Every finding on record at Fair Havens Senior Living

Based on interview and record review, the facility failed to report an allegation of possible abuse/neglect to the Administrator and to the State Survey Agency for 1 of 5 residents (R6) reviewed for abuse/neglect in a sample list of 14.Findings Include:R6's Face Sheet documented an initial admission date of 07/15/2025 with diagnoses including History of Falling, Anemia, Anxiety, Atherosclerotic Heart Disease, Chronic Obstructive Pulmonary Disease, Venous Thrombosis and Embolism, Essential Hypertension, Major Depressive Disorder, Polyneuropathy, Overactive Bladder, Peripheral Vascular Disease, Iron Deficiency Anemia, Unspecified Dementia, Acquired Absence of Left Leg Above Knee, Retention of Urine.The Minimum Data Set (MDS) for R6 dated 8/11/2026 documented a Brief Interview for Mental Status (BIMS) score of 9, indicating R6 had moderate cognitive impairment.On 08/25/2026 at 9:11 AM, V1 Administrator reported being aware of an incident on 08/07/2026 involving a resident's daughter calling the police after the resident fell. V1 stated that the incident was not reported to V1 as possible neglect or abuse; therefore, V1 did not report it. V1 confirmed that if the terms neglect or abuse had been used, V1 would have reported the incident.On 08/25/2026 at 9:16 AM, V2 Director of Nursing (DON) reported receiving a call from V31 Licensed Practical Nurse (LPN) stating that a resident's family member had called the police after their mother fell. V2 DON denied coming to the facility that night, noting that V32 Former Associate Director of Nursing (ADON) was on duty. V2 DON also denied receiving any allegations of neglect or abuse from residents, families, or staff on 08/07/2026.On 08/25/2026, three attempts were made to interview V32 Former ADON and V31 LPN; V31 and V32 were unavailable.Facility Incident Reports dated 05/24/206-08/24/2026 documented a fall incident that occurred on 08/07/2026 at 8:30 PM with R6.R6's Progress Notes were reviewed. A noted entered by V31 LPN on 08/07/2026 at 9:00 PM documents POA (Power of Attorney) arrived at facility and expressed concerns regarding residents current falls. POA stated that she feels the continue falls are an ongoing issue and expressed concern regarding possible abuse/neglect. Writer then acknowledged POAs concerns and explained that appropriate post- fall protocol has been initiated. POA then questioned why an alarm was not being utilized in w/c (wheelchair). Writer attempted to address concerns and provided reassurance. POA remained dissatisfied and stated she plans to contact IDPH and PD (local police department) regarding her concerns. POA has left facility. An additional Progress Note for R6 entered by V31 LPN on 08/07/2026 at 9:45 PM documents PD here at facility and is assisted by nurse manger.On 08/25/2026 at 11:24 AM, V1 Administrator confirmed that R6's Progress Note dated 08/07/26 at 9:00 PM regarding possible abuse/neglect had not been reported to V1. V1 stated that as the facility's abuse coordinator, V1 would expect such concerns to be reported, and that V1 would now file a Reportable Event.The facilities Abuse policy last revised on 10/2022 documents the following Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer.

Based on interview and record review the facility failed to protect the residents right to be free from physical abuse from another resident for two (R5, R7) of five residents reviewed for abuse on the sample list of 14 residents. Findings include:R5's electronic health record (EHR) documented R5 has resided at the facility since 8/12/2022. R5's EHR documented R5 has diagnoses including, but not limited to Cerebral Infarction, Major Depressive Disorder, Muscle Weakness Generalized and Unspecified Dementia with Agitation.R5's most recent Minimum Data Set (MDS) dated [DATE] documented R5 has a brief interview for mental status (BIMS) score of 9 indicating R5 is not cognitively intact.R5's care plan initiated on 8/12/2022 documents the following focus for R5, (R5) has a behavior problem r/t (related to) withdrawal, sadness, crying, refusing treatments, rejection of care, refusing medications, resident on Depakote r/t behaviors, throwing objects revised on 7/28/2026 with targeted interventions in place.R7's EHR documented R7 was most recently re-admitted to the facility on [DATE] with diagnosis to include Schizoaffective Disorder, Major Depressive Disorder Severe with Psychotic Symptoms, Generalized Anxiety Disorder and Hypoglycemia.R7's MDS dated [DATE] documents R7 has a BIMS score of 12 indicating R7 is cognitively intact.R7's Care Plan initiated on 5/24/2021 documents the following focus for R7, (R7) has a behavior problem screaming and yelling at staff, throwing objects last revised on 7/28/2026 with targeted interventions in place.The facilities initial Incident Report Form for abuse investigation dated 7/24/2026 at 12:10 PM, documents staff reported to the administrator that while residents were eating lunch, (R5) threw a cold drink at (R7) and the container and liquid hit (R5). Residents were immediately separated and nurse (V33 Registered Nurse) performed head to toe assessment on both residents. No injuries noted will continue to monitor. The facilities final investigation report dated 7/30/2026 concludes an isolated resident-to-resident altercation occurred between R5 and R7 on 7/24/2026. The final investigation report goes on to further document that one staff member, V36 Certified Nursing Assistant (CNA), witnessed the incident and immediately intervened.On 8/25/2026 at 12:35 PM, unsuccessful attempt was made to contact V33 Registered Nurse.On 8/25/2026 at 12:55 PM, unsuccessful attempt was made to contact V36 CNA.On 8/25/2026 at 1:35 PM, R7 stated somewhat remembering the resident to resident altercation that occurred on 7/24/2026 between R7 and R5. R7 stated not recalling why the altercation began or what caused R7 and R5 to become upset. R7 stated that R5 threw something at R7, and that R7, in return, threw an item back at R5. R7 denied recalling what items were thrown. R7 stated that R7 and R5 used to be good friends and that the friendship is missed, but R7 and R5 now sit at different tables in the dining room following the incident. R7 stated feeling safe in the facility. R7 stated that no injuries occurred and that a nurse completed a skin assessment following the incident. R7 denied any long term psychosocial effects.On 8/27/2026 at 11:26 AM, V1 (Administrator) stated being notified immediately after the altercation occurring on 7/24/2026 between R5 and R7. V1 stated that the facility's investigation determined an isolated resident to resident altercation occurred between R5 and R7.Facility's Abuse policy dated 10/2022 documents every resident has the right to be free from abuse. Facility's abuse policy also states the facility prohibits the abuse of residents.

Based on observation, interview, and record review, the facility failed to ensure medications were administered as ordered for three of three (R4, R5 and R6) residents reviewed for medication administration in a sample list of 12. Findings include: 1.) On 8/14/2026 at 7:55 AM, during medication pass, V5 Licensed Practical Nurse (LPN) was looking for R4's antibiotic medication, Rifaximin (non-absorbable antibiotic), oral tablet 550 milligrams (mg) and was unable to find the medication in the medication cart. R4 stated to V5 that R4 had not received the medication since returning from the hospital on 8/11/2026. V5 stated to R4 that it's on hold and pending with V2 Director of Nursing (DON).On 8/14/2026 at 8:35 AM V5 stated R4 returned from the hospital earlier this week with an order for Rifaximin oral tablet 550mg but has not received it since readmission due to medication cost. V5 stated pharmacy is waiting for V2 or V1 Administrator to approve that the medication be sent.R4's hospital discharge orders on 8/11/2026 show R4 to continue Antibiotic Rifaximin at facility upon hospital discharge.On 8/14/2026 at 8:49 AM R4 states R4 has not received Rifaximin since R4 left hospital on 8/11/2026 due to insurance and has not received the antibiotic.R4's Medication Administration Record (MAR) for R4's antibiotic, Rifaximin, shows a 9 in documentation space for the 9:00 AM dose on 8/12/2026, indicating there should be a progress note regarding the administration of this medication, and documented H on 8/12/2026 at 5:00 PM dose, indicating the medication is on hold, therefore R4 did not receive either dose of R4's antibiotic on 8/12/2026. This MAR documented R4's antibiotic was not administered on 8/13/2026 for 9:00 AM dose, again signed with an H indicating it was still on hold. R4's antibiotic was signed out as having been given on 8/13/2026 but V1 states medication was not available on 8/13/2026 so could not have been given at 5:00 PM on 8/13/26.R4's progress note entered on 08/14/2026 at 9:35 AM documents on 08/12/2026 at 8:19 AM, R4's antibiotic Rifaximin was not administered because it was not covered by the resident's insurance and request was sent to the V2 DON per pharmacy. As a result, R4 did not receive Rifaximin on 08/12/2026, 8/13/2026 and 08/14/2026, causing R4 to miss 6 doses of the antibiotic.R4's physician order dated 8/11/2026 documents the order, Rifaximin 550 mg oral tablets 1 tablet by mouth twice daily, for Alcoholic Cirrhosis of Liver without Ascites, with a start date of 08/12/2026 and an end date of 09/11/2026.On 08/14/2026 at 10:30 AM V3 (Wound Nurse) confirmed that R4 returned to the facility on [DATE], and that V2 had been notified that Rifaximin was not being administered due to a pending cost approval. V3 stated the physician was aware of the issue and had given orders to hold the medication. However, upon review of R4's progress notes and physician orders, V3 confirmed there was no documentation indicating that the physician had been notified or that an order had been entered to hold Rifaximin.On 8/14/026 at 10:30 AM V3 further clarified that when a date and time entry on the MAR is left blank, this indicates the medication was not administered.On 8/14/2026 at 10:59 AM V14 Registered Nurse/RN stated that R4 has not been getting antibiotic Rifaximin since return from hospital due to being on hold and needing approval. V14 stated V14 received order from doctor on 8/14/2026 to put Rifaximin on hold. V14 stated V14 notified doctor today, on 8/14/2026, regarding order for Rifaximin not being started due to cost.On 08/15/2026 at 9:20 AM V2 stated R4's Antibiotic Rifaximin was on hold. V2 notified V1 and owner of facility regarding price of antibiotic (Rifaximin). V2 stated V2 expects nurses to notify doctors right away when medication is not available.On 8/15/2026 at 9:48 AM V1 stated R4's Rifaximin was approved yesterday on 8/14/2026 and pharmacy was supposed to send this medication last night.R4's medical record documents R4 was admitted on [DATE] with diagnosis of Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, Essential (Primary), Hypertension, Chronic Kidney Disease, Stage 2, Venous Insufficiency (Chronic) (Peripheral), Anemia, Hypothyroidism, Heart Failure, Peripheral Vascular Disease, Lymphedema, Non-Pressure Chronic Ulcer Of Other Part Of Left Lower Leg With Fat Layer Exposed, Non-Pressure Chronic Ulcer Of Other Part Of Right Lower Leg With Fat Layer Exposed. R4's Minimum Data Set (MDS) dated [DATE] documented the resident as cognitively intact, indicating R4 could report whether medications were administered.On 08/14/2026 at 9:40 AM., R4 stated R4 did not receive their 5:00 a.m. medications. R4 states they are supposed to have their famotidine pill, levothyroxine pill, and azelastine ophthalmic eye drops.R4's physician orders show R4 is to have the following medications: Azelastine HCl Ophthalmic Solution 0.05%, 1 drop in both eyes twice daily, ordered 08/11/2026. Famotidine 40 mg, 1 tablet orally daily, ordered 08/12/2026. Levothyroxine 100 micrograms (mcg), 1 tablet orally daily, ordered 08/12/2026.On 8/14/2026 at 1:00 p.m. R4's medications remain not signed out on R4's MAR. R4's Famotidine, Levothyroxine and Azelastine not signed out at 5:00 a.m. and no note in progress noted that doctor was called and why medication was not given. 2.) On 8/14/2026 at 7:58 AM R6 stated R6 did not receive R6's scheduled 5:00 am medication today that helps with R6's shaking.R6's physician order dated 4/19/26 documents Alprazolam 0.5mg 1 tablet by mouth twice a day at 5:00am and 8:00pm.On 8/14/2026 at 11:23 AM R6's MAR (Medication Administration Record) documents that the 5:00 am Alprazolam dose still had not administered as ordered.On 8/14/2026 at 1:00 PM, further record review for R6 confirmed the 5:00 AM Alprazolam dose remained unsigned on the MAR. There was no progress note explaining why the medication was not administered and no documentation indicating the physician was notified. R6's medical record documents R6 was admitted on [DATE] with documented Diagnoses including Diastolic (Congestive) Heart Failure, Chronic Obstructive Pulmonary Disease, Acute Respiratory Failure With Hypoxia, Acute Pulmonary Edema, Other Hyperlipidemia, Iron Deficiency Anemia, Essential (Primary) Hypertension, Generalized Anxiety Disorder, Essential Tremor, and Acute Pericarditis. R6's Minimum Data Set, dated [DATE] documents the resident as moderately intact, indicating R6 could report whether medications were administered. 3.) On 8/14/2026 at 8:46 AM, R5 stated R5 did not get R5's 5:00 AM medications. R5 states R5 is supposed to have R5's blood sugar checked, R5 is supposed to take a levothyroxine pill, and get a lidocaine patch applied to both knees at that time. R5 had no lidocaine patches on either one of R5's knees.R5's physician order dated 5/30/25 documents Lidocaine External patches 4 percent apply to both knees topically two times a day for pain management (patches on at 5:00 am and removed at 7:00 pm). R5's physician order dated 7/3/2026 documents the order for blood sugar via finger stick every morning at 5:00 am on Monday and Fridays (observation was on Friday). R5's physician order dated 5/31/2025 documents the order: Levothyroxine 50 mcg 1 tablet in the morning at 5:00 am .R5's MAR dated August 2026 documents that the 5:00 am medications and blood sugar check, levothyroxine, and lidocaine patches-were not signed out as given/administered. There was no nursing documentation explaining why R5's medications were not administered and no note indicating the physician was notified.On 8/15/2026 at 9:20 AM V2 (DON) confirmed that R5's medications were not signed out as given on R5's MAR for 8/14/2026 at 5:00 am.On 8/14/2026 at 9:50 AM R5's medical record documents R5 was admitted on [DATE] with documented Diagnoses including Chronic Obstructive Pulmonary Disease, Hypokalemia, Anxiety Disorder, Hypothyroidism, Bilateral Primary Osteoarthritis Of Knee and Type 2 Diabetes Mellitus Without Complications.R5's MDS dated [DATE] documents the resident as cognitively intact, indicating R5 could report whether medications were administered.The facility's policy, Medication Administration, effective March 2014 states: #1 Drugs will be administered in accordance with orders of licensed medical practitioners of the State in which the facility operates. #17 In the event a drug is unavailable, the charge nurse shall be responsible for notifying the pharmacy for delivery. #19 The medication administration record (MAR) will be verified against physician's orders. #20 Medications shall be recorded on the MAR promptly after each administration by the individual who administered the drug. #28 Clarifications and/or questions related to administering medications will be directed to the next highest authority in nursing service, and if needed the attending physician or pharmacist.

Based on observation, interview, and record review, the facility failed to provide thorough and timely incontinence care for two (R51 and R45) of three residents, reviewed for incontinence care in a sample list of 52 residents. This failure resulted in R51 being hospitalized for treatment for a Urinary Tract Infection (UTI) and R45 requiring antibiotic treatment for multiple Urinary Tract Infections (UTI). Findings include: 1. R51's care plan dated 7/21/26 documents R51 was at risk for an activities-of-daily-living self-care deficit related to diagnoses including Metabolic Encephalopathy, Sepsis, Cystitis, Alzheimer's /Disease, Chronic Obstructive Pulmonary Disease, and Trigeminal Neuralgia. The care plan documented R51 required maximum assistance from one staff member for personal hygiene, dressing, toileting, bed mobility, and transfers. R51's lab results dated 5/15/26 documents a clean-catch urine culture was collected. Culture and Sensitivity results dated 5/19/2026 documented greater than or equal to 100,000 colony-forming units per milliliter of Escherichia coli. The organism was identified as an extended-spectrum beta-lactamase-producing organism. On 5/19/2026, R51 was started on antibiotic therapy. Physicians order confirmed Cephalexin Tablet 500mg (milligrams) Give one tablet by mouth two times a day for infection for ten days. R51s lab results on 6/13/26 documents a clean-catch urine culture was collected. Culture and Sensitivity results dated 6/15/2026 documented greater than or equal to 100,000 colony-forming units per milliliter of Escherichia coli. The organism was identified as an extended-spectrum beta-lactamase-producing organism. R51's Electronic Medical Record (EMR) census profile documents R51 was hospitalized from [DATE] to 6/17/26. There was a handwritten note on the lab results dated 6/13/26 noting that R51 was in the hospital 6/13/26 – 6/17/26. There were no progress notes regarding R51's hospitalization. On 7/28/2026, Nursing progress notes documented that R51 complained of burning with urination, appeared more confused than usual, experienced a change in mental status, and showed signs of lethargy. The physician was notified, and a urinalysis with culture and sensitivity was ordered. R51's lab results dated 7/28/26 documents a clean-catch urine culture was collected. Culture and Sensitivity results dated 7/29/2026 documented greater than or equal to 100,000 colony-forming units per milliliter of Escherichia coli. On 7/30/2026, R51 was started on antibiotic therapy. Physicians order confirmed Macrobid Oral Capsule (Nitrofurantoin Monohyd Macro) Give 100 mg by mouth two times a day for UTI (Urinary Tract Infection) for seven Days. R51's restorative progress note dated 7/30/2026 documents R51 was incontinent of bowel and bladder and required staff assistance with toileting, hygiene, and perineal care to maintain comfort, dignity, and skin integrity. R51's Progress notes dated 7/31/2026 through 8/4/2026 documented continued antibiotic treatment for the Urinary Tract Infection. R51's Minimum Data Set (MDS) documents that R51 has moderate cognitive impairment and states that R51 is dependent on staff for toileting hygiene, showers and bathing, Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of two or more helpers is required for the residents to complete the activity. On 8/3/2026 at approximately 5:50 AM, V77 Certified Nursing Assistant (CNA) removed two incontinence briefs and one incontinence liner from beneath R51. The removed products were saturated with urine that was yellow, emitted a strong ammonia odor, and contained dried, speckled pieces of bowel movement. V77 CNA used a wet towel to cleanse R51's frontal perineal area. During cleansing, R51 cried out, Oh, oh, oh. V77 CNA directed R51 to roll onto the right side and stated dried stool was present on R51's buttocks. V77 CNA made multiple cleansing attempts and repeatedly rubbed the area to remove the dried stool. Multiple reddened areas of varying sizes were observed on R51's buttocks. The skin remained intact, with no open areas observed. During continued cleansing, R51 again cried out, Oh, oh, oh. V77 CNA dried R51's buttocks and applied a clean incontinence brief. On 8/3/2026 at approximately 5:50 AM, during the observed care, V77 CNA stated R51 had last received incontinence care and had been changed at approximately 2:30 AM, approximately three hours and 20 minutes earlier. V77 CNA stated V77 was assigned approximately 15 residents during the shift. Review of R51's electronic bowel-and-bladder task records showed entries on 8/3/2026 at 1:06 AM and 7:43 AM. The records did not contain an entry at or near 2:30 AM. V2 Director of Nursing (DON), stated CNAs were expected to document the time a resident was toileted or received incontinence care. V2 stated the documented time should reflect when the care was provided, not when the CNA later entered or completed the documentation. Therefore, the task records did not support V77's statement that R51 received incontinence care at approximately 2:30 AM. On 8/5/2026 at 12:40 PM, V22 Infection Preventionist (IP) stated prolonged exposure to urine or feces in soiled incontinence products could negatively affect a resident's skin and could contribute to infections that might otherwise not occur. On 8/5/2026 at 1:00 PM, V2 DON, stated leaving a resident wet for an extended period could negatively affect the resident and could contribute to infection and skin breakdown. On 8/5/2026 at 1:00 PM, V1 Administrator and V2, DON stated leaving a resident wet for an extended period could negatively affect the resident and could contribute to infection and skin breakdown. The facility failed to provide timely and effective incontinence and perineal care to R51, who was dependent on staff for toileting and hygiene. R51 was found with urine-soiled incontinence products and dried feces remaining on the buttocks, experienced pain during the repeated removal of dried stool, and had multiple reddened areas on the buttocks. 2. Review of R34's Minimum Data Set, dated [DATE] documents R34 has moderate cognitive impairment. R34 is dependent on staff for Toileting Hygiene, Showers, Bathing, and Personal Hygiene. Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of two or more helpers is required for the residents to complete the activity. R34's Braden skin-risk assessment dated [DATE] documented R34 was very moist, chairfast, very limited in the ability to make frequent or significant position changes independently, and at risk for friction and shear. R34's care plan documented R34 required maximum assistance for personal hygiene, dressing, toileting, and bed mobility and required two staff members and a mechanical lift for transfers. The care plan directed staff to check and change R34 every two hours and as needed to keep R34 clean, dry, and odor-free; provide incontinence care after each episode; and wash, rinse, and dry the perineal area. On 7/30/2026 at 12:48 PM, V41 Certified Nursing Assistant (CNA), and V9 Certified Nursing Assistant (CNA), transferred R34 from the wheelchair to the bed using a full-body mechanical lift. V41 CNA removed an incontinence brief and an absorbent insert. The brief and insert were visibly saturated with light-brown liquid and emitted a strong ammonia odor. V41 CNA used three disposable wipes to cleanse R34's buttocks but did not cleanse all areas that were contaminated with urine. R34's skin was intact and reddened, with deep skin creases observed. V41 CNA directed R34 to roll onto the R34's back and used two disposable wipes to cleanse the frontal and outer perineal areas. V41 CNA did not spread R34 labia to cleanse inner folds. V41 CNA then applied a clean incontinence brief. V41 continued wearing the same gloves used during the mechanical-lift transfer and removal of the saturated products. V41 did not remove the gloves or perform hand hygiene before beginning perineal care. On 7/30/2026 immediately following the 12:48 PM care observation, V41 CNA stated V9 had assisted with changing R34 at approximately 9:50 AM. Approximately two hours and 58 minutes elapsed before the saturated products were removed at 12:48 PM, exceeding the care-planned two-hour interval by approximately 58 minutes. V41 CNA stated staff doubled R34's incontinence products because the previous-shift staff member had done so and because R34 was a heavy wetter. V41 CNA stated doubling the products could affect R34's skin but did not know whether the effect would be positive or negative. On 8/5/2026 at 1:00 PM, V2 DON stated staff should not double incontinence briefs or pads unless the intervention was included in the resident's care plan. V2 stated only one resident in the facility, R52, was currently care planned for double incontinence briefs. On 8/5/2026 at 12:40 PM, V22 Infection Preventionist (IP) stated residents seated in wheelchairs should be checked at least hourly for repositioning needs and incontinence. V22 stated checking a resident by patting over the resident's clothing was not an acceptable method of determining whether the resident was wet or soiled. R34's task report included interventions directing staff to cleanse the abdominal folds and buttocks with soap and warm water, pat the areas dry, and apply nystatin powder every shift. The task report also directed staff to cleanse the buttocks and sacrum, pat the area dry, and apply zinc barrier cream every shift. The task report documented the skin-care interventions as administered during the 6:00 AM to 2:00 PM shift on 7/30/2026. During the observed care at 12:48 PM, soap and warm water were not used to cleanse R34's buttocks and sacrum, the areas were not patted dry, and zinc barrier cream and nystatin powder were not observed to be applied. 3. On 7/30/26 from 10:33 AM to 2:20 PM, during observation, R45 was observed in R45's wheelchair in the dining room, at the nurses' station, in the hallway and in R45's room. During this time, no staff approached R45 to offer assist with toileting or to check R45 for incontinence. On 7/30/26 at 2:20 PM, R45 propelled self to the bathroom, stood and pulled pants and adult incontinence brief down, then sat down and urinated on the toilet. R45's adult incontinence brief was saturated with dark yellow urine and had smears of feces on the brief. The brief smelled strongly of urine. R45 pulled up the same soiled brief and pants and transferred self to the wheelchair and then transferred self to bed in the same soiled adult incontinence brief. On 7/30/26 at 2:53 PM, V19 CNA stated R45 takes care of self and will call for help. V19 CNA attempted to check R45 for incontinence and R45 was uncooperative. V19 CNA was wearing gloves and felt R45's pants in R45's groin area and stated, (V19) is dry. V19 did not visually check R45 for incontinence. R45's Face Sheet documented R45 was admitted to the facility on [DATE] with the diagnoses of Unilateral Primary Osteoarthritis, Left Knee. R45's Minimum Data Set (MDS) dated [DATE] documents R45 is severely cognitively impaired and requires assist of one with toileting and substantial/maximum assistance with personal hygiene. R45's Care Plan dated 6/29/2026 documents R45 has bladder/bowel incontinence with the following interventions included in the care plan: Check resident every two hours and assist with toileting as needed and provide peri care after each incontinent episode. R45's laboratory test results dated 7/30/2026 document's R45's urinalysis and culture results to be positive for a Urinary Tract Infection and identified the causative bacteria as Enterobacter cloacae complex. R45's physician order dated 7/30/26 documents the order for Macrobid (antibiotic) Oral Capsule 100 MG (milligrams) GIVE ONE CAPSULE BY MOUTH TWO TIMES A DAY FOR UTI FOR SEVEN DAYS R45's laboratory test results dated 6/17/2026 documents R45's urinalysis with a handwritten order at the bottom of the page. R45's physician order dated 6/22/26 documents the order for Macrobid Oral Capsule 100 MG GIVE ONE CAPSULE BY MOUTH TWO TIMES A DAY FOR UTI FOR SEVEN DAYS. On 7/30/2026 at 2:05 PM, V61 CNA stated during rounds R45 was asleep in R45's bed. V61 CNA stated said during rounds V61 checks if a resident is wet or soiled with bowel movement. V61 CNA performs rounds at start of shift, at 1030AM, then right after lunch. V61 stated R45 does a lot on their own and doesn't need CNAs assist for toileting. On 7/30/2026 at 2:28 PM, V15 Licensed Practical Nurse (LPN) stated R45 was confirmed to have a Urinary Tract Infection and V15 LPN was awaiting orders for treatment. V15 LPN stated R45 is not a big drinker and tends to have Urinary Tract Infections, R45 is a soda drinker and staff encourage R45 to drink more water. V15 LPN stated staff attempt to toilet R45 but R45 takes self to the bathroom but is incontinent. V15 LPN stated R45 will pull the light if R45 requires assistance with care. V15 LPN stated staff do provide R45 with verbal cues and reminders for toileting. On 8/4/2026 at 12:40 PM, V22 Infection Preventionist stated that the facility follows standard practice guidelines of repositioning every hour while a resident is up in a wheelchair. This practice helps to prevent skin break down. CNA staff are to check resident's dependent for toileting or incontinent residents every two hours and assisting them with toileting every two hours. Those residents may not know they have to go to the bathroom or that they are wet. R45 would need cueing as R45 is forgetful. CNA staff still need to be checking on R45 for incontinence even though R45 will sometimes take self to bathroom. During a check for R45 CNA staff should go in and ask if R45 needs to go to the bathroom, check their adult incontinence brief and offer toileting. They should wake up R45 and ask if R45 needs to go to the bathroom and check their adult incontinence brief and offer toileting. It would not be appropriate for a CNA to determine if a resident was dry by using their gloved hands to pat outside a residents' clothing to determine if the adult incontinence brief was wet. They would have to open the adult incontinence brief and check the inner liner or check for the line indicating the adult incontinence brief was wet. V22 stated that leaving a resident sitting in a wet adult incontinence brief would contribute to a Urinary Tract Infection. V22 confirmed R45 to have an active Urinary Tract Infection. On 8/4/2026 at 1:00PM, V1 Administrator stated toileting should also be provided according to facility policy and that call lights should be answered when residents requested assistance. For residents with cognitive impairment, staff should follow the resident's care plan. V1 stated incontinent residents should be checked at least every two hours. V1 further stated they would not expect staff to pat a resident over the resident's clothing to determine whether the resident was wet. On 8/4/2026 at 1:03 PM, V2 Director of Nursing (DON) stated that leaving a resident wet for an extended period could negatively affect the resident and could contribute to infection and skin breakdown. The facility's undated policy titled Toileting Assistance Policy documents the purpose of the policy is to promote resident dignity, comfort, independence, continence, skin integrity, and safety by providing timely and individualized toileting assistance in accordance with each resident's care plan. The policy documents It is the policy of this facility to provide toileting assistance that is individualized to each resident's needs, preferences, and functional abilities. Staff will encourage residents to maintain their highest practicable level of independence while ensuring privacy, safety, and infection prevention practices are followed. Residents will be offered assistance to the toilet as needed per residents' request. Procedure 2. Follow the resident's individualized care plan regarding toileting, transfer status, assistive devices, and level of assistance required. Quality Assurance: The facility will routinely monitor documentation, toileting, continence programs, skin integrity, and resident outcomes to ensure compliance with this policy and applicable federal and state regulations. The facility's policy dated August 2008 documents The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Step nine documents For a female resident: a. Wet washcloth and apply soap or skin cleansing agent/ no rinse cleanser. (1) May use cleansing wipes. b. Wash perineal area, wiping from front to back. (1) Separate labia and wash area downward from front to back. Inspect the area for any open areas, drainage and other abnormalities. (2) Continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side, and using downward strokes. (3) Rinse perineum thoroughly in same direction. (4) Gently dry perineum. Step e. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. Do not reuse the same washcloth or water to clean the labia. 12. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. 13. Reposition the bed covers. Make the resident comfortable.

