isolation. On [DATE] at 8:03 AM, V2 (Director of Nursing/DON) stated, We have 2 new residents that are positive for COVID this week (R10) and (R33). R10's Lab with a specimen collected date of [DATE] and reported date of [DATE] document R10 was positive for COVID-19. 3. According to the Facility's [DATE] Census Report, R13 and R14 were roommates. R14's Progress Notes dated [DATE] at 2:00 PM, Resident had loose stool. Rapid COVID test done and positive results. (V18 Nurse Practitioner) here and aware. R14's PCR (polymerase chain reaction) COVID test was collected [DATE] and reported on [DATE] and document R14 was positive for COVID-19. There was no documentation R14 was removed from the room which R14 shared with R13 at the time R14 tested positive for COVID-19 on [DATE]. R14's Progress Notes dated [DATE] at 12:00 PM, Seen by (V18), COVID positive PCR. R14's Progress Notes dated [DATE] at 12:00 PM, Isolation continues, COVID positive. On [DATE] at 2:38 PM, V2 (Director of Nursing/DON), stated, (R13) was in a room by self and (R14) became (R13's) roommate on [DATE] according to my census report. R14's POS for February 2022, does not document any contact isolation for R14. R13's Progress Notes dated [DATE] at 11:00 AM, Change in condition reported to (V18 Nurse Practitioner), increased incontinence, sleeping more, hand tremors. R13's Progress Notes dated [DATE] at 9:00 AM, Resident stated (R13) isn't feeling well, loose stools x (times) 1, Respiratory even and non-labored. Alert and orientated able to make needs known. R13's Progress Notes does not document R13 was placed on any type of isolation at that time. R13's Progress Notes dated [DATE] at 9:00 AM, chest x-ray reported to (V18) New order [MEDICATION(S)] 100 milligrams by mouth for 10 days. R13's Progress Notes dated [DATE] at 12:30 PM, Labs reported to (V18 Nurse Practitioner) New order push fluids repeat BMP (Basic Metabolic Panel) [DATE]. R13's Progress Notes dated [DATE] at 2:00 PM, Resident on isolation related possible COVID. Antibiotics related to pneumonia. Stated (R13) doesn't feel well. Poor appetite, cough noted, Physician notified. This was 3 days later after R13's symptoms first appeared. R13's [DATE] physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The POS does not document any contact isolation. R13's Progress Notes dated [DATE] at 11 AM, Isolation related COVID. Continues Antibiotic related to pneumonia. R13's Progress Notes dated [DATE] STAT BMP (basic metabolic panel) ordered for today, Resident alert and orientated able to make needs known. Appetite is better, today 75 % of breakfast. No distress noted. R13's COVID-19 Lab results, collected on [DATE] and results dated [DATE] at 3:23 PM, document Positive [CONDITION(S)]-CoV-2/COVID-19 PCR. R13 remained in a room with R14 from ,d+[DATE] through [DATE] and facility was unaware if R13 was COVID-19 positive during this time. R13's Progress Notes dated [DATE] at 10:31 AM document, POA (Power of Attorney) notified facility that resident had expired [DATE]. R13's Hospital Discharge/Death Summary documented R13 was admitted to the hospital on [DATE] and expired on [DATE]. The Summary Documented Patient tested positive for COVID. On [DATE] at 11:32 AM, V2 (Director of Nursing/DON), stated, We do not track room numbers for COVID positive residents. We do not document names and room numbers only names on the infection control log. I have a room roster and map that I highlight any positive cases of COVID. I am not sure when (R13) and (R14) became roommates. Normally, if a resident is positive then the whole room goes on contact isolation for both people. We have the daily census that we go by. I usually highlight that room, so I know that room is positive for COVID. (R13) was in a room by self and (R14) became (R13's) roommate on [DATE], according to the census report. 4. The Facility's [DATE] Census Daily Report document R9 and R19 were roommates. R19's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R19's Progress Notes dated [DATE] at 6 PM to 6 AM, Resident has a big cough will continue to monitor. R19's medical records do not document any COVID-19 testing was performed for R19 before [DATE], although R19 was experiencing symptoms of COVID-19. R19's medical records also do not document R19 went into quarantine isolation after experiencing signs and symptoms of COVID-19. R19's COVID -19 Lab Specimen Collected date of [DATE] and reported date of [DATE] documents R19 was positive for COVID. R9's [DATE] Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's medical record documents R9 continued to reside with R19 after R19 tested positive for COVID-19 on [DATE]. R9's Progress Notes dated [DATE] at 1:00 PM, Resident has been resting in bed, noted of non -productive cough. Resident (R9) feels fine other than (R9's) cough. R9's Lab Test specimen collected [DATE] and reported [DATE] documented R9 tested positive for COVID-19. R9's POS dated [DATE] at 4:00 PM, documents R9 was COVID-19 positive. R9's POS does not have any order for isolation regarding R9's COVID-19 positive diagnosis. R9's Progress Notes, dated [DATE] at 4:00 PM, documents R9 was positive for COVID-19 on [DATE], which was four days after R9's roommate tested positive for COVID-19. R9's medical record had no documentation R9 was removed from the room when R19 tested positive for COVID-19 on [DATE]. On [DATE] at 3:28 PM V2 stated, If a resident has COVID symptoms then we contact the doctor, and the doctor will tell us to put them on isolation. All isolations should be documented in the patient's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE] at 12:03 PM V1 (Administrator) stated I do not believe that residents who test positive for COVID have to be separated from their roommate because they will automatically both go on contact isolation. The January Census Logs provided by the facility document R9 and R19 shared a room from [DATE] to [DATE]. On [DATE] at 8:49 AM V32 (On Call Physician for the Facility) stated, I would expect the Facility to be following CDC guidelines and recommendations for COVID-19. I would expect residents that are positive for COVID-19 to be separated from negative residents and both to be put on quarantine. We would not want the negative resident to become positive for COVID. By keeping them together the negative has a better chance of getting COVID-19 if they are not separated. If the facility is on outbreak status, I would expect all staff to be wearing N95 mask and eye protection, goggles or face shields. 5. From [DATE] through [DATE] date of exit, the Centers for Disease Control and Prevention (CDC) COVID-19 Data Tracking website documents the Facility's County Community Transmission Rate as High for COVID-19. On [DATE] at 5:10 AM, on the XXX hall, V4 (LPN) was passing out medications and entering residents' rooms on the XXX hall. V4 was wearing a surgical mask only, with no eye protection, face shield, or goggles. V4's mask was not covering her nose. V4 entered all the resident's rooms on the XXX hall with no N95 or eye protection while passing out her medications. On [DATE] at 5:11 AM, V4 stated she did not have any residents on the XXX hall that were positive for COVID-19 and the facility was not on outbreak status for COVID. On [DATE] at 5:12 AM, V7 (CNA) was not wearing any mask/source protection or eye protection and walked from the YYY hall to the XXX hall and back to the YYY hall nurses' station. On [DATE] at 5:13 AM, V7 stated the facility was not on outbreak status and there are no residents in the facility with COVID-19. V7 stated I am not aware of any resident positive for COVID. On [DATE] at 5:14 AM, V6 (CNA) was only wearing a surgical mask with no eye protection. V6 was working the dementia hall and was providing direct patient care to R10. V6 entered R10's room and took incontinent pads inside the room and closed the door. After exiting V6 stated she had cleaned (R10) up. V6 was walking down the hallway on the dementia unit and checking on residents. On [DATE] at 5:15 AM, V5 (LPN) was wearing normal eyeglasses and a surgical mask, but it was not covering her nose. V5 was the nurse for the YYY hall, and she was standing on the dementia unit going from the nurse's area to the activity area where R30, R31 and R32 were sitting then back to the nurse's station area and back into the YYY hall non-dementia area nurse's station area. On [DATE] at V5 stated, I am not aware of any resident in the facility that has COVID, and we are not on any outbreak status. On [DATE] at 5:27 AM V6 (CNA) stated, I just came back to the facility from having COVID. I am working a double shift today. I am not sure if anyone on this hall has COVID. I don't think so though. On this unit, we have a lot of residents that are really active in the middle of the night and early morning. I do not think we are on outbreak status. I just came from being out, so I am not 100 percent sure. On [DATE] at 6:14 AM V1 (Administrator) stated, We are not on outbreak status for COVID. We are testing once a week. We are having residents eat in their rooms, but it is only as a precaution. On [DATE] at 6:30 AM, R23 was in R23's wheelchair on the XXX hallway, and R23 was not wearing a mask. R23 was propelling self in the wheelchair and was stopping to talk to V9 (LPN). R23 was not wearing a mask or maintaining a 6-foot social distance. No staff was offering R23 assistance or reminders to wear R23's mask. There was no isolation precaution signage on R23's room door or PPE available for staff throughout the survey although R23 is unvaccinated, and the facility is on current outbreak status. On [DATE] at 12:33 PM, during the lunch service on the dementia care unit, R10, R12, R24, R27, R28, R30, R31 and R32 were in the dining area. V11 (CNA) was serving food and was only wearing a surgical mask with no eye protection and the mask was not covering her nose. On [DATE] at 12:38 PM, V6 (CNA) was on the dementia, was feeding at the table and was wearing a N95 mask, however, she was not wearing any type of eye protection. On [DATE] at 12:39 PM on the dementia unit, V14 (CNA) was wearing a surgical mask, but no eye protection and the mask was not covering her mouth. V14 was sitting in the dining room while residents were eating their lunch and V14 was charting at a table and was within 6 feet or less from other residents in the dining room including R24, R27, R28, R30, R31 and R32. On [DATE] at 1:42 PM, V15 (CNA) was sitting next to V16 (CNA) at the nurse's station and they were not six feet apart and they were not wearing any type of mask or eye protection while sitting there and talking with each other. On [DATE] at 2:32 PM, V12 (CNA) was on the dementia unit hall which was housing 2 positive cases of COVID-19 and she was wearing a surgical mask that was pushed down to her neck exposing her entire face. V12 was not wearing an N95 or eye protection. At 2:33 PM, V12 stated she was just leaving because her shift was over. On [DATE] at 10:49 AM, V1 (Administrator) stated Our County COVID rate is low today dropped from last week. I do not expect our staff to wear N95 and or eye protection unless they are taking care of a COVID positive resident because our COVID rate is low. V1 was the Infection Control Specialist for the Facility. 6. From [DATE] until [DATE], R11 and R12 on the dementia unit were the only residents on contact droplet isolation for COVID-19. The weekly COVID-19 Vaccination Cumulative Summary for Residents for Long Term Care Facilities Tracking Worksheet provided by the Facility on [DATE] at 10:03 AM, documents the following residents were not vaccinated. R2, R22, R24, R25, R26 and R31. None of these residents were on contact droplet isolation from ,d+[DATE] through [DATE]. On [DATE] at 10:32 AM V2 (DON) stated, We did have some residents and staff test positive for COVID a few days ago but everyone has done their quarantine and we do not have any resident on isolation precautions, and we are not on outbreak status. We test everyone here every Wednesday. Everyone in the facility is tested on ce a week. We do not test twice a week. I do not have any test (results) available for this past week because of the storm the lab was not able to process the samples and they were not any good. We should be getting this week's results sometime on Friday. We were not able to test staff because of the storm last week so I do not have any test for staff or residents for the past 14 days. We do not do any rapid testing we only do PCR test. On [DATE] at 2:15 PM, V2 (DON) stated, Our infection control specialist is no longer working here. We have a new staff member that has taken over the position, but she has only been in the position for 6 days now I believe. She still has to do the training. (V1 Administrator) has the certification for the Infection Control Specialist (ICP). We follow recommendations regarding COVID from (V17 Medical Director) and (V18 Nurse Practitioner.) On [DATE] at 12:10 PM, V2 stated they did not conduct contact tracing. V2 stated, We use the Broad-based approach for our COVID testing. We test immediately, and then each week following. We test every Wednesday and we do not do rapid testing. We do the PCR lab test that usually come back within two to four days. We identify new positives from the labs. 7. On [DATE] at 9:22 AM V1 (Administrator) stated, Staff are to check in with the time clock which will take their temperature and require them to answer COVID questions. If someone answers 'Yes' then the questions will prompt them to see the supervisor either myself or the DON. We will do a rapid test on them and if they are negative then they can work if they are positive then we will send them home. Of course, if they have vomiting then we would automatically send them home. On [DATE] at 9:23 AM V2 (DON) stated, We now have a clock that staff are to use, and it takes their temperatures and ask them some questions. We no longer do the paper version. If staff answer 'Yes' to any of the questions it will automatically prompt them to see a supervisor. We will then screen them and do a rapid test on them. If they are negative, then they can continue to work their shift. The Employee, Vendor Consultant COVID Screening Questionnaire which is to be completed by all people entering the facility undated documents, Please complete upon entrance to the facility and give to the Nurse/DON. In an effort to protect our residents and staff from illness, we are screening all employees, vendors, surveyors, Ombudsman and consultants. New or worsening cough? Sore Throat? Chills or shaking with chills? Pain, GI upset (vomiting or diarrhea)? If you mark Yes to any new onset of a symptom below you must be evaluated by a nurse (Document p2). On [DATE] at 4:03 PM V3 (LPN) ICP in training, stated, I have to go home. I am not feeling well. I think I ate something that bothered me. I am really nauseous. I had weight loss surgery, so I have to be careful. I hope I feel better tomorrow. On [DATE] at 9:06 AM V2 stated, Any staff member with symptoms of COVID will get a rapid test. We document all testing in the COVID tracking log. If they were tested , they are logged in the book. On [DATE] at 9:07 AM, the COVID-19 tracking log was reviewed and does not document V3 was tested for COVID-19 when she was feeling nauseous and left work on [DATE]. On [DATE] at 9:09 AM, V3 was sitting at the nurse's station. V3 stated, I did not test for COVID because I know it was from my surgery. No, I do not have a waiver for not testing. I did not know I needed one. On [DATE] at 10:59 AM, R33 was on the XXX hall, door was open, there was PPE outside of the door. R33 was laying on the bed, eyes were closed. R33's Lab Report date specimen collected [DATE] and reported [DATE] document R33 was positive for COVID-19. On [DATE] at 4:22 PM V26 (Former Infection Control Preventionist) stated, Yes, I worked at the facility as the ICP. It was tough because staff were constantly not wearing masks. I was always trying to get staff to follow basic CDC guidelines. I was having issues with testing, as we were supposed to be testing and I was getting push back from the company because they did not want us to test. We were not testing like we should have been testing and I just could not handle it, so I left. I am now working at another facility, and we are testing here two times a week just like we are supposed to. On [DATE] at 10:14 AM V16 (Local Health Department Infection Prevention Manager) stated, The facility is in outbreak status, and we are in the 'high risk' category, all staff should be wearing N95 mask and eye protection and following all CDC infection control guidelines. It makes no sense for any staff member not to be wearing mask at this point. The facility had two residents test positive on [DATE], two more residents testing positive on [DATE], and then one staff member on [DATE] followed by 3 more residents testing positive on [DATE]. The facility should be testing two times a week and reporting. As of today, I do not have any more information as far as anyone else testing positive, but they have to go 28 days straight without anyone else testing positive before they are out of outbreak status. I would expect the facility to set up yellow and red zones in the facility if they have a positive resident for COVID and set up designated red and yellow areas. When community transmission levels are substantial or high, Health Care Providers (HCP) must wear a well-fitted mask and eye protection while present in patient care areas. HCP are not required to wear eye protection for COVID-19 when working in non-patient care areas (e.g., offices, main kitchens, maintenance areas) when there are substantial or high community COVID-19 transmission levels. HCP should wear eye protection when entering the patient care areas. Unvaccinated staff should be tested twice a week since we are in high transmission per the guidance from the State. (The information the Local Health Department received was not the same information found in residents' medical records. R13 was documented as testing positive for COVID on [DATE]. On [DATE], R12 was documented as positive for COVID.) The Center for Disease Control (CDC) and Prevention Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Home website, updated [DATE], documents, A strong infection prevention and control program is critical to protect both resident and healthcare personnel. Even as nursing homes resume normal practice, they must sustain core ICP (infection control practices) and remain vigilant for [CONDITION(S)]-Co- among residents and HCP in order to prevent spread and protect residents and HCP from severe infections, hospitalization and death. Determine the location of the COVID-19 care unit and create a staffing plan. The location of the COVID-19 unit should ideally be separated from other rooms or units housing residents without confirmed [CONDITION(S)]-CoV-2 infection. Ideally, a resident suspected or confirmed [CONDITION(S)]-Co-C-2 infection should be moved to a single person room with a private bathroom. Ideally the HCP who will be assigned to work only in the COVID-19 care unit. The CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic dated [DATE] document, NIOSH-approved N95 or equivalent or higher-level respirators should be used for: All aerosol-generating procedures, NIOSH-approved N95 or equivalent or higher-level respirators can also be used by HCP working in other situations where additional risk factors for transmission are present such as the patient is not up to date with all recommended COVID-19 vaccine doses, unable to use source control, and the area is poorly ventilated. They may also be considered if healthcare-associated [CONDITION(S)]-CoV-2 transmission is identified and universal respirator use by HCP working in affected areas is not already in place. To simplify implementation, facilities in counties with substantial or high transmission may consider implementing universal use of NIOSH-approved N95 or equivalent or higher-level respirators for HCP during all patient care encounters or in specific units or areas of the facility at higher risk for [CONDITION(S)]-CoV-2 transmission. Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters. Place a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). The patient should have a dedicated bathroom. Facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with [CONDITION(S)]-CoV-2 infection. Dedicated means that HCP are assigned to care only for these patients during their shifts. Only patients with the same respiratory pathogen should be housed in the same room. The CDC Facility COVID-19 Screening Form updated on [DATE] documents, Documents the following questions: Regardless of your vaccination status, have you experienced any of these symptoms in the list below in the past 48 hours; fever or chills, cough, shortness of breath, fatigue, muscle weakness or body aches, headache, new loss of taste or smell, sore throat, congestion, nausea or vomiting, or diarrhea. If you have had any of these symptoms in the last 48 hours, DO NOT physically return to the workplace until symptoms have been improving for more than 48 hours. If you have a medical condition that causes any of these symptoms and you need access to a CDC facility within the next few days, you will need a waiver from CDC's Occupational Health Clinic (OHC). To begin the waiver process, please contact your CIO management officer and ask them to request a waiver on your behalf through OHC. When OHC contacts you, please be ready to email medical documentation supporting your waiver request to ClinicInfo@cdc.gov. Waivers will only be granted in exigent circumstances and only if it is safe to do so. OHC will not respond to waiver requests made by individuals. Fully vaccinated individuals or individuals up-to-date with their COVID-19 vaccines who have symptoms will also require a waiver and should work through their Management Officer. The COVID-19 Control Measures Policy provided by the facility on [DATE] at 1:30 PM, with a revision dated of [DATE] document, To prevent transmission of the COVID-19 Virus and to control outbreaks. In the event of a facility outbreak, all employees must wear an N95 and eye protection when caring for all residents until 14 days have passed with no new cases. For facilities residents in a county where the community transmission level is substantial or high, employees providing services to residents must wear a face mask and eye protection. If residents are out in the facility or in the presence of others, face coverings should be worn if tolerated, regardless of vaccination status. If a resident is unable to tolerate face coverings, then a face shield can be utilized. Employees should screen prior to beginning of shift. If any employee is identified as being ill, ask them to return home and contact their primary physician. Asymptomatic, fully vaccinated residents that have prolonged close contact with someone confirmed positive for COVID-19, should be quarantined for 10 days and tested as above. Educate all employees, if having symptoms or a respiratory infection, fever, sore throat, nausea, vomiting, diarrhea, extreme fatigue, muscle pain, loss of taste and/or smell to not report to work and to contact their supervisor. All staff regardless of vaccination status, should socially distance and wear facemasks during breaks and avoid areas that social distancing cannot occur (i.e. employee area for breaks, conference rooms). If a resident is symptomatic regardless of vaccination status, place in isolation using transmission-based precaution and test as above. Asymptomatic fully vaccinated residents that have had prolonged close contact with someone confirmed positive for COVID-19, must be quarantined for 10 days and tested as above. Doors shall remain closed for residents who have a positive [MEDICATION(S)] or PCR or are suspected of having COVID-19. 8. The Facility's Resident Census and Conditions of Residents form, CMS 672, dated [DATE] documented the facility had a census of 54 residents. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility too the following actions to remove the Immediacy: 1. The facility tracks all infections into the Infection Control log binder along with a map of the building to determine patterns/trends by the DON ongoing basis. 2. Administrator re-trained on proper PPE in resident care areas, s/s (signs and symptoms) of COVID-19 to report, and updated COVID policies per SCC and CDC guidelines by another administrator not associated with facility. Date:[DATE] 3. Facility assigned staff (Minimum Data Set Coordinator) complete Isolation audits ensured by the DON on [DATE] and then ongoing monthly. 4. The facility once notified of a positive COVID 19, residents are immediately placed on quarantine in the designated COVID unit. If they have a roommate, the roommate will be placed on PUI and quarantine and tested (PCR) ensured by Administrator Date: [DATE] and ongoing. 5. We have no residents currently under PUI who are symptomatic, other than two positives in isolatio [TRUNCATED]

Based on observation, interview, and record review the Facility failed provide service/treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in R4's developing an infection in his left eye socket. Finding includes: R4's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's Minimum Data Set (MDS) dated [DATE] document R4 was an extensive assist of one-person physical assist for personal hygiene, including combing hair, brushing teeth, shaving, washing/drying face and hands. R4's MDS also documents R4 has impaired vision and was severely impaired for cognition. On 9/23/2021 at 10:20 AM, R4 was laying in the bed. R4 has a glass prosthetic eye in the left eye orbit. R4's left prosthetic eye was dirty with what appeared as a film covering his eye. On 9/23/2021 at 11:05 AM, V4 (Licensed Practical Nurse/LPN) stated, There was no order to clean (R4's) glass eye. (R4) use to clean it himself with water but he can't do it anymore, so we do it for him. On 9/29/2021 at 9:03 AM, R4 was in his room laying on the bed. (R4) is unable to answer any questions in English as R4 is Spanish speaking. Surveyor asked resident questions in Spanish and when asked in Spanish R4 was able to reply. R4 has a glass prosthetic eye on his left side which appears to have a slimy build up around the opening of the eye. On 9/29/2021 at 9:04 AM, R4 stated in Spanish, My wife (R3) was no longer together. Moved wife a few months ago. Wife here in facility in otra habitacion (other room). R4's wife was not in the same room with R4. R4 stated his wife use to clean and care for his left eye. On 9/29/2021 at 2:01 PM, V9 (R3's and R4's daughter) stated, My mom has taken care of my dad her whole life and now her health is declining, and it has been hard. It breaks my heart. I do not think they are even caring for my dad's glass eye. Nobody seems to know anything when I ask questions. I know with COVID it has been tough, but I know he is supposed to have help with cleaning the eye and the specialist to exam the glass eye at least once a year and I am not sure they are even doing that. On top of that he had an infection in that eye, and I wonder if they are doing what they are supposed to be doing with it. On 9/29/2021 at 2:23 PM, V12 (agency Certified Nursing Assistant) stated, (R4) takes his own eye out. I gave him a washcloth and he washes his face and cleans his own eye with the washcloth. He usually uses the same washcloth for his face and eye. He will wash his face, take out his eye, and then clean his eyeball with the washcloth. R4's July 2021 POS document [MEDICATION(S)] (antibiotic), 2 left eye drops four times a day for seven days. R4's Progress Notes dated 7/18/2021 at 10:30 AM, Resident remains on Med A with skilled therapy, Resident is also on ABT (antibiotic therapy) eye drops. Left eye does have scant amount of green drainage. R4's Progress Notes dated 7/25/2021 at 1:00 AM, Resident remains on follow up related to eye infection. R4's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's Care Plan does not document any care or interventions the facility is doing to address R4's glass eye. R4's Care Plan does not address R4's glass eye. On 10/1/2021 at 3:30 PM, V2 (Director of Nursing/DON) stated, I would expect (R4's) glass eye to be addressed in the Care and the Physician Orders. Honestly, I am not even sure what the proper care would even be for a glass eye I could not say without asking the Physician. On 10/1/2021 at 4:50 PM, V14 (Social Service) stated there were currently no eye vision contractors coming into the facility and they were in the process of trying to obtain one. V4 stated R4 did not currently have any appointments with any eye doctors. On 10/2/2021 at 11:01 AM, V15 (Optometrist) stated, Any resident with a glass eye should clean the eye daily with saline solution and check for protein deposits. Protein deposits will give the prosthesis a dull appearance. Hands should be clean before handling the prosthetic eye. Once a year they need to go to see the Ocularist to make sure everything is good with the prosthetic. If hands are not clean this could easily lead to an infection in the eye. On 10/5/2021 at 1:21 PM, V2 stated there was no policy related to glass eye care.