Based on interview and record review, the facility failed to complete wound monitoring and failed to follow Physician's orders for wound care for one resident (R8) and failed to transcribe and provide Physician ordered wound care for one resident (R6). This failure affects two (R8, R6) of three residents reviewed for wound care in the sample list of 22. This failure resulted in R8's left foot wound becoming infested with parasitic fly larvae (maggots) and leaving R6 feeling mortified and upset. Findings Include: R8's Census Detail and Minimum Data Set List (undated) documents R8 was originally admitted to the facility on [DATE]. R8's current Diagnosis List (undated) documents R8 experiences medical diagnoses including, Peripheral Vascular Disease, Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Personal History of Other Venous Thrombosis and Embolism, Mild Cognitive Impairment, and Atherosclerosis of Native Arteries of Extremities. R8's Wound Care Physician Progress Notes from V54, Wound Care Physician, dated 6/1/2026, documents R8 is experiencing Left lower extremity -Wound present on the third and fourth toes. Wound Of the Left, Fourth Toe Full Thickness documented Wound Size ([NAME] x Width x Depth): 1 x 1.5 x Not Measurable cm (centimeter). Wound of the Left, Third Toe Undetermined Thickness documented Wound Size (L x W x D): 0.6 x 1 x Not Measurable cm Depth is unmeasurable due to presence of dried fibrinous exudate. R8's Wound Care Physician Progress Notes from V54, dated 6/15/2026, documents the patient's advancing peripheral arterial disease/gangrene significantly increases their susceptibility to complications. V54 physician orders are as follows, Betadine paint apply twice daily and as needed: if saturated, soiled, or dislodged. R8's Wound Care Physician Orders from V54, dated 6/15/2026, documents to Cleanse left foot 3rd & 4th digits with NS (normal saline) generic wound cleanser, pat dry, and paint with betadine, every shift for Abrasions to left 3rd & 4th digits -Start Date 06/15/2026 6:00 PM. R8's Wound Care Physician Progress Notes from V54, Wound Care Physician, dated 6/22/2026, documents Signing off on patient who remains in the facility. No further treatment orders noted. R8's Wound Care Physician Progress Notes from V54, dated 6/26/2026, documents Wound of The Left, Fourth Toe Full Thickness with a documented Wound Size (L x W x D): 3 x 1.4 x 0.5 cm. Wound of the Left, Third Toe Full Thickness with a documented Wound Size (L x W x D): 3.2 x 1 x 0.5 cm. R8's medical record contained nursing progress note written by V2, Director of Nursing (DON), dated 6/29/2026 at 09:33AM documenting Writer explained that the wound care physician was in the facility and performed debridement of the wound. During the debridement, maggots were observed between the resident's left third and fourth toes. The physician thoroughly cleansed and removed the maggots and issued new wound care treatment orders. There were no orders in R8's record documenting therapeutic use of maggots for any wound treatment. R8's Care plan dated 05/26/2026 documents Staff to ensure resident is wearing non-skid socks or socks with shoes on when up in wheelchair or ambulating. On 07/06/26 at 06:45AM R8 was lying in bed with a wound dressing on the left foot dated 7/6/2026. On 7/1/26 at 09:45AM V32, License Practical Nurse, (LPN) stated V19, wound nurse, is supposed to do the wound care during the week, and nursing staff on the weekends. V32 stated V32 prefers to perform the wound care to monitor the wound. V32 stated nurses doing the wound care would be able to tell if a wound is doing better or worse and inform the physician. On 7/1/26 at 10:52AM V19, Wound Nurse, stated R8 did not have a wound dressing over the left foot/toe wounds. V19 stated the wound care physician ordered the wounds to be painted with betadine twice daily. V19 stated parasitic fly larvae (maggots) was removed from R8's foot wound by the physician. V19 stated staff was supposed to keep R8's foot covered with a sock/shoe but clearly they did not. V19 confirmed the nurses completing the treatment should have noticed a decline/worsening in the wound and informed the physician. On 7/6/26 at 12:20PM V55, R8's family, stated every time V55 would visit R8, R8 would not have on socks or shoes and V55 would have to tell staff to put them on R8. V55 further stated R8's floor was often sticky and smelled of urine. V55 stated V55 was informed by a nurse that R8 did have parasitic fly larvae (maggots) in R8's left foot wound, and V55 was not surprised due to lack of footwear to protect the foot. V55 stated R8, if cognitively intact, would be mortified and terribly upset knowing staff was not taking proper precautions and care to prevent parasitic fly larvae (maggots) from developing in the wounds. On 7/6/26 at 1:30PM, V54, Wound care physician, stated V54 cleansed, debrided and removed several parasitic fly larvae (maggots) from R8's left foot wound. V54 stated the wound deteriorated from eschar (scab) to an open and draining wound bed. V54 stated/confirmed the parasitic fly larvae (maggots) would have gotten there from the wound being exposed due to a lack of footwear. On 7/6/26 at 3:15PM V19, Wound Nurse, stated V2, DON, entered the wrong date for the progress note, the parasitic fly larvae (maggots) were discovered and removed from R8's wound on 6/26/26 by V54, wound physician. 2. On 7/6/2026 at 6:53am, observed R6 lying in bed with head of the bed elevated, tube feeding cycling, bilateral pressure reducing heel boots intact and bilateral pressure wound dressings intact. Left heel, bordered foam gauze dressing dated 6/29/26. Right heel, bordered foam gauze dressing dated 6/29/26. Right lateral ankle, bordered foam gauze dressing dated 6/29/26. V49 Licensed Practical Nurse (LPN) reviewed R6's wound locations in the electronic chart, confirmed the dressings to the bilateral heels and right ankle were dated 6/29/26 and stated dressing changes are performed by the wound nurse or by nursing staff if the wound nurse is unavailable. R6's physician orders dated 6/9/2026 document: DTI (Deep Tissue Injury) R (Right) heel: cleanse with NS(normal saline)/generic wound cleanser, pat dry, apply (barrier film) and cover with a border foam dressing. Every day shift every Mon (Monday), Fri (Friday) AND as needed and DTI L (Left) heel: cleanse with NS/generic wound cleanser, pat dry, apply (barrier film) and cover with a border foam dressing. Every day shift every Mon, Fri AND as needed. The Specialty Physician Wound Evaluation and Management Summary for R6 dated 6/29/26 documents UNSTAGEABLE DTI OF THE RIGHT, LATERAL ANKLE UNDETERMINED THICKNESS: Primary Dressing(s) Silicone bordered foam apply twice a week and as needed: if saturated, soiled, or dislodged. For 23 days. Peri Wound Treatment (barrier film) apply twice a week and as needed: if saturated, soiled, or dislodged. For 23 days. On 7/6/2026 at 7:45am, R6 had no active physician order for this wound location dressing change. R6's treatment administration record (TAR) report dated July 2026 documents a dressing change was administered to the right heel on 7/3/2026 by and unidentified nurse and to the left heel on 7/3/2026 by the same unidentified nurse. On 7/6/2026 at 10:45AM, V19 LPN, Wound Nurse observed R6's right lateral ankle dressing dated 6/29/2026 and bilateral heel dressing dated 6/29/2026. V19 also observed R6's G-tube (Gastrostomy tube) dressing dated 7/6/2026. V19 stated as of 7/1/2026, V19 would be the primary nurse to change dressings on Mondays with the wound physician rounds and all other dressing changes would be done by the nursing staff on shift as ordered by the physician. V19 stated a checkmark with initials on the TAR would indicate the task had been completed. V19 stated V19 would expect to see R6's dressings changed and dated for 7/3/2026 as indicated on the TAR by an unidentified nurse. V19 was not aware that a physician order for dressing changes to the right lateral ankle had not been entered. R6's care plan documents R6 was admitted to the facility on [DATE] with diagnoses including Altered Mental Status, Tubulo-Interstitial Nephritis, Dysphagia, Unspecified Intellectual Disabilities, Muscle Wasting and Atrophy, Protein-Calorie Malnutrition, and Reduced Mobility. R6's care plan revised on 6/29/2026 Documented Pressure Ulcer-stage 2 pressure to R heel-DTI L heel-DTI R lateral ankle. Interventions include Apply heel protectors, Educate (R6)/(R6's Representative) about proper skin care to prevent skin breakdown, Encourage (R6) to frequently shift weight, Ensure (R6) has heel protectors on while in bed, float heels as tolerated, Keep skin clean and well lubricated, Limit sitting time T&R (turn and reposition) per facility protocol, Monitor nutritional status, Notify provider if no signs of improvement on current wound regimen, Pressure relieving cushion to w/c (wheelchair) Pressure relieving mattress to bed, Provide skin care per facility guidelines and PRN as needed, Provide wound care per treatment order and Refer to specialized practitioner for wound management. R6's Minimum Data Set (MDS) dated [DATE], documents that a Brief Interview for Mental Status (BIMS) was not completed. R6 was not interviewable related to an inability to comprehend. On 7/6/2026 at 2:20PM, V1 Administrator stated nurses are expected to follow physician orders for medication orders and treatments including dressing changes. Pressure/Skin Breakdown – Clinical Protocol dated January 2017 documents The physician will authorize pertinent orders related to wound treatment, including pressure redistribution surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents.

Based on observation, interview and record review, the facility failed to ensure residents remained free from physical abuse for two (R3, R4) of three residents reviewed for abuse in a sample list of 22.Findings include:R3's Electronic Health Record (EHR) documents diagnoses including Chronic Obstructive Pulmonary Disease, Dementia, and Anxiety Disorder.R3's Minimum Data Set, dated [DATE] documents R3 has moderate cognitive impairment.R3's care plan revised on 3/13/25 documents R3 was assessed to be at low risk for abuse related to R3's dependency on others.R4's EHR documents diagnoses including Parkinson's Disease, moderate Dementia with psych disturbance, and Schizophrenia.R4's EHR documents on 5/27/26 R4 was uncooperative with completing the Brief Interview for Mental Status.R4's care plan revised on 12/11/24 documents R4 uses psychotropic medications for diagnoses of Schizophrenia and Dementia with Psychosis and Behaviors of Physical Aggression.R4's care plan revised on 12/3/25 documents R4 is assessed to have moderate cognitive impairment and cognitive function, Dementia, or impaired thought.R4's care plan revised on 5/21/26 documents R4 has a behavior problem related to restlessness, agitation, physical aggression, wandering, spitting out medications, yelling at staff, rejecting care, and rejecting assessments.On 6/30/26 at 12:39 PM, R3 stated R4 kicked R3 in the lower leg four times on 5/12/26. R3 stated after R4 kicked R3, R4 then slapped a nurse across the face. R3 stated staff separated R3 and R4, then the police arrived and R4 was taken away for five days. R3 stated R3 feels safe in the facility as long as R3 stays away from R4, stating R4 is a violent person.On 6/30/26 at 2:14 PM, V15 Certified Nursing Assistant stated on 5/12/26 V15 was in the process of taking R4 back to R4's room from the dining room. R3 came near R4 in passing and R4 kicked R3 in the leg. V15 stated R4 was not provoked by R3.On 6/30/26 at 2:24 PM, V30 Licensed Practical Nurse stated R4 hit V30 in the head on 5/12/26, the same day R4 kicked R3 in the dining room. V30 stated R4 often displays frequent unpredictable behaviors especially if R4 has too much caffeine. V30 stated on the day R4 was being physical with R3 and V30, R4 was sent to the hospital for evaluation.On 7/1/26 at 12:19 PM, R4 was observed moving throughout the facility interacting with other residents without staff supervision.R4's Hospital admission History and Physical dated 5/12/26 documents R4 is presenting to the hospital from the facility on the afternoon of 5/12/26 after R4 struck another resident. R4's primary doctor was contacted and the doctor recommended R4 be evaluated at the hospital.The facility's final Facility Incident Report Form, dated 5/12/26, documents Based on the investigation, there is evidence to substantiate the allegation of (R4) kicking (R3) however, due to the cognitive status of (R4), there is no evidence of willful intent and no physical or mental effects.R4's progress note dated 5/13/26 documents due to R4's behaviors and associated safety concerns, the attending physician has determined that R4 is not an appropriate fit for this facility. These behaviors present potential risks to the safety and well-being of R4, fellow residents, staff, and visitors.The facility's abuse policy dated October 2022 documents this facility affirms the rights of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. The policy defines abuse as any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. The policy defines physical abuse as the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. The policy states physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.

Based on observation, interview and record review the facility failed to maintain a comfortable and safe temperature level between the temperature range of 71 to 81 F for two (R10 and R19) of three residents reviewed for comfortable environment in the sample list of 22.Findings include: On 06/29/26 at 10:12 AM two residents (R10 and R19) were gathered in the dining room/common area. Common area was felt very warm. State agency provided hygrometer registered the ambient air temperature at 83 degrees Fahrenheit. After 10 minutes of direct observation in the same common area the temperature rose to 85.1 degrees Fahrenheit (F).On 06/29/26 at 12:40 PM the dining room common area temperature is measured at 85.1 degrees Fahrenheit on state agency provided hygrometer. V1, Administrator confirmed reading on the hygrometer.On 06/29/26 at 1:00 PM the therapy gym, which is adjacent/connected to the dining room, is observed with an ambient air temperature of 87.4 degrees F. V1 confirmed observation temperature on state agency provided hygrometer. On 06/29/26 at 1:38 PM R19 stated R19 does not spend a lot of time in the dining room because it has been hot out there.On 06/29/26 at 10:10 AM R10 stated the dining room is unbelievably hot the last few days and often returns to R10's room for cool air. R10 stated the air conditioner has not worked in several days.On 06/29/26 at 12:45 PM V1 confirmed the air conditioning unit for the dining room/common area was not working as well as one of the wall mounted air conditioning units. V1 stated the air conditioning unit was inspected on 06/23/26 and the failed part was not ordered till 06/25/26.On 06/29/26 at 1:00 PM V1 stated all meal service, and activities will occur in resident rooms due to heat in the common area/dining room until the air conditioning is fixed and therapy will occur in an air-conditioned room until the air conditioning is fixed. On 06/29/26 at 1:50 PM V1 stated V1 did not know when the last HVAC (heating, ventilation, air conditioning) inspection occurred prior to 6/23/26 inspection.R10's care plan documents R10 was admitted to the facility on [DATE] with diagnosis of Chronic Obstructive Pulmonary Disease, Hyperlipidemia, Symptoms and Signs Involving the Musculoskeletal System, Abnormalities of Gait and Mobility, History of Falling, Chronic Fatigue, Muscle Weakness (Generalized), Lack of Coordination, and Multiple Sclerosis.R10's Minimum Data Set (MDS) dated [DATE], documents R10 is cognitively intact.R19 care plan documents R19 was admitted to the facility on [DATE] with diagnosis of Cerebral Infarction, Cerebrovascular Disease, Need for Assistance with Personal Care, Depression, Generalized Anxiety Disorder, Primary Insomnia, Hyperlipidemia, Pain, and Gastro-Esophageal Reflux Disease Without Esophagitis.R19's Minimum Data Set (MDS) dated [DATE], documented that R19 is cognitively intact.

Based on observation, interview and record review the facility failed to maintain a sanitary kitchen by not covering porous construction surfaces in food preparation and cooking areas, failed to obtain food service temperatures at each meal and failed to maintain an effective pest control program. These failures have the potential to affect all 94 residents residing in the facility. Findings include:The facility Daily Midnight Census dated 6/14/26 documented 94 residents residing in the facility.The facility Pest Control Service Visit Checklist dated 5/13/26 documented roaches were observed in the kitchen near the dishwasher and in the laundry room. This same report documented that follow-up treatment was recommended.The facility Pest Control Service Visit Checklist dated 6/10/26 documented a roach was observed near the dishwasher. This same report recommended the facility address moisture and/or leaks.The facility was unable to provide food service temperature logs for the period of 6/1/26 through 6/7/26.On 6/14/26 from 8:00 AM through 8:40 AM, observation of the facility's main kitchen, where all resident meals are prepared and cooked, revealed the following:Dozens of ant and gnat carcasses were visible on the floor along the perimeter of the serving area walls.A hole measuring approximately eight inches wide by four inches high was present in the kitchen wall adjacent to a food preparation area and the flat-top grill. In the same corner, the baseboard was detached from the wall for approximately 16 inches, exposing an open void behind the baseboard.The wall directly above the food preparation area and handwashing sink consisted of a brown, porous paper-like material that was torn in several locations. The same wall also exposed yellow porous construction material with scratches and loose edges measuring approximately two to three feet high and ten feet wide.One ceiling tile was missing directly above the cooking area, exposing the attic space above. A large pot of hot water was simmering on the stove directly beneath the opening in the ceiling.The wall above the three-compartment dishwashing sink consisted of approximately three feet by twelve feet of rough, porous plaster material. The wall contained liquid drip marks and scattered food debris.Dustpans were stored in an open closet without a door. The handled dustpans were lying flat on the floor and contained at least one-half inch of accumulated grime. Two dustpans were lying directly on top of a black pest control bait station.The dry storage area contained several dead roaches on the floor beneath the dry cereal storage shelves.The walk-in cooler, which contained multiple large bags of lettuce, had numerous cut lettuce leaves that were brown and emitted a sour vegetable odor.On 6/14/26 at 8:45 AM and again at 11:50 AM, V4 [NAME] and V6 Prep [NAME] were observed preparing and cooking breakfast and lunch meals directly beneath the exposed wall surfaces, the opening in the ceiling, and adjacent to the exposed openings behind the baseboards.On 6/14/26 at 12:00 PM, V4 [NAME] stated the dietary staff were using the kitchen to its full extent while remodeling was underway. V4 [NAME] stated the kitchen areas should be covered but added, That's not my concern. My concern is to cook the food.On 6/14/26 at 9:40 AM, V1 Administrator stated the kitchen cabinets had been removed from the walls on 6/11/26 and the kitchen was currently undergoing remodeling. V1 stated the new wall surfaces should be here 6/15. V1 further stated the kitchen had been sprayed again after the cabinets were removed just to be on the safe side because there had been issues with pests. V1 stated the holes would be covered that day to assist with pest control and reduce the potential for debris to contaminate resident meals. V1 also stated the maintenance department would cover all exposed wall surfaces to prevent any further risk of food contamination from construction materials.

Based on observation, interview and record review the facility failed to provide two (R4, R5) residents their entire physician ordered diets out of five reviewed for Dietary Services in a sample list of five residents. Findings include:The facility Resident Council Minutes dated 5/20/26 document dietary staff are not looking at the resident tickets when serving meals. 1. R4's Electronic Medical Record (EMR) documents medical diagnoses as Hemiplegia and Hemiparesis following Cerebrovascular Disease affecting Right dominant side, Cerebrovascular disease, Aphasia, Dementia, Cerebral Infarction and Anemia. R4's Minimum Data Set (MDS) dated [DATE] documents R4 as being moderately impaired in decision making skills. This same MDS documents R4 requires staff assistance for setting up his meals. R4's Care Plan initiated 12/5/24 documents an intervention to provide and serve R4 diet and supplements as ordered. R4's Physician Order Sheet (POS) dated June 1-30, 2026 documents a physician order starting 6/30/25 to provide a regular diet of regular consistency with thin liquids. This same order documents R4 is to be provided whole milk with each meal and fortified ice cream with lunch and supper.On 6/14/26 at 7:50 AM R4 was sitting at his breakfast table after finishing his breakfast. R4 was not served milk for breakfast. R4 had a full glass of water sitting in front of him. On 6/14/26 at 1:15 PM R4 stated he did not get his milk for breakfast or lunch. R4 stated he is supposed to get ice cream for his lunch but did not get any ice cream. R4 stated he likes whole milk and ice cream and his Physician told him he is supposed to have whole milk with each meal. R4 was served two glasses of lemonade to drink for lunch. R4 did not have any ice cream included with his lunch meal. 2. R5's Electronic Medical Record (EMR) documents medical diagnoses as Rhabdomyolysis, Nephropathy, Hereditary Spastic Paraplegia, Cerebral Palsy, Chronic Kidney Disease Stage 3 and Iron Deficiency Anemia. R5's Minimum Data Set (MDS) dated [DATE] documents R5 as moderately cognitively impaired. This same MDS documents R5 requires staff assistance with setting up his meals. R5's Care Plan initiated 8/13/22 to provide and serve diet as ordered.R5's Physician Order Sheet (POS) dated June 1-30, 2026 a Physician order dated 8/12/22 to provide a No Added Salt diet of regular consistency with thin liquids. This same order documents R5 is to be provided a banana and mighty shake with each meal.On 6/14/26 at 7:50 AM R5 was sitting at a dining room table having finished with his breakfast. R5 did not receive a banana nor a mighty shake. On 6/14/26 at 1:00 PM R5 was not served a banana nor a mighty shake for lunch. R5 stated he likes bananas and the shake but was not served them. R5 stated he would eat the banana and drink the mighty shake if they were served to him. On 6/14/26 at 8:50 AM V4 [NAME] stated today's (6/14/26) breakfast should have included a 'Breakfast fruit of the day' but no fruit was delivered on the truck. V4 [NAME] stated no one went to the store this morning for bananas, whole milk and mighty shakes. On 6/14/26 at 8:45 AM V6 Prep [NAME] stated she prepares the foods for the cook and also gets all of the cold foods/drinks ready for the meal to be served. V6 Prep [NAME] stated sometimes the kitchen does run out of food but then the staff will make something or 'run out' and get an alternative. V6 Prep [NAME] stated the facility does not have whole milk, mighty shakes and bananas. V6 Prep [NAME] no one went to the store to obtain those items.On 6/14/26 at 9:40 AM V1 Administrator stated residents should be served the diet that their physician orders including fruits and supplements. V1 stated the facility was out of bananas, whole milk and mighty shakes but V1 was not notified of the need for these items. V1 Administrator confirmed the facility did not follow the physician ordered diets for R4 and R5. V1 Administrator stated she is unsure if there is a specific policy but the expectation is to serve the resident the diet ordered by their physician.

Based on observation, interview and record review, the facility failed to ensure the use of an indwelling (foley) catheter anchoring device for three (R1, R4, R5) of four (R1, R3, R4 and R5) residents reviewed for catheters in the sample of six residents.Findings include:R1's Care Plan dated 4/8/2026 documents an admission date of 03/06/2026. The Care Plan documents a diagnosis of Obstructive and Reflux Uropathy and Retention of Urine.R1's Care Plan dated 01/13/2026 documents R1 requires use of indwelling foley catheter due to diagnosis of Retention and Obstruction.R1's Minimum Data Set (MDS) dated [DATE] documents R1 has an indwelling catheter.R1's Minimum Data Set (MDS) dated [DATE] documents R1 has moderate cognitive impairment.R1's Order Review Report dated 5/29/2026 documents a physician order dated 3/6/2026 for foley catheter care every shift.On 5/28/2026 at 11:01 am, an observation conducted of V9 Restorative Aide and V10 Certified Nurse Assistant (CNA) providing catheter care for R1. During this observation, R1's indwelling catheter was not secured to R1's leg and there was no catheter anchoring device observed in place.On 5/28/2026 at 11:32 am, V10 CNA confirmed R1 did not have the catheter anchoring device in place and V10 stated R1 should have a catheter anchoring device in place at all times to keep the indwelling catheter in place and prevent it from getting pulled out. V10 stated R1 did not have the anchor device when V10 got R1 up this morning.On 5/28/2026 at 11:35 am, V9 Restorative Aide confirmed R1 did not have the catheter anchoring device at this time and stated R1 should have the anchor to keep the foley catheter in place.On 5/28/2026 at 11:44 am, V8 Licensed Practical Nurse stated all residents that have indwelling catheter should have anchor in place to keep the indwelling catheter from getting pulled out of the bladder.R4's Care Plan dated 5/13/2026 documents an admission date of 04/13/2026. The Care Plan documents a diagnosis of Obstructive and Reflux Uropathy and Hydronephrosis.R4's Care Plan dated 5/01/2026 documents R4 requires use of indwelling foley catheter related to diagnosis of Bladder Obstruction and Hydronephrosis. This care plan documents an intervention to monitor for decreased output. Pain, cloudy, foul-smelling urine, abdominal distention, and fever. Report abnormalities to Medical Director.R4's Situation, Background, Assessment, Recommendation (SBAR) note dated 5/20/2026 R1 was sent to the hospital due to symptoms of being diaphoretic, hypotension, elevated pulse, distended abdomen with pain on palpation, emesis and poor output.R4's hospital electronic medical records dated 5/20/2026 documents an impression of decreased urine output, and hematuria with labs and urinalysis consistent with urinary tract infection and possible sepsis, complicated by acute kidney injury and hydronephrosis in the setting of foley malfunction/malposition.On 5/29/2026 at 9:59 am, V17 (R4's) family member stated V17 was at the emergency room (ER) with R4 on 5/20/2026 and confirmed the indwelling catheter was changed by the emergency room (ER) nurse upon R4's arrival at the ER and confirmed there was no catheter anchoring device in place on R4's indwelling catheter at that time. R5's Care Plan dated 4/8/2026 documents an admission date of 01/17/2026. This Care Plan documents a diagnosis of Obstructive and Reflux Uropathy.R5's Care Plan dated 9/24/2025 documents R5 has an indwelling catheter due to diagnosis of obstruction.R5's Minimum Data Set (MDS) dated [DATE] documents R5 is cognitively intact.R5's Order Review Report dated 5/29/2026 documents a physician order dated 3/25/2026 for foley catheter care every shift.On 5/28/2026 at 1:31 pm, an observation was conducted of V6 Certified Nursing Assistant (CNA) and V7 Restorative Aide providing foley catheter care for R5. During this observation, there was no catheter anchoring device observed in placed on R5's catheter.On 5/28/2026 at 1:42 pm, V6 CNA confirmed there was no catheter anchoring device on R5 when V6 got R5 up this morning. V6 stated R5 should have an anchoring device to keep the foley catheter in place.On 5/28/2026 at 1:45 pm, V7 Restorative Aide confirmed that R5 did not have the anchoring device at this time. V7 stated nurses are the ones who applies the anchoring device and CNAs should be reporting to the nurse if there is no anchoring device in place on a resident.On 5/28/2026 at 1:59 pm, V8 Licensed Practical Nurse (LPN) stated nurses applies the catheter anchoring devices and confirmed all residents that have foley catheters should have the anchoring device in place to keep the foley catheter from getting pulled out of the bladder. V8 stated no one told V8 that R5 did not have a catheter anchoring device.On 5/29/2026 at 12:09 pm, V2 Director of Nursing stated V2 expects all residents that have indwelling catheter to have a catheter anchoring device in place at all times to keep the catheter from getting pulled out of the bladder.Facility's Catheter Care, Urinary policy dated September 2005 documents ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site.

Based on observation, interview and record review, the facility failed to place the call light within reach of one (R2) of five (R1, R2, R3, R5 and R6) residents reviewed for alternative communication methods in the sample of six residents.Findings include:The Facility Policy and Procedure for Call Light System dated 1/1/2025 documents that it is the policy of the facility to provide a means of communication to meet the needs of each resident. Staff will follow established procedures to respond to the residents' requests and needs. This policy further documents to assure the call light is within easy reach of the resident.R2's Care Plan dated 5/13/2026 documents admission date of 07/15/2025. This Care plan documents a diagnosis of history of falling, anxiety disorder, cognitive impairment and dementia.R2's Minimum Data Set (MDS) dated [DATE] documents R2 has moderate cognitive impairment.R2's Care Plan dated 7/15/2025 documents R2 is at risk for falls related to deconditioning, gait/balance problem, unaware of safety needs, vision/hearing problems. This Care plan documents a goal of R2 will be free of falls through the next review. This care plan further documents an intervention to ensure R2's call light is within reach and encourage R2 to use it for assistance as needed. R2 needs prompt response to all requests for assistance.Facility's Incident log dated 5/28/2026 documents R2 had multiple incidents of falls on different dates; 4/25/2026, 5/8/2026, 5/12/2026, and 5/17/2026.On 5/28/2026 at 9:37am, R2 was sitting in R2's wheelchair in the room with the call light on the floor next to R2's bed. R2 was located in the middle of the room and was approximately seven feet away from the call light.On 5/28/2026 at 10:00 am, R2 was in R2's wheelchair in the room with the call light on the floor (same area as 9:37 am) and not within R2's reach.On 5/28/2026 at 11:47 am, R2 was in R2's wheelchair in the room with call light remaining on the floor next to the bed (same area as 9:37 am) and out of reach. R2 stated R2 does not know where the call light is.On 5/28/2026 at 12:15 pm, R2 was in R2's wheelchair in the middle of the room, call light remains on the floor next to the bed (same area as 9:37 am) and out of reach.On 5/28/2026 at 12:15 pm, V4 Certified Nurse Assistant (CNA) came into R2's room to talk to R2. This surveyor asked V4 where the call light should be placed. V4 stated call lights should be where residents can see it and closer where residents do not need to move a lot to reach it. V4 confirmed R2's call light was on the floor and V4 stated R2's call light should not be on the floor. V4 did not pick up or move the call light at this time. On 5/28/2026 at 12:18 pm, V5 Registered Nurse (RN) stated call light should be next to the residents where the residents can reach it. V5 confirmed R2's call light was on the floor and V5 stated R2's call light should not be on the floor because R2 cannot reach it. V5 stated V5 will move the call light next to R2 at this time.On 5/29/2026 at 7:40 am, R2 was lying in bed at this time. Call light was noted to be clipped to the privacy curtain approximately four feet from the floor and approximately five feet away from R2.On 5/29/2026 at 7:45 am, V13 Certified Nurse Assistant (CNA) confirmed call light was clipped to the privacy curtain and stated it should be next to R2 and not clipped to the curtain.On 5/29/2026 at 12:09 pm, V2 Director of Nursing stated V2 expects the call lights to be within resident's reach.

Based on observation, interview, and record the facility failed to maintain an effective pest control program by failing to ensure sanitation interventions were implemented according to their pest control policy for three (R2, R4, R7) of five residents reviewed for insects on the sample list of seven and has the potential to affect all 91 residents residing in the facility.The facility's Pest Control Policy with a revision date of 2/3/2022 contains documentation stating the facility shall maintain an effective pest control program. This policy contains prevention and intervention which includes eliminating sites of breeding and entry and regularly removing garbage and trash.On 4/30/2026 at 9:30 AM, food debris was covering the floor in the kitchen preparation and storage areas. There were cardboard boxes sitting on top of a wet floor. The bottom of the boxes was wet.On 4/30/2026 at 9:45 AM, food debris was noted to be scattered along the baseboards in the hallway. Multiple brown drips and splatters were on the baseboards and walls in the hallway.On 4/30/2026 at 10:05 AM, two of the three facility dumpsters were open. Around the outside of the dumpsters, fencing, and landscape borders lay trash, food containers, and gloves.On 4/30/2026 at 10:23 AM, food debris was noted on the floor in the dry food storage area and carboard boxes were on the floor. The sink in the kitchen was dripping water, and the water was pooled under the sink and flowed out into the food preparation area. Multiple insect carcasses were on the floor in the corners of the dry food storage and underneath the dry storage freezer.On 4/30/2026 at 12:45 PM, a half inch long brown insect was crawling on the floor in the facility conference room which is located directly across the hall from the kitchen. At that time, V6 Maintenance Director looked at the insect and stated it was a cockroach.On 4/30/2026 at 4:11 PM, food debris continued to lay on the floor. The carboard boxes continued to sit on the floor. Opened food containers were under the dry storage bins. Multiple insect carcasses observed scattered throughout the kitchen.On 4/30/26 at 9:48 AM, R4 stated R4 had seen a big bug the size of a quarter crawling across R4's television set about a month ago.On 4/30/2026 at 9:50 AM, R2 stated R2 has seen roaches on the floor and crawling up the walls. R2 stated that's why the bed cannot be against wall, R2 has seen roaches the entirety of R2's stay.On 4/30/26 at 9:52 AM, R7 stated R7 saw a roach on the floor in his room about a month ago.On 4/30/2026 at 4:00 PM, V16 Pest Control Technician stated V16 comes to the facility about once a month. V16 stated V16 has treated the facility for an infestation of roaches. V16 stated V16 recommends that the facility keeps the kitchen, and resident rooms clean without food and trash lying around. V16 stated V16 has seen empty food containers such as empty chip bags under the residents' beds. V16 stated the situation is not under control at this time. V16 stated problem areas include the kitchen, laundry, nurses' station, breakroom, dining room, food storage areas, and the resident rooms.On 5/1/2026 at 9:45 AM, V6 Maintenance Director stated the pest control company recommended interventions to decrease food areas and breeding areas by keeping the facility clean, ensuring food is properly stored and not left out, ensuring food trays are removed from bedrooms and hallways promptly when finished. V6 stated it is everyone's responsibility to keep their messes cleaned up and if they see a mess, it is expected that staff will clean it up. V6 stated it is the dietary staff's responsibility to keep the kitchen clean. V6 stated V6 would expect the kitchen to be clean and free of debris.On 5/1/2026 at 10:15 AM, V1 Administrator stated the facility has been struggling with pest control and has implemented a checklist for keeping the kitchen area clean, educating staff, and deep cleaning resident rooms. V1 expects the housekeeping and dietary staff to follow pest control recommendations. V1 stated the kitchen is not clean and the staff do not follow recommendations provided by staff to ensure the pest control program is effective.The facility census report dated 4/30/26 documents there are 91 residents residing in the facility.

Based on interview and record review the facility failed to ensure the right to be free from physical abuse for four (R3, R6, R7, R10) of six residents reviewed for abuse on the sample list of twelve residents. Findings 1. The facilities abuse investigation dated 3/15/2026 at 8:45 PM documents that R3 became agitated with R10 accusing R10 of being in R3's house. R3 began hitting R10 on the head with a shoe. This investigation documents V10 Licensed Practical Nurse witnessed R3 hitting R10 on the head with a shoe. On 3/24/2026 at 12:46 PM, when asked about the incident occurring on 3/15/2026 at 8:45 PM, R10 stated R10 recalls being hit a few times with a shoe by R3. R10 stated R3 was accusing R10 of being in R3's home. R10 stated this interaction scared R10. R10 stated the shoe was a house slipper. On 3/24/2026 at 1:25 PM, V1 Administrator stated that V1 investigated the 3/15/2026 incident. V1 stated after interviewing R10 and V10 Licensed Practical Nurse, it was determined R3 did hit R10 multiple times in the head with a shoe. V1 stated the allegation of abuse was substantiated. 2. R6's undated care plan documents an admission date to this facility on 10/25/2024 with the following diagnosis: Poisoning by Hydantoin Derivatives, Essential Hypertension, and Cerebral Infarction. R6's Minimal data set dated [DATE] documents R6 with moderate cognitive impairment. R7's Minimal data set dated [DATE] documents R7 with severe cognitive impairment. R7's undated care plan documents an admission date to the facility on [DATE] with the following diagnosis: Schizophrenia, Dysphagia, Oropharyngeal Phase, Constipation, Hyperlipidemia, and Benign Prostatic Hyperplasia. The facilities abuse investigation dated 2/9/2026 at 8:45 PM documents that R7 had aggressive behaviors towards R6. R6 reported to staff that R7 hit R6 with a closed fist. This investigation documents R7's admission to physical contact with R6. On 3/23/2026 at 10:55 AM, R6 stated R6 had been hit by his roommate in the past however could not recall the specific date it occurred. On 3/23/2026 at 11:19 AM, R7 was deemed non-interviewable due to R7's severe cognitive decline along with the diagnosis of dysphasia. On 3/23/2026 at 3:15 PM, when asked about the incident occurring on 2/9/2026 involving R6 and R7, V7 Licensed Practical Nurse stated R7 admitted to hitting R6 on the arm when V7 questioned R7 on 2/9/2026. The facility's Abuse Policy dated 10-2022 documents and defines abuse as any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means (210 ILCS 45/1-103).

Based on observation, interview, and record review the facility failed to ensure transportation staff were trained according to manufacturer's instructions to safely secure a wheelchair in the transportation van and failed to check a security strap when a resident reported movement of the wheelchair. These failures resulted in R3 sliding forward in the wheelchair when the transportation van was moving down a hill away from the facility which then resulted in the wheelchair flipping forward and R3 sliding out of the wheelchair onto the floor causing R3's left leg to become entangled in the foot pedal and underneath R3's body. After landing on the floor from the wheelchair, R3 was screaming in severe pain and sustained a 17-centimeter laceration to the left lower leg which required eight sutures and fractures of the left tibia and fibula (lower leg) which required hospital admission. These failures affect three of three residents (R3, R8, R12) reviewed for accidents in the sample list of 16.The Immediate Jeopardy began on 12/10/25 when R3 slid from the wheelchair onto the van floor while being transported to a physician appointment. V1 Administrator was notified of the Immediate Jeopardy on 2/2/26 at 2:20pm. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 2/3/26, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service and physical training.Findings Include:R3's Care Plan dated 4/29/2024 documents an admission date of 04/29/2024. The Care Plan documents R3's diagnoses as Acute on Chronic Diastolic (Congestive) Heart Failure, Morbid (Severe) Obesity Due To Excess Calories, Hypertension, Localized Edema, Depression, Anxiety Disorder, Heart Disease, and Chronic Kidney Disease. The Care Plan further documents R3 has Weakness, Bilateral Lower Edema, and Impaired Mobility and R3 uses a wheelchair for mobility and requires one-two staff members assistance to complete Activities of Daily Living.On 1/26/26 at 09:00 AM V1, Administrator provided an Investigation Report for R3's 12/10/25 fall. The Investigation Report documents R3 is alert and oriented, that R3 needs staff assistance with activities of daily living and transfers, that R3 is unable to ambulate, and R3's mode of locomotion is manual wheelchair and R3 needs assistance with propelling.The same report documents this Summary of events/situation:- On 12/10/25 At 12:30pm it was reported to V2, Director of Nursing (DON) that R3 had fallen out of her wheelchair while being transported. V2 entered bus and noted R3 with buttocks on wheelchair while upper body and head were resting on arm rest of vehicle, left leg beneath R3, right leg on foot pedal. Nurse (V11 Licensed Practical Nurse (LPN)) from unit, DON, and Transportation aid removed the seat belt from across R3 and removed all other attachments from the wheelchair and assisted R3 onto the floor. Nurse (V11) completed head toe assessment and noted R3 had multiple lacerations to the left lower extremity. R3 stated, When driver went over bump in the road, I slid forward in my wheelchair. Range of motion noted in all extremities except when the left leg was moved R3 complained of pain. Physician made aware and gave orders to send to ER (Emergency Room) for evaluation and treatment. POA (Power of Attorney) made aware of fall and of orders to send to ER for evaluation and treatment. Nurse cleansed left lower extremity, applied ABD (abdominal pad), and covered with kerlix. R3 returned to the facility with eight sutures to left upper anterior laceration and left tibia and fibula fracture. Root cause: R3 slid forward in wheelchair. The same investigation dated 12/10/25 at 12:30pm documents V13's (Van Driver), witness statement dated 12/10/25 as stating I (V13) was pulling away from the building when I heard Res (R3) screaming. I (V13) looked in the rearview mirror and saw Res (R3) leaning forward in w/c (wheelchair), bracing self on the seat next to her. I drove back around to get help; she (R3) couldn't hold herself up. Her (R3) leg went back underneath her, and blood was everywhere.The same investigation dated 12/10/25 at 12:30pm documents V2's witness statement dated 12/12/25 as Writer (V2) was called out to come out to van by transportation aide (V13) stating res (R3) had fallen. Writer entered bus and noted res (R3) leaning forward resting on arm rest of vehicle. Buttocks at the edge of chair with left leg bent. Right leg extended with large amount of blood noted. Res was released from wheelchair and assisted onto bus floor. Nurse (V11 LPN) completed assessment. Ambulance called.R3's Emergency Department (ED) physician notes dated 12/10/25 at 1:56pm document on 12/10/25 at 1:45pm Chief Complaint: R3 arrived to the ED (Emergency Department) for a fall 20 minutes ago out of a wheelchair in a transport van. Complaint of bilateral lower extremity pain. Lacerations to the left and right lower extremity, currently mild bleeding noted. Associated diagnosis: Fall involving wheelchair causing injury; Displaced Oblique fracture of shaft of left tibia. V14, Orthopedic Surgeon's note dated 12/31/25 documents: This patient (R3) fell out of her wheelchair while in a transport van on 12/10/2025. She was taken to local hospital with complaints of bilateral lower leg pain. She did sustain several lacerations to the lower extremities as well. They obtained x-rays and a CT (Computed Tomography) scan of the left lower extremity. A left proximal tibia fracture and left fibular head fracture was noted. The Note documents V14 was consulted on 12/11/25 and R3 has been toe touch weightbearing to the left lower extremity in a knee immobilizer but is essentially wheelchair bound and remains in the immobilizer. This note documents an impression of the CT Scan of R3's Left Lower Extremity performed at the local hospital, as fracture of the proximal tibia metadiaphysis (upper region of the tibia), fracture of the fibular head, fracture of the distal fibula with the extension to the level of the ankle syndesmosis (joint and supporting ligaments that connect the tibia and fibula) and anterior inferior tibiofibular avulsion fracture from the anterior syndesmotic tubercle (bony prominence on the front outer aspect of the distal shin bone).On 01/28/2026 at 09:45am V13, Van Driver stated (on 12/10/25) V13 took R3 to the van via a wheelchair, applied wheelchair restraints, lap belt, closed the doors and got into the drivers' seat and began driving down the hill in front of the facility. V13 then stated V13 heard R3 yell out. V13 stated she looked into the mirror, saw R3's wheelchair tipped forward, and R3 leaning forward, V13 then put the van in park, and looked at R3, and decided V13 needed help and drove the van around the parking lot as fast as she could back up the hill on the other side to the main entrance and ran inside to get staff to help. V13 stated V2 and V11 came outside to help R3. On 01/28/2026 at 10:00am V11, License Practical Nurse, stated on 12/10/25 V13 came into the building in a panic requesting help, V2 Director of Nurses and V11 went to the van. V11 stated R3 was sitting on the floor in front of the tipped wheelchair with blood under R3. V11 stated R3 slid forward and was sitting on the floor of the van on R3's buttocks. V11 then demonstrated by leaning the chair forward and stated the wheelchair was tipped forward like this and R3 was leaning onto the chair/seatbelt. V11 stated they (V2 and V11) had a difficult time unlatching the seat belt and wheelchair due to the tension of R3's body weight and wheelchair positioning. V11 stated the scene resembled a car accident. V11 stated after getting R3 free of seatbelts and moving the wheelchair, R3 was then re-assessed and noted to have a large laceration to the top of the left shin. V11 stated V2 applied pressure while V11 retrieved dressing supplies. V11 stated EMS (Emergency Medical Services) arrived and took over care of R3 as V11 finished the dressings. V11 stated R3 was alert and oriented and complained of severe pain in the left leg.On 01/29/26 at 09:19am V11, License Practical Nurse (LPN), stated the restraint straps were still attached to the wheelchair, but extended out taught and V13 was struggling to free the straps while V11 and V2 were trying to help free R3 from the wheelchair/shoulder strap.On 01/28/2026 at 09:52am V2, Director of Nursing (DON) stated (on 12/10/25) V13 came inside asking for help, V2 and V11 went to the van. V2 stated the wheelchair was tipped forward, R3 was on the floor with R3's left leg under her and yelling out in pain. V2 stated the staff unlatched the wheelchair, positioned R3 flat on the floor, and noted a left lower leg laceration. V2 stated V11, Licensed Practical Nurse (LPN), retrieved dressing supplies, cleaned and dressed R3's wound while waiting on Emergency Medical Services (EMS) to arrive.On 1/26/26 at 12:42pm V12, Registered Nurse Case Manager, stated V12 visited R3 after R3 returned from the hospital. V12 stated R3 informed V12 that R3 felt the wheelchair move when V13, Van Driver engaged the van and began moving and R3 alerted V13 that R3's wheelchair was moving and V13 stated to R3 that R3 would be ok. V12 stated R3 told V12, R3 then slid from the wheelchair and onto the van floor sustaining a broken left leg and a large laceration of the left leg.On 01/28/2026 at 09:56am V13, Driver, stated V13 was not formally trained on driving the van or securing residents into the van. V13 stated V13 received a packet, which was a safety checklist. V13 stated V13 does not have a daily checklist of the van for safety nor has V13 received any supervised training.On 01/29/26 at 09:30am V1, Administrator, provided V13, Driver's, Employee File. The File contained two driver education/training checklists. One dated 10/10/25 and a second dated 12/11/25. The second training checklist was a photocopy with V5, Maintenance Director's name photocopied and V13's name written in. V1 provided a job description dated 01/28/26 signed by V13.On 01/29/26 at 10:45am V5, Maintenance Director, stated V5 trained V13, Driver, on the van restraint system usage otherwise V13 would not know how to use the van. V5 stated the form was photocopied with V5's signature and the driver's name was added to the top of the sheet. V5 acknowledged there is no signature on the form from the trainee (V13) to indicate the trainee received the training.On 01/29/26 at 11:15am V13, Driver, stated V13 did not receive the driver education training after the accident on 12/11/25 as indicated on the training sheet. V13 stated V13 recognized the checklist but received the checklist on a prior unknown date prior to the 12/10/25 accident.On 01/29/26 at 11:30am V13, Driver Loaded R8 into the transport van via the rear entry lift. V13 then secured R8 via the (Company Name) mechanical retractable system by attaching the J hooks of the system to the arm rests of R8's wheelchair. The noted angle of the straps was 65-75 degrees, and the straps were twisted at time of attachment. V13 acknowledged the restraints were attached to the arm rests of the wheelchair. V13 stated this is how V13 restrains a resident for transport. On 01/29/26 at 12:15pm V5, Maintenance Director, was unable to give an accurate return demonstration of use of the transport van restraint system used in the transport van. V5 gave a return demonstration of the (Company Name) manual strap system, not the mechanical retractable system used in the transport van. V5 stated the j hooks should be attached to the frame of the wheelchair only not the arm rests or a moveable part.On 01/29/26 at 1:15pm R12 stated R12 has ridden in the transport van with V13 as driver. R12 stated V13, the driver, has secured R12's wheelchair by using the arm rests as the anchoring point multiple times.On 2/2/26 at 1:01pm V1, Administrator stated the facility does not have a transportation policy.On 2/2/26 at 8:51am V1, Administrator provided an undated Job Description for the Transportation Aide that documents: Purpose: Provide safe and timely transportation to meet the Residents' needs in compliance with federal, state, local, and corporate requirements. Essential Tasks are documented as - Ensure all Residents are transported to their destinations in a safe and timely manner, follow all state and local motor vehicle laws, assume responsibility for the Residents' safety while transporting.On 2/2/26 at 8:51am review of V13's, Certified Nursing Assistant/Driver training forms dated 10/10/25 and 12/11/25 documents on page two of three: Follow Your Manufacturers' Guide for Specific Instructions on How to Secure the Wheelchair and Client.The training form further documents a checklist titled: Wheelchair Securement and Patient Restraint. The checklist follows as:Secures REAR of wheelchair inside wheelchair van:Inspects straps for damage.Confirms floor anchor position for straps is within the width of the rear wheels.Pulls straps straight out to chair and attaches to appropriate anchor point on the wheelchair frame.Does not allow straps to twist.Allows straps to retract and manually tightens them by twisting the ratchet knob.Secures FRONT of wheelchair inside wheelchair van:Confirms floor anchor positions for straps are on outward sides from front corners.Pulls straps straight out to chair and attaches to appropriate anchor point on the wheelchair frame.Does not allow straps to twist.Allows straps to retract and manually tightens them by twisting the ratchet knob.The above checklist is check marked as training completed and verified by V5, Maintenance Director/Trainer for V13's training checklists dated 10/10/25 and 12/11/25.On 2/2/26 at 10:00am review of the (Company Name) Use and Care Manual-- Vehicle Anchorages & Accessories For 4-Point Wheelchair Securement Systems dated 2020: Documents on page four the following: Tie-Down Hooks must be attached to a solid wheelchair frame (no spokes, wheels or movable components) at an approximate 45-degree angle with floor. The manual further documents: The (Company Name) 4-Point Wheelchair Securement Systems should not be operated by anyone who does not have full comprehension of how the system works or if the system is not working properly. This (Company Name) 4-Point Wheelchair Securement System and its components MUST be regularly inspected, cleaned and maintained-reference the Maintenance and Care section in this manual. Page 21 documents: The following items should be inspected and serviced by an experienced and trained technician during the scheduled maintenance of the (Company Name) 4-Point Wheelchair Securement System. Always keep belts clean and off the floor by using a storage device such as a (Company Name) wall pouch. We recommend one storage device per wheelchair location. All systems and components MUST be regularly inspected, tightened, cleaned, and maintained.On 01/26/26 at 09:17am V15, R3's Family stated he was advised R3's wheelchair tipped over in the van, broke R3's leg, and R3 had to go to the hospital. V15 stated that on 12/31/26 R3 had a follow up appointment with the orthopedic surgeon (V14) and that R3 required surgery and R3 had new wounds on R3's left leg, left heel and right heel. V15 stated R3's left leg wound became heavily infected and R3 passed away from the infection.The facility presented an abatement plan to remove the immediacy on 2/2/26. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on 2/3/26, and the survey team accepted the abatement plan on 2/3/26.The Immediate Jeopardy that began on 12/10/25 was removed on 2/3/26 when the facility took the following actions to remove the Immediacy.On 2/3/26 Surveyor was able to confirm onsite that the facility took the following measures to remove the immediacy:On 2/3/26 V2, Director of Nursing, conducted in-service education about the proper securing of resident wheelchairs in the transportation van, including the newly developed facility policy, for the six approved transportation drivers and the maintenance director.On 2/3/26 V2, Director of Nursing, utilized a video training about the securement straps and seat belts in the transportation van for each of the six approved transportation drivers and the maintenance director.On 2/3/26 V2, Director of Nursing, conducted return demonstrations for each of the six approved transportation drivers and the maintenance director.On 2/3/26 V2, Director of Nursing, developed a new facility policy for securement of wheelchairs in the transportation van.On 2/3/26 V2, Director of Nursing, reviewed the job description for the transportation drivers.On 2/3/26 V2, Director of Nursing, developed a list of approved transportation drivers.On 2/3/26 V2, Director of Nursing, conducted an Ad-Hoc Quality Assurance Meeting to discuss the Immediate Jeopardy citation, needed training, proficiency checklist, list of approved drivers, review of transportation aide job description, development and corporate approval of facility policy, and abatement plan.On 2/3/26 V2, Director of Nursing, began conducting audits for three residents utilizing the facility van to be transported to appointments, R102, R103, and R104.On 2/3/26 V2, Director of Nursing, confirmed each of the six transportation drivers completed proper demonstration for securement technique of an occupied wheelchair into the facility transportation van.

Based on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for one (R1) of eight residents reviewed for abuse in the sample of list of eight. This failure resulted in R1 obtaining fingernail marks and bleeding to the right forearm when R2 scratched R1 during a physical altercation. Findings Include:The Facility Abuse Prevention and Reporting policy effective 11/2017, documents this facility affirms the right of their residents to be free from abuse, neglect, exploitation, misappropriation of property, and deprivation of goods and services. This policy documents abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. The same policy documents physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. The policy documents as part of the resident's life history on the admission assessment, comprehensive care plan, and MDS (Minimum Data Set) assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, history of trauma or misappropriation of resident property, who have needs, triggers and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of abuse, neglect, exploitation, mistreatment or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis and update as necessary.The Nursing Progress Note dated12/24/25 at 7:18PM by V22 Licensed Practical Nurse documents Writer heard a commotion in the resident's room when I went inside, I observed both roommates physically touching each other. (R2) was in her wheelchair with back facing (R1's) bed and (R1) had her back facing the door she was stating 'she's got ahold of me, she's on my side of the room bothering my stuff,' (R2) yelled back 'and so what are you going to do about it.' I removed the object they were both holding (a Hanger) and gently pulled (R2's) hands off (R1's) arm. I pulled (R1) out into the hallway, then pulled (R2) into and down the hallway where they were a good distance apart, but I could keep an eye on both. While assessing both I observed (R1's) forearm bloody. Once area was cleaned, I noticed what appeared to be nail marks and a couple of superficial scratches. Area cleansed, TOA (Triple Antibiotic Ointment) applied and covered. Resident is now in room alone; she says arm is sore but wants to wait for bedtime tramadol. On 1/26/2026 at 11:07AM, R2 was lying in bed, on her right side with R2's bed against the wall. R2 stated I don't remember R2 started calling for the Certified Nursing Assistant to get R2 out of bed.On 1/26/2026 at 11:15AM, R103 who stated she is R2's roommate, stated that R2 hits and screams at the staff when the staff try to help R2 with any activities of daily living. On 1/26/2026 at 12:05PM, V22 Licensed Practical Nurse stated that R1 has had behaviors of aggressiveness. V22 also stated R1 received fingernail scratches from R2 due to R2 was on R1's side of the room going through R1's personal belongings and R2 wanted the remote which led to an altercation and R2 becoming aggressive with R1. On 2/4/2026 at 11:00AM, V2 (Director of Nursing) stated there was no skin assessment or care plan update/revision for R1 completed after the incident on 12/24/25 between R1 and R2. V2 stated R1 did receive fingernail scratches on R1's Right Forearm by R2. V2 also stated the facility has no behavioral services and if a resident needs behavioral services, the facility sends the resident out to a behavioral center. V2 stated R2 has not been evaluated by a behavioral center, and no abuse or behavioral assessments were completed after the resident-to-resident interaction.On 2/4/2026 at 12:38PM, V1 Administrator confirmed there were fingernail scratches on R1's right forearm and R2 was removed from R1's room and that R1 didn't want R2 as a roommate.

Based on observation, interview, and record review the facility failed to provide hygienic catheter care, monitor urinary catheter output, and timely treat symptoms of urinary tract infection for three of four residents (R2, R5, R49) reviewed for urinary catheters/urinary tract infections (UTIs) in the sample list of 49. These failures resulted in R49 developing urinary retention, UTI, urosepsis, acute kidney injury, and hydronephrosis that required hospitalization and urinary stent placement. Findings include:1.) On 12/07/2025 at 8:13 AM, R49 was observed lying in bed with a urinary catheter drainage bag attached to the bed frame. A sign near R49's doorway indicated that R49 was on Enhanced Barrier Precautions (EBP), requiring gown and gloves for high-contact care activities, including catheter care and transfers. A container with personal protective equipment (PPE) was present on R49's door.At 1:04 PM, R49 stated he had had the catheter for a long time and that it was last changed approximately one month earlier while hospitalized for a UTI. R49 stated that staff do not empty the catheter as often as they should and that some staff provide better catheter care and cleaning than others. V32, R49's spouse, stated that staff should have identified changes in R49's urine. V32 further stated that she received a phone call the night R49 was sent to the hospital with red-tinged urine and that R49 required placement of urinary stents.On 12/08/2025 at 10:55 AM, V5 and V7, Certified Nursing Assistants (CNAs), entered R49's room with a full mechanical lift while R49 was seated in his wheelchair. V5 and V7 did not don gowns upon entering the room. At 11:04 AM, R49 was in bed, and V5, V6, and V7 were present in the room without gowns. All three staff members washed their hands, applied gloves, and assisted with catheter care without wearing gowns. V7 cleansed and dried R49's inner thighs and penis, making contact with the urinary catheter multiple times. V7 cleansed the catheter tubing near the insertion site but did not clean the length of the tubing as required.R49's Minimum Data Set (MDS), dated [DATE], documents that R49 scored in the higher range for moderate cognitive impairment and has a urinary catheter. R49's active care plan includes a problem dated 10/24/2024 for urinary catheter use, with interventions to change the catheter as ordered and to monitor, record, and report signs and symptoms of UTI, including no urine output.R49's physician progress note dated 05/24/2025, recorded by V35, Urologist, documents that R49 was admitted to the hospital with an indwelling urinary catheter, severe UTI, and sepsis. The note documents that R49's catheter was changed and that R49 requires monthly catheter changes, which could be performed at the long-term care facility or in V35's office. This plan was discussed with R49 and his family. A urology progress note dated 10/03/2025 documents continuation of the indwelling catheter with monthly changes.R49's December 2025 Medication Administration Record (MAR) documents an order to change the urinary catheter as needed as of 07/08/2025. R49's June 2025 MAR documents an order to change the catheter every 30 days. There is no documentation in R49's medical record that the catheter was changed after 06/23/2025 until 11/16/2025, when R49 was hospitalized . There is also no documentation that urinary catheter output was routinely measured or monitored during this period prior to 12/04/2025.A nursing note dated 11/16/2025 at 12:47 PM documents that R49 had no urine output, low blood pressure and pulse, difficulty speaking and swallowing, altered mental status, lethargy, and labored breathing. R49's temperature was 99.1 F, pulse 29 beats per minute, respirations 18 per minute, and blood pressure 102/57. The physician was notified on 11/16/2025 at 6:51 AM.R49's Hospital History and Physical dated 11/16/2025 documents admission for urosepsis, septic shock, catheter-associated UTI, acute kidney injury, bilateral hydronephrosis, and bilateral renal cysts. R49's creatinine was 3.9 on arrival, compared to a baseline of approximately 0.8. R49 presented with lethargy, pulse rates in the 130s, and systolic blood pressure in the 80s despite fluid administration. R49 had urinary retention upon arrival; the catheter was changed with a return of nearly 900 milliliters of purulent urine. R49 has a history of multidrug-resistant bacterial infections. A physician progress note dated 11/21/2025 documents urine culture results of greater than 100,000 colony-forming units (CFU)/mL of mixed bacteria, continued IV antibiotics, and placement of bilateral urinary stents on 11/17/2025.On 12/08/2025 at 1:47 PM, V5 and V6, CNAs, were questioned regarding EBP. V6 stated PPE is worn whenever entering the room. V5 stated that for catheter care, gown and gloves are worn and that staff identify residents on precautions by posted signage and PPE supplies. V5 correctly described catheter cleaning as a downward motion approximately four inches from the insertion site. V5 and V6 confirmed that gowns were not worn during R49's transfer and catheter care. At 1:59 PM, V7 confirmed she did not clean the four inches of catheter tubing and did not wear a gown during catheter care.On 12/09/2025 at 10:33 AM, V9, Infection Preventionist (IP), stated that catheter changes are completed per physician orders and documented in nursing notes or on the MAR or Treatment Record. On 12/10/2025 at 9:35 AM, V9 stated that the purpose of EBP is to protect residents from staff-transmitted germs and that staff are expected to wear gown and gloves when EBP is in place, particularly for residents with urinary catheters.On 12/09/2025 at 10:36 AM, V10, Licensed Practical Nurse/Wound Nurse, stated that per the 10/03/2025 urology note, R49's catheter was to be changed monthly. V31, MDS Coordinator, stated that she rounded with V33, R49's primary physician, who changed the catheter order to as needed without consulting the urology office. V10 stated that urine output monitoring would be documented on CNA task sheets. At 12:22 PM, V10 stated R49 was seen by urology in April, May, October, and November 2025. V10 further stated that R49's catheter was last changed on 06/23/2025 and that there was no documentation of catheter changes until 11/16/2025, no follow-up with urology regarding the order change, and no documentation of urine output monitoring until 12/04/2025, when an audit was completed by V2, Director of Nursing.On 12/09/2025 at 12:02 PM, V34, Urology Nurse for V35, stated that R49 was seen as a new patient in April 2025 and again in October 2025, and that V35 saw R49 during hospitalizations in May and November 2025. Provider notes indicated that R49's catheter was to be changed monthly, and no catheter changes were completed in the clinic. V34 stated that the facility should monitor for UTI signs such as changes in urine color or characteristics, cloudiness or blood, and complaints of flank pain. Standard nursing practice also includes measuring, recording, and monitoring urinary catheter output. Decreased output may indicate UTI. Failure to change a catheter can contribute to UTIs, and delayed identification or treatment of UTI can lead to sepsis. V34 stated that if these interventions had been performed, R49's hospitalization may have been prevented.On 12/10/2025 at 11:04 AM, V36, LPN, stated that she sent R49 to the hospital in November after the night nurse, V37, LPN, reported that during the 5:00 AM medication pass R49 was mumbling and experiencing swallowing difficulties. V36 stated she assessed R49's vital signs due to concern for possible sepsis given R49's history. R49 had minimal urine output, low pulse and blood pressure, and labored breathing.On 12/10/2025 at 11:41 AM, V37 stated that R49 appeared stable until approximately 5:30 AM, when a CNA reported that R49 was shaking and did not look well. Vital signs were checked and reported as normal, and the information was passed on in report. V37 stated she could not recall R49's urinary output that night, as nurses do not routinely document urine output.2.) On 12/09/2025 at 1:25 PM, V38 and V39, CNAs, transferred R2 from the toilet to her wheelchair in the 200-unit shower room. V38 pushed R2's wheelchair across the hall into R2's room, and R2's urinary catheter tubing was observed dragging on the floor, as confirmed by V39. A clip was attached to the tubing but was not used to keep the tubing off the floor. V39 removed R2's urinary collection bag from beneath the wheelchair and held it above the level of R2's bladder, causing urine to drain back toward the bladder, then placed the bag on R2's lap. Cloudy sediment was observed in R2's urine.V38 and V39 transferred R2 into bed using a full mechanical lift. The CNAs did not wear gowns during the transfers or while handling R2's urinary catheter, despite signage outside R2's room indicating Enhanced Barrier Precautions and the requirement to wear gowns for high-contact care. V39 acknowledged that the clip could be used to keep tubing off the floor and confirmed that the urinary collection bag had been raised above the bladder.R2's care plan dated 09/24/2025 documents use of a urinary catheter. A urine culture and sensitivity dated 12/08/2025 documents 50,000-99,999 CFU/mL of Escherichia coli (ESBL) and 25,000-50,000 CFU/mL of vancomycin-resistant Enterococcus faecalis.3.) On 12/08/2025 at 9:54 AM, V40, R5's family member, stated concerns that R5 experiences frequent UTIs and that nursing staff do not always follow up in a timely manner when urinalysis is requested. V40 stated that nurses must request orders from the physician and that results sometimes take weeks.R5's MDS dated [DATE] documents severe cognitive impairment, total bowel and bladder incontinence, and dependence on staff for toileting hygiene.A nursing note dated 09/17/2025 documents that V40 reported R5 complained of burning with urination and foul-smelling urine. The physician was notified; however, there is no documentation that a urine sample was collected until 09/19/2025, nor are results documented from that sample. Nursing notes document that another urine sample was collected on 09/24/2025, with results received on 09/26/2025 (nine days after symptom onset). Orders were received for Keflex 500 mg twice daily for 10 days.R5's urine culture and sensitivity dated 09/26/2025 documents 50,000-99,999 CFU/mL of E. coli.On 12/09/2025 at 12:14 PM, V31, MDS Coordinator, stated that laboratory pickup occurs Monday through Friday and that on weekends staff must transport specimens to the local hospital. V9, Infection Preventionist, and V31 were asked to provide documentation that R5's 09/19/2025 urine sample was sent to the laboratory.On 12/09/2025 at 3:06 PM, V2, Director of Nursing, stated that no additional documentation was available regarding R5's urine samples or results.

Based on Observation, Interview and Record Review the facility failed to protect the dignity and psychosocial wellbeing for two residents (R26, R69) reviewed for dignity out of a sample list of 49. This failure resulted in psychosocial harm for R26, R69 with feelings of disrespect.Findings Include: 1.) The Minimum Data Set, dated [DATE] documents that Resident R26 is severely cognitively impaired, requires maximum assistance with activities of daily living, and has a diagnosis of dementia. On 12/07/2025 at 8:30 AM, R26 was observed lying in bed on the left side, with the right side of the head positioned partially on a pillow and partially against the wall. The wall next to the bed, which was flush with the west wall, had noticeable dried brown hand wipes on the white surface. On 12/07/2025 at 8:51 AM, V2 (Director of Nursing) observed R26 and stated that the substance on the wall was feces and that the resident's head was lying in the feces. On 12/08/2025 at 2:31 PM, V11 (R26's Power of Attorney) stated that R26 was in the facility for rehabilitation. V11 stated that no one had contacted them regarding R26's head lying in feces and further stated, My mom wouldn't have appreciated her head lying in poop. 2.) The Minimum Data Set, dated [DATE] documents that Resident R69 is cognitively intact and requires maximum assistance with activities of daily living. On 12/07/2025 at 8:27 AM, R69 stated that when needing to use the restroom, the call light system is activated; however, at times it has taken over an hour for staff to respond. R69 stated this delay resulted in urinary incontinence and made the resident feel disrespected. On 12/07/2025 at 11:40 AM, V15, Licensed Practical Nurse, stated that all call lights should be answered as quickly as possible and that a response time of over an hour is not acceptable. V15 further stated that R69 is alert and would know when restroom assistance is needed. The facility policy, revised April 2007, documents that the facility will make every effort to assist each resident in exercising their rights to ensure that residents are always treated with respect, kindness, and dignity.

Based on observation, interview, and record review the facility failed to properly transfer a resident (R2) for one of two residents reviewed for accidents in the sample list of 49. This failure resulted in bruising and pain to R2's right leg. Findings include:The facility's Safe Lifting and Movements of Residents policy, dated August 2008, documents that resident transfer needs will be assessed on an ongoing basis and that transfer status will be documented in the care plan.On 12/07/2025 at 10:30 AM, R2 stated that the previous night staff struck the back of her right leg against the bed frame while using a sit-to-stand lift. R2 stated that management was aware and had looked at her leg that morning. R2 grimaced when moving her right leg and stated that the incident caused pain to her right leg.On 12/09/2025 at 1:10 PM, V38 and V39, Certified Nursing Assistants (CNAs), used a sit-to-stand lift to transfer R2 onto the toilet in the 200-unit shower room. R2 held on with both hands, bore weight with a bent posture, and the chest strap remained loose. R2 did not fully stand, and her knees remained bent. R2 had lymphedema (swelling) in both legs. V39 stated that R2 uses a full mechanical lift for transfers in and out of bed and a sit-to-stand lift for toilet transfers, which was approved by therapy.At 1:28 PM, V38 and V39 transferred R2 from the toilet back to her wheelchair using the sit-to-stand lift. R2 was observed to have a baseball-sized blue/purple bruise on the back of her right calf/knee. R2 stated, See what they did to me. They banged my leg on the bed. It hurts. V39 asked R2 if she had reported this to the nurse, and R2 stated that nurse management was aware. R2 exhibited visible facial grimacing, moaning, and complaints of pain during the transfers.V38 and V39 transported R2 to her room and transferred her into bed using a full mechanical lift. V39 stated that staff do not tighten the chest strap on the sit-to-stand lift because R2 refuses and does not like it, and that R2 usually stands better than that. A sign posted on R2's wall near the bed instructed staff to use a full mechanical lift for bed transfers and a sit-to-stand lift for toilet transfers.At 1:44 PM, R2 stated that some staff use the full mechanical lift and some use the sit-to-stand lift to transfer her into bed. R2 stated that she did not have right leg pain prior to the incident that caused the bruise.R2's Minimum Data Set, dated [DATE] documents that R2 is cognitively intact and dependent on staff for chair, bed, and toilet transfers. R2's care plan documents a diagnosis of lymphedema and was revised on 11/18/2025 to reflect transfer status as a mechanical sit-to-stand lift for toileting in the shower room and a full mechanical lift to and from bed. This information is also reflected in CNA task lists and charting.R2's nursing note dated 12/07/2025 at 6:35 AM documents bruising and hardening to the back of the right leg near the knee area, with complaints of slight pain. Nursing notes and the December 2025 Medication Administration Record document that Tramadol 50 mg was administered on 12/07/2025 at 8:30 AM for complaints of right leg pain rated 5 out of 10, with follow-up pain rated at 4.On 12/09/2025 at 2:40 PM, V25, CNA, stated that she worked on R2's hallway on Saturday night (12/06/2025) and that a sit-to-stand lift was used to transfer R2 into bed; however, V25 stated she was not the individual who rammed R2's leg into the bed frame. V25 stated that V26 was the other CNA assisting with R2's transfers that night and that V26 operated the lift. V25 stated that she did not realize anything had occurred until R2 asked V25 and V26 to look at her leg after the transfer because R2 felt something on the back of her leg. V25 stated she had recently started working on that hallway and had asked how R2 transferred; she was told R2 used a sit-to-stand lift. V25 stated it was not until Sunday that she learned R2 was supposed to use a full mechanical lift, after V2, Director of Nursing, spoke to her regarding R2's bruising.On 12/09/2025 at 2:49 PM, V2 stated that R2's bruise occurred during a transfer when R2 was positioned too close to the bed. V10, Licensed Practical Nurse/Wound Nurse, stated that she investigated R2's bruising and interviewed R2 and the CNAs. V10 stated that R2 reported the CNAs used a sit-to-stand lift to transfer her into bed and pushed too hard on the lift, causing R2's leg to strike the metal bed frame. V10 interviewed V25 and V26 and confirmed that V26 operated the lift with assistance from V25. V10 stated that both CNAs were educated on proper transfer techniques, instructed to use caution during transfers, and issued verbal warnings for improper transfer, as R2 requires a full mechanical lift for bed transfers.Employee Disciplinary Reports dated 12/07/2025 document that V25 and V26 received verbal warnings for improper transfer, specifically using a sit-to-stand lift instead of a full mechanical lift, resulting in the resident sustaining a bruise to the leg after contact with the metal bed frame.