Based on interview and record review the facility failed to ensure residents receive timely assessment, pain management and medical treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in R2 having at least a 12-hour delay in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Minimum Data Set (MDS), dated [DATE], documented R2 is cognitively impaired. R2's MDS documented she required staff supervision for bed mobility, transfers, walking in room, locomotion on and off the unit and eating. R2's MDS documented she required limited assistance from staff with bathing and dressing. The MDS documented she required extensive assistance of one staff person for toilet use and personal hygiene. R2's MDS documented she was not steady during transitions and walking but was able to stabilize without staff assistance. The MDS documented R2 used a walker. The Facility's Incident Investigation form dated 8/17/21 documented V15's (Housekeeper) account as between 10:30 AM and 11:00 AM, V15 stated she was cleaning rooms on the looking glass unit and R6 was going in and out of other resident's rooms when R6 approached R2's room and tried to shut the door. V15 documented R2 held the door handle on the inside of her room they pulled R2's door back and forth hard enough to hear it slam each time. R2 yelled at R6 to stop. V15 documented a Certified Nurse's Assistant (CNA), or nurse came and got R6 a few minutes later. R2's Physical Therapy (PT) daily treatment note, date 8/18/21 with no time, documented R2 was in bed. The Note documented R2 refused to participate in therapy and demonstrated agitation secondary to voicing right upper extremity pain. The Note documented there was bruising on R2's right wrist and pain and bruising was reported to the nurse. R2's Nurse's Note dated 8/18/21 at 1:55 PM, documented R2 complained of arm pain. Facility's AIM for wellness form dated 8/18/21, documented R2 had complaint of pain to right wrist. The form documented R2 held right arm tight and twisted it at times. The form documented Behavior: aggression and yelling and staff, skin: contusion and bruising started at approximately 12:00 PM, pain was 8/10 (8 out of 10 with 10 being the worst pain). The form documented Nursing note: CNA told this nurse that resident complained of pain to her right forearm, wrist and hand. Assessed arm no bruising at 7:00 AM, bruising appeared at until around 12:00 PM. Resident noted to squeeze arm tight at times. Resident guarding arm and will not use walker, she stated that it hurts too bad to use walker. NP (Nurse Practitioner) and POA (Power of Attorney) notified. NP will visit today to look at her arm. V13, Licensed Practical Nurse (LPN) signed the form on 8/18/21 at 10:30 PM. R2's Nurse's Note, dated 8/18/21, at 4:00 PM documented (NP) here to look at R2's right arm/wrist NO (new order) x ray to rt (right) hand and arm POA notified. There was no documentation the Xray was obtained after Nurse Practitioner saw R2 at 4:00 PM. R2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Use Tylenol as ordered PRN. R2's Nurse's Note, dated 8/18/21, at 10:30 PM, documented arrival at night shift a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's physician's telephone order sheet dated 8/18/21 at 10:30 PM, x-ray right arm due to complaint of pain/discomfort. R2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .) R2's Nurse's Note, dated 8/18/21 at 11:50 PM, documented x-ray here to obtain x-rays (R2) was uncooperative, cursing at tech refusing to position so that x-rays can be obtained CNA and nurse assisted with (R2) screaming and trying to run away from x-ray technician and threatened to slap x-ray technician finally after 20 minutes was able to get x-rays. The Note documented 11:55 PM, documented x-ray technician reported preliminary results showed fracture to right forearm. The Note documented 12:30 AM, call placed to V1, the Administrator after attempting several times and reported findings call placed to ambulance service for transportation to ER (emergency room ). NP called for orders. At 12:50 AM, the resident's POA informed of pending transfer to a local ER. At 1:00 A.M., ambulance here and resident transported on stretcher. Her right forearm was wrapped with ace wrap. Resident was resistant and verbally aggressive. R2's Xray report, dated 8/18/21, documented Impressions: acute, mildly displaced distal ulnar fracture. R2's August 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's PO, dated 4/22/2019, documents Acetaminophen, 325 mg (milligrams), take 2 tables '650 mg' by mouth every 8 hours as needed. R2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's nurse's note dated 8/19/21 at 4:10 AM documented she was readmitted to the facility from the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . No complain of pain or discomfort voiced. R2's Nurse's note dated 8/19/21 at 1:40 PM documented R2 resting quietly in bed. She refused breakfast this morning and ate 100% of lunch. Complaint of right arm pain hurting, administered Tylenol and she has been resting. On 8/31/21 at 1:17 PM V3, Assistant Director of Nurses, ADON, stated she expected staff to contact the x-ray company as soon as an x-ray order is obtained from the NP. V3 stated The standard for an x-ray wait time is four to six hours, but it varies depending on the workload of the x-ray technician. Staff should have followed up on the x-ray after six hours. V3 stated she was aware the x-ray was not done by 10:00 PM and it was then ordered STAT (immediately). V3 stated the memory care/looking glass unit residents have dementia and are moderately to severely cognitively impaired. V3 stated R2 is a resident who cannot express pain on a pain scale, but she can express pain verbally, via facial grimacing and/or guarding the area of pain. V3 stated she expected staff to administer pain medication in a timely manner, document where the compliant of pain was located then reassess the resident for pain during the next interaction with the resident.

Based on interview and record review the facility failed to ensure residents receive adequate supervision to prevent falls for 1 of 3 residents (R2) reviewed for falls in the sample of 9. This failure resulted in R2 having multiple falls and sustaining a 4-centimeter (cm) laceration to her forehead requiring emergency care. Finding include: R2's Physician's Order Sheet (POS), dated August 2021, documented R2 had diagnoses of dementia with agitation, [CONDITION(S)], A-Fib, CAD, and anxiety. R2's Minimum Data Set (MDS), dated [DATE], documented R2 is cognitively impaired. R2's MDs documented she required staff supervision for bed mobility, transfers, walking in room, locomotion on and off the unit and eating. R2's MDS documented she required limited assistance from staff with bathing and dressing. The MDS documented she required extensive assistance of one staff person for toilet use and personal hygiene. R2's MDS documented she was not steady during transitions and walking but was able to stabilize without staff assistance. The MDs documented R2 used a walker. R2's current, Care Plan, undated documented (R2) is at risk for falls relating to use of assistive devices, medication use, history of falls diagnosis of osteopenia. Currently (R2) ambulates independently with wheeled walker to destination at a fast pace. R2's Care Plan Goal, dated 3/11/2021, documents Will have no falls while ambulating thru next review. R2's Interventions, all dated 12/11/2020, document Review quarterly and as needed during daily care and services of resident's plan for safety, giving verbal cues, as needed to gain resident's participation in minimizing risk factors and injury; (R2) ambulates independently with wheeled walker to destination; Assess cognitive deficits and accommodate forgetfulness regarding safely devices and environmental risks; Inform physician of any falls, including report of injuries. Request physician review of medications and conditions during nursing home visit especially after falls. R2's Nurse's Note, dated 7/22/21 at 5:07 PM, documented R2 had an unwitnessed fall with possible head injury. The Note documented Refer to fall report for more details. Facility's AIM for Wellness form, dated 7/22/21, documented R2 had a fall with possible head injury. The form documented Nursing note: (R2) was found on the floor in the looking glass dining room in semi fowlers position guarding the back of her head. (R2) stated I fell and hit my head. No apparent injuries observed. Range of motion and neurological checks within normal limits. (R2) appeared to have been transferring without use of walker. Her physician and family were notified. Tylenol 650 mg (milligrams) was administered for complaint of headache. (R2) was transferred to the local hospital for a head cat scan. The Director of Nurses (DON) was aware. The form was signed at 8:00 P.M. There is no documentation in R2's medical record the facility reassessed R2's risk for falls and implemented progressive interventions to address R2's fall and to prevent her from future falls. R2's Nurse's Note, dated 7/30/21 at 2:00 PM, documented R2 had a fall around 1:30 PM in hallway and the fall was witnessed by nurse. The Note documented R2's vitals within normal limits and no pain was reported. The Note documented R2 did not hit her head. The Note documented Nurse Practitioner (NP) notified and ordered neuro checks per facility protocol. Notified family and DON (Director of Nurse's) of fall. Facility's AIM for wellness form, dated 7/30/21, documented R2 fell when walking with walker. The form documented neuro checks were ordered. The Functional status evaluation documents Falls (more than one), NP (Nurse Practitioner) and family notified (R2) fell with walker just went down did not hit her head. Vitals good. Walked to room with walker. The Form's Nursing note documented Fall in hallway walking with walker, just went slowly down, did not hit her head. (R2) talking after fall wanting to get up. Assist of one and walker to stand. (R2) walked to her room. Notified NP and family. New orders for neuro checks per facility protocol. The form was signed at 2:00 PM. There is no documentation in R2's medical record the facility reassessed R2 for falls and implemented progressive interventions to address R2's fall and to prevent her from future falls. R2's Nurse's Note dated 7/31/21 at 6:40 AM, documented Sent res to ER (emergency room ) due to bump to back right side of head for evaluation sent to local hospital. (R2's) family and DON notified. Left message to call. Administrator notified of resident going to ER. R2's Nurse's Note dated 7/31/21 at 11:30 A.M. documented R2 was back to facility by ambulance. The Note documented NNO (No New Orders.) POA (Power of Attorney) is aware. Facility's AIM for wellness form, dated 7/31/21, documented bump to right side back of head noted by 10:00 PM - 6:00 AM nurse. The form documented R2 was sent to ER for evaluation. The form documented Manage: physician recommendations and/or nursing interventions: send to ER for evaluation. The form was signed on 7/31/21 at 9:00 AM. There is no documentation in R2's medical record the facility implemented progressive interventions to address R2's fall and need for supervision and to prevent her from future falls. R2's Nurse's Note, dated 8/4/21 at 12:28 AM, documented Heard res yell out 'aww' and loud noise coming from room (resident room) nurse ran to room and noted res seated on floor on buttocks bleeding profusely from 4 cm (centimeter) x (by) 0.2 cm laceration to mid-hairline upper forehead pressure and cool compress applied. 12:30 AM call placed to ambulance service to arrange for transport to ER. states pain to bilateral knees but non-compliant and refused to allow nurse to assess moving extremities independently AROM (active range of motion). Res (Resident) crying and yelling wanting to see her mother reassurance given per writer en route to ER call placed to NP and notified of fall with injury and transfer. 12:50 AM POA notified of fall with injury and transfer to ER 12:55 AM call placed to (local hospital) gave report to (Registered Nurse) or res fall and condition on transfer 1:00 A.M. Call placed to (V14, Unit Coordinator) and notified of all the above. 8/4/21 1:30 PM continue on incident follow up (IFU) for fall laceration to mid forehead no signs or symptoms of infection to mid forehead complaint of head pain PRN Tylenol given. Resident walks with walker and reminded to slow down when walking gait unsteady at times. Facility's AIM for wellness form dated 8/4/21, documented R2 fell and sustained a laceration to forehead. The form documented R2 fell three times since mid-July 2021 sent to ER for evaluation. The form documented Functional status evaluation: falls (more than one), behavioral evaluation: danger to self or others, depression, aggression, skin evaluation: laceration, wound 4 cm laceration to mid upper forehead at hairline, pain evaluation: forehead, scalp, knees 7/10 pain intensity with grimacing. The form was signed at 1:15 AM. Facility's Investigation report for skin tears/bruises, dated 8/4/21, documented assistive devices in good working order and without any sharp, rough or torn areas: walker nearby and turned over on its side. There is no documentation in R2's medical record the facility implemented progressive interventions to address R2's falls, need for increased supervision and to prevent her from future falls. On 8/20/21 at 10:54 AM V15 Therapy Director, stated (R2) has declined cognitively and physically over the last 9 to 12 months. (R2) has had a lot of falls and they have worked with her often. She does not always remember to use her walker. Staff are instructed to keep her walker close to her at all times for a visual cue to remind her to use it. On 9/1/21 at 1:30 PM V3 Assistant Director of Nurse's (ADON), stated she feels R2 is falling due to the dementia disease process. V3 stated R2 should not get up by herself and she is often volatile. The Facility's Fall Prevention Policy, revised 11/18/2018, documents Immediately after any resident fall the unit nurse will assess the resident provide any care or treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. The unit nurse will place documentation of the circumstances of a fall in the nurses notes or on an AIM for Wellness form along with any new intervention deemed to be appropriate at that time. The unit nurse will also place any new intervention on the CNA assignment worksheet. Report all falls during the morning Quality Assurance meetings Monday through Friday. All falls will be discussed in the Morning Quality Assurance meeting and any new interventions will be written on the care plan.

Based on interview and record review the facility failed to provide continual abdominal thrusts to open an obstructed airway, failed to initiate CPR (cardiopulmonary resuscitation) once the resident became unresponsive and failed to activate emergency medical procedures per facility policy for 1 of 1 residents (R2) reviewed for CPR in the sample of 8. This failure resulted in R2's aspiration and death. Findings include: The web site, entitled patient.info/doctor/choking-and foreign-body-airway-airway-obstruction-fbao (Foreign Body Airway Obstruction) and entitled Choking and Foreign Body Airway Obstruction (FBAO) written by Dr. Roger Henderson, [DATE], documents, Choking is the physiological response to sudden obstruction of the airways. FBAO causes asphyxia and is a terrifying condition, occurring very acutely, with the patient often unable to explain what is happening to them. If severe, it can result in rapid loss of consciousness and death if first aid is not undertaken quickly and successfully. Immediate recognition and response are of the utmost importance. Choking due to inhalation of a foreign body usually occurs whilst eating. Severe Obstruction - This is indicated by: The victim not being able to breathe or speak/vocalize. Wheezy breath sounds. Attempts at coughing that are quiet or silent. Cyanosis and diminishing conscious level. The victim is unconscious. Choking is a risk whenever food is consumed. FBAO represents a true medical emergency in adults, with a mortality rate of just over 3 % (percent). MANAGEMENT - Adults. In severe obstruction in a conscious patient: Stand to the side and slightly behind the victim, support the chest with one hand and lean the victim well forwards. Give up to 5 back blows between the should blades with the heel of your other hand (checking after each if the obstruction has been relieved). If unsuccessful, give up to 5 abdominal thrusts. Continue alternating 5 back blows and 5 abdominal thrusts until successful or the patient becomes unconscious. In an unconscious patient: Lower to the floor. Call an ambulance immediately. Begin CPR (even if a pulse is present in the unconscious victim). The Adult First Aid/CPR/AED (Automated External Defibrillator) ready reference guide from the American Red Cross (undated), Copyright 2011, page 4 documents, in part, UNCONSCIOUS CHOKING, chest does not rise with rescue breaths. After checking the scene and the injured or ill person: 1. Give rescue breaths, re tilt the head and give another, rescue breaths 2. Give 30 chest compressions. If the chest still does not rise, give 30 chest compressions. TIP: Person must be on firm, flat surface. Remove CPR breathing barrier when giving chest compressions. 3. Look for and remove object if seen. 4. Give 2 rescue breaths. If breaths do not make the chest rise - repeat steps 2 through 4. If the chest clearly rises - CHECK for breathing. Give care based on conditions found, CPR - No breathing. 1. Give 30 chest compressions. 2. Give 2 rescue breaths. 3. Do not stop. Continue cycles of CPR. Do not stop CPR except in one of these situations: You find obvious signs of life, such as breathing, an AED is ready to use. Another trained responder or EMS (Emergency Medical Services) personnel take over. You are too exhausted to continue. The scene becomes unsafe. Facility Policy revised on [DATE] and Reviewed [DATE], documents, Airway Obstruction - Abdominal Thrust Maneuver: It is the policy to maintain a staff trained in the assessment and treatment of [REDACTED]. All employees shall be trained within a reasonable length of time after initial employment and as needed thereafter, in the following procedure for airway obstruction management. 1. Assess for extent of obstruction. If resident is able to speak or cough, or if wheezing is audible, resident may have a partial obstruction--continue to observe. If resident is unable to cough or speak, or is clutching the neck between thumb and index finger, the resident has an obstructed airway. 2. Call out for help. 3. Perform the Abdominal Thrust Maneuver. a. Stand behind the resident. b. Place arms around the resident abdomen between the naval and rib cage. c. Grasp one fist with the other hand and place the thumb side of the fist against the resident's abdomen. d. Press in with quick, forceful inward and upward thrusts. e. Repeat thrusts until the obstruction is relieved or the resident becomes unconscious. The Policy further documents, 6. Should the resident become unconscious, supporting the head and neck, lower the resident to the floor and continue the Abdominal Thrust Maneuver for an unconscious victim. a. Activate the emergency medical service system. b. Open the airway with the head/chin lift. Assess for breathlessness. If no breath, place the ambu bag or shield over the resident's mouth and nose, attempt to administer two rescue breaths. The policy and procedures of the facility are not intended to replace sound clinical judgment in the delivery of health care and are not intended to replace the prevailing standard of care. c. If unable to ventilate, straddle the resident's thighs. d. Place the heel of one hand on the resident's abdomen midline and between the navel and Xyphoid process. e. Thrust inward and upward quickly 5 times. f. Assess for dislodgement of the foreign body. g. Repeat procedure until the obstruction is relieved or the emergency medical team arrives and takes over. 8. Inform the physician and family. 9. Document date, time, and all occurrences in the medical record. R2's Practitioner Order for Life-Sustaining Treatment (POLST) Form, dated [DATE] and signed by the Nurse Practitioner on [DATE], documents in part, B. Comfort-Focused Treatment: Primary goal of maximizing comfort. Relieve pain and suffering through the use of medication by any route as needed: use oxygen, suctioning and manual treatment of [REDACTED]. R2's Death Visit Report (Hospice report), dated [DATE] at 12:00 PM, documents, Significant observations, Interventions and/or comments: Pt (patient) aspirated, [MEDICATION NAME] performed multiple times unsuccessfully. R2's Triage Note, dated [DATE] at 5:53 PM, documents in part, Call Detail: Caller (V12) states that patient (R2) aspirated at dinner. [MEDICATION NAME] given and a 'few chili beans' dislodged, however, pt. went limp and died while [MEDICATION NAME] being given. There is no documentation in R2's medical record the Emergency Medical Service (i.e. 911) was notified. R2's Certificate of Death, dated (MONTH) 03, 2019, documents in part, CAUSE OF DEATH a. ASPIRATION, and the Certificate further documents approximate interval between onset and death being, MINUTES. On [DATE] at 12:12 PM, V16, Certified Nurse's Aide (CNA), stated on [DATE], R2 got up from the meal. R2 started walking past V19, CNA, and R2's breathing was gurgling. V16 stated she left the unit to get the nurse (V12). V12 arrived and started to perform the [MEDICATION NAME] on R2. V12 then stopped the [MEDICATION NAME], left the unit and returned with V14, LPN. V16, CNA, stated V14 started to perform the [MEDICATION NAME] and nothing could be done. V16 further stated that R2 was unresponsive and that both nurses (V12 and V14) put R2 back to bed and then R2 stopped breathing shortly after she was put into bed. On [DATE] at 2:10 PM, V19, CNA, stated she was working with V16, CNA, on [DATE] when she noted R2's cheek bones turning really red, because she was sitting next to V16 at the dining room table. V19 stated the nurse, V12, was on another unit at that time. V19 recalls V12 and V14 performing the [MEDICATION NAME] on R2 and recalls at some point R2 was not breathing, V19 recalls V12 and V14 discussing R2's time of death and who to call. On [DATE] at 2:40 PM, V12, LPN, stated on [DATE] at about 5:50 PM, she was on another unit (Hen House Dining Room) and not on the secure unit where R2 resided. V12 stated V16 and V19 were on the secure unit and that residents were in the dining room finishing up their dinner. V12 further stated R2 was served a regular diet. V12 stated one of the aides (V16 or V19) came to the dining area off the unit to inform her that R2 was choking. V12 stated when she arrived to the unit, she noted R2 with a red face, her respirations were labored, and she was talking (normally non-verbal). V12 stated she performed the [MEDICATION NAME] and might have gotten a little phlegm. V12 said R2 was still standing upright, attempting to walk down the hall, and both CNAs (V16 and V19) were holding onto R2, and she (V12) continued to do the [MEDICATION NAME]. V12 then stated she sat R2 down in a chair and left the unit to get another nurse (V14, LPN). When V12 and V14 returned to the unit, she believes V14 did about 8 thrusts and (R2) didn't have any respirations or any vital signs. On [DATE] at 11:20 AM, V14, LPN, stated when he arrived to the unit he did the [MEDICATION NAME] on R2 and wasn't sure how many thrusts were given, but knows it was greater than 5. V14 further stated R2 then remained flaccid, and not breathing, she remained unresponsive. V14 also stated V16 and V19 moved R2 from the regular chair to a wheelchair and they took her to her room and put her to bed. Nurse notes on [DATE] at 5:50 PM document, Resident respirations decreased, placed resident in w/c (wheelchair) and laid in bed with HOB (head of bed) elevated to make comfortable. Resident a DNR (do not resuscitate) and Hospice. Nurse notes on [DATE] at 6:05 PM document, No respirations or pulse obtainable. V12, LPN, stated on [DATE] at 3:20 PM that (R2) Resident was Hospice, We did not call an ambulance or do CPR. V14, LPN, stated on [DATE] at 11:20 AM, She was a Hospice and DNR, we did not do CPR or call an Ambulance. On [DATE] at 9:34 AM, V1, Administrator, stated the expectation for staff if a resident is choking and not able to get anything expelled during the [MEDICATION NAME] Maneuver, that she would hope they would call an ambulance. On [DATE] at 10:21 AM, V23, Interim Medical Director, stated he would expect the [MEDICATION NAME] Maneuver to be performed on a resident that is choking and for EMS to be summoned. CPR to be initiated should a resident become unresponsive if suspected of choking and no longer breathing. V23 also stated he is aware R2 cause of death being that of Aspiration.

Based on interview and record review, the facility failed to prevent abuse and prevent misappropriation of resident's property for two of three residents (R15 and R42) reviewed for abuse in the sample of 32. This failure resulted in R15 being hit by staff and receiving a bruised eye. Findings include: 1. R15's Minimum Data Set (MDS), dated [DATE], documents R15's Brief Interview for Mental Status Score (BIMS) of 2 indicating R15 has severely impaired cognition. R15's Physician order [REDACTED]. The Incident Report Form-IDPH Notification, dated 9/5/18, documented Resident alleged staff member hit him when he got him up. Resident assessed and facility initiated an investigation per protocol. The Form documented R15 sustained a bruise. The Facility's final letter regarding R15's abuse investigation, dated 9/11/18, documents an allegation of physical abuse involving R15 and V15, Certified Nurse's Assistant, CNA. The letter documented On 9-5-18 at approximately 6:50 AM, staff reported that (R15) had made an allegation that a staff member had hit him. The nurse assessed and noted a red area at the corner of the left eye. The facility initiated investigation per protocol including notification of resident's physician, family and suspension of the employee. The facility notified the local police department. The nurse reported that she approached (R15) about getting dressed for the day. The nurse reports (R15) stated, 'Why did you do that to me? I've never been treated this way?' The nurse noticed a red area at the corner of the resident's eye. The letter documented During the investigation, V11(CNA), stated that V15 ( night shift CNA) had given her report that (R15) had been combative during morning care. According to V11, day shift CNA; V15 (CNA) reported that she had to f*** him up. V11, reported to the nurse and they contacted the Administrator to report. The letter documented that V15 denied the allegation and denied having physical contact with R15. The letter documented In conclusion, through investigation, the facility was able to substantiate the allegation and (V15) was terminated. R15's Nurse's Note, dated 9/5/18 at 6:30 AM documented I opened the door, the res (resident) (R15) was sitting in his w/c (wheelchair) facing the window. I went et (and) got the res et brought him to the sink to see if I could get his clothes on him et the res (R15) started yelling @ (at) me again that he was treated so bad et that he was punched. I kneeled down to talk to him et @ this time I noticed the res left eye was swollen et had a gray color to it so I called the CNA (V11) into the room to see the res (R15) eye. The res cont (continued) to say he was punched in his eye. The Local Police Department Offense/Incident Report, dated 9/5/18, documented the police officer took a report of aggravated battery of victim over 60. The report documented V1 ( Administrator), advised she observed a black and blue mark under the left eye of (R15). I met with (R15) who was not very talkative. I did observe bruising under his left eye. On 2/7/19 at 9:05 AM, V11 stated My shift started at 6:00 AM on 9/5/18. I received report from (V15) around 6:15-6:30 AM, that (R15) did not want to get up that morning but he was up in his chair. V11 stated during this report, she had to assist another resident. She stated when she was done and as V15 was leaving the building, V15 walked by her and said I had to f*** (R15) up. V11 stated she immediately informed V13, LPN (Licensed Practical Nurse) of what V15 had stated as she was leaving. V11 further stated that she did see the bruise on R15's face near R15's left eye on the morning of 9/5/18. R15 did not have a bruise on his face the day before. On 2/7/19 at 9:10 AM, V13, LPN, stated, I came in on day shift 9/5/18 and received report from the night shift nurse around 6:30 AM. It was around 6:45 AM when I noticed that (R15) was in his room naked. I went in to assist (R15) and he did not want me to touch him. He said he was hit. I noticed his left eye was red and that is when (V11) entered the room and informed me what (V15) had told her as she was leaving the building. I immediately notified V2, Director of Nursing, (DON) who came down to assess (R15). V13 further stated that R15, for at least the next 48 hours, was not his usual self as he presented with a hurt broken disappointed affect. On 2/7/19 at 9:15 AM, V12, CNA, stated I got to (R15's) room around 6:30 AM-6:45 AM on 9/5/18 and at that time (V13) and (V11) were in the room with (R15). V12 further stated that R15 was in his room, refusing care, sitting in the corner crying, very upset and stating that someone had hit him. On 2/7/19 at 9:30 AM, V2, (DON) stated, I was paged around 6:50 AM on 9/5/18 to come back to the Looking Glass Unit right away. I was informed by (V13) that (R15) had stated that 'someone' had hit him and that his left eye was red. I assessed (R15) at that time and (R15) repeatedly stated 'I can't believe someone did this to me. I can't believe someone did this to me.' V2 stated It was very sad. V2 further stated that R15 did have discoloration under the left eye. V2 continued that R15, due to his dementia diagnosis ,was unable to state who hit him but I was able to use simple questions to determine who it was, further stating that it was a younger, person of color. I notified (V1, Administrator) at that time. V2 stated that V15 had already left the building from the completion of her shift. On 2/8/19 at 8:30 AM, V1 stated (V2) contacted me as soon as she assessed (R15) related to the suspected abuse. V1 stated (V15) was notified on 9/5/18 that she was suspended until the allegation of abuse was completed. Once my investigation was completed, I was able to substantiate the abuse allegation and (V15) was terminated on 9/10/18. 2. R42's (MONTH) POS documents a [DIAGNOSES REDACTED]. R42's POS also documents [REDACTED]. R42's MDS dated [DATE] documents a BIMS score of 15 out of 15, indicating no cognitive impairment On 01/31/2019 at 10:00 AM, R42 stated, Yes there was a staff member V7 (Licensed Practical Nurse/LPN) a while back that was fired for taking my medication. It was a few months back. (V7) has not been back and no longer works here. She was taking my pain medication. On 02/08/2019 at 1:08 PM, V6, (LPN) stated, I was working the night the medicine was missing. I was helping out, passing medications, when I noticed R42 had some white pills on the card that were taped in place, The pills had a different code than the other pills. I immediately notified V3 (Resident Care Coordinator). We found out later that the pills were [MEDICATION NAME] instead of the [MEDICATION NAME]. When we started checking, there were other medications that were wrong as well. On 02/08/2019 at 1:40 PM, V1, Administrator stated, Yes, we terminated (V7) as we felt like (V7) was the only one who could have stolen the drugs from (R42) and we did not suspect anyone else. (V7) had left her shift for the day and she never came back into the building and she was terminated. I started an investigation immediately when I found out drugs were missing. The Follow Up Letter Notification to the State dated 09/21/2019 at 8:18 AM, related to the incident on 9/21/2019 documents the following, During the medication pass, V6 (Licensed Practical Nurse, LPN), reported a possible misappropriation of resident's medication card. The nurse noted there were 2 tablets that had been taped back in the medication card. The nurse noted that the 2 tablets that were taped in the card were different than the prescribed card. V6, LPN, notified the nurse manager on duty, V3 (Resident Care Coordinator), of the discrepancy. During the investigation V3 was able to confirm the 2 tablets were not the correct medication for the card. It was identified that the 2 tablets taped in the card were [MEDICATION NAME]. It was noted that R42 did not miss any doses of the prescribed medication. The nurse manager completed an audit of all controlled medications in the facility. It was noted that all controlled medication counts were correct, however there were discrepancies noted with administration times from V7, LPN. In conclusion, after a thorough investigation,including review of staff interviews, the facility was able to substantiate that there were discrepancies during V 7's previous shift, in addition to possible misappropriation of resident's medication. The facility has made a decision to terminate her employment. R42's Controlled Substance Record documents on 09/12/2018 received 2 doses of [MEDICATION NAME]-[MEDICATION NAME] on 09/12/2018 at 4PM. V6's statement dated 09/12/2018 documents, I worked a 10 hour shift, splitting the hallways medication pass. I passed the residents' 4 PM medications. This was to help the nurse scheduled 2PM- 10PM. On 09/13/2018, during my medication pass, I was getting a resident's medication ready to give. This resident gets a narcotic pain medication. When signing the narcotics sheet, I noticed that the nurse that relieved me on 09/12/2018 had signed out a 4PM narcotic pain pill. There was no reason for her to give this medication because I had already given it . V7 was aware of this. When I looked at the narcotic card, I noticed there was tape holding two pills and seen the print on those two pills were different from the other pills in the card. After I seen this, I notified my supervisor. She then went through all of the narcotics in the box and checked all narcotic sheets for any other mistakes. More mistakes were found. On 02/01/2019 at 2:01 PM, V3 stated, No, we did not suspect any other staff member of taking the pills. V7 had only worked here for a short time and V7 was terminated. On 02/08/2019 at 1:16 PM, V3 stated Yes, we fired V7 for the drug mix up.