Based on observation, interview, and record review the facility failed to serve meals at the posted times. This failure has the potential to affect all 95 residents in the facility. Findings Include:On 12/10/25 Record Review of DIET [NAME] SERVICES POLICY documents the dietary department shall maintain and keep current a policy and procedure manual inaccordance with applicable state and local requirements for food-service that ensures efficient operation and delivery of appropriate food service to residents. The policy further documents three (3) well-planned meals will be served at regularly scheduled hours. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 12/7/25 documents a census of 95 residents.On 12/10/25 at 09:30am V16, Certified Dietary Manager, confirmed the facility scheduled meal times are breakfast at 07:30am, lunch at 11:30am, and dinner at 5:00pm.On 12/07/25 breakfast was observed starting serving at 08:10am and lunch at 12:15pm.On 12/08/25 Breakfast was observed started serving at 08:17am. On 12/10/25 at 09:30am V16, Certified Dietary Manager, stated the breakfast meal was late being served today because no staff rolled silverware, and that needed done to serve breakfast. On 12/8/25 at 12:27pm R52 stated meals are served late all the time. On 12/7/25 V1, Admin, provided a binder that list the assigned meal times as breakfast at 07:30am, lunch at 11:30am, and dinner at 5:00pm

F575 Required PostingsBased on observation, interview, and record review the facility failed to post the name, address, and telephone number of the state agency in an accessible location in the facility. This failure has the potential to affect all 95 residents currently residing in the facility. Findings:The facility's Long-Term Care Facility Application for Medicare and Medicaid, dated 12/07/2025, documents a census of 95 residents.On 12/09/2025 at 10:20 AM, during a Resident Council meeting, Resident R17 stated she had not seen any information posted in the facility related to the State Agency. Resident R34 then stated she denied seeing any information displayed in the facility regarding how to file a complaint with the State Agency. Residents R15, R37, R1, R52, R72, and R96, who were also present at the Resident Council meeting, agreed that they were not aware that State Agency information was posted in the facility.On 12/09/2025 at 11:18 AM, when asked whether the facility had a sign posted with State Agency information, V1, Administrator, directed this surveyor to the front entrance, past the alarmed entry doors, into the foyer, where contact information for the State Agency complaint procedure was displayed at an elevation above this surveyor's eye level while standing. The State Agency contact information was not clearly visible from inside the facility.

Based on interview and record review, the facility failed to remove a washcloth from the adult incontinence brief after cares were provided. This failure resulted in R2 experiencing a foul odor causing R2 to feel humiliated and embarrassed while in public. R2 was one of three residents reviewed for quality of care on a sample list of nine.Findings include:On [DATE] at 2:30PM, Employee handbook dated revised [DATE], documents on page 3: We count on you, our employees, to focus on the provision of quality care and excellent services for our residents and to do so with a high level of dignity, compassion, and responsiveness to their physical, medical, and emotional needs.R2's Clinical Census, undated, documents an original admission date of [DATE]. Minimum Data Set completed on [DATE], document a Brief Interview for Mental Status (BIMS) score of 12 of 15. A score of 12 indicates R2 has moderate cognitive impairment. R2's Care plan dated [DATE] documents diagnosis of: End Stage Renal Disease, Essential (Primary) Hypertension, Hereditary and Idiopathic Neuropathy, Paraplegia. The same care plan documents: Usual ADL (Activities of Daily Living) Performance: R2 is independent for eating with set up help. Max A (maximum assistance) of one to two is needed for personal hygiene, dressing, toileting & bed mobility, dependent with transfers with a total body mechanical lift of two. On [DATE] at 10:30am, R2 stated on [DATE] R2 activated his call light at 07:00am to get help from the nursing staff to get cleaned up and dressed for dialysis. R2 stated the transportation bus picks him up at 08:00am for dialysis. R2 stated two (2) certified nursing assistants (CNA) came into the room at 07:50am to get R2 ready for dialysis and were very hurried in trying to get him ready for the bus. R2 stated R2 made the bus and went to dialysis, upon completion on his dialysis treatment R2 stated he smelled something on himself and was now upset because he does not like being dirty or smelling.R2 stated that he asked the dialysis nurse if she smelled something, she replied yes, she does. R2 stated he asked the bus driver if he smelled something, R12 stated the bus driver stated he did when the bus driver leaned over to secure the wheelchair. R2 stated he was humiliated and did not talk the ride from the dialysis center to the facility.R2 stated that upon arriving back to the facility he asked the staff to lay him down and help him get cleaned up, to which the second shift CNAs did. Upon opening up the incontinence brief, the CNA behind him exclaimed Oh my God and held up a washcloth she stated was from inside the brief and causing the odor.R2 stated he was humiliated at the smell and could not believe someone left a washcloth in his brief.On [DATE] at 12:00 pm, V8 LPN (License Practical Nurse), stated that she was the nurse on duty on [DATE] and sometime in the afternoon a CNA reported to her that when providing cares to R2 and the CNA removed the brief there was a washcloth in the brief. V8 stated that R2 was very mad and upset and refused an assessment of the area and wanted to be left alone.On [DATE] at 12:35pm, V9 CNA stated she was told there was a washcloth in the incontinence brief, but unsure how that happened.On [DATE] at 1:38pm, V10 CNA stated she assisted V9 CNA in getting R2 ready for dialysis but R2 was very upset and yelling at staff. V10 stated she was told there was a towel in the brief but does not know how it got there.On [DATE] at 1:48pm, V11 CNA stated when R2 returned from dialysis R2 requested help in getting cleaned up due to having a smell from his body. V11 stated R2 was transferred to the bed via the total mechanical body lift, rolled over and removed the brief and discovered a wet washcloth in the intergluteal cleft, (skin fold between the buttocks). V11 stated R2 was very upset at the smell and that a washcloth was left inside the brief. V11 stated R2 requested to be left alone once cares were completed. Example 2Based on interview and record review the facility failed to notify the primary care physician of a change in condition when the onset of multiple episodes of diarrhea began for one (R7) of three residents reviewed for death on the sample list of nine.1 This failure resulted in R7 having multiple episodes of untreated diarrhea for eight consecutive days. Findings Include:On [DATE] at 11:30 AM, Record review of Notification of Resident Change in Condition Policy, Undated, states: It is the policy of this facility to promptly notify the resident, their legal representative and attending physician of changes in the resident's health condition. The same document states under Standards: 2. The licensed nurse is to use professional judgment in determining changes in condition based on assessment and findings or signs and symptoms of change which could lead to deterioration if not treated. 3. Clinical change in condition is determined by resident visualization, medical record review, clinical assessment findings and care plan review. Review of high-risk clinical issue such as skin breakdown, falls, weight loss, dehydration and others are conducted on a daily basis. 7. Changes in the resident's condition will be communicated to the direct care staff by verbal shift-to-shift report, revision in resident assignments and by use of the 24 hour written shift report.On [DATE] at 2:00 pm, R7's care plan dated [DATE] documents an admission date of [DATE] with the diagnosis of Heart Failure and Type 2 Diabetes Mellitus with Hyperglycemia. R7 admitted to the facility for therapy with the discharge plan to return home. This care plan documents R7 is incontinent. This care plan does not document that R7 has a history of diarrhea.R7's Bowel Movement and Continence Look Back record for the last 30 (days) documents by nursing staff that R7 was incontinent of bowels and had loose/diarrhea on [DATE] at 8:51 pm and 11:25 pm, on [DATE] at 7:45 am and 11:12 pm, on [DATE] at 10:38 am, and on [DATE] at 10:59 pm.R7 Bowel Movements and Continence Look Back record is incomplete from [DATE] thru [DATE]. On [DATE] at 1:32 pm, V19 Certified Nursing Assistant stated V19 cared for R7 most nights V19 worked. V19 stated R7 was incontinent of her bowels and had loose/diarrhea stools at least every other night. V19 stated V19 documented in the medical record the loose/diarrhea stools and V19 stated V19 informed the nurse on duty when R7 had loose stools. R7's Nurse's Note dated [DATE] at 5:30 pm, written by V22 Licensed Practical Nurse documents R7 had three (3) episodes of diarrhea after returning from dialysis.On [DATE] at 10:36 am, V22 stated R7 had three loose/diarrhea stools on [DATE] after returning from the dialysis clinic at 5:15 pm. V22 stated V22 filled out an SBAR (Situation, Background, Assessment, and Recommendation form) and faxed it to the physician (V16) at 5:30 pm due to a concern for C Diff (Clostridium Difficile) and requested an antidiarrheal medication. V22 stated V22 does not recall if R7 had loose/diarrhea stools on other days. V22 stated she did not provide R7 with antidiarrheal medication due to no order. R7's medical record does not document that R7's physician was notified of R7's diarrhea or that R7 was treated for diarrhea which started on [DATE]. On [DATE] at 1:25 pm, V21 stated V21 took care of R7. V21 stated R7 was incontinent of bowel and bladder at nighttime. V21 stated V21 recalled, R7 having loose/diarrhea stools once or twice for sure. V21 stated on the morning of [DATE] at 6:00 am, V21 went into R7's room to do the blood glucose and R7 was not acting herself. V21 stated she proceeded to do the blood glucose, and it did not register on the meter, it stated high. V21 stated V21 proceeded to send R7 to the emergency room. V21 stated R7 blood glucose reading were elevated at times. V21 doesn't recall being informed by staff that R7 was having frequent loose/diarrhea stools. R7's Laboratory Report documents a stool sample collected on [DATE] at 10:46 PM was positive for Clostridium Difficile (C-Diff).On [DATE] at 10:27am, V16 Primary Care Physician stated that V16 was not notified of R7 having multiple loose/diarrhea stools documented as starting on [DATE] in the medical record. V16 stated V16 expects the nursing staff to notify him when a resident is having multiple and frequent loose/diarrhea stools. On [DATE] at 11:18am, V26 registered nurse stated V26 was the nurse on duty [DATE] from 11:00pm to 06:00am. V26 stated she does not recall being told by the CNA (Certified Nursing Assistant) that R7 had a loose/diarrhea stool.On [DATE] at 09:54am, V28 License Practical Nurse V28 stated the expectation is that the CNA will inform the nurse when a resident is having loose stools, and the nurse will inform the physician. V28 stated that the nurses have access to bowel and bladder charting and can look to see how the residents are being charted on. V28 confirms the documentation of loose/diarrhea stools in the medical record of R7. V28 confirmed V22 should have called the physician on the telephone after completing the SBAR. V28 confirms there is no SBAR (Situation, Background, Assessment, and Recommendation form) completed by V22 in the medical record. Example 3Based on interview and record review, the facility failed to ensure physician orders were accurately transcribed and implemented for one (R7) of one resident reviewed for blood glucose monitoring in a sample list of nine residents. These failures resulted in R7 being hospitalized for Diabetic Ketoacidosis.Findings include:On [DATE] at 2:00 pm, R7's care plan dated [DATE] documents an admission date of [DATE] with the diagnosis of Heart Failure and Type 2 Diabetes Mellitus with Hyperglycemia. R7 admitted to the facility for therapy with the discharge plan to return home.R7's Discharge Plan dated [DATE] at 8:59:32 documents on page three (3) under section Discharge Instructions: * Blood Glucose monitoring - check blood sugar before meals and at bedtime. On [DATE] at 2:00pm, R7 Record review documents a physician order for Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 10 units subcutaneously one time a day related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA (E11.65) -Start Date [DATE] at 0900.On [DATE] at 2:00pm, R7 Record review does not contain a physician order for blood glucose monitoring- check blood sugar before meals and at bedtime. On [DATE] at 2:22pm, R7 Record review of nursing progress notes documents on [DATE] at 06:17am, V21 LPN (Licensed Practical Nurse) documents R7 exhibited symptoms of altered mental status with a blood glucose over 500mg/dl (milligrams per deciliter). On [DATE] at 2:22pm, the next progress note entered in the R7's Record review of nursing progress notes documents V22 LPN, called the local hospital in regard to the condition of R7 and was told R7 was admitted to the hospital with Diabetic Ketoacidosis and Urinary Tract Infection. On [DATE] at 2:25pm, hospital record review documents R7 arrived at the local hospital emergency room on [DATE] at 6:31am.On [DATE] at 2:25pm, Record review of hospital notes V23 Registered Nurse (RN), documents Nursing home reports altered mental status. That patient was sweating and clammy with a temp of 102.4 and R7 blood glucose was over 600. Laboratory results obtained in the hospital document a blood sugar of 738mg/dl.On [DATE] at 10:27am, V16 Primary Care Physician stated R7's elevated blood glucose level on [DATE] at 06:00am was secondary to infection and likely would have been elevated at bedtime. On [DATE] at 1:25pm, V21 LPN stated on the morning of [DATE] at 06:00am, V21 went into R7's room to do the blood glucose and R7 was not acting herself. V21 stated she proceeded to do the blood glucose, and it did not register on the meter, it stated high. V21 stated V21 proceeded to send R7 to the emergency room. V21 stated R7's blood glucose readings were elevated at times.On [DATE] at 10:22am, V3 DON and V4 ADON, confirm R7's transfer physician orders dated [DATE] document Blood Glucose monitoring - check blood sugar before meals and at bedtime. V3 DON and V4 ADON confirm R7's medical record physician orders section does not contain the physician order for Blood Glucose monitoring - check blood sugar before meals and at bedtime.

Based on observation, interview, and record review the facility failed to protect a resident from staff verbal abuse for one of three residents (R1) reviewed for abuse in the sample of 36. These failures resulted in R1 feeling intimidated and verbally abused by V4 (RN/Registered Nurse) and R1 experiencing ongoing mental anguish, fear, and anxiety. Findings include: The facility's Abuse Prevention Program policy dated October 2022 documents, The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, or mistreatment. This facility prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. This will be done by establishing and environment that promotes resident sensitivity, resident security, and prevention of mistreatment. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, reasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individuals' age, ability to comprehend, or disability. R1's Admission Record documents R1 was admitted to the facility on [DATE] with the diagnosis of Paraplegia. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is cognitively intact and has no behaviors. On 12-27-24 at 10:00 AM R1 was sitting up in his bed. R1's eyebrows were raised and R1's eyes were wide open when he stated in a high-pitched, shaky voice, Last Tuesday (12-17-24) around 7:30 PM I was in my room and had just sprayed room spray. The room stunk. I told (V5/CNA/Certified Nursing Assistant) to close the door so the stink from the hallway did not come into my room. V4 (Registered Nurse) was out in the hallway and came storming into my room like the Tasmanian Devil, got in my face, and yelled at me, 'Let me school you on when you can and cannot call the state in here. You do not get to tell us when the state can come in here.' (V4) looked like she wanted to fight me. I told (V4) that I said the stink not the state. I am paralyzed and cannot defend myself. (V4) scared me and I yelled at (V4) to get the f*** out of my room. (V5) was in the room and witnessed (V4) yelling at me. (V5) told me she could not believe that (V4) yelled at me like that and felt like (V4) wanted to Whip my a**! My heart rate was up and I have had so much anxiety over this since (V4) did this. I text (V1/Administrator-In-Training) right after that and told (V1) that I felt threatened and abused and I was scared of (V4). (V1) just disciplined me and said she (V1) heard I had been acting up that night so I need to be nice. (V4) continued to work that night and even came back into my room later and said, I am here to offer an apology. You can either except it yes, or no? I told her to get out of my room and I did not want her taking care of me. I have been scared of (V4) ever since. I do not feel safe in my own room, and nobody has even talked to me since this. You would think (V1) would talk to me to see if I am alright. On 12-27-24 at 10:40 AM V1 (Administrator-In-Training) stated, I am going to just be honest with you. (R1) has a history of being ridiculous. (R1) text me on 12-17-24 and told me (V4) was being rude to him. I called (R1) and he said (V4) overheard (R1) saying that the door needs to be shut or state would be called in. (R1) reported (V4) went into (R1's) room and said to (R1) the door does not have to be shut just because (R1) wanted to shut the door and the state would not come in just because the door was open. (R1) told me he did not say state he said stink and (V4) did not have to be rude. (R1) may have said he felt threatened by (V4). On 12-27-24 at 12:25 PM V5 (CNA) stated, I was in the room on 12-17-24 when (V4) came into (R1's) room. (R1) was talking to me about making sure the door was shut to keep the stink from the hallway out of his room. (V4) was out in the hallway when (R1) was talking to me. Next thing I knew (V4) barged into (R1's) room and was in (R1's) face screaming and threatening (R1) by yelling, Let me school you on when the state can and cannot be called. (V4's) body language looked like she wanted to fist fight (R1). I could not believe how (V4) was acting. (R1) told (V4) he said stink not state and then yelled at (V4) to get the f*** out of his room. I do not know why (V4) even felt like it was her place to come into (R1's) room over a conversation (R1) and I were having. (R1) was definitely scared of (V4) and has told me he does not feel safe having (V4) take care of him.

Based on interview and record review, the facility failed to complete wound treatments,wound measurements, and wound monitoring for a resident as ordered by the primary care physician. This failure affects one resident (R4) out of three reviewed for wound care on a sample of five. This failure resulted in R4's facial wound becoming infested with parasitic fly larvae (maggots). Findings include: R4's Census Detail and Minimum Data Set List (undated) documents R4 was originally admitted to the facility 02/13/2019. R4's current Diagnosis List (undated) documents R4 experiences medical diagnoses including Cognitive Communication Deficit, Age-Related Cognitive Decline, Repeated Falls, Need For Assistance With Personal Care, Alzheimer's Disease, Dementia, Unspecified Severity, With Psychotic Disturbance, and Disorder Of The Skin And Subcutaneous Tissue. R4's Primary Care Physician Progress Notes from V14, Primary Care Physician, dated 3/22/2024, documents R4 was experiencing a lesion on the right cheek which was progressively increasing in size. The same note has the lesion size listed as approximately 2 in (inches) by 1.5 in with necrotic tissue. R4's wound assessment notes provided from 3/22/2024 through 6/28/2024 do not include consecutive weekly wound assessment measurement notes recorded in the clinical record. R4's wound assessment notes dated: 3/22/2024, 4/12/2024, 4/25/2024, 5/6/2024, 5/22/2024 6/7/2024, 6/13/2024, 6/20/2024 and 6/28/2024 do not contain wound measurements. R4's Physician order, dated 4/19/24, documents apply warm compress to R(right) cheek to loosen any dried blood. Cleanse cheek with soap and water every shift as needed. R4's Treatment sheet schedule for Jun (June) 2024 is missing treatment documentation for: warm compress order - 6/8/24, 6/20/24, 6/21/24, 6/22/24 and 6/28/24. R4's Treatment sheet schedule for Jun (June) 2024 is further missing documentation for: monitoring cancer lesion to R lateral face for 6/8/24, 6/20/24, 6/21/24, 6/22/24 and 6/28/24. There were no orders in R4's record documenting therapeutic use of maggots for any wound treatment. R4's Nurses note, dated 7/1/2024 11:43 AM, states R4 is awake and restless. V13 (Nurse) went in cleaned R4 up changed bed linen and gown. R4 was moaning and grunting so V13 gave R4 morphine then cleaned the wound to R4 face and surrounding covered with wet to dry dressing to slow bleeding and eliminate/slow unwanted fly and gnat attention. R4's Physician order, dated 7/2/24, documents cleanse R(right) cheek with generic wound cleanser/ND, pat dry. Apply gauze moistened in Dakin's (treatment diluted bleach solution used to prevent and treat skin and tissue infections) 1/4 strength to wound bed. Cover with ABD (dressing) and secure with retention tape. On 7/3/2024 at 1:30 PM, V16, Nurse, states the maggots were noticed on 6/30/24, and that everyone (Doctor, Nurse Management and family) was notified including hospice team. V16 states the Wound Nurse (V12) helped remove the maggots from the wound. On 7/8/2024 at 11:05 AM, V12 states V12 was informed of the maggots in R4's wound on 7/1/24. V12 states V12 and V13 cleaned the wound and removed the maggots from the wound. On 7/8/2024 at 11:05 AM, V12, Licensed Practical Nurse/Wound Nurse, stated R4's wound to the right side of the face was measured in the past, but has not been measured in last few weeks. V12 states the clinical record (EMR) shows the last measurement was taken. On 7/8/2024 at 11:53AM, V3, Assistant Director of Nursing, states V3 was informed of the maggots in R4's wound on 7/1/24, and V12 and V13 had cleaned and removed them from the wound.

Based on interview and record review, the facility failed to supervise and assist a resident (R1)with a transfer and ambulation which resulted in a fall and subsequent injuries. R1 was sent to the emergency room and diagnosed with a left comminuted displaced oblique humeral diaphyseal fracture, a right displaced olecranon fracture, a right angulated impacted distal radial fracture, and a right displaced base of fifth proximal phalanx fracture which required emergency treatment, overnight hospitalization , and subsequent surgery. R1 is one of three residents reviewed for accidents/falls on the sample list of four. Findings Include: The facilities Falls and Fall Risk Managing policy, dated August 2008, documents the facility will identify interventions related to a resident's specific risks in an attempt to prevent the resident from falling and minimize complications from falling. R1's Medical Diagnoses list, dated March 2024, documents R1 is diagnosed with Chronic Obstructive Pulmonary Disease, Heart Failure, Chronic Respiratory Failure, Cerebral Infarction, Lung Cancer, Protein Calorie Malnutrition, and Chronic Pain. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact and requires Supervision or Touching Assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for all transfers and ambulation. R1's discharge MDS, dated [DATE], documents R1 required Supervision or Touching Assistance for all ambulation. R1's ADL (Activity of Daily Living) Restorative Assessment and Progress Note, dated 1/20/24, documents R1 is full weight bearing and has safety risk factors which include oxygen use, glasses, shortness of breath or trouble breathing. R1 requires supervision or touching assistance for all transfers and walking. R1 requires the use of a walker for ambulation. R1 required a restorative walking program. R1 is able to transfer with supervision and set up. R1 is able to walk with a four wheeled walker with supervision and verbal cues as needed. R1's Care Plan, dated 10/4/23, documents R1 is at risk for falls related to weakness, Chronic Obstructive Pulmonary Disease, Cerebral Infarction, and Lung Mass. Staff are educated to assist R1 with all transfers and use a gait belt. The same Care Plan also documents R1's transfer status is one assist. The same Care Plan documents R1 has ADL and self-care deficiency and requires requires supervision of one staff for balance support during ambulation with wheeled walker. The same Care Plan documents R1 has a Ambulation ADL Self Care Performance Deficit and staff should use a gait belt and assist R1 to transfer and stand and walk with wheeled walker. Staff should remind R1 to look up, take steps and lift feet, monitor for fatigue, dizziness, or shortness of breath, and keep room free of clutter and safety hazards. The Facility Reported Incident, dated 2/25/24, documents at 11:25 AM, R1 was seen in her room ambulating towards the bathroom by a staff member (V9, Certified Nurses Assistant CNA), who was walking down the hall. At 11:30 AM, V5, Licensed Practical Nurse, heard R1 yelling for help and found R1 on the floor. R1 complained of pain in her arms, and R1 was sent to the emergency room for evaluation, diagnosed with multiple fractures, and underwent surgical repair. On 3/10/24 at 12:55 PM, V5, Licensed Practical Nurse/LPN, stated she takes care of R1 all of the time. V5 stated she does not consider R1 a fall risk, and R1 often walked to the bathroom and down to the dining room on her own using her walker. V5 stated on 2/25/24 at 11:30 AM, she found R1 laying on the floor of her room face down and yelling for help. V5 stated R1 stated she was coming back from the bathroom and got her feet tangled in her oxygen tubing. R1 complained of arm pain and was sent to the ER for evaluation. On 3/12/24 at 4:13 PM, V9, Certified Nurses Assistant/CNA, stated she observed R1 on 2/25/24 at about 11:25 AM in her room. V9 stated she (V9) was telling residents it was time for lunch and helping them to the dining room. V9 stated she was not aware R1 required supervision or cueing or assistance for transfers or walking, and did not offer to assist her. On 3/12/24 at 2:57 PM, R1 was in her bed with a cast on her right arm and sling on her left. R1 appeared melancholy and had a flat affect. R1 stated she was very frustrated that when she attempted to walk back from the bathroom, she got her feet tangled in her oxygen tubing and fell and broke both arms. R1 stated this fall has set her back so far, and she is not happy about having to go through therapy and not being able to walk or do things for herself anymore. R1 stated before the fall, she walked in her room and down the hallway to the dining room without any supervision or assistance from staff. R1 stated she thought staff felt she was safe to walk on her own, and no one ever told her she needed assistance or supervision. R1 stated if staff had told her to use her call light for help before getting up, she would have done so. On 3/13/24 at 11:00 AM, V1, Administrator, confirmed R1's Assessments and Care Plan prior to her fall on 2/25/24 document R1 required at least supervision/cueing/assistance/gait belt while walking and ambulating. V1 confirmed there is no documentation R1 refused to use call light for help. V1 stated staff need education on providing ambulation assistance for R1 and being with her at all times. V1 confirmed R1 is a fall risk due to Chronic Obstructive Pulmonary Disease (COPD), recent lung cancer treatments, continuous oxygen use, and required walker use, even if she hasn't had prior falls. On 3/13/24 at 12:30 PM, V18, Medical Director and R1's Primary Physician, confirmed R1 is a fall risk due to her COPD, Shortness of Breath, continuous use of oxygen, intermittent weakness, and use of a walker for ambulation. V18 confirmed R1 fell due to tripping over oxygen tubing, which caused multiple fractures which required surgical repair. V18 confirmed staff should make sure they have accurate assessments and staff are educated on resident needs. V18 stated R1 was more likely to need assistance after laying down, and staff should have instructed R1 to use the call light for assistance.

Based on interview and record review, the facility failed to recognize/remove an accident hazard to prevent a fall for one of three residents (R3) reviewed for falls in a sample list of six residents. This failure resulted in R3 falling and sustaining a nasal fracture and hematoma. Findings include: R3's Care Plan, updated 1/4/24, includes the following diagnoses: Dementia with Psychotic Disturbance, Muscle Weakness, and Alzheimer's Disease. R3's Care Plan includes an identified problem: (R2) is high, risk for falls related to Confusion, Gait/balance problems, Incontinence, Unaware of safety needs, history of fall with fracture, vitamin D deficiency, Dementia with Behaviors. Staff educated to encourage (R3) to sit up in wheelchair when observed reaching to pick up objects off the floor. R3's Minimum Data Set (MDS), dated [DATE], documents R3 is severely cognitively impaired, wanders, uses wheelchair for mobility, and is incontinent of bowel and bladder. R3's Incident Summary, dated 12/27/23 at 2:20PM, documents, (R3) was self propelling in wheelchair through the hallways and was seen going through the trash. Staff redirected (R3) to the dining room, where there was a big bag of trash outside therapy's door. (R3) attempted to reach for the trash and fell out of wheelchair forward. (Physician) ordered (R3) to the emergency room for evaluation and treatment. Findings were closed nasal fracture. Power of Attorney notified. (R3) returned to the facility with cold packs as tolerated and pain medications. R3's emergency room note by V11, Medical Doctor (MD), dated 12/27/23 at 3:26PM, documents, [AGE] year old female presents to the emergency department after a fall. Patient was sitting in a wheelchair when she fell over hitting her head. Under Physical Examination V11 documented Head Large Hematoma to Forehead. R3's Computerized Axial Tomography (CAT) scan, dated 12/27/23 at 4:14PM, documented, A nasal bone fracture is present with mild depression. On 1/17/24 at 1:00PM, V5, Certified Occupational Therapy Assistant/Therapy Director, stated, I would say placing the trash outside our door in the dining room was a safety hazard we would have been able to control. We were aware (R3) will pick up and rummage through things she finds on the floor. That is how she fell . She leaned forward in her wheelchair to pick through the trash bag and fell forward. (R3) broke her nose when she hit her face on the floor. On 1/17/24 at 1:30PM, V9, Assistant Director of Nursing (ADON), stated, I did the investigation for (R3's) fall. (V9, Certified Nurse's Aide/CNA) observed (R3) in the hall going through the trash shortly before the fall in the dining room. (V9) redirected (R3) to the dining room. Therapy placed a large bag of trash outside their door in the dining room. (R3) started digging through the trash, and when she leaned forward she fell forward out of her wheelchair and hit face first on the floor. We could immediately see (R3's) nose was deformed. We sent (R3) to the emergency room and she came back with a broken nose. We know (R3) leans forward and picks at things she sees. It is on her care plan. The facility's policy Falls and Fall Risk Management (not dated) states, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling and try to minimize complications from falling.