A. Based on observation, record review, and interview, the facility failed to properly assess, evaluate, and monitor the use of side rails and the potential risk for entrapment for 2 of 3 residents (R3, R8) reviewed for side rail entrapment hazards in the sample of 15 and 8 residents (R16, R22, R31, R32, R33, R34, R35, R43) in the supplemental sample. This failure resulted in an immediate jeopardy. While the Immediate Jeopardy was removed on 3/22/17, the facility remains at Severity Level 2 as the facility continues to in-service staff, and update policies and procedures as needed. Findings include: 1. The U.S. Food and Drug Administration (FDA) publication Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment - Guidance for Industry and FDA Staff issued March 10, 2006 documented To reduce the risk of head entrapment, opening in the bed system should not allow the widest part of a small head (head breadth measured across the face from ear to ear) to be trapped. The publication documented FDA is therefore using a head breadth dimension of 120 mm (millimeters) (4 3/4 inches) as the basis for its dimensional limit recommendations. The publication documented regarding neck entrapment To reduce the risk of neck entrapment, openings in the bed system should not allow a small neck to become entrapped. The publication documented The FDA is recommending 60 mm (2 3/8 inches) as an appropriate dimension for neck diameter. The publication documented regarding chest entrapment The openings in a bed system should be wide enough not to trap a large chest through the openings between split rails. The FDA's dimensional limit for the chest is 12 1/2 inches. The publication documented a potential area for entrapment as Zone 1: Within the Rail. The publication documented a potential area for entrapment as Zone 6: Between the End of the Rail and the Side Edge of the Head or Foot Board. 2. On 3/16/17 from 12:00 PM until 1:00 PM, the survey team identified R3, R8, R22, R31, R32, R34, and R43 had siderails on their beds which had areas within the rails (Zone 1) that did not meet the FDA dimensional limit recommendations of 4 3/4 inches. These side rails were of the same type. There were two areas which measure 7 1/2 inches wide and 7 3/4 inch long between the bars of the rails in Zone 1. 3. R3's Quarterly Minimum Data Set (MDS), dated [DATE], documents R3's Brief Interview for Mental Status (BIMS) score of 11 (moderately impaired for decision making). The MDS further documents R3 request extensive assistance of two staff members for bed mobility and transferring. R3's March 2017 physician's orders [REDACTED]. R3's Side Rail Assessment, dated 1/2/17, documents in part, Physical Function: difficulty with balance or poor trunk control, history of falls; Mental status: combative with care; Medical Disorders: Alzheimer's/Dementia; Recommendations: left side rail; Indications for side rail: serves as safeguard during random movements while asleep; Potential risks/complications of side rail use: physical: reduced function capacity; urinary incontinent/retention; contractor; entrapment in the rail; reduced circulation; constipation; skin impairment/decubitus ulcer, increased incidence of falls. The Interdisciplinary team (IDT) has reviewed the residents' capabilities, needs and preferences in relation to side rail use and has determined the benefits of side rail use outweigh the risks at this time. R3's Fall Care Plan, dated 5/18/16, documents (R3) has risk factors that require monitoring and intervention to reduce potential for self injury. Consider medical conditions, sensory alterations, balance, gait, assistive devices, cognition, mood/behavior, safety awareness, compliance, medications restriction, restraints. Risk factors include weakness, confusion, recent falls, left hemi, behaviors (attempts to get up without assist). (R3) has a history of non-compliant with calling for assistance to get out of bed and continues to ignore safety issues. On 3/16/17 at 1:20 PM, E8, Licensed Practical Nurse (LPN), stated R3 uses the side rails to help with Activities of Daily living (ADLs). On 3/20/17 at 2:10 PM, R3 was in bed with the right 1/2 side rail in the up position. 4. R22's Quarterly MDS, dated [DATE], documents R22's BIMS score of 15 (cognitively intact). The MDS further documents extensive assistance of two staff members for bed mobility and total dependence of two staff members for transfers. R22's Side Rail Assessment, conducted and reviewed on 12/6/16 and 3/2/17, documents in part, Physical Function: poor bed mobility, currently using side rails for position or support; Mental status: poor cognitive status, combative with care; Medical Disorders:Alzheimer's/Dementia, Mental Retardation (MR); Recommendations: 1/2 rail, left side rail; Indications for side rail: serves as enabler to promote independence in bed mobility, resident expresses desire to have the side rail for security; Benefits of side rails use: prevent injury to self or others; Potential risks/complications of side rail use: physical: reduced function capacity; urinary incontinent/retention; contractor; entrapment in the rail; reduced circulation; constipation; skin impairment/decubitus ulcer, increased incidence of falls. The Interdisciplinary team (IDT) has reviewed the residents' capabilities, needs and preferences in relation to side rail use and has determined the benefits of side rail use outweigh the risks at this time. Comments: (R22) has own bed from home with side rails he uses for bed mobility. R22's Care Plan, dated 5/2016, documents, in part Falls: /2 siderails up on each side for bed mobility; Pressure Ulcers: 1/2 siderails up to aid in bed mobility related to right sided hemi. On 3/16/2017 at 1:15 PM, E5, Certified Nurse Aide (CNA), stated R22 uses side rails and is care planned for them. On 3/16/17 at 1:20 PM, E8 stated R22 uses the side rails to help with Activities of Daily living (ADLs). On 3/20/17 at 2:10 PM, R22 was in bed with the left 1/2 side rail in the up position. 5. R34's Admission MDS, dated [DATE], documents R34's BIMS score of 12 (cognitively intact) and requires extensive assistance of two staff members for bed mobility and transferring. R34's Side Rail Assessment, dated 2/17/17, documents in part, Physical Function: poor bed mobility difficulty with balance or poor trunk control; Recommendations: left 1/2 side rail; Indications for side rail: serves as enabler to promote independence in bed mobility and in getting in/out of bed. Potential risks/complications of side rail use: physical: reduced function capacity; urinary incontinent/retention; contractor; entrapment in the rail; reduced circulation; constipation; skin impairment/decubitus ulcer, increased incidence of falls. The Interdisciplinary team (IDT) has reviewed the residents' capabilities, needs and preferences in relation to side rail use and has determined the benefits of side rail use outweigh the risks at this time; Comments: use for bed mobility and help for getting in/out bed. R34's Care Plan, dated 2/24/17 documents (R34) request 1/2 siderails up to aid in bed mobility, and getting in and out of bed. On 3/16/17 at 1:20 PM, E8 stated R34 uses the side rails to help with Activities of Daily living (ADLs). 6. R43's Admission MDS, dated [DATE], documents a BIMS should not be conducted for R43. The MDS documents a staff assessment for mental status score of 3 (severely impaired for daily decision making). The MDS further documents R43 requires extensive assistance of two staff members for bed mobility and total dependence on two staff members for transfers. R43's Side Rail Assessment, dated 12/22/16, documents in part, Physical Function: history of falls; Mental status: poor cognitive status; Medical Disorders: Alzheimer's/Dementia; Interventions: frequent staff monitoring while in bed; Recommendations: no rail; Indications for side rail: side rails do not appear to be indicated at this time; Benefits of side rail use: none marked; Potential risks/complications of side rail use: physical: reduced function capacity; urinary incontinent/retention; contractor; entrapment in the rail; reduced circulation; constipation; skin impairment/decubitus ulcer, increased incidence of falls. The Interdisciplinary team (IDT) has reviewed the residents' capabilities, needs and preferences in relation to side rail use and has determined side rails are unnecessary at this time. R43's Care Plan, dated 7/1/16, documents: Falls: (R43) has risk factors that require monitoring and interventions to reduce potential for self injury. R43's Care Plan does not address side rails. On 3/21/17 at 9:07 AM, E12, LPN, stated R43 uses side rails. 7. R31's Annual MDS, dated [DATE], documents R31's BIMS score of 14 (cognitively intact). The MDS further documents R31 requires limited assistance of one staff member for bed mobility and transfers. R31's Side Rail Assessment, dated 1/5/17, documents in part, Physical Function: currently using side rails for position or support; Medical Disorders: Neurological disorders causing involuntary movements, Alzheimer's/Dementia; Recommendations: left side rails; Indications for side rail: serves as enabler-unable to stand independently, serves as enabler to promote independence in bed mobility, serves as enabler to promote independence in getting in/out of bed, resident expresses desire to have the side rail for security; Potential risks/complications of side rail use: physical: reduced function capacity; urinary incontinent/retention; contractor; entrapment in the rail; reduced circulation; constipation; skin impairment/decubitus ulcer, increased incidence of falls. The Interdisciplinary team (IDT) has reviewed the residents' capabilities, needs and preferences in relation to side rail use and has determined: nothing marked; Comments: aids with (R31) getting in and out of bed, assist with bed mobility and repositioning. (R31) request use of siderail. R31's Care Plan, dated 1/5/17 documents: Falls: (R31) has risk factors that require monitoring and interventions to reduce potential for self injury. Risk factors include: seizures. The Care Plan documents 11/15/16, 1/2 right siderail up per (R31's) request for sitting up in bed. On 3/16/17 at 1:26 PM, R31 stated she used side rails so she (R31) doesn't fall out of bed. R31 further stated she cannot get out of bed without them. On 3/21/17 at 9:00 AM, R31 was in bed with bilateral side rails in the up position. 8. R32's Quarterly MDS, dated [DATE], documents R32's BIMS score of 12 (moderately impaired cognition). This MDS also documents that R32's needs supervision with bed mobility. On 3/16/2017 at 1:00 PM, R32's side rail measures 7 (inches) by 7 and 3/4 within Zone 1 of the rails. R32's Side Rail Assessment, dated 2/16/2017, documents Able to make needs known and poor cognitive status. This assessment also documents Alzheimer's/Dementia. The recommendations document Side rails do not appear to be indicated at this time. The IDT has reviewed the resident's capabilities beds and preferences in relation to the side rail use and has determined: Side rail use is unnecessary at this time. The IDT has reviewed the resident's capabilities, needs and preferences in relation to side rail use and has determined side rail use is unnecessary at this time. On 3/16/2017 at 4:11 PM, R32's right side rail was in the up position and R32 was in bed lying on back with eyes closed. On 3/17/2017 at 8:17 AM R32's right side rail was in the up position and R32 was in bed on back with eyes closed. R32's Care Plan, dated 11/21/2016, does not document side rail use. 9. R8's Quarterly MDS, dated ,[DATE], documents R8's BIMS score of 14 (cognitively intact). R8's Physical Restraint/Enabler, dated 3/1/2017, documents in part, Enabler per patient request to make her feel safe in bed related to not falling out. Risks verses benefits patient request. On 3/21/2017 at 9:30 AM, R8's left side rail was up. R8 stated, That side rail is always up, it is never down. My side rails are up when I am in bed. R8's Care Plan, dated 11/14/2016, documents, Half-side rails in up position (per request) while in bed to facilitate safe and more independent bed mobility. On 3/21/2107 at 9:01 AM, when asked if R8 uses side rails, E6, CNA, stated, Yes she uses them all the time, they are up now. 10. R16's MDS, dated [DATE], documents a BIMS should not be conducted for R16. The MDS documents a staff assessment for mental status score of 3 (severely impaired for daily decision making). This MDS also documents that R16 requires extensive assistance of 1 staff member for bed mobility and extensive assistance of 2 staff members for transfers. R16's SIDE RAIL ASSESSMENT, dated 2/1/17, documents, in part, Medical Disorders: CVA (Cerebral Vascular Accident) and Alzheimer's/ Dementia, Recommendations: No side rails indicated at this time. R16's Care Plan, dated 4/1/16, does not address the use of side rails. On 3/16/17 at 1:15 PM, R16's bed was observed with bilateral side rails in the raised position. There was a 13.5 inch gap between the edge of the head board to the top of the side rails, Zone 6. On 3/16/ 17 at 1:20 PM, E13, CNA, stated, R16 will grab the rails to help with positioning. 11. R35's MDS, dated [DATE], documents, R35 has a BIMS score of 14 (cognitively intact). This MDS also documents that R35 requires extensive assistance of 1 staff member for bed mobility and transfers. R35's SIDE RAIL ASSESSMENT, dated 1/17/17, documents, in part, Medical Disorders: CVA (Cerebral Vascular Accident) and Alzheimer's/ Dementia, Recommendations: No side rails indicated at this time. R35's Care Plan, dated 5/25/16, does not address the use of side rails. On 3/20/17 at 12:30 PM, R35's bed was observed with bilateral side rails in the raised position. The side edge of the head board to the rail measured 12 inches long, Zone 6. On 3/21/17 at 9:43 AM, R35 stated, I don't use them. I don't know why they are there. On 3/21/17 at 9:45 AM, E6, CNA, stated (R35) does use the rails for positioning and stability with standing. 12. R33's MDS, dated [DATE], documents R33's BIMS score of 9 (moderately impaired cognition). This MDS also documents that R33 requires extensive assistance of 1 staff member for bed mobility and extensive assist of 2 staff members for transfers. R33's SIDE RAIL ASSESSMENT, dated 2/14/17, documents, in part, Medical Disorders: Alzheimer's/ Dementia, Recommendations: 1/2 rail on left side rail and right side rail. This assessment does not document a medical condition for the use of the side rail. R33's Physician order [REDACTED]. R33's Care Plan, dated 2/22/17, documents, in part, Category: Falls: 1/2 rails up bilaterally to aid in bed mobility and positioning with staff assist. On 3/20/17 at 3:07 PM, R33 was in bed with the bilateral side rails in the raised position. The gap between the head board to the top of the side rails measured 17 inches long, Zone 6. On 3/16/17 at 1:10 PM, E8 stated, (R33) uses her side rails for safety, she has not had falls so unsure why safety. 13. On 3/21/17 at 1:00 PM, an interview was conducted with E1, Administrator and Z1, Regional Director. Z1 stated she was unaware the siderails on some of the beds did not meet the FDA dimensional guidelines. On 03/21/17 at 1:00 PM, Z1, Regional Director, stated We received those beds as a donation from the hospital. We did buy mesh and covers for the side rails. We did not know the mesh wasn't on the siderails at this time. The facility's Physical Restraint/Enabler Policy dated 08/08/11 documents Physical restraint is any manual or physical or mechanical device, material,or equipment attached or adjacent to the resident's body, which the individual cannot easily remove. Which restricts freedom of movement or normal access to one's body. They include but are not limited to: bed rails, Self release waist restraints, lap top cushions, and vest restraints. The Immediacy was determined to have begun on 3/16/17 when the survey team identified R3, R8, R22, R31, R32, R34 and R43 were using siderails on their beds that did not meet the FDA dimensional limit recommendations of 4 3/4 inches within Zone 1 (between the rails). On 3/21/17 at 3:45 PM, E1, Administrator, was notified of the Immediate Jeopardy. On 3/23/17, surveyors determined through observation, interview and record review, the facility took the following actions to remove the Immediacy on 3/22/17: On 3-21-17 the following was initiated/completed: 1. The Regional Nurse, Resident Care Coordinator and MDS Coordinator completed an audit for use of side rails, including assessment, physician orders, consent and care plans were reviewed and updated to reflect the resident's side rail needs. 2.The Regional Maintenance Director and facility Maintenance Director completed a siderail zone assessment of all resident beds that use side rails and adaptive equipment including required foam bumpers and mesh covering were placed on beds to ensure zone compliance. The facility had all items on hand for compliance. 3. The Regional Nurse initiated 100% staff in-servicing for all departments including Administration, Nursing, Housekeeping/Laundry, Dietary, and Maintenance regarding Supervision to Prevent Accidents for use of siderails including Siderail Zone Assessment, Consent, Physician Orders, Restraint / Enabler Policy & Procedure. On 3-22-17 the following was completed: 4. The Regional Director of Operations completed the 100% staff in-servicing for all departments including Administration, Nursing, Housekeeping/Laundry, Dietary, and Maintenance regarding Supervision to Prevent Accidents for use of siderails including Siderail Zone Assessment, Consent, Physician Orders, Restraint / Enabler Policy & Procedure. B. Based on observation, interview and record review the facility failed to ensure hazardous materials were stored safely away from the generators and water heaters with the potential for explosion and fire hazard. This has the potential to affect all of the 68 residents living in the facility. Findings include: 1. On 03/16/2017 at 8:43 AM, located in a locked room on the main floor of the facility was a large diesel generator. Sitting adjacent to the generator less than 6 millimeters away was a large plastic container of diesel oil with 1.5 liter of oil still inside of it. Approximately 2 feet in front of the generator, was a mop head lying in the floor. In this room were 2 large 97 gallon water heaters approximately 7 feet from the generator. Next to one of the 92 gallons heaters was a cart. On the cart was a ¼ gallon container of primer and sealant, 2 half full one gallon containers of semi gloss paint and 2 one gallon containers of paint with the labels removed. On the cart there were three aerosol cans. One of the cans was WD-40 which was half full. Next to the other 97 gallon water heater was a large bucket with a folded linen cloth on top and next to that was an empty aerosol can. On 03/16/2017 at 8:49 AM, E4, Maintenance Director, stated I have been working here for eight months now. That oil can has been next to the generator since I started. No, I don't think the oil is a hazard sitting next to the generator because there are no spark plugs on the generator. On 03/16/2017 at 4:08 PM, E4 stated Yes, I think the aerosol cans could be a fire hazard. The paint cans and cart have been there since I started. I am not sure what kind of paint is even inside them because they have been here since I started and the labels have peeled off. I can't tell you if its water or oil based because the label is gone. We have always kept them on the cart. The Material Safety Data Sheet (MSDS) from the primer and sealant, with a revision date of 02/29/2016, document in part, storage: Store in cool, dry, well ventilated area away from sources of heat, combustible materials, and incompatible substances. Keep container tightly closes when not in use. The MSDS for WD-40, with revision date of March 2010, documents DANGER! Flammable aerosol. Contents under pressure. Harmful or fatal if swallowed. If swallowed, may be aspirated and cause lung damage. May cause eye irritation. Avoid eye contact. Use with adequate ventilation. Keep away from heat, sparks and all other sources of ignition. 2. The Resident Census and Conditions of Residents, CMS 672, dated 03/14/2017, documents that the facility has 68 residents living in the facility.