Based on observation, interview, and record review, the facility failed to ensure two staff were present for care as directed in the assessment, failed supervise residents and develop post fall interventions, failed to ensure wheelchair restraint equipment was functioning properly for transport, and failed to complete post fall assessments for four of four residents (R4, R1, R2 and R3) reviewed for falls on the sample list of four residents. These failures resulted in R4 rolling out of bed and R4's gastrostomy tube becoming dislodged and causing tissue damage when only one staff was providing care, R1 falling and obtaining a femur fracture when staff failed to supervise R1 and failed develop post fall interventions to prevent subsequent falls, and R2 falling and obtaining a clavicle fracture when staff failed to supervise R2 during ambulation. Findings include: 1.) R4's Undated Face Sheet documents medical diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left non-dominant side, Left Side Weakness, Dysphagia, Aphasia, Nothing by Mouth (NPO), Gastrostomy Tube (G-tube), Trans Ischemic Attack (TIA), Convulsions and Chronic Embolism and Thrombosis of Deep Veins of Right Upper Extremity. R4's Minimum Data Set (MDS), dated [DATE], documents R4 as severely cognitively impaired. This same MDS documents R4 as requiring extensive assistance of two people for bed mobility, dressing, toileting, personal hygiene, and total dependence of two people using a mechanical lift for transfers. R4's Care Plan documents a fall intervention, dated 7/17/22, of, Staff to position (R4) in center of bed. R4's Nurse Progress Note, dated 2/15/23 at 11:49 PM, documents, Fall Details: Date / Time of Fall: 02/15/2023 11:00 PM Fall was witnessed. Fall occurred in the Resident's room. Activity at the time of fall: rolled out of bed. Did fall result in an emergency room (ER) visit/hospitalization : Yes. ER Visit/hospitalization Details: per physician request. Conclusion: Did environmental factors contribute to the fall: No. Did Resident's current medical condition(s) contribute to the fall: No. Any additional needs identified: Yes. Needs identified: Re-education. Needs identified: Floor Mat. R4's Fall Investigation, dated 2/15/23, documents, (V19) Certified Nurse Aide (CNA) giving care to (R4) and (R4) slid off of bed. (V19) CNA notified (V16) Licensed Practical Nurse (LPN). (V16) LPN observed (R4) laying on Left side of body on floor area and (R4) assessed. (R4's) G-tube was pulled out when (R4) fell . (R4) alert, nonverbal, unable to do Range of Motion (ROM) due to position (R4) was in. Ambulance called, Physician notified and orders given to send to emergency room for evaluation and treatment and to reinsert G-tube. (R4) unable to give description. This same report documents, Summary of event/situation: At 11:31 PM (V19) CNA notified (V16) LPN that (R4) was on the floor. (V16) entered room and noted (R4) on floor. During assessment (R4's) G-tube was observed to be displaced. Root Cause: (R4) not positioned correctly during care. Intervention: (V19) educated and in serviced on turning an repositioning correctly during care. R4's emergency room record, dated 2/16/23, documents, (R4) arrives via ambulance service from facility for evaluation of a fall out of bed. (R4) is nonverbal, bedbound from prior stroke. Per facility staff, (R4's) bed was approximately four feet in the air and (R4's) Gastrostomy tube (G-tube) was pulled out on the way down. (R4) alert, nonverbal and drooling. This same report documents, G-tube replacement Narrative notes: Procedure specific details: Tract greater than four weeks old. Dilated with 20 French (F) and 22F catheter. Could not get a 24F G-tube in. Downsized to 22F that went in smoothly. On 2/16/23 at 3:00 PM, V16, Licensed Practical Nurse (LPN), stated, (V19) Certified Nurse Aide (CNA) was providing incontinent care to (R4). (V19) is a new CNA and did not know (R4) requires two staff for most cares. (R4) had a major stroke and no longer has use of his entire left side and right Leg. (R4) can move his right arm a little bit, but nothing significant. (R4) requires two staff for incontinence care and turning and positioning in bed. (R4) also has an air mattress so we (staff) know how dangerous those can be. (V19) CNA should not have been providing cares to (R4) by herself. That is why (R4) fell out of his bed. That is how (R4) got hurt. I had to send (R4) to the hospital because (V19) accidentally pulled out (R4's) feeding tube when trying to turn (R4). The hospital had to put in a smaller tube because the tissue was damaged around where the feeding tube goes in. They (hospital) told me in report that the tissues were swollen around the stoma site so the same sized feeding tube would not fit. On 2/17/23 at 11:10 AM, V19, Certified Nurse Aide (CNA), stated, I am a new CNA. I just got my CNA a month ago and started working for this facility. I did not receive report the day (R4) fell out of bed. The other CNA's had all left. I know there is a care plan to follow, but I do not know how to see it in our (staff) computerized charting. I had (R4) propped up on his right side in bed. (R4) was laying on the side of the bed facing the door to his room and I was on the opposite side by the window. I was holding (R4) over with one hand and providing incontinence care with my other hand. Apparently, (R4) began to roll towards his side of the bed. (R4) is so big. I am very small built, so I couldn't stop (R4) from rolling off the bed. As (R4) was rolling, I used both hands and was grabbing at everything I could to keep him from falling. I must have grabbed on to the feeding tube, because by the time (R4) hit the floor, his feeding tube was out. It still had the bubble on the end and everything. I had (R4) positioned too close to the edge. (R4) is supposed to have two staff members helping with turning and positioning in bed since he can't do anything for himself. I should have had another CNA in there with me. On 3/17/23 at 3:40 PM, V23, Medical Director, stated, (R4) is a resident who requires total care from the staff. (R4) could never fall out of bed on his own. This is a direct example of staff negligence. That staff member (V19) should have had another person helping. (R4) requires the assistance of two staff member for all cares. This facility is lucky (R4) did not have any fractures or bleed since he is on a significant amount of Coumadin. The facility caused trauma to (R4's) stoma site by ripping out the feeding tube when they (staff) caused him to fall out of bed. There is no excuse for this. 2.) R1's undated Face Sheet documents medical diagnoses of non-Displaced Intertrochanteric Fracture of Right Femur, Liver Cell Carcinoma, Weakness, Chronic Systolic and Diastolic Congestive Heart Failure, Chronic Obstructive Pulmonary Disease (COPD), History of Falling, Ischemic Cardiomyopathy, Abnormalities of Gait and Mobility, and Dizziness. R1's Minimum Data Set (MDS), dated [DATE], documents R1 as cognitively intact. This same MDS documents R1 as requiring extensive assistance of one person for bed mobility, transfers, locomotion on and off unit, dressing, toileting and personal hygiene. R1's Fall Risk Evaluation, dated 1/14/23, documents R1 was at risk for falls. R1's Careplan documents a fall intervention, date 1/25/23, of, Educate (R1) to ask for assistance from dining room to room. This same Care Plan does not include a fall intervention for R1's 1/18/23 fall. R1's Post Fall Evaluation, dated 1/18/23, documents, (R1) trying to ambulate to (R1's) room from dining room and slid out of wheelchair. R1's Interdisciplinary Team Note, dated 1/18/23, documents, Fall Details: Date / Time of Fall: 01/18/2023 4:45 PM Fall was not witnessed. Fall location: dining hall. Activity at the time of fall: ambulating to dining room. Was a safety evaluation completed/documented prior to the fall: No. Did an injury occur as a result of the fall: No. Did fall result in an emergency room (ER) visit/hospitalization : No. Fall Details Note: (R1) was trying to ambulate to his room from the dining hall and slid out of his wheelchair. Conclusion: History of prior falls: Yes. Any similarities between current and post falls: Yes. Prior Fall Note: Resident attempted to ambulate himself and fell . Any additional needs identified: No. R1's Nurse Progress Note, dated 1/23/23 at 11:40 AM, documents, (R1) found lying on floor in the dining room in front of his wheelchair. (R1) alert and verbal, complains of pain on his right side, arm, hip and leg. (R1) was able to move his left arm and leg,but not his right side. (R1) denied hitting his head, (R1) was unable to assist with getting back in wheelchair. Ambulance service called. Paramedics administered Fentanyl injection at the facility. Ambulance service transported resident to hospital. R1's Post Fall Evaluation, dated 1/23/23, documents, (R1) was ambulating without assist in dining room R1's Nurse Progress Note, dated 1/23/23 at 4:15 PM, documents, Writer spoke to nurse at hospital. (R1) admitted due to rght hip fracture. R1's Nurse Progress Note, dated 1/23/23 at 9:53 PM, documents, Fall Details: Date / Time of Fall: 01/23/2023 11:00 AM Fall was not witnessed. Fall location: Dining room. Activity at the time of fall: ambulating without assist. Reason for fall: ambulating without assist Did an injury occur as a result of the fall: Yes. Did fall result in an emergency room (ER) visit/hospitalization : Yes. Contributing Factors: Recent change in environment: No. Was fluid spilled on floor: No. Clutter present on the floor: No. Floor mat was on floor: No. Poor lighting in the area: No. (R1) complains of pain. Pain Description: Right arm, Right Leg, Right Hip Pain: 10/10. Conclusion: Did environmental factors contribute to the fall: No. Did Resident's current medical condition(s) contribute to the fall: No. History of prior falls: Yes. History of falls at the facility. Any similarities between current and post falls: Yes. R1's Right Hip X-Ray Report dated 1/23/23 documents Impression: Near nondisplaced Intertrochanteric Fracture on the Right R1's emergency room report dated 1/23/23 documents (R1) is a [AGE] year old male who presents to emergency department after a fall resulted in a Closed Nondisplaced Intertrochanteric Fracture of the Right Femur. Orthopedics was consulted and will see (R1). R1's Nurse Progress Note, dated 1/27/23 at 6:09 PM, documents, (R1) returned to facility from hospital. (R1) had a closed non-displaced fracture of right femur. Three incisions noted to the right lateral leg. Superior incision on right upper leg has 19 staples, middle incision on lateral upper leg has five staples and incision on lateral side of right knee has eight staples. On 1/16/23 at 12:50 PM, V14, Restorative Lead Certified Nurse Aide (CNA), stated, (R1) required a mechanical lift when he was first admitted . (R1) used that lift for two weeks until about 1/20/23 and was then upgraded to one assist with pivot transfers. I remember (R1) telling me 'I just can't do it. I am too weak' referring to being upgraded. (R1) wanted to stay on the mechanical lift. On 1/17/23 at 3:30 PM, V23, Medical Director, stated R1 had a general decline in health due to advancing disease processes. V23 stated, (R1) had lost a lot of strength and should have had staff assisting him with ambulation. If (R1) fell on [DATE] by walking by himself and falling, then the staff should have care planned that event so it would not happen again. If the staff would have been monitoring (R1) and care planned the 1/18/23 fall, the chances that (R1) would have fallen again on 1/23 the same way would be nil. (R1) may have not gotten the fractured hip on 1/23/23 if the staff were following their fall policies and paying attention to (R1). 3.) R2's undated Face Sheet documents medical diagnoses of Nondisplaced Fracture of Right Clavicle, Moderate Dementia with Psychotic Disturbance and Atrial Fibrillation. R2's Fall Risk Assessment, dated 12/8/22, documents R2 is at risk for falls. R2's Restorative Assessment, dated 1/2/23, documents, (R2) is able to walk with no devices with supervision and verbal cues for direction as needed. R2's Minimum Data Set (MDS), dated [DATE], documents R2 as severely cognitively impaired. This same MDS documents R2 as requiring extensive assistance of one person for bed mobility, transfers, walking in room and corridor, locomotion on and off unit, dressing, eating, toileting and personal hygiene. R2's Nurse Progress Note, dated 1/30/23 at 5:07 PM, documents, (V15) Certified Nurse Aide (CNA) reported that (R2) was on floor in dining room. (R2) has discolored area on right forehead. Neurological assessments initiated. (R2) up walking independently right after this incident R2's Nurse Progress Note, dated 1/30/23 at 5:36 PM, documents, Fall Details: Date / Time of Fall: 01/30/2023 5:00 PM Fall location: Dining room. Activity at the time of fall: ambulating. Reason for the fall was evident. Did an injury occur as a result of the fall: Yes. Injury details: Hematoma to Right Forehead. Did fall result in an emergency room (ER) visit/hospitalization : No. Contributing Factor Note: (R2) self ambulated and tripped in dining room. Conclusion: Any similarities between current and post falls: Yes. Conclusion Note: (R2) self ambulates and has tripped in past. R2's Post Fall Evaluation, dated 1/30/23, documents ,Alerted (R2) was on the floor in the dining room. (R2) assessed, stood back up and continued to ambulate independently. Hematoma to Right Forehead. This same evaluation documents R2 was not sent to emergency room for evaluation. R2's Nurse Progress Note, dated 2/4/23 at 9:32 AM, documents, (R2) was ambulating when noticed that (R2's) right shoulder appeared to not be in alignment with the rest of his upper body. Assessed (R2) and noticed some swelling with a small bruise to the right shoulder area. (R2) did grimace and say ouch when palpating the distal end of right clavicle. R2's X-Ray Report, dated 2/4/23, documents, Impression: Right Clavicle: Fracture of the distal end of the Clavicle. R2's Final Incident Report to Illinois Department of Public Health (IDPH), dated 2/7/23, documents, Incident category: Fall with physical harm or injury. This same report documents, Investigation was conducted and after interviewing staff, it was found that (R2) had fallen on 1/30/23 while ambulating in dining room. On 2/4/23 (R2) was ambulating down hallway from room when (V9) Registered Nurse (RN) noted that (R2) had an abnormality of Right Shoulder. (V9) RN assessed (R2) and noted swelling and bruising to Right Shoulder and while assessing range of motion (R2) said 'ouch'. (R2) unable to give description. (R2) did not have any unusual incident that might have caused the injury aside from the fall on 1/30/23. Staff interviewed were not aware of anything else happening. (R2) stated no one hurt him. There is no evidence of abuse. (R2's) X-Ray results showed non-displaced fracture of distal end of right clavicle. On 2/16/23 at 1:45 PM, R2 was walking in hallway on a different unit than where R2 resides, with no staff present. On 2/16/23 at 12:55 PM, V14, Restorative Lead Certified Nurse Aide (CNA), stated, (R2) walks all over the place. (R2) is supposed to have supervision with ambulation. You have to keep your eyes on (R2) or who knows where he will end up. On 2/16/23 at 2:05 PM, V9, Registered Nurse (RN), stated, (R2) was walking down the hall towards me on 2/4/23. I have been (R2's) nurse plenty of times and I noticed he wasn't holding his shoulders like normal. I asked (R2) if there was anything wrong with his right shoulder because he was just holding it weird. I assessed (R2's) shoulders and that is when he said 'ouch' when I palpated his right shoulder. There was a small bruised area on the top of (R2's) right shoulder. The bruise didn't look fresh but it was hard to tell since it was small. On 2/16/23 at 2:10 PM, V15, Certified Nurse Aide (CNA), stated, I was pushing another resident to the dining room to supper on 1/30/23. I saw (R2) so I told him to follow us to the dining room. (R2) was behind me a few feet. (R2) can walk on his own. (R2) just needs directions where to go. (R2) had bent down to pick a cookie up off the floor and fell . (R2) got a goose egg on his forehead. If I had been able to see (R2) I could maybe have prevented him from falling and breaking his shoulder, but I was in front of (R2). I should have been walking beside (R2) instead of in front of him. I should have been where I could see (R2). On 2/16/23 at 2:45 PM, V16, Licensed Practical Nurse (LPN), stated, I was called by staff to come check out (R2) after because he fell . (R2) was sitting on his bottom on the floor of the area between the two dining rooms. (R2's) forehead area was starting to swell. I started neurological checks, assessed (R2) who had no obvious injury at that time so we (staff) sat him up in a dining room chair. (R2) then got up on his own and walked away. I guess (R2) was not hurt since he got up and walked away. There was no reason to continue the neurological checks. After dinner, (R2) was laying down in bed so we (staff) put ice on (R2's) head. (R2) had a nice sized goose egg. I told the doctor that (R2) had a goose egg on his forehead, and the doctor said 'there was no reason to send (R2) to the emergency room unless he 'lost consciousness'. At the time (R2) fell , I was focused on his head injury, not his shoulder. (R2) could have had an injury but not noticed by the staff, since we (staff) were all focused on the goose egg on his forehead. On 2/17/23 at 3:45 PM, V23, Medical Director, stated, (R2) more than likely got a hairline fracture from the fall on 1/30/23. That is why the staff did not notice directly at that time. (R2) walks all over the place without supervision. (R2) is not supposed to walk without supervision, but I have seen him do it. (R2) does not require hands on assistanc,e but he certainly needs closer monitoring. How are you going to monitor someone who is walking behind you? The staff should have been supervising (R2) more closely. That would have prevented (R2's) major injury of a fractured clavicle. 4.) R3's Undated Face Sheet documents medical diagnoses of Hemiplagia and Hemiparesis following Cerebral Infarction affecting Right dominant side, Dysphagia, Muscle Weakness, Lack of Coordination, Need for Assistance with Personal Care and Anemia. R3's Minimum Data Set (MDS), dated [DATE], documents R3 as cognitively intact. This same MDS documents R3 requires extensive assistance of two people for transfers, total dependence of one person for locomotion on and off unit and extensive assistance of one person for personal hygiene and dressing. R3's Post Fall Evaluation, dated 2/7/23, was initiated but not completed. This same evaluation had categories listed of fall details, contributing factors,education review, physical findings, vital, skin, conclusion which were all completely blank. R3's Electronic Medical Record (EMR) does not document fall, neurological, skin or pain assessments for R3's fall on 2/7/23. R3's Nurse Progress Notes, dated 2/7/23 at 10:30 AM, documents, Fall Details: Fall location: transport bus Activity at the time of fall: (R3) in route to physician appointment. Reason for fall: (R3) wheelchair tipped over during transport. Was a safety evaluation completed/documented prior to the fall: Yes. Date of safety evaluation: 02/07/2023 Safety teaching documented before the fall: No. Did an injury occur as a result of the fall: Yes. Injury details: skin tear/abrasion. Skin Issue: Skin Tear Left Forearm. Skin Issue: Skin Tear Location: Right Elbow Skin Issue: Skin Issue Location: Left Shin. Conclusion: Did environmental factors contribute to the fall: Yes. Environment Factor Note: seatbelt malfunction Did Resident's current medical condition(s) contribute to the fall: No. Conclusion Note: (R3) fell due to environmental causes. On 2/16/23 at 2:30 PM, R3 stated, I was going to an appointment so they (staff) put me in the van that belongs to the facility. (V18) Certified Nurse Aide (CNA)/Transport Aide put me in the van and buckled me in. I know I had a strap over my lap, but couldn't see if (V18) buckled any of the other straps. (V18) hit a huge pothole as she was turning the van into the hospital parking lot. That is when I fell over in my wheelchair. I fell to my right side. I don't think I was hurt, but I was so scared I wet all over myself. I can hold my bladder, but not if I get thrown around like that. I was really scared. They (staff) told me later that one of the straps was loose on the bottom side so that is why I fell over. My daughter is riding with me from now on to make sure I am safe. On 2/17/23 at 7:45 AM, V18, Transport Aide/Certified Nurse Aide (CNA), stated, I was taking (R3) to an appointment that morning. I was turning into the hospital parking lot when I heard a commotion in the back so I looked in my rearview mirror and saw (R3's) wheelchair and (R3) leaning to (R3's) right. (R3) did not fall completely over. I would guess (R3) ended up at about a 45 degree angle to his Right side. I did not see if (R3) hit his head, but I did not see the entire fall. I do not think (R3) hit his head, but I can not say for sure. I noticed (R3) was bleeding a small amount from his Right hand. I got some wet wipes and cleaned off the blood from (R3's) hand. I just lifted (R3's) wheelchair back into position. That is when I noticed that the strap that was supposed to hold down (R3's) wheelchair was loose. That is how (R3) fell over, because the latch on the floor malfunctioned. For some reason the tensioner did not hold tension on the safety belt. After I got (R3) situated again, I continued to drive to the hospital to drop him off. (R3's) daughter met (R3) at the hospital, and I reported (R3's) fall to (R3's) daughter. I did not tell any medical personnel from the hospital about (R3) falling. I got back to the facility and let (V22, Assistant Director of Nurses/ADON) know about the incident. After I picked (R3) back up from the hospital and returned him to the facility, that is when staff obtained a set of vital signs. I did not get any vital signs after (R3) fell . I do not keep the blood pressure cuff or stethoscope on the van. I let (V21, Maintenance Director) know that the seatbelt latch had malfunctioned. I should have called the facility right after (R3) fell in the van. I have been educated on the policy for that now. On 2/17/23 at 2:00 PM, V22, Assistant Director of Nurses (ADON), stated V18, Transport Aide, notified V22 of R3's fall during transport upon V18's return to facility. V22, ADON, stated, (V18, Transport Aide) stated she had seen (R3) fall so I told her since it was a witnessed fall we (staff) did not have to do neurological assessments. After talking with (V18) again about that incident, it is apparent (V18) did not actually see (R3) fall, but heard it, and looked back to see (R3) had already fallen. On 2/17/23 at 2:10 PM, V2, Director of Nurses (DON), stated, There was some confusion about (R3's) fall being witnessed or not. Initially, it was reported that (V18) did see (R3) fall but that was because of the way the questions were asked of (V18). I have educated (V22) on investigative questions and not to assume anything. I have also educated (V18, Transport Aide) on reporting falls as soon as they happen and being clear on reporting if a fall is witnessed or not. With (R3's) fall, (V18, Transport Aide) should have immediately called the facility for guidance. We (facility) should have started and completed the neurological assessments, the post fall evaluation should have been completed, the pain assessment and fall assessment should have been completed, there should have been assessment, treatment and follow up for (R3's) injuries and the notifications were not made timely due to a delay in reporting the fall initially. This was a mess. This is also a learning process for myself and staff so that we (facility) can do better next time. On 2/17/23 at 3:10 PM, V21, Maintenance Director, stated, On the day (R3) fell in the van I was notified after (V19) returned to the facility with the van. I looked at the safety belt system in the van and saw that the latch tensioner on one of the tie downs did not function like it was supposed to. Those latch tensioners run on gears within an outer casing. You can't see the gears. We do monthly inspections on the vans. There is a whole checklist. I had just checked that van a week or so before (R3) fell over. Everything else worked ok then but like I said, there is no way to tell when those tensioners are going bad. It just happens. Unfortunately (R3) fell in the van that day because the equipment was faulty. I am just glad no one was hurt too bad. On 2/17/23 at 3:35 PM, V23, Medical Director, stated the facility should have documented the fall, the neurological assessments, the fall evaluations, injuries and the follow up orders from the minor injury should have been initiated. V23 stated, It may seem like a skin tear but if the licensed staff are not monitoring that area it becomes infected and then requires antibiotics which would all be unnecessary if the staff would follow their policies and do their job. That fall should have been reported immediately to licensed nursing staff who could have directed (V19) on what to do for (R3). Instead (V19) took matters into her own hands and broke a lot of rules. The facility policy titled 'Falls-Clinical Protocol', revised August 2008, states as a part of the initial assessment, the nurse shall assess and document/report the following: vital signs, recent injury, musculoskeletal function, change in cognition or level of consciousness, neurological status, pain, precipitating factors and details on how fall occurred. Based on assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or Subdural Hematoma have been ruled out or resolved. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling.

These Failures require more than one deficient practice statement. A. Based on observation, interview, and record review, the facility failed to follow physician orders, promptly notify the physician of an acute change in condition, complete additional monitoring, and notify the physician of abnormal lab results for residents with a known history of [CONDITION(S)]. This failure affects two of three residents (R93 and R8) reviewed for hospitalization s on the total sample list of 50. These failures resulted in a delay of subsequent treatment, resulting in a 5 day hospitalization for (R93) and a 4 day hospitalization for (R8). B. Based on observation, interview, and record review, the facility failed to identify, assess ,and treat a skin injury, and implement physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in a delay in treatment and R47 experiencing periodic unrelieved pain. Findings include: The facility's undated policy, titled Post [CONDITION(S)] Monitoring and Observation with Implanted A-V Shunt, documents, Policy: rounds will be conducted by the charge nurse at least two times per shift. Procedure: 5- Monitor for excess [CONDITION(S)] and degree of pitting. Monitor for [CONDITION(S)]. The facility's policy, with a revision date of August 2008, titled Change in Condition or Status documents: Policy statement: Our facility shall promptly notify the resident, his or her attending physician and representative of changes in the residents medical/mental condition and/or status. Policy interpretation and Implementation: 1. The Director of Nursing or designee will notify the residents attending physician or On-call Physician when there has been: d- A significant change in the residents physical/emotional/mental condition; e- a need to alter the residents medical treatment significantly; i- instructions to notify the physician of changes in the residents condition. 2: A significant change of condition is a decline or improvement in the residents status that: 1- will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. 4: Notification will be made as soon as possible (within 24 hours of a change occurring in the residents medical/mental/condition or status). In medical emergencies notification should be made as soon as possible after occurrence of the event. 5: The DON or designee will record in the residents medical record information relative to changes in the residents medical/mental condition or status. A. 1) R93's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R93's medical record documents on 6/11/2022, alerted by Certified Nursing Assistant that resident was observed on the floor, resident lying on side gasping for air, lips were blue in color, was cold and clammy, unable to respond to command eyes were wide open, did eventually verbalize help and I can't breathe. 6/11/2022 Resident admitted to (local hospital), diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R93's Emergency Department provider notes, dated 6/11/22, documents, Chief Complaint: patient presents with shortness of breath, Clinical impression: Acute on Chronic [CONDITION(S)]. R93 readmitted to the facility on [DATE]. R93's medical record documents under physician orders: daily weight every day shift for monitoring, start date: 6/17/22, Fluid Restriction of 1,000 milliliters, start date: 6/17/22. R93's Treatment Administration Records dated September 2022 document under Daily weight every day shift for monitoring 6:00 AM to 2:00 PM: 9/1/22: 201.6 (pounds) 9/2/22: 201(pounds) 9/3/22 and 9/4/22 (NA is documented) no weight recorded 9/5/22: 201.8 (pounds)9/6/22: 201 (pounds) 9/7/22: 201 (pounds) 9/8/22: (NA is documented) no weight recorded 9/9/22: 202.4 (pounds) 9/10/22: 202.4 (pounds) 9/11/22: 201.5 (pounds) 9/12/22: 201.5 (pounds) 9/13/22: 202 (pounds) 9/14/22: (blank) No weight recorded 9/15/22: 202.2 (pounds) 9/16/22: 209.6 (pounds) 9/17/22 (NA is documented) no weight recorded 9/18/22: 210.2 (pounds) 9/19/22: 210 (pounds) 9/20/22: 210 (pounds) 9/21/22: 209.5 (pounds) 9/22/22: (NA is documented) No weight recorded 9/23/22: (X is documented) No weight is recorded R93's medical record documents on 9/24/2022 at 5:49 AM, has had a sudden change of condition this morning, alerted writer that patient appeared to have trouble breathing. Patient was anxious, grunting, gurgling, very abnormal lung sounds noted, red in color, breathing fast. Blood pressure: 174/109, Respirations 24, Pulse: 107, Oxygen saturation: 79% Room Air at time of assessment. Patient continued to say hurry help me. Ambulance called. 9/24/22 at 2:06 PM, admitted to the hospital for Acute Chronic [CONDITION(S)]. R93's medical record does not contain documentation R93's physician (V16) was notified of R93's weight gain of 7.4 pounds on 9/16/22, or that R93's weight continued to average 209 to 210 pounds from 9/16/22 through 9/21/22. R93's medical record did not contain documentation R93's lung sounds were being monitored or if R93 was being assessed or monitored for [CONDITION(S)] from 9/16/22 through 9/23/22, after R93 had a 7 to 8 pound weight increase from normal average weight. R93's Emergency Department provider notes, dated 9/24/22, document, Chief Complaint: patient presents with shortness of breath, Clinical impression: 1- Acute on Chronic [CONDITION(S)], Unspecified Heart Failure type. On 10/31/22 at 3:03 PM, V16, Physician, stated A 3-5 pound weight gain in one day for patient with CHF ([CONDITION(S)]) should be reported to me. Assessments for CHF/symptoms is variable for each patient, but (staff) should be reporting weight changes, [CONDITION(S)], and shortness of breath. On 11/01/22 at 11:00 AM, V2, Director of Nursing, stated, When a resident is a daily weight it should be documented on the Treatment Administration Records. V2 confirmed if weights are not documented, the staff forgot to record or complete the task. V2 confirmed weights were not recorded for R93 on 9/3/22, 9/4/22, 9/8/22, 9/14/22, 9/17/22, 9/22/22 and 9/23/22. V2 stated the physician should have been notified of (R93's) 7 to 8 pound weight gain and additional monitoring of (R93's) lung sounds and monitoring for [CONDITION(S)] should have been done, due to R93's history of [CONDITION(S)]. A.2.) On 10/24/22 at 10:57 AM, R8 stated R8 has pain due to [CONDITION(S)] to R8's bilateral lower extremities. R8 stated R8 readmitted to the facility about a week ago, after being hospitalized for a heart condition and [CONDITION(S)]. At 11:04 AM, V9, Certified Nursing Assistant, pulled back R8's blankets. R8's bilateral lower extremities were edematous and swollen from feet to calves. R8's undated diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's Care Plan revised on 5/25/22 documents R8 has CHF and includes interventions:Check breath sounds and monitor/document for labored breathing. Monitor/document for the use of accessory muscles while breathing. Give cardiac medications as ordered. Monitor/document/report to MD (physician) PRN (as needed) any s/sx (signs/symptoms) of [CONDITION(S)]: dependent [CONDITION(S)] of legs and feet, periorbital [CONDITION(S)], SOB (shortness of breath) upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of the lungs, Orthopnea, weakness and/or fatigue, increased heart rate ([CONDITION(S)]) lethargy and disorientation. R8's 10/25/22 Order Summary Report documents an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . (pounds) or more in 1 day or 5 lbs. or more in 1 week. This report documents R8's diet order as NAS (No Added Salt) diet Regular texture, Regular consistency, Avoid high cholesterol foods, offer diet condiment and diet drinks for diet. R8's October 2022 Treatment Administration Record documents R8's weights as 272.3 lbs. on 10/14, 297 lbs. on 10/15 (26.7 lb gain in 1 day), 297.6 on 10/16, and 297.7 on 10/17. There are no documented weights in R8's medical record for 10/8, 10/11, 10/18, and 10/20/22. R8's Nursing Notes document: On 10/17/2022 at 11:32 AM, R8 had weight gain with worsening swelling to left breast, and 3+ pitting [CONDITION(S)] to bilateral lower extremities. This information was faxed to R55's Physician (V16). There are no documented assessments of R8 on 10/15/22, 10/16/22, or after 10/17/22 at 11:32AM, until 10/18/22 at 9:20 AM. There is no documentation R8's physician was notified of R8's [CONDITION(S)] and weight gain prior to 10/18/22. On 10/18/2022 at 9:20 AM, V28 (Cardiologist) office was notified of R8's weight gain, 3+ pitting [CONDITION(S)] to R8's bilateral upper and lower extremities, and left breast and facial [CONDITION(S)]. R8 complained of having a wheezing feeling in R8's chest and shortness of breath off and on. Lung sounds were diminished on the left side. On 10/18/22 at 10:58 AM, orders were received to give additional doses of [MEDICATION(S)] (diuretic) for the next two days and obtain Brain Natriuretic Peptide (BNP), Magnesium, and Basic Metabolic Panel (BMP). There are no documented assessments of R8 until 10/19/22 at 6:23 PM, when R8 complained of nausea and not feeling well, and R8 was transferred to the local hospital. R8's BMP, dated 9/23/22, documents R8's BUN (Blood Urea Nitrogen) was 51 (high), and Creatinine was 2.3 (high). There is no documentation R8's physician was notified of these laboratory results. R8's Nursing Notes document: On 9/24/2022 at 10:14 PM, R8 complained of chest pain/tightness and was transferred to the hospital. R8's After Visit Summary for hospital stay 9/25/22-10/3/22 documents Acute Exacerbation of CHF ([CONDITION(S)]) and Acute Kidney Injury as the reason for R8's hospital admission. This summary documents orders to obtain CBC and BMP by 10/9/22. There is no documentation these laboratory orders were implemented prior to 10/12/22. R8's CBC (Complete Blood Count) and BMP, dated 10/12/22, document R8's Hemoglobin was 9.1 (low), Hematocrit was 30 (low), White Blood Cell count 2.7 (low), BUN was 37 (high), Creatinine was 2.3 (high), and Estimated Glomerular Filtration Rate was 21 (low). There is no documentation R8's physician was notified of the laboratory results on 10/12/22. R8's Renal Panel on 10/18/22 documents R8's Sodium was 129 (low), BUN was 54 (high) and Creatinine was 2.3 (high). R8's After Visit Summary, dated 10/22/22, documents CHF Exacerbation as R8's hospital diagnosis. This summary documents discharge instructions for a 2000 milliliter (ml) fluid restriction. There is no documentation that R8's order for a fluid restriction was implemented. On 10/25/22 at 12:54 PM, V7, Registered Nurse ,reviewed R8's weights and nursing notes. V7 confirmed R8's weight gain noted on 10/15/22. V7 stated V7 was the nurse on 10/17/22, and obtained R8's weight on 10/17/22. V7 stated V7 believed R8's weight was accurate, and there were no reported problems with the scale. R8 had general weight gain and [CONDITION(S)] to bilateral lower extremities and left breast that day. V7 did not hear back from R8's physician on 10/17/22, so V7 passed the information on in report. V7 stated physician notification is documented in a nursing note and daily weights are recorded on the Treatment Administration Record. V7 confirmed there was no documentation V28, Cardiologist, or V16, Physician, were notified of R8's weight gain identified on 10/15/22 until 10/18/22 (3 days later.) On 10/31/22 at 11:58 AM, V2, Director of Nursing, stated, (R8) is not on a fluid restriction, and the nurses are to review hospital discharge orders to ensure implementation of the orders. The nurse managers are suppose to follow up on the orders. V2 stated nurses should assess symptoms of CHF, document assessments in the nursing notes, and notify the physician the day the weight gain is identified. V2 confirmed there are no assessments of R8's CHF symptoms/monitoring from 10/15/22 until 10/17/22, and no documentation the physician was notified of R8's symptoms prior to 10/18/22. On 11/01/22 at 11:05 AM, V2 confirmed R8's CBC and BMP ordered to be completed by 10/9/22 were not drawn until 10/12/22. V2 stated there is no documentation R8's physician was notified of R8's laboratory results on 9/23/22 and 10/12/22. On 11/1/22 at 11:58 AM, V25, Physician Assistant (at V28 Cardiologist office), stated: (V25) evaluated (R8) on 10/22/22, while (R8) was in the hospital. Ideally, the facility should be monitoring (R8's) weight daily, and reporting a gain of 2 lb or more in a 24 hour period. (R8) has been having problems with keeping fluid off. A fluid restriction of 2000 ml per day was started during hospital stay in October, and should still be a current order. (R8) goes into acute kidney injury when we try to [MEDICATION(S)] (R8), so we thought a fluid restriction may help. The facility should be monitoring/assessing (R8's) labs regularly, and (R8's) weight, [CONDITION(S)], and oxygen saturation at least daily to identify fluid volume overload and CHF exacerbation. Ideally they should notify our office the same day (R8's) symptoms/changes are identified. It may have been too late when the diuretic was increased in order to take effect and prevent (R8's) hospitalization (on 10/19/22). If notified sooner, it is hard to say, but may have prevented (R8's) hospitalization . (R8) has bad kidneys, [CONDITION(S)] (Hypertension), and Renal Disease that affects (R8's) kidney function and contributes to CHF exacerbation. B.1) On 10/24/22 at 1:58 PM, R47 was wearing a foam boot to R47's left foot. R47 stated R47 has a pressure point to R47's heel, and complained of pain to the area. R47 stated R47 was suppose to be getting [MEDICATION(S)] two weeks ago, but that never happened and Tylenol doesn't cut it. R47 stated about two weeks ago, R47 bumped R47's right ankle on R47's wheelchair causing a skin tear. R47's right posterior ankle contained an adhesive dressing. R47 removed the dressing exposing a small pea sized open area. There was a scabbed area to R47's right outer ankle. R47 stated R47 just received the foam boot today. R47's Minimum Data Set, dated dated [DATE], documents R47 is cognitively intact, and requires extensive assistance of one staff person for dressing. R47's Care Plan revised 9/22/22 documents R47 Has actual or risk for impairment to skin integrity related to: [CONDITION(S)] (Chronic Obstructive Pulmonary Disorder), DM 2 (Type 2 Diabetes Mellitus), Chronic respiratory failure with [CONDITION(S)], [CONDITION(S)], sleep apnea with [CONDITION(S)], usage, fragile skin, bruises easily from chronic steroid use for [CONDITION(S)]. Dry calloused feet. Hx (history) of or actual DTI (Deep Tissue Injury) to heel. Interventions include: (R47) to wear offloading boot while in bed as tolerated. Treat per orders. R47's Skin & Wound Evaluations document: On 9/2/22 R47 asked the nurse to look at R47's foot and R47 said that it felt like R47 had stepped on a nail. A left heel Deep Tissue Injury (DTI) was noted, and measured 2.7 centimeters (cm) long by 3.6 cm wide. Skin protectant was applied and R47 was given an offloading boot. On 9/19/22 R47 was compliant with wearing the pressure reliving boot. On 9/27/22 the DTI was callous like and measured 0.4 cm by 0.5 cm. On 10/24/22 the wound measured 0.7 cm by 0.5 cm. R47's Wound Evaluation & Management Summaries, recorded by V27, Wound Physician, document the following: On 10/3/22 V47's initial evaluation of R47's wound documents the left heel wound as a partial thickness diabetic wound that measured 3 cm by 2 cm. V27 ordered a foam dressing to be applied twice weekly. On 10/11/22 R47 had neuropathic pain to the heel. V47 ordered a [MEDICATION(S)] 4 % patch to be applied to the left heel daily, on for 12 hours then off for 12 hours. On 10/17/22, the wound measured 0.6 cm by 0.4 cm by 0.1 cm deep. [MEDICATION(S)] 4 % patch is listed as the primary dressing. There is no documentation R47 is noncompliant with wearing a pressure relieving boot, or R47's skin injuries to the right ankle were identified, assessed, and reported to V16, Physician, to obtain treatment orders. R47's October 2022 Treatment Administration Record (TAR) documents R47's skin was assessed twice weekly and R47's skin was intact. The twice weekly wound dressing was not implemented until 10/13/22 (10 days after ordered). V27's [MEDICATION(S)] order was not initiated as ordered on 10/11/22 until 10/25/22 (14 days later.) R47's October 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R47's September 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/31/22 at 10:22 AM, R47 was lying in bed. R47 was wearing a foam boot to the right foot, and there was no boot on the left foot. V7, Registered Nurse, pulled back the [MEDICATION(S)] patch on R47's left heel exposing a dry, dark, scabbed area. V7 stated V7 was not aware R47 has any other wounds. V7 confirmed R47 has scabbed areas to the right outer and posterior ankle. On 10/31/22 at 10:24 AM, V7 stated, Generally, if there is an open wound we notify the physician, obtain treatment orders, and document an assessment of the area. V7 confirmed there is no documentation or treatment orders for R47's right ankle wounds. On 10/31/22 at 3:28 PM, V27, Wound Physician, stated, The primary cause of (R47's) left heel wound is diabetes and not pressure. (R47) should be wearing a pressure relieving boot to the left foot. (R47) has neuropathic pain to the wound and the [MEDICATION(S)] has helped. The facility has access to (V27's) notes within 24 hours of (V27's) visit, and (V27) expects the orders to be implemented within 24 hours. On 11/1/22 at 11:31 AM, V8, Registered Nurse, stated V8 rounds with V27, Wound Physician, weekly, and V20, Wound Nurse, had previously been rounding with V27. V20 has been working from home, and implements the wound treatment orders. V20 updates the residents' record and then notifies V8. V8 stated R47's left heel wound started as a callous, and a wound dressing was initiated on 10/13/22. V8 confirmed there was no treatment order for R47's left heel wound prior to 10/13/22. V8 confirmed the [MEDICATION(S)] patch was ordered on 10/11/22, and not implemented until 10/25/22. V8 stated: R47 is suppose to wear a boot to the left foot, but (R47) does (R47's) own thing. I (V8) have educated (R47). Skin assessments are done by the nurses twice weekly and recorded on the TAR. The floor nurses are responsible for identifying wounds and notifying the physician to obtain treatment orders. V8 was not aware R47 has skin tears to the right ankle. R47 is alert and oriented times 3 (person, place, time). The facility's Pressure Ulcers/Skin Breakdown- Clinical Protocol revised August 2008 documents: The nurse shall document an assessment of residents' skin conditions including wound stage, measurements, and characteristics. The physician will authorize pertinent orders related to wound treatments, including pressure redistribution surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc. (etcetera), and application of topical agents.