Based on interview and record review the facility failed to properly address the psychosocial needs and follow the plan of care for a resident with Dementia, with known fears of water and increased behaviors while showering for 1 of 5 residents ( R3) reviewed for individualized care in the sample of 5. This failure resulted in R3's increased behaviors during a shower that resulted in R3's left ankle fracture which required hospitalization and surgical intervention. Findings include: 1. R3's June 2016 Physician order [REDACTED]. R3's Minimum Data Set (MDS), dated [DATE], documents R3 was unable to complete the cognition interview, resident is rarely/never understood. R4's MDS, dated [DATE], documents R4 requires extensive assistance with two staff members for toileting and showering. The MDS further documents R3 does not exhibit behavioral symptoms. The MDS also documents R3 rejected care that is necessary to achieve the resident's goals for healing and well-being. R3's Care Plan, dated 6/5/14, documents: Behavior, with a review date of 1/25/16: Resident is known/has history of displaying inappropriate behavior and or resisting care/services. Specific behavior exhibited, resists care, physically and verbally aggressive to staff, delusional about food preferences. Related diagnosis/condition, dementia, depression, [MEDICAL CONDITION] unspecified. Cognitive Loss/Dementia, with a start date of 6/20/14: Behavior exhibited refusal/fear of water showers. Resident's specific information can be physically/verbally abusive when resisting care. Falls with review date of 1/25/16: Resident has risk factors that require monitoring and intervention to reduce potential for self injury. A) See also Behavior care plan. minimize fall risk through reducing agitation and impulsive behavior. Behavior: Use two staff members for showers for safety due to resisting care. Fears water or lotion on skin or hair. Multiple Interventions for Previous Falls noted under the Fall Care Plan. Activity of Daily Living (ADL) Function Rehab, with start date of 6/20/14 and review date of 1/25/16: Self care deficit-needs supervision and or assist to complete quality care and or poorly motivated to complete ADL. As evidenced by does not like clothes to touch floor when dressing and is fearful of anything wet touching hair or skin which results in resisting showers or sponge baths. Resident specific information/preferences will need two staff to bath resident. A) will receive shower. Will need two staff to bath resident due to fear of water. R3's Bowel assessment dated [DATE] documents: Staff assist (R3) to bathroom, requires 2 assist frequently with toileting needs related to agitation during care. R3's Behavior Monitoring Record For March, April, May and June 2016 documents: Agitation at staff. Documentation for 3/17/16 Record states leaning, twisting with assisted transfer stating 'I'm going to fall'. Documentation for 4/13/16 Record states being ambulated in hallway, calling out 'Don't hurt me. Don't drop me'. June's Tracking is blank. R3's SBAR (Situation, Background, Assessment, Recommendation) Communication Form, dated 4/14/16, documents: Resident Evaluation: Mental Status Evaluation: dementia, no changes observed, Functional Status Evaluation: decreased mobility, Behavioral Evaluation: depression, social withdrawal, Respiratory Evaluation: (blank), Cardiovascular Evaluation: (blank), Abdominal/GI Evaluation: date of last bowel movement: 4/14/16, Situation: (entire section-blank), Background: (entire section-blank). R3's Social Service Progress Notes documents: 7/10/15, IDT(Interdisciplinary Team) met this morning to discuss (R3's) behaviors. (R3) hit CNA (Certified Nurse Assistant) who was assisting her out of bed. Team will continue to monitor. 9/11/15 IDT met this morning to discuss behavior tracking. (R3) scratched CNA while attempting to assist her to dinner. Team will continue to redirect and monitor. 9/18/15 IDT met this morning to discuss behavior tracking. (R3) was resistive with CNAs trying to give her a shower and was difficult to calm down. Team will continue to redirect and monitor. 11/13/15 IDT met this morning to discuss behavior tracking. (R3) became agitated with staff during ADL care as well as resistive. team redirected and will continue to monitor. 11/20/15 IDT met this morning to discuss behavior tracking. (R3) became agitated during shower and ADL care and resisting care. Staff redirecting and will continue to monitor. 12/4/15 IDT met this morning to discuss behavior tracking. (R3) was becoming agitated during shower care. Staff redirected and will continue to monitor. The next entry is 4/14/16 documenting the hospital requesting R3's guardianship paperwork. R3's Nursing Notes dated 4/14/16 documents in part: 7:20 AM, Called to shower room by (E5, CNA). She (R3) lunged, started slipping. (E5) had tried to straighten (R3) prior to impact of extended left leg against commode base. (R3) now lowered to floor into sitting position. Left lower leg/ankle area with a 1 cm (centimeter) whitened area with hard object. Feet beneath this area. Deviation of foot of inner rotation-welling occurring .Stabilized Left lower leg using magazines and ace wrap. no wt (weight) bearing as 4 transfer (R3) to w/c (wheelchair) then to (R3) bed. 0730, call placed to (Z1, Nurse Practitioner) returning call with orders to send to ER (emergency room ) for evaluation r/t (related to) left lower leg dislocation, [MEDICAL CONDITION], and pain. 835 AM Call received from hospital inquiring to how LL (left lower) leg trauma occurred. Told of large loose stool incontinence required shower for cleansing, (R3) lunged and slipped. (Z2, Medical Doctor) indicates fracture has occurred, surgical intervention being considered. Nursing Notes dated 4/15/16, 9:00 AM, documents IDT meeting held with review of previous fall. Interventions to educate staff assistance of 2 for showering. R3's Hospitalist History and Physical dated 4/14/16 documents Admission: HPI (History of Present Illness); [AGE] year-old with history of Alzheimer's dementia present to the ED (Emergency Department) from NH (Nursing Home) for left ankle pain and deformity s/p (status [REDACTED]. Per NH nurse, (R3) was wearing a gait belt and her leg slipped in the shower and she slid into a commode. The aide reported hearing a pop. Upon exam, unable to obtain any history from (R3) due to confusion. Per nurse, her baseline is A/O (alert and orientated) x 0. History obtained from ED records. Upon arrival to ED, the physical noted purple discoloration of left foot and second and 3rd toes on right foot, which he noted to greatly improve close to normal color. Physical Exam: Musculoskeletal. Extremities; ROM (Range of Motion) grossly intact, Pain with ROM (left ankle), ROM decreased (left ankle), other (left ankle with hourglass posterior splint in place, foot warm DP (dorsalis pedis) pulse 2+, neurovascular intact, slight purple discoloration to 2nd and 3rd toes of right root. Other Test Results: Left ankle x-ray: decreased mineralization, trimalleolar fracture with mild displacement of fracture ligaments. Assessment/Plan: Problem List (1) Trimalleolar Fracture of ankle, closed. Assessment/Plan: X-ray left ankle reveals trimalleolar fracture with mild displacement of fracture ligaments. Admit to medical floor. Orthopedic surgeon consulted. Plans for surgery. (3) Alzheimer's dementia: Assessment/Plan Continue home regimen fall precautions. R3's Orthopedic Consult dated 4/14/16 documents in part: Assessment/Plan: Problem List (1) Closed trimalleolar fracture of left ankle. Overall the ankle really shows significant displacement and a trimalleolar fracture has an inherent instability. Therefor the recommendation is for an open reduction internal fixation to reposition the alignment and allow for rigid fixation. This would also allow for a little earlier mobilization and weight bearing. However still carry the inherent risk of surgery. Conversely I think to treat this from a close/conservative standpoint is going to leave her with a completely dysfunctional ankle for which she would have difficulty even with limited weightbearing .We'll plan on proceeding to the operating room on 4/15/16 at 1 PM as long as patient is stable for surgery. On 6/14/16 at 10:30 AM, E1, Administrator, stated E19, Registered Nurse (RN), who was working the day R3 fell is no longer an employee of the facility. On 6/14/16 at 12:38 PM, E4, Licensed Practical Nurse (LPN), stated she works the 200 hall and dementia unit. On 6/14/16 at 2:21 PM, E4 stated R3 had behaviors. E4 stated R3 would not want to get up, or take medications sometimes. E4 stated R3 was uncooperative with showers or any care. E4 stated R3 would pull away from staff and state she (R3) wants to go back to her room or say No. E4 stated R3 was never agreeable with any care. On 6/14/16 at 1:00 PM, E5, CNA, stated she was the CNA who assisted R3 in the shower on 4/14/16 when R3 fell . E5 stated R3 had a bowel movement and went to shower R3 to clean her up. E5 stated she was drying R3 off and R3 jumped up and started walking swiftly towards toilet. E5 stated R3's foot slipped and turned and hit ankle on toilet and then R3 sat down on toilet. On 6/14/16 at 1:20 PM, E3, LPN stated R3 required normally an assist of one staff, sometimes 2 depending on mood. E3 stated they made sure there were 2 people to assist R3 with ADL's. E3 stated R3 like to guide you the way she wanted to go and R3 would try and hurry. On 6/14/16 at 2:26 PM, E3 stated R3 had behaviors at times like pulling away from staff while doing care, and only eating white foods. E3 stated sometimes when staff would change or toilet R3, she would pull away and she (R3) is done with care. On 6/14/16 at 1:55 PM, Z1, Nurse Practitioner, stated R3 had a fractured ankle and was sent out of the facility and ultimately had surgery. Z1 stated R3's unsteady at times and uncooperative at times as well. Z1 stated getting R3 a shower is like pulling teeth because R3 is uncooperative. On 6/14/15 at 2:15 PM, E8, LPN, stated R3 had behaviors and would get combative. E8 stated R3 didn't want to get up and preferred her room. E8 stated R3 didn't like showers, or to get her hair brushed or get dressed. E8 stated R3 was a timid physical. On 6/14/16 at 2:25 PM, E9, RN, stated R3 does have behaviors, like asking for food, but is easily redirected. E9 stated he is unsure if R3 has problems with showers and stated no one has reported anything like that to him. On 6/14/16 at 2:30 PM, E10, CNA, stated R3 does not resist care or have behaviors. E10 stated R3 just repeats herself. On 6/14/16 at 3:00 PM, E13, CNA, stated R3 had a tendency to pull away from staff. E13 further stated R3 always tried to pull away from you, and R3 could ambulate. E13 stated she thinks R3 requires only one staff member for assistance but stated I try and get another staff. (R3) is terrified of falling. E13 stated she has never given R3 a shower, but thinks you have to have 2 people because R3 does pull away. On 6/15/16 at 9:20 AM, E14, CNA, documents she worked with R3 on the dementia unit and R3 does have behavior. E24 stated You'll have to ask nurse what behaviors there are. On 6/15/16 at 9:33 AM, E15, Care Plan/MDS Coordinator, stated Care Plans are updated every 3 months unless a resident has a significant change. E15 stated the Care Plans and MDS are updated to the best of my knowledge-I do the best I can. E15 stated R3 required 1-2 staff assist and R3 was on the dementia unit so it depended on her behaviors. E15 stated R3 had behaviors like hitting, pulling away, throwing fecal matter on the floor and resisting care. E15 stated R3 didn't like water too much and R3's family had told the facility that she didn't like water. E15 stated she probably reviewed the Care Plan, just didn't put a date down. On 6/15/16 at 10:15 AM, E1, Administrator, stated I encourage staff to look at MDS and Care plan to see resident information. E1 stated she educated staff on using the MDS and Care Plan and that the information is kept behind the nurses station for staff use. E1 stated she expects the Care Plan/MDS to be updated. E1 stated she expects staff to utilize 2 staff members with known behaviors in the shower. E1 stated the facility has bed bath cloths and shower caps for use to bathe residents if unable to shower. On 6/15/16 at 12:05 PM, during a telephone interview, E2, Interim Director of Nursing (DON)/Regional Nurse, stated she has been the interim since approximately 5/14/16. E2 stated she thinks R3 was on the dementia unit. E2 stated she would expect staff to follow resident Care Plan and MDS. E2 stated if a resident was having behaviors at the time of shower, staff could use bed bath cloths, reapproach later, or have another staff member who has better rapport try. E2 stated she would expect staff to know about individual care and the MDS/Care Plan be accurate and updated with any changes. On 6/16/16 at 9:40 AM, E1, stated they do not have a special policy for dementia care residents. E1 further stated that all residents have individualized care. The Facility's undated Comprehensive Assessment/Care Planning Policy documents in part: It is the policy of this Facility to comprehensively assess, in a timely manner, each resident to this facility. The results of this resident assessment shall serve as the basis for determining resident need, and subsequently how care shall be planned for each resident.

Based on interview and record review the facility failed to properly transfer, provide a thorough investigation, and implement progressive interventions for falls for 2 of 5 residents (R2, R3) reviewed for falls in the sample of 5. This failure resulted in R2 having multiple emergency room visits requiring intervention for lacerations to the head, concussion and compression fracture. The failure resulted in R3's left ankle fracture requiring hospitalization and surgical intervention. Findings include: 1. R3's June 2016 Physician order [REDACTED]. R3's Minimum Data Set (MDS), dated [DATE], documents R3 was unable to complete the cognition interview, resident is rarely/never understood. R4's MDS, dated [DATE], documents R4 requires extensive assistance with two staff members for toileting and showering. The MDS further documents R3 does not exhibit behavioral symptoms. The MDS also documents R3 rejected care that is necessary to achieve the resident's goals for healing and well-being. R3's Care Plan, dated 6/5/14, documents: Behavior, with a review date of 1/25/16: Resident is known/has history of displaying inappropriate behavior and or resisting care/services. Specific behavior exhibited, resists care, physically and verbally aggressive to staff, delusional about food preferences. Related diagnosis/condition, dementia, depression, psychosis unspecified. Cognitive Loss/Dementia, with a start date of 6/20/14: Behavior exhibited refusal/fear of water showers. Resident's specific information can be physically/verbally abusive when resisting care. Falls with review date of 1/25/16: Resident has risk factors that require monitoring and intervention to reduce potential for self injury. A) See also Behavior care plan. minimize fall risk through reducing agitation and impulsive behavior. Behavior: Use two staff members for showers for safety due to resisting care. Fears water or lotion on skin or hair. Multiple Interventions for Previous Falls noted under the Fall Care Plan. Activity of Daily Living (ADL) Function Rehab, with start date of 6/20/14 and review date of 1/25/16: Self care deficit-needs supervision and or assist to complete quality care and or poorly motivated to complete ADL. As evidenced by does not like clothes to touch floor when dressing and is fearful of anything wet touching hair or skin which results in resisting showers or sponge baths. Resident specific information/preferences will need two staff to bath resident. A) will receive shower. Will need two staff to bath resident due to fear of water. R3's Bowel assessment dated [DATE] documents: Staff assist (R3) to bathroom, requires 2 assist frequently with toileting needs related to agitation during care. R3's Behavior Monitoring Record For March, April, May and June 2016 documents: Agitation at staff. Documentation for 3/17/16 Record states leaning, twisting with assisted transfer stating 'I'm going to fall'. Documentation for 4/13/16 Record states being ambulated in hallway, calling out 'Don't hurt me. Don't drop me'. June's Tracking is blank. R3's SBAR (Situation, Background, Assessment, Recommendation) Communication Form, dated 4/14/16, documents: Resident Evaluation: Mental Status Evaluation: dementia, no changes observed, Functional Status Evaluation: decreased mobility, Behavioral Evaluation: depression, social withdrawal, Respiratory Evaluation: (blank), Cardiovascular Evaluation: (blank), Abdominal/GI Evaluation: date of last bowel movement: 4/14/16, Situation: (entire section-blank), Background: (entire section-blank). R3's Social Service Progress Notes documents: 7/10/15, IDT(Interdisciplinary Team) met this morning to discuss (R3's) behaviors. (R3) hit CNA (Certified Nurse Assistant) who was assisting her out of bed. Team will continue to monitor. 9/11/15 IDT met this morning to discuss behavior tracking. (R3) scratched CNA while attempting to assist her to dinner. Team will continue to redirect and monitor. 9/18/15 IDT met this morning to discuss behavior tracking. (R3) was resistive with CNAs trying to give her a shower and was difficult to calm down. Team will continue to redirect and monitor. 11/13/15 IDT met this morning to discuss behavior tracking. (R3) became agitated with staff during ADL care as well as resistive. team redirected and will continue to monitor. 11/20/15 IDT met this morning to discuss behavior tracking. (R3) became agitated during shower and ADL care and resisting care. Staff redirecting and will continue to monitor. 12/4/15 IDT met this morning to discuss behavior tracking. (R3) was becoming agitated during shower care. Staff redirected and will continue to monitor. The next entry is 4/14/16 documenting the hospital requesting R3's guardianship paperwork. R3's Nursing Notes dated 4/14/16 documents in part: 7:20 AM, Called to shower room by (E5, CNA). She (R3) lunged, started slipping. (E5) had tried to straighten (R3) prior to impact of extended left leg against commode base. (R3) now lowered to floor into sitting position. Left lower leg/ankle area with a 1 cm (centimeter) whitened area with hard object. Feet beneath this area. Deviation of foot of inner rotation-welling occurring .Stabilized Left lower leg using magazines and ace wrap. no wt (weight) bearing as 4 transfer (R3) to w/c (wheelchair) then to (R3) bed. 0730, call placed to (Z1, Nurse Practitioner) returning call with orders to send to ER (emergency room ) for evaluation r/t (related to) left lower leg dislocation, edema, and pain. 835 AM Call received from hospital inquiring to how LL (left lower) leg trauma occurred. Told of large loose stool incontinence required shower for cleansing, (R3) lunged and slipped. (Z2, Medical Doctor) indicates fracture has occurred, surgical intervention being considered. Nursing Notes dated 4/15/16, 9:00 AM, documents IDT meeting held with review of previous fall. Interventions to educate staff assistance of 2 for showering. R3's Hospitalist History and Physical dated 4/14/16 documents Admission: HPI (History of Present Illness); [AGE] year-old with history of Alzheimer's dementia present to the ED (Emergency Department) from NH (Nursing Home) for left ankle pain and deformity s/p (status [REDACTED]. Per NH nurse, (R3) was wearing a gait belt and her leg slipped in the shower and she slid into a commode. The aide reported hearing a pop. Upon exam, unable to obtain any history from (R3) due to confusion. Per nurse, her baseline is A/O (alert and orientated) x 0. History obtained from ED records. Upon arrival to ED, the physical noted purple discoloration of left foot and second and 3rd toes on right foot, which he noted to greatly improve close to normal color. Physical Exam: Musculoskeletal. Extremities; ROM (Range of Motion) grossly intact, Pain with ROM (left ankle), ROM decreased (left ankle), other (left ankle wit horoglass posterior splint in place, foot warm DP (dorsalis pedis) pulse 2+, neurovascular intact, slight purple discoloration to 2nd and 3rd toes of right root. Other Test Results: Left ankle x-ray: decreased mineralization, trimalleolar fracture with mild displacement of fracture ligaments. Assessment/Plan: Problem List (1) Trimalleolar Fracture of ankle, closed. Assessment/Plan: X-ray left ankle reveals trimalleolar fracture with mild displacement of fracture ligaments. Admit to medical floor. Orthopedic surgeon consulted. Plans for surgery. (3) Alzheimer's dementia: Assessment/Plan Continue home regimen fall precautions. R3's Orthopedic Consult dated 4/14/16 documents in part: Assessment/Plan: Problem List (1) Closed trimalleolar fracture of left ankle. Overall the ankle really shows significant displacement and a trimalleolar fracture has an inherent instability. Therefor the recommendation is for an open reduction internal fixation to reposition the alignment and allow for rigid fixation. This would also allow for a little earlier mobilization and weight bearing. However still carry the inherent risk of surgery. Conversely I think to treat this from a close/conservative standpoint is going to leave her with a completely dysfunctional ankle for which she would have difficulty even with limited weightbearing .We'll plan on proceeding to the operating room on 4/15/16 at 1 PM as long as patient is stable for surgery. R3's Operative Report, dated 4/15/16, documents in part: Procedure Performed: open reduction internal fixation left trimalleolar ankle fracture. Open reduction internal fixation to include a lateral place and screw technique for the lateral malleolus fracture. 2 screw fixation for the medical malleolus fracture. No fixation required for the posterior malleolus fracture which reduced after the bimalleolar fixation. On 6/14/16 at 10:08 AM, E6, CNA, stated she has taken care of R3, but was not working the day R3 fell . E6 stated R3 was in the dementia care unit before her fall and she was walking and required one staff member for assistance for showers. E6 stated she does not know of R3's fall history because she just started at the facility in May. On 6/14/16 at 10:11 AM, E7, CNA, stated she took care of R3 after surgery and is unsure if she had any previous falls. E7 stated she thinks R3 walked around before fall, but doesn't know how fall happened. E7 stated she started at the facility in April. On 6/14/16 at 10:30 AM, E1, Administrator, stated E19, Registered Nurse (RN), who was working the day R3 fell is no longer an employee of the facility. E1 stated fall investigations are part of the Quality Assurance and the facility does not give them out. E1 stated Care Plans are in the binder and is the most updated and working Care Plan for residents. E1 stated SBAR is in residents' charts and document fall information. E1 stated the facility has been inservicing on filling out the SBAR completely. On 6/14/16 at 12:38 PM, E4, Licensed Practical Nurse, LPN, stated she works the 200 hall and dementia unit. E4 stated she worked prior to R3's fall in April. E4 stated she was unsure if she was working as a CNA or LPN during this time since she just received LPN license in March/April. E4 stated R3 was dependent on staff for at least most ADLs. E4 stated R3 required at least 2 staff members for showers, and toileting R3 was at least 1 staff member. E4 stated R3 would ambulate, but she wasn't steady and R3 would always say she was going to fall. E4 stated she did not believe R3 had a history of [REDACTED]. On 6/14/16 at 2:21 PM, E4 stated R3 had behaviors. E4 stated R4 would not want to get up, or take medications sometimes. E4 stated R3 was uncooperative with showers or any care. E4 stated R3 would pull away from staff and state she (R3) wants to go back to her room or say No. E4 stated R3 was never agreeable with any care. On 6/14/16 at 1:00 PM, E5, CNA, stated she was the CNA who assisted R3 in the shower on 4/14/16 when R3 fell . E5 stated R3 had a bowel movement and went to shower R3 to clean her up. E5 stated she was drying R3 off and R3 jumped up and started walking swiftly towards the toilet. E5 stated R3's foot slipped and turned and hit ankle on the toilet and then R3 sat down on the toilet. E5 stated she called for help and E19 came in. E5 stated E19 assessed R3 and called in E3, LPN, Resident Care Coordinator (RCC), and it took 3 staff to get R3 up and put her in wheelchair. E5 stated she didn't know if R3 had any history of falls. E5 stated R3 was unsteady and R3 required one staff member for showering, toileting or ADLs. On 6/14/16 at 1:20 PM, E3, LPN, stated she was informed R3 fell on [DATE] in the shower room and R3 was complaining of pain to ankle. E3 stated she was not directly involved in assisting R3, and believes it was E20, the Previous Director of Nursing. E3 stated R3 is not someone the facility normally talks about for falls and have not had previous falls that she is aware of. E3 stated R3 required normally an assist of one staff, sometimes 2 depending on mood. E3 stated they made sure there were 2 people to assist R3 with ADLs. E3 stated R3 liked to guide you the way she wanted to go and R3 would try and hurry. On 6/14/16 at 2:26 PM, E3 stated R3 had behaviors at times like pulling away from staff while doing care, and only eating white foods. E3 stated sometimes when staff would change or toilet R3, she would pull away and she (R3) is done with care. On 6/14/16 at 1:55 PM, Z1, Nurse Practitioner, stated R3 had a fractured ankle and was sent out of the facility and ultimately had surgery. Z1 stated before the fracture, R3 ambulated with assistance or used the rails in the dementia unit. Z1 stated she is only in the facility once a week and has seen R3 ambulate. Z1 stated R3's unsteady at times and uncooperative at times as well. Z1 stated she did not want to speculate if R3's fall could have been prevented if 2 staff members were showering R3. Z1 stated getting R3 a shower is like pulling teeth because R3 is uncooperative. On 6/14/15 at 2:15 PM, E8, LPN, stated R3 was ambulatory and needed 1 assist of staff for any ADLs, including bathing and toileting. E8 stated R3 had behaviors and would get combative. E8 stated R3 didn't want to get up and preferred her room. E8 stated R3 didn't like showers, or to get her hair brushed or get dressed. E8 stated R3 was a timid physical. On 6/14/16 at 2:25 PM, E9, RN, stated he has only been employed at the facility for one month and wasn't here when R3 had a fall in April. E9 stated R3 does have behaviors, like asking for food, but is easily redirected. E9 stated he is unsure if R3 has problems with showers and stated no one has reported anything like that to him. E9 stated he is unsure if R3 had a history of [REDACTED]. On 6/14/16 at 2:30 PM, E10, CNA, stated R3 does not resist care or have behaviors. E10 stated R3 just repeats herself and does not know of previous falls. E10 stated she has been employed at the facility for 2 weeks. On 6/14/16 at 3:00 PM, E13, CNA, stated she recalled R3's fall in the shower room. E13 stated R3 had a tendency to pull away from staff. E13 further stated R3 always tried to pull away from you, and R3 could ambulate. E13 stated she thinks R3 requires only one staff member for assistance, but stated I try and get another staff. (R3) is terrified of falling. E13 stated she has never given R3 a shower, but thinks you have to have 2 people because R3 does pull away. On 6/15/16 at 9:20 AM, E14, CNA, stated she worked with R3 on the dementia unit and R3 does have behaviors. E24 stated you'll have to ask nurse what behaviors there are. On 6/15/16 at 9:33 AM, E15, Care Plan/MDS Coordinator, stated Care Plans are updated every 3 months unless a resident has a significant change. E15 stated the Care Plans and MDS are updated to the best of my knowledge-I do the best I can. E15 stated R3 required 1-2 staff assist and R3 was on the dementia unit so it depended on her behaviors. E15 stated R3 had behaviors like hitting, pulling away, throwing fecal matter on the floor and resisting care. E15 stated R3 didn't like water too much and R3's family had told the facility that she didn't like water. E15 stated she probably reviewed the Care Plan, just didn't put a date down. On 6/15/16 at 10:15 AM, E1, Administrator, stated I encourage staff to look at MDS and Care plan to see resident information. E1 stated she educated staff on using the MDS and Care Plan and that the information is kept behind the nurses station for staff use. E1 stated if residents are MDS/Care Planned for 2 staff members then they (staff) should use 2 staff members. E1 stated she expects the Care Plan/MDS to be updated. E1 stated she expects staff to utilize 2 staff members with known behaviors in the shower. E1 stated the facility has bed bath cloths and shower caps for use to bathe residents if unable to shower. On 6/15/16 at 12:05 PM, during a telephone interview, E2, Interim Director of Nursing (DON)/Regional Nurse, stated she has been the interim since approximately 5/14/16 and she does not recall how R3 transfers without reviewing her Care Plan. E2 stated she thinks R3 was on the dementia unit. E2 stated she would expect staff to follow resident Care Plan and MDS. E2 stated if resident having behaviors at the time of shower, staff could use bed bath cloths, reapproach later, or have another staff member who has better rapport try. E2 stated she would expect staff to know about individual care and the MDS/Care Plan be accurate and updated with any changes. On 6/16/16 at 9:14 AM, E15, LPN and E1 both confirmed R3 had a history of [REDACTED]. E15 stated she should have coded the 4/23/16 MDS for previous falls. The Facility's Fall Prevention Policy, dated 9/3/15, documents in part: To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each residents' wishes/desires for maximum independence and mobility. 2. Staff must observe residents for safety. If residents with a high risk code are observed up or getting up, help must be summoned or assistance must be provided to the resident. It also documents 5. The unit nurse will place documentation of the circumstances of the fall in the nurses notes along with any new intervention deemed to be appropriate at the time. The unit nurse will also place any new intervention on the CNA assignment worksheet. 6. Report all falls during the morning Quality Assurance meetings Monday through Friday. All falls will be discussed and comments will be written on the Quality Assurance Fall tracking form and any new interventions will be written on the care plan. 2. R2's Admission Record, undated, documents R2 was admitted [DATE]. R2's June 2016 Physicians Order Sheet (POS) documents [DIAGNOSES REDACTED]. R2's MDS dated [DATE] and 9/16/15 both document R2 is moderately impaired, is only able to stabilize with staff assistance during surface to surface transfers, has impairment to one side of his upper extremity and has a history of falls. R2's Care Plan last reviewed 5/16/16 documents in part, Falls: Potential for falls related to bilateral AKA, has balance issues, CVA with left [DIAGNOSES REDACTED] and is incontinent. Interventions, 9/11/15: (R2) request seat belt on while up in wheelchair related feels weak, able to remove seat belt on own. (R2) does not have any legs. 11/23/15: Physical Therapy/Occupational Therapy (PT/OT) to evaluate and treat related increased weakness. 11/17/16 Educate (R2) to go to bed when tired. 11/29/15: Re-educate (R2) to use reacher when something out of reach. 3/19/16: Sent to emergency room and returned with sutures done lip received tetanus at hospital. (R2 stated he felt dizzy and hit mouth on night stand). Monitor suture site for signs and symptoms of infection, remove as ordered. PRN (as needed) pain meds. 5/18/16: Re-educate staff/(R2) to have help with transfers and wait for assistance. 5/29/16: Frequent reminders for proper wheelchair positioning. 6/6/16: Seat belt repositioned on wheelchair to allow for better trunk control. 6/8/16: Self releasing seat belt alarm was added today. OT to evaluate for positioning. R2's Fall Risk Assessments, dated 9/16/15, 12/8/15, 2/29/16, 4/29/16 and 5/16/16, document R2 is a high risk for falls. R2's Physical Therapy Plans of Care, dated 6/13/16 and 12/03/15, both document, Functional Deficits: Balance, Fall Risk - moderate risk and Balance, Fall Recovery- moderately impaired. R2's Physical Restraint/Enabler Assessment, dated 9/11/15, documents, Mental Status: Alert: Yes, Short Attention Span: No, Orientated to: Person and Place, Disorientated: Intermittent. Balance When Sitting: Falls forward: Yes, Falls/Leans sideways: Yes to Right, Slumps: Yes. Recovery of Balance (while sitting): Forward: Yes, Backward: No, Sideways: Yes. Ambulation: Does not ambulate related to both above knee amputations. Describe Risk versus Benefits: able to release seat belt of own/command. (R2) request self release belt for positioning, he is a bilateral AKA, with paralysis on right side, uses left arm/hand for mobility of wheelchair. (R2) states seat belt will keep him in his wheelchair, not a restraint. Reviewed 12/8/15 with no changes. 6/8/16 self releasing seat belt alarm was added to alert staff of (R2) leaning over in wheelchair related to no lower extremities, poor trunk control. R2's Nurse's Note, dated 10/27/15 at 6:20 PM, documents in part, Called to outside patio, found (R2) laying on ground on his back in front of wheelchair. Other (alert) residents stated he started sliding down and eventually slid out of wheelchair underneath wheelchair . No bruises or apparent injuries. No other documentation found in R2's Clinical Record for this fall. R2's Nurse's Note, dated 11/17/15 at 7:00 PM, documents in part, Called to TV room per CNA. Found (R2) laying on floor on his back. (R2) had removed his seat belt and fell asleep causing him to fall face first into the floor. (R2) has a 3.3 x 1.6 cm (centimeter) laceration to midforehead. Complaint of headache . Orders received to send to ER (emergency room ). R2's Nurses Note, dated 11/17/15 at 11:45 PM, documents in part, (R2) arrived back to facility via stretcher. (R2) has 8 sutures to cent (center) of forehead. The Facility's Final Report for R2, dated 11/20/15, documents in part, On 11/17/15 at 7:00 PM (R2) was observed on the floor in the TV room. He was assessed by the nurse and noted to have a laceration to forehead. Physician and family notified with orders to send to ER for evaluation where he received sutures to the laceration. During the investigation (R2) stated that he was watching TV and fell asleep causing him to lean forward resulting in fall. (R2) wears a self releasing seat belt as a reminder which he reports that he had unfastened while watching TV prior to the fall. The fall was a result of (R2) falling asleep in his chair while watching TV. The IDT met, reviewed and residents care plan has been updated to reflect current status. R2's Nurse's Note dated 11/29/15 at 7:45 documents in part, Heard (R2) yelling, went to see what was going on when nurse walked into room (R2) noted to be sitting in the wheelchair his head was on the floor. (R2) sat up with assistance unable to let us know what happened just motioned to the floor, no item on the floor to be picked up. No red marks or bleeding to forehead. No red mark to abdomen where seat belt was in place attached in place and around waist. No other documentation found in R2's Clinical Record for this fall. R2's Nurse's Note, dated 3/19/16 at 4:40 PM, documents in part, This nurses heard resident yelling for help. Upon entering room this nurse found (R2) slumped over in his wheelchair with large amount of blood on floor, beside table and bottom part of bed . Noted (R2) to have a 2 inch deep laceration above upper lip (R2) stated he was dizzy and went to his room to lay down and collapsed . New order received to send to emergency room . R2's Nurses's Note, dated 3/20/16 at 2:00 AM, documents in part, (R2) received 5 stitches to upper lip. (R2) received a tetanus shot. The Facility's Final Report for R2, dated 3/26/16, documents in part, On 3/19/16 at approximately 4:10 PM (R2) was observed leaning over on his nightstand while still in his wheelchair and assessed by the nurse with a laceration to his upper lip. Physician and family notified with orders to send to the ER where he received sutures. The facility initiated investigation per protocol. Staff reported that (R2) passed the nurse in the hallway stated that he was dizzy and going to his room. The nurse went to (R2's) room where he was noted to be leaning over on his nightstand while still in his wheelchair with laceration to his upper lip. The laceration was a result of (R2) having dizziness and leaning over night stand will still in his wheelchair. The room was assessed with [REDACTED]. The IDT reviewed and updated care plan reflect current status. R2's Nurse's Note, dated 5/8/18, untimed, documents in part, Called to room by nurse, (R2) noted on floor on back, states (I fell from chair.) R2's Nurse's Note, dated 5/8/16 at 10:00 PM, documents, Sent to hospital emergency room for evaluation. R2's Nurse's Note, dated 5/9/16 at 1:30 AM, documents in part, (R2) returned to facility with DX (diagnosis): of Brain Concussion. On the same day, R2's Nurses' Notes document at 4:00 PM Neuro checks WNL (within normal limits). See neuro/head trauma assessment form. No other documentation found in R2's Clinical Record for this fall. R2's Emergency Department (ED) Provider Documentation sheet created 5/9/16 documents in part, ED Arrival Date: 5/8/16. History of Present Illness, Chief Compliant: Head Injury. [AGE] year old male nursing home resident who fell while transferring from the wheelchair and struck his head. (R2) is on blood thinners. No LOC (loss of consciousness). No other injuries. General Appearance: Mild Distress: Well Developed: Well Nourished. Diagnosis/Impression: Primary Impression: Brain concussion. R2's Nurses Note, dated 5/29/16 at 9:55 PM, documents, See SBAR related to fall. SBAR Communication Form for R2, dated 5/29/16, documents in part, Situation: Things that make the condition or symptom worse are (R2) removing seatbelt. Things that make the condition or symptom better are wearing seatbelt. Resident Evaluation: 10. Neurological Evaluation, abnormal speech, dizziness and unsteadiness. Appearance: (R2) was laying on his back on floor. He stated he hit his head. (R2 does have a small goose egg to right forehead) Nursing Notes: (R2) had undone his seatbelt and was leaning forward and toppled out of his chair. R2's Nurses's Note, dated 6/6/16 at 9:50 AM, documents in part, (R2) was leaving (R2's) Room, when he fell to the floor hitting his head. This caused a small laceration on his forehead. Sent to hospital. Transferred via ambulance. R2's Nurse's Note, dated 6/6/16 at 2:30 PM, documents in part, (R2) returned to facility via ambulance Laceration to right forehead measures 2 cm with 3 sutures dry and intact. R2's ED Provider Documentation sheet created 6/6/16 documents in part, ED Arrival Date 6/6/16. History of Present Illness, Chief Complaint: Head Injury. [AGE] year old male from nursing home after a mechanical fall from wheelchair. (R2) at baseline significantly limited in his ability to communicate. Today he is awake, eyes open, complaint of facial pain and neck pain, unable to quantify, unable to provide additional descriptors, unsure why he fell or if he is able to tell me (Z4, ED Physician). No loss of consciousness, reportedly witnessed by staff, 911 called. Has a laceration on his forehead with a dressing in place. History of right sided contractures and bilateral AKA's. Normally his is orientated x 1-2, here will tell me (Z4) his name is (R2). Procedures, Laceration Location Description: Right (side of forehead), Laceration Description: Linear, Length: 3 cm, Number of Sutures: 3. Diagnosis/Impression: Primary Impression: Laceration of head, Additional Impression: Traumatic hematoma of forehead. R2's Radiology Report, dated 6/6/16, documents, Procedure Description: CT (Cat Scan) Lumbar Spine WO (without contrast), Impression: Mild compression fracture deformity superior endplate of L2 of indeterminate age. Findings: L1-2: Spondylosis, Concern for recent superior endplate mild compression fracture L1. The Facility's Final Report for R2, dated 6/10/16, documents in part, On 6/6/16 at approximately 9:50 AM, (R2) was propelling himself in his wheelchair out of his room and fell forward out of the wheelchair. (R2) does wear a seat belt to aid in trunk stability due to his bilateral AKA. At the time of the fall (R2's) seat belt was unbuckled. (R2) is able to undo the seat belt and does at time. When asked if he unbuckled his seat belt, he stated he was not sure. In conclusion, the facility has determined that (R2) fell as a result of trunk instability due to not having his seat belt buckled. It was determined that he unbuckled the seat belt and he has been educated on the importance of keeping it buckled. The IDT met, new interventions were discussed and his care plan has been updated to reflect the changes. R2's Nurse's Note, dated 6/8/16 at 12:30 PM, documents in part, (R2) in tv room reaching for a magazine. Seat belt was intact but (R2) able to unlock. (R2) fell hitting his posterior head causing 2 cm (centimeter) laceration. Pressure dressing was applied. Bleed stopped. C/O (complaint of) left shoulder and back pain . Ambulance notified for transfer to hospital. R2's Nurse's Note, dated 6/8/16 at 6:35 PM, documents in part, Resident returned to facility via stretcher/ambulance, accompanied per 2 attendants with 3 staples dry and intact to posterior scalp. SBAR dated 6/8/16 documents R2 had a decreased level of consciousness (sleepy lethargic), new pain with complaint of left shoulder pain and back pain. The Facility's Final Report for R2, dated 6/13/16, documents in part, On 6/8/16 at approximately 12:30 PM, (R2) was noted to be lying on the floor on his back in the TV area. Noted a laceration to the back of his head and he was complaining of back and shoulder pain. New order received to send to the ER for further evaluation and treatment. While at the ER, sutures were placed to close the laceration. (R2) stated he was reaching to get a magazine off of the shelf and fell out of wheelchair. (R2) does wear a seat belt to aid in trunk stability due to his bilateral AKA. Recently his seat belt was moved from his pelvis area to better fit around his chest area to aid in truck stability. At the time of the fall (R2's) seat belt was unbuckled. The CNA that was assigned to (R2) stated earlier in the day (R2) had unbuckled his seat belt and she buckled it and educated him on the importance of keeping it buckled. The facility determined that (R2) fell as a result of trunk instability due to not having his seat belt buckled. The IDT met, new interventions were discussed and his care plan has been updated to reflect the changes. R2's ED Provider Documentation sheet created 6/8/16 documents in part, ED Arrival Date 6/8/16. History of Present Illness, Chief Complaint: Head Injury. [AGE] year old male via EMS (Emergency Medical Services) who I (Z4) am familiar with from earlier this week after a a similar fall. Today (R2) was reportedly reaching for something in the dining room and fell out of his chair striking the back of his head, no LOC (loss of consciousness), denies neck pain, reportedly has a scalp laceration on the back of his head, denies chest pain or dyspnea, no abdominal pain, no other complaints, rates pain (god d***). Procedures, the 3 cm linear scalp laceration was prepped and draped in the sterile fashion. The galea was notable intact and the skin was closed with three staples. Diagnosis/Impression: Primary Impression: Scalp laceration, Additional Impression: Scalp hematoma. On 6/13/16 at 1:10 PM, R2 was sitting in the hallway with a 1 inch laceration about his right eye. At that time, R2 was wearing a seat belt up under his upper abdomen. On 6/15/16 at 8:25 AM, E3, LPN, asked R2 to remove his seat belt. R2 then took his left hand grabbed the belt from under his chest and released the Velcro belt. On 6/13/16 at 3:00 PM, R2 stated that he has fallen 6 or 7 times lately and he now is wearing a new seat belt that sits higher on his abdomen. He then stated that he like

Based on observation, record review and interview, the facility failed to identify pressure sores; failed to accurately assess pressure sores; failed to turn and reposition residents; failed to monitor; and failed to provide interventions developed for pressure sores for 6 of 6 residents (R1, R2, R5, R6, R10 and R11) reviewed for pressure sores in the sample of 11. This failure resulted in R2 developing an avoidable unstageable pressure sore on his left heel; R5 developed multiple avoidable stage 2 and stage 3 pressure sores on his coccyx; R6 developed avoidable pressure sores on his heels; R10 developed multiple avoidable stage 2 pressure sores that facility was unaware; and R11 developed multiple avoidable pressure sores from a leg brace and pressure sore on the coccyx that weren't identified until after she died . Findings include: 1. R5's Minimum Data Set (MDS) of [DATE] documents R5 has no cognitive impairment; is totally dependent on 3 or more staff for transfer; requires extensive assistance with hygiene and toilet use; and is occasionally incontinent of bowel and bladder. R5's Care Plan of [DATE] documents R5 is at risk for Pressure Ulcer per Braden Risk Assessment with interventions, in part; turn and position every 2 hours; maintain clean, dry, wrinkle free linens; monitor site for infection - redness, swelling, drainage, foul smell, decline in function, reduced mobility; toilet, change brief when wet and upon rising at bedtime and after meals; to lay down after meals per MD's order. R5 was observed on [DATE] up in his wheel chair from 12:20PM to 2:05PM. At 1:00PM, R5 stated he had been up in his wheel chair all morning and stated he wears an incontinent brief. R5 stated he wanted to lay down. At 2:05PM, E6 and E7, Certified Nurse Aides (CNA's) stated they got R5 up at 7:30AM and that R5 had not been out of his wheel chair since then. E3, Registered Nurse (RN)/Acting Director of Nursing from a sister facility, came into the room. The CNA's transferred R5 to an air flow bed with 2 bed pads under him and removed his incontinent brief that was saturated with urine and the folded pad on the seat of his wheel chair was wrinkled and bunched up in areas. The back of R5's thighs and buttocks were deep creased and red. R5 had a bunched up 4 x 4 dressing on his coccyx that was 4 x 4 inches dated [DATE]. R5 stated he was tired and his eye lids were heavy. The CNA's were observed to do incontinent care and by the time they were done, R5's dressing was loose and only adhering to his right buttock and partially to the left buttock. On [DATE] at 12:13PM, E3 was asked if anyone changed R5's dressing yesterday afternoon after he was transferred to bed. E3 stated treatments are done only one time a day. E3 stated she didn't know if anyone changed the dressing, "probably not." R5 was observed on [DATE] every 15 to 20 minutes up in his wheel chair from 10:30AM to 2:35PM. At 1:45PM, R5 told stated that he wanted to go to bed. At 1:50PM, E21, RN/Assistant Director of Nursing from a sister facility was informed R5 wanted to go to bed. E21 stated E7, CNA, told her that when they got R5 up that morning, his pressure sore didn't look good. At 2:05PM, E11, CNA, stated she was suppose to give R5 a shower the other day, but his pressure sore on his bottom didn't look good and she was afraid it might become infected so she gave him a bed bath. At 2:15PM R5 was informed that staff would be in to lay him down and R5 stated, "Good." At 2:25PM, R5 was still up, had a visitor in his room and stated he wanted them to lay him down. E10, Licensed Practical Nurse (LPN) was informed that R5 wanted to lay down and that Surveyor wanted to see his pressure sore on his coccyx. At 2:35PM R5 was transferred to bed by E17 and E18, CNA's. R5's incontinent brief was saturated with urine and urine was at the crotch. R5's buttocks were deep creased and red along with the back of his thighs. R5 stated his bottom hurt. "They said it was healed but it 's getting bad. It hurts." At 2:55PM, E21 removed the bandage on R5's coccyx/sacrum area. There was a large pressure sore irregular in shape the size of a quarter with slough along the right edge and multiple open pressure sores surrounding the larger pressure sore. There was macerated tissue surrounding the multiple pressure sores. R5's Treatment Administration Record for February 2012 shows documentation on [DATE], "Coccyx cleansed and Island Drsg (dressing) applied til Multiplex come in. Doesn't appear to be opened skin red & irritated with old scar tissue 5.3 cm x 2.5 cm x 0.1 area" facility identifies depth but documents it is not open. On [DATE]:45PM and 3:40PM, E1 was asked for the assessment of R5's pressure sore on his coccyx. E1 stated E3 was working on it. On [DATE] at 9:45AM, E1 again was asked for the assessment on R5's coccyx. At 10:00AM, E3 provided a Shower Abnormal Skin Report dated [DATE] and signed by E3 documenting "Coccyx 5 x 1.5" At 10:07AM, E3 and another Surveyor looked at R5's pressure sore on his coccyx. There was a larger pressure sore on R5's coccyx with slough on the outer right edge and multiple open pressure sores surrounding the larger pressure sore with two having slough and one long thin scabbed area to the lower right. Surrounding skin of the coccyx area and the one to the immediate right was macerated. E3 stated the facility had the coccyx staged as a stage 3, but she would stage the area at the coccyx to be a stage 4. R5 stated the pressure sore hurt and it was from sitting on it to long. At 11:00AM, E3 stated she did not previously assess R5's pressure sore on his coccyx and the first time she saw it was today with the Surveyor. E3 stated the pressure sore was assessed by E25, Administrator from a sister facility on [DATE]. E3 confirmed there was no staging of the pressure sore and that E25 failed to assess individual pressure sores and measured the whole area as one pressure sore. E3 stated she had signed the shower sheet because she filled it out. E3 stated E25 has told her the pressure sore measured 5 x 1.5 cm. E3 stated, "There is a system problem at this facility. No system in place for assessing pressure sores." E3 confirmed there is no assessment on R5's coccyx and stated she would do an assessment and measure today. On [DATE] at 11:48PM, E3 provided a Weekly Wound Tracking form dated [DATE] documenting R5's pressure sores on the coccyx. The center of the coccyx was assessed as a stage 3 pressure sore measuring 4 x 3 x .2 cm minimal drainage and no odor. A pressure sore on the left of the coccyx was assessed as a stage 2 measuring .6 cm x .6 cm x .1 cm with minimal drainage and area for odor was left blank. A pressure sore to the right of the coccyx was assessed as a stage 3 measuring .5 x 3 [MEDICAL CONDITION] cm with minimal drainage and the area for odor was left blank. Date of onset of the pressure sores was documented as [DATE]. The facility Policy and Procedure for Preventative Skin Care dated ,[DATE], documents: "Policy: To provide preventative skin care through repositioning and careful washing, rinsing, drying, and observation of the resident's skin condition to keep them clean, comfortable, well groomed, and free from pressure ulcers." Procedures, in part; "Any resident identified as being at high risk for potential skin breakdown shall be turned and repositioned at a minimum of every two (2) hours; Maintain wrinkle free, clean, dry bed linen; Keep incontinent residents clean and dry..." lower left extremity. R11's Treatment Sheet, dated ,[DATE], documented R11 wore a "(special) Boot" to2. R2's MDS, dated [DATE], documented R2 was extensive assistance of one person physical assistance with mobility and transfer and upper and lower extremity functional limitations in range of motion. R2's Care Plan, start date [DATE], documented R2 was at risk for skin breakdown related to decreased mobility. It was also noted the Nurse was to do skin check two times per week. R2's Care Plan, dated [DATE], documented "Area to (L) (left) heel (unstageable) eschar off [DATE] Stage II." It was also noted "[DATE] refer to (wound management clinic)." R2's Treatment Records and Weekly Skin Summaries, dated ,[DATE], ,[DATE] and ,[DATE], did not consistently document R2's skin was checked two times per week. R2's skin was documented as being checked on [DATE], [DATE] and [DATE] without skin breakdown. R2's skin check, dated [DATE], documented "weekly skin assessment re heels 4.3 x 5.5 x utd deep tissue injury/pressure area to left heel. Scrotum and groin excoriated. All (?) skin intact." R2's Treatment Record, Weekly Skin Summaries and chart did not document his left heel pressure area was identified at lesser stage or alternative interventions were put in place to prevent his left heel from developing a pressure sore with deep tissue injury. 3. R11's MDS, dated [DATE], documented R11 was a cognitively impaired resident with upper and lower extremity functional limitation in range of motion and at risk for pressure sore development. R11's Care Plan, start dated [DATE], documented R11 was a potential for skin breakdown. It was also noted to assess skin and to do a skin check times twice per week. R11's Treatment Records and Weekly Skin Summaries, dated ,[DATE], ,[DATE], ,[DATE] and ,[DATE], did not document R11's skin was consistently checked two times a day. It was also documented R11's skin was checked on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. R11's Treatment Records and Weekly Skin Summaries did not document lower extremity skin breakdown R11's Illinois Health Care Facility Report on Resident Death, dated [DATE], documented R11 had "(l) Pressure sores/Decub coccyx .5cm x 1.5 Stage II" and "Other conditions "(2) large st (skin tear) to left of coccyx 3.5 x 3cm, (3) (L) (left) inner knee 3 cm x 3 cm (4) small darken area (L) outer need/top length 1.2 x 2.5 not open." It was also documented on a pictorial of R11 that(1) was on her coccyx and (2), (3) and (4) were on her her left foot at all times. Z4 (R11's Power of Attorney) stated, on [DATE] at 8:45a.m., that the facility was not aware of R11's knee and leg area until Z4 instructed unidentified staff to check R11's left lower extremity. Z4 also stated R11 wore a left lower extremity brace, or boot, and that the brace was pressing against R11's skin. 4. The physician's orders [REDACTED]. The MDS, dated [DATE], documents R10 as severely cognitively impaired and is total care requiring assist of at least two staff persons for locomotion, toilet use, hygiene and bathing; and requires extensive assist of at least 2 staff persons for all transfers with a mechanical lift, bed mobility, dressing and eating. The MDS also documents R10 has bilateral upper and lower extremity limitations and is always incontinent of bowel and has a urinary catheter. The care plan, dated last review [DATE], documents R10 is at risk for pressure ulcers related to decreased mobility, bilateral upper extremity contractures, [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. The approach/interventions listed, in part, skin check with routine care by CNA - inform nurse of abnormal findings; nurse to do skin check two times per week, and turn and position every two hours and prn (as needed). On [DATE] at 10:15 AM, R10 was observed sitting up in his high back wheelchair in his room. At 11:00 AM, R10 was still sitting in his high back wheelchair in his room. At 11:50 AM, R10 was observed in his high back wheelchair in the dining room. At 12:50 PM, R10 was back in his room in the high back wheelchair. At 1:35 PM, R10 was observed in his high back wheelchair in his room. At 2:20 PM, R10 was still in his room in the high back wheelchair. At 3:10 and 3:45 PM, R10 remained in his room in the high back wheelchair. On [DATE], at 9:05 AM, R10 was observed to be at the nurses station in his high back wheelchair. At 9:15 AM, he was propelled to his room and left in the high back wheelchair. At this time, this surveyor asked E12 (CNA) to observe R10 transfer to bed and to do a skin check. At 10:55 AM, R10 was observed to already be in bed, transferred by E12 and E13 (CNA's). E14 (RN) and E23 (LPN) were observed coming out of the room. Upon entering R10's room, R10 was lying in bed with pants down at his ankles and side rails up. An area to the left hip was noted and appeared to be approximately pea sized with serosanguineous drainage with reddened edges, thick white cream was noted in and around the wound. E13 stated that the white cream was barrier cream that the CNA's had been putting on after showers. E13 also stated that the wound was noted to be opened today. Another open area was noted on the coccyx. This open area is in a linear shape directly between the folds of the buttocks approximately 3 cm in length. The wound had small amount of serosanguineous drainage with reddened edges. White cream was also noted around the wound. Multiple scabbed areas noted to bilateral lower legs. On [DATE] 1:20 PM, R6 was observed to be in his high back wheelchair in his room. At 2:30 PM, R6 was propelled to the activity area in his high back wheelchair. At 3:45 PM, R6 was observed in his high back wheelchair in his room. On [DATE], a late entry nurses note from [DATE] at 4:40 PM, documents the physician called back with orders for wound treatments for R10. It also documents R10 had multiple skin concerns as follows; right medial shin scabbed area 2.2 x 1.1 cm, right superior shin scabbed area 2.4 x 1.1 cm and right upper shin scabbed area 0.5 x 0.5 cm. Also, on the left upper thigh/hip area measuring 0.6 x 2.4 cm open, and on the coccyx 1.0 x 0.5 cm open. On [DATE], Laboratory Reports document R10 had [MEDICATION NAME] of 3.8 (3XXX,[DATE].5 g/dl range) and Total Protein of 6.9 (5XXX,[DATE].3 g/dl range). Treatment records for the months of [DATE], January and February 2012 indicate "skin check two times per week on shower days." There is nothing checked as being performed for the month of December or February and only [DATE] and 31 is checked as performed. On [DATE] at 1:25 PM, Z3 stated "This is the first time in [AGE] years that he has had any pressure sores." When asked if she knew how R10 developed these pressure sores, she stated "obviously they leave him in his chair too long." She also stated that she has been complaining for months that his wheelchair needed some sort of footboards or a way to elevate his feet to help prevent him from sliding down too far in his chair. 5. The physician's orders [REDACTED]. The MDS, dated [DATE], documents R6 is severely cognitively impaired and requires extensive assist of at least two staff persons with all transfers, bed mobility, dressing and bathing. It also documents R6 is a total assist with at least two staff persons for toilet use and is frequently incontinent of bowel and bladder. It documents R6 to have both upper and lower extremity limitations and does not currently ambulate. The care plan, last updated [DATE], documents R6 is at risk for pressure ulcers and the approach/intervention listed, in part, as reposition every two hours and prn. On [DATE] at 10:15 AM, R6 was observed to be sitting in a wheelchair in his room. At 12:12 PM, R6 was still sitting in his room in his wheelchair. At 12:25 PM, R6 propelled himself to the dining room for lunch. At 12:50 PM, R6 was observed to propel himself to the nurses station then outside to smoke. At 1:45 PM, R6 was observed in his wheelchair outside smoking. At 2:30 PM, R6 was observed in his room sitting in the wheelchair. At 3:15 PM, R6 was sitting in his wheelchair next to door to the outside smoking area. On [DATE] at 9:05 AM, R6 was observed sitting in his wheelchair next to door to the outside smoking area. At 11:05 AM, R6 was observed in his room sitting in his wheelchair. At 11:30 AM, R6 was observed propelling himself down the hallway to the nurses station. At 1:30 PM, R6 was observed being propelled via wheelchair to his room. At 1:45 PM, R6 was observed propelling himself to the nurses station then outside to smoke. At 2:10 PM, R6 was observed propelling himself to the nurses station then back outside to smoke. On [DATE] at 9:10 AM, R6 was observed to be sitting up in his wheelchair in his room. At 11:15 AM, R6 was observed to be out at the nurses station in his wheelchair. R6 was not observed out of his wheelchair throughout the survey from [DATE] to [DATE]. A physician's note, dated [DATE], documents that R6 had a stage III decubitus ulcer on the left foot. R6 was admitted to the facility on [DATE]. The physician's orders [REDACTED]. A wound consultation report dated [DATE], documents that R6 had left and right heel ulcers. The wound tracking report for February 2012 documents R6's stage III left heel ulcer measured 0.7 x 0.8 x 0.3 cm and the right heel ulcer measured 2.0 x 4.4 x 0.3 cm and is determined to be unstageable. The wound consultation report for [DATE] documents R6's left heel ulcer measured 0.7 x 1.7 x 0.3 cm and the right heel ulcer measured 1.7 x 4.5 x 0.3 cm, showing a decline in the wound status for both heels. 6. The MDS, dated [DATE], identifies R1 to have short/long term memory deficits with severe cognitive impairment and is totally dependent on staff for all activities of daily living including mobility and transfers. According to the care plan dated [DATE], R1 has a potential for altered skin integrity due to decreased mobility and incontinence. The interventions included turning/reposition every 2 hours and as needed (PRN), pericare after each inc (incontinent) episodes, pressure relief mattress, and skin check daily among others. The care plan indicates that R1 has no pressure ulcers at this time. On [DATE] at 12pm, R1 was in her wheelchair in the dining room preparing for lunch. R1 was observed to eat lunch in her wheelchair and then be moved to the television room where she remained in her wheelchair. At 3:45pm, the observation ended with R1 still in her wheelchair. R1 was observed at 15 minute intervals with no turning/repositioning or toileting being done as indicated in the care plan. R1 had no pressure relieving cushion in her wheelchair. On [DATE] at 12noon, R1 was again in the wheelchair in the dining room. At 1:43pm, R1 was transferred to the toilet and a urine soaked incontinent brief was removed. She had no pressure relieving cushion in her wheelchair. Her buttocks and gluteal folds were very red with deep creases throughout. E12 and E13, CNA's provided incomplete incontinent care and transferred her back into the wheelchair where she remained until the observation ended at 3:45pm.