Based on interview and record review, the facility failed to prevent falls with injuries for three residents (R4, R6, R7) of four residents reviewed for falls in the sample of four. This failure resulted in R7 rolling out of bed and sustaining a right frontal scalp laceration, requiring sutures. Findings include: 1. R7's undated Medical Diagnoses document R7's diagnoses as: History of Falling, Mild Cognitive Impairment, and Muscle Weakness. R7's MDS, dated [DATE], documents R7 as not cognitively intact, requires extensive assistance of two person physical assist for bed mobility and extensive assistance for personal hygiene. R7's Fall Risk Evaluation, dated 8/19/22, documents R7 as a high fall risk. R7's Care Plan, dated 8/22/22, documents R7 is at risk for falls related to deconditioning, poor communication/comprehension, and unaware of safety needs. R7's Emergency Care Center After Visits Summary, dated 8/26/22, documents R7 sustained a right frontal scalp laceration requiring sutures. The facility's Fall Report, dated 9/1/22, documents V7, Certified Nursing Assistant/CNA was washing R7, and turned around to grab a towel and R7 rolled off the bed, sustaining a forehead laceration. On 9/7/22 at 10:17 AM, V2, ADON (Assistant Director of Nursing) stated R7 fell because V7 turned away from R7. 2. R4's undated Diagnoses page documents R4's diagnoses as: Difficulty Walking, Muscle Weakness, Age-related [CONDITION(S)] without current pathological fracture, Other Abnormalities of Gait and Mobility. R4's Minimum Data Set (MDS), dated [DATE], documents R4 as cognitively intact, requires extensive assistance of one physical assist for transfers and toileting, and is not steady and can only stabilize self with staff assistance. R4's Care Plan dated, 7/31/22, documents R4 ambulates using a two wheeled walker and gait belt, provide walker and gait belt (for R4). The facility's Fall Report, dated 8/17/22, documents V8, Certified Nursing Assistant (CNA), was pushing R4 out of the bathroom, and R4 fell forward onto the floor onto R4's face. R4's Hospital Records. dated 8/18/22, document for the cervical spine, a small density adjacent to the anterior inferior aspect of C6 (cervical vertebra), mild prevertebral soft tissue prominence, bony irregularity at the anteroinferior endplate of the C6 vertebra, findings concerning for acute avulsion fracture. These same records document a small laceration to upper underside of upper lip, nasal deformity, signs of injury and nasal tenderness present; angulation bilateral nasal bone consistent with age indeterminate fracture, new since 2013, correlate with symptoms and point tenderness. On 9/7/22 10:27 AM, V8, CNA, stated V8 first took R4 to the bathroom, helped R4 to the toilet, left R4 in the bathroom by R4's self, and had R4 turn the call light on when done. V8 stated when V8 came back, V8 transferred R4 from the toilet to the wheelchair with a gait belt and one assist, and as V8 was pushing R4 from the bathroom in the wheelchair, R4 just fell over to the floor on R4's face. V8 stated V8 is not sure if R4 has a history of falls, if there are care plans at the nurses station that all staff have access to, but V8 has not looked at R4's care plan. On 9/8/22 at 10:10 AM, R4 stated a gait belt was not used to assist R4 when R4 fell on [DATE], and they never use a gait belt with R4. On 9/8/22 at 12:40 PM, V1, Administrator, stated V1 believes the resident (R4) when R4 said R4 did not have a gait belt on R4 for the fall on 8/17/22. 3. R6's undated Medical Diagnoses document R6's diagnoses as: Morbid (severe) Obesity due to excess calories, [CONDITION(S)] and [CONDITION(S)] affecting left non-dominant side, Muscle Wasting and Atrophy, Primary Generalized [CONDITION(S)], Age-Related [CONDITION(S)] with current Pathological Fracture, Muscle Weakness, Other Secondary Scoliosis, Charcot's Joint. The facility's Fall Report, dated 7/30/22, documents R6's left foot was not on the floor board of the mechanical lift, and the lift strap was not placed correctly on R6 during a transfer. The facility's Employee Disciplinary Report, dated 7/30/22, documents nature of incident as disregard for resident safety and failure to follow instruct/procedures, with V5, Certified Nursing Assistant (CNA), as the recipient of the discipline. Employee comments on this same report document V5 as stating, I'm sorry, tell them it was my fault. R6's MDS, dated [DATE], documents R6 is cognitively intact. R6's Fall Risk Evaluation, dated 7/30/22, documents R6 as a fall risk. R6's Care Plan, dated 7/31/22, documents R6 is at risk for falls due to decreased physical mobility and weakness. R6's Treatment Administration Record (TAR), dated 8/1/22 through 8/31/22, documents R6 receiving treatments to R6's left lower extremity 7/31/22 through 8/24/22. On 9/7/22 at 10:50 AM, V2, Assistant Director of Nursing (ADON), stated the CNA, V5, transferred R6 improperly for the sit to stand lift. R6 was not put on the sit to stand correctly, causing R6 to be brought to the ground receiving an abrasion to his lower left extremity. V2 stated V5 received a disciplinary write up, but then V5 just quit. V5 was unable to be reached as V5's phone was disconnected. On 9/8/22 at 3:00 PM, R6 stated, I was not on the lift very good and was slipping out. I don't know what was wrong, there has not been any problems doing this before. R6 also stated R6 got a cut on R6's lower leg. The facility's Falls and Fall Risk Management policy, Revised August 2008, documents the staff will identify interventions to the resident's specific risks and causes and to try to prevent the resident from falling. The facility's undated Mechanical Lift Transfers policy documents the procedure is to follow the manufacturer's instructions for the specific type of mechanical lift and to use two staff members when transferring a resident on sling mechanical lift.

Failures at this level required more than one deficient practice statement. A. Based on interview and record review, the facility failed to complete root cause analyses of falls and implement fall interventions for one of four residents (R1) reviewed for falls on the sample list of eight residents. These failures resulted in R1 falling and suffering a displaced, impacted fracture of her left femoral neck. B. Based on observation, interview, and record review, the facility failed to adequately monitor the exit to a courtyard to ensure resident smoking was supervised for two of three residents (R4 and R5) reviewed for smoking in the sample list of eight residents. Finding Include: A. R1's Minimum Data Set, dated dated [DATE], documents R1 is severely cognitively impaired, incontinent of bowel and bladder, requires assist of one staff for activities of daily living, exhibits wandering behavior which puts her at significant risk of getting to a potentially dangerous place. R1's Care Plan, updated 5/22/22, documents, (R1)is at risk for falls related to: history of falls; R1 uses the closet door to assist self into standing position. with an intervention to keep in high visual areas as allows. R1's progress note, dated 4/7/22 at 1:13AM, documents, entered (R1's) room and saw (R1) sitting on floor next to wheelchair. R1's progress note, dated 4/18/22 at 6:04PM, documents, heard (R1) yelling for help went into room and found (R1) sitting in front of her wheel chair with cushion on top of her. R1's progress note, dated 4/26/22 at 2:56PM, documents, (R1) was attempting to use the toilet and her wheel chair was not locked and she slipped and sat on the floor. R1's progress note, dated 5/7/22 at 2:37PM, documents, (R1) was up in her wheel chair sitting in front of bathroom door when she slid out of wheel chair. When arrived noted (R1) had a bag, a can of chips, and other items behind her in the wheel chair. Removed these items. R1's 4/7/22, 4/18/22, 4/26/22, and 5/7/22 falls were documented, but no root cause analysis was completed to determine resident centered interventions to prevent falls in the future. R1's progress note, dated 5/19/22 at 3:19PM, documents, Resident sent to (local hospital) emergency room for evaluation after a fall causing Left hip and leg pain Power of Attorney and Medical Doctor aware, (ambulance) arrived and transported resident at 12:50pm. R1's progress note, dated 5/19/22 at 4:09PM, documents, admitted to (hospital) diagnoses: Closed displaced fracture of left femoral neck, Acute Compression fracture of body of thoracic vertebra, age unknown. R1's incident report by V1, Administrator documents Nurse heard R1 holler out. Went to R1's room and found R1 lying on the floor. R1's root cause analysis form, dated 5/19/22, documents the root cause was, (R1) was reaching behind her for a drink she sits behind her in her wheelchair and slid out of the wheelchair. The new intervention implemented was (R1) was moved closer to the nurse's station for increased monitoring. On 6/16/22 at 3:30PM, V1, Administrator, stated, The intervention to move R1 closer to the nurse's station does reflect we recognized (R1) needed more supervision. I see now that if we had done that following one of the previous falls we might have been more successful in preventing other falls. The facility's policy Falls and Fall Risk Managing, dated August of 2008, states 3. Identifying the cause of a fall or fall risk. c. The staff will continue to collect and evaluate information until they either identify the cause or the cause cannot be found. B. The facility's Incident Report form, dated 5/30/22 at 2:21PM, documents, It was reported that (R4 and R5) went out at an unscheduled smoking time. Staff went out at the end of an altercation. R4 reported that R5 kicked him. R4 was noted to have a small cut on his right toe. R4's Minimum Data Set (MDS), dated [DATE], documents R4 is cognitively in tact. R4's Smoking Assessment, dated 5/11/22, documents that he can smoke cigars with staff supervision. R5's Minimum Data Set (MDS), dated [DATE], documents R5 is moderately cognitively impaired. R5's smoking Assessment, dated 2/21/22, indicates he requires:Smokers Apron, Assist with Lighting Cigarette, Assist with Holding Cigarette, Supervised Smoking, and Cigarettes and Lighter Kept in Med Room. On 6/16/22 at 4:09PM, R4 stated, I did sneak out and smoke alone sometimes. I don't get along with (R5) and yes we got in a screaming match (5/30/22). We were both mad and he's crazy and he kicked me. I got a little scrape, but it was nothing. I was kicking too. It's really easy to get out in the courtyard without staff. There is a big red button right on the outside of the door and if you turn off the alarm no staff know you're out there. On 6/16/22 at 4:15PM, R5 stated, (R4) called me a name and both of us had sneaked out without the staff to smoke. Well one thing led to anther and we both kicked at each other. The workers heard us and broke it up. It's easy to get out that door. All ya gotta do is push the big red button. On 6/16/22 at 4:22PM, surveyor opened the door to the courtyard and pushed the big red button. The alarm was silenced, and by 5:00PM no staff had checked the door. On 6/16/22 at 5:05PM, V1, Administrator, stated, I was not aware that door alarm could be shut off so easily. It is very hot outside and it could be dangerous for residents to go out there alone.

Based on observation, interview, and record review, the facility failed to supervise residents at risk for elopement, failed to maintain a functional door alarm/electronic monitoring system, and failed to implement additional safety precautions during the alarm system failure for fifteen (R1-R15) of fifteen residents reviewed for elopement on the sample list of 15. This failure resulted in R1, a resident with severe cognitive impairment, exiting the facility alone and undetected by staff on 6/28/21 at 5:34 am. R1 was found 0.9 miles from the facility walking on Route 48 (a three-lane highway) on 6/28/21 at 5:57 am. During the time of the elopement, R1 sustained a witnessed fall, which resulted in a two-centimeter laceration to R1's left eyebrow which required sutures. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 7/6/21, the facility remained out of compliance at a Severity Level 2. The facility has had receiver boxes installed on all door alarm monitors, and the electronic monitoring system is now fully functional. The facility has also provided education to all staff on the Electronic Monitoring System and is in the process of doing daily checks to ensure the Electronic Monitoring System remains functional. Findings Include: The facility Elopement and Search Policy, dated February 2014, documents this policy is a method for protecting residents who are at risk for elopement and for conducting an organized search for a resident who cannot be located. All nursing personnel are responsible for knowing the whereabouts of residents for which they are assigned. Residents are not permitted to leave the building alone unless a physician order is present. Residents who have been identified as cognitively impaired and who have been assessed as an elopement risk will be provided with an elopement prevention device (arm or ankle bracelet), or be placed in an area of the facility that has a door alarm device with audible sound, or on a secured/locked unit. All personnel are responsible for promptly reporting/replacing malfunctioning elopement prevention devices. Maintenance is responsible for fixing/replacing any exit doors that do not alarm. Appropriate security measures will be implemented to assure the resident is monitored to prevent reoccurrence of elopement. R1's Elopement Report, dated 6/28/21 by V8, RN (Registered Nurse), documents at 5:34 am, another hall called {station 2} and alerted staff there was a door alarm on station 4 sounding, and staff needed to check on R1. Staff immediately checked R1's room as well as the entire station 2 {where R1 resides}. Staff proceeded down to station 4 to check the door alarm that was sounding. A sweep of the facility campus, as well as the other halls were checked. R1 was seen approximately 5-10 minutes prior to receiving the call. At 5:57 am, V8 was notified R1 was with staff. When V9, CNA (Certified Nursing Assistant), found R1 outside of the building, R1 was ambulating. V9 called out R1's name, and R1 turned around, lost balance and fell to the ground, at which time R1 hit R1's head on the ground causing a laceration to R1's left eyebrow area. R1's Elopement Report, dated 6/28/21, includes a note from V1, Administrator, documents after interviewing staff and reviewing R1's medical record, R1 is alert with confusion. R1 wandered and walked down station 4 exiting outside door. Station 3 nurse (V10, Licensed Practical Nurse, LPN) heard the alarm sound when exiting another resident's room. Staff immediately went to station 4 exit door and had a head count performed, which was off by 1. Staff immediately went outside searching for R1. R1 was nowhere on facility grounds. Staff got in cars and found R1 walking on a nearby road. Staff called R1's name which startled R1. When R1 turned to look, R1 fell . R1 was brought back to the facility. A head to toe assessment performed, to reveal a small cut to forehead, which was cleansed and bandaged. R1 was put on 1:1's and a staff member is [NAME] station 4 {where the electronic monitoring monitor is located}. R1's MDS (Minimum Data Set), dated 5/20/21, documents R1's BIMS (Brief Interview for Mental Status) Score as 5, which indicates severe cognitive impairment. This MDS also documents R1 requires supervision for ambulation, and wanders. R1's Care Plan, dated 6/15/21, documents R1 has Dementia and has a behavior problem of wandering and exit seeking, with an intervention to place an electronic monitoring bracelet on R1. On 6/28/21 at 10:45 am, R1 was not in R1's room. V4, CNA (Certified Nursing Assistant), assigned to station 2, where resident resides, stated V4 was unsure where R1 is; R1 wanders all over, you might want to check on station 3, that is where he was just moved from. On 6/28/21 at 10:48 am, R1 was observed ambulating in station 3, without 1:1 supervision as there were no staff in the area. R1 had a bandage over R1's left eyebrow area. R1 stated R1 hit R1's head on R1's truck yesterday, and that is why R1 had the bandage covering R1's left eye. R1 did not recall eloping from the facility or getting into a car with a staff member. On 6/28/21 at 11:10 am, V8, RN (Registered Nurse), stated R1 is normally up all night pacing the halls. Around 5:20 this morning, (R1) was at the nurses station. (R1) was pacing as usual. At 5:34 am, I (V8) got a call from someone on station 3, not sure who, that called and stated the door alarms were sounding on station 4, and that we (facility staff on station 2) needed to make sure (R1) was here. I (V8) had everyone start to do head checks and I (V8) went to station 4. The exit {door} on station 4 was the door that was sounding. I (V8) announced over the speaker to do a head count and I (V8) went outside and walked around the facility to see if I (V8) could find (R1). (R1) was not in the facility nor outside so myself (V8), (V9 CNA (Certified Nursing Assistant)), and (V10 LPN (Licensed Practical Nurse)) got in our cars and drove around looking for (R1). V8 stated at 5:57 am, V9 called V8 to report V9 had located R1 on Route 48. V9 also reported to V8 when V9 called R1's name, R1 turned around and fell , receiving a laceration to R1's left eyebrow. V8 stated R1 is confused and oriented to R1's name only. R1's Progress Notes, dated 6/28/21, documents R1 is picking at the wound closure strips that had been applied to R1's left eyebrow, as a result of the fall that happened after R1 eloped from the facility, and they are no longer keeping the laceration closed. R1 was sent to the hospital and returned with six sutures in place. The facility undated Listing of Residents at Risk for Elopement documents R1-R15 are at risk and utilize an Electronic Monitoring Device. A facility Work Order #4038, dated 3/25/21, documents the monitors for the electronic monitoring system are not working. An Email Communication provide by the facility, from V11, Electronic Monitoring Contractor, dated 6/28/21, documents on 5/4/21, a new Black Box Transmitter was installed at the facility and an additional six receivers were ordered. On 6/28/21 at 11:24 am, V3 stated the receivers that were ordered are what will make the station monitors work with the new black box communicator. Until then, even with the new black box {on station 4}, the monitors on the stations don't work. At this time, V3 also confirmed that the facility electronic monitoring system has not been fully functional since 3/25/21. On 6/28/21 at 11:02 am, V3, Maintenance Director, stated the facility recently got a new main alarm communicator box for the electronic monitoring system due to the previous one no longer working, but the new communicator box does not communicate with the other alarm boxes on the different Stations {parts of the building} like the previous one did. V3 stated the only way to know if an alarm for the electronic monitoring system is alarming {to show the door has opened}, is if you are on that station and can hear it, or if you are on station 4 looking at the alarm communicator, since the monitors on the other stations aren't working. On 6/28/21 at 12:55 pm, V8, RN, stated the monitors on the walls should be on and then when a resident who is an elopement risk gets close to them or tries to open the door, the monitor will tell us which door is alarming and which resident caused it to go off. V8 stated the monitors have not been working for awhile. Had the monitors been working, I (V8) would have known immediately this morning that the door was sounding and I (V8) could have responded but I (V8) couldn't hear the door {alarm} on station 4, from here on station 2 (across the building). Station 4 is currently closed so no staff {are} down there. The only way station 3 heard it this morning is because it was quiet at 5:30 am. V8 stated nothing new had been implemented by the facility for resident safety while the electronic monitoring system wasn't functioning correctly. On 6/28/21 at 1:10 pm, V12, LPN, stated the electronic monitoring system has not worked in months. You can only hear the alarms on your station. V12 also stated, it wasn't until after this morning's elopement {by R1}, that they {facility} initiated every hour check sheets for us to fill out on the resident location for those residents who are at risk for elopement. On 6/28/21 at 1:25 pm, there was no staff on station 4 monitoring the electronic monitoring system monitor. On 6/28/21 at 1:30 pm, V13, QA (Quality Assurance) Nurse, stated the electronic monitoring system monitors were not working and haven't worked since 3/25/21, and no other interventions were put into place for resident safety. On 6/28/21 at 1:32 pm, V1, Administrator, confirmed the electronic monitoring system had not been fully functional since March 2021 due to waiting on parts to make the electronic monitoring system monitors work. On 6/28/21 at 1:38 pm, V2, DON (Director of Nursing), stated V2 had been off work from February - May 2021, but upon V2's return, V2 was made aware that the electronic monitoring systems monitors did not work and that the facility was waiting on parts for it. V2 explained the audible alarm at the door itself still worked but that the monitors on the floor (hallways and stations) didn't work expect for on station 4, so unless you were in close proximity to the actually door that had been alarmed, staff would not be able to hear the alarm sounding. V2 stated no new safety measures were put into place while the monitors were down. V2 stated V2 had been made aware the morning of 6/28/21 that R1 had eloped from the facility, and made it to the roadway (Route 48) but was unsure of the exact location R1 was found. On 6/28/21 at 1:42 pm, V14, SSD (Social Service Director), stated when R1 first came to the facility, R1 would wander around, but not try to exit, but this past week, R1 has been exit seeking, and trying to get out. V14 confirmed the electronic monitoring system has not been fully functional since March 2021 and stated no other systems were put into effect at that time for resident safety and monitoring of residents at risk for elopement. On 6/28/21 at 2:22 pm, there was no staff on station 4 monitoring the electronic monitoring system monitor. On 6/28/21 at 2:32 pm, V9, CNA, stated V9 was at station 2 when V9 was alerted that a door alarm was sounding so staff needed to make sure all of our residents were in their rooms. V9 stated V9 could not hear an alarm sounding. When we realized R1 was not in R1's room, (V8, RN) immediately announced overheard that a head count needed to happen. Some people stayed inside looking, while others went outside looking on the property and others left in their cars. V9 stated V9 left in V9's car. I rode around, and rode around, and finally saw (R1). (R1) was walking down the main road. V9 stated R1 was walking south and was by a stoplight and there were cars driving past {R1} and nobody even stopped until I (V9) yelled (R1's) name and (R1) fell . I (V9) pulled over to the side of the road and then a car stopped to help, but I (V9) told them {people in the car} that I (V9) didn't need their help. V9 stated R1 received a laceration above R1's left eye during the fall. V9 was unable to state exactly where R1 was located due to not knowing the names of the road, so at 3:17 pm, observations were completed with V9 on R1's whereabouts, which was at the intersection of Route 48 and Rock Springs Road, 0.9 miles from the facility. This location is a busy, three lane state highway with a railroad running parallel to the road, and a speed limit of 40 MPH (miles per hour). In order to get to get to this location on foot, R1 would have had to either walked on the road from the nursing facility, or walked through the properties of the surrounding the nursing facility which is located in a densely wooded neighborhood, which V9 confirmed. On 6/29/21 at 8:45 am, there was no staff on station 4 monitoring the electronic monitoring system monitor. On 6/29/21 at 9:10 am, V3, Maintenance Director, stated the parts to make the hall and station monitors work came in and V3 installed them during the afternoon of 6/28/21, but that the electronic monitoring system monitors are still not working. An Immediate Jeopardy situation was identified on 6/29/21. The Immediate Jeopardy was identified to have begun on 3/25/21 when the facility monitors for the electronic monitoring system were no longer functional. The facility did not implement additional measures for supervision and safety of the residents. On 6/29/21 at 3:08 pm, V1, Administrator, and V2, DON, were notified of the Immediate Jeopardy situation. On 7/6/21 between 9:20 am - 10:00 am, the surveyor confirmed through observation, interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. V1 provided a receipt of work completed by the Vendor that documents the Vendor installed the receiver boxes for the Electronic Monitoring System on 6/29/21, and the Electronic Monitoring System is now fully functional. 2. All alarmed exterior doors were checked with V18, Floor Maintenance. All door alarms and monitors are functioning and communicating with the main system monitor located on station 4. 3. V1 provided documented inservice training to all employees regarding the Electronic Monitoring System Policy and Procedure. 4. V1 provided audit forms for daily monitoring of the Electronic Monitoring System, since the Immediate Jeopardy was identified on 6/29/21. There was no documented monitoring of the Electronic Monitoring System for 7/3/21 or 7/4/21. On 7/6/21 at 10:05 am, V1 stated the Electronic Monitoring System functional checks were not completed on 7/3/21 or 7/4/21. On 7/6/21 the facility provided an addendum outlining coverage of staff to ensure audits are completed as planned.

Based on observation, interview, and record review, the facility failed to provide safety and supervision to prevent falls by failing to implement effective post fall interventions after a resident rolled out of bed. This failure resulted in R1 subsequently rolling out of bed again, and sustaining fractures to the nasal bones. The facility also failed to thoroughly investigate an incident, identify root cause, and implement interventions for two of four residents (R1 and R3) reviewed for falls on the total sample list of eight. Findings include: 1. R1's fall risk assessment, dated 10/3/2020, documents a fall risk score of 18, indicating high risk for falls. R1's medical record documents on 11/23/2020, found on floor in resident's room, the resident was lying on the floor on her right side. R1's medical record, dated 11/24/2020, documents, Post Fall Evaluation, Fall Details: Fall was not witnessed. Fall occurred in the Resident's room. Activity at the time of fall: Rolled out of bed The reason for the fall was not evident. R1's Fall incident investigation form documents: Fall 11/23/2020 at 12:30 PM documents, Resident is alert with confusion, readmitted to our facility on 11/17/2020 post left Above the Knee Amputation. After reviewing the medical record, talking to the staff and resident, the root cause of fall is related to acute condition change and other contributing factors such as medical diagnosis. R1's Fall incident investigation form did not identify or document resident- centered interventions to prevent future occurrences for R1 rolling out of bed. R1's medical record documents, 12/2/2020 at 1:23 AM staff notified writer that resident was on floor. observed resident lying on her right side, holding her face. Bed side table, next to res (resident) face. Resident has a small laceration to nose with minor bleeding & swelling at this time. Resident has bruising to right side of face. Resident has a goose egg above right eye. R1's medical record, dated 12/2/2020, documents, Post Fall Evaluation Fall Details: Fall was not witnessed. Fall occurred in the Resident's room. Activity at the time of fall: rolled out of bed The reason for the fall was not evident. Did an injury occur as a result of the fall: Yes. Injury details: small laceration on nose, bruising & swelling Did fall result in an emergency room visit/hospitalization : Yes, emergency room . R1's Emergency's room provider notes document, date of service: 12/2/2020 at 3:02 AM. Chief Complaint: Patient presents with fall. Patient states that she was sleeping when she rolled and fell out of bed. Patient sustained injuries to the face, bruises and abrasions and nose bleed. Examination: CT facial bones without contrast, 12/2/2020, Impression: Fractures of the anterior nasal bones with overlying soft tissue swelling. Re-evaluation time: 12/2/2020 at 4:17 AM, Clinical impression: 1. Closed fracture of nasal bone. On 6/23/21 at 2:15 PM AM, V2, Director of Nursing (DON), confirmed there were no interventions put into place after R1 rolled out of bed on 11/23/2020; then R1 rolled out of bed again on 12/2/2020 and suffered a nasal fracture. V2 stated, When a resident falls, the nurses complete a fall evaluation form, we then investigate the fall, determine the root cause, and develop new interventions to prevent further falls. V2 stated R1 did have an air mattress on her bed, I don't know if it could have been because of that or not. 2. R1's care plan, with a revision date of 10/5/2020, documents R1 is at risk for falls due to deconditioning, history of falls. Interventions: 10/3/2020: place mat next to bed. On 6/21/21 at 2:00 PM, and on 6/22/21 at 5:00 AM, R1 was observed lying in bed, there was no fall mat next to R1's bed. On 6/22/21 at 5:25 AM, V11, Registered Nurse, stated, (R1) is newer to this hallway, she was down here and then moved to another unit then came back down here. I am not sure that (R1) does use a mat beside (R1's) bed. On 6/23/21 at 11:45 AM, V2, Director of Nursing, stated R1 should have a mat beside R1's bed. 3. R3's fall risk assessment, dated 3/20/21, documents a fall risk score of 15, indicating R3 is at high risk for falls. R3's medical record documents, Post Fall Evaluation Fall Details: Date/Time of Fall: 03/31/2021 at 7:30 PM Fall was not witnessed. Fall occurred in the bathroom. Activity at the time of fall: Attempting to get herself off of toilet Reason for the fall was evident. Reason for fall: Attempting to get herself off of toilet. R3's medical record contained no documentation a post fall assessment investigation was completed to determine the root cause of R3's fall on 3/31/21 at 7:30 PM, or develop and implement new interventions. On 6/23/21 at 11:45 AM, V2, Director of Nursing, stated, When a resident falls the nurses complete a fall evaluation form, we then investigate the fall, determine the root cause, and develop new interventions. V2, DON, confirmed there was no investigation completed for R3's fall on 3/31/21 at 7:30 PM, no root cause was determined, or interventions developed. The facility's policy, with a revision date of August 2008, titled Falls- Clinical Protocol documents, Assessment and Recognition: 5. The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc. a) Falls should be categorized as a) those that occur while trying to rise from a sitting or lying to an upright position., b) those that occur while upright and attempting to ambulate, c) other circumstances such as sliding out of a chair or rolling from a low bed to the floor. They should be identified as witnessed or unwitnessed. Cause identification: 1. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. a) causes refer to factors that are associated with or that directly result in a fall. b) Often, multiple factors in varying degrees contribute to a falling problem. Treatment/Management: 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. 2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation.