Based on record review, interview and observation, the facility failed to provide supervision to prevent falls for 1 of 2 residents (R32) reviewed for falls in the sample of 7. The findings include: R32 was admitted to the facility on [DATE], and the March 2012 Physician order [REDACTED]. The March 2012 POS documented the following orders: 2/29/12-"okay for seat belt in wheelchair", 9/14/11-"use pad alarm in bed", "use alarmed self releasing seat belt when up", and 8/3/11 - "Dycem in wheelchair". The Care Plan dated 5/19/11-3/6/12 assessed R32 as "High Risk for Fall". The Care Plan identified that R32 was assessed as "high risk" due to "balance" and [DIAGNOSES REDACTED]. Does not wait for assist". On 1/23/12 the "Plan of Approach" added "Do not leave unattended in room. Remove w/c (wheelchair) from room when in bed". The Care Plan documented as approaches to use tab alarm in wheelchair, provide on-going education regarding the use of a call light and waiting for assist, check proper placement and seat belt function. The "Investigation Report for Falls" dated 4/11/12 documented R32 was found at approximately 7:00 AM on the floor. R32 stated he was reaching for a paper and slid from the wheelchair. The report documented the call light was not in reach. The report does not document the location where R32 was found. The nurses notes dated 4/11/12 documents R32 was "reaching for a paper on his counter...". The report documented the fall was not witnessed. No injuries were noted. The "Investigative Report for Skin Tears/Bruises" dated 4/15/12 documented R32 was found on the floor in his room by his family. The report documented R32 said he un-did his seatbelt because it was too tight, and he slid to the floor. The report documented the incident "occurred while unattended". The report documented R32 was counseled regarding use of the call light for assistance. The nurses notes dated 4/15/12 confirmed the report. On 4/17/12, R32 was observed in his room unattended at 9:45 AM, 9:55 AM and 10:15 AM. The call light was not in reach. R32 was asleep in his wheelchair. At 10:15 AM, E3, Certified Nurse Aide, was asked if there were any special instructions for R32, and she stated "How did he get in there?" E3 stated R32 was not supposed to be in his room unattended because he tries to transfer himself and subsequently falls. E3 asked R32 if he wanted to go to an activity. R32 left the room in his electric wheelchair. E1, Administrator, stated on 4/17/12 at 12:05 PM that she had talked to R32 about being unattended in his room, and R32 stated he knew he was not supposed to be in the room unattended. E1 stated after it was reported to her on 4/17/12 that R32 was unattended in his room, she talked to Occupational Therapy for other positioning device to keep R32 from sliding.

A. Based on observation and interview, the facility failed to ensure safe hot water temperatures in resident access areas for 3 residents (R2, R5, R7) in the sample of 11 and 17 residents (R12-R22 and R25-R30) in the supplemental sample. Findings include: During the tour of the facility on 2/28/12 hot water temperatures were taken in the building. The hot water temperatures on the 100 hallways were elevated. The following temperatures were taken: a. Room 114 lavatory - 116 degrees F (Farenheit) at 10:40AM b. Room 110 lavatory - 118 degrees F at 10:41AM c. Room 105 lavatory - 117 degrees F at 10:44AM d. Room 100-114 Hall Shower room lavatory - 117 degrees F at 11:36AM e. Room 116 lavatory - 116 degrees F at 11:51AM f. Room 121 lavatory - 117 degrees F at 11:53AM In an interview E16, Maintenance Director, on 3/1/12 at 11:30 AM. he stated he adjusted the hot water temperature down. He said that he had ordered a new thermometer to monitor the temperatures. B. Based on record review, observation and interview the facility failed to implement fall interventions for 2 of 6 residents (R1, R2) reviewed for falls in the sample of 11 and 1 resident (R38) in the supplemental sample. This failure resulted in R1 incurring a fractured right femoral head after unsupervised ambulation. 1. The Minimum Data Set ((MDS) dated [DATE] identifies R1 to have short/long term memory deficits with severe cognitive impairment and is totally dependent on staff for all activities of daily living. According to the Care Plan dated 8/11/11, R1 was at risk for falls due to balance issues. The goal was to have no falls by 11/9/11. The interventions included assist with all transfers using a gait belt, use wheelchair for mobility, self release alarmed seat belt on when up, bed sensor when in bed, low bed and mat on floor. The fall risk assessment record documents repeated falls for R1 on 7/31/11, 8/2/11, 8/6/11 and again on 9/12/11. According to an Incident Report dated 9/2/11, R1 attempted to stand up unassisted on 9/12/11 at approximately 7:15pm and was "redirected by staff with self releasing lap belt in place and working." The report indicates that approximately 10 minutes later, R1 took her belt off and attempted to stand again. The report documents "while staff was running to assist her, patient fell on to floor. Assessment revealed severe guarding of left hip and leg as well as 1.5cm x 2.5cm x 0.2cm laceration to left temple." R1 was sent to the emergency room where she was diagnosed to have a fracture of the right femoral head. Surgery was not done and she returned to the facility. In addition, a CT Scan done 9/12/11 also revealed a small hemorrhage, left frontal lobe region. The careplan has only one intervention dated 10/5/11 added following her fall/fracture/hemorrhage and that indicated staff was to "have her hold baby doll + care for it when she is agitated or attempts to stand." There is no further interventions added or deleted until 1/25/12 when an intervention "may use clip/tab alarm and/or lap alarm if indicated" was added. On 1/27/12 at 2:20pm, a reporting form identified another fall for R1. The reports documents that R1 was "sleeping" at the time of the fall and was found sitting on the floor with her legs extended. A personal alarm was in place and sounding staff was unable to reach her before she hit the floor. The causative factor indicates R1 "slipped out of chair" but fails to identify any preventative measures to implement to prevent future falls. There are no new interventions added to prevent further falls. On 2/28/12 at 10am, R1 was sitting in her wheelchair in a dark lounge by herself. Her back was to the door and she was slumped over to the right sleeping in her wheelchair. The television was on. At 1:30pm, she was back in the television room by herself . She remained there until 2:38pm when she was noted to be sleeping in her wheelchair in front of the piano. No staff was in the room. She had an alarm clipped to her shirt and another alarm attached to the back of her wheelchair. On 2/29/11 at 1:43pm, R1 was transferred to the toilet by E12 and E13, Certified Nurses Aides. E12 identified that R1 had an alarm box on her wheelchair for the self release belt but that the alarm did not work and that was why she had a clip alarm on. E12 and E13 both stated R1 can self release the belt. On 3/1/12 at 3:30pm, incident/fall reports were requested on R1's falls dated 7/31/11, 8/2/11, and 8/6/11 from E1, Acting Administrator. On 3/2/11 at 11:35am, E1 confirmed that she was unable to find any reports on falls for R1 on those dates. According to the nurses notes dated 12/3/11, 12/29/11, 12/31/11 and 2/11/12, R1 sustained repeated skin tears on her upper arms and lower extremeties. The physician's orders [REDACTED]. On 12/31/11, a skin tear to the right forearm was identified in addition to the right outer calf area of the leg. On 2/11/12, an order was documented for a skin tear on the left lower extremity. The facility has no reports on these injuries to determine causative factors according to E1 Acting Administrator on 3/2/12 at 10am. Review of R1's care plan dated 8/11/11 identifies pressure ulcer potential and includes the skin tears on 12/19/11 and 12/31/11 but fails to include any intervention to prevent future skin tears from occurring. On 2/28/12 at 3:27pm, R1 was noted to have a dressing on her left lower leg that was pulled up/rolled up exposing a scabby area with some bright red blood present. R1 was observed pulling and scratching at it. On 2/29/11 at 1:45pm, R1's left lower leg was again noted to have a gauze dressing on it. Interview with E10, LPN on 2/29/11 at 2:15pm indicates that the dressing is for a skin tear to her left shin area which she thinks she got from bumping into the wheelchair pegs. R1 was sitting across the hall in her wheelchair. She had no pedals on her wheelchair and the pegs to attach the pedals had no padding on them. On 3/1/12, the facility completed a "Shower/Abnormal Skin Report" on R1 and noted the area on her left lower leg to measure 2.5cm x 1.6cm x 0.1cm "pink (not) open (no) bleeding." There is no explanation as to how R1's leg wound can have a depth of 0.1cm when there is no break in the skin. There is no documentation that indicates the facility identified the causative factors of R1's multiple skin tears and developed/implemented a prevention plan. 3. The MDS dated [DATE] identifies R3 to require stand by assist/supervision for transfers. The Falls Risk assessment dated [DATE] indicates R3 is high risk for falls and has occasional confusion. According to the care plan of 11/30/11, R3 is at risk of falls due to seizure activity, balance, CVA (cerebral vascular accident) and arthritis. The care plan for falls prevention indicates R3 uses a sensor alarm in bed and chair when up although the care plan also indicates R1 is "currently independent" in transfers. According to the care plan, R3 had a fall on 12/5/11 at 11:30am and staff was educated to the alarms and functioning. The fall report dated 12/5/11 indicates R3 was "transferring self s (without) assist. No alarm in place. Re-educated staff regarding bed + chair sensor alarm c (with) periodic checks" in the bathroom. A fall risk assessment done at that time identify R3 to have balance problems with walking, needs assist to stand and is confused. The investigation indicates R3 was attempting to self transfer without assistance and was found on the floor. Alarm was not on. On 12/24/11 at 11:15am, R3 was again found on the floor when staff found her. The causative factor is identified as "transferring self without assistance" wheelchair to bed. The fall prevention techniques identified in place at the time of the fall was "call light in reach." The report indicates R3 "needs to ask for assistance by using call light." However, the report doesn't indicate whether or not the alarm was in place and in working condition/sounding at the time. In addition, the risk assessment done at the time of the fall fails to indicate what R3's safety awareness is and whether she is capable/willing to use the call light. On 2/11/12, R3 was found on the floor again at 8:55am when she was attempting a self transfer with "unsteady gait. Pt (patient) is a 1 assist c transfer." The report identifies the w/c alarm and grip socks in place as prevention techniques at the time of the incident. Review of the care plan dated 11/30/11 fails to reflect R3's non-compliance to call for assistance prior to attempting self transfer and whether or not she can appropriately use the call light given her confusion. In addition, there is no documentation that shows the facility identified 2 of the 3 falls occurred when R3 was taking herself to the toilet, one after breakfast and one just prior to lunch. The care plan for falls prevention fails to reflect her toileting needs in an effort to prevent her from self transferring. On 2/28/12 at 10:21am during the initial tour of the building with E8, Business Office manager, R3's alarm sounded. R3 had her room door shut and when E8 entered the room, R3 was already on the toilet and her wheelchair was sitting in the doorway of the bathroom. E8 had to call for assistance to help transfer R3 back to her chair. R3's room door was noted to remained closed throughout the survey making visual checks on R3 from the hallway for monitoring impossible unless her door was opened. This also is not reflected in the care plan. 4. According to the MDS dated [DATE], R38 has short/long term memory deficits with severe cognitive impairment and requires extensive assist of one to total assistance of staff for all activities of daily living including mobility and transfers. R38 is currently receiving Hospice Services. The physician's orders [REDACTED]. On 3/1/12 at 1:48pm, R38 was observed being transferred to her bed from the wheelchair by E12 and E22, CNA's. She had a gauze dressing on her right lower extremeties with multiple bruises on her left shin. Review of the care plan dated 11/11 fails to reflect R38's skin tears. A Hospital History and Physical dated 11/3/11 identifies R38 to have "multiple skin tears and ecchymosis to bilateral upper and bilateral lower extremities"" when admitted through the emergency room . The facility has no skin tears for R38 identified on their incident/accident log provided on 2/28/12. According to the Treatment sheets weekly summary, R38 has a history of repeated skin tears that the facility has failed to identify and implement a prevention plan.

Based on interview and record review the facility failed to follow their policy for [MEDICAL CONDITION] (trach) care and failed assess and identify a base line for the frequent suctioning of R2's trach, failed to notify the physician of increased suctioning of R2'[MEDICAL CONDITION] once per hour to every 30 to 45 minutes, and failed to alert the physician of R2's, 02sats repeatedly dropping below 90% prior to suctioning for 1 of 2 residents (R2) reviewed for [MEDICAL CONDITION] care in the sample of 4. R2 became non-responsive and died . This failure resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at Severity Level 2, as the facility continued to educate staff and evaluated the effectiveness of their [MEDICAL CONDITION] policies and procedures and their system of communication. Findings included: 1. A review of E7's, Licensed Practical Nurse (LPN), nurses notes dated [DATE] at 10:40 PM, documented R2 was admitted to the facility with a [DIAGNOSES REDACTED]. The nurses notes document R2 had Oxygen 4.5 Liters at 35% humidified air delivered via the trach. R2 was to receive Glucerna 1.5 at 45 ml per hour continuous via [DEVICE]. E7's, 10:40 PM nurses note documented R2's Oxygen Saturation (O2-sat) level was 93% - 94% upon admission. A review of the Emergency Medical Services Patient Care Report dated [DATE] at 2237 (10:37 PM) documented the following in part; Subjective Data - [AGE] year old man admitted to hospital on [DATE] for [MEDICAL CONDITION] due to poor swallow and aspiration of saliva. Per RN (Register Nurse) (at hospital) requires frequent suctioning. Able to express when he does need suctioned. Patient with catheter, has Peripheral Inserted Central Catheter Line from Right bicep. Keeping foley in. Oxygen Saturation 97%. "LPN at SNF (skilled nursing facility) states she is not sure [MEDICAL CONDITION] is supplied to nursing home." Objective data - 23:00 (11:00 PM) - On 35% high humidity with ventri mask. Report given to LPN at nursing home. Informed LPN that I am not trained on nursing home equipment. Waited at nursing home while LPN contacted someone to let her know how the equipment works. On [DATE] at 3:15PM, E7 stated, " R2 arrived around 10:45PM. I have suctioned people before, but was not familiar with the machine used for humidified air. I called E3, LPN to come in and help me get R2's oxygen set up. E3 arrived about 11:00 PM, and she then called the pharmacy to get instructions on how to set up the humidified air machine. The ambulance left around 11:30 PM, after R2 was set up and stable. R2 would turn on his light when he felt short of breath, and point to his chest. I suctioned R2 5 or 6 times during the night. R2's, Oxygen Saturation (02-sats) stayed in the low 90's through out the shift. There was not a lot of fluid when I suctioned him. R2 slept off and on during the night when not being suctioned. He did not appear to be in distress when I cared for him. I documented the care in the nurses notes. We do not have a form for suctioning, it is just written in the nurses notes." E7's nurses notes dated [DATE], from 1:00 AM to 6:00 AM, failed to evidence documentation that R2 was suctioned "5 or 6 times" during the night as E7 had reported. E7 made two entries on [DATE] at 3:05 AM and 4:30 AM, and both document "suctioned small amount of mucous". R2's O2-sats are recorded once on [DATE], at 3:05 AM, as 93% to 94%. There is no documented information in R2's nurses notes on the other (4) times R2 was suctioned during the night on [DATE], or, his behaviors of turning on the light and pointing to his chest when feeling short of breath. On [DATE], no documentation was evidenced in the nurses notes by E7, regarding R2's vital signs, quality of respirations, bilateral breath sounds, type of secretions, condition of trach/stoma site, cough, or ascultation of R2. On [DATE] at 1:00 PM, E9, Certified Nurses Aide, CNA, stated " I cared for R2 during the night of [DATE], and he did sleep off and on. R2 put his light on several times, I think at least 4 times, to have the nurse come and check [MEDICAL CONDITION] suction him. On [DATE] at 10:00 AM, in a telephone interview, E12, LPN, stated, "I came in at 6:00 AM. E7, suctioned R2 before she left, about 6:30 AM, and he was asleep till around 8:00 AM. I suctioned R2 at 8:00 AM, and removed a large amount of whitish secretions at that time. I was told in report that R2 had to be suctioned frequently. After 8:00 AM, E3, LPN, came in, and was responsible for the care of R2. I did come and help E3 several times during the day with R2's suctioning. R2 would turn on his light and point to his chest when he felt short of breath. His 02-sat's would go down to around 88%, and his heart rate would go up to around 115 or so. After suctioning, his O2-sat's would go back up to the lower 90's, and his heart rate would go down below 100. We were suctioning him throughout the day about every 45 minutes or so. R2 usually had a lot of fluid when I suctioned him. I did not discuss with E3, about calling the doctor about his needing to be suctioned so often, as we were told R2 needed frequent suctioning. R2's 02-sats would be stable after he was suctioned." A review of R2's nurses notes failed to show documentation by E12 that she had cared for or suctioned R2 on [DATE]. The nurses notes contain no documentation on how often R2's O2-sats had fallen into the 88% range between suctioning as described by E12, and had no information on secretions, amounts and type, results of E12's suctioning and no information regarding the stoma site, or R2's behaviors. On [DATE] at 10:00 AM, E3, LPN, stated, "E7 called me on [DATE] at around 10:45 PM, to come and help her set up R2's humidified oxygen because E7, was not familiar with the equipment. I came in around 11:00PM. I called the pharmacy where the equipment came from, and got directions on how to set up the machine for humidified air. When R2 was set up I stayed to help get R2's doctors orders written and get information faxed to the pharmacy for his medications. I left at around 12:30 AM. At 8:00 AM, I returned to work and was in charge of R2's care. E12 helped me with R2's suctioning during the day. I suctioned R2 at 8:30 AM, and his 02-sat's at that time were around 92%. R2 used his call light to let us know when he needed to be suctioned. It seemed that we (E12 and E3) suctioned R2 about every 30 to 45 minutes. I thought this was not a problem, because I was told R2 needed to be suctioned frequently. R2 was gotten up in a geriatric chair at 12:00 PM for one hour and tolerated this well. R2 had visitors at one point during the day and he seemed calmer then also. After 1:00 PM, I noticed more than once that prior to suctioning his 02-sat's would drop to 88% or 89%. After suctioning they would go back up to 90% or 92%. R2's secretions were white and and I did not get a lot of fluid when I suctioned him. During these times, R2 did not seem in distress, just very anxious. He would point to his chest to show he was short of breath. He put on his call light a lot, and seemed like he did not want to be left alone in his room. I have taken care of other residents with trach's in previous jobs, and did not feel uncomfortable caring for R2." A review of E3's nurses notes dated [DATE], documents she suctioned R2 at 8:15 AM, 10:15 AM, 1:00 PM and 1:30 PM. The notes document that each time R2 had moderate amounts of white phlegm, but fail to document O2-sats, consistency of secretions, condition of R2'[MEDICAL CONDITION], or any of the behaviors of anxiousness that E3 described of R2 during the day. At 2:30 PM, E3 documented, "[MEDICATION NAME] done. Spo2 (O2-sats) ,[DATE]%, suctioned large amount of phlegm. No other information is documented regarding R2's, O2-sats being in the upper 88% - 89%'s prior to suctioning, or the condition of R2's trach. At 3:30 PM, E3 did document R2's 02-sat's were 89% and he was suctioned for a moderate amount of white phlegm. On [DATE] at 1:30 PM, E3 stated, "I did not think he was being suctioned too often. I had been told by E7, that the hospital reported R2 was being suctioned frequently, and he was on an antibiotic for pneumonia. I did not think to ask the doctor or his nurse if suctioning R2 every 30 to 45 minutes was too much. I did not call the hospital to verify how frequently R2 had been suctioned when there. I documented everything in the nursing notes. There were no other forms to be filled out regarding R2'[MEDICAL CONDITION] suctioning. Z3, Nurse Practitioner also came and saw R2, the morning of [DATE], and she did not say he looked unstable. At 3:00 PM, E5, LPN, came in and took over R2's care. E5 did tell me that she thought R2 should be sent to the emergency room , because he needed so much suctioning, but I did not agree. I told E5, R2 looked stable to me, and was only anxious when he needed to be suctioned. I gave her the [MEDICATION NAME] medication and told her do his breathing treatment, and recheck him. I gave E5 the medication cart keys and left the floor to do paperwork at 3:30 PM." In a telephone interview on [DATE] at 10:15 AM, E3 stated, "On [DATE], I do not think R2 changed his behavior from morning to afternoon. He was putting on his light every 15 - 20 minutes throughout the day. He was being suctioned every 30 to 45 minutes. It was after lunch I noticed 02-sat's would go down to 88% or 89%, but after suctioning they would go back up in the lower 90%'s and R2 would be calmer. I feel he was stable on my shift. None of the CNA staff told me they thought R2 should go to the hospital." On [DATE] at 11:00 AM, E5, stated, "I came in to work at 3:00 PM, was given report on R2, and saw him at 3:15 PM. I have have had training and cared for and [MEDICAL CONDITION] in a previous job. At 3:15 PM, R2 looked uncomfortable and needy. I told E3, shouldn't R2 be sent out if he needed to be suctioned, so often. E3 did not agree and handed me R2's nebulizer medicine and told me to give the treatment to give R2. R2's 02-sat's were 88%, his pulse was over 100 and he appeared anxious and distressed. He was pointing at [MEDICAL CONDITION] repeatedly. After the nebulizer treatment his Ps02 was 93%, and he did calm a little. R2, was on the call light about every 15 - 20 minutes, was very anxious, and seemed to need someone in the room with him to reassure him. I had E10, CNA, stay with him off and on and this helped him calm down. At 4:30 PM, I suctioned R2, he was teary, and after suctioning his 02-sat's were 90%. I spoke with him, he seemed easily consoled and calmer. At 5:00 PM, I suctioned R2, his 02-sat's was 87% and pulse was over 100 and he was again very anxious, so I suctioned R2 and then called the physician's office to discuss R2's being so anxious. At 5:15 PM, Z2, Nurse Practitioner (NP), returned my call. I told her R2 seemed very anxious. Z2 ordered [MEDICATION NAME] 1mg IM / Now, to be given. I (E5) was not able to give the [MEDICATION NAME] as there was none in the stock supply in the building. I called and faxed the order to the pharmacy to have [MEDICATION NAME] sent out for R2. I did not call Z2 back and tell her we had no IM [MEDICATION NAME]. At 5:30 PM, I (E5) saw R2 and he was resting in bed, gave him a stuffed animal to hold, I checked his tube feeding, he was resting, he nodded and opened his eyes when I spoke to him." E5's nurses notes dated [DATE] at 3:15 PM, documented "Upon entering room, resident (R2) appeared to be in distress. Sp02 (O2-sats) @ 88%. Neb treatment given, resident denies pain with nod of head, wheezing noted in upper and lower bilateral lobes. No distress noted, will continue to monitor." At 4:30 PM, E5's notes documented, "Resident in room, teary eyed, continues to deny pain with nod of head, pointing to trach. Suctioned with small amount phlegm extracted. Sp02 at 90%." At 5:00 PM, E5 documented "resident appears anxious, Sp02 at 90%, writer called to Dr's (physician)exchange, awaiting call back. At 5:15 PM, E5's notes documented that Z2, returned the call and ordered [MEDICATION NAME] 1mg for Anxiety. A review of the physician's orders [REDACTED]." On [DATE] at 2:50 PM, E5 stated "At 6:00 PM, E6, LPN, came on duty and I gave him report. I informed him of R2's status. During the report, between 6:10 PM and 6:20 PM, the pharmacy called back and said the [MEDICATION NAME] had not been approved and needed the doctors signature. At about 6:30 PM, E6, called me to R2's room and told me R2 didn't look right. I attempted to locate an apical and radial pulse and found none. R2's eyes were fixed. E6 said to call 911 and he started CPR with E13, CNA. The Emergency Medical Technicians (EMT) / Ambulance was here within 10 minutes, and they continued CPR and left the building at about 6:50 PM." A nurses note dated [DATE], 6:45 PM, by E5, documented in part, "Writer summoned to residents room, resident lying on back, eyes affixed, unable to obtain apical pulse, no respirations, requested crash cart, CPR started, 911 called, CPR continued. Ambulance here and 2 EMT's, continued CPR out of building." On [DATE] at 2:37 in a telephone interview, E6, LPN, confirmed that he had only seen R2 for the first time on [DATE] at 6:30 PM, when he was found non-responsive. E6 stated he called E5 for help, and CPR was started and 911 called for assist. E6 stated that E13 did help with CPR. On [DATE], at 4:00 PM in a telephone interview with E13, she stated that she was assigned to care for R2 on [DATE]. E13 stated that she arrived at 6:00 PM, and immediately went to the dining room to help feed other residents, and did not see R2 until called by E6, to assist with CPR on R2. On [DATE] at 2:37 PM in a telephone interview, E6, stated that he arrived at work at 6:00 PM, and received report on R2, from E5. E6 stated that at about 6:15 PM the pharmacy called and reported R2's [MEDICATION NAME] order had not been approved and needed the physician's signature. E6 stated he went to do rounds and at 6:30 PM he entered R2's room and found him unresponsive. R2 was lying in bed with no palpable pulse and eyes fixed. E6 stated he started CPR with E13, while E5, called for an ambulance. E6 stated the R2 had no vitals when he (R2)left the building. In additional interviews done on [DATE], with E8 and E10, both CNA's, they both verified on [DATE], R2 used his call light every 30 minutes or so to get the nurse to suction him. When he was short of breath he would point to his chest, and he seemed anxious, but was more calm when staff were in the room. On [DATE] at 2:00 PM, E11 CNA, stated, "I helped to care for R2 on [DATE] during the day shift. I came at 6:00 AM. R2 would put on his light every 20 or 30 minutes. He either put on his light or would bang his hand on the wall to get someone to come to him. The nurses were in his room every 30 minutes or so to suction him. R2, seemed scared to me and I did ask once if E3, thought he should be sent to the emergency room . E3 told me R2 was stable. On [DATE], at 9:40 AM, in a telephone interview E1, Administrator, stated " I did pop in and check on R2 at various times during the day. R2 did seem nervous to be in the facility, I thought it ws because he was no longer in the hospital. On [DATE], no day staff approached me about R2's or said that R2 needed to go to the hospital. On [DATE], at about 5:00 PM, E5, did voice concern about R2 needing to be suctioned so often and told me, "I'm probably going to send him (R2) out." I told E5, if you feel you need to send any resident out, that is your call. E1, stated she left at around 5:00 PM, and saw R2 before she left. At that time R2 was laying quietly in his bed and smiled when she spoke to him." E1, stated that on [DATE] and [DATE], no DON or RN staff on were on duty that day to assess the status of R2, his [MEDICAL CONDITION], or level of care needed. On [DATE], at 10:00 AM, in an telephone interview with E1, she stated "Prior to this incident, the facility had not provided the nurses any training in [MEDICAL CONDITION] in the past year. I asked all the nurses if they had [MEDICAL CONDITION] or experience, and they E3, E5, E6, E7, and E12, told me they had been trained and had done suctioning in previous jobs, and were comfortable with doing suctioning." A review of the facility's Monthly Staffing Schedule for the month of [DATE], indicated the facility did not have RN coverage for for 21 of 31 days in [DATE]. This included ,[DATE] and [DATE]. E1 confirmed there was no RN coverage in an interaview on [DATE] at 11:00AM. E1, also confirmed the facility did not have a Director of Nursing from the end of [DATE] through [DATE]. The facility provided a policy, Tracheal Suctioning ,[DATE], and a policy, Suctioning [MEDICAL CONDITION] ,[DATE]. Both policies document reasons for and procedures to follow when suctioning [MEDICAL CONDITION]. However, both policies fail to document how to assess the status of a [MEDICAL CONDITION] resident, or to determine if suctioning is effective, or how frequently to suction. Both policies advise nurses to note the nature of secretions as to if they are thin, tenacious, bloody, foul odor, color and volume. The policy Tracheal Suctioning Policy does document #25 - Document in nurses notes the results of Suctioning. On [DATE] at 2:00 PM, in a telephone interview with Z2, Nurse Practitioner, she stated, "On [DATE], at dinner time, E5 did call me about R2. E5 told me he was a [MEDICAL CONDITION], and he was very anxious. I asked if the facility had IM-[MEDICATION NAME] available in the building, if so, give him 1mg / IM. If it helped his anxiety, I was thinking to make it a PRN order. It is not unusual for [MEDICAL CONDITION] to feel anxious about their ability to breath. If R2 was requiring suctioning every 30 to 45 minutes, I should have been called much sooner. When E5 called, she did not tell me that R2 was requiring suctioning so frequently. Knowing this, I and may not have ordered the [MEDICATION NAME], and probably would have ordered him sent out to the emergency room to be sure he was stable. I was not notified that he had gone to the ER or that he had passed away. On [DATE] at 3:00 PM, in a telephone interview with Z1, R2's physician, he stated; "Typically when you increase suctioning, it increases secretions. The question is, is this frequent suctioning the norm for R2. If staff had called and given this information about needing suctioning so often, we might have done something different, as [MEDICATION NAME] can slow down the respirations. I believe they (facility) should have called sooner. As R2, was new to my service, I would probably have sent him to the hospital to be sure he was stable." On [DATE] at 4:00 PM, in a telephone interview with Z3, Nurse Practitioner, she stated, "I was in the building on [DATE], and did see R2, between 10:00 AM and 11:00 AM. At that time he had just been suctioned, his lungs sounded okay, and his color was good. He was not demanding. After I saw R2, I moved to the other side of the building and was there till about 4:00 PM. At no time did any staff come to me and tell me they were suctioning R2 every 30 to 45 minutes. I should have been told or at least asked, about R2 having to be suctioned so frequently. No one came and asked me anything, or I would have looked at him. On [DATE] at 11:10 AM, a telephone interview was done with Z5, RN (Registered Nurse)-CCU (Critical Care Unit) Nurse Manager, and Z6-RN, responsible for the transfer of R2 to the nursing home. Z6 stated, "On [DATE], when transferred, R2 was stable, meaning his vital signs were within normal parameters, and he was responding well to his trach. Prior to transfer, I told the nursing home nurse, that R2 was being suctioned frequently, about every 2 hours. At the hospital, he did have a lot of secretions that did cause his 02-sats to go down into the upper 80's and his pulse would go up to around 116 - 120. When suctioned this would reverse. He had [MEDICAL CONDITION] 6 days. When he first got [MEDICAL CONDITION] needed suctioning more frequently, but at the time of discharge he was being suctioned about every 2 hours. I put the phone number to the CCU unit on the transfer information so the facility could call with any questions they might have about R2. No one called that night to me to ask anything about R2." E5 stated, I believe R2 was being suctioned about every 2 hours at time of discharge. Depending on the person some people produce more secretions, and the amount can vary depending on the time of the day. However, more frequent suctioning every 30 to 45 minutes can sometimes produce more secretions. When people have pneumonia, they have thicker secretions, and this can be auscultated. None of my staff have reported, being contacted by the nursing home regarding R2. Being suctioned every 30 to 45 minutes would not be normal for a [MEDICAL CONDITION]. If this happened while on the unit we would be calling the doctor to have the patient assessed." A review of Z7's hospital discharge note dated [DATE], documented in part, "patient was trached during hospitalization [MEDICAL CONDITION] done for persistent atelectasis secondary to mucous plug. Patient's condition improved gradually, but he still is repeat suction almost every 2 hours. Fever resolved. Leukocytoses improved. Diabetes is being well controlled. Aspiration pneumonia improved with IV Antibiotics. He has otherwise remained stable on the day of discharge." On [DATE] at 11:15 AM, E14, Respiratory Therapist, stated, "I was not at the facility at the time R2 was there. However, because of the frequency of R2's suctioning being every 30 to 45 minutes, if asked, I would have advised the facility to contact R2's physician and update him as to what was going on. With R2's 02sats going down to 88% and then back up repeatedly, in a supposedly [MEDICAL CONDITION], staff should alert the physician and make sure no other interventions are wanted, or see if the doctor may want the resident sent out to the ER for an evaluation." R2's Certificate of Death, dated [DATE] documented the cause of death was Aspiration Pneumonia and [MEDICAL CONDITION]. The immediate Jeopardy was identified to have begun on [DATE], when staff; failed to recognize that frequent suctioning of R2'[MEDICAL CONDITION] be a medical emergency; failed to notify the physician of increased suctioning of R2's tracch, and failed to alert the physician of R2's, 02sats repeatedly dropping below 90% prior to suctioning. E1, Administrator, E2, Director of Nursing, and E15 Regional Nursing Director were notified of the Immediate Jeopardy on [DATE] at 3:20 PM. The facility took the following actions to remove the Immediacy, and the Surveyor confirmed through interview and record review: 1. On [DATE], the facility conducted individual in-service training for all staff with a Certified Respiratory Therapist. All licensed staff received inservice training [MEDICAL CONDITIONS], with testing and return demonstrations to completed. 2. On [DATE], all licensed staff were inserviced on Family and Physician Notification of changes in Resident Condition, and proper documentation in the clinical record. 3. On [DATE], The Director of Nursing and Regional Nursing Director inserviced all licensed staff on Respiratory Assessment, Oxygen Therapy, Pulse Oximetry, [MEDICAL CONDITION] Care, Suctioning, Changing a [MEDICAL CONDITION], Artificial Airway Emergencies, and [MEDICAL CONDITION] Insertion. Licensed staff was inserviced on Subcutaneous Injections including Insulin and [MEDICATION NAME] administration and Preparing and Maintaining Intravenous Infusions. 4. On [DATE], The Director of Nursing and Regional Nursing Director inserviced all nursing staff on Ostomy Care, Supra Pubic Catheter Care, and Oral, Dental, and Eyeglass Care. 5. On [DATE], Nursing Management and the Administrator initiated the following Protocols: a. Ensure all staff member will be trained and educated on proper use of equipment prior to it being put into service in the facility, and all newly hired staff will be educated on the use of equipment during the orientation process. b. The Interdisciplinary Team will review all new resident referrals to determine any staff education required, and equipment needs prior to admission. c. The Interdisciplinary Team will contact the Regional Director with medically complex referrals prior to making a final decision on the admission. d. Facility Administration will re-ass nursing staff for educational needs, and standards of practice. 6. On [DATE], The Quality Assurance Team forwarded all copies of inservice materials to the Medical Director for review. 7. On [DATE], The facility has contracted with a Certified Respiratory Therapist to make an initial visit for any new admission with a [MEDICAL CONDITION] and monthly thereafter to monitor the respiratory status and ensure continued compliance.

Based on interview and record review the facility neglected to follow their policy for [MEDICAL CONDITION] (trach) care and neglected to assess and identify a base line for the frequent suctioning of R2's trach, neglected to notify the physician of increased suctioning of R2'[MEDICAL CONDITION] once per hour to every 30 to 45 minutes, and neglected to alert the physician of R2's, 02sats repeatedly dropping below 90% prior to suctioning for 1 of 2 residents (R2) reviewed for [MEDICAL CONDITION] care in the sample of 4. R2 became non-responsive and died . Findings include: 1. A review of E7's, Licensed Practical Nurse (LPN), nurses notes dated [DATE] at 10:40 PM, documented R2 was admitted to the facility with a [DIAGNOSES REDACTED]. The nurses notes document R2 had Oxygen 4.5 Liters at 35% humidified air delivered via the trach. R2 was to receive Glucerna 1.5 at 45 ml per minute continuous via [DEVICE]. E7's, 10:40 PM nurses note documented R2's Oxygen Saturation (O2-sat) level was 93% - 94% upon admission. On [DATE] at 3:15PM, E7 stated, " R2 arrived around 10:45PM. I have suctioned people before, but was not familiar with the machine used for humidified air. I called E3, LPN to come in and help me get R2's oxygen set up. E3 arrived about 11:00 PM, and she then called the pharmacy to get instructions on how to set up the humidified air machine. The ambulance left around 11:30 PM, after R2 was set up and stable. R2 would turn on his light when he felt short of breath, and point to his chest. I suctioned R2 about 5 or 6 times during the night. R2's, Oxygen Saturation (02-sats) stayed in the low 90's through out the shift. There was not a lot of fluid when I suctioned him. R2 slept off and on during the night when not being suctioned. He did not appear to be in distress when I cared for him. I documented the care in the nurses notes. We do not have a form for suctioning, it is just written in the nurses notes." E7's nurses notes dated [DATE], from 1:00 AM to 6:00 AM, failed to evidence documentation that R2 was suctioned "5 or 6 times" during the night as E7 had reported. E7 made two entries on [DATE] at 3:05 AM and 4:30 AM, and both document "suctioned small amount of mucous". R2's O2-sats are recorded once on [DATE], at 3:05 AM, as 93% to 94%. There is no documented information in R2's nurses notes on the other (4) times R2 was suctioned during the night on [DATE], or, his behaviors of turning on the light and pointing to his chest when feeling short of breath. On [DATE], no documentation was evidenced in the nurses notes by E7, regarding R2's vital signs, quality of respirations, bilateral breath sounds, type of secretions, condition of trach/stoma site, cough, or ascultation of R2. On [DATE] at 10:00 AM, in a telephone interview, E12, LPN, stated, "I came in at 6:00 AM. E7, suctioned R2 before she left, about 6:30 AM, and he was asleep till around 8:00 AM. I suctioned R2 at 8:00 AM, and removed a large amount of whitish secretions at that time. I was told in report that R2 had to be suctioned frequently. After 8:00 AM, E3, LPN, came in, and was responsible for the care of R2. I did come and help E3 several times during the day with R2's suctioning. R2 would turn on his light and point to his chest when he felt short of breath. His 02-sat's would go down to around 88%, and his heart rate would go up to around 115 or so. After suctioning, his O2-sat's would go back up to the lower 90's, and his heart rate would go down below 100. We were suctioning him throughout the day about every 45 minutes or so. R2 usually had a lot of fluid when I suctioned him. I did not discuss with E3, calling the doctor about his needing to be suctioned so often as we were told R2 needed frequent suctioning. R2's 02-sats would be stable after he was suctioned." A review of R2's nurses notes failed to show documentation by E12 that she had cared for or suctioned R2 on [DATE]. The nurses notes contain no documentation on how often R2's O2-sats had fallen into the 88% range between suctioning as described by E12, and had no information on secretions, amounts and type, results of E12's suctioning and no information regarding the stoma site, or R2's behaviors. On [DATE] at 10:00 AM, E3, LPN, stated, "E7 called me on [DATE] at around 10:45 PM, to come and help her set up R2's humidified oxygen because E7, was not familiar with the equipment. I came in around 11:00PM. I called the pharmacy where the equipment came from, and got directions on how to set up the machine for humidified air. When R2 was set up I stayed to help get R2's doctors orders written and get information faxed to the pharmacy for his medications. I left at around 12:30 AM. At 8:00 AM, I returned to work and was in charge of R2's care. E12 helped me with R2's suctioning during the day. I suctioned R2 at 8:30 AM, and his 02-sat's at that time were around 92%. R2 used his call light to let us know when he needed to be suctioned. It seemed that we (E12 and E3) suctioned R2 about every 30 to 45 minutes. I thought this was not a problem, because I was told R2 needed to be suctioned frequently. R2 was gotten up in a geriatric chair at 12:00 PM for one hour and tolerated this well. R2 had visitors at one point during the day and he seemed calmer then also. After 1:00 PM, I noticed more than once that prior to suctioning his 02-sat's would drop to 88% or 89%. After suctioning they would go back up to 90% or 92%. R2's secretions were white and and I did not get a lot of fluid when I suctioned him. During these times, R2 did not seem in distress, just very anxious. He would point to his chest to show he was short of breath. He put on his call light a lot, and seemed like he did not want to be left alone in his room. I have taken care of other residents with trach's in previous jobs, and did not feel uncomfortable caring for R2." A review of E3's nurses notes dated [DATE], documents she suctioned R2 at 8:15 AM, 10:15 AM, 1:00 PM, 1:30 PM and 3:30 PM. The notes document that each time R2 had moderate amounts of white phlegm, but fail to document O2-sats, consistency of secretions, condition of R2'[MEDICAL CONDITION], or any of the behaviors of anxiousness that E3 described of R2 during the day. At 2:30 PM, E3 documented, "[MEDICATION NAME] done. Spo2 (O2-sats) ,[DATE]%, suctioned large amount of phlegm. No other information is documented regarding R2's, O2-sats being in the upper 88% - 89%'s prior to suctioning, or the condition of R2's trach. At 3:30 PM, E3 did document R2's 02-sat's were 89% and he was suctioned for a moderate amount of white phlegm. On [DATE] at 1:30 PM, E3 stated, "I did not think R2 was being suctioned too often. I had been told by E7, that the hospital reported R2 was being suctioned frequently, and he was on an antibiotic for pneumonia. I did not think to ask the doctor or his nurse if suctioning R2 every 30 to 45 minutes was too much. I did not call the hospital to verify how frequently R2 had been suctioned when there. I documented everything in the nursing notes. There were no other forms to be filled out regarding R2'[MEDICAL CONDITION] suctioning. Z3, Nurse Practitioner also came and saw R2, the morning of [DATE], and she did not say he looked unstable. At 3:00 PM, E5, LPN, came in and took over R2's care. E5 did tell me that she thought R2 should be sent to the emergency room , because he needed so much suctioning, but I did not agree. I told E5, R2 looked stable to me, and was only anxious when he needed to be suctioned. I gave her the [MEDICATION NAME] medication and told her do his breathing treatment, and recheck him. I gave E5 the medication cart keys and left the floor to do paperwork at 3:30 PM." In a telephone interview on [DATE] at 10:15 AM, E3 stated, "On [DATE], I do not think R2 changed his behavior from morning to afternoon. He was putting on his light every 15 - 20 minutes throughout the day. He was being suctioned every 30 to 45 minutes. It was after lunch I noticed 02-sat's would go down to 88% or 89%, but after suctioning they would go back up in the lower 90%'s and R2 would be calmer. I feel he was stable on my shift. None of the CNA's staff told me they thought R2 should go to the hospital." On [DATE] at 11:00 AM, E5, stated, "I came in to work at 3:00 PM, was given report on R2, and saw him at 3:15 PM. I have have had training and cared for and [MEDICAL CONDITION] in a previous job. At 3:15 PM, R2 looked uncomfortable and needy. I told E3, shouldn't R2 be sent out if he needed to be suctioned, so often. E3 did not agree and handed me R2's nebulizer medicine and told me to give the treatment to give R2. R2's 02-sat's were 88%, his pulse was over 100 and he appeared anxious and distressed. He was pointing at [MEDICAL CONDITION] repeatedly. After the nebulizer treatment his Ps02 was 93%, and he did calm a little. R2, was on the call light about every 15 - 20 minutes, was very anxious, and seemed to need someone in the room with him to reassure him. I had E10, CNA, stay with him off and on and this helped him calm down. At 4:30 PM, I suctioned R2, he was teary, and after suctioning his 02-sat's were 90%. I spoke with him, he seemed easily consoled and calmer. At 5:00 PM, I suctioned R2, his 02-sat's was 87% and pulse was over 100 and he was again very anxious, so I suctioned R2 and then called the physician's office to discuss R2's being so anxious. At 5:15 PM, Z2, Nurse Practitioner (NP), returned my call. I told her R2 seemed very anxious. Z2 ordered [MEDICATION NAME] 1mg IM / Now, to be given. I (E5) was not able to give the [MEDICATION NAME] as there was none in the stock supply in the building. I called and faxed the order to the pharmacy to have [MEDICATION NAME] sent out for R2. I did not call Z2 back and tell her we had no IM [MEDICATION NAME]. At 5:30 PM, I (E5) saw R2 and he was resting in bed, gave him a stuffed animal to hold, I checked his tube feeding, he was resting, he nodded and opened his eyes when I spoke to him." E5's nurses notes dated [DATE] at 3:15 PM, documented "Upon entering room, resident (R2) appeared to be in distress. Sp02 (O2-sats) @ 88%. Neb treatment given, resident denies pain with nod of head, wheezing noted in upper and lower bilateral lobes. No distress noted, will continue to monitor." At 4:30 PM, E5's notes documented, "Resident in room, teary eyed, continues to deny pain with nod of head, pointing to trach. Suctioned with small amount phlegm extracted. Sp02 at 90%." At 5:00 PM, E5 documented "resident appears anxious, Sp02 at 90%, writer called to Dr's exchange, awaiting call back. At 5:15 PM, E5's notes documented that Z2, returned the call and ordered [MEDICATION NAME] 1mg for Anxiety. A review of the physician's orders [REDACTED]." On [DATE] at 2:50 PM, E5 stated "At 6:00 PM, E6, LPN, came on duty and I gave him report. I informed him of R2's status. During the report, between 6:10 PM and 6:20 PM, the pharmacy called back and said the [MEDICATION NAME] had not been approved and needed the doctors signature. At about 6:30 PM, E6, called me to R2's room and told me R2 didn't look right. I attempted to locate an apical and radial pulse and found none. R2's eyes were fixed. E6 said to call 911 and he started CPR with E13, CNA. The Emergency Medical Technicians (EMT) / Ambulance was here within 10 minutes, and they continued CPR and left the building at about 6:50 PM." A nurses note dated [DATE], 6:45 PM, by E5, documented in part, "Writer summoned to residents room, resident lying on back, eyes affixed, unable to obtain apical pulse, no respirations, requested crash cart, CPR started, 911 called, CPR continued. Ambulance here and 2 EMT's, continued CPR out of building." On [DATE] at 2:37 PM in a telephone interview, E6, stated that he arrived at work at 6:00 PM, and received report on R2, from E5. E6 stated that at about 6:15 PM the pharmacy called and reported R2's [MEDICATION NAME] order had not been approved and needed the physician's signature. E6 stated he went to do rounds at 6:30 PM and when he entered R2's room, R2 was unresponsive. R2 was lying in bed with no palpable pulse and eyes fixed. E6 stated he started CPR with E13, while E5, called for an ambulance. E6 stated the R2 had no vitals when he left the building. On [DATE], at 10:00 AM, in an telephone interview with E1, she stated "Prior to this incident, the facility had not provided the nurses any training in [MEDICAL CONDITION] in the past year. I asked all the nurses if they had [MEDICAL CONDITION] or experience, and they E3, E5, E6, E7, and E12, told me they had been trained and had done suctioning in previous jobs, and were comfortable with it." The facility provided a policy, Tracheal Suctioning ,[DATE], and a policy, Suctioning [MEDICAL CONDITION] ,[DATE]. Both policies document reasons for and procedures to follow when suctioning [MEDICAL CONDITION]. However, both policies neglected to document how to assess the status of a [MEDICAL CONDITION] resident, or to determine if suctioning is effective, or how frequently to suction. Both policies advise nurses to note the nature of secretions as to if they are thin, tenacious, bloody, foul odor, color and volume. The policy Tracheal Suctioning Policy does document #25 - Document in nurses notes the results of Suctioning. On [DATE] at 2:00 PM, in a telephone interview with Z2, Nurse Practitioner, she stated, "On [DATE], at dinner time, E5 did call me about R2. E5 told me he was a [MEDICAL CONDITION], and he was very anxious. I asked if the facility had IM-[MEDICATION NAME] available in the building, if so, give him 1mg / IM. If it helped his anxiety, I was thinking to make it a PRN order. It is not unusual for [MEDICAL CONDITION] to feel anxious about their ability to breath. If he was requiring suctioning every 30 to 45 minutes, I should have been called much sooner. When E5 called, she did not tell me that R2 was requiring suctioning so frequently. Knowing this, I and may not have ordered the [MEDICATION NAME], and probably would have ordered him sent out to the emergency room to be sure he was stable. I was not notified that he had gone to the ER or that he had passed away. On [DATE] at 3:00 PM, in a telephone interview with Z1, R2's physician, he stated; "Typically when you increase suctioning, it increases secretions. The question is, is this frequent suctioning the norm for R2. If staff had called and given this information about needing suctioning so often, we might have done something different, as [MEDICATION NAME] can slow down the respirations. I believe they (facility) should have called sooner. As R2, was new to my service, I would probably have sent him to the hospital to be sure he was stable." On [DATE] at 4:00 PM, in a telephone interview with Z3, Nurse Practitioner, she stated, "I was in the building on [DATE], and did see R2, between 10:00 AM and 11:00 AM. At that time he had just been suctioned, his lungs sounded okay, and his color was good. He was not demanding. After I saw R2, I moved to the other side of the building and was there till about 4:00 PM. At no time did any staff come to me and tell me they were suctioning R2 every 30 to 45 minutes. I should have been told or at least asked, about R2 having to be suctioned so frequently. No one came and asked me anything, or I would have looked at him. On [DATE] at 11:10 AM, a telephone interview was done with Z5, RN(Register Nurse)-CCU(Critical Care Unit) Nurse Manager, and Z6-RN, responsible for the transfer of R2 to the nursing home. Z6 stated, "On [DATE], when transferred, R2 was stable, meaning his vital signs were within normal parameters, and he was responding well to his trach. Prior to transfer, I told the nursing home nurse, that R2 was being suctioned frequently, about every 2 hours. At the hospital, he did have a lot of secretions that did cause his 02-sats to go down into the upper 80's and his pulse would go up to around 116 - 120. When suctioned this would reverse. He had [MEDICAL CONDITION] 6 days. When he first got [MEDICAL CONDITION] needed suctioning more frequently, but at the time of discharge he was being suctioned about every 2 hours. I put the telephone number to the CCU unit on the transfer information so the facility could call with any questions they might have about R2. No one called that night to me to ask anything about R2." E5 stated, I believe R2 was being suctioned about every 2 hours at time of discharge. Depending on the person some people produce more secretions, and the amount can vary depending on the time of the day. However, more frequent suctioning every 30 to 45 minutes can sometimes produce more secretions. When people have pneumonia, they have thicker secretions, and this can be auscultated. None of my staff have reported, being contacted by the nursing home regarding R2. Being suctioned every 30 to 45 minutes would not be normal for a [MEDICAL CONDITION]. If this happened while on the unit we would be calling the doctor to have the patient assessed." R2's Certificate of Death, dated [DATE] documented the cause of death was Aspiration Pneumonia and [MEDICAL CONDITION].