Based on record review, observation, and interview, the facility failed to monitor weight loss, failed to obtain weights, failed to obtain a Physician ordered therapeutic diet and nutritional supplements as recommended, failed to provide Physician ordered nutritional supplements, failed to follow Registered Dietician recommendations, and failed to assist with feeding as needed (R3) for three of three (R1, R2 and R3) residents reviewed for weights and diets on the sample of five. These failures resulted in hospitalization for medical management of R3's caloric intake and hydration needs and newly diagnosed [CONDITION(S)] and Dehydration. Findings include: The facility policy titled 'Weight Assessment and Intervention, revised August 2008, documents the following: Policy Statement: The nursing staff and the Dietician will cooperate to prevent, monitor and intervene for undesirable weight loss or gain for our residents. Policy Interpretation and Implementation: Any change of greater than or less than five pounds within 30 days will be retaken for confirmation. If verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. The Dietician will respond within 24 hours of receipt of written notification. Significant weight changes are defined as: more or less than 5% in 30 days, more or less than 7.5% within 90 days and more or less than 10% in six months. 1.) R3's undated Face Sheet documents R3 was admitted to facility on 1/15/21, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Care Plan, dated 1/25/21, documents R3 has a nutritional problem or potential nutritional problem and to weigh per facility protocol, notify Physician, Registered Dietician, and family of any significant weight changes. Interventions listed include: monitor intake and record every meal. Offer substitutions if 50% or less of meal is consumed. Monitor, Record, Report to Physician signs of malnutrition: Emaciation, muscle wasting, significant weight loss of greater than 5% in one month, greater than 7.5% in three months and/or greater than 10% in six months. Provide and serve diet as ordered. R3's Minimum Data Set (MDS), dated [DATE], documents R3 as requiring extensive assistance with eating. This same MDS documents R3 as having modified independence in decision making. R3's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The same POS's documents 90 milliliters of a 2.0 Calorie supplement to be given three times per day for weight maintenance was discontinued on 4/13/21. The same POS does not document a Physician ordered diet or nutritional supplements from 4/13/21-5/16/21. R3's Weights and Vitals Exceptions Report, dated 5/18/21, documents R3's weights as: 2/12/21 weight is documented as 153.0 pounds (lbs) indicating a 9.2% weight loss in one month since admission on 1/15/21. 4/19/21 weight is documented as 126.4 lbs indicating a 17% weight loss in three months since admission on 1/15/21. 5/14/21 weight is documented as 110.0 lbs indicating a 21.3% weight loss since 3/4/21 weight documented as 139.8 lbs. R3's Nurse Progress Notes document the following: 4/21/21 at 12:16 PM ---V13, Registered Dietician (RD), documents Weight triggering for -22.1% for past three months (162.2 pounds on 1/22/21). Physical appearance shows signs of malnutrition. Continue offering one high calorie/fortified at meals with one of these being chocolate fortified pudding. Supplement diet with Med Pass if intakes less than 50% at meals. Update diet order in Electronic Medical Record (EMR). 5/14/21 at 12:05 PM---V13, RD, documents Weight triggering for -4.9% x 1 week (126.2# on 4/29) and -21.6% x 3 mo (153# on 2/12). Please update diet order in EMR. Continued weight loss at this time is not desired. Recommend consider discussing Gastrostomy tube (G-tube) placement per resident/Power of Attorney (POA) wishes related to continued weight loss and consistent poor PO intakes. 5/18/21 at 6:16 PM--V17, Licensed Practical Nurse (LPN), documents Resident (R3) admitted to hospital for observation. V23, Physician, documents in Hospital emergency room Record, dated 5/18/21, R3 has lost about 40 pounds within the last few months and as been coming recurrently to the hospital with dehydration. Patient (R3) is not able to manage his nutritional and caloric needs. R3's Hospital History and Physical, dated 5/18/21, documents given his (R3) history of Dementia, he (R3) does require assistance with feedings. This same record documents R3's Principle Problem of [CONDITION(S)] and Active Problem of Dehydration. This same record documents Plan for (R3) is aggressive Intravenous hydration for [CONDITION(S)] (associated with decreased oral intake of fluids and food). Gastroenterology has been consulted for PEG tube placement. On 5/14/21 at 8:55 AM, R3 was sitting in a recliner chair in room with breakfast tray on bedside table. R3's breakfast tray did not have any type of supplement or high calorie/fortified foods included. Staff were not present during the breakfast meal to assist resident with eating, offer alternatives, or encourage R3 to eat. R3's skin appeared very dry. R3's lips were dry and wrinkled. On 5/14/21 at 12:50 PM, R3 was sitting in recliner chair in room with his lunch tray sitting on bedside table in front of R3. No supplements or fortified foods were included with the lunch tray. R3 stated, would like chocolate ice cream but they didn't give it to me. Staff were not present during the lunch meal to assist R3 with eating, offer alternatives, or encourage R3 to eat. 2.) R1's undated Face Sheet documents R1 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set (MDS), dated [DATE], documents R1 requires limited assistance of one staff for eating. This same MDS documents R1's Brief Interview for Mental Status score of 4 out of a possible 15 points, indicating severe cognitive impairment. R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Care Plan, dated 3/24/21, documents R1 has a nutritional problem or potential nutritional problem and to weigh per facility protocol, notify Physician, Registered Dietician, and family of any significant weight changes. Interventions listed include: monitor intake and record every meal. Offer substitutions if 50% or less of meal is consumed. Monitor, Record, Report to Physician signs of malnutrition: Emaciation, muscle wasting, significant weight loss of greater than 5% in one month, greater than 7.5% in three months and/or greater than 10% in six months. Provide and serve diet as ordered. Provide and serve supplements as ordered. R1's Weight Summary documents R1's admission (3/12/21) weight as 146.6 pounds (lbs). R1's Weight and Vitals Exceptions Report, dated 5/18/21, documents the following weights: 4/7/21 weight was documented as 135.0 pounds (lbs), indicating a 7.5% weight loss in less than one month. 5/7/21 weight was documented as 122.2 lbs, indicating a 7.5% weight loss since admission on 3/12/21. R1's Nurse Progress Notes document the following: 4/7/21 at 12:56 PM, V13, Registered Dietician (RD), documents, Weight triggering for -7.9% x 1 mo (146.6# on 3/12). Recommend adding one high calorie/fortified food to each meal, continuing magic cup (fortified nutrtional supplement) at lunch and adding one to dinner as well. 5/17/21 at 2:59 PM, V13, Registered Dietician (RD), documents, Weight triggering for -9.5% x 1 mo (135# on 4/7). Admission weight was 146.6# on 3/12. Recommend to add one high calorie/fortified food at all meals and add magic cup to dinner as kilocalorie (kcal) support. On 5/14/21 at 8:55 AM, R1's bedside table was sitting in hallway next to R1. Bedside table had breakfast tray and two drinks on it. R1's breakfast tray did not include any high calorie/fortified supplements of any kind. There appeared to be 2-3 bites taken from the breakfast meal. Staff did not assist R1 with eating, nor did they encourage R1 to eat breakfast, or offer alternatives. On 5/14/21 at 12:50 PM, R1 was sitting in a wheelchair propelling self in hall. R1 was served his lunch tray by staff. R1's lunch tray did not include any high calorie/fortified foods or supplements. Staff did not assist R1 with eating, nor did they encourage R1 to eat breakfast, or offer alternatives. On 5/18/21 at 9:15 AM, R1's breakfast tray was sitting on the bedside table by nurses station. R1's breakfast tray did not include any high calorie/fortified foods or supplements. R1 was sitting in wheelchair in room. Staff did not assist R1 with his breakfast tray, nor did they offer alternatives, or encourage R1 to eat the breakfast meal. On 5/19/21 at 8:30 AM, R1 was laying flat in bed with R1's breakfast tray sitting on the bedside table approximately a foot away from bed. R1's breakfast tray included bacon, toast/jelly, egg omelette, and a cup of peaches, and drinks were water and cranberry juice. V12, Minimum Data Set (MDS)/Registered Nurse (RN), confirmed R1 did not have any fortified foods or high calorie foods included in breakfast meal. On 5/19/21 at 8:40 AM, V14, Dietary Manager, stated fortified food for the breakfast meal is super cereal oatmeal, and none of the foods offered to R1 for breakfast were high calorie or fortified. 3.) R2's undated Face Sheet documents R2 was admitted on [DATE], with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status score of 3 out of a total possible 15 points, indicating severe cognitive impairment. This same MDS documents R2 as requiring extensive assistance of one person physical assist with eating. R2's Care Plan, dated 9/24/20, documents R2 has a nutritional problem or potential nutritional problem and to weigh per facility protocol, notify Physician, Registered Dietician, and family of any significant weight changes. Interventions listed include: monitor intake and record every meal. Offer substitutions if 50% or less of meal is consumed. Monitor, Record, Report to Physician signs of malnutrition: Emaciation, muscle wasting, significant weight loss of greater than 5% in one month, greater than 7.5% in three months and/or greater than 10% in six months. Provide and serve diet as ordered. R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Weight Summary documents weight obtained on 11/10/20 was 149.6 pounds (lbs). Per this same Summary R2's weight obtained on 2/3/21 was 143.0 lbs and 5/7/21 weight obtained was 123.0 lbs. R2's Weight and Vitals Exceptions report, dated 5/18/21, documents R2's weight on 3/4/21 as 135.0 lbs indicating a 10.6% weight loss in three months. R2's Nurse Progress Notes document: On 3/19/21 at 11:34 AM, V13, RD, documents, Reviewed for weight. Weight 135# (3/4). Weight on 12/5 was 151#. Significant loss of -10.6% x 3 mo. Recommend to weigh biweekly to monitor nutrition status. Goal is for no further weight loss. On 5/17/21 at 2:43 PM, V13, RD, documents, Resident does have significant weight loss with -17.8% x 6 mo (149.6# on 11/10). Recommend to weigh biweekly to monitor nutrition status. R2's Electronic Medical Record (EMR) does not document bi weekly weights obtained. On 5/14/21 at 8:50 AM, R2 was sitting in a chair at the bedside eating breakfast. R2 did not have any type of supplements on meal tray. Staff did not offer alternatives, encourage R2 to eat the meal, or assist R2 with eating. On 5/14/21 at 12:25 PM, R2 was laying in bed at 30 degrees, with his food tray sitting on bedside table that was positioned over R2's chest area. R2's lunch tray included pulled pork sandwich, baked beans, pasta salad, one slice of pie, two Styrofoam cups of thickened water, and one cup of thickened red and white swirled liquids. R2 was attempting to reposition self in more upright position. Staff did not assist R2 during the meal service, did not encourage R2 to eat the meal, or offer alternatives. R2's lunch tray did not include any supplements. On 5/18/21 at 9:15 AM, R2 was sitting in chair with his breakfast tray and drinks on his bedside table. Breakfast tray did not include any high calorie/fortified foods or any type of supplements. Staff did not assist R2 with eating, offer alternatives, or encourage to eat meal. On 5/18/21 at 11:00 AM, V13, Registered Dietician (RD), stated R1, R2 and R3 have had undesirable significant weight loss. V13 stated she made a diet recommendation for R3 including supplements on 4/21/21 which was never followed up on by facility. V13 confirmed R3 did not have a diet ordered or supplements ordered from 4/13/21-5/17/21. V13 stated the facility was aware R3 had already been losing weight and should have done a better job for this resident. V13 stated, (R3) has been losing weight since admission. V13 stated was aware of R3 not having a diet order or supplements ordered as of 4/21/21, and progress note was made with recommendations and to update diet order in Electronic Medical Record (EMR). V13 stated when V13 reviewed R3 again on 5/14/21 for nutritional needs, V13 noted diet had not been ordered, and supplements had not been ordered. V13, RD, stated R3 should have been placed on weekly weights and monitored more closely by facility. V13 stated R2's undesired significant weight loss could have been prevented if supplements were given as ordered. V13 stated on 4/7/21, V13 recommended that facility was to add high calorie and fortified foods to all of R1's meals, and also recommended a magic cup at dinner time. V13 stated this recommendation has not been carried out by facility. V13, RD, stated R1's weight loss could have been prevented if supplements were offered and encouraged as recommended by V13. V13 stated, Not having a diet order or supplement orders in place for nutritionally high risk residents (R1, R2 and R3) who were already known to have weight loss issues is unacceptable. V13 stated, These residents may have not gained any weight but nutritional supplements do help a nutritionally high risk resident maintain weight. These residents may not have lost so much weight if diet and supplements orders were in place and/or being followed, had someone been assisting them (R1, R2 and R3) with meals and they (R1, R2 and R3) were monitored for significant weight loss. V13 stated V13 has access to resident tray cards through a computerized program and is able to see that recommendations are not being added to resident tray cards. V13 stated, It is very important for RD recommendations to be followed up on, weights need to be reviewed closely and Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/18/21 at 12:15 PM, V3, Assistant Administrator/Registered Nurse (RN), stated R1, R2 and R3 have had undesirable significant weight loss. V3 stated R1, R2 and R3 should have been placed on weekly weights after significant weight loss was noted. V3 stated residents should have been provided feeding assistance as needed to aid in combating weight loss. V3 confirmed R3 did not have a diet order in place and did not have any supplements ordered from 4/13/21-5/17/21. V3 stated R3 was sent to hospital 5/18/21 for medical intervention related to significant weight loss. V3 stated the facility is unable to provide documentation of any supplements being offered since return from last hospital stay 4/19/21. V3 stated the facility discontinued the orders when R3 went out to the hospital on 4/13/21, but never reinstated those diet or supplement orders until 5/17/21. V3 stated R2 should have been provided the nutritional supplements that were ordered by the Physician. V3 confirmed R2's weight loss 14% in past three months and 18% in past six months. V3 stated R1 should have been served the nutritional supplements that were recommended by V13, RD. V3 confirmed R1's weight loss of 17% in past two months and 6% in last month. V3 stated the facility did not follow the Weight Policy, monitor weights, or actively attempt to prevent weight loss for R1, R2 and R3. We messed up. These residents may not have lost so much weight if we (the facility) were doing what we were supposed to do. They (R1, R2, R3) should have had a diet order and supplements order in place and being offered as recommended, staff should have been helping them eat and offering substitutes but they (staff) weren't. We can't do anything to fix all of our mistakes. All we can do is try to do better going forward.

Based on interview and record review, the facility failed to prevent misappropriation of resident's(R1) property. R1 is one of three residents reviewed for misappropriation in the sample of three.This failure resulted in $1747.99 of unauthorized charges being made to R1's credit card account immediately following R1's death in the facility. Findings include: R1's Face Sheet (undated) documents R1 admitted to the facility on [DATE], and died in the facility on [DATE]. R1's credit card statement ([DATE]) documents charges for the period from [DATE] to [DATE], including 22 unauthorized charges totaling $1747.99 beginning the day immediately after R1's death in the facility. The Facility Incident Report Form ([DATE]) documents V3 (R1's Representative) reported to the facility on [DATE] unauthorized charges were made to R1's credit card while a resident of the facility. On [DATE] at 10:15AM, V3 reported canceling R1's credit card on [DATE], and then receiving R1's credit card statement on [DATE], and noticing unauthorized charges following R1's death in the facility on [DATE]. V3 reported R1 would not have authorized anyone to use R1's credit card. On [DATE] at 12:49PM, V8 (Social Services Director) reported facility staff are supposed to complete a property Inventory Record documenting a resident's personal property brought with them upon their admission to the facility. At 1:15PM, V8 reported not knowing if R1 had an Inventory Record completed at the time of admission, or if facility staff attempted to find one for R1 following V3's report to the facility of R1's credit card theft and unauthorized use. V8 reported if a resident declines to have property held by the facility, then staff will chart the resident's property being kept by the resident, and V8 or the nurse or whoever admits the resident does the charting. On [DATE] at 1:27PM, V3 stated, I am horrified, it is awful that someone would do that. That is a new low, the fact that the day after (R1) died , they started spending on (R1's) credit card. V3 stated R1 would have been horrified about having R1's credit card stolen and used after R1's death in the facility. On [DATE] at 2:05PM, V2 (Director of Nursing) stated, I am not sure if R1 had a property Inventory Record completed at the time of R1's admission and if the Inventory Record is not in R1's electronic medical record, it probably was not done by facility staff. V2 reported the facility process for handling a resident's credit card is to ask to inventory the property if the resident wants to keep the property in their possession while at the facility. On [DATE] at 9:47AM, V9 (R1's friend) reported retrieving R1's personal property from the facility following R1's death, and noting R1's wallet did not contain R1's credit card. On [DATE] at 1:21PM, V3 reported R1 did not have any outside visitors the entire time he was a resident at the facility so no opportunity existed for anyone other than facility staff to misappropriate R1's credit card. On [DATE] at 2:12PM, V7 (R1's friend) reported transporting R1 to the facility for admission on [DATE]. V7 reported R1 possessed R1's wallet at the time of the admission. On [DATE], R1's electronic medical record (undated) did not contain any property Inventory Record for R1 or any charting documenting R1's property at the time of admission.

Based on observation, interview and record review, the facility failed to provide adequate supervision for one resident (R1) reviewed for elopement and falls in the sample of three. This failure resulted in R1's elopement and a fall from R1's wheelchair outside of the facility in the parking lot resulting in a laceration to R1's left forehead and a fractured vertebrae to R1's lumbar region. Findings include: A facility Missing Resident and Elopement policy dated 8/23/13 documents: It is the policy of (facility) to provide a safe environment for all residents. (facility) will properly assess residents and plan their care to prevent accidents related to wandering behavior or elopement. Elopement is defined as slipping away secretly, running away, leaving without accompaniment or knowledge of the staff. Procedure: Assessment and Identification of Wandering Residents: 2). A resident with Alzheimer's/Dementia that is ambulatory will be considered at risk for elopement and an appropriate care plan will be put in place; 4.) Each resident's required level of supervision will be assessed based on wandering behaviors. This information will be documented in the resident's medical record, and used in the care planning process. If a resident is identified at risk for elopement, the following steps will be taken: 1). If clinically indicated, an alarm bracelet will be placed on the resident to audibly alert staff of attempts by the resident to exit; 2.) The resident's care plan shall address behavior using resident specific goals and/or approaches by the interdisciplinary team; 3). A current picture of the resident will be maintained in the facility; 4). Facility staff will ensure that all exit alarms are responded to immediately. 1.) Resident will wear an alarm bracelet to alert staff if he/she is trying to leave the facility. The bracelet will be checked every shift for placement and function. 4.) Resident's wandering episodes will be tracked and resident specific approaches/interventions added to the care plan as determined by the interdisciplinary team; 5.) If exacerbation of the behavior continues, 1:1 supervision may be considered until the physician can assess the resident for etiology. 7.) An Exit Seeking book identifying risk for elopement will be placed at each nurse's station and at receptionist desk so staff is aware of residents to be closely monitored. When any door alarm sounds, staff shall: 1). Check the alarm panel to determine which door has been opened. DO NOT ASSUME someone else has already done this; 2). Check the exit door for any exiting resident by means of a visual check. Also perform search of the building parameter for exited resident. Elopement policy: 6). A detailed incident report will be completed and submitted to administration and immediately notify appropriate State agencies. An Initial incident report with a fax date stamp of 7/1/18 and 11:19 a.m., did not provide details of an unwitnessed elopement on 6/30/18 at approximately 8:00 p.m. of a resident being outside of the facility with an unwitnessed fall with injuries. A Face sheet for R1 was located in an Exit Seeking book for closely monitoring for exit seeking. R1's current [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) dated (MONTH) 4, (YEAR), documents a BIMS of 9 and Section P documents that a Wander/elopement alarm is used daily. An Elopement Risk Assessment for R1 dated 4/6/18 documents a [DIAGNOSES REDACTED]. R1 had falls on 5/5/18; 5/10/18; 6/1/18; 6/5/18; 6/9/18; 6/11/18; 6/25/18; and 6/28/18. A care plan dated 6/25/18 for R1 documents that R1 is an elopement risk/wanderer with the following interventions: check (alarm bracelet) wanderguard battery function weekly and as needed (PRN), check placement every shift and PRN, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, and identify pattern of wandering. R1's progress note dated 5/10/18 documents: Resident has been exit seeking and exhibits exit seeking behaviors. and a post fall summary dated 5/10/18 documents: Resident (R1) had been extremely agitated and exit seeking. R1's progress note dated 6/14/18 documents: Additional monitoring that is required: falls, aspiration harm to self or others, may attempt to exit. An alarm journal for R1 documents that on 6/30/18, two hours prior to R1 eloping, R1's alarm was activated on 8 separate occasions indicating R1 was exit seeking or loitering by the front door at the following times: 5:46:20 p.m., 6:04:28 p.m.; 6:41:16 p.m.; 6:41:29 p.m.; 6:41:37 p.m.; 7:39:59 p.m.; 7:40:16 p.m.; 7:40:35 p.m. There is no documentation indicating R1 was redirected or interventions put in place during these times. On 6/30/18 at 7:40:01 p.m., R1's door alarm was activated and the time to clear was 3 minutes and 6 seconds. On 7/9/18 at 1:30 p.m., V1, Administrator stated: The time to clear is when a staff member punches in a code when a resident whose alarm has been activated have been located or redirected. No staff member witnessed the elopement or the resident fall from R1's wheelchair in the driveway on 6/30/18 in the evening. A local ambulance document dated 6/30/18 for services provided to R1 documents: Unit notified at 6/30/18 19:51:56 (7:51:56, 911 call); arrived on scene 6/30/18 at 19:58:33 (7:58.33). R1's last door alarm time (7:40:01 p.m.) and time of 911 call (7:51.56) call indicate a time difference of 11 minutes and 55 seconds from R1 being located until the 911 call was placed. On 7/3/18 at 1:15 p.m., V2, Director of Nursing stated: There is no staff witness to R1 leaving the facility. The doors must have been opened by someone going out or coming into the building. There is no documentation of R1 being redirected or interventions put in place during the evening of R1's elopement. R1 was found outside with injuries. There is no witness to this fall. I was not notified until Monday morning when I came to work. I am acting Administrator while V2 is on vacation. The resident is very noncompliant. The resident is never allowed outside by R1's self. Leaving the building unsupervised would be considered an elopement. There is no physician order for [REDACTED]. On 7/2/18 at 3:10 p.m., V4, Certified Nursing Aide stated: Saturday, (MONTH) 30, the alarm to the front door was going off around 7:00 p.m. or so, not really sure of the time. I looked at front door area and didn't see anyone in the doorway or outside. The alarm continued to go off and I eventually exited the building after a minute or so and heard someone yelling help. (R1) was down the hill laying in the road by a fire hydrant. R1's wheelchair was upright and R1 was facing pointing down the hill and partially on his back and had blood coming from his forehead. I ran back inside to the front desk and called Station 2 for R1's nurse (V8). Another nurse (V9) came out and I grabbed some towels and brought them to the nurses. I did not see R1 leave the building or fall. On 7/2/18 at 3:40 p.m., V5, Certified Nursing Aide stated: The door alarm was going off and (V9) told me to go check out the front door and another CNA (V4) was outside with (R1) who was on (R1's) left side, face up and (R1's) head was bleeding. The wheelchair was upright. V8 was the nurse who called 911. It was about 10 minutes or so. There was no one at the front desk. The alarm had been going off for a while and it was sometime after 7:00 p.m. On 7/3/18 at 10:20 a.m., V9, Licensed Practical Nurse stated: I heard an alarm go off several times and V4 was outside and heard someone yelling for help. I went outside and found (R1) on the asphalt down the driveway by the fire hydrant. R1's wheelchair was upright and R1 was on the ground. R1 was probably outside only for about 5 minutes. The alarm had been going off earlier and his name and another resident (R4) was showing up. The alarms confused me, I thought it was a glitch. I knew that (R4) had been discharged so I was not sure what was going on. I sent the aide to call 911. R1 requires a lot of supervision, (R1) is not on my hall but is always wandering. There was no staff at the front door. I was working Station 4. V8 was R1's nurse. On 7/3/18 at 10:30 a.m., V8, Licensed Practical Nurse stated: Last time I saw R1 was around 7:00 p.m., (R1) refused meds and asked me for a glass of water. I heard a page over the intercom to come outside. (R1) was on the ground in the roadway where cars park by a fire hydrant. I didn't know (R1) was an elopement risk, I don't normally work in this area. (R1's) room is on the 200 hall far away from the front of the building. On 7/9/18 at 9:30 a.m., V12, Certified Nursing Aide stated: R1 was wearing an alarm bracelet that was in the system for another resident, (R4). Someone took an alarm bracelet (Tag #84) off my desk which was still assigned in the system to (R4) who had been discharged on [DATE] and placed it on R1's ankle or wrist. I was not notified by anyone that the device had been placed on R1. R1 had (R1's) own alarm bracelet (Tag #57) assigned to R1 and it was on R1's wheelchair, not R1's body. On 7/3/18 at 2:45 p.m., V15, Emergency Medic, stated: When we were taking care of the patient, I overheard some of ladies stating they had heard an alarm but could not see anyone in front of the door. The alarm kept going off, so they finally sent someone out to check and said they should have acted sooner. When I assessed the Resident (R1) was very warm and it was really hot outside that day, in the upper 90's, (R1) was probably outside at least 5 minutes or so. On 7/3/18 at 3:35 p.m., V10, Regional Clinical Nurse stated: In order to prevent this from reoccurring, we need to educate families. The resident's elopement was a contributing factor to (R1's) fall and injury. We have put up signs on the front doors alerting families to not let residents out. Apparently, there were two alarm bracelets on R1. One was still activated for another resident who had been discharged . On 7/3/18 at 3:00 p.m., V13, Receptionist stated: I left early that night, 6:00 p.m. There is no one at the front desk after that and the doors are not locked. The first set of doors open from the outside automatically and the second set of doors you have to push a red button and either pull open the door or push the handicapped button and they will open automatically. There is a pass code needed to exit the building. The doors are never locked. On 7/9/18 at 11:25 a.m., V14, Family member to R5, stated: I was bringing in my uncle (R5) from being outside and when I pushed the button to come in, the double doors opened and (R1) went out in (R1's) wheelchair. This would have been around 7:00 p.m. or so. I can't remember if I heard an alarm, but I did not notice any staff members in the area or coming towards the front doors as were were walking down the hall to my uncle's room (R5) on the 200 hall. When I went back outside about 15 minutes later or so, I noticed a man was being taken care of down the driveway. When I asked what happened, a staff member told me that a resident got out. I said, I saw a man in a wheelchair go out when I came in. A local emergency room provider notes dated 6/30/18 at 8:43 p.m., for R1 documents that (R1) is an [AGE] year old man who arrives in the emergency department via EMS from (R1's) nursing home for evaluation of a fall. EMS reports the patient fell on the sidewalk while (R1) was trying to escape the nursing home. (R1) arrives in the emergency department with spinal precautions. (R1) has a bleeding wound on R1's head. Physical exam: Head is with abrasion to left forehead with tissue loss and abrasions to bilateral knees. Lumbar spine findings: Acute anterior wedge compression fracture of L1 with 60% loss of height, 5 mm retropulsion. Fracture extends through the anterior and posterior cortex and superior and inferior endplates. A neurosurgeon consultation note dated 7/1/18 at 9:23 a.m. for R1 documents that (R1) is severely lethargic this morning, minimally responsive and is unable to open eyes with verbal or painful stimulus; recommend lumbar brace for comfort, Surgery is not recommended, recommend physical therapy as tolerated when brace is in place. On 7/3/18 at 8:30 a.m., R1 was in a local hospital. R1 was unable to state what happened the day of the incident. R1 had a large abrasion to R1's left forehead. R1 was drowsy and hard to awake. A local hospital provider notes dated 7/2/18 at 12:48 p.m., documents: Patient (R1) has been accepted for admission to an out of town nursing home facility for admission on 7/3/18.

Based on record review and interview the facility failed to ensure a safe environment by failing to provide direct one on one staff supervision for a resident (R1) with aggressive behaviors as specified in R1's Care Plan. This failure resulted in three falls for one of seven residents (R1) reviewed for abuse / safe environment on the sample of 11. Findings include:. R1's Physician order [REDACTED]. R1's Minimum (MDS) data set [DATE] documents R1 has severe cognitive impairment and ambulates with staff assistance. R1's Care Plan dated 5/21/18, page 17, documents an intervention for one on one with staff supervision. R1's Fall Risk Evaluation dated 5/11/18 documents R1 is at high risk for falls. R1's Fall Report dated 5/28/18 at 01:27 am documents R1 fell in R1's room. The same fall report documents Predisposing Environmental Factors, Wet floor. On 6/14/18 at 12:30 pm, V19, Licensed Practical Nurse / Restorative/ Fall Investigation Designee submitted R1's Post - Fall Management QA (Quality Assurance) Form which dated the 5/28/18 fall occurrence at 01:27 am. R1's Post - Fall Management QA Form documents the following:: Wet floor - gait imbalance. Do not leave alone in bathroom. R1's Fall Report dated 06/07/18 at 07:32 am documents R1 was found on the floor in R1's room. The same fall report documents While one on one attendant (V9, Certified Nursing Assistant) took a five minute break thinking (R1) had fallen asleep, the resident (R1) got out of bed and was found sitting on the floor in (R1's) room. On 6/14/18 at 12:30 pm, V19, Licensed Practical Nurse / Restorative/ Fall Investigation Designee submitted R1's Post - Fall Management QA Form which dated 06/07/18 fall occurrence at 07:32 am. R1's Post - Fall Management QA Form documents the following: Root Cause, unattended. Re-educate attendant (V9) not to leave (R1) alone. R1's Fall Report dated 06/09/18 at 8:30 pm documents R1 was found sitting on the floor behind the door in (R1's) room. On 6/14/18 at 12:30 pm, V19, Licensed Practical Nurse / Restorative/ Fall Investigation Designee submitted R1's Post - Fall Management QA (Quality Assurance) Form which dated 06/09/18 (untimed) fall occurrence. R1's Post - Fall Management QA (Quality Assurance) Form documents the following: Resident (R1) was observed by staff (V38) sitting on the floor behind the door. (R1) frequently lowers (R1's) self to the floor to sit and or scoot around. (R1) has a one on one sitter due to behaviors, for safety. (R1) was incontinent, confused and easily agitated. Sitter (V38) had stepped away momentarily. On 6/14/18 at 12:30 pm V19, Licensed Practical Nurse / Restorative/ Fall Investigation Designee stated I reviewed and investigated all (R1's) falls. V19 also stated We educated all nursing staff not to leave (R1) alone, not even for a minute, even if they perceive (R1) to be asleep, have another staff member relieve for any breaks. That is what is always expected when (R1) has a one on one (supervision). The facility policy Fall Prevention dated (MONTH) 02, 2010 documents the following: It is the policy of (Company) to provide each resident with an appropriate assessment and interventions to prevent falls and minimize complications if a fall occurs. Additionally, all resident falls in the facility are analyzed and trended through the QA (Quality Assurance) process to maintain a safe environment.

Based on interview and record review the facility failed to follow the plan of care which required extensive assistance of 2 persons for bed mobililty for R1. R1 was repositioned in bed by one staff person resulting in a Fractured Left Femur. R1 is one of three residents reviewed for injuries in the sample of three. Findings include: The Care Plan dated 7/5/17 documents R1 requires extensive assistance of two persons with bed mobility. The Minimum (MDS) data set [DATE] documents R1 requires extensive, 2+ (plus) persons, physical assistance with bed mobility. The Resident Abuse Investigation Final Report dated 8/27/17 documents E7 Certified Nurses Assistant heard a 'pop' while turning R1 with a draw sheet to change R1's incontinence brief. An x-ray of R1's left leg was obtained, the x-ray report dated 8-23-17 showed an acute obliquely oriented fracture of the mid femoral diaphysis. The Exam Description section specifies Left Femur Radiographs, History Moved patient and heard a pop with deformity of the leg. History of multiple fractures. The 8-27-17 facility Final Report report documents the facility spoke with the radiologist who reviewed R1's x-ray results and the radiologist confirmed that the type of fracture was consistent with being turned in bed. On 9/21/17 at 11:47 AM E7 CNA stated on 8/22/17 at around 4:00 AM, E7 heard a 'pop' come from R1's left leg when E7 attempted to turn R1 in bed with a draw sheet to change R1's incontinence brief. E7 stated E7 was the only one in the room and E7 was providing care for R1 by E7's self. On 9/21/17 at 3:00 PM E2 Director of Nurses stated E7 CNA should have followed R1's Plan of Care and used two persons to perform R1's care on 8/22/17 instead of only one.