Based on observation, interview and record review, the facility failed to assess; implement safety devices; and transfer properly, 4 (R5, R9, R13, R11) of 8 residents with a history of falls or were risk for falls. This failure resulted in both R9 and R13 being hospitaized for a fractured hip. Findings include: 1. R9's Physician order [REDACTED]. The POS shows an order for [REDACTED]. The POS shows an order on 1-4-11 for Librium 50 mg TID (three times a day) x 2 days then 25 mg TID x 3 days then 25 mg BID (twice a day) x 3 days then 25 mg daily x 3 days then stop. R9's Minimum Data Set (MDS) of 12-28-10 identifies R9 requiring limited assistance of 1 person, physical assistance for transfer and ambulation and is independent in bed mobility. The MDS shows balance during transition and walking is not steady, only able to stabilize with human assistance. The MDS shows falls since admission. R9's Nursing Admission Assessment of 12-20-10 stated admission diagnosis, "increased confusion, weakness, history of falls." The Social Service Admission Care Plan states R9 is very confused and a fall risk. The Fall Risk Assessment of 12-24-10 identifies R9 as being at high risk for falls. Nurses Notes from 12-20-10 through 1-6-11 documents that R9 made several attempts to stand. . On 1-6-11 at 3:45PM the Nurse Notes shows R9 fell and had external rotation to right lower extremity and was being sent to the hospital and admitted for a right hip fracture. R9's Medication Administration Record (MAR) shows R9 received 50 mg of Librium at 8PM on 1-5-10 and 50 mg on 1-6-10 at 7AM, and Percocet and Ativan at midnight prior to the fall at 1:05PM. R9's QUALITY CARE REPORTING FORM of 12-24-10 at 1205AM states R9 reached for her soda and fell out of bed. Report shows she had a bed alarm and floor mat. Under the question, "What are you doing differently to prevent another fall right now. " It's documented "1-1", yet Nurses Notes of 12-21-10 show they were doing "1-1's "with R9. There are no new fall interventions identified in the report. That section of the report was left blank. R9 had another QUALITY CARE REPORTING FORM dated 12-25-10 that fails to identify time and location of another fall. The report identifies and alleged fall but does not say where she fell and how she fell . The report states wheel chair alarm was in place and doing 15 minute checks. The report identifies R9 as having Dementia, Impaired Cognition and Unsteady Gait. Under what new intervention was implemented to prevent any further falls, it is documented, "W/C alarm in place." (Nurses Notes show that this is not a new intervention. Under "What are you doing differently to prevent another fall right now" it is documented, every 15 minute checks, personal alarm, supervised by staff when up in wheel chair. Nurses Notes show all these interventions were being used previously. E16 reviewed the above report and stated R9 had fallen from her wheel chair on 12-24-10. E16 confirmed the report did not identify that R9 fell from a wheel chair and confirmed the date was illegible. E16 stated R9 had two falls on 12-24-10, one from bed and one from the wheel chair. E16 confirmed the facility failed to assess and implement new safety interventions for R9 even though she kept trying to get up unattended. E16 confirmed all fall interventions were implemented when R9 was admitted to the facility. Fall investigation report of 1-12-11 concerning R9's fall from her wheel chair on 1-6-10 that resulted in a fractured right hip, states R9 was usually cooperative with staff members but requires frequent prompts not to stand and attempt to walk without a staff member present. The report stated the root cause of the fall was R9 stood up and attempted to walk, tripped over another resident foot pedal. R9 was observed on 1-11-11 at 1:03PM, to be in bed with a large bandage on her right hip. R9 had a pad alarm on her bed, but the alarm did not sound when R9 was turned and repositioned during care. On 1-11-11, R9's Power of Attorney stated prior to the fall, R9 would lean forward and try to stand up from her wheel chair. She was asked if R9's wheel chair alarm would go off and she stated, No, the cord was pretty long and R9 would have had to leaned too far before the alarm would have gone off. She stated she would tell R9 to set back down or lean back and she would. On 1-12-10, the alarm cord was measured and was 20 inches long. On 1-13-11, E2 and E16 stated they had shortened R9's alarm cord to her wheel chair and checked other residents and shortened their alarms. On 1-14-10 the facility provided a PHYSICAL RESTRAINT CONSENT, REHABILITATION SCREEN, and PHYSICAL RESTRAINT/ENABLER ASSESSMENT all dated 1-12-11 for safety interventions to be used to prevent falls. The facility implemented a lap cushion to R9's wheel chair 2. R11's Minimum Data Set (MDS), dated [DATE], documented severely cognitively impaired, incontinent of bowel and bladder, total assistance of two plus persons physical assistance with mobility, transfer and toileting. R10's Care Plan, dated not dated and provided as R10's current Care Plan, documented that R10 was incontinent of bowel and bladder due to decreased mobility and decreased cognition. After toileting, E5 and E14 stood R11 up from the toilet and provided further incontinent care and dressing while they support R11's weight by holding on held on to her under arms and loosing holding on the the gait belt. Again, R11 appeared to be confused with repeated verbalization, not completely supporting her weight, unsteady and attempting to sit down. During transfers and care, E4, E5 and E11 did not re-seat R11 and provide alternative transfer techniques. 3. R13's Patient Transfer Form physician's orders [REDACTED]. Dementia and a history of multiple fractures (Right Hip and Compression Fractures Thoracic Spine) and a history of falls with Closed Head Injury. R13's MDS, dated [DATE],documented moderately impaired cognition with short and long term memory problems, limited assistance of one person physical assistance with mobility and expense assistance of one person physical assistance with transfer and walking, functional imitation in range of motion of leg and impaired standing balance. The facility's fall Risk Assessment, dated 4-26-10, documented that R13 was high risk for falls. The facility's Therapy Weekly Progress Report, dated 6-9-10 and 6-16-10, documented R13's barriers to progress were R13's multiple fractures and decreased safety awareness.. R13's Quality Care Reporting Form, as provide by the facility for Incident/Fall Occurrences, documented: On 4-28-10, R13 rolled out of bed incurring a 3.0cm x 3.0cm bump on her right forehead. Interventions "alarm put in place, 15 min (minute) checks assist to bathroom/bedpan every 2 hours, 1/2 side rail put on bed for bed mobility."; On 5-22-10, slide out of wheel chair with no injury. Intervention was to place a non skid material in her wheel chair; On 6-5-10, fell after attempting to transfer herself out of bed incurring left forehead and left forearm skin tears. Intervention no change; On 6-10-10, fell after attempting to put self to bed incurring a right elbow skin tear. Intervention to inform Therapy; On 7-3-10, R13 stood up, wheel chair, not locked, missed chair when sat down; and, On 7-7-10, R13 fell after getting out of bed and going to the bathroom. R13 incurred left forehead laceration and left hip pain. R13 was admitted to a local hospital with a left hip fracture. R13's Nursing Admission Assessment, dated 4-26-10, documented R13 was to have 15 minute checks, bed in low positron and chair in front of bed." The facility provided a copy of R13's Care Plan, not dated, which documented R13's low bed position was not care planned until after R13's 7-7-10 fall. R13's 7-7-10 Fall Documentation Worksheet, dated 7-7-10, documented "What are you doing different to prevent another fall right now...low bed with mats." R13's previous fall investigations did not document that R13's bed was in a low position. E1, Administrator, stated, on 1-14-10, that R13's low bed position had not been care planned until after R13's 7-7-10 fall. R13's Quality Care Reporting Forms, for the above documented falls, did not document that R13's bed in a low position prior to her falls. 4. R5's Care Plan, signature date 4-14-10, documented that R5 had a history of [REDACTED]. E15, Care Plan Coordinator, stated, on 1-11-11 at 11:50a. m., that R5's alarm was apart of his care plan for fall prevention. R5 was observed lying in his bed, on 1-10-11 at 11:25a.m. and 1-11-11 at 11:25a.m. On 1-10-11at 12:00 noon and 1-11-11 at 12:00 noon, R5 was observed walking out of his room with an assistive walking device and no alarm was heard sounding prior to his ambulation or at the time of his ambulation. E15 stated, on 1-11-11 at 12:00 noon, that R5's bed did not have an alarm in place. E3, Licensed Practical Nurse (LPN), stated, on 1-12-10 at 8:50a.m., that R5 often took of his alarm and hid it. R5's Care Plan did not document R5's behavior of removing his alarm or provide alternative fall prevention interventions to address R5's behavior of removing his alarm. The facility provided a Rehabilitation Screen, dated 1-12-11, which assessed R5's falls and his alarm which was recommended to be used at night time to increase his safety and decreased his falls.

Based on record review, interview and observation it was determined that the facility failed to identify the medical symptom for use of a restraint, identify least restrictive measures tried, and identifying risks versus the benefits for 1 (R1) of 1 residents reviewed for restraint use. This failure resulted in R1's decrease in ambulation and transfer abilities. The findings include: R1 was admitted to the facility on [DATE] with diagnoses, in part, of Alzheimer disease, dementia with aggressive behaviors, hypertension, and agitation [MEDICAL CONDITION]. R1 was prescribed [MEDICATION NAME] 5 milligrams on 5/7/10. On 5/13/10 R1 was [MEDICATION NAME] mg daily. On 6/24/10 R1 was prescribed [MEDICATION NAME] 0.5 mg three times per day and this was increased on 7/22/10 to 1 mg three times per day. On 5/5/10 R1 had an order for [REDACTED]. This was confirmed by E6, Corporate Nurse, on 10/4/10. E3, Minimum Data Set Nurse, stated on 9/30/10 that she had not done an assessment of the [MEDICAL CONDITION] medications for R1 and the last one done was 4/1/10. According to the nurses notes and incident reports dated 7/15/10 and 7/23/10 R1 got up out of bed and fell . R1 received a laceration to the left forehead on 7/23/10. The incident report dated 7/23/10 does not identify that the bed alarm was not working when R1 got out of bed, however, E7, Certified Nurse Aide, confirmed on 9/29/10 that the alarm was not sounding when she found R1 on the floor. The intervention for the fall when R1 got out of bed on 7/23/10 was to place R1 in a wheelchair with a lap cushion to prevent further falls. The investigation summary sent to the department dated 7/26/10 stated "related to unsteady gait, and increased decline in cognition residents son and facility as team made decision it was time to place (R1) in wheelchair with front and back anti-tippers and lap cushion. (R1) will be ambulated to and from meals, as she is able and will be ambulated to and from bathroom to maintain her ambulation abilities as long as possible". There is no physician order for [REDACTED]. Z1, Physician, stated on 10/4/10 that he ordered the lap cushion due to R1 falling. Z1 stated the medical symptom/[DIAGNOSES REDACTED]. Review of the incident report investigations noted there were no incident reports for falls while R1 was ambulating documented. On 5/2/10 R1 was standing up from a chair and fell back onto the chair fracturing her ribs. On 6/29/10 R1 was standing at the nurses station and when placing a cup on the nurses station and sat on the floor. The nurses notes identified R1 as ambulatory throughout the facility on on 4/18/10, 5/31/10, 6/11/10, 6/26/10, 7/2/10, 7/17/10, and 7/20/10. R1 was observed on all days of the survey in her wheelchair with a lap cushion on. R1 was observed trying to take the lap cushion off but could not on 9/29/10. The Minimum Data Set ((MDS) dated [DATE] does not identify R1 has a "chair prevents rising". The MDS dated [DATE] assessed R1 as independent with set up help only for transfers, walk in room and walk in corridor. The significant change MDS dated [DATE] assessed R1 as requiring limited assistance with one person physical assist for transfers, and walking in the room and corridor. Balance while standing decreased from "Unsteady, but able to rebalance self without physical support" to "Partial physical support during test". The MDS dated [DATE] also noted that the activities of daily living function had "deteriorated". Bowel and bladder incontinence was also increased. The "Physical Restraint/Enabler Assessment" dated 6/11/10 stated "Per family request, MD agreed to lap (cushion)". The "Diagnosis/Medical Symptoms" listed were "Alzheimers (with) aggressive behaviors, [MEDICAL CONDITION], agitation". The medications of [MEDICATION NAME],[MEDICATION NAME] were listed but there was no assessment of the use of the medication or the possible contribution to falls. R1 also receives [MEDICATION NAME] and [MEDICATION NAME]. Neither is listed on the assessment. The "Medication Administration Record" lists "orthostatic [MEDICAL CONDITION]" as a potential side effect for both medications. The assessment states under "Initiation of new med" as "No". Under the section "Describe Risks vs. (versus) Benefits" it only states "Keeps her from ambulating (without) assistance. Res does not appear to dislike or be uncomfortable in W/C (wheelchair) (with) lap (cushion). Res ambulated to (and ) from toilet et (and) to (and) from meals. Son in agreement". Risks such as decrease in ambulation, transfer abilities, increased agitation, pressure sores, increased incontinence, or injuries was not assessed. The restraint assessment stated "Check all attempts at lesser restrictive alternatives and describe the outcomes along with the date attempted". The following alternatives were checked, however, no date was documented: "Diversional Activities", "Rocking Chair", "Regular timed toileting", "Physical Therapy", "Lower Bed (with) mats", "Verbal Cueing", "Regular Exercise", "Call Light answered promptly", "Dycem/posey grip", "Occupational therapy", "Wedge Cushion", PT/OT eval (evaluate) (and) tx (treatment) for balance et (and) endurance", "1:1 (with) res (resident) when possible". The last Physical Therapy note was 6/16/10 as the "Therapy Discharge Note". The note stated R1 was discharged due to "progress Plateau". The "discharge outcome" noted R1 was "Mod I" for sit to stand and could ambulate 200 feet throughout the facility with hand held assistance. The discharge recommendation was "Cont (continue) supervised gait within facility". The use of a bed alarm was not documented. The care plan dated 6/11/10 identified as a problem that R1 was "ambulatory and wanders the facility". The goal was to "maintain current level of ADL function with no complications thru next evaluation". R1 was also identified as a high risk for elopement. The care plan also identified as a problem "Able to ambulate independently but short attention span and confusion puts resident at high risk for falls". There is no mention of unsteady gait or poor balance. The care plan was not updated until 7/24/10 and stated "Res (resident) found on floor in room by CNA (Certified Nurse Aide) (with) large lac (laceration) to L (left) forehead". The care plan also stated "Res now has N.O. (nursing order) for lap (cushion) (with) verbal consent from son. Placed in W/C (wheelchair) (provided by hospice) (with) front/back tippers. Will be ambulated to/from meals as tol (tolerated), ambulate to/from bathroom in order to maintain ambulatory abilities, place res in hi/low bed". E3, MDS Nurse, stated on 9/30/10 that the physician had thrown up his hands at one point and said that R1 either needed to be hospice or restrained as she would fall and the family would sue. E3 stated that they could have done 1 on 1's but if someone would call off then "that's out the window". E3 stated R1 "has resigned herself to sit in the chair". When asked why R1 was admitted to hospice on 6/30/10 E3 stated the son and physician had decided. E3 stated R1 hasn't changed and stated R1 was still "feisty" and can walk. E3 stated it "changed her because we put her in a chair". E3 stated on 10/6/10 that they had not put the lap cushion on R1 on 6/11/10 because they did not have a wheelchair or lap buddy in the facility. E3 stated when R1 was admitted to hospice they had asked for the lap cushion and wheelchair. E3 stated that with the last fall on 7/23/10 they put the lap cushion on R1. E3 stated that the family did not want to restrain R1 but once they talked to hospice and Z1, Physician, they did agree to try at Z1's insistence. E3 confirmed that there were no signed consents for the use of the lap cushion but verbal consent had been obtained. The nurses notes dated 7/23/10 documented that R1 had fallen when she got up from bed and received a laceration to the forehead. According to the nurses notes at 3:15 PM R1 returned from the hospital and was placed in a wheelchair with a lap cushion. At 7:00 PM the nurses notes states "(Up) in W/C (wheelchair) (with) lap (cushion). Anxious, attempting to remove lap (cushion). Attempting to stand up on own. Meds (Medications) given as per orders...". There was no documentation in the nurses notes that the family was notified of the lap cushion and wheelchair nor was there a verbal consent for the use of the restraint. R1 was observed during the days of the survey in her wheelchair with the lap cushion present. On 9/29/10 at the noon meal the lap cushion was not removed from the wheelchair as R1 sat at the table. R1 was observed on 9/29/10 at the nurses station attempting to pull the lap cushion off the wheelchair.

Based on observation, record review, and interview it was determined that the facility neglected to monitor food intake, notify the physician of a significant weight loss, aggressively intervene to address poor intake and assist with eating for 1 (R1) of 3 residents reviewed. This neglect resulted in R1 experiencing a significant weight loss of 16% over a 6 month period. The findings include: R1 was admitted to the facility on [DATE] with diagnoses, in part, of Alzheimer disease, dementia with aggressive behaviors, hypertension, and agitation [MEDICAL CONDITION]. Her weight on Jan., 2009 was 159.2 pounds. The current physician order [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed R1 as severely cognitively impaired and as requiring one person limited physical assistance for eating. The MDS does not identify a significant weight loss and documented R1's weight at 138 pounds even though the weight log documented 111.3 pounds. R1's weight has decreased from 131.9 pounds on April, 2010 to 104.4 pounds on 9/22/10 as documented on the weekly weight log. This is a significant weight loss of 21% in 6 months. On 10/6/10 staff stated R1's weight was reweighed with the Hoyer lift scale and the weight was actually 111 pounds which is still a 16% significant weight loss. Z1, Physician, stated on 10/4/10 that he was unaware of that significant weight loss and should have been notified. Z1 stated that R1 should be fed and expected staff to assist her to eat. Z1 stated that R1 was admitted to hospice due to failure to thrive. Z1 stated he would call the facility to make sure staff were feeding R1. Observation of the noon meal on 9/29/10 and the breakfast meal on 9/30/10 noted R1 did not receive appropriate assistance with eating at both meals. Staff did not provide finger foods for R1 nor did they offer more food or fluids when they were consumed. Z2, Registered Dietitian, stated on 10/4/10 that the last time she had reviewed R1 her weight was 111.3 pounds. Z2 stated that the order should have read to offer finger foods when possible, but if the physician order [REDACTED]. Z2 stated that R1 was declining and losing weight so hospice had been initiated in July. Z2 confirmed that staff should have offered R1 more food or liquids if she would have taken them. Z2 stated that [MEDICATION NAME],[MEDICATION NAME] could alter appetite when asked if there were any issues with medications R1 received that could affect her weight. There was no assessment of the medications and their possible side effects.

Based on record review and interview it was determined that the Facility failed to provide supervision and assistive devices for 1 (R1) of 3 residents reviewed that sustained a fall with an injury. This failure resulted in R1 falling and sustaining a laceration to the forehead which required an emergency room visit. R1 was also restrained after the fall on 7/23/10. The findings include: R1 was admitted to the facility on [DATE] with diagnoses, in part, of Alzheimer disease, dementia with aggressive behaviors, hypertension, and agitation psychosis. R1 was prescribed Lexapro 5 milligrams on 5/7/10. On 5/13/10 R1 was prescribed Ambien 5 mg daily. On 6/24/10 R1 was prescribed Ativan 0.5 mg three times per day and this was increased on 7/22/10 to 1 mg three times per day. On 5/5/10 R1 had an order for [REDACTED]. There was no assessment of the medication nor was there an assessment for potential orthostatic hypotension for R1. This was confirmed by E6, Corporate Nurse, on 10/4/10. E3, Minimum Data Set Nurse, stated on 9/30/10 that she had not done an assessment of the psychotropic medications for R1 and the last one done was 4/1/10. Review of the facility Medication Administration Record for R1 notes potential side effects for Norvasc and Bumex as "Orthostatic Hypotension". Ambien aslo has listed "hypotension" as a side effect. The "Geriatric Dosage Handbook", 12th edition notes as a monitoring parameter for Bumex to take blood pressure "standing and sitting/supine". Patient information for Lexapro includes rising slowly from a sitting or lying position. Nursing considerations for Ativan include sedation and supervision of ambulation. According to the nurses notes and incident reports dated 7/15/10 and 7/23/10 R1 got up out of bed and fell . R1 received a 3 inch laceration to the left forehead on 7/23/10. R1 was sent to the emergency room and the laceration was glued. The incident report dated 7/23/10 does not identify that the bed alarm was not working when R1 got out of bed, however, E7, Certified Nurse Aide, confirmed on 9/29/10 that the alarm was not sounding when she found R1 on the floor. The intervention for the fall when R1 got out of bed on 7/23/10 was to restrain R1 in a wheelchair with a lap cushion to prevent further falls. The investigation summary sent to the department dated 7/26/10 stated "related to unsteady gait, and increased decline in cognition residents son and facility as team made decision it was time to place (R1) in wheelchair with front and back anti-tippers and lap cushion. (R1) will be ambulated to and from meals, as she is able and will be ambulated to and from bathroom to maintain her ambulation abilities as long as possible". There was no documentation that the alarm was not sounding. There is no physician order for [REDACTED]. Z1, Physician, stated on 10/4/10 that he ordered the lap cushion due to R1 falling. Z1 stated the medical symptom/[DIAGNOSES REDACTED]. Review of the incident report investigations noted there were no incident reports for falls while R1 was ambulating documented. On 5/2/10 R1 was standing up from a chair and fell back onto the chair fracturing her ribs. On 6/29/10 R1 was standing at the nurses station and when placing a cup on the nurses station and sat on the floor. The nurses notes identified R1 as ambulatory throughout the facility on 4/18/10, 5/31/10, 6/11/10, 6/26/10, 7/2/10, 7/17/10, and 7/20/10. R1 was observed on all days of the survey in her wheelchair with a lap cushion on. R1 was observed trying to take the lap cushion off but could not on 9/29/10. The MDS dated [DATE] assessed R1 as independent with set up help only for transfers, walk in room and walk in corridor. The significant change MDS dated [DATE] assessed R1 as requiring limited assistance with one person physical assist for transfers, and walking in the room and corridor. Balance while standing decreased from "Unsteady, but able to rebalance self without physical support" to "Partial physical support during test". The MDS dated [DATE] also noted that the activities of daily living function had "deteriorated". Bowel and bladder incontinence was also increased. The "Physical Restraint/Enabler Assessment" dated 6/11/10 stated "Per family request, MD agreed to lap (cushion)". The "Diagnosis/Medical Symptoms" listed were "Alzheimers (with) aggressive behaviors, psychosis, agitation". The medications of Lexapro, Ambien and Ativan were listed but there was no assessment of the use of the medication or the possible contribution to falls. R1 also receives Bumex and Norvasc. Neither is listed on the assessment. The "Medication Administration Record" lists "orthostatic hypotension" as a potential side effect for both medications. The assessment states under "Initiation of new med" as "No". The care plan dated 6/11/10 identified as a problem that R1 was "ambulatory and wanders the facility". The goal was to "maintain current level of ADL function with no complications thru next evaluation". R1 was also identified as a high risk for elopement. The care plan also identified as a problem "Able to ambulate independently but short attention span and confusion puts resident at high risk for falls". There is no mention of unsteady gait or poor balance. The care plan was not updated until 7/24/10 and stated "Res (resident) found on floor in room by CNA (Certified Nurse Aide) (with) large lac (laceration) to L (left) forehead". The care plan also stated "Res now has N.O. (nursing order) for lap (cushion) (with) verbal consent from son. Placed in W/C (wheelchair) (provided by hospice) (with) front/back tippers. Will be ambulated to/from meals as tol (tolerated), ambulate to/from bathroom in order to maintain ambulatory abilities, place res in hi/low bed". E3, MDS Nurse, stated on 9/30/10 that the physician had thrown up his hands at one point and said that R1 either needed to be hospice or restrained as she would fall and the family would sue. E3 stated that they could have done 1 on 1's but if someone would call off then "that's out the window". E3 stated R1 "has resigned herself to sit in the chair". When asked why R1 was admitted to hospice on 6/30/10 E3 stated the son and physician had decided. E3 stated R1 hasn't changed and stated R1 was still "feisty" and can walk. E3 stated it "changed her because we put her in a chair".

Based on record review, interview and observation it was determined that the facility failed to maintain 1 (R1) of 3 residents reviewed nutritional status and weight. This failure resulted in R1 experiencing a significant weight loss of 16% of her body weight in a 6 month period. The findings include: R1 was admitted to the facility on [DATE] with diagnoses, in part, of Alzheimer disease, dementia with aggressive behaviors, hypertension, and agitation [MEDICAL CONDITION]. Her weight on Jan., 2009 was 159.2 pounds. The current physician order [REDACTED]. R1 also had an order on 7/28/10 for 4 oz. house supplement three times per day and on 8/11/10 milk with 2 PM snack. On 5/4/10 the physician ordered "Assist with Feeding" for R1. On 9/17/10 the physician ordered to mix ice cream in house supplement three times per day. The Minimum Data Set ((MDS) dated [DATE] assessed R1 as severely cognitively impaired. R1 was also assessed as requiring one person limited physical assistance for eating. The MDS does not identify a significant weight loss and documented R1's weight at 138 pounds even though the weight log documented 111.3 pounds. The care plan dated 6/1/10 states " ...for weight loss due to severely impaired cognitive abilities. Does not recognize she is hungry. Needs to be escorted to meals daily. Recent weight loss noted". The care plan does not identify that R1 has had a significant weight loss. There are no specific approaches for R1 other than "Provide set up and hands on assist as needed to encourage me to eat my food. Offer finger foods. There is no assessment by a Speech/Language therapist in the medical record. On 9/30/10 E2, Director of Nursing, provided 2 "Dietary Services Communication" sheets that were sent to the physician as physician notification of weight loss. The communication sheet dated 8/12/10 only noted R1 was "98% IBW (Ideal Body Weight)" but there were no weights documented on the communication sheet. Z2, Dietitian, recommended that the 2 PM snack beverage "to be milk". There was no mention of a significant weight loss. On 9/14/10 Z2 sent a "Dietary Service Communication" to the physician that stated "Wt (weight) (decrease) 1 & 3 mo. (Months)" and "93% IBW (Ideal Body Weight)". There was no mention of a significant weight loss nor were any actual weights documented on the sheet. The recommendation was to mix ice cream in the 4 oz. supplement three times per day. R1 was already receiving 4 oz. house supplement three times per day. On 10/6/10 the facility provided a "Dietary Service Communication" sheet dated 6/14/10 that noted the weight at 123.8 pounds. The dietary recommendations were to "trial 90 ml (milliliters) med (medication) pass supplement followed by encouragement of H2O (water)" and "please specify finger foods to be offered when possible". R1's weight has decreased from 131.9 pounds on April, 2010 to 104.4 pounds on 9/22/10. This is a significant weight loss of 21% in 6 months. Z1, Physician, stated on 10/4/10 that he was unaware of that significant weight loss and should have been notified. Z1 stated that R1 should be fed and expected staff to assist her to eat. Z1 stated that R1 was admitted to hospice due to failure to thrive. Z1 stated he would call the facility to make sure staff were feeding R1. On 10/6/10 E1 stated that they had discovered on 10/6/10 R1 had been weighed by a stand up scale for the second and third week of September when she had been weighed with a hoyer lift scale on the first week of September. E1 stated E4 wrote a statement to confirm this. E4 stated in the written statement dated 10/6/10 that when she weighed R1 with the hoyer scale her weight was the the same as the first week or 111.4 pounds. This is still a 16% significant weight loss over a six month period and the physician was not informed of the weight loss. Observation of the noon meal on 9/29/10 at 12:15 PM noted R1 sitting in the dining room at the table in her wheelchair with the lab cushion on. R1 was playing in her food with her hands. R1's drinks of milk and chocolate supplement were out of reach for R1. There was no staff present to help R1. At 12:30 PM the same situation was observed. At 12:45 PM R1 was observed in the same position smashing her bread up in her hands. R1's drinks were still out of reach. R1's cut up breaded patty, mashed potatoes, and carrots were mixed together and the plate was full. At 12:50 PM three staff came into the room and sat with 3 other residents to assist them to eat. E4, Certified Nurse Aide, approached R1 at 12:55 PM and tried to get her to drink her house supplement. E4 stood at R1's side while she tried to get her to drink. At 1:00 PM E4 gave R1 an 8 ounce glass of water and she drank the entire glass. This glass was filled and she again drank the whole glass. E4 offered R1 her chocolate supplement and she drank the whole glass. E4 then moved the empty supplement glass out of R1's reach as she continued to reach for the glass. E4 stated it was gone and did not give R1 any other drinks. None of the fortified milk was offered. E4 stated that R1 ate a few bites of mashed potatoes and pudding. The menu for ""Finger Food" states to give tator tots in place of mashed potatoes and a pudding pop in place of pudding. On 9/30/10 at the breakfast meal R1 was observed at 8:40 AM in the dining room. All food on the plate had been eaten and all her fluids of milk, juice, water and supplement were gone. R1 was feeding herself super cereal from a bowl and ate all of the cereal. At 8:55 AM E5, Social Service, approached R1 and asked her if she was done. At 8:57 AM E5 offered R1 a glass of water which she drank. There was no more food or fluids given to R1. At 9:05 AM E4 approached R1 and tried to take her from the dining room. R1 kept pulling her self back to the table. E4 stated they were closed, put the lap cushion back on R1 and took her from the dining room. There was no offer for more food or fluids. Z2, Registered Dietitian, stated on 10/4/10 that the last time she had reviewed R1 her weight was 111.3 pounds. Z2 stated that the order should have read to offer finger foods when possible but if the physician order [REDACTED]. Z2 stated that R1 was declining and losing weight so hospice had been initiated in July. Z2 confirmed that staff should have offered R1 more food or liquids if she would have taken them. Z2 stated that [MEDICATION NAME],[MEDICATION NAME] could alter appetite when asked if there were any issues with medications R1 received that could affect her weight. There was no assessment of the possible side effects of the medication. R1's [MEDICATION NAME] was increased on 6/24/10 from 0.5 mg as needed to 0.5 mg three times per day. On 7/22/10 the [MEDICATION NAME] was increased to 1 mg three times per day. On 5/7/10 R1 received an order for [REDACTED].