Based on interview and record review, the facility failed to safely transfer one resident (R2) in three residents (R1,R2,and R3) reviewed for falls in a sample of nine residents. This failure resulted in a fall which caused a fracture of R2's right fibula and tibia. This past noncompliance occurred from 11/22/16 to 12/13/16. Findings include: R2's physician's orders [REDACTED]. Rehab (Rehabilitation) Addendum Note Physical Therapy dated 11/8/16 for R2 by E12, Physical Therapist documents due to patient's complaint of pain in multiple joints, patient will benefit from (sling mechanical lift) transfers for safety. R2's Minimum Data Set ((MDS) dated [DATE] documents R2 as requiring extensive assistance by two staff for transferring. R2's care plan documents an intervention added by E10, Licensed Practical Nurse (LPN), Rehabilitation Nurse dated 11/15/16 stating extensive assistance of two staff and (sling mechanical lift) for the completion of all transfers. The facility's Incident/Accident Report or Unusual Occurrence to Illinois Department of Public Health for R2 dated 11/23/16 at 8:00AM reporting the fall of 11/22/16 documents [DIAGNOSES REDACTED]. Risk Management Witness Interview Form dated 11/22/16 at 5:00PM by E13, Certified Nursing Assistant (CNA) documents me (E13) and coworker (E14) assisted (walked) (R2) to bathroom using gait belt. When it was time to get up (R2) was having a little trouble. We grabbed the sit-to-stand (mechanical lift). This document also states Resident said (R2) couldn't stand up and begin going to ground saying my foot. A sling mechanical lift was not used for transfer as indicated R2's Physical Therapy assessment and R2's care plan. Risk Management Witness Interview Form dated 11/22/16 at 5:00PM by E14, Certified Nursing Assistant (CNA) documents me (E14) and coworker (E13) assisted walked (R2) to bathroom with gait belt. This document also states when we tried getting (R2) up (R2) said (R2's) foot hurt and couldn't stand. So we got sit-to-stand (mechanical lift) and (R2) said (R2) couldn't stand and was gonna' fall and (R2) went down on sit-to-stand and said (R2) twisted foot. A sling mechanical lift was not used for transfer as indicated R2's Physical Therapy assessment and R2's care plan. E13 and E14 were unable to be reached for interview. On 5/23/17 at 1:00PM E4, Licensed Practical Nurse (LPN), Care Plan Coordinator and E5, Registered Nurse (RN), Care Plan Coordinator acknowledged that (R2) has required a mechanical lift with extensive assistance of two staff since 11/15/16 per care plan. On 5/23/17 at 1:12PM E10, Licensed Practical Nurse (LPN), Restorative Nurse acknowledged that R2 was documented as requiring a sling mechanical lift and staff assist of two persons as of 11/8/16. On 5/23/17 at 1:12PM E10, Licensed Practical Nurse (LPN), Restorative Nurse acknowledged that R2 was documented as requiring a sling mechanical lift and staff assist of two two persons as of 11/8/16. On 5/23/17 at 2:10PM E6, Physical Therapy Assistant (PTA)/Director of Therapy stated On 11/8/16 (E12) Physical Therapist evaluated (R2) per (Z3), Medical Doctor's order for transfer (ability). At that evaluation E12 found that (R2) required (sling mechanical lift) and extensive assistance of two staff for safety for all transfers. On 5/24/17 at 8:40AM Z3, Medical Doctor,(MD) stated that R2 sustained the fracture of R2's distal tibia and fibula during the fall that occurred on 11/22/16. Facility policy Mechanical Lift and Transfers dated 5/26/09 states It is the policy of (the facility) to identify and designate residents who require assistance to transfer by a mechanical lift for the safety of both residents and staff members. The product specifications for the brand of sit-to-stand lift utilized by the facility dated 3/12/12 states (sit-to-stand lift) is intended for use with patients who are able to actively participate in the raising motion. On 5/23/17 at 4:30PM E1, Administrator acknowledged that the facility is aware that on 11/22/16 R2 fell during an improper transfer which caused a fracture to R2's right distal fibula and tibia. Prior to the survey date of May 24,2017, the facility had taken the following action to correct the noncompliance. R2's post fall Patient Transfer Status Rehabilitation Department Recommendations were documented by E12, Physical Therapist on 11/28/16. E12 assessed R2 to require a (sling mechanical lift) for transfer. R2's care plan from R2's readmission to the facility on [DATE] to present date reflects this need. A complete audit of care plans for the entire facility was documented on 11/23/16 by E4, Registered Nurse (RN), E17 RN, E18 RN, and E3,RN. This audit included verification that level of transfer for all residents was up to date and correct. In-service education was documented as completed for all staff by E1,Administrator and E10, Licensed Practical Nurse (LPN), Restorative Nurse on 11/23/16 for all personnel involved in direct resident care employed by facility as of date of in-service. The subject of this in-service was How to Check the (resident care task list) for Transfer Status with Return Demo (demonstration). A signed attendance sheet was provided to document attendance. The facility's procedure for When a Resident's Transfer Status is Changed was reviewed individually on 11/23/16 by E1,Administrator with E6, Physical Therapy Assistant/Rehabilitation Director and E10,Licensed Practical Nurse (LPN), Restorative Nurse. Both participants are documented to have signed attendance verification. The facility's updated Transfer Audit Form document that three resident transfers were observed and supervised daily from 11/25/16 through 12/13/16. These audits were signed as completed by licensed nursing and therapy staff. On 5/23/17 at 4:30PM E1, Administrator stated as of 11/23/16 transfer safety was assessed as an issue to follow for the facility's Quality Assurance Committee. Since that time this issue has been tracked and monitored as a part of the facility's quality assurance process. E1 provided Quality Assurance meeting notes and signed attendance records for quarterly quality assurance committee meetings in which resident transfer was identified as a problem. Action plans were formulated and ongoing monitoring is being completed.

Based on observation, interview and record review the facility failed to follow their policy for urinary catheter insertion, failed to assess a resident for complications after urinary catheter placement, failed to prevent cross contamination during urinary catheter care and failed to maintain urinary catheter drainage tubing off the floor for two of four residents (R1 and R5) reviewed for indwelling urinary catheters in the sample of five. These failures resulted in R1 experiencing severe pain and gross hematuria. Findings include: 1. The Minimum (MDS) data set [DATE] documents that R1 is cognitively intact. The physician's orders [REDACTED]. E5's (Registered Nurse) Nurses Note for R1 dated [DATE] at 5:35 am (entered as a late note on [DATE]) states (R1) complaining of not being able to urinate. Writer reinserted (urinary) catheter at this time with return of urine. Resident voices relief. 0600 resident complaining of pain output in (urinary catheter) bloody. Resident given pain pill .0730 resident continues to complain of pain output in (urinary) catheter continues to be frankly bloody. Writer contacted Z1 and received orders to do a CBC (Complete Blood Count), PT/INR ([MEDICATION NAME] Time/International Normalized Ratio) and irrigate (urinary catheter) until clear. Day shift nurse (E3 Licensed Practical Nurse) to do labs and irrigate (urinary catheter) E3's Nurses Note for R1 dated [DATE] states Problem/Symptom is hematuria, SOB (short of breath), purple/blue lips, pale face, increased confusion, temperature 101.3 (degrees foresight). This problem started when writer went into room to draw stat CBC, PT/INR at 8:30 (am) and noticed condition change .MD (Medical Doctor) ordered to send resident to ER (emergency room ). Resident left facility around 0945. Reported to (Z1 Physician) at 8:35 AM. The Emergency Department Note dated [DATE] states (R1) blood seen in (urinary catheter) and bag .The pain is at a severity of ,[DATE]. The pain is severe today the patient was in severe distress. The Hospital Admission History and Physical dated [DATE] at 10:25 AM states Genitals - gross hematuria, (urinary catheter) in place, traumatic in appearance .(R1) came in with pain in suprapubic region. (R1) (urinary catheter) balloon appeared to be in the urethra, gross hematuria seen. Catheter was replaced in ER (emergency room ). Patient continues to have hematuria. On [DATE] at 1:50 PM E5 Registered Nurse stated that on the morning of [DATE] R1's abdomen was distended and that R1 complained that he could not urinate so she reinserted an indwelling urinary catheter at 5:35 AM. E5 stated that at 6:00 AM R1 complained of pain and that frank blood was present in R1's catheter bag. E5 stated she did not ask R1 where his pain was but that she assumed the pain was associated with the urinary catheter. E5 stated she gave R1 a pain pill at that time. On [DATE] at 12:20 PM E5 stated that when she noted blood in R1's catheter bag and he complained of pain on [DATE] she did not assesses R1's abdomen for distention or examine R1's penis or catheter insertion site. At that time E5 stated that when she inserted R1's urinary catheter she advanced the catheter until approximately 30 cc (cubic centimeters) of urine flowed into the catheter tubing and then she inflated the catheter balloon. E5 stated a small amount of urine flowed into the catheter tubing after she inflated the catheter balloon. E5 stated she did not advance the catheter to near the bifurcation of the catheter tube prior to inflating the balloon. On [DATE] at 1:05 PM E3 LPN stated that during shift change report on [DATE] between 7:30 AM and 8:00 AM E4 Certified Nurses Aide reported to E3 and E5 that R1 had blood in his catheter bag. E3 stated that she checked R1's catheter bag and E4 then notified Z1 of R1's condition and received orders for stat PT/INR, CBC and to irrigate R1's urinary catheter. E3 stated that when she returned to draw R1's blood and irrigate his catheter that she noticed a complete change in (R1). E3 stated that R1 was confused and short of breath. E3 stated she irrigated R1's catheter and blood returned in the tubing. E3 stated at that time she called Z1 and R1 was transferred to the Emergency Department. On [DATE] at 1:10 PM Z3 Emergency Department Registered Nurse stated that when R1 arrived in the Emergency Department on [DATE] she was sure that the urinary catheter balloon was inflated in R1's urethra. Z3 stated that there was more length on the urinary catheter tubing than she would expect and that the catheter was not draining urine. Z3 stated that R1 was in severe pain and that frank blood was coming out around the catheter insertion site. Z3 stated that approximately 40 cc of blood was present in the catheter drainage bag. Z3 also stated that R1's penis was swollen and bruised. Z3 stated that Z4 Emergency Department Physician instructed her to remove the urinary catheter and insert a new catheter. emergency room Notes dated [DATE] document that R1 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. Z5 (Infectious Disease Physician) Hospital Progress Note dated [DATE] (R1) Impression - [MEDICAL CONDITION] probably secondary to complicated urinary tract infection .Posttraumatic hematuria, secondary to (urinary catheter) Multiorgan failure secondary [MEDICAL CONDITION] .probable pneumonia right lung. The Discharge Summary dated [DATE] documents that R1 died at the hospital on [DATE] and that the cause of R1's death was cardiorespiratory arrest from septic shock, [MEDICAL CONDITION], hematuria. On [DATE] at 2:50 PM E2 Director of Nurses stated that E5 should have advanced the urinary catheter tubing three or four more inches into R1's urethra after she noted urine return in the tubing before inflating the catheter balloon to ensure the balloon was not in the urethra. E2 also stated that E5 should have deflated the balloon and reassessed the catheter placement when R1 complained of pain and blood was noted in his catheter. The policy related to Urinary Catheter Insertion dated [DATE] states Advance catheter almost to its bifurcation (for male patient) .prevents the balloon from becoming trapped in the urethra .make sure the catheter is draining properly before inflating balloon, then withdraw catheter slightly .inadvertent inflation of the balloon within the urethra is painful and causes urethral trauma. 2. On [DATE], at 11:30 AM, E7, Certified Nurse Assistant (CNA), and E12, CNA, transferred R5 from wheelchair to bed via mechanical lift. E12 donned gloves prior to transferring R5 to the bed. E12 touched R5's clothing, incontinent brief and towel with gloves on. E12, with the same contaminated gloves on, performed catheter care on R5 - E12 held R5's labia open, then got a clean cloth and wiped R5's perineal area and urinary catheter tubing. E12 continued perineal care then placed brief and pants on R5 with the same contaminated gloves. E12 then removed the contaminated gloves and washed E12's hands. On [DATE], at 11:55 AM, E12 was pushing R5 to the dining room via R5's wheelchair. R5's indwelling catheter tubing was dragging on the floor underneath R5's wheelchair. E12 stated E12 did not know it was dragging. E12 stated the bars on the wheelchair are crisscrossed and the catheter bag does not stay up. E12 then adjusted the catheter tubing so it was not dragging, On [DATE], at 12:00 PM, E12 stated she did not change gloves because it was the spur of the moment and E12 was nervous. E12 stated she should have changed gloves after getting R5 in bed and taking R5's pants down. E12 stated she should have changed E12's gloves before starting catheter care. On [DATE], at 12:50 PM, E2, Director of Nurses (DON), stated personally gloves should be changed every time they wipe. E2 stated noticing E12 kept gloves on for the whole time and that E12 should have washed E12's hands. E2 stated they should have known better than to let the catheter tubing drag on the ground for infection control reasons. Management of the Patient with an Indwelling (Self-Retaining) Catheter and Closed Drainage System, date [DATE], states to wash hands immediately before and after handling any part of the system.

Based on interview, observation and record review, the facility failed to ensure that adequate supervision and assistance to prevent falls was provided for 1 of 11 resident (R1) reviewed for falls in a sample of 24. This failure resulted in R1 falling which resulted in multiple fractures requiring surgical interventions. Findings include: 1. According to the falls log, R1 fell and sustained a fractured distal right humerus, a spiral fracture of the distal tibia, and a comminuted fracture of the right distal femoral shaft on 5/4/12. The Minimum Data Set ((MDS) dated [DATE] identifies R1 to have no cognitive impairment and no memory deficits. The MDS indicates R1 required limited assist of one staff for transfers, walking in room, and toilet use. The MDS also indicates R1 was not steady, "only able to stabilize with human assistance" for walking and moving on/off the toilet. The Incident/Accident Report dated 5/4/12 indicates R1 had a witnessed fall and documented "res (resident) states she was walking back to recliner from commode et (and) slipped. Stated "Must have peed on the way to the bathroom because the floor was wet." The summary of comprehensive Investigation concluded that R1 was being assisted back to the bed and R1 slipped on dribbled urine. The report documents the "CNA (Certified Nurses Aide) was unable to prevent resident from falling." Information obtained following the fall, documents that E11, CNA, failed to use a gait belt. Interview with E11, CNA, on 10/26/12 at 9:45am confirmed that R1 did not have a gait belt on when she ambulated her from the recliner to the commode. E1 stated she turned to get toilet paper and barrier cream and when she turned back around, R1 had started to ambulate by herself. E11 stated R1 fell to the floor. E11 stated there may have been urine on the floor but wasn't sure. E11 acknowledged that she should have had a gait belt on R1 at the time of the transfer. Interview with E1, Administrator, on 10/25/12 at 1:45pm confirmed that the CNA did not use a gait belt and acknowledged that gait belt use is a facility policy. The facility policy entitled "Gait Belt" dated 5/26/09 documents that it is the policy of the facility that gait belts are utilized on all residents requiring physical assistance with transfer unless contraindicated. Under section 2, it documents "Direct care staff will utilize the gait belt for all transfers requiring "hands-on" assistance with a pivot or manual transfer. On 10/23/12 at 4pm, R1 was in her wheelchair at bedside. She had a hoyer sling under her and stated she has been a total mechanical lift since her fall and is not walking yet. R1 stated she is hopeful to return home. R1 recalled the fall and stated she still has a wound from surgery on her fractured arm. R1 stated she is still recovering from the fall with therapy as well.

Based on observation and record review the facility failed to ensure the proper transfer and supervision during transfer for one of two residents observed for transfers (R10) in a sample of 14. Findings include: On 12-19-12 at 2:15p.m. E4 (Certified Nurse Aide) was preparing to transfer R10 to the bathroom for toileting/incontinence care. As E4 pushed the sit to stand mechanical lift into R10's room, E2 (Consulting Nurse/Acting Director of Nurses), who was standing in the hallway outside of R10's room and could see the mechanical lift, asked E4 if she needed assistance. E4 stated that she did not need any assistance with providing care to R10. E4 wrapped the mechanical sit to stand sling around R10's back and under her arms, then wrapped a strap around R10's lower legs. E4 then engaged the mechanical sit to stand device which lifted R10 out of her wheelchair. R10 was unable to hold onto the handle bars of the lift and was hanging from the lift by her underarms. R10's knees were bent and her feet were not supporting her body weight while she was in the mechanical lift. There was no additional staff present to supervise R10 to ensure that R10's arms would not raise over her head and slip out of the sling while E4 pushed R10 from the back of the mechanical lift device. E4 proceeded to transfer R10 into the bathroom and onto the toilet. R10 had her eyes closed throughout the sit to stand mechanical lift transfer and was unable to follow commands. Once E4 had pushed R10 into the bathroom and had R10 positioned on the toilet, E4 walked out of the bathroom closing the door to the bathroom to within a few inches. E4 stated that there wasn't enough room for her to move to the other side of R10 to provide care because of the size of the mechanical lift. E4 stated that she needed to go around through another resident's room to enter the bathroom from the other side in order to provide incontinence care to R10. When describing how R10 is transferred from surface to surface using the sit to stand mechanical lift E4 stated, "The bad thing is she can't hold on." R10's annual Comprehensive Minimum Data Set ((MDS) dated [DATE] documents that R10 was unable to complete the brief interview for mental status. The MDS documents that the staff assessment for mental status indicates that R10 is severely impaired. The MDS documents that R10 requires the extensive assist of two people for transfers. A corporate mechanical lift transfer policy dated 7-27-12 indicates to, "Use two staff members when transferring a resident on mechanical lift." Additional instructions on the policy indicate to, "instruct the resident to hold the hand grips..." The policy also indicates to, "obtain assistance from another staff member for transfer." On 12-20-12 at 10:30 E3 (Senior Administrator) stated that the facility had been using an older facility policy which mechanical lift policy which indicated that a resident may be transferred using one person. E3 stated that the facility had not started using the corporate mechanical lift policy dated 7-27-12. A manufacturers operators requirements for using a mechanical lift dated 2009 indicates to, "Assessment of needs unique to each patient remains the responsibility of the caregiver. Physical limitations, medical conditions, psychological or behavioral factors should dictate the number of caregivers required for safe patient transfers." A facility mechanical lift policy dated 8-01-2005 indicates that, "The sling should never 'ride up' into the resident's shoulder area. If this occurs, it is a mis-transfer and should be reassessed for procedure, type of sling, and/or appropriateness of the stand."

Based on observation, interview, and record review the facility failed to identify, through an ongoing comprehensive assessment, a side rail entrapment hazard for R2, one of five residents reviewed for side rail use in the sample of five. This failure resulted in an immediate jeopardy situation when R2's head was found to be entrapped between the side rail and mattress. The facility failed to recognize this incident as a fall, failed to thoroughly investigate and document details of the incident, and failed to examine and document a root cause analysis of the entrapment. While the immediacy was removed on [DATE] the facility remained out of compliance at a Severity Level 2. The facility is in the process of monitoring the effectiveness of new policy implementation and re-education efforts directed at staff so as to identify and address potential entrapment hazards. Findings include: On [DATE] at 9:20 a.m. E1, Administrator stated that he was informed of R2's death on the evening of [DATE] by a telephone call he received from E2, Director of Nursing. E1 stated he was notified by E2 that R2's "legs had slid off of the bed" and that R2 "had not been caught in" or otherwise impacted by a side rail. On [DATE] at 9:30 a.m. E2 stated she received a call from Licensed Practical Nurse (LPN), E3 on [DATE] at 8:35 p.m. which indicated that R2's legs and buttocks had slipped off the bed, and that when she was discovered she was unresponsive and had no vital signs. A written statement completed on [DATE] by E2 confirms this information. E2's document states that E3 reported to her that R2's "...legs and buttocks were on the floor and that her upper body was still on the bed...that top of head was near lower end of grab bar...(R2) was lying partially on her right side on the bed with her face away from the rail-on the mattress of bed and that her entire head, shoulders and neck were below the grab bar...her legs were on the floor and buttocks was close to the floor..." The report continues that two CNA's (Certified Nurse Aides) placed R2 "...back into bed" and that R2 "...was unresponsive and had no palpable VS (vital signs)." On [DATE] at 9:30 a.m. E1 and E2 stated that an incident report related to R2's event was not completed. E2 stated that this event was not considered to be an "incident" and that E2 "didn't see any relationship to her death and the side rail." E1 and E2 stated that this event was not reported to the State Survey and Certification Agency (Illinois Department of Public Health). E2 stated that there "was no sign of strangulation, but my impression was that she died in bed, her legs relaxed, she then fell out of bed." E3, LPN stated on [DATE] at 12:40 p.m. that she was a first responder to R2's event on [DATE] along with CNA, E6. E3 stated that upon entering the room R2's "body (legs and bottom) was on the floor, her head was stuck between the bed rail and mattress, the rail was pressed against her right ear, her face was into the mattress, her back was toward me (as I entered) from behind the curtain, she was in a squatted position...I couldn't believe what I was seeing." E3 stated that R2's head was positioned "right where the bed folds...the head of the bed was elevated approximately 30 degrees...and when she was on the floor she was sitting erect...the air mattress was squishy, it wasn't tight against her head." E3 stated she immediately assessed R2. E3 stated that R2's "nose was laying to the side, her face was smashed...when she was lying down her nose was lying toward her right cheek..." E3 stated there were no marks on her face and her eyes showed no petechiae. E3 stated R2 was not breathing, there was no pulse, and no blood pressure. E3 stated that she immediately phoned her Supervisor, E2, Director of Nursing and notified her of these details. E3 continued that E2 soon arrived at the facility at which time E2 examined R2. E3 stated that she was concerned about R2 strangling or suffocating. E3 stated that E2 assured her that there were no signs or symptoms of this. E3 stated that she did not document any nurse's notes and no incident report related to what she had witnessed related to R2. E3 stated that E2 indicated to her that she (E2) "would take care of it." E3 stated that she was advised by E2 to contact the Coroner, Physician, and family and notify them that R2 had "passed away". E3 stated that she was told by E2 to "be vague" and not to offer any details. E3 stated that she "just did what my Supervisor told me to do." On [DATE] at 3:00 p.m. E6, CNA stated she was a first responder to R2's incident the evening of [DATE] along with E2. E6 stated she "saw (R2's) feet on the floor under the curtain" when she walked by her room. E6 stated she immediately notified E2 who was present at the nurse's station. E6 stated they both entered R2's room where E6 described R2 as "slouched, feet on the floor, neck on the bed rail, against it...the right side of her head was against the rail, she was facing the bed, with her face against the bed...she was not breathing." E6 stated she and E2 then "placed her (R2) slowly on the floor flat on her back, her mouth was open...there were no marks on her face or head..." E1, Administrator stated on [DATE] at 9:15 a.m. that he had not been notified of the details of the event involving R2 on [DATE]. E1 confirmed at this time that there had been no incident report completed, no nursing assessment documented, and no documentation related to an investigation or documented root cause analysis completed. E1 stated that it "was a poor decision by (E2)...that it should have been viewed as a fall." E1 stated that "there should have been an incident report completed and medical assessment documented." According to R2's [DATE] Physician order [REDACTED]. The most recent Minimum (MDS) data set [DATE] assesses her as being cognitively intact and being totally dependent on one person for bed mobility and two persons for transfers. R2 is assessed as having range of motion impairments for both upper and lower extremities. R2 is assessed as being 66 inches in height and 153 pounds. She was admitted to hospice care on [DATE]. R2 is assessed as using no physical restraints. Z1, Hospice Case Manager for R2 stated on [DATE] that R2 was admitted to hospice on [DATE] and utilized a low air flow mattress supplied by the hospice provider R2's most recent Side Rail assessment dated [DATE] reflects that she was assessed for the use of Assist Rails to the left and right sides of her bed to "serve as an enabler to promote independence" and that "the resident has requested to have side rails while in bed." The assessment indicates that R2 had the assist rails in place since [DATE]. E1 stated on [DATE] at 4 p.m. that this was the most recent side rail assessment for R2. R2's Care Plan dated [DATE] reflects that R2 is at risk for falls related to decreased physical mobility, weakness and decreased range of motion to left shoulder and bilateral hips secondary to Cerebrovascular Accident with left [DIAGNOSES REDACTED], dementia, and generalized pain. Her care plan addresses R2's anxiety, verbal and physical aggression, chronic pain, and hospice admission. An intervention includes to assist with turning and repositioning in bed and chair. R2's Care Plan fails to address the use of side rails and the use of a low air loss mattress and potential associated entrapment hazards. A Fall report dated [DATE] documents that R2 sustained a fall from her bed. The investigation conclusion states "interdisciplinary team review for this incident and determine resident was reaching for something on her bedside table, was in bed at the time leaning too far table not in reach and rolled out of bed..." The report indicates R2 sustained no injuries. The documented Plan of Action documents "make sure bedside table is within reach with personal items within reach." The fall report and investigation does not address R2's side rail use in conjunction with a low air loss mattress and potential safety/entrapment issues. E4, CNA stated on [DATE] at 12:15 p.m. that R2 "could move around in bed pretty good...she could roll left and right...she needed help getting centered in bed...she would get to the edge of the bed a lot...sometimes her shoulder would be against the side rail...we had to put her legs up on the bed a lot...we would report this to the nurse..." E9, CNA stated on [DATE] at 3:30 p.m. that R2 "used to move around in bed...that night ([DATE]) she was propped on her side with a pillow...she could have been a little more centered...she was really impatient..." E5, CNA stated on [DATE] at 11:25 a.m. that R2 had the ability to move herself to the edge of the bed but preferred to stay in bed. E7, LPN stated on [DATE] at 10 a.m. that R2 "could throw her legs out of bed if she wanted to..." E8, LPN stated at this time that R2 "could move to the edge of the bed if she wanted to..." E11, LPN stated on [DATE] at 10:30 a.m. that R2 had "...some ability to use her grab bars to hold on...she was very particular on her care and would use the call light to direct her care...on occasion would get her feet and lower legs over the edge of the bed indicating she wanted to get up and we'd get her up...she did have increasing confusion and bursts of energy indicating she wanted up or repositioned..." Examination of R2's bed on [DATE] at 2 p.m. with E1, Z2 Corporate Director of Quality and Compliance, and Z5 Corporate Administrator reflected that the bed was equipped with bilateral assist bars measuring approximately 12 inches wide by approximately 16 inches in height. R2's bed was equipped with a mechanically operated inflatable air mattress ,[DATE] inches thick when inflated. The assist bar placement was immediately adjacent to the segment of the mattress and bed frame that articulates the head of bed. A 4 to 5 inch gap exists between the assist rail and the compressed edge of the mattress when weight or pressure is applied to the air mattress surface. The gap widens when the head of the bed is elevated creating an entrapment hazard. The manufacturer's User-Service Manual for the Assist Handle that was used on R2's bed specifies "Important Precautions" and documents multiple warning statements including "Warning: Risk of Serious Injury or Death...Use a properly sized mattress in order to minimize the gap between the side of the mattress and the assist device. This gap must be small enough to prevent a resident from getting his/her head or neck caught in this location. Make sure that raising or lowering the bed, or articulating the sleep surface does not create hazardous gaps. Failure to do so could result in serious injury or death." This manual also states "Warning: An optimal bed system assessment should be conducted on each resident by a qualified clinician or medical provider to ensure maximum safety of the resident. The assessment should be conducted within the context of, and in compliance with, the state and federal guidelines related to the use of restraints and bed system entrapment guidance, including the Clinical Guidance for the Assessment and Implementation of Side Rails published by the Hospital Bed Safety Workgroup of the U.S. Food and Drug Administration..." The manual continues and states "Note: The assist device is intended for use as an aid in entering or exiting the bed sleep area, as well as a stable handhold during self positioning within the bed sleep area." Facility policy titled "Proper Use of Side Rails" dated [DATE] states "...Upon admission, quarterly and with a significant change in condition, an assessment will be completed to determine the resident's symptoms or reason for utilizing side rails...the use of side rails as an assistive device will be addressed in the resident care plan...when side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk of entrapment..." Z2 stated on [DATE] at 1 p.m. "...our current side rail assessment clearly does not address potential entrapment hazards. Anything attached laterally to the side of the bed can be potentially hazardous and should be evaluated...the current process here involves maintenance services evaluating the beds and rails...there needs to be a better clinical correlation on an individualized basis..." Z2 confirmed at this time that there was no other, more current assessment for R2's side rail use other than the [DATE] assessment. An Immediate Jeopardy situation began on [DATE] when R2's head was discovered to be entrapped between her side rail and mattress. The facility failed to identify the entrapment hazard and mitigate it given her known risk factors. E1 was notified of the Immediate Jeopardy situation on [DATE] at 2:30 p.m. The surveyor confirmed through interview, observation, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. R2 was removed from the entrapment immediately and lowered to the floor to facilitate assessment. R2's Do Not Resuscitate was verified and honored. Completed [DATE] by E3. 2. Residents with specialty air-mattresses and all residents using side rails or bed accessories have been evaluated for the risk of potential entrapment. Side/assist rails have been eliminated and removed when possible. Risks have been minimized for those residents who continue to use side/assist rails. Completed [DATE] by E1, Z2, and Z5. 3. Operating policy related to the use of side rails was revised to reflect "...individual factors that place resident at increased risk for potential entrapment will be evaluated and considered when determining utilization of side/assist rails or bed accessories...evaluation of entrapment zones will be evaluated to determine dimensions between the side/assist rails or bed accessory does not place the resident at increased risk of potential entrapment. The evaluation will be conducted prior to utilization of the side/assist rails or bed accessories and periodically thereafter...Manufacturer recommendations will be reviewed and incorporated into the plan of care as clinically indicated..." Completed on [DATE] by E1, Z2 and Z5. 4. Education was provided related to identification of unusual occurrences, incident reporting and investigation, notification of changes, bed safety and entrapment risks. Nurses who are responsible for completing Side Rail assessments and determining potential entrapment risks have been educated. Completed [DATE] by Assistant Director of Nursing and Regional Clinical Nurse.

Based on observation and record review the facility failed to ensure the proper transfer and supervision during transfer for one of two residents observed for transfers (R10) in a sample of 14. Findings include: On 12-19-12 at 2:15p.m. E4 (Certified Nurse Aide) was preparing to transfer R10 to the bathroom for toileting/incontinence care. As E4 pushed the sit to stand mechanical lift into R10's room, E2 (Consulting Nurse/Acting Director of Nurses), who was standing in the hallway outside of R10's room and could see the mechanical lift, asked E4 if she needed assistance. E4 stated that she did not need any assistance with providing care to R10. E4 wrapped the mechanical sit to stand sling around R10's back and under her arms, then wrapped a strap around R10's lower legs. E4 then engaged the mechanical sit to stand device which lifted R10 out of her wheelchair. R10 was unable to hold onto the handle bars of the lift and was hanging from the lift by her underarms. R10's knees were bent and her feet were not supporting her body weight while she was in the mechanical lift. There was no additional staff present to supervise R10 to ensure that R10's arms would not raise over her head and slip out of the sling while E4 pushed R10 from the back of the mechanical lift device. E4 proceeded to transfer R10 into the bathroom and onto the toilet. R10 had her eyes closed throughout the sit to stand mechanical lift transfer and was unable to follow commands. Once E4 had pushed R10 into the bathroom and had R10 positioned on the toilet, E4 walked out of the bathroom closing the door to the bathroom to within a few inches. E4 stated that there wasn't enough room for her to move to the other side of R10 to provide care because of the size of the mechanical lift. E4 stated that she needed to go around through another resident's room to enter the bathroom from the other side in order to provide incontinence care to R10. When describing how R10 is transferred from surface to surface using the sit to stand mechanical lift E4 stated, "The bad thing is she can't hold on." R10's annual Comprehensive Minimum Data Set ((MDS) dated [DATE] documents that R10 was unable to complete the brief interview for mental status. The MDS documents that the staff assessment for mental status indicates that R10 is severely impaired. The MDS documents that R10 requires the extensive assist of two people for transfers. A corporate mechanical lift transfer policy dated 7-27-12 indicates to, "Use two staff members when transferring a resident on mechanical lift." Additional instructions on the policy indicate to, "instruct the resident to hold the hand grips..." The policy also indicates to, "obtain assistance from another staff member for transfer." On 12-20-12 at 10:30 E3 (Senior Administrator) stated that the facility had been using an older facility policy which mechanical lift policy which indicated that a resident may be transferred using one person. E3 stated that the facility had not started using the corporate mechanical lift policy dated 7-27-12. A manufacturers operators requirements for using a mechanical lift dated 2009 indicates to, "Assessment of needs unique to each patient remains the responsibility of the caregiver. Physical limitations, medical conditions, psychological or behavioral factors should dictate the number of caregivers required for safe patient transfers." A facility mechanical lift policy dated 8-01-2005 indicates that, "The sling should never 'ride up' into the resident's shoulder area. If this occurs, it is a mis-transfer and should be reassessed for procedure, type of sling, and/or appropriateness of the stand